Vamana Virechana – Emesis and Purgation – Ashtanga Hridayam Sutrasthana 18

This chapter explains in detail regarding Vamana and Virechana Panchakarma procedures. Who are best suited for these therapies, who are not, what are the signs to observe during the procedure, complications and treatments for such complications. It is the 18^th Chapter of Ashtang Hridya Sutrasthana. It is called as Vamana Virechana Vidhi Adhyaya. 

Shloka recitation video

Vamana – Emesis should be administered for increase of Kapha either alone or in combination with other Doshas where Kapha is predominant.
Virechana – purgation should be administered to treat increase of Pitta – alone or in combination with other Doshas where Pitta is predominant. 1

Persons suitable for Vamana

Persons suitable for Vamana procedure – Vamana Arha
Emesis should be administered to persons suffering  from
Navajwara – fever of recent origin
Atisara – diarrhoea, dysentery
Adha:pitta – Pitta imbalance in lower part of abdomen
Pittasruk – Bleeding disorder due to Pitta imbalance
Rajayakshma – Chronic Respiratory disorder
Kushta – skin diseases
Meha – diabetes, urinary tract disorders
Apachi, Granthi – Goiter, tumor, fibroid
Shleepada – Elephantiasis, Filariasis
Unmada – Schizophrenia
Kasa – cough, cold
Shwasa – Chronic Respiratory tract disease, Asthma
Hrullasa – nausea
Visarpa – herpes
Stanyadosha – vitiated breast milk
Urdhvaroga – diseases affecting neck and above region  1b-2b

Persons not suitable for Vamana

 Persons not suitable for Vamana Panchakarma – Vamana Anarha – Avamya
Garbhini –  The pregnant woman,
Rooskha – persons who are dry –not undergone oleation therapy,
Kshudhita – hungry,
Nitya Dukhita – constantly grief-stricken,
Children, old persons,
Krusha – the emaciated,
Sthula – the obese,
Hrudrogi – patient of heart disease,
Kshata – the wounded,
Durbala – weak, debilitated,
Who are having bouts of vomiting,
Pleeha – enlargement of spleen,
Timira – blindness,
Krimikoshta – intestinal parasites,
Upward movement of vata and Asra- blood,
Soon after administration of Vamana,
Who have loss of speech, dysuria,
Udara – ascites, intestinal obstruction,
Tumor of the abdomen,
Who faced difficulties during Vamana therapy,
Who have strong digestive activity,
Arsha – hemorrhoids
Urdhva Vata – upward movement of air – reverse peristalsis,
Giddiness / Dizziness – enlargement of the prostate,
Parshva vata – pain in the flanks and diseases caused by vata;
Person suffering from poisoning,
Indigestion and who have consumed  incompatible foods. 3b-6

Persons suitable for purgation

Virechyah – persons suitable for purgation therapy:-
Diseases requiring purgation therapy are-
Gulma – Tumors of the abdomen,
Arsha – Piles,
Visphota- blisters,
Vyanga – discolored patch on face,
Kamala – Jaundice, Liver disease
Jeernajwara – Chronic fever,
Udara – ascites, intestinal obstruction
Poisoning, Chronic poisoning
Chardi – Vomiting
Pleeha – Disease of the spleen, Splenomegaly,
Haleemaka – advanced jaundice,
Vidradhi – Abscess,
Timira – blindness,
Kacha, Syanda – Cataract
Pain in the large intestine,
Diseases of male and female urogenital system
Wounds/ Ulcers,
Vatasra – Gout,
Urdhwarakta – bleeding disorders of upper parts of the body (such as nasal bleeding)
Diseases of blood vitiation,
Mutraghata – Dysuria
Shakrut graham – constipation
Those persons who are Suitable for emesis therapy- enumerated in earlier verses commencing with “ those suffering from Kustha” are curable- to be treated with purgation therapy. 8-10a Those diseases are –
Kushta – skin diseases
Meha – diabetes, urinary tract disorders
Apachi, Granthi – Goiter, tumor, fibroid
Shleepada – Elephantiasis, Filariasis
Unmada – Schizophrenia
Kasa – cough, cold
Shwasa – Chronic Respiratory tract disease, Asthma
Hrullasa – nausea
Visarpa – herpes
Stanyadosha – vitiated breast milk
Urdhvaroga – diseases affecting neck and above region

