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| | === ''Vidhi Vimarsha'' === | | === ''Vidhi Vimarsha'' === |
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| − | ==== Derivation of term ====
| + | ''Kshatakshina'' is a disease characterized by depletion of body tissues due to chest injury. In present era, the condition occurs due to over exertion, strenuous work beyond one’s capacity, direct or indirect injury to the chest. The conditions like pneumothorax, pleural effusion and related respiratory conditions need to be addressed simultaneously by the surgical team to prevent progression of emaciation and complications of injury to vital lung tissues. |
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| − | Another reading of this term ''kshatakshina'' is ''kshinakshata.'' This term implies that the injury to the chest (''kshata'') is caused by diminution of vital elements, like semen and ''ojas'' (''kshina'').
| + | ==== Etiopathology ==== |
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| − | Some other scholar read ''kshatakshina'' as ''kshatakshaya.'' According to them, description of this chapter refers to two diseases, viz. ''kshata'' and ''kshaya''. In this context, referring to verse 13 of this chapter, the cardinal sign of both ''kshata'' and ''kshina'' are described. This view is not tenable, because this disease is described in the singular form, while describing the premonitory signs and symptoms (verse 12) and prognostic signs and symptoms (verse 14).
| + | The etiological factors can be divided into two categories viz. (1) Exogenous factors related to over-exertion/ strenuous physical activity that causes trauma to the lung tissues, excess weight lifting and excess sexual intercourse. Studies showed that strenuous athletic activities like vigorous swimming, heavy weight lifting, jolting, etc. can cause pneumothorax (PTX), pleural effusion and pneumomediastinum (PTM) etc. (2) Endogenous factors related to malnutrition that cause depletion of body tissues and excess intake of food having dry properties (less intake of unctuous dietary substances like ghee, oil, fats. Lipids leading to dryness in body) |
| | + | The etiological factors described for ''kshata'' are related to those that cause spontaneous lung injury. |
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| − | From the above it appears that the ''kshatakshina'' is a singular entity as a disease, and as a result of causative factors, its signs and symptoms are manifested in two different ways.
| + | ==== Pathogenesis ==== |
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| − | ==== ''Nirghata'' ====
| + | The disease has acute onset without any premonitory signs. This shows sudden appearance of clinical features due to traumatic etiology. As disease progresses, it leads to depletion of body tissues causing emaciation. |
| | + | *''Dosha'' : ''Vata-pitta'' aggravation, ''kapha'' depletion |
| | + | *''Dhatu'': Rasa, shukra, mamsa and ojas |
| | + | *''Samprapti'' type: ''Atipravritti'' and ''dhatukshaya janya'' |
| | + | *Clinical features and conditions resembling the disease |
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| − | ''Nirghata'' is a type of weapon. Alternatively, the term ''nirghata'' implies throwing a substance with the impact of excessive strength.
| + | The patient suffers from fever, pain, mental depression, diarrhea, anorexia, indigestion, cough with putrid sputum grayish in color, foul smelling, and yellow and knotty, in large quantities, with blood. |
| | + | *Subjective and objective parameters (scales with references) |
| | + | *Clinical examination: Chest auscultation for added sounds, decreased air entry, Body mass index. Lung function tests including spirometry |
| | + | *Pathological/radiological/ investigations: Sputum test for presence of Acid fast bacilli, RBCs, Chest X ray for fracture of ribs, opacity in lungs, pneumonia patch, pneumothorax, plural effusion etc. |
| | + | *Differential diagnosis:Pulmonary tuberculosis, Carcinoma of lungs, oesophageal varieces |
| | + | *Complications |
| | + | **Pulmonary tuberculosis |
| | + | *Prognosis: Curable if newly developed, and mildly emaciated, palliable in chronic stage, incurable in advanced stage and severely emaciated with multiple system involvement |
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| − | ===== Difference between ''kshatakshina'' and ''rajayakshma'' ===== | + | ===== Management of disease ===== |
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| − | Though ''kshatakshina'' resembles with ''rajayakshma'', the latter is caused by the simultaneous vitiation of all the three ''doshas'', and it has a different etio-pathogenic processs ([[Chikitsa Sthana]] 8:15). Signs and symptoms of these two diseases, namely ''kshatakshina'' and ''rajayakshma'' are different in presentation. Negligence in the treatment of ''kshatakshina'' leads to ''rajayakshma''.
