Asthapana basti

Asthapana basti or niruha basti (therapeutic decoction enema) is a prime treatment for disorders due to vitiation of vata dosha. It can expel out the increased dosha. [Cha.Sa. Siddhi Sthana 1/27] Niruha basti (therapeutic decoction enema) can pacify vata at its root i.e. colon. Thus, it protects the whole body from diseases due to vata dosha. Both asthapana (therapeutic decoction enema) and virechana (therapeutic purgation) remove the doshas from the body through the colon. Asthapana basti (therapeutic decoction enema) has the advantage of eliminating dosha without causing difficulties like belching, pain in the heart region and koshtha (gut). [Cha.Sa. Siddhi Sthana 10/07] Niruha (therapeutic decoction enema) can be administered in weak persons, where virechana is contraindicated. (therapeutic purgation) [Cha.Sa. Chikitsa Sthana 28/86] Virechana (therapeutic purgation) is contraindicated in children and old people, whereas asthapana (therapeutic decoction enema) can be used for lifetime. [Cha.Sa. Siddhi Sthana 10/07] This chapter focuses on the concept and practices of asthapana basti (therapeutic decoction enema).

Contributors

Section/Chapter/topic	Concepts/Basti/Asthapana basti
Authors	Adarsh P. M. 1, Deole Y.S. 2
Reviewer & Editor	Basisht G.3
Affiliations	1 Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India 2 Department of Kayachikitsa, G. J. Patel Institute of Ayurvedic Studies and Research, New Vallabh Vidyanagar, Gujarat, India 3 Rheumatologist, Orlando, Florida, U.S.A.
Correspondence emails	dryogeshdeole@gmail.com, carakasamhita@gmail.com
Publisher	Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India
Date of publication:	August 25, 2023
DOI	10.47468/CSNE.2023.e01.s09.145

Etymology and derivation

Asthapana: The word asthapana is derived from aan, stha with lyut suffix in Sanskrit. This means to stay in one place (for longer time). Asthapana prevents the aging process by fixing the malfunctioning dosha.
Niruha: The word niruha is derived from nir (निर्) (privative)+ uha (ऊहा) (reasoning)+ karane (करणे घञ्). Thus, the word niruha stands for the treatment whose effect is beyond reasoning (or effective without any doubt).

