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Upakalpaniya Adhyaya (view source)

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<big>'''Abstract :'''</big>

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<div style="text-align:justify;">This chapter focuses on the pre-requisites for construction of a well-equipped hospital facility suitable for administration of Panchakarma therapies in continuation with the discussion on purification procedures (samshodhana karmas) from the preceding chapters. Pre-procedure, main procedure and post-procedure guidelines have been described in detail in this chapter. The descriptions of dosages of drugs for vamana (therapeutic emesis) and virechana (therapeutic purgation) with assessment of inadequate, proper and excess purification are detailed. Afflictions of dosha, complications, dietetic regimen during the therapy and after the therapy (samsarjana karma or graduated diet) have also been clearly elaborated. </div>

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<div style="text-align:justify;">This chapter focuses on the pre-requisites for construction of a well-equipped hospital facility suitable for administration of [[Panchakarma]] therapies in continuation with the discussion on purification procedures (samshodhana karmas) from the preceding chapters. Pre-procedure, main procedure and post-procedure guidelines have been described in detail in this chapter. The descriptions of dosages of drugs for [[vamana]] (therapeutic emesis) and [[virechana]] (therapeutic purgation) with assessment of inadequate, proper and excess purification are detailed. Afflictions of [[dosha]], complications, dietetic regimen during the therapy and after the therapy (samsarjana karma or graduated diet) have also been clearly elaborated. </div>

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'''Keywords''': Pre-requisites for [[Panchakarma]] hospital, ''vamana, virechana'', therapeutic emesis, therapeutic purgation, hospital management.

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'''Keywords''': Pre-requisites for [[Panchakarma]] hospital, ''[[vamana]], [[virechana]]'', therapeutic emesis, therapeutic purgation, hospital management.

</div>

== Introduction ==

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[[Upakalpaniya Adhyaya]] is a part of the ''Kalpana Chatushka'' tetrad and follows the chapters on pre-purification (''snehana'' (oleation) and ''swedana'' (sudation)) procedures. The sequence of chapters suggests that after completing the pre-purification procedures, the vitiated ''~~doshas~~'' come into ''koshtha'' (gut) and should be expelled out by suitable procedures like therapeutic emesis or therapeutic purgation. Guidelines for managing the purification therapies as well as for setting up a good [[Panchakarma]] hospital with all infrastructure and equipment required for patient care have been described in this chapter. The rationale for providing guidelines for setting up a hospital is that, should complications arise, prompt medical care could be provided to the patient. Special emphasis has been given to the need for planning of relevant equipment and medicines required for [[Panchakarma]] and any medical care it may necessitate. It is incredible to think that 3000 years back when there were hardly any indoor hospital facilities available in other parts of the world, there were thinkers and practitioners who could conceive of such a hospital management system as described in this text.

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[[Upakalpaniya Adhyaya]] is a part of the ''Kalpana Chatushka'' tetrad and follows the chapters on pre-purification (''[[snehana]]'' (oleation) and ''[[swedana]]'' (sudation)) procedures. The sequence of chapters suggests that after completing the pre-purification procedures, the vitiated ''[[dosha]]s'' come into ''koshtha'' (gut) and should be expelled out by suitable procedures like therapeutic emesis or therapeutic purgation. Guidelines for managing the purification therapies as well as for setting up a good [[Panchakarma]] hospital with all infrastructure and equipment required for patient care have been described in this chapter. The rationale for providing guidelines for setting up a hospital is that, should complications arise, prompt medical care could be provided to the patient. Special emphasis has been given to the need for planning of relevant equipment and medicines required for [[Panchakarma]] and any medical care it may necessitate. It is incredible to think that 3000 years back when there were hardly any indoor hospital facilities available in other parts of the world, there were thinkers and practitioners who could conceive of such a hospital management system as described in this text.

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It is important to assess the ''dosha'', potency of drugs, location, time, strength, body constitution, diet, mental status, and the age of a patient before initiating any purification procedure. The preparation of the patient, clinical observations during purification therapy and post-procedure management (with appropriate dietary regimen) are three important steps for successful completion of any purification therapy. Therapies, if administered properly, can cure diseases or reduce their recurrence, but if not done well, can cause complications and therefore require a sound understanding of the guidelines (or protocols) for [[Panchakarma]].

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It is important to assess the ''[[dosha]]'', potency of drugs, location, time, strength, body constitution, diet, mental status, and the age of a patient before initiating any purification procedure. The preparation of the patient, clinical observations during purification therapy and post-procedure management (with appropriate dietary regimen) are three important steps for successful completion of any purification therapy. Therapies, if administered properly, can cure diseases or reduce their recurrence, but if not done well, can cause complications and therefore require a sound understanding of the guidelines (or protocols) for [[Panchakarma]].