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| − | ===== Onset of diseases =====
| + | **Experience based clinical practices: |
| | + | ***Applied principles in management of disease conditions |
| | + | ***Styptic agents to stop bleeding |
| | + | ***Binding agents for union of bones and injured tissues |
| | + | ***Nourishing regimen for depletion of body tissues |
| | + | ***Rejuvenation therapies |
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| − | The tern ''avyakta'' literally means unmanifested. But in the present context it implies less manifested. This shows that the disease has acute onset/sudden onset without any incubation period. The term ''vaisesika'', in the verse 13 implies ‘specially manifested’ or ‘excessively manifested’.
| + | ====== ''Shodhana chikitsa'' (body purification treatments) and procedures ====== |
| | + | Purification treatments are not indicated in this disease. |
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| − | The term ''kshina'', meaning diminution or atrophy of tissue elements, implies diminution of semen and ''ojas'' (vital essence).
| + | Therapeutic massage with ''kshirabala'' oil, ''Bala-ashwagandha lakshadi'' oil is done. |
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| − | According to some other scholars, the description in verse 13, pertains to the two groups of signs and symptoms, which are manifested in two different stages (type of this disease).
| + | Chest physiotherapy for improving lung functions is advised. |
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| − | ==== Etiological factors ==== | + | ====== ''Shamana chikitsa'' (pacification treatments) with list of formulations and medicines ====== |
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| − | All the mentioned etiological factors can be divided into two categories viz:
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| − | #Exogenous factors related to over-exertion/ strenuous malpractice of physical activity that causes trauma to the lung tissues,
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| − | #Endogenous factors related to malnutrition that causes depletion of body tissues. The etiological factors described for ''kshata'' are related to those that causes spontaneous lung injury and the clinical feature suggest that it is a condition of pneumothorax.
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| − | Studies showed that strenuous athletic activities like vigorous swimming, heavy weightlifting, sudden jerks, etc. can cause pneumothorax (PTX) and pneumomediastinum (PTM).
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| − | ==== Differential diagnosis ====
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| − | Clinical Features of Sahasajanya Rajayaksma Clinical Features of Kshata-Kshina Clinical Features of Kshataja Kasa
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| − | 1. Chest pain
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| − | 2. Cough
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| − | 3. Hemoptysis, along with other 8 sympoms. 1. Chest pain
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| − | 2. Cough
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| − | 3. Hemoptysis
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| − | May accoompained with Atisara (Ca.Ci. 8/16) 1.Dry cough followed by hemoptysis,
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| − | 2. Pricking, sharp, piercing, tearing, intense chest pain,
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| − | 3. Fever (jvara), dyspnea (svasa), morbid thirst (trisna), and change in voice (vaisvarya) is also present.
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| − | Examing the etiological factors, pathogenesis and clinical features it is clear all the three disease have same etiopathogenesis as well as clinical manifestation. Now the question arise that if all these three disease are same then what is the reason for their separate description? To answer this question it is necessary to explore the similarity and distinction between these three diseases. The main difference between these three appears in their management as follows:
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| − | Table 1: Difference in the treatment of Sahasajanya Rajayakshma and Kshata-Kshina
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| − | Treatment of Sahasajanya Rajayakshma Treatment of Kshata-Kshina Treatment of Kshataja Kasa
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| − | 1. Management of Sahasajanya Rajayaksma is not mentioned separately,
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| − | 2. Management is given according to the symptoms,
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| − | 3. For the management of Kasa and Parsvasula present in all types of Rajayaksma external as well internal treatment is given.
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| − | 4. Mild vamana and virecana is indicated,
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| − | 5. Use of different types of svedana like nadi, samkara, pariseka is indicated (Ca.Ci.8/71-76),
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| − | 6. Raktamoksana is indicated in Parsvasula (Ca.Ci.8/82)
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| − | 7. Use of external applications like pradeha, aalepa, pariseka, etc is given.
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| − | 8. Use of Sandhaniya drugs like laksha, madhuyasti is not mentioned. 1. Atyayika cikitsa (emergency management),
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| − | 2. Use of Sandhaniya, jeevaniya, brnhaniya drugs like laksha, madhuyasti, amalaki, vidarikanda, etc.
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| − | 1. Atyayika cikitsa (emergency management),
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| − | 2. Use of jeevaniya and brnhaniya drugs like ghrta, kseera, etc.
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| − | 3. Use of Dhumapana when the traumatic injury heals.
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| − | 4. Use of Sandhaniya drugs like laksha, madhuyasti is not mentioned.
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| − | 5. Pancakarma is not indicated.
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| − | Kshaya is described as one among the four causes of rajayakshma and at some place it is used as synonym of rajayakshma like kshayaja kasa, kshayaja grahani etc.
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| − | Sushruta describes 8 types of kshaya as–vyavaya (sexual intercourse), shoka(grief), sthavirya (old age), vyayam (exercise), adhva (excess walking), upvasa(fasting), vrana (traumatic injury) and urahkshata (chest injury) (Su. Ut. 41/21). Some scholar hold the view that kshaya and rajayaksma are two different diseases, kshaya is a condition of excessive depletion of dhatus whereas rajayakshma is an aoupsargika disease i.e. infectious state. According to them when infection occurs in an immunocompromised state then only it can be called rajayakshma.
