Ama

Ama is a state of or products formed due to incomplete digestion, metabolism, or transformation. Agni (digestion and metabolism) is a factor responsible for changing the state of a substance. In human biology, the digestion and metabolic processes convert food and other substances into compatible and nourishing body components. If these processes are incomplete, poor or slow, then the final products formed are of poor quality. Agni is one of the most important factors responsible for health (prakrita) abnormalities, and diseases (vikriti). Life span, strength, health, and immunity all depends on agni. [Cha. Sa. Chikitsa Sthana 15/03] If agni is disturbed, then proper digestion does not occur which results in improperly transformed food/metabolites are termed as ‘Ama’. [A. H. Sutra Sthana 13/25] The concept of ama in ayurveda is very important in pathogenesis of disease. One of the synonyms of vyadhi (disease) is “aamaya” which means caused by ama. [Cha. Sa. Nidana Sthana 1/05] Classification of stages of diseases (vyadhi) is based on the presence and absence of ama i.e., sa-ama avastha (stage associated with ama) and nirama avastha (stage not associated with ama). The treatment protocol also depends on stages of ama such as in diarrhoea associated with ama(ama-atisara), styptic therapy (stambhana) is contraindicated. Whereas, in the diarrhoea without ama (nirama stage) / or chronic diarrhoea (jeerna atisara), styptinc therapy (stambhana) is advised. Thus, concept of ama is significant in understanding the etiopathogenesis, diagnosis as well as treatment of diseases. This chapter describes concept of ama with its contemporary views and researches done on it.

Contributors

Section/Chapter/topic	Concepts & Practices/Ama
Authors	Dubey M.1, Deole Y.S.2
Reviewer & Editor	Basisht G.3,
Affiliations	1Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India 2Department of Kayachikitsa, G. J. Patel Institute of Ayurvedic Studies and Research, New Vallabh Vidyanagar, Gujarat, India 3Rheumatologist, Orlando, Florida, U.S.A.
Correspondence emails	dr.manish181@gmail.com, dryogeshdeole@gmail.com, carakasamhita@gmail.com
Publisher	Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India
Date of publication:	August 01, 2023
DOI	10.47468/CSNE.2023.e01.s09.143

Etymology (nirukti)

1. Aamyate ishat pachyate: It means the product formed due to poor or improper digestion(apurna paka or paka rahita or alpa paka).
2. Soannajo rasa iti amah, annarasasyo va apakvasya tanyantare aam vyapdeshat: Ama is originated from the food. If the initial product of food after digestion (annarasa) is not properly formed, then the outcome of such digestion is known as ama.

Definition

1. Weak digestive factors (jatharagni) cause poor digestion (avipaka) of rasa (primary product of digested food). This poorly formed product is called ‘ama’. This is the cause for vitiation of all dosha (aggravation of all dosha). [Cha. Sa. Chikitsa Sthana 15/44]
2. Ama is the root cause for almost all the diseases.
3. Ama is the first component formed due to weak digestive processes. It is in amashaya (site of storage of food in intermediary stage of digestion and metabolism). [A. H. Sutra Sthana. 13/25]
4. Ama is the component formed during digestion of food.
5. The first state of vitiated dosha is called ‘ama’.
6. The byproducts of metabolism if not properly eliminated or utilized in the body are considered as ama.
7. The uncooked food (or annarasa) if, retained for longer time in stomach undergoes fermentation/putrefaction, this state of rasa is ama. This ama further joined with dosha is termed as amadosha. It is as toxic as visha (poison) produced by spoiled kodrava (Paspalum scrobiculatum L., Italian millet contaminated by fungus). [A. H. Sutra Sthana 13/26-27]

Causes

Impairment of agni (digestive process) due to following reasons causes ama.

