Hikka Shwasa Chikitsa
Chikitsa Sthana Chapter 17. Management of Hikka (Hiccups) and Shwasa (Dyspnea)
| Section/Chapter | Chikitsa Sthana Chapter 17 |
|---|---|
| Preceding Chapter | Pandu Chikitsa |
| Succeeding Chapter | Kasa Chikitsa |
| Other Sections | Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Kalpa Sthana, Siddhi Sthana |
| Translator and commentator | Rao M. |
| Reviewer | Ojha S.N., Mali P. |
| Editors | Singh G., Goyal M., Deole Y.S., Basisht G. |
| Year of publication | 2020 |
| Publisher | Charak Samhita Research, Training and Skill Development Centre |
| DOI | 10.47468/CSNE.2020.e01.s06.018 |
Abstract
The chapter deals with the etio-pathogenesis and management of hikka (hiccups) and shwasa (dyspnea). The general causative factors include dietary and environmental pathogens and specific pathogenesis is due to involvement of vata and kapha as major dosha. Thus five types of hikka and shwasa are elaborated. The classification is based upon clinical presentation of disease and includes three types each of hikka and shwasa with bad prognostic signs pointing to imminent death. The description comprehends basic principles of management focused on removing obstruction of kapha and allowing proper flow of vata by means of purification therapies, sudation, nasal errhines, medicated smoking and various formulations. The management emphasizes on nourishment and pacification therapies to successfully treat and prevent shwasa and hikka conditions. Depletion therapies are strongly contra-indicated as they may worsen the condition of patient and disease.
Keywords: Shwasa, hikka, dyspnea, hiccups, tamaka shwasa, bronchial asthma, respiratory disorders, vamana, therapeutic emesis, virechana, therapeutic purgation, swedana, sudation.
Introduction
Hikka (hiccups) and shwasa (dyspnea/shortness of breath) may be caused due to pandu roga with pathological signs of anemia (alpa rakta), abnormal fat metabolism(alpa medaska) and depletion of body constituents (dhatu-kshaya). [Chakrapani Cha.Sa. Chikitsa Sthana 17/1]. That is why this chapter follows the chapter on Pandu Chikitsa. The term 'Shwasa' denotes physiological process of respiration and pathological sign too. In physiological process, breathing without any distress is seen; however pathological signs can be diagnosed if person suffers any distress during breathing and has to take extra efforts for same.Hikka and shwasa have common etiological factors (karana) like raja (pollen or dust particles), dhuma (smoke) etc., location (sthana) and treatment or mula. For that reason, both conditions are described in the same chapter.
Hikka and shwasa are two diseases of serious nature which can be presented at terminal stages of life and as complication of other diseases [Cha.Sa. Chikitsa Sthana 17/6]. These can cause death if not treated properly. The etiological factors, site, origin of both hikka and shwasa are same, and hence the line of treatment is also common. The etiological factors related to food, regimen and mental faculties lead to the aggravation of vata in the pranavaha srotas and derangement of kapha situated in the chest region producing lethal blockage of prana vayu.
The maha (severe form), gambhira (having depth) and vyapeta (originating after food and with complications) types of hikka are incurable. If the vyapeta or yamala hikka (with two hiccups together) is associated with symptoms of emaciation, delirium, pain, excess thirst and stupor then it is incurable for treatment, while it is curable in non emaciated and mentally strong individual with unimpaired dhatus and indriyas performing their normal function. Kshudra hikka (minor variety) and annaja hikka (due to improper food intake) are curable types of hikka. Maha (severe form), urdhva (shallow respiration) and chinna (irregular pattern dyspnea) shwasa are incurable and lead to death very fast. Tamaka (with black outs) and kshudra shwasa (minor variety) are curable if patient is strong, and disease is in early stage, while in weak patients they are yapya (work as palliatives).
The patient suffering from hikka and shwasa should be treated with oleation, unctuous sudation to liquefy the accumulated kapha, soften the channels and to facilitate vatanulomana (movement of vata in its normal direction). This should be followed by the administration elimination therapy in the form of vamana (emesis therapy), virechana (purgation), nasya and following of wholesome diet and regimen. The palliative medications should be administered keeping in view the condition of patient and stage of disease. Avoiding the causative factors and following wholesome regimen is important to prevent progress of disease and to reverse the pathogenesis. In brief shodhana followed by brimhana therapy (nourishing therapy) and shamana treatment (palliative therapy) are the ideal management methods in hikka and shwasa. All diseases of respiratory system and channels transporting vital breath (pranvaha srotas) are treated based on the principles of management of shwasa laid down in this chapter. [Cha. Sa.Vimana Sthana 5/26]
Sanskrit Text, Transliteration and English Translation
Now we shall expound the chapter "Hikka-Shwasa chikitsa"(Management of Hikka (Hiccups) and Shwasa (Dyspnea)). Thus said Lord Atreya. [1-2]
Agnivesha’s query
वेदलोकार्थतत्त्वज्ञमात्रेयमृषिमुत्तमम् |
अपृच्छत् संशयं धीमानग्निवेशः कृताञ्जलिः ||३||
य इमे द्विविधाः प्रोक्तास्त्रिदोषास्त्रिप्रकोपणाः |
रोगा नानात्मकास्तेषां कस्को भवति दुर्जयः ||४||
Agnivesha , an intelligent disciple, asked his doubt with modest salute of folded hands to Lord Atreya, who has the knowledge about the subject and principles of the Vedas “The diseases are categorized under two categories (samanyaja and nanatmaja) of three dosha (vata, pitta and kapha) aggravated due to three factors (like unwholesome utilization of sense organs (asatmendriyartha samyoga), intellectual errors (pajnaparadha) and advent of maturity of time (parinama)). Which among these diseases is most difficult to cure?” [3-4]
Atreya’s reply and nature of disease of shwasa and hikka
अग्निवेशस्य तद्वाक्यं श्रुत्वा मतिमतां वरः |
उवाच परमप्रीतः परमार्थविनिश्चयम् ||५||
कामं प्राणहरा रोगा बहवो न तु ते तथा |
यथा श्वासश्च हिक्का च प्राणानाशु निकृन्ततः ||६||
अन्यैरप्युपसृष्टस्य रोगैर्जन्तोः पृथग्विधैः |
अन्ते सञ्जायते हिक्का श्वासो वा तीव्रवेदनः ||७||
After listening to Agnivesha, Lord Punarvasu, the most prudent among the sages was very delighted and made ultimate and conclusive statement. “In fact there are many diseases which can kill a patient. But none of the diseases is as lethal as shwasa and hikka as they can cause immediate death. The person suffering from any other disease can also get eventually afflicted with enormously painful hikka and shwasa at the time of death.”[3-7]
Predominance of dosha and affliction of dhatu
कफवातात्मकावेतौ पित्तस्थानसमुद्भवौ |
हृदयस्य रसादीनां धातूनां चोपशोषणौ ||८||
तस्मात् साधारणावेतौ मतौ परमदुर्जयौ |
मिथ्योपचरितौ क्रुद्धौ हत आशीविषाविव ||९||
Hikka and shwasa are mainly kapha and vata dominant in nature. They originate at the site of pitta (upper part of stomach). This results in further depletion of dhatu like rasa dhatu situated in heart. Hence generally they are extremely difficult to treat. After getting afflicted with this disease, if one indulges in unwholesome regimens, then disease gets aggravated and results in death just as from fatal snake venom. [8-9]
Etiological factors
पृथक् पञ्चविधावेतौ निर्दिष्टौ रोगसङ्ग्रहे |
तयोः शृणु समुत्थानं लिङ्गं च सभिषग्जितम् ||१०||
रजसा धूमवाताभ्यां शीतस्थानाम्बुसेवनात् |
व्यायामाद्ग्राम्यधर्माध्वरूक्षान्नविषमाशनात् ||११||
आमप्रदोषादानाहाद्रौक्ष्यादत्यपतर्पणात् |
दौर्बल्यान्मर्मणो घाताद्द्वन्द्वाच्छुद्ध्यतियोगतः ||१२||
अतीसारज्वरच्छर्दिप्रतिश्यायक्षतक्षयात् |
रक्तपित्तादुदावर्ताद्विसूच्यलसकादपि ||१३||
पाण्डुरोगाद्विषाच्चैव प्रवर्तेते गदाविमौ |
निष्पावमाषपिण्याकतिलतैलनिषेवणात् ||१४||
पिष्टशालूकविष्टम्भिविदाहिगुरुभोजनात् |
जलजानूपपिशितदध्यामक्षीरसेवनात् ||१५||
अभिष्यन्द्युपचाराच्च श्लेष्मलानां च सेवनात् |
कण्ठोरसः प्रतीघाताद्विबन्धैश्च पृथग्विधैः ||१६||
Five types of hikka and shwasa, based on etiology, signs, symptoms and treatment are being elaborated here, listen to them carefully:
- Environmental factors: Dust, smoke and wind, residing in cold place, use of cold water.
- Regimen: Excessive exercise, excessive sexual intercourse, excess walking,
- Diet: Intake of dry food, vishamashana (food in excessive or less quantity at irregular time)
- Conditions: Accumulation of ama, anaha (constipation associated with flatulence), dryness in the body, excessive depletion (apatarpana), weakness, injury to marmas (vital points), rapid change in exposure to heat and cold, diarrhea, fever, vomiting, rhinitis, kshata (injury), kshaya (wasting), raktapitta (bleeding disorder), udavarta (upward movement of vata), visuchika (enteritis), alasaka (sluggish bowel), pandu (anemia) and intake of poisons can result in hikka and shwasa.
