Sutrasthana 1.25 — The Two Types of Therapeutics

"Ausadha (medicaments, therapies) is, in brief, of two kinds sodhana (purifictory) and samana (palliative). For the dosas of the body, basti (ememata), vireka (purgations) and vamana (emesis) are the best therapies respectively; likewise are taila (oil), ghrta (ghee, butterfat) and madhu (honey)."

Translation: Prof. K.R. Srikantha Murthy, Ashtanga Hridayam Vol. I (Sutrasthana), Chowkhamba Krishnadas Academy, Varanasi.

Note: Sodhana is the method of eliminating the aggravated dosas from the body forcibly, thus purifying it. Samana is to mitigate the aggravated dosas within the body itself. Murthy's "25." extends into the first half of verse 26 (naming basti, vireka, vamana and taila, ghrta, madhu). Basti (enemas) is best for mitigating vata; purgation for pitta; emesis for kapha. Taila (oil) is ideal for vata, ghee for pitta, and honey for kapha.

With this half-verse, Vāgbhaṭa establishes the most fundamental decision tree in all of Āyurvedic therapeutics. Every treatment ever prescribed — every herb, every procedure, every dietary adjustment — falls into one of two categories: śodhana (purification, elimination) or śamana (palliation, pacification). There is no third option. The physician's first clinical decision, before selecting a specific remedy, is which of these two roads the patient needs.

The Sanskrit is as compact as the principle it states. Śodhanaṃ śamanaṃ ca iti dvividhaṃ tat punaḥ smṛtam — "That [therapeutics] is remembered as being of two kinds: śodhana and śamana." The word smṛtam ("remembered," "traditionally held") signals that Vāgbhaṭa is not innovating here — he is codifying a distinction that predates him, one embedded in the Caraka Saṃhitā and Suśruta Saṃhitā and accepted as axiomatic by every Āyurvedic lineage. The word punaḥ ("again" or "further") connects this half-verse to the preceding discussion of disease — having established what goes wrong, Vāgbhaṭa now turns to what the physician does about it. And the word dvividham ("of two kinds") closes the door on ambiguity. Not three kinds. Not a spectrum. Two.

Let's unpack each term.

Śodhana derives from the root śudh — to purify, to cleanse. In clinical practice, śodhana refers to the active elimination of aggravated doṣas from the body. The doṣas have accumulated beyond what the body can rebalance on its own, so the physician forcibly removes them. This is not gentle. Murthy's note uses the word "forcefully" — the aggravated material is driven out through one of the body's natural exits: the mouth (through vamana, therapeutic emesis), the rectum (through virecana, purgation, or basti, medicated enema), or the nostrils (through nasya, nasal administration). Together with raktamokṣaṇa (bloodletting), these five procedures constitute pañcakarma — the five purificatory actions that represent the most powerful therapeutic intervention in Āyurveda.

The logic of śodhana rests on a specific understanding of pathology. In the Āyurvedic model, disease follows a six-stage progression called ṣaṭ-kriyākāla (the six stages of disease development): sañcaya (accumulation), prakopa (aggravation), prasara (spreading), sthāna-saṃśraya (localization in tissues), vyakti (manifestation), and bheda (differentiation/complications). In the early stages — accumulation and aggravation — the doṣas are still in their home seats: vāta in the colon, pitta in the small intestine, kapha in the stomach and lungs. Here, śamana may suffice. But once the doṣas have spread (prasara) and lodged in distant tissues (sthāna-saṃśraya), the gentle approach often cannot reach them. The pathological material has migrated away from the alimentary tract and settled in joints, skin, reproductive tissue, or the nervous system. Śodhana works by first mobilizing these deep-seated doṣas back to the alimentary tract through preparatory procedures, then expelling them through their nearest exit. It is, in essence, a reversal of the disease process — recalling the doṣas from where they've lodged and driving them out the way they came in.

Śodhana is the heavier medicine. It requires preparation — days or weeks of snehana (oleation, both internal and external) and svedana (sudation, therapeutic sweating) to loosen and mobilize the deep-seated doṣas before they can be expelled. The oleation saturates the tissues with medicated ghee or oil, which dissolves the doṣas from their attachment sites the way oil dissolves resin. The sudation then liquefies them further and drives them toward the digestive tract. Only after this preparation — which Caraka calls pūrvakarma (preparatory procedures) — can the main procedure safely begin.

