Bahya Kriya Karmas-PANCHAKARMA

‘ Human body is non linear and follows the holistic rules of universe’’ –Dr. B.M Hegde

The modern equation of disease: Damage done by Harmful agent + Body’s reaction = Disease Our science follows a distinctive discretion of the disease, centered for the purpose of treatment: Vikara prakr̥ti : adṣṭhānāntarāṇi: hetuviśeṣa = upakramam.

“Ayurveda never visualizes cohorts but it views through individual phenotypes.”

‘In clinical medicine don’t be satisfied by seeing the flower (the obvious), try to see the insect sitting over it (the minute); but missing the obvious and seeing the minute is unpardonable.’ Dr Kashinath padhiary

Concept of disease in routine ayurvedic clinical practice ……….

कः पुनरसौ रोग इित । अवस्थािविशष्टो दोषः। नरिसंहभाष्यम.१-१ kaḥ punarasau roga iti. avasthāviśiṣṭo doṣaḥ. narasiṁhabhāṣyam. 1-1

बुद्ध्वा स्थानिवशेषांश्च दोषाणां च बला । िचिकित्सतिमदं कुयादहू ापोहिवकल्पिवत ॥ चरकसंिहता िचिकत्सास्थानम२९-१५५

Message from Caraka

मा�ाकाला�या युि�ः िसि�युर्�ौ �ितिष्ठ । ितष्ठत्युप�र युि�ज्ञो �व्यज्ञानव ॥ चरक संिहता सू�स्थानम्२-१६

Line of treatment………………

ु मवधारणिमदमवे धानिमदं निे त न य ु िचिकायां िह धानमवानिवधानम ।् R.V.Su.१-९३

Cikitsā Apakarṣaṇa

Prakr̥ti vighāta

nidāna tyāga

Ābhyantara Bāhya

bāhya ābhyantara abhyaṅga sveda pradeha pariṣekādi

Prakr̥tivighātaḥ duṣṭasya doṣādeḥ dehasthasya śamanaṃ sāmyakaram’

Vikprakr̥ti : General components analysed (Like doṣāvastha) : • Āma, līna, utkliṣṭha etc. Specific disease pattern, like (roge doṣāvasthā) •Raktotleda ( rakta pitta , visarpa) •Bahu, abaddha medo-māṃsa –śarīraja kleda •Rakta mārga nihanana (vātarakta) •Dhātu śaithilya (pāṇḍu, kuṣtha ) •Saṃhata doṣa (śotha) And the basic knowledge of • sāmānya vyādhi • nānātmaja vyādhi

Sāmānyaja or nānātmaja vyādhi svabhāva vyādhi viśiṣha doṣāvastha sāmāny doṣādyavsth

duṣyāvasthā

vikāra prakr̥ti

Śodhana And Bāhya kriyā kramāḥ

Śotha Tridoṣa Tvak Māṃsa Asr̥k  Bahiḥ sirāḥ  Saṃhataṃ sophaṃ  Śodhana - less

Kuṣtha – śopha- visarpa Visarpa kuṣtha tridoṣa tridoṣa tvaṅ tvaṅ lasīkā lasīkā asr̥k asr̥k āmiṣa āmiṣa   bahiḥ sirāḥ tiryaggāḥ sirāḥ   utkliṣtḥa svabhāva dūṣayanti ślathī kr̥tya   Nirhr̥te asre śodhana Viśuddhe antaḥ Doṣe tvaṅ-māmsa Saṃśraye  bahiḥ kriya

Kevalaṃ  Dhātu sārataḥ kṣaya  Sneha svedau

Vāta vyādhi  āvaraṇajaṃ  pratibandhakatvāt  śodhana  Saṃśuddhasya Utthite agniḥ  Sneha svedau

vāta śoṇita  margāvaraṇa and rakta duṣṭi   medaḥ-kapha sāme Āvaraṇa   āḍhya vātokta sveda, vidhi laṅghana pācana vāta śoṇitakīṃ  Kriyāṃ kevala vāta cikitsā

Kevala vāta- dhātu sārakṣaya Sneha  Saṃśuṣka dhātūn Puṣṇāti Balaṃ Agni balaṃ Puṣṭiṃ

