Vamana

The word vamana means the act of vomiting. It is one of the five purification therapies (panchakarma). It is the best preventive measure and treatment for disorders due to vitiation of kapha dosha. [Cha.Sa.Sutra Sthana 25/40] The dosha accumulated in the upper part of the body (trunk and supraclavicular region) is evacuated by therapeutic emesis. [Cha.Sa.Sutra Sthana 20/19][Cha.Sa.Kalpa Sthana 1/4] 'Vamana' is also a therapeutic procedure to expel vitiated dosha by administration of medicine to induce vomiting. On the other hand, 'Chhardi' is a disease with a predominant feature of vomiting due to various underlying pathologies. The present article deals with vamana, i.e., therapeutic emesis.

Contributors

Section/Chapter/topic	Chikitsa / Panchakarma/ Vamana
Authors	Aneesh E.G., Deole Y.S.
Reviewed by	Basisht G.
Affiliations	Charak Samhita Research, Training and Development Centre, I.P.G.T.& R.A., Jamnagar
Correspondence email:	carakasamhita@gmail.com
Publisher	Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India
Date of first publication:	November10, 2020
DOI	10.47468/CSNE.2020.e01.s09.032

Etymology and derivation

The Sanskrit root 'vam' means ejection, giving out, oozing, stream, etc.The word 'vamana' is derived from the root 'vama' and adding a suffix 'lyut'. It has four meanings,

• Destroying, crushing (mardane)
• Vomiting (chhardane)
• Expelling, going out (nissarane)
• Movement, oozing or flowing (svargabishyanda) (svarga means movement and abhishyanda means oozing, flowing etc.).

Synonyms

Vama, vamana, vami, vamathu, chhardi, chhardana, ullekhana, shodhana, samshodhana, udgirana and urdhvamukhadoshaharana.

Classification

Two types of vamana are performed in clinical practice based on the condition of the patient and disease.

1. Instant therapeutic emesis (sadyavamana) in acute conditions like poisoning. [Cha.Sa.Chikitsa Sthana 23/45]
2. Classical therapeutic emesis (vamana): It includes preparatory procedures of unction and fomentation therapies. It is prescribed in management of chronic conditions.

Indications

Therapeutic emesis is indicated in the following pathogenic conditions:

• Excess aggravation of kapha dosha.[Cha.Sa.Sutra Sthana 16/16]
• Kapha dosha associated with pitta dosha.[A.S.Sutra Sthana 27/4]

Precautions

Therapeutic emesis is prescribed in an individual with good physical and mental strength (bala) and in those who are accustomed with the act of vomiting.[Sha.Sa. Uttarakhanda 3/2]

Contraindications

Diseases: Chest injury, heart diseases, diseases due to improper functioning of vata, anuria, splenic disorder, abdominal lump, ascites, prostate enlargement, cataract, headache etc.

Physiological conditions: Old age (above 60 years), children (below 10 years), excessively emaciated or obese, exhausted due to physical activities or worry, pregnancy.

Other consequent panchakarma procedures: One who has been treated with medicated enema with decoction or with oil. [Cha.Sa.Siddhi Sthana 2/8]

Vamana procedure

The total procedure can be discussed under the following three steps:

1. Pre therapeutic measures (purvakarma)
2. Therapeutic measures (pradhanakarma)
3. Post therapeutic measures (pashchatkarma)

Pre therapeutic measures (purva karma)

The pre-emesis procedure aims to prepare the body for emesis and to bring toxins to gut for expulsion.

Pachana (digestive) therapies are administered to correct digestion and detach the microcellular toxins (ama).

Unction (snehana) is prescribed in a suitable dose for a duration until proper unction features are observed. This is generally done for three to seven days.

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.Hr. Sutra Sthana 16/36] 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]

Selection of emetic medicines

The medicines are selected based on their properties specific to targeted dosha involved in the pathogenesis.[table 1]

Table 1: The dosha specific active properties of medicine

Dosha involved in pathogenesis	Selective properties of medicine
Kapha	Sharp (tikshna), hot (ushna), spicy (katu)
Kapha + Pitta	Cold (hima), Sweet (swadu)
Kapha + Vata	Unctuous (snigdha), sour (amla), salty (lavana)

[A.S. Sutra Sthana 27/12]

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 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.