- Diet: Regular intake of nishpava (beans), masha (black gram), pinyaka (oil cake), tila taila (sesame oil), pishta (cakes and pastry), shaluka (lotus stem), vishtambhi anna (food aggravating vata), vidahi (food causing burning sensations), heavy to digest food, flesh of aquatic and marshy animals, curd, raw milk, abhishyandhi (ingredients leading to obstruction of channels), food aggravating kapha
- Injury: Injury to throat and chest
- Others: Various types of vibandha (obstructions) [10-16]
General Samprapti (pathogenesis)
मारुतः प्राणवाहीनि स्रोतांस्याविश्य कुप्यति |
उरःस्थः कफमुद्धूय हिक्काश्वासान् करोति सः ||१७||
घोरान् प्राणोपरोधाय प्राणिनां पञ्च पञ्च च |१८|
By the above mentioned etiological factors the vata gets aggravated in the pranavahasrotas ( channels carrying prana) and deranges the kapha situated in the chest region producing lethal blockage of pranavayu and five types of dreadful hikka and shwasa. [17-18]
Premonitory symptoms
उभयोः पूर्वरूपाणि शृणु वक्ष्याम्यतः परम् ||१८||
कण्ठोरसोर्गुरुत्वं च वदनस्य कषायता | हिक्कानां पूर्वरूपाणि कुक्षेराटोप एव च ||१९||
आनाहः पार्श्वशूलं च पीडनं हृदयस्य च | प्राणस्य च विलोमत्वं श्वासानां पूर्वलक्षणम् ||२०||
Following are the premonitory symptoms of both the diseases:
Heaviness in throat and chest, astringent taste in mouth, and distension of abdomen are the premonitory symptoms of hikka.
Anaha (constipation with flatulence), pain in the flanks, pain in the cardiac region, abnormal movement of pranavayu are the premonitory symptoms of shwasa.[18-20]
Specific pathogenesis of hikka
प्राणोदकान्नवाहीनि स्रोतांसि सकफोऽनिलः | हिक्का करोति संरुध्य तासां लिङ्गं पृथक् शृणु ||२१||
क्षीणमांसबलप्राणतेजसः सकफोऽनिलः | गृहीत्वा सहसा कण्ठमुच्चैर्घोषवतीं भृशम् ||२२||
करोति सततं हिक्कामेकद्वित्रिगुणं तथा | प्राणः स्रोतांसि मर्माणि संरुध्योष्माणमेव च ||२३||
सञ्ज्ञां मुष्णाति गात्राणां स्तम्भं सञ्जनयत्यपि | मार्गं चैवान्नपानानां रुणद्ध्युपहतस्मृतेः ||२४||
साश्रुविप्लुतनेत्रस्य स्तब्धशङ्खच्युतभ्रुवः | सक्तजल्पप्रलापस्य निर्वृतिं नाधिगच्छतः ||२५||
महामूला महावेगा महाशब्दा महाबला | महाहिक्केति सा नॄणां सद्यः प्राणहरा मता ||२६||
इति महाहिक्का |
- Vishesha samprapti: Vata along with kapha blocks the channels carrying prana, udaka and anna and produces hikka.
A List of the signs and symptoms of many types is elaborated further:
- Mahahikka: Vata along with kapha affects the throat of an individual whose mamsa dhatu (muscles), strength, prana and agni are depleted. It further produces remarkably loud and resonant hiccups occurring in bouts of two or three constantly. The blockage of pranavaha srotas (channels carrying prana).
- Vayu along with aggravated kapha obstructs the pranavaha srotas and marma jatharagni resulting in loss of consciousness, stiffness in the body and also obstructs the channels of food and drinks. There is impairment of memory, tears in the eyes and stiffness in the temples and displacement of eyebrows. He suffers from delirium along with obstruction of speech, which does not get relief by any means. Maha hikka is mahamula (deep rooted), mahavega (massive attack), mahashabda (very loud sound), maha bala (very strong). This can lead to death immediately, hence named as mahahikka. [21-26]
Gambhira hikka
हिक्कते यः प्रवृद्धस्तु कृशो दीनमना नरः | जर्जरेणोरसा कृच्छ्रं गम्भीरमनुनादयन् ||२७||
सञ्जृम्भन् सङ्क्षिपंश्चैव तथाऽङ्गानि प्रसारयन् | पार्श्वे चोभे समायम्य कूजन् स्तम्भरुगर्दितः ||२८||
नाभेः पक्वाशयाद्वाऽपि हिक्का चास्योपजायते | क्षोभयन्ती भृशं देहं नामयन्तीव ताम्यतः ||२९||
रुणद्ध्युच्छ्वासमार्गं तु प्रनष्टबलचेतसः | गम्भीरा नाम सा तस्य हिक्का प्राणान्तिकी मता ||३०||
इति गम्भीरा हिक्का |
Excessive aggravation of kapha and vayu in an aged, emaciated and mentally depressed individual leads to hikka. This hikka is characterised by deep and resonant sound, and affliction of the chest. He yawns, contracts and expands his body, and while respiring he contracts both the flanks making murmuring sounds, and suffers from stiffness and pain. In such a patient the hikka arises from the umbilicus or pakvashaya (intestines) with pain all over the body. During this time his body bends and he suffers from black outs, obstruction in the respiratory tract and loss of strength and unconsciousness. Such hikka is known as gambhira hikka which ultimately results in death. [27-30]
Vyapeta hikka
व्यपेता जायते हिक्का याऽन्नपाने चतुर्विधे | आहारपरिणामान्ते भूयश्च लभते बलम् ||३१||
प्रलापवम्यतीसारतृष्णार्तस्य विचेतसः | जृम्भिणो विप्लुताक्षस्य शुष्कास्यस्य विनामिनः ||३२||
पर्याध्मातस्य हिक्का या जत्रुमूलादसन्तता | सा व्यपेतेति विज्ञेया हिक्का प्राणोपरोधिनी ||३३||
इति व्यपेता हिक्का |
The vyapeta hikka produced after the intake of four types of food (i.e. eatable, chewable, drinkable, lickable) and gets aggravated after food gets digested. He suffers from delirium, vomiting, diarrhea, thirst and unconsciousness. There is yawning, watering of eyes, dryness of mouth and bending of the body, and adhmana (distension of the abdomen). This hikka originates from the root of the clavicle and attack is not continuous. Hikka is injurious to life. [31-33]
Kshudra hikka
क्षुद्रवातो यदा कोष्ठाद्व्यायामपरिघट्टितः | कण्ठे प्रपद्यते हिक्कां तदा क्षुद्रां करोति सः ||३४||
अतिदुःखा न सा चोरःशिरोमर्मप्रबाधिनी | न चोच्छ्वासान्नपानानां मार्गमावृत्य तिष्ठति ||३५||
वृद्धिमायस्यतो याति भुक्तमात्रे च मार्दवम् | यतः प्रवर्तते पूर्वं तत एव निवर्तते ||३६||
हृदयं क्लोम कण्ठं च तालुकं च समाश्रिता | मृद्वी सा क्षुद्रहिक्केति नृणां साध्या प्रकीर्तिता ||३७||
इति क्षुद्रहिक्का |
The vayu gets slightly aggravated in the koshtha (alimentary tract), due to the physical exercises and reaches the throat and produces kshudra hikka. This does not produce much pain and does not afflict the head and vital parts (hridaya marma). In this type of hikka, the doshas do not reside or get lodged in the channels of respiration, food and drinks. This gets aggravated on exertion and subsides on taking food. Hikka gets subsided by itself also. The doshas are situated in cardiac region, kloma, throat and palate. This mild form of hikka is curable and known as kshudra hikka. [35-37]
Annaja Hikka
सहसाऽत्यभ्यवहृतैः पानान्नैः पीडितोऽनिलः | ऊर्ध्वं प्रपद्यते कोष्ठान्मद्यैर्वाऽतिमदप्रदैः ||३८||
तथाऽतिरोषभाष्याध्वहास्यभारातिवर्तनैः | वायुः कोष्ठगतो धावन् पानभोज्यप्रपीडितः ||३९||
उरःस्रोतः समाविश्य कुर्याद्धिक्कां ततोऽन्नजाम् | तथा शनैरसम्बन्धं क्षुवंश्चापि स हिक्कते ||४०||
न मर्मबाधाजननी नेन्द्रियाणां प्रबाधिनी | हिक्का पीते तथा भुक्ते शमं याति च साऽन्नजा ||४१||
इत्यन्नजा हिक्का |
The vayu gets aggravated and moves in the upward direction due to the intake of excess food or drinks in hurry or excess of alcohol, anger, talking, laughing, weightlifting etc. factors aggravate vayu in koshtha (alimentary tract) gets afflicted by food and drinks and move in the upward direction and get lodged in channels of chest and produce annaja hikka. This hikka occurs slowly and intermittently along with sneezing. The hikka that does not afflict vital points (marma) and organs and it subsides after drinking water or taking food is known as annaja hikka.[38-41]
Prognosis of hikka
अतिसञ्चितदोषस्य भक्तच्छेदकृशस्य च | व्याधिभिः क्षीणदेहस्य वृद्धस्यातिव्यवायिनः ||४२||
आसां या सा समुत्पन्ना हिक्का हन्त्याशु जीवितम् | यमिका च प्रलापार्तितृष्णामोहसमन्विता ||४३||
अक्षीणश्चाप्यदीनश्च स्थिरधात्विन्द्रियश्च यः | तस्य साधयितुं शक्या यमिका हन्त्यतोऽन्यथा ||४४||
The hikka destroys a person suffering from excessive accumulation of dosha, emaciated due to fasting, emaciated due to disease, weak due to ageing or excessive indulgence in sex. The symptoms of delirium, pain, excess thirst and stupor in yamika hikka patient make it incurable for treatment.
