The necessity of timely Panchakarma treatment, signs and symptoms of excessive and inadequate administration of Vamana and Virechana procedure, and their management etc are explained in 16th chapter of Charaka Samhita Sutrasthana.
Effect of the quality of physician on the result of treatment
A qualified physician is the one, who is
– well acquainted with the principles of treatment,
– who is wise,
– is well-versed in textual knowledge and is prompt in action. T
The patient, who is administered with proper Vamana (emesis) and Virechana (purgation) treatments by such a physician attains happiness and becomes free from diseases.
On the other hand, if a person who only claim to be a physician without any practical knowledge of Ayurveda, administers these therapies, the patients would subject themselves to further complications because of the excessive or inadequate administration Panchakarma treatment.
Samyak Virechana Lakshana
Signs and symptoms of proper Virechana treatment (purgation)
Samyak Virechana Lakshana –
Dourbalya – tiredness, slimness,
Laghava – lightness of the body
Glani – tiredness of sense organs
Vyadheenaam anuta – recession of diseases,
Hrit Shuddhi – Feeling of clarity in heart,
Varna Shuddhi – feeling of clarity in skin, restoration of normal skin complexion,
Kshut Trishna – timely hunger and thirst
Kaale Vega Pravartanam – timely initiation of natural urges. – like defecation, urination etc.
Buddhi Indriya Mano shuddhi – clarity in intellect, sense faculties and mind,
Marutasya Anulomana – Movement of Vata in proper direction in the body.
Kayagneshcha anuvartanam – proper digestion and metabolic activities.
Virechana Heena Yoga Lakshana
Signs and symptoms of inadequate purgation – Virechana Heena Yoga Lakshana –
Shteevana – spitting,
Hrudaya Ashuddhi – chest discomfort, lack of clarity
Utklsehaha shleshma Pittayo – nausea, feeling of increase (overflowing) of Kapha and Pitta
Adhmana – bloating, feeling of distention
Aruchi – anorexia, lack of taste
Chardi – vomiting
Daurbalya – weakness
Alaghava – lack of lightness
Jangha Uru Sadana – stiffness of hip and thighs
Tandra – sense organ tiredness,
Staimitya – stiffness
Peenasa – running nose
Marutasya Nigraha – Obstruction of Vata
Virechana Atiyoga Lakshana
Signs and symptoms of excessive purgation – Virechana Atiyoga Lakshana –
Excretion of faeces, Pitta, Kapha and Vata.
Excretion of liquid through anus, resembling a mix of water from blood, fat and muscle tissue.
Excretion of black coloured blood without Shleshma (Kapha) and Pitta.
The patient will be afflicted with thirst and he may faint due to vitiated Vata. [5-10]
Vamana Atiyoga Lakshana
Signs and symptoms of over-emesis – Vamana Atiyoga Lakshana –
They are same as signs of excessive purgation. Over-emesis may cause the diseases of the head and neck due to the vitiation of Vata and disturbance of speech. Hence one should consult only such physician who is well-qualified for the administration of the therapy and who can ensure longevity and happiness. [11-12]
Indications for Vaman and Virechan
Whenever there is excessive aggravation of Doshas, Panchakarma treatment should be done. Signs and symptoms of excessive aggravation of Doshas (Bahudosha) are –
Aruchi – Anorexia, lack of taste,
Sthoulya – obesity
Panduta – Anemia
Gaurava – heaviness
Klama – exhaustion,
Pidaka, Kota, Kandu – eruption of pimples, urticaria, itching
Arati – lack of inclination for work, lack of co-ordination in sense organs,
Alasya – Laziness,
Shrama, Daurbalya – Fatigue, Weakness,
Daurgandhya – foul smell of the body,
Avasaadaka – lassitude,
Vitiation / aggravation(Utklesa) of Kapha and Pitta,
Nidranasha / Atinidrata – sleeplessness or excessive sleep,
Tandra – drowsiness, weak sense organs,
Kalibya – impotency,
Abuddhitvam – impediment to intelligence,
Ashasta swapna darshana – inauspicious dreams,
Bala Varna Pranasha -loss of strength and complexion in spite of the intake of nutritious diet.
In the event of such signs and symptoms, the patient should be administered with emesis and purgation treatment with due regard to the vitiated Dosha and strength of the patient.[13-16]
Advantages of Shodhana (elimination therapy)
By the administration of these therapies the vitiated Doshas are eliminated through the alimentary tract,
Kayagni Vardhana – the digestion and metabolism power gets enhanced,
Vyadhi upashamana – diseases are cured and
Prakruti anuvartana – normal health is restored;
The sense faculties, mind, intelligence, and complexion become clear and gain strength;
The person gains
Bala – strength and immunity,
Psuhti – plumpness, body nourishment
Apatya – off-springs (for those seeking infertility treatment) and
Vrushata – Virlity, good sexual power.
