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Introduction

Ayurveda, like other system of traditional medicine has its unique features. Ayurveda emphasizes promotion of the positive health and prevention of deasease. Vamana Karms is one of the Panchakarma therapies which eliminates the vitiated kapha to maintain a state of normalcy and equilibrium which is the fundamental basis of health according to Ayurvedic classic. The act of expelling the impurities i.e. vitiated Doshas through the upper channel (mouth) is known as Vamana (emesis).[1] In this process 'Apakwa' Pittaand Kapha are forcibly expelled out through the upward route.Here the word "Apakwa" literally means "undigested or unriped". [2] When Pitta is undigested or unriped, it metamorphoses into 'Vidagdha state', which is one of the sets of Ajirna in that condition also Vamana is indicated.  Vamana Karma is the most important part of the Shodhana Karma. [3] Shodhana Chikitsa has its unique importance in Ayurveda. The word Shodhana means the act of cleaning correcting, improving, and refining of metals, removal, eradiction, substraction etc. i.e. the radical removal of the causative factors of a disease by specialised therapy called Shodhana Chikitsa. The property of Sweda Dravya is Ushna, Tikshna, Sara, Snigdha, Ruksha etc. The administration of Sneha creates Klinnata to malas and doshas situated in the dhatu, srotamsi and sakhas. The klinna malas are liquified by the use of swed karma. Sweda is caused by applying heat by various methods helps to increase the circulation of Rasa, Rakta and doshas. In fact the pores of the walls of the cells membranes (srotas) are opened and the obstruction of malas and dhatus are removed and there by blood circulation in all parts of the body is also increased. The waste products produced after the metabolic process of the body from various parts (sakhas) are carried to koshta and kept ready for elimination.[4]

Aims and Objective:  the present study, clinical and laboratory investigations were conducted.

 (1) To evaluate the effect of poorva karmas namely snehana and swedana and (2) to evalute the effect of the vamana karma on blood chemistry with Modern Scientific parameters.

MATERIAL AND METHODS

The 44 Patients having classical signs and symptoms of Tamaka swasa (Bronchial Asthama) as described in Bruhat-trayi was selected. A special proforma including all the etiological factors of Tamaka swasa with Dushti Lakshan (signs and symptoms of vitiation) of Dosha, Dusha, Srotasa, etc, was designed for assessment of all the patients. The Patients were thoroughly questioned and examined according to proforma. Ethical clearance and inform consent were obtained before conducting the trial.  

Criteria for selection of the patients

Inclusion Criteria –

• Patients should be indicated for Snehan and Vamana karmas.

• The patient’s age between 18 - 50 years male & Female.

• Patients having Uttam & Madhyam Bala & Uttam & Madhyam Satwa.

• Patients diagnosed with Kaphaj & Pittaj Tamaka Swasa (Bronchial Asthama)

Exclusion Criteria -

• The patient’s age below 18 years and above 50 years.

• Patients having Avar bala & Avar satwa.

• Patients having hatred for sneha (Snehadweshi)

• HTN, DM, IHD, Anemic, Immunocompressed patients were excluded.

• Patients having Pneumonitis, Brochiectasis, Emphysema, smoker’s cough were excluded.

• Patients having Ulcers related to GIT were excluded.

Haematological Investigaion –

• Blood for Heamoglobine ( Hb gms%), Total leucocyte counts (TLC /cumm), Differential leucocyte counts (DLC),  Erythrocyte Sedimentation Rate (ESR),

Biochemical Investigaion – 

• Total Cholesterol, 

• Sr. Bilirubin,  Sr. Proteins, Sr. Alk.Phosphate, Sr. Calcium,  

• Blood Urea, Sr. Creatinine,  Sr. Sodium, Sr. Potassium

• Random Blood sugar

Grouping: For the convenience of the trial the patients were grouped into two as treated and control group. The treated and control group consists of 44 patients. 22 patients in treated group and 22 patients in control group.

• Treated group were managed with Snehapana, Bahya Snehana & swedan karma and finally Vamana karma.

