त्रयोविंशोऽध्यायः । अथातः कृत्याकृत्यविधिमध्यायं व्याख्यास्यामः, यथोवाच भगवान् धन्वन्तरिः ॥१॥
Now we shall discuss the Chapter, which deals with the Prognosis of an ulcer (Krtyakrtya-vidhi-adhyaya). 1
तत्र वयःस्थानां दृढानां प्राणवतां सत्त्ववताञ्च सुचिकित्स्या व्रणाः, एकस्मिन् वा पुरुषे यत्रैद्गुणचतुष्टयं तस्य सुखसाधनीयतमाः ॥२॥
A boil or an ulcer appearing in a patient who is young, muscular (in frame), strong, or is possessed of an indomitable courage and fortitude proves readily amen able to healing measures and applications; how much more so when one appears in a patient in whom all these four conditions simultaneously obtain. 2
तत्र, वयःस्थानां प्रत्यग्रधातुत्वादाशु व्रणा रोहन्ति । दृढानां स्थिरबहुमांसत्वाच्छस्त्रमवचार्य्यमाणं शिरास्नाय्वादिविशेषान् न प्राप्नोति। प्राणवतां वेदनाभिघाताहारयन्त्रणादिभिर्न ग्लानिरुत्पद्यते । सत्त्ववतां दारुणैरपि क्रियाविशेषैर्न व्यथा भवति, तस्मादेतेषां सुखसाधनीयतमाः । त एव विपरीत गुणा वृद्धकुशाल्पप्राणभीरुषु द्रष्टव्याः ॥३॥
An ulcer in a young patient is speedily healed owing to the fresh and vigorous vitalizing principles of the body; whereas the one, which appears in a person of strong and muscular build, finds a speedy and successful termination owing to the inability of the incising instrument to cut deep into the hard and tough muscles of the affected part and to reach down, or in any way destroy the underlying veins and nerves, etc. A strong and vigorous patient can easily endure a considerable amount of burning pain, etc. and does not feel distressed by a strict regimen of diet. A man of stupendous endurance and fortitude can sustain the fatigue and worry of even the most painful surgical operation. Accordingly, a boil or an ulcer, appearing in a patient of the above said description, is easily and speedily healed, whereas the one, which affects either an old, emaciated, or timid person or one of small strength and endurance, takes time to heal. 3
स्फिक्पायुप्रजननललाटगण्डौष्ठपृष्ठकर्णफलकोषोदरजत्रुमुखाभ्यन्तरसंस्थाः सुखरोपणीया व्रणाः । अक्षिदन्तनासापाङ्गश्रोत्रनाभिजठरसेवनीनितम्बपार्श्वकुक्षिवक्षः कक्षास्तनसन्धिभागगताः सफेनपूयरक्तानिलवाहिनोऽन्तःशल्याश्च दुश्चिकित्स्याः ॥४॥
Boils or ulcers, which appears in the regions of the buttocks (Sphik), or about the anus, and the organs of generation, or on the back, forehead, cheek, or lips, or in the region of the external ears, or on the testes or the abdomen, or in the cavity of the mouth, or about the nape of the neck, or above the clavicles, can be easily healed. Those, that are seated in the eyes, or in the gums, the nostrils or the exterior angle of the eye, or in the cavity of the ears, abdomen or the umbilicus, or about any suture of the body, hips, ribs, arm-pits, chest, breasts, sides, or the joints, as well as those, that secrete frothy blood or pus with a gurgling sound, or contain any foreign matter embedded in their inside, are healed only with the greatest difficulty. 4
अधोभागाश्चोर्ध्वभागनिर्व्वाहिणो रोमान्तोपनखमर्म्मजङ्घास्थिसंश्रिताश्च । भगन्दरमपि चान्तर्मुखं सेवनीकुटकास्थिसंश्रितम् ॥५॥