• Fasting or not taking food (abhojana)
• Indigestion (ajirna)
• Intake of excessive quantity of food (atibhojana)
• Intake of unequal proportion of food (vishama bhojana)
• Taking incompatible or non-habitual food (asatmya bhojana)
• Intake of heavy, cold, excessively dry food products
• Untoward effects of improper virechana (purgation), vamana (emesis), snehana (oleation)
• Depletion of body tissues by chronic diseases
• Changes in climate/season
• Suppression of natural urges (vegadharana) [Cha. Sa. Chikitsa Sthana 15/42-44]
• Food with qualities such as heavy to digest (guru), dry (ruksha), cold (sheeta), dried/dehydrated (shushka), disliked by consumer (dvishta), constipation-causing (vishtambhi), those causing burning sensation (vidahi), unclean (ashuchi), incompatible food intake (viruddha anna), consumed untimely (akala bhojana)
• Mental status while taking food: Intake of food when mind is affected by desires (kama), anger (krodha), greed (lobha), infatuation (moha), envy (irshya), shame (hri), grief (shoka), conceit (maana), anxiety (udvega), fear (bhaya), etc. [Cha.Sa. Vimana Sthana 2/8]

Diseases caused by ama

The undigested food gets fermented (shuktata) leading to onset of toxic symptoms. [Cha. Sa. Chikitsa Sthana 15/42-44] Ama further leads to various digestive disorders like amajirna (indigestion due to saama pitta), vishtabdhajirna (indigestion due to saama vata), vidagdha ajirna (indigestion due to saama kapha), visuchika (non-infectious gastroenteritis), alasaka (sluggish bowels), vilambika (gastro-intestinal stasis). [Su. Sa. Uttara Sthana 56/3] The diseases caused by ama at various dhatu level are jwara (fever), atisara (diarrhoea), pravahika (dysentery), etc. The chronic conditions caused by ama are such as grahini-dosha (functional impairment of agni), udara roga (ascites and abdominal enlargement), yakrit vyadhi (liver disorders), jalodara (ascites), shotha (oedema), pandu (anemia), prameha (obstinate urinary disease), amavata (rheumatism), etc.
The acidic nature (amla bhava) of undigested food (apakva anna) is called as suktata (acidic /sour nature of undigested food) which further acts like a visha (poison) that will further produce number of other diseases, so this can be compared to symptoms of amavisha. This uncooked food further combines with dosha (regulatory functional factors of the body), dhatu (major structural components of the body) or mala (metabolic waste or byproducts) and produces their respective symptoms accordingly. [Cha. Sa. Chikitsa Sthana 15/46-49]
When ama combines with pitta dosha, it produces pitta dominant diseases such as burning sensation (daha), thirst (pipasa), diseases of oral cavity (mukha roga), hyperacidity (amlapitta) etc. When it combines with kapha dosha, it produces kapha dominant diseases such as rajayakshma (consumption), pinasa (chronic rhinitis), prameha (obstinate urinary disease), etc. When combines with vata dosha, it produces different types of vata dominant diseases. When combines with mutra (urine) or gets lodged in mutravaha srotasa (urinary tract), to produce mutra roga such as mutrakrichhra (dysuria), mutraghata (urinary retention), prameha (obstinate urinary disease), etc. When combines with purisha (feces) produces diseases of kukshi (pelvis) or udara roga (diseases of abdomen). When combines with rasa etc. dhatu (seven major structural components of the body), then produces their respective diseases.

Premonitory features (ama purvarupa)

Purvarupa (prodromal symptoms) of ama in general are, such as stiffness of body, anorexia, excessive sleep, pallor, dullness and especially irritation to food or playing activities in case of children. [Ka. Sa. Sutra Sthana 25/32-33]

Characteristics of ama

Ama possesses characteristics such as liquid (drava), heavy (guru), attains different colors, slimy (snigdha), viscid (pichchila), thready (tantumatva), foul smelling (durgandhi). Ama is etiological factor of all diseases and produces symptoms such as various types of pain (shoola), obstructs channels (srotorodhaka), undigested (avipakva), lethargic (sadanakaraka), etc.

Clinical features of dosha (saama dosha) and dhatu (saama dhatu) associated with ama

Ama state of dosha or dhatu is termed as a saama dosha or saama dhatu respectively. These manifest different symptoms and produces number of diseases. [A. H. Sutra Sthana 13/26-27]

These produce general features of saama and nirama state as below:

Blockage or clogging of srotasa (channels)

• Loss of strength
• Feeling of heaviness
• Improper functions of vata dosha
• Accumulation of mala (metabolic wastes)
• Lethargy
• Low digestive capacity
• Excessive salivation
• Retention of mala (waste products)
• Aversion towards food and tiredness. [A. H. Sutra Sthana 13/23-24]

In case of state without ama (nirama), the opposite of above features are observed.

