Charaka Vrana Chikitsa – 25th Chapter – Wounds, Ulcers

25th chapter of Charaka Samhita, Chikitsa Sthana deals with symptoms and treatment of internal and external wounds and ulcers. It is called Vrana Chikitsa Adhyaya.

Treatment of wounds and ulcers
We shall now explore the treatment of 2 types of Ulcers. Thus, said Lord Atreya. [1-2]

Prologue

Finding an opportune moment, Agnivesha respectfully requested his preceptor, Lord Atreya who was well versed in the spiritual and physical sciences, and as free from the afflictions of self- pride as well as vanity, as follows:
“O! Lord. 2 types of Ulcers are enumerated in the chapter dealing it the complication of diseases (vide Sutra 19:4:7) O! Bestower of happiness, you may kindly expound the signs and symptoms as well as treatment of these two types of ulcers. [3-4]

wound healing

Guru’s reply

Having heard this query, the Preceptor replied, as follows:
O! disciple, now listen about the Linga (signs and symptoms including etiology) and Bheshaja (therapeutic measures) of both the types of ulcers, viz, nija (endogenous) and Agantuja (Exogenous) which were enumerated, in brief, earlier (in Sutra 19;4: 7) [5- ½ 6]

Nija Agantuja Vrana

Nija and Agantuja Vrana – Endogenous and exogenous ulcers:
The Nija or endogenous type of Vrana (ulcer) is caused by the vitiation of Doshas of the body, and
The Agantuja type of ulcer is caused by eternal factors like Vadha (wound caused by stabbing, etc,), Bandha (wound caused by tying with a rope etc), fall and injury by fangs, teeth and nail. This type of exogenous ulcer is also caused by exposure to (contact with) poison, fire and sharp- edged weapon.
The exogenous ulcer bears special characteristic features in as much as these can be cured by
• Mantra (Incantation)
• Agada (Talisman) and
• External application of drugs in the form of paste
They have specific causative factors, and they have specific signs and symptoms (which are localised). The Nija or endogenous types of ulcer, however, bears opposite characteristic features. [6 ½- 8]
If the endogenous type of ulcer do not yield to the treatment (specified above) because of its association with the Doshas of the body, then even such exogenous ulcer is treated with medicines (to be) prescribed for endogenous ulcer, depending upon the strength of the aggravated Doshas. [9]

Pathogenesis of Endogenous Ulcers

Vata, Pitta and Kapha being aggravated by their respective causative factors get lodged in the exterior (eternal pathway) of the body to give rise to endogenous type of ulcer in the human beings [10]

Vataja Vrana

Vatika type of ulcer is characterised by
• Stabdha – stiffness
• Kathina samsparsha – hardness in touch
• Manda srava – scant discharge
• Ati tivra ruk – excruciating pain
• Tudyate – pricking sensation
• Sphurana – throbbing and
• Shyava aruna maruta sambhava – bluish black coloration [11]

Treatment of Vatika Ulcer:
The patient suffering from Vatika type of ulcer is treated with
• Sampurna – filling buccal cavity of the ulcer
• Snehapana – oleation therapy and
• Snigdha – fomentation
• Upanaha – application of hot paste of drugs
• Pradeha – application of ointment and
• Pariseka (affusion) which are of unctuous nature [12]

Pittaja Vrana

Signs and Symptoms of Paittika Vrana:
The patient suffering from Paittika type of ulcer gets
• Trishna – thirst
• Moha – unconsciousness
• Jwara – fever
• Sweda – sweating
• Daha – burning sensation
• Dushti – putrification and
• Avadarana – sloughing out of tissues and
• Vidyat gandhaih putika srava – elucidation of foul smelling material (pus) from the ulcer [13]

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Treatment of Paittika Ulcer:
Paittika type of ulcer is treated with
• Pradeha – application of hot paste of drugs and
• Parisechana (affusion)
• Sarpi pana – intake of medicated ghee and
• Virechana – purgation therapy prepared of cooling, sweet and bitter drugs. [14]

Kaphaja Vrana

Signs and Symptoms of Kaphaja Vrana:
The Kaphaja type of ulcer is characterised by
• Bahu piccha – excessively slime exudation
• Guru – heaviness
• Snigdha – unctuousness
• Stimita – numbness
• Manda vedana – mild pain
• Pandu varna – pallor
• Alpa sanklesha – less of sloughing and
• Chira kari — long duration (chronic nature). [15]

Treatment of Kaphaja Vrana:
Kaphaja type of ulcer is treated with
• Pradeha (application of hot paste of drugs) and
• Parisechana (affusion) prepared of drugs which are Kashaya (astringent), Katu (pungent), Ruksha (dry) and Ushna (hot).
The patient suffering from this type of ulcer is given
• Langhana (Fasting) and
• Pachana (which helps in the metabolic transformation of uncooked material of the body) therapies [16]

