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| CLINICAL RESEARCH |
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| Year : 2011 | Volume
: 32
| Issue : 4 | Page : 487-493 |
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A comparative study on Vamana Karma with Madanaphala and Krutavedhana in Ekakushtha (Psoriasis)
Jaimin R Patel1, Santoshkumar Bhatted2
1 Lecturer, Department of Kaya Chikitsa, JS Ayurved Mahavidhyalaya, Nadiad, Gujarat, India
2 Associate Professor, Department of Panchakarma, National Institute of Ayurveda, Jaipur, Rajasthan, India
| Date of Web Publication | 14-May-2012 |
Correspondence Address:
Santoshkumar Bhatted
Associate Professor, Department of Panchakarma, National Institute of Ayurveda, Madhav Vilas, Palace, Amer Road, Jaipur, Rajasthan
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0974-8520.96121
 Abstract | | |
Vamana Karma (therapeutic emesis) is the best therapy for the elimination of vitiated Kapha Dosha. In the present clinical practice Madanaphala (Randia dumetorum) is mainly used for Vamana Karma. Apart from Madanaphala, five other drugs, and in total 355 formulations are described in Charaka Samhita; one of them is Krutavedhana (Luffa acutangula) kalpa (formulations). Krutavedhana is specially indicated in Gadha (compact) Dosha condition like Kushtha (skin diseases), Garavisha (slow poison), and so on, for Vamana Karma. The present study aimed to observe the effect on Vamana Karma and by that its effect on Ekakushtha (Psoriasis). Krutavedhana Beeja Churna (seed powder) was given with Madhu (honey) and Saindhava (rock salt) as Vamana Yoga (emetic formulation), to compare it with Madanaphala Pippali Churna (seed powder). After the Sansarjana Krama (special dietetic schedule), Panchatikta Ghrita (medicated ghee) was given as Shamana Sneha (pacifying oleation). An average dose of Krutavedhana was 5.9 g. Krutavedhana could produce a good number of Vega (bouts), Pittanta Lakshana (bile coming out at the end of Vamana), and Pravara Shuddhi (maximum cleansing) in a majority of patients. Madanaphala is the best among all Vamaka (emetic) drugs, but Krutavedhana showed a similar to higher effect on Vamana Karma in terms of Antiki, Maniki, Vaigiki, and Laingiki Shuddhi (cleansing criteria). Vamana Karma by Krutavedhana showed better relief in Matsyashakalopamam (silvery scale), Kandu (itching), and Rukshataa (dryness), while Madanapahala showed better relief in Krishnaruna Varna (erythema). After completion of the Shamana (pacifying) treatment, both the groups showed nearly the same effect on Asvedanam (lack of perspiration), Matsyashakalopamam, Kandu, Rukshataa, Krishnaruna Varna, and Mahaavaastu (bigger lesion). Keywords: Ekakushtha, Krutavedhana, Madanaphala, Panchatikta Ghrita, Psoriasis , Vamana Karma
How to cite this article:
Patel JR, Bhatted S. A comparative study on Vamana Karma with Madanaphala and Krutavedhana in Ekakushtha (Psoriasis). AYU 2011;32:487-93 |
| Introduction | |  |
Panchakarma , the unique therapies of Ayurveda, attract the attention of people for the treatment of various disorders and also for their preventive and promotive effect. With increase of awareness and global acceptance, it is the need of the hour to work on individual Karma, with different formulations for different diseases, in a scientific manner. Therefore, in the present study Vamana Karma has been selected for the treatment of Ekakushtha (psoriasis). Vamana Karma is the best therapy [1] for the elimination of vitiated Kapha Dosha from all over the body through Aamashaya (stomach) by means of medically induced vomiting.
