Vamana Virechana Vyapat Siddhi

Siddhi Sthana Chapter 6. Management of complications of improper therapeutic emesis and purgation

Vamana Virechana Vyapat Siddhi

Section/Chapter	Siddhi Sthana Chapter 6
Preceding Chapter	Netrabastivyapat Siddhi
Succeeding Chapter	Bastivyapat Siddhi
Other Sections	Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana
Translator and commentator	Ramya A.
Reviewer	Mangalasseri P.
Editors	Thakar A. B., Mangalasseri P., Deole Y.S., Basisht G.
Year of publication	2020
Publisher	Charak Samhita Research, Training and Skill Development Centre
DOI	10.47468/CSNE.2020.e01.s08.007

Abstract

The chapter deals with complications due to improper administration of purification therapies vamana (therapeutic emesis) and virechana( therapeutic purgation). Adequate dosage according to agni(digestion power) and koshtha (bowel habit), proper quality of medicine, time of administration, follow up diet regimens are important to prevent complications. Observation of status of patient during purification therapy with the signs of proper, inadequate, excess elimination, causes and management of complications are described in detail in this chapter. The ten common complications like aadhmana (distension of abdomen), parikartika (fissure in ano), srava (excess discharge), hrid-graha (congestion in cardiac region), gatra-graha (body stiffness), jeevaadana (bleeding), vibhramsha (prolapse of rectum), stambha (body stiffness), upadrava (complications) and klama (fatigue without exertion) are elaborated. The causes behind this include incompetency either of the attendant, or drug, or physician or the patient.
Keywords: Vamana (therapeutic emesis), Virechana (therapeutic purgation), Vyapad (complications), Shodhana (purification therapy).

Introduction

The chapter Vamana Virechana Vyapat Siddhi explains the complications of improper administration of shodhana karma and their effective management. Three earlier chapters dealt with complications of basti (therapeutic enema). In same sequence of describing complications of purification therapies, those of therapeutic emesis and purgation are described in this chapter.

Earlier in Sutra Sthana 15th chapter (Upakalpaniya Adhyaya), the procedure of vamana and virechana are explained in detail. Their further specifications like signs and symptoms of proper, inadequate and excess actions are explained in first chapter (Kalpana Siddhi) of this section. The indications and and contra-indications are described in the second chapter (Panchakarmiya Siddhi). The remaining details of therapeutic emesis and purgation are explained in the present chapter.

The suitable seasons for shodhana, proper timing for the administration of snehana (oleation) and swedana (sudation) are required because doshas get naturally vitiated in specific seasons and are associated in case of disease. Specific pre-requisites for adequate purification are to be considered prior to the procedure. Assessment of vitiation of dosha, agni (digestive power), koshtha (bowel) and unctuousness of patient are most important factors for administration of purification therapy. Proper diet and digestion of previous day meal, stable mental state of patient is important to get benefits of purification.

The physician should keenly observe the patient during purification therapy for assessing signs of eliminating doshas otherwise complications may arise. The physician shall be well versed with diagnosis and management of these complications.

Sanskrit text, Transliteration and English Translation

अथातो वमनविरेचनव्यापत्सिद्धिम् व्याख्यास्याम: ||१||

इति ह स्माह भगवानात्रेय: ||२||

अथ शोधनयो: सम्यग्विधिमूर्ध्वानुलोमयो: |

असम्यकृतयोश्चैव दोषान् वक्ष्यामि सौषधान् ||३||

AthAto vamanavirechana vyApatsiddhim vyAkhyAsyAmah I

Iti ha SmAh BhagwAnAtreyah II

Atha Shodhanayoh Samyagvidhimurdhvanulomayoh I

Asamyak krutayohshchaiva doshAn vakshyAmi SaushadhAn II

Now we shall expound the chapter "Vamana Virechana Vyapat Siddhi" (Management of complications of improper therapeutic emesis and purgation). Thus said Lord Atreya.

Now, let me explain:

• The procedure for proper administration of vamana and virechana
• The complications appearing because of inappropriate administration
• The effective treatment for the management of complications.[1-3]

Seasons for purification

अत्युष्णवर्षशीता हि ग्रीष्मवर्षाहिमागमाः|

तदन्तरे प्रावृडाद्यास्तेषां साधारणास्त्रयः||४||

atyuṣṇavarṣaśītā hi grīṣmavarṣāhimāgamāḥ|

tadantarē prāvr̥ḍādyāstēṣāṁ sādhāraṇāstrayaḥ||4||

atyuShNavarShashItA hi grIShmavarShAhimAgamAH|

tadantare prAvRuDAdyAsteShAM sAdhAraNAstrayaH||4||

Excess heat, rain and cold are the signature features of summer (greeshma), rainy (varsha) and winter (hemanta) seasons respectively. The three seasons viz., the period between summer and rains (pravrita), autumn (sharada) and spring (vasanta), which come in between the above mentioned are known as general seasons (sadharana ritu). [4]

प्रावृट् शुचिनभौ ज्ञेयौ शरदूर्जसहौ पुनः|

तपस्यश्च मधुश्चैव वसन्तः शोधनं प्रति||५||

एतानृतून् विकल्प्यैवं दद्यात् संशोधनं भिषक्|

स्वस्थवृत्तमभिप्रेत्य व्याधौ व्याधिवशेन तु||६||

prāvr̥ṭ śucinabhau jñēyau śaradūrjasahau punaḥ|

tapasyaśca madhuścaiva vasantaḥ śōdhanaṁ prati||5||

ētānr̥tūn vikalpyaivaṁ dadyāt saṁśōdhanaṁ bhiṣak|

svasthavr̥ttamabhiprētya vyādhau vyādhivaśēna tu||6||

prAvRuT shucinabhau j~jeyau sharadUrjasahau punaH|

tapasyashca madhushcaiva vasantaH shodhanaM prati||5||

etAnRutUn vikalpyaivaM dadyAt saMshodhanaM bhiShak|

svasthavRuttamabhipretya vyAdhau vyAdhivashena tu||6||

The months Shuchi (Aashadha, Mid June to Mid July) and Nabha (Shravana, Mid July to Mid August) together are known as Pravrita ritu. The months Urja (Kartika, Mid October to Mid November) and Saha (Margashersha –Mid November to Mid December) are known as Sharada ritu. The months Tapasya (Phaalguna -Mid February to Mid March) and Madhu (Chaitram- mid March to mid April) are known as Vasanta ritu. These seasons are specially mentioned here for the sake of administration of shodhana therapy (purificatory procedures). The physician shall select an appropriate purificatory procedure to preserve the health after determining the exact season. However, in case of disease, it has to be done with respect to the nature of the clinical condition in any of the seasons.[5-6]

Importance of oleation in Panchakarma

कर्मणां वमनादीनामन्तरेष्वन्तरेषु च|

स्नेहस्वेदौ प्रयुञ्जीत स्नेहं चान्ते प्रयोजयेत्||७||

karmaṇāṁ vamanādīnāmantarēṣvantarēṣu ca|

snēhasvēdau prayuñjīta snēhaṁ cāntē prayōjayēt||7||

karmaNAM vamanAdInAmantareShvantareShu ca|

snehasvedau prayu~jjIta snehaM cAnte prayojayet||7||

In between the sequential administration of purificatory procedures like vamana (emesis) etc., snehana (oleation) and swedana (sudation) therapies need to be administered and snehana (oleation) shall be administered at the end (also). [7]

Indications of purification

विसर्पपिडकाशोफकामलापाण्डुरोगिणः |

अभिघातविषार्तांश्च नातिस्निग्धान् विरेचयेत्||८||

visarpapiḍakāśōphakāmalāpāṇḍurōgiṇaḥ |

abhighātaviṣārtāṁśca nātisnigdhān virēcayēt||8||

visarpapiDakAshophakAmalApANDurogiNaH |

abhighAtaviShArtAMshca nAtisnigdhAn virecayet||8||

In case of clinical conditions like visarpa, pidaka, shopha, kamala, pandu as well as in trauma and toxication, and in those who are not excessively oleated purification therapies shall be administered. [8]

नातिस्निग्धशरीराय दद्यात् स्नेहविरेचनम्|

स्नेहोत्क्लिष्टशरीराय रूक्षं दद्याद्विरेचनम्||९||

nātisnigdhaśarīrāya dadyāt snēhavirēcanam|

snēhōtkliṣṭaśarīrāya rūkṣaṁ dadyādvirēcanam||9||

nAtisnigdhasharIrAya dadyAt snehavirecanam|

snehotkliShTasharIrAya rUkShaM dadyAdvirecanam||9||

The individual with excessively oleated body should never be given an unctuous or snigdha virechana. The body with excessive oleation should be given un-unctuous or ruksha virechana.[9]

Procedure of taking purgatives for therapy

स्नेहस्वेदोपपन्नेन जीर्णे मात्रावदौषधम्|

एकाग्रमनसा पीतं सम्यग्योगाय कल्पते||१०||

snēhasvēdōpapannēna jīrṇē mātrāvadauṣadham|

ēkāgramanasā pītaṁ samyagyōgāya kalpatē||10||

snehasvedopapannena jIrNe mAtrAvadauShadham|

ekAgramanasA pItaM samyagyogAya kalpate||10||

The person after undergoing snehana (oleation) and swedana (sudation procedures) can have the medicine for elimination with fully concentrated mind. In addition, it should be ensured that the medicine is taken only after the full digestion of previous food. Only then, the proper elimination ensues.[10]

स्निग्धात् पात्राद्यथा तोयमयत्नेन प्रणुद्यते|

कफादयः प्रणुद्यन्ते स्निग्धाद्देहात्तथौषधैः||११||

आर्द्रं काष्ठं यथा वह्निर्विष्यन्दयति सर्वतः|

तथा स्निग्धस्य वै दोषान् स्वेदो विष्यन्दयेत् स्थिरान्||१२||

क्लिष्टं वासो यथोत्क्लेश्य मलः संशोध्यतेऽम्भसा|

स्नेहस्वेदैस्तथोत्क्लेश्य शोध्यते शोधनैर्मलः ||१३||

snigdhāt pātrādyathā tōyamayatnēna praṇudyatē|

kaphādayaḥ praṇudyantē snigdhāddēhāttathauṣadhaiḥ||11||

ārdraṁ kāṣṭhaṁ yathā vahnirviṣyandayati sarvataḥ|

tathā snigdhasya vai dōṣān svēdō viṣyandayēt sthirān||12||

kliṣṭaṁ vāsō yathōtklēśya malaḥ saṁśōdhyatē'mbhasā|

snēhasvēdaistathōtklēśya śōdhyatē śōdhanairmalaḥ ||13||

snigdhAt pAtrAdyathA toyamayatnena praNudyate|

kaphAdayaH praNudyante snigdhAddehAttathauShadhaiH||11||

ArdraM kAShThaM yathA vahnirviShyandayati sarvataH|

tathA snigdhasya vai doShAn svedo viShyandayet sthirAn||12||

kliShTaM vAso yathotkleshya malaH saMshodhyate~ambhasA|

snehasvedaistathotkleshya shodhyate shodhanairmalaH || 13||

Like how water gets out of a vessel smeared with oil, similar is the removal of doshas from a properly oleated body. Just like the fire propels the water out from the wet log wood, similarly the sudation propels out the stable doshas from the pre-oleated body. The way in which the clothes adhered with dirt is cleaned using water, which removes the dirt, similarly the stable malas that are liquefied after oleation and sudation are removed by proper purificatory therapies.[11-13]

