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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 33-39

Management of multiple sclerosis through Ayurveda: A case report


1 Department of Kaya Chikitsa, Raj Shree Ayurvedic Medical College and Hospital, Bareilly, Uttar Pradesh, India
2 Department of Panchakarma, All India Institute of Ayurveda, New Delhi, India
3 Department of Kaya Chikitsa, All India Institute of Ayurveda, New Delhi, India

Date of Submission25-Aug-2021
Date of Acceptance30-Nov-2021
Date of Web Publication20-Apr-2022

Correspondence Address:
Dr. Soniya Gupta
Department of Kaya Chikitsa, Raj Shree Ayurvedic Medical College and Hospital, Bareilly - 243 501, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacr.jacr_64_20

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  Abstract 


Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system). In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problem between brain and rest of the body. Steroids are the drugs of choice in conventional systems but fail to provide a complete cure. There is no direct reference to the disease in Ayurveda, but based on the clinical picture, treatment can be planned. A 28-year-old male patient diagnosed with MS approached the Panchakarma outpatient department with chief complaints of difficulty in balancing while standing and walking, weakness in bilateral lower limbs, and lower backache. On examination of presentation according to Ayurveda, this manifestation was diagnosed as a type of Vata vyadhi (~diseases caused by a Vata dosha). Considering the case, different Panchakarma (~five bio-purification therapies) procedures including Ruksha churna pinda swedana (~dry fomentation), Takradhara (~therapeutic buttermilk dripping), Kshara basti (~therapeutic enema therapy by alkali substance), Snehapana (~internal administration of medicated lipids), and Virechana (~therapeutic purgation) followed by Kalabasti (~therapeutic enema therapy) and Nasya (~intranasal drug administration) were adopted along with Shamana (~palliative) therapy. After completion of 45-day stay in hospital and one month Shamana treatment on follow-up, considerable improvement was recorded in subjective parameters. Assessments were made using the Kurtzke Expanded Disability Status Scale which was 8 before treatment and decreased to three after follow-up. The Functional Assessment of MS was reduced from 158 to 102. The Visual Analog Scale which was 8 before treatment was decreased to 1 with increased quality of life according to the SF-36 Quality of Life Scale.

Keywords: Kalabasti, Kshara basti, multiple sclerosis, Nasya, Pinda swedana, Virechana


How to cite this article:
Gupta S, Kundra L, Yadava RK, Dharmarajan P. Management of multiple sclerosis through Ayurveda: A case report. J Ayurveda Case Rep 2022;5:33-9

How to cite this URL:
Gupta S, Kundra L, Yadava RK, Dharmarajan P. Management of multiple sclerosis through Ayurveda: A case report. J Ayurveda Case Rep [serial online] 2022 [cited 2022 May 28];5:33-9. Available from: http://www.ayucare.org/text.asp?2022/5/1/33/343508




  Introduction Top


Multiple sclerosis (MS) is an inflammatory disease in which fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms. Myelin is a protecting and insulating sheath covering the nerves. MS is a prototypic autoimmune disease of the Central Nervous System (CNS).[1] The lesions of MS typically arise within the optic nerves, spinal cord, brain stem, and the periventricular white matter of the cerebral hemispheres. Research suggests that the proportion of women with MS is increasing and that roughly between two or three women have MS for every man with the condition.[2] MS affects the ability of nerve cells in the brain and spinal cord to communicate with each other. MS is a gradual process, which goes on for weeks, months, and years. The cause remains unknown to modern science. Theories include autoimmune, genetic, infections, and environmental factors. Symptoms presented in the current case who was already diagnosed as MS could be correlated with Vata vyadhi in Ayurveda. The Ayurvedic point of view that Ama (~metabolic toxin) is the main causal factor behind autoimmune disorders cannot be ignored. Considering the involvement of Vata dosha associated with Ama in the present case, the treatment protocol was planned along with Shamana aushadha.


  Patient Information Top


A 28-year-old male, non-diabetic, normotensive patient, student by profession presented to the Panchakarma outpatient department with the complaints of difficulty in balance for standing and walking, weakness in bilateral lower limbs, and continuous lower backache for the last three years.