Similarly, an abscess or an ulcer appearing in the nether region of the body and pointing upward, or the one appearing on the extremity of scalp (Romanta) or about the end of a finger-nail, or in any of the vulnerable parts of the body, as well as the one affecting either of the thigh bones (femurs), should be looked upon as equally hard to cure. Likewise an abscess or an ulcer affecting a bone of the pelvis (Sronikanda-Acetabulum), as well as a fistula in ano opening inward should be regarded as hard to cure. 5
भवति चात्रकुष्ठिनां विषजुष्टानां शोषिणां मधुमेहिनाम् । व्रणाः कृच्छ्रेण सिध्यन्ति येषाञ्चापि व्रणे व्रणाः ।।६।।
Authoritative verse on the subject: An ulcer (Vrana) appearing in a leper (Kusthi) or in a person suffering from diabetes (Madhumeha, or from Sosa (lit: pulmonary consumption) or from the effects of poison, as well as the one appearing in a pre-existing ulcer, should be looked upon as curable only with the greatest difficulty. 6
अवपाटिकानिरुद्धप्रकशसन्निरुद्धगुद- जठरग्रन्थिक्षतक्रिमयः प्रतिश्यायजाः कोष्ठजाश्च, त्वग्दोषिणां प्रमेहिणां वा ये परिक्षतेषु दृश्यन्ते; शर्करा सिकतामेहो वातकुण्डलिकाऽष्ठीला दन्तशर्करोपकुशः कण्ठशालूकं निष्कोषणदूषिताश्च दन्तवेष्टा विसर्पास्थिक्षतोर क्षतव्रणग्रन्थिप्रभृतयश्च याप्याः ॥७॥
Yapya ulcers: An ulcer incidental to, and affecting the seat of any of the following diseases, viz. Avapatika (paraphimosis), or Niruddha-Prakas (phimosis), or Sanniruddha-guda (constriction of the anus), or Jathara (abdominal-dropsy), or Granthi (glandular inflammation), and characterised by the germination of parasites in its interior, as well as the one appearing in the cavity of the abdomen, or affecting the mucous linings of the intestines, or brought about by the corrosive secretions of a nasal catarrh (Pratisyaya), and infested with parasites, should be considered as only admitting of a palliative treatment. Similarly palliation is the only remedy in the case of an ulcer which appears in a patient suffering from any morbid secretion from the urethra (Prameha) or from any form of cutaneous affections, marked by worms in its inside.
Likewise a case of gravel (Sarkara), or urinary calculi (Sikata) in which the urine is found to be charged with concretions, or leaves a deposit of sandy sediment, can not be radically cured by medicine alone. A case of Vata-kundalika, Asthila, Upakusa, Kantha-saluka, Danta-sarkara, Danta-vesta, Visarpa, Asthiksata, Uru-ksata, or VranaGranthi, may not perfectly yield to medicine alone. In an inflammation of the gums resulting from the use of poisonous twigs as brushes for teeth (Niskasana) a temporary amelioration is all that can be expected from a good and efficient treatment. 7
साध्या याप्यत्वमायान्ति याप्याश्चासाध्यतां तथा । घ्नन्ति प्राणानसाध्यास्तु नराणामक्रियावताम् ।।८।।
यापनीयं विजानीयात् क्रिया धारयते तु यम् । क्रियायान्तु निवृत्तायां सद्य एव विनश्यति ।। ९ ।।
प्राप्ता क्रिया धारयति याप्यव्याधितमातुरम् । प्रपतिष्यदिवागारं विष्कम्भः साधुयोजितः ।।१०।।
