E-ISSN:2456-3110

Review Article

Palliative Care

Journal of Ayurveda and Integrated Medical Sciences

2022 Volume 7 Number 8 September
Publisherwww.maharshicharaka.in

A review on Palliative Care in Pakshaghata

Janardhan Dhande V.1*, Rikibe P.2, Sane V.3
DOI:

1* Vaishnavi Janardhan Dhande, Post Graduate Scholar, Department of Panchakarma, PDEA’s College of Ayurved and Research Centre Akurdi, Pune, Maharashtra, India.

2 Pournima Rikibe, Associate Professor, Department of Panchakarma, PDEA’s College of Ayurved and Research Centre Akurdi, Pune, Maharashtra, India.

3 Varsha Sane, H.O.D., Department of Panchakarma, PDEA’s College of Ayurved and Research Centre Akurdi, Pune, Maharashtra, India.

Add life into days not just days into life, Ayurveda being the most renowned traditional systems of medicine that has survived and flourished from ages till date, guides how to live a healthy life and treat various medical conditions and can be apply on current healthcare issues. Non-communicable diseases (NCDs), also known as chronic diseases, Because of their long duration and slow progression. Pakshaghata means paralysis of one half of the body, here impairment of Karmendriyas, Gnyanendriyas and Manas occurs. Pakshaghata can be correlated with hemiplegia which results from cerebrovascular accident - stroke. Talking about paralyzed patients’ poor prognosis, unfruitful efforts, physical dependency, lost hope and mental instability results in worsening condition. Paralyzed patients get affected medically, mentally, morally and socially, to make their life better and convenient here we are trying to explore ayurveda’s intervention in improving palliative care practices of paralyzed patients. Care that is aimed at control of these symptoms, whether or not the patient is undergoing ongoing disease-directed therapy to control the Pakshaghata, is thus a key feature of high-quality patient-centered care. The treatment of Pakshaghata is time consuming and expensive too. In Ayurveda Pakshaghata treatment schedule adopted according to the Avastha. Hence there is need for Ayurvedic approach to manage the condition by re-establish the circulation and improves quality of life of patient.

Keywords: Non Communicable Diseases, Pakshaghata, Stroke, Palliative Care, Holistic Approach

Corresponding Author How to Cite this Article To Browse
Vaishnavi Janardhan Dhande, Post Graduate Scholar, Department of Panchakarma, PDEA’s College of Ayurved and Research Centre Akurdi, Pune, Maharashtra, India.
Email: 		Vaishnavi Janardhan Dhande, Pournima Rikibe, Varsha Sane, A review on Palliative Care in Pakshaghata. J Ayu Int Med Sci. 2022;7(8):60-66.
Available From
https://www.jaims.in/jaims/article/view/2027

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2022-08-01 2022-08-03 2022-08-10 2022-08-17 2022-08-24
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 16%

© 2022by Vaishnavi Janardhan Dhande, Pournima Rikibe, Varsha Saneand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Palliative care is a care beyond cure. According to WHO- Palliative care - is an approach that improves the quality of life of patients and their families facing the problem associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual.[1] Only less than 1% of its population is accessible to pain and palliative care.[2]

Non-communicable diseases (NCDs), also known as chronic diseases, are not passed from person to person. These are of long duration and slow progression. There are no limitations for age and religions to affect by NCDs. NCDs are often associated with older age groups, but evidence shows that 16 million of all deaths attributed to non-communicable diseases (NCDs) occur before the age of 70. Cardiovascular diseases (like heart attacks and stroke) are one of the major NCDs. Children, adults and the elderly are all vulnerable to the risk factors that contribute to non-communicable diseases. Its prevalence is about 9 cases/1000 in the global population.[3]

Patients with Pakshaghata often experience symptoms of disease and treatment that contribute to distress and diminish their quality of life. Care that is aimed at control of these symptoms, whether or not the patient is undergoing ongoing disease-directed therapy to control the Pakshaghata, is thus a key feature of high-quality patient-centered care. The initiation of palliative care and discussion of the patients’ goals and preferences earlier in the course of disease can lead to improved symptom control, reduced distress throughout the disease-directed therapy, and care delivery that matches the patients’ preferences.

