CIKITSĀ AND ITS CLASSIFICATIONS

The word Cikitsā is majorly used in Āyurveda science to describe the management of various physical and psychological aliments of living beings. The word “Cikitsā” roots its derivation from ‘Kit Rogapānayane’ Dhātu   as  Kit+kit+san+a = cikitsā.. The definition of Cikitsā described in VaidyakaŚabda Sindhu  as  “YaKriyā VyādhiHarani Sa Cikitsā” which implies the act or method which is responsible for elimination of aliment is Cikitsā. 

SYNONYMS OF THE WORD CIKITSĀ –

There are various synonyms of the word Cikitsā described to explain the wide arena of its functioning. They are summarized below – 

• Vyādhiharam – The act which relieves disease – व्याधिनहरतियततदव्यधिहरम |
• Pathya – The  act which is beneficial for the biological systems and life span in general – पथिहितंपथ्यंयापथोनपेतमंपथ्यं|
• Sādhanaṃ – The tool or act  –  साध्यतेअनेनइतिसाधनं |
• Auṣadha– The word Auṣadhais majorly used to describe the medicine and since for management of a disease it is a major tool both medicine and treatment complements and complete each other thus the word Auṣadhais at times used to describe the cikitsā. औषधिभिनिष्पन्न्मव्यधिहितमतदुपलक्षणत्वातसर्वेचिकित्सितंऔषधंरूढ़मं|
• Prāyaścittam– It is used to describe in sense of correcting one’s own mistakes. Since aliments are resultant of such deeds thus correcting them is Prāyaścittam.
• Praśamanam – As per the principles of Āyurveda the causes of a disease is the vitiation of doṣas  thus on the Praśamanam (pacification of the Doṣas) health can be restored.
• प्रकर्षेणशमयतियेनतत |
• Prakṛtisthāpanam– The wordPrakṛtisthāpanam itself completely and beautifully describes the aim and functioning of the Cikitsāi.e  is to  establish the homeostasis or more appropriately to  establish homeodynamic of the body.
• प्रकृतोलोकानांधातूनस्थापयतियेनतत |
• Hita– The act which is beneficial for a biological system is Hitam. हितंपोषकत्वात |
• Kriyā – The literary meaning of the word is act or effort done for betterment of health status.

Apart from these there are few other synonyms of Cikitsā used, they are  -Bhaiṣajya, Agada, Jāyu, Upāya,Ceṣṭa, Pravṛtti, Karaṇa, Pratikāma, Upakrama, Bhiṣagjita, Upacāram, Nigraha, Vaidya Karma , Ullaghranāmaetc.

DEFINITION OF CIKITSĀ

The method which causes the establishment of balance between the doṣa within the body resulting in pacification of disease is termed as cikitsā .

• याभिःक्रियाभिर्जायन्तेशरीरे धातवः समाः| 
  सा चिकित्सा विकाराणां कर्म तद्भिषजां स्मृतम्||च.सू.16/34||

CLASSIFICATION OF CIKITSĀ

The various classification of Cikitsā described in the Āyurveda texts are summarized below.

1.Ekavidhacikitsā(one types of treatment) – The most important aim of Cikitsā is to eradicate the causative factor of the disease it is termed as theNidānaParivarjana.

संक्षेपतक्रियायोगोनिदानपरिवर्जनम | सु.उ.1

2. Dvividhacikitsā (two types of treatment) – There are three different sets of Dividhacikitsā classification. They are

• Santarpaṇa Cikitsā and Apatarpaṇa Cikitsā
• Śamana Cikitsā and Śodhana Cikitsā
• Dravyabhūta Cikitsā and Adravyabhūta Cikitsā

 Santarpaṇa Cikitsā and Apatarpaṇa Cikitsā

Santarpaṇa Cikitsā or Bṛṃhaṇa Cikitsā – In these forms of treatments effort for promotion of anabolism are encouraged for eradication of disease conditions. 

Apatarpaṇa Cikitsā or Laṅghana Cikitsā – In these forms of treatments effort for promotion of catabolism are encouraged for eradication of disease conditions.

Thus can be simplified that the whole treatment of the all sorts of disease can be broadly classified in two forms of treatment. The first one is SantarpaṇaCikitsā,  that is  to provide something to the body which is lacking in it, like in nutritional deficiency diseases of  Protein, fat, carbohydrate, dietary vitamins and minerals, hormone deficiency (hypothyroidism, DM), immunodeficiency  etc. The other sets of treatment is  ApatarpaṇaCikitsā which remove the substances excess in the body and attributes the causative factor of  the diseases like  in obesity, vitamin poisoning, metabolic disorders which causes accumulation of unwanted metabolites causing diseases. 

Śamana Cikitsā and Śodhana Cikitsā

Śamana Cikitsā – These forms of the treatment pacifies the disease causing situations which can again get aggravated in presence of the causative factors. Like in allergic diseases (respiratory ailments, skin conditions, migraine etc) certain drugs can manage but again on the exposure to trigger factors it reappears.   

Śodhana Cikitsā – These types of the treatments are the more upgraded types of treatments than the ŚamanaCikitsā. It eradicates the complete pathology of the diseases within the body itself and thus provide a better relief and there are reduced chances or severity of reappearance of the symptoms on exposure to trigger or allergen factors. These are repeated as per the requirements of the patients conditions for sustained relief and at times lead to complete eradications of the diseased conditions.

Dravyabhūta Cikitsā and Adravyabhūta Cikitsā

Dravyabhūta Cikitsā – In these types of treatments matter (in any form solid, liquid and gas) is used for the treatment in any form (oral applications, tropical applications etc.)  of the  disease.

Adravyabhūta Cikitsā – In these types of treatments matter is not used for the treatment of the disease.The examples of this type of  therapy are like counselling, Psychotherapy etc. 

 3. Trividha Cikitsā–

There are three different sets of Trividha Cikitsā classification.

