Dwivraniya Chikitsa
Chikitsa Sthana Chapter 25. Management of two types of Vrana (ulcers)
| Section/Chapter | Chikitsa Sthana Chapter 25 |
|---|---|
| Preceding Chapter | Madatyaya Chikitsa |
| Succeeding Chapter | Trimarmiya Chikitsa |
| Other Sections | Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Kalpa Sthana, Siddhi Sthana |
| Translator and commentator | Singh L., Sharma A., Dudhamal T.S. |
| Reviewer | Dudhamal T.S. |
| Editors | Dudhamal T.S., Deole Y.S., Basisht G. |
| Year of publication | 2020 |
| Publisher | Charak Samhita Research, Training and Skill Development Centre |
| DOI | 10.47468/CSNE.2020.e01.s06.026 |
Abstract
Vrana (ulcers) are of two types, nija vrana (endogenous ulcers) and agantuka vrana (exogenous ulcers). This classification is based on etiology and mode of treatments. Endogenous ulcers are caused by vitiation of vata etc. dosha from initial stage while exogenous ulcers are caused initially by various types of trauma and later dosha vitiation occurs. Complications of ulcers like visarpa (erysipelas), sirastambha (constricted vessels), jwara (fever) etc. have been described. Importance of bloodletting is described during the stage of vrana shopha (i.e.inflammatory phase), alleviation of impure blood from body reduces toxic chemicals and pacifies dosha. Description of fracture, its complications and management is elaborated. Dahakarma (cauterization) causes constriction of blood vessels to prevent bleeding from ulcer. Application of alkaline substances (kshara) on ulcer can be done along with surgical intervention and cauterization. Prognosis of ulcer can be described on the basis of type of ulcer and its various locations.
Keywords: Vrana (ulcer), trividha pariksha, bloodletting, dahakarma (cauterization), shodhanakarma (cleansing of ulcer), ropankarma (healing of ulcer), wound management, non healing ulcers.
Introduction
The term vrana literally means destruction or rupture or discontinuation of body tissues. This chapter gives comprehensive information about endogenous and exogenous ulcers. Trividha pariksha or three different ways of examination of ulcer is done by darshana (inspection), prashna (interrogation) and sparshana (palpation). Inspection i.e. visual examination deals with general examination (whole body) and local examination (specific part or organ) to make proper diagnosis. The etiological factors, nature of pain, ability to get used to food (satmya/asatmya), drugs, status of digestive power etc are examined by interrogation. Palpation is the mode of direct examination done by palpating the margin, size, depth, temperature, stiffness or hardness etc. Prognosis of ulcer is determined by its location eg. skin (tvaka), blood vessels (shira), muscle tissue (mamsa dhatu), fatty tissue (meda dhatu), bone (asthi dhatu), ligament (snayu), vital organs (marma)[1],visceras of chest and abdomen (antarashraya)[2] [ Cha. Sa. Sharira Sthana 7/10 ]
Various complications of ulcers like visarpa (erysipelas), pakshaghata (hemiplegia), shirastambha (constricted vessels), jwara (fever) etc. are described. Sloughing of ligaments and vessels, deep seated appearance of maggots, fracture of bone near the ulcer, presence of foreign body in the ulcer etc hamper the healing process. Treatment of nija vrana (endogenous ulcer)[3] is different from agantuja vrana (exogenous ulcer) because endogenous ulcers are caused by vitiation of vatadi doshaja, and exogenous ulcers are initially caused by various type of trauma such as vadha (stab injury etc.), bandha (excessive tying), prapatana (injury due to fall), injury due to teeth and nail etc. But later on in exogenous ulcers also involvement of dosha takes place and then treatment should be adopted as nija vrana (endogenous ulcer). In endogenous ulcers, shodhana therapy should be adopted by vamana (emesis), virechana (purgation) and basti (medicated enema) and blood letting for removal of doshaja (toxic materials) from body. [ Cha. Sa. Sutra Sthana 16/17 ] and agnikarma. Agnikarma has ushna guna (hot property) which is opposite to vata and kapha. Due to heat, vasodilation leads to alleviation of srotorodha resulting in proper vascularity to organ or part. In exogenous ulcers, local treatment with use of kshara (alkaline substances), surgical intervention and cauterization is recommended.
Sanskrit Text, Transliteration and English Translation
Now we shall expound the chapter "Dwivraniya chikitsa" (Management of two types of ulcers).Thus said Lord Atreya.[1-2]
Query by Agnivesha
परावरज्ञमात्रेयं गतमानमदव्यथम् |
अग्निवेशो गुरुं काले विनयादिदमब्रवीत् ||३||
भगवन्! पूर्वमुद्दिष्टौ द्वौ व्रणौ रोगसङ्ग्रहे |
तयोर्लिङ्गं चिकित्सां च वक्तुमर्हसि शर्मद! ||४||
Agnivesha, in opportune moment, respectfully submitted to his teacher Atreya, knower of the best and the worst and devoid of conceit, ego and suffering –“ O Lord ! Two types of ulcers have been mentioned earlier under enumeration of disorders; kindly describe their symptoms and treatment O conferer of happiness!”[3-4]
Classification and etiology of vrana
इत्यग्निवेशस्य वचो निशम्य गुरुरब्रवीत् |
यौ व्रणौ पूर्वमुद्दिष्टौ निजश्चागन्तुरेव च ||५||
श्रूयतां विधिवत् सौम्य! तयोर्लिङ्गं च [१] भेषजम् |
निजः शरीरदोषोत्थ आगन्तुर्बाह्यहेतुजः ||६||
वधबन्धप्रपतनाद्दंष्ट्रादन्तनखक्षतात् |
आगन्तवो व्रणास्तद्वद्विषस्पर्शाग्निशस्त्रजाः ||७||
मन्त्रागदप्रलेपाद्यैर्भेषजैर्हेतुभिश्च ते |
लिङ्गैकदेशैर्निर्दिष्टा विपरीता निजैर्व्रणैः [२] ||८||
After listening the request of Agnivesa the teacher said – ‘O gentle! Listen about the symptoms and treatment of the two types of vrana (ulcers) , endogenous ulcer and exogenous ulcer, as mentioned earlier.The endogenous ulcers occur from the bodily dosha, whereas the exogenous ulcers are caused by external causative factors. Exogenous ulcer are caused by blowing, binding, falling down, injury with fangs, teeth or nails as well as due to poisonous contact, fire and weapons etc. Exogenous ulcers are different from the endogenous ones in respect of treatment with mantra (incantations), anti-poisonous pastes for external application etc. While endogenous ulcer bears opposite characteristic features in respect of etiology, sign symptoms and treatment. [5-8]
Importance of dosha dominance in treatment
Exogenous ulcers not being pacified and having endogenous causative factors should be treated as endogenous ulcers according to predominance of dosha.[9]
Endogenous ulcers
यथास्वैर्हेतुभिर्दुष्टा वातपित्तकफा नृणाम् |
बहिर्मार्गं समाश्रित्य जनयन्ति निजान् व्रणान् ||१०||
Vata, pitta and kapha are vitiated by their respective causes get lodged in external passage and thus produce endogenous ulcers. [10]
Dosha dominant vrana and their treatment
Vata dominant vrana and treatment
स्तब्धः कठिनसंस्पर्शो मन्दस्रावोऽतितीव्ररुक् [१] |
तुद्यते स्फुरति श्यावो व्रणो मारुतसम्भवः ||११||
सम्पूरणैः स्नेहपानैः स्निग्धैः स्वेदोपनाहनैः |
प्रदेहैः परिषेकैश्च वातव्रणमुपाचरेत् ||१२||
The ulcer caused by vata is stiff, hard to touch, with scanty exudation, excruciating and pricking pain with throbbing and blackish discoloration. Vatika ulcer should be treated with sampurana (filling of ulcer cavity), intake of unctuous substances (oleation therapy), unctuous fomentation and poultices, ointments and sprinklings.[11-12]
Pitta dominant vrana and treatment
तृष्णामोहज्वरस्वे(क्ले)ददाहदुष्ट्यवदारणैः |
व्रणं पित्तकृतं विद्याद्गन्धैः स्रावैश्च पूतिकैः ||१३||
शीतलैर्मधुरैस्तिक्तैः प्रदेहपरिषेचनैः |
सर्पिष्पानैर्विरेकैश्च पैत्तिकं शमयेद्व्रणम् ||१४||
Pittaja ulcer is known from thirst, unconsciousness, fever, sweating, burning sensation, impurity, tearing and foul smell with discharge of pus from ulcer. One should pacify the pittaja ulcer by anointing and sprinkling with cold, intake of sweet and bitter drugs, intake of ghee and purgation. [13-14]
Kapha dominant vrana and treatment
बहुपिच्छो गुरुः स्निग्धः स्तिमितो मन्दवेदनः |
पाण्डुवर्णोऽल्पसङ्क्लेदश्चिरकारी कफव्रणः ||१५||
कषायकटुरूक्षोष्णैः प्रदेहपरिषेचनैः |
कफव्रणं प्रशमयेत्तथा लङ्घनपाचनैः [३] ||१६||
Kaphaja ulcer has much sliminess, heavyness, unctuousness, numbness, with mild pain, paleness in color, little slough and prolonged healing. Kaphaja ulcer is treated with anointing and sprinkling with astringent, pungent, dry and hot drugs as well as fasting and digestive measures.[15-16]
तौ द्वौ नानात्वभेदेन निरुक्ता विंशतिर्व्रणाः |
तेषां परीक्षा त्रिविधा, प्रदुष्टा द्वादश स्मृताः ||१७||
स्थानान्यष्टौ तथा गन्धाः, परिस्रावाश्चतुर्दश |
षोडशोपद्रवा दोषाश्चत्वारो विंशतिस्तथा ||१८||
तथा चोपक्रमाः सिद्धाः षट्त्रिंशत् समुदाहृताः |
विभज्यमानाञ्छृणु [१] मे सर्वानेतान् यथेरितान् ||१९||
Above two types of ulcers are further divided into twenty types on the basis of distinctive features. Their examination can be done by three ways, signs of excess vitiation at site of ulcers are of twelve types, eight locations, fourteen types of discharges, sixteen complications, twenty four defects and thirty six therapeutic measures. Now listen about these in details. [17-19]
Twenty types of ulcers
कृत्योत्कृत्यस्तथा [१] दुष्टोऽदुष्टो मर्मस्थितो न च |
संवृतो दारुणः स्रावी सविषो विषमस्थितः ||२०||
उत्सङ्ग्युत्सन्न एषां च व्रणान् विद्याद्विपर्ययात् |
इति नानात्वभेदेन निरुक्ता [२] विंशतिर्व्रणाः ||२१||
Curable (can be treated with surgical intervention), incurable; infected, non-infected; situated in vital parts, not situated in vital parts; closed, open; hard, soft; discharging, non-discharging; poisonous, non-poisonous; unevenly located, evenly located; pouched, un-pouched; elevated, depressed – these are the twenty types of ulcers according to various distinguishing features.[20-21]
Three fold examination
दर्शनप्रश्नसंस्पर्शैः परीक्षा त्रिविधा स्मृता |
वयोवर्णशरीराणामिन्द्रियाणां च दर्शनात् ||२२||
हेत्वर्तिसात्म्याग्निबलं परीक्ष्यं वचनाद्बुधैः |
स्पर्शान्मार्दवशैत्ये च परीक्ष्ये सविपर्यये ||२३||
Examination of ulcer can be performed by three methods e.g. by inspection, interrogation and palpation.
