a critical study of indigenious suture materials w.s.r …

A CRITICAL STUDY OF INDIGENIOUS SUTURE MATERIALS W.S.R TO MANAGEMENT OF KSHATAJA VRANA

BY

Dr. RAVINDRA G. VARMA

B.A.M.S

DISSERTATION SUBMITTED TO RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF SURGERY (Ayurveda)

In

SHALYA TANTRA

Under the guidance of

Dr. SRINIVAS K. BANNIGOL M.D. (Ayu)

PROFESSOR AND HEAD DEPARTMENT OF POST-GRADUATE STUDIES IN SHALYA TANTRA

Ayurveda Mahavidyalaya, Hubli.

Under the co-guidance of

DR. SIDDANAGOUDA A. PATIL M.S. (Ayu)

Reader Department of Post-Graduate studies in Shalya Tantra


DEPARTMENT OF POST GRADUATE STUDIES IN SHALYA TANTRA,

AYURVEDA MAHAVIDYALAYA HUBLI-580024

i

2010

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A CRITICAL STUDY OF

INDIGENIOUS SUTURE MATERIALS W.S.R TO MANAGEMENT OF

KSHATAJA VRANA” is a bonafied and genuine research work carried out by me

under the guidance of Dr. SRINIVAS K. BANNIGOL M.D. (Ayu), Professor and

Head, Department of Post-Graduate studies in Shalya Tantra, AYURVEDA

MAHAVIDYALAYA, HUBLI.

Dr. RAVINDRA G. VARMA

P.G. SCHOLAR

Department of Post-Graduate Studies in Shalya Tantra

Ayurveda Mahavidyalaya,

Hubli, (Karnataka)

ii

Date:

Place: Hubli

DEPARTMENT OF POST GRADUATE STUDIES IN SHALYA

TANTRA

AYURVEDA MAHAVIDYALAYA, HUBLI

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A CRITICAL STUDY OF

INDIGENIOUS SUTURE MATERIALS W.S.R TO MANAGEMENT

OF KSHATAJA VRANA” is a bonafied research work done by Dr.

RAVINDRA G. VARMA in partial fulfillment of the requirement for the

degree of MASTER OF SURGERY (AYURVEDA) in SHALYA TANTRA.

Guide

DR. SRINIVAS K. BANNIGOL M.D. (Ayu),

Professor and Head Department of Post-Graduate studies in Shalya Tantra Ayurveda Mahavidyalaya

Hubli (Karnataka).

iii

Date: Place: Hubli

DEPARTMENT OF POST GRADUATE STUDIES IN SHALYA

TANTRA


CERTIFICATE BY THE CO-GUIDE



KSHATAJA VRANA” is a bonafied research work done by Dr. RAVINDRA G.

VARMA in partial fulfillment of the requirement for the degree of MASTER OF

SURGERY (AYURVEDA) in SHALYA TANTRA.

CO - GUIDE

DR. SIDDANAGOUDA A. PATIL M.S. (Ayu)

Reader Department of Post-Graduate studies in Shalya Tantra, AYURVEDA MAHAVIDYALAYA,

HUBLI (KARNATAKA).

iv

Date: Place: Hubli

ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE

INSTITUTION


Certificate


INDIGENIOUS SUTURE MATERIALS W.S.R TO MANAGEMENT OF KSHATAJA

VRANA” is a bonafied research work done by Dr. RAVINDRA G. VARMA under the

guidance of Dr. SRINIVAS K. BANNIGOL, M.D. (Ayu), Professor and Head,

Department of Post-Graduate studies in Shalya Tantra, AYURVEDA MAHAVIDYALAYA,

HUBLI

DATE:

PLACE: HUBLI

v

H.O.D Dr. SRINIVAS K. BANNIGOL

M.D. (Ayu), Professor and Head

Department of Post-Graduate studies in Shalya Tantra, Ayurveda

Mahavidyalaya, Hubli

DATE: PLACE: HUBLI

PRINCIPAL Dr. S.J.DESHAPANDE

Principal

Ayurveda Mahavidyalaya,

Hubli

DATE: PLACE: HUBLI

COPYRIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this dissertation /

thesis in print or electronic format for academic / research purpose.

Date:

Place: Hubli

© RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

vi

Dr. RAVINDRA G. VARMA P.G. SCHOLAR

DEPARTMENT OF POST-GRADUATE STUDIES IN SHALYA TANTRA AYURVEDA MAHAVIDYALAYA,

HUBLI, (KARNATAKA)

ACKNOWLEDGMENT

ACKNOWLEDGEMENT

Any work would be incomplete without a gratifying note to the persons

involved in its accomplishment. This Acknowledgement is just a humble reminder

of the immense contribution made by innumerable people towards the completion

of this dissertation.

I am very much indebted to my Maa Smt. Bhudhanadevi & Papa Shri.

Gangaprasad G Varma and my both Sister’s. I express my humble and heartily

gratitude to my beloved wife Dr.Sarita who’s lovable and inspiring manner were key

factors of my success and progress. My potential has been always appreciated to its

best by them in their unique disciplined way.

At this landmark of thesis completion. The unfathomable world of medicine

with as many possibilities and immeasurable boundaries poses an un-navigable path

to a novice. Since the day I set my foot into DR.S.K.BANNIGOL PROFESSOR

& H.O.D. SHALYA TANTRA DEPT and my beloved Guide has been my MENTOR.

The founder of this Dissertation, his relentless support and valuable inputs during

the entire period of the research work helped me and see the fruition of my dreams.

I am really grateful to my Co-Guide Dr.S A Patil for his untiresome guidance

throughout the study.

I thank to Dr C.Thyagaraja, Dr.Deepak, Dr.Srivatas N and Dr.Prabhu for

their friendly co-operation. I specially thanks to Dr. Mahesh Desai for his support in

making Statistical Data.

I wish to propose my sincere thanks to Dr.S.J.Deshapande Principal, and

Dr.M.A.Kundgol Ex-Principal, Ayurveda Mahavidyalaya, Hubli, for their

encouragement and support.

My Heartiest gratitude to my beloved and revered teachers Dr.P.G.Subbanagouda, Head of K.C Dept, Dr. M. A. Hullur and Dr.A.S Prashant

for their guidance and timely help throughout my studies. My sincere thanks to Dr.

A.I.Sanakal HOD of Panchakarma Dept. for his constant support and

encouragement given to me and rectifying my mistakes. My sincere thanks to

Dr.J.R.Joshi HOD of Siddhanta Dept. for his constant support in the entire research

VII

ACKNOWLEDGMENT

work. I am extremely grateful to Dr. B. B. Joshi, and Dr.Pradeep Agnihotri, and Dr.

Anita, for there valuable guidance.

My profound thanks to Mr.Nagraj Jenntali production manager of MCO Hospital

Aids Pvt. Ltd Hubli, for doing Sterility Test, Tensile Test and Diameter of my Suture

materials.

I extremely thanks to my beloved friend Dr.Vijay S.Dhaygonde for his valuable

support for my dissertation through his patients.

I acknowledge my revered seniors Dr.Seema, Dr.Amit, Dr.Arvind, Dr.Gireesh,

Dr.Sivakumar, Dr.Thanvantri, Dr.Rahul, Dr.Madhusudhan and Dr.Reshma for their

well wish and good support.

I am thankful to my batch mates Dr.Sunil, Dr.Praveen, Dr.Suhail, Dr.Piyush,

Dr.Keshav, Dr.Anil and my juniors Dr.Hari, Dr.Raghavendran, Dr.Markandaya,

Dr.Manoj, Dr.Yogesh, Dr.Alok and Dr.Rohini for assisted me to entire my work.

I pay my humble respect to all my teaching staff, office staff and hospital staff

for their help during this work. I would like to thank Mr.Rajshekhar, P.G Librarian

& Mr.Prashanth U.G Librarian A.M.V Hubli.

My sincere thanks to all my patients who have actively participated in the

clinical trial, without them this project would not have been successful.

I also express my thanks to all those who have helped me directly or indirectly in

successful completion of my dissertation work.

(Dr. RAVI G VARMA.)

VIII

Abbreviations ix

LIST OF ABBREVIATIONS

A.Hr : Astanga Hridaya

A.Sa : Astanga Sangraha

A.T : After treatment

B.P : Bhava prakashan

B.R : Bhaishajya Ratnavali

B.T : Before treatment

C.D : Chakra Datta

Chi : Chikitsa sthana

Ch.S : Charaka Samhita

Dal : Dalhana commentary

Dif : Difference

H.S : Highly significant

I.P.D : Indoor patient Department

M.D : Mean Difference

Ma.ni : Madhava nidana

Ni : Nidana sthana

No : Number

N.S : Not significant

O.P.D : Outdoor patient Department

‘p’ : Probability

S : Significant

S.D : Standard Deviation

S.E : Standard Error

Sha.S : Sharangadhara Samhita

Su : Sutra sthana

Su.S : Sushruta Samhita

V.S : Vanga Sena

Y.R : Yoga Ratnakara

“A Critical Study of Indigenious Suture Materials W.S.R to Management of Kshataja Vrana”

Abstract x


ABSTRACT

Surgery is art and suturing is fine art. The people in the present era are too

much conscious about their cosmetic look. In case of repair of external skin injury and

after undergoing surgical procedure, everybody demands that there should be no scar

or minimum scar formation. People are even undergoing cosmetic surgery to get rid

of ugly scars. Keeping this fact in view, in the field of surgical practice, lot of

emphasis has been given for search of scar less suturing materials and suturing

techniques.

Wound is the first disease faced by man since his very existence. Hence more

emphasis on wound management has been given in Shalya Tantra. Sushruta has

explained different types of suture materials like flax, grass, cotton threads, silk

threads, hair, tendons, heads of giant ants, animal gut etc. Keeping this in mind, the

present study an indigenous suture material Ashwa Bala and Guduchi Snayu are

selected as a suture material in the management of Kshataja vrana.

The patients suffering from Kshataja vrana or undergone any minor surgical

procedure who fulfills the criteria of selection of the present study were selected. The

patients were subjected for detail clinical examination and investigations as per the

specially designed proforma. The present clinical study comprises of 30 patients.

They were divided into three groups as Group-A, Group-B and Group-C each

having 10 patients. The group-A patients were subjected to Seevana karma by Ashwa

Bala. Group-B patients were sutured by Guduchi snayu and Group-C patients were

sutured by Cotton thread no 10. All the three Group patients received Tab Triphala

Guggulu (500mg) 2 tabs Tid for ten day and Panchavalkala churna for local application.

Seevana Karma done by Ashwa Bala showed very minimal scar formation, rare

chance of infection. Seevana Karma done by Guduchi Snayu showed medium scar

formation, rare chance of infection. Seevana Karma done by Cotton Thread no 10

showed medium scar formation, chance of infection.

KEY WORDS:

Kshataja Vrana, Ashwa Bala, Guduchi Snayu, Cotton Thread no 10, Triphala

Guggulu, Panchavalkala Churna.

CONTENTS

CONTENTS

ACKNOWLEDGEMENT

ABBREVATIONS

ABSTRACT

LIST OF TABLES

LIST OF GRAPHS

LIST OF FIGURES

PART 1

1. Introduction………………………………………………… 1 – 4

2. Objectives and Previous work done………………………… 5 – 6

3. Review of Literature………………………………………… 7 – 74

PART 2

4. Methodology……………………………………………….. 75 – 83

PART 3

5. Observations and Results…………………………………… 84 – 105

6. Discussion………………………………………………….. 106 – 120

7. Conclusion…………………………………………………. 121 – 123

8. Summary…………………………………………………… 124 – 126

9. Bibliographic References…………………………………... 127 - 130

10. Annexure…………..……………………………………….. i – ix


Introduction 1

INTRODUCTION

Surgery is art and suturing is fine art. The people in the present era are too

much conscious about their cosmetic look. In case of repair of external skin injury and

after undergoing surgical procedure, everybody demands that there should be no scar

or minimum scar formation. People are even undergoing cosmetic surgery to get rid

of their ugly scars. Keeping this fact in view, in the field of surgical practice, lot of

emphasis has been given for search of scar less suturing materials and suturing

techniques.

The problem of wound healing has attracted the attention of a large number of

investigators. The importance of wound healing has been recognized fundamentally

essential for the study and practice of surgery. In the past, quite a number of skillful

surgeons have shown their keen interest in the study of wound healing. Surgery is the

field which basically deals with different types of wounds, injuries and wound

healing. The Ayurvedic surgical text i.e. Sushruta Samhita focuses main attention on

wounds, their types and their management. Sushruta, the pioneer of Surgery, deals

with classical way in which different types of wounds are to be managed. Wound is

the first disease faced by man since his very existence. Hence more emphasis on

wound management has been given in Shalya Tantra.

Success of surgery depends on wound closure and wound healing. Surgeons

must be able to restore the physical integrity and function of the injured or diseased

tissue with the lowest incidence of infection end the most aesthetically pleasing

results. Hence surgical practice revolves around Management of surgically incised

wounds and/or Traumatic wounds.

An incision that heals by first intention i.e. with primary union of wound

edges does so, within minimum time with no separation of wound ergot and with


Introduction 2

minimal scar formations therefore wound closure by first intention is always

appreciated and is achieved by suturing the wound.

Suturing is the procedure of mechanical wound closure with the help of

suturing material. The principle role of suture material is to hold wound edges so that

healing can proceed without delay and prevention of infection of the tissue until

healing is completed. Thus sutures play an important role in wound repair by

providing support to healing wound. In Modern surgical practice many kinds of

ligature and suture materials are available. These suture materials and techniques of

suturing are so much advanced that they fulfill the requirements of present day

surgical practice.

Sushruta has explained different types of suture materials like flax, grass,

cotton threads, silk threads, hair, tendons, heads of giant ants, animal gut etc. Many

natural suturing materials that are described in ancient literature are in practice today.

Of which silk and cotton threads are the most employed nonabsorbable materials,

easy to use and of low cost. In spite of this there is constant quest for search of newer

techniques and suture materials.

The suture materials used now a days they only provide mechanical support to

wound edges but do not contain any medicinal properties, which can help to fasten the

wound healing process and will help to decrease the scar formation after healing.

Keeping this in mind in the present study an indigenous suture material Ashwa

Bala and Guduchi Snayu are selected as a suture material in the management of

Kshataja vrana.

