The Respiratory System
On average, humans breathe approximately 13 pints of air per minute.1 The act of respiration is both a voluntary, and involuntary activity of the human body. The involuntary part comes from the drive of life and the automatic response of breathing to survive, sometimes without any extra thought. Every cell needs oxygen in order to maintain life. Upon taking an inhalation, oxygen and other gases are brought into the lungs through the nose or the mouth. Once there, the oxygen is sent and distributed throughout the bloodstream to give breath, life force energy, to the entire body. The oxygen replaces the carbon dioxide that is eventually brought back to the lungs and carried out via the exhalation. The airways, lungs, blood vessels, and muscles are the primary components of the respiratory system; they are also directly affected in persons who have asthma.2
Airways include the nose and sinus cavities, mouth, throat, windpipe and bronchial tubes. Once air is inhaled from either the nose or the mouth, it passes through the throat down the windpipe, otherwise known as the trachea. The trachea serves as the pathway to the lungs. Here, the windpipe breaks off into bronchial tubes: one to the right lung, one to the left. These two tubes are then deconstructed further into bronchioles where the breath finally reaches its end point, the alveoli (air sacs). It is here that gas is turned into oxygen and completes its function of supplying life to the body.3Upon inhalation, the air must travel around the entire body to fully oxygenate a person; which is why having open airways is so important. The bronchial tubes are lined with small, “nose-hair” like cilia that move mucous up and out of the airways to help keep the pathways clear. When a cough or sneeze takes place, the body is trying to get rid of the mucous that is holding dust and other unwanted germs away from the lungs.
Both the lungs and blood vessels bring oxygen, and expel carbon dioxide from the body with each breath. The muscles necessary for successful breathing include the diaphragm, abdominal and neck muscles.4The diaphragm draws downward during an inhalation, providing air the space to expand and fill the lungs. The intercostal muscles between the ribs also play a role in creating space to breathe, as well as helping to protect the chest cavity.5 In a healthy airway, the tissue is pink and the pathway is clear with no swelling or overproduction of mucous. Having healthy tissue and respiratory functions allows for easy, calm, breathing. When pathologies occur that obstruct the free flow of oxygen input- carbon dioxide output, many things can happen.
Both allopathic and ayurvedic medicine relate asthma, a respiratory disease, to the term dyspnea, or difficulty breathing.6,7 Asthma is a disease that causes the airways to become swollen and inflamed.8 The inflammation results in the narrowing of the passageway itself, which is then prone to various substances irritating the area and causing an, “asthma attack”. These particles are referred to as “asthma triggers”. An asthma trigger is another word for an allergen or a substance that may cause an allergic reaction. Some examples of asthma triggers are pollen, tobacco, dust, and the common cold. In fact, most people who have allergies, also experience asthma.9 The main symptoms that are often experienced during an attack are wheezing, shortness of breath, chest tightness, and coughing.10
The American Lung Association has reported that there are 3 main changes that may occur in asthmatic persons.11 First, the once pink colored tissue with clear, wide-open airways for breath to flow easily in and out of is no longer so. The tissue is now inflamed, red and swollen. The inflammation is also always present, even when no other symptoms of asthma are. The inflamed tissue is now more vulnerable to any particles that may be inhaled from the surrounding environment. This first main change of inflammation throughout the airways presents two new problems/risks: the inflammation is making it more difficult to breathe because the airways are no longer wide open, and the now alarmed airways are more susceptible to experience a negative body response from allergens in the air.
The second main change that can happen is referred to as bronchoconstriction.12 This condition presents as tightening of the smooth muscles surrounding the already swollen airways. Inflammation and now muscle constriction are closing in on the once wide-open airway. This pathology of bronchoconstriction is linked to extrinsic asthma that often occurs in children due to an allergic reaction.13
An increase in mucous secretion to try and protect the airway and body from letting the allergen in is the final main change that happens during an asthma attack.14 Inflammation, muscle constriction and added thick mucous is a recipe for extremely difficult breathing.
