Power Point Presentation On Ama Vata (Rheumatoid Arthritis), Created by Dr R.L.D.S. Ranasinghe, Medical Officer, Post Graduate Scholar, Institute of Indigenous Medicine, University Of Colombo, Sri Lanka.

1. Dr (Ms) R.L.D.S. Ranasinghe
MD Scholar, Dept of Kaya Chikitsa ,
University of Colombo, Rajagiriya.
Prof (Ms) E.R.H.S.S Ediriweera
Dept of Kaya Chikitsa , IIM,
University of Colombo, Rajagiriya.
1

2. g Objectives
g Case presentation
g Review of Ayurveda
g Review of Modern
g Acknowledgement
2

3. gUnderstand the patho-physiology,
signs and symptoms & treatments of
Amavata
gGeneral review on related Modern
Aspects
gImprove diagnosis skills of diseases
g presentation skills to present case
studies
3

4. vName : Mr S.G.W Rudrigu
vAge : 33 Yrs
v Date of Admission : 09th September 2013
v Ward No : 11
v Bed No : 15
v Address : No. 12/10, Handala, Wattala.
v Occupation : Spray painter for 16 yrs
v Nationality : Sinhalese
v Religion : Catholic
v Marital Status : Married
4

5. vMain complaint with duration:
Pain, stiffness & edema of several joints
notably wrist, hand, ankle & feet (3 months)
vOther complaints:
Thirst, Nocturia, Increase sweating (3 months)
5

6. o According to the patient,
o 3 months before; the patient was asymptomatic.
Suddenly he got throbbing pain over both the upper
limbs along with lethargy ,generalized weakness and
thirst. Simultaneously pain was shifted to the RT & LT
lower limbs.
o 1 week after the onset of disease, he suffered from
fever with edema and Pain in the joints: the RT elbow,
RT & LT Knee wrist joints, RT & LT Knee Shoulder joints
& then to the RT & LT Knee Joints gradually.
6

7. ¬ Medical History
RT & LT Knee joint edema at ate age of 7 yrs
Diabetes Mellitus - Identified before 3 months with the onset of the
disease
FBS- 194 mg/ dL (2013. 08. 07)
¬ Surgical History - minor surgery has done in the ankle joint
after RTA
¬ Psychiatric History
¬ Treatment History
- NAD
1. Allopathic treatment for Diabetes Mellitus – 3/ 12
2. Allopathic treatment for joint pain & edema – 8/ 52
- No improvement with allopathic treatment
3. Admitted for Ayurvedic treatment for the first time just before 3 /52
7

8. 53 yrs
DM+ , Rheumatoid Arthritis
35yrs
DM+ 30 yrs
DM+
27 yrs
DM+
57 yrs
7 yrs 3 yrs
8

9. o Diet: Break fast - Bread & Curries, Short eats
Lunch - Rice, Vegetables, Egg
Meat (Chicken, Beef, Mutton)-Daily
Dinner - Rice, Vegetables & meat
More like to eat Spicy & Fried food.
o Appetite: impaired appetite at the onset of the disease
9

10. o Sleep : Disturbed due to Nocturia
o Bath : Evening with cold water, Daily
o Bowel habits : Once/ Day,
Colour - Yellow
Odour - Normal
Character - Asamhata Mala, Sticky
o Micturition : D / N – 3/2 times
Colour - Pale
Odour - Normal
o Addiction : No addictions
o Social status : Living near to the sea side & river
side 10

11. GENERAL PHYSICAL EXAMINATION
• General condition - Average
• BP - 130 /80 mmHg
• PR - 74 / min
• RR - 14 / min
• Weight - 67 kg
• Height - 164 cm
• Tongue - Coated
• Temperature - intermittent febrile Usually in the
evening
• Skin - Normal
• Thyroid
• Pallor NAD
• Icterus
• Cyanosis
• Clubbing
• Enlarged LN
NAD
11

12. 1) LOCO MOTOR SYSTEM
§ Gati (Range of movements) :
• Left Shoulder joint - Abduction
- Adduction
- Rotation
- Elevation
• Left wrist joint - Flexion
- Extension
- Rotation
Limited due to edema &
pain
Limited due to edema &
pain
§ Sandhi sputana (Joint crepitus ) - Presented in both knee
joints
§ Sparsha asahyata (Joint tenderness)
§ Sandhi shota (Joint swelling )
§ Rakta varnata (Redness)
§ Ushnata (Heat)
- Presented in affected joints
§ Mamsa ksaya/ shosha (Muscle wasting) - NAD
12

