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A study on vamana Dhouti in Tamaka Shwasa (Bronchial Asthma) with special reference to Vasantha Ritu, MoniLal Das, S.D.M. College of Ayurveda and Hospital. Hassan.2005
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THESIS SUBMITTED TO
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
AS A PARTIAL FULFILMENT FOR THE DEGREE OF
DOCTOR OF MEDICINE (AYURVEDA)
SWASTHAVRITHA
BY
MONILAL DAS
UNDER THE GUIDENCE OF
Dr. RAMANA. G.V. M.D. (AYU)
PROF & H.O.D, DEPT. OF SWASTHAVRITHA
DEPARTMENT OF POST – GRADUATE STUDIES IN
SWASTHAVRITHA
SRI DHARMASTHALA MANJUNATHESHWARA
COLLEGE OF AYURVEDA & HOSPITAL
HASSAN – 573 201
I
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled “A study on vamana Dhouti
in Tamaka Shwasa (Bronchial Asthma) with special reference to Vasantha Ritu” is bonafide and
genuine research work carried out by me under the guidance of Dr. G.V.RAMANA, Professor &
HOD Department of Post Graduate Studies in Swasthavritha S.D.M. College of Ayurveda and
Hospital. Hassan.
Date: MONILAL DAS
Place: Hassan
II
DEPARTMENT OF POST GRADUATE STUDIES IN
SWASTHAVRITHA.
S.D.M. COLLEGE OF AYURVEDA & HOSPITAL
HASSAN
(Affiliated to Rajiv Gandhi University of Health Sciences, Bangalore,
Karnataka)
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled “A study on Vamana Dhouti
in Tamaka Shwasa (Bronchial Asthma) with special reference to
Vasantha Ritu” is a bonafide research work done by Monilal Das in
partial fulfillment for the degree of Ayurveda Vachaspathi (Doctor of
medicine) in Swasthavritha
III
Professor and HOD
Dept. of PG studies in
Swasthavritha
SDMCA & Hospital, HASSAN
DEPARTMENT OF POST GRADUATE STUDIES IN SWATHVIRTHA
S.D.M. COLLEGE OF AYURVEDA & HOSPITAL, HASSAN
(Affiliated to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka)
ENDORSEMENT BY THE H O D; PRINCIPAL / HEAD OF THE
INSTITUTION
This is to certify that the dissertation entitled “A study on Vamana Dhouti in
Tamaka Shwasa (Bronchial Asthma) with special reference to Vasantha
Ritu” is a bonafide research work done by MoniLal Das under the guidance of
Prof. Dr. Ramana.G.V , Department of Post Graduate Studies in
Swasthavritha S.D.M. College of Ayurveda & Hospital, Hassan.
IV
,
Seal & Signature of the H.O.D Prof. Dr. G V Ramana MD (AYU)
Dept. of PG studies in Swasthavritha S D M College of Ayurveda Hassan
Seal & Signature of the Principal Prof. Dr. Prasanna N. Rao MS (AYU), Ph.D
Principal
S D M College of Ayurveda Hassan
COPYRIGHT
DECLARATION BY THE CANDIDATE
I hereby declare that the Rajiv Gandhi University of Health Sciences,
Karnataka shall have the rights to preserve, use, and disseminate this
dissertation in print or electronic format for academic / research
purpose.
V
Date: Monilal Das
Place: Hassan
© Rajiv Gandhi University of Health Sciences, Karnataka
.
ACKNOWLEDGEMENT
My heartiest thanks go to the Director of Health services,
Govt.of Tripura for giving me a chance to pursue post graduation course.
I bow my head in gratitude to the divinity Dr. D. Virendra
Heggadeji, the president of SDM Educational Society. I extend my
sincere thanks to Prof. S. Prabhakar Secretary, SDM.E.S for providing
me an opportunity to join in this esteemed institution.
I am greatly indebted to our respected principal Prof.
Prasanna. N. Rao for supporting me in every wake of my P.G
education at Hassan and also for his encouragement during my studies.
VI
The words are inadequate to express with profound reverence my
heartiest gratitude & indebtedness to my teachers and Guide Dr.
Ramana. G. V, Prof & HOD and , Dr. Sajitha .K Asst. professor,
for their unforgettable parental affection and patience, cooperation to give
suggestions at every step in accomplishing the present work.
I am very grateful to my teachers, Dr. T .B. Tripathi, Dr.
Prakash Hegde for their timely help and suggestions during my study. I
am thankful to all the staff and my PG colleagues of S.D.M. College of
Ayurveda and Hospital Hassan, for their cooperation during my study.
It is a privilege for me to express my thanks and best wishes to
my department colleagues Dr. Srikanth Sajjanar, Dr. Guheshwar Patil,
Dr. Shivakumar, Dr. Manish Arora, Dr. Ashok Patil, Dr. Shivakumar
Harti , and Dr Ashok A.
I can not forget the moral support given by Dr C. B Singh, Dr
Amarnath, Dr Avnish Pathak and Dr. Rohith and others. I extend my
sincere thanks to Librarian and other staff for their valuable support during
my studies.
It was not possible to complete this work without Patients
therefore I am very much great full to each and every patient who co-
operated me for this work.
I am very grateful to my parents late Dr. H P Das & Mrs.
Kanan kana Das, my wife Mrs. Deepa Das, brothers, nephew, mother in
VII
law Mrs. Pratibha Jowardhar, father in law Late. Shambunath
Jowardhar and the whole family members including my beloved
daughter, for their constant help and support.
May Lord Dhanwanthri bless all with Hitayu and Sukhayu who
helped me directly and indirectly in completing this work.
MoniLal Das
LIST OF ABBREVIATIONS
Ch. - Charaka Samhita
Su. - Sushruta Samhita
A.S. - Astanga Sangraha
A.H. - Astanga Hridaya
B.P. - Bhava Prakash
B.R - Bhaishajya Ratnavali
M.N. - Madhava Nidana
C.D. - Chakradatta
Sha. sam - Sharangadhara Samhita
su. - Sutrasthana
Sha - Shareera Sthana
Ni - Nidana Sthana
VIII
Ci - Chikitsa Sthana
I - Indriya Sthana
Ka - Kalpa Sthana
U - Uttara tantra
Purva - Purva khanda
AEC - Absolute eosinophilia count
TC - Total Count
DC - Differential count
ESR - Erythrocyte Sedimentation rate
PEFR - Peak Expiratory Flow Rate
T.B. - Text Book
T.S. - Tamaka Shwasa
UTRI - Upper Respiratory Tract Infection
AT - After treatment
BT - Before treatment
VDVR – Vamana dhauti in Vasantha Ritu
VDIR – Vamana dhauti irrespective of Ritu
Contents
INTRODUCTION……………………………………………………… 01
REVIEW OF LITERATURE
CHAPTER: 01 – TAMAKA SHWASA……………………………….. 03
CHAPTER: 02 – VAMANA DHOUTI……………………………….. 43
CHAPTER: 03 – VASANTHA RITU ………………………………… 58
MATERIALS AND METHODS …………………………………… 66
OBSERVATIONS …………………………………………………… 71
IX
RESULTS...……………………………………………………………..
81
DISCUSSION…………………………………………………….……
95
CONCLUSION ………………………………………………………..
101
SUMMARY……………………………………………………………
103
REFERENCES………………………………………………………...
105
BIBLIOGRAPHY………………………………………………………
109
ANNEXURE……………………………………………………………
112
List of tables Table No.
Table Contents
1 Showing Nidana of Shwasa / Tamaka Shwasa 2 Showing Purvaroopa of Shwasa Roga 3 Showing the Roopa of Tamaka Shwasa 4 Showing Sapeksha Nidana of Tamaka Shwasa 5 Showing the Vyavachedaka Nidana of Tamaka Shwasa 6 Showing types of Asthma 7 Showing differential diagnosis Asthma with COPD 8 Showing difference b/n bronchial asthma and Tropical eosinophilia
X
9 Showing Pathya Ahara & Vihara 10 Showing Apathy a Ahara & Vihara 11 Age wise distribution of 20 patients of Tamaka Shwasa 12 Sex wise distribution of 20 patients of Tamaka Shwasa 13 Religion wise distribution of 20 patients of Tamaka Shwasa 14 Marital status wise distribution of 20 patients of Tamaka Shwasa 15 Education wise distribution of 20 patients of Tamaka Shwasa 16 Occupation wise distribution of 20 patients of Tamaka Shwasa 17 Socio-economic status distribution of 20 patients of Tamaka Shwasa 18 Habitat wise distribution of 20 patients of Tamaka Shwasa 19 Prakriti wise distribution of 20 patients of Tamaka Shwasa 20 Sara, Samhanana wise distribution of 20 patients of Tamaka Shwasa 21 Satva, Satmya wise distribution of 20 patients of Tamaka Shwasa 22 Vyayama Shakti wise distribution of 20 patients of Tamaka Shwasa 23 Agni wise distribution of 20 patients of Tamaka Shwasa 24 Diet wise distribution of 20 patients of Tamaka Shwasa 25 Addiction wise distribution of 20 patients of Tamaka Shwasa 26 Desha wise distribution of 20 patients of Tamaka Shwasa 27 Nidana wise distribution of 20 patients of Tamaka Shwasa 28 Effect of VDVR on Ghurghurata 29 Effect of VDVR on Shwasakrichrata 30 Effect of VDVR on Kasa 31 Effect of VDVR on Kanthodhvmsa 32 Effect of VDVR on Duration of attack 33 Effect of VDVR on frequency of attack 34 Effect of VDVR on PEFR 35 Effect of VDIR on Ghurghurata 36 Effect of VDIR on Shwasakrichrata 37 Effect of VDIR on Kasa 38 Effect of VDIR on Kanthodhvmsa 39 Effect of VDIR on Duration of attack 40 Effect of VDIR on frequency of attack 41 Effect of VDIR on PEFR
1
Introduction
Research is consolidation, correlation, interpretation and widening of the existing
knowledge. It has to be a continuing process to keep one self update with new
developments. Ayurveda gives importance to prevention of diseases rather than
treatment. It approaches the diseases through the person. Unlike other systems where
medicines are the prime for health; diet, work and regulations are more important in
Ayurveda. Perfect understanding and practice of these factors help every individual to
avert diseases and to have everlasting health and happiness.
Tamaka Shwasa is explained to be a kastha sadhya vyadhi. It requires the careful
monitoring of medicine, diet and regimen for effective control. With slight variation in
any of these factors, exacerbations can occur. The emotional status and the influence of
season can not be ignored. It has remained as a challenge even in this period of advance
medical facilities.
The disease analogous with this is Bronchial Asthma. It consists of repeated
attacks of breathlessness and wheezing. It is a disease of larger and medium sized
airways of lungs with obstruction to the outflow of air from lungs. The symptoms come
in episodes which are triggered by various allergens, change of season, stress and
emotional factors.
The extent of population affected by this disease is constantly increasing as the air
pollution is on rise with urbanization and industrialization. With no permanent cure in
vicinity maintenance is needed in the form of modification in diet and regimen.
The alternate positive health systems like yoga, naturopathy are to be researched
to find an effective alternative treatment method.
2
The disease shows a prevalence rate of 20 to 30% among population. Since many
of the cases shows the onset at an early age preventive measures can be initiated from
child hood itself. Various treatments are proven with different success rates as in every
patient the etiology and severity of disease is different.
Vamana karma is indicated in Vasantha ritu even in healthy individuals also to
eliminate aggravated kapha Dosha. In patients with prabhuta kapha Dosha, sadyo vamana
has been implemented with good results. This procedure requires physician’s supervision
and can not be tried by the patient himself. Since the disease nature requires repeated
administration of procedure, this can not be indicated in all.
Shatkriyas of yoga are explained with a view of cleansing different systems of the
body. Vamana dhauti is explained as a procedure effective in relieving respiratory and
digestive disorders. The simple method enables a patient to undertake the treatment at his
home by himself. Earlier studies conducted have proved its efficacy in Tamaka Shwasa.
But this study indents to observe the efficacy of vamana dhauti when conducted in
Vasantha ritu, with that of other seasons.
A total of 20 patients were selected and divided in to two groups. Group ‘A’
patients were subjected with Vamana dhauti in Vasantha ritu, and Group ‘B’ patients
were administered in other than Vasantha ritu. With diet and other regimen common for
all the patients in both groups an effort is made to study influence of Vasantha ritu in
influencing the efficacy of the treatment.
3
Tamaka Shwasa Nirukti & Paribhasha
The word Tamaka Shwasa is composed of two words. They are ‘Tamaka’ and
‘Shwasa’.
The word Shwasa is derived from the Sanskrit root Shwas, meaning “to breathe”.
“Shwasiti Anena Iti Shwasaha” 1- breathing of air is known as Shwasa (Apte dictionary).
This derivation represents the physiological aspect of breathing.
“Shwasasthu Bhasthrikadhmana Vatordwagamitha” 2- as per this derivation the
word Shwasa refers to expiration of the air, producing sound similar to the one generated
while blowing the air with a blower by the blacksmith. This refers to the forceful
laboured breathing, probably with wheezing sound. The description unravels the
pathological expression of breathing and is the cardinal symptom of Shwasa roga.
Tamaka
“Tamyati Anena Iti Tamaka, Tamaka Glanou3as per this Sanskrit derivation, the
word Tamaka represents a diseased condition, which presents with darkness in front of
the eyes or tiredness. Tamaka means to cause darkness or tiredness.
“Tamayati Iti Tamaka, Tama Eva Tama” 4– this is another derivation of the word
Tamaka. According to this derivation, the illness that causes darkness or the illness which
itself represent darkness, is called by the name Tamaka.
Tamaka Shwasa
“Tamakascha Asou Shwasacha Tamaka Shwasa” 5 this line explains
manifestation of the difficulty in breathing, which occurs mainly during the night time.
This is called as Tamaka Shwasa. Difficulty in breathing is the cardinal symptom of
Tamaka Shwasa, and in extreme cases it may be associated with darkness in front of the
4
eyes. Also the attacks of Tamaka are considered to be worst during the night. These
natures of the illness are unraveled in the above said etymological derivation.
Susruta: Defines “Tamaka Shwasa as Vischeshat durdine tamyethi Shwasaha”6 as
“Tamaka Shwasa”. It means the attack of Shwasa with tamapravesha which occurs
especially during “Durdina”.
The meaning of durdina is not explained in this context. But in Charaka Samhita
it is stated that symptoms gets aggravated during cloudy days7.
Vijaya Rakshita: Explains Tamaka Shwasa as
“Shwasasthu bhasthrikadmana Samavathordwa gamani” .
Which means it is a disease where in the expiration of air produces a sound
similar to the sound of bellow of the blacksmith.
HISTORICAL REVIEW
PREVEDIC AND VEDIC PERIOD
The available literatures of Prevedic and Vedic period reveal that the physiology
of respiration, the role of Prana in respiration, the concept of Apana are mentioned at a
number of occasions. The word Prana is coined to describe the act of respiration. Some of
the references like pranad vayu jayate (10-90-13); ayumapranaha (1-66-1) reveals the
same. In Yajurveda also, the process of respiration, the act of inspiration, the effort of
expiration and involvement of Prana Vayu in respiration are elaborated. The concept of
respiration and the role of Pranavayu in respiration is also clearly described in atharvana
Veda.
5
UPANISHAD KALA
The act of inspiration and expiration is mentioned as the prime physical sign of life in
Amanaskopanishath. Further, the opinion of absence of respiration suggesting the death
is also described.
In Brihadaranyakopanishath the Prana is referred by the names Angirasa and Ayusya.
The function of controlling the body mechanisms are attributed to Prana Vayu in this
book. In the Chandogyopanishath8, the Prana has been named as Angeera and Brhaspati.
The role of Prana in nourishing the body is elaborated here.
The diseased conditions of Pranavaha srotas that includes Hikka, Shwasa and Kasa
are described and the role of deranged Vayu in its causation is explained in Yoga
Chudamanyam.
The organ of respiration is symbolically compared to the bird Crane; the two wings of
the bird representing the organ of respiration, the trunk indicating the heart, and the neck
of the bird expressing the wind pipe are discussed in detail in Hamsopanishath.
SAMHITA KALA
Charaka Samhita
The detailed description of Shwasa and its five varieties are found in 17th chapter
of Chikitsa Sthana. The elaborate explanation of etiological factors, pathogenesis,
premonitory symptoms, clinical manifestations as well as complete radical treatment of
Shwasa is given here. Pratamaka and Santamaka Shwasa, the variant forms of Tamaka
Shwasa are also described in Charaka Samhita.
6
Sushruta Samhita
The whole description of Shwasa roga, its types and the treatment is available in
Sushruta Samhita.
Bhela Samhita
Shwasa as a symptom is mentioned in Bhela Samhita. In the form of complication
of many disorders Shwasa is described in this treatise.
Harita Samhita
Etiopathogenesis, line of treatment and dietetics of Shwasa Roga are described at
full length in Harita Samhita. The relevant descriptions are available in the 14th chapter of
third Sthana of this work.
Kasyapa Samhita
In Khila Sthana, the brief description of Shwasa Roga with its treatment is
described along with Kasa Roga.
Ashtanga Hridaya and Ashtanga Sangraha
In both Nidana Sthana and Chikitsa Sthana the relevant description of Shwasa
Roga is available in these books.
Madhava Nidana
12th chapter deals with the diagnostic aspect of the Swasa Roga in this book of
Madhava Nidana.
7
MEDIEVAL PERIOD
Chakrapanidatta:
Description of Shwasa Roga available in this book is in accordance with the
Brihatrayi.
Chakradatta:
His treatise describes Shwasa Chikitsa in the 12th chapter along with Hikka Roga.
Arunadatta:
In his commentary titled Sarvangasundara on Ashtanga Hridaya, has mentioned
the etiological factors of Shwasa and has opined the predominant involvement of Kapha
Dosha in the etiopathogenesis of Shwasa Roga.
Kalyanakaraka:
The description of herbomineral combinations that may be prescribed in patients
suffering from Shwasa Roga is unique in this text book.
Ayurvedarasayana:
Indukara says the aggravated Kapha is the cause of Shwasa.
Bhavaprakasha and Yogaratnakara:
Both these works describe the Shwasa Roga at full length and this is in
accordance with the description available in Brihatrayi.
8
NIDANA
The causative factors of Shwasa Roga in general are also the etiological factors of
Tamaka Shwasa. Tamaka Shwasa may develop as an independent illness, as a result of
exposure to specific Vata and Kapha vitiating factors. The disease may also manifest as a
sequel of certain disorder like Anaha, Raktapitta. Here Tamaka Shwasa manifests as a
Nidanarthakara Roga. To be more precise, the illness Tamaka Shwasa may be
1. Nidhanottha – the resultant of specific incriminatory factors
2. Rogottha – a sequel of certain disease
Chakrapani 9 commenting on the nidanas of the tamaka Shwasa classified them
into two heading like a) Vata prakopaka Nidana
b) Kapha prakopaka Nidana.
