A congenital condition Situs inversus

Situs inversus (also called situs transversus or oppositus) is a congenital condition in which the major visceral organs are reversed or mirrored from their normal positions. The normal arrangement of internal organs is known as situs solitus while situs inversus is generally the mirror image of situs solitus. Although cardiac problems are more common than in the general population, most people with situs inversus have no medical symptoms or complications resulting from the condition, and until the advent of modern medicine it was usually undiagnosed.

Epidemiology

Situs inversus is found in about 0.01% of the population or about 1 person in 10,000.

 In the most common situation, situs inversus totalis, it involves complete transposition (right to left reversal) of all of the abdominal organs.

The heart is not in its usual position in the left chest, but is on the right, a condition known as dextrocardia (literally, right-hearted). Because the relationship between the organs is not changed, most people with situs inversus have no medical symptoms or complications.

    In rarer cases such as situs ambiguus or heterotaxy, situs cannot be determined. In these patients, the liver may be midline, the spleen absent or multiple, and the bowel malrotated. Often, structures are duplicated or absent altogether. This is more likely to cause medical problems than situs inversus totalis.

Signs and symptoms

In the absence of congenital heart defects, individuals with situs inversus are phenotypically normal, and can live normal healthy lives, without any complications related to their medical condition.

    There is a 5–10% prevalence of congenital heart disease in individuals with situs inversus totalis, most commonly transposition of the great vessels. The incidence of congenital heart disease is 95% in situs inversus with levocardia.

Many people with situs inversus totalis are unaware of their unusual anatomy until they seek medical attention for an unrelated condition, such as a rib fracture or a bout of appendicitis. The condition may also be discovered during the administration of certain medicines or during tests such as a barium meal or enema. The reversal of the organs may then lead to some confusion, as many signs and symptoms will be on the atypical side. For example, if an individual with situs inversus develops appendicitis, they will present to the physician with lower left abdominal pain, since that is where their appendix lies. Thus, in the event of a medical problem, the knowledge that the individual has situs inversus can expedite diagnosis. People with this rare condition should inform their doctors before an examination, so the doctor can redirect their search for heart sounds and other signs. Wearing a medical identification tag can help inform health care providers in the event the person is unable to communicate.

Cause

Situs inversus has an autosomal recessive pattern of inheritance.

Situs inversus is generally an autosomal recessive genetic condition, although it can be X-linked or found in identical "mirror image" twins.

About 25% of individuals with situs inversus have an underlying condition known as primary ciliary dyskinesia (PCD). PCD is a dysfunction of the cilia that manifests itself during the embryologic phase of development. Normally functioning cilia determine the position of the internal organs during early embryological development, and so embryos with PCD have a 50% chance of developing situs inversus. If they do, they are said to have Kartagener syndrome, characterized by the triad of situs inversus, chronic sinusitis, and bronchiectasis. Cilia are also responsible for clearing mucus from the lung, and the dysfunction causes increased susceptibility to lung infections. Kartagener syndrome can also manifest with male infertility as functional cilia are required for proper sperm flagella function.

Effect on anatomy

If the heart is swapped to the right side of the thorax, it is known as "situs inversus with dextrocardia" or "situs inversus totalis". If the heart remains on the normal left side of the thorax, a much rarer condition (1 in 2,000,000 of the general population), it is known as "situs inversus with levocardia" or "situs inversus incompletus".

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Diagnosis

Diagnosis of situs inversus can be made using common radiographic imaging techniques such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI).

Treatment

No treatment needed, as the subject is otherwise healthy.

History

Dextrocardia (the heart being located on the right side of the thorax) was first seen and drawn by Leonardo da Vinci in 1452–1519, and then recognised by Marco Aurelio Severino in 1643. However, situs inversus was first described more than a century later by Matthew Baillie

Statistics about Situs Inversus

1. Up to 5% of people with Situs Inversus have a functional heart defect, which is up to five times greater than the general population rate.

2. The amount of births that occur with Situs Inversus that have the underlying condition of Primary Ciliary Dyskinesia [PCD]: 1 in 4.

3. In the United States, the chances of having a child born with Situs Inversus is just 1 in 10,000.

4. 4 out of 5 people who have Situs Inversus also have a right-sided aortic arch.

5. The percentage of people who have cogenital heart disease with Situs Inversus: up to 10%.

6. When levocardia is present, the incidence of congenital heart disease climbs to 95%.

7. The dextrocardia version of Situs Inversus was first seen and documented by Leonardo da Vinci, but wasn’t recognized until 1643.

8. Levocardia occurs in only 1 in 22,000 births.

09. When PCD is present in embryos, the chances of Situs Inversus happening are 1 in 2.

10. 20% of people who are born with Situs Inversus have Kartagener Syndrome, but 50% of those with the syndrome have Situs Inversus.

11. Life expectancy rates with Situs Inversus are similar to that of the general population.

12. When marriages occur between people who are descended from the same direct ancestor, the incident rates of Situs Inversus tend to trend higher.

13. COPD rates and other breathing issues, including asthma, are slightly higher in cases of Situs Inversus than with the general population.

14. People with Situs Inversus have a higher than average risk to develop bronchiectasis, pneumonia, conductive deafness, and communicating hydrocephalus.

  There is a third version of Situs Inversus that sometimes occurs, but it is often called Situs Ambiguous instead. This is because there are several organs that are displaced from their regular location in the body, but the distribution is randomized instead of clearly defined. Some doctors do not consider this to be a case of Situs Inversus because there is no inversion. Instead of having the right lung on the left, the ambiguous version might provide two right lungs instead.

It is believed that many factors are involved in the development of Situs Inversus, but the cause doesn’t have a definite reason behind it. It is also believed that there is at least one gene that helps to contribute to the formation of Situs Inversus. That is because it is known to run in families, although it is just as likely to happen in an isolated fashion as it is to occur in families that have a history of it. Although organ issues, especially cardiac functions, can be disrupted in children born with this condition, it is also possible for children to have no complications at all.

Living with Situs Inversus

It is very possible to have Situs Inversus and live a very normal, fulfilling life. Writers, actresses, and professional athletes have all been diagnosed with this condition and have not had any complications to note.

The most important aspect of living with Situs Inversus is to let medical professionals know that this condition exists. Because it is so rare, doctors simply assume that the human body they are examining has been created correctly.

The goal of living with Situs Inversus is to simply treat the symptoms as they occur. The most common issues are the development of sinus infections and other items that can be treated with basic antibiotics. Surgery is rarely an option for people with this condition because there is often no way to correct the situation. It is an instance where two wrongs really do end up making a right.

PCD primary Ciliary dyskinesia

The main consequence of impaired ciliary function is reduced or absent mucus clearance from the lungs, and susceptibility to chronic recurrent respiratory infections, including sinusitis, bronchitis, pneumonia, and otitis media. Progressive damage to the respiratory system is common, including progressive bronchiectasis beginning in early childhood, and sinus disease (sometimes becoming severe in adults). However, diagnosis is often missed early in life despite the characteristic signs and symptoms. In males, immotility of sperm can lead to infertility, although conception remains possible through the use of in vitro fertilization, there also are reported cases where sperm were able to move. Trials have also shown that there is a marked reduction in fertility in female sufferers of Kartagener's Syndrome due to dysfunction of the oviductal cilia.

