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Various complications of ulcers like ''visarpa'' (erysipelas), ''pakshaghata'' (hemiplegia), ''shirastambha'' (constricted vessels), ''jwara'' (fever) etc. are described. Sloughing of ligaments and vessels, deep seated appearance of maggots, fracture of bone near the ulcer, presence of foreign body in the ulcer etc hamper the healing process. Treatment of ''nija vrana'' (endogenous ulcer)<ref>Kaviraj Atrideva Gupta, Astanga Hridaya, Vidyotini Tika, Uttara tantra Chap 26, shlok no.13 , Reprint 2005, Chaukhambha Sanskrit Sansthan, Varanasi, pp 26</ref> is different from ''agantuja vrana'' (exogenous ulcer) because endogenous ulcers are caused by vitiation of ''vatadi doshaja'', and exogenous ulcers are initially caused by various type of trauma such as ''vadha'' (stab injury etc.), ''bandha'' (excessive tying), ''prapatana'' (injury due to fall), injury due to teeth and nail etc. But later on in exogenous ulcers also involvement of ''dosha'' takes place and then treatment should be adopted as ''nija vrana'' (endogenous ulcer). In endogenous ulcers, ''shodhana'' therapy should be adopted by ''vamana'' (emesis), ''virechana'' (purgation) and ''basti'' (medicated enema) and blood letting for removal of ''doshaja'' (toxic materials) from body<ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Sutrasthana, Chap 16, shlok no.17 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 321.</ref> and ''agnikarma''. ''Agnikarma'' has ''ushna guna'' (hot property) which is opposite to ''vata'' and ''kapha''. Due to heat, vasodilation leads to alleviation of ''srotorodha'' resulting in proper vascularity to organ or part. In exogenous ulcers, local treatment with use of ''kshara'' (alkaline substances), surgical intervention and cauterization is recommended.

Various complications of ulcers like ''visarpa'' (erysipelas), ''pakshaghata'' (hemiplegia), ''shirastambha'' (constricted vessels), ''jwara'' (fever) etc. are described. Sloughing of ligaments and vessels, deep seated appearance of maggots, fracture of bone near the ulcer, presence of foreign body in the ulcer etc hamper the healing process. Treatment of ''nija vrana'' (endogenous ulcer)<ref>Kaviraj Atrideva Gupta, Astanga Hridaya, Vidyotini Tika, Uttara tantra Chap 26, shlok no.13 , Reprint 2005, Chaukhambha Sanskrit Sansthan, Varanasi, pp 26</ref> is different from ''agantuja vrana'' (exogenous ulcer) because endogenous ulcers are caused by vitiation of ''vatadi doshaja'', and exogenous ulcers are initially caused by various type of trauma such as ''vadha'' (stab injury etc.), ''bandha'' (excessive tying), ''prapatana'' (injury due to fall), injury due to teeth and nail etc. But later on in exogenous ulcers also involvement of ''dosha'' takes place and then treatment should be adopted as ''nija vrana'' (endogenous ulcer). In endogenous ulcers, ''shodhana'' therapy should be adopted by ''vamana'' (emesis), ''virechana'' (purgation) and ''basti'' (medicated enema) and blood letting for removal of ''doshaja'' (toxic materials) from body<ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Sutrasthana, Chap 16, shlok no.17 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 321.</ref> and ''agnikarma''. ''Agnikarma'' has ''ushna guna'' (hot property) which is opposite to ''vata'' and ''kapha''. Due to heat, vasodilation leads to alleviation of ''srotorodha'' resulting in proper vascularity to organ or part. In exogenous ulcers, local treatment with use of ''kshara'' (alkaline substances), surgical intervention and cauterization is recommended.

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

== Sanskrit Text, Transliteration and English Translation ==

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

Now we shall expound the chapter "Dwivraniya chikitsa" (Management of two types of ulcers).Thus said Lord Atreya.[1-2]

Thus said Lord Atreya.[1-2]

==== Query by Agnivesha ====

=== Query by Agnivesha ===

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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]

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'' ====

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

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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]

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 ====

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

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

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

==== Endogenous ulcers ====

=== Endogenous ulcers ===

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

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

==== ''Dosha'' dominant ''vrana'' and their treatment ====

=== ''Dosha'' dominant ''vrana'' and their treatment ===

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

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

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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]

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 =====

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

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''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]

''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 =====

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

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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]

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 ====

=== Twenty types of ulcers ===

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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]

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 ====

=== Three fold examination ===

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Age, complexion and color, body parts and sense organs are examined by inspection. Etiology, nature of pain, suitability and power of digestion should be known by patient’s statement. By palpation softness and coldness are known with their contraries. [22-23]

Age, complexion and color, body parts and sense organs are examined by inspection. Etiology, nature of pain, suitability and power of digestion should be known by patient’s statement. By palpation softness and coldness are known with their contraries. [22-23]

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

=== Twelve types of ulcers ===

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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]

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 ====

=== Sites of vitiation ===

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

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'' ====

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

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

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 ====

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

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The experts have mentioned sixteen complications of wounds such as erysipelas, paralysis, occlusion in blood vessels, tetanus, and mental confusion, and insanity, pain in wound, fever, thirst, lockjaw, cough, vomiting, diarrhea, hiccups, dyspnea and trembling.[28-31]