Further screening through the nidanas reveals that Nidanas like
1) Amotapadakha nidana and
2) Khavaigunyotpadaka nidana are observed.
Moreover, evolution of the vitiation of Vata and Kapha Dosha, the so called
Sannikrista Nidana, is the result of exposure to Viprakrista Nidana in the form of faulty
intake of food and behavior. Among the list of Viprakrista Nidanas, one can differentiate
the Pradhanika Hethu and Vyabhichari Hethu based on etiology and predisposing factors.
Specific dietetic factors like Ruksha -Sheeta Ahara Sevana, excessive physical exercise,
are capable of mediating in the form of Sannikrista Nidana10. Hence, these are the
Pradhanika Hetu of the illness. Contrary to this, exposure to cold weather and other
similar factors that predispose the illness in patients suffering from Tamaka Shwasa is
9
suggestive of Vyabhichari nature of causative factors. The Nidana of Tamaka Shwasa is
enlisted below.
Table No: 1 Showing Nidana of Shwasa / Tamaka Shwasa
Factors C. S S.S A.H A.S M.N
Vata-Prakopa Ahara
Rukshanna - Ununctuous food + + - - +
Visamashana - Irregular food habit + + - - +
Adhyashana - Habit of eating frequently - + - - -
Anasana - Observation of fast for long - + - - +
Dvandvatiyoga - Mutually contradicting
foods
+ - - - -
Sheetashana - Cold foods - + - - +
Visha – Poison + + - - +
Sheetapana - Cold drinks - + - - +
Pitta-Prakopa Ahara
Tilataila - Gingely oil + - - - -
Vidahi - Food causing burning sensation + + - - +
Katu -Spicy food - - - + -
Usna - Hot food - - - + -
Amla - Sour - - + - -
Lavana - Salt - - + + -
Kapha-Prakopa Ahara
10
Nispava - Dolichos lablab + - - - -
Masa - Vigna radiatus + - - - -
Pistanna – Pastries + - - - -
Saluka - Rhizome of lotus + - - - -
Guru dravyas - Heavy food + + - - +
Jalajamamsa - Meat of aquatic animals + - - - -
Anupa mamsa - Meat of marshy animals + - - - -
Dadhi – Curds + - - - -
Amaksira - Unboiled milk + - - - -
Utkleda - Kaphakara food + + - - +
Vistambhi + + - - +
Vata-Prakopa Vihara
Rajas - Dust / Pollen + + + + +
Dhuma - Smoke + + + + +
Vata - Cold breeze + + + + +
Sheeta Sthana - Cold places + + - - +
Sheeta ambu - Cold water + + + + +
Ativyayama - Excessive exercises + + - - +
Gramya dharma + - - - +
Apatarpana - Emaciating techniques + - + - +
Shuddhi Atiyoga - Excessive purification + + - - +
Kantha/Urah pratighata - Injury to + - - - +
11
throat/chest
Bharakarshita - Emaciation due to lifting
heavy weights
+ + - - +
Adhwahata - Excessive walking + + - - +
Karmahata - Excessive-work + + - - +
Veganirodha - Suppression of urges - - - + -
Abhighata - Injury - + + + -
Marmabhighata–Injury to vital structures + - - - +
Pitta-Prakopa Vihara
Usna – Hot - - - + -
Vata-Prakopa Vihara
Abhishyandi Upacara - Administration of
substances which obstruct the channels
+ - - - +
Divasvapna - Day sleeping - - - - -
Vataja-Vyadhi / Avastha Sambandhi Nidana
Anaha + - - - -
Dourbalya + - - - -
Atisara + - - - +
Kshaya - + - - -
Ksataksaya + - - - -
Udavarta + - - - -
Visucika + - - - -
12
Panduroga + + + + -
Visa Sevana + + + + -
Vibandha + - - - -
Pittaja
Rakta pitta + - - - -
Jwara + - - - +
Kaphaja
Kasa - - + + -
Amapradosa - + - - -
Chardi + - + + -
Pratisyaya + - - - -
Amatisara - - + + -
The etiological factors listed above can independently cause the imbalance of
Vata and Kapha Dosha, the predominant Sannikrista Hetu of Tamaka Shwasa. Along
with this, the list also includes some factors that may vitiate the Pitta Dosha as well as
derange the Pitta Sthana. Most of the etiological factors particularly the one related to the
food mediate the vitiation of the Dosha through the Amasaya. Some other factors like
exposure to the dust directly provocate the Vata Dosha in the Pranavaha srotas.
13
POORVA ROOPA
The Laxanas that appear after the Dosha Dushya Sammurchana are known as
Poorva Roopa11.
As no specific Poorva Roopa are explained for Tamaka Shwasa, the Poorva
Roopa explained in the context of Shwasa can be considered for Tamaka Shwasa12. The
vitiated Vata and Kapha Doshas afflict Rasa Dhatu in the Uras. The symptoms like
Anaha, Adhmana, Bhakthadwesa, and Vairasya are the result of Pitta Sthana
involvement. Parshwa Shoola and Sankha Nistoda indicate the extent of Doshic
circulation. Hridaya pidana and Pranavilomata are indicative of localization of the
Doshas in the Uras13.
Table no: 2 Showing Purvaroopa of Shwasa Roga
Symptoms C.S S.S A.H M.N
Anaha – distension of abdomen + + + +
Adhmana – fullness of the abdomen - - - +
Arati – restlessness - + - -
Bhakthadwesa – aversion to take food - + - -
Vadanasya Vairasya – abnormal taste in the
mouth - + - -
Parshwa Shoola – pain in the sides of the
chest + + + +
Pidana hridayasya – tightness of the chest + + + +
Pranasya vilomata – obstruction to
expiration + - + +
Sankha Nistoda – temporal headache - - + +
14
To sum up, the vitiated Doshas stemming out from the Adhogata Amasaya
circulates in the Uras, Kantha and Siras. Consequently, these Doshas gets localized in the
Pranavaha srotas and produces symptoms like Parshwa Shoola, Hridaya Pidana and Prana
Vilomata, before the actual manifestation of breathlessness.
Bheda - Types of Tamaka Shwasa
Tamaka Shwasa has been classified into two varieties on the basis of association
with Pitta Dosha. They are ‘Pratamaka’ and ‘Santamaka’14.
‘Pratamaka’ is a direct varient of Tamaka Shwasa. It occurs as a result of
Udavarta, Rajasevana, Ajeerna, Klinnakya and by Vegadharana. Here the Tamaka
Shwasa Laxanas are associated with Jwara and Moorcha.
‘Santamaka’ is a further variant of Pratamaka according to Chakrapani.
Gangadhara considered it as an ‘Upadrava’ of ‘Pratamaka’If a patient of Pratamaka
Shwasa feels darkness around him or feels like sinking into unconsciousness due to
Tamodoshavastha of Manas, it can be considered as Santamaka. In both these conditions
though Kapha and Vata are involved the Pittadosha also has main role in the pathogenesis
of the disease. Hence it gets relieved by Sheetalopachara
ROOPA
Vata, Kapha Doshas, Rasa Dhatu and Pranavaha srotas are the predominant
factors involved in the pathogenesis of Tamaka Shwasa. Depending on the extent of
vitiation they determine the clinical manifestations of the disease. Forceful audible
respiration along with expectoration is the cardinal symptom of the disease
15
Episodic abnormality in the breathing pattern is the diagnostic symptom of
Tamaka Shwasa. Obstruction in the Pranavaha srotas due to its stiffness and
accumulation of kapha renders the phenomena known as Pranavilomata 15. This in turn
causes the abnormality in breathing.
Shwasa: Patient may experience feeling of Hridaya pidana16 (Tightness of the chest).
Expiration becomes difficult due to obstruction. Forced respiration results in audible
respiration in the form of abnormal wheeze. Respiration also becomes rapid and will be
much faster than the normal rate of 15 / minute. Breathlessness worsens on any physical
exercise or work. Bouts of paroxysmal cough also worsen the dyspnoea. Expectoration
of sticky sputum gives temporary relief. The patient feels more ease at breathing in the
sitting position. During the severe attacks of breathlessness, patient even may not be able
to speak and perspiration may be seen on the forehead. His conscious may deteriorate.
Kasa17: Paroxysmal productive cough will be associated with breathlessness. Distressing
bouts of cough brings out small amount of tenacious sputum and brings some temporary
relief in dyspnoea.
Kapha Nistivana: 18 abnormally increased secretion of Sleshma in the Pranavaha srotas
is a predominant feature of Tamaka Shwasa. Sputum is tenacious and therefore can not
be brought out easily. It may be mucoid, muco purulent, whitish or yellowish.
Accumulation of the sputum in the Kanta region also causes rattling sounds during forced
respiration producing the Kanta Ghurghurata 19.
Pinasa20: Running nose, sneezing, stuffiness of the nose is another category of symptoms
seen in Tamaka Shwasa. In patients with history of allergy this may be the initial
16
symptom. Followed by this, within an hour or a day the patient develops breathlessness
and other manifestations of the illness.
Depending upon the influence of offending substance, the mode of onset may
vary from insidious, gradual to acute onset. Premonitory symptoms may start with Pinasa
and related symptoms. In some others, irritant cough may be the initial symptom. And yet
other patients may experience difficulty in breathing in the form of tightness of the chest,
followed by the development of other symptoms. Severity of the illness may vary with
different episodes of the illness.
Recurrent attacks of the illness are the hallmark of this disease. Exposure to the
predisposing factors may suddenly initiate an attack of Tamaka Shwasa. In the long run
the symptoms of the illness may become continuous one. This also badly affects the
general condition of the patient and he is likely to get emaciated. Further, the
involvement of Hridaya worsens the prognosis.
Factors like Exposure to dust, cold weather, and cloudy weather that aggravate the
Vata and Kapha Dosha initiate or aggravate an attack of Tamaka Shwasa. In contrast to
this, the factor that are opposite to this, relieve the symptoms.
Table no:3 Showing the Roopa of Tamaka Shwasa
1 Pinasa – running nose, sneezing, stuffiness of
the nose
+ + + +
2 Shwasa – dyspnoea + + + +
3 Tivra Vega Shwasa – rapidity of breathing + + + +
17
4 Amuchyamane Tu Bhrisham – severe
breathlessness if sputum is not expectorated
out.
+ + + +
5 Vimokshante Sukham – slight relief in
breathlessness on spitting out the sputum.
+ + + +
6 Anidra – breathlessness disturbs sleep. + - - -
7 Sayanah Shwasa Piditaha – discomfort
worsens on lying.
+ + + +
8 Aseeno Labhate Soukhyam – feels easy to
breathe in sitting position.
+ + + +
9 Pratamyati Ati Vegat – deterioration of
consciousness
+ - + +
10 Kasa – Cough + + + +
11 Pramoham Kasamanascha – frequent
deterioration of consciousness during
paroxysm of cough
+ - + +
12 Kanta Ghurghuraka – rattling + - - -
13 Kantodhwamsa – soreness of the throat + - - -
14 Utshoonaksa –edema around the eyes. + - + +
15 Vishuskasya – dryness of mouth + - + +
16 Lalata Sweda – sweating in the forehead + + + +
17 Meghaihi Abhivardhate – cloudy weather
worsens the attack
+ - + +
18
18 Sheeta Ambu – cold water + - + +
19 Pragvata – breeze + - + +
20 Sleshmala – Kaphakara + - + +
21 Usnabhinandate – likes hot thing + - + +
22 Aruchi – anorexia - + + +
23 Trishna – excessive thirst - + + +
24 Vepathu – tremors - - + +
25 Vamathu – expectoration - + - -
Among the symptoms, Shwasa, Pratamyati Ati Vegat – deterioration of
consciousness, Pinasa, Kasa are related to Pranavaha srotas. Aruchi is indicative of
Annavaha srotas involvement. Affection of Udakavaha srotas is represented by Trishna,
Vishuskasya. The symptoms like Tivra Vega Shwasa, Anidra, and Vishuskasya indicates
the predominance of Vata Dosha. The Kapha predominant type of Tamaka Shwasa can
be appreciated by Pinasa, Amuchyamana Kapha, Kanta Ghurghurata and Kasa
symptoms.
19
Table no: 4 Showing Sapeksha Nidana of Tamaka Shwasa
Sl.
No Symptoms Tamaka Swasa
Kshataja
Kasa Rajayakshma
1 Swasa Swasa with teevra
vega is the
prartyatma lakshana
One of the
symptoms
One of the
symptoms of
ekadasha roopa
Rajayakshma
2.
Kasa Present Initially dry Present
3.
Stivana Kruchra Stivana Rakta yukta Pichila, visra,
bahala, haritha,
swetha, peeta
varna rasa Stivana,
some times rakta
yukta
4. Jwara Absent Present Present
5. Dhatu
Shoshanna
A late feature Late feature Present
6. Shabda Gurguruta Paravata
koojana
-
7. Shoola Parshwa shoola Vedana in
kantha
pradesha
Parshwa shoola
shira shoola
20
Table no: 5 Showing the Vyavachedaka Nidana of Tamaka Shwasa
Symptoms Tamakashwasa Maha shwasa Urdhwa shwasa Chinna shwasa Kshudra shwasa
Shwasa Ateeva teevra vega Uchaihi shwasati Deergam shwasati Urdwamshwasati
Shwasati vichinnam
Rooksha ayasodbhava shwasa
Shabda Gurguruta Matta Vrishabhavat
_ _ _
Conciousness Pramoha Pranasta Gyanavignana
Pramoha Murcha _
Netra Uchritaksha Vibhrantalochana & Vivrataksha
Uchaihishwasati &Vibhrantaksha
Viplutaksha Raktaikalochana
_
Shoola Parshwa Shoola _ Vedanartha Marmachedha No indriya vyatha
Vak Krichrat Shaknoti Bhashitam
Vishirnavak _ Pralapana _
Asya Vishuskasya _ Shuskasya Pari shuskasya _
Sweda Lalata sweda _ _ _ _
Miscellaneous Badha mutra varcha _ Arati Anaha, vivarna Precipitated by vyayama & ahara no much distress
Sadhyasadhyat Yapya /sadhya Asadhya Asadhya Asadhya Sadhya
21
Samprapti 21
Charaka opines that “the Vitiated kapha obstructs vata and vitiates it in the srotas.
The obstructed vayu tries to over come the obstruction and moves in all the directions
producing shwasa.
Susruta says the Pranavayu goes against its individually combines with Kapha
and causes Shwasa Roga 22.
Bhavamishra and Yogarathnakara’s opinion regarding Samprapti coincides with
Charaka, where as Madhavakara’s coincides with Sushruta.
Vagbhata further emphasised that the Annavaha Srotas23 is also involved and
hence the production of Kapha in Amashaya is affected. Thus Shwasa Roga is regarded
as Amasaya Samudbhava.
Samprapti Ghataka
Dosha: Pranavayu, Udanavayu, Avalambaka Kapha.
Dushya: Rasa dhatu
Agni: Jataragni and Rasadhatwagni
Ama: Jataragni and Dhatwagnimandya
Srotas: Pranavaha Srotas
Dusti Prakara: Sanga, Vimarga Gamana
Udbhavastana: Amashaya ( Adhogata Amasaya), Pitta Sthana
Adhistana: Uras
Sancharastana: Pranavaha Srotas as well as Urah, Kanta, Siras.
Vyakta Stana: Uras
Roga Marga: Abhyantara.
22
Arista Laxana of Tamaka Shwasa
Deergha Uchwasa, Nishwasa; Graditha Mootra, Pureesha associated with
Agnimandya; Atisara, Jwara, Hikka, Chardi, Medrashopha and Andashopha if these
symptoms and signs appear it indicates bad prognosis.
Sadhyasadhyata 24
Tamaka Shwasa becomes sadhya if it is treated in early stages, though it is stated
as a Yapya Vyadhi. As per Dalhana it also becomes Asadhya if it is associated with
Jwara and Murcha. As per Vagbhata Tamaka Shwasa is Yapya, but can become Sadhya if
it is treated in the beginning and if it occurs in a strong person.
Upasaya and Anupasaya 25:
Ushna Ahara and Ushna Vihara are the Upasaya of Tamaka Shwasa. Sheetambu,
Sheetavayu, Pragvata and Sleshma Aharas are the Anupasaya.
CIHIKITSA OF TAMAKA SHWASA
The effective treatment of Tamaka Shwasa cannot be united, as its pathology
involves multiple varying factors as vitiated Vata and Kapha dosha stemming out from
the Pittasthana, afflicting the Rasadhatu in Pranavaha Srotas produces the illness.
Therefore the treatment should aim at the rectification of the imbalance of Vatadosha
and Kaphadoshas. The unique pathogenesis posses complexity in planning the treatment
since both require contradictory line of treatment.
Tamaka Shwasa samprapti involves multiple factors in the form of vitiated Vata
and Kaphadosha involving the Pittasthana, afflicting the Rasadhatu in Pranavaha Srotas
and produces the illness. Therefore the treatment should aim at the rectification of the
23
imbalances of Vatadosha and Kaphadosha. Since the treatment for these are opposite to
each other the pathogenesis posses complexity in planning the treatment. The final
treatment planned should effectively pacify the Vata dosha and Kaphadoshas.
Following modalities of treatment can be carried out
1. Abhyanga and Swedana –Application of the oil over the chest followed by
sudation.
2. Vamana – undertaking therapeutic emesis.
3. Dhoomapana – Therapeutic inhalation of the medicated smoke
4. Virechana Karma – undertaking therapeutic purgation.
5. Pratisyayavat Chikitsa – Treatment in the line of rhinitis.
6. Kasa roga Chikitsa – Treatment of Kasa roga.
7. Vata hara Chikitsa – Elimination of vitiated Vata Dosha.
8. Kapha hara Chikitsa – Pacification of vitiated Kapha Dosha.
9. Mano Dosha Chikitsa – Correction of emotional disturbances.
10. Kapha Vilayana Chikitsa – Liquefaction of the sputum.
VAMANA KARMA26
The presentation of patients suffering from Tamaka Shwasa is not uniform. Some
patients present with symptoms suggestive of dominant Vata dosha and are characterized
mostly by dry cough and prominent wheezing. In such patients, Vamana Karma is not an
ideal choice. In patients presenting with symptoms of dominant Kapha dosha, which is
characterized by paroxysmal productive cough, with tenacious sputum, and bouts of
distressing paroxysmal cough associated with breathlessness. In such patients Vamana
24
Karma may be most ideal. This renders clearness in the Pranavaha Srotas and thereby
allows free passage of the Prana vayu.