Consequences if medicines taken during indigestion

अजीर्णे वर्धते ग्लानिर्विबन्धश्चापि जायते|

पीतं संशोधनं चैव विपरीतं प्रवर्तते||१४||

ajīrṇē vardhatē glānirvibandhaścāpi jāyatē|

pītaṁ saṁśōdhanaṁ caiva viparītaṁ pravartatē||14||

ajIrNe vardhate glAnirvibandhashcApi jAyate|

pItaM saMshodhanaM caiva viparItaM pravartate||14||

If the medicine for purification is administered before the digestion of the previous meal, it will lead to glani (tiredness), vibandha (obstruction of feces and urine), and an action that is opposite to that intended by elimination therapy. (virechana oushadha will lead to vamana and vice versa.)[14]

Characteristics of appropriate dosage of medicine

अल्पमात्रं महावेगं बहुदोषहरं सुखम्|

लघुपाकं सुखास्वादं प्रीणनं व्याधिनाशनम्||१५||

अविकारि च व्यापत्तौ नातिग्लानिकरं च यत्|

गन्धवर्णरसोपेतं विद्यान्मात्रावदौषधम्||१६||

alpamātraṁ mahāvēgaṁ bahudōṣaharaṁ sukham|

laghupākaṁ sukhāsvādaṁ prīṇanaṁ vyādhināśanam||15||

avikāri ca vyāpattau nātiglānikaraṁ ca yat|

gandhavarṇarasōpētaṁ vidyānmātrāvadauṣadham||16||

alpamAtraM mahAvegaM bahudoShaharaM sukham|

laghupAkaM sukhAsvAdaM prINanaM vyAdhinAshanam||15||

avikAri ca vyApattau nAtiglAnikaraM ca yat|

gandhavarNarasopetaM vidyAnmAtrAvadauShadham||16||

The following properties are characteristic to the appropriate dosage of medicines prescribed for purification:

• It should work optimally in small dosage
• It must have quick action
• It must eliminate large amounts of dosha
• It should bring in comfort
• It should be easily digestible
• It must be palatable
• It must be vitalizing and disease pacifying
• It should not lead to any other complication
• It should not produce tiredness
• It should be endowed with good smell, color, taste etc. and should be pleasing in nature.[15-16]

Careful administration of medicine with mental concentration

विधूय मानसान् दोषान् कामादीनशुभोदयान् |

एकाग्रमनसा पीतं सम्यग्योगाय कल्पते||१७||

vidhūya mānasān dōṣān kāmādīnaśubhōdayān |

ēkāgramanasā pītaṁ samyagyōgāya kalpatē||17||

vidhUya mAnasAn doShAn kAmAdInashubhodayAn |

ekAgramanasA pItaM samyagyogAya kalpate||17||

The individual who drinks the medicine leaving away the negative mental feelings like lust etc. concentrating only on the medicines and the administration of the therapy, will bring the proper action of the medicine or therapy. [17]

Diet before purification therapy

नरः श्वो वमनं पाता भुञ्जीत कफवर्धनम्|

सुजरं द्रवभूयिष्ठं, लघ्वशीतं विरेचनम्||१८||

उत्क्लिष्टाल्पकफत्वेन क्षिप्रं दोषाः स्रवन्ति हि|१९|

naraḥ śvō vamanaṁ pātā bhuñjīta kaphavardhanam|

sujaraṁ dravabhūyiṣṭhaṁ, laghvaśītaṁ virēcanam||18||

utkliṣṭālpakaphatvēna kṣipraṁ dōṣāḥ sravanti hi|19|

naraH shvo vamanaM pAtA bhu~jjIta kaphavardhanam|

sujaraM dravabhUyiShThaM, laghvashItaM virecanam||18||

utkliShTAlpakaphatvena kShipraM doShAH sravanti hi|19|

The individual scheduled to undergo vamana on the next day should have foods which are easily digestible, rich in fluids and will increase the kapha dosha. Similarly, the individual scheduled to undergo virechana should have foods which are light and hot. Since the first diet leads to vitiation and second diet leads to reduction of kapha, the doshas are removed quickly and completely. [18-18½]

Signs of proper elimination

पीतौषधस्य तु भिषक् शुद्धिलिङ्गानि लक्षयेत्||१९||

ऊर्ध्वं कफानुगे पित्ते विट्पित्तेऽनुकफे त्वधः|

हृतदोषं वदेत् कार्श्यदौर्बल्ये चेत् सलाघवे||२०||

pītauṣadhasya tu bhiṣak śuddhiliṅgāni lakṣayēt||19||

ūrdhvaṁ kaphānugē pittē viṭpittē'nukaphē tvadhaḥ|

hr̥tadōṣaṁ vadēt kārśyadaurbalyē cēt salāghavē||20||

pItauShadhasya tu bhiShak shuddhili~ggAni lakShayet||19||

UrdhvaM kaphAnuge pitte viTpitte~anukaphe tvadhaH|

hRutadoShaM vadet kArshyadaurbalye cet salAghave||20||

The physician who had administered medicines for purification must be in observation for the following symptoms:

• For vamana, the pitta is expelled out after the elimination of kapha
• For virechana, the elimination of fecal matter will be followed by pitta and thereafter by kapha

When doshas are eliminated, the patient will experience emaciation, weakness and lightness of body.[19-20]

वामयेत्तु ततः शेषमौषधं न त्वलाघवे|

स्तैमित्येऽनिलसङ्गे च निरुद्गारेऽपि वामयेत्||२१||

आलाघवात्तनुत्वाच्च कफस्यापत् परं भवेत्|२२|

vāmayēttu tataḥ śēṣamauṣadhaṁ na tvalāghavē|

staimityē'nilasaṅgē ca nirudgārē'pi vāmayēt||21||

ālāghavāttanutvācca kaphasyāpat paraṁ bhavēt|22|

vAmayettu tataH sheShamauShadhaM na tvalAghave|

staimitye~anilasa~gge ca nirudgAre~api vAmayet||21||

AlAghavAttanutvAcca kaphasyApat paraM bhavet|22|

If after the completion of the purificatory procedures, there is presence of residual medicines, vamana must be administered. If there is no feeling of lightness, then also vamana should be performed. Vamana must be specifically performed, when there is staimitya (a feeling of wet covering), obstruction of vayu and absence of belching. Vamana should be continued till there is lightness of the body and reduction of kapha. If continued, it can result in serious consequences. [21-21½]

वमिते वर्धते वह्निः शमं दोषा व्रजन्ति हि||२२||

वमितं लङ्घयेत् सम्यग्जीर्णलिङ्गान्यलक्षयन्|

तानि दृष्ट्वा तु पेयादिक्रमं कुर्यान्न लङ्घनम्||२३||

vamitē vardhatē vahniḥ śamaṁ dōṣā vrajanti hi||22||

vamitaṁ laṅghayēt samyagjīrṇaliṅgānyalakṣayan|

tāni dr̥ṣṭvā tu pēyādikramaṁ kuryānna laṅghanam||23||

vamite vardhate vahniH shamaM doShA vrajanti hi||22||

vamitaM la~gghayet samyagjIrNali~ggAnyalakShayan|

tAni dRuShTvA tu peyAdikramaM kuryAnna la~gghanam||23||

The one who has been purified by vamana will have augmented agni, leading to the alleviation of dosha. He need to undergo fasting till the signs of proper digestion of drugs for vamana is seen. For one having those signs, peyadi kramam (regulatory diet regimen) has to be initiated. He should not undergo further langhana (fasting). [22-23]

संशोधनाभ्यां शुद्धस्य हृतदोषस्य देहिनः|

यात्यग्निर्मन्दतां तस्मात् क्रमं पेयादिमाचरेत्||२४||

saṁśōdhanābhyāṁ śuddhasya hr̥tadōṣasya dēhinaḥ|

yātyagnirmandatāṁ tasmāt kramaṁ pēyādimācarēt||24||

saMshodhanAbhyAM shuddhasya hRutadoShasya dehinaH|

yAtyagnirmandatAM tasmAt kramaM peyAdimAcaret||24||

The individual who is purified after elimination therapy and removal of dosha from the body, has his agni diminished. Hence it is highly pertinent to institute dietary regimen termed peyaadi kramam. [24]

कफपित्ते विशुद्धेऽल्पं मद्यपे वातपैत्तिके|

तर्पणादिक्रमं कुर्यात् पेयाऽभिष्यन्दयेद्धि तान्||२५||

kaphapittē viśuddhē'lpaṁ madyapē vātapaittikē|

tarpaṇādikramaṁ kuryāt pēyā'bhiṣyandayēddhi tān||25||

kaphapitte vishuddhe~alpaM madyape vAtapaittike|

tarpaNAdikramaM kuryAt peyA~abhiShyandayeddhi tAn||25||

When there is little elimination of kapha and pitta through purification therapy, in alcoholics and in persons with predominance of vata and pitta dosha, the dietary regimen called tarpanaadi kramam need to be started instead of peyaadi kramam, as peyadi may increase kapha causing abhishyandam (clogging of the channels of circulation).[25]

Signs of digested and undigested medicine

अनुलोमोऽनिलः स्वास्थ्यं क्षुत्तृष्णोर्जो मनस्विता|

लघुत्वमिन्द्रियोद्गारशुद्धिर्जीर्णौषधाकृतिः||२६||

क्लमो दाहोऽङ्गसदनं भ्रमो मूर्च्छा शिरोरुजा|

अरतिर्बलहानिश्च सावशेषौषधाकृतिः||२७||

anulōmō'nilaḥ svāsthyaṁ kṣuttr̥ṣṇōrjō manasvitā|

laghutvamindriyōdgāraśuddhirjīrṇauṣadhākr̥tiḥ||26||

klamō dāhō'ṅgasadanaṁ bhramō mūrcchā śirōrujā|

aratirbalahāniśca sāvaśēṣauṣadhākr̥tiḥ||27||

anulomo~anilaH svAsthyaM kShuttRuShNorjo manasvitA|

laghutvamindriyodgArashuddhirjIrNauShadhAkRutiH||26||

klamo dAho~a~ggasadanaM bhramo mUrcchA shirorujA|

aratirbalahAnishca sAvasheShauShadhAkRutiH||27||

The signs of properly digested medicine include:

• Normal movement of vayu
• Timely manifestation of hunger
• Thirst
• Enthusiasm
• Mental happiness
• A feeling of lightness
• Proper functioning of sensorium
• Clear belching

The signs of presence of undigested medicinal residue are:

• Fatigue
• Burning sensation
• General weakness
• Giddiness
• Fainting
• Headache
• Restlessness
• Loss of strength

अकालेऽल्पातिमात्रं च पुराणं न च भावितम्|

असम्यक्संस्कृतं चैव व्यापद्येतौषधं द्रुतम्||२८||

akālē'lpātimātraṁ ca purāṇaṁ na ca bhāvitam|

asamyaksaṁskr̥taṁ caiva vyāpadyētauṣadhaṁ drutam||28||

akAle~alpAtimAtraM ca purANaM na ca bhAvitam|

asamyaksaMskRutaM caiva vyApadyetauShadhaM drutam||28||

The drug of the following nature may result in quick complication:

• Unseasonal use
• Being administered in sub or supra-optimal dose.
• Being stored for a longer time
• Being not properly triturated.
• Being not properly processed.