Age, complexion and color, body parts and sense organs are examined by inspection. Etiology, nature of pain, suitability and power of digestion should be known by patient’s statement. By palpation softness and coldness are known with their contraries. [22-23]
Twelve types of ulcers
श्वेतोऽवसन्नवर्त्माऽतिस्थूलवर्त्माऽतिपिञ्जरः [१] |
नीलःश्यावोऽतिपिडको रक्तः कृष्णोऽतिपूतिकः ||२४||
रोप्यः कुम्भीमुखश्चेति प्रदुष्टा द्वादश व्रणाः |
चतुर्विंशतिरुद्दिष्टा [२] दोषाः कल्पान्तरेण वै ||२५||
White, with depressed margins, very thick margins, much greyish (pinjara), blue, blackish, surrounded with numerous boils, red, black, very fetid odor, non- healing nature and bottle-necked (narrow opening) these are twelve types of defective (dushta) ulcers.[24-25]
Sites of vitiation
त्वक्सिरामांसमेदोऽस्थिस्नायुमर्मान्तराश्रयाः |
व्रणस्थानानि निर्दिष्टान्यष्टावेतानि सङ्ग्रहे ||२६||
In the treatise, eight locations of wounds have been mentioned such as skin, blood vessels, flesh, fat, bone, ligament, vital parts and viscera.[26]
Specific odors of vrana
Eight types of wound odors have been defined by the experts like ghee, oil, muscle-fat, pus, blood, and cadaver, sour and fetid.[27]
Fourteen types of discharges and sixteen complications
लसीकाजलपूयासृग्घारिद्रारुणपिञ्जराः |
कषायनीलहरितस्निग्धरूक्षसितासिताः ||२८||
इति रूपैः समुद्दिष्टा व्रणस्रावाश्चतुर्दश |
विसर्पः पक्षघातश्च सिरास्तम्भोऽपतानकः ||२९||
मोहोन्मादव्रणरुजो ज्वरस्तृष्णा हनुग्रहः |
कासश्छर्दिरतीसारो हिक्का श्वासः सवेपथुः ||३०||
षोडशोपद्रवाः प्रोक्ता व्रणानां व्रणचिन्तकैः |३१|
Discharges from ulcers are of fourteen types in appearance such as lasika (like lymph), water, pus, blood, color of exudation as yellow, reddish, brownish, ochre-colored, blue, green, unctuous, rough, white and black.
The experts have mentioned sixteen complications of wounds such as erysipelas, paralysis, occlusion in blood vessels, tetanus, and mental confusion, and insanity, pain in wound, fever, thirst, lockjaw, cough, vomiting, diarrhea, hiccups, dyspnea and trembling.[28-31]
Causes of non-healing ulcers
स्नायुक्लेदात्सिराक्लेदाद्गाम्भीर्यात्कृमिभक्षणात् [१] ||३१||
अस्थिभेदात् सशल्यत्वात् सविषत्वाच्च [२] सर्पणात् |
नखकाष्ठप्रभेदाच्च चर्मलोमातिघट्टनात् [३] ||३२||
मिथ्याबन्धादति स्नेहादतिभैषज्यकर्षणात् |
अजीर्णादतिभुक्ताच्च विरुद्धासात्म्यभोजनात् ||३३||
शोकात् क्रोधाद्दिवास्वप्नाद्व्यायामान्मैथुनात्तथा |
व्रणा न प्रशमं यान्ति निष्क्रियत्वाच्च देहिनाम् ||३४||
परिस्रावाच्च गन्धाच्च दोषाच्चोपद्रवैः सह |
व्रणानां बहुदोषाणां कृच्छ्रत्वं चोपजायते ||३५||
Defects are known to be twenty four according to etiological factors which are as follows: moistening of ligaments, excess of fluid in blood vessels, deepness, eaten by maggots, cracking of bones, presence of foreign body, presence of toxins, spreading, excessive tearing with nails or wooden piece, friction of skin, friction of body hair, faulty bandage, over-application of uncting substance, excessive emaciation due to over dose, indigestion, over-eating, intake of incompatible food items, unsuitable food, grief, anger, day-sleep, physical exercise, sexual intercourse and inactivity.These factors lead to delay in the healing process. Ulcers having much impurity become difficult to be cured due to presence of excessive discharges, odors, defects and complications.[31-35]
Factors affecting prognosis
त्वङ्मांसजः सुखे देशे तरुणस्यानुपद्रवः |
धीमतोऽभिनवः काले सुखसाध्यः स्मृतो व्रणः ||३६||
गुणैरन्यतमैर्हीनस्ततः कृच्छ्रो व्रणः स्मृतः |
सर्वैर्विहीनो विज्ञेयस्त्वसाध्यो निरुपक्रमः [१] ||३७||
Wound is easily curable if it is located in skin and muscles, easy places, youthful age, without complication, in a wise patient and of recent origin. If it is devoid of some of these qualities it is curable with difficulty and when it is devoid of all the qualities it is incurable and thus not to be treated.[36-37]
Principles of management
व्रणानामादितः कार्यं यथासन्नं विशोधनम् |
ऊर्ध्वभागैरधोभागैः शस्त्रैर्बस्तिभिरेव च ||३८||
सद्यः शुद्धशरीराणां प्रशमं यान्ति हि व्रणाः |३९|
In cases of wound, first of all, purification with therapeutic emesis, purgation, shastra karma (surgical intervention) and basti (medicated enema) should be done after assessment of condition because the wounds get healed quickly in those with cleansed body.[38-39]
Procedures for management of ulcers
यथाक्रममतश्चोर्ध्वं शृणु सर्वानुपक्रमान् ||३९||
शोफघ्नं षड्विधं चैव शस्त्रकर्मावपीडनम् |
निर्वापणं ससन्धानं स्वेदः शमनमेषणम् ||४०||
शोधनौ रोपणीयौ च कषायौ सप्रलेपनौ |
द्वे तैले तद्गुणे [१] पत्रं छादने द्वे च बन्धने ||४१||
भोज्यमुत्सादनं दाहो द्विविधः सावसादनः |
काठिन्यमार्दवकरे धूपनालेपने शुभे ||४२||
व्रणावचूर्णनं वर्ण्यं रोपणं लोमरोहणम् |
इति षट्त्रिंशदुद्दिष्टा व्रणानां समुपक्रमाः ||४३||
Hereafter listen about all the measures of treatment in order such as – measures for pacification of swelling, six types of surgical operations, pressing, cooling?, uniting, fomentation, pacification, probing, cleansing, healing, cleaning paste, healing paste, cleaning oil, healing oil, two types of covering with leaf, two types of bandaging, diet, elevation, two types of cauterization, depression, hardening fumigation, softening fumigation, hardening paste, softening paste, powdering, colorization, healing, repilatory- these are the thirty six measures of treatment of wounds.[39-43]
Guidelines for management of ulcers
पूर्वरूपं भिषग्बुद्ध्वा व्रणानां शोफमादितः |
रक्तावसेचनं कुर्यादजातव्रणशान्तये ||४४||
शोधयेद्बहुदोषांस्तु स्वल्पदोषान् विलङ्घयेत् |
पूर्वं कषायसर्पिर्भिर्जयेद्वा मारुतोत्तरान् ||४५||
न्यग्रोधोदुम्बराश्वत्थप्लक्षवेतसवल्कलैः |
ससर्पिष्कैः प्रलेपः स्याच्छोफनिर्वापणः परम् ||४६||
विजया मधुकं वीरा बिसग्रन्थिः शतावरी |
नीलोत्पलं नागपुष्पं प्रदेहः स्यात् सचन्दनः ||४७||
सक्तवो मधुकं सर्पिः प्रदेहः स्यात् सशर्करः |
अविदाहीनि चान्नानि शोफे भेषजमुत्तमम् ||४८||