VIRECHANA KARMA27
Many a time the patients of tamaka Shwasa give history of allergy or
hypersensitivity to dust and pollen. The answer for such illness is Virechana Karma and
Rasayana Chikitsa. Charaka pronounced this as “Tamaketu Virechanum”. When
employed in between the attacks Virechana karma prevents the attack of Shwasa, reduces
its severity, and minimizes the duration and frequencies of illness. It is also essential to
conduct shodhana before undertaking ‘Naimittika rasayana’ prayoga.
After Virechana, Samsarjana Karma is advised for about 3 to 5 days. By this
Virechana procedure, Doshas stemming out from Pitta sthana gets eliminated. It is worth
mentioning here that, Vata dosha is one of the predominant Dosha involved in the
Samprapti of Tamaka Shwasa. Virechana causes Vatanulomana and thus helps in the
reversal of Vilomagati of Prana vayu. Distension of abdomen, constipation and such
other symptoms which are associated in some patients are best treated by this procedure.
BRIMHANA AND RASAYANA CHIKITSA28
Rasayana chikitsa when administered improves the defence mechnism of different
Srotas, and reduces the abnormal reactions to simple factors in the surroundings. Further
in the long run if it is allowed it may lead to emaciation of the body and chronicity of the
complaint. This can be prevented by the Brimhana and rasayana Chikitsa. Virechana
followed by Vyadhihara Rasayana and Brihmana Chikitsa forms the ideal treatment of
choice to be tried in between the attacks of tamaka shwasa.
25
PRATISHYAYAHARA CHIKITSA
Charaka opines that chronic Pratishyaya may become a cause for Tamaka
Shwasa. Sneezing, running nose, stuffiness are the prominent symptoms that are
associated in Tamaka Shwasa. In a typical attack the patient shows these upper
respiratory tract symptoms. Within hours of this the patient develops wheezing. This
chronological order of symptom manifestation is more suggestive of Pratishyaya Roga as
the cause of Tamaka Shwasa. In such patients along with medicines of Tamaka Shwasa,
the Pratishyaya hara Chikitsa also should be adopted 29.
KASA ROGA CHIKITSA30
Kasa Roga is another disease which is said to predispose Tamaka Shwasa. The
clinical course in this could be the development of productive cough, with or without
manifestation of fever. Characteristically, sputum will be muco purulent or yellowish.
Within a day or two, breathlessness and wheezing follows. This unique evolution of
symptoms is very much indicative of Kasa Roga precipitating attack of Tamaka Shwasa.
Therefore implementing treatment of Kasa Roga in patients of Tamaka Shwasa may be
justified.
26
VATA HARA CHIKITSA
Stiffness, constriction and spasm in respiratory passages are responsible for the
breathlessness and the wheezing sounds in patients of Tamaka Shwasa. Charaka has
advised Sroto mardavakara Chikitsa to relieve the detrimental effect of Vata Dosha
KAPHANISSARAKA CHIKITSA
Effective removal of Sleshma secreted in the Pranavaha srotas forms the principal
treatment of Tamaka Shwasa. Symptomatic approach with expectorant treatment is
desired when the mucoid sputum is disturbing.
BRONCHIAL ASTHMA
The description of Tamaka Shwasa is similar to the disease Bronchial Asthma and
the opinion in this is unanimous. Hence analyzing the description of Bronchial Asthma is
relevant in the present context. Hence the etiology, pathogenesis, clinical symptoms,
laboratory examinations and differential diagnosis of Bronchial Asthma are elaborated in
the following pages.
Definition31
Bronchial asthma is a disease characterised by hyper reactive airways, leading to
episodic, reversible broncho constriction, owing to increased responsiveness of the
tracheo-bronchial tree to various internal and external stimuli.
27
Types32
In contemporary science for the epidemiological and clinical purposes, asthma is
broadly classified into 2 varieties. But because of the unclear pathological and clinical
distinction, a third variety is also added. They are
1) Allergic or extrinsic asthma.
2) Idiosyncratic or Intrinsic asthma.
3) Mixed variety.
Table no:6 Showing types of Asthma
Sl. Extrinsic Intrinsic
1) Immune reaction type 1 hyper sensitivity Non-immune abnormal autonomic
regulation of airways.
2) Family history of hyper sensitivity is
common
No family history
3) Usually starts in childhood Starts in adult life
4) Preceded by infantile eczema and hyper
sensitivity to food
No evidence of atopy
5) Increased level of IgE found in serum
Predisposition to form IgE antibodies
IgE antibodies may be found but no
particular predisposition. Normal
level of IgE in serum
6) Recognisable allergens like pollens,
dandruff, house dust, mite, etc.
No recognisible allergens
7) Attacks often gets diminished in later
years
Attacks increase in severity with
chronicity
8) Chronic bronchitis seldom develops Associated with nasal polyps and
chronic bronchitis
9) Emphysema unusual Emphysema commonly develops
10) No drug sensitivity Drug sensitivity may develop
(Aspirin, Pencilin, etc.)
11) Positive response to skin provocation test Negative skin provocation test
28
Clinical features 33:
Cardinal symptoms of all these types of asthma are
1) Dyspnoea
2) Wheeze
3) Cough
4) Sensation of chest tightness.
Pathogenesis of Asthma
This can be expalined under two heading.
i) Atopic Asthma
ii) Non-atopic Asthma.
Atopic Asthma can be explained in two phases
i) Early phase Reaction
ii) Late phase Reaction.
Early phase Reaction
This occurs in case of airborne antigens. The reaction occurs first in sensitised
mast cells on the mucosal surface. Mediators like histamine, leukotriens, cytokinease, etc
gets released from the mast cells. These mediatiors opens up the mucosal intercellular
tight junctions, and more antigen enters into submucosal mast cells. Added to it direct
stimulation of sub epithelial vagal receptors provokes bronchial constriction through
central and local reflexes. This occurs within a minute after the stimulation and is called
the ‘acute or immediate reaction’ or response. ‘IgE’ triggered reaction includes release of
both primary and seconday mediators.
29
The primary mediators are Histamine and Leukotriens B4. The Histamine causes
broncho constriction by direct and cholinergic reflex action. There by Increased venular
permiability and increase in the secretions occurs.
The secondary mediators like Leukotreins C4, D4 and E4, which are extremely
potent mediators causes prolonged broncho constriction and increased vascular
permiability and increases mucus secretion. Prostoglandin D2 also causes broncho
constriction , increased permiability and increased mucus secretions.
In late phase reaction, it starts after 4-8 hours later and may persist for 12-24
hours. It is mediated by leukocytes i.e. eosonophils, neutrophils and lymphocytes. These
cells are released by the chemotactic fatcors and cytokines, derived from the mast cells
during acute phase response or by other mediators produced by the chronic inflammatory
cells which are already present in asthmatic patients. Such leukocytes releases the
mediators that stimulates the onset of late reaction. Histamine releasing factor produced
by various cell types i.e. Basophils, Neutrophils, Eosonophils. Basophilis causes broncho
construction and edema. Neutrophils causes further inflammatory injury. Eosonophils
causes epithelial damage and airway constructions.
Non-atopic Asthma
It is non-allergic type, where microbial antigen plays the role. Here there will be
hyper sensivity to microbial antigens.Virus infections induces inflammation of the
respiratory mucosa and lowers the threshold of the sub epithelial vagal receptors to
irritants. There by inhaled air pollutants such as So2, ozone, No2, etc. contribute to
chronic airway inflammation and hyper reactivity.
30
Reversibility tests for detection of Asthma 34
Breathing tests are performed before and after inhalation of a product, which opens the
airways. If reading is increased by 15% or more after inhaling, the airway
narrowing is said to be reversible and confirms tested asthma. Even asthmatic
patient do not always show reversibility on every occasion tested, but it is
nevertheless very useful diagnostic test in patient in whom it is suspected.
Peak Expiratory Flow Rate (PEFR)
This is a simple method of measuring airway obstruction and it will detect moderate or
severe disease. The simplicity of the method is its main advantage. It is measured using a
standard Wright Peak Flow Meter or mini Wright Meter. The needle must always be reset
to zero before PEF is measured.
The PEFR is the maximum rate of airflow that can be achieved during a sudden forced
expiration form a position of full inspiration.
Procedure: In standing posture, check the instrument cursor on zero. Take a deep
breathe, place peak- flow meter in the mouth. (Hold horizontally) and close lips. Blow
suddenly with full force. Note the number indicated by cursor. Repeat the procedure to
obtain three readings. Write down the best or mean of three readings for assessment.
Peak Expiratory Flow Rate (PEFR) Reading and its advantage in Tamaka Shwasa
patient 35.
The good points about PEFR are
31
The PEFR reflects the caliber of the airways and is most useful for day-to-day
monitoring of asthma
The PEFR device is cheap and convenient
The bad points about PEFR are that the value depends on
Effort
Technique
PEFR monitoring in asthma
The measurement of peak expiratory flow rate (PEFR) three to four times per day
allows the diagnosis and assessment of the severity of asthma.
Untreated asthma is characterized by
Greater than 10% diurnal variability in PEFR
Lowest values in the morning
Optimally, PEFR measurements should be carried out twice daily separated by about
12 hours (usually early morning and early evening) to look for excessive diurnal variation
(usually PEFR slightly lower in the evening), as a sign of bronchial hyper reactivity.
Current International Guidelines on Asthma Management rely very much on a patient
regularly using a PEFR Meter at home for monitoring asthma. Recording the readings
and seeking medical guidance on the treatment is desirable.
32
It is understood that in UK with population of only 52 million (approx. 5% of
India), over 340,000 PEFR meters are sold annually. It is estimated that there are around
5 million PEFR meters in use in UK. In USA with a population of 285 million, 1,900,000
meters are sold annually. But the annual sale of PEFR meters in India is around 3000 to
4000 units only. The experience in UK has shown that the emergency admissions of
asthmatics to hospital has reduced to a considerable extent, thus releasing the beds for
other patients and saving the national health system hundreds of thousand of pounds
One does hear occasionally of physicians judging the condition of the airways on
the basis of blowing of candles. In all fairness one has to concede that this was a useful
tool in the era before the invention of the PEFR meter but not today. Today in the era of
MRI, CT scan, ultrasound imaging, pulmonary ultrasound imaging, pulmonary function
test spirometry etc, one needs more precise indicator which can give objective
information so as to effectively diagnose and treat asthma. No doubt, a few selected
patients are subjected to pulmonary function test. Such a test will show the status of
PEFR at a particular time. However the PEFR levels continually change on account of
several factors including medication. Therefore unless the patient is regularly monitored
for the PEFR and its changes studied, a patient can not be treated effectively.
On investigating, it was found that attending physicians did not spend sufficient
time properly explaining the PEFR meter’s use, interpretation of the readings, time to
report for follow up etc. If time is taken out by the physician to do this, then home
monitoring of PEFR will be on rise, benefiting both the patient and the physician.
Management of asthma has to be a partnership between the patient and the physician.
Not much importance is given to the fact that unmonitored asthma could result
33
in emergency visits, injections, nebulizations or a life threatening situation needing
immediate hospitalization involving huge cost, loss of income, missed classes in schools
or colleges, and on a wider scale even the loss of income. This entire can be avoided or at
least minimized when home monitoring of asthma is done in very regular way and
readings recorded so as to help in their interpretation and take the necessary steps to
avoid emergencies. Inquiry with physicians reveals that some of them do recommend to
their patients to buy a PEFR meter and use it; however most of the patients do not follow
the advice. It has been observed that just prescribing a PEFR meter does not cut much ice
with the patient. Majority of them avoid buying one. It is fervently hoped that time will
soon come when the need of home monitoring of asthma will be well understood by a
large body of Indian physicians and who in turn will recommend their use to the patients.
This will considerably boost effective management of asthma in our country.
Differential Diagnosis 36
The clinical presentation of Bronchial Asthma during an attack is so typical that
the diagnosis of Asthma is straight forward in most of the occasions. Hence other
diseases associated with dyspnoea and wheezing is usually not difficult to differentiate.
The cardinal symptom of Bronchial Asthma when present in episodes is very
characteristic and this itself differentiates it from other diseases presenting with
breathlessness. Added to this, the family or personal history of allergic manifestations
like eczema, rhinitis, and urticaria when available further confirms the diagnosis of
Bronchial Asthma.
Spirometric evaluation of the lung volumes is a valuable test both in making the
diagnosis as well as assessing the severity and improvement. Demonstration of reversible
34
airway obstruction is the diagnostic criteria. Two puffs of a beta adrenergic agonists
causing 15% or greater increase in FEV1 is defined as reversibility of airway obstruction.
Further, during the asymptomatic period, if the Spirometric results are normal, increased
airway resistance can be demonstrated on exposure to histamine or methacholine. The
response to the treatment may be assessed by measuring the peak expiratory flow rates
(PEFRs) and / or FEV1.It is worth mentioning here that normal values for FEV1 and
FVC are based on the population studies. And therefore it is likely to be changed,
according to the race, height, age and gender of the patients. Both these values of lung
volumes are expressed as absolute values and percentage predicted of normal values for
FVC and FEV1. The values over 80% of the predicted are defined as within normal
range. The ratio of FEV1/FVC is expressed in percentage, and a normal young individual
is capable to expire at least 80% of his vital capacity in one second. A ratio below 70% is
therefore indicative of obstructive pathology. In comparison to FVC if the FEV1 is
reduced disproportionately and which results in FEV1/FVC ratio is less than 70 to 80%
and is suggestive of obstructive pathology. And these findings of Spiro metric values are
suggestive of Bronchial Asthma. Other than this demonstration of positive wheal and
flare reactions to skin tests to various allergens is diagnostic but such findings do not
necessarily correlate with the intrapulmonary events. Sputum and blood eosinophilia is an
additional finding. Measurement of serum IgE levels are also helpful but are not specific
for Asthma. Chest roentgenograms showing hyperinflation are also seen in many patients
but are not mandatory for diagnosis.
Even though the presentation of asthma is clear-cut in manifestation, it is
differentiated from the following diseases.
35
UPPER AIRWAY OBSTRUCTION BY TUMOR OR LARYNGEAL EDEMA
Occasionally confused with Asthma, it is present with strider and the harsh
respiratory sounds can be localized to the area of trachea. Diffused wheezing throughout
both lung fields is usually absent however it is sometimes difficult to differentiate.
Laryngoscope or bronchoscope may be required
GLOTTIC DISFUNCTION
Narrowing of the glottis, during inspiration and expiration produces episodic
attack of severe airway obstruction. Occasionally carbon dioxide retention develops.
Unlike asthma the arterial oxygen tension is well preserved. Glottis should be examined
when the patient is symptomatic. Normal findings at such times exclude, normal findings
during asymptomatic periods don’t.
ENDOBRONCHIAL DISEASE
Persistent wheezing localized to one area of the chest in association with
paroxysms of coughing indicates Endo bronchial disease such as foreign body aspiration,
a neoplasm or bronchial stenosis.
It produces inspiratory strider and respiratory distress in the new-born & young
infant.
LARYNGO TRACHEO BRONCHITIS
It is usually caused by a viral infection in the infant young child producing
inspiratory strider, typically worse at night. Some children have repeated an attack, which
is termed spastic croup and is often confused with asthma.
36
VOCAL CORD DYSFUNCTION
It is usually misdiagnosed as asthma, which typically affects the adolescents or
young adults. The condition is due to an emotional disorder (Probably hysterical) in
which there is vocal cord adduction during inspiration and or expiration. Unlike asthma,
symptoms are not worse at night or while asleep.
Occasionally mimic asthma but the findings of moist basilar rales, gallop
rhythms, blood tinged sputum and other signs of heart failure allow the appropriate
diagnosis to be reached.
BRONCHOSPASM
It occurs with carcinoid tumors, recurrent pulmonary emboli and chronic
bronchitis – there are no true symptom free periods and one can usually obtain a history
of chronic cough and sputum production as a background on which acute attacks of
wheezing are super imposed.
EOSINOPHILIC PNUEMONIAS
These are often associated with asthmatic symptoms, as are various chemical
pneumonia and exposures to insecticides and cholinergic drugs. Bronchospasm can be
occasionally seen being a manifestation of systemic vasculitis with pulmonary
involvement.
37
BRONCHIAL ASTHMA AND CARDIAC ASTHMA
Bronchial asthma is the more correct name for the common form of asthma. The
term ‘bronchial’ is used to differentiate it from ‘cardiac’ asthma, which is a separate
condition that is caused by heart failure. Although the two types of asthma have similar
symptoms, including wheezing (a whistling sound in the chest) and shortness of breath,
they have quite different causes.
Cardiac asthma
With cardiac asthma, the reduced pumping efficiency of the left side of the heart
leads to a build up of fluid in the lungs. This fluid build up causes the airways to narrow
and causes wheezing. Cardiac asthma is often indistinguishable from bronchial asthma.
The main symptoms are:
shortness of breath and wheezing;
increase in rapid and shallow breathing;
increase in blood pressure and heart rate; and
feeling of apprehension
The pattern of shortness of breath also provides a clue — people with bronchial asthma
tend to experience a shortness of breath early in the morning, whereas people with heart
failure and cardiac asthma tend to feel a worsening of shortness of breath one to 2 hours
after going to bed.
38
Cardiac asthma is a life-threatening condition, and you should consult your doctor if you
have any concerns or are experiencing any symptoms.
Bronchial asthma
For most people with bronchial asthma, the pattern is periodic attacks of
wheezing alternating with periods of quite normal breathing. However, some people with
bronchial asthma alternate between chronic shortness of breath and episodes of even
worse shortness of breath.
Strong risks for developing bronchial asthma include being a person who is genetically
susceptible to asthma and being exposed early in life to indoor allergens, such as dust
mites and cockroaches, and having a family history of asthma or allergy.
Bronchial asthma attacks can be triggered (precipitated or aggravated) by various
factors, which include
respiratory tract infections
cold weather
exercise
cigarette smoke and other air pollutants
stress
Some people can develop asthma in adult life due to a intolerance that their body
develops to aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) (in which
case exposure to aspirin or NSAIDs can trigger an asthma attack), or due to an allergy
39
that they develop to certain chemicals in the workplace (called ‘occupational asthma’, in
which case exposure to the chemical triggers an asthma attack).
