शल्यतन्त्र Paper I, Part B

शल्यतन्त्र
Paper I
PART B
CHAPTER I: Shat kriyakala
Ṣaṭ Kriyākāla is the process of understanding the pathogenesis of a disease in

consecutive stages.
If the accumulated Doṣas will not be eliminated from the body, they become stronger
and advance to latter stages which will be more difficult to manage.
सञ्चयं च प्रकोपं च प्रसरं स्थानसश्रं यम् ।

व्यक्तं भेदं च यो वेक्ि दोषाणां स भवेक्िषक् ॥ (सु - सू - २१/३६)
1) Sañchaya (Accumulation)
2) Prakopa (Aggravation)
3) Prasara (Spreading)
4) Sthānasaṁshraya (Localization)
5) Vyakti (Manifestation)
6) Bheda (Differentiation/Complication)
The one who knows/understands these 6 stages can be called a physician.
1) Sañchaya Avasthā
Gradual accumulation of Dosha in its respective seat is known as Sañchaya.
Vāta Sañchaya in Pakvāshaya, Pitta in Nābhi, and Kapha in Uras.
Lakṣaṇa:
Chaya Kāraṇa Vidveṣa - The person develops aversion towards the causative factors
which are responsible for accumulation of the Dosha.
a) Vāta Sañchaya Lakṣaṇa: Stabdha Koṣṭhatā, Pūrṇa Koṣṭhatā

b) Pitta Sañchaya Lakṣaṇa: Pīta aṅga varṇa
c) Kapha Sañchaya Lakṣaṇa: Mandoṣmatā, Aṅga gaurava, Ālasya
Chikitsā: Nidāna parivarjana, Pathya sevana, Hetu viparīta Chikitsā
If the Doṣas are eliminated in the stage of accumulation itself, they do not progress to
the further stages and do not become more harmful.
2) Prakopa Avasthā
Aggravation and liquification of the accumulated Doṣa within its respective seat is
known as Prakopa. It is known as Vilayana Rūpa Vṛddhi; expansion of the Doṣa through
liquification.
Bheda: - 2
i) Chaya Prakopa: It is the condition in which Sañchaya Avasthā occurs before

Prakopa. First the Doṣa gets accumulated and then gradually aggravated.
The Prakopa Lakṣaṇa will not be seen strongly unless there are favourable conditions
for the causative factors leading to further aggravation.
ii) Achaya Prakopa: It is the condition in which Doṣa Prakopa occurs abruptly without
occurrence of Sañchaya Avasthā. Hence it is known as Achaya Prakopa.
Causative factors for Achaya Prakopa may include:
- Toxic substances
- Allergic components
- Powerful pathogenic organisms
- Sudden abnormal climatic changes
Lakṣaṇa:
a) Vātaja Prakopa Lakṣaṇa: Koṣṭha Toda, Sañcharaṇa (motion / gurgling sound)
b) Pittaja Prakopa Lakṣaṇa: Amlodgāra, Pipāsā, Paridāha
c) Kaphaja Prakopa Lakṣaṇa: Annadveṣa, Hṛdaya Utkleda (heaviness of the chest)
Chikitsā: Nidāna parivarjana, Pathya sevana, Hetu viparīta Chikitsā

3) Prasara Avasthā
Spreading or overflowing of the aggravated and liquefied Doṣa from its respective seat to
other places is known as Prasara. The movement of any Doṣa occurs due to Vāta only. The
Doṣas are travelling through Srotas in different directions; Ūrdhva Adho Tiryak.
Bheda: - 15
Single Doṣa = 4 Three Doṣas = 4
Two Doṣas = 6 Four Doṣas = 1
i) Vāta prasara
ii) Pitta prasara ix) Pitta Rakta
iii) Kapha prasara x) Kapha Rakta
iv) Rakta prasara xi) Vāta Pitta Kapha
v) Vāta Pitta xii) Vāta Kapha Rakta
vi) Vāta Kapha xiii) Pitta Kapha Rakta
vii) Pitta Kapha xiv) Vāta Pitta Rakta
viii) Vāta Rakta xv) Vāta Pitta Rakta Kapha
Lakṣaṇa:
a) Vāta Prasara Lakṣaṇa: Vāyu-vimargagamana, Āṭopa (आटोपो रुजापूर्क
व उदरक्षोभः ।)
b) Pitta Prasara Lakṣaṇa: Oṣachoṣa (burning/sucking pain due to heat), Paridāha,
Dhūmāyana (sensation of smoke coming from mouth)
c) Kapha Prasara Lakṣaṇa: Arochaka, Avipāka, Aṅgasāda, Chardi
Chikitsa: Nidāna parivarjana, Pathya sevana, Hetu-liṅga Chikitsā

The principle of treatment at this stage is to correct/repair the Āshaya into which the
Doṣa has spread.
4) Sthānasaṁshraya Avasthā
Localization of the spreading Doṣa at a place where there is obstruction of Srotas and
Khavaiguṇya is known as Sthānasaṁshraya. This is known as Doṣa-Dūshya Samūrchana.
The interaction and reaction between Doṣa and Dūshya is mandatory for a disease to
manifest. Upon localization, the vitiated Doṣa will slowly start to damage the tissue.
Bheda:
i) Udaragata -> Gulma, Vidradhi, Udararoga, Agnimāndya, Vibandha, Ānāha,
Visūchikā, Atisāra, Pravāhikā, Vilambikā, etc.
ii) Bastigata -> Prameha, Ashmarī, Mūtrāghāta, Mūtradoṣa, etc.
iii) Meḍhragata -> Niruddhaprākaṣa, Upadaṁsha, Shukradoṣa, etc.
iv) Gudagata -> Bhagandara, Arsha, etc.
v) Vṛṣaṇagata -> Vṛṣaṇa vriddhi, Shopha, etc.
vi) Ūrdhvajatrugata -> Ūrdhvajatrugata Vikāra (Shiroroga, Mukharoga, Netraroga,
Karṇaroga, Nāsaroga, etc.)
vii) Tvak-Māṁsa-Shoṇitagata -> Kṣudraroga, Kuṣṭha, Visarpa, etc.
viii) Medogata -> Granthi, Apachī, Arbuda, Galagaṇda, Alaji, etc.
ix) Asthigata -> Asthi vidradhi, Asthimajjagata Vāta, etc.
x) Pādagata -> Shlīpada, Vātarakta, Vātakaṇṭaka, etc.
xi) Sarvāṅgagata -> Jvara, Vātavyadhi, Pāṇḍu, Shoṣa, etc.
Lakṣaṇa: Pūrvarūpa and mild Rūpa of the respective disease are seen.
Chikitsā: According to involved Doṣa, Dūshya or both
5) Vyakti Avasthā
Manifestation / Appearance of main symptoms of the disease occurs in Vyakti Avastha.
Lakshana: Cardinal signs and symptoms of the disease are clearly expressed.
Examples सन्त्तापलक्षणो ज्वरः
सरणलक्षणोऽक्तसारः
पूरणलक्षणमुदरक्मक्त
Chikitsa: Vyādhi pratyanīka Chikitsā (according to the respective disease)
6) Bheda Avasthā
Bheda Avasthā is the final stage which manifests due Dīrgha-kāla-anubandha (chronic
presence of the disease) by neglecting the disease in its previous stages or improper
treatment. The aggravated Doṣa are deeply rooted and highly aggravated.
The disease which has reached Bheda Avastha is very difficult to manage, will likely develop
complications and may even become incurable.
CHAPTER Ii: Vranshothadi
 Vraṇashotha / Vraṇashopha
Shopha is a localised swelling in a part of body involving Tvak and Māṁsa which may be
even or uneven, massive and knotty in consistency.
The vitiated Vāta Doṣa displaces the vititated Pitta, Rakta and Kapha, and pushes them
into the Srotas. The Vāyu is obstructed by the circulating Doṣas and causes accumulation
of Pitta, Rakta and Kapha in between Tvak and Māṁsa, which results in swelling of the
local area, known as Shopha.
 Bheda: (Ā. Sushruta)

1) Vātaja
2) Pittaja
3) Kaphaja
4) Raktaja
5) Sannipātaja
6) Āgantuja
 Sāmānya Lakṣaṇa: Gaurava, Anavasthita (unstable), Utsedha (elevated/swollen),

Uṣmā, Sirātanutva, Lomaharṣa, Aṅgavivarṇatā
 Visheṣa Lakṣaṇa:
1) Vātaja -> Kṛṣṇa-Aruṇa, Paruṣa, Mṛdu, Anavasthita, Toda, Vedanā
2) Pittaja -> Pīta-Sarakta, Mṛdu, Shīghra anusāra (fast spreading), Oṣa, Choṣa
3) Kaphaja -> Pāṇḍu, Kaṭhina, Snigdha, Shīta, Manda anusāra, Kaṇḍū
4) Raktaja -> Smiliar to Pittaja Lakṣaṇa; colour tends to be more dark
5) Sannipātaja -> Tridoṣa Lakṣaṇa
6) Āgantuja -> Similar to Pittaja Lakṣaṇa; colour tends to be more reddish
 Vraṇashotha Avasthā:
1) Āmāvasthā (stage of minor tissue damage)
2) Pachyamānāvasthā (stage of acute inflammation)
3) Pakvāvasthā (stage of pus formation)
1) Āmāvasthā Lakṣaṇa
Mandoṣmatā, Shītashophatā, Tvak-savarṇatā, Sthairya, Mandavedanatā,
Alpashophatā
2) Pachyamānāvasthā Lakṣaṇa
- Feeling as being pricked by a pin, bitten by ants, cut by a sharp instrument,
hit by rod, pressed by hands, rubbed by fingers, burnt by Agni or Kṣāra
- Oṣa Choṣa Paridāha
- Pain like being stung by a scorpion
- No relief in sitting or lying position
- Gradually increased swelling
- Discolouration of the skin
- Jvara, Dāha, Pipāsā, Aruchi
3) Pakvāvasthā Lakṣaṇa
- Increased severity of pain
- Pallor, decreased swelling Pāṇḍutā, Alpashophatā
- Appearence of wrinkles, crackling of the skin
- Feeling the pus in the swelling like movement of water in a filled urinary
bladder
- When it is pressed on one side, pressure is felt on another site
- Repeated pricking pain, itching and elevation of swelling
- Decrease of complications
- Increased appetite
 Shopha Upadrava:
Chardi, Hikkā, Shvāsa, Kāsa, Aruchi, Tṛsṇā, Jvara, Atisāra, Daurbalya
 Chikitsā:
A) Saptopakrama
1) Vimlāpana (Rubbing/Squeezing/Pressing)
2) Avasechana (Blood letting)
3) Upanāha (Application of poultice)
4) Pāṭana (Draining/Incising)
5) Shodhana (Cleaning)
6) Ropaṇa (Healing)
7) Vaikṛtāpaha (Repairing the scar)
Āmashotha -> Vimlāpana, Avasechana, Upanāha

Pakvashotha -> Pāṭana
Vraṇa Chikitsā -> Shodhana, Ropaṇa, Vaikṛtāpaha
B) Ekādashopakrama
1) Apatarpaṇa (Fasting)
2) Ālepa (Application of paste)
3) Pariṣeka (Irrigation)
4) Abhyaṅga (External oleation)
5) Svedana (Fomentation)
6) Vimlāpana (Rubbing/Squeezing/Pressing)
7) Upanāha (Application of poultice)
8) Pāchana (Inducing suppuration)
9) Visrāvana (Blood letting/Draining)
10) Snehana (Internal oleation)
11) Shodhana (Vamana & Virechana; Emesis & Purgation)
 Inflammation
Inflammation is the immune system’s natural response to injury and illness. It helps in
removing or neutralizing the cause of injury, to draw more blood to the area, to increase
the body’s defense mechanism, to remove necrotic cells, and enhance repair.
 Types:
1) Acute
2) Chronic
1) Acute
Acute inflammation is typically caused by injuries, like a sprained ankle, or by
illnesses, like bacterial infections and common viruses. The acute inflammation
process happens quickly and can be severe.
Signs & Symptoms:

- Calor (heat due to arterial dilatation)
- Dolor (pain by swelling and irritation of local nerves)
- Rubor (redness due to increased blood flow and temperature)
- Tumor (swelling due to increased permeability)
- Loss of function
Depending on the cause and severity of the wound, acute inflammation can
last from a few days to a few months.
Sometimes acute inflammation is localized to one area, and sometimes it is
systemic. When the body identifies a harmful invader, such as a bacteria or
virus, it initiates a whole-body immune response to fight it off. White blood
cells trigger the release of several inflammatory chemicals.
2) Chronic
Chronic inflammation is also referred to as slow, long-term inflammation
lasting for prolonged periods of several months to years. Generally, the extent
and effects of chronic inflammation vary with the cause of the injury and the
ability of the body to repair and overcome the damage.
Conditions associated with chronic inflammation include:
High blood pressure, High cholesterol, Kidney disease, Various types of cancer,
Depression, Neurodegenerative disorders (like Alzheimer's disease),
Autoimmune disorders, Osteoporosis, Fatty liver disease
Chronic inflammation often progresses quietly, with few independent

symptoms. Despite its subtlety, chronic inflammation represents a major
threat to the health and longevity of a large population of individuals.
Factors which cause Chronic Inflammation:

- Physical inactivity. An anti-inflammatory chemical process occurs in the
bloodstream when muscles are in motion. People who do not meet the
minimum activity recommendations for optimal health have an increased risk
of age-related diseases.
- Obesity. Fat tissue, especially visceral fat (a deep layer of fat around the
abdominal organs), actually produces pro-inflammatory chemicals.
- Diet. Diets high in saturated fat, trans-fat, and refined sugar are associated
with increased inflammation, especially in overweight people.
- Smoking. Smoking cigarettes lowers the production of anti-inflammatory

molecules and increases inflammation.
- Low sex hormones. Sex hormones like estrogen and testosterone suppress
inflammation. Lower levels of these hormones, common in advanced age,
increase the risk of inflammatory diseases.
- Stress. Psychological stress is associated with increased inflammation.
- Sleep disorders. People with irregular sleep schedules have more markers of
inflammation than people who get a regular eight hours a night.
- Age. Research shows that chronic inflammation gets worse with age.
 Vidradhi
Vidradhi is a swelling due to collection of pus within the tissues.
 Nidāna:
- Guru-Asātmya-Viruddha-Shuṣka-Saṁsṛṣṭa-Vidāhi Āhāra
- Ativyavāya, Ativyāyāma, Vega vidhāraṇa
- Rakta prakopa Nidāna; Ātapa, Agni, Kṣāra, etc.
 Saṁprāpti:
Vitated Doṣas located around Asthi contaminate Tvak, Rakta, Māṁsa and Meda,
and will produce a swelling which develops gradually, increases in size and gets
hard in consistency to form Vidradhi.
 Sāmānya Lakṣaṇa:
- Mahāmūla (deeply rooted)
- Rujāvanta (associated with pain)
- Vṛtta (rounded in shape)
 Bheda:
1) Bāhya Vidradhi
2) Abhyantara Vidradhi
-> Bāhya Vidradhi – 6 1) Vātaja

2) Pittaja
3) Kaphaja
4) Raktaja
5) Sannipātaja
6) Kṣataja / Abhighātaja
 Visheṣa Lakṣaṇa:
1) Vātaja Vidradhi
- Kṛṣṇa-Aruṇa varṇa
- Paruṣa, Atyartha Vedana
- Viṣamasaṁsthiti (uneven swelling; increases & decreases)
- Chitra Utthāna Pāka (develops and suppurates in a variable manner)
- Tanu srāva
2) Pittaja Vidradhi
- Rakta-Tāmra-Shyāva varṇa
- Jvara, Dāha, Tṛṣṇā
- Kṣipra Utthāna Paka (develops and suppurates quickly)
- Pīta srāva
3) Kaphaja Vidradhi
- Pīta-Shveta varṇa
- Shīta, Stabdha, Alpavedana, Kaṇḍū, Hrillāsa, Jṛmbha, Aruchi, Gurutva
- Chira Utthāna Pāka (develops and suppurates slowly)
- Pāṇḍu srāva
4) Raktaja Vidradhi
- Kṛṣṇa Sphoṭa (Vidradhi is surrounded by black coloured blisters)
- Shyāva varṇa
- Tīvradāha, Ruja, Jvara
- Pittaja Vidradhi Lakṣaṇa
5) Sannipātaja Vidradhi
- Nānā-Varṇa-Ruja-Srāva (various colours, pains and discharges)
- Viṣama (irregular shaped, uneven)
- Mahān (large in size)
- Viṣama pachyate (irregular in ripening)
6) Kṣataja / Abhighātaja Vidradhi

When the body is injured, the person who indulges in Apathya Āhāra Vihāra,
theheat of the wound gets dispersed by Vāta, which will vitiate Rakta and
Pitta, and gives rise to Jvara, Tṛṣṇā, Dāha and other symptoms of Pittaja
Vidradhi.
-> Abhyantara / Antar Vidradhi – 10

The Doṣa which get vitiated due to Nidāna sevana, alone or in combination, localizes at on of
the following sites to cause Abhyantara Vidradhi.
1) Guda -> Vātanirodha

2) Bastimukha -> Kṛcchra-Alpa Mūtratā
3) Kloma -> Adhikā Pipāsā
4) Nābhī -> Hikkā, Āṭopa
5) Kukṣi -> Māruta prakopa
6) Vaṅkṣaṇa -> Kaṭī-Pṛṣṭha Tīvragraha
7) Vṛkka -> Pārshva saṅkocha
8) Yakṛt -> Shvāsa, Tṛṣṇā
9) Plīhā -> Ucchvāsa avarodhana
10) Hṛdaya -> Sarvāṅga Tīvragraha
 Chikitsā:
Jalaukāvachāraṇa, Mṛdu Virechana, Laghu Anna, Svedana
Āmāvasthā -> Shopha Chikitsā & Raktamokṣaṇa

Pakvāvasthā -> Pāṭana & Visrāvaṇa, afterwards Vraṇa Chikitsā
External application:
- Āmāvasthā -> Yavādi lepa (Yava, Godhūma, Mudga)
- Vātaja Vidradhi -> Thick and lukewarm Kalka prepared from Vātaghna Dravya added
with profuse Sneha (Taila or Ghṛta), Shigru mūla Upanāha for Vātaja Vidradhi
- Pittaja, Raktaja and Kṣataja Vidradhi -> Lepa prepared from Sārivā, Lākṣā, Madhuka
and Sharkara or from Payasya, Ushīra and Chandana, pounded with Kṣīra
- Kaphaja Vidradhi -> Iṣṭikā-Sikatā-Lauha-Goshakṛt Svedana or Kalka with Uṣṇa Mūtra
Internal medications:
- Apakva Antar Vidradhi -> Kvātha prepared from Shveta Punarnavā and Varūṇa
- Vātaja Vidradhi -> Punarnavādi kvātha (Punarnavā, Devadāru, Shuṇṭhī, Dashamūla,
Harītakī, Guggulu, Eraṇḍa taila)
- Pittaja, Raktaja & Kṣataja Vidradhi -> Triphalā kvātha with Trivṛt
- Kaphaja Vidradhi -> Triphalādi kvātha (Triphalā, Shigru, Varūṇa, Dashamūla,
Guggulu, Gomūtra)
 Abscess
An abscess is a collection of pus within the tissue. It is a painful condition which can
develop anywhere in the body.
Abscesses usually form because of an infection or because a foreign object becomes

trapped in tje body. When the body fights an infection or tries to destroy a foreign object
trapped inside, white blood cells fill the affected tissues, and the resulting fluid is called
pus. Pus contains living and dead bacteria, living and dead white blood cells, and the
remnants of the cells and tissue that were killed or injured by the infection or by your
body’s immune response.
 Etiology:
An abscess may be caused by a variety of common conditions including:
- Foreign object trapped inside the body, such as a thorn or piece of metal that
breaks off in the skin; also, retained foreign body fragments after previous
attempted removal
- Infected diverticulum in the large intestine can cause a diverticular abscess
- Infection at the site of previous surgery (perioperative wound contamination)
- Skin infection may result in an abscess
- Tooth infection may progress to a periodontal abscess
- Wound or trauma to the skin, especially a puncture wound, may cause an abscess
 Types:
Abscesses can form throughout the body, both in locations that are visible and
internally, where they may go unnoticed and cause serious complications, including
organ damage.
The most common types of abscess are:

1) Skin abscess, caused by infections that result in pus collecting in the skin.
These can include infections from bacteria (most commonly Staphylococcus),
infections in the hair follicle (folliculitis), boils, or minor wounds or injuries that
become infected. Skin abscesses can form anywhere on the body.
2) Dental abscess, which can form in the center of a tooth (the pulp) and spread
to the root or bone structures that hold the tooth. A tooth can become
infected when bacteria get in through an opening, such as a cavity caused by
tooth decay or an injury that results in a broken, chipped or cracked tooth.
Less common types of abscess include:

1) Abdominal abscess, which can be near or inside abdominal organs such as the
liver, pancreas or kidneys. Causes of abdominal abscess include infections,
burst organs (such as appendix or ovary), and IBD.
2) Amebic liver abscess, a type caused by amebiasis, an intestinal infection that

can spread to the liver. The infection results from the intestinal parasite
Entamoeba histolytica, which is spread through food and water contaminated
with feces containing the parasite.
3) Anorectal abscess, located in or near the anus or rectum, most commonly

caused by sexually transmitted diseases, infection of anal fissures, blocked
glands, or trauma to the area.
4) Bartholin abscess (or cyst), which can form in the Bartholin glands located on
each side of the opening of the vagina. The duct from the gland can become
blocked, causing fluid to build up over time, potentially leading to an infection
and formation of an abscess.
5) Brain abscess, typically the result of a bacterial or fungal infection in part of

the brain. The pressure created by the abscess can cause serious brain issues,
including seizures, loss of muscle function, and language problems. A brain
abscess is a medical emergency that requires immediate treatment.
6) Pyogenic liver abscess, which is simply an area on the liver that produces pus.
This can result from many types of abdominal infection, an infection of the
tubes that drain bile, or trauma to the liver.
 Signs & Symptoms:
Abscess symptoms vary depending on the location of the abscess and underlying
disease, disorder or condition.
Skin symptoms that may occur along with an abscess

- Calor, Rubor, Dolor, Tumor
- Oozing or drainage of fluid
- Loss of function
Other symptoms that may occur along with an abscess

- Enlarged lymph nodes
- Fatigue or malaise
- Fever, chills or sweating
- Headache, Joint pain
- Loss of appetite or rapid weight loss
- Nausea, vomiting or diarrhea
- Neurological symptoms (if abscess presses on nerves or parts of the brain)
- Pain, such as a toothache for a tooth abscess or abdominal pain for an abdominal
abscess
 Treatment:
- When pus is not localized, conservative treatment with suitable antibiotics.
- When pus is localized, drainage is mostly indicated. Pus is examined and specific
antibiotic may be given.
Hilton’s Method of Incision and Drainage:

The method of opening an abscess ensures that no blood vessel or nerve in the
viscinity is damaged.
1. Topical anaesthesia is achieved with the help of ethyl chloride spray.
2. Stab incision made over a point of maximum fluctuation in the most dependent
area along the skin creases, through skin and subcutaneous tissue.
3. If pus is not encountered, further deepening of surgical site is achieved with
sinus forceps (to avoid damage to vital structures).
4. Closed forceps are pushed through the tough deep fascia and advanced towards
the pus collection.
5. Abscess cavity is entered and forceps opened in a direction parallel to vital
structures.
6. Pus flows along sides of the beaks.
7. Explore the entire cavity for additional loculi.
8. Placement of drain: A soft yeat’s or corrugated rubber drain is inserted into the
depth of the abscess cavity; and external part is secured to the wound margin with
the help of suture
9. Drain is left for at least 24 hours.
10. Dressing is applied over the site of incision taken extraorally without pressure.
 Piḍikā / Boils
A boil, also called furuncle, is a skin infection that starts in a hair follicle or oil gland.
At first, the skin turns red in the area of the infection, and a tender lump develops. After
four to seven days, the lump starts turning white as pus collects under the skin.
The most common places for boils to appear are on the face, neck, armpits, shoulders,
and buttocks. When one forms on the eyelid, it is called a stye. If several boils appear in a
group, this is a more serious type of infection called a carbuncle.
 Etiology:
Most boils are caused by a germ (staphylococcal bacteria). This germ enters the
body through tiny nicks or cuts in the skin or can travel down the hair to the follicle.
Following health problems make people more susceptible to skin infections:

- Diabetes
- Problems with the immune system
- Poor nutrition
- Poor hygiene
- Exposure to harsh chemicals that irritate the skin

A boil starts as a hard, red, painful lump usually about half an inch in size. Over the
next few days, the lump becomes softer, larger, and more painful. Soon a pocket of
pus forms on the top of the boil. Follwing are the signs of a severe infection:
- The skin around the boil becomes infected. It turns red, painful, warm, and
swollen.
- More boils may appear around the original one.
- Fever
- Swollen lymph nodes
 Treatment:
- Apply warm compresses and soak the boil in warm water. This will decrease the
pain and help draw the pus to the surface. Once the boil comes to a head, it will
burst with repeated soakings. This usually occurs within 10 days of its appearance.
- When the boil starts draining, wash it with an antibacterial soap until all the pus is
gone and clean with alcohol. Apply a medicated ointment (topical antibiotic) and a
bandage. Continue to wash the infected area two to three times a day and to use
warm compresses until the wound heals.
- Do not pop the boil with a needle. This could make the infection worse.
 Nāḍīvraṇa
Vraṇa which has been become chronic, due to improper management or negligience of
management, is called Nāḍīvraṇa.
 Nidāna:
- Mismanagement of Vraṇa by mistaking Apakva Avasthā for Pakva Avasthā
- Ignoring Pakva Avasthā and not treating it
- Excessive accumulation of pus, which then enters into the deeper tissues involving
Tvak, Māṁsa, Sirā, Snāyu, Sandhi, Asthi, Marma, etc.
 Bheda: (Ā. Vāgbhaṭa)

1) Vātaja
2) Pittaja
3) Kaphaja
4) Sannipātaja
5) Āgantuja/Shalyaja
 Lakṣaṇa:
1) Vātaja Nāḍīvraṇa
- Paruṣa, Sūkṣmamukhī, Sashūla
- Discharge with excessive foam which occurs at night
2) Pittaja Nāḍīvraṇa
- Tṛṣṇā, Tāpa, Toda, Sadana, Jvara, Bheda (tearing sensation)
- Yellowish and excessive hot discharge which occurs during the day
3) Kaphaja Nāḍīvraṇa
- Bahu, Ghana, Stimita, Ruk, Kaṭhina, Sakaṇḍū
- Whitish and slimy discharge which occurs at night
4) Sannipātaja Nāḍīvraṇa
- Dāha, Jvara, Shvasana, Mūrcchna, Vaktra shoṣa
- Tridoṣa lakṣaṇa
5) Āgantuja/Shalyaja Nāḍīvraṇa
Shalya remaining inside the body causes Nāḍīvraṇa quickly. Its discharge
comes out suddenly along with foam. It is serosanguineous (discharge that
contains both blood and a clear yellow liquid known as blood serum), hot, and
associated with continuous pain.
 Sādhyāsādhyatā:
- Ekadoṣaja & Shalyaja Nāḍīvraṇa -> Kṛcchrasādhya
- Sannipātaja Nāḍīvraṇa -> Asādhya
 Chikitsā:
- Nāḍīvraṇa has to be probed, incised and opened, after which it is cleaned, and
measures to promote healing are applied.
- Vātaja Nāḍīvraṇa -> Upanāha, Pāṭana, Pūya visrāvaṇa, Kalka made from
Apāmārga, Tila & Saindhava lavaṇa
- Pittaja Nāḍīvraṇa -> Pāṭana followed by application of Kalka made from

Mañjiṣṭha, Nāgadantī, Haridrā and Dāruharidrā.
- Kaphaja Nāḍīvraṇa -> Pāṭana followed by application of Kalka made from Tila,
Sauraṣṭriī, Nikumba, Ariṣṭa and Saindhava lavaṇa.
- Shalyaja Nāḍīvraṇa -> Pāṭana followed by extraction of Shalya, Vraṇa shodhana,

application of Kalka made of Tila, Madhu and Ghṛta.
Internal medicines:
- Rāsnādi Guggulu, Panchatikta Ghṛta Guggulu
- Āragvadhādi Varti, Jātyādi Varti
- Jātyādi Ghṛta, Saindhavādhya Taila
 Sinus
A sinus wound is defined as a discharging blind-ended track that extends from the
surface of an organ to an underlying area or abscess cavity.
A fistula, however, is an abnormal passage between a hollow organ and the skin surface.
A sinus is only open on one end, whereas a fistula is a communicating channel. The word
derives from the Latin word meaning ‘pipe’. A common example are anal fistulas, which
are often associated with Crohn’s disease.
 Classification of Sinus:
1) Congenital – like preauricular sinus
2) Traumatic – sinus occurs following a trauma in which a foreign body is
implanted into deep tissue and infection occurs
3) Inflammatory – like osteomyelitic sinus, tuberculous sinus, actinomycotic sinus
4) Neoplastic – sinus occurs due to degenerative changes of malignant growth or
due to secondary infection of malignant growth which was incised for
drainage.
5) Miscellaneous – like Pilonidal sinus
Pilonidal disease is a chronic skin infection in the crease of the buttocks near
the coccyx. A pilonidal sinus is a small hole or tunnel which may fill with fluid
or pus, causing the formation of a cyst or abscess. It occurs in the cleft at the
top of the buttocks. A pilonidal cyst usually contains hair, dirt, and debris. It
can cause severe pain and can often become infected. If it becomes infected, it
may ooze pus and blood and have a foul odor.
- Discharges from the opening of the sinus, such as pus, caseating material, bone
spicules, sulpher granules, etc.
- Pain
- Edge is raised and often indurated
- Sprouting granulation tissue over the sinus opening often occurs
 Local Examination:
A) Inspection
1) Number -> single or multiple sinuses
2) Position -> Pilonidal sinus in sacrococcygeal region, TB sinus in the neck
3) Opening -> Sprouting granulation tisse at the opening suggests precence of
foreign body at the depth.
The opening of TB sinus is often wide and the margin is thin.
4) Discharge
5) Surrounding skin
B) Palpitation
1) Tenderness -> Sinus from inflammatory source will be tender
2) Wall of sinus -> To check thickening of the wall which is seen in chronic cases
3) Mobility -> Sinus fixed to a bone in osteomyelitis is immobile
4) Lump -> Presence of a lump in the surrounding area indicates tubercular
lymphadenitis
C) Probe examination
1) The direction and depth of sinus is examined
2) Presence of any foreign body
3) Evaluation of discharge (fresh or not) which comes out upon withdrawal
 Investigation:
1) Discharge: Culture and sensitivity
2) X-ray, ESR, MRI
3) Sinusogram
4) Biopsy from edge of sinus
 Treatment:
1) Treat the cause
2) Removal of foreing body if present
3) Excision of sinus track
4) Antibiotics
5) Analgesics if excessive pain is present
6) Proper dressing
 Vraṇa Granthi & Keloid
Vraṇa Granthi is a complication of a healing wound. It occurs when during the healing
process the patient follows Apathya Āhāra Vihāra, gets injured or the wound is not
properly treated/bandaged. Vāta prakopa occurs, leading to Rakta shoṣaṇa in the Vraṇa
causing Vraṇa Granthi with Lakṣaṇa such as Kaṇḍū, Dāhayukta & Utsedha.
Vraṇa Granthi is Kṛcchrasādhya. It is treated by Chedana followed by Agnikarma.
When the skin is injured, fibrous tissue called scar tissue forms over the wound to repair
and protect the injury. In some cases, extra scar tissue grows, forming smooth, hard
growths called keloids.
Keloids can be much larger than the original wound. They are most commonly found on
the chest, shoulders, earlobes, and cheeks. However, keloids can affect any part of the
body. Although keloids are not harmful to health, they may create cosmetic concerns.
 Etiology & Risk Factors:

Most types of skin injury can contribute to keloid scarring. These include:
Acne scars, burns, chickenpox scars, ear piercing, scratches, surgical incision sites,
vaccination sites, etc.
An estimated 10% of people experience keloid scarring. Men and women are
equally likely to have keloid scars. People with darker skin tones are more prone to
keloids.
Other risk factors associated with keloid formation include:
- Being of Asian descent
- Being of Latino descent
- Being pregnant
- Being younger than 30 years of age
- Inheritance

Keloids come from the overgrowth of scar tissue. Keloid scars tend to be larger
than the original wound itself. They may take weeks or months to develop fully.
The symptoms of a keloid can include:
- A localized area that is flesh-colored, pink, or red
- A lumpy or ridged area of skin that is usually raised
- An area that continues to grow larger with scar tissue over time
- An itchy patch of skin
While keloid scars may be itchy, they are usually not harmful to health. One may
experience discomfort, tenderness, or possible irritation from clothing or other
forms of friction.
 Keloids vs. Hypertrophic Scars:
Keloids are sometimes confused with another more common type of scar called
hypertrophic scars. These are flat scars that can range from pink to brown in color.
Unlike keloids, hypertrophic scars are smaller, and they can go away on their own
over time.
Hypertrophic scars occur equally among genders and ethnicities, and they are
commonly caused by various forms of physical or chemical injuries.
At first, fresh hypertrophic scars can be itchy and painful, but the symptoms
subside as the skin heals.
 Treatment for Keloids:

- Moisturizing oils can help to keep the tissue soft. These might help reduce the size
of the scar without making it worse. Keloids tend to shrink and become flatter over
time, even without treatment.
- Less-invasive treatments, such as silicone pads, pressure dressings, or injections,

especially if the keloid scar is a fairly new one. These treatments require frequent
and careful application to be effective, taking at least three months to work.
- In the case of very large keloids or an older keloid scar, surgical removal is
indicated. After removing the keloid, the scar tissue may grow back again, and
sometimes it grows back larger than before. However, the benefits of removing a
large keloid may outweigh the risk of postsurgery scars.
- Cryosurgery/Cryotherapy is perhaps the most effective type of surgery for keloids.

The process works by using extreme cold to freeze the keloid with liquid nitrogen.
 Marmāghāta / Shock
A shock is a condition of acute circulatory failure.
It is characterized by prolonges hypotension leading to inadequate tissue perfusion.
All forms of shock result in reduction of effective blood flow (hypoperfusion). It leads to
reduced delivery of oxygen and nutrients, and further, dysfunction of cells.
 General Features:
- Pale, cold and moist skin
- Fast, thready pulse
- Shallow respiration
- Decreased BP
- Oliguria
 Types:
1) Hypovolemic shock
Hypovolemia is total decease in blood or fluid volume.
It may be caused due to severe haemorrhage, fluid loss due to vomiting and
diarrhoea, burns, dehydration.
Management:
Arrest bleeding, IV fluids, Oral rehydration, Treat underlying causes
2) Obstructive shock
It may be caused due to obstruction within veins, compression of heart or
pressure on vessels.
Management:
Heparin, Thrombolysis, Pericardiocentesis, Chest decompression, Chest
drainage
3) Cardiogenic shock
It is caused due to decreased cardiac output due to myocardial infarction,
valve dysfunction, dysrhythmias, cardiomyopathy, cardiac failure.
Management:
Early thrombolysis, Valve replacement surgery, Correction of dysrhytmias
4) Neurogenic shock
It is the result of autonomic dysregulation following spinal cord injury, usually
secondary to trauma. This dysregulation is due to a loss of sympathetic tone
and an unopposed parasympathetic response.
Management:
IV fluids, Vasopressors (norepinephrine, epinephrine, dopamine, vasopressin),
Atropine
5) Allergic shock
It is caused due to hypersensitivity manifesting as a shock; Anaphylaxis.
Management:
Epinephrine, Adrenaline, Chlorphenamine, Hydrocortisone, Bronchodilators,
Oxygen, Fluids, Prevention
6) Septic shock
It is caused due to sepsis in the body at any site. It leads to organ
hypoperfusion, further to multi-organ failure, resulting in acute respiratory
distress syndrome.
Management:
Initial resuscitation, Antibiotics, Identification of exact cause, Vasopressors,
Inotropic therapy
 General Management:
- Establish and maintain clear airways
- Ensure adequate ventilation
- Adequate intravenous access
- Continuous cardiac monitoring
- Urinary catheter
- Recording of fluid balance
- Centra venous monitoring
- Maintain optimum temperature
- Acid-base balance assessment
- Treatment of underlying disorder
 Kotha / Gangrene
Gangrene is a general term that can be used to describe a number of conditions that
involve death and subsequent decay of the tissue in one regional portion of the body.
Gangrene is macroscopic death of tissue with super added putrefaction.

A complication of necrosis, gangrene can arise because of critically insufficient
blood supply. The affected tissue may be the skin, muscles, or internal organs.
Blood provides oxygen and nutrients to feed the tissue cells and immune system
components, such as antibodies, to ward off infections. Without a substantially
functioning blood supply, the cells struggle to survive and ultimately die.
This necrosis or cell death, can result when a portion of the body's tissues becomes
infected, injured or constricted, interrupting the blood supply. In addition, tissue in
a particular region of the body may have a decrease in the amount of blood supply
due to a number of diseases or conditions, such as arteriosclerosis, diabetes,
smoking or wound infections including those related to surgery.
Any of these afflictions can significantly increase a person's likelihood of

contracting gangrene. Another indicator of susceptibility is a suppressed immune
system. Patients with HIV or who are undergoing chemotherapy are at a far greater
risk of infection due to the weakened state of their immune system. Severe burns
or frostbite can also cause gangrene in body tissues due to the necrosis that results
from such injuries or conditions.
 General Clinical Features:

- Loss of colour in the affected body part. The area will become discoloured and
eventually turns dry and dark.
- Shiny appearance of skin and shedding of skin with a clear line fo demarcation
between the affected and healthy skin.
- Pain which is later followed by a loss of sensation and immobility.
- Foul smelling discharge leaking from the sore
- 5L’s -> Loss of pulsation
Loss of colour
Loss of temperature
Loss of sensation
Loss of function
 Types:
There are several types of gangrene, but the three most common variations are:
Dry gangrene, Wet gangrene, and Gas gangrene.
Less common variations include Internal gangrene and Fournier's gangrene.
Gangrene can involve any part of the body, but the most common sites include the
toes, fingers, feet and hands.
-> Dry gangrene
Dry gangrene is a condition that involves tissue death and turns it dry, dark and mummified
due to arterial occlusion; ischaemia. It occurs gradually, progresses slowly and affects the
lower extremities of the body (toes and feet) due to insufficient blood supply to the tissues.
Dry gangrene is very common in individuals suffering from arteriosclerosis, high cholesterol,
diabetes and smoking. In dry gangrene, due to necrosis, the tissue becomes shrunken and
blackened and gets detached. Dry gangrene is usually less severe than wet gangrene and
may result in auto-amputation (i.e., spontaneous detachment from the body and elimination
of a gangrenous part).
-> Wet gangrene

Wet gangrene is gangrene due to necrotising bacterial infections. The site becomes swollen,
discoloured and blebs may manifest. Wet gangrene may lead to cellulitis, loss of extremity,
septicemia and death.
-> Gas gangrene

Gas gangrene is a highly lethal infection of soft tissue, caused by Clostridium species, with
Clostridium perfringens being the most common. This is synonymous with clostridial
myonecrosis or myositis and is characterized by rapidly progressive gangrene of the injured
tissue along with the production of foul-smelling gas.
-> Internal gangrene

This type of gangrene occurs when blood flow to an internal organ is blocked; for example,
when the intestines bulge through a weakened area of muscle in the stomach area (hernia)
and become twisted. Left untreated, internal gangrene can be deadly.
-> Fournier's gangrene

Fournier gangrene is an acute necrotic infection of the scrotum, penis or perineum. It is
characterized by scrotum pain and redness with rapid progression to gangrene and
sloughing of tissue.
-> Kotha
In Āyurveda, gangrene can be considered as Kotha under Duṣṭa Vraṇa due to Mārgāvaraṇa
and Dhātu Kṣaya. Mārgāvaraṇa and Dhātu Kṣaya are the two major causative comorbidities
of Vātavyādhi. Vātavyādhi may be categorized as Kevala Vātaja, Saṁṣiṣṭa Doṣaja and
Avaraṇa according to the effect of Nidāna or due to the comorbidities of Mārgāvaraṇa and
Dhātu Kṣaya. The word Mārga in general refers to any channels within the body, but,
contextually, it refers to the vessels carrying the nutrients, and Avaraṇa refers to
obstruction. Pathological probability of gangrene may be accumulation of morbid Kapha and
Pitta Doṣa within the channels that the momentum of the Vāta Doṣa a circulation in the
channels or impairment of momentum. The influence of Mārgāvaraṇa is not limited proximal
to the obstruction but distal to the obstruction, the circulation of the nutrients is affected
and hence the body part distal to the obstruction is deprived of nutrition and hence suffers
from pathology of Dhātu Kṣaya.
Management includes Kaishora Guggulu, Sañjīvanī Vaṭī and Dashāṅga Lepa.
-> Amputation
The word amputation is derived from the Latin ‘amputare’ – ‘to cut off.’
Amputation is the surgical removal of all or part of a limb such as an arm, leg, hand, foot,
finger, or toe.
 Reasons for Amputation:

There are many reasons an amputation may be necessary. The most common is
poor circulation because of damage or narrowing of the arteries; peripheral arterial
disease. Without adequate blood flow, the body's cells cannot get oxygen and
nutrients they need from the bloodstream. As a result, the affected tissue begins to
die and infection may set in.
Other causes for amputation may include:
- Severe injury (from a vehicle accident or serious burn, for example)
- Cancerous tumor in the bone or muscle of the limb
- Serious infection that does not get better with antibiotics or other treatment
- Thickening of nerve tissue, called a neuroma
- Frostbite, Gangrene
 Amputation Procedure:
An amputation usually requires a hospital stay of five to 14 days or more,
depending on the surgery and complications. The procedure itself may vary,
depending on the limb or extremity being amputated and the patient's general
health. Amputation may be done under general anesthesia or with spinal
anesthesia, which numbs the body from the waist down.
When performing an amputation, the surgeon removes all damaged tissue while
leaving as much healthy tissue as possible.
General Steps during an amputation procedure:

- Ligation of the suppyling artery and vein to prevent haemorrhage
- Muscles are trasacted
- Bone is sawed by oscillating saw
- Sharp and rough edges of the bone are trimmed
- Skin and muscle flaps are transposed over the stump
- Distal stabilization of muscle is recommended where the muscle is attached to the
bone or its periosteum to allow effective muscle contration.
 Granthi
Granthi is a kind of swelling which is hard, knotty and rough.
Aggravated Vātādi Doṣa vitiate Māṁsa & Rakta to cause Granthi.

Aggravated Vāta Doṣa with Kapha Doṣa vitiate Meda to cause Medoja Granthi.
 Bheda:
1) Ā. Sushruta = Vātaja, Pittaja, Kaphaja, Medoja, Sirāja
2) Ā. Charaka = Vātaja, Pittaja, Kaphaja, Medoja, Sirāja, Māṁsaja
3) Ā. Vāgbhaṭa = Vātaja, Pittaja, Kaphaja, Medoja, Sirāja, Māṁsaja,
Raktaja, Asthija, Vraṇaja
1) Sādhya -> Vātaja, Pittaja, Kaphaja, Medoja, Sirāja, Māṁsaja, Raktaja, Vraṇaja
2) Asādhya -> Asthija, Sthūla, Kaṭhina, Chala, Marma-Kaṇṭha-Udara sthāna
 Pathyāpathya:
1) Pathya -> Rakta Shāli, Purāṇa Ghṛta, Yava, Mudga, Paṭola, Rakta Shigru, Guggulu
2) Apathya -> Dugdha, Ikṣu, Anūpa Māṁsa, Madhura, Guru, Abhiṣyandi Āhāra
 Chikitsā:
1) Āmāvasthā -> Shopha Chikitsā
2) Pakvāvasthā -> Mūlavat Chedana, Agnikarma, Vraṇa Chikitsā
Svarjikādi Lepa (Svarjikā kṣāra, Mūlaka kṣāra and Shaṅkha bhasma) destroys
Granthi, Arbuda, etc.
Apakva Granthi not located on Marma should be excised and cauterized.
Afterwards, scrapping and application of Pratisāraṇīya Kṣāra is beneficial.
 Vātaja Granthi:
1) Lakṣaṇa
- Toda, Kṛṣṇa varṇa, Amṛdu (similar to a urinary bladder filled with air)
- Discharge of serosanguinous fluid in case of rupture.
2) Chikitsā
- Hiṁsrādi Lepa (Hiṁsrā, Rohiṇī, Guḍūchī, Bhārgī, Shyonaka, Bilva, Aguru,
Tālaparṇī pounded with Gopitta)
- Svedana, especially Upanāha Svedana
- Pakva Granthi should be incised and pus is drained. It should be washed with
Kvātha of Bilva, Arka and Narendra.
- Tila bīja ground with Eraṇḍa patra and Saindhava lavaṇa is applied for Vraṇa
shodhana.
- Vraṇa ropaṇa is done by application of Taila processed with Kṣīra, Viḍaṅga,
Yaṣṭī, Amṛtā.
 Pittaja Granthi & Raktaja Granthi:
1) Lakṣaṇa
- Dāha, Choṣa, Rakta Sapīta varṇa, Pāka
- Discharge of hot blood in case of rupture.
- Raktaja Granthi may contain Jantu (worms) and have loss of tactile sensation.
2) Chikitsā
- Jalaukāvacharaṇa followed by Pariṣeka with Kṣīra-Udaka.
- Madhukādi Lepa (Madhūka, Jambu, Arjuna, Vetasa)
- Shīta Kaṣāya prepared from Kākolyādi Gaṇa mixed with Sharkara.
- Harītakī chūrṇa with Drākṣā svarasa or Ikṣu svarasa
- Pakva Granthi is incised and washed with Kvātha of Vanaspati Dravya
- Vraṇa shodhana by Tila bīja & Madhuka
- Vraṇa ropaṇa by Ghṛta processed with Madhura Dravya
 Kaphaja Granthi:
1) Lakṣaṇa
- Shīta, Avivarṇa/Varṇa Tvachat (colour like skin), Alparuja, Atikaṇḍū, Pāṣāṇavat
(similar like a stone), Chira vṛddhi
- Discharge of white and thick pus in case of rupture.
2) Chikitsā
- Vamana Virechana, Svedana, Vimlāpana by fingers, iron rods, stones
- Dantīmūlādi Lepa (Dantī, Chitraka, Snuhī, Arka, Guḍa, Bhallātaka, Kāsīsa)
- Surgical excision of Granthi even though it is not Pakva
- Agnikarma
 Medoja Granthi:
1) Lakṣaṇa
- It increases or decreases according to increase or decrease of fat in the body.
- Snigdha, Mahān, Alparuja, Atikaṇḍū
- Discharge similar like Taila / Ghrita in case of rupture.
2) Chikitsā
- Repeated Tāpasvedana with iron
- Pakva Medoja Granthi should be incised and washed with Gomūtra.
- Vraṇa shodhana by Tila bīja, Haratāla, Saindhava lavaṇa, Yava kṣāra, Madhu
and Ghṛta
- Vraṇa ropaṇa by Taila processed with Karañja, Guñja, Iṅgudī and Gomūtra
 Sirāja Granthi:
1) Lakṣaṇa
- Protuberant round, painful & mobile Sirāja Granthi is Kṛcchrasādhya.
- Painless, fixed, large situated over Marma is Asādhya.
2) Chikitsā
- Sahachara Taila pāna
- Upanāha with Vātahara Dravya
- Basti karma
- Sirāvyadha
 Māṁsaja Granthi:
1) Lakṣaṇa
Snigdha, Mahānta, Kaṭhina, Sirānaddha (network of veins), Kaphākṛti (symptoms
of aggravated Kapha)
2) Chikitsā
Chedana, Rakta stambhana, Agnikarma
 Asthija Granthi:
Protuberant or depressed Granthi developing after a fracture or trauma. It may cause
displacement of bones. Asthija Granthi is Asādhya.
 Vraṇaja Granthi / Vraṇa Granthi