• Daivavyapāśraya , Yuktivyapāśraya and Satvāvajaya cikitsā
• Antaḥ Parimārjana Cikitsā, Bahiḥparimārjana Cikitsā and Shastra Pranidhana Cikitsā
• Laṅghana Cikitsā, Laṅghana Pācana Cikitsā and Doṣavesechana Cikitsā

Daivavyapāśraya , Yuktivyapāśraya and Satvāvajaya cikitsā–

Daivavyapāśraya cikitsā(Spiritual healing, Energy healing)  – The DaivaVyapāśraya Cikitsā  somewhat type of  psychotherapy and it there could be use of matter or not. The major support taken in this type of treatments is by the Spiritual dimension of the patients. These forms of treatments could be in form of religious ceremony. This could be used to treat various   Physical, Psychological and spiritual aliments. This could be considered the most initial type of community medicine.

Yuktivyapāśraya Cikitsā(clinical medicine)– These types of treatments are planned by using medicines or physical modalities for certain types of Physical and Psychological aliments. Most of the treatments provides in the routine clinical care comes under this heading.

Satvāvajaya Cikitsā  (cognitive therapies) –  In these types of treatments are the basic cognitive therapies which is a relative focused Psychotherapy for varieties of conditions .  In this the negativity towards  one’s self  or world is resolved to develop a healthy behavioural pattern.

AntaḥParimārjana Cikitsā, Bahiḥparimārjana Cikitsā and Shastra Pranidhana Cikitsā

AntaḥParimārjana Cikitsā–  These type of treatments are basically a part of clinical medicine involves in administration  of  medicine inside the body by any of the given drugs routes (oral , parentral etc). In Āyurveda there are various routes of drug delivery they are – AuṣadhaPāna, Vamana, Virecana, Nasya, Basti, Uttara Basti, Gaṇḍūṣa, Pratisārana, etc.

Bahiḥparimārjana Cikitsā– These forms of treatments are basically the tropical application of the drugs. The various forms ofBahiḥparimarjan Cikitsā in Āyurveda are –   Abhyaṅga, Svedana, udvartana, lepa etc.

Shastra pranidhana cikitsā– In these forms of treatments sharp metallic instruments are used. These are basically used in some sort of minor or major surgical procedure. They includes Śāstrakarma, Siravvadha, Pracchāna, JalaukaAvacharana, ĀlābuandghaṭīAvacharana. 

LaṅghanaCikitsā, Laṅghana Pācana Cikitsā and Doṣavesechana Cikitsā –

Laṅghana Cikitsā–   These types of treatments basically are planned to create a artificial crisis of starvation to boost up the metabolism. This causes the reduction in toxic loads and assist in completion of metabolism of many intermediate byproducts. This generally does not contain medications for boosting up metabolism except at times dīpana drugs can be administered. The therapies included in this type of Laṅghana are – PipāsāMāruta, ĀtapaUpavāsa, Vyāyāma and Dīpana. These types of treatment  is only suitable for the by-products at superfical levels or more precisely on the level of G.I.T. 

Laṅghana Pācana cikitsā– These types of treatments are the upgraded forms of Laṅghana Cikitsā. In this certain medications or modalities are added that assist in digestion of intermediate by products. These treatments enhance the enzymatic secretions and provides catalysts in the metabolic processes at GIT level and hepatic metabolism. This majorly used in the presence of intermediate by products at the circulatory levels.

Doṣavesechana cikitsā– These forms of treatments are the most superior forms of treatments for removal of the toxic loads of the body. It is used to remove the inner most embedded toxic substances from intracellular regions. It involves the completion of metabolism at the various levels (System level, tissue level, cellular level) and draining of waste substance in the circulation and enhances removal from the various excretory sites. This is also used to remove the free radicals, harmful heavy metals, antigens, Autoantibodies etc. These therapies involves Vamana Karma, VirecanaKarma, Basti Karma, Nasya Karma And Raktamokṣaṇa

4. CaturvidhaCikitsā –

• VṛddhaDoṣaNiharthavya, KṣīṇaDoṣaBṛṃhithavya, PrakupitaDoṣaPraśamithavya and SāmaDoṣaParipālana
• Saṃśodhana, Saṃśamana, Āhāra and Ācāra

Vṛddha Doṣa Nirhana, Kṣīṇa Doṣa Bṛṃhaṇa, Prakupita Doṣa Śamana and Sāma Doṣa Paripālana

This Caturvidha cikitsā basically simplifies all the steps used in the management of any sort of disease. It  is the prime line of management in all the disease exist or will exist in the living world.  The four principles are –

Vṛddha Doṣa Nirharana– This implies that anything which is in increased status and is resulting in development of pathology of a disease should be reduced.

Kṣīṇa Doṣa Bṛṃhaṇa– This implies that anything which is in reduced status and is resulting in development of pathology of a disease should be enhanced.

Prakupita Doṣa Śamana– This implies that anything which is in vitiated (increased beyond limits) and will status and is resulting in development of pathology of a disease should be pacified (removed and reduced).

Sāma Doṣa Paripālana– This implies that anything which is in balanced status and is resulting in healthy status should be maintained.

Saṃśodhana, Saṃśamana, Āhāra and Ācāra

This Caturvidha Cikitsā basically summarizes all the required components to be taken into consideration while managing a disease.

Saṃśodhana – Saṃśodhana is the most effective treatment for eradicating the causative of the disease pathology as described earlier, it completely destroy the foundation of disease when used along with the other three components of this CaturvidhaCikitsā. It has long term benefits and often used in chronic and severe conditions.

Saṃśamana – Saṃśamana is a lighter treatment as compared to the Saṃśodhana but is useful in conditions of relative milder pathology or can be used in conditions where Saṃśodhana is not possible and it is also used after sanśodhana for a complete eradication of the pathology. Most of the clinical medicines is mostly focused in these types of treatments.

Āhāra– For sustaining a life the most important component is nutrition.  It is a cause of continuity of life as well cause of health status either good or diseased. This is a important component that is to be considered while managing a disease condition. It is the most ancient form of medical nutritional therapy. In this approach a tailored diet is planned and provided for a particular  diseases to the particular individual need.