The symptoms of bronchial asthma include
a feeling of tightness in the chest;
difficulty in breathing or shortness of breath;
wheezing; and
coughing (particularly at night)
Table no: 7 Showing differential diagnosis Asthma with COPD37
HISTORY COPD ASTHMA
Allergy or asthma in
family of patient
No Yes
Cough and sputum Over many years. Often present
On set of breathlessness Gradual. Sudden
Variable breathlessness Slight. Much
Attack of breathlessness at
rest. Cough at night.
Wakens and then coughs Awakens due to cough
Investigation
Improvement in PEFR
after bronchodilator, i.e.
Reversible obstruction.
Little or none Usually
Daily variation in PEFR Little. Varies day to day
Treatment.
Effects. Negligible Improvement.
40
Table no: 8 Showing difference between bronchial asthma and Eosinophilia 38
HISTORY BRONCHIAL
ASTHMA.
EOSINOPHILIA
Age. Usually starts before any 3
year of age.
Any age
Duration of symptom
cough and dyspnoea
Long duration. Short duration.
Fever Rare Common
Loose weight Seldom Fairly common
Auscultatory signs Compatible with degree of
cough and breathlessness
Disproportion between cough
breathlessness and sign
Investigation:
Blood Normal white blood count
esoinophils8-15%
Leukocytosis eosinophilia
marked
Chest radiograph Increased bronchial
marking
Matting may be seen
Treatment No known cure Diethyl carbemazine specific
41
Treatment
The main goal of therapy is to reduce brething discomfort and to prevent re-
occurrences of asthmatic attacks. The acute symptoms of asthma may resolve
spontaneously or may often require therapy with 2 - agonists. The late phase reactions
may require treatment with steroids.
Drugs for asthma 39
2 adrenergic antagonists, cortico steroids, cholinergic antagonists and
theophylline.
Adrenergic agonists: In patients showing only ocassional intermittent symptoms
inhalation of adrenergic antagonists with 2 activity are the drug of choice. These are
potent broncho dilators which relax the smooth muscles airway .
-agonists have a rapid onset of action and provides relief for 4-6 hours. They may be
used for symptamatic releif of broncho constriction. 2 selective agents such as i)
Pirbuterol ii) Terbutaline iii) Albuterol. ‘Salmetrol’ has a long duration of action which
cause broncho dilatation for atleast 12 hours. It has slow onset of action and should not
be used in acute asthmatic attacks.
Cortico steroids: Indicated in Patients who require inhalation of 2 adrenergics
frequently. In severe asthmatics inhaled variety of gluco-corticoids will be the drug of
choice.
Steroids have no direct effect on the airway smooth muscles. They decrease the
number and activity of the cells involved in the airway inflammation such as
macrophages, eosonophilis and T-lymphocytes. Prolonged inhalation of steroids reduces
the hyper responsiveness of airway smooth muscles to a variety of broncho constriction
42
stimuli such as allergens, and irritants. Steroids reduces inflammation by reversing
mucosal oedema, decreases the permiability of capillaries and inhibit the release of
leukotrins. So bronchial reactivity is greatly reduced by employing these agents.
Cholinergic antagonists: Anticholinergic agents are less effective than -adrenergic
agonists. They block the vagally mediated contractions of airway smooth muscles and
decreases mucus secretions.
Theophylline: Is a potent bronchodilator that relieves the obstruction in chronic asthma
and decreases the symptoms of chronic disease.
43
VAMANA DHAUTI
Vamana dhauti, jala dhauti, gajakarni, varisara, dhauti, kunjal etc… are various
terms used for this procedure. 40
In yogic science, the procedure of vamana karma is popularly known as ‘Vamana
dhauti’. It is a very simple procedure, which can be adopted easily, and also is a cost
effective procedure. The patient can adopt the procedures by himself when necessity
arises.37
Ancient yogis have developed six scientific yogic techniques known as
shatkarmas. They are neti, dhauti, nauli, basti, kapalabhati, and trataka. They constitute
the part of Hathayoga explained by Swatmaram. According to another ancient yogic text
Gheranda Samhita, there are seven steps to qualify for the attainment of self realization.
One among these is purification of the body by shatkarmas41. Without eliminating
the toxins and imparities from the body, it is very difficult to practice the higher yoga
techniques. In Ayurveda also higher therapies like Rasayana and vajikarana can not be
undertaken without purifying the body through panchakarmas
Vamana dhauti is a method of cleaning the stomach by voluntary vomiting.
Vamana dhauti is also called as kunjal kriya. Charaka Samhita explains similar procedure
in Shwasa chikitsa. Sarangadhara mentioned vamana in ajeerna roga by using sukhoshna
lavanambupana42.
There is no clear description about specifications like, method, quantity,
procedure and precautions which are to be taken. But the same procedure has been
explained in yoga therapy in a detail manner under the context of kunjal kriya. Kunjal
kriya can be considered as a shorter version of vamana karma, which has already been
44
proved beneficial in Kaphaja disorders. Sages like Swami Satyananda Saraswathi and
Raghavendra Swami of Malladihalli have adopted this kriya with much efficacy. They
have explained the details about the kriyas and their benefits in treating the Asthma and
other Kaphaja disorders very effectively. And in many yoga centers researchers have
proved this effect.
There are references indicating Vamana dhauti in healthy persons also. In
diseased conditions this must be done once in 2-3 days or daily depending upon the
patient’s condition. In this study Vamana dhauti was conducted only once and its effect
was studied once in 15 days for one month period.
The term kunjal kriya contains two words i.e., kunjal + kriya. Here kunjal means
‘elephant’39and ‘kriya’ means procedure.
It means the elephant before drinking the water through the trunk cleans
the trunk first by filling it with water and spit it out forcibly. Based on this concept
authors have adopted the similar procedure in yoga as a cleansing procedure for upper
GIT and named it as kunjal kriya.
Indication and Contraindications for vamana dhauti 43
This practice may be done independently by individuals, who suffer from specific
ailments such as kapha pradhana vikara.
45
Table Showing the Indication and Contraindication of Vamana Dhauti
Indication Contraindication
Asthma Gastric ulcers
Common cold Hernia
Sinusitis Heart problems
Tonsillitis High blood pressure
Bronchitis Cancer
Cough Tuberculosis with blood vomiting
Whooping cough duodenal ulcer
Indigestion Child below the age of 7 years
Acidity Old age above 60 years
Tuberculosis Any abdominal surgery
Vamana dhauti – procedure
Materials Required for Vamana dhauti
1. Luke warm water with salt
2. Vessels
3. Bucket
4. Towels
5. Glass
46
Vamana dhauti is best done as first thing in the morning on an empty stomach
Vamana dhauti is to be done after evacuating the bladder and bowels
light and comfortable cloths must be worn
A clean bucket or a small container of 3-4 liters should be filled with lukewarm
water, rock salt must be added (approximately 1/2 tsp to 1 lit water)
This technique should be done with a relaxed mind
The water should be drunk slowly till the brim
The person slightly bend forwards and without undue strain vomits out the water
Till he feel lightness of stomach this should be continued
After completing Vamana dhauti rest is essential for 45 minutes
After 45 minutes a special preparation of rice cooked with ghee should be given.
This preparation is necessary to activate and lubricate the digestive tract in a
gentle manner.
For at least one week after doing Vamana dhauti all chemically processed, acidic,
and non-vegetarian foods should be strictly avoided.
Alcohol, tea, coffee, acidic fruits should be avoided.
47
As per the observations of Dr. Deena Nathrai, Department of Psychiatry, K.G.S.
Medical College, Lucknow following results occur in kunjal kriya
1. In digestive system decreased peristalsis and increased release of glucose into the
blood from the liver
2. Dilation of the alveoli in lungs stops acute asthma
3. Heart beats faster and blood vessels dilate supplying more oxygen to the heart
muscle
4. The lungs get exercised by the action of the diaphragm on the abdomen which
thus helps in better breathing function.
5. In addition to flushing out the stomach and esophagus contents, Kunjal is also an
excellent cleaning technique for the lungs and hence it is very beneficial for
asthmatics.
6. The strong contraction of pyloric sphincter produces a shock wave along the
vagus nerve which then releases the spasm within the bronchial tree.
7. Kunjal is in fact recommended as instant relief for any one feeling the onset of an
asthma attack. If an asthmatic performs kunjal every morning over several
months their attacks will get less and less frequent.
8. The contractions of kunjal help the breathing mechanism and improve blood
supply to the whole of abdominal and thoracic area.
9. It is good technique for those with decreased digestion. It help to relieve
indigestion, gas and acidity complaints
10. It tones up the abdominal muscles and other internal organs
48
Mechanism of Vamana
During Vamana the action of diaphragmatic pressure on the stomach flushes out
its contents at physical level. The pyloric sphincter, which is a muscle located at the
bottom or outgoing end of the stomach, normally remains closed except when the food is
sent down into the gastro intestinal tract for further digestion. But when it receives a
message from the brain that the body needs to expel the contents of the stomach which
may be due to vitiated food presence, or when one has nausea due to illness, the sphincter
and the surrounding muscles make strong contractions in the reverse direction, forcing
the contents of the stomach upwards.
The lungs and trachea which have mucus linings can get coated with toxic waste
through air pollution, or activities like mouth breathing, smoking, and poor diet which
can inhibit their correct functioning. When flushing out the stomach contents with
Kunjal kriya due to the connected nerve reflex in lungs also helps to expel excessive
mucus and relieves bronchospasm.
Mechanism of action of Vamana dhauti in Tamaka Shwasa
In Tamaka Shwasa, the expectoration of kapha takes place as a result of
reflex action of pyloric sphincter gives immediate relief to the patients. This type of
procedure helps in mild to moderate asthmatic attacks. The mode of action of the therapy
can be mainly due to the expectoration of sputum. Apart from this the procedure also
helps in increasing the Agni which in turn reduces the influence of kapha and ama.
49
Gheranda Samhita one among the Hatha yoga texts gives a detail description
about Kriyas. Description of Kriyas and their short explanation is given here.
KRIYAS
Dhauti Basti Neti Nauli Trataka
Kapalabhati
Jala Basti Jala Neti Vatakrama
Shushka Basti Sutra Neti Vyukrama
Shitkrama
Antardhauti Dantadhauti Hriddhauti Mulashodhana
Vatasara Dantamula Danda Dhauti (Cakrikarma)
Varisara Jihvamula Vamana Dhauti
(Ganeshakriya)
(Sankha Karnarandhra ( Gajakarni / Baghi)
prakshalana) Kapalarandhra Vastu Dhauti
Bahishkrita
50
List of Kriyas
Cleansing by air Vatasara, Shushka/ sthala basti and
Kapalabhati.
Cleansing by water Vamana, gajakarni, varisara (Sankha
prakshalana), jala neti, Vyukrama and
Shitkrama kapalabhati and jala basti.
Cleansing by friction or appliance Danda dhauti, vastra dhauti, sutraneti,
Dantamula and Jihvamula.
Cleanses by manipulating the organ Vahnisara, nauli, trataka and Vata basti.
Dhauti 44
Antar Dhauti
Vatasara (Cleansing the intestine)
Method: Draw in air slowly through the mouth forming it like the beak of a crow,
move the abdomen and then slowly expel the air through the lower passage.
Bahishkrita (Cleansing the intestine and rectum)
It is a method of cleansing by air and water. It is quite difficult method,
performed by retaining the air inside the intestine and passing it out through the lower
passage and by cleansing the rectum with water. Generally Vatasara and Bahishkrita
are not practiced, as they are difficult methods.
51
Danta Dhauti
Dantamula (Cleansing the teeth)
Method: One should rub the root of the teeth with the extract of khadira plant (Acacia
Catechu) or with earth until impurity is removed. Every morning one should do it to
preserve his teeth.
Jihvamula (Cleansing the tongue)
Method: Putting the index, middle and ring fingers in to the throat, one should rub out
the impurities and clean the root of the tongue slowly. Thus one can be free from
diseases arising from phlegm.
Karnarandhra (Cleansing the ear)
Method: One should rub the auditory canal by inserting the tip of index finger into it.
By constant practice an auditory sensation is experienced.
Kapalarandhra (Cleansing the upper palate)
Method: Everyday, after waking from sleep after meals, and at the end of the day, one
should rub the Bhalarandhra (hindmost part of the roof of the mouth) by reaching the
thumb of the right hand there. By this constant practice one should ward off diseases
due to phlegm. The Nadis becomes purified and vision becomes clear.
52
Mulashodhana (Cleansing the anus)
Method: One should diligently clean the rectum with the stem of turmeric (plant), or
with the middle finger and water again and again. This Mulashodhana cures
constipation and indigestion, gives radian complexion and nourishment to body and
stimulates the digestive organs.
Shatkriyas are explained in classics of yogic science thousands of years ago in
Hatha yoga Pradipika and Gheranda Samhita.
Six kriyas are Trataka, Basti, Kapalabhati, Dhauti, Neti and Nauli.
Trataka
This cleansing process is described in all yogic texts. It is related to eyes and
different Nadis of eyes. It is a cleansing process practiced with eyes.
Keeping the eyes steady, one should attentively stare at a small object until
tears come out. This is called Trataka by the teachers 45.
Without winking one should gaze a minute at an object until tears begin to fall
from the eyes. This is called Trataka by the wise.46
Kapalabhati47
This cleansing process is related to respiratory system. It gives effect on all the
parts of the respiratory system. It also gives effect on all the parts of the respiratory
53
system (from Nose to Alveoli). In different schools of Yoga it is also practiced as
Pranayama.
Kapala - Forehead
Bhati - to shine
Kapalabhati means shining of the forehead.
Rapid performance of Rechaka and Puraka like the bellow of a blacksmith is
kapalabhati; it is a well known destroyer of kapha disorders.48
One should draw in air through Ida (the left nostril) and expel it through the
Pingala (the right nostril). Again drawing air through the Pingala one should expel it
through the Chandra (left nostril) 49.
After rapidly inhaling and exhaling one should not hold (the breath). By
practicing in this manner one can ward off disorders of phlegm.
Neti 50
Neti is a Cleansing process related to nostrils. It helps for cleaning and
opening the nasal passage and to increase the sensitivity of the nasal mucosa.
The word Neti represents Nasal passage.
Neti is Practiced By
Using water: Luke – warm or as it is or to which certain agents like salt, milk, honey
etc. are added. Luke warm, salt mixed water is mostly preferred. This is called Jala
Neti.
54
Using soft cotton cord: Soft cotton cord smeared with wax is called Sutra-Neti.
Using rubber catheter of 4-6 size or thin rubber tube can be used. This is Rubber –
Neti (modified from of Sutra Neti)
Jala Neti
After drawing water through the nostrils one should expel it through the
mouth. Repeatedly taking water (in this way), this Vyukrama (Bhalabhati) cures
diseases of phlegm.
Sucking water by the mouth so as to produce a hissing sound one should throw
it out through the nostrils. By this practice one become handsome51.
Sutra Neti
Introducing through the nose a smooth nine inches long piece of thread, one
should pull it out through the mouth. This is Neti as declared by the accomplished
Yogis.
Nauli
Nauli 52 is described in all the traditional yogic texts. In Hatha Pradipika it is
mentioned as Lauliki. This Kriya is related to abdomen. It gives good massage to
abdominal column.
Nauli means isolation and rolling manipulation of the abdominal recti.
Lauliki means pendulum. Lola means movement, rolling and agitation.
When Nauli is practiced the abdominal muscles seem to flow like rolling
waves of the ocean.
55
With Shoulders bent forward one should rotate the abdomen right and left with the
speed of a fast rotating pool. This is called Nauli by the accomplished Yogis 53.
Rapidly move the abdomen from side to side. This (Lauliki) destroys all
diseases and increases the heat of the body 54.
Dhauti 55
Dhauti means cleansing. There are three branches of Dhauti. They are
Vamana Dhauti, Danda Dhauti, Vastra Dhauti.
Danda Dhauti
Danda – a stalk (Tube), Dhauti – Cleansing. Cleansing the upper part of the
digestive system with the help of a stalk.
In modern method, a rubber tube about 90 cm. long 0.5 cm. bore is used in the
place of plantain or turmeric stalk since the rubber tube can be used many times after
sterilization.
One should insert the stalk of plantain, turmeric or cane into the throat and
moving it there (up and down) and then slowly drawing it out.
Vastra Dhauti
Vastra – Cloth, Dhauti –Cleansing
One should swallow slowly, as advised by the guru, a wet (piece of) cloth four
fingers (approx. three inches) in breadth and fifteen feet long, and then slowly
drawing it out. This process is known as Vastra Dhauti.56
56
Basti
Basti – Yogic flushing of the Colon. Literally Basti means lower abdomen. It
is a cleansing process related to lower part of the abdomen, large intestine. In olden
days enema pots were prepared by the bladder of animals (Goat, Sheep, Deer, etc.) for
elimination of large intestine by introducing water into anus (Now enema pot is used).
Negative pressure is created in intestines by performing Uddiyana and Nauli.
Inserting a tube into the anus and adopting the Utkastasana pose in navel depth
water. One should wash (The interior) by contracting (and relaxing after the tube is
removed) this process is known as Basti.57
Basti is said to be of two kinds: Jala Basti and Shushka Basti. Jala Basti is
practiced in water while Shushka basti is done always on the ground.58
Raising the lower part of the back (in the supine position and moving the
pelvic region of the abdomen) one should dilate and contract the anus as in Ashwini
Mudra59.
57
Inter-Relationship of Kriyas with Chakras 60
Name of the Kriya Related Anatomical Part of
the Body
Awareness and stimulation
of Chakras
Dhauti Esophagus (throat)
Stomach
Visuddha
Anahata
Basti Colon (perineum) Manipura
Swadhisthana
Mooladhara
Neti Nose, head and
Air passages
Ajna
Visuddha
Nauli Intestines, Liver, Kidney,
Pancreas (Navel)
Anahata
Manipura
Swadhisthana
Mooladhara
Trataka Eyes, Eyebrow center Ajna
Kapalabhati Head, Nose, Air sinuses,
Lungs, Abdomen
Sahasrara
Ajna
Visuddha
Anahata
Manipura
58
Vamana in Vasantha Ritu
Ayurveda advocates prevention of diseases and promotion of health through
implementation of principles of Dinacharya, Ritucharya and Ratricharya 73. It is not
possible to have knowledge of suitable diet and regimen for different seasons
without having the knowledge of time factor in the form of seasons and their
manifestations.
The kala or time factor for bheshaja yoga is of 2 types as kshanadi and
vyadhyavastha 74. Kshanadi kala constitutes kshana, nadika, muhurta, yama, aha, ratri,
paksha, masa, ritu, ayana & samvatsara. Vyadhyavastha kala constitutes ama, pakva,
apakva, nava, purana, taruna etc 75.