  Clinical Findings Top


Initial history revealed that the patient was asymptomatic before three years. He gradually developed difficulty in walking. For the same complaints, the patient visited to modern hospital, where he was advised an magnetic resonance imaging of the brain, which revealed that multiple small discrete lesions involving the frontoparietal periventricular as well as some part of subcortical white matter lying perpendicular to the surface of lateral ventricles with involvement of callososeptal interface and corpus callosum with the largest lesion in the left basal ganglia region with no active lesion in the present scan and as a case of MS. He was under conventional medical supervision with methylprednisolone 32 mg twice a day for about 2½ years. On general examination, he was hemodynamically stable (pulse rate = 76/min regular with normal volume and blood pressure – 110/80 mmHg in sitting position). There was no such related family history. Pain was dull in nature, aggravating on walking and long standing, changing posture while lying, with climatic and diurnal variations (increased in cold climate and nighttime), and on eating Amla dravya (~sour substances). There was no history of stiffness. Pain worsened on prolonged lying in the supine position during the night. Pain was relieved after some physical activities. CNS examination showed memory, higher psychic functions; cranial nerves were intact, and motor examination was done (bilateral lower leg) [Table 1].
Table 1: Motor examination (bilateral lower limb)

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  Diagnostic Focus and Assessment Top


The Kurtzke Expanded Disability Status Scale (EDSS)[3] was 8, the Functional Assessment of MS (FAMS)[4] was 158, and pain on the Visual Analog Scale (VAS)[5] was scored up to 8. Quality of life was assessed by the SF-36 Scale. Based on the symptoms, he was diagnosed as Avaranajanya dhatukshaya vatavyadhi. Hence, here the Vata vyadhi treatment principles were adopted. Initially, Ama pachana (~digestion of metabolic toxin) as Avarana chikitsa was done to remove Ama or Avarana, and then, Shodhana (~therapeutic purification) was done followed by Brimhana karma (~therapeutic strengthening). Shamana chikitsa also planned according to Doshavastha (~state of Dosha).


  Therapeutic Focus and Assessment Top


After obtaining written informed consent, the patient was advised for Avarana chikitsa (Ama pachana), considering the status of Dosha, Ayurvedic oral medicines for Ama pachana were planned in this case [Table 2]. Treatment was continued for eight days and followed up daily in IPD, wherein vitals were well within normal limits. As the patient complained of constipated bowels, Gandharva hastadi eranda taila was added.[6] After that, Panchakarma procedure was planned in which Ruksha churna pinda sweda, Takra dhara (~therapeutic buttermilk dripping), Talam (~medicated paste applied on the crown or forehead), and Kshara basti were used [Table 3] and [Table 4].[7] After Ama pachana, the patient was suggested for Shodhana chikitsa (Virechana) and advised to stop all internal medicines.[8] After 10 days, Virechana karma was planned in which Snehapana with Brahmi ghritam was given for five days and then Sarvanga abhyanga (~whole-body therapeutic oil massage) and Swedana (~fomentation) were suggested for the next four days [Table 5] and [Table 6]. This was followed by Virechana with Trivrit avaleha and Peyadi samsarjana karma (~a process of resuming normal diet) advised as per Madhyama shuddhi (~moderate stage of purification) for five days.[9],[10] After Shodhana chikitsa, Brimhana chikitsa was planned in which Brimhana kalabasti was suggested along with Sarvanga abhyanga with Bala taila, Nadi swedana (~fomentation using local steam) with Dashamoola kwatha[11],[12] [Table 7]. Patra pinda swedana (~leaf bolus fomentation), Talapotchil (~therapeutic application of medicines overhead), Pizichil (~type of oil massage familiar in Kerala), and Shirobasti (~retention of oil) were done along with Kalabasti [Table 8]. Observations of Brimhana kalabasti were done during Basti, appetite was decreased, bowels were constipated due to faulty diet taken by the patient, but it was managed with Shamana aushadhi [Table 9].[13] After Brimhana kalabasti, Nasya and Shastika shali pinda swedana (~rice bolus fomentation) were adopted for Brimhana [Table 10].[14] Shamana aushadhi was suggested for one month [Table 11].
Table 2: Ayurvedic medicines adopted for Ama pachana