For the Vamana Karma, mainly Madanaphala is widely used, and the other Vamaka drugs and their formulations are not in usual practice. Apart from Madanaphala, five other drugs and in total 355 formulations are described in Charaka Samhita,[2] one of them is Krutavedhana Kalpa, which indicates the selection of different drugs and formulations in accordance to the Dosha, Dushya (tissues), and disease. Krutavedhana is specifically mentioned for a Gadha Dosha condition, like Kushtha, Pandu (anemia), Pliha Roga (splenomegaly), Shopha (edema), Gara Visha,[3] and so on. Ekakushtha has been taken for present study. Ekakushtha is one among the Kshudra Kushtha (minor skin diseases) with the dominance of Kapha and Vata Dosha in particular, and the Rakta (blood) is vitiated in general. Ekakushtha can be co-related with psoriasis. Thus, in the present study Vamana Karma has been conducted by Madanaphala and Krutavedhana in the patients of psoriasis.
Aims and objectives
- To assess the effect of Krutavedhana on Vamana Karma
- To compare the effect of Madanaphala Pippali and Krutavedhana Yoga on Vamana Karma
- To compare the effect of Vamana Karma performed by Madanaphala Pippali and Krutavedhana on the alleviation of the signs and symptoms of psoriasis.
| Materials and Methods | | |
The patients having classical signs and symptoms of Ekakushtha (psoriasis), as described in Bruhatrayi, were selected. A special proforma including all the etiological factors of Kushtha with Dushti Lakshana (signs and symptoms of vitiation) of Dosha, Dushya, Srotasa (channels), and so on, was designed for assessment of all the patients. The patients were thoroughly questioned and examined on the basis of the proforma. Ethical clearance and informed consent were obtained before conducting the trial.
Selection of patients
Patients suffering from Ekakushtha were selected from the Outpatient Department (OPD) and the Inpatient Department (IPD) of the I.P.G.T. and R.A., Hospital, Jamnagar, irrespective of religion, sex, occupation, caste, and so forth.
Inclusion criteria
- Age between 18 and 60 years
- Ekakushtha is diagnosed as per Ayurveda
Exclusion criteria
- Age below 18 years and above 60 years
- Patients of, hypertension, tuberculosis, carcinoma, other life-threatening, and complicated diseases, and major systemic illnesses
Pathological investigation
- Blood for Hemoglobin (HB), Total Count (TC), Differential Count (DC), Erythrocyte Sedimentation Rate (ESR)
- Routine and microscopic examination of urine
Biochemical investigation
- Lipid profile, Fasting blood sugar (FBS)
Grouping
Patients were randomly divided and studied under two Groups, namely, Group A and Group B, irrespective of religion, sex, occupation, caste, and the like.
Group A: In this group Vamana Karma was performed by Madanaphala Pippali. Panchatikta Ghrita was given as Shamana, after Sansarjana Krama.
Group B: In this group Vamana Karma was performed by Krutavedhana. Panchatikta Ghrita was given as Shamana, after Sansarjana Krama.
Procedure, drug, dose, and duration
Properties of Madanaphala and Krutavedhana
Madanaphala
Rasa : Kashaya, Madhura, Tikta, Katu
Guna: Laghu, Ruksha
Veerya: Ushna
Vipaka: Katu
Prabhava: Vamaka
Krutavedhana
Rasa: Tikta
Guna: Laghu, Ruksha, Tikshna
Veerya: Ushna
Vipaka: Katu
Prabhava: Ubhayatobhagahara
Internal Shamana Yoga
After the Sansarjana Krama Panchatikta Ghrita was given as Shamana Yoga, in both groups, in the dose of 20 ml, twice a day for 15 days.
Follow-up
After Shamana Yoga, follow-up was done, for 30 days.
Pathya - Apathya (Dos and don'ts)
Pathya - Apathya was advised to the patient as per the classics.
| Criteria for Assessment | | |
- Assessment of Vamana Karma was done by observing the features of Samyaka Yoga (proper induction), Ayoga (inadequate induction), and Atiyoga (excessive induction), with Antiki, Maniki, Laingiki, and Vaigiki Shuddhi.
- Changes in signs and symptoms of psoriasis were assessed by a specially designed proforma.
- The effect on Vamana Karma and effect on psoriasis in both the groups were compared.
- Statistical tools: The results were compared by the paired't' test and percentage-wise comparison between the two groups.
Scoring pattern
The scoring pattern was based on the scoring of National Psoriatic Foundation (NPF), for signs and symptoms of psoriasis and a special scoring pattern was adopted for certain signs and symptoms of Ekakushtha.