Synonyms: Asthapana basti, niruha basti, kashaya basti

Types of asthapana basti

1. Based on veerya (potency) :
1. Mridu asthapana basti (mild potency): The basti with mild potency is indicated in diseases of short duration, easy to cure, and having minimum strength.[Cha.Sa. Siddhi Sthana 10/15,16]. It is indicated in persons of inferior mental strength (avara sattva).[Su.Sa. Chikitsa Sthana 38/90]. It is indicated explicitly in old age and children.[Su.Sa. Chikitsa Sthana 35/10]The basti becomes mild (mridu), when milk (ksheera) etc. are added to it.[Cha.Sa. Siddhi Sthana 7/63]
   Prasrutika basti is an example of mridu basti (basti with mild potency), which is indicated for tender/delicate persons(sukumaras). There are chatur prasrutika, pancha prasrutika, shat prasrutika, sapta prasrutika and nava prasrutika bastis mentioned in prasruthayogika siddhi.
2. Teekshna asthapana basti (strong potency): The basti with strong potency is indicated in diseases of prolonged duration, challenging to cure, and having maximum strength. It can be administered in persons having superior mental strength (pravara sattva). The basti will get sharpness (teekshnatvam), when it gets added with cow’s urine (gomutra), pilu (Salvadora persica Linn), Chitraka (Plumbago zeylanica), salt (lavana) and alkali (kshara).
2. Based on effect (karma):
1. Utkleshana basti: This type of basti is intended to aggravate dosha in dormant state (leena avastha). After initial aggravation, the basti expelles the dosha to create equilibrium. Eranda beeja (seed of Ricinus communis), madhuka (Madhuka longifolia), pippali (Piper longum), saindhava (rock salt) and hapusha phala (Juniperus communis Linn.) as kalka are the ingredients of utkleshana basti. [Su.Sa. Chikitsa Sthana 35/93]
2. Doshahara basti : This pacifies dosha by removing them. The ingredients of doshahara basti are satahva (Anethum sowa), madhuka (Madhuca longifolia), kutaja beeja (Holarrhena antidysenterica), madanaphala (Randia dumetorum) along with kanjika (fermented rice gruel) and gomutra (cow’s urine). [Su.Sa. Chikitsa Sthana 35/94].
3. Dosha shamana basti: This pacifies dosha with mild potency. Priyangu (Callicarpa macrophylla), Madhuka (Madhuca longifolia), Musta (Cyperus rotundus), Rasanjana (semisolid extract obtained from decotion of Berberis aristata with milk) along with cow’s milk (goksheera) are the ingredients. [Su.Sa. Chikitsa Sthana 35/95]
3. Yapana basti (enema for sustaining life)
   Yapana bastis can be administered in all seasons. There are 12 types of yapana bastis mentioned and they are indicated in different stages of all diseases. They serve the action of niruha basti (therapeutic decoction enema) and sneha basti (therapeutic unctuous enema). Mustadi yapana basti. shaliparnyadi yapana basti, sthiradi yapana basti are examples of yapana basti. [Cha.Sa. Siddhi Sthana 12/16-17]
4. Piccha basti (enema for healing)
   Piccha basti is a kind of asthapana basti prepared using slimy (picchila) dravyas. It is indicated in conditions like diarrhea (atisara), where there is bleeding from rectum. [Cha.Sa. Chikitsa Sthana 19/93]
5. Ksheera basti (enema with medicated milk)
   The type of asthapana basti where medicated milk (shrita ksheera) is used instead of decoction is known as ksheera basti. It is also a kind of mridu basti (basti with mild potency). It is indicated mainly in diseases like vatarakta (rheumatism due to vitiated vata and rakta), sandhigata vata (degenerative joint disorder), visarpa (erysipelas), vatavyadhi (disorders due to vata) etc.
6. Rakta basti (enema with animal blood)
   Rakta basti contains the blood of freshly killed animals which is indicated mainly in atisara(diarrhea) where the patient is debilitated by losing blood through the rectum. It is indicated in raktatisara (ulcerative colitis with blood in stools) and jeevadana vyapat of virechana (therapeutic purgation) and basti (therapeutic enema). [Cha.Sa. Siddhi Sthana 6/82]
7. Doshaghna basti
1. Vataghna basti
   In diseases having the aggravation vata dosha, the basti processed with the decoction prepared out of drugs having the property to pacify vata (vataghna aushadha). Trividha sneha (combination of three snehas viz ghee, plant oil and muscle fat.), amla dravyas (drugs having sour taste) and saindhava (rock salt) is used. [Su.Sa. Chikitsa Sthana 38/77]
2. Pittaghna basti
   In diseases associated with pitta dosha, basti (therapeutic enema) processed with the decoction of nyagrodhadi gana combined with kakolyadi gana as kalka (paste) along with ghee and sugar is advised. [Su.Sa. Chikitsa Sthana 38/78]
3. Kaphaghna basti
   In diseases having an association of kapha dosha, basti (therapeutic enema) processed with the decoction of aragvadhadi gana combined with pippalyadi gana as kalka (medicinal paste) along with honey, cow’s urine (gomutra) is to be used. [Su.Sa. Chikitsa Sthana 38/79]
4. Rakta shamana basti
   In diseases having loss of blood (shonita pravrutti), the enema processed with the decoction prepared out of ksheeri vrikshas (group of trees starting from nyagrodha) combined with sugar cane juice), milk, ghee, and sugar is used. [Su.Sa. Chikitsa Sthana 38/80]
8. Shodhana basti
   The enema, which is processed with the decoction and medicinal paste of shodhana dravyas (group of drugs with purifying action), with rock salt and unctuous substance (sneha) is known as the shodhana basti. [Su.Sa. Chikitsa Sthana 38/81]
9. Lekhana basti:
   The enema is processed with the decoction of triphala, cow’s urine, honey, alkali (kshara) and combined with ushakadi gana as a medicinal paste (kalka), known as lekhana basti. [Su.Sa. Chikitsa Sthana 38/82]
10. Brimhana basti:
    The basti processed with the decoction of drugs having the nourishing property(brimhana) combined with the drugs having a sweet taste (madhura rasa) as a medicinal paste (kalka) along with ghee and meat soup (mamsarasa) is known as brimhana basti. [Su.Sa. Chikitsa Sthana 38/83]
11. Grahi basti
    The enema is processed with the drugs of priyangvadi gana combined with ambashtadi gana as medicinal paste and honey and ghee known as grahi basti. [Su.Sa. Chikitsa Sthana 38/87]
12. Madhutailika basti
    When honey (madhu) and oil (taila) are given equal importance in enema, then it is known as madhutailika basti. Yapana basti, yuktharadha basti and siddha basti are synonyms of madhutailika basti. It helps remove the doshas and bring up the strength and complexion of a patient. The peculiarity of this kind of enema is that there will be no restrictions on diet, beverages, travel, and sexual intercourse. The enema shows many benefits to the patient with no complications at all. [Su.Sa. Chikitsa Sthana 38/114]
13. Yuktaratha basti
    The patient can travel in chariot (ratha) after taking this enema. Hence it is named as yuktaratha basti. This basti has ingredients like erandamuladi as decoction; vacha (Acorus calamus), madhuka (Madhuca longifolia) and pippali (Piper longum) as medicinal paste and taila (sesame oil) as unctuous substance (sneha). [Su.Sa. Chikitsa Sthana 35/8]
14. Siddha basti
    The attainment of strength, nourishment, and complexion and the cure of many diseases can be possible by this basti, and thus, it is named siddha basti. Yavakoladi siddha basti is one of its examples processed with the decoction of yava (Hordeum vulgare), kola (Ziziphus mauritiana Lamk Z.jujuba Lamk), and kulattha (Dolichos biflorus ), along with the medicinal paste of magadhika (Piper longum) and yashtyahva (Glycyrrhiza glabra).[Su.Sa. Chikitsa Sthana 38/97-99]
15. Vaitarana basti
1. Gomutra vaitarana basti
   Fruit pulp of Tamarindus indicus as paste (amleeka kalka), jaggery, rock salt and cow’s urine along with little quantity of oil (taila) is used for the preparation of gomutra vaitarana basti. [Chakradatta Niroohadhikara 72/33]
2. Ksheera vaitarana basti
   All the ingredients are the same as gomutra vaitarana basti except cow’s milk in place of cow’s urine here. [Vang.Sa. Basti Adhikara 86-189]
16. Ardhamatrika basti
    It has a total quantity of 12 pala (1 pala equals 48g), which is half that of dvadasha prasrutha basti. Here decoction of dashamoola (group of roots of 10 drugs), honey, rock salt and shatapushpa (Anethum sowa) as medicinal paste is used. [Vang.Sa. Basti Adhikara 172-181]
17. Vrishya basti
    The decoction of egg of chataka (hen sparrow) and uchataka along with cow’s milk, ghee, sugar and athmagupta phala (fruit of Mucuna pruriens) as admixture (avapa) is aphrodisiac (vajikarana) in nature. [Su.Sa. Chikitsa Sthana 38/84]
18. Chakshushya basti
    Erandmauladi decoction, yashtyahva (Glycyrrhiza glabra) as the medicinal paste, and honey, rock salt, and oil are the ingredients of chakshushya basti. [A. Hri.Kalpa Sthana 4/27-29]
19. Churna basti
    Churnabasti has pain relieving (shulaghna) properties with hot water as a liquid component (dravadravya) instead of decoction. The medicinal paste of rasna (Pluchea lanceolata), vacha (Acorus calamus), bilva (Aegle marmelos), shatahva (Anethum sowa), ela (Eletteria cardamomum), putika (Holoptelia integrifolia), krishna (Piper longum), daru (Cedrus deodara) and kushdha (Saussuria lappa C. B Clarke) is used. [Cha.Sa. Siddhi Sthana 10/13-14]