A samvatsara consists of 2 ayanas, each ayana consists of 3 ritus and each ritu
consists of 2 masas. Thus there are totally 12 masa constituting 6 ritus. Vriddha vagbhata
opines that these ritus are according to mrugaadi twelve rashis which is being confirmed
by jyotishya sastra as “mrugaadiraashidwayabhanubhogat shad rutavaha” 76.
Classics have described vasantha ritu as 77
It is described under uttarayana
It is Adana kala wherein the person will have less strength.
It is considered under ushna kala
It constitutes chaitra & vaishaka masa (phalguna & chaitra masa Acc to Sushruta)
It is constituted by meena & mesha rashis
Kashaya rasa is predominant in this ritu
This ritu correlates with mid May to mid July period (spring season)
59
The difference of opinion by acharya vagbhata & Sushruta has been justified by
Hemadri the commentator of Ashtanga hridaya. He justifies the difference by saying, if
meena raashi appears in the beginning of phalguna then vasantha ritu will have phalguna
& chaitra and if meena raashi appears in the end of phalguna then vasantha ritu will have
chaitra & vaishaka masa. He also strongly suggests to, consider ritu as per raashi so that
one can overcome the variations in the ritu vibhajana.
1 Dalhana comments “Arkarashmipiraviaytha” in spring it is liquefied like solid
ghee and not dried up which is pacification the sun being intense and kapha
being in profuse quantity 78.
2 During the spring, the accumulated kapha is liquefied by heat of sun and as
such disturbs the power of digestion and cause many diseases .So one should
administer therapies like emesis 79.
3 During the spring, the accumulated kapha is liquefied by heat of sun rays and as
such disturbs the power of digestion and cause many diseases. So one should
administer therapies like emesis 80.
4 Chakrakapani comments on elimination therapies of emesis, purgation, and niruha
and anuvasana type enema and shiro virechana should be administered so as to
eliminate the Doshas. Emesis therapy should be administered in the month of
chitra only 81.
5 The Kapha which has accumulated during sisira gets increased still more by
the hot sun, and produce many diseases, by hampering the digestive activity.
so administration of emetics , inhalation, gandusha, nasal medication , exercise
,soup of meat of animals of desert region should be undertaken 82.
60
6 The heat of sun gradually increases and liquefies the thick kapha which fills up
tissues and cavities of the body83. So it should removed out by emesis,
inhalation strong smoke, mouth gargles and nasal drops.
7 Kapha which has undergone increase in sisira become liquefied by the heat of
sun in Vasantha, diminishes the agni, and give rise to many diseases, hence it
should be controlled quickly by resorting to strong emesis, nasal medication and
other therapies, and also foods which are easily digestible along with dry physical
exercises dry massage to decrease the kapha 84
The period of Adana kala comprises of seasons sisira, vasantha & grishma where
the effects of the hot sun and dry winds increases progressively during this period.
Simultaneously, the tastes like Katu, Tikta and Kashaya, all have absorbing affects on the
body during Sisira, Vasanta and Grishma ritus respectively. The physical weakness
during this is not only by absorbing tendency of sun and winds on the body, but
also by absorption of the humidity and moistness from the surrounding atmosphere and
simultaneously of the Katu, Tikta, and Kashaya rasas 85.
Vasantha Ritu lakshana
The characters of vasantha ritu are described as follows. During vasantha ritu the
wind will blow from south direction, the suns rays are coppery red in color indicating its
teekshnatwa, the trees are full of fresh sprouts, barks & leaves indicating regenerative
process of plants, there will greenery all around indicating fresh plant generation and is
accompanied by the sound of cookoo, bees etc. Thus there will be fresh development of
plants associated with teekshna surya kirana 86.
61
The characters of vasantha ritu as explained above indicate pakvata
(mature state) of plants as they are regenerating and there will be strong penetrative sun
rays. The penetrative nature of sun rays is justifiable, as the sun moves little towards the
north in its elliptical pathway (uttarayana) and vasantha ritu being the middle ritu among
the 3 ritus, the sun will be nearest to earth, and so it is more penetrative in nature. The
previous ritus (sisira, hemanta, sharad, varsha) provide the basic requirements for plants
like moisture, humidity, water etc and the sun rays of vasantha ritu initiates the growth,
and thus there will be rapid regeneration of plant kingdom.
Similarly there will be changes in the humans also i.e. the kapha which is
accumulated in the previous ritu (sisira ritu) gets liquefied by the teekshnatwa of sun rays
which is further hampers the agni due to its qualities. When Agni gets hampered there
will improper digestion of food & doshas, leading to kapha vriddhi in amashaya. Thus
there will be excess of kapha vriddhi by its liquefaction & agnimandya thereby leading to
many diseases 87.
The teekshnatwa of sun rays are only eligible to liquefy the kapha in
vasantha ritu because kapha is excess in quantity and sun rays are not severe as in
grishma 88 to dry up the kapha. Hence there will be kaphaja vyadhi utpatti and
agnimandya janya vikara.
Diet and Regimen in Vasantha Ritu
This is the season where strength and vigour of individuals have the tendency to
fall and remain moderate when compared to other seasons. Based on the doshika
62
schedules, keeping in view the vasantha ritu, Charaka has given detail account of
dietetics and daily regimen habits.
In order to balance the changes of external environment with internal
environment, one should administer therapies like emesis, etc and should avoid
heavy unction, amla & madhura rasa diets. One should avoid sleep during the day time.
At the advent of Vasanta one should habitually resort to excise, unction, smoking,
gargling, and collyrium in a moderate way. The excretory orifice should be washed with
lukewarm water. one should smear his body with Chandana , Agaru, and use the food
consisting of barely and wheat , meet of sarabha , sasa, ena, lava and kapinjala 89.
The regimen described for vasantha ritu is mainly to eliminate excess kapha
which is due to liquefaction thereby preventing agnimandya and thus promoting health.
All the procedures mentioned as regimen are aimed at expelling kapha to maintain
homeostasis 90.
Acharya Charaka mentions “vasante karmaani vamanaadeeni kaarayet” 91, which
strongly suggests adopting vamana as the prime therapy to expel kapha 92.
We know that kapha is predominantly situated in the region above Hridaya 93
which is nothing but uras. The predominant sthana of kapha is amashaya. Pranavaha
sroto mula is hrudaya 94. Prana vata pervades through pranavaha srotas supplying the vital
energy (ambara peeyusha) to the body 95. The kapha which is liquefied in vasantha ritu,
gets increased in its pradhana sthana i.e. uras, and thus obstructs the pranavaha srotas.
Obstruction of pranavaha srotas hampers the movement of prana vata & udana vata
leading to different respiratory diseases. Among them tamaka swasa is prominent because
of its frequent manifestation & threatening nature. The treatment principle in tamaka
63
swasa is to expel the accumulated kapha in the pranavaha srotas thereby enabling free
movement of prana, the vital energy 96. The best procedure to expel kapha is vamana 97.
Chaitra masa is the best masa to perform vamana karma so that excess kapha can
be expelled out of body completely because of ritu sadharana characters being observed
in this masa 98.
By the above description it is clear that
There will be excess kapha in vasantha ritu.
Tamaka swasa is caused by obstruction of pranavaha srotas by kapha.
Kapha can be best expelled out of body by vamana karma.
Vamana karma should be done in vasantha ritu to get good control over
kapha dosha.
Chaitra masa is the preferable masa to perform Vamana due to its ritu
sadharanata.
Patho- physiology of kapha diseases
In all slaishmika diseases the inherent natural qualities of kapha is obviously
manifested either fully or partly and based on this a competent physician can correctly
diagnose the slaismika type of disease. The inherent qualities of kapha are
Unctuousness
Coolness
Whiteness
Heaviness
64
Sweetness
Steadiness
Sliminess
Viscosity
Diseases due to vitiated kapha should be treated with drugs having, pungent,
bitter, astringent, penetrative, hot and unctuous qualities, and by such therapies like
Swedana, Vamana, Nasya, vyayama, etc which are all having kapha hara properties. Of
all the modalities sated above emetic therapy is excellent for treating the disease of kapha
because emesis acts on the pradhana sthana of kapha i.e. amashaya and thus alleviates
kaphaja vyadhi in the body. This can be better understood by the simile of the withering
away of paddy, barley, etc of the cornfield when field full of water is broken99.
Ayurveda recommends periodic shodhana 100 as a way to maintain good health
and to prevent disorders from taking root in the body. Just like regular periodical flushing
of machinery, body toxins should be flushed out periodically to maintain good health of
organs and systems of the body to function more efficiently for a longer period of time.
This elimination of toxins from the body can be carried out by undergoing the shodhana
procedures mentioned in the classics. Since the tridoshas are characterized by their
qualities, predominant regions of the body, chayadi kala and their functions, the shodhana
procedure is also different for each dosha and should be performed considering the state
of dosha (chaya, prakopa adi). Cleansing regime is important to maintain healthy life in a
healthy individual and to treat and prevent the diseases in a diseased person.
When the digestive process is incomplete or inefficient, partially digested food
matter is left behind in the digestive system. This substance, called ama in ayurveda,
65
becomes toxic to the physiology if allowed to stay in the body or build up over time. Ama
is not only inherently toxic in itself, it also clogs the channels of the body, further
disrupting the flow of digestion and leading to an escalating cycle of toxin build-up.
The shodhana procedures explained in Ayurveda are easy to follow on a regular
basis not only correct the doshic imbalances but also enhances the digestive fire by
removing ama accumulation.
The time for Internal Cleansing is recommended by Ayurveda in seasonal routine
(ritucharya) as well as daily routine (dinacharya). Each season brings with it its own
challenges with respect to health and need to be balanced. The time when the seasons
change is the best time to do a cleansing regime; to eliminate the earlier season’s
accumulation of ama and to prepare the body for the new season. Spring, especially, is
considered an ideal time to rejuvenate the homeostasis of the body, in keeping with
Nature’s own calendar for rejuvenation. With the melting of the snows and the thawing
of the ground, the fluids in the body also start flowing more freely, and performing an
internal cleansing routine at this time accelerates the flushing of toxins. Hence it is
advised to undergo Vamana in vasantha ritu.
66
Research is a scientific study, investigation or experiment done to establish facts
and analyze their significance. Many a time research is done to validate age old principles
with fresh proofs or parameters. In research the problem is tested with a suitable
experimental method; and honest observations are made to arrive at logistic conclusions.
A research need not always end with positive results.
‘Tamaka Shwasa’ is mentioned elaborately in classics of Ayurveda. The
conventional Ayurvedic treatment is expensive and time consuming. The disease is
effectively managed by following restriction of diet and regimen even with out
medications. The eliminative therapies like vamana have proven its efficacy beyond
doubt. But to find out a suitable simple alternate treatment method, and to observe the
effect of season in influencing its efficacy this study was planned.
Aims of the study
1. To observe the effect of Vamana dhauti in Tamaka Shwasa
2. To study the effect of Vasantha ritu in influencing the efficacy of Vamana dhauti
Source of data
The required cases were selected from the Tamaka Shwasa patients attending for
treatment at OPD and IPD sections of S.D.M.C.A. and H, Hassan.
Study Design
20 Patients suffering with Tamaka Shwasa who fulfill the inclusion criteria were
selected randomly for the clinical trial and assigned into two groups. Each group contains
a minimum of 10 patients.
67
Group A: Patients of this group were administered with Vamana Dhauti ‘once’ during
‘Vasantha Ritu’.
Group B: Patients of this group were administered with Vamana Dhauti ‘once’
‘irrespective of season’.
Follow up was conducted once in 15 days for one month after the Vamana dhauti.
Inclusion criteria
1. Patients who complain of chronic asthma but not in attack were selected
2. Patients between 17 to 60 years were selected irrespective of sex, religion,
occupation and socioeconomic status.
Exclusion criteria
1. Patients with acute attack or sever exacerbation and status asthmatics
were excluded.
2. Patient suffering with any other systemic disorders.
Patients unfit for undergoing Vamana Dhauti.
ICD - 10 criteria was taken for diagnosing cases of Bronchial Asthma
1. Episodes of chronic wheezing, dyspnoea, cough, feeling of tightness in the chest
2. Prolonged expiration and diffuse wheezing on physical exertion.
3. Limitation of airflow on pulmonary function test or positive Broncho provocation
challenge test.
Assessment Criteria
68
1. The overall clinical assessment was done by noting reduction in
intensity of the main symptoms Shwasa Kruchata, Ghurghurata, Kasa,
and Kantodhwamsa.
2. Observations made on changes in duration and frequency of attacks.
3. Peak flow meter reading tested before and after treatment and at
follow up intervals.
Grading
Efficacy of the therapy will be assessed based on improvement in the signs and
symptoms observed before and after vamana dhauti.
Overall effect
Marked Improvement - 71 to 100 % relief in signs and symptoms
Moderate Improvement - 31 to 70 % relief in signs and symptoms
Mild Improvement - Less then 30 % relief in signs and symptoms
Unchanged - No improvement in sign and symptoms
Statistical analysis
For the statistical calculation of the above said parameters, paired‘t’ test was
adopted and SD, SE, t and p values were calculated.
Improvement is assessed on the basis of scoring scale assigned to signs and symptoms of
Tamaka Shwasa as follows.
69
Grading of Symptoms for assessment
Shwasa
Absent -0
Present in kapha kala; aggravated on severe exertion -1
Present irrespective of kala; aggravates on mild exertion - 2
Disturbs daily routine; aggravates even during rest- - 3
Kasa
Absent - o
Present Occasionally - 1
Frequently present -2
Almost continuous - 3
Kantodhwamsa
Absent; speaks more sentences easily in one breath -0
Speaks a full sentence in one breath -1
Speaks in phrases in one breath -2
Continuous unable to speak in phrases - 3
Ghurghuraka
No wheeze -0
Mild wheezing at mid to end expirations - 1
Moderate loud wheeze through out expiration - 2
Severe loud wheeze expiratory and inspiratory wheezing - 3
70
Duration of attack
No symptoms -0
Brief for hours -1
Prolonged for 2-3 days -2
Almost continuous -3
Frequency of attack
No attack - 0
One episode per month -1
More than one episode per month - 2
Four or more episode per month -3
Follow up of the study
Follow up of the study was done at 15 days interval for 1 month.
71
Observations
Now-a-day, due to increased stress and strain; increased levels of
pollution, and decreased immunity levels a variety of new diseases are coming up. One of
such disease is Tamaka Shwasa (Bronchial asthma), which adversely affects the patients
in all the sphere of their life.
Tamaka Shwasa is one variety of Shwasa bheda described in our classics.
The disease offers a challenge for treatment as it has no cure in any system of medicine.
Yoga science explains the procedure Vamana Dhauti which is indicated for this disease.
It is a very simple procedure which can be adopted very easily and also is a cost effective
procedure. The patients can themselves adopt the procedure when necessity arises. Under
this context, in Shwasa Chikitsa our Acharyas have also mentioned to make use of
lavanambupana to induce emesis. A study was under taken to analyze the effect of this
procedure when conducted during Vasantha Ritu and also during other Ritu.
The study contains two groups, first group was administered Vamana Dhauti once
during Vasantha Ritu (VDVR) and another group was administered Vamana Dhauti once
irrespective of Ritu (VDIR).
GENERAL OBSERVATIONS
20 patients of Tamaka Shwasa were studied in this study.
They were treated in two groups. In group A Vamana Dhauti was conducted once during
Vasantha Ritu (VDVR) and in group B Vamana Dhauti was conducted once irrespective
of Ritu (VDIR). Each group contains minimum 10 patients. Here the data pertaining to all
72
the 20 patients of Tamaka Shwasa is being presented. The results obtained in both the
groups after study are presented under separate headings.
Nidanatmaka (Etiopathogenesis) Presentation of 20 patients of Tamaka Shwasa
Table –1 Age wise distribution of 20 patients of Tamaka Shwasa
No of Patients Age
VDVR Group VDIR Group
Total
No.
Percentage
21-30 0 3 3 15
31- 40 4 4 8 40
41 - 50 3 0 3 15
51 - 60 3 3 6 30
Age: In this study of 20 patients of Tamaka Shwasa, 40% patients were in 31-40 years
age groups, followed by 30% in age group of 51-60. Remaining 15% patients were in the
age group of 21-30 & 41-50 years (Table-1).
Table –2 Sex wise distribution of 20 patients of Tamaka Shwasa
No of Patients Sex
VDVR Group VDIR Group
Total
No.
Percentage
Male 4 5 9 45
Female 6 5 11 55
Sex: In this study 20 patients of Tamaka Shwasa, 55% patients were female and 45%
were male (Table-2).
73
Table –3 Religion wise distribution of 20 patients of Tamaka Shwasa
No of Patients Religion
VDVR Group VDIR Group
Total
No.
Percentage
Hindu 10 10 10 100
Muslim 0 0 0 0
Others 0 0 0 0
Religion: All the patients of this study were Hindus (Table-3).
Table –4 Marital status wise distribution of 20 patients of Tamaka Shwasa
No of Patients Marital status
VDVR Group VDIR Group
Total
No.
Percentage
Married 10 9 19 95
Unmarried 0 1 1 5
Marital status: In this study 20 patients of Tamaka Shwasa, 95% were married and 5%
were unmarried (Table - 4).
74
Table –5 Education wise distribution of 20 patients of Tamaka Shwasa
No of Patients Education
VDVR Group VDIR Group
Total
No.
Percentage
Uneducated 3 2 5 25
Up to 10th Class 2 3 5 25
Higher Secondary 1 0 1 5
Graduates 1 3 4 20
Higher education 3 2 5 25
Education: In this study of 20 patients of Tamaka Shwasa, 25% patients were un
education and up to SLC, 20% were graduate. Only 5% were higher secondary education
(Table -5).
Table –6 Occupation wise distribution of 20 patients of Tamaka Shwasa
No of Patients Occupation
VDVR Group VDIR Group
Total
No.
Percentage
House-wife 7 4 11 55
Service class 1 2 3 15
Business 0 1 1 5
Agriculture 2 3 5 25
Occupation: In this study of 20 patients of Tamaka Shwasa, 55% patients were house
wives, 25% agriculturists, 15% service class, 5% business class (Table -6).
75
Table –7 Socio-economic status wise distribution of 20 patients of Tamaka Shwasa
No of Patients Socio-economic
VDVR Group VDIR Group
Total
No.
Percentage
Poor 4 3 7 35
Middle 5 7 12 60
Rich 1 0 1 5
Socio- economic status: In this study most of the patients i.e. 60% were of middle class,
35% of poor and 5% patients were belonging to rich class of the society (Table -7).
