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Dwivraniya Chikitsa (view source)

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{{#seo:

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|title=Dwivraniya Chikitsa

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|titlemode=append

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|keywords=Vrana (ulcer), trividha pariksha, bloodletting, dahakarma (cauterization), shodhanakarma (cleansing of ulcer), ropankarma (healing of ulcer), wound management, non healing ulcers

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|description=Chikitsa Sthana Chapter 25. Management of two types of Vrana (ulcers)

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}}

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<big>'''[[Chikitsa Sthana]] Chapter 25. Management of two types of Vrana (ulcers) </big>'''

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=== Sanskrit Text, Transliteration and English Translation ===

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अथातो द्विव्रणीयचिकित्सितं व्याख्यास्यामः ||१||

इति ह स्माह भगवानात्रेयः ||२||

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athātō dvivraṇīyacikitsitaṁ vyākhyāsyāmaḥ||1||

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iti ha smAha bhagavAnAtreyaH ||2||

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</div></div>

Now we shall expound the treatment of two types of ''vrana'' (ulcer).

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==== Query by Agnivesha ====

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परावरज्ञमात्रेयं गतमानमदव्यथम् |

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तयोर्लिङ्गं चिकित्सां च वक्तुमर्हसि शर्मद! ||४||

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parāvarajñamātrēyaṁ gatamānamadavyatham|

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tayorli~ggaM cikitsAM ca vaktumarhasi sharmada! ||4||

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</div></div>

Agnivesha, in opportune moment, respectfully submitted to his teacher Atreya, knower of the best and the worst and devoid of conceit, ego and suffering –“ O Lord ! Two types of ulcers have been mentioned earlier under enumeration of disorders; kindly describe their symptoms and treatment O conferer of happiness!”[3-4]

==== Classification and etiology of ''vrana'' ====

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इत्यग्निवेशस्य वचो निशम्य गुरुरब्रवीत् |

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लिङ्गैकदेशैर्निर्दिष्टा विपरीता निजैर्व्रणैः [२] ||८||

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ityagnivēśasya vacō niśamya gururabravīt|

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li~ggaikadeshairnirdiShTA viparItA nijairvraNaiH [2] ||8||

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</div></div>

After listening the request of Agnivesa the teacher said – ‘O gentle! Listen about the symptoms and treatment of the two types of ''vrana'' (ulcers) , endogenous ulcer and exogenous ulcer, as mentioned earlier.The endogenous ulcers occur from the bodily ''dosha'', whereas the exogenous ulcers are caused by external causative factors. Exogenous ulcer are caused by blowing, binding, falling down, injury with fangs, teeth or nails as well as due to poisonous contact, fire and weapons etc. Exogenous ulcers are different from the endogenous ones in respect of treatment with ''mantra'' (incantations), anti-poisonous pastes for external application etc. While endogenous ulcer bears opposite characteristic features in respect of etiology, sign symptoms and treatment. [5-8]

==== Importance of ''dosha'' dominance in treatment ====

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व्रणानां निजहेतूनामागन्तूनामशाम्यताम् |

कुर्याद्दोषबलापेक्षी निजानामौषधं यथा ||९||

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vraṇānāṁ nijahētūnāmāgantūnāmaśāmyatām|

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kuryAddoShabalApekShI nijAnAmauShadhaM yathA ||9||

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</div></div>

Exogenous ulcers not being pacified and having endogenous causative factors should be treated as endogenous ulcers according to predominance of ''doshas''.[9]

==== Endogenous ulcers ====

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यथास्वैर्हेतुभिर्दुष्टा वातपित्तकफा नृणाम् |

बहिर्मार्गं समाश्रित्य जनयन्ति निजान् व्रणान् ||१०||

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yathāsvairhētubhirduṣṭā vātapittakaphā nr̥ṇām|

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bahirmArgaM samAshritya janayanti nijAn vraNAn ||10||

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</div></div>

''Vata, pitta'' and ''kapha'' are vitiated by their respective causes get lodged in external passage and thus produce endogenous ulcers. [10]

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===== ''Vata'' dominant ''vrana'' and treatment =====

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स्तब्धः कठिनसंस्पर्शो मन्दस्रावोऽतितीव्ररुक् [१] |

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प्रदेहैः परिषेकैश्च वातव्रणमुपाचरेत् ||१२||

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stabdhaḥ kaṭhinasaṁsparśō mandasrāvō'titīvraruk [1] |

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pradehaiH pariShekaishca vAtavraNamupAcaret ||12||