Vraṇa Granthi is a complication of a healing wound. It occurs when during the healing
process the patient follows Apathya Āhāra Vihāra, gets injured or the wound is not
properly treated/bandaged. Vāta prakopa occurs, leading to Rakta shoṣaṇa in the
Vraṇa causing Vraṇa Granthi with Lakṣaṇa such as Kaṇḍū, Dāhayukta & Utsedha.
Vraṇa Granthi is Kṛcchrasādhya. It is treated by Chedana followed by Agnikarma.
 Cyst
A cyst is a non-cancerous, sac-like structure filled with fluid, pus or gas. Cysts may occur
anywhere in the body and can vary in size from a microscopic dot to a larger one that
may even displace organs and tissue.
 Etiology:
Cysts are a common abnormality affecting people of all ages. There are different
types of cysts with a wide variety of causes. Some of the most common causes of
cyst formation are as follows:
- Obstruction to normal secretions of a particular organ (such as sebum glands)
- Infections (mostly parasitic infections)
- Tumors
- Genetic defects
- Cellular defects
- Injuries
- Chronic inflammatory conditions
- Embryonic development defect
 Types:
Some of the most common types of cyst include:
1) Acne cysts: Cystic acne, or nodulocystic acne, is a severe type of acne in which
the skin’s pores become blocked, leading to infection and inflammation.
2) Arachnoid cysts: Arachnoid cysts may affect newborn babies. The arachnoid
membrane covers the brain. During fetal development, it doubles up or splits
to form an abnormal pocket of cerebrospinal fluid.
3) Baker’s cysts: Baker’s cysts are also called popliteal cysts. A person with a
Baker’s cyst often experiences a bulge and a feeling of tightness behind the
knee. The pain may worsen when extending the knee or during physical
activity. Baker’s cysts usually develop due to a problem with the knee joint,
such as arthritis or a cartilage tear.
4) Bartholin’s cysts: Bartholin’s cysts can occur if the ducts of the Bartholin gland,
which are situated inside the vagina, become blocked.
5) Breast cysts: Breast cysts are common and may be painful, but they do not
usually require any treatment. In females, these cysts can develop or change in
size throughout the menstrual cycle, and they often disappear on their own.
6) Chalazion cysts: Very small eyelid glands, called meibomian glands, make a
lubricant that comes out of tiny openings in the edges of the eyelids. Cysts can
form there if the ducts are blocked. These are known as chalazion cysts.
7) Dermoid cysts: Dermoid cysts comprise mature skin, hair follicles, sweat
glands, and clumps of long hair, as well as fat, bone, cartilage, and thyroid
tissue.
8) Epididymal cysts: Epididymal cysts, or spermatoceles, form in the vessels

attached to the testes. This type of cyst is common and does not typically
impair fertility or require treatment.
9) Ganglion cysts: Ganglion cysts are small, harmless cysts that form on or near a
joint or covering of a tendon. They usually develop on the wrist but can also
appear on the hand, foot, ankle, or knee.
10) Hydatid cysts: Hydatid cysts develop due to a relatively small tapeworm. These
cysts form in the lungs or liver. Treatment options include surgery and
medication.
11) Ovarian cysts: Ovarian cysts are fluid-filled sacs that develop on one or both of
the ovaries. They may develop as a normal part of the reproductive cycle or be
pathologic. They may be asymptomatic or painful.
12) Pilonidal cysts: Pilonidal cysts form in the skin near the tailbone or lower back,
and they sometimes contain ingrown hair. These cysts can grow in clusters,
which sometimes creates a hole or cavity in the skin; pilonidial sinus.
13) Sebaceous cysts: Sebaceous cysts fill with sebum and are less common than
epidermoid cysts. They often form within sebaceous glands, which are part of
the skin and hair follicles. Ruptured or blocked sebaceous glands can lead to
sebaceous cysts.
14) Vocal fold cysts:

There are two types of vocal fold cyst: Mucus retention cysts and Epidermoid
cysts. Vocal fold cysts can interfere with the quality of a person’s speech,
sometimes causing their vocal cords to produce dipliphonia or dysphonia.
 Arbuda
That which causes harm and death is known as Arbuda.
Location, etiology, clinical features, involvement of Doṣa and Dushya, and treatment of
Granthi and Arbuda are identical. Arbuda is larger in size compared to Granthi.
 Lakṣana: वृिं क्स्थरं मन्त्दरुजं महान्त्तमनल्पमल

ू ं क्चरवृद्् यपाकम् ।
- Vṛtta (round)
- Sthira (stable / fixed)
- Mandaruja (mild pain)
- Mahānt (large)
- Analpamūla (deep seated roots)
- Chiravṛddhi (grows slowly)
- Apāka (never suppurates)
 Bheda:
1) Vātaja
2) Pittaja
3) Kaphaja
4) Raktaja
5) Māṁsaja
6) Medoja
1) Sādhya -> Vātaja, Pittaja, Kaphaja, Medoja
2) Asādhya -> Raktaja, Māṁsaja, Mahāmūla, Marmasthāna
 Adhyarbuda:
When an additional Arbuda grows over a pre-existing one, it is known as Adhyarbuda
or Dvandvaja Arbuda.
 Dvirarbuda:
When two Arbuda grow simultaneously or one soon after the other, it is known as
Dvirarbuda.
 Tumor
The National Cancer Institute defined a tumor as “an abnormal mass of tissue that
results when cells divide more than they should or do not die when they should.”
 Types:
1) Benign: These are not cancerous. They either cannot spread or grow, or they
do so very slowly.
2) Premalignant: In these tumors, the cells are not yet cancerous, but they have
the potential to become malignant.
3) Malignant: Malignant tumors are cancerous. The cells can grow and spread to
other parts of the body.
1) Benign Tumors
Most benign tumors are not harmful, and they are unlikely to affect other parts of the body.
However, they can cause pain or other complication if they press against nerves or blood
vessels or if they trigger the overproduction of hormones, as in the endocrine system.
Examples of benign tumors include:

Adenomas
Adenomas develop in glandular epithelial tissue, which is the thin membrane that covers
glands, organs, and other structures in the body.
Examples include:
- Polyps in the colon
- Fibroadenomas, a common form of benign breast tumor
- Hepatic adenomas, which occur on the liver
Adenomas do not start as cancer. However, some can become adenocarcinomas.
Fibroids
Fibroids, or fibromas, are benign tumors that can grow on the fibrous or connective tissue of
any organ.
They can be “soft” or “hard,” depending on the proportion of fibers to cells.

There are many types of fibroma, including:
- Angiofibromas, which can appear as small red bumps on the face
- Dermatofibromas, which appear on the skin, often on the lower legs
Some fibromas can cause symptoms and may need surgery. In rare cases, fibroids can
change and become fibrosarcomas, which are cancerous.
Hemangiomas
Hemangiomas are benign tumors that form when blood vessels grow excessively.
They can appear as red “strawberry marks” on the skin or they can develop inside the body.
They are often present at birth and disappear during childhood.
Hemangiomas do not usually require treatment, but laser surgery and other options are
available if they do not go away.
Lipomas
Lipomas are a form of soft tissue tumor and consist of fat cells. They can appear at any age
but often affect people from 40-60 years old.
Most lipomas are small, painless, rubbery, soft to the touch, and movable. They often
appear on the back, shoulders, arms, buttocks, and the tops of the legs.
2) Premalignant Tumors
These type of tumors are not cancerous, but need close monitoring in case they become
malignant.
Examples of premalignant tumors include:

Actinic keratosis
Also known as solar keratosis, this growth involves patches of crusty, scaly, and thick skin.
It is more likely to affect fair-skinned people, and sun exposure increases the risk.
Sometimes, actinic keratosis will transform into squamous cell carcinoma.
Cervical dysplasia
In cervical dysplasia, a change occurs in the cells that line the cervix. Abnormality is usually
detected during a Pap smear exam. Cervical dysplasia often stems from the human
papillomavirus (HPV).
The cells are not cancerous, but they may become malignant 10-30 years later, resulting in
cervical cancer.
Metaplasia of the lung

These growths occur in the bronchi, the tubes that carry air into the lungs. The lining of the
bronchi contains glandular cells. In some people, including smokers, these can change and
become squamous cells, or cancer.
Leukoplakia
Leukoplakia causes thick white patches to form in the mouth.
These patches are painless, have an irregular shape, are slightly raised, and are not possible
to scrape off.
3) Malignant Tumors
Cancer is a generic term for a large group of diseases that can affect any part of the body.
Other terms used are malignant tumor and neoplasm.
Properties of a malignant tumor are:

i) It grows in an unlimited, aggressive manner.
ii) It invades surrounding tissues.
iii) It does metastasis.
Metastasis is the spread of a disease from one organ / part to another non-adjacent organ /
part. The new tumor is called secondary or metastatic tumor. Its cells are like those of the
original tumor, so it is also named after the original type.
E.g.: Breast cancer -> Metastasis to lung -> Metastatic breast cancer in lung
Cancer is a leading cause of death worldwide. The most common causes of cancer death are
cancers of lung, liver, stomach, colon, rectum, breast & oesophagus.
Different types of malignant tumor originate in different types of cell.
Examples include:
i) Carcinoma: These tumors form from epithelial cells, which are present in the skin and the
tissue that covers or lines the body’s organs. Carcinomas can occur in the stomach, prostate,
pancreas, lung, liver, colon, or breast. They are a common type of malignant tumor.
ii) Sarcoma: These tumors start in connective tissue, such as cartilage, bones, fat, and
nerves. They originate in the cells outside the bone marrow. Most sarcomas are malignant.
iii) Germ cell tumor: These tumors develop in the cells that produce sperm and ova.
They usually occur in the ovaries or testicles, but they may also appear in the brain,
abdomen, or chest.
iv) Blastoma: These tumors form from embryonic tissue or developing cells. Blastomas are
much more common in children than in adults. They can lead to tumors in the brain, eye, or
nervous system.
Etiology:
Cancers are caused by abnormalities in the genetic material of the transformed cells.
i) Mutation: Chemical carcinogen
ii) Mutation: Ionizing radiation
iii) Viral or Bacterial Infection
iv) Hormonal imbalances
v) Immune system dysfunction
vi) Hereditary
vii) Other causes, such as trans-placental from mother to foetus, unhealthy diet
Risk factors:
Tobacco, Overweight, Obesity, Unhealthy diet, Lack of physical activity, Alcohol, Sexual
transmitted infection, Ionizing and non-ionizing radiation, Urban air pollution, Exposure to
indoor smoke from household use of solid fuels
Mode of spread:
- Blood stream
- Lymphatic drainage
- Both
- Direct spread
Signs & Symptoms:

i) Local
Unusual lump / swelling, haemorrhage, pain, ulceration, compression of surrounding tissues
ii) Metastatic
Enlarged lymph nodes, cough, haemoptysis, hepatomegaly, bone pain, fracture of affected
bone, neurological defects
iii) Systemic
Weight loss, poor appetite, fatigue, night sweats, anemia, etc.
Pathogenesis:
Causes -> Cell proliferation: uncontrolled & uncoordinated cell division or replication ->
Angiogenesis: new vascular tree grows to supply oxygen & nutrients to neoplastic cells ->
Growth: continuous cell proliferation leads to formation of lump / mass -> Metastasis ->
Growth: cell proliferation of secondary tumour
Diagnosis:
- Clinical observation
- Histopathological study or biopsy
- Radiological investigation
Treatment:
Primary treatment. The goal of a primary treatment is to completely remove the cancer
from the body or kill all the cancer cells.
Any cancer treatment can be used as a primary treatment, but the most common primary
cancer treatment for the most common types of cancer is surgery. If the cancer is
particularly sensitive to radiation therapy or chemotherapy, one of those therapies may be
chosen as primary treatment.
Adjuvant treatment. The goal of adjuvant therapy is to kill any cancer cells that may remain
after primary treatment in order to reduce the chance that the cancer will recur.
Any cancer treatment can be used as an adjuvant therapy. Common adjuvant therapies
include chemotherapy, radiation therapy and hormone therapy.
Palliative treatment. Palliative treatments may help relieve side effects of treatment or signs
and symptoms caused by cancer itself. Surgery, radiation, chemotherapy and hormone
therapy can all be used to relieve symptoms. Other medications may relieve symptoms such
as pain and shortness of breath.
Cancer treatment options include:
Surgery. The goal of surgery is to remove the cancer or as much of the cancer as possible.
Chemotherapy. Chemotherapy uses drugs to kill cancer cells.
Bone marrow transplant. A bone marrow transplant, also known as a stem cell transplant,
can use one’s own bone marrow stem cells or those from a donor. A bone marrow
transplant allows the use of higher doses of chemotherapy to treat cancer. It may also be
used to replace diseased bone marrow.
Radiation therapy. Radiation therapy uses high-powered energy beams, such as X-rays or
protons, to kill cancer cells. Radiation treatment can come from a machine outside the body
(external beam radiation), or it can be placed inside the body (brachytherapy).
Immunotherapy. Immunotherapy, also known as biological therapy, uses the body's
immune system to fight cancer. Cancer can survive unchecked in the body because the
immune system does not recognize it as an intruder. Immunotherapy can help the immune
system "see" the cancer and attack it.
Hormone therapy. Some types of cancer are fueled by the body's hormones. Examples
include breast cancer and prostate cancer. Removing those hormones from the body or
blocking their effects may cause the cancer cells to stop growing.
Cryoablation. This treatment kills cancer cells through extreme coldness. During
cryoablation, a thin, wand-like needle (cryoprobe) is inserted through the skin and directed
into the cancerous tumor. A gas is pumped into the cryoprobe in order to freeze the tissue.
Then the tissue is allowed to thaw. The freezing and thawing process is repeated several
times during the same treatment session in order to kill the cancer cells.
Radiofrequency ablation. This treatment uses electrical energy to heat cancer cells, causing
them to die. During radiofrequency ablation, a thin needle is guided into the cancer tissue.
High-frequency energy passes through the needle and causes the surrounding tissue to heat
up, killing the nearby cells.
CHAPTER Iii: Vrana
The word Vraṇa is derived from ‘Vraṇ’, which means ‘splitting’, ‘tearing’ or ‘wounding’.
Vraṇa is the condition where tissue is destroyed. Sometimes, even after complete healing,
Vraṇa leaves discolouration or a scar for life (Vraṇa Vastu).
Vraṇa is mainly of 2 types:

1) Nija / Shārīraja
2) Āgantuja
 Nija Vraṇa
Nija Vraṇa occur due to internal factors, which are the vitiated Sharīra Doṣa; Vāta, Pitta,
Kapha & Rakta.
 Saṁprāpti: Apathya Āhāra Vihāra -> Doṣa Duṣti -> Doṣa get lodged in Bahirmārga;
mainly in Tvak & Māṁsa -> Formation of Shopha -> Formation of Pūya -> Rupture
of skin -> Vraṇa
 Prakāra, Lakṣaṇa & Chikitsā: (According to Ā. Charaka)

A) Based on Doṣa: - 3
No. Prakāra Lakṣaṇa Chikitsā

1 Vātaja Stabdha, Kaṭhina sparsha, Mandasrāva, Saṁpūraṇa, Snehapāna
Atitīvra ruk, Sphurati, Shyāva varṇa
Snigdha Upanāha Svedana, Pradeha, Pariṣeka
2 Pittaja Tṛṣṇā, Moha, Jvara, Sveda, Dāha, Duṣṭi, Shīta Madhura Snigdha Pradeha, Parīṣeka
Avadāraṇa (burst / broken open)
Ghṛtapāna, Virechana
3 Kaphaja Picchila, Guru, Snigdha, Stimita, Kaṇḍū, Kaṣāya Kaṭu Rūkṣa Uṣṇa Pradeha, Pariṣeka
Mandavedana, Pāṇḍu varṇa, Alpakleda,
Chirakārī Laṅghana, Pāchana
B) Based on specific distinguishing factors: - 20 (Viṁshati Vraṇa)

1) Kṛtya (requires surgical intervetion) 2) Ukṛtya
3) Duṣṭa (impure) 4) Aduṣṭa
5) Marmasthita (located on Marma) 6) Na Marmasthita
7) Saṁvṛta (closed) 8) Vivṛta
9) Dāruṇa (hard) 10) Mṛdu
11) Srāvī (with discharge) 12) Asrāvī
13) Viṣayukta (poisonous) 14) Viṣarahita
15) Viṣamasthita (irregularly located) 16) Samasthita
17) Utsaṅgī (deeply rooted) 18) Anutsaṅgī
19) Utsanna (elevated) 20) Anutsanna
 Prakāra: (According to Ā. Sushruta & Ā. Vāgbhaṭa)
1) Vātaja 6) Vāta-Kaphaja 11) Vāta-Pitta-Raktaja
2) Pittaja 7) Vāta-Raktaja 12) Vāta-Kapha-Raktaja
3) Kaphaja 8) Pitta-Kaphaja 13) Pitta-Kapha-Raktaja
4) Raktaja 9) Pitta-Raktaja 14) Vāta-Pitta-Kaphaja
5) Vāta-Pittaja 10) Kapha-Raktaja 15) Vāta-Pitta-Kapha-Raktaja
-> Sāmānya Lakṣaṇa = Ruk
-> Vraṇa Avasthā

 Duṣṭa Vraṇa: (Vitiated wound)
Vraṇa in a patient who does not control his/her Indriyas, or who follows Mithya
Āhāra Vihāra, or even if Pathya is followed but wrong treatment is applied by the
physician, such a Vraṇa will become severely vitiated difficult to treat; this is known
as Duṣṭa Vraṇa.
Bheda & Lakṣaṇa:

A) According to Ā. Charaka – 12 types of Duṣṭa Vraṇa based on Lakṣaṇa
1) Shveta (White) 7) Atipiḍikā (Covered with boils)
2) Avasanna Vartma (Depressed) 8) Rakta (Red)
3) Atisthūla Vartma (Elevated) 9) Kṛsṇa (Black)
4) Atipiñjara (Excessively grey) 10) Atipūtika (Excessive foul smell)
5) Nīla (Blue) 11) Aropya (Non-healing)
6) Shyāva (Blackish) 12) Kumbhī Mukha (Narrow opening)
B) According to Ā. Sushruta
Bheda: Vātaja, Pittaja, Kaphaja, Raktaja, Sannipātaja, Āgantuja
Lakṣaṇa:
- Atisaṁvṛta or Ativivṛta
- Atikaṭhina or Atimṛdu
- Utsanna or Avasanna
- Atishīta or Atyuṣṇa
- Kṛṣṇa, Rakta, Pīta, Shukla, etc.
- Gandhātyartha
- Ati Dāha, Pāka, Rāga, Kaṇḍū, Shopha, Piḍakā, Vedana
- Pūtipūya srāva
- Duṣṭa Shoṇita srāva
- Unmārgī
- Utsaṅgī
- Dīrghakāla anubandhī
 Shuddha /Prashastra Vraṇa: (Clear wound)
Shuddha Vraṇa is the wound which is produced without vitiated Doṣa; it is
generally caused by a surgical incision. These type of Vraṇa do not require specific
treatments but should be protected from contamination.
Lakṣaṇa: Mṛdu, Shlakṣṇa, Snigdha, Nātirakta, Nātipāṇḍu, Nātishyāva, Nātiruk,

Na Utsanna, Na Utsaṅgī, Ropya
 Ruhyamāna / Rohī Vraṇa: (Healing wound)

- Kapota varṇa pratimā (colour like a pigeon; grey)
- Kleda varjita (devoid of moisture/exudation)
- Sthira Chipiṭikāvanta (flakes of skin adhering firmly)
 Samyak Rūdha Vraṇa: (Healed wound)

- Agranthi
- Ashūna (no swelling)
- Aruja
- Tvak varṇa
-> Vraṇa Parīkṣā

Following factors of Vraṇa should be examined - Sthāna (location), Akṛti (shape), Gandha
(smell), Srāva (discharge/exudate), Vedanā (pain).
 Vraṇa Sthāna / Vraṇa Vāstu / Aṣṭa Parigraha:

No. Ā. Charaka Ā. Sushruta
1 Tvak Āshraya Tvakgata Vraṇa
2 Sirā Sirā
3 Māṁsa Māṁsa
4 Medas Snāyu
5 Asthi Asthi
6 Snāyu Sandhi
7 Marma Koṣṭha
8 Antara / Koṣṭhāshrita Marma
 Vraṇa Akṛti:
1) Āyata (Rectangular)
2) Chaturasra (Quadrangular)
3) Vṛtta (Circular)
4) Tripuṭaka (Triangular)
If Vraṇa has other shapes, it is difficult to treat.
 Aṣṭa Vraṇa Gandha:
A) According to Ā. Charaka
1) Sarpi 5) Rakta
2) Taila 6) Shyāva
3) Vasā 7) Amla
4) Pūya 8) Pūtika
B) Based on Doṣa
1) Vātaja -> Kaṭu 5) Vāta-Pittaja -> Lāja
2) Pittaja -> Tīkṣṇa 6) Vāta-Kaphaja -> Atasī taila
3) Kaphaja -> Visra 7) Pitta-Kaphaja -> Tila taila
4) Raktaja -> Loha 8) Sannipātaja -> Mixed
 Vraṇa Srāva:
A) According to Ā. Charaka
1) Lasīka 8) Kaṣāya
2) Jala 9) Nīla
3) Pūsa / Pūya 10) Harita
4) Asṛk / Rakta 11) Snigdha
5) Haridrā 12) Rūkṣa
6) Aruṇa 13) Sita
7) Piñjara 14) Asita
B) Based on Doṣa
1) Vātaja -> Srāva is Paruṣa, Shyāva, resembles Dadhimastu, Kṣārodaka, etc.
2) Pittaja -> Srāva is Uṣṇa, resembles Gomūtra, Bhasma, Kaṣāyodaka, etc.
3) Kaphaja -> Srāva is Shīta, resembles Navanīta, Majjā, Narikelodaka, etc.
4) Sannipātaja -> Srāva resembles Kāñjī, Shuddha Jala, Mudgayūṣa, etc.
C) Based on Vraṇa Sthāna