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| − | According to Ayurveda rajayakshma is a syndrome that has many associated diseases both as predromal disease as well as complication and therefore vivid description of rajayakshma is available in the Ayurvedic texts. Cluster of eleven, six or three symptoms that may persist as an independent disease, is termed as rajayakshma. Many synonyms are given for rajayakshma describing the disease from different angles as the two synonyms we described above and many others. Basically the vast diversity of the disease can’t be wrapped in a single term and therefore Acharya used various terminologies for full description of this multifactorial and multidimensional disease. Rajayakshma means an immunocompromised state that is more suspectible for developing secondary infections.
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| − | Examing the etiology and clinical feature of ksayaja kasa and rajayakshma make it clearer:
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| − | Table 2: Similarity between nidana (etiological factors) of ksayaja kasa and rajayakshma:
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| − | Nidana (etiological factors) of ksayaja kasa Nidana (etiological factors) of rajayakshma
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| − | 1. Visamasana (irregular, faulty dietary habit)
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| − | 2.Vegavighata (suppression of natural urge)
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| − | 3. Ativyavaya (excessive sexual intercourse)
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| − | 4. Excessive thinking of hatred things.
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| − | 5. --- 1.Visamasana (irregular, faulty dietary habit)
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| − | 2.Vegavighata (suppression of natural urge)
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| − | 3. Ativyavaya (excessive sexual intercourse)
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| − | 4. Excessive grief, anxiety, envy, ambitions, fear, anger etc.,
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| − | 5. Sahasa (excessive strenuous physical activity)
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| − | Table 3: Similarity between clinical features of ksayaja kasa and rajayakshmajanya kasa
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| − | Clinical features of ksayaja kasa Clinical features of rajayakshmajanya kasa
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| − | 1. Foul smelling, greenish, mucopurulent sputum, hemoptysis
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| − | 2.Jwara (fever),
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| − | 3. Atisara (diarrhea),
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| − | 4.Parsvaruka (chest pain),
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| − | 5.Pinasa (rhinitis),
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| − | 6. Aruchi (anorexia),
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| − | 7. Svarabheda (hoarseness of voice),
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| − | 8. Kasa (cough) (Ca.Ci.18/25-28) 1. Picchila (sticky), bahula (excessive), visram (foul smelling), harita (greenish in colour), svetapitakam (muco-purulent) (Ca.Ci. 8/51)
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| − | 2.Jwara (fever),
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| − | 3. Atisara (diarrhea),
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| − | 4.Parsvaruka (chest pain),
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| − | 5.Pinasa (rhinitis),
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| − | 6. Aruci (anorexia),
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| − | 7. Svarabheda (hoarseness of voice),
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| − | 8. Kasa (cough)
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| − | From the above discussion it is very clear that ksayaja kasa refers to kasa in rajayakshma i.e. ksaya is used as a synonym of rajayakshma and it denotes a state where the disease causes so much debility and immunity is compromised to such extent that secondary infection becomes more severe. While describing the management of ksayaja kasa, Acharya Caraka describes the treatment of discoloration of urine and dysuria as:
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| − | Charaka says that if the patient of ksayaja kasa suffers from discoloration of urine or dysuria then he should be given ghrit processed with the decoction of kadamba, vidarikanda and tala.
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| − | This shows that discoloration of urine (hematuria) is associated with Ksaya or rajayakshma. Genitourinary tuberculosis is the most common cause of painless hematuria.With one-third of the world's population currently harboring latent mycobacterium tuberculosis infection, many modern day texts on nephrology do not discuss genitourinary TB as a serious cause of urological infections and advanced renal disease. Classic TB symptoms are rarely observed in these patients, compounding the difficulty of a diagnosis. Many times treatment of renal TB is delayed due to the vagueness of chronic, intermittent, and nonspecific urinary symptoms. Thus it is clear that the clinical features described for kshina are the features of renal tuberculosis that may appear abruptly (like sudden onset of hematuria in a patient of renal tuberculosis requiring prompt management).
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| − | Now let us try to understand the meaning of second word- kshata and its significance as a disease. Kshata means trauma or injury. Sahasajanya rajayakshma cause kshata in the urah(chest) similarly in kshataja kasa also there is urahkshata. Thus there are three places where urahkshata is encountered in Ayurvedic texts namely- sahasajanya rajayakshma, kshataja kasa and kshatakshina. Let us discuss the similarity between these three conditions to draw a conclusion.
