Virechana (विरेचनम्)

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Virechana karma is one another Panchakarma therapy where morbid doshas in the body are eliminated through anal route by inducing purgation in a controlled manner. Virechana literally means evacuation, excretion or purgation. It is a prime method in the treatment of morbid pitta dosha and its related disorders. Virechana karma is most commonly and widely known as one of the detoxification processes. In few traditional Indian houses, purgation is followed in the sharada rtu or lunar calender months of ashvin and karthika masas (mid-august to mid-october) with a minimum quantity of castor oil. But only the purgation and not the whole process of virechana is followed. Although, this must and should be done under the supervision and advise of Vaidya or concerned physician trained in conducting Panchakarmas.

Basti karma, which is another Panchkarma therapy also expels the morbid doshas through anal route, but the procedure and the drug administration are very dissimilar. The drug is administered through anal route in basti while it is administered though oral route in virechana.

Definition

Virechana karma is defined as below,

तत्र दोषहरणमूर्ध्वभागं वमनसञ्ज्ञकम्, अधोभागं विरेचनसञ्ज्ञकम्; उभयं वा शरीरमलविरेचनाद्विरेचनसञ्ज्ञां लभते (Char. Samh. 1.4)

Meaning: The procedure in which the morbid doshas are expelled out from body through mouth is called as vamanam, Iwhere these doshas are expelled out via) anal route by (controlled and therapeutic) purgation is called as virechana karma. Since by any route the morbid doshas in body are eliminated or evacuated both of these karmas can be called as virechana.

However virechana refers to theraputic purgation as a general rule.

According to Sharangdhar Samhita (purv. khan.4.25) virechana karma is  a process wherein the virechaka dravyas (purgative drugs) expel the digested or undigested food particles through anal route.

Etymology

In Vachaspatyam, etiology of the word virechanam can be found.

वि + रिच--णिच्--ल्युट् । मलादेर्निःसारणे

According to this etyology, the word Virechana is derived from the root 'ric' which means to expel. The term virechanam can be spit into 3 parts as below,

Vi – upasarga (prefix)

ric- dhatu (root)

Lyut- pratyaya (suffix)

Meaning- to expel or evacuate the mala (impurity).

Thus, expulsion of morbid doshas or malas (impurities) of body is known as virechanam. In Ayurveda this term specifically indicates such expulsion through anal route by purgation which is done in a controlled manner as a theraputic procedure.

Indications for Virechana Karma

Before advising the patient for virechana karma, physician considers whether the patient is fit or unfit for virechana procedure.

Indications for any panchakarma are mainly based on the dominance of dosha in a particular disorder and the site at which dosha provokes.  Thus, to mention few, indications for virechana karma are,

• Gulma (swelling in abdomen)
• Arshas (piles/haemorrhoids)
• Visphota (skin eruptions)
• Kamala (jaundice)
• Jeerna Jwara (chronic fever)
• Vidradhi (abscess)
• Timira (eye condition)
• Krimi (worm infestations)
• Vrana (wounds and ulcers)
• Pakvashaya vyatha (intestinal conditions)
• Vatarakta (gout)
• Apasmara (epilepsy)
• Yoni dosha (reproductive diseases) etc.

Contraindications for Virechana Karma

Virechana is not advised in Kapha dosha predominant diseases. In such cases virechana may not be carried out successfully due to excess kapha dosha hampering the action of virechaka dravyas (Purgative drugs). Inappropriately conducted virechana then can lead to complications. Also in individuals who have very weak digestive strength (agni) and overall strength (Balam), virechana is not recommended.

There are certain conditions listed in the classical treatises wherein Virechana karma is not advised by Ayurveda acharyas,

• Alpa agni (weak digestive fire)
• Adhoga raktapitta (bleeding disorders through lower orifices)
• Kshatakshina (emaciation)
• Atisaara (diarrhoea)
• Baala (infant)
• Kshama (weak)
• Garbhini(pregnant)
• Abhighata (injury)
• Durbala(weak)
• Madatyaya(alcoholic)
• Durbala indriya(weak sensory organs) etc

Procedure

The procedure of virechana karma is divided in 3 steps

1. Purva Karma (pre procedure/before procedure)
2. Pradhana Karma (main procedure)
3. Pashchat Karma (after procedure)

Purva karma

Before assigning the patient for Virechana karma it is essential to decide whether the individual is fit for virechana karma. If condition of patient is not appropriately checked there are high chances of complications.