Vegetative origin suture material used today is Linen and Cotton. Out of

which both of them have got some disadvantages. Linen has to be imported which

results in increase in cost and cotton thread is known for its more tissue reaction and


Introduction 3

high chances of infection. While other natural origin suture material like silk and

Nylon have also got some disadvantages. Silk is known to produce stitch granuloma

and have high infection rate. Knot tying is the main problem with Nylon, as too

smooth and stiff knots are likely to slip. Hence when an ideal suture material is to be

prepared it should have some qualities like good strength, minimal tissue reaction,

easy knotting and holding properties less expensive, uniform diameter, easy

sterilization. All these factors, further encouraged prompted to study the efficacy of

Ashwa Bala and Guduchi Snayu as suture materials.

Guduchi has got tikta rasa (bitter taste) which is supposed to be supporting

factor in wound healing process. Also it has got anti-bacterial, anti inflammatory

activity which will certainly help in healing and prevention of complications of

wound. Keeping all these things and easy availability of Guduchi in mind, Guduchi

Snayu had been selected for the study.

Ashwa Bala has been taken for study, which is mentioned in ancient literature

and very easily available. Suturing with Horsehair was routinely practiced in ancient

India and at various places all over the world. Sushruta mentioned it as a Seevana

Dravya and especially in the surgical management of Pakshma-kopa i.e. Trichiasis.

Historically Horsehair has been used mainly for skin suturing; Shore B. R.

(1936) closed the wound edges with interrupted Horsehair sutures after excision of a

recurring connective tissue tumor. Dubois J. in 1958 had successfully worked on the

subject immediate perineorrhaphy in two planes with horsehair figure of eight sutures.

There are many references that mentioned Horsehair as a Civil War Sutures.

During war it has been used as an emergency suture when there was shortage of other

suture materials. Although suture materials and aspects of the technique have changed

substantially over time, the goal remain the same: closing the dead space, supporting


Introduction 4

and strengthening wounds until healing increases their tensile strength, approximating

skin edges for an aesthetically pleasing and functional results and minimizing the risk

of bleeding and infection. Keeping all these things and wide availability of Horsehair

in mind the research project, Horsehair had been undertaken for the study.

The patients suffering from Kshataja vrana or undergone any minor surgical

procedure who fulfills the criteria of selection of the present study were selected. The

patients were subjected for detail clinical examination and investigations as per the

specially designed proforma. The present clinical study comprises of 60 patients.

They were divided into three groups as Group-A, Group-B and Group-C each

having 20 patients. The group-A patients were subjected to Seevana karma by Ashwa

Bala. Group-B patients were sutured by Guduchi snayu. And Group-C patients were

sutured by Cotton thread no 10. All the three Group patients received Tab Triphala

Guggulu (500mg) 2 tabs Tid for ten day and Panchavalkala churna for Avachurna (local

application).

It is a comparative clinical study. In the present dissertation, there are three

parts, Part 1, Part 2 and Part 3. The Part 1 deals with the Introduction, Objectives,

Literary Review, and Part 2 deals with the Methodology and Part 3 deals with

Observations, Results, Discussion, Conclusion and Summary.

The observations and results obtained from the clinical study have

analyzed statistically to evaluate the significance of the curative properties of therapies.

The section of discussion includes the appraisal of the results obtained from the

clinical studies. The studies have concluded with the summary and conclusion of the

entire work.


Objectives of the study 5


OBJECTIVES OF THE STUDY

The present clinical work has been undertaken for the evaluation of following

objectives:-

1. To review and analyze available literature of Seevana karma and Seevana

dravya in Ayurvedic texts.

2. To asses tensile strength & flexibility of "Ashwa Bala" and "Guduchi

Snayu".

3. To find out an effective preservative materials for "Ashwa Bala" and

"Guduchi Snayu".

4. To assess the efficacy of "Ashwa Bala" and "Guduchi Snayu" for Seevana

karma as described in Ayurvedic Samhita’s.

5. To evaluate any side effect of "Ashwa Bala" and "Guduchi Snayu" in

Seevana karma.

6. To observe the nature of scar formation over wound healing.

Previous work done 6

PREVIOUS WORK DONE

1. Dr. Rakesh Pandey, Study of Seevana Karma and Its Effect on Wound

Healing by Banaras Hindu University (BHU) Varanasi, In 2004.

2. Dr Sweta Yedke, Experimental Evaluation of Horse Hair as Non- Absorbable

Monofilament Suture by, Nagpur Government Ayurvedic College, Nagpur

University, Nagpur, In 2006 .

3. Dr Yogesh D Narkhede, Study of Efficiency of Guduchi Pratan (Tinospora

Cordifolia) as Herbal Suture Material in Twak Sivan Karma by, Sumatibhai

Shah Ayurveda Mahavidyalaya, Hadapsar, Pune, In 2006.


Historical Review 7

Historical Review

History tells us about the past time, how the time began, the development and

evolution of the mankind occurred. It helps to reveal hidden facts and ideas of

concerned subject. The earliest description of the management of vrana is found in

‘Vedas’.

In review of literature about Kshataja vrana starting from Vedic period to

Modern literature we find many references regarding the clinical features, diagnosis,

treatment and other aspects of Kshataja vrana. Historical review of a disease is to

present the evolution of systematized knowledge extending over a period of time.

This helps one to understand disease and its management properly. Historical review

of the disease Kshataja vrana and Seevana karma is discussed under the following

headings.

A. PREVEDIC PERIOD (Before 8000 B.C):

B. VEDIC PERIOD (8000 B.C-6000B.C):

A) PREVEDIC PERIOD (Before 8000 B.C): No literature was available in this period.

B) VEDIC PERIOD (8000 B.C-6000B.C):

In Rigveda we find that legs were amputated and replaced by iron substitutes,

injured eyes were plucked out and arrows shafts were extracted from the limbs

of the Aryan Warriors1.

Ashwinikumars replaced the head of Dadhichi sage by horse head. Then again

replaced it with original one 2.

In Ramayana vrana management had been dealt in 74/33 and in Mahabharata

also the treatment of Kshataja vrana has been mentioned3.


Historical Review 8

POURANIKA PERIOD:

In Garuda purana, Nidana sthana 171th chapter, Kshataja vrana has been mentioned4.

I) SAMHITA PERIOD (1000B.C- 700 B.C): This period was the golden era for Ayurveda.

During this period Various Acharya’s explained in detail about Kshataja vrana, Nidana,

Samprapti, Lakshana, chikitsa and Seevana karma

a) Sushruta Samhita (1000-800 B.C): - Acharya Sushruta explained about Kshataja

vrana in 2nd chapter i.e. SadyoVrana Chikitsa of Chikitsa sthana5.

Acharya Sushruta explained about Seevana karma in 5th chapter i.e. Agroupharnia6,

25th chapter i.e. Ashtavidha Shastra Karma Vidhi7 in Sutra sthana and 1st chapter i.e.

Dvivraniya Chikitsam of Chikitsa sthana8.

b) Charaka Samhita (1000 B.C): - Acharya Charaka has not devoted a separate

chapter on Shastra karma. Acharya Charaka explained about Vrana and Seevana

karma in 25th chapter i.e. Dvivraniya Chikitsam of chikitsa sthana9.

c) Bhela Samhita (1000 B.C): - Acharya Bhela explained about Kshataja vrana and

Seevana karma in Chikitsthana 27th chapter i.e. Vrana Chikitsa Adhyaya10.

d) Vangasen: Explained about Kshataja vrana in 55th chapter i.e. Agantuja Vrana of

Chikitsa Adhyaya11.

e) Palkapya: Author of book on Hasti Ayurveda had mentioned about Seevana

karma.


Historical Review 9

1. SANGRAHA PERIOD (7th A.D):

a) Astanga Sangraha- In Sutra Sthana 38th Chapter of Shastra Karma Vidhi

explained about Seevana karma12 and in Uttara Sthana Sadhyo Vrana Pratiseda

chapter 3rd explained -about Kshataja vrana13.

b) Astanga Hridaya- In Sutra Sthana 26th Chapter of Shastra Vidhi explained

about Seevana karma14 and 29th Chapter of Sutra Sthana i.e. Shastra Karma Vidhi

explained about Seevana karma15.

c) Indu commentator of Astanga Hridaya had explained about Seevana karma.

2. BUDDHA PERIOD (500 B.C- 600 A.D):

During this period various surgical procedures like Kalpa mochana (craniotomy), eye

surgeries were performed.

3. MEDIEVAL PERIOD (1000A.D- 1800 A.D):

a) Madhava Nidana (700th A.D) : - (Madhukosha) 43rd chapter as SadyoVrana16

explained about Kshataja vrana.

b) Kashyapa Samhita: - Acharya Kashyapa explained the treatment of Kshataja

vrana in Chikitsa sthana 11th chapter .i.e. Dvivarniya17.

c) Yogaratnakara (1700 A.D): - Explained about SadyoVrana chikitsa in

Uttaradha18.

d) Bhaishajya Ratnavali: - Has explained about SadyoVrana chikitsa Adhyaya

19.


Ayurvedic Review 10

Ayurvedic Review Vrana is the most important disease in Shalya Tantra. Any Shalya or Shalya

karma leads to formation of vrana. So the knowledge of Aetiopathogenesis, types,

diagnosis and management of vrana is most essential in the practice of Shalya Tantra.

Vrana is basically categorized into Nija vrana and Agantuja vrana. This

classification is based on the etiology. The Nija vrana is due to the vitiation of bodily

doshas, where as Agantuja vrana is due to external factors. Kshataja vrana is one type

of Agantuja vrana.

Kshataja Vrana:

Kshataja Vrana is a type of Agantuja Vrana. In Sushruta Samhita six

types of Agantuja vrana has been described20. All these vranas will occur due to

external injury. The brief descriptions of these six types of Agantuja Vrana are given

below.

1. Chinna vrana: This vrana is caused due to the injury by sharp instruments or

objects. The literal meaning of the word Chinna is to cut in two parts. In this

vrana the parts of the body are cut and separated either partially or completely.

This vrana is associated with severe pain and excessive bleeding.

2. Bhinna vrana: This vrana is caused due to the injury by sharp and pointed

instruments or objects. The literal meaning of the word Bhinna is incised. In

this vrana the Ashaya’s i.e. Hollow viscera’s of the body are injured. This

vrana is associated with severe pain and excessive internal bleeding and

discharge of the contents of the injured Ashaya.

3. Viddha vrana: This vrana is caused due to the injury by pointed instruments

or objects. The literal meaning of the word Viddha is penetrating. In this vrana

the injury is caused to other than Ashaya’s i.e. Solid viscera’s of the body are


Ayurvedic Review 11

injured. This vrana is associated with severe pain and excessive bleeding and

partial or complete protrusion of the organ present at the site of injury is seen.

4. Kshataja vrana: As this is the Subject of the Dissertation, so dealt separately

in detail.

5. Pichhita vrana: The literal meaning of the word pichhita is to crush. This

vrana is caused due to the crushing of the body parts in between two objects.

This is of two types i.e. Pichhita and Sa Asthi pichhita. This vrana is

associated with broadening of the injured part, pain and bleeding. In Sa Asthi

pichhita, the Asthi bhagna is seen.

6. Ghrustha vrana: The literal meaning of the word Ghrustha is brushing. This

vrana is caused due to brushing of the objects to body surface. The vrana is

associated with pain and slight yellowish discharge.

Charaka has not mentioned further types of Agantuja vrana where as Vagbhata has recognized following types of Agantuja vrana. Vagbhata21: Ghrustha, Avkrita, Vicchinna, Pravilambita, Patita, Viddha, Bhinna.

KSHATAJA VRANA Vyutpatti:

The term Kshataja Vrana comprises of two words i.e. Kshataja and Vrana. The

literal meaning of these two words is as follows.

Kshataja:

The literal meaning of the term Kshataja is given as22,

“Ksahatatha vranath jayate utpadayte iti”

It means that the vrana which is produced by kshata is known as Kshataja

vrana. It is streelinga word.


Ayurvedic Review 12

Vrana:

The word vrana is derived from the root verb Vranoti meaning – to cover, to

envelop and to protect. This is further suffixed by “ach” in the sense of bhava

and “Ch” sound is elided and the form remains “Vrana + a” in the sense of

“Gaatra Vichurnane” 23. It is pullinga word.

“Vrana Gaatra Vicoornnane Vranayati iti Vranaha”. 24

“Gaatra” means tissue.

“Vichurnane” means destruction, break, rupture, and discontinuity of the body

or tissue.

The destruction / break / rupture / discontinuity of body tissue are called

Vrana.

Vrana Definition:

Condition in which there is destruction of tissue in particular

part and also leaves scar after healing and its imprint persisting

life long, is called Vrana25.

Kshataja vrana Definition: 26

The Kshataja vrana is defined as the vrana produced by the

aghata of external sharp object or instrument resulting into not

too Chinna or too Bhinna vrana.

Nidana: 27

As this is Agatuja type vrana, the Nidana for this vrana is due

to external trauma by sharp edged objects.

Samprapti: 28

Due to the trauma by sharp object twacha, mamsa and sira

videernata takes place causing Agantuja Vrana.


Ayurvedic Review 13

SCHEMATIC REPRESENTATION OF SAMPRAPTI

Bahya Aghata

Injury to Twak, Mamsa and Sira

Gaatra Vichurnane

Kshataja Vrana

Vedana and Rakta srava

Vata Prakopa

Improper Treatment

Dosha vaishmya

Nija Vrana After seven days

Lakshana: 29

• Aghata to twak, mamsa and sira

• Twak videernata

• Vedana

• Rakta srava


Ayurvedic Review 14

Samprapti Ghatakas: Dosha : Vata Dushya : Twak, Mamsa, Rakta. Agni : Jatharagni vaishyamya, Twak dhatwagni vaishymya. Agni dusti : Vishamagni. Srotas : Rasa, Rakta & Mamsa vaha srotas. Srotodusti : Sanga, Gatra vidarana. Udbhava sthana : Twak. Sanchari sthana : Twak. Vyadhi adhisthana : Twak. Roga marga : Bahya Roga marga. Vyadhi swabhava : Ashukari. Saptahat : Dosha samsarga - Nija vrana. Chikitsa: Chikitsa sutra:

To stop the bleeding and to increase the rate of vrana ropana Seevana karma

is done. After Seevan karma, samyak bandhana of vrana is done with ropana

dravyas. 30

Due to aghata and rakta srava in kshataja vrana leads to vata prakopa. So vata

shamana upayas are to be adopted immediately. Sthanika parisheka, abhyanga,

swedana and upanaha by vatahara dravyas are desirable.

Following are some of the drugs used for vedana shamaka and vrana ropana.

Churnas: Ajamodadi churna, Panchavalkala churna, Yastimadhu churna, Amalaki

Churna.


Ayurvedic Review 15

Gutikas: Triphala guggulu, Saptanga guggulu.

