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Vamana Virechana Vyapat Siddhi (view source)

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Now we shall ~~explore~~ the chapter ~~on the ‘complications~~ of improper therapeutic emesis and purgation ~~and their successful management’~~. Thus said Lord Atreya.

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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:

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*The effective treatment for the management of complications.[1-3]

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==== Seasons for purification ====

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=== Seasons for purification ===

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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]

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==== Importance of oleation in [[Panchakarma]] ====

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=== Importance of oleation in [[Panchakarma]] ===

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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]

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==== Indications of purification ====

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=== Indications of purification ===

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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]

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==== Procedure of taking purgatives for therapy ====

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=== Procedure of taking purgatives for therapy ===

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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]

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==== Consequences if medicines taken during indigestion ====

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=== Consequences if medicines taken during indigestion ===

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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]

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==== Characteristics of appropriate dosage of medicine ====

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=== Characteristics of appropriate dosage of medicine ===

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*It should be endowed with good smell, color, taste etc. and should be pleasing in nature.[15-16]

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==== Careful administration of medicine with mental concentration ====

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=== Careful administration of medicine with mental concentration ===

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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]

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==== Diet before purification therapy ====

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=== Diet before purification therapy ===

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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]

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==== Signs of proper elimination ====

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=== Signs of proper elimination ===

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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]

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==== Signs of digested and undigested medicine ====

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=== Signs of digested and undigested medicine ===

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*Being not properly processed.

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==== Ten complications of emesis and purgation ====

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=== Ten complications of emesis and purgation ===

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*''Aatura-vaigunya'' (incompetency of the patient). [29-30]

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==== Three types of purification according to its signs ====

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=== Three types of purification according to its signs ===

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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]

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==== Various conditions and management ====

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=== Various conditions and management ===

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

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==== Signs of excess elimination and management ====

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=== Signs of excess elimination and management ===

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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]

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==== Importance of diet after purification ====

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=== Importance of diet after purification ===

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''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)

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==== Complication of ''adhmana'' (abdominal distension) and its management ====

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=== Complication of ''adhmana'' (abdominal distension) and its management ===

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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]

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==== Complication of ''parikartika'' (fissure in ano) and its management ====

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=== Complication of ''parikartika'' (fissure in ano) and its management ===

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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]

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==== Complication of ''paristrava'' (discharge) and its management ====

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=== Complication of ''paristrava'' (discharge) and its management ===

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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]

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==== Complication of ''hridgraha'' (chest congestion) and its management ====

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=== Complication of ''hridgraha'' (chest congestion) and its management ===

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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]

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

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

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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]

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==== Complication of ''jeevadana'' (bleeding) and its management ====

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=== Complication of ''jeevadana'' (bleeding) and its management ===

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''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]

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==== Complication of ''gudavibhramsha'' (rectum prolapse) and its management ====

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=== Complication of ''gudavibhramsha'' (rectum prolapse) and its management ===

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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]

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==== Complication of ''stambha'' (stiffness) and its management ====

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=== Complication of ''stambha'' (stiffness) and its management ===

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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]

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==== Complications and its management ====

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=== Complications and its management ===

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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]

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==== ''Klama'' (fatigue without exertion) and its management ====

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=== ''Klama'' (fatigue without exertion) and its management ===

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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]

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==== Summary ====

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=== Summary ===

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== Vidhi Vimarsha (Applied Inferences ) ==

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==== Importance of oleation and sudation therapies before purification ====

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=== 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 (A.H.Su.17/29).

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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)

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==== Indications of ''Virechana'' ====

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=== 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. (A.H.Su.16/43). 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.

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

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==== Indications of ''Sneha Virechana and Ruksha Virechana'' ====

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=== Indications of ''Sneha Virechana and Ruksha Virechana'' ===

Following the principle, ''vridhisamane sarvesham vipareetai viparyata'' (A.H.Su.1/14) 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)

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==== Procedure of ''virechana'' ====

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=== 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.

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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)

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==== Similes for action of ''virechana'' ====

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=== 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)

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==== Contraindication in state of indigestion ====

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=== 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.

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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 A.H.Suu. Maatrasheetiyam Adhyayam (A.H.Su.8/55) can be taken into account. (Verses 14)

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==== Characteristics of proper dosage ====

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=== 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.

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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)

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==== Importance of concentration while taking purification treatment ====

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=== 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 )

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==== Diet before purification treatment ====

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=== 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 (C.S.Si.1/9)

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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)

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==== Signs of proper purification ====

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=== 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)

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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)

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==== After measures of ''vamana'' ====

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=== 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)

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==== Importance of specific diet after purification treatment ====

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=== 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 ''vasti'', ''peyadi'' is not mentioned because the status of ''agni'' after ''vasti'' is not hampered as much as in ''virechana'' and ''vamana''.

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

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==== Signs of digestion of purification medicine ====

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=== 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)

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==== Complications of purification treatment ====

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=== 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]]. (A.H.Su.1/27). 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.

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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)

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==== Signs of improper purification and its consequences ====

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=== 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)

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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)

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==== ''Ayoga'' (less purification) ====

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=== ''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.

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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)

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==== Hazards of excess purification and its management ====

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=== 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.

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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)

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==== Management of excess emesis====

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=== 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)

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==== Diet after procedure ====

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=== 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)

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==== Significant concepts in the chapter ====

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=== Significant 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)

Agnivesha

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