Table –8 Habitat wise distribution of 20 patients of Tamaka Shwasa
No of Patients Habitat
VDVR Group VDIR Group
Total
No.
Percentage
Urban 7 6 13 65
Rural 3 4 7 35
Habitat: In this study of 20 patients of Tamaka Shwasa, 65% were urban and 35% were
rural dwellers (Table -8).
76
Table –9 Prakriti wise distribution of 20 patients of Tamaka Shwasa
No of Patients Prakriti
VDVR Group VDIR Group
Total
No.
Percentage
Vata-Pittaja 1 0 1 5
Vata-Kaphaja 7 7 14 70
Pitta- Kaphaja 0 1 1 5
Sama Dosha 2 2 4 20
Prakriti: Table No. 9 shows that maximum patients (70%) were having Vata-Kaphaja
Prakriti. 20% patients were of Sama Dosha Prakriti Remaining 5% patients were of Pitta-
Kaphaja and Vata- Pittaja Prakriti.
Table –10 Sara, Samhanana wise distribution of 20 patients of Tamaka Shwasa
No of Patients Sara & Samhanana
VDVR Group VDIR Group
No of Patients Percentage
Pravara 1 0 1 5
Madhyama 9 10 19 95
Avara 0 0 0 0
Sara and Samhanana: The Table No. 10 shows that most of the patients were of
Madhyama Sara (95%) and Madhyama Samhanana.
77
Table –11 Satva, Satmya wise distribution of 20 patients of Tamaka Shwasa
No of Patients Satva Satmya
VDVR Group VDIR Group
Total
No.
Percentage
Pravara 2 0 2 10
Madhyama 7 10 17 85
Avara 1 0 1 5
Satva and Satmya: In this study 85% patients had Madhyama Satva and Madhyama
Satmya. 10% patients had Pravara Satva and Pravara Satmya .only 5% patients were
belongs to Avara Satva and Satmya (Table No. 11).
Table –12 Vyayama Shakti wise distribution of 20 patients of Tamaka Shwasa
No of Patients Vyayama Shakti
VDVR Group VDIR Group
Total
No.
Percentage
Pravara 1 0 1 5
Madhyama 8 10 18 90
Avara 1 0 1 5
Vyayama Shakti: The 90% patients were had Madhyama Vyayama Shakti. 5% were had
Avara Vyayama Shakti and Pravara Vyayama Shakti (Table No. 12).
78
Table –13 Agni wise distribution of 20 patients of Tamaka Shwasa
No of Patients Agni
VDVR Group VDIR Group
Total
No.
Percentage
Sama 1 0 1 5
Vishama 1 1 2 10
Manda 7 7 14 70
Teekshnagni 1 2 3 15
Agni: Out of 20 patients 70% patients had Mandagni, 15% patients had Teekshnagni, and
10% of patients possess Vishamagni only 5% patients Samagni (Table No. 13).
Table –14 Ahara wise distribution of 20 patients of Tamaka Shwasa
No of Patients Ahara
VDVR Group VDIR Group
Total
No.
Percentage
Veg 5 3 8 40
Non-Veg 5 7 12 60
Ahara: The status of Ahara in Table No. 14 depicts that 60% patients were taking mixed
diet and 40% were of vegetarian.
79
Table –15 Addiction wise distribution of 20 patients of Tamaka Shwasa
No of Patients Addiction
VDVR Group VDIR Group
Total
No.
Percentage
Tea/coffee 8 4 12 60
Betel leaf 2 4 6 30
Others 0 2 2 10
Ahara: The status of Addiction in Table No. 15 depicts that 60% patients were taking
tea/coffee and 30% were taking betel leaf and 10% patients were consuming alcohol.
Table: 16 Desha wise distribution of 20 patients of Tamaka Shwasa
No of Patients Desha
VDVR Group VDIR Group
Total
No.
Percentage
Anupa 10 6 16 80
Sadharana 0 4 4 20
Desha: The status of Desha in table no.16 shows that 80% patients were from Anupa
Desha and 20% patients were from Sadharana Desha.
80
Table: 17 Nidana wise distribution of 20 patients of Tamaka Shwasa
No of Patients Nidana
VDVR Group VDIR Group
Total
No.
Percentage
Vayu Sevana 5 6 11 55
Rajo Sevana 5 5 10 50
Dhooma 4 6 10 50
Vyayama 5 6 11 55
Vega Dhahran 3 4 7 35
Sheeta Sthana 2 4 6 30
Sheeta Sevana 2 5 7 35
Nidana: From both the groups it was observed that Rajo Sevana 50%, Dhooma Sevana
50%, Vyayama 55%, were are the Nidana factors and among remaining Vayu Sevana
55%, Sheeta Sthana 30% and Sheeta Sevana 35% were involved.
81
Results
Effect of Vamana Dhauti in Vasantha Ritu
Table: Showing effect on Ghurghurata
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
2.6 1.2 1.4 53.85 1.074 0.339 4.14 <0.001
Follow up after
30 days
2.6 0.3 2.3 88.46 0.849 0.340 4.11 <0.001
Follow up after
60 days
2.6 0.5 2.1 80.77 0.823 0.260 6.53 <0.001
Effect on Ghurghurata
Vamana Dhauti conducted in Vasantha Ritu provided 53.85 % of relief in
Ghurghurata in 15 days. During the follow up study after 30days the percentage of
relief was 88.46%. Which was statically significant (p <0.001).
82
Table: Showing effect on Shwasakrichrata
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
1.5 1 0.5 33.33 0.674 0.213 7.95 <0.001
Follow up after
30 days
1.5 0.7 0.8 53.33 0.632 0.2 4.00 <0.001
Follow up after
60 days
1.5 0.4 1.1 73.33 0.875 0.276 7.60 <0.001
Effect on Shwasakrichrata
Vamana Dhauti conducted in Vasantha Ritu provided 33.33 % of relief in
Shwasakrichrata in 15 days which was statically significant (p <0.001).
During follow up study after 30days the percentage of relief was 53.33% and
this was increased up to 73.33 % during 60 days follow up.
Table: Showing effect on Kasa
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
1.8 1.5 0.3 16.66 0.471 0.1491 8.71 <0.001
Follow up after
30 days
1.8 0.7 1.1 61.11 0.632 0.2001 5.99 <0.001
Follow up after
60 days
1.8 0.5 1.3 72.22 0.816
0.258 7.75 <0.001
83
Effect on Kasa
Vamana Dhauti conducted in Vasantha Ritu provided 16.66 % of relief in Kasa in
15 days. During follow up study after 30days the percentage of relief was 61.11% and
this was further increased up to 72.22 % during 60 days follow up.
Table: Showing effect on Kanthodhvmsa
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
1.2 0.6 0.6 50.0 0.823
0.260 2.69 <0.02
Follow up after
30 days
1.2 0.5 0.7 84.0 0.819
.259 3.86 <0.001
Follow up after
60 days
1.2 .8 0.4 33.0 0.666
0.210 4.76 <0.001
Effect on Kanthodhvmsa
Vamana Dhauti conducted in Vasantha Ritu provided 50.0 % of relief in
Kanthodhvmsa in 15 days .During follows up study after 30days the percentage of relief
was 84.0% and 33.0%, 60 days.
84
Table: Showing effect on Duration of attack
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
1.4 0.7 0.7 50.00 0.483 0.262 3.80 <0.001
Follow up after
30 days
1.4 0.4 1.0 71.42 0.666 0.210 4.76 <0.001
Follow up after
60 days
1.4 0.9 0.5 35.71 0.843 .266 2.22 <0.02
Effect on Duration of attack
Vamana Dhauti conducted in Vasantha Ritu provided 90.0 % of relief in Duration
of attack in 15 days. During follow up study after 30days the percentage of relief
decreased to 71.42% and this was further decreased to 35.71% in 60 days.
Table: Showing effect on frequency of attack
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
1.5 0.5 1.0 66.66 0.875 0.276 3.26 <0.001
Follow up after
30 days
1.5 0.3 1.2 80.00 0.918 0.290 4.13 <0.001
Follow up after
60 days
1.5 1.3 0.2 13.33 0.948 0.3 4.30 <0.001
85
Effect on frequency of attack
Vamana Dhauti conducted in the Vasantha Ritu provided 66.66 % of relief
in frequency of attack in 15 days. During follow up study after 30days the percentage of
relief was increased to 80 % and this was decreased to 13.33 % in 60 days.
Table: Showing effect on PEFR
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
2.2 1.5 0.7 31.81 0.788 .249 5.22 <0.001
Follow up after
30 days
2.2 0.7 1.5 68.18 0.316 0.1 7.00 <0.001
Follow up after
60 days
2.2 1.6 0.6 27.27 0.516 O.163 9.81 <0.001
Effect on PFR
Vamana Dhauti conducted in Vasantha Ritu provided 31.81 % of relief in PEFR
in 15 days which was statically significant (p <0.001). During follow up study after
30days the percentage of relief was increased to 68.18 % and this was decreased to 27.27
% in 60 days.
86
Effect of Vamana Dhauti other than Vasantha Ritu
Table: Showing effect on Ghurghurata
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
1.8 0.7 1.1 61.11 0.737 0.233 3.80 <0.001
Follow up after
30 days
1.8 0.6 1.2 66.66 1.07 0.340 4.11 <0.001
Follow up after
60 days
1.8 1.6 0.2 11.11 0.516
0.163 9.81 <0.001
Effect on Ghurghurata
Vamana Dhauti conducted in other then Vasantha Ritu provided 61.11 % of relief
in Ghurghurata in 15 days which was statically highly significant (p <0.001). During
follow up study after 30days the percentage of relief was increased to 66.66 % and this
was decreased to 11.11 % in 60 days.
87
Table: Showing effect on Shwasakrichrata
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
1.8 0.9 0.9 50.00 0.7O7 0.223 4.04 <0.001
Follow up after
30 days
1.8 0.7 1.1 61.11 0.823 0.260 4.98 <0.001
Follow up after
60 days
1.8 0.4 1.4 77.77 0.875 0.276 7.60 <0.001
Effect on Shwasakrichrata
Vamana Dhauti conducted in other then Vasantha Ritu provided 50 % of relief in
Shwasakrichrata in 15 days which was statically significant (p <0.001). During follow up
study after 30days the percentage of relief was increased to 61.11 % and this was
decreased to 22 % in 60 days.
Table: Showing effect on Kasa
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
2 1. 0 1.0 50 0.707 0.223 2.24 <0.05
Follow up after
30 days
2 0.7 1.3 65 0.823 0.026 4.98 <0.001
Follow up after
60 days
2 1.6 0.4 20 0.632 0.200 10.0 <0.001
88
Effect on Kasa
Vamana Dhauti conducted in other then Vasantha Ritu provided 50 % of relief in
Kasa in 15 days which was statically significant (p <0.001). During follow up study after
30days the percentage of relief was increased to 65 % and this was decreased to 20 % in
60 days.
Table: Showing effect on Kanthodhvmsa
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
2.1 0.7 1.4 66.66 0.918
0.290 6.20 <0.001
Follow up after
30 days
2.1 0.4 1.7 80.95 0.823
0.260 6.53 <0.001
Follow up after
60 days
2.1 0.9 1.2 57.14 0.948
0.300 4.33 <0.001
Effect on Kanthodhvmsa
Vamana Dhauti conducted in other then Vasantha Ritu provided 60.66 % of relief
in Kanthodhvmsa in 15 days which was statically significant (p <0.001). During follow
up study after 30days the percentage of relief was increased to 80.95 % and this was
decreased to 57.14 % in 60 days.
89
Table: Showing effect on Duration attack
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
1.5 0.4 1.1 73.00 0.7264 0.229 6.11 <0.001
Follow up after
30 days
1.5 0.5 1.0 66.66 0.699 0.221 6.33 <0.001
Follow up after
60 days
1.5 0.7 0.8 53.33 0.918
0.290 4.13 <0.001
Effect on Duration attack
Vamana Dhauti conducted in other then Vasantha Ritu provided 66.66 % of relief
in decreasing duration attack in 15 days which was statically significant (p <0.001).
During follow up study after 30days the percentage of relief was maintained at
66.66 % and this was decreased to 53.33 % in 60 days.
Table: Showing effect on Frequency of attack
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
1.7 0.9 0.8 47.05 0.421 0.133 6.01 <0.001
Follow up after
30 days
1.7 0.3 1.4 82.35 0.948 0.300 4.33 <0.001
Follow up after
60 days
1.7 0.4 1.3 76.47 1.032 0.326 3.68 <0.001
90
Effect on Frequency of attack
Vamana Dhauti conducted in other than Vasantha Ritu provided 47.05 % of relief
in decreasing frequency of attack in 15 days which was statically significant (p <0.001).
During follow up study after 30days the percentage of relief was increased to
82.35 % and this was decreased to 76.47 % in 60 days.
Table: Showing effect on PEFR
Means
Score Data
BT AT
Mean
difference
% of
relief S.D. S.E. t p
Follow up after
15 days
1.7 0.7 1.0 58.82 0.458 0.144 9.02 <0.001
Follow up after
30 days
1.7 0.1 1.6 94.11 0.421
0.133 13.5 <0.001
Follow up after
60 days
1.7 0.4 1.3 76.47 0.816
0.258 3.80 <0.001
Effect on PEFR
Vamana Dhauti conducted in other then Vasantha Ritu provided 58.82 % of relief
in PEFR in 15 days which was statically significant (p <0.001).
During follow up study after 30days the percentage of relief was increased to
92.11 % and this was decreased to 76.47 % in 60 days.
91
Desha wise distribution of 20 patients of Tamaka Shwasa
0
10
20
30
40
50
60
70
80
VDVR TOTAL
ANUPA
SADHARANA
Addiction wise distribution of 20 patients of Tamaka Shwasa
0
10
20
30
40
50
60
VDVR VDIR TOTAL %age
Tea/Coffee
Betal leaf
Others
Ahara wise distribution of 20 patients of Tamaka Shwasa
0
10
20
30
40
50
60
VDVR VDIR TOTAL %age
Veg
NON-VEG
Agni wise distribution of 20 patients of Tamaka Shwasa
0
10
20
30
40
50
60
70
VDVR VDIR TOTAL %age
SAMA
VISHAMA
MANDA
TEEKSHNA
Vyayama Shakti wise distribution of 20 patients of Tamaka Shwasa
0
20
40
60
80
100
VDVR VDIR TOTAL %age
PRAVARA
MADHYAMA
AVARA
Age wise distribution of 20 patients of Tamaka Shwasa
0
5
10
15
20
25
30
35
40
VDVR VDIR TOTALNo
%age
20-30
31-40
41-50
51-60
92
Addiction wise distribution of 20 patients of Tamaka Shwasa
0
10
20
30
40
50
60
VDVR VDIR TOTAL %age
Tea/Coffee
Betal leaf
Others
Occupation wise distribution of 20 patients of Tamaka Shwasa
0
10
20
30
40
50
60
VDVR VDIR TOTAL %age
Housewife
Service class
Business
Agriculture
Sex wise distribution of 20 patients of Tamaka Shwasa
0
10
20
30
40
50
60
VDVR VDIR TOTAL %age
Male
Female
Prakriti wise distribution of 20 patients of Tamaka Shwasa
0
10
20
30
40
50
60
70
VDVR VDIR TOTAL %age
V P
V K
P K
SAMA
93
2.6
1.8
1.2
0.7
0
0.5
1
1.5
2
2.5
3M
ean S
core
B.T. A.T.
EFFECT ON GURGURATA
VDVR
VDIR1.5
1.8
0.5
0.9
0
0.5
1
1.5
2
Mean S
core
B.T. A.T.
EFFECT ON SWASKRICHTA
VDVR
VDIR
1.2
2.1
0.6 0.7
0
0.5
1
1.5
2
2.5M
ean S
core
B.T. A.T.
EFFECT ON KANTHODHVMSA
VDVR
VDIR
1.8
2
1.5
1
0
0.5
1
1.5
2
Mean S
core
B.T. A.T.
EFFECT ON KASA
VDVR
VDIR
1.5
1.7
0.5
0.9
0
0.5
1
1.5
2
Mean S
core
B.T. A.T.
EFFECT ON FREQUENCY OF ATTACK
VDVR
VDIR
1.41.5
0.7
0.4
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Mean S
core
B.T. A.T.
EFFECT ON DURATION OF ATTACK
VDVR
VDIR
94
2.2
1.71.5
0.7
0
0.5
1
1.5
2
2.5
Mean S
core
B.T. A.T.
EFFECT ON PEFR
VDVR
VDIR
95
Discussion
Interpretation of various observations made in the study is done in this part to
arrive at conclusions about the demographic features of the disease and the efficacy of
Vamana dhauti procedure in Vasantha ritu.
Age wise distribution of patients shows that the disease affects people of all ages
and 40% of patients were in the age group of 30 to 40 years which show affliction of
people who will be having more chance of exposure to various Nidana Kara bhava.
Sex wise distribution show higher incidences among females who naturally have
are with lesser immunity status. Due to their frequent exposure to house hold dust and
other allergy inducing factors and due to lesser immunity levels more occurrences among
females can be explained. However this need observation in large sample studies.
Religion wise distribution does not hold good in this study as all patients were of
Hindu community. Since the majority of patients reporting at our hospital are Hindus,
and also due to their higher percentile among population this observation can not be
generalized.
Socio economic status shows the affliction of above 60% in middle and lower
groups. Since they constitute the major groups of population, this observation can be
justified.
Urban and rural distributions show 65% in urban areas. This indicates
involvement of air and other forms of pollution which have a higher influence.
Occupation wise involvement shows more occurrences among house wives
which may be due to their nature of work as explained earlier.
96
Literacy status wise observation did not yielded any significant observation as
all sorts of people were affected irrespective of literacy status.
Prakriti wise distribution shows 70% afflictions among vatha Kaphaja Prakriti.
Since the disease Samprapti involves the involvement of these two Doshas, indulgence of
Nidhanottha karana by them predispose to the disease. Hence prevention should aim at
these Prakriti people.
Diet pattern indicate 60% belonging to mixed group. Mamsa Sevana and guru
abhisyanda Ahara Sevana may form a potent initiating or aggravating factor in the
disease.
Vyasana wise observations do not pointed to any specific involvement.
Anupa Desha contributed 80% of observed cases. This observation is justifiable
since it influences the occurrence of Kaphaja vikara.
Ritu involvement was noted in almost all cases as the aggravations occurred with
onset of Vasantha Ritu. However this study was conducted only in patients of
avegavastha.
Nidana factors involved were Rajosevana in 50% patients, Dhooma Sevana in
50%, Sheetala Vayu Sevana in 55%.