• The control group patients were treated with Shaman Chikitsa of treatment adopted for the respective disease.

Group A

Group B -In control group the patients were treated with symptomatic treatment only. In Tamaka Swasa patients Swaskuthar, Swaschintamani, Dashamool kwatha, Katuthraya Kwatham 90 ml, tds, kanakassav with vasa avleha 30 ml tds and Chausastha prahar pippali with milk were given for 30 days.[6]

All these investigation were repeated at the day of vamana karma at morning and also in the seventh day of vamana karma in treated group patients. In control group patients laboratory investigations were repeated only at the end of the treatment i.e. after 3 months. All patients were advised to fast for about 12 hours before the collection of blood sample. Generally at morning without any taking of food, liquids or water. Blood was collected from the cubical vein.

Parameters of assessment -

 1. Selection of Vamana drugs.

 2. Determination of dosage

 3. The degree of vamana effects

• Time of onset of vamanvega

• Number of vegas produced

• Volume for vega.

• total volume/ weight of vomitus

• colour, consistency.

• Total time taken for the last vamanvega,

• rate of elimination of kapha during vamankarma,

• Appearance of pitta during vamankarma

4. Clinical assessment of the immediate systemic effect of vamankarma such as pluse rate,respiration rate, and blood pressure etc.

5. Complication

6. Delayed effects of vamankarma.

a. Changes in the digestive and metabolic activity such as time taken for appetite.

b. Clinical recovery from the sign and symptoms.

c. Functional restoration of the body.

PROCEDURE AND CLINICAL TRIAL [7]

1. Administration of Snehapana :-

   Before starting Snehapana the physician should confirm that the patient appetite and digestive power are suitable for conducting Snehapana. Snehapana was started with an initial dose of 30 ml. on the first day and increased the does to 60 ml, on the second day. From third day onwards the dose was decided according to the digestive power shown by the patient on previous days and continued until Samyak Snigdha Lakshanas are seen or a maximum period of 7 days. During Snehapana the nature of the digestive power & thirst were recorded daily. This was done mainly to assess the state of Koshta of the patient.

2. Swedakarma :

After noticing the samyak snigdha lakshanas the patients were allowed to undergo for Swedakarma on the next day. Sarwang Bashpasweda was selected for this purpose. This was preceded by Abhyanga in 7 th about 45 minutes. For this Bala tailum was used in Tamaka swasa patients, Abhyanga and Sweda should be done on 8 th day and 9 th day i.e. before the Vamana process at 7 A.M.  It was noted that desired effects of sweda karma were seen in all patients with in 20 mins. After completing this poorva karma the investigations were carried out.

3. Vamana therapy: - A day previous to vamana therapy i.e. after two days of sweda karma the patients were fed with Rice and Curd which have a property of kaphotklesha. On the day of vamana karma during the kaphakala i.e. morning period the patients were once again subjected to local massage with Sneha and swedakarma before administering the vamana drug. Afterward 1 liter of milk was given to the patient to drink followed by the actual vamana drug in a single does.  It contains processed 5 gm Madanphala. (madanphala Beej churna processe (Bhavana) by Madanphala kwatha seven times ). Prepared Madanphala yoga mixed with honey and this paste administered.In most of the cases spontaneous vomiting was starting with in a maximum period of 30 minutes. Yastimadhu fanta was given frequently as an adjuvent to original vamana drug to induce vomiting. To get samyak vamana vega, quantity of Saindava lavana with warm water was administered lastly to evacuate morbid kapha if necessary. It act as a sadhya Tarpana as well to gate Stamina to patient.After vamana karma these patients were given as short course of samsarjana karma in the form of peya for 7 days. During the entire process of treatment no other medicines were given to these patients.On the 7 th days of vamana karma the laboratory investigations were once again carried out and recorded.The laboratory investigations were carried out in order to assess the treatment in this group also.

