EVALUATION OF THERAPEUTIC EFFECT OF  CHITRAKADI AVALEHYA IN PATIENTS OF TAMAKA                 SHWASA – A CLINICAL STUDY  ...
DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA        S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574 118                    ...
DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA     S. D. M. COLLEGE OF AYURVEDA, UDUPI – 574 118                     ...
AcknowledgementsWith a bowed Head, to the Almighty;       I am ever grateful to Dr. U. N. Prasad, Prof. and H.O.D. of Kaya...
I am grateful to the manager and the staff of the S.D.M. AyurvedicPharmacy for providing me the drug compounds of my study...
CONTENTSLIST OF TABLESLIST OF FIGURESLIST OF ABREVIATIONS                                                        Page No  ...
LIST OF TABLES                                                                   Page No.1. Nidana of Shwasa / Tamaka Shwa...
29. a. & b. Effect on Sputum of Tamaka Shwasa in Group 1 and 2            10530. a. & b. Effect on Body Position of Tamaka...
LIST OF FIGURES                                                                     Page No.1. Age group Incidence of pati...
29. Effect on Heart Rate of Tamaka Shwasa in Group 1 and 2                11130. Effect on Mental status of Tamaka Shwasa ...
Introduction                            INTRODUCTION                 Prānāpanou nimeśādya jīvanam manaso gatihi           ...
Introductionsince the beginning of the research work; yet a significant break-through to rootout the illness remains elusi...
Introductionthe complete treatment of Tamaka Shwasa as expounded in the Ayurvedicliterature4. Among these procedures, the ...
Introduction       The second chapter elaborates the general description of disease TamakaShwasa. The etiology, clinical m...
Conceptual Study                ETYMOLOGICAL DERIVATION      Vatavyadhi,      Raktapitta,     Vatarakta,     Grahani,     ...
Conceptual Studydescription unravels the pathological expression of breathing and is the cardinalsymptom of Shwasa roga.Ta...
Conceptual Study                       HISTORICAL REVIEWPREVEDIC AND VEDIC PERIOD:       The available literatures of Prev...
Conceptual StudyPrana Vayu in this book. In the Chandogyopanishath, the Prana has been namedas Angeera and Brhaspati. The ...
Conceptual StudyHarita Samhita:        Etiopathogenesis, line of treatment and dietetics of Shwasa Roga aredescribed at fu...
Conceptual StudyKalyanakaraka: The description of herbomineral combinations that may beprescribed in patients suffering fr...
Conceptual Study                                   NIDANA       The causative factors of Shwasa Roga in general are also t...
Conceptual Study   Table No: 1 – Showing Nidana of Shwasa / Tamaka Shwasa:                  Factors                 C. S8 ...
Conceptual StudyVistambhi                                      +       +   -      -       +                               ...
Conceptual StudyKsataksaya                                      +       -       -       -      -Udavarta                  ...
Conceptual Study                               SAMPRAPTHI       Episodic attacks, rapid development, chronicity, perpetuat...
Conceptual Studyepisodes of the illness. This intermittent nature of the environmental variationdetermines the episodic na...
Conceptual Studyinvolvement of Dosha and Dushya belonging to the same category, as well asaffliction of hridaya marma expl...
Conceptual Studyregion obstructs the Prana Vayu. The Prana Vayu passing through this Sleshma,causes bubbling and a peculia...
Conceptual Studytypical symptoms of Pitta Dosha is called as Pratamaka and SantamakaShwasa47.       Vitiated Prana Vayu al...
Conceptual Study   10. Roga Marga – Madhyama.      Vitiated Vata and Kapha Dosha afflicting Rasa Dhatu localizing in thePr...
Conceptual Study                             POORVAROOPA      Pathology of Tamaka Shwasa includes the vitiation of Vata an...
Conceptual Study      To sum up, the vitiated Doshas stemming out from the Adhoamasayacirculates in the Uras, Kantha and S...
Conceptual Study                                     ROOPA       Vata as well as Kapha Dosha, Rasa Dhatu and Pranavaha sro...
Conceptual Studybreathlessness, patient even may not be able to speak; perspiration may be seenin the forehead and even hi...
Conceptual Studybreathing in the form of tightness of the chest, followed by the development ofother symptoms45.Severity: ...
Conceptual StudyTable No. 3 – Showing the Roopa of Tamaka Shwasa:Sl.                   Symptoms                      C.S49...
Conceptual Study      Among the symptoms, Shwasa, Pratamyati Ati Vegat – deterioration ofconsciousness, Pinasa, Kasa are r...
Conceptual Study                     MODERN PERSPECTIVE      Tamaka Shwasa may be caused by multiple factors. Exposure to ...
Conceptual Studyduration of individual attacks may vary from few hours to days or months. Inbetween the attacks the patien...
Conceptual Studyextracts of air born antigens will also be negative. In addition to this, thebiochemical investigations re...
Conceptual Study   Decrease in forced respiratory volumes and flow rates,   Hyper inflation of the lungs and thorax,   Inc...
Conceptual Study       Drugs like aspirin, colouring agents such as tetragin, Beta-adrenergicantagonists and sulphiting ag...
Conceptual Studynon productive. Then the respiratory sound becomes loud and is audible.Wheezing appears both during inspir...
Conceptual StudyDemonstration of reversible airway obstruction is the diagnostic criteria. Twopuffs of a beta adrenergic a...
Conceptual Studyshowing hyperinflation are also seen in many patients but are not mandatory fordiagnosis57.      To sum up...
Conceptual Study               UPASHAYA AND ANUPASHAYA       It has been said in the Ayurvedic classics that predominance ...
Conceptual Study       Following table no.4 - gives the details of Upashaya and Anupashaya inTamaka Shwasa.               ...
Conceptual Study                          SADHYASADHYATA       The factors involved in the genesis of Samprapti of Tamaka ...
Conceptual Study                           SAPEKSA NIDANA       Diagnosis is successfully made by thoroughly observing the...
Conceptual Study       Undue awareness of breathing and is uncomfortable.       Abnormal form of breathing may be observed...
Conceptual Study      Kasa, Pratishyaya, Kshathakshya [respiratory tract illness], ManasaDosha [emotional factors] may pre...
Conceptual StudyShwasa or respiratory distress due to abdominal conditions. But sudden attack ofShwasa is also frequently ...
Conceptual Studysuggestive of apnoeustic breathing. When 5 to 10 breaths of hyperventilation isfollowed by apnoea, this ab...
Conceptual StudySeverity of the illness:       Severity may be Daruna, Mridu or Aniyamita in different types of ShwasaRoga...
Conceptual Studyare the manifestation of Tamaka Shwasa71. All these symptoms are possible inBronchial Asthma.       Furthe...
Conceptual Study   - Meghambu Sheetha Pragvatha - exposure to cloudy or cold weather, cold     water   - Sleshmala Ahara V...
Conceptual Study      In a nut shell, Shwasa Roga is diagnosed when the clinical manifestationsuggests variation of Vata-K...
Conceptual Study                                 CHIKITSA      The effective treatment of Tamaka Shwasa can not be unified...
Conceptual Study   10. Kapha Vilayana Chikitsa –Liquification of the sputum.   11. Srotomardavakara Chikitsa – Softening o...
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EVALUATION OF THERAPEUTIC EFFECT OF CHITRAKADI AVALEHYA IN PATIENTS OF TAMAKA SHWASA – A CLINICAL STUDY, ANIL KUMAR RAI.D, 2001 – 2002, DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA , S. D. M. COLLEGE OF AYURVEDA, UDUPI – 574 118,

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  1. 1. EVALUATION OF THERAPEUTIC EFFECT OF CHITRAKADI AVALEHYA IN PATIENTS OF TAMAKA SHWASA – A CLINICAL STUDY Dissertation submitted to the Rajiv Gandhi University of Health Sciences,Bangalore, Karnataka in partial fulfillment of the regulations for the award of the degree of DOCTOR OF MEDICINE (AYU) By ANIL KUMAR RAI.D., B. A. M. S. GUIDE: DR. SRINIVASA ACHARYA.G., M.D. (AYU) Asst. Professor, S. D. M. C. A., Udupi DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA S. D. M. COLLEGE OF AYURVEDA, UDUPI – 574 118 2001 - 2002
  2. 2. DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574 118 CERTIFICATE This is to certify that the dissertation entitled “Evaluation of Therapeuticeffect of Chitrakadi Avalehya in patients of Tamaka Shwasa – A clinicalstudy” is the record of the research work conducted by Dr. Anil Kumar Rai. D.under my direct supervision and the guidance of Dr. G. Srinivasa Acharya, S. D.M. College of Ayurveda, Udupi. The candidate has put in sincere effort in both the conceptual andclinical studies. This title has not been awarded Degree, Diploma, Associateship,Fellowship or similar honors from this University. I recommend and forward the same for being submitted for evaluation tothe adjudicators.Place: Udupi Dr. U. N. Prasad, M.D. (Ayu)Date: Professor and Head of the Department of Post graduate studies in Kayachikitsa S. D. M. College of Ayurveda, Udupi.
  3. 3. DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA S. D. M. COLLEGE OF AYURVEDA, UDUPI – 574 118 CERTIFICATE This is to certify that the dissertation entitled “Evaluation of Therapeuticeffect of Chitrakadi Avalehya in patients of Tamaka Shwasa – A clinicalstudy” is the record of the research work conducted by Dr. Anil Kumar Rai D.under my direct supervision and guidance. The candidate has put in sincere effort in both the conceptual andclinical studies. I recommend the same for being submitted for evaluation to theadjudicators.Place: Udupi Dr. G. Srinivasa Acharya, M.D. (Ayu)Date: Asst. Professor and Guide Department of Post graduate studies in Kayachikitsa S. D. M. College of Ayurveda, Udupi.