97
Discussion on Results
Ghurghuraka
After vamana dhauti the mean score got reduced from 2.6 to 1.2 with an average
change of 1.4 and improvement of 53.8% in VDVR group which is significant. (p<0.001)
In VDIR group after vamana dhauti the mean score got reduced from 1.8 to 0.7
with an average change of 1.1 and improvement of 61.1 which is significant. (p<0.001)
Follow up studies revealed the patients of VDVR had the higher percentile of
relief than the VDIR group. This may be due to better elimination of kapha in Vasantha
ritu.
Shwasa Kruchrata
After vamana dhauti the mean score got reduced from 1.5 to 1 with an average
change of 0.5 and improvement of 33% in VDVR group which is significant. (p<0.001)
In VDIR group after vamana dhauti the mean score got reduced from 1.8 to 0.7
with an average change of 1.1 and improvement of 61.1 which is significant. (p<0.001)
Follow up studies revealed the patients of VDVR had the higher percentile of
relief than the VDIR group. In VDIR group, the relief percentage in symptoms got
reduced in follow up studies.
98
Kasa
After vamana dhauti the mean score got reduced from 1.8 to 1.5 with an average
change of 0.3 and improvement of 33% in VDVR group which is significant. (p<0.001)
In VDIR group after vamana dhauti the mean score got reduced from 2 to 1 with
an average change of 1 and improvement of 50% which is significant. (p<0.001)
Follow up studies revealed in the patients of both groups higher percentile of
relief was observed in 1st follow up but the same was maintained only in VDVR group in
2nd follow up.
Kantodhwamsa
After vamana dhauti the mean score got reduced from 1.2 to 0.6 with an average
change of 0.6 and improvement of 50% in VDVR group which is significant. (p<0.001)
In VDIR group after vamana dhauti the mean score got reduced from 2.1 to 0.7
with an average change of 1.4 and improvement of 66% which is significant. (p<0.001)
Follow up studies revealed patients of both the groups showed higher percentile
of relief in 1st follow up but the same was decreased in 2nd follow up.
Duration of attack
After vamana dhauti the mean score got reduced from 1.4 to 0.7 with an average
change of 0.7 and improvement of 50% in VDVR group which is significant. (p<0.001)
In VDIR group after vamana dhauti the mean score got reduced from 1.5 to 0.4
with an average change of 1.1 and improvement of 66% which is significant. (p<0.001)
99
Follow up studies revealed patients of both the groups showed higher percentile
of relief in 1st follow up but the same was decreased in 2nd follow up.
Frequency of attack
After vamana dhauti the mean score got reduced from 1.5 to 0.5 with an average
change of 1 and improvement of 66% in VDVR group which is significant. (p<0.001)
In VDIR group after vamana dhauti the mean score got reduced from 1.7 to 0.9
with an average change of 0.8 and improvement of 47% which is significant. (p<0.001)
Follow up studies revealed patients of both the groups showed higher percentile
of relief in subsequent follow ups. This clearly shows the efficacy of vamana dhauti in
relieving frequency of attacks.
PEFR reading
After vamana dhauti the mean score got reduced from 2.2 to 1.5 with an average
change of 0.7 and improvement of 31.8% in VDVR group which is significant. (p<0.001)
In VDIR group after vamana dhauti the mean score got reduced from 1.7 to 0.7
with an average change of 1 and improvement of 58.8% which is significant. (p<0.001)
Follow up studies revealed patients of both the groups showed higher percentile
of relief in subsequent follow ups. This shows that vamana dhauti increases respiratory
volume.
During vamana dhauti the avarodha by kapha in Pranavaha srotas will be
eliminated and hence it relieves Ghurghuraka. The removal of ama along with kapha
enables to have deepana effect, which also may contribute for this.
100
Shwas Kruchrata is due to obstruction to Prana Vayu by kapha. .Increase in
respiration activity during vamana dhauti increases the depth of respiratory movements.
Since respiration is an efficient means for increasing tissue metabolism, by which
oxygen is absorbed more by the tissues and carbon dioxide is eliminated.
During this procedure all smooth muscles gets relaxed and most prominent effect
will be exerted on bronchi. It has been observed that after the kriya broncho- dilatation
was consistently produced and vital capacity was increased. This study has demonstrated
the immediate efficacy of vamana dhauti in dilating the bronchus as observed by
significant improvement in the peak flow meter reading.
Decrease in respiratory distress relieves the symptoms Kasa and Kantodhwamsa.
These symptoms got reduced significantly in this study.
Vamana dhauti can be used in Kaphaja vyadhi like in Tamaka Shwasa during kapha
kala. The effect of vamana dhauti could be due to cleansing effect of warm salt mixed
water which distends the esophagus. The osmolarity of the salt solution may soothen
the parasympathetic and irritant receptors, there by reducing impulses reaching the
bronchial tree from these receptors. This brings about decrease of inflammatory
changes and hence diminishes frequency of asthmatic attacks.
The observance of better results in VDVR group during follow ups indicate that
when administered in Vasantha ritu vamana dhauti gives better efficacy. Even though the
initial observations are almost similar for both groups the importance of vamana dhauti in
Vasantha ritu is significant for getting better relief as per this study.
101
Conclusion
Following conclusions can be drawn from the present study.
Exogenous causes play major role in Asthma than endogenous causes
Association of Vihara Sambandhi Nidanas explained in classics is clearly evident
The clinical entity of Tamaka Shwasa is closely resemble with the descriptions of
Bronchial Asthma of contemporary science
The chronicity of the disease proves the ‘yapya’ nature of the disease
Avoiding of causative factors and regular practice of dhauti may help to certain
extent
Maximum incidences were reported in 31 to 50 years age group, among females
55%, Hindu religion 100%?, in moderate nature of work 55%, urban area
residents 65%, mixed diet habits 60%, and habitants of Anupa Desha 80%
Majority of patients belonged to vatha kapha Prakriti, preferring Madhura, Amla
Rasa , Madhyama Satmya 95%, and Madhyama Satva 85%
Among the Nidana factors involvement of Sheeta Vayu 55%, Dhooma 50% were
predominant
Aggravations of symptoms were more during Vasantha Ritu.
The cardinal symptoms like Ghurghuraka, Shwasa Kruchrata, Kasa,
Kantodhwamsa, were seen in most of the patients
Irrespective of the season all the patients were benefited by undergoing Vamana
Dhauti
102
The objective of this study was to assess the influence of Vasantha Ritu on the
efficacy of Vamana dhauti. No significant superior efficacy was observed for
parameters like Shwasa Kruchrata, Kasa, duration and frequency of attacks in
VDVR group over VDIR group immediately after therapy. But in the follow up
studies the efficacy was higher.
Results show the efficacy of vamana dhauti was more in parameters like
Ghurghuraka and peak flow meter readings immediately after the therapy but the
same were not sustained. This shows that the procedure is effective in expulsion
of clogged kapha instantly and increases the lung respiratory volume, and there is
need to undertake therapy frequently.
Overall efficacy of the treatment was 57% in Ghurghuraka, 52% in Shwasa
Kruchrata, 55% in Kasa, 58% in Kantodhwamsa, 82% in reducing duration of
attack, 56% in decreasing frequency of attack, and 81% in improving the PEFR
reading irrespective of the season.
Since the efficacy was found to be waning off in subsequent follow ups, the
procedure can be indicated on regular basis to sustain the efficacy.
Though the results show insignificant efficacy for Vasantha ritu, further trails are
needed with large sample size and by undertaking more sittings of vamana dhauti
procedure
Since no complications were found in patients during and after the study the
procedure can be indicated in all patients of Tamaka Shwasa
Though the results are obtained from a small sample, they offer hope for Tamaka
Shwasa patients.
103
Summary
The present study titled “A study on Vamana dhouti in Tamaka Shwasa with
special reference to Vasantha Ritu” was conducted to observe the effect of Vamana
dhouti in Tamaka Shwasa. It also intends to note the influence of Vasantha Ritu in
influencing the efficacy of therapy. The patients attending OPD units of SDMCA&H
formed the source of data.
Since the clinical features of Bronchial Asthma closely resemble the features of
Tamaka Shwasa the same was considered as nearest clinical entity for the study.
The disease affects all the age groups and the commencement can be traced to
early age in many cases. Among the different etiological factors history of allergy,
change of seasons and intolerance to certain foods play an important role.
Considering the chronic nature of disease and due to absence of an effective
curative therapy importance is to be given for prevention. A treatment like Vamana
dhouti due to its simple way of technique and adaptability for conduction at home can be
popularized among the patients.
Review of literature was done in four chapters. First chapter dealt with
detail descriptions of the disease in terms of Ayurvedic and contemporary views. In
second chapter the procedure Vamana dhouti was analyzed. Third chapter was assigned
for discussions on the influence of Vasantha Ritu on the disease and the procedure.
Fourth chapter explains the importance of prevention in this disease with possible
interventional factors.
104
In the clinical study aims and objectives of study, materials and methods,
inclusion and exclusion criteria and assessment criteria was mentioned. In the annexure
part case sheets, diet chart and the data of clinical study is included.
The clinical study was conducted among 20 patients of Tamaka Shwasa, who
were assigned randomly in to two groups. Group A was conducted with Vamana dhouti
once in Vasantha Ritu and in group B Vamana dhouti was conducted once in other than
Vasantha Ritu. The dietetic advices and regimen prescribed was similar to all the patients
in both groups.
The observations and results made in the study are presented in the respective
parts. Relevant explanations are made in discussion part on the observations. Statistical
significance and its interpretations are included in the same chapter.
The results show that Vamana dhouti has better efficacy when conducted in
Vasantha Ritu compared to other seasons. Hence the therapy can be considered in the
treatment of Tamaka Shwasa patients.
105
References
Tamaka Shwasa Niruki & Paribhasha
1. Apte dictionary
2. Amara kosha
3. Shabda kalpa druma part II pp-589
4. Shabda kalpa druma part II pp-590
5. Amarakosha,Amara shudha commentary, Vanoushadhi Varga 120./8
6. sushrutha samhita uttar tantra 51.8
7. Chandogyopanishad 1:2:10-12
8. Ch.Ci.17.62, Chakrapani
9. Ch.Ci.17.10-16, Chakrapani
10. M.N.1.8
11. Ch.Ci.17.17
12. Ch.Ci.17.17
13. Ch.Ci.17.63-64
14. Ch.Ci.17.62-64
15. A.H.Ni.4.7
16. A.H.Ni.4.8
17. A.H.Ni.4.7
18. Ch.Ci.17.56 ,
Su.U.51.7
19. Ch.Ci.17. 55-60,
A.S.Ni.4.3-4
20. Ch.Ci.17. 56
21. A.H.Ni.4.9
22. Su.U.51.8
23. Ch.Ci.17.59-61
24. Ch.Ci.17.62
106
25. Ch.Ci.17.121
26. Ch.Ci.17.72,
Su.U.51.53
27. Ch.Ci.17.57
28. Ch.Ci.1:3.36-40
29. Ch.Ci.17.99-101
30. Ch.Ci.17.103
31. Harrison’s principles of internal medicine pp. 1051, 1053
32. A P I text book of medicine pp.261
33. Medicine for students by golwalla pp.244-245
34. Medicine for students by golwalla pp.244-245
35. Yoga for asthma publd by SVYP
36. Harrison’s principles of internal medicine pp.1051
37. Medicine for students by golwalla pp.244-245
38. Medicine for students by golwalla pp.244-245
39. Medicine for students by golwalla pp.244-245
Harrison’s principles of internal medicine pp1059
VAMANA DHAUTI
40. Kriya, cleansing in yoga publ by yoaga bharati pp.10
41. Kriya, cleansing in yoga publ by yoaga bharati pp.10-11
42. Kriya, cleansing in yoga publ by yoga bharati PP. 20
43. Sha. Sam. U. 3.20
44. Yogic Management of Common Disease
45. Kriya, cleansing in yoga publ by yoaga bharati pp.11
46. Hatha yoga pradeepika 2.32
47. Gheranda samhita.1.52
48. Kriya, cleansing in yoga publ by yoaga bharati pp.44
49. Hatha yoga pradeepika. 2.36
50. Gheranda samhita.1.55
107
51. Kriya, cleansing in yoga publ by yoaga bharati pp.49
52. Gheranda samhita.1.57
53. Kriya, cleansing in yoga publ by yoaga bharati pp.72
54. Hatha yoga pradeepika. 2.34
55. Gheranda samhita.1.61
56. Kriya, cleansing in yoga publ by yoaga bharati pp.114
57. Gheranda samhita.1.37
58. Hatha yoga pradeepika. 2.27
59. Gheranda samhita.1.44
60. Kriya, cleansing in yoga publ by yoaga bharati pp.151
61. A P I text book of Medicine pp.228
62. A P I text book of Medicine pp.227-228
63. Food and medicine Dr Swaminathan vol.I pp.170
64. Ch.Su.27.243-246
65. Food and medicine Dr Swaminathan vol.I
66. A.H.Ci.7.69-71
B.R.16.122-127
67. A.H.Ci.7.69-71
B.R.16.122-127
68. A.H.Su.2.2-26
69. Yoga for bronchial asthma publ by SVYP pp.125
70. Yoga for bronchial asthma publ by SVYP pp.12-13
71. Yoga for bronchial asthma publ by SVYP pp.132
72. Gheranda samhita.1.55
108
Vamana in Vasantha ritu
73. B.P.Purva .12-13
74. A.H.Su.1.24
75. A.H.Su.1.24, Aruna & Hemadri
76. A.H.su.3.3 Hemadri
77. A.H.Su.3.20
78. Su.Su.6.12, Dalhana
79. Ch. Su.6.23
80. Ch. Su.6.23
81. Ch. Su.6.23, Chakrakapani
82. A.S.Su. 4.22-24
83. A.S.Su. 4.22-24, Indu
84. A.H.Su.3.19
85. A.H.Su.3.18-20
86. A.S.Su.4.22-24
87. A.h.Su.3.18-20
88. Su.Su.6.12 Dalhana
89. Ch.Su.6.22-24
90. A.H.Su.3.19
91. Ch.Su.6.23
92. Ch.Su.6.23, Charkrapani
93. A.H.Su.1.4)
94. Ch.Vi.5.8
95. Sha.Sam.Pratama.5.49
96. Ch.Ci.17.72
97. A.H.Su.1.24
98. Ch.Su.6.23, Charkrapani
99. Ch. Su. 20. 19
100. A.Sa.Su.4.25
109
Bibliography
1.Agnivesha (2004), Charaka Samhita (Hindi Commentary by Vidyothini), Vol-I,
Reprint 2004. Chaukamba Bharati Academy Publication, Varanasi, pp- 829, 548,
696, 1009, 1027, 771. Vol-II, pp- 614-640, 938, 9-14, 4-53.
2.Agnivesha (2000), Charaka Samhita with English Translation [by Bhagwandasha
R.K. Sharma], Volume IV, II Edition, Chaukamba Sanskrit Series Office,
Varanasi, pp. 117-135.
3.Anonymous, Yogaratnakara with Vaidyaprabha, Hindi Commentary, 1st Edition,
1998. Edr. Dr. Indradevi Tripathi and Dr. Daya Shankar Tripathi, Krishnadas
Academy, Varanasi, pp. 340, 341, 342, 344.
4.Apte V.S. (1985), The Students Sanskrit English Dictionary, Shatilal Jain, Delhi.
5.Bhela; BhelaSamhita, Edtr. Sharma P.V., 1st Edition, 2000, Chaukamba
Vishwabharati, Varanasi.
6.Bhava Misra; Bhavaprakash, Vidyothini Hindi Commentary, 1st Edition1993,
Choukambha Sanskrit Sansthan, Varanasi, Part II.
7.Brahmanand Tripathi (1999), Astanga Hridaya, Nirmal Hindi Commentary, 1st
Edition, Edr. Bramhanand Tripathi, Chaukamba Sanskrit Pratisthana, Delhi, pp.
609 to 626.
8.Braunwald, Harrison’s Principle’s of Internal Medicine, 13th Edition, McGraw Hill
Medical Publications, Vol. II, pp. 1167-1172.
9.Chakrapani (1994), Charaka Samhita, Edition IV, Edtr.. Vaidya Jadavaji Trikamji
Acharya, Chaukamba Sanskriti Sansthan Publisher, Varanasi, pp. 533-539.
10. Christopher Halsett et. al., Devidson’s Principles of Medicine, Edtr.
Christopher Halsett et.al,. 19th Edition, 2002. Churchil Livingstone, U.K. pp. 513-
518.
11. Chaudri, Concise Medical Physiology, 3rd Edition, 2000, New Central Book
Agency, Calcutta.
12. Dalhana, Sushruta Samhita, Nibandha Sangraha Sanskrit Commentary, Editor
Jadavaji Trikamaji Acharya, Reprint 1999. Chaukamba Surabharati Prakashana,
Varanasi,
110
13. Dr. H.R. Nagendra & R. Nagaratna, A new light for Asthmatics,1st edition,
Nov 1998 Vivekananda yoga kendra prakashana, Banagalore,
14. Dr. Ravi R Javalgekar, The yoga science for everyone, 1st edition,1990,
Chaukamba Sanskrit Samsthana, Varanasi.
15. Dr. Nagaratna & Dr. Nagendra, Positive Health, 1st edi. Reprint 2003
Swamyvivekananda yoga prakashana Bangalore.
16. Dr. Gyanendra Pandey, Dravya guna vignana, part-III, 1st edition, 2001,
Krishnadas Academy, Varanasi, pp- 116-134.
17. Gangadhara, Charaka Samhita, Part IV, 1st Edition, 1999, Chaukamba
Orientalia, Varanasi, pp. 3002 to 3032.
18. Gananath Sen, Siddhanta Nidana, part –I, 5th edition, 1966, Chaukamba
Sanskrit series office, Varanasi.
19. Indu (1980), Astanga Sangraha, Shashilekha Sanskrit Commentry, Editor
Athavale A.P. Shrimad Atreya Prakashana.
20. Jejjata (1941), Nirantara padavyabya (Charaka Samhita) II Part, 2nd Edition,
Shri, Motilal Banarasidas, Lahore.
21. Kumar and Clark, Clinical medicine, 4th edition, Editor Praveen Kumar and
Michael Clark, 1998, pp- 785-790
22. Madhavakar, Madhavanidana, Madhukosha Sanskrit Commentary with
Vidyotini Hindi Commentary, Edtr. Prof. Yadunandana Upadhayaya. 25th Edition,
1995, Part I, pp. 281 to 301.
23. Monier William, A Sanskrit English Dictionary, 5th Edition, 1997, Motilal
Banarasidas Publishers Private Limited, Delhi.
