Reflection-5

As Dr. Aazad writes the prescription for his last patient and his assistant closes the main entrance of the clinic, Aarav, Kabir, and Rohan arrive from the rear. They know that Dr. Aazad is usually willing to spend time with them after the hustle and bustle of the clinic subsides in the late evening.

Kabir: Uncle, we finished another chapter from the book. This one focused entirely on Apāna Vāyu.

Aarav: Three cases again, a merchant with constipation, a woman in prolonged labour, and a soldier who could not pass urine or stool after a fall.

Rohan: Charaka linked them all to Apāna Vāyu, the downward movement that controls elimination, reproduction and menstruation.

Kabir: But would those treatments actually work today?

Dr. Azad: Let us examine them one by one. In the case of merchant, castor oil is still recognised as a strong laxative. Its active compound, ricinoleic acid, stimulates bowel contractions. In modern terms, this would likely be diagnosed as functional constipation, possibly slow-transit type, since his digestion was otherwise normal, but the stool was not being eliminated.

Aarav: How is bowel movement controlled?

Dr. Azad: It is largely regulated by the autonomic nervous system, particularly the parasympathetic supply to the large intestine.

Aarav: He gave it, and the man passed stool within two muhurtas, about an hour and a half. Is that realistic?

Dr. Azad: Yes, that is well within the usual range for castor oil. Its effect typically appears between one and six hours, depending on the dose and the person’s condition. In his case, the bowels were still active, so relief came on the earlier side. The warm fomentation may have eased tension, but the oil did most of the work.

Rohan: And the labour case?

Dr. Azad: That is more complex. If there is no mechanical obstruction and the uterus is simply slow, things can restart naturally. Warm compresses can help the mother relax. A rectal oil enema might stimulate reflex pelvic activity.

Kabir: But in modern obstetrics, what is the main driver for labour progress?

Dr. Azad: Hormones, especially oxytocin from the brain and prostaglandins from the uterus. They coordinate contractions and cervical changes, acting as the main drivers of labour. Nerve signals also reach the uterus, but their influence is secondary.

Aarav: So, Apāna Vāyu groups them together, but modern science sees a different mechanism for labour?

Dr. Azad: Exactly.

Rohan: Then is it really correct to put constipation, labour, and urinary retention under the same heading? If the causes are so different, could the ancients have been grouping them only by symptoms?

Dr. Azad: That is a fair point. Ancient classification was functional, not anatomical. They noticed that these different problems all involved a failure of downward and outward movement. In the absence of neurophysiology and endocrinology, identification of the specific cause was not possible then. They were less concerned with identifying the precise cause.

Kabir: But if cause matters for treatment, could they have sometimes been wrong about what was really happening?

Dr. Azad: Certainly. Without modern anatomy, physiology, and hormonal science, they sometimes mistook a shared effect for a shared cause. That is why these systems need reinterpretation when used today.

Kabir: What about menstruation? That is also mentioned under Apāna Vāyu.

Dr. Azad: Menstruation is mostly governed by the cyclical changes in ovarian and pituitary hormones, particularly estrogen and progesterone. The autonomic nervous system has almost no role in initiating menstruation, although it can influence some associated symptoms such as cramps through smooth muscle tone. So again, the ancient classification groups it with Apāna Vāyu based on the downward movement, but the underlying mechanisms are primarily hormonal.

Aarav: What about the third case?

Dr. Azad: In the third case, the soldier appears to have had neurogenic bladder and bowel after spinal injury. Modern physiology would explain this as disruption of the sacral parasympathetic outflow, part of the autonomic nervous system. The autonomic nervous system is indeed the common link for many Apāna Vāyu functions such as urination, defecation, and the erectile phase of sexual function. Ejaculation, however, is primarily driven by sympathetic outflow. Labour and menstruation, by contrast, are mainly driven by hormonal factors, with neural reflexes playing a supportive role.

Rohan: So, the common force idea holds for some but not all functions.

Dr. Azad: Yes. Ancient physicians grouped them together by observing the shared pattern of downward expulsion. Modern medicine can separate them by nerve pathways, hormonal control, and anatomical structures such as muscles.

Rohan: But is there any clinical condition where all these functions could be lost or impaired?

Dr. Azad: Yes, a spinal cord lesion at or above S2–S4 can result in neurogenic bladder, neurogenic bowel, and sexual dysfunction.

Kabir: Ah, that is interesting! Possibly such observations of spinal injuries might have led to the assumption that a common regulator operates in all these domains.

Dr. Azad: That is quite possible. The impairment of these functions after spinal injury does not mean they are all controlled by a single nerve center in normal physiology, but rather that they share overlapping neural pathways that can be disrupted together.

Aarav: What about Uttara Vasti for the soldier? Is that really effective?

Dr. Azad: In partial injuries, yes. It works much like modern catheterisation, which is still the standard for acute urinary retention. The warm fluid could trigger reflex contraction of the bladder. But with complete spinal cord injury, that would not succeed.

Rohan: Or could it be that some patients would have recovered on their own, and the treatment just happened to be given at the right time?

Dr. Azad: That is possible. Recovery from partial blockages or temporary nerve suppression can occur naturally. In the absence of controlled observation, cause and coincidence can be hard to separate.

Aarav: This brings me back to last chapter’s Prāṇa Vāyu. Is the concept the same kind of abstraction?

Dr. Azad: No, there is an important difference. Prāṇa Vāyu is tied to an experiential process, you can feel your own breath and sense the inward movement. Apāna Vāyu is a proposed functional category, you do not feel Apāna itself, you see its effects in elimination, reproduction, and menstruation.

Rohan: So one is directly felt, the other is observed through patterns.

Dr. Azad: Exactly. Both are abstractions, but one comes from inner experience, the other from noticing the same direction and outcome in different organs.

Kabir: And the ancient unifying principle was valuable even if the modern explanations are more detailed.

Dr. Azad: That is the point. Function-based grouping can reveal patterns across systems. Anatomy and physiology then add precision, and endocrinology explains cases like labour and menstruation where the pattern is similar but the mechanism is different.

The boys thank him and step out, each imagining how different the same problems would look in Charaka’s gurukula and in today’s hospital.