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| − | Table 4: Similarity between the nidana (etiological factors) of sahasajanya rajayaksma, Kshata-kshina and kshataja kasa
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| − | Nidana of Sahasajanya Rajayaksma Nidana of Kshata- Kshina Nidana of Kshataja- Kasa
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| − | 1. Battle,
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| − | 2. Excessive reading,
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| − | 3. Lifting heavy weight,
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| − | 4. Covering a long distance, walking on foot,
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| − | 5. Excessive swimming,
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| − | 6. Jumping,
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| − | 7. Falling from high altitude,
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| − | 8. Excessive trauma.
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| − | 1. Fighting with stronger person,
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| − | 2. Reciting scriptures at the top of voice,
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| − | 3. Lifting heavy weight,
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| − | 4. Covering a long distance walking on foot,
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| − | 5. Crossing a big river by swimming,
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| − | 6. Sudden long and high jump,
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| − | 7. Falling while walking over uneven place or from high altitude,
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| − | 8. Being excessively injured by other violent and curel acts. 1.Fighting with stronger person,
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| − | 2. Excessive battling
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| − | 3.Lifting heavy weight
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| − | 4.Excessive walking, covering a long distance walking on foot,
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| − | 5. Fighting with strong animal or try to restrain them,
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| − | 6. Excessive sexual indulgence.
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| − | Table 5: Similarity between the samprapti (pathogenesis) of sahasajanya rajayaksma, kshata-kshina and kshataja kasa:
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| − | Samprapti (Pathogenesis) of Sahasajanya Rajayaksma Samprapti (Pathogenesis) of Kshata-Kshina
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| − | Samprapti (Pathogenesis) of Kshataja Kasa
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| − | Indulgence in strenuous physical activity causes injury to the chest.
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| − | | Kshata kshina gets manifested as a result of the injury to the chest due to the excessive strenuous physical activity. Indulgence in strenuous physical activity causes injury to the chest.
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| − | From the above table it is obvious that Kasa appears in Kshayaja rajayakshma is elaborated under the heading of Kshataja Kasa. As the Sahasajanya Rajayaskshma is a very serious and emergency condition and managemnt of which is lacking in the chapter of Rajayakshma. its emergency management is described in a separate chapter under the heading of Kshata Kshina. Use of Sandhaniya drugs like laksha (mainly indicated for the healing of fracture of bone) and madhuyashti clearly indicates that in Kshata Kshina there is external trauma (ribs fracture leading to pneumothorax) that should be managed with quick remedies. As Acharya has given only conservative management for the Kshata- Kshina it excludes the possibility of surgical interventions in Kshata-Kshina (tube drainage with or without medical pleurodesis, vacuum-assisted thoracostomy (VATS) with pleurodesis and/or closure of leaks and bullectomy, and open surgical procedures such as thoracotomy for pleurectomy or pleurodesis) at that time. In the chapter of Rajayakshma, the symptomatic treatment is described and therefore it is necessary to elaborate the management of acute dreaded complications like pneumothorax and hematuria in separate chapter.
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| − | ==== ''Kshatakshina'' as complication of ''Rajayakshma'' ====
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| − | यच्चोपदेक्ष्यते पथ्यं क्षतक्षीणचिकित्सिते| यक्ष्मिणस्तत् प्रयोक्तव्यं बलमांसाभिवृद्धये| (Ca.Ci.8/183)
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| − | Here, Charaka says that the regimen described in the chapter of [[Kshatakshina Chikitsa]] should also use for the management of ''Rajayakshma'' for enhancing strength and muscle mass.
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| − | यच्चोक्तं यक्ष्मिणां पथ्यं कासिनां रक्तपित्तिनाम्| तच्च कुर्यादवेक्ष्याग्निं व्याधिं सात्म्यं बलं तथा| (Ca.Ci. 11/94)
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| − | In this chapter (that has been revised by Dalhana), it is mentioned that with due regard to ''agni'' (power of digestion), nature of disease, wholesomeness diet and regimens prescribed for ''rajayakshma, kasa'' and ''raktapitta'' should be used for the management of ''kshatakshina''.
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| − | Thus it is clear that the management of ''kshatakshina'' should be adjuvant with the management of ''rajayakshma'' for proper treatment or it can be said that ''kshatakshina'' management is applicable in emergency condition with acute manifestations like hemoptysis and hematuria whereas management of ''rajayakshma'' is applicable for chronic stage of disease.
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| − | Basically the controversy in accepting ''kshatakshina'' as advanced state or complication of ''rajayakshma'' appears because of misinterpretation of following verse:
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| − | उपेक्षिते भवेत्तस्मिन्ननुबन्धो हि यक्ष्मणः| प्रागेवागमनात्तस्य तस्मात्तं त्वरया जयेत्| (Ca. Ci. 11/95)
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| − | If the patient suffering from ''kshatakshina'' is not given appropriate treatment on time, then this may lead to ''rajayakshma''.