Sveda  vakraṃ stabdhaṃ savedanaṃ  yatheṣṭhaṃ ānamayituṃ śakyate

Prāṇāścābhivardhayati

Eäò´É±ÉÆ xÉ iÉÖ {ÉÚ´ÉÉÈMÉ: º´ÉänùºÉäSÉxÉEò¨ÉÇhÉɨÉÂ* Ê ´É¶Éä¹ÉÊ´ÉÊvÉxÉè´ÉÉiÉÉä MÉhªÉiÉä ʴɤÉÖvÉè®úªÉ¨ÉÂ** SSV

Role of the different modes of bāhya sneha / sveda

To meet the different nuances of doṣas / expression of same disease “Ayurveda never visualizes cohorts but it views through individual phenotypes.”

वात�ेष्मो�वं दृष्ट्वा पृथग्वा स्वेद

vāte

kaphe

dvayoḥ

snigdhaḥ

rūkṣaḥ

sādhārāṇa

The variant forms of sveda and the clinical states where they have to be administered are well expounded in Br̥hadyogataraṅgiṇī. ¤ÉÉÁɪÉɨÉÉxiÉ®úɪÉɨÉ{ÉÉ·ÉǶÉÚ±ÉEòÊ]õOɽþÉxÉÂ* Jɱ±ÉÒnùhb÷É{ÉiÉÉxÉÉè SÉ ºxÉä½þº´Éänù{ÉÖ®èúVÉǪÉäiÉÂ** >ð¯ûºiɨ¦ÉÆ VɪÉäpÚùIɺ´Éänù¨ÉnÇùxÉ EòÉèʶÉEèò:** ´ÉɨÉxÉi´ÉÉRÂóMɺÉRÂóEòÉäSɦÉRÂóMɦÉänùOɽþ´ªÉlÉÉ:* ¨ÉnÇùxÉ ´ÉκiÉʦÉ: C´ÉÉlÉè: º´ÉänùxÉè¶SÉ Ê¦É¹ÉMÉ VɪÉäiÉÂ* +{ÉiÉÉxɵÉhÉɪÉɨÉÉè ºxÉä½èþµÉÇhÉ ÊSÉÊEòÎiºÉiÉè:* +RÂóMÉ®úÉèIªÉºiɨ¦ÉEò¨{ÉEòɶªÉÇEòɶªÉÇ iÉÉänùxÉä** nùÉè¤ÉDZªÉä º¡Öò®úhÉä §ÉƶÉä ºxÉä½èþ¨ÉÇnÇùxÉʨɶªÉiÉä*

• In conditions like bāhyāyāma, antarāyāma, pārśvaśūla, kaṭigraha, khallī, daṇḍāpatānaka, sneha sveda is the first line of management. • In conditions like ūrustambha rūkṣa sveda has to be implemented primarily. • In vāmana, aṅgasaṅkoca, bhaṅga,bheda, graham and vyathā sveda is indicated. • In aṅgaraukṣya, stambha, kampa, kārśya, toda, daurbalya, sphuraṇa, bhraṃśa – snehamardana is recommended.

Bāhya kriyākramāḥ Mūrdha sekādi vidayaḥ saṃhitāsvapi sūcitāḥ. Keralīyādr̥taṃ caiṣāṃ sādhu vakṣye kriyākramaṃ. Abhyaṅga seka picavo vastiścaiva caturvidhaṃ. Dvitīyaṃ secanaṃ tatra pradhānam r̥ṣibhiḥ smr̥tam.’ SSV The bāhya kriyākramās are basically grouped into four categories viz. abhyaṅga; seka ; Picu Vasti And the variant procedres; of which seka is given higher importance.

