Pradhana Karma consists of the five techniques mentioned earlier. Each of these techniques is meant to purify a particular dosha (vata pitta, kapha) in the body.
A. Vamana (emesis)
Emesis is usually given for kapha type of disorders. Today it is not very commonly practiced. After sneha, sveda, if the patient has a good digestion and a pleasant sleep, the patient is made to consume specific types of gruel, milk, fish, curds etc. Next morning the patient is given a paste of emetic drugs followed by intake of an emetic decoction. It is mentioned that it should be done on an auspicious day after chanting certain mantras. After a muhurta (around 48 minutes), the person starts getting bouts of vomiting. If the bouts are insufficient, consuming lukewarm emetic decoction should induce it. The spells of vomiting and the quantity differ according to the dose of medicine consumed. Generally four, six, eight spells are considered good in minimum, medium and maximum types of emesis.
After vamana, certain inhalation is given with medicated smoke. Complete rest is taken on that day, and in the evening the patient is given thin gruel.
What the restrictions in the diet and routine, management of complications, effects of good vomiting, what drugs to be used in each stage are few other topics detailed in the classical texts.
Vamana is good for all kapha disorders. It helps in improving sleep and reducing excessive sleep; it is useful in treating mental disorders, asthma, epilepsy, skin diseases (visarpa, kushtha), anaemic conditions, migraine, kapha type of heart conditions, tumours of the neck, poisoning, infertility and minor conditions like pimples etc.
Emesis is given in fever which is new, diarrhoea, bleeding through orifices of lower part of the body, tuberculosis type conditions, leprotic conditions and skin disorders, diabetes, goiter, tumours, filariasis, mental disorders of kapha type, cough, dyspnoea, nausea, disorders of breast milk and diseases of upper part of the body, where there is predominance of kapha.
Pregnant women, persons with dryness of the body and hunger, the exhausted, children, the aged, the emaciated, the obese, patients with heart disease, wounds, vomiting condition, enlarged spleen, blindness due to cataract, worm infestation, upward movement of vata or haemorrhoids. It is also avoided for those who have been given enema, who have loss of speech, dysuria, enlargement of abdomen with fluid accumulation, tumour in abdomen, who respond poorly to emesis or have strong digestion, giddiness, enlargement of the prostate, pain in flanks, diseases caused by vata except for those who are suffering from poisonous affections, indigestion or have taken incompatible food.
B. Virechana (purgation)
Purgation is mainly done for pitta type of conditions. It also takes care of the kapha, which is located in the place of pitta. In the Panchakarma procedure, virechana is done after vamana. In this case again snehana and sveda have to be done. Virechana medication is given in the morning. The materials, dosage etc are decided based on the condition, strength, digestive capacity and bowel habits of the patient, dosa involvement and season.
Small quantity of warm water can be consumed till one gets complete evacuation. It could also prevent dehydration. According to the classical texts, ten, twenty and thirty evacuations are considered the best for mridu (mild), madhyama (medium) and uthama (maximum) types of purgation respectively. If the virechana is done after snehana and svedana, it does not lead to complications such as dehydration.
Persons with abdominal tumors, piles, boils on the body, discolouration of face, jaundice including advanced stages, chronic fevers, enlargement of abdomen due to fluid collection, artificial poisoning (gara), vomiting, spleen disorders, abscesses, blindness (timira), cataract (kaca), pain in large intestine, genito-urinary conditions, worm infestation, wounds or ulcers, gout, bleeding through orifices of upper part of the body , disease of blood, suppression of urine, obstruction of faeces, those who are suitable for emesis like skin diseases and diabetes.
Persons suffering from recent fever, less digestive power, bleeding through orifices in the lower part of the body, injury of the rectum, diarrhoea, with foreign body, who have given enema, those who have hard bowel movement, those who suffer from excess oleation and consumption.
General Qualties of Vamana and Virechana
"Budhiprasadam balam indriyanam dhatusthiratvam jvalanasya deeptim
Chirat ca pakam vayasah karoti samsodhanam samyagupasyamanam" [ Astangahrdaya ]
Clarity of intellect, strengthens the senses, stability of body tissues , increased digestive capacity, regulated aging are the effects of purification therapy (if done properly)
C. Vasti (medicated enema)
Medicated enema is highly effective in vata type of disorders. It is also applied in other dosa disorders as well. Vasti is considered as half of the treatment in Ayurveda. There are two types of medicated enema. They are done with decoction (kashaya) and unctuous materials (sneha) like oil, ghee etc. Kashayavasti is known as asthapana, which means, that which stabilize sneha vasti is otherwise known as anuvasana, which means ‘ that which stays along’. Thus anuvasana is considered as a subsidiary to kashaya vasti. A third type of vasti is uthara vasti to treat genitourinary conditions. Vasti is administered with a specially prepared yantra (instrument). Specifications of the instrument are detailed in the texts. Generally kashayavasti is done before food and sneha vasti after food.
