Charaka Chikitsa Sthana: Visarpa Chikitsa 21st Chapter

21st Chapter of Charaka Samhita Chikitsa Sthana is called Visarpa Chikitsa. It deals with the symptoms, types, curability and treatment for herpes disease. 

अथातो विसर्प चिकित्सितं व्याख्यास्यामः||१||
इति ह स्माह भगवानात्रेयः||२||
athāto visarpa cikitsitaṃ vyākhyāsyāmaḥ||1||
iti ha smāha bhagavānātreyaḥ||2||
Let us explore the chapter on the treatment of Visarpa (erysipelas, herpes, spreading type of skin disease). Thus, said Lord Atreya [1-2]

Prologue:
कैलासे किन्नराकीर्णे बहु प्रस्रवणौषधे|
पादपै र्विविधैः स्निग्धै र्नित्यं कुसुम सम्पदा||३||
वमद्भिर्मधुरान् गन्धान् सर्वतः स्वभ्यलङ्कृते|
विहरन्तं जितात्मानमात्रेयमृषिवन्दितम्||४||
महर्षिभिः परिवृतं सर्वभूतहिते रतम्|
अग्निवेशो गुरुं काले विनयादिदमुक्तवान्||५||
भगवन्! दारुणं रोगमाशीविषविषोपमम्|
विसर्पन्तं शरीरेषु देहिनामुपलक्षये||६||
सहसैव नरास्तेन परीताः शीघ्रकारिणा|
विनश्यन्त्यनुपक्रान्तास्तत्र नः संशयो महान्||७||
स नाम्ना केन विज्ञेयः सञ्ज्ञितः केन हेतुना|
कतिभेदः कियद्धातुः किन्निदानः किमाश्रयः||८||
सुखसाध्यः कृच्छ्रसाध्यो ज्ञेयो यश्चानुपक्रमः|
कथं कैर्लक्षणैः किं च भगवन्! तस्य भेषजम्||९||
तदग्निवेशस्य वचः श्रुत्वाऽऽत्रेयः पुनर्वसुः|
यथावदखिलं सर्वं प्रोवाच मुनिसत्तमः||१०||
kailāse kinnarā kīrṇe bahu prasravaṇauṣadhe|
pādapai rvividhaiḥ snigdhai rnityaṃ kusuma sampadā||3||
vamadbhirmadhurān gandhān sarvataḥ svabhyalaṅkṛte|
viharantaṃ jitātmānamātreyamṛṣivanditam||4||
maharṣibhiḥ parivṛtaṃ sarvabhūtahite ratam|
agniveśo guruṃ kāle vinayādidamuktavān||5||
bhagavan! dāruṇaṃ rogamāśīviṣaviṣopamam|
visarpantaṃ śarīreṣu dehināmupalakṣaye||6||
sahasaiva narāstena parītāḥ śīghrakāriṇā|
vinaśyantyanupakrāntāstatra naḥ saṃśayo mahān||7||
sa nāmnā kena vijñeyaḥ sañjñitaḥ kena hetunā|
katibhedaḥ kiyaddhātuḥ kinnidānaḥ kimāśrayaḥ||8||
sukhasādhyaḥ kṛcchrasādhyo jñeyo yaścānupakramaḥ|
kathaṃ kairlakṣaṇaiḥ kiṃ ca bhagavan! tasya bheṣajam||9||
tadagniveśasya vacaḥ śrutvā”treyaḥ punarvasuḥ|
yathāvadakhilaṃ sarvaṃ provāca munisattamaḥ||10||

Lord Punarvasu Atreya, who was self-controlled, who was being worshipped by the sages of eminence, and who was dedicated to the welfare of all living beings, was walking around Mount Kailasa, the abode of Kinnaras (celestial musicians) and several springs, which was aromatic all around because of the sweet fragrance emitting from the blossoming flowers. Agnivesha approached him (the preceptor) with queries regarding  the ailment terrific like cobra venom spreading to various body parts. Agnivesha inquired –  “People get afflicted with this serious disease instantaneously, and if not properly treated, succumb to death. So we are seriously concerned about this ailment.
Kindly enlighten us on the following aspects of this disease:
1. What is the name of this ailment?
2. Why is the name given to the disease?
3. What are the different varieties of this disease?
4. Which are the Dhatus (tissue elements, Doshas and waste products) involved in the causation of this disease?
5. What are the etiological factors of this disease?
6. Where is this disease located?
7. How to identify the varieties of this disease which are easily curable, which are difficult of cure and which are incurable?
8. What are the signs and symptoms (of different varieties) of this disease?
9. What is the treatment of this disease?”
Having heard the above queries of Agnivesha Lord Punarvasu Atreya, the sage of eminence, explained all the relevant details of this disease” Visarpa “as follows: [3-10]

Genital herpes

Name of the Ailment and Its Justification:
विविधं सर्पति यतो विसर्पस्तेन स स्मृतः|
परिसर्पोऽथवा नाम्ना सर्वतः परिसर्पणात्||११||
vividhaṃ sarpati yato visarpastena sa smṛtaḥ|
parisarpo’thavā nāmnā sarvataḥ parisarpaṇāt||11||

This ailment is called Visarpa because it spreads (Sarpana) in different directions (vide i.e Vividha). This is also called Parisarpa because it spreads (Sarpana) all over the body (Pari i.e Paritah). [11]

Visarpa Bheda – types: 
स च सप्तविधो दोषैर्विज्ञेयः सप्तधातुकः|
पृथक् त्रयस्त्रिभिश्चैको विसर्पो द्वन्द्वजास्त्रयः||१२||
वातिकः पैत्तिकश्चैव कफजः सान्निपातिकः|
चत्वार एते विसर्पा वक्ष्यन्ते द्वन्द्वजास्त्रयः||१३||
आग्नेयो वातपित्ताभ्यां ग्रन्थ्याख्यः कफवातजः|
यस्तु कर्दमको घोरः स पित्तकफ सम्भवः||१४||
sa ca saptavidho doṣairvijñeyaḥ saptadhātukaḥ|
pṛthak trayastribhiścaiko visarpo dvandvajāstrayaḥ||12||
vātikaḥ paittikaścaiva kaphajaḥ sānnipātikaḥ|
catvāra ete visarpā vakṣyante dvandvajāstrayaḥ||13||
āgneyo vātapittābhyāṃ granthyākhyaḥ kaphavātajaḥ|
yastu kardamako ghoraḥ sa pittakapha sambhavaḥ||14||

Types of Visarpa:
Visarpa which is caused by the vitiation of 7 Dhatus (4 tissue elements and 3 Doshas to be explained in the subsequent verse no. 15), is of 7 types, viz
1. Vatika
2. Paittika
3. Kaphaja
4. Sannipatika
5. Vata-Pittaja
6. Kapha-Vataja and
7. Pitta- Kaphaja.

The type of Visarpa caused by:
Vata- Pitta is called Agneya Visarpa.
Kapha-Vata is called Granthi Visarpa.
Pitta-Kapha is called Kardamaka Visarpa which represents a serious condition. [12-14]

7 Elements Involved in the Pathogenesis of Visarpa:
रक्तं लसीका त्वङ्मांसं दूष्यं दोषास्त्रयो मलाः|
विसर्पाणां समुत्पत्तौ विज्ञेयाः सप्त धातवः||१५||
raktaṃ lasīkā tvaṅmāṃsaṃ dūṣyaṃ doṣāstrayo malāḥ|
visarpāṇāṃ samutpattau vijñeyāḥ sapta dhātavaḥ||15||

The 7 Dhatus (elements) which give rise to Visarpa are:
1. Rakta (blood)
2. Lasika (Lymph)
3. Tvak (skin)
4. Mamsa (Muscle tissue) and
Doshas, viz
5. Vata,
6. Pitta and
7. Kapha [15]

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Visarpa Nidana – Causes: 
लवणाम्ल कटूष्णानां रसानामतिसेवनात्|
दध्यम्ल मस्तु शुक्तानां सुरासौवीरकस्य च||१६||
व्यापन्नबहुमद्योष्णरागषाडवसेवनात्|
शाकानां हरितानां च सेवनाच्च विदाहिनाम्||१७||
कूर्चिकानां किलाटानां सेवनान्मन्दकस्य च|
दध्नः शाण्डाकिपूर्वाणामासुतानां च सेवनात्||१८||
तिल माष कुलत्थानां तैलानां पैष्टिकस्य च|
ग्राम्यानूपौदकानां च मांसानां लशुनस्य च||१९||
प्रक्लिन्नानामसात्म्यानां विरुद्धानां च सेवनात्|
अत्यादानाद्दिवास्वप्नादजीर्णाध्यशनात् क्षतात्||२०||
क्षत बन्ध प्रपतनाद्धर्मकर्मातिसेवनात् |
विषवाताग्निदोषाच्च विसर्पाणां समुद्भवः||२१||
एतैर्निदानैर्व्यामिश्रैः कुपिता मारुतादयः|
दूष्यान् सन्दूष्य रक्तादीन् विसर्पन्त्यहिताशिनाम्||२२||
lavaṇāmla kaṭūṣṇānāṃ rasānāmatisevanāt|
dadhyamla mastu śuktānāṃ surāsauvīrakasya ca||16||
vyāpannabahumadyoṣṇarāgaṣāḍavasevanāt|
śākānāṃ haritānāṃ ca sevanācca vidāhinām||17||
kūrcikānāṃ kilāṭānāṃ sevanānmandakasya ca|
dadhnaḥ śāṇḍākipūrvāṇāmāsutānāṃ ca sevanāt||18||
tila māṣa kulatthānāṃ tailānāṃ paiṣṭikasya ca|
grāmyānūpaudakānāṃ ca māṃsānāṃ laśunasya ca||19||
praklinnānāmasātmyānāṃ viruddhānāṃ ca sevanāt|
atyādānāddivāsvapnādajīrṇādhyaśanāt kṣatāt||20||
kṣata bandha prapatanāddharmakarmātisevanāt |
viṣavātāgnidoṣācca visarpāṇāṃ samudbhavaḥ||21||
etairnidānairvyāmiśraiḥ kupitā mārutādayaḥ|
dūṣyān sandūṣya raktādīn visarpantyahitāśinām||22||

Visarpa is caused by the following factors:
1. Lavaṇāmla kaṭūṣṇānāṃ rasānāmatisevanāt – Excessive intake of hot ingredients having Saline, sour and pungent tastes.
2. Intake of Dadhi (sour curd), Mastu (the liquid in the upper part of curd), Sukta(vinegar), Sura(alcoholic drinks) and Sauvira (a sour drink prepared of dehusked barley)
3. Excessive intake of Madya (a type of alcoholic drink), and intake of polluted Madya, Raga (condiments) and Shadava (pickles) prepared of excessively hot ingredients.
4. Intake of Haritas (ingredients eaten in raw form described in Sutrasthana 27: 166- 177), Vidahis (ingredients causing burning sensation),Kurchika (curdled milk preparation), Kilata (cheese), Mandaka (Immature curd) Sandaki (a type of fermented wine) and such other fermented drinks, Tila – Sesame (Sesamum indicum), Masha (black gram), Kulattha (horse gram), different types of oil and pastries
5. Intake of meat of animals which are domesticated, and who inhabit marshy land and water.
6. Intake of Lashuna (garlic)
7. Intake of Praklinna (putrefied), Asatmya (unwholesome) and Viruddha ahara (mutually contradictory) ingredients
8. Intake of food in the large quantity, Diva swapna (sleeping during day time), intake of food before the previous meals digested and intake of food immediately after the meal (Adhyasana)
9. Affliction by Kshaya (depletion of body tissues), Injury, Bandha (being tied with ropes, etc)and falls:
10. Excessive exposure to hot sun and excessive physical work and
11. Exposure to poisons, strong wind and fire.
Because of the contribution of the above mentioned causative factors, Vata, etc get aggravated to vitiate the Dushyas (tissue elements), Viz Rakta (blood) etc. to cause Visarpa in a person who indulges in unwholesome food. [16-22]

Herpes zoster infection

Herpes zoster infection

Visarpa Adhishtana – Location: 
बहिःश्रितः श्रितश्चान्तस्तथा चोभयसंश्रितः|
विसर्पो बलमेतेषां ज्ञेयं गुरु यथोत्तरम्||२३||
बहिर्मार्गाश्रितं साध्यमसाध्यमुभयाश्रितम्|
विसर्पं दारुणं विद्यात् सुकृच्छ्रं त्वन्तराश्रयम्||२४||
अन्तःप्रकुपिता दोषा विसर्पन्त्यन्तराश्रये|
बहिर्बहिःप्रकुपिताः सर्वत्रोभयसंश्रिताः||२५||
bahiḥśritaḥ śritaścāntastathā cobhayasaṃśritaḥ|
visarpo balameteṣāṃ jñeyaṃ guru yathottaram||23||
bahirmārgāśritaṃ sādhyamasādhyamubhayāśritam|
visarpaṃ dāruṇaṃ vidyāt sukṛcchraṃ tvantarāśrayam||24||
antaḥprakupitā doṣā visarpantyantarāśraye|
bahirbahiḥprakupitāḥ sarvatrobhayasaṃśritāḥ||25||

Depending upon the location, Visarpana is of 3 types as follows:
1. Bahih-Srita (Visarpa located in the periphery)
2. Antah-Srita (Visarpa located in the interior part of the body) and
3. Ubhaya-Samsrita (Visarpa located in both the periphery and the interior part of the body)
The above mentioned 3 types of Visarpa are consecutively more and more serious.