Kashayas: Triphala kashaya, Panchavalkala kashaya, Nyagrodadi kashaya.

Tailas: Doorvadi taila, Kampilaka taila, Prapouandarikadi taila, Manjistadi taila,

Karanja Taila, Tila taila, Nimba taila, Jatyadi taila.

Ghrita: Kampilaka ghrita, Doorvadi ghrita, Yasti madhu ghrita, Jatyadi ghrita,

Karanjadya ghrita, Prapouandarikadya ghrita, Tiktakadya ghrita

Vrana Ropana:

The ropana of vrana has different stages. Four different stages are

recognized during the process of complete healing of vrana. They are;

Dusta vrana avastha

Shudha vrana avastha

Ruhyamana vrana

Samyak rudha vrana

Stage wise lakshana are as follows: Dusta vrana avastha: 31

The following lakshanas are seen in Dusta Vrana

Atisamvrutha or Ativivrutha,

Atikatina or Mrudu

Utsanna or Avasanna

Atisheeta or Ushna

Having Krisna, Rakta, Peeta, or Shukla one of the colour.

Filled with Pootipuya, PootiMamsa, PootiSira, PootiSnayu Pootipuya

srava etc.

Moving in Oblique track.


Ayurvedic Review 16

Shudha vrana avastha: 32

The following lakshanas are seen in Shudha Vrana

Not invaded by Tridoshas

Having Shyaava Osta

Jihwa resembles to Talaabha, Mrudu, and Snigdha

Not having Vedana and Srava

Vrana looks good

Develops Sama pidika

Ruhyamana vrana: 33

The following lakshanas are seen in Ruhyamana Vrana

Kapotha varna Vrana

Devoid of Kleda

Has Sthira pidika

Samyak rudha vrana: 34

Lakshanas:

Vrana which has healed in its seat without eruptions (Granthi), vedana or

swelling has the colour as that of twak and is even is said to Samyak rudha

vrana.


Ayurvedic Review 17

Seevana Karma:

Seevana karma is one type of shastra karma. Seevana karma is done in

Agantuja vrana, as well as, in Shastra karma nimittaja vrana. Sushruta has mentioned

eight types of Shastra karma. The brief description of this shastra karma is given

below.

TYPES OF SHASTRAKARMA: 35

Ayurveda have classically described different types of Shastra karma

according to different diseases. Sushruta has described eight types of Shastra karma.

Those are Chedhana, Bhedana, Lekhana, Vydhana, Eshana, Aharana, Visravana, and

Seevana.

1) Chedhana: “Chidira Dvidhakarne” 36

Chedhana means cutting and bifurcating into two parts i.e. nothing but Excision.

Indications: Chedhana is indicated in Apakesu (non-suppurative), Katina (hard),

Sthiresu (fixed lesions), and in Snayu Kothesu (necrosis of ligament)

etc.

Diseases: Arsha, Bhagandara, Granthi, Arbuda, Charmakila, Valmeeka etc.

Instruments used: Vrudhi patra, Nakha Shastra, Mudrika, Ardhadhara, Utpala

patra.

2) Bhedana: “Bhidira Vidarane” 37

Bhedana means Incision.

Indications: Bhedana is indicated in vrana which have Antha Puyesu (pus inside

without opening ), Avakatresu (with pus pockets), Utsanga (sinuses).

Diseases: Vidradhi, Visarpa, Vrudhi, Shopha, Gilayyu etc.

Instruments used: Vrudhi patra, NakhaShastra,Mudrika,Ardhadhara,Utpala patra.


Ayurvedic Review 18

3) Lekhana: “Lekhyam Lekhaneya” 38

The surgical procedure in which scarification is done is called as

Lekhana. It is nothing but Scrapping.

Indications: It is indicated in vrana which are Kathina (hard), Sthoola vrutta ostan

(thick and rounded margins), Diryamana punaha punaha (cracking now

and then), Kathina utsanna mamsa (hard and raised granulation) .

Diseases: Rohini, Kilasa, Upajivihika, Medhoroga, Adhijivihika, Arsha etc.

Instruments used: Mandalagraha, Karapatra.

4) Vydhana: It is also called as Puncturing.

Indications: It is indicated different Siras, Mutravruddhi, and Udakadara.

Instruments used: Kutharika, Vrihimukha, Suchi.

5) Eshana: “Esyahm Nadiyadi” 39

The surgical procedure which is carried out with the help of Eshani is

called as Eshana. It also known as Probing.

Indications: Sinuses and Vrana with oblique course and foreign body are subjected to

Eshana karma.

Diseases: Nadi vrana, Bhagandara.

Instruments used: Eshani

6) Aharana: “Aharanam Aharniyam” 40

The surgical procedure which is used to draw out anything from the

body is called as Aharana. It is also called as Extraction.

Indications: It is indicated in Aharana of Dantasarkara, Mutrasarkara, Padasarkara,

Any Shalya, Moodhgarbha, and Faeces accumulated in rectum.

Instruments used: Badisha, Danta shanku, Garbha sankhu.


Ayurvedic Review 19

7) Visravana: The surgical procedure which is used for secreting or evacuating something

from the body is called as Visravana. It is nothing but Drainage.

Diseases: Vidradhi, Shopha, Kustha, Shleepada, Visarpa etc. Instruments used: Suchi, Kusapatra, Sararimukha, Trikurcaka etc. 8) Seevana: “Tantusantanam or Suhcyukarma” 41

Joining of the two bifurcated tissues is called Seevana or the surgical

procedure which is carried out with help of Suchi is called as Seevana. It is

nothing but Suturing.

Indications: Seevana karma is done in disorders caused by incised and well scraped

lesions, fresh vrana, and those situated in moving joints.

Charaka has described six types of Shastra karma which are as follows 42

Patana

Vydhana

Chedhana

Lekhana

Pracchana

Seevana

Whereas Vagbhata extended these into thirteen types as 43

1) Utpatana 8) Chedhana

2) Patana 9) Bhedana

3) Seevana 10) Vydhana

4) Eshana 11) Manthana

5) Lekhana 12) Grahana

6) Pracchana 13) Dahana

7) Kuttana


Ayurvedic Review 20

Detail description of Seevana Karma is given in the following paragraphs. DEFINITION OF SEEVANA KARMA (SUTURING): 44

Seevana karma is the process of tying two ends of thread for union of wound

edges and is done with the help of needle and appropriate suturing material.

AIM OF SEEVANA KARMA: 45

The purpose of seevana karma is to approximate the wound edges for proper

and faster healing i.e. Vrana Sandhan. Aim is to unite, repair and support the injured

tissue until healing is completed. This will achieve complete haemostasis and normal

restoration of tissue function.

INDICATIONS FOR SEEVANAKARMA: 46

Brihattrayi were agreed on the fact that suturing should be resorted to the case

of an open ulcer due to the action of the deranged fat after its vitiated contents has

been fully scrapped out as well as in the case of an uncomplicated Sadyo Vrana.

Importance is given to Sadyo Vrana and clearly mentioned that the wound should be

sutured Sadyo Dine i.e. at the same day.

Dalhana in his commentary has elaborated this principle as wounds over head,

forearm, face, ears, lips; nose, cheek, neck, upper extremities, abdomen, gluteal

region, reproductive organs, penis, scrotum etc are to be sutured immediately.

Acharya Vagbhata stated that immediate suturing should be done on excised or

hanged out tissues.47

Charakacharya described that the flanks, bowels, abdomen etc which are subjected

to deep surgery should be sutured.48


Ayurvedic Review 21

CONTRAINDICATIONS FOR SEEVANAKARMA: 49

Sushruta in Asthavidhasashtra Karma Adhyaya had clearly mentioned that

vrana infected by Kshara, Agni, and Visha, Vrana from which air is leaking, Vrana in

which dusta Rakta and Shalya are present are ayogya for seevana karma. In case if the

vrana is contaminated, one should do the shodana of the vrana then do the seevana

karma with all possible aseptic precautions.

Dalhanacharya comments that the vrana over the joints like knee, elbow etc

where bones are fractured or dislocated and where much tissue is lost should not be

sutured.

PROCEDURE:

Sushruta has explained the exact way in which the vrana should be sutured in order to

avoid complications and promote better wound healing.

The wound margins should be elevated and approximated well and should be sutured

with appropriate material.

While suturing needle should neither be inserted away from the wound margins not

very close to margins. If needle is inserted away from margins it causes tension on

wound margins and ultimately produces pain. And if needle is inserted very close to

margins, there is chance of cut through the margin.

Dalhanacharya comments that the surgeon should insert needle in the tissues neither

too far nor too close, distant from margin, close to margin considering the desired

result. The stitches given too far from each other it will hamper wound healing and

stitches given too close will contract the wound edges.


Ayurvedic Review 22

WOUND PREPARATION: 50, 51

Before suturing the wound, it should be cleaned thoroughly the devitalized tissue or

any foreign material like dirt, dust, hair, sequestrations of bones, clotted blood all

need to be removed from the wound. This will reduce the chances of sepsis. Then the

detached parts of tissues, fractured bones are placed in their normal position.

Achievement of complete haemostasis is confirmed and wound is stitched with suture

material inserted in a needle.

IMPORTANCE OF DEBRIDEMENT & CLEANING THE WOUND:

The most important steps in the prevention of infection in a traumatic wound involve

preparation, irrigation, and debridement. The importance of meticulous wound care

cannot be overemphasized. All devitalized tissue needs to be removed so that

possibility of infection is markedly reduced.

The process of wound infection and its disadvantages were not unknown to ancients.

Sushruta has clarified that blood clots, foreign materials like stones, hair, nails,

fragment of fractured bone etc should be removed and Wound should be thoroughly

cleaned and then apply suture If these materials are not removed, the wound will

proceed to Pakavastha i.e. Suppurations and will increase pain over affected part. 52

TYPES OF SEEVANAKARMA: 53

Sushruta and Astanga Sangrahakar have explained four types of suturing techniques.

They are,

1. Vellitaka

2. Gophanika

3. Tunnasevani

4. Rujugranthi

Acharya Vagbhata had mentioned ‘Granthi’ instead of ‘Rujugranthi’.


Ayurvedic Review 23

Vellitaka :

Vellitaka i.e. round. This is achieved by suturing continuously along the length of the

wound rapping the wound edges inside it.

Gophanika:

The vrana which are shaped as footprints of crow or are wide, they are sutured with

gophanika type of suturing.

Tunnasevani:

It is done as like as the torn up garments are sutured. It is advisable in vrana over the

eyelids.

Rujugranthi:

In this needle is inserted in vrana margins and sutured, keeping some distance

between two stitches.

SEEVAN UPAKARANAS: Seevana upkarana’s i.e. the materials used for seevana karma are mainly two

namely Seevana dravya and Suchi. The description of these is as following.

SEEVANA DRAVYA: 54

Sushruta Samhita is one of the Indian surgical texts which includes detail description

about different types of suture materials both vegetative and animal origin which are

either absorbable or non-absorbable Sushruta had worked with many natural materials

like fine threads, flax of Ashmantak, Guduchi, Trinaushadhi like Shanaj (a type of

grass), Cotton threads, Silk threads, horsehair and Snayu (tendons/ligaments).

He had used the Heads of Giant Ants to effectively staple a wound over intestine

while performing surgery for perforations. The live creatures were affixed to the

edges of the wound, which they clamped shut with their pincers. Then the physician

cut the insects bodies off, leaving the jaws in place. 55, 56, 57


Ayurvedic Review 24

The ancients well knew the interference of blood in repair and regeneration of

wounds. The rakta vitiated by vata causes dehiscence of wound, vitiated by pitta

causes suppuration, vitiated by kapha causes itching of the wounds. Large amount of

bleeding causes inflammation and ischemia hampers the wound healing58. So they had

given prime importance to achieve haemostasis while performing any surgical

intervention. For the purpose, the act of tying bleeding vessels i.e. ligation was well

known. Acharya Chakrapani emphasizes to clean the wound with chilled water, catch

the bleeding vessel with instrument, and ligate its open end to arrest bleeding.

In the same manner the procedure of ligating the vessels is described in Vagbhartartha

Kaumudi. The bleeding vessels were caught with the forceps and tied tightly with

snayu i.e. catgut and then wound is bandaged with tight compression bandage.

SUCHI (NEEDLES): 59

Along with different suture materials Sushruta also explained three different types of

needles which have to be used for suturing the wounds over different parts of body.

They are,

1. Vritta Dyangula: It is Round body and two fingers long. Used for seevana of

vrana over the organs with less Mamsa.

2. Aayata Tryangula: It is Cutting and three fingers long. Used for seevana of

vrana over the organs having more Mamsa.

3. Dhanurvkra: It is Curved. Used for seevana of wounds over Marma sthana

(Vital organs), vrushana etc.

Along with these three types of needles Sushruta has described another special

type of needle named Yavamukhi Suchi. This needle is described for excision of

tumor. 60


Ayurvedic Review 25

Vagbhata in Ashtang Hridaya has also described three types of needles61 resembling

Sushruta’s description as

1. Vrutta: It is cylindrical. Used for seevana of vrana over the organs having

more Mamsa

2. Tryangula: It is Cutting and three fingers long. Used for seevana of vrana

over the organs having less Mamsa

3. Vrihi: It resembles paddy in shape. It is used to stitch intestine, stomach and

marmas.

Palakapya have described three types of needles as Tridhara, Chaturdhar, and

Vrittakara. And he has mentioned special type of needle of eight angula length

resembling trunk of elephant. But he has not mentioned the use of this needle.


Modern Review 26


Modern Review As surgery is the field mainly related with injury and its managements, modern

science has described in detail carious types of wounds, their management. While

describing wound following Information can be obtained.

Wounds: 62

A wound is discontinuity or break in the surface epithelium. A wound is simple when

only skin is involved. It is complex when it involves underling nerves, vessels.

Types of Wounds: 63, 64

Modem science have classified wounds mainly in two categories Closed wounds and

Open wounds

A) Closed Wounds

a. Contusion

b. Abrasion

c. Haematoma

a. Contusion: Can be minor soft tissue without break in the skin or something it

can be major due to run over by a vehicle. Generally it produces discoloration

of skin due to collection of blood underneath.

b. Abrasion: In this wound, epidermis of the skin is scraped away thus exposing

dermis. They are painful as dermal nerve ending are exposed. These wounds

need cleaning, antibiotics and proper dressing.

c. Haematoma: This refers to collection of blood. It follows injury or

spontaneously as in patients who have bleeding tendencies such as

haemophilla. Depending upon the site, it can be subcutaneous, intramuscular

or even subperiosteal. Haematoma in the knee joint may have to be aspirated

followed by compression bandage. Small haematomas get absorbed, if not

may get infected.