Many affected individuals experience hearing loss and show symptoms of otitis media which demonstrates variable responsiveness to the insertion of myringotomy tubes or grommets. Some patients have a poor sense of smell, which is believed to accompany high mucus production in the sinuses (although others report normal - or even acute - sensitivity to smell and taste). Clinical progression of the disease is variable, with lung transplantation required in severe cases. Susceptibility to infections can be drastically reduced by an early diagnosis. Treatment with various chest physiotherapy techniques has been observed to reduce the incidence of lung infection and to slow the progression of bronchiectasis dramatically. Aggressive treatment of sinus disease beginning at an early age is believed to slow long-term sinus damage (although this has not yet been adequately documented). Aggressive measures to enhance clearance of mucus, prevent respiratory infections, and treat bacterial superinfections have been observed to slow lung-disease progression. Although the true incidence of the disease is unknown, it is estimated to be 1 in 32,000, although the actual incidence may be as high as 1 in 15,000

Fibroadenoma Breast

          Fibroadenomas, are benign breast tumours characterized by an admixture of stromal and epithelial tissue. Breasts are made of lobules (milk producing glands) and ducts (tubes that carry the milk to the nipple). These are surrounded by glandular, fibrous and fatty tissues. Fibroadenomas develop from the lobules. The glandular tissue and ducts grow over the lobule to form a solid lump.

Since both fibroadenomas, and breast lumps as a sign of breast cancer can appear similar, it is recommended to perform ultrasound analyses and possibly tissue sampling with subsequent histopathologic analysis in order to make a proper diagnosis. Unlike typical lumps from breast cancer, fibroadenomas are easy to move, with clearly defined edges. Fibroadenomas are sometimes called breast mice or a breast mouse owing to their high mobility in the breast

Signs and symptoms

Fibroadenomas are benign (not harmful in effect) tumours of the breast, most often present in women in their 20s and 30s. Clinically, fibroadenomas are usually solid breast lumps that are:

• Painless

• Firm or rubbery

• Mobile

• Solitary-round with distinct, smooth borders

• Found in either one or both breasts

Cause

     The cause of fibroadenoma is unknown (idiopathic). A connection between fibroadenomas and reproductive hormones has been suggested which may explain why they present themselves during reproductive years, increase in size during pregnancy, and regress post-menopause.

Higher intake of fruits and vegetables, higher number of live births, lower use of oral contraceptives and moderate exercise are associated with lower frequency of fibroadenomas.

Cytology

The diagnostic findings on needle biopsy consist of abundant stromal cells, which appear as bare bipolar nuclei, throughout the aspirate; sheets of fairly uniform-size epithelial cells that are typically arranged in either an antler-like pattern or a honeycomb pattern. These epithelial sheets tend to show typical metachromatic blue on Diff-Quik staining. Foam cells and apocrine cells may also be seen, although these are less diagnostic features. The gallery images below demonstrate these features..

Macroscopic

Approximately 90% of fibroadenomas are less than 3 cm in diameter. However, these tumors have the potential to grow reaching a remarkable size, particularly in young individuals. The tumor is round or ovoid, elastic, and nodular, and has a smooth surface. The cut surface usually appears homogenous and firm, and is grey-white or tan in colour. The pericanalicular type (hard) has a whorly appearance with a complete capsule, while the intracanalicular type (soft) has an incomplete capsule.

Fibroadenoma of the breast is a benign tumor composed of a biphasic proliferation of both stromal and epithelial components that can be arranged in two growth patterns: pericanalicular (stromal proliferation around epithelial structures) and intracanalicular (stromal proliferation compressing the epithelial structures into clefts).

These tumors characteristically display hypovascular stroma compared to malignant neoplasms. Furthermore, the epithelial proliferation appears in a single terminal ductal unit and describes duct-like spaces surrounded by a fibroblastic stroma. The basement membrane is intact.

Treatment

Fibroadenomas can be expected to shrink naturally and so, most are simply monitored. Monitoring fibroadenomas involves regular check-ups to make sure that the breast mass is not growing and is not potentially cancerous. Check-ups involve physical examinations performed every 3–6 months and optional diagnostic imaging performed every 6–12 months for 1–2 years. Generally, surgery is only recommended if the fibroadenoma gets larger or causes increased symptoms. They are removed with a small margin of normal breast tissue if the preoperative clinical investigations are suggestive of the necessity of this procedure. A small amount of normal tissue must be removed in case the lesion turns out to be a phyllodes tumour on microscopic examination.

Some fibroadenomas respond to treatment with ormeloxifene.

Fibroadenomas have not been shown to recur following complete excision or transform into phyllodes tumours following partial or incomplete excision.

Non-invasive Surgical Interventions

There are several non-invasive options for the treatment of fibroadenomas, including percutaneous radiofrequency ablation (RFA), cryoablation, and percutaneous microwave ablation. With the use of advanced medical imaging, these procedures do not require invasive surgery and have the potential for enhanced cosmetic results compared with conventional surgery.

Cryoablation

The FDA approved cryoablation of a fibroadenoma as a safe, effective, and minimally-invasive alternative to open surgical removal in 2001. During cryoablation, ultrasound imaging is used to guide a probe into the mass of breast tissue. Extremely cold temperatures are then used to destroy the abnormal cells, and over time the cells are reabsorbed into the body. The procedure can be performed as an outpatient surgery using local anesthesia, and leaves substantially less scarring than open surgical procedures and no breast tissue deformation.

The American Society of Breast Surgeons recommends the following criteria to establish a patient as a candidate for cryoablation of a fibroadenoma:

1.       The lesion must be sonographically visible.

2.       The diagnosis of a fibroadenoma must be confirmed histologically.

3.       The lesion should be less than 4 cm in diameter.

High Intensity Focused Ultrasound

Epidemiology

Of all breast tissue samples taken, fibroadenomas comprise about 50%, and this rate rises to 75% for tissue sample in women under the age of 20 years. Fibroadenomas are more frequent among women in higher socioeconomic classes and darker-skinned people. Body mass index and the number of full-term pregnancies were found to have a negative correlation with the risk of fibroadenomas. There are no known genetic factors that influence the rate of fibroadenomas. The rate of occurrence of fibroadenomas in women have been reported in literature to range from 7% to 13%.

A fibroadenoma is a very common benign (not cancer) breast condition. The most common symptom is a lump in the breast which usually moves when you touch it.

Fibroadenomas often develop during puberty so are mostly found in young women, but they can occur in women of any age. Men can also get fibroadenomas, but this is very rare.   

Symptoms of fibroadenoma

A fibroadenoma is usually felt as a lump in the breast which has a rubbery texture, is smooth to the touch and moves easily under the skin.

Fibroadenomas are usually painless, but sometimes they may feel tender or even painful, particularly just before a period.

Types of fibroadenoma

1.     Simple fibroadenoma

Most fibroadenomas are about 1–3cm in size and are called simple fibroadenomas. When looked at under a microscope, simple fibroadenomas will look the same all over. Simple fibroadenomas don’t increase the risk of developing breast cancer in the future.

2.     Complex fibroadenoma

Some fibroadenomas are called complex fibroadenomas. When these are looked at under a microscope, some of the cells have different features.

Having a complex fibroadenoma can very slightly increase the risk of developing breast cancer in the future.

3.     Giant or juvenile fibroadenoma

Occasionally, a fibroadenoma can grow to more than 5cm and may be called a giant fibroadenoma. Those found in teenage girls may be called juvenile fibroadenomas.

Causes

It’s not known what causes a fibroadenoma. It’s thought that it probably occurs because of increased sensitivity to the hormone oestrogen.

Breasts are made up of lobules (milk-producing glands) and ducts (tubes that carry milk to the nipple). These are surrounded by glandular, fibrous and fatty tissue.

Fibroadenomas develop from a lobule. The glandular tissue and ducts grow over the lobule and form a solid lump.

Diagnosis

If you find a breast lump, see your GP (local doctor). They’re likely to refer you to a breast clinic where you’ll be seen by specialist doctors or nurses.

At the breast clinic you’ll have various investigations, known as ‘triple assessment’, to help make a definite diagnosis. This assessment consists of:

•        a breast examination

•        ultrasound scan (uses high frequency sound waves to produce an image) and/or a mammogram (breast x-ray)

•        a core biopsy and/or a fine needle aspiration (FNA).

