A review article on Treatment of Chhardi acc to Charaka Samhita w.s.r. to vomiting

Vol.01, Issue-05, November 2024

Author: Dr. Manish Singh Tomar, MD, PhD Ayurveda

Abstract

Chhardi, commonly known as vomiting, is a vital protective reflex that expels harmful substances from the stomach. In Ayurveda, detailed in the classical text Charaka Samhita, Chhardi is comprehensively analyzed in terms of its types, causes, pathogenesis, clinical features, prognosis, and treatment. This article explores Chhardi Chikitsa (treatment of vomiting) as presented by Acharya Charaka, correlating traditional Ayurvedic principles with contemporary medical understanding. By examining the etiology, pathophysiology, symptomatology, and therapeutic approaches, we aim to bridge ancient wisdom and modern science, providing a holistic view of vomiting and its management.

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Introduction

Vomiting is a common symptom encountered across various medical conditions. It serves as a defensive mechanism to eliminate ingested toxins or irritants from the gastrointestinal tract. While often self-limiting, persistent vomiting can lead to complications such as dehydration, electrolyte imbalance, and nutritional deficiencies.

In Ayurveda, vomiting is referred to as Chhardi, and it is considered a significant disorder affecting the gastrointestinal system (Annavaha Srotas). The Charaka Samhita, one of the foundational texts of Ayurveda attributed to Acharya Charaka, provides an in-depth analysis of Chhardi, including its types, causative factors, pathogenesis, clinical manifestations, prognosis, and therapeutic strategies.

This article delves into the Ayurvedic perspective of Chhardi Chikitsa as outlined by Charaka, drawing parallels with modern medical concepts. By integrating classical Ayurvedic knowledge with contemporary medical insights, we aim to enhance understanding and foster integrative approaches to managing vomiting.

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Understanding Chhardi (Vomiting) in Ayurveda

Definition

Chhardi is defined in Ayurveda as the forcible expulsion of gastric contents through the mouth due to the upward movement of Doshas, primarily Vata, Pitta, and Kapha, or their combination, affecting the stomach (Amasaya) and gastrointestinal tract.

Types of Chhardi

Acharya Charaka classifies Chhardi into five types based on the predominant Dosha involvement and causative factors:

1. Vataja Chhardi: Vomiting due to the aggravation of Vata Dosha.
2. Pittaja Chhardi: Vomiting resulting from the aggravation of Pitta Dosha.
3. Kaphaja Chhardi: Vomiting caused by the aggravation of Kapha Dosha.
4. Tridoshaja (Sannipataja) Chhardi: Vomiting involving all three Doshas.
5. Dwishtaartha Yukta Chhardi: Vomiting due to psychological factors like seeing or experiencing something unpleasant.

Sanskrit Reference:

• “Dōṣaiḥ pr̥thak tri-prabhavāś catasrō, Dviṣṭārtha-yōgād api pañcamī syāt.” (Verse 6)

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Etiology (Nidana) of Chhardi

Ayurvedic Perspective

General Causes

1. Dietary Factors:
   • Consumption of Incompatible Foods (Viruddhahara):
     • Eating foods that are heavy, unwholesome, or difficult to digest.
   • Overeating or Indigestion:
     • Excessive intake leading to Ama (undigested food) accumulation.
2. Lifestyle Factors:
   • Excessive Physical Exertion (Ativyayama):
     • Overexertion aggravating Vata Dosha.
   • Fasting or Irregular Eating Habits:
     • Disturbing normal digestive functions.
3. Psychological Factors:
   • Emotional Stress:
     • Fear, grief, or shock affecting Vata and leading to vomiting.
   • Disgust or Repulsion:
     • Seeing or experiencing something unpleasant (Dwishtaartha Yukta).
4. Environmental Factors:
   • Exposure to Toxins or Poisons:
     • Ingestion of contaminated food or substances.
5. Medical Conditions:
   • Underlying Diseases:
     • Fever, gastrointestinal disorders, or other systemic conditions.