During an asthma attack, both child and adult alike may experience sensations such as breathing out of a straw and unable to catch enough air. They may also feel fear or panic of not being able to breath. Visual symptoms to watch for and that require immediate help include: the lips and face turning a blue tone color, severe drowsiness or confusion, and rapid pulse.15
Cause of Asthma
The National Asthma Education and Prevention Program Expert Panel Report stated that asthma typically begins early in life. The long-term outcome of the disease is determined by the earliest recognizable signs and symptoms and is best treated from early onset to ensure the most preventative and effective care possible is offered.16 Childhood asthma can arise before age five, and can be identified by the same signs and symptoms as adult asthma. To name a few: shortness of breath during exercise or at rest, a whistling/ wheezing sound coming from deep in the chest, and coughing fits. Many articles stress the similarities between asthma symptoms and other childhood pathologies, expressing the often complicated process of correctly diagnosing the disease.17,18,19,20
A study by Diana Raedler and Bianca Schaub looked at possible explanations about where asthma comes from and/or how it is brought about. Having one or both parents who also have asthma (genetic link), air pollutants both inside and outside (environmental link), and various respiratory infections both viral and bacterial are some causative factors to both childhood and long-term asthma.21` The National Heart, Lung and Blood Institute (nhlbi) believe the most important factor in developing asthma is atopy, or the inherited predisposition to develop allergies/asthma.22 The institute also discusses the hygiene hypothesis theory and how the more recent trend in the western-world of placing an emphasis on keeping things clean and bacteria-free, may actually be causing immune systems to develop in ways that are making people more likely to have asthma.
The hygiene theory also referred to as the microbiome theory brings attention to possible negative effects that the lack of various microbes, or bacteria present in western households is creating. Andrew H. Liu from the department of pediatrics/section of pulmonary medicine researched and reported that living with various “creatures” in early life such as: domestic animals, household pests, and older siblings that carry various organisms could actually protect against the early onset of allergy and asthma development.23 The U.S National Library of Medicine supports the notion that although the quality of outdoor air has been improving over the past decade, cases of people with asthma have been increasing; they too believe that changes in the indoor environment may be linked.24
On the other hand, Steve Turner of Pragmatic and Observational Research mentions that although asthma is generally seen as an allergic condition, 38% to 80% of asthma attacks in children are connected to the rhinovirus, a respiratory infection associated with the common cold.25,26,27 Another study reported that 40% of infants who experienced respiratory syncytial virus (RSV) and parainfluenza virus, continued to have asthmatic symptoms later in life.28 It is clear that although there have been decades of research done on asthma, there are many facets that need to be further explored in order to fully understand how asthma is created in the body, and what can be done to prevent and/or cure this disease.
Ayurvedic Understanding of Tamaka Svasa (Asthma)
Asthma is one type of lung disease that causes the person to experience difficulty breathing. According to the Charaka Samhita, there are five main types of svasa, or dyspnea (difficulty breathing). It states that svasa is predominately a kapha-vata condition, and that the diseases associated with difficulty breathing are created from the seat of Pitta (the small intestine). This leads to the eventual drying up of the heart and dhatus/tissues of the body.29 Depending on the type of asthma, there are different ways of approaching the patient.
According to Dr. Marc Halpern’s text, Clincial Ayurvedic Medicine, kapha type asthma, or tamaka svasa is cultivated from a weakness in the lungs and bronchi, along with the surplus of sweet, sour, and salty tastes; including overeating heavy, hard-to-digest foods. In vata-type svasa, there is also a weakness in the lungs but with an added malfunction of the immune system.30 Pitta dosha may also be involved however if that is the case, treatment will include the pacification of kapha or vata, along with protocols to get rid of an infection as well.
Kapha dosha accumulates and becomes aggravated in the stomach (ambuvaha srota). It then overflows into the rasa and raktavaha srotas, which leads to the excess mucous that complicates the flow through the channels. The rasavaha srota carries the element of water and provides “juice”, or the basic nourishment to the body. The raktavaha srota is the channel that’s responsible for carrying red blood cells and vessels throughout the body, distributing fire, or heat throughout.31 When kapha overflows into these channels, the excess of heavy and dense qualities begin to infiltrate and relocate to places they should not be. In the case of kapha-driven tamaka svasa, kapha relocates to the water metabolism and bronchi channels of the body.32 In Ayurveda, these channels are called the ambuvaha and pranavaha srotas. It is here that mucous and swollen bronchi create a decreased flow of air, hindering the intake of prana vayu, or life force needed to sustain life.