Modern Review 27


B Open wounds- A. Incised

B. Lacerated

C. Penetrating

D. Crushed a. Incised wounds: They are caused by sharp objects like knife, blade and

glass. This type of wound has a sharp edge and is less contaminated.

Primary suturing is ideal for such wounds as it gives a neat and clean scar.

b. Lacerated wounds: They are caused by blunt objects like fall on a stone

or due to road traffic accidents. Edges are jagged. The injury may involve

only skin and subcutaneous tissue or sometimes deeper structure also. Due

to the blunt nature of the object, there is crushing of the tissue which may

result in hematoma, bruising or even necrosis of the tissue. These wounds

are treated by wound excision and primary suturing provided they are

treated within six hours of the injury.

c. Penetrating wounds: They are not uncommon nowadays. Stab injuries of

abdomen are very notorious. It may look like an innocent injury with a

small, one or two cm. long, cut. But internal organ like intestine, liver,

spleen or mesenteric blood vessels might have been damaged. All

penetrating wounds of the abdomen should be admitted and observed for

at least 24 hours. Layer by layer exploration and repair, though

recommended, may not be possible at time due to oblique track of the

wound.

d. Crushed or contused wounds: They are caused by blunt trauma due to

run over by vehicle, wall collapse, earthquakes or industrial accidents.

These wounds are dangerous as they may cause severe haemorrhage, death

Modern Review 28


of the tissue and crushing of blood vessels. These patients are more prone

for gas gangrene, tetanus etc. Adequate treatment involves a good

debridement and removal of all dead and necrotic tissues.

The special features of an incised wound are as follows -

1. The hemorrhage is free, from the fact that the vessels are cleanly divided. The

amount necessarily depends on the size of the vessels involved, and the vascularity of

the part, its continuance, upon the density of the structures allowing or not of

contraction and retraction of the severed ends.

2. Retraction of the lips of wound also occurs, the amount depending upon the

elasticity and character of the part involved and the degree of tension to which it is

exposed.

3. Bruising of margins of the incision is absent, so that under ordinary circumstances

rapid healing (by first intension) should obtain. The surfaces, to begin with are lined

by a microscopic layer of damaged tissue, some of which may be actually dead, but if

suitable precautions are taken; this is absorbed, and in no way interferes with

satisfactory union.

The chief dangers of an incised wound are

1) Haemorrhoge

2) Injury to subcutaneous structure, such as nerves, tendons, muscles etc.

3) The risk involved from infection

Modern Review 29


PRINClPLES OF HEALING: Tissue injury - wound healing:

Wound healing is the summation of a number of processes that follows injury. These

include coagulation, inflammation, matrix synthesis and deposition. These are

followed by angiogenesis, fibroplasia, epithelization, contraction, and remodeling and

scar maturation.

There are three distinct stages of tissue injury (wounding) and repair (healing). These

include: 1 Inflammation, 2. Proliferation and scar formation and 3.Maturation.

Inflammation (l-4 days):-

The initial injury leads to the recruitment of inflammatory cells into the wound, once

a clot forms in response to disrupted blood vessels. This scenario entails a complex

interaction between local tissue mediators and cells that migrate into the wound. The

inflammatory phase occurs in the first few days as inflammatory cells migrate into the

wound. Migration of epithelial cells has been shown to occur within the first 12-24

hours, but further new tissue formation occurs over the next 10-14 days.

After the initial tissue injury, the inflammatory response produced by the tissues

involves a diffuse increase in tissue fluids. In addition, there is an increase in blood

supply and cellular elements (which appear in damaged tissue). This occurs in order

to begin the healing or repair process. The increased blood supply causes

erythematous skin changes.

During this phase, Lymphocytes and other cellular elements remove damaged and

dead tissue by the action of the enzymes. This removal of damaged tissue is it termed

debridement.

This action of debridement is produced by the proteolytic enzyme activity of the

white blood cells (leukocytes). Pain is a normal protective response to tissue injury.

Modern Review 30


Proliferation of collagen and scar formation (5-20days): -

Epithelialization and neovascularization result from the increase in cellular activity.

Stromal elements in the form of extracellular matrix materials are secreted and

organized.

Fibroblasts produce the collagen fibers, which are dispensed into the wound. The

major substance of connective tissue is collagen. It is the collagen that helps

determine the tensile strength of the wound and produces the scar (cicatrix).

Scar maturation (from 20 day onward): -

During the scar maturation stage, a significant amount of collagen is produced,

dispensed and remodeled across the wounded tissues. After a period of time, the

wound can withstand normal stress. In addition, the scar usually contracts during this

phase. The duration of this phase is variable, depending on the specific type of tissues

that are wounded. About 95% of the full strength of the wound is usually reached by

six weeks after injury.

Finally, tissue remodeling, in which wound contraction and tensile strength · is

achieved, occurs in the next 6-12 months. Systemic illness and local factors can affect

wound healing.

After injury the wound, which has been sutured with a suture material also show

similar type of healing pattern. Just after a surgical incision, a number of epithelial

cells and connective tissue cells die and the basement membrane is disrupted.

This clean and uninfected injury is enough to target an inflamrnatory response that

will be absolutely necessary for the wound healing. Immediately after the incision, the

wounds covered with clotted blood containing fibrin and blood cells. This fibrin clots

receives within 24 hours an amount of neutrophils, attracted by inflammatory factors

locally released. At this time, we also have mitotic activity of the basal layer of the

Modern Review 31


epidermis. By the day 3, macrophages are the most common cells in the tissue,

instead of neutrophils. The main feature at this moment is the granulation tissue that

consists of fibroblasts and new capillary with amorphous substance all around. By the

5th day, granulation tissue and neovascularization are maximal. Collagen fibrils are

present and begin to bridge the incision, following the epithelial migration. After 1

week there is still connective tissue proliferation, but inflammatory features have

virtually disappeared At the end of the first month, the scar is completed within an

intact epithelial layer, covering a new cellular connective tissue net, devoid of

inflammation Epithelization starts in 2 days -complete in 7 to 10 days at the rate of 1-

2mm/day.

Fundamentally there are three types of healing: 65, 66

I] Healing by first intention - As mentioned, healing by primary intention is that

which follows surgical wound closure with sutures. In the primary intention method,

surgical wound closure facilitates the biological event of healing by joining the wound

edges.

Surgical wound closure directly opposes the tissue layers, which serves to minimize

new tissue formation within the wound. However, remodeling of the wound does

occur, and tensile strength is achieved between the newly apprised edges.

Closure can serve both functional and aesthetic purposes. These purposes include

elimination of dead space by approximating the subcutaneous tissues, minimization of

scar formation by careful epidermal alignment and avoidance of a depressed scar by

precise eversion of skin edges.

Uncomplicated healing by primary intention occurs with minimal edema, minimal

discharge and no bacterial infection. The tensile strength of the wound increases

Modern Review 32


significantly and the skin obtains approximately 85-90% of its tensile strength before

the wounding healing by primary intention is the most desirable to the surgeon.

II] Healing by second intention - If the healing does not occur by primary intention

and the wound is left to granulate closed; this is termed healing by second intention.

In this case, angiogenesis and fibroblast proliferation result in the formation of

granulation tissue. This contracts to reduce the wound area and allows epithelization

across its surface to achieve wound closure. This is known as healing by second

intention. Healing by secondary intention is a slower process and usually takes four to

eight weeks to reepithelize the area.

III] Healing by third intention - This is also termed as delayed primary closure. This

is the method of choice in contaminated, dirty, infected wounds with loss of tissue.

The surgeon may debride the nonviable tissue before closure. Surgical closure with

sutures is usually performed about four to six days after injury. Unlike secondary

intention, the wound is closed with delayed suturing, rather than being allowed to

close entirely by granulation. The healing process may occur abnormally. There are

many aberrations of growth, but the most common is called keloid. Keloid is a

turnoral scar resulted from accumulation of excessive amounts of collagen. The

reasons for keloid formation still remain unknown, but are known that it's more

common in afro-Caribbean.

Through the years, imaginative biologists have suggested methods to accelerate

healing. To date, this avenue of research has resulted in important findings on the

repair of dehisced and resutured wounds. Incised wounds allowed healing for short

periods, then dehisced and immediately resutured, developed strength at a

significantly faster rate than the primary wound. The benefits of secondary wound

Modern Review 33


healing can be realized in patients requiring surgical intervention soon after the first

procedure.

Complications of wound Healing: 67

1) Implantation of cyst.

2) Painful scars.

3) Cictrisation – It often produces various deformities.

4) Keloid formation.

5) Neoplasia – (squamous cell carcinoma)

The wound healing process is influenced by many systemic and local host factors

1} Local factors –

A) Favorable: -

1. Tissue in the wound should be healthy with good blood supply.

2. No dead tissue should be left in the wound.

3. No tension in the tissue planes.

4. No heamatoma (collection of blood under skin is heamatoma).

5. Minimum of foreign material (e.g. ligature, suture)

6. No pathogenic bacteria.

B) Unfavorable: -

1. Poor blood supply due to trauma or vascular disease.

2. Presence of dead or damaged tissue

3. Tension (e.g. abdominal pressure increases due to sneezing etc)

4. Heamatoma

5. Presence of large amount of foreign materials.

6. Presence of pathogenic bacteria.

II} General Factors - Nutritional state of the patient is very important. Protein

deficiency and particularly ascorbic acid deficiency inhibits collagen synthesis and

impairs healing.

Modern Review 34


Glucocorticoids therapy, by its anti-inflammatory aspects, retards healing. Patient’s

age is also a systemic factor that plays a role. Hemorrhagic factors, such as ischemia,

play a role and foreign bodies, such as sutures and/or other fragments constitute

impediments to healing.

The following conditions delay or hamper the quality of wound healing –

1) Anemia.

2) Uremia.

3) Jaundice.

4) Diabetes.

5) Blood dyscrasis.

6) Malignant diseases.

7) Cytotoxic drugs.

History of Suturing: 68

Sometimes between 50,000 and 30,000 B.C eyed needles were invented, and by

20,000 B.C., bone needles became the standards that were not improved upon until

the Renaissance. It is reasonable to assume that these needles were used to sew

wounds together, became Neolithic ("of the 'New' Stone Age") skulls have been

found, showing that trepanning (a form of surgery where a hole is drilled or scraped

into the skull) was used successfully. Evidence shows that the wounds must have been

closed up after the procedure because there is bone growth inward from the edges of

the hole; this means that the patient was not only alive at the time of the operation, but

lived for a considerable period of tone afterward.

The primitive men in the beginning of more modern times give examples of how early

surgery was performed. Native Americans used cautery (the burning of the body to

Modern Review 35


remove or close a part of it) and East African tribes would ligate (tie off) blood

vessels with tendons and close wounds with acacia thorns pushed through the wounds

with strips of leaves wound around the two protruding ends in a figure eight. South

African methods of wound closure use larger black ants to bite the wounds edges

together, with their powerful jaws acting as Michel clips.

The bodies would then be twisted off, leaving the head in the place to keep the

wounds closed.

In more ancient times (1,900 B.C.), the king of Babylon, Hammurabi, engraved his

country's laws on a pillars. Some of these laws related to surgical practice; one stated

that “If a physician should make a severe wound with an operating knife and kill a

patient or destroy an eye, his hands shall be cut off." Because of this and similar other

laws, the Babylonian practice of medicine declined so far that people with illness and

disease were carried into the market square so that they could get recommendations

and advice form people who had already experienced the illness.

In the seventh century B.C., the Greeks began to found medical attention; it was also

at this particular time that medicine was finally recognized as a science. A Greek

physician by the name of Hippocrates is considered to be one of the most outstanding

figures in the history of medicine. His main contribution to surgery was his detailed

clinical description and the discarding of treatments impounded on tradition or

wishful thinking rather than on rationality.

Sometime around 30 A.D., a medical encyclopedia was written by a Roman named

Aurelius Cornelius Celsus. His work, De Re Medicina, tells the reader that sutures

should be "soft, and not over twisted, so that they may be more easy on the part." He

is also credited with first substantiated mention of ligating by recommending it as a

secondary means of stopping a hemorrhage.

Modern Review 36


Galen, an ancient Greek physician from A.D. 150, gained a sterling reputation from

treating and suturing the served tendons of gladiators, giving them a chance at

recovery rather than the sure fate of paralysis. He was an authority on suture thread

materials and has many recommendations on which material would be best for each

sort of wound closure in his books Del Methodo Medendi. Also, Gale, along with

Hippocrates, recognized two kinds of wounds: a clean wound and dirty wound (which

required drainage before healing could occur)

Another development in suturing was Avicenna's realization that some traditional

materials had a tendency to break down rapidly; because of this, he invented the first

monofilament suture by using pig's bristles.

Avicenna may have been the Prince of Physicians, but the Prince Surgeons was

undoubtedly Albucasis. In his first book, he recommended the indiscriminate use of

cautery, but in his second book, the use of the cutting instruments and sutures were

implemented instead. In this book he described a technique called a Double suture"

which is still used today.

Suture Material

Definition: 69, 70, 71, 72

Ligature - When a pedicle is tied it is called as a ligation and the material used is

called as ligature.

Suture - When two cut edges are approximated either continuously or interruptedly it

is called as suturing and the material used for it is called as suture.

A suture is any thread or strand which brings into opposition two surface or tissue,

while ligature is any thread or strand which obliterates the lumen of ductular structure.

Modern Review 37


Ideal qualities for suture or ligature - AY Chery (1980)

a) It should have good strength.

b) It should produce minimal tissue reaction.

c) It should have easy knotting and handling properties.

d) It should glide through tissue easily.

e) It should remain in the tissue till that time as required of it.

f) It can be employed in infected sites.

g) It should not be too expensive.

h) It should have minimal complication

i) It should have uniform diameter. Uniform diameter dominates potential breaking

points and provides higher tensile strength.

j) It should be of the material that can be easily sterilized Staining strength and

pliability and without alteration of its physical and chemical properties.

k) It would be freely available and less expensive.