1) Tvakgata Vraṇa -> Srāva resembles water with mild bad smell and yellow color
2) Sirāgata Vraṇa -> Srāva will be thin, discontinuous, slimy, adhering
3) Māṁsagata Vraṇa -> Srāva resembles Ghṛta which is dense, whitish and sticky
4) Snāyugata Vraṇa -> Srāva will be unctuous, thick and mixed with blood
5) Asthigata Vraṇa -> Srāva will be unctuous, mixed with Majjā and Rakta
6) Sandhigata Vraṇa -> Srāva will be slimy, sticky and mixed with blood. It only
occurs due to any movement of the affected joint.
7) Koṣṭhagata Vraṇa -> Srāva will be mixed with blood, urine, faeces, pus, water
8) Marmagata Vraṇa -> Not mentioned separately as they are included under
Tvaksthita Vraṇa
 Vraṇa Vedanā:
1) Vātaja -> Todana (pricking pain), Bhedana (breaking pain), Chedana (cutting
pain), Tāḍana (beating pain), Āyāmana (stretching pain), Manthana
(drilling pain), Vikṣepaṇa (moving pain), Chumuchumāyana
(irritating/itching pain), Avabhañjana (tearing pain), Sphoṭana (bursting
pain), Vidāraṇa (crushing pain), Kampana (cramping/trembling pain)
2) Pittaja -> Oṣa (local burning pain), Choṣa (sucking pain), Paridāha (general
burning sensation), Uṣma vṛddhi (increased temperature), Kṣāravat
Siktavat Kṣata (pain as if injured by caustic substance or hot liquid)
3) Kaphaja -> Kaṇḍū, Gurutva, Suptatva, Alpavedanā, Stambhana, Shaitya

4) Raktaja -> Same as Pittaja
5) Sannipātaja -> Mixture of VPK
6) Duṣṭa Vraṇa -> Ativedanā due to excessive vitiated Doṣa
7) Upadrava -> Ā. Sushruta classified complications related to Vraṇa into:
1) Vraṇita Upadrava (generalized complications)
2) Vraṇa Upadrava (local complications)
-> Upadrava
 According to Ā. Sushruta – Vraṇita Upadrava: - 10
Jvara, Atisāra, Mūrcchā, Hikkā, Chardi, Arochaka, Shvāsa, Kāsa, Avipāka, Tṛṣṇā
 According to Ā. Charaka: - 16
Visarpa, Pakṣaghāta, Sirāstambha, Apatānaka, Moha, Unmāda, Vraṇaruja, Jvara,
Tṛṣṇā, Hanugraha, Kāsa, Chardi, Atisāra, Hikkā, Shvāsa, Vepathu
-> Vraṇa Doṣa

Vraṇa Doṣa are 24 factors which hinder the healing process of a wound.
1) Snāyu kleda (sloughing of ligaments) 13) Atisneha

2) Sirā kleda (sloughing of blood vessels) 14) Atibhaiṣajya karṣaṇa
3) Gambhīra (deep seated wound) 15) Ajīrṇa
4) Kṛmi bhakṣaṇa (maggots) 16) Atibhukta
5) Asthi bheda (bone fracture) 17) Viruddha bhojana
6) Sashalyatva (foreign body) 18) Asātmya bhojana
7) Saviṣatva (poison) 19) Shoka
8) Sarpaṇa (spreading ulcer) 20) Krodha
9) Nakha Kāṣṭha prabheda (splinter of nails or wood) 21) Divāsvapna
10) Charma atighaṭṭa (excessively touched by skin) 22) Vyāyāma
11) Loma atighaṭṭan (excessively touched by hair) 23) Maithuna
12) Mithya bandha (improper bandage) 24) Niṣkriyātva (negligence)
 Vraṇa Chikitsā
 Ṣaṣṭi Upakrama:
Ṣaṣṭi Upakrama are 60 types of remedies which can be adopted for Vraṇa Chikitsā.
1) Apatarpaṇa 21) Sandhāna 41) Pāṇḍukarma

2) Ālepa 22) Pīḍana 42) Pratisaraṇa
3) Pariṣeka 23) Shoṇita sthāpana 43) Romasañjanana
4) Abhyaṅga 24) Nirvāpaṇa 44) Romāpaharaṇa
5) Sveda 25) Utkārikā 45) Basti
6) Vimlāpana 26) Kaṣāya 46) Uttarabasti
7) Upanāha 27) Varti 47) Bandha
8) Pāchana 28) Kalka 48) Patradāna
9) Visrāvana 29) Sarpi (Siddha) 49) Kṛmighna
10) Sneha 30) Taila (Siddha) 50) Bṛmhaṇa
11) Vamana 31) Rasakriyā 51) Viṣaghna
12) Virechana 32) Avachūrṇana 52) Shirovirechana
13) Chedana 33) Vraṇa dhūpana 53) Nasya
14) Bhedana 34) Utsādana 54) Kavala
15) Dāraṇa 35) Avasādana 55) Dhūmapāna
16) Lekhana 36) Mṛdukarma 56) Madhu
17) Eṣaṇa 37) Dāruṇakarma 57) Sarpi
18) Āharaṇa 38) Kṣārakarma 58) Yantra
19) Vyadhana 39) Agnikarma 59) Āhāra
20) Sīvana 40) Kṛṣṇakarma 60) Rakṣavidhāna
1-12 = Vraṇa Shopha Chikitsā

13-20 = Pūya Bhedana & Visrāvana
21-34 = Vraṇa Shodhana & Ropaṇa
35-60 = To remove any residual Doṣa & to prevent recurrence
-> Refer to Sushruta Saṁhitā, Chikitsā Sthāna, Adhyāya 1

 Vraṇitopāsanīya:
Vraṇitopāsanīya is the care of the patient who was afflicted with Vraṇa.
1) Vraṇitagāra
Vraṇitagāra is the ward of the patient. It should be clean (Shuchi), devoid from
exposure to direct sunlight (Ātapa varjita) and wind (Nivāta). The bed (Shayya)
should be comfortable with its headend directed towards east. A patient who
is suffering from pain and misery should be consoled and distracted by friends
and family.
Dhūpa should be performed twice a day for Rakṣakarma. It is done with
following Drayya: Sarṣapa, Ariṣṭapatra, Ghṛta, Lavaṇa or with Nimba Vachādya
2) Pathya
Āhāra: Alpamātra of porridge prepared from Purāṇa Shāli with Sneha Dravya.
Yūṣa prepared from Taṇḍulīya, Jīvantī, Suniṣaṇṇaka, Vastuka, Balāmūla,
Vartaka, Paṭola, Karavellaka fried in Ghṛta and added with Saindhava lavaṇa.
Yava, Godhūma, Ṣaṣṭika, Mudga, Dāḍima
Vihāra: Vishrama, Dhūpa, Shirodhārā, Ātapa-Māruta varjana
3) Apathya
Āhāra: Navadhānya, Māṣa, Tila, Kalāya (peanut), Kulattha, Niṣpāva, Haritaka
shāka, Shuṣka shāka, Amla-Lavaṇa-Kaṭu Rasa, Guḍa, Shītodaka, Piṣṭika, Pāyasa,
Dadhi, Dugdha, Takra, Madya, Ariṣṭa, Āsva, Sidhu, Surā, Anūpa-Udaka māṁsa
Vihāra: Chaṅkramaṇa, Vyāyāma, Divāsvapna, Rātrijāgaraṇa, Maithuna,

Ātapa-Māruta sevana
 Āgantuja Vraṇa & Sadyovraṇa
Āgantuja Vraṇa occur due to external factors. Sadyovraṇa is the specific term used to
describe wounds due to injuries.
 Nidāna:
Āgantuja Vraṇa can be caused by:
- Vadha (striking)
- Bandha (binding)
- Prapatana (falling down)
- Daṁṣṭrā (fangs / stings)
- Danta (teeth)
- Nakha (nails)
- Viṣa (poison)
- Agni (fire)
- Kṣāra (caustics)
- Shastra (sharp weapons / instruments)
- Āshma (stones)
- Kāṣṭha (wood)
- Etc.
 Prakāra: (Ā. Sushruta)

1) Chinna (incised / excised injury / cut wound)
2) Bhinna (penetrating / perforating injury to a cavity)
3) Viddha (punctured injury)
4) Kṣata (lacerated wound)
5) Picchita (crushed wound / contusion / bruise)
6) Ghṛṣṭa (abrased wound)
1) Chinna Vraṇa
Chinna Vraṇa is an extensive wound due to a sharp edge, either oblique or
straight, associated with separation of a part of the body.
2) Bhinna Vraṇa
Bhinna Vraṇa is an injury to a body cavity which leads to escape of fluids.
Koṣṭha Bhinna Lakṣaṇa:

- When Koṣṭha is injured, it gets filled with Rakta.
- Rakta may escape through urethra, anus, mouth or nose.
- Dāha, Jvara, Mūrcchā, Shvāsa, Tṛṣṇā, Annadveṣa
- Vāta-Viṭ-Mūtra saṅga
- Atisveda, Akṣiraktatā, Āsasya Loha-gandha
- Gātra daurgandhya
- Hrt-Pārsvha shūla
Āmāshaya Bhinna Lakṣaṇa:
- When Āmāshaya is injured, it gets filled with Rakta.
- Rudhira Chardi (repeated haematemesis)
- Atimātra Ādhmāna (severe abdominal distension)
- Bṛshadāruṇa Shūla (excruciating abdominal pain)
Pakvāshaya Bhinna Lakṣaṇa:

- When Pakvāshaya is injured, it gets filled with Rakta.
- Rakta may escape from any of the orifices.
- Ruja, Gaurava, Shītatā
3) Viddha Vraṇa
Viddha Vraṇa is a punctured wound by a pointed object at any other part than
body cavities. The foreign body may either remain inside the injured site or has
pierced through and completely come out at the other end.
4) Kṣata Vraṇa
Kṣata Vraṇa is neither a cut nor a perforation, but it is in between Chinna and
Bhinna Vraṇa.
5) Picchita Vraṇa
Picchita Vraṇa is the injury due to a severe blow or pressure.
It is of 2 types:
i) Savraṇa -> the body part gets compressed and a wound is formed, similar to
a laceration.
ii) Avraṇa -> the body part gets compressed but there is no open wound;
blood capillaries are damaged and form a contusion.
6) Ghṛṣṭa Vraṇa
Ghṛṣṭa Vraṇa is the wound in which skin is removed by rubbing or any similar
cause. It is associated with burning sensation and discharge.
 Sadyovraṇa Chikitsā: (Bhaiṣajya Ratnāvalī)

- Yaṣṭīmadhu Kalka mixed with slighty warmed Ghṛta is applied.
- Pariṣeka with Apāmārga svarasa to stop bleeding.
- Application of Karpūra Ghṛta and bandaging the wound to promote healing.
- Vraṇa Chikitsā
 Sadyovraṇa Upadrava:
- Kotha (gangrene)
- Visarpa (erysipals)
- Uttiya Shopha (cellulitis)
- Dhanustambha (tetanus)
- Jalaka Vraṇa (actinomycosis)
Gangrene is death of body tissue due to a lack of blood flow or a serious bacterial infection.
Gangrene commonly affects the arms and legs, including the toes and fingers, but it can also
occur in the muscles and in organs inside the body.
Erysipelas is a bacterial skin infection involving the upper dermis that characteristically
extends into the superficial cutaneous lymphatics. It is a tender, intensely erythematous,
indurated plaque with a sharply demarcated border.
Cellulitis is a common, potentially serious bacterial skin infection. The affected skin appears
swollen and red and is typically painful and warm to the touch. Cellulitis usually affects the
skin on the lower legs, but it can occur in the face, arms and other areas.
Tetanus is an infection caused by bacteria called Clostridium tetani. When the bacteria
invade the body, they produce a poison (toxin) that causes painful muscle contractions.
Another name for tetanus is “lockjaw”. It often causes a person's neck and jaw muscles to
lock, making it hard to open the mouth or swallow.
Actinomycosis is a long-term infection that causes sores, or abscesses, in the body's soft
tissues. Actinomycosis is usually found in the mouth.
 Wound
A wound by true definition is a breakdown in the protective function of the skin; the loss
of continuity of epithelium, with or without loss of underlying connective tissue (i.e.
muscle, bone, nerves) following injury to the skin or underlying tissues/organs caused by
surgery, a blow, cut, sting, bite, chemicals, heat, cold, friction, shear force, pressure or as
a result of disease, such as leg ulcers or carcinomas.
 Etiology:
1) Mechanical agents can cause a wound by trauma through a blow, a fall or
other forms of pressure. The mechanical agent may be sharp or blunt.
E.g.: Knifes, hammer, firearms, broken glass, traffic/machinery accidents, etc.
2) Chemical agents in the form of strong acids or alkalis can cause chemical
injuries in case of direct exposure.
E.g.: Hydrofluoric acids, formic acid, anhydrous ammonia, phenol, etc.
3) Radioactive agents like x-rays, gamma rays, ionizing radiations have the
capacity to incite inflammatory reactions within the exposed tissue. Excessive
exposure leads to injury of the tissue and causes radation injuries.
4) Pathogentic agents such as bacteria are capable to initiate inflammatory

processes. They may not only act as a primary agent; instead they often enter
the body after a mechanical injury occurred. The pathogenic agents attack the
local tissue and are capable of provoking necrosis or to invade the entire body.
 Classification of Wounds:
1) Open or Closed -> Open wounds are the wounds with exposed underlying
tissue/organs and open to the outside environment. On the other hand, closed
wounds are the wounds that occur without any exposure to the underlying
tissue and organs.
2) Acute or Chronic -> A wound can be classified as acute or chronic depending

on the healing time. Acute wounds are those that heal without any
complications in a predicted amount of time. While chronic wounds, on the
other hand, are those that take a relatively long time to heal with some
complications.
3) Clean or Contaminated -> Clean wounds are those that do not have any
foreign material or debris inside whereas contaminated wounds or infected
wounds are those that might have some dirt, bacteria, or other foreign agents.
4) Internal or External -> Internal wounds can be due to impaired circulation,

nervous system functions, neuropathy or medical illness, or decreased supply
of blood, oxygen, or other nutrients. External wounds can be due to an outside
force or trauma caused by penetrating objects or non-penetrating trauma.
a) Penetrating Wounds: They are the result of trauma and break through the
full thickness of the skin, including: Stab wounds, Cuts, Surgical wounds, etc.
b) Non-penetrating Wounds: These wounds are the result of blunt trauma or

friction with other surfaces, including: Abrasions, Lacerations, Contusions, etc.
 Closed Wounds
Closed wounds are the wounds that occur without any exposure to the underlying tissue
and organs.
 Causes:
Closed wounds are usually caused by direct blunt trauma sustained when falling
down or in motor vehicle accidents. Even with the skin intact, the damage can
reach down to the underlying muscle, internal organs and bones. Crush wounds
can sometimes be caused by heavy falling objects, such as might happen in a car
accident or collapsing building.
 Types:
1) Contusions/Bruises: These are a common type of sports injury, where a direct
blunt trauma can damage the small blood vessels and capillaries, muscles and
underlying tissue, as well the internal organs and, in some cases, bone.
Contusions present as a painful bruise with reddish to bluish discoloration that
spreads over the injured area of skin.
2) Haematomas: These include any injury that damages the small blood vessels
and capillaries resulting in blood collecting and pooling in a limited space.
Hematomas typically present as a painful, spongey rubbery lump-like lesion.
Hematomas can be small or large, deep inside the body or just under the skin;
depending on the severity and site of the trauma.
3) Crush injuries: These are usually caused by an external high pressure force
that squeezes part of the body between two surfaces. The degree of injury and
pain can range from a minor bruise to a complete destruction of the crushed
area of the body, depending on the site, size, duration and power of the
trauma.
 Complications:
Closed wounds can be complicated due to severe bleeding, large bruises, nerve
damage, bone fractures and internal organ damage. However, the most serious
complication of closed wounds is known as the compartment syndrome. This
syndrome involves the lower and/or upper limbs (especially the legs and forearms),
where the damage causes swelling and increased pressure in the fascia that
surrounds the muscles, nerves and blood vessels in that area. The increased
pressure can block the blood supply to the affected limbs, causing severe damage
to the muscles and nerves. The damage can be permanent, leading to loss of
function, and may necessitate amputation.
 Management:
In closed wounds, the main goal of treatment is to control the pain, and keep the
bleeding and inflammation to a minimum. This is done by using ice packs,
compression, elevation and immobilization of the affected limb or area.
However, in cases of compartment syndrome, a physician can make linear surgical
cuts through the fascia to alleviate the pressure. The wound is usually left open for
two to three days while covered with a sterile bandage to allow the swelling to
subside and prevent further pressure from building up.
X-ray can be used for diagnosis if bone fracture is suspected. Fractures generally
require casting. In cases of severe trauma, other forms of imaging may be used.
These include ultrasound, CT scan and MRI, which can detect organ damage and
internal bleeding.
Topical antibiotic ointment may be applied locally to wounds in cases of associated

skin lacerations and abrasions.
The use of crutches and other walking aids may be prescribed to immobilize the
injured limb or area. These can be especially helpful for injuries to weight bearing
sites, to prevent further damage, reduce pain and accelerate healing. A tetanus
shot, painkillers and anti-inflammatory medications can also be helpful.
 Open Wounds
Open wounds are the wounds with exposed underlying tissue/organs and open to the
outside environment.
 Causes: Falls, accidents with sharp objects, and car accidents are the most common
causes of open wounds.
 Types:
1) Abrasions: An abrasion is an injury to the skin, resulting from scraping away of
the superficial layers of the skin. Depending on the manner in which abrasions
are caused, they are classified into:
Scratch, Graze, Pressure abrasion, Impact abrasion
2) Laceration: Laceration / Lacerated wound is one in which the skin and

sometimes the deeper tissues are torn or lacerated as a result of blunt
violence. It is the result of tearing or stretching of tissues. The edges of
lacerated wounds are irregular. Laceration is of 4 types:
Split-lacerations, Stretch-lacerations, Avulsions, Tears
3) Puncture wounds: A puncture is a small hole caused by a pointy object, such
as a nail or needle. Punctures may not bleed much, but these wounds can be
deep enough to damage internal organs.
When a puncture wound enters into tissue, it is called a penetrating wound.
When a puncture wound pierces through, it is called a perforating wound.
4) Incised wound: Incised wounds are produced by objects having sharp cutting
edge such as a knife, razor, etc.
An incised wound can be caused by three ways:
a) Striking
b) Drawing
c) Sawing
5) Firearm wound: Firearm wounds / Gun-shot wounds are produced by

projectiles discharged from firearms and present the general characteristics of
lacerated wounds, but the character varies according to the:
- Nature of the projectile.
- Velocity of the projectile at the moment of impact.
- Distance of the fire-arm from the body at the time of discharge.
- Angle at which it struck the body.
 Management:
Minor or acute open wounds may not require medical treatment or only home
remedies. However, severe open wounds that involve significant bleeding will
require immediate medical attention.
Open wound care should involve the following steps:

1) Stop the bleeding: Using a clean cloth or bandage, gently apply pressure to the
wound to promote blood clotting.
2) Clean the wound: Use clean water and a saline solution to flush away any debris
or bacteria. Once the wound is clean, pat it dry with a clean cloth. Surgical
debridement may be required to remove debris from severe wounds that contain
dead tissue, glass, bullets, or other foreign objects.
3) Treat the wound with antibiotics: After cleaning the wound, apply a thin layer of
antibiotic ointment to prevent infection.
4) Close and dress the wound: Closing clean wounds helps promote faster healing.
Waterproof bandages and gauze work well for minor wounds. Deep open wounds
may require stitches or staples. However, leave an already infected wound open
until the infection clears.
5) Routinely change the dressing: The Centers for Disease Control and Prevention
(CDC) recommend removing the old bandages and checking for signs of infection
every 24 hours. Disinfect and dry the wound before reapplying a clean adhesive
bandage or gauze. Remember to keep the wound dry while it heals.
 Stages of Wound Healing
The stages of wound healing proceed in an organized way and follow four processes:
hemostasis, inflammation, proliferation and maturation. Although the stages of wound
healing are linear, wounds can progress backward or forward depending on internal and
external patient conditions.
1) Hemostasis Phase
Hemostasis is the process of the wound being closed by clotting. Hemostasis starts when
blood leaks out of the body. The first step of hemostasis is when blood vessels constrict
to restrict the blood flow. Next, platelets stick together in order to seal the break in the
wall of the blood vessel. Finally, coagulation occurs and reinforces the platelet plug with
threads of fibrin which are like a molecular binding agent. The hemostasis stage of
wound healing happens very quickly. The platelets adhere to the sub-endothelium
surface within seconds of the rupture of a blood vessel's epithelial wall. After that, the
first fibrin strands begin to adhere in about sixty seconds. As the fibrin mesh begins, the
blood is transformed from liquid to gel through pro-coagulants and the release of
prothrombin. The formation of a thrombus or clot keeps the platelets and blood cells
trapped in the wound area. The thrombus is generally important in the stages of wound
healing but becomes a problem if it detaches from the vessel wall and goes through the
circulatory system, possibly causing a stroke, pulmonary embolism or heart attack.
2) Inflammatory Phase
Inflammation is the second stage of wound healing and begins right after the injury when
the injured blood vessels leak transudate (made of water, salt, and protein) causing
localized swelling. Inflammation both controls bleeding and prevents infection. The fluid
engorgement allows healing and repair cells to move to the site of the wound. During the
inflammatory phase, damaged cells, pathogens, and bacteria are removed from the
wound area. These white blood cells, growth factors, nutrients and enzymes create the
swelling, heat, pain and redness commonly seen during this stage of wound healing.
Inflammation is a natural part of the wound healing process and only problematic if
prolonged or excessive.
3) Proliferative Phase
The proliferative phase of wound healing is when the wound is rebuilt with new tissue
made up of collagen and extracellular matrix. In the proliferative phase, the wound
contracts as new tissues are built. In addition, a new network of blood vessels must be
constructed so that the granulation tissue can be healthy and receive sufficient oxygen
and nutrients. Myofibroblasts cause the wound to contract by gripping the wound edges
and pulling them together using a mechanism similar to that of smooth muscle cells. In
healthy stages of wound healing, granulation tissue is pink or red and uneven in texture.
Moreover, healthy granulation tissue does not bleed easily. Dark granulation tissue can
be a sign of infection, ischemia, or poor perfusion. In the final phase of the proliferative
stage of wound healing, epithelial cells resurface the injury. It is important to remember
that epithelialization happens faster when wounds are kept moist and hydrated.
Generally, when occlusive or semiocclusive dressings are applied within 48 hours after
injury, they will maintain correct tissue humidity to optimize epithelialization.
4) Maturation Phase
Also called the remodeling stage of wound healing, the maturation phase is when
collagen is remodeled from type III to type I and the wound fully closes. The cells that
had been used to repair the wound but which are no longer needed are removed by
apoptosis, or programmed cell death. When collagen is laid down during the proliferative
phase, it is disorganized and the wound is thick. During the maturation phase, collagen is
aligned along tension lines and water is reabsorbed so the collagen fibers can lie closer
together and cross-link. Cross-linking of collagen reduces scar thickness and also makes
the skin area of the wound stronger. Generally, remodeling begins about 21 days after an
injury and can continue for a year or more. Even with cross-linking, healed wound areas
continue to be weaker than uninjured skin, generally only having 80% of the tensile
strength of unwounded skin.
The stages of wound healing are a complex and fragile process. Failure to progress in the
stages of wound healing can lead to chronic wounds. Factors that lead up to chronic
wounds are venous disease, infection, diabetes and metabolic deficiencies of the elderly.
Careful wound care can speed up the stages of wound healing by keeping wounds moist,
clean and protected from reinjury and infection.
 Bites & Stings
Stings and bites from insects are common. They often result in redness and swelling in
the injured area. Sometimes a sting or bite can cause a life-threatening allergic reaction
or transmit pathogens (viruses, bacteria, or parasites) to humans.
 Causes:
Most insects do not usually attack humans unless they are provoked. Many bites
and stings are defensive. Insects sting to protect their hives or nests or when
incidentally touched or disturbed.
A sting or bite injects venom composed of proteins and other substances that may
trigger an allergic reaction in the victim. The sting also causes redness and swelling
at the site of the sting.
Bees, wasps, hornets, yellow jackets, and fire ants are members of the
Hymenoptera family. Bites or stings from these species may cause serious reactions
in people who are allergic to them.
When a bee stings, it loses the entire injection apparatus (stinger) and actually dies
in the process.
A wasp can inflict multiple stings because it does not lose its injection apparatus
after it stings.
Fire ants inject their venom by using their mandibles (the biting parts of their jaw)
and rotating their bodies. They may inject venom many times.
Puss caterpillars have hollow "hairs" or spines (setae) that break when touched and
the toxin is injected into the skin.
In contrast, bites from mosquitoes are not defensive; mosquitoes are looking to get
blood for a meal.
Typically, most mosquitoes do not cause significant illnesses or allergic reactions
unless they convey "vectors," or pathogenic microorganisms that live within the
mosquitoes.

