Wound and its Management – An Ayurvedic perspective

Shalya Tantra is a signi icant branch of Ayurveda. The name of the sagephysician Susruta is well known in the ield of surgery. Many surgical and para-surgical techniques have been described for the management of various diseases. Vrana is one of them which have been managed by a human being from starting of civilization. Under the circumstances, the irst thing which theman came across was the injury from different sources which was causing Vrana (wound). Thewound is very common in both developed anddeveloping countries. It is a breach in the normal tissue continuum, resulting in a variety of cellular & molecular sequel. A wound is a major health problem because the incidence of severe complications is high & inancial resources are limited. Vrana is an important chapter of Shalya Tantra due to its involvement in many surgical conditions. This, phenomena of Vrana is not only limited to the cutaneous lesion but may also extend up to muscles blood vessels, ligaments, bones, joints, visceral organs and other vital parts of the body. The diagnostic criterion has been dealt in a very detailedmanner by Acharya Susruth. In this article, efforts have been made to throw light on the pathology of Vrana, its classi ication, diagnosis, and it’s healing.


Etymology of Vran̩ a
The word 'Vran̩ a' is derived from the root "Vrīya" having the meaning "to recover" (Anil, 2013) , which is further suf ixed by "ach" in the sense of bhava. The "Ch' sound is joined the form remains "Vran" + "a", in the sense of "Gātra Vichurnane".

De inition of Vran̩ a
It is based on its initial effect as well as on the basis of its resultant scar. "Gātra" means Body (body tissue or part of body)."Vichurnane " means destruction, break, rupture and discontinuity (of the body or tissue). "The destruction / break / rupture / discontinuity of body/ tissue / part of body, is called "Vran̩ a." (Sushruta, 2012a). Acārya Susruta has explained that "the scars of a wound never disappear even after complete healing and its imprint persists lifelong and it is called Vran̩ a by the wise" (Sushruta, 2012b).

Classi ication of Vran̩ a
Vran̩ a is mainly divided into two categories-Nija and āgantuja. Further classi ication of Vran̩ a on different basis given in Table 1, (Sushruta, 2012c).

THE METHOD OF EXAMINATION
The method of examination is a technique by which the particular disease and the involved dosha are determined. Grossly, the examination of Vrana can be divided into two groups. These different methods are applied for a de inite diagnosis, and having a clear knowledge of complications and prognosis of the Vrana and also helps in their management.

LOCAL EXAMINATION
Local examination of Vrana is described by Sushruta based on ive parameters (Panch Lakshana) (Sushruta, 2012d)

Gandha (Smell)
Various types of smell may be present in different Vrana due to affection of Dosha, Sushruta described Gandha into two groups-Normal and abnormal. The normal smell is found, according to doshas, as Katu in Vata, Tikshna in pitta. Aamagandhi in Kapha, Lohagandha in rakta mixed type in sannipataja dosha, laja gandha in vatapitta, Atsi tail in pit-taKaphaja and smell of tila tail in pitta kapha dosha. The gandha like wine, Ghrita etc. are abnormal of smell are helpful in the determination of prognosis (Sushruta, 2012e).

Srava (Discharge)
The srava are local secretions of Vrana. Charaka has categorized Vranasrava but not according to Doshic predominance. Sushruta described discharges according to Doshas and Dushya involved in 8 Vrana Vastu and according to prognosis Sravas of Vrana according to dushya involved are (Sushruta, 2012g) as mentioned in Table 2 Among these eight sites, there are some important sites Vrana that needs special attention and ignorance of discharge from these sites can turn fatal. A surgeon should always be keen to observe these features. Some of the sites, along with the nature of discharge that is indicative of poor prognosis (Sushruta, 2012h), are mentioned in Table 3.

Vedana (Pain)
Vedana is a sensation which can be felt by the patient like abnormal tension, protrusion or pressure. Thus Vedanas have been described by Sushruta according to dosha involved (Sushruta, 2012i).
In Vataja Vrana, the Vedana is felt locally, severe pain as pricking, piercing, cutting, without any cause and shifting character comes on or is vanished.
In Pittaj Vrana burning sensation is followed by sucking pain. Heat and burning sensation in wholebody patient feels as being heated over the ire, due to the local rise of temperature and pain like an application of alkaline water.
In sannipataja, Vrana mixed type of pain of all 3 doshas is felt.

Akriti
Akriti includes the size, shape, edges and margins of the Vrana. The size of Vrana may be larger or small. The shape of Vrana in normal conditions as described by Sushruta is elongated, elliptical, rectangular or circular. In the case of agantuja Vrana shape depends on instrument causing injury margins of Vrana may be everted inverted or irregular (Sushruta, 2012j).

PROGNOSIS -SADHYASADHYATA
Such an understanding of surgeons is forecast about a disease. Therefore undertaking the treatment of any wound a surgeon must pay attention to the

Site of wound
Wounds situated in buttocks, rectum, genitals, forehead, cheeks, lips, back, ear, scrotum, abdomen, root of neck and interior of the mouth heal up easily (Sushruta, 2012k).