Vata-type asthma begins in the colon, or purishavaha srota, before overflowing into the rasa and raktavaha channels. Instead of mucous entering the channels, the light and dry qualities of vata begin to dry them up. Because of this, the channels no longer have too much in them causing blockage, rather the bronchi become weakened and vulnerable to allergens associated with bronchial constriction. In other words, an outside substance causes the body to muscularly respond by squeezing the airflow channel, making it difficult to breath.33
The symptoms observed are similar to those seen from the allopathic viewpoint, however there is more insight into what to expect depending on what type of tamaka svasa, or asthma is present. With kapha-type asthma, the person will experience an increase of fluid and mucous production. This overproduction overflows into the airways, obstructing normal airflow to and from the lungs (bronchi). Vata driven asthma also experiences difficulty breathing, but the symptoms are associated with the mind. Feelings of fear and anxiety are more likely to be present in this type of asthma. It is important to keep these differences in mind when deciding on the path of treatment. 34
The Mayoclinic foundation reported on four different tests that are given to both adults and children over the age of 5 to measure the health of the lungs. A “peak flow” test is given to quickly measure how large of an exhalation can be created. This is done by having the patient blow as hard as possible into an instrument so that the exhale rate can be recorded. Another test requires deep exhalations into a device called a spirometer. A common spirometry measurement determines how much air can be forced out in one second.35 Another test measures how much nitric oxide gas is present in the exhaled breath: the higher the nitric oxide level, the higher indication of inflamed airways. A pulse oximetry test measured through the fingernail discovers how much oxygen is present in the blood.36 All of these tests help doctors determine if it is in fact asthma, or some other respiratory condition that is happening.
Once diagnosed with asthma, there are a series of treatments and recommendations available for adults and children of all ages. Individuals with asthma who are experiencing an attack are generally in need of emergency “rescue” treatment. Medication that is given via an inhaler is used when immediate relief from airway obstruction is needed. An example of this is albuterol.37 This medicine is referred to as an, “inhaled short-acting beta2-agonist”, meaning that it works quickly to relax the bronchial constriction, allowing for more air to reach the lungs and eventually the entire body.38 For children under the age of five, a nebulizer, or machine that is placed over the child’s mouth, creates a medicated mist to deliver the same medicine as the inhaler. 39
There are also a number of long-term medicines that are prescribed for both children and adults. Inhaled steroids are found to be one of the most-effective anti-inflammatory medicines available today. The long-term use medicines are to be used daily, even when no asthma exacerbations are present.40 The NHLBI explain that the steroids used to treat asthma are non-habit forming, and are found to be safe for children as young as 2 years old. Other options for long-term use include: cromolyn sodium, leukotriene modifiers, and theophylline. Cromolyn sodium is for mild, consistent asthma and is a non-steroid anti-inflammatory. Leukotriene is taken in pill form and works to block chemical reactions in the airways. Also in a capsule, theophylline relaxes and opens up the airways and is often taken at night.41 Most long-term treatments are prescribed with a fast-relief treatment in the case of an emergency.
Working closely with a physician and keeping track of the number and severity of asthma attacks are important in the management of the disease. Other advices given are to avoid any known asthma triggers as much as possible, take medicine as prescribed (both for asthma and allergy), and be prepared for when an attack does happen.42 The 2015 National Review of Asthma Deaths believes that educating the children, parents, and teachers as well as having personal plans of prevention and care are what is needed to help improve the number of children with asthma as well as the success of specific treatments.43
Ayurvedic belief says that no two people experiencing the same condition will have the same treatment protocol. Instead, there are guidelines that are to be adapted to the individual based upon their own unique doshic makeup and current doshic imbalance. Another way to say this would be evaluating the patient’s prakruti and vikruti and then coming up with a highly individualistic plan to support them back into balance. Preceding any form of pancha karma, or cleansing action, there should be a period of purva karma, or preparation that occurs to not only help prepare for, but support the body through the process. There is also a process of samsarjana karma following the cleanse. This is the slow re-introduction of constitutionally appropriate foods to help the body recover and seal in the benefits.
