Ashtanga Hridayam Cikitsasthanam Chapter 18: Visarpa Chikitsa (Treatment of herpes)

The 18^th chapter of Chikitsasthanam of Ashtanga Hridayam is named as Visarpa Chikitsitam Adhyayah. This chapter deals with the explanation of ‘treatment of herpes’.

The topics covered in this chapter include –

• Treatment principles in herpes
• Formulations to induce emesis in herpes
• Formulations to induce purgation in herpes
• Palliative treatment
• Bloodletting in herpes
• Medicated ghee in nirama stage of herpes
• Indications for external treatment in herpes
• Vataja Visarpa Cikitsa
• Pittaja Visarpa Cikitsa
• Sleshmika Visarpa Cikitsa
• Kaphaja Visarpa Cikitsa
• Management of Vata associated with ama localized in seats of kapha or pitta
• Management of Visarpa caused by combination of doshas
• Agni Visarpa Cikitsa
• Granthi Visarpa Cikitsa
• Medicinal pastes, diet and therapies to break the tumor
• Suppuration and excision of tumors
• Bloodletting
• Treatment of external and internal wound
• Importance of Virecana Ghrta

Pledge by the author(s)

अथातो विसर्पचिकित्सितं व्याख्यास्याम: ।
इति ह स्माहुरात्रेयादयो महर्षय: ।
After having offered prayers to the God, henceforth we are going to explain the chapter pertaining to the explanation of ‘treatment of herpes’.Thus say (pledge) Atreya and other sages.

Treatment principles in herpes

आदावेव विसर्पेषु हितं लङ्घनरूक्षणम् ।
रक्तावसेको वमनं विरेकः स्नेहनं न तु ॥ १ ॥
In herpes it is beneficial to administer langhana (thinning the body with fasting etc.), ruksana (causing dryness)rakta avaseko – blood-letting,vamanaṃ – emesis, virekaḥ – and purgation therapies  in the beginning of treatment itself, but not snehana (oleation therapy).

Formulations to induce emesis in herpes

प्रच्छर्दनं विसर्पघ्नं सयष्टीन्द्रयवं फलम् ।
पटोलपिप्पलीनिम्बपल्लवैर्वा समन्वितम् ॥ २ ॥
Emesis done by using Randia dumetorum together with Glycyrrhiza glabra, Randia spinosa  and indrayava – seeds of Holarrhena antidysenterica mixed with  Trichosanthes dioica, Piper longum ,leaves of Azadirachta indica destroys visarpa.

Formulations to induce purgation in herpes

रसेन युक्तं त्रायन्त्या द्राक्षायास्त्रैफलेन वा ।
विरेचनं त्रिवृच्चूर्णं पयसा सर्पिषाऽथवा ॥ ३ ॥
योज्यं कोष्ठगते दोषे विशेषेण विशोधनम् ।
Purgation should be done by using powder of Operculina turpethum mixed with the juice/ decoction of either Gentiana kurroo, Vitis vinifera, triphala (Haritaki – Terminalia chebula, Vibhitaki – Terminalia bellirica, Amalaki – Emblica officinalis); or milk or ghee should be added especially when the doshas, are lodged in the alimentary tract, especially for the purpose of cleansing them (doshas).

Palliative treatment

अविशोध्यस्य दोषेऽल्पे शमनं चन्दनोत्पलम् ॥४॥
मुस्तनिम्बपटोलं वा पटोलादिकमेव वा ।
शारिवामलकोशीरमुस्तं वा क्वथितं जले ॥ ५ ॥
For persons who are unfit for purifactory therapies and when the doshas are mild, samana (palliative therapy) is ideal.  Santalum album, Nymphaea alba, Cyperus rotundus, Azadirachta indica candana – and Trichosanthes dioica; or  Trichosanthes dioica and others (Patoladi gana) (vide chapter 15 of sutrasthana); or Hemidesmus indicus, Emblica officinalis, Vetiveria zizoanioides and Cyperus rotundus boiled with water should be administered.