The yamika hikka is curable in an individual who is not emaciated, not weak mentally, the dhatu and indriya are unaffected and performing their normal function. Otherwise in case if body is weak, it is incurable. [42-44]
Specific pathogenesis of Shwasa
यदा स्रोतांसि संरुध्य मारुतः कफपूर्वकः | विष्वग्व्रजति संरुद्धस्तदा श्वासान्करोति सः ||४५||
The aggravated vayu along with vitiated kapha obstructs the channels (of prana, udaka and annavaha) and spreads throughout the body and produces shwasa. [45]
Mahashwasa
उद्धूयमानवातो यः शब्दवद्दुखितो नरः | उच्चैः श्वसिति संरुद्धो मत्तर्षभ इवानिशम् ||४६||
प्रनष्टज्ञानविज्ञानस्तथा विभ्रान्तलोचनः | विकृताक्ष्याननो बद्धमूत्रवर्चा विशीर्णवाक् ||४७||
दीनः प्रश्वसितं चास्य दूराद्विज्ञायते भृशम् | महाश्वासोपसृष्टः स क्षिप्रमेव विपद्यते ||४८||
इति महाश्वासः |
The patient breathes with a loud noise during the night due to the upward movement of aggravated vayu like intoxicated bull. The vayu gets obstructed and the person becomes unconscious. The eyes get distorted and he cannot visualize properly. The eyes and face become abnormal and the elimination of urine and feces is obstructed and the voice becomes feeble and the person looks tired and respiration could be heard from distance, such person suffering from mahashwasa succumbs to death very fast. [46-48]
Urdhva Shwasa
दीर्घं श्वसिति यस्तूर्ध्वं न च प्रत्याहरत्यधः | श्लेष्मावृतमुखस्रोताः क्रुद्धगन्धवहार्दितः ||४९||
ऊर्ध्वदृष्टिर्विपश्यंश्च विभ्रान्ताक्ष इतस्ततः | प्रमुह्यन् वेदनार्तश्च शुष्कास्योऽरतिपीडितः ||५०||
ऊर्ध्वश्वासे प्रकुपिते ह्यधःश्वासो निरुध्यते | मुह्यतस्ताम्यतश्चोर्ध्वं श्वासस्तस्यैव हन्त्यसून् ||५१||
इत्यूर्ध्वश्वासः |
The vitiated kapha obstructs channels of respiration leading to aggravation of vata resulting in prolonged expiration and shallow inspiration (breath doesn’t get deeply inspired). The patient looks up with moving eye balls as if he is scared of something. When he gets afflicted with this type of shwasa he suffers from unconsciousness, dryness of mouth, restlessness. The upward movement of vayu is aggravated resulting in obstruction of downward movement and unconsciousness, black outs and he succumbs to death quickly. [49-51]
Chhinna Shwasa
यस्तु श्वसिति विच्छिन्नं सर्वप्राणेन पीडितः | न वा श्वसिति दुःखार्तो मर्मच्छेदरुगर्दितः ||५२||
आनाहस्वेदमूर्च्छार्तो दह्यमानेन बस्तिना | विप्लुताक्षः परिक्षीणः श्वसन् रक्तैकलोचनः ||५३||
विचेताः परिशुष्कास्यो विवर्णः प्रलपन्नरः | छिन्नश्वासेन विच्छिन्नः स शीघ्रं प्रजहात्यसून् ||५४||
इति छिन्नश्वासः |
The patient suffering from chhinna shwasa has interrupted breath as the prana(vital centers) [Cha. Sa. Sutra Sthana 29] is afflicted. There is complete stoppage of breath, such individual suffers from intense pain as if cutting of the marma (vital parts), constipation with abdominal distension, sweating, unconsciousness, burning sensation in basti (bladder and urinary system), excessive tears in the eyes, emaciation of the body, the eyes become red when patient struggles to breath, mental disorientation, dryness of mouth, discoloration of skin, delirium, looseness of joints. An individual suffering from above said features of chhinna shwasa succumbs to death very quickly. [52-54]
Tamaka Shwasa
प्रतिलोमं यदा वायुः स्रोतांसि प्रतिपद्यते | ग्रीवां शिरश्च सङ्गृह्य श्लेष्माणं समुदीर्य च ||५५||
करोति पीनसं तेन रुद्धो घुर्घुरुकं तथा | अतीव तीव्रवेगं च श्वासं प्राणप्रपीडकम् ||५६||
प्रताम्यत्यतिवेगाच्च कासते सन्निरुध्यते | प्रमोहं कासमानश्च स गच्छति मुहुर्मुहुः ||५७||
श्लेष्मण्यमुच्यमाने तु भृशं भवति दुःखितः | तस्यैव च विमोक्षान्ते मुहूर्तं लभते सुखम् ||५८||
अथास्योद्ध्वंसते कण्ठः कृच्छ्राच्छक्नोति भाषितुम् | न चापि निद्रां लभते शयानः श्वासपीडितः ||५९||
पार्श्वे तस्यावगृह्णाति शयानस्य समीरणः | आसीनो लभते सौख्यमुष्णं चैवाभिनन्दति ||६०||
उच्छ्रिताक्षो ललाटेन स्विद्यता भृशमर्तिमान् | विशुष्कास्यो मुहुः श्वासो मुहुश्चैवावधम्यते ||६१||
मेघाम्बुशीतप्राग्वातैः श्लेष्मलैश्चाभिवर्धते | स याप्यस्तमकश्वासः साध्यो वा स्यान्नवोत्थितः ||६२||
इति तमकश्वासः |
The vayu moves in the opposite direction due to the obstruction in the respiratory tract, stiffness in the neck, head aggravates the kapha and produces rhinorrhoea, and gurghuraka sound (rhonchi). Exceedingly severe attack afflicts the prana and enhances severity. During severe attack, the patient faints repeatedly, has severe cough and becomes unconscious. The patient finds it difficult to expectorate the phlegm and feels relieved for period of 1 muhurta (3 hours) after expectoration of phlegm. There is hoarseness of voice and patient speaks with difficulty, even he does not get proper sleep, and on lying down he suffers from dyspnea as his flanks are afflicted by vayu. He feels comfortable in the sitting position. He likes hot things. His eye balls are always prominent, there is sweat on the forehead, dryness of the mouth, gets repeated attacks of dyspnea, and it increases and subsides repeatedly. In gets aggravated when appearance of clouds in the sky, rains, cold weather, easterly winds and kapha enhancing food and behavior. The tamaka shwasa having above mentioned features is yapya (palliable) and in the initial stages it is curable disease. [55-62]
Types of Tamaka Shwasa
ज्वरमूर्च्छापरीतस्य विद्यात् प्रतमकं तु तम् | उदावर्तरजोऽजीर्णक्लिन्नकायनिरोधजः ||६३||
तमसा वर्धतेऽत्यर्थं शीतैश्चाशु प्रशाम्यति | मज्जतस्तमसीवाऽस्य विद्यात् सन्तमकं तु तम् ||६४||
इति प्रतमकसन्तमकश्वासौ |
In a patient of tamaka shwasa if jwara (fever) and unconsciousness are occurring as complication, then it is called as pratamaka shwasa. The shwasa produced due to udavarta (upward movement of vayu in koshtha), dust, indigestion, excessive liquid accumulation in the body (klinna kaya), and suppression of natural urges results in increase of tama. This gets relieved by following of cooling regimen. The person suffering from this shwasa feels as if he is submerged in darkness, thus it is known as santamaka.[63-64]
Kshudra shwasa
रूक्षायासोद्भवः कोष्ठे क्षुद्रो वात उदीरयन् | क्षुद्रश्वासो न सोऽत्यर्थं दुःखेनाङ्गप्रबाधकः ||६५||
हिनस्ति न स गात्राणि न च दुःखो यथेतरे | न च भोजनपानानां निरुणद्ध्युचितां गतिम् ||६६||
नेन्द्रियाणां व्यथां नापि काञ्चिदापादयेद्रुजम् | स साध्य उक्तो बलिनः सर्वे चाव्यक्तलक्षणाः ||६७||
इति श्वासाः समुद्दिष्टा हिक्काश्चैव स्वलक्षणैः |६८|
Due to intake of dry food and exertion, vata is mildly vitiated in koshtha and moves in the upward direction i.e respiratory tract resulting in kshudra shwasa. The patient suffering from this type of shwasa does not have any affliction of various body parts and the functions are not affected. It is not very painful as it does not affect the channels of food and drinks nor does it cause pain to the sense organs. This is curable if the symptom is not completely manifested and the patient is strong. Thus all the types of hikka and shwasa are elaborated along with their signs and symptoms.[65-67]
Necessity of quick management of hikka and shwasa
एषां प्राणहरा वर्ज्या घोरास्ते ह्याशुकारिणः ||६८||
भेषजैः साध्ययाप्यांस्तु क्षिप्रं भिषगुपाचरेत् | उपेक्षिता दहेयुर्हि शुष्कं कक्षमिवानलः ||६९||
Among them the fatal varieties (like maha hikka, gambhira hikka, vyapeta hikka, maha shwasa, urdhva shwasa, chhinna shwasa are incurable types) should not be treated. While the curable and controllable variety of hikka and shwasa should be treated with medicine quickly. If neglected then it destroys the prana of the patient as the fire burns away the dry grass very fast.[68-69]
Guidelines for treatment of hikka and shwasa
कारणस्थानमूलैक्यादेकमेव चिकित्सितम् | द्वयोरपि यथादृष्टमृषिभिस्तन्निबोधत ||७०||
हिक्काश्वासार्दितं स्निग्धैरादौ स्वेदैरुपाचरेत् | आक्तं लवणतैलेन नाडीप्रस्तरसङ्करैः ||७१||
तैरस्य ग्रथितः श्लेष्मा स्रोतःस्वभिविलीयते | खानि मार्दवमायान्ति ततो वातानुलोमता ||७२||
यथाऽद्रिकुञ्जेष्वर्कांशुतप्तं विष्यन्दते हिमम् | श्लेष्मा तप्तः स्थिरो देहे स्वेदैर्विष्यन्दते तथा ||७३||
स्विन्नं ज्ञात्वा ततस्तूर्णं भोजयेत् स्निग्धमोदनम् | मत्स्यानां शूकराणां वा रसैर्दध्युत्तरेण वा ||७४||
ततः श्लेष्मणि संवृद्धे वमनं पाययेत्तु तम् | पिप्पलीसैन्धवक्षौद्रैर्युक्तं वाताविरोधि यत् ||७५||
निर्हृते सुखमाप्नोति स कफे दुष्टविग्रहे | स्रोतःसु च विशुद्धेषु चरत्यविहतोऽनिलः ||७६||
The etiological factors, site, origin of both hikka and shwasa are same and hence the treatment is also same. Kindly listen attentively the treatment of hikka and shwasa as known by the seers.