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Characteristic Features:
These types of ulcers have the following characteristic features:
1. These are further classified into 20 varieties, depending upon the differences in their nature
2. These are to be examined in 3 different ways
3. In the advanced stage of their manifestation, they exhibit 12 characteristic features
4. Their locations are 8 in number
5. They are associated with 8 types of foul odours
6. They have 14 types of discharges
7. They have 16 types of complications
8. There are 24 factors which cause impediments in the healing of these ulcers and
9. There are 36 effective therapeutic measures for the treatment of these ulcers.
All the above mentioned factors will be described hereafter individually. Listen to me! [17-19]

Vrana Bheda

Vrana Bheda – Twenty varieties of Ulcers:
Depending upon their various characteristic features, ulcers are of 20 varieties as follows
1. Krtya or those requiring intervention, viz, incision, etc, [this term is also interpreted as “curable”].
2. Akrtya or those not requiring surgical intervention. These are just to be healed [this term is also interpreted as” incurable]
3. Dusta or purified ulcer
4. Adusta or ulcers which are not purified
5. Marmasthita or ulcers located in the Marmans(vital organs)
6. Amarmasthita or ulcers not located in the vital organs
7. Samvrta or closed ulcers
8. Vivrata or open (exposed) ulcers
9. Daruna or hard ulcers
10. Adaruna or soft ulcer
11. Sravin or ulcers with profuse discharge
12. Asravin or ulcers with no discharge or scanty discharge
13. Savisa or ulcers having poisonous effects or those caused by poisons
14. Avisa or ulcers which are not poisonous or which are not caused by poisons
15. Visamasthita or ulcers having regular brooders or which are located in the uneven parts of the body.
16. Samasthita or ulcers having regular borders or which are located in the uneven arts of the body
17. Utsangin or ulcers having thin borders
18. Anutsangin or ulcers having thin borders
19. Utsanna or ulcers having elevated surface and
20. Anutsanna or ulcers having depressed surface. [20-21]

Methods of examination

Examination of the ulcer and the patient suffering from this ailment is to be carried out in 3 different ways, viz,
• Darshana – inspection
• Prashna – interrogation and
• Samsparsha – palpation
To be examined by Darshana (inspection):
• Vaya – age
• Varna – colour
• Sharira – nature of the physique and
• Indriya – sense organs
To be examined by Prashna (interrogation):
• Hetu – etiology
• Arti – nature of the pain
• Satmya (wholesomeness of food, drugs, etc.) and
• Agni Bala (power of digestion and metabolism)
To be examined by Samsparsha (palpation):
• Mardava – Stiffness or hardness and
• Shaitya – coldness or heat in the ulcerated part of the body are [22-23]

Ulcer in advanced stage

Characteristic Features of Ulcer in Advanced Stage:
12 characteristic features indicating the advanced stage of morbidity of an ulcer are as follows
1. Shwetatva – Paleness of the ulcer
2. Avasanna Vartmatva – depression of the margin of the ulcer
3. Ati SthulaVartmatva – excessive thickness of the margin of the ulcer
4. Ati Pinjaratva – excessively red and yellow mixed coloration of the ulcer
5. Neelatva – blue coloration of the ulcer
6. Shyavatva – blackish brown coloration of the ulcer
7. Ati pidakatva – appearance of eruption in excess around the ulcer
8 – 9 Rakta-Krsnatva – red or black coloration of the ulcer
10. Ati putitva – excessive putrefaction of the ulcer
11. ropyatva – recurrence of the ulcer, after it is healed and
12. Kumbhi mukhatva – the ulcer having a narrow opening with an expanded base like a jar
These morbid conditions are also classified into 24 categories depending upon their association with causative factors like Snayu-kleda (sloughing of ligament). [24-25]

Vrana Sthana

Vrana Sthana – Seats of Manifestation of Ulcers:
Ulcers, in brief, are manifested in the following 8 locations:
1. Tvag Ashraya – located in the skin
2. Sira ashraya – located in the vessels
3. Mamsa ashraya – located in the muscle tissue
4. Medas-Ashraya – located in the fat tissue
5. Asthyashraya – located in the bones
6. Snayu- Ashraya – located in the ligaments
7. Marman-Ashraya – located in the vital organs and
8. Antarashraya or Kosthashraya – located in the visceras of the chest and abdomen [26]

Vrana Gandha

Vrana Gandha – Different Odours of Ulcer:
According to the physicians specialised in determining different types of odours, the smell emanating from the ulcers are of 8 types, as follows:
1. Sarpis – smell of the ghee
2. Taila – smell of oil
3. Vasa – smell of fat
4. Puya – smell of pus
5. Rakta – smell of blood
6. Syava – smell which emanates when curd is rubbed over copper
7. Amla -smell associated with a sour substance and
8. Puti – putrid smell [27]