Ten complications of emesis and purgation

आध्मानं परिकर्तिश्च स्रावो हृद्गात्रयोर्ग्रहः|

जीवादानं सविभ्रंशः स्तम्भः सोपद्रवः क्लमः||२९||

अयोगादतियोगाच्च दशैता व्यापदो मताः|

प्रेष्यभैषज्यवैद्यानां वैगुण्यादातुरस्य च||३०||

ādhmānaṁ parikartiśca srāvō hr̥dgātrayōrgrahaḥ|

jīvādānaṁ savibhraṁśaḥ stambhaḥ sōpadravaḥ klamaḥ||29||

ayōgādatiyōgācca daśaitā vyāpadō matāḥ|

prēṣyabhaiṣajyavaidyānāṁ vaiguṇyādāturasya ca||30||

AdhmAnaM parikartishca srAvo hRudgAtrayorgrahaH|

jIvAdAnaM savibhraMshaH stambhaH sopadravaH klamaH||29||

ayogAdatiyogAcca dashaitA vyApado matAH|

preShyabhaiShajyavaidyAnAM vaiguNyAdAturasya ca||30||

The ten cardinal complications arising out of improper administration of emesis and purgation are:

• Aadhmana (distension of abdomen)
• Parikartika (fissure in ano)
• Srava (excess discharge)
• Hrid-graha (congestion in cardiac region)
• Gaatra-graha (body stiffness )
• Jeevaadana (bleeding)
• Vibhramsha (prolapse of rectum)
• Stambha (body stiffness)
• Upadrava (complications)
• Klama (fatigue without exertion)

The above complications arise out of either under activity or excessive activity of the drug because of the following:

• Preshya-vaigunyam (incompetency of the attendant)
• Bhaishajya-vaigunya (incompetency of drug)
• Vaidya-vaigunya (incompetency of physician)
• Aatura-vaigunya (incompetency of the patient). [29-30]

Three types of purification according to its signs

योगः सम्यक्प्रवृत्तिः स्यादतियोगोऽतिवर्तनम्|

अयोगः प्रातिलोम्येन न चाल्पं वा प्रवर्तनम्||३१||

श्लेष्मोत्क्लिष्टेन दुर्गन्धमहृद्यमति वा बहु|

विरेचनमजीर्णे च पीतमूर्ध्वं प्रवर्तते||३२||

क्षुधार्तमृदुकोष्ठाभ्यां स्वल्पोत्क्लिष्टकफेन वा|

तीक्ष्णं पीतं स्थितं क्षुब्धं वमनं स्याद्विरेचनम्||३३||

प्रातिलोम्येन दोषाणां हरणात्ते ह्यकृत्स्नशः|

अयोगसञ्ज्ञे, कृच्छ्रेण याति दोषो नवाऽल्पशः||३४||

yōgaḥ samyakpravr̥ttiḥ syādatiyōgō'tivartanam|

ayōgaḥ prātilōmyēna na cālpaṁ vā pravartanam||31||

ślēṣmōtkliṣṭēna durgandhamahr̥dyamati vā bahu|

virēcanamajīrṇē ca pītamūrdhvaṁ pravartatē||32||

kṣudhārtamr̥dukōṣṭhābhyāṁ svalpōtkliṣṭakaphēna vā|

tīkṣṇaṁ pītaṁ sthitaṁ kṣubdhaṁ vamanaṁ syādvirēcanam||33||

prātilōmyēna dōṣāṇāṁ haraṇāttē hyakr̥tsnaśaḥ|

ayōgasañjñē, kr̥cchrēṇa yāti dōṣō navā'lpaśaḥ||34||

yogaH samyakpravRuttiH syAdatiyogo~ativartanam|

ayogaH prAtilomyena na cAlpaM vA pravartanam||31||

shleShmotkliShTena durgandhamahRudyamati vA bahu|

virecanamajIrNe ca pItamUrdhvaM pravartate||32||

kShudhArtamRudukoShThAbhyAM svalpotkliShTakaphena vA|

tIkShNaM pItaM sthitaM kShubdhaM vamanaM syAdvirecanam||33||

prAtilomyena doShANAM haraNAtte hyakRutsnashaH|

ayogasa~jj~je, kRucchreNa yAti doSho navA~alpashaH||34||

The three types of outcome for Vamana and Virechana are:

• Samyaka yoga indicates optimum action of elimination therapy
• Ati-yoga indicates excess elimination
• Ayoga indicates insufficient or no elimination

The medicines administered for virechana, in a patient with aggravated and excited status of kapha, will act as vamaka under the following conditions:

• If the medicine is having bad smell
• The drug not being wholesome
• Large quantity of medicine
• Intake of medicine before the previous meal is digested

The medicines administered for vamana will cause virechana under the following conditions:

• Vamana is performed on an individual who is hungry,
• An individual with mridu –koshtha,
• An individual with little increase of kapha,
• If the medicine is tikshna (penetrating / potent),
• If the medicine is reminent and agitating

Whether in vamana or virechana, if the medicines work in opposite, it is termed ayoga or inadequate action. It is also called the same, if doshas are not eliminated or eliminated with difficulty. [31-34]

Various conditions and management

पीतौषधो न शुद्धश्चेज्जीर्णे तस्मिन् पुनः पिबेत्|

औषधं न त्वजीर्णेऽन्यद्भयं स्यादतियोगतः||३५||

कोष्ठस्य गुरुतां ज्ञात्वा लघुत्वं बलमेव च|

अयोगे मृदु वा दद्यादौषधं तीक्ष्णमेव वा||३६||

pītauṣadhō na śuddhaścējjīrṇē tasmin punaḥ pibēt|

auṣadhaṁ na tvajīrṇē'nyadbhayaṁ syādatiyōgataḥ||35||

kōṣṭhasya gurutāṁ jñātvā laghutvaṁ balamēva ca|

ayōgē mr̥du vā dadyādauṣadhaṁ tīkṣṇamēva vā||36||

pItauShadho na shuddhashcejjIrNe tasmin punaH pibet|

auShadhaM na tvajIrNe~anyadbhayaM syAdatiyogataH||35||

koShThasya gurutAM j~jAtvA laghutvaM balameva ca|

ayoge mRudu vA dadyAdauShadhaM tIkShNameva vA||36||

If after intake of medicine for elimination, the medicine is digested and there is no elimination, then the medicine should be taken again. If the medicine is not digested, it should not be given as it may lead to atiyoga.

One has to understand the nature of koshtha (whether guru or laghu) and the strength of the body for giving either mild (mridu) or potent (teekshna) medicine. [35-36]

वमनं न तु दुश्छर्दं दुष्कोष्ठं न विरेचनम्|

पाययेतौषधं भूयो हन्यात् पीतं पुनर्हि तौ||३७||

vamanaṁ na tu duśchardaṁ duṣkōṣṭhaṁ na virēcanam|

pāyayētauṣadhaṁ bhūyō hanyāt pītaṁ punarhi tau||37||

vamanaM na tu dushchardaM duShkoShThaM na virecanam|

pAyayetauShadhaM bhUyo hanyAt pItaM punarhi tau||37||

Never give emetic drug to people who are unsuitable for vamana; virechana to those with unsuitable koshtha, if medicine intake happens in such conditions it may even lead to death.[37]

अस्निग्धास्विन्नदेहस्य रूक्षस्यानवमौषधम्|

दोषानुत्क्लिश्य निर्हर्तुमशक्तं जनयेद्गदान्||३८||

विभ्रंशं श्वयथुं हिक्कां तमसो दर्शनं भृशम् |

पिण्डिकोद्वेष्टनं कण्डूमूर्वोः सादं विवर्णताम्||३९||

asnigdhāsvinnadēhasya rūkṣasyānavamauṣadham|

dōṣānutkliśya nirhartumaśaktaṁ janayēdgadān||38||

vibhraṁśaṁ śvayathuṁ hikkāṁ tamasō darśanaṁ bhr̥śam |

piṇḍikōdvēṣṭanaṁ kaṇḍūmūrvōḥ sādaṁ vivarṇatām||39||

asnigdhAsvinnadehasya rUkShasyAnavamauShadham|

doShAnutklishya nirhartumashaktaM janayedgadAn||38||

vibhraMshaM shvayathuM hikkAM tamaso darshanaM bhRusham |

piNDikodveShTanaM kaNDUmUrvoH sAdaM vivarNatAm||39||

Ayoga happens when asnigdha (under-oleated) and asvinna (under-sudated) person with ruksha nature of the body, is administered a recipe, which is stored for long duration. Here, the drug is unable to remove doshas from the body by creating dosha-utklesha. Such a condition will lead to symptoms like vibhramsha (virechana oushadha will lead to vamana and vice versa), swelling, hiccups, black-out, cramps in calf muscle, itching, fainting and discoloration.[38-39]

स्निग्धस्विन्नस्य चात्यल्पं दीप्ताग्नेर्जीर्णमौषधम्|

शीतैर्वा स्तब्धमामे वा दोषानुत्क्लिश्य नाहरेत्||४०||

तानेव जनयेद्रोगानयोगः सर्व एव सः|

विज्ञाय मतिमांस्तत्र यथोक्तां कारयेत् क्रियाम्||४१||

तं तैललवणाभ्यक्तं स्विन्नं प्रस्तरसङ्करैः|

पाययेत पुनर्जीर्णे समूत्रैर्वा निरूहयेत्||४२||

निरूढं च रसैर्धान्वैर्भोजयित्वाऽनुवासयेत्|

फलमागधिकादारुसिद्धतैलेन मात्रया||४३||

स्निग्धं वातहरैः स्नेहैः पुनस्तीक्ष्णेन शोधयेत्|

न चातितीक्ष्णेन ततो ह्यतियोगस्तु जायते||४४||

snigdhasvinnasya cātyalpaṁ dīptāgnērjīrṇamauṣadham|

śītairvā stabdhamāmē vā dōṣānutkliśya nāharēt||40||

tānēva janayēdrōgānayōgaḥ sarva ēva saḥ|

vijñāya matimāṁstatra yathōktāṁ kārayēt kriyām||41||

taṁ tailalavaṇābhyaktaṁ svinnaṁ prastarasaṅkaraiḥ|

pāyayēta punarjīrṇē samūtrairvā nirūhayēt||42||

nirūḍhaṁ ca rasairdhānvairbhōjayitvā'nuvāsayēt|

phalamāgadhikādārusiddhatailēna mātrayā||43||

snigdhaṁ vātaharaiḥ snēhaiḥ punastīkṣṇēna śōdhayēt|

na cātitīkṣṇēna tatō hyatiyōgastu jāyatē||44||

snigdhasvinnasya cAtyalpaM dIptAgnerjIrNamauShadham|

shItairvA stabdhamAme vA doShAnutklishya nAharet||40||

tAneva janayedrogAnayogaH sarva eva saH|

vij~jAya matimAMstatra yathoktAM kArayet kriyAm||41||

taM tailalavaNAbhyaktaM svinnaM prastarasa~gkaraiH|

pAyayeta punarjIrNe samUtrairvA nirUhayet||42||

nirUDhaM ca rasairdhAnvairbhojayitvA~anuvAsayet|

phalamAgadhikAdArusiddhatailena mAtrayA||43||

snigdhaM vAtaharaiH snehaiH punastIkShNena shodhayet|

na cAtitIkShNena tato hyatiyogastu jAyate||44||

Ayoga happens in the following conditions too :

• Even after proper sneha-sweda there is sub-optimal dose of medicine
• Due to increased agni (digestive capacity), quick digestion of medicine happens

If there is ama dosha, the medicine for vamana will not work in the desired manner. The case is similar also with virechana drugs.

