Vishnumaya PDF

A CLINICAL STUDY ON PARISEKA VIDHI IN THE
MANAGEMENT OF DUSTA VRANA

WITH ARAGWADHA KASHAYA
By
VISHNUMAYA B.A.M.S.
Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka Bangalore
In partial fulfillment of the requirements for the degree of
MASTER OF SURGERY (AYU)

In
SHALYA TANTRA
Under the Guidance of
Dr.DEENAPRAKASH BHARADWAJ M.D. (AYU)
Professor
Department Of Post Graduate Studies in Shalya Tantra

K.V.G. Ayurveda Medical College,
Sullia - 574327
2010
Rajiv Gandhi University of Health Sciences
Karnataka, Bangalore
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled “A CLINICAL STUDY

ON PARISEKA VIDHI IN THE MANAGEMENT OF DUSTHA VRANA WITH
ARAGWADHA KASHYA” is a bona fide and genuine research work carried out
by me under the guidance of Dr.DEENAPRAKASH BHARADWAJ M.D.(Ayu),
Professor, Dept. of Post Graduate Studies in Shalya Tantra, K.V.G. AYURVEDA

MEDICAL COLLEGE, Sullia.
Date: 25-11-2010 VISHNUMAYA
Place: Sullia
i
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled “A CLINICAL STUDY ON
PARISEKA VIDHI IN THE MANAGEMENT OF DUSTHA VRANA WITH
ARAGWADHA KASHAYA” is a bona fide research work done by VISHNUMAYA
in partial fulfillment of the requirement for the degree of MASTER OF
SURGERY (AYU), under my guidance.
Date: 25-11-2010 DR. DEENAPRAKASH BHARADWAJ

M.D. (AYU)
Place: Sullia Professor,
Department of Post Graduate Studies in
Shalya Tantra,
K.V.G. Ayurveda Medical College, Sullia.
ii
ENDORSEMENT BY THE H.O.D, PRINCIPAL / HEAD OF
THE INSTITUTION
This is to certify that the dissertation entitled “A CLINICAL STUDY

ON PARISEKA VIDHI IN THE MANAGEMENT OF DUSTHA VRANA
WITH ARAGWADHA KASHYA” is a bona fide research work done by
VISHNUMAYA under the guidance of Dr. DEENAPRAKASH BHARDWAJ
M.D.(Ayu), Professor, K.V.G. AYURVEDA MEDICAL COLLEGE, SULLIA.
DR.DEENA PRAKASH BHARADWAJ DR. N. S.SHETTAR
Professor & Head of the Department Principal
Department of Post Graduate Studies in K.V.G. Ayurveda

Shalya Tantra, Medical College, Sullia.
K.V.G. Ayurveda Medical College, Sullia.
Date: 25-11-2010 Date: 25-11-2010
Place: Sullia Place: Sullia
iii
COPYRIGHT
Declaration by the Candidate
I hereby declare that the Rajiv Gandhi University of Health Sciences,
Karnataka, shall have the rights to preserve, use and disseminate this
dissertation / thesis in print or electronic format for academic / research
purpose.
Date: 25-11-2010
Place: Sullia VISHNUMAYA
© Rajiv Gandhi University of Health Sciences, Karnataka
iv
Dedicated to
My Beloved Parents
and
Revered Teachers
v
ACKNOWLEDGEMENT
I pay obeisance to the feet of Almighty with whose shower of blessings this task has
ventured without any hindrances.
I would like to dedicate this work to my parents. My father, Bhargavan Pillai, who
guided me well to stay focused and achieve my goals. My mother, Saraswathy , who knows
me better than myself, inspired to be a better person. My brother in law Satheesh, my sister
Smitha and also Arun Kumar without their moral support, it is inconceivable to complete
this work.
I whole heartedly thank Dr. Kurunji Venkataramana Gowda, Founder, K.V.G.
Academy Of Liberal educations for giving me an opportunity to study in this institution.
I express my deepest gratitude to my revered teacher and guide Dr Deena Prakash
Bharadwaj Prof, Dept. Of Shalyatantra, K.V.G.A.M.C,Sullia who has guided me
throughout my research work. I offer my sincere thanks for his scholarly guidance in carrying
out this research work.
This thesis would have never attained its present form without the valuable
suggestions provided by Dr. Udayashanker, Prof Dept. Of Shalyatantra, Dr.Mohanlal
(Professor), Dr. G.K.Prasad (Professor) and Dr. Harshavardhana (Lecturer), Dept. of Shalya
tantra, K.V.G.A.M.C,Sullia
I avail this opportunity to thank Dr N. S. Shettar, Principal, K.V.G.A.M.C. for
evincing keen interest in my endeavors and for continued encouragement.
I express my deep gratitude to my respected teachers Dr Krishnaprakash, Dr Asok,
Dr Rohini Bharadwaj, Dr Rajasekar, Dr Leeledhar, Dr. Sanathkumar, Dr. Purushotham,
Dr Chetan, Dr. Hari Prasad and all the teaching staff for their Support and encouragement.
I express my gratitude to Dr. Gururaj, and Dr. Ashwini, Dr. Geetha kumary my
previous co- Guide for their valuable suggestions.
I am very much thankful to my classmates, juniors and friends for their help and
support.
I thank Dr.Archana A.R., Dr.Jayanthi C.K .for the valuable suggestions in the clinical
study.
I express my sincere and deep gratitude to Mr. Midhun.N.N for his wholehearted
encouragement as well as providing all necessary facilities for the statistical work.
It is my duty to thank the para-medical and non-teaching staff of K.V.G.A.M.C and
my patients for their kind co-operation whose total support made me to complete this work
successfully. I thank the library staff for timely help.
I also remember the affectionate help received from my teachers and friends of
S.J.S.A.C. Chennai. who has inspired me the ability to pursue my academic career.
I express my deep gratitude to all the members of my family for their affection and
benediction, which were intuitive during the entire phase of study.
Last but not least I express my sincere thanks whose names are not taken here
but who have helped me a lot.
Dr VISHNUMAYA
LIST OF ABBREVIATIONS USED
A.H – Ashtanga Hrudaya
A.S – Ashtanga Samgraha
B.P – Bhavaprakasha
B.S – Bhela Samhita
C.D _ Chakra datta
C.S – Charaka Samhita
G.N _ Gada Nigraha
H.S _ Haritha Samhitha
M.N – Madhava Nidana
S.S – Sushruta Samhita
V.S – Vangasena
ABSTRACT
Back ground: In the day-to-day surgical practice we are facing problems in treating Dustha
vrana effectively in spite of the modernized facilities.
Objectives: To evaluate the effect of Aragwadha kwatha Pariseka in the management of

Dustha vrana.
Methods: 30 diagnosed case of Dustha vrana are selected for study and recorded through the
proforma designed for single group of observational study .
Results: Middle aged males of low income group are the highest sufferers. Aragwadha kwatha
reduced the intensity of Pancha lakshna , with statistically significant proof.
Interpretation: Aragwadha kwatha has Tridosa shamaka property. It has both Shodhana and
Ropana property it also shows significant Sotha hara property.
Probably due to the above properties it hastens the wound healing process which helps in
reduction of wound size.
Conclusion: Argwadha kwatha reduces the symptoms of Dustha vrana by its Shodhana and
Ropana properties. Time taken for Sodhana of Dustha vrana is approximately one to one and half
week and time taken for Ropana is approximately 2-3 weeks.
Key words: Dustha vrana , Aragwadha kwatha , Pariseka , Shodhana , Ropana , Shotha hara.

INDEX
SL.NO CONTENTS PAGE.NO
1 INTRODUCTION 1-2
2 OBJECTIVES 3
3 REVIEW OF LITERATURE 4-61
4 CLINICAL STUDY 62-67
5 OBSERVATION AND RESULTS 68-84
6 DISCUSSION 85-90
7 CONCLUSION 91
8 SUMMARY 92
9 BIBLIOGRAPHIC REFERENCES 93-99
10 ANNEXURE 100-109

LIST OF TABLES
Table Page
Description
No. No.
1. Nidana of Vrana 7
2. Vrana vastu 8
3. Vrana Sthaana and its Lakshanas Acc. to Maadhavakara 8
4. Lakshanas of Vrana as per doshic predominance 10
5. Lakshanas of Dvandvaja, Tridoshaja and Sannipataja Vrana 11
6. Classification of Agantuja Vrana 12
7. Agantuja Vrana based on shape and severity of injury 13
8. Lakshana of Suddha Vrana 14
9. Lakshanas of Dushta Vrana 15-16
10. Charaka’s classification of Vrana 17
11. Vrana Varna 18
12. Vrana gandha according to Sushrutha 18
13. Vrana ganda according to Charaka 19
14. Vrana srava according to Sushrutha 19
15. Vrana srava according to Charaka 20
16. Asadhyata according to Sthana 20
17. Vrana Vedana 20
18. Vranithasya upadrava 21

19. Principal treatment of Vrana 25-27
20. Distribution of 30 patients of Dushta vrana according to age 68
21. Distribution of 30 patients of of Dushta vrana according to sex 69
22. Distribution of 30 patients of Dushta vrana according to religion 70
23. Distribution of 30 patients of Dustha vrana according to occupation 71
24. Distribution of 30 patients of Dustha vrana according to socioeconomic 72
status
25. Distribution of 30 patients of Dustha vrana based on their Addictions 73
26. Distribution of 30 patients of Dustha vrana according to Diet habit 74
27. Distribution of 30 patients of Dustha vrana based on its Chronicity 75
28. Distribution of 30 patients of Dustha vrana based on their part affected 76
29. Treatment Effect of Aragwadha kwatha Pariseka on Ruja 77
30. Treatment Effect of Aragwadha Kwatha Pariseka on Daha 77
31. Treatment Effect of Aragwadha Kwatha Pariseka on Kandu 78
32. Treatment Effect of Aragwadha Kwatha Pariseka on Thodam 78
33. Treatment Effect Of Aragwadha Kwatha Pariseka On Sravam 79
34. Treatment effect of aragwadha Kwatha pariseka on Gandha 79
35. Treatment effect of aragwadha Kwatha pariseka on Akruthi 80
36. Assessment of Total Effect of Therapy 67
37. Over all effect of Aragwadha Kwatha Pariseka 80

LIST OF FIGURES
No. Description
1 Aragwadha twak
2 Dushta vrana picture
3 Parts of an Ulcer
4 Types of Edges
LIST OF GRAPHS
Graph Description Page
No. No.
1. Distribution of 30 patients of Dustha Vrana according to age 68
2. Distribution of 30 patients of Dustha Vrana according to sex 69
3. Distribution of 60 patients of Arshas according to religion 70
Distribution of 30 patients of Dustha Vrana according to
4. occupation 71
Distribution of 30 patients of Dustha Vrana According to socio
5. economic status 72
Distribution of 30 patients of Dustha Vrana based on their
6. addiction 73
7. Distribution of 30 patients of Dustha Vrana based on their diet 74
Distribution of 30 patients of Dustha Vrana based on their
8. Chronicity. 75
Distribution of 30 patients of Dustha Vrana based on their part
9. affected 76
10. Treatment effect of Aragwadha Kwatha on Ruja 81
11. Treatment effect of Aragwadha Kwatha on Daha 81
12. Treatment effect of Argwadha Kwatha on Kandu 81
13. Treatment effect of Aragwadha Kwatha on Thodam 82

14. Treatment effect of Aragwadha Kwatha on Srava 82
15. Treatment effect of Aragwadha Kwatha on Gandha 83
16. Treatment effect of Aragwadha Kwatha on Size 83
17. Over all effect of Aragwadha Kwatha on Dustha Vrana 84

Introduction
INTRODUTION
Each individual taking birth on this earth definitely suffers from pain of the first assault
on the umbilical chord. Probably for this reason Acharya Susrutha have given importance for the
topic of wound healing.
Non-healing wound is a serious problem in surgical practice. . Due to infection, wound

become complicated. Each day new anti biotics are coming to cope up with the infections . But
they are effective up to certain extent only and become resistant to themselves. Healing of vrana
is a natural process but due to the interference of vitiated dosha`s , Vrana becomes Dustha and
normal healing process gets delayed.1 Achieving better wound healing with minimal scar and
controlling pain effectively are the prime motto of every surgeon.
Vrana ropana is a natural process ,but due to various factors the vrana becomes dusitha
and the healing becomes complicated and delayed.
For Acharya Susrutha “Health was not a disease free state, but a normal state of mind
body and soul2 . He emphasized the un interrupted association of manas with indriyas and in turn
with their arthas in association with soul. So the management of the disease start from the earlier
stage of vitiation of dosha to the total recovery,which means bringing back the site of lesion to
normalcy in all respect. Hence we can say that Susrutha acharya`s point of wound management
was more through than even conceived today.
In present day wound is said to be healed when epithelization is complet , but as per
Susrutha `s view he emphasized on the point ‘Vaikritapaham3’ that means the measure which
will bring the normal color , surface and hair growth of the skin.
For a good healing to take place the patient`s physical and emotional well being is also
essential. But due to many morbid factors achievement of good health is not at all possible. It can
be achieved only in a multi disciplinary approach with pain less or less invasive technique.
Susrutha has mentioned the importance of multi disciplinary management for vrana since
time immemorial. Procedures which are effective, causing minimal discomfort to the patient and
A Clinical study on Pariseka Vidhi in the Management of Dusta Vrana with Aragwadha kashaya
Page 1
Introduction
provide early recovery are in high demand. Aharya Susrutha has mentioned 60 upakramas4
vrana chikitsa. Each modality has got its own prime importance in which Pariseka is one which
has got shodaka and ropoka in action and which is a low cost and easiest method
All the Samhithas and nigantus have mentioned the drug Aragwadha in the management
of Dusta vrana. Hence an attempt is made to evaluate the efficacy of Pariseka with Aragwadha
Kashya in Dusta vrana.
Page 2
Objectives
OBJECTIVES OF THE STUDY
Dustha vrana is one of the most commonest diseases faced by many medical practitioners
today. It worsens the patient`s condition and even affects his psychological conditions too. The
condition becomes fatal when there arises a complication.
Normal healing process is affected by local factors like slough infections and many more
factors. A clean or tidy wound in a healthy body heals faster with less scar as compared to an
untidy wound. So in the present study care is taken to maintain the hygiene of the wound in all
the stages of wound healing.
Ayurveda has described in detail about Dusta vrana starting from the nirukti , definition ,
classification and even the complication in detail. Susrutha has mentioned shasti upakramas for
the management of Dusta vrana. Pariseka is one among them. Aragwadha is proved to be
effective in dusta vrana. Hence the present study is to evaluate the Shodana effect of Aragwadha
kwatha pariseka in the management of dusta vrana.
By keeping all these views the following study is conducted with the below mentioned
objectives.
• To understand dusta vrana in proper.

• To know about Aragwadha kwatha.
• To study the pariseka vidhi.
• To evaluate the effect of Aragwadha Kwatha pariseka in the case of dusta vrana and to
assess the results wholly after study of the above said procedure in seleted 30 cases
A Clinical Study On Pariseka Vidhi In The Management Of Dusta Vrana With Aragwadha Kashaya
Page 3
Review of Literature
REVIEW OF LITERATURE
HISTORICAL REVIEW
The art of surgery had been evolved from the way of healing of wounds, because the
trauma was only the primary cause, which a man had identified, in early days. The earliest
description of-the management of wound is found in 'Vedas'. They are the oldest books of the
world, which were written about 5000 years BC.
The earliest records of surgical treatment in the history was in 'Rigveda', where the Queen
'Vishwala' who accompanied her husband king 'Khela' to the battlefield and received a major
Injury over the leg. The devine doctors 'Ashwini Kumaras’ amputated the injured leg of the
Queen and replaced it by an artificial limb.5 In Ramayana, certain drugs were described to treat
‘Lakshmana’ who was severely injured by ‘Meghnada’ in the war field. They are named as
'Sandhana Karani', 'Vishalya Karani', 'Savarnva Karani', and ‘Sanjivani’.6
In Mahabharata (1000 BC), Bhishma is said to have been attended by a band of army
surgeons when he was wounded in the war. There are mentions, where during war every soldier
used to carry with them the first-aid materials for wound management, which included honey,
Ghrita and bandages.7
A detailed study of wound healing can be found only in Ayurvedic Samhitas. Atreya
Punarvasu (20OO BC), expanded the knowledge of Vranas systematically with their Nidana,
Lakshanas and Chikitsa. Apart from these he has emphasized in detail about Dushtavrana. He
was being a physician did not go in the depth of the subject, but he was the first to mention a
quite large number of wound healing drugs. In the period of Acharya Sushruta (1000 B.C), the
knowledge about wound was excellent. He was being a surgeon knew its value and has dealt
almost all possible clinical aspects of wound healing in detail. Though he has mentioned,
Nidana, Vargikarana, Lakshanas, Sadya-Asadya, Chikitsa and its Upadravas. Yet he had thrown
more light on Dushtavrana or non-healing ulcers. In the period of Buddha (7th century B.C), the
knowledge of wound was deteriorated and the people were considered surgery as Asuri chikitsa.
An ancient physician Vagbhata (5th Century AD)/ described the knowledge of wound healing by
adding some of his observations to the treatise which had been already mentioned by Charaka
Page 4
and Sushruta. He classified the Vrana on the phase basis and had advocated different
preparations of drugs and modalities of treatment.
Though, an elaborate description of wound-healing drugs were found in the Ayurvedic

