Panchakarma –The Gem of Ayurvedic therapies

Panchakarma has become a familiar term to most of us today, with many of us having undergone the Panchakarma therapy ourselves, or knowing someone who went through the same. The term has so much of a reach now, that it is often used synonymously with Ayurveda. For a common man, Panchakarma is Ayurveda and in a doctors perspective it’s his bread and butter. But a critical analysis of the current proceedings in the Ayurvedic sector today reveals that the practice of Panchakarma, or at least that what is being practiced in the name of Panchakarma, differs significantly, from the instructions mentioned in the classical texts of Ayurveda.

Concept of disease and treatment in Ayurveda

Panchakarma is a critical component of Ayurvedic treatment and to understand the term, one needs to know how Ayurveda describes the concept of disease and their treatment.  The statement ‘Ayurveda is not a treatment but a way of life’ is perhaps ubiquitous today, and it essentially means that Ayurveda aims to maintain the normality of health in people in addition to the recovery of health in the diseased.

The concept of Ayurveda is based on the Tridosha theory. According to this concept, the physical, physiological and psychological aspects of all individuals are attributed to their Tri-doshas, or the three humors that are Vata, Pitta and Kapha. A balance in these three doshas leads to a normalcy in their health, and a loss of it gradually results in manifestation of diseases. A lot of factors such as diet, habits, exercise, emotional factors, seasonal variations, age to name a few, may be responsible for this vitiation. To put in a nutshell, treatment in Ayurveda is about bringing the three doshas back to normalcy.

When thinking of dosas and their balance, a question may arise as to how we bring all diseases under a single roof of dosa vitiation. How can we include conditions like infections that result from external causes? Well, Ayurveda classifies diseases into Nija (caused due to factors within the body) and Aganthu (caused due to external factors). In case of Nija, vitiation of dosa occurs first prior to the disease, whereas in Aganthu the causative factor precedes the vitiation of dosa. Thus, deviation from the normalcy of dosas occurs in both cases. Hence treatment in Ayurveda consists of several steps, which include identification of the causes of the disease and their prevention (nidana parivarjana), expulsion of the vitiated dosa from the body (sodhana chikitsa), alleviation of the dosas that are vitiated (samana chikitsa) and finally the rejuvenation of the body to its original state (rasayana chikitsa). Among this, samana chikitsa and sodhana chikitsa are the major treatments. Samana chikitsa is relatively simple and can be done on an outpatient basis. Dosa balance can be restored by the gentle procedures of samana if the perturbation is mild. Sodhana chikitsa/ Panchakarma is a more complex procedure, and it expels the vitiated dosas from the body.  In more simple terms, Panchakarma flushes out the toxins and uproots the disease completely, and is done especially when the perturbation of dosas is severe.

Panchakarma/ sodhana chikitsa, are the five evacuative procedures for active intervention in the treatment of diseases. They are to medicine as surgical procedures are to surgery. India’s vastness and its diversity is reflected in the Ayurvedic treatment styles; especially in Kerala where the Panchakarma treatment was given lot of importance in the early periods. The Vaidyas of old days had developed many special procedures which are not elaborated in the classical text books of Ayurveda. For these reasons Panchakarma in Kerala occupies a special place.

Concept of personalized medicine in Ayurveda

The normalcy of doshas in an individual is considered as prakriti of that particular individual. Prakriti can be somewhat regarded as the ayurvedic way of determining the genetic constitution of an individual in terms of three doshas. Genomic studies of recent times have proved that people with similar prakriti have identical genetic makeup. Though the prakriti is grouped broadly into seven depending upon the predominance of one (3 types) or two (3 types) or three doshas (1 type), innumerable permutations and combinations are possible between them. It is similar to each human having a unique genetic combination, where two persons can be genetically similar, but not exactly alike. Disease is considered as a deviation from prakriti. Since the normalcy in doshas is unique for each individual, their deviation from normalcy is also unique, and consequently so is the required treatment for the individual. This is essentially why we call Ayurveda a Personalized medicine. However, this doesn’t imply the need for a thousand different medicines for a thousand different patients with the same disease. But this aspect of Ayurveda makes it impossible to have a perfect prefixed protocol of treatment without evaluating the patient.