Metrical texts: In a patient neglecting a disease at its preliminary stage, (or otherwise not observing a strict regimen) even a curable malady may speedily develop into one which admits only of palliative measures, while a disease of the last named type is soon transformed into an incurable one. An incurable disease under the circumstances speedily finds a fatal termination. A patient laid up with a disease, which only admits of a palliative treatment, lives so long as the course of the medical treatment is continued, and will die almost simultaneously with its discontinuance. Just as a prop or a pillar can prevent the collapse of a tumbling edifice, so palliative measures, judiciously applied by a skilful physician, may keep off the inevitable in a disease which knows no radical cure. 8-10
अत ऊर्द्धमसाध्यान् वक्ष्यामः। मांसपिण्डवदुद्गताः प्रसेकिनोऽन्तःपूंय वेदनावन्तोऽश्वापानवदुवृतौष्ठाः; केचित् कठिना गोश्रृङ्गवदुन्नतमृदुमांसप्ररोहाः; अपरे दुष्टरुधिरास्राविणस्तनुपिच्छिलास्राविणो वा मध्योन्नताः; केचिदवसन्नशुषिरपर्य्यन्ताः शणतूलवत् स्नायुजालवन्तो दुद्दर्शनाः; वसामेदोमज्जमस्तुलुङ्गस्राविणश्च दोषसमुत्थाः । पीतासितमूत्रपुरीषवातवाहिनश्च कोष्ठस्थाः, त एवोभयतोभागव्रणमुखेषु पूयरक्तनिर्व्वाहिणः; (क्षीणमांसानाञ्च) सर्व्वतोगतयक्षाणुमुखा मांसवद्वदवन्तः सशब्दवातवाहिन्क्ष शिरः कण्ठस्थाः; क्षीणमांसानाञ्च पूयरक्तनिर्व्वाहिणोऽरोचकाविपाककासश्वासोपद्रवयुक्ताः । भिन्ने वा शिरः कपले यत्र मस्तुलुङ्गदर्शनं त्रिदोषलिङ्गप्रादुर्भावः कासश्वासौ वा यस्येति ॥११॥
Incurable diseases Now we shall describe the types of diseases which are usually held as incurable. An ulcer (Vrana) cropping up like a fleshy tumour, painful and containing pus in its inside, and which is characterised by a copious secretion, with its edges raised like those of the genital of a mare, should be understood as belonging to the incurable type. A condylomatous (papillomatous) ulcer which is soft and raised like the horn of a cow, or the one which is moderately raised or elevated at its base, and secretes an exudation of vitiated blood, or a thin slimy secretion, should be likewise regarded as incurable. An ulcer with an embossed or heaved up centre, and one dipped or fissured at its extremity should be regarded as past all remedy. An ulcer covered over with shreds of ligaments, and looking as if studded with loose shreds of hemp, should be given up as incurable. Similarly, an ulcer due to the deranged condition of any of the fundamental humours, and secreting an exudation composed of coagulated blood, fat, marrow and brain-matter should be deemed incurable.
Likewise, an ulcer, in a weak and emaciated person, which is located within the cavity of the abdomen, (Kostha) and which assumes either a black or yellowish colour, and exudes a secretion composed of urine, pus, blood and fecal matter, which finds its outlet both through the upward and downward fissures of the body (the mouth and the anus) making a rumbling, gurgling sound, or which simultaneously secretes pus and blood through both the channels, should be regarded as belonging to the incurable class. An ulcer in an emaciated patient, which is situated either on the head or in the throat, and which is narrow-mouthed and is traversed by a network of capillaries, and studded with fleshy or papillomatous eruptions, should be regarded as incurable. A distinctly audible sound or report is heard in these ulcers which are found to be charged with wind.
