Basics of Chikitsaa

Vaidya Vilas Nanal
AVP

Introduction :
The term Chikitsaa arises from the verb Kit Rogaapanayane, meaning, to alleviate disease. Charaka defines Chikitsaaas all such measures, that when employed, establishes the physician equilibrium of the body constituents and re-establishes health. All this should be done by a competent physician only. This definition is so broad that it includes not only medication but also other non-material methods like meditation, offerings to fire, and the deities, as well as counselling. In the same definition, he has categorically stated that health and disease management is the function of a trained, qualified and competent physician and not of a quack.

It is also the chief of the eight branches / specialties of Ayurveda because: –

1. A physician has to deal with these diseases much more frequently than with the other branches,
2. Internal diseases are difficult to diagnose and therefore to treat and finally
3. All other specialties presuppose a sound knowledge of this branch; all surgeons must be good clinicians first.

The scope of this branch is described as follows: Kaaya Chikitsaa is that branch of Ayurveda which deals with systemic diseases, Psychosomatic disorders their diagnosis and management both from preventive, promotive and curative aspects till their recurrence is sealed off.

Human life is an inseparable confluence of four basic constituents: –

1. Physical body
2. Sense organs
3. Mind and
4. Soul, Spirit, Aatman, Consciousness etc.

Each has certain qualities attributed to it and due to which they fully partake in the life process when they are in a state of harmony. When extrinsic or intrinsic factors come in contact with the internal milieu of the body, they succeed in disturbing its equilibrium and the result is manifested in disease. Depending upon the nature of the intensity of assault, the diseases exhibit a variety of symptomatology. Their base remains twofold viz. body (soma) and the mind (psyche). Though these two have been separately enumerated most of the diseases are psychosomatic in nature. Causative factors have been elaborately classified and described in the texts and by the commentators too. Similarly the management too has been classified into various categories. The main aim is to re-establish the lost balance, restore a state optimum function of all the body life constituents and make it a happy and beneficial one.

The management always aims at relieving the person from suffering, in and so the attending physician must assess the condition diligently and accurately. This is known as Nidaana or diagnosing the condition. It is done by two methods positive i.e. by identifying the situation by studying the symptomatology, the cause effect relationship and the pathogenesis in depth; the other method is of elimination of all other possibilities and then to arrive at the final diagnosis or the differential diagnosis. In practice one has to employ both the methods judiciously. (Refer to the article on Nidaana).

This understanding gives the physician the complete clinical picture of both the patient and his disease as well as information regards the onset, duration and progression; the strength of the disease and the possible course it would take in case of failure to treat; the possible complications that could arise or signs of fatality, the residual damage that could remain in case of chronic or less severe disease. Planning the management presupposes this understanding.

Definition and Elaboration of the Concept

1. Physical diseases need physical handling. This is mainly of two types:

Panchakarma (please refer to Panchakarma article elsewhere) Purificatorymeasures; this is a set of five procedures that physically eliminate the contaminant, vitiated Dosha_s (please refer to the article on concept of Dosha elsewhere) out of the system. These purificatorymeasures are as under: –

• Emesis Vamana, it is useful for diseases of Kapha and it eliminates the vitiated, disease causing Kapha by medicine induced vomiting
• Purging Virechana is useful for diseases of the Pitta and it eliminates the vitiated disease causing Pitta by drug induced purging.
• Enemata Basti it is useful in conditions arising out of aggravated Vaata. This helps eliminate and control the vitiated and diseases causing Vaata by retention of liquid enemata.
• Nasal instillations Nasya these modalities are useful for Dosha_s harbouring in the supra-clavicularregion and which cannot be accessed by the previous methods.
• Blood-letting Raktamokshan`a this modality is employed to eliminate the vitiated Dosha_s circulating in the internal environment and which defy attempts of bringing them to the alimentary canal for elimination. This is also used to treat sensory symptoms like parasthesiae.