Characteristics of different types of suture materials:

a) Absorbable material - It gets absorbed in the body either by enzymatic. Digestion

or removed by phagocytosis e.g. catgut or broken by hydrolysis and then removed by

phagocytosis e.g. polyglactin (Vicryl)

b) Non absorbable material - This type of suture material remains in the body and

retains its tensile strength for at least one year. E.g. Prolene, skinless steel ore, thread,

silk, dc.

c) Tensile strength of material:

1) Straight pull tensile strength – minimum amount of tension required to

break filaments

Modern Review 38


2) Knot pull tensile strength - minimum amount of tension required to break

the knot given by the material knot pull tensile strength is more important than

straight pull tensile strength in surgical practice because a surgeon is more

concerned whether a knot will break up or not. This is measured during

manufacturing by special meter, and it is expressed in kilograms.

d) Smoothness - The smoother the suture material the easier the passage through the

tissue with least trauma e g. monofilament. Prolene is smooth so it is Preferred in

Vascular Surgery.

e) Knot Security- Monofilament sutures have smooths Surface, so the knot will slip

and open up. Therefore at least five Knots should be tied. Since surface is rough in

Polyfilament suture the knot will be held more securely e.g. silk (two to three knots

are enough).

f) Filament Arrangement of Thread:

1. Monofilament-Structure is produced from single filaments of the material, e.g.

prolene, polyamide, novafil, etc.

2. Polyfilament- Multiple filaments are used. The sub-types are

a) Twisted, e.g. cotton threads, linen;

b) Braided, e.g. braided silk, braided Vicryl (polyglactin), banded polyester;

c) Flossed, ergs floss silk (used previously for hernia repairs.

Advantages and Disadvantages of Filaments Arrangement of Thread:

i. Monofilament Structure: Organisms cannot enter the substances of monofilaments

thread. So chances of infection are minimum, but due to its smooth surface knots are

likely to slip. There is no fraying of the end on cutting.

Modern Review 39


ii. Polyfilament Sutures: There are crevices between the strands of the ployfilament

threads. So organism enters into it and infection may set in easily. When the ends are

cut, there is fraying of filaments which is more in twisted thread than in braided one.

But knots given are sufficient secured due to rough surface.

g) Tissue Reaction Excited by Material: Ideally, the surface material should be

chemically inert in tissues and should not affect the normal healing process. Cotton

thread and catgut are irritants because they are foreign materials and contain protein.

New synthetic materials, e.g. polyglactin, polydioxinone, prolene, novafil and steel

are least irritating.

CLASSIFICATION OF SUTURE MATERIALS: - General classification of suture material includes -

1. Natural and Synthetic

2. Absorbable and Nonabsorbable

3. Monofilament and Multifilament.

Natural materials are more traditional and still are used in suturing today Synthetic

materials cause less reaction, and the resultant inflammatory reaction around the

suture material is minimized.

Measurements of the in vivo degradation of sutures separate them into two general

Classes. They are broadly classified as absorbable and nonabsorbable sutures. Sutures

that undergo rapid degradation in tissues, losing their tensile strength within 60 days,

are considered absorbable sutures. Those that maintain their tensile strength for longer

than 60 days are nonabsorbable sutures. This terminology is somewhat misleading

because even some non-absorbable sutures (i.e., silk, cotton and nylon) lose some

tensile strength during this 60-day interval.

Modern Review 40


ABSORBABLE SUTURE MATERIALS: -

Natural

1) Catgut

Catgut is a misnomer of Kitgut which mean a medieval three stringed violin-like

musical instrument string of which are used by ancient people as a suture material.

This absorbable suture was known to Galen (A.I). 131-201) lord Baron Joseph Lister

(1827-1912) hardened this material and minimized the tissue reaction; Lister turned to

the leather thread and found that chromic acid was used to tan leather. He

incorporated this advent of world war I, George Marsor local pharmacist, was

involved in catgut manufactured and produced eyeless needled sutures where a strand

of suture material was attached to butt of needle.

Catgut is prepared from submucosa of the sheep's intestine. Sheep's & submucosa has

rich content of elastic tissue which accounts for high tensile strength of catgut.

Duration and absorption of catgut

Plain catgut retains its tensile strength approximately for 10 days and chromic catgut

for 20 days Tensile strength of chromic catgut is zero after 30 days and gets absorbed

completely in 100 days. Catgut being protein gets absorbed by proteolytic enzymes

derived from Lysozymes contained within polymorphs and macrophages, it can also

get absorbed enzymatic digestion.

Advantages of catgut

i) It is absorbable

ii) It is monofilament.

iii) Got good tensile strength.

iv) It is smooth and pliable in handling

v) It has got good knotting property.

vi) It can be used in infecting wounds.

Modern Review 41


Disadvantages of catgut

i) It being protein; produces tissue reaction.

ii) Snapping of catgut can take place.

iii) Loss of tensile strength when it is most required.

iv) Expensive.

Other Natural absorbable Suture material

a) Collagen Sutures

These sutures are made by excluding homogenized tendon. A chilles of beef,

cattle. They are 100% pure collages. They are also available in plain and

chromic form. Behave similar to catgut. Finer gauges are used in ophthalmic

surgery as tissue reaction is probably less than that of catgut.

b) Cargile membrance

It is a thin sheath of tissue obtained from submucosa of ceacum ox. It was

used earlier to cover surface from which peritoneum was removed in

abdominal surgery, to prevent adhesions in abdominal surgery; for isolating

ligations, as a covering for packing material in submucosal resection.

Presently it is being replaced by prolene mesh.

c) Fascia lata sutures

Fascia lata is obtained from thigh muscles of beef. It was used previously in

hernia repair. Fascia lata from the patient himself, in correcting the drooping

of eyelids and facial

d) Kangaroo's tendons

They are obtained from individual tail tendons of kangaroo. It varies from 10-

18 inches in length. These are not used in present days.

Modern Review 42


e) Skin Ribbon suture

It is described by Gosset long strip of skin is used as a suture for this the customary

incision is made and one extremity of this is rounded by excision of a tiny segment of

skin. Strip of skin, 0.5cm wide is then cut from the margin of wound, continued

around one end, so that its total length equals twice that of the wound. Skin is put in

boiled water for 10 minutes. So that epidermis is separated, which is removed. Then

the ribbon is threaded on Galle's needle. It is used in Herniorrhaphy by simple suture,

repairs of incision hernia. It is advantageous as it is readily available, cheap, good

hold of tissue.

2. Synthetic

1) Polyclycolic acid (Dexan)

It is synthetic and absorbable suture material. It is non-protein polymer of glycolic

acid. It could self coloured or died green. It can coated or uncoated. It is absorbed by

esterase enzyme system.

Advantages-

• Minimum tissue reaction.

• Less tissue edema.

• Uniform absorption.

• Can be used in the presence of infection as inflammation does not

alter the absorption, as it is not absorbed by phagocytosis.

• Better knot holding properties.

• Less fraying of ends.

Uses-

• Intestinal anastomosis.

• Ligation of pedicles.

Modern Review 43


• In billiary surgery

• Less tissue reaction and edema, hence it is the conventional suture,

especially for cosmetic surgery.

2) Vicryl-(Polyglaction):

Polyglaction is a synthetic, absorbable suture material. Polyglaction 910 is the

copolymer of glycolme and lachide. It is polyfilament braided suture manufactured by

process of extrusion. Vicryl can be self colored. It can also be coated with lubricant.

The coating on vicryl consists of casterate, lactide and glycolide. Starts loosing tensile

strength in 40 days and absorbs completely between 60 to go'h day. Rapid viracy is a

braided, synthetic, absorbable suture material, while in color, which looses its tensile

strength after 14 days and gets completely absorbed between 35.42 days.

Advantages

• Minimal tissue reaction

• No trying

• Excellent handling characteristics

• Its distinct violet color is highly visible in the wound.

• Unique molecular structure causes polyglactin to retain its strength during the

critical healing period and then to be absorbed rapidly, that is, the suture is

absorbed after it has served its function.

• Can be used in presence of infection.

Disadvantages

• It is rough, so causes sawing action over tissue.

• It requires a specific knotting technique.

Modern Review 44


Uses-

• Intestinal anastomosis.

• Ligation of pedicles.

• Closure of laparotomy for peritonitis/ intestinal perforation.

2) Polydioxinone suture (PDS)

Latest synthetic absorbable made from homopdyme of polydiaxanone. It is

monofilament suture material. It 100 see tensile strength in 56 days and gets

absorbed in 180 by hydrolysis.

B) NON ABSORBABLE SUTURE MATERIAL 1) Natural

1) Cotton Thread-

It is natural, non-absorbable suture material of vegetative origin. It is twisted

polyfilarnent available in reels in unsterile form. Sterilization of cotton thread is

achieved by autoclaving it. These are available in sizes from no. 2, 8, 10, 20, 40, 60,

and 80, (No. 2 is thickest and No. 80 is thinnest)

Advantages

• Cheapest and freely available.

• Knotting is secure and easily hand

Disadvantages

• It absorbs fluids by capillary action, so there are more chances of infection.

• Tissue reaction is more.

• It frays easily and has low tensile strength.

Uses

• Stitching of slain.

• To tie pedicles, e.g. haemorrhoidectomy.

• To ligate the omentum after its resection.

Modern Review 45


• To ligate the intestine or colon during resection or to prevent soling of

peritoneal cavity.

2) Linen

It is natural non-absorbable, ployfilament suture material of vegetable origin,

made from jute fibers. It is spun from long staple flax fibers, especially selected for

surgical use and twisted into a tight and uniform stand without any slubs, fuzziness

and waviness. It is cellulose in nature.

It gains 10% tensile strength when wet. It has got good knotting properties. It is used

for ligating pedicles, transfixation of hernial sac; haemorrhoidectomy.

3) Silk

It is a natural, non absorbable, ployfilament suture material obtained from

cocoon of silk warm larvae. It is proteinous in nature initially it is covered by an

albumious layer, which is removed by degumming. It is braided round a core and

coated with was to reduce capillary action. It is sterilized by gamma radiation.

Advantages -

• It does not soak up fluids.

• It never becomes limp oz brittle.

• It ties down smoothly and securely.

• Its natural elasticity gives it an extensibility that signals when optimum knot

placement has been achieved.

Disadvantages-

• Stitch granuloma

• Infection rate is high as compared to synthetic material.

Uses-

• To ligate blood Vessels.

• To repair hernia.

Modern Review 46


• To suture nerve.

• To Suture grafts in vascular surgery.

• To suture tendons.

• For fixing the skin grafts.

2) Synthetic

1) Nylon

It is a synthetic, non-absorbable suture. It is called Nylon because it was

discovered simultaneously at New York and London (Ny-Newyork. Lon London)

Advantages-

• Less irritant.

• High tensile strength, which is retained for a long period.

• It is Cheaper.

Disadvantages

• Knot is slippery.

• Infection due crevices is braided nylon.

• Too Smooth and stiff Knots likely to slip.

Uses

• To Suture skin.

• To repair Hernia.

2) Prolene:

It is made up of polymer of propylene (polypropylene). It is a synthetic non-

absorbable suture.

Advantage

• It is monofilament, so it does not harbour microorganism ad hence no chances

of infection.

Modern Review 47


• High degree of smoothness, so it requires much less force to draw through the

tissue.

• It can be easily placed and pulled out, so it is preferred in plastic surgery and

in vascular surgery.

• Its sky blue color has high visibility in tissue.

• It is pliable, so it ties securely and can be easily handled.

• Less thrombogenic, which is important factor in vascular surgery

• It retains its tensile for years which makes it the suture of choice when

extended approximation is must.

• It is unwet by blood, unweakened by tissue enzyrnes, and offers prolonged

tensile strength, even in infected areas.

Uses:

• Plastic surgery.

• Vascular surgery for anastomosis between vessels or between vessels and

synthetic graft.

• Cardiovascular surgery, e.g. to close the ventricular puncture during closed

mitral valvotomy.

• Tendon repair, hernia repair.

3) Polyamide (Ethilon)

It is synthetic, non absorbable, monofilament suture material.

Advantages

• Minimal tissue reaction

• Remarkable smooth.

• High degree of elasticity with secure knot tying.

• Extremely strong.

Modern Review 48


Uses-

• As tension stitch to close laparotomy

• For single layer closure of laparotomy wound.

4) Stainless steel wire-

It is made up of stainless steel. It produces very little tissue reaction. It is used

for interdental wiring in treatment of fracture mandible, as alone suture in fracture of

patella, olecranon process of ulna. Only the disadvantages are cutaneous discomfort

and less firm knots.

Classifying sutures into groups depending on how they behave in tissues makes

choosing the right suture material easier.

Following are the specific areas for uses of different suture material according to their

sizes.

Size Uses

7/0 & smaller - Ophthalmology, Microsurgery

6/0 - Used on areas requiring little or no retention. Primarily

used for cosmetic effects. Face, Blood vessels.

5/0 - Used for areas involving the face, neck, nose, ears,

eyebrows and eyelids.

4/0 - Used in areas requiring minimal retention. It is the most

common size utilized for superficial wound closure.

Mucosa, Neck, Hands, Limbs, Tendons, Blood Vessels.

3/0 - Used in areas requiring good retention. Limbo Trunk,

Gut,

Blood Vessels.

2/0 - Used for high stress areas requiring strong retention.

Trunk,

Fascia, Viscera, Blood Vessels

0 & larger - Abdominal wall closure, Fascia, Drain sites, Arterial

lines, Orthopedic surgery.

Modern Review 49


Removal Date:

Sutures (stitches) at a particular site should be removed as follows:

Site Removal Date

• Face - 3-4 days

• Eyelid - 3-5 days

• Ear - 4-5 days

• Nose - 3-5 days

• Lip - 4-5 days

• Neck - 5 days

• Scalp - 6 days

• Chest or abdomen - 7-10 days

• Back - 10-14 days

• Penis - 7-10days

• Joint-extensor surface - 10-14 days

• Joint-flexor surface - 8-10 days

• Arms & back of hands - 7-9 days

• Fingertips - 10-12 days

• Legs & top of feet - 10 days

• Palms and soles - 14 days

NEEDLES

The surgical needles are sharp, pointed instruments. They are used for punching tissue

for guiding the thread or wire to suture or pass a ligature around the vessels. These are

available in wide range of type, shapes, lengths and thickness The choice of needle to

be used must rest with the surgeon. Several favors such as requirement of specific

procedure the nature of the tissue to be sutured, the accessibility of the operative area,

and preferred technique of individual surgeon are taken into account.

The surgical needles are classified into different types according to their characters

i.e.

Modern Review 50


1. According to shape – Strait / Curved

2. According to cutting edge - Round body / Cutting body

3. According to its top - Triangular / Round / Blunt

Eyeless needle is one of the frequently used types of needle in which one strand of

suture material is attached to swage of a needle during manufacturing. Eyeless needle

has following advantages.

• It causes minimal tissue trauma as only a single swaged suture is drawn

through the tissue.