Samhitas, their systematic description is available only in Sushruta-Samhita, where Dushtavrana
and its manifold management were described very comprehensively. But for a thorough study of
this subject, the primary approach is the exploration of all concerned literature.
Page 5
LITERARY REVIEW OF VRANA
The word vrana is derived from the verb root vra-vranoti which means to cover or to
envelop and to protect.
Vranayati iti vrana8 (Dalhana):.
There is scar formation after healing of the vrana.
Derivation
Vrana gatra vichurnana8 /
Gatra means tissue (body part) vichurnana means destruction, disruption of continuity break,
rupture, and discontinuity.
Vrana is the destruction/break/rupture or discontinuity of the body tissue or part of the body is
called vrana.
Vranayati gatraum vivarnya karoti iti vrana9
There is discoloration at the site of vrana after healing.
Definition10
Sa vranoti Acchadayati Yasmat Syaat Vrana Iti11.
It covers or conceals the under lying tissues hence vrana
As the scar of a wound never disappears even after complete healing and its imprint lifelong is
called vrana by the wise.
Classification
All the Acharya `s classify vrana in 2categories.
• Nija
• Agantuja
Depending upon the causative factor
Based on the nature of wound it is again classified into
• Dustha vrana
• Sudha vrana
• Ruhyamanna vrana
• Roodha vrana
Page 6
NIDANA OF VRANA12
The causes or nidana of vrana are same as the factors reponsible for the vitiationof
Doshas. These are classified as Aaharaja and Vihaaraja Kaaranas and Vicharaja. They are as
follows
Table no:1 Nidana
Dosha Ahara Vihara
Vata Laghu, Katu,Kashaya,Thikta,Ruksha Ahara, Balavat Vigraha, Athi Vyayama,

Shaaka,Vallura etc Vyavaya,Ratrijagarana,
Langana etc
Pitta Katu, Amla, Lavana, Teekshna, Ushna Krodha, Shoka, Bhaya, Aayasa,
,Laghu,Vidaahi, Tila Taila, Pinyaka, Kulatha etc Upavasa, Maithuna etc
Kapha Madhura, Amla,Lavana , Snigdha,Picchila, Masha, Divaswapna, Avyayama, Aalasya

Godhuma etc
Raktha Drava,snigdha,guru Krodha,anala and atapa sevana,srama

etc.
AGANTUJA NIDANA13
Parusha, Pashu, Pakshi, Vyala, Sareesrapa, Prapatana, Peedana, Prahara, Agni, Kshara,
Visha, Teekshnaushadha prayoga , Shakala, Kapala prahara abhigata , Shringa, Parashu, Shakti,
Kunta, Abhighata.
Page 7
DUSHYA14
Dushya `s are the vrana vasthu or vrana sthana mentioned by Susrutha
Table No. 2-Vrana vastu
Sushrutha14 Twak,Mamsa,Sira ,Snayu, Sandhi, Asthi,Koshta,Marma
Charaka15 Twak, Sira, Mamsa, Meda, Asthi, Snayu, Marma, Antarasraya
Vagbhata16 Twak, Mamsa, Sira, Snayu, Sandhi, Asthi, Koshta, Marma
Madava Nidana also opines the same regarding vrana vastu as per Susrutha. But while
explaining each vrana adhisthana and lakshna of vrana he adds marama rahitha
Vrana Sthana and its Lakshanas by Madhava Nidana17:
Table no 3 -Vrana Sthana and its Lakshanas by Madhava Nidana:
Vrana “Sthaana” Vrana Lakshanas according to Sthaana
Mamsa, Sira, Snayu, Asthi, Associated with vertigo and delirium

Sandhi – Vrana
Marma Rahita “Siradi” Viddha – Profuse Discharge like “Indragopa”. Reddish appearance
Vrana
Marma Rahita “Snayu” Viddha Laxity of body part, severe pain, delayed wound healing,
– Vrana inactivity of the body part
Marma Rahita “Sandhi” Viddha Excessive pain, weakness, inflammation at the site, complete
– Vrana absence of activities
Marma Rahita “Asthi” Viddha – Day and night severe pain and not subsides in any position
Vrana
Mamsa Marma Viddha – Vrana Loss of tactile sense, discoloration
Page 8
Note : Madhava nidana has not given the features of marma stana gata vrana in the chapter of
Dustha vrana.
Lakshana18:
Samanya: Ruk (pain)
Vishesha: Depends on the involvement of Dosha
Classification:
In Ayurveda, vrana is classified as,
Vrana is mainly classified into two types depending on the doshic vitiation and by external
factors. They are
1. Nija caused by pavana , pitta , kapha, shonitha , and the combination of them i.e.
dwandaja Sanniptha
2. Agantuja caused by external factors
3. The shareerja vrana is classified into Ekadoshaja , Dvidoshaja , Tridoshaja , Sannipata ,

Nimmittjaja. The lakshanas are explained below.
Page 9
VRANA LAKSHANAS AS PER PREDOMINENCE OF DOSHAS 19
Table no: 4 vrana lakshanas as per predominance of doshas
Dosha Vedana Srava Akruti Varna Anya lakshanas
Todha, Sheeta,Picchila, Shyava, Picchila, sheeta

Vata Bheda,Chatachatayana Alpasrava Manda Krushna, Rooksha
Teevra Ruk,Sphurana Srava resembling Aruna, Stabdha
Mastu, Bhasma and
Mamsa,pulakambu kapotha Katina
or Asthi
Pitta pain resembling Vrana Srava resembling - Neela, Daha, Paka,

caused by Kshaara Kimshuka flower, Peeta, Raga, studded
oosha Ushna. Pootisrava Kapila with Peeta
Srava is warm, Pingala - Pidaka
large in quantity Trushna, Moha,
resembling Jwara, Sveda
Kimshuka, Taila Kleda, Daha
or solution of
Bhasma
Kapha Picchila, sheeta Shukla, Sheeta, - Pandu Mandhavedana,
Sandra Alpa
samkleda Kandu
Ghanasrava Guruthwam
Chirakaari
Alparuk, Kandu
Sthaimithya
Raktha Pravaala Smells like
Dhala Turanga
Nichaya sthaana, Smells
Raktha like Vaaji
Sthaana
Vedanaayuktha,
Dhoomayana
Sheela and
having features
of Pitta
Page 10
LAKSHANAS OF DVANDVAJA, TRIDOSHAJA AND SANNIPATAJA VRANA20

Susrutha explained the lakshanas of vrana according to the combination of doshas.
Vagbhatt a and Madhavkara also explains the same.
Table No: 5 Lakshanas of Dvandvaja, Tridoshaja and Sannipataja Vrana
Type of Vrana combination. Lakshanas
Yellowish colored or dark red colour and

Vatapitta
discharge, shows pricking and burning pain.
Rough,indurated,and with frequent discharge of

Vatasleshma
little cold slimy fluid.itching and pricking pain.
Yellowish colour,hot discharge and burning

Pittakapha
sensation
Rough,shallow,red in colour,with pricking

Vatashonithaja
pain,numbness and red discharges.
Rapidly spreading,fishy odour and blackish hot

Pittashonithaja
discharge
Red,indurate,slimy,with itching blood mixed

Kaphasonithaja
pus discharge
Pricking and burning pain ,with thin yellowish

Vatapittashonitaja
blood stained discharge
Itching ,tingling sensation,and blood mixed

Vatakaphasonitaja
thick whitish discharge
Burning sensation,itching,redness,and pus

Kaphapittashonitaja
mixed thick bloody discharge
Pricking pain,tingling sensation,churning

Vatapittakaphasonithaja pain,itching,numbness,redness,pus formation
and various types of pain and discharge
Page 11
AGANTHUJA VRANA
Susrutha has mentioned about Aganthuja vrana as sadhyo vrana in chikitsa sthana
2ndchapter. The general shapes of aganthuja vrana are Aayata , Caturasra , Tryasra , Manda ,
Ardhacandra and Vishala. Susrutha also mentioned that even though only 6 types are explained
but vrana akruti are of various types. Madhavakara`s explanation is similar to that of Susrutha.
CLASSIFICATION OF AGANTUJA VRANA
Table no: 6 Classification of Agantuja Vrana

Sushrutha 6 types Chinna, .Bhinna, Viddha, .Kshata, Piccita, Ghrushta
Samhitha21
Chinna(5) Grishta,Avakrita,Viccinna,Vilambhi,Patita,
Ashtanga
Vidda Anuvidda, Uttundita, Ativida, Nividda Anubhinna
Samgraha22 3types
(8) ,Bhinnothundita, Atibhinna, Nirbhinna
Piccita(2) 1.Savarna
2.Avarna
Ashtanga 8 types Ghrishta, Avakrita, Viccinna, Pravalambita, Patita, Vidda,
Hrudaya23 Bhinna,Vidalita
Page 12
Characters of Agantuja Vrana based on shape and severity of injury24:
Table no: 7- Agantuja Vrana based on shape and severity of injury
Extensive cut injury, Oblique or Straight separation of

Chinna
Body parts
Bhinna Perforation of Ashaya and profuse discharge
Deep injury with or without perforation of Ashaya

Viddha
Neither a cut injury nor a perforation; but exhibits the nature of both and uneven
Kshata shaped
Crushed injury extended filled with Majja and Rakta

Picchita
Rub injury skin gets peeled off, burning sensation and

Ghrushta
discharge
CLASSIFICATION BASED ON AVASTHA

Based on avastha vrana can be classified into
1. DUSHTA VRANA
2. SUDDHA VRANA
Lakshana of Suddha Vrana25
The sudhha is devoid of all the three doshas. Before treatment it is important to know
about the suddha and dushta of vrana. Usually the sudhha vrana does not need any treatment
whereas dushta vrana is difficult to treat. The floor of the vrana should be at surface level. The
discharge and pain should be absent. The explanation according to Susrutha and Vagbhatta are
almost similar. Charaka also in brief has explained the features of dusta vrana.
Page 13
The Lakshanas of Sudhha vrana according to various Acharya`s is as follows:
Table No 8- Lakshana of Suddha Vrana
Sushruta25 Caraka26 A.H.27 M.Ni.28

ÆSurface of wound is just ÆSurface of ÆWound surface
like tongue. wound is just like is just like tongue.
tongue.
ÆRecent origin. ÆColor of wound is ÆVery soft.
reddish black. ÆSoft.
ÆUn affected by the three ÆSlimy.
Dosha. ÆModerate pain. ÆSurface is
smooth and ÆPainless.
ÆEdges with a slight ÆElevation and normal.
blackish colour and having depression are ÆNot too much
granulation tissue. absent. ÆAbsence of pain discharge.
and secretion.
ÆAbsence of pain and
secretion.
.
ÆEven surface through out
the wound area.
ÆSlimy surface.
ÆRegular surface.
DUSTA VRANA LAKSHANA

Dustha means getting vitiated by dosha`s29
Dustha means there is localization of Doshas or Dushta means getting vitiated by doshas.
Vrana which smells badly (foul odour) has abnormal color with profuse discharge , intense pain
and takes long period to heal is said to be Dusta and the features opposite to that are of suddha
vrana. In this context we can understand it as a non-healing wound. The features of Dusta vrana
will vary according to the predominant dosha present in it.
TYPES OF DUSTA VRANA30:
Dusta vrana is classified based on the involvement of doshas, those are as follows
• Vataja
• Pittaja
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• Kaphaja
• Raktaja
• Sannipataja
• Agantuja
Lakshanas depending upon the shape , discharge , consistency and chronicity according
to various Acharyas
Table No-9-- Lakshanas of Dushta Vrana
Sushruta30 Caraka31 A.H32. M.Ni33. Sa. Sam34.
ÆExtremely ÆNo specific ÆToo ÆPurulent ÆOppositeLakshana

narrow or wide Lakshanas hard/Too profuse blood of Suddha Vrana.
mouthed. mentioned by soft. stained
ÆToo soft. Caraka, but by ÆToo discharge.
ÆElevated or classification it elevated/ ÆLarge cavity.
Depressed is characterized Too ÆFoulsmelling.
ÆBlack or red in 12 inverted. ÆSevere pain.
or white ÆWhite. ÆToo ÆOpposite
colored. ÆDepressed path. hot/Too Lakshanas of
ÆToo cold or ÆToo thick path. cold. Suddha Vrana.
Hot. ÆToo yellow, ÆColour of
ÆFull of Pooti blue, blackish, Vrana is
Pooya, Sira, grey. red/ black.
Snayu, Pooti ÆBlack foul ÆSevere
Pooya Sraavi. smelling. painful.
ÆUpward or ÆWide cavity ÆBurning
oblique filled with pus. sensation.
course of ÆNarrow mouth ÆInflamed.
suppuration. ÆRedness
Page 15
ÆPus runs in and itching

to cavity and is present.
fissures, ÆChronic in
having foul nature.
smell.
ÆBurning
sensation,
Redness and
itching
ÆPustules
crop up
around,
secrete blood
CLASSIFICATION ON THE BASIS OF STAGE OF HEALING

• Ruhyamaana vrana
• Samyak Roodha vrana
Ruhyamaana vrana lakshana35
This is the healing stage of vrana. Vrana which has kapotha varna and has sthira pitika is
said to be ruhyamaan vrana. Similar type of description is mentioned by Vagbhata and in
Madhav nidhana.
Samyak Roodha vrana36
Vrana which has healed in its seat (dwelling place) without eruptions (Granthi) pain
(Vedana) or swelling and has the color as that of twak and is even is said to be samyak roodha
vrana.
Page 16
CHARAKA`S CLASSIFICATION OF VRANA37
Table No-10-- Charaka’s classification of Vrana
Krithya Akritya
Dushta Adushta
Marmasthita Amarmasthita
Samvrutha Vivrutha
Daruna Adaruna
Sravi Asravi
Savisha Avisha
Vishamasthita Samasthita
Utsangi Anutsangi
Utsanna Anutsanna
PANCHA LAKSHANAS
The Pancha lakshanas are
• Varna
• Vedana
• Srava
• Gandha
• Akruthi
Vrana varna38
Susrutha says that the color of vrana is according to the involvement of doshas. They are
as follows
Page 17
Table No-11- Vrana varna
Dosha Vrana vrana
Vata Bhasma,kapotha,asthi,aruna and krishna varna
Pitta Neela,Peeta,Haritha,Syava,Krushna,Raktha,Kapila,Pingala
Kapha Shveta,snigdha,pandu
Rakta Same as pitha
Sannipataja Mixed colours
Vrana gandha39
Susrutha explains the vrana gandha as follows
Table No-12-Vrana gandha according to Sushrutha
Dosha Vrana gandha

Vata Katu gandha
Pitta Theekshna gandha
Kapha Ama gandha
Raktha Loha gandha
Sannipatha Katu, theekshna and ama gandha
Vata pitta Laja gandha
Vata kapha Athasi
Pitta kapha Taila
Page 18
Charaka40 explained gandha according to various substance like Grutha , oil etc and also
some of the bodily constituents like blood etc.
Table No-13- Vrana ganda according to Charaka
Ghruta Pootika
Taila Amla
Vasa Syava
Pooya Rakta
Vrana srava41
Based on the site and dosha involved Acharya Susrutha has explained different kinds of
discharge that can be observed in vrana , which are as follows;
Table No-14-Vrana srava according to Sushruth
VranaStana Vata Pitta Kapha Sannipata
Twak Parusa gomedaka Navanita nalikerodaka
Mamsa Syava gomuthra Kasisa Ervaruka rasa
Sira Avasyaya Bhasma Majja Kanjika
Snayu Dadhimastu Sankha Pishti Arukodaka
Asthi Ksarodaka Kasaya Tila Priyangu phala
Sandhi Mamsadhavana madvika Nalikerodaka Yakrut
Koshta Pulakodaka Thailam Varaha vasa Mudgayusa
Page 19
Charaka42 has mentioned 14 types of sravas in general. They are as follows;

Table No-15-Vrana srava according to Charaka
Lasika Jala
Pooya Asrk
Aruna Haridra
Kashaya Pinjara
Haritha Neela
Rooksa Snigdha
Sita Asita
Asadhyta according to srava43 ;

The prognosis is decided according to the type of discharge. It is explained in the below
table. When there is involvement of visceral structures then it is considered as incurable
Table No. 16 - Asadhyata according to Sthana
Prognosis Srava
Pulakodaka like exudates from Pakvashaya, Ksharodaka type of Srava

Asadhya from Raktashaya, Kalaya type of Srava from Amashaya and
Trikasandhi Pradesha
Vrana vedana44
Table No. 17 –Vrana Vedana
Vata Thodana,Bedana,Tadana,Chedana,Ayamana,Mantana,Viksepana,
Chumachumayana,Nirdahana,Avabhajana,Spotana,Vidarana,Utpa
dana,Kampana,Purana,Sthambana,Akunchana and various other
types of pain
Pitta Osha,Chosa,Paridaha,Dhoomayana and pain similar to alkaline
substances put on vrana
Rakta Same like Pitta
Kapha Kandu ,Guruthwa,Suptata,Alpa vedana
Sannipathaja Lakshanas of all threedosas
Page 20
Vrana akruthi45
Susrutha mentioned 4 normal shapes for ulcer. Others are having irregular shapes and
they are difficult to treat. The vrana akruthi s are Ayata , Caturasra , Vrutta , Triputaka
As per Vagbhata shape of vrana is purely of Aagantuja variety because it is recognized

by the shape of salya or foreign body inserted
Upadrava (Complications)
They may be pertaining to the wound or pertaing to the patient
Vranasya updrava46 (pertaining to the wound)
Upadrava of vrana includesVikrutha Gandhaadi Panca ie the abnormality in them. For eg

some of normal shapes are told for vrana. Other than these are considered as abnormal shapes or
updrava. The vranasya upadravas are Gandha, Srava , Varna , Vedana, Akruti.
Vranithasya upadrava(pertaining to patient)
Vranithasya upadrava are some systemic diseases that occurs as complication of vrana.
Table No-18--- Vranithasya upadrava

