Vamana (वमनम्)

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Vamana karma is one of the panchakarma procedure wherein there is controlled therapeutic emesis or vomiting. Vamana translates to act of vomiting, ejecting or emesis. Thus, it is a type of shodhana karma (detoxification process) or Panchakarma treatment in Ayurveda where the doshas which are morbid are eliminated from stomach through induced vomiting. Vamana karma is a frontline treatment protocol in the treatment of various kapha dosha related disorders. Vamana karma along with other panchakarma therapies are amongst the most known and widely used procedures not just for treatment purposes but for prevention of diseases that might develop due to seasonal changes as well and are considered as rejuvenating therapies commonly. However, it is not a procedure that can be done casually. It needs thorough screening, expert monitoring, strict compliance to the pre & post diet lifestyle recommendations.

Definition of Vamana therapy

Acharya Charaka has defined the process of vamana as follows,

तत्र दोषहरणमूर्ध्वभागं वमनसञ्ज्ञकम् (Char. Samh 1.4)

Meaning: When the morbid doshas in the body are eliminated through oral route in a controlled manner by vomiting, the procedure is known as vamana karma.

Acharya Sharangadhara in his treatise Sharangadhara Samhita described that, the procedure wherein undigested pitta dosha and kapha dosha (both) are forcibly made to travel towards oral route and by there are expelled out through vomit is called as vamana karma.(shar. purv.4.8)

Etymology

The word “vamana” in Sanskrit is made from root word “vam” which means to eject. Suffix “lyut” is added.

वमन न० वम ल्युट् ।१ मर्दने २ छर्दने मेदि०) (Vachaspatyam)

Vama and lyut pratyaya together makes word vamana.

Meaning, to vomit, to expel, to move or movement.

Indications for Vamana Karma

Before advising the patient for vamana karma, physician considers whether the patient is fit or unfit for vamana 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 vamana karma are,

• Nava jwara(Acute fever),
• Atisaara (diarrhoea),
• adhoga rakta pitta (bleeding disorders),
• rajayakshma (tuberculosis),
• kushta (different types of skin disorders),
• prameha (diabetes),
• arbuda (tumours),
• kasa (cough),
• shwasa (asthma),
• medoroga (obesity etc),
• hridroga (heart diseases),
• apasmara (epilepsy),
• arshas (piles),
• pandu (anaemia) etc. (asht. sutr.27) (char. sidd.2.10) (sush.chik. 33.18)  

Contraindications for Vamana Karma

Vamana is mainly not considered in Vata dosha predominant diseases, where body is highly emaciated, in very weak and very old individuals. Thus, to mention few,

• Ati baala (In infant),
• ati vriddha (very old),
• durbala (weak),
• shranta (tired),
• kshudita (hungry),
• pipasita (excessive thirst),
• bhaaarahata (exhausted from lifting weights),
• garbhini (pregnancy),
• chinta prasakta (suffering from anxiety),
• krimi (worm infestations),
• urdhvaga raktapitta (bleeding disorders having pathology in upper half of body) etc.

Vamana Procedure

The whole vamana therapy is divided in 3 sections,

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

Purva Karma (Pre procedure/before procedure)                                               

It mainly includes the procedure which is supposed to done before vamana karma.