  4. 4. AcknowledgementsWith a bowed Head, to the Almighty; I am ever grateful to Dr. U. N. Prasad, Prof. and H.O.D. of Kayachikitsadepartment S.D.M. College of Ayurveda for his encouragement, support andhelpful suggestions. I wish to offer my sincere thanks to Prof. Dr. M. H. Rayabhagi, Principaland Dr. D. Krishnamoorthy, the Vice-Principal, S.D.M. College of Ayurveda, fortheir encouragement and support. I express my deep sense of gratitude to my Teacher and GuideDr. G. Srinivas Acharya for the magnitude of his dynamic and untiresomeguidance throughout the study. I would like to put on record the affection andcare with which my esteemed Guide directed me during the study. I wish to express my gratitude to the authorities of S.D.M. EducationalSociety for providing me all the requisite facilities to carry out this work. My gratitude due to Dr. Y. Narayana Shetty, Superintendent andDr. Deepak S. M., Deputy Superintendent of the S.D.M. Ayurveda Hospital,Udupi for their valuable support and encouragement. I acknowledge the contributions of Teachers Dr. B. V. Prasanna,Dr. Srikanth U., Dr. Poornima Nayak, Dr. Jayakrishna Nayak, Dr. Veerakumar,Dr. Niranjan Rao, Dr. Nagaraj and Dr. Prasanna Mogasale.
  5. 5. I am grateful to the manager and the staff of the S.D.M. AyurvedicPharmacy for providing me the drug compounds of my study to specifications. I am grateful to Mr. Harish Bhat, Librarian, for providing me with all thebooks I needed. I am indebted to my batch mates Dr. Mahanthesh, Dr. Sajith, Dr. KishoreKumar, Dr. Basavaraj and Dr. Surekha for their help through out the study. Dr. Sriranjani, Dr. Sandhya, Dr. Prashanth, Dr. Narayan Nambi,Dr. Nirmala will forever remain in my memories for their tremendous compliancein compiling this study. My cordial thanks to Dr. Chaitra, Dr. Shainy, internees for their significantcontribution in compilation of the study. My special thanks to Shri Raghavendra Maiya for his excellent formattingand to M/S Suraj Copiers and Vishal printers for bringing out quality copies. Dr. Anil Kumar Rai
  6. 6. CONTENTSLIST OF TABLESLIST OF FIGURESLIST OF ABREVIATIONS Page No INTRODUCTION 1PART – I: CONCEPTUAL STUDY Chapter I – Historical Review 5 Chapter II – Etymology of Tamaka Shwasa 9 Nidana 11 Samprapti 15 Poorvaroopa 21 Roopa 23 Modern Perpetuation 28 Upashaya – Anupashaya 36 Sadhya – Asadhyata 38 Sapeksha Nidana 39 Chikitsa 48 Pathya – Apathya 57 Chapter III - Drug Review 61PART – II: CLINICAL STUDY Materials and Methods 79 Observations and Results 88Part – III: DISCUSSION 134Part – IV: SUMMARY AND CONCLUSION 145REFERENCESBIBLIOGRAPHYAPPENDIX-CASE SHEET
  7. 7. LIST OF TABLES Page No.1. Nidana of Shwasa / Tamaka Shwasa 122. Poorvaroopa of Shwasa Roga 213. Roopa of Tamaka Shwasa 264. Upashaya and Anupashaya in Tamaka Shwasa 375. Pathya in Tamaka Shwasa 576. Apathya in Tamaka Shwasa 597. Age group Incidence of patients 898. Sex Incidence of patients 909. Marital status of patients 9010. Education level of patients 9111. Patients according to their religion 9212. Habitat Incidence 9213. Socio economic status 9314. Occupation 9315. Addictions 9416. Dietary habits 9517. Prakriti of patients 9518. Sara of patients 9619. Samhanana of patients 9720. Satvataha analysis of patients 9721. Satmya of patients 9822. Analysis of state of Agni 9923. Analysis of state of Koshta 9924. Bala of patients 10025. a. & b. Effect on severity of Tamaka Shwasa in Group 1 and 2 10126. a. & b. Effect on Dyspnoea of Tamaka Shwasa in Group 1 and 2 10227. a. & b. Effect on Speech of Tamaka Shwasa in Group 1 and 2 10328. a. & b. Effect on Cough of Tamaka Shwasa in Group 1 and 2 104
  8. 8. 29. a. & b. Effect on Sputum of Tamaka Shwasa in Group 1 and 2 10530. a. & b. Effect on Body Position of Tamaka Shwasa in Group 1 and 2 10631. a. & b. Effect on Respiratary Rate of Tamaka Shwasa in Group 1 and 2 10732. a. & b. Effect on Expansion of Chest of Tamaka Shwasa in Group 1 and 2 10833. a. & b. Effect on Laboured breathing of Tamaka Shwasa in Group 1 and 2 10934. a. & b. Effect on Breath sounds of Tamaka Shwasa in Group 1 and 2 11035. a. & b. Effect on Heart Rate of Tamaka Shwasa in Group 1 and 2 11136. a. & b. Effect on Mental status of Tamaka Shwasa in Group 1 and 2 11237. Effect of Chitrakadi Avaleha on absolute values of spirometer 11338. Effect of Chitrakadi Avaleha on predicted percentage of spirometer 11539. Effect of Pushkaramoolasava and Durjalajeta Rasa on absolute values of spirometer 11740. Effect of Pushkaramoolasava and Durjalajeta Rasa on predicted percentage of spirometer. 11941. Comparison of effect of treatment on severity in two groups 12142. Comparison of effect of treatment on Dyspnoea in two groups 12243. Comparison of effect of treatment on Speech in two groups 12344. Comparison of effect of treatment on Cough in two groups 12445. Comparison of effect of treatment on Sputum in two groups 12546. Comparison of effect of treatment on Body Position in two groups 12647. Comparison of effect of treatment on Respiratory Rate in two groups 12748. Comparison of effect of treatment on Expansion of Chest in two groups 12849. Comparison of effect of treatment on Laboured breathing in two groups 12950. Comparison of effect of treatment on Breath sounds in two groups 13051. Comparison of effect of treatment on Heart Rate severity in two groups 13152. Comparison of effect of treatment on Mental Status in two groups 13253. The overall effect in two groups. 133
  9. 9. LIST OF FIGURES Page No.1. Age group Incidence of patients 892. Sex Incidence of patients 903. Marital status of patients 904. Education level of patients 915. Patients according to their religion 926. Habitat Incidence 927. Socio economic status 938. Occupation 949. Addictions 9410. Dietary habits 9511. Prakriti of patients 9612. Sara of patients 9613. Samhanana of patients 9714. Satvataha analysis of patients 9815. Satmya of patients 9816. Analysis of state of Agni 9917. Analysis of state of Koshta 10018. Bala of patients 10019. Effect on severity of Tamaka Shwasa in Group 1 and 2 10120. Effect on Dyspnoea of Tamaka Shwasa in Group 1 and 2 10221. Effect on Speech of Tamaka Shwasa in Group 1 and 2 10322. Effect on Cough of Tamaka Shwasa in Group 1 and 2 10423. Effect on Sputum of Tamaka Shwasa in Group 1 and 2 10524. Effect on Body Position of Tamaka Shwasa in Group 1 and 2 10625. Effect on Respiratory Rate of Tamaka Shwasa in Group 1 and 2 10726. Effect on Expansion of Chest of Tamaka Shwasa in Group 1 and 2 10827. Effect on Laboured breathing of Tamaka Shwasa in Group 1 and 2 10928. Effect on Breath sounds of Tamaka Shwasa in Group 1 and 2 110
  10. 10. 29. Effect on Heart Rate of Tamaka Shwasa in Group 1 and 2 11130. Effect on Mental status of Tamaka Shwasa in Group 1 and 2 11231. Effect of Chitrakadi Avaleha on absolute values of spirometer 11432. Effect of Chitrakadi Avaleha on predicted percentage of spirometer 11633. Effect of Pushkaramoolasava and Durjalajeta Rasa on absolute values of spirometer. 11834. Effect of Pushkaramoolasava and Durjalajeta Rasa on predicted percentage of spirometer. 12035. Comparison of effect of treatment on severity in two groups 12136. Comparison of effect of treatment on Dyspnoea in two groups 12237. Comparison of effect of treatment on Speech in two groups 12338. Comparison of effect of treatment on Cough in two groups 12439. Comparison of effect of treatment on Sputum in two groups 12540. Comparison of effect of treatment on Body Position in two groups 12641. Comparison of effect of treatment on Respiratory Rate in two groups 12742. Comparison of effect of treatment on Expansion of Chest in two groups 12843. Comparison of effect of treatment on Laboured breathing in two groups 12944. Comparison of effect of treatment on Breath sounds in two groups 13045. Comparison of effect of treatment on Heart Rate severity in two groups 13146. Comparison of effect of treatment on Mental Status in two groups 13247. The overall effect in two groups. 133
  11. 11. Introduction INTRODUCTION Prānāpanou nimeśādya jīvanam manaso gatihi . Indriyāntharasanchāraha preranam dhāranam ća yat 1̣ Prana and Apana or to say breathing out and breathing in are the sine quenon phenomenon of life. To and fro movement of air through the Pranavahasrotas is the vital sign of Prana, the normalcy of which suggests health. Theabnormality of respiration indicates disease, and its cessation marks death. Thisunique sign of life is affected in the disease Tamaka Shwasa2. This abnormalityof breathing as indicative of forthcoming death in the long run merits seriousattention. The organ of breathing, producer of the vital sign of life, turns into amusical box. It produces all sorts of music, which is never melodious; rather it isthe cry of the organ heading towards complete failure for want of air. Any illnessin a person enforces him to be restricted to bed. This is the usual consequenceof disease. Disease even incapacitates a person from being active. Thepresentation of Tamaka Shwasa is peculiar in this regard. Patient is made toprop up instead of lying on the bed. This is the most comfortable position for thepatient when the breath is diseased3. Even though the patient is incapacitated,the illness forces him to sit down. Rest, in his dictionary, is not on the bed but onthe chair. This is the pathetic situation of the patient. The saga continues: theprinciples and practice of any medicinal system, conventional or alternative,does not claim effective treatment that can eliminate the roots and branches ofthe illness. Added to this, continuing the treatment will be a difficult task forpeople who do not have two pennies to rub together. A lot of water has flowed 1
  12. 12. Introductionsince the beginning of the research work; yet a significant break-through to rootout the illness remains elusive; this is the bitter truth. Furthermore, it is extremelydifficult to nip this progressive malady in its bud. It is an open truth that even themost intelligent physician will have a bumpy ride in planning a treatment torelieve the symptoms of this illness. Radical treatment of Tamaka Shwasa is theGordian knot waiting to be cut. Bronchial asthma is the name of this illness in the realm of conventionalmedicine. As is stated, this disease is common both in children as well as adults.Clinical presentation of the illness is never ambiguous and therefore thediagnosis is easy and straight forward. It is recognized to be more common in theso called developed countries as compared to developing countries. It has beenreported that one percent of Indians have Asthma. In contrast to this,approximately 15% of adults and 7.1% to 10% of children in the United Statesand Australia have this disorder. Many among the asthmatics need dailymedication. The word ‘Asthma’ is a derivation of a Greek word, meaning panting orgasping. The word remains as we have no better word to describe it. Difficulty inbreathing whenever present cannot be called as Asthma. The prefix bronchial,specifies the fact that the basic problem is in the tracheobronchial tree. With thegrowing knowledge about Asthma, this condition is clearly defined anddifferentiated from other illness with breathlessness. Sequential administration of the Snehana, Swedana, Kaphotkleshakaradiet, Shodhana, Dhumapana, Shamana and Rasayana line of treatment forms 2