47
Sushrutha Athisara, Murcha,Hikka, Chardi, Arochaka, Swasa
Kasa, Avipaka, Thrishna ,Jvara
Charaka48 Atisara, Pakshagata, Hikka,Apathanaka,Moha
Swasa,Unmada,Vranaruja,Hanugraha,
Thrishna,Kasa,Chardi,Vepadhu,Visarpa, Sirastambha
Page 21
Sadhya – Asadhyatha
Characters of Sukha sadhya vrana49
• Vrana in young masculine persons with strong mental powers
• Ulcers appears in the regions of Spik , Payu , Prajanana , Lalata , Ganda ,Oshta ,
Karna ,Phalakosa , Udara , Jathru , Abhyantra mukha
Characters of Kriccrha Sadhya vrana50

If the sthaana of vrana is in bone , teeth , nose , lateral angle of eye , Srotas , umbilicus ,
stomach , suture , buttock , flanks , abdomen , thorax , breast , joints, those that secrete frothy
blood/pus with a gurgling sound or contain any foreign matter embedded in their inside
• Vrana of leprosy , diabetes , tuberculosis , poisons etc.
• Vrana having foul smell , 16 said complication and with said 24 vrana dosha
Characters of Yapya vrana51

The vrana incidental to and affecting the seat of any of the following diseases such as
Avaptika , Niruddha –Prakash , Sannirudh Gudha , Jatara , Granthi , Prathisyaya , Vata
Kundalika , Asthila , Upakusa , Kanta Saluki , Danta sarkara , Danta vesta Uru kshata and Vrana
granthi.
Characters of Asadhya Vrana52

Ulcer cropping up like mamsa pinda , painfull, containing pus filled cavity with its edge
raised like those of aswa apana.
• Ulcer which is soft and raised like the horn of a cow.
• Ulcer elevated at its base and secretes an exudation of vitiated blood or thin slimy
secretion.
• An ulcer having raised center and one fissured or dipped at its periphery surrounding
area contains snayu jala and vrana with horrible appearance.
• Vrana secreting an exudation of vasa , majja , medas , and mastulunga.
Page 22
• Koshta vrana which discharges either black or yellowish fluid or exudates a secretion
composed of urine , faecal matter and air.
• Koshta vrana with pus and blood comes out from mouth , anus and from vrana site.
• Wind coming out of the vrana seated in sira and kanta.
• Upadravas such as arochaka , avipaka , kasa, swasa found in an emaciated vrana rogi
with pus discharge.
Case of fractured skull , associated with kasa , swasa , masthulunga darsana and tridosha
dushti lakshana
Page 23
VRANA CHIKITSA
Vranitagara53
Vrana chikitsa should be done in Vranithagara. It should be auspicious and in
accordance with Vastushastra. Vranitha will not suffer from physical , mental and traumatic
disorders by residing in such Aagara. Raksha karma should be done along with Dhoopana.
In that Aagra , the bed should be nice , well laid provided with comfortable
mattresses and linen , with its head end towards the east and well protected with a weapon. The
Vranitha person lie on that bed. The affectionate friends who should be good conversationalist
also attend on him. The patient should be protected carefully.
Saptha vidha upakrama54
Saptha upakrama starts from the stage of Vrana Sopha. They are Vimlapana , Avasehana
, Upnaha , Patana , Sodhana , Ropana , Vaikrutapaha.
Vimlapana:
It is done with thumb or bamboo reeds , ie local application of pressure is done at the
site of sopha.
Avasechana :
This is done with the help of jaloka , sringa , alabu or sastra.
Upanaha:
It is the process of application of poultice to induce paka
Patana:
It is a surgical procedure or a para surgical procedure by applying of a paste prepared by
particular medicaments used for the removal of pus from a pakva sopha
Sodhana:
Sodhana is one of the important therapies in the management of ulcer. It can be achieved
by Sudha jala , Kwatha , Varti , Kalka , Madhu ,Ghruta ,Taila , Rasakriya , Lepa and
Avachoornana .
Ropana:
Ropana drugs are those which helps in the healing of vrana. It is usually done after the
sodhana of vrana. For the Ropana various Kashaya , Rasakriya , Varti , Lepa and Avachoornana
are mentioned.
Page 24
Vaikrutapaha:
These are the cosmetic treatment used after healing process vig- Krishna krma , Pandu
karma , Loma sanjana , Lomapaharana.
SHASTI UPAKRAMA55
Sushruta has described the sixty measures (Shasti Upakrama`s) for wound management
from its manifestation to the complete healing including preventive measures and dietary
regimen and rehabilitation of the patient. He has given much importance to Shodhana and
Ropana in the management of Dushta vrana and has given extensive formulations of
medicaments useful to manage different conditions of wound.
Table No-19--- Principal treatment of Vrana
Upakrama Sushruta56 Charak 57 Kashyap58 A.sa & A.hr59

Apatarpana + - - -
Aalepa + - Pralepa Pradeha
Parisheka + - + +
Abhyanga + - - +
Swedana + - - +
Vimlapana + - - +
Upanaha + - + -
Pacahana + - - +
Vistravan + - + +
Snehana + - + -
Vamana + - - +
Virechana + - - +
Chedana + + - -
Bhedana + Patana - -
Darana + - - +
Lekhana + + - -
Eshana + + - -
Aharana + - - -
Vyadhana + + - -
Sravana + - - -
Sivana + + - -
Sandhana + + - -
Pidana + + Avapidana - +
Page 25
Shonit sthapana + - - -
Nirvapana + + - +
Utkarika + - - -
Kashaya + + - -
Varti + - - +
Kalka + - + -
Sarpi + + - Ropan ghrit
Taila + + - Ropan taila
Rasakriya + - - +
Avachoornan + + - Choorna
Vrana shodhana + kathinakara, - +
mardavakara
Utsaadana + + - +
Avasaadana + + - +
Mrudukarana + maradavakarma, - +
Aalepana.
Daranakarma + kaathinyakara aalepa. - +
Ksharkarma + + Daha - +
Agnikarma + + Daha - +
Krishnakarma + Varnya Savarnikaran Savarnikaran
Pandukarma + Varnya Savarnikaran Savarnikaran
Pratisarana + - - -
Romasanjanan + +Lomarohana - +
Lomapaharana + - - -
Basti + - - -
Uttarbasti + - - -
Bandha + + + -
Patradana + Patrachedana,(bahya - -
abhyantar)
Krimighna + - - -
Brimhana + - - -
Vishaghna + - - -
Shirovirechana + - - -
Nasya + - - -
Kavala dharana + - - -
Dhoom + - - -
Page 26
Madhu-Sarpi + - - -
Yantra + - - -
Aaharana + Bhojya - -
Rakshavidhana + - - -
Shophaghna - + - -
Shamana - + + -
Chadana - + - -
Shodhanalepa - + - +
Ropanalepa -- + - +
Ropana - + + -
Utklinnaprakshalana - - + Prakshalan
Shodhana - - + -
Prachenna - + - -
For the purpose of Shodhan and Ropana 7 Kriya kalpas are mentioned. They are Kashaya , Kalka
, Varthi , Rasakriya , Avachoorna , Taila and Sarpi. Depending on the combination of drugs the
Kriya kalpas may be of Shodhana or Ropana.
PATHYA60
Susrutha has explained about the diet and regimen for the quick healing of the wound and to
avoid complication
• Hot liquefied food prepared with jeerna Sali should be taken along with ghee and jangala
mamsa ras.
• Tanduleeyam , jeevanthi , sunishannkam , vasthuka , balamoolaka , varthaka , patola ,
karavellaka , dadima , amalaka , mudgam , sakthu , vilepi , kulmasa should be given to
the patient as food.
APATHYA
Ahara :- Diet consisting of navadhanya , masha , tila , kalaya , kulatha , nispava , harilakasaka ,
amla , vallora , suskh saka , ajamamsa , avimamsa , anupamamsa , vasa , sheeta jalam , krishara ,
payasa , dadhi , dugdam , takra increases the pus and dosha
All varieties of Madhya including maireya , arishta , asava , sidhu , sura should be
avoided because amal ruksha ushna asukari properties of Madhya will aggravate the
condition of vrana.
Vihara :‐ Excessive exposure to athapa , vata , rajas , dhooma , athi bojana , darsana , harsa , bhaya ,
kroda , visamasna , visama sayana and ajeerna.
Page 27
REVIEW OF MODERN LITERATURE
Trauma is the one among the causative factor of a wound or discontinuity of tissues.
Usually healing of a clean wound when not affected by any adverse factors , starts with in a few
hours . It does not require any treatment. But this natural phenomenon of healing is not very
often allowed to happen , due to various retarding factors. So it is very necessary to know about
the wound , its causative factors of wound healing pattern and the factors which interfere in the
normal process of healing.
DEFINITION
• An ulcer is a break in the continuity of the covering epithelium , skin or mucous
membrane. It may either follow molecular death of the surface epithelium or it traumatic
removal61.
• An ulcer is a discontinuity of the skin or mucous membrane which occurs due to the
microscopic death of the tissue. Thus ulcer can occur any where in the body(skin) , oral
cavity , penis (mucous membrane) or in the duodenum intestines etc62.
• An ulcer is a discontinuity of the epithelial surface. There is usually progressive
destruction of surface tissue , cell by cell as distinct from death of macroscopic portion63
eg:. Gangrene or necrosis
• Wound is a discontinuity or break of the surface. In a simple wound only skin is
involved. It can be complex wound when it involves underlying nerves , vessels ,
tendons64 etc.
• A wound is defined as disruption of cellular and anatomic continuity of skin.
Parts of an ulcer65
Figure No 1- Parts of an ulcer Figure No 2- Types of Edge
Page 28
Margin : It is junction between normal epithelium and ulcer. It may be regular or

irregular or oval.
Edge : Edge is the one which connects the floor of ulcer to the margin. Different edges
are as follows
Sloping edge : It is seen in a healing ulcer. Its inner part is red because of healthy
granulation tissue. Its outer part is white due to scar or fibrous tissue. Its middle part is
blue due to epithelial proliferation.
Undermined edge : It is seen in spreading type of ulcer like tuberculous ulcer , where
disease process advances in the deeper plane.
Punched out edge : It is seen in gummatous ulcer and in trophic ulcer.
Raised and pearly white beaded edge : It is seen in rodent ulcer.
Everted edge (rolled out edge) : It is seen in carcinomatous ulcer due to
proliferating malignant tissues over the normal skin.
Floor : It is the one which is seen. Floor may contain discharge , granulation tissue.
Base : Base is the one on which ulcer rests. It may be bone or soft tissues.
CLASSIFICATION66
Ulcers are classified into two categories , on the basis of :-.

• Clinical features .
• Pathological factors.
Clinically an ulcer may be

1. Spreading :- When the surrounding skin of the ulcer is inflamed and the floor is covered
with slough with out any evidence of granulation tissues.
2. Healing :- When there is granulation tissue in the floor of the ulcer , the surrounding skin is
not inflamed and the edge shows bluish outline of growing epithelium , more over there is
slight serous discharge.
3. Callous :- When there is pale granulation tissue in the floor ; there are considerable
indurations , at the base edge and surrounding skin. This ulcer shows no tendency towards
healing.
Page 29
Pathologically , the ulcer are classified into