Drugs for vamana karma: In this clinical trial madanphala used as an emetic drug. Madanphala fruits and seeds used for the process. Madanphala beej process ( bhavana ) By kwatha of madanphala for 7 times and this medicines is administered along with honey, milk etc.Present clinical trial Yastimadhu phanta used as vamanopaga dravya. powder which is helpful to eliminate vitiated morbid kapha dosha.
Saindhava lavana used as vamanopaga dravya which is used with Madanphala yoga.Cow milk is used for Akanthapana. smoothing action due to milk used along with madanphala yoga.

Observation

The present study was conducted on forty four patients suffering from Tamaka  swasa. This was divided into two equal groups as treated and control. The selection was made according to the criteria mentioned in the Performa without any sex discrimination. All the cases were thoroughly examined and laboratory investigations such as routine hematological and serological tests were carried out and recorded at the time of admission. All these investigations were repeated two more times in the treated patients and one more time in control group patients.

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Discussion

There are three important events in vamanakarma

1.  Development of kaphotheklesha in the Amasaya by the administration of certain dietary articles like cured and Rice mashaksheera etc on the previous night.

2. The emptying of the gastric contents by Vamanakarma.

A) The elimination of kapha which is already in the utklesha state due to the preparation of the patient.

B) Loss of water and also the other constituents of gastric juice like Amlarasa pitta.

3. Due to the loss of above stated substances of gastric juice certain marginal changes in the composition of the rasa - rakta complex. The mechanism of Vamana karma is complicated in nature. The kapha located in the stomach supports all other kaphas of the body by its Ambukarma. As explained by the definition kapha contributes to the welfare of the body supplying it with its watery components. This particular function of maintaining welfare of the body through its watery component is known as Ambukarma. The different kaphas in the body represent organs of the body by support and nourishment. These may also be understood as various extracellular fluids components of the body but the transport of essential nutrients including water into different fluid compartment for the specific purpose of support and nutrition of the respective organs associated with this kaphas is through the rasa rakta complex especially of the rasa component. Similarly the Ambukarma of the kapha is also associated with the rasa component of the rasa rakta complex as explained by susrutha the kledaka kapha which is located in the Amasaya if, eliminated from that organ by the upper route through the process of vamana kriya being supporter of all the other kaphas of the body corrects the vitiation of the kapha in the body. Here there is important to note that the elimination of kapha was understood by its apdhatu through the mouth will prevent its passage through the kshudranthras. Therefore vamana kriya will prevent the reabsorption of this factor through the Kshudranthras and therapy ensures a definite elimination from the body.

The creation of utklesha state helps by its Anupravanabhava in attracting the vitiated kapha into the koshta particularly amasaya. By equating the kapha with mucopoly- saccharides, while studying the effects of vamana karma by K.N. Udupa and R.H. Singh as already established that there is increased elimination of kapha from the stomach. Since pitta is also located in the Amasaya during the process of Vamanakriya this is also eliminated from Amasaya (stomach) through the mouth. While describing the physical qualities of pitta susrutha as stated that the rasa of pitta is katu and vidagdha state it is Amla. Dalhana explained that the taste is right state in katu and the immature state in Amla. Therefore the taste of pitta present in Amasaya where in the digestion of the food is and complete and the products of such digestion are only Ama ( immature ) due to the Amalavastha as to be considered as amla rasa only. it is an undisputed fact that the Amlarasa of pitta located in Amasaya is due to Hcl component of the gastric juice. Therefore in the process of vamanakarma the amlarsa pitta along with the Hcl is eliminated from the stomach by upper route. Therefore it is clear that there is loss of not only water but also the chloride ( cl) radical. Along with this chloride radical certain amount of Sodium ( Na+) is also eliminated.

The present topic of hypothesis is that the administration of sneha and sweda karmas will bring the vitiated doshas from the various part of the body ( Sakhas ) through the transport vehicle of rasa rakta complex to koshta, while conducting the vamana karma the vitiated doshas will be eliminated through the mouth and leads to radical removal of the causative factors of the somatic diseases and there by maintain the doshas in an equilibrium state.

              In view of the above facts the hypotheses of the topic is extremely appreciated and throw light on the bodily changes after the vamana karma in the rasa component of rasa-rakta complex.