An ulcer in an emaciated patient, which secretes blood and pus, and is attended with indigestion, cough, painful respiration and nonrelish for food, as well as a case of fractured skull, attended with cough, dyspnoea, secretion of brain-matter, and symptoms peculiar to the concerted action of the three deranged humours of the body, should be given up as past all remedy. 11
भवन्ति चात्रवसां मेदोऽथ मज्जानं मस्तुलुङ्गञ्च यः सवेत् । आगन्तुस्तु व्रणः सिध्येन्न सिध्येद् दोषसम्भवः ।। १२ ।।
Authoritative verses on the subject: A traumatic ulcer, which exudes a secretion of fat, marrow or brain-matter, may prove amenable to medical treatment, whereas a humoural ulcer under the circumstance will prove incurable. 12
अमर्म्मोपहिते देशे शिरासन्ध्यस्थिवर्ज्जिते । विकारो योऽनुपर्य्येति तदसाध्यस्य लक्षणम् ।।१३।।
क्रमेणोपचयं प्राप्तो धातूननुगतः शनैः । न शक्य उन्मूलयितुं वृद्धो वृक्ष इवामयः ।।१४।।
स स्थिरत्वान्महत्त्वाच्च धात्वनुक्रमणेन च। निहन्त्यौषधवीर्य्याणि मन्त्रान् दुष्टग्रहो यथा ।। १५ ।।
An ulcer appearing at any part of the body other than a vital one (Marma), and which is found to invade its successive elements though without affecting any vein, bone, joint, etc. should be regarded as incurable. Just as a tree, that has grown old and that has spread its roots deep into the soil, can not be uprooted, so a disease can not be eradicated that has gained in strength and maturity with the process of time, and that has gradually invaded the different essential principles of the body. A disease, which, having been neglected at the outset, has run on to one of a lingering or persistent type by invading the successive elements of the body, and has thereby gained in strength and intensity, baffles medicines, (of tested and marked efficacy), just as malignant astral combinations tend to nullify potent incantations. 13-15
अतो यो विपरीतः स्यात् सुखसाध्यः स उच्यते । अबद्धमूलः क्षुपको यद्वदुत्पाटने सुखः।।१६।।
त्रिभिर्दोषैरनाक्रान्तः श्यावौष्ठः पिडकासमः । अवेदनो निराम्रावो व्रणः शुद्ध इहोच्यते ।।१७।।
Symptoms of cleansed healthy ulcers: An ulcer, not belonging to any of the above said types, may prove easily amenable to the curative efficacies of medicines, In other words, an ulcer of recent origin is easily uprooted like a tender sapling of recent growth. An ulcer, which is unaffected by any of the three deranged bodily humours, and which assumes a dark brown hue along its edges, and is characterised by the absence of any pain, pustular eruptions or secretions, and which is of an even or of an equal elevation throughout its length, should be regarded as cleansed (asepsised or healthy), and divested of all morbid matter or principle (Suddha-Vrana). 16-17
कपोतवर्णप्रतिमा यस्यान्ताः क्लेदवर्ज्जिताः । स्थिराश्चिपिटिकावन्तो रोहतीति तमादिशेत् ।।१८।।
Symptoms of Healing Ulcers : An ulcer, which is dovecoloured (yellowish dusky), and is not lardaceous at its base, and is further characterised by the absence of any muco-purulent secretion along its margin, and which has become hard and surrounded by shreds of dead skin, and presents symptoms of healthy granulation, should be looked upon as in course of healing. 18
रूढवर्त्मानमग्रन्थिमशूनमरुजं व्रणम्। त्वक्सवर्णं समतलं सम्यगुरूढं विनिर्द्दिशेत् ॥ ॥ १९ ॥
Symptoms of Healed Ulcers: An ulcer, with its edges firmly adhered and characterised by the absence of any pain and swelling and not appearing knotty or glandular to the touch and that has left a cicatrix of the same hue with surrounding skin, should be considered as perfectly healed. 19
atorgrantura व्यायामादभिघातादजीर्णतः । हर्षात् क्रोधाद् भयाद् वाऽपि व्रणो रूढोऽपि दीर्य्यते । । २० ।।
Causes, such as mental excitements, as excessive grief and ecstacies of joy, anger or fright, as well as an external blow, or excessive physical exercise, or an abnormal excitation of any of the deranged humours, or an impaired digestion, may tend to reopen an ulcer recently adhered and healed. Accordingly such acts and conditions should be avoided by an ulcer-patient. 20
इति सुश्रुतसंहितायां सूत्रस्थाने कृत्याकृत्यविधिर्नाम त्रयोविंशोऽध्याययः ॥२३॥
Thus ends the twenty-third Chapter of the Sutrasthana in the Susruta Samhita. which treats of the prognosis of ulcers.