• Non specific
• Specific
• Malignat
Non specific ulcers
Many causes are there for such ulcers. According to the cause these ulcers are
classified as below
a) Mechanical – Dental ulcers of the tongue from jagged tooth, from pressure of a
splint.
b) Physical – Eletrical or X- ray burn
c) Chemical – From application of caustics.
d) Arterial ulcer- As occurs in atherosclerosis , Buerger`s disease and Raynaud
disease (primary and secondary)
e) Venous ulcer- Eg venous ulcer in post phelbitic limb
f) Neurogenic ulcer – .
g) Tropical ulcer – These ulcers are occurring in the legs and feet of the people in
the Tropical countries. Infection by Vincent organism in a small abrasion may
cause such ulcer Ulcers associated with malnutrition , anemia ,
avitaminosis and rheumatoid arthritis are also included in this group.
h) Cryopathic ulcer – Ulcers due to chilblains and cold injury are included in this.
i) Martorell`s ulcer(hypertensive ulcer)
j) Bazin`s ulcer (erthrocyanoid ulcer)
k) Diabetic ulcer
l) Miscellaneous ulcer – Ulcer may be associated with (i) Polycythemia (ii)
Leukaemia (iii) Systemic sclerosis , (iv) Ulcerative colitis , (v) Poliomyelitis ,
(vi) Arteriovenous fistula, (vii) Acholuric jaundice (viii) Various collagen
disorders and (ix) Chronic lymphoedema. Cortisone ulcers are also included in
this group.
m) Infective ulcer – Pyogenic ulcer are included in this group , which may occur at
any age. This type is almost due to constant re infection as a result of unclean
Page 30
habits , poor hygiene , and inadequate dressings. Anemia and poor nutritional
status are pre disposing factors.
In infective ulcer the clinical features are as follows:-
Discolouration of the affected side , pus discharge , foul smell , fever local rise
of temperature , swelling , pain , loss of function .
2 . Specific ulcers are seen in tuberculosis, syphilis , soft sore and actinomycosis.
3.Malignant ulcers : e.g. epithelioma , rodent ulcer , and malignant melanoma.
Traumatic ulcer:
According to the cause of trauma, the ulcer may be situated anywhere in the body. But
these ulcers occur more commonly where the skin is closely applied to bony prominences e.g.
shin, maleoli and back of the heel. These are small, painful and circular ulcers. These ulcers heel
quickly and do not become chronic unless supervened by infection or ischaemia, which may turn
this ulcer to chronicity. The typical example of such ulcer is the ‘footballer’s ulcer’
Arterial ulcers:
These ulcers are caused by inadequate skin circulation. Impaired circulation usually
occurs in the extremities (arms and legs), especially on the top of the foot, and is signaled by lack
of pulse; cool or cold skin; skin that appears shiny, thin, and dry; loss of skin hair; and delayed
capillary return time. (To test capillary return time, briefly push on an area and then release:
normal color should return in 3 seconds or less). Pain is the main complaint. These ulcers tend to
be punched out and destroy the whole skin and the deep fascia and may expose the tendons in the
floor of the ulcer.
Buerger’s disease (thromboangitis obliterans), a disease of men between 20 and 40 years
of age, may also presents with such ulcer. Patches of dry gangrene are also present along with
the arterial ulcer. Arteriography is important to detect the arterial disease. Treatment of arterial
ulcers has two goals: re-establishing circulation with medical treatment and healing the wound.
Page 31
Ischaemic leg ulcer:
An ischaemic leg ulcer is usually localized to the foot or the outer side of the lower leg.
There are usually other signs of compromised arterial supply, such as atrophy of the skin of the
toes. The ischaemic ulcer is often more painful and has less discharge than a venous ulcer.
Venous ulcers:
The basic cause of venous ulcer is abnormal venous hypertension in the lower-third of the
leg, ankle and dorsum of the foot. They are shallow, not too painful, and may have a weeping
discharge. Although venous valves cannot be repaired, the return of blood through the veins can
be improved by physical activity and by compression, which can be supplied by compression
stockings, dressings, or mechanical pumping devices.
A venous leg ulcer is usually localized within the distal third of the lower leg, more often on
the medial than on the lateral side. The skin around the ulcer often shows epithelial atrophy, lack
of hairs and increased pigmentation.
Diabetic ulcers:
Diabetics have impaired wound healing and impaired resistance to infection. The disease
leads to changes of the walls in small and medium arteries with impaired blood flow. The
thickening of capillary membrane will impair passage of leucocytes to the wounded tissue. The
leucocytes function is also impaired. Diabetic neuropathy with loss of protective reflexes renders
the diabetic patient more prone to injuries.
Diabetes results in a narrowing of the small arteries, which can cause ulcers. This narrowing
cannot be resolved, but can be prevented by careful glucose control. Diabetes also causes
peripheral neuropathy and the loss of sensation, especially sharp-dull discrimination, in the legs
and feet. For this reason, injuries to the feet may go un noticed and can progress into serious
wounds.
In addition, peripheral neuropathy can cause deformity of the foot (Charcot foot
deformity) because of inappropriate stresses being placed on the bones, resulting in micro
fractures; this deformity in turn results in bony prominences and swelling that contributes to
ulceration. Neuropathy cannot be cured, but careful glucose control slows its progress. Diabetics
must be extremely vigilant about foot care, and should seek immediate medical attention for any
wounds. Special shoes can help relieve pressure.
Page 32
Pressure ulcers:
Also known as bedsores, pressure ulcers are very common in older and immobile
persons. When too much pressure is placed on them, cells do not get enough oxygen. Such
pressure occur when cells are sandwiched between a bony prominence (elbow, heel, or tailbone)
and a hard surface (bed or wheelchair). Those cells closest to the bone begin to die, and the
wound spreads toward the skin surface. Thus, a pressure ulcer indicates not only a surface
wound, but also a deep tissue wound.
The risk of pressure ulcers can be reduced by enhancing mobility, maintaining skin and general
health, ensuring good nutrition, and monitoring weight (patient should be neither too heavy nor
too light).
Tropical ulcer:
The most characteristic feature of this ulcer is its callousness towards healing. Its edge
slightly raised and exudes copious serosanguineous discharge. Every effort should be made to
detect the cause behind the ulcer and to treat accordingly. Otherwise it may retain its existence or
even spread rapidly.
The ulcer, which develops due to infection by Vincent’s organisms in a small abrasion or breach
of continuity of the skin due to trauma or insect bite, commences as a papule with a zone of
surrounding inflammation and indurations.
Tuberculous ulcer:
Such ulcer usually develops due to bursting of cold abscess. This cold abscess may form
– (i) from matted lymph nodes; (ii) from tuberculosis of bone and joint;
(iii) from submucous lesions e.g. intestinal tuberculosis or tongue tuberculosis.
Characteristic features:
Size and shape – oval in shape with irregular crescentic border
Number – is often multiple
Edge – thin, reddish, blue and undermined
Depth – shallow
Pain – slight pain is often accompanied with such ulcer
Floor – pale granulation tissue is seen on the floor with variable amount of discharge
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Base – slight induration is characteristic feature of this ulcer which indicates chronicity of this
ulcer. Base is usually attached to the pathological lesion underneath which may be lymph nodes,
bone or joint.
Syphilitic ulcers:
Ulcers due to syphilis are seen in all the three stages of this disease.
In primary syphilis: A hard chancre or hunterian chancre is seen. This usually develops at the
site of entry of the treponemes in about 3 to 4 weeks after exposure. The sites are external
genitelia, but it may occur at extragenital sites e.g. lip, tongue, nipple, perianal region etc. The
regional lymph nodes are enlarged which are firm, discrete and painless.
In secondary syphilis: Ulcer may develop in the form of mucous patches, snail-track ulcer or
more so in the form of condylomas.
Mucous patches – these are white patches of thickened epithelium.
Snail track ulcer – these are multiple small, round and superficial erosions which coalesce to
form narrow, curved and shallow ulcers which are called ‘Snail - track ulcers’. These ulcers are
commonly seen in the mouth.
Condyloma lata – these are fleshy, wart-like growths, mostly seen at mucocutanous junction e. g.
angles of the mouth, anus vulva etc. these are in fact raised, flat, white and hypertrophied
epithelium, which often present as fungating sessile masses. The surfaces are moist and teemed
with treponemes.
In tertiary syphilis: The typical lesion in this stage is the localized gumma or gummatous ulcer.
Gummatous ulcer: Gumma is a syphilitic hypersensitivity reaction consisting of granulation
tissue with central necrosis. Sloughing of this granulation tissue produces the gummatous ulcer
which is known for its punched-out indolent edge and painlessness. In the floor there is
yellowish grey gummatous tissue. On healing it leaves a silvery ‘tissue paper’ scar.
Characteristic sites of this ulcer are –
(i) Over subcutaneous bones
(ii) In the scrotum particularly on its anterior surface in relation to the testis.
(iii)Occasionally in the tongue.
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Soft chancre or sore (Ducrey’s) – these are multiple painful acute ulcers with oedematous
edge and yellowish slough on the floor. These are seen on external genitelia. These ulcers
generally appear three days after infection and discharge copious purulent secretion. The
regional lymph nodes show the picture of acute lymphadenitis with tendency towards
suppuration.
Marjolin’s ulcer - this is a squamous cell carcinoma arising from a long standing benign ulcer
or scar
Epithelioma (Squamous cell or Epidermoid carcinoma) – It arises from prickle cell layer of
the skin and hence may occur anywhere in the body. But it is more commonly seen on the lips,
cheek, hands, penis, vulva and old scars. It may also occur in the internal organs.
Rodent ulcer: It is usually confined to the upper part of the face above the line joining the
angle of the mouth to the lobule of the ear, occurring frequently near the inner canthus of the eye
Classification of surgical wounds67
1. Clean wound: Herniorrhphy , Excisions , Surgeries of the joints etc
2. Clean / Contaminated wound: Appendicectomy , bowel surgeries , gall bladder , biliary
and pancreatic surgeries.
3. Contaminated wound: Acute abdominal conditions , Open fresh accidental wounds
4. Dirty/Infected wound: Abscess drainage , Pyocele , Empyema of gall bladder , faecal
peritonitis
Wounds are also described as-,
1) Superficial wounds:
Only the epidermis is damaged. The true skin – corium – is intact. Thus the tensile strength of
the tissue remains unchanged. Continuity is restored by growth of epithelium from the wound
edges and/or from hair follicles, sebaceous or sweat glands. Healing occurs without scar
formation. However, changes in skin pigmentation may appear.
2) Deep wounds:
In deep wounds healing will differ depending on whether there is loss of tissue or not.
a) Deep wounds without loss of tissue:
In these wounds the wound edges can be adapted by sutures and/or surgical tape. Both
continuity and strength must be restored. Continuity is restored in the deeper layers by
formation of connective tissue and on the surface by epithelial overgrowth. During the
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inflammatory phase there is redness and swelling in the wound area and the patient may
initially have pain. The wound feels stiff. At the end of proliferative phase the scar is a
narrow red line. During maturation the scar turns white but often also becomes border.
Uncomplicated healing of a wound of this type is called healing by first intention.
b) Deep wounds with loss of tissue:
As in other wounds the inflammatory phase lasts a few days. During the proliferative
phase the wound gradually fills with granulation tissue when vessels and fibroblasts
invade the coagulum. Replacement of lost tissue and restoration of continuity requires
formation of a fair amount of new tissue. This will take time. In the previously described
deep wound without loss of tissue the granulation tissue is rapidly covered and protected
by epithelium. In wounds with loss of tissue the granulation tissue is only slowly covered
by epithelium advancing from the wound edges. Even under favorable conditions the
epithelial border advances only about one millimeter a day. The area to be covered by
epithelium diminishes by wound contraction caused by certain cells within the
granulation tissue-myofibroblasts. The unprotected granulation tissue is associated with
increased risk of complications, i.e. infection during healing. During the proliferative
phase the wound is weeping and often covered by light yellow fibrinous coagulum.
Beneath this fibrin the granulation tissue appears as a grainy, easily bleeding, red surface.
Advancing thin epithelium may be seen as a light grey – red brim at wound edges. When
finally the surface is covered by epithelium there is a continuous maturation of the
granulation tissue with remolding of the collagen structure and reduction of the number
of blood vessels. The newly formed epithelium is thin and has low resistance to trauma of
any kind. This type of healing, so – called healing by second intention, takes longer and
gives a proper result in appearance and strength than healing by first intention
Types of wound according to different types of injuries68.
Incised wounds
They are caused by sharp instruments. These wounds are relatively clean. After suitable
exploration, in which the underlying structures are repaired, these wounds may be closed by
primary suture if the wound is explored within 6hours of its occurrence. Within this period all
damaged tendons, nerves and major blood vessels should be repaired.
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Lacerated wound
These wound commonly occur following road traffic accidents. The wounds have jagged
edges with certain lacerated and devitalized structures inside the wound. Thorough debridement
of these wounds is required, if received within 6hours of injury. The object is to convert the
lacerated wound into an almost incised wound. Repair
of tendons and nerves is not recommended at the time of initial surgery due to risk of infection
and should wait for 4 to 6 weeks for complete healing of the wound and these repairs are done as
secondary procedure after healing.
Penetrating wounds
It is similar to incised wounds, except that its depth is more. The wound should be explored
layer by layer, followed by primary suturing, if it has come with in 6 hours of injury.
Crushed wounds
These occur due to industrial, road traffic and war injuries. These wounds are managed by
debridement and removal of all necrotic tissue. . These wounds are dangerous as they may cause
sever hemorrhage, death of the tissues and crushing of blood vessels.
From practical point of view wounds are classified into:
1) Tidy wounds- Contains no devitalized tissues, inflicted by sharp instruments.
2) Untidy wounds- These result from crushing, tearing, and avulsion etc and contain
devitalized tissue.
Examination of an Ulcer69
- The examination of the ulcer is as follows;
History:
1. Mode of onset: It includes the causes of ulcer
2. Duration: Ulcers may be acute or chronic. Incubation period is also important in
syphilitic or chancroid ulcers. e.g. syphilis – 3-4 weeks, chancroid – 3-4 days
3. Pain: Ulcers associated with inflammation will be painful. Painless ulcers e.g. syphilitic
and tropic ulcers. Tubercular ulcers are slightly painful. Malignant ulcers are absolutely
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painless to start with and never become painful unless they infiltrate structures supplied
by pain nerve endings.
4. Discharge: Smell, colours, quantity is also important . Contents of the discharge can be
blood, serum or pus. This may be purulent or non purulent.
Physical examination: Before going to the local examination the patient has to be
examined for his general health for the evidence of malnutrition or diseases like diabetes,
tuberculosis, syphilis or any neurological diseases
Local examination
I. Inspection
a) Site or position: Different types of ulcers are confined to different parts of the body. They
can be roughly shown as:- Gummatous ulcers-Vicinity of the knee, subcutaneous bones
such as sternum, tibia or skull. Rodent ulcers - Upper part of the face above a line joining
angle of mouth, the ear, frequently occurring near the inner canthus of the eye. Varicose
ulcers- Medial aspect of the lower half of the leg.
b) Number- Ulcers may be single or multiple as indicative of some diseases like
tuberculosis or syphilis.
c) Size and shape- Tuberculous ulcers are oval or having irregular cresentic bodies.
Syphilitic ulcers are usually circular or semi-lunar, may unite resulting a serpinginous
ulcer. Varicose ulcers are oval vertically. Malignant ulcers are irregular in size and shape.
d) Floor- Observation of floor is very important in noting the healing of an ulcer. Red and
pinkish granulation tissue is indicative of an healthy healing ulcer and pale, smooth
granulation of a slow healing ulcer. Membranous or slough cover floor is seen in
gummatous ulcer. Malignant ulcer- posses fungation or cauliflower appearance in
squamous cell carcinoma, ulcerating black mass in malignant melanoma.
e) Edge- Ulcer edge will be inflamed and oedematous in spreading condition but while
healing shows red granulation tissue, blue and white zone at the periphery.
• Undermined edge- e.g. Tuberculous ulcers
• Punched out edge- e.g. Gummatous ulcer, deep trophic ulcer
• Sloping edge- e.g. Venous ulcers or in healing traumatic ulcers
• Raised and pearly – white beaded edge- e.g. Rodent ulcer
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o Rolled out (Everted) edge- Squamous – celled carcinoma or ulcerated

adenocarcinoma
f) Surrounding area: on examination the surrounding area is hard and pigmented in
varicose ulcers, red, glossy and oedematous in acute inflamed ulcers.
g) Discharge: Smell, quantity and colour of the discharge is to be assessed. Spreading
ulcers usually having purulent discharge, healing ulcers- scanty and serous discharge.
II. Palpation:
A) Tenderness: While examining an ulcer one should note down position and degree of
tenderness. An acutely inflamed ulcer is always exquisitely tender. Chronic ulcers such as
Tuberculous and syphilitic ulcers are slightly tender. Varicose ulcers may or may not be
tender. Neoplastic ulcers are generally not tender.
B) Edge and margin: Marked induration of the edge is characteristic feature of a carcinoma.
A certain degree induration or thickness is expected in any chronic ulcer, whether it is a
gummatous ulcer or a syphilitic or a trophic ulcer.
C) Base: Slight induration of the base is expected in any chronic ulcer, but marked
induration base is an important feature of squamous celled carcinoma and hunterian
chancre.
D) Depth: Trophic ulcers may be as deep as to reach even the bone.
E) Bleeding: Healthy granulation and malignant ulcer will bleed during palpation.
F) Relations with deeper structures: The ulcer is made to move over the deeper structures to
know whether it is fixed to any of these structures. A gummatous ulcer over a
subcutaneous bone is often fixed to it. Malignant ulcers will obviously be fixed to the
deeper structures by infiltration.
G) Surrounding skin: Increased temperature and tenderness of the surrounding skin indicates
the ulcer to be of acute inflammatory origin. The mobility of the surrounding skin is
examined. Fixity to deeper structures indicates the malignant nature of the lesion.
Examination of lymph nodes: In acutely inflamed ulcers the regional lymph nodes become
enlarged, tender and show the signs of acute lymphadenitis, later on, the nodes become soften to
form an abscess. In Tuberculous ulcer the lymph nodes become enlarged, matted and slightly
tender.
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Investigations:
a. Complete blood picture – HB%, TC, DC, ESR, Peripheral smear. Low HB% is found in
chronic ulcers. High total count indicates infection.
b. Urine and blood examination to rule out diabetes.
c. Pus for culture and sensitivity.
d. Biopsy – non healing or malignant ulcers.
General principles of ulcer management70

The main aim of ulcer management is to ensure the quickest and most durable form of
healing with a minimal scar.
(a) Debridement: Removal dead and devitalized tissues are essential to prevent bacterial
growth.
(b) Topical agents: A wide variety of topical wound cleaning agents being available and
bacteriostatic agents being promoted for local wound application. The properties of some
agents are:
(i) Povidine Iodine: Strong bactericidal for Gram positive and Gram negative.
(ii) Chlorhexidine: Bactericidal mainly for Gram positive.
(c) Protecting adjacent skin is important as a moist environment promotes maceration.
(d) Filling dead space: Dead space promotes anaerobic infection. In order to achieve healing
from the base of a large cavity, insert packing which prevents cavity collapse but does not
add to the wound tension.
(e) Treatment of the underlying disease.
Treatment of different types of ulcers71

It can be discussed under following headings;
1. Treatment of spreading ulcers: After obtaining pus culture or sensitivity report, appropriate
antibiotics are given. Many solutions are available to treat the slough, like hydrogen peroxide
or eusol.
2. Treatment of healing ulcers: Regular dressings are done for few days with antiseptic creams
like liquid iodine, zinc oxide or silver sulphadiazine preparation. A swab is taken to rule out
the presence of streptococcus haemolyticus which is a contraindication for skin grafting. If
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the ulcer is small, it heals by itself with Epithelialisation, from the cut edge of ulcer. If the
ulcer is large, free split skin graft is applied as early as possible.
3. Treatment of chronic ulcers: These are the ulcers which do not respond to conventional
methods of treatment. Some special forms of treatment are available, their usefulness is
doubtful. They are as follows;
Infrared radiation, short-wave therapy, U V Rays decrease the size of ulcer. Amnion
helps in Epithelialisation. Chorion helps in granulation tissue
4)Treatment of non-specific ulcers: Any underlying cause is treated e.g. varicose veins, diabetes
and arterial disease. Many lotions and non-adhesive applications are used to aid the separation of
sloughs, hasten granulation and stimulate epithelialisation. Hypochlorite solution and 0.5% silver
nitrate are popular in the early stages, and later 1% zinc sulphated solution. Ointments and
creams used include zinc oxide and 1% hydrocortisone. Excessive granulation needs to be
discouraged by excision, curettage or by the application of a caustic such as silver nitrate.
WOUND HEALING72
Wound is the loss of continuity of tissue due to injury. The restoration of this continuity
is a complex biological response. Many studies have taken place for this complex mechanism .
The surgeon’s prime effort should be to prevent, minimize and eliminate these factors which
retards wound healing process. Healing on the other hand is the body response to any injury for
normal structure and function of the body.
In humans regeneration is up to epithelium and liver. Most of the tissues heal by repair
resulting in scaring. Following injury wound healing is an active dynamic process with no
intervening lag period. It has been subjectively divided in to stages while in actuality it is a
variety with various stages coexisting at the same time. The process of healing involves two
distinct processes.
Regeneration73: Replacement of damaged tissue by similar type of tissue. This takes place by
proliferation of parenchymal cells and results in complete restoration of original tissues.
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Repair73: Replacement of damaged tissue by granulation tissue followed by fibrosis and scar
tissue formation. This occurs when the surrounding specialized cells do not posses the capacity
to proliferate. Some times both processes take place at the same time.
Regeneration and Repair can be accomplished by the following two ways:
Healing by first intention (primary union): It is found in a clean incised wound due to a surgical
incision where in there is only a potential space between the edges. It produces a clean, neat, thin
scar.
Healing by second intention (secondary union): In this the wound is infected and breaks open
with pus discharge and wound with skin loss, also primary suturing is not possible. The wound
takes longer time to heal with an ugly scar.
The 4 basic processes in wound healing are74
1) Inflammation
2) Wound contraction
3) Epithelization
4) Granulation tissue formation
Wound heals by the same basic processes , but their application is different in closed and open
wounds.
Inflammation
Immediately after disturbance of tissue integrity, inflammation occurs. Platelet become

adherent and with clotting factor form haemostatic plug to stop bleeding from the small blood
vessels. The blood vessel undergoes transient vasoconstriction followed by vasodilatation.
Histamine is said to be the primary mediator of inflammatory vascular response. This is liberated
by platelets, mast cells, and granulocytes. Histamine produces local vasodilatation and increase
permeability of small blood vessels. With increase of permeability protein and plasma leak out of
the vessels .however action of histamine is short lived and local sources are depleted rapidly.
Soon the kinin takes over the job of implicating local vascular response from
histamine.Kallikrein,an enzyme found in plasma and in granulocytes,releases bradykinin and
kalliden.In the presence of kinins,the local cells produce a variety of prostaglandins. These
prostaglandins seems to be the final mediator of acute inflammation and lay a chemotactic role
for white cells and fibroblasts.
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In the dynamic stage of inflammation, actively motile cells, white cells migrate into the
wound and start engulfing and removing cellular debris and injured tissue fragments. At first,
polymorphonuclear leucocytes control .This stage has also chemical mediators. Lucotaxine, a
peptide formed in damaged tissue by the enzymatic destruction of albumin, is thought to be the
chemotactic agent-attracting leukocyte into the wound.
As the transient face of white cell migration ends, the granular sites with shorter life die
and release acid hydrolysis into the local environmental previously the proportion of the
granulocyte and monocyte in the wound area where in the same ratio as they are in the blood. As
the granular cells are dying, the proportion of monocyte increases significantly and these
monocytes continue there scavenging activity for weeks. Monocytes become the dominant cell
by 5th day they are phagocytic and ingest cellular debris. It has been found out experimentally
that wound healing may proceed normally in the absence of granulocytes and lymphocytes, but
monocyte must be present to create normal fibroblast production. Depression of monocyte will
delay wound healing
Classical local signs of inflammation.
1) Heat (color) Æ Large amount of warm blood and energy produced

