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

(vachaspatyam)

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

Vama and lyut pratyaya together makes word vamana.

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

(वमथु पु० वम--अथुच् । वमने उद्गिरणे अमरकोषः ।

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

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

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. 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.

Patient must swallow vamana drug at once to avoid initial nausea.

After administration of drug, patient must be kept under constant observation.  A large vessel must be kept ready to collect the vomitus.

Once the bouts of vomiting start, forehead and chest of patient must be held by nurse. Back of the patient’s is gently massaged to comfort the patient.

Each Vega (bout) should be observed, counted and assessed by sound, colour, taste, consistency, odour etc.

There are few parameters addressed by acharyas to assess the vitiation of doshas, and effects after procedure.

SHUDDHI(PURIFICATION)	PRAVARA (high)	MADHYAMA (medium)	AVARA (low)
VAIGIKI (number)	8 vega(bout)	6 vega(bout)	4 vega(bout)
MANIKI (measurement)	2 prastha	1.1/2 prastha	1 prastha
ANTIKI (end effect/product)	Pitta(bile)	pitta	pitta

1 prastha = 640 gm(approx.)

There are certain features stated by acharyas to assess whether the procedure has been done appropriately and if the doshas have been eradicated completely, which are samyak yoga(appropriate), ayoga(insufficient) and atiyoga(excess) lakshanas(symptoms) which are seen in patient or an individual. Following each feature are mentioned below in the tabular form,

(char. siddh.1.15-17)

SAMYAK YOGA(APPROPRIATE)	AYOGA(INSUFFICIENT)	ATIYOGA(EXCESS)
On time vega(bout) initiation	No initiation of vega (bout)	Excessive thirst
Kapha dosha, pitta dosha, vata dosha elimination sequence	Skin eruptions	Delusions
Vega’s(bout) stop by itself	Excess salivation	Giddiness
purification of bodily channels	Itching all over body	Vitiation of vata dosha and its related disorders
Feeling of lightness	Heaviness of body	Excessive Weakness
Cleanliness of the sensory organs	Improper cleansing of channels	Loss of sleep or insomnia
	rashes

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. (char. sidd.6.29)

Pashchat Karma

It includes few dietic and behavioral restrictions and advises after the vamana karma.

1. After appropriate vamana karma patient is made to wash mouth clean with warm water and must rest in a room which is not very well ventilated or where there is not direct air.
2. Dhumapana or inhalation of medicated smoke wherein the dravya or drugs are decided based on the condition of the patient. Dhumapana is essential procedure to eliminate the kapha doshas which are adhered to bodily channels locally. (sush. chik.33.11)
3. There are certain behavioural 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. excessive sexual intercourse, sleeping during daytime, staying awake late at night are few restrictions to be avoided after vamana karma.
4. Samsarjana krama meaning diet after vamana karma (rehabilitation diet) must be given upto seven days depending on the level of shuddhi(purification) that is avara(high), madhyama(medium) or hina(low) shuddhi starting 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” is specifically 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 liquidy in nature and helps the weak digestive ability which is present after the vamana karma.
6. For the next three consecutive meals “vilepi” which is again a kind of gruel, made with red type of rice is given. This is semisolid in consistency.
7. After this,” odana” which is a well cooked rice made with red rice along with mudga yusha(soup from green gram) is given for next three meals. Warm water is consumed during samsarjana krama.
8. For the next three meals meat soup is given. Later, the patient is expected to have a normal diet.

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

Indications for Vamana Karma

Indications for vamana can be categorised according to the dominance of dosha in a particular disorder and the site at which dosha provokes.  Thus, to mention few,

Acute fever, diarrhoea, bleeding disorders, tuberculosis, different types of skin disorders, diabetes, tumours, cough, asthma, obesity, heart diseases, epilepsy, piles, anaemia etc. (asht. sutr.27) (char. sidd.2.10) (sush.chik. 33.18)  

Contraindications for Vamana Karma

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

In infant, very old, weak, tired, hungry, excessive thirst, exhausted from lifting weights, pregnancy, suffering from anxiety, worm infestations, bleeding disorders having pathology in upper half of body etc.

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 principal 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 nut shell, 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 rutu where kapha dosha is seen in prakopa awastha (exaggerated). Mainly in chaitra month of hindu calendar which is mid-March to mid-April.   (char. Sutr.10.46)

Dashavidha(10 fold examination parameters) and astha vidha pareeksha (8 fold examination parameters)  alongside modern clinical parameters, like respiratory system examination, Gastrointestinal Tract examination, Cardiovascular examination etc. also B.P, temperature, pulse etc before and during vamana karma.

Few pathological and biochemical examinations, ECG etc before vamana karma as a routine is done.

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

Patients who are undergoing vamana karma for the first time in them, very low amount of matra(dose) is considered.