Initially the patient suffering from hikka and shwasa should be treated with massage with combination of rock salt and sesame oil over the chest region followed by administration of unctuous sudation by means of nadi sveda or prastara sveda or sankara sveda. By this the clogged kapha gets liquefied in the channels and the channels become soft and vata moves in the downward direction (vatanulomana). As the ice on the top of the mountain gets liquefied by the rays of the sun, the kapha accumulated in the srotas get liquefied by swedana.
After the administration snehana (oleation) and swedana (sudation), one has to give rice along with unctuous substances. The meat soup prepared from fish or pig or curds in large quantity should be taken in meals. When the kapha gets aggravated due to above mentioned means vamana (emesis therapy) should be administrated with powder of pippali (piper longum Linn), saindhava (rock salt) and honey. While selection of the drugs care should be taken not to administer the vata aggravating drugs. After the expulsion of vitiated kapha the patient feels relieved as the vata gets alleviated and moves in the normal direction as obstructed srotas are cleared. [70-76]
Treatment of remaining dosha
लीनश्चेद्दोषशेषः स्याद्धूमैस्तं निर्हरेद्बुधः | हरिद्रां पत्रमेरण्डमूलं लाक्षां मनःशिलाम् ||७७||
सदेवदार्वलं मांसीं पिष्ट्वा वर्तिं प्रकल्पयेत् | तां घृताक्तां पिबेद्धूमं यवैर्वा घृतसंयुतैः ||७८||
मधूच्छिष्टं सर्जरसं घृतं मल्लकसम्पुटे | कृत्वा धूमं पिबेच्छृङ्गं बालं वा स्नायु वा गवाम् ||७९||
स्योनाकवर्धमानानां नाडीं शुष्कां कुशस्य वा | पद्मकं गुग्गुलुं लोहं शल्लकीं वा घृताप्लुतम् ||८०||
The dosha remaining after the administration of vamana treatment should be expelled by means of dhuma (medicated smoking). The haridra (turmeric), roots of eranda (Ricinus communis Linn), laksha (Ficus Lacor Buch-Ham), manahshila (realgar, an Arsenic compound), jatamansi (Nardostachys jatamansone BC), are powdered properly and wick is prepared. This wick is smeared with ghee and used for medicated smoking. The barley should be mixed with ghee and used for smoking.
The bee wax, rala (exudate of Shorea robusta Gaertn.) and ghee are kept in inside two mud plates (mallaka samputa). The smoke coming out of it after application of heat should be inhaled for smoking.
Cow’s horn, hair, ligaments are mixed and used for smoking by putting it in dhuma netra. Shyonaka, roots of eranda (Ricinis communis Linn) and kusha (Desmostachya bipinnata Stapf.) should be filled with above mentioned drugs and used as a pipe for smoking. Padmaka (Prunus puddum), guggulu (Commiphora mukul (Hook ex Stocks), agaru (Aquallaria agollacha Roxb) and shallaki (Boswellia serrata Roxb.) are powdered and mixed with ghee and used for smoking. [77-80]
Management of complications
स्वरक्षीणातिसारासृक्पित्तदाहानुबन्धजान् | मधुरस्निग्धशीताद्यैर्हिक्काश्वासानुपाचरेत् ||८१||
The hikka and shwasa patient accompanied with complications like feeble voice, diarrhea, raktapitta (bleeding disorder) should be treated with medicines having properties of sweet, unctuous, and cold. [81]
Precautions and guidelines for swedana (sudation)
न स्वेद्याः पित्तदाहार्ता रक्तस्वेदातिवर्तिनः | क्षीणधातुबला रूक्षा गर्भिण्यश्चापि पित्तलाः ||८२||
कोष्णैः काममुरःकण्ठं स्नेहसेकैः सशर्करैः | उत्कारिकोपनाहैश्च स्वेदयेन् मृदुभिः क्षणम् ||८३||
तिलोमामाषगोधूमचूर्णैर्वातहरैः सह | स्नेहैश्चोत्कारिका साम्लैः सक्षीरैर्वा कृता हिता ||८४||
नवज्वरामदोषेषु रूक्षस्वेदं विलङ्घनम् | समीक्ष्योल्लेखनं वाऽपि कारयेल्लवणाम्बुना ||८५||
अतियोगोद्धतं वातं दृष्ट्वा वातहरैर्भिषक् | रसाद्यैर्नातिशीतोष्णैरभ्यङ्गैश्च शमं नयेत् ||८६||
उदावर्ते तथाऽऽध्माने मातुलुङ्गाम्लवेतसैः | हिङ्गुपीलुबिडैश्चान्नं युक्तं स्यादनुलोमनम् ||८७||
Contra-indication for swedana in shwasa
The patient of shwasa and hikka suffering from burning sensation, bleeding, and excessive sweating, depleted dhatu, loss of strength, dryness, and associated with condition of pregnancy or having pitta Prakriti should not be administered swedana(sudation).
Mridu swedana (mild sudation)
In such condition, if it is very essential then mild sudation should be given over chest and throat region for short duration, in the form of parisheka with warm oil or application of warm utkarika (a kind of poultice) mixed with sugar or upanaha(poultice).
Utkarika(poultice)
Utkarika is prepared with powders of sesame, black gram and wheat are mixed with vatahara sneha and gruel and swedana is done or warm gruel and milk are used for swedana in the form of parisheka.
Vamana
The patient suffering from fever of recent origin and ama dosha should be treated with ruksha sweda and langhana. Or vamana (emesis) should be induced by administering saindhavalavana (rock salt) and water.
Meal should be taken along with vata alleviating meat soups etc. in condition of aggravation of vata due to excessive vamana. Alleviation of vata should also be done by massage with vatahara drugs which are not cold, nor hot in property. [82-87]
Two types of patients as per dosha dominance
हिक्काश्वासामयी ह्येको बलवान् दुर्बलोऽपरः | कफाधिकस्तथैवैको रूक्षो बह्वनिलोऽपरः ||८८||
कफाधिके बलस्थे च वमनं सविरेचनम् | कुर्यात् पथ्याशिने धूमलेहादिशमनं ततः ||८९||
वातिकान् दुर्बलान् बालान् वृद्धांश्चानिलसूदनैः | तर्पयेदेव शमनैः स्नेहयूषरसादिभिः ||९०||
The patients suffering from hikka and shwasa are of two types i.e. one having strength and other weak. One has aggravation of kapha and other having dryness and vata predominance.
Management of patient having strength: The patient of hikka and shwasa having kapha predominance and strength should be treated with therapeutic emesis and purgation along with wholesome food and regimen. Further alleviation should be done with medicated smoking and administration of lehya etc.
Management of weak patient:The patient having aggravation of vata and weakness, children and elderly hikka, shwasa patients should be managed with vata alleviating medicines and nourishing sneha, soups, and meat soup. [88-90]
Contra-indication for Purification therapy in hikka and shwasa patients
अनुत्क्लिष्टकफास्विन्नदुर्बलानां विशोधनात् | वायुर्लब्धास्पदो मर्म संशोष्याशु हरेदसून् ||९१||
दृढान् बहुकफांस्तस्माद्रसैरानूपवारिजैः | तृप्तान्विशोधयेत्स्विन्नान् बृंहयेदितरान् भिषक् ||९२||
बर्हितित्तिरिदक्षाश्च जाङ्गलाश्च मृगद्विजाः | दशमूलीरसे सिद्धाः कौलत्थे वा रसे हिताः ||९३||
If purification therapy is administered in the hikka shwasa patients without aggravation of kapha, in patients contraindicated for swedana or in very weak patients, then the aggravated vayu afflicts marma (vital points) and results in death instantaneously.