Curability: The Visarpa located in the periphery of the body is curable.
The Visarpana located in the interior part of the body represents a serious condition which is difficult of cure.
When the Doshas spread in the internal organs of the body, they cause the interior type of Visarpana.
When they spread in the exterior part of the body, they cause peripheral type of Visarpa.
If however, they spread all over the body, they cause Visarpa located in both the Periphery and the interior part of the body. [23-25]

Signs and Symptoms of Antar Visarpa:
मर्मोपघातात् सम्मोहादयनानां विघट्टनात्|
तृष्णातियोगाद्वेगानां विषमाणां प्रवर्तनात्||२६||
विद्याद्विसर्पमन्तर्जमाशु चाग्निबलक्षयात्|
अतो विपर्ययाद्बाह्यमन्यैर्विद्यात् स्वलक्षणैः||२७||
marmopaghātāt sammohādayanānāṃ vighaṭṭanāt|
tṛṣṇātiyogādvegānāṃ viṣamāṇāṃ pravartanāt||26||
vidyādvisarpamantarjamāśu cāgnibalakṣayāt|
ato viparyayādbāhyamanyairvidyāt svalakṣaṇaiḥ||27||

The signs and symptoms of internal Visarpa:
• Marma upaghata – Affliction of Marma (vital organs, specially heart),
• Sammoha – unconsciousness,
• Vighattana – obstruction to the channels of circulation,
• Trshna – excessive thirst
• Udvega vishamanam pravartanat – irregular manifestation of normal urges and
• Agni bala kshyat – instantaneous diminution of the power of digestion
The external type of Visarpa is characterized by the signs and symptoms related to the respective Doshas (which are to be described hereafter). [26-27]

Herpes zoster

Herpes zoster

Asadhya Visarpa – incurable: 
यस्य सर्वाणि लिङ्गानि बलवद्यस्य कारणम्|
यस्य यस्य सर्वाणि लिङ्गानि बलवद्यस्य कारणम्|
yasya sarvāṇi liṅgāni balavadyasya kāraṇam|
yasya yasya sarvāṇi liṅgāni balavadyasya kāraṇam|

Characteristics of Incurable Visarp:
If Visarpa is associated with all the signs and symptoms (describes in respect of each variety), if it is caused by strong causative factors, if it is associated with painful complications, and if it is located in the vital organs, then this leads to death. [28]
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Vataja Visarpa Nidana, Samprapti: 
रूक्षोष्णैः केवलो वायुः पूरणैर्वा समावृतः|
प्रदुष्टो दूषयन् दूष्यान् विसर्पति यथाबलम्||२९||
rūkṣoṣṇaiḥ kevalo vāyuḥ pūraṇairvā samāvṛtaḥ|
praduṣṭo dūṣayan dūṣyān visarpati yathābalam||29||

Etiology and Pathogenesis of Vatika Visarpa:
Vayu aggravated by its own causative factors like ununctuous and hot ingredients or being occluded[ by Kapha and Pitta] because of over- nourishment, Vitiates the Dushyas (Tissue elements), and spreads in accordance with its own strength [to cause Vatika type of Visarpa]. [29]

Vataja Visarpa Lakshana: 
तस्य रूपाणि- भ्रम दवथु पिपासा निस्तोद शूलाङ्गमर्दो द्वेष्टन कम्प ज्वर तमक- कासास्थिसन्धिभेद विश्लेषण वेपनारोचकाविपाकाश्चक्षुषोराकुलत्वमस्रागमनं पिपीलिका सञ्चार इव चाङ्गेषु, यस्मिंश्चावकाशे विसर्पो विसर्पति सोऽवकाशः श्यावारुणाभासः श्वयथुमान् निस्तोद भेद शूलायामसङ्कोच हर्ष स्फुरणैरतिमात्रं प्रपीड्यते, अनुपक्रान्तश्चोपचीयते शीघ्रभेदैः स्फोटकैस्तनुभिररुणाभैः श्यावैर्वा तनु विशदारुणाल्पास्रावैः, विबद्ध वातमूत्रपुरीषश्च भवति, निदानोक्तानि चास्य नोपशेरते विपरीतानि चोपशेरत इति वातविसर्पः||३०||
tasya rūpāṇi- bhrama davathu pipāsā nistoda śūlāṅgamardo dveṣṭana kampa jvara tamaka- kāsāsthisandhibheda viśleṣaṇa vepanārocakāvipākāścakṣuṣorākulatvamasrāgamanaṃ pipīlikā sañcāra iva cāṅgeṣu, yasmiṃścāvakāśe visarpo visarpati so’vakāśaḥ śyāvāruṇābhāsaḥ śvayathumān nistoda bheda śūlāyāmasaṅkoca harṣa sphuraṇairatimātraṃ prapīḍyate, anupakrāntaścopacīyate śīghrabhedaiḥ sphoṭakaistanubhiraruṇābhaiḥ śyāvairvā tanu viśadāruṇālpāsrāvaiḥ, vibaddha vātamūtrapurīṣaśca bhavati, nidānoktāni cāsya nopaśerate viparītāni copaśerata iti vātavisarpaḥ||30||

Signs and symptoms of Vatika type of Visarpa:
1. Bhrama – dizziness, Davathu (burning sensation in eyes etc.,) Pipasa – thirst,
2. Nistoda – Pricking pain, Shoola – colic pain, Anga marda – Malaise,Udvestana – Cramps, Kampa – Tremors
3. Jwara – fever,Tamaka (a type of Asthma), Kasa -bronchitis,
4. Asthi sandhi bheda – pain in the bones and joints and their dislocation, Vepana – Shivering
5. Aruchi – anorexia, Avipaka – Indigestion
6. Aksha susho – cloudiness of the eyes, Arukula – lachrymation, and Pipilika – a feeling as if ants are crawling over the body
7. The space through which the Visarpa spreads becomes Shyava aruna bhasa – grayish or Pinkish in color and Shvayathu – edematous.
8. That space becomes excessively afflicted with Nistoda – pricking pain, Bheda – breaking pain, Shoola – colic pain, Sankocha – expansion, Harsha – contraction, Sphurana – tingling sensation and Prapidyate – throbbing sensation.
9. If not treated, the space becomes replete (accumulated) with instantaneous cracking, pustules which are small in size and pink or grayish in color, and secretion of liquid with is thin, transparent,pink and in small quantity
10. Vibaddha vata mutra purisha – Arrest of the vomiting of flatus, urine and stool and
11. Factors described to cause vata- visarpa are not homologatory to such a patient. On the other hand, the patient feels comfortable with ingredients having opposite attributes. [30]

Varicella zoster

Pittaja Visarpa Nidana and Samprapti: 
पित्तमुष्णोपचारेण विदाह्यम्लाशनैश्चितम्|
दूष्यान् सन्दूष्य धमनीः पूरयन् वै विसर्पति||३१||
pittamuṣṇopacāreṇa vidāhyamlāśanaiścitam|
dūṣyān sandūṣya dhamanīḥ pūrayan vai visarpati||31||

Etiology and Pathogenesis of Paittika visarpa:
Pitta, accumulated because of hot regiments, and by the intake of Vidahi (which cause burning sensation) and sour food, vitiates the Dushyas (tissue elements), fills up (obstructs) the Dhamanis (Channels of blood circulation) and spreads which gives rise to Paittika type of Visarpa. [31]

Paittika Visarpa Lakshana:
तस्य रूपाणि- ज्वरस्तृष्णा मूर्च्छा मोहश्छर्दिररोचकोऽङ्गभेदः स्वेदोऽतिमात्रमन्तर्दाहः प्रलापः शिरोरुक् चक्षुषोराकुलत्वमस्वप्नमरतिर्भ्रमः शीतवातवारितर्षोऽतिमात्रं हरित हारिद्रनेत्र मूत्रवर्चस्त्वं हरितहारिद्ररूपदर्शनं च, यस्मिंश्चावकाशे विसर्पोऽनुसर्पति सोऽवकाशस्ताम्र हरित हारिद्र नील कृष्ण रक्तानां वर्णानामन्यतमं पुष्यति, सोत्सेधैश्चातिमात्रं दाह सम्भेदनपरीतैः स्फोटकैरुपचीयते तुल्यवर्णास्रावैश्चिरपाकैश्च, निदानोक्तानि चास्य नोपशेरते विपरीतानि चोपशेरत इति पित्तविसर्पः||३२||
tasya rūpāṇi- jvarastṛṣṇā mūrcchā mohaśchardirarocako’ṅgabhedaḥ svedo’timātramantardāhaḥ pralāpaḥ śiroruk cakṣuṣorākulatvamasvapnamaratirbhramaḥ śītavātavāritarṣo’timātraṃ harita hāridranetra mūtravarcastvaṃ haritahāridrarūpadarśanaṃ ca, yasmiṃścāvakāśe visarpo’nusarpati so’vakāśastāmra harita hāridra nīla kṛṣṇa raktānāṃ varṇānāmanyatamaṃ puṣyati, sotsedhaiścātimātraṃ dāha sambhedanaparītaiḥ sphoṭakairupacīyate tulyavarṇāsrāvaiścirapākaiśca, nidānoktāni cāsya nopaśerate viparītāni copaśerata iti pittavisarpaḥ||32||

Signs and symptoms of Paittika type of Visarpa:
1. Jwara – Fever, Trushna – morbid thirst
2. Murchha – fainting, Moha – unconsciousness
3. Chardi – vomiting, Aruchi – anorexia
4. Anga bheda – breaking pain in the body, Ati matra sveda – excessive sweating and Antar daha- burning sensation in the interior part of the body
5. Pralapa – Delirium, Shiro ruk – headache, turbidity of the eyes, Asvapna – sleeplessness
6. Arati – dislike for everything, Bhrama – giddiness and Shita vata aavarita – excessive longing for cold wind and cold water
7. Harita (Green) and Haridra (yellow) coloration of the Akshu (eyes), Mutra (urine) and stool
8. Harita haridra rupa darshana – Green and yellow vision of objects
9. The space in which this disease spreads, becomes either Tamra (coppery colored), Harita(green) , Haridra (yellow), Nila (blue),Krishna (black) or Rakta (red)
10. This space becomes full of pustules which are excessively swollen and associate with excessive burning sensation and breaking pain
11. The exudates from these pustules have the colors like those of the pustules
12. These pustules get suppurated very quickly and
13. Factors described to cause Pitta-Visarpa are not homogatory to such a patient. On the other hand. The patient feels comfortable with the ingredients, having the opposite attributes. [32]

Kaphaja Visarpa Nidana, Samprapti: 
स्वाद्वम्ल लवण स्निग्ध गुर्वन्न स्वप्न सञ्चितः|
कफः सन्दूषयन् दूष्यान् कृच्छ्रमङ्गे विसर्पति||३३||
svādvamla lavaṇa snigdha gurvanna svapna sañcitaḥ|
kaphaḥ sandūṣayan dūṣyān kṛcchramaṅge visarpati||33||

Etiology and Pathogenesis of Kaphaja Visarpa:
Kapha accumulated because of the intake of ingredients which are
• Madhura (sweet)
• Amla (sour)
• Lavana (Saline)
• Snigdha (unctuous) and
• Diva swapna – heavy sleep [during day time] vitiates the Dushyas (tissue elements) and spreads slowly which gives rise to Kaphaja type of Visarpa. [33]

Signs and Symptoms of Kaphaja Visarpa:
तस्य रूपाणि- शीतकः शीतज्वरो गौरवं निद्रा तन्द्राऽरोचको मधुरास्यत्वमास्योपलेपो निष्ठीविका छर्दिरालस्यं स्तैमित्यमग्निनाशो दौर्बल्यं च, यस्मिंश्चावकाशे विसर्पोऽनुसर्पति सोऽवकाशः श्वयथुमान् पाण्डुर्नातिरक्तः स्नेह सुप्ति स्तम्भ गौरवैरन्वितोऽल्पवेदनः कृच्छ्रपाकैश्चिरकारिभिर्बहुलत्वगुपलेपैः स्फोटः श्वेतपाण्डुभिरनुबध्यते, प्रभिन्नस्तु श्वेतं पिच्छिलं तन्तुमद्धनमनुबद्धं स्निग्धमास्रावं स्रवति, ऊर्ध्वं च गुरुभिः स्थिरैर्जालावततैः स्निग्धै र्बहुलत्वगुपलेपैर्व्रणैरनुबध्यतेऽनुषङ्गी च भवति, श्वेत नख नयन वदन त्वङ्मूत्रवर्चस्त्वं, निदानोक्तानि चास्य नोपशेरते विपरीतानि चोपशेरत इति श्लेष्म विसर्पः||३४||
tasya rūpāṇi- śītakaḥ śītajvaro gauravaṃ nidrā tandrā’rocako madhurāsyatvamāsyopalepo niṣṭhīvikā chardirālasyaṃ staimityamagnināśo daurbalyaṃ ca, yasmiṃścāvakāśe visarpo’nusarpati so’vakāśaḥ śvayathumān pāṇḍurnātiraktaḥ sneha supti stambha gauravairanvito’lpavedanaḥ kṛcchrapākaiścirakāribhirbahulatvagupalepaiḥ sphoṭaḥ śvetapāṇḍubhiranubadhyate, prabhinnastu śvetaṃ picchilaṃ tantumaddhanamanubaddhaṃ snigdhamāsrāvaṃ sravati, ūrdhvaṃ ca gurubhiḥ sthirairjālāvatataiḥ snigdhai rbahulatvagupalepairvraṇairanubadhyate’nuṣaṅgī ca bhavati, śveta nakha nayana vadana tvaṅmūtravarcastvaṃ, nidānoktāni cāsya nopaśerate viparītāni copaśerata iti śleṣma visarpaḥ||34||

The following are the signs and symptoms of Kaphaja type of Visarpa:
• Sheeta – Feeling of chill, Shita jvara – cold-fever
• Gauravam – heaviness, Ati nidra – excessive sleep, Tandra – drowsiness
• Aruchi -anorexia, Madhura aasya – sweet taste in the mouth, Aasya aalepa – adherence of sticky material in the mouth, spitting of Saliva, Chardi -vomiting
• Aalasya – laziness, Staimityam – timidity, Agni nasha -diminution of the power of digestion (Agni) and Daurbalyam – weakness
• The space in which the disease (Visarpa) spreads, becomes Shyvathuman – edematous, pāṇḍurnātiraktaḥ sneha – Pale- yellow, not very red and unctuous;
• There is Supti (numbness), Stambha (stiffness), Gauravam (heaviness) and Alpa vedana (less of pain in the body)
• The pustules in this space get suppurated very late, they become chronic, they appear in large number; he skin over these pustules gets covered with sticky material, and these pustules are either white or place- yellow in color
• When there is eruption of these pustules, then exudates which is white , slimy, fibrous, dense, knotty and unctuous, comes out
• After the eruption of these pustules, the space is covered with ulcers which are heavy (deep- seated) stable, surrounded by the capillary net work, unctuous and covered with many skin scabs (sticks skins)
• These ulcers continue to stay for a long time
• The nails, eyes, face, skin, urine and stool of the patient are white in color and
The factors described to cause Kaphaja Visarpa are not liked by the patient. On the other hand, the patient feels comfortable with the ingredients having opposite attributes. [34]