Pakshaghata patients gets hampered physically and psychologically due to their disease and treatment. their families also suffer from great emotional distress during care giving. If early palliative care is given to such patients, it can control the disease, improve their quality of life and reduce the cost of care. Early palliative care access can also extend survival. holistic approach in palliative care caters to the physical, psychological, social and spiritual needs of the individual. “Maintain the health of a healthy individual by prevention

of disease and to cure the diseased ones.” Are what Ayurveda states as the objective? Ayurveda being the foremost life science describes ways to prevent and manage lifestyle disorders. It provides proper dietary management and lifestyle advices through Dinacharya (daily regimen), Ritucharya (seasonal regimen), Panchakarma (Bio-purification therapies), and Rasayana (rejuvenation) therapies. The Sadvritta (ideal routines) and Aachara Rasayana (code of conduct) are of utmost importance to maintain a healthy and happy socio-psychological wellbeing of a person. Pakshaghata means paralysis of one half of the body, here impairment of Karmendriyas, Gnyanendriyas and Manas occurs.[4]

Pakshaghata can be correlated with hemiplegia which results from cerebrovascular accident - stroke. Stroke is heterogeneous group of disorder. Lifestyle disorders are increasing day-by-day, and stroke is the one among them. It is the 3rd most cause of death and disability world-wide. The treatment of Pakshaghata is time consuming and expensive too. With advent of modern drugs, the treatment pattern of disease has grossly changed, where the drugs employed counteracts only symptoms temporarily and the underlying pathology goes on progressively to worsen the condition decreasing the quality of life of the patient. In Ayurveda Pakshaghata treatment schedule adopted according to the Avastha (condition of disease). Hence there is need for Ayurvedic approach to manage the condition by re-establish the circulation and improves quality of life of patient.

Pakshaghata

“Paksha” denotes either half of the body and “Aghata denotes paralysis.[5] Word Literally means “paralysis of one half of the body. Here impairment of Karmendriyas, Gnyanendriyas and Manas seen. Acharya Vagbhata states about Pakshaghata, when Vata getting aggravated, dries up the Srotas (macro and micro channels) and Snayu (tendons) of one side (half) of the body, makes the organ/ parts of that side incapable of functioning and loss of sensation.[6]

Hemiplegia

It is a condition of total or partial paralysis of one side of the body, with numbness in limbs, slurred speech, etc., Cerebrovascular accidents such as thromboembolism and hemorrhage of cerebral arteries considered to be the major cause for this condition.


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Nidana

According to a survey of Ayurvedic literature, no specific etiological cause for Pakshaghata has been identified. As a result, all elements that aggravate Vata Dosha in the body are the fundamental cause of Pakshaghata. In numerous Ayurvedic scriptures, causes are described for Vata diseases. Consumption of dietary goods that exacerbate the Vata Dosha is referred to as Aharajanya causes vitiating Vata Dosha. Behavioural elements that aggravate Vata Dosha are among the Viharajanya factors that vitiate Vata Dosha. Manasajanya elements that vitiate Vata Dosha include factors that impact the mind, such as Chinta, Shoka, Kama, Krodha, Bhaya, and others. Abhighata, Prapatan Marmaghata, and other Abhighataj elements vitiate Vata Dosha. Prapidan Vigraha Prahar Balvad Prahar Balvad Vigraha Other elements that vitiate Vata Dosha include seasonal variations, severe purificatory methods, and other causes that cause Vata Dosha aggrevation.[7],[8]

Poorvarupa: Vata Vyadhi's Poorvarupa can be compared to Pakshaghata's. Avyakta Lakshana is mentioned by Acharya Charaka as the Poorvarupa of any Vata Vyadhi.[9]

Rupa: Anyatara Paksha Chesta Nivritti, Anyatara Pakshahanan, Achetana, Akarmanyata, Hasta Pada Sankocha, Sira Snayu Vishosha, Vak Stambha, Ruja Toda, Shoola, Sandhibandha, Vimoksha, Daha, Santap, Moorcha Shaitya, Shopha, Gurutva.[10],[11],[12]

Upashaya: Nidana which contributes in Pakshaghata can be taken as Upashaya for it.