What is Panchakarma?  

The term Panchakarma means

Pancha’  – five

‘Karma’- Processes

The five Karmas include Nasya (instillation of Nasal Medication), Vamana (Emesis/Vomitting), Virechana (Purgation), Sneha Vasthi (Oil enema) and Kashaya Vasthi (decoction enema). Rakta moksha (blood letting) is also an important process in the surgical point of view of Ayurveda, even though it is not included under Panchakarma.

A Panchakarma treatment can be divided to three phases

  • Purva Karma/ Preceding phase/ Preparatory phase

This phase includes Snehapana (oil/ghee intake) and Sweda karma (sudation therapies).

  • Pradhana Karma/ Main Phase of Panchakarma treatment

Includes the five processes mentioned above

  • Paschaat Karma/ Succeeding phase/ Follow up phase

Includes the dietary patterns called Peyadi Krama

All these procedures may not be performed in all patients. The required procedures are determined from the condition of the patient and are up to the discretion of the doctor.

Purva Karma/Preparatory phase

Snehapana  (Oil/ghee intake)

Snehapana can be performed in two ways. One method is to have oil/ghee daily in small doses (Vicharana snehapana) along with normal food. The second method is to have oil/ghee in increasing dose on empty stomach for 3-7 days (Accha Snehapana). The second method can be done only when the person is completely under doctor’s direct supervision since there are increased chances of complications. The type of snehapana, the dosage, type of oil/ghee/animal fat, number of days depends upon the patient’s strength and disease condition and should be determined by the doctor.

Snehapana is arguably the most difficult form of treatment for the patient as well as the doctor, especially when performed in high doses. The oil or ghee consumed as part of this procedure spreads all over the body, and in the last days of snehapana, one can smell the ghee in the hair, skin and bed of the patient and also feel the oil in their skin and hair follicles.

Svedana Karmas (sudation therapies)

Svedana Karmas are done in conjunction with external oil application. It’s normally done after internal administration and along with external application of oil. It includes almost all types of massages. These processes are often done under the label of Panchakarma whereas in reality it is only a preparatory therapy of Panchakarma. Svedana Karma can be done in various techniques like oil application and steaming, application of bolus made of medicated powders, leaves, rice etc. The required technique is selected depending upon the condition of the patient. This phase of treatment is usually pleasurable to the patient, but many restrictions are required for a successful therapy. Generally, it is done for seven days, but it is not a rule. The procedure can be continued till the certain symptoms of saturation or optimum application (samyak lakshanas) appear in the patient. More than one svedana karma can be done in a patient.

The oil intake/ snehapana and sudation therapies/ sweda karmas can also be done as samana chikitsa. In such cases, it is not associated with Panchakarmas. However, for doing Panchakarmas, oil intake and sudation therapy is mandatory. The five purification procedures on their own can’t remove vitiated dosas present in the vast network of body channels. Hence the purvakarmas help to loosen and mobilize the dosas from the body channels, clear the openings of the channel into the alimentary canal and deliver them into its lumen.

The five Pradhana Karmas/ main processes

Vamana/Emesis

The Vamana process is done to eliminate the vitiated Kapha dosa from the body. Specific emetic drugs are selected as per the condition of the patient and repeated emesis is induced for the complete elimination of doshas.

Virechana/Purgation

Virechana is done to eliminate the vitiated Pitta dosha from the body. The purgative drug and its dose are determined by the condition of the patient.

Vasthi/ Enema

Vasthi is of two types – Kashaya Vasthi (Non lubricant enema) and Sneha vasthi (lubricant enema). It is done to eliminate the vitiated Vata dosha. Decoction enema/Kashaya vasthi plays a major role in elimination of doshas, but it can be applied only in combination with oil enema. Otherwise, it may give rise to complications. The number of days and medication for vasthi is determined by the condition of the patient. Vasthi alone is regarded as half treatment in many conditions.