Palliative treatment

दुरालभां पर्पटकं गुडूचीं विश्वभेषजम् ।
पाक्यं शीतकषायं वा तृष्णाविसर्पवान् पिबेत् ॥ ६ ॥
दार्वीपटोलकटुकामसूरत्रिफलास्तथा ।
सनिम्बयष्टीत्रायन्तीः क्वथिता घृतमूर्छिताः ॥ ७ ॥
Patient of visarpa having thirst should drink either the decoction or cold infusion of Fagonia cretica, Fumaria parviflora, Tinospora cordifolia, and Zingiber officinalis; or decoction of Cedrus deodara, Trichosanthes dioica, Picrorrhiza kurroa, Lens culinaris,  triphala (Haritaki – Terminalia chebula, Vibhitaki – Terminalia bellerica & Amalaki – Emblica officinalis), Azadirachta indica, Glycyrrhiza glabra Gentiana Kurroa processed with ghee.

Bloodletting in herpes

शाखादुष्टे तु रुधिरे रक्तमेवादितो हरेत्।
त्वङ्मांसस्नायुसङ्क्लेदो रक्तक्लेदाद्धि जायते॥८॥
When the blood gets vitiated  in the sakhas (tissues), blood-letting itself should be done,  first, because increase of moisture in the skin, muscles, tendons etc.,  occurs due to increase of moisture in the blood itself.

Medicated ghee in nirama stage of herpes

निरामे श्लेष्मणि क्षीणे वातपित्तोत्तरे हितम्।
घृतं तिक्तं महातिक्तं शृतं वा त्रायमाणया॥९॥
When there are no symptoms of ama, when kapha has decreased  but vata and pitta are predominant, then either tiktakaghrta, mahatiktaghrta (chapter 19 of cikitsasthan) of that prepared by the decoction of Gentiana kurroo are beneficial.

Indications for external treatment in herpes

निर्हृतेऽस्रे विशुद्धेऽन्तर्दोषे त्वङ्मांससन्धिगे।
बहिःक्रियाः प्रदेहाद्याः सद्यो विसर्पशान्तये॥१०॥
After blood-letting when the interior (of the alimentary canal) becomes cleared, and the doshas are found localised in the skin, muscles, and joints, then external treatments such as pradeha (application of warm poultice) etc. subside visarpa soon.

Vataja Visarpa Chikitsa

शताह्वा मुस्तवाराही वंशार्तगलधान्यकम् ।
सुराह्वा कृष्णगन्धा च कुष्ठं चालेपनं चले ॥ ११ ॥
In visarpa arising from Vata application of paste of śatāhvā – Anethum sowa, musta – Cyperus rotundus, vārāhī – Dioscorea bulbifera, vaṃśa – Bambusa arundinacea, ārtagala – Nila Saireyaka – Barleria strigose, dhānyakam – Coriandrum sativum,   surāhvā – Cedrus deodara, kṛṣṇagandhā ca – Moringa oleifera kuṣṭhaṃ – and Saussurea lappa is ideal.

Pittaja Visarpa Chikitsa: Nyagrodhadi Lepa

न्यग्रोधादिगणः पित्ते तथा पद्मोत्पलादिकम् ।
न्यग्रोधपादास्तरुणाः कदलीगर्भसंयुताः ॥ १२ ॥
बिसग्रन्थिश्च लेपः स्याच्छतधौतघृताप्लुतः ।
पद्मिनीकर्दमः शीतः पिष्टं मौक्तिकमेव वा ॥ १३ ॥
शङ्खः प्रवालं शुक्तिर्वा गैरिकं वा घृतान्वितम् ।
In that arising from pitta, paste of either the herbs of nyargodhadi gana (chapter 15 of sutrasthana)  padma utpalādikam – or padmotpaladi etc. (chapter 20 cikitsthana of astangasangraha) is beneficial.
So also the paste of tender aerial roots of Ficus bengalensis, the pith of Musa paradisiaca, and Nelumbium speciosum, bathed with satadhauta ghrta (ghee washed in water for hundred times) or the slush / mud of lotus lake or paste of mauktika (pearls) conch, coral, oyster shell or of gairika (red ochre) mixed with ghee and applied cold are also beneficial.