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Table 3: Plan for Avarana chikitsa and Amapachana with Panchakarma

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Table 4: Ksharabasti schedule

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Table 5: Schedule of Snehapana with Brahmi ghrita

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Table 6: Schedule of Sarvanga abhyanga and Swedana

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Table 7: Contents of Niruha and Anuvasana basti

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Table 8: External procedures done along with Brimhana basti

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Table 9: Observation of Brimhana kalabasti

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Table 10: Nasya and Shashtika shali pinda swedana

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Table 11: Shamana chikitsa (December 26, 2018-January 26, 2019)

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  Timeline Top


The timeline for drug treatment is given in [Table 12].
Table 12: Timeline

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  Follow-up and Outcomes Top


Considerable reduction in the symptoms was recorded after treatment. Pain completely disappeared after the follow-up. The pain on VAS reduced from 8 to 1 and EDSS decreased from 8 to 3 and FAMS was reduced from 158 to 102, with increased quality of life according to the SF-36 Quality of Life Scale [Graph 1], [Graph 2], [Graph 3].




  Discussion Top


MS is defined as demyelination of sheaths around the axons of the brain and spinal cord, which gradually affects most of the nerves. In the present case, the patient showed symptoms such as difficulty in balance for standing and walking, weakness in both lower limbs, and lower backache and stiffness associated with heaviness in body. Vata prakopa (~vitiation of Vata dosha) is caused either by Avarana or Dhatu kshaya (~diminution of the tissue elements). Avarana may also lead to a Dhatu kshaya causing further vitiation of Vata. Due to Avarana, symptoms such as Guruta (~heaviness in body), Stambha (~stiffness), Ruka (~pain) are expected.[15] There might be a high probability of Avarana due to Ama in the pathogenesis. Therefore, initially Ama pachana was done. Ruksha churna pinda swedana, Takra dhara, and Kshara basti along with internal medicines were further followed. After that Shodhana karma was done by administering Virechana. Then Brimhana karma via Kala basti, Nasya and external therapies was done which eventually worked on Dhatu kshaya and Mastishka kshaya (~depletion of brain tissues) as a Vata vyadhi chikitsa.

Avarana/Ama pachana chikitsa

In Ruksha churna pinda swedana, Jadamayadi churna was used for seven days due to its effect on Tridosha, mainly Vata and Pitta dosha.[16] Here, it was used for Rukshana karma (~induction of dryness therapeutically). Rukshana was done to remove Ama. Reduction in pain, stiffness, and lightness in body was observed after completion of Ruksha churna pinda swedana. In Takra dhara, Takra (~butter milk) with the combination of Amalaki churna and Musta (Cyperus rotundus Linn.) is used for seven days as it produces a calming effect on the brain and nervous system. Thus, it helps to release anxiety, and possibly improve neurological functions.[17] In Kshara basti, Kshara (~alkali) has Agneya guna (~attributes of Agni in five basic elements), Tridosha shamaka (~pacification of Tridosha), Ushna (~hot potency), Teekshna (~sharp), Pachana (~digestion), and Shodhana properties. Due to Gomutra's antagonistic qualities toward Kapha dosha, it causes removal of Ama as well as Sroto shodhana (~purification of circulatory channels) and Laghuta (~lightness) in the body. Agnitundi vati and Sudarshana churna are also used for Deepana pachana as they possess Ama pachana properties.

Shodhana chikitsa

Virechana karma was used as a Shodhana chikitsa in which Majja (~bone marrow) is considered as a component of Pittadhara kala (~tissue element of Pitta dosha).[18] Hence, management of its vitiation was done by Virechana karma with Trivrit avaleha and Draksha phanta.