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

Table 2: Dose patterns for therapeutic emesis

Form of medicine	Maximum dose	Medium dose	Minimum dose
Decoction	5760 ml (9 prastha)*	3840ml (6 prastha)*	1920ml (3 prastha)*
Paste /Tablet/Powder	48 gms (1 pala)*, 144gm (3 pala)**#	24 gms (2 karsha)*, 96gms (2 pala)**, 72 gms#	12 gms (1 karsha)*, 48gms (1 pala)**#

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

Therapeutic emesis (pradhana karma)

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 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]

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]

Observation of the patient

After the administration of emetic medicine, signs of impending vomiting are observed. The patient is advised to expect vomiting bouts.

• Sweating on the forehead of patient indicates a liquefied and moving state of dosha.
• Horripilation indicates the movement of dosha from its site.
• The distension of the abdomen indicates dosha reaching the stomach.
• Chest congestion and excessive salivation indicate the upward movement of dosha towards the mouth. [Cha.Sa.Sutra Sthana 15/11]

Appearance of sweating and salivation may be due to cutaneous vasoconstriction mediated by sympathetic nerves and parasympathetic nerves respectively. 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]

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.Hr. Sutra Sthana 18/20] All these actions help the patient for effortless vomiting.

Inadequate emesis

Even after all these measures, if the bouts are inadequate, paste prepared out of Piper longum (pippali), Phyllanthus emblica (amalaki), mustard (sarshapa), Acorus calamus (vacha) and rock salt mixed with warm water is administered. And the whole procedure is repeated. [Cha.Sa.Kalpa Sthana 1/14]

Endpoints

The procedure is continued till the appearance of signs of adequate emesis or bile (pitta) in the vomitus.

Post therapeutic measures (pashchat karma)

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.

Pharmacodynamics of emesis

The emetic medicines remove toxins from the whole body by their properties and predominance of agni and vayu mahabhuta. [Cha.Sa.Kalpa Sthana 1/5]

Features of optimal emesis

Beginning of vomiting after a specific time gap after the intake of vamana medication, following features are observed:

• Sequential expulsion of kapha, pitta and vata without any obstruction
• Feeling of clarity in head, chest, sense organs and flanks
• Feeling of lightness
• Feeling of only a minimal exertion
• Natural stoppage of vomiting [Cha.Sa.Siddhi Sthana 1/15][A.Hr. Sutra Sthana 18/25]

Features of inadequate emesis

• Appearance of vesicular eruptions (sphotaka), urticaria (kotha), itching
• Discomfort in chest and body channels
• Heaviness of body
• Absence of vomiting, vomiting with obstructions
• Expulsion of only medicine in vomitus
• Fever [Cha.Sa.Siddhi Sthana 1/16] [A.Hr. Sutra Sthna 18/23-24]

Features of excessive emesis

• The appearance of thirst (trit)
• Unconsciousness (moha)
• Fainting (murchcha)
• Aggravation of vata dosha
• Insomnia
• Debility
• The appearance of blood in vomit
• Burning sensation
• Dryness of throat.[Cha.Sa.Siddhi Sthana 1/17] [A.Hr. Sutra Sthana 18/25-26]

Assessment of adequate purification

The following four factors are considered to assess the purification level (maximum, moderate and minimum) through therapeutic emesis.[Cha.Sa.Siddhi Sthana 1/14]

Endpoint observation of vomitus (antiki)

The physician's decision to continue or to stop emesis therapy primarily depends on observation of the vomitus. The following are endpoints of vamana:

• The appearance of pitta in vomitus [Cha.Sa.Siddhi Sthana 1/14] or
• Expulsion of medicine [A.S. Sutra Sthana 27/23] or
• Reduction in the amount of kapha in vomitus [A.S. Sutra Sthana 27/13]

In a study conducted on 30 healthy volunteers, 66.7% of participants completed the therapeutic emesis by expelling pitta. In another study on 60 participants, more than half of them (56.52%) expelled pitta in the final bout of vomiting. The person may experience bitterness in the mouth or a burning sensation in throat by pitta's expulsion. A pH scale can be used to monitor the changes in vomitus. The pH of vomitus is reported as 6 – 6.5. As the emesis progresses the acidic pH changes into slightly alkaline and by the expulsion of pitta it becomes alkaline. 7.61 was the average pH recorded at the end of the emesis therapy during a study conducted on 29 individuals. In another study conducted on 22 individuals 5.5 pH during the initial bouts of vomiting changed to 8.06 in final bouts.