Sleshmika Visarpa Chikitsa: Triphaladi Lepa

त्रिफलापद्मकोशीरसमङ्गाकरवीरकम् ॥ १४ ॥
नलमूलान्यनन्ता च लेपः श्लेष्मविसर्पहा ।
Paste of triphala (Haritaki – Terminalia chebula, Vibhitaki – Terminalia bellerica & Amalaki – Emblica officinalis), padmaka – Prunus puddum, uśīra – Vetiveria zizanioides, samaṅgā – Rubia cordifolia, karavīrakam – Nerium indicum, nalamūlāni – Arundo donax, and Hemidesmus indicus applied externally cures visarpa arising from Kapha.

Kaphaja Visarpa Chikitsa

धवसप्ताह्वखदिरदेवदारुकुरण्टकम् ॥ १५ ॥
समुस्तारग्वधं लेपो वर्गो वा वरुणादिकः ।
आरग्वधस्य पत्राणि त्वचः श्लेष्मातकोद्भवाः ॥१६॥
इन्द्राणिशाकं काकाह्वा शिरीषकुसुमानि च ।
Application of paste of dhava – Anogeissus latifolia, saptāhva – Alstonia scholaris, khadira – Acacia catechu, devadāru – Cedrus deodara, kuraṇṭakam – Barleria prionitis, musta –  dhava – Cyperus rotundus āragvadhaṃ – and Cassia fistula or of herbs of Varunadi gana (chapter 15 of sutrasthana) or of the leaves of āragvadhasya – Cassia fistula, bark of  śleṣmātaka udbhavāḥ –  Cordia dichotama, indrāṇi śākaṃ – leaves of Citrullus colocynthis, kākāhvā – Solanum nigrum  and flowers of Albizia lebbeck (cures visarpa of Kapha origin).

Kaphaja Visarpa Chikitsa

सेकव्रणाभ्यङ्गहविर्लेपचूर्णान् यथायथम् ॥१७॥
एतैरेवौषधैः कुर्याद्वायौ लेपा घृताधिकाः ।
Recipes for bathing, anointing, fumigating, topical application of paste and powder for dusting the wound  should be prepared by these herbs only. The pastes mentioned for the treatment of visarpa of vata origin should be mixed with more quantity of ghee.

Management of Vata associated with ama localized in seats of kapha or pitta

कफस्थानगते सामे पित्तस्थानगतेऽथवा ॥ १८ ॥
अशीतोष्णा हिता रूक्षा रक्तपित्ते घृतान्विताः ।
अत्यर्थशीतास्तनवस्तनुवस्त्रान्तरास्थिताः ॥ १९ ॥
योज्याः क्षणे क्षणेऽन्येऽन्ये मन्दवीर्यास्त एव च ।
When vayu associated with ama, is found lodged either in the seat of kapha  or of pitta it is beneficial to use it neither cold nor hot (in other words, slightly warm) and dry (without addition of fats). In case of aggravation of rakta (blood) and pitta,  it should be mixed with ghee, made very cold, thin concealed inside thin cloth, applied fresh, minute after minute (every time).  Since the same paste is applied again and again  becomes weak in action.

Management of Visarpa caused by combination of doshas

संसृष्टदोषे संसृष्टमेतत्कर्म प्रशस्यते ॥ २० ॥
In visarpa arising from the combination of the doshas, it is ideal to combine the treatment suitability.

