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Therapeutic massage (abhyanga) and fomentation therapy (swedana) are generally advised for three sessions after completing internal unction therapy.

Therapeutic massage (abhyanga) and fomentation therapy (swedana) are generally advised for three sessions after completing internal unction therapy.

The day of therapeutic emesis is decided only after observing proper unction and fomentation features in an individual.  [A.H Sutra Sthana 16/36] This can be continued for two or three days. [Cha.Sa.[[Kalpa Sthana]] 1/14]

The day of therapeutic emesis is decided only after observing proper unction and fomentation features in an individual.  [A.Hr. Sutra Sthana 16/36]<ref name=Hridaya>Vagbhata. Ashtanga Hridayam. Edited by Harishastri Paradkar Vaidya. 1st ed. Varanasi: Krishnadas Academy;2000.</ref> This can be continued for two or three days. [Cha.Sa.[[Kalpa Sthana]] 1/14]

The diet on the previous day of therapeutic emesis includes food items which provoke [[kapha]] [[dosha]]. This includes fish, black gram (masha), sesame (tila), [A.H. Sutra Sthana 18/12] meat soup, milk, curd, oil cakes etc. [A.S. Sutra Sthana 27/10][Cha.Sa.[[Kalpa Sthana]] 1/14]

The diet on the previous day of therapeutic emesis includes food items which provoke [[kapha]] [[dosha]]. This includes fish, black gram (masha), sesame (tila), [A.H. Sutra Sthana 18/12]<ref name=Hridaya/> meat soup, milk, curd, oil cakes etc. [A.S. Sutra Sthana 27/10]<ref name=Sangraha/>[Cha.Sa.[[Kalpa Sthana]] 1/14]

====Selection of emetic medicines====

====Selection of emetic medicines====

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[A.S. Sutra Sthana 27/12]

[A.S. Sutra Sthana 27/12]<ref name=Sangraha/>

====Dose of vamana medicine====

====Dose of vamana medicine====

The dose of the formulation depends upon the bowel pattern (koshtha) of the individual. Therapeutic emesis is easily administered in an individual with [[kapha]] [[dosha]] dominant soft bowel. [Hemadri on A.Hr. Sutra Sthana 18/15]

The dose of the formulation depends upon the bowel pattern (koshtha) of the individual. Therapeutic emesis is easily administered in an individual with [[kapha]] [[dosha]] dominant soft bowel. [Hemadri on A.Hr. Sutra Sthana 18/15]<ref name=Hridaya/>

   

   

The individualized dose of Randia dumetorum (madanaphala) seeds is equal to the size of a closed fist of the patient. [Cha.Sa.[[Kalpa Sthana]] 1/14] This mean dose is standardized as 13.51 gm.<ref name=Dass4>RK Dass, NN Bhatt et al.A comparative clinical study on standardization of Vamana Vidhi by classical andtraditional methods Ayu. 2012 Oct-Dec; 33(4): 517–522. doi: 10.4103/0974-8520.110531</ref>  

The individualized dose of Randia dumetorum (madanaphala) seeds is equal to the size of a closed fist of the patient. [Cha.Sa.[[Kalpa Sthana]] 1/14] This mean dose is standardized as 13.51 gm.<ref name=Dass4>RK Dass, NN Bhatt et al.A comparative clinical study on standardization of Vamana Vidhi by classical and traditional methods Ayu. 2012 Oct-Dec; 33(4): 517–522. doi: 10.4103/0974-8520.110531</ref>  

The following table shows various dose patterns advised in patients.[table 2]  

The following table shows various dose patterns advised in patients.[table 2]  

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   *[Dalhana on Su.Sa.Chikitsa Sthana 33/7], **[Sha.Sa. Uttara khanda 3/15], #[Ka. Khilasthana 7/44]

   *[Dalhana on Su.Sa.Chikitsa Sthana 33/7]<ref name=Susruta>Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005.</ref>, **[Sha.Sa. Uttara khanda 3/15]<ref name=Shargadara/>, #[Ka. Khilasthana 7/44]ref name=Kashyapa>Vrddhajivaka, Kasyapa Samhita. Edited by Tewari P V, Reprint edition. Varanasi: Chaukhambha visvabharati; 2008</ref>

===Therapeutic emesis (pradhanakarma)===

===Therapeutic emesis (pradhanakarma)===

Therapeutic emesis is always performed early morning during the time of the natural increase of [[kapha]] [[dosha]].  After completing proper sleep and passage of natural urges in the morning, the individual follows whole-body therapeutic massage and fomentation.The patient should be seated comfortably in a chair of a suitable height.  

Therapeutic emesis is always performed early morning during the time of the natural increase of [[kapha]] [[dosha]].  After completing proper sleep and passage of natural urges in the morning, the individual follows whole-body therapeutic massage and fomentation.The patient should be seated comfortably in a chair of a suitable height.  

