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→Vidhi Vimarsha
=== ''Vidhi Vimarsha'' ===
=== ''Vidhi Vimarsha'' ===
==== Pathogenesis ====
''Mahasrotus'' (gastrointestinal tract) has two parts, upper part is ''annavaha srotus'' and lower part is ''purishvaha srotus''. ''Atisara'' is related to ''purishvaha srotus'' and ''chhardi'' is to ''annavaha srotus''. Etiological factors of ''chhardi'' are irritating food and practices to ''amashaya'' (stomach). They are ''vata'' vitiating, impairing ''annavaha srotus''. Even before the digestion process starts the food comes out because of action of ''urdhvavata'' or ''udanavata'', therefore, there is no involvement of ''agni''. ''Chhardi'' is a defense mechanism to expel the toxins out of the stomach. There is vacuum created by repeated expulsion of stomach contents and ''rasayinis''(villi) instead of their normal function of absorption, they start secreting body fluids into to the stomach.
==== Types of ''chhardi'' ====
Diseases are classified according to the dominance of ''doshas''-involved and their mutual amalgamation, which are of four types. The 5th type of ''chhardi'' (''dwishtarthayoga'') is due to aversive food related to the involvement of ''panchagyanendriyas'' (five sense organs) and their ''vishaya upalabdhi'' (Cha su 1/54) (perceivance of senses). The contact through ''rupa'' (visible) or ''rasa'' (taste) or ''gandha'' (smell) or ''sparsha'' (touch) or ''shabda'' (hear) or in combination with each other, stimulates body mechanism which results in ''dwistarthayoga chhardi'' (vomiting due to aversion). One cannot exclude the role of ''manah'' (mind) as predisposing factor in causing ''dwistarthayoga chhardi''.
''Douhruda janita'' (pregnancy induced vomitting), ''satmya prakopaja'' (vomiting due to inadequacy of substances) and ''krimija'' (vomiting due to microbial infection) type of ''chhardi'' are other causes of ''chhardi''.
===== ''Vataja chhardi'' =====
There are many factors that increase ''vata'' in the ''sharira'' . Particular ''ahara'' (food), ''vihara'' (lifestyle) and mental factors increase ''vata'' and its ''gunas'' (properties). This aggravation of ''vata gunas'' like ''rukshata'' (dryness), ''laghuta'' (lightness), etc. plays a role in causing ''vataja chhardi''. ([[Sutra Sthana]] 1/59) ''doshas'' conjugate (''sammurchhana'' ([[Sutra Sthana]] 18/46) with a particular organ (''mahasrotas, amashaya, marma'' (vital organ), ''urdhwabhaga'' (upper trunk, etc) as ''dushyas'' (affected ''dhatus'') to cause ''vataja chhardi'' (as ''utkshepana'' (upward movement), ''adhahkshepana'' (downward movement), etc are the ''karmas'' (actions) of ''vayu'')-(7-9).
===== ''Pittaja chhardi'' =====
Nidanas of pittaprakopaka increase pitta in nature and cause provocation of gunas like ushna (hot), tikshna (sharp), snigdha (unctous), etc. (Charaka sutra sthana 1/60) in the body. This aggravated pitta joins (Sammurchhana) with a particular organ (rasāyani, amāshaya, marma, urdhwabhaga, etc) as dushyas. The conjugation of dosha and dushya has affinity towards urdhwabhaga which results in pittaja chhardi (10-11).
===== ''Kaphaja chhardi'' =====
Nidānas of kaphaprakopaka increase kapha in nature which causes provocation of gunas like guru (heavyness), sheeta (coldness), manda (slowness), etc. (Charaka Sutra sthana 1/60) in the body. This aggravated Kapha joins (sammurchhana) with a particular organ (urah (chest), shirah (head), rasāyani marma, urdhwabhaga, etc.) as dushyas. This amalgamation of dosha and dushya has affinity towards urdhwabhaga which results in kaphaja chhardi (12-13).
===== ''Sannipataja chhardi'' =====
Intake of diet containing all rasas or tastes ideal but the intake of food with imbalances in rasas leads to the vitiation of tridoshas(Ch.Su.26/90-101)and causes sannipataja chhardi which has varied manifestations covering broad signs of tridosha involvement ( verses 14-15).
The sama-varna-gandha (color & smell similar to) of vomitus is due to conjugation with purisha (stool) and mutra (urine). This conjugation indicates involvement of multiple srotasas and have tendency towards asadhyata (incurable)(Charaka Vimana 5/3) ( verses 16-17).
Excessive loss of any dhatu (rasa-rakta-vasa, etc) due to physical exercise or vamana vega (bouts) or arising out of any complications in the form of diseases like kasa (cough), shwasa (asthama), jwara (fever), etc. are considered to be life threatening.
==== Treatment ====
• Langhana becomes the first line of treatment in chhardi as shamana chikitsa (pacificatory treatment). Samshodha can be preferred where doshas are in utklisht stage and ready to be expelled out. Vamana is recommended when doshas are accumulated in amashya or amashayottha (originating from stomach or upper gastro-intestinal tract). Whereas virechana is recommended in case of post-amashayottha (in lower gastro intestinal tract) accumulated doshas, considering nearest route of samshodhana. The choice of drugs should be done as per the doshanashakatva (capacity to subside the vitiated doshas) ( verse 20).