Importance in the preservation of health and prevention

Therapeutic enema is advised in healthy individuals during the rainy season where there is vitiation of all three doshas [A. Hri. Sutra Sthana 3/42], after the administration of vamana (therapeutic emesis) and virechana (therapeutic purgation). [A. Hri. Sutra Sthana 3/45]

Importance in the management of diseases

• Basti (therapeutic enema) therapy (asthapana and anuvasana) is the most important among the therapies for treating vata dosha disorders. It enters the intestine (pakvashaya) after the administration cuts the root of aggravation of vata and thereby it pacifies vata all over the body. Its effect is like cutting the root of a tree (disease) will destroy the whole tree (disease). [Cha.Sa. Sutra Sthana 20/13]
• Basti (therapeutic enema), in general, is helpful in the prevention of aging, and it produces health, strength, proper digestion, intelligence, voice, and complexion.
• It is recommended for both children and old age as it effectively cures diseases without causing complications.
• It removes the vit (stool), shleshma, pitta and vata dosha from the body.
• It provides compactness to the body and strength to shukra dhatu (the 6^th basic structural element of the body).
• It removes doshas from the body’s channels and thus pacifies all diseases. [Cha.Sa. Siddhi Sthana 1/27]
• Administration of niruha basti (therapeutic decoction enema) before anuvasana basti (therapeutic unctuous enema) clears the channels.. It helps properly transport unctuous substance (sneha) like the pipe which carries water when the impurities causing obstruction are removed. [Su.Sa. Chikitsa Sthana 38/84]
• Basti (asthapana and anuvasana) is important as it is the prime treatment for vata. Vata is the reason for the diseases originating in peripheral tissues (shakha), visceral organs (koshtha), vital points of the body (marma), upper part of the body (urdhva), entire body (sarvavayava) and individual parts of the body (anga). The same vata is responsible for separating and combining stool, urine, pitta, etc. at their sites. As basti is supreme in managing vata, it is said to be half of the entire therapeutics. [Cha.Sa. Siddhi Sthana 1/38-40]