Vrana Srava

Vrana Srava – Nature of discharge from ulcers:
Discharges from ulcers are, in brief, of 14 types, as follows
1. Lasika-Srava – discharge of lymph –like fluid
2. Jala Srava – watery discharge
3. Puya-Srava – Discharge of Pus
4. Asrk- Srava – blood discharge
5. Haridra Srava – discharge which is yellow like turmeric
6. Aruna- Srava – discharge which is reddish in colour
7. Pinjara-Srava – discharge which is mixed red and yellow in color
8. Kasaya- Srava – discharge of brownish black color
9. Neela Srava – discharge of blue color
10. Harita Srava – discharge of green color
11. Snigdha Srava – discharge of unctuous nature
12. Rooksha Srava – discharge of Dry nature
13. Sita Srava – discharge of white color and
14. Asita Srava – discharge of black color [28 – ½ 29]

Complications of ulcers

Complications of ulcers, according to the specialists’ in this branch are 16 in number as follows
1. Visarpa – erysipelas
2. Paksaghata – hemiplegia
3. Sirastambha – stiffness of vessels
4. Apatanaka – convulsions
5. Moha – unconsciousness
6. Unmada – insanity
7. Vrana ruk – acute pain in ulcers
8. Jvara – fever
9. Trsna – morbid thirst
10. Hanugraha – lock- jaw
11. Kasa – cough
12. Chardi – vomiting
13. Atisara – Diarrhoea
14. Hikka – hiccup
15. Svasa – dyspnoea
16. Vepathu – trembling [29 ½- ½ 31]

Impediments in Healing

Factors which cause impediments in the healing of ulcers are 24 in number, and are as follows:
1. Snayu- Kleda – Sloughing of ligaments
2. Sira- Kleda – sloughing of Vessels
3. Gambhirya – when the ulcers is deep seated
4. Krmi- bhaksana – appearance of Maggots, therapy causing denudation of the tissues of the ulcer
5. Asthibheda – fracture of bone near the ulcer
6. Sasalyatva – presence of foreign bodies in the ulcer
7. Savishatva – presence of poison in the ulcer
8. Sarpanatva – spreading of the ulcer
9. Nakha- kastha- prabheda – excessive injury by nails and wood pieces
10. Charma- Atighattana – excessive denudation of the skin
11. Loma- Atighattana – excessive denudation of the small hair near the skin
12. Mitya-Bandha – wrong bandaging
13. Atisneha – excessive oleation
14. Ati- bhaisajya- Karshana – emaciation of the tissues near the ulcer because of application of drugs in excess
15. Ajirna – indigestion
16. Atibhukta – over eating
17. Viruddha-Bhojana – intake of mutually contradictory ingredients of food etc
18. Asatmya- bhojana – intake of unwholesome food
19. Shoka – grief
20. Krodha – anger
21. Diva- swapna – sleep during the day time
22. Vyayama – excessive physical exercise
23. Maithuna- sexual intercourse
24. Niskriyatva – negligence of using proper therapeutic measures [31 ½ – 34]

Vrana Sadhya Asadhyata

Reasons of Ulcers becoming difficult of cure:
If the ulcer is caused by several Doshas (Vayu, pitta and Kapha), and is associated in excess with morbid secretions, odours, Doshas (factors causing impediments in the healing of ulcers) and other complications, then it becomes Kruchra sadhya (difficult of cure). [35]

Vrana Sadha – Asadhyata – Curable, difficult of cure and incurable Ulcers:
Factors indicating easy curability of ulcers are as follows:
1. Confinements of the ulcer to the skin and muscle tissues alone
2. Location in an easily approachable site
3. Young age of the patient
4. Non-association of the ulcer with complications
5. Enough wisdom of the patient to use appropriate treatment regularly
6. Recent origin of the ulcer and
7. Conduciveness of the season for the treatment of the ulcer
If any of the above mentioned factors are backing, then the ulcer becomes difficult of cure (Krcchra – Sadhya).
If all the above mentioned factors are lacking then the ulcer becomes incurable (Asadhya), and its treatment should not be attempted (Nirupakrama). [36- 37]

Shodhana or Elimination Therapy

In the beginning, the patient suffering from ulcer should appropriately be given elimination therapies for the purification of the body and elimination of the morbid mater] through the upward track (Vamana or emesis) and downward track (Virecana or purgation), by venesection with the help of sharp edged instruments, and by medicated enema (basti). When the body becomes cleansed of the morbid matter, the ulcer gets healed up instantaneously. [38- ½ 39]

