21st Chapter of Charaka Samhita Chikitsa Sthana is called Visarpa Chikitsa. It deals with the symptoms, types, curability and treatment for herpes disease.Let us explore the chapter on the treatment of Visarpa (erysipelas, herpes, spreading type of skin disease). Thus, said Lord Atreya [1-2]
Table of Contents
Lord Punarvasu Atreya, who was self-controlled, who was being worshipped by the sages of eminence, and who was dedicated to the welfare of all living beings, was walking around Mount Kailasa, the abode of Kinnaras (celestial musicians) and several springs, which was aromatic all around because of the sweet fragrance emitted from the blossoming flowers. Agnivesha approached him (the preceptor) with queries regarding the ailment terrific like cobra venom spreading to various body parts. Agnivesha inquired – “People get afflicted with this serious disease instantaneously, and if not properly treated, succumb to death. So we are seriously concerned about this ailment.
Kindly enlighten us on the following aspects of this disease:
1. What is the name of this ailment?
2. Why is that name given to the disease?
3. What are the different varieties of this disease?
4. Which are the Dhatus (tissue elements, Doshas and waste products) involved in the causation of this disease?
5. What are the etiological factors of this disease?
6. Where is this disease located?
7. How to identify the varieties of this disease which are easily curable, which are difficult of cure and which are incurable?
8. What are the signs and symptoms (of different varieties) of this disease?
9. What is the treatment of this disease”?
Having heard the above queries of Agnivesha Lord Punarvasu Atreya, the sage of eminence, explained all the relevant details of this disease” Visarpa “as follows? [3-10]
Name of ailment and justification
This ailment is called Visarpa because it spreads (Sarpana) in different directions (vide i.e Vividha). This is also called Parisarpa because it spreads (Sarpana) all over the body (Pari i.e Paritah). 
Types of Visarpa
Visarpa which is caused by the vitiation of 7 Dhatus (4 tissue elements and 3 Doshas to be explained in the subsequent verse no. 15), is of 7 types, viz
6. Kapha-Vataja and
7. Pitta- Kaphaja.
The type of Visarpa caused by:
Vata- Pitta is called Agneya Visarpa.
Kapha-Vata is called Granthi Visarpa.
Pitta-Kapha is called Kardamaka Visarpa which represents a serious condition. [12-14]
7 elements in Visarpa pathogenesis
7 Elements Involved in the Pathogenesis of Visarpa:
The 7 Dhatus (elements) which give rise to Visarpa are:
1. Rakta (blood)
2. Lasika (Lymph)
3. Tvak (skin)
4. Mamsa (Muscle tissue) andDoshas, viz
6. Pitta and
7. Kapha 
Visarpa Nidana – Causes:
Visarpa is caused by the following factors:
1. Lavamla kan rasnmatisevant – Excessive intake of hot ingredients having Saline, sour and pungent tastes.
2. Intake of Dadhi (sour curd), Mastu (the liquid in the upper part of curd), Sukta(vinegar), Sura(alcoholic drinks) and Sauvira (a sour drink prepared of dehusked barley)
3. Excessive intake of Madya (a type of alcoholic drink), and intake of polluted Madya, Raga (condiments) and Shadava (pickles) prepared of excessively hot ingredients.
4. Intake of Haritas (ingredients eaten in raw form described in Sutrasthana 27: 166- 177), Vidahis (ingredients causing burning sensation),Kurchika (curdled milk preparation), Kilata (cheese), Mandaka (Immature curd) Sandaki (a type of fermented wine) and such other fermented drinks, Tila – Sesame (Sesamum indicum), Masha (black gram), Kulattha (horse gram), different types of oil and pastries
5. Intake of meat of animals which are domesticated, and who inhabit marshy land and water.
6. Intake of Lashuna (garlic)
7. Intake of Praklinna (putrefied), Asatmya (unwholesome) and Viruddha ahara (mutually contradictory) ingredients
8. Intake of food in the large quantity, Diva swapna (sleeping during day time), intake of food before the previous meals digested and intake of food immediately after the meal (Adhyasana)
9. Affliction by Kshaya (depletion of body tissues), Injury, Bandha (being tied with ropes, etc)and falls:
10. Excessive exposure to hot sun and excessive physical work and
11. Exposure to poisons, strong wind and fire.
Because of the contribution of the above mentioned causative factors, Vata, etc get aggravated to vitiate the Dushyas (tissue elements), Viz Rakta (blood) etc. to cause Visarpa in a person who indulges in unwholesome food. [16-22]
Visarpa Adhishtana – Location:
Depending upon the location, Visarpa is of 3 types as follows:
1. Bahih-Srita (Visarpa located in the periphery)
2. Antah-Srita (Visarpa located in the interior part of the body) and
3. Ubhaya-Samsrita (Visarpa located in both the periphery and the interior part of the body)
The above mentioned 3 types of Visarpa are consecutively more and more serious.
The Visarpa located in the periphery of the body is curable.
The Visarpana located in the interior part of the body represents a serious condition which is difficult of cure.
When the Doshas spread in the internal organs of the body, they cause the interior type of Visarpa.
When they spread in the exterior part of the body, they cause peripheral type of Visarpa.
If however, they spread all over the body, they cause Visarpa located in both the Periphery and the interior part of the body. [23-25]
Antar Visarpa symptoms
The signs and symptoms of internal Visarpa(Antar visarapa)
• Marma upaghata – Affliction of Marma (vital organs, specially heart),
• Sammoha – unconsciousness,
• Vighattana – obstruction to the channels of circulation,
• Trishna – excessive thirst
• Udvega vishamanam pravartanat – irregular manifestation of normal urges and
• Agni bala kshyat – instantaneous diminution of the power of digestion
The external type of Visarpa is characterized by the signs and symptoms related to the respective Doshas (which are to be described hereafter). [26-27]
Asadhya Visarpa lakshana
Characteristics of Incurable Visarpa:
If Visarpa is associated with all the signs and symptoms (describes in respect of each variety), if it is caused by strong causative factors, if it is associated with painful complications, and if it is located in the vital organs, then this leads to death. 