Persons not suitable for purgation

 Contra indication for Virechana – Avirechya – Virechana Anarha–
Navajwara – fever of recent origin
Alpa Agni – poor digestive activity,
Adhoga Raktapitta – bleeding disease of lower part of the body (such as bleeding per rectum)
Wounds, Ulcers of the rectum
Atisara – diarrhoea, dysentery
Sashalya – foreign bodies;
Who have been administered decoction enema,
Krurakoshta – Persons who naturally have hard bowel movement,
Atisnigdha – who have undergone excess of Oleation treatment
Shosha – emaciated 10b-11

Emesis therapy procedure

 Vamana Vidhi- Procedure of emesis therapy:-
Next, during temperate seasons, after administering oleation and sweating therapy properly,
On the day previous to the day of emesis,
Make sure that the patient has slept well the previous night.
Make sure that his previous food is well digested.
In the morning of the previous day of Vamana, at first, auspicious rituals are carried out.
Next, Kapha Dosha is excited in the patient by administering peya (drink) / thin gruel prepared from fish, Masha (black gram) ,Tila (Sesame) etc. added with little quantity of fats, in the morning.

On the day of Vamana, again, it is made sure that the patient’s previous food has got digested and he had slept well.
He is either maintained on empty stomach or a little quantity of ghee is given.
The aged, children, the debilitated, VIPs and cowards, should be made to drink wine, milk, sugarcane juice or meat juice added with honey and Saindhava salt, appropriate to the disease, to their maximum capacity.
Later, after determining the nature of his bowels (Intestines – Koshta), the emetic drug is administered sanctifying it with the following hymn-

“Let Brahma, Daksa, Ashvinis, Rudra, Indra, the Earth, Moon, Sun, Air, Fire, Sages, comity of herbs, and of living beings protect you; let this medicine be to you like  Rasayana for the Sages, Nectar for Gods and Sudha for the good serpents; Om, Salutations to the medicine.” Uttering these hymns, he should drink the medicine, facing east. 12-18a

Note: The medicine given for Vamana depends on the disease. It usually contains Madanaphala (Randia spinosa), Licorice etc. Various combinations of Vamana drugs are discussed in a later chapter.

Vamana Vidhi – Procedure of Vamana –
After consuming the medicine, he should await for one Muhurta – 48 minutes for the commencement of vomiting, with keen intent.
With the appearance of oppression in the chest and salivation he should try to vomit.
If the bouts are not coming up easily, he should tickle his throat either with his fingers or a soft tube without injuring the throat,
Sitting on a seat of the height of one knee, the bouts of vomiting should be held supported by another person.
His umbilical region and back should be massaged in upward direction. 18-21a

In case of increase of Kapha, vomiting should be induced with drugs having properties like penetrating, hot and Pungent (Teekshna, Ushna, Katu);
In case of Pitta with drugs of sweet and cold properties and
In case of association of Vata with Kapha, with drugs of Unctuous, sour and salt properties. (Snigdha Amla Lavana) 21b-22a

Vomiting should be allowed till the appearance (coming out) of Pitta or complete expelling of Kapha. 22b

If bouts are insufficient, they should be induced again and again by drinking water boiled with Kana, Dhatri, Siddhartha and salt. (Long pepper, Amla, White mustard and black salt)

Less bouts – Ayoga – Non – commencement of bouts, bouts coming on with hindrance or elimination of the medicine only – are the features of Ayoga– inadequate bouts; from it arise, excess of expectoration, itching, appearance of skin rashes, fever etc. 23b-24

Proper bouts – Samyak Yoga –
Kapha, Pitta and Vata coming out in successive order, without any hindrance,
Calmness of the mind and cessation of vomit bouts on its own,
Absence of features of inadequate bouts and
Feeling of not too much of discomfort are the features of samyagyoga- proper bout .25a

 In Atiyoga- excess bouts the vomited materials will be frothy,  with glistening particles and blood;
The patient will experience weakness, burning sensation, dryness of the throat, giddiness, powerful disease of vata origin and even death due to discharge of life supporting blood. 25b-26

Care after emesis therapy

Care after vomiting therapy – Vamanottara Upachara–
After  the patient had proper bouts of vomiting, he should be comforted with encouraging words, made to inhale any one kind of smoke (Dhuma)- mild, medium, or strong, and then allowed to follow the regimen similar to after-care of oleation therapy. 27

Then, either in the evening  or next morning, after feeling hungry, after bath with warm water, he can eat the mass prepared with red rice or if he is not feeling hungry he should adhere to the following regimen of Peya (Thin gruel) etc. 28 This regimen is called Samsarjana Karma.