Quantity of vomitus (maniki)

The quantitative output of vomitus is measured. If approximately 1280ml(2 prastha) of vomitus is expelled out, it is considered a maximum purification level. The 960ml(1.5 prastha) and 640ml (1 prastha) are considered moderate and minimum purification levels respectively. [Cha.Sa.Siddhi Sthana 1/14] Vagbhata differs in opinion by considering 640ml (1 prastha) and 320ml (1/2 prastha) as moderate and minimum levels of purification. [A.Hr.Sutra Sthana 18/31]

The quantity of dosha expelled (maniki) should be calculated by excluding the intake of all medicines given to the patient.[Cha.Sa.Siddhi Sthana 1/14] Practically it is observed that the amount of vomitus is always less when compared to the intake consumed by patient. In other words, some amount of total intake remains inside the patient's body. So, more practically, the intake-output ratio should be measured to better understand the amount of dosha expelled. For this purpose, the Maniki Shuddhi Index (MSI) is introduced.

Maniki Shuddhi Index = (Volume inside ÷ Volume input) × 100

A lesser MSI indicates a greater evacuation. If MSI is more, it suggests more residual fluids in the body.

Number of bouts of vomitus (vaigiki)

The number of large bouts of vomitus are counted. If the person had eight bouts of vomiting, it is considered as maximum purification. Six bouts and four bouts are considered as moderate and minimal purification levels, respectively. [Cha.Sa.Siddhi Sthana 1/13]

A bout of vomiting to be called as 'vega' should possess certain characters. Quantity and force of that particular bout of vomiting and the time required to expel can be considered to assess the 'vega'.

a. Quantity: The quantity of vomitus should be more.

b. Force of expulsion: Depending on the source from which bout originates, it is graded into 4. Grade 1 indicates vomitus coming from mouth or oropharyngeal region. If it is from the oesophageal region, it is considered as Grade 2. Grade 3 represents that which comes from the stomach and the projectile vomiting with good force is included under Grade 4.

c. Time: The expulsion of greater quantity in short period and expulsion of lesser quantity for a longer period can be considered as 'vega' .

Clinical features (laingiki)

The clinical features for inadequate, adequate and excess emesis are considered for assessment. In a study, conducted on 69 apparently healthy persons, maximum participants attained feeling of lightness as the feature of optimal emesis.

Complications of therapeutic emesis

Complications may occur in therapeutic emesis due to incompetency of attendant, medicine, physician or patient. The ten cardinal complications arising out of improper administration of emesis are:

• Distension of abdomen(aadhmana)
• Fissure in ano(parikartika)
• Excess discharge from mouth (srava)
• Chest congestion (hridgraha)
• Body stiffness (gaatragraha)
• Bleeding(jeevaadana)
• Prolapse of rectum(vibhramsha)
• Body rigidity (stambha)
• Complications of disease (upadrava)
• Fatigue without exertion (klama) [Cha.Sa. Siddhi Sthana 6/29-30]

Utmost care shall be taken in order to avoid these complications.

Importance in preservation of health and prevention

Therapeutic emesis is the best measure for prevention and management of disorders due to kapha dosha. Healthy individual is advised to follow therapeutic emesis in spring season (vasanta ritu) as a part of seasonal regimen. [Cha.Sa.Sutra Sthana 6/23] It can also be taken during autumn or just prior to rainy season [Sha.Sa.Uttarakhanda 3/1] or when the weather is neither too hot nor too cold.[A.Hr.Sutra Sthana 18/12] Vamana conducted in spring season among 69 participants was found to be safe, and the participants' overall well-being was also improved.

Importance in management of disease

Therapeutic emesis is principle treatment for kapha dosha dominant types of skin disorders, acute fever, nausea, anorexia, psychiatric disorders. [Cha.Sa.Siddhi Sthana 2/10] A study among 15 participants having PCOS associated with scanty menstruation (artavakshaya) showed encouraging results after vamana and medicines with hot potency.

Contemporary views

Physiology of vomiting

Vomiting is the expulsion of upper gastrointestinal contents forcibly through mouth. To evoke vomiting, there should be a stimulus that triggers one of the detection systems in the body. The activation of this detection system initiates the vomiting reflex.

Vagus is the main nerve involved in the detection of emetic stimuli. The electrical stimulation of these abdominal visceral afferents induces vomiting within 20 seconds. Vagal afferent fibers which are involved in emesis are of two types

1. Mechanoreceptors
2. Chemoreceptors

Mechanoreceptors: It is located in the muscular wall of the gut. It gets activated by the contraction and distension of the gut. Distension of gastric antrum or proximal small intestine stimulates these afferents and may induce vomiting. The consumption of gruel, milk, decoction as a part of emetic therapy acts on mechanoreceptors.