The physician observing shopha (swelling) as prodromal sign in the beginning should apply blood-letting to prevent the manifestation of wound. One should evacuate the persons with plenty of impurity and lighten those with little impurity. He should overcome the wound predominant in vata first with decoctions and ghritas. Paste of nyogrodha bark (Ficus bengalensis Linn.), udumbara (Ficus glomerata Roxb.), ashwattha (Ficus religiosa Linn.), plaksha (Ficus lacor Buch.Ham.) and vetasa (Salix caprea Linn.) are mixed with ghee is an excellent cooling for inflammation, other local applications prescribed are (1) vijaya (Terminalia chebula Retz.), madhuka (Glycyrrhiza glabra Linn.), vira , bisagranthi, shatavari (Asparagus racemosus Willd.), nilotpala (Nymphea stellata Willd.), nagapuspa (Mesua ferrea Linn.) and sandal (Santalum album Linn.). (2) Parched grain flour, madhuka, sarkara and ghee. Avidahi (non-burning) food is the best remedy for inflammation.[44-48]
Patana (incision) and upanaha (poultice)
स चेदेवमुपक्रान्तः शोफो न प्रशमं व्रजेत् |
तस्योपनाहैः पक्वस्य पाटनं हितमुच्यते ||४९||
तैलेन सर्पिषा वाऽपि ताभ्यां वा सक्तुपिण्डिका |
सुखोष्णा शोफपाकार्थमुपनाहः प्रशस्यते ||५०||
सतिला सातसीबीजा दध्यम्ला सक्तुपिण्डिका |
सकिण्वकुष्ठलवणा शस्ता स्यादुपनाहने ||५१||
रुग्दाहरागतोदैश्च विदग्धं शोफमादिशेत् |
जलबस्तिसमस्पर्शं सम्पक्वं पीडितोन्नतम् ||५२||
उमाऽथो गुग्गुलुः सौधं पयो दक्षकपोतयोः |
विट् पलाशभवः क्षारो हेमक्षीरी मुकूलकः ||५३||
इत्युक्तो भेषजगणः पक्वशोथप्रभेदनः |
सुकुमारस्य, कृच्छ्रस्य शस्त्रं तु परमुच्यते ||५४||
If swelling of ulcers treated in this way does not subside, poultice should be applied and when ripened should be incised. Warm poultice of the bolus of parched grain flour mixed with oil or ghee or both is useful for ripening of inflammation. The bolus of parched grain flour mixed with tila (Sesamum indicum Linn.), linseeds (Linum usitatissimum Linn.), sour curd, yeast, kustha (Saussurea lappa C. B. Clarke) and salt is recommended as poultice.
Swelling is known as vidagdha (under ripening) by the symptoms such as pain, burning sensation, redness and piercing pain. The same should be known as ripened when it is like water-bag on palpation and rises on pressure. Linseed, guggulu (Commiphora mukul), latex of snuhi (Euphorbia neriifolia Linn.), feces of chicken and pigeon, alkali of palasha (Butea monosperma Linn.), svarnakhsiri (Argemone mexicana Linn.) and mukulaka (Pistacia vera Linn.). This is the group of drugs which helps in the tearing of ripened inflammation in delicate patients otherwise it should be operated upon surgically.[49-54]
Six types of surgical procedures
Surgical treatment is of six types such as – incision, puncturing, excision, scrapping, scarification and suturing.[55]
Indications of various surgical procedures
नाडीव्रणाः पक्वशोथास्तथा क्षतगुदोदरम् |
अन्तःशल्याश्च ये शोफाः [१] पाट्यास्ते तद्विधाश्च ये ||५६||
दकोदराणि सम्पक्वा गुल्मा ये ये च रक्तजाः |
व्यध्याः शोणितरोगाश्च विसर्पपिडकादयः ||५७||
उद्वृत्तान् स्थूलपर्यन्तानुत्सन्नान् कठिणान् व्रणान् |
अर्शःप्रभृत्यधीमांसं छेदनेनोपपादयेत् ||५८||
किलासानि सकुष्ठानि लिखेल्लेख्यानि बुद्धिमान् |
वातासृग्ग्रन्थिपिडकाः सकोठा रक्तमण्डलम् ||५९||
कुष्ठान्यभिहतं चाङ्गं शोथांश्च प्रच्छयेद्भिषक् |
सीव्यं कुक्ष्युदराद्यं तु गम्भीरं यद्विपाटितम् ||६०||
इति षड्विधमुद्दिष्टं शस्त्रकर्म मनीषिभिः |६१|
Sinuses, ripened inflammations (i.e.suppurated ulcer or abscess), intestinal perforation, intestinal obstruction, having foreign body within and other similar conditions are incisable. Ascites, suppurated tumor and raktaja gulma (uterine tumor), blood disorders such as erysipelas, boils etc, are treated by puncturing. Wounds protruded with thick margins, elevated, hard, piles etc and other growths should be excised.The wise physician should scrape leucoderma, skin diseases and other such disorders which need scraping. The physician should perform scarification over vatarakta(nodular swelling), granthi (cysts) pimples, urticarial rashes, red patches, skin diseases, injured parts and swellings. Suturing should be done in pelvic, abdominal surgeries (i.e., laparotomy) etc.Thus the scholars have mentioned six types of surgical treatments.[56-61]
Vrana pidana(pressing of wound)
सूक्ष्माननाः कोषवन्तो ये व्रणास्तान्प्रपीडयेत् ||६१||
कलायाश्च मसूराश्च गोधूमाः सहरेणवः |
कल्कीकृताः प्रशस्यन्ते निःस्नेहा व्रणपीडने ||६२||
Wounds with narrow opening and multiple loculi should be pressed on. Kalaya (Pisum sativum Linn.), masura (Lens culinaris Medic.), wheat (Triticum sativum Lam.) and peas pounded and applied as paste without mixing any fat are useful for pressing the wound.[61-62]
Various treatment modalities for pacification of ulcer
शाल्मलीत्वग्बलामूलं तथा न्यग्रोधपल्लवाः |
न्यग्रोधादिकमुद्दिष्टं बलादिकमथापि वा ||६३||
आलेपनं निर्वपणं तद्विद्यात्तैश्च [१] सेचनम् |
सर्पिषा शतधौतेन पयसा मधुकाम्बुना ||६४|
निर्वापयेत् सुशीतेन रक्तपित्तोत्तरान् व्रणान् |६५|
Bark of shalmali (Salmalia malabarica Schott), bala (Sida cordifolia) root, tender leaves of nyagrodha – this group (of drugs) known as nyagrodhadi or baladi acts as cooling agent applied as paste and sprinkling. Wounds predominant in raktapitta should be cooled by applying very cold ghee washed hundred times, milk or decoction of madhuka (Madhuka indica).[63-65]
लम्बानि व्रणमांसानि प्रलिप्य मधुसर्पिषा ||६५||
सन्दधीत समं वैद्यो बन्धनैश्चोपपादयेत् |
तान्समान्सुस्थिताञ्ज्ञात्वा फलिनीलोध्रकट्फलैः ||६६||
समङ्गाधातकीयुक्तैश्चूर्णितैरवचूर्णयेत् |
पञ्चवल्कलचूर्णैर्वा शुक्तिचूर्णसमायुतैः ||६७||
धातकीलोध्रचूर्णैर्वा तथा रोहन्ति ते व्रणाः |६८|
Chronic wound should be pasted with honey and ghee there after bandaged leads to evenly union.When they are evenly set, powder of priyangu (Callicarpa macrophylla Vahl.), lodhra (Symplocos racemosa Roxb.), katphala (Myrica esculenta Buch-Ham.), lajjalu (Mimosa pudica Linn.) and dhataki (Woodfordia fruticosa Kurz.) should be applied thereon or the powder of panchavalkala mixed with that of sukti bhasma (pearl ash) or the powder of dhataki and lodhra should be applied.