by metabolic reactions.
2) Redness (rubor) Æ Due to increased vasodilatation at the site.
3) Swelling (tumor)Æ Presence of fluid in the tissues surrounding the wound.
4)Pain (dolor) Æ May be caused by damage to nerve endings, activation of
kinin system, pressure of the fluid or presence of enzymes such as prostaglandin’s which causes
chemical irritation
5) Loss of function
Wound Contraction:-
For centuries wound contraction has been observed in open wounds with tissue loss
for centuries. Only recently however, the mechanism responsible for wound contraction has been
investigated extensively. This wound contraction does not begin immediately and that about three
to for days before the movement of the edge become measurable. This period when no wound
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contraction is noticed, is called as initial lag period. After this period there is a period of rapid
contraction, which is completed by the 14th day. At this time the wound is reduced approximately
80% of its original size. The magnitude of the contraction varies with the species of animals and
with shape, size, site of the wound
The amount of contraction depends on the amount of skin available surrounding the
wound to be extended over the wound. Hands and face of a young person do not contain excess
skin so wound contraction is limited in these places whereas the cervical region or face of the old
person wound contraction may be more and effective due to lax skin around. When loss of skin
occurs over an area such as malleolar surface of the lower leg and ankle, wound contraction simply
cannot occur because there is not enough extra skin around the defect.
The first step in studying the wound contraction is to define precisely where the fundamental
process is located.It should be determined whether a centripetal movement occurs because an
energy or power source is pulling the skin edge to the center of the defect.
In order to explain the mechanism of wound contraction, a number of factors have been
proposed. These are as under;
i) elimination of fluid by drying has been suggested as a cause of diminution in the size of
wound. But this has not been substantiated, as water content of central wound tissue at
the beginning of wound contraction has not changed significantly as at the end of
contraction.
ii) Contraction of collagen has also been incriminated as the cause of wound contraction, but
wound contraction proceeds at a stage when the collagen content of granulation tissue is
very small.
iii) Discovery of myofibroblasts appearing in active granulation tissue has resolved the
controversy surrounding the mechanism of wound contraction. These cells have features
intermediate between those of fibroblasts and smooth muscle cells. Their migration in to
the wound area and their active contraction decreases the size of defect.
Factors inhibiting wound contraction:
1)Corticosteroid administration
2)Contraction does not occur normally in burns
3)Immediate skin grafting
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4)X-irradiation
5)Colchicines and vinblastin also inhibit wound contraction, as they are inhibitors of
microtubule formation in the myofibroblasts
6)Cytotoxic agents particularly the cytochrome poisons in non-lethal doses.
Epitheliasation
In skin wounds the epidermis immediately adjoin to the wound edge becoming
thickening on the 1st day. Marginal basal cells loose their firm attachment to the under lying
dermis, enlarge and begins to migrate into the wounds. The fixed basal cells in the wound
undergo rapid mitotic division and daughter cell migrates. With in 48 hrs the entire wound
surface is re-epithelised. After bridging the wound effect the migrating epithelial cells loose the
flattened appearance and become more columnar in shape. Layering of the epithelium starts and
surface cells keratinize. The epithelial cells also migrate down the suture tracts. Subsequent
epithelial thickening and keranization produce marked foreign body reaction and formation of
sterile abscess, so non absorbable suture should be removed in right time.
In one sentence the epitheliazation of wound occurs by proliferation and migration of the
marginal basal cell lying close to the wound margin. When there is skin loss, dermal pits left
behind act as island for regenerating epithelium but there is no regeneration of hair follicle, sweat
and sebaceous gland in the new epidermis.
GRANULATION TISSUE FORMATION:
The haematoma within the wound is soon replaced by granulation tissue, which consists of new
capillaries and fibroblasts.
Granulation tissue formation is preceded by two phases.
I. Phase of traumatic inflammation
II. Phase of demolition.
The granulation tissue is mainly formed by proliferation and migration of the surrounding
connective tissue elements. It is in fact composed of in the first instance by capillary
loops and fibroblasts with a variable number of inflammatory cells. So initially it is a
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highly vascular tissue, it gradually turns into an avascular scar tissue. The two stages are
considered in this process.
Stage of vascularisation: As mentioned above the wound clot is invaded by the macrophages,
which with their phagocytic activities remove the particulate matters and move towards the
centre of the wound. This process is followed by capillaries loops and fibroblasts. The ingrowths
of capillary loops and fibroblasts which help to form living granulation tissue are known as
Organization.
Solid buds of endothelial cells grow out of the existing damaged blood vessels at the
surface of the wound. These undergo canalization and by anastomosis with their neighbours form
a series of vascular arcades. Under the electron microscope gaps are seen between the
endothelial cells and the basement membrane is poorly formed. These newly formed capillary
loops leak protein and thus the tissue fluid which is formed is a very suitable medium for
fibroblastic growth. Gradually these capillary loops differentiate, a few acquire muscle coat and
become arterioles, whereas others enlarge to form thin walled venules. A few disappear or persist
as part of the capillary bed. The source of smooth muscle fibres to form arterioles is either cell
migration or differentiation of existing primitive mesenchymal cells.
The fibroblasts, which accompany the capillary loop, gradually become larger to become
elongated fibrocytes. During this process of fibro genesis, pH becomes alkaline. Collagen is
formed ultimately from these fibroblasts. Collagen is an extra cellular secretion from specialized
fibroblasts and the basic molecules which fibroblasts synthesis is frequently called tropocollagen.
This tropocollagen condenses in the mucopolysaccharide extra cellular space to form fibrils.
These fibrils are grouped together to form the reticulin fibres. These fibrils when condensed
together to form the collagen fibres. This collagen is not inert and it undergoes constant turnover
under the influence of tissue collagenase. There are several types of collagen which differ in the
amino acid sequence of the constituent chains, though hydroxyproline, proline and glycin
dominate. Type 1 collagen is found in the tendon, ligament, skin and bone. Type 2 collagen is
found in cartilage, mainly articular and costal cartilages. Type 3 collagen is found foetal dermis
and later on is replaced by type 1 collagen at birth. Type 3 collagen appears to be an important
component of tissues with unusual degree of elasticity such as aorta, oesophagus and uterus. The
aminoacids found in the collagen are hydroxyproline and hydroxylysine. Other fibrous tissues
Page 46
such as elastin do not contain significant amount of hydroxyproline. Fibroblasts are also thought
to be responsible for the production of mucopolysaccharide ground substance.
Stage of devascularisation: In this stage fibroplasia proceeds and some vessels undergo
atrophy, whereas others show endarteritis obliterans that means their lumens become obliterated
due to intimal proliferation.So the granulation tissue looks pale at this stage, which is known as
devascularisation. At the beginning of this stage, nerve fibres and lymphatics form. With the
ingrowths of nerve fibres, the arteriole exhibits rhythmic contraction. The new lymphatics
develop from existing lymphatics in the same way as do the capillary loops. Mast cells also make
their appearance and their granules are derived from the ground substance. At later stage these
mast cells disappear and hyalinization occurs. There is also formation of scar tissue. This process
is known as cicatrisation. Collagen turns over and remodeling in the scar never stops. In fact the
turn over of collagen in scar tissue is faster than in other tissues. The phenomenon of scar
remodeling is the basic function of injured tissues. The gross appearance of remodeling scars
suggests that collagen fibers are altered and rewoven into different architectural patterns with
time.
Tensile strength: The strength of a healing wound is of great practical importance to the
surgeon. It acts as the main safeguard against wound dehiscence. Experimentally it may be
estimated by measuring the force necessary to disrupt the wound. In the first few days the
strength of a wound is only that of the clot which cements the cut surfaces together. Later on
various changes takes place in the wound healing process and at the end the tensile strength of
the wound corresponds to the increase in amount of collagen present.
Factors influencing the tensile strength of the wound are:
1) Direction of the wound: Skin wounds parallel to the lines of langer heal faster. Skin
incisions made across langer’s lines tend to gape and their healing is delayed. Tensile strength of
the wound becomes more when this is parallel to the lines of langer.
2) Pull of underlying muscles: The wounds which are parallel to the pull of the underlying
muscles constitute strong scar.
3) Previous wound: Resutured wounds heal faster than those sutured primarily, as the
repairative process has already commenced.
4) Abdominal binders: Reduce the rate of gain in strength.
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Factors affecting granulation tissue formation:

Cortisone administration: Excess corticosteroid administration inhibits granulation tissue
formation. Fibroblasts remain small with little collagen formation. This effect is well accepted in
experimental animals, but corticosteroid in normal dosage may not influence wound healing in
human beings.
Scurvy: in this condition though vascular granulation tissue is formed, yet there is failure of
collagen formation. Instead there are thick reticulin fibres. Maturation to collagen does not occur
in the absence of vitamin-C
Protein starvation: Also causes delayed formation of collagen. There remains excessive
accumulation of poorly- sulphated ground substance.
Complications of wound healing75:
1. Implantation cysts
2. Painful scars
3. Cicatrisation – it often produces various deformities
4. Keloid formation
5. Neoplasia.
Factors influencing wound healing: These can be divided in to two groups;
I. General factors:
Age – wound healing is fast in the younger, but it is normal in old age, unless associated with
debilitating diseases or ischemia or diabetes etc.
Nutrition –
(i) Protein deficiency – it causes the injury of granulation tissue and collagen formation. It
should be noted that it is not always due to inadequate intake, but may be due to excessive loss
e.g. Nephrotic syndrome, chronic inflammatory conditions etc.
(ii) Vitamin – C deficiency
(iii) Vitamin - A – is required for proper epithelialisation
(iv) Zinc, calcium, copper and manganese deficiency – zinc is an essential component of
many enzymes which are involved in protein synthesis. There is some failure of
granulation tissue formation in case of zinc deficiency. Others are essential minerals
which are also required for proper wound healing. These may be depleted in intestinal
fistulas and burns.
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1. Hormones:-
(i) Corticosteroids
(ii) Desoxycorticosterone acetate and anabolic steroids like testosterone are also
concerned with increasing the speed of wound healing.
Local factors:
1. Position of skin wound – the skin wounds which are parallel to the lines of Langer, heals
faster. These lines of Langer are due to arrangements of collagen bundles in the dermis.
2. Blood supply – Wounds with poor blood supply heals slowly. E.g. wounds of pre tibial region,
wounds in ischaemic limbs, and wounds of leg in patients with varicose veins.
3. Tension – If the wound is in tension, its healing will be jeopardized. Haematoma and infection
increases tension.
4. Infection – Once infection occurs wound healing is always delayed. It may be considered as
the most important factor that delays healing. Due to infection, fibroblasts face tough time to
persist as they have to compete with inflammatory cells and bacteria for oxygen and nutrients. So
proper granulation tissue formation and collagen formation becomes affected.
5. Movement: - It delays wound healing so rest is essential for healing. Delicate capillary loops
of granulation tissue, delicate epithelium gets damaged due to movement
6. Exposure to ionizing radiation: - Previous X –Irradiation may affect vascularity of the part. It
also causes delay in the formation of granulation tissue. But most important is that it inhibits
wound contraction
7. Foreign bodies: - These include tissue reaction and inflammation. If sutures are kept for
longer period, it may cause aseptic abscess.
8. Adhesions to bony surfaces: - cause delay in wound healing by preventing proper wound
contraction. This is seen particularly in wounds over tibia.
9. Necrosis: - this obviously retards healing.
10. Lymph drainage: - Impairment of lymph drainage causes oedema of the part which
jeopardizes the process of wound healing. Elevation of such limb often facilitates healing.
11 . Ultraviolet light: - has been confirmed experimentally to increase the rate of healing.
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MANAGEMENT OF WOUNDS76
1. Wound should be inspected and classified as per the type of wounds.
2. If it is in a vital area –
The airway should be maintained.
The bleeding, if present, should be controlled.
Administrations of Intravenous fluids are started.
Oxygen, if required, may be given.
Communicating injuries and fractures etc. should be looked for.
3. If it is an incised wound, primary suturing is done after thorough cleaning.
4. If it is a lacerated wound, then the wound is excised and primary suturing is done.
5. If it is a crushed or devitalized wound, there will be oedema and tension in the wound. So after
wound debridement or wound excision by excising all devitalized tissue, the oedema is allowed
to subside. Then delayed primary suturing is done.
6. If it is a deep devitalized wound, after wound debridement it is allowed to granulate
completely. Later, if the wound is large, a split skin graft (Thiersch graft) is used to cover the
defect.
7. In a wound with tension, fasciotomy is done so as to prevent the development of
compartmental syndrome.
8. Vascular or nerve injuries are dealt with accordingly. Vessels are sutured with 6-zero
polypropylene non absorbable suture material. If the nerves are having clean cut wounds, it can
be sutured primarily with polyprolelene 6-zero or 7-zero suture material. If there is difficulty in
identifying the nerve ends or there are crushed cut ends of nerves, then marker stitches are placed
using silk at the site and later secondary repair of the nerve is done.
9. Internal injuries (intracranial by craniotomy, intrathoracic by intercostals tube drainage,
intraabdominal by laparotomy) have to be dealt with accordingly. Fractured bone is also
identified and properly dealt with.
10. Antibiotics, fluid and electrolyte balance, blood transfusion, tetanus toxoid, or anti tetanus
globulin (ARG) injection should be given.
Wound debridement (wound toilet, or wound excision) - is liberal excision of all
devitalized tissue at regular intervals (of 48-72 hours), until healthy bleeding and vascular tidy
wound is created.
Page 50
Primary suturing- means suturing the wound immediately within 6 hours. It is done in clean
incised wounds.
Delayed primary suturing- means suturing the wound in 48 hours to 10 days. It is done in
lacerated wounds. This time is allowed for the oedema to subside.
Secondary suturing- means suturing the wound in 10-14 days or later. It is done in infected
wounds. After the control of infection, once healthy granulation tissue appears, secondary
suturing is done.
Page 51
DRUG REVIEW
In the Chastuspada of treatment the Drugs or Dravya has been placed next to the Physician77. So
Dravya is an important part of Chikitsa. The wide range of knowledge regarding the drug is very
essential to the Physician, because without the proper knowledge of the drug or aushda the
patient cannot be treated properly. The drug act as Dosha Pratyanic, Vyadhi Pratynic and Ubhaya
Pratyanic. So the drugs which used will be acting as Ubhaya Pratyanic. Acharya Charaka says
that each dravya in this universe comprises of a medicinal value it is the Physician`s intellect to
select the appropriate one.
Though healing of an ulcer is a natural process various types of micro organism like bacteria
with their pathogenic action inhibit the healing process by releasing toxins. So, since ancient
time healing of vrana is a serious issue. Our Acharya `s have explained in detail about vrana
and vrana roopana.
For a good healing to take place the drug must possess two properties i.e.
1. Vrana Shodhana - For debriment of wound
2. Vrana Ropana – For the healing of wound
It is important to find a single drug which have both Vrana Shodhana and Vrana
Roopana78 properties. For the present study Argwadha bark was selected
ARAGWADHA KWATHA
Aragwdha kvatha is a simple preparation. The only ingredient is Aragwadha bark

which is available through out India.
Description about Aragwadha
History of the drug

VEDIC PERIOD
Aragavadha is mentioned in the vedas.
PURANA PERIOD
No reference regarding this drug in any puranas.
Page 52
SAMHITA PEROID
79
¾ Charaka samhita :
Aragavadha is mentioned in sutrasthana, chikitsasthana, vimanasthana and kalpasthana

and some synonyms and also a separate chapter is mentioned for this.
¾ Sushruta samhita:
Sushruta also mentioned Aragavadha in his suthra, chikitsa and kalpa sthana and some
synonyms are also mentioned.
¾ Astanga hrudaya:
In Astanga hrudaya Aragavadha is mentioned in suthra, chikitsa and kalpa sthana and
uttarasthana and some of synonyms also mentioned.
MEDIEVAL PERIOD
¾ Sushruta nighantu:
The drug with its actions, synonyms, properties and indications are mentioned in this
book in Aragvadha gana.
¾ Astanga nighantu:
The drug with its synonyms, properties is mentioned in this book.
¾ Dhanvantari nighantu:
The drug is mentioned in guduchyadhi varga and also its synonyms and properties are
mentioned.
¾ Hrudaya deepika nighantu:
The drug is mentioned in tripada varga along with its synonyms.
¾ Shaligrama nighantu80:
The drug with its synonyms, properties is mentioned in this book.
¾ Mahoushadi nighantu:
The synonyms, properties and parts used are mentioned in this book.
Madanapala nighantu:
The drug with its synonyms, actions, properties and indications are mentioned in
thisbook.
¾ Kaiyadeva nighantu81:
The drug is mentioned in aoushadi varga with its synonyms, properties, action and
indications.
Page 53
Bahavaprakasha nighantu82:
The drug is mentioned in haritakyadhi varga with its synonyms, properties and
indications.
¾ Raja nighantu:
Here the synonyms, properties and indications are mentioned in prabadradi varga.
¾ Nighantu adarsha:
Here Acharya gives an account of definition of the drug, synonyms, properties, uses,
vernacular names are mentioned.
¾ Priya nighantu:
In these book synonyms, properties and actions are mentioned.

