Changes

Now the treatment of the curable varieties of ''visarpa'' will be described.  

Now the treatment of the curable varieties of ''visarpa'' will be described.  

If the ''visarpa'' is caused with ''ama dosha'' (''dosha'' in the state of incomplete transformation) and is located in ''kaphasthana'' (in thorax and upper body parts), then ''langhana'' (fasting therapy), ''vamana'' (emesis) therapy, ''tikta'' (bitter) drugs internally and application of paste of drugs with dry and cold properties externally is beneficial.  

If the ''visarpa'' is caused with ama [[dosha]]([[dosha]] in the state of incomplete transformation) and is located in [[kapha]]sthana (in thorax and upper body parts), then [[langhana]] (fasting therapy), [[vamana]] (emesis) therapy, ''tikta'' (bitter) drugs internally and application of paste of drugs with dry and cold properties externally is beneficial.  

The same treatment should be adopted in case of association of ''ama'' and location in ''pitta sthana'' (abdomen and middle parts of body).  

The same treatment should be adopted in case of association of ''ama'' and location in [[pitta]] sthana (abdomen and middle parts of body).  

In addition, ''raktamokshana'' (blood letting) and ''virechana'' (purgation therapy) are specially indicated.  

In addition, [[rakta]]mokshana (blood letting) and [[virechana]] (purgation therapy) are specially indicated.  

If ''sama'' (with ''ama dosha'') ''visarpa'' is arouse from ''vatashaya'' (pelvis and lower part of body) ununctuous measures are indicated in the beginning. Even in association with ''rakta-pitta'' uncting measure is not regarded as beneficial in the beginning.  

If ''sama'' (with ama [[dosha]]) ''visarpa'' is arouse from ''vatashaya'' (pelvis and lower part of body) ununctuous measures are indicated in the beginning. Even in association with [[rakta]]-[[pitta]] uncting measure is not regarded as beneficial in the beginning.  

In ''vataja visarpa'' and ''paittika visarpa'' of mild aggravated ''dosha tiktaka ghritam'' is beneficial. But if the ''pitta dosha'' is excessively aggravated then ''virechana'' should be given.  

In [[vata]]ja visarpa and paittika visarpa of mild aggravated [[dosha]] tiktaka ghritam is beneficial. But if the [[pitta]] [[dosha]] is excessively aggravated then [[virechana]] should be given.  

In the condition of excessively aggravated ''dosha,'' ghee should not be given at first which does not cause ''virechana''. Because non purgating ghee occlude the ''dosha'' resulting in decomposed skin, flesh and blood. Hence in ''visarpa virechana'' followed by ''raktamokshana'' is recommended because the disorder is located in blood.[43-49]

In the condition of excessively aggravated [[dosha]], ghee should not be given at first which does not cause [[virechana]]. Because non purgating ghee occlude the [[dosha]] resulting in decomposed skin, flesh and blood. Hence in visarpa, [[virechana]] followed by [[rakta]]mokshana is recommended because the disorder is located in blood.[43-49]

=== Formulations used in ''visarpa'' ===

=== Formulations used in ''visarpa'' ===

Thus the treatment principles of ''visarpa'' have been described in brief. The same is being detailed further.  

Thus the treatment principles of ''visarpa'' have been described in brief. The same is being detailed further.  

   

   

In ''kapha pittaja visarpa'', ''vamana'' should be given with the ''madana'' (Randia spinosa), ''madhuka'' (Glycyrrhiza glabra Linn), ''nimba'' (Azadirachta indica), and fruits of ''vatsaka'' (Holarrhena antidysenterica Linn).  

In [[kapha]] [[pitta]]ja visarpa, [[vamana]] should be given with the ''madana'' (Randia spinosa), ''madhuka'' (Glycyrrhiza glabra Linn), ''nimba'' (Azadirachta indica), and fruits of ''vatsaka'' (Holarrhena antidysenterica Linn).  

In ''visarpa vamana'' is beneficial with ''patola'' (Trichosanthes dioica Roxb), ''pichumarda'' (Azadirachta indica), ''pippali'' (Piper longum linn), ''madana'' (Randia spinosa) and ''indrayava'' (Holarrhena antidysenterica Linn).  

In visarpa [[vamana]] is beneficial with ''patola'' (Trichosanthes dioica Roxb), ''pichumarda'' (Azadirachta indica), ''pippali'' (Piper longum linn), ''madana'' (Randia spinosa) and ''indrayava'' (Holarrhena antidysenterica Linn).  

Further, all those formulations which will be described in ''kalpasthana'' in connection with the disorders of ''kapha pitta'' should be used for the patients of ''visarpa'' as well because they are eliminative of morbid ''dosha'' and are beneficial.[50-53]

Further, all those formulations which will be described in ''kalpasthana'' in connection with the disorders of [[kapha]] [[pitta]] should be used for the patients of ''visarpa'' as well because they are eliminative of morbid [[dosha]] and are beneficial.[50-53]

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Physician should administer ''patola patra'' (Trichosanthes dioica Roxb.), ''mudga'' (green gram) and ''amalaki'' juice (Emblica officinalis) mixed with ghee. [54-61]

Physician should administer ''patola patra'' (Trichosanthes dioica Roxb.), ''mudga'' (green gram) and ''amalaki'' juice (Emblica officinalis) mixed with ghee. [54-61]

=== Formulations for ''dosha'' situated in ''koshtha, pitta'' dominant ''visarpa'' and ''virechana'' ===

=== Formulations for [[dosha]] situated in koshtha, [[pitta]] dominant ''visarpa'' and [[virechana]] ===

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''Trayamana ghritam'' of tested efficacy mentioned in the treatment of ''gulma'' should be administered by the brilliant physician to alleviate ''visarpa''.  

''Trayamana ghritam'' of tested efficacy mentioned in the treatment of ''gulma'' should be administered by the brilliant physician to alleviate ''visarpa''.  

The powder of ''trivritta'' (Operculina turpethum Linn) mixed with ghee or milk or hot water or ''mridvika'' (Vitis vinifera Linn) juice should be administered for ''virechana'' and is tested to alleviate ''visarpa'' or ''trayamana'' (Gentiana kurroo) decocted with milk should be given for ''virechana''.  