The experts have mentioned sixteen complications of wounds such as erysipelas, paralysis, occlusion in blood vessels, tetanus, and mental confusion, and insanity, pain in wound, fever, thirst, lockjaw, cough, vomiting, diarrhea, hiccups, dyspnea and trembling.[28-31]

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

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

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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]

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 ====

=== Factors affecting prognosis ===

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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]

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 ====

=== Principles of management ===

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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]

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 ====

=== Procedures for management of ulcers ===

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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]

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 ====

=== Guidelines for management of ulcers ===

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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]

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) ====

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

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Swelling is known as ''vidagdha'' (under ripening) by the symptoms such as pain, burning sensation, redness and piercing pain. The same should be known as ripened when it is like water-bag on palpation and rises on pressure. Linseed, ''guggulu'' (Commiphora mukul), latex of ''snuhi'' (Euphorbia neriifolia Linn.), feces of chicken and pigeon, alkali of ''palasha'' (Butea monosperma Linn.), ''svarnakhsiri'' (Argemone mexicana Linn.) and ''mukulaka'' (Pistacia vera Linn.). This is the group of drugs which helps in the tearing of ripened inflammation in delicate patients otherwise it should be operated upon surgically.[49-54]

Swelling is known as ''vidagdha'' (under ripening) by the symptoms such as pain, burning sensation, redness and piercing pain. The same should be known as ripened when it is like water-bag on palpation and rises on pressure. Linseed, ''guggulu'' (Commiphora mukul), latex of ''snuhi'' (Euphorbia neriifolia Linn.), feces of chicken and pigeon, alkali of ''palasha'' (Butea monosperma Linn.), ''svarnakhsiri'' (Argemone mexicana Linn.) and ''mukulaka'' (Pistacia vera Linn.). This is the group of drugs which helps in the tearing of ripened inflammation in delicate patients otherwise it should be operated upon surgically.[49-54]

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

=== Six types of surgical procedures ===

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

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

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

=== Indications of various surgical procedures ===

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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]

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) ====

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

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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]

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 ====

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

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Application of above measures leads to proper wounds healing.[65-68]

Application of above measures leads to proper wounds healing.[65-68]

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

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

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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]

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'' ====

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

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Barley powder (Hordeum vulgare Linn.), ''madhuka'' (Glycyrrhiza glabra Linn.) and ''tila'' mixed with ghee should be applied as warm paste for alleviating burning sensation and pain. ''Payasa'' prepared of ''mudga'' (Phaseolus radiates Linn.) mixed with ''tila'' should be applied as poultice to pacify pain and burning sensation. These management principles are beneficial in wounds.[72-79]

Barley powder (Hordeum vulgare Linn.), ''madhuka'' (Glycyrrhiza glabra Linn.) and ''tila'' mixed with ghee should be applied as warm paste for alleviating burning sensation and pain. ''Payasa'' prepared of ''mudga'' (Phaseolus radiates Linn.) mixed with ''tila'' should be applied as poultice to pacify pain and burning sensation. These management principles are beneficial in wounds.[72-79]

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

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

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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]

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) ====

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

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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]

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 ====

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

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Similarly, oil prepared with equal quantity of ''prapaundarika, mahuka, kakoli'' (Roscoca procera Wall.), ''kshirakakoli'' (Roscoca procera Wall.), ''chandana'' and ''rakta chandana'' (Pterocarpus santalinus Linn.) is an excellent ulcer healing agent. Oil cooked with ''durva'' juice or ''kampillaka'' or paste of ''daruharidra'' bark is an important ulcer healer. By the above method ''ghrita'' should be prepared and used for healing, ulcers predominant in ''rakta'' and ''pitta''.[86-94]

Similarly, oil prepared with equal quantity of ''prapaundarika, mahuka, kakoli'' (Roscoca procera Wall.), ''kshirakakoli'' (Roscoca procera Wall.), ''chandana'' and ''rakta chandana'' (Pterocarpus santalinus Linn.) is an excellent ulcer healing agent. Oil cooked with ''durva'' juice or ''kampillaka'' or paste of ''daruharidra'' bark is an important ulcer healer. By the above method ''ghrita'' should be prepared and used for healing, ulcers predominant in ''rakta'' and ''pitta''.[86-94]

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

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

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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]

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 ====

=== Contraindications ===

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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]

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 ====

=== Suitable food and medicines ===

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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]

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) ====

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

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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]

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) ====

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

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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]

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 ====

=== External applications ===

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The hairless spots are smeared with oil and  dusting with the ash of skin, hair, hoof, horns and bone of quadrupeds, reproduces hairs.The treatment of sixteen complications of wounds has been mentioned in their respective contexts.[113-119]

The hairless spots are smeared with oil and  dusting with the ash of skin, hair, hoof, horns and bone of quadrupeds, reproduces hairs.The treatment of sixteen complications of wounds has been mentioned in their respective contexts.[113-119]

==== Summary ====

=== Summary ===

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=== Tattva Vimarsha (Fundamental Principles) ===

== Tattva Vimarsha (Fundamental Principles) ==

*''Vrana'' (ulcers) are broadly classified into two types viz. ''nija'' (endogenous) and ''agantu'' (exogenous).  