Agni Visarpa Chikitsa: Shata Dhauta Ghrita

शतधौतघृतेनाग्निं प्रदिह्यात्केवलेन वा ।
सेचयेद्घृतमण्डेन शीतेन मधुकाम्बुना ॥ २१ ॥
सिताम्भसाऽम्भोदजलैः क्षीरेणेक्षुरसेन वा ।
पानलेपनसेकेषु महातिक्तं परं हितम् ॥ २२ ॥
Agni visarpa should be bathed with satadhauta ghrta (ghee washed a hundred times) or with plain ghee, or sprinkled with the scum of ghee or cold decoction of Glycyrrhiza glabra, solution of sugar, decoction of Cyperus rotundus, milk or juice of sugarcane all made cold. mahatiktakaghrta (chapter 19 of cikitsa sthana) is best  for drinking, external application and bathing the skin.

Granthi Visarpa Chikitsa

ग्रन्थ्याख्ये रक्तपित्तघ्नं कृत्वा सम्यग्यथोदितम् ।
कफानिलघ्नं कर्मेष्टं पिण्डस्वेदोपनाहनम् ॥ २३ ॥
For granthi visarpa treatments prescribed for raktapitta (chapter 2 of cikitsa sthana)  should be done first, followed by treatments which mitigate kapha and Vata such as pinda sveda – and upanaha (chapter 17 of sutrasthana).

Granthi Visarpa Chikitsa: Dashamoola Taila Sechana

ग्रन्थिविसर्पशूले तु तैलेनोष्णेन सेचयेत् ।
दशमूलविपक्वेन तद्वन्मूत्रैर्जलेन वा ॥ २४ ॥
In case of pain in granthi visarpa, the skin should be bathed with warm oil prepared with dashamula, likewise with cow urine or water boiled with dashamula.

Granthi Visarpa Chikitsa

सुखोष्णया प्रदिह्याद्वा पिष्टया कृष्णगन्धया ।
नक्तमालत्वचा शुष्कमूलकैः कलिनाऽथवा ॥ २५ ॥
Application of warm paste of  either Moringa oleifera, naktamāla tvacā – bark of Pongamia pinnata, śuṣkamūlakaiḥ – dried Raphanus sativus or Terminalia bellerica should be done.

Medicinal pastes, diet and therapies to break the tumor

दन्ती चित्रकमूलत्वक् सौधार्कपयसी गुडः ।
भल्लातकास्थि कासीसं लेपो भिन्द्याच्छिलामपि ॥२६॥
बहिर्मार्गाश्रितं ग्रन्थिं किं पुनः कफसम्भवम् ।
दीर्घकालस्थितं ग्रन्थिमेभिर्भिन्द्याच्च भेषजैः ॥ २७ ॥
मूलकानां कुलत्थानां यूषैः सक्षारदाडिमैः ।
गोधूमान्नैर्यवान्नैर्वा ससीधुमधुशार्करैः ॥ २८ ॥
सक्षौद्रैर्वारुणीमण्डैर्मातुलुङ्गरसान्वितैः ।
त्रिफलायाः प्रयोगैश्च पिप्पल्याः क्षौद्रसंयुतैः ॥ २९ ॥
देवदारुगुडूच्योश्च प्रयोगैर्गिरिजस्य च ।
मुस्तभल्लातसक्तूनां प्रयोगैर्माक्षिकस्य च ॥ ३० ॥
धूमैर्विरेकैः शिरसः पूर्वोक्तैर्गुल्मभेदनैः ।
तप्तायोहेमलवणपाषाणादिप्रपीडनैः ॥ ३१ ॥
Paste of dantī – Baliospermum montanum, citrakamūla tvak – bark of Plumbago zeylanica, milky sap of Euphorbia neriifolia, arka payasī – and latex of Calotropis gigantea, jaggery, bhallātaka asthi – Semecarpus anacardium seed kāsīsaṃ – and ferrous sulphate breaks even the stone; what then to say – of external tumor  arising from kapha? Even the tumor which is long standing should be broken up with these herbs;  With the use of soup of either mulaka – Raphanus sativus or Dolichos biflorus added with alkali and Punica granatum ,mess prepared with from godhuma – Triticum aestivum or mess prepared with Hordeum vulgare followed by drink of sidhu mixed with honey and sugar, with honey and varuni manda along with juice of Citrus medica. Administration of triphala (Haritaki – Terminalia chebula Vibhitaki – Terminalia bellerica & Amalaki – Emblica officinalis)  and Piper longum mixed with honey, of Cedrus deodara and Tinospora cordifolia or use of of asphaltum Cyperus rotundus, Semecarpus anacardium and saktu – roasted flour of cereals with honey; by fumigation (of the affected part), purgative therapy for the head, (that is nasya – nasal medication), previously mentioned measures  for opening the tumor by touching the tumor with heated plaque of with  iron or gold, salt  stone etc.