Application of above measures leads to proper wounds healing.[65-68]
Management of bone fracture and dislocation
अस्थिभग्नं च्युतं सन्धिं सन्दधीत समं पुनः ||६८||
समेन सममङ्गेन कृत्वाऽन्येन विचक्षणः |
स्थिरैः कवलिकाबन्धैः कुशिकाभिश्च संस्थितम् ||६९||
पट्टैः प्रभूतसर्पिष्कैर्बध्नीयादचलं सुखम् |
अविदाहिभिरन्नैश्च पैष्टिकैस्तमुपाचरेत् ||७०||
ग्लानिर्हि न हिता तस्य सन्धिविश्लेषकारिका |
विच्युताभिहताङ्गानां विसर्पादीनुपद्रवान् ||७१||
उपाचरेद्यथाकालं [१] कालज्ञः स्वाच्चिकित्सितात् |७२|
Fractured bone and dislocated joints should be set correctly comparing with its counterpart. Setting with firm pad-bandages and splints, it should be immobilized without any discomfort by binding with cloth pieces dipped in plenty of ghee. The patient should be kept on non-burning foods (avidahi) made of flour. Such patients should not resort to physical exercise which may cause dislocation of joint. The physician, according to time, should treat the complications such as erysipelas etc in fracture and dislocation of bone. [68-72]
Management of various conditions of vrana
शुष्का महारुजः स्तब्धा ये व्रणा मारुतोत्तराः |
स्वेद्याः सङ्करकल्पेन ते स्युः कृशरपायसैः ||७२||
ग्राम्यबैलाम्बुजानूपैर्वैशवारैश्च संस्कृतैः |
उत्कारिकाभिश्चोष्णाभिः सुखी स्याद्व्रणितस्तथा ||७३||
सदाहा वेदनावन्तो ये व्रणा मारुतोत्तराः |
तेषामुमां तिलांश्चैव भृष्टान् पयसि निर्वृतान् ||७४||
तेनैव पयसा पिष्ट्वा कुर्यादालेपनं भिषक् |
बला गुडूची मधुकं पृश्निपर्णी शतावरी ||७५||
जीवन्ती शर्करा क्षीरं तैलं मत्स्यवसा घृतम् |
संसिद्धा समधूच्छिष्टा शूलघ्नी स्नेहशर्करा ||७६||
द्विपञ्चमूलक्वथितेनाम्भसा पयसाऽथवा [१] |
सर्पिषा वा सतैलेन कोष्णेन परिषेचयेत् ||७७||
यवचूर्णं समधुकं सतिलं सह सर्पिषा |
दद्यादालेपनं कोष्णं दाहशूलोपशान्तये ||७८||
उपनाहश्च कर्तव्यः सतिलो मुद्गपायसः |
रुग्दाहयोः प्रशमनो व्रणेष्वेष विधिर्हितः ||७९||
Wounds which are dry, intensely painful, stiffened and predominant in vata should be fomented by bolus fomentation with krishara and payasa (a type of dietary preparation). Similarly, they should be fomented with seasoned vesavara made of the meat of domestic, burrow-dwellers, aquatic or marshy animals or hot utkarika. Thus the patient gets relief. If the wounds predominant in vata have burning sensation and pain, they should be pasted upon with linseed and sesamum seeds roasted, then dipped in milk and again pounded with the same milk. Bala (Sida cordifolia Linn.), guduchi (Tinospora cordifolia), madhuka (Glycyrrhiza glabra Linn.), prishnaparni (Uraria picta Desv), shatavari (Asparagus racemosus Willd), jivanti (Leptadenia reticulate W. & A.), sugar, milk, oil, fish fat, ghee cooked with beeswax is known as sneha sarkara, it relieves pain.The wound should be sprinkled with warm decoction of two panchamula (ie.dashamula), milk and ghee with oil.
Barley powder (Hordeum vulgare Linn.), madhuka (Glycyrrhiza glabra Linn.) and tila mixed with ghee should be applied as warm paste for alleviating burning sensation and pain. Payasa prepared of mudga (Phaseolus radiates Linn.) mixed with tila should be applied as poultice to pacify pain and burning sensation. These management principles are beneficial in wounds.[72-79]
Eshana (Probing)
सूक्ष्मानना बहुस्रावाः कोषवन्तश्च ये व्रणाः |
न च मर्माश्रितास्तेषामेषणं हितमुच्यते ||८०||
द्विविधामेषणीं विद्यान्मृद्वीं च कठिनामपि |
औद्भिदैर्मृदुभिर्नालैर्लोहानां वा शलाकया ||८१||
गम्भीरे मांसले देशे पाट्यं लौहशलाकया |
एष्यं विद्याद्व्रणं नालैर्विपरीतमतो भिषक् ||८२||
In case of wounds with narrow opening, profuse discharge and pouch and not situated in vital parts, probing is beneficial. Probe is of two types – soft and hard, the former is made of soft stalks of plants and the latter of iron (metallic) rods. In deep and muscular parts iron rods preferred while in other parts plant stalks should be used for probing. [80-82]
Vrana shodhana (local purification of ulcers)
पूतिगन्धान् विवर्णांश्च बहुस्रावान्महारुजः |
व्रणानशुद्धान् विज्ञाय शोधनैः समुपाचरेत् ||८३||
त्रिफला खदिरो दार्वी न्यग्रोधादिर्बला [१] कुशः |
निम्बकोलकपत्राणि कषायाः शोधना मताः ||८४||
तिलकल्कः सलवणो द्वे हरिद्रे त्रिवृद्धृतम् |
मधुकं निम्बपत्राणि प्रलेपो व्रणशोधनः ||८५||
Wounds with foul odor, abnormal color, profuse discharge and intense pain should be known as dushta vrana (unclean) and as such wounds should be treated with cleansing agents. Decoctions of triphala, khadira (Acasia catechu Willd), daruharidra (Berberis aristata DC), nyagrodhadi group, bala (Sida cordifolia Linn.), kusa (Desmostachya bipinnata Stapf.), leaves of nimba (Azadirachta indica A. Juss) and badara (Zizyphus jujube Lam.) are regarded as cleansing drugs. Tila paste, salt, haridra (Curcuma longa Linn.), daruharidra (Berberis aristata DC), trivrit (Operculina turpethum Linn.) ghrita, madhuka, nimba leaves – this formulation is said as wound cleanser. [83-85]
Ropana (healing) of ulcer
नातिरक्तो नातिपाण्डुर्नातिश्यावो न चातिरुक् |
न चोत्सन्नो न चोत्सङ्गी शुद्धो रोप्यः परं व्रणः ||८६||
न्यग्रोधोदुम्बराश्वत्थकदम्बप्लक्षवेतसाः |
करवीरार्ककुटजाः कषाया व्रणरोपणाः ||८७||
चन्दनं पद्मकिञ्जल्कं दार्वीत्वङ्नीलमुत्पलम् |
मेदे मूर्वा समङ्गा च यष्ट्याह्वं व्रणरोपणम् ||८८||
प्रपौण्डरीकं जीवन्ती गोजिह्वा धातकी बला |
रोपणं सतिलं दद्यात् प्रलेपं सघृतं व्रणे ||८९||
कम्पिल्लकं विडङ्गानि वत्सकं त्रिफलां बलाम् |
पटोलं पिचुमर्दं च लोध्रं मुस्तं प्रियङ्गुकम् ||९०||
खदिरं धातकीं सर्जमेलामगुरुचन्दने |
पिष्ट्वा साध्यं भवेत्तैलं तत् परं व्रणरोपणम् ||९१||
प्रपौण्डरीकं मधुकं काकोल्यौ द्वे च चन्दने |
सिद्धमेतैः समैस्तैलं परं स्याद्व्रणरोपणम् ||९२||
दूर्वास्वरससिद्धं वा तैलं कम्पिल्लकेन वा |
दार्वीत्वचश्च कल्केन प्रधानं व्रणरोपणम् ||९३||
येनैव विधिना तैलं घृतं तेनैव साधयेत् |
रक्तपित्तोत्तरं दृष्ट्वा रोपणीयं व्रणं भिषक् ||९४|
Those ulcers, are not very red, pale, blackish, painful, elevated and protruded should be known as clean and appeals healing process. Decoction of nyagrodha, udumbara, asvattha, kadamba, plaksha, vetasa, karavira (Nerium indicum Mill.), arka (Calotropis procera R. Br.) and kutaja (Holarrhena antidysentrica Linn.) are wound healing. Chandana (Santalum album Linn.), lotus stamens, daruharidra bark, blue water lily, meda (Polygonatum airrhifolium Royle), mahameda (Polygonatum airrhifolium Royle), murva (Marsdenia tenacissima W. & A.), lajjalu (Mimosa pudica Linn.) and madhuyasti- this formulation is wound healer. Prapaundarika, jivanti, gojihva (Onosma bracteatum Wall.), dhataki, bala and sesamum should be applied as paste with ghee for wound healing. Kampillaka (Mallotus philippinensis Muell Arg), vidanga (Embelia ribes Burm), kutaja, triphala, bala, patola (Trichosanthes dioica Roxb.), nimba, musta (Cyperus rotundus Linn.), priyangu, khadira, dhataki, sarja, ela (Elleteria cardamomum Maton.), aguru (Aquilaria agallocha Roxb.) and chandana are pounded together and oil is extracted. This oil is used as ulcer healing agent.
