Integrated approach in bridging the gap betweenBiomedicine - A reductionistic science and Ayurveda- A holistic science

Introduction

The new advents and innovations in technology has not let the medical science unaffected. The impact is immense enough that the Modern Evidence based Medicine is considered as Main stream medicine while all other Traditional Medical and healing systems are considered as Alternate Systems. While the former is strongly based in Reductionism the latter is a Holistic approach. The social media and the abundance of means of mass communication has spread the knowledge of all streams of medicine to every corner of the world. The community is aware of most of the medical streams available but is rather confused as which stream to opt for! The personals of Medical community are nowhere an exception for confusion.

Today the Medical schools train the students to view the Holistic sciences through the lens of reductionism, while the reductionists are developing holistic thoughts. The trainers and even the trainees are desperate enough without knowing what to choose, Holism or Reductionism! Never the less both have equal importance and knowing the two is surely a benefit only if one knows to truly amalgamate the two. This amalgamation is termed as ‘Integrated Approach’.

It’s true that the Integration or Integral Approach is spreading like a wild fire, but as the amalgamation is not properly channeled, it is leading to wrong interpretations. There is need to know as how Integration of two streams of medical sciences has to be done without violating the fundamental principles and retaining the sanctity of the sciences. This is an approach to illustrate as how Ayurveda and Biomedicine (Contemporary science) can be integrated.

The article here contains two illustrations;

1. Integration of Biomedicine into Ayurveda; Peripheral Vascular Disease into Vatarakta.

2. Integration of Ayurveda into Bimedicne; Sanyaasa into Cardiac Conduction Block.

1) Integration of Biomedicine into Ayurveda.:

Here, with the example of Peripheral Vascular Disorders, the aim is to illustrate as how the different presentations of a set of disorder can be deducted into different pathological conditions of Ayurveda. Peripheral Vascular Disorders: Peripheral Vascular disorders mainly involve disorders of Peripheral arteries and Peripheral veins. Vaguely all the Peripheral Vascular Disorder are designated as Vatarakta in Ayurveda. But merely naming it as Vatarakta shall not benefit to plan the Chikitsa. The Integration has to done such that if facilitates to plan the Ayurveda Chikitsa. Following is short list of Peripheral Vascualr Disorders;

Peripheral Venous Disorders

i.Venous edema

ii.Varicose veins

iii. Deep Venous Thrombosis.

Peripheral Arterial Disorders:

i. Burgers Disease

ii. Raynaud’s Disease

Vatarakta:

युगप�ातर�िनिम�ांवेदनांजनयतीितवातर�म्| 

(Su. Ci. 5.4)^[1].

When the clinical features of Vata & Rakta are presented simultaneously, the condition is called Vatarakta. The simultaneous presentation of Vata & Raktaja features can be outcome of various Samprapti like, Rakta gata vata, Rakta avruta Vata, Vatashonita. Raktagata vata is caused when Vata is vikrutha but Rakta is prakruta. Raktavruta vata is caused when Vata is prakruta but Rakta is vikruta. Vatashonita is caused when both Vata and Rakta simultaneously undergo dusthi. Thus within broad spectrum Vatarakta includes, Rakta gata vata, Rakta avruta Vata, Vatashonita.

Integration of Peripheral Vascular Disorders into Vatarakta:

Venous Edema: Vataja Swayathu

Venous edema is caused in subjects who stand/ sit for long duration of time, or because of obstruction to venous drainage. Here due to hampered venous drainage there is stasis of blood within veins. Following the stasis, the hydrostatic pressure within the vein column of blood rises, this leads to exudation of blood into the extravascular compartment, leading to edema. When the subject (patient) is lying flat or with elevated limbs, the blood within the veins drains back, the hydrostatic pressure within veins reduces and the edema subsides. Thus the edema subsides at night as the subject rests and aggravates during day time as the subject is active (Diva Bali Shotha). Further in chronic cases of venous edema, there is deposition of hemosiderin, a product obtained by RBC lysis in extravascular compartment. This leads to blackish discoloration of limbs (Asita Varna). Due to impaired vascular drainage, the peripheral nerves suffer from some degree of hypoxia, which leads to altered sensation, or tingling sensation or pain (neuritis)- Supti, harsha, arti. All these are the presentations of Vataja Swayathu. Thus venous edema can be considered as Vataja Swayathu. 