Brimhana therapy in hikka shwasa: Strong and sturdy patient with aggravated kapha should be administered with meat soup prepared from aquatic and marshy animals followed by swedana and vamana. Weak patient without aggravation of kapha should be administered brimhana (nourishment therapy). [91-93]
Various formulations
निदिग्धिकां बिल्वमध्यं कर्कटाख्यां दुरालभाम् | त्रिकण्टकं गुडूचीं च कुलत्थांश्च सचित्रकान् ||९४||
जले पक्त्वा रसः पूतः पिप्पलीघृतभर्जितः | सनागरः सलवणः स्याद्यूषो भोजने हितः ||९५||
रास्नां बलां पञ्चमूलं ह्रस्वं मुद्गान् सचित्रकान् | पक्त्वाऽम्भसि रसे तस्मिन् यूषः साध्यश्च पूर्ववत् ||९६||
पल्लवान्मातुलुङ्गस्य निम्बस्य कुलकस्य च | पक्त्वा मुद्गांश्च सव्योषान् क्षारयूषं विपाचयेत् ||९७||
दत्त्वा सलवणं क्षारं शिग्रूणि मरिचानि च | युक्त्या संसाधितो यूषो हिक्काश्वासविकारनुत् ||९८||
कासमर्दकपत्राणां यूषः शोभाञ्जनस्य च | शुष्कमूलकयूषश्च हिक्काश्वासनिवारणः ||९९||
सदधिव्योषसर्पिष्को यूषो वार्ताकजो हितः | शालिषष्टिकगोधूमयवान्नान्यनवानि च ||१००||
हिङ्गुसौवर्चलाजाजीबिडपौष्करचित्रकैः | सिद्धा कर्कटशृङ्ग्या च यवागूः श्वासहिक्किनाम् ||१०१||
दशमूलीशटीरास्नापिप्पलीमूलपौष्करैः | शृङ्गीतामलकीभार्गीगुडूचीनागराम्बुभिः ||१०२||
यवागूं विधिना सिद्धां कषायं वा पिबेन्नरः | कासहृद्ग्रहपार्श्वार्तिहिक्काश्वासप्रशान्तये ||१०३||
पुष्कराह्वशटीव्योषमातुलुङ्गाम्लवेतसैः | योजयेदन्नपानानि ससर्पिर्बिडहिङ्गुभिः ||१०४||
Nidigdhikadi yoga: Nidigdhika (Solanum surattense Burm. f), bilva (Aegle marmelos Corr.), karkta (Rhus succedania Linn.), duralabha (Fagonia cretica Linn.), trikanthaka (Tribulus terrestris Linn.), guduchi (Tinospora cordifolia Willd Miers ex Hook f. & Thoms ), chitraka (Plumbago zyelanica Linn.) and kulattha (horse gram- Dolicus lab lab) are taken in equal quantity and boiled in water as yusha and filtered. This filtrate is fried in ghee and taken with pippali (Piper longum Linn.), shunthi (Zingiber officinale Roxb.) and saindhava lavana (rock salt) is conducive to hikka shwasa patients.
Rasnadi yusha: Rasna (Pluchea lanceolata C B Clarke), bala (Sida cordifolia Linn. ), laghupanchamula (Shalaparni- Desmodium gangeticum DC., prishniparni -Uraria picta Desv., Brihati- Solanum Indicum Linn., kanthakari – Solanum surattense Burm. f, gokshura- Tribulus terrestris Linn.) and chitraka (Plumbago zeylanica Linn.) are taken in equal quantity and boiled with mudga (green gram) and water as earlier described yusha.
Matulungadi yusha: Leaves of matulunga (Citrus medica Linn.), nimba (Azadirachta indica A. Juss), kulaka are taken in equal quantity and mixed with mudga (green gram) and cooked in water as yusha. Further trikatu powder (maricha-Piper nigrum Linn, pippali- Piper longum linn. and shunthi-Zingiber officinale Roxb.) should be added at the time drinking in hikka shwasa patients.
Mudga yusha: Rock salt, yavakshara, seeds of drum stick and maricha (pepper) powder should be added to the already prepared mudga yusha and consumed in hikka shwasa patients.
Yusha prepared from leaves of kasamarda (Senna occidentalis Linn), shobhanjana (drum stick- Moringa oleifera Lam.), and dry radish should also be given in hikka shwasa.
The yusha prepared from juice or decoction of brihati (Solanum indica Linn.) should be mixed with ghee, curd, maricha, pippali and shunthi is conducive in hikka and shwasa disease. Old shali (Oriza sativa Linn.), shashthika (variety of rice maturing in 60 days), godhuma (wheat- Triticum aestivum Linn.), yava (Barley- Hordium vulgare Linn.) are pathya in hikka and shwasa.
Hingvadi yavagu: The yavagu (gruel) prepared from hingu (Ferula narthex Boiss.), sauvarchala (variety of salt), ajaji (Cuminum cyminum Linn.), bida (variety of salt), pushkara (Inula racemosa Hook. f.), chitraka (Plumbago zeylanica Linn.) and karkataka shringi (Rhus succedania Linn.) is beneficial in hikka and shwasa patients.
Dashamuladi yavagu: yavagu prepared from dashamula, shati (Hedychium spicatum Buch Ham.), rasna (Pluchea lanceolata C B Clarke), pippalimula (Piper longum Linn), pushkara (Inula racemosa Hook. f), karkata shringi (Rhus succedania Linn), amalaki (Emblica officinals Gaertn), bharngi (Clerodendrum serratum Linn. Moon.), guduchi (Tinospora cordifolia Wiild Miers ex Hook f. & Thoms), nagara (Zingiber officinale Roxb.) and water alleviates kasa (cough), hridgraha (heart problem), parshvarti (pain in the flanks), hikka (hiccough) and shwasa (dysnea).
Pushkaradi yavagu: Yavagu prepared from pushkara (Inula racemosa Hook f.), shati (Hedychium spicatum Buch Ham.), vyosha (maricha, pippali, shunthi), matulunga (Citrus medica Linn.), amlavetasa (Garcenia morella Desr) and hingu (Ferula narthex Boiss.) should be used in hikka shwasa patient. [94-104]
दशमूलस्य वा क्वाथमथवा देवदारुणः | तृषितो मदिरां वाऽपि हिक्काश्वासी पिबेन्नरः ||१०५||
पाठां मधुरसां रास्नां सरलं देवदारु च | प्रक्षाल्य जर्जरीकृत्य सुरामण्डे निधापयेत् ||१०६||
तं मन्दलवणं कृत्वा भिषक् प्रसृतसम्मितम् | पाययेत्तु ततो हिक्का श्वासश्चैवोपशाम्यति ||१०७||
हिङ्गु सौवर्चलं कोलं समङ्गां पिप्पलीं बलाम् | मातुलुङ्गरसे पिष्टमारनालेन वा पिबेत् ||१०८||
सौवर्चलं नागरं च भार्गीं द्विशर्करायुतम् | उष्णाम्बुना पिबेदेतद्धिक्काश्वासविकारनुत् ||१०९||
भार्गीनागरयोः कल्कं मरिचक्षारयोस्तथा | पीतद्रुचित्रकास्फोतामूर्वाणां चाम्बुना पिबेत् ||११०||
मधूलिका तुगाक्षीरी नागरं पिप्पली तथा | उत्कारिका घृते सिद्धा श्वासे पित्तानुबन्धजे ||१११||
श्वाविधं शशमांसं च शल्लकस्य च शोणितम् | पिप्पलीघृतसिद्धानि श्वासे वातानुबन्धजे ||११२||
सुवर्चलारसो दुग्धं घृतं त्रिकटुकान्वितम् | शाल्योदनस्यानुपानं वातपित्तानुगे हितम् ||११३||
शिरीषपुष्पस्वरसः सप्तपर्णस्य वा पुनः | पिप्पलीमधुसंयुक्तः कफपित्तानुगे मतः ||११४||
मधुकं पिप्पलीमूलं गुडो गोश्वशकृद्रसः [१] | घृतं क्षौद्रं कासश्वासहिक्काभिष्यन्दिनां शुभम् ||११५||
खराश्वोष्ट्रवराहाणां मेषस्य च गजस्य च | शकृद्रसं बहुकफे चैकैकं मधुना पिबेत् ||११६||
क्षारं चाप्यश्वगन्धाया लिह्यान्ना क्षौद्रसर्पिषा | मयूरपादनालं वा शकलं शल्लकस्य वा ||११७||
श्वाविज्जाण्डकचाषाणां [२] रोमाणि कुररस्य वा | शृङ्ग्येकद्विशफानां [३] वा चर्मास्थीनि खुरांस्तथा ||११८||
सर्वाण्येकैकशो वाऽपि दग्ध्वा क्षौद्रघृतान्वितम् | चूर्णं लीढ्वा जयेत् कासं हिक्कां श्वासं च दारुणम् ||११९||
एते हि कफसंरुद्धगतिप्राणप्रकोपजाः [४] | तस्मात्तन्मार्गशुद्ध्यर्थं देया लेहा न निष्कफे ||१२०||
Drinks in hikka shwasa patients: The patient suffering from hikka shwasa should drink water prepared in dashamula or devadaru (Cedrus deodara (Roxb.) Loud.) or madira (variety of alcohol) on feeling thirst.
Pathadyasava: patha (Cissampelos pareira Linn.), madhurasa (Marsdenia tenacissima Wight. & Am), rasna (Pluchea lanceolata C B Clarke), sarala (Operculina turpethum (Linn.) silva Manso) and devadaru (Cedrus deodara (Roxb.) Loud.) are washed and crushed and these ingredients should be put in suramanda (an alcoholic preparation). Small quantity of salt is added to this and administered in one prasrita dosage to alleviate hikka shwasa.
Hingvadi dravya: Hingu (Ferula northex Boiss), sauvarchala (Variety of salt), kola (Zizipus jujube Lam), samanga (Rubia cordifolia Linn.), pippali (Piper longum Linn.), bala (Sida cordifolia Linn.) are taken in equal quantity and made in to fine paste in juice of matulunga (Citrus medica Linn.). This paste is mixed in aranala and given to hikka shwasa patient.