Fibroadenomas are often easier to identify in younger women. If you’re in your early 20s or younger, your fibroadenoma may be diagnosed with a breast examination and ultrasound only. However, if there’s any uncertainty about the diagnosis, a core biopsy or FNA will be done.

If you’re under 40, you’re more likely to have an ultrasound than a mammogram. Younger women’s breast tissue can be dense which can make the x-ray image less clear so normal changes or benign breast conditions can be harder to identify. However, for some women under 40, mammograms may still be needed to complete the assessment.

Surgery

Sometimes an operation called an excision biopsy is needed to remove a fibroadenoma if it’s a large, complex or juvenile fibroadenoma. You can also ask to have a fibroadenoma removed.

This may be done using a local or general anaesthetic.

Your surgeon may use dissolvable stitches placed under the skin which won’t need to be removed. However, if a non-dissolvable type is used, they will need to be taken out a few days after surgery. You’ll be given information about this and about looking after the wound before you leave the hospital.

Vacuum assisted excision biopsy

You may be offered a vacuum assisted excision biopsy to remove the fibroadenoma. This is a way of removing small fibroadenomas under local anaesthetic, without having surgery.

After an injection of local anaesthetic, a small cut is made in the skin. A hollow probe connected to a vacuum device is placed through this. Using an ultrasound or mammogram as a guide, the fibroadenoma is sucked through the probe by the vacuum into a collecting chamber. The biopsy device is used in this way until all of the fibroadenoma has been removed. This may mean that an operation under a general anaesthetic can be avoided. The tissue removed is sent to a laboratory and examined under a microscope. This procedure can cause some bruising and pain for a few days afterwards.

REVIEW OF NASYA KARMA

Introduction:

            Nasa has been considered as the gateway of Shirah and to uproot the deep seated morbid doshas Nasya therapy has been recommended by almost all the Acharyas^1,2. Urdhvajatrugata Rogas and their management have a special place in Ayurveda. Shirah being the prime seat of knowledge and also the prime controller of the entire body has been termed as Uttamanga. Hence, the diseases occurring in the Urdhvajatru have been very clearly highlighted in the Ayurvedic classics along with their management. Nasa is considered to be that Indriya, whose functions are not only limited to respiration but is also considered as a pathway for drug administration. In Ayurveda, special procedure called Nasya has been mentioned.

            Hence, in the present study Mukhadooshika, which is one of the Urdhvajatrugata Roga has been selected and for its management Nasya Karma with Apamarga Taila in the form of Shodhana Nasya has been planned.

Description of Nasa

Historical background of Nasa:

Atharvaveda

            In Atharvaveda the description of nine chidras & indriya has been mentioned & description of Netra, Nasa & Dantakrimi with its Mantras3^,4.

Bhagwata Gita

            In Bhagwata Gita the description of Indriya has been mentioned5.

Ayurvedic Review

Etymology:

                        The word ‘NASA’ is derived from the root ‘Nasru’. With addition of suitable suffix, the word Nasa is formed.

Definition & Synonyms:

                        Nasa is described as the seat of Ghranendriya i.e. sense of smell6.

            Amarkosha mentioned the synonyms of Nasa as Nasika, Ghranam, Gandhavaha, Ghrana.

Embryology:

            Acharya Charaka while explaining the embryology of organs in a pregnant woman states that Sarva Indriyas are developed during the third month of Garbhavastha7.                  In Garbhopnishada it is mentioned that Mukha (oral cavity), Nasa (nose), Akshi (eyes) and Shrotra (ears) are developed in sixth month of pregnancy8.

Anatomy:

            In Ayurvedic literature, there is no detailed description of Nasa Sharira at one place like the anatomical description of other organs, whereas Nasa is included among the five Gyanendriya.

            Acharya Sushruta has considered Nasa as Pratyanga. Similarly while enumerating the external orifices of the body; he has also considered two nostrils among the main nine external orifices.

Nasa is comprised of,

ü  Bones - 3

ü  Peshi - 2

ü  Dhamani - 2

ü  Siras - 24

ü  Marmas – 2

            Acharya Sushruta has mentioned the length of Nasika as 2-1/3 Angulas9. Acharya Dalhana the commentator of Sushruta Samhita clarifying about the length of each nostril as Tribhag Angulas i.e. 1-1/3 (inches). Angulas in length as far as horizontal plain is concerned1⁰.

            Acharya Sushruta told that 2 Dhamanis are present in the nose, which is responsible for Gandhajnana. This may be the Olfactory nerve pair, which is the sensory Cranial nerve responsible for Olfaction1¹.

            Sushruta, while explaining the 24 Siras classified them into four groups of six each as Vatavaha, Pittavaha, Kaphavaha and Raktavaha1².

            Acharya Charaka has given only short description of Nasa Sharira. He has mentioned only one nasal bone. Further he has also described Nasa as a sense organ13.

Indriya Panch Panchkam 14

ü  Indriya: Ghranendriya

ü  Indriya Dravya: Prithvi

ü  Indriya Adhisthana : Nasa

ü  Indriya Artha: Gandha

ü  Indriya Buddhi: Ghrana Buddhi

ü  Marmas: Acharya Vagbhata has stated that the two Marmas are situated in Nasika15.

ü  Phana: These are the Marmas which perform the olfactory function.

ü  Shringataka: These are Sadhyapranahara Marmas associated with Nasa, which also used to explain various diseases like Kshavathu, Brishakshava etc.

ü  Matruka: These are Sira Marmas associated with Nasa.

NASYA KARMA

Historical background of Nasya:

Rigveda

            Although it is very difficult to say that the procedure of Nasya karma therapy was in practice during Vedic period. But the few Mantras of Rigaveda indirectly refer towards the Karmas which are included under Panchakarma measures. There is a Mantra of Rigveda, in which eradication of Roga from the routes of Nasa (Nostrils), Chibuka (Chin), Shira (Head), Karna (ear) & Rasana (tongue) are mentioned. Thus one can think that the references of eradication of disease from the above mentioned routes most probably refer towards Nasa (nose) or Shirovirechana.

Ramayana

            A reference regarding the use of “Sanjivani” for Nasya karma is available in Valmiki Ramayana when Lakshmana became Unconscious drug was blown by Meghnada to make him conscious.

Ayurvedic Classics

            The subject of Nasya therapy has been elaborately described in Charaka and Sushruta Samhitas. During 6th century A. D. Vagbhatta, Vriddha Vagbhatta wrote Ashtanga Hridaya and Ashtanga Samgraha respectively and has elaborately dealt with the subject in their works. Chakrapani (11th Century A. D.) and Yogaratnakar have also contributed to the subject. Nasya karma has been used for Pumsavan Vidhi since Aacharya Charaka16.

Etymology of Nasya:

            The word nasya is derived from ‘Nasa’ Dhatu which conveys the sense of Gatimotion and Vyapti means pervasion. In Ayurvedic texts; the Nasa Dhatu is inferred in the sense of nose.

            According to Vachaspatyam, the word “Nastah” means being in the nose or the things beneficial to the nose¹⁷.

Definition of nasya:

            In Ayurveda, the word Nasya has been taken specifically to mention the root of administration of the drugs.

Sushruta Samhita18

            As stated by Sushruta medicines or medicated oil administered through the nose is known as Nasya.

Aruna Dutta & Bhava Prakash19

            According to them all drugs & measures that are, administered through the nasal passage are called Nasya. Sharangdhara & Vaghbhata20 are of same view.

Synonyms:                             

            Sirovirechana, Shirovireka, Murdhavirechana, Nstahkarma, Navana are the synonyms of Nasya Karma.

Shirovirechana, Shirovireka, Murdhavirechana:

            Sushruta specify the word Shirovirechana to describe a particular variety of Nasya karma21. The word Virechana means elimination of morbid Doshas from the body. This Shirovirechana or Murdhavirechana indicates its main function elimination of morbid Doshas particularly from the Shira or parts situated above the clavicle.