It requires assessment — the patient must have sufficient bala (strength) to withstand the procedure. And it requires post-procedure care — saṃsarjana krama, the graduated reintroduction of food and activity over days, beginning with thin rice water and progressively returning to normal diet. The body after śodhana is like freshly plowed soil — clean but vulnerable. Improper post-procedure diet can seed new imbalance faster than the disease that was just removed. When properly administered, śodhana addresses the root of the disease by removing the pathological material entirely. The doṣas don't just calm down — they leave.

Śamana derives from the root śam — to pacify, to calm, to bring to rest. In clinical practice, śamana refers to the pacification of aggravated doṣas within the body itself. Nothing is expelled. Instead, the physician uses herbs, diet, lifestyle modifications, and practices to coax the aggravated doṣas back toward equilibrium. Murthy's note captures the distinction precisely: śamana is "to mitigate the aggravated dosas within the body itself."

Śamana is the lighter medicine. It works through the seven classical śamana techniques enumerated by Caraka (Sūtrasthāna 22): pācana (digestive stimulation, using herbs that digest āma without necessarily increasing agni), dīpana (kindling of agni, increasing digestive fire so the body can process its own backlog), kṣut (therapeutic fasting, giving the digestive system space to clear), tṛṣṇā (therapeutic thirst management, calibrating fluid intake), vyāyāma (exercise, which mobilizes stagnant doṣas through movement and heat), ātapa (sun exposure, using the external fire of the sun to dry and warm excess kapha), and maruta (wind/air exposure, using the drying quality of wind to reduce moisture-heavy imbalances). These seven methods don't remove the doṣas — they transform the internal environment so that the doṣas settle back into their proper seats and resume their normal functions. Where śodhana is surgery, śamana is diplomacy.

The distinction between dīpana and pācana is worth a moment's attention, because it illustrates how precise the śamana framework is. Dīpana herbs — like śuṇṭhī (dry ginger) — increase the digestive fire. Pācana herbs — like musta (nut grass) — digest āma (toxic residue) without increasing agni. These are different interventions for different stages of the same problem. If agni is low and āma is present, you need dīpana first (kindle the fire) and pācana second (burn the backlog). If agni is adequate but āma has accumulated during illness, you need pācana alone. This kind of granularity within the śamana framework shows that "palliation" is not a synonym for "doing less." It's a different kind of precision.

The clinical decision between śodhana and śamana depends on three primary factors:

Severity of accumulation. When doṣas have deeply penetrated the dhātus (tissues) and are producing structural pathology — chronic disease, tumor growth, tissue destruction — śamana is often insufficient. The material must be removed. Conversely, when the imbalance is recent, mild, or functional rather than structural, śamana may be all that's needed. The Caraka Saṃhitā offers a useful rule of thumb: if the doṣas are still in their home seats (the alimentary tract), śamana can reach them. If they've spread to the dhātus and srotāmsi (channels), śodhana may be required to pull them back.

Strength of the patient. Śodhana is demanding. The five procedures tax the body's resources significantly — vamana and virecana in particular are depleting events that require substantial vital reserves. A patient who is already weakened by disease, age, or constitutional fragility may not survive the cure. Caraka (Sūtrasthāna 16) devotes an entire chapter to assessing bala before prescribing śodhana, and classical texts are explicit: administering śodhana to a weak patient is malpractice. For these patients, śamana is not a lesser choice — it's the only safe one. The Suśruta Saṃhitā adds that children, the elderly, pregnant women, and the emotionally distressed should generally receive śamana rather than śodhana, regardless of the severity of their doṣa accumulation.

Season and geography. The timing of śodhana matters. Ṛtucaryā (seasonal regimen) guidelines specify which śodhana procedures are appropriate in which seasons — vamana in spring (when kapha naturally liquefies and mobilizes upward), virecana in autumn (when pitta is ready to move downward), basti in the rainy season (when vāta is aggravated and the colon is the optimal route). Administering the wrong procedure in the wrong season risks driving doṣas deeper instead of expelling them. Geography matters too, as the previous verse on deśa established — the environmental doṣa modifies both the disease and the treatment. A physician in a kapha-dominant Anūpa region will prescribe śodhana more frequently for kapha conditions than one in a vāta-dominant Jāṅgala region, where the priority shifts toward nourishing, stabilizing śamana approaches.