Saama and nirama features of dosha, dhatu and mala

Table no. 1: Features of saama dosha: [Bhavaprakash. Pratham khanda. Jwara chikitsa. 49-50, 52, 54]

Saama dosha (dosha associated with ama)	Lakshana (symptoms)
Saama vayu (vata dosha associated with ama)	constipation (vibandha), weak digestive capacity, body stiffness, gargling sound in abdomen(antrakunjan), painful sensation (vedana), swelling (shopha), pricking pain (nistoda), sequential and fleeting pain in various body parts, pain increases after oleation therapy, during morning and evening time, during cloudy weather
Saama pitta (pitta dosha associated with a	Foul smell, color of pitta will be greenish/ light blackish, amla bhava of [[Pitta|pitta (sour nature of pitta), heaviness, sour eructation, burning sensation in throat and cardiac region.
Saama kapha (kapha dosha associated with ama)	Avila (increase turbidity in mala), thick in consistency, feeling of sticky phlegm in throat, foul smell cough, lack of appetite.

Table no.2: Nirama dosha lakshana: [Bhavaprakash. Pratham khand. Jwara chikitsa. 51,53,55]

Nirama dosha (dosha not associated with ama)	Lakshana (symptoms)
Nirama vayu (vata dosha not associated with ama)	Proper elimination of metabolic wastes (mala), dryness of skin, no obstruction of body channels, mild pain, vitiated vata subsides by snehana (oleation therapy).
Nirama pitta (pitta dosha not associated with ama)	Coppery and yellowish color of pitta, increased body temperature, pungent taste of pitta, does not yield bad smell, improves taste, appetite and strength.
Nirama kapha (kapha dosha not associated with ama)	Frothy in nature, free from threads, pallor, cough, light in nature, cleans oral cavity.

Table no. 3: Saama dhatu lakshana: [Cha. Sa. Sutra Sthana 28/9-19]

Saama dhatu (dhatu associated with ama)	Lakshana (symptoms/diseases)
Saama rasa dhatu	Anorexia, tastelessness, hrillasa (nausea), pandu (pallor), jwara (fever), klaibya (impotency).
Saama rakta dhatu	Various types of skin disorders and abscess, raktapitta (hemorrhagic disorders), inflammation of anus/penis/oral cavity, kamala (jaundice), vatarakta (gout), arsha (piles).
Saama mamsa dhatu	Arbuda (tumor), galashundi (tonsilitis), gandamala (cervical adenitis), upajihivika (inflammation of epiglottis).
Saama meda dhatu	Prameha purvarupa (prodromal features of prameha), galaganda (goiter), madhumeha (diabetes mellitus), atisthaulya (obesity).
Saama asthi dhatu	Pain in teeth and bones, bony growth, disorders of hair/nails, toothache.
Saama majja dhatu	Pain in joints, giddiness, syncope (murchha), blackouts (tama)
Saama shukra dhatu	impotency (klaibya), sexual dysfunction, abortion, miscarriage, no conception, disorders of semen.

Features of state without ama (nirama lakshana)

In stage devoid of ama (nirama avastha), all seven dhatus perform their normal functions and are devoid of symptoms of ama.[A. H. Sutra Sthana 11/4]

Table no. 4: Saama mala lakshana : [Cha. Sa. Chikitsa Sthana 15/49, 94]

Saama mala (waste products associated with ama)	Symptoms
Saama mutra (urine associated with ama)	Mutra roga (urological disorders), obstruction to urinary passage
Saama purisha (feces associated with ama)	Heavy, pellet like hard, foul smelling, passing little quantity of stool with difficulty, sinks in water.

Table no. 4: Nirama mala lakshana:

Nirama mala (Waste products not associated with ama)	Symptoms
Nirama mutra (urine not associated with ama)	Without any urinary disorders or abnormal symptoms.
Nirama purisha (feces not associated with ama)	Stool floats on water, laghuta (lightness).