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| − | Therefore well before the arrival of this ailment (attack of ''rajayakshma''), the ''kshatakshina'' should be treated, subdued (cured).
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| − | In the above discussion, we see that there is conflict between the statements given in chapter originally written by Charaka (Ca.Ci. 8/183) and that restored by Dalhana (Ca. Ci.11/94). In chapter 8th, Charaka says that the treatment given in the next chapter (i.e., this one) is also applicable for rajayakshma whereas in chapter 11th, Charaka says that the regimens given in the chapter of ''rajayakshma'' should be given to the patient of ''Kshatakshina''. Thus it is clear that the management of both the diseases is interrelated but the controversy appears in accepting the sequence of protocol to be followed for the management of diseases.
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| − | Therefore it can be concluded that ''kshatakshina'' is the specific state of ''rajayakshma'' that appears acutely and required prompt treatment. Accepting ''kshatakshina'' as a singular disease refers to a cascade of autoimmune reactions that results in a complex syndrome known as Pulmonary-Renal Syndrome. Indulgence in the specific etiological factors provokes the activity of specific auto-antibodies pervading the specific loci and destructing the body tissues that ultimately results in dreaded consequences.
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| − | ==== Management of ''kshatakshina'' ====
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| − | Herbs used for the management of Kshata-kshina can be classified in two category viz. (1) having antioxidant properties and (2) having hemostatic and bone healing properties.
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| − | Different views on formulations:
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| − | In the verse 16, in the place of ‘savatsaka’ there is a variant reading ‘dvivatsaka’. If this variant reading is accepted, then two parts of vatsaka are to be added in this recipe, other being one part each. According to some scholars, both the male and female varities of vatsaka, described in Kalpa 5:5, are to be used in this recipe.
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| − | In the above recipe, the quantity of honey to be added is not mentioned. It should be taken in sufficient quantity and added to the powder for making paste, from out of which pills could be conveniently prepared.
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| − | When there are five or more liquids mentioned to be added in a recipe of medicated ghee, then each of them, according to the general rule, should be taken in the quantity equal to that of ghee. However the quantity of each of these liquids is specially described here to strengthen that general rule.
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| − | In verse 40, patra etc. are described to be taken in the quantity of two karsas. This quantity applies to all the ingredients taken together. However, experiences physician use each of ingredients in the prescribed quantities, i.e. two karshas each.
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| − | For the preparation of the decoction, the eleven drugs mentioned above should be added with eight times of water and reduced to one forth. Thus the quantity of the decoction will be twenty two palas. [This is in accordance with the commentary of Gangadhara. Cakrapani’s commentary in Nirnayasagara edition is different from C.K. Sen & Co. edition. Both of them perhaps, full of textual incongruities]. The quantity of milk should be four times of ghee. According to some scholars, milk should be four times of the quantity of the decoction.
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| − | For the preparation of decoction, eight palas of madhuka and one prastha of draksha should be added with four times of water and reduced to one fourth. Thus in total, the quantity of decoction will be one and half prastha. [According to general rule (paribhasha), the total quantity of liquid should be four times of ghee. But if the quantity of decoction is taken according to the above mentioned commentary of Cakrapani, then it will be less than the quantity of ghee. This may, however be treated as an exception to the general rule.]
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| − | ==== Sarpi guda ====
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| − | This medicated ghee is prescribed to be prepared by adding sugar and honey. This will reduce the ghee to the form of a paste and it is suitable only to be used as linctus. This should be given to the patient having aggravated pitta. If sugar and honey are not added to the medicated ghee, then it remains in the liquid form (in warm condition). This liquid form of medicated ghee should be given to the patient having aggravated vayu, to drink. Alternatively, the medicated ghee mixed with the powders, prescribed in verse 54, and made to a paste form, should be used by the patient having aggravated pitta. When it is in a melted state, it should be given to the patient having aggravated vayu.
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| − | The medicated ghee is generally given in a small dose, i.e. one karsha (12ml). This quantity is enough to alleviate pitta, but it does not suppress the agni (the power of digestion).