śirodhāra 21

Seka Procedure: Śirasseka Kāya seka Dravya Kaṣāya Kṣīra Dhānyāmla Sneha Takra

Śirasseka 1. fever with burning – sensation & dizziness milk 2. nocturnal fever ,, 3. Arocaka ,, 4. Somaroga ,, 5. Svarasāda Śīrodhārā and vasti 6. jvara (antarvraṇa) takradhāra 7. ardita śirodhāra and kāyaseka With balātaila 8. Prameha Takradhāra 9. asr̥gdhara milk 10. ardhāvabhedaka śirodhāra

Y 2/57 Y -2 C.M C.M Y 11/1 Y 2/76 Y 40 Y 26 Y 26 AKD

Experiments on śirodhārā elucidate some of its actions over the physiological and psycho-somatic strata of the body. •Śirodhārā induced bradycardia, and the expired gas analysis showed a decreased tidal volume and CO2 excretion. • A power frequency analysis of R-R variability in ECG during shirodhara, in order to assess the balance of the autonomic nervous system, indicated that the cardiac sympathetic activity was suppressed during and after śirodhāra. •The EEG results monitored during the process of śirodhārā indicated restful alertness in which the frontal lobe, limbic system and medulla oblongata were activated. These metabolic, ECG, and EEG findings support the reported experiences of relaxed and low metabolic states during śirodhārā. •The differences in heart rate, CO2 excretion, sympathetic tone, and EEG were quite similar to the findings reported in the study of meditation, and they indicate a change in the function of the frontal lobe, limbic system, brain stem, and autonomic nervous system.

• The assessment of POMS (Profile of Mood States) score after a course of śirodhārā revealed anxiolytic effects. The result indicated a significant decrease of tension and anxiety, and a tendency towards a decrease in exhaustion. It also showed some kinds of ASC (Altered States of Consciousness). The highest ASC scores were obtained in the domains of trance, passiveness, timeless sensation, wordless sensation, and concentration. •A study showed that śirovasti and śirodhāra, in progressive degenerative cerebellar ataxia showed subjective improvement in walking and there was a statistically significant improvement in the overall and anteroposterior balance indices of dynamic stability. - Sriranjini SJ, etal Improvement of balance in progressive degenerative cerebellar ataxias after Ayurvedic therapy: A preliminary report. Neurol India 2009;57:166-71; Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore

Kāya seka 26

In Dhārākalpa we find a very brief mentioning of the procedure, kāyaseka. The first detailed description regarding the procedure of kāyaseka is found in the Hr̥dayapriya of Parameśvaraśivadvija (Vaikkaittu Pāccumuttatu): • vata • vatottara roga • rukshitanga Duration

- yamardha

Sneha seka Benefits •Drudhatha of Dhathus •Vrushatha, Deha, Agni, Varna, Ojas •Sthairyam •Indriyapatavam •Jaraso mandyam, Chira jeevitham

Indications of kāyaseka • Āyāma • Śoṣa vāta • Pakṣāghāta • apabāhuka •Ākṣepaka •Apatanra • jihvāstambha • hanugraha • gr̥dhrasī • viśvācī • rakta vāta • kampa • stambha •Prasupti •Sramsa vyāsa vyathā • sarvāṅga ekāṅga vāta – gulma mehādikeṣu api KPC.

Kāyaseka 1. burning sensation and thirst in prameha 2. ākṣepa , āyāma, and apatānaka 3. Aśīti vāta vikāras 4. apatānaka 5. bāhyāyāma, paṅguvāta

sarvāṅga takradhāra Snehadhārā and ṣāṣṭika piṇḍa sveda taila ghr̥ta traivritsneha rasataila

Y 40 CM Suśruta AKD

Picu daṇḍāpatānaka

vātāśani taila

manyāstambha

vātāśanī taila dhānvantara taila

AKD

Nasal discharge / block Without oil – sigru / thulasi swarasa with breast milk With Eranda thaila with thrikatu etc Śirovasti Ardita

trimiśraka taila balādhātryādi taila

Y 40

Sirovasthi  Oil

is warmed to comfortable temparature  Oil poured into the vasthiputaka through a strip of cloth & coconut leaflet which touches the scalp  Filled up to a height of 2-3cm above the hair root.

Siro Vasthi  Time - between 3 to 6 pm  Pre operative procedure:

Shave the head completely.  Make sure to empty bowel and bladder  Keep cotton /cloth in both ears 

• to prevent the entry of oil in to the ear.

 Do generalised

abhyanga.

Sirovasthy - indications  Arditha 

Thrimisraka thaila / baladhathryadi

 Darunaka 

Darunaka thailam / durdhoorapathradi

 Sirograha 

sirovasthi with dasamoola, mathulunga etc. >>> oil

 Insomnia, Indriyasada, dryness of eyes etc

Piṇḍasveda C.S.Su.14/25-26 • • • • • • •

Tila Māṣa Kulattha Odana Āmiṣa Ghr̥ta Taila

The indications of ṣāṣṭikasveda सव�षु केवलािनल�वकारे ष्वन्तबर्�हः स्नेहस्. तैरेव च मांसैमर्हास्नेहसंसृ�ैस्तद�ानाम्भी A.S.Ci.23

• • • • • •

sarvanga ekanga sosha ghoreshu anila vyadhishu Ayama- akshepa Sankoca stambha pakshavadhadishu

�पण्डा�दस्वेदाः

1. It is clear from Aṣṭāṅgasaṅgrahakāra, vātavyādhi cikitsa that the diseased condition of vāta which is not associated with any other doṣā-s (i.e., kevalānila avasthā), is ideal for administration of piṇḍa sveda. 2. The first reference regarding this procedure is detected in the rājayakṣma cikitsāadhikāra of Carakasaṃhitā; wherein svedana with a preparation of grains boiled in milk is mentioned in condition of śūla( caused by vāta doṣa) in the regions of the head (śiraḥ), flanks (pārśva) and shoulder blade (aṃsa). A.H. Ci. 4/14 3. The reference from śvāsa also clarifies that the svedana using milk etc., is ideal in conditions where the benefits of svedana are looked for but the patient is not suitable for the svedana. 4. Ṣāṣṭikapiṇḍa sveda is advocated in vātika kāsa associated with emaciation 5 In śvāsa ṣāṣṭikapiṇḍasveda and sneha dhārā with ghee and oil is beneficial

6. ṣāṣṭika piṇḍasveda and snehadhārā are also employed similarly in the m anagement of hiccup (hidhmā) 7. In hemiplegia (pakṣāghāta), sudation with the bolus of sesame seeds or ṣāṣṭika rice is recommended, or godhūmapiṇḍasveda processed in the milk decoction of balā and the flesh soup of wild cock is also recommended 8. ṣāṣṭika piṇḍasveda is also advocated in the management of chardi, udāvarta, halīmaka, vātaśleṣmajāśmarī. 9. In the management of diseases of vāta (vātavyādhi) ṣāṣṭikapiṇḍasveda plays an essential role, it is prescribed in the treatment of ardita, apabāhuka, ākṣepa, āyāma, sarvāṅgavāta, jaṅghāgraha, ūrugraha, trikagraha, pr̥ṣṭhagraha and kaṭigraha, sakthisvāpa, jihvāstaṃbha, saktiśoṣa and śūla. 10. In khalāyakhañja, godhūma piṇdasveda processed in milk and saireyaka decoction is indicated 11. ṣāṣṭika piṇḍa sveda is indicated in khañja vāta. 12. Sveda with tilakalka is advocated in vātaja śūla 13. In ardhāvabhedaka and sūryāvarta sudation with tila triturated in milk and jīvanīya group of drugs is beneficial; 14. I n vātaja mūtrakr̥cchra, snigdha sveda, lepa, seka and avagāha are indicated.

Ūṣma sveda The other treatment processes which are in vogue at Kerala are: patra poṭṭala sveda, jaṃbīra poṭṭala sveda, dhānya poṭṭala sveda and cūrṇa poṭṭala sveda.

ु ऊा तूािरकालो कपालोपलपांसिभः। पभेन धाेन करीष िसकता तषु ैः॥ अनेकोपाय स ैः योो देशकालतः। A.H.Su. 17/6

Some of the materials used for ūṣma sveda are: utkārikā loṣṭa kapāla upala pāṃsu patrabhaṅga dhānya karīṣa sikatā tuṣa

It is a ball-like cake prepared by boiling grains or pulses and seeds like atasī, kusuṃbha etc. earthen lump brick fragments stone sand chopped leaves grains and pulses dung of cow and other animals gravels husk.

Patrapoṭṭala sveda The process of sudation using a bolus of chopped leaves is called patrapoṭṭala sveda. This procedure is extension of the verse ‘patrabhaṅgena’ in ūṣmā sveda. Śridāsapaṇḍita explain that patrabhaṅga refers to a cluster of chopped leaves and sprouts. े । पभेन छद समूहन तथा पभेन पाणां भः समूहः, पभः िनकृ िकसलय समूहः।

Aruṇadatta. Śridāsapaṇḍita

A direct reference regarding patra poṭṭala sveda is available in the traditional text of Kerala, Ārogya kalpadruma, under the context of vātavyādhi cikitsā. ु ु िशिचाक िनगडीवरण ैरडपवैः अैवा तमैि ै ैलि ैके रकै ः। कापासिपिडकाः कृ ा तािभािभरेववा सेहपाे से िनिािभमु मु ः॥ A.K.D. 17/36,37

The leaves of the following plants are usually used for this purpose, either entirely or selectively as necessary: eraṇḍa - Ricinus communis Linn. arka - Calotropis gigantica R.Br Dhattūra - Datura metel.Linn. nirguṇḍī - Vitex nigundo Linn. śigru - Moringa oleifera Lam. varaṇa - Crataeva religiosa Forst. vāsa - Adhatoda vasica Nees. karañja -Pongamia pinnata(Linn) vr̥kṣāmla - Tamarindus indica Linn. Method of preparation The fresh leaves are cut into small pieces and fried in a pan with grated coconut and a suitable medicated oil till it assumes a brownish colour. In certain cases, powdered drugs may also be added. This mixture is divided into two or four equal parts, added into the pieces of cloth and tied in the form of a bolus with a tuft of cloth above it to hold.

Some of the clinical conditions where patrapoṭṭala sveda is indicated are: • patrapoṭṭala sveda with castor leaves and coconut gratings is beneficial in painful state of āntravr̥ddhi • sveda with the leaves of tamarind and coconut gratings is indicated in udāvarta • the same poṭṭala is also beneficial in pakṣāghāta and sarvāṅga vāta • the sudation with the leaves of castor is indicated in kaṭīgraha • in pārśvaśūla, poṭṭala sveda with arkapatra is applied after anointing either with dhānvantara taila, kṣīrabalā taila or vātāśanī taila.

Vālukāsveda The sveda from vāluka is also a variety of ūṣma sveda. In the early texts the vālukāsveda is indicated for sannipātajvara; and in the later texts it is extended to other conditions like āmavāta. Vālukāsveda is one of the primary treatment processcess in tridoṣaja jvara and in vātakapha jvara The purpose of its indication is mainly to eradicate the kapha, by which the pitta and vāta can be pacified easily. By the depletion of kapha the channels get clarified resulting in lightness of the body. It is in Bhāvaprakāśa and later texts that the vālukā sveda is indicated in the treatment of āmavāta.

1. Udvartana with tvak, patra, rāsnā, aguru, śigru, kuṣṭha, vacā and śatāhvā triturated in dhānyāmla cures khallī and visūcikā. 2. Udvartana with the paste of siddharthaka, rajanī, prapunnāṭa , tila mixed in oil is recommended in śītapitta. 3. Elādi gaṇa is also used for udvartana. 4. Udvartana with picumana and other drugs is indicated in ūrustambha. 5. Nimbādi and mustādi udvartana formulations are also mentioned. Udvartana with the leaves of āragvadhā, kākamācī triturated in buttermilk is mentioned in kūṣṭha. 6. In sidhma, udvartana with the friut of dhātrī, sarjarasa, pākya (yavakṣāra), triturated in sauvīra is beneficial. 7. Rūkṣā udvartana is advocated in prameha. 8. In kṣaya, udvartana with the paste of aśvagandha, apāmārga, nākulāī, gaurasarṣapa, tilā and bilva is indicated. 9. Udvartana with burnt turmeric removes the bad odour of the body 10. Udvartana with tila and other drugs cures the bad odour caused by vitiated medas.

7. In sidhma, udvartana with the friut of dhātrī, sarjarasa, pākya (yavakṣāra), triturated in sauvīra is beneficial. 8. Rūkṣā udvartana is advocated in prameha. 9. In kṣaya, udvartana with the paste of aśvagandha, apāmārga, nākulāī, gaurasarṣapa, tilā and bilva is indicated. 10. Udvartana with burnt turmeric removes the bad odour of the body 11. Udvartana with tila and other drugs cures the bad odour caused by vitiated medas.

Na amulaṃ likhyate kiñcit na anapekṣita muchyate Śubhaṃ