Dr.Vilas Nanal
AVP
The disease Pakshaaghaata is a common entity that an Ayurvedic physician is called upon to manage. He encounters this disease in all its three stages viz. the acute, sub acute and chronic. As all of you have some knowledge of Ayurveda, I shall confine myself to a brief theoretical aspect and then shall present a few cases managed by me.
Charaka while describing the Sampraapti of Pakshaaghaata makes a mention of Siraa and Snaayu involvement by the vitiated Dosha_s
According to Sus`hruta these are derived from the Naabhi originally in the intra uterine period. Originating from their traverse the whole body and provide nourishment and help drain the waste products. Rakta and Meda Dhaatu_s are the source from which they are formed. He also attributes very important functions to them in the smooth working of the body mechanism. E.g. they are the carriers of Vaata, Pitta, Kapha and Rakta in the body. He classifies them into four main categories
- Vaatavaha Siraa
- Pittavaha Siraa
- Kaphavaha Siraa and
- Raktavaha Siraa
Each of these performs a set of important functions. They are as under: –
Vaatavaha Siraa: Are responsible for the co-coordinated voluntary activities of the body, they are responsible for cognition, analysis of the situation and effective execution of the decision taken by the higher centers. Thus transportationof all the incident stimuli to appropriate destination is the function of Vaatavaha Siraa in the body. Hence when they are affected by the vitiated Vaayu the result is Vaata disease characterized by dysfunction, abnormal movements, paralysis, sensory motor afflictions, loss of control over bowel/bladder etc.
Pittavaha Siraa: These are responsible for maintaining body temperature, skin color and complexion, proper functioning of Agni and a state of general well being. Therefore when the vitiated Pitta harbors in them various Pitta predominant disorders result e.g. burning, discoloration, tingling and numbness, sweating, confusion etc.
Kaphavaha Siraa: They are responsible for unctuousness, lubrication, and stability to body constituents and joints during movement, power and zeal. Therefore when vitiated Kapha affects these, the result is occlusion of the vessels, heaviness, loss of power, inertial, lethargy, paleness etc.
Raktavaha Siraa: They are responsible for the fluid level of the tissues, skin color, and definite cognition of the tactile stimulus. Hence when the vitiated Rakta affects them they result in laxity of vessels, discoloration, ulcers, Parasthesia, loss of touch etc.
From the foregoing discussion the role of Siraa_s in the pathogenesis and management should be clear. This is the unique contribution of Ayurveda to the understanding of Pakshavadha.
Snaayu the second constituent of the Sampraapti of Pakshavadha is best described as ligaments and tendons. They perform the function of binding, holding together two parts. Thus imparting stability and power to movement is their prime function. Some authors have equated the peripheral nerves to the Snaayu_s. the Rakta and Meda as mentioned earlier like the Siraa_s form this. But the difference is in the degree of Kharataa. As Meda is a Sneha it cannot be completely dried out hence when the Agni and Vaayu interact with Meda and Rakta the result is a tough, tenacious structure that can withstand a large amount of push and pull and still remain intact. The peripheral nerves are also tough and are made of nerve fibers. They can if needed perform the binding of parts that they traverse. The ensuing laxity of the rotator cuff and the shoulder joint capsule results in Subluxationof the affected shoulder joint in a chronic Hemiplegicperson. This condition seriously hampers the chances of recovery of upper extremity and especially the hand function. The vital role of अभ्यंग in the management of Pakshavadha is a common experience.
Sus`hruta classifies the Snaayu_s into four broad categories and describes their anatomical locations.
- Prattanavat Snaayu
- Vritta Snaayu
- Pruthu Snaayu and Shus`hira Snaayu
Each performs some important functions. They are as under:-
Pratanavat Snaayu: These are situated mainly in the extremities. Their function is to provide attachments to various muscles and help them in voluntary movements, to provide stability to the limb during various states.
Vritta Snaayu: Is rounded tendons and ligaments. They are found in the back. They act as an anchor to the various postural muscles of the back Viz. Erector Spinaegroup of muscles.
Prithu Snaayu: These are the flat tendons and ligaments. They are found in the region of the knee, elbow and the wrists. They have a short span and are mainly useful in imparting stability to the joint they cross.
Sushira Snaayu: these are the sphincters situated in the stomach, rectum and the urinary bladder. Their function is to hold the contents of the respective organ till the process is complete by remaining closed during the process. At the end of the process they open and facilitate the passage of the contents in a controlled manner.