Diet regimen – Samsarjana Krama

 Samsarjana – Peyadi Ahara Karma– Regimen of liquid Diet –
Persons who have had the maximum, medium and minimum purificatory therapies, should consume Peya- thin Gruel,
Vilepi- thick Gruel,
Akruta Yusa- soup not processed with fat, salt, sours etc.
Krutayusa- Soup processed with fat, salt and Sours and
Rasa- meat juice- in Successive order, for three, two and one Annakala- time of meal respectively. 29

Note:
Eating periods = Anna Kala.
Each day has two anna kala. – morning and evening.
If the maximum vomiting bouts were observed (Ati Yoga), then, the patient should take Peya, Vilepi, Akruta Yusha, Kruta Yusha and Mamsarasa – three eating periods (Annakala) each. The patient will not have any food except these. Likewise, for medium vomiting bouts, the number of eating periods is two and for lesser bouts (Heena Yoga), the number of eating period (Anna kala) is one.

Benefits of Samsarjana Karma –
Just as a spark of fire after being fed by grass, powder of dry cow dung etc, gets augmented gradually and becomes great, steady, and capable of burning everything, similarly, the internal digestion fire, by the Samsarjana regimen, in the patient who has undergone Vamana karma, gains strength. 30

Number of bouts and quantity

Vega Samkhya- Mana- Number of Bouts and quantity:-

For Vamana,
Heenayoga – Minimum bouts – 4 bouts
Madhyama vega – Moderate – 6 bouts
Atiyoga – Maximum bouts – 8 bouts

For Virechana –
Heenayoga – 10 bouts of purgation or half prastha of purgated material (384 grams)
Madhyamayoga – 20 bouts – 1 prastha of material (768 grams)
Atiyoga – 30 bouts. – 2 prastha (1,536 grams). 31

Vomiting therapy is allowed till the expulsions of Pitta
Purgation therapy is allowed till Kapha comes out;
Measurement to be done after rejecting 2 – 3 bouts, containing faeces in case of Virechana and after rejecting the medicine- emetic Drug in case of Vamana. 32

Purgation therapy procedure

Virechana Vidhi- Purgation therapy procedure –
After Vamana therapy, patient is given Samsarjana regimen. After that, he is again given Snehana and Swedana treatment.

In the morning, after Kapha time has lapsed (after around 9 – 10 am,) Virechana drug should be given. The kind and quantity of purgation medicine should be selected after determining the nature of his Kostha (alimentary tract, bowels). 33

A person with Mrudukoshta (soft intestines), even milk will induce purgation.
For a person with Krurakoshta, (hard bowels, intestines), even Trivrit (a purgative herb) might cause purgation with great difficulty. 34

For Pitta disease, Kashaya – astringent and Madhura – sweet drugs should be used for purgation.
For Kapha disease, Katu  (pungent) herbs should be given for purgation.
For Vata, drugs with Snigdha – unctuous, oily, Ushna (hot) and Lavana (salt) tasting herbs are used. 35

If bouts of purgation do not commence, he should drink hot water and his abdomen should be fomented with warmed palms of the hand. 36a

If, on the day of consuming the purgative drug, the patient responds poorly, he should be allowed to take his food on that day and the purgative drugs administered again on the next day;
Persons who have unstable and unlubricated alimentary tract, should consume the purgative drugs after ten days – during which Snehana and sweating therapies should be done  because the body which has been well prepared with Snehana and sweating therapies, will be able to have purgation properly;
Then the purgative drug should be administered after considering all aspects and remembering the procedures described earlier . 36b-38a

Vishama Yogah – Abnormal bouts

Ayoga – lesser quantity of purgation ­-
Discomfort in the region of the heart and abdomen,
Aruchi – anorexia,
Too much of Kapha and Pitta increase in the intestines (because they are not properly thrown out of the body) or expulsion of Doshas  coming out through the mouth,
Kandu – itching,
Vidaha – burning sensation,
Pitika – eruption on the skin,
Peenasa – rhinitis,
Vata Vidgraha – blocking of flatus and constipation
are the features of Ayoga- inadequate bout of purgation therapy;
Opposite of these are the features of proper bouts;