Criteria for the assessment of overall effect of the therapies
- Complete remission: 100% relief in the signs and symptoms
- Marked improvement: > 76% relief in the signs and symptoms
- Moderate Improvement: 51 - 75% relief in the signs and symptoms
- Improved: 26 - 50% relief in the signs and symptoms
- Unchanged: Below 25% relief in the signs and symptoms
Observations
General observations
A total of 30 patients were registered. Among them, in Group A - 13 patients completed the treatment and two patients discontinued, and in Group B - 14 patients completed the treatment and one patient left the treatment. Maximum number of patients, (40%) belonged to the age group of 36 - 45 years, 66.67% were male, 93.33% were of Hindu religion, 76.67% were married, 60% belonged to the middle class, 36.68% had primary education, 33.33% were businessmen, and 56.67% were habituated to a vegetarian diet. Maximum number of patients, (56.67%) had regular bowel habits and 46.67% had Madhyama Koshtha (moderate bowel); 73.34% had Madhura (sweet), Amla (sour), Lavana (salt), Rasa (taste) dominancy in their diet. Fifty percent had a dietary pattern of Vishamashana (irregular pattern of diet) and 40% were addicted to tobacco.
Dashvidha Pariksha (Tenfold method of examination)
Maximum (40%) of the patients had Kapha-Vata Prakruti (constitution) followed by Pitta-Kapha Prakruti in 30% of the patients. Seventy percent of the patients had Madhyama Sara (moderate tissue buildup) and Pramana (quantity), 50% patients were of Pravara Satva (superior mental power), and 60% of the patients had Madhyama Abhyavarana and Jarana Shakti (moderate capacity for intake and digestion of food).
Nidaanaas
Maximum number of patients (83.33%) took Viruddha Aahaara (contradictory food), [4] like milk + Khichadi (Indian food recipe prepared from rice and green gram) and 70% of the patients consumed Fast food and curd. Divaswapna (day sleep) was observed in maximum, (50%) of the patients, followed by Ajirnashana (food intake during the state of indigestion) in 30%, and Shitoshna Vyatyas Sevana (alternative hot and cold usage) in 26.67% of the patients. Chinta (worrying) was reported in 50% of the patients. Only one patient (3.33%) had positive family history of psoriasis.
Rupa
Krishna Aruna Varna, Kandu, Rukshataa, Mahaavaastu, and Matshyashakalopam were found in 100% of the patients followed by Asvedanam in 86.66% of the patients. Nail involvement was present in 23.33% of the patients and joint involvement was found in 20% of the patients. Maximum number of patients, that is, 83.33% had Vata Kapha dominance and all the patients had Twak and Rakta Dushti (skin and blood vitiation). As for the signs of psoriasis, maximum (90%) of patients had a positive Auspitz's sign. [5] The plaque variety of psoriasis was found in 83.33% of the patients. Maximum patients, (40%) had 91 - 100% of skin area involvement and 26.67% patients had 10 - 12 years chronicity. Maximum, (83.33%) of the patients reported winter season as the aggravating factor, followed by stress in 40% and smoking in 13.33% of the patients.
Review of Vamana Karma
Maximum, (43.34%) of the patients had Samyak Snigdha Lakshana (features of proper internal oleation) on the seventh day of Snehapana. Average maximum dose of ghee was 216.3 ml, average minimum dose of ghee was 31.5 ml, and average total dose of ghee was 756.15 ml. The average quantity taken for Aakanthapana (stomach filled up to the throat) was 996 ml, while time taken for the Aakanthapana was 5.5 minutes. The average dose of Madanaphala was 6 g and the average dose of Krutavedhana was 5.9 g.
Average time taken for induction of the first Vega was 12 minutes in Group A, while it was 15.4 minutes (Avg.) in Group B. After administering Vamana yoga, self-induced and projectile Vega was observed in 38.46% of the patients in Group A and 50% of the patients in Group B. The average number of Vega was 5.46 in Group A, while it was 7.3 in Group B. Average number of Upavega (smaller bouts) was 8.53 in Group A, while it was 6.7 in Group B.
The average quantity of Yashtimadhu Phanta was 3.5 l in both groups. The average quantity of Saindhavajala (salt water) was 3.08 l in both groups.