¾ Yoga ratnakara:
In this book quality of the drug is mentioned
¾ Sahasra yoga:
In this book formulation of the drug is mentioned.
MODERN PERIOD
Almost all the modern books have mentioned about the drug
¾ Indian medicinal plants: by Krithikar K.R. and B.D. Basu
In this book vernacular names, habitat, parts used, properties and uses are mentioned
¾ Indian material media: by K.M. Nadakarni
In this book vernacular names, habitat, parts used, actions and its uses are mentioned.
¾ Glossary of Indian medicinal plants:
In this book regarding the references of samhita of the drug are mentioned.
¾ Dravya guna vijnana: by P.V. Sharma83
In this book detailed explanation of drug is explained in systematic form.
¾ The wealth of India:
In this book it is mentioned about synonyms, vernacular names, morphology, and useful
parts, phyto chemistry and actions of the drug
Page 54
BIONOMINAL NOMENCLATURE
Sanskrit : Aragavadha
Latin name : Cassia fistula Linn.
Kingdom : Plantae
Division : spermatophyta
Sub division : Angiosperm
Class : Dicotyledons
Sub class : Poly patellae
Order : Rosales
Series : Caesalpinaceae
Family : Cossia
Genus : fistula
Species : Colyciflorae
Kula : Shimbi Kula
Upakula : Pooti karanja
VERNACULAR NAMES84
Sanskrit : Aragvadha, karnikara, krutamala, arevata
English : Indian laburnum, purging fistula, pudding pipe tree
Hindi : Amalatar, girimala, sonhali
Kannada : Kokke. kokemara
Malayalam : Konna, konikkonna
Tamil : Konna, konaraikkai
Telugu : Relo chefter, arag vadhamu, kolaponna
Bengali : Sonalu, sondal
Gana`s according various Acharyas & nighantu
Charaka samhita : Kustaghna

Kandughna
Virechana
Tiktaskandha
Page 55
Sushruta samhita : Aragvadhadi

Shamadi
Adhobhagahara
Kaiyadeva nighantu : Usadhi varga

Bhavaprakasha nighantu : Haritakyadhi varga
Dhanvantari nighantu : Guduchathi varga
Raja nighantu : Prabhadhathi varga
Sushruta nighantu : Aragavadhi gana
Astanga nighantu : Aragavadhi gana
Kula : Shimbi Kula

Family : Cossia
Latin name : Cassia fistula Linn.
English name : Indian laburnum
HABITAT OF THE FAMILY84

The family consists of herbs, shrubs, or trees
Flowers : More or less regular
Calyx : Free or united imbricate
Corolla : Free, imbricate ascending in buct
Stamens : 10 or few, free, ravel many
Pollen gram : Simple
Leaves : Usually pinnate, sometimes bippinole ravel simple
Botanical description
Aragvadha is Cassia fistula Linn. Belongs to the family Caesalpinaleae
That is moderate sized handsome deciduous tree, 8-15cm in height, with greenish grey smooth
bark when young of rough when did exfoliation in hard scales.
Page 56
Leaves:
Pinnately compound, leaflets 4-8 pair, ovate, acute, bright green, globosely above, pallor
and silvery pubescent beneath when young, main nerves numerous.
Flowers:
Bright yellow in lax pendulum racemes 30-50cm long shortly stipulate, nearly straight,
smooth, shiny
The tree flowers ones a year in the month of April.
Seed:
Broadly ovate, horizontal immersed in dark colored sweetish pulp
Fruit:
Pendulous, nearly, straight, dark brown or brownish black, smooth, shining, hard,
mebhiscent, seeds many, broadly ovate, smooth, and light to dark or reddish brown.
Useful parts:
Pulp, root, bark, flowers, pods, leaves
Properties:
Rasa- Madhura, tikta,
Guna- Guru, mrides, snigdha,
Veerya - Sheeta,
Vipaka - Madhura,
Karma : Pitta hara, kapha pitta hara, vata pitta hara
Actions:
Pitta hara, kapha pitta hara, vata pitta shamaka
HABIT OF THE DRUG84

Aragvadha is a deciduous medium sized tree unto 24m height and 1.8 m girth with a
straight bole up to 15 m branches is spreading and slender.
Bark:
Greenish smooth, exfoliating, woody scales up to 1.5cm thick
Page 57
Root:
A much branched tap root
Leaves:
Compound, alternate 20-40cm long, ramal, stipulate, small and caduious petiolate
Leaflets:
4-8 pairs, ovate or, oblong, entire, acute, sub sessile, glabrous and leathery
Bright green and glabrous above paler and silvery pubescent beneath
Flowers:
30-50cm long, arranged in lax racemes bright yellow color
Calyx: 1 cm long, segments oblong, obtuse
Corolla: 3.8cm, across
Petals: 5, sub equal, obovate, shortly clawed, viewed stamen all antheriferous.
Pods:
Pendulous, cylindrical in shape, rarely straight smooth shining, 30-60cm long dark brown
or brown in color
Seeds:
Broadly ovate, endospermic, light brown, hard, smooth, shining 8mm long, 5mm thick
PHYTO CHEMISTRY84
Leaves:
Anthroquinone derivatives very little tannins and glycosides
Root bark:
Phlobaphences
Oxgyanthroquinone substances
Stem bark:
10-20% tannin
Pulp:
Resin, anthrax-quinone derivatives, volatile oil 3 waxy substances resimose substances
Page 58
Pulp of pod:
Sugar 60%, mucilaginous substances, glutine, pectin, coloring matter, calcium oxalate,
alkalis, resin and watery contents
Flowers:
Glycosides
PARTS USED
¾ Pulp, root, bark, flowers, pods and leaves are mainly used for medicinal purposes
VISHISHTA YOGA
Aragvadhadi kashaya
Aragvadharista
Aragvadhodi leha
Aragavadhadi taila
USES OF DIFFERENT PARTS

Flowers:
It is made in to decoctions and given in stomach disorders
Leaves:
It is used for purgation in kustha
Paste of leaves applied externally for ring worms
It is also given for pustules, chill blim, insect bite, facial paralysis, rheumatism
Bark:
Root bark is grinded with rice water and used as nasya and lepa
Root bark is a good laxative
Bark leaves mixed and rubbed with oil and applied for ringworms, insect bites, facial
paralysis etc.
Root is useful in fever, heart diseases, constipation and biliousness etc
Seeds:
Powdered seeds are prescribed as an emetic
Page 59
Pulp:
It is applied for gout, rheumatism, snake bite etc
It is mild laxative
For kamala
In the flatulent colic of children it is commonly applied round the umblicus to produce
motion
In general Aragwadha is having Tiktha and Madhura Rasa and Sheeta Veerya. Thus acts
as Vranashodhaka, Vedanasthapaka, Shothahara and Vranaropaka and also helps in Tridosha
Shamana.
Kwatha kalpana
The term Kvatha has been derived from the word – ‘Kvathana’ i.e. boiling. It is third in series of
Panchavidha Kashaya Kalpana85.
Definition: - The preparation obtained by boiling the drugs with water is called as Kashaya.
Synonyms: - Shrita, Kashaya, Kvatha, Niruha
General use of Kashaya:-
1. As Aushadhi used as Shodhana and Shamana Aushadhi.
• For Shodhana: - In Abyantara shodhana various Kashayas are used for Vamana,
Virechana and Niruha basti. In Bahya Shodhana Kashayas are used for vrana
Shodhana and Prakshalana.
• For Shamana: - In Abhyantara Shamana Kashayas are used as Shamana
Aushadhis. In Bahya Shamana Kashayas are used for Parisheka, Avagaha, Kavala
and Gandusha.
2. In preparation of various Upakalpana Kashayas are used in preparing various
Upakalpana like Arishta, Sneha- Kalpana and Avaleha etc.
3. As Anupana Kashayas are used in different Vyadhis along with other drugs as
Anupana.
Page 60
Preparation of Aragwadha Kvatha:

It contains two procedures. First one is the preparation of the Kvatha Choorna and next is
the preparation of the Kvatha.
Ingredients of Aragwadha Kvatha

The dried bark of aragwadha is powered and kwatha churna is prepared . For 50 gm
Kwatha churna 800 ml water is taken. Then it is boiled under mild fire until it becomes
1/4th of its original quantity. Then it is removed from fire and filtered86.
Page 61
Methodology
METHODOLOGY
MATERIALS AND METHODS
Research is the careful investigation or enquiring in a systematized manner to gain

new knowledge with an intention which helps to solve problems. The final aim of any research
in the field of medical science is to find out appropriate remedies for particular ailments and
promote healthy living.
Methodology is the entire process of study. When a scientific study is conducted,

methodology is a very important aspect which has to be given due consideration. This includes
the procedure for selection, the description of materials , clinical trial and the statistical technique
used for analysis. Clinical study is an important step to compare and to assess the efficacy of
Aragwadha kashya in the management of Dusta vrana.
Methodology
Cleansing or debridment of the wound is an important step in the management of Dustha
vrana.Pariseka is that process which means pouring of the medicament from a measured height
over the affected site with a definite purpose i.e. Shodhana primarily in this study. The
medicament which is in the liquid form is freshly prepared every time. Pariseka is carried out
over the wound and around the wound , because Pariseka is over and around as conveyed by the
word “Parisamantha seka ithi parisek”. The temperature of the fluid may be as per the need,
which is governed by climate , anticipated action of kashya and condition of the wound.
Aims and objectives of the study
• To understand dusta vrana in proper.

• To know about Aragwadha kwatha.
• To study the pariseka vidhi.
• To evaluate the effect of Aragwadha Kwatha pariseka in the case of dusta vrana and to
assess the results wholly of the study of the above said procedure in seleted 30 cases
Source of Data:
A Clinical Study on Pariseka Vidhi in the Management of Dusta Vrana with Aragwadha Kashaya
Page 62
Methodology
Diagnosed cases of DushtaVrana were randomly selected irrespective of their age, sex,
cast, creed etc from Out Patient and In Patient Department of Shalyatantra, K.V.G.A.M.C&H
Sullia
Method of Collection of Data:
Clinically diagnosed 30 Patients of DushtaVrana were assigned in single group for the
observational study. And the results were assessed on comparative studies of features of BT and
AT. A special proforma was designed for this study. The patients were examined completely
on Ayurvedic and Modern concepts of examination and essential investigations were performed
to diagnose and assess the Dushtavrana. The sign and symptoms will be recorded on the
proforma designed specially for the study.
Duration of Treatment: 15 days.
a) Observation period:
The patients were observed for Dustha vrana Lakshana. Assessment of the relief in the
signs and symptoms was recorded on 1st day, 3rd day, 6th day , 9th day and 12th of the treatment.
b) Inclusion Criteria:
Patients between the age group of 20-70 years with irrespective of sex , religion and caste.
c) Exclusion criteria :
Madhumeha
Visarpa
Systemic disorders like kamala , rajayakshma etc
Page 63
Methodology
Investigations :
- Routine investigations.
- Culture and sensitivity of discharge wherever necessary.
- Histopathological examination wherever necessary.
Study duration :
Pariseka with Aragwadha kwatha – 15 days
Follow up period - 15 days
Treatment schedule :
Aragwadha Kvatha Pariseka was done once daily (Morning) for 15 minutes and a dry sterile
pad was placed over the wound & bandaging of wound is done. The schedule is divided into
three stages
Poorva karma:
Removal of excessive hair on and around the wound by trimming with scissors.
The bed should be covered with rubber sheet to avoid spillage of the kashaya.
Position of the patient:

The patient is made to sit or lie down in a comfortable position. So that the Pariseka vidhi can be
done without interruption causing no discomfort to the patient.
Pradhana karma:
A standard method of Pariseka was set to have uniformity in all the cases. Freshly prepared
Aragwadha Kwatha after becoming sukoshna (approximately360c-36.50c) was taken in an
autoclaved bowl after filtering a through sterilized cotton cloth. It is poured over and around the
vrana for about 10 cm sq area of vrana. Instillation of kwatha was done continuously for about
15 minutes from a height of about 10 cm above the wound. The fluid was allowed to get
collected in a vessel by keeping the vessel in contact with the dermis of the part in a most
shallow area so that fluid get collected in the vessel naturally.
Page 64
Methodology
Paschat karma:
1. The drained out fluid was taken away and observed for dislodged particles from the vrana.
2. Vrana and surrounding area was dried and cleansed by wet and squeezed swab
3. After draining thorough examination of the wound is done and recording of each information
was also.
4 .After allowing the wound to get dry naturally , dry sterile pad was kept over the wound and
bandaging is done.
5. Patient is then taken to ward.
Assessment criteria:
The patient’s response was assessed on the basis of subjective and objective criteria by assigning
the suitable score to each parameter. The method adopted for scoring was as follow:
Subjective criteria-
Pain -
0- No pain.
1- Localized feeling of pain during movement but tolerable.
2- Localized feeling of pain which affects movement.
3- Localized feeling of pain during rest but not disturbing sleep.
4- Localized feeling of pain disturbing sleep
Burning sensation-
0- No burning.
1- Mild localized,intermittant burning sensation.
2- Moderate localized and some time feeling of burning.
3- Severe localized and often burning which does not disturb sleep.
4- Continuous burning sensation disturbing the sleep
Page 65
Methodology
Itching –
0- No itching.
1- Mild localized itching sensation.
2- Moderate localized itching sensation.
3- Severe, localized but not disturbing sleep.
4- Continuous itching which disturbs sleep
Tenderness-
0- No tenderness.
1- Mild tenderness
2- Moderate tenderness.
3- Severe tenderness
4- Tenderness with just touching with soft object like cloth or cotton thread
Objective criteria
Smell-
0- No smell.
1- Minimum bad smell.
2- Moderate bad smell.
3- Severe but tolerable.
4- Foul smell which is intolerable
Size-
A sterile blotting paper is placed over the ulcer and pressed with uniform pressure. The
impression is directly measured at its maximum length and breadth.
Discharge-
0- No discharge
1- Mild dischrge
2- Moderate discharge
3- Severe discharge
4- Bandage gets wet completely and needs to be changed before 24 hrs.
Page 66
Methodology
ASSESSMENT OF TOTAL EFFECT OF THERAPY
Table 36 showing assessment of total effect of therapy
Complete remission 100% relief in signs and symptoms and walking by patient
without any pain were considered as complete remission
Marked improvement 75-99% relief in signs and symptoms
Moderate improvement 50-74% relief in signs and symptoms
Mild Improvement 25 – 49% relief in signs and symptoms
Unchanged No change in signs and symptoms
FOLLOW UP STUDY:
Follow up study of each case was done on the 15 th day after the discharge of the patient.
Statistical Analysis:
For assessing the improvement of symptomatic relief and to analyze statistically the
observations were recorded before starting the treatment, during the course of treatment i.e.
every 3rd day , after the treatment and after follow- up period (i.e on the 30 th day of treatment).
The mean, percentage, S.D, S.E, and t-value (paired t-test) were calculated from the observation
recorded. The total result including the overall effect of therapy is given in tables for the present
study.
Page 67
Observation and results
OBSERVATION & RESULTS

In the present study, 30 patients suffering from Dusta vrana fulfilling the inclusion criteria were
studied and were randomly categorised .
AGE
Table No.20 Distribution of 30 patients of Dustha vrana according to age.
Age N=30 %
20-30 1 3%
31-40 6 20%
41-50 9 30%
51-60 8 27%
61-70 6 20%
Distribution of 30 patients of Dustha vrana according to age.
Analysis of age incidence of 30 patients suffering from Dusta vrana showed more number of
patients between the age group of 41-50 years ie 30% , followed by the age group 51-60 years
i.e. 27% and 6 were from the age group 61-70 &31-40 years. . Details of the age incidence are
given in Table no 20 and graphically represented in Figure No.1
Graph No. 1, Distribution of 30 patients of dustha vrana according to age
Page 68
SEX
. Table No.21Distribution of 30 patients of Dustha vrana according to Sex
Sex N=30 %
Male 17 56
Female 13 43
In the present study 56% of males were registered in comparison to 43% of females. Details of the sex
incidence are given in table no.21 and graphically represented in graph no . 2.
Graph No. 2, Distribution of 30 patients of dustha vrana according to sex
Page 69
RELIGION
Table No.22Distribution of 30 patients of Dustha vrana according to Religion
Religion N=30 %
60%
Hindu
18
Muslim 20%
6
Christian 6 20%

60% of the patients were Hindus in the study, 20% each in Muslim and Christian category .
Distribution of patients according to the religion are given in Table No.22 and graphically
represented in Figure no.3.
Graph No. 3, Distribution of 30 patients of dustha vrana according to religion
Page 70
OCCUPATION
Table no 23Distribution of 30 patients of Dustha vrana according to Occupation.
occupation N=30 %
Rubber 10 33
tappers
Hotel 9 30
workers
House wives 5 16
Business 3 10
Agriculture 2 6
Student 1 3
Among the 30 patients selected for the study 10 patients were rubber tappers i.e. 33%, followed
by hotel workers i.e.9 in no which is 30 % and the rest were in the series like house wife ,
business , agriculture and student in the manner 5, 3, 2, 1 each. Distribution of patients according
to the occupation are given in Table No.23 and graphically represented in graph no. 4
Graph No. 4, Distribution of 30 patients of dustha vrana according to occupation
Page 71
SOCIO ECONOMIC STATUS
Table no 24
Distribution of 30 patients of Dustha vrana according to Socio economic status
Socio economic status N=30 %
Poor class 16 53
Middle class 10 33
Upper middle class 4 13
The patients of the present study were categorised under 3 group based on their socio economic status. In
that 53% belongs to the poor class, 10% belongs to the middle class and 13% belongs to the upper middle
class. Distribution of patients according to the socio economic status are given in Table No.24 and
graphically represented in graph no . 5
Graph No. 5, Distribution of 30 patients of dustha vrana according to socio economic status
Page 72
ADDICTIONS
Table no 25Distribution of 30 patients of Dustha vrana based on addictions.
Addictions N=30 %
Pan chewing 7 23
Smoking 5 16
Alcohol 2 6
In the present study 14 patients was having various additions. 23% i.e. 7 patients were having
the habit of pan chewing , 16% i.e. 5 were smokers and 6% i.e. 2 were alcoholic. Distribution of
patients based on their addictions are given in Table No.25 and graphically represented in graph
no.6
Graph No. 6, Distribution of 30 patients of dustha vrana according to addictions
Page 73
DIET
Table no 26Distribution of 30 patients of Dustha vrana based on diet.
Diet N=30 %
Vegetarian 8 27
Mixed diet 22 73
In the present study maximum of the patient were on mixed diet i.e.73% (22) and the rest were
vegetarians i.e. 27% (8). Distribution of patients according to the religion are given in Table
No.26 and graphically represented in graph no.7
Graph No. 7, Distribution of 30 patients of dustha vrana according to diet
Page 74
CHRONICITY
Table no 27Distribution of 30 patients of Dustha vrana based on Chronicity.
Chronicity N=30 %
Upto 3 months 21 70
Upto 6 months 5 17
Upto 1 year 4 13
In the present study 21 (70%) patients were suffering with the chronicity upto 3 months, 5 (17%)
patients were suffering with the chronicity upto 6 months, 4 (13%) patients were suffering with
chronicity upto 1 year. Distribution of patients based on their chronicity are given in Table No.27
and graphically represented in graph no 8
Graph No. 8, Distribution of 30 patients of dustha vrana according to Chronicity
Page 75
PART AFFECTED
Table no 28 Distribution of 30 patients of Dustha vrana based on Part affected.
Part affected N=30 %
Upper limb 3 10
Lower limb 27 90
In the present study 27 patients (90%) were having Dustha vrana on the lower limb and rest 3
patients (10) were having Dustha vrana on the upper limb. Distribution of patients based on the
part affected are given in Table No.28 and graphically represented in graph no.9
Graph No. 9, Distribution of 30 patients of dustha vrana according to part affected
Page 76
RESULTS
Effects of Aragwadha kashya pariseka in Dustha vrana
As mentioned earlier 30 patients of Dustha vrana were treated with Aragwadha kashya . The
effects of this type of treatment on each parameter were as follow:
Effect of Aragwadha kwatha pariseka on pain

