The Ayurvedic Shodhana Chikitsa, otherwise popularly known as Panchakarma chikitsa, has gained much momentum in the past decades. Unfortunately, in spite of its miraculous therapeutic effects the changes they stimulate when administered into the human body to bring about the disease cure is hitherto unexplored. Deeper analysis of the therapeutic action guides to a hypothesis relating to Stress coping mechanism of the body’s physiology. Probably, it may be said, these therapies exhibit their action by stimulating a kind of Eustress (metabolic, thermal, fluid) into the body physiology driving into force the body’s controlling and working systems to work in favour of re-establishing the lost homeostasis, i.e, the state of health.
Keywords: Shodhana Chikitsa, Panchakarma, Eustress, Homeostatis
Ayurvedic Shodhana Chikitsa is the hard core of the Ayurvedic therapeutics. This unique concept of the Ayurvedic medical science offers a viable alternative for the management of not only contemporary but also the newly emerging ailments at deeper community levels, locally and globally. Not only the classical references but also the clinical experiences support the fact that diseases once cured by administering these therapies show minimal or no recurrence at all1.Despite of this fact, to explain the probable mode of action of these therapeutic modalities in terms of biomedical science is a challenging task2. The present paper is an attempt to analyze a possible mode of action of these Panchakarma therapies in terms of Bio-medical principles.
Procedure of Panchakarma therapies – a classical literature review
The Panchakarma therapy is executed in three stages, namely- poorvakarma (preparatory therapies), pradhana karma (major purificatory therapy) and paschat karma (post purification aftercare3. The preparatory therapies include snehana (oleation therapy) and swedana (sudation therapy),classically intended to enhance the efficacy of purificatory procedures by making the disease causing morbid waste, accumulated in the body, available for easy elimination. The major purificatory therapies include vamana (emesis), virechana (purgation), vasthi (enema), nasya (nasal drug administration) and rakta moksha (blood letting) which washes the body off the accumulated impurities4. Post purification aftercare includes rest, diet care and other minor therapies like dhumapana (fumigation) etc. to pacify the humoral imbalances which could possibly creep in during the therapy5.
· Snehana (oleation therapy)
Sodhanapoorvaka snehana [oleation prior to purification] is generally administered in the form of intake of large doses of any snehana drug (fat or oil enriched formulations) ghrta (ghee), taila (oil), vasa (muscle fat) and majja (bone-marrow fat), administered in empty stomach early in the morning, followed by frequent intake of small quantities of after-drinks processed with deepana (kindling digestion) drugs like sunthi (dried ginger) to aid its digestion. After digestion only a very light diet like is allowed. This protocol is followed till the samyak snigdha lakshanas (signs of adequate oleation) are observed or for a maximum of seven days6 .
· Swedana (sudation therapy)
This procedure aims at inducing sweating in the body. While Vagbhatta has broadly listed four major classes of agneya swedana karmas (sweating induced by application of direct fire) namely Taapa, Upanaaha, Ushma and Drava7 , Charaka has elaborated these into thirteen8. Still further anagneya sweda (sweating induced without application of direct fire) methods have been suggested for conditions where agneya sweda cannot be applied9.
· Vamana (Emesis)
Vamana is chiefly indicated for kapha predominant conditions10. Here, following snehapana, the doshotklesha (exciting/mobilizing the doshas for elimination) is brought about by giving diet including matsya (fish), masha (black gram), tila (seasame), ksheera (milk) etc. on the prior day. On the day of vamana, the procedure is done during the kaphakala, i.e, early morning before sunrise, the patient being made to drink either ksheera (milk), ikshurasa (sugarcane juice), yavagu (porridge) etc to his maximum capacity, followed by the drug administration including teekshna dravyas (potent/penetrating drugs) like madana (Randia dumetorum) and yashtimadhu (Glycyrrhiza glabra ) in the form of kashaya (deecoction) or churna (powder) mixed with honey and saindhava (rock salt). The patient is observed for a period of a muhurta (48 min), the maximum expected time of appearance of vamana vega11.
· Virechana (Purgation)
Virechana is a better option for those having a predominance of pitta12. The procedure of virechana is also conducted by administration of strong drugs. Unlike Vamana doshotkleshana is not made on previous day and the drug administration is scheduled after the sleshma kala to avoid the complication which may arise due to incomplete evacuation owing to the obstruction by kapha at the grahani13.
· Vasthi (Enema)
Vasti has been included under the sodhana chikitsa and is said to be the best management for Vata dosha14. Vasthi is administered as a combination of Niruha and Snehana Vasthis in a specified pattern as Yoga, Kala or Karma vasthi, varying in the total number of each type of vasthis15. Niruha or kashaya vasthi (decoction enema) is administered in empty stomach, preferable during morning while Sneha or Anuvasana vasthi (oil enema) is indicated after food. The procedure is common to both: primary snehana as in Vamana or Virechana is not required; only local oil application and massage over the lower abdomen and low back region is sufficient, followed by swedana and then the patient is made to lie down in the left lateral position and vasthi is administered; to ease the administration of vasthi dravya (enema material) into the pakwasaya the patient is advised to breathe through the open mouth. After the administration of vasthi the patient is made to rest in supine position and attend to the urge of defecation as and when it appears. The maximum time of retention for Niruha and Anuvasana vasthis is one muhurta (48 min) and 3 yamas (9 hours) respectively16.