चल�तनु�व�प�षोऽ�णोऽ�सतः�सु ि�तहषा��त�युतोऽ�न �म�ततः| �शा�य�त�ो�नम�त�पी�डतो�दवाबल�च�वयथु ः समीरणात ्|| (Ca.Ci.12.12)² 

Varicose Veins: Vataadhika Vatashonita:

Obviously the presentation of venous edema is an outcome of underlying varicose veins, but initially they remain unnoticed. If the subject with venous edema continuous to stand or sit for long duration, or because of impaired valves the hydrostatic pressure with the veins increases and in long duration causes structural deformity. This deformity is presented as engorgement of veins (Siraayaama- Ayama is Vistaranam). Gradually the engorged veins lose their anatomical stability and turn out to be tortuous. These tortuous veins are called as varicose veins. Thus in Varicose veins along with features of venous edema, the subject also presents with tortuous veins.

�वशेषतः�सरायामशूल�फु रणतोदनम्| शोथ�यका��य�रौ�यंच�यावतावृ��हानयः| (Ca. Ci. 29.25)³

Deep Venous Thrombosis: Gambhira Vatashonita

The varicosity of deeper veins of calf muscles, or due to venous incompetence of deeper veins leads to formation of clots within the veins. The clots formed further obstructs the venous drainage. Thus engorgement of vein within the calves present as edema (Swayathu Stabdah). The subject experiences pain deep within the calves (Antar Brusha Artiman). The venous stasis imparts reddish inflamed appearance to the limb (Shyava or Tamra varna). The condition is painful and may be sometimes associated with low grade fever.

ग�भीरे�वयथु ः�त�धःक�ठनोऽ�तभृ�शा�त�मान ्| �याव�ता�ोऽथवादाहतोद�फु रणपाकवान ्|| (Ca. Ci. 29.25)⁴ 

Peripheral Arterial Disorders:

Burgers Disease: Raktagata Vata

The disease is caused by obstruction of arteries either because of atherosclerotic changes or thrombus leading to reduced vascular supply to the region distal to obstruction. As a result of hypo perfusion of blood, there is deficiency of oxygen & nutrition supply to the tissues. This leads to irritation of nerves- painful extremities (Teevra Ruja), burning sensation (Sa Santapa), cold extremities. The muscles undergo atrophic changes (Krushata), blackish discoloration (Vaivarnya), brittleness of nails, loss of hairs, further in the distal most part necrotic changes can be seen.

�ज�ती�ाःसस�तापावैव�य�कृ शताऽ��चः| गा�ेचा�ं �षभु�त�य�त�भ�चासृ�गतेऽ�नले|| (Ca.Ca.28.31)⁵

Raynaud’s Disease: Raktagata Vata- Leena Dosha Avastha

The disease is episodic, usually with exposure to cold climate, there is severe vaso constriction, leading to hypoxic insult to peripheries. During episodes, initially there is vaso constriction leading to pale cold extremities, with severe pain. Once the limb is made warm, there is vaso dilatation leading to flush of blood to extremities, thus reddish discoloration of limb.

The condition can be correlated to Raktagata Vata, but Vata is in Leena Avastha. (Ca. Su.28.32)^[6] i.e Vata is not Balavan to cause disease but being is Rakta Dhatu awaits for Hetu (cold climate), to attain Vyaktata. Once the Hetu is aborted, the symptoms are relieved.

Importance:

Though in both Arterial and Venous disorders Vata and Rakta play major role the Chikitsa of the two shall differ considerably. In Venous disorders the pathological event involves Margaavarana. The Vatashonitha Chikitsa can be adopted here. Initially the Rakta Upakrama in the form of Rakta Mokshana or Virechana has to be done with due consideration of Vata. Once Rakta Avarana is removed, Vata can be treated with Basti or other Vata Upakrama.

But considering Arterial Disorders, the pathological event involves Gata-Vata Samprapti. Hence Vata has to be addressed first. Basti would be the primary Upakrama of choice. Snehana with Virechaka Sneha (for Rakta Prasadana) like Sukumara Gritha can also be the choice. As the condition is Vatapradhana, Rakta mokshana wouldnot be ideal in Arterial disorder as it causes further Vata Vruddhi.

2) Integration of Ayurveda into Contemporary Science:

Here with example of Sanyaasa an attempt is made to integrate the classical Ayurveda clinical condition into a systemic disorder (Cardiac Conduction Block) of Contemporary science.

स��य�तस��इ�तमृ�युमुखेवत�मान�वा�स��य�तइव स��य�तः | (Dalhana on Su.U.46.20)⁷ �भूतदोष�तमसोऽ�तरेका�स�मू ि�छ�तोनैव�वबु�यतेयः| स��य�तस��ोभृशदुि�च�क��यो�ेय�तदा बु ��मतामनु�यः| यथाऽऽमलो�टंस�लले�न�ष�तंसमु�रेदा�व�वल�नमेव| त�वि�च�क�से��वरया�भष�तम�वेदनंमृ�युवशं �यातम्|(Su.U.46.20-21)⁸

SANYAASA: Sanyasta Samjnya- condition where there is samjnya nasha- loss of consciousness and the condition is deteriorating towards death. Sanyaasa is condition caused by Prabhuta dosha and elevated tamas. A condition where in an individual is Sammurchita (in syncope attack), is not gaining the consciousness (even after sheetala pittahara upakrama) because of elevated tamas and prabhuta dosha is termed as Sanyaasa, it is regarded to be difficult for treatment.