The powder of ''trivritta'' (Operculina turpethum Linn) mixed with ghee or milk or hot water or ''mridvika'' (Vitis vinifera Linn) juice should be administered for [[virechana]] and is tested to alleviate ''visarpa'' or ''trayamana'' (Gentiana kurroo) decocted with milk should be given for [[virechana]].  

The decoction of ''triphala'' (''Haritaki, Bibhitaki'' and ''Amalaki'') mixed with ghee and ''trivritta'' (Operculina turpethum Linn) and used for ''virechana'' to alleviate ''visarpa'' and ''jwara''.

The decoction of ''triphala'' (''Haritaki, Bibhitaki'' and ''Amalaki'') mixed with ghee and ''trivritta'' (Operculina turpethum Linn) and used for [[virechana]] to alleviate ''visarpa'' and ''jwara''.

   

   

The juice of ''amalaki'' (Emblica officinalis) mixed with ghee should be administered in ''visarpa'' patient of heavy bowel the same preparation mixed with ''trivritta'' (Operculina turpethum Linn) powder is beneficial.  

The juice of ''amalaki'' (Emblica officinalis) mixed with ghee should be administered in ''visarpa'' patient of heavy bowel the same preparation mixed with ''trivritta'' (Operculina turpethum Linn) powder is beneficial.  

When the morbid ''dosha'' are situated in ''kostha'' (internally), these measures should be administered.[62-67]

When the morbid [[dosha]] are situated in ''kostha'' (internally), these measures should be administered.[62-67]

=== Formulations for ''dosha'' situated in ''shakha'' and modes of blood letting ===

=== Formulations for [[dosha]] situated in ''shakha'' and modes of blood letting ===

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If ''dosha'' in ''shakha'' (body elements) vitiate the blood then ''raktamokshana'' should be administered at first. The physician should use ''vishana'' (deer horn) in ''vata'' dominance, ''jalauka'' (Hirudinea medicinalis) in ''pitta'' dominance and ''alabu'' (lagenaria siceraria) in ''kapha'' dominance for blood letting or physician should perform ''siravyadha'' (blood letting through vein) promptly from the adjacent vein to the affected part, without which ''rakta kleda'' (putrifying blood content) gives rise to decomposed skin, flesh and ligaments. [68-70]

If [[dosha]] in ''shakha'' (body elements) vitiate the blood then ''raktamokshana'' should be administered at first. The physician should use ''vishana'' (deer horn) in [[vata]] dominance, ''jalauka'' (Hirudinea medicinalis) in [[pitta]] dominance and ''alabu'' (lagenaria siceraria) in [[kapha]] dominance for blood letting or physician should perform ''siravyadha'' (blood letting through vein) promptly from the adjacent vein to the affected part, without which ''rakta kleda'' (putrifying blood content) gives rise to decomposed skin, flesh and ligaments. [68-70]

=== External applications ===

=== External applications ===

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After the body is cleansed internally (systemic) and morbid ''dosha'' remains in the skin and flesh (external tissues), or ''dosha'' morbidity is little, the external treatment to be carried out will now be described.  

After the body is cleansed internally (systemic) and morbid [[dosha]] remains in the skin and flesh (external tissues), or [[dosha]] morbidity is little, the external treatment to be carried out will now be described.  

The bark of ''udumbara'' (Ficus glomerata), ''madhuka'' (Glycyrrhiza glabra Linn), ''padmakinjalka'' (Prunas cerasoides), ''utpala'' (Nymphaea nouchali), ''nagapuspa'' (Mesua ferrea Linn) and ''priyangu'' (Callicarpa macrophylla) mixed with ghee and applied externally as ''pradeha'' and is beneficial.  

The bark of ''udumbara'' (Ficus glomerata), ''madhuka'' (Glycyrrhiza glabra Linn), ''padmakinjalka'' (Prunas cerasoides), ''utpala'' (Nymphaea nouchali), ''nagapuspa'' (Mesua ferrea Linn) and ''priyangu'' (Callicarpa macrophylla) mixed with ghee and applied externally as ''pradeha'' and is beneficial.  

The bark of ''sirisa'' (Albizzia lebbeck) and ''bala'' (Sida cordifolia Linn) mixed with ghee. ''Nyagrodha'' (Ficus bengalensis Linn), ''udumbar'' (Ficus glomerata), ''plaksha'' (Ficus sycomorus), ''vetas'' (Salix caprea Linn), ''asvattha'' (Ficus religiosa) leaves and bark mixed with ample ghee used as a cold ''alepan'' is beneficial.  

The bark of ''sirisa'' (Albizzia lebbeck) and ''bala'' (Sida cordifolia Linn) mixed with ghee. ''Nyagrodha'' (Ficus bengalensis Linn), ''udumbar'' (Ficus glomerata), ''plaksha'' (Ficus sycomorus), ''vetas'' (Salix caprea Linn), ''asvattha'' (Ficus religiosa) leaves and bark mixed with ample ghee used as a cold ''alepan'' is beneficial.  

All these external applications are beneficial in ''vata pitta'' predominant ''visarpa''.   

All these external applications are beneficial in [[vata]] [[pitta]] predominant ''visarpa''.   

Other external applications useful in ''kapha'' predominant ''visarpa'' will be described here after. ''Triphala'' (''haritaki, bibhitaki'' and ''amalaki''), ''padmaka'' (Prunas cerasoides), ''usir'' (Vetiveria zizanioidis Linn), ''samanga'' (Mimosa pudica), ''karviraka'' (Nerium indicum), root of ''nala'' (Phragmites australis) and ''ananta'' (hemidesmus indicus) should be used externally as a ''pradeha''.  

Other external applications useful in [[kapha]] predominant ''visarpa'' will be described here after. ''Triphala'' (''haritaki, bibhitaki'' and ''amalaki''), ''padmaka'' (Prunas cerasoides), ''usir'' (Vetiveria zizanioidis Linn), ''samanga'' (Mimosa pudica), ''karviraka'' (Nerium indicum), root of ''nala'' (Phragmites australis) and ''ananta'' (hemidesmus indicus) should be used externally as a ''pradeha''.  