Because of the above mentioned causes, the earlier mentioned conditions like vibhramsha will happen. These come under ayoga. The intelligent physician must understand the same and treat accordingly.

Here the taila (oil) processed with lavana (salt) has to be applied and made to undergo prastara and sankara kind of sudation. Once the medicine for vamana or virechana must be administered again or else kashaya basti (decoction enema) with cow’s urine has to be done. After the administration of kashaya basti, food with meats of animals of arid regions (jangala mamsa rasa) should be taken and should be followed by administration of sneha basti (oil enema).

Sneha basti can be done by oil processed with madana (Randia dumetorum), pippali (Piper longum), devadaru (Cedrus deodara), in proper dose. Once adequate oleation happens, elimination must be done with a recipe containing teekshna drugs.

However, the medicines that are ati-teekshna should not be given, as it may result in atiyoga.[40-44]

Signs of excess elimination and management

अतितीक्ष्णं क्षुधार्तस्य मृदुकोष्ठस्य भेषजम्|

हृत्वाऽऽशु विट्पित्तकफान् धातून्विस्रावयेद्द्रवान्||४५||

बलस्वरक्षयं दाहं कण्ठशोषं भ्रमं तृषाम्|

कुर्याच्च मधुरैस्तत्र शेषमौषधमुल्लिखेत्||४६||

वमने तु विरेकः स्याद्विरेके वमनं पुनः |

परिषेकावगाहाद्यैः सुशीतैः स्तम्भयेच्च तत्||४७||

कषायमधुरैः शीतैरन्नपानौषधैस्तथा|

रक्तपित्तातिसारघ्नैर्दाहज्वरहरैरपि||४८||

अञ्जनं चन्दनोशीरमज्जासृक्शर्करोदकम्|

लाजचूर्णैः पिबेन्मन्थमतियोगहरं परम्||४९||

शुङ्गाभिर्वा वटादीनां सिद्धां पेयां समाक्षिकाम्|

वर्चःसाङ्ग्राहिकैः सिद्धं क्षीरं भोज्यं च दापयेत्||५०||

जाङ्गलैर्वा रसैर्भोज्यं पिच्छाबस्तिश्च शस्यते|

मधुरैरनुवास्यश्च सिद्धेन क्षीरसर्पिषा||५१||

atitīkṣṇaṁ kṣudhārtasya mr̥dukōṣṭhasya bhēṣajam|

hr̥tvāśu viṭpittakaphān dhātūnvisrāvayēddravān||45||

balasvarakṣayaṁ dāhaṁ kaṇṭhaśōṣaṁ bhramaṁ tr̥ṣām|

kuryācca madhuraistatra śēṣamauṣadhamullikhēt||46||

vamanē tu virēkaḥ syādvirēkē vamanaṁ punaḥ |

pariṣēkāvagāhādyaiḥ suśītaiḥ stambhayēcca tat||47||

kaṣāyamadhuraiḥ śītairannapānauṣadhaistathā|

raktapittātisāraghnairdāhajvaraharairapi||48||

añjanaṁ candanōśīramajjāsr̥kśarkarōdakam|

lājacūrṇaiḥ pibēnmanthamatiyōgaharaṁ param||49||

śuṅgābhirvā vaṭādīnāṁ siddhāṁ pēyāṁ samākṣikām|

varcaḥsāṅgrāhikaiḥ siddhaṁ kṣīraṁ bhōjyaṁ ca dāpayēt||50||

jāṅgalairvā rasairbhōjyaṁ picchābastiśca śasyatē|

madhurairanuvāsyaśca siddhēna kṣīrasarpiṣā||51||

atitIkShNaM kShudhArtasya mRudukoShThasya bheShajam|

hRutvA~a~ashu viTpittakaphAn dhAtUnvisrAvayeddravAn||45||

balasvarakShayaM dAhaM kaNThashoShaM bhramaM tRuShAm|

kuryAcca madhuraistatra sheShamauShadhamullikhet||46||

vamane tu virekaH syAdvireke vamanaM punaH |

pariShekAvagAhAdyaiH sushItaiH stambhayecca tat||47||

kaShAyamadhuraiH shItairannapAnauShadhaistathA|

raktapittAtisAraghnairdAhajvaraharairapi||48||

a~jjanaM candanoshIramajjAsRuksharkarodakam|

lAjacUrNaiH pibenmanthamatiyogaharaM param||49||

shu~ggAbhirvA vaTAdInAM siddhAM peyAM samAkShikAm|

varcaHsA~ggrAhikaiH siddhaM kShIraM bhojyaM ca dApayet||50||

jA~ggalairvA rasairbhojyaM picchAbastishca shasyate|

madhurairanuvAsyashca siddhena kShIrasarpiShA||51||

When a patient who is with mridukoshtha, who is affected with hunger, is provided with an exceedingly strong vamana or virechana, it results in the quick elimination of not only the faecal matter, pitta and kapha, but also the drava-dhatu (liquid content of the body). Consequently, there will be sudden depression of strength and voice, dryness of throat, giddiness and thirst. In such a condition, it is preferable to eliminate the residual drug in the koshtha using the drugs of madhura gana (mentioned in sweet category).

If ati-yoga happens like this during attempting vamana, the residual doshas are eliminated by initiating a virechana and vice-versa.

The following remedies need to be instituted fast for stambhana (To check the supra-optimal purificatory effect of therapy).

By providing cold irrigation (parishekam) and tub bath (avagaaham)

By providing foods, drinks and medicine which are sheeta (cold), kashaya (astrigent) and madhura (sweet).

By following appropriate regimens prescribed for rakta-pitta, atisaara, daaha and jwara.

For ati-yoga of virechana, sharkarodakam (sugar syrup) added with rasaanjana (Berberis aristata), chandana (Santalum album), usheera (Vetivera zizanoides), blood of goat, cornflake powder etc. can be taken to stop excessive loss of fluid. Then peya made from vata shunga (leaf buds of banyan tree) added with honey, milk or porridge processed with samgraahi substances (that which pacifies excess bowel movements) like the priyangvaadi gana, food added with jaangala maamsa rasam (meat soup of animals from arid region), picchha basti mentioned in rakta-arshas, sneha basti using ghee made out of milk processed with madhura aushadha (sweet drugs).[46-51]

वमनस्यातियोगे तु शीताम्बुपरिषेचितः|

पिबेत् कफहरैर्मन्थं सघृतक्षौद्रशर्करम्||५२||

सोद्गारायां भृशं वम्यां मूर्च्छायां धान्यमुस्तयोः|

समधूकाञ्जनं चूर्णं लेहयेन्मधुसंयुतम्||५३||

वमतोऽन्तःप्रविष्टायां जिह्वायां कवलग्रहाः|

स्निग्धाम्ललवणैर्हृद्यैर्यूषक्षीररसैर्हिताः||५४||

फलान्यम्लानि खादेयुस्तस्य चान्येऽग्रतो नराः|

निःसृतां तु तिलद्राक्षाकल्कलिप्तां प्रवेशयेत्||५५||

वाग्ग्रहानिलरोगेषु घृतमांसोपसाधिताम्|

यवागूं तनुकां दद्यात् स्नेहस्वेदौ च बुद्धिमान्||५६||

vamanasyātiyōgē tu śītāmbupariṣēcitaḥ|

pibēt kaphaharairmanthaṁ saghr̥takṣaudraśarkaram||52||

sōdgārāyāṁ bhr̥śaṁ vamyāṁ mūrcchāyāṁ dhānyamustayōḥ|

samadhūkāñjanaṁ cūrṇaṁ lēhayēnmadhusaṁyutam||53||

vamatō'ntaḥpraviṣṭāyāṁ jihvāyāṁ kavalagrahāḥ|

snigdhāmlalavaṇairhr̥dyairyūṣakṣīrarasairhitāḥ||54||

phalānyamlāni khādēyustasya cānyē'gratō narāḥ|

niḥsr̥tāṁ tu tiladrākṣākalkaliptāṁ pravēśayēt||55||

vāggrahānilarōgēṣu ghr̥tamāṁsōpasādhitām|

yavāgūṁ tanukāṁ dadyāt snēhasvēdau ca buddhimān||56||

vamanasyAtiyoge tu shItAmbupariShecitaH|

pibet kaphaharairmanthaM saghRutakShaudrasharkaram||52||

sodgArAyAM bhRushaM vamyAM mUrcchAyAM dhAnyamustayoH|

samadhUkA~jjanaM cUrNaM lehayenmadhusaMyutam||53||

vamato~antaHpraviShTAyAM jihvAyAM kavalagrahAH|

snigdhAmlalavaNairhRudyairyUShakShIrarasairhitAH||54||

phalAnyamlAni khAdeyustasya cAnye~agrato narAH|

niHsRutAM tu tiladrAkShAkalkaliptAM praveshayet||55||

vAggrahAnilarogeShu ghRutamAMsopasAdhitAm|

yavAgUM tanukAM dadyAt snehasvedau ca buddhimAn||56||

In atiyoga of vamana, the whole body irrigation must be done with cold water. Mantha must be prepared with ghee, honey and sugar.

If atiyoga happens with belching and fainting, powdered dhanyaka (Coriandum sativum), musta (Cyonodon dactylon), rasanjana (Berberis aristata) etc. added with honey can be licked.

If due to excessive vamana, his tongue goes inside, a vegetable soup milk or meat soup which are prepared by incorporating unctuous, salty, sour and pleasant ingredients can be used for gargling. Eating sour fruits in front of him by others will also be helpful.

If the tongue comes out, a paste of tila(sesame) and draksha (grapes) can be applied over it and can be made to move out.