Clinical presentations due to ama

There are mainly two types of ama dosha or ama dosha vikara (disease) viz; visuchika (non-infectious gastroenteritis /choleretic diarrhoea) and alasaka (sluggish bowel/intestinal obstruction). [Cha. Sa. Vimana Sthana. 2/10] Food taken in excessive quantity is the cause for sudden aggravation of all three dosha and formation of ama. All aggravated three dosha combine with ama and produce diseases like alasaka and visuchika. [A. H. Sutra Sthana. 8/5-12]

1. Visuchika (gastro-enteritis):
   The word visuchika derived from “suchi” means needle or “suchi vidh vedana” (pricking pain). The expulsion of ama dosha (undigested food) through both upper and lower passages of the gastrointestinal tract is called visuchika (non-infectious gastroenteritis). The doshas when tend to move outwards from both upper and downwards routes means both vomiting and diarrhoea occurs simultaneously. Due to aggravation of vata and other doshas different types of pain occur as the patients feels as if his body is being pricked by needles (suchi) so the disease is named visuchika. It can be compared with gastro-enteritis due to pathogens such as Cholera bacilli. Complications caused by visuchika are, abdominal colic, vertigo, abdominal distension, tremors and rigidity by vata dosha. Pitta causes jwara (fever), atisara (diarrhoea), burning sensation within body, thirst, fainting and drowsiness. Kapha dosha leads to chardi (vomiting), heaviness of the body, unable to speak, excessive salivation and cough.
2. Alasaka (sluggish bowels):
   The word Alasaka derived from word “Alasa” means no movement. When frail person having weak digestive power and excess of kapha in the body, it habitually suppresses the urges of passing flatulence, micturition and bowels and at the same time consumes sthira (solid), guru (heavy), atishushka (excessively dry), and sheeta (cold), in excessive quantities then his ingested food gets afflicted by vayu (vata dosha). Even exerting pressure does not push the undigested food out of the passage since it is obstructed by kapha, by excreta accumulated already, and also because of sluggish nature caused by all these factors. Vishtambhan (stasis) of dosha occurs so the ama remains/stagnated within the stomach i.e., food neither passes upwards nor downward. This condition is called alasaka. All the characteristic features of ama dosha, except vomiting and diarrhoea, are manifested severely in alasaka. This can be compared with Cholera sicca where, the entire body fluids are dragged into the intestines and intestines gets paralyzed and the patients dies because of tissue dehydration. Aggravated vata dosha vitiates the consumed food and kapha dosha obstructs the channels. The undigested food remains in gut without any further process. It causes irritation and colicky pain without vomiting or diarrhoea.

Dandaka alasaka (delayed and obstructive digestive process wherein body becomes stiff like a stick): Severely vitiated dosha associated with ama spreads all over the channels of body and spreads throughout the body. The extremely vitiated dosha move obliquely towards other body channels to block them. As all body channels are blocked by ama, the body becomes rigid like wooden rod/staff (danda). This condition is critical and needs urgent medical care. Such clinical condition is known as dandalasaka/ dandaka alasaka.

Ama visha

An individual who regularly consumes incompatible diet, indulge in adhyashana (multiple heavy meals in short intervals) and ajirnashana (eats even before the previous meal is digested), the ama dosha is formed. It resembles and manifests features of poisoning. Hence it is called ama visha. It is a difficult to cure because of its acute presentation and its contradictory line of management. [Cha. Sa. Vimana Sthana 2/12] The symptoms produced by ama visha are such as stasis in body (vishtambha), fatigue (sadana), indigestion (ajirna), headache (shirashoola), fainting (moorcha), vertigo (bhrama), stiffness of back (pristha-kati graha), yawning (jrimbha), malaise (angamarda), thirst(trishna), fever (jwara), vomiting (chhardi), tenesmus(pravahana), anorexia (arochaka), indigestion (avipaka).

Chikitsa (management)

Treatment of ama dosha:

• The following principles are adopted to manage a clinical condition associated with ama.
• Deepana (stimulating the digestive process)
• Pachana (assisting the digestion and metabolism)
• Sneha (oleation with medicines having digestion stimulant properties)
• Sweda (fomentation)
• Shodhana (purification) at appropriate time when dosha are in a state of getting expelled out.