*''Vrana'' (ulcers) are broadly classified into two types viz. ''nija'' (endogenous) and ''agantu'' (exogenous).  

== Vidhi Vimarsha (Applied Inferences ) ==

== Vidhi Vimarsha (Applied Inferences ) ==

==== Classification of ulcers and causes ====

=== Classification of ulcers and causes ===

As said earlier, ulcers are of two types i.e. ''nija'' and ''agantuja'', another classification is clean and infected wound. ''Nija vrana'' (endogenous ulcer) are caused by vitiation of ''doshas'' in the body or due to disease process. The term ''sharira desotha'' (ie.endogenous in origin) is used for morbid factors occurring in the body that cause ''nija vrana'' (i.e. endogenous ulcer). While ''agantuja vrana'' (exogenous ulcer) are caused by external factors (trauma or surgical intervention) like wound caused by stab injury, poisons, fire and sharp weapons or excessive tying of that organ (''bandha'') etc. In exogenous ulcers, vitiation of ''dosha'' occurs later. ''Nija vrana'' i.e. ''vataja, pittaja, kaphaja, raktaja'' and ''sannipataja'', are caused due to faulty habit, mode of living and seasonal variation. These vitiated ''dosha'', after a series of pathological processes (''shada-kriyakala'') get lodged at particular site resulting in the formation of ''vrana''.

As said earlier, ulcers are of two types i.e. ''nija'' and ''agantuja'', another classification is clean and infected wound. ''Nija vrana'' (endogenous ulcer) are caused by vitiation of ''doshas'' in the body or due to disease process. The term ''sharira desotha'' (ie.endogenous in origin) is used for morbid factors occurring in the body that cause ''nija vrana'' (i.e. endogenous ulcer). While ''agantuja vrana'' (exogenous ulcer) are caused by external factors (trauma or surgical intervention) like wound caused by stab injury, poisons, fire and sharp weapons or excessive tying of that organ (''bandha'') etc. In exogenous ulcers, vitiation of ''dosha'' occurs later. ''Nija vrana'' i.e. ''vataja, pittaja, kaphaja, raktaja'' and ''sannipataja'', are caused due to faulty habit, mode of living and seasonal variation. These vitiated ''dosha'', after a series of pathological processes (''shada-kriyakala'') get lodged at particular site resulting in the formation of ''vrana''.

==== ''Samprapti'' (pathogenesis of ''vrana''): based on ''shadakriya kala'' ====

=== ''Samprapti'' (pathogenesis of ''vrana''): based on ''shadakriya kala'' ===

[[File:Dwivraniya1.png|500px]]

[[File:Dwivraniya1.png|500px]]

                                                                                                

                                                                                                

==== Clinical pictures of ''vrana'' ====

=== Clinical pictures of ''vrana'' ===

The following ulcer is the case of diabetic ulcer. Clinical features include throbbing pain, swelling, redness, necrosis of involved tissue and non healing ulcer since 6 months.

The following ulcer is the case of diabetic ulcer. Clinical features include throbbing pain, swelling, redness, necrosis of involved tissue and non healing ulcer since 6 months.

'''Image 5: ''Shuddha vrana'''''

'''Image 5: ''Shuddha vrana'''''

==== Investigations and their clinical interpretation in brief ====

=== Investigations and their clinical interpretation in brief ===

   

   

The clinical features of ulcers are ulceration /disccontineous of skin, discharge (pus/blood/ serum), bad odor, differenct size, painful/painless ulcers. The above symptoms are described by Acharya Sushruta (''gandha, varna, sava, vedana, akruti''). On the basis of which kind of ulcer (varicose ulcer, diabetic ulcer, arterial ulcer, bedsores, leprotic ulcer, rodent ulcer, etc) the symptoms may vary.  In all types of ulcers on the basis of history and clinical examinations the following investigations play important role in diagnosis and prognosis of the Ulcer. TLC (Total leucocyte count), Hb% , Serum crestnine, BSL (Blood sugar level) swab culture, X-ray of affected part if chronic ulcer. If TLC are increase than normal range suggest the acute infection. if Hb% is low then the ulcer will heal delay due hyposia to the tissue. If serum creatinine is increased that might be due to kidney problem which hampered healing of ulcer. In diabetic patients BSL assessment is important for healing as glucose liden tissue are reluctant to heal. Swab culture of wound discharge is necessary to know the organism. Lastly s-xay is essential to know extension of wound upto bone/osteomylituis.   

The clinical features of ulcers are ulceration /disccontineous of skin, discharge (pus/blood/ serum), bad odor, differenct size, painful/painless ulcers. The above symptoms are described by Acharya Sushruta (''gandha, varna, sava, vedana, akruti''). On the basis of which kind of ulcer (varicose ulcer, diabetic ulcer, arterial ulcer, bedsores, leprotic ulcer, rodent ulcer, etc) the symptoms may vary.  In all types of ulcers on the basis of history and clinical examinations the following investigations play important role in diagnosis and prognosis of the Ulcer. TLC (Total leucocyte count), Hb% , Serum crestnine, BSL (Blood sugar level) swab culture, X-ray of affected part if chronic ulcer. If TLC are increase than normal range suggest the acute infection. if Hb% is low then the ulcer will heal delay due hyposia to the tissue. If serum creatinine is increased that might be due to kidney problem which hampered healing of ulcer. In diabetic patients BSL assessment is important for healing as glucose liden tissue are reluctant to heal. Swab culture of wound discharge is necessary to know the organism. Lastly s-xay is essential to know extension of wound upto bone/osteomylituis.   