The difference in average quantity of output and input was 0.48 l in Group A, while it was 0.06 l in Group B.
Clear Pitta appeared in 30.76% of the patients in Group A and 28.57% of the patients in Group B. In the Pittanta Lakshana, Katu-Tiktaasyata (spicy and bitter taste in mouth) was observed in 53.84% of the patients in Group A and 64.28% of the patients in Group B. Galakantha Daha (burning sensation in throat) was observed in 61.53% of the patients in Group A and 64.28% of the patients in Group B.
In Samyaka Vamita Lakshana (signs and symptoms of proper emesis): [6] Kale Pravruti (timely expulsion) was observed in 69.23% of the patients in Group A and in 85.71% of the patients in Group B. Yathakrama Doshadarshana (expulsion of Dosha in order) was observed in 69.23% of the patients in Group A and in 78.51% of the patients in Group B.
Pravara Shuddhi was observed in 53.84% of the patients in Group A and in 71.42% of the patients in Group B.
| Results | | |
Effect of therapy on laboratory investigations
After completion of the treatment, there were no major changes observed in the Hb, TC, DC or ESR in both the groups.
After completion of the treatment, in Group A Serum Triglyceride decreased by 15.37% and in Group B by 12.68%; while HDL had increased by 10.01% in Group B and by 01.69% in group A, but it was statistically in significant.
After Vamana Karma in Group A, The relief was 34.61% in Kandu, 27.77% in Matshyashakaopam, 26.83% in Krishna aruna varna, 7.69% in Rukshata. Among them, relief in Kandu, Matsyashakalopam, and Krishna Aruna Varna was statistically highly significant. In other symptoms, the result was insignificant [Table 1]. | Table 1: Effect of therapy after Vamana Karma on the chief symptoms in Group A
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After Vamana Karma in Group B, the relief was 50% in Kandu, 40.74% in Matsyashakalopam, 30% in Rukshata, 20.69% in Krishna Aruna Varna, 3.57% in Asvedanam, and 8.82% in Mahavastu. Among them, relief in Kandu, Matsyashakalopam, and Rukshata was statistically highly significant. Relief in Krishna Aruna Varna was statistically significant. In other symptoms, the result was insignificant [Table 2]. | Table 2: Effect of therapy after Vamana Karma on chief symptoms in Group B
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After completion of treatment in Group A, The relief was 71.42% in Kandu, 70.37% in Matsyashakalopam (Scaling), 51.51% in Rukshata, 55.55% in Krishna Aruna Varna, 38.24% in Mahavastu, and 44% in Asvedanam. The result was highly significant in Matsyashakalopam, Krishna Aruna Varna, Kandu, and Rukshata. A significant result was found in Asvedanam and Mahavastu [Table 3]. | Table 3: Effect of therapy after complete treatment on chief symptoms (Vamana followed by Shamana) in Group A
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After completion of treatment in Group B, The relief was 77.35% in Kandu, 72.22% in Matsyashakalopam, 51.90% in Krishna Aruna Varna, 52.5% in Rukshata, 44% in Asvedanam, and 42.10% in Mahavastu. The result was highly significant in Asvedanam, Matsyashakalopam, Krishna Aruna Varna, Kandu, and Rukshata. Significant result was found in Mahavastu [Table 4]. | Table 4: Effect of therapy after complete treatment on chief symptoms (Vamana followed by Shamana) in Group B
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Overall effect of the therapy
15.38% of the patients were completely cured in Group A, while none were completely cured in Group B.
7.69% of the patients had marked improvement in Group A, while 28.58% patients in Group B had marked improvement.
46.15% of the patients showed moderate improvement in Group A, while 21.42% of the patients in Group B showed moderate improvement.
23.07% of the patients showed improvement in Group A, while 35.71% patients in Group B showed improvement.
7.69% of the patients remained unchanged in Group A, while 14.29% of the patients in Group B remained unchanged.
| Discussion | | |
Disease
Mahavastu , Matsyashakalopam, Krishna Aruna Varna, Kandu, and Rukshata were found in 100% of the patients, which clearly indicates the similarity of Ekakushtha with psoriasis. Although Ekakushtha is considered as Kshudra Kushtha, in the present senerio psoriasis is one of the severe skin diseases, which is Krichhra Saadhya in the treatment.