Similarly, oil prepared with equal quantity of prapaundarika, mahuka, kakoli (Roscoca procera Wall.), kshirakakoli (Roscoca procera Wall.), chandana and rakta chandana (Pterocarpus santalinus Linn.) is an excellent ulcer healing agent. Oil cooked with durva juice or kampillaka or paste of daruharidra bark is an important ulcer healer. By the above method ghrita should be prepared and used for healing, ulcers predominant in rakta and pitta.[86-94]
Patta bandhana (bandage)
कदम्बार्जुननिम्बानां पाटल्याः पिप्पलस्य च |
व्रणप्रच्छादने विद्वान् पत्राण्यर्कस्य चादिशेत् ||९५||
वार्क्षोऽथवाऽऽजिनः क्षौमः पट्टो व्रणहितः स्मृतः |
बन्धश्च द्विविधः शस्तो व्रणानां सव्यदक्षिणः ||९६||
For covering the wound, leaves of kadamba, arjuna, nimba, patala (Stereospermum suaveolens DC.), pippala (Ficus religiosa Linn.) and arka should be used. Bandage made of plant bark, deer hide or flaxen cloth is used in wounds. Bandaging of wounds are of two types i.e, It can be started either from left or right side. [95-96]
Contraindications
लवणाम्लकटूष्णानि विदाहीनि गुरूणि च |
वर्जयेदन्नपानानि व्रणी मैथुनमेव च ||९७||
नातिशीतगुरुस्निग्धमविदाहि यथाव्रणम् |
अन्नपानं व्रणहितं हितं चास्वपनं दिवा ||९८||
Patients of ulcer should abstain from salt, sour, pungent, hot, burning and heavy food and drinks and also sexual intercourse. Food and drinks that are not too cold, heavy and fatty, non-burning, according to the nature of ulcer are beneficial, while day-sleep is not suitable in these patient.[97-98]
Suitable food and medicines
स्तन्यानि जीवनीयानि बृंहणीयानि यानि च |
उत्सादनार्थं निम्नानां व्रणानां तानि कल्पयेत् ||९९||
भूर्जग्रन्थ्यश्मकासीसमधोभागानि गुग्गुलुः |
व्रणावसादनं तद्वत् कलविङ्ककपोतविट् ||१००||
For raising the depressed wounds galactogogues (stanyajanana), vitalizers (jeevaniya) and bulk promotives (brinhaniya) drugs should be applied. Similarly, bhurjagranthi (nodes in the tree of Butea utilis), asmakasisa (copper sulphate), purgatives, guggulu and excrement of sparrow and pigeon should be used for depressing the wounds. [99-100]
Indications and contraindications of agni karma (cauterization)
रुधिरेऽतिप्रवृत्ते तु च्छिन्ने च्छेद्येऽधिमांसके |
कफग्रन्थिषु गण्डेषु वातस्तम्भानिलार्तिषु ||१०१||
गूढपूयलसीकेषु गम्भीरेषु स्थिरेषु च |
कलाप्तेषु [१] चाङ्गदेशेषु कर्माग्नेः सम्प्रशस्यते ||१०२||
मधूच्छिष्टेन तैलेन मज्जक्षौद्रवसाघृतैः |
तप्तैर्वा विविधैर्लोहैर्दहेद्दाहविशेषवित् ||१०३||
रूक्षाणां सुकुमाराणां गम्भीरान्मारुतोत्तरान् |
दहेत् स्नेहमधूच्छिष्टैर्लोहैः क्षौद्रैस्ततोऽन्यथा ||१०४||
बालदुर्बलवृद्धानां गर्भिण्या रक्तपित्तिनाम् |
तृष्णाज्वरपरीतानामबलानां विषादिनाम् ||१०५||
नाग्निकर्मोपदेष्टव्यं स्नायुमर्मव्रणेषु च |
सविषेषु च शल्येषु नेत्रकुष्ठव्रणेषु च ||१०६||
Excessive hemorrhage after excision, excisable growths, kaphaja nodules, glands, stiffness and disorders due to vata, wounds with hidden pus and lymph, deep and firm; and after amputation of body part, cauterization is prescribed. The expert in cauterization should cauterize the spot with beeswax, oil, marrow, honey, muscle-fat, ghrita or various heated metallic sticks. Wounds deep and predominant in vata and in patients rough and delicate should be cauterized with fat or beeswax otherwise with iron stick or honey. Cauterization should not be applied in children, debilitated, old persons, pregnant women, those suffering from internal hemorrhage, thirst, fever, weak and poisoned persons and in wounds situated at ligaments and vital parts, poisoned, foreign body, ophthalmic and leprotic wounds.[101-106]
Kshara karma (application of alkali) and dhupana(fumigation)
रोगदोषबलापेक्षी मात्राकालाग्निकोविदः |
शस्त्रकर्माग्निकृत्येषु क्षारमप्यवचारयेत् ||१०७||
कठिनत्वं व्रणा यान्ति गन्धैः सारैश्च धूपिताः |
सर्पिर्मज्जवसाधूपैः शैथिल्यं यान्ति हि व्रणाः ||१०८||
रुजः स्रावाश्च गन्धाश्च कृमयश्च व्रणाश्रिताः |
शैथिल्यं मार्दवं चापि धूपनेनोपशाम्यति ||१०९||
लोध्रन्यग्रोधशुङ्गानि खदिरस्त्रिफला घृतम् |
प्रलेपो व्रणशैथिल्यसौकुमार्यप्रसाधनः ||११०||
सरुजः कठिनाः स्तब्धा निरास्रावाश्च ये व्रणाः |
यवचूर्णैः ससर्पिष्कैर्बहुशस्तान् प्रलेपयेत् ||१११||
मुद्गषष्टिकशालीनां पायसैर्वा यथाक्रमम् |
सघृतैर्जीवनीयैर्वा तर्पयेत्तानभीक्ष्णशः ||११२||
The physician conversant with dose, time and agni (heat) may apply alkali in cases amenable to surgical treatment and cauterization according to severity of disease and morbidity. Wounds attain hardness by being fumigated with aromatic substances and heartwood. The wounds get softened if fumigated with ghrita, marrow or muscle-fat. Through fumigation pain, discharges, odors, maggots, hardness and softness of wounds are removed. Lodhra, leaf-buds of nyagrodha, khadira, triphala and ghrita - this combination used as paste provides looseness and softness in wounds. The wounds which are painful, hard, stiff and without discharge should be pasted frequently with barley powder mixed with ghrita. Wounds may be saturated by applying frequently the paste of payasa (cereals cooked with milk) made of mudga, shashtika and shali rice or jivaniya drugs mixed with ghrita.[110-112]
External applications
ककुभोदुम्बराश्वत्थलोध्रजाम्बवकट्फलैः |
त्वचमाश्वेव गृह्णन्ति त्वक्चूर्णैश्चूर्णिता व्रणाः ||११३||
मनःशिलैला [१] मञ्जिष्ठा लाक्षा च रजनीद्वयम् |
प्रलेपः सघृतक्षौद्रस्त्वग्विशुद्धिकरः परः ||११४||
अयोरजः सकासीसं त्रिफलाकुसुमानि च |
करोति लेपः कृष्णत्वं [२] सद्य एव नवत्वचि ||११५||
कालीयकनताम्रास्थिहेमकान्तारसोत्तमैः [३] |
लेपः सगोमयरसः सवर्णीकरणः परः ||११६||
ध्यामकाश्वत्थनिचुलमूलं लाक्षा सगैरिका |
सहेमश्चामृतासङ्गः कासीसं चेति वर्णकृत् ||११७||
चतुष्पदानां त्वग्लोमखुरशृङ्गास्थिभस्मना |
तैलाक्ता चूर्णिता भूमिर्भवेल्लोमवती पुनः ||११८||
षोडशोपद्रवा ये च व्रणानां परिकीर्तिताः |
तेषां चिकित्सा निर्दिष्टा यथास्वं स्वे चिकित्सिते ||११९||
By dusting the wounds with the powders of barks of kakubha (Termalia arjuna), udumbara, asvattha, lodhra (Symplocos racemosa Roxb), jambu (Eugenia jambolana Lam) and katphala (Myrica esculenta Buch-Ham) they heals the skin quickly.
Manashila (Realgar), manjishtha, lac, haridra and daruharidra used as paste with ghee and honey is an excellent cleanser of skin.
The paste prepared by bhasmas of iron, kasisa and triphala (haritaki,vibhitaki and amalaki) flowers provide blackness in the newly formed skin quickly.
Kaliyaka (Jateorhiza palmata Miers), nata /tagara (Valeriana wallichii DC), mango seeds, nagakeshara, iron and triphala powder mixed with cow-dung juice make an excellent paste for reviving normal color in skin.
Roots of dhyamaka, ashvattha and nichula (Barringtonia acutangula Linn), lac, gairic(red-ochre), nagakeshara and kasisa – These restore the natural colour of the skin.
The hairless spots are smeared with oil and dusting with the ash of skin, hair, hoof, horns and bone of quadrupeds, reproduces hairs.The treatment of sixteen complications of wounds has been mentioned in their respective contexts.[113-119]
Summary
तत्र श्लोकौ-
द्वौ व्रणौ व्रणभेदाश्च परीक्षा दुष्टिरेव च |
स्थानानि गन्धाः स्रावाश्च सोपसर्गाः क्रियाश्च याः ||१२०||
व्रणाधिकारे सप्रश्नमेतन्नवकमुक्तवान् |
मुनिर्व्याससमासाभ्यामग्निवेशाय धीमते ||१२१||
Now the summing up verses –
Two types of wounds, kinds of wounds, examination of wounds, defects, locations, odors, discharges, complications and treatment modalities are described. These topics after queries have been described in brief as well details by the sage to the wise Agnivesha in the chapter on treatment of wound (Dwivraniya Chikitsa). [120-121]
इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते दृढबलसम्पूरिते चिकित्सास्थाने द्विव्रणीयचिकित्सितं नाम पञ्चविंशोऽध्यायः ||२५||
Tattva Vimarsha (Fundamental Principles)
- Vrana (ulcers) are broadly classified into two types viz. nija (endogenous) and agantu (exogenous).
