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→Vidhi Vimarsha
=== ''Vidhi Vimarsha'' ===
=== ''Vidhi Vimarsha'' ===
==== 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 ''doshas'' 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'':
Sanchaya – Accumulation of doshas at specific site.
Prakopa – Vitiated doshas, stage of aggravation of doshas.
Prasara – Spread of aggravated doshas in body through circulatory system.
Sthana sansraya – Stage of localization of vitiated doshas at specific site or organ i.e. vrana shopha.
Vyaktavastha – Stage of clinical manifestations of diseases (i.e. vidradhi-abscess) formation.
Bhedavastha – Stage of complications of diseases (i.e. vrana upadrava)
Clinical pictures of vrana:
The following ulcer is the case of diabetic ulcer. Clinical features include thrombing 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 coloation 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 chronicicty 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, aterial 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 creatnie 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 septesemia. 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.Raktamokshan is an important modality (Sushruta samhita. Chi. 1/27-28) 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.[ ] 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. (Su. Chi. 1/8).
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 doshas are less aggravated. In the beginning of edema, therapeutic measures aimed to alleviate aggravated vata followed by other dosha viz. 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 Charaka is same as for bhedana by Sushruta. Any similar or new procedure can be applied in wound management as per the surgeon’s freedom. [ ]
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 stablise the fractured bone or dislocated joint by application of splints. Proper alignment of bone is mandatory for healing of fractured bone.[ ] Suitable dietary regimen should be followed with avoidance of vidahi (food which causes burning sensation) food. [ ] Strenous 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). (Su. Su.25/10).
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 infective organisms, 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[ ] and fifteen types. [ ]
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.[ ] 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. [ , ] 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),[ ] jeevaniya (life promoters e.g. vitamins)[ ] and brimhaniya gana (nourishing drugs) [ ] 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. [ ] 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 dhupan karma (fumigation therapy) in wound sterilization healing process:
Fumigation of ulcer is done with dhupan dravyas (fumigating materials). [ , ] 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.
1. 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. (SU. Su. ---) [ ]
2. The nagrodhyadi group is indicated in wound as cooling for wounds which is found healing potential in one research. [ ]
3. 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 antiinflammatory, cleaning and healing potential in some research studies carried out and published in reputed journals of Ayurveda.[ , , , , , ]
4. 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 beewax is known as ‘sneha sarkara’, it relieves pain. Some studies have highlighted the wound healing potential of honey mixed with above drugs. [ , ]
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) [ , , , ] and haridra (Curcuma longa Linn.) are mentioned as the shodhan and ropan(healing) of wound. [ , , ] The daruharidra (Berberis aristata DC) also showed antimicrobial effect. [ ]
Wounds with foul odour, 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,[ ] 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. [ , , , , , , ]
5. 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.) [ ] 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-[ ] 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.) [ ] 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.
6. The physician conversant with dose, time and agni (heat) may apply alkali in cases amenable to surgical operations.[ , , , ]
7. By dusting the wound with the powders of barks of kakubha (Termalia arjuna),[ ] udumbara,[ ] ashvattha, lodhra (Symplocos racemosa Roxb), jambu (Eugenia jambolana Lam) and katphala (Myrica esculenta Buch-Ham) they heals the skin quickly. Manashila (Realgar), manjistha, [ , ] 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.
Caraka 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.
Shodhan (Cleansing) formulations:
1. 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.
2. Tila paste, salt, haridra (Curcuma longa Linn.), daruharidra (Berberis aristata DC), trivrit (Operculina turpethum Linn.) ghrita, madhuka, nimba leaves.
3. Manahsila (Realgar), manjistha, lac, haridra and daruharidra used as paste with ghee and honey
Ropan (healing) formulations:
1. 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-
2. Pase of ghee prepared with Prapaundarika, jivanti, gojihva (Onosma bracteatum Wall.), dhataki, bala and sesamum
3. 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
4. Oil prepared with equal quantity of prapaundarika, mahuka, kakoli (Roscoca procera Wall.), ksirakakoli (Roscoca procera Wall.), chandana and rakta chandana (Pterocarpus santalinus Linn.)
5. Oil cooked with durva juice or kampillaka or paste of daruharidra bark.
6. 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:
1. The paste prepared by bhasmas of iron, kasisa and triphala (haritaki,vibhitaki and amalaki) flowers provides blackness in the newly formed skin quickly.
2. 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.
3. Roots of dhyamaka, asvattha and nicula (Barringtonia acutangula Linn), lac, gairic(red-ochre), nagakesara and kasisa-These restores the natural colour of the skin.
4. 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 Charaka mentioned that wounded patients should abstain from salt, sour, pungent, hot, burning and heavy food and drinks and also sexual intercourse.
=== Glossary ===
=== Glossary ===