===== Complications of ulcer =====

==== Complications of ulcer ====

If ulcer is not treated properly it may lead to local and systemic infection leading to septicemia. The tissue necrosis leads to gangrene which further need to amputation.  

If ulcer is not treated properly it may lead to local and systemic infection leading to septicemia. The tissue necrosis leads to gangrene which further need to amputation.  

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

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

Two factors mainly affect the process of wound healing viz. local factors and systemic factors.

Two factors mainly affect the process of wound healing viz. local factors and systemic factors.

Local factors are infection, necrosis, foreign body, vascular insufficiency, lymphatic obstruction, continuous movement of part. Systemic causes include old age, protein deficiency, vit-c and zinc deficiency, diabetes mellitus.  

Local factors are infection, necrosis, foreign body, vascular insufficiency, lymphatic obstruction, continuous movement of part. Systemic causes include old age, protein deficiency, vit-c and zinc deficiency, diabetes mellitus.  

==== Treatment of ''vrana'' (ulcers) ====

=== Treatment of ''vrana'' (ulcers) ===

===== Purification measures =====

==== Purification measures ====

Purificatory measures eliminate toxic material from body and improve healing process of ulcer. In case of endogenous ulcer removal of morbid matters (i.e. ''doshaja'') emesis through upward route, purgation through downward route are advised. Other purificatory measures like oleation therapy, sudation therapy should be done prior to emesis, purgation etc. For local purification of ulcer, venesection and ''vrana basti'' should be done.''Raktamokshana'' is an important modality (Sushruta Samhita. Chi. 1/27-28) indicated predominantly in local vitiation of ''rakta'' as in ''dushta vrana''. So along with emesis and purgation blood letting is also important treatment modalities with the help of ''jalauka'' (leech application), veinpuncture etc.

Purificatory measures eliminate toxic material from body and improve healing process of ulcer. In case of endogenous ulcer removal of morbid matters (i.e. ''doshaja'') emesis through upward route, purgation through downward route are advised. Other purificatory measures like oleation therapy, sudation therapy should be done prior to emesis, purgation etc. For local purification of ulcer, venesection and ''vrana basti'' should be done.''Raktamokshana'' is an important modality (Sushruta Samhita. Chi. 1/27-28) indicated predominantly in local vitiation of ''rakta'' as in ''dushta vrana''. So along with emesis and purgation blood letting is also important treatment modalities with the help of ''jalauka'' (leech application), veinpuncture etc.

Selection of therapeutic measures is done as per condition of ''vrana'' and patient.  

Selection of therapeutic measures is done as per condition of ''vrana'' and patient.  

===== Thirty six treatment measures =====

==== Thirty six treatment measures ====

Thirty six types of therapeutic measures are described for the treatment of ulcer. Sixty types of treatment measures are described under the head of ''shashtiupakrama'' regarding ulcer treatment.<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, chikitsa sthana Chap 1, shlok no.8 ,Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 5</ref> It is not necessary that all the thirty six or sixty therapeutic measures have to be applied in treating an ulcer. I A patient at a time 1 or 4 type of procedures are essential in single case of ''vrana'' according to condition of the wound. (Su. Chi. 1/8).

Thirty six types of therapeutic measures are described for the treatment of ulcer. Sixty types of treatment measures are described under the head of ''shashtiupakrama'' regarding ulcer treatment.<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, chikitsa sthana Chap 1, shlok no.8 ,Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 5</ref> It is not necessary that all the thirty six or sixty therapeutic measures have to be applied in treating an ulcer. I A patient at a time 1 or 4 type of procedures are essential in single case of ''vrana'' according to condition of the wound. (Su. Chi. 1/8).

In early stage of ulcer only inflammation appears. At this stage bloodletting should be done to break the further manifestation of ulcer. Purificatory measures should be performed in excessively aggravated doshas while lightning measures should be adopted if ''doshas'' are less aggravated. In the beginning of edema, therapeutic measures aimed to alleviate aggravated ''vata'' followed by other ''dosha'' viz. ''pitta'' and ''kapha'' are advised. Application of various pastes made of ''vijaya, madhuka, vira, bisagranthi'' etc. also reduce edema. Edema reducing dietary regimen like light food and food that does not cause burning sensation (''avidahi'') should be followed.

In early stage of ulcer only inflammation appears. At this stage bloodletting should be done to break the further manifestation of ulcer. Purificatory measures should be performed in excessively aggravated doshas while lightning measures should be adopted if ''doshas'' are less aggravated. In the beginning of edema, therapeutic measures aimed to alleviate aggravated ''vata'' followed by other ''dosha'' viz. ''pitta'' and ''kapha'' are advised. Application of various pastes made of ''vijaya, madhuka, vira, bisagranthi'' etc. also reduce edema. Edema reducing dietary regimen like light food and food that does not cause burning sensation (''avidahi'') should be followed.