Vrana Chikitsa

Now, hear about all the 36 therapeutic measures [for the treatment of ulcers] to be described in the order hereafter. These are, as follows:
1. Shophaghna ( therapeutic measures for relieving oedema)
2. 7 Shastra karman ( six surgical measures—vide verse no 55)
8. Avapidana (compression by the application of paste of drugs)
9. Nirvana (sprinkling of cooling medicated decoction for alleviating burning sensation and heat of the ulcers)
10. Sandhana (restoration of muscles and fractured bones in the location of the ulcer)
11. Swedana ( fomentation)
12. Samana( application of the paste of drugs for the alleviation of pain and burning sensation in the ulcer)
13. Eshana( robbing)
14. Sodhana- Pralepa(washing the cleansing decoction)
15. Sodhana Pralepa (application of the paste of drugs for cleaning in ulcer)
16. Ropana Kashaya( washing the ulcer with healing decoction)
17. Ropana pralepa – application of the paste of drugs for the healing of ulcer
18. Shodhana Taila ghrta( application of medicated oil and medicated ghee for the cleansing of the ulcer)
19. Ropana Taila ghrta( application of the medicated oil and medicated ghee for the healing of the ulcer)
20. Patra ( covering the ulcer with the leaves of the medicinal plants)
21. Chadana (padding the ulcer with gauze)
22. 23 Bandhana ( two type of bandaging)
24. Bhojya – diet and regimens
25. Utsadana – elevation of the deep-seated ulcer
26. Avasadana – removal of excessively projected tissues in the ulcer
27. – Daha – cauterization and
28 – Kshara
29. Kathinyakara Dhupana – fumigation for the hardening of the excessively soft of the ulcer
30. Mardavakara dhupana – fumigation for softening the excessively hard tissues of the ulcer
31. Kathinyakara alepana – application of ointment for hardening the excessively soft tissues of the ulcer
32. Mardavakara alepana – application of ointment for softening the excessively hard tissues of the ulcer
33. Avachurnana – dusting the powder of drugs over the ulcer
34. Ropana – application of recipes for growth of clear skin over the ulcer
35. Varnya – restoration of the normal color of the skin over the ulcer
36. Loma- rohana – application of recipes for the restoration of small hair over the skin after the ulcer is healed [39 ½- 43]

Shophaghna Chikitsa (therapeutic measures to relieve oedema):
In the premonitory stage, when the ulcer(abscess) is not fully manifested, but only oedema, the physician, after ascertaining it, should apply blood-letting therapy, to avert its manifestation.
If the Doshas are aggravated in excess, the patient is given- Shodhana (elimination) therapy, and if these Doshas are essay aggravated, then Langhana (fasting) therapy is administered. The patient is given decoctions of drugs and medicated ghee for the alleviation of Doshas. In the beginning, however, these therapeutic measures should aim at alleviating the aggravated Vayu followed by other Doshas (Pitta and Kapha).
Application of the paste of bark of Nyagrodha – Ficus bengalensis, Udumbara – Ficus racemosa, Asvattha – Ficus relgiosa, Plaksa – Ficus lacor and Vetasa – Salix caprea, along with ghee is, especially effective in order to receive oedema.

Application of the Pradeha (ointment of paste) of
• Vijaya (Bala – Country mallow (root) – Sida cordifolia
• Madhuka– Licorice – Glycyrrhiza glabra
• Vira
• Bisagranthi – Nelumbium speciosum
• Shatavari – Asparagus racemosus
• Nilotpala – Nymphaea stellata and
• Nagapuspa – Messua ferrea along with
• Chandana (Sandalwood – Santalum album) also relieves oedema.
Roasted barley flour and the powder of Madhuka– Licorice – Glycyrrhiza glabra, mixed ghee and sugar is applied for correcting oedema in ulcers.
Food ingredients which do not cause burning sensation (avidahin) are immensely useful for the cure of oedema in ulcers. [44- 48]

Shastrakarma for Vrana

Shastrakarma for Vrana – Surgical Interventions:
If oedema does not subside despite the above therapeutic measures, then it is got suppurated by the application of Upanaha (hot paste of drugs). Thereafter, its opening incisions are beneficial.
A bolus prepared of Saktu (roasted barley flour) mixed with oil or ghee or both is applied as warm poultice which is useful for causing suppuration of the abscess.
A bolus prepared of Saktu (roasted barely flour) and mixed with Tila – Sesame (Sesamum indicum), Seeds of Atasi – Linum usitatissimum , Sour curd, Kinva (Yeast), Kushta – Saussurea lappa and salt is useful as Upanaha(hot poultice).
If the abscess is characterized by Ruk (pain), Daha (burning sensation), Raga (redness) and Toda (pricking pain), then it is to be diagnosed as Vidagdha or semi matured if it is fully matured (sampakva) or saturated, then in becomes like Jala basti samprasha (after bag to touch), and Pidita unnatam (when pressed it gets elevated of its own again)
These constitute the group of drugs, the external application of which helps in the rupture of the suppurated abscess, these drugs are useful for the patients who are of tender nature (sukumara) who cannot stand surgical intervention:
• Uma – linseed
• Guggulu (Commifora mukul Engl)
• Sudha-ayas (snuhi- Ksira)
• Stool or Daksa (cock) and Kapota,
• Alkali preparations of Palasa – Butea monosperma, Hema (Mesua ferrea) Ksiri (Kankustha) and Mukulaka (danti)
If the patient is Krcchra (physically and mentally strong), then, incision of the suppurated abscess is an excellent remedial measure. [49- 54]