If there is problem in speech or other disorders of vata, he can be given a porridge made of ghee and meat juice. The intelligent physician then must do snehana (oleation) and swedana (sudation).[52-56]

Importance of diet after purification

वमितश्च विरिक्तश्च मन्दाग्निश्च विलङ्घितः|

अग्निप्राणविवृद्ध्यर्थं क्रमं पेयादिकं भजेत् ||५७||

vamitaśca viriktaśca mandāgniśca vilaṅghitaḥ|

agniprāṇavivr̥ddhyarthaṁ kramaṁ pēyādikaṁ bhajēt ||57||

vamitashca viriktashca mandAgnishca vila~gghitaH|

agniprANavivRuddhyarthaM kramaM peyAdikaM bhajet ||57||

Peyadi krama (peyadi diet regimen) must be followed by those who undergo Vamana and Virechana, who have diminished agni and who is under fasting for improving the jatharaagni ( digestion and metabolism) and prana shakti(vitality)

Complication of adhmana (abdominal distension) and its management

बहुदोषस्य रूक्षस्य हीनाग्नेरल्पमौषधम्|

सोदावर्तस्य चोत्क्लिश्य दोषान्मार्गान्निरुध्य च||५८||

भृशमाध्मापयेन्नाभिं पृष्ठपार्श्वशिरोरुजम्|

श्वासविण्मूत्रवातानां सङ्गं कुर्याच्च दारुणम्||५९||

अभ्यङ्गस्वेदवर्त्यादि सनिरूहानुवासनम्|

उदावर्तहरं सर्वं कर्माध्मातस्य शस्यते||६०||

bahudōṣasya rūkṣasya hīnāgnēralpamauṣadham|

sōdāvartasya cōtkliśya dōṣānmārgānnirudhya ca||58||

bhr̥śamādhmāpayēnnābhiṁ pr̥ṣṭhapārśvaśirōrujam|

śvāsaviṇmūtravātānāṁ saṅgaṁ kuryācca dāruṇam||59||

abhyaṅgasvēdavartyādi sanirūhānuvāsanam|

udāvartaharaṁ sarvaṁ karmādhmātasya śasyatē||60||

bahudoShasya rUkShasya hInAgneralpamauShadham|

sodAvartasya cotklishya doShAnmArgAnnirudhya ca||58||

bhRushamAdhmApayennAbhiM pRuShThapArshvashirorujam|

shvAsaviNmUtravAtAnAM sa~ggaM kuryAcca dAruNam||59||

abhya~ggasvedavartyAdi sanirUhAnuvAsanam|

udAvartaharaM sarvaM karmAdhmAtasya shasyate||60||

If medicine with low potency and in small quantity is given in patients with excessively vitiated dosha, excess dryness in body, low digestive power and udavarta then it leads to further aggravation of dosha resulting in obstruction in channels, severe abdominal distension in umbilical region, pain in the back, flanks and head, severe dyspnea, retention of urine, feces and flatus. This condition shall be treated with abhyanga (oil massage), swedana (sudation), varti (use of suppositories), niruha along with anuvasana (decoction and oil enema) and all the treatment that cure udavarta. [58-60]

Complication of parikartika (fissure in ano) and its management

स्निग्धेन गुरुकोष्ठेन सामे बलवदौषधम्|
क्षामेण मृदुकोष्ठेन श्रान्तेनाल्पबलेन वा||६१||

पीतं गत्वा गुदं साममाशु दोषं निरस्य च|
तीव्रशूलां सपिच्छास्रां करोति परिकर्तिकाम्||६२||

लङ्घनं पाचनं सामे रूक्षोष्णं लघुभोजनम्|
बृंहणीयो विधिः सर्वः क्षामस्य मधुरस्तथा||६३||

snigdhēna gurukōṣṭhēna sāmē balavadauṣadham|
kṣāmēṇa mr̥dukōṣṭhēna śrāntēnālpabalēna vā||61||

pītaṁ gatvā gudaṁ sāmamāśu dōṣaṁ nirasya ca|
tīvraśūlāṁ sapicchāsrāṁ karōti parikartikām||62||

laṅghanaṁ pācanaṁ sāmē rūkṣōṣṇaṁ laghubhōjanam|
br̥ṁhaṇīyō vidhiḥ sarvaḥ kṣāmasya madhurastathā||63||

snigdhena gurukoShThena sAme balavadauShadham|
kShAmeNa mRudukoShThena shrAntenAlpabalena vA||61||

pItaM gatvA gudaM sAmamAshu doShaM nirasya ca|
tIvrashUlAM sapicchAsrAM karoti parikartikAm||62||

la~gghanaM pAcanaM sAme rUkShoShNaM laghubhojanam|
bRuMhaNIyo vidhiH sarvaH kShAmasya madhurastathA||63||

If potent (purification) medicine is given in properly oleated patients, with guru koshtha(heavy bowel), in cases of ama dosha, body being lean with mridu koshtha (soft bowel), fatigued and less strength, then doshas reach guda (rectum) in sama condition and get expelled out immediately. It results in parikartika (fissure in ano) with severe pain, mucous and bloody secretions. In amadosha or sama conditions, fasting (langhana), digestive (pachana), drying (rukshana), should be done and easily digestible (light) and hot food must be taken. For those whose body is emaciated, every brimhana (nourishing) measure like food with madhura rasa (sweet taste) dominance must be taken. [61-63]

आमे जीर्णेऽनुबन्धश्चेत् क्षाराम्लं लघु शस्यते|
पुष्पकासीसमिश्रं वा क्षारेण लवणेन वा||६४||

सदाडिमरसं सर्पिः पिबेद्वातेऽधिके सति|
दध्यम्लं भोजने पाने संयुक्तं दाडिमत्वचा||६५||

देवदारुतिलानां वा कल्कमुष्णाम्बुना पिबेत्|
अश्वत्थोदुम्बरप्लक्षकदम्बैर्वा शृतं पयः||६६||

कषायमधुरं शीतं पिच्छाबस्तिमथापि वा|
यष्टीमधुकसिद्धं वा स्नेहबस्तिं प्रदापयेत्||६७||

āmē jīrṇē'nubandhaścēt kṣārāmlaṁ laghu śasyatē|
puṣpakāsīsamiśraṁ vā kṣārēṇa lavaṇēna vā||64||

sadāḍimarasaṁ sarpiḥ pibēdvātē'dhikē sati|
dadhyamlaṁ bhōjanē pānē saṁyuktaṁ dāḍimatvacā||65||

dēvadārutilānāṁ vā kalkamuṣṇāmbunā pibēt|
aśvatthōdumbaraplakṣakadambairvā śr̥taṁ payaḥ||66||

kaṣāyamadhuraṁ śītaṁ picchābastimathāpi vā|
yaṣṭīmadhukasiddhaṁ vā snēhabastiṁ pradāpayēt||67||

Ame jIrNe~anubandhashcet kShArAmlaM laghu shasyate|
puShpakAsIsamishraM vA kShAreNa lavaNena vA||64||

sadADimarasaM sarpiH pibedvAte~adhike sati|
dadhyamlaM bhojane pAne saMyuktaM dADimatvacA||65||

devadArutilAnAM vA kalkamuShNAmbunA pibet|
ashvatthodumbaraplakShakadambairvA shRutaM payaH||66||

kaShAyamadhuraM shItaM picchAbastimathApi vA|
yaShTImadhukasiddhaM vA snehabastiM pradApayet||67||

If parikartika continues even if the ama got digested, light food added with kshara (alkalizing) and amla (sour) is good. For aggravated vayu, ghee medicated with pomegranate juice, puspa-kaaseesa (green vitriol- Ferrous sulphate), kshara (alkalies), lavana(salts) and dadima (Punica granatum) can be used. The powder of skin of dadima along with sour curd can be taken or with other food. The paste made of devadaru (Cedrus deodara) and tila (sesame) can be taken in hot water. Milk processed with the skin of ashwatha (Ficus bengalensis), udumbara (Ficus glomerata), plaksha (Ficus lacor) and kadamba (Anthocephalus kadamba) can be taken. Pichchha basti can be done using madhura rasa (drugs with sweet taste) and cooling ingredients and sneha basti with oil processed with yashti madhu (Glycerrhiza glabra) can be done.[64-67]

Complication of paristrava (discharge) and its management

अल्पं तु बहुदोषस्य दोषमुत्क्लिश्य भेषजम्|

अल्पाल्पं स्रावयेत् कण्डूं शोफं कुष्ठानि गौरवम्||६८||

कुर्याच्चाग्निबलोत्क्लेशस्तैमित्यारुचिपाण्डुताः|

परिस्रावः स, तं दोषं शमयेद्वामयेदपि||६९||

स्नेहितं वा पुनस्तीक्ष्णं पाययेत् विरेचनम्|

शुद्धे चूर्णासवारिष्टान् संस्कृतांश्च प्रदापयेत्||७०||

alpaṁ tu bahudōṣasya dōṣamutkliśya bhēṣajam|

alpālpaṁ srāvayēt kaṇḍūṁ śōphaṁ kuṣṭhāni gauravam||68||

kuryāccāgnibalōtklēśastaimityārucipāṇḍutāḥ|

parisrāvaḥ sa, taṁ dōṣaṁ śamayēdvāmayēdapi||69||

snēhitaṁ vā punastīkṣṇaṁ pāyayēt virēcanam|

śuddhē cūrṇāsavāriṣṭān saṁskr̥tāṁśca pradāpayēt||70||

alpaM tu bahudoShasya doShamutklishya bheShajam|

alpAlpaM srAvayet kaNDUM shophaM kuShThAni gauravam||68||

kuryAccAgnibalotkleshastaimityArucipANDutAH|

parisrAvaH sa, taM doShaM shamayedvAmayedapi||69||

snehitaM vA punastIkShNaM pAyayet virecanam|

shuddhe cUrNAsavAriShTAn saMskRutAMshca pradApayet||70||

In the patients with excessively vitiated doshas, when only a small dose of medicine is given, the dosha get aggravated and discharged out in little quantity frequently. This result in alpa shopha (swelling), kandu (itching), kushtam (skin diseases), gauravam (heaviness), agni naasham (destruction of digestive power), utklesham (nausea), staimityam ( feeling of body covered with wet cloths), aruchi (ageusia) and pandu (anemia). The entire spectrum is called parisravam. In this condition, the aggravated dosha must either be alleviated or removed out by emesis. Otherwise after oleation, potent virechana medicine can be given again for purification after which arishta (alcoholic medicated preparations) processed with drugs that enhance agni (digestive power) can be used. [68-70]