Indications of asthapana basti

• Sarvanga roga – The diseases are affecting the whole body.
• Ekanga roga – The diseases are affecting the organs.
• Kukshiroga – Diseases affecting the abdomen and pelvis
• Vata varcha mutra sanga – Obstruction to flatus, feces, urine
• Adhmana – abdominal distension
• Angasupti – Organ-level numbness
• Krimikoshtha – The gut infested with worms.
• Balavarnamamsaretaskshaya – depletion of strength, complexion, muscle, and sperms
• Atisara – Diarrhea without the involvement of metabolic dysfunction (ama)
• Udavarta - Upward movement of vata due to retention of stool and urine
• Parvabheda – Pain in joints
• Pleeha - Splenomegaly
• Abhitapa – Burning sensation
• Gulma – A type of lump
• Shula – Abdominal colic of different pathologies
• Shirakarnashula – Pain on head and ear
• Bhagandra – Fistula
• Unmada - Insanity
• Jwara - Fever
• Hrudaya parshva prushta katigraha – Pain over heart, sides of chest, lower back, and hip.
• Hrudroga – Diseases affecting heart
• Bhradhna - Inguinal hernia
• Vepana - Tremor
• Sphikjanujangha shula – Pain on flanks, knee, and calf
• Akshepaka - convulsions
• Gourava – Heaviness of body
• Ati laghava – Excessive lightness of body
• Uru gulpha parshnishula – Pain over thigh, ankle, and heel
• Rajakshaya – loss of menstrual blood with burning
• Vishamagni – Irregular state of agni
• Shosha - Emaciation
• Bahu, anguli, stanantashula – Pain over arms, fingers, and middle of chest
• Stambha - Stiffness
• Antrakujana – Gurgling sound in the intestine
• Parikartika – sharp cutting pain in anus
• Danta nakha parvasthi shula – Pain on teeth, nails bones and joints
• Anaha - Barborygmus with distention
• Pratishyaya – A type disease affecting nose including coryza
• Ashmari – Renal calculi
• Khuda – A disesase which is affecting the skin and muscle over the joints of legs and hands first and later spreads to deeper sites
• Vatavyadhi – Diseases originates from vitiated vata
• Alpalpodhana – Voidance of stool frequently in less quantity
• Sashabdodhana – Voidance of stool with sound
• Ugragandhodhana- Voidance of stool having foul smell. [Cha.Sa. Siddhi Sthana 2/16]

Niruha basti is also indicated in following diseases

• Adhimantha - glaucoma
• Ardita - facial paralysis
• Pakshaghata - hemiplegia
• Udara - obstinate disorders affecting the abdomen including Ascites.
• Upadamsha - syphilis
• Mutrakruchhra - dysuria
• Shukra artava stanya nasha: Depletion of semen, menstruation, and breast milk
• Hanugraha – lock jaw
• Manyagraha – neck stiffness
• Sharkara – multiple gravel like particle in urine
• Mudhagarbha – abnormal fetal presentation. [Su. Sa. Chikitsa Sthana 35/5]

Contraindications

• Persons suffering from severe weakness
• Injuries.
• Fainting
• Those who have undergone the process of purification any.
• Those whose life depends on the strength of morbid matter (agantu dosha) to survive [Cha.Sa. Siddhi Sthana .1/37]

Ingredients of niruha basti

As the name suggests, the important and predominant content of niruha basti (therapeutic decoction enema) is a decoction of herbs depending upon the disease condition of the patient. Its other ingredients are honey, rock salt, unctuous substances (usually oil or ghee) and medicinal paste. In some conditions, cow’s urine, fermented liquid preparation out of grains (dhanyamla), meat soup, milk etc. are used either as an alternative or as an admixture (Avapa) to the combination of basti.

Quantity of ingredients

The general dosage of ingredients for 1152 ml (dvadasha prasruta) basti are as follows. While preparing, there is a specific sequence of mixing the ingredients and their quantity is listed below.

1. Honey (madhu): 192 ml (2 prasruta)
2. Rock salt (saindhava): 12 gram (1 karsha)
3. Oil/ghee/unctuous substance (sneha): 288 ml (3 prasruta)
4. Medicinal paste (kalka): 96 gram (1 prasruta)
5. Decoction (kashaya): 384 ml (4 prasruta) to 480 ml (5 prasruta) *[Su.Sa. Chikitsa Sthana 38/37-39]
6. Additives (avapadravya): 192 ml (2 prasruta) [Cha.Sa. Siddhi Sthana 3/30]

The proportion of sneha (unctuous substance) and honey is based on dosha association.