Agnivisarpa – Nidana, Samprapti: 
वातपित्तं प्रकुपितमतिमात्रं स्वहेतुभिः|
परस्परं लब्धबलं दहद्गात्रं विसर्पति||३५||
vātapittaṃ prakupitamatimātraṃ svahetubhiḥ|
parasparaṃ labdhabalaṃ dahadgātraṃ visarpati||35||

Etiology and Pathogenesis of Agni- Visarpa:
Vata Dosha and Pitta Dosha are simultaneously aggravated because of their respective causative factors, gain strength from each other and spread over the body along with burning sensation which is called Agni- Visarpa. [35]

Agni Visarpa Lakshana: 
तदुपतापादातुरः सर्वशरीरमङ्गारैरिवाकीर्यमाणं मन्यते, छर्द्यतीसार मूर्च्छा दाह मोह ज्वर तमकारोचकास्थिसन्धिभेद तृष्णाविपाकाङ्गभेदादिभिश्चाभिभूयते, यं यं चावकाशं विसर्पोऽनुसर्पति सोऽवकाशः शान्ताङ्गारप्रकाशोऽतिरक्तो वा भवति, अग्निदग्ध प्रकारैश्च स्फोटैरुपचीयते, स शीघ्रगत्वादाश्वेव मर्मानुसारी भवति, मर्मणि चोपतप्ते पवनोऽतिबलो भिनत्त्यङ्गान्यतिमात्रं प्रमोहयति सञ्ज्ञां, हिक्काश्वासौ जनयति, नाशयति निद्रां, स नष्टनिद्रः प्रमूढसञ्ज्ञो व्यथितचेता न क्वचन सुखमुपलभते, अरतिपरीतः स्थानादासनाच्छय्यां क्रान्तुमिच्छति, क्लिष्टभूयिष्ठश्चाशु निद्रां भजति, दुर्बलो दुःखप्रबोधश्च भवति; तमेवंविधमग्निविसर्प परीतम चिकित्स्यं विद्यात्||३६||
tadupatāpādāturaḥ sarvaśarīramaṅgārairivākīryamāṇaṃ manyate, chardyatīsāra mūrcchā dāha moha jvara tamakārocakāsthisandhibheda tṛṣṇāvipākāṅgabhedādibhiścābhibhūyate, yaṃ yaṃ cāvakāśaṃ visarpo’nusarpati so’vakāśaḥ śāntāṅgāraprakāśo’tirakto vā bhavati, agnidagdha prakāraiśca sphoṭairupacīyate, sa śīghragatvādāśveva marmānusārī bhavati, marmaṇi copatapte pavano’tibalo bhinattyaṅgānyatimātraṃ pramohayati sañjñāṃ, hikkāśvāsau janayati, nāśayati nidrāṃ, sa naṣṭanidraḥ pramūḍhasañjño vyathitacetā na kvacana sukhamupalabhate, aratiparītaḥ sthānādāsanācchayyāṃ krāntumicchati, kliṣṭabhūyiṣṭhaścāśu nidrāṃ bhajati, durbalo duḥkhaprabodhaśca bhavati; tamevaṃvidhamagnivisarpa parītama cikitsyaṃ vidyāt||36||

Signs and symptoms of Agni visarpa:
1. Being afflicted by this type of Visarpa, the patient feels as if his whole body is sprinkled with live charcoal
2. Affliction by Chardi (vomiting), Atisara (Diarrhoea), Murccha (Fainting), Daha (burning sensation), Moha (unconsciousness), Jwara (fever), Tamaka (a feeling as if entering into darkness), Aruchi (anorexia), Asthi bheda (pain in the bones and joints), Trushna (morbid thirst), Avipaka (indigestion), Anga bheda (breaking pain all over the body), etc
3. The space in which the Visarpa spreads appears likes the extinguished charcoal (bark) or excessively red
4. The space becomes surrounded with pustules like those accused by burns
5. If afflicts the Marmans (vital organs) because of its nature to spread rapidly
6. Because of the affliction of the vital organs, the Vata Dosha gets excessively aggravated to cause breaking pain in the limbs in excess and unconsciousness
7. This aggravated Vata Dosha causes Hikka (hiccup), Shvasa (Asthma) and Insomnia;
8. Because of lack of sleep, his mind becomes dull, he feels miserable and he never feels happy any where
9. Because of this disposition of disliking for everything, he leaves his habits an seat, and desires to go to bed
10. Being afflicted with miseries, he gets sleep quickly and
11. He becomes so weak that it becomes very difficult to awaken him from sleep
The patient suffering from Agni- Visarpa like this (with the above mentioned signs and symptoms) is incurable. [36]

Kardama Visarpa Nidana Samprapti:
कफपित्तं प्रकुपित्तं बलवत् स्वेन हेतुना|
विसर्पत्येकदेशे तु प्रक्लेदयति देहिनम्||३७||
kaphapittaṃ prakupittaṃ balavat svena hetunā|
visarpatyekadeśe tu prakledayati dehinam||37||

Etiology and Pathogenesis of Kardama- Visarpa:
Kapha and Pitta get simultaneously aggravated because of their respective etiological factors, and spread in a localized manner, giving rise to softening of the tissues of the locality. This is called Kardama- Visarpa [37]

Kardama Visarpa Lakshana: 
तद्विकाराः- शीतज्वरः शिरोगुरुत्वं दाहः स्तैमित्यमङ्गावसदनं निद्रा तन्द्रा मोहोऽन्नद्वेषः प्रलापोऽग्निनाशो दौर्बल्यमस्थिभेदो मूर्च्छा पिपासा स्रोतसां प्रलेपो जाड्यमिन्द्रियाणां प्रायोपवेशनमङ्गविक्षेपोऽङ्गमर्दोऽरतिरौत्सुक्यं चोपजायते, प्रायश्चामाशये विसर्पत्यलसक एकदेशग्राही च, यस्मिंश्चावकाशे विसर्पो विसर्पति सोऽवकाशो रक्तपीत पाण्डुपिडकावकीर्ण इव मेचकाभः कालो मलिनः स्निग्धो बहूष्मा गुरुः स्तिमितवेदनः श्वयथुमान् गम्भीरपाको निरास्रावः शीघ्रक्लेदः स्विन्नक्लिन्नपूतिमांसत्वक् क्रमेणाल्परुक् परामृष्टोऽवदीर्यते कर्दम इवावपीडितोऽन्तरं प्रयच्छत्युपक्लिन्नपूतिमांसत्यागी सिरास्नायुसन्दर्शी कुणपगन्धी च भवति सञ्ज्ञास्मृतिहन्ता च; तं कर्दमविसर्पपरीतमचिकित्स्यं विद्यात्||३८||
tadvikārāḥ- śītajvaraḥ śirogurutvaṃ dāhaḥ staimityamaṅgāvasadanaṃ nidrā tandrā moho’nnadveṣaḥ pralāpo’gnināśo daurbalyamasthibhedo mūrcchā pipāsā srotasāṃ pralepo jāḍyamindriyāṇāṃ prāyopaveśanamaṅgavikṣepo’ṅgamardo’ratirautsukyaṃ copajāyate, prāyaścāmāśaye visarpatyalasaka ekadeśagrāhī ca, yasmiṃścāvakāśe visarpo visarpati so’vakāśo raktapīta pāṇḍupiḍakāvakīrṇa iva mecakābhaḥ kālo malinaḥ snigdho bahūṣmā guruḥ stimitavedanaḥ śvayathumān gambhīrapāko nirāsrāvaḥ śīghrakledaḥ svinnaklinnapūtimāṃsatvak krameṇālparuk parāmṛṣṭo’vadīryate kardama ivāvapīḍito’ntaraṃ prayacchatyupaklinnapūtimāṃsatyāgī sirāsnāyusandarśī kuṇapagandhī ca bhavati sañjñāsmṛtihantā ca; taṃ kardamavisarpaparītamacikitsyaṃ vidyāt||38||

Signs and symptoms of Kardama Visarpa:
1. Sheeta jvara – Cold fever, Shiro ruk – heaviness of the head, Daha – burning sensation
2. Staimitya (timidity), Anga avasada – Prostration of the limbs
3. Nidra – sleep, Tandra – drowsiness, Moha – Unconsciousness
4. Anna dvesha – dislike for food, Pralapa – delirium, Agni nasha – diminution of the power of digestion
5. Daurbalya -weakness, Asthi bheda – breaking pain in the bones, Murcha – fainting
6. Pipasa – morbid thirst, Srotasam pralepa – adhesion of sticky material in the channels ofcirculation,insensibility(jadya) of sense organs, constant feeling for voiding stool
7. Anga-Viksepa (stretching of limbs), Angamarda -Malaise
8. Arti – disliking for every thing and Utsukya – anxiety
9. This disease generally spreads in slow spread in the Amashaya (region of the stomach) and gets localized there
10. The space in which this type of Visarpa spreads, becomes as if studded with eruptions of Rakta pita pandu pidaka -red, yellow and pale- yellow color
11. The space looks muddy, black, dirty and unctuous , and it is excessively hot , Gaurava (heavy), with dull pain, oedema and deep-seated suppuration
12. These eruptions are free from any exudation and become sloughy very quickly.
13. The skin and muscle tissue over these eruptions are shriveled, sticky and suppurated.
14. The pain over this space is less and it appears gradually
15. By rubbing, these eruptions get cracked, and when pressed, sticky and putrefied muscle tissue comes out of these eruptions
16. In the space at the bottom of these eruptions(after taking out the slough), one can visualize vessels and ligaments, and smell like that of a dead body is emitted from this space and
17. The patient loses consciousness and memory.
This is called Kardama- Visarpa, and it is incurable. [38]

Granthi Visarpa Nidana, Lakshana:
स्थिर गुरु कठिन मधुर शीत स्निग्धान्नपानाभिष्यन्दि सेविनाम व्यायामादिसेविनाम प्रतिकर्म शीलानां श्लेष्मा वायुश्च प्रकोपमापद्यते, तावुभौ दुष्ट प्रवृद्धावतिबलौ प्रदूष्य दूष्यान् विसर्पाय कल्पेते; तत्र वायुः श्लेष्मणा विबद्धमार्गस्तमेव श्लेष्माणमनेकधा भिन्दन् क्रमेण ग्रन्थिमालां कृच्छ्रपाकसाध्यां कफाशये सञ्जनयति, उत्सन्नरक्तस्य वा प्रदूष्य रक्तं सिरास्नायुमांसत्वगाश्रितं ग्रन्थीनां मालां कुरुते तीव्ररुजानां स्थूलानामणूनां वा दीर्घवृत्तरक्तानां, तदुपतापाज्ज्वरातिसार कास हिक्का श्वास शोष- प्रमोह वैवर्ण्यारोचकाविपाक प्रसेक च्छर्दि र्मूर्च्छाङ्ग भङ्ग निद्रारतिसदनाद्याः प्रादुर्भवन्त्युपद्रवाः; स एतैरुपद्रुतः सर्वकर्मणां विषयमतिपतितो विवर्जनीयो भवतीति ग्रन्थिविसर्पः||३९||
sthira guru kaṭhina madhura śīta snigdhānnapānābhiṣyandi sevināma vyāyāmādisevināma pratikarma śīlānāṃ śleṣmā vāyuśca prakopamāpadyate, tāvubhau duṣṭa pravṛddhāvatibalau pradūṣya dūṣyān visarpāya kalpete; tatra vāyuḥ śleṣmaṇā vibaddhamārgastameva śleṣmāṇamanekadhā bhindan krameṇa granthimālāṃ kṛcchrapākasādhyāṃ kaphāśaye sañjanayati, utsannaraktasya vā pradūṣya raktaṃ sirāsnāyumāṃsatvagāśritaṃ granthīnāṃ mālāṃ kurute tīvrarujānāṃ sthūlānāmaṇūnāṃ vā dīrghavṛttaraktānāṃ, tadupatāpājjvarātisāra kāsa hikkā śvāsa śoṣa- pramoha vaivarṇyārocakāvipāka praseka cchardi rmūrcchāṅga bhaṅga nidrāratisadanādyāḥ prādurbhavantyupadravāḥ; sa etairupadrutaḥ sarvakarmaṇāṃ viṣayamatipatito vivarjanīyo bhavatīti granthivisarpaḥ||39||

Etiology, Pathogenesis, Signs and Symptoms of Granthi- Visarpa:
Kapha and Vayu get aggravated because of the following:
1. Intake of food and drinks which are Sthira (having the attribute of stability), Guru (heavy), Kathina (hard), Madhura (sweet), Shita (cold), Snigdha (unctuous) and Abhisyandi (ingredients which cause obstruction to the channels of circulation)
2. Avyayama – Lack of exercise etc and
3. Habitually avoiding administration of elimination therapies (panca-karma) at the appropriate time.
Both these vitiated Doshas get excessively aggravated and vitiated the Dushyas (tissue elements) giving rise to Visarpa.
The channel of circulation of vayu gets obstructed by the aggravated Kapha (which causes further aggravation of Vayu). This aggravated Vayu, on its turn, causes splitting of the Kapha into several parts gradually giving rise to a serious of Granthis (glandular enlargements) in the abodes of Kapha. These enlarged glands get suppurated very slowly and the ailment is different of cure.
Besides, in a person having excess off blood, [aggravated Vayu and Kapha] vitiated the blood giving rise to a series of glandular enlargements located in vessels, ligaments (or nerves), muscles and skin. These enlarged glands are extremely painful; some of these might be big in size and some others small; and some of these might be elongated, some of these might be elongated, some round in shape and some of these might be elongated, some round in shape and some of these are red in color.