13. GALS:
• Gait: Slow and painful gait
• Arms: Difficulty in pronation and supination (painful) in LT
wrist joint
Pain – When squeezed the hand across the
metacarpals of the LT hand
Power Grip - reduced (Difficulty in holding)
— Legs: Sandhi sputana both knee
joints
13

14. SPINE:
• Thoracic Spine: Internal and external rotation- Normal
• Lumbar Spine:
• Flexion-Normal • Extension-Normal • Lateral Bending-Normal
• Cervical Spine:
• Rotation-Normal • Flexion, Extension and Lateral bending-Normal
14

15. JOINTS:
• Inspection
• MCP, PIP, DIP, MTP Wrist joints
• Swelling Symmetrical involvement
• Redness Deformities - NAD
• Palpation.
• Tenderness & warmth (MCP, PIP, DIP, MTP, Wrist, Elbow
joints) • Stiffness of the joints
15

16. 2) CARDIOVASULAR SYSTEM
• S1, S2 - Clear . No thrills or murmurs
3) RESPIRATORY SYSTEM
• No added sounds
4) GIT
P/A
• No tenderness
• No organomegaly
5) CNS
NAD Clinically
Higher functions
Sensory system
• Cranial nerves
Motor functions
•Reflexes- LT knee jerk
exaggerated
• Other Reflexes - Normal
16

17. I. Prakriti : Vata Pitta
II. Vikriti : Will be described in next slide
III. Sara : Rasa, Rakta, Mamsa, Asthi, Majja, Sukra - Madhya Sara
IV. Sanhanana : Madhya Samhata
V. Pramana : Madhya pramana (Weight-67 kg, Height -164 cm BMI = 25)
VI. Sattva : Madhya Sattva
VII. Satmaya : Shad Rasa Satmaya
VIII. Ahara shakti: Before After
i. Abyavarana shakti : Prawara Madhya
ii. Jarana shakti : Prawara Madhya
IX. Vyayama shakti : Before After
Prawara Madhya
X. Vayah : Madhyama (35 Yrs)
17

18. ¬ Hethu (Nidana) – Viprakrusta Nidana
Ahara : Katu Rasa, Snigdha, Guru guna
Atisewana
Viharana : Seeta jala sewana, Spray painting
(chemicals)
Vyadhi : Madumeha+
¬ Dosha - Vata, Kapha
¬ Dushya - Rasa, Rakta, Mamsa, Asthi, Majja, Sukra.
¬ Prakiti - Vata, Pitta
¬ Desha - Anupa Desha Near to the riverside & Seaside
¬ Kala - Adana kala
¬ Bala - Roga bala: Kruccha sadya
Atura bala: Madhyama
¬ Lakshana - Edema, pain & stiffness of the joints
18

19. 1. Nadi:
i. Gati - 72/ min
ii. Yati - Samanthara
iii. Akruti - Purna
iv. Samhati - Mrudu
2. Mutra : D/ N – 3 / 2 times
3. Mala : Once/Day, Asamhata mala
4. Jivha : Ama
5. Shabda : Prakrita hrid & pupphusa shabda Ubhaya Janu
sandhi sphutana
6. Sparsha : Ushna sparsa in affected sandhis
7. Druk : Prakrita
8 . Akriti : Madhyama
19

20. 1. Prana vaha Srotas : Prakrita
2. Udaka vaha Srotas : Vikrita; Thalu shosha+
3. Anna vaha Srotas : Vikrita
4. Rasa vaha Srotas : Vikrita; Sandhi shota+
5. Rakta vaha Sorts : Vikrita; Sandhi shota+
6. Mamsa vaha Srotas : Prakrita
7. Medo vaha Srotas : Prakrita
8. Asthi vaha Srotas : Vikrita; Sandhi sula, Shota +
9. Majja vaha Srotas : Prakrita
10. Shukra vaha Srotas : Vikrita; Madhu +
11. Muthra vaha Srotas : Vikrita; Ratrimutrata +
12. Purisha vaha Srotas : Vikrita; Asamhata mala+
13. Sweda vaha Srotas : Vikrita; Atisweda+
14. Mano vaha srotas : Prakrita
20