==== Indications and process of six fold surgical procedures ====

=== Indications and process of six fold surgical procedures ===

Six types of surgical procedures are described for treatment of ulcer such as ''patana'' (incision), ''vyadhana'' (puncturing), ''chhedana'' (excision), ''lekhana'' (scrapping), ''pracchana'' (scarification) and ''seevana'' (suturing). ''Patana'' procedure described by Charak is same as for ''bhedana'' by Sushruta. Any similar or new procedure can be applied in wound management as per the surgeon’s freedom. <ref>K. H. Krishnamurthy, editor Prof. P.V. Sharma, Bhela Samhita, Chikitsa sthana, Chap.27, Shloka 14-15, pp 468, Reprint 2008, Chaukhambha Visvabharati, Varanasi.</ref>

Six types of surgical procedures are described for treatment of ulcer such as ''patana'' (incision), ''vyadhana'' (puncturing), ''chhedana'' (excision), ''lekhana'' (scrapping), ''pracchana'' (scarification) and ''seevana'' (suturing). ''Patana'' procedure described by Charak is same as for ''bhedana'' by Sushruta. Any similar or new procedure can be applied in wound management as per the surgeon’s freedom. <ref>K. H. Krishnamurthy, editor Prof. P.V. Sharma, Bhela Samhita, Chikitsa sthana, Chap.27, Shloka 14-15, pp 468, Reprint 2008, Chaukhambha Visvabharati, Varanasi.</ref>

===== ''Pidana'' (Compression) =====

==== ''Pidana'' (Compression) ====

Widening of external opening (mouth) of ulcer or abscess along with breaking of multiple loculi to make uniform cavity, to avoid the collection of pus in multiple pockets and facilitate free drainage of pus. ''Pidana'' (compression) is also helpful to squeeze out the collected pus. For compression various pastes are applied over the ulcer of abscess except on mouth openings.

Widening of external opening (mouth) of ulcer or abscess along with breaking of multiple loculi to make uniform cavity, to avoid the collection of pus in multiple pockets and facilitate free drainage of pus. ''Pidana'' (compression) is also helpful to squeeze out the collected pus. For compression various pastes are applied over the ulcer of abscess except on mouth openings.

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

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

The basic guidelines for management of fracture and dislocation are to stabilize the fractured bone or dislocated joint by application of splints. Proper alignment of bone is mandatory for healing of fractured bones.<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, chikitsa sthana Chap 3, shlok no.18-19, Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 28</ref> Suitable dietary regimen should be followed with avoidance of ''vidahi'' (food which causes burning sensation) food.<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, chikitsa sthana Chap 3, shlok no.4-5 , Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 27</ref> Strenuous exercise is not allowed during healing period due to risk of re-fracture and dislocation. Complications due to fracture of bone or dislocation of joint are managed as per condition. For e.g. If ulcer is due to fracture of bone then treatment of ulcer along with fracture management should be adopted.

The basic guidelines for management of fracture and dislocation are to stabilize the fractured bone or dislocated joint by application of splints. Proper alignment of bone is mandatory for healing of fractured bones.<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, chikitsa sthana Chap 3, shlok no.18-19, Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 28</ref> Suitable dietary regimen should be followed with avoidance of ''vidahi'' (food which causes burning sensation) food.<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, chikitsa sthana Chap 3, shlok no.4-5 , Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 27</ref> Strenuous exercise is not allowed during healing period due to risk of re-fracture and dislocation. Complications due to fracture of bone or dislocation of joint are managed as per condition. For e.g. If ulcer is due to fracture of bone then treatment of ulcer along with fracture management should be adopted.

===== ''Eshanakarma'' (probing) =====

==== ''Eshanakarma'' (probing) ====

It is used in ulcer of narrow opening with expanded base (eg.undermined ulcers). Various types of probes are used in ulcer to know the direction of tract or cavity, depth and discharge from ulcer or sinuses. Generally probing is not done if ulcer is located at vital organs (''marma sthana'') but in specific conditions as in fistula in ano it can be performed. As per site of ulcer various probes either hard or soft can be used. If deep seated and located at fleshy area hard probe (metallic) is used, in superficially seated ulcers soft probe is used. Probing is essential to know the depth of wound particularly in ''nadivrana'' (sinus at any part of the body) or fistula (fistula-in ano is one kind). (Su. Su.25/10).

It is used in ulcer of narrow opening with expanded base (eg.undermined ulcers). Various types of probes are used in ulcer to know the direction of tract or cavity, depth and discharge from ulcer or sinuses. Generally probing is not done if ulcer is located at vital organs (''marma sthana'') but in specific conditions as in fistula in ano it can be performed. As per site of ulcer various probes either hard or soft can be used. If deep seated and located at fleshy area hard probe (metallic) is used, in superficially seated ulcers soft probe is used. Probing is essential to know the depth of wound particularly in ''nadivrana'' (sinus at any part of the body) or fistula (fistula-in ano is one kind). (Su. Su.25/10).

===== ''Vrana shodhana'' (cleaning of ulcer) =====

==== ''Vrana shodhana'' (cleaning of ulcer) ====

Cleaning of ulcer is done with ''shodhana'' drugs (cleansing agents) leads to ''vrana ropana'' (wound healing) process.

Cleaning of ulcer is done with ''shodhana'' drugs (cleansing agents) leads to ''vrana ropana'' (wound healing) process.

