Virechana

The word ‘vireka’ or ‘virechana’ means purging or evacuation. It is one of the five purification procedures (panchakarma). Virechana is the best treatment to expel the vitiated pitta dosha.[Cha.Sa.Sutra Sthana 25/40] This procedure is indicated for therapeutic purpose. The purges are induced after administration of medicine and stopped after effect is over. This procedure is different from pathological diarrhea caused due to disease pathogens. The elimination of waste materials can be done through the upper and lower routes. The word ‘shirovirechana’ is used to denote evacuation of morbid dosha from supraclavicular region by intra nasal administration of medicine. However, in a broader sense the term ‘virechana’ is used to denote the elimination of dosha from large bowels i.e. therapeutic purgation. [Cha.Sa.Kalpa Sthana 1/4] This article focuses on therapeutic purgation. The word ‘purge’ is used to indicate a bout of defecation caused by purgative medicine.

Contributors

Section/Chapter/topic	Chikitsa / Panchakarma/ Virechana
Authors	Aneesh E.G., Deole Y.S.
Reviewed by	Basisht G.
Affiliations	Charak Samhita Research, Training and Development Centre, I.P.G.T.& R.A., Jamnagar
Correspondence email:	carakasamhita@gmail.com
Date of first publication:	December 01, 2020
DOI	10.47468/CSNE.2020.e01.s09.033

Etymology and derivation

The word virechana is derived by adding ‘vi’ prefix and ‘lyut’ suffix to the Sanskrit root ‘rich’ [vacaspatyam]. It means evacuation of waste materials (mala nissaranam).

Synonyms

Vireka, adhobhagaharana, praskandana, rechana, adhaparisrava, kaya virechana

Classification

Based on mode of action of medicines

Virechana is administered through four methods based on state of morbid conditions and mode of action of purgative medicines.

1. Anulomana (carminative laxative)
2. Sramsana
3. Bhedana(choleretic)
4. Rechana (stimulant purgation)

Based on the inherent nature of medicine

1. Unctuous (snigdha) purgatives like castor oil etc. indicated in morbid conditions caused by excess dryness in gut.
2. Dry (ruksha) purgatives like Terminalia chebula (haritaki) etc. indicated in morbid conditions caused by excess unctuousness in gut.[Cha.Sa.Siddhi Sthana 6/9]

Based on the administration procedure

• Therapeutic purgation (virechana) without preparatory procedures like oleation and sudation (sadyavirechana)
• Therapeutic purgation (virechana) including preparatory procedures

Indications

Purificatory procedures like therapeutic purgation is advocated only in case of excessive aggravation of pitta dosha.[Cha.Sa.Sutra Sthana 16/16] It is an important treatment for vitiation of rakta dhatu, mamsa dhatu, meda dhatu and shukra dhatu. It is also indicated in conditions caused due to pitta dosha associated with kapha dosha, encroachment of kapha in site of pitta and vice versa.[A.S.Sutra Sthana.27/4]

Contraindications

Diseases: Diarrhea, rectal bleeding, hematuria, vaginal bleeding, flatulence, acute fever, acute rhinitis, injury to rectum etc.

Condition of patient: Aged persons, children, pregnant women, weak, excessively thin or excessively obese persons.

Other panchakarma procedures: Immediately after therapeutic enema with decoction.[Cha.Sa.Siddhi Sthana 2/11-12]

Virechana procedure

The total procedure can be discussed under the following three stages

1. Pre-therapeutic procedure (purvakarma)
2. Therapeutic procedure (pradhanakarma)
3. Post-therapeutic procedure (pashchatkarma)

Pre-therapeutic measures (purvakarma)

The pre-purgation procedure aims to prepare the body for purgation and to bring toxins to gut for expulsion. Digestive (pachana) therapies are administered to correct digestion and detach the microcellular toxins (ama).

Unction (snehana) is prescribed in a suitable dose for a duration until proper unction features are observed. This is generally done for three to seven days.

Therapeutic massage (abhyanga) and fomentation therapy (swedana) are generally advised for six sessions in three days after completing internal unction therapy. [Cha. Sa. Sutra Sthana 13/80]

The person is advised to take light to digest food, sour fruits and hot water on previous day of virechana. [Su.Sa.Chikitsa Sthana.33/20] The food prior to virechana should not increase kapha dosha, because it can adversely affect purgation. The less amount of kapha dosha present in the gut at the time of virechana is important for complete benefits of virechana. [Cha.Sa.Siddhi Sthana 1/9] The three days interval prior to main procedure is meant to reduce the kapha dosha, possibly aggravated due to oleation therapy.

Selection and dose of purgative medicine

There are three dosages of the drug based on the strength of the patient. Strength of the medicine depends on strength of the patient.

Table 1: Dose of purgative medicine

Sr.No.	Strength of the Patient	Strength of the medicine	Dosage for decoctions	Dosage*
1.	Good strength (strong individual)	Most potent (strong purgatives)	96 gms (2 pala)	48 gms (1 pala)
2.	Moderate strength	Moderately potent (moderate purgatives)	48 gms (1 pala)	24 gms (2 karsha)
3.	Less strength (weak)	Mild potent (mild purgatives/laxative)	24 gms (½ pala)	12 gms (1 karsha)

[Dalhana on Su.Sa.Chikitsa Sthana 33/20]

 *Dosage as per Sharangadhara if the medicine used is in the form of paste or tablet or powder form.[Sha.Sa.Uttara Khanda 4]

Therapeutic purgation (pradhanakarma)

Therapeutic purgation is always performed late morning during the time of the natural decrease of kapha dosha and increase of pitta dosha. [A.Hr.Sutra Sthana.18/33] Practically the purgative medicines are administered between 9 AM to 11 AM on empty stomach. The person is advised to pass stool whenever the urge is felt and to take rest in between the urges. He should not indulge in other activities and should concentrate in the procedure itself. [Su.Sa. Chikitsa Sthana 33/21] Drinking a little amount of warm water and mild sudation with warm palms over abdomen region to trigger the urge is advised.[A.Hr.Sutra Sthana.18/36] The person should never withhold the urge for defecation and should not strain while passing the stool [Su.Sa. Chikitsa Sthana 33/22] as these may aggravate the vata dosha. After intake of purgative medicine, the person should only use warm water for drinking and cleaning purpose. Cold water may obstruct the movement of dosha and thereby prevents evacuation due to its styptic action.

Purgative medicine shows effect only after its digestion. [Su.Sa.Chikitsa Sthana 33/34] Depending upon the time required for digestion of medicine, the first urge to defecate varied from one hour to three hours after administration of medicine.

Observation of the patient

The vital parameters of person like pulse rate, volume, blood pressure and signs of dehydration (if any) are observed frequently. The features of status of dosha are assessed clinically and number of purges are counted.

Post therapeutic measures (pashchatkarma)

The patient is advised to take complete rest in a room and avoid direct exposure to wind. The patient is advised to take hot water bath and follow specific dietary pattern (samsarjana krama), when he feels hungry.

Pharmacodynamics of virechana

The purgative medicines remove toxins from the whole body by their properties and predominance of jala and prithvi mahabhuta. [Cha.Sa.Kalpa Sthana 1/5]

Features of optimal purgation

• Sequential expulsion of feces, pitta, kapha and vata dosha
• Feeling of lightness in the body and sense organs
• Clarity in body channels
• Improved digestion process [Cha.Sa.Siddhi Sthana 1/17]

Features of inadequate purgation

• Vitiation of kapha, pitta and vata dosha
• Decreased digestion
• Heaviness in body
• Coryza
• Drowsiness
• Vomiting
• Anorexia
• Absence of normal movement of vata [Cha.Sa.Siddhi Sthana 1/18]

Features of excess purgation

• Reduction of kapha and pitta dosha and aggravation of vata dosha
• Numbness
• Body ache
• Tiredness
• Tremor
• Insomnia
• Debility
• Blackouts
• Insanity
• Hiccups [Cha.Sa.Siddhi Sthana 1/19]

Assessment of adequate purification

The following four factors are considered to assess the purification level (maximum, moderate and minimum) through therapeutic purgation.

Endpoint observation of content of the last purge (antiki)

The physician's decision to continue or to stop purgation therapy primarily depends on observation of the patient and content of last purge. It is generally observation of kapha dosha [Cha.Sa.Siddhi Sthana 1/14] or whitish fecal matter with mucus.

Quantity of fecal matter (maniki) and number of purges (vaigiki)

Table 2: Expected quantity of fecal matter as per three categories of purgation.

Level of purification in purgation	Amount of fecal matter	Number of purges (vega)
Maximum	2560ml (4 prastha)	30 purges
Moderate	1920 ml (3 prastha)	20 purges
Minimum	1280ml (2 prastha)	10 purges

[Cha.Sa.Siddhi Sthana 1/14]

The quantity must be considered after excluding the contents of the first two purges. [Cha.Sa.Siddhi Sthana 1/14] In a study, it is observed that the average number of bouts passed were 17, when virechana is administered in 15 patients using a combination containing Terminalia chebula, Terminalia bellirica, Emblica officinalis, Picrorhiza kurroa, Operculina turpethum and castor oil.

Clinical features (laingiki)

The clinical features for inadequate, adequate and excess purgation as mentioned above are considered for assessment.

Complications of therapeutic purgation

Complications may occur in therapeutic purgation due to incompetency of attendant, medicine, physician or patient. The ten cardinal complications arising out of improper administration of purgation are:

• Distension of abdomen (aadhmana)
• Fissure in ano (parikartika)
• Excess discharge from mouth (srava)
• Chest congestion (hridgraha)
• Body stiffness (gaatragraha)
• Bleeding (jeevaadana)
• Prolapse of rectum (vibhramsha)
• Body rigidity (stambha)
• Complications of disease (upadrava)
• Fatigue without exertion (klama) [Cha.Sa. Siddhi Sthana 6/29-30]

Utmost care shall be taken in order to avoid these complications.

Other methods of purgation

Other than therapeutic purgation procedure, following methods are implied to achieve effect of elimination of dosha through bowels. These methods are based on the pharmacotherapeutic actions.

Anulomana

This includes expulsion of waste products/feces (mala) after its complete digestion (paka) of ama (incompletely digested wastes and toxins) and detachment from their abodes. [Sha.Sa.Purva khanda.4/4] The medicine kindles the digestion and metabolic process (agni) first and further increases the liquidity (dravaguna) and mobility (saraguna) of waste products for smooth passage through rectum. [Adhamalla on Sha.Sa.Purva khanda 4/4] Anulomana medicines are predominant of aap and prithvi mahabhuta which results in unobstructed downward movement of the waste materials. Along with the digestion of waste products, it also improves the digestion process by dosha.Anulomana can have an effect on samanavata (type of vata responsible for digestion) and its site of action may be the gastro intestinal tract.

This can be compared to carminative laxatives. Carminative laxatives due to the presence of volatile oils stimulate the digestive system and regulates gut contractions. It may also increase the water retention in intestinal lumen. In a study conducted on 15 participants, anulomana procedure took approximately 258 minutes to complete. Most number of participants did not pass kapha in their final bout of purgation. In 73.46% of participants the consistency of stool as per bristol stool scale lies in category 7 (watery, no solid pieces, entirely liquid).

Sramsana

This includes expulsion of waste products/feces (mala) with or without its digestion and stools may be sticky. [Sha.Sa.Purva khanda.4/5]

The waste materials (mala) adhered to the gut (koshtha) are removed through the anal route in digested or undigested form. It may act on apanavata (type of vata responsible for excretion). Sramsana medicines might be acting over the last part of small intestine and on large intestine motility.

This can be compared to emollient laxatives otherwise called as stool softeners. By its action more fats and water get added to the stool and makes it easy for evacuation. It prevents hardening of feces by adding moisture to it. This type of laxatives neither aimed to stimulate digestive enzymes nor increase the motility of gut.

Bhedana

This includes evacuation of waste products/feces after disintegrating the formed/solidified or unformed state. [Sha.Sa.Purva khanda.4/6]

The liquefied (abaddha) or solidified (baddha/pindita) fecal matter gets forcefully excreted out through this type of purgation. The action is more intense. The drug might be sharply acting (tikshna), hot (ushna) and light (laghu) in nature. Bhedana medicines might be acting over large intestine and increases intestinal motility.

The bhedana drugs can be considered as choleretics. It causes powerful constriction of gall bladder leading to the expulsion of more quantity of bile into the gastro intestinal tract. It stimulates the peristaltic movement which inturn leads to purgation.

Rechana

This includes elimination of waste products/feces with or without its digestion, in watery form. [Sha.Sa.Purva khanda.4/7]

The digested or undigested fecal matter gets evacuated in watery form. It affects mainly on large intestine and increases secretions of intestine and its motility.

This can be considered under stimulant purgatives as it causes forceful evacuation of bowels in watery form. The drugs may increase the water retention in the gut lumen. In order to achieve this secretion must be increased along with less absorption of water.

In a study conducted on 15 participants rechana shows the mean duration to complete procedure is 401.33 minutes. The purgation starts within one hour in most participants. Majority of participants (86.67%) attained evacuation of kapha in the last bout of purgation. The consistency of stools as per Bristol stool scale in most participants (92.38%) lies in category 7 (watery, no solid pieces, entirely liquid).

Importance in preservation of health and prevention

In healthy individuals, therapeutic purgation is advised in autumn season (sharad) during natural aggravation of pitta dosha. [Sha.Sa.Uttrakhanda.4/4] It helps to prevent many diseases caused due to pitta aggravation and rakta vitiation.

Importance in management of disease

Virechana is effective in eliminating excessive aggravated pitta dosha and balancing it. [Cha.Sa.Sutra Sthana 20/16] Therefore it is the principle treatment for pitta predominant diseases like chronic fever (jwara), anaemia (pandu), jaundice (kamala) etc.[Cha.Sa.Siddhi Sthana 2/13], hemiplegia (pakshaghata) [Cha.Sa.Chikitsa Sthana 28/100) and bronchial asthma (shwasa).[Cha.Sa.Chikitsa Sthana 17/121]

Physiology of purgation

Various types of medicines are used as laxatives and purgatives. The pharmacological action varies according to the type of medicine.

Stimulant or irritant laxatives

Irritant oil, anthraquinone group etc. are stimulant laxatives.

Anthraquinone: It stimulates the large bowel. Sodium chloride and water absorption takes place. This produces the semi solid stools. The time of onset of purgation is 6-8 hours.

Irritant oil: E.g.: Castor oil. It is digested by pancreatic lipase to glycerol and ricinoleic acid. This acid acts as irritant and produces purgation by acting on small intestine. It produces copious liquid stool along with griping. The time of onset is 2 -3 hours.

Osmotic laxatives

Certain salts when given orally won’t get absorbed much but instead are retained in gastro intestinal tract. This exerts an osmotic effect which results in retention of considerable amount of water, which in turn increases the bulk and causes mechanical effect as laxative. Thus, its action is mechanically.

Along with this the stimulation of intestinal secretory and motor activity by the release of cholecystokinine-pancreozymin may also happen. The time of onset for purgation is 3-6 hours. Eg: MgSO4, Milk of magnesia

Bulk laxatives

The oral administration of certain natural or semi-synthetic polysaccharides and cellulose derivatives, which does not get absorbed but they increase the indigestible residual part. The residue absorbs water and swells up. This provides the stimulus for defecation because of mechanical distention. The time of onset is 12-36 hours. Eg: Isapgol, Agar

Emollient laxatives

This type of laxatives directly acts on feces. It softens or lubricates the fecal matter. It does not initiate peristalsis. They are mild in action and have late onset. Eg: Liquid paraffin

Mode of action of therapeutic purgation

Laxatives may alter fluid dynamics of mucosal cells in the GIT. This will result in fluid accumulation in gut either by impairing water and electrolyte absorption by inhibiting Na+ and K+ ATPase of villous cells or by increasing water and electrolyte secretion by stimulating adrenal cyclase in crypto cells.

The virechana medicine may cause hyperemia as a result of intestinal mucosal inflammation. This may alter the permeability and as a result more protein rich fluids might get transported across the vessel walls into the gut. Increase in the fluid content in the gut ultimately results in evacuation.

Current researches

Therapeutic purgation has effect on the body electrolytes. After virechana, a reduction in serum sodium, serum chloride and serum potassium levels were reported along with an increase in serum calcium levels. All these changes were within the normal limits, which show the safety of this procedure.

Virechana showed significant relief in signs and symptoms of bronchial asthma. In a study conducted on 24 patients the breath holding capacity and peak expiratory flow rate improved, when compared with pacifying therapy.

The purificatory procedure virechana helps to increase the total sperm count and sperm motility and a reduction in abnormal form of sperms is reported in a study on 42 male infertility cases. Serum LH level shows significant increase.

Virechana shows significant reduction in both systolic and diastolic blood pressure in patients with essential hypertension associated with obesity and diabetes mellitus. Virechana significantly reduces the plasma catecholamine levels. Virechana prior to rasayana therapy can effectively treat eczema and also reduces the recurrence of the disease.

In an animal study virechana is found to be effective in the management of metabolic syndrome. After virechana reduction in fecal fat content, fasting blood glucose and serum triglyceride were noted. Reduced fatty changes in liver, heart and kidney were also reported.

In a case report on rheumatoid arthritis, virechana showed significant reduction in RA factor to 50 IU/ml from earlier level of 94 IU/ml. Virechana followed by avoidance of allergens reduced the CRP level from 22.7mg/l to 1.8 mh/l. After 3 months of follow up the IgE levels reduced from 680kU/l to 53.7 kU/l. The 40% relief in pain and stiffness of joints were reported soon after the virechana.

A study conducted on 20 non-insulin dependent diabetes patients showed a better reduction in fasting blood sugar (FBS) and post prandial blood sugar (PPBS) levels through virechana, when compared with therapeutic emesis (vamana). The 51.5% reduction is observed in FBS levels after virechana, at the same time PPBS values shows 81.6% reduction. It is assumed that virechana acts on liver and pancreas as they are the sites of pitta dosha. It may reduce the hepatic glucose production or may increase the insulin secretion.

In a study on 110 overweight and obese patients, average 4.61 KG weight loss was observed after purgation therapy (virechana). In another study conducted on 30 dyslipidemia persons, a significant reduction is reported in serum cholesterol, triglyceride and VLDL levels after virechana. LDL also shows reduction. Serum HDL increased significantly. Evacuation of pitta is the prime phenomenon achieved through virechana. Large amount of bile is excreted through virechana which results in reduction of cholesterol levels.

In a study conducted on 30 patients, virechana is reported to be more effective in reducing the signs and symptoms of psoriasis than therapeutic emesis (vamana).

List of theses done

1. Dalvi Prachi (2002): Role of Virechana and Amalakyadirasayana in the management of Amavata (Rheumatoid arthritis). Department of Kayachikitsa, IPGT&RA Jamnagar
2. Parmar Sheetal (2002): The role of Virechana and Triphaladi Ghana-Vati in the management of Madhumeha(Diabetes mellitus). Department of Kayachikitsa, IPGT&RA Jamnagar
3. Sangeetha G (2002): Clinical study on the effect of Pippalyavaleha and VirechanaKarma in the management of TamakaShvasa. Department of Kayachikitsa, IPGT&RA Jamnagar
4. Bhayal Ramesh B (2003): Role of Virechana Karma and shaman chikitsa in the management of Uccha-Raktacchapa (essential hypertension). Department of Kayachikitsa, IPGT&RA Jamnagar
5. Mehta Sariga M (2003): Etiopathological study of sthaulya (obesity) & assessment of the effect of Devadarvyadivati and Virechana karma. Department of Kayachikitsa, IPGT&RA Jamnagar
6. Pandya Ashutosh (2003): A comparative study of VirechanaKarma and Sramsana in the management of Pakshaghata. Department of Kayachikitsa, IPGT&RA Jamnagar
7. Sahu Rita A K (2003): Clinical assessment of the role of kansa-hareetaki and virechana in amavata. Department of Kayachikitsa, IPGT&RA Jamnagar
8. Ahuja Harish (2004): A clinical study on the efficacy of Virechana and Medohara Rasayana in the management of Madhumeha w.s.r. to Diabetes mellitus. Department of Kayachikitsa, IPGT&RA Jamnagar
9. Mali Pavan (2004) : A clinical study on the role of Shireeshadyavaleha and Virechana in the management of Tamaka Shvasa. Department of Kayachikitsa, IPGT&RA Jamnagar
10. Bhatkoti Mayank (2005): A comparative clinical study of vaitaranabasti and virechana karma in the management of amavata. Department of Kayachikitsa, IPGT&RA Jamnagar
11. Bhimani Ketan (2005) : Comparitive study of Virechana karma and Jalaukavacharana in the management of Vicharchika. Department of Kayachikitsa, IPGT&RA Jamnagar
12. TejalKhunt (2005) : Comparitive study on the Virechana Karma and Lekhana Basti in the management of Sthaulya. Department of Kayachikitsa, IPGT&RA Jamnagar
13. Tikoo Ajay (2005): Clinical study on the role of Virechana Karma in the management of Madhumeha w.s.r to Diabetes mellitus. Department of Kayachikitsa, IPGT&RA Jamnagar
14. Priti Sharma (2006): The role of Amritabhallatka Avaleha and Virechana karma in the management of Amavata. Department of Kayachikitsa, IPGT&RA Jamnagar
15. Rajesh Sachdevani (2006): A clinical study on the role of Virechana and kusthanghna mahakashaya in the management of Vicharchika. Department of Kayachikitsa, IPGT&RA Jamnagar
16. Jyoti Kumari (2007): A comparative clinical study of Nygrodhadighanavati and Virechana karma in the management of Madhumeha (Diabetes Mellitus ). Department of Panchakarma, IPGT&RA Jamnagar
17. Akhil Nath Parida (2008): Comparitive study of Vamana and Virechana karma in Ekakushtha w.s.r to Psoriasis. Department of Panchakarma, IPGT&RA Jamnagar
18. Vimal M Vekaria (2008): Comparative study of Virechana karma and kala basti in the management of Pakshaghata. Department of Panchakarma, IPGT&RA Jamnagar
19. Gohil Jalpa H (2009): A comparative clinical study of Virechana karma and kala basti in management of Amavata. Department of Panchakarma, IPGT&RA Jamnagar
20. Gyanendra D Shukla (2010): A Comparative Study of Efficacy of Virechana and Basti Karma with Shamana therapy in the Management of Essential Hypertension. Department of Panchakarma, IPGT&RA Jamnagar
21. Rajeev Pandey (2010): A Comparative Clinical Study of Vamana and Virechana Karma in the management of Sthula Pramehi W.S.R to Type II Diabetes mellitus. Department of Panchakarma, IPGT&RA Jamnagar
22. Chetan M Gulhane (2011): A Clinical Study of Virechana Karma, Takradhara and Makandi [Coleus forskohlii (Wild) Briq.] Ghanavati in the Management of Ekakushtha (w.s.r. to Psoriasis). Department of Panchakarma, IPGT&RA Jamnagar
23. Kundan Gadhvi (2011): A Comparative Study between the Efficacy of Vamana and Virechana Karma in the Management of TamakaShvasa (Bronchial Asthma). Department of Panchakarma, IPGT&RA Jamnagar
24. Monica Agrawal (2011): Clinical study on the Effect of Virechana Karma and PandughniVati in the Management of Pandu w.s.r. to Iron Deficiency Anaemia. Department of Panchakarma, IPGT&RA Jamnagar
25. Nakul A Jethva (2011): A Clinical Study on the Effect of Virechana Karma and Amalaki Rasayana in the Management of Kshina Shukra w.s.r. to Oligozoospermia. Department of Panchakarma, IPGT&RA Jamnagar
26. Anjali J Malli (2012): The effect of Vamanottara virechana karma followed by vardhanana pippalirasayana in the management of hypothyroidism. Department of Panchakarma, IPGT&RA Jamnagar
27. Nikunj M (2012): A comparative study of vrishyabasti and kulinga (Blepharis edulis) after virechana karma in the management of kshinashukra w.s.r to oligozoospermia. Department of Panchakarma, IPGT&RA Jamnagar
28. Nilesh Kumar L Patel (2013): A comparative study between Dhatryadikwatha and manshiladilepa along with and without trivritadi yoga virechana administrated in the management of shvitra w.s.r to vitiligo. Department of Panchakarma, IPGT&RA Jamnagar
29. Shweta Patil (2013): A comparative study on the effect of vamana and virechana karma followed by brumhana snehapana (kantakarighrita) in the management of tamaka shvasa w.s.r to Bronchial asthma. Department of Panchakarma, IPGT&RA Jamnagar
30. Sunita Sheike (2013): A comparative study between vamana and virechana karma in the management of sthulapramehi w.s.r to type-ll diabetes mellitus. Department of Panchakarma, IPGT&RA Jamnagar
31. Odedra Jayeshji Jesaji (2014): Comparative study of virechana karma and kokilakshadighanavati in the management of amavata w.s.r to rheumatoid arthritis. Department of Panchakarma, IPGT&RA Jamnagar
32. Patairya Pratiksha Prakash (2014): A clinical study on the role of vamana and virechana in the management of hypothyroidism with punarnava-aruta-guggulu. Department of Panchakarma, IPGT&RA Jamnagar
33. Rao Rajdip Rajeshbhai (2017): A comparative clinical study of dhatyadikwatha and external application of phalgupatraswarasa along with and without virechana in the management of shwitra w.s.r to vitiligo. Department of Panchakarma, IPGT&RA Jamnagar
34. Singh Karishma mahi Pal Singh (2017): A comparative clinical study of virechana and triphladyaguggulu along with punarnavadikashaya in the management of hypothyroidism. Department of Panchakarma, IPGT&RA Jamnagar
35. Chetana Mehta (2017): A comparative study of virechana karma and vidangadiyoga in the management of sthaulya w.s.r to obesity. Department of Panchakarma, IPGT&RA Jamnagar
36. Sunita vasiya (2018): A comparative clinical study on the effect of virechana karma and mandura vajra vataka in the management of pandu w.s.r to iron deficiency anaemia. Department of Panchakarma, IPGT&RA Jamnagar
37. Ritika Mishra (2018): A clinical study to evaluate and compare the efficacy of vamana, virechana and shamana in the management of ekakushtha w.s.r to psoriasis. Department of Panchakarma, IPGT&RA Jamnagar
38. Laveena Kumari(2018): A comparative clinical study to evaluate the effect of virechana, vamana and shwasahara yoga in the management of tamaka shwasa w.s.r to bronchial asthma. Department of Panchakarma, IPGT&RA Jamnagar
39. Shiho Oikawa (2018): Virechana karma along with vaitaranabasti followed by mahabhallataka avaleha in the management of amavata wsr to rheumatoid arthritis-A comparative randomized controlled study . Department of Panchakarma, IPGT&RA Jamnagar

Related chapters

Upakalpaniya Adhyaya, Chikitsaprabhritiya Adhyaya, Kalpana Siddhi, Shyamatrivrita Kalpa Adhyaya, Chaturangula Kalpa Adhyaya, Tilvaka Kalpa Adhyaya, Sudha Kalpa Adhyaya, Saptalashankhini Kalpa Adhyaya, Dantidravanti Kalpa Adhyaya

Abbreviations

Cha. = Charak, Su. = Sushruta, A. = Ashtanga, S. = Sangraha, Hr. = Hridayam, Sa. = Samhita, Sha. = Sharangadara

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