Etiology and Pathogenesis of Vatika Visarpa:
Vayu aggravated by its own causative factors like ununctuous and hot ingredients or being occluded[ by Kapha and Pitta] because of over- nourishment, Vitiates the Dushyas (Tissue elements), and spreads in accordance with its own strength [to cause Vatika type of Visarpa]. 
Vataja Visarpa Lakshana:
Signs and symptoms of Vatika type of Visarpa:
1. Bhrama – dizziness, Davathu (burning sensation in eyes etc.,) Pipasa – thirst,
2. Nistoda – Pricking pain, Shoola – colic pain, Anga marda – Malaise,Udvestana – Cramps, Kampa – Tremors
3. Jwara – fever,Tamaka (a type of Asthma), Kasa -bronchitis,
4. Asthi sandhi bheda – pain in the bones and joints and their dislocation, Vepana – Shivering
5. Aruchi – anorexia, Avipaka – Indigestion
6. Aksha susho – cloudiness of the eyes, Arukula – lacrimation, and Pipilika – a feeling as if ants are crawling over the body
7. The space through which the Visarpa spreads becomes Shyava aruna bhasa – greyish or Pinkish in color and Shvayathu – oedematous.
8. That space becomes excessively afflicted with Nistoda – pricking pain, Bheda – breaking pain, Shoola – colic pain, Sankocha – expansion, Harsha – contraction, Sphurana – tingling sensation and Prapidyate – throbbing sensation.
9. If not treated, the space becomes replete (accumulated) with instantaneous cracking, pustules which are small in size and pink or greyish in color, and secretion of liquid with is thin, transparent,pink and in small quantity
10. Vibaddha vata mutra purisha – Arrest of the vomiting of flatus, urine and stool and
11. Factors described to cause vata- visarpa are not homologatory to such a patient. On the other hand, the patient feels comfortable with ingredients having opposite attributes. 
Etiology and Pathogenesis of Paittika visarpa:
Pitta, accumulated because of hot regiments, and by the intake of Vidahi (which cause burning sensation) and sour food, vitiates the Dushyas (tissue elements), fills up (obstructs) the Dhamanis (Channels of blood circulation) and spreads which gives rise to Paittika type of Visarpa. 
Paittika Visarpa Lakshana:
Signs and symptoms of Paittika type of Visarpa:
1. Jwara – Fever, Trushna – morbid thirst
2. Murchha – fainting, Moha – unconsciousness
3. Chardi – vomiting, Aruchi – anorexia
4. Anga bheda – breaking pain in the body, Ati matra sweda – excessive sweating and Antar daha- burning sensation in the interior part of the body
5. Pralapa – Delirium, Shiro ruk – headache, turbidity of the eyes, Asvapna – sleeplessness
6. Arati – dislike for everything, Bhrama – giddiness and Shita vata aavarita – excessive longing for cold wind and cold water
7. Harita (Green) and Haridra (yellow) coloration of the Akshu (eyes), Mutra (urine) and stool
8. Harita haridra rupa darshana – Green and yellow vision of objects
9. The space in which this disease spreads, becomes either Tamra (coppery colored), Harita(green) , Haridra (yellow), Nila (blue),Krishna (black) or Rakta (red)
10. This space becomes full of pustules which are excessively swollen and associate with excessive burning sensation and breaking pain
11. The exudates from these pustules have the colors like those of the pustules
12. These pustules get suppurated very quickly and
13. Factors described to cause Pitta-Visarpa are not homogatory to such a patient. On the other hand. The patient feels comfortable with the ingredients, having the opposite attributes. 
Etiology and Pathogenesis of Kaphaja Visarpa:
Kapha accumulated because of the intake of ingredients which are
• Madhura (sweet)
• Amla (sour)
• Lavana (Saline)
• Snigdha (unctuous) and
• Diva swapna – Sleeping during day time vitiates the Dushyas (tissue elements) and spreads slowly which gives rise to Kaphaja type of Visarpa. 
Signs and Symptoms of Kaphaja Visarpa: Kaphaja Visarpa Lakshana
The following are the signs and symptoms of Kaphaja type of Visarpa:
• Sheeta – Feeling of chills, Shita jvara – cold-fever
• Gauravam – heaviness, Ati nidra – excessive sleep, Tandra – drowsiness
• Aruchi -anorexia, Madhura aasya – sweet taste in the mouth, Aasya aalepa – adherence of sticky material in the mouth, spitting of Saliva, Chardi -vomiting
• Aalasya – laziness, Staimityam – timidity, Agni nasha -diminution of the power of digestion (Agni) and Daurbalyam – weakness
• The space in which the disease (Visarpa) spreads, becomes Shyvathuman – edematous, purntirakta sneha – Pale- yellow, not very red and unctuous;
• There is Supti (numbness), Stambha (stiffness), Gauravam (heaviness) and Alpa vedana (less of pain in the body)
• The pustules in this space get suppurated very late, they become chronic, they appear in large number; he skin over these pustules gets covered with sticky material, and these pustules are either white or place- yellow in color
• When there is eruption of these pustules, then exudates which is white , slimy, fibrous, dense, knotty and unctuous, comes out
• After the eruption of these pustules, the space is covered with ulcers which are heavy (deep- seated) stable, surrounded by the capillary net work, unctuous and covered with many skin scabs (sticks skins)
• These ulcers continue to stay for a long time
• The nails, eyes, face, skin, urine and stool of the patient are white in color and
The factors described to cause Kaphaja Visarpa are not liked by the patient. On the other hand, the patient feels comfortable with the ingredients having opposite attributes. 