The classical principle of Ayurvedic shodhana chikitsa is that these purificatory procedures eliminates out the morbid doshas which are causing the disease and thereby restores the equilibrium of tridoshas defining the state of health. But technically speaking, it can be said that these procedures are aimed at preparing the body to get its own corrective mechanisms stimulated so as to effectively respond to the existing crisis and thus to speed up the healing. The stimulation is provided through sodhana chikitsa in the form of a hitherto inexperienced and unexpected intervention into the normal physiological equation of the living body.
For appreciation of this, a better understanding of the basic principles of physiology is inevitable. Accordingly, the normal Cell health and functioning is maintained by a state of Homeostasis in the internal environment of the body, i.e., the Milieu interieur popularly known as the ECF of the body17. The state of homeostasis is measured in terms of pH,osmolarity, nutrients concentration, oxygen concentration, waste removal from ECF18. This homeostasis is maintained by the co-ordinated functioning of the physiological systems of the body, broadly grouped under two-Working systems and the Controlling systems19. Respiratory, digestive, circulatory and excretory systems are the working systems whereas the Nervous and the endocrine system are the controlling systems of the body. Only the ECF is constantly flowing material keeping in direct contact with all the systems of the body and thus it is the only medium which can be manipulated to bring about changes in these physiological systems. This principle is made use of in the Ayurvedic shodhana chikitsa procedures.
This concept can be elaborated under the purview of Stress which is defined as a physiological reaction by an organism to an uncomfortable or unfamiliar physical or psychological stimulus. This stress is of two kinds – Eustress and Distress20. The one whose outcome is a negative response is called Distress whereas the one capable of generating a positive beneficial response is called as Eustress. To be more precise, Sodhana chikitsas are a sort of Eustress which alerts the body’s corrective mechanisms by stimulating the controlling systems of the body, thereby, exhibiting their influence through the working systems of the body to achieve a normal homeostasis i.e., the state of normal cell health.
In snehana, the patient is sustained on a fat rich diet while maintaining a gluco-deprived state. But the normal physiology of the body is accustomed to the glucose metabolism alone. Thus snehapana is actually creating a fat metabolic challenge preceded by glucose metabolic challenge. Such a metabolic challenge is identified as a Eustress and which, in turn stimulates the two major controlling systems of the body- Nervous system and Endocrine system. As an output of this stimulation the hormonal secretions are increased especially those of Adrenaline and Cortisol which initiate an Immuno suppressor and anti inflammatory responses through the working systems21. The dose of shodhanapoorvaka snehapana is decided considering the digestive capacity (agni) of the individual or in other terms the time taken to digest a particular amount of sneha. The body absorbs and metabolizes the maximum amount of fat required to support the physiological functions during this gluco-deprived state while the excess is eliminated out, explaining the elimination of fat with feaces during the administration of higher doses of sneha during the latter days of snehapana. Thus, the aim of snehapana is to create a Eustress in the form of a metabolic challenge at the physiological level which alerts the body’s mechanism to fight against the crisis and re-establish the homeostasis.
Swedana or sweating is a response of the body achieved by creating a thermal challenge by manipulating the factors of thermal comfort which are defined in terms of air temperature, air velocity, air humidity, mean radiant heat, metabolism and insulation22. The safe limit of these factors determines the zone of thermal comfort for an individual. Thus, the methods of inducing sweating (swedana) mentioned in the ayurvedic literatures are nothing but different manipulations of the factors of thermal comfort, for example, Jenthaka sweda and karshu sweda are manipulations of the air temperature in a closed room; Naleesweda,valukasweda of air humidity; taila pariseka,kwathaparisheka by manipulating radiant heat; anagneya sweda like gurupravarana by the method of insulation; Ayasa,bhaya,ahava,Krodha,bhuripana,kshut manipulating the metabolic rate and in general the indication for swedana in nivatagraha is a manipulation of air velocity. Precisely, the aim of such swedana procedures is to conduct the heat from a source to the human body using a heat conductor. The different types of swedakarma explained are nothing but just the modes of transferring different degrees of heat energy as per the required condition based on the calorific value of the heat conductor involved there whether it is kashaya, taila, churna, patra, shahtika pinda etc. Accordingly different degrees of swedana are attained in different doshic predominances, as mentioned upanaha in vata, drava in pitta and tapa and ushma in kapha. A thermal eustress thus created calls for the body’s corrective mechanism to come into play, chiefly by the stimulation of the autonomic nervous system; one of the most important among these being the decrease in the cardiac output23. In response to this the medullary Cardio-Vascular control centre brings about peripheral vaso-constriction and increased central circulation which helps to restore the normal cardiac output thereby improving the circulation to the affected areas promoting healing24.