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</div></div>

The ulcer caused by ''vata'' is stiff, hard to touch, with scanty exudation, excruciating and pricking pain with throbbing and blackish discoloration. ''Vatika'' ulcer should be treated with ''sampurana'' (filling of ulcer cavity), intake of unctuous substances (oleation therapy), unctuous fomentation and poultices, ointments and sprinklings.[11-12]

===== ''Pitta'' dominant ''vrana'' and treatment =====

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तृष्णामोहज्वरस्वे(क्ले)ददाहदुष्ट्यवदारणैः |

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सर्पिष्पानैर्विरेकैश्च पैत्तिकं शमयेद्व्रणम् ||१४||

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tr̥ṣṇāmōhajvarasvē(klē)dadāhaduṣṭyavadāraṇaiḥ|

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sarpiShpAnairvirekaishca paittikaM shamayedvraNam ||14||

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</div></div>

''Pittaja'' ulcer is known from thirst, unconsciousness, fever, sweating, burning sensation, impurity, tearing and foul smell with discharge of pus from ulcer. One should pacify the ''pittaja'' ulcer by anointing and sprinkling with cold, intake of sweet and bitter drugs, intake of ghee and purgation. [13-14]

===== ''Kapha'' dominant ''vrana'' and treatment =====

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बहुपिच्छो गुरुः स्निग्धः स्तिमितो मन्दवेदनः |

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कफव्रणं प्रशमयेत्तथा लङ्घनपाचनैः [३] ||१६||

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bahupicchō guruḥ snigdhaḥ stimitō mandavēdanaḥ|

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kaphavraNaM prashamayettathA la~gghanapAcanaiH [3] ||16||

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</div></div>

''Kaphaja'' ulcer has much sliminess, heavyness, unctuousness, numbness, with mild pain, paleness in color, little slough and prolonged healing. ''Kaphaja'' ulcer is treated with anointing and sprinkling with astringent, pungent, dry and hot drugs as well as fasting and digestive measures.[15-16]

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तौ द्वौ नानात्वभेदेन निरुक्ता विंशतिर्व्रणाः |

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विभज्यमानाञ्छृणु [१] मे सर्वानेतान् यथेरितान् ||१९||

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tau dvau nānātvabhēdēna niruktā viṁśatirvraṇāḥ|

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vibhajyamAnA~jchRuNu [1] me sarvAnetAn yatheritAn ||19||

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</div></div>

Above two types of ulcers are further divided into twenty types on the basis of distinctive features. Their examination can be done by three ways, signs of excess vitiation at site of ulcers are of twelve types, eight locations, fourteen types of discharges, sixteen complications, twenty four defects and thirty six therapeutic measures. Now listen about these in details. [17-19]

==== Twenty types of ulcers ====

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कृत्योत्कृत्यस्तथा [१] दुष्टोऽदुष्टो मर्मस्थितो न च |

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इति नानात्वभेदेन निरुक्ता [२] विंशतिर्व्रणाः ||२१||

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kr̥tyōtkr̥tyastathā [1] duṣṭō'duṣṭō marmasthitō na ca|

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iti nAnAtvabhedena niruktA [2] viMshatirvraNAH ||21||

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</div></div>

Curable (can be treated with surgical intervention), incurable; infected, non-infected; situated in vital parts, not situated in vital parts; closed, open; hard, soft; discharging, non-discharging; poisonous, non-poisonous; unevenly located, evenly located; pouched, un-pouched; elevated, depressed – these are the twenty types of ulcers according to various distinguishing features.[20-21]

==== Three fold examination ====

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दर्शनप्रश्नसंस्पर्शैः परीक्षा त्रिविधा स्मृता |

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स्पर्शान्मार्दवशैत्ये च परीक्ष्ये सविपर्यये ||२३||

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darśanapraśnasaṁsparśaiḥ parīkṣā trividhā smr̥tā|

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sparshAnmArdavashaitye ca parIkShye saviparyaye ||23||

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</div></div>

Examination of ulcer can be performed by three methods e.g. by inspection, interrogation and palpation.