Table 1. Ingredients’ proportion in basti formulation based on dosha association

	Vata predominance	Pitta dosha anubandha	Kapha dosha anubandha
Honey	3 pala (144 ml)	4 pala (192 ml)	6 pala (288 ml)
Unctuous substance	6 pala (288 ml)	4 pala (192 ml)	3 pala (144 ml)

[Cha.Sa. Siddhi Sthana 3/30]

Dose of asthapana basti in different age groups

The dose of basti formulation as per age. It is shown in table 2.

Table 2: Age specific dose of basti formulation

Age	Dosage
1 year	½ prasruta (48 ml)
Increase the dosage by ½ prasrutha each year till 12 years	48 ml to 576 ml
12 years	576 ml (6 prasruta)
Increase the dosage by 1 prasruta each year till 18 years	576 ml to 1152 ml
18 year and above until age 70	1152 ml (12 prasruta)
Above 70 years	960 ml (10 prasruta)

[Cha.Sa. Siddhi Sthana 3/31-32]

Table 3: Sushruta’s view on age specific dose of basti formulation

Age	Dosage
1 year	2 prasruta (192 ml)
8 years	4 prastuta (384 ml)
16 years	8 prasruta (768ml)
25 years and above up to 70 years	12 prsruta (1152 ml)
Above 70 years	8 prasruta (768 ml)

[Su.Sa. Chikitsa sthana 35/7]

Procedure of administration of asthapana basti

The procedure of administration of basti can be divided into three stages like the samshodhana (therapeutic emesis and purgation) procedures. They are.

1. Pre therapeutic procedure (purvakarma)
2. Chief therapeutic procedure (pradhana karma)
3. Post therapeutic procedure (paschat karma)

1. Pre therapeutic procedure (purvakarma)
1. Preparation of the medicine
1. Preparation of asthapana basti (therapeutic decoction enema) formulation by the collective missing of ingredients mentioned above using a churner (khaja).
2. The prepared formulation filled into the enema bag by tying it with the enema nozzle (bastinetra) without catching air inside and without producing wrinkles above the bag.
3. The tip of the enema nozzle should be inserted with a wick (varti) to prevent its leaking.
2. Preparation of the patient
1. The patient must have undergone oil application and sudation.
2. The patient must have an empty bowel and bladder.
3. The patient must not have a severe appetite.
2. Therapeutic procedure (pradhana karma)
• The patient should be lying in the left lateral position with the head side either raised or at the same height as that of the leg on a fair couch which is not lifted too much.
• The patient should be lying in an left lateral position with his own arm as the pillow below head.
• The right leg should be flexed at the knee whereas the left leg should be in extended position.
• The anal orifice (guda) should be lubricated and the 1/4th of the total length of the lubricated enema nozzle (which is equal to the distance from the tip of nozzle to the karnika at the tip) should be inserted in the same direction of the vertebral column.
• The hand of the person giving enema should not be shaking during the insertion of the nozzle.
• Repeated squeezing of the enema bag is not favorable, and the nozzle should be withdrawn slowly and carefully. [Cha.Sa. Siddhi Sthana 3/17-20]
3. Post therapeutic procedure (paschat karma)
• After the proper elimination of enema, the patient should have undergone bath with lukewarm water and take boiled rice with thin meat soup.
• The patient should be given anuvasana basti (therapeutic unctuous enema) with the oil (taila) having 1/4^th quantity of that of asthapana (therapeutic decoction enema) processed with drugs having the property to pacify vata and having sour taste, for the nourishment of the body after the digestion of the above-mentioned diet in the evening. [Cha.Sa. Siddhi Sthana 3/27-30]

Diet after the niruha basti (therapeutic decoction enema)

Table 4: Diet after niruha basti in different dosha involvement

Dosha Involvement	Diet
Vata	meat soup (mamsarasa)
Pittanubandha (association of Pitha)	milk (ksheera)
Kaphanubandha (association of kapha)	soup of pulses of various kinds (yusha)

[Cha.Sa. Siddhi Sthana 3/70]

Number, adjuvant, and properties of niruha basti in different dosha involvement

Table 5: Number, adjuvant, and properties of niruha basti in different doshas

Dosha involvement	Adjuvant	properties	number
Vata	Meat soup (mamsa rasa)	Unctuous (snigdha), Hot in potency (ushna)	1
Pitta association	Milk (payas)	Sweet (svadu), cold in potency (sheeta)	2
Kapha association	Cows’ urine (mutra)	Pungent (katu), hot in potency (ushna), sharp in action (teekshna)	3

Complications of asthapana basti

There are mainly 12 complications of asthapana basti (therapeutic decoction enema) arise because of its improper administration. They are as below.

