An integrated approach in the treatment of varicose ulcer
A 61-year-old male patient presented to KLE Ayurveda Hospital, Belgaum, Karnataka, with the complaint of reddish ulcers above lateral malleolus of the right leg for 2 weeks, associated with pricking pain, burning sensation around the ulcers, edema, and blackish discoloration over the right lower limb. For the last 5 years, the patient had been suffering from varicose veins, and 2 years back, he developed varicose ulcer on the medial aspect of the ankle joint on the same leg and was treated with biomedicines successfully. Patient was addicted to Bīḍi (Indian cigarette filled with tobacco flake and wrapped in a Bauhinia racemosa leaf tied with a string at one end) smoking for 20 years, but had stopped it for the last 2 years. He was habituated to standing for long hours in his job, i.e. about 8 to 10, hours for the past 22 to 30 years. There was no history of any chronic illness such as diabetes mellitus and hypertension.\nOn examination, a reddish large ulcer and many small oval ulcers with sloping edges were found, along with mild serous discharge around lateral malleolus of the right leg. The large ulcer measured 3 cm in length, 2 cm in width, and 1.75 cm in depth, with three to four small ulcers without granulation tissue. The patient also had swelling and blackish discoloration around right ankle joint and feet, with grade III tenderness around an ulcer. Varicosity on calf region of the right lower limb tested positive for Trendelenburg test and negative for Moses’ sign, but pedal pulse was present which was suggestive of varicose ulcer features [].\nOn the basis of symptoms such as attivivṛttavraṇa (spreading nature), utsanna (elevated margin), raktavarṇa (reddish), srāva (secretion), dāha (burning sensation), and shopha (swelling) present in the patient, he was diagnosed as having duṣṭa vraṇa with vātapradhānatridoshajavraṇa. Informed consent was obtained from the patient for documentation and publication of his case history.\nThe following treatment schedule was executed:\nNimbāmr.tādi castor oil (processed castor oil with Azadirachta indica and Tinospora cordifolia) - 50 ml orally used for Nitya virecana with 50 ml Śuntṇ hīkashāyam for three continuous days Nitya virecana is the specific therapy in Ayurveda in which the medicine may be processed in oil or as decoction is administered orally for cleansing the bowel and liver system. This improves the Agni metabolism of the individual. This is the first and necessary step in any Basti therapy. Next therapy is the main line of treatment, i.e. Basti karma (specific scheduled course of medicine administered through rectal route).\nOn day 4 of management, Mañjiṣṭhādi Basti karma was started with Balaguḍūcyādi Anuvāsana Basti (60 ml) in kāla basti pattern. The schedule was planned in accordance with the chart given below.\nIn the preparation of enema decoction, the above order was followed for the mixing of medicine, and decoction enema was usually administered on empty stomach.\nIn N2 Basti, Go arkam (distilled cow's urine) is not added for the decoction and the Kaśāyam (decoction) preparation is changed to Kāyam (decoction) preparation is changed to Ks.īrapāka preparation.\nSpecific decoction processed in milk –Mañjiṣṭhā + Guḍūci + Yaṣṭhimadhu Kṣīrapāka (300 ml) used to prepare enema decoction.\nAB, Anuvāsana Basti (enema for oleation consists of only the medicine processed in oil or ghee).\nThe pain was measured on visual analogue scale (VAS), the edema was measured by figure-of-eight method of measuring ankle joint swelling,[] and the ulcerated wound was assessed by measurement and granulation tissue formation.\nNoticeable improvement in the symptoms was seen, it was upto 60% in Śotha (edematous swelling), Dāha (burning sensation) was reduced up to 40%, and Toda (pricking sensation) was reduced up to 30% after Nitya virecana. Moreover, Basti karma, Śotha (edematous swelling) was reduced to 95%, Dāha to 70%, and Toda (pricking sensation) was reduced to 80%. Healing of the ulcerous wound started with the proliferative stage by the 3rd day of the Basti course and the wound got healed up to 90% after the whole course of Basti karma with no adverse event during the entire course of treatment [].