''Khadira'' (Acacia catechu), ''saptaparna'' (Alstonia scholaris), ''musta'' (Cyperus rotundus linn), ''aragvadha'' (Cassia fistula Linn), ''dhava'' (Anogeissus latifolia, Wall). ''Kurantaka'' (Lawsonia inermis) and ''devdaru'' (Cedrus deodar) should be applied externally as a ''pradeha''.

''Khadira'' (Acacia catechu), ''saptaparna'' (Alstonia scholaris), ''musta'' (Cyperus rotundus linn), ''aragvadha'' (Cassia fistula Linn), ''dhava'' (Anogeissus latifolia, Wall). ''Kurantaka'' (Lawsonia inermis) and ''devdaru'' (Cedrus deodar) should be applied externally as a ''pradeha''.

''Aragvadha'' leaves (Cassia fistula Linn.) and ''sleshmantak'' bark (Cordia dichotoma), ''indrani shak'' (Vitex negundo Linn), ''kakahva'' (Canvalia gladiata) and ''sirisa'' flowers (Albizia lebbeck Linn.), ''saivala'' (Spirogyra maxima) root of ''nala'' (Phragmites australis), ''veera'' (Pueraria tuberose) and ''gandpriyangu'' (Callicarpa macrophylla),  ''triphala'' (''Haritaki, Bibhitaki'' and ''Amalaki''), ''madhuka'' (Glycyrrhiza glabra Linn), ''prapaundrika'' (nelumbo nucifera), ''hribera'' (Pavonia odorata), bark of ''darvi'' (Berberis aristata), and ''bala'' (Sida cordifolia Linn.) - these should be applied singly, dually or collectively as a ''pradeha''. All these external applications should be mixed with small quantity of ghee.  In ''vata pitta'' predominant condition these preparations should be mixed with profuse quantity of ghee.

''Aragvadha'' leaves (Cassia fistula Linn.) and ''sleshmantak'' bark (Cordia dichotoma), ''indrani shak'' (Vitex negundo Linn), ''kakahva'' (Canvalia gladiata) and ''sirisa'' flowers (Albizia lebbeck Linn.), ''saivala'' (Spirogyra maxima) root of ''nala'' (Phragmites australis), ''veera'' (Pueraria tuberose) and ''gandpriyangu'' (Callicarpa macrophylla),  ''triphala'' (''Haritaki, Bibhitaki'' and ''Amalaki''), ''madhuka'' (Glycyrrhiza glabra Linn), ''prapaundrika'' (nelumbo nucifera), ''hribera'' (Pavonia odorata), bark of ''darvi'' (Berberis aristata), and ''bala'' (Sida cordifolia Linn.) - these should be applied singly, dually or collectively as a ''pradeha''. All these external applications should be mixed with small quantity of ghee.  In [[vata]] [[pitta]] predominant condition these preparations should be mixed with profuse quantity of ghee.

The applications of ''shatdhaut ghrita'' as ''pradeha'' or effuse with cold ghee scum, or cold milk or cold decoction of ''madhuka'' (Glycyrrhiza glabra Linn), or ''panchavalka'' (bark of ''nygrodha, udumbara, asvattha, plaksa'' and ''vetasa''), the physician should use frequently in ''vata, rakta'' and ''pitta'' predominant ''visarpa''.

The applications of ''shatdhaut ghrita'' as ''pradeha'' or effuse with cold ghee scum, or cold milk or cold decoction of ''madhuka'' (Glycyrrhiza glabra Linn), or ''panchavalka'' (bark of ''nygrodha, udumbara, asvattha, plaksa'' and ''vetasa''), the physician should use frequently in [[vata]], [[rakta]] and [[pitta]] predominant ''visarpa''.

The external application mentioned as ''pradeha'' may also be used for sprinkling or for preparation ''ghrita yoga'' or ''churna yoga'' used for dusting in wounds of ''visarpa'', ghee cooked with ''durva'' juice promotes wound healing.

The external application mentioned as ''pradeha'' may also be used for sprinkling or for preparation ''ghrita yoga'' or ''churna yoga'' used for dusting in wounds of ''visarpa'', ghee cooked with ''durva'' juice promotes wound healing.

Thin ''predeha'' should be applied as thick paste repeatedly after removing the previous one, but without washing it.  

Thin ''predeha'' should be applied as thick paste repeatedly after removing the previous one, but without washing it.  

In ''kaphaja visarpa, pradeha'' should be repeatedly applied as thick paste after removing the previous dried paste.

In [[kapha]]ja visarpa, pradeha should be repeatedly applied as thick paste after removing the previous dried paste.

The ''pralepa'' should be prepared as ''kalka'' (micronized paste) and applied of thickness equal to one third of the thumb.  

The ''pralepa'' should be prepared as ''kalka'' (micronized paste) and applied of thickness equal to one third of the thumb.  

The diet regimen helps to alleviate ''visarpa'' is described here after.

The diet regimen helps to alleviate ''visarpa'' is described here after.

In the beginning ''langhana'' (fasting therapy) should be given. There after use of ''mantha'' (roasted flour mixed with water in specific proportion and kept for specific time) is beneficial. The ''mantha'' should be without unctus ingredients and added with honey and sugar. It becomes sweet sour in taste due to mixing of ''dadima'' (Punica granatum Linn.) or ''amalaki'' (Emblica officinalis) and ''parushaka'' or ''mrdvika'' (Vitis vinifera Linn) or ''kharjura'' (Phoenix sylvestris) and boiled water should be used to prepare ''mantha''.  

In the beginning [[langhana]] (fasting therapy) should be given. There after use of ''mantha'' (roasted flour mixed with water in specific proportion and kept for specific time) is beneficial. The ''mantha'' should be without unctus ingredients and added with honey and sugar. It becomes sweet sour in taste due to mixing of ''dadima'' (Punica granatum Linn.) or ''amalaki'' (Emblica officinalis) and ''parushaka'' or ''mrdvika'' (Vitis vinifera Linn) or ''kharjura'' (Phoenix sylvestris) and boiled water should be used to prepare ''mantha''.  