It is important to do a full purva karma, or preparation, for 1-4 weeks before doing any type of purification therapy. According to the Charaka Samhita, there are four general steps to focus on when dealing with difficulty breathing/svasa.44 Abyangha (massage) with thorough fomentation comes first. The application of heat should be most concentrated on the areas of the chest and throat with a warm combination of a formula referred to as, “Utkarika”. One example of this preparation includes: sesamum, black gram, and wheat, mixed with vata alleviating herbs with “sour things or milk”.45 The Astanga Hrydayum also suggests the use of sudation, or sweating, in persons suffering from cough, runny nose, dyspnea…diseases of vata, kapha, and ama.46 The Charaka Samhita further explains that by freeing up the excess phlegm, the passageways become soft and vata dosha can then be encouraged to come away from the tissues and back to its home site in the colon. To create a clearer picture, the authors of the Charaka Samhita wrote, “As on hilly forests the snow is liquefied by the heat of sun-rays, the sticky phlegm in the body gets dissolved by the heat of the sudation.”.47
The next step is preparing the body to vomit, referred to in Ayurveda as vamana, The way to do this is to create a kapha imbalance in the stomach, also known as bringing back the excess mucous in the body to its home site in the digestive system.48 The California College of Ayurveda recommends that the patient drink 8 oz of whole milk with 2-4 tsp of sugar and 2 tsp of ghee the night before vamana. Two cups of fennel/mint tea are taken in the morning between 6-8am. Finally, a strong decocted tea of licorice root is sipped until the urge to purge out of the mouth occurs. The purge itself is what catapults the excess phlegm out of the system; the excess mucous that was once blocking the pathway is no longer in the system. The Charaka Samhita advises the patient to take an emetic formula made up of pippali, rock salt and honey.49 Following the cleanse, it is important to continue to take care of the body as it will feel depleted. The college endorses lots of rest, meditation, and a diet consisting of rice that has been cooked with a lot of water to make a thin, easy to digest, gruel. It is also suggested to only eat once the appetite returns. Sipping ginger tea to help rebuild the digestive agni, or flame is also helpful.
The fourth step that may be needed in getting to the root of tamaka svasa is smoking specific, individualized formulas to remove any remaining ama that may be still stuck in the tissues. 50A purgative may also be given to help restore the body’s natural direction of elimination.
It is noted in the classical text that the patient must be categorized as “strong” or “weak”. This will greatly help determine what plan of action to take. It clearly states that children should be nourished with vata-pacifying foods, especially vegetable and meat soups.51 If the child has high ojas and a predominance of kapha dosha, the vamana cleanse is still recommended. However, if a vata predominance is found, the procedure should be skipped all together. In this case, the Charaka Samhita encourages the intake of various wild animal meat soups cooked in a decoction of dashmula, or horse gram tea. In general, a diet that helps to alleviate kapha and vata in the system will help a person suffering with the difficulty of breathing, caused by asthma.
If a person is experiencing kapha-driven asthma, than a kapha-pacifying diet should be followed. When excess kapha exists in the body, there is most likely an excess intake of sweet, sour and salty foods. Some of examples of these are: oats, cheese, sweet fruits, squash, various nuts, and red meat. Using the principle of opposites decrease each other, a kapha cleansing diet focuses on bitter, pungent and astringent tastes. The bitter taste focuses on reducing rakta dhatu while the pungent taste cleanses all the other dhatus. The astringent taste tonifys the tissues and helps to reduce rasa dhatu. Together these three tastes help reduce inflammation; mucous and fluid build up/retention in the annavaha (digestive system) and pranavaha (respiratory) srotas.52 Some examples of these foods include: amaranth, dried fruits, sprouts and other raw fibrous vegetables, dark poultry meat, and mung beans.
Another way of making sure the diet is supporting the body back into balance is to incorporate the use of spices. Ayurveda seeks to use warming spices such as black pepper, cinnamon, clove, garlic and anise, to name a few. These herbs warm up the body and support the clearing out of blockages and stagnant tissues from the digestive system.53 One meal example to pacify dyspnea, or difficulty breathing mentioned in the Charaka Samhita is to prepare a gruel or decoction of, “dasamula, sati, rasna, pippalimula, puskaramula, karkatasrngi, tamalaki, bhargi, guduci, sunthi, and hribera”. 54
A supportive breakfast for kapha could be a small bowl of oatmeal made with quinoa, spiced with cardamom, clove and cinnamon and a small dollop of aged honey. A possible lunchtime meal could be red lentil and split pea salad with a plethora of vegetables (artichokes, dark leafy greens, cilantro, and carrots) sprinkled with sunflower seeds and spices to aid digestion. If there is hunger in the evening, a light dinner such as broth with spiced vegetables is a good option. It is also important to keep the digestive fire strong, so the intake of warming/ cleansing teas are recommended as well.55
In cases of vata-driven asthma, a vata-reducing diet is necessary. Dr. Marc Halpern points out that a “mono-diet” of kitchari involving rice, beans and spice mixtures for one week will help to “desensitize” the body.56 From this point, there is a re-introduction of food that will focus on nourishing the body with sweet, salty and sour foods- avoiding the bitter, astringent, and pungent ones. Warming spices such as, dried ginger and trikatu are also incorporated to help support the digestive capability.