Ācāra– Ācāra is the cognitive behavioural therapy as discussed above. It is customized for a particular individual’s need.

The last two components are generally followed in preventive medicine also as per the Āyurveda principles.

5. Pañcavidha Cikitsā-

• Pañcaśodhana
• Pañcakarma

Pañcaśodhana

The Pañcaśodhana are the five most intense Laṅghana therapies used for eradication of completely metabolized toxic waste products from the nearest excretion sites. They includes – 

Vamana Karma – In Vamana Karma the toxin drainage sites are respiratory tracts and a parts of upper GIT tracts. This therapy facilitates expulsion of toxins from the cavity of drainage sites to outside the body through the oral orifice.

Virecana Karma– In Virecana Karma the toxin drainage sites are the liver, gall bladder, pancreas, gall bladder and parts of GIT up to small intestine or more precisely the level up to which active digestion is carried on.  This process facilitated complete expulsion of drained toxic waste from these  site to outside of body through anal orifice. 

Nirūha Basti Karma– In NirūhaBasti Karma the toxic drainage site is large intestine directly and indirectly urinary bladder and uterine cavity.  It facilitated the expulsion of waste from the anal orifice.

Nasya Karma– In Nasya Karma the site of toxic drainage is nasal cavity, buccal cavity and a part of upper respiratory tracts. It facilitates removal of toxins from nasal cavity and buccal cavity.

Raktamokṣaṇa Karma – In Raktamokṣaṇa Karma the circulatory toxins load within the components of blood or more precisely within the RBC’s are expelled from the body using various therapeutic phlebotomy procedure like Sirāvedha,Pracchāna, AlābuAvacaraṇa,Ghaṭī Avacaraṇa, ŚṛṅgaAvacaraṇaand JalūkaAvacaraṇa.

Pañcakarma

Similarly like Pañcaśodhana there are Pañcakarma therapies. The only difference between the two is the latter had replaced the RaktamokṣaṇaKarma with AnuvāsanaBasti Karma. 

Vamana Karma

VirecanaKarma

NirūhaBasti Karma

AnuvāsanaBasti Karma – In AnuvāsanaBasti Karma theharmful lipid soluble gaseous and other by-products formed within the body from the decomposition of residual food material and from the activities of gut microflora is expelled from the body through anal orifice. 

NasyaKarma

6. Ṣaḍvidhaupkrama or Cikitsā-

LaṅghanaKarma– In these types of treatments the catabolism is enhanced by inducing deficiency crisis situations.

BṛṃhaṇaKarma – In these types of treatments the anabolism is promoted by supplementing essential nutrients.

RūkṣanaKarma – In this types of treatments metabolism is decrease by the enhancing the resistance or VātaPrakopa.  

SnehanaKarma– In this types of treatments metabolism is enhanced decreasing the  resistance or enhance mobility of metabolites  or causing VātaŚamana.  

SvedanaKarma– The metabolic activities are enhance by increasing the core body temperature. 

Stambhanakarma – The metabolic activities are reduced by decreasing the core body temperature. 

Antaḥ and Bahiḥ ParimārjanaCikitsā basically deals with the Āyurveda drug delivery routes. While managing a disease condition one most important component is the administration of drug to the patient. These drugs are the administered in the subjects through various drug delivery  routes. In Āyurveda these routes are broadly classified in two categories. 

AntaḥParimārjanaCikitsā –

तत्रान्तःपरिमार्जनं यदन्तःशरीरमनुप्रविश्यौषधमाहारजातव्याधीन् प्रमार्ष्टि|

                                                                                                                  Ca.su.11/55

The treatments  where the drug components come in the contact of internal tissues of body.  Most of the treatment in Āyurveda is tropical in nature and targets the mucous membrane or the inner linings of the cavities. According to the drug route the targeted site of tissue contact varies. The various targets organs selected for drug delivery in Āyurveda are – 

1.MukhaMārga(Oral administration) – It is a type of enteral drug delivery route. In this route drug is taken through the mouth and intended to reach the systemic circulation after digestion within the GIT.  The preparations which are formulated are Svarasa, Cūrṇa Kalka, Kaṣāya, Himaphāṇṭa,  Avaleha,  Āsava,  Ariṣṭa,  Guṭikā,  Guggulu,Vaṭi,Vaṭaka, Taila, Ghṛta, Arka etc. to be administered through oral orifice.  The Karma of Pañcakarma which comes under its umbrella are Snehapāna, Vamana Karma, VirecanaKarma. There are various subtypes of the oral administration in Āyurveda –

Pratisārana– In this the drug is rubbed within the buccal cavity. It may be considered sublabial or buccal route.

Kalka Grahaṇa(modified forms of gargles) – In this the solid drug withoutwithout liquid content is kept within the oral cavity and rotated within the buccal cavity for stipulated time and spitted out. 

GaṇḍūṣaGrahaṇa(modified forms of gargles) – In this large amount of liquid drug  (the volume of drug does not permits movement on the buccal caity) is kept within the oral cavity for stipulated time and spitted out. 

MukhaDhūma– In this vapors are inhaled through buccal cavity are exhaled through buccal cavity itself. The intention of this drug delivery is majorly the upper Respiratory tracts.

2. NāsāMārga(Nasal route) – In this type of drug delivery the drugs in either solid (Pradhamana orDhmāpāna), liquid ( lipid base – Marśa, Pratimarśa, water base – Avapīḍaka ), gaseous ( DhūmaNasya) forms are administered through nasal orifice. This majorly covers the Nasya Karma of the Pañcakarma, and at few incidence Vamana and VirecanaKarma (use of Nāsā Yoga of Vamana and VirecanaDravyato induce Vamana and VirecanaKarma). 

3.KarṇaMārga(Otologic route) – In this route the drugs majorly either liquid (lipid base –  Sneha, water base – Mūtra, Kvātha, Svarasa) and at times gaseous (dhūma) are used with intention to treat the various condition of external ear. The Karma that comes within its spectrum are Karṇadhāvana, Karṇapūraṇaand karṇadhūpana.