In a condition without ama, the main principle of treatment is shamana (palliative). Shodhana is indicated based on the state of dosha. If the dosha are in dormant (leena) state, then shodhana is prohibited. [A. H. Sutra Sthana 13/28-29] Apatarpana (depleting procedure) is the prime line of treatment for ama dosha. The apatarpana is of three types viz., langhana (fasting), langhana- pachana and dosha avasechana (shodhana). Based on the avastha of dosha the type of apatarpana is to be advised i.e., in low grade (alpa) dosha stage, langhana (fasting) as it stimulates the digestive process by predominance of agni (fire element) and vayu (air element) mahabhuta. In moderate grade (madhyama) dosha stage, langhana and pachana (fasting with digestant) should be adopted. In highly aggravated (bahu) dosha state, dosha avasechana or shodhana (purification) as to remove out vitiated dosha and ama from the body. [Cha. Sa. Vimana Sthana 3/43-44]

Treatment of alasaka:

The curable variety of ama dosha should be eliminated through vamana (emesis), by administering warm saline water and thereafter swedana (fomentation) and application of phala varti (suppositories) while the patient is kept on upavasa (fasting). [Cha. Sa. Vimana Sthana 2/13]

Treatment of visuchika:

In case of visuchika, treatment should start with langhana (fasting) followed by specific dietary regimen as followed in therapeutic purgation (virechana). [Cha. Sa. Vimana Sthana 2/13]

Amadosha chikitsa:

In case of reoccurrence of the diseases caused by ama, the first line of treatment is apatarpana i.e., depletion therapy. If the disease further progresses even after depletion therapy, appropriate measures should be adopted to counter the morbid condition. Experts recommend the use of vyadhi viprit ausadha measures (treatment which is antagonistic to the disease) rather than hetu viprita aushadha (treatment which is antagonistic to the etiological factors). [Cha. Sa. Vimana Sthana 2/13]

Prevention of recurrence of ama dosha

When the patient is relieved from excessive morbidity of ama, and his digestive capacity (agni) is restored, the following treatment shall be administered to prevent recurrence of ama:

• Abhyanga (therapeutic massage)
• Niruha basti (enema with decoction) and anuvasana basti (unctuous enema)
• Appropriate snehapana (internal administration of unctuous substances)

Careful assessment of the status of dosha, drugs, place, time, strength, body, diet, satmya (habituation), psyche, constitution, age etc. and diseases shall be done during the treatment. [Cha. Sa. Vimana Sthana. 2/13]

Treatment of ama in other disease conditions

If ama dosha is in grahani (duodenum) and symptoms of ama dosha are present, then emesis is advised by warm water, madanphala (Randia dumetorum) (Emetic nut) or pippali (Piper longum) or sarshapa (Brassica campestris).
If ama dosha is in leena avastha (dormant state), deepana medicines are advised first. If amadosha is spread throughout the body then first langhana is to be given followed by pachana medicines. [Ca. Sa. Chikitsa Sthana 15/73-75]
If stomach is free from amadosha, then panchakola churna (powder) and peyadi laghu ahara (light to digest thin gruel) and deepana (drugs which kindles digestive fire) medicines should be given. [Cha. Sa. Chikitsa sthana 15/76]
Following measures to be adopted for shamana chikitsa (palliative therapy) in general during the treatment of Ama:

• Langhana (fasting)
• Ushna peya (lukewarm gruel)
• Laghu anna sevana (light diet)
• Ruksha odana (un-unctuous preparation cooked cereals)
• Tikta yusha sevana (intake of soup prepared with tikta rasa (bitter taste))
• Pachana drugs (digestant drugs)
• Swedana (fomentation)
• Urdhwa or adha shodhana (elimination of doshas from upper body channels or lower body channels) i.e., vamana (emesis) or virechana (purgation).
• Niruha basti (un-unctuous enema)