• A series of large holes left behind by an eyed needle carrying double suture

strands are likely to cause contamination of peritoneal cavity following a

bowel anastomosis or haemorrhage or following a vascular anastomosis which

can be avoided by an eyeless needle.

• Each patient has a benefit of a new sharp needle. A reusable needle is

potentially dull, burred or tarnished.

• The eyeless needle does not unthread easily and, if accidentally dropped, it can

be easily recovered since it is swaged to the suture strand. Premature

unthreading of an eyed needle cause interrupts and delays in closure with a

high risk of possible needle loss in a body cavity or in an orifice.

Suture Technique The primary suture line is the line of sutures that holds the wound edges in

approximation during healing by first intention. It may consist of a continuous strand

of material or a series of interrupted suture strands. Other types of primary sutures,

such as deep sutures, buried sutures and subcuticular sutures, are used for specific

indications.

Modern Review 51


Continuous research into present and future methods of wound closure techniques

make it important for surgeons and surgical specialists to stay informed about the

most up-to-date findings concerning all types of modern bound closure techniques.

Following are the types of wound closure techniques:-

1. Simple interrupted suture

2. Mattress - a) Horizontal mattress suture

b) Vertical mattress suture

3. Continuous- a) Running Closure Baseball Stitch

b) Running interlocking suture

c) Running intracuticular suture.

d) Purse-string suture

4. Others - Staples, Skin Adhesives, Tissue Glut methods of

wound closure.

The size of the bite, and the interval between bites should be consistent and will

depend on thickness of tissue being approximated. The minimal size amount of suture

material should be used to close the wound.

Skin sutures should be leaved in place for an average of 7 days. In locations where

healing is slow and cosmesis is less important (the back and begs). Sutures should be

leaved for 10- 14 days. In locations where cosmesis in important (the face), suture can

be removed after 3days but the wound should be reinforced with skin tapes.

1. Needle holder is used to hold the needle, grasping the needle with the tip of driver,

between half and two thirds of the way along the needle. If the needle is held less than

half way along; it will be difficult to take proper bites and to use the angle of the

needle Holding the needle too close to the end where the suture is attached may result

Modern Review 52


in flattening of the needle and a lack of control. Needle holder should be hold such

that fingers are free of the rings and so that wrist can be rotated.

2. Pass the needle tip through the skin at 90o angle.

3. The curve of needle is used by turning the needle through tissue, trying to push the

needle will straighten the needle.

4. Deep wounds in the layers are closed with either absorbable or monofilament non

absorbable sutures.

1. Simple interrupted suture:-

The needle is inserted at a 90° angle to the skin within 1-2 mm of the wound edge and

in the superficial layer. The needle should exit through the opposite side equidistant to

the wound edge and directly opposite the initial insertion An equal amount of tissue is

to be opposed on each side. All knots are placed on the same side.

It is commonly used to repair lacerations. It permits good aversion of wound edge. It

is used only when there is minimal skin tension.

2. Mattress:-

It provides a relief of wound tension and precise apposition of the wound edges. As it

is more complex it consumes more time for closure of wound.

a) Horizontal mattress suture :-

The horizontal mattress can be used to oppose skin of different thickness. The

entrance and exit sites for the needle are at the same distance from the wound

edge. Half-buried mattress sutures are useful at corners. On one side, an

intradermal component exists, in which the surface is not penetrated. Knot is

placed at the skin surface on the opposing edge of the wound.

Modern Review 53


b) Vertical mattress suture :-

Vertical mattress sutures can aid in averting the skin edges. This technique is also

employed for attachments to a fascial layer The needle penetrates at 90° to the

skin surface near the wound edge and can be placed in deeper layers either

through the dermal or subdermal layers. The needle exited through the opposite

wound edge at the same level, and then turned to repenetrate that same edge but

at a greater distance from the wound edge. The final exit is through the opposing

skin edge, again at a greater distance from the wound edge than the original

needle entrance site. Knot is placed at the surface. A knot placed under tension

risks a stitch mark.

3. Simple running suture:-

This suture method entails similar technique to the simple suture without a knotted

completion alters each throw. Precision penetration and tissue opposition is required.

The speed of this technique is its hallmark; however, it is associated with excess

tension and strangulation at the suture line if too tight, which leads to compromised

blood flow to the skin edges.

4. Running interlocking suture:-

Another variant is the simple locked running suture, which has the same advantages

and similar risks. The locked Variant allows for greater accuracy in skin alignment.

Both styles are easy to remove. Additionally the running sutures are more watertight.

5. Subcuticular suture:-

Subcuticular sutures are continuous or interrupted sutures placed in the dermis,

beneath the epithelial layer. Continuous subcuticular sutures are placed in a line

parallel to the wound. This technique involves taking short, lateral stitches the full

length of the wound

Modern Review 54


After the suture has been drawn taut, the distal end is anchored in the same manner as

the proximal end. This may involve tying or any of a variety of anchoring devices.

Subcuticular suturing may be performed with absorbable suture, which does not

require removal, or with monofilament non-absorbable suture that is later removed by

simple removing the anchoring device at one end and pulling the opposite end.

This type of suturing has excellent cosmetic result. It is useful in wounds with strong

skin tension, especially for patients who are prone to keloid formation.

6. Deep sutures:-

Deep sutures ace placed completely under the epidermal skin layer. They may be

placed as continuous or interrupted sutures and are not removed postoperatively.

7. Buried strep:-

Buried sutures are placed so that the knot protrudes to the inside, under the layer to be

closed. This technique is useful when using large diameter permanent sutures on

deeper layers in thin patients who may be able to feel large knots that are not buried.

8. Purse string sutures:-

Purse-string sutures are continuous sutures placed around a lumen and tightened like a

drawstring to invert the opening. They may be placed around the stump of the

appendix, in the bowel to secure an intestinal stapling device, or in an organ prior to

insertion of a tube (such as the aorta, to hold the cannulation tube in place during an

open heart procedure).

9. Retention sutures:-

All abdominal layers are held together without tension; the suture takes the tension

off the wound edges.

Use for patients debilitated as a result of malnutrition, old ages immune deficiency or

a advanced cancer; those with impaired healing and patients suffering from conditions

Modern Review 55


associated with increased India abdominal pressure, such as obesity, asthma or

chronic cough.

Also use in cases of abdominal wound dehiscence.

Monofilarnent nylon is a suitable material.

Retention suture technique: -

• Insert retention suture through the entire thickness of the abdominal wall

leaving them untied at first Suture may be simple (through and through) or

mattress in type.

• Insert a continuous peritoneal suture and continue to close the wound in

layers.

• When the skin closure is complete, tie each suture apex threading it through a

short length of plastic or rubber tubing. Do not tie the suture under tension, to

avoid compromising blood supply to the healing tissues.

• Leave the suture in place for atleast 14 days.

Alternative methods of wound closure –

There is few recently developed wound closure devices are available which are

oftenly used by many surgeons in their routine practice.

These are as follows

i. Mechanical Stapler

ii. Metal clips

iii. Steri strips

iv. Topical skin adhesives

v. Adhesive tape

vi. Tissue glues

Modern Review 56


Mechanical Stapler:-

Humer Hulti, was first to use this device successfully in Hungary, to close stomach.

The stapler closure is mainly used for large wounds that are not on the face. Stapling

is especially useful for closing scalp wounds. Many surgeons routinely use staples for

closure of standard abdominal, thorax and extremity incisions. Advantage of stapling

includes ease of use, rapidity, low risk of infection, minimal damage to host defenses

and strong closure. A variety of stapling devices is available for wound closure.

Disadvantages include less precise wound edge alignment and cost.

Metal clips:-

These are mainly used for skin closure. It allows quick and accurate closure. These

are more expensive but save operating time. All clips are easy to remove and give

cosmetically acceptable scars.

Steri strips:-

Steri strips are reinforced microporous surgical adhesive tapes. Steri strips are used to

provide extra support to suture line, either when running Subcuticular sutures are used

or after sutures are removed. Wound closure tapes may reduce spreading of the scar if

they kept in place for seven weeks after suture removal. Often, they are used with a

tissue adhesive. These tapes are rarely used for primary wound closure.

Topical Skin Adhesives: -

Low tension wounds (those where the skin edges lie close together without

significant tension) can be closed by gluing the skin edges together with a

Butylcyanoacrylate skin adhesive. They have been used successfully for the closure of

traumatic lacerations and surgical incisions. Application of butylcyanoacrylate was

found to be more rapid and cost effective suturing.

Modern Review 57


Adhesive Tape: -

There are many surgical products available, which may be used during wound closure

and other operative procedures, which involve suturing. Skin closure tapes are an

effective alternative to sutures or staples when tensile strength and resistance to

infection are not critical factors. Skin closure tapes can also be used to complement

suture or staple closures. Stress is applied uniformly to the collagen fibers, aiding in

rapid fiber orientation and increased tensile strength.

Tissue glues: -

The use of tissue glues is not widespread despite much published work on the subject.

The cyanoacrylates have been used for shin closure but require perfect haemostasis if

they are to work well. They are as expensive as disposable metal stapling units but

quick to use and do not delay wound healing.

Tissue glues involving fibrin work on me conversion of fibrinogen by thrombin to

fibrin with cross-linking by factor XIII, Aprotinin retards breakup of the fibrin

network by plasmin. The network has good adhesive properties and has been used for

haemostasis in the liver and spleen. It has also been used in neurosurgery for dural

tears, in ear, nose, throat and ophthalmic surgery to attach skin grafts, and in general

surgery for the prevention of postoperative adhesions in me pericardium and the

peritoneum. The use of fibrin glues in support of anastomosis after low anterior

resection is promising.

Fibrin glues have been used to control gyro intestinal hemorrhage at endoscopies but

do not work when bleeding is brisk. Fibrin glues are more effective in haemostasis

when combined with collagen.

Modern Review 58


Knot Tying:-

There are many knot tying variations and techniques, all with the intention of

completing a secure square knot. A complete square knot consists of two Sequential

throws that lie in opposite directions. This is necessary to create a knot that will not

sleep.

A surgeon’s knot is a variation in which double throw is followed by a single throw to

increase the friction on the suture material and to decrease the initial slip until a full

square knot has been completed.

Use a minimum of two complete square knots on any substantive vessel and more

when using monofilament suture. If the suture material is slippery, more blot throws

will be required to ensure that the sutures does not come undone or slip. When using a

relatively 'non - slippery' material such as silk, as few as three throws may be

sufficient to ensure a secure knot.

Cut sutures of slippery materials longer than those of "non - slippery" materials. There

is a balance between the need for security of knot and desire to leave as little foreign

material in the wound as possible.

Techniques of knot tying -

There are three basic techniques of knot tying

a. Instrument tie

b. One handed knot

c. Two handed knot

a. Instrument tie -

• This is the most straight forward and the most commonly used technique; take

care to ensure that the knots are tied correctly.

• Hands must be crossed to produce a square knot, to prevent slipping.

Modern Review 59


b. One Handed knot -

• One handed knot is used to place deep seated knots and when one limb of

suture is immobilized by needle or instrument.

• Hand tying has the advantage of tactile sensations lost when instruments; if

you place the first throw of knot twice, it will slide into place, but will have

enough friction to hold while the next throw is placed.

c. Two handed knot -

It is most secure and routinely practiced by many surgeons

Drug Review 60

DRUG REVIEW

In this study the materials used are

Ashwa Bala 73

Guduchi Snayu 74

Cotton Thread no 10 75

Triphala Guggulu 76

Panchwalakala Churna 77

The brief descriptions of these drugs are dealt in the forthcoming paragraphs.

ASHWA BALA

In medicinal practice of ancient India, hair has been used for many purposes.

Bala (hair) is considered as an excreta i.e. Mala of asthi dhatu. It is generated in the

process of intrinsic oseotic digestion. Dhatu are the composing factor of the body

responsible for the functioning and structural existence of the body. Dhatu generates

Upadhatu. Hair is considered as Upadhatu of Majja. It is also considered as mala of

Asthi dhatu.

Hair is mentioned as one amongst Upa-Yantras. These Upa-Yantras i.e. minor

surgical accessories should be applied according to the necessities of each case to be

determined by the surgeon 78.

Hair is also mentioned as Anushastra. In the absence of probe or director, hair

or finger can be used for the purpose of searching79. Acharya Sushruta in his treatise

mentioned Bala (hair) as a Seevana Dravya. Dalhanacharya in another chapter

clarified that hair of Horse should be used. It was widely used in those days. It is

clearly mentioned in Vagbhatartha Kaumudi to use Human Hair or Horse Tail Hair to

tie up the Piles.


Drug Review 61

In skull injuries alter removing foreign material or an arrow Bundle of Hails

had been used to pack the wound and the hair are to be removed one by one, as

wound heals up gradually80.

Sushruta and Vagbhata both had described to use bundle of hairs tied to a long

thread for extraction of fish bones from the throat. The patient is directed to swallow

the ball of hairs with some liquid and emetics are to be administered to excite

vomiting. The foreign body gets entangled in the ball and suddenly pulled out by the

thread outside 81.

Horse Hair: 82

Hair consists of keratin, which is a type of protein. Keratin is a familiar

material to all of us. There are two main forms of keratin: α-helices, which are found

in hair, and β-sheets.

As the names suggest, α -helical keratin contains keratin molecules arranged

in helices and held in place by hydrogen bonds, whereas β-sheet keratin contains

keratin molecules arranged in flat sheets, in which adjacent molecules are antiparallel

due to more favorable interactions between side-groups. If hair keratins are stretched

in steam, then they develop a β-sheet configuration.

In Yogaratnakara it is advised to rub the throat of the recently delivered

women by a finger surrounded by hair, to help the expulsion of the placenta.

Treatment of Trichiasis (Pakshma-kopa) was also a common procedure at ancient

time83.

Sushruta described full account on surgical treatment for Trichiasis. He says:

after being treated with sneha (a special diet) the patient sits facing the surgeon. An

excision in the shape and size of barleycorn should be made in the eyelid horizontally


Drug Review 62

parallel leaving two parts below the eyebrow and one part above the eyelashes. The

surgeon should then suture up the two edges with horse's hair.

Historically horse hair was used for many purposes in medical field. It was

used to tie together the misplaced tooth after traumatic injury to Jaw bone. During war

maxillofacial wounds were managed by general principles and primary closure of the

soft tissue wound with horse hair and there was no instance of gas bacillus infection

reported in this group of wounds.

Many times horse hair was used as a drainage device. It had been placed in

scalp wound to facilitate drainage of accumulated blood. Keen in 1888 used Horse

Hair as drainage device against post operative epidural hemorrhage in neurosurgery.