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==== Twelve types of ulcers ====

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श्वेतोऽवसन्नवर्त्माऽतिस्थूलवर्त्माऽतिपिञ्जरः [१] |

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चतुर्विंशतिरुद्दिष्टा [२] दोषाः कल्पान्तरेण वै ||२५||

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śvētō'vasannavartmā'tisthūlavartmā'tipiñjaraḥ [1] |

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caturviMshatiruddiShTA [2] doShAH kalpAntareNa vai ||25||

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</div></div>

White, with depressed margins, very thick margins, much greyish (''pinjara''), blue, blackish, surrounded with numerous boils, red, black, very fetid odor, non- healing nature and bottle-necked (narrow opening) these are twelve types of defective (''dushta'') ulcers.[24-25]

==== Sites of vitiation ====

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त्वक्सिरामांसमेदोऽस्थिस्नायुमर्मान्तराश्रयाः |

व्रणस्थानानि निर्दिष्टान्यष्टावेतानि सङ्ग्रहे ||२६||

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tvaksirāmāṁsamēdō'sthisnāyumarmāntarāśrayāḥ|

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vraNasthAnAni nirdiShTAnyaShTAvetAni sa~ggrahe ||26||

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</div></div>

In the treatise, eight locations of wounds have been mentioned such as skin, blood vessels, flesh, fat, bone, ligament, vital parts and viscera.[26]

==== Specific odors of ''vrana'' ====

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सर्पिस्तैलवसापूयरक्तश्यावाम्लपूतिकाः |

व्रणानां व्रणगन्धज्ञैरष्टौ गन्धाः प्रकीर्तिताः ||२७||

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sarpistailavasāpūyaraktaśyāvāmlapūtikāḥ|

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vraNAnAM vraNagandhaj~jairaShTau gandhAH prakIrtitAH ||27||

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</div></div>

Eight types of wound odors have been defined by the experts like ghee, oil, muscle-fat, pus, blood, and cadaver, sour and fetid.[27]

==== Fourteen types of discharges and sixteen complications ====

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लसीकाजलपूयासृग्घारिद्रारुणपिञ्जराः |

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षोडशोपद्रवाः प्रोक्ता व्रणानां व्रणचिन्तकैः |३१|

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lasīkājalapūyāsr̥gghāridrāruṇapiñjarāḥ|

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ShoDashopadravAH proktA vraNAnAM vraNacintakaiH |31|

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</div></div>

Discharges from ulcers are of fourteen types in appearance such as ''lasika'' (like lymph), water, pus, blood, color of exudation as yellow, reddish, brownish, ochre-colored, blue, green, unctuous, rough, white and black.

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==== Causes of non-healing ulcers ====

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स्नायुक्लेदात्सिराक्लेदाद्गाम्भीर्यात्कृमिभक्षणात् [१] ||३१||

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व्रणानां बहुदोषाणां कृच्छ्रत्वं चोपजायते ||३५||

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snāyuklēdātsirāklēdādgāmbhīryātkr̥mibhakṣaṇāt [1] ||31||

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vraNAnAM bahudoShANAM kRucchratvaM copajAyate ||35||

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</div></div>

Defects are known to be twenty four according to etiological factors which are as follows: moistening of ligaments, excess of fluid in blood vessels, deepness, eaten by maggots, cracking of bones, presence of foreign body, presence of toxins, spreading, excessive tearing with nails or wooden piece, friction of skin, friction of body hair, faulty bandage, over-application of uncting substance, excessive emaciation due to over dose, indigestion, over-eating, intake of incompatible food items, unsuitable food, grief, anger, day-sleep, physical exercise, sexual intercourse and inactivity.These factors lead to delay in the healing process. Ulcers having much impurity become difficult to be cured due to presence of excessive discharges, odors, defects and complications.[31-35]

==== Factors affecting prognosis ====

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त्वङ्मांसजः सुखे देशे तरुणस्यानुपद्रवः |

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सर्वैर्विहीनो विज्ञेयस्त्वसाध्यो निरुपक्रमः [१] ||३७||

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tvaṅmāṁsajaḥ sukhē dēśē taruṇasyānupadravaḥ|

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sarvairvihIno vij~jeyastvasAdhyo nirupakramaH [1] ||37||

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</div></div>

Wound is easily curable if it is located in skin and muscles, easy places, youthful age, without complication, in a wise patient and of recent origin. If it is devoid of some of these qualities it is curable with difficulty and when it is devoid of all the qualities it is incurable and thus not to be treated.[36-37]

==== Principles of management ====

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व्रणानामादितः कार्यं यथासन्नं विशोधनम् |

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सद्यः शुद्धशरीराणां प्रशमं यान्ति हि व्रणाः |३९|

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vraṇānāmāditaḥ kāryaṁ yathāsannaṁ viśōdhanam|

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sadyaH shuddhasharIrANAM prashamaM yAnti hi vraNAH |39|

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</div></div>

In cases of wound, first of all, purification with therapeutic emesis, purgation, ''shastra karma'' (surgical intervention) and ''basti'' (medicated enema) should be done after assessment of condition because the wounds get healed quickly in those with cleansed body.[38-39]

==== Procedures for management of ulcers ====

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यथाक्रममतश्चोर्ध्वं शृणु सर्वानुपक्रमान् ||३९||