4. Akṣi (Ophthalmic route) – In this route the drugs majorly is liquid (lipid base – sneha, water base – Kvātha, Svarasa, PuṭapākaSvarasa) and at times solid (Añjana) are used with intention to treat the various condition of eyes. The karma that comes within its spectrum are Seka, Āścyotana, Añjana, Tarpaṇaand  Puṭapāka. The other two Karma of Netra Kriyākalpa, Piṇḍī or Kavalikā or Piṇḍika and  Biḍālakacomes under theBahiḥparimārjanaCikitsā. 

5.Guḍa(Rectal administration) – It shares the status of enteral drug delivery route along with oral route. The Drug is injected through the anal orifice. The drug is majorly liquid [lipid base – Snehaas in AnuvāsanaBasti, colloidal solution – mixture of lipids and aqueous solutions using the polarity of honey as in NirūhaBasti, and aqueous based as Jala Basti (yogic enema)], solid (GuḍaVarti) and rarely gas (GuḍaDhūpana). The most obvious karma included in this rectal route of administration are AnuvāsanaBasti, NirūhaBasti, GuḍaVartiand GuḍaDhūpana.

6. MūtraMārga (Intravesical route) – This is a type of urogenital route of drug delivery. In this type of drug is infused in the bladder through urethral opening facilitated by the use of catheters. The drugs in majorly liquid (lipid base – Sneha Basti, or aqueous based – KaṣāyaBasti) and less often solid (Mūtravarti). The Karma include in this type of drug delivery is Uttarabasti.

7. Yoni Mārga (Intra-uterine route) – This route share the status of urogenital route of drug delivery along with the intravesical route. In Āyurveda also they share the terminology, Uttarabasti.  The drugs in majorly liquid (lipid base – Sneha Basti, yoni picu, or aqueous based – KaṣāyaBasti) and less often solid (Yonivarti) and gaseous (Yoni Dhūpana). The karma include in this type of drug delivery is Uttarabasti, Yoni Piṇḍaor YoniDhāraṇa, Yoni Picu,Yoni Dhāvanaand Yoni Dhūpana.

8. Kākapada Mārga (Parentral route- Intravenous) – This type of drug administration  stimulates more like intravenous and often used in emergencies like in ViṣaCikitsā. The solid or liquid drug is applied on the freshly prepared wound or a wound itself. In this form the Jalaukāvacaraṇa can also be included because in the process certain therapeutic agents of leech saliva are injected in the body. Although  much is not explored in this aspect. 

The other forms that may qualify the definition of AntaḥParimārjanaCikitsā are theNirvāpaṇa, Patradanaand Madhusarpī used for healing of Varṇa. In this there are applications of the drugs on the non-healed wound tissues so technically the drugs is coming in contact of the inner tissues of the body.

Bahiḥparimārjana Cikitsā –

The treatment that aims at the application of drugs on the outer surface of the body is termed asBahiḥparimārjanaCikitsā. The epicutaneous tropical drugs qualifies the category of Bahiparimārjanacikitsā.  The drugs used in these can be expected to have a transdermal effect that is applied on the surface of the body but on absorption in the body may have systemic effects.  The various forms of Āyurveda treatments that are included in it are  mostly included inPūrvakarmaof the Pañcakarma.

Types of bahiḥparimārjana cikitsā  – The various types of Bahiḥparimārjana Cikitsā  are –

1. SnehanaKarma– The Karma included in is these are basically the methods of BāhyaSnehana. They can be classified in Ekāṅgaand Sarvāṅga on the basis of the extent of their application on the body. It includes – 

• Abhyaṅga
• Mardana
• Unmardana
• Pādāghāta
• Saṃvāhana
• Udvartana/Utsādana
• Udgharśana
• Avagāha
• Pariṣeka
• Lepa
• Pralepa
• Updeha
• Talam
• Takradhāra

2. Sneha PūrvakaSvedanaKarma– The methods included in these are basically snehana methods with an element of heating factor (Svedana Karma) included in it . As said above they can also be classified in Ekāṅga and Sarvāṅga. It includes following procedures –

• PatrapiṇḍaSveda
• Ṣāṣṭikaśālī PiṇḍaSveda
• CūrṇaPiṇḍaSveda
• JambīraPiṇḍaSveda
• KukkuṭāṇḍaSveda
• Anna Lepa
• BāṣpaSveda
• NāḍiSveda
• KṣīraBāṣpaSveda
• AvagāhaSveda
• PariṣekaSveda
• Pizichil
• Kṣīradhāra
• UpānahaSveda
• SthānikaBasti – Kaṭī Basti, Jānu Basti, GrīvaBasti, PṛṣṭhaBasti, UrahBasti etc on the basis of site of applications.
• MūrdhniTaila – śiro-Abhyaṅga,Śirodhārā, Śiropicu and Śirobasti,
• ŚiroLepa (Talapotichil),

3. RūkṣaSvedanaKarma– In these types of Karma there is Svedana applied on the body surface without the use of Sneha Dravya. They can also be classified in Ekāṅga and Sarvāṅga. It includes –

• CūrṇaPiṇḍaSvedana
• KārpāsaPiṇḍaSvedana
• DhānyaPiṇḍaSvedana
• Kalka piṇḍaSvedana
• VālukaSvedana
• IshtikaSvedana
• DhanyamlaDhārā
• KaṣāyaDhārā
• BashpaSveda
• NāḍiSveda
• AtapaSvedana
• VātaSvedana

Preventive aspect of Bahiḥparimārjana Cikitsā– Some if these Bahiḥparimārjana Cikitsā  are include as preventive medicine in Ṛtucaryā also. They are –

• HemantaṚtu(winter season) and ŚiśiraṚtu(dewy season) – Abhyaṅga, Utsādana, MūrdhniTaila, JentākaSveda, ĀtapaSveda
• VasanthaṚtu(spring season) – Udvartana, Candana, AgaruLepa
• GrīṣmaṚtu(Summer season) – CandanaLepa
• VarśaṚtu(Rainy season) – Pragharśana, Udvartana, CandanāḍiSugandhitā DravyaPrayoga. 