What makes this classification so durable is its completeness. Every therapeutic intervention in Āyurveda — from a single herb to a 21-day pañcakarma protocol — is either removing something from the body or calming something within it. There is no middle ground, and there doesn't need to be. The binary is exhaustive. A treatment that eliminates pathological material is śodhana. A treatment that restores balance without elimination is śamana. The physician's skill lies in knowing which the patient needs, and when to shift from one to the other as the disease and the patient's strength evolve over the course of treatment.

A single course of therapy may involve both, sequentially. A patient might begin with śamana to build strength, transition to śodhana when bala is sufficient, and return to śamana for maintenance after the purification is complete. The two are not opponents — they're partners in a treatment sequence, and the skilled physician moves between them the way a sculptor moves between chisel and sandpaper.

Vāgbhaṭa's placement of this verse is deliberate. He has just established the diagnostic framework — doṣa, dhātu, mala, prakṛti, deśa, kāla, bala. Now he turns to therapeutics, and his first move is not to list remedies or procedures but to establish the fundamental binary. This is characteristic of his method throughout the Sūtrasthāna: principles first, specifics later. Know the decision before you know the options. The entire therapeutic content of the Aṣṭāṅga Hṛdayam — the elaborate pharmacology, the surgical procedures, the dietary prescriptions across six sthānas and thousands of verses — is organized under these two headings. Every treatment that follows is either śodhana or śamana. This half-verse is the key that sorts them all.

The binary of eliminate-or-pacify appears independently across the world's major healing traditions. The convergence is not coincidental — it reflects a universal observation about what goes wrong in a body and the two fundamentally different things a physician can do about it.

Greek and Roman medicine. From Hippocrates onward, Western classical medicine distinguished between catharsis (purging, evacuation) and regulation (adjustment of diet and lifestyle to restore balance). Hippocratic catharsis included emetics, purgatives, bloodletting, and diuretics — methods of forcibly removing pathological material from the body. The Hippocratic text On the Nature of Man states that when a humor is in excess, the physician must evacuate it through the nearest available exit — the same logic that drives Āyurvedic śodhana. Hippocratic regulation included dietary modification, exercise, bathing, and changes in air and environment — methods that adjust the body's internal conditions without forcible removal. The structural parallel with Vāgbhaṭa's śodhana and śamana is precise: one removes, the other rebalances.

Galen (2nd century CE) systematized this further, classifying all therapeutics as either evacuative or restorative, and introduced the concept of pepsis — the body's ability to "cook" or process morbid matter before it can be evacuated. This maps almost exactly to the Āyurvedic concept of pācana (digestion of āma) as a preparatory step within treatment. Galen's framework governed European medicine for over a millennium and still echoes in modern gastroenterology's distinction between cathartic and regulatory approaches to bowel disorders.

Unani medicine. Unani tibb inherits the Greek framework through the Islamic medical tradition and formalizes it within a comprehensive therapeutic taxonomy. The Unani physician's therapeutic options are organized into four modes: ilāj bil-tadbīr (regimenal therapy), ilāj bil-ghidhā (dietotherapy), ilāj bil-dawā (pharmacotherapy), and ilāj bil-yad (surgery/manual procedures). Within these, the fundamental distinction between istifrāgh (evacuation — purgation, emesis, bloodletting, cupping, diuresis) and tadīl-e-mizāj (correction of temperament through non-evacuative means) operates exactly as Vāgbhaṭa's binary does. Ibn Sīnā's Canon of Medicine explicitly distinguishes between treatments that expel morbid matter (māddah) and treatments that correct the temperament (mizāj) without expulsion. His decision criteria mirror Āyurveda's with remarkable specificity: the strength (quwwat) of the patient, the maturity (nuzj) of the morbid matter, and the stage of the disease determine whether evacuation or regulation is appropriate. Ibn Sīnā even warns against premature evacuation — expelling morbid matter before it has "ripened" — which parallels the Āyurvedic caution against administering śodhana before proper pūrvakarma (preparatory procedures) have mobilized the doṣas.