Breakfast for a vata pathology could be a small bowl of oatmeal made with milk, ghee, cinnamon, cardamom and maple syrup. A possible beneficial lunch option includes nourishing cooked root vegetables such as sweet potato, squash and carrots, with mungbeans, white rice; fresh ginger, cumin and bay leaf. Like kapha, dinner should be kept light, however still nourishing. A bone broth soup with easy to digest vegetables such as leeks or water chestnuts is one example. Another point to remember is that if there is a vata dosha imbalance, the digestive ability is compromised and unstable. It may be beneficial for vata to eat smaller portions, several times a day. In this case, takras (mixture of yogurt, water and spices) and perhaps small snacks such as dates with ghee may be taken in-between meals.
Having an understanding of how asthma presents itself in the body can help a person to create an individualized plan to help support the specific expression of the disease.
There are many lifestyle recommendations that Ayurveda offers in support of a healthy, more balanced routine and life. The key to incorporating them into daily life is to introduce the practices slowly, over time, to cultivate a routine that works well for the person. There are three guidelines to proper food preparation including meditating prior to or upon entering the kitchen, and keeping the mind present while acknowledging the spirit of the food. By doing these things, the mind and body are encouraged to remain calm and focused on the preparation, digestion, and eventual benefits of what was eaten.57
Another set of fifteen guidelines to help cultivate a more sattvic, or peace-filled lifestyle, free from dis-ease and imbalance are described in the Charaka Samhita: “Healthy individuals as well as patients should observe the following, even while using such of the food articles which are most wholesome by nature: One should eat only food which is hot, unctuous, and not contradictory in potency and that too, after the digestion of the previous meal. Food should be taken in proper place equipped with all the accessories, without talking and laughing, with concentration of mind and paying due regard to one’s self”. 58
Outside of recommendations surrounding food, cultivating a mediation practice can help calm the mind and body’s response to an asthma attack, helping to alleviate the symptoms sooner. 59 Aromatherapy and the use of calming oils such as lavender, and clearing oils such as eucalyptus in an air diffuser may help calm the bronchioles as well. Developing a yoga nidra/ pranayama, or breath-work, practice will over-time teach a person how to become in control of their breath. Breathing is an involuntary action that the body largely regulates to sustain life. However, it is also voluntary in that it can be trained and manipulated by the Self. Yoga asana is another way to start becoming aware of breath and how it relates to efficiency of day-to-day bodily functions. Thich Nhat Hanh, a Vietnamese Buddhist monk said, “Your breathing should flow gracefully, like a river, like a water snake crossing the water, and not like a chain of rugged mountains or the gallop of a horse. To master our breath is to be in control of our bodies and minds. Each time we find ourselves dispersed and find it difficult to gain control of ourselves by different means, the method of watching the breath should always be used.”60
Therapeutic vamana, or vomiting, as mentioned above, works well for kapha-driven asthma, while rectal bastis (both cleansing with decoctions and nourishing with oils) help pacify vata-driven asthma symptoms.61
Many herbs and herbal formulas are extremely useful in treating persons with asthma, however they are not to be used in replacement of allopathic medicine (i.e rescue inhaler) during an attack. Instead, they are more supplemental and used best as a preventative measure against future attacks.62 Sebastian Pole, author of, Ayurvedic Medicine- The principles of traditional practice, shares various herbs to decrease wheezing, phlegm and kapha, and improve breathing for vata. For acute cases of asthma, Pole suggests sipping on ½ mahanarayan oil in licorice water.63 In chronic,wet, kapha-type asthma, he suggests herbs such as pushkaramoola, vasa, anthrapachaka and ephedra.64 Dr. Marc Halpern recommends the use of bala, and rasayanas such as ashwagandha and shatavari to help build ojas (immune system).65 Dr. Halpern also brings attention to three specific herbs that are special to the treatment of asthma.