The principle behind purification is to rid the internal environment of various Patho-physiological blocks that have developed between the vitiated Dosha_s and the harbouring body constituents. Thus they re-establish the proper movement of Vaata along its natural pathways.

S`hamana Chikitsaa / Palliative measures to not eliminate the contaminants out of the internal environment but they render them in such a form that they do not remain contaminants any more. This is done by improving the Agni function (Agni is the individuals digestive capacity Refer to Agni article elsewhere). These are of seven types and described below: –

Paachana :
It is aimed at relieving the burden on the weak digestive power, which leads to formation of a transient metabolite, which is a toxic, occluding and non-nourishing substance, called Aama. It is generated in place of Aahaara Rasa because of which it has access to all the sites of Rasa. Since this is a contaminating substance and heavier, grosser, slimier, slower owing to its larger molecule size, it cannot penetrate the cells and the result is occlusion. Thus it exhibits a natural tendency to hamper the normal functioning of the local constituents. Hence the first step in any management, where the purification is not possible, the physician has to try and convert this undigested or partly converted material and free the constituents of its burden. This is effectively done by improving the intensity of the digestive power of the person. The first to come to the rescue is the pungent taste, which is made up of a combination of fire and air. These substances intensify the digestive activity and thus reduce the burdenof Aama. The next is the bitter taste. This has a predominance of air and space. This too results in absorbing the extra fluids in the internal milieu and thus reduces the burden on Agni. The next are the salty and sour tastes which too have a fire component in them thus they improve the digestive capacity. The last is the astringent taste, which has the air component in it. These substances reduce the excess fluidity and unctuousness from the internal milieu and render it dry, light thus reducing the Aama. The only taste that is useless for Paachana is sweet. These substances act mainly on the Dhaatvagni_s or the parts of the Jaat haraagni that are situated in the basic seven tissues controlling their metabolism.

Deepana :
It is aimed at intensifying the gastric fire / Jaat `haragni, it is the main source of conversion of ingested food and water. It is responsible for the generation of Aahaara Rasa and thus reaches the nourishment to all other body constituents. The abnormal function of Agni e.g. hypo function or Mandaagni, hyper function or Teekshn`aagni, or erratic function or Vishamaagni leads to generation of Aama. This results in malnutrition of the tissues and occlusion of the internal spaces. This further leads to various conditions of occluding retentive nature along with Vaata aggravation. In order to set this right the procedure adopted is called Deepana. It is best done by pungent, sour tastes, preparations like Aasava or Arisht`a (dosage form containing self generated alcohol) This intensified Agni then converts the Aama to a non-toxic form and brings it to the alimentary canal for elimination. Ayurveda professes that most of the intrinsic diseases are a result of malfunctioning of Agni. Hence management of Agni is the essence of health management.

Kshut Nirodha:
It is withholding hunger, fasting or restricted food intake. Today the merits of fasting are being realized by the people and the medical fraternity alike, as a per excellence eradicator of free radicals and antioxidants. If total fasting is difficult to endure then restricted food intake according the condition under treatment is advised. This reduces the burden over the Agni and the amount of circulating Aama. It is a very tool in the management of Santarpana diseases (conditions arising out of plenty of every thing food, drink, rest). The food restriction is specific to disease conditions. It can be used as a promotiveand a preventive tool also. It has been incorporated into the daily regiment and people observe fasts generally once a week. However they do not adhere to the diet that is expected during the fast and this results in further Aama generation; the most common example of wrong diet being sago, potatoes, bananas, sweet potato, coconut etc on the day of fast. A fast is to be observed for giving rest to the overworked digestive system so that it has a chance to cope up with accumulated Aama and be ready for the next meal on the following day.

