PG Module 5
VIRECHANA KARMA
EXPLANATORY NOTES
आध्मानं परिकर्तिश्च स्रावो हृद्गात्रयोर्ग्रहः|
जीवादानं सविभ्रंशः स्तम्भः सोपद्रवः क्लमः||
अयोगादतियोगाच्च दशैता व्यापदो मताः|
प्रेष्यभैषज्यवैद्यानां वैगुण्यादातुरस्य च|| (Cha. Si. 6/29-30)
The ten cardinal complications arising out of improper administration of emesis and purgation are ādhmāna (distension of abdomen), parikartikā (fissure in ano), srāva (excess discharge), hṛtgraha (congestion in cardiac region), gātragraha(body stiffness), jīvadāna (bleeding during vomiting), vibhraṃśa (rectal prolapse), sthambha (body stiffness), upadrava (complications), klama (fatigue without excertion).
The above complications arise out of either under activity or excessive activity of the drug because of Preṣya-vaiguṇya (incompetency of the attendant), Bhaiṣajya-vaiguṇya (incompetency of drug),Vaidya-vaiguṇya (incompetency of physician), Ātura-vaiguṇya (incompetency of the patient).
The above complications arise out of either under activity or excessive activity of the drug because of Preshya-vaigunyam (incompetency of the attendant), Bhaishajya-vaigunya (incompetency of drug), Vaidya-vaigunya (incompetency of physician), Aatura-vaigunya (incompetency of the patient).
वैद्यातुरनिमित्तं वमनं विरेचनं च पञ्चदशधा व्यापद्यते |
तत्र वमनस्याधो गतिरूर्ध्वं विरेचनस्येति पृथक्; सामान्यमुभयोः– सावशेषौषधत्वं, जीर्णौषधत्वं, हीनदोषापहृतत्वं, वातशूलम्, अयोगो, अतियोगो, जीवादानम्, आध्मानं, परिकर्तिका, परिस्रावः, प्रवाहिका, हृदयोपसरणं, विबन्ध, अङ्गप्रग्रह इति || (Su. Chi. 34/4)
Fifteen different kinds of vyāpat may result from an injudicious use of emetics and purgatives owing to the ignorance of the physician or of the patient. Of these fifteen, the upward coursing in cases of purgatives and the downward coursing in cases of emetics are peculiar to each of them respectively. The fourteen other remaining vyāpat are common to both. They are Sāvaśeṣaauṣadhatva (continuance of the drug in the stomach), Jīrṇaauṣadhatva (complete digestion of the medicine), Hīnadoṣaapahṛtatva (insufficient elimination of the Doṣas from the system), Adhika-doṣaipahritatva (excessive elimination of the Doṣas from the system), Vātaśūla (pain due to vāta), Ayoga (insufficient dosage), Atiyoga (over dosage), Jīvādāna (vomiting blood), Ādhmāna (distention of abdomen), Parikartikā (cutting pain in the anus.), Parisrāva (oozing out of stools), Pravāhikā( (diarrhoea), Hṛdayaupasaraṇa (rising of the Doṣas towards the heart) and Vibandha (constipation).
Virecana Ayoga and Atiyoga Vyāpat explained by Carakācārya
According to Carakācārya, vyāpats may be caused due to virecanaayoga and atiyoga.
Virecana Ayoga Vyāpat
श्लेष्मोत्क्लिष्टेनदुर्गन्धमहृद्यमतिवाबहु|
विरेचनमजीर्णेचपीतमूर्ध्वंप्रवर्तते||३२|| (Cha. Si. 6/32)
The medicines administered for virecana, in a patient with aggravated and excited status of kapha, will act as vāmaka, if the medicine is having bad smell, the drug not being wholesome, large quantity of medicine, intake of medicine before the previous meal is digested.
प्रातिलोम्येनदोषाणांहरणात्तेह्यकृत्स्नशः|
अयोगसञ्ज्ञे, कृच्छ्रेणयातिदोषोनवाऽल्पशः|| (Cha. Si. 6/33-34)
Whether in vamana or virecana, if the medicines work in opposite, it is termed ayoga or inadequate action. It is also called the same, if doṣas are not eliminated or eliminated with difficulty.
अस्निग्धास्विन्नदेहस्यरूक्षस्यानवमौषधम्|
दोषानुत्क्लिश्यनिर्हर्तुमशक्तंजनयेद्गदान्||
विभ्रंशंश्वयथुंहिक्कांतमसोदर्शनंभृशम् |
पिण्डिकोद्वेष्टनंकण्डूमूर्वोःसादंविवर्णताम् (Cha. Si. 6/38-39)
Ayoga happens when asnigdha (under-oleated) and asvinna (under-sudated) person with rūkṣa nature of the body, is administered a recipe, which is stored for long duration. Here, the drug is unable to remove doṣas from the body by creating doṣa-utklesha. Such a condition will lead to symptoms like vibhraṃśa(virecana auṣadha will lead to vamana and vice versa), swelling, hiccups, black-out, cramps in calf muscle, itching, fainting and discoloration.
स्निग्धस्विन्नस्यचात्यल्पंदीप्ताग्नेर्जीर्णमौषधम्|
शीतैर्वास्तब्धमामेवादोषानुत्क्लिश्यनाहरेत्||
तानेवजनयेद्रोगानयोगःसर्वएवसः|
विज्ञायमतिमांस्तत्रयथोक्तांकारयेत्क्रियाम्|| (Cha. Si. 6/40-41)
Ayoga happens in conditions such a as administration of sub-optimal dose of medicine even after proper sneha-sweda and quick digestion of medicine happens due to increased agni.
If there is āmadoṣa, the medicine for vamana will not work in the desired manner. The case is similar also with virecana drugs.
Because of the above mentioned causes, the earlier mentioned conditions like vibhraṃśawill happen. These come under ayoga. The intelligent physician must understand the same and treat accordingly.
Virecana Ayoga Vyāpat management
तंतैललवणाभ्यक्तंस्विन्नंप्रस्तरसङ्करैः|
पाययेतपुनर्जीर्णेसमूत्रैर्वानिरूहयेत्||
निरूढंचरसैर्धान्वैर्भोजयित्वाऽनुवासयेत्|
फलमागधिकादारुसिद्धतैलेनमात्रया||
स्निग्धंवातहरैःस्नेहैःपुनस्तीक्ष्णेनशोधयेत्|
नचातितीक्ष्णेनततोह्यतियोगस्तुजायते|| (Cha. Si. 6/42-44)
Taila (oil) processed with lavaṇa(salt) has to be applied and made to undergo prastara and saṅkara kind of sudation. Once the medicine for vamana or virecana must be administered again or else kaṣāya basti (decoction enema) with cow’s urine has to be done. After the administration of kaṣāya basti, food with meats of animals of arid regions (jāṅgalamāṃsa rasa) should be taken and should be followed by administration of sneha basti (oil enema).
Sneha basti can be done by oil processed with Madana (Randiadumetorum), Pippali (Piper longum), Devadāru (Cedrus deodara), in proper dose. Once adequate oleation happens, elimination must be done with a recipe containing tīkṣṇadrugs. However, the medicines that are ati-tīkṣṇashould not be given, as it may result in atiyoga.
Virecana Atiyoga Vyāpat and management
अतितीक्ष्णंक्षुधार्तस्यमृदुकोष्ठस्यभेषजम्|
हृत्वाऽऽशुविट्पित्तकफान्धातून्विस्रावयेद्द्रवान्||४५||
बलस्वरक्षयंदाहंकण्ठशोषंभ्रमंतृषाम्|
कुर्याच्चमधुरैस्तत्रशेषमौषधमुल्लिखेत्||४६||
वमनेतुविरेकःस्याद्विरेकेवमनंपुनः |
परिषेकावगाहाद्यैःसुशीतैःस्तम्भयेच्चतत्||४७||
कषायमधुरैःशीतैरन्नपानौषधैस्तथा|
रक्तपित्तातिसारघ्नैर्दाहज्वरहरैरपि||४८|| (Cha. Si. 6/ 45-48)
When a patient who is with mṛdukoṣṭha, who is affected with hunger, is provided with an exceedingly strong vamana or virecana, it results in the quick elimination of not only the faecal matter, pitta and kapha, but also the drava-dhātu (liquid content of the body). Consequently, there will be sudden depression of strength and voice, dryness of throat, giddiness and thirst. In such a condition, it is preferable to eliminate the residual drug in the koṣṭha using the drugs of madhuragaṇa(mentioned in sweet category).
If ati-yoga happens like this during attempting vamana, the residual doṣas are eliminated by initiating a virecana and vice-versa.
Stambhana can be done by providing cold irrigation (pariṣeka) and tub bath (avagāha), providing foods, drinks and medicine which are śīta (cold), kaṣāya (astrigent) and madhura (sweet) rasa and following appropriate regimens prescribed for rakta-pitta, atisāra, dāha and jwara.
अञ्जनंचन्दनोशीरमज्जासृक्शर्करोदकम्|
लाजचूर्णैःपिबेन्मन्थमतियोगहरंपरम्||४९||
शुङ्गाभिर्वावटादीनांसिद्धांपेयांसमाक्षिकाम्|
वर्चःसाङ्ग्राहिकैःसिद्धंक्षीरंभोज्यंचदापयेत्||५०||
जाङ्गलैर्वारसैर्भोज्यंपिच्छाबस्तिश्चशस्यते|
मधुरैरनुवास्यश्चसिद्धेनक्षीरसर्पिषा||५१|| (Cha. Si. 6/ 49-51)
The patient suffering from complications of atiyoga of purgation therapy should take mantha prepared of añjana, candana, uśīra, majjā, asṛk, śarkarā and water along with lājacūrṇa. This is an excellent recipe for curing overaction of virecana therapy. Take peyā prepared of the śuṅga of vaṭa, nyagrodha, udumbara, aśvatthā and kapītana mixed with honey. Take milk and food articles prepared by boiling with drugs which are varcaḥ sāṅgrāhika or intestinal astringents. Take food along with jāṅgalamāṃsarasa. Administer picchā basti and anuvāsanabasti with kṣīrasarpi cooked with drugs belonging to madhuravarga.
Vyāpat | Nidāna | Lakṣanas | Treatment |
Ayoga | Expulsion of doṣa in small amount or in reverse route or doṣas are not at all expelled | Vibhraṃśa,śvayathu, hikkā, tamaḥdarśana, piṇḍikodveṣṭana, kaṇḍū, ūrusāda, vivarṇa | Abhyaṅga with taila and lavaṇa, then saṅkara and prastarasveda. Nirūhabasti with gomūtra, then anuvāsana with taila processed with madana, māgadhi, dāru. Again tīkṣṇaśodhana should be given after proper snehana with vātaharadravya. |
Atiyoga | Excessive expulsion of aggravated doṣas due to atitīkṣṇadravyas, administered when hunger and who has mṛdukoṣṭha. | Balasvarakṣaya, dāha, kaṇḍaśoṣa, bhrama | Vamana with Madhura dravya for expulsion of remaining dravya. Mṛduvirecana in atiyoga of vamana and vamana in atiyoga of virecana. Raktapitta, dāha, jvara, atisāra line of management is opted. Picchābasti, anuvāsana of kṣīrasarpī. |
Ādhmāna | Due to the administration of alpamātrā auṣadha in bahu doṣaja condition and in rūkṣa, hīnaagni, udāvartacondition, doṣas cannot be eliminated properly and it obstructs the srotas. | Pṛṣṭhapārśvaśirorujā, śvāsa, obstruction of viṭ mūtravāta. | Udāvarta line of management is opted. |
Parikartikā | Tīkṣṇaauṣadhi administered to a snigdhapuruṣa having guru koṣṭha associated with āma or in durbala having mṛdukoṣṭha, auṣadhi reaches to the rectum to cause excitement of doṣas with āma. | Expulsion of doṣas and āma through guda with severe pain and bleeding. | In āma condition, laṅghana, pācana, rūkṣa-uṣṇa-snigdhaāhāra. For durbala persons, bṛṃhaṇa with Madhura dravyas. If no improvement then ghṛta along with dāḍimarasa+puṣpakāsīsa, kṣāra/lavaṇa. Kalka of Devadāru and tila with warm water. Milk processed with aśvatthā, udumbara, plakṣa, kadamba. Picchā basti with Kaṣāya, Madhura, śītadravyas and Sneha basti with taila processed with yaṣṭimadhu. |
Parisrāva | Alpaauṣadhi administered to a person with aggravated doṣas, only small amount of doṣas is eliminated. | Kaṇḍū, śopha, kuṣṭa, gaurava, decrease of agni and bala, aruci, pāṇḍutā. | Vamana after snehana, tīkṣṇavirecana after samśodhana. Administration of cūrṇa, āsava,ariṣṭa |
Hṛtgraha | If a person undergoes vegadhāraṇa during virecana, the doṣas aggravates and reaches hṛdaya and produce hṛtgraha | Hikkā, kasa, pārśva arti, akṣivibhrama, jihvākhaṇḍādinisaṃjñā Due to aggravated vāyu, pain in the heart. | When mūrchā due to pitta – vamana with Madhura dravya.if due to kapha,vamana with kaṭudravya, for remaining doṣas, pācana is indicated after śodhana |
Gātragraha | If a person supresses the vega after intake of auṣadhi, vāyu gets obstructed by kapha, or there will be atiśodhana, then vāyu gets viṭiated and causes graha in the limbs | Stambha, vepathu, nistoda, Sāda, udveṣṭana, manthana | Vātahāra treatments like snehana, svedana.etc. |
Jīvādāna | In mṛdukoṣṭha person, if tīkṣṇadravyas are administered or when administered in alpadoṣa, pure blood gets eliminated. | If blood is mixed with food and given to crows and dogs -if they eat it is jīvarakta, otherwise raktapitta. If a cloth is immersed with blood and washed with warm water and becomes discoloured. It is of raktapitta. And if it is completely clean, it is jīvarakta.tṛṣṇā, mūrchā, mada. | Pitta nāśakacikitsā, raktapāna, raktabasti. Basti with-kṣīra processed with shyāma, kāśmarī, badarī, dūrvā, uśīra, ghṛtamaṇḍa, and añjana. Picchābasti, Anuvāsana with ghṛtamaṇḍa. |
Vibhraṃśa | Three types- gudavibhraṃśa, sañjñā vibhraṃśa, kaṇḍvādivibhraṃśa. | It occurs when śodhanadravyas stops its action before proper expulsion of doṣas. | In gudavibhraṃśa- stambhana by Kaṣāyadravyas. Then guda is inserted to its own site. In sañjñā vibhraṃśa- hearing to sāmaveda or music. In kaṇḍvādi – according to the condition. |
Stambha | If snigdhadravyas are used for śodhana, to a properly snigdha purusha, then the dravyas due to their mṛdu, guṇa becomes difficult of expelling doṣas. These doṣas displaced from their own sites gets obstructed. | Vātasanga, gudastambha, śūla. | Laṅghana, pācana, tīkṣṇabasti, virecana. |
Upadrava | If rūkṣavirecana given to a rūkṣa and durbala person, vāta gets aggravated immediately and causes complications. | Stambha and śūla all over the body. | Snehana, svedana, vātahāraupakrāmas. |
Klama | Mṛdudravya when administered to a snigdha person, it aggravates kapha and pitta. As a result, vāta gets aggravated. | Tandra, gaurava, daurbalya, aṅgasāda | Immediate vāmana,laṅghana-pācana,tīkṣṇasnigdhaśodhana. |
According to Suśruta:
Vyāpats | Nidāna | Lakṣaṇa | Treatment |
Ūrdhvagamanavyāpat of virecana |
Virecanadravya administered in apariśuddhaāmāśaya, before complete digestion of previously taken meal, it moves upwards and causes vamana. |
| Immediate śodhana of āmāśaya. Followed by tīkṣṇavirecana. If associated with āma, it should be treated accordingly. Amount of virecanadravya should be moderate and palatable. If ūrdhvagamana of virecanadravyaoccurs,again after taking all these measures, then the auṣadhi must not be taken for the third time, rather virecana is done by madhu, ghṛta, phāṇita and leha. |
Sāvaśeṣa auṣadhavyāpat | If alpamātrā auṣadhi is given and stays stagnant in the āmāśaya the involvement of doṣa, it is not eliminated. | Tṛṣṇā, pārśvaśūla, chardi, Mūrchā, parvabheda, hṛllāsa, arati, udgāraaviśuddhi |
|
Jīrṇaauṣadha | If alpamātrā auṣadhi in a tīkṣṇaagni and in a krūrakoṣṭha person is administered, the doṣas gets aggravated and cannot be eliminated. | Balavibhraṃśa, vyādhivibhraṃśa | Auṣadhi should be in bahu mātrā and tīkṣṇa |
Hīnadoṣaapahṛtatva | Alpamātrā auṣadhi administered in snigdha and svinna persons, the doṣas cannot be eliminated properly. | In case of virecana- gudaparikartana, ādhmāna, śirogaurava, and vyādhivṛddhi. | Snehana, svedana and virecana is administered. for balavān and bahu doṣaperson,repeatedvamana or virecana is to be given on the third day. |
Vātaśūla | If rūkṣaaauṣadhi is administered to an improper snehya and svedya person and who has no restriction on food and regimen | Pārśva, pṛṣṭha, śroṇi, manya, hṛdayaśūla, mūrchā, bhrama, sañjñā nāśa. | dhānyasweda followed with anuvāsana with yaṣṭimadhutaila. |
Ayoga | If alpamātrā and alpavīryaauṣadhi is administered to an improper snehya and swedya person. It cannot move either upwards or downwards. It aggravates the doṣas and produces balakṣaya. | Ādhmāna, hritgraha, tṛṣṇā, mūrchā, dāha. In asamyakvirecana, medicine administered to any snehya and svedya, it causes stabdha, śūla, vātavibandha, kaṇḍū, maṇḍalakuṣṭa. | Virecana with tīkṣṇa Kaṣāya.in asamyakvirecana, āsthāpana is given first. Then after proper Sneha, tīkṣṇavirecana should be given. If the medicine is not proper, or if virecana does not occur, uṣṇodaka should be taken to stimulate the medicine followed by pāṇitāpa over pārśva and udara. |
Atiyoga | If tīkṣṇaauṣadhi is administered in atimātrā to a mṛdukoṣṭha person who has undergone snehana and svedana, it causes atiyoga | Excessive expulsion of kapha, sometimes associated with rakta. Balavibhraṃśa,vātaprakopa occurs. | śītaambupariṣecana , avagāha with śītaambu, vamana with śītataṇḍulodaka, mixed with honey. Picchā basti, anuvāsana by dugdha and ghṛta, priyaṅgvādicūrṇa to be taken with taṇḍulodaka. Dugdha or māṃsa rasa can be taken. |
Jīvādāna |
| Watery stool like Chandrika. Later on, it passes like māṃsadhāvanajala. It is followed by pure blood. Then gudabhraṃśa, vepathu, complications of ativirecana may occur. | In gudabhraṃśa, after snehana and svedana, guda is inserted manually to its own site. In vepathu, vātavyādhi line of management is opted. In excessive bleeding, āsthāpana with kāśmarī phala, badarī, dūrvā, uśīra, ghṛtamaṇḍaAñjana. In śoṇitaṣṭhīvana, raktapitta and raktaatisāra line of management is opted. |
Ādhmāna | If anuṣṇa, asnigdhaauṣadhi is administered to a rūkṣakoṣṭha, and having bahu doṣa and annaśeṣa in koṣṭha medicine produces ādhmāna. | Vibandha of mūtra and purīṣa, samunnataudara, pārśvabhaṅga, gudabastinistoda, aruci | Svedana, varti, dīpana, basti. |
Parikartikā | If atitīkṣṇa, atiuṣṇa, atilavaṇa, or atirūkṣaauṣadhi, is administered for a kṛśa, mṛdukoṣṭha and rūkṣa person pitta vāta increases. | dāha, and parikartana in guda, nābhi, basti, śirameḍhra, anilasaṅga, bhakta aruci. | Picchā basti with yaṣṭimadhu, tilakalka, madhu and ghṛta. Pariṣeka with cold water. Anuvāsana with ghṛtamaṇḍa and taila processed with yaṣṭimadhu. Anuvāsana is to be given after intake of food with pāyasa. |
Parisrāva | If mṛduauṣadhi is given to a person having krūrakoṣṭha or bahu doṣa it only stimulates the doṣa, but does not eliminate. | Daurbalya, udaraviṣṭambha, aruci, gātrasadana, excreation of pitta and kapha with śūla. | Āsthāpanabasti with palāśa, bala and madhu. Again, Sneha followed by śodhana is to be done after remission of the complaint |
Hṛdayaupasaraṇa | If the aggravated doṣa enters the hṛdaya, it produces severe pain | Dantakiṭakiṭāyana, udgataaksha, jihvakhādatipratāmyaticeta | Abyanga followed by dhānyasveda, anuvāsana with yashtimadhutaila, tīkṣṇasirovirecana and basti according to doṣa. |
Water and electrolyte imbalance:
To prevent dehydration, restore electrolytes, solutions containing glucose and electolytes.eg: rehydralyte.
IV therapy
SHOCK:
A state with reduction in systemic tissue perfusion, resulting in decreased delivery of oxygen and reduced removal of waste products, leading to tissue injury.
Causes of hypovolaemic shock: haemorrhage, burns, dehydration, oedema.
Some of the specific management measures are; arrest bleeding, administration of intra venous fluids, oral rehydration.
Bleeding per rectal: initially, oxygen has to be provided and the heart of the patient has to be monitored.
IV will be given to administer fluids and for a possible blood transfusion.
Resuscitate the patient –IV fluids, blood
Platelets may be required for those on antiplatelet agents.
Reverse bleeding disorders – colonoscopy with haemostatic techniques like clipping/ adrenaline injections.
If bleeding continues significantly and resources available then embolization.
Hematemesis: endoscopic injections with adrenaline1:10000, thrombin, sclerosant, or saline all halve the risk of bleeding. Tranexamic acid. Omeprazole 60 mg IV stat.
CarakaSaṃhita–sūtrasthāna, kalpasthāna, siddhi sthāna and cikitsā sthāna with cakrapāni commentary
SuśrutaSaṃhita– sūtrasthāna, cikitsā sthāna with Ḍalhaṇacommentary.
Aṣṭāṅgahṛdaya – sūtrasthāna, kalpasthānawith hṛdayabodhika and Āyurvedarasayāna commentary.
Aṣṭāṅgasaṅgraha– sūtrasthāna, kalpasthāna.
ŚāraṅgadharaSaṃhita –pūrvakhaṇḍaand uttarakhaṇḍa. With ahāmalla commentary and Āyurvedadīpikā.