Shat Vidha Shastrakarma for Vrana – Six surgical Measures:
The sites of surgical measures useful for the treatment of ulcers and abscesses are, as follows:
1. Patana – Incision
2. Vyadhana – Puncturing
3. Chedana – Excision
4. Lepana or Lekhana – Scooping
5. Pracchana – scarification or rubbing and
6. Sivana – Suturing [55]

Patana (incision):
Incision is useful for the following types of ulcers:
1. Nadi- Vrana – sinus
2. Pakva- Vrana – Suppurated abscess or ulcer
3. Ksatodara – intestinal perforation
4. Baddha Gudodara – intestine obstruction
5. Antah- Shalya – wounds and ulcers having foreign body inside
6. Similar other ailments [56]

Vyadhana (puncturing):
Puncturing is useful for the following ailments:
1. Dakodara – Ascites
2. Pakva- Gulma – suppurated tumor
3. Rakta- Gulma – uterine tumor and
4. Ailments caused by the vitiation of blood like Visarpa (erysipelas and herpes) and Pidaka (pimple). [57]

Chedana (Excision):
Excision is useful in the following types of ulcer:
1. Udvrtta – ulcers having overgrowing granulation tissue
2. Sthula-Paryanta – ulcers having thick margin
3. Utsanna – elevated ulcer
4. Kathina – hard ulcer and
5. Adhi- Mamsa – protruded muscle tissue like Arsas or piles [58]

Lekhana (Scraping):
A wise physician should employ the scraping type of surgical measure for the following ailments:
1. Kilasa – leucoderma
2. Kushta – obstinate skin diseases including leprosy and
3. Such other skin diseases requiring scraping therapy. [ ½ 59]

Pracchana (Scarification):
A physician should apply scarification therapy for the following:
1. Vatasrk – nodes developed as result of rheumatoid arthritis and gout
2. Granthi – enlarged lymph glands
3. Pidaka – pimples
4. Kotha – urticarial patches
5. Rakta- Mandala – red and Circular patches in the skin
6. Kushta – lepromatous growths
7. Abhihata- Anga – limbs affected by injury and
8. Sotha – edematous parts [59 ½ – ½ 60]

Sivana (Suturing):
Deep incision in the pelvis, abdomen, etc, is sutured. Thus, 6 type of surgical interventions are described, in brief, b the experts in surgery. [60 ½- ½ 61]

Avapidana (Compression)
For the treatment of ulcers (abscesses) having a fine opening, and expanded base (pouch fomentation), Pidana (compression) therapy is administered.
Application of the paste of kalaya – Pisum sativum, Masura – Lensesculenta, Godhuma – wheat – Triticum sativum and Harenu without the addition of any fat is immensely helpful for this compression therapy. [61 ½ – 62]
For the external application in paste form, and for sprinkling (affusion) in decoction form, the following recipes are useful:
1. Bark of shalmali – Salmalia malabarica and root of Bala – Country mallow (root) – Sida cordifolia
2. Leaves of Nyagrodha – Ficus bengalensis
3. Group of drugs beginning with Nyagrodha – Ficus bengalensis described in the verse no 46
4. Group of drugs beginning with Bala – Country mallow (root) – Sida cordifolia( Vijaya) described in the verse no 47 and
5. Sprinkling with cold ShataDhauta ghrta ( ghee washed with water for 100 times) or with cold milk or with the cold decoction of Madhuka– Licorice – Glycyrrhiza glabra, if the ulcer is caused by the vitiation of Rakta and Pitta 63- ½ 65]

Mamsa Sandhana (restoration of Muscle Tissue):
If the muscle tissue over the ulcer is hanging loose, then the physician should smear it with honey and ghee, and appropriately restore it. Thereafter, the wound is bandaged.
After ascertaining its proper and stable restoration, the ulcer is sprinkled with the following:
1. Powder of Phalini – Callicarpa macrophylla, Lodhra – Symplocos racemosa, Katphala – Myrica nagi, Samanga – Rubia cordifolia and Dhataki – Woodfordia fruticosa
2. Powder of the barks of Nyagrodha – Ficus bengalensis, Udumbara – Ficus racemosa, Asvattha – Ficus religiosa, Parisa – Ficus arnottiana and Plaksa – Ficus lacor. Taken together, these are called Pancha- Valkala (five barks). To these drugs, powder of Sukti ( Badarika) may be added and
3. Powder of Dhataki – Woodfordia fruticosa and Lodhra (Symplocos racemosa).
By the above measures, the ulcer gets healed up. [65 ½ – ½ 68]