Being afflicted by this type of Visarpa, the patient may get complications like
Jwara – fever
Atisara – diarrhoea
Kasa – bronchitis
Hikka – hiccup
Tamaka shvasa – asthma
Kshaya – consumption
Sammoha – unconsciousness
Vaivarnya – Discoloration of the skin
Aruchi – anorexia,
Avipaka – indigestion,
Praseka – Salivation,
Chardi – vomiting,
Murchha – fainting,
Anga bheda – Fractures in the limbs,
Ati nidra – excessive sleep,
Arati (dislike for everything) and
Anga sada – prostration
The patient having all these complications transcends all the therapeutic measures. Therefore, treatment of such patients is attempted. [39]

Complications (Upadrava):
उपद्रवस्तु खलु रोगोत्तरकालजो रोगाश्रयो रोग एव स्थूलोऽणुर्वा, रोगात् पश्चाज्जायत इत्युपद्रवसञ्ज्ञः|
तत्र प्रधानो व्याधिः, व्याधेर्गुणभूत उपद्रवः, तस्य प्रायः प्रधानप्रशमे प्रशमो भवति|
स तु पीडाकरतरो भवति पश्चादुत्पद्यमानो व्याधि परिक्लिष्ट शरीरत्वात्; तस्मादुपद्रवं त्वरमाणोऽभिबाधेत||४०||
upadravastu khalu rogottarakālajo rogāśrayo roga eva sthūlo’ṇurvā, rogāt paścājjāyata ityupadravasañjñaḥ|
tatra pradhāno vyādhiḥ, vyādherguṇabhūta upadravaḥ, tasya prāyaḥ pradhānapraśame praśamo bhavati|
sa tu pīḍākarataro bhavati paścādutpadyamāno vyādhi parikliṣṭa śarīratvāt; tasmādupadravaṃ tvaramāṇo’bhibādheta||40||

Complications:
The ailment which is associated with a disease, and is manifested after the manifestation of the main disease is called Upadrava (complication). It may be a major or minor ailment.
It is called Upa- Drava because it occurs after the manifestation of the disease. It is the main disease which is predominant, and the ailment which appears as a complication is of secondary nature. The complication generally gets subsided when the main disease is cured. But the complication which is already very weak due to its earlier affliction by the main disease Therefore, the treatment of such complications is undertaken expeditiously. [40]

Sannipatika Visarpa
सर्वायतन समुत्थं सर्व लिङ्ग व्यापिनं सर्वधात्वनुसारिणमाशुकारिणं महात्ययिकमिति सन्निपात विसर्पमचिकित्स्यं विद्यात्||४१||
sarvāyatana samutthaṃ sarva liṅga vyāpinaṃ sarvadhātvanusāriṇamāśukāriṇaṃ mahātyayikamiti sannipāta visarpamacikitsyaṃ vidyāt||41||

The Sannipatika type of Visarpa is caused by all the etiological factors [described in respect of each of the earlier varieties of Visarpa]. All the signs and symptoms described in respect of each of the earlier varieties of Visarpa are manifested in this type of Visarpa. It pervades all the Dhatus (tissue elements). It spreads instantaneously, and it is a serious ailment. This Sannipatika type of Visarpa is incurable [41]

Prognosis:
तत्र वात पित्त श्लेष्म निमित्ता विसर्पास्त्रयः साध्या भवन्ति; अग्निकर्दमाख्यौ पुनरनुपसृष्टे मर्मणि अनुपगते वा सिरा स्नायु मांस क्लेदे साधारण क्रियाभिरुभावेवाभ्यस्यमानौ प्रशान्तिमापद्येयाताम्, अनादरोपक्रान्तः पुनस्तयोरन्यतरो हन्याद्देहमाश्वेवाशीविषवत्; तथा ग्रन्थिविसर्पमजातोपद्रवमारभेत चिकित्सितुम्, उपद्रवोपद्रुतं त्वेनं परिहरेत्; सन्निपातजं तु सर्वधात्वनुसारित्वादाशुकारित्वाद्विरुद्धोपक्रमत्वाच्चासाध्यं विद्यात्||४२||
tatra vāta pitta śleṣma nimittā visarpāstrayaḥ sādhyā bhavanti; agnikardamākhyau punaranupasṛṣṭe marmaṇi anupagate vā sirā snāyu māṃsa klede sādhāraṇa kriyābhirubhāvevābhyasyamānau praśāntimāpadyeyātām, anādaropakrāntaḥ punastayoranyataro hanyāddehamāśvevāśīviṣavat; tathā granthivisarpamajātopadravamārabheta cikitsitum, upadravopadrutaṃ tvenaṃ pariharet; sannipātajaṃ tu sarvadhātvanusāritvādāśukāritvādviruddhopakramatvāccāsādhyaṃ vidyāt||42||

Vatika-Visarpa, Paittika-Visarpa and Kaphaja-Visarpa- these 3 types are curable.
Agni-Visarpa and Kardama-Visarpa can be alleviated by the habitual (constant) use of general therapeutic measures (to counteract the respective etiological factors) only when the vital organs (like heart, etc). are not afflicted, and when there is no softening of the vessels, ligaments and muscle tissue. If not properly treated, any one of these two may cause instant death like snake poison.

The patient of Granthi-Visarpa is treated only if its complications are not manifested. If the complications are already manifested, then the patient should not be treated.
Sannipatika type of Visarpa is incurable because it pervades all the tissue elements, it spreads instantaneously and its treatment involves mutually contradictory therapeutic measures. [42]

Visarpa Chikitsa Sutra: Line of treatment
तत्र साध्यानां साधनमनुव्याख्यास्यामः||४३||
लङ्घनोल्लेखने शस्ते तिक्तकानां च सेवनम्|
कफस्थानगते सामे रूक्षशीतैः प्रलेपयेत्||४४||
पित्तस्थानगतेऽप्येतत् सामे कुर्याच्चिकित्सितम्|
शोणितस्यावसेकं च विरेकं च विशेषतः||४५||
मारुताशयसम्भूतेऽप्यादितः स्याद्विरूक्षणम्|
रक्तपित्तान्वयेऽप्यादौ स्नेहनं न हितं मतम्||४६||
वातोल्बणे तिक्तघृतं पैत्तिके च प्रशस्यते|
लघुदोषे, महादोषे पैत्तिके स्याद्विरेचनम्||४७||
न घृतं बहुदोषाय देयं यन्न विरेचयेत्|
तेन दोषो ह्युपष्टब्धस्त्वङ्मांसरुधिरं पचेत्||४८||
तस्माद्विरेकमेवादौ शस्तं विद्याद्विसर्पिणः|
रुधिरस्यावसेकं च तद्ध्यस्याश्रयसञ्ज्ञितम्||४९||
tatra sādhyānāṃ sādhanamanuvyākhyāsyāmaḥ||43||
laṅghanollekhane śaste tiktakānāṃ ca sevanam|
kaphasthānagate sāme rūkṣaśītaiḥ pralepayet||44||
pittasthānagate’pyetat sāme kuryāccikitsitam|
śoṇitasyāvasekaṃ ca virekaṃ ca viśeṣataḥ||45||
mārutāśayasambhūte’pyāditaḥ syādvirūkṣaṇam|
raktapittānvaye’pyādau snehanaṃ na hitaṃ matam||46||
vātolbaṇe tiktaghṛtaṃ paittike ca praśasyate|
laghudoṣe, mahādoṣe paittike syādvirecanam||47||
na ghṛtaṃ bahudoṣāya deyaṃ yanna virecayet|
tena doṣo hyupaṣṭabdhastvaṅmāṃsarudhiraṃ pacet||48||
tasmādvirekamevādau śastaṃ vidyādvisarpiṇaḥ|
rudhirasyāvasekaṃ ca taddhyasyāśrayasañjñitam||49||

Visarpa Chikitsa Sutra: Line of treatment
If the Doshas causing Visarpa are of Ama (uncooked) nature and if these Doshas are located in the abode of:
Kapha (upper part of the body, i.e chest, neck and head) – Langhana (fasting) and Vamana (emetic) therapies are useful. Such a patient is given ingredients having Katu (bitter) taste. The affected part of the body is anointed with the paste of the ingredients having ununctousness and cooling effect.
Pitta (i.e Middle part of the body), then also the therapeutic measures suggested above is administered. In addition, blood letting and purgation therapies are specifically administered to such patients.
Vayu (lower part of the body), then Rookshana  therapy is administered in the beginning. Since the disease involves the vitiation of Rakta (blood) and Pitta (in the Samanya Samprapti or general Pathogenesis), in the begining, oleation therapy is not useful.

If Vayu is aggravated in excess and Pitta is less aggravated to cause Visarpa, then Tiktaka Ghrta (Charaka Chikitsasthana 7: 140- 150) is useful. However, if Pitta is aggravated in excess, then the patient is treated with purgation therapy.
If the Doshas causing Visarpa are aggravated in excess then recipes of medicated ghee which do not cause purgation is not administered. Otherwise, these recipes of medicated ghee (which are not purgatives) occlude the Doshas resulting in the sloughening (Paka) of the skin, muscle tissue and blood. Therefore, in the beginning the Visarpa patient is given purgation therapy. This patient is administered blood-letting therapy. Because the vitiated blood is the Asraya (main supporting factor) in the pathogenesis of Visarpa [43- 49]

इति वीसर्पनुत् प्रोक्तं समासेन चिकित्सितम्|
एतदेव पुनः सर्वं व्यासतः सम्प्रवक्ष्यते||५०||
iti vīsarpanut proktaṃ samāsena cikitsitam|
etadeva punaḥ sarvaṃ vyāsataḥ sampravakṣyate||50||

In the above verses, the treatment of Visarpa is described only in brief. The treatment in detail will be spelt out hereafter. [50]

Vamana Yoga – Emetic Recipes:
मदनं मधुकं निम्बं वत्सकस्य फलानि च|
वमनं सम्प्रदातव्यं विसर्पे कफपित्तजे||५१||
पटोल पिचुमर्दाभ्यां पिप्पल्या मदनेन च|
विसर्पे वमनं शस्तं तथा चेन्द्रयवैः सह||५२||
यांश्च योगान् प्रवक्ष्याभि कल्पेषु कफपित्तिनाम्|
विसर्पिणां प्रयोज्यास्ते दोषनिर्हरणाः शिवाः||५३||
madanaṃ madhukaṃ nimbaṃ vatsakasya phalāni ca|
vamanaṃ sampradātavyaṃ visarpe kaphapittaje||51||
paṭola picumardābhyāṃ pippalyā madanena ca|
visarpe vamanaṃ śastaṃ tathā cendrayavaiḥ saha||52||
yāṃśca yogān pravakṣyābhi kalpeṣu kaphapittinām|
visarpiṇāṃ prayojyāste doṣanirharaṇāḥ śivāḥ||53||

Vamana Yoga – Emetic Recipes:
If Visarpa is caused by either Kapha or Pitta or both Kapha and Pitta, then the patient is given emetic therapy with the following recipes:
1. Madana – Randia dumetrom, Madhuka– Licorice – Glycyrrhiza glabra, Nimba – Neem (Azadirachta indica) and Fruits of Vatsaka (Holarrhena antidysenterica Wall.)
2. Patola – Trichosanthes dioica,Picumarda, Pippali – Long pepper fruit – Piper longum,madana and Indra –Yava – Barley (Hordeum vulgare) [51- 53]

Kashaya Yogas – Herbal decoction: 
मुस्त निम्ब पटोलानां चन्दनोत्पलयोरपि|
सारिवामलकोशीर मुस्तानां वा विचक्षणः||५४||
कषायान् पाययेद्वैद्यः सिद्धान् वीसर्पनाशनान्|
किराततिक्तकं लोध्रं चन्दनं सदुरालभम्||५५||
नागरं पद्म किञ्जल्कमुत्पलं स बिभीतकम्|
मधुकं नागपुष्पं च दद्याद्वीसर्प शान्तये||५६||
प्रपौण्डरीकं मधुकं पद्मकिञ्जल्कमुत्पलम्|
नागपुष्पं च लोध्रं च तेनैव विधिना पिबेत्||५७||
द्राक्षां पर्पटकं शुण्ठीं गुडूचीं धन्वयासकम्|
निशापर्युषितं दद्यात्तृष्णा वीसर्प शान्तये||५८||
पटोलं पिचुमर्दं च दार्वीं कटुकरोहिणीम्|
यष्ट्याह्वां त्रायमाणां च दद्याद्वीसर्पशान्तये||५९||
पटोलादिकषायं वा पिबेत्त्रिफलया सह|
मसूर विदलै र्युक्तं घृतमिश्रं प्रदापयेत्||६०||
पटोलपत्र मुद्गानां रसमामलकस्य च|
पाययेत घृतोन्मिश्रं नरं वीसर्प पीडितम्||६१||
musta nimba paṭolānāṃ candanotpalayorapi|
sārivāmalakośīra mustānāṃ vā vicakṣaṇaḥ||54||
kaṣāyān pāyayedvaidyaḥ siddhān vīsarpanāśanān|
kirātatiktakaṃ lodhraṃ candanaṃ sadurālabham||55||
nāgaraṃ padma kiñjalkamutpalaṃ sa bibhītakam|
madhukaṃ nāgapuṣpaṃ ca dadyādvīsarpa śāntaye||56||
prapauṇḍarīkaṃ madhukaṃ padmakiñjalkamutpalam|
nāgapuṣpaṃ ca lodhraṃ ca tenaiva vidhinā pibet||57||
drākṣāṃ parpaṭakaṃ śuṇṭhīṃ guḍūcīṃ dhanvayāsakam|
niśāparyuṣitaṃ dadyāttṛṣṇā vīsarpa śāntaye||58||
paṭolaṃ picumardaṃ ca dārvīṃ kaṭukarohiṇīm|
yaṣṭyāhvāṃ trāyamāṇāṃ ca dadyādvīsarpaśāntaye||59||
paṭolādikaṣāyaṃ vā pibettriphalayā saha|
masūra vidalai ryuktaṃ ghṛtamiśraṃ pradāpayet||60||
paṭolapatra mudgānāṃ rasamāmalakasya ca|
pāyayeta ghṛtonmiśraṃ naraṃ vīsarpa pīḍitam||61||