</div>

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</div></div>

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Lord Atreya replied, “Oh Agnivesha!, it is possible for us to treat the patients successfully and also impart instructions for correct administration. But there is none who is able to grasp such instructions or having grasped it, is able to apply it or put it into practice. The variations in conditions of dosha, drugs, place, time, strength, body, diet, suitability, mind pattern, constitution, and age are subtle to understand. While considering these factors, when even a person with great intellect and pure knowledge gets confused, then what will be the condition of a person with less intellect? [5]

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Lord Atreya replied, “Oh Agnivesha!, it is possible for us to treat the patients successfully and also impart instructions for correct administration. But there is none who is able to grasp such instructions or having grasped it, is able to apply it or put it into practice. The variations in conditions of [[dosha]], drugs, place, time, strength, body, diet, suitability, mind pattern, constitution, and age are subtle to understand. While considering these factors, when even a person with great intellect and pure knowledge gets confused, then what will be the condition of a person with less intellect? [5]

=== Equipments and arrangements for purification therapy ===

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#'''Animals in hospital campus:''' Presence of ''lava'' (common quail), ''kapinjala'' (grey partridge), ''shasha'' (rabbit), ''harina'' (black buck), ''ena'' (antelope), ''kalapucchaka'' (black-tailed deer), ''mrigamaika'' (red/hog deer), and ''urabhra'' (wild sheep) is necessary. There should be a good, healthy, cow with her calf alive (i.e., milking cow) with adequate provision for her feed (fresh grass), shelter and water.

#'''Pots and vessels:''' Provision should also be made of vessels and containers, such as beakers, water vessels (''patti''), sipping spoons (''aachmaniya''), tubs (''udakostha''), big and small earthen jars (''manika'' and ''ghata''), frying pan (''pithara''), jug (''paryoga''), small and big pitchers (''kumbhi kumbha''), bowl (''kunda''), saucer (''sardva''), ladle (''darvi''), mat (''kata''), coverplate (''udanchana''), cooking pan (''paripachana''), churning stick (''manthana)'', leather, cloth, thread, cotton, wool, etc.

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#'''Bedding and sitting arrangements:''' Arrangements should be made for beds and seats, etc. kettle and spittoon, well spread bed sheets, coverlets, cushion with pillows to facilitate resting, sitting for treatments like oleation, fomentation, massage, unction, shower, anointment, emesis, purgation, ''asthapana'' (type of enema with decoction), ''anuvasana'' (type of enema with oil), elimination of ''dosha'' from head, and bed-pans for passing of stool and urine.

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#'''Bedding and sitting arrangements:''' Arrangements should be made for beds and seats, etc. kettle and spittoon, well spread bed sheets, coverlets, cushion with pillows to facilitate resting, sitting for treatments like oleation, fomentation, massage, unction, shower, anointment, emesis, purgation, ''asthapana'' (type of enema with decoction), ''anuvasana'' (type of enema with oil), elimination of ''[[dosha]]'' from head, and bed-pans for passing of stool and urine.

#'''Accesories for purification:''' Well washed roller stone and grinding stones (mortars) that should be well polished, hard and of medium size, along with well cleaned pestles, sharp instruments, accessories, smoking pipe, tube for enema and douche, broom, scales and measuring vessels should be arranged.

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#'''Food and medicines for patients:''' The following food items and medicines should be arranged: ''ghee,'' oil, muscle fat, marrow, honey, ''phanita'' (a sugar cane preparation ), salt, fuel, various types of wine like the one prepared of honey, ''sidhu, sura, sauviraka,'' ''maireya, medaka, tushodaka,'' curd, whey, ''udasvit'' (a mixture of water and butter milk in equal parts), ''dhanyamla'' (sour gruel), ''shali'' rice (Oryza sativa Linn.), ''shashtika'' rice (a variety of Oryza sativa Linn), ''mudga'' (green gram- phaseolus mungo Linn.), ''masha'' (black gram- Phaseolus radiatus Linn.), ''yava'' (Hordeum vulgara Linn.), ''tila'' (sesamum indicum Linn.), ''kulattha'' (Dolichos bifforus Linn.), ''badara'' (zizyphus jujube Lam.), ''mridvika'' (vitis vinifera Linn.), ''kashmarya'' (Gmelina arborea Linn.), ''parushaka'' (Grewia asiatica Linn.), ''abhaya'' (Terminalia chebula Linn.), ''amalaki'' (Emblica officinalis Garrin), ''bibhittaka'' (Termalia bellerica Roxb.) , and other drugs employed in oleation, fomentation, emesis, purgation, those having the combined action of emesis and purgation, those that are known to stop emesis and purgation, appetizers and ''vata''-pacifying medicines, etc., carminatives, other medicines conducive to the treatment of complications, and also those which are useful in and after-treatment. [7]