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| − | The term ‘nirunaddhi’, in verse 53, has a different reading as ‘na runaddhi’. If the latter reading is accepted, then the last foot of the verse 53 will mean “ghee when used as drink, alleviate vayu, but it does not suppress the agni” (power of digestion). [The latter reading appears to be more appropriate]
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| − | In the verse 54, the ghee is to be made to a paste form by adding the powder tvakksiri, sarkara and laja. The quantity of these powders is not specified. Therefore, these have to be taken in such quantities as are capable of making the ghee into a thick paste form. Vata, udumbara, asvattha, plaksa and kapittha- these are the ksirivrksas (plant having milky latex). According to salakya tantra, udumbara, vata, asvattha, madhuka and plaksa- these five are called ksirivrksas. [Chakrapani’s statement and the reference are at variance in as much as in the place of kapitna, madhuka (madhuka according to C.K.Sen & Co. edition) is used kapitana is generally used as a synonym of other drugs like sirisa and amrataka and not of madhuka. Bhavaprakasa has included parisa (according to some, sirisa or vetaasa) in the place of kapitana.
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| − | Thirteen drugs mentioned in the verse no.56 are to be taken (One pala each). To this, eight times of water should be added and reduced to one fourth. Thus the quantity of the decoction will be twenty six palas. To this, fifty two palas of milk and twenty six palas of each of vidari (juice) and goat meat (soup) should be added. Thus, in total, one hundred and thirty palas of liquid should be added to ghee and cooked. According to some scholars, the decoction should be prepared by adding sixteen times of water and reduced to one fourth. Thus, the quantity of the decoction will be fifty two palas. If this is accepted, then the quantity of other liquids should be increased. But for practical purpose, these drugs mentioned in the verse 56, should be made to a decoction in such a way that it become equal to the quantity of ghee.If this is accepted, then the decoction (one part), milk (two parts), the juice of vidari (one part) and the goat meat soup (one part) – these four liquids are to be used in the preparation this medicated ghee in which the ghee and the decoction should be in equal quantities. Alternatively, the juice of vidari and goat-meat soup taken together should be one part. Thus the ghee should be cooked with four parts of liquid in conformity with the general rule. A similar recipe is also described in Jatukarana.
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| − | In this recipe, decoction should be same in quantity as ghee and the quatity of the drug to be used for decoction may be varied as a special case.
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| − | Khaj means a stirrer and the rod of the stirre can be ten angulas (19-50 cm) or one hasta (45-72cm) in length. Wrapping the cakes with bhurjapatra promotes therapeutic potency.
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| − | A similar recipe is available in the work of Jatukarana.
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| − | For the preparation of this recipe, milk, oil, ghee and sugar should first of all be cooked till the water content of milk evaporates. This is indicated by the term ‘kvathita’ in verse 68. Thereafter, powders of drugs mentioned in the verse 66-67, should be added and mixed well.
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| − | Cakrapanidatta’s commentary on verse number 70 is not very clear. However, it can be explained as follows:
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| − | Cow’s milk intended to be used in this recipe, is not for the sake of ‘ghrtapaka’, but for intial preparation (karanataya). It seems that the various ingredients prescribed to be used for this recipe are not required to be mixed up with the prescribed quantity of milk in its intial stage. It is only after cow’s milk is sufficiently boiled and become considerably thick, that various ingredients should be mixed up there with and the process of the cooking of the recipe should be started. Otherwise, if all the ingredients are mixed up with cow’s milk in the very early stage, it may not be possible to have the desired density of the preparation.
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| − | The quantity of milk should be determined on the basis of the dose of nagabala- root etc. [According to the general rule, milk should be eight times of the drug, and of this thirty two times of water should be added, boiled and reduced to one- forth. The drug which is generally used in a coarsely powdered form, should then be strained out and the milk should be given to the patient.]