Brimhana chikitsa

Basti is considered as Ardha chikitsa (~half treatment), and also adds to it that it is best for Vata dosha.[19] Considering this, Kalabasti was preferred for regulation of normal functions of Vata dosha with Brimhana dravyas.[20] In Patra pinda swedana, Patra of Shigru (Moringa oleifera Lam.), Eranda (Ricinus communis L.), and Arka (Calotropis gigantea [L.] W. T. Aiton) were used for Swedana.[21] The drugs of Swedana gana possess Ushna veerya (~hot potency), Snigdha (~unctuous), and Sukshma (~micro) guna. It alleviates Vata, Pitta, and Kapha settled in muscles, joints, and soft tissue. In Pizichil, Ksheerabala taila was used. Bala (Sida cordifolia Linn.) possess Balya (~providing strength) and Vata-pittahara property due to its Madhura rasa (~sweet taste), Guru, and Snigdha guna.[22] It can be considered as an improved version of Snehana and Swedana to alleviate Vata dosha in a better manner. Its application might stimulate nerve cells and strengthen the muscular tissue. Shastika shali pinda sweda was chosen to reduce increased Vata dosha inside the body. It possesses Brimhana, Vatahara, and Balya properties.[23] Heating impact of the Shastika shali pinda swedana causes vasodilatation; as a result of this, blood circulation improves and results in increased metabolic activity with the stimulation of neural receptors within the skin or tissue and helps in carrying away the toxins. Talam and Talapothichil, Rasnadi churna, and Ksheerabala 101 taila were used, which possess Vata shamaka and Balya properties and thus help in nourishing the Indriyas (~sensory organs) and pacifying the Vata dosha. In Shirobasti, Ksheerabala taila and Tila taila were used that have Balya property. It results in nourishment of Mamsa (~muscles), Asthi (~bone), and Majja dhatu. It helps in nourishing the Indriyas and brain. For Nasya, Brahmi ghrita was used and it possess Balya and Brimhana properties, therefore, it gives nourishment to nerve fibers, alleviates Vata dosha, and promotes the clarity of senses.[24] It also improves intelligence, cognitive functions, and learning skills.[25] The drug administered through nose as Nasya reaches the brain and then it eliminates the morbid Dosha responsible for producing the disease.

Shamana chikitsa

Ashtavargam kashayam contains Bala (Sida cordifolia Linn.), Sahachara (Barleria prionitis Linn.), Eranda (Ricinus communis Linn.), Shunthi (Zingiber officinale Rosc.), Rasna (Pluchea lanceolata C. B. Clarke), Devadaru (Cedrus deodara Roxb. Loud.), Sindhuvara (Vitex negundo Linn.), and Rasona (Allium sativum Linn.) which is indicated for the management of Vataroga.[26] As MS is relatable clinically to Vata vyadhi, the drugs present here are best for reducing Vata dosha, so it worked well in this case. Capsule Palsinuron works in neuromuscular disorders of CNS, which contains Mahavatavidhwamsa rasa, Sameerapannaga rasa, Ekangaveera rasa, and Sootashekhara rasa. The patient was having complaints of loss of strength in lower limbs and loss of memory. Considering this, Saraswatarishta described in Rasayana adhikara was prescribed. Its benefits described are “Ayurveeryasmruti vivardhana” and “Medhabalakanti vivardhana.”[27] Balyam granules having ingredients such as Ashwagandha (Withania somnifera Linn. Dunal), Shatavari (Asparagus racemosus Willd), Amalaki (Emblica officinalis Gaertn.), and Shankhapushpi (Convolvulus pluricaulis Chois) that are responsible for increasing strength and nourishment to brain tissues due to their Balya property with no adverse effects.[28] Narasimha rasayana referred in Rasayana vidhi is used to curtail the imbalancing factor of lower limbs, i.e., the term used by Acharya here is “Sthiranga.”[29] Gandharvahastadi eranda taila is used to clear bowels and for Shodhana purpose also. Considering the aggravated Vata in the body, Balarishta was added in the management.


  Conclusion Top


Multiple sclerosis is a progressive disorder with manifold impact producing multiple systemic effects. The definite cause of MS is unknown, it can be understood as one among autoimmune diseases, and there is no exact treatment protocol in contemporary science. Ayurveda can contribute to some extent in such situations. Combined Ayurvedic treatment of the abovementioned oral Ayurvedic drugs and Panchakarma procedures were helpful in treating the patient of MS. Relief in symptoms can be attributed to combined effect of the Ama pachana, Shodhana, Brimhana, and Shamana chikitsa. During the follow-up, one month Shamana chikitsa was done and no further Panchakarma procedure was needed in this patient. Although a single case report cannot claim to be an efficacious treatment for all such cases and as the disease runs a long course, the same treatment protocol cannot be followed in all cases. Nature of procedures, duration, and choice of other drugs will differ from case to case. They need to be selected depending on the clinical presentation.