If ulcer is contaminated i.e.presence of infection causing vectors, profuse secretion, presence of slough etc, in these conditions purificatory measures like debridement of ulcer (i.e. removal of slough), irrigation with ''shodhana kashaya'' or paste (purificatory measures) should be applied. Once ulcer becomes clean, healthy granulation tissue formation starts. To enhance and protect the granulation tissue ''vrana ropana'' drugs (healing drugs) either externally or internally or in combination are used.

If ulcer is contaminated i.e.presence of infection causing vectors, profuse secretion, presence of slough etc, in these conditions purificatory measures like debridement of ulcer (i.e. removal of slough), irrigation with ''shodhana kashaya'' or paste (purificatory measures) should be applied. Once ulcer becomes clean, healthy granulation tissue formation starts. To enhance and protect the granulation tissue ''vrana ropana'' drugs (healing drugs) either externally or internally or in combination are used.

==== Bandaging material, methods and its applicability in ''vrana'' (wound) ====

=== Bandaging material, methods and its applicability in ''vrana'' (wound) ===

Bandaging of wound is very important as it stabilizes wounded part, prevents external injury, prevents contamination from external sources and enhances healing process. Bandaging should not be too tight, nor too loose. Act of bandaging may be from right or left side while others have mentioned fourteen types<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, Sutra sthana Chap 18, shlok no.17 , Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 98</ref> and fifteen types. <ref>Kaviraj Atrideva Gupta, Astanga Hridaya, Vidyotini Tika, Sutra sthana Chap 29, shlok no.59-60, Reprint 2005, Chaukhambha Sanskrit Sansthan,Varanasi, pp 161</ref>

Bandaging of wound is very important as it stabilizes wounded part, prevents external injury, prevents contamination from external sources and enhances healing process. Bandaging should not be too tight, nor too loose. Act of bandaging may be from right or left side while others have mentioned fourteen types<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, Sutra sthana Chap 18, shlok no.17 , Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 98</ref> and fifteen types. <ref>Kaviraj Atrideva Gupta, Astanga Hridaya, Vidyotini Tika, Sutra sthana Chap 29, shlok no.59-60, Reprint 2005, Chaukhambha Sanskrit Sansthan,Varanasi, pp 161</ref>

==== Diet: Wholesome and unwholesome aahar-vihar and ulcer healing promoters ====

=== Diet: Wholesome and unwholesome aahar-vihar and ulcer healing promoters ===

''Lavana'' is ''vishyandi'' i. e. producing more secretions from tissues; it aggravates ''kapha'' and ''pitta'' and mitigates ''vata''.<ref>Kaviraj Atrideva Gupta, Astanga Hridaya, Vidyotini Tika, Sutra sthana Chap 6, shlok no.143, Reprint 2005, Chaukhambha Sanskrit Sansthan,Varanasi, pp 64</ref> Due to ''kapha'' and ''pitta'' vitiating properties it causes sliminess (''kledana'') and burning pain. Excessive ''lavana, amla'' and ''katu rasa'' will provoke ''vata dosha'' and may produce various types of pain. ''Vidahi'' food also leads to burning sensation due to ''srotorodha'' while sexual intercourse leads to ''dhatukshaya'' and aggravates ''vata''. <ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Chikitsa sthana, Chap 28, shlok no.59 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 788</ref>, <ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Vimana sthana, Chap 5, shlok no.24 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 714</ref>. Day time sleep causes ''srotorodha'' and gives rise to vitiation of ''kapha'' that leads to swelling. Elevation of depressed ulcer is very important aspect of healing process. In Ayurvedic classics ''stanya janana'' (galactogogue),<ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Sutrasthana, Chap 4, shlok no.17 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 83</ref> ''jeevaniya'' (life promoters e.g. vitamins)<ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Sutrasthana, Chap 4, shlok no.1 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 71.</ref> and ''brimhaniya gana'' (nourishing drugs)<ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Sutrasthana, Chap 4, shlok no.2 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 72.</ref> are described. All these drugs have nutritional value (''dhatu poshana'') that helps in ulcer healing.

''Lavana'' is ''vishyandi'' i. e. producing more secretions from tissues; it aggravates ''kapha'' and ''pitta'' and mitigates ''vata''.<ref>Kaviraj Atrideva Gupta, Astanga Hridaya, Vidyotini Tika, Sutra sthana Chap 6, shlok no.143, Reprint 2005, Chaukhambha Sanskrit Sansthan,Varanasi, pp 64</ref> Due to ''kapha'' and ''pitta'' vitiating properties it causes sliminess (''kledana'') and burning pain. Excessive ''lavana, amla'' and ''katu rasa'' will provoke ''vata dosha'' and may produce various types of pain. ''Vidahi'' food also leads to burning sensation due to ''srotorodha'' while sexual intercourse leads to ''dhatukshaya'' and aggravates ''vata''. <ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Chikitsa sthana, Chap 28, shlok no.59 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 788</ref>, <ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Vimana sthana, Chap 5, shlok no.24 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 714</ref>. Day time sleep causes ''srotorodha'' and gives rise to vitiation of ''kapha'' that leads to swelling. Elevation of depressed ulcer is very important aspect of healing process. In Ayurvedic classics ''stanya janana'' (galactogogue),<ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Sutrasthana, Chap 4, shlok no.17 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 83</ref> ''jeevaniya'' (life promoters e.g. vitamins)<ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Sutrasthana, Chap 4, shlok no.1 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 71.</ref> and ''brimhaniya gana'' (nourishing drugs)<ref>Pandit Kashi Nath Shastri, Dr. Gorakhanath Chaturvedi, Charak Samhita, Ist part, Sutrasthana, Chap 4, shlok no.2 ,Reprint 2005, Chaukhambha Bharati Academy, Varanasi, pp 72.</ref> are described. All these drugs have nutritional value (''dhatu poshana'') that helps in ulcer healing.