Shape of the wound
The wound which is long, rectangular, circular and triangular are easily curable. Other shapes are dif icult to cure.

Foreign bodies in the wound
Wounds having foreign bodies cure with dif icult.

Certain speci ic disease
Wounds of those patients suffering from leprosy, Poison, tuberculosis and diabetes are cured with dificulty (Sushruta, 2012m).

Constitution of the patient
Wounds are easily curable in patients who are young, strong, full of vitality and with tolerant psyche (Sushruta, 2012n).

healing in Ayurveda)
Though there are two types of Vrana-Nija and Agantuja, the line of management of them is the same except in the initial stage.

Paschat Karma
In connection with surgical treatment, the Purva karma is considered as the preoperative measure as, which includes the preparation of the materials for a surgical procedure, and preparation of the patient to make him it for operation. Pradhana Karma is the operation proper which includes the eight surgical measures. Paschat karma means the post-operative care, which includes all the measures for the complete healing of the wound and the wounded areas restores the normal colour and surface without any abnormality.
The medicines he advocated for the management includes local application to subside the Vranashopha in the primary stage, local washing to get the wound clean and devoid of infection, fumigation and other internal medicines for healing purpose and lastly cosmetic medicines.
Sushruta's seven principles in the management are as follows.

Vaikritapaham
All the sixty measures (Upakarmas) are coming under the above said seven principles and grouped such as.
Wound bed preparation is a new paradigm in wound care all over the world. It is de ined as management of wound to accelerate endogenous healing or to facilitate the effectiveness of therapeutic measures. In other words, to create a viable wound bed by removing barriers of healing. Wound bed preparation addresses the ive clinical observations summarized by the acronym -TIMES which unites the cellular and clinical components of wound healing. These are Tissue (non-viable), Infection or In lammation, Moisture imbalance, non-advancing Edge of the wound, Surrounding skin (Mulder, 2009).

Management of tissues
It is de ined as the removal of non-viable tissue and encouragement of viable and well-vascularized tissues to grow. It is achieved by the process of debridement. In Ayurveda, debridement can be categorized as surgical, mechanical and chemical. Surgical debridement causes minimal damage to surrounding tissue and the fastest way to remove debris and necrotic material from the wound bed. Surgical measures depend upon the extent of slough present on the wound bed. Excision, incision, drainage are mainly applied in surgical debridement. To arrest bleeding during debridement four haemostatic measures applied: sandhana (applying astringent lotions to vessels that cause vasoconstriction), skandana (coagulation by cold application), pachana (application of drug causing the arrest of bleeding), and dahana (thermal cauterization). Parisheka is a type of wound irrigation mentioned in ayurveda comes under mechanical debridement. Kshara (caustics) are used as a chemical debridement agent.

Control of in lammation and infection
These comprise local measures which reduce local in lammatory reactions and promote healing. It also includes some systemic measures like bloodletting, purgation, emesis etc. that helps in excretions of toxins out of the circulation. To control infection, the number of ayurvedic formulations described in various forms which not only converts dushtaVrana into shuddha Vrana but also accelerates a healing of Vrana. The patient is advised to maintain hygiene to avoid invade of organisms in the wound.

For moisture imbalance
use of the cleansing application in various forms like decoctions, wicks, pastes, medicated buttermilk and oil, thickened extract, dusting powder helps to balance the moisture of the Vrana. Also, a procedure such as covering with leaves according to vitiated doshas helps to control the moisture of Vrana.

Management of non-advanced edge of the wound
Various procedures mentioned above like scrapping, depilation, hardening, softening, and removal of over granulation, encouraging granulation tissue formation, warming application, edge approximation used for management of non-advanced edge of the wound.

Protection of surrounding skin
Bandaging and application of leaves keep dressing in place and prevent skin damage. Instead of procedures for wound bed preparation, some procedures mentioned for removal of maggots, pain management, healing measures like suturing, use of healing drugs in various forms are used for faster healing of Vrana. Subsequently, for the restoration of the normalcy of scar -various methods employed like pigmenting procedure, depigmenting, and skin colour restoration, for encouraging hair growth. Sushruta also given detail about the type of diet patient should take and behaviour of the patient should be during day and night time.

DIET
The diet of a patient entertaining an open wound should preferably consist of light dietetic articles in small quantities. Only freshly prepared should be taken. Above all, digestive upsets should be avoided. The wound to be healed fast and to prevent complication the diet mentioned by Acharya susrutha has to be followed (Sushruta, 2012q).
Hot lique ied food prepared form old rice, mixed with ghee in small quantity with meat soup a good diet for wounded by which quick healing will occur.

CONCLUSIONS
Acharya Susurtha, the father of Indian surgery, has described Vrana as one of the main subjects in his treatise sushruth samhita. He has described Vrana from its different aspects, right from the de inition, causes etc. to the management of its scar tissue. A lot of importance has been given to vrana by him and he has made it as a base, as the whole of surgical treatment deals with wounds and their healing.