  13. 13. Introductionthe complete treatment of Tamaka Shwasa as expounded in the Ayurvedicliterature4. Among these procedures, the Shamana line of treatment that includesoral administration of medicine is of utmost importance as the administration isvery easy and also effective. Plenty of research works have been carried out inrelation to the Shamana treatment as directed in Ayurveda and their therapeuticeffect is proved. Many more herbal combinations are described in Ayurveda andtheir therapeutic effect in Tamaka Shwasa is yet to be explored.Chitrakadyavaleha is one such herbal combination mentioned in the CharakaSamhita, the efficacy of which is still to be proved by modern research methods.By looking at the individual herbal constituents, it appears that this combinationshould be very effective in combating the attack of Tamaka Shwasa. But theproof of the pudding is in its eating. Therefore the present research work isplanned to evaluate the relative merit of the oral administration ofChitrakadyavaleha in comparison to the Ayurvedic medicines prescribed inregular practice, in the present day5. The present dissertation work entitled - A clinical study to evaluate thetherapeutic effect of Chitrakadyavaleha in patients suffering from TamakaShwasa consists of following chapters. ● Conceptual study ● Clinical study ● Discussion ● Summary and conclusion. The Conceptual study further comprises three separate chapters. Thefirst, where the Etymological derivation and brief description of the historicalaspect of the illness from Vedic era to the present time is being explored isentitled Historical review. 3
  14. 14. Introduction The second chapter elaborates the general description of disease TamakaShwasa. The etiology, clinical manifestations, pathogenesis, prognosis andgeneral principle of treatment are discussed here. The composition of the drug compounds Chitrakadyavaleha, DurjalajetaRasa and Pushkaramoolasava is detailed in the third chapter entitled Drugreview. The properties of the individual herbs used in the preparation of themedicinal compound in brief are also given here. Clinical study is the topic of second part of the dissertation. The materialsand methods of the present work with complete description of the assessmentcriteria are given here. The descriptive statistical analysis of the sample taken forthe study is methodically elaborated. The observation, results and their statisticalanalysis are presented in order with tables and graphs. In the chapter entitled Discussion, the results obtained are criticallyanalyzed to unravel the truth of efficacy of the combination taken for the study.The final conclusions drawn from the present clinical research work are detailedin the chapter Summary and Conclusion. This clinical study is a sincere effort to add newer combinations ofShamana treatment with proved efficacy to the list already present. Thetreatment adopted here may have some edge over the other combinationsprescribed in routine practice, With this hope, the present work is carried out. It isalso hoped that this work will pave new avenues for enthusiastic researchworkers to further advance in this field and find a better cure for this lingeringmalady. With this noble intention this work is presented. 4
  15. 15. Conceptual Study ETYMOLOGICAL DERIVATION Vatavyadhi, Raktapitta, Vatarakta, Grahani, Gudabhramsa,Kshataksheena and Panajeerna are the names of some of the diseases. Thecriteria for naming these diseases in Ayurveda are not uniform. While namingsome of the diseases, the causative dosha is considered as in Vata Vyadhi. Thediseases Raktapitta and Vatarakta are named after the Dosha and Dushyainvolved in their Samprapti. Site of the illness is considered while coining a nameto the diseases like Grahani. Cardinal symptom of the illness is the criteria fornaming many other diseases like Chardi and Atisara. Likewise, the predominantsymptom of breathlessness is the basis for naming the disease, Shwasa. Theword Tamaka Shwasa is the name of an illness consisting of the two words - theword Shwasa refers to the name of the disease, where as, the word Tamakarefers to a subtype of the Shwasa Roga.Shwasa: The word Shwasa is derived from the Sanskrit root Shwas, meaning “tobreathe”. “Shwasiti Anena Iti Shwasaha” - breathing of air is known as Shwasa(Apte dictionary). This derivation represents the physiological aspect ofbreathing. “Shwasasthu Bhasthrikadhmana Vatordwagamitha” - as per this derivationthe word Shwasa refers to expiration of the air, producing sound similar to theone generated while blowing the air with a blower by the blacksmith. This refersto the forceful laboured breathing, probably with wheezing sound. The 9
  16. 16. Conceptual Studydescription unravels the pathological expression of breathing and is the cardinalsymptom of Shwasa roga.Tamaka: “Tamyati Anena Iti Tamaka, Tamaka Glanou” as per this Sanskritderivation, the word Tamaka represents a diseased condition, that presents withdarkness in front of the eyes or tiredness. Tamaka, meaning to cause darknessor tiredness. “Tamayati Iti Tamaka, Tama Eva Tama” – this is another derivation of theword Tamaka in the Sanskrit literature. According to this derivation, the illnessthat causes darkness or the illness itself is the darkness, is called by the nameTamaka.Tamaka Shwasa: “Tamakascha Asou Shwasacha Tamaka Shwasa” – this line explainsmanifestation of the difficulty in breathing, which occurs mainly during the nighttime. This is called as Tamaka Shwasa. Difficulty in breathing is the cardinalsymptom of Tamaka Shwasa, and in extreme cases it may be associated withdarkness in front of the eyes. Also the attacks of Tamaka are considered to beworst during the night. These natures of the illness are unraveled in the abovesaid etymological derivation. 10
  17. 17. Conceptual Study HISTORICAL REVIEWPREVEDIC AND VEDIC PERIOD: The available literatures of Prevedic and Vedic period reveal that thephysiology of respiration, the role of Prana in respiration, the concept of Apanaare mentioned at a number of occasions. Akin to the present understanding inRigveda, the word Prana is coined to describe the act of respiration. Some of thereferences like pranadvayu jayate (10-90-13), ayumapranaha (1-66-1) revealsthe same. In Yajurveda also, the process of respiration, the act of inspiration, theeffort of expiration and involvement of Prana Vayu in respiration are elaborated.Few to mention - vatam pranena nasike (yaju 15-2) pranasya apyathatvam (yajur16-15). Further, in Atharvaveda, the word Matarishwa is coined to denote thePranavayu. The concept of respiration and the role of Pranavayu in respiration isalso clearly described in the last treatise among the Vedas. vatoprana ucyata(a.m 11-15, 19-6/7)- this is one of the lines from the Atharvaveda revealing thePrana Vayu and the concept of respiration.UPANISHATH KALA: The act of inspiration and expiration is mentioned as the prime physicalsign of life in Amanaskopanishath. Further, the opinion of absence of respirationsuggesting the death is also described. The lines from this Upanishad goes likethis - svasocchvasatmaka prana (am-1-33) and avasocchusa hinastu niscitammuktaevasaha In Brhadaranyakopanishath the Prana is referred by the names Angirasaand Ayusya. The function of controlling the body mechanisms are attributed to 5
  18. 18. Conceptual StudyPrana Vayu in this book. In the Chandogyopanishath, the Prana has been namedas Angeera and Brhaspati. The role of Prana in nourishing the body is elaboratedhere (CHA 1:2:10/11/12). The diseased conditions of Pranavaha srotas that includes Hikka, Shwasaand Kasa are described and the role of deranged Vayu in its causation isexplained in Yoga Chudamanyam. The organ of respiration is compared to the bird Crane; the two wings ofthe bird representing the organ of respiration, the trunk indicating the heart, andthe neck of the bird symbolically expressing the wind pipe are discussed in detailin Hamsopanishath.SAMHITA PERIOD:Charaka Samhita: The detailed description of Shwasa and its five varieties are found in 17thchapter of Chikitsa Sthana. The elaborate explanation of etiological factors,pathogenesis, premonitory symptoms, clinical manifestations as well as completeradical treatment of Shwasa is given here. Pratamaka and Santamaka Shwasa,the variant forms of Tamaka Shwasa are also described in Charaka Samhita.Sushruta Samhita: The whole description of Shwasa roga, its types and the treatment isavailable in Sushruta Samhita.Bhela Samhita: Shwasa as a symptom is mentioned in Bhela Samhita. In the form ofcomplication of many disorders Shwasa is described in this treatise. 6
  19. 19. Conceptual StudyHarita Samhita: Etiopathogenesis, line of treatment and dietetics of Shwasa Roga aredescribed at full length in Harita Samhita. The relevant descriptions are availablein the 14th chapter of third Sthana of this work.Kasyapa Samhita: In Khila Sthana, the brief description of Shwasa Roga with its treatment isdescribed along with Kasa Roga.Ashtanga Hridaya and Ashtanga Sangraha: In both Nidana Sthana and Chikitsa Sthana the relevant description ofShwasa Roga is available in these books.Madhava Nidana: 12th chapter deals with the diagnostic aspect of the Swasa Roga in thisbook of Madhava Nidana.MEDIEVAL PERIOD:Chakrapanidatta: Description of Shwasa Roga available in this book is inaccordance with the Brihatrayi.Chakradatta: His treatise describes Shwasa Chikitsa in the 12th chapter alongwith Hikka Roga.Arunadatta: In his commentary titled Sarvangasundara on Ashtanga Hridaya,Arunadatta has mentioned the etiological factors of Shwasa and has opined thepredominant involvement of Kapha Dosha in the etiopathogenesis of ShwasaRoga. 7