Trit`nirodha:
Trit`nirodha is withholding thirst or restricting water intake. It is very difficult to restrict water intake completely but in certain conditions like ascitis, Ayurveda advises complete refraining from water and the patient is shifted to cows milk or buttermilk till his condition subsides sufficiently. Other condition where water retention is the cause of disease, excretion of fluids is another condition where it is essential to restrict water intake. The via media suggested for this situation is called as Siddha Jala i.e. medicated water prepared by using various herbs in specified amounts and is administered throughout the day. Depending upon the predominant Dosha it could be boiled or cooled or served hot. It is advised during the rainy season for normal persons due to humidity and overcast skies the digestive capacity is compromised and it definitely leads to Aama generation. To prevent this, observing fast and consuming hot and medicated water is advised. This proves beneficial if followed faithfully.

Vyaayaama:
Vyaayaama is physical exercise, any physical activity done regularly repeatedly, till half the capacity of the person yields beneficial results. The symptoms of having reached half your capacity are

1. Breathe through mouth
2. Appearance of sweat on the forehead,
3. Axillae, tip of the nose, joints etc.

These are indications that a person should stop his exercise at this point; else it could lead to serious consequences. Exercise is a powerful modality for managing diseases of musculoskeletaland neurological origin. It is useful to improve the tone of the postural muscles and muscle power of the voluntary muscle groups; it imparts stability by managing the excess fluid in the tissues and it is crucial in converting the Aama by intensifying the Agni. It should be done under supervision initially and with sharp eye for the signs described earlier. Physiotherapy and occupational therapy are the paramedical branches dealing with rehabilitation and exercise.

Aatapa Sevaa:
Aatapa Sevaa is exposure to suns rays; it has affinity with Rakta Dhaatu. A word of caution is that exposure to the sun should preferably be in the evening and not in the morning. The intensity of the rising sun increases with every passing moment while it is decreasing in the evening. Persons who are sensitive to the sun should take care or avoid it completely. It has a beneficial effect on blood circulation.

Marut Sevaa:
Marut Sevaa is exposure to dry, clean wind or clime. In some conditions a change of climate is beneficial for controlling the disease process. Excessive humidity, pollution with high percentage of suspended particulate matter is injurious to the internal milieu. A change of climate helps medication. Some authorities interpret it as practice of Praan`aayaama the Yogic breathing technique, breath control. This in short was the set of palliative treatments where the vitiated Dosha_s are not expelled but converted by increasing, intensifying the digestive fire activity. This forms the bulk of the practice of a Vaidya.

Rasaayana :
It is the rejuvenation branch of Ayurveda. It means to improve the Rasa substantively, qualitatively and functionally too and to improve its reach to the smallest possible unit the S`hareera Paramaan`u or the individual cell. This rejuvenation is done in various ways.

General Kut`ee Praaves`hika, in this procedure the patient is confined and isolated during the course of the treatment. The selected medicine is administered at sunrise in such a sufficient dose that he can skip a meal. He undergoes Panchakarma before admission; followed by Abhyanga, Udvartana (removing the excess oil from the skin with dry herbal powders) and Snaana (bath) with medicated water followed by a strict diet and regimen. The results are astounding as if the patient is reborn with all the benefits of Rasaayana. Specific to the disease, age season etc. Vyaadhi Apunarbhava e.g. for obesity use of S`hilaajatu, Triphalaa; for Grahanee (intestinal motility disorders) use of Parpati and fresh Takra / Buttermilk without adding water. For the desired effect etc. Kaamya Rasaayana use of Bhringaraaja / Ecliptaalba for liver disorders. Without elaborate regimen or restrictions Ayurveda advises a Vaataatapika Rasaayana i.e. a small amount of Chyavanapraas`ha at sunrise for a long period during winter without much dietary restrictions and similarly use of Kooshmaan`d`a Rasaayana in summer etc.