Specific Causes for Each Type

1. Vataja Chhardi:
   • Excessive Physical Activity:
     • Overexertion leading to Vata aggravation.
   • Use of Strong Emetics or Purgatives:
     • Misuse causing upward movement of Vata.
2. Pittaja Chhardi:
   • Consumption of Hot, Spicy, and Pungent Foods:
     • Aggravating Pitta Dosha.
   • Exposure to Heat or Sunlight:
     • Excessive heat increasing Pitta.
3. Kaphaja Chhardi:
   • Intake of Heavy, Oily, and Sweet Foods:
     • Increasing Kapha Dosha.
   • Overeating and Daytime Sleeping:
     • Leading to Kapha accumulation.
4. Tridoshaja Chhardi:
   • Combination of Factors Affecting All Doshas:
     • Severe or chronic conditions involving multiple Doshas.
5. Dwishtaartha Yukta Chhardi:
   • Emotional Disturbances:
     • Seeing or experiencing repulsive objects or events.

Sanskrit References:

• “Vyāyāmatīkṣṇauṣadhaśōkarōga-bhayōpavāsādyatikarśitasya, Vāyur mahāsrōtasi sampravr̥ddha…” (Verses 7-8)
• “Ajīrṇa-kaṭu-amla-vidāhi-ashītaiḥ, Āmāśaye pittam udīrṇa-vēgam…” (Verse 10)

Modern Correlation

1. Gastrointestinal Disorders:
   • Gastritis and Peptic Ulcers:
     • Inflammation leading to nausea and vomiting.
   • Gastroenteritis:
     • Infections causing irritation of the stomach lining.
2. Dietary Factors:
   • Food Poisoning:
     • Ingestion of contaminated food causing vomiting.
   • Overeating or Indigestion:
     • Leading to nausea and vomiting.
3. Motion Sickness:
   • Vestibular Disturbances:
     • Sensory mismatch causing vomiting.
4. Pregnancy (Morning Sickness):
   • Hormonal Changes:
     • Leading to nausea and vomiting.
5. Medications and Toxins:
   • Side Effects:
     • Certain drugs inducing vomiting.
   • Toxin Ingestion:
     • Poisoning causing emesis.
6. Psychological Factors:
   • Anxiety and Stress:
     • Emotional states triggering vomiting.

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Pathogenesis (Samprapti) of Chhardi

Ayurvedic Perspective

General Pathogenesis

1. Aggravation of Doshas:
   • Due to etiological factors, Doshas become aggravated and move in an upward direction.
2. Impairment of Agni (Digestive Fire):
   • Disturbed Doshas impair the digestive fire, leading to accumulation of Ama.
3. Stimulation of Vomiting Center:
   • The accumulated Doshas irritate the stomach and esophagus, stimulating vomiting.
4. Upward Movement of Doshas:
   • Vitiated Doshas obstruct normal downward flow (Apana Vata) and move upward (Udana Vata).

Specific Pathogenesis for Each Type

1. Vataja Chhardi:
   • Vata Aggravation:
     • Dryness and roughness increase Vata, causing upward movement.
   • Stimulation of Vomiting:
     • Vata stimulates the vomiting center leading to forcible expulsion.
2. Pittaja Chhardi:
   • Pitta Aggravation:
     • Heat and sharpness of Pitta irritate the stomach lining.
   • Inflammation:
     • Leads to burning sensation and vomiting of bile.
3. Kaphaja Chhardi:
   • Kapha Aggravation:
     • Increased heaviness and mucus production.
   • Obstruction:
     • Kapha obstructs channels, leading to nausea and vomiting of mucus.
4. Tridoshaja Chhardi:
   • All Doshas Aggravated:
     • Severe imbalance causing complex symptoms.
5. Dwishtaartha Yukta Chhardi:
   • Psychological Factors:
     • Mind affecting bodily functions through Vata.