The principle of Cikitsā is basically the four basic rules in management of disease explained under the heading of Caturvidha Cikitsā in the previous unit. It states –

दोषाः क्षीणा बृंहयितव्याः, कुपिताः प्रशमयितव्याः, 

वृद्धा निर्हर्तव्याः, समाः परिपाल्या इति सिद्धान्तः ||  ( Su.chi.33/3)

To understand the principles of the Cikitsā it is necessary to understand the various pathological steps adopted in the phenomena of disease development.  In Āyurvedic terminology it is called Kriyākāla of Doṣas. Thus it is mandatory to understand Kriyākāla prior understanding the concept and application of principles of Cikitsā. 

The beauty of the ancient Indian languages like Sanskrit, in which most of the Āyurveda text is available is the formation of words. Each and every term is a self-explanatory in its self. The development of terminology is based on very rational grounds. So before understanding  Kriyākāla it is essential to understand the  term itself.The literal meaning of ‘Kriyā’ is ‘action or doing something’. In terms of diseases management it implies the ‘treatment of disease’ either Auṣadhasevana, PañcakaramaCikitsā or any attempt of any sort for improvements of disease conditions.  The term ‘Kāla’ means the ‘time dimension’. On combining both these word the term Kriyākāla has originated which implies “the time dimension for treatment of diseases in reference to the disease pathogenesis”. Thus the clinical practical applicability of the subject becomes self-explanatory. It offers the window periods within the pathology of disease which can be utilized for the destruction of the pathology of the disease and restoring the healthy status. In most of the disease there are three (Caraka Samhita, Vāgbhaṭa Samhita) or six (Suśruta Samhita, more elaborated one) basic essential  Kriyākāla. They may be easy recognizable or may be too rapid  that it slips away unnoticeable. The management of the disease varies on the basis of these Kriyākāla. Thus it can be interpreted that the principles of Cikitsā is applied on the basis of Kriyākāla  or the Kriyākāla is the most determining factor for disease management.  This is explained by

Dalhaṇa Ācārya as    –

क्रियाकालइतिकर्मावसरचिकित्सावसरश्च |

Its importance as described by Ācārya Suśruta  states  –

अप्राप्तेवाक्रियाकालेप्राप्तेनकृताक्रिया |

क्रियाहिनातिरिक्तावासाध्येषुअपिनसिध्यति ||सु. सू. 35/२२

If a treatment is adopted prior or after Kriyākāla or not adopted in Kriyākāla, thenit is unfulfilling even in a easily curable condition irrespective of over or under medication. This highly advocated the appropriate timing of the treatment commencement.

सञ्चयेऽपहृतादोषालभन्तेनोत्तरागतीः |

तेतूत्तरासुगतिषुभवन्तिबलवत्तराः ||सुसू २१/३७||

Another factor that makes Kriyākāla important that it provides the knowledge of the appropriate time dimension which is obvious in most of the disease condition the earliest Kriyākāla except in few like in Raktaja Gulma in females, for  implementation of treatment and types and level of  targeted treatment. In facilitates the early subsiding of disease with fewer effort as compared to the treatment provided in later stages when the disease status complexes. (Su.su.21/37)

Types of Kriyākāla –  As per the number the two classification of Kriyākāla are –

• Trividha Kriyākāla
• Ṣaṭvidha Kriyākāla

Trividha Kriyākāla – The three basic Kriyākāla comprises of –

1. Doṣa Caya
2. Doṣa Prakopa
3. Doṣa Prasara

Doṣa Caya – Doṣa Caya implies the accumulation of the causative that is primarily responsible for the disease. Like in certain assumed autoimmune disease of let say hepatic tissues, there is development of autoantibodies in large number due to presence of an antigen in large volume within a tissue system level can be termed as Doṣa Caya. 

Doṣa Prakopa – Doṣa Prakopa implies the spread of accumulative causative  at the primary site of origin itself as a whole. Like spread of autoantibodies without or without antigen in the complete liver in the example can be termed as Doṣa Prakopa.

Doṣa Prasara – Doṣa Prasara implies the spread of the causative beyond the perimeters of its primary site of origin and spreading in the nearby systems and ultimately in whole of body along with developments of consequence of its spread. In example the circulation of the antibodies in the firstly in hepatic and splenic region and then in whole of the body can be understood as the Doṣa Prasara. 

Thus the above description simplifies the few recent steps of pathological development that are essential in most of the disease conditions. It also enables the chances of treatments in these steps.

Application of  TrividhaKriyākāla in Treatment –

Treatments in Doṣa Caya–  If the pathology is  at the primary site of origin. It can be only identified when there is accumulation of causative. Since the human body have self-pacifying (compensatory, stabilizing) mechanism for minor disturbance as it is auto programmed for maintenance of appropriate haemodynamic.  In presence of causative beyond this limit will qualifies for the Doṣa Caya condition. The most obvious treatment at this point of time dimension is   either removal, decrease or change the form of causative factors at the very particular site of origin.  So thus the aim in this step is evident and crystal clear. As in terms of Āyurveda  ‘Nidāna Parivarjana’.    

Treatments in Doṣa Prakopa – In this step there is spread of causative within the perimeter of the primary site. Now the treatments which are followed in the Doṣa Caya is to be followed along with the extra efforts since there is spread of the causative. So the degree of the treatments will increase. As in the example there will Be Nidāna Parivarjana, treatment of hepatic system (Yakṛta Śodhaka and Yakṛta Balakara Auṣadha is to be administered). This step is a bit difficult to treat than the prior one but still in approach.