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इति षट्त्रिंशदुद्दिष्टा व्रणानां समुपक्रमाः ||४३||

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yathākramamataścōrdhvaṁ śr̥ṇu sarvānupakramān||39||

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iti ShaTtriMshaduddiShTA vraNAnAM samupakramAH ||43||

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</div></div>

Hereafter listen about all the measures of treatment in order such as – measures for pacification of swelling, six types of surgical operations, pressing, cooling?, uniting, fomentation, pacification, probing, cleansing, healing, cleaning paste, healing paste, cleaning oil, healing oil, two types of covering with leaf, two types of bandaging, diet, elevation, two types of cauterization, depression, hardening fumigation, softening fumigation, hardening paste, softening paste, powdering, colorization, healing, repilatory- these are the thirty six measures of treatment of wounds.[39-43]

==== Guidelines for management of ulcers ====

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पूर्वरूपं भिषग्बुद्ध्वा व्रणानां शोफमादितः |

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अविदाहीनि चान्नानि शोफे भेषजमुत्तमम् ||४८||

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pūrvarūpaṁ bhiṣagbuddhvā vraṇānāṁ śōphamāditaḥ|

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avidAhIni cAnnAni shophe bheShajamuttamam ||48||

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</div></div>

The physician observing ''shopha'' (swelling) as prodromal sign in the beginning should apply blood-letting to prevent the manifestation of wound. One should evacuate the persons with plenty of impurity and lighten those with little impurity. He should overcome the wound predominant in ''vata'' first with decoctions and ghritas. Paste of ''nyogrodha'' bark (Ficus bengalensis Linn.), ''udumbara'' (Ficus glomerata Roxb.), ''ashwattha'' (Ficus religiosa Linn.), ''plaksha'' (Ficus lacor Buch.Ham.) and ''vetasa'' (Salix caprea Linn.) are mixed with ghee is an excellent cooling for inflammation, other local applications prescribed are (1) ''vijaya'' (Terminalia chebula Retz.), ''madhuka'' (Glycyrrhiza glabra Linn.), ''vira , bisagranthi, shatavari'' (Asparagus racemosus Willd.), ''nilotpala'' (Nymphea stellata Willd.), ''nagapuspa'' (Mesua ferrea Linn.) and ''sandal'' (Santalum album Linn.). (2) Parched grain flour, ''madhuka, sarkara'' and ghee. ''Avidahi'' (non-burning) food is the best remedy for inflammation.[44-48]

==== ''Patana'' (incision) and ''upanaha'' (poultice) ====

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स चेदेवमुपक्रान्तः शोफो न प्रशमं व्रजेत् |

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सुकुमारस्य, कृच्छ्रस्य शस्त्रं तु परमुच्यते ||५४||

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sa cēdēvamupakrāntaḥ śōphō na praśamaṁ vrajēt|

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sukumArasya, kRucchrasya shastraM tu paramucyate ||54||

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</div></div>

If swelling of ulcers treated in this way does not subside, poultice should be applied and when ripened should be incised. Warm poultice of the bolus of parched grain flour mixed with oil or ghee or both is useful for ripening of inflammation. The bolus of parched grain flour mixed with ''tila'' (Sesamum indicum Linn.), linseeds (Linum usitatissimum Linn.), sour curd, yeast, ''kustha'' (Saussurea lappa C. B. Clarke) and salt is recommended as poultice.

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==== Six types of surgical procedures ====

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पाटनं व्यधनं चैव छेदनं लेपनं तथा |

प्रच्छनं सीवनं चैव षङ्विधं शस्त्रकर्म तत् ||५५||

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pāṭanaṁ vyadhanaṁ caiva chēdanaṁ lēpanaṁ tathā|

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pracchanaM sIvanaM caiva Sha~gvidhaM shastrakarma tat ||55||

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</div></div>

Surgical treatment is of six types such as – incision, puncturing, excision, scrapping, scarification and suturing.[55]

==== Indications of various surgical procedures ====

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नाडीव्रणाः पक्वशोथास्तथा क्षतगुदोदरम् |

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इति षड्विधमुद्दिष्टं शस्त्रकर्म मनीषिभिः |६१|

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nāḍīvraṇāḥ pakvaśōthāstathā kṣatagudōdaram|

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iti ShaDvidhamuddiShTaM shastrakarma manIShibhiH |61|