21. Ø Dosha : Vata, Kapha
Ø Dushya : Rasa, Rakta, Mamsa, Asthi, Majja , Sukra
Ø Adishtana : Sharirika
Ø Srotas :
Rasa Vaha Srotas ,Rakta Vaha Srotas
Mamsa Vaha Srotas, Asthi Vaha Srotas
Majja Vaha Srotas, Shukra Vaha Srotas
Udaka Vaha Srotas, muta, Mutra Vaha Srotas
Sweda Vaha Srotas
Ø Samuttana : Amasha
Ø Agni : Mandagni
Ø Ama : Ama
Ø Srotodushti : Sanga
Ø Udbhawastana : Sarvanga sandhi
Ø Sadhya Asadhyata : Kruccha sadhya
Ø Roga marga : Madhyama (Marma, Asthi,Sandhi)
21

22. q FBS - 194 mg/dl (2013.08.07)
99 mg/dl (2013.10.10) Within normal range with drug control
q UFR
Reaction - Acidic
Albumin
Sugar
Pus cells
Epithelial cells
q CRP - 12mg/ dL Raised
q ESR - 11/ 1st hr Raised
q PCV - 48%
q RF - < 8 IU/mL
Occasional
22

23. Differential diagnosis
AMAVATA
SANDHISHOTA
SSANDHIGATA
VATA
GAMBHIRA
VATA RAKTA
Nidana Viruddha ahara, Snigda
ahara, Alpa chesta etc.
Vata kopakara
Ahara, Viharana
Vata & Rakta
kopakara Ahara,
Viharana
Rupa Angamarda, Aruchi,
Trushna, Alasya etc
Shula, Shota,
Prasaranakunchan
a Vedana
Daha, Supti,
Vaivarnya,
Sphutana etc
Sthana Start from small joints
of hands & spread
Mainly start with
weight bearing
large joints
Start from the
end parts of the
hands & feet
Dosha Kapha, Vata Vata Predominant Vata, Pitta
23

24. Differential diagnosis
Rheumatoid Arthritis Gout Osteoarthritis
INFLAMMOTRY DISEASE METABOLIC DISORDER DEGENERATIVE
DISEASE
PROLIFERATION OF
SYNOVIAL MEMBRANE
IMPAIRED PURINE
METABOLISM
DEGENERATION OF
ARTICULAR
CARTILAGE
ATLEAST 3 JOINTS ARE
INVOLVED
MONOARTICULAR WEIGHT BEARING
JOINTS
MORNING STIFFNESS -
1HR
MORNING STIFFNESS-NA
MORNING
STIFFNESS- 15MTS
PAIN- EXTREME PAIN-MILD PAIN-MILD
24

25. PAIN SUBSIDE BY WORKING
OR EXERCISE
Cont.
NO RELATION PAIN AGGRAVATED DURING
WORKING-RELEVIED BY REST.
MIDDLE AGE-20-35
F:M- 3:1
MIDDLE AGE-ABOVE 40
M:F- 8:1
ABOVE 50YRS
F:M- 2:1
R.A - POSITIVE
E.S.R-RAISED
SERUM PURINE LEVEL IS
MORE THAN 600MG
E.S.R- NORMAL
R.A -NEGATIVE
X -RAY SHOWS REDUCED
JOINT SPACE, SOME TIMES
DEGRATION OF BONE MASS
X RAY X-RAY SHOWS OSTEOPHYTES
AND DEGENERATIVE
CHANGES
25

26. NAVA AMAVATA PRAVRUDHA AMAVATA JEERNA AMAVATA
1.ARUCHI. 1.INVOLVEMENT OF HASTA,
PADA SIRO, GULPHA,TRIKA
ETC
1. DESTRUCTION OF
ARTICULAR CARTILAGE.
2.ALASYA. 2.SHOTHA ,STABDHATA 2.OSTEOPOROSIS.
3.GOURAVA. 3.EXTREME PAIN. 3.DEFORMITIES.
4. JWARA 4.PRASEKA,ARUCHI. 4.POLYARTHRITIS.
5.HRILLASA 5.HRIDAYA GOURAVA AND
HRITGRAHA.
6.APAKTHI. 6.CHARDI,BHRAMA,MOORC
HA, ANAHAM.
26