The following decoctions are useful for the treatment of Visarpa:
1. Decoction of Musta (Cyperus rotundus), Nimba – Neem (Azadirachta indica) and Patola – Trichosanthes dioica
2. Decoction of Chandana (Sandalwood – Santalum album) and Utpala (Nymphaea alba) Sariva – Indian Sarsaparilla – Hemidesmus indicus , Amalaka, Ushira – Vetiver – Vetiveria zizanioides and Musta (Cyperus rotundus)

A wise physician should administer these (above mentioned therapeutically effective decoctions for the cure of Visarpa.
1. Decoction of Kirata- Tikta – Swertia chirata, Lodhra (Symplocos racemosa), Chandana (Sandalwood – Santalum album), Duralabha – Fagonia arabica, Nagara – Zingiber officinale, Androciums of Padma – Lotus (Nelumbo nucifera), Utpala (Nymphaea alba), Bibhitaka – Terminalia bellerica, Madhuka– Licorice – Glycyrrhiza glabra, and Naga-Puspa
2. Decoction of Prapaundarika (Nymphaea lotus) – red variety,Madhuka– Licorice – Glycyrrhiza glabra, Androceums of Padma – Lotus (Nelumbo nucifera), Utpala (Nymphaea alba),Naga-Puspa and Lodhra (Symplocos racemosa)
3. The Sita – white variety of Cynodon dactylon-Kasaya (cold decoction) prepared of Draksha – Raisin – Vitis vinifera, Parpataka, Sunthi – Zingiber officinale, Guduchi – Tinospora cordifolia and Dhanvasaka this is useful for the cure of morbid thirst and Visarpa
4. The cold decoction of Patola – Trichosanthes dioica,Picumarda,Darvi,Katuka-Katukarohini – Picrorhiza kurroa, Yasti- Madhu – Glycyrrhiza glabra and Trayamana – Gentiana kurroo
5. To the above mentioned recipe of Patola – Trichosanthes dioica, etc. Triphala and Dehusked seeds of masura may be added, and made to a decoction. This decoction is added with ghee and
6. Decoction of the leaves of Patola – Trichosanthes dioica, Mudga and the juice of Amalaki – Emblica offcinalis. This decoction is administered by adding ghee. [54-61]

Recipes of Medicated Ghee
यच्च सर्पिर्महातिक्तं पित्त कुष्ठ निबर्हणम्|
निर्दिष्टं तदपि प्राज्ञो दद्याद्वीसर्पशान्तये||६२||
त्रायमाणाघृतं सिद्धं गौल्मिके यदुदाहृतम्|
विसर्पाणां प्रशान्त्यर्थं दद्यात्तदपि बुद्धिमान्||६३||
त्रिवृच्चूर्णं समालोड्य सर्पिषा पयसाऽपि वा|
घर्माम्बुना वा संयोज्य मृद्वीकानां रसेन वा||६४||
विरेकार्थं प्रयोक्तव्यं सिद्धं वीसर्पनाशनम्|
त्रायमाणाशृतं वाऽपि पयो दद्याद्विरेचनम्||६५||
त्रिफलारस संयुक्तं सर्पिस्त्रिवृतया सह|
प्रयोक्तव्यं विरेकार्थं विसर्प ज्वरनाशनम्||६६||
रसमामलकानां वा घृतमिश्रं प्रदापयेत्|
स एव गुरुकोष्ठाय त्रिवृच्चूर्णयुतो हितः||६७||
दोषे कोष्ठगते भूय एतत् कुर्याच्चिकित्सितम्|६८|
yacca sarpirmahātiktaṃ pitta kuṣṭha nibarhaṇam|
nirdiṣṭaṃ tadapi prājño dadyādvīsarpaśāntaye||62||
trāyamāṇāghṛtaṃ siddhaṃ gaulmike yadudāhṛtam|
visarpāṇāṃ praśāntyarthaṃ dadyāttadapi buddhimān||63||
trivṛccūrṇaṃ samāloḍya sarpiṣā payasā’pi vā|
gharmāmbunā vā saṃyojya mṛdvīkānāṃ rasena vā||64||
virekārthaṃ prayoktavyaṃ siddhaṃ vīsarpanāśanam|
trāyamāṇāśṛtaṃ vā’pi payo dadyādvirecanam||65||
triphalārasa saṃyuktaṃ sarpistrivṛtayā saha|
prayoktavyaṃ virekārthaṃ visarpa jvaranāśanam||66||
rasamāmalakānāṃ vā ghṛtamiśraṃ pradāpayet|
sa eva gurukoṣṭhāya trivṛccūrṇayuto hitaḥ||67||
doṣe koṣṭhagate bhūya etat kuryāccikitsitam|68|

MadhuTiktaka Ghrita described earlier (in Chikitsa 7: 144-150) for the treatment of Paittika Kushta is used by a wise physician to cure of Visarpa.
The reputed of Trayamana Ghruta described earlier (in Chikitsa 5: 128- 129) for the treatment of Gulma (Phantom tumor) also is used by a wise physician for the treatment of Visarpa.

The powder of Trivrt – Operculina turpethum is boiled by adding ghee or milk, and administered along with warm water or the juice of Mrdvika for purgation. This is a reputed recipe for the cure of Visarpa.
Similarly, milk boiled by adding Trayamana is administered to cause purgation in a patient of suffering from Visarpa.
The decoction of Triphala is added with ghee and Trivrt – Operculina turpethum and given for purgation to the patient of Visarpa associated with fever.
Similarly, the decoction or juice of Amalaki – Emblica officinalis is administered for purgation, by adding ghee. If the patient of Visarpa had costive bowel, then the powder of Trivrt – Operculina turpethum is added to this recipe.
If the Doshas in the patient of visarpa in the Kostha (Gastro- Intestinal tract), the also the above mentioned recipes are to be administered. [62- ½ 68]

Raktamokshana – Blood- letting Therapy for Bahi Visarpa:
शाखादुष्टे तु रुधिरे रक्तमेवादितो हरेत्||६८||
भिषग्वातान्वितं रक्तं विषाणेन विनिर्हरेत्|
पित्तान्वितं जलौकोभिः, कफान्वितमलाबुभिः||६९||
यथासन्नं विकारस्य व्यधयेदाशु वा सिराम्|
त्वङ्मांसस्नायुसङ्क्लेदो रक्तक्लेदाद्धि जायते||७०||
śākhāduṣṭe tu rudhire raktamevādito haret||68||
bhiṣagvātānvitaṃ raktaṃ viṣāṇena vinirharet|
pittānvitaṃ jalaukobhiḥ, kaphānvitamalābubhiḥ||69||
yathāsannaṃ vikārasya vyadhayedāśu vā sirām|
tvaṅmāṃsasnāyusaṅkledo raktakledāddhi jāyate||70||

Raktamokshana – Blood- letting Therapy for Bahi Visarpa:
If the blood in the periphery is vitiated to cause Visarpa, then in the beginning, blood – letting therapy is administered by the physician.
Vatanvita Rakta – Shrunga  (Vishaana) – If the vitiated Rakta is associated with aggravated Vayu, then the vitiated blood is taken out through the help of horn.
Pittanvita Rakta – Jalauka – If there is associated of aggravated Pitta, then the blood is taken out with the help of leech.
Kaphanvita Rakta – Alabu – If there is association of aggravated Kapha, then the vitiated blood is taken out with the help of alabu (the outer shell of the fruit with the pulp removed).

In addition, Venesection is performed to take out the vitiated blood from the adjacent vein. This blood- letting therapy is essential], without which the vitiated blood gives rise to the sloughening of the skin, muscle tissue and ligaments. [68 ½ – 70]

External therapies
अन्तःशरीरे संशुद्धे दोषे त्वङ्मांस संश्रिते|
आदितो वाऽल्पदोषाणां क्रिया बाह्या प्रवक्ष्यते||७१||
antaḥśarīre saṃśuddhe doṣe tvaṅmāṃsa saṃśrite|
ādito vā’lpadoṣāṇāṃ kriyā bāhyā pravakṣyate||71||

Even after the interior of the body is cleansed [by the above mentioned elimination therapies], the residual Doshas remain in the exterior of the body, i.e in the skin and muscle tissue. To remove these morbid Doshas, external therapies is administered. Such external therapies can also be administered in the beginning, if the Dosha causing Visarpa are less aggravated.

Udumbaradi Pradeha:
उदुम्बर त्वङ्मधुकं पद्म किञ्जल्कमुत्पलम्|
नागपुष्पं प्रियङ्गुश्च प्रदेहः सघृतो हितः||७२||
udumbara tvaṅmadhukaṃ padma kiñjalkamutpalam|
nāgapuṣpaṃ priyaṅguśca pradehaḥ saghṛto hitaḥ||72||

The paste of the bark of Udumbara – Ficus racemosa, Madhuka– Licorice – Glycyrrhiza glabra,Padma – Lotus (Nelumbo nucifera)- kinjalka, Utpala (Nymphaea alba), Naga puspa and Priyangu (Callicara macrophylla) is added with Ghee and applied externally(Pradeha) for the cure of Visarpa. [72]

Nyarodhadya Lepa
न्यग्रोधपादास्तरुणाः कदली गर्भ संयुताः|
बिसग्रन्थिश्च लेपः स्याच्छतधौतघृताप्लुतः||७३||
nyagrodhapādāstaruṇāḥ kadalī garbha saṃyutāḥ|
bisagranthiśca lepaḥ syācchatadhautaghṛtāplutaḥ||73||

The paste of the tender adventitious roots of Nyagrodha – Ficus bengalensis, Pith of Kadali and Bisa- Granthi(rhizome of lotus) is mixed with Shata- Dhauta- Ghrta (ghee washed with water for 100 times) and applied externally. [73]

Kaliyadi Pralepa
कालीयं मधुकं हेम वन्यं चन्दन पद्मकौ|
एला मृणालं फलिनी प्रलेपः स्याद्धृताप्लुतः||७४||
kālīyaṃ madhukaṃ hema vanyaṃ candana padmakau|
elā mṛṇālaṃ phalinī pralepaḥ syāddhṛtāplutaḥ||74||

The paste of Kaliya, Madhuka– Licorice – Glycyrrhiza glabra, Hema (Mesua ferrea), Vanya, Chandana (Sandalwood – Santalum album), Padmaka – Prunus cerasoides, Ela (Elettaria cardamomum Maton) Mrnala and Phalini is mixed with ghee and applied externally. [74]

Shadvaladi –Pradeha:
शाद्वलं च मृणालं च शङ्खं चन्दनमुत्पलम्|
वेतसस्य च मूलानि प्रदेहः स्यात् सतण्डुलः||७५||
śādvalaṃ ca mṛṇālaṃ ca śaṅkhaṃ candanamutpalam|
vetasasya ca mūlāni pradehaḥ syāt sataṇḍulaḥ||75||

The paste of Shadvala (Durva (Cynodon dactylon), Mrunala, Shankha, Chandana (Sandalwood – Santalum album), Utpala (Nymphaea alba), root of Vetasa and Tandula (rice) is applied externally. [75]

Sarivadya-Pralepa:
सारिवा पद्मकिञ्जल्कमुशीरं नीलमुत्पलम्|
मञ्जिष्ठा चन्दनं लोध्रमभया च प्रलेपनम्||७६||
sārivā padmakiñjalkamuśīraṃ nīlamutpalam|
mañjiṣṭhā candanaṃ lodhramabhayā ca pralepanam||76||

The paste of Sariva – Indian Sarsaparilla – Hemidesmus indicus, Padma – Lotus (Nelumbo nucifera)- Kinjalka, Ushira – Vetiver – Vetiveria zizanioides, nila- Utpala (Nymphaea alba), Manjistha – Rubia cordifolia, Chandana – Santalum album, Lodhra (Symplocos racemosa) and Abhaya – Terminalia chebula is applied externally. [76]

Naladadi Pralepa
नलदं च हरेणुश्च लोध्रं मधुक पद्मकौ |
दूर्वा सर्जरसश्चैव सघृतं स्यात् प्रलेपनम्||७७||
naladaṃ ca hareṇuśca lodhraṃ madhuka padmakau |
dūrvā sarjarasaścaiva saghṛtaṃ syāt pralepanam||77||

The paste of Nalada, Harenu, Lodhra (Symplocos racemosa), Madhuka– Licorice – Glycyrrhiza glabra, Padmaka – Prunus cerasoides, Durva – Cynodon dactylon and Sarja (Vateria indica)-Rasa is mixed with ghee and applies externally. [77]

यावकाः सक्तवश्चैव सर्पिषा सह योजिताः|
प्रदेहो मधुकं वीरा सघृता यव सक्तवः||७८||
yāvakāḥ saktavaścaiva sarpiṣā saha yojitāḥ|
pradeho madhukaṃ vīrā saghṛtā yava saktavaḥ||78||

Yavaka (gruel prepared of barley) or Saktu (roasted flour of cereals) is mixed with ghee and applied externally.
The paste of Madhuka– Licorice – Glycyrrhiza glabra, Vara and Yava – Barley (Hordeum vulgare)-Saktu (Flour prepared of roasted barley) is mixed with ghee and applied externally. [78]

Baladi Lepa
बलामुत्पल शालूकं वीरामगुरु चन्दनम्|
कुर्यादालेपनं वैद्यो मृणालं च बिसान्वितम्||७९||
balāmutpala śālūkaṃ vīrāmaguru candanam|
kuryādālepanaṃ vaidyo mṛṇālaṃ ca bisānvitam||79||

The physician should apply externally the paste of Bala – Country mallow (root) – Sida cordifolia, Utpala (Nymphaea alba)- Saluka (rhizome of lotus), Vira Kanda(Vidari (Ipomoea paniculata / Pueraria tuberosa), Aguru – Aquallaria agallocha and Chandana (Sandalwood – Santalum album).
Similarly, the paste of Mrnala (root of lotus) Bisa (stem of lotus) is applied externally. [79]