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</div></div>

Sinuses, ripened inflammations (i.e.suppurated ulcer or abscess), intestinal perforation, intestinal obstruction, having foreign body within and other similar conditions are incisable. Ascites, suppurated tumor and ''raktaja gulma'' (uterine tumor), blood disorders such as erysipelas, boils etc, are treated by puncturing. Wounds protruded with thick margins, elevated, hard, piles etc and other growths should be excised.The wise physician should scrape leucoderma, skin diseases and other such disorders which need scraping. The physician should perform scarification over ''vatarakta'' (nodular swelling), ''granthi'' (cysts) pimples, urticarial rashes, red patches, skin diseases, injured parts and swellings. Suturing should be done in pelvic, abdominal surgeries (i.e., laparotomy) etc.Thus the scholars have mentioned six types of surgical treatments.[56-61]

==== ''Vrana pidana''(pressing of wound) ====

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सूक्ष्माननाः कोषवन्तो ये व्रणास्तान्प्रपीडयेत् ||६१||

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कल्कीकृताः प्रशस्यन्ते निःस्नेहा व्रणपीडने ||६२||

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sūkṣmānanāḥ kōṣavantō yē vraṇāstānprapīḍayēt||61||

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kalkIkRutAH prashasyante niHsnehA vraNapIDane ||62||

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</div></div>

Wounds with narrow opening and multiple loculi should be pressed on. ''Kalaya'' (Pisum sativum Linn.), ''masura'' (Lens culinaris Medic.), wheat (Triticum sativum Lam.) and peas pounded and applied as paste without mixing any fat are useful for pressing the wound.[61-62]

==== Various treatment modalities for pacification of ulcer ====

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शाल्मलीत्वग्बलामूलं तथा न्यग्रोधपल्लवाः |

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निर्वापयेत् सुशीतेन रक्तपित्तोत्तरान् व्रणान् |६५|

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śālmalītvagbalāmūlaṁ tathā nyagrōdhapallavāḥ|

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nirvApayet sushItena raktapittottarAn vraNAn |65|

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</div></div>

Bark of ''shalmali'' (Salmalia malabarica Schott), ''bala'' (Sida cordifolia) root, tender leaves of ''nyagrodha'' – this group (of drugs) known as ''nyagrodhadi'' or ''baladi'' acts as cooling agent applied as paste and sprinkling. Wounds predominant in ''raktapitta'' should be cooled by applying very cold ghee washed hundred times, milk or decoction of ''madhuka'' (Madhuka indica).[63-65]

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लम्बानि व्रणमांसानि प्रलिप्य मधुसर्पिषा ||६५||

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धातकीलोध्रचूर्णैर्वा तथा रोहन्ति ते व्रणाः |६८|

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lambāni vraṇamāṁsāni pralipya madhusarpiṣā||65||

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dhAtakIlodhracUrNairvA tathA rohanti te vraNAH |68|

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</div></div>

Chronic wound should be pasted with honey and ghee there after bandaged leads to evenly union.When they are evenly set, powder of ''priyangu'' (Callicarpa macrophylla Vahl.), ''lodhra'' (Symplocos racemosa Roxb.), ''katphala'' (Myrica esculenta Buch-Ham.), ''lajjalu'' (Mimosa pudica Linn.) and ''dhataki'' (Woodfordia fruticosa Kurz.) should be applied thereon or the powder of ''panchavalkala'' mixed with that of ''sukti bhasma'' (pearl ash) or the powder of ''dhataki'' and ''lodhra'' should be applied.

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==== Management of bone fracture and dislocation ====

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अस्थिभग्नं च्युतं सन्धिं सन्दधीत समं पुनः ||६८||

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उपाचरेद्यथाकालं [१] कालज्ञः स्वाच्चिकित्सितात् |७२|

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asthibhagnaṁ cyutaṁ sandhiṁ sandadhīta samaṁ punaḥ||68||

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upAcaredyathAkAlaM [1] kAlaj~jaH svAccikitsitAt |72|

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</div></div>

Fractured bone and dislocated joints should be set correctly comparing with its counterpart. Setting with firm pad-bandages and splints, it should be immobilized without any discomfort by binding with cloth pieces dipped in plenty of ghee. The patient should be kept on non-burning foods (''avidahi'') made of flour. Such patients should not resort to physical exercise which may cause dislocation of joint. The physician, according to time, should treat the complications such as erysipelas etc in fracture and dislocation of bone. [68-72]

==== Management of various conditions of ''vrana'' ====

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शुष्का महारुजः स्तब्धा ये व्रणा मारुतोत्तराः |

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रुग्दाहयोः प्रशमनो व्रणेष्वेष विधिर्हितः ||७९||

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śuṣkā mahārujaḥ stabdhā yē vraṇā mārutōttarāḥ|

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rugdAhayoH prashamano vraNeShveSha vidhirhitaH ||79||