Declaration of patient consent

The authors certify that they have obtained patient consent form, where the patient has given his consent for reporting the case along with the images and other clinical information in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was financially supported by the All India Institute of Ayurveda, New Delhi, India.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kidd D, Barkhof F, McConnell R, Algra PR, Allen IV, Revesz T. Cortical lesions in multiple sclerosis. Brain 1999;122:17-26.  Back to cited text no. 1
    
2.
Singhal BS, Advani H. Multiple sclerosis in India: An overview. Ann Indian Acad Neurol 2015;18 Suppl S1:S2-5.  Back to cited text no. 2
    
3.
Kurtzke JF. Rating neurologic impairment in multiple sclerosis: An expanded disability status scale (EDSS). Neurology 1983;33:1444-52.  Back to cited text no. 3
    
4.
Cella DF, Dineen K, Arnason B, Reder A, Webster KA, karabatsos G, et al. Validation of the functional assessment of multiple sclerosis quality of life instrument. Neurology 1996;47:129-39.  Back to cited text no. 4
    
5.
Paul-Dauphin A, Guillemin F, Virion JM, Briançon S. Bias and precision in visual analogue scales: A randomized controlled trial. Am J Epidemiol 1999;150:1117-27.  Back to cited text no. 5
    
6.
Sharma SP, editor. Sanskrit Commentary on Ashtanga Samgraha of Vrddha Vagbhata; Sutra Sthana. Ch. 15., Ver. 25. Varanasi: Chaukhambha Samskrit Series Office; 2012. p. 521.  Back to cited text no. 6
    
7.
Tripathi ID, editor. Hindi Commentary Chakradatta of Chakrapani. Ch. 73., Ver. 29-31. Varanasi: Chaukhambha Sanskrita Bhawan; 2015. p. 455.  Back to cited text no. 7
    
8.
Tripathi BN, editor. Hindi Commentary, Sharangadhara Samhita of Pandita Sharngadhar Acharya. Part I., Ch. 4., Ver. 11. Varanasi: Chaukhambha Sanskrita Bhawan Edition; 2011. p. 34.  Back to cited text no. 8
    
9.
Niteshwar K, Vidyanath R. English Commentary, Sahasrayogam. Ch. 7. Varanasi: Chaukhambha Sanskrit Series Office; 2014. p. 291.  Back to cited text no. 9
    
10.
Upadhyaya Y, editor. Vidyotini Hindi Commentary on Ashtanga Hrudaya of Vagbhata. Ch. 2., Ver. 9. Varanasi: Chaukhambha Surbharati Prakashan; 2017. p. 743.  Back to cited text no. 10
    
11.
Sastri R, editor. Chikitsa Sthana. In: Vidyotani. Hindi Commentary on Charaka Samhita of Agnivesha. Part 2., Ch 28., Ver. 156. Varanasi: Charaka Chaukhambha Orientalia; 2015. p. 803.  Back to cited text no. 11
    
12.
Shastri A, editor. Ayurveda Tatva Sandipika. Hindi Commentary on Sushruta Samhita of Maharsi Sushruta; Sutra Sthana. Ch. 38., Ver. 71. Varanasi: Chaukhambha Sanskrit Sansthan; 2016. p. 169.  Back to cited text no. 12
    
13.
Upadhyaya Y, editor. Vidyotini Hindi Commentary on Astanga Hrudayam of Vagbhata. Sutra Sthana. Ch. 19., Ver. 64. Varanasi: Chaukhambha Prakashan; 2008. p. 169.  Back to cited text no. 13
    