Suppuration and excision of tumors

आभिः क्रियाभिः सिद्धाभिर्विविधाभिर्बले स्थितः ।
ग्रन्थिः पाषाणकठिनो यदि नैवोपशाम्यति ॥ ३२ ॥
अथास्य दाहः क्षारेण शरैर्हेम्नाऽपि वा हितः ।
पाकिभिः पाचयित्वा वा पाटयित्वा तमुद्धरेत् ॥३३॥
If the hard and deep rooted tumor  does not break  even by these different kinds of treatment of proven efficacy and remains stony hard,   it should then be burnt (cauterised)  either with ksara (alkalies) or red hot arrow  or rod of gold; Or it should be made to undergo suppuration  by herbs which promote pus formation  and then excised  and removed.

Bloodletting

मोक्षयेद्बहुशश्चास्य रक्तमुत्क्लेशमागतम् ।
पुनश्चापहृते रक्ते वातश्लेष्मजिदौषधम् ॥ ३४ ॥
The blood  which is vitiated and coming up from the tumor should be let out in large quantity; after removing the blood, medicines which mitigate Vata and Kapha should be administered.

Treatment of external and internal wound

प्रक्लिन्ने दाहपाकाभ्यां बाह्यान्तर्व्रणवत्क्रिया ।
दार्वीविडङ्गकम्पिल्लैः सिद्धं तैलं व्रणे हितम् ॥ ३५ ॥
दूर्वास्वरससिद्धं तु कफपित्तोत्तरे घृतम् ।
When the tumor becomes greatly moist from burning (cauterisation) and suppuration,  treatment  should be like those of external and internal wounds. Oil prepared with Berberis aristata, Embelia ribes, and Mallotus philippensis is good for the wound (healing). Ghee prepared with fresh juice of Cynodon dactylon is good for the wound which has predominance of Kapha and Pitta.

Bloodletting

एकतः सर्वकर्माणि रक्तमोक्षणमेकतः ॥ ३६ ॥
विसर्पो न ह्यसंसृष्टः सोऽस्रपित्तेन जायते ।
If all the other treatment are at one side, blood-letting alone is at the other.  Visarpa  does not occur without being associated with  rakta-pitta (bleeding disease), blood alone is the seat of it (visarpa). Hence, blood-letting should be done many times/ in large quantities.

Importance of Virechana Ghrita

न घृतं बहुदोषाय देयं यन्न विरेचनम् ।
तेन दोषो ह्युपस्तब्धस्त्वग्रक्तपिशितं पचेत् ॥३८॥
No medicated ghee which is not a purgative  should be given to the patient (of visarpa), who has great increase of doshas; if done so, it (ghee) obstructs  the doshas  and cooks (destroys) the skin, blood and muscle tissues.

इति श्री वैद्यपति सिंहगुप्तसूनु श्रीमद्वाग्भटविरचितायामष्टाङ्गहृदयसंहितायां चतुर्थे चिकित्सितस्थाने विसर्पचिकित्सितं नामाष्टादशोऽध्याय: ॥ १८ ॥
Thus, ends the chapter visarpa cikitsa- the eighteenth in cikitsitasthana of asthangahrsaya samhita composed by Srimad Vagbhata, son of Sri Vaidyapati Simhagupta.