Sanskrit References:

• “Vāyur mahāsrōtasi sampravr̥ddha, Utklēśya dōṣāṁs tata ūrdhvam asyan…” (Verses 7-8)
• “Āmāśayē pittam udīrṇa-vēgam… Vamiṁ karōti.” (Verse 10)

Modern Correlation

1. Vomiting Reflex Pathway:
   • Central Nervous System:
     • Chemoreceptor trigger zone (CTZ) and vomiting center in the brain.
   • Peripheral Pathways:
     • Irritation of the gastrointestinal tract sends signals to the brain.
2. Role of Neurotransmitters:
   • Dopamine, Serotonin, and Acetylcholine:
     • Mediate the vomiting reflex.
3. Mechanisms Leading to Vomiting:
   • Gastrointestinal Irritation:
     • Toxins or irritants stimulate receptors.
   • Vestibular Disturbances:
     • Motion sickness affecting the inner ear.
4. Psychological Factors:
   • Cerebral Cortex Influence:
     • Emotions and sensory inputs can trigger vomiting.

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Clinical Features (Lakshana) of Chhardi

General Symptoms

• Nausea:
  • Sensation of unease and discomfort in the stomach.
• Vomiting:
  • Forceful expulsion of stomach contents.
• Dehydration Signs:
  • Dry mouth, thirst, decreased urine output.
• Abdominal Discomfort:
  • Pain or cramps in the stomach area.

Specific Symptoms for Each Type

Vataja Chhardi:

• Vomitus Characteristics:
  • Thin, frothy, with undigested food particles.
• Associated Symptoms:
  • Dry mouth, hoarseness of voice, giddiness.
• Systemic Features:
  • Body ache, headache, chest pain, constipation.
• Nature of Vomiting:
  • Forceful, occurs with great effort, scanty amount.

Sanskrit Reference:

• “Hr̥t-pārśva-pīḍā-mukha-śōṣa-mūr-dha-nābhy-arti-kāsa-svara-bhēda-tōdaiḥ, Udgāra-śabda-prabalaṁ saphēnaṁ vicchinna-kr̥ṣṇaṁ tanukaṁ kaṣāyam…” (Verses 8-9)

Pittaja Chhardi:

• Vomitus Characteristics:
  • Yellowish, greenish, bitter, sour, hot.
• Associated Symptoms:
  • Burning sensation, excessive thirst, dizziness.
• Systemic Features:
  • Fever, fainting, irritability.
• Nature of Vomiting:
  • Frequent, with a burning sensation in the chest and throat.

Sanskrit Reference:

• “Mūrcchā-pipāsā-mukha-śōṣa-mūrdha-tālva-kṣi-santāpa-tamōbhramārtaḥ, Pītaṁ bhr̥śōṣṇaṁ haritaṁ satiktaṁ dhūmraṁ ca pittēna vamēt sadāham.” (Verse 11)

Kaphaja Chhardi:

• Vomitus Characteristics:
  • Thick, pale, sweet, slimy, containing mucus.
• Associated Symptoms:
  • Heaviness, lethargy, excessive salivation.
• Systemic Features:
  • Drowsiness, loss of appetite, coldness.
• Nature of Vomiting:
  • Without much effort, copious amount, relieving heaviness.

Sanskrit Reference:

• “Tandrāsyamādhurya-kapha-prasēka-santōṣa-nidrā-ruci-gauravārtaḥ, Snigdhaṁ ghanaṁ svādu kaphād viśuddhaṁ salōma-harṣō’lparujaṁ vamētu.” (Verse 13)

Tridoshaja Chhardi:

• Vomitus Characteristics:
  • Mixed features: various colors, thick, foul-smelling.
• Associated Symptoms:
  • Severe abdominal pain, indigestion, burning sensation.
• Systemic Features:
  • Breathlessness, confusion, weakness.
• Nature of Vomiting:
  • Severe, persistent, difficult to manage.

Sanskrit Reference:

• “Chardiḥ tridōṣāt lavaṇām lanīla-sāndrōṣṇa-raktaṁ vamatāṁ nr̥ṇāṁ syāt.” (Verse 15)

Dwishtaartha Yukta Chhardi:

• Vomitus Characteristics:
  • Induced by psychological factors; content varies.
• Associated Symptoms:
  • Aversion, disgust, mental agitation.
• Systemic Features:
  • Emotional disturbances.
• Nature of Vomiting:
  • Occurs upon seeing or thinking of unpleasant objects.