Vamana, virechana, sodhana vasti
In a vamana or a virechana or a sodhana vasti, a state of mild fluid loss - Hypo hydration- is created in the body by the loss of body fluid including water, electrolyte, proteins, and metabolic wastes. While in Vamana and Virechana this hypohydration is stimulated by administering a strong purgative or emetic which drives out the intracellular fluid into the GIT, in Vasthi this is attained by administering a hypertonic solution into the anus which extracts out the intracellular fluid from lower GIT. This is a physiological Eustress which send signals to the Para Ventricular Nuclei of hypothalamus which in turn stimulates the secretion of hormones like Corticotropin Releasing Hormone (CRH) and Argenine Vasopressin. These hormones activate the hypophyseal portal system subsequently activating the locus ceruleus/ noradrenergic (LC/NE) system. At the end of this chain of responses the ANS and the Neuroendocrine responses are stimulated25. These being the controlling systems of the body, their stimulation help to restore the normal physiological functioning of the other working systems thereby enhancing the process of healing.
By creating a hypohydration in the ECF, which triggers the response in the Controlling systems of the body thermoregulatory, endocrine, plasma, GI tract, Cardiovascular, and metabolic stimulation can be established thereby restablishing the lost state of cell health26. For example, the hyperosmotic internal environment created by hypohydration reduces the evaporative heat loss by reducing the activity of medial pre-optic warm-sensitive neurons of hypothalamus (thermo regulatory response of hypohydration).As discussed above; hypohydration stimulates ADH secretion increasing the overall cardiac output (cardiovascular response of hypohydration). Briefly, by inducing a Vamana or a Virechana in the GI tract or by administering a Vasti the stimulus can be transmitted through the ECF even for healing an ulcer at the tip of the finger or the toe; or to cure any psychiatric disorders; or even to manage a condition like cystic fibrosis. Thus, by inducing a Eustress through the ECF the body’s corrective mechanism can be recruited to heal a crisis anywhere in the body. This explains the broad spectrum of diseases enlisted as the indications of such treatment modalities.
However, while manipulating the body systems in the above mentioned therapies, the important thing is to note when and where to stop the procedures so as to prevent complications by flaring up the pathology or triggering pathology anew. For this demarcation, textual references are available about the samyak lakshanas and atiyoga lakshanas of these therapies. The snehavyapat lakshanas co-relate well with the pathological symptoms of improper fat digestion in the gut and transportation precipitated due to the factors interfering with fat digestion and transportation like larger doses (atimatra) or non-observance of dietetic restrictions (mithya ahaara). Similarly, the symptoms of sweda vyapat like trishna, moorcha, amgasada, bhrama etc co-incide with the pathological symptoms of electrolyte imbalance induced during conditions like heat stroke leading to excessive sweating. To prevent this pathology the physician can make use of scales of thermal comfort like Skin wettedness ,Fighter Index of Thermal Stress (FITS),Effective Heat Strain Index (EHSI),Predicted Sweat Loss ,Physiological Strain Index (PSI),Modified Discomfort Index (MDI),Environmental stress index (ESI),etc. based on the objective assessment for thermal discomfort27.
Likewise, in vamana, virechana and vasthi also this physiological limit of the state of hypohydration can be assessed through the samyak lakshanas of these sodhana chikitsas. The symptom morbid thirst (trishana) discussed under the vyapat lakshanas of these therapies, is an identified first sign of dehydration. The thirst centre in the hypothalamus is stimulated only when there is a Na+ ion concentration exceeding a minimum of 2mE/L above the normal which results only from excessive fluid loss from the body. Thus, the perfect delineation between the samyak and atiyoga lakshanas highlight the fact that these therapies are aimed at making manipulations in the physiological systems only within the safe limit.
Directions for Future Research
Thus, it is evident that an analysis of the ayurvedic sodhana chikitsa is incomplete without the discussions of the concepts of Eustress and Hypodydration. So, in the present paper these sodhana chikitsa have been evaluated on the bio-medical aspects of these two phenomenons – Eustress and Hypohydration. But, the subject not being of much practical relevance to the bio-medicos, the textual and research references regarding the concept of Hypohydration are very few. A better understanding about this subject is, however, available in sports medicines with sufficient evidence based research works. Thus, the principles of Ayurvedic sodhana chikitsa formulated centuries ago, though may seem to be an inexplicable miracle, but are equally scientific as any other present day medical therapy. Any phenomenon in this universe holds behind it a definite scientific reasoning. Even the Ayurvedic sodhana chikitsa is not an exception to this.
Accepting these discussions as the working hypotheses future preliminary studies on animal models must be planned in terms of measurable biochemical parameters, which could later be extended to human models safely. However, it cannot be denied that the present hypotheses generated in this paper are only a minute part of the understanding of these therapies and that these have to be viewed in multiple dimensions for its perfect decoding.