            Charaka has used the term “Nastah Pracchardana” for Nasya22, which denotes Shodhana done by Nasya23.

Nastah & Navana:

            The word Nastah & Navana denotes the site of administration. Nasta – Karma & Navana karma means the measures which are beneficial to nose, or region of the nose. On this basis it could be said that Nasya karma is a therapeutic measure where the drug (medicated oil or other) administered through Nasa mainly to eliminate the vitiated doshas situated in Shirah & its constituent parts, curing the diseases of those parts (Urdhvajatrugata Vikaras).

Classification of Nasya:

Table No. 1 Classification of Nasya

                        Nasya is classified in various ways by different Acharyas but ultimately all the procedures are same. Mainly classified according to its mode of action i.e. Shodhana, Shamana, etc & on the basis of various forms of drug preparation utilized for the Nasya karma e.g. Churna, Sneha, etc. The classifications according to various Acharyas are shown in table.

No.	Name of Acharya	No. of Types	Classification
1	Charaka24,25	3 5 7	According to mode of action -  Rechana, Tarpana, Shamana According to the method of administration – Navana, Avapidana, Dhmapana, Dhuma, Pratimarsha According to various parts of drugs utilized – Phala, Patra, Mula, Kanda, Pushpa, Niryasa, Twaka
2	Sushruta26	5	Shirovirechana, Pradhamana, Avapida, Nasya, Pratimarsha
3	Vagbhatta27	3	Virechana, Brimhana, Shamana
4	Kashyapa28	2	Brimhana, Karshana
5	Sharangadhara29	2	Rechana, Snehana
6	Bhoja30	2	Prayogika, Snaihika
7	Videha31	2	Sangya Prabodhaka, Stambhana,

            It is clear from the above discription that two types of classification of Nasya Karma are available in Ayurvedic literature. One is based on the pharmacological actions viz. Rechana, Tarpana etc. Other is based on the preparation of drug and the method of its application e.g.  Dhmapana (Powder is blowed) Avapida (Extracted Juice is used) Dhuma (Smoking through nose).

            It is clear from the above description that the types of classification of Nasya Karma are available in Ayurvedic literature. One is based on the pharmacological actions viz. Rechana, Tarpana etc. and the other is based on the preparation of drug and the method of its application e.g. Dhmapana (Powder is blowed), Avapida (Extracted Juice is used) and Dhuma (smoking through nose) etc. Also Classification according to the dose to be dropped into the nostrils e.g. marsha and pratimarsha described by Acharya Vagbhata.

            Taking the Charaka’s classification as the basis, all the above mentioned types of Nasya are being described here seperately.

1. Navana Nasya

            Navana is one of the important and well applicable therapies of Nasya Karma.

Method:

            Navana is administered by instilling the drops of a medicated oil or Ghrita in the nose.

Instrument:

            Charaka has described Pranadi (pippet or dropper) for it41. Navana is generally the Sneha Nasya and is known as Nasya in general42.

Classification:

            It can be mainly classified into Snehana and Shodhana Nasya.

1. a. Snehana Nasya

            As the word Sneha suggests, Snehana Nasya gives strength to all the Dhatus and is used as Dhatuposhaka.

Dose:

            The following is the dosage schedule for Sneha Nasya43.

Table No. 2 Dose of Sneha Nasya

1	Hina matra	8 drops in each nostril
2	Madhyama matra	16 drops in each nostril (Shukti Pramana)
3	Uttama matra	32 drops in each nostril (Panishukti Pramana)

Bhoja has mentioned: -

8 drops              Prayogika Sneha Nasya

16 drops            Sneihika Nasya.

According to Doshabala qauntity can be adjusted doubled or tripled.

Benefits of Sneha Nasya44:

            It is used for the oiling in the feeling of head lightness. It gives strength to neck, shoulder and chest and increases eye sight.

Indications of Sneha Nasya45:

            Sneha Nasya can be given in the following conditions:-

Vatika Shirahshula,     Keshapata,                  Dantapata,       Shmashrupata,

Tivrakarnashula,          Timira,                         Nasaroga,        Mukhashosha,

Avabahuka,                 Akalaja Valita,            Akalaja Palita,

Darunaprabodha  and             Vatapittaja Mukharoga.

1. b. Shodhana Nasya

            Sushruta’s Shirovirechana type is included in Shodhana type of Navana Nasya. It eliminates the vitiated Doshas.

Drugs:

            In this type of Nasya, oil prepared by Shirovirechana Dravya like Pippali, Vidanga, Shigru etc. is selected46.

Dose:

Table No. 3. Dosage schedule according to Sushruta47

1	Uttama	8 drops
2	Madhyama	6 drops
3	Hina	4 drops

Indications:

            It can be used in the following conditions:

            Kaphapurna Talu & Shira, Aruchi, Shirogaurava, Shula, Pinasa, Ardhavabhedaka, Krimi, Pratishyaya, Apasmara, Gandhagyananasha and Urdhvajatrugata Kapharogas48; and Urdhvajatrugata Shopha, Praseka, Arbuda and Kotha⁴⁹.

  In healthy persons Navana Nasya should be given according to the following seasonal schedule50.

Table No. 4 Indications of Nasya according to Season

Sl.No	Season	Nasya to be given at
1	Shita Kala	Noon
2	Sharada and Vasanta	Morning
3	Grishma Rutu	Evening
4	Varsha Rutu	Only when sun is visible

Time Schedule:

Table No.5. Navana Nasya Schedule51

Sl.No	Roga	Nasya to be given at
1	In Kaphaja Roga	Fore noon
2	In Pittaja Roga	Noon
3	In Vataja Roga	After Noon

2. Avapida Nasya

Definition:

            In Avapida Nasya, juice is expressed from paste or kalka of a drug. The word Avapida means it is expressed juice of leaves or paste (kalka) of required medicine52.

Method:

            The paste (kalka) of required medicine is placed in a white and clean cloth and thereafter it is squeezed to obtain the required quantity of juice, directly in the nostrils of the patients. The administration of the drug in this way is known as Avapida nasya53. This type of nasya may also be given with kalka (paste) etc.54

            It may also be given by dipping the swab (pichu) into the Kwatha (decoction) or Sheeta (cold infusion) or Swarasa (juice) of the required drug55. Though Acharya Sushruta has categorized this under Shirovirechana, Avapida has also been used for Stambhana purpose in treatment of Raktapitta where Sharkara and Ikshu rasa are utilized for the same56.

Charaka has described two types of Avapida Nasya57.

1.      Stambhana Nasya: For this type ikshu rasa, milk etc. are used.

2.      Shodhana Nasya: For this type Saindhava, Pippali etc. are used.

According to Chakrapani, Avapida nasya is of three types:

1.      Shodhana

2.      Stambhana

3.      Shamana

Videha has mentioned two types of Avapida Nasya.

1.      Sangya prabodhana: It is one type of shodhana nasya.

2.      Stambhana: It is one type of shamana nasya.

Table No.6. Dose of Shirovirechana, Avapida Nasya58

1	Hina Matra	4 drops
2	Madhyama Matra	6 drops
3	Uttama Matra	8 drops

Indications:

Table No.7. Indications of Avapida Nasya59

Manasaroga	Apasmara	Shirovedana
Apatantraka	Moha	Mada
Murchha	Sanyasa	Bhaya
Krodha	Bhiru	Sukumara
Krisharogi	Stri	Raktapitta
Vishabhighata	Chitta	Vyakulavastha

            Sharangdhara recommends the Avapida Nasya for the patients suffering from Galaroga, Vishamajwara Manovikara and Krimi60.

3. Dhmapana Nasya

            It is a specific Shodhana Nasya.