The response to a sting or bite is variable and depends on a variety of factors.
Most bites and stings result in pain, swelling, redness, itching, or blister.
The skin may be broken and become infected. If not treated properly, these local
infections may become severe and cause a condition known as cellulitis.
Symptoms of a severe reaction include hives, wheezing, shortness of breath,
unconsciousness, and even death within 30 minutes.
Stings from large hornets or multiple (hundreds or thousands) bee stings have been
reported to cause muscle breakdown and kidney failure and death.
Bites from a fire ant typically produce a pustule, or a pimple-like sore, that is
extremely itchy and painful.
Spider bites like the brown recluse may cause blistering and necrotic skin ulceration
while black widow spider bites cause more systemic symptoms such as abdominal
pain, nausea, vomiting, chest pain and rarely, respiratory problems.
Ant bites are usually seen singly or in small clusters and each bite may develop a
small central area of pus.
 Home Remedies:
Treatment depends on the type of reaction to the bite or sting. If there is only
redness and pain at the site of the bite, application of ice is adequate treatment.
Clean the area with soap and water to remove contaminated particles left behind
by some insects. These particles may further contaminate the wound if not
removed. Refrain from scratching the bite or sting area because this may cause the
skin to break down and an infection to form. Intermittent cold packs or ice may
reduce swelling.
Itching at the site of the bite may be treated with an over-the-counter
antihistamine such as diphenhydramine (Benadryl) in cream or pill form. Calamine
lotion also helps relieve the itching.
People who have a history of severe reactions to bites or stings may have been
prescribed an anaphylaxis kit (n kit). The kit contains an epinephrine injector,
tourniquet, and an antihistamine. The treatment should be followed by an
evaluation in an emergency department to be sure the person recovers completely.
 Medical Treatment:
Treatment for serious reactions to stings or bites may begin with epinephrine
(subcutaneous); diphenhydramine (Benadryl) and steroids (drugs in the cortisone
family) are also usually given IV. Oral antibiotics may be given for infected bite
wounds. For seriously ill people, an IV will be started, oxygen given, and a heart
monitor used until the symptoms have improved with medications.
For those bites and stings that lead to transmission of pathogenic organisms, the
next step is to see health care professionals to obtain a definitive diagnosis so
appropriate treatment(s) may be done.
The patient may be referred to an allergist for desensitization therapy. After testing
to determine which venom the person is sensitive to, gradually increased doses of
venom are injected over time. Desensitization is usually effective in preventing a
severe reaction to future stings.
 Burns & Scalds (Dagdha Vraṇa)
Burns and scalds are damage to the skin caused by heat.
A burn is caused by dry heat whereas a scald is caused by wet heat.
 Classification of Burns:
Burns are classified as first-, second-, third-degree, or fourth-degree depending on
how deeply and severely they penetrate.
1) First-degree (superficial) burns. First-degree burns affect only the outer layer
of skin, the epidermis. The burn site is red, painful, dry, and without blisters.
Long-term tissue damage is rare, but may consist of an increase or decrease in
the skin color.
2) Second-degree (partial thickness) burns. Second-degree burns involve the

epidermis and part of the lower layer of skin, the dermis. The burn site looks
red, blistered, and may be swollen and painful.
3) Third-degree (full thickness) burns. Third-degree burns destroy the epidermis

and dermis. They may go into the innermost layer of skin, the subcutaneous
tissue. The burn site may look white or blackened and charred.
4) Fourth-degree burns. Fourth-degree burns go through both layers of the skin

and underlying tissue as well as deeper tissue, possibly involving muscle and
bone. There is no feeling in the area since the nerve endings are destroyed.
 Surface Area:
In addition to the depth of the burn, the total surface area of the burn is significant.
Burns are measured as a percentage of total body area affected. The "rule of nines"
is often used. This calculation is based upon the fact that the surface area of the
following parts of an adult body each correspond to approximately 9% of total (and
the total body area of 100% is achieved):
- Head = 9%
- Chest (front) = 9%
- Abdomen (front) = 9%
- Upper/mid/low back and buttocks = 18%
- Each arm = 9%
- Each palm = 1%
- Groin = 1%
- Each leg = 18% total (front = 9%, back = 9%)
As an example, if both legs (18% x 2 = 36%), the groin (1%) and the front chest and
abdomen were burned, this would involve 55% of the body.
Only second- and third-degree burn areas are added together to measure total
body burn area. While first-degree burns are painful, the skin integrity is intact and
it is able to do its job with fluid and temperature maintenance.
If more than 15-20% of the body is involved in a burn, significant fluid may be lost.
Shock may occur if inadequate fluid is not provided intravenously. As the
percentage of burn surface area increases, the risk of death increases as well.
Patients with burns involving less than 20% of their body should do well, but those
with burns involving greater than 50% have a significant mortality risk, depending
upon a variety of factors, including underlying medical conditions and age.
 First Aid Management:

1) Major Burns
- Protect the burned person from further harm. For electrical burns, make sure
the power source is off before approaching the burned person.
- Make certain that the person is breathing.
- Burned areas swell rapidly. Therefore, remove jewelry, belts and other
restrictive items, especially from around burned areas and the neck; but do
not try to remove anything that is stuck to the burnt skin, as this could cause
more damage.
- Cover the area of the burn. Use a cool, moist bandage or a clean cloth.
- Do not immerse large severe burns in water. Doing so could cause a serious
loss of body heat and lead to hypothermia.
- Elevate the burned area. Raise the wound above heart level, if possible.
- Watch for signs of shock. Signs and symptoms include fainting, pale
complexion or breathing in a notably shallow fashion.
2) Minor Burns
- Cool the burn. Hold the burned area under cool (not cold) running water or
apply a cool, wet compress until the pain eases.
- Remove rings or other tight items from the burned area. Try to do this quickly
and gently, before the area swells.
- Do not break blisters. Fluid-filled blisters protect against infection. If a blister
breaks, clean the area with water (mild soap is optional). Apply an antibiotic
ointment. But if a rash appears, stop using the ointment.
- Apply lotion. Once a burn is completely cooled, apply a lotion, such as one
that contains aloe vera or a moisturizer. This helps prevent drying and provides
relief.
- Bandage the burn. Cover the burn with a sterile gauze bandage (not fluffy
cotton). Wrap it loosely to avoid putting pressure on burned skin. Bandaging
keeps air off the area, reduces pain and protects blistered skin.
- If needed, take an over-the-counter pain reliever, such as ibuprofen (Advil,
Motrin IB), naproxen sodium (Aleve) or acetaminophen (Tylenol).
 Complications:
Complications of deep or widespread burns can include:
- Bacterial infection, which may lead to a bloodstream infection (sepsis)
- Fluid loss, including low blood volume (hypovolemia)
- Dangerously low body temperature (hypothermia)
- Breathing problems from the intake of hot air or smoke
- Scars or ridged areas caused by an overgrowth of scar tissue (keloids)
- Bone and joint problems, such as when scar tissue causes the shortening and
tightening of skin, muscles or tendons (contractures)
When death results due to a thermal injury, the causes may be:
a) Primary shock (neurogenic shock)
b) Secondary shock due to exudation of serum from the burnt area and consequent
depletion of blood volume
c) Asphyxia due to inhalation of fumes and smoke
d) Fat embolism
e) Septicemia
 Frostbite
Frostbite occurs when the skin is exposed to extreme or prolonged cold. The skin freezes,
as do tissues beneath the surface of the skin. In extreme cases, muscle, nerves, and
blood vessels may also freeze.
Skin may freeze within minutes when exposed to temperatures that fall below freezing.
Even if temperatures are above freezing, the skin is likely to freeze if it is wet or exposed
to severe wind chills.
Frostbite also occurs when the skin directly contacts very cold surfaces. This type of
exposure may immediately freeze the skin that touches the frozen surface.
 Risk Factors:
- Improper clothing in freezing areas
- Weakend body due to fatigue, hunger, dehydration, physical labor, injury, or
alcohol consumption
- Smoking (smoking narrows blood vessels and slows down circulation, allowing
frostbite to advance more rapidly)
- Medical conditions such as diabetes, depression, cardiovascular disease, or
peripheral vascular disease (these conditions may weaken the ability to notice and
appropriately respond to the cold)
- Beta-blocker medications
- Young children and the elderly are more likely to suffer from frostbite.
- Skin feels prickly and/or numb
- Skin is discolored (red, white, gray, or yellow)
- Pain around the exposed area
Frostbite is severe when the following symptoms emerge:

- Blisters on the skin
- Skin turns black
- Joints and muscles are stiff or not functioning
Regardless of the severity of frostbite, medical care should be sought if the

frostbite is associated with fever, dizziness, swelling, redness, or discharge in the
frostbitten area.
 Management:
- Seek shelter from the cold.
- Warm the hands by tucking them under the arms.
- If possible, stay indoors and remove wet clothing and jewelry.
- Once inside, place the hands and feet in warm water, and cover the rest of the
body with a blanket.
- Avoid sources of heat such as lamps, fire, or heating pads. These can burn
frostbitten skin.
- Drink warm liquids in case of dehydration
- Most cases of frostbite can be treated by warming the affected areas in water.
Sterilization of the affected skin and wrapping it in a dressing should be done.
- In the most extreme cases, bone, muscle, and nerves experience damage.
Amputation surgery may be necessary.
 Ulcers
An ulcer is a painful sore that is slow to heal and sometimes recurs. Ulcers are not
uncommon. How they appear and their corresponding symptoms depend on what
caused them and where they occur.
Ulcers can appear anywhere in or on the body, from the lining in the stomach to the
outer layer of the skin.
Some cases of ulcers disappear on their own, but others require medical treatment to
prevent serious complications.
 Types:
1) Peptic ulcers
2) Arterial ulcers
3) Venous ulcers
4) Mouth ulcers
5) Genital ulcers
1) Peptic Ulcers
Peptic ulcers are sores that develop on the inside lining of the stomach, the upper portion of
the small intestine, or the esophagus. They form when digestive juices damage the walls.
Peptic ulcers are most often caused from inflammation after being infected with
Helicobacter pylori (H. pylori) bacteria and long-term use of painkillers.
Types of peptic ulcers:

i) Gastric ulcers
ii) Esophageal ulcers
iii) Duodenal ulcers
Symptoms: Burning pain, bloating, belching, heartburn, nausea, vomiting, unexplained

weight loss, chest pain
2) Arterial Ulcers
Arterial (ischemic) ulcers are open sores that primarily develop on the outer side of the
ankle, feet, toes, and heels. Arterial ulcers develop from damage to the arteries due to lack
of blood flow to the tissue. These forms of ulcers can take months to heal and require
proper treatment to prevent infection and further complications.
Arterial ulcers have a “punched out” appearance accompanied with a number of symptoms,
including red, yellow, or black sores, hairless skin, leg pain, no bleeding, the affected area is
cool to touch from minimal blood circulation.
3) Venous Ulcers
Venous ulcers are the most common type of leg ulcers. These are open wounds often
forming on the leg, below the knee and on the inner area of the ankle. They typically
develop from damage to the veins caused by insufficient blood flow back to the heart.
In some cases, venous ulcers cause little to no pain unless they are infected. Other cases of
this condition can be very painful. Other symptoms may include inflammation, swelling,
itching, scabbing, discharge.
4) Mouth Ulcers
Mouth ulcers are small sores or lesions that develop in the mouth or the base of the gums.
They are commonly known as canker sores.
These ulcers are triggered by a number of causes, including biting the mucous membrane
inside the mouth, food allergies, forceful teeth brushing, hormonal changes, vitamin
deficiencies, bacterial infection, indigestion, diseases.
Mouth ulcers are common and usually heal within two weeks. They can be uncomfortable
but should not cause significant pain. Minor mouth ulcers appear as small, round ulcers that
leave no scarring. In more severe cases, they can develop into larger and deeper wounds.
Other serious symptoms associated with this type of ulcer may include unusually slow
healing (lasting longer than three weeks), ulcers that extend to the lips, difficulty in chewing,
eating or drinking, indigestion, fever, diarrhea.
5) Genital Ulcers
Genital ulcers are sores that generally develop in the genital area. They are usually caused by
sexually transmitted infections (STIs), but genital ulcers can also be triggered by trauma,
inflammatory diseases, or allergic reactions to skin care products. If cause by STIs, ulcers are
also seen in the anus, mouth or on the breasts.
In addition to sores, symptoms that may accompany genital ulcers include rash or bumps in
the affected area, pain or itching, swollen glands in the groin area, fever.
 Prameha Piḍakā
Prameha Piḍakā are complications occuring in patients afflicted with Prameha due to
prolonged presence of vitiated Doṣas. Prameha Piḍakā are diabetic carbuncles / boils.
 Bheda: (Ā. Sushruta & Ā. Vāgbhaṭa)

1) Sharāvikā are the boils which resemble Sharāva (curved earthen pan) in shape.
2) Sarṣapikā are the boils which resemble white mustard in colour and size.
3) Kacchapikā are the boils which are elevated like a tortoise shell, with a rough
surface, and causing burning sensation.
4) Jālinī are the boils which cause severe burning sensation and appear like a
network of fibres on the skin.
5) Vinatā are the boils which are deep rooted, large, painful, moist and appear on
the back and abdomen.
6) Putriṇī are the boils which are spread over a large area with multiple blisters at
the center.
7) Masūrikā are the boils which resemble red lentils.
8) Alajī are the boils which are red or white in color, appear as they are about to
rupture and cause severe pain.
9) Vidārikā are the boils which resemble the tubers of Vidārī.
10) Vidradhikā are the boils which possess similar features like Vidradhi Roga.
Sādhya -> Sarṣapikā, Vinatā, Masūrikā, Alajī, Vidradhikā
Kṛcchrasādhya -> Sharāvikā, Kacchapikā, Jālinī, Putriṇī, Vidārikā; Piḍakā which are
associated with burning sensation, excessive thirst, fever, hallucinations, which
spread easily, and have red or black discolouration.
 Chikitsā:
- Prameha should be controlled.
- Apakva Piḍakā -> Raktamokṣaṇa / Jalaukāvacharaṇa
- Pakva Piḍakā -> Pāṭana & Vraṇa Chikitsā
- Nyagrodhādi Gaṇa Kaṣāya with Gomūtra is administered internally.
- Āragvadhādi Gaṇa Kaṣāya should be used internally and externally for Udvartana.
- Mudgaparṇyādi Kvātha, Anantādi Kvātha
- Prameha Piḍakāhara Lepa (Udumbara kṣīra & Bākuchī chūrṇa)
- Gandhaka chūrṇa with Guḍa is taken internally; it cures 20 types of Prameha and
10 types of Prameha Piḍakā.
- Sārivādi Lauha (250-500 mg) with Madhu and Ghṛta is indicated in 10 types of
Prameha Piḍakā, all types of Ashas, and Tvak vikāra.
 Carbuncle / Boils
A carbuncle is a red, swollen, and painful cluster of boils that are connected to each
other under the skin.
A boil (or furuncle) is an infection of a hair follicle that has a small collection of pus
(called an abscess) under the skin.
Usually, a carbuncle is most likely to occur on the back or nape of the neck. But it may
also develop in other areas of the body such as the buttocks, thighs, groin, and armpits.
Most carbuncles are caused by Staphylococcus aureus bacteria, which inhabit the skin
surface, throat, and nasal passages. These bacteria can cause infection by entering the
skin through a hair follicle, small scrape, or puncture, although sometimes there is no
obvious point of entry.
Carbuncles are filled with pus, a mixture of old and white blood cells, bacteria, and dead
skin cells. They must drain before they are able to heal. Carbuncles are more likely than
boils to leave scars.
An active boil or carbuncle is contagious. The infection can spread to other parts of the
person's body or to other people through skin-to-skin contact or the sharing of personal
items. So it is important to practice appropriate self-care measures, like keeping the area
clean and covered, until the carbuncle drains and heals.
 Risk Factors:
Old age, obesity, poor hygiene, and poor overall health are associated with
carbuncles. Other risk factors for carbuncles include chronic skin conditions, which
damage the skin's protective barrier, Diabetes, Kidney disease, Liver disease, or any
condition or treatment that weakens the immune system.
Diabetes does not cause boils directly. The increased level of blood sugar may
cause damage to the blood vessels which can result in decreased blood flow
towards the skin, and therefore make the skin more susceptible to bacterial and
fungal infection.
Carbuncles can also occur in otherwise healthy, fit, younger people, especially
those who live together in group settings such as college dorms and share items
such as bed linens, towels, or clothing. In addition, people of any age can develop
carbuncles from irritations or abrasions to the skin surface caused by tight clothing,
shaving, or insect bites, especially in body areas with heavy perspiration.
The boils that collect to form carbuncles usually start as red, painful bumps. The
carbuncle fills with pus and develops white or yellow tips that weep, ooze, or crust.
Over a period of several days, many untreated carbuncles rupture, discharging a
creamy white or pink fluid.
Superficial carbuncles, which have multiple openings on the skin's surface, are less
likely to leave a deep scar. Deep carbuncles are more likely to cause significant
scarring.
Other symptoms include fever, fatigue, and a feeling of general sickness. Swelling
may occur in nearby tissue and lymph nodes, especially lymph nodes in the neck,
armpit, or groin.
 Home Remedies:
- The cardinal rule is to avoid squeezing or irritating a carbuncle, which increases
the risk of complications and severe scarring.
- Warm compresses may promote the drainage and healing of carbuncles. Gently
soak the carbuncle in warm water, or apply a clean, warm, moist washcloth for 20
minutes several times per day. Similar strategies include covering the carbuncle
with a clean, dry cloth and gently applying a heating pad or hot water bottle for 20
minutes several times per day. After each use, washcloths or cloths should be
washed in hot water and dried at a high temperature.
- Washing the carbuncle and covering the area with a sterile bandage also may
promote drainage and healing and help prevent the infection from spreading. Over-
the-counter medications such as acetaminophen or ibuprofen can help relieve the
pain of an inflamed carbuncle.
- It is important to thoroughly wash the hands after touching a carbuncle. Launder

any clothing, bedding, and towels that have touched a carbuncle and avoid sharing
bedding, clothing, or other personal items.
CHAPTER IV: tvak vikara
 Kṣudra Roga
Kṣudra means small or minor. The diseases caused by minor factors, having less
symptoms and complications, less severe symptoms, and which require little treatment
are called Kṣudra Roga.
 Number of Kṣudra Roga:

1) Ā. Sushruta -> 44
2) Ā. Vāgbaṭa -> 36
3) Ā. Mādhava -> 43
4) Ā. Shārṅgadhara -> 60
 Sushrutokta Kṣudra Roga:

1) Ajagallikā 23) Kadara
2) Yavaprakhyā 24) Alasa
3) Andhālajī 25) Indralupta
4) Vivṛtā 26) Dāruṇaka
5) Kacchapikā 27) Aruṃṣikā
6) Valmīka 28) Palita
7) Indravṛddhā 29) Masūrikā
8) Panasikā 30) Yauvanapiḍakā
9) Pāṣāṇagardabha 31) Padminīkaṇṭaka
10) Jālagardabha 32) Jatumaṇi
11) Kakṣā 33) Māṣaka
12) Visphoṭaka 34) Charmakīla
13) Agnirohiṇī 35) Tilakālaka
14) Chippa 36) Nyaccha
15) Kunakha 37) Vyaṅga
16) Anushayī 38) Parivartikā
17) Vidārikā 39) Avapāṭikā
18) Sharkarārbuda 40) Niruddhaprakāsha
19) Pāmā 41) Sanniruddhaguda
20) Vicharchikā 42) Ahipūtana
21) Raktasā 43) Vṛṣaṇakacchū
22) Pādadārikā 44) Gudabhraṁsha
 Ajagallikā
Ajagallikā is compared to a form of subcutaneous lymph gland enlargement. It is due to
vitiation of Kapha and Vāta Doṣa. This condition is commonly seen in children.
 Lakṣaṇā: Snigdha, Savarṇā (colour as the surrounding skin), Grathitā (knotty),

Niruja (painless), its shape resembles Mudga
 Chikitsā: Jalaukāvacharaṇa, Application of Shaṅkha bhasma, Yavakṣāra and Shukti;

After it has become Pakva, Ajagallikā should be punctured with a fresh thorn of
Kaṇṭakārī.
 Visphoṭaka
Visphoṭaka are vesicles resembling those which occur due to burns. They are
predominantly produced by Pitta and Rakta. Visphoṭaka may occur anywhere on the
body and are associated with Jvara.
 Nyaccha
Nyaccha are round painless eruptions which may be large or small, dark-coloured or
whitish, and may be present from birth.
 Vyaṅga & Nīlikā