- The treatment of both types of ulcers is based upon the dosha dominance.
- Endogenous ulcers are caused due to vitiation of dosha located in external pathways.
- The clinical features of vata dominance in ulcer are stiffness, hardness on touch, scanty exudation, excruciating and pricking pain with throbbing and blackish discoloration. It should be treated with sampurana (filling of ulcer cavity), intake of unctuous substances (oleation therapy), unctuous fomentation and poultices, ointments and sprinklings.
- The clinical features of pitta dominant ulcer are excessive thirst, unconsciousness, fever, sweating, burning sensation, impurities at the site of ulcer, tearing and foul smell with discharge pus from ulcer. The treatment includes anointing and sprinkling with cold drugs, intake of sweet and bitter drugs, intake of ghee and purgation.
- The clinical features of kapha dominance in ulcer are sliminess, heaviness, unctuousness, numbness, with mild pain, paleness in color, little slough and prolonged healing. It is treated with anointing and sprinkling with astringent, pungent, dry and hot drugs as well as fasting and digestive measures.
- The two types of ulcers are further divided into twenty types on the basis of distinctive features. Their examination can be done by three ways, signs of excess vitiation at site of ulcer are of twelve types, eight locations, fourteen types of discharges, sixteen complications, twenty four defects and thirty six therapeutic measures.
- Skin, blood vessels, flesh, fat, bone, ligament, vital parts and viscera are involved in the pathogenesis of ulcer.
- The treatment of ulcer is done in two ways viz.1. systemic treatment (internal administration of medicine) and 2. Local treatment of ulcer. The treatment is done with drugs that promote healing, purify body and local site of ulcer.
- The first principle of management of ulcer is body purification through therapeutic emesis, purgation, shastra karma (surgical intervention) or basti (medicated enema) after assessment of condition because the ulcers get healed quickly in those with cleansed body.
- The thirty six measures for treatments of ulcers are those for pacification of swelling, six types of surgical operations, pressing, refrigerating, uniting, fomentation, pacification, probing, cleansing, healing, cleaning paste, healing paste, cleaning oil, healing oil, two types of covering with leaf, two types of bandaging, diet, elevation, two types of cauterization, depression, hardening fumigation, softening fumigation, hardening paste, softening paste, powdering, colorization, healing, repillatory.
- At first, bloodletting therapy is done first to reduce swelling in ulcer. Upanaha (hot poultice) and patana (incision) are done according to stage of ulcer.
- Six types of surgical treatments are incision, puncturing, excision, scrapping, scarification and suturing.
- The contraindications in ulcer patients include salt, sour, pungent, hot, burning and heavy food and drinks, sexual intercourse. Food and drinks that are not too cold, heavy and fatty, non-burning, according to the nature of ulcer are beneficial. Day-sleep is not suitable in these patients.
- Fractured bone and dislocated joints should be set correctly comparing with its counterpart. Setting with firm pad-bandages and splints, it should be immobilized without any discomfort by binding with cloth pieces dipped in plenty of ghee.
Vidhi Vimarsha (Applied Inferences )
Classification of ulcers and causes
As said earlier, ulcers are of two types i.e. nija and agantuja, another classification is clean and infected wound. Nija vrana (endogenous ulcer) are caused by vitiation of dosha in the body or due to disease process. The term sharira desotha (ie.endogenous in origin) is used for morbid factors occurring in the body that cause nija vrana (i.e. endogenous ulcer). While agantuja vrana (exogenous ulcer) are caused by external factors (trauma or surgical intervention) like wound caused by stab injury, poisons, fire and sharp weapons or excessive tying of that organ (bandha) etc. In exogenous ulcers, vitiation of dosha occurs later. Nija vrana i.e. vataja, pittaja, kaphaja, raktaja and sannipataja, are caused due to faulty habit, mode of living and seasonal variation. These vitiated dosha, after a series of pathological processes (shada-kriyakala) get lodged at particular site resulting in the formation of vrana.
Samprapti (pathogenesis of vrana): based on shadakriya kala
Clinical pictures of vrana
The following ulcer is the case of diabetic ulcer. Clinical features include throbbing pain, swelling, redness, necrosis of involved tissue and non healing ulcer since 6 months.
Image 1: Vata dominant ulcer
The following ulcer is the case of non healing ulcer due to boils. Clinical features include burning pain, redness, pus discharge, slough, with redness of involved tissue and non healing ulcer since 1month.
Image 2: Pitta dominant ulcer
The following ulcer is the case of non healing ulcer due to DCT (Deep vein thrombosis). Clinical features include pain, irregular superficial ulcer, redness, mild pus discharge, slough, with redness of involved tissue and non healing ulcer since 8 months.
Image 3: Kapha dominant ulcer
The following ulcer is the case of infected diabetic non healing ulcer (Diabetic foot). Clinical features include severe burning pain, black coloration of first toe with pus discharge, slough, bad smell and deformity in great toe. This is non healing ulcer since 2 months.
Image 4: Dushta vrana
The following ulcer is the case of healing traumatic ulcer at anterior part of tibia/lower leg.. Clinical features include mild pain, no discharge, and margins and thick and inflamed due to their chronic nature and the granulation tissue are seen at base of ulcer. So this is a healing ulcer.
Image 5: Shuddha vrana
Investigations and their clinical interpretation in brief
The clinical features of ulcers are ulceration /disccontineous of skin, discharge (pus/blood/ serum), bad odor, differenct size, painful/painless ulcers. The above symptoms are described by Acharya Sushruta (gandha, varna, sava, vedana, akruti). On the basis of which kind of ulcer (varicose ulcer, diabetic ulcer, arterial ulcer, bedsores, leprotic ulcer, rodent ulcer, etc) the symptoms may vary. In all types of ulcers on the basis of history and clinical examinations the following investigations play important role in diagnosis and prognosis of the Ulcer. TLC (Total leucocyte count), Hb% , Serum crestnine, BSL (Blood sugar level) swab culture, X-ray of affected part if chronic ulcer. If TLC are increase than normal range suggest the acute infection. if Hb% is low then the ulcer will heal delay due hyposia to the tissue. If serum creatinine is increased that might be due to kidney problem which hampered healing of ulcer. In diabetic patients BSL assessment is important for healing as glucose liden tissue are reluctant to heal. Swab culture of wound discharge is necessary to know the organism. Lastly s-xay is essential to know extension of wound upto bone/osteomylituis.
Complications of ulcer
If ulcer is not treated properly it may lead to local and systemic infection leading to septicemia. The tissue necrosis leads to gangrene which further need to amputation.
Causes of non-healing
Two factors mainly affect the process of wound healing viz. local factors and systemic factors.
Local factors are infection, necrosis, foreign body, vascular insufficiency, lymphatic obstruction, continuous movement of part. Systemic causes include old age, protein deficiency, vit-c and zinc deficiency, diabetes mellitus.
Treatment of vrana (ulcers)
Purification measures
Purificatory measures eliminate toxic material from body and improve healing process of ulcer. In case of endogenous ulcer removal of morbid matters (i.e. doshaja) emesis through upward route, purgation through downward route are advised. Other purificatory measures like oleation therapy, sudation therapy should be done prior to emesis, purgation etc. For local purification of ulcer, venesection and vrana basti should be done.Raktamokshana is an important modality[4] indicated predominantly in local vitiation of rakta as in dushta vrana. So along with emesis and purgation blood letting is also important treatment modalities with the help of jalauka (leech application), veinpuncture etc.
Selection of therapeutic measures is done as per condition of vrana and patient.
Thirty six treatment measures
Thirty six types of therapeutic measures are described for the treatment of ulcer. Sixty types of treatment measures are described under the head of shashtiupakrama regarding ulcer treatment.[5] It is not necessary that all the thirty six or sixty therapeutic measures have to be applied in treating an ulcer. I A patient at a time 1 or 4 type of procedures are essential in single case of vrana according to condition of the wound.[5]
In early stage of ulcer only inflammation appears. At this stage bloodletting should be done to break the further manifestation of ulcer. Purificatory measures should be performed in excessively aggravated doshas while lightning measures should be adopted if dosha are less aggravated. In the beginning of edema, therapeutic measures aimed to alleviate aggravated vata followed by other doshaviz. pitta and kapha are advised. Application of various pastes made of vijaya, madhuka, vira, bisagranthi etc. also reduce edema. Edema reducing dietary regimen like light food and food that does not cause burning sensation (avidahi) should be followed.
Indications and process of six fold surgical procedures
Six types of surgical procedures are described for treatment of ulcer such as patana (incision), vyadhana (puncturing), chhedana (excision), lekhana (scrapping), pracchana (scarification) and seevana (suturing). Patana procedure described by Charak is same as for bhedana by Sushruta. Any similar or new procedure can be applied in wound management as per the surgeon’s freedom. [6]
Pidana (Compression)
Widening of external opening (mouth) of ulcer or abscess along with breaking of multiple loculi to make uniform cavity, to avoid the collection of pus in multiple pockets and facilitate free drainage of pus. Pidana (compression) is also helpful to squeeze out the collected pus. For compression various pastes are applied over the ulcer of abscess except on mouth openings.