Chemoreceptors: The intraluminal environment is monitored by these receptors which are present in the mucous of the upper gut. These receptors respond to acid, alkali, temperature, mucosal stroking and irritants. The herbs like Randia dumetarum, Acorus calamus etc. act on chemoreceptors.

These stimuli are carried to the chemoreceptor trigger zone(CTZ) located in the caudal part of the fourth ventricle in the obex region. Once the CTZ gets stimulated it, in turn, activates the vomiting center and produces the vomiting.

Vomiting is caused by co-ordination between various physiological systems and between the autonomic and somatic components of the nervous system. This co-ordination occurs in brain stem. Nucleus tractus solitaries may be the major integrative nucleus for visceral afferent information. The series of events taking place in the vomiting reflux can be divided into two phases. 1) Pre-ejection and 2) ejection phase.

Pre-ejection phase: Two important gut motor events are occurring in this phase. Profound relaxation of proximal stomach mediated by vagal efferent nerves and a retrograde giant contraction originates in the mid small intestine which travels towards the stomach. These two mechanisms help to concentrate the GIT contents into the stomach.

Ejection phase: The contraction of somatic muscles of abdomen and diaphragm occurs in this phase. The relaxation of peri-esophageal diaphragm happens probably which helps the passage of gastric contents into esophagus. Hence the expulsion of gastric contents is caused by the compression of stomach by constriction of abdominal muscles along with the descending diaphragm.

Mode of action of therapeutic emesis

The emetic mixture and food items given during emesis act on two stimuli 1) Chemical and 2) Physical. The chemical stimulus is provided by the emetic medicine causing gastric mucosal irritation. These may have a direct action over CTZ in brain. The physical stimulus is seen by distension of stomach due to optimal consumption of fluid intake (aakanthapana). Different medicines used for emesis show different effects on the body. For e.g. In psoriasis patients,vamana with Luffa acutangula (krutavedhana) shows better results as compared to Randia dumetorum (madanaphala). More research is needed to find out the exact mode of action of individual drugs used for vamana.

Current researches

Effect on biochemical parameters

Various physiological and biochemical changes occur after therapeutic emesis. In a study conducted on 30 healthy volunteers, Erythrocyte sedimentation rate (ESR), LDL and blood urea decreased significantly immediately after emesis. Slight reduction in serum sodium, potassium, creatinine and protein levels was reported. Plasma histamine and plasma adrenaline also reduced insignificantly. Total leukocyte count, HDL, SGOT and SGPT were increased significantly immediately after vamana. Plasma dopamine, nor adrenaline and IgE were insignificantly increased. A reduction in ESR and AEC is reported in a study among 15 participants with seed powder of Lagenaria siceraria (ikshvaku).

Examination of vomitus

The macroscopic examination of vomitus shows presence of mucus in almost all bouts especially in the initial bouts. The specific gravity of vomitus was found to be 1.025 to 1.030. Chemical examination shows presence of bile salts in most of the samples and bile pigments in some. The presence of proteins was also reported ranged from 10-30 mg/dl. There is a transition in pH from acidic in the initial bouts to alkaline in the later bouts, which can be taken as an indicator for pitta's presence. Mucopolysaccharide content (Hexosamine) of vomitus may be considered as an indicator of kapha.

Therapeutic efficacy

In another study on 47 patients of type 2 diabetes mellitus, reduction in kapha dominant symptoms like excessive urination and its turbidity was observed after vamana. Reduction in fasting blood sugar and post-prandial blood sugar was also observed more than therapeutic purgation (virechana) administered group. This study postulates that through its property to reduce kapha and fat/adipose tissue (meda), vamana may also minimize insulin resistance. Vamana promotes the insulin function by reducing the circulating free fatty acids in the body. Vamana, through its body channel cleansing and digestion stimulating actions may stimulate glucose metabolism at liver.

Vamana performed in 15 bronchial asthma patients showed a significant reduction in symptoms like breathlessness, cough, wheezing and expectoration. There was a significant improvement in lung function tests parameters like peak expiratory flow and forced expiratory volume.

Vamana with Lagenaria siceraria (ikshvaku) followed by pacifying therapy showed significant changes in the signs and symptoms of Poly Cystic Ovarian Syndrome (PCOS). Good improvements were observed in delayed menses (55.68%) and prolonged interval of menses (42.91%). Significant changes were observed in the mean non dominant follicles and ovarian volume. Vamana with ikshwaku has testosterone lowering effect. Follicle-stimulating hormone gets stimulated by the lesser level of Luteinizing hormone. It helps in the maturation of follicles.