Etiology and Pathogenesis of Agni- Visarpa:
Vata Dosha and Pitta Dosha are simultaneously aggravated because of their respective causative factors, gain strength from each other and spread over the body along with burning sensation which is called Agni- Visarpa. 
Agni Visarpa Lakshana:
Signs and symptoms of Agni visarpa:
1. Being afflicted by this type of Visarpa, the patient feels as if his whole body is sprinkled with live charcoal
2. Affliction by Chardi (vomiting), Atisara (Diarrhoea), Murccha (Fainting), Daha (burning sensation), Moha (unconsciousness), Jwara (fever), Tamaka (a feeling as if entering into darkness), Aruchi (anorexia), Asthi bheda (pain in the bones and joints), Trushna (morbid thirst), Avipaka (indigestion), Anga bheda (breaking pain all over the body), etc.
3. The space in which the Visarpa spreads appears likes the extinguished charcoal (bark) or excessively red
4. The space becomes surrounded with pustules like those accused by burns
5. If afflicts the Marmans (vital organs) because of its nature to spread rapidly
6. Because of the affliction of the vital organs, the Vata Dosha gets excessively aggravated to cause breaking pain in the limbs in excess and unconsciousness
7. This aggravated Vata Dosha causes Hikka (hiccup), Shwasa (Asthma) and Insomnia;
8. Because of lack of sleep, his mind becomes dull, he feels miserable and he never feels happy any where
9. Because of this disposition of disliking for everything, he leaves his habits an seat, and desires to go to bed
10. Being afflicted with miseries, he gets sleep quickly and
11. He becomes so weak that it becomes very difficult to awaken him from sleep
The patient suffering from Agni- Visarpa like this (with the above mentioned signs and symptoms) is incurable. 
Etiology and Pathogenesis of Kardama- Visarpa:
Kapha and Pitta get simultaneously aggravated because of their respective etiological factors, and spread in a localized manner, giving rise to softening of the tissues of the locality. This is called Kardama- Visarpa 
Kardama Visarpa Lakshana:
Signs and symptoms of Kardama Visarpa:
1. Sheeta jwara – Cold fever, Shiro ruk – heaviness of the head, Daha – burning sensation
2. Staimitya (timidity), Anga avasada – Prostration of the limbs
3. Nidra – sleep, Tandra – drowsiness, Moha – Unconsciousness
4. Anna dvesha – dislike for food, Pralapa – delirium, Agni nasha – diminution of the power of digestion
5. Daurbalya -weakness, Asthi bheda – breaking pain in the bones, Murcha – fainting
6. Pipasa – morbid thirst, Srotasam pralepa – adhesion of sticky material in the channels of circulation,insensibility(jadya) of sense organs, constant feeling for voiding stool
7. Anga-Viksepa (stretching of limbs), Angamarda -Malaise
8. Arti – disliking for every thing and Utsukya – anxiety
9. This disease generally spreads in slow spread in the Amashaya (region of the stomach) and gets localized there
10. The space in which this type of Visarpa spreads, becomes as if studded with eruptions of Rakta pita pandu pidaka -red, yellow and pale- yellow color
11. The space looks muddy, black, dirty and unctuous , and it is excessively hot , Gaurava (heavy), with dull pain, oedema and deep-seated suppuration
12. These eruptions are free from any exudation and become sloughy very quickly.
13. The skin and muscle tissue over these eruptions are shriveled, sticky and suppurated.
14. The pain over this space is less and it appears gradually
15. By rubbing, these eruptions get cracked, and when pressed, sticky and putrefied muscle tissue comes out of these eruptions
16. In the space at the bottom of these eruptions(after taking out the slough), one can visualize vessels and ligaments, and smell like that of a dead body is emitted from this space and
17. The patient loses consciousness and memory.
This is called Kardama- Visarpa, and it is incurable. 
Etiology, Pathogenesis, Signs and Symptoms of Granthi- Visarpa:
Kapha and Vayu get aggravated because of the following:
1. Intake of food and drinks which are Sthira (having the attribute of stability), Guru (heavy), Kathina (hard), Madhura (sweet), Shita (cold), Snigdha (unctuous) and Abhisyandi (ingredients which cause obstruction to the channels of circulation)
2. Avyayama – Lack of exercise etc and
3. Habitually avoiding administration of elimination therapies (panca-karma) at the appropriate time.
Both these vitiated Doshas get excessively aggravated and vitiated the Dushyas (tissue elements) giving rise to Visarpa.
The channel of circulation of vayu gets obstructed by the aggravated Kapha (which causes further aggravation of Vayu). This aggravated Vayu, on its turn, causes splitting of the Kapha into several parts gradually giving rise to a serious of Granthis (glandular enlargements) in the abodes of Kapha. These enlarged glands get suppurated very slowly and the ailment is different of cure.
Besides, in a person having excess of blood, [aggravated Vayu and Kapha] vitiated the blood giving rise to a series of glandular enlargements located in vessels, ligaments (or nerves), muscles and skin. These enlarged glands are extremely painful; some of these might be big in size and some others small; and some of these might be elongated, some of these might be elongated, some round in shape and some of these might be elongated, some round in shape and some of these are red in color.
Being afflicted by this type of Visarpa, the patient may get complications like
Jwara – fever
Atisara – diarrhoea
Kasa – bronchitis
Hikka – hiccup
Tamaka shwasa – asthma
Kshaya – consumption
Sammoha – unconsciousness
Vaivarnya – Discoloration of the skin
Aruchi – anorexia,
Avipaka – indigestion,
Praseka – Salivation,
Chardi – vomiting,
Murchha – fainting,
Anga bheda – Fractures in the limbs,
Ati nidra – excessive sleep,
Arati (dislike for everything) and
Anga sada – prostration
The patient having all these complications transcends all the therapeutic measures. Therefore, treatment of such patients is attempted. 