27. Diagnosis
— Viruddha ahara, Snigda
ahara, Alpa chesta Seta
jala, Vata sparsa etc.
— Angamarda, Aruchi,
Trushna, Alasya etc
— Start from small joints
of hands & spread
— Kapha, Vata
— Inflammatory disease
— At least 3 joints are involve
— Morning stiffness
— Pain
— Middle age- 33 yrs
— E.S.R-Raised
— CRP -Raised
Amavata sandhi shota Rheumatoid Arthritis
27

28. ë Duration : 3 weeks (2013.09.20 - 2012.10.15)
ë Improvements: Fever & Ama conditions subsided
Internal medications
§ Denibadi decoction 120 ml, bd, before meal
§ Kaphahara kwatha 2 tablespoonful, bd, before meal
§ Chandra prabha vati 2 bd with hot water, after meal
— Haritakyadi vati 2 bd with hot water, after meal
External applications
§ Dashanga Lepaya – To affected joints, morning & evening with
juice of tamarind leaves
28

29. Patyapatya
Patya Ahara
•Yava
•Kulatta
•Rakta shali
•Drumstics
•Punarnava
•Bittergourd
•Ginger
•Rasona
•Ginger with takra
•Hot water
Patya Viharana
— Warm water bath
— a gentle walk after
consumption of food
29

30. Apatya Ahara Apatya Viharana
• Guru snigdha ahara
• Sweets
• Uncooked food
• Salty food
• Oily food
• Fast food
• Fish
• Milk
• Ghee
• Cold water
— Cold breeze and excessive
wind
— Bathing with cold water
— water intake immediately
after consuming food
30

31. 31

32. Etymology of Amavata
—
- Ama and Vata unites to form Amavata
(Vijayaraksihta)
•
- Vata associated with Ama creating a disease
Known as Amavata
(Vijayarakshita)
32

33. •
(Amarakosha)
- The substance which undergoes a typical change
in the processes of digestion is known as Ama
•
(Amarakosha)
Etymology of Ama
•
33

34. Aetiopathogenisis of Amavata
Ma. Ni. 25/ 1-5
34

35. Aetiology of Amavata
35

36. Samprapti of Ama Vata
Ahara
Viruddha
ahara,
Snigdha
ahara, Guru
Ahara
Viharana
Diwa svapna,
Nischalata,
Manasika
Chinta,
Shoka. Bhaya,
Krodha
Agni mandya
Sanchaya
Prakopa
Ama visha
Sama Vata
Sleshma sthana
Dhamani
Dushti by Tridosha
Prasara
Dushti by Tridosha
Rasavaha srotas Trika sandhi
pravesha
Daurbalya,
Sandhi shota,
Shula
Sandhi
sthabdata
Amavata
Stahana
Samsraya
Vyakti
36

37. Rupa- General clinical features
Ma. Ni. 25/ 6
— Body ache
— Anorexia
— Thirst
— Malaise
— A feeling of heaviness
— Fever
— Indigestion
— Inflammation of the body parts
(myositis , fibrositis, arthritis etc)
37

38. Pravruddha Amavata (Exacerbation of Amavata)
Ma. Ni. 25/ 7- 10
38

39. 39

40. • When Amavata gets exacerbate Pravruddha Amavata
(most distressing of all the diseases)
• Where ever the (Ama) Dosha reaches
joints of the hands
feet
cervical region (pelvic &
shoulder)girdles ,
knees & thighs
• The affected part is excessively painful as if it is bitten by
scorpions
Produces painful
swelling
40

41. • anorexia & a feeling of
heaviness
• loss of the drive
• bad taste in the mouth
• poly urea & a burning
sensation
• hardness in the abdomen
• colicky pain &
• reversal of normal sleeping
habit
• thirst
• vomiting
• vertigo
• Fainting
• pericardial discomfort
• constipation
• stiffness
• gurgling intestinal
sounds
• meteoric & other
troublesome
complications
It gives rise to
41

42. Features of doshik predominance in Amavata
(Ma. Ni 25/11)
— with the predominance of Pitta
there is redness & heat(locally)
— whereas with predominance of Vata
the pain is severe
— In Kapha, feeling of being covered
with wet cloths, heaviness & itching
42