  20. 20. Conceptual StudyKalyanakaraka: The description of herbomineral combinations that may beprescribed in patients suffering from Shwasa Roga is unique in this text book.Ayurvedarasayana: Indukara says the aggravated Kapha is the cause ofShwasa.Bhavaprakasha and Yogaratnakara: Both these works describe the ShwasaRoga at full length and this is in accordance with the description available inBrihatrayi. 8
  21. 21. Conceptual Study NIDANA The causative factors of Shwasa Roga in general are also the etiologicalfactors of Tamaka Shwasa. Tamaka Shwasa may develop as an independentillness, as a result of exposure to specific Vata and Kapha vitiating factors6. Thedisease may also manifest as a sequel of certain disorder like Anaha, Raktapitta.Here Tamaka Shwasa manifests as a Nidanarthakara Roga7. To be moreprecise, the illness Tamaka Shwasa may be 1. Nidhanottha – the resultant of specific incriminatory factors 2. Rogottha – a sequel of certain disease Moreover, evolution of the vitiation of Vata and Kapha Dosha, the socalled Sannikrista Nidana, is the result of exposure to Viprakrista Nidana in theform of faulty intake of food and behaviour. Among the list of Viprakrista Nidanas,one can differentiate the Pradhanika Hethu and Vyabhichari Hethu vis a visetiology and predisposing factors. Specific dietetic factors like Ruksha -SheetaAhara Sevana or else excessive physical exercise, are capable of mediatingevolution of Sannikrista Nidana. Hence, these are the Pradhanika Hetu of theillness. Contrary to this, exposure to cold weather and other similar factors thatpredispose the illness in patients suffering from Tamaka Shwasa is suggestive ofVyabhichari nature of causative factors. The Nidana of Tamaka Shwasa is listedin the table no: 1. 11
  22. 22. Conceptual Study Table No: 1 – Showing Nidana of Shwasa / Tamaka Shwasa: Factors C. S8 S.S9 A.H10 A.S11 M.N12 Vata-Prakopa AharaRukshanna - Ununctuous food + + - - +Visamashana - Irregular food habit + + - - +Adhyashana - Habit of eating frequently - + - - -Anasana - Observation of fast for long - + - - +Dvandvatiyoga - Mutually contradicting + - - - -foodsSheetashana - Cold foods - + - - +Visha – Poison + + - - +Sheetapana - Cold drinks - + - - + Pitta-Prakopa AharaTilataila - Gingely oil + - - - -Vidahi - Food causing burning sensation + + - - +Katu -Spicy food - - - + -Usna - Hot food - - - + -Amla - Sour - - + - -Lavana - Salt - - + + - Kapha-Prakopa AharaNispava - 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 + + - - + 12
  23. 23. Conceptual StudyVistambhi + + - - + Vata-Prakopa ViharaRajas - Dust / Pollen + + + + +Dhuma - Smoke + + + + +Vata - Cold breeze + + + + +Sheeta Sthana - Cold places + + - - +Sheeta ambu - Cold water + + + + +Ativyayama - Excessive exercises + + - - +Gramya dharma - Excessive sexual + - - - +intercoursesApatarpana - Emaciating techniques + - + - +Shuddhi Atiyoga - Excessive purification + + - - +Kantha/Urah pratighata - Injury to + - - - +throat/chestBharakarshita - Emaciation due to lifting + + - - +heavy weightsAdhwahata - Excessive walking + + - - +Karmahata - Excessive-work + + - - +Veganirodha - Suppression of urges - - - + -Abhighata - Injury - + + + -Marmabhighata–Injury to vital structures + - - - + Pitta-Prakopa ViharaUsna – Hot - - - + - Vata-Prakopa ViharaAbhishyandi Upacara - Administration of + - - - +substances which obstruct the channelsDivasvapna - Day sleeping - - - - - Vataja-Vyadhi / Avastha Sambandhi NidanaAnaha + - - - -Dourbalya + - - - -Atisara + - - - +Kshaya - + - - - 13
  24. 24. Conceptual StudyKsataksaya + - - - -Udavarta + - - - -Visucika + - - - -Panduroga + + + + -Visa Sevana + + + + -Vibandha + - - - - PittajaRakta pitta + - - - -Jwara + - - - + KaphajaKasa - - + + -Amapradosa - + - - -Chardi + - + + -Pratisyaya + - - - -Amatisara - - + + - The etiological factors listed above can independently cause theimbalance of Vata and Kapha Dosha, the predominant Sannikrista Hetu ofTamaka Shwasa. Along with this, the list also includes some factors that mayvitiate the Pitta Dosha as well as derange the Pitta Sthana. Most of the etiologicalfactors particularly the one related to the food mediate the vitiation of the Doshathrough the Amashaya. Some other factors like exposure to the dust directlyprovocate the Vata Dosha in the Pranavaha srotas. 14
  25. 25. Conceptual Study SAMPRAPTHI Episodic attacks, rapid development, chronicity, perpetuation are theexclusive features of Shwasa Roga more particularly the Tamaka Shwasa. Theunique nature of Samprapthi of Tamaka Shwasa determines this clinicalpresentation of the illness. When we look into the list of etiological factors in the ancient texts, someof them are worth mentioning, as they are same to both normal persons as wellas patients suffering from Tamaka Shwasa. To mention some, exposure to dust,winter season, cloudy weather etc. But on exposure to these factors only thepatient of Tamaka Shwasa suffers from an episode of Tamaka Shwasa, whereas the normal person makes merry of the situation. The person having the historyof the illness becomes sick on exposure to the causative factors. Ayurvedaexplains this phenomenon as - Avyadisaha Sarira - lack of resistance to theillness33. To elaborate, either because of the faulty habits or due to maldevelopment or else the result of inborn errors related to the Pranavaha srotas,these so called etiological factors predisposes to the illness. Frequent change is the unmatched, inherent disposition of theenvironment in which the person lives. This varying disposition may be related tothe cosmic rhythm in the form of seasons. Or else, the pollutants like dust smokeetc. or the clarity bring about the change in the atmosphere. Among thesevariations in the environment, the rainy season, cloudy atmosphere, winter,smoke, dust are described as enemies of the patient34 having weak Pranavahasrotas. Consequent to exposure to these variations the person suffers from the 15
  26. 26. Conceptual Studyepisodes of the illness. This intermittent nature of the environmental variationdetermines the episodic nature of theTamaka Shwasa35. During the initial stages of the illness few of the above said factors arecapable of initiating the disease process in any given patient. As the year passesdue to the perpetuation of the illness the Pranavaha srotas becomes more andmore debilitated. Consequently more and more number of factors acquire abilityto predispose an attack of Tamaka Shwasa in a weakened Pranavaha srotas.The end result is the attack of Tamaka Shwasa becoming more and morefrequent and ultimately loses its episodic nature and becomes a continuousphenomena with exacerbations and remissions36. Vata Dosha and Kapha Dosha are invariably involved in the pathogenesisof Tamaka Shwasa. Imbalance of Vata Dosha is best treated by Snigdha line oftreatment37. Whereas, vitiated Kapha Dosha is treated by Ruksha line oftreatment. Theoretically, when both Vata and Kapha Dosha are vitiated mutually,contradictory therapeutic procedures have to be employed, thus posing apractical problem in planning the final treatment. Kapha Dosha and Rasa Dhatuboth belong to the same category in relation to their properties. It is a generalprinciple of pathogenesis, that the Dosha and the Dhatu belonging to the samecategory have a natural tendency to rapidly progress in the process ofpathogenesis. Similar to this in Tamaka Shwasa also, Kapha Dosha that afflictsthe Rasa Dhatu, contributes to the rapid development of the illness. Further,during the course of the illness, the Hridaya marma is said to be afflicted38. Thisadds to the severity of illness. Put together, the mutual contradictory treatment, 16
  27. 27. Conceptual Studyinvolvement of Dosha and Dushya belonging to the same category, as well asaffliction of hridaya marma explains the acute onset, chronic course and severityof the illness. Independent vitiation of Prana Vata and Kapha Dosha occurs in TamakaShwasa due to the effect of specific etiological factors. By virtue of its RukshaSheeta and Khara qualities the abnormal Prana Vayu renders hardening andnarrowing of Pranavaha Srotas. This aspect of the pathogenesis is explained inCharaka Samhita while discussing the treatment of Tamaka Shwasa where hementions about the Srotomardavakara Chikitsa - rectifying the abnormality of thesrotas39. The normal upward course of the Pranavayu is obstructed by theabnormally stiff Pranavaha srotas. Secondly, like the other Srotas, secretion isthe natural process seen in the Pranavaha Srotas. Here Sleshma is the normalsecretion and is abnormally increased by the vitiated Prana Vayu. This further,adds to the obstruction to the passage of Prana Vayu leading to Pranavilomata40. Narrowing of the Pranavaha srotas together with accumulation ofSleshma obstructs the smooth flow of Prana Vayu. Pranavilomata and theresultant turbulent breathing leads to abnormal audibility of respiration41 or to saythis produces wheezing. Charaka opines that the obstruction to the passage ofPrana Vayu also leads to rapid breathing42. In normal individuals the rate ofrespiration is said to be 15/min and in a patient suffering from Tamaka Shwasa,rate of respiration is abnormally increased and it may reach up to 40/min. Furtherthe presence of Sleshma in Pranavaha srotas more particularly in the Kanta 17
  28. 28. Conceptual Studyregion obstructs the Prana Vayu. The Prana Vayu passing through this Sleshma,causes bubbling and a peculiar sound, which is called as Kanta Ghurghuraka isproduced43. Productive cough is another effect of obstruction of Prana Vayu in thePranavaha srotas. As the cough brings out the Sleshma, obstruction to the PranaVayu is minimized, leading to temporary relief in breathlessness to the patient44. The etiological factor leads to independent vitiation of Kapha Dosha inTamaka Shwasa. This Kapha Dosha in conjunction with Rasa Dhatu isresponsible for abnormal secretion of Sleshma in the Pranavaha srotas45. It issaid that this Sleshma is thick, sticky and tenacious and contributes to theobstruction in the Pranavaha srotas. Excessively secreted tenacious Sleshma isexpectorated out with much difficulty during the bouts of coughing46. The KantaGhurghuraka or the rattling sound is also suggestive of increased Sleshma. Other than the usual presentation, involvement of the Pitta Dosha may beseen in certain patients of Tamaka Shwasa. When this is the case the over allpresentation of the Tamaka Shwasa is also changed accordingly. The frequentepisodes of Tamaka Shwasa are related to the exposure to Sheeta, Snigdha andsuch other factors that provocates the Vata and Kapha Dosha and this is theusual presentation. If the association of Pitta Dosha is present this nature of theillness is reversed and hence exposure to these factors may bring aboutremittance of symptoms in the patient. This unique nature of the illness isattributed to Pitta Dosha involvement. These symptoms like Jwara, Murcha aresuggestive of Pitta vitiation. Such a variant form of Tamaka Shwasa with the 18