The ailment which is associated with a disease, and is manifested after the manifestation of the main disease is called Upadrava (complication). It may be a major or minor ailment.
It is called Upa- Drava because it occurs after the manifestation of the disease. It is the main disease which is predominant, and the ailment which appears as a complication is of secondary nature. The complication generally gets subsided when the main disease is cured. But the complication which is already very weak due to its earlier affliction by the main disease Therefore, the treatment of such complications is undertaken expeditiously. 
The Sannipatika type of Visarpa is caused by all the etiological factors [described in respect of each of the earlier varieties of Visarpa]. All the signs and symptoms described in respect of each of the earlier varieties of Visarpa are manifested in this type of Visarpa. It pervades all the Dhatus (tissue elements). It spreads instantaneously, and it is a serious ailment. This Sannipatika type of Visarpa is incurable 
Vatika-Visarpa, Paittika-Visarpa and Kaphaja-Visarpa- these 3 types are curable.
Agni-Visarpa and Kardama-Visarpa can be alleviated by the habitual (constant) use of general therapeutic measures (to counteract the respective etiological factors) only when the vital organs (like heart, etc). are not afflicted, and when there is no softening of the vessels, ligaments and muscle tissue. If not properly treated, any one of these two may cause instant death like snake poison.
The patient of Granthi-Visarpa is treated only if its complications are not manifested. If the complications are already manifested, then the patient should not be treated.
Sannipatika type of Visarpa is incurable because it pervades all the tissue elements, it spreads instantaneously and its treatment involves mutually contradictory therapeutic measures. 
Line of treatment
Visarpa Chikitsa Sutra: Line of treatment
If the Doshas causing Visarpa are of Ama (uncooked) nature and if these Doshas are located in the abode of:
Kapha (upper part of the body, i.e chest, neck and head) – Langhana (fasting) and Vamana (emetic) therapies are useful. Such a patient is given ingredients having Katu (bitter) taste. The affected part of the body is anointed with the paste of the ingredients having ununctousness and cooling effect.
Pitta (i.e Middle part of the body), then also the therapeutic measures suggested above is administered. In addition, blood letting and purgation therapies are specifically administered to such patients.
Vayu (lower part of the body), then Rookshana therapy is administered in the beginning. Since the disease involves the vitiation of Rakta (blood) and Pitta (in the Samanya Samprapti or general Pathogenesis), in the beginning, oleation therapy is not useful.
If Vayu is aggravated in excess and Pitta is less aggravated to cause Visarpa, then Tiktaka Ghrta (Charaka Chikitsasthana 7: 140- 150) is useful. However, if Pitta is aggravated in excess, then the patient is treated with purgation therapy.
If the Doshas causing Visarpa are aggravated in excess then recipes of medicated ghee which do not cause purgation is not administered. Otherwise, these recipes of medicated ghee (which are not purgatives) occlude the Doshas resulting in the sloughing (Paka) of the skin, muscle tissue and blood. Therefore, in the beginning the Visarpa patient is given purgation therapy. This patient is administered blood-letting therapy. Because the vitiated blood is the Ashraya (main supporting factor) in the pathogenesis of Visarpa [43- 49]
In the above verses, the treatment of Visarpa is described only in brief. The treatment in detail will be spelt out hereafter. 
Vamana Yoga – Emetic Recipes:
If Visarpa is caused by either Kapha or Pitta or both Kapha and Pitta, then the patient is given emetic therapy with the following recipes:
1. Madana – Randia dumetrom, Madhuka– Licorice – Glycyrrhiza glabra, Nimba – Neem (Azadirachta indica) and Fruits of Vatsaka (Holarrhena antidysenterica Wall.)
2. Patola – Trichosanthes dioica,Picumarda, Pippali – Long pepper fruit – Piper longum,madana and Indra –Yava – Barley (Hordeum vulgare) [51- 53]
Kashaya Yogas – Herbal decoction:
The following decoctions are useful for the treatment of Visarpa:
1. Decoction of Musta (Cyperus rotundus), Nimba – Neem (Azadirachta indica) and Patola – Trichosanthes dioica
2. Decoction of Chandana (Sandalwood – Santalum album) and Utpala (Nymphaea alba) Sariva – Indian Sarsaparilla – Hemidesmus indicus , Amalaka, Ushira – Vetiver – Vetiveria zizanioides and Musta (Cyperus rotundus)
A wise physician should administer these (above mentioned therapeutically effective decoctions for the cure of Visarpa.
1. Decoction of Kirata- Tikta – Swertia chirata, Lodhra (Symplocos racemosa), Chandana (Sandalwood – Santalum album), Duralabha – Fagonia arabica, Nagara – Zingiber officinale, Androciums of Padma – Lotus (Nelumbo nucifera), Utpala (Nymphaea alba), Bibhitaka – Terminalia bellerica, Madhuka– Licorice – Glycyrrhiza glabra, and Naga-Puspa
2. Decoction of Prapaundarika (Nymphaea lotus) – red variety,Madhuka– Licorice – Glycyrrhiza glabra, Androceums of Padma – Lotus (Nelumbo nucifera), Utpala (Nymphaea alba),Naga-Puspa and Lodhra (Symplocos racemosa)
3. The Sita – white variety of Cynodon dactylon-Kasaya (cold decoction) prepared of Draksha – Raisin – Vitis vinifera, Parpataka, Sunthi – Zingiber officinale, Guduchi – Tinospora cordifolia and Dhanvasaka this is useful for the cure of morbid thirst and Visarpa
4. The cold decoction of Patola – Trichosanthes dioica,Picumarda,Darvi,Katuka-Katukarohini – Picrorhiza kurroa, Yasti- Madhu – Glycyrrhiza glabra and Trayamana – Gentiana kurroo
5. To the above mentioned recipe of Patola – Trichosanthes dioica, etc. Triphala and Dehusked seeds of masura may be added, and made to a decoction. This decoction is added with ghee and
6. Decoction of the leaves of Patola – Trichosanthes dioica, Mudga and the juice of Amalaki – Emblica offcinalis. This decoction is administered by adding ghee. [54-61]
Recipes of Medicated Ghee
MadhuTiktaka Ghrita described earlier (in Chikitsa 7: 144-150) for the treatment of Paittika Kushta is used by a wise physician to cure of Visarpa.