43. Amavata Prabheda
• Doshanubandha Lakshanas (BP)
(1) Vatanubandha : Sasulam
(2) Pittanubandha : Sadaha, Saraga
(3) Kaphanubandha : Stimitatam
• Doshanubandha (Madhavakara)
Vata,Pitta,Kapha,VP,VK,PK,Sannipataja.
• Avastha bhedena: (Madhavakara)
Samanya.
Pravrudha.
43

44. Sadhya asadhya bhava -Prognosis
Ma. Ni. 25/12
— One Dosha involved → curable
— Two Dosha involved → relievable
— Three Dosha involved → difficult to cure
(Inflammation of all over the body)
44

45. Upadrava (Complications)
•Sankocha and Khanjata (Vijayarakshita)
•Kalaya khanjata (Bhavaprakasha)
•Jadya, Antrakujana, Anaha, Chardi (Anjana Nidana)
•Angavaikalya (Harita)
•Akshepana (Gayadasa)
•Vatavyadhi (Vachaspati vaidya )
45

46. Amavata Cikitsa
(Bha. Pra.Ma.Kha 26/ 14,15)
• Langhana(fasting)
• Swedana (sudation)
• Use of drugs of Tikta katu rasa
• Deepana (stimulating appetite)
• Virecana (purgaation)
• Oleation (snehapana)
• Vasti (enema)
• Ruksha sweda valuka pottalee (use of bags of heeted sand)
• Upanaha (applying poultiecs) without use of sneha
46

47. Anthah parimarjana
1. Ama pacana, Jvara hara
1. Pachanamruta Decoction, Pata ½ bd, Before meal
2. Murva 10 Decoction, Pata ½ bd, Before meal
3. Amrutashtaka Decoction, Pata ½ bd, Before meal
4. Beli mul 16 Decoction, Pata ½ bd, Before meal
5. Denibadiya Decoction, Pata ½ bd, Before meal
6. Hinguvastaka Churna, 30 grns, bd with hot water, After meal
7. Sudarsana Churna 30 grns, bd with hot water, After meal
8. Seetarama Vati 3 bd, bd with hot water, After meal
9. Avipattikara Churna 30 grns, bd with hot water, After meal
47

48. 2. After Ama Pachana – Nirama avastha
1. Rasna 7 Decoction, Pata ½ bd, Before meal
2. Rasna 13 Decoction,Pata ½ bd, Before meal
3. Sinhanada Guggulu 2 bd with Bavila, sudulunu water , After meal
4. Hinguwashtaka churna 30 grns, with hot water, After meal
5. Rasnadi guggulu, 2 bd, with hot water, After meal
6. Vata gajendrsinha rasa, 2 bd, with hot water, After meal
7. Amavatari rasa, 2 bd, with hot water, After meal
48

49. Madhumeha Cikitsa- Along with Amavat chikitsa
— Nishatripal veniwelgata Decoction, Pata ½ bd, Before meal
— Triphala Churna, 30 grns, bd with hot water, After meal
— Haritakyadi Vati, 2 bd, with hot water, After meal
— Somanatha Rasa, 2 bd, with hot water, After meal
49

50. Bahir parimarjana
Ø Swedana- Ruksha sweda
• Valuka pottali
• Pottali sweda by using ruksha dravya such as Saindava,
Karpasa, Kulattha, Tila, Eranda, Atasi, Punarnava,
Ø Snehana – Ruksha sneha Abhyanga (In Nirama avastha)
1. Mee taila
2. Saidavadi taila
3. Amavata taila
4. Nirgundi taila
Ø Lepa
1. Dhusturadi Lepa
2. Satapushpadi Lepa
3. Hinsrapadi Lepa
4. Humbas mati pattuwa
5. Dasanga Lepa
6. Delipothu pattuwa 50

51. 51

52. Rheumatoid Arthritis is a chronic Systemic
Inflammatory disorder of unknown etiology
52

53. Epidemiology
• Affects 0.5- 1.0% of the population world wide
• Peak prevalence between the ages of 30 and 50 years
• RA has an incredibly high disease burden and cost to
society
• Drastic affect on quality of life
• Increased disability (80% disabled after 20 years of
disease)
• Patients with RA have shorter life expectancies
53