Synonym:

            Pradhmana Nasya

Definition:

            This type of nasya is instilled with Churna specifically for Shirovirechana. This nasya is mentioned as Dhmapana in Charaka Sam. and as Pradhamana in Sushruta Sam.

Instrument:

            In this type, fine powder of drug is administered through nasal passage. For this purpose specific Nadi yantra, a tube like instrument with length of 6 angulas and with open ends is utilized61.

Method:

            Fine powder of required drug is kept at one end and air is blown from the other end, so that the medicine gets puffed into the nostrils. Videha has advocated a different procedure in this context according to him, fine powder is kept in a pottali of thin cloth and then patient is asked to inhale deeply, so that the subtle particles of medicine enter into nostrils.

Dose:

            According to Videha62

ü  Three Muchuti (3 pinches) for method with Shadangula nadi.

ü  Two tolas i.e. 20 gms for pottali method.

ü  Drugs specifically mentioned for Pradhmana nasya.

ü  Rock salt, garlic, guggulu, maricha, vidanga etc.

ü  Here we observe that the drugs used in Pradhmana nasya are Tikshna (irritative) and it would be safe to remain cautious while executing this Nasya.

Indications:

            According to Sushruta63,

1.      Chetovikara

2.      Krimija shiroroga

3.      Vishabhipanna

4. Dhuma Nasya

            Inhalation of medicated Dhuma by nasal route and elimination of dosha by oral route is called Dhuma Nasya. Acharya Sushruta has remained aloof from description of this Nasya. According to Chakrapani, fume taken by mouth is known as Dhumapana and is not included in Nasya64.

Types and Instrument:

            Acharya Charaka has mentioned special Dhuma Nadi for Dhuma Nasya. The length of the Nadi depends upon the type of the Dhuma Nasya, details of which are as under65

Table No.8 Showing The Length of Dhuma Yantra Nadi

Sl.No	Type of Dhuma Nasya	Length of Nadi
1	Prayogika	36 angula
2	Vairechanika	24 angula
3	Snaihika	32 angula

                                               

            Breadth of the nadi should be as per measurement of one’s own angula.

Dose66:

ü  Two puffs are to be taken for Prayogika Dhuma.

ü  3 to 4 puffs are to be taken for Vairechanika Dhuma.

ü  A single puff is advised for snaihika Dhuma.

Table No.9. Drugs Used for Dhuma Nasya67

1	Prayogika Dhuma	Priyangu, Ushira, etc.
2	Vairechanika Dhuma	Aparajita, Apamarga etc
3	Snaihika Dhuma	Vasa, Ghrita etc

Indication of Dhuma Nasya:

            It is indicated for treatment of Shiroroga, Nasaroga and Akshiroga68.

5. Marsha – Pratimarsha Nasya

            The methods shared by both these types are common but the variation occurs in context of dose. In Pratimarsha Nasya 1 – 2 drops are administered while in Marsha the dose is of 6 to 10 drops.

5.a.Pratimarsha Nasya:

            Following method is employed for Pratimarsha Nasya. A finger is dipped in the appropriate sneha up to 2 phalanges and then oil is allowed to drop from it in both nostrils. Patient is advised to expel out the sneha, which comes in oral cavity.

Dose:

            2 drops, morning as well as in evening hours69. The sneha should be in such an amount that it reaches from nose to gullet but should not be enough to produce secretions in gullet.

Indications70:

            Pratimarsha can be given in

ü  Any age          

ü  Any season

ü  Even in not suitable time and season i.e. in Varsha and Durdina

ü  Bala                             - Vriddha

ü  Bhiru                           - Sukumara

ü  Weak patients                         - Kshtakshama

ü  Trishna Pidita              - Mukhashosha

ü  Valita and Palita 

Contraindications71:

            It is contraindicated in

ü  Dushta Pratishyaya     - Krimija Shiroroga

ü  Badhirya (deafness)    - Bahudosha

ü  Madhyapi (drunkers –habitual)

ü  Utklishta Doshas.

            It is contraindicated in such persons because the Sneha Matra is quite insufficient to eliminate Doshas or Kriminasha and already aggravated Doshas may get vitiated further. Sushruta and Sharangadhara have described 14 suitable times for Pratimarsha Nasya, while Vagbhatta has mentioned fifteen Kala.

Table No.10. Various Timings for Pratimarsha Nasya72

No	Time for Pratimarsha Nasya	Su.	As. H.	Sha.
1	After leaving the bed in morning	+	+	+
2	After cleaning the teeth (with Dantadhavana)	+	+	+
3	Before going outside	+	-	+
4	After exercise	+	+	+
5	After sexual intercourse	+	+	+
6	After walking	+	+	+
7	After urination	+	+	+
8	After passing Apanavayu	+	-	-
9	After Kavala	+	+	+
10	After Anjana	+	+	+
11	After meal	+	+	+
12	After sneezing	+	-	-
13	After sleeping in the noon	+	+	+
14	In the evening	+	+	+
15	After vomiting	-	+	+
16	After Shirobhyanga	-	+	-
17	After defaecation	-	+	+
18	After laughing	-	+	-

                                   

            Pratimarsha in Nasya is a very innocent procedure; it never produces any complication and by its virtue checks any disease process.

5.b Marsha Nasya

            The method of administration of Marsha Nasya resembles that of Pratimarsha but as said earlier the dose varies.

Dose:

            In Marsha Nasya, 6 to 10 drops of Sneha are administered.

Drugs:

            Though all Sneha dravya like oil, ghee, etc. can be utilized but use of oil is advisable because Shira is the place of Kapha and oil is inherently opposite to Kapha in properties.

            Marsha Nasya is quickly effective and more beneficial than its counterpart i.e. pratimarsha73.                                          

Classification Of Nasya According To Karma:

            This type of classification is given in Charaka Samhita as well as Ashtanga Hridaya74.

Rechana

Brimhana

Shamana

Sangyaprabodhana (Shodhana)

Krimighna

Stambhana

Karshana

Raktastambhana

Doshastambhana

Chart No.7 Classification According to Karma (Pharmacological Action)

      

            The types Rechana, Tarpana and Shamana are described by Acharya Charaka and Vagbhatta. Sushruta has not described the Shamana Nasya. He has given only two types viz. Shirovirechana and Snehana.

            Kashyapa has mentioned Brimhana and Karshana types of Nasya karma i.e. Sangya Prabodhana and Stambhana, according to their pharmacological action.

            All these types can be included into the classification of Charaka, as in previous pages. Details of each type of Nasya according to the Karma, is as under.

Rechana Nasya:

            The Nasya, which eliminates vitiated Doshas of Shira through the nasal route, is also called Rechana Nasya. It is also termed as Karshana Nasya.

Drugs75:

            Apamarga, Pippali, Maricha etc. are drugs of choice that can be used for Rechana Nasya. Kwatha, Swarasa or Tikshna sneha of above drugs may also be utilized for the same.

Indications:

            Stambha, Supti, Gaurava, Shiroroga etc76.

            According to Sushruta and Vagbhatta, it is used in Shleshma abhivypta like Talukantaka, Shirokrimi, Arochaka, Pinasa, Pratishyaya, Urdhvajatrugata Shopha, Praseka, Vairasya, Arbuda, Dadru and Kotha77.

Shirovirechana Nasya may be given with Kalka, Churna and Svarasa also, but if the immediate effects are required, Churna should be used78. If Rechana Nasya is to be given in patients of weak will power then Sneha preparation of Rechana dravya is applied.

Tarpana Nasya:

            Tarpana is that type of Nasya, which is specially indicated in a Dhatukshaya (degeneration). Tarpana Nasya resembles Snehana Nasya described by Sushruta and Sharangadhara and Brimhana Nasya mentioned by Acharya Vagbhatta in its properties and actions.

Drugs:

            Drugs of Madhura skandha and Sneha prepared with Vata-Pittahara drugs are used for above type79. Exudation of certain trees, meat soups and blood may also be administered80.