Asthi Sandhana (Restoration of Fractured Bones):
If there is fracture or dislocation of bone, it is set (put in appropriate place) correctly by a wise physician keeping the alignment at par with the other unaffected limb or the art of the body. Then it is stabilised by rapping with cotton and splints. It should, thereafter, be bandaged with a cloth profusely smeared with ghee, and made immobile as well as comfortable.
The patient is given food and pastries which do not cause burning sensation (Avidahi). Such a patient should not resort to physical exercise which may cause dislocation of the joints.
If the patient having dislocation of the joints or fracture of bones suffers from complications like erysipelas, then the physician should administer treatment relevant to the concerned ailment (complication) at appropriate time. [68 ½ – ½ 72]

Vrana Svedana (Fomentation)
If the ulcer is predominated by aggravated Vayu because of which it is
• Sushka (dry)
• Maha ruja (extremely painful) and
• Stabdha (stiff),
Then the patient is given Sankara type of fomentation therapy (vide Sutra 14: 41) with the help of
• Krshara (Preparation of rice and Mung dal),
• Payasa (preparation of the rice and milk), and
• Sizzled and hot Veshavara (Poultice) prepared of the meat of animals who are domesticated and who live in burrows or water marshy land this makes the patient comfortable. [2/3 72- 73]

Shamana (Alleviation Therapy)

Roasted Uma and Tila – Sesame (Sesamum indicum) is soaked in milk, and made to a paste by triturating with the same milk. The physician should apply this paste to cure the ulcer caused by aggravated Vayu associated with burning sensation as well as pain.
Oil (1 part) is cooked by adding milk (4 parts), and the paste (1/4th part in total) of Bala – Country mallow (root) – Sida cordifolia, Guduchi – Tinospora cordifolia, Madhuka– Licorice – Glycyrrhiza glabra, Prsniparni, Shatavari – Asparagus racemosus, Jivanti – Leptadenia reticulata, Sarkara (sugar), fat of fish, Ghee and bee’s wax (all taken in equal quantities) external application of this preparation (semi- solid in consistency) cures pain in the ulcer.
Sprinkling the ulcer with the decoction, or medicated milk or medicated ghee or medicated oil prepared by boiling with Dasha-Mula (Bilva – Aegle marmelos, Syonaka – Orchis mascula, Gambhari – Gmelina arborea, Patala – Ficus microcarpa, Ganikarika – Premna integrifolia, Shala- Parni, Prsni-parni, Brihati – Solanum indicum, Kantakari – Solanum xanthocarpum and Goksura – Tribulus terrestris) is useful.
Application of Luke warm paste made with the powder of barley added with Madhuka– Licorice – Glycyrrhiza glabra, Tila or ghee alleviates burning sensation and pain in the ulcer.
Application of the hot poultice prepared of Tila – Sesame (Sesamum indicum), Mudga – Vigna radiate and Payasa (preparation of milk and rice) alleviates pain and burning sensation in the ulcer.
The above mentioned recipes are useful in the treatment of ulcer. [74-79]

Eshana (probing)

Probing is useful for ulcer having
• Sukshma aanana – narrow opening
• Bahu srava – excessive secretion and
• Kosha vanta – expanded base provided these are not located in vital organs.
Probes are of two types. Viz,
• Soft probes are made of soft stems of plants and
• Hard probes are made of metals if the ulcer is deep- seated and located in a fleshy area, and then it is probed by a metallic probe followed by excision.
If the ulcer is of opposite nature, then probing is done by the stalk or stem of plants [80- 82]

Shodhana (Cleansing of wounds)

The characteristic features of unclean ulcer which is required to be cleansed:
• Puti gandha – Putrid odor
• Vivarna – discoloration,
• Bahu srava – excessive discharge and
• Maha ruja – excruciating pain
The decoction of Haritaki – Terminalia chebula, Bibhitaka – Terminalia bellerica, Amalaki – Emblica officinalis, Khadira (Acacia catechu), Daruharidra – Berberis aristata, drugs belonging to Nyagrodhadi group (vide verse no . 46), Bala – Country mallow (root) – Sida cordifolia, Kusa (Desmostachya bipinnata) and tender leaves of Nimba – Neem (Azadirachta indica) and Kola helps in the cleansing of ulcer.
Application of the paste of Tila – Sesame (Sesamum indicum), salt, Haridra (turmeric – Curcuma longa), Daru haridra – Berberis aristata, Trivrt – Operculina turpethum, ghee, Madhuka– Licorice – Glycyrrhiza glabra and leaf of Nimba – Neem (Azadirachta indica) cleanses the ulcer. [83-85]

Ropana (healing)

The ulcer which is not very red, not very pale, not very brownish black not associated with excruciating pain, not much elevated and not associated with pockets (Utsangi), is suitable for the administration of healing therapy.
The decoctions of Nyagrodha – Ficus bengalensis, Udumbara – Ficus racemosa, Asvattha – Ficus religiosa, Kadamba – Anthocephalus indicus, Plaksa – Ficus lacor, Vetasa, Karavira – Nerium indicum, Arka – Calotropis gigantea and Kutaja – Connessi (Holarrhena antidysenterica Wall.) are useful for healing ulcers.
Similarly, the decoction of Chandana (Sandalwood – Santalum album), Padmakinjalka (filaments of lotus), bark of Daruharidra – Berberis aristata, Nilotpala, Meda – Polygonatum cirrhifolium, Maha-Meda – Polygonatum verticllatum, Murva – Marsdenia tenacissima, Samanga – Rubia cordifolia and Yastimadhu – Glycyrrhiza glabra helps in the healing of ulcer.
The paste of prapaundarika, Jivanti – Leptadenia reticulata, Gojihva – Onosma bracteatum, Dhataki – Woodfordia fruticosa, Bala – Country mallow (root) – Sida cord folia and Tila – Sesame (Sesamum indicum), along with ghee is applied on the ulcer (for its healing).
Oil cooked with the paste of Kampillaka – Mallotus philippinensis, Vidanga – Embelia ribes, Vatsaka (Holarrhena antidysenterica Wall.), Haritaki – Terminalia chebula, Bibhitaki – Terminalia bellerica, Amalaki – Emblica officinalis, Bala – Country mallow (root) – Sida cordifolia, atola, Pichumarda – Azadirachta indica, Lodhra (Symplocos racemosa), Musta (Cyperus rotundus), Priyangu – Callicarpa macrophylla, Khadira (Acacia catechu), Dhataki – Woodfordia fruticosa, Sarja (Vateria indica), Ela – Elatteria cardamum, Aguru – Aquallaria agallocha and Chandana (Sandalwood – Santalum album) is immensely useful for healing ulcers.
Similarly, oil cooked with Prapaundarika (Nymphaea lotus) – red variety, Madhuka– Licorice – Glycyrrhiza glabra, Kakoli – Fritillaria roylei, Ksheerakakoli – Lilium polyphyllum, Chandana (Sandalwood – Santalum album) and Rakta- Chandana (Sandalwood – Santalum album) is especially effective for healing ulcers.
The medicated oils prepared with the ingredients and methods similar to the preparation of medicated oil described above. [86- 94]

Patra – Application of Leaves over Ulcer:
A wise physician should cover the ulcer with the leaves of Kadamba – Anthocephalus indicus, Arjuna (terminalia arjuna), Nimba – Neem (Azadirachta indica), Patala – Ficus microcarpa, Pippali – Piper longum and Arka – Calotropis gigantea. [95]

Chadana (Padding):
The Ulcer, [after the application of the above mentioned leaves] is padded with the barks [ fibres] of trees, leather, silk or cotton gauze which is very useful. [½ 96]

Bandha (Bandage):
The ulcer is tied with a Bandage either clock- wise or anti- clock-wise.
All the 14 types of Bandage described in the book of surgery are covered under the 2 categories described in the book of surgery are covered under the two categories described above.

Bhojya (diet and Regimes)
The patient having ulcer avoid such ingredients of food and drinks which are
• Lavana – saline
• Amla – sour,
• Katu – pungent,
• Ushna – hot, Vidahi (which cause burning sensation) and
• Guru – heavy(hard to digest)                                                                                     He should also avoid sexual intercourse.
Depending upon the nature of [the Doshas in the causation of], the ulcer, the patient should take food and drinks which are not too cold, too heavy, too unctuous and drinks which are not too cold, too heavy, too unctuous and vidahi (which cause burning sensation) he should not sleep during the day time. [97 – 98]

Utsadana [Elevation]:
For the elevation of depressed ulcer, the paste of drugs belonging to
• Stanya- Varga (group of Galactogogues)
• Jivaniya- Gana (group of life- promoters) and
• Brumhaniya- Varga (group of nourishing drugs) is used over it. [99]

Avasadana (Removal of excessive Granulation):
For the removal of excessive granulation, tissue over the ulcer, the nodes of Bhurja (Betula utilis D. Don.), Asma- Kasisa (dhatu- Kasisa), Purgative drugs (like Trivrt), Guggulu (Commifora mukul Engl.) and the stool of Kalavinka as well as Kapota may, effectively, be applied. [100]

Agni- Karma

Agni karma (cauterization including application of heat) is useful for ulcer associated with excessive bleeding, after excision of the hanging flesh, in muscular over- growth, in glands enlarged because of aggravated kapha, in goitre in stiffness and for such other ailments caused by aggravated Vayu. It is also useful when the ulcer has hidden pockets containing pus and lymph, when the ulcer is deep- seated in the stable part of the body.
This therapy (Agni- karma) may be administered by an expert in this branch of healing with hot bee’s wax, oil, bone- marrow, honey, fat or ghee, or with red hat instruments prepared of different types of metals.
If the patient is dry, and is of tender nature, and if the ulcer is deep-seated and is caused by the aggravated Vayu predominantly, then Agni-Karma( cauterization) is done with the help of hot fat, bee’s wax, metallic instruments and honey. Such measures are employed otherwise.
Agnikarma (cauterization) is prohibited for
• Bala – infants,
• Durbala – weak and
• Vrdhha – old persons,
• Garbhinya – pregnant women,
• Patients suffering from Rakta- Pitta (ailment characterized by bleeding from various parts of the body),
• Trishna – thirst and
• Jvara – fever,
• Paritanam abalanam – omen and poisoned persons
It is also prohibited if the ulcer is located in ligaments, vital organs, if the ulcer is caused by poisoned weapons (arrows), in ulcers of the eyes and ulcers arising out of Kushta (obstinate skin diseases including Leprosy). [101- 106]