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| − | Present clinical management of kshata-kshina:
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| | Name of medicine Dose Time of administration Anupana(vehicle) | | Name of medicine Dose Time of administration Anupana(vehicle) |
| | 1.Laksha mixture 10-20 grams Frequently Vasavaleha | | 1.Laksha mixture 10-20 grams Frequently Vasavaleha |
| | 2. Amruta prasha ghee 10 -20 grams After lunch and dinner Milk | | 2. Amruta prasha ghee 10 -20 grams After lunch and dinner Milk |
| − | 3. Suvarna malini vasant 120-240 mg In between two meals Milk | + | 3. Suvarna malini vasanta 120-240 mg In between two meals Milk |
| − | 4. Lakshm vilasa 60-120 mg In between two meals Milk | + | 4. Lakshmi vilasa 60-120 mg In between two meals Milk |
| | 5.Vanga mishrana 250 to 500 mg In between two meals Milk | | 5.Vanga mishrana 250 to 500 mg In between two meals Milk |
| | + | |
| | + | Pathya or recommended diet: Light to digest food like shali rice, wheat, green gram, pomegranate, dry grapes, mango, amalaka, goat milk and ghee prepared of it, medicated milk, meat juice of goat |
| | + | Pathya or recommended activity: Total bed rest |
| | + | Apathya or contraindicated diet: Excess hot, pungent, salty food causing burning sensation, heavy to digest food. |
| | + | Apathya or contraindicated activity: Over exertion, strenuous exercise, weight lifting etc. |
| | + | Parallel management of chest injury: |
| | + | Use of sandhaniya drugs like laksha (mainly indicated for the healing of fracture of bone) and madhuyashti clearly indicates that in kshata kshina there is external trauma (ribs fracture leading to pneumothorax) that should be managed with quick remedies. As only conservative management for the kshata- kshina is described, it excludes the possibility of surgical interventions in kshata-kshina in that era. However nowadays the surgical procedures like tube drainage with or without medical pleurodesis, vacuum-assisted thoracostomy (VATS) with pleurodesis and/or closure of leaks and bullectomy, and open surgical procedures such as thoracotomy for pleurectomy or pleurodesis) are conducted to decrease the chances of incurability of kshata ksheena. At the present time, it is necessary to elaborate the management of acute dreaded complications like pneumothorax and hematuria in separate chapter. |
| | + | Future Scope for Research: |
| | + | • Exploring the clinical evidences for the immunomodulator and hemostatic properties of Sida Veronicaefolia Lam. (Nagabala). |
| | + | • In vitro and in-vivo evaluation of hemostatic property of Boerhavia diffusa and clinical demonstration of its use in hemoptysis. |
| | + | • Exploring the role of autoantibodies in the pathogenesis of tuberculosis and its relation with genetic suspectibility. |
| | + | • Evaluating the role of laksha (Laccifer lacca) and madhuyasti (Glycyrrhiza glabra) in rehabilitating pulmonary tissues in acute pulmonary injury. |
| | + | • Evaluating role of anti-oxidant drugs [like amalaki (Emblica officinalis)] and vitamin C in the management of chronic inflammatory as well as infectious pulmonary diseases. |
| | + | Further reading: |
| | + | [1] Curtin SM, Tucker AM, Gens DR. Pneumothorax in sports: issues in recognition and follow-up care. Phys Sportsmed 2000;28:23 – 32. |
| | + | [2] Miles JW, Barrett GR. Rib fractures in athletes. Sports Med 1991;12:66 – 9. |
| | + | [3] Garcia VF, Gotschall CS, Eichelberger MR, Bowman LM. Rib fractures in children: a marker of severe trauma. J Trauma 1990;30:695 – 700. |
| | + | [4] Armstrong CP, Vanderspuy J. The fractured scapula: importance in management based on series of 62 patients. Injury 1984;15:324 – 9. |
| | + | [5] Ferro RT, McKeag DB. Neck pain and dyspnea in a swimmer. Phys Sports Med 1999;27. |
| | + | [6] Neer II CS. Fractures about the shoulder. In: Rockwood Jr CA, Green DP, editors. Fractures. Philadelphia: JD Lippincott; 1984. p. 713 – 21. |
| | + | [7] Pfeiffer RP, Young TR. Case report: spontaneous pneumothorax in a jogger. Phys Sportsmed 1980;8:65 – 7. |
| | + | [8] Marnejon T, Sarac S, Cropp AJ. Spontaneous pneumothorax in weightlifters. J Sports Med |
| | + | Phys Fitness 1995;35:124 – 6. |
| | + | [9] Simoneaux SF, Murphy BJ, Tehranzadeh J. Spontaneous pneumothorax in a weightlifter. Am J Sports Med 1990;18:647 – 8. |
| | + | [10] Harker CP, Neuman TS, Olson LK, et al. The roentgenographic findings associated with air |
| | + | embolism in sport scuba divers. J Emerg Med 1993;11:443 – 9. |