Thereafter linctus made of the flour of roasted barley and ''shali'' rice and mixed with ghee should be given in the form of ''avalehika''. After digestion of ''avalehika'', one should take old ''shali'' rice with soup of green gram or lentils or Bengal gram, soured or not soured with pomegranates and added with ''patola'' (Trichosanthes dioica Roxb) and ''amalaki''. He may also take meat soup of wild animals without ghee and added with ''parushaka'' or ''draksha'' or ''dadima'' or ''amalaki''. Red or white or extra long variety of ''shastika'' rice, which are old, well boiled and residual water should be completely drained, it is beneficial food.  

Thereafter linctus made of the flour of roasted barley and ''shali'' rice and mixed with ghee should be given in the form of ''avalehika''. After digestion of ''avalehika'', one should take old ''shali'' rice with soup of green gram or lentils or Bengal gram, soured or not soured with pomegranates and added with ''patola'' (Trichosanthes dioica Roxb) and ''amalaki''. He may also take meat soup of wild animals without ghee and added with ''parushaka'' or ''draksha'' or ''dadima'' or ''amalaki''. Red or white or extra long variety of ''shastika'' rice, which are old, well boiled and residual water should be completely drained, it is beneficial food.  

The persons who have predominance of ''kapha'' and not suited to rice should be given the preparation of barley or wheat or ''purana shali'' which is suitable.[108-114]

The persons who have predominance of [[kapha]] and not suited to rice should be given the preparation of barley or wheat or ''purana shali'' which is suitable.[108-114]

=== Contra-indications in ''visarpa'' ===

=== Contra-indications in ''visarpa'' ===

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Of these measures, predominantly ''sheeta'' (cool) measures are prescribed in ''pitta'' dominant condition, ''ruksha'' in ''kapha'' dominant condition and ''snigdha'' in ''vata'' dominant condition of ''visarpa''.

Of these measures, predominantly ''sheeta'' (cool) measures are prescribed in [[pitta]] dominant condition, ''ruksha'' in [[kapha]] dominant condition and ''snigdha'' in [[vata]] dominant condition of ''visarpa''.

In ''agni visarpa, vata-pitta'' pacifying measures are beneficial and in ''kardama visarpa'' mostly ''kapha pitta'' alleviating measures should be administered.[116-117]

In agni visarpa, [[vata]]-[[pitta]] pacifying measures are beneficial and in ''kardama visarpa'' mostly [[kapha]] [[pitta]] alleviating measures should be administered.[116-117]

=== Treatment of ''granthi visarpa'' ===

=== Treatment of ''granthi visarpa'' ===

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The ''granthi visarpa'', on inspection is predominant in ''rakta pitta''; the physician experienced in timely management should treat the case with ''rukshana'' (de-oleation), ''langhana'' (lightening therapy), ''seka'' (affusion), and ''pradeha'' (external application) of ''panchavalka, siramoksha'' (blood letting), ''jalauka'' (leech therapy), ''vamana'' (emesis therapy), ''virechana'' (purgation therapy) and ''kashaya- tikta'' (astringent and bitter) ghee preparations.  

The ''granthi visarpa'', on inspection is predominant in [[rakta]] [[pitta]]; the physician experienced in timely management should treat the case with [[rukshana]] (de-oleation), [[langhana]] (lightening therapy), ''seka'' (affusion), and ''pradeha'' (external application) of ''panchavalka, siramoksha'' (blood letting), ''jalauka'' (leech therapy), [[vamana]] (emesis therapy), [[virechana]] (purgation therapy) and ''kashaya- tikta'' (astringent and bitter) ghee preparations.  

After cleansing of body by ''vamana'' and ''virechana, rakta mokshana'' should be administered and the measures alleviating ''vata-kapha'' are beneficial.

After cleansing of body by [[vamana]] and [[virechana]], [[rakta]] mokshana should be administered and the measures alleviating [[vata]]-[[kapha]] are beneficial.

When there is pain in ''granthi visarpa, upanaha'' (hot poultice) of warm and unctuous ''utkarika'' (medicinal pancake) or ''vesavara'' (medicated meat) application on the affected part is beneficial.

When there is pain in ''granthi visarpa, upanaha'' (hot poultice) of warm and unctuous ''utkarika'' (medicinal pancake) or ''vesavara'' (medicated meat) application on the affected part is beneficial.

The warm oil prepared from ''dashamoola'' (roots of ten plants) should be sprinkled on the affected part. Warm ''kustha'' (costus) oil added with ''pakya kshara'' (prepared medicinal alkali) or warm cow’s urine or decoction of ''vata kaphahar'' leaves should be used as affusion on the affected part.

The warm oil prepared from ''dashamoola'' (roots of ten plants) should be sprinkled on the affected part. Warm ''kustha'' (costus) oil added with ''pakya kshara'' (prepared medicinal alkali) or warm cow’s urine or decoction of [[vata]] [[kapha]]hara leaves should be used as affusion on the affected part.

The warm paste of ''ashvagandha'' (Withania somnifera) should be applied as ''pradeha'' on the affected part.  

The warm paste of ''ashvagandha'' (Withania somnifera) should be applied as ''pradeha'' on the affected part.  

The warm paste of dried ''mulaka'' (Raphanus sativus) or bark of ''naktamala'' (Pongamia pinnata) or bark of ''bibhitaka'' (Terminalia bellirica) should be applied externally as a ''lepa'' on the affected part. ''Bala'' (Sida cordifolia Linn), ''nagabala'' (Grewia hirsuta), ''pathya'' (Terminalia chebula), ''bhurjagranthi'' (betula bhojpatra), ''bibhitaka'' (Terminalia bellirica), ''vamsha'' leaves (bambusa vulgaris) and ''agnimantha'' (Premna mucronata) should be applied as ''pralepa'' on ''granthi''.