यवचूर्णं समधुकं सघृतं च प्रलेपनम्|
yavacūrṇaṃ samadhukaṃ saghṛtaṃ ca pralepanam|
The paste of the powder of barley and Madhuka– Licorice – Glycyrrhiza glabra is mixed with ghee and applied externally. [½ 80]

हरेणवो मसुराश्च समुद्गाः श्वेत शालयः||८०||
पृथक् पृथक् प्रदेहाः स्युः सर्वे वा सर्पिषा सह|
hareṇavo masurāśca samudgāḥ śveta śālayaḥ||80||
pṛthak pṛthak pradehāḥ syuḥ sarve vā sarpiṣā saha|

Harenu, Masura, Mudga and white variety of Shali-rice- – these drugs taken individually or all together is made to a paste, mixed with ghee and applied externally [80 ½ – ½ 81]

पद्मिनी कर्दमः शीतो मौक्तिकं पिष्टमेव वा||८१||
शङ्खः प्रवालः शुक्तिर्वा गैरिकं वा घृताप्लुतम्|
(पृथगेते प्रदेहाश्च हिता ज्ञेया विसर्पिणाम्)|
Padminī kardamaḥ śīto mauktikaṃ piṣṭameva vā||81||
śaṅkhaḥ pravālaḥ śuktirvā gairikaṃ vā ghṛtāplutam|
(pṛthagete pradehāśca hitā jñeyā visarpiṇām)|

The cooling mud from a lotus pond or the paste of pearl, or the paste of Sankha, or the paste of Pravala, or the paste of Sukti, or the paste of Gairika is mixed with ghee and applied externally which is useful for the patient suffering from Visarpa. [81 ½ – ½ 82]

Prapanudarikadi Pralepa
प्रपौण्डरीकं मधुकं बला शालूकमुत्पलम्||८२||
न्यग्रोध पत्रदुग्धीके सघृतं स्यात् प्रलेपनम्|
prapauṇḍarīkaṃ madhukaṃ balā śālūkamutpalam||82||
nyagrodha patradugdhīke saghṛtaṃ syāt pralepanam|

The paste of Prapaundarika (Nymphaea lotus) – red variety, Madhuka– Licorice – Glycyrrhiza glabra, Bala – Country mallow (root) – Sida cordifolia, Saluka, Utpala (Nymphaea alba), leaves of Nyagrodha – Ficus bengalensis and Dugdhika is mixed with ghee and applied externally. [82 1/2 – ½ 83]

बिसानि च मृणालं च सघृताश्च कशेरुकाः||८३||
शतावरी विदार्योश्च कन्दौ धौतघृताप्लुतौ|
bisāni ca mṛṇālaṃ ca saghṛtāśca kaśerukāḥ||83||
śatāvarī vidāryośca kandau dhautaghṛtāplutau|

The paste of Bisa (Lotus Root), Mrinala (lotus stalk) or Kasheru is mixed with ghee and applied externally.
Similarly, the paste of Shatavari – Asparagus racemosus and Vidari (Ipomoea paniculata / Pueraria tuberosa) mixed with Shata-Dhauta- Ghrta (Ghee washed with water 100 times) may be used externally. [83 ½- ½ 84]

शैवालं नलमूलानि गोजिह्वा वृष कर्णिका||८४||
इन्द्राणिशाकं सघृतं शिरीषत्वग्बलाघृतम् |
śaivālaṃ nalamūlāni gojihvā vṛṣa karṇikā||84||
indrāṇiśākaṃ saghṛtaṃ śirīṣatvagbalāghṛtam |

The paste of Saivala (Vallisneria spiralis moss), the root of Nava (Nala), Gojihva, Vrsa- Karnika (Musika-Parnika) and leaves of Indrani (Nirgundi (Vitex negundo) is mixed with ghee and applied externally. Similarly, the paste of the bark of Sirisha (Albizzia lebbeck Benth.) mixed with Bala – Country mallow (root) – Sida cordifolia-Ghrta may be applied externally. [84 ½ – ½ 85]

न्यग्रोधोदुम्बर प्लक्ष वेतसाश्वत्थ पल्लवैः||८५||
त्वक्कल्कैर्बहुसर्पिर्भिः शीतैरालेपनं हितम्|
nyagrodhodumbara plakṣa vetasāśvattha pallavaiḥ||85||
tvakkalkairbahusarpirbhiḥ śītairālepanaṃ hitam|

The paste of the leaves of barks of Nyagrodha – Ficus bengalensis, Udumbara – Ficus racemosa, Plaksa – Ficus virens, vetasa and Asvattha – Ficus relgiosa is mixed with profuse quantity of ghee and applied externally after making these cool. [85 ½- ½ 86]

प्रदेहाः सर्व एवैते वात पित्तोल्बणे शुभाः||८६||
सकफे तु प्रवक्ष्यामि प्रदेहानपरान् हितान्|
pradehāḥ sarva evaite vāta pittolbaṇe śubhāḥ||86||
sakaphe tu pravakṣyāmi pradehānaparān hitān|

All the above mentioned Pradehas (recipes used externally in paste form) are useful in the Visarpa caused by the aggravation of Vata and Pitta. Other recipes, in addition to the above mentioned ones, which are useful in the treatment of Visarpa caused by aggravated Kapha, will be described hereafter. [86 ½ – ½ 86]

Triphala Pradeha
त्रिफलां पद्मकोशीरं समङ्गां करवीरकम्||८७||
नलमूलान्यनन्तां च प्रदेहमुपकल्पयेत्|
triphalāṃ padmakośīraṃ samaṅgāṃ karavīrakam||87||
nalamūlānyanantāṃ ca pradehamupakalpayet|

The paste of Triphala, Padmaka – Prunus cerasoides, Ushira – Vetiver – Vetiveria zizanioides, Samanga – Rubia cordifolia, Karaviraka, root of Nala and Ananta mixed with a small quantity of ghee is useful in Kaphaja type of Visarpa. [87 ½ – ½ 88]

Khadiradya lepana:
खदिरं सप्तपर्णं च मुस्तमारग्वधं धवम्||८८||
कुरण्टकं देवदारु दद्यादालेपनं भिषक्|
khadiraṃ saptaparṇaṃ ca mustamāragvadhaṃ dhavam||88||
kuraṇṭakaṃ devadāru dadyādālepanaṃ bhiṣak|

The paste of Khadira – Acacia catechu, Saptaparna – Alstonia scholaris, Musta (Cyperus rotundus), Aragvadha (Cassia fistula), Dhava – Anogeissus latifolia, Kurantaka and Devadaru (Cedrus deodara) mixed with a small quantity of ghee is useful in kaphaja type of Visarpa. [88 ½ – ½ 89]

Kaphaja Visarpa Yogas:
आरग्वधस्य पत्राणि त्वचं श्लेष्मातकस्य च||८९||
इन्द्राणि शाकं काकाह्वां शिरीष कुसुमानि च|
शैवालं नलमूलानि वीरां गन्ध प्रियङ्गुकाम्||९०||
त्रिफलां मधुकं वीरां शिरीष कुसुमानि च|
प्रपौण्डरीकं ह्रीबेरं दार्वी त्वङ्मधुकं बलाम्||९१||
पृथगालेपनं कुर्याद्द्वन्द्वशः सर्वशोऽपि वा|

āragvadhasya patrāṇi tvacaṃ śleṣmātakasya ca||89||
indrāṇi śākaṃ kākāhvāṃ śirīṣa kusumāni ca|
śaivālaṃ nalamūlāni vīrāṃ gandha priyaṅgukām||90||
triphalāṃ madhukaṃ vīrāṃ śirīṣakusumāni ca|
prapauṇḍarīkaṃ hrīberaṃ dārvī tvaṅmadhukaṃ balām||91||
pṛthagālepanaṃ kuryāddvandvaśaḥ sarvaśo’pi vā|

The following recipes are useful in the kaphaja type of Visarpa:
1. Paste of the leaves of Aragvadha (Cassia fistula) and the bark of Slesmataka
2. Paste of the leaves of Indrani, Kakahva and flowers of Sirisha (Albizzi lebbeck Benth.)
3. Paste of Saivala (Vallisneria spiralis)(moss), root of Nala, Vira and Gandha-Priyangu (Callicara macrophylla)
4. Paste of Triphala,Madhuka– Licorice – Glycyrrhiza glabra,Vira and flowers of Sirisha (Albizzi lebbeck Benth.) and
5. Paste of Prapaundrarika – Nymphaea lotus, Hribera, bark of Darvi – Berberis aristata, Madhuka– Licorice – Glycyrrhiza glabra and bala – Sida cordifolia

The above mentioned recipes may be used individually or two of these may be combined or all of these may be used together externally by adding a small quantity of ghee for the cure of Kaphaja type of Visarpa. [89 ½ – ½ 92]

Use of ghee in Recipes:
प्रदेहाः सर्व एवैते देयाः स्वल्प घृता प्लुताः||९२||
वातपित्तोल्बणे ये तु प्रदेहास्ते घृताधिकाः|
घृतेन शतधौतेन प्रदिह्यात् केवलेन वा||९३||
pradehāḥ sarva evaite deyāḥ svalpa ghṛtā plutāḥ||92||
vātapittolbaṇe ye tu pradehāste ghṛtādhikāḥ|
ghṛtena śatadhautena pradihyāt kevalena vā||93||

All the recipes described above for external application to treat Kaphaja type of Visarpa is mixed with ghee only in small quantity. The recipes described earlier for the treatment of Vatika and Paittika types of Visarpa should however, be added with ghee in profuse quantity.
Even Shata Dhauta ghrita (ghee washed with water 100 times) also can be used externally for the treatment of Visarpa. [92 ½ – 93]
Read more about Shata Dhauta ghrita

Recipes to cleanse the skin lesions: – Seka Yogas
घृतमण्डेन शीतेन पयसा मधुकाम्बुना|
पञ्चवल्ककषायेण सेचयेच्छीतलेन वा||९४||
वातासृक्पित्तबहुलं विसर्पं बहुशो भिषक्|
ghṛtamaṇḍena śītena payasā madhukāmbunā|
pañcavalkakaṣāyeṇa secayecchītalena vā||94||
vātāsṛkpittabahulaṃ visarpaṃ bahuśo bhiṣak|

If the Visarpa is caused by the excessive aggravation or vitiation of Vata, Rakta and Pitta, then the Physician is effuse  (Seka)[the ulcers] frequently with the supernatant part of ghee or cooled milk or cooled decoction of Madhuka– Licorice – Glycyrrhiza glabra or the cooled decoction of Pancha-Valkala. [94 – ½ 95]

Recipes Used in different other Forms:
सेचनास्ते प्रदेहा ये त एव घृतसाधनाः||९५||
ते चूर्णयोगा वीसर्पव्रणानामवचूर्णनाः|
secanāste pradehā ye ta eva ghṛtasādhanāḥ||95||
te cūrṇayogā vīsarpavraṇānāmavacūrṇanāḥ|

The recipes described above for effusion (secana) and for external application (Pradeha) may also be used for cooking medicated ghee. Similarly, these ingredients (recipes) can also be used for dusting (Avachurnna). Application of this medicated ghee and dusting the powders of these recipes help in the healing the ulcers of Visarpa.

Durvadi –Ghrta and Darvyadi Avachurna
दूर्वा स्वरस सिद्धं च घृतं स्याद्व्रणरोपणम्||९६||
दार्वीत्वङ्मधुकं लोध्रं केशरं चावचूर्णनम्|
dūrvā svarasa siddhaṃ ca ghṛtaṃ syādvraṇaropaṇam||96||
dārvītvaṅmadhukaṃ lodhraṃ keśaraṃ cāvacūrṇanam|

Ghee cooked with the juice of Durva (Cynodon dactylon) is applied externally which helps in the healing of the ulcers caused by Visarpa.
Avachurnana – dusting – Similarly, the powder of the bark of Darvi – Berberis aristata, madhuka, Lodhra (Symplocos racemosa) and Kesara may be used for dusting over these ulcers. [96 ½ – ½ 97]

Recipe for the Washing Ulcers
पटोलः पिचुमर्दश्च त्रिफला मधुकोत्पले||९७||
एतत् प्रक्षालनं सर्पिर्व्रणचूर्णं प्रलेपनम्|९८|
paṭolaḥ picumardaśca triphalā madhukotpale||97||
etat prakṣālanaṃ sarpirvraṇacūrṇaṃ pralepanam|98|

Decoction of Patola – Trichosanthes dioica, Picumarda, Triphala, Madhuka– Licorice – Glycyrrhiza glabra and Utpala (Nymphaea alba) may be used for washing ulcers of Visarpa. Medicated ghee prepared of the above mentioned ingredients may be applied over these ulcers. Similarly, the powder of these ingredients may be used for dusting over these ulcers of Visarpa. [97 ½ – ½ 98]