==== Indications and contraindications of agnikarma (cauterization) in various disorders ====

=== Indications and contraindications of agnikarma (cauterization) in various disorders ===

''Agni karma'' (cauterization by application of heat) is used as precaution for excessive bleeding ulcers, excision of hanging flesh, ''kaphaja granthi'' (enlarged gland due to ''kapha''), goitre and in stiffness (associated with ''vata'') etc. ''Agnikarma'' has ''ushna guna'' (hot property) which is opposite to ''vata'' and ''kapha''. Due to heat, vasodilation leads to alleviation of ''srotorodha'' resulting in proper vascularity to organ or part. ''Dahakarma'' (cauterization) causes constriction of blood vessels so prevents bleeding from ulcer.<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, Sutra sthana Chap 14, shlok no.40 ,Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 72</ref> Cauterization is performed with the help of many substances like unctuous or ununctous substances etc by many ways e.g. Small spot (''bindu''), shape of ring (''valaya'') etc depending on nature of disease, strength of patient and time of application.

''Agni karma'' (cauterization by application of heat) is used as precaution for excessive bleeding ulcers, excision of hanging flesh, ''kaphaja granthi'' (enlarged gland due to ''kapha''), goitre and in stiffness (associated with ''vata'') etc. ''Agnikarma'' has ''ushna guna'' (hot property) which is opposite to ''vata'' and ''kapha''. Due to heat, vasodilation leads to alleviation of ''srotorodha'' resulting in proper vascularity to organ or part. ''Dahakarma'' (cauterization) causes constriction of blood vessels so prevents bleeding from ulcer.<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, Sutra sthana Chap 14, shlok no.40 ,Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 72</ref> Cauterization is performed with the help of many substances like unctuous or ununctous substances etc by many ways e.g. Small spot (''bindu''), shape of ring (''valaya'') etc depending on nature of disease, strength of patient and time of application.

==== Importance of ''dhupana karma'' (fumigation therapy) in wound sterilization healing process ====

=== Importance of ''dhupana karma'' (fumigation therapy) in wound sterilization healing process ===

Fumigation of ulcer is done with ''dhupana dravyas'' (fumigating materials).<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, Sutra sthana Chap 5, shlok no.17 ,Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 24</ref>, <ref>Kaviraj Atrideva Gupta, Astanga Hridaya, Vidyotini Tika, Uttara tantra Chap 25, shlok no.45, Reprint 2005, Chaukhambha Sanskrit Sansthan,Varanasi, pp 542.</ref>. Purpose of fumigation is to make suitable conditions for better ulcer healing such as local sterilization, vasodilation, decreased discharge and removal of foul smell.  

Fumigation of ulcer is done with ''dhupana dravyas'' (fumigating materials).<ref>Kaviraja Ambikadutta Shastri, Sushruta Samhita, Ist part, Sutra sthana Chap 5, shlok no.17 ,Reprint 2013, Chaukhambha Sanskrit Sansthan, Varanasi, pp 24</ref>, <ref>Kaviraj Atrideva Gupta, Astanga Hridaya, Vidyotini Tika, Uttara tantra Chap 25, shlok no.45, Reprint 2005, Chaukhambha Sanskrit Sansthan,Varanasi, pp 542.</ref>. Purpose of fumigation is to make suitable conditions for better ulcer healing such as local sterilization, vasodilation, decreased discharge and removal of foul smell.  

#By dusting the wound with the powders of barks of kakubha (Termalia arjuna),<ref>Narayana A, Swamy RK . A medico-historical review of Arjuna (Terminalia arjuna, w. & a.). Bulletin of the Indian Institute of History of Medicine. 1998; 26(1-2): 1-10</ref> udumbara,<ref>Vinaya Kumar, P.V. Tiwari. Post-Cautery Effect of Udumbar Ointment on Cervical Erosion, Ancient Science of Life 1993 July ; 13 (1-2) :97-101</ref> ashvattha, lodhra (Symplocos racemosa Roxb), jambu (Eugenia jambolana Lam) and katphala (Myrica esculenta Buch-Ham) they heals the skin quickly. Manashila (Realgar), manjistha,<ref>Baria J, Gupta SK, Bhuyan C. Clinical Study of Manjishthadi Ghrita in Vrana Ropana. AYU. 2011; 32 (1): 95-99.</ref>,<ref>Singh AK, Srivastava PK, Shukla VK. Evaluation of Nimba taila and Manjistha churna in non healing ulcer. International Research Journal of Pharmacy. 2011; 2(5):201-210</ref> lac, haridra and daruharidra used as paste with ghee and honey is an excellent cleanser of skin.