In 1906, horse hair was placed through a corneal paracentesis in an attempt to drain a

hypopion externally. The same technique was later used to treat two patients with

painful absolute glaucoma.

The Egyptian practice of embalming or mummifying the body contributed to

certain extent, to the knowledge of anatomy, surgery and bandaging. Many of these

mummies were found to have Horse Hair sutures on their bodies. Howard in his

article –Mysterious Mummies of China- mentioned a male mummy bearing marks on

its chest possibly had been incised due to lung disease and then sewn up with Horse

Hair sutures. Another of these Chinese Mummies was found to have postoperative

Horse Hair sutures in his neck. One Aryan Mummy was also found with signs of

surgery sown up with sutures of horse hair.

Among the ancient Egyptians, circumcision of males was practiced as early as

5000 B.C. This was the archaeological finding of Eliot Smith in excavations of the

prehistorical cemetery of Naga-adder. Indeed popular urological text of Charles

Chedwood (1921) recommended leaving long interrupted Horse Hair sutures while


Drug Review 63

performing circumcision, so that compressive strips of iodoform and petroleum gauze

could be securely tied down over the suture line.

Abraham Groves (1847-1935) in his early operative days used Horse Hair for

sutures taken directly from the horse's tail, in the operation of appendecetomy.

Brigham (1883) proposed the use of waxed Horse Hair sutures in the operation for

Harelip. He claimed that the advantage of Horse Hair over other sutures lies in the

little irritation, which is excited by their presence. He had repeatedly left the suture of

this sort in a flap during three weeks, without it's showing a disposition to slough out.

Roger Scott (2001) mentioned one case in the newsletter - a lady came to emergency

room with significant laceration of her face. Horse Hair was the desirable suture for

plastic surgery of the face. Sutures were placed meticulously and lastly washed with

saline and each suture came untied. Therefore it can be said that after suturing with

horse hair the field should be kept dry.

Robert Kravetz (2003) in his article - A look back Horse Hair Sutures stated that

Horse Hair was popular among Civil War Surgery. Horse Hair thoroughly washed

with soap and then boiled to render them free from tetanus spores.

During civil wars because of the naval blockades, there was no silk for suturing.

Cotton thread was not a success as it broke down before the wound had healed

sufficiently and provoked infection in the wounds then Horse Hair was tried. But

because it was too stiff in its natural state, it was boiled in water to soften and become

more pliable. The Horse Hair was sterile when it came from boiling. It was also used

as an emergency suture. Terry Martin - one character from the article - was wounded

near one of his eyelid and the German doctor sown up his wound with Horse Hair

from a Horses Tail, explaining that no sutures were available. Horse Hair was a suture

of plastic surgery and was widely used for suturing the skin injuries84.


Drug Review 64

With this background, in this present study Ashwa Bala (Horse hair) has been used as

suture material for seevana in Kshataja vrana.

Guduchi

Botanical name - Tinospora cordifolia

- Tinospora - To stretch like a bow.

- Cordi-Kardium-heart folio-leaves

Family - Menispermaceae

- Meni-moon, sperm (seed) Moon like seed

Nirukti -

Amruta : Prevents death

Vatsadani : Cows eat the plant

Chinnaruha : Grows even get cut

Guduchi : Protects from diseases

Tantrika : Protects life of whole family

Madhuparni : Leaves are sweet in taste

Names in other languages-

• Hindi : Giloya, Gurcha

• Bengali : Gulancha, Giloya

• Guajarati : Gilo

• Kannada : Amrutavalli, Yogvalli, Madhuarni

• Malayalam : Chittamrutu, Amritu

• Marathi : Gulwel

• Panjabi : Gilo, Garham

• Tamil : Shindilkodi

• Telagu : Tippatigo

• Arabic : Gilo

• Assam : Amrutata, Siddhitata

• Urdu : Gilo


Drug Review 65

Synonyms

Amruta Jivanti China

Arnrutavalli Tantrika Vishalya

Chinna Sona Rasajani

Chinnod bhava Somavalli Chandrahasa

Vatsadani Kundali Vayastha

There are total 198 various synonyms available for Guduchi

Gana Guduchi has been described in various Ganas in Brihattrayi.

Vayasthapana

Dahaprashamana

Trishnanigrahana Charaka Samhita

Stanya shodhana

Triptghna

Guduchyadi Ashtanga Hridaya

Patoladi

Aragwadhadi Sushruta Samhita

Syamadi

Vallipanchamula Rasatarangini

Panchatikta

• Rasa - Tikta, Katu, Kashaya

• Virya – Ushna

• Vipaka - Madhura

• Prabhav - Rasayana, Pramehanashak, Vataraktanashak,

Hridrognashak.

Origin of Guduchi: According to mythological description in Bhavaprakash, Guduchi is originated

from the Amruta given by God Indra to Vanar Sena of Rama.

Parts used:

Root, Stem and Leaves.


Drug Review 66

Properties and uses:

Guduchi has been in use in the indigenous system of medicine since remote

past. The leaves of Guduchi are mentioned under Tikta-saka varga which is claimed

to be salutary and useful in treating kushta, meha, jwara, svasa, kasa and aruchi

(Sushruta). It has been indicated in Ayurvedic treatises in various ailments like

kamala (Jaundice), Jvara (fever), vatarakta and so on. The fresh plant is said to be

more efficacious than tile dry and the stem is the part which is mostly used, from

which a kind of starch is prepared known as Giloe-Ke-Sat or Guduchi-Satva.

According to Bhavamisra (1969) Guduchi is considered as bitter, tonic,

astringent, diuretic and a potent aphrodisiac and curative against skin infections,

jaundice, diabetes, chronic diarrohea and dysentery. Dhanvantari Nighantu mentions

other properties and uses such as cure for bleeding piles, promoting longevity, curing

itching and erysipelas (Aiyer and Koiarnmal, 1963). Its use has been indicated in

heart diseases, hypertension, leprosy, helminthiasis and rheumatoid arthritis (Kirtikar

and Basu, 1933. Misra1969. Sharma1969 and Shah, 1968). It has been in extensive

use in India as a valuable tonic, alterative and antipyretic. It caught the notice of

European physicians in India as a specific tonic, and diuretic (Watt, 1893, Pendse and

Bhatt, 1932). The drugs itself as well as a tincture prepared from it are now official in

the Indian Pharmacopoeia.

Tinospora cordifolia is mentioned in Ayurvedic literature as a constituent of

several compound preparations used in general debility, dyspepsia, fever and urinary

diseases. Fleming remarked on its use as a febrifuge and as a drug in gout. Ainslie

described the root as a powerful emetic.

Gulancha was included in the Bengal Pharmacopoeia of 1844 and the Indian

Pharmacopoeia of 1868. Gulancha which grow on Neem trees is considered to be

most efficacious for remedial purpose (Watt 1972).


Drug Review 67

Microscopical characters:

Stem:-

The drug occurs as long, cylindrical, glabrous, soft wooded pieces which show

characteristic nodal swelling. The fresh stems are greenish with a smooth surface but

the older stems have a warty surface due to the presence of circular lenticels. The

stem consists of a single layer of epidermis of cubical type of cells covet externally

with cuticle which is moderately thick and striated. Following the epidermis is the

cortex composed of two or four layers of collenchyma and four to six layers of

parenchyma. The angular thickening of the cortex is not so well developed. Beneath

the cortex is a ring of continuous pericycle composed of 4 to 6 layers of slightly thick

walled fibers which are lignified. Their walls show a slightly pitted thickening. The

peri-cyclic fibers appear to cap the vascular bundles and the intervening medullary

rays between the bundles also get slightly lignified and join the pericyclic strands and

thus a continuous ring of pericyclic fibers is formed. The stem is represented by 6 to 8

bicollaieral vascular bundles. A thin layer of cambium exists between the external

phylum and the xylem. The central part of the stem is occupied by pith consisting of

isodiametric and circular, thin walled parenchyma.

Aerial root: - The aerial roots are usually seen associated with the pieces of stem.

The roots are thread like, whereas the mature ones resemble the young stem except

for the presence of nodal swellings.

Leaf:-

The leaves are simple, alternate and exstipulate. The petiole is slender and fairly long

ranging between 3 to 7cms. The base of the petio1e is pulvinate and slightly twisted at

base. The blade is broadly ovate to roundish, cordate with a diameter of 5 to 9cms.

The surface is smooth. Lower surface is pale coloured; the upper surface is glaucous.

The tip is acute or sharply acuminate the base has a broad sinus.


Drug Review 68

Physical constant values:-

Ash, extractive and moisture content of the stem of Tinospora cordifolia

Percentage

Top ash 6.55

Acid insoluble ash 0.80

Water insoluble ash 3.20

Sulphlated ash 3.80

Water soluble ash 3.35

Alcohol soluble extractive 10.32

Water soluble effective 20.80

Moisture content 8.40

Chemistry:-

The stem has been investigated by several workers and the different

constituents reported are: a glucoside, alkaloidal constituents, three crystalline

substances, two bitter principles and a neural fatty alcohol (Pendse and Dutt, 1932-33,

Jois, 1941, Ghosh and Chatterjee, 1962, Bhide el al, 1941- 42, Kidwaiet at 1949,

Sehgal and Majumdar 1959).

Fluckiger (1884) first reported the presence of alkaloid and bitter principles

present in the stem. Pendse and Dutt (1932) ascertained the presence of an alkaloid in

the plant. Bhide and coworkers (1941) investigated the stems of plant reared on

mango tree in the Western Ghats and isolated from the alcoholic extract bitter

substances A and B and a neutral substance. Bitter principle appears to be oetaeosand;

Jois (1941) isolated from the plant three substances melting at 75-77°C, 83 84°C and

181°C respectively. The first two may have been more or less pure neutral substances

and third was perhaps the bitter substances B isolated by Bhide and co workers. These

authors found that the above mentioned principles could not be obtained from plants

reared on neem trees. Then Siddiqui (1949) re-investigated the stern and found three

substances


Drug Review 69

1) Giloin, a glycoside.

2) Gilenin a non glycoside bitter.

3) Gilo sterol .

Further the presence of the bitter principles columbin, chasmanthin and palmarin in

the drug has been reported. In another study three bitter compounds, named

tinosporin, tinosporic acid and tinosporal have been reported in the stem (Anon,

1976). The leaves are rich in protein and fairly calcium and phosphorus.

Medicinal and Pharmacological activities of Guduchi:-85

a) Anti infective activity-

The antibacterial activity of aqueous extract of Tinospora cordifolia against E-

coli, Proteus vulgaris, Enterobacter faecalis, Salmonela typhi, Staphylococcus aureus

were tested using disc diffusion assay - significant antibacterial activity against all test

organisms. An ether extract of steam was shown to inhibit in vitro growth

mycobacterium tuberculosis.

b) Anti inflammatory activity

An aqueous steam extract of Tinospora Cordifolia significantly inhibited the

acute inflammatory response evoked in rats. An aqueous steam extract of Tinospora

Cordifolia was also shown to exert a significant anti inflammatory effect in both

cotton pellet induced granuloma and formalin induced arthritis.

Along with these properties Guduchi also has -

• Antipyretic effect

• Antistress effect

• Antiallergic effect

• Antineoplostic effect

In the present study Guduchi Snayu was used as suture material. The fresh stem of

Guduchi stem were taken and cut in the length of 30-40cm. The stem skin was peeled


Drug Review 70

off to get wet snayu of Guduchi, which were kept in solution for sterilization. The

fresh snayu were used for suturing of Kshataja vrana.

COTTON THREAD

It is a natural, non-absorbable suture material of vegetable origin. It is made from

cotton fibers. It is a twisted polyfilament available in reels in unsterile form. It should

be always used wet for maximal strength.

Sterilization: Long pieces of thread are rolled around tube and autoclaved

Available Sizes: 2, 8, 10, 20, 40, 60, 80; No. 2 is thickest and No. 80 the thinnest.

Advantages:

1. Cheap and freely available.

2. Knotting is secure and easily handled.

Disadvantages:

1. It absorbs fluids by capillary action, so there are more chances of infection.

2. Tissue reaction is more.

3. It frays easily and has low tensile strength.

Uses:

1. Stitching of skin.

2. To tie pedicles, e.g. haemorrhoidectomy.

3. To ligate the omentum after its resection.

4. To ligate the intestine or colon during resection or to prevent soiling of the

peritoneal cavity.

4. In the treatment of high fistula in-Ano by Seton method, when the internal

opening is above the anorectal ring.


Drug Review 71

Triphala Guggulu

Triphala Guggulu is prepared in the Dept. of Rasa shastra and Bhaishajya Kalpana,


Ingredients of Triphala Guggulu

Triphala Choorna - 3 parts / 3pala

Pippali - 1 part / 1 pala

Shuddha Guggulu - 5 parts / 5 pala

Guggulu Shodhana:

Physical impurities like stones, leaves etc are removed.

The guggulu is crushed into small pieces.

Guggulu is used for preparation of the medicines.

The guggulu is then bundled in cloth and boiled in Dola yantra containing any one of

the following:

Gomutra

Triphala Kwatha

Vasa Patra Swarasa

Dugda

Triphala Kwatha is used for Shodhana. The boiling is continued in Dola yantra until

all the Guggulu is passed out of the cloth.

The residue in the cloth is discarded and the fluid is boiled till it forms a solid mass.

The mass is dried in sun and then pounded in pestle in stone mortar by adding little

quantity of ghrita till it becomes waxy. Shuddha Guggulu is soft, waxy and brown in

colour.


Drug Review 72

Method of Preparation of Triphala Guggulu:

Shuddha guggulu was taken in required quantity and grounded finely. Triphala

Churna and Pippali Churna as mentioned were added and pounded in Khalwa yantra.

When the mixture became soft waxy and brown in colour gutikas of 500 mg were

prepared

Dosage: - 500mg.

Anupana: - Ushna Jala / Triphala Kwatha

Indications: - Vrana, Arsha, Bhagandara, Gulma, Shotha.