1. Ayoga – Untoward effects due to insufficient dose administration
2. Athiyoga – Untoward effects due to excess dose administration
3. Klama - exhaustion without exertion
4. Adhmana – abdominal distension
5. Hikka - hiccups
6. Hrudprapti – reaching cardiac region
7. Urdhvavata – upward dislocation of vata
8. Pravahika - dysentery
9. Shiro arti – headache
10. Angaarti – bodyache
11. Parikartha – sharp cutting pain in anus
12. Parisrava - excessive secretion

The following table shows details about these complications.

Name of complication	Etiology	Signs and Symptoms	Management
Ayoga	Administration of decoction enema which is. cold in nature having less quantity of salt, unctuous substance fluid part (drava dravya) thick in nature In patients having heaviness due to chronic constipation, vata dominance and dry koshtha (Viscera).	Increased abdominal heaviness, obstruction of flatus, urine and fecus. Severe pain in umbilicus Burning sensation Itching Discolouration Anorexia Loss of appetite	Intake of hot decoction mentioned in the management of diarrhea (pramathya) Different types of sudations Anal suppositories Virechana (therapeutic purgation) Bilvadi decoction enema
Atiyoga	Use of extreme sharp and hot formulation in mridukoshtha (delicate bowel nature)	Signs and symptoms same as that of atiyoga (exceeded effect) mentioned in vamana (therapeutic emesis) and virechana (therapeutic purgation)	Administration of decoction enema having the Medicinal paste (kalka) of prushni parni (Uraria picta), Sthira (Desmodium gangeticum), padma (Nelumbo nucifera), kashmarya (gmelina arborea), madhuka (Madhuca longifolia) and bala (Sida cordifolia) Fluid part (drava dravya) having the decoction of draksha (Vitis vinifera), water prepared out of pakva loshta (heated iron or earth) and madhuka (madhuca longifolia) Unctuous part – Ghee
Klama	Soft Enema administered in remanence of ama (product of impaired digestion and metabolism)	Weariness Burning sensation Chest pain Loss of consciousness feeling as if wrapped/cramps. heaviness	Sudation with dry drugs Deepana (drugs enhancing digestion and metabolism) Decoction enema with dashamula (group of ten roots) and gomutra (Cow’s urine)
Adhmana	Administration of enema having less potency in patients having great aggravation of doshas, dryness and constipation	Abdominal distension severe form of flatulence as if vital point (marma) is afflicted. Burning sensation Heaviness of abdomen Pain on inguinal region and testes.	Suppository prepared out of shyamaphaladi yoga. Bilvadi niruha basti Anuvasana (Therapeutic unctuous enema) with Sarala (Pinus longifolia) and devadaru (Cedrus deodara)
Hikka	Administration of enema having extreme sharpness in action in patients who are weak and having delicate bowel nature.		The medications of hiccup and drugs having nourishment property Therapeutic unctuous enema with balasthiradi thaila Intake of black salt (krishna lavana) with hot water medicated smoking, linctus, milk, sudations, and food processed with vata pacifying drugs
Hrudprapti	Administration of enema which is having extremely high potency or by pushing the vata to the rectum by its complete drainage	Shaking the heart	Kasadi basti Therapeutic unctuous enema processed with drugs pacifying vata
Urdhvata	Administration of enema at the time of suppression of urges of flatus, urine, and feces.	Enema comes out through mouth. Syncope	Flashing water on the face Rub gently over the sides of chest and abdomen. Fanning over him Terrifying the patient with fearful sounds Torturing the patient by pulling him up in the air by holding his hair and shaking it. Holding the neck of the patient tightly not causing death Intake of paste of Areca catechu (kramuka kalka) mixed with sour substances. Dashamulika asthapana basti (medicated decoction enema) with cow’s urine (gomutra) as adjuvant (avapa) when the enema is obstructed in large intestine. Bilvadi siddha basti when the enema is obstructed in chest region. Nasal medication, medicated smoking and wrapping the head with sarshapa (Brassica indica) when it is blocked there in the head.
Pravahika	Administration of soft potency drug or less quantity drug in greatly aggravated doshas.	Dysentery Swelling of urinary bladder and anal region Exhaustion of calf and thigh	Abhyanga (Massage) Sweda (sudation) Niruha (therapeutic decoction enema) added with sodhana dravyas (purifying drugs) like trivruth (Operculina turpethum) or anulomana dravyas like milk.
Shiro arti	Enema having soft potency and less quantity in weak, constipated, and severely aggravated dosha.	Deafness Tinnitus Coryza Visual Illusions	Massage with taila (sesame oil) processed with lavana(salt) Pradhamana nasya (Nasal medication using medicated powder) Dhumapana (medicated smoking) of purificatory variety. Anuvasana (therapeutic unctuous enema) with teekshna anulomana drugs (sharp and directive)
Angarti	Administering enema which has the properties like heaviness and sharp potency in more than required quantity in patients who haven’t undergone snehana and swedana (sudation therapy)	Pain all over the body resembling wrapping, pricking, breaking, and quivering.	Massage with sesame oil (taila) processed with salt. Seka (sudation by streaming of pre-warmed liquid) with hot water, decoction prepared out of the leaves of Eranda (Ricinus communis) Prasthara sweda (Sudation by lying on bed) Niruha basti (Therapeutic decoction enema) with dasamula and bilva thaila. Avagaha (sudation by sitting in tub) Anuvasana basti (Therapeutic unctuous enema) with yashti madhu taila or bilva thaila.
Parikartika	Administering dry, sharp potent and excess quantity of enema in delicate bowels and minimally increased doshas	Sharp cutting pain in anus Pricking pain on sacral region, groin, and urinary bladder. Pain below the umbilicus	Enema with the medicines having sweet taste and cold potency. Enema with srajarasa (Vateria indica) yashtyahva (Glycyrrhiza glabra) Jingini (lannea coromandelica) etc.
Parisrava	Administration of enema having sour taste, salt, hot and sharp potency in patients having the disease of Pitta	Excretion of pitta (bilious humor) of different colours Loss of consciousness Uncontrolled diarrhea	Enema is prepared out of goat’s milk processed with fresh (ardra) shalmali (salmalia malabarica) leaf sprouts. Enema is prepared with the leaves of vata (Ficus bengalensis) etc. in milk. Seka (streaming of liquid) and pradeha (thick anointment) out of sweet and cold drugs