Sauvarchaladi churna: Sauvarchala (variety of salt), nagara (zingiber officinale Roxb.), bharngi (Clerodendrum serratum Linn.) should be taken in equal quantity and mixed with double quantity of sharkara (sugar). This combination should be taken with hot water.
Bharngi nagaradi churna: Bharngi and shunthi (Zingiber officinale Roxb.), maricha (Piper nigrum Linn.), yavakshara (alkali prepared from barley), pitadru (Berberis aristata DC.), chitraka (Plumbago zeylanica Linn.), asphota (Hemidesmus indicus R Br.) are used individually with hot water in hikka shwasa.
Utkarika: Utkarika should be prepared from madhulika (finger millet), vamshalochana, shunthi (Zingiber officinale Roxb.), pippali (Piper longum Linn.) by cooking in ghee and used in shwasa associated with pitta.
The meat of shashvita or rabbit or blood of shallaka should be cooked with pippali ghrita should be used in shwasa associated with vata.
In the shwasa associated with vata and kapha should be administered combination of juice of sauvarchala, milk, ghee and trikatu and shali variety of rice.
In shwasa associated with kapha pitta should be given juice of flowers of shirisha (Albizzia lebbeck Benth), or juice of saptaparna leaves (Alstonia scholaris R Br.) along with pippali powder (Piper longum Linn.).
Madhukadi yoga: Madhuka (Glycyrrhiza glabra Linn.), pippalimoola (root of Piper longum Linn.), jaggery, juice of dungs of cow or horse, ghee, honey subsides kasa (cough), shwasa (dyspnea), hikka (hiccups) and abhishyanda (conjunctivitis).
In shwasa with aggravated kapha the juice of dung of donkey, horse, camel or pig should be administered with honey.
The alkali prepared from roots of ashvagandha (Withania somnifera Linn.) should be licked with honey and ghee. Alkali prepared stalk of feather of peacock, alkali of quills of fish, hair of shashvita, alkali of bones of jandaka, chasha, or kurara, skin, bones and hooves of shringi, ekashapha, dvishapha etc. animals are burnt into ash separately and alkali is prepared. This powder administered with honey and ghee results in cure of kasa (cough), hikka (hiccups) and shwasa (dyspnea).
Above said kshara lehya (Alkaline linctus) clear the kapha in the obstructed respiratory tract and subsides the aggravated pranavayu. Hence the alkaline linctus should be given to purify the channels obstructed by kapha if there is no obstruction by kapha it should not be administered. [105-120]
Guidelines for management of tamaka shwasa
कासिने च्छर्दनं दद्यात् स्वरभङ्गे च बुद्धिमान् | वातश्लेष्महरैर्युक्तं तमके तु विरेचनम् ||१२१||
उदीर्यते भृशतरं मार्गरोधाद्वहज्जलम् | यथा तथाऽनिलस्तस्य मार्गं नित्यं विशोधयेत् ||१२२||
An intelligent doctor in shwasa associated with cough and hoarseness of voice should be administered vamana and in tamaka shwasa virechana should be given with vata-kaphahara medicines.
If the path of flowing water is blocked the enhancing pressure of water breaks the dam similarly the path obstructed by kapha aggravates vata and causes harm, hence always the path of vayu should be cleaned by means of purification. [121-122]
Shatyadi churna
शटीचोरकजीवन्तीत्वङ्मुस्तं पुष्कराह्वयम् | सुरसं तामलक्येला पिप्पल्यगुरु नागरम् ||१२३||
वालकं च समं चूर्णं कृत्वाऽष्टगुणशर्करम् | सर्वथा तमके श्वासे हिक्कायां च प्रयोजयेत् ||१२४||
An equal quantity of the fine powders of shati (Hedychium spicatum Buch Ham.), choraka (Angelica glauca Edgew), jivanti (Leptadenia reticulate W & A.), tvak (Cinnamomum zeylanica Breyn), musta (Cyperus rotundus Linn.), pushkara mula (Inula recimosa Hook f.), surasa (Ocimum sanctum Linn.), tamalaka (Phyllanthus urinaria Linn.), pippali (Piper longum Linn.), agaru (Aquilaria agollacha Roxb.), nagara (Zingiber officinale Roxb.), balaka (Vetiveria zizinioidis (Linn.) Nash.) is mixed with eight parts of sugar should be kept and us in tamaka shwasa and hikka. [123-124]
Muktadi churna
मुक्ताप्रवालवैदूर्यशङ्खस्फटिकमञ्जनम् | ससारगन्धकाचार्कसूक्ष्मैलालवणद्वयम् [१] ||१२५||
ताम्रायोरजसी रूप्यं ससौगन्धिकसीसकम् [२] | जातीफलं शणाद्बीजमपामार्गस्य तण्डुलाः ||१२६||
एषां पाणितलं चूर्णं तुल्यानां क्षौद्रसर्पिषा | हिक्कां श्वासं च कासं च लीढमाशु नियच्छति ||१२७||
अञ्जनात्तिमिरं काचं नीलिकां पुष्पकं तमः | मल्यं [३] कण्डूमभिष्यन्दमर्म चैव प्रणाशयेत् ||१२८||
इति मुक्ताद्यं चूर्णम् |
Equal quantities of the bhasmas of mukta (pearls), pravala (coral), vaidurya (cat’s aye gem), shankha (conch), sphatika (crystal quartz), anjana (lead), sasara (potent crystals of above mentioned drugs), gandhaka (sulfur), arka (Calotropis procera (Ait) R Br.), sukshmaila (Elettaria cardomum Maton), lavana dvayam (sauvarchala and saindhava), tamra (copper), ayas (iron), rajata (silver), saugandhika (variety of manikya, ruby), jatiphala (Myristica fragrans Houtt), seeds of shana, apamarga (Achyranthes aspera Linn. ) are given in the dose of one panitala (karsha-12gms) along with ghee and honey. The administration of this powder cures hikka, shwasa and kasa. On application in the form of anjana (collyrium) to eyes destroys timira (blindness), kacha(glaucoma), nilika, pushpaka, vision defects, itching of eyes, abhishyanda (conjunctivitis) and arma (pterigium).[125-128]
Shatyadi churna
शटीपुष्करमूलानां चूर्णमामलकस्य च | मधुना संयुतं लेह्यं चूर्णं वा काललोहजम् ||१२९||
Equal quantity of fine powders of shati (Hedychium spicatum Buch Ham.), pushkaramula (Inula racemosa Hook f.) or amalaki (Emblica officinalis Gaertn.) or loha bhasma ( iron ore) should be licked along with honey.
Nasya formulations
सशर्करां तामलकीं द्राक्षां गोश्वशकृद्रसम् | तुल्यं गुडं नागरं च प्राशयेन्नावयेत्तथा ||१३०||
लशुनस्य पलाण्डोर्वा मूलं गृञ्जनकस्य वा | नावयेच्चन्दनं वाऽपि नारीक्षीरेण संयुतम् ||१३१||
सुखोष्णं घृतमण्डं वा सैन्धवेनावचूर्णितम् | नावयेन्माक्षिकीं विष्ठामलक्तकरसेन वा ||१३२||
नारीक्षीरेण सिद्धं वा सर्पिर्मधुरकैरपि | पीतं नस्तो निषिक्तं वा सद्यो हिक्कां नियच्छति ||१३३||
सकृदुष्णं सकृच्छीतं व्यत्यासाद्धिक्किनां पयः | पाने नस्तःक्रियायां वा शर्करामधुसंयुतम् ||१३४||
Juice of tamalaki (Phyllanthus urinaria Linn.), draksha (Vitis vinifera Linn.), cow dung and horse mixed with sugar or equal quantities of jaggery, ginger should be used for licking or nasya.
At the time of severe attack of hikka and shwasa, nasya should be administered from juice of roots of lashuna (Allium sativum Linn.) or palandu (Allium cepa Linn.) or grinjana (Daucas carota Linn) or chandana (Santalum album Linn.) with human milk.
The supernatant part of ghee mixed with saindhava lavana or juice of alaktaka along with bees’ feces or human milk should be given in the form of nasya. Medicated ghee prepared from madhura varga should be given orally or in the form of nasya pacifies hikka and shwasa very quickly. Alternate oral consumption of hot and cold milk or usage in the form of nasya alleviates hikka quickly. [130-134]
Ghee formulations and other therapies
अधोभागैर्घृतं सिद्धं सद्यो हिक्कां नियच्छति | पिप्पलीमधुयुक्तौ वा रसौ धात्रीकपित्थयोः ||१३५||
लाजालाक्षामधुद्राक्षापिप्पल्यश्वशकृद्रसान् | लिह्यात् कोलमधुद्राक्षापिप्पलीनागराणि वा ||१३६||
शीताम्बुसेकः सहसा त्रासो विस्मापनं भयम् | क्रोधहर्षप्रियोद्वेगा हिक्काप्रच्यावना मताः ||१३७||
हिक्काश्वासविकाराणां निदानं यत् प्रकीर्तितम् | वर्ज्यमारोग्यकामैस्तद्धिक्काश्वासविकारिभिः ||१३८||
हिक्काश्वासानुबन्धा [१] ये शुष्कोरःकण्ठतालुकाः | प्रकृत्या रूक्षदेहाश्च सर्पिर्भिस्तानुपाचरेत् ||१३९||
दशमूलरसे सर्पिर्दधिमण्डे च साधयेत् | कृष्णासौवर्चलक्षारवयःस्थाहिङ्गुचोरकैः ||१४०||
कायस्थया च तत् पानाद्धिक्काश्वासौ प्रणाशयेत् |१४१|
The administration of ghee prepared by boiling adhobhagahara (purgatives) drugs instantly cures hikka. Administration of pippali (Piper longum Linn.) along with honey or juice of dhatri (Emblica officinalis Gaertn.), and kapittha (Limonia acidissima L.) alleviates hikka quickly.