  29. 29. Conceptual Studytypical symptoms of Pitta Dosha is called as Pratamaka and SantamakaShwasa47. Vitiated Prana Vayu also irritates the Nasa causing increased secretionand manifestation like Peenasa, Kshawathu etc48. The imbalance of Vata andKapha Dosha afflicts the Rasa Dhatu in the pathogenesis of Tamaka Shwasa.During the attack of Tamaka Shwasa almost all the symptoms of Kapha Doshavitiation are mediated through the Rasa Dhatu. Among the list of symptoms:productive cough, sputum etc are the symptoms pathognomonic of Rasa Dhatuabnormality. Moreover, abdominal symptoms like Adhmana, Anaha are also theresult of incriminated Rasa Dhatu. As the disease runs a chronic course, thevitiated Vata Dosha dries up the circulating Rasa Dhatu contributing to theweakness and emaciation in the patient49. Factors involved in the generation of Samprapti of Tamaka Shwasa areelaborated in the following lines. 1. Udbhava Sthana – Pitta Sthana, Adhoamasaya. 2. Sanchara Sthana – Urah, Kanta, Siras. 3. Ashraya – Uras. 4. Avayava – Pranavaha Srotas, Hridaya. 5. Srotas – Pranavaha, Udakavaha, Annavaha. 6. Srotodusti Prakara – Sangha, Vimarga Gamana 7. Dosa – Pranavayu, Avalambaka Sleshma. 8. Dushya – Rasa Dhatu. 9. Avastha – Ama. 19
  30. 30. Conceptual Study 10. Roga Marga – Madhyama. Vitiated Vata and Kapha Dosha afflicting Rasa Dhatu localizing in thePranavaha srotas results in the development of Tamaka Shwasa. As citedearlier, reduced resistance power of the Pranavaha srotas against the disease isa prerequisite. Repeated illness of the Pranavaha srotas may affect its resistantpower against the disease or else frequent exposure to etiological factors likeRaja may affect the inborn defense mechanism of the Pranavaha srotas.50 Further, Kapha prakriti persons who are intolerant to factors that increasethe Kapha Dosha have a tendency to become a patient of Tamaka Shwasa.Predominance of Kapha in children may predispose to this illness and is afrequent observation in clinical practice. Ayurveda describes these factorspredisposing to illness as Vyadhi Asaha Shareera in general. The same is alsoapplicable to Tamaka Shwasa. Secondly, the Pranavaha srotas and the Rasa Dhatu have their root in theHridaya. And therefore the disease is likely to pathologically influence theHridaya marma. The Hridaya Pidana in the premonitory stage is suggestive ofthe same51. Later during the long course of the illness the Hridaya marma maybe seriously affected and may cause Hridaya Marmabhigathajanya VatajaRoga52. 20
  31. 31. Conceptual Study POORVAROOPA Pathology of Tamaka Shwasa includes the vitiation of Vata and KaphaDosha afflicting the Rasa Dhatu in the Uras. This unique pathology determinesthe premonitory symptoms in the premonitory stage. Following table gives theglance of the Poorvaroopa of the illness, which are also premonitory symptomsof other types of Shwasa. The symptoms like Anaha, Adhmana, Bhakthadwesa,and Vairasya all are the result of the illness stemming out from the Pittasthana.Needless to say, these are also suggestive of imbalance of Kapha Dosha.Further, Parswa Shoola and Shankha Nistoda indicate the extent of Doshiccirculation.Hridaya pidana and Pranavilomata are pathognomonic of localizationof the Doshas in the Uras.Table No. 2 – Showing Poorvaroopa of Shwasa Roga: Symptoms C.S33 S.S34 A.H35 M.N36 Anaha – distension of abdomen + + + + Adhmana – fullness of the - - - + abdomen Arati – restlessness - + - - Bhaktadwesa – aversion to - + - - take food Vadanasya vairasya – - + - - abnormal taste in the mouth Parshwa shoola – pain in the + + + + sides of the chest Peedanam hridayasya – + + + + tightness of the chest Pranasya vilomata – + - + + obstruction to expiration Shankha nistoda – temporal - - + + headache 21
  32. 32. Conceptual Study To sum up, the vitiated Doshas stemming out from the Adhoamasayacirculates in the Uras, Kantha and Siras. Consequently, these Doshas gettinglocalized in the Pranavaha srotas produces symptoms like Parshva Shoola,Hridaya Peedana and Prana Vilomata, before the actual onset of breathlessness. 22
  33. 33. Conceptual Study ROOPA Vata as well as Kapha Dosha, Rasa Dhatu and Pranavaha srotas are thepredominant factors involved in the pathogenesis of Tamaka Shwasa. And forapparent reasons, these factors determine the course and clinical manifestationof the disease. More details of the symptoms are given in the table no. 3.Forceful respiration with audibility is the cardinal symptom of the disease.Paroxysmal productive cough is the associated frequent manifestation. Mode ofonset, course, aggravating factors, relieving factors that are varying with regardsto breathlessness and cough are very typical and are diagnostic of TamakaShwasa.Shwasa: Abnormality in the breathing pattern, which is episodic, is the cardinalsymptom of Tamaka Shwasa37.Obstruction in the Pranavaha srotas due to itsstiffness and accumulation of Sleshma renders the phenomena known asPranavilomata. This in turn causes the abnormality of breathing. Patient is likelyto experience Hridaya peedana – tightness in the chest. Expiration becomesdifficult due to obstruction. Forced respiration results in audibility of respiration inthe form of abnormal wheeze. Respiration also becomes rapid and will be muchfaster than the normal rate-15/ minute. Breathlessness worsens on walking,speaking or any other physical exercise. Bouts of paroxysmal cough also worsenthe dyspnoea, and expectoration of sticky sputum gives some temporary relief38.During the attack of Tamaka Shwasa, the patient feels more ease for breathing inthe sitting position rather than lying position39. During the severe attack of 23
  34. 34. Conceptual Studybreathlessness, patient even may not be able to speak; perspiration may be seenin the forehead and even his conscious may deteriorate40.Kasa: Paroxysmal productive cough associates with the breathlessness.Distressing bouts of cough brings out small amount of tenacious sputum.Paroxysms of cough, although increases breathlessness, at the same time aidsspitting out of sticky sputum and brings some temporary relief in dyspnoea41.Kapha Nistivana: Abnormally increased secretion of Sleshma in the Pranavahasrotas is a predominant feature of Tamaka Shwasa42. Sputum is tenacious andtherefore can not be brought out easily. It may be mucoid, mucopurulent, whitishor yellowish. Accumulation of the sputum in the Kanta region also causesbubbling during forced respiration producing the Kanta Ghurghurata or rattling43.Pinasa: Running nose, sneezing, stuffiness of the nose is another category ofsymptoms seen in Tamaka Shwasa. On exposure to dust or such other offendingsubstances, this may be the initial symptom. Followed by this, within an hour orday the patient develops breathlessness and other manifestations of the illness44.Onset: Spontaneous rapid development is the characteristic feature. Of course,depending upon the influence of offending substance, the mode of onset mayvary from insidious, gradual to acute onset. Premonitory symptoms followed bythe development of breathlessness, is the usual course that includes symptomsrelated to Annavaha srotas. In some patients the episode of Tamaka Shwasamay start with Pinasa and related symptoms. In some others, irritant cough maybe the initial symptom. And yet other patients may experience difficulty in 24
  35. 35. Conceptual Studybreathing in the form of tightness of the chest, followed by the development ofother symptoms45.Severity: Severity of the illness may vary in different episodes of the illness. Inworst attacks of the Tamaka Shwasa, patient may even find it difficult to speak.His speech may be restricted to a word or so. Perspiration may be seen on theforehead. The consciousness of the patient may also markedly deteriorate46.Course: Recurrent attacks of the illness are the hallmark. Exposure topredisposing factors suddenly initiates an attack of Tamaka Shwasa. In the longrun and leaving its episodic nature, the symptoms of the illness may becomecontinuous one. Continuous illness also badly affects the general condition of thepatient and he is likely to get emaciated. Further, the involvement of Hridaya mayadd to the list of symptoms, worsening the prognosis.47Modifying factors: Factors that provocate the Vata and Kapha Dosha initiate oraggravate an attack of Tamaka Shwasa. To mention some, exposure to dust,cold weather, cloudy weather aggravates the condition48. In contrast to this, thefactor that are opposite to this, relieve the symptoms like clarity of theatmosphere, absence of smoke in the air, warm weather etc. 25
  36. 36. Conceptual StudyTable No. 3 – Showing the Roopa of Tamaka Shwasa:Sl. Symptoms C.S49 S.S50 A.S51 A.H52No. 1 Pinasa – running nose, sneezing, stuffiness + + + + of the nose 2 Shwasa – dyspnoea + + + + 3 Tivravega Shwasa – rapidity of breathing + + + + 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 + - + + conciousness10 Kasa – Cough + + + +11 Pramoham Kasamanascha – frequent + - + + deterioration of consciousness during paroxysm of cough12 Kanta Ghurghuraka – rattling + - - -13 Kantodhwamsa – soreness of the throat + - - -14 Utshoonaksa –oedema around the eyes. + - + +15 Vishuskasya – dryness of mouth + - + +16 Lalata Sweda – sweating in the forehead + + + +17 Meghaihi Abhivardhate – cloudy weather + - + + worsens the attack18 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 - + - - 26
  37. 37. Conceptual Study Among the symptoms, Shwasa, Pratamyati Ati Vegat – deterioration ofconsciousness, Pinasa, Kasa are related to Pranavaha srotas. Aruchi isindicative of Annavaha srotas involvement. Affection of Udakavaha srotas isrepresented by Trishna, Vishuskasya. In spite of these manifestations, the disease runs a chronic course andthere is every possibility of Dhatu Kshaya and further provocation of Vata Dosha.This will add to the list of symptoms. The clinical presentation may vary a littledepending upon relative predominance of vitiated Vata Dosha and Kapha Dosha.The differentiation of the illness in terms of predominance of vitiated Doshas isessential while planning the treatment. The symptoms like Tivra Vega Shwasa, Anidra, Vishushkasya indicatesthe predominance of Vata Dosha. The Kapha predominant type of TamakaShwasa can be appreciated by Pinasa, Amuchyamana Kapha, KantaGhurghurata, and Kasa symptoms. 27