Sanskrit Reference:

• “Dviṣṭa-pratīpāśuci-pūtyamēdhya-bībhatsa-gandhāśana-darśanaiś ca, Yac chardayēt taptamanā manōdhnair dviṣṭārtha-saṁyōga-bhavā matā sā.” (Verse 18)

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Prognosis (Sadhya-Asadhya) of Chhardi

Ayurvedic Perspective

• Sadhya (Curable):
  • Chhardi without complications.
  • Early stages of Vataja, Pittaja, Kaphaja Chhardi.
• Yapya (Manageable):
  • Chronic vomiting with manageable symptoms.
• Asadhya (Incurable):
  • Chhardi with complications like bleeding (blood or pus in vomitus).
  • Severe dehydration, altered consciousness, or chronic cases with significant weakness.

Sanskrit Reference:

• “Kṣīṇasya yā chardir atipravr̥ddhā sōpadravā śōṇita-pūya-yuktā, Sa-candrikāṁ tāṁ pravadanty asādhyāṁ sādhyāṁ cikitsed anupadravāṁ ca.” (Verse 19)

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Treatment (Chikitsa) of Chhardi

Ayurvedic Principles

1. Nidana Parivarjana (Avoidance of Causative Factors):
   • Eliminating the causative dietary and lifestyle factors.
2. Shodhana (Purification Therapies):
   • Vamana (Emesis):
     • Indicated in Kaphaja Chhardi to expel excess Kapha.
   • Virechana (Purgation):
     • Used in Pittaja Chhardi to eliminate excess Pitta.
   • Anulomana (Downward Movement):
     • Encouraging the downward flow of Doshas.
3. Shamana (Palliative Therapies):
   • Herbal Medications:
     • Using specific herbs to balance Doshas and alleviate symptoms.
   • Dietary Management:
     • Adjusting diet according to the type of Chhardi.
   • Lifestyle Modifications:
     • Rest, stress management, avoiding exertion.
4. Langhana (Fasting):
   • Light fasting to kindle Agni and digest Ama, especially in Ama-related vomiting.

Specific Treatments According to Doshas

Vataja Chhardi Chikitsa

1. Initial Management:
   • Oleation Therapy (Snehana):
     • Use of medicated ghee (Ghrita) or oils to pacify Vata.
   • Anulomana (Downward Movement):
     • Herbal formulations promoting downward movement.
2. Herbal Formulations:
   • Ginger (Zingiber officinale):
     • Promotes digestion and relieves nausea.
   • Pippali (Piper longum):
     • Enhances digestive fire and pacifies Vata.
   • Saindhava Lavana (Rock Salt):
     • Improves digestion and balances Vata.
3. Dietary Recommendations:
   • Warm and Nourishing Foods:
     • Soups, rice gruel with spices.
   • Avoid Cold and Dry Foods:
     • Preventing further Vata aggravation.

Sanskrit Reference:

• “Vātātmikāyāṁ hr̥dayadravārto naraḥ pibēt saindhava-vaddhr̥taṁ tu…” (Verse 24)

Pittaja Chhardi Chikitsa

1. Initial Management:
   • Cooling and Soothing Measures:
     • Use of herbs with cooling properties.
   • Virechana (Purgation):
     • Mild purgatives to eliminate Pitta.
2. Herbal Formulations:
   • Amalaki (Emblica officinalis):
     • Cooling and Pitta-pacifying.
   • Draksha (Vitis vinifera):
     • Grapes providing cooling and nourishing effect.
   • Sugar and Honey:
     • Sweet taste pacifies Pitta.
3. Dietary Recommendations:
   • Cooling Foods:
     • Rice gruel, coconut water, pomegranate juice.
   • Avoid Hot, Spicy Foods:
     • Preventing Pitta aggravation.