Laja (puffed rice), laksha (Ficus lacor Buch Ham.), madhu (honey), draksha (Vitis vinifera Linn.), pippali (Piper longum Linn.), juice of horse dung or kola (Zizipus jujube Lam.), draksha (Vitis vinifera Linn.), pippali (Piper longum Linn.), nagara (Zingiber officinale Roxb.) should be licked along with honey by patient suffering from hikka.
Sudden sprinkling of water, intimidation, distraction from thoughts, fear, anger, happiness, love, anxiety alleviate hikka.
The individual suffering from hikka and shwasa should refrain from etiological factors if he wants to get relief.
The patient of hikka and shwasa having associated with complications like dryness of chest, throat, and palate or having dryness of body by nature should be administered medicated ghee preparations.
Dashamuladi ghrita: Medicated ghee prepared from boiling dashamula kashaya, dadhimanda (supernatant part of curd), krishna (Piper nigrum Linn.), and sauvarchala (Variety of salt), yava kshara (alkali made of barley), vayastha (Bacopa monnieri), hingu (Ferula narthex Boiss), choraka (Angelica glauca Edgew), kayastha (Ocimum sanctum) are used internally in hikka and shwasa.[135-140]
Tejovatyadi ghee
तेजोवत्यभया कुष्ठं पिप्पली कटुरोहिणी ||१४१||
भूतीकं पौष्करं मूलं पलाशश्चित्रकः शटी | सौवर्चलं तामलकी सैन्धवं बिल्वपेशिका ||१४२||
तालीसपत्रं जीवन्ती वचा तैरक्षसम्मितैः | हिङ्गुपादैर्घृतप्रस्थं पचेत्तोये चतुर्गुणे ||१४३||
एतद्यथाबलं पीत्वा हिक्काश्वासौ जयेन्नरः | शोथानिलार्शोग्रहणीहृत्पार्श्वरुज [१] एव च ||१४४||
इति तेजोवत्यादिघृतम् |
Tejovatyadi ghrita: Tejovati (Zanthoxylun armatum DC.), abhaya (Terminalia chebula Retz.), kushtha (Saussurea lappa C.B. Clarke.), pippali (Piper longum Linn.), katukarohini (Picrorhiza kurroa Royle ex Benth), bhutika (Cymbopogon Citratus), paushkara mula (Inula recemosa Hook f.), palasha (Butea monosperma (Linn.) Kuntze.), chitraka (Plumbago zeylanica Linn.), shati (Hedychium spicatium Buch Ham.), sauvarchala (variety of salt), tamalaki (Phyllanthus urinaria Linn.), saindhava (rock salt), bilva (Aegle marmelos Corr.), talisa patra (Abies webbiana Lindle.), jivanti (Leptadenia reticulate W & A.), each are taken in one karsha quantity and hingu (Ferula narthex Boiss.) in 1/4th quantity and ghee in one prastha quantity (4 parts) and ghee is prepared as per classics. This ghee should be taken as per ones strength to conquer hikka and shwasa. It is also effective in edema vataja arsha (hemorrhoids), grahani (digestive disorders), hritparshva rija (pain in the cardiac region and flanks).[141-144]
Manahshiladi ghee
मनःशिलासर्जरसलाक्षारजनिपद्मकैः | मञ्जिष्ठैलैश्च कर्षांशैः प्रस्थः सिद्धो घृताद्धितः ||१४५||
जीवनीयोपसिद्धं वा सक्षौद्रं लेहयेद्धृतम् | त्र्यूषणं दाधिकं वाऽपि पिबेद्वासाघृतं तथा ||१४६||
इति मनःशिलादिघृतम् |
Manashila (realgar), sarja rasa (exudate of Shorea robusta Gaertn.), laksha (Ficus lacor Buch Ham.), rajani (Curcuma longa Linn), padmaka (Nelumbo nucifera Gaertn.), manjishtha (Rubia cordifolia Linn.), alai (Haratala- yellow orpiment), are each taken in one karsha (12 gm) quantity and ghee in one prastha quantity and ghee is prepared in classical way. [145-146]
Ghee prepared in jivaniya gana drugs is licked with honey or trishna (maricha, pippali, shunthi) or dadhika ghrita or vasa ghrita should be consumed in hikka and shwasa.
General guidelines for prevention and management
यत्किञ्चित् कफवातघ्नमुष्णं वातानुलोमनम् | भेषजं पानमत्रं वा तद्धितं श्वासहिक्किने ||१४७||
वातकृद्वा कफहरं कफकृद्वाऽनिलापहम् | कार्यं नैकान्तिकं ताभ्यां प्रायः श्रेयोऽनिलापहम् ||१४८||
सर्वेषां बृंहणे ह्यल्पः शक्यश्च प्रायशो भवेत् | नात्यर्थं शमनेऽपायो भृशोऽशक्यश्च कर्शने ||१४९||
तस्माच्छुद्धानशुद्धांश्च शमनैर्बृंहणैरपि | हिक्काश्वासार्दिताञ्जन्तून् प्रायशः समुपाचरेत् ||१५०||
The food, drinks and drugs having kapha-vatahara and ushna (hot) property which facilitate the normal movement of vata (vatanulomana) should be given in the patient of hikka and shwasa.
Hikka shwasa treatment based on dosha: The medicines or food that aggravate vata and destroy kapha or aggravate kapha and alleviate vata must never be used in the treatment.
However drugs that alleviate vata and aggravate kapha can be used in exceptional conditions.
Brimhana(nourishment therapy) administered in hikka and shwasa and its complications make them curable. The shamana treatment (palliative therapy) prevents the complications. Karshana (depletion therapy) makes hikka and shwasa incurable.
Hence shamana (palliative) and brimhana (nourishment) therapy should be done in hikka and shwasa with or without purification of the body. [147-150]
Summary
तत्र श्लोकः
दुर्जयत्वे समुत्पत्तौ क्रियैकत्वे च कारणम् | लिङ्गं पथ्यं च हिक्कानां श्वासानां चेह दर्शितम् ||१५१||
इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृतेऽप्राप्ते दृढबलसम्पूरिते चिकित्सास्थाने हिक्काश्वासचिकित्सितं नाम सप्तदशोऽध्यायः ||१७||
In the chapter of hikka and shwasa the reason for explaining them together, their similarity in causes, treatment, the features and pathyas are explained. Thus in the treatise by Agnivesha, redacted by Charaka and completed by Dridhabala, this concludes the chapter entitled Hikka Shwasa Chikitsa.
Tattva Vimarsha (Fundamental Principles)
- Hikka and shwasa originate at the site of pitta (upper part of stomach). The nature of disease is mainly kapha and vata dominant. The aggravation leads to depletion of dhatu like rasa situated in heart.
- The environmental pathogens like dust, pollen, smoke particles, improper diet and lifestyle regimen, and various other obstructions in channels carrying prana can cause the diseases.
- Hikka and shwasa can originate secondary to various conditions like ama, anaha (constipation associated with flatulence), excess dryness in the body, excessive depletion (apatarpana), weakness, injury to marmas (vital points), frequent exposure to heat and cold, diarrhea, fever, vomiting, rhinitis, kshata (injury), kshaya (wasting), raktapitta (bleeding disorder), udavarta (upward movement of vata), visuchika (enteritis), alasaka (sluggish bowel), pandu (anemia) and intake of poisons. In this case, the treatment will focus on primary disease along with management of hikka and shwasa also.
- Pranavaha srotasa (channels carrying prana) are mainly involved in the pathogenesis of hikka and shwasa.
- Vayu along with kapha blocks the channels carrying prana, udaka and anna and produces mahahikka.
- The protocol for management of shwasa includes:
- Liquefying kapha by snehana( massage) with oil mixed with rock salt
- Channelizing and further liquefying it to get expelled out by swedana (sudation)
- Intake of unctuous food for increasing quantity of kapha (in order to make it convenient to get expelled out as seen in mucolyic drugs) and pacification of vata.
- Therapeutic emesis to expel out vitiated kapha dosha
- Medicated smoking with drugs having hot potency to remove remaining kapha dosha
- Anulomana (treating vata to move in normal direction) is the principle of management for obstructed vata in case of hikka and shwasa.
- Shwasa associated with cough and hoarseness of voice should be treated with vamana (therapeutic emesis)
- In tamaka shwasa, virechana (therapeutic purgation) should be given with vata-kaphahara medicines.
- It is always required to keep the path of vata, clean (respiratory tract) by frequent purification therapies and removing obstruction.
- Purification therapies like vamana and virechana shall be administered after assessing bala(strength)of patient.
- The food, drinks and drugs having kapha-vata alleviating properties, ushna (hot) potency and facilitating normal movement of vata (vatanulomana) should be given in the patient of hikka and shwasa.
- Brimhana (nourishment therapy) administered in hikka and shwasa and its complications make them curable. The shamana treatment (palliative therapy) prevents the complications. Karshana (depletion therapy) makes hikka and shwasa incurable.
Hence strong medicines and therapies leading to depletion of tissues should never be administered in hikka and shwasa patients.
Vidhi Vimarsha (Applied Inferences )
Origin of diseases
The origin of hikka shwas diseases occurs at the site of Pitta dosha (Pitta sthana) which is lower part of stomach and duodenum from undigested food substances. [Chakrapani Cha.Sa. Chikitsa Sthana 17/8] The upper part of stomach is referred to as the site for kapha dosha,.[Chakrapani Cha.Sa. Sutra Sthana 20/8]. Therefore the lower end of stomach and duodenum is considered as the site of origin of shwasa and hikka. Derangement of digestion and metabolism is an important basic pathological event leading to vitiation of kapha and its manifestation (vyakti sthana) in chest.