Indications:

            Vatika Shiroroga, Dantapata, Keshapata, Darunaka and other Vata-Pittaja roga. Sushruta advises Sneha Nasya for increasing general strength and to improve the vision power and its acquity. It is also used for curing the Shirah kampa and Ardita81.

Shamana Nasya:

            It is described by Charaka as well as Vagbhatta and Pratimarsha and Stambhana Nasya can be co-related with it.

Definition:

            The type of Nasya which is used for alleviation of Dosha of Shira is called Shamana Nasya.

Drugs:

            Usually drugs beneficial for particular diseases are chosen for this type and the carrier is a Sneha dravya.

Indication:

ü  It is indicated to check the bleeding occurring in the course of Raktapitta82.

ü  It is also indicated in Vali, Palita, Khalitya, Darunaka, Raktaraji, Vyanga and Nilika.

ü  It can also be used to improve the power of eyes, ears and nose.

Indications of Nasya83:

            Nasya therapy may be given in all diseases except in the conditions mentioned earlier. The specific indications of Tarpana Nasya, Shodhana Nasya, Shamana Nasya, Shirovirechana, Navana, Avapida, Dhmapana and Dhuma Nasya etc. have already been discussed in the classification of Nasya, but Charaka has described the following general indications, where Nasya therapy should be used.

ü  Shirostambha                          Gadgadatva

ü  Ardhavabhedaka                     Vaggraha

ü  Shirahshula                              Grivaroga

ü  Akshishula                              Swarabheda

ü  Shukra Roga-Netragata          Galashundika

ü  Raji                                          Galashaluka

ü  Timira                                      Galaganda

ü  Vartmaroga                             Upajihvika

ü  Pinasa                                      Manyastambha

ü  Nasa Shula                              Ardita

ü  Danta Stambha                       Apatantraka

ü  Danta Shula                            Apatanaka

ü  Danta Harsha                          Karnashula

ü  Danta Chala                            Arbuda

ü  Hanugraha                               Skandharoga              

ü  Mukharoga                              Ansashula

            According to Ashtanga Samgraha if the Nasya is to be given as a part of performing the complete Panchakarma then, it should be given after Basti karma.

Contraindication of Nasya:

            In our classics - Brihattrayi some special conditions have been mentioned where Nasya should not be administered, otherwise various complications may occur. In general, in all patients Nasya should not be administered on Durdina (Rainy day) or in Anrutu (Viparita Kala).

Table No.11. Contra Indications Of Nasya Mentioned In Brihattrayi:

Sr.	Anasyarha	Charaka	Sushruta	Vagbhatta
1	Bhuktabhakta	+	+	+
2	Ajirni	+	+	-
3	Pitta Sneha	+	+	+
4	Pitta Mad	+	+	+
5	Pitta Toya	+	+	+
6	Snehadi Patukamah	+	-	+
7	Snatah Shirah	+	-	+
8	Snatukamah	+	+	+
9	Kshudharta	+	-	+
10	Shramarta	+	+	-
11	Matta	+	-	-
12	Murcchita	+	-	-
13	Shastradandahrita	+	-	-
14	Vyavayaklanta	+	-	-
15	Vyayamaklanta	+	+(Shranta)	-
16	Panaklanta	+	-	-
17	Navajwara Pidita	+	-	-
18	Shokabhitapta	+	-	-
19	Virikta	+	-	+(Shuddha)
20	Anuvasita	+	+(Datta Basti)	+(Datta Basti)
21	Garbhini	+	+	+
22	Navapratishyayarta	+	-	-
23	Apatarpita	-	+	+(Shuddha)
24	Pittadravah	-	+	+
25	Trishnarta	+	+	-
26	Gararta	-	+	+
27	Kruddha	-	+	-
28	Bala	-	+	-
29	Vriddha	-	+	-
30	Vegavarodhitah	-	+	+ (Vegarta)
31	Raktasravita	-	-	+
32	Sutika	-	-	+
33	Shvasapidita	-	-	+
34	Kasapidita	-	-	+

Suitable time for giving Nasya:

            According to Charaka generally Nasya should be given in Pravrita, Sharada and Vasant Rutu. However in emergency it can be given in any season by providing artificial conditions of the above mentioned seasons, for example in summer, Nasya can be given in cold places and in cold season, it can be given in hot places.

Table No.12. Time Schedule of Nasya in Different Seasons84

SL.No	Rutu	Nasya to be given at
1	Grishma Rutu	Morning
2	Shita Rutu	Noon
3	Varsha Rutu	When day is clear
4	Sharada + Vasanta	Morning
5	Shishira + Hemanta	Noon
6	Grishma + Varsha	Evening

            According to Sushruta in normal condition Nasya should be given on empty stomach.

Table No.12. Time Schedule of in Doshaja Vikaras85

SL.No	Doshaja Vikara	Nasya to be given at
1	Kaphaja Vikara	Morning
2	Pittaja Vikara	Noon
3	Vataja Vikara	Evening

                                   

            Vagbhatta has prescribed same timings as Sushruta has mentioned. According to Doshaja Vikara he has suggested some more important points.

            Sharangadhara has described same time schedule for different seasons as Sushruta has mentioned. He further states that – Nasya can be given in night, if the patient is suffering from Lalasrava, Supti, Pralapa, Putimukha, Ardita, Karnanadi, Trishna, Shiroroga and such conditions like excessive vitiated Doshas.

Course of Nasya Karma:

Vagbhata

            Nasya Karma may be given for seven consecutive days. In conditions like Vata Dosha in head, hiccough, loss of voice, Manyasthamba, Apatanaka etc. it may be done twice a day (in morning and evening)86.

            Nasya should be given for 3 days, 5 days, 7 days and 8 days or till the patient shows the symptoms of Samyaka Nasya as stated in Ashtanga Samgraha87.

Bhoja

            Bhoja says that if Nasya is given continuously beyond nine days then it becomes Satmya to patients and if given further, it neither benefits nor harms the patients.

Sushruta

            According to Sushruta, Nasya may be given repeatedly at the interval of 1, 2, 7 or 21 days depending upon the condition of the patient and the disease him suffer88.

Charaka

            Charaka has not mentioned specific duration of the Nasya therapy, but instead suggested to give it according to the severity of disease.

Table No. 14. Course of Nasya Karma

No.	Name of Acharaya	Days
1	Sushruta	1,2,7,21
2	Bhoja	9
3	Vagbhatta	3,5,7,8

Dose of Nasya:

            The dose of Nasya drug depends upon the drug utilized for it and the variety of the therapy. Charaka has not prescribed the dose of the Nasya. Sushruta and Vagbhatta have mentioned the dose in form of Bindu (drops), here one Bindu means the drop which smears after dipping the two phalanges of Pradeshini (index) finger in oil89.

Table. No.15. Showing the Dosage of Nasya Karma

		Drops in Each Nostril
No.	Type of Nasya	Hrasva Matra	Madhyam Matra	Uttam Matra
1	Shamana Nasya	8	16	32
2	Shodhana Nasya	4	6	8
3	Marsha Nasya	6	8	10
4	Avapida Nasya	4	6	8
5.	Pratimarsha Nasya	2	2	2

Dose According to Videha:

            The common dose for Pradhamana Nasya is 3 Muchuti (here one Muchuti = the quantity of Churna which may come in between index finger and thumb = 2.4 Ratti.)

Dose According to Sharangadhara90:

            Sharangadhara has described the following dosage schedule for Nasya Karma depending upon the variety of material used.