Nidanas and Samprapti observed in the present study: Nidanas like Shita-Ushna Vyatyasa Sevana, Stress, Bija Dosha (genetic factor), and Environment may lead to Dhatu Shaithilyata (laxity of the tissues) in Twak, Rakta, Mamsa (muscular tissue), Lasika (fluid and lymph). Viruddha Aahara, that is, milk + Khichadi, fast food, curd, and Maamsa Sevana (meat intake) and Divaswapna also leads to vitiation of Kapha and Rakta. These vitiated Doshas reach the Dushya like Twak and so on, and result in Sthana Samshraya Avastha (accumulation at the site of the lesion) and then produce symptoms of Ekakushtha.[7]
Drug
The drug Krutavedhana was taken for the study of Vamana Karma. There is no specific reference in the classics regarding the part of Krutavedhana that has to be used for Vamana Karma. One reference was found in Nighantu Aadarsha, regarding the use of its Beeja, and its dose is 20 to 30 grains (125 mg). Based on this, Krutavedhana Beeja Churna was selected for Vamana Karma in the present study. As per classical reference, it was given with Saindhava and Madhu, with the Anupana (vehicle) of Yashtimadhu Phaanta.
Vamana Karma
Dose of Vamana Yoga - Average dose of Madanaphala was 6 g and the average dose of Krutavedhana was 5.9 g. Dose should be given according to the Bala (strength), Prakriti, Dosha, and Koshtha of the patient.
The dose of Madanaphala may be taken at 6, 7, and 8 g for Mridu, Madhyama, and Krura Koshtha (soft, moderate, and hard bowel), respectively. The dose of Krutavedhana may be taken at 5, 6 and 7 g for Mridu, Madhyama, and Krura Koshtha, respectively.
Vaigiki (based on the number of bouts)
Time of First Vega - 12 minutes (Avg.) was taken for induction of the first Vega in Group A, while it was 15.4 minutes (Avg.) in Group B. This indicates that Krutavedhana took more time for induction of Vamana Vega.
Self-induced and projectile Vega was the main quality expected in the first Vega of Vamana Karma, which was found in 50% of the patients with Krutavedhana. It might be because it had more Tikshana and Vamaka Prabhava (strong emetic property).
More Vega induced by Krutavedhana and more Upavega induced by Madanaphala was observed. Although Vega depends on many things like, patient's intake, cooperation, Satva, and so on, from this data it can be stated that Krutavedhana produces more Vega in comparison to Madanaphala.
Maniki (based on quantity)
As per the Maniki criteria Hina Shuddhi (mild cleansing) was observed in Group A and even Hina Shuddhi was not observed in Group B. Practically the difference in output and input was not found to be more than 500 ml, which is the lower side of Hina Shuddhi as per the Maniki criteria.
Antiki (based on end point)
The clear greenish yellow Pitta that appeared in both the groups was nearly the same. Clear Pittanta may not be possible in all patients. Pittanta Lakshana is an indirect method to observe the Pitta Nirgamana (expulsion of bile). It was little more in Group B, may be because of more Vega observed in this group.
Laingiki (based on sigs and symptoms)
Samyaka Vamita Lakshanas indicate the process of Vamana and the subjective feeling of the patients after Vamana Karma. It was observed to be slightly more in Group B, may be because of the greater number of Vega and Pittanta Lakshana.
Pravara Shuddhi was observed in 53.84% of the patients in Group A, while it was 71.42% in Group B. Shuddhi depends upon the Antiki, Maniki, Laingiki, and Vaigiki criteria. By this, it can be stated that Krutavedhana may produce better Vamana Karma in comparison to Madanaphala.