Vāta combined with Pitta get aggravated due to anger and exertion, reach the face and
give rise to painless, thin and brownish patches on the skin. This is known as Vyaṅga
(freckles). That which develops on the body or face, with similar features but black in
colour, is known as Nīlikā.
Chikitsā:
- Sirāvyadha, Pralepa, Abhyaṅga
- Kalka of Arjuna tvak or Mañjiṣṭha mixed with Madhu
- Vyaṅgahara Lepa -> Kola majjā mixed with Guḍa, Navanīta and Madhu
- Kalka of Varuṇa tvak and Ajādugdha
- Jātīphala Kalka for Vyaṅga & Nīlikā
- Kanaka taila, Kumkumādya taila, for Abhyaṅgārtha
- Application of Sarṣapa taila in the evening on the face provides Vaktra prasādana.
 Chippa
Chippa is compared to paronchyia. It is due to vitiated Vāta and Pitta Doṣa, and Māṁa
Dhātu located near the nail bed.
 Lakṣaṇā: Ruja, Dāha, Pāka
 Chikitsā:
- Svedana with Uṣṇodaka, Utkṛtya (excision), application of Sarjarasa chūrṇa,
Bandhana
- Frequent application of Kalka prepared from Harītakī and Haridrā svarasa.
 Paronychia
Paronychia is an infection of the skin around the fingernails or toenails. Bacteria or a type
of yeast called Candida typically cause this infection. Bacteria and yeast can even
combine in one infection.
Depending on the cause of the infection, paronychia may come on slowly and last for
weeks or show up suddenly and last for only one or two days.
The symptoms of paronychia are easy to spot and can usually be easily and successfully
treated with little or no damage to the skin and nails.
The infection can become severe and even result in a partial or complete loss of the nail
if not treated.
 Acute Paronychia: An acute infection almost always occurs around the fingernails
and develops quickly. It is usually the result of damage to the skin around the nails
from biting, picking, hangnails, manicures, or other physical trauma.
Staphylococcus and Enterococcus bacteria are common infecting agents in the case
of acute paronychia.
 Chronic Paronychia: Chronic paronychia can occur on the fingers or toes, and it
comes on slowly. It lasts for several weeks and often recurs. It is typically caused by
more than one infecting agent, often Candida yeast and bacteria. It is more
common in people who are constantly exposed to water.
 Symptoms: The symptoms of both acute and chronic paronychia are very similar.
They are largely distinguished from each other by the speed of onset and the
duration of the infection. Chronic infections come on slowly and last for many
weeks. Acute infections develop quickly and do not last long. Both infections can
have the following symptoms:
- Redness, tenderness, swelling of the skin around the nail
- Pain, itching
- Pus-filled blisters
- Changes in nail shape, color, or texture
- Detachment of the nail
 Management:
- In case of collection of pus under the skin, the infected area should be soaked in
warm water several times per day and dried thoroughly afterwards. The soaking
will encourage the area to drain on its own.
- Antibiotics, Antifungals, Analgesics
- If abscess forms, I&D (Incision & Drainage)
 Kadara
Kadara is compared to the skin condition called corn. It is formed predominantly due to
vitiation of Rakta and Meda. It mostly occurs on the sole of the foot, especially when
walking barefoot.
 Lakṣaṇa: Knotty, painful, hard growth, raised or sunk at the center, which exudates
and resembles Kola bīja.
 Chikitsā: Utkṛtya (excision / scrapping) of the affected area without leaving any
residue. The site is then burnt with hot oil or fire.
 Corn
Foot corns are hardened layers of skin that develop from the skin’s response to friction
and pressure. These commonly occur on the soles, tip of the toes and dorsal surface of
interphalangeal joints.
 Symptoms:
- Rough, hard, yellowing patch of lumpy or bumpy skin
- Sensitive skin
- Pain when wearing shoes or while walking
 Management:
- It may be possible to remove the corn by following these steps:
1) Soak the foot in a warm bath with Epsom salts.
2) After the soak, pat the feet dry with a clean towel and moisturize with a
hydrating lotion or cocoa butter.
3) Continue this process daily until the corn has softened.
4) After it has softened and is not painful anymore, gently rub the corn with a
pumice stone.
5) If the corn is between the toes, use an emery board, also known as a nail file, to
rub them.
6) Repeat these steps until the corn has disappeared, which may take a few weeks.
- Another possible method:

1) Soak the foot daily as described above.
2) Dry the foot and apply castor oil.
3) After moisturizing the corn with castor oil, protect it with a special corn pad that
can be purchased at the pharmacy. Corn pads help relieve the pressure from the
area so that the corn can heal.
4) After applying, make sure to wear socks that are not too tight. It could take
several weeks for the corn to heal.
For achieving quicker results, corn pads containing salicylic acid can be applied.
 Maṣaka
Māṣaka are painless, firm, blackish eruptions which resemble Māṣa in shape. They occur
mainly due to Vāta Doṣa.
It can be treated by excision followed by Agnikarma or Kṣārakarma (e.g.: Kṣāra Ghṛta).
 Tilakālaka
Tilakālaka are blackish, painless spots on the skin which are not elevated and about the
size of a Tila bīja.
 Charmakīla / Tvak Arsha

Charmakīla is compared with warts. It occurs mainly due to vitiated Vyāna Vāyu and
Kapha Doṣa. The vitiated Doṣa which localize in the skin produce small nail-like growths.
Vāta pradhāna -> Toda

Kapha pradhāna -> Grathita & Vaivarṇya
Pitta Rakta pradhāna -> Rūkṣa, Kṛṣṇa varṇa
 Warts
Warts are small, firm bumps on the skin caused by viruses in the human papillomavirus
(HPV) family. Warts are common in children and can affect any area of the body.
 Types:
1) Common warts. Usually found on fingers, hands, knees, and elbows, a
common wart is a small, hard bump that is dome-shaped and usually grayish-
brown. It has a rough surface that may look like the head of a cauliflower, with
black dots inside.
2) Flat warts. These are about the size of a pinhead, are smoother than other
kinds of warts, and have flat tops. Flat warts may be pink, light brown, or
yellow. Most children who get flat warts have them on their faces, but they
can grow anywhere and can appear in clusters.
3) Plantar warts. Found on the sole of the foot, plantar warts can be very
uncomfortable, and feel like walking on a small stone.
4) Filiform warts. These have a finger-like shape, are usually flesh-colored, and
often grow on or around the mouth, eyes, or nose.
 Management:
- Topical creams -> salicylic acid, imiquimod
- Electrodessication, Cryosurgery, Surgical curettage
 Mukhadūṣikā / Yauvanapiḍakā
Mukhadūṣikā is compared to acne vulgaris. It occurs mainly due to vitiated Kapha, Vāta
and Rakta. Piḍakā (eruption) resembling thorns of Shālmalī appear on the face of young
people (Yauvana).
Chikitsā: Vamana, Sirāvyadha, Pralepa, Abhyaṅga

- Kalka of Lodhra, Dhānyaka and Vachā
- Haridrādi Kalka (Haridra, Dāruharidrā, Yaṣṭīmadhu, Mañjiṣṭha, Kālīyaka, Kuchandana,
Kamala, Padmaka, Kumkuma, Kapittha, Tiṇḍuka, Plakṣa, Nyagrodha, Kṣīra)
- Haridrādi taila
 Acne Vulgaris
Acne vulgaris is the formation of comedones, papules, pustules, nodules, and/or cysts as
a result of obstruction and inflammation of pilosebaceous units (hair follicles and their
accompanying sebaceous gland). Acne develops on the face and upper trunk.
 Etiology:
The most common trigger is puberty. During puberty, surges in androgens
stimulate sebum production and hyperproliferation of keratinocytes.
Other triggers include:
- Hormonal changes that occur with pregnancy or the menstrual cycle
- Occlusive cosmetics, cleansers, lotions, and clothing
- High humidity and sweating

- Skin lesions and scarring can be a source of significant emotional distress. Nodules
and cysts can be painful. Lesion types frequently coexist at different stages.
- Whiteheads are flesh-colored or whitish palpable lesions 1 to 3 mm in diameter;
blackheads are similar in appearance but with a dark center.
- Papules and pustules are red lesions 2 to 5 mm in diameter. Papules are relatively
deep. Pustules are more superficial.
- Nodules are larger, deeper, and more solid than papules. Such lesions resemble
inflamed epidermoid cysts, although they lack true cystic structure.
- Cysts are suppurative nodules. Rarely, cysts form deep abscesses. Long-term
cystic acne can cause scarring that manifests as tiny and deep pits (icepick scars),
larger pits, shallow depressions, or hypertrophic scarring or keloids.
 Niruddhaprakāsha / Niruddhamaṇi / Phimosis
Niruddhaprakāsha is the condition in which the glans penis is covered by constriction of
prepuce (foreskin) leading to obstruction of urinal flow. Prepuce cannot be pulled back
to expose the complete glans penis.
 Causes:
- Foreskin is too narrow to pass over glans penis
- Inner surface of foreskin is fused with glans penis
- Frenulum is too short to allow complete retraction of foreskin
(Frenulum is an elastic band of tissue under foreskin that connects to the glans
penis.)

- Prepuce cannot or only slightly be retracted
- Slow urination with mild pain
- Swelling due to urine
- Greater risk of inflammation of glans penis
 Treatment:
- Dilatation of preputial meatus
- Topical steroid creams like cortisone
- Surgery: Circumcision - complete removal of the foreskin
CHAPTER V: Manya vikara
 Galagaṇḍa
The swelling which hangs like scrotum in the throat region is called Galagaṇḍa.
Duṣṭa Kapha Doṣa along with Vāta Doṣa localize at throat region to vitiate Meda Dhātu
and cause Galagaṇḍa.
 Bheda:
1) Vātaja
2) Kaphaja
3) Medoja
 Lakṣaṇa:
1) Vātaja Galagaṇḍa
- Toda
- Kṛṣṇa-Sirā avanaddha (covered by a network of blackish veins)
- Kṛṣṇa / Aruṇa varṇa
- It may be rough and discharge pus
- Āsasya Vairasy
- Tālu-Gala Shoṣa
- When associated with Medo duṣṭi, it grows slowly but gradually, is painless
and unctuous.
2) Kaphaja Galagaṇḍa
- Savarṇa (same colour as the surrounding skin)
- Sthira, Alparuk, Kaṇḍū, Shīta
- Mahān (large swelling)
- Chiravṛddhi
- Āsasya Mādhurya
- Tālu-Gala Pralepa
3) Medoja Galagaṇḍa
- Snigdha, Mṛdu, Pāṇḍu varṇa
- Niruja, Atikaṇḍū
- Decrease or increase of Meda Dhātu influence the size of the swelling
- Snigdhāsyatā
 Chikitsā:
- Pathya: Vamana, Virechana, Svedana, Dhūmapāna, Sirāvyadha, Agnikarma, Kṣāra,
Pralepa, Laṅghana, Purāṇa Ghṛta pāna, Guggulu, Shilājatu
Rakta Shāli, Yava, Mudga, Paṭola, Rakta Shigru, Rūkṣa Kaṭu Dravya, Dīpana Dravya
- Apathya: Kṣīra, Ikṣu, Māṁsa, Piṣṭānna, Amla Madhura Guru Abhiṣyanda Dravya
- Varuṇa mūlatvak kvātha with Madhu

- Kāñchanāra tvak kvātha with Shuṇṭhī chūrṇa
- Kāñchanāra tvak chūrṇa pounded with Taṇḍulodaka and mixed with Shuṇṭhī.
1) Vātaja
- Nāḍī Svedana with Vātahara Dravya
- Nichulādi Lepa (Nichula, Shigru bīja, Dashamūla, Uṣṇodaka)
2) Kaphaja
- Upanāha Svedana with Kaphahara Dravya
- Devadāryādi Lepa (Devadāru & Indravāruṇī)
- Vamana, Shirovirechana, Virechana
3) Medoja
- External application of Sneha followed by Sirāvyadha
- Kalka from Shyāmā-Trivṛt, Snuhī, Maṇḍūra Bhasma, Dantī, Rasāñjana
- Khadira sāra Kvātha with Gomūtra for internal administration
 Goiter
Goiter is an abnormal enlargement of the thyroid gland.
Simple Goiter
Simple (nontoxic) goiter, which may be diffuse or nodular, is non-cancerous hypertrophy
of the thyroid gland without hyperthyroidism, hypothyroidism, or inflammation.
Except in severe iodine deficiency, thyroid function is normal and patients are
asymptomatic except for an obviously enlarged, non-tender thyroid.
 Etiology:
Simple nontoxic goiter, the most common type of thyroid enlargement, is
frequently noted at puberty, during pregnancy, and at menopause. The cause at
these times is usually unclear. Known causes include:
- Intrinsic thyroid hormone production defects
- Ingestion of foods that contain substances that inhibit thyroid hormone synthesis
(goitrogens, e.g.: cassava, broccoli, cauliflower, cabbage), as may occur in countries
in which iodine deficiency is common.
- Drugs that can decrease the synthesis of thyroid hormone (e.g.: amiodarone or
other iodine-containing compounds, lithium)

The patient may have a history of low iodine intake or over-ingestion of food
goitrogens. In the early stages, the goiter is typically soft, symmetric, and smooth.
Later, multiple nodules and cysts may develop.
 Investigations:
- Thyroidal radioactive iodine uptake
- Thyroid scan
- Thyroid ultrasonography
- Thyroxine (T4), triiodothyronine (T3), thyroid-stimulating hormone (TSH) levels
In the early stages, thyroidal radioactive iodine uptake may be normal or high with
normal thyroid scans. Thyroid function test results are usually normal. Thyroid
antibodies are measured to rule out Hashimoto thyroiditis.
In endemic goiter, serum TSH may be slightly elevated, and serum T4 may be low-
normal or slightly low, but serum T3 is usually normal or slightly elevated.
Thyroid ultrasonography is done to determine whether there are nodules that are
suggestive of cancer.
 Management: Depends on cause
In iodine-deficient areas, the following eliminate iodine deficiency:
- Iodine supplementation of salt
- Oral administration of iodized oil
- Intramuscular administration of iodized oil yearly
- Iodination of water, crops, or animal fodder
- Goitrogens being ingested should be stopped.
In other instances, suppression of the hypothalamic-pituitary axis with thyroid

hormone blocks thyroid-stimulating hormone (TSH) production (and hence
stimulation of the thyroid). Moderate doses of L-thyroxine (100 to 150 mcg orally
once a day depending on the serum TSH) are useful in younger patients to reduce
the serum TSH to the low-normal range.
L-Thyroxine is contraindicated in older patients with non-toxic nodular goiter,

because these goiters rarely shrink and may harbor areas of autonomy so that L-
thyroxine therapy can result in hyperthyroidism.
Large goiters occasionally require surgery or iodine-131 to shrink the gland enough
to prevent interference with respiration or swallowing or to correct cosmetic
problems.
Toxic Goiter
Toxic nodular goiter involves an enlarged thyroid gland. The gland contains areas that
have increased in size and formed nodules. One or more of these nodules produce too
much thyroid hormone.
Alternative Names: Toxic multinodular goiter; Plummer disease; Thyrotoxicosis - nodular

goiter; Overactive thyroid - toxic nodular goiter; Hyperthyroidism - toxic nodular goiter;
Toxic multinodular goiter; MNG

Toxic nodular goiter starts from an existing simple goiter. It occurs most often in
older adults. Risk factors include being female and over 55 years old. This disorder
is rare in children. Most people who develop it have had a goiter with nodules for
many years. Sometimes the thyroid gland is only slightly enlarged, and the goiter
was not diagnosed.
Sometimes, people with toxic multinodular goiter will develop high thyroid levels
for the first time. This mostly occurs after intake of a large amount of iodine
intravenously or by mouth. The iodine may be used as contrast for a CT scan or
heart catheterization.
Taking medicines that contain iodine, such as amiodarone, may also lead to the
disorder. Moving from a country with iodine deficiency to a country with a lot of
iodine in the diet can also turn a simple goiter into a toxic goiter.
Fatigue, Frequent bowel movements, Heat intolerance, Increased appetite,
Increased sweating, Irregular menstrual period, Muscle cramps, Nervousness,
Restlessness, Weight loss
Older adults may have symptoms that are less specific. These may include:
Weakness and fatigue, Palpitations and chest pain or pressure, Changes in memory
and mood
Toxic nodular goiter does not cause the bulging eyes that can occur with Graves
disease. Graves disease is an autoimmune disorder that leads to an overactive
thyroid gland (hyperthyroidism).
 Investigations:
A physical exam may show one or many nodules in the thyroid. The thyroid is often
enlarged. There may be a rapid heart rate or a tremor.
Other tests that may be done include:

- Serum thyroid hormone levels (T3, T4)
- Serum TSH (thyroid stimulating hormone)
- Thyroid uptake and scan or radioactive iodine uptake
- Thyroid ultrasound
 Management:
- Beta-blockers can control some of the symptoms of hyperthyroidism until thyroid
hormone levels in the body are under control.
- Radioiodine therapy may be used. Radioactive iodine is given by mouth. It then

concentrates in the overactive thyroid tissue and causes damage. In rare cases,
thyroid replacement is needed afterwards.
Surgery to remove the thyroid may be done in case of:

- Very large goiter
- Goiter is causing dyspnoea and dysphagia
- Thyroid cancer
 Gaṇḍamālā
Gaṇḍamālā is the condition in which Kapha Doṣa along with association of Vāta and Pitta,
vitiates Meda Dhātu leading to a series of glandular swellings in axillae, shoulders and
neck region.
 Nidāna: Divāsvapna, Meda vṛddhikara Āhāra, Duṣṭa Ambupāna

 Chikitsā:
- Pathya: Vamana, Virechana, Svedana, Vairechanika Dhūmapāna, Sirāvyadha,
Agnikarma, Kṣāra, Pralepa, Laṅghana, Purāṇa Ghṛta pāna, Guggulu, Shilājatu
- Kāñchanāra Guggulu
- Bhallātakādi Lepa
- Gandhakādi Lepa
- Nasya with either one of the following: Nirguṇḍī mūla, Nimba taila, Vachā and
Pippalī with Madhu
 Cervical Lymphadenopathy
Lymphadenopathy is palpable enlargement of ≥ 1 lymph nodes. Lymphadenitis is
lymphadenopathy with pain and/or signs of inflammation (redness, tenderness).
Cervical lymphadenopathy refers to a local form of lymphadenopathy in which only the
lymph nodes in the cervical area are enlarged.
It is an acute condition, common in children.
 Pathophysiology of Lymphadenopathy:
Some plasma and cells (e.g.: cancer cells, infectious microorganisms) in the
interstitial space, along with certain cellular material, antigens, and foreign
particles enter lymphatic vessels, becoming lymphatic fluid. Lymph nodes filter the
lymphatic fluid on its way to the central venous circulation, removing cells and
other material. The filtering process also presents antigens to the lymphocytes
contained within the nodes. The immune response from these lymphocytes
involves cellular proliferation, which can cause the nodes to enlarge (reactive
lymphadenopathy). Pathogenic microorganisms carried in the lymphatic fluid can
directly infect the nodes, causing lymphadenitis, and cancer cells may lodge in and
proliferate in the nodes.
 Causes:
- Staphylococcus infections
- Streptococcal pharyngitis
- Cat scratch diseases: Bartonella henselae bacteria
- Viral respiratory infections; bronchitis, common cold, etc.
- Ear infection, Tonsillitis, Chickenpox, Cancer
 Symptoms:
- Swollen lymph nodes, prolonged tenderness and pain
- Fever, Runny nose
- Sore throat
- URT infections
- Weight loss
 Diagnosis: CBC, CT scan, PET, Lymph node biopsy, Chest radiography
 Management:
- Antibiotics: Clindamycin, Trimethoprim, Sulfamethoxazole, Amoxicilli
- Antiviral, NSAD, Ibuprofen
- Adequate rest
- Symptomatic treatment for pain, fever, etc.
- Warm and wet compress
If the lymph nodes are swellings because of cancerous growth, treatment may
include:
- Chemotherapy
- Irradiation therapy
- Lymphadenectomy
 Apachī
Apachī is the condition in which there is chronic presence of Gaṇḍamālā, glandular
swelling in axillae, shoulders & neck region. It is mainly due to vitiated Kapha and Meda.
 Lakṣaṇa:
- The lumps are Sthira, Vṛtta, Snigdha
- Alparuja, Kaṇḍū
- The swelling grows steadily, but slowly
- When injured, the lumps start suppurating and discharging pus. The swelling
disappears and recurs at another location in the body.
 Chikitsā:
- Pathya: Vamana, Virechana, Svedana, Dhūmapāna (Vairechanika), Sirāvyadha,
Agnikarma, Kṣāra, Pralepa, Laṅghana, Purāṇa Ghṛta pāna, Guggulu, Shilājatu
- Vyoṣādya Taila for Nasya: Trikaṭu, Viḍaṅga, Madhuka, Saindhava, Devadāru, Taila
- Chandanādya Taila for Pānārtha: Chandana, Harītaki, Lākṣā, Vachā, Kaṭuka, Taila
10-20 ml with warm water or milk.
- Guñjādya Taila for Abhyaṅga: Guñja mūla, Karavīra, Shyāmā, Arka, Sarṣapa, Taila,
Gomūtra, Pippalī, Maricha Pañcha lavaṇa
 Lymphadenitis
Lymphadenitis is an acute infection of one or more lymph nodes.
Lymphadenitis is a feature of many bacterial, viral, fungal, and protozoal infections.