Nasya/ Nasal instillation of medicine

Nasya includes the instillation of nasal medication and is done for the elimination of doshas; mainly in diseases affecting the head and neck region. The puravakarmas like snehapana and generalized swedana is not mandatory for nasya. But application of oil and fermentation is done in the head and neck region just before the procedure.

Rakta Moksha/ Blood Letting

Rakta Moksha is also an important process of Sodhana, but it is not included under the title of Panchakarma. This process includes the removal of impure blood from different sites in the body through scarification using a metallic instrument and application of leeches. The site depends upon the disease condition. This treatment is seen to be effective in conditions where other treatment procedures fail to yield results. The purva karmas mentioned above are generally not indicated in rakta moksha. Rakta moksha is no less important in surgical treatment than vasthi/enemas in medical treatment. Great care has to be taken to stay clear of vital spots during this procedure. The technique for bleeding by leeches is masterly and was a therapeutic practice that was used all over the world even in the first half of the twentieth century.

The surgical branch of Ayurveda –Salya tantra is not so familiar to many. Today, only a few surgical techniques are practiced by Ayurvedic Surgeons. Surgical treatment in Ayurveda enjoyed high prestige up to the time of Jivaka who performed a trephination of the skull on King Bimbisara and served as a personal physician to Buddha. But surgical techniques lost its prime status within a few centuries after the Buddha.

These five therapies can be done alone or in combination as per the disease condition. Usually virechana (purgation) must be done 14 days after Vamana (emesis) and Vasthi (enema) must be done seven days after virechana. Even though this is the rule in classical text books, the major consideration in determining the gap between therapies is the patient’s health. The gap is to be greater in case of a patient who is weak, and vice versa. In any case, a very short gap of a single day or less is not at all advisable between two therapeutic procedures.

Paschat Karma/ Follow up treatments

The follow up phase is equally important as the main treatment phase. During this phase the body will be in a very fragile condition. The digestive capacity will be weak and to protect and enhance the same, certain dietary patterns and restrictions (pathya kala) are advised for this period. The Pathya kala is generally equal to number of days that was required for the treatment. In practice, it is normal to take up to three months before receiving the benefits of a panchakarma, even though changes start to occur just after the treatment. Therefore, in order to obtain the benefits in its entirety, the adherence to the regimens of this period is very important. This period doesn’t require hospitalization.

Pancha Karma for a Healthy Person

Pancha Karma can be done in healthy persons to maintain their health. Dinacharya (daily regimens) and rithucharya (seasonal regimens) are two important aspects of maintenance of health in Ayurveda. Daily regimens include the daily diet and habits that we need to follow to maintain our health whereas seasonal regimens include those that need to be followed in specific seasons. Sodhana processes in Panchakarma are indicated as part of seasonal regimens and are usually performed in the transition phase from one season to another. The outbreaks of diseases are more likely during changes in climate or season. This is due to the fact that our body becomes weak when there is a sudden climatic and temperature change. Ayurveda explains it with the tridosha concept as sudden increase of doshas, and Pancha Karma is done to eliminate it, making the body strong and immune to diseases.

In such cases, consumption of small amounts of oil/ghee with food along with sudation therapies is done as poorva karma. The type of Sodhana – Vamana/ Virechana/ Vasthi is done as per the condition of the person. The follow up treatments is done as mentioned above. Doing these Panchakarma treatments in the right time every year is in some sense a repair therapy for the body. Any machine which we use in our day to day life requires a service after a particular period of usage. This is critical in order to keep the machine in optimum working condition and extend its life span. Likewise, a properly done panchakarma helps in maintaining the health of an individual.

“Panchakarma” today

A quick search in Google about Panchakarma today yields about 560,000 results. Despite such a large number of articles and websites that attempt to explain Panchakarma, it is deplorable that the information provided in nearly all of them are inaccurate and misleading. Instead of the original five therapies, one can obtain details of at least 50 different treatments in the name Panchakarma, with the real therapies given the least importance of all. In the real world, there are a plethora of “treatment” centers offering Panchakarma treatment as packages, which has led the common people to think of Panchakarma as a special massaging technique that constitutes an enjoyable activity for their vacation.