14.
Sastri R, editor. Sidhhi Sthana. In: Vidyotani Hindi Commentary on Charaka Samhita of Agnivesh. Part 2., Ch. 9., Ver. 92. Varanasi: Charaka Chaukhambha Orientalia; 2015. p. 1070.  Back to cited text no. 14
    
15.
Shastri R, editor. Chikitsa Sthana. In: Vidyotani Hindi Commentary on Charaka Samhita of Agnivesha. Part 2., Ch. 28., Ver. 76-81. Varanasi: Charaka Chaukhambha Orientalia; 2015. p. 951-2.  Back to cited text no. 15
    
16.
Niteshwar K, Vidyanath R. English Commentary, Sahasrayogam. Ch. 3. Varanasi: Chaukhambha Sanskrit Series Office; 2014. p. 110.  Back to cited text no. 16
    
17.
Rastogi S, Baiswar A, Nishchal A, Nischal A, Srivastav PS. Effect of shirodhara in generalized anxiety disorder. J Humanit 2016;6:e27.  Back to cited text no. 17
    
18.
Shastri A, editor. Ayurveda Tatva Sandipika. Hindi Commentary on Sushruta Samhita of Maharsi Sushruta. Kalpa Sthana. Ch. 4., Ver. 31. Varanasi: Chaukhambha Sanskrit Sansthan; 2005. p. 43.  Back to cited text no. 18
    
19.
Shastri R, editor. Sidhhi Sthana. In: Vidyotani Hindi Commentary, Charaka Samhita of Agnivesha. Part 2., Ch. 1., Ver. 39. Varanasi: Charak Chaukhambha Orientalia; 2015. p. 1169.  Back to cited text no. 19
    
20.
Singhal GD, editor. Sushruta Samhita, Uttara Tantra. Part 2., 2nd ed., Ch. 38., Ver. 83. Bangalore: Chaukambha Sanskrit Pratisthana; 2014. p. 525.  Back to cited text no. 20
    
21.
Shastri R, editor. Sutra Sthana. In: Vidyotani Hindi Commentary on Charaka Samhita of Agnivesha. Part 1., Ch. 4., Ver. 22. Varanasi: Charaka Chaukhambha Orientalia; 2015. p. 33.  Back to cited text no. 21
    
22.
Shastri R, editor. Sutra Sthana. In: Vidyotani Hindi Commentary on Charaka Samhita of Agnivesha. Part 1., Ch. 25. Varanasi: Charak Chaukhambha Orientalia; 2015. p. 468.  Back to cited text no. 22
    
23.
Srilakshmi D, Chaganti S. A holistic approach to the management of Erb's palsy. J Ayurveda Integr Med 2013;4:237-40.  Back to cited text no. 23
[PUBMED]  [Full text]  
24.
Patwardhan B. Integrity of ayurveda. J Ayurveda Integr Med 2016;7:189-90.  Back to cited text no. 24
    
25.
Yadav KD, Reddy KR, Kumar V. Beneficial effect of Brahmi Ghrita on learning and memory in normal rat. Ayu 2014;35:325-9.  Back to cited text no. 25
[PUBMED]  [Full text]  
26.
Niteshwar K, Vidyanath R. English Commentary, Sahasrayogam. Ch. 1. Varanasi: Chaukhambha Sanskrit Series Office; 2014. p. 45.  Back to cited text no. 26
    
27.
Mishra SN, editor. Siddhi Prada Hindi Commentary on Bhaisajya Ratnavali of Kaviraj Govind Das Sen. Vol. 2., Ch. 73., Ver. 178-192. Varanasi: Chaukhambha Orientalia; 2017. p. 1122.  Back to cited text no. 27
    
28.
Niteshwar K, Vidyanath R. English Commentary, Sahasrayogam. Ch. 5. Varanasi: Chaukhambha Sanskrit Series Office; 2014. p. 239.  Back to cited text no. 28
    
29.
Upadhyaya Y, editor. Vidyotini Hindi Commentary on Astanga hrudayam of Vagbhata. Uttara Sthana. Ch. 39., Ver. 173. Varanasi: Chaukhambha Prakashan; 2008. p. 1204.  Back to cited text no. 29
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12]



 

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Abstract
Introduction
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Clinical Findings
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Follow-up and Ou...
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