Contemporary approach

The oral route is considered as the most convenient route for drug administration. However, oral medications are not possible in some clinical and pharmaceutical perspective in several circumstances. Rectal route may be used as a clinical alternative in these circumstances which yields both systemic and local actions. The hepatic first-pass metabolism effect can be reduced by rectal administration by partially bypassing the liver following systemic absorption. Rectal formulations are mainly used in the systemic conditions such as pain, fever, nausea, vomiting, migraines, allergies, and sedation.
Boofing or rectal administration medication and other fluids are administered through rectum. There they are absorbed by capillaries of rectum and thus enter the circulatory system and distribute them to whole body. One of the studies also showed that basti medicine reaches up to ileo-caecal junction.
As compared with oral administration, rectal administration is faster in action and higher in bioavailability. Vomiting can be prevented by rectal administration thus it prevents the loss of drug. The two third of rectum’s venous drainage is in the middle and inferior rectal vein which drains directly to systemic circulation and only one third of it goes to the hepatic portal system. Thus, two third of rectal administered drug bypasses the metabolic phase. It can be administered at home which doesn’t require inpatient setup as in intravenous administration. Many of the oral drugs can be modified for rectal administration by crushing and suspending them in water.
There are many digestive tract problems where the rectal route can be selected for drug administration such as bowel obstruction, dysphagia etc. In palliative care and long-term care, it is the cheap and safe alternative to intravenous or subcutaneous delivery of medications.

Methods of rectal route administration

1. Suppository – Insertion of a solid drug into the rectum which dissolves to produce local and systemic effects.
2. micro-enema – Less than 10 ml of liquid drug solution
3. large volume enema - Greater in quantity so that it can expel the feces out and deliver the drug.
4. catheter – A catheter that can safely remain in the rectum for repeated use is inserted.

Asthapana basti (therapeutic decoction enema) can be considered as large volume enema where the quantity of liquid helps in the propulsion of the contents from colon by peristalsis.

Solutions used for enema

• Plain water – It works simply by the mechanical expansion of colon.
• Normal saline – normal saline does almost the same work except it prevents the loss of electrolytes and retains the fluid for long time which may soften an impaction.
• Castile soap – It causes irritation of colon’s lining and increases the urgency to defecate.
• Glycerol – It is a bowel mucosa irritant which induces peristalsis via hyperosmotic effect.
• Equal parts of milk and molasses – They are heated together slightly above the body temperature. It can retain the water portion of enema in the intestine.
• Mineral oils – These can act as lubricants and stool softener.