Management of fracture and dislocation
The basic guidelines for management of fracture and dislocation are to stabilize the fractured bone or dislocated joint by application of splints. Proper alignment of bone is mandatory for healing of fractured bones.[7] Suitable dietary regimen should be followed with avoidance of vidahi (food which causes burning sensation) food.[8] Strenuous exercise is not allowed during healing period due to risk of re-fracture and dislocation. Complications due to fracture of bone or dislocation of joint are managed as per condition. For e.g. If ulcer is due to fracture of bone then treatment of ulcer along with fracture management should be adopted.
Eshanakarma (probing)
It is used in ulcer of narrow opening with expanded base (eg.undermined ulcers). Various types of probes are used in ulcer to know the direction of tract or cavity, depth and discharge from ulcer or sinuses. Generally probing is not done if ulcer is located at vital organs (marma sthana) but in specific conditions as in fistula in ano it can be performed. As per site of ulcer various probes either hard or soft can be used. If deep seated and located at fleshy area hard probe (metallic) is used, in superficially seated ulcers soft probe is used. Probing is essential to know the depth of wound particularly in nadivrana (sinus at any part of the body) or fistula (fistula-in ano is one kind).[9]
Vrana shodhana (cleaning of ulcer)
Cleaning of ulcer is done with shodhana drugs (cleansing agents) leads to vrana ropana (wound healing) process. If ulcer is contaminated i.e.presence of infection causing vectors, profuse secretion, presence of slough etc, in these conditions purificatory measures like debridement of ulcer (i.e. removal of slough), irrigation with shodhana kashaya or paste (purificatory measures) should be applied. Once ulcer becomes clean, healthy granulation tissue formation starts. To enhance and protect the granulation tissue vrana ropana drugs (healing drugs) either externally or internally or in combination are used.
Bandaging material, methods and its applicability in vrana (wound)
Bandaging of wound is very important as it stabilizes wounded part, prevents external injury, prevents contamination from external sources and enhances healing process. Bandaging should not be too tight, nor too loose. Act of bandaging may be from right or left side while others have mentioned fourteen types[10]and fifteen types. [11]
Diet: Wholesome and unwholesome aahar-vihar and ulcer healing promoters
Lavana is vishyandi i. e. producing more secretions from tissues; it aggravates kapha and pitta and mitigates vata[12]
Due to kapha and pitta vitiating properties it causes sliminess (kledana) and burning pain. Excessive lavana, amla and katu rasa will provoke vata dosha and may produce various types of pain. Vidahi food also leads to burning sensation due to srotorodha while sexual intercourse leads to dhatukshaya and aggravates [[vata].] [ Cha. Sa. Chikitsa Sthana 28/59 ], [ Cha. Sa. Vimana Sthana 5/24].
Day time sleep causes srotorodha and gives rise to vitiation of kapha that leads to swelling. Elevation of depressed ulcer is very important aspect of healing process. In Ayurvedic classics stanya janana (galactogogue),[Cha. Sa. Sutra Sthana 4/17 ] jeevaniya (life promoters e.g. vitamins) [ Cha. Sa. Sutra Sthana 4/1 ] and brimhaniya gana (nourishing drugs) [ Cha. Sa. Sutra Sthana 4/2] are described. All these drugs have nutritional value (dhatu poshana) that helps in ulcer healing.
Indications and contraindications of agnikarma (cauterization) in various disorders
Agni karma (cauterization by application of heat) is used as precaution for excessive bleeding ulcers, excision of hanging flesh, kaphaja granthi (enlarged gland due to kapha), goitre and in stiffness (associated with vata) etc. Agnikarma has ushna guna (hot property) which is opposite to vata and kapha. Due to heat, vasodilation leads to alleviation of srotorodha resulting in proper vascularity to organ or part. Dahakarma (cauterization) causes constriction of blood vessels so prevents bleeding from ulcer.[13]Cauterization is performed with the help of many substances like unctuous or ununctous substances etc by many ways e.g. Small spot (bindu), shape of ring (valaya) etc depending on nature of disease, strength of patient and time of application.
Importance of dhupana karma (fumigation therapy) in wound sterilization healing process
Fumigation of ulcer is done with dhupana dravyas (fumigating materials).[14],
[15]. Purpose of fumigation is to make suitable conditions for better ulcer healing such as local sterilization, vasodilation, decreased discharge and removal of foul smell.
Fumigation also relieves pain, discharge and kills microorganisms due to vata, [[kapha] ]alleviating property along with antiseptic property.Various types of preparations are used to harden or soften the wounds as per condition of wound.
- Research studies on management of ulcers: The physician observing inflammation as prodromal sign in the beginning should apply blood-letting to prevent the manifestation of wound. Sushruta also indicated blood letting in initial stage of abscess or inflammatory conditions and in ischemic condition of the wound.[16],[17]
- The nagrodhyadi group is indicated in wound as cooling for wounds which is found healing potential in one research.[18]
- The panchavakkal (Vata (Ficus bengalensis Linn), Udumbara (Ficus glomerata Roxb.), Ashvattha (Ficus religiosa Linn.), Parisha/Pāriśa (Thespesia populenoides L.) and Plaksha (Ficus lacor Buch Ham.),) is indicated for the healing of chronic wound. In resent studies panchavalkal has anti-inflammatory, cleaning and healing potential in some research studies carried out and published in reputed journals of Ayurveda.[19],[20],[21], [22], [23],[24]
- Bala (Sida cordifolia Linn.), guduchi (Tinospora cordifolia), madhuka (Glycyrrhiza glabra Linn.), prshnaparni (Uraria picta Desv), satavari (Asparagus racemosus Willd), jivanti (Leptadenia reticulate W. & A.), sugar, milk, oil, fish fat, ghee cooked with beeswax is known as sneha sarkara, it relieves pain. Some studies have highlighted the wound healing potential of honey mixed with above drugs. [25],[26]Various preparations containing following herbal drugs have wound cleaning effect in single and combination of drugs. The recent studies showed their efficacy as evidence based. Leaves of nimb (Azadirachta indica A. Juss)[27],[28],[29],[30] and haridra (Curcuma longa Linn.) are mentioned as the shodhan and ropan(healing) of wound. [31],[32],[33] The daruharidra (Berberis aristata DC) also showed antimicrobial effect. [34]Wounds with foul odor, abnormal colour, profuse discharge and intense pain should be known as dusta vrana (unclean) and as such wounds should be treated with cleansing agents. Decoctions of triphala, khadira (Acasia catechu Willd), daruharidra (Berberis aristata DC), nyagrodhadi group, bala (Sida cordifolia Linn.), kusa (Desmostachya bipinnata Stapf.), leaves of nimb (Azadirachta indica A. Juss) and badara (Zizyphus jujube Lam.) are regarded as cleansing drugs. Tila paste, salt, haridra (Curcuma longa Linn.), daruharidra (Berberis aristata DC), trivrit (Operculina turpethum Linn.) ghrita, madhuka, nimba leaves- this formulation is said as wound cleanser. Most of the ingredients like triphala,[35] khadira, daruharidra, nyagrodhadi group nimb, haridra, daruharidra, madhuka are the ingredients of jatyadi taila /ghrita which is well known formulation in managment of chronic wound for shodhan and ropan of wounds. [36],[37],[38],[39],[40],[41],[42]
- The drugs which are helpful for healing of fresh and infected or chronic wounds are mentioned in the text. Among these drugs following drugs are having some research studies carried out for their healing effect.Decoction of Panchavalkal (nyagrodha, udumbara, asvattha, parish plaksha), karavira (Nerium indicum Mill.), arka (Calotropis procera R. Br.)[43] and kutaja (Holarrhena antidysentrica Linn.) are wound healing. Candana (Santalum album Linn.), daruharidra bark, meda (Polygonatum airrhifolium Royle), mahameda (Polygonatum airrhifolium Royle), murva (Marsdenia tenacissima W. & A.), lajjalu (Mimosa pudica Linn.) and madhuyasti[44]- this formulation is wound healer. Prapaundarika, jivanti, gojihva (Onosma bracteatum Wall.), dhataki, bala and sesamum should be applied as paste with ghee for wound healing. Kampillaka (Mallotus philippinensis Muell Arg), vidanga (Embelia ribes Burm), kutaja, triphala, bala, patola (Trichosanthes dioica Roxb.), nimba, musta (Cyperus rotundus Linn.), priyangu, khadira, dhataki, sarja, ela (Elleteria cardamomum Maton.), aguru (Aquilaria agallocha Roxb.) and candana are pounded together and used for cooking oil. This oil is used as ulcer healing agent. Similarly, oil prepared with equal quantity of prapaundarika, mahuka, kakoli (Roscoca procera Wall.), ksirakakoli (Roscoca procera Wall.), chandana and rakta chandana (Pterocarpus santalinus Linn.)[45] is an excellent ulcer healing agent. Oil cooked with durva juice or kampillaka or paste of daruharidra bark is an important ulcer healer.[46],[47],[48] By the above method ghrita should be prepared and used for healing, ulcers predominant in rakta and pitta.