Treatments in Doṣa Prasara – In this step there is spread of causative beyond the perimeter of the primary site. Now the treatment which were followed in the Doṣa Prakopa is to be followed along with the extra efforts and taking in consideration of the site which is being harmed by its spread.  So the degree of treatments gets still higher. As in above said example along with the treatment given above the treatment of the site and the presentation of the diseases is to be managed. To simplify it more better let say if the autoantibodies are affecting the joints and harming the connective tissues of the region then the new treatment approach aims at Nidāna Parivarjana, Yakṛta Śodhaka, Yakṛta Bala Kara Auṣadha, attempts to reduce the circulatory volumes of the antibodies, management of the presenting symptoms on the site of damage and attempts to minimize the deformity in joint structure (Lakṣaṇa Cikitsā, Asthi and Sandhi Poṣaka Cikitsā) are added in the appropriate line of management.  As we can see that while we are summarizing this in a writing also it appears complicated. And when it is used in application it stills get complicated because at time these multiple treatments and the condition of patients in terms of health, his will power, his economic status and many more factors does not support each other. So it appears the tougher to beak pathogenesis at this step.

Ṣaṭvidha Kriyākāla – 

Ācārya Suśruta had further elaborated these Kriyākāla and added three more Kriyākāla and has a slight difference in view all the basic principles remain the same. The initial three can be designated as pre-clinical stages and the latter three as clinical stages. The Ṣaṭvidha are – (Su.Su. 21/36)

सञ्चयं च प्रकोपं च प्रसरंस्थानसंश्रयम् |

व्यक्तिंभेदं च योवेत्तिदोषाणां  स भवेद्भिषक् ||सु.सू २१/३६||

1. Doṣa Caya
2. Doṣa Prakopa
3. Doṣa Prasara
4. Doṣa Sthānasaṃśraya
5. Doṣa Vyakti
6. Doṣa Bheda

Doṣa Caya – In Doṣa Caya state the causative gets accumulated at the site of origin (Primary base).

Doṣa Prakopa – In Doṣa Prakopa state the causative gets accumulated at primary site beyond the capacity of body to maintain its haemodynamic.

Doṣa Prasara –In Doṣa Prakopa state the causative will spread in the whole of body due to its great volumes.

Doṣa Sthānasaṃśraya – In Doṣa Stanāsāmshraya state the causative will select the appropriate site or sites for its presentation. This will the secondary base, the site of action.

Doṣa Vyakti – In Doṣa Vyakti state there is ‘Vyakti’, clinical  presentation of symptoms caused due to activities of causative at the secondary site. This is a full-fledged diseased condition.

Doṣa Bheda  – Doṣa Bheda state appears in chronic condition of the disease state and there are developments of secondary complications.

Application of Ṣaṭvidha Kriyākāla in Treatment –

Doṣa Caya – Since in Doṣa Caya state the causative gets accumulated at the site of origin (Primary base).  And they can be identified easily by the subject himself or the care taker giver. There is presence of Stabdhapūrṇakoṣṭhata (Heaviness and rigidity at the primary site), Pītabhastha(Paleness), Madouṣmatā (Lack of metabolic activity), Aṅganām Gaurava(heaviness in body), Caya Karaṇa Dveṣa(strong repulsion from the causative). This is the first KriyāKāla (first window period for treatment).

The Primary Cause of Stabdhapūrṇakoṣṭhataat the primary site is the inflammation. And it is the initial step in every pathology. It is followed by Pītabhastha(Paleness due accumulation of inflammatory debris or pus or lack of fresh circulatory blood). This attributes in disturbance in metabolism or destruction of metabolic site causing Madouṣmatā(Lack of metabolic activity resulting in loss of heat production) all these ultimate results in AṅganāmGaurava(heaviness at site) caused due to excessive deposition of inflammatory debris and non-metabolized products. As the recovery or compensatory mechanism the body itself repels from the primary cause of inflammation. This is the time zone when the cause that has caused the inflammation is stopped and attempts are made to correct the pathology that is always the opposite of the primary cause. This phenomenon is termed as NidānaParivarjana in Āyurveda. This is the prime treatment of all disease and most often this comes under the umbrella of lifestyle modifications.  This is the step which disqualifies to be arena of PañcakarmaCikitsā and minor measures are sufficient to deal the pathogenesis.  

तत्रसञ्चितानांखलुदोषाणांस्तब्धपूर्णकोष्ठतापीतावभासतामन्दोष्मताचाङ्गानांगौरवमालस्यंचयकारणविद्वेषश्चेतिलिङ्गानिभवन्ति |तत्रप्रथमःक्रियाकालः ||१८|| (Su. Su. 21/18)

Doṣa Prakopa – Since in Doṣa Prakopa state the causative gets accumulated at primary site beyond the capacity of body to maintain its homeodynamics. This is observed by presence of symptoms of Koṣṭha Toda (pain in abdomen), Sañcaraṇa(pain caused due to movement), Amlikā (Hyperacidity), Pipāsā (excessive thirst),Parīdāha(burning sensation in extremity), Annadveṣa (lack of interest in meals intake) and Hṛdaya Utkleśa (nausea). 

These symptoms of basically indicated the disturbances at the hepatic level or GIT level that is the primary site of all metabolism. Since the GIT is the site where continuous  and rigorous metabolism is in process as compared to others site thus it is the prime place for observation of these symptoms which indicates the changes of metabolism beyond the normal status. This refers that the disturbance in the metabolism at the prime site of inflammation has succeeded in disturbance of the whole of the metabolism of the body. This is the initial step in development of a Physical aliment. In terms of Āyurveda the Agni is disturbed and this Mandāgni is the source of all the disease. This is also an opportunity or the second window period  for the treatment. The focus of the treatment is shifted in this step from NidānaParivarjana to the correction of Agni. Efforts of all sort are attempted to correct the Agni like Dīpana and Pācanakarma. The preventive aspect of Pañcakarma is used at this level.