  38. 38. Conceptual Study MODERN PERSPECTIVE Tamaka Shwasa may be caused by multiple factors. Exposure to dust,inhalation of smoke are a few to mention. Shwasa and Kasa are the cardinalsymptoms of this disease of Pranavaha srotas. Avarudha Marga of Pranavayu isthe principal pathology. Course of the illness reveals episodic nature. Laterduring the course of the illness there is every possibility of involvement of theHridaya marma. Prognostically it is described as a Yapya Vyadhi. When we lookinto these details of the illness Tamaka Shwasa, all these characteristic featuressimulate the description of Bronchial Asthma elaborated in the so calledconventional medicine. The description of Tamaka Shwasa is akin to BronchialAsthma and the opinion is unequivocal. Hence the description of BronchialAsthma is relevant in the present context. The etiology, pathogenesis, clinicalsymptoms, laboratory examination and differential diagnosis of Bronchial Asthmaare elaborated in the following pages. Bronchial Asthma, as the name itself indicates is an illness of thetracheobronchial tree and may be caused due to a plethora of etiological factors.Hypersensitivity of the respiratory system to the offending substances is thebasic pathology. Increased responsiveness of the air passages leads to its widespread narrowing impeding the free passage of air, more particularly duringexpiration. Episodic difficulty in breathing, paroxysmal dry or productive coughassociated with wheeze is the characteristic clinical manifestation of this malady.The signs and symptoms of the illness develop spontaneously and with equalreadiness, the symptoms subside when treated with specific medications. The 28
  39. 39. Conceptual Studyduration of individual attacks may vary from few hours to days or months. Inbetween the attacks the patient will be totally asymptomatic. The illness is neverconsidered as a killer disease; even then very rarely an acute attack of the illnessmay lead to death in some patients53. Bronchial Asthma is not an uncommon illness. A survey study reveals thatabout 4 to 5% of American populations suffer from this illness. Though this illnesscan start at any age of the persons, the incidence is said to be more common inchildren. As indicated by a study, about 50% of the patients of Bronchial Asthmadevelop this illness below the age of 10 years. Further it is also observed that it ismore common in male children than females. Depending upon the nature andclinical presentation and its relation to etiologic factors, Bronchial Asthma isclassified into two broad types as Allergic and Idiosyncratic. Personal or family history of either respiratory or skin allergy is verycharacteristic of allergic asthma. Such patients may suffer from allergic rhinitis,eczema or positive wheal and flare skin reaction to intradermal injection ofextracts of air born antigens. Another phenomena seen in this form of theBronchial Asthma is increased level of IgE immunoglobulins in the serum.Provocation test involving inhalation of specific antigen will show a positive reportin such patients. In the second category of patients known as idiosyncratic, the clinicalpresentation is totally different. These patients neither give the personal or familyhistory of allergic respiratory disease, nor give the history of allergicmanifestation of the dermis. The flare skin reaction to intradermal injection of 29
  40. 40. Conceptual Studyextracts of air born antigens will also be negative. In addition to this, thebiochemical investigations reveal no abnormal increase in the level of IgEimmunoglobulins. It is worth mentioning here that some of the patients will not fit into both ofthe above said types of asthma. In such patients, the characteristic features ofboth the categories of illness will be present. And therefore these patients do notfit in to any of the above said category. Such patients fall into the third i.e. Mixedgroup category. Whole pathology of Bronchial Asthma is centered around the nonspecifichyperirritability of the tracheobronchial tree. Severity of an episode of Asthmadepends upon the reactivity of the respiratory system. It is observed that the viralinfection of the respiratory tract increases the reactivity of the airways. Hyperresponsiveness manifests in the form of inflammation of the tracheobronchialtree. Corroborating this, the study of the bronchioalveolar lavage fluid showedabnormal presence of mast cells, epithelial cells, neutrophils, esinophils,macrophages and lymphocytes. The cells involved in the inflammatory processrelease the mediators, and few to mention - histamine, bradykinin, theleukotrienes C, D and E, platelet activating factors and prostaglandins. Thesemediators cause inflammatory changes in the tracheobronchial tree that includesbroncho constriction, vascular congestion, and oedema formation. Along with thisthe tenacious secretion reduces of the diameter of the airways. The ultimateresult is the following changes in the functioning of the respiratory system.Increase in air way resistance, 30
  41. 41. Conceptual Study Decrease in forced respiratory volumes and flow rates, Hyper inflation of the lungs and thorax, Increased work of breathing, Alteration in respiratory muscle function, Changes in elastic muscle recoil, Abnormal destruction of both ventilation and pulmonary blood flow with mismatched ratios Altered arterial blood gas concentrations. Forced vital capacity tends to be =<50% of normal. The forced expiratoryvolume (FEV1) averages 30% or less of predicted, while the maximum andminimum mid expiratory flow rates are reduced to 20% or less of expected.Hypoxia: Hypocapnea and respiratory alkalosis. Frequently electrocardiographic evidence of right ventricular hypertrophy and pulmonary hypertension. The etiopathogenesis of the illness is related to factors like Allergic,Pharmacologic, Enviornmental, Occupational, Infectious, Exercise related andEmotional. The interaction between the antigen and mast cells activate therelease of IgE by the T and B lymphocytes. This results in sensitization to theoffending substances and that is how on exposure to these results in allergicresponse of the respiratory system. Feathers, animal danders, dust, mites,moulds and other antigens that can present continuously in the environment is ashort list of common allergens. 31
  42. 42. Conceptual Study Drugs like aspirin, colouring agents such as tetragin, Beta-adrenergicantagonists and sulphiting agents are the few examples of pharmacologicalstimuli resulting in the initiation of an episode of Bronchial Asthma. Studies haverevealed that the episode of asthma due to pharmacological agents is usuallysevere and occasionally may prove fatal54. Environment and the Air pollution is another major cause of the illness.Concentration of atmospheric pollutants and antigens, increase in heavilyindustrial and densely polluted urban areas. These incriminatory factorscontribute to the development of Bronchial Asthma in many of the patients.Certain occupation is another factor facilitating the occurrence of BronchialAsthma in some. Exposure to metal salts, wood and vegetable dusts,pharmaceutical agents, industrial chemicals and plastics, biologic enzymes andanimal and insect dust, serums secretions are the important factors causing theillness and are related to the occupation. It is more interesting to note that inpatients suffering from Bronchial Asthma physical exercise can initiate anepisode of Bronchial Asthma. Ventilation produced by the exercise, thetemperature and the water content of the inspired air the factors centered aroundexercise cause an attack of Bronchospasm. Further it is also understood thatemotional stress can also initiate an episode of Bronchial Asthma.Clinical Features55: Dyspnoea, cough and wheezing are the three exclusive symptoms ofbronchial symptoms of Bronchial Asthma. Initially the breathlessness may beexperienced as constriction of the chest. In this initial phase, usually the cough is 32
  43. 43. Conceptual Studynon productive. Then the respiratory sound becomes loud and is audible.Wheezing appears both during inspiration and expiration. Characteristically theexpiration becomes prolonged. Associated with these symptoms, the patient mayhave tachypnoea, tachycardia and mild hypertension. Over inflation of the lungsduring the attack of Bronchial Asthma leads to the physical sign of increasedanterior-posterior diameter of the chest. Ronchi and Crepitation is frequentlyheard on auscultation. During severe attacks due to minimal flow of the airwheezing may also become absent. Laboured breathing may become evident bythe activity of the accessory muscles of respiration. Severe bronchospasm maybe associated with paradoxical pulse. During the later phase of an attack ofAsthma the cough becomes productive. Sputum is characteristically tenacious,consisting of mucous, casts of distal airways. Microscopically the sputum showseosinophils and charcot-laden crystals.Differential Diagnosis56: The clinical presentation of Bronchial Asthma during an attack is so typicalthat the diagnosis of Asthma is straight forward in most of the occasions. Thecardinal symptom of Bronchial Asthma when present in episodes is verycharacteristic and this itself differentiates it from other diseases presenting withbreathlessness. Added to this, the family or personal history of allergicmanifestations like eczema, rhinitis, and urticaria when available justifies thediagnosis of Bronchial Asthma. Spirometric evaluation of the lung volumes is a valuable test both inmaking the diagnosis as well as assessing the severity and improvement. 33