Focal lymphadenitis is prominent in streptococcal infection, tuberculosis or
nontuberculous mycobacterial infection, tularemia, plague, cat-scratch disease, primary
syphilis, lymphogranuloma venereum, chancroid, and genital herpes simplex.
Multifocal lymphadenitis may occur in patients with the following:
- Infectious mononucleosis
- Cytomegalovirus infection
- Toxoplasmosis
- Brucellosis
- Secondary syphilis
- Disseminated histoplasmosis

Lymphadenitis typically causes pain, tenderness, and lymph node enlargement.
Pain and tenderness typically distinguish lymphadenitis from lymphadenopathy.
With some infections, the overlying skin is inflamed, occasionally with cellulitis.
Abscesses may form, and penetration to the skin produces draining sinuses.
Fever with chills and general weakness is common.
 Diagnosis:
- Clinical evaluation
- The underlying disorder is usually suggested by history and examination. If not,
aspiration and culture or excisional biopsy is indicated.
 Treatment:
- Treatment of lymphadenitis is directed at the cause and is usually empiric.
Options include IV antibiotics, typically directed at Staphylococcus aureus and
Streptococcus pyogenes; antifungals; and antiparasitics depending on etiology or
clinical suspicion.
- Many patients with lymphadenitis may respond to outpatient therapy with oral
antibiotics. However, many patients also go on to form abscesses, which require
surgical drainage; an extensive procedure is done with accompanying IV antibiotics.
- In children, IV antibiotics are commonly needed. Hot, wet compresses may relieve
some pain.
- Lymphadenitis usually resolves with timely treatment, although residual,
persistent, nontender lymphadenopathy is common.
 Pāṣāṇagardabha
Pāṣāṇagardabha is characterized by an immovable Shopha at the root of the lower jaw
associated with mild pain. It is due to Kapha and Vāta Duṣṭi.
Chikitsā:
- Svedana
- Kapha-Vātahara Kalka for Shopha; Manaḥshila, Haratāla, Kuṣṭha, Devadāru
- Once it is in Pakvāvasthā, Visrāvaṇa is done.
 Mumps
Mumps is a viral infection that primarily affects saliva-producing (salivary) glands that are
located near the ears, called parotid glands. Mumps can cause swelling in one or both of
these glands. Mumps is a form of parotitis; inflammation of the parotid gland/s.
People who contracted mumps once cannot get affected by it again.
 Etiology:
Mumps Virus (MuV) is known as orthorubulavirus or mumps rubulavirus.
It spreads easily from person to person through infected saliva.
General modes of transmission include droplet infection and shared utensils.
 Incubation period: 2-3 weeks

Some people infected with mumps virus have either no signs or symptoms or very
mild ones.
If symptoms occur, they usually include:
- Unilateral or bilateral swelling of parotid glans with pain
- Odenophagia
- Dysphagia
- Fever
- Headache
- Muscle aches
- Weakness & fatigue
- Loss of appetite
 Complications:
Complications of mumps are rare, but potentially serious.
Most mumps complications involve inflammation and swelling in some part of the
body, such as:
- Testicles. This condition, known as orchitis, causes one or both testicles to swell in
males who have reached puberty. Orchitis is painful, but it rarely leads to sterility.
- Brain. Viral infections such as mumps can lead to inflammation of the brain
(encephalitis). Encephalitis can cause neurological problems and become life-
threatening.
- Membranes and fluid around the brain and spinal cord. This condition
known as meningitis, can occur if the mumps virus spreads through the
bloodstream to infect the central nervous system.
- Pancreas. The signs and symptoms of this condition, known as pancreatitis,
include pain in the upper abdomen, nausea and vomiting.
Other complications of mumps include:

- Hearing loss. Hearing loss can occur in one or both ears. Although rare, the
hearing loss is sometimes permanent.
- Heart problems. Rarely, mumps has been associated with abnormal heartbeat
and diseases of the heart muscle.
- Miscarriage. Contracting mumps during pregnancy, especially early on, may lead
to miscarriage.
 Prevention & Management:

- The best way to prevent mumps is to be vaccinated against the disease. Most
people have immunity to mumps once fully vaccinated.
The mumps vaccine is usually given as a combined measles-mumps-rubella (MMR)
inoculation, which contains the safest and most effective form of each vaccine.
Two doses of the MMR vaccine are recommended before a child enters school.
Those vaccines should be given when the child is:
Between the ages of 12 and 15 months
Between the ages of 4 and 6 years
- Symptomatic treatment can be done:

Rest in case of weakness & fatigue.
Analgesics & anti-pyretics, such as acetaminophen and ibuprofen.
Ice packs can be applied on the swollen glands.
- Precautions:
Intake of plenty of fluids to avoid dehydration due to fever.
Sof diet like soup and foods that are not hard to chew (chewing may be painful
when the glands are swollen).
Avoidance of acidic foods and beverages which may increase the pain.
- Home quarantine for anyone who is infected. A person can usually return to work
or school about one week or 10 days after mumps is diagnosed and if the individual
has recovered. At this point, mumps is no longer contagious. Mumps usually runs
its course in a couple of weeks.
 Sialadenitis
Sialadenitis is a bacterial infection of a salivary gland, usually due to an obstructing stone
or gland hyposecretion.

Sialadenitis usually occurs after hyposecretion or duct obstruction but may develop
without an obvious cause. The major salivary glands are the parotid,
submandibular, and sublingual glands.
Sialadenitis is most common in the parotid gland (parotitis) and typically occurs in:
- Patients in their 50s and 60s
- Chronically ill patients with xerostomia
- Patients with Sjögren syndrome
- Adolescents and young adults with anorexia
- Children (age 1 to18 years) with juvenile recurrent parotitis of undetermined
etiology
The most common causative organism is Staphylococcus aureus; others include

streptococci, coliforms, and various anaerobic bacteria.

- Fever, chills, and unilateral pain and swelling
- The gland is firm and diffusely tender, with erythema and oedema of the overlying
skin. Pus can often be expressed from the duct by compressing the affected gland
and should be cultured.
- Focal enlargement may indicate an abscess.
 Investigations: CT scan, Ultrasonography, MRI
 Treatment:
- Antistaphylococcal antibiotics
- Hydration, sialagogues (e.g.: lemon juice, hard candy, or some other substance
that triggers saliva flow), warm compresses, gland massage, and good oral hygiene
are also important.
- Abscesses require drainage.
- Occasionally, a superficial parotidectomy or submandibular gland excision is
indicated for patients with chronic or relapsing sialadenitis.
CHAPTER Vi: Sira Vikara
 Superficial Venous Thrombosis

Superficial venous thrombosis is a blood clot in a superficial vein of the upper or lower
extremities or, less commonly, in one or more veins of the chest or breast (Mondor
disease).
Superficial venous thrombosis in the upper extremity most commonly results from IV
infusions or catheterization; varicose veins seem to be the main risk factor for the lower
extremity, especially among women. Superficial venous thrombi rarely cause serious
complications and rarely become emboli.

Typically, patients present with pain, tenderness, or an indurated cord along a
palpable superficial vein. The overlying skin is usually warm and erythematous.
Migratory superficial venous thrombosis, which develops, resolves, and recurs in

normal veins of the arms, legs, and torso at various times, is a possible harbinger of
pancreatic cancer and other adenocarcinomas (Trousseau syndrome).
 Diagnosis:
Diagnosis is based on history and physical examination. Patients with superficial
venous thrombosis above the knee have an increased risk of deep venous
thrombosis (DVT) and should have ultrasonography.
 Management:
- Warm compresses and nonsteroidal anti-inflammatory drugs (NSAIDs)
- Sometimes anticoagulation:
In patients with extensive superficial venous thrombosis, anticoagulation (e.g. with
low molecular weight heparin, fondaparinux) is often beneficial. The optimal
regimen and duration are unknown, but most experts recommend using either low
molecular weight heparin (e.g. enoxaparin 40 mg subcutaneously once a day or
fondaparinux 2.5 mg subcutaneously once a day) and treating for about 1 month.
 Deep Venous Thrombosis (DVT)
Deep venous thrombosis (DVT) is clotting of blood in a deep vein of an extremity (usually
calf or thigh) or the pelvis. DVT is the primary cause of pulmonary embolism.
 Deep Veins of the Legs:

Lower extremity DVT is much more likely to cause pulmonary
embolism (PE), possibly because of the higher clot burden. The
superficial femoral and popliteal veins in the thighs and the
posterior tibial and peroneal veins in the calves are most
commonly affected. Calf vein DVT is less likely to be a source of
large emboli but can propagate to the proximal thigh veins and
from there cause PE.
 Etiology:
Many factors can contribute to DVT. Cancer is a risk factor for
DVT, particularly in older patients and in patients with recurrent
thrombosis. The association is strongest for mucin-secreting
endothelial cell tumors such as bowel or pancreatic cancers.
Occult cancers may be present in patients with apparently
idiopathic DVT, but extensive workup of patients for tumors is
not recommended unless patients have major risk factors for
cancer or symptoms suggestive of an occult cancer.
 Pathophysiology:
Lower extremity DVT most often results from:
- Impaired venous return (eg, in immobilized patients)
- Endothelial injury or dysfunction (eg, after leg fractures)
- Hypercoagulability
Upper extremity DVT most often results from:

- Endothelial injury due to central venous catheters
- Pacemakers
- Injection drug use
Upper extremity DVT occasionally occurs as part of superior vena cava (SVC)
syndrome (compression or invasion of the superior vena cava by a tumor and
causing symptoms such as facial swelling, dilated neck veins, and facial flushing) or
results from a hypercoagulable state or subclavian vein compression at the thoracic
outlet. The compression may be due to a normal or an accessory first rib or fibrous
band (thoracic outlet syndrome) or occur during strenuous arm activity.
Deep venous thrombosis usually begins in venous valve cusps. Thrombi consist of
thrombin, fibrin, and red blood cells with relatively few platelets (red thrombi);
without treatment, thrombi may propagate proximally or travel to the lungs.
 Complications:
Common complications of deep venous thrombosis include
- Chronic venous insufficiency
- Postphlebitic syndrome
- Pulmonary embolism
Much less commonly, acute DVT leads to phlegmasia alba dolens or phlegmasia
cerulea dolens, both of which, unless promptly diagnosed and treated, can result in
venous gangrene.

DVT may occur in ambulatory patients or as a complication of surgery or major
medical illness. Among high-risk hospitalized patients, most deep vein thrombi
occur in the small calf veins, are asymptomatic, and may not be detected.
When present, symptoms and signs of DVT, such as vague aching pain, tenderness
along the distribution of the veins, edema, erythema, are nonspecific, vary in
frequency and severity, and are similar in arms and legs.
Dilated collateral superficial veins may become visible or palpable. Calf discomfort
elicited by ankle dorsiflexion with the knee extended (Homans sign) occasionally
occurs with distal leg DVT but is neither sensitive nor specific.
Tenderness, swelling of the whole leg, > 3 cm difference in circumference between
calves, pitting edema, and collateral superficial veins may be most specific.
Low-grade fever may be present; DVT may be the cause of fever without an
obvious source, especially in postoperative patients. Symptoms of pulmonary
embolism, if it occurs, may include shortness of breath and pleuritic chest pain.
 Investigations: Ultrasonography, Sometimes D-dimer testing, MRI, MRV (Magnetic

Resonance Venography), CT scan
 Treatment:
- General supportive measures include pain control with analgesics, which may
include short (3- to 5-day) courses of a nonsteroidal anti-inflammatory drug
(NSAID). Extended treatment with NSAIDs and aspirin should be avoided because
their antiplatelet effects may increase the risk of bleeding complications.
- In addition, elevation of legs (supported by a pillow or other soft surface to avoid
venous compression) is recommended during periods of inactivity.
- Anticoagulants; All patients with DVT are given anticoagulants. Typically, patients
are initially given an injectable heparin (unfractionated or low molecular weight)
for 5 to 7 days, followed by longer term treatment with an oral drug.
- Inferior vena cava (IVC) filter; An IVC filter may help prevent pulmonary embolism
in patients with lower extremity DVT who have contraindications to anticoagulant
therapy or in patients with recurrent DVT (or emboli) despite adequate
anticoagulation. An IVC filter is placed in the inferior vena cava just below the renal
veins via catheterization of an internal jugular or femoral vein. Some IVC filters are
removable and can be used temporarily.
- Surgery; Surgery is rarely needed. However, thrombectomy, fasciotomy, or both

are mandatory for phlegmasia alba dolens or phlegmasia cerulea dolens
unresponsive to thrombolytics to try to prevent limb-threatening gangrene.
 Haemangioma
Haemangioma is a benign tumor that occurs in the endothelial lining of the blood
vessels. These tumors usually develop within the first few weeks of life but often resolve
independently by the time a child is ten years of age. Haemangioma is the most common
type of tumor found in children.
Haemangiomas do not cause problems in most infants. However, some may open and
bleed or ulcerate. This may be painful. Depending on their size and location, they may be
disfiguring. Additionally, they may occur with other central nervous system or spine
abnormalities.
External growths may also occur with other internal haemangiomas. These affect organs
such as the brain, respiratory sytem, liver or other parts of the GIT.
 Stages of Development:
There are essentially three stages of haemangioma development:
1) The proliferation stage, where the hemangioma grows rapidly. This stage can
last as long as one year.
2) The resting stage, where very little change occurs in the lesion’s appearance.
This stage lasts until the child is aged around one to two years.
3) The involution stage, where the tumor starts to shrink. In 50% of cases, the
tumor has disappeared by the time the child reaches five years of age and
most cases have disappeared by time children are ten years old.
In a few rare cases, hemangiomas do not diminish in size nor disappear.
 Pathology:
The endothelial cells lining the blood vessels multiply at an abnormally fast rate and
eventually form a lump. Haemangiomas may be superficial and develop on the
surface of the skin or they may be deep and form below the skin surface.
Surface haemangiomas may be warm to touch, as they are supplied by their own
blood vessels. Their texture may also resemble the surface of a strawberry and
these lesions are sometimes referred to as strawberry haemangiomas.
Haemangiomas can also be a combination of superficial and deep, appearing as a
raised red area with a bluish swelling caused by blood vessels deeper down.
Haemangiomas do not normally cause symptoms during or after their formation.
However, they may cause some symptoms if they grow large or in a sensitive area
or if there are multiple haemangiomas.
Haemangiomas of the skin usually appear as small red scratches or bumps. As they
grow, they look like burgundy-colored birthmarks. Skin haemangiomas are
sometimes called strawberry haemangiomas because of their deep red
appearance.
Haemangiomas inside the body present with symptoms specific to the organ that is
affected. For example, a haemangioma affecting the gastrointestinal tract or liver
may present with symptoms such as nausea, vomiting, abdominal discomfort, loss
of appetite, a feeling of fullness in the abdomen.
 Investigations: Visual inspection on physical examination, Ultrasound, MRI, CT scan
 Management:
A single, small haemangioma usually requires no treatment. It will likely go away on
its own. However, some cases may require treatment, such as skin haemangiomas
that develop ulcerations or sores, or are in specific areas on the face such as the lip.
Treatment options include:

Beta-blockers: Oral propranolol, Topical beta-blockers such as timolol gel
These beta-blockers can be used for small, superficial haemangiomas. They may
also have a role in treating smaller ulcerated haemangiomas.
Corticosteroid medication: Corticosteroids may be injected into a haemangioma to

reduce its growth and to stop inflammation.
Systemic steroids, such as prednisone and prednisolone, are not typically used
anymore. Although, they may have a role for those who cannot use other
medications such as beta-blockers.
Laser treatment: Laser treatment can be used to remove haemangiomas on the

top layers of the skin. In some cases, a surgeon may use laser treatment to reduce
redness and improve the appearance.
Surgery: If the hemangioma is small enough, it can be surgically removed.
For hemangiomas on the organs: Haemangiomas within the body may require
treatment if they grow too large or cause pain.
Treatment options for these haemangiomas include:
- Surgical removal of the haemangioma
- Surgical removal of the damaged organ or damaged area
- In haemangiomas of the liver, tying off of the main blood supply to the
haemangioma may be an option
 Varicose Veins
Varicose veins are large, swollen veins that often appear on the legs and feet. They
happen when the valves in the veins do not work properly, so the blood does not flow
effectively.
In severe cases, a varicose vein may rupture, or develop into varicose ulcers on the skin.

The veins have one-way valves so that the blood can travel in only one direction. If
the walls of the vein become stretched and less flexible, the valves may get weaker.
A weakened valve can allow blood to leak backward and eventually flow in the
opposite direction. When this occurs, blood can accumulate in the vein(s), which
then become enlarged and swollen.
The veins furthest from the heart are most often affected, such as those in the legs.
This is because gravity makes it harder for blood to flow back to the heart.
Any condition that puts pressure on the abdomen has the potential to cause
varicose veins; for instance, pregnancy, constipation and, in rare cases, tumors.
General risk factors for varicose veins include menopause, pregnancy, > 50 years,
standing for long periods, family history of varicose veins, obesity.
Pregnancy and varicose veins

Women are much more likely to develop varicose veins during their pregnancy than
at any other time in their lives. Pregnant women have much more blood in their
body; this places extra pressure on the circulatory system.
Additionally, changes in hormone levels can lead to relaxation of the blood vessel
walls. Both these factors raise the risk of having varicose veins.
As the uteru grows, there is more pressure on the veins in the mother’s pelvic area.
In the majority of cases, the varicose veins go away after the pregnancy is over; this
is not always the case, and sometimes, even if the varicose veins improve, there
may be some left visible.

In the majority of cases, there is no pain, but signs and symptoms of varicose veins
may include:
- Veins look twisted, swollen, and lumpy (bulging)
- Veins are blue or dark purple
- Aching legs
- Legs feel heavy, especially after exercise or at night
- Minor injury to the affected area may result in longer bleeding than normal
- Lipodermatosclerosis – fat under the skin just above the ankle can become hard,
resulting in the skin shrinking
- Swollen ankles
- Telangiectasia in the affected leg (spider veins)
- There may be a shiny skin discoloration near the varicose veins, usually brownish
or blue in color
- Venous eczema, skin in the affected area is red, dry, and itchy
- When suddenly standing up, some patients experience leg cramps
- High percentage of people with varicose veins also have restless legs syndrome
(an uncontrollable urge to move the legs)
- Atrophie blanche; irregular whitish patches that look like scars appear at the
ankles
 Prevention:
- Plenty of exercise or walking
- Maintain healthy body weight
- Avoid standing still for too long
- Do not sit with crossed legs
- Sit or sleep with raised feet
 Management:
- If the patient has no symptoms or discomfort and is not bothered by the sight of
the varicose veins, treatment might not be necessary. However, if there are
symptoms, treatment may be required to reduce pain or discomfort, address
complications, such as leg ulcers, skin discoloration, or swelling.
- Compression stockings. Compression stockings squeeze the patient’s legs and

improve circulation. They are tight around the ankles and loose further up the leg.
In this way, compression stockings encourage proper blood flow upwards, against
gravity and back towards the heart.
Compression stockings may help with discomfort, pain, and swelling, but research
has not confirmed whether they stop the varicose veins from worsening, or even
prevent them.
- Surgery. If varicose veins are large, they may need to be removed surgically. This
is usually done under general anesthesia. In most cases, the patient can go home
the same day – if surgery is required on both legs, they may need to spend one
night in hospital.
Laser treatments are often used to close off smaller veins, and also spider veins.
Strong bursts of light are applied to the vein, which gradually fades and disappears.
- Ligation and stripping. Two incisions are made, one near the patient’s groin at the
top of the target vein, and the other is made further down the leg, either at the
ankle or knee. The top of the vein is tied up and sealed. A thin, flexible wire is
threaded through the bottom of the vein and then pulled out, taking the vein with
it. This procedure does not usually require a hospital stay. Ligation and stripping
can sometimes result in bruising, bleeding, and pain. In extremely rare occasions,
there may be deep vein thrombosis.
After surgery, most patients will need 1-3 weeks to recover before going back to
work and other normal duties. During recovery time, compression stockings are
worn.
- Sclerotherapy. A chemical is injected into small and medium-sized varicose veins,

which scars and closes them. A few weeks later, they should fade. A vein may need
to be injected more than once.
- Radiofrequency ablation. A small incision is made either above or below the

knee, and with the help of an ultrasound scan; a narrow tube (catheter) is threaded
into the vein. A probe is inserted into the catheter, which emits radiofrequency
energy. The radiofrequency energy heats up the vein, causing its walls to collapse,
effectively closing it and sealing it shut. This procedure is preferred for larger
varicose veins. Radiofrequency ablation is usually done with a local anesthetic.
- Endovenous laser treatment. A catheter is inserted into the patient’s vein. A small
laser is threaded through the catheter and positioned at the top of the target vein;
it delivers short energy bursts that heat up the vein, sealing it shut. With the aid of
an ultrasound scan, the laser is thread all the way up the vein, gradually burning
and sealing all of it. This procedure is done under local anesia. There may be some
nerve injury, which is usually brief.
- Transilluminated powered phlebectomy. An endoscopic transilluminator (special

light) is threaded through an incision under the skin so that the veins which need to
be taken out are clearly visible. The target veins are cut and removed with a suction
device through the incision.
A general or local anesthetic may be used for this procedure. There may be some
bleeding and bruising after the operation.
CHAPTER ViI: dhamani vikara
 Aneurysm (Dhamanī Granthi)

An aneurysm is the enlargement of an artery caused by weakness in the arterial wall.
Often there are no symptoms, but a ruptured aneurysm can lead to fatal complications.
Not all cases of unruptured aneurysm need active treatment. However, when an
aneurysm ruptures, internal bleeding occurs and emergency surgery is needed.
In case of a brain aneurysm, operation is only performed if there is a high risk of rupture.
The potential risk of brain damage resulting from surgical complications is too great.
 Risk Factors:
- Smoking tobacco (by far the most common risk factor)
- Hypertension
- Poor diet
- Sedentary lifestyle
- Obesity
 Types:
Aneurysms are classified by their location in the body. The arteries of the brain and
heart are the two most common sites of a serious aneurysm.
The bulge can take two main shapes:

1) Fusiform aneurysms bulge all sides of a blood vessel
2) Saccular aneurysms bulge only on one side
1) Aortic aneurysm
The aorta is the large artery that begins at the left ventricle of the heart and
passes through the chest and abdominal cavities. The normal diameter of the
aorta is 2-3 cm but can bulge to beyond 5 cm with an aneurysm.
The most common aneurysm of the aorta is an abdominal aortic aneurysm
(AAA). This occurs in the part of the aorta that runs through the abdomen.
Without surgery, the annual survival rate for an AAA of over 6 cm is 20%.
AAA can rapidly become fatal, but those that survive the transfer to a hospital
have a 50% chance of overall survival.
Less commonly, a thoracic aortic aneurysm (TAA) can affect the part of the
aorta running through the chest. TAA has a survival rate of 56% without
treatment, and 85% following surgery. It is a rare condition, as only about a
quarter of aortic aneurysms occur in the chest.
2) Cerebral aneurysm
Aneurysms of the arteries that supply the brain with blood are known as
intracranial aneurysms. Due to their appearance, they are also known as
“berry” aneurysms.
A ruptured aneurysm of the brain can be fatal within 24 hours. 40% of brain
aneurysms are fatal, and around 66% of those who survive will experience a
resulting neurological impairment or disability.
Ruptured cerebral aneurysms are the most common cause of a type of stroke
known as subarachnoid hemorrhage (SAH).
3) Peripheral aneurysm
An aneurysm can also occur in a peripheral artery. Types of peripheral
aneurysm include:
i) Popliteal aneurysm: This happens behind the knee. It is the most common
peripheral aneurysm.
ii) Splenic artery aneurysm: This type of aneurysm occurs near the spleen.
iii) Mesenteric artery aneurysm: This affects the artery that transports blood
to the intestines.
iv) Femoral artery aneurysm: The femoral artery is in the groin.
v) Carotid artery aneurysm: This occurs in the neck.
vi) Visceral aneurysm: This is a bulge of the arteries that supply blood to the
bowel or kidneys.
Peripheral aneurysms are less likely to rupture than aortic aneurysms.

 Atherosclerosis
Atherosclerosis is a disease in which plaque builds up inside your arteries.
Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood.
Over time, plaque hardens and narrows the arteries. This limits the flow of oxygen-rich
blood to the organs and other parts of the body.
 Causes & Risk Factors:

The exact cause of atherosclerosis is not known. However, studies show that
atherosclerosis is a slow, complex disease that may start in childhood. It develops
faster with age.
Atherosclerosis may start when certain factors damage the inner layers of the
arteries. These factors include:
- Unhealthy blood cholesterol levels. This includes high LDL cholesterol and low
HDL cholesterol.
- High blood pressure. Blood pressure is considered high if it stays at or above

140/90 mmHg over time. In case of diabetes or chronic kidney disease, high blood
pressure is defined as 130/80 mmHg or higher.
- Smoking. Smoking can damage and tighten blood vessels, raise cholesterol levels,
and raise blood pressure. Smoking also does not allow enough oxygen to reach the
body's tissues.
- Unhealthy diet. Foods that are high in saturated and trans fats, cholesterol,
sodium (salt), and sugar can worsen other atherosclerosis risk factors.
- Insulin resistance, Diabetes, Overweight or obesity, Lack of physical activity, Older

age, Family history of early heart disease
Plaque may begin to build up where the arteries are damaged. Over time, plaque
hardens and narrows the arteries. Eventually, an area of plaque can rupture.
When this happens, blood cell fragments called platelets stick to the site of the
injury. They may clump together to form blood clots. Clots narrow the arteries even
more, limiting the flow of oxygen-rich blood to the body.