Complication of hridgraha (chest congestion) and its management

पीतौषधस्य वेगानां निग्रहान्मारुतादयः|

कुपिता हृदयं गत्वा घोरं कुर्वन्ति हृद्ग्रहम्||७१||

स हिक्काकासपार्श्वार्तिदैन्यलालाक्षिविभ्रमैः|

जिह्वां खादति निःसञ्ज्ञो दन्तान् किटिकिटापयन्||७२||

न गच्छेद्विभ्रमं तत्र वामयेदाशु तं भिषक्|

मधुरैः पित्तमूर्च्छार्तं कटुभिः कफमूर्च्छितम्||७३||

पाचनीयैस्ततश्चास्य दोषशेषं विपाचयेत्|

कायाग्निं च बलं चास्य क्रमेणोत्थापयेत्ततः ||७४||

पवनेनातिवमतो हृदयं यस्य पीड्यते|

तस्मै स्निग्धाम्ललवणं दद्यात् पित्तकफेऽन्यथा||७५||

pītauṣadhasya vēgānāṁ nigrahānmārutādayaḥ|

kupitā hr̥dayaṁ gatvā ghōraṁ kurvanti hr̥dgraham||71||

sa hikkākāsapārśvārtidainyalālākṣivibhramaiḥ|

jihvāṁ khādati niḥsañjñō dantān kiṭikiṭāpayan||72||

na gacchēdvibhramaṁ tatra vāmayēdāśu taṁ bhiṣak|

madhuraiḥ pittamūrcchārtaṁ kaṭubhiḥ kaphamūrcchitam||73||

pācanīyaistataścāsya dōṣaśēṣaṁ vipācayēt|

kāyāgniṁ ca balaṁ cāsya kramēṇōtthāpayēttataḥ ||74||

pavanēnātivamatō hr̥dayaṁ yasya pīḍyatē|

tasmai snigdhāmlalavaṇaṁ dadyāt pittakaphē'nyathā||75||

pItauShadhasya vegAnAM nigrahAnmArutAdayaH|

kupitA hRudayaM gatvA ghoraM kurvanti hRudgraham||71||

sa hikkAkAsapArshvArtidainyalAlAkShivibhramaiH|

jihvAM khAdati niHsa~jj~jo dantAn kiTikiTApayan||72||

na gacchedvibhramaM tatra vAmayedAshu taM bhiShak|

madhuraiH pittamUrcchArtaM kaTubhiH kaphamUrcchitam||73||

pAcanIyaistatashcAsya doShasheShaM vipAcayet|

kAyAgniM ca balaM cAsya krameNotthApayettataH ||74||

pavanenAtivamato hRudayaM yasya pIDyate|

tasmai snigdhAmlalavaNaM dadyAt pittakaphe~anyathA||75||

After taking (emetic) medicine, if one restricts the urges (of vomiting bouts), vata etc. dosha get aggravated and located in precordium, resulting in severe chest congestion. This leads to hiccups, pain in flanks, cough, fatigue, salivation, perplexion of eyes/rolling of eyes, fainting with tongue bite and severe grinding of teeth. In this case, without getting confused, the physician must immediately make the patient to vomit. For pitta murchita (fainting due to aggravation of pitta), madhura rasa (sweet taste) medicines need to be used and for kapha murchita (fainting due to aggravation of kapha), katu rasa (pungent taste) need to be used.

Digestive medicines shall be given to digest remaining dosha and sequential rehabilitation to re-instate agni (digestive power) and strength of the body shall be done. If there is excessive vomiting because of vitiation of vayu leading to chest congestion, then it shall be treated with unctuous, sour and salty medicines. If there is increase in kapha and pitta, those opposite to unctuous, sour and salty properties that is un-unctuous, bitter and pungent tastes need to be taken.[71-75]

Complication of gatra-graha (body stiffness) and its management

पीतौषधस्य वेगानां निग्रहेण कफेन वा|

रुद्धोऽति वा विशुद्धस्य गृह्णात्यङ्गानि मारुतः||७६||

स्तम्भवेपथुनिस्तोदसादोद्वेष्टनमन्थनैः|

तत्र वातहरं सर्वं स्नेहस्वेदादि कारयेत् ||७७||

pītauṣadhasya vēgānāṁ nigrahēṇa kaphēna vā|

ruddhō'ti vā viśuddhasya gr̥hṇātyaṅgāni mārutaḥ||76||

stambhavēpathunistōdasādōdvēṣṭanamanthanaiḥ|

tatra vātaharaṁ sarvaṁ snēhasvēdādi kārayēt ||77||

pItauShadhasya vegAnAM nigraheNa kaphena vA|

ruddho~ati vA vishuddhasya gRuhNAtya~ggAni mArutaH||76||

stambhavepathunistodasAdodveShTanamanthanaiH|

tatra vAtaharaM sarvaM snehasvedAdi kArayet ||77||

After taking (emetic) medicines, if one restricts the urges (vomiting bouts) or get obstructed because of vitiated kapha, then the excessively vitiated vata causes body stiffness. This results in stiffness, tremor, pricking pain, fainting, cramps and fatigue. This condition shall be managed with all vata alleviating treatments like oleation, sudation etc. [76-77]

Complication of jeevadana (bleeding) and its management

अतितीक्ष्णं मृदौ कोष्ठे लघुदोषस्य भेषजम्|

दोषान् हृत्वा विनिर्मथ्य जीवं हरति शोणितम्||७८||

तेनान्नं मिश्रितं दद्याद्वायसाय शुनेऽपि वा|

भुङ्क्ते तच्चेद्वदेज्जीवं न भुङ्क्ते पित्तमादिशेत्||७९||

शुक्लं वा भावितं वस्त्रमावानं कोष्णवारिणा|

प्रक्षालितं विवर्णं स्यात् पित्ते शुद्धं तु शोणिते||८०||

तृष्णामूर्च्छामदार्तस्य कुर्यादामरणात् क्रियाम्|

तस्य पित्तहरीं सर्वामतियोगे च या हिता ||८१||

मृगगोमहिषाजानां सद्यस्कं जीवतामसृक्|

पिबेज्जीवाभिसन्धानं जीवं तद्ध्याशु गच्छति ||८२||

तदेव दर्भमृदितं रक्तं बस्तिं प्रदापयेत्|

श्यामाकाश्मर्यबदरीदूर्वोशीरैः शृतं पयः||८३||

घृतमण्डाञ्जनयुतं शीतं बस्तिं प्रदापयेत्|

पिच्छाबस्तिं सुशीतं वा घृतमण्डानुवासनम्||८४||

atitīkṣṇaṁ mr̥dau kōṣṭhē laghudōṣasya bhēṣajam|

dōṣān hr̥tvā vinirmathya jīvaṁ harati śōṇitam||78||

tēnānnaṁ miśritaṁ dadyādvāyasāya śunē'pi vā|

bhuṅktē taccēdvadējjīvaṁ na bhuṅktē pittamādiśēt||79||

śuklaṁ vā bhāvitaṁ vastramāvānaṁ kōṣṇavāriṇā|

prakṣālitaṁ vivarṇaṁ syāt pittē śuddhaṁ tu śōṇitē||80||

tr̥ṣṇāmūrcchāmadārtasya kuryādāmaraṇāt kriyām|

tasya pittaharīṁ sarvāmatiyōgē ca yā hitā ||81||

mr̥gagōmahiṣājānāṁ sadyaskaṁ jīvatāmasr̥k|

pibējjīvābhisandhānaṁ jīvaṁ taddhyāśu gacchati ||82||

tadēva darbhamr̥ditaṁ raktaṁ bastiṁ pradāpayēt|

śyāmākāśmaryabadarīdūrvōśīraiḥ śr̥taṁ payaḥ||83||

ghr̥tamaṇḍāñjanayutaṁ śītaṁ bastiṁ pradāpayēt|

picchābastiṁ suśītaṁ vā ghr̥tamaṇḍānuvāsanam||84||

atitIkShNaM mRudau koShThe laghudoShasya bheShajam|

doShAn hRutvA vinirmathya jIvaM harati shoNitam||78||

tenAnnaM mishritaM dadyAdvAyasAya shune~api vA|

bhu~gkte taccedvadejjIvaM na bhu~gkte pittamAdishet||79||

shuklaM vA bhAvitaM vastramAvAnaM koShNavAriNA|

prakShAlitaM vivarNaM syAt pitte shuddhaM tu shoNite||80||

tRuShNAmUrcchAmadArtasya kuryAdAmaraNAt kriyAm|

tasya pittaharIM sarvAmatiyoge ca yA hitA ||81||

mRugagomahiShAjAnAM sadyaskaM jIvatAmasRuk|

pibejjIvAbhisandhAnaM jIvaM taddhyAshu gacchati ||82||

tadeva darbhamRuditaM raktaM bastiM pradApayet|

shyAmAkAshmaryabadarIdUrvoshIraiH shRutaM payaH||83||

ghRutamaNDA~jjanayutaM shItaM bastiM pradApayet|

picchAbastiM sushItaM vA ghRutamaNDAnuvAsanam||84||

If in the individual with mridu koshtha (soft bowel), and less aggravated dosha, highly potent (virechana) medicine is administered, that will result in the removal of dosha after which bleeding ensues and then finally lead to evacuation of jeeva rakta (pure, functioning blood).

If the evacuated material is mixed with food and given to crow or dog, if they eat it, it can be confirmed that it is jeeva-rakta. If, they do not eat, then the blood is mixed with pitta (as seen in rakta-pitta).

If the evacuated blood is applied over a cloth and the cloth is washed with hot water, if the blood remains, it is bile and if the cloth clears off, it is jeeva-rakta.

When jeeva-rakta gets evacuated, it results in burning sensation, fainting and intoxication. Here all treatments for impending death, all kinds of pitta nashaka treatments and treatments told in atiyoga must be done. For those whose jeeva-rakta is getting evacuated immediately, the blood of deer, cow, buffalo, goat etc. need to be given orally. That will sustain life because blood of animals gets immediately transformed to the human. The same blood can be used for basti by adding churna of darbha (Desmostachya bipinnata).

Basti, coolant in nature, using milk processed with drugs like shyama (Cassia fistula), kashmari (Gmelina arborea), badara (Zizyphus mauritiana), durva (Cyonodon dactylon), usheera (Vetiveria zizanoides) need to be done. Or coolant pichchha basti or sneha basti with ghrita manda is effective. [78-84]

Complication of gudavibhramsha (rectum prolapse) and its management

गुदं भ्रष्टं कषायैश्च स्तम्भयित्वा प्रवेशयेत्|

साम गान्धर्वशब्दांश्च सञ्ज्ञानाशेऽस्य कारयेत्||८५||

यदा विरेचनं पीतं विडन्तमवतिष्ठते|

वमनं भेषजान्तं वा दोषानुत्क्लिश्य नावहेत्||८६||

तदा कुर्वन्ति कण्ड्वादीन् दोषाः प्रकुपिता गदान्|

स विभ्रंशो मतस्तत्र स्याद्यथाव्याधि भेषजम्||८७||

gudaṁ bhraṣṭaṁ kaṣāyaiśca stambhayitvā pravēśayēt|

sāma gāndharvaśabdāṁśca sañjñānāśē'sya kārayēt||85||

yadā virēcanaṁ pītaṁ viḍantamavatiṣṭhatē|

vamanaṁ bhēṣajāntaṁ vā dōṣānutkliśya nāvahēt||86||

tadā kurvanti kaṇḍvādīn dōṣāḥ prakupitā gadān|

sa vibhraṁśō matastatra syādyathāvyādhi bhēṣajam||87||

gudaM bhraShTaM kaShAyaishca stambhayitvA praveshayet|

sAma gAndharvashabdAMshca sa~jj~jAnAshe~asya kArayet||85||

yadA virecanaM pItaM viDantamavatiShThate|

vamanaM bheShajAntaM vA doShAnutklishya nAvahet||86||

tadA kurvanti kaNDvAdIn doShAH prakupitA gadAn|

sa vibhraMsho matastatra syAdyathAvyAdhi bheShajam||87||

If there is rectal prolapse, it should be positioned by using kashaya dravya (astringent drugs) and pushed in its own location. If there is loss of consciousness, then he should be consoled and exposed to music therapy.