1. Collection of material: Though a very basic karma or part of process it is essential to keep the ingredients and materials required for the therapy ready beforehand. Includes oil for abhyanga, medicines used to induce vomiting, medicines required for dhumapana (therapeutic smoking post vamana) etc. A vaidya may ask patient to buy from the store or the material will be made available by the Vaidya only.
2. Assessment of patient: there is consideration of few aspects in patient or individual before vamana karma. Whether the individual is vamya (indicated for vamana) or avamya (contraindicated for vamana) will be assessed by a vaudya. Ashta vidha pariksha or 8 fold examination of the patient will be conducted. Dosha and balam (strength) of patient will be critically analyzed and on that basis the entire vamana procedure would be planned.
3. Pachana karma: Pachana refers to kindling digestive fire enhancing the digestive strength of the patient. Pachana is done with the help of some oral medications. This procedure prepares body to accept, digest and metabolise the oily or fatty substances which will be given before vamana. This is essential because the body is not used to accept large amount of ghee or oil orally in routine. And ghee or oil given in this stage without pachanam might cause digestive trouble or throw out the the substance as it is.
4. Snehapanam: This is the most important part of purvakarma or pre procedure of vamana. Mostly a medicated ghee is given for oral consumption to a patient before starting vamana. The procedure takes minimum 3 to maximum 7 days before vamana. A Vaidya assesses the patient daily during this procedure and decides whether the snehapana should be continued by the patient on next day or to be kept on hold or to be stopped. Also a vaidya tells the dosage of medicated ghee to be taken on next day after assessment on previous day in certain cases. The entire procedure requires careful monitoring and strict compliance to the dos and donts advised to patient. Medicated ghee and its dosage is decided according to the condition, disease of the individual an dususlaly the ghee is administered in increasing order starting from the minimal dose at the beginning.
5. Abhyanga and swedana: Later, on the day of completion of snehapanam, abhyanga (oil massage) followed by swedanam (steam bath or fomentation) is done for 2-3 days until the day of vamana karma.
6. Diet before Vamana karma: Diet starts from the day of snehapana (oral administration of ghee or oil) which is the chief part of pre vamana procedure. Diet differs during snehapanam and just a day before vamana procedure. During snehapanam, a patient is advised to take food only when the consumed ghee is fully digested, stomach feels light, appetite is felt. On that time easy to digest, light, simple, regular diet is to be taken. However the diet on day prior to vamana is designed specifically to aid the vamana procedure. Individual is advised to take foods which are liquid in consistency, ushna (hot) in potency and which is abhishyandi (heavy and slimy, eg; curd), should not be unctuous and should be clean.
7. Water: Patient is advised to take only warm water from the start to end of the vamana procedure.
8. Every pre procedure plays an important role in the whole vamana karma. In a nutshell with snehapana, there is aggravation and dislocation of the vitiated doshas in the body and when abhyanga and swedana is done these doshas are moved from the distant body parts to stomach, then with the help of vamana dravya these doshas are expelled out from the body through controlled vomiting.
9. 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 Vamana 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 early morning.
2. Once again in the morning Abhyanga and swedana (whole body oil massage and steam bath) of the patient is done.
3. After these procedures and offering prayers to god, The patient is made to sit on a comfortable and relaxed chair. Just before administration of vamana dravya milk, curd, decoction of yashtimadhu (glychirhyza glabra) etc is given to elderly and very young patients, boiled pulses soup(yavagu) mixed with ghee is also given. After that a vaidya gives a vamana medicine to the patient.
4. Dosage of Vamana medicine: Dosage of the medicine used for vamana varies depending on various factors related to the patient and disease. Thus even when a standard dosage for vamana drug is mentioned it is advised to be measured by that individual patient's hand. Acharya Charaka, advises the dose of vamaka dravya (emetic drug) should be as much as patient can hold the drug in his hand’s fist. The commentators of Ashtanga Hrudayam of Vagbhata have specified the parameters on the basis of which the dosage is to be decided. They have advised to decide dosage on the basis of individual’s strength, the disease severity, and more importantly with respect to koshta (digestive ability). Koshta is one another unique and wide concept, but precisely it indicate capacity of the individual to hold the waste products of digestion inside the body. Along with the vamana dravya, a patient might be given suitable liquids like sugarcane juice or milk or some decoction in large amount to drink so as to facilitate easy induction of vomiting and removal of accumulated doshas through that. Vamana dravya (emetic drug) is administered which is based on the above assessment and differs with everyone.
5. Patient is advised to swallow vamana drug at once to avoid initial nausea.
6. After administration of drug, patient is kept under constant observation.  His vitals are checked, nadi pariksha is also done.
7. A large vessel is kept ready to collect the vomitus.
8. Once the bouts of vomiting start, forehead and chest of patient is held by nurse and back of the patient is gently massaged to provide support as well as easy passage of vomitus.
9. Each Vega (bout of vomiting) is observed, counted and assessed by sound, color, taste in patients mouth, consistency, quantity, odor etc.
10. A vaidya carefully monitors the entire process and decides when to give extra medicine or when to stop. There are certain parameters described in treatises on the basis of which a vaidya decides the level of cleansing of vitiated doshas and time to stop vamana. Number of bouts of vomiting, their quantity and certain signs & symptoms are criteria for assessment of grade of purification through vamana. 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), ayoga (insufficient elimination) and atiyoga (excess elimination)
    
