Virechana

• The process of expulsion of precipitated and vitiated Dosha through the lower parts of the body (G.I. tract {Anus}) by induction of Virechaneeya drug is calledVirechana .
• Depending upon the Dosha combination,different types of Virechana are used to eradicate the disorders and to establish equilibrium.e.g. Sramsana (Mridu Virechana) with Aaragvadha(Cassia fistula)is the lineof management in Vaata Dosha situated in Pitta Sthaana .
• Bhedana / Rechana: Teekshn`a Virechana with Snuk Paya( latex of Euphorbia nerifolia) is useful in Kapha Dosha situated in Pitta Sthaana.

Sub Type As per Efficacy/Material Used:

• Mridu Virechana: – It is a type of purgation in which the stools / excreta is expelled in small quantity without damaging Pureeshadharaa Kalaa e.g. Aaragvadha
• Sukha Virechana: – It is a type of purgation in which after improving agni function stools / excreta is expelled without any straining eg. Trivrita
• Teekshn`a Virechana : It is a type of purgation in which the stools / excreta is expelled with drastic impulse eg. Danti , Snuk Paya Ref. C. Su. 25/40 .
• Snigdha Virechana: – ( unctuous) purgation eg.Eran`d`a Sneha ( castor oil / Ricinus communis )
• Rooksha Virechana: – ( dry ) purgation eg. Hareetakee (Terminalia chebula ) C. Chi. 6/9, S. Chi. 33/41.

Description: Kaala/Vaya/Ahoraatra/ Ritu/Bhukta:

• This procedure is the first choice for management of Pitta prominent disorders and a seasonal regime in S`harada Ritu when there is natural tendency of aggravation and vitiation of Pitta. C. Su. 6/44, C.Su. 26/40
• Virechana is induced just after the end of Kapha Kaala . A H. Su.18/33
• In condition of depleted (Alpa) Kapha Dosha status, Virechana is induced properly.
• In case of aggravated condition of Kapha if Virechana is induced it can cause emesis; therefore the purgation is given to the patient in fasting condition.
• Virechana should be induced on the 15^th day after Vamana.

1. Su.15/16 ( Chakrapaan`ee)

Poorvakarma :

1. If Virechana is to be induced , the patient should undergo oleation as per indication/ disease internal as well as external Snehana for 7 days in gradually increasing dose.
2. Svedana: Sudation as per indication/disease. Saarvadehika Svedana is advised for 7 days so that the Dosha get liquified and enter Kosht`ha.
3. Prior to Virechana if the patient has undergone emesis then there should be gap of 2 days after Samsarjana Krama is completed. when patient starts having normal diet, he should be given Snehana (external and internal) again for next 4 days. Then external oleation (Abhyanga ) and appropriate Svedana for rest 3 days.
4. 3 days rest period is indicated prior to Virechana .During these days the patient should be given a diet which is adjuvant to purgation which is having following qualities. Unctuous, liquid, lukewarm, like sour fruit juiceor meat soup. The diet should be such that it does not increase Kapha Dosha. C. Su.15/13
5. If Svedana is contraindicated in any condition of the patient then after Snehana the above mentioned food regime is advised for rest period of 3 days.
6. Selection of appropriate and suitable time for purgation.

Instrument checklist:

Purgative Drugs, Bed , Bedpans (Pratigraha) , Macintosh , Measuring instruments, Lab for checking stool, Fragrant scents ( natural) , Containers for medicines, Emergency medication for management of Atiyoga and Vyaapad, Cloths for patients and Apron and mask for Vaidya. In a case of Ayoga Basti yantra and Vamana (emetics) medicines.

Patient preparation:

• Pre procedural counselling shoud be done to maintain good psychological status.
• Examination of patient for Arhataa / digestion status of prior day and Das`havidha Parikshaa
• Examining the Dosha for signs of Utklesha and their entry in the Kosht`ha.
• Examination for signs of adequate Snehana and Svedana.
• Prior to Virechana the patient should be asked to drink lukewarm water and juice of Beejapoora (Citrus medica) S. Chi. 33/20

Pradhaanakarma:

• The suitable Virechana medicine should be administered in the morning three hours after sunrise.

• After induction the purgative drug, due to intolerable smell and taste, there may be an evidence of vomiting. So to avoid this, after the administration of the drug cold water should be sprinkled over patients face and the patient should be advised gargles with lukewarm water.
• Also fresh and sour fruits like Jambeera (Citrus medica) should be smelled and the patient should rest for a while.
• For continuous purgation lukewarm water should be given continuously.
• Due to this Vaataanulomana occurs and the patient can pass the stool in lying position without straining.
• If drugs like Jayapaala yoga are to be used then cold water should be administered after that for continuous purgation. (Due to lukewarm water the oil contents in those medicines will get washed off and proper effect wont be achieved.)
• In adequate Virechana first the stools Pitta Kapha Vaata are chronologically expelled.
• To maintain continuous purgative effect lukewarm water or cold water should be administered continuously and Svedana should be applied over abdomen (Kosht`ha)by warming hands of Vaidya / Parichaaraka A. S. Su. 27/31
• The bouts containing stools should be ignored and only bouts containing Dosha counted.
• The S`huddhi type should be decided considering the Vegiki, Antiki, Maaniki and Laingiki Parikshaa.

4 .Laingiki : Expulsion of urine stools Pitta medicine Kapha in sequential order .

For each Vega, Utsarjita Mala should be collected in separate pan and examined for Maatraa, Varn`a and Gandha. C. Si. 1/16, S. Chi. 33/23-24

• Contact of cold water should be avoided (externally and internally) during the procedure.

Paschaatkarma :

• When the Virechana Vega stop and the desired results of Samyak Yoga are obtained the patient should rest for a while.
• The patient should avoid following things immediately after purgation

o Speaking loudly.

o Excessive intake of food.

o Sitting for a long time.

o Excessive walking.

o Expressing grief or anger

o Exposure to cold air.

o Excessive travelling on fast moving vehicle.

o Sexual Intercourse

o Keeping awake late night.

o Sleeping at day time

o Viruddha Bhojana

o Withholding natural urges . H.S. kasture pp 346

• Samsarjana Krama Diet administration should be according to the Samsarjana Krama. During S`hodhana lot of fluid is lost leading to diminished function of Agni. This has to be gradually replenished, the sequence is known as Samsarjana Krama.
• S`hamana Aushadha and Tarpan`a should be administered in patients in whom Alpa S`hodhana is acquired. Same should be administered in patients with Kapha Pitta Praadhaanya and in alcoholic patients.
• If Nirooha Basti is to be planned it is to be administered on the 9^th day or 7^th day.

Samyak Yoga:

• Sroto S`huddhi (Clears Srotas{channels of the body })
• Kukshi S`huddhi( Cleansing of Kosht`ha(G.I. tract ) )
• Hrid-S`huddhi
• Indriya Parsaadana (Improvement in the functioning of sensory and motor organs )
• Indriya Urjaa Praapti ( Imparts energy to sensory and motor organs)
• S`hareera & Naabhee Laghutaa ( Sensation of lightness in body and umbilical region )
• Agni Deepti ( Increases the Agni function )
• Vatanulomana ( Ensures proper movement of Vaata in its normal course and direction)
• Anaammayatva ( Prevents occurrence of diseases i.e. imparts healthy status )

Heenayoga:

• Kapha Parakopa
• Pitta Prakopa
• Vaata Prakopa (Vitiation of three Dosha )
• Agnimaandya (Decreased intensity of Agni.)
• Gaurava (Sensation of heaviness )
• Partis`hyaaya ( Coryza with thick mucus secretion)
• Tandraa ( Sleepiness )
• Chhardi (Vomiting )
• Pid`ik`aa ( Boils )
• Aruchi (Decreased perception of taste )
• Vaata Partilomataa(Reversal of Vaata due to obstruction of its normal movement )
• Daaha (Burning sensation )
• Hrit Kukshi As`huddhi (Filthy sensation in of Kosht`ha and heart )
• Kan`d`oo (Pruritus)
• Vit`sanga (Constipation)
• Mootra sanga (Retention and decreased output of urine )

Vyapad:

• Aadhmaana ( Flatulence )
• Parikarta ( Cutting sensation in anal region )
• Parisraava ( Oozing of the excreta )
• Hridgraha ( Tightness sensation in cardiac region )
• Gaatra Graha ( Stiffness in gatra { organs } )
• Anga Graha ( Stiffness sensation of body )
• Jeevaadana ( Per rectal bleeding- frank blood with or without stools )
• Vibrams`ha ( Rectal Prolapse )
• Stambha (Stiffness )
• Upadrava ( Complications )
• Klama ( Exhaustion/fatigue )
• Vamana (Emesis of purgative drug due to its intensity it causes upward movement of g.i.tract causing emesis )
• Saavas`heshaushadhatva ( Complications due to residual drug effect )
• Jeern`aaushadhatva ( Complications due to digested drug effect )
• HeenaDoshaaparhitatva ( Incomplete expulsion of Dosha )
• Vaata S`hoola
• Hridyaopsaaran`a ( Effect of drug inferring cardiac function.)
• Vibandha (Constipation )

Atiyoga:

• Vaata kshaya
• Pitta Kshaya
• Kapha Kshaya( Deterioration in the function of Tridosha )
• Klama ( Exhaustion / fatigue )
• Kampa ( Tremors )
• Nidraa ( Sleep)
• Daurbalya ( Debility )
• Tama Praves`ha ( Syncope )
• Unmaada ( Insanity )
• Hikkaa ( Hiccough )
• Moorchchhaa (Fainting )
• Guda Brams`ha ( Prolapse of the rectum )
• S`hoola ( Pain )
• Nis`hleshma Pittam Udakam S`hvetam Krishn`am Salohitam Atinissaran`am
• Excessive expulsion of Udaka ( Water not containing S`hleshma and Pitta and which is white, black or blood red in colour.)
• Maamsa Dhaavana Tulya Nissaran`a ( Expulsion of Udaka which resembles to water in which meat is washed.)
• Meda Khan`d`aabha Nissaran`a ( Expulsion of Udaka which resembles Meda Dhaatu which is fragmented. Watery stool may contain pieces of fat or fat globules.)

Other Description:

• Virechana therapy is indicated for Pittasthaanaashrita Vyaadhi.
• In Kaashyapa Siddhi Sthaana it is mentioned that Virechana enhances the activity of S`hukra Dhaatvagni.
• Sneha Virechana should be administered in Vaataja Abhishyanda and Adhimantha Netra Roga.
• After S`hastrakarma or Agni and Kshaarakarma over Vartmaars`ha, S`hushkaars`ha (Netra Roga) and Arbuda Netra Roga Virechana should be induced to eliminate the S`hesha Dosha.
• Snigdha Virechana is indicated in Klaibya and Dhvajabhangaja Klaibya.

Dose decision should be made as per the indication:

The age limit of the dosage is from the 20 to 50 years

1 tolaa = 10 grams; 1 ratti = 125 mg (S.G. Uttara Khanda 4/18, 19)

Vamana (Emesis)

• The process of inducing forceful and complete elimination of Apakva Pitta and Kapha by emetic medication.

Description:Kaala/Vaya/Ahoraatra/Ritu/Bhukta

• Emesis should be induced in spring season by Teekshn`a (intense) drugs for a healthy person as a preventive measure. A H. Su. 3/18
• The actual emesis should be induced in the forenoon in a moderate season.

Poorvakarma (Prerequisites):

Instrument Checklist:

• Paatra, Vastra Khan`d`a, Pratigraha, Measuring Glass

Patient Preparation:

• Fomentation and oleation should be administered.
• The patient should be advised to take head bath.
• Dose of the emetic drug should be decided according to the Vyaadhibala, Kosht`ha, Des`ha, Vaya and Kaala. According to Charaka Madanaphala Pippali should be given in amount of Antarnakha Musht`i Pramaan`a (fist full). According to Sus`hruta the dose of the decoction should be 10-20 Tolaa, that of Choorn`a or Kalkashould be 1 Tolaa.
• Abhyantara Snehapaana (internal oleation), Abhyanga (external oleation) and fomentation should be administered for 3 days. Internal oleation should always beSalavan`a (added with rock salt).Then only external oleation and fomentation should be applied for next 3 days (The day of completion of internal oleation, Vis`hraama Dina and the morning of Vamana day.)
• Patient counselling and efforts should be done to maintain good mental health.
• Patient should be asked to consume Kapha precipitating diet (like fish, black gram, sesame) on the previous night of emesis. He should be asked to consume Peyaa, Yavaagu, Ghee or only milk on the morning of emesis.

Pradhaanakarma

• The patient should sit on a chair of height equal to knee (Vamana Peet`ha). The chair should have a comfortable back so that the patient can rest in between two bouts.
• The patient should be covered with a clean white cloth up to his neck. The patient should be asked to consume the prescribed Vaamaka medicine. There are three methods of consuming this.

o Consuming food items like milk, curd, meat soup etc medicated with pro-emetic drugs.

o First consuming above mentioned food items and then consuming pro-emetic drugs.

o Consuming decoction of Yasht`eemadhu etc added with pro-emetic drugs.

• Following Mantra should be chanted while consumption of the emetic drug.

• After consumption of medicine the physician should foment patients face, chest, and back with warm hands (made by heating).
• Then one should wait for one Muhoorta (48 min) for the first bout.
• When the perspiration occurs over forehead it is the sign of moving, liquefied and upcoming Dosha.
• When Romaharsha appears it is the sign of movement of Dosha towards the alimentary canal.
• When there is increase of salivary secretions inside mouth it is the sign of movement of Dosha towards mouth. The patient should be asked to vomit inside the container kept in front of the patient. If emesis doesnt occur then the patient should be asked to induce emesis by inserting his finger or any blunt tube like structure inside throat. If this doesnt induce emesis then again Madanaphala Yoga should be administered with honey.
• The assistant should stand behind the patient and should massage the patient from below upwards on back. He should hold his hands over patients temporal region tightly.
• The physician should monitor following things during the procedure

o Pulse

o Blood pressure

o Heart rate

o Respiration rate and quality

o The bouts should be examined according to quantity, sounds, properties and taste Very small quantity of emetic material and expulsion with loud noise is a sign of aggravation of Vaata Dosha. Slimy and fibrous emetic material is a sign of aggravation of Kapha Dosha. The colour of the emetic drug should be kept in mind while accessing the Doshaprakopa according to colour of the emetic material. Appearance of red coloured material in emetic material is a sign of bleeding and emesis should be stopped immediately. Knowing the taste inside the patients mouth also helps to understand the Doshaprakopa. Patients abdomen should be palpated frequently during the procedure.

• The signs of adequate emesis should be accessed according to following chart

Laingiki Parikshaa Expulsion of Praseka emetic drug Kapha and then Pitta in a sequential manner.

Pas`hchaatkarma

• The patient should be cleaned after adequate emesis and then advised to rest for 48 minutes.
• Dhoomapaana (medicated smoking) This helps to decrease the sliminess inside throat and oral cavity. Due to this the throat, nose and channels situated in upper part of the body get cleaned.
• The patient should be advised to avoid following things immediately after emesis

o Uchcha Bhaashan`a (talking in high pitch)

o Atyas`hana (consuming food frequently and in large quantity)

o Ati Chankraman`a (extensive walking)

o Krodha (anger)

o S`hoka (grieving)

o Hima (contact with cold)

o Aatapa Sevana (exposure to sunrays)

o Yaanayaana (travelling on a fast moving vehicle)

o Pravaata Sevana (exposure to air or fan)

o Graamyadharma (indulgence in sexual activity)

o Divaasvaapa (sleeping in day time)

o Atisthaana (sitting in one position for along time)

o Avas`hyaaya (avoid dew)

o Nis`hi Asvapana (not sleeping at night)

o Viruddhaas`hana (consuming incompatible food items)

o Ajeern`aas`hana (consuming food before the previous meal is digested)

o Asaatmya Bhojana

o Pramitaas`hana (eating food in very small quantity)

o Heena, Guru and Vishama Bhojana

o Vega Sandhaaran`a (withholding natural urges)

o Vega Udeeran`a (provoking natural urges)

• Diet should be administered according to the Sansarjana Krama from the evening of emesis.
• In the absence of adequate emesis Santarpan`a should be administered instead of Sansarjana Krama.
• If Virechana is to be administered after Vamana then Snehapaana should be started from the 9^th day after emesis.

Other Information:

• This procedure is indicated in Utsanna Maamsayukta S`hotha and Dusht`a S`hyaama Varn`yukta Rakta containing Vran`a.
• After S`hastrakarma or Agni and Kshaarakarma over Vartmaars`ha, S`hushkaars`ha (Netra Roga) and Arbuda Netra Roga Vamana should be induced to eliminate theS`hesha Dosha.