The warm paste of dried ''mulaka'' (Raphanus sativus) or bark of ''naktamala'' (Pongamia pinnata) or bark of ''bibhitaka'' (Terminalia bellirica) should be applied externally as a ''lepa'' on the affected part. ''Bala'' (Sida cordifolia Linn), ''nagabala'' (Grewia hirsuta), ''pathya'' (Terminalia chebula), ''bhurjagranthi'' (betula bhojpatra), ''bibhitaka'' (Terminalia bellirica), ''vamsha'' leaves (bambusa vulgaris) and ''agnimantha'' (Premna mucronata) should be applied as ''pralepa'' on ''granthi''.

''Danti'' (Baliospermum montanum), bark of ''chitraka'' root (Plumbago zeylanica Linn), latex of ''snuhi'' (Euphoria nerrifolia) and ''arka'' (Calatropis gigantean), jaggery, seed of ''bhallataka'' (Semecarpus anacardium linn) and ''kasisa'' (green vitriol) application as a ''lepa'' breaks even a stone, then what to speak of the nodules caused by ''kapha'' and situated in external regions of body. Long standing ''granthi'' should be broken by the use of the internal medications such as ''Yusha'' of ''mulaka'' (Raphanus sativus) and ''kullatha'' (Macrotyloma uniflorum.) added with ''kshara'' (prepared alkali) and ''dadima'' (Punica granatum), food prepared from ''godhum'' and ''yava'' with ''sidhu'', honey and sugar, ''varuni'' scum with honey and ''matulung'' juice (Citrus medica), use of ''triphala'' with ''pippali'' (Piper longum linn) and honey, ''musta'' (Cyperus rotundus linn) or ''bhallataka saktu'' (Semecarpus anacardium linn) and honey, ''devadaru'' (Cedrus deodara), ''guduchi'' (Tinospora cordifolia) and ''girija'' (Asphaltum punjabianum).

''Danti'' (Baliospermum montanum), bark of ''chitraka'' root (Plumbago zeylanica Linn), latex of ''snuhi'' (Euphoria nerrifolia) and ''arka'' (Calatropis gigantean), jaggery, seed of ''bhallataka'' (Semecarpus anacardium linn) and ''kasisa'' (green vitriol) application as a ''lepa'' breaks even a stone, then what to speak of the nodules caused by [[kapha]] and situated in external regions of body. Long standing ''granthi'' should be broken by the use of the internal medications such as ''Yusha'' of ''mulaka'' (Raphanus sativus) and ''kullatha'' (Macrotyloma uniflorum.) added with ''kshara'' (prepared alkali) and ''dadima'' (Punica granatum), food prepared from ''godhum'' and ''yava'' with ''sidhu'', honey and sugar, ''varuni'' scum with honey and ''matulung'' juice (Citrus medica), use of ''triphala'' with ''pippali'' (Piper longum linn) and honey, ''musta'' (Cyperus rotundus linn) or ''bhallataka saktu'' (Semecarpus anacardium linn) and honey, ''devadaru'' (Cedrus deodara), ''guduchi'' (Tinospora cordifolia) and ''girija'' (Asphaltum punjabianum).

''Dhuma, shirovirechana,'' measures described to break the ''gulma'' in [[Gulma Chikitsa]] chapter, as well as iron, salt, stone, gold and copper should be used for ''prapidana'' (compression) of ''granthi''.

''Dhuma, shirovirechana,'' measures described to break the ''gulma'' in [[Gulma Chikitsa]] chapter, as well as iron, salt, stone, gold and copper should be used for ''prapidana'' (compression) of ''granthi''.

If ''granthi'' is strong, firm and stony hard and not responding to all these proven methods of treatment then it is better to be cauterized with ''kshara'' (medicinal alkali) or hot metal arrow or hot gold or after making it suppurate by applying suitable suppurative medications one should open and extract.  

If ''granthi'' is strong, firm and stony hard and not responding to all these proven methods of treatment then it is better to be cauterized with ''kshara'' (medicinal alkali) or hot metal arrow or hot gold or after making it suppurate by applying suitable suppurative medications one should open and extract.  

Besides, vitiated blood should be eliminated, frequently followed administration of ''vata'' and ''kapha'' pacifying medicines, ''dhuma'' (fumigation therapy), ''shirovechana'' (errhine therapy), ''swedana'' (sudation) and ''parimardana'' (pressure method). If ''dosha'' do not pacify, ''pachana'' (suppuration) treatment is beneficial. When the ''granthi'' is decomposed with ''agni'' and suppuration then physician should treat it with external and internal ''shodhana'' (cleansing) and ''ropana'' (healing) as described in ''Vrana Chikitsa''.

Besides, vitiated blood should be eliminated, frequently followed administration of [[vata]] and [[kapha]] pacifying medicines, ''dhuma'' (fumigation therapy), ''shirovechana'' (errhine therapy), [[swedana]](sudation) and ''parimardana'' (pressure method). If [[dosha]] do not pacify, [[pachana]] (suppuration) treatment is beneficial. When the ''granthi'' is decomposed with ''agni'' and suppuration then physician should treat it with external and internal ''shodhana'' (cleansing) and ''ropana'' (healing) as described in ''Vrana Chikitsa''.

''Kampillaka'' (Mallotus philippinensis), ''vidanga'' (Embelia ribes Burm), ''daruharidra'' (Berberis aristata) and ''karanja'' fruit (Pongamia pinnata), the paste of all these drugs should be used to prepare oil which is indicated in the treatment of ''granthi vrina''.

''Kampillaka'' (Mallotus philippinensis), ''vidanga'' (Embelia ribes Burm), ''daruharidra'' (Berberis aristata) and ''karanja'' fruit (Pongamia pinnata), the paste of all these drugs should be used to prepare oil which is indicated in the treatment of ''granthi vrina''.

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</div></div>

The line of treatment of ''granthi'' should be applied for the treatment of ''kaphaja galganda''.  

The line of treatment of ''granthi'' should be applied for the treatment of [[kapha]]ja galganda''.  