Table 29
Sl. SYMPTOM Measures % S.D (+-) S.E (+-) t value p value
No BT BT-AT
1 PAIN 2.800 AT 1.633 1.167 42.000 0.974 0.296 3.936 <0.001
2 FU 1.200 1.600 57.000 1.212 0.369 4.340 <.001
Effect of Aragwadha kwatha pariseka (AKP) on pain before and after the treatment in 30
patients of Dustha vrana are given below. In AKP, statistical analysis revealed that the mean pain
score of Dustha vrana which was 2.800 before the treatment was reduced to 1.633 after the
treatment and after follow up it became 1.200 with 57% improvement. This change is
statistically highly significant (P≤0.001). Further details with Standard Deviation, Standard Error
of Mean, ‘t’ value and P value are given in Table No29 and graphically represented in figure
No: 10
Effect of Aragwadha kwatha pariseka on burning sensation

Table 30
Sl. SYMPTOM Measures % S.D S.E t p
No BT BT- (+-) (+-) value value
AT
1 BURNING 3.300 AT 1.467 1.833 56.000 1.233 0.375 4.886 <.001
2 SENSATION FU 1.133 2.167 66.000 1.432 0.436 4.972 <.001
Effect of Aragwadha kwatha pariseka (AKP) on burning sensation before and after the
treatment in 30 patients of Dustha vrana are given below. In AKP, statistical analysis revealed
that the mean burning sensation score of Dustha vrana which was 3.3002 before the treatment
was reduced to 1.467 after the treatment and after follow up it became 1.133 with 66%
improvement. This change is statistically highly significant (P≤0.001). Further details with
Standard Deviation, Standard Error of Mean, ‘t’ value and P value are given in Table No30 and
graphically represented in figure No:11
Page 77
Effect of Aragwadha kwatha pariseka on itching

Table no 31
Sl. SYMPTOM Measures % S.D (+- S.E (+- t p
No BT BT- ) ) value value
AT
1 ITCHING 3.467 AT 0.933 2.533 73.000 1.542 0.469 5.400 <.001
2 FU 0.533 2.933 85.000 1.779 0.541 5.418 <.001
Effect of Aragwadha kwatha pariseka (AKP) on itching before and after the treatment in 30
patients of Dustha vrana are given below. In AKP, statistical analysis revealed that the mean
itching score of Dustha vrana which was 3.467 before the treatment was reduced to 0.933 after
the treatment and after follow up it became 0.533 with 85% improvement. This change is
No:12
Effect of Aragwadha kwatha pariseka on tenderness

Table no 32
Sl. SYMPTOM Measures % S.D (+- S.E (+- t p
No BT BT- ) ) value value
AT
1 TENDERNESS 2.800 AT 1.600 1.200 43.000 0.970 0.295 4.067 <.001
2 FU 1.367 1.433 51.000 1.125 0.342 4.187 <.001

Effect of Aragwadha kwatha pariseka (AKP) on tenderness before and after the treatment in 30
tenderness score of Dustha vrana which was 2.800 before the treatment was reduced to 1.600
after the treatment and after follow up it became 1.367 with 51% improvement. This change is
No: 13
Page 78
Effect of Aragwadha kwatha pariseka on discharge

Table 33
No BT BT-AT
1 DISCHARGE 4.000 AT 0.600 3.400 85.000 1.737 0.529 6.431 <.001
2 FU 0.233 3.767 94.000 1.893 0.576 6.539 <.001
Effect of Aragwadha kwatha pariseka (AKP) on discharge before and after the treatment in 30
discharge score of Dustha vrana which was 4.000 before the treatment was reduced to 0.600
after the treatment and after follow up it became 0.233 with 95% improvement. This change is
No:14
Effect of Aragwadha kwatha pariseka on smell

Table no 34

No BT BT-AT
1 SMELL 3.333 AT 0.333 3.000 90.000 1.863 0.567 5.293 <.001
2 FU 0.067 3.267 98.000 1.989 0.605 5.396 <.001

Effect of Aragwadha kwatha pariseka (AKP) on smell before and after the treatment in 30
smell score of Dustha vrana which was 3.333 before the treatment was reduced to 0.333 after the
No:15.
Page 79
Effect of Aragwadha kwatha pariseka on size

Table no 35
No BT BT-AT
1 SIZE 4.000 AT 2.167 1.833 46.000 0.995 0.303 6.056 <.001
2 FU 1.900 2.100 53.000 1.139 0.347 6.057 <.001
Effect of Aragwadha kwatha pariseka (AKP) on size before and after the treatment in 30
patients of Dustha vrana are given below. In AKP, statistical analysis revealed that the mean size
score of Dustha vrana which was 4.000 before the treatment was reduced to 2.167 after the
No:16
ASSESSMENT OF TOTAL EFFECT OF THERAPY

Table no 37
Category No. of patients Percentage
Complete remission 0 0
Marked improvement 11 36
Moderate 18 60
improvement
Mild Improvement 1 3
Unchanged 0 0
Page 80
Graph no10 Graph showing effect of aragwadha kashya pariseka on ruk
Graph no 11
Graph showing effect of aragwadha kwatha pariseka on daha
Graph no 12
Graph showing effect of aragwadha kwatha pariseka on kandu
Page 81
Graph no 13
Graph showing effect of aragwadha kwatha pariseka on thodam
Graph no 14
Graph showing effect of aragwdha kwatha pariseka on srava
Page 82
Graph no 15
Graph showing effect of aragwadha kwatha pariseka on gandha
Graph no 16
Graph showing effect of aragwdha kwatha pariseka on size
Page 83
Graph no 17
Graph showing over all effect of aragwadha kwatha pariseka on Dustha vrana
Page 84
Discussion
DISCUSSION
Dustha vrana is a chronic ailment which causes the individual a long term sufferings.
Management of wounds has been a great challenge since antiquity for the surgeons through out
the world. When the wounds are not treated in proper time even the curable (sadhya) ulcer may
develop into yaapya , yaapya to asadhya and asadhya to fatal and may even cause death. As per
Ayurveda if proper care is not taken for simple wounds like chinnaa etc it may in turn becomes
dustha vrana which has got the characteristic features like profuse discharge , foul smell , having
irregular floor and unhealthy granulation tissue.
Healing is a natural process but inhibited by many factors. The main goal or achievement
of sodhana chikitsa is to alleviate these inhibitory factors. Finally at the end of sodhana chikitsa
dushta vrana becomes sudha vrana and ropana chikitsa has to be followed there after.
Ayurvedic classics also has given importance is for sthanika chikitsa along with other treatments.
In present surgical practice also wound debridement is of main importance for removing the slough tissue
so that wound healing may take place faster. In Ayurveda non surgical measures are also mentioned along
with surgical measures. They are Kashyaya , Varti , Kalka , Rasakriya , Avachurnana etc (su/chi/1/17-18).
Pariseka with Aragwadha Kvatha for Shodhana of Vrana is mentioned in Ayurveda.
Many chemical agents have been mentioned for wound healing, in Modern medicine but they
prove to be unsuccessful in their action due to the fact that they are only able to act on a particular point
of the healing cascade. So it is therefore essential that wound healing agents which possess biological
property will act on a broader mechanism of wound healing process
To attain proper wound healing it is very much essential to remove the local dusthi i e the local
derangement of dosha`s. The local dosha dathu dusti can be removed by Aragwada kashaya by to its
sodhana action i.e. the srava hara ,shopha , shoola , daha hara and kandughna properties.
So in this study Aragwadha was selected for pariseka of dusta vrana to assess its sodhana hara
action which facilitate healing.
A Clinical Study on Pariseka Vidhi in the management of Dusta Vrana with Aragwadha Kashaya
Page 85
Discussion
Discussion on literary review
The etiological factors specifically the indulgence in the Apathya Ahara, Vihara, they also
become the factors which claim important role in producing and continuing of the Dusta vrana.
Discussion on diagnosis
It is purely on the assessment of the clinical presentation of the cases.
Incidence
Age and sex
Maximum patients were of the age group between 31-70 years- i.e. 97%. And 56% were males.
It shows that middle aged male group indulge in more hard work which result in stress full life.
Perhaps this may be the reason why males frequently get affected by dustha vrana.
Occupation
In the present study maximum incidence of occupation was rubber tapping followed by hotel
workers and house wives respectively. So the incidence of injuries and exposure to unhygienic
conditions are more in such occupation.
Religion
In the present study maximum patients were found Hindus followed by Muslims and
Christians. They are 60%, 20% , 20% respectively. There is no significance in the formation of
vrana in either of the religion or caste except that the data shows the predominance of Hindus in
the local area.
Socio economic status

In the present study maximum number of patient was from poor family followed by
middle class. They are 53 , 33% respectively. This may be one of the cause of dusta vrana by not
doing the treatment in proper time and also due to unhygienic condition malnutrition. Which is
yet to be established.
Page 86
Discussion
Marital status
In the present study 77% were married and 23% were unmarried. Most of the patients are
over 30 years of age.
Dietary habits
In the present study 73.3% were found to have mixed diet were as 26.3% were only
vegetarians i.e. 22 patients were non-vegetarians and 8 patients were vegetarians.
Area involved
Out of 30 cases 27 patients had dushta vrana in legs. This is probably due to the fact that
legs are more prone to get trauma often and repeatedly. Also stasis of blood in the legs (veins)
for comparatively more longer time (due to causes of their own) in comparison to upper
extrimities.
Addictions
In the present study 55% of the patient i.e. 16 patients didn’t have any addictions were as
45% of the patient i.e. 14 patients were having various additions like pan chewing , alcoholism
and smoking respectively. Additions may cause the vitiation of the doshas in the body which in
turn may produce the Dusta vrana. Again the alcohol (in the consumers) when taken excessively,
may cause physical/mental trauma and that may in turn prove to reward with a trauma or
Abhigata in due course leading to Dushta Vrana.
Discussion on Assessment criteria
30 patients of dustha vrana treated with Aragwadha kwatha pariseka and its sodhana
action on vedana , kandu , daha , ruja , srava gandha and akuruthi were assessed by assigning
suitable score to each symptom
Observations were made in the 30 patients Before Treatment and After Treatment with
Aragwadha Kwatha Parisheka with regard to the different subjective and objective criteria listed
in the study proforma. The treatment shown significant changes on all clinical features of ulcers,
because drugs selected promoted the natural healing process and checked the disease Dushta
Vrana.
Page 87
Discussion
Effect on pain : Out of 30 patients 21 of were complaining of pain before treatment. Aragwadha
kwatha provided maximum of 42% pain relief. The mean score was 2.800. And after treatment
it was reduced to 1.633. The madhura rasa, mridu and snighda guna and madhura vipaka may be
the cause which eradicate the pain of the drug.
Effect on burning sensation:

Out of 30 patients 25 patients had burning sensation. The mean score of burning
sensation was 3.300 before the treatment and after the treatment the score was 1.467.Burning
sensation was reduced to 56% after the treatment and during follow up it was reduced to 66%.
The daha is due to pravrudha pitta dosha. The Aragwadha kwatha having madhura and tiktha
rasa, seethe veerya has pitthara property may have reduced the burning sensation.
Effect on itching:
Out of 30 patients 26 patients complained of itching. The mean score of itching was
3.467 before the treatment and after the treatment it was 0.933. Kandu was reduced to 73% after
the treatment and during the follow up period it was 85%. The tikta rasa and madhura vipaka of
the drug might have taken major role in alleviating the kandu.
Effect on tenderness:
Out of 30 patients 21 patients suffered from tenderness. The mean score of tenderness
was 2.800 before the treatment and was 1.200 after the treatment. The over all effect of
tenderness during the treatment was 43% and during follow up it was 51%. The madhura rasa,
mrudhu and snigdha guna and madhura vipaka which act as vata pitta hara and so the tenderness
might have been cleared.
Effect on discharge:
All 30 patients were complaining of discharge. The mean score of discharge before the
commencement of treatment was 4.000 and after the treatment the mean score was 0.600. All
most in all patients there was a remarkable difference in discharge. The over all effect of
Aragwadha kwatha on discharge was 90% after the treatment and reached 98% during the follow
Page 88
Discussion
up. The tiktha rasa, seeta veerya claims to be the causes in rectifying this feature of discharge in
all the 30 cases.
Effect on smell:
Out of 30 patients 26 patients had bad smell. The mean score of smell was 3.333 before
the treatment and was 0.067 after the treatment. The effect of Aragwadha kwatha on smell was
90% after the treatment and 98% during the follow up. The madhura rasa guru snighda guna and
madhura vipaka of the drug ultimately nullify the unpleasant gandha of the Vrana.
Effect on size:
All the patients had various akuruthi for the dustha vrana. The mean score for size before
the treatment was 4.000 and after the treatment the mean score was 2.167. The over all effect of
Argawadha kwatha on the effect on size was 46% after the treatment and 53% during the follow
up. The akuruti of the vrana is mainly on the basis of Tri dosha `s so all factors such as rasa,
guna , veerya , vipaka of the drug in their own way have caused the shodhana and does heal the
wound properly.
Pariseka vidhi:
The temperature of the fluid, the height from which it is made to fall , and the un
interrupted time factor of pouring the dravya and the rasa gunadi bhedas of in total have helped
in removing the slough and debris of the wound with minimal or no mechanical trauma and the
healing effect may be action of the drug as well as the body capacity to replenish the healing
process over the hurdles are removed .
On the basis of the above study it can be concluded that Aragwadha kwatha pariseka
proved to be highly effective in relieving the symptoms like kandu (85%) , srava (98%) , and
gandha (98%) in comparison to the other symptoms like pain (57%) , burning sensation (66%) ,
tenderness (51%) and finally size (53%) which can be said as significant or moderate in action..
Page 89
Discussion
Over all effect of the Aragwadha Kwatha Pariseka:

Considering the over all response of the patients to Aragwadha kwatha pariseka shows
that 36 % of the patients had marked improvement(table 37)
On the basis of the above results it can be concluded that pariseka vidhi by Aragwadha
kashaya causes soodhana of Dustha vrana and provides significant relief in all its symptoms.
Mode of action of drugs

In Dushta Vrana healing does not occur due to discharge and slough. For the removal of
slough and discharge, the drugs should have the qualities of Guru, Tiktha Rasa and Aragwadha
possesses all these requisite qualities. Further Aragwadha Kwatha by its Stambhana, Kapha
Shamana, Pitta Shamana, Rukshata, Kledashoshaka and Lekhana Sramsana property checks the
Srava and remove the slough in the ulcer. Although the drug is of Sheeta Veerya it helps in Daha
Shamana. Due to all these actions Aragwadha has provided significant relief in the symptom and
done proper Shodhana of Dushta Vrana which ultimately leads to its proper healing which is the
goal in its treatment.
Chart No. 4 Mode of Action of Drugs
Aragwadha

Madhura, Tiktha Rasa Predominance Sheeta Veerya

Mridu, Snigdha Guna

1) Stambhana Pitta Shamana
2) Kapha Shamana
3) Pitta Shamana
4) Kledashoshana
5) Lekhana
6) Sramsana
Reduction in Srava

Shodhana of Dushtavrana
Page 90
Conclusion
CONCLUSION
In the present study 30 patients of Dustha vrana were subjected to pariseka with Aragwadha
kwatha to obtain vrana shuddhi and vrana ropana.
In the present study maximum no: of patients i.e. 30% were from middle age group 41-50 years.
Male female ratio in this study is 5:4.
In this localit , among the Dustha vrana cases Hindus(60%) out number others.
Economically poor populatio (53%) are the most sufferers.
Rubber plantation workers (33%) were high in number
Non – vegetarian diet (73%) may delay the wound healing
Lower limb ulcers( 90%) definitely heal slow.
Maximum no: of patients i.e. 70% were having chronicity up to 3 months duration.
Efficacy of Aragwadha kwatha Pariseka in the management of Dustha vrana

Significant relief were seen in all patients depending on the subjective and objective
criteria. Pariseka with Aragwadha kwatha in the management of Dustha vrana proved highly
significant relief in srava 98% gandha 98% and kandu 83% when compared to other criteria`s
like daha , ruk , thoda and akruthi. By the virtue of Sodhana , Srava hara and Vrana ropana
action of Aragwadha most of the dathu dusti was ceased. Proper management of Dustha vrana
by timely pariseka with Aragwadha kwatha facilitates early wound healing. Thus our great
Acharya`s observations on the modality and the drugs of the wound healing stand valid even
today – as per the study conducted here at K.V.G.A.M.C &H ,Sullia.
Scope for further study:

The present study on Dustha vrana with Aragwadha kwatha Pariseka proves to be
effective. Further study should be conducted in a large scale. This modality should be tested with
other dravyas at multiple centers in different seasons.
Page 91
Summary
SUMMARY
The dissertation entitled as “A Clinicl study on Pariseka Vidhi in the Management of Dusta
Vrana with Aragwadha Kashya” consists of introduction, disease review, drug review, observation,
discussion, conclusion and summary.
Introduction gives a general idea about Dusta Vran, importance of the Dusta Vrana in present
time, about the intervention, need of special attention to the present study, aims and objectives of
the study. The study was planned with the objectives of finding a non-operative, convenient and
economical method of management of Dusta Vrana.
Disease review, there is an explanation on the term Dusta Vrana, brief history of Dusta Vrana
in various classics, citation of nidana etc., chikitsa are mentioned . Different aspects of the
disease Wounds such as definition, aetiology etc. are elaborately explained.
Treatment review, contain brief expalanation about the treatment, description about Aragwadha
Pariseka.
Review of the drug, contains the detailed description of Aragwadha. In this section information
about the plant from recent books, vernacular names and description of their uses are mentioned.
Clinical study deals with description of clinical study with specific reference to patients,
selection, inclusion and exclusion criteria, criteria for assessment of signs and symptoms; method
of treatment, dose, duration etc of present study.
Result of clinical Study, the result obtained after completion of 15 days treatment and a follow
up of 15 days after treatment was discussed. The observations before and after treatment are
tabulated, percentage of improvement is taken, grading is done, and this is analyzed statistically
with student paired 't' test. Thus assessment of clinical trial is done.
Discussion deals with the discussion on the literary review of disease, treatment and drug,
interpretation of results and observations, probable mode of action of treatment etc.
The conclusions are drawn by analysing different aspects of treatment and clinical trial.
Page 92
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Page 99
Incidence Chart
INCIDENCE CHART
SL. SOCIO- MARRITAL
0.P.NO. NO NAME AGE SEX RELIGION OCCUPATION ECONOMIC STTUS ADDICTIONS DIET PART CHRONICITY
PAN
98432 1 SUNDAR NAIK 50 MALE HINDU HOTEL WORKER POOR UNMARRIED CHEWING MIXED LL 6M
97482 2 DAMODAR 65 MALE HINDU BUSINESS MIDDLE MARRIED SMOKING MIXED LL 9M
UPPER
97648 3 CHINNAPA 63 MALE HINDU BUSINESS MIDDLE MARRIED MIXED LL 9M
UPPER
99362 4 KRISHNAPPA 65 MALE HINDU BUSINESS MIDDLE MARRIED MIXED LL 6M
97396 5 JAYARAM 48 MALE HINDU HOTEL WORKER POOR MARRIED SMOKING MIXED LL 5-6M
UPPER
97480 6 SUNITHA 45 FEMALE HINDU HOUSE WIFE MIDDLE MARRIED VEGETARIAN LL 3M
98721 7 RAM NAIK 52 MALE HINDU HOTEL WORKER MIDDLE MARRIED VEGETARIAN LL 15D
98224 8 MOHAMMED 55 MALE MUSLIM AGRICULTURIST MIDDLE MARRIED SMOKING MIXED LL 15D
RUBBER
98368 9 DAVID 40 MALE CHRISTIAN TAPPING POOR MARRIED ALCOHOLIC MIXED LL 2M
RUBBER
97711 10 GOPINATH 55 MALE HINDU TAPPING MIDDLE UNMARRIED VEGETARIAN LL 1M
RUBBER PAN
96999 11 ELSAMMA 49 FEMALE CHRISTIAN TAPPING POOR MARRIED CHEWING MIXED LL 4M
RUBBER PAN
97042 12 HASEENA 36 FEMALE MUSLIM TAPPING POOR MARRIED CHEWING MIXED LL 1M
RUBBER PAN
97103 13 MARY 59 FEMALE CHRISTIAN TAPPING POOR MARRIED CHEWING MIXED LL 1M
97020 14 JAYALEKSHMI 56 FEMALE HINDU HOUSE WIFE POOR MARRIED MIXED LL 2M
98769 15 WILFRED 55 MALE CHRISTIAN HOTEL WORKER POOR MARRIED MIXED LL 5-6M
98092 16 AKBAR 35 MALE MUSLIM HOTEL WORKER MIDDLE MARRIED SMOKING MIXED LL 1-1/2M
98018 17 REVATHI 22 FEMALE HINDU STUDENT POOR UNMARRIED MIXED LL 1-1/2M
98209 18 MEHAZINA 47 FEMALE MUSLIM HOUSE WIFE POOR MARRIED MIXED LL 13M
UPPER
98178 19 ANNAPURNA 56 FEMALE HINDU HOUSE WIFE MIDDLE MARRIED VEGETARIAN LL 20D
RUBBER
97019 20 SAMPATH 39 MALE HINDU TAPPING MIDDLE MARRIED MIXED LL 1M
RUBBER
97210 21 RAVINDRA 42 MALE HINDU TAPPING MIDDLE MARRIED SMOKING VEGETARIAN LL 15D
Page 106
Incidence Chart
97048 22 RENUKA 38 FEMALE HINDU HOUSE WIFE MIDDLE MARRIED VEGITERIAN LL 1Y

97289 23 ASHRAF 61 MALE MUSLIM HOTEL WORKER POOR UNMARRIED MIXED LL 3W
97313 24 ULAHANAN 42 MALE CHRISTIAN AGRICULTURIST POOR UNMARRIED VEGITERIAN UL 2M
97415 25 RAMAKRISHNA 65 MALE HINDU HOTEL WORKER MIDDLE MARRIED MIXED LL 2W
98029 26 KABIR 32 MALE MUSLIM HOTEL WORKER POOR UNMARRIED ALCOHOLIC MIXED LL 1M
GOPINATH
98093 27 BHAT 66 MALE HINDU HOTEL WORKER MIDDLE UNMARRIED VEGITERIAN UL 1-1/2M
RUBBER PAN
98402 28 SARADA 47 FEMALE HINDU TAPPING POOR MARRIED CHEWING MIXED LL 40D
RUBBER PAN
98403 29 KASTURBA 58 FEMALE HINDU TAPPING POOR MARRIED CHEWING MIXED LL 3M
RUBBER PAN
98406 30 CAROLINE 43 FEMALE CHRISTIAN TAPPING POOR MARRIED CHEWING MIXED UL 45D
Page 107
Incidence Chart
RESULT CHART
BURNING
PAIN SENSATION ITCHING TENDERNESS DISCHARGE SMELL SIZE
NAME BT AT FU BT AT FU BT AT FU BT AT FU BT AT FU BT AT FU BT AT FU
SUNDAR NAIK 4 2 1 4 2 1 4 1 0 4 1 1 4 1 0 4 0 0 4 2 2
DAMODAR 0 0 0 4 1 0 4 1 0 0 0 0 4 1 0 4 1 0 4 1 1
CHINNAPPA 0 0 0 4 1 1 4 1 0 0 0 0 4 1 0 0 0 0 4 2 2
KRISHNAPPA
NAIK 0 0 0 4 1 1 4 0 0 0 0 0 4 1 0 0 0 0 4 2 2
JAYARAM 4 2 2 4 0 0 4 1 0 4 2 2 4 0 0 4 0 0 4 2 2
SUNITHA 4 3 2 4 2 1 4 1 0 4 4 3 4 0 0 4 0 0 4 2 2
RAM NAIK 0 0 0 4 2 2 4 1 1 0 0 0 4 0 0 4 0 0 4 2 2
MOHAMMED 4 1 1 0 0 0 4 1 1 4 2 1 4 0 0 4 0 0 4 2 1
DAVID 4 2 2 4 2 1 4 2 1 4 2 2 4 0 0 4 1 0 4 2 2
GOPINATH 0 0 0 4 2 1 4 0 0 0 0 0 4 0 0 4 1 0 4 2 2
ELSAMMA 4 2 1 0 0 0 0 0 0 4 2 1 4 1 0 4 1 0 4 2 2
HASEENA 4 2 2 4 2 1 4 1 1 4 2 2 4 0 0 4 0 0 4 2 2
MARY 0 0 0 4 2 2 4 1 0 0 0 0 4 0 0 4 0 0 4 2 1
JAYALEKSHMI 4 2 2 4 4 3 4 2 2 4 4 4 4 1 1 4 1 0 4 2 2
WILFRED 0 0 0 4 1 0 4 0 0 0 0 0 4 1 1 4 0 0 4 2 1
AKBAR 4 2 1 4 2 1 4 0 0 4 3 2 4 1 1 4 0 0 4 3 3
REVATHI 4 4 3 4 1 1 4 1 0 4 3 3 4 1 1 4 1 1 4 3 2
MEHAZINA 4 4 3 3 2 2 4 2 1 4 2 2 4 1 1 4 2 1 4 2 2
ANNAPURNA 4 2 1 4 2 1 4 1 1 4 2 2 4 1 0 4 0 0 4 2 2
SAMPATH 0 0 0 4 2 2 4 2 2 0 0 0 4 0 0 4 0 0 4 2 2
Page 108
Incidence Chart
RAVINDRA 4 2 2 4 2 2 4 2 2 4 2 2 4 2 1 4 0 0 4 2 2
ASHRAF 4 3 2 0 0 0 4 2 1 4 2 2 4 1 0 4 0 0 4 2 1
HUSSAIN 4 3 4 2 2 4 1 0 4 3 2 4 0 0 4 1 0 4 3 3
DEVARAJ 4 2 1 4 1 1 4 1 1 4 2 2 4 0 0 4 0 0 4 3 3
RAMAKRISHNA 4 3 2 4 2 2 0 0 0 4 2 2 4 1 0 4 1 0 4 2 2
KABIR 4 1 1 4 2 2 4 1 0 4 2 1 4 0 0 0 0 0 4 2 1
GOPINATH BHAT 4 3 2 4 2 2 0 0 0 4 2 1 4 1 1 0 0 0 4 3 2
SARADA 4 2 2 0 0 4 1 1 4 2 2 4 1 0 0 0 0 4 1 1
KASTURBA 4 2 1 0 0 0 0 0 0 4 2 2 4 0 0 4 0 0 4 2 2
CAROLINE 0 0 0 4 2 2 4 1 1 0 0 0 4 1 0 4 0 0 4 3 3
Page 109
Annexure
DEPARTMENT OF SHALYA TANTRA K.V.G. AYURVEDA MEDICAL

COLLEGE AND HOSPITAL
AMBETADAKA –SULLIA .
PROFORMA OF CASE SHEET FOR THE STUDY OF ARAGWADHA KWAATHA

PARISHEKA IN THE MANAGEMENT OF DUSHTÀ VRANA
Name: Case No:

Age: OPD No:
Sex: M/F IPD No:
Religion: Room No. & bed No.:
Socio- economic status: Date of admission:
Marital status: M/UM Date of discharge:
Occupation: Treatment started on:
Address: Treatment completed on:
I. MAIN COMPLAINTS:
1) VRANA: a) Kaala ( Duration ):

b) Sthana:
c) Onset: (Sudden/ Recurrent/ gradual)
d) Course of illness:
e) Number of ulcers:
2) SRAAVA (Discharge): (a) Present/Absent

(b) Varna (colour)
(c) Consistency
3) RAKTA SRAAVA: Present/Absent
4) VEDANA: (a) Present/Absent

(b) Continuous/Intermittent
(c) Intensity
Page 100
Annexure
5) GANDHA: Present/Absent
6) KANDU: (a) Present/Absent
(b) Duration
(c) Intensity
7) DAAHA (Burning sensation): Present/Absent
8) JVARA: Present/Absent
(a) Duration
(b) Character
(c) Rigors
(d) Chills
(e) Periodicity
9) ANY OTHER ASSOCIATED COMPLAINTS:
II. HISTORY OF PRESENT ILLNESS:
III. HISTORY OF PAST ILLNESS:
IV. FAMILY HISTORY:
V. PERSONAL HISTORY:
(1) Appetite: Good/Moderate/Poor
(2) Diet: Vegetarian/Mixed
(3) Bowel: R/IR Constipated/Loose Stools
(4) Micturition:
(5) Sleep: Sound/Disturbed
(6) Addictions:
VI. TREATMENT HISTORY:
VII. OBS. HISTORY/GYNAEC HISTORY:
Page 101
Annexure
VIII. GENERAL EXAMINATION:
A) (a) Nakha:
(b) Nayana:
(c) Jihvaa:
(d) Pulse: Rate: Rhythm:
(e) B.P:
IX. SYSTEMIC EXAMINATION:

(1) Cardio Vascular System:
(2) Respiratory System:
(3) Central Nervous System:
(4) Gastro Intestinal System:
(5) Other Systems:
X. EXAMINATION OF THE ULCER:

A. SAMAANYA PAREEKSHAA:
(a) Darsàna Pareekshaa:
(i) Aakruti:
(ii) San’khyaa:
(iii)Sthaana:
(iv) Varna of the Vrana:
(v) Sraava: Present/Absent
- Consistency:
- Colour:
- Gandha(smell)
(vi) Margin of the Vrana:
(vii) Edge of the Vrana:
Undermined
Page 102
Annexure
Sloping
Punched out
Raised and Pearly white beaded
Rolled out
(viii) Floor:
(ix) Varna of the surrounding area:
(x) Sòtha on the surrounding area: Present/Absent
(b) Sparsàna Pareekshaa:

(i) Size of the ulcer: Length
Breadth
Depth
(ii) Floor: Rough/Smooth

Hard/Soft
(iii)Bleeding on touch: Present/Absent
(iv) Tenderness: Present/Absent
XI. INVESTIGATION:
1) Blood examination:
1) Hb%
2) TC
3) DC
4) ESR
5) RBS
2) Urine examination:
1 Routine
2 Sugar
2) OTHER IF REQUIRED:
Page 103
Annexure
XII. DIAGNOSIS ACCORDING TO THE CAUSE
XIII. CHIKITSA
ASSESSMENT OF RESULTS
A. CLINICAL PARAMETERS
Subjetive Response
SUBJETIVE B/T DAY 3 DAY 6 DAY 9 DAY12 A/T

PARAMETER
RUJA
DAHA
KANDU
THODAM
Objective Response
OBJECTIVE B/T DAY3 DAY6 DAY9 DAY12 A/T
PARAMETER
GATRAM
SRAVAM
GANDHA
Page 104
Annexure
FOLLOW UP
RESULT:
SIGNATURE OF GUIDE
Date: Signature:
Page 105

DUSHTA VRANA
ARAGWADHA TWAK
INTRODUCTION
REVIEW OF
LITERATURE
SUMMARY
OBJECTIVES
CLINICAL
STUDY
OBSERVATIONS
CONCLUSION
DISCUSSION
ANNEXURE
BIBLIOGRAPHIC
REERENCES

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A CLINICAL STUDY ON PARISEKA VIDHI IN THE

MANAGEMENT OF DUSTA VRANA

Dissertation submitted to the

In partial fulfillment of the requirements for the degree of

MASTER OF SURGERY (AYU)

Under the Guidance of

Dr.DEENAPRAKASH BHARADWAJ M.D. (AYU)

Department Of Post Graduate Studies in Shalya Tantra

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A CLINICAL STUDY

by me under the guidance of Dr.DEENAPRAKASH BHARADWAJ M.D.(Ayu),

Professor, Dept. of Post Graduate Studies in Shalya Tantra, K.V.G. AYURVEDA

Date: 25-11-2010 VISHNUMAYA

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A CLINICAL STUDY ON

PARISEKA VIDHI IN THE MANAGEMENT OF DUSTHA VRANA WITH

ARAGWADHA KASHAYA” is a bona fide research work done by VISHNUMAYA

in partial fulfillment of the requirement for the degree of MASTER OF

SURGERY (AYU), under my guidance.

Date: 25-11-2010 DR. DEENAPRAKASH BHARADWAJ

ENDORSEMENT BY THE H.O.D, PRINCIPAL / HEAD OF

This is to certify that the dissertation entitled “A CLINICAL STUDY

DR.DEENA PRAKASH BHARADWAJ DR. N. S.SHETTAR

Professor & Head of the Department Principal

Department of Post Graduate Studies in K.V.G. Ayurveda

Date: 25-11-2010 Date: 25-11-2010

Place: Sullia Place: Sullia

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences,

dissertation / thesis in print or electronic format for academic / research

Place: Sullia VISHNUMAYA

© Rajiv Gandhi University of Health Sciences, Karnataka

A.H – Ashtanga Hrudaya

A.S – Ashtanga Samgraha

B.S – Bhela Samhita

C.D _ Chakra datta

C.S – Charaka Samhita

G.N _ Gada Nigraha

H.S _ Haritha Samhitha

M.N – Madhava Nidana

S.S – Sushruta Samhita

Objectives: To evaluate the effect of Aragwadha kwatha Pariseka in the management of

SL.NO CONTENTS PAGE.NO

3 REVIEW OF LITERATURE 4-61

4 CLINICAL STUDY 62-67

5 OBSERVATION AND RESULTS 68-84

9 BIBLIOGRAPHIC REFERENCES 93-99

3. Vrana Sthaana and its Lakshanas Acc. to Maadhavakara 8

4. Lakshanas of Vrana as per doshic predominance 10

5. Lakshanas of Dvandvaja, Tridoshaja and Sannipataja Vrana 11

6. Classification of Agantuja Vrana 12

7. Agantuja Vrana based on shape and severity of injury 13

8. Lakshana of Suddha Vrana 14

9. Lakshanas of Dushta Vrana 15-16

10. Charaka’s classification of Vrana 17

11. Vrana Varna 18

12. Vrana gandha according to Sushrutha 18

13. Vrana ganda according to Charaka 19

14. Vrana srava according to Sushrutha 19

15. Vrana srava according to Charaka 20

16. Asadhyata according to Sthana 20

17. Vrana Vedana 20

18. Vranithasya upadrava 21