The entire plant is used in herbal treatments for asthma. It is a bronchodilator, expectorant, antispasmodic, and antipyretic.66 This means it helps widen the airways, loosen and oust mucous from the lungs, relieve spasms of the smooth, involuntary muscles of the bronchi, and reduces fever. Vasa is pacifying for pitta and kapha, and when mixed with heavy, warming herbs becomes beneficial for vata too.67
This herb is light and dry in nature and is beneficial for kapha dosha. It acts as an expectorant and bronchodilator, which again helps to break up obstructions and widen the airways. There is an FDA restriction due to it being abused by athletes for performance and weight loss reasons, however, under guidance can be helpful for asthmatic symptoms.
Thyme, which does not have any FDA restrictions, has similar affects as Ephedra but is much less potent on the body and therefore is used more for long-term management and prevention of the disease. 68
Asthma is a disease that causes the airways to become constricted and blocked due to various factors both genetic and environmental. Symptoms of asthma include wheezing, difficulty breathing, and coughing. This literature review has touched on only a small portion of the extensive allopathic and ayurvedic approaches to understanding and managing this disease. While it is clear that the western approach is necessary, especially during an asthma attack, ayurvedic approach allows the care and prevention plans to go much further than taking prescriptions and staying away from potential triggers in the environment. It allows a person to approach this disease from many other angles (i.e paying attention to what they eat, cultivation of daily routines, treatments and therapies). To conclude, there is an absolute necessity to incorporate both sides of the health and well-being coin when managing this disease.
4 Ibid. 2
5 Dr. Marc Halpern. Clinical Ayurvedic Medicine. 6th ed. Dr. Marc Halpern and the California College of Ayurveda.
7 Gabriel Van Loon, trans. Charaka Samhita Handbook on Ayurveda. Vol. 2. Gabriel Van Loon, 2003.
13 Henry Gong, Jr., ed. “Wheezing and Asthma.” In Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd ed. Butterworth, 1990.14-13
14 Ibid. 11
15 “Asthma.” Medline Plus. Accessed December 3, 2016. https://medlineplus.gov/ency/article/000141.htm.
17 “Asthma.” PubMed Health. Accessed December 3, 2016. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0062942/.8
18 Ibid. 16
20 Dr. Marc Halpern. Principls of Ayurvedic Medicine. 10th ed. Dr. Marc Halpern and The California College of Ayurveda.
23 Andrew H. Liu. Liu,”Revisiting the Hygiene Hypothesis for Allergy and Asthma.” Journal of Allergy and Clinical Immunology, October 2015. Accessed December 3, 2016. doi:10.1016/j.jaci.2015.08.012
25 Ibid. 19
26 Ibid. 16
27 Ibid 20
28 Ibid. 16
29 Ibid. 7
30 Ibid. 5, p. 2-67
31 Ibid. 20
32 Ibid. 5
33 Ibid. 5
34 Ibid. 5
35 Shobi, Anandi, Tullu S, Milind, and Lahiri Keya. “Evaluation of Symptoms & Spirometry in Children Treated for Asthma.” Indian Journal of Medical Research 144, no. 1 (2016): 124-27. Accessed December 3, 2016. doi:10.4103/0971-5916.193299.
38 Ibid. 22
39 Ibid. 36
40 Ibid 16
41 Ibid. 22
42 Ibid. 9
Steve Turner.”Predicting and Reducing Risk of Exacerbations in Children with Asthma in the Primary Care Setting: Current Perspectives.” Pragmatic and Observational Research 7 (2016): 33-39. Accessed December 3, 2016. doi:https://dx.doi.org/10.2147/POR.S98928
44 Ibid. 7, p. 868
45 Ibid 7, p, 869
46 Prof. Murthy Prof. K.R Srikantha, trans. Vagbhata’s Astanga Hrydayum. Vol. 1. Varanasi: Chowkhamba Krishnadas Academy, n.d. Print.
47 Ibid. 7
48 Ibid. 7
49 Ibid. 7
50 Ibid. 7
51 Ibid. 7
52 Ibid. 20
53 Dr. Marc Halpern. Principls of Ayurvedic Medicine- Textbook Supplement. Dr. Marc Halpern and the California College of Ayurveda, 2013.
54 Ibid. 7
55 Ibid. 5
56 Ibid. 20, p. 2-68
57 Ibid. 20
58 Ibid. 20
59 Ibid. 5
61 Ibid. 5
62 Ibid. 5
63 Sebastian Pole. Ayurvedic Medicine: The Principles of Traditional Practice. Singing Dragons, 2013.
64 Ibid, p. 335
65 Ibid. 5
66 Ibid. 5, p. 2-66
67 Ibid. 5
68 Ibid. 5