The following changes are expected in the Rasa component of Rasa Rakta complex .As regards to the total Leukocytes count in all acute and chronic diseases it is found to be raised. A remarkable reduction was noticed in treated and control group. So it is also one of easily detectable things to observe the disease activity.   It was noticed that no remarkable change was observed in hemoglobin and total Leukocytes count percentage.In case of DLC - Eosinophils showed remarkable reduction (p 0.001) in treated and control group. It is effective in allergic and non allergic conditions.The statistically significant reduction was noticed in ESR ( p 0.001) in treated group.Rise in ESR is an important change commonly occurring in all type of allergic conditions like Swasa, Rheumatoid arthritis, gout, skin diseases. ESR is considered an easily detectable index of diseases activity and so it is worthwhile to study ESR as  an index of inhibition/ progression of the disease in the present study ESR was reduced after snehana and swedana and reduced after vaman karma. So it is important to note that the disease process has been reduced. Reduction in the ESR after vaman karma indicates drop in reactive changes in the body in this study.  

A significant increase was observed in the serum cholesterol level after sneha and sweda (0.20). But after vaman karma it was significantly reduced (p 0.001 ).Sr. Cholesterol is significantly increases after snehana and swedana which tally with the large amount of ghrita consume by the patients. It may be noted that the amount of fats ( ghrita ) provided during the snehapana will increase absorption of cholesterol but it does not cross the normal limit, thus the serum cholesterol level will increase in the body.The sample taken Seven days after vamana showed significant drop in cholestrol as compared to the base line level. This drop level of cholesterol due to vomiting induced drug (Vamana karma) and subsequent restricted diet for 7 days.Many of the metabolic waste products , specially those which are lipid in nature or are soluble in lipids can be eliminated by vaman karma, after the subject has properly prepared in advance by snehana and swedana kriyas. So far reduction of cholesterol level was noticed after vamana.As regards to the serum Alkaline phosphates (p 0.001) level. it was also observed that the serum bilirubin was increased slightly ( p 0.50 ). Both these are related to liver functions. Liver is the largest and most significant metabolic organ of the body. it is the centre of diverse metabolic reaction that occur in the body. So after vamana  the metabolic process of the body may be enhanced. This also indicated that excessive dose of ghrita and Saponin ( vamak drug ) in this procedure is  safe for Liver metabolic activity. The significant increase was noticed in the total serum proteins ( p 0.001 ) after vaman karma. The positive proteins balance relate well in the increase in the body weight, indicating positive metabolism. So the rise in proteins and increase body weight of the patients indicate better health. As a fact the proteins metabolism has been enhanced after Vamana, it leads to anabolic process in the body. This plasma proteins ( Albumin, Globulin ) plays an important role in conferring immunity to the body. So it can co-relate that vaman therapy maintains the preservation and longevity of life.

              In this study further onwards the rise in proteins need to be analysed in term of various fraction like Albumin and globulin. Similarly the positive metabolism is also reflecting in marginal raised calcium level ( p 0.50). The marginal increase of blood Urea ( p 0.50 ) and serum Creatinin ( p 0.50 ) was noticed due to HCL and water lost in the Vomitus which is expected to reduce the glomerular filtration rate a normal excretory route of Urea.  And also indicate that Vaman therapy given in this procedure is not harmful to kidney rather it is safe. As far as electrolytes are concern the drop in sodium level is significant. This possibility is induced by intense nausea and vomiting by Saponin ( Alkoloids of Madanfala fruits) this low sodium level will also result in lowering of osmotic pressure unless in fluid retention there by indirectly helpful in proper maintenance of circulation.There was significant reduction was noticed in serum sodium ( p 0.001) after vaman karma because different kaphas as explained earlier represent only same of the special systems of extracellular fluid which contains more of sodium when compared with intracellular fluid. However no significant changes was observed in potassium level ( p 0.50). It was noticed that a marginal increased of serum potassium (p 0.50) level after Vaman. Since it is the main catiron of the intracellular fluid which are least highly effected due to this  process. The significant increase within the normal level was noticed in blood sugar level after sneha and sweda and after vaman karma ( p 0.001 ). Mean fasting Blood sugar level 92.1 and after sneha and sweda and before vaman karma it was raised 98.6 mg/ dl and later on it drops marginally 97.2 mg/dl in an avarage. This small rise from the initial 92.1 to 97.2 mg% is presumable high adrenergic activity induced during vamana process. Adrenergic activity releases Adrenaline can also result in raised level of Glucocorticoids may be concluded that Adrenaline effect helps to reduced the symptoms of Bronchial Asthama and Glucocorticoroids will be addition Contributory factor. It was observed that all the serological results were increased after sneha sweda karmas. The doshas which may have lodged in koshta, dhatu or srotas made klinnata by the administration of Sneha. The Klinna malas are liquified by the use of sweda karma in the presence of agni. This agni ( Enzymes ) will increase the metabolic activity of the body. So far these results were increased after sneha and sweda karmas.