Samprapti: Vayu, as per Acharya Charaka, when it enters either the right or left side of the body, it dries up the Sira and Snayu of that region, causing loss of movement, constriction of the hand or leg, and Ruja and Vakstambha[13]

According to Sushrutacharya, exacerbated Vata passes through the Urdhvaga, Adhoga, and Tiryaka Dhamanis, weakening the Sandhi Bandha and resulting in Vaam or Dakshinpaksha Hanan. The patient's half of the body becomes inoperable, loses sensation, falls down, or dies.[14]

Vagbhatacharya has incorporated Charaka's and Sushrutacharya's Samprapti, and he claims that Vayu holds half of the body, dries up Sira and Snayu, loosens Sandhi Bandha, and kills either half of the body.[15]

Samprapti Ghatak

Doshas: Vata (All five types; Prana, Udana Vayu especially), Pitta (Pachak Pitta, Ranjak Pitta especially), Kapha (Shleshak and Avalambaka Kapha especially)

Dushyas: Rasa, Rakta, Mamsa, Meda Dhatu and Manas

Agni: Jatharaagni, Dhatvaagni

Ama: Dhatwaagni-Maandya-Janya

Strotasa: Rasavaha, Raktavaha, Mamsavaha, and Medavaha

Strotodushti: Atipravrutti, Sanga, Siraagranthi & Vimaarga Gamana

Udbhava Sthana: Pakwaashaya

Sanchara Sthana: Urdhwa, Adhah, Tiryak Dhamanis

Adhisthana: Shira

Rogamarga: Madhyam Roga Marga

Vyakti Sthana: Either Dakshin or Vama Paksha.[16]

Sadhya - Asadhyatva

It is essential to understand the curability of any disease before beginning treatment. Pakshaghata was categorised by Charakacharya as Kashtasadhya or Asadhya. Only Sadhya if the sickness has just started, there are no complications, and the patient is Balawana.[17]

According to Acharya Sushruta Pakshaghata generated by Shuddha Vata is classified as Kashtasadhya, Samsrushta Dosha Pitta or Kapha is classified as Sadhya, and Kshaya is classified as Asadhya.[18]

According to Acharya Vagbhat Pakshaghata caused by Shuddha Vata is Krichha Sadhyatama, Samsrushta Dosha causes Krichha Sadhya, and Kshaya causes Asadhya.[19]

"Saadhyam Anyen Samyuktam," says Acharya Maadhava, implying that Pakshaghata, along with other doshas, is easily curable.[20]

Palliative care in Pakshaghata patients

4 types of patients come in ayurveda OPD in terms of Pakshaghata are follow up cases, non-responsive cases, who got undesired effects and who wants solely Ayurveda treatment.


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Acharya Charaka has stated treatment principle of Pakshaghata as ‘Swedanam Snehasayuktam Pakshaghate Virechanam’. In Ayurveda text treatment of Pakshaghata is depend on principles of treatment of Vatavyadhi. In any Ayurveda treatment Nidan Parivarjanam plays very important role.[25]

Nidana Parivarjana (avoidance of etiological factors) - management of treatable risk factors and diseases like hypertension, acute encephalitis, heart disease etc. and avoidance trauma.

Samshodhan Chikitsa

Snehana - Snehana is performed in two ways: external and internal. Patient's Aam Awastha and Niram Awastha are first ruled out. Acharya Vagbhata and Charaka mentioned basic principle to treat Vatavyadhi, when Vatavyadhi is caused by alone Vatadosha, and patient is in Nirupstambhit Awastha then patient should be administered with Snehapan (Ghrita, Vasa, Taila, Majja) food mixed with Sneha, Anuvasan Basti after that Abhyanga. Dashmuladi Ghruta, Chitrakadi Ghruta, Baladi Ghruta, Nirgundi Taila, Karpas Taila, Rasna Taila, Ashwagandha Taila, Prasarani Taila, Bala Taila, Atibala Taila.[21],[22]

Sushruta has specially mentioned Anu Taila for Abhyanga.[23]

In Upastambhit Awastha after correct Deepan, Pachan, and Rookshan, internal administration of Sneha (Taila/Ghrita) should be performed.

Swedana - patients who are now well administered with Sneha should be opt for Swedan.