  44. 44. Conceptual StudyDemonstration of reversible airway obstruction is the diagnostic criteria. Twopuffs of a beta adrenergic agonists causing 15% or greater increase in FEV1 isdefined as reversibility of airway obstruction. Further, during the asymptomaticperiod, if the spirometric results are normal, increased airway resistance can bedemonstrated on exposure to histamine or methacholine. The response to thetreatment may be assessed by measuring the peak expiratory flow rates(PEFRs) and / or FEV1.It is worth mentioning here that normal values for FEV1and FVC are based on the population studies. And therefore it is likely to bechanged, according to the race, height, age and gender of the patients. Boththese values of lung volumes are expressed as absolute values and percentagepredicted of normal values for FVC and FEV1. The values over 80% of thepredicted are defined as within normal range. The ratio of FEV1/FVC isexpressed in percentage, and a normal young individual is capable to expire atleast 80% of his vital capacity in one second. A ratio below 70% is thereforeindicative of obstructive pathology. In comparison to FVC if the FEV1 is reduceddisproportionately and which results in FEV1/FVC ration is less than 70 to 80%and is suggestive of obstructive pathology. And these findings of spirometricvalues are suggestive of Bronchial Asthma. Other than this demonstration ofpositive wheal and flare reactions to skin tests to various allergens is diagnosticbut such findings do not necessarily correlate with the intrapulmonary events.Sputum and blood eosinophilia is an additional finding. Measurement of serumIgE levels are also helpful but are not specific for Asthma. Chest roentgenograms 34
  45. 45. Conceptual Studyshowing hyperinflation are also seen in many patients but are not mandatory fordiagnosis57. To sum up, Tamaka Shwasa explained in Ayurveda may be compared toBronchial Asthma described by the modern counterparts. Hypersensitivity of therespiratory system to a plethora of allergen is said to be the principal pathology.Inflammation of the tracheobronchial tree results in congestion, bronchospasmand tenacious sputum. Breathlessness, cough and wheeze are the cardinalsymptom of the illness. Spirometric test reveals obstructive phenomena in the airpassages. 35
  46. 46. Conceptual Study UPASHAYA AND ANUPASHAYA It has been said in the Ayurvedic classics that predominance of Vata andKapha is observed in Urdhwa Shwasa as well as in Maha Shwasa.Predominance of Pitta Dosha in a patient suffering from Shwasa ispathognomonic of Chinna Shwasa. Moreover, predominance of Kapha Dosha ischaracteristic of Tamaka Shwasa and trivial vitiation of Vata Dosha leads toKshudra Shwasa. This Pradhanya Samprapthi of Shwasa Roga helps in thedifferentiation of the individual types of Shwasa as the remission or exacerbationof the illness depends upon these factors.This is the description of Upashaya or Anupashaya in Shwasa Roga. Abnormal Koshtagata Vata is the feature, suggestive of KshudraShwasa58. Hence, the aggravation of the illness after food intake is characteristic.Likewise, the factors that worsen the imbalance of Kapha Dosha lead toexacerbation of Tamaka Shwasa as predominance of Kapha Dosha is noted inthe pathogenesis. Added to this, the environmental factors may directly influencethe Pranavaha srotas resulting in an episode of Tamaka Shwasa. 36
  47. 47. Conceptual Study Following table no.4 - gives the details of Upashaya and Anupashaya inTamaka Shwasa. Upashaya59 Anupashaya60Ushna Ahara Vihara Sheeta Ahara Vihara , Sheeta Ambu- cold water.Aseeno Labhate Soukhyam – feels Shayanath Shwasa Piditaha –comfortable to breath in sitting position. discomfort worsens on lying.Vimokshante Sukham – spontaneous Presence of Kapha in the Pranavahaslight relief in breathlessness on srotas worsens the difficulty inspitting out the sputum. breathing.Dry sunny weather relieves the Meghaihi Abhivardhate – cloudysymptoms weather worsens the attack this aggravates the problem.Quiet atmosphere is favourable Pragvata – breezeClear atmosphere, devoid of smoke Exposure to dust or smoke worsensand dust helps in reducing the the attack of Tamaka Shwasasymptoms.Factors that reduces the Kapha Sleshmala - Kapha aggravatingvitiation brings out relief. factorsadd to the disease. In short, after the onset of the disease, the factors that provocate theKapha Dosha, when indulged, worsens the illness. This mainly includes bothdietetic as well as seasonal factors. The environmental factors exposed to thePranavaha srotas provocates Vatadosha and hence adds to worsen the attack ofTamaka Shwasa. The dietetic and environmental factors that oppose the Vataand Kapha Dosha bring relief in symptoms. 37
  48. 48. Conceptual Study SADHYASADHYATA The factors involved in the genesis of Samprapti of Tamaka Shwasa areunique. Vata and Kapha Dosha that are invariably involved in the pathogenesisdemand treatments that are mutually contradictory. The Kapha Dosha and RasaDhatu belonging to the same category show more affinity for a pathologicalinteraction and poses problem in planning the treatment. Weak resistance of thePranavaha srotas against the diseases adds to this insult. Environment which ishostile to the patient increases the tendency of the episodes of Tamaka Shwasa.Influence of these unique features of Samprapti of Tamaka Shwasa determinesthe severity as well as poor prognosis of the illness. By virtue of the lingeringnature of the illness, Tamaka Shwasa is categorized as a Yapya Vyadhi61.Disease may be best controlled by the combination of effective treatment, as wellas strict restriction of dietetic and behavioural factors. Lacuna in any of theseChikitsa or Pathya factors, leads to initiation of fresh episode of the illness. Further, Acharya Charaka opines that if the total duration of the illness isshort i.e., less than 6 months, then effective treatment may produce completecure. Contrary to this, the perpetuation of the illness for a long duration, say foryears, causes further provocation of Vata Dosha resulting in emaciation of thebody. Also, during the later stages of the illness, there is every possibility ofinvolvement of Hridaya. These changes in the long run, further add to thediscomfort and render the illness as an incurable one. On occasions, it may evenprove fatal for the same reason62. 38
  49. 49. Conceptual Study SAPEKSA NIDANA Diagnosis is successfully made by thoroughly observing the patient toexplore the clinical manifestations and analyzing the symptoms to determine thevitiation of Dosha, involvement of Dhatu, affliction of srotas, as well as otherevents of Samprapthi. Diagnosis of Shwasa Roga can be made easily by the firsttwo steps as the clinical presentation reveals the vitiation of Vata - Kapha Dosha,afflicting the Rasa Dhatu, involving the Pranavaha srotas. But it is a difficult taskto evaluate and identify the individual types of Shwasa due to its identicalSamprapthi factors. Even then, the differentiation may be made easy byanalyzing the duration of the illness, mode of onset, character, course of illness,severity, associated phenomena, modifying factors, and the seasonal variationsof the Shwasa Roga. Also, the types of Shwasa Roga i.e. Maha Shwasa, UrdhvaShwasa, Chinna Shwasa, Tamaka Shwasa and Kshudra Shwasa may becompared to metabolic acidosis, acute pulmonary oedema, disturbance ofrespiratory centre, bronchial asthma and respiratory distress due to abdominaldistension respectively. Expression of the symptom Shwasa is not uniform among the patients,though it is difficulty in breathing, patient may describe the same in any one ofthe following ways- Sense of fatigue in the chest. Vague discomfort in the chest while breathing. Breathlessness Sense of choking or suffocation. 39
  50. 50. Conceptual Study Undue awareness of breathing and is uncomfortable. Abnormal form of breathing may be observed in unconscious patients.All these expressions though dissimilar should be considered as Shwasa.Previous history of illness: In most of the occasions, the disease Shwasa manifests as consequenceof certain diseases. Acharya Charaka has listed these diseases as etiologicalfactors63. These causative factors are segregated in the following paragraphs topredispose specific type of Shwasa Roga with some preoccupation of modernmedical science. Atisara, Chardi, Visuchika, Shudhyatiyoga, Dourbalya, and Apatarpanaare the diseases in which metabolic acidosis may occur during the course of theillness. Loss of alkali in diaorrhea as well as malnutrition and starvation leading toketosis in protracted vomiting, leads to metabolic acidosis. It can be consideredthat these disease entities predisposes to Maha Shwasa. The group of diseases like Hridaya Marmabhigata [Disease of heart],Pandu Roga [Anaemia], Raktapitta [bleeding disorder leading to Anaemia] leadsto cardiac failure and in turn causes pulmonary oedema. Also, these diseasesmay predispose to Urdhwa Shwasa. The conditions like Siromarmabhigata [disease related to the brain],Hridaya Marmabhigatha [Disease of heart], Basti Marmabhigatha [Renal illness],and Visha Sevana [poisoning] may alter the functioning of the respiratory centre.The result is abnormality of respiration. The same etiological factors may lead toChinna Shwasa 40
  51. 51. Conceptual Study Kasa, Pratishyaya, Kshathakshya [respiratory tract illness], ManasaDosha [emotional factors] may predispose to Tamaka Shwasa. These are alsothe clinical conditions that may predispose to Bronchial Asthma. Ama Dosha, Anaha, Udavarta, Alasaka - in these diseases the distentionof abdomen is a common phenomena and leads to Kshudra Shwasa. Unduedistension of the abdomen precipitates laboured breathing. From the foregoing, it is clear that the consideration of the pre-existingillness gives substantial information for the differentiation of individual type ofShwasa Roga.Duration: Duration is another criteria by which differentiation of types of ShwasaRoga can be made easy. Short duration of the illness is typical of Maha Shwasa,Urdhwa Shwasa and Chinna Shwasa, so also the metabolic acidosis, pulmonaryoedema and disturbance of respiratory centre respectively. In contrast to this,patient of Tamaka Shwasa or obstructive airway disease usually gives a longhistory of illness. And in case of Kshudra Shwasa, the duration may be variable.Mode of Onset: Like the duration of illness, the mode of onset of Shwasa is also useful inthe differential diagnosis. Sudden onset of Shwasa is a symptom suggestive ofMaha Shwasa, Urdhwa Shwasa and Chinna Shwasa. Gradual onset of thedisease is mostly seen in Tamaka Shwasa or Bronchial asthma and Kshudra 41