Pathogenesis
Derangement of digestion and metabolism (agnimandya) causes malformation and nourishment of all body tissues (dhatu). This further leads to vitiation of kapha and pitta dosha resulting in increase in vata dosha. [Chakrapani Cha.Sa. Sutra Sthana 6/34]
Causes of shwasa
The etiological factors of shwasa can be classified as:
Exogenous factors:
Pollen and air pollutants (raja), fumes (dhuma), exposure to wind (prag-vata sevan), injury to vital organs (marmaghata), injury to throat, chest (kantha uras pratighat), staying at cold place (sheeta sthana sevana)
Endogenous factors:
- Vata vitiating causes: food with dry properties (ruksha aahara), cold water and drinks (sheeta ambu sevan), exercise (vyayama), excess walking (adhva sevana)
- Kapha vitiating causes: Meats of marshy and aquatic animals (jalaja-anup mamsa), curd (dadhi), Lablab purpurens L.(nishpav), black gram (masha), sesame paste (pinyak), heavy to digest food (guru-bhojana), milk (ksheera).
- Metabolic toxins provoking factors (aam pradoshaja hetu): irregular diet (vishamashana), curd (dadhi), food causing obstruction in channels (abhishyandi), improperly boiled milk (aam ksheera), heavy to digest food (guru bhojana)
Factors causing defective body systems (Khavaigunyakar):
Pollen (raja), fumes (dhuma), excess walking (adhvasevana), wrestling (dvandva), chest injury (kshatakshaya), injury to vital organs (marma ghata).
Co-morbid conditions (nidanarthakara roga):
Rhinitis (pratishyaya), cough(kasa) and disorders due to reverse functions of vata (udavarta).
Diseases causing defects in site of origin (mula sthana dushtikar vyadhi):
Diarrhoea (atisara), fever (jwara), vomitting (Chchardi), cholera (visuchika),and sluggish bowel (alasaka)
Disease provoking factors (preraka hetu):
Cloudy atmosphere(meghambu), cold exposure and consumption (sheet sevana),direct exposure to air(prak-vata ), exposure to pollen and pollutants (raja), fumes(dhuma) and physical exertion (vyayama).
Complication of kasa:
Shwasa results due to chronicity/complication of kasa. [A.H.NI.4/1]
Hikka
Continuous stimulation of diaphragm causes bouts of hiccups. Due to which the air is expelled out with loud sound (mahasabdha) and due to continuous diaphragmatic movement the patient is unable to eat (margam chaivannapananam runaddhi). Severe and prolonged hiccups may lead to exhaustion, fatigue, malnutrition, weight loss, dehydration and even death in the extreme situations.
The hyperventilation due to hiccups can lead to hypocapnia i.e. reduced level of CO2 in blood leading to cerebral vasoconstriction, leading to cerebral hypoxia and this can cause transient dizziness (upahatasmruteh), visual disturbances, and anxiety.
Pranvaha srotas includes the respiratory center in the brain (prano atra murdhaga) along with respiratory tract from nasal cavity till the alveoli. Role of hridaya is also significant. The cardio-pulmonary relationship can be easily understood in diseases like left ventricular failure with marked decrease in ejection fraction and pulmonary congestion leading to respiratory distress. Hridaya is site of origin (mula sthana) for rasavaha srotas. Rasa and rakta dhatu are part and parcel of udakvaha srotas. The content of udakvahasrotas is decided by the gastrointestinal tract. Thus one can understand why mahasrotas has been mentioned as mulasthana of pranvahasrotas.
Matta rishabha eva nisha (like a bull)
Nasal flaring (Matta rishabha eva nisha) occurs when a person is having severe difficulty in breathing or respiratory distress. It is most commonly seen in children and infants; Respiratory distress is observed in acute respiratory distress syndrome, a serious reaction to various forms of injuries to the lung, and infant respiratory distress syndrome, a syndrome in premature infants caused by developmental insufficiency of surfactant production and structural immaturity in the lungs.
Management
The management protocol for hikka and shwasa includes following:
- Snehana(unction or oleation): Chest massage on the front, back and sides) with hot sesame oil or mahanarayana oil mixed with rock salt
- Swedana (sudation): Fomentation with dashamula kwatha or erandamula kwatha vapors by means of steam (bashpa) or through a tube (nadi).
- Vamana (therapeutic emesis) with mixture of piper (pippali), rock salt and honey, decoction of yasthtimadhu and madanaphala are also used.
- Virechana(therapeutic purgation) with eranda taila (castor oil),draksha kwatha and triphala kwatha
- Shamana medicines: Following drugs are used in treatment of hikka and shwasa:
- Pippali
- Dhattura
- Arka
- Malla
- Abhraka
- Maricha
- Vasa
- Yashtimadhu
- Decoctions: Dashamula kwatha, Bharangyadi kwatha, Yastimadhu decoction, Dashamula katutrayadi kashayam
- Powder formulations: Sitopaladi churna, talisadi churna, karpuradi churna,Chausashta prahar pippali, Tankana
- Other formulations: Shvasakuthara rasa, Suvarna malini vasanta rasa, laghu malini vasanta,Lakshmivilas rasa, Kumarkalyan rasa (in children).
- Asava-arishta: Kanakasava, dashamularishta, draksharishta, vasavaleha.
Current researches
In a study, bharangyadi avaleha and vasa avaleha has shown good efficacy in children suffering from tamak shwasa (asthma).[1]. In another study carried out in children suffering from asthma, Ashtangavaleha and Vyaghreehareetakee Avaleha have shown good efficacy.[2]
Management with Shirishavaleha[3], Nithya virechana and Nayopayam kashaya [4], Vasa Avaleha and its granules [5] have also shown efficacy in management of shwasa.
The polyherbal compound Shirishadi formulation in the form of nasal spray and tablet by oral administration has shown potent anti-asthmatic activity in patients of bronchial asthma. It was also been concluded that this polyherbal compound can be used as “Therapeutic Agents” in the management of an acute attack of asthma as well as chronic persistent asthma.[6]
In a study on review of efficacy of different forms of vasa (Adhatoda vasica), it is observed that extract (Ghana), medicated ghee (Vasa Ghrita) , and Vasa Avaleha (Swarasa/ Kwatha) are effective in cases of management of bronchial asthama. [7]
A randomized double blind clinical trial showed that Sameera Pannaga Rasa (arseno-mercurial formulation) has a significant action in cases bronchial asthma. It could decrease total leukocyte count, eosinophil count, ESR and can improve Peak Expiatory Flow Rate along with providing symptomatic relief.[8]
Experience based views
In chronic cases of Shwasa, internal administration of unctuous substance (abhyantara snehana) in pure form or medicates formulation like dashamula ghrita is useful to control vata dosha. This reduces dryness (kharatva) of respiratory tract (pranavah srotas) and pacifies movement of vata (vatanulomana). In chronic stage of svasa, vata becomes more dominant while in new cases Kapha dominancy is observed.[9]
Drugs prescribed for Pandu, Shotha and Kasa may be used in the management of Shwasa(Su.Utt 51/43). Drugs prescribed for Kasa, Kshaya, chhardi and hikka can be used for Shwasa.(A.H.ch.59)
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References
- ↑ Gohel SD, Anand IP, Patel KS. A comparative study on efficacy of Bharangyadi Avaleha and Vasa Avaleha in the management of Tamaka Shwasa with reference to childhood asthma. Ayu. 2011;32(1):82-89. doi:10.4103/0974-8520.85736
- ↑ Dubey AK, Rajagopala S, Patel KS. Comparative clinical efficacy of Ashtangavaleha and Vyaghreehareetakee Avaleha on Tamaka Shwasa (bronchial asthma) in children. Ayu. 2014;35(4):384-390. doi:10.4103/0974-8520.158995
- ↑ Yadav SS, Galib, Patgiri B, Prajapati PK. Clinical efficacy of two different samples of Shirishavaleha in Tamaka Shwasa (Bronchial Asthma). Ayu. 2012;33(2):255-260. doi:10.4103/0974-8520.105247
- ↑ Shyam PM, Ramachandran AP, Acharya GS, Shrilatha KT. Evaluation of the role of Nithyavirechana and Nayopayam kashaya in Tamaka Shwasa. Ayu. 2010;31(3):294-299. doi:10.4103/0974-8520.77151
- ↑ Paneliya AM, Patgiri B, Galib R, Prajapati PK. Efficacy of Vasa Avaleha and its granules on Tamaka Shwasa (bronchial asthma): Open-label randomized clinical study. Ayu. 2015;36(3):271-277. doi:10.4103/0974-8520.182760
- ↑ Kajaria D, Tripathi J, Tiwari S. Anti-asthmatic effect of Shirishadi compound through nasal spray actuation. Ayu. 2014;35(3):261-269. doi:10.4103/0974-8520.153738
- ↑ Gupta A, Prajapati PK. A clinical review of different formulations of Vasa (Adhatoda vasica) on Tamaka Shwasa (asthma). Ayu. 2010;31(4):520-524. doi:10.4103/0974-8520.82032
- ↑ Mashru M, Galib R, Shukla VJ, Ravishankar B, Prajapati PK. Effect of Sameera Pannaga Rasa (arsenomercurial formulation) in the management of Tamaka Shwasa (bronchial asthma) - Randomized double blind clinical study. Ayu. 2013;34(4):346-351. doi:10.4103/0974-8520.127692
- ↑ Personal email communication by Dr. Mali Pawan, dt. January 03, 2020