Kshara

The physician well versed in the dose, time of administration and heat (agni) required by the patient of ulcer on the basis of the strength of the disease and doshas, should also administer Kshara (alkali preparations) to such of the patients for whom surgical intervention and Cauterization are indicated [107]

Dhupana

When fumigated with aromatic drugs and the heart- wood of aromatic plants, the ulcerated tissue gets hardened
Fumigation with the fume of ghee, bone- marrow and muscle fat softness the ulcerate tissues. [108 – 109]

Alepa, Avachurnana

Alepa (application of Ointments):
Application of ointment prepared of Lodhra (Symplocos racemosa), root of Nyagrodha, (Vata), Khadira (Acacia catechu), Haritaki – Terminalia chebula, Vibhitaka – Terminalia bellerica and Amalaki – Emblica officinalis by adding ghee cures looseness and tenderness of the ulcerated tissues.
If the ulcer is associated with pain, hardness, stiffness and dryness (without and discharge), then it is frequently anointed with barley- flour mixed with ghee.
The ulcer having the above mentioned characteristics is frequently anointed with Payasa (a preparation of milk) of Mudga, Shashtika type of rice appropriately. This ulcer is anointed with the medicated ghee prepared by boiling with the drugs belonging to the Jivaniya (life promoting) group of drugs (vide Sutra 4: 19) [110- 112]

Avachurnana (dusting of wounds)
Dusting over the ulcer with the powder of the bark of Kakubha – Terminalia arjuna, Udumbara – Ficus racemosa, Asvattha – Ficus religiosa, Lodhra (Symplocos racemosa), Jambu – Eugenia jambolana and Katphala – Myrica nagi helps in the formation of new skin over it quickly. [113]
Ropana (Promotion of Healthy Skin):
Application of the paste of Manahsila, Ela (Elettaria cardamomum Maton), Manjistha – Rubia cordifolia, laksa, Haridra (turmeric – Curcuma longa) and Daruharidra (Berberis aristata) along with ghee and honey helps in the promotion of healthy skin over the ulcer. [114]

Varnya (Restoration of Normal skin color):
Application of the ointment prepared of the Bhasmans of Lauha and Kasisa, and flowers of Haritaki – Terminalia chebula, Vibhitaka – Terminalia bellerica and Amalaki – Phyllanthus officinalis helps in the formation of Pigments (blackness) instantaneously over the nearly formed skin over the ulcer.
Kaliyaka, Nata (Valeriana wallicii), pulp of the seed of Amra – mango – Mangifera indica, Hema (Mesua ferrea) (Dhustura or the Bhasman of gold), Kanta and Rasottama (mercury or ghee) is made to a paste by triturating with the juice of cow-dung application of this paste over the skin (which has grown over the ulcer) helps in the restoration of its original color.
Dhyamaka, Asvattha – Ficus religiosa, root of Nicula – Barringtonia accuntangula, Laksa and Gairika (red ochre) should made to a paste and applied over the skin developed over the ulcer which promotes restoration of its natural color. Similarly, [application of the paste of] Hema (Mesua ferrea) (Dhustura or the Bhasman of gold], Amrta- Sanga (Khararika Tuttha) and Kasisa promotes the natural color of the skin. [115- 117]

Loma Rohana (Restoration of Growth of Hair):
The skin, Hair, hoof, horn and bones of quadruped animals is burnt and reduced to ash. To this ash, oil is added. Application of this medicated oil makes the fresh skin developed over the ulcer full of natural hair. [118]

Treatment of complications

16 ailments which appear as complications of ulcer (vide verse nos. 28-30) are to be treated according to the lines of treatment suggested for each one of them. [119]

Summary:
In this chapter on ‘Ulcer’, along with Agnivesha’s query, the nine topics explained both, in brief and in detail, by the sage (Atreya) are, a follows:
1. 2 categories of ulcer
2. Classification of ulcers
3. Examination of ulcers
4. Morbid effects of ulcers
5. Location of ulcers
6. Odour of ulcer
7. Nature of the discharge from ulcers
8. Complications and method of treatment of ulcers [120- 121]

Colophon
Thus, ends the 25th chapter dealing with the treatment of 2 types of ulcers of Chikitsa- sthana (Section on the treatment of diseases) in Agnivesha’s work as redacted by Charaka, and supplemented by Drudhabala.

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