Current researches

Theses works on ama

Following are the some theses work of ama

1. A clinical study on the role of ama in relation to Grahini roga and its management by kallingadi ghanavati and tryushnadi ghrita
   Discussion over role of ama in relation to Grahani disease: When the vitiated dosha get confined only to the organ grahani (duodenum), then it should be called ‘Grahani dosha’. But when the vitiated doshas travels throughout the rasadi dhatus (seven bodily tissues) i.e. throughout the body, then it should be called as ‘Grahani roga’ (functional impairment of agni). The grahani and agni (digestive process) are having co-existing nature/dependent on each other (adhara adheya sambandha). This view is confirmed by corroborative evidence from recent development in pathology. The mucosal damage in the form of villous atrophy and other microvillus changes in different enteropathies affect the enzymes present in the enterocyte brush borders. When the disease process progresses, further it affects the pancreatic secretion as it depends upon cholecystokinin and secretin secretion from the enterocyte. The immature epithelial cells are unable to secrete the required amount of cholecystokinin and secretin. In the pathogenesis (samprapti) of grahani disease, Acharya Charak elaborated a series of events as below.
   Indulgence in causes that vitiate agni (digestive f) → agni dushti (vitiation og agni) → indigestion (apachana) → production of ama (non-metabolized, poorly formed product) → putreification (shukta paka)→ advanced condition of ama manifestating as a poisoning codition (anna visha or ama visha) → grahani dosha (functional impairement of grahini) → grahani dushti (vitiation of grahani)→ grahini roga (diseases manifestating as functional impairement of agni/digestive funtions). Ama is the root cause of almost all diseases produced in the body and the treatment of any disease can be based on stage of the disease associated with ama (saama) & stage of the disease not associated with ama (nirama avastha).
   Outcome of clinical study: This clinical trial was carried out in 66 patients of 16-60 year of age group having cardinal sign and symptoms of grahani disease. Patients were selected randomly into Group A, Group B and Group C treated by kallingadi ghanavati, tryushnadi ghrita and combination of both (ghanavati & ghrita) respectively for 2 weeks. The overall effect of therapies showed that better results observed in group B in comparison to group A. In comparison of all three groups, group C showed slight better results than those of rest two groups.
2. Association of stress inducing factors (manoabhitapakara bhava) and free radical over madhumeha
   Discussion over association of stress inducing factors (manoabhitapakara bhava) and free radicals with chronic metabolic diseases such as diabetes mellitus type 2 (madhumeha):
   This research explains about how adherence with stress (manobhitapakara bhava) lead to produce ama or free radical, and in turn produces chronic metabolic diseases. The harmony of mind (manas) responsible for the perfect harmony of body. Altered external living sources like demographic alteration, change in family system, urbanization, industrialization, westernisation have a potent role to induce the pathogenesis at psychic level as well as body level by the faulty pattern of adaptataion. Repeated attachment with stress (kamadi bhavas) are the potent cause for morbidity and mortality rate of obstinate urinary disease/diabetes melitus type 2(madhumeha). This is not only for the cause but it also responsible for the complication. Excessive generation of free radical sustained affection of stress (manobhitapakara bhavas) altered the body defence mechanism, which in terms can be understand. Treatment like pacifying vitiated manasika dosha (manasa doshahara), counseling, antistress approach, dipana (appetizers), pachana (digestives), can check the vicious pathogenesis involved in madhumeha (obstinate urinary disease/ diabetes mellitus type 2).
   Outcome of the study: There is a direct relation of the mean score of manobhitapakara bhavas (stress), lipid peroxide and fasting blood sugar. By changing mode of life style, optimistic attitude, keeping faith in good, decreasing the high blood pressure level stress hormones can be reduced. Which it reflects through the sufficient decrease in signs and symptoms of the disease.
3. A critical and comparative study of Ama and Free radical theory with special reference to Amavata
   Outcome of study: Free radical is an atom/molecule that contains one or more unpaired electron, which requires neutralisation by free radical scavengers. Thus it exists in an incomplete metabolic state which is also the state of ama described as incompletely digested (avipakvam). Free radicals cause damage to cell membrane and thus the cell is destroyed. This destruction may lead to putrification and foul smell generations which is similar to one of the property of ama described as unpleasant smell (durgandham). Though ama remains in the body as isolated or not mized (asamyuktam), but due to its properties like excessive sliminess (bahupicchilam) etc. it sticks to normal healthy body tissues very quickly, similar is the case with free radicals. To seek stability in their structure they quickly attack the healthy molecules of the body and thus setting a chain reaction. The cells throughout body are continously exposed to these damaging molecules, same has been described for ama as causing sluggishness of whole body (sadanam sarva gatranam). From above one can observe that properties of free radicals are similar to the properties of ama described in classics. Now the process of production of free radicals in body and production of ama would be considered. So it may be concluded that the causative factors (nidana) such as heavy to digest (guru), unctuousness (snigdha) etc. qualities of diet (ahara) of amavata (rheumatism) as mentioned in the classics have a specific role to play in production of ama and also in the generation of free radicals. Also the line of treatment of ama advocated in the classics is effective in reducing the level of ama as well as free radicals. So it can be inferred that a positive correlation exists between ama and free radicals.
4. A critical study of Trividhakuksiyavimana w.s.r. to amotpatti and its management
   Outcome of study: In this study, 2 groups are there, group I (treatment group) patients have been given chaturushna churna (powder) followed by wholesome diet (pathya) and light to digest food. Whereas, in group II (control group) patients received placebo treatment and wholesome diet (pathya) and light to digest food.. Dosha (ama dosha and tridosha (vata, pitta and kapha)) when adhere to amashaya (stomach), the desired response of the medicine may not be obtained which is observed in clinical study. Due to this the 21 days duration of therapy did not produce total cure response. So, we can say that if in disease, treatment regimens opposite to disease (vyadhi viparita ausadha) doesn’t produce good response, then it is to be inferred that here amashaya (stomach) is adhered with ama dosha. In this stage, as advised in Trividhakuksiyavimana adhyaya (2nd chapter of Charak Samhita Vimana Sthana), depleting therapy (apatarpna) should be administered. If presence of disease stage (vyadhi anubandha) remains, then the treatment regimens opposite to disease (vyadhi viparita aushadha) is to be advised.