In case of Atiyoga – excess bouts
After the elimination of faeces, Pitta, Kapha and Vata in succeeding order, there will be elimination of watery material which does not contain Kapha or Pitta, which is white, black or slightly red in color, resembling the water in which meat has been washed or resembling a piece of fat;
prolapse of the rectum, thirst, giddiness, sunken eyes and diseases caused by excess of vomiting will appear. 40-42

The person who has undergone proper purgation therapy, should be administered all other therapies, except inhalation of smoke, which are described under emesis therapy; afterwards he should stick to the regimen of diet, in the same way as of emesis therapy and then resume his normal food. 42-43

On the day of administration of purgation,
If the patient has weak digestion strength (Mandagni), coated feeling in the gut, and if the digestion symptoms of previous food are not seen, the he should be made to fast. By this fasting he will not be harmed by the discomfort caused by the obstruction of Doshas, aggravated by oleation, sweating therapies. 44-45a

The digestive activity becomes weak by purification therapies, blood letting, oleation and fasting; hence the regimen of Peya- thin Gruel etc. should be followed. 45b-46a

Peya should not be given when only little quantities of Pitta and Kapha are expelled out, to the person who is addicted to wine, and in whom Vata and Pitta are predominant; for them regimen of Tarpana etc. – nourishing therapy are suitable. 46b-47a

Vamana (Emesis) brings out Doshas which are Apakva – (not cooked / processed by heat)
Whereas Virechana (purgation) brings  out the Doshas which have undergone Paka (cooking- processed by heat); hence in case of emesis – the physician need not await Doshapaka (cooking of the Doshas). 47

A person who is weak, who has great amount of increased Doshas develops purgation on his own – without consuming purgative drug; he should be treated with foods which are purgative. 48.

Persons who are weak, who have undergone purification therapy previously, who have little amount of imbalanced Doshas, who are emaciated and whose nature of the alimentary tract is not known should be given mild purgative drug in a small dose; It is better given in small doses often;
Large dose given once creates doubt of death;

The drug in small and repeated doses will eliminate the circulating Doshas little by little; in a weak person, little quantity of Doshas should only be mitigated by mild drugs, they need not be expelled out by purification therapies . 49b-51

Doshas which are more in quantity trouble the person greatly and even kill him, if not expelled out by purification therapies.

Person who have weak digestion strength, Krura koshta – hard bowels (hard natured alimentary tract), should be administered ghee processed with Kshara and Lavana (Alkalis and salts), to augment his digestive capacity and vanquish Kapha and Vata; afterwards he should be given purification therapies. 52

In persons who are Rooksha (dry), who have great increase of Vata, who have hard natured Alimentary tract (Krura koshta), who do exercise regularly and who have strong digestion strength, the purgative drug gets digested without producing purgation; for them, an enema should be given first and then purgative drug which is Snigdha – (unctuous, oily) should be given ;
Or the faeces should be removed first by using a strong rectal suppository made from fruits; the Doshas thus initiated in their movement, the purgative drug expels them easily. 53-55

Persons who are suffering  from poison , Abhighata (Trauma), Pitika (skin eruption), Kushta – skin diseases, Shopha (inflammation),  Visarpa- herpes, Kamala (Jaundice), Anaemia and Diabetes, should be given the purgative therapy without too much of Snehana (oleation). Mild oleation itself is sufficient for them. All of them should be given fatty purgatives; those who have had oleation earlier should be given dry- non- fatty purgatives. 56

Note: Virechana is of two types – Snigdha Virechana and Rooksha Virechana.

Snigdha Virechana- done by fatty purgatives, such as a castor oil. Or the fatty material is mixed with herbs. Such as Castor oil mixed with Haritaki.
Rooksha Virechana – wherein dry purgative herb alone is given. For example, Trivrit Lehyam.

Doshas getting loosened from the body by oleation and sweating therapies are expelled out by purification therapies just like the dirt from the cloth – by washing. 58

The body of the person who resorts to purification therapies without undergoing oleation and sweating habitually, gets broken just like a log of dry wood while being bent.

Benefits of purification tharapies

 Shodhana Phala- benefits of Purification therapies:-
Clarity of the mind, strength of the sense organs, stability of the tissues, keenness of digestive power and slow ageing occur from purification therapies, if properly undertaken. 60
Thus ends the chapter- Vamana Virechana Vidhi- The eighteenth in Sutrasthana of Astangahrudaya.