• Haritaki is known for its laxative action (anulomaneeya). It not only tridoshahara but also posseses many more qualities (Charaka Chikitsa 1/1/29-34) which can be helpful for samprapti vighanatana (breaking pathogenesis) in chhardi. The choice of hridya dravya (liking to mind) is recommended in chhardi which should be given with madya (alcohol) and dugdha (cow milk) as an anupana. Madya due to its specific guna (Cha. Su. 27/ 193-195) results in quick absorption of the dravya and hastens the mode of action. Dugdha (cow milk) along with many other qualities (Cha su 27/217-18) is naturally saraka (purgative) in nature which makes anulomana gati (natural movements) of vayu.
• As the doshas are already in utklishta avastha(stage of aggravation or ready to come out), the choice of valliphala for vamana is considered as a mridu (mild). On the other hand if the patient is weak and cannot tolerate the vamana effort, shamana chikitsa should be considered. The treatment planning should be done keeping manah as center point. The diet or pathya should be a manah prasannakara (mind pleasing) (Cha. Chi. 20/ 41-42) . It should be preferably mamsarasa, dry food or liquid diet which is easily digestible ( verses 21-22).
• In vataja chhardi, laghu susanskrita mamsarasa (processed meat soup) is helpful in easy digestion and gives strength due to vatapacifying property. The yusha prepared from amlarasatmaka (sour taste) is not only vata pacifying but also stimulates the heart and leads to Anulomana gati of vayu. Ghrita as sanskaranuvartana (synergistically increases the properties of associated drugs) (Cha. Su. 27/231-32, Cha. Su. 13/13) can be benifitial in vātaja hridroga.
• If the aggravated doshas are in distal part of amāshaya (post- amāshaya) the nearest route to remove pitta is through virechana procedure. If the aggravated pitta is in amāshaya then the nearest route to remove pitta is through vamana. Both these procedures should be adopted in balavan rogi (physically strong) judiciously clubbing with proper samsarjana krama (protocol after purification procedure) to prevent aggravation of vata dosha.
• For shamana treatment the selection of drugs should be pitta pacifying, manapralhadakara (mind pleasing) and balya (strength of patient) criteria. The mechanism of action of these drugs can be through hetu viparita (anti-etiology), vyadhi viparita (anti-disease) or Hetu-vyadhi veeparita chikitsa (anti-cause & disease treatment).
• For kaphaja chhardi chikitsa, as the doshas are situated in kaphashaya (amāshaya / ura) the nearest and ideal route is vamana. The choice of dravyas for vamana should be kaphahara like pippali, sarshapa, nimbatoya, madanaphala, etc. The choice of treatment is based on aggravated dosha, sanchayasthana (place of accumulation), sannikrishtha marga (nearest route), dosha-shamaka guna of dravyas, etc.
• Various types of Yusha, Ragashadava, Panaka (Cha.Su.27/279-281) are kaphahara, madhura-amlarasatmaka (sweet & sour), deepaneeya-pachaneeya (appetizer & digestant) in nature.
• For chhardinigrahana (anti-emetic group), the drugs should be kashaya rasatmaka (astringent taste), sheetaveerya (cool potency) and kaphaghna (kapha alleviators) in nature. The manahshiladi yoga (a formulation) is considered to be vyadhiviparitarthakari (anti-disease) measures.
• In case of dvistarthayoga chhardi (vomiting due to hate/ aversion) The treatment includes ashvāshana (assurance), vārtālāpa (conversation), mitramandali (friend circle), mananusarena ahara-vihara (preferable food & lifestyle). By doing so one can easily overcome the disease for the time being and once the Vegavastha (vomiting bouts) is overcome, actual conceptual treatment can be adopted.
• The vegakalina or chronic chhardi, whether mild or severe, involves constant irritation of involved body parts/systems which leads to poor nourishment of dhatus resulting in dhatuksheenata. Such a long term dhatukshaya (loss of dhatus) increases vata in the body. The management should be purely vatashamaka treatment especially stambhana (which restricts the vamana vega) in combination with brimhana (nourishment to dhatus).
The selection of drugs plays very important role here. Most of the dravyas mentioned here are vichitrapratyarabhadha (extraordinary) in nature which achieve stambhana but won’t increase vata. The description about sarpiguda (a formulation), kalyanaka ghrita (a formulation), vrishya yoga (a formulation), avalehas (a formulation) etc. are the desired formulations for the management may have synergistic action.
==== Current clinical practice for management of chhardi (referred from Chikitsa Pradeep page 25) ====
{|class="wikitable"
!scope = "col"| Type
!scope = "col"| Medicine
!scope = "col"| Dosage
!scope = "col"| Time
!scope = "col"| ''Anupana''
|-
| ''Vata'' dominant and ''vata-pitta'' dominant
| ''Shankha bhasma''
| 60-120 mg
| Frequently
| ''Nimbu Panaka'' (lemon water)
|-
|}
Type Medicine Dose Time Anupana
Vata dominant and Vata-pitta dominant Shankha bhasma 60-120 mg Frequently Numbu panaka ( lemon water)
Pitta dominant Sutashekhara kalpa 500-1000 mg Frequently Dadimavaleha
Kapha dominant Mayu picchha mashi 1gram-3 grams Frequently Ardrakavaleha
Tridoshaja Bruhad vata chintamani 50-100 mg Frequently Ardraka swarasa + sugar + honey
Dauhridaja ( in pregnancy) Swarnashekhara mixture 250-500 mg After meals Ardraka swarasa + Nimbu swarasa + rock salt
Krumija Vidanga-yavani phanta 20-40 ml Empty stomach two times --
==== Further researches ====
Many parenteral and oral medicines are available in conventional medical systems for management of dehydration and emergency conditions. The ayurveada drugs listed in this chaper need to be researched further for evaluating their efficacy specifically in conditions where the parenteral administration is contra-indicated and in case of drug intorerance.
=== Glossary ===
=== Glossary ===