List of theses done

1. Lineswala Gaurang (2002) : Clinical study on the role of Vamana and shamana in the management of kaphaja galaganda w.s.r to hypothyroidism. Department of Kayachikitsa, IPGT&RA Jamnagar
2. Chandaliya Sachin S (2003): A clinical study on standardization of Vamana Karma w.s.r to antiki, vaigiki, maniki and laingiki criteria. Department of Kayachikitsa, IPGT&RA, Jamnagar
3. Chandrakar Jayaprakash (2005): Cilinical study on the role of Vamana Karma in the management of Yuvana Pidika. Department of Kayachikitsa, IPGT&RA Jamnagar
4. Ranjip Dass (2006): A clinical study on the standardization of Vamana vidhi w.s.r to classical and traditional methods. Department of Kayachikitsa, IPGT&RA Jamnagar
5. Kapil A Pandya (2007): A comparative clinical study of Vamana Karma and Jalaukavacharana in the management of Vicharchika. Department of Panchakarma, IPGT&RA Jamnagar
6. Akhil Nath Parida (2008): Comparative study of Vamana and Virechana karma in Ekakushtha w.s.r to Psoriasis. Department of Panchakarma, IPGT&RA Jamnagar
7. Padhsala Satish V (2009): A comparative study on Vamana karma by using shuddhaghrita and samskritaghrita as abhyantarasnehpana in Ekakushtha w.s.r to Psoriasis. Department of Panchakarma, IPGT&RA Jamnagar
8. Jaimin R Patel (2010): A Comparative Study on Vamana Karma with Madanaphala and Krutavedhana W.S.R. to Ekakushtha (Psoriasis). Department of Panchakarma, IPGT&RA Jamnagar
9. Rajeev Pandey (2010): A Comparative Clinical Study of Vamana and Virechana Karma in the management of Sthula Pramehi W.S.R to Type II Diabetes mellitus. Department of Panchakarma, IPGT&RA Jamnagar
10. Kundan Gadhvi (2011): A Comparative Study between the Efficacy of Vamana and Virechana Karma in the Management of Tamaka Shvasa (Bronchial Asthma). Department of Panchakarma, IPGT&RA Jamnagar
11. Neetu jain (2012): A forwarding clinical study on standardization of vamana karma w.s.r to antiki, vaigiki, maniki and laingiki criteria. Department of Panchakarma, IPGT&RA Jamnagar
12. Shaizi Layeeq (2013): A clinical study on the effect of Vamana karma and Amalaki rasayana in the management of Pandu w.s.r to iron deficiency anaemia. Department of Panchakarma, IPGT&RA Jamnagar
13. Shweta Patil (2013): A comparative study on the effect of vamana and virechana karma followed by brumhana snehapana (kantakari ghrita) in the management of tamaka shvasa w.s.r to Bronchial asthma. Department of Panchakarma, IPGT&RA Jamnagar
14. Sunita Sheike (2013): A comparative study between vamana and virechana karma in the management of sthula pramehi w.s.r to type-ll diabetes mellitus. Department of Panchakarma, IPGT&RA Jamnagar
15. Patairya Pratiksha Prakash (2014): A clinical study on the role of vamana and virechana in the management of hypothyroidism with punarnava-aruta-guggulu. Department of Panchakarma, IPGT&RA Jamnagar
16. Ritika Mishra (2018): A clinical study to evaluate and compare the efficacy of vamana, virechana and shamana in the management of ekakushtha w.s.r to psoriasis. Department of Panchakarma, IPGT&RA Jamnagar
17. Laveena Kumari(2018): A comparative clinical study to evaluate the effect of virechana, vamana and shwasahara yoga in the management of tamaka shwasa w.s.r to bronchial asthma. Department of Panchakarma, IPGT&RA Jamnagar

More information

Upakalpaniya Adhyaya, Madanakalpa Adhyaya, Jimutaka Kalpa Adhyaya, Ikshvaku Kalpa Adhyaya, Dhamargava Kalpa Adhyaya, Vatsaka Kalpa Adhyaya, Kritavedhana Kalpa Adhyaya, Kalpana Siddhi, Panchakarmiya Siddhi, Vamana Virechana Vyapat Siddhi

Abbreviations

Cha. = Charak, Su. = Sushruta, A. = Ashtanga, S. = Sangraha, Hr. = Hridayam, Sa. = Samhita, Sha. = Sharangadara, Ka. = Kashyapa

List of References

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References