Purva karma (Purva- pre, Karma-procedure) includes the process which involves everything which is to be done before the actual virechana karma,

1. Collection of materials- This includes keeping all the essential material, equipments, medicines to induce purgation or to manage complications ready beforehand. Few medicines and oil for abhyanga might be asked by your Vaidya to be brought from store.
2. Assessment of patient – Patient or individual will be assessed on the basis of various parameters like, Dashavidha pareeksha or 10-fold examination which includes assessment of prakrti of patient, aggrvated doshas, balam (strength), Kala (time of the year and climate), age and many other aspects. Ashtavidha pareeksha or 8-fold examination which includes nadi (pulse), bowel, bladder movements etc. This assessment is essential to know the strength of the patient and dose fixation. Virechana is not given to patients aged below 16 and above 70 years of age. Patient’s blood pressure, pulse and various systemic examination will also be carried out when necessary. Basic biochemical test is done if necessary.
3. Deepana and pachana karma – This is one the important pre procedure which involves kindling of digestive fire and enhancing the metabolism through medicines before posting the patient for virechanam and starting the snehapanam (oral administration of medicated ghee or oil). Deepana and pachana dravyas (drugs) are administered orally before virechana karma to prepare the body for digestion of heavy quantities of ghrita, Virechana medicine etc which will be decided by the Vaidya.
4. Snehapanam – Snehapana (Sneha- an unctous substance like ghee or oil, pana-to drink) or administration of medicated ghee is essential before virechana karma. For a period of 3-7 days in the morning, medicated ghee is administered orally in escalating pattern until Vaidya decides to stop on the basis of signs and symptoms of oleation (snehanam) in the patient's body. The dose and period are decided based on the digestive ability of individual and signs of proper oleation (Snehanam) in the body. Appropriately done snehapanam is crucial for proper conduction of virechanam.
5. Abhyanga and swedanam – Abhyanga with medicated oil is done followed by swedana (sudation or fomentation or full body steam bath) after completion of snehapana until the day of virechana,. Usually there is gap of 2-3 days between completion of snehapanam and the day of actual virechana karma and in this gap abhyanagm and swedanam is done
6. Diet before virechanam karma– Dietic regimen during the snepana is strictly followed to ease the process the virechana. Virechanam required high pitta dosha in body, thus after snehapana patient is advised to consume food, which is liquidy in nature and hot in potency, it should not be too unctuous. A day before virechana karma patient is advised to take laghu (light), ushna (hot), drava (liquidy), snigdha (unctuous), phalaamla rasa (juice of sour fruits) etc.
7. Water -Dduring this entire process of virechanam, the patient is advised to take lukewarm water whole time.
8. Matra nirnaya (dose fixation) – The dosage of virechana dravya is decided based on parameters like agni (digestive fire), roga balam (severity of disease), rogi balam (strength of patient), formulation of drug like churna (powder), kvatha (decoction), etc

Individual or patient is well acknowledged about the procedure beforehand. To keep the patient in good mental health, patient is required to have a good sleep, overhead bath, worn clean clothes, worshiping deities. Thus, a positive, happy and calm atmosphere is necessary.

Pradhana Karma

1. On the day of Virechana karma, the patient is advised to remain empty stomach. After the daily morning routine like brushing, bowel movement and bathing the patient is advised to reach the panchakarma clinic in the morning.
2. Once again in the morning Abhyanga and swedana (whole body oil massage and steam bath) of the patient is done.
3. Administration of virechana dravya- After these procedures and offering prayers to god, the patient is made to sit on a comfortable and relaxed chair. It is essential to administer drug or virechaka dravya after kapha kala has passed (early morning period with cold in the atmosphere is known as kapha dominant time) thus the medicine is given around 9am till 11am in the morning on empty stomach.
4. Observation and advises – Patient must gargle with hot water to avoid initial nausea due to drug.  Patient is advised to take rest, not get exposed to cold winds or air conditioners. Hot water is given at repeated intervals for easy and unhindered vegas (bouts) of purgation.  Hot water bag for abdominal fomentation might be given. The vegas (bouts) of virechana take time to start compared to vamana vegas (bout), thus patient must wait and be attentive. Patient is told to observe color, quantity, odor etc of the each vega and inform to Vaidya. This helps to understand the elimination of morbid doshas and extent of purificaiton. The purification might occur in varying number of vega (bout) which are influenced by few factors like strength of medicine, age of patient, strength of patient, strength of disease etc.
5. There are certain features stated by acharyas to assess whether the procedure has been done appropriately and if the doshas have been eradicated completely indicating samyak yoga (appropriate elimination), ayoga (insufficient elimination) and atiyoga (excess elimination). Vaidya observes these features and accordingly takes a call to continue or stop the process of virechanam.
6. Once the virechanam karma is completed patient is assessed for presence any kind of complications like, Adhmana (Distension of abdomen), parikartika (cutting like pain in anal region), hridgraha  (cardiac spasms or ache), srava (excessive discharge of any kind), jivadana (blood discharge), graha (rigidity and spasms) etc. these complications can arise if the virechana karma is done inappropriately. Further treatment is given immediately in any such case.