Method of Using Ointments (Pradeha or lepa)
प्रदेहाः सर्व एवैते कर्तव्याः सम्प्रसादनाः||९८||
क्षणे क्षणे प्रयोक्तव्याः पूर्वमुद्धृत्य लेपनम्|
अधावनोद्धृते पूर्वे प्रदेहा बहुशोऽघनाः||९९||
देयाः प्रदेहाः कफजे पर्याधानोद्धृते घनाः|
त्रिभागाङ्गुष्ठमात्रः स्यात् प्रलेपः कल्कपेषितः||१००||
नातिस्निग्धो न रूक्षश्च न पिण्डो न द्रवः समः|
न च पर्युषितं लेपं कदाचिदवचारयेत्||१०१||
न च तेनैव लेपेन पुनर्जातु प्रलेपयेत्|
क्लेदवीसर्पशूलानि सोष्णाभावात् प्रवर्तयेत्||१०२||
लेपो ह्युपरि पट्टस्य कृतः स्वेदयति व्रणम्|
स्वेदजाः पिडकास्तस्य कण्डूश्चैवोपजायते||१०३||
उपर्युपरि लेपस्य लेपो यद्यवचार्यते|
तानेव दोषाञ्जनयेत् पट्टस्योपरि यान् कृतः||१०४||
अतिस्निग्धोऽतिद्रवश्च लेपो यद्यवचार्यते|
त्वचि न श्लिष्यते सम्यङ्न दोषं शमयत्यपि||१०५||
तन्वालिप्तं न कुर्वीत संशुष्को ह्यापुटायते|
न चौषधिरसो व्याधिं प्राप्नोत्यपि च शुष्यति||१०६||
तन्वालिप्तेन ये दोषास्तानेव जनयेद्भृशम्|
संशुष्कः पीडयेद्व्याधिं निःस्नेहो ह्यवचारितः||१०७||
pradehāḥ sarva evaite kartavyāḥ samprasādanāḥ||98||
kṣaṇe kṣaṇe prayoktavyāḥ pūrvamuddhṛtya lepanam|
adhāvanoddhṛte pūrve pradehā bahuśo’ghanāḥ||99||
deyāḥ pradehāḥ kaphaje paryādhānoddhṛte ghanāḥ|
tribhāgāṅguṣṭhamātraḥ syāt pralepaḥ kalkapeṣitaḥ||100||
nātisnigdho na rūkṣaśca na piṇḍo na dravaḥ samaḥ|
na ca paryuṣitaṃ lepaṃ kadācidavacārayet||101||
na ca tenaiva lepena punarjātu pralepayet|
kledavīsarpaśūlāni soṣṇābhāvāt pravartayet||102||
lepo hyupari paṭṭasya kṛtaḥ svedayati vraṇam|
svedajāḥ piḍakāstasya kaṇḍūścaivopajāyate||103||
uparyupari lepasya lepo yadyavacāryate|
tāneva doṣāñjanayet paṭṭasyopari yān kṛtaḥ||104||
atisnigdho’tidravaśca lepo yadyavacāryate|
tvaci na śliṣyate samyaṅna doṣaṃ śamayatyapi||105||
tanvāliptaṃ na kurvīta saṃśuṣko hyāpuṭāyate|
na cauṣadhiraso vyādhiṃ prāpnotyapi ca śuṣyati||106||
tanvāliptena ye doṣāstāneva janayedbhṛśam|
saṃśuṣkaḥ pīḍayedvyādhiṃ niḥsneho hyavacāritaḥ||107||

Method of Using Ointments (Pradeha or lepa)
All the above mentioned ointments cure Samprasadana (which brings back the natural color of the skin or which cause alleviation of Raktha and Pitta). These are to be used repeatedly after removing the previously applied ointment.
The earlier used ointment is removed without washing with water, and thereafter, fresh ointment which is not very thick is applied. This process is repeated for several times.
In Kaphaja Visarpa, thick ointment is used after the previously applied ointment is dried up and removed. The triturated paste is used externally in the form of ointment, and the thickness of this paste is 3/4th of the thickness of the thumb.
The paste is neither too unctuous nor too unctuous. The paste is neither in a bolus from nor should it be too thin. The paste is of moderate consistency.
The paste which has become stale should never be used over the ulcers of Visarpa. The same paste which was used earlier and removed of Visarpa. The same paste which was used earlier and removed is again.

The paste smeared over a piece of cloth is used (tied as a bandage) over these ulcers because, this arrests the evaporation of heat from these ulcers thereby causing sloughing, spread of the ulcers (Visarpa) and Pain. It produces more of heat as a result of which pimples appears in the skin giving rise to itching.
If the paste is applied over the earlier one (without removing the earlier paste), then the same ailments arise as are describes above (application of the paste by smearing over a cloth).

If the paste is applied in a thin layer, then while drying, the layer of the paste develops cracks, and it gets dried up before the medical value penetrates into the skin to cure the ailment
If the paste is applied without adding ghee, it produces the same adverse effects as those produced by the application of a thin layer of the paste (described above) while getting dried up, this paste causes more pain or aggravates the disease [98- 107]

Wholesome Food and Drinks
अन्नपानानि वक्ष्यामि विसर्पाणां निवृत्तये|
लङ्घितेभ्यो हितो मन्थो रूक्षः सक्षौद्रशर्करः||१०८||
मधुरः किञ्चिदम्लो वा दाडिमामलकान्वितः|
सपरूषक मृद्वीकः सखर्जूरः शृताम्बुना||१०९||
तर्पणैर्यवशालीनां सस्नेहा चावलेहिका|
जीर्णे पुराणशालीनां यूषैर्भुञ्जीत भोजनम्||११०||
मुद्गान्मसूरांश्चणकान् यूषार्थमुपकल्पयेत्|
अनम्लान् दाडिमाम्लान् वा पटोलामलकैः सह||१११||
जाङ्गलानां च मांसानां रसांस्तस्योपकल्पयेत्|
रूक्षान् परूषक द्राक्षा दाडिमामलकान्वितान्||११२||
रक्ताः श्वेता महाह्वाश्च शालयः षष्टिकैः सह|
भोजनार्थे प्रशस्यन्ते पुराणाः सुपरिस्रुताः||११३||
यवगोधूमशालीनां सात्म्यान्येव प्रदापयेत्|
येषां नात्युचितः शालिर्नरा ये च कफाधिकाः||११४||
annapānāni vakṣyāmi visarpāṇāṃ nivṛttaye|
laṅghitebhyo hito mantho rūkṣaḥ sakṣaudraśarkaraḥ||108||
madhuraḥ kiñcidamlo vā dāḍimāmalakānvitaḥ|
saparūṣaka mṛdvīkaḥ sakharjūraḥ śṛtāmbunā||109||
tarpaṇairyavaśālīnāṃ sasnehā cāvalehikā|
jīrṇe purāṇaśālīnāṃ yūṣairbhuñjīta bhojanam||110||
mudgānmasūrāṃścaṇakān yūṣārthamupakalpayet|
anamlān dāḍimāmlān vā paṭolāmalakaiḥ saha||111||
jāṅgalānāṃ ca māṃsānāṃ rasāṃstasyopakalpayet|
rūkṣān parūṣaka drākṣā dāḍimāmalakānvitān||112||
raktāḥ śvetā mahāhvāśca śālayaḥ ṣaṣṭikaiḥ saha|
bhojanārthe praśasyante purāṇāḥ suparisrutāḥ||113||
yavagodhūmaśālīnāṃ sātmyānyeva pradāpayet|
yeṣāṃ nātyucitaḥ śālirnarā ye ca kaphādhikāḥ||114||

Wholesome food and drinks useful for curing Visarpa
The patient in the beginning should observe fast. Thereafter, he is given Mantha (roasted flour of cereals added with water in profuse quantity).This drink is free from any unctuous material, but is added with Dadima – Pomegranate – Punica granatum, Amalaka, Parushaka – Grewia asiatica, Mrudvika and Kharjura – dates. The above mentioned flour of roasted cereals and other ingredients is mixed with boiled water.
The roasted flour of barley and Shali type of rice may be added with ghee, and given to the patient to eat in the form of linctus.

The above mentioned recipe is digested the patient is given boiled old rice along with vgetable soup. Mudga, Masura and Chanaka are used for the preparation of this vegetable soup. To these Yusha, patola – Trichosanthes dioica and Amalaka may also be added for the preparation of the soup. This soup may not be made sour. But if the patient so desires, then the soup can be made sour by adding sour Dadima – Pomegranate.
The patient is given the soup of the meat of animals inhabiting an arid zone. The meat-soup is added with any unctuous material like ghee, Parusaka – Grewia asiatica, Draksha – Raisins, Dadima – Pomegranate – Punica granatum and Amalaka may be added while preparing the meat soup.
Red, white Mahahva types of Shali rice, and Sastika type of rice, which are old and which are boiled with the residual water completely removed, is given to the patient as food.
Depending upon the eating habit (wholesomeness), the patient may be given either barley or wheat or Shali type of rice to eat. If Shali type of rice is not very homologatory, and if kapha is aggravated in excess, (then barley and wheat is used as food). [108- 114]

Unwholesome Diet, Drinks and Regimens
विदाहीन्यन्नपानानि विरुद्धं स्वपनं दिवा|
क्रोध व्यायाम सूर्याग्निप्रवातांश्च विवर्जयेत्||११५||
vidāhīnyannapānāni viruddhaṃ svapanaṃ divā|
krodha vyāyāma sūryāgnipravātāṃśca vivarjayet||115||

The patient suffering from Visarpa should avoid the following:
1. Food and drinks which are Vidahi (causing burning sensation)
2. Viruddha ahara – Mutually contradictory ingredients of food and drinks;
3. Diva svapna – Sleep during the day time
4. Krodha – Anger,Vyayama – Physical exercise and envy and
5. Exposure to hot rays of the sun, fire and strong wind. [115]

General Line of Treatment:
कुर्याच्चिकित्सितादस्माच्छीतप्रायाणि पैत्तिके|
रूक्षप्रायाणि कफजे स्नैहिकान्यनिलात्मके||११६||
वातपित्त प्रशमनमग्निवीसर्पणे हितम्|
कफपित्त प्रशमनं प्रायः कर्दमसञ्ज्ञिते||११७||
kuryāccikitsitādasmācchītaprāyāṇi paittike|
rūkṣaprāyāṇi kaphaje snaihikānyanilātmake||116||
vātapitta praśamanamagnivīsarpaṇe hitam|
kaphapitta praśamanaṃ prāyaḥ kardamasañjñite||117||

From the above mentioned recipes, the cooling ones are to be used for Paittika type of Visarpa. The ununctous type of recipe is used for Kaphaja type of Visarpa. For the treatment of Vatika type of Visarpa, unctuous type of recipe is used.
Agni- Visarpa is treated with recipes which alleviate Vayu and Pitta.
Kardama- Visarpa is treated with recipes which generally alleviate kapha and Pitta.

Treatment of Granthi- Visarpa:
रक्त पित्तोत्तरं दृष्ट्वा ग्रन्थि वीसर्पमादितः|
रूक्षणै र्लङ्घनैः सेकैः प्रदेहैः पाञ्चवल्कलैः||११८||
सिरा मोक्षै र्जलौकोभि र्वमनैः सविरेचनैः|
घृतैः कषाय तिक्तैश्च कालज्ञः समुपाचरेत्||११९||

raktapittottaraṃ dṛṣṭvā granthi vīsarpamāditaḥ|
rūkṣaṇai rlaṅghanaiḥ sekaiḥ pradehaiḥ pāñcavalkalaiḥ||118||
sirā mokṣai rjalaukobhi rvamanaiḥ savirecanaiḥ|
ghṛtaiḥ kaṣāya tiktaiśca kālajñaḥ samupācaret||119||

If granthi- Visarpa is dominated by Rakta and Pitta, then in the beginning, the patient is given
Ruksana (drying therapy),
Langhana (fasting therapy),
Seka (affusion) with the decoction of Panca- valkala,
Sira-Moksa (venesection),
Jalaukavacarana (blood- letting therapy with leech),
Vamana (emetic therapy),
Virecana (Purgation therapy) and medicated ghee prepared of Astringent and bitter drugs.
The physician should administer these therapies in appropriate time. [118- 119]

ऊर्ध्वं चाधश्च शुद्धाय रक्ते चाप्यवसेचिते|
वातश्लेष्महरं कर्म ग्रन्थिवीसर्पिणे हितम्||१२०||
ūrdhvaṃ cādhaśca śuddhāya rakte cāpyavasecite|
vātaśleṣmaharaṃ karma granthivīsarpiṇe hitam||120||

After the body is cleansed through upward tract (by emetic therapy) and through downward tract (by purgation therapy) and after the administration of blood-letting therapy, the patient suffering from granthi-Visarpa is given external therapies, etc for the alleviation of Vata and kapha. [120]

External Therapy for Granthi Visarpa:
उत्कारिकाभिरुष्णाभिरुपनाहः प्रशस्यते|
स्निग्धाभिर्वेशवारैर्वा ग्रन्थि वीसर्प शूलिनाम्||१२१||
utkārikābhiruṣṇābhirupanāhaḥ praśasyate|
snigdhābhirveśavārairvā granthi vīsarpa śūlinām||121||

The patient suffering from Granthi- Visarpa associate with colic pain is given external application of Upanaha (thick layer of paste applied when it is warm) with Utkarika (Pancaka) or Vesavara (Minced meat) which are warm and which are mixed with fat (ghee or oil). [121]

Affusion for Granthi Visarpa:
दशमूलोपसिद्धेन तैलेनोष्णेन सेचयेत्|
कुष्ठतैलेन चोष्णेन पाक्यक्षारयुतेन च||१२२||
गोमूत्रैः पत्रनिर्यूहैरुष्णैर्वा परिषेचयेत्|
daśamūlopasiddhena tailenoṣṇena secayet|
kuṣṭhatailena coṣṇena pākyakṣārayutena ca||122||
gomūtraiḥ patraniryūhairuṣṇairvā pariṣecayet|
The nodules of Granthi- Visarpa are sprinkled with warm oil medicated by boiling with Dasha-Mula. The oil cooked with Kushta and added with Pakva- Ksara (an Alkali preparation details of which are described in Susruta- Samhita) may also be used, when warm, for the affusion of these nodules. Similarly, affusion could be made with warm cow’s urine or warm juice of the leaves (which alleviate Vayu and Kapha, but do not cause vitiation of Rakta and Pitta). [122 -½ 123]

Paste of External Application:
सुखोष्णया प्रदिह्याद्वा पिष्टया चाश्वगन्धया||१२३||
शुष्क मूलक कल्केन नक्तमालत्वचाऽपि वा|
बिभीतक त्वचां वाऽपि कल्केनोष्णेन लेपयेत्||१२४||
बलां नागबलां पथ्यां भूर्जग्रन्थिं बिभीतकम्|
वंशपत्राण्यग्निमन्थं कुर्याद्ग्रन्थिप्रलेपनम्||१२५||
दन्ती चित्रक मूलत्वक् सुधार्कपयसी गुडः|
भल्लातकास्थि कासीसं लेपो भिन्द्याच्छिलामपि||१२६||
बहिर्मार्गास्थितं ग्रन्थिं किं पुनः कफसम्भवम्|
sukhoṣṇayā pradihyādvā piṣṭayā cāśvagandhayā||123||
śuṣka mūlaka kalkena naktamālatvacā’pi vā|
bibhītaka tvacāṃ vā’pi kalkenoṣṇena lepayet||124||
balāṃ nāgabalāṃ pathyāṃ bhūrjagranthiṃ bibhītakam|
vaṃśapatrāṇyagnimanthaṃ kuryādgranthipralepanam||125||
dantī citraka mūlatvak sudhārkapayasī guḍaḥ|
bhallātakāsthi kāsīsaṃ lepo bhindyācchilāmapi||126||
bahirmārgāsthitaṃ granthiṃ kiṃ punaḥ kaphasambhavam|

The warm paste of either Ashwagandha – Withania somnifera or dried radish or the bark of Naktamala (Karanja (Pongamia pinnata) is applied over the nodules.