Swedan should be Snehayukta. Mustadi Upanaha, Utkarikadi Upanaha, Awagaha and Parisechan with Vatahar Dravyasiddha Kwath, Dugdha, or Taila. Nadi Sweda, Pradeha or Upanaha of Til, Atasi, Sarshapa mixed with Kanji, Gandhadravya Lepa, Shali Shashtik Pinda Sweda, Shalwan Upanaha in Upastambhit Awastha has been mentioned by Acharya Sushruta, again Acharya Sushruta has given Swedana for rigid or contracted body part is Bandhana with silk, cotton or woollen cloth or Salwan Upanaha.[21],[22]

Virechana - If due to Maladosha, Snehan Swedan is unable to eradicate Vatadosha then for Vatanuloman one should go for Snehayukta Mridu Virechan for that one can give Eranda Tail mixed with milk, Tilvaka Siddha Ghutra, Saptala Siddha Ghruta, Gandharvahastyadi Taila.[24],[25],[26]

Basti - Patients who cannot be treated with Virechana procedure, Niruha Basti prepared with Dipan Pachan Dravya is an option. Sushruta has specially mentioned Bala Taila Anuvasan Basti for Pakshaghata patients. Various types of Yapan Basti mentioned in Charak Siddhisthana can be given for enhance the Bala and Dhatu of the patient. In Amavastha Lekhana Basti Choorna Basti can be given.[27]

Nasya - Navan Nasya - with Ksheerbala and Bramhi Taila, Dhooma Nasya - with Ksheera, and Bala Churna, Pratimarsha Nasya with Dhanwantar 101 Taila, Anu Taila, Avapida Nasya with Bramhi Swaras, Dhoompan is with Vacha Choorna and Pippali Choorna. When patient approaches in unconscious state Pradhaman Nasya with Vacha, Pippali, Vidanga, Apamarga churna can be administer. According to doshavastha in morning - Pardhman Nasya with Brahmi Churna + Vacha Churna is indicated as Kapha predominancy is there. In evening - Pratimarsha Nasya with Brahmi Ghrita is indicated as Pitta is predominant at evening time.[23]

Shirovasti - Shirodhara, Shiropichu, Shirobasti, Shiroahyanga are very important part of Panchakarma Chikitsa in Pakshaghata as it relieves stress. with medicated oils such as Baladhatryadi Taila, Mansi Taila, Narayana Taila / Ksheera Bala Taila / Chandana Bala Lakshadi Taila.[23]

Shodhan Chikitsa in Pakshaghata

Awastha Nirupstambhit Upastambhit
Snehapan Ghrita, Taila, Vasa, Majja. (Taila best as Vataghna) Contraindicated
Snehan Anu Taila, Baladi Taila, Chitrakadi Taila, Dashmuladi Taila, Karpasasthyadi Taila If needed then only by Ushna, Tikshna Dravya. If pain persist then with Vishgarbha Taila, Sarshap Taila, Brihat Saindhavadi Taila
Swedan Snigdha Sweda, Upanaha, Nadi Sweda, Sankar Sweda, Prastar Sweda Ex- Shashti Shali Pinda Sweda Ruksha Sweda, Patrapinda Sweda, Churnapinda Sweda
Virechan Snehayukta Mrudu Virechan Eranda Tail with Milk, Tilwaksiddha Ghruta, Gandharwa Hastyadi Erand Taila. Mridu Virechan, Anuloman
Basti Anuvasan Basti with Bala Taila, Narayan Taila, Balya Dravya Asthapan Basti with Ruksha Dravya, Lekhan Basti, Churna Basti.

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Shaman Aushadhi

Internal medicines should be given after assessment of Upastambhit or Nurupstambhit Awastha.[28]

Awastha Nirupstambhit (Dhatukshay) Upastambhit (Margawrodhjanya)
Treatment Dhatuvruddhikar Margawrodhjanya
Aushadh Shatavari Kalpa, Kushmandawaleha, Kushmandpak, Mahayograj Guggul, Hemgarbha, Vasantkusumakar Guggul Kalpa, Yograj Guggul, Kaishor Guggul, Amruta, Rasna, Sinhanad, Rasnadi, Maharasnadi, Ekangaveer, Aampachak Vati, Vaatvidhwansab Ras
Rasa Madhur, Amla, Lawan Katu, Tikta
Vipak Madhur Katu
Virya Shita Ushna
Dravya Guru And Balya Laghu, Strotoshodhi, Dipaniya, Pachaniya, Ruksha, Anabhishyandi
Anupan Dugdha, Ghruta, Sharkara Madhu, Ushnodak
Aahar Snigdha, Dugdha, Manmsa, Madhur, Amla Rasatmak Laghu, Drava, Ushna, Dipan Pachan Dravyasiddha, Lashuna, Ardrak, Hingu Siddha Yusha, Kulattha Yusha