तेषांप्रकोपात्कोष्ठतोदसञ्चरणाम्लीकापिपासापरिदाहान्नद्वेषहृदयोत्क्लेदाश्चजायन्ते |

तत्रद्वितीयःक्रियाकालः ||२७||(Su. Su. 21/27)

Doṣa Prasara – In Doṣa Prasara, the disturbances in metabolism becomes evident in other sites secondary to GIT or hepatic level. The examples of these types of symptoms are Vāyu Vimārga Gamana, Āṭopa due to provocation of Vāta, Oṣa, Coṣa, Parīdāha, Dhūmāyan due to provocation of Pitta, Arocaka, Avipāka, Aṅgasāda and Chardidue to provocation of Kapha.  Due to disturbances of the digestive process at the Prakopa stage there are disturbances at the  assimilation and excretion processes which results in  above said symptoms. The disturbances in digestion causes disturbances in gut microbiota axis and causes excessive production of gaseous compound, beyond to be accommodated in the cavity of large intestine forcing it to rise higher in the small intestine and upper GIT causing symptoms like Vāyu Vimārgagamana, Āṭopa. This further disturbs the digestive process of protein and fats at the intestinal level and causing disturbed metabolism of bile and similar compounds resultant of hepatic metabolism and hamper their excretion resulting in increased circulatory levels and develops the symptoms like Oṣa, Coṣa, Parīdāha, Dhūmyān. The next and final level of disturbances in this step is complete destruction of Digestive process. The digestive process becomes too weak to completely digest the carbohydrates of the meal component resulting in symptoms of  Arocaka, Avipāka, Aṅgasādaand Chardi. At this step the GIT  and hepatic metabolism system surrenders its self. The treatment opportunity at this level enable us to correct the hepatic metabolism and digestive  process at the GIT level. In addition  to above said treatments an AnulomakaAuṣadhaor Mala Śodhakabecomes necessary to remove the Doṣa along with the enhancement of  PācanaDravyaand Karma. This is the stage when the preventive and curative aspect of Pañcakarma should be utilized.  In this the SaṃśodhanaKarma (Vamana and Virecana) should be used.

एवंप्रकुपितानांप्रसरतांवायोर्विमार्गगमनाटोपौ, ओषचोषपरिदाहधूमायनानिपित्तस्य, अरोचकाविपाकाङ्गसादाश्छर्दिश्चेतिश्लेष्मणोलिङ्गानिभवन्ति; तत्रतृतीयःक्रियाकालः ||३२||(Su.Su.21/32)

Doṣa Sthānasaṃśraya – In this step the most appropriate site for disease production is selected which is obvious the site of most disturbed metabolism due to the primary causative factor in addition to another causative which has individually caused the disturbances in metabolism at the particular site. Thus the reason for Sthanāsāmshraya are due to clubbing of two separate Nidāna resulting in the early stage of disease development. The symptoms produced in this stage are mild and within the range of treatments. This stage in Āyurveda is termed as the Pūrvarūpa Avastha. The picture of the disease and the system related becomes clear in the stage. In addition to the treatment described above their is addition of Nidāna Parivarjana of the individual Nidāna caused at the targeted system along with the corrective and target oriented drug delivery vehicles. In this step also the Sanśodhana and specifically indicated Karma according to Doṣa and Sthāna Vyavasta are adopted.

The various diseases related to various systems are –

अतऊर्ध्वंस्थानसंश्रयंवक्ष्यामः |

एवंप्रकुपितातांस्ताञ्शरीरप्रदेशानागम्यतांस्तान्व्याधीन्जनयन्ति |

तेयदोदरसन्निवेशंकुर्वन्तितदागुल्मविद्रध्युदराग्निसङ्गानाहविसूचिकातिसारप्रभृतीञ्जनयन्ति; बस्तिगताःप्रमेहाश्मरीमूत्राघातमूत्रदोषप्रभृतीन्; मेढ्रगतानिरुद्धप्रकशोपदंशशूकदोषप्रभृतीन्; गुदगताभगन्दरार्शःप्रभृतीन्; वृषणगतावृद्धीः; ऊर्ध्वजत्रुगतास्तूर्ध्वजान्; त्वङ्मंसशोणितस्थाःक्षुद्ररोगान्कुष्ठानिविसर्पांश्च; मेदोगताग्रन्थ्यपच्यर्बुदगलगण्डालजीप्रभृतीन्; अस्थिगताविद्रध्यनुशयीप्रभृतीन्; पादगताःश्लीपदवातशोणितवातकण्टकप्रभृतीन्; सर्वाङ्गगताज्वरसर्वाङ्गरोगप्रभृतीन्; तेषामेवमभिसन्निविष्टानांपूर्वरूपप्रादुर्भावः; तंप्रतिरोगंवक्ष्यामः |तत्रपूर्वरूपगतेषुचतुर्थःक्रियाकालः(Su.Su.21/33)

Doṣa Vyakti – In this state there is ‘Vyakti’, (Clinical  presentation of symptoms caused due to activities of causative at the secondary site). This is a full-fledged diseased condition. At this time zone the treatment of a particular disease as per the Bala of the patients is adopted. This is the last window period of management that can be achieved with efforts. Beyond this the disease complicates and results in secondary disorders. This is the step when the prescribed Auṣadha and Pañcakarma Cikitsā is adopted as per the Cikitsā Sūtra of the disease. 

अतऊर्ध्वंव्याधेर्दर्शनंवक्ष्यामः- शोफार्बुदग्रन्थिविद्रधिविसर्पप्रभृतीनांप्रव्यक्तलक्षणताज्वरातीसारप्रभृतीनां च | तत्रपञ्चमःक्रियाकालः(Su.Su.21/34)

Doṣa Bheda  – In this stage if the treatment is ignored then it reaches to the limit where it is considered incurable due to development of complex syndrome. This is the last and final stage where treatment could be adopted. Although this treatment is extreme difficult and more rigorous than any other step. In this condition patients has also become too fragile. In Āyurveda terms there is Jīrṇatā in the Vyādhi and involvement of Vāta. Technically the patients is beyond the reach of Śodhana Cikitsā. Basically such kind of patients are subjected to Mṛdutama Śodhana and Yāpana Karma.     