Traditional Chinese Medicine. TCM frames the equivalent distinction as xiè fǎ (draining/reducing methods) versus bǔ fǎ (supplementing/tonifying methods). The eight therapeutic methods (bā fǎ) of TCM — sweating (hàn), vomiting (tù), purging (xià), harmonizing (hé), warming (wēn), clearing (qīng), supplementing (bǔ), and reducing (xiāo) — can be sorted into the same binary. Sweating, vomiting, purging, and clearing are xiè methods that expel pathogenic excess from the body — they are śodhana under different names. Warming, supplementing, and harmonizing are bǔ methods that strengthen the body's internal regulatory capacity — they are śamana in a different language. The Huangdi Neijing (Yellow Emperor's Classic) states the principle concisely: "For excess, drain; for deficiency, supplement." The TCM physician, like the Āyurvedic one, must first determine whether the patient's condition is one of excess (shí zhèng, requiring xiè/śodhana) or deficiency (xū zhèng, requiring bǔ/śamana) before selecting specific remedies. Zhang Zhongjing's Shanghan Lun (Treatise on Cold Damage, ~200 CE) builds its entire therapeutic logic on this distinction, specifying which of the eight methods applies at each stage of disease progression.

Tibetan medicine. Sowa Rigpa uses the terms sbyong (purification) and zhi (pacification) — directly cognate with śodhana and śamana. The rGyud-bzhi (Four Tantras, the foundational Tibetan medical text) organizes its third tantra (the Instructional Tantra) along this same axis: gentle remedies that calm imbalance versus forceful procedures that expel it. Tibetan purificatory practices include therapeutic emesis, purgation, nasal cleansing, enema, and gtar (bloodletting from specific points) — a five-fold system that closely mirrors Āyurvedic pañcakarma. The adaptation to Tibetan conditions is instructive: at high altitude, where the thin, cold, dry air dominates, the aggressive depletion of śodhana is riskier. Tibetan physicians tend to rely more heavily on gentle śamana — warming herbs, moxibustion, dietary adjustment — and reserve śodhana for severe or urgent cases. The framework is the same; the calibration shifts with the terrain.

The Yoga tradition. The ṣaṭ-karmas (six purificatory practices) of Haṭha Yoga — neti (nasal cleansing), dhauti (digestive tract cleansing), nauli (abdominal churning), basti (yogic enema), kapālabhāti (skull-shining breath), and trāṭaka (fixed gazing) — are the yogic equivalent of śodhana, purifying the gross and subtle channels before prāṇāyāma and meditation can do their calming work (the yogic equivalent of śamana). The Haṭha Yoga Pradīpikā (2.21) prescribes the ṣaṭ-karmas specifically for practitioners whose doṣas are imbalanced, and states that those whose doṣas are already balanced may proceed directly to prāṇāyāma. This is the same decision logic: if there's excess, purify first; if balance is adequate, pacify and refine. The yogic tradition treats the entire spectrum from gross physical purification to the subtlest mental stillness as different registers of the same śodhana-to-śamana progression.

Western naturopathic and vitalist traditions. The concept of the "healing crisis" — the temporary worsening of symptoms that accompanies deep cleansing — is a recognition that elimination therapy operates differently from palliative therapy. Naturopathic physicians trained in the Thomsonian or eclectic traditions distinguished between "alterative" treatments (which gently shift the constitution over time, akin to śamana) and "heroic" treatments (which forcibly expel pathological material, akin to śodhana). Sebastian Kneipp's water cure, the European fasting traditions of Paracelsus and Buchinger, and the American hygienic movement of Shelton and Ehret all operate on versions of this binary. The debates within naturopathy about gentle versus aggressive intervention — still very much alive — are a modern reenactment of the same clinical decision Vāgbhaṭa formalized fourteen centuries ago.

Across all these systems, the same clinical logic holds: when the body is burdened with excess that it cannot process on its own, the physician must help it expel the burden. When the body's own regulatory capacity is intact but misdirected, the physician adjusts the conditions so the body can rebalance itself. These are two different problems requiring two different solutions, and every physician in every tradition — whether they say śodhana, catharsis, istifrāgh, xiè, or sbyong — must answer the question before reaching for a remedy.