The reputed of Trayamana Ghruta described earlier (in Chikitsa 5: 128- 129) for the treatment of Gulma (Phantom tumor) also is used by a wise physician for the treatment of Visarpa.
The powder of Trivrt – Operculina turpethum is boiled by adding ghee or milk, and administered along with warm water or the juice of Mrdvika for purgation. This is a reputed recipe for the cure of Visarpa.
Similarly, milk boiled by adding Trayamana is administered to cause purgation in a patient of suffering from Visarpa.
The decoction of Triphala is added with ghee and Trivrt – Operculina turpethum and given for purgation to the patient of Visarpa associated with fever.
Similarly, the decoction or juice of Amalaki – Emblica officinalis is administered for purgation, by adding ghee. If the patient of Visarpa had costive bowel, then the powder of Trivrt – Operculina turpethum is added to this recipe.
If the Doshas in the patient of visarpa in the Kostha (Gastro- Intestinal tract), the also the above mentioned recipes are to be administered. [62- ½ 68]
Medicines for Visarpa from Sahasra Yoga text book
1. Visarpahara Kashaya
2. Tiktaka Ghrita
3. Mahatiktaka Ghrita
4. Vrisha Ghrita
5. Panchavalkadi taila
6. Chandanadi Taila
7.Vrana bhairava Taila
8. Khandasama choorna
9. Kulakadi Kashaya
10. Nannaryadi kashaya
11. Chundatkarutamadi Kashayam
12. Trayantyadi Kashayam
13. Nalpamaradi Tailam
Raktamokshana – Blood- letting Therapy for Bahi Visarpa:
If the blood in the periphery is vitiated to cause Visarpa, then in the beginning, blood – letting therapy is administered by the physician.
Vatanvita Rakta – Shrunga (Vishaana) – If the vitiated Rakta is associated with aggravated Vayu, then the vitiated blood is taken out through the help of horn.
Pittanvita Rakta – Jalauka – If there is associated of aggravated Pitta, then the blood is taken out with the help of leech.
Kaphanvita Rakta – Alabu – If there is association of aggravated Kapha, then the vitiated blood is taken out with the help of alabu (the outer shell of the fruit with the pulp removed).
In addition, Venesection is performed to take out the vitiated blood from the adjacent vein. This blood- letting therapy is essential], without which the vitiated blood gives rise to the sloughing of the skin, muscle tissue and ligaments. [68 ½ – 70]
Even after the interior of the body is cleansed [by the above mentioned elimination therapies], the residual Doshas remain in the exterior of the body, i.e in the skin and muscle tissue. To remove these morbid Doshas, external therapies is administered. Such external therapies can also be administered in the beginning, if the Dosha causing Visarpa are less aggravated.
The paste of the bark of Udumbara – Ficus racemosa, Madhuka– Licorice – Glycyrrhiza glabra,Padma – Lotus (Nelumbo nucifera)- kinjalka, Utpala (Nymphaea alba), Naga puspa and Priyangu (Callicara macrophylla) is added with Ghee and applied externally(Pradeha) for the cure of Visarpa. 
The paste of the tender adventitious roots of Nyagrodha – Ficus bengalensis, Pith of Kadali and Bisa- Granthi(rhizome of lotus) is mixed with Shata- Dhauta- Ghrutha (ghee washed with water for 100 times) and applied externally. 
The paste of Kaliya, Madhuka– Licorice – Glycyrrhiza glabra, Hema (Mesua ferrea), Vanya, Chandana (Sandalwood – Santalum album), Padmaka – Prunus cerasoides, Ela (Elettaria cardamomum Maton) Mrnala and Phalini is mixed with ghee and applied externally. 
The paste of Shadvala (Durva (Cynodon dactylon), Mrunala, Shankha, Chandana (Sandalwood – Santalum album), Utpala (Nymphaea alba), root of Vetasa and Tandula (rice) is applied externally. 
The paste of Sariva – Indian Sarsaparilla – Hemidesmus indicus, Padma – Lotus (Nelumbo nucifera)- Kinjalka, Ushira – Vetiver – Vetiveria zizanioides, nila- Utpala (Nymphaea alba), Manjistha – Rubia cordifolia, Chandana – Santalum album, Lodhra (Symplocos racemosa) and Abhaya – Terminalia chebula is applied externally. 
The paste of Nalada, Harenu, Lodhra (Symplocos racemosa), Madhuka– Licorice – Glycyrrhiza glabra, Padmaka – Prunus cerasoides, Durva – Cynodon dactylon and Sarja (Vateria indica)-Rasa is mixed with ghee and applies externally. 
Yavaka (gruel prepared of barley) or Saktu (roasted flour of cereals) is mixed with ghee and applied externally.
The paste of Madhuka– Licorice – Glycyrrhiza glabra, Vara and Yava – Barley (Hordeum vulgare)-Saktu (Flour prepared of roasted barley) is mixed with ghee and applied externally. 
The physician should apply externally the paste of Bala – Country mallow (root) – Sida cordifolia, Utpala (Nymphaea alba)- Saluka (rhizome of lotus), Vira Kanda(Vidari (Ipomoea paniculata / Pueraria tuberosa), Aguru – Aquallaria agallocha and Chandana (Sandalwood – Santalum album).
Similarly, the paste of Mrnala (root of lotus) Bisa (stem of lotus) is applied externally. 
The paste of the powder of barley and Madhuka– Licorice – Glycyrrhiza glabra is mixed with ghee and applied externally. [½ 80]
Harenu, Masura, Mudga and white variety of Shali-rice- – these drugs taken individually or all together is made to a paste, mixed with ghee and applied externally [80 ½ – ½ 81]
The cooling mud from a lotus pond or the paste of pearl, or the paste of Sankha, or the paste of Pravala, or the paste of Sukti, or the paste of Gairika is mixed with ghee and applied externally which is useful for the patient suffering from Visarpa. [81 ½ – ½ 82]
The paste of Prapaundarika (Nymphaea lotus) – red variety, Madhuka– Licorice – Glycyrrhiza glabra, Bala – Country mallow (root) – Sida cordifolia, Saluka, Utpala (Nymphaea alba), leaves of Nyagrodha – Ficus bengalensis and Dugdhika is mixed with ghee and applied externally. [82 1/2 – ½ 83]
The paste of Bisa (Lotus Root), Mrinala (lotus stalk) or Kasheru is mixed with ghee and applied externally.
Similarly, the paste of Shatavari – Asparagus racemosus and Vidari (Ipomoea paniculata / Pueraria tuberosa) mixed with Shata-Dhauta- Ghruta (Ghee washed with water 100 times) may be used externally. [83 ½- ½ 84]
The paste of Saivala (Vallisneria spiralis moss), the root of Nava (Nala), Gojihva, Vrsa- Karnika (Musika-Parnika) and leaves of Indrani (Nirgundi (Vitex negundo) is mixed with ghee and applied externally. Similarly, the paste of the bark of Sirisha (Albizzia lebbeck Benth.) mixed with Bala – Country mallow (root) – Sida cordifolia-Ghrta may be applied externally. [84 ½ – ½ 85]
The paste of the leaves of barks of Nyagrodha – Ficus bengalensis, Udumbara – Ficus racemosa, Plaksa – Ficus virens, vetasa and Asvattha – Ficus relgiosa is mixed with profuse quantity of ghee and applied externally after making these cool. [85 ½- ½ 86]
All the above mentioned Pradehas (recipes used externally in paste form) are useful in the Visarpa caused by the aggravation of Vata and Pitta. Other recipes, in addition to the above mentioned ones, which are useful in the treatment of Visarpa caused by aggravated Kapha, will be described hereafter. [86 ½ – ½ 86]
The paste of Triphala, Padmaka – Prunus cerasoides, Ushira – Vetiver – Vetiveria zizanioides, Samanga – Rubia cordifolia, Karaviraka, root of Nala and Ananta mixed with a small quantity of ghee is useful in Kaphaja type of Visarpa. [87 ½ – ½ 88]
The paste of Khadira – Acacia catechu, Saptaparna – Alstonia scholaris, Musta (Cyperus rotundus), Aragvadha (Cassia fistula), Dhava – Anogeissus latifolia, Kurantaka and Devadaru (Cedrus deodara) mixed with a small quantity of ghee is useful in kaphaja type of Visarpa. [88 ½ – ½ 89]
Kaphaja Visarpa Yogas:
The following recipes are useful in the kaphaja type of Visarpa:
1. Paste of the leaves of Aragvadha (Cassia fistula) and the bark of Slesmataka
2. Paste of the leaves of Indrani, Kakahva and flowers of Sirisha (Albizzi lebbeck Benth.)
3. Paste of Saivala (Vallisneria spiralis)(moss), root of Nala, Vira and Gandha-Priyangu (Callicara macrophylla)
4. Paste of Triphala,Madhuka– Licorice – Glycyrrhiza glabra,Vira and flowers of Sirisha (Albizzi lebbeck Benth.) and
5. Paste of Prapaundrarika – Nymphaea lotus, Hribera, bark of Darvi – Berberis aristata, Madhuka– Licorice – Glycyrrhiza glabra and bala – Sida cordifolia
The above mentioned recipes may be used individually or two of these may be combined or all of these may be used together externally by adding a small quantity of ghee for the cure of Kaphaja type of Visarpa. [89 ½ – ½ 92]
Use of ghee in Recipes:
All the recipes described above for external application to treat Kaphaja type of Visarpa is mixed with ghee only in small quantity. The recipes described earlier for the treatment of Vatika and Paittika types of Visarpa should however, be added with ghee in profuse quantity.
Even Shata Dhauta ghrita (ghee washed with water 100 times) also can be used externally for the treatment of Visarpa. [92 ½ – 93]
Read more about Shata Dhauta ghrita
Recipes to cleanse the skin lesions: – Seka Yogas
If the Visarpa is caused by the excessive aggravation or vitiation of Vata, Rakta and Pitta, then the Physician is effuse (Seka)[the ulcers] frequently with the supernatant part of ghee or cooled milk or cooled decoction of Madhuka– Licorice – Glycyrrhiza glabra or the cooled decoction of Pancha-Valkala. [94 – ½ 95]
Recipes Used in different other Forms:
The recipes described above for effusion (secana) and for external application (Pradeha) may also be used for cooking medicated ghee. Similarly, these ingredients (recipes) can also be used for dusting (Avachurnna). Application of this medicated ghee and dusting the powders of these recipes help in the healing the ulcers of Visarpa.
Durvadi –Ghrta and Darvyadi Avachurna
Ghee cooked with the juice of Durva (Cynodon dactylon) is applied externally which helps in the healing of the ulcers caused by Visarpa.
Avachurnana – dusting – Similarly, the powder of the bark of Darvi – Berberis aristata, madhuka, Lodhra (Symplocos racemosa) and Kesara may be used for dusting over these ulcers. [96 ½ – ½ 97]
Recipe for the Washing Ulcers
Decoction of Patola – Trichosanthes dioica, Picumarda, Triphala, Madhuka– Licorice – Glycyrrhiza glabra and Utpala (Nymphaea alba) may be used for washing ulcers of Visarpa. Medicated ghee prepared of the above mentioned ingredients may be applied over these ulcers. Similarly, the powder of these ingredients may be used for dusting over these ulcers of Visarpa. [97 ½ – ½ 98]
Method of Using Ointments (Pradeha or lepa)
All the above mentioned ointments cure Samprasadana (which brings back the natural color of the skin or which cause alleviation of Raktha and Pitta). These are to be used repeatedly after removing the previously applied ointment.
The earlier used ointment is removed without washing with water, and thereafter, fresh ointment which is not very thick is applied. This process is repeated for several times.
In Kaphaja Visarpa, thick ointment is used after the previously applied ointment is dried up and removed. The triturated paste is used externally in the form of ointment, and the thickness of this paste is 3/4th of the thickness of the thumb.
The paste is neither too unctuous nor too dry. The paste is neither in a bolus from nor should it be too thin. The paste is of moderate consistency.
The paste which has become stale should never be used over the ulcers of Visarpa. The same paste which was used earlier and removed of Visarpa. The same paste which was used earlier and removed is again.
The paste smeared over a piece of cloth is used (tied as a bandage) over these ulcers because, this arrests the evaporation of heat from these ulcers thereby causing sloughing, spread of the ulcers (Visarpa) and Pain. It produces more of heat as a result of which pimples appears in the skin giving rise to itching.
If the paste is applied over the earlier one (without removing the earlier paste), then the same ailments arise as are describes above (application of the paste by smearing over a cloth).
If the paste is applied in a thin layer, then while drying, the layer of the paste develops cracks, and it gets dried up before the medical value penetrates into the skin to cure the ailment
If the paste is applied without adding ghee, it produces the same adverse effects as those produced by the application of a thin layer of the paste (described above) while getting dried up, this paste causes more pain or aggravates the disease [98- 107]
Wholesome diet, regimen
Wholesome foods and drinks useful for curing Visarpa
The patient in the beginning should observe fast. Thereafter, he is given Mantha (roasted flour of cereals added with water in profuse quantity).This drink is free from any unctuous material, but is added with Dadima – Pomegranate – Punica granatum, Amalaka, Parushaka – Grewia asiatica, Mrudvika and Kharjura – dates. The above mentioned flour of roasted cereals and other ingredients is mixed with boiled water.
The roasted flour of barley and Shali type of rice may be added with ghee, and given to the patient to eat in the form of linctus.
The above mentioned recipe is digested, the patient is given boiled old rice along with vgetable soup. Mudga, Masura and Chanaka are used for the preparation of this vegetable soup. To these Yusha, patola – Trichosanthes dioica and Amalaka may also be added for the preparation of the soup. This soup may not be made sour. But if the patient so desires, then the soup can be made sour by adding sour Dadima – Pomegranate.
The patient is given the soup of the meat of animals inhabiting an arid zone. The meat-soup is added with any unctuous material like ghee, Parusaka – Grewia asiatica, Draksha – Raisins, Dadima – Pomegranate – Punica granatum and Amalaka may be added while preparing the meat soup.
Red, white Mahahva types of Shali rice, and Shashtika type of rice, which are old and which are boiled with the residual water completely removed, is given to the patient as food.
Depending upon the eating habit (wholesomeness), the patient may be given either barley or wheat or Shali type of rice to eat. If Shali type of rice is not very homologatory, and if kapha is aggravated in excess, (then barley and wheat is used as food). [108- 114]
Unwholesome diet, regimen
Unwholesome Diet, Drinks and Regimens
The patient suffering from Visarpa should avoid the following:
1. Food and drinks which are Vidahi (causing burning sensation)
2. Viruddha ahara – Mutually contradictory ingredients of food and drinks;
3. Diva swapna – Sleep during the day time
4. Krodha – Anger,Vyayama – Physical exercise and envy and
5. Exposure to hot rays of the sun, fire and strong wind. 
General Line of Treatment
From the above mentioned recipes, the cooling ones are to be used for Paittika type of Visarpa. The ununctous type of recipe is used for Kaphaja type of Visarpa. For the treatment of Vatika type of Visarpa, unctuous type of recipe is used.
Agni- Visarpa is treated with recipes which alleviate Vayu and Pitta.
Kardama- Visarpa is treated with recipes which generally alleviate kapha and Pitta.
Treatment of Granthi Visarpa
If granthi- Visarpa is dominated by Rakta and Pitta, then in the beginning, the patient is given
Ruksana (drying therapy),
Langhana (fasting therapy),
Seka (affusion) with the decoction of Panca- valkala,
Jalaukavacarana (blood- letting therapy with leech),
Vamana (emetic therapy),
Virecana (Purgation therapy) and medicated ghee prepared of Astringent and bitter drugs.
The physician should administer these therapies in appropriate time. [118- 119]
After the body is cleansed through upward tract (by emetic therapy) and through downward tract (by purgation therapy) and after the administration of blood-letting therapy, the patient suffering from granthi-Visarpa is given external therapies, etc for the alleviation of Vata and kapha. 
External Therapy for Granthi Visarpa:
The patient suffering from Granthi- Visarpa associate with colic pain is given external application of Upanaha (thick layer of paste applied when it is warm) with Utkarika (Pancaka) or Vesavara (Minced meat) which are warm and which are mixed with fat (ghee or oil). 
Affusion for Granthi Visarpa:
The nodules of Granthi- Visarpa are sprinkled with warm oil medicated by boiling with Dasha-Mula. The oil cooked with Kushta and added with Pakva- Kshara (an Alkali preparation details of which are described in Susruta- Samhita) may also be used, when warm, for the affusion of these nodules. Similarly, affusion could be made with warm cow’s urine or warm juice of the leaves (which alleviate Vayu and Kapha, but do not cause vitiation of Rakta and Pitta). [122 -½ 123]
Paste of External Application:
The warm paste of either Ashwagandha – Withania somnifera or dried radish or the bark of Naktamala (Karanja (Pongamia pinnata) is applied over the nodules.