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#'''Food and medicines for patients:''' The following food items and medicines should be arranged: ''ghee,'' oil, muscle fat, marrow, honey, ''phanita'' (a sugar cane preparation ), salt, fuel, various types of wine like the one prepared of honey, ''sidhu, sura, sauviraka,'' ''maireya, medaka, tushodaka,'' curd, whey, ''udasvit'' (a mixture of water and butter milk in equal parts), ''dhanyamla'' (sour gruel), ''shali'' rice (Oryza sativa Linn.), ''shashtika'' rice (a variety of Oryza sativa Linn), ''mudga'' (green gram- phaseolus mungo Linn.), ''masha'' (black gram- Phaseolus radiatus Linn.), ''yava'' (Hordeum vulgara Linn.), ''tila'' (sesamum indicum Linn.), ''kulattha'' (Dolichos bifforus Linn.), ''badara'' (zizyphus jujube Lam.), ''mridvika'' (vitis vinifera Linn.), ''kashmarya'' (Gmelina arborea Linn.), ''parushaka'' (Grewia asiatica Linn.), ''abhaya'' (Terminalia chebula Linn.), ''amalaki'' (Emblica officinalis Garrin), ''bibhittaka'' (Termalia bellerica Roxb.) , and other drugs employed in oleation, fomentation, emesis, purgation, those having the combined action of emesis and purgation, those that are known to stop emesis and purgation, appetizers and ''[[vata]]''-pacifying medicines, etc., carminatives, other medicines conducive to the treatment of complications, and also those which are useful in and after-treatment. [7]

</div>

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=== Dose of emetics ===

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The dosage of the decoction of the fruit of ''madanaphala'' (Randia dumetorum Lam.) and also of all the other drugs used in purification therapy should be decided according to the needs of an individual. A dose that produces the desired effects of purification of the vitiated ''dosha'' and does not cause excess or inadequate purification is regarded as the ideal dose for the patient. [10]

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The dosage of the decoction of the fruit of ''madanaphala'' (Randia dumetorum Lam.) and also of all the other drugs used in purification therapy should be decided according to the needs of an individual. A dose that produces the desired effects of purification of the vitiated ''[[dosha]]'' and does not cause excess or inadequate purification is regarded as the ideal dose for the patient. [10]

=== Observation of patient after giving dose ===

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After administration of the decoction, the patient should be observed for one muhurt (approximately 48 minutes). The first noticeable effect will be perspiration indicating liquification of dosha. Thereafter, the patient would exhibit horripilation showing movement of dosha from its own position. The third stage will produce distension of the abdomen indicative of the ~~doshas~~ having shifted to the gut. Nausea and salivation occur in the fourth stage, indicating the upward movement of dosha. At this stage, the patient should be asked to sit on a comfortable chair of knee height, which is well-covered with bed sheet and have towel, pillow and cushion at its side. Good friends, whose presence is not embarrassing to the patient, should attend him and support his head, press his navel, and massage his back in order to facilitate emesis. [11]

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After administration of the decoction, the patient should be observed for one muhurt (approximately 48 minutes). The first noticeable effect will be perspiration indicating liquification of [[dosha]]. Thereafter, the patient would exhibit horripilation showing movement of [[dosha]] from its own position. The third stage will produce distension of the abdomen indicative of the [[dosha]]s having shifted to the gut. Nausea and salivation occur in the fourth stage, indicating the upward movement of [[dosha]]. At this stage, the patient should be asked to sit on a comfortable chair of knee height, which is well-covered with bed sheet and have towel, pillow and cushion at its side. Good friends, whose presence is not embarrassing to the patient, should attend him and support his head, press his navel, and massage his back in order to facilitate emesis. [11]

</div>

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Thereafter, the treating physician should instruct the patient to vomit without straining himself excessively by aiding his urge to vomit, by opening mouth, palate and throat widely, by slightly bending the neck and upper part of body forward, by provoking the urge that is not well apparent, by inserting well manicured two fingers, or stalks of blue lily, night lotus or while water lily (Nymphaea alba Linn.) in the throat. The patient should follow this advice. The physician should carefully observe the patient and episodes of the vomiting, keep a count of those events, and monitor the nature of the vomitus in the container to understand the proper functioning of medicine. The physician should then assess the character of ''vamana'' and decide its proper, inadequate or excessive nature. It is from this observation that the physician can determine the subsequent line of treatment. [12]