11. Individual is further observed for any kind of complications. Distension of abdomen, cutting like pain in anal region, cardiac spasms or ache, excessive discharge of any kind, blood discharge, rigidity and spasms etc. these complications can arise if the vamana karma is done inappropriately. Further treatment is given immediately in any such case.

Pashchat Karma

Once the vaidya decides to stop Vamana the post vamana procedures are considered and these are known as Pashchat karmas. Pashchata karma of vaman include Mouth cleansing, therapeutic smoking, rest, diet plan and some lifestyle related advices.

1. After appropriate vamana 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. Dhumapanam: Dhumapana (धूमपानम्) or inhalation of medicated smoke wherein the dravya or herbs to be smoked are decided based on the health of the patient. Dhumapana is essential procedure to eliminate the remnant kapha dosha which is adhered to bodily channels locally even after vamana.
3. 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 to be avoided after vamana karma.
4. Samsarjana krama: (संसर्जन क्रमम्) It refers to the specific diet plan after vamana karma (rehabilitation diet) which is given for at least 3 to 7 days depending on the grade of shuddhi (purification) happened by vamana. 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.
5. 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 helps the weak digestive state which is present after the vamana karma.
6. 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.
7. 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.
8. Warm water is consumed during samsarjana krama.
9. 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 vamana. Thus if one follows all the diet and other guidelines carefully can recover from illness and also prevent adverse effects of the therapy.

Mode of action of vamana karma

Vamana karma is not just a gastric lavage, or a pathological vomiting, it is a complete systemic cleansing of morbid Kapha dosha having widespread advantages. When vamana drug is given orally, the active principle present in the drug reaches the cell where it forces the cell to release the toxins back in the stomach. From there on the vomiting occurs. This process occurs due to the irritant action of the drugs, which leads to mild inflammation at the site of action. This in turn leads to increased permeability in the capillaries which will allow the absorption as well as excretion of the substances. The vamana drug are given in full stomach when the pyloric end of stomach is closed allowing all the activities of the vamana dravya to remain in stomach itself. At the end of process bile is seen in vomitus due to flux of antiperistalsis set during the process, which means that the pyloric valve is open, and the procedure is completed or the morbid kapha dosha has been completely expelled out.

In a nutshell, vomiting in modern view is a cascade of events which leads to expulsion of upper gastrointestinal contents.

Therapeutic considerations

Vamana is advised even prophylactically in Vasant rutucharya where kapha dosha is seen in prakopa awastha (exaggerated). Mainly in Chaitra month of hindu calendar which is mid-March to mid-April. 

Assessment of the patient before Vamana includes Dashavidha (10 fold examination parameters) and astha vidha pareeksha (8 fold examination parameters)  alongside other clinical examinations like respiratory system examination, Gastrointestinal Tract examination, Cardiovascular examination etc. Blood Pressure, temperature, pulse and other vitals are also checked before, during and after vaamana karma. In certain traditions of vaidys or at institute level, routine blood check up, ECG etc are also done before the patient is posted for vamana.

Vamana is contraindicated in vata dosha related diseases but there can be certain exceptions also, in such cases mild vamana is indicated.