Yoga: Practice of Pranayama (Anuloma Viloma, Nadi shodhana, Bhramari and meditation along with the practice of Yama and Niyama. Yoga Nidra, Breath awareness (BAW) and relaxation techniques viz. Instant relaxation technique (IRT), quick relaxation technique (QRT), deep relaxation technique (DRT) and cyclic meditation (CM). Kriyas: Kunjal, Kapalbhati. Selected Asanas: Surya Namaskar, Tadasana, Katichakrasana, Konasana, Pavanmuktasana, Bhujangasana, Uttanpadasana (Ekpad), Vakrasana, Makarasana, Ardhshalabhasana, Shavasana Pranayama: Nadishodhana, Suryabhedi, Bhastrika.

Ahara: Just like medicines diet also plays an important role in management of any disease condition. Acharyas has mentioned diet for Vatavyadhi are meat soup, pulses soup, milk, Madhur, Amla, Lawan Rasayukta Ahar, Ghruta, sweet citrous fruits.[29]

Counselling: During counselling advice the patient to. Be active and optimum use of affected part. Exercise regularly to affected part. Continue exercises as suggested by the physiotherapist. To increase the practice of exercise gradually. Take balanced diet. Maintain healthy body weight. Limit salt intake and fat in diet. Control of hypertension and diabetes mellitus. Check lipid profile periodically. Avoid over exertion. Avoid smoking and alcohol consumption.

Discussion

With Panchakarma we may cure completely or make patient self-abled. Before starting proper Shodhana, Rookshana should be done upto Nirama Avastha.

After this we will go for Snehana and Swedana according to condition of patient. Then proper Shodhana by Virechana, Basti and Nasya. Nasya and Basti should not be administered at same time.

Nasya, Shamana Aushadhi, other therapies and Pathya Apathya should be followed continuously after Samsarjana Karma. Repeated Shodhana is mandatory in Pakshaghata patient. As well as counselling is important for patients’ wellbeing.

Conclusion

From above line of treatment stated in Ayurveda we can attain optimum wellbeing of Pakshaghata patient that will make patient self-abled and thus patient himself and family will be mentally sound and thus will achieve good palliative care.

Reference

1. World health organization; palliative care; 2021 [cited 2022 march 15] Available from:https://www.who.int/news-room/fact-sheets/detail/palliative-care

2. Dr. MR. Rajgopal, director, WHO collaborating centre for policy and training on access to pain relief and founder- chairman, pallium -The current status of palliative care in India. [cited 2022 march 15] Available from-https://www.theatlantic.com/health/archive/2017/02/india-palliative-care/517995/

3. Global Health Estimates. Geneva: World Health Organization; 2012. [cited 2022 april 24] Available from: http://www.who.int/healthinfo/global_burden

4. Charak Samhita of Agnivesa; by Acharya Vidyadhar Shukla and R. Tripathi; Chaukhamba Sanskrit Pratishthan; reprint 2017; Chikitsa Sthana 28/55; Pg No 697.

5. Dr.Nimmi M. Menon, Dr. Manjunath Adiga, Ayurvedic management of Pakshaghata with special reference to hemiplegia in terms of CVA of thrombotic origin- A single case report, wjpls,2022, vol 8, Issue 8, 187-198.


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6. Dr. Bramhanand Tripathi, Ashtang hridayam of Shrimad Vagbhata, Choukhamba Sanskrit Pratisthan; Reprint 2015, Nidan Sthana 15/38-39; Pg No 542.

7. Acharya Vidyadhar Shukla and R. Tripathi, Charak Samhita of Agnivesa, Chaukhamba Sanskrit Pratishthan, reprint 2017, Chikitsa Sthana 28/15-18; Pg No 690.

8. Dr. Anant Ram Sharma, Sushrut Samhita of Maharshi Sushruta, Choukhamba Surbharati Prakashan; reprint 2015, volume I, Nidan Sthana 1/60-62, Pg No 465.

9. Acharya Vidyadhar Shukla and R. Tripathi, Charak Samhita of Agnivesa, Chaukhamba Sanskrit Pratishthan, reprint 2017, Chikitsa Sthana 28/19-18, Pg No 690.

10. Acharya Vidyadhar Shukla and R. Tripathi, Charak Samhita of Agnivesa, Chaukhamba Sanskrit Pratishthan, reprint 2017, Chikitsa Sthana 28/53-55, Pg No 697.

11. Dr. Anant Ram Sharma, Sushrut Samhita of Maharshi Sushruta, Choukhamba Surbharati Prakasha, reprint 2015, volume 1, Nidan Sthana 1/62, Pg No 465.

12. Dr. Bramhanand Tripathi, Ashtang Hridayam of Shrimad Vagbhata, Choukhamba Sanskrit Pratisthan, Reprint 2015, Nidan Sthana 15/38, Pg No 542.

13. Acharya Vidyadhar Shukla and R. Tripathi, Charak Samhita of Agnivesa, Chaukhamba Sanskrit Pratishthan, reprint 2017, Chikitsa Sthana 28/53-55,Pg No 697.

14. Dr. Anant Ram Sharma. Sushrut Samhita of maharshi sushruta, choukhamba surbharati prakashan, reprint 2015, volume 1, nidan sthana 1/60-62, Pg No 465.

15. Dr. Bramhanand Tripathi, Ashtang Hridayam of Shrimad Vagbhata, Choukhamba Sanskrit pratisthan, Reprint 2015, Nidan Sthana 15/38, Pg No 542.

16. Vd.Y.G.Joshi, Textbook of Kayachikitsa, PSV Publications, Reprint 2016, Vatavyadhi chapter, Pg No 259.

17. Acharya Vidyadhar Shukla and R. Tripathi, Charak Samhita of Agnivesa, Chaukhamba Sanskrit Pratishthan, reprint 2017, Chikitsa Sthana 28/235,Pg No 722.

18. Dr. Anant Ram Sharma, Sushrut Samhita of Maharshi Sushruta, Choukhamba Surbharati Prakashan, reprint 2015, volume 1, Nidan Sthana 1/63, Pg No 466.

19. Dr. Bramhanand Tripathi, Ashtang Hridayam of Shrimad Vagbhata, Choukhamba Sanskrit Pratisthan, Reprint 2015, Nidan Sthana 15/41, Pg No 542.

20. Bramashankar S, Madhav Nidan, Madhukosha Vyakhya, Chaukhambha Publication, Varanasi, reprint 2012, volume 1, Vatavyadhi Nidan, Sloka no. 43, Pg No. 163.

21. Acharya Vidyadhar Shukla and R. Tripathi, Charak Samhita of Agnivesa, Chaukhamba Sanskrit Pratishthan, reprint 2017, Chikitsa Sthana 28/75-77, Pg No 70.

22. Dr. Bramhanand Tripathi, Ashtang Hridayam of Shrimad Vagbhata, Choukhamba Sanskrit Pratisthan, Reprint 2015, Chikitsa Sthana 21/1-3, Pg No 803.

23. Dr. Anant Ram Sharma, Sushrut Samhita of Maharshi Sushruta, Choukhamba Surbharati Prakashan, reprint 2015, volume 1, Chikitsa Sthana 4/19, Pg No 218.

24. Acharya Vidyadhar Shukla and R. Tripathi, Charak Samhita of Agnivesa, Chaukhamba Sanskrit pratishthan, reprint 2017, Chikitsa Sthana 28/83,Pg No 702.

25. Acharya Vidyadhar Shukla and R. Tripathi, Charak Samhita of Agnivesa, Chaukhamba Sanskrit pratishthan, reprint 2017, Chikitsa Sthana 28/100, Pg No 75.

26. Dr. Bramhanand Tripathi, Ashtang hridayam of Shrimad Vagbhata, Choukhamba Sanskrit Pratisthan, Reprint 2015, chikitsa sthana 21/44,Pg No 809.

27. Acharya Vidyadhar Shukla and R. Tripathi, Charak Samhita of Agnivesa, Chaukhamba Sanskrit pratishthan, reprint 2017, Chikitsa Sthana 28/86, Pg No 703.

28. Vd.Y.G.Joshi, Textbook of Kayachikitsa, PSV Publications, Reprint 2016, Vatavyadhi chapter, Pg No 260.

29. Dr. Anant ram sharma, Sushrut Samhita of Maharshi Sushruta, Choukhamba Surbharati Prakashan, reprint 2015, volume 1, Chikitsa Sthana 4/13, Pg No 206.


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