Usually kashaya vasti is done after virechana. Initially a few sneha vastis are done to make the pakvasaya (large intestine) unctuous. Kashayavasti is done in the morning after doing oil application and sudation. The patient has to lie on the left lateral side of the body. According to dosa, disease, strength of the patient and age, kashayavasti is prepared. Decoction, paste and oil are added and churned for some time for making a homogenous mixture. Then it is made milky warm. If this is applied cold or very hot it will lead to complications. It takes 10-15 minutes to pass bowels after kashaya vasti. Few seconds after vasti, patient has to lie down on the back. If vasti stays for more than 48 minutes it would lead to complications. Diet and routine restrictions have to be followed. Immediately after the noon food, sneha vasti has to be done. Vasti getting blocked, distension of abdomen, headache, tenesmus, heaviness, upward movement of vasti are a few complications when there is hypo action. When vasti is given in excess, it will result in body pain, stomach pain, hiccups, pain in the naval, heart disease and bleeding from rectum.
There are three types of vasti courses. They are yoga, kala and karma. Yoga vasti includes eight vastis – 4 of kashaya and 4 of sneha in an alternate order. Similarly kala consists of 15 vastis and karma 30.
There are different types of vastis based on the dose, materials used or action. They are dvadasaprasrithika, madhutailika, rajayapana, yapana, lekhana vasti, brimhana vasti, pichavasti, ksheeravasti, siddhavasti etc.,
Uthara vasti is another major technique, which is applied through penis, vagina, or urinary tract. This is effective in reproductive problems, urinary disorders including calculi, uterine, disorders like bleeding, endometriosis, fibroid, vaginal disorders, infertility and delicate pregnancy (with chances of miscarriage)
i) Anuvasana vasti (unctuous enema)
Anuvasana is either given independently or along with kashaya vasti. Thus this has both rejuvenative or nourishing and purificatory effect on the body. As the quantity is relatively less this is given with syringe. A particular quantity of oil or ghee is administered through anal orifice. After giving snehavasti, the patient is asked to lie on the back and the buttocks are tapped with the legs of the patient or with physician’s hand. The legs are lifted up and down two to three times. This is to retain the material inside. After few minutes the patient can move around. Normal motion along with oil would occur after few minutes. It will lead to complication if it stays for more than three yamas. Anuvasana makes the naval region unctuous; it facilitates downward movement of vayu, strengthens the body, and nourishes body tissues. Matra vasti is given in smaller dose. For this purpose generally other purificatory techniques are not done.
Persons of powerful digestion, Disease of Vata origin, persons suitable for decoction enema.
Persons not suitable for decoction enema are those suffering from anemia, jaundice, diabetes, rhinitis, lack of food, diseases of spleen, diarrhea, hard bowels, enlargement of abdomen caused by kapha, eye diseases like ophthalmia, obese, worm infestation, gout, goiter, filariasis , and scrofula, who have taken artificial poison (gara)
ii) Kashaya vasti (decoction enema)
Specially prepared decoctions are used for this purpose. The quantity given is one litre or more. Specially prepared instrument is used for administration of vasti. The main purpose of kashaya vasti is purification. It is also given as nourishing or for preventive purposes. The dosage, formulation etc are decided based on the purposes for which it is given.
Persons with abdominal tumour, distention of abdomen, gout, diseases of spleen, diarrhoea (not associated with any other conditions), pain in the abdomen, chronic fever, running nose, obstruction of semen, flatus and faeces, enlargement of scrotum, urinary stone, amenorrhea, vata diseases are suitable for decoction enemas.
The persons who have taken excessive oleation, those suffering from injury to the chest, emaciation, diarrhea due to ama, vomiting, who have undergone purificatory therapies, who have been administered nasal medication, who are suffering from breathing disorders, cough, excessive salivation, piles, flatulence, weak digestion, swelling of the rectum, who have just taken food, who are suffering from enlargement of abdomen due to intestinal obstruction or perforation or fluid accumulation, skin conditions like leprosy, diabetes and pregnant women in the seventh month should not be given decoction enema.
D. Nasya (nasal medication)
Nasya is applied in kapha disorders. This is very effective in disorders above shoulders. It is applied in unconsciousness, headache, hemiplegia, other neurological disorders etc. There are two types of nasya. They are marsa and pratimarasa. Marsa is major type of nasya, which is again divided into uttama (maximum), madhyama (medium) and adhama (minimum) types. Pratimarsa is done in a small dose as a daily routine for healthy people, elderly and children. Nasya can be done either by oil/ghee, juice, decoction, paste or powder. Nasya is given in the morning for kapha disorders, during the noon for pitta disorders and in the evening for vata disorders.
Before doing nasya the face is applied with oil and fomentation is given. Then nasya material is applied to both nostrils in the prescribed quantity. Deep breath is taken through the nostrils itself by keeping the mouth open. If it is powder, then mild blowing of the material into the nostrils is done. Then shoulder, forehead, nape of the neck, both palms are massaged gently. The material that comes out is spitted out. Later medicated smoke is inhaled. After that rest should be taken. Restrictions for diet and routine are same as that of snehana.