अतऊर्ध्वमेतेषामवदीर्णानांव्रणभावमापन्नानांषष्ठःक्रियाकालः, ज्वरातिसारप्रभृतीनां च दीर्घकालानुबन्धः ।तत्राप्रतिक्रियमाणेऽसाध्यतामुपयान्ति ॥३५॥(Su.Su.21/35)

Apart from describing the pathology there are physiological Kriyākāla also that are described in the terms ofSvasthavṛtta. In these Kriyākālathe Nidāna are not within the control of human factor but in control of environmental factor and it is suggested if modification is made accordingly in the lifestyle then there is self-subsidising of the developed pathology. These Kriyākāla are described under the following terminology. 

  As the name suggest there are  six basic strategies of treatment of a disease. Singly or combination of these strategies are adopted in treatment of any sort of disease that had existed or will exist in this globe. These are the universal laws of treatment.

The six basic Karma of Cikitsā described in Caraka Samhita are – (Ca.su.22/4)

1. Laṅghana
2. Bṛṃhaṇa
3. Rūkṣana
4. Snehana
5. Svedana
6. Stambhana

लङ्घनं बृंहणं काले रूक्षणं स्नेहनं तथा|

स्वेदनं स्तम्भनं चैव जानीते यः स वै भिषक् (Ca.su.22/4)

The generalized definitions of Ṣaḍ Upakrama are –

Laṅghana – The process or drug or factor which produces Laghuta (lightness or catabolic effects) in body is termed as Laṅghana. (Ca.su.22/9)

In Laṅghana treatment the basic concept is to enhance the metabolism and more precisely in the catabolic direction in the order to remove the undigested or semi digested metabolite to enable the nutritive part to be utilized in the energy production and body building whereas the waste part is converted in the appropriate excretory form. The Pūrvakarma Pācana, Snehana – Svedana assist in this mechanism of completion of metabolism whereas the Śodhana enhance the process of evacuation of excretory products from the body.

Bṛṃhaṇa–– The process or drug or factor which produce Bṛṃhaṇa (anabolic effect) in body is termed as Bṛṃhaṇa. (Ca.su.22/10)

In Bṛṃhaṇa the anabolism is promoted to enhance the energy production and tissue building substances. The Snehana Karma, Tarpaṇa, Anuvāsana- Mātraā Basti, Marśa- Pratimarśa Sneha  etc. are much more of importance in this reference.

Rūkṣana  – The process or drug or factor which produce Rūkṣata (roughness) in body is termed as Rūkṣana. (Ca.su.22/10)

This is the method to check the dyslipidaemia like condition and prevents metabolic syndrome and associated disorders. This method is the unique of Āyurveda to check the disorders caused due to the present eating habits of junk foods. It may assist in controlling the major giant disease of present like Diabetes and Hypertension. The major issues with the present day junk meals is the zero nutritional value and the trans-fat which behave like saturated fat in body they clog up the human arteries and cause plaque. As per the Nutritional analysis of junk food in India environment portal. It was reported in 2008 that junk food eating pregnant or breast-feeding mother’s  have obesity prone offsprings and they have high risk for  diabetes, raised cholesterol, and high blood fat. Findings of 2012 suggests that pregnant mothers on high sugar fat diets have babies with altered food preferences ( especially for junk food)  because of  changed foetal brain’s reward pathway. The various therapies which are included in Rūkṣana regime is Udvartana, Lekhana Basti, Vālukā Svedana etc. Rūkṣana Kriyās.  

Snehana – The process or drug or factor which  produce Snigdhata (smoothness & ointing effect) in body is termed as Snehana. Snehana Karma imparts Viṣyandana, Mārdava and Kledana. (Ca.Su.22/11)

The Snehana Karma is a complex treatment and it varies depending on the motive of its use. If the motive of Snehana Karma is to enhance energy supplementation sources and body building supplies it is termed as Bṛṃhaṇasneha. In case the motive of Snehana is to facilitates the removal of lipid soluble toxic impurities or facilitated the membrane bound organelles containing it is termed as Śamana or Śodhana Sneha. The properties Viṣyandana, Mārdava and Kledana are the properties of Śamana or Śodhana Sneha.

Svedana – The process or drug or process which produce Svedana (fomentation or cause perspiration) in body is termed as Svedana. Svedana relieves  Sthambha, Gaurava  and Śīta (Ca.Su.22/11).

The Svedana karma is one of the major Pūrvakarma and it majorly enhances the metabolic process and assist in excretion of water soluble waste products in sweat. Apart from this various physiological effects imparted by Svedana Karma are – increased vasodilatation, decreased viscosity of body fluids, changes in  nerve conductions, increased pain threshold, changes in muscle strength, increased metabolic rate, increased tissue extensibility, have effect on pulse rate & blood pressure  and  increased rate of breathing.

Sthambhana – The process or drug or factor which produce Stambhana  (restrict movements) in body is termed as Sthambhana. (Ca.su.22/12)

The Stambhana exerts its therapeutic effects by affecting the haemodynamic, neuromuscular and metabolic processes of the body. It is majorly used in Acute inflammation, to accelerate recovery from injury, reduce pain, reduce oedema, arrest bleeding, reduction of spasticity in Upper motor neuron disorders, Facilitation of muscle contractions, Symptomatic managements in multiple Sclerosis  and adjunctive measure for exercise and stretching.

Role of  Pañcakarma in application of Principles of  Ṣaṭvidha and Dvividha Upakrama– The Ṣaṭvidha and Dvividha Upakrama are the main principles or the motives which are implemented  through the various process of Pañcakarma.

These Ṣaṭvidha Upkarma are further summarized in two Karma by Vāgbhaṭa Samhita  as – (Ah.su.14/1-4)

1. Santarpaṇa Karma
2. Apatarpaṇa Karma

In Santarpaṇa Karma Bṛṃhaṇa, Snehana, Stambhana are included & in Apatarpaṇa Karma Laṅghana, Rūkṣana & Svedana are included.

Role of  Pañcakarma in application of Principles of  Ṣaṭvidha and Dvividha Upkrama– The Ṣaṭvidha and Dvividha Upakrama are the main principles or the motives which are implemented  through the various process of Pañcakarma.