If the virechana drug stops action after the elimination of the fecal matter and the emetic recipe stops action after the elimination of medicine, the excited doshas do not get properly eliminated leading to symptoms like itching etc. This spectrum is termed as vibhramsha. These should be managed as per their individual disease protocols. [85-87]

Complication of stambha (stiffness) and its management

पीतं स्निग्धेन सस्नेहं तद्दोषैर्मार्दवाद्वृतम्|

न वाहयति दोषांस्तु स्वस्थानात् स्तम्भयेच्च्युतान्||८८||

वातसङ्गगुदस्तम्भशूलैः क्षरति चाल्पशः|

तीक्ष्णं बस्तिं विरेकं वा सोऽर्हो लङ्घितपाचितः||८९||

pītaṁ snigdhēna sasnēhaṁ taddōṣairmārdavādvr̥tam|

na vāhayati dōṣāṁstu svasthānāt stambhayēccyutān||88||

vātasaṅgagudastambhaśūlaiḥ kṣarati cālpaśaḥ|

tīkṣṇaṁ bastiṁ virēkaṁ vā sō'rhō laṅghitapācitaḥ||89||

pItaM snigdhena sasnehaM taddoShairmArdavAdvRutam|

na vAhayati doShAMstu svasthAnAt stambhayeccyutAn||88||

vAtasa~ggagudastambhashUlaiH kSharati cAlpashaH|

tIkShNaM bastiM virekaM vA so~arho la~gghitapAcitaH||89||

Unctuous medicine for virechana when given to a person with an oleated body, because of the mild nature of doshas, they are not let out and cause occlusion in its own site. Because of the obstructed vayu, there will be obstruction and pain in the rectum and there will be frequent expulsion of doshas in little quantity.

Here highly potent basti or virechana, need to be given. First he must observe fast or take light food (langhana), then give pachana (digestive medicine ). [88-89]

Complications and its management

रूक्षं विरेचनं पीतं रूक्षेणाल्पबलेन वा|

मारुतं कोपयित्वाऽऽशु कुर्याद्धोरानुपद्रवान्||९०||

स्तम्भशूलानि घोराणि सर्वगात्रेषु मुह्यतः|

स्नेहस्वेदादिकस्तत्र कार्यो वातहरो विधिः||९१||

rūkṣaṁ virēcanaṁ pītaṁ rūkṣēṇālpabalēna vā|

mārutaṁ kōpayitvāśu kuryāddhōrānupadravān||90||

stambhaśūlāni ghōrāṇi sarvagātrēṣu muhyataḥ|

snēhasvēdādikastatra kāryō vātaharō vidhiḥ||91||

rUkShaM virecanaM pItaM rUkSheNAlpabalena vA|

mArutaM kopayitvA~a~ashu kuryAddhorAnupadravAn||90||

stambhashUlAni ghorANi sarvagAtreShu muhyataH|

snehasvedAdikastatra kAryo vAtaharo vidhiH||91||

Individual with un-unctuous body and who is weak, when given an un-unctuous virechana recipe, will result in severe vitiation of vayu and cause serious complications. Vitiated vayu results in whole body stiffness and colicky pain. Here oleation and sudation therapies along with protocol for management of vata needs to be adopted. [90-91]

Klama (fatigue without exertion) and its management

स्निग्धस्य मृदुकोष्ठस्य मृदूत्क्लिश्यौषधं कफम्|

पित्तं वातं च संरुध्य सतन्द्रागौरवं क्लमम्||९२||

दौर्बल्यं चाङ्गसादं च कुर्यादाशु तदुल्लिखेत्|

लङ्घनं पाचनं चात्र स्निग्धं तीक्ष्णं च शोधनम्||९३||

snigdhasya mr̥dukōṣṭhasya mr̥dūtkliśyauṣadhaṁ kapham|

pittaṁ vātaṁ ca saṁrudhya satandrāgauravaṁ klamam||92||

daurbalyaṁ cāṅgasādaṁ ca kuryādāśu tadullikhēt|

laṅghanaṁ pācanaṁ cātra snigdhaṁ tīkṣṇaṁ ca śōdhanam||93||

snigdhasya mRudukoShThasya mRudUtklishyauShadhaM kapham|

pittaM vAtaM ca saMrudhya satandrAgauravaM klamam||92||

daurbalyaM cA~ggasAdaM ca kuryAdAshu tadullikhet|

la~gghanaM pAcanaM cAtra snigdhaM tIkShNaM ca shodhanam||93||

For those with unctuous and mridu koshtha, if mild purificatory medicine is given, there is aggravation of kapha causing obstruction to pitta and vata resulting in fatigue, heaviness of body, loss of strength, excruciating pain. Here the medicine must be given to vomit immediately. Then accordingly langhana (fasting) and pachana (digestive medicine) need to be done followed by purification with strong and unctuous medicines. [92-93]

Summary

तत्र श्लोकौ-

इत्येता व्यापदः प्रोक्ताः सरूपाः सचिकित्सिताः|

वमनस्य विरेकस्य कृतस्याकुशलैर्नृणाम् ||९४||

एता विज्ञाय मतिमानवस्थाश्चैव तत्त्वतः|

दद्यात् संशोधनं सम्यगारोग्यार्थी नृणां सदा||९५||

tatra ślōkau-

ityētā vyāpadaḥ prōktāḥ sarūpāḥ sacikitsitāḥ|

vamanasya virēkasya kr̥tasyākuśalairnr̥ṇām ||94||

ētā vijñāya matimānavasthāścaiva tattvataḥ|

dadyāt saṁśōdhanaṁ samyagārōgyārthī nr̥ṇāṁ sadā||95||

tatra shlokau-

ityetA vyApadaH proktAH sarUpAH sacikitsitAH|

vamanasya virekasya kRutasyAkushalairnRuNAm ||94||

etA vij~jAya matimAnavasthAshcaiva tattvataH|

dadyAt saMshodhanaM samyagArogyArthI nRuNAM sadA||95||

Thus the features of complications that may arise due to vamana and virechana by un-skilled physician and their management are described. Intelligent ones must always properly understand these states and administer proper purification therapy in the persons desiring health. [94-95]

Tattva Vimarsha (Fundamental Principles)

• The purification treatments shall be done in specific seasons in which the doshas are in vitiated state naturally. In case of disease, it can be followed anytime.
• Vamana (therapeutic emesis) for kapha dosha shall be followed in vasanta (spring season from mid February to mid April in India); virechana (therapeutic purgation) for pitta dosha shall be followed in sharada (Autumn season from mid October to mid December in India); basti (therapeutic enema) for vata dosha shall be followed in pravrita (early rains season from mid June to mid August in India).
• Snehana (oleation) therapy shall be done in between two purification therapies and at the end of purification. This is to prevent vitiation of vata dosha after purification.
• Oleation shall neither be excess nor be less for proper purification.
• Purification therapy shall always be taken after proper digestion of previous day meal and in appropriate dosage.
• The stable mental state of patient is important to get benefits of purification.
• Diet before and after purification is important for maximum sustaining effects. The previous day meal before vamana shall be easily digestible, rich in fluids and increasing kapha. The previous day meal before virechana shall be light to digest and hot.
• In proper vamana, the pitta is expelled out at the end. In proper virechana, kapha is expelled out at the end. Emaciation, weakness and lightness of body are other signs of proper purification.
• The physician should keenly observe the patient during purification therapy for assessing signs of eliminating doshas. The conditions and complications shall be treated based on dosha dominance and disease protocols.
• Assessment of vitiation of dosha, agni (digestive power), koshtha (bowel) and unctuousness of patient are most important factors for administration of purification therapy. Otherwise complications may arise due to improper dosage, potency of medicines.

Vidhi Vimarsha (Applied Inferences )

Importance of oleation and sudation therapies before purification

The shloka highlights the importance of the spacing of sneha-sweda in between the therapies. Shodhanaanga snehapaana and swedana before vamana or virechana brings in the utklishta doshas (after snehapaana), to the koshtha (after swedana) and eliminates it

Chakrapani while commenting here says, one should not misunderstand the context as sneha sweda is required only once before all shodhana. The mentioning of sneham ca ante prayojayet, is important in clinical practice. Once the patient gets discharged from the hospital after shodhana, the physician must use a sneha internally after peyadikramam. Chakrapani says, it is to control the fatigue caused by the samshodhana karma that the use of samshamana sneha is told here.(Verse 7)

Indications of Virechana

On analyzing the samprapti of the conditions (visarpa, pidaka etc.) mentioned here, it is well evident that the common thread in them is kapha-pitta dushti. Shopha is also a clinical condition where there is prohibition to use oleating substances like guda, aanoopa-amisha etc.. Here abhighaata and visha which is always an acute emergency presenting kapha-pitta dushti also requires immediate shodhana without much swedana. Pandu roga is a condition which is entitled for the use of sneha prayoga like kalyanakaghrita. Here, Acharya cautions not to reach ati-snigdhatwam. Visarpa is also a condition where in snehana is prohibited.

In practice, usually in all these conditions virechana is done with ruuksha prayoga like churna, kashaya etc. Avipathi churna,Vidangatandulaadi churna,, Trivrita kashaya, Maanibhadra churna (churna form of Maanibhadra gudam-), Patolaadi shodhana kashayam (sahasrayoga) are used.(Verse 8)

Indications of Sneha Virechana and Ruksha Virechana

Following the principle, vridhisamane sarvesham vipareetai viparyata if an excessively oleated person is administered a drug which is unctuous in nature, it will not work, rather when medicine of opposite guna like ruksha is used for shodhana, the appropriate action will happen. Chakrapani says sneha virechana means snigdha virechana, that is virechana with snigdha (unctuous) dravya. If sneha virechana is given to an atisnigdha shareera, because of sneha prakarsha (excess sneha) the vitiated doshas already in a the morbid state cannot be removed. These vitiated doshas that has already moved from their site will clog the srotas. Hence to remove this vitiated dosha ununctuous/ruksha kind of shodhana need to be performed. (Verse 9)

Procedure of virechana

Samyak is the word used to indicate appropriate/ optimum action in many contexts. Any kriyakrama is performed for its appropriate outcome as desired by the physician. The shloka here reveals the four important limbs of it, which are equally important. The first being the proper preparation of the patient in the form of sneha sweda, the second being the physiological status of the patient with respect to ahaara, only then can the agni do its duty. So the medicine has to be given after the ahaara is digested. The third being the importance of maatra which is previously well explained in Trividhakukshiya Vimana. There, the Acharya lays importance to the appropriate maatra of ahaara. Here Acharya, gives importance to the appropriate maatra of aushadha. Only the desired dosage is acted upon by agni to create the optimum response in the body.