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</div></div>

Wounds which are dry, intensely painful, stiffened and predominant in ''vata'' should be fomented by bolus fomentation with ''krishara'' and ''payasa'' (a type of dietary preparation). Similarly, they should be fomented with seasoned ''vesavara'' made of the meat of domestic, burrow-dwellers, aquatic or marshy animals or hot ''utkarika''. Thus the patient gets relief. If the wounds predominant in ''vata'' have burning sensation and pain, they should be pasted upon with linseed and sesamum seeds roasted, then dipped in milk and again pounded with the same milk. ''Bala'' (Sida cordifolia Linn.), ''guduchi'' (Tinospora cordifolia), ''madhuka'' (Glycyrrhiza glabra Linn.), ''prishnaparni'' (Uraria picta Desv), ''shatavari'' (Asparagus racemosus Willd), ''jivanti'' (Leptadenia reticulate W. & A.), sugar, milk, oil, fish fat, ghee cooked with beeswax is known as ''sneha sarkara'', it relieves pain.The wound should be sprinkled with warm decoction of two ''panchamula'' (ie.''dashamula''), milk and ghee with oil.

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==== ''Eshana'' (Probing) ====

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सूक्ष्मानना बहुस्रावाः कोषवन्तश्च ये व्रणाः |

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गम्भीरे मांसले देशे पाट्यं लौहशलाकया |

एष्यं विद्याद्व्रणं नालैर्विपरीतमतो भिषक् ||८२||

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sūkṣmānanā bahusrāvāḥ kōṣavantaśca yē vraṇāḥ|

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gambhIre mAMsale deshe pATyaM lauhashalAkayA |

eShyaM vidyAdvraNaM nAlairviparItamato bhiShak ||82||

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</div></div>

In case of wounds with narrow opening, profuse discharge and pouch and not situated in vital parts, probing is beneficial. Probe is of two types – soft and hard, the former is made of soft stalks of plants and the latter of iron (metallic) rods. In deep and muscular parts iron rods preferred while in other parts plant stalks should be used for probing. [80-82]

==== ''Vrana shodhana'' (local purification of ulcers) ====

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पूतिगन्धान् विवर्णांश्च बहुस्रावान्महारुजः |

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तिलकल्कः सलवणो द्वे हरिद्रे त्रिवृद्धृतम् |

मधुकं निम्बपत्राणि प्रलेपो व्रणशोधनः ||८५||

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pūtigandhān vivarṇāṁśca bahusrāvānmahārujaḥ|

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tilakalkaH salavaNo dve haridre trivRuddhRutam |

madhukaM nimbapatrANi pralepo vraNashodhanaH ||85||

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</div></div>

Wounds with foul odor, abnormal color, profuse discharge and intense pain should be known as ''dushta vrana'' (unclean) and as such wounds should be treated with cleansing agents. Decoctions of ''triphala, khadira'' (Acasia catechu Willd), ''daruharidra'' (Berberis aristata DC), ''nyagrodhadi'' group, ''bala'' (Sida cordifolia Linn.), ''kusa'' (Desmostachya bipinnata Stapf.), leaves of ''nimba'' (Azadirachta indica A. Juss) and ''badara'' (Zizyphus jujube Lam.) are regarded as cleansing drugs. ''Tila'' paste, salt, ''haridra'' (Curcuma longa Linn.), ''daruharidra'' (Berberis aristata DC), ''trivrit'' (Operculina turpethum Linn.) ''ghrita'', ''madhuka, nimba'' leaves – this formulation is said as wound cleanser. [83-85]

==== ''Ropana'' (healing) of ulcer ====

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नातिरक्तो नातिपाण्डुर्नातिश्यावो न चातिरुक् |

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येनैव विधिना तैलं घृतं तेनैव साधयेत् |

रक्तपित्तोत्तरं दृष्ट्वा रोपणीयं व्रणं भिषक् ||९४|

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nātiraktō nātipāṇḍurnātiśyāvō na cātiruk|