              The patients were keenly observed and the various signs and symptoms presented by them were studied. It was seen that the usual complications of nausea, and indigestion were noticed during the snehapana therapy. After noticing the samyak swinna lakshanas the vamana was conducted in the sleshmakala i.e. in morning hour 8.10 to 9.15 A.M. 

1. An average standard vamana was found to on sure within 20 ± 6.1 after the               administration of vamana drug.

               2.  Swedpravritti mean 13.4 ± 4.5, Lomharsha Mean 14.1 ± 4.98

              3.  Udaradhan mean 15.7 ± 5.8 Lalasrao mean 17.1 ± 5.87

              4.  Hrillhas mean 17.5 ± 5.92

              5.  First Vamana vega mean 20 ± 6.1

              6.  Presence of kapha from 1 st and 2nd vega.

              7.  Appearance of pitta ( pittadarshan ) 71.5 ± 19.22

              8.  Average number of Vaman Vegas 7 ± 1.36

              9. The quantity of vomitus expelled after vamana was mean 605 ± 187.

An average standard vamana will produced certain systemic physiological effects such as.

• Increase in the pulse rate 18.5 ± 5.48

• Increase in the respiration rate 6.2 ± 2.7

• Increase in the systolic blood pressure it was 11.7 ±

• Increase in the diastolic blood pressure it was 10.81 ±

• Increase in the body wt. after vamana was 1 to 2 kg

An average standard vamana produced remarkable improvement in cardinal signs and symptoms of Tamaka swas.

Swaskrichhata, kasa, Gurguruk, Shirogrivagraha were relieved by 70% and mukhashosha, aruchi, agnimandya, malawstambha was relieved by 50%.

All the patients improved from the disease process with in a limited period of 21 days after vamana karma. They were improved in there digestive capacity and metabolic activity and general conditions of body. The systemic physiological increase may be due to exhaustive process of treatment. These changes undergo considerable fluctuations during the excitement, exercise etc. The same procedure can also be applied here as excitement during the vamana. The clinical improvements were agrees with laboratory investigations. The patients were reported good relief during the follow up studies. The most interesting phenomena was noted in this small series was that the patients who were undergone vamana therapy from Tamaka swas got surprising response. Most of the signs and symptoms were disappeared within a short time after vamana karma.No inspiring results were obtained from the control group patients.

Conclusion

The trial can be concluded as follows:   

1. Vaman can improve the functional and metabolic activity of the body. It maintains the health of the individual and helps for the promotion, Preservation and longevity of the life.

2. The clinical signs and symptoms of Tamaka Swasa were decreased. Since it will eliminates the vitiated kapha and it subsides congestion of the chest which is usual phenomena of Tamaka Swasa. It minimizes the relapses and also the intensity of Tamaka swasa.

3. All the serological results are within the normal limits both in treated and control group patients

4. The Vaman karma process is not harmful to liver, kidney and Hepatorenal Function rather it is safe.

5. The present trial is only a preliminary study on this subject even though some changes have been found in the Blood chemistry, it is suggested to conduct further studies on various diseases indicated to Vaman karma, where abnormal blood chemistry can be noticed due to the pathological condition of the respective diseases.