Strip away the Sanskrit, the Greek, the Chinese, the Arabic — and what remains is a question every person faces when something is wrong, whether in the body, the mind, or the life:

This is not a medical question alone. It's a diagnostic framework for any stuck situation. Some problems are caused by an excess that must be eliminated — a toxic relationship, a destructive habit, an unprocessed grief that has lodged in the tissue. No amount of adjustment will fix what needs to be expelled. Other problems are caused by a misdirection of forces that are, in themselves, healthy — misapplied effort, scattered attention, a good impulse expressed in the wrong context. These don't need elimination. They need redirection. The forces themselves aren't the problem; their arrangement is.

The universal principle: the nature of the imbalance determines the nature of the remedy. Applying śamana (gentle rebalancing) to a condition that requires śodhana (elimination) produces the frustrating experience of doing everything right and seeing nothing change. The diet is clean, the practices are consistent, the intention is sincere — but the underlying accumulation remains because it was never expelled. Conversely, applying śodhana to a condition that requires śamana — forcible removal of something that just needs recalibrating — creates unnecessary disruption. Quitting a job that needed restructuring. Ending a relationship that needed a conversation. Fasting when the issue was timing, not quantity.

Vāgbhaṭa's binary is a thinking tool. Before acting on any imbalance — physical, emotional, relational, professional — ask: is this an accumulation problem or an arrangement problem? The answer determines whether you need to purge or adjust, cut or redirect, release or reorganize. The question is simple. The honesty required to answer it is not.

There's a deeper layer here. The two approaches correspond to two different relationships with discomfort. Śodhana says: this must go. It requires the willingness to face the temporary intensification that comes with any genuine purge — the fever before the clearing, the confrontation before the peace, the grief before the release. Śamana says: this belongs here, but it's in the wrong proportion or the wrong place. It requires the patience to work with what is, adjusting conditions gradually until the system finds its own equilibrium. Both require discipline. Neither is the easy path. But they're different kinds of difficulty, and confusing them — applying patience where courage is needed, or applying force where patience is needed — is how people stay stuck for years.

And here is the part most people resist: śodhana is uncomfortable. Elimination therapy — whether it's a pañcakarma procedure, a difficult conversation, or the release of a pattern that has defined you for years — involves a period where things get worse before they get better. The aggravated material has to move through the system on its way out. The temptation is to stop midway, to switch to the gentler path of śamana because the discomfort of elimination feels like harm. But a half-completed śodhana is worse than no śodhana at all — the mobilized doṣas, now dislodged but not expelled, settle into new locations and create new problems. The same is true of any incomplete purge in life. If you're going to eliminate, complete the process.

The converse trap is subtler. Some people default to śodhana for everything — the perpetual cleanse, the serial purge, the person who is always detoxing, always cutting things out, always in crisis-mode removal. This is śodhana misapplied as identity. The body — and the life — need substance as well as space. There comes a point where the purification is complete and what's needed is the quiet work of śamana: nourishment, maintenance, the unglamorous daily care that keeps things running well. Knowing when to stop purging and start building is as much a skill as knowing when to start purging in the first place.

The śodhana/śamana framework translates directly into modern health decisions, and it resolves a confusion that traps many people: the belief that gentle, gradual lifestyle adjustment is always superior to more aggressive intervention.

Sometimes it is. And sometimes it isn't. The verse gives us the criterion for deciding.

• Chronic conditions that have not responded to dietary and lifestyle changes after sustained effort. If six months of clean eating, good sleep, and regular movement haven't resolved chronic digestive issues, skin problems, or joint pain, the issue may be accumulated āma (metabolic waste) or deeply lodged doṣas that need to be expelled, not merely soothed. The key marker: the pattern keeps returning despite consistent intervention. That recurrence is the signal that something needs to come out, not just settle down.
• Seasonal transitions, particularly spring and autumn. Classical Āyurveda prescribes vamana (emesis) in spring when kapha naturally liquefies and mobilizes, and virecana (purgation) in autumn when pitta is ready to release. These are the windows when the body is primed to let go. Modern equivalents: a supervised cleanse, a fasting protocol, or a formal pañcakarma program administered by a qualified practitioner. The important word there is "supervised." Self-directed śodhana, particularly the more aggressive procedures, carries real risk.
• After a period of significant dietary excess, medication use (especially antibiotics, steroids, or long-term pharmaceutical courses), environmental exposure, or emotional suppression — situations where material has accumulated beyond the body's capacity to self-correct.