The paste of Bala – Country mallow (root) – Sida cordifolia, Nagabala, Pathya, Bhurja (Betula utilis D. Don.) granthi, Vibhitaka, leaves of Vamsa (Bamboo) and Agnimantha – Clerodendrum phlomidis is useful for the application over these nodules of Granthi- Visarpa.
Application of the paste of Danti – Baliospermum montanum, bark of the root of Chitraka – Leadword – Plumbago zeylanica, latex of Sudha, Latex of Arka – Calotropis procera, Jaggery, seed of Bhallataka (Semecarpus anacardium Linn.) and Kasisa breaks even a stone, what to speak of the nodules caused by Kapha which are located in the exterior of the body. [123 ½- ½ 127]
Recipes for external Application over Chronic Nodules:
For breaking open chronic nodules, the following recipes and therapies is administered
1. The patient should use the soups of Mulaka – Raphanus sativus and Kulattha – Dolichos biflorus along with Alkalies and Dadima – Pomegranate – Punica granatum
2. The patient may take boiled wheat or barley along with Sidhu (a type of wine), honey and sugar.
3. The patient should drink supernatant part of Varuni(a type of alcoholic drink) along with honey and the juice of Matulunga – Lemon variety – Citrus decumana / Citrus limon
4. Triphala along with Pippali – Long pepper fruit – Piper longum and honey is administered to the patient
5. The roasted flour of Musta (Cyperus rotundus) or Bhallataka – Semecarpus anacardium is given to him
6. Maksika (iron pyrite) or Devadaru (Cedrus deodara) and Guduchi – Tinospora cordifolia or Shilajatu is administered to the patient
7. The patient is given Dhuma(smoking therapy) and Siro- Virecana(inhalation therapy) for the elimination of morbid matter from the head
8. Recipes described earlier (in Chikitsa ; 5) for breaking open the growth of Gulma(Phantom tumor) and
9. Putting pressure on the nodules with (hot) iron, bolus of salt, stone, gold, or copper. [127 ½ – 131]
Agnikarma and Shastrakarma for Granthi Visarpa treatment:
Cauterization and Surgical Intervention
If these nodules have become strong, stabilized, and hard like stone, and therefore, not amenable to the above mentioned
Therapeutic measures, then their cauterization with the help of Alkalis or hot rod of gold is useful.
These nodules get suppurated by the external application of suppurating ointments. Thereafter, these suppurated nodules are incised and removed. The blood from this location which is already incited is taken out frequently. After the vitiated blood is removed, medicines for the alleviation of Vata and kapha are given to the patient.
He is given Dhuma (smoking therapy), Shiro- virecana (inhalation therapy for the elimination of morbid from the head), Svedana (fermentation therapy), and Parimardana (rubbing therapy). If by the above mentioned therapeutic measures, the vitiated Doshas do not get alleviated, then the patient is given Pacana (recipes to bring about maturity of the Ama or immature metabolic product) therapy.
When these nodules have become soft because of cauterization and application of suppuration recipes, the physician should treat these nodules of Granthi- Visarpa like an ulcer with the cleansing and healing therapies both externally and internally. [132- 136]
Treatment of Ulcers
Oil is cooked with the paste of Kampillaka – Mallotus philippinensis, Vidanga – Embelia ribes, Darvi – Berberis aristata and fruit of Karanja (Pongamia pinnata). This medicated oil is used (externally) in the treatment of ulcers of Granthi- Visarpa.
A wise physician, acquainted with the propriety of the location and time, is administer the therapies described in the chapter dealing with the ‘’Therapeutics for two kinds of ulcers” i.e in the 25th chapter of this section. Thus, ends the description of the treatment of Granthi Visarpa [137- 138]
Treatment of Galaganda (Goiter)
The therapeutic measures described above for the treatment of the nodules of Granthi- Visarpa are useful for the treatment of Gala-Ganda (goiter) caused by the aggravation of kapha. Habitual intake of ghee, milk and decoctions, prevent the occurrence of Gala Ganda or goiter (including Ganda-Mala or cervical adenitis) caused by aggravation of Vayu in association of Kapha. [139- 140]
Importance of Blood Letting Therapy
Since Visarpa is over manifested without the vitiation of Rakta and Pitta, blood letting therapy (which is the most effective measure to correct this morbidity) can match all the other modes of treatment described above for curing Visarpa.
Therefore, the therapeutic measures to all alleviate the fundamental causative factors, viz; Rakta and Pitta are described in this chapter. It is not that the therapeutic measures for the alleviation off other causative factors in specific cases viz. Vata and Kapha are not explained here. Thus, the therapeutic measures both in general (for the alleviation of Rakta and Pitta) and in specific cases (for the alleviation of other causative factors like Vayu and Kapha) is described both in brief and in detail. A wise physician should administer these therapies appropriately (with desecration). [141-143]
Thus, Punarvasu (Atreya) explained the perfect treatment of Visarpa to Agnivesha, the learned inquier with reference to the following topics:
1. Derivation of the Visarpa
2. Synonyms of Visarpa
3. Doshas, Dushyas (tissue elements) and other causative factors of Visarpa
4. The Ashraya (location) of Visarpa in different channels viz exterior or interior part of the body
5. The seriousness and non- seriousness of different types of Visarpa
6. Signs and symptoms and complications of different types of Visarpa
7. Nature of Upadrava (complication)
8. Curability and incurability of different types of Visarpa and
9. Appropriate therapeutic for the treatment of curable varieties of Visarpa. [144-146]
Thus, ends the 21st chapter in Chikitsa Sthana (section on treatment of diseases) dealing with the treatment of visarpa (erysipelas and herpes) in Agnivesha’s work as redacted by Charaka.