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Thereafter, the treating physician should instruct the patient to vomit without straining himself excessively by aiding his urge to vomit, by opening mouth, palate and throat widely, by slightly bending the neck and upper part of body forward, by provoking the urge that is not well apparent, by inserting well manicured two fingers, or stalks of blue lily, night lotus or while water lily (Nymphaea alba Linn.) in the throat. The patient should follow this advice. The physician should carefully observe the patient and episodes of the vomiting, keep a count of those events, and monitor the nature of the vomitus in the container to understand the proper functioning of medicine. The physician should then assess the character of ''[[vamana]]'' and decide its proper, inadequate or excessive nature. It is from this observation that the physician can determine the subsequent line of treatment. [12]

</div>

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Now the signs to decide the proper, inadequate and excessive administration of ''vamana karma'' are explained. Inadequate ''vamana'' (''ayoga'') has absence of emesis, emesis of drug only or obstruction during the episodes or may lead to purgation. If the medicine is administered properly, there will be proper emesis depending upon time of administration, quantity of medicine administered, and level of comfort of the patient. There may be three types of properly administered ''vamana'', categorized by the amount of evacuated ''dosha'' as ''mridu'' (mild), ''madhyama'' (moderate) and ''tikshna'' (maximum). Over-administration of therapy may lead to frothy or blood stained vomitus. The following complications may arise due to over-administration or inadequate administration of the therapy: distension of abdomen, searing or cutting pain, excessive salivation, palpitation, rigidity, stiffness, displacement of the viscera of the body, hematemesis, and fatigue.[13]

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Now the signs to decide the proper, inadequate and excessive administration of ''[[vamana]] karma'' are explained. Inadequate ''[[vamana]]'' (''ayoga'') has absence of emesis, emesis of drug only or obstruction during the episodes or may lead to purgation. If the medicine is administered properly, there will be proper emesis depending upon time of administration, quantity of medicine administered, and level of comfort of the patient. There may be three types of properly administered ''[[vamana]]'', categorized by the amount of evacuated ''[[dosha]]'' as ''mridu'' (mild), ''madhyama'' (moderate) and ''tikshna'' (maximum). Over-administration of therapy may lead to frothy or blood stained vomitus. The following complications may arise due to over-administration or inadequate administration of the therapy: distension of abdomen, searing or cutting pain, excessive salivation, palpitation, rigidity, stiffness, displacement of the viscera of the body, hematemesis, and fatigue.[13]

</div>

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After proper emesis (''vamana''), the patient is advised to wash his face, hands and feet, and then take rest for one ''muhurta'' (48 minutes). Thereafter, he is directed to inhale medicated smoke (''dhumapana'') made up of ingredients that are ''snaihika'' (unctuous), ''vairechanika'' (errhine) or ''upashamaniya'' (sedative) – whatever is suitable for him - and then made to wash again . [14]

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After proper emesis (''[[vamana]]''), the patient is advised to wash his face, hands and feet, and then take rest for one ''muhurta'' (48 minutes). Thereafter, he is directed to inhale medicated smoke (''dhumapana'') made up of ingredients that are ''snaihika'' (unctuous), ''vairechanika'' (errhine) or ''upashamaniya'' (sedative) – whatever is suitable for him - and then made to wash again . [14]

Thereafter, the patient should enter a room that is not too aerated or ventilated and made to lie down there. He should avoid the following activities: speaking loudly, sitting in one position for a long time, standing in one position for long duration, going for long walks, getting subjected to extreme emotions such as anger or grief, excessive cold, sun, dew, flowing winds, traveling by any vehicle, sexual intercourse, staying awake for late hours at night, and sleeping during daytime. Intake of incompatible dietary items taken before complete digestion of previous food, unwholesome diet, eating meals at improper time, eating food articles consisting of only one taste, lacking good quality, heavy to digest, mixed with improper food, and suppression/provocation/excitation of natural urges should also be avoided. [15]

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</div></div>

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''Sansarjana karma'' (rehabilitation diet) should be initiated from the same evening or the next day after ''vamana'' (therapeutic emesis).

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''Sansarjana karma'' (rehabilitation diet) should be initiated from the same evening or the next day after ''[[vamana]]'' (therapeutic emesis).

The patient should take bath with lukewarm water.

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Thereafter, the patient should take food having different tastes and should start taking his normal diet from the seventh night. [16]

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=== Procedure of ''virechana'' (therapeutic purgation) ===

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=== Procedure of ''[[virechana]]'' (therapeutic purgation) ===

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On completion of the post-therapeutic, rehabilitative, dietetic program, oleation and fomentation therapies should be administered again. When the patient has come to normalcy, has slept well, and the food taken by him has been digested, he should be asked to offer homage to ''agni'' (fire) and the Gods, and perform auspicious chants. Brahmins should then be invited to recite the ''svastivachanas'' (auspicious chants) on an auspicious day with favorable ''nakshatra'' (star constellation), ''karana'' and ''muhurta''. The patient should thereafter be given a drink made up of the paste of root of ''trivrit'' (Operculina turpethum R. B.) in one ''karsha'' (12 gm) dose after stirring and mixing up with suitable liquids. Variations in ''dosha'', medicinal drugs, place of residence, time, strength, body, diet, suitability, mind, constitution, and age should be factored in while administering this therapy. After the patient has been administered purgation therapy properly, the complete regimen prescribed for ''vamana'' (therapeutic emesis), except herbal smoking, should be followed till he regains normal strength, complexion and health. After he feels physically and mentally normal, has slept well and the food taken by him is fully digested, he should take full bath, apply unction, wear garlands, untorn cloths and favorite ornaments, and appear before friends and relatives. Thereafter, he should be free to lead a normal life. [17]

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On completion of the post-therapeutic, rehabilitative, dietetic program, oleation and fomentation therapies should be administered again. When the patient has come to normalcy, has slept well, and the food taken by him has been digested, he should be asked to offer homage to ''agni'' (fire) and the Gods, and perform auspicious chants. Brahmins should then be invited to recite the ''svastivachanas'' (auspicious chants) on an auspicious day with favorable ''nakshatra'' (star constellation), ''karana'' and ''muhurta''. The patient should thereafter be given a drink made up of the paste of root of ''trivrit'' (Operculina turpethum R. B.) in one ''karsha'' (12 gm) dose after stirring and mixing up with suitable liquids. Variations in ''[[dosha]]'', medicinal drugs, place of residence, time, strength, body, diet, suitability, mind, constitution, and age should be factored in while administering this therapy. After the patient has been administered purgation therapy properly, the complete regimen prescribed for ''[[vamana]]'' (therapeutic emesis), except herbal smoking, should be followed till he regains normal strength, complexion and health. After he feels physically and mentally normal, has slept well and the food taken by him is fully digested, he should take full bath, apply unction, wear garlands, untorn cloths and favorite ornaments, and appear before friends and relatives. Thereafter, he should be free to lead a normal life. [17]

The above mentioned ways of carrying out purification or cleansing procedures are prescribed for a king, royalty or for the people having immense wealth. [18]

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</div></div>

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The benefits of a properly administered purification therapy include elimination of vitiated ''dosha'', alleviation of disease, improvement in strength, complexion and longevity. [22]

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The benefits of a properly administered purification therapy include elimination of vitiated ''[[dosha]]'', alleviation of disease, improvement in strength, complexion and longevity. [22]

=== Summary ===

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In summary, all the prerequisites for the administration of therapeutic emesis and purgation to resourceful persons (i.e., kings and members of the royalty), including their utility, dose, signs and symptoms of inadequate administration, proper administration, and over-administration, afflicted dosha, complications, regimen prescribed during the therapy and those prescribed in the course of the post-therapeutic rehabilitative dietetic program have been explained by the Lord Punarvasu in this Kalpana Chapter.[23-25]

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In summary, all the prerequisites for the administration of therapeutic emesis and purgation to resourceful persons (i.e., kings and members of the royalty), including their utility, dose, signs and symptoms of inadequate administration, proper administration, and over-administration, afflicted [[dosha]], complications, regimen prescribed during the therapy and those prescribed in the course of the post-therapeutic rehabilitative dietetic program have been explained by the Lord Punarvasu in this Kalpana Chapter.[23-25]

</div>

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*It is necessary to manage the [[Panchakarma]] hospital properly, equipping it with good quality medicines and skilled staff for assuring successful administration of purification therapies.

*All possibilities of complications and their management should be considered before initiating any treatment.

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*Clinical observation of patients at each stage during purification therapy is necessary to assess movement of ''dosha''.

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*Clinical observation of patients at each stage during purification therapy is necessary to assess movement of ''[[dosha]]''.

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*The dose of emetics should be decided according to individual needs considering all key variables such as ''dosha,'' potency of medicine, place of residence, time of administration, strength of patient, constitution, dietary pattern, suitability and age. A suitable post-therapeutic rehabilitative dietary regimen should be designed (taking into consideration the needs and predisposition of the patient) and administered, after therapeutic emesis and purgation, in order to restore the normal levels of ''agni'' and strength of the patient.

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*The dose of emetics should be decided according to individual needs considering all key variables such as ''[[dosha]],'' potency of medicine, place of residence, time of administration, strength of patient, constitution, dietary pattern, suitability and age. A suitable post-therapeutic rehabilitative dietary regimen should be designed (taking into consideration the needs and predisposition of the patient) and administered, after therapeutic emesis and purgation, in order to restore the normal levels of ''agni'' and strength of the patient.

*Sometimes all enlisted pre-requisites cannot be made available, especially when treating poorer or less resourceful patients. In such cases, the procedures can be followed with the available and suitable medicines.

*Properly administered purification is beneficial for removal of morbid toxins, alleviation of disease while improving strength, complexion and longevity of a person.

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##'''Staff requirements'''- For smooth running of the hospital, adequate staff support should be made available. The attendants should possess necessary nursing skills, good conduct, hygiene, character, devotion, and compassion and be conversant in the administration of therapies.

##'''Recreational measures'''- The fact that various forms of recreation such as music, poetry, and drama were suggested, made available or arranged within hospices or healthcare facilities shows how elaborate and extensive the field of healthcare management was within [https://en.wikipedia.org/wiki/[[Ayurveda]] [[Ayurveda]]]. Today, hospices or healthcare services providers arrange for televisions and music system in the rooms of patients.

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##'''Drugs, equipments and other resources''': Kitchen appliances and utensils of varied sizes should be available within the kitchen. Arrangements should be made for the availability of bedding with appropriate furnishings (bedsheet and pillow), towel, clean cloths, cotton, wool and various other equipments for smooth induction of oleation, massage, sudation, emesis, purgation, medicated enema, and ''nasya'' to the patients. There should also be grinding stones with pestle, knife, smoking pipes, weighing scale, enema tubes and measuring vessels. Food articles like ''ghee'', oil, muscle fat, honey, salt, gruel, various types of wine and ''dhanyamla'' should be available in the hospital. Various drugs like ''shali'' (rice), ''mudga'' (pulses), ''tila'', ''kullattha'', ''parushaka'', and ''triphala'' should be made available, along with drugs to treat complications arising during procedures. This is akin to having a pharmacy within the premises of a hospital.

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##'''Drugs, equipments and other resources''': Kitchen appliances and utensils of varied sizes should be available within the kitchen. Arrangements should be made for the availability of bedding with appropriate furnishings (bedsheet and pillow), towel, clean cloths, cotton, wool and various other equipments for smooth induction of oleation, massage, sudation, emesis, purgation, medicated enema, and ''[[nasya]]'' to the patients. There should also be grinding stones with pestle, knife, smoking pipes, weighing scale, enema tubes and measuring vessels. Food articles like ''ghee'', oil, muscle fat, honey, salt, gruel, various types of wine and ''dhanyamla'' should be available in the hospital. Various drugs like ''shali'' (rice), ''mudga'' (pulses), ''tila'', ''kullattha'', ''parushaka'', and ''triphala'' should be made available, along with drugs to treat complications arising during procedures. This is akin to having a pharmacy within the premises of a hospital.

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#'''General plan of treatment'''- The patient should be admitted in the hospital for administration of therapeutic emesis and purgation procedures. Before application of these cleansing procedures, the patient should undergo some pre-therapeutic procedures such as ''langhana-pachana'' (restricted diet and improving digestion), ''snehana'' (oleation) and ''swedana'' (sudation). Their importance and mode of action is enumerated below:

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#'''General plan of treatment'''- The patient should be admitted in the hospital for administration of therapeutic emesis and purgation procedures. Before application of these cleansing procedures, the patient should undergo some pre-therapeutic procedures such as ''[[langhana]]-[[pachana]]'' (restricted diet and improving digestion), ''[[snehana]]'' (oleation) and ''[[swedana]]'' (sudation). Their importance and mode of action is enumerated below:

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##''Langhana-pachana'':

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##''[[Langhana]]-[[pachana]]'':

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###''Langhana'' (light diet and exercise)-

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###''[[Langhana]]'' (light diet and exercise)-

[[File:Langhana.png]]

*In the modern world, there is increased food consumption, especially the consumption of junk food that cause increased stress on our metabolism. The normal human body has sufficient capabilities to remove most metabolic toxins if upawasa (fasts) are observed periodically. These fastings help “clear the backlog” of excess strain put on our bodily systems, quite like the way an office clerk clears his backlog of work on a specific day when there is no new work. An ''upavasa'' (fasting) is a custom that helps make people abstain from heavy meals. While light aerobic exercises are very good in expelling toxins accumulated in the body by way of sweating and calorie consumption, fastings help provide relief to our digestive systems.

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###''Pachana'' (Digestants):

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###''[[Pachana]]'' (Digestants):

[[File:Pachana- Digestants.png]]

*Digestants or digestives help in aiding the process of digestion and metabolism in our bodies.

*They aid in the digestion of ama[undigested intestinal products and intermediate metabolites] already present in the body.

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##''Snehana'':

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##''[[Snehana]]'':

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###''Snehapana''- Unctuous agents or fats that make dosha slimy, moist, slippery and work as solvents:

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###''Snehapana''- Unctuous agents or fats that make [[dosha]] slimy, moist, slippery and work as solvents:

[[File:Snehapana.png]]

*Use of fats as a solvent: There are two types of solvent in biochemistry - polar and non-polar. Among polar solvents, water is the best while among non-polar solvents, ketones (intermediate metabolic products of fats) are the best solvents. These solvents, during their course of internal administration, may react with cellular and metabolic debris and convert them into a soluble form that could be easily excreted out through urine, faeces or sweat by means of [[Panchakarma]] procedures.

*Use of fats as a high energy substance-Oils and fats yield 9 KCal energy in contrast to 4.5 Kcal from carbohydrates and proteins, which could be expended as a substitute or replacement source of energy during purification procedure.

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##''Swedana''- As discussed earlier, ''swedana'' helps liquefy sticky ''dosha'' within our bodies and opens the orifices of circulatory channels (''srotas''), while facilitating the process of dissolving of harmful ~~doshas~~ before they are ejected out through the gut by means of subsequence therapies.

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##''[[Swedana]]''- As discussed earlier, ''[[swedana]]'' helps liquefy sticky ''[[dosha]]'' within our bodies and opens the orifices of circulatory channels (''srotas''), while facilitating the process of dissolving of harmful [[dosha]]s before they are ejected out through the gut by means of subsequence therapies.

*''Abhyanga'' (massage) – The recommended method of massage involves employing pounding and thumping-like action similar to that employed in washing of cloths, for better removal of impurities.

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*''Swedana'' (heat) – it is the application of heat (either dry or wet) on the external body surface to remove ''ama'' and ''mala'' from the body. Just as cleaning is more effective with warm water, similarly removal of ''ama, dosha'' and ''mala'' is easier with fomentation or applying heat to the body.

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*''Swedana'' (heat) – it is the application of heat (either dry or wet) on the external body surface to remove ''ama'' and ''[[mala]]'' from the body. Just as cleaning is more effective with warm water, similarly removal of ''ama, [[dosha]]'' and ''[[mala]]'' is easier with fomentation or applying heat to the body.

[[File:Swedana.png]]

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4.Vamana karma-

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4.[[Vamana]] karma-

After proper purvakarma (or pre-purification activities), key purification procedures such as therapeutic emesis are administered to the patient, using substances such as madanaphala along with honey, rock salt, phanita (jaggery) and the powder of madhuka.

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Benefits of vamana karma (therapeutic emesis): Vamana karma is a procedure indicated for the removal of toxins, especially kapha-pitta dosha situated in the upper part of gut. Vamana is done before virechana karma because if virechana is administered before vamana, the provoked kapha descends downwards to grahani [duodenum part and site of agni] and covers it, resulting in a feeling of heaviness and indigestion. The vamana procedure is initiated with a dose of decoction of madanphala mixed with honey, madhuka, rock salt and phanita. Madanphala is a widely used medicine for therapeutic emesis due to its potency. All other ingredients aid in the process of emesis and removal of toxins. Rock salt has the potential to carry drugs to microchannels and increase secretions to expel out toxins. [9-10]

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Benefits of [[vamana]] karma (therapeutic emesis): [[Vamana]] karma is a procedure indicated for the removal of toxins, especially [[kapha]]-[[pitta]] [[dosha]] situated in the upper part of gut. [[Vamana]] is done before [[virechana]] karma because if [[virechana]] is administered before [[vamana]], the provoked [[kapha]] descends downwards to grahani [duodenum part and site of agni] and covers it, resulting in a feeling of heaviness and indigestion. The [[vamana]] procedure is initiated with a dose of decoction of madanphala mixed with honey, madhuka, rock salt and phanita. Madanphala is a widely used medicine for therapeutic emesis due to its potency. All other ingredients aid in the process of emesis and removal of toxins. Rock salt has the potential to carry drugs to microchannels and increase secretions to expel out toxins. [9-10]

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It is necessary to clinically assess movement of dosha from shakha (peripheral tissues) to the koshtha (gut) to expel the vitiated dosha from the body. Symptoms and signs of each stage are as follows:

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It is necessary to clinically assess movement of [[dosha]] from shakha (peripheral tissues) to the koshtha (gut) to expel the vitiated [[dosha]] from the body. Symptoms and signs of each stage are as follows:

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a. Appearance of sweating indicates liquification of dosha due to ushna (hot) and teekshna (strongly acting) properties of the drugs mentioned above. In this process, any morbid matter present in the system is fragmented and then expelled.

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a. Appearance of sweating indicates liquification of [[dosha]] due to ushna (hot) and teekshna (strongly acting) properties of the drugs mentioned above. In this process, any morbid matter present in the system is fragmented and then expelled.

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b. Pilling of hair (horripilation) indicates the movement of dosha towards amashaya (stomach), again caused due to the ushna (hot) property of the medication. The dosha elements detach and move towards the koshtha, from where these morbid elements get ejected out of the body through channels in the periphery.

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b. Pilling of hair (horripilation) indicates the movement of [[dosha]] towards amashaya (stomach), again caused due to the ushna (hot) property of the medication. The [[dosha]] elements detach and move towards the koshtha, from where these morbid elements get ejected out of the body through channels in the periphery.

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c. Abdominal discomfort is a sign of dosha entering into the amashaya (stomach).

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c. Abdominal discomfort is a sign of [[dosha]] entering into the amashaya (stomach).

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d. Nausea, salivation and pain in the chest indicate that the ~~doshas~~ are on the verge of being expelled out through the mouth. [11]

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d. Nausea, salivation and pain in the chest indicate that the [[dosha]]s are on the verge of being expelled out through the mouth. [11]

Signs of inadequate emesis:

Inadequate emesis may be caused due to hard bowel (krura koshtha), excessive accumulation of toxins, inadequate quantity of medicine, or if the dosha are less excited (anutklishta) owing to improper pre-procedures of oleation and sudation, or if the patient has increased appetite (deeptagni).

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F. Samsarjana karma [The rehabilitative post therapeutic diet]:

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It is necessary to restore the strength of agni and prana (vitality) after administering any therapeutic procedure. A sequential order of various dietary recipes prepared from rice and green gram should be followed. Vamana process mainly takes place in amashaya, which is the site for kledaka kapha, pachaka pitta and saman vayu. These are the prime factors that control all processes in this part of the gastro-intestinal tract. During the process of vamana, potent emetics stimulate the udan vayu and provoke expulsion of toxins through the mouth. At the end of emesis, the digestive power is weakened and so is the strength of the patient. Therefore in order to provide nourishment and restore proper digestive capabilities in the patient, a regimen that is easy to digest and rich in nutritive value is prescribed - for seven days (in case of good strong emesis), for five days (in moderate emesis), and three days (in mild emesis). This differs according to the frequency of taking meals. [16]

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It is necessary to restore the strength of agni and prana (vitality) after administering any therapeutic procedure. A sequential order of various dietary recipes prepared from rice and green gram should be followed. [[Vamana]] process mainly takes place in amashaya, which is the site for kledaka [[kapha]], pachaka [[pitta]] and saman vayu. These are the prime factors that control all processes in this part of the gastro-intestinal tract. During the process of [[vamana]], potent emetics stimulate the udan vayu and provoke expulsion of toxins through the mouth. At the end of emesis, the digestive power is weakened and so is the strength of the patient. Therefore in order to provide nourishment and restore proper digestive capabilities in the patient, a regimen that is easy to digest and rich in nutritive value is prescribed - for seven days (in case of good strong emesis), for five days (in moderate emesis), and three days (in mild emesis). This differs according to the frequency of taking meals. [16]

The diet can be started on same day of purification therapy after taking bath. At first, the patient should be given lukewarm gruel prepared with shali (rice). This gruel should be very thin (manda) in nature, no spices are added to it. The quantity is to be given according to the digestive power of the patient. This is repeated for 2nd and 3rd meal time. Now a days people eat usually 3 times a day inspite of 2 times as advocated in [[Ayurveda]]. Hence a regimen with two meal times is quite insufficient and people always feel hungry; so we should redesign our diet schedule and plan according to three meal times per day. Thereafter the diet became thick rice like vilepi with salt and little spices as per taste for next three meal times. Then yusha (very thin soup of green gram) added with unctuous substance like ghee/oil, salt and above mentioned rice should be given for next 3 consecutive meal times. From the 10th meal time, meat soup should be given with rice, but for a vegetarian person it should be replaced by khichari, thin and thick. Thereafter the patient should be advised to take his normal diet from 7th night onwards.

The preparation of diet recipes is as below:

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| rowspan="1" style="text-align: left;" | 1

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| rowspan="1" style="text-align: left;" | ''vamana/ virechana''

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| rowspan="1" style="text-align: left;" | ''[[vamana]]/ [[virechana]]''

| rowspan="1" style="text-align: left;" | No diet

| rowspan="1" style="text-align: left;" | Rice + 14 times water cook it, sieve it and drink the water part only

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====Virechana karma [therapeutic purgation]:====

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====[[Virechana]] karma [therapeutic purgation]:====

G. After completion of the post therapeutic dietetic program, the pre-therapeutic procedures like oleation and sudation should be administered again for therapeutic purgation. All the procedures should be similar to therapeutic emesis except medicated smoking. It is not done after purgation.

Eganeesh

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