Jaram krichrena labhate – ageing process slows down,
Chiram jeevati – one can live healthily for long time.
Therefore, one should take proper elimination therapy in time. [17-19]
Lasting effect of elimination therapy
Simile regarding the lasting effect of elimination therapy:
The vitiated Doshas that are balanced out by by fasting and digestive drugs, at times get re-aggravated. But those eliminated by elimination therapies (Panchakarma treatment) do not recur. Doshas can be compared with trees. Unless the tree is uprooted from its root, it will grow in spite of branches being chopped off. Such is the case with the vitiated Doshas. They go on causing diseases unless they are eliminated from their very root. [20-21]
Restorative measures after elimination therapy
Elimination therapy reduces Dhatus (body tissues) as well. Hence, after Shodhana treatment, restorative treatment is needed. One should take nourishing diet together with ghee, meat soup, milk and vegetable soup which are good for heart.
He should also have massage, unction, bath, Niruha (decoction enema) and Anuvasana (oil enema) types of enema. By doing so, one attains happiness and longevity.[22-23]
Management of over and under elimination
People who suffer from Atiyoga – excess of Panchakarma treatment, should drink ghee or take sweets prepared with oil and ghee.
Anuvasana (oil enema) Basti can be administered in them,
For those who suffer from Ayoga – inadequate Panchakarma, should be given oleation treatment followed by elimination therapy, with due regard to the dose, time, strength of patient and other relevant factors.
Management of complication arising out of improper oleation, fomentation and elimination therapies as well as post-elimination dietetic program will be subsequently explained in Siddhisthana. [24-26]
Theory of natural homeostasis
Disturbance in the equilibrium of body tissues (Dhatus) is caused by disturbance of causative factors of health. Balancing of causative factors of health leads to health. Being healthy – is the natural state of the body. Hence, the imbalance gets cured naturally and automatically 
Destruction as a passive phenomenon
There is a causative factor for the manifestation of beings but no causative factor as such exists for their annihilation. Some are of the view that annihilation of beings is caused by the non-effectiveness of the causative factors of health. 
Questions against the theory of natural homeostasis
After listening to those words, Agnivesha inquired, “if disease can be cured automatically then what are the necessities of a qualified physician? What are those imbalanced Dhatus that are brought to normalcy by physician? What after all, does the treatment amount to? What is it prescribed for? When the purpose for which the treatment is prescribed, is automatically served what is the use of any treatment at all[29-30]
Answer in favor of the theory of natural homeostasis
Lord Punarvasu replied. “I shall explain to you the views of sages in this connection. The causative factors for the annihilation cannot be comprehended because such factors do not exist at all. This is on the analogy of time. Time is always in the process of quick movement, it automatically goes on changing or destroying itself. No causative factor as such exists which causes movements, change or destruction of time. So all things that are produced, perish naturally, without any cause. [31-32]
So no causative factor exists for the annihilation of a being. Therefore, there is no possibility for bringing out a change in the destruction pattern of a being. 
Definition and aim of treatment
साचिकित्सा विकाराणां कर्मतद्भिषजां स्मृतम्||३४||
Those processes that exples the imblanced doshas and bring about equilibrium is called as Chikitsa. It is the duty of Physician.
The purpose of such action is to prevent the disturbance of the equilibrium of Dhatus and maintain their equilibrium. By avoiding causing factors and adopting those responsible for the maintenance of equilibrium, discordance of Dhatus is automatically prevented and their normal state of equilibrium is maintained.
By taking recourse to disease causing factors, the physician well versed in treatment brings about equilibrium of dhatus and so he is the bestowed of physical happiness and longevity. By virtue of his ability to bestow physical happiness and longevity, physician is verily regarded as a donor of virtue, wealth and desires pertaining to this world and the world beyond.[34-38]
The duties of a qualified physician, defects of an unqualified one, signs and symptoms of adequate, inadequate and excessive administration of elimination therapies, signs and symptoms of patients with aggravated Dosas, benefits of elimination therapy, principles of treatment of complications that arise during the administration of the elimination therapy, the propriety of treatment and duties of a physician- all this has been dealt with by the sage in this chapter on the “Duties of a Qualified Physician.”[39-41]
Thus ends the sixteenth chapter on the “Duties of a qualified Physician” of the Sutra Section of Agnivesa’s work as redacted Caraka.
Here ends the fourth quadrate on the” Therapeutically Processes.