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yenaiva vidhinA tailaM ghRutaM tenaiva sAdhayet |

raktapittottaraM dRuShTvA ropaNIyaM vraNaM bhiShak ||94||

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</div></div>

Those ulcers, are not very red, pale, blackish, painful, elevated and protruded should be known as clean and appeals healing process. Decoction of ''nyagrodha, udumbara, asvattha, kadamba, plaksha, vetasa, karavira'' (Nerium indicum Mill.), ''arka'' (Calotropis procera R. Br.) and ''kutaja'' (Holarrhena antidysentrica Linn.) are wound healing. ''Chandana'' (Santalum album Linn.), lotus stamens, ''daruharidra'' bark, blue water lily, ''meda'' (Polygonatum airrhifolium Royle), ''mahameda'' (Polygonatum airrhifolium Royle), ''murva'' (Marsdenia tenacissima W. & A.), ''lajjalu'' (Mimosa pudica Linn.) and ''madhuyasti''- this formulation is wound healer. ''Prapaundarika, jivanti, gojihva'' (Onosma bracteatum Wall.), ''dhataki, bala'' and sesamum should be applied as paste with ghee for wound healing. ''Kampillaka'' (Mallotus philippinensis Muell Arg), ''vidanga'' (Embelia ribes Burm), ''kutaja, triphala, bala, patola'' (Trichosanthes dioica Roxb.), ''nimba, musta'' (Cyperus rotundus Linn.), ''priyangu, khadira, dhataki, sarja, ela'' (Elleteria cardamomum Maton.), ''aguru'' (Aquilaria agallocha Roxb.) and ''chandana'' are pounded together and oil is extracted. This oil is used as ulcer healing agent.

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==== ''Patta bandhana'' (bandage) ====

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कदम्बार्जुननिम्बानां पाटल्याः पिप्पलस्य च |

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वार्क्षोऽथवाऽऽजिनः क्षौमः पट्टो व्रणहितः स्मृतः |

बन्धश्च द्विविधः शस्तो व्रणानां सव्यदक्षिणः ||९६||

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kadambārjunanimbānāṁ pāṭalyāḥ pippalasya ca|

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vArkSho~athavA~a~ajinaH kShaumaH paTTo vraNahitaH smRutaH |

bandhashca dvividhaH shasto vraNAnAM savyadakShiNaH ||96||

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</div></div>

For covering the wound, leaves of ''kadamba, arjuna, nimba, patala'' (Stereospermum suaveolens DC.), ''pippala'' (Ficus religiosa Linn.) and ''arka'' should be used. Bandage made of plant bark, deer hide or flaxen cloth is used in wounds. Bandaging of wounds are of two types i.e, It can be started either from left or right side. [95-96]

==== Contraindications ====

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लवणाम्लकटूष्णानि विदाहीनि गुरूणि च |

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नातिशीतगुरुस्निग्धमविदाहि यथाव्रणम् |

अन्नपानं व्रणहितं हितं चास्वपनं दिवा ||९८||

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lavaṇāmlakaṭūṣṇāni vidāhīni gurūṇi ca|

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nAtishItagurusnigdhamavidAhi yathAvraNam |

annapAnaM vraNahitaM hitaM cAsvapanaM divA ||98||

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</div></div>

Patients of ulcer should abstain from salt, sour, pungent, hot, burning and heavy food and drinks and also sexual intercourse. Food and drinks that are not too cold, heavy and fatty, non-burning, according to the nature of ulcer are beneficial, while day-sleep is not suitable in these patient.[97-98]

==== Suitable food and medicines ====

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स्तन्यानि जीवनीयानि बृंहणीयानि यानि च |

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भूर्जग्रन्थ्यश्मकासीसमधोभागानि गुग्गुलुः |

व्रणावसादनं तद्वत् कलविङ्ककपोतविट् ||१००||

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stanyāni jīvanīyāni br̥ṁhaṇīyāni yāni ca|

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bhUrjagranthyashmakAsIsamadhobhAgAni gugguluH |

vraNAvasAdanaM tadvat kalavi~gkakapotaviT ||100||

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</div></div>

For raising the depressed wounds galactogogues (''stanyajanana''), vitalizers (''jeevaniya'') and bulk promotives (''brinhaniya'') drugs should be applied. Similarly, ''bhurjagranthi'' (nodes in the tree of Butea utilis), ''asmakasisa'' (copper sulphate), purgatives, ''guggulu'' and excrement of sparrow and pigeon should be used for depressing the wounds. [99-100]

==== Indications and contraindications of ''agni karma'' (cauterization) ====

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रुधिरेऽतिप्रवृत्ते तु च्छिन्ने च्छेद्येऽधिमांसके |

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नाग्निकर्मोपदेष्टव्यं स्नायुमर्मव्रणेषु च |

सविषेषु च शल्येषु नेत्रकुष्ठव्रणेषु च ||१०६||

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rudhirē'tipravr̥ttē tu cchinnē cchēdyē'dhimāṁsakē|