There are three types of nasya based on its action. They are sodhana / virechana (eliminative), samana (pacifying), brimhana (nourishing).Virechana type is done for headache, heaviness of head, eye disease, disease of throat, oedema, tumours of the neck, worm infestation, tumours in the body, leprosy, epilepsy and rhinitis. Brimhana type is done for vata type of headache, migraine, loss of voice, dryness of mouth and nose, speech problems, pain and voice, dryness of mouth and nose, speech problems, pain and movement problems in arms. Samana is done for discoloration on the face, diseases of hair and eyes.
Who have just consumed water, alcohol, artificial poison, oleation, or those who wish to consume them, who taken bath, who have had blood letting, acute rhinitis, having natural urges of the body (like defecation, urination, sneezing etc), immediately after delivery, dyspnoea, cough, those who have undergone purificatory therapies, who have been given enema, unsuitable seasons, on sunless days except in emergency during diseases. Nasya is not done for children who are less than seven years or to the old above 80 years.
By doing nasya the shoulders, skin, neck and chest become strong and bright, senses become stable, and grey hairs disappear.
E. Raktamoksha (blood letting)
Apart from this raktamoksha (blood letting) is also considered as one of the techniques in purification. Blood becomes impure due to activities and food that aggravate pitta and kapha. For removing the impure blood, these techniques are used. There are four different types of methods used – Siravedha (cutting the blood vessel), prachana (pricking), jalooka (application of leech), sringa, alabu, ghatika (application of horn etc.) Siravedha takes care of blood all over the body, prachana is good for a specific location, blood that is hardened in one place and deeply rooted should be removed with jalooka (leech) and where there is lack of sense of touch, there horn also should be applied.
In siravedha a particular blood vessel is cut with instrument called kuthari, Snehana, sveda are done prior to that. It is done in the noon (pittakala), A tight bandage is given near the place where blood letting is to be done. The blood vessel is tapped and when it comes up it is massaged. Then the vessel is cut till sufficient quantity of blood is taken out. It is done for mental disorders, epilepsy, headache, tumours of neck, sciatica, arthritis etc.
Prachana: After tying a tourniquet, multiple pricks are made in the skin with a sharp instrument. Blood oozes out of the body and when sufficient amount of blood is passed out the tourniquet is removed and the area is washed with a medicated decoction. Prachana is mainly used in skin diseases.
A small prick is made and leech is applied to the affected area of the body. It is mentioned in the literature that leeches take the bad blood from the tobacco to the mount of it . Leech should be made to vomit and till the blood comes out of the body of it.
Jalooka is used for persons who are weak, young, old and those who cannot tolerate other methods of bloodletting. As leeches have cooling nature these are used in pitta type of disorders. They are commonly used in abdominal swellings, piles, inflammatory abscess, skin diseases, arthritic conditions, eye diseases, poisonous bites, erysipelas etc. There are 12 species of leeches used in Ayurveda and are classified into poisonous and non-poisonous types. Six out of twelve are poisonous and the others are non-poisonous. If poisonous leeches are used for blood letting then complications like itching, inflammation, fever and unconsciousness happen.
The poisonous leeches grow in dead matter, urine, faecal matter of poisonous fishes, frogs, insects, in putrid water etc. The non-poisonous ones originate from the dead matter of lotus, lily, white lily, fragrant white lotus, moss, etc. The non-poisonous leeches are best if collected from yavana (Greece / north west India/Junagad), pandya (Tirunelveli, Madurai districts of Tamilnadu), sahya (northern parts of Western Ghats / and poutana (Paithan on the north bank of Godavari) regions. These have good strength and are fast acting.
A few interesting facts about leeches:
Length of the body ranges upto 20cm and has 34 segments. The digestive system contains a pouch in which food can be stored for several months. They have two suckers. One on the anterior and the other on the posterior end. The saliva of the leech contains a substance that anaesthetizes the wound area, dilates the blood vessels to increase blood flow and prevent the blood from clotting. The anticoagulam Hirudin is used for medicinal purpose.
Srunga, alabu, and ghatika
This is a method of extraction of blood through cupping. Materials like horn (srnga), fruit of a plant (alabu Cucumis lagenarius), or a special type of pot (ghatika) are used. An incision is made on the part where bloodletting is to be done and over that cupping is done by creating a vacuum by burning some material inside the instrument.
Those who are below 16 years old or above seventy, have had bleeding, those who have not undergone sneha and sveda, excessive sveda affected persons, patients suffering from vata condition, women who are pregnant or just delivered, those who have indigestion or diarrhoea, bleeding disorders, breathing disorders, ascitis, vomiting, anasarca or immediately after vamana etc.
Some scholars do not include raktamoska in Panchakarma. A reason mentioned is that Panchakarma is a technique that helps the body to eliminate the materials through its natural orifices in the form o faecal matters, sweat, breath, phlegm, urine etc. Whereas there is no natural way in which blood can come out of the body, bloodletting is not included in this. Apart from this, there are socio – cultural factors that have also influenced this. Bloodletting or other surgical interventions were considered a taboo and unclean during some period in the history when the concept of ahimsa was prevalent. Another reason was that the rakta was not included a dosa. Even then raktamoksha was appreciated by many classical authors describing it as one of the best techniques for rakta vikara (blood disorders).