Sanskrit Reference:

• “Pittātmikāyām anulomanārthaṁ drākṣā-vidārī-kṣurasaiḥ trivr̥t syāt…” (Verse 26)

Kaphaja Chhardi Chikitsa

1. Initial Management:
   • Vamana (Emesis):
     • Inducing vomiting to expel excess Kapha.
   • Stimulation of Digestive Fire (Agni Deepana):
     • Using spices and herbs.
2. Herbal Formulations:
   • Vamana Dravyas:
     • Pippali, Sarshapa (mustard seeds), Nimba (Azadirachta indica).
   • Digestive Herbs:
     • Ginger, black pepper, long pepper.
3. Dietary Recommendations:
   • Light and Warm Foods:
     • Barley gruel, soups with spices.
   • Avoid Heavy, Oily Foods:
     • Reducing Kapha accumulation.

Sanskrit Reference:

• “Kaphātmikāyāṁ vamanaṁ praśastaṁ sa-pippalī-sarṣapa-nimba-tōyaiḥ…” (Verse 34)

Tridoshaja Chhardi Chikitsa

1. Complex Management:
   • Addressing All Three Doshas:
     • Requires careful balancing using specific formulations.
   • Supportive Care:
     • Maintaining hydration and electrolyte balance.
2. Prognosis:
   • Generally guarded; requires prompt and intensive management.

Sanskrit Reference:

• “Yaiṣā pr̥thaktvēna mayā kriyōktā, Tāṁ sannipātē’pi samasya buddhyā…” (Verse 40)

Dwishtaartha Yukta Chhardi Chikitsa

1. Psychological Support:
   • Counseling and Reassurance:
     • Alleviating mental distress.
   • Exposure to Pleasant Stimuli:
     • Engaging in enjoyable activities.
2. Herbal and Dietary Measures:
   • Use of Aromatic Substances:
     • Pleasant fragrances to soothe the mind.
   • Favorite Foods and Drinks:
     • Providing comfort and pleasure.

Sanskrit Reference:

• “Manōbhighātē tu manōnukūlā vācaḥ samāśvāsana-harṣaṇāni…” (Verse 41)

Specific Formulations Mentioned in the Text

1. Vataja Chhardi Remedies:
   • Saindhava-Ghrita:
     • Ghee mixed with rock salt.
   • Dhanyaka-Nagara (Coriander and Ginger) Decoction:
     • Helps in pacifying Vata and promoting digestion.
2. Pittaja Chhardi Remedies:
   • Draksha Juice:
     • Cooling and soothing.
   • Laja (Puffed Rice) Mantha:
     • A drink made with puffed rice, sugar, and water.
3. Kaphaja Chhardi Remedies:
   • Vamana with Pippali and Sarshapa:
     • Inducing emesis to expel Kapha.
   • Takra Siddha Yusha:
     • Soups prepared with buttermilk and spices.
4. Herbal Pastes and Powders:
   • Kalkas and Churnas:
     • Preparations using herbs like Amalaki, Haritaki, and Pippali.

Sanskrit References:

• “Vallī-phalādyair vamanaṁ pibēd vā…” (Verse 22)
• “Kaphātmikāyāṁ vamanaṁ praśastaṁ sa-pippalī-sarṣapa-nimba-tōyaiḥ…” (Verse 34)

Dietary Recommendations

1. General Guidelines:
   • Easily Digestible Foods:
     • Light meals that are gentle on the stomach.
   • Frequent Small Meals:
     • Preventing overload on the digestive system.
2. Vataja Chhardi:
   • Warm and Nourishing Foods:
     • Soups, broths, rice with ghee.
   • Avoid Cold and Dry Foods:
     • Such as crackers or raw vegetables.
3. Pittaja Chhardi:
   • Cooling Foods:
     • Coconut water, cucumber, sweet fruits.
   • Avoid Spicy and Sour Foods:
     • Chilies, citrus fruits.
4. Kaphaja Chhardi:
   • Light and Warm Foods:
     • Barley, millet, spiced soups.
   • Avoid Dairy and Sweets:
     • Which can increase Kapha.

Lifestyle Modifications

• Rest:
  • Adequate rest to conserve energy.
• Stress Management:
  • Techniques like meditation and deep breathing.
• Hygiene Practices:
  • Maintaining cleanliness to prevent infections.

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Modern Medical Management

1. Symptomatic Treatment:
   • Antiemetic Medications:
     • Drugs like ondansetron, metoclopramide to control vomiting.
2. Hydration:
   • Oral Rehydration Solutions (ORS):
     • To replace lost fluids and electrolytes.
   • Intravenous Fluids:
     • In cases of severe dehydration.
3. Dietary Adjustments:
   • Clear Liquids:
     • Water, clear broths, ice chips.
   • Bland Diet:
     • BRAT diet (Bananas, Rice, Applesauce, Toast).
4. Treating Underlying Causes:
   • Infections:
     • Antibiotics or antivirals if necessary.
   • Gastrointestinal Disorders:
     • Proton pump inhibitors, H2 blockers for gastritis or ulcers.
5. Psychological Support:
   • Counseling:
     • For stress or anxiety-related vomiting.

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Discussion

The Ayurvedic concept of Chhardi provides a comprehensive understanding of vomiting, including its types, causes, and management strategies. The detailed descriptions in Charaka Samhita align closely with modern medical knowledge, particularly regarding the physiological mechanisms and symptomatology.

Key Correlations:

• Vataja Chhardi and Neurological Vomiting:
  • Related to motion sickness, vestibular disorders.
• Pittaja Chhardi and Inflammatory Vomiting:
  • Associated with gastritis, ulcers, and bile reflux.
• Kaphaja Chhardi and Mucus-Related Vomiting:
  • Similar to vomiting due to excessive mucus or respiratory secretions.

Ayurvedic Treatment Approaches:

• Holistic Management:
  • Emphasis on balancing Doshas, eliminating causative factors, and strengthening digestion.
• Use of Herbal Formulations:
  • Many herbs used have known antiemetic, anti-inflammatory, and digestive properties.
• Diet and Lifestyle:
  • Importance of diet and lifestyle in preventing and managing vomiting.

Modern Medicine Approaches:

• Symptomatic Treatment:
  • Focus on controlling vomiting and preventing complications.
• Addressing Underlying Causes:
  • Identifying and treating the root cause of vomiting.
• Preventive Measures:
  • Vaccinations, hygiene practices, and dietary guidelines.

Integrative Potential:

• Complementary Therapies:
  • Incorporating Ayurvedic herbs like ginger, which has proven antiemetic effects.
• Holistic Care:
  • Combining stress management and lifestyle modifications from Ayurveda with modern treatments.

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Conclusion

Chhardi Chikitsa as described by Acharya Charaka offers valuable insights into the holistic management of vomiting. The emphasis on understanding the underlying Dosha imbalance, tailored treatments, and the integration of diet and lifestyle modifications aligns with modern approaches to patient-centered care.

By correlating Ayurvedic principles with contemporary medical knowledge, we can enhance our understanding of vomiting and develop integrative strategies that harness the benefits of both traditional wisdom and modern science.

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References

1. Charaka Samhita, Chikitsa Sthana, Chapter 20: Chhardi Chikitsa.
2. Sharma, P. V. (1981). Charaka Samhita: Text with English Translation. Chaukhambha Orientalia.
3. Lad, V. (2002). Textbook of Ayurveda. Ayurvedic Press.
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5. World Health Organization (WHO). (2019). Management of Nausea and Vomiting.
6. Ernst, E., & Pittler, M. H. (2000). Efficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trials. British Journal of Anaesthesia, 84(3), 367-371.
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8. Smith, H. S., & Smith, E. J. (2010). Nausea and vomiting. Annals of Palliative Medicine, 1(1), 20-28.
9. Rastogi, S., & Pandey, M. M. (2020). Evidence-based practice of traditional medicines in the treatment of digestive disorders. Chinese Herbal Medicines, 12(1), 1-14.