54. Aetiology
— Gender : women before the menopause are affected3
times more than men & equal sex incidence thereafter
— Familial : Increase incidence in those who with a
family history of RA
— Genetic factors: Human Leucocyte Antigen HLA- DR4
& HLA- DrB1
54

55. Rheumatoid Arthritis: Key Features
• Inflammatory synovitis
• Palpable synovial swelling
• Morning stiffness >1 hour, fatigue
• Symmetrical and polyarticular (>3 joints)
• Typically involves wrists, MCP, and PIP joints
• Typically spares certain joints
— Thoracolumbar spine
— DIPs of the fingers and IPs of the toes
55

56. Rheumatoid Arthritis:Key Features (cont’d)
• May have nodules: subcutaneous or
periosteal at pressure points
• Rheumatoid factor
• 45% positive in first 6 months
• 85% positive with established disease
• Not specific for RA, high titer early is a bad sign
• Marginal erosions and joint space narrowing on x-ray
• Symptoms >6 weeks’ duration
• Often lasts the remainder of the patient’s life
56

57. Non -Articular manifestations
57

58. The Normal Joint
58

59. Pathogenesis of Rheumatoid Arthritis
Inflammed synovial tissue (synovitis)
• Villous hyperplasia
• Intimal cell proliferation
• Inflammatory cell infiltration
T cells, B cells, macrophages and
plasma cells
• Production of cytokines and
proteases
• Increased vascularity
• Self-amplifying process
59

60. Deformities of Rheumatoid
Arthritis
60

61. Investigations
Blood screening:
— ESR
— C Reactive Protein
— FBC with differential
— RF
— Serum calcium phosphate & alkaline phosphate
— Serum uric acid
— ASOT
Additional imaging techniques:
• CT scans
• AP & Lateral tomography (x-ray)
• MRI scan
• USS (good for assessing the presence of fluid)
61

62. Differential diagnosis
Rheumatoid Arthritis Gout Osteoarthritis
INFLAMMOTRY DISEASE METABOLIC DISORDER DEGENERATIVE
DISEASE
PROLIFERATION OF
SYNOVIAL MEMBRANE
IMPAIRED PURINE
METABOLISM
DEGENERATION OF
ARTICULAR
CARTILAGE
ATLEAST 3 JOINTS ARE
INVOLVED
MONOARTICULAR WEIGHT BEARING
JOINTS
MORNING STIFFNESS -
1HR
MORNING STIFFNESS-NA
MORNING
STIFFNESS- 15MTS
PAIN- EXTREME PAIN-MILD PAIN-MILD
62

63. PAIN SUBSIDE BY WORKING
OR EXERCISE
Cont.
NO RELATION PAIN AGGRAVATED DURING
WORKING-RELEVIED BY REST.
MIDDLE AGE-20-35
F:M- 3:1
MIDDLE AGE-ABOVE 40
M:F- 8:1
ABOVE 50YRS
F:M- 2:1
R.A - POSITIVE
E.S.R-RAISED
SERUM PURINE LEVEL IS
MORE THAN 600MG
E.S.R- NORMAL
R.A -NEGATIVE
X -RAY SHOWS REDUCED
JOINT SPACE, SOME TIMES
DEGRATION OF BONE MASS
X RAY X-RAY SHOWS OSTEOPHYTES
AND DEGENERATIVE
CHANGES
63

64. Differential diagnosis
RHEUMATIC FEVER SEPTIC
ARTHRITIS
PSORIATIC
ARTHRITIS
C.V.S DISEASE STAPHYLOCCUS
AUREUS
GENITIC
STREPTOCOCCUS
.P
FEVER D.I.P ARTHRITIS
GENITIC ARTHRITIS SACRO ILITIS
FEVER MYALGIA IRITIS
64

65. ANOREXIA PERICARDITIS ASSYMMETRIC
OLIGO ARTHRITIS
SYMMETRY NEPHROTIC SYNDROME NAIL CHANGES
CNS EPILEPSY
LEUCOCYTOSIS
Cont..
65

66. § Evaluate the progress & continue the relevant treatment
§ Physiotherapy
§ Rehabilitation of the Patient
66

67. Acknowledgement
— Department of Kaya chikitsa, Institute of Indigenous
Medicine, University of Colombo, Rajagiriya.
— Director, National Ayurveda Hospital Sri Lanka.
— RMO, National Ayurveda Hospital Sri Lanka.
67

68. 68