| | + | [11] Curtin SM, Tucker AM, Gens DR. Pneumothorax in sports: issues in recognition and follow-up care. Phys Sportsmed 2000;28:23 – 32. |
| | + | [12] Partridge RA, Coley A, Bowie R, Woolard RH. Sports-related pneumothorax. Ann Emerg Med1997;30:539 – 41. |
| | + | [13] Funk DA, McGanity PL, Hagemeier III KF, Schenck Jr RC. Pneumothorax in high school |
| | + | football. Tex Med 1998;94:72 – 4. |
| | + | [14] Ziser A, Vaananen A, Melamed Y. Diving and chronic spontaneous pneumothorax. Chest 1985;87:264 – 5. |
| | + | [15] Belham GJ, Adler M. Pneumothorax in a boxer. Br J Sports Med 1985;19:45. |
| | + | [16] Sadat-Ali M, Al-Arfaj AL, Mohanna J. Pneumothorax due to soccer injury. Br J Sports Med |
| | + | 1986;20(2):91. |
| | + | [17] Ciocca M. Pneumothorax in a weight lifter. Phys Sportsmed 2000;28. |
| | + | [18] Harmer PA, Moriarty J, Walsh M, Bean M, Cramer J. Distant entry pneumothorax in a competitive fencer. Br J Sports Med 1996;30:265–6. |
| | + | [20] Fischer RP, Flynn TC, Miller PW, Thompson DA. Scapular fractures and major ipsilateral upper torso injuries. Curr Concepts Trauma Care 1985;1:14– 6. |
| | + | [21] Morgan EJ, Henderson DA. Pneumomediastinum as a complication of athletic competition. |
| | + | Thorax 1981;36:155–6. |
| | + | [22] O’Kane J, O’Kane E, Marquet J. Delayed complication of a rib fracture. Phys Sportsmed |
| | + | 1998;26. |
| | + | [23] Kizer KW, MacQuarrie MB. Pulmonary air leaks resulting from outdoor sports. A clinical series and literature review. Am J Sports Med 1999;27:517– 20. |
| | + | [24] Volk CP, McFarland EG, Horsmon G. Pneumothorax: on field recognition. Phys Sportsmed |
| | + | 1995;23:43 – 6. |
| | + | [25]. Pasternak, M.S., & Rubin, R.H. (2001). Urinary tract tuberculosis. In R.W. Schrier (Ed.), Diseases of the kidney and urinary tract. (7th ed.) (pp. 1017-1037). Philadelphia: Lippincott Wil liams & Wilkins. |
| | + | [26]. Gibson, M.S., Puckett, M.L., & Shelly, M.E. (2004). Renal tuberculosis. RadioGraphics, 24, 251-256. |
| | + | [27]. Anwar, N., & Azher, A. (2002). Tuberculosis in a solitary kidney. Pakistan Journal of Medical Research, 41(4), 173-174. |
| | + | [28]. Soliman, M.S., Lessnau, K., & Hashmat, A. (2006). Tuberculosis of the genitourinary system. Retrieved March 11,2007, from http://www.emedicine.com/med/topic3073..htm. |
| | + | [29]. Centers for Disease Control and Prevention. (2005). Controlling tuberculosis in the United States. Mortality and Morbidity Weekly Reports (MMWR): Recommended Reports 54 (RR-12), 1-77. |
| | + | [30]. Khan, A.N., Chandramohan, M., & MacDonald, S. (2004, November 5). Tuberculosis, genitourinary tract. Retrieved March 11, 2007from http://www.emedicine.com/radio/topic721.ht |
| | + | [31] Ahmed, M., & Murty, K. V. (2003). Isolated tuberculous pyonephrosis of a native kidney in a renal allograft recipient,an unusual manifestation of tuberculosis – A case report. Indian Journal of Nephrology, 13, 75-79. |
| | + | [32]. Kenney, P.J. (1990). Imaging of chronic renal infections. American Journal of Radiology, 155, 485-494. |
| | + | [33]. Christensen, W. (1974). Genitourinary tuberculosis: Review of 102 cases. Medicine (Baltimore), 53, 377-390. |
| | + | [34] Kathuria, P; Sanghera, P; Stevenson, FT; Sharma, S; Lederer, E; Lohr, JW; Talavera, F; Verrelli, M (21 May 2013). "Goodpasture Syndrome Clinical Presentation". In Batuman, C. Medscape Reference. WebMD. Retrieved 14 March 2014. |
| | + | [35] Schwarz, MI (November 2013). "Goodpasture Syndrome: Diffuse Alveolar Hemorrhage and Pulmonary-Renal Syndrome". Merck Manual Professional. Retrieved 14 March 2014. |
| | + | [36] Seo P, Stone JH (July 2004). "The antineutrophil cytoplasmic antibody-associated vasculitides". Am. J. Med. 117 (1): 39–50. |
| | + | [37] Berden, A; Göçeroglu, A; Jayne, D; Luqmani, R; Rasmussen, N; Bruijn, JA; Bajema, I (January 2012). "Diagnosis and management of ANCA associated vasculitis.". BMJ 344: e26. |
| | + | [38] Pandey Manisha, Sonker Kanchan, Kanoujia Jovita, Koshy M. K., Saraf Shubhini A. Sida Veronicaefolia as a Source of Natural Antioxidant. International Journal of Pharmaceutical Sciences and Drug Research 2009; 1(3): 180-182. |
| | + | [39]Bhattacharya A, Chatterjee A, Ghosal S, Bhattacharya SK. Antioxidant activity of active tannoid principles of Emblica officinalis (amla). Indian J Exp Biol. 1999 Jul;37(7):676-80. |
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| | === Future Scope for Research === | | === Future Scope for Research === |