Drug Review 73

Properties of Triphala Guggulu: Table No 1: Showing the Properties of Ingredients of Triphala Guggulu:

Drug Botanical Name

Upaukta anga Rasa Guna Veerya Vipaka Dosha

Karma Sanstanik

Karma

Hareetaki Terminalia Chebula Phala Except

Lavana Laghu,

Rooksha Ushna Madhura Tridoshaghna

Shothahar Vedanasthapak vranashodhan,

vranaropan

Vibhitaki Termminalia bellirica Phala Kashay

a Ruksha, Laghu Ushna Madhura Tridosha

ghna

Shothahar Vedanasthapak,raktasthabhan,

Amalaki Emblica Officinalis Phala

Lavana rahita, Amla

pradhana

Guru Rooksha Sheeta

Sheeta Madhura Tridoshaghna

Dahprashaman

Pippali Piper Longum Phala Katu Laghu,

Snigdha Anushna Sheeta Katu Pittahara Shothahar

Vedanasthapak

Guggulu

Comniphora mukul Niryas Tikta

Katu Ruksha Laghu Ushna Katu Vatakap

hashmak

Vedanasthapak,vranashodhan,

vranaropn

PANCHAVALKALA CHURNA:

Panchavalkala: - The stem barks of Ksheeri vraksha are called, as

Panchavalkala. Those are Nyagroda, Udumbara, Ashwattha, Pareesha, and Plaksha.

Barks of these plants were dried well. Then these stem barks were fine powdered in

pulvariser and later fine powder of each drugs in equal quantity were mixed

thourghly. This fine powder was used as Avchurna after suturing over the twak in

kshataja vrana.


Drug Review 74

Properties of Panchavalkala drugs: Table No 2: Showing Properties of Panchavalkala drugs:

Dravya Nama

Nyagroda Udumbara Ashwattha Pareesha Plaksha

Latin Name Ficus

bengalensis

Ficus

glomerata

Ficus

religiosa

Thespesia

Populnea

Ficus

Infectoria

Varga Vatadi Vatadi Vatadi Vatadi Vatadi

Kula Vata Vata Vata Vata Vata

Gana (Su) Nyagrodadi Nyagrodadi Nyagrodadi Nyagrodadi Nyagrodadi

Family Moraceae Moraceae Moraceae Malvaceae Moraceae

Paryaya Vata,

Raktaphala

Shringi,

Bahupada

Jatiphaladi,

Yadnyanga

Hemadugdha

Bodhidru

Gajashana

Chalapatra

Pippala

Kapichoota

Kamandala

Gardabanda

Kapeetana

Jati

Parkari

Parkati

Chemical

composition

Tannin- 11 % Tannin- 14

%

Tannin 4 % Populinin,

Herbectin,

Populnetin

Tannin 10

%

Upayukta

anga

Twak Twak Twak Twak Twak

Rasa Kashaya Kashaya,

Madhura

Kashaya Kashaya,

Madhura

Kashaya

Guna Guru, Ruksha Guru,

Ruksha

Guru,

Ruksha

Guru,

Snigdha

Guru,

Ruksha

Veerya Sheeta Sheeta Sheeta Sheeta Sheeta

Vipaka Katu Katu Katu Madhura Katu

Doshaghnata Kapha, Pitta Kapha, pitta Kapha Pitta Kapha, Pitta Kapha, Pitta

Rogaghnata Vrana

Visarpa

Daha,Yoni roga

Vrana

Rakta Vikara

Vrana

Daha ,Yoni

roga

Vranashofa

Daha,

Vidradhi

Shotha

Raktapitta

Yoniroga


Materials and Methods 75

MATERIALS AND METHODS

A well-defined protocol is one amongst the most important requirements in a

clinical study. The clinical study is very essential, as a part of research work, to

establish effectiveness of the drugs and to re-assess its effectiveness.

The present study aims at comparative efficacy of Indigenous Suture materials

in Kshataja vrana. In this chapter the various materials required for the study along

with their descriptions and method of suturing are explained. The study plans along

with assessment criteria are also dealt.

Following were materials required for this study.

1. Ashwa Bala 4. Panchavalkala Churna.

2. Guduchi Snayu 5. Tab Triphala Guggulu

3. Cotton thread no 10

MATERIALS:

Material used for group A:

Ashwa Bala, 5cc syringe, Gauze pieces, Needle holder, Gloves, Cutting

needle, Triphala kashaya, Panchavalkala Churna, 2% Xylocaine, Tab Triphala

Guggulu.

Material used for group B:

Guduchi Snayu, 5cc syringe, Gauze pieces, Needle holder, Gloves, Cutting

needle, Triphala kashaya, Panchavalkala Churna, 2% Xylocaine, Tab Triphala

Guggulu.

Material used for group C:

Cotton thread no 10, 5cc syringe, Gauze pieces, Needle holder, Gloves,

Cutting needle, Triphala kashaya, Panchavalkala Churna, 2% Xylocaine, Tab

Triphala Guggulu



Preparation of Seevana dravyas (Suture material):

1. Ashwa Bala:

Ashwa Bala were collected from the tail of horse. Then the Ashwa bala were

washed thoroughly, later they were preserved in different materials such as Tila Taila

and Lysol (Benzalkonium Chloride) for sterilization. Then Ashwa bala were tested for

their physical characteristics like Tensile strength and Diameter at MCO Hospital

Aids Pvt. Ltd Hubli.

Tensile Strength:

The Tensile strength of Ashwa bala were measured on a special motor driven

tensile strength testing machine on which two types of tensile strength were seen such

as Straight pull tensile strength and Knott pull tensile strength.

Diameter:-

The device used for determining the diameter of Ashwa Bala is known as

Mitutoyo Dial Gauge, equipped with direct readings dial. A gauge graduated to 1µm

was used in the device. 10 strands of Ashwa Bala were laid across the centre of the

anvil presser foot lowered gently until its entire weight rest upon the Ashwa Bala and

reading was noted.

2. Guduchi Snayu:

Guduchi Snayu was collected from the herbal garden of Ayurveda

Mahavidyalaya, Hubli. As Guduchi Snayu loses its tensile strength if it becomes dry.

Hence fresh Guduchi stems were used to obtain Guduchi snayu. The Guduchi Snayu

was preserved in different materials such as Tila Taila and Lysol (Benzalkonium

Chloride) for sterilization.



Tensile Strength:

The Tensile strength of Guduchi Snayu were measured on a special motor driven

tensile strength testing machine on which two types of tensile strength were seen such

as Straight pull tensile strength and Knott pull tensile strength.

Diameter:-

The device used for determining the diameter of Guduchi Snayu is known as

Mitutoyo Dial Gauge, equipped with direct readings dial. A gauge graduated to 1µm

was used in the device. 10 strands of Guduchi Snayu were laid across the centre of the

anvil presser foot lowered gently until its entire weight rest upon the Guduchi Snayu

and reading was noted.

3. Cotton Thread no 10: Standard cotton thread no 10 was purchased from surgical shop. Cotton thread no

10 were preserved in different materials such as Tila Taila and Lysol (Benzalkonium

Chloride) for sterilization.

Tensile Strength:

The Tensile strength of cotton thread no 10 were measured on a special motor

driven tensile strength testing machine on which two types of tensile strength were

seen such as Straight pull tensile strength and Knott pull tensile strength.

Diameter:-

The device used for determining the diameter of cotton thread no 10 is known

as Mitutoyo Dial Gauge, equipped with direct readings dial. A gauge graduated to

1µm was used in the device. 10 strands of cotton thread no 10 were laid across the

centre of the anvil presser foot lowered gently until its entire weight rest upon the

cotton thread no 10 and reading was noted.



METHODOLOGY

Source of Data:

Subjects attending OPD and IPD of postgraduate department of Shalya Tantra

of Ayurveda Mahavidyalaya Hospital Hubli

Method of collection of data:

1. Subjects attending OPD and IPD of postgraduate department of Shalya Tantra

of Ayurveda Mahavidyalaya Hospital Hubli, who were fit for the study as per

inclusion criteria, were selected randomly.

2. Subjects were registered and details were recorded in specially designed Case

Sheet Proforma.

3. Pain was graded based on McGill Pain Index Score.

4. Review of intensity of pain, infection was done Before and After Treatment.

Inclusion Criteria:

1. Patient with clinical features of Kshataja Agantuja Vrana.

2. Patient with Kshataja Agantuja vrana, which is not more than 5 cm in length

3. Patients of Kshataja Vrana attending OPD within 8 hours of trauma.

4. Patient undergone Minor surgical excisions like Cyst and Tumors were also

included.

5. Patient of both the sexes of age group 5-60years.

Exclusion Criteria:

1. Patient who are contraindicated for Seevana karma.

2. Kshataja Agantuja Vrana with injury to major blood vessels and nerves.

3. Kshataja Agantuja Vrana associated with Bhagna (Fracture)

4. Patients with Uncontrolled diabetes.

5. Patient with infective conditions like HIV and HbsAg were excluded.



Parameters of study:

Following subjective parameters were considered for the study.

1) Vedana (Pain)

2) Sankramana (Infection)

All the patients were examined once in two days during the treatment for assessment

of these parameters.

Gradation of Parameters:

Vedana (Pain):

Pain was recorded before and after treatment based on McGill Pain Index Score.

No pain - 0

Mild pain - 1

Discomforting pain - 2

Distressing pain - 3

Horrible pain - 4

Excruciating pain - 5

Sankramana (Infection):

Infection was recorded until the vrana healed completely on Self Scoring

Index.

No infection - 0

Mild - 1

Moderate - 2

Severe - 3



Objective:

Objective parameter includes

Ropana kala (Healing time):

Vrana chinha (Scar) formation:

Gradation Parameters:


Healing time was based on number days required for complete healing of

vrana.

5 days - 1

7 days - 2

10 days - 3

12 days - 4

Vrana chinha (Scar) formation:

No scar - 0

Small scar - 1

Medium scar - 2

Big scar - 3

INVESTIGATIONS:

Blood:

Hb % RBS

BT HIV 1& 2

CT HbsAg



Study Design: Present study was a comparative clinical study.

Sample size: Minimum of 30 patients were selected randomly and categorized into

three groups as Group A, Group B and Group C

Group A:

Sample Size: Minimum of 10 patients

Procedure: Seevana karma by Using Ashwa Bala.

No of dressings: Once in two days, on 7th day alternate suture removal were

be done and on 10th day total suture removal were done.

Locally: Application of Panchavalkala Churna.

Internally: Tab -Triphala Guggulu (500mg) 2 tid for 10 days with hot water.

Duration: Suturing on first day and subsequent dressing and internal

medication for 10 days.

Follow up: Follow up for 20 days

Group B:


Procedure: Seevana karma by Using Guduchi Snayu.




Internally: Tab -Triphala Guggulu (500mg) 2 tid for 10 days with hot water.






Group C:


Procedure: Seevana karma by Cotton thread no 10.




Internally: Tab Triphala Guggulu (500mg) 2 tid for 10 days with hot water.




ASSESSMENT CRITERIA:

A. Criteria of assessment were based on improvement in subjective and objective

parameters. The results were categorized as,

Complete relief -- 100%

Marked relief -- Above 75% improvement

Moderate relief -- 50 to 75% improvement

Mild relief -- 25 to 50% improvement

No relief -- Below 25% improvement.

B. Overall assessment was done on the comparison of subjective and objective

symptom score index between the groups, which were subjected for statistical

analysis.



The analyses of the effects of therapy were based on “student t test”

application. The significance is discussed on the basis of the mean score, percentage,

SD, SE, t and p values.

Level of significance:

p = > 0.05 is statistically insignificant.

p = < 0.05 is statistically significant.

p = < 0.01 and < 0.001 is statistically highly significant.


Observations 84

OBSERVATIONS

30 Subjects who were fulfilling the Inclusion criteria were randomly selected

and were taken for the present study. Subjects were divided into three groups as

Group A, Group B and Group C with each group having 10 subjects. Data was

collected as:

1) Demographic Data

2) Data related to disease

i) Subjective parameters.

ii) Objective Parameters.

Details of the data have been presented in the following tables.

1) Demographic Data: Age incidence

Table No 3: Showing Age wise distribution:

Age (in yrs.) Group A Group B Group C Total %

0-10 1 2 3 6 20

11-20 2 4 3 9 30

21-30 4 2 2 8 26.67

31-40 2 2 2 6 20

41-50 1 00 00 1 3.33

51-60 00 00 00 00 00

06 (20%) subjects were in the age group 0-10 yrs, 09 (30%) subjects were in

age group 11-20yrs, 08 (26.67%) subjects were in 21-30 yrs, 06 (20%) subjects were

in age group 31-40 yrs of age and 01 (3.33%) subjects were in age group 41-50 yrs of

age.


Observations 85

Sex incidence

Table No 4: Showing Sex wise distribution:

Sex Group A Group B Group C Total %

Male 9 7 5 21 70

Female 1 3 5 9 30

21 (70%) subjects in the study were males while 09 (30%) subjects were females.

Religion

Table No 5: Showing Religion wise distribution:

Religion Group A Group B Group C Total %

Hindu 9 8 9 26 86.67

Muslim 1 2 1 4 13.33

A Maximum number of study subjects i.e. 26 (86.66%) subjects were Hindu and 04

(13.33%) subjects were Muslim.

Marital status

Table No 6: Showing Marital Status wise Distribution:

Status Group A Group B Group C Total %

Married 6 4 3 13 43.33

Unmarried 4 6 7 17 56.67

13 (43.33%) subjects were married while 17 (56.67%) subjects were unmarried.

Education Table No 7: Showing Education wise distribution:

Education Group A Group B Group C Total %

Uneducated 1 0 0 1 3.33 Primary 4 7 6 17 56.67

Secondary 3 3 2 8 26.67 Graduate 2 0 2 4 13.33

Post Graduate 00 00 00 00 00


Observations 86

17 (56.67%) subjects were up to Primary education, 08 (26.67%) subjects

were educated up to secondary, 04 (13.33%) subjects were graduates and 01(3.33%)

subjects were uneducated.

Occupation

Table No 8: Showing Occupation wise distribution:

Occupation Group A Group B Group C Total %

Labour 4 3 1 8 26.67 Business 2 0 0 2 6.67

Agriculture 00 00 00 00 00 Service 1 0 0 1 3.33

House Wife 1 1 1 3 10 Student 2 6 8 16 53.33

08 (26.67%) subjects belonged to Labour class, 02 (6.67%) subjects belonged

to Business class, 01 (3.33%) subjects Service classes each, 03 (10%) subjects were

House wives and 16 (53.33%) subjects were students.

Socioeconomic status

Table No 9: Showing Economic status wise distribution:

Socio-economic

status

Group A Group B Group C Total

%

Poor 2 0 1 3 10 Middle 8 10 9 27 90

Rich 00 00 00 00 00

A Maximum number of subjects i.e. 27 (90%) subjects were of middle class

and 03 (10%) subjects belonged to poor class.


Observations 87

Dietary habits

Table No 10: Showing Dietary Habit wise Distribution:

Diet Group A Group B Group C Total %

Vegetarian 3 3 2 8 26.67

Mixed 7 7 8 22 73.33

08 (26.67%) subjects were vegetarians while 22 (73.33) subjects were

consuