Upakalpaniya Adhyaya

Sutra Sthana Chapter 15. Guidelines for Hospital Management and Purification Treatment

Abstract :

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.

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

Upakalpaniya Adhyaya

Section/Chapter	Sutra Sthana Chapter 15
Tetrad/Sub-section	Kalpana Chatushka
Preceding Chapter	Swedadhyaya
Succeeding Chapter	Chikitsaprabhritiya Adhyaya
Other Sections	Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana

Introduction

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. 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.

Sanskrit text, Transliteration and English Translation

अथात उपकल्पनीयमध्यायं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

athāta upakalpanīyamadhyāyaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

athAta upakalpanIyamadhyAyaM vyAkhyAsyAmaH||1||

iti ha smAha bhagavAnAtreyaH||2||

Now we shall expound the chapter "upakalpaneeya" (Guidelines for Hospital Management and Purification Treatment). Thus said Lord Atreya.[1-2]

Guidelines for physicians before commencing treatment

इह खलु राजानं राजमात्रमन्यं वा विपुलद्रव्यं वमनं विरेचनं वा पाययितुकामेन भिषजा प्रागेवौषधपानात् सम्भारा उपकल्पनीयाभवन्ति सम्यक्चैव हि गच्छत्यौषधे प्रतिभोगार्थाः, व्यापन्ने चौषधे व्यापदः परिसङ्ख्याय प्रतीकारार्थाः; न हि सन्निकृष्टे कालेप्रादुर्भूतायामापदि सत्यपि क्रयाक्रये सुकरमाशु सम्भरणमौषधानां यथावदिति||३||

iha khalu rājānaṁ rājamātramanyaṁ vā vipuladravyaṁ Vamanaṁ virēcanaṁ vā pāyayitukāmēna bhiṣajāprāgēvauṣadhapānāt sambhārā upakalpanīyā bhavanti samyakcaiva hi gacchatyauṣadhē pratibhōgārthāḥ,vyāpannē cauṣadhē vyāpadaḥ parisaṅkhyāya pratīkārārthāḥ; na hi sannikr̥ṣṭē kālē prādurbhūtāyāmāpadisatyapi krayākrayē sukaramāśu sambharaṇamauṣadhānāṁ yathāvaditi||3|| iha khalu rAjAnaM rAjamAtramanyaM vA vipuladravyaM VamanaM virecanaM vA pAyayitukAmena bhiShajAprAgevauShadhapAnAt sambhArA upakalpanIyA bhavanti samyakcaiva hi gacchatyauShadhepratibhogArthAH, vyApanne cauShadhe vyApadaH parisa~gkhyAya pratIkArArthAH; na hi sannikRuShTekAle prAdurbhUtAyAmApadi satyapi krayAkraye sukaramAshu sambharaNamauShadhAnAMyathAvaditi||3||

A physician willing to administer various purification therapies, especially to a king, royalty or a wealthy person, should arrange various necessary drugs and equipments well in advance of the procedures and know correct administration of counter-acting drugs in case of complications. Because, in case of emergency, if complications occur, it is not possible to easily and immediately arrange drugs through sale or import. [3]

Query by Agnivesha about success of treatment

एवंवादिनं भगवन्तमात्रेयमग्निवेश उवाच- ननु भगवन्! आदावेव ज्ञानवता तथा प्रतिविधातव्यं यथा प्रतिविहितेसिध्येदेवौषधमेकान्तेन, सम्यक्प्रयोगनिमित्ता हि सर्वकर्मणां सिद्धिरिष्टा, व्यापच्चासम्यक्प्रयोगनिमित्ता; अथसम्यगसम्यक् च समारब्धं कर्म सिद्ध्यति व्यापद्यते वाऽनियमेन, तुल्यं भवति ज्ञानमज्ञानेनेति||४||

ēvaṁvādinaṁ bhagavantamātrēyamagnivēśa uvāca- nanu bhagavan! ādāvēva jñānavatā tathāpratividhātavyaṁ yathā prativihitē sidhyēdēvauṣadhamēkāntēna, samyakprayōganimittā hisarvakarmaṇāṁ siddhiriṣṭā, vyāpaccāsamyakprayōganimittā; atha samyagasamyak ca samārabdhaṁkarma siddhyati vyāpadyatē vā'niyamēna, tulyaṁ bhavati jñānamajñānēnēti||4||

evaMvAdinaM bhagavantamAtreyamagnivesha uvAca- nanu bhagavan! AdAveva j~jAnavatA tathApratividhAtavyaM yathA prativihite sidhyedevauShadhamekAntena, samyakprayoganimittA hisarvakarmaNAM siddhiriShTA, vyApaccAsamyakprayoganimittA; atha samyagasamyak ca samArabdhaMkarma siddhyati vyApadyate vA~aniyamena, tulyaM bhavati j~jAnamaj~jAneneti||4||

When Lord Atreya said this, Agnivesha said, “O Lord! A learned physician should prescribe a treatment in such a way that it should surely and invariably be successful. The success of all treatments depends upon proper administration and complications due to improper administration. However, sometimes, the success or failure of treatment doesn’t follow the rules of proper or improper administration, hence knowledge and ignorance becomes equal.” [4]

Reply by Atreya

तमुवाच भगवानात्रेयः- शक्यं तथा प्रतिविधातुमस्माभिरस्मद्विधैर्वाऽप्यग्निवे श! यथा प्रतिविहिते सिध्येदेवौषधमेकान्तेन,तच्च प्रयोगसौष्ठवमुपदेष्टुं यथावत्; नहि कश्चिदस्ति य एतदेवमुपदिष्टमुपधारयितुमुत्सहेत, उपधार्य वा तथा प्रतिपत्तुंप्रयोक्तुं वा; सूक्ष्माणि हि दोषभेषजदेशकालबलशरीराहारसात्म्यसत्त्वप्रकृतिवयसामवस्थान्तराणि, यान्यनुचिन्त्यमानानिविमलविपुलबुद्धेरपि बुद्धिमाकुलीकुर्युः किं पुनरल्पबुद्धेः; तस्मादुभयमेतद्यथावदुपदेक्ष्यामः- सम्यक्प्रयोगं चौषधानां,व्यापन्नानां च व्यापत्साधनानि सिद्धिषूत्तरकालम्||५||

tamuvāca bhagavānātrēyaḥ- śakyaṁ tathā pratividhātumasmābhirasmadvidhairvā'pyagnivēśa! yathāprativihitē sidhyēdēvauṣadhamēkāntēna, tacca prayōgasauṣṭhavamupadēṣṭuṁ yathāvat; nahi kaścidastiya ētadēvamupadiṣṭamupadhārayitumutsahēta, upadhārya vā tathā pratipattuṁ prayōktuṁ vā; sūkṣmāṇihi dōṣabhēṣajadēśakālabalaśarīrāhārasātmyasattvaprakr̥tivayasāmavasthāntarāṇi, yānyanucintyamānānivimalavipulabuddhērapi buddhimākulīkuryuḥ kiṁ punaralpabuddhēḥ;tasmādubhayamētadyathāvadupadēkṣyāmaḥ- samyakprayōgaṁ cauṣadhānāṁ, vyāpannānāṁ cavyāpatsādhanāni siddhiṣūttarakālam||5||

tamuvAca bhagavAnAtreyaH- shakyaM tathA pratividhAtumasmAbhirasmadvidhairvA~apyagnivesha!yathA prativihite sidhyedevauShadhamekAntena, tacca prayogasauShThavamupadeShTuM yathAvat; nahikashcidasti ya etadevamupadiShTamupadhArayitumutsaheta, upadhArya vA tathA pratipattuM prayoktuMvA; sUkShmANi hidoShabheShajadeshakAlabalasharIrAhArasAtmyasattvaprakRutivayasAmavasthAntarANi,yAnyanucintyamAnAni vimalavipulabuddherapi buddhimAkulIkuryuH kiM punaralpabuddheH; tasmAdubhayametadyathAvadupadekShyAmaH- samyakprayogaM cauShadhAnAM, vyApannAnAM cavyApatsAdhanAni siddhiShUttarakAlam||5||

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

इदानीं तावत् सम्भारान् विविधानपि समासेनोपदेक्ष्यामः; तद्यथा- दृढं निवातं प्रवातैकदेशं सुखप्रविचारमनुपत्यकंधूमातपजलरजसामनभिगमनीयमनिष्ठानां च शब्दस्पर्शरसरूपगन्धानां सोदपानोदूखलमुसलवर्चःस्थानस्नानभूमिमहानसंवास्तुविद्याकुशलः प्रशस्तं गृहमेव तावत् पूर्वमुपकल्पयेत्||६||

idānīṁ tāvat sambhārān vividhānapi samāsēnōpadēkṣyāmaḥ; tadyathā- dr̥ḍhaṁ nivātaṁ pravātaikadēśaṁsukhapravicāramanupatyakaṁ dhūmātapajalarajasāmanabhigamanīyamaniṣṭhānāṁ caśabdasparśarasarūpagandhānāṁ sōdapānōdūkhalamusalavarcaḥsthānasnānabhūmimahānasaṁvāstuvidyākuśalaḥ praśastaṁ gr̥hamēva tāvat pūrvamupakalpayēt||6||

idAnIM tAvat sambhArAn vividhAnapi samAsenopadekShyAmaH; tadyathA- dRuDhaM nivAtaMpravAtaikadeshaM sukhapravicAramanupatyakaM dhUmAtapajalarajasAmanabhigamanIyamaniShThAnAMca shabdasparsharasarUpagandhAnAM sodapAnodUkhalamusalavarcaHsthAnasnAnabhUmimahAnasaMvAstuvidyAkushalaH prashastaM gRuhameva tAvat pUrvamupakalpayet||6||

Until then, we will briefly describe various pre-requisites recommended for administering purification therapies. First of all, an architect should search for a spacious building that is well-built, with good ventilation, comfortable moving space, located at a distance from other big buildings, free from harmful smoke, excessive light, dust, moisture, undesirable noise, scenes, touch, taste and smell. It should consist of basic amenities such as access to water, sanitation (lavatory and bathroom) and a kitchen with mortar-pestle[6]

Arrangements for hospital staff and accessories

ततः शीलशौचाचारानुरागदाक्ष्यप्रादक्षिण्योपपन्नानुपचारकुशलान् सर्वकर्मसु पर्यवदातान्सूपौदनपाचकस्नापकसंवाहकोत्थापकसंवेशकौषधपेषकांश्च परिचारकान् सर्वकर्मस्वप्रतिकूलान्, तथागीतवादित्रोल्लापकश्लोकगाथाख्यायिकेतिहासपुराणकुशलानभिप्रायज्ञाननुमतांश्च देशकालविदः पारिषद्यांश्च, तथालावकपिञ्जिलशशहरिणैणकालपुच्छकमृगमातृकोरभ्रान्, गां दोग्ध्रीं शीलवतीमनातुरां जीवद्वत्सांसुप्रतिविहिततृणशरणपानीयां, पात्र्याचमनीयोदकोष्ठमणिकघटपिठरपर्योगकुम्भीकुम्भकुण्डशराव-दर्वीकटोदञ्चनपरिपचनमन्थानचर्मचेलसूत्रकार्पासोर्णादीनि च, शयनासनादीनि चोपन्यस्तभृङ्गारप्रतिग्रहाणिसुप्रयुक्तास्तरणोत्तरप्रच्छदोपधानानि सोपाश्रयाणि [१]संवेशनोपवेशनस्नेहस्वेदाभ्यङ्गप्रदेहपरिषेकानुलेपनवमनविरेचनास्थापनानुवासन-शिरोविरेचनमूत्रोच्चारकर्मणामुपचारसुखानि, सुप्रक्षालितोपधानाश्च सुश्लक्ष्णखरमध्यमा दृषदः, शस्त्राणि चोपकरणार्थानि,धूमनेत्रं च, बस्तिनेत्रं चोत्तरबस्तिकं च, कुशहस्तकं च, तुलां च, मानभाण्डं च,घृततैलवसामज्जक्षौद्रफाणितलवणेन्धनोदकमधुसीधुसुरासौवीरकतुषोदक- मैरेयमेदकदधिदधिमण्डोदस्विद्धान्याम्लमूत्राणिच, तथा शालिषष्टिकमुद्गमाषयवतिलकुलत्थबदरमृद्वीकाकाश्मर्यपरूषकाभयामलकबिभीतकानि, नानाविधानि चस्नेहस्वेदोपकरणानि द्रव्याणि, तथैवोर्ध्वहरानुलोमिकोभयभाञ्जि,सङ्ग्रहणीयदीपनीयपाचनीयोपशमनीयवातहरादिसमाख्यातानि चौषधानि; यच्चान्यदपि किञ्चिह्यापदः परिसङ्ख्यायप्रतीकारार्थमुपकरणं विद्यात्, यच्च प्रतिभोगार्थं, तत्तदुपकल्पयेत्||७||

tataḥ śīlaśaucācārānurāgadākṣyaprādakṣiṇyōpapannānupacārakuśalān sarvakarmasu paryavadātānsūpaudanapācakasnāpakasaṁvāhakōtthāpakasaṁvēśakauṣadhapēṣakāṁśca paricārakānsarvakarmasvapratikūlān, tathāgītavāditrōllāpakaślōkagāthākhyāyikētihāsapurāṇakuśalānabhiprāyajñānanumatāṁśca dēśakālavidaḥpāriṣadyāṁśca, tathā lāvakapiñjilaśaśahariṇaiṇakālapucchakamr̥gamātr̥kōrabhrān, gāṁ dōgdhrīṁśīlavatīmanāturāṁ jīvadvatsāṁ suprativihitatr̥ṇaśaraṇapānīyāṁ,pātryācamanīyōdakōṣṭhamaṇikaghaṭapiṭharaparyōgakumbhīkumbhakuṇḍaśarāva-darvīkaṭōdañcanaparipacanamanthānacarmacēlasūtrakārpāsōrṇādīni ca, śayanāsanādīnicōpanyastabhr̥ṅgārapratigrahāṇi suprayuktāstaraṇōttarapracchadōpadhānāni sōpāśrayāṇi [1] saṁvēśanōpavēśanasnēhasvēdābhyaṅgapradēhapariṣēkānulēpanaVamanavirēcanāsthāpanānuvāsana-śirōvirēcanamūtrōccārakarmaṇāmupacārasukhāni, suprakṣālitōpadhānāśca suślakṣṇakharamadhyamādr̥ṣadaḥ, śastrāṇi cōpakaraṇārthāni, dhūmanētraṁ ca, bastinētraṁ cōttarabastikaṁ ca, kuśahastakaṁ ca,tulāṁ ca, mānabhāṇḍaṁ ca,ghr̥tatailavasāmajjakṣaudraphāṇitalavaṇēndhanōdakamadhusīdhusurāsauvīrakatuṣōdaka-mairēyamēdakadadhidadhimaṇḍōdasviddhānyāmlamūtrāṇi ca, tathāśāliṣaṣṭikamudgamāṣayavatilakulatthabadaramr̥dvīkākāśmaryaparūṣakābhayāmalakabibhītakāni,nānāvidhāni ca snēhasvēdōpakaraṇāni dravyāṇi, tathaivōrdhvaharānulōmikōbhayabhāñji,saṅgrahaṇīyadīpanīyapācanīyōpaśamanīyavātaharādisamākhyātāni cauṣadhāni; yaccānyadapikiñcihyāpadaḥ parisaṅkhyāya pratīkārārthamupakaraṇaṁ vidyāt, yacca pratibhōgārthaṁ,tattadupakalpayēt||7||

tataH shIlashaucAcArAnurAgadAkShyaprAdakShiNyopapannAnupacArakushalAn sarvakarmasu paryavadAtAnsUpaudanapAcakasnApakasaMvAhakotthApakasaMveshakauShadhapeShakAMshca paricArakAnsarvakarmasvapratikUlAn, tathAgItavAditrollApakashlokagAthAkhyAyiketihAsapurANakushalAnabhiprAyaj~jAnanumatAMshca deshakAlavidaHpAriShadyAMshca, tathA lAvakapi~jjilashashahariNaiNakAlapucchakamRugamAtRukorabhrAn, gAM dogdhrIMshIlavatImanAturAM jIvadvatsAM suprativihitatRuNasharaNapAnIyAM,pAtryAcamanIyodakoShThamaNikaghaTapiTharaparyogakumbhIkumbhakuNDasharAva-darvIkaToda~jcanaparipacanamanthAnacarmacelasUtrakArpAsorNAdIni ca, shayanAsanAdInicopanyastabhRu~ggArapratigrahANi suprayuktAstaraNottarapracchadopadhAnAni sopAshrayANi [1]saMveshanopaveshanasnehasvedAbhya~ggapradehapariShekAnulepanaVamanavirecanAsthApanAnuvAsana-shirovirecanamUtroccArakarmaNAmupacArasukhAni, suprakShAlitopadhAnAshcasushlakShNakharamadhyamA dRuShadaH, shastrANi copakaraNArthAni, dhUmanetraM ca, bastinetraMcottarabastikaM ca, kushahastakaM ca, tulAM ca, mAnabhANDaM ca,ghRutatailavasAmajjakShaudraphANitalavaNendhanodakamadhusIdhusurAsauvIrakatuShodaka-maireyamedakadadhidadhimaNDodasviddhAnyAmlamUtrANi ca, tathAshAliShaShTikamudgamAShayavatilakulatthabadaramRudvIkAkAshmaryaparUShakAbhayAmalakabibhItakAni,nAnAvidhAni ca snehasvedopakaraNAni dravyANi, tathaivordhvaharAnulomikobhayabhA~jji,sa~ggrahaNIyadIpanIyapAcanIyopashamanIyavAtaharAdisamAkhyAtAni cauShadhAni; yaccAnyadapiki~jcihyApadaH parisa~gkhyAya pratIkArArthamupakaraNaM vidyAt, yacca pratibhogArthaM,tattadupakalpayet||7||

After setting up the hospital building, the following accessories should be kept ready:

1. Attending staff: Staff with good conduct, hygiene, character, devotion, dexterity, compassion, and with proficiency in nursing and administering therapies should be appointed. They should be skilled in cooking soups, rice, giving baths, massage, in handling (bed-ridden) patients, and also in formulating (grinding, etc.) medicines. The staff should be willing to do all duties.
2. Other staff: People well-versed with singing, playing musical instruments, panegyrics, recitation of verses, ancient lores, short stories, itihasa (history), purana (ancient spiritual texts), who are quick learners, who are obedient, and who have good knowledge of time and place should be appointed.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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]

Preparation of patient before therapeutic emesis

ततस्तं पुरुषं यथोक्ताभ्यां स्नेहस्वेदाभ्यां यथार्हमुपपादयेत्, तं चेदस्मिन्नन्तरे मानसः शारीरो वा व्याधिः कश्चित्तीव्रतरःसहसाऽभ्यागच्छेत्तमेव तावदस्योपावर्तयितुं [१] यतेत, ततस्तमुपावर्त्य तावन्तमेवैनं कालं तथाविधेनैव कर्मणोपाचरेत्||८|| ततस्तं पुरुषं स्नेहस्वेदोपपन्नमनुपहतमनसमभिसमीक्ष्य सुखोषितं सुप्रजीर्णभक्तं शिरःस्नातमनुलिप्तगात्रंस्रग्विणमनुपहतवस्त्रसंवीतं देवताग्निद्विजगुरुवृद्धवैद्यानर्चितवन्तमिष्टे नक्षत्रतिथिकरणमुहूर्ते कारयित्वा ब्राह्मणान्स्वस्तिवाचनं प्रयुक्ताभिराशीर्भिरभिमन्त्रितां मधुमधुकसैन्धवफाणितोपहितां मदनफलकषायमात्रां पाययेत्||९||

tatastaṁ puruṣaṁ yathōktābhyāṁ snēhasvēdābhyāṁ yathārhamupapādayēt, taṁ cēdasminnantarēmānasaḥ śārīrō vā vyādhiḥ kaścittīvrataraḥ sahasā'bhyāgacchēttamēva tāvadasyōpāvartayituṁ [1] yatēta,tatastamupāvartya tāvantamēvainaṁ kālaṁ tathāvidhēnaiva karmaṇōpācarēt||8|| tatastaṁ puruṣaṁ snēhasvēdōpapannamanupahatamanasamabhisamīkṣya sukhōṣitaṁ suprajīrṇabhaktaṁśiraḥsnātamanuliptagātraṁ sragviṇamanupahatavastrasaṁvītaṁdēvatāgnidvijaguruvr̥ddhavaidyānarcitavantamiṣṭē nakṣatratithikaraṇamuhūrtē kārayitvā brāhmaṇānsvastivācanaṁ prayuktābhirāśīrbhirabhimantritāṁ madhumadhukasaindhavaphāṇitōpahitāṁmadanaphalakaṣāyamātrāṁ pāyayēt||9||

tatastaM puruShaM yathoktAbhyAM snehasvedAbhyAM yathArhamupapAdayet, taM cedasminnantaremAnasaH shArIro vA vyAdhiH kashcittIvrataraH sahasA~abhyAgacchettameva tAvadasyopAvartayituM [1]yateta, tatastamupAvartya tAvantamevainaM kAlaM tathAvidhenaiva karmaNopAcaret||8|| tatastaM puruShaM snehasvedopapannamanupahatamanasamabhisamIkShya sukhoShitaMsuprajIrNabhaktaM shiraHsnAtamanuliptagAtraM sragviNamanupahatavastrasaMvItaMdevatAgnidvijaguruvRuddhavaidyAnarcitavantamiShTe nakShatratithikaraNamuhUrte kArayitvAbrAhmaNAn svastivAcanaM prayuktAbhirAshIrbhirabhimantritAMmadhumadhukasaindhavaphANitopahitAM madanaphalakaShAyamAtrAM pAyayet||9||

Thereafter, patients are to be admitted to the hospital and treated by means of oleation and fomentation therapies as required. If an acute and serious psychological or somatic disease occurs during the course of this treatment, the physician should treat it first. Even after curing it, the same treatment should be continued for an equivalent duration.[8]

When the physician is assured of successful administration of oleation and fomentation therapies and on ensuring that the patient’s mind is normal, that he has slept well, the food taken by him is well-digested, has taken full bath, his body well anointed, that he has worn a garland and untorn clean clothes, and that he has offered worship to the God, fire, Brahmin, mentors, elderly persons and the physician, Brahmins should be requested to recite auspicious chants and bestow their blessings on the patient on an auspicious day with favorable nakshatra (constellation), date, karana and muhurta (these terms are of astrological importance). Thereafter, the physician should administer a dose of the decoction of the fruit of madanaphala (Randia dumenorum Lam.) along with honey, rock-salt, phanita (a preparation of sugar cane juice) and the powder of madhuka (Glycyrrhiza glabra Linn.).[9]

Procedure of therapeutic emesis

मदनफलकषायमात्राप्रमाणं तु खलु सर्वसंशोधनमात्राप्रमाणानि च प्रतिपुरुषमपेक्षितव्यानि भवन्ति; यावद्धि यस्य संशोधनं पीतंवैकारिकदोषहरणायोपपद्यते न चातियोगायोगाय, तावदस्य मात्राप्रमाणं वेदितव्यं भवति||१०|| पीतवन्तं तु खल्वेनं मुहूर्तमनुकाङ्क्षेत, तस्य यदा जानीयात् स्वेदप्रादुर्भावेण दोषं प्रविलयनमापद्यमानं, लोमहर्षेण चस्थानेभ्यः प्रचलितं, कुक्षिसमाध्मापनेन च कुक्षिमनुगतं, हृल्लासास्यस्रवणाभ्यामपि चोर्ध्वमुखीभूतम्, अथास्मैजानुसममसम्बाधं सुप्रयुक्तास्तरणोत्तरप्रच्छदोपधानं सोपाश्रयमासनमुपवेष्टुं प्रयच्छेत्, प्रतिग्रहांश्चोपचारयेत्,लालाटप्रतिग्रहे पार्श्वोपग्रहणे नाभिप्रपीडने पृष्ठोन्मर्दने चानपत्रपणीयाः सुहृदोऽनुमताः प्रयतेरन्||११||

madanaphalakaṣāyamātrāpramāṇaṁ tu khalu sarvasaṁśōdhanamātrāpramāṇāni capratipuruṣamapēkṣitavyāni bhavanti; yāvaddhi yasya saṁśōdhanaṁ pītaṁvaikārikadōṣaharaṇāyōpapadyatē na cātiyōgāyōgāya, tāvadasya mātrāpramāṇaṁ vēditavyaṁbhavati||10||

pītavantaṁ tu khalvēnaṁ muhūrtamanukāṅkṣēta, tasya yadā jānīyāt svēdaprādurbhāvēṇa dōṣaṁpravilayanamāpadyamānaṁ, lōmaharṣēṇa ca sthānēbhyaḥ pracalitaṁ, kukṣisamādhmāpanēna cakukṣimanugataṁ, hr̥llāsāsyasravaṇābhyāmapi cōrdhvamukhībhūtam, athāsmai jānusamamasambādhaṁsuprayuktāstaraṇōttarapracchadōpadhānaṁ sōpāśrayamāsanamupavēṣṭuṁ prayacchēt,pratigrahāṁścōpacārayēt, lālāṭapratigrahē pārśvōpagrahaṇē nābhiprapīḍanē pr̥ṣṭhōnmardanēcānapatrapaṇīyāḥ suhr̥dō'numatāḥ prayatēran||11||

madanaphalakaShAyamAtrApramANaM tu khalu sarvasaMshodhanamAtrApramANAni capratipuruShamapekShitavyAni bhavanti; yAvaddhi yasya saMshodhanaM pItaMvaikArikadoShaharaNAyopapadyate na cAtiyogAyogAya, tAvadasya mAtrApramANaM veditavyaMbhavati||10||

pItavantaM tu khalvenaM muhUrtamanukA~gkSheta, tasya yadA jAnIyAt svedaprAdurbhAveNa doShaMpravilayanamApadyamAnaM, lomaharSheNa ca sthAnebhyaH pracalitaM, kukShisamAdhmApanena cakukShimanugataM, hRullAsAsyasravaNAbhyAmapi cordhvamukhIbhUtam, athAsmaijAnusamamasambAdhaM suprayuktAstaraNottarapracchadopadhAnaM sopAshrayamAsanamupaveShTuM prayacchet, pratigrahAMshcopacArayet, lAlATapratigrahe pArshvopagrahaNe nAbhiprapIDanepRuShThonmardane cAnapatrapaNIyAH suhRudo~anumatAH prayateran||11||

Dose of emetics

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

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]

Instructions to patient during procedure

अथैनमनुशिष्यात्- विवृतोष्ठतालुकण्ठो नातिमहता व्यायामेन वेगानुदीर्णानुदीरयन् किञ्चिदवनम्यग्रीवामूर्ध्वशरीरमुपवेगमप्रवृत्तान् प्रवर्तयन् सुपरिलिखितनखाभ्यामङ्गुलिभ्यामुत्पलकुमुदसौगन्धिकनालैर्वा कण्ठमभिस्पृशन्सुखं प्रवर्तयस्वेति, स तथाविधं कुर्यात्; ततोऽस्य वेगान् प्रतिग्रहगतानवेक्षेतावहितः, वेगविशेषदर्शनाद्धि कुशलोयोगायोगातियोगविशेषानुपलभेत, वेगविशेषदर्शी पुनः कृत्यं यथार्हमवबुध्येत लक्षणेन; तस्माद्वेगानवेक्षेतावहितः||१२||

athainamanuśiṣyāt- vivr̥tōṣṭhatālukaṇṭhō nātimahatā vyāyāmēna vēgānudīrṇānudīrayan kiñcidavanamyagrīvāmūrdhvaśarīramupavēgamapravr̥ttān pravartayansuparilikhitanakhābhyāmaṅgulibhyāmutpalakumudasaugandhikanālairvā kaṇṭhamabhispr̥śan sukhaṁpravartayasvēti, sa tathāvidhaṁ kuryāt; tatō'sya vēgān pratigrahagatānavēkṣētāvahitaḥ,vēgaviśēṣadarśanāddhi kuśalō yōgāyōgātiyōgaviśēṣānupalabhēta, vēgaviśēṣadarśī punaḥ kr̥tyaṁyathārhamavabudhyēta lakṣaṇēna; tasmādvēgānavēkṣētāvahitaḥ||12||

athainamanushiShyAt- vivRutoShThatAlukaNTho nAtimahatA vyAyAmena vegAnudIrNAnudIrayanki~jcidavanamya grIvAmUrdhvasharIramupavegamapravRuttAn pravartayansuparilikhitanakhAbhyAma~ggulibhyAmutpalakumudasaugandhikanAlairvA kaNThamabhispRushansukhaM pravartayasveti, sa tathAvidhaM kuryAt; tato~asya vegAn pratigrahagatAnavekShetAvahitaH,vegavisheShadarshanAddhi kushalo yogAyogAtiyogavisheShAnupalabheta, vegavisheShadarshI punaHkRutyaM yathArhamavabudhyeta lakShaNena; tasmAdvegAnavekShetAvahitaH||12||

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]

The signs of proper and improper emesis procedure

तत्रामून्ययोगयोगातियोगविशेषज्ञानानि भवन्ति; तद्यथा- अप्रवृत्तिः कुतश्चित् केवलस्य वाऽप्यौषधस्य विभ्रंशो विबन्धोवेगानामयोगलक्षणानि भवन्ति; काले प्रवृत्तिरनतिमहती व्यथा यथाक्रमं दोषहरणं स्वयं चावस्थानमिति योगलक्षणानिभवन्ति, योगेन तु दोषप्रमाणविशेषेण तीक्ष्णमृदुमध्यविभागो ज्ञेयः; योगाधिक्येन तुफेनिलरक्तचन्द्रिकोपगमनमित्यतियोगलक्षणानि भवन्ति| तत्रातियोगायोगनिमित्तानिमानुपद्रवान् विद्यात्- आध्मानं परिकर्तिका परिस्रावो हृदयोपसरणमङ्गग्रहो जीवादानं विभ्रंशःस्तम्भः क्लमश्चेत्युपद्रवाः||१३||

tatrāmūnyayōgayōgātiyōgaviśēṣajñānāni bhavanti; tadyathā- apravr̥ttiḥ kutaścit kēvalasyavā'pyauṣadhasya vibhraṁśō vibandhō vēgānāmayōgalakṣaṇāni bhavanti; kālē pravr̥ttiranatimahatī vyathāyathākramaṁ dōṣaharaṇaṁ svayaṁ cāvasthānamiti yōgalakṣaṇāni bhavanti, yōgēna tudōṣapramāṇaviśēṣēṇa tīkṣṇamr̥dumadhyavibhāgō jñēyaḥ; yōgādhikyēna tuphēnilaraktacandrikōpagamanamityatiyōgalakṣaṇāni bhavanti| tatrātiyōgāyōganimittānimānupadravān vidyāt- ādhmānaṁ parikartikā parisrāvōhr̥dayōpasaraṇamaṅgagrahō jīvādānaṁ vibhraṁśaḥ stambhaḥ klamaścētyupadravāḥ||13|

tatrAmUnyayogayogAtiyogavisheShaj~jAnAni bhavanti; tadyathA- apravRuttiH kutashcit kevalasyavA~apyauShadhasya vibhraMsho vibandho vegAnAmayogalakShaNAni bhavanti; kAlepravRuttiranatimahatI vyathA yathAkramaM doShaharaNaM svayaM cAvasthAnamiti yogalakShaNAnibhavanti, yogena tu doShapramANavisheSheNa tIkShNamRudumadhyavibhAgo j~jeyaH; yogAdhikyena tuphenilaraktacandrikopagamanamityatiyogalakShaNAni bhavanti| tatrAtiyogAyoganimittAnimAnupadravAn vidyAt- AdhmAnaM parikartikA parisrAvohRudayopasaraNama~ggagraho jIvAdAnaM vibhraMshaH stambhaH klamashcetyupadravAH||13||

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]

Post procedure instructions

योगेन तु खल्वेनं छर्दितवन्तमभिसमीक्ष्य सुप्रक्षालितपाणिपादास्यं मुहूर्तमाश्वास्य, स्नैहिकवैरेचनिकोपशमनीयानांधूमानामन्यतमं सामर्थ्यतः पाययित्वा, पुनरेवोदकमुपस्पर्शयेत्||१४|| उपस्पृष्टोदकं चैनं निवातमागारमनुप्रवेश्य संवेश्य चानुशिष्यात्- उच्चैर्भाष्यमत्याशनमतिस्थानमतिचङ्क्रमणंक्रोधशोकहिमातपावश्यायातिप्रवातान् यानयानं ग्राम्यधर्ममस्वपनं निशि दिवा स्वप्नंविरुद्धाजीर्णासात्म्याकालप्रमितातिहीनगुरुविषमभोजनवेगसन्धारणोदीरणमिति भावानेतान्मनसाऽप्यसेवमानः सर्वमहोगमयस्वेति | स तथा कुर्यात्||१५||

yōgēna tu khalvēnaṁ charditavantamabhisamīkṣya suprakṣālitapāṇipādāsyaṁ muhūrtamāśvāsya,snaihikavairēcanikōpaśamanīyānāṁ dhūmānāmanyatamaṁ sāmarthyataḥ pāyayitvā,punarēvōdakamupasparśayēt||14||

upaspr̥ṣṭōdakaṁ cainaṁ nivātamāgāramanupravēśya saṁvēśya cānuśiṣyāt-uccairbhāṣyamatyāśanamatisthānamaticaṅkramaṇaṁ krōdhaśōkahimātapāvaśyāyātipravātān yānayānaṁgrāmyadharmamasvapanaṁ niśi divā svapnaṁviruddhājīrṇāsātmyākālapramitātihīnaguruviṣamabhōjanavēgasandhāraṇōdīraṇamitibhāvānētānmanasā'pyasēvamānaḥ sarvamahō gamayasvēti | sa tathā kuryāt||15||

yogena tu khalvenaM charditavantamabhisamIkShya suprakShAlitapANipAdAsyaM muhUrtamAshvAsya,snaihikavairecanikopashamanIyAnAM dhUmAnAmanyatamaM sAmarthyataH pAyayitvA,punarevodakamupasparshayet||14||

upaspRuShTodakaM cainaM nivAtamAgAramanupraveshya saMveshya cAnushiShyAt-uccairbhAShyamatyAshanamatisthAnamatica~gkramaNaM krodhashokahimAtapAvashyAyAtipravAtAnyAnayAnaM grAmyadharmamasvapanaM nishi divA svapnaMviruddhAjIrNAsAtmyAkAlapramitAtihInaguruviShamabhojanavegasandhAraNodIraNamitibhAvAnetAnmanasA~apyaseVamanaH sarvamaho gamayasveti | sa tathA kuryAt||15||

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]

Rehabilitation diet after purification

अथैनं सायाह्ने परे वाऽह्नि सुखोदकपरिषिक्तं पुराणानां लोहितशालितण्डुलानां स्ववक्लिन्नां मण्डपूर्वां सुखोष्णां यवागूंपाययेदग्निबलमभिसमीक्ष्य, एवं द्वितीये तृतीये चान्नकाले, चतुर्थे त्वन्नकाले तथाविधानामेव शालितण्डुलानामुत्स्विन्नांविलेपीमुष्णोदकद्वितीयामस्नेहलवणामल्पस्नेहलवणां वा भोजयेत्, एवं पञ्चमे षष्ठे चान्नकाले, सप्तमे त्वन्नकालेतथाविधानामेव शालीनां द्विप्रसृतं सुस्विन्नमोदनमुष्णोदकानुपानं तनुना तनुस्नेहलवणोपपन्नेन मुद्गयूषेण भोजयेत्,एवमष्टमे नवमे चान्नकाले, दशमे त्वन्नकले लावकपिञ्जलादीनामन्यतमस्य मांसरसेनौदकलावणिकेन नातिसारवताभोजयेदुष्णोदकानुपानम्; एवमेकादशे द्वादशे चान्नकाले; अत ऊर्ध्वमन्नगुणान् क्रमेणोपभुञ्जानः सप्तरात्रेणप्रकृतिभोजनमागच्छेत्||१६||

athainaṁ sāyāhnē parē vā'hni sukhōdakapariṣiktaṁ purāṇānāṁ lōhitaśālitaṇḍulānāṁ svavaklinnāṁmaṇḍapūrvāṁ sukhōṣṇāṁ yavāgūṁ pāyayēdagnibalamabhisamīkṣya, ēvaṁ dvitīyē tr̥tīyē cānnakālē,caturthē tvannakālē tathāvidhānāmēva śālitaṇḍulānāmutsvinnāṁvilēpīmuṣṇōdakadvitīyāmasnēhalavaṇāmalpasnēhalavaṇāṁ vā bhōjayēt, ēvaṁ pañcamē ṣaṣṭhēcānnakālē, saptamē tvannakālē tathāvidhānāmēva śālīnāṁ dviprasr̥taṁsusvinnamōdanamuṣṇōdakānupānaṁ tanunā tanusnēhalavaṇōpapannēna mudgayūṣēṇa bhōjayēt,ēvamaṣṭamē navamē cānnakālē, daśamē tvannakalē lāvakapiñjalādīnāmanyatamasyamāṁsarasēnaudakalāvaṇikēna nātisāravatā bhōjayēduṣṇōdakānupānam; ēvamēkādaśē dvādaśēcānnakālē; ata ūrdhVamananaguṇān kramēṇōpabhuñjānaḥ saptarātrēṇa prakr̥tibhōjanamāgacchēt||16||

athainaM sAyAhne pare vA~ahni sukhodakapariShiktaM purANAnAM lohitashAlitaNDulAnAM svavaklinnAMmaNDapUrvAM sukhoShNAM yavAgUM pAyayedagnibalamabhisamIkShya, evaM dvitIye tRutIyecAnnakAle, caturthe tvannakAle tathAvidhAnAmeva shAlitaNDulAnAmutsvinnAMvilepImuShNodakadvitIyAmasnehalavaNAmalpasnehalavaNAM vA bhojayet, evaM pa~jcame ShaShThecAnnakAle, saptame tvannakAle tathAvidhAnAmeva shAlInAM dviprasRutaMsusvinnamodanamuShNodakAnupAnaM tanunA tanusnehalavaNopapannena mudgayUSheNa bhojayet,evamaShTame navame cAnnakAle, dashame tvannakale lAvakapi~jjalAdInAmanyatamasyamAMsarasenaudakalAvaNikena nAtisAravatA bhojayeduShNodakAnupAnam; evamekAdashe dvAdashecAnnakAle; ata UrdhVamananaguNAn krameNopabhu~jjAnaH saptarAtreNaprakRutibhojanamAgacchet||16||

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.

First, Second and Third meal

His first meal should consist of a lukewarm gruel (manda) prepared with an old, red variety of shali rice (Oryza sativa Linn.), well cooked with fourteen times water by volume. The gruel should be very thin and liquid, taking into consideration the weakened digestive power of the patient. It should be repeated for the second and third meal.

Fourth, Fifth and Sixth meal

For the fourth meal, a gruel (vilepi) prepared with four times water by volume and with red shali rice, well cooked, warm and without unctuous substance or salt, or with a small quantity of unctuous substance and salt should be given. Warm water is to be taken after the intake of gruel. The same type of diet is to be continued for the fifth and sixth meal.

Seventh, Eighth and Ninth meal

For the seventh meal again, well cooked rice (odana) prepared with red shali rice of two prasrita (approximately 160 gram) along with a very thin soup of mudga ( green gram, Phaseolus mungo Lines.) , added with a small quantity of unctuous substance and salt should be given. Warm water should be given to the patient after his consuming the porridge. The same diet is to be repeated for the eighth and the ninth meal.

Tenth, Eleventh and Twelth meal

For the tenth meal, a thin meat soup of common quail, grey partridge etc., prepared with water and salt should be given. Warm water is to be taken after this. This is again to be repeated for the eleventh and twelth meal. Thereafter, the patient should take food having different tastes and should start taking his normal diet from the seventh night. [16]

Procedure of virechana (therapeutic purgation)

अथैनं पुनरेव स्नेहस्वेदाभ्यामुपपाद्यानुपहतमनसमभिसमीक्ष्य सुखोषितं सुप्रजीर्णभक्तंकृतहोमबलिमङ्गलजपप्रायश्चित्तमिष्टे तिथिनक्षत्रकरणमुहूर्ते ब्राह्मणान् स्वस्ति वाचयित्वा त्रिवृत्कल्कमक्षमात्रंयथार्हालोडनप्रतिविनीतं पाययेत् प्रसमीक्ष्य दोषभेषजदेशकालबलशरीराहारसात्म्यसत्त्वप्रकृतिवयसामवस्थान्तराणिविकारांश्च, सम्यक् विरिक्तं चैनं वमनोक्तेन धूमवर्जेन विधिनोपपादयेदाबलवर्णप्रकृतिलाभात्, बलवर्णोपपन्नंचैनमनुपहतमनसमभिसमीक्ष्य सुखोषितं सुप्रजीर्णभक्तं शिरःस्नातमनुलिप्तगात्रंस्रग्विणमनुपहतवस्त्रसंवीतमनुरूपालङ्कारालङ्कृतं सुहृदां दर्शयित्वा ज्ञातीनां दर्शयेत्, अथैनं कामेष्ववसृजेत्||१७||

भवन्ति चात्र- अनेन विधिना राजा राजमात्रोऽथवा पुनः| यस्य वा विपुलं द्रव्यं स संशोधनमर्हति||१८||

athainaṁ punarēva snēhasvēdābhyāmupapādyānupahatamanasamabhisamīkṣya sukhōṣitaṁsuprajīrṇabhaktaṁ kr̥tahōmabalimaṅgalajapaprāyaścittamiṣṭē tithinakṣatrakaraṇamuhūrtē brāhmaṇānsvasti vācayitvā trivr̥tkalkamakṣamātraṁ yathārhālōḍanaprativinītaṁ pāyayēt prasamīkṣyadōṣabhēṣajadēśakālabalaśarīrāhārasātmyasattvaprakr̥tivayasāmavasthāntarāṇi vikārāṁśca, samyakviriktaṁ cainaṁ Vamanaōktēna dhūmavarjēna vidhinōpapādayēdābalavarṇaprakr̥tilābhāt,balavarṇōpapannaṁ cainamanupahatamanasamabhisamīkṣya sukhōṣitaṁ suprajīrṇabhaktaṁśiraḥsnātamanuliptagātraṁ sragviṇamanupahatavastrasaṁvītamanurūpālaṅkārālaṅkr̥taṁ suhr̥dāṁdarśayitvā jñātīnāṁ darśayēt, athainaṁ kāmēṣvavasr̥jēt||17||

bhavanti cātra- anēna vidhinā rājā rājamātrō'thavā punaḥ| yasya vā vipulaṁ dravyaṁ sa saṁśōdhanamarhati||18||

athainaM punareva snehasvedAbhyAmupapAdyAnupahatamanasamabhisamIkShya sukhoShitaMsuprajIrNabhaktaM kRutahomabalima~ggalajapaprAyashcittamiShTe tithinakShatrakaraNamuhUrtebrAhmaNAn svasti vAcayitvA trivRutkalkamakShamAtraM yathArhAloDanaprativinItaM pAyayetprasamIkShya doShabheShajadeshakAlabalasharIrAhArasAtmyasattvaprakRutivayasAmavasthAntarANivikArAMshca, samyak viriktaM cainaM Vamanaoktena dhUmavarjenavidhinopapAdayedAbalavarNaprakRutilAbhAt, balavarNopapannaMcainamanupahatamanasamabhisamIkShya sukhoShitaM suprajIrNabhaktaM shiraHsnAtamanuliptagAtraMsragviNamanupahatavastrasaMvItamanurUpAla~gkArAla~gkRutaM suhRudAM darshayitvA j~jAtInAMdarshayet, athainaM kAmeShvavasRujet||17||

bhavanti cAtra- anena vidhinA rAjA rAjamAtro~athavA punaH| yasya vA vipulaM dravyaM sa saMshodhanamarhati||18||

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]

दरिद्रस्त्वापदं प्राप्य प्राप्तकालं विशोधनम्| पिबेत् काममसम्भृत्य सम्भारानपि दुर्लभान्||१९||

न हि सर्वमनुष्याणां सन्ति सर्वे परिच्छदाः| न च रोगा न बाधन्ते दरिद्रानपि दारुणाः||२०||

यद्यच्छक्यं मनुष्येण कर्तुमौषधमापदि| तत्तत् सेव्यं यथाशक्ति वसनान्यशनानि च||२१||

daridrastvāpadaṁ prāpya prāptakālaṁ viśōdhanam| pibēt kāmamasambhr̥tya sambhārānapi durlabhān||19||

na hi sarVamanauṣyāṇāṁ santi sarvē paricchadāḥ| na ca rōgā na bādhantē daridrānapi dāruṇāḥ||20||

yadyacchakyaṁ manuṣyēṇa kartumauṣadhamāpadi| tattat sēvyaṁ yathāśakti vasanānyaśanāni ca||21||

daridrastvApadaM prApya prAptakAlaM vishodhanam| pibet kAmamasambhRutya sambhArAnapi durlabhAn||19||

na hi sarVamanauShyANAM santi sarve paricchadAH| na ca rogA na bAdhante daridrAnapi dAruNAH||20||

yadyacchakyaM manuShyeNa kartumauShadhamApadi| tattat sevyaM yathAshakti vasanAnyashanAni ca||21||

In case of any disorder requiring purification therapy, poor people can be prescribed the medication without being made to collect all the rare equipment. Because common people cannot afford to have all the recommended resources arranged, but because they can also suffer from the severe nature of the disease, emergency provisions, including drugs, cloths, and food articles should be made easily available and accessible to the patients. [19-21]

Benefits of purification therapy

मलापहं रोगहरं बलवर्णप्रसादनम्| पीत्वा संशोधन सम्यगायुषा युज्यते चिरम्||२२||

malāpahaṁ rōgaharaṁ balavarṇaprasādanam| pītvā saṁśōdhana samyagāyuṣā yujyatē ciram||22||

malApahaM rogaharaM balavarNaprasAdanam| pItvA saMshodhana samyagAyuShA yujyate ciram||22||

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

Summary

तत्र श्लोकाः- ईश्वराणां वसुमतां वमनं सविरेचनम्| सम्भारा ये यदर्थं च समानीय प्रयोजयेत्||२३||

यथा प्रयोज्या मात्रा या यदयोगस्य लक्षणम्| योगातियोगयोर्यच्च दोषा ये चाप्युपद्रवाः||२४||

यदसेव्यं विशुद्धेन यश्च संसर्जनक्रमः| तत् सर्वं कल्पनाध्याये व्याजहार पुनर्वसुः||२५||

tatra ślōkāḥ- īśvarāṇāṁ vasumatāṁ Vamanaṁ savirēcanam| sambhārā yē yadarthaṁ ca samānīya prayōjayēt||23||

yathā prayōjyā mātrā yā yadayōgasya lakṣaṇam| yōgātiyōgayōryacca dōṣā yē cāpyupadravāḥ||24||

yadasēvyaṁ viśuddhēna yaśca saṁsarjanakramaḥ| tat sarvaṁ kalpanādhyāyē vyājahāra punarvasuḥ||25||

tatra shlokAH- IshvarANAM vasumatAM VamanaM savirecanam| sambhArA ye yadarthaM ca samAnIya prayojayet||23||

yathA prayojyA mAtrA yA yadayogasya lakShaNam| yogAtiyogayoryacca doShA ye cApyupadravAH||24||

yadasevyaM vishuddhena yashca saMsarjanakramaH| tat sarvaM kalpanAdhyAye vyAjahAra punarvasuH||25||

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]

इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते श्लोकस्थाने उपकल्पनीयो नाम पञ्चदशोऽध्यायः||१५||

ityagnivēśakr̥tē tantrē carakapratisaṁskr̥tē ślōkasthānē upakalpanīyō nāma pañcadaśō'dhyāyaḥ||15||

ityagniveshakRute tantre carakapratisaMskRute shlokasthAne upakalpanIyo nAmapa~jcadasho~adhyAyaH||15||

Thus ends the fifteenth chapter on “Prerequisites for therapeutic (Panchakarma) treatment” of Sutra Sthana , of Agnivesha’s work as redacted by Charak.

Tattva Vimarsha (Fundamental Principles)

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

Vidhi Vimarsha (Applied Inferences)

Construction of a hospital

1. A well equipped facility with the following recommended criteria is needed for various ayurvedic purification treatments:
   1. Location- An architect should design the building on a site not situated in a hilly terrain nor located near a bigger building but located on a clean, sunny, flat surface near a water reservoir.
   2. Facilities- The building should have all the necessary facilities for indoor patients, with good source for light, water, ventilation, kitchen, and sanitation (toilet, bath, etc).
   3. 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.
   4. 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 Ayurveda Ayurveda. Today, hospices or healthcare services providers arrange for televisions and music system in the rooms of patients.
   5. 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.
2. 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:
   1. Langhana-pachana:
      1. Langhana (light diet and exercise)-

• 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.

1. 1. 1. Pachana (Digestants):

• 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.

1. 1. Snehana:
      1. Snehapana- Unctuous agents or fats that make dosha slimy, moist, slippery and work as solvents:

• 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.

1. 1. 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.

• 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.
• 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.

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. 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] 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: 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. 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. c. Abdominal discomfort is a sign of dosha entering into the amashaya (stomach). d. Nausea, salivation and pain in the chest indicate that the doshas 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). Signs of excess emesis: Excessive emesis (atiyoga) causes the appearance of blood-mixed, foamy vomitus. This might be due to tender status of gut (mridu koshtha), overdose of medicine, and/or decreased strength of the patient. 5. Dhumapana: After completion of emesis, the patient is advised to take rest and inhale one of three types of smoke: oleated, purgative or therapeutic, depending upon the condition of the patient. After smoking, the patient is advised to not indulge in speaking out loud, standing for prolonged periods of time, walking for long, or supression of natural urges.

F. Samsarjana karma [The rehabilitative post therapeutic diet]: 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: a. Peya/ Yavagu: Rice in lesser quantity with more water (1 part rice :14 times water) b. Vilepi: 1/4th amount rice and water with pinch of rock salt and oil (1 part rice :4 times water) c. Akrita Yusha: Soup of green gram [mudga yusha] with odana [rice] without unctuous substance and salt (1 part rice : four times water) d. Krita yusha: Soup of green gram [mudga yusha] with odana [rice] with unctuous substance and salt (1 part rice : four times water) e. Mamsarasa: Meat juice of lava, kapinjala, ena, harina with rice.

Type of emesis	Episodes of vomiting	Meals per day	Total days for completion of diet regimen
Mild	4	2	3
Moderate	6	2	3
Strong	8	8	7

Five day diet schedule for post therapeutic regimen in case of moderate therapeutic emesis:

Day	Morning	Noon	Night
1	vamana/ virechana	No diet	Rice + 14 times water cook it, sieve it and drink the water part only
2	Rice + 14 times water cook it, sieve it and drink the water part only	Rice + 14 times water cook it, sieve it and drink the water part only	Rice + 4 times water cook it, add salt and jeera powder
3	Rice + 4 times water cook it, add salt and jeera powder	Rice + 4 times water cook it, add salt and jeera powder	Mudga pulse + 4 times water cook it and drink it with above mentioned rice.
4	Mudga pulse + 4 times water cook it and drink it with above mentioned rice.	Mudga pulse + 4 times water cook it and fry it with oil and drink it with above mentioned rice.	Meat soup and above mentioned rice or for a vegetarian person thin Khichari
5	Meat soup and above mentioned rice or thin Khichari	Meat soup and above mentioned rice or thick Khichari	Normal meal

Justification of diet:

S. No.	Recipe	Food composition
1	Peya, Vilepi	Carbohydrate
2	Yusha	Protein
3	Mamsa rasa	Fat

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.