Vaajikaran`a :
It deals mainly with the reproductive tissue metabolism as well as the regenerative activity / capacity of the body. In case of sexually active persons the activity though immense pleasure results in depletion of S`hukra. This terminal and the most potent tissue are a result of thirty days efforts and processing of the ingested food by the various Agni types. It is the main contributor to formation of Oja. Excessive indulgence without consideration to Prakriti, Dhaatu Saarataa, Age, Season, dietary content etc. leads to accumulation and aggravation of Vaata of a high order and significant tissue damage that is difficult to replenish. The accumulated Vaata, depletes S`hukra or Oja whichmakes the condition very difficult to treat or endure. All diseases affect the regenerative activity hence the management is not complete without adding, some S`hukra facilitating agent, like Rasaayana Vaajikaran`a too can be of general purpose that is effective on all the Dhaatu_s or it could be diseases specific or tissue specific. Substances like gold, silver, mercury As`hvagandhaa, Shilaajatu, cows milk and cows ghee etc. can have a multiple role to play in the body.

The purpose of this elaborate and logical exercise is to re-establish the deranged balance of Dosha_s and to cleanse the contaminated Dhaatu_s and other constituents, improve and maintain Agni activity at optimum, maintain smooth function of mind, sense organs and thus establish an optimal state of function of all the body constituents and induce a sense of well being. Health is not a mere absence of disease but a positive state, which needs to be maintained. In order to achieve this it is important to have as clear an understanding of the Hetu, Lakshan`a and Sampraapti of the situation under consideration. The nature of the causative factor, the method of its spread and the course it would take if not treated are all important factors. The amount and intensity of vitiated Dosha_s involved in the Sampraapti, also give a guideline to the measures to be adopted. Basic considerations like Santarpan`a, Apatarpan`a are important clues to measures needed to manage the situation.

Other modalities of Chikitsaa are as under:

Daivavyapaas`hraya:
This involves rituals, wearing amulets, oblations to various deities believed to ameliorate the condition. Any disease when scientifically diagnosed treated fails to yield desired relief then the sages advice is to consider the Karma dimension. This particular modality deals with the Karma Vipaaka. Here the logic of elicitablecause and effect is not apparent. Jyotisha, Atharvaveda procedures like wearing amulets, Man`i. chanting of Mantra_s, offering ghee, medicinal herbs etc. to the holy fire to be carried to the deity are some of the measure that fall under this category.

Satvaavajaya :
This involves psychological measures like counselling and use of antagonistic emotions to counter the effects of the one causing disturbance. All the diseases are psychosomatic in nature but those conditions in which the psychological component is pronounced are classified as Maanasa Vyaadhi_s, they warrant Satvaavajaya Chikitsaa. In these situations the insight is impaired; the relation between the situation and its perception is lost or affected leading to diverse and bizarre responses to a stimulus. Counselling is aimed mainly at moulding the mindset, making the person realize the fact of the matter, his capabilities, strengths and weaknesses etc. teach him relaxation techniques to combat stress, use of Yoga postures, breathing techniques, meditation are all very helpful. The role of medicines is minimal here as all such agents have a tendency of developing dependence on them. It is aimed at instilling self confidence and esteem in the patient by counselling, offering objective analysis of his perceived predicament, helping him find a solution to the same by refraining from succumbing to various desires that have him in the trouble in the first place, help him wherever essential but ensure that he / she does not develop emotional attachment to the physician. Ask him to read relevant literature, scriptures, reported cases etc.

Yuktivyapaas`hraya :
Means management of the disease by intervention by either medicine or surgery or othermodalities like food and regiment to control the condition logically and rationally. Yukti is putting diverse facts together and constructing possible scenario as regards the causation, progress of the disease to the minute and then planning the management. This scheme is Yukti and management based on this is Vyapaas`hraya. The previous four fold management (S`hodhana, S`hamana, Rasaayana and Vaajikaran`a) falls under this heading. Surgery in conditions that warrants it, cauterisation, branding etc. also is a part of this modality. Alteration of diet, changing it from unwholesome to wholesome, regulating the life style is also a part of this modality.