The paste of Bala – Country mallow (root) – Sida cordifolia, Nagabala, Pathya, Bhurja (Betula utilis D. Don.) granthi, Vibhitaka, leaves of Vamsa (Bamboo) and Agnimantha – Clerodendrum phlomidis is useful for the application over these nodules of Granthi- Visarpa.

Application of the paste of Danti – Baliospermum montanum, bark of the root of Chitraka – Leadword – Plumbago zeylanica, latex of Sudha, Latex of Arka – Calotropis procera, Jaggery, seed of Bhallataka (Semecarpus anacardium Linn.) and Kasisa breaks even a stone, what to speak of the nodules caused by Kapha which are located in the exterior of the body. [123 ½- ½ 127]

Recipes for external Application over Chronic Nodules:
दीर्घकाल स्थितं ग्रन्थिं भिन्द्याद्वा भेषजैरिमैः||१२७||
मूलकानां कुलत्थानां यूषैः सक्षारदाडिमैः|
गोधूमान्नैर्यवान्नैर्वा ससीधुमधुशर्करैः||१२८||
सक्षौद्रैर्वारुणीमण्डै र्मातुलुङ्ग रसान्वितैः|
त्रिफलायाः प्रयोगैश्च पिप्पलीक्षौद्र संयुतैः||१२९||
मुस्तभल्लातशक्तूनां प्रयोगैर्माक्षिकस्य च|
देवदारु गुडूच्योश्च प्रयोगैर्गिरिजस्य च||१३०||
धूमैर्विरेकैः शिरसः पूर्वोक्तैर्गुल्मभेदनैः|
अयो लवण पाषाण हेम ताम्र प्रपीडनैः||१३१||
dīrghakāla sthitaṃ granthiṃ bhindyādvā bheṣajairimaiḥ||127||
mūlakānāṃ kulatthānāṃ yūṣaiḥ sakṣāradāḍimaiḥ|
godhūmānnairyavānnairvā sasīdhumadhuśarkaraiḥ||128||
sakṣaudrairvāruṇīmaṇḍai rmātuluṅga rasānvitaiḥ|
triphalāyāḥ prayogaiśca pippalīkṣaudra saṃyutaiḥ||129||
mustabhallātaśaktūnāṃ prayogairmākṣikasya ca|
devadāru guḍūcyośca prayogairgirijasya ca||130||
dhūmairvirekaiḥ śirasaḥ pūrvoktairgulmabhedanaiḥ|
ayo lavaṇa pāṣāṇa hema tāmra prapīḍanaiḥ||131||

For breaking open chronic nodules, the following recipes and therapies is administered
1. The patient should use the soups of Mulaka – Raphanus sativus and Kulattha – Dolichos biflorus along with Alkalies and Dadima – Pomegranate – Punica granatum
2. The patient may take boiled wheat or barley along with Sidhu (a type of wine), honey and sugar.
3. The patient should drink supernatant part of Varuni(a type of alcoholic drink) along with honey and the juice of Matulunga – Lemon variety – Citrus decumana / Citrus limon
4. Triphala along with Pippali – Long pepper fruit – Piper longum and honey is administered to the patient
5. The roasted flour of Musta (Cyperus rotundus) or Bhallataka – Semecarpus anacardium is given to him
6. Maksika (iron pyrite) or Devadaru (Cedrus deodara) and Guduchi – Tinospora cordifolia or Shilajatu is administered to the patient
7. The patient is given Dhuma(smoking therapy) and Siro- Virecana(inhalation therapy) for the elimination of morbid matter from the head
8. Recipes described earlier (in Chikitsa ; 5) for breaking open the growth of Gulma(Phantom tumor) and
9. Putting pressure on the nodules with (hot) iron, bolus of salt, stone, gold, or copper. [127 ½ – 131]

Agnikarma and Shastrakarma for Granthi Visarpa treatment: Cauterization and Surgical Intervention
आभिः क्रियाभिः सिद्धाभिर्विविधाभिर्बली स्थिरः|
ग्रन्थिः पाषाणकठिनो यदा नैवोपशाम्यति||१३२||
अथास्य दाहः क्षारेण शरैर्हेम्नाऽथ वा हितः|
पाकिभिः पाचयित्वा वा पाटयित्वा समुद्धरेत्||१३३||
मोक्षयेद्बहुशश्चास्य रक्तमुत्क्लेशमागतम्|
पुनश्चापहृते रक्ते वातश्लेष्मजिदौषधम्||१३४||
धूमो विरेकः शिरसः स्वेदनं परिमर्दनम्|
अप्रशाम्यति दोषे च पाचनं वा प्रशस्यते||१३५||
प्रक्लिन्नं दाहपाकाभ्यां भिषक् शोधनरोपणैः|
बाह्यैश्चाभ्यन्तरैश्चैव व्रणवत् समुपाचरेत्||१३६||
कम्पिल्लकं विडङ्गानि दार्वीं कारञ्जकं फलम्|
पिष्ट्वा तैलं विपक्तव्यं ग्रन्थिव्रणचिकित्सितम्||१३७||
द्विव्रणीयोपदिष्टेन कर्मणा चाप्युपाचरेत्|
देशकालविभागज्ञो व्रणान् वीसर्पजान् बुधः||१३८||
इति ग्रन्थिविसर्पचिकित्सा|
ābhiḥ kriyābhiḥ siddhābhirvividhābhirbalī sthiraḥ|
granthiḥ pāṣāṇakaṭhino yadā naivopaśāmyati||132||
athāsya dāhaḥ kṣāreṇa śarairhemnā’tha vā hitaḥ|
pākibhiḥ pācayitvā vā pāṭayitvā samuddharet||133||
mokṣayedbahuśaścāsya raktamutkleśamāgatam|
punaścāpahṛte rakte vātaśleṣmajidauṣadham||134||
dhūmo virekaḥ śirasaḥ svedanaṃ parimardanam|
apraśāmyati doṣe ca pācanaṃ vā praśasyate||135||
praklinnaṃ dāhapākābhyāṃ bhiṣak śodhanaropaṇaiḥ|
bāhyaiścābhyantaraiścaiva vraṇavat samupācaret||136||
kampillakaṃ viḍaṅgāni dārvīṃ kārañjakaṃ phalam|
piṣṭvā tailaṃ vipaktavyaṃ granthivraṇacikitsitam||137||
dvivraṇīyopadiṣṭena karmaṇā cāpyupācaret|
deśakālavibhāgajño vraṇān vīsarpajān budhaḥ||138||
iti granthivisarpacikitsā|

Cauterization and Surgical Intervention
If these nodules have become strong, stabilized, and hard like stone, and therefore, not amenable to the above mentioned
Therapeutic measures, then their cauterization with the help of Alkalis or hot rod of gold is useful.
These nodules is got suppurated by the external application of suppurating ointments. Thereafter, these suppurated nodules is incised and removed. The blood from this location which is already incited is taken out frequently. After the vitiated blood is removed, medicines for the alleviation of Vata and kapha are given to the patient.
He is given Dhuma (smoking therapy), Shiro- virecana (inhalation therapy for the elimination of morbid from the head), Svedana (fermentation therapy), and Parimardana (rubbing therapy). If by the above mentioned therapeutic measures, the vitiated Doshas do not get alleviated, then the patient is given Pacana (recipes to bring about maturity of the Ama or immature metabolic product) therapy.
When these nodules have become soft because of cauterization and application of suppuration recipes, the physician should treat these nodules of Granthi- Visarpa like an ulcer with the cleansing and healing therapies both externally and internally. [132- 136]

Treatment of Ulcers
य एव विधिरुद्दिष्टो ग्रन्थीनां विनिवृत्तये|
स एव गलगण्डानां कफजानां निवृत्तये||१३९||
गलगण्डास्तु वातोत्था ये कफानुगता नृणाम्|
घृत क्षीर कषायाणामभ्यासान्न भवन्ति ते||१४०||
ya eva vidhiruddiṣṭo granthīnāṃ vinivṛttaye|
sa eva galagaṇḍānāṃ kaphajānāṃ nivṛttaye||139||
galagaṇḍāstu vātotthā ye kaphānugatā nṛṇām|
ghṛta kṣīra kaṣāyāṇāmabhyāsānna bhavanti te||140||

Oil is cooked with the paste of Kampillaka – Mallotus philippinensis, Vidanga – Embelia ribes, Darvi – Berberis aristata and fruit of Karanja (Pongamia pinnata). This medicated oil is used (externally) in the treatment of ulcers of Granthi- Visarpa.
A wise physician, acquainted with the propriety of the location and time, is administer the therapies described in the chapter dealing with the ‘’Therapeutics for two kinds of ulcers” i.e in the 25th chapter of this section. Thus, ends the description of the treatment of Granthi Visarpa [137- 138]

Treatment of Galaganda (Goiter)
यानीहोक्तानि कर्माणि विसर्पाणां निवृत्तये|
एकतस्तानि सर्वाणि रक्त मोक्षणमेकतः||१४१||
विसर्पो न ह्यसंसृष्टो रक्तपित्तेन जायते|
तस्मात् साधारणं सर्वमुक्तमेतच्चिकित्सितम्||१४२||
विशेषो दोषवैषम्यान्न च नोक्तः समासतः|
समासव्यासनिर्दिष्टां क्रियां विद्वानुपाचरेत्||१४३||
yānīhoktāni karmāṇi visarpāṇāṃ nivṛttaye|
ekatastāni sarvāṇi rakta mokṣaṇamekataḥ||141||
visarpo na hyasaṃsṛṣṭo raktapittena jāyate|
tasmāt sādhāraṇaṃ sarvamuktametaccikitsitam||142||
viśeṣo doṣavaiṣamyānna ca noktaḥ samāsataḥ|
samāsavyāsanirdiṣṭāṃ kriyāṃ vidvānupācaret||143||

The therapeutic measures described above for the treatment of the nodules of Granthi- Visarpa are useful for the treatment of Gala-Ganda (goiter) caused by the aggravation of kapha. Habitual intake of ghee, milk and decoctions, prevent the occurrence of Gala Ganda or goiter (including Ganda-Mala or cervical adenitis) caused by aggravation of Vayu in association of Kapha. [139- 140]

Importance of Blood Letting Therapy
Since Visarpa is over manifested without the vitiation of Rakta and Pitta, blood letting therapy (which is the most effective measure to correct this morbidity) can match all the other modes of treatment described above for curing Visarpa.

Therefore, the therapeutic measures to all alleviate the fundamental causative factors, viz; Rakta and Pitta are described in this chapter. It is not that the therapeautic measures for the alleviation off other causative factors in specific cases viz. Vata and Kapha are not explained here. Thus, the therapeutic measures both in general (for the alleviaton of Rakta and Pitta) and in specific cases (for the alleviation of other causative factors like Vayu and Kapha) is described both in brief and in detail. A wise physician should administer these therapies appropriately (with desecration). [141-143]

Summary: 
तत्र श्लोकाः-
निरुक्तं नाम भेदाश्च दोषा दूष्याणि हेतवः|
आश्रयो मार्गतश्चैव विसर्प गुरु लाघवम्||१४४||
लिङ्गान्युपद्रवा ये च यल्लक्षण उपद्रवः|
साध्यत्वं, न च, साध्यानां साधनं च यथाक्रमम्||१४५||
इति पिप्रक्षवे सिद्धिमग्निवेशाय धीमते|
पुनर्वसुरुवाचेदं विसर्पाणां चिकित्सितम्||१४६||
tatra ślokāḥ-
niruktaṃ nāmabhedāśca doṣā dūṣyāṇi hetavaḥ|
āśrayo mārgataścaiva visarpagurulāghavam||144||
liṅgānyupadravā ye ca yallakṣaṇa upadravaḥ|
sādhyatvaṃ, na ca, sādhyānāṃ sādhanaṃ ca yathākramam||145||
iti piprakṣave siddhimagniveśāya dhīmate|
punarvasuruvācedaṃ visarpāṇāṃ cikitsitam||146||

Thus, Punarvasu (Atreya) explained the perfect treatment of Visarpa to Agnivesha, the learned inquier with reference to the following topics:
1. Derivation of the Visarpa
2. Synonyms of Visarpa
3. Doshas, Dushyas (tissue elements) and other causative factors of Visarpa
4. The Asraya (location) of Visarpa in different channels viz exterior or interior part of the body
5. The seriousness and non- seriousness of different types of Visarpa
6. Signs and symptoms and complications of different types of Visarpa
7. Nature of Upadrava (complication)
8. Curability and incurability of different types of Visarpa and
9. Appropriate therapeutic for the treatment of curable varieties of Visarpa. [144-146]

Colophon
इत्यग्निवेशकृते तन्त्रे चरक प्रतिसंस्कृते चिकित्सा स्थाने
विसर्प चिकित्सितं नामैकविंशोऽध्यायः||२१||
ityagniveśakṛte tantre caraka pratisaṃskṛte cikitsā sthāne
visarpa cikitsitaṃ nāmaikaviṃśo’dhyāyaḥ||21||

Thus, ends the 21st chapter in Chikitsa Sthana (section on treatment of diseases) dealing with the treatment of visarpa (erysiples and herpes) in Agnivesha’s work as redacted by Charaka.


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