ü  Tikshnaushadhi Churna - 1 Shana (4 Masha)/(24 Ratti)

ü  Hingu – 1 Yava (½ Ratti)

ü  Saindhava – 1 Masha (6 Ratti)

ü  Dugdha – 8 Shana (64 Drops)

ü  Jala (Aushadha Siddha) – 3 Karsha (3 Tola)

ü  Madhura Dravya – 1 Karsha (1 Tola)

            If the Nasya is given in less quantity than the prescribed dose then it does not eliminate the Doshas completely and cause heaviness, loss of appetite, cough, salivation, coryza, vomiting and disorders of the throat etc. If the Snehana Nasya is administered in the excessive dose it may produce the symptoms of Atiyoga

Nasyavidhi:

The procedure of Nasya karma may be classified under following headings:

ü  Purva Karma (Pre-measures)

ü  Pradhana Karma (Chief measure)

ü  Pashchata Karma (Post-measures)

Purva Karma (Pre-measure):

            It is advisable that all materials, drugs and equipments like napkin, utensils necessary for Nasya karma are collected in sufficient quantity prior to Nasya karma.

            Patient should be prepared for Nasya karma. It can be described in detail as under. Special room for Nasya should be prepared which should be free from atmospheric effects like direct blow of air or dust and it should be lighted properly91.

Nasya Asana:

            It should be placed in Nasya room. It consists of -

ü  A chair for sitting purpose

ü  A cot for lying purpose

Nasya Aushadhi:

            Drug required for Nasya karma in the form of Kalka, Churna, Kwatha, Kshira, Udaka, Sneha, Asava etc. should be collected in sufficient quantity.

            Drug for counter acting any complications during or after the nasya should also be kept ready.

Table No. 16. Nasya Yantra : It should be collected according to the types of Nasya

A dropper or Pichu	For Snehana, Avapida, Marsha and Pratimarsha Nasya.
Shadangula Nadi	For Pradhmana Nasya
Dhuma Yantra	For Dhuma Nasya

            Besides it is also necessary that a stove, bowl, napkins, spitting pits and an efficient assistant are kept handy.

Selection of the Patient:

            The patient should be selected according to the indications and contra-indications of Nasya described in classics.

Preparation of the Patient:

            The following things should be looked carefully to prepare the patient for Nasya Karma.

ü  Patient should have passed his natural urges like urine & stool.

ü  Should have completed his routine activities like tooth brushing, bath, etc.

ü  Mridu Abhyanga (massage) should be done on scalp, forehead, face and neck for 3 to 5 minutes by medicated oil92.

ü  Nadi sweda or tapa sweda can be done93.

ü  Eyes should be bandaged with a clean gauze piece after placing lotus petals and cotton pads over the closed eyelids for protect the eyes from swedana.

ü  Patient is made to lie in supine position with slightly elevated legs and head extended backwards94.

Pradhana Karma (Chief measure):

            The procedure to be adopted for the Nasya karma is described here as per the statements of Charaka, Vagbhata and susrutha.

Posture of the Patient:

ü  The medicine should mildly warmed over a water bath (Ushnambu taptha)

ü  After covering the eyes with clean cotton cloth95, the physician should raise the tip of the patient’s nose with his left thumb and with the right hand the luke warm medicine (Sukhoshna drug) should be poured by a Pranadi (gokarna) in both the nostrils alternately in a continuous single stream.

ü  Immediately after installation of medicine mild massage is done over pani, pada, greeva and skanda96.

ü  The patient should asked to inhale the medicine in moderate force and to split it out through the mouth turning the head to either side alternatively without rising from the cot97.

Pashchata Karma (Post-measure):

            The following regimen should be followed after administration of Nasya.

ü  The patient is made to lie in the same position for 100 mathra kalas (3-5 minutes)98.

ü  Medicated Dhumapana and Gandusha are advocated to expel out the residue mucus lodged in Kantha i.e.for kantha sudhi99.

ü  Patient should stay at windless place. Light meal (Laghu Aahara) and luke warm water (Sukhoshna Jala) is allowed100.

ü  One should avoid dust, smoke, sunshine, alcohol, hot bath, riding, anger, excess fat and liquid diet101.

ü  Day sleep and cold water for any purpose like Pana, Snana etc. should be avoided after NasyaKarma102.

Precautions:

ü  While positioning the patient for nasya, if the head is not sufficiently bend the nasya dravya will not enter shiras and if head is more bent dravyas may enter to masthulunga and causes complications like headache, dizziness etc.

ü  The patient should avoid swallowing of Nasya Aushadhi. If the medicine is swallowed and the split is not done properly then it will causes Kaphotklesha, agneemandya and aggravation of the disease.

ü  If the medicine is very less in quantity then it will excite the doshas but will not expel them out and so leads to feeling of heaviness, loss of taste, cough excessive salivation, Rhinitis, Vomiting and disease of throat.

ü  Large quantity of medicine will give rise complication of Atiyogas.

ü  Pouring the entire oil all of a sudden will make the oil enter in to wrong routes, diseases of head, Rhinitis, exudation from the nose, and obstruction of inspiration.

ü  If the medicine is very hot, that can lead to burning sensation, formation of ulcer, Jwara, bleeding through nostrils, headache, disturbance of vision, fainting and giddiness.

ü  Very cold medicine will cause ayoga lakshanas.

Samyak Yoga, Ayoga and Atiyoga of Nasya Karma:

            After Nasya karma the symptoms of its Samyaka yoga, Ayoga and Atiyoga should be observed, which are being described here as under.

Samyak Yoga:

            The symptoms of adequate, Nasya according to Charaka are Urah-shiro-laghava (Feeling of lightness in chest and head). Indriyavishuddhi (sensorial proficiency) and Srotovishuddhi (cleansing of channels). In addition, Sushruta has described Sukhaswapna-prabodhana (good sleep and awakening), Chitta-Indriya-prasannata (mental and sensorial happiness) and Vikaropashama (Improvement). Besides this proper respiration and sneezing have been described by Vagbhatta as general symptoms of Samyaka Yoga of Nasya Karma.

Table.No.17. Showing Samyaka Yoga Lakshana¹⁰³

Symptoms	Ch.	Su.	As. H.	Sha.	B. P.	Ka.
Urah Laghuta	+	-	-	-	+	-
Shiro Laghuta	+	+	-	-	-	-
Netra Laghuta	-		+	+	-	+
Laghuta	-		-	-	+	-
Srotovishuddhi	+	+	-	+	+	+
Swaravishuddhi	-		+	-	-	-
Vaktravishuddhi	-		+	-	-	-
Indriyaachchta-prasada	+	+	-	+	+	+
Netrateja Vriddhi	-		+	-	-	+
Chitta Prasada	-	+	-	+	+	+
Vikaropashama	-	+	-	+	+	-
Sukha Svapna Prabodha	-	+	+	-	-	-
Sukhachchvasa	-	+	-	-	-	-
Arati	-	-	-	-	-	-
Medha	-	-	-	-	-	-
Bala	-	-	-	-	-	-

Samyak yoga of Brumhana Nasya:

            Felling of lightness of head, good sleep and wakening, pacification of symptoms, clarity of sense organs and feeling of well being.

Samyak yoga of Virechana  Nasya:

            Lightness of head, Purity of channels, Cure of the disease, pleasant mind and sense organs.

Ayoga:

            If Nasya is not given in proper way or the dose is less, features of inadequate Nasya arise which are Shirogaurava (heaviness in head), Galopalepa (throat coated with mucus) and Nishthivana (excessive spitting104). According to Sushruta, Kandu (Itching), Upadeha (feeling of wetness), Guruta (heaviness), Srotasam Kapha Srava (excess mucus secretion in channels) are the symptoms of Hina Shuddhi105. Vitiation of Vata, dryness in Indriya, no relief in the symptoms of the disease106, dryness in mouth and nose are other symptoms of Ayoga of Nasya karma.