The ''vatika galaganda'' associated with ''kapha'' may be cured by regular use of ghee, milk and decoction preparations.[139-140]

The ''vatika galaganda'' associated with [[kapha]] may be cured by regular use of ghee, milk and decoction preparations.[139-140]

=== Importance of ''raktamokshana'' in ''visarpa'' ===

=== Importance of ''raktamokshana'' in ''visarpa'' ===

If all the therapeutic measures described here as curative of ''visarpa'' be put on one side and ''raktamokshana'' on other, they will be found equal.  

If all the therapeutic measures described here as curative of ''visarpa'' be put on one side and ''raktamokshana'' on other, they will be found equal.  

''Visarpa'' never occurs without the association of the ''rakta'' and ''pitta'' hence entirely general treatment has been described. It does not mean that line of treatment as per other ''dosha'' predominance is not explained here. Thus, the therapeutic measures both in general and specific cases are described both in brief and in detail. The expert physician should administer these therapies appropriately.[141-143]

''Visarpa'' never occurs without the association of the [[rakta]] and [[pitta]] hence entirely general treatment has been described. It does not mean that line of treatment as per other [[dosha]] predominance is not explained here. Thus, the therapeutic measures both in general and specific cases are described both in brief and in detail. The expert physician should administer these therapies appropriately.[141-143]

=== Summary ===

=== Summary ===

Now the summing up verses –

Now the summing up verses –

Derivation,synonyms, classification, ''dosha, dushya,'' etiology, the habitat, the severe and mild gradation, symptoms and signs, complications, the nature of complications, prognosis and treatment of curable ones. All these aspects has been explained by Punarvasu Atreya for the inquisitive and intelligent Agnivesha under the treatment of ''visarpa''. [144-146]

Derivation,synonyms, classification, [[dosha]], dushya, etiology, the habitat, the severe and mild gradation, symptoms and signs, complications, the nature of complications, prognosis and treatment of curable ones. All these aspects has been explained by Punarvasu Atreya for the inquisitive and intelligent Agnivesha under the treatment of ''visarpa''. [144-146]

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== Tattva Vimarsha (Fundamental Principles) ==  

== Tattva Vimarsha (Fundamental Principles) ==  

*Seven elements are involved in the pathogenesis of ''visarpa'' viz., ''rakta, lasika, tvak, mamsa, vata, pitta'' and ''kapha''.  

*Seven elements are involved in the pathogenesis of ''visarpa'' viz., [[rakta]], lasika, tvak, [[mamsa dhatu]], [[vata]], [[pitta]] and [[kapha]].  

*''Visarpa'' is acute spreading disease and fatal in nature. General etiological factors of ''visarpa'' are diet and life style related, injury, poisons, toxins, burns etc., some of these cause vitiation of ''dosha'' and ''khavaigunya'' (disease prone condition) in ''dhatu'' and some cause direct vitiation of ''dosha'' and ''dhatu'' leading to ''visarpa''. Hence favorable condition for infection or disease phenomenon occurs at first therefore, diet and lifestyle related factors are important preventive measures.

*''Visarpa'' is acute spreading disease and fatal in nature. General etiological factors of ''visarpa'' are diet and life style related, injury, poisons, toxins, burns etc., some of these cause vitiation of [[dosha]] and ''khavaigunya'' (disease prone condition) in [[dhatu]] and some cause direct vitiation of [[dosha]] and [[dhatu]] leading to ''visarpa''. Hence favorable condition for infection or disease phenomenon occurs at first therefore, diet and lifestyle related factors are important preventive measures.

*Excess intake of salt, sour, pungent, hot articles lead to vitiation of ''rakta'' first and then lead to ''visarpa''.  

*Excess intake of salt, sour, pungent, hot articles lead to vitiation of [[rakta]] first and then lead to ''visarpa''.  

*''Visarpa'' is manifested externally, internally or in both pathways. Severity of disease increases respectively in these cases.  

*''Visarpa'' is manifested externally, internally or in both pathways. Severity of disease increases respectively in these cases.  

*Classification and pathogenesis of ''visarpa'' is based upon involvement of ''dosha'' as per their severity. Treatment protocol is designed for primarily involved predominant ''dosha''. If the ''visarpa'' is caused with ''ama dosha'' (the state of incomplete transformation) and is located in ''kaphasthana'' (in thorax and upper body parts), then ''langhana'' (fasting therapy), ''vamana'' (emesis) therapy, ''tikta'' (bitter) drugs internally and application of paste of drugs with dry and cold properties externally is beneficial.  

*Classification and pathogenesis of ''visarpa'' is based upon involvement of [[dosha]] as per their severity. Treatment protocol is designed for primarily involved predominant [[dosha]]. If the ''visarpa'' is caused with ama dosha (the state of incomplete transformation) and is located in ''kaphasthana'' (in thorax and upper body parts), then [[langhana]] (fasting therapy), [[vamana]] (emesis) therapy, ''tikta'' (bitter) drugs internally and application of paste of drugs with dry and cold properties externally is beneficial.  

*The same treatment should be adopted in case of association of ''ama'' and location in ''pitta sthana'' (abdomen and middle parts of body). In addition, ''raktamokshana'' (blood letting) and ''virechana'' (therapeutic purgation therapy) are specially indicated.  

*The same treatment should be adopted in case of association of ''ama'' and location in [[pitta]] sthana (abdomen and middle parts of body). In addition, ''raktamokshana'' (blood letting) and [[virechana]] (therapeutic purgation therapy) are specially indicated.  

*If ''sama'' (with ''ama dosha'') ''visarpa'' occurs from ''vatashaya'' (pelvis and lower part of body) dry measures are indicated in the beginning. Even in association with ''rakta-pitta'', unction measure is not regarded as beneficial in the beginning.  

*If ''sama'' (with ''ama dosha'') ''visarpa'' occurs from ''vatashaya'' (pelvis and lower part of body) dry measures are indicated in the beginning. Even in association with [[rakta]]-[[pitta]], unction measure is not regarded as beneficial in the beginning.  

