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Introduction

Acharya Charaka has described Yukti as one of the Chaturvidha Pariksha and also included it under Paradi Gunas. Thus Yukti is such a concept which has been described in Ayurveda as both Pariksha and Guna. As Pariksha, it is described for the knowledge of Sat (manifested) and Asat (unmanifested) things and also for the establishment of theory of re-birth. Whereas when described as Guna, Yukti is regarded as a tool for the successful treatment i.e. ‘Chikitsa Siddhi Upaya’.[1],[2] Description of Yukti under Paradi Gunas is very significant as these Gunas (properties) are mandatory to be there in the physician and the pharmacist who actually take part in formulating the treatment plan. Commentator Chakrapani has opined about Yukti that, ‘a process or methodology which is the perfect one and purposeful for achieving the desired effect is Yukti; while the methodology without perfection, logic or principle will never be Yukti, but is termed as Ayaugiki or Ayukti’. Here Yukti works as a Guna and plays an important role in formulating perfect therapeutic regimen for a particular disease.[3] Yukti is the property which is being applied either by the physician or by the pharmacist to get success in the treatment and formulations. It is high caliber of Yukti that a physician or a pharmacist can postulate or fabricate numerous newer aspects of a drug or formulation as per need and requirements for the treatment, which may not be quoted or advised in the text. Thus a physician who is proficient in the principles of propriety (Yukti) is always superior to those who are acquainted with the drugs only.[4] Administration of a drug with a specific Anupana to increase its efficacy is also based on Yukti Guna of physician. Considering this fact, effect of Anupana Yojana of Sauvarchala Lavana (Unaqua NaCl) with Haritaki (Terminalia chebula Retz.) in the disease Purishaja Anaha (Constipation) was assessed in the present study. For this, one group was given Haritaki with Koshna Sauvarchala Lavana Jala (lukewarm water containing Sauvarchala Lavana) as Anupana while other group was treated by Haritaki with Koshna Jala (plain lukewarm water) as Anupana. The Yukti i.e. rationality behind choosing Haritaki and Sauvarchala Lavana can be understood by the classical references, in which both these drugs are said to have Vibandha and Anahahara properties.[5],[6] The study was designed with the following aims and objectives.

Aim and Objectives

To evaluate and assess the effect of Anupana Yojana (Yukti Guna) in the management of Purishaja Anaha with Haritaki.

Materials and Methods

Criteria for Selection of patients:

Patients having classical signs and symptoms of Purishaja Anaha[7] were selected for the study irrespective of cast, religion, occupation and sex. Informed and written consents of all the patients were taken before registration. Clinical study had been started after getting approval of Institutional Ethics Committee (IEC Appr. No.-PGT/7-A2012-2013/1964, dated 21/09/2012). The study had been registered in Clinical Trials Registry of India (CTRI Reg. No.-CTRI/2013/09/003974, dated 12/09/2013).

Exclusion criteria

Patients below 20 years and above 60 years of age were excluded from the study. Patients suffering from any systemic disease which intervenes with treatment and patients in which Haritaki and Sauvarchala Lavana are contraindicated were also excluded from the study.

Grouping and Sampling: Registered patients were randomly divided in two groups with drugs and posology as shown in Table 1.

 HS Group: These patients were treated with tablets of Haritaki with Koshna Sauvarchala Lavana Jala as Anupana.

H Group   :  These patients were treated with tablets of Haritaki with Koshna Jala as Anupana.

Investigations:  All the patients were subjected to routine haematological, urine and stool examinations only to exclude any other pathology.

Criteria for assessment: The main criteria for the assessment were clinical subsidence in the symptoms of Purishaja Anaha. Symptomatic relief obtained by the treatment given, was assessed B.T. (before treatment) and A.T. (after treatment) with gradation on the basis of scoring pattern.

Criteria for assessment of overall effect of therapy:

Statistical Analysis

The information gathered on the basis of observations was subjected to statistical analysis in terms of mean (X), standard deviation (S.D.) and standard error (S.E.). Paired ‘t’ test was applied at each symptom individually in both groups, while unpaired ‘t’ test was applied to study the comparative results in both the groups at the levels of P<0.05, P<0.01 and P<0.001.