Table No. 18. Ayoga Lakshana107

Sl.No	Symptoms	Ch.	Su.	As. H.	Sha.	B.P.	Ka.
1	Shirogaurava and  Dehagaurava	+	-	-	+	+	+
2	Galopalepa	+	-	-	-	-	-
3	Nishthivana	+	-	-	-	-	-
4	Kandu	-	+	+	+	+	-
5	Kaphapraseka	-	-	-	-	-	-
6	Upadeha	+	-	+	+	-	-
7	Rukshata	+	-	-	+	+	+
8	Vata Vaigunya	+	-	-	-	-	-
9	Srotoriktata	-	-	-	-	+	-
10	Srotasamkaphasrava	+	-	-	+	+	+
11	Nasashosha	-	+	-	-	-	-
12	Asyashosha	-	+	-	-	-	-
13	Akshistabdhata	-	+	-	-	-	-
14	Shiroshunyata	-	+	-	-	-	-
15	Vyadhi Vridhdhi	-	-	-	-	-	+

Ayoga of Brumhana Nasya:

            Aggravation of vata, dryness of Indriyas, persistence of disease.

Ayoga of Virechana Nasya:

            Itching, feeling of coating in the body, heaviness, exudation of kapha.

Atiyoga:

            According to Charaka, the general features of excessive Nasya are, feeling of Arati (uneasiness) and Toda (pricking like pain in the head, eyes, temporal region and ears)108. Kapha Srava (Salivation), Shirahshula (headache) and Indriya Vibhrama (confusion) are the symptoms of Atiyoga of Nasya109. Mastulungagama, Vatavriddhi, Indriyavibhrama and Shiroshunyata (emptiness of head) are also the symptoms of Atiyoga of Shirovirechana.

Table No. 19. Atiyoga Lakshana110

Symptoms	Ch.	Su.	As. H.	Sha.	B.P.	Ka.
Shirogaurava	-	+	+	+	+	-
Shiroshunyata	-	+	-	+	+	-
Shirovedana	+	-	-	-	-	+
Netra Vedana	+	-	-	-	-	-
Shankhavedana	+	-	-	-	-	-
Suchitodavata Pida	+	-	-	-	-	-
Indriya Vibhrama	-	+	-	+	+	+
Mastulungagama	-	+	-	-	-	-
Snehapurna Srotasa	-	-	-	-	+	-
Karna Talu Upadeha	-	-	-	-	-	-
Vata Vriddhi	+	-	-	-	-	+
Kandu	-	+	-	-	-	-
Praseka	-	+	+	+	-	-
Pinasa	-	+	-	-	-	-
Aruchi	-	-	+	-	-	-
Deha Daurbalya	-	-	-	-	-	+
Unmada	-	-	-	-	-	-
Pitta Vriddhi	-	-	-	-	-	-
Hridaya Shula	-	-	-	-	-	-
Suryavarta Roga	-	-	-	-	-	-
Atripti	-	-	-	-	-	-

Atiyoga of Brumhana Nasya:

            Hyper salivation, Heaviness of head, indriya vibhrama.

Atiyoga of Virechana Nasya:

            Exudation of Masthulunga, Vata vrudhi, Indriya vibhrama, feeling of emptiness of head.

Treatment principle of Heenasudhi and Atisudhi:

            In case of heene sudhi kaphahara chikitsa can be done and in atisudhi vata hara chikitsa should be done.

Vyapada:

            After completion of the Nasya Karma, if patient does not follow the regimen mentioned previously then the Prakopa of Dosha may again occur leading to many Vyapada110. Generally complications arise by two ways one is from Doshotklesha and the other from Doshakshaya. The complications, which are produced by provocation of Doshas, the treatment should be done on the line of Shodhana therapy and if complications are arise from Doshakashaya, then the treatment to be given on the line of Brimhana therapy112.

            If Nasya is given in the contra-indicated conditions like Ajirna, Bhuktabhakta, Jalapitta etc. or in season or time e.g. cloudy atmosphere in which Nasya Karma is contra indicted, then there is possibility of production of Kapha rogas like asthama, cough, sinusitis and indigestion etc. In such conditions, the treatment should be done with Kaphanashaka Upachara like use of Ushna and Tikshna Aushadha and Karma113.

            If Nasya is given in Krishasharira (emaciated), Virikta (patient who had taken Virechana), Garbhini (pregnant lady), Vyayama klanta (exhausted with exercise) and in Thirsty person then vitiation of vata takes place and may lead to Vataj vikara. In all the above conditions, Vatanashaka procedures like Snehana, Brimhana and Swedana should be done. The pregnant lady should specifically be treated with the use of Ghrita and Milk114. The conditions like fever, Shokabhitapta and in Madyapita, if Nasya is performed then Timiraroga may occure. Ruksha, Sheeta Anjana, Lepa and Putapaka should be applied for the treatment of these conditions115.

            For Nasya if the drug used is very hot or cold or given in less or in excess quantity or during administration of Nasya the patient has lowered his head more or sneezed or Nasya is given during the time when it is contra- indicated then it may lead to the complications like Trishna and Udgara116.

            If Patient gets Murccha during Nasya, he should be treated with the pouring of cold water on Lalata and Kapala117.

Benefits of Nasya:

            Patient who regularly observes Nasya Karma does not become victim of diseases of eyes, ears and nose. His hair and beard does not turn gray. His hair doesn’t falls but instead grows fast. Diseases like common cold, migraine, headache, facial paralysis, etc. can be alleviated. The joints, sinus, tendons and bones of his cranium acquire great strength. His face becomes cheerful and plump and his voice becomes mallow, firm and stentorian. Strength of all sense organs increases greatly. There will be no sudden invasion of disease in the upper parts (Urdhvajatrugata) of the body. He experiences the symptoms of old age later.

            Disease of the supra clavicular region are cured in the person who practices Nasya. He gets clarity of senses, good smell of mouth and the strength of jaw, teeth, arms, chest, etc. He never suffers from the premature appearance of wrinkles, premature hair falling and Vyanga.

Mode of Action of Nasya Karma:

            The clear description regarding the mode of the Nasya Karma is not available in Ayurvedic classics. According to Charaka, Nasa is the portal (gateway) of Shirah118. The drug administered through nose as Nasya reaches to the brain and elininates only the morbid Doshas responsible for producing the disease. In Ashtanga samgraha, it is explained that Nasa being the door way to Shira (head), the drug administered through nostrils, reaches Shringataka (a Sira Marma by Nasa Srota) and spreads in the Murdha (Brain) taking route of Netra (eye), Shrota (ear), Kantha (throat), Siramukhas (opening of the vessels) etc. and scratches the morbid Doshas in supra clavicular region and extracts them from the Uttamanga119.

            Sushruta has clarified Shringataka Marma as a Sira Marma formed by the union of Siras (blood vessels) supplying to nose, ear, eye and tongue120. Commentator Indu of Ashtanga Samgraha opined Shringataka as the inner side of middle part of the head i.e. Shiraso Antarmadhyam. Under the complications of Nasya Karma Sushruta noted that the excessive eliminative errhine might cause Mastulunga to flow out to the nose121.

            According to all Acharyas, Nasa or nose to be the gateway of Shira. It does not mean that any anatomical channel connects directly to the brain but it might be connected through blood vessels or through nervous system (olfactory nerve etc.)

            It is an experimentally proven fact that where any type of irritation takes place in any part of the body, the local blood circulation is always increased. This is the result of natural protection function of the body. Something happens when provocation of Doshas takes place in Shirah due to irritating effect of administered drug, which resulting an increase of the blood circulation of brain. So extra accumulated morbid Dosha are expelled out from small blood vessels and ultimately these morbid Doshas are thrown out by the nasal discharge, tears and by salivation.

According to Vrudda Vagbhata:

Drug administered through nose -the doorway to sheera

Reaches the Shringataka marma of Head (Sheera), which is a sira marma and formed by the siras of nose, eyes, kantha and shrotra

The drug spreads by the same route

Scratches the morbid Doshas of Urdhwajatru and extracts them from the Uttamanga