#By dusting the wound with the powders of barks of kakubha (Termalia arjuna),<ref>Narayana A, Swamy RK . A medico-historical review of Arjuna (Terminalia arjuna, w. & a.). Bulletin of the Indian Institute of History of Medicine. 1998; 26(1-2): 1-10</ref> udumbara,<ref>Vinaya Kumar, P.V. Tiwari. Post-Cautery Effect of Udumbar Ointment on Cervical Erosion, Ancient Science of Life 1993 July ; 13 (1-2) :97-101</ref> ashvattha, lodhra (Symplocos racemosa Roxb), jambu (Eugenia jambolana Lam) and katphala (Myrica esculenta Buch-Ham) they heals the skin quickly. Manashila (Realgar), manjistha,<ref>Baria J, Gupta SK, Bhuyan C. Clinical Study of Manjishthadi Ghrita in Vrana Ropana. AYU. 2011; 32 (1): 95-99.</ref>,<ref>Singh AK, Srivastava PK, Shukla VK. Evaluation of Nimba taila and Manjistha churna in non healing ulcer. International Research Journal of Pharmacy. 2011; 2(5):201-210</ref> lac, haridra and daruharidra used as paste with ghee and honey is an excellent cleanser of skin.

==== Potential areas /Scope for research ====

=== Potential areas /Scope for research ===

The ingredients like bala (Sida cordifolia Linn.), kusa (Desmostachya bipinnata Stapf.), badara (Zizyphus jujube Lam.), trivrit (Operculina turpethum Linn.), karavira (Nerium indicum Mill.), kutaja (Holarrhena antidysentrica Linn.), meda (Polygonatum airrhifolium Royle), mahameda (Polygonatum airrhifolium Royle), murva (Marsdenia tenacissima W. & A.), lajjalu (Mimosa pudica Linn.), gojihva (Onosma bracteatum Wall.), dhataki, ela (Elleteria cardamomum Maton.), aguru (Aquilaria agallocha Roxb.), kakoli (Roscoca procera Wall.), ksirakakoli (Roscoca procera Wall.) are mentioned for wound healing so there is a scope to find out their clinical wound healing effect.

The ingredients like bala (Sida cordifolia Linn.), kusa (Desmostachya bipinnata Stapf.), badara (Zizyphus jujube Lam.), trivrit (Operculina turpethum Linn.), karavira (Nerium indicum Mill.), kutaja (Holarrhena antidysentrica Linn.), meda (Polygonatum airrhifolium Royle), mahameda (Polygonatum airrhifolium Royle), murva (Marsdenia tenacissima W. & A.), lajjalu (Mimosa pudica Linn.), gojihva (Onosma bracteatum Wall.), dhataki, ela (Elleteria cardamomum Maton.), aguru (Aquilaria agallocha Roxb.), kakoli (Roscoca procera Wall.), ksirakakoli (Roscoca procera Wall.) are mentioned for wound healing so there is a scope to find out their clinical wound healing effect.

Charak mentioned some formulations for shodhan (cleansing) and ropan (healing) in this chapter. Along with single drug these formulations need to be further studied for their scientific validation.

Charak mentioned some formulations for shodhan (cleansing) and ropan (healing) in this chapter. Along with single drug these formulations need to be further studied for their scientific validation.

==== ''Shodhana'' (Cleansing) formulations ====

=== ''Shodhana'' (Cleansing) formulations ===

#Decoctions of triphala, khadira (Acasia catechu Willd), daruharidra (Berberis aristata DC), nyagrodhadi group, bala (Sida cordifolia Linn.), kusa (Desmostachya bipinnata Stapf.), leaves of nimb (Azadirachta indica A. Juss) and badara (Zizyphus jujube Lam.) are regarded as cleansing drugs.  

#Decoctions of triphala, khadira (Acasia catechu Willd), daruharidra (Berberis aristata DC), nyagrodhadi group, bala (Sida cordifolia Linn.), kusa (Desmostachya bipinnata Stapf.), leaves of nimb (Azadirachta indica A. Juss) and badara (Zizyphus jujube Lam.) are regarded as cleansing drugs.  

##Powders of barks of kakubha (Termalia arjuna), udumbara, asvattha, lodhra (Symplocos racemosa Roxb), jambu (Eugenia jambolana Lam) and katphala (Myrica esculenta Buch-Ham).

##Powders of barks of kakubha (Termalia arjuna), udumbara, asvattha, lodhra (Symplocos racemosa Roxb), jambu (Eugenia jambolana Lam) and katphala (Myrica esculenta Buch-Ham).

==== Remedies for post healing complications ====

=== Remedies for post healing complications ===

#The paste prepared by bhasmas of iron, kasisa and  triphala (haritaki,vibhitaki and amalaki) flowers provides blackness in the newly formed skin quickly.  

#The paste prepared by bhasmas of iron, kasisa and  triphala (haritaki,vibhitaki and amalaki) flowers provides blackness in the newly formed skin quickly.  

The role of diet is very important in wounded patients which can be considered for further research as Charak mentioned that wounded patients should abstain from salt, sour, pungent, hot, burning and heavy food and drinks and also sexual intercourse.

The role of diet is very important in wounded patients which can be considered for further research as Charak mentioned that wounded patients should abstain from salt, sour, pungent, hot, burning and heavy food and drinks and also sexual intercourse.

=== References ===

== References ==

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