A patient suffering with the episode of Sanyaasa, should be subjected to the treatment to regain the consciousness before he starts sweating. Sweating indicates the poor prognosis of the condition.

A clinical condition presenting with similar clinical presentation is Stoke Adams Syndrome (A Cardiac Conduction Block)

Stoke adams syndrome ^[9] Stoke Adams syndrome is a disorder related to the abnormality in conduction system of heart. In this condition the patient will have complete A-V block, which is transient, may persist for few minutes or few hours or few days or weeks. During the episodes of conduction block, the impulses conducted from Atria doesn’t reach the ventricles. Thus the ventricular contraction is arrested.

Each time the A-V conduction is blocked, the ventricles often do not start functioning until a delay of 5-30 seconds. This results from the phenomenon called ‘Overdrive Suppression’, means that the ventricular excitability at first is in a suppressed state because the ventricles are driven by the atria at a rate greater than their natural rate of rhythm.

Since the brain cannot remain active for more than 4-7 seconds without blood supply, the subject experiences syncope. However after a few seconds some parts of purkinje fibres distal to the block begins discharging the impulse rhythmically at a rate of 15-40 beats per minute and act as pacemakers of ventricles. Eventually with ventricular contraction the blood flushes through the cerebral circulation and thus the patient gains consciousness. This phase where the purkinje fibres uptake the function of impulse production and thus leads to gaining back of consciousness can be termed as ‘Murcha’

Now, there are instances when the Purkinje fibres fail to pick up the activity of discharging impulse and thus leading to prolonged arrest of ventricular activity. With the arrest of ventricular activity both brain and the heart itself will suffer from hypoperfusion and thus hypoxic insult. Initially because of hypo perfusion to brain the patient experiences syncope. If ventricular arrest continuous further, the heart experiences hypoxia which in-turn stimulates Sympathetic nervous system. As a result of Sympathetic stimulation, sweating is seen along with many other responses related to cardiac activity. So sweating indicates the hypoxic insult of heart tissues. Further if the ventricular arrest continuous, it becomes detrimental to subjects health and causes death.

Acharya Susrutha advices to start with intervention before onset of sweating. With the onset of sweating, it indicates that along with brain the heart is suffering from hypoxic insult. In this situation when two of the vital organs goes dysfunctional, sustenance of life becomes difficult, leading to death. Thus an episode of unconsciousness-syncope (Samjnya Nasha) is gradually leading towards death ( Mrutyu mukhe vartamanah), and the condition is termed as Sanyaasa.

Importance: Acharya Susrutha describes the chikitsa of Sanyaasa; initially Teekshna Vamana and Virechana has to be given, advised with Laghu Pathya bhojana, Followed by one month of Shamana chikitsa with Triphala and Chitraka bhavitha Shilajatu and sharkara. Further, Jeerna Gritha has to be advised to the patient.

�बु�स��ंवमनानुलो�यै�ती�णै�व�शु�ंलघुप�यभु�तम्| फल��कै ि�च�कनागरा�यै�तथाऽ�मजाता�जतुनः�योगैः | सशक� रैमा�समुप�मेत�वशेषतोजीण�घृतंसपा�यः || (Su. U. 46.24)¹⁰

This chikitsa siddhanta has to be systematically experimented and validated with respect to conduction abnormalities of heart (conduction block). If the results be positive, then it would be one of the valued contributions of Ayurveda towards cardiology and hence the mankind.

Discussion

Owing to the need for Integration or Integrated Approach in the present era, it is essential to structure the integration on strong grounds. Both the sciences should be given due consideration and justified equally. Here the attempt was made to integrate Biomedicine a Reductionist science with Ayurveda a Holistic science. For illustration of the concept of Integration, two clinical conditions were considered. Peripheral Vascular Disorder, a clinical diagnosis of contemporary medicine and Sanyaasa a clinical diagnosis of classical Ayurveda stream.