24. Maharshi Patanjali, Patanjali Yoga Darshanam, Hindi vyakhya by Swamy Sri
Bramha lina muni, Chaukamba Sanskrit Samsthana, Varanasi.
25. Pancham singh, The Hatha Yoga Pradipika, translated to English, 4th edition.
1992, Munshiram manohar lal publishers ltd, New Delhi
26. Raja Radha Kanta Deva; Shabda Kalpadrum, 3rd Edition, Chaukamba
Sanskrit Series Office, Varanasi, part-II, pp- 590, Part-IV, pp- 178-179.
111
27. Robin and Kumar, Robins Pathology, 7th Edition, 2003. Edtr. Robin, Kumar,
Cortan, Published by Hawvrt (India) Private Limited, New Delhi, pp. 455, 456,
457, 458.
28. Sainani G.S., API Text Book of Medicine, 6th Edition, 1999, Published by
Association of Physicians of India, Bombay, pp- 286- 290.
29. Sharangadhara (2001), Sharangdhara Samhita (English Translated by
Srikantamurthi) IV Edition, Chaukhamba Orientalia, Varanasi,
30. Sharma P.V. Chakradatta Edtr. P.V. Sharma, 2nd Edition, 1998, Chaukamba
Publishers, Varanasi,
31. Sharma P.V., Dravya Guna Vijyana, Vol. II, Edition 1999, Chaukamba Bharati
Academy, Varanasi. Pp- 275-299
32. Sushruta, Sushruta Samhita Ayurveda TattvaSandipika, Hindi Commentary,
11th Edition, 1997. Editor, Kaviraja Ambikadutta Shastri, Chaukamba Sanskrit
Bhavana,
33. Stedman’s medical dictionary, 27th edition, 1999, published by Lippincott
williums and Wilkins, pp- 159
34. Taber’s cyclopaedic medical dictionary, Vol- I, published by Jaypee Brothers,
19th edition, pp- 188
35. Kriya, cleansing in yoga publ by yoaga bharati pp.10
36. Gheranda samhita. Rai Bahadur Sing-Chandra Vasu, 3rd Edition-1980.
37. API Text Book of Medicine edited by G S Sainani & co.6th edition 1999.
Published by Association of Physicians of India, Bombay, page 208-210
38. Oxford Clinical Dietetics & Nutrition by F.P.Antia & Philip Abraham, 4th
edition, 2002, pubished by oxford university press, page 176,336-346.
112
RESEARCH PROFORMA
DEPARTMENT OF SWASTHVRITHA
S.D.M. College of Ayurveda and Hospital, Hassan Title: A study on the efficacy of Vamana dhouti in Vasantha Ritu Scholar: Dr. MoniLal Das Guide : Dr. G. V. Ramana Professor and H.O.D. Department of Swasthavritta
Name : Sl.No.
Address : Group : A /B
Age : OPD No:
Sex : IPD No:
Religion : Ward/Bed No:
Occupation : D.O.A. :
Education : D.O.D. :
Socio-economic Status: Result :
D.O. Commencement :
D.O. Completion:
113
Pradhana Vedana( Kala Prakarsha)
Anubhandhi Vedana
Pradhana Vedana Vrittanta
Poorva Vyadhi Vrittanta
Koutumbika Vrittanta
Vayaktika Vrittanta
a) Ahara : Veg / Mixed Time: Regular / Irregular Rasa: M/A/L/K/T/T Samashana / Adhyashana / Vishamashana / Anashana Type of Food: During attack: Attack free period: b) Vihara c) Nidra : Sound / Disturbed / Good
Sleeping hrs/day :
Divaswapna : Present / Absent
d) Vyasana (Habits) :
114
e) Appetite : Poor / Moderate / Good
f) Environment : Mental exertion / Physical exertion
& activity
g) Emotional : Anxiety / Tension / Depression / Jovial / Anger
Condition Irritation / Fear / Jealousy
h) Mala Pravritti : Regular / Irregular
No. of Vegas / Day
Consistency : Grathitha / Drava / Picchita / Sama / Nirama /
Phenila
Colour : Swethabha / Peethabha / Aruna / Rakta / Krishna
Kosta : Mrudu / Madhyama / Krura
i) Mootra Pravrutti: Normal / Abnormal
No. of Vegas /day /night
Quantity : Alpa / Madhyama / Bahu
Colour : Swethabha / Peethabha / Raktabha
j) Vyayama : No / Less / Proper / Excess / Irregular
Nature:
Excise induced asthma : Present / Absent
k) Desha : Urban / Rural
Jangala/Anupa/AnupaSadharana/Sadharan
l) Known history of Allergy :Present / Absent
(If any) Allergy to Dhooli (Dust) / Dhooma (Smoke) /
Raja (Pollen Grains) / Sheeta (cold) / Aushadhi/
Ahara/pets/Cosmetics/Chemicals/ Others
115
Symptoms : Cold / Cough / Nasal irritation / Nasal discharge/
Sneezing / Eye irritation / Itching/ Wheezing
Duration :
n) Gynecological History : Menarche age
(In case of females) Menstrual History: Regular / Irregular
Menorrhagia/Metrorrhagia/Dysmenorrhoea/
Leukorrhoea
Poorva Chikitsa Vrittanta
Drugs administered Duration Mode of Admn.
Bronchodilators:
Steroids :
Others :
H/O Hospitalization: Present / Absent
(For similar complaints)
General Examination
General appearance:
Built Conjunctiva:
Nourishment Tongue:
Pulse Nails:
B.P Lymph nodes:
Resp.rate
116
Temperature JVP
Height Edema / Puffiness
Weight Cyanosis
Systemic Examination
1. Cardio Vascular System
2. Central nervous system
3. Gastro- intestinal system
4. Musculo skeletal system
Detail Examination of respiratory system
PRASHNA PAREEKSHA
Dyspnea and Wheeze
Onset of first attack:
Duration of attack:
Frequency of attack:
Any occasional variations:
Aggravating factors:
Relieving factors:
117
Mode of onset : Sudden/Gradual/episodic/continuous/
Initially episodic followed by continuous
Time of occurrence: Early morning/Evening/day/night/
Day and night/No timing
Periodicity: Seasonal/Perennial/Irregular
Proceeded by: Sneezing/nasal irritation/nasal discharge
Cough/ wheeze
Cough:
a) Present / Absent
b) Dry / Productive
c) If present relation with the attack
d) Duration
e) Nocturnal / day / continuous
Sputum:
Quantity
Viscosity
Smell
Colour
Postural variation
Haemoptysis
Fever
a) present /Absent
b) If present relation with attack
c) Continuous/Intermittent
118
d) Duration
e) Associated with
Inspection (Darshana Pareeksha)
I. Shape of chest:
II. Respiratory Rate:
III. Respiratory Rhythm: Regular/ Irregular
IV. Type of breathing: Abdominothoracic / Thoraco abdominal
V. Accessory muscles: Involved / Not Involved
Of respiration & Alae nasi movement during the attack
VI. Audible Wheeze: Present / Absent
Palpation (Sparshana pareeksha)
I. Trachea : Centrally placed / Deviated
II. Expansion : Symmetrical / Asymmetrical
III. Vocal fremitus : Normal / Decreased / Increased
Percussion (Akothana Pareeksha)
Percussion Note : Resonant/Hyper resonant/Dull/Stony dull
Areas :
Auscultation (Shadbha Pareeksha)
1. Type of breath sounds: Normal: Vesicular
119
Abnormal: Bronchial / Broncho- vesicular
2. Foreign Sounds : Present / Absent
Wheeze / Crackle/ Pleural friction rub
Site:
3. Vocal resonance site : Normal / Increased / Decreased
PRAYOGA SHALEEYA PARIKSHA [ROUTINE INVESTIGATIONS]
B.T. A.V. A.T.
Blood Investigations Hb%
TC
DC
P
L
M
E
B
ESR
AEC
Radiological findings
Chest X-ray (if necessary )
Special Investigation
PEFR
120
ATURA BALA PRAMANA PAREEKSHA
1 Prakrutitaha Shareera V/P/K Manasa S/R/T
2 Sarataha P/M/A
3 Samhananataha P/M/A
4 Satmyataha P/M/A
5 Satvataha P/M/A
6 Pramanataha P/M/A
7 Vyayama Shaktitaha P/M/A
8 Ahara Shaktitaha Abhyavaharana Shakti P/M/A Jarana Shakti P/M/A
9 Agni Sama / Vishama / Manda / Teekshna
Vikruti Pareeksha
Dosha pareeksha Dushya/sroto pareeksha a) Rasavaha b) Raktavaha c) Mamsavaha d) Medavaha e) Majjavaha f) Asthivaha g) Sukravaha Hetu pareeksha Nidana Poorvarupa Roopa Upashaya / Anupashaya Samprapti
121
Samprapti Ghataka
Dosha Srotas Dushya Srotodusti Prakara Agni Udbhava Sthana Ama Sanchara sthana Vyakta sthana Roga marga Desha Jata
Samridha Bala Vyadhita
Upadrava (if any)
Arista (if any)
Sadhyasadhata:
Chikitsa: 1. Shamana with Anupana 2. Pathya
a) Ahara b) Vihara c) Achara d) Vichara
3. Apathya
Parinama
122
Nidana of Tamaka Shwasa
Sl. No AHARA SAMBANDHI
Exposure to Nidana factors
Sl. No VIHARA SAMBANDHI
Exposure to Nidana factors
Sl. No
Vyadhi Avastha Sambandhi
Exposure to Nidana factors
B.T D.T. A.T. B.T D.T A.T. B.T D.T A.T
1 Sheetapana 37 Apatarpana
2 Sheeta ashana 21 Vayu sevana 38 Atisara
3 Guru bhojana 22 Raja sevana 39 Jwara
4 Abhishyandi bhojana 23 Dhooma sevana 40 Chardi
5 Ruksha bhojana 24 Vyayama 41 Kasa
6 Vidahi ahara 25 Vegadharana 42 Pandu
7 Vistambi ahara 26 Sheeta sthana 43 Rookshata
8 Adhyashana 27 Bhara vahana 44 Anaha
9 Shleshmala ahara 28 Sheeta snana 45 Vibhandha
10 Jalaja mamsa 29 Atapa sevana 46 Amapradosha
11 Anoopa mamsa 30 Abhishyandhi upachara 47 Pratishyaya
12 Ama ksheera 31 Adwagamana 48 Kshata Kshaya
13 Dadhi 32 Dwandwa sevana 49 Dourbalya
14 Nishpava 33 Asatmya sevana 50 Vishoochika
15 Vishamashana 34 Sheetasana 51 Udavartha
16 Pinyaka 35 Others 52 Raktapitta
17 Tila Taila Agantu Karana
18 Pista padartha 53 Marma Aghata
19 Amla rasa 54 Visha 20 Others 55 Kantorasa Pratighata
123
Poorva Roopa of Tamaka Shwasa
Sl. No B.T A.T
1 Anaha 2 Hridaya Peedana 3 Pranasya Vilomata 4 Ashya Vairasya 5 Shankha Bhedha 6 Shoola 7 Admana 8 Bhaktadwesha 9 Aruchi 10 Parshwa Shoola
124
Diet Chart
6:00 AM – Jala dhauti (Vomiting induction) with hot Water mixed with saindhava lavana
7:00 AM – 2-4 flakes of garlic with goat’s milk
8:00 AM – 2 dosa (rice, moong dal, whole wheat) OR
3 idlies (rice, moong dal, whole wheat) OR
2 chapaties (whole wheat, yava),
Chatni – garlic, onion, ginger, palak, Bitter gourd, kakamachi (Black night –
Shade), chakramarda (ring worm plant Leaves)
Drink: Hot water boiled & cooled water, 100 ml with honey.
11:00AM:
Fresh Fruit Juice – 200 ml (grapes, lemon, tamarind, Pome granate, lemon, watermelon)
OR
Buttermilk – 200ml with 1 pinch saindhava lavana
OR
Fruits – Grapes [dry & wet], pomegranate, wood
-apple, watermelon, governor’s plum, pear, Ripen cucumber
1: 30 PM: Lunch – Rice – 1 cup / Wheat chapaties – 3, Sambar – Bimbi
Carrot, Tender radish, beans etc.
EVENING
5:00 PM – Goat’s milk – 100 ml / shunthi jala / tulasi patra swarasa etc.
NIGHT: Dinner
8:30 PM : Rice – 1 cup, Sambar – bimbi, tender radish, drum stick, carrot, kushmanda
[white gourd melon] - 1 cup
Vegetable salad – 1 cup – carrot, cucumber, spinach, garden porslane.
Sips of hot water can be allowed in between.
125
Master Chart no.01 showing details of incidences of clinical study
Sl.no
O.P.D No
Name Age Sex Religion Occupation Diet Vihara Vyasana
1 82478 DT Kumar 60 M Hindu Business Vegetarian Vayu Sevana Tea/coffee 2 73181 Nanjundamma 37 F Hindu Housewife Vegetarian Rajo Sevana Tea/coffee 3 86888 Laxman 25 M Hindu Agriculture Vegetarian Vayu Sevana Tea/coffee 4 83745 DT jayakumar 40 M Hindu Agriculture Mixed Vayu Sevana Alcohol 5 88175 HL Sumalatha 23 F Hindu Housewife Mixed Sheeta Sevana Betel leaf 6 82551 Krishnagouda 55 M Hindu Agriculture Mixed Rajo Sevana Betel leaf 7 83082 S Ravi 25 M Hindu Lecturer Vegetarian Vega Dharan Alcohol 8 86334 Siddha Gowda 60 M Hindu Agriculture Mixed Vayu Sevana Betel leaf 9 18713 Leelavathi 46 F Hindu Housewife Mixed Vega Dharan Tea/coffee 10 75514 Yashodha gowda 52 F Hindu Lecturer Mixed Rajo Sevana Tea/coffee 11 69040 Nethravathi 43 F Hindu Housewife Mixed Sheeta Sevana Betel leaf 12 96315 Malay Gowda 59 M Hindu Agriculture Mixed Vayu Sevana Tea/coffee 13 96710 Jyothi. 32 F Hindu Housewife Vegetarian Vega Dharan Tea/coffee 14 96724 Laxmamma 39 F Hindu Housewife Mixed Sheeta Sevana Tea/coffee 15 86732 Shivamma 42 F Hindu Housewife Mixed Vega Dharan Tea/coffee 16 60251 Shanthi 39 M Hindu Worker Mixed Dhooma Betel leaf 17 60241 Gowramma 32 F Hindu Housewife Mixed Sheeta Sevana Tea/coffee 18 70347 Somashekar 36 M Hindu Carpenter Vegetarian Rajo Sevana Betel leaf 19 96777 Pushpa 38 F Hindu Housewife Vegetarian Sheeta Sevana Tea/coffee 20 97512 leelavathi 41 F Hindu Housewife Vegetarian Dhooma Tea/coffee
126
Master Chart no 02. Showing details of incidences of clinical study
Sl .no
Name Prakruti Desha Satwa Satmya Agni Vyayama shakti
Sara / samhanana
1 DT Kumar VK Sadharana Madhyama Madhyama Teekshna Madhyama Madhyama 2 Nanjundamma VK Anupa Madhyama Madhyama Manda Madhyama Madhyama 3 Laxman VK Anupa Madhyama Madhyama Manda Madhyama Madhyama 4 DT jayakumar VP Anupa Madhyama Madhyama Manda Madhyama Madhyama 5 HL Sumalatha VPK Anupa Madhyama Madhyama Manda Madhyama Madhyama 6 Krishnagouda VK Anupa Madhyama Madhyama Teekshna Madhyama Madhyama 7 S Ravi VK Anupa Madhyama Madhyama Manda Avara Madhyama 8 Siddha Gowda VK Anupa Madhyama Madhyama Manda Madhyama Madhyama 9 Leelavathi VK Anupa Madhyama Madhyama Manda Madhyama Madhyama 10 Yashodha gowda VK Anupa Madhyama Madhyama Manda Madhyama Madhyama 11 Nethravathi VK Anupa Madhyama Madhyama Manda Madhyama Madhyama 12 Malay Gowda VPK Sadharana Pravara Pravara Teekshna Madhyama Madhyama 13 Jyothi. PK Anupa Madhyama Madhyama Manda Madhyama Madhyama 14 Laxmamma VK Anupa Madhyama Madhyama Vishama Madhyama Madhyama 15 Shivamma VPK Sadharana Madhyama Madhyama Sama Pravara Madhyama 16 Shanthi VK Sadharana Madhyama Madhyama Manda Madhyama Madhyama 17 Gowramma VPK Anupa Madhyama Madhyama Manda Madhyama Madhyama 18 Somashekar VK Anupa Avara Avara Vishama Madhyama Madhyama 19 Pushpa VK Anupa Pravara Pravara Manda Madhyama Pravara 20 leelavathi VK Anupa Madhyama Madhyama Manda Madhyama Madhyama
127
Master chart No.3 showing Assessment Parameters for Relief in signs and symptoms of Tamaka Shwasa
Sl No
Ghurghuraka Shwasa Kruchrata
Kasa Kantodhwamsa Duration of attack
Frequency of attack
PEFR
BT AT BT AT BT AT BT AT BT AT BT AT BT AT 1 3 0 2 0 2 0 2 0 2 0 2 0 2 0 2 3 1 1 0 3 1 0 1 3 0 1 1 2 0 3 3 0 3 2 3 1 0 1 1 0 2 1 3 0 4 3 1 1 1 2 1 1 1 1 0 1 1 2 1 5 2 1 2 0 1 0 2 1 1 1 1 1 3 1 6 2 0 1 0 2 0 1 1 1 1 2 0 1 0 7 2 0 1 1 2 0 0 1 1 0 1 0 2 0 8 2 1 1 0 2 1 2 0 1 1 1 1 3 0 9 3 0 2 0 2 0 2 1 2 0 1 1 2 0 10 2 0 1 0 1 1 2 1 2 1 2 1 2 1 11 3 0 2 0 1 1 1 0 1 0 3 0 1 0 12 2 0 3 1 2 1 2 1 3 0 2 0 2 0 13 1 0 2 0 1 1 1 0 2 0 2 0 2 1 14 2 0 2 0 3 0 3 0 2 0 2 0 2 0 15 3 1 3 0 3 1 3 1 2 0 1 0 2 0 16 3 0 3 0 3 1 3 0 1 1 1 1 2 0 17 1 1 2 0 1 0 1 0 2 0 2 1 2 0 18 3 0 3 0 3 2 3 0 2 0 1 2 2 0 19 1 1 2 0 2 1 2 0 2 0 2 0 2 0 20 1 0 1 1 2 1 2 0 1 0 1 1 2 0