Other classification of Chikitsaa is under the following three headings:

Antah Parimaarjana :
Antah is internal and Parimaarjana is purification of the internal environment hence it is a group of modalities that when used internally manage to establish equilibrium of the vitiated Dosha_s. They improve the Rasa Dhaatu substantially, qualitatively and functionally thereby establishing homeostasis. This has an explicit effect on the Rasa and its circulation and Rasa in turn is dependent on Agni function for its generation, hence these types of modalities act on Agni full tilt (it is the purifier par excellence in the universe.)

Bahih Parimaarjana :
BahihMeans external and Parimaarjana is cleansing, purification, thus all such external measures using the skin as e.g. the Abhyanga(massage), Lepa (anointing), Parisheka (sprinkling of medicated oil or liquids on the affected part), Avagaaha (immersion bath involving the affected part or general), Unmardana (kneading the affected part) etc. result in pacifying the external manifestations on the skin or external symptoms of internally vitiated Dosha_s fall under this category.

S`hastra Pran`idhaana:
Is surgical intervention, it is of eight types, various incisions to cut, puncture, cleanse debride, explore, manipulate, extract, reduce and set fractures and finally suture, applying leeches, chemical cauteryetc. are the modalities of this particular branch.

Chikitsaa Paada Chatusht`aya:
Management of any disease is a team effort and Ayurvedadescribes the team as having the following four participants: –

1. Vaidya – the first and the most important member of the team, if he is competent then the patient has a chance to recover. The sages have described the basic minimum attributes that a physician should possess to be successful they are as under:
   Daaksha attentiveness, alertness about the patients condition,
   Teerthaattas`haastraartha one who has learned the science from an adept; according to the method prescribed; to his teachers satisfaction and after he grants his permission as well as the royal permission to commence the profession of healing.
   Drisht`akarmaa one who has had adequate practical experience of his craft under the able guidance of his teacher and finally
   S`huchi one who understands the importance of purity and cleanliness in his thought, word and practice
2. Dravya the substances with which the physician tries to manage a disease should also possess the following four attributes
   Bahu Kalpa it should have the possibility of variety of dosage forms, it should be possible to use it in innovative form and processes,
   Bahu Gun`a it should have a wide range of attributes in it,
   Sampanna it should be possessed of proper inherent qualities like colour, time of picking, harvesting, properly stored, devoid of impurities etc. and finally
   Yogya will produce the therapeutic clinical effect after administration to the patient.
3. Upasthaataa is the attendant, nursing care provider in the management of the patient. He / she should also possess the following four qualities:
   Anurakta attached to the patient, one who has the well being of his charge at the centre of his thoughts and is compassionate
   S`huchi clean himself and diligent about the cleanliness of his charge and the environment,
   Daksha alert to the condition of his charge and
   Buddhimaana intelligent, prompt in responding to the need of his charge
4. Rogee is the patient; he also should possess the following four qualities:
   Aad`hya very well to do to downright rich, this is important for providing specialized health care, building a cottage for Rasaayana, and for delivery etc.
   Bhishak Vas`hya should willingly submit himself to the control of his physician, should have faith in him and be ready to comply with his instructions,
   Dnyaapaka should be capable of lucidly describing his situation to the attending physician and
   Satvavaana should possess strong will to overcome the disease and become healthy; should be ready for whatever may be the treatment modality adopted faithfully. Dietary restrictions imposed upon him by the attending physician
   
   About the efficacy of the medicine

The administered medicine should exhibit its action on the condition for which it was administered without generating any untoward effect. The specialty of Ayurvedic management is that it is holistic in every sense of word. It has due consideration to all the aspects of the disease and the diseased person. The consideration Apunarbhava or ensuring non-recurrence of the disease, disease specific rejuvenation is some of the aspects worthy of special notice.

Vaidya Vilas Nanal
Sr. Scientist AyuSoft. Pune.

Last updated on February 15th, 2021 at 11:02 am