Contemporary views and research updates on ama

Ama is an important principle to understand the etiopathogenetic of all disorders and to decide the treatment modalities. Agni is the digestive and metabolic factor responsible for any transformation in body. Transformation of food material predominantly takes place at the level of gastrointestinal tract (grahani-seat of jatharagni) and at the level of tissues (dhatvagni-abodes of dhatu). Dysfunction of agni results into undigested or partly digested intermediator product called as ama. Ama act as toxic element and form the basis for many pathological conditions. It can be considered raw, uncooked, unripe, immature, undigested or incompletely oxidized / metabolized or similar to a poisonous substance that disrupts body physiology. Accumulation of metabolic waste (mala) may takes place at various levels in body physiology. The amalgamation of aggravated dosha with metabolic waste results in ama formation, which is considered the initial stage of disease formation. Origin of ama is mainly considered from gastrointestinal tract (amashaya). Agni functions at different levels; hence, ama can be formed at different levels at different body sites. Forms of agni - jatharagni, bhutagni and dhatvagni functions at different level hence any impairment at the corresponding level leads to ama formation.

Digestion process starts from mouth where mechanical and chemical digestion of food takes place. Thinking, smelling and seeing food secrets saliva, helps in digestion. Component of saliva like water, mucus, electrolytes and enzymes has a unique function. Starch breakdown starts here due to the enzyme in saliva called salivary amylase. Mucus lubricates the food and helps in the formation of bolus in mouth. Small food particles are dissolved by saliva and it makes dry food moist enough to swallow comfortably. If person is not following dietary codes, eating hurriedly without proper mastication, disturbed mental health while taking food will affect this cephalic phase of digestion. It will lead to ama formation due to improper digestion process in mouth. Mastication of food is subjected to condition of teeth. Studies have attempted to find a correlation between tooth loss and nutrition. Deteriorated dental health affects mechanical digestion process and leads to nutritional deficiency. Another study observed that modifying the mastication rate alters the glycemic index of rice. Its glycemic index classification shows impact of digestion process on the final outcome of food.

Health of a person is essentially dependents on healthy gut. Mucosal integrity is more important for proper absorption of nutrient from villi. The intestines also play an essential role in protecting the body from harmful bacteria and toxins. If mucosal integrity is hampered it results into leaky gut syndrome. It affects the lining of intestinal mucosa leading to bacteria and other toxins to pass into the bloodstream. It also leads to the imbalance of gut microbiome.

This gut leakage and dysbiosis leads to gut inflammation, also disrupt an immune homeostasis. It causes systemic immune activation, neurological disturbances and auto immune diseases. All these predisposing conditions cause ama formation which triggers many complex pathological conditions, act as route cause for many diseases.