General Observations

Total 50 patients were registered; 25 each, in both the groups. There were no patients dropped out during the treatment in both the groups. Majority of the patients were male (66%), married (94%) and belonging to lower middle class status (48%). In observations related to Malapravritti (excretion of stool), all the patients (100%) showed Balapurvaka Malapravahana (straining during defecation) while Grathita Malapravritti (hardened stool) was observed in 98% of the patients. Majority of the patients (56%) were having Mandagni (decreased digestive power) whereas chronicity of the disease was less than 3 months in maximum patients (56%). Among Aharaja Hetu (causes related to diet), Viruddhashana (intake of unwholesome food) and Vishamashana (consuming less or more quantity of food at improper time) was observed in 96% and 92% of the patients respectively. Whereas Adhyashana (consuming more quantity of food even before the previous meal is digested) and Ati Katu-Tikta-Kashaya Rasa Sevana (excessive intake of pungent, bitter and astringent food) was found in 60% and 54% of the patients respectively. Among Viharaja Hetu (causes related to lifestyle), Divasvapa (sleep during day time) and Vegavidharana (suppression of natural urges) was observed in 86% and 64% of the patients respectively. Whereas Ativyayama (excessive exercise) and Ratrijagarana (vigil during night) was found in 42% and 38% of the patients respectively.

 Results

Effect of therapy on chief complaints: Effect of therapy on chief complaints of Purishaja Anaha which are; Purisha Apravartana, Udarashula, Udara Adhmana, Kati-prushtha Shula and Stambha in HS and H Groups is as shown in Figure 1.

Effect of therapy in HS Group: The drug provided highly significant relief (< 0.001) in all the parameters of chief complaints.  The percentage relief was 82% in Purisha Apravartana, 90.67% in Udarashula, 83.33% in Udara Adhmana while it was 82% and 78% in Kati-prushtha Shula and Stambha respectively.

Effect of therapy in H Group: The drug provided highly significant relief (< 0.001) in all the parameters of chief complaints.  The percentage relief was 68% in Purisha Apravartana, 58.67% each in Udarashula and Udara Adhmana while it was 50.67% and 53.33% in Kati-prushtha Shula and Stambha respectively.

Effect of therapy on associated complaints

Effect of therapy on associated complaints of Purishaja Anaha which are; Sashula Malapravritti, Udara Gaurava, Vata Apravartana and Mutra Apravritti in HS and H Groups is as shown in Figure 2.

Effect of therapy in HS Group: Maximum i.e. 90.67% relief was observed in Udara Gaurava followed by 87.5% relief in Mutra Apravritti. The relief was 86% in Sashula Malapravritti while it was 67.39% in Vata Apravartana. Statistically highly significant relief (< 0.001) was seen in Sashula Malapravritti, Udara-Gaurava and Vata Apravartana while it was significant (< 0.05) in Mutra Apravritti.

Effect of therapy in H Group: Maximum i.e. 65.22% relief was observed in Vata Apravartana followed by 62.67% relief in Sashula Malapravritti, 62.50% relief in Mutra Apravritti and 58.67% relief in Udara-Gaurava. Statistically highly significant relief (< 0.001) was seen in Sashula Malapravritti, Udara-Gaurava and Vata Apravartana while relief was insignificant (> 0.05) in Mutra Apravritti.

Total and comparative effect of therapy:Total and comparative effect of therapy in HS and H Groups, studied as percentage of patients showing improvement in different categories is as shown in Figure 3.

HS Group: Out of 25 patients in this group, 8% patients showed complete remission, 64% patients showed marked improvement whereas 28% patients got moderate improvement. There were no patients in mild improvement and unchanged categories in this group.

H Group: Out of 25 patients in this group, 12% patients showed marked improvement, 72% patients showed moderate improvement whereas 16% patients got mild improvement. There were no patients in complete remission and unchanged categories in this group.

tables

fig. and Charts

Discussion

In the group of Paradi Gunas which are also termed as Chikitsakiya Gunas, Yukti Guna has been studied here specifically. Yukti is the property which is being applied either by the physician or by the pharmacist to get success in the treatment and formulations. As Yukti is a rationality based on proper combination of multiple factors those are employed in a process to get the desired and perfect effect, in Chikitsa which is also based on the process as above, the role of Yukti becomes crucial. With the invention of Yukti-vyapashraya Chikitsa, there started a new era of treating diseases according to Dosha, Dushya, Desha, Prakriti, Kala etc of an individual. With the application of Yukti, a broad field was obtained for the use of a single drug in treatment of different diseases as well as different stages of the same disease. Also a single drug can be used in many ways by means of different Anupana, Aushadha Kala, Matra, Kalpana etc which is nothing but the applied aspect of Yukti only. Administration of a drug with a specific Anupana to increase its efficacy is also based on Yukti Guna of physician. This is in accordance with Chakrapani’s description about Yukti, in which he says that Yukti is nothing but the Samichina Kalpana of Bheshaja i.e. apt usage of medicine on the basis of Dosha, Dushyadi factors.[3] In the clinical study, an attempt was made to evaluate the effect of Anupana Yojana (Yukti Guna) practically by using Haritaki with Koshna Sauvarchala Lavana Jala as Anupana in the disease Purishaja Anaha. Logic behind the effect of Anupana Yojana has been discussed as follows.