Fourthly, the relevance of focused mind is explained. Chakrapani says the patient must concentrate only on the action of shodhana, the presence of negative emotions like lust, anger, jealousy will only have negative effect on the outcome.(Verse 10)

Similes for action of virechana

We can see the use of similes at various contexts in Ayurvedic classics. It not only gives the reader a clear idea behind the concept, but it also reveal observational talent of Ayurvedic seers to relate external world (macrocosm) with the internal world (microcosm), principles acting inside the body are similar to that act outside and vice versa. The simile of pot smeared with oil to oleated body and water that can be taken out linked to shodhana therapy explain the action to its fullest. Similarly, the malas removed from the body by shodhana similar to the dirt adhered to the cloth by rinsing in water also explains the mechanism of action in the most understandable way. (Verses 11-13)

Contraindication in state of indigestion

The importance of understanding the physiological state of the human body during the shodhana therapy is revealed here. We can see the lakshana indicating srotorodha and ama-avastha like glaani and vibandha on administering medicine to patient in ajeerna avastha. Here this ajeerna will definitely lead to ama, which will again aggravate the condition.

For the practical assessment of the jeerna-ahaara in the patient to be administered with the shodhana therapy, the following signs and symptoms can be assessed like the elimination of the feces and urine unobstructed, when the mind is clear, belching are pure, hunger is well manifest, flatus moving downward, digestive activity is clean, sense organs are clear, body is light as mentioned in by Vagbhata can be taken into account. (Verses 14)

Characteristics of proper dosage

The lakshana of maatravada aushadham touches all aspects of an ideal drug. We can see the pharmacoleptic, pharmacological and pharmacokinetic aspects being mentioned here for selecting the right drug in the appropriate dosage.

Each formulation has its own guna with respect to its contents. Even though the drug has its guna, the outcome of the kriyakrama in the patient will also depend on the physiological and the environmental factors too. However, an ideal drug and its ideal dosage in a particular clinical condition, in a particular patient can only be assessed only after the continuous practice and experience of the physician. The same medicine may have different outcome in different patients. Hence, an ideal drug even though is important, more important is fixing the dosage appropriately considering all other factors.(Verses 15-16)

Importance of concentration while taking purification treatment

The shloka 17 explains the context of ekagra manah, as mentioned earlier. It reinforces the idea that negative emotions of mind like kaamaadi would hinder the effective outcome of shodhana for which the mind must be free and fully concentrating only on shodhana therapy.(Verse 17 )

Diet before purification treatment

After warning about ajeerna ahaara, the present context explain the guna of ahaara. For vamana, all kind of kapha-aggravating ahaara that is easily digestible and liquid in nature is advised on the previous day which is to facilitate the intending karma. The increased kapha state as specified in Kalpana Siddhi as well as the decreased kapha state are important for vamana and virechana respectively. Kapha is the dosha that basically decides the action [Cha.Sa.Siddhi Sthana 1/9]

For virechana, the ahaara on the previous day is mentioned to be laghu and asheeta, that is, easily digestible and hot. Hence, the action of vamana happens with utklishta kapha and for virechana with alpa kapha. In similar context, Susruta Samhita Chikitsa Sthana, he speaks of pitta-utklehsa before virechana, with amla dravya like beeja-purka rasa. This will also ultimately result in alpa-kaphatvam.

In practice, we give porridge made of maasha (black gram) with sugar, yogurt, boiled fish with no spices, preparation of masha like idli (south Indian dish), rice and milk porridge, milk peda, jalebi (north indian sweet) as kaphakara ahaara before vamana. On previous day of virechana like hot rasam (A south Indian dish mainly of tamarind juice, lime juice etc. with meal.) (Verse 18)

Signs of proper purification

The sloka explains specific objective signs to assess optimum activity of the shodhana karma. Like in vamana, the output of kapha is succeeded by bile and in virechana, first feces must come out followed by pitta and then kapha. However, after both the procedure, if done properly, will make the patient feel light, fatigued and emaciated which indicates the expulsion or mitigation of kapha and pitta and increase of vata as expected after any shodhana therapy. (Verse 19-20)

Even though acharya gives us practical tips to understand the presence of residual drug and emesis to be done to remove the residue, in our limited experience, we have not come across such practice. The practice of vamana as a correction therapy other than main procedure is seldom done. (Verse 21)

After measures of vamana

The after-measure of vamana is specifically told here. It probably highlights the seriousness of the procedure, which is the only one done in the pratiloma direction among the Panchakarma. Hence, the removal of residual dosha becomes even more pertinent. (Verse 22-23)

Importance of specific diet after purification treatment

As explained already in the first chapter of Siddhi Sthana, the mentioning of peyaadikrama here again, is only to reinforce its importance in the practice of shodhana karma. However, Chakrapani, in his commentary reminds the fact that, after basti, peyadi is not mentioned because the status of agni after basti is not hampered as much as in virechana and vamana.

Chakrapani intelligently compare the context wherein it is mentioned that shodhanakriya improves / kindles agni. He says it is as mentioned in [ Cha. Sa. Siddhi Stahan 1/17,22]. He says the agni is kindled when compared to the earlier status of agni before shodhana. (Verse 24-25)

Signs of digestion of purification medicine

We can see jeerna-aushadha lakshana exhibits all types of jeerna-ahaara lakshana too. Signs of residual drug indicate lakshana of ama. In the next shloka, he warns of inappropriate medicine, which is unseasonal, untimely collected, stored for long period, improperly processed etc. This shloka sequentially expresses the idea that if there are signs of residual drug, the factors considered here may be reasoned upon. (Verse 26-28)

Complications of purification treatment

The 10 sets of vyapat are explained either as ayoga or atiyoga, because ultimately drug can act broadly only in these contexts. Very intelligently acharya says, this can happen because of defect in preshya (attendant), bhaishajya (drug), vaidya (physician) and atura (patient). These are also the chatushpada mentioned in Ayurveda.. In the above context, we can see the change in the order. The attendant comes in first, then drug, then the physician and then only the patient.

Probably the clinical observation of acharya might have lead him to this conclusion, but most of the time, it is the attendant who becomes responsible, because of ill-equipped expertise, then comes the drug. However, the position of rogi is the last one, because the vaidya must have the capability to correct even the rogi. (Verse 29-30)

Any procedure can have the outcome only in three ways, which is explained here. Hence, the procedure has to be analyzed within the frame of these three outcomes. (Verse 31)

Signs of improper purification and its consequences

When virechana dravya with the said qualities causes vamana, two conditions mentioned here are shleshmotklishta avastha and ajeerna avastha. In both cases, there is always a tendency for vamana which is of course not the classical shodhana but just to let out the things because the body could not assimilate the virechana aushadha intended to cause virechana. Now similarly, when the patient who is hungry with less kapha and has the potent drug for vamana will lead to virechana . The reason being the digestion of aushadha by the agni. It is very well told that the virechana aushadha can act only in paripakwa avastha and vamana in avipaakwa avastha. (Verse 32-34)

Finally the status of koshtha and strength of the patient decides which kind of medicine has to be given in case of ayoga. The mentioning of avoiding repeated dose if the patient is not suitable also gains clinical relevance. Acharya warns in the context that such usage inappropriately can even lead to death. (Verse 35-37)

Ayoga (less purification)

Before going for specific vyapat, the general presentation of ayoga is explained. Here also, the aspect touching the preparation of the individual, quality of medicine is touched upon. The medicine that is stored for a long time is used in an improperly oleated and sudated individual will not be able to move out the morbid doshas properly. Here we can see mostly the vata kopa lakshanas, like the pindikodweshtana, tamaso darshanam etc. Kapha-pitta dushti lakshana like kandu is also seen.

Usually in clinical practice, this is encountered commonly, when the snehapana is compromised for various reasons without attaining proper samyak lakshana, medicines with low quality or long stored ones is also seen to play its role. (Verse 38-39)

These verses explain the possibility of ayoga even after proper sneha sweda. The relevance of agni and quality of medicine are reinforced here. (Verse 40-41)

The treatment mentioned here is again reversing the dosha dushti using various kriya krama. The role of niruha basti here relates to the context where in durvirechya, due to ruksha bahvaanila krura koshta are advised to undergo niruha first. (Verse 42-44)

Hazards of excess purification and its management

Chakrapani in the context comments that this indicates atiyoga of virechana only since seeing of vata, pitta, kapha is mentioned and on administering medicine in patient who is hungry and with mridu koshtha is mentioned. He also adds that the context can also be interpreted as atiyoga of vamana by using the ati-teekshna dravya and atiyoga of virechana if medicine is used in a hungry patient with mridu koshta. He says, the order of vata, pitta and kapha should be changed and applied to the context logically.

The signs and symptoms presented here points to many emergency contexts. The practice of going for vamana in case of atiyoga of virechana and vice-versa is not done widely. However, the use of parisheka, avagaaha and managing with internal medicines are done more. Vilwadi gutika, sidhamakara dhwaja, dhanwantaram gutika, kalashakadi kashaya etc are the commonly used ones. (Verse 45-48)

The treatment for atiyoga of vamana and virechana is mentioned separately. For virechana, the effect of internal medicines is told. The use of milk which itself is rechana in nature is used while processing with drugs of opposite guna. Picha basti and anuvasana basti with madhura gana dravya will definitely be sthambhana in action. (Verse 49-51)

Management of excess emesis

For vamanatiyoga, kaphahara dravya has to be considered. Here we can see many emergency situations like fainting, protrusion of tongue inside and outside, vakgraha etc. the management has also to be fixed by using simple techniques like eating tamarind in front of the patient which will stimulate the physiology to correct itself. Techniques like pushing back of the tongue to normal after applying the paste of tila and draaksha demand the skill of the physician. (Verse 52-56)

Diet after procedure

The shloka lays importance to the use of peyadi after atiyoga of vamana and virechana considering the excessively hampered agni. (Verse 57)

Important concepts in the chapter

The ten vyapat adhmana, parikatika, parisraava, hrdayopasarana, anga graham, jeevaadaana, vibhramsha, sthambha, upadrava and klama are explained in a systematic manner. Each vyapat represent a cluster of signs and symptoms. However, every context begins with explaining the possible causative factors for the happening. On analyzing the various causes told for vyapat, we can see the doshic status, the general quality of the sharira and the koshtha, the status of agni, the physiological state of the individual-all plays an important role. The treatments mentioned are also grouped. The physician may not see all the signs and symptoms for each as told in the text, but can infer from some of the presentation. It becomes the responsibility of the intelligent physician to select the appropriate karma for the treatment of the complication presented. The presentation of vyapat itself reveals the clinical skill of Charak to observe the minute presentation in the body. Each complication is self-explanatory as mentioned in the text. However, in the present day practice, how much a modern day Ayurveda physician encounters these complications is an issue to be discussed about. Whether the lack of quality of the shodhana performed, change in practical standards, problem at all four levels of the chatushpada could be the cause.(Verse 58-90)

The chapter ends by reinforcing the idea of a knowledgeable physician who knows, where, when, how to apply shodhana therapy accurately and thus avoid complications.

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References