- The physician conversant with dose, time and agni (heat) may apply alkali in cases amenable to surgical operations.[49],[50],[51],[52]
- By dusting the wound with the powders of barks of kakubha (Termalia arjuna),[53] udumbara,[54] ashvattha, lodhra (Symplocos racemosa Roxb), jambu (Eugenia jambolana Lam) and katphala (Myrica esculenta Buch-Ham) they heals the skin quickly. Manashila (Realgar), manjistha,[55],[56] lac, haridra and daruharidra used as paste with ghee and honey is an excellent cleanser of skin.
Potential areas /Scope for research
The ingredients like bala (Sida cordifolia Linn.), kusa (Desmostachya bipinnata Stapf.), badara (Zizyphus jujube Lam.), trivrit (Operculina turpethum Linn.), karavira (Nerium indicum Mill.), kutaja (Holarrhena antidysentrica Linn.), meda (Polygonatum airrhifolium Royle), mahameda (Polygonatum airrhifolium Royle), murva (Marsdenia tenacissima W. & A.), lajjalu (Mimosa pudica Linn.), gojihva (Onosma bracteatum Wall.), dhataki, ela (Elleteria cardamomum Maton.), aguru (Aquilaria agallocha Roxb.), kakoli (Roscoca procera Wall.), ksirakakoli (Roscoca procera Wall.) are mentioned for wound healing so there is a scope to find out their clinical wound healing effect.
Charak mentioned some formulations for shodhan (cleansing) and ropan (healing) in this chapter. Along with single drug these formulations need to be further studied for their scientific validation.
Shodhana (Cleansing) formulations
- Decoctions of triphala, khadira (Acasia catechu Willd), daruharidra (Berberis aristata DC), nyagrodhadi group, bala (Sida cordifolia Linn.), kusa (Desmostachya bipinnata Stapf.), leaves of nimb (Azadirachta indica A. Juss) and badara (Zizyphus jujube Lam.) are regarded as cleansing drugs.
- Tila paste, salt, haridra (Curcuma longa Linn.), daruharidra (Berberis aristata DC), trivrit (Operculina turpethum Linn.) ghrita, madhuka, nimba leaves.
- Manahsila (Realgar), manjistha, lac, haridra and daruharidra used as paste with ghee and honey
- Ropan (healing) formulations:
- Decoction of nyagrodha, udumbara, asvattha, kadamba, plaksha, vetasa, karavira (Nerium indicum Mill.), arka (Calotropis procera R. Br.) and kutaja (Holarrhena antidysentrica Linn.) are wound healing. Candana (Santalum album Linn.), lotus stamens, daruharidra bark, blue water lily, meda (Polygonatum airrhifolium Royle), mahameda (Polygonatum airrhifolium Royle), murva (Marsdenia tenacissima W. & A.), lajjalu (Mimosa pudica Linn.) and madhuyasti-
- Pase of ghee prepared with Prapaundarika, jivanti, gojihva (Onosma bracteatum Wall.), dhataki, bala and sesamum
- Oil of Kampillaka (Mallotus philippinensis Muell Arg), vidanga (Embelia ribes Burm), kutaja, triphala, bala, patola (Trichosanthes dioica Roxb.), nimba, musta (Cyperus rotundus Linn.), priyangu, khadira, dhataki, sarja, ela (Elleteria cardamomum Maton.), aguru (Aquilaria agallocha Roxb.) and candana
- Oil prepared with equal quantity of prapaundarika, mahuka, kakoli (Roscoca procera Wall.), ksirakakoli (Roscoca procera Wall.), chandana and rakta chandana (Pterocarpus santalinus Linn.)
- Oil cooked with durva juice or kampillaka or paste of daruharidra bark.
- Powders of barks of kakubha (Termalia arjuna), udumbara, asvattha, lodhra (Symplocos racemosa Roxb), jambu (Eugenia jambolana Lam) and katphala (Myrica esculenta Buch-Ham).
Remedies for post healing complications
- The paste prepared by bhasmas of iron, kasisa and triphala (haritaki,vibhitaki and amalaki) flowers provides blackness in the newly formed skin quickly.
- Kaliyaka (Jateorhiza palmata Miers), nata /tagara (Valeriana wallichii DC), mango seeds, nagakesara, iron and triphala powder mixed with cow-dung juice make an excellent paste for reviving normal colour in skin.
- Roots of dhyamaka, asvattha and nicula (Barringtonia acutangula Linn), lac, gairic(red-ochre), nagakesara and kasisa-These restores the natural colour of the skin.
- Lodhra, leafbuds of nyagrodha, khadira, triphala and ghrita - this combination used as paste provides looseness and softness in wounds.
The role of diet is very important in wounded patients which can be considered for further research as Charak mentioned that wounded patients should abstain from salt, sour, pungent, hot, burning and heavy food and drinks and also sexual intercourse.
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References
- ↑ Sushruta. Chikitsa Sthana, Cha.1 Dwivraneeya Chikitsitam Adhyaya verse 134. In: Kaviraja Ambikadutta Shastri Editors. Sushruta Samhita. reprint ed. Varanasi: Chaukhambha Sanskrit Sansthan;2013. pp 16.
- ↑ Sushruta. Chikitsa Sthana, Cha.2 Sadyovrana Chikitsitam Adhyaya verse 12. In: Kaviraja Ambikadutta Shastri Editors. Sushruta Samhita. reprint ed. Varanasi: Chaukhambha Sanskrit Sansthan;2013. pp 16.
- ↑ Vagbhata. Uttara Sthana, Cha.26 Sadyovranapratishedha Adhyaya verse 13. In: Kaviraj Atrideva Gupta, Editors. Ashtanga Hridayam. Reprint ed. Varanasi: Chaukhambha Sanskrit Sansthan;2005.pp 26
- ↑ Sushruta. Chikitsa Sthana, Cha.1 Dwivraniya Chikitsitam Adhyaya verse 27-18. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1.
- ↑ Jump up to: 5.0 5.1 Sushruta. Chikitsa Sthana, Cha.1 Dwivraneeya Chikitsitam Adhyaya verse 8. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1.
- ↑ Bhela, Chikitsa sthana, Chap.27, Verse 14-15 . In:K. H. Krishnamurthy,Prof. P.V. Sharma Editors, reprint edition, Varanasi; Chaukhambha Visvabharati, 2008, pp 468.
- ↑ Sushruta. Chikitsa Sthana, Cha.3 Bhagnachikisitam Adhyaya verse 18-19. In: Kaviraja Ambikadutta Shastri Aacharya, Editors. Sushruta Samhita. Reprint ed. Varanasi: Chaukhambha Sanskrit Sansthan;2013. pp 28.
- ↑ Sushruta. Chikitsa Sthana, Cha.3 Bhagnachikisitam Adhyaya verse 4-5. In: Kaviraja Ambikadutta Shastri Aacharya, Editors. Sushruta Samhita. Reprint ed. Varanasi: Chaukhambha Sanskrit Sansthan;2013. pp 28.
- ↑ Sushruta. Sutra Sthana, Cha.25 Ashtavidashastrakarmeeya Adhyaya verse 10. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.1.
- ↑ Sushruta. Sutra Sthana, Cha.18 Vranalepanabandhavidhi Adhyaya verse 17. In: Kaviraja Ambikadutta Shastri, Editors. Sushruta Samhita. Reprint ed. Varanasi: Chaukhambha Sanskrit Sansthan;2013. pp 98
- ↑ Vagbhata. Sutra Sthana, Cha.29 Shastrakarmavidhi Adhyaya verse 59-60. In: Kaviraj Atrideva Gupta, Editors. Ashtanga Hridayam. reprint ed. Varanasi:Chaukhambha Sanskrit Sansthan,2005.p.4.pp 161
- ↑ Vagbhata. Sutra Sthana, Cha.6 Annaswarupavijnaneeyam Adhyaya verse 143. In: Kaviraj Atrideva Gupta, Editors. Ashtanga Hridayam. Reprint ed. Varanasi: Chaukhambha Sanskrit Sansthan;2005 pp 64.
- ↑ Sushruta. Sutra Sthana, Cha.14 Shonitavarnaneeya Adhyaya verse 40. In: Kaviraja Ambikadutta Shastri, Editors. Sushruta Samhita. Reprint ed. Varanasi: Chaukhambha Sanskrit Sansthan;2013. pp 72
- ↑ Sushruta. Sutra Sthana, Cha.5 Agropaharaneeya Adhyaya verse 17. In: Kaviraja Ambikadutta Shastri, Editors. Sushruta Samhita. Reprint ed. Varanasi:Chaukhambha Sanskrit Sansthan ;2013. pp 24.
- ↑ Vagbhata. Uttara Sthana, Cha.25 Vranapratishedha Adhyaya verse 45. In: Kaviraj Atrideva Gupta,Editors. Ashtanga Hridayam. Reprint ed. Varanasi: Chaukhambha Sanskrit Sansthan;2005.pp 542.
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- ↑ Lad M, Bandgar S. Management of non healing wound with Nyagrodhadi kwatha and Jatyadi ghruta (classical ayurvedic preparations). Global Journal of Research on Medicinal Plants & Indigenous Medicine (GJRMI). 2012; 1 (7): 301-308
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- ↑ Singh AK, Srivastava PK, Shukla VK. Evaluation of Nimba taila and Manjistha churna in non healing ulcer. International Research Journal of Pharmacy. 2011; 2(5):201-210