Peripheral Vascular Disorders and Vatarakta: Peripheral Vascular Disorder is a broad umbrella term which includes mainly disorders of Arteries and Veins. Each of the clinical condition is having different presentations and so also unique treatments to address them. But all the Peripheral Vascular Disorders are considered under Vatarakta in Ayurveda. Vatarakta or Vatashonita has its own set of etiology, prodromal and cardinal signs and symptoms. It has a vivid line of chikitsa described. But not all (or none) of the chikitsa of Vatarakta would be essential in every case of Peripheral Vascular Disorder. Thus there is need to reduce this Vatarakta into more precise diagnosis based on Samprapti. If the diagnosis is reduced to the extent that Samprapti is defined, it would facilitate to plan the chikitsa accordingly.

From the integration of Peripheral Vascular Disorder with Vatarakta, it can be derived that, Vataja Swayathu, Vataadhikta Vatashonita, Gambheera Vatashonita are the different diagnosis under which Peripheral Venous Disorders can be placed. Further reducing the diagnosis to unwind the Samprapti, Vataadhika Vatashonita and Gambeera Vatashonita are types of Vatashonita which is an Anyonya Avarana Janya Vikara (Anyonya Avarana of Rakta and Vata). Defining the Samprapti of Swayathu, it is also an outcome of Margaavarodha of Vata by Kapha Pitta and Asruk (Ca. Ci. 12. 8)^[11]. Thus Venous Disorders can be clubbed under Raktaavruta Vata Samprati.

र�तावृतेसदाहा�त���व�मांसा�तरजोभृशम्|| भवे�सरागः�वयथुजा�य�तेम�डला�नच| (Ca. Ci. 28. 63)¹²

Considering the Arterial disorders, they hold close similarity with the features of Raktagata Vata. Arterial disorders, in contrary to venous disorders do not present with edema. Similarly the features of Raktagata Vata do not express Swayathu or Shopha as a symptom.

Thus on Integration it can be concluded that both arterial and venous disorders present with common features of Pain, burning sensation etc. (features of neuritis), Discoloration of skin, together substantiating the presence of Vata and Raktaja Lakshana. But venous disorders in general do present with edema, but Arterial disorders do not present with edema. The clinical features of arterial and venous disorders can be interpreted on two different lines of Samprapti,

1) Raktavruta Vata

2) Raktagata Vata.

The differentiating factor between the two Samprapti is presence or absence of Shopha. Thus the Peripheral vascular disorders present with features of Vatarakta (simultaneous presentation of Vata and Raktaja Lakshana); Arterial disorders can be diagnosed as outome Raktagata Vata, while venous disorders as Raktaavruta Vata.

Sanyaasa and Cardiac Conduction Blocks: Sanyaasa is defined as a clinical condition wherein the subject is in unconscious state or state of comatose. So commonly Sanyaasa is correlated to Coma state. But Coma status can be outcome of numerous causes, so it is essential to define the underlying pathophysiology.

The description of the disorder Sanyaasa is purely based on symptoms, and further on, the samprapti invovles ‘Tamo Dosha’ (a Manasika Dosha). The subject is unconscious, subjective feelings cannot be assessed. Onset of sweating shall indicate poor prognosis. Totally the subject is close to death, there are chances to revive the subject if only timely actions are undertaken, but the clinical condition is unclear and highly difficult to be ascertained. Without knowing the exact pathological event initiation into treatment is impossible. To overcome this pathetic condition, primarily an insight into Sanyaasa is essential. To facilitate this, integrated approach was taken up. With the integration the condition was closely correlated to Stokes Adams Syndrome, a Cardiac Conduction Block. Thus not only the gravity of Sanyaasa was unraveled but Integrated Approach also opened up a new insight for treatment of Cardiac Conduction Blocks.

Thus Integrated Approach should be such that it facilitates the physician to plan the Chikitsa and step forward with it.

Conclusion

Integration of concepts doesn’t mean to define the concepts in Reductionism and Holism to be synonymous. Integrated approach is that wherein the Holistic sciences are scrutinized and reduced to simpler form and the segregated information derived from reductionist sciences are tailored to Holism; in a nutshell the efforts are to make the concepts clear and convincing.

Integration of two sciences if channeled appropriately unwinds some mysterious concepts. But the interpretations derived from Integration needs to be subjected to validation. The individual attempting for Integrated Approach should have vast encyclopedic knowledge of the two sciences to be integrated. Finally the Integration should help the medical community to understand the concepts better, and thus ease the efforts towards well-being of mankind, instead should not create more ambiguity and confusion.

It should be remembered that patient community is the population which all the medical systems target. Similarly the aim of all medical systems is to provide the best possible comfort to patient community by relieving from their sufferings. The path adopted by each system to fulfill this aim does differ. A wise physician should know to choose and suggest the best path to relieve the sufferings of the sufferer. Hence the physician should have considerable knowledge of prevailing medical systems. Integration of the knowledge of different medical streams shall than yield to be fruitful.