  52. 52. Conceptual StudyShwasa or respiratory distress due to abdominal conditions. But sudden attack ofShwasa is also frequently seen in Tamaka Shwasa.Character of Shwasa: One of the most useful criteria to differentiate the Shwasa roga isunderstanding the character of Shwasa. In Tamaka Shwasa64 and KshudraShwasa65 there will be laboured breathing with predominance of expiration. Dueto the bronchospasm , patient has to put more effort during expiration inBronchial Asthma. The loud and prolonged expiration that can be heard from a distance, ischaracteristic of Maha Shwasa66. Similarly in case of metabolic acidosis,hyperventilation is evident , breathing is intensive with hissing and is known asKussmauls’ respiration. Patient shows prolonged expiration with no or shallow inspiration and isdiagnostic of Urdhwa Shwasa67. Also, in acute pulmonary oedema there will beasphyxiation as the alveoli are flooded with fluid and breathing is rapid. Phase of respiration and no respiration occurring alternatively ispathognomonic in Chinna Shwasa68 In comparison to this, when the disturbedfunctioning of the respiratory centre develops, the respiration will be irregular.Alternative gradual appearance of phase of apnoea and hyperventilation ischaracteristic of Cheyne stokes breathing. Waxing and waning of respiration isalso typical feature of this periodic breathing. When in case of periodicbreathing, period of apnoea is followed by few deep breaths, then it is known asBiots’ breathing. Presence of pause of 2 to 3 minutes after full inspiration is 42
  53. 53. Conceptual Studysuggestive of apnoeustic breathing. When 5 to 10 breaths of hyperventilation isfollowed by apnoea, this abnormality is identified as post hyperventilationapnoea. Respiration alternans refers to omitting of few breaths from time to time.Ataxic breathing is with varying rate and depth of respiration. These differentforms of abnormal breathing types manifest when the functioning of therespiratory centre is disturbed as in case of vascular diseases of the brain andsevere cardiac failure.Course of the illness: Course of the illness is not uniform in different types of Shwasa. Thesymptoms persist continuously since the onset in case of Maha Shwasa, UrdhwaShwasa and Chinna Shwasa. And it may terminate in the death of the patient. Soalso, in case of metabolic acidosis, acute pulmonary oedema and disturbance ofrespiratory centre. Definitely the prognosis is poor if energetic treatment is notemployed. Occasionally, the course of the illness in Tamaka Shwasa may beprolonged with continuous manifestation of symptoms but there will beexacerbations and remissions. Episodic nature and long course of the illness is very typical of TamakaShwasa. And this is also true in case of Bronchial Asthma. The course of illnessin Kshudra Shwasa is not specific; it may be continuous or intermittent anddepends upon the inducing abdominal condition. 43
  54. 54. Conceptual StudySeverity of the illness: Severity may be Daruna, Mridu or Aniyamita in different types of ShwasaRoga. The illness is severe in case of Maha Shwasa, Urdhwa Shwasa andChinna Shwasa69. In these types of Shwasa the patient is functionally incapableand confined to bed. Added to this, patient exhibits different states of alteredconsciousness like Tamodarshana- darkness in front of the eyes, Moha –confusional state, Pranasta Jnana Vijnana – loss of orientation of time andspace, Pralapa – delirium, Vichetanata – complete loss of consciousness. Thisseverity of illness also holds good for metabolic acidosis, acute pulmonaryoedema and disturbed functioning of respiratory centre. Minimal severity of theillness is typical feature of Kshudra Shwasa70. Here functional ability of thepatient is not appreciably diminished. Aniyamita – severity of the illness isvariable in Tamaka Shwasa as well as Bronchial Asthma. Severe episodesmanifest some times and mild attacks at other times. Degree of severity can alsobe assessed by the amount of physical work inducing dyspnoea. In this way,severity of the illness is helpful in defining the type of Shwasa Roga.Associated Phenomena: The symptom Shwasa is usually associated with other symptoms. Theseassociated symptoms are dissimilar in different types of Shwasa. And for thesame reason, this can be effectively used in differential diagnosis. The symptomlike Sakapha Kasa - productive cough, Pinasa – running nose, Ghurghuraka –rattling, Kantodwamsa – soreness of throat, Vishuskasya – dryness of mouth,Lalata Sweda – sweat in the forehead, Ucchunaksa – oedema around the eyes 44
  55. 55. Conceptual Studyare the manifestation of Tamaka Shwasa71. All these symptoms are possible inBronchial Asthma. Further, in the case of MahaShwasa, Pranasta Jnana Vijnana [loss oforientation to time and space] and Badha Moothra Varcha - constipation andretention of urine are associated72. This can also happen in metabolic acidosis. Chinna Shwasa is associated with Marmachedha Ruk, chest pain, BastiDaha, Mootra Nirodha disturbance of urinary system, Pralapa, Moorcha alteredstates of conciousness73. These symptoms though nonspecific may develop inpatients with disturbance of respiratory centre and depend upon the causativeillness. Symptomatology of Urdhva Shwasa is very specific. Sleshmavrtha MukhaShotha [flooding of mouth and nostrils with respiratory secretion is invariablyseen in acute pulmonary oedema along with, Urdhwa Dristi [upward gaze],Vibrhantha Akshi [unstable eye movement] and Pramoha [confused state]74 Absence of associated symptoms is seen in Kshudra Shwasa or there maybe symptoms of predisposing illness.Modifying Factors: Severity of Shwasa is frequently altered by some aggravating andrelieving factors. By identifying these factors, one can differentiate the types ofShwasa Roga. Aggravation of Shwasa Roga occurs in following states: - Amuchayamana Sleshma - Lack of expectoration - Shayana Stiti - Patient in lying position 45
  56. 56. Conceptual Study - Meghambu Sheetha Pragvatha - exposure to cloudy or cold weather, cold water - Sleshmala Ahara Vihara - exposure to Kaphakara food and habits - Rajo Dhuma Sevana - exposure to dust and smoke - Ratri Samaya - night time - Manodosha - emotional factorsIn contrast to this, Shwasa gets subsided by the following factors - Sleshma Nishtivana - expectoration of sputum - Ushna Upachara - warm environment & food - Asine Sukhanubhava - more comfort in the upright position These modifications in Shwasa are very typical of Tamaka Shwasa75. Butin case of Maha Shwasa, Urdhwa Shwasa or Chinna Shwasa any such factorsdo not modify the disease state. Food intake and physical work aggravates theKshudra Shwasa. This is how the modifying factors vary in different Shwasa.Seasonal Variations: The incurable types of Shwasa that includes Maha Shwasa, UrdhvaShwasa and Chinna Shwasa and those that have fatal outcome, manifestcomparatively for a short duration. Hence, seasonal changes do not influence theseverity of illness. In contrast to this, in Tamaka Shwasa, worsening of the illnessis frequently noted in the rainy and the winter seasons. No such variations withseasonal changes occur in KshudraShwasa. Thus, when the influence ofseasonal variation on disease process is noted, it is suggestive of TamakaShwasa and nothing else. 46
  57. 57. Conceptual Study In a nut shell, Shwasa Roga is diagnosed when the clinical manifestationsuggests variation of Vata-Kapha Dosha, affliction of Rasa Dhatu in thePranavaha srotas. Further evaluation and differentiation of individual types ofShwasa Roga is made possible by analyzing the previous history of illness,severity, associated symptoms, modifying factors and seasonal variations. Asthese factors show a variation in the clinical presentation, diagnosis is muchsimplified. Further, it can be noted that the respiratory distress in metabolicacidosis stimulates the Maha Shwasa. Pattern of respiration in acute, severepulmonary oedema is identical with that of Urdhwa Shwasa. Irregular form ofbreathing seen in disturbance of respiratory centre can be best compared toChinna Shwasa. Clinical picture of Tamaka Shwasa is akin to Bronchial Asthma.Kshudra Shwasa, most probably referred to dyspnoea , is secondary toabdominal conditions. This elaborate analysis of symptom is a simple andpracticable method of differential diagnosis of Shwasa Roga. And it is a wellknown fact that, precise diagnosis is the sheet anchor of the medical practice. 47
  58. 58. Conceptual Study CHIKITSA The effective treatment of Tamaka Shwasa can not be unified, as thepathology involves multiple varying factors. Vitiated Vata and Kapha Doshastemming out from the Pitta Sthana, afflicting the Rasa Dhatu in the Pranavahasrotas produces the illness. Therefore, the procedures aimed at the rectificationof the imbalances of Vata Dosha, as well as Kapha Dosha forms the sheetanchor of treatment of Tamaka Shwasa which is individually quite opposite.Thus, the unique pathogenesis poses complexity in planning the treatment. Thefinal treatment planned should pacify the Vata as well as Kapha Doshaeffectively, simultaneously not causing any further addition to the imbalance ofVata and Kapha Dosha. With the due consideration of this, following principles oftreatment are advocated in the Ayurvedic classics. 1. Abhyanga and Swedana –Application of the oil over the chest followed by sudation. 2. Vamana – Therapeutic emesis. 3. Dhoomapana – Therapeutic inhalation of the smoke from the burning herbs. 4. Virechana Karma – Therapeutic purgation. 5. Pratisyaya Chikitsa – Treatment of rhinitis. 6. Kasaroga Chikitsa – Treatment of Kasaroga. 7. Vatahara Chikitsa – Elimination of vitiated Vata Dosa. 8. Kaphahara Chikitsa – Pacification of vitiated Kapha Dosa. 9. Manasa Dosha Chikitsa –Correction of emotional disturbances. 48
  59. 59. Conceptual Study 10. Kapha Vilayana Chikitsa –Liquification of the sputum. 11. Srotomardavakara Chikitsa – Softening of the channels of respiration. 12. Kaphanissaraka Chikitsa – Expectoration of sputum. 13. Kasaghna Chikitsa – Treatment of cough 14. Rasayana Chikitsa – Rejuvenating the Pranavaha srotas and body. Judicial employment of these therapeutic procedures brings aboutmaximum relief to the patient suffering from Tamaka Shwasa. The details ofthese procedures are given in the following paragraphs.Abhyanga and Swedana: Treatment of Tamaka Shwasa differs both during the attack and inbetween the attacks. During the episode of Tamaka Shwasa, the Doshas are in astate of provocation and contrary to this, in between the attacks the Doshas aresilent and are not apparent, thus demanding different treatment. To make it moreclear, the treatment is planned during the attack to negate the effect ofSamprapti. In contrast to this, in between the attacks, the treatment is planned toprevent the initiation of new Samprapti thereby, forming the complete treatmentof Tamaka Shwasa76. Pranavilomata is a pathological event during an episode of TamakaShwasa and is said to be due to the tenaecious Kapha obstructing the passageof Prana Vayu. Bringing it out by liquifying the sputum is the principle and firsttreatment of this condition. This can be achieved by Abhyanga and Swedanaover the chest thereby allowing the free passage of Prana Vayu. Acharya 49

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