= Ama and free radical theory

In contemporary sciences, the concept of ama can be related with free radical oxidative damage and autoimmune disorders.

In recent years, the concept of free radical theory of oxidative damage in human diseases is accepted widely. Free radicals consist of an atom or molecule which have an unpaired electron. The tendency of such atom to gain an electron from other substances makes it highly reactive species to have a high capacity to oxidize biological molecules such as lipids, nucleic acids, proteins, etc. During the disease process, infections, toxins and trauma, these free radicals get released in body and cause diseases. Free radicals play a significant role in some of the diseases like rheumatoid arthritis, inflammatory gut disorder like ulcerative colitis, diseases of connective tissue, atherosclerosis, myocardial infarction, stroke, cancer, parkinsonism, Alzheimer’s, dementia, diabetes mellitus, etc.

Ama refers to intermediate or by product of metabolism which have a tendency to block the microchannels of the body (srotas avarodha). So ama is an important factor for the manifestation of local or systemic diseases. Ama plays a key role in pathogenesis of all diseases. Agni (digestive capacity) is not just pertaining to amashaya (stomach) or grahani only, but its present at every cellular level. Disturbance in agni can lead to formation of ama at cellular level also. This ama formation at cellular level can produce various disorders like rheumatoid arthritis etc. as mentioned above. Ama can be related with free radicals at cellular level.

Ama at cellular level

Formation of ama occurs at the level of tissues or cellular level due to impaired metabolism or due to free radical activity. Free radicals are highly reactive atom or molecule which is having one or more unpaired electrons. It always tries to have stability by giving its electron or by acquiring extra electron form adjacent molecules. After providing the electron adjacent molecule becomes unstable and acts as a free radical, a chain reaction sets in to damage many molecules. A higher concentration of free radicals causes damage to the cellular structure like DNA, protein, lipid, and other cell parts. It causes disturbance in homeostasis of body leading to disease condition.

Metabolic waste functions as ama

Tissue nutrients after action of metabolism (dhatvagni) nourishes body tissues and part is formed as excretory product (mala). Accumulation of this metabolic waste beyond certain limits disrupts the dosha homeostasis, leads to formation of ama. Depending on the type of metabolic waste and predominance of dosha exhibits many diseases.

Ama formation occurs due to the accumulation of toxic or intermediate product of metabolism in the body termed as mala. These intermediate products are formed due to defect in the metabolism of protein, carbohydrate or lipid. Excessive uric acid is formed due to improper metabolism of protein which is hazardous to body tissue and joint structure. Lactic acid, acetone and ketone bodies are formed due to improper metabolism of carbohydrate and fats. Lack of insulin activity defunct carbohydrate metabolism and leads to formation of intermediate products in the body. This intermediate products act as ama and leads to many disease conditions.

Ama and auto-immune diseases

Auto-immune diseases occur when immune system is attacked by anticipated response against antigen or toxins. These antigens or toxins trigger the inflammatory response. This concept of auto-immune disorders can be compared with the concept of ama. The antigen/toxins can be compared with ama, that produce improper metabolites/toxins within the body. This ama triggered inflammatory response in body results in number of the diseases. Ama at cellular level modulates the response of the body leading to develop incompatible autoimmune response that damages tissues. Crohn’s disease, psoriasis, rheumatoid arthritis, ankylosing spondylitis, are auto immune diseases caused by response against ama or antigen. The immune cells of the body do not attack the body cells suddenly, it happens because of lack of cellular communication as the cells being covered by ama or toxins. The ama is caused by weak digestive fire which affects the proper tissue production and oja (immunity) formation. So, we can consider the poor digestion and weak immunity is the root cause for auto-immune disorders. Therefore, by adopting ayurveda principles of treatment of ama, one can manage the auto-immune disorders.

Related chapters

• Trividhakukshiya Vimana
• Matrashiteeya Adhyaya
• Rasa Vimana
• Sharira Vichaya Sharira
• Grahani Chikitsa
• Ahara vidhi
• Viruddha Ahara
• Amavata
• Rheumatic diseases
• Obesity and Metabolic Syndrome
• Langhana
• Deepana
• Pachana

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