Chief complaints:

From the obtained data though it is evident that both HS and H Groups are showing statistically highly significant results in chief complaints but HS group is showing percentage wise more relief in all the parameters of chief complaints. Also on comparing the effects in both groups by applying unpaired ‘t’ test, it was found that HS Group is showing highly significant results than H Group in Udarashula (< 0.001), Udara Adhman (< 0.001), Kati-prushtha Shula (< 0.01) and significant result in Kati-prushtha Stambha (< 0.05) [Table 2]. This data supports the hypothesis that Anupana Yojana of

Sauvarchala Lavana Jala with Haritaki definitely has effect in curing the disease Purishaja Anaha in a better way. Here Sauvarchala Lavana with its Laghu, Sukshma, Tikshna and Vatashamaka properties has increased the efficacy of Haritaki which is evident from the obtained data. Though H group is also showing significant results but this may be due to the Anulomana property of Haritaki which will certainly show improvement in the above said symptoms but this improvement will be up to a certain limit only which is evident from the less percentage relief in H group [Figure 1].

Associated complaints:

From the obtained data it is evident that, in HS Group due to increased Anulomana effect of Haritaki with Sauvarchala Lavana, associated symptoms like Udara Gaurava, Sashula Malapravritti have also got relieved remarkably. The improvement in the associated symptoms in H group is not as remarkable as in HS group [Figure 2]. Also on comparing the effects in both groups by applying unpaired ‘t’ test, it was found that HS Group is showing highly significant results than H Group in Sashula Malapravritti (< 0.001) and Udara-Gaurava (< 0.001) [Table 3].

Total effect of therapy:

8% complete remission was seen in HS group whereas no patients showed complete remission in H group. This indicates combination of Haritaki and Sauvarchala Lavana is more efficient than only Haritaki. 64% and 12% marked improvement was seen in HS and H groups respectively. This again indicates increased efficacy of Haritaki with Anupana of Sauvarchala Lavana Jala. 28% and 72% moderate improvement was observed in HS and H groups respectively whereas 16% mild improvement was observed there in H group while no patients showed mild improvement in HS group. Less number of patients showing moderate improvement and not a single patient showing mild improvement in HS group is because most of the patients are showing marked and complete relief in this group. While more patients showing moderate improvement in H group suggest that Haritaki when used singly is capable of giving results up to a certain extent only. There were no patients in the unchanged category in both the groups. This is because both groups are showing some improvement /effect in the symptoms of Purishaja Anaha [Figure 3].

Probable mode of action of drug:

Probable mode of action of drug can be understood with the help of a flow chart shown in Figure 4. In Purishaja Anaha the chief factor in Samprapti formation is increased Ruksha Guna of Apana Vata, which leads to accumulation of Purisha and obstruction to its normal passage.[7] When Haritaki is given in such condition as a single drug, it will show improvement owing to its Anulomana property but due to Rukshatva and Kashayatva of Haritaki, this improvement will be up to a certain extent only.[8] When given along with Sauvarchala Lavana, Haritaki shows better results as Lavanata and Sarata of Sauvarhala will pacify the Rukshata of Haritaki. Also Sara and Bhedana Gunas of Sauvarchala will increase the Anulomana effect of Haritaki.

Conclusion

This study was carried out with the hypothesis that Yojana of Anupana (Yukti Guna) will increase the efficacy of Haritaki in treating the disease Purishaja Anaha. Thus obtained observations which show better results in HS group than H group are in accordance with the hypothesis made. Though both groups are showing recognizable improvement, better results in HS group are indicative of increased efficacy of Haritaki when given along with Koshna Sauvarchala Lavana Jala as Anupana and thus proving the rationality behind formulating the treatment plan. This also proves the importance and applicability of Yukti Guna in treating a disease in a better way.