*In ''vataja visarpa'' and ''paittika visarpa'' of mild aggravated ''dosha, tiktaka ghritam'' is beneficial. But if the ''pitta dosha'' is excessively aggravated then ''virechana'' should be given.  

*In [[vata]]ja visarpa and ''paittika visarpa'' of mild aggravated [[dosha]], tiktaka ghritam'' is beneficial. But if the [[pitta]] [[dosha]] is excessively aggravated then [[virechana]] should be given.  

*In the condition of excessively aggravated ''dosha'', ghee should not be given at first, which does not cause ''virechana''. Because non purgating ghee occlude the ''dosha'' resulting in decomposed skin, flesh and blood. Hence in ''visarpa, virechana'' followed by ''raktamokshana'' is recommended because the disorder is located in blood.

*In the condition of excessively aggravated [[dosha]], ghee should not be given at first, which does not cause [[virechana]]. Because non purgating ghee occlude the [[dosha]] resulting in decomposed skin, flesh and blood. Hence in ''visarpa, virechana'' followed by ''raktamokshana'' is recommended because the disorder is located in blood.

*If ''dosha'' in ''shakha'' (body elements) vitiate the blood, then ''raktamokshana'' should be administered first. The physician should use ''vishana'' (deer horn) in ''vata'' dominance, ''jalauka'' (Hirudinea medicinalis) in pitta dominance and ''alabu'' (lagenaria siceraria) in ''kapha'' dominance for blood letting or physician should perform ''siravyadha'' (blood letting through vein) promptly from the adjacent vein to the affected part, without which ''rakta kleda'' (putrifying blood content) gives rise to decomposed skin, flesh and ligaments.

*If [[dosha]] in ''shakha'' (body elements) vitiate the blood, then [[rakta]]mokshana should be administered first. The physician should use ''vishana'' (deer horn) in [[vata]] dominance, ''jalauka'' (Hirudinea medicinalis) in [[pitta]] dominance and ''alabu'' (lagenaria siceraria) in [[kapha]] dominance for blood letting or physician should perform ''siravyadha'' (blood letting through vein) promptly from the adjacent vein to the affected part, without which ''rakta kleda'' (putrifying blood content) gives rise to decomposed skin, flesh and ligaments.

*External application in the form of ''pralepa, pradeha'' and ''alepana'' (local applications of pastes) are to be used repeatedly for treatment of external lesions in ''visarpa''. The guidelines shall be followed for local applications.  

*External application in the form of ''pralepa, pradeha'' and ''alepana'' (local applications of pastes) are to be used repeatedly for treatment of external lesions in ''visarpa''. The guidelines shall be followed for local applications.  

*Diet articles with sweet, bitter, cooling and blood pacifying properties is prescribed in the treatment of ''visarpa''.

*Diet articles with sweet, bitter, cooling and blood pacifying properties is prescribed in the treatment of ''visarpa''.

*''Vidahi'' (that causes burning) and ''viruddha'' (mutually contradictory or incompatible) diet, day sleep, anger, exercise, exposure to sun heat, fire and fast winds are contraindicated in ''visarpa''.

*''Vidahi'' (that causes burning) and ''viruddha'' (mutually contradictory or incompatible) diet, day sleep, anger, exercise, exposure to sun heat, fire and fast winds are contraindicated in ''visarpa''.

*Predominantly ''shita'' (cool) measures are prescribed in ''pitta'' dominant condition, ''ruksha'' in ''kapha'' dominant condition and ''snigdha'' in ''vata'' dominant condition of ''visarpa''. In ''agni visarpa, vata-pitta'' pacifying measures are beneficial and in ''kardama visarpa'' mostly ''kapha pitta'' alleviating measures should be administered.

*Predominantly ''shita'' (cool) measures are prescribed in [[pitta]] dominant condition, ''ruksha'' in [[kapha]] dominant condition and ''snigdha'' in [[vata]] dominant condition of ''visarpa''. In ''agni visarpa, [[vata]]-[[pitta]] pacifying measures are beneficial and in ''kardama visarpa'' mostly [[kapha]] [[pitta]] alleviating measures should be administered.

*The ''granthi visarpa'', on inspection is predominant in ''rakta pitta'', the physician experienced in timely management should treat the case with ''rukshana'' (de-oleation), ''langhana'' (lightening therapy), ''seka'' (affusion), and ''pradeha'' (external application) of ''panchavalka, siramoksha'' (blood letting), ''jalauka'' (leech therapy), ''vamana'' (emesis therapy), ''virechana'' (purgation therapy) and ''kashaya- tikta'' (astringent and bitter) ghee preparations. After cleansing of body by ''vamana'' and ''virechana, rakta mokshana'' should be administered and the measures alleviating ''vata-kapha'' are beneficial.

*The ''granthi visarpa'', on inspection is predominant in [[rakta]] [[pitta]], the physician experienced in timely management should treat the case with [[rukshana]] (de-oleation), [[langhana]] (lightening therapy), ''seka'' (affusion), and ''pradeha'' (external application) of ''panchavalka, siramoksha'' (blood letting), ''jalauka'' (leech therapy), [[vamana]] (emesis therapy), [[virechana]] (purgation therapy) and ''kashaya- tikta'' (astringent and bitter) ghee preparations. After cleansing of body by [[vamana]] and [[virechana]], [[rakta]] mokshana should be administered and the measures alleviating [[vata]]-[[kapha]] are beneficial.

*The same line of treatment of ''granthi'' should be applied for the treatment of ''kaphaja galganda''. The ''vatika galaganda'' associated with ''kapha'' may be cured by regular use of ghee, milk and decoction preparations.

*The same line of treatment of ''granthi'' should be applied for the treatment of [[kapha]]ja galganda''. The ''vatika galaganda'' associated with [[kapha]] may be cured by regular use of ghee, milk and decoction preparations.