Atherosclerosis usually does not cause signs and symptoms until it severely
narrows or totally blocks an artery.
Many people do not know that they have atherosclerosis until they have a medical
emergency, such as a heart attack or stroke.
Some people may have signs and symptoms of the disease. These mainly depend
on which arteries are affected.
1) Coronary Arteries
The coronary arteries supply oxygen-rich blood to the heart. If plaque narrows
or blocks these arteries (causing a disease called ischemic heart disease), a
common symptom is angina. Angina is chest pain or discomfort that occurs
when the heart muscles do not get enough oxygen-rich blood.
Angina may feel like pressure or squeezing in the chest. It may also be felt it in
the shoulders, arms, neck, jaw, or back. Angina pain may even feel like
indigestion. The pain tends to get worse with activity and go away with rest.
Emotional stress also can trigger the pain.
Other symptoms of ischemic heart disease are shortness of breath and
arrhythmias.
Plaque can also form in the heart's smallest arteries. This disease is called
coronary microvascular disease (MVD). Symptoms of coronary MVD include
angina, shortness of breath, sleep problems, fatigue, and lack of energy.
2) Carotid Arteries
The carotid arteries supply oxygen-rich blood to the brain. If plaque narrows or
blocks these arteries (a disease called carotid artery disease), a stroke may
occur. These symptoms may include:
- Sudden weakness
- Commonly unilateral paralysis or numbness of the face, arm, or leg
- Confusion
- Trouble speaking or understanding speech
- Trouble seeing in one or both eyes
- Dyspnoea
- Dizziness, trouble walking, loss of balance or coordination
- Loss of consciousness
- Sudden and severe headache
3) Peripheral Arteries
Plaque also can build up in the major arteries that supply oxygen-rich blood to
the legs, arms, and pelvis (a disease called peripheral artery disease).
If these major arteries are narrowed or blocked, numbness, pain, and,
sometimes, dangerous infections may occur.
4) Renal Arteries
The renal arteries supply oxygen-rich blood to the kidneys. If plaque builds up
in these arteries, chronic kidney disease may develop. Over time, chronic
kidney disease causes a slow loss of kidney function.
Early kidney disease often has no signs or symptoms. As the disease gets worse
it can cause tiredness, oligo- or polyuria, loss of appetite, nausea, swelling in
the hands or feet, itchiness or numbness, and trouble concentrating.
 Complications:
Aneurysms, Angina, Chronic kidney disease, Coronary or carotid heart disease,
Heart attack, Heart failure, Stroke, Peripheral artery disease, Arrhythmia
 Investigations: Blood sugar, Lipid profile, Stress testing, Angiography, CT scan,

Intravascular ultrasound (IVUS)
 Management:
- Lifestyle changes: Slow or stop atherosclerosis by taking care of the risk factors.
That means a healthy diet, exercise, and no smoking. These changes will not
remove blockages, but they are proven to lower the risk of heart attacks and
strokes.
- Medication: Drugs for high cholesterol and high blood pressure will slow and may
even halt atherosclerosis.
- Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is

a procedure that is used to open blocked or narrowed coronary arteries. PCI can
improve blood flow to the heart and relieve chest pain. Sometimes a small mesh
tube called a stent is placed in the artery to keep it open after the procedure. This
is known as stenting.
- Coronary artery bypass grafting (CABG), arteries or veins from other areas in the
body are used to bypass or go around the narrowed coronary arteries. CABG can
improve blood flow to the heart, relieve chest pain, and possibly prevent a heart
attack.
- Bypass grafting also can be used for leg arteries. For this surgery, a healthy blood
vessel is used to bypass a narrowed or blocked artery in one of the legs. The
healthy blood vessel redirects blood around the blocked artery, improving blood
flow to the leg.
- Carotid endarterectomy is a type of surgery to remove plaque buildup from the

carotid arteries in the neck. This procedure restores blood flow to the brain, which
can help prevent a stroke.
 Buerger’s Disease
Buerger’s disease, also called thromboangiitis obliterans (TAO), is an inflammation of
small- and medium-sized blood vessels.
Although any artery can be affected, it usually presents with blockages of the arteries to
the feet and hands, leading to pain and tissue damage.
The disease is found worldwide and can affect people of any race and age group.
However, it mainly affects Asian and Middle Eastern men between the ages of 40-45 who
heavily use, or have heavily used, tobacco products, including chewing tobacco.
The specific cause of Buerger’s disease remains unknown.

Buerger’s disease begins by causing arteries to swell and blood clots to form. This
restricts normal blood flow and prevents blood from fully circulating through the
tissues. This results in necrosis because the tissues are starved of nutrients and
oxygen.
Buerger’s disease usually starts with pain in the areas affected, followed by
weakness. The symptoms include:
- Recurring pain in the hands and feet, or legs and arms
- Open sores on the toes or fingers
- Pale toes or fingers when in cold temperatures
- Inflamed veins
 Management:
There is no cure for Buerger’s disease. However, the single-most important factor
in improving symptoms and preventing its progression is quitting smoking.
In rare cases, the pain may be so severe that a surgical procedure called a
sympathectomy may be performed to eliminate the pain. In this procedure nerves
to an affected area are cut.
On the other hand, some patients report symptom improvement by drinking plenty
of fluids and staying active, which increases the circulation.
Vasodilators may be helpful as well.
Amputation might be necessary in case of severe infection or gangrene.
 Raynaud’s Disease
Raynaud’s disease is when blood vessels in the fingers and/or toes temporarily overreact
to low temperatures or stress.
 Types:
1) Primary Raynaud’s (or Raynaud’s disease) happens without any other illness
behind it. The symptoms are often mild.
2) Secondary Raynaud’s (Raynaud’s syndrome, Raynaud’s phenomenon) results

from another illness. It is often a condition that attacks the body’s connective
tissues, like lupus or rheumatoid arthritis. It is less common, but more likely to
cause serious health problems. This can include skin sores and even gangrene.
These happen when cells and tissue in the toes and fingers die from lack of
blood.
 Stages:
1) Stage of Syncope: Abnormal exposure to cold causes arteriole vasospasm
along with tingling and numbness. As a result, the affected part becomes pale /
white; severe pallor develops.
2) Stage of Asphyxia: After a brief period of vasoconstriction, capillaries dilate,

filling up with deoxygenated blood resulting in bluish discoloration – cyanosis
with burning sensation.
3) Stage of Recovery / Rubor: As the attack passes, relaxation of arterioles

occurs, circulation improves and red engorgement of the part takes place.
 Diagnosis:
1) Cold and Warm Water Test
Initially, the fingers/toes are kept in cold water. After 5 minutes, pallor of digits
is observed. Then, warm water is poured over the affect area which results in
cyanosis. Then the full spasm relaxes in warm water and rubor is seen.
This test is positive for Raynaud’s disease.
2) Digital Artery Pressure

Pressure in the arteries of fingers are measured before and after the hands
have been cooled. A decrease of at leastr 15 mmHg is diagnostic for Raynaud’s.
 Management:
Management mainly includes preventing attacks or limiting them when they occur.
In case of secondary Raynaud’s, the underlying disease is also treated.
- Avoid tobacco, smoking, including second-hand smoke
- Regular exercise boosts the circulation
- Manage stress factors to prevent attacks
- Temperature should be kept constant; exposure to cold should be avoided or kept

to a minimum.
- Proper clothing for cold weather. Wear multiple layers, gloves, and heavy socks.
Chemical warmers for pockets, gloves, and socks can be considered.
- When an attacks comes on, hands/feet should be kept in warm water or held
under flowing warm water.
- Avoid medications such as decongestants with phenylephrine, diet pills, migraine

medications with ergotamine, herbal medications with ephedra, and blood
pressure medication clonidine (Catapres); these narrow the blood vessels.
- Vasodilators can be given; e.g. Reserpine 0.25-0.5 mg daily orally for 2 weeks.
- I.V. low molecular weight Dextron is beneficial during an attack.
- Antibiotics, analgesics and occasionally surgical debridement may be necessary

for ischaemic ulcers.
- In case of severe symptoms, cervico-thoracic sympathectomy can be considered.
- Amputation in case of necrosis.

CHAPTER ViIi: snayu vikara
 Ganglion (Snāyu Granthi)

A ganglion is a sac-like swelling or cyst formed from the tissue that lines a joint or
tendon. The tissue, called synovium, normally functions to produce lubricating fluid for
these areas. A ganglion is a cyst formed by the synovium that is filled with a thick jelly-
like fluid. While ganglia can follow local trauma to the tendon or joint, they usually form
for unknown reasons. Occasionally, ganglia are early signs of arthritis that will become
more obvious in the future.
 Causes & Risk Factors:

Ganglions can be caused by inflammation of the tissue lining joints and tendons.
This inflammation can be a result of local injury or underlying arthritis.

Ganglia can form around any joint, but they are most frequently found in the wrist
and ankles. They are usually painless and often barely visible as localized swellings.
They typically do not appear to be inflamed.
The largest ganglions form behind the back of the knee, causing a sense of fullness
or tightness. A ganglion here is referred to as a Baker cyst, named after the doctor
who originally described the condition.
 Management:
A ganglion can spontaneously rupture and go away. Sometimes, gentle massage is
all that is necessary.
Other treatment options include removal of the ganglion fluid with a needle and
syringe (aspiration) with or without an injection of cortisone medication.
Occasionally, the entire ganglion is resected with surgery. People with a persisting
or recurring ganglion should be evaluated for signs of systemic forms of arthritis,
such as rheumatoid arthritis.
 Tennis Elbow
Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow generally caused
by overuse. Playing tennis or other racquet sports can cause this condition. However,
several other sports and activities besides sports can also put a person at risk.
Tennis elbow is inflammation or, in some cases, microtearing of the tendons that join the
forearm muscles on the outside of the elbow. The forearm muscles and tendons become
damaged from overuse; repeating the same motions again and again. This leads to pain
and tenderness on the outside of the elbow.
The elbow joint is a joint made up of three bones: humerus, radius and ulna. There are
two bony bumps at the distal end of the humerus called medial and lateral epicondyle,
where several muscles of the forearm begin their course.
Muscles, ligaments, and tendons hold the elbow joint together.

Lateral epicondylitis, or tennis elbow, involves the muscles and tendons of the forearm
that are responsible for the extension of the wrist and fingers. The forearm muscles
extend the wrist and fingers. The forearm tendons, often called extensors, attach the
muscles to bone. The tendon usually involved in tennis elbow is called the Extensor
Carpi Radialis Brevis (ECRB).
 Symptoms:
The symptoms of tennis elbow develop gradually. In most cases, the pain begins
mild and slowly worsens over weeks and months. There is usually no specific injury
associated with the start of symptoms.
Common signs and symptoms of tennis elbow include:
- Pain or burning on the lateral part of the elbow
- Weak grip strength
- Sometimes, pain at night
The symptoms are often worsened with forearm activity, such as holding a racquet,
turning a wrench, or shaking hands. The dominant arm is most often affected.
 Management:
Non-surgical Treatment
Approximately 80% to 95% of patients have success with nonsurgical treatment.
1) Rest. The first step toward recovery is to give the affected arm proper rest for
several weeks.
2) Medications. Acetaminophen or anti-inflammatory medications (such as

ibuprofen) may be taken to help reduce pain and swelling.
3) Physical therapy. Specific exercises are helpful for strengthening the muscles
of the forearm, e.g. wrist stretching exercises with elbow extended.
4) Brace. Using a brace centered over the back of the forearm may also help
relieve symptoms of tennis elbow.
5) Steroid injections. Steroids, such as cortisone, are very effective anti-

inflammatory medicines.
6) Platelet-rich plasma. Platelet-rich plasma (PRP) is a biological treatment

designed to improve the biologic environment of the tissue. This involves
obtaining a small sample of blood from the arm and centrifuging it (spinning it)
to obtain platelets from the solution. Platelets are known for their high
concentration of growth factors, which can be injected into the affected area.
While some studies about the effectiveness of PRP have been inconclusive,
others have shown promising results.
An injection of PRP is used to treat tennis elbow.
7) Extracorporeal shock wave therapy. Shock wave therapy sends sound waves
to the elbow. These sound waves create "microtrauma" that promotes the
body's natural healing processes.
Surgical Treatment
If symptoms do not respond after 6 to 12 months of non-surgical treatments,
surgical methods might be necessary.
Most surgical procedures for tennis elbow involve removing diseased muscle and
reattaching healthy muscle back to the bone.
1) Open surgery. The most common approach to tennis elbow repair is open
surgery. This involves making an incision over the elbow. Open surgery is
usually performed as an outpatient surgery. It rarely requires an overnight stay
at the hospital.
2) Arthroscopic surgery. Tennis elbow can also be repaired using miniature

instruments and small incisions. Like open surgery, this is a same-day or
outpatient procedure.
3) Rehabilitation. Following surgery, the arm may be immobilized temporarily

with a splint. About 1 week later, the sutures and splint are removed.
After the splint is removed, exercises are started to stretch the elbow and
restore flexibility. Light, gradual strengthening exercises are started about 2
months after surgery.
 Bursitis
Bursitis is a painful condition that affects the small, fluid-filled sacs, called bursae, which
cushion the bones, tendons and muscles near the joints. Bursitis occurs when bursae
become inflamed.
There are over 150 bursae in the human body. The bursae are lined with synovial cells.
Synovial cells produce a lubricant that reduces friction between tissues. This cushioning
and lubrication allows our joints to move easily. When a person has bursitis, movement
or pressure is painful. Overuse, injury, and sometimes an infection from gout or
rheumatoid arthritis may cause bursitis.
 Symptoms:
- Pain that increases with movement or pressure
- Tenderness, even without movement
- Swelling
- Loss of movement
If the bursitis is caused by an infection, it is called septic bursitis. A patient with

septic bursitis may have the following additional symptoms:
- Fever
- Redness in the affected area
- The affected area feels hot when touched
 Common Areas of Bursitis:

1) Shoulders
2) Elbows
3) Ankles
4) Knees
5) Buttocks
6) Hips
7) Thighs
 Management:
- Padding can protect the affected bursae from contact.
- Not using the joints in the affected area unless necessary.
- Placing ice packs wrapped in a towel on the affected area can help reduce pain
and inflammation. The ice should not be placed directly on the skin.
- Raising the affected area. Less blood will gather if it is elevated, and this may help
reduce inflammation.
- Painkillers. Ibuprofen is effective as a painkiller and to reduce inflammation.
For more severe symptoms of bursitis:

- Injection of steroids to block prostaglandin.
- Antibtiotics if bacterial infection has been diagnosed.
- Rarely, bursa may have to be surgically drained.
CHAPTER ix: Standard precautions for
prevention of Disease transmission
Standard precautions combine the major features of universal precautions (UP) and body
substance isolation (BSI), and are based on the principle that all blood, body fluids,
secretions, excretions (except sweat), non-intact skin and mucous membranes may contain
transmissible infectious agents. Standard precautions include a group of infection-
prevention practices that apply to all patients, regardless of suspected or confirmed
infection status, in any setting in which health care is delivered. These include: hand hygiene;
use of gloves, gown, mask, eye protection or face shield, depending on the anticipated
exposure; and safe injection practices. Also, equipment or items in the patient environment
likely to have been contaminated with infectious body fluids must be handled in a manner
that prevents transmission of infectious agents (e.g. wear gloves for direct contact, contain
heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before
use on another patient). The application of standard precautions during patient care is
determined by the nature of the health-care worker–patient interaction and extent of
anticipated blood, body fluid or pathogen exposure. For some interactions (e.g. performing a
venepuncture), only gloves may be needed; during other interactions (e.g. intubation), use
of gloves, gown, and face shield or mask and goggles is necessary. Standard precautions are
also intended to protect patients by ensuring that health-care personnel do not carry
infectious agents to patients on their hands or via equipment used during patient care.
Assume that every person is potentially infected or colonized with an organism that could be
transmitted in the health-care setting and apply the following infection control practices
during the delivery of health care.
Hand hygiene
1) During the delivery of health care, avoid unnecessary touching of surfaces in close
proximity to the patient to prevent both contamination of clean hands from environmental
surfaces and transmission of pathogens from contaminated hands to surfaces.
2) When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled
with blood or body fluids, wash the hands with either a non-antimicrobial or an antimicrobial
soap and water.
3) If hands are not visibly soiled, or after removing visible material with non-antimicrobial
soap and water, decontaminate hands in the clinical situations described in 3. a-f.
The preferred method of hand decontamination is with an alcohol-based hand rub.
Alternatively, hands may be washed with an antimicrobial soap and water. Frequent use of
alcohol-based hand rub immediately following handwashing with non-antimicrobial soap
may increase the frequency of dermatitis.
Perform hand hygiene:

3.a. Before having direct contact with patients
3.b. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin,
or wound dressings
3.c. After contact with a patient’s intact skin (e.g. when taking a pulse or blood pressure or
lifting a patient)
3.d. If hands are likely to move from a contaminated body site to a clean body site during
patient care
3.e. After contact with inanimate objects (including medical equipment) in the immediate
vicinity of the patient
3.f. After removing gloves.
1) Wash hands with non-antimicrobial or antimicrobial soap and water if contact with
spores (e.g. Clostridium difficile or Bacillus anthracis) is likely to have occurred. The
physical action of washing and rinsing hands under such circumstances is
recommended because alcohols, chlorhexidine, iodophors and other antiseptic
agents have poor activity against spores.
2) Do not wear artificial fingernails or extenders if duties include direct contact with
patients at high risk for infection and associated adverse outcomes (e.g. those in
intensive care units [ICUs] or operating rooms).
Gloves
1) Wear gloves when it can be reasonably anticipated that contact with blood or other
potentially infectious materials, mucous membranes, non-intact skin, or potentially
contaminated intact skin (e.g. of a patient with incontinence of stool or urine) could occur.
2) Wear gloves with fit and durability appropriate to the task.
2.a. Wear disposable medical examination gloves for providing direct patient care.
2.b. Wear disposable medical examination gloves or reusable utility gloves for cleaning the
environment or medical equipment.
2.c. Remove gloves after contact with a patient and/or the surrounding environment
(including medical equipment) using a proper technique to prevent hand contamination. Do
not wear the same pair of gloves for the care of more than one patient. Do not wash gloves
for the purpose of reuse since this practice has been associated with the transmission of
pathogens.
2.d. Change gloves during patient care if the hands are likely to move from a contaminated
body site (e.g. perineal area) to a clean body site (e.g. face).
Safe injection practices
Take care to prevent injuries when using needles, scalpels and other sharp instruments or
devices; when handling sharp instruments after procedures; when cleaning used
instruments; and when disposing of used needles.
1) Use an aseptic technique to avoid contamination of sterile injection equipment.
2) Needles, cannulae and syringes are sterile, single-use items; they should not be
reused for another patient or to access a medication or solution that might be used
for a subsequent patient.
3) Do not recap, bend, break or hand-manipulate used needles; if recapping is

required, use a one-handed scoop technique only; use safety features where
available; place used sharps in a puncture-resistant container.
General Precautions in OT (Operation Theatre) for HIV/Hepatitis Patients

- The operating table is covered with a sheet of polythene.
- The number of thatre personal is reduced to a minimum. Inexperienced personnel should
not be allowed to assist.
- Staff with abrasion or lacerations on their hands are not allowed inside the theatre.
- Staff must wear over-shoes, disposable gloves & water resistant gowns, and eye protection.
- Double gloves & eye protection for staff which is directly involved with the operation like
the surgeon, assistant, scrub nurse.
- Any blood spilled in the theatre should be decontaminated by chlorous as soon as possible.
- Well marked disposable bags should be used for the collection of waste which should be
disposed through incineration.
- Avoid sharp injuries, prefer scissors or diathermy to scalpel, use skin clips, avoid needle
stick injuries, a closed apparatus is used for wound drainage, proper autoclaving after the
surgery is essential.

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शल्यतन्त्र​​ Paper I, Part B

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शल्यतन्त्र

Ṣaṭ Kriyākāla is the process of understanding the pathogenesis of a disease in

सञ्चयं च प्रकोपं च प्रसरं स्थानसश्रं यम् ।

The one who knows/understands these 6 stages can be called a physician.

a) Vāta Sañchaya Lakṣaṇa: Stabdha Koṣṭhatā, Pūrṇa Koṣṭhatā

Chikitsā: Nidāna parivarjana, Pathya sevana, Hetu viparīta Chikitsā

i) Chaya Prakopa: It is the condition in which Sañchaya Avasthā occurs before

Chikitsā: Nidāna parivarjana, Pathya sevana, Hetu viparīta Chikitsā

Chikitsa: Nidāna parivarjana, Pathya sevana, Hetu-liṅga Chikitsā

Chikitsā: According to involved Doṣa, Dūshya or both

 Bheda: (Ā. Sushruta)

 Sāmānya Lakṣaṇa: Gaurava, Anavasthita (unstable), Utsedha (elevated/swollen),

Āmashotha -> Vimlāpana, Avasechana, Upanāha

Signs & Symptoms:

Chronic inflammation often progresses quietly, with few independent

Factors which cause Chronic Inflammation:

- Smoking. Smoking cigarettes lowers the production of anti-inflammatory

- Stress. Psychological stress is associated with increased inflammation.

-> Bāhya Vidradhi – 6 1) Vātaja

6) Kṣataja / Abhighātaja Vidradhi

-> Abhyantara / Antar Vidradhi – 10

1) Guda -> Vātanirodha

Āmāvasthā -> Shopha Chikitsā & Raktamokṣaṇa

Abscesses usually form because of an infection or because a foreign object becomes

The most common types of abscess are:

Less common types of abscess include:

2) Amebic liver abscess, a type caused by amebiasis, an intestinal infection that

3) Anorectal abscess, located in or near the anus or rectum, most commonly

5) Brain abscess, typically the result of a bacterial or fungal infection in part of

Skin symptoms that may occur along with an abscess

Other symptoms that may occur along with an abscess

Hilton’s Method of Incision and Drainage:

Following health problems make people more susceptible to skin infections:

 Signs & Symptoms:

 Bheda: (Ā. Vāgbhaṭa)

- Pittaja Nāḍīvraṇa -> Pāṭana followed by application of Kalka made from

- Shalyaja Nāḍīvraṇa -> Pāṭana followed by extraction of Shalya, Vraṇa shodhana,

 Etiology & Risk Factors:

 Signs & Symptoms:

 Treatment for Keloids:

- Less-invasive treatments, such as silicone pads, pressure dressings, or injections,

- Cryosurgery/Cryotherapy is perhaps the most effective type of surgery for keloids.

 Etiology & Risk Factors:

Any of these afflictions can significantly increase a person's likelihood of

 General Clinical Features:

-> Wet gangrene

-> Gas gangrene

-> Internal gangrene

-> Fournier's gangrene

 Reasons for Amputation:

General Steps during an amputation procedure:

Aggravated Vātādi Doṣa vitiate Māṁsa & Rakta to cause Granthi.

 Vraṇaja Granthi / Vraṇa Granthi

8) Epididymal cysts: Epididymal cysts, or spermatoceles, form in the vessels

14) Vocal fold cysts:

 Lakṣana: वृिं क्स्थरं मन्त्दरुजं महान्त्तमनल्पमल

Examples of benign tumors include:

Adenomas do not start as cancer. However, some can become adenocarcinomas.

They can be “soft” or “hard,” depending on the proportion of fibers to cells.

Examples of premalignant tumors include:

Metaplasia of the lung

Properties of a malignant tumor are:

Different types of malignant tumor originate in different types of cell.

शल्यतन्त्र Paper I, Part B

शल्यतन्त्र Paper I, Part B