Mode of absorption in rectal route

The rectal region is drained by rectal (hemorrhoidal) veins and lymphatic vessels. The superior rectal vein drains the upper part of the rectum, and its lower part drains by inferior and middle rectal veins. More specifically, the superior rectal vein drains into the portal vein, hence it passes through the liver before getting into the systemic circulation. In contrast, the inferior and middle rectal veins drain into the inferior vena cava and, therefore, directly into systemic circulation. Between these three rectal veins exist extensive anastomoses, which connect all three veins throughout the rectum. The rectum is also extensively drained by the lymphatic system that originates in the mucosa and submucosa. The influence of the lymphatic vessels on the absorption of drugs is not well established; however, it may contribute to the systemic absorption of highly lipophilic drugs. Lymphatic drainage also avoids the hepatic first-pass effect.
Depending on the physicochemical characteristics of the drug, transportation of drug molecules occurs passively via paracellular diffusion (between cells) or transcellular diffusion (through the cell). Paracellular transport is preferred for more hydrophilic molecules, ionized molecules, and high molecular weight compounds. However, by the narrow tight junction space in rectum it can be restricted. Therefore, the transcellular route is the main mechanism for drug absorption in the rectum. Transcellular diffusion is affected by many factors, but it is usually proportional to the lipid solubility of the drug. Drug molecules in the non-ionized form are much more lipophilic than the ionized form. At the relatively neutral pH of the rectum, basic drugs with an acid dissociation constant (pKa) near or above the physiologic range tend to be more readily absorbed, as they will predominantly be in their non-ionized form.
The rate of absorption depends on the property of constituents of basti (enema) too. The irritant property of adjuvants causes mild inflammation in the colon which alters the permeability of capillaries and thus enhances the absorption.

Importance of retention of the formulation

For local and systemic drug absorption the drugs need to be retained for an adequate period. The bio availability and efficacy of the drug is directly proportional to the contact time of the drug with the rectal mucosa. The drug molecules must cross the mucosal layer to reach the epithelial cells lining the rectum.

Importance of fluid volume

The small fluid volume may reduce the absorption of the drug as the rectum is deficient in fluid levels which may produce problem of dissolution of some drugs

Current research works

• A comparative study on the effect of virechana (therapeutic purgation) and vaitarana basti in amavata (rheumatoid arthritis) patients concluded that vaitarana basti had given better relief in amavata than viechana.
• Yapana basti administered through drip method and putaka method have shown definite improvement in patients of kampavata (parkinsonism). The drip method has shown better improvement in general symptoms, associated symptoms, functional assessment, and signs.
• Kala basti has shown better improvement in amavata (rheumatoid arthritis) when compared with virechana.
• Administration of Erandamuladi yapana basti in comparison with Erandabija ksheera paka in patients of katigraha have shown better improvement in signs and symptoms of basti group.Damayanthie Fernando (2011): Assessment of Clinical Efficacy of ErandamuladiYapana Basti and ErandaBijaKshiraPaka in the management of Kati Graha w.s.r. to Lumbar Spondylosis. Department of Panchakarma, IPGT&RA Jamnagar
• Clinically in patients treated with lekhana basti there was a decrease in s. cholesterol, s.low density lipoprotein and s. apolipoprotein B. There was a significant reduction in BMI, weight, body fat storage etc. It was effective to a lesser extent on lipid profile than triphala guggulu.
• A comparative study between the effect of rectal administration and oral administration of the same group of drugs (guduchi bhadramustadi) have proved the higher efficacy of rectal administration for the management of sthoulya.
• In a comparative study, vaitararana basti has shown marked improvement in 45% of patients of ghridrasi. Whereas siravyadha has shown marked improvement in 55% of patients. Vaitarana basti was found more effective than siravedha in stambha (stiffness), spandana (twitching), suptata (numbness), sakthikshephanigraha (SLR) and gaurava(heaviness).
• Yapana basti combined with patrapinda sweda and shamana medicine has shown relatively more effectiveness in the management of majority of symptoms in cervical spondylosis than the group in which yapana basti was not administered in combination. The group in which yapana basti combined has also shown prevention from recurrence and long-lasting effects.
• Study of dashamooladi basti in the management of acute stage of amavata has revealed an overall mild improvement in 40% patients, and minor improvement was observed in remaining 60% patients. Complete remission or marked improvement was not found in any of the patient.
• The study of lekhana basti in sthoulya has shown marked improvement in 6.66% patients. The 90.90% patients achieved moderate improvement, and 3.03% patients had mild improvement whereas no patients remain unimproved after the treatment.
• Asthapana basti with udumbara kwatha in raktatisara (ulcerative colitis) has shown complete relief from signs and symptoms in one patient, marked and moderate improvement in 7 and 9 patients respectively.

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