The mixture of emetic medicines is given empty stomach. The selection of emetic medication depends upon the disease condition or status of health of the patient. The most commonly used emetic medicine is Randia dumetorum (madanaphala) and Acorus calamus (vacha). The emetic medications are given as powder, decoction or as paste mixed with honey and salt. [A.S.Sutra Sthana 27/10] There are 355 formulations described in [[Kalpa Sthana]] for therapeutic emesis.

The mixture of emetic medicines is given empty stomach. The selection of emetic medication depends upon the disease condition or status of health of the patient. The most commonly used emetic medicine is Randia dumetorum (madanaphala) and Acorus calamus (vacha). The emetic medications are given as powder, decoction or as paste mixed with honey and salt. [A.S.Sutra Sthana 27/10]<ref name=Sangraha/> There are 355 formulations described in [[Kalpa Sthana]] for therapeutic emesis.

   

   

The emetic mixture provokes [[dosha]] and stimulates their natural movement to get expelled out through vomiting. Adding honey and salt helps in liquefying and detaching [[kapha]] [[dosha]]. [A.S. Sutra Sthana 27/16]

The emetic mixture provokes [[dosha]] and stimulates their natural movement to get expelled out through vomiting. Adding honey and salt helps in liquefying and detaching [[kapha]] [[dosha]]. [A.S. Sutra Sthana 27/16]<ref name=Sangraha/>

Then after a waiting time of maximum 48 minutes (one muhurta), the individual is advised to consume optimum quantity (akanthapana) of gruel (yavagu) mixed with little amount of ghee or milk or sugarcane juice or soups or alcoholic preparations.[A.Hr. Sutra Sthana 18/13-14] The liquids can be processed with emetic medicines, if needed. [Dalhana on Su.Sa. Chikitsa Sthana 33/7]  

Then after a waiting time of maximum 48 minutes (one muhurta), the individual is advised to consume optimum quantity (akanthapana) of gruel (yavagu) mixed with little amount of ghee or milk or sugarcane juice or soups or alcoholic preparations.[A.Hr. Sutra Sthana 18/13-14]<ref name=Hridaya/> The liquids can be processed with emetic medicines, if needed. [Dalhana on Su.Sa. Chikitsa Sthana 33/7]<ref name=Susruta/>

====Observation of the patient====

====Observation of the patient====

Appearance of sweating and salivation may be due to cutaneous vasoconstriction mediated by sympathetic nerves and parasympathetic nerves respectively.<ref name=Andrews5>Andrews PL. Physiology of nausea and vomiting. Br J Anaesth. 1992;69(7 Suppl 1):2S-19S. doi:10.1093/bja/69.supplement_1.2s</ref> When the bouts of vomiting start, the person should open his mouth widely to facilitate the easy and unobstructed evacuation.

Appearance of sweating and salivation may be due to cutaneous vasoconstriction mediated by sympathetic nerves and parasympathetic nerves respectively.<ref name=Andrews5>Andrews PL. Physiology of nausea and vomiting. Br J Anaesth. 1992;69(7 Suppl 1):2S-19S. doi:10.1093/bja/69.supplement_1.2s</ref> When the bouts of vomiting start, the person should open his mouth widely to facilitate the easy and unobstructed evacuation.

If the bouts of vomiting are not occuring, the patient’s palate should be tickled to induce gag reflex.[A.Hr. Sutra Sthana 18/18].

If the bouts of vomiting are not occuring, the patient’s palate should be tickled to induce gag reflex.[A.Hr. Sutra Sthana 18/18]<ref name=Hridaya/>

====Supporting the patient====

====Supporting the patient====

When the vomiting starts, attendants should support the patient on sides and forehead of the person. Gentle massage with hands is done in an upward direction on patient's back. [A.H. Sutra Sthana 18/20] All these actions help the patient for effortless vomiting.  

When the vomiting starts, attendants should support the patient on sides and forehead of the person. Gentle massage with hands is done in an upward direction on patient's back. [A.Hr. Sutra Sthana 18/20]<ref name=Hridaya/> All these actions help the patient for effortless vomiting.  

====Inadequate emesis====

====Inadequate emesis====

===Post therapeutic measures (pashchatkarma)===

===Post therapeutic measures (pashchatkarma)===

After completion of procedure and bouts of emesis end,the patient is then advised medicated smoke inhalation (dhumapana) which helps to remove the remaining [[kapha]] adhered to the body channels.  [A.S.Sutra Sthana 27/21]. [Su.Sa.Chikitsa Sthana 33/10] The patient is advised to take complete rest in a room and avoid direct exposure to wind. The patient is advised to take hot water bath and follow specific dietary pattern (samsarjana krama), when he feels hungry.

After completion of procedure and bouts of emesis end,the patient is then advised medicated smoke inhalation (dhumapana) which helps to remove the remaining [[kapha]] adhered to the body channels.  [A.S.Sutra Sthana 27/21]<ref name=Sangraha/> [Su.Sa.Chikitsa Sthana 33/10]<ref name=Susruta/> The patient is advised to take complete rest in a room and avoid direct exposure to wind. The patient is advised to take hot water bath and follow specific dietary pattern (samsarjana krama), when he feels hungry.

==Pharmacodynamics of emesis==

==Pharmacodynamics of emesis==