== Vidhi Vimarsha (Applied Inferences ) ==

== Vidhi Vimarsha (Applied Inferences ) ==

=== Causative factors of ''visarpa'' in contemporary era ===

=== Causative factors of ''visarpa'' in contemporary era ===

Modern point of view ''visarpa'' is generally caused by a variety of infections. As per Punarvasu Atreya, the general etiological factors of ''visarpa'' are diet and lifestyle, injury, poisons, toxins, burns etc; some of these cause vitiation of ''dosha'' and ''khavaigunya'' (disease prone condition) in ''dhatu'' and some cause direct vitiation of ''dosha'' and ''dhatu'' leading to ''visarpa''. This is confusing to the new scholars. Atreya's understanding of etiology is more specific because favorable condition for infection occurs at first then infection therefore diet and lifestyle related factors are described in detail and in the beginning. In treatment plan this concept of favorable environment should be considered. Change in internal body environment is possible by ''shodhana'' therapy and ''aushadha'' along with treatment of infection.  

Modern point of view ''visarpa'' is generally caused by a variety of infections. As per Punarvasu Atreya, the general etiological factors of ''visarpa'' are diet and lifestyle, injury, poisons, toxins, burns etc; some of these cause vitiation of [[dosha]] and ''khavaigunya'' (disease prone condition) in [[dhatu]] and some cause direct vitiation of [[dosha]] and [[dhatu]] leading to ''visarpa''. This is confusing to the new scholars. Atreya's understanding of etiology is more specific because favorable condition for infection occurs at first then infection therefore diet and lifestyle related factors are described in detail and in the beginning. In treatment plan this concept of favorable environment should be considered. Change in internal body environment is possible by ''shodhana'' therapy and ''aushadha'' along with treatment of infection.  

=== Pathophysiology of ''Visarpa'' [flow chart] ===

=== Pathophysiology of ''Visarpa'' [flow chart] ===

''Paittika visarpa'' symptoms are suggestive of severe skin disease (erysipelas, extensive herpes, burns etc.) and are curable with appropriate management.  

''Paittika visarpa'' symptoms are suggestive of severe skin disease (erysipelas, extensive herpes, burns etc.) and are curable with appropriate management.  

''Kaphaja visarpa'' appears as progressively but gradually spreading ailment, suggestive of acute skin infection (erysipelas etc.) and is curable.  

[[Kapha]]ja visarpa appears as progressively but gradually spreading ailment, suggestive of acute skin infection (erysipelas etc.) and is curable.  

''Agni visarpa'' is a serious infection of skin and lead to septicemia like condition. ''Agnivisarpa'' with the signs and symptoms described here is a serious ailment and is incurable. This ailment may be cured if vitals are not involved.  

''Agni visarpa'' is a serious infection of skin and lead to septicemia like condition. ''Agnivisarpa'' with the signs and symptoms described here is a serious ailment and is incurable. This ailment may be cured if vitals are not involved.  

==== Evidence based studies ====

==== Evidence based studies ====

''Visarpa'' is acute and fatal in nature and maximum [[Ayurveda]] hospitals have limited facilities for emergency managements. Some of clinicians are treating self limiting minor cases of herpes as a ''visarpa'' following the treatment of ''pittaja visarpa''. A case study on effect of Ayurvedic management in oro-facial herpes was conducted. The diagnosed case of oro-facial herpes in 72-year-old male patient  was treated with medicines of bitter taste (tikta rasa) internally, diet regimen, anulomana variety of therapeutic purgation (virechana) and topical application of cold (sheeta)-dry(ruksha) medicines(lepa). The case is observed symptom free after a total period of 164 days.<ref>Mutnali K, Roopa BJ, Shivaprasad T, Yadav R. Ayurveda management of oro-facial herpes: a case report. J Ayurveda Integr Med. 2020 Jul-Sep;11(3):357-359. doi: 10.1016/j.jaim.2020.06.003. Epub 2020 Aug 4. PMID: 32768346; PMCID: PMC7527852.</ref>

''Visarpa'' is acute and fatal in nature and maximum [[Ayurveda]] hospitals have limited facilities for emergency managements. Some of clinicians are treating self limiting minor cases of herpes as a ''visarpa'' following the treatment of [[pitta]]ja visarpa. A case study on effect of Ayurvedic management in oro-facial herpes was conducted. The diagnosed case of oro-facial herpes in 72-year-old male patient  was treated with medicines of bitter taste (tikta rasa) internally, diet regimen, anulomana variety of therapeutic purgation (virechana) and topical application of cold (sheeta)-dry(ruksha) medicines(lepa). The case is observed symptom free after a total period of 164 days.<ref>Mutnali K, Roopa BJ, Shivaprasad T, Yadav R. Ayurveda management of oro-facial herpes: a case report. J Ayurveda Integr Med. 2020 Jul-Sep;11(3):357-359. doi: 10.1016/j.jaim.2020.06.003. Epub 2020 Aug 4. PMID: 32768346; PMCID: PMC7527852.</ref>

=== Researches done on ''visarpa'' ===

=== Researches done on ''visarpa'' ===

#Vagbhata, Ashtanga Hridyam ,Cikitsa Sthana,18. Visarpa chikitsitam Adhyaya .Translated to English by Prof. K.R. Shrikanth Murthy,  7 th ed., Vol. 1. Varanasi: Chaukhambha Krishnadas Academy; 2010. p. 221.   

#Vagbhata, Ashtanga Hridyam ,Cikitsa Sthana,18. Visarpa chikitsitam Adhyaya .Translated to English by Prof. K.R. Shrikanth Murthy,  7 th ed., Vol. 1. Varanasi: Chaukhambha Krishnadas Academy; 2010. p. 221.   

#Vagbhata,Ashtanga Hridyam , Nidana Sthana, Chap 13 Pandurogasophavisarpa Nidana.Translated by Prof. K.R. Shrikanth Murthy, 7 th ed., Vol. 1. Varanasi: Chaukhambha Krishnadas Academy; 2010. p. 221. </div>

#Vagbhata,Ashtanga Hridyam , Nidana Sthana, Chap 13 Pandurogasophavisarpa Nidana.Translated by Prof. K.R. Shrikanth Murthy, 7 th ed., Vol. 1. Varanasi: Chaukhambha Krishnadas Academy; 2010. p. 221. </div>

== References ==  

== References ==