Under such circumstances, it cannot be stressed enough that Panchakarma is a procedure that needs to be performed with the utmost care as in the case of a surgery, and such a procedure requires a lot of professional expertise. A lot of co-operation from the side of patient is also required in this treatment procedure. Each and everything related to the patient such as the diet, activities, sleep etc will be regulated by the physician with a lot of restrictions. It is also crucial that the patient be on complete rest. However, such rigor is often not followed in the so called Panchakarma packages. For instance, the oil application and massage techniques are given priority over the sodhana/elimination phase. The patient will definitely feel better after the sudation processes, but it will be only temporary since the doshas are not eliminated from the body. Even if shodhana process is performed, it is usually not done in accordance with the rules, but instead as a milder version of the real process. Although, in such approaches there are lesser chance of adverse effects, the benefits will also be less. Ultimately, this means that if we analyze the cost to benefit ratio of such packages, they may prove to be a loss of time and money.

It is critical to realize that any activity done in the name of Panchakarma that does not adhere to the systematic methods of original treatment procedure will cause more harm than good. The success of Panchakarma is hence conditional, and only upon the satisfaction of all the strict requirements mentioned earlier.

A few do’s and don’ts in Panchakarma

  • Emesis and purgation must be performed in the proper season except in emergency situations. Severe heat, rain and cold should be avoided.
  • Between two evacuative procedures the patient should undergo lubricant and fomentation therapy.
  • Use hot water for all purposes
  • Avoid exercise, exposure to cold and sun, travelling, day sleep.
  • Must be calm emotionally
  • Diet must be restricted as per the condition of the patient and the treatment he is undergoing.

These are just a few guidelines that are most important, and the list is not exhaustive. These restrictions are imposed because the body will be weak during the treatment. With treatments being done as part of holiday trip now-a-days, it is often the case that people undergo a therapy in the morning, hit the waves in the evening at the beach before sitting down to enjoy their favorite cocktail later in the night. With such practices becoming a commonplace, it becomes necessary to reiterate the fact that. Doing panchakarma in the wrong way may result in adverse effects in the long term.

Contraindications of Panchakarma

Panchakarma treatment is contraindicated in a wide spectrum of disease conditions. But in today’s scenario many centers perform panchakarma without considering these factors. To make matters worse, in some cases the package of treatment is actually selected by the patient itself and not the doctor. If contraindicated treatments are done in such conditions, it will result in worsening of the existing disease or even the onset of a new disease. A few examples are cited below.

  • Oil application is contraindicated when the digestion is not proper.
  • Sudation therapies are contraindicated in patients suffering from conditions like skin disease, diabetes, obesity etc.
  • Emesis is contraindicated in weak persons, heart disease, poor vision, urine retention etc.
  • Purgation is contraindicated in rectal prolapse, bleeding per rectum, emotional stress, alcohol addiction, severe constipation etc.
  • Non lubricant enema is contraindicated in indigestion, weak digestion, diabetes, skin diseases, bleeding piles
  • Lubricant enema is contraindicated in empty stomach, acute fever, diabetes, weak digestion, bleeding piles etc.

Ayurveda- a science so powerful which possess the potential to answer the health needs of the mankind remains likes an uncut diamond. So is the case with Panchakarma- the un-chiseled Kohinoor of Ayurvedic therapeutic system. The current practice and propagation of Ayurveda in the black shadows of so called Panchakarma centers will draw this elite science into an abyss. It’s up to our current Ayurveda fraternity and its well wishers to take the necessary steps for reclaiming its lost dignity. In pursuit of that greatness each and every one of us who love this science should work in tandem.

“Drugs are like nectar; administered by the ignorant, however they become weapons, thunderbolt or poison. One should therefore shun the ignorant physician.”(Susrutha Samhitha)

 

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