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nAgnikarmopadeShTavyaM snAyumarmavraNeShu ca |

saviSheShu ca shalyeShu netrakuShThavraNeShu ca ||106||

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</div></div>

Excessive hemorrhage after excision, excisable growths, ''kaphaja'' nodules, glands, stiffness and disorders due to ''vata'', wounds with hidden pus and lymph, deep and firm; and after amputation of body part, cauterization is prescribed. The expert in cauterization should cauterize the spot with beeswax, oil, marrow, honey, muscle-fat, ''ghrita'' or various heated metallic sticks. Wounds deep and predominant in ''vata'' and in patients rough and delicate should be cauterized with fat or beeswax otherwise with iron stick or honey. Cauterization should not be applied in children, debilitated, old persons, pregnant women, those suffering from internal hemorrhage, thirst, fever, weak and poisoned persons and in wounds situated at ligaments and vital parts, poisoned, foreign body, ophthalmic and leprotic wounds.[101-106]

==== ''Kshara karma'' (application of alkali) and ''dhupana''(fumigation) ====

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रोगदोषबलापेक्षी मात्राकालाग्निकोविदः |

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मुद्गषष्टिकशालीनां पायसैर्वा यथाक्रमम् |

सघृतैर्जीवनीयैर्वा तर्पयेत्तानभीक्ष्णशः ||११२||

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rōgadōṣabalāpēkṣī mātrākālāgnikōvidaḥ|

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mudgaShaShTikashAlInAM pAyasairvA yathAkramam |

saghRutairjIvanIyairvA tarpayettAnabhIkShNashaH ||112||

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</div></div>

The physician conversant with dose, time and ''agni'' (heat) may apply alkali in cases amenable to surgical treatment and cauterization according to severity of disease and morbidity. Wounds attain hardness by being fumigated with aromatic substances and heartwood. The wounds get softened if fumigated with ''ghrita'', marrow or muscle-fat. Through fumigation pain, discharges, odors, maggots, hardness and softness of wounds are removed. ''Lodhra,'' leaf-buds of ''nyagrodha, khadira, triphala'' and ''ghrita'' - this combination used as paste provides looseness and softness in wounds. The wounds which are painful, hard, stiff and without discharge should be pasted frequently with barley powder mixed with ''ghrita''. Wounds may be saturated by applying frequently the paste of ''payasa'' (cereals cooked with milk) made of ''mudga, shashtika'' and ''shali'' rice or ''jivaniya'' drugs mixed with ''ghrita''.[110-112]

==== External applications ====

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ककुभोदुम्बराश्वत्थलोध्रजाम्बवकट्फलैः |

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षोडशोपद्रवा ये च व्रणानां परिकीर्तिताः |

तेषां चिकित्सा निर्दिष्टा यथास्वं स्वे चिकित्सिते ||११९||

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kakubhōdumbarāśvatthalōdhrajāmbavakaṭphalaiḥ|

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ShoDashopadravA ye ca vraNAnAM parikIrtitAH |

teShAM cikitsA nirdiShTA yathAsvaM sve cikitsite ||119||

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</div></div>

By dusting the wounds with the powders of barks of ''kakubha'' (Termalia arjuna), ''udumbara, asvattha, lodhra'' (Symplocos racemosa Roxb), ''jambu'' (Eugenia jambolana Lam) and ''katphala'' (Myrica esculenta Buch-Ham) they heals the skin quickly.

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==== Summary ====

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तत्र श्लोकौ-

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व्रणाधिकारे सप्रश्नमेतन्नवकमुक्तवान् |

मुनिर्व्याससमासाभ्यामग्निवेशाय धीमते ||१२१||

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tatra ślōkau-

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vraṇādhikārē sapraśnamētannavakamuktavān|

munirvyāsasamāsābhyāmagnivēśāya dhīmatē||121||

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</div></div>

Now the summing up verses –

Two types of wounds, kinds of wounds, examination of wounds, defects, locations, odors, discharges, complications and treatment modalities are described. These topics after queries have been described in brief as well details by the sage to the wise Agnivesha in the chapter on treatment of wound ([[Dwivraniya Chikitsa]]). [120-121]

+

इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते दृढबलसम्पूरिते चिकित्सास्थाने द्विव्रणीयचिकित्सितं नाम पञ्चविंशोऽध्यायः ||२५||

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ityagnivēśakr̥tē tantrē carakapratisaṁskr̥tē dr̥ḍhabalasampūritē cikitsāsthānē dvivraṇīyacikitsitaṁ nāmapañcaviṁśō'dhyāyaḥ||25||

ityagniveshakRute tantre carakapratisaMskRute dRuDhabalasampUrite cikitsAsthAne dvivraNIyacikitsitaM nAma pa~jcaviMsho~adhyAyaH ||25||

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</div></div>

=== ''Tattva Vimarsha'' / Fundamental Principles===

Agnivesha

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