• Early-stage imbalances where the doṣa aggravation is recent and mild. A few days of bloating, a week of poor sleep, a temporary flare of anxiety — these respond to dietary adjustment, herbal support, and lifestyle modification without requiring elimination. Most day-to-day health management is śamana. In fact, effective śamana is what prevents the need for śodhana. The person who catches a vāta imbalance in its first week and adjusts with warm food, oil, and rest will never need the pañcakarma that the person who ignores the same signals for six months will eventually require.
• When strength is low. During illness recovery, pregnancy, postpartum, extreme stress, or in the very young and very old, the body cannot sustain the demands of śodhana. Gentle rebalancing is not a compromise — it's the appropriate intervention for a system without reserves. Pushing elimination on a depleted body does harm. This is a common mistake in wellness culture: the exhausted person who attempts an aggressive cleanse or extended fast, misreading their fatigue as toxicity when it's depletion. Depleted systems need nourishment and stability, not another round of subtraction.
• For mental and emotional imbalances, Vāgbhaṭa himself prescribes śamana-type interventions later in this chapter: dhī (right understanding), dhairya (courage/steadiness), and ātma-vijñāna (self-knowledge) — cognitive and contemplative practices that rebalance the mind without forcible catharsis. Meditation, conscious breathing, and reflective practice are śamana for the mind — they don't expel thoughts or emotions but create the conditions under which the mind naturally reorders itself.

The daily application. Most of dinacharya (daily routine) is śamana — the ongoing, gentle maintenance that keeps the doṣas in balance so that śodhana becomes unnecessary. Oil pulling, tongue scraping, abhyaṅga (self-massage with warm oil), seasonal diet, appropriate exercise, proper sleep timing — these are all śamana measures. They work by continuously adjusting the internal environment rather than waiting for accumulation to reach crisis level. Think of it this way: śamana is the daily maintenance that keeps a house in good repair. Śodhana is the renovation you need when the maintenance was neglected for too long. Both are necessary at different times, but the person who maintains well needs renovation far less often.

The modern śamana toolkit extends well beyond herbs and diet. Anti-inflammatory nutrition, regular movement calibrated to one's constitution and energy level, adequate sleep in a dark room, morning sunlight exposure, cold or warm water therapy, breathwork, prāṇāyāma, time in nature, and the management of stress load through pacing and boundaries — all of these are śamana in modern dress. They don't eliminate anything from the body. They adjust the conditions under which the body operates, allowing the body's own intelligence to restore equilibrium. The seven classical śamana methods that Caraka lists — pācana, dīpana, fasting, thirst management, exercise, sun exposure, and wind exposure — are simply the Āyurvedic vocabulary for the same interventions.

The critical mistake — Using śamana when śodhana is needed. This looks like doing "all the right things" — the perfect diet, the daily practices, the supplements — while the underlying accumulation persists. The symptoms may dampen temporarily but always return because the cause was never removed. If you've been managing a chronic condition with lifestyle measures for years without resolution, it may be time to consult a qualified Āyurvedic practitioner about whether a supervised śodhana protocol is appropriate. The marker of misapplied śamana is cyclical recurrence: the pattern clears, returns, clears, returns, never fully resolving.

The other critical mistake — Using śodhana when śamana is needed. Aggressive cleanses, prolonged fasting, extreme dietary restriction, or emotional catharsis pursued as a habit rather than a targeted intervention — these deplete what doesn't need depleting. Not every imbalance is an accumulation. Some conditions require nourishment, stability, and patience rather than another round of purging. The current wellness culture's bias toward "detox" is a systematic overapplication of śodhana to conditions that require śamana. The marker of misapplied śodhana is increasing fragility: each cleanse leaves the person slightly weaker, more sensitive, less resilient — because the problem was never excess. It was insufficiency.

A simple self-assessment — When facing a persistent health concern, ask two questions. First: is this pattern caused by something that has accumulated and needs to leave? (Congestion, chronic inflammation, sluggish digestion with visible āma on the tongue, a feeling of heaviness and obstruction.) Second: is this pattern caused by a system that's running incorrectly and needs recalibration? (Erratic energy, variable digestion, anxiety, insomnia, sensitivity to stimuli — signs of dysregulation rather than accumulation.) The first answer points toward śodhana. The second points toward śamana. When both are present — accumulation on top of dysregulation — the classical sequence applies: build strength with śamana first, administer śodhana when bala is sufficient, then return to śamana for long-term maintenance.