Effect of therapy after Vamana Karma on chief symptoms
After the Vamana Karma, Group B showed better relief in Matsyashakalopam, Kandu, and Rukshata, because Krutavedhana was 'Atyartha Katu Tikshnoshna'[8] (excessive pungent hot and penetrating). On account of the Gunas by which it acts on Gadha Dosha and also by its Kushthaghna Prabhava (specific capacity against the skin diseases) it might have provided better relief for these symptoms. Both the groups showed nearly similar results in Krishna Aruna Varna because Vamana Karma eliminated the vitiated Pitta along with the Kapha, thereafter formation of Prashasta (proper) Rasa Dhatus took place, which might have reduced Krishna Aruna Varna. Both the groups showed no relief in Asvedanam and Mahavastu, because these features were indicative of a longstanding nature, severe pathology, and deeply involved the Dhatus. Only Vamana Karma or any other Shodhana (cleansing) might not be capable of relieving it, without the administration of Shamana drugs, for longer duration.
Effect of therapy after complete Treatment (Vamana followed by Shamana) on chief symptoms
After complete treatment, both the groups showed almost similar effect on Asvedanam, Mahavastu, Matsyashakalopam, Krishna Aruna Varna, Kandu, and Rukshata. Ekakushtha is Kapha Vata Pradhana Kushtha and its line of treatment is 'Vamanam Shlaeshmottareshu Kushtheshu'[9] (emesis is best for Kapha-dominant skin diseases). Therefore, first Vamana Karma should be done to elinimate the vitiated Kapha Dosha along with Pitta. For the Vata Dosha, Sneha is indicated as 'Vatottareshu Sharpi' (Ghee is best for Vata-dominant skin diseases) and after Vamana, Snehapana is also indicated in Kushtha as 'Snehasya Panam Ishtam Shuddhe Koshthe' (internal oleation after cleansing). [10] In this study after Vamana Karma, Panchatikta Ghrita was given as Shamana Sneha, which settled the Vata, residual Pitta, and also purified the Rasa and Rakta, by its Tikta Rasa (bitter taste) and Kushthaghna property. Thus, after complete treatment, both the groups showed nearly similar results.
| Conclusion | | |
Ekakushtha is quite similar to psoriasis due to its maximum similarity in chief signs and symptoms.
Beeja is a useful part of Krutavedhana and in powder form; its dose is 5 to 7 g for Vamana Karma.
Krutavedhana has produced a good number of Vega, Pittanta Lakshana, and Pravara Shuddhi in a majority of patients.
Madanaphala is the best among all Vamaka drugs, but Krutavedhana shows a similar to higher effect on Vamana Karma, in terms of Antiki, Maniki, Vaigiki, and Laingiki Shuddhi.
Vamana Karma by Krutavedhana showed better relief in Matsyashakalopam, Kandu, and Rukshata, while Madanphala showed better relief in Krishn Aruna Varna.
After completion of treatment, both the groups showed almost similar effect on Asvedanam, Matsyashakalopam, Kandu, Rukshata, Krishnaruna Varna, and Mahavastu.
Krutavedhana may be taken as one of the best Vamaka Dravya for Vamana Karma in Ekakushtha.
| References | | |
| 1. | Agnivesha, Charaka Samhita. Sutra Sthana 25/40. Chakrapanidatta, Ed. Vaidya Jadavaji Trikamaji Acharya. Varanasi: Chaukhambha Prakashana; Reprint 2007. p. 132. 
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| 2. | Ibidem Sutra Sthana 4/4, p. 30.
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| 3. | Ibidem Kalpa Sthana 6/4, p. 661.
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| 4. | Ibidem Sutra Sthana 26/83, p. 149.
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| 5. | Pavithran K. API Text Book of Medicine. Editor Shah SN, Valia RG 7 th ed. Mumbai: Published by Association of Physicians of India, 2006 p. 1326.
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| 6. | Agnivesha, Charaka Samhita. Siddhi Sthana 1/15. Chakrapanidatta, Ed. Vaidya Jadavaji Trikamaji Acharya. Varanasi: Chaukhambha Prakashana; Reprint 2007. p. 680.
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| 7. | Ibidem Nidana Sthana 5/7, p. 218.
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| 8. | Ibidem Kalpa Sthana 6/4, p. 661.
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| 9. | Ibidem Chikitsa Sthana 7/39, p. 452.
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| 10. | Ibidem Chikitsa Sthana 7/42, p. 452.
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[Table 1], [Table 2], [Table 3], [Table 4]
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