Pashchata Karma

Once the vaidya decides to stop virechana karma, the post virechana procedures are considered and these are known as Pashchat (post) karmas. Pashchata karma of virechanam include Mouth cleansing, rest, diet plan and some lifestyle related advices. These post procedures are similar to the post procedures of vaman karma except the therapeutic smoking part which is not done after virechanam.

1. After appropriate virechana karma patient is made to wash mouth clean with warm water and must rest in a room where there is not direct exposure to cold air or fan or AC.
2. There are certain behavioral instructions stated to avoid further complications.  Patient should avoid sitting or standing in one position for too long, long walks must be avoided, speaking loudly, anger, grief, exposure to excessive cold, sunlight, winds etc. sexual indulgence, sleeping during daytime, staying awake late at night are few restrictions imposed on patient after virechana karma.
3. Samsarjana krama: (संसर्जन क्रमम्) It refers to the specific diet plan after virechana karma (rehabilitation diet) which is given for at least 3 to 7 days depending on the grade of shuddhi (purification) happened by virechanam. It is to be started from the same day (evening) of the procedure or on the next day morning if there is any vitiation of doshas observed and remaining doshas are yet to be eradicated.
4. On the first day or as a first meal, “manda” (मण्डम्) is given. It is ideally made with red variety of rice which is a gruel like food preparation which is given for three consecutive meals. This kind of preparation is liquid in nature and supports the weak digestive state which is present after the virechana karma.
5. For the next 1 or 2 consecutive meals “vilepi” (विलेपी) which is again a kind of gruel, made with red type of rice is given. This is semisolid in consistency.
6. After this, "odanam” (ओदनम्) which is a well cooked rice made with red rice along with mudga yusha (मुद्ग यूषम् soup from green gram) is given for next one or three meals.
7. Warm water is consumed during samsarjana krama.
8. For the next one or three meals meat soup is given or for vegetarians simple regular diet is started. Later, the patient is expected to have a normal diet.

In this way gradual shift in diet from rice water to normal diet helps one to regain his digestive strength which is significantly hampered in the process of virechana. Thus if one follows all the diet and other guidelines carefully can recover from illness quickly, even permanently and also prevent adverse effects of the therapy.

Mode of action

Virechana karma can be closely related to inducing laxation, purgation, evacuants in modern texts. Laxatives induce mild inflammation in the lower bowel to promote water and electrolyte accumulation and stimulation of intestinal motility. From this view, virechaka dravyas (purgative substances) are mild irritant to stomach and intestinal mucosa to cause inflammation. Thus, permeability of the membrane changes. This mechanism allows quick initial absorption of virechaka dravyas and later leads to excretion of morbid substances due to the active principle present in the drug. Precisely, virechana karma is a whole systemic cleansing procedure rather than induced purgation. The advantages are wide spread and not organ specific.

According to Ayurveda, pitta dosha in body is of 'sara' guna. Sara refers to the instability or precisely outgoing downward movement due to fluid state. Thus the natural way of removing accumulated morbid pitta on daily basis is smooth bowel movements. Naturally when pitta is in excess there should be more bowel movements than normal to excrete it or eliminate it. Thus virechana is believed to be the the best method to eliminate accumulated excess pitta out of the body. According to Charka Samhita the medicines used to carry out virechanam are dominant in prthvi and Jala mahabhutas. Inherently these mahabhutas have downward movement due to heaviness. Thus they tend to expel the doshas by creating the downward movement known an virechanam.

Other therapeutic considerations

After the intake of virechana dravyas vega initiation will take around 60 to 120 mins. Since virechana yoga or medicine needs to be digested before and only then the bouts start. This mechanism depends on the digestive ability of the individual known as agni and dose of the medicine decided by a Vaidya.

In some conditions of bahu kapha (excessive kapha dosha), bouts of purgation start in the evening after the liquefication of kapha dosha. Patient is kept under observation in such conditions.

In some cases, it might happen that the virechaka drug may not work and the bouts of virechana might not start at all. Then the vaidya would reassess the patient and plan the next course of action. May a times virechaka medicine is given again on the same day if there are no vegas (bouts) or dosha elimination seen.

Patient must properly update vaidya about number, color, other features of eliminated wastes and the gap between the vega (bouts) as well.

In few cases vamanam (vomiting) occurs after the intake of virechaka medicine due to initial nausea. In such conditions Vaidya asks patient to wash mouth clean and fasting is done on that day and virechana karma is conducted again on the next day.

Virechana karma is carried out prophylactically in sharad rtu of hindu lunar calander (At the beginning of Ashvin masa mostly) which is mid-august till mid- September under the supervision of a Vaidya. Virechana being the front line shodhana treatment in pitta dosha related disorders and pitta dosha being naturally elevated during sharad rtu the virechana process happens at ease and prevents seasonal diseases due to pitta aggravation.