Sus`hruta lays great emphasis on the proper knowledge of Snaayu_s. Since these last play an important role in the management of Pakshavadha. In the later stage of Pakshavadha the sub-Luxationof the shoulder joint occurs as a result of the laxity of the Snaayu_s there. When this takes place it results in a hampered hand function, immobility of the fingers. Hence it is a vital that in the initial stage only a triangular sheath is given to the patient with a round, firm support in the armpit, taking care to include the elbow in the sling. Tightness of the Snaayu_s at the hip and the knee result in the typical Hemiplegicgait i.e. walking with Circumductionof the lower extremity.
It is commonly believed that the brain does not have a significant role to play in the Sampraapti of Pakshavadha. It is not true, as Charaka has clearly stated that the S`hiromarma harbors a specialized form of Majjaacalled Mastulunga. This Mahaa Sneha is the final abode of the various Indriya_s and their Praan`a_s. the Tarpaka Kapha also resides there to nourish the Indriya_s. similarly to this effect Bhela Samhitaa has made some interesting observations in the Chikitsaa Sthaana and Sutra Sthaana too. He clearly states the diseases arising out of the vitiation of Asthi and Majjaa Dhaatu_s include Pakshagraha along with Apasmara (convulsive disorder), उन्माद (affective disorder), Bhanga (pain characterized by breaking), Kampana (tremors), Gaatra Shosha (wasting, atrophy of organs), Ardita (facial palsy), Kun`i (flexion Contracture at elbow), Kubja (Potts spine or Kyphosis due to collapsed vertebral bodies), Hanugraha (Temporo-Mandibular Subluxation), Paangulya (Paraplegia), Sandhi–Vichyuti (dislocations at various joints) and other Vaata Roga_s. even a casual look at the list would be sufficient to explain the meaning of the author. All these conditions are a result of the central nervous system disorder either traumatic or due to intrinsic factors. Similarly Charaka also enumerates a list of conditions as a result of the S`hiro Mahaa Marma that clearly throws light on the connection between the Mastulunga and the well being of the body-Indriya and mind complex. They are as follows: – Manyaa Stambha, Ardita, Chakshu Vibhrama, Moha, Udvesht`ana, कास, श्वास, Chesht`a Naas`ha Hanu Graha, Mookataa, Gadgada Vak, Akshi Nimeelana, Gan`d`a Spandana, Jrimbhaa, Laalaa Sraava, Svarahaani, Vadana Jihmatva along with others. In another place while describing the Shiro Roga due to vitiated Vaata, he enumerates a list of symptoms that clearly spell the CNS relation.
Marma_s also have a critical role in the manifestation of Pakshavadha too. Injury to the Marma_s like Lohitaaksha, Kakshadhara directly results in Pakshavadha.
Clinical Picture of Pakshavadha
Acute stage: Is characterized by complete Akarman`ya i.e. Paralysis, which is flaccid in nature, loss of speech with or without drooping, loss of bowel, bladder control, and facial distortion.
Sub acute stage: Flaccidity replaced by mild Spasticity, slurred speech, partial movements but un-coordinated in nature, some control over bowel and bladder.
Chronic stage: Exhibit the following shoulder subluxation, flexion at the elbow, Pronatedforearm, wrist and fingers in flexion, mild swelling over the fingers, slurred but coherent speech, extension of the lower extremity resulting in apparent lengthening, this gives rise to the typical Hemiplegic Circumductorygait, fully developed Spasticityand the movements of the upper extremity in either flexion or extension synergy pattern.
Charaka gives a more or less similar account of the condition, which is as under:
Involvement of either the right or the left half of the body, with or without half of the face; distortion of the nose, eyebrows, cheeks, skin folds, of the forehead, mouth which result in difficulty in chewing and swallowing. The eyes do not move in tune with speech. Choking of the nose resulting in arrested sneezing difficulties in speech like slowness, slurring, incoherent, weakness, and stuttering etc. looseness of teeth and inability to chew as well as partial to complete loss of hearing, hoarseness of voice. Pain in various parts like feet, hands, head, shins, ears etc.
In the later stage due to the affliction of the Siraa, Snaayu, Kan`d`araa and मर्म_s the involved parts become S`hushka i.e. dried out and wasted. This result in contracturesof the extremities, stiffness at the joints, pain on attempted movement fixed facial expression like a grimace.
Due to involvement of the Rakta and Meda Dhaatu_s and there by products like Siraa, Kan`d`araa, Snaayu and above all Majjaa and Marma_sthe role of Snehana is very important. This is a fact, which every Ayurvedic physician knows only too well.
The stage wise line of management that is followed by us is described below:
If the person is present in the evolving state, the procedure routinely done is Rakta Mokshan`a i.e. blood letting by Venepuncture. The amount varies with the age and (Bala) strength of the patient but it is not less than 50 ml at a time. This immediately helps change the Dosha Gati and arrests the progress of the Vega further. The rationale for this is: – the vitiated disease creating Dosha_s circulate in the body through the medium of Rasa Rakta complex. When this contaminated complex is let out the stimulus results in alteration of the Dosha Gati and Sampraapti Bala is reduced considerably. This has shown considerable and consistent results in all of the cases treated so far. Age or gender was no bar for the treatment.
In case the patient is Krisha or Apatarpita / Lean or emaciated we use:-
Mahaa Yogaraaja Guggulu 500 mg and Raupya Taapyaadi Loha 250 mg in Praan`a and Vyaana Kaala twice a day along with freshly prepared Balaamoola and Maasha Kvaatha 60 ml
In Udaana Kaala Eran`d`a Sneha 20 mlsis given with Vishvaa and Shatapushpaa Kvaatha 60 ml.
For अभ्यंग and नस्य Dhaanvantara Taila
In the sub acute stage after about ten days Basti is commenced.
Eran`d`a Moola and Das`ha Moola Nirooha Basti alternating with Balaa Taila Anuvaasana are given. The course is selected after evaluating the person.
Care in the acute stage is taken to prevent (Amsa Sransa) or shoulder Subluxationfrom taking place. A triangular sling does this with a support to the armpit and the elbow is included in the sling. This way the arm is supported adequately and the wrist is spared from supporting the dead weight of the arm.
In the chronic stage when the Stambha is marked and the effective movements are severely restricted, use of Lavan`a Sneha is important. Hence Mahaa Maasha Saindhava Taila is used. Similarly Lavan`a Po`t`alee Sveda is done after the अभ्यंग. The Anuvaasana Basti is alternated with Yaapana Basti prepared from Balaa or Yashtimadhu and all the Sneha substances like ghee, Tila Taila, Madhu, Guda and Saindhava in a Ksheera Paaka base is administered.
In cases characterized by भ्रम and S`hira S`hoola a Lepa of Arjuna and Aamalakee Kalka was applied to the Head in the afternoon (Pitta Kala) this immediately reduces भ्रम and Shira Shoola.
In the long standing or Chirottha cases we administer various Yaapana Basti_s. Most commonly used is the Vrishya Yaapana consisting of: –
In males, Balaa, Atibalaa, Apaamaarga Beeja, Yava, Yasht`imadhu Ksheerapaaka with Ghrita, Taila, Madhu, Gud`a (Jaggery) and Saindhava as Prakshepa. In case of female patients first Balaadi Yaapana of Charaka Siddhi 9 is given in the head lowered position. The time of administration is in the evening immediately after some food. We encourage retention of the Basti Dravya for as long a time as possible. The Yaapana Basti alternates with Anuvaasan Basti of Shuddha Balaa Taila and Saindhava.
In Santarpita or Sthoola patients i.e. well-built or obese persons we use Ekaangaveer Rasa. The Sampraapti in these people is more of Srotorodha Pradhaana or more occluding in nature, along with Yogaraaja Guggulu. The reason is the contents of Ekaangaveera are mostly Malla derivatives. It is very powerful and Aama Paachana and Vaata S`haamaka in nature. It improves the formation of Rasa by causing Aama Paachana. This is combined with fresh Mahaa Raasnaadi Kvaatha 60 ml as Anupaana
The Nirooha Basti is of Dashamoola and Madana Phala Kvaatha, alternating with Sahachara Taila Anuvaasana.
For अभ्यंग and नस्य, Sahacharaadi Taila is used. For Svedana Nirgun`d`ipatra, Baashpa Sveda is given.
In the chronic stages, when the Stambha is marked Lavan`a and Nirgun`d`ipatra Pot`t`alee Sveda is administered.
In case of S`hira S`hoola, a Lepa of Dhanvayaasa is applied to the Lalaat`a / forehead.
In case of Gadgad Vaak Jihvaa Pratisaaran`a by Haridraa and Akaarakarabha (Akkalakaara) is followed by Tila Taila Gan`doosha are advised. In case the person is Balavaana and the disease is not responding to the conventional treatment, Rakta Moksha is done from the Siraa in the sub Mandibularregion. This gives a very satisfactory result.
As an adjuvant to the चिकित्सा a Sramsana or Anulomana is always prescribed at bedtime.
I have tried to put before you the prevalent practice of management of Pakshavadha at our hospital in Pune. I have tried to restrict myself to the practical and applied aspect of the condition and not indulged in the textual aspects only. (I do hope that, I have been able to evoke a thought process in the minds of the various students and practitioners from the audience)
Dr.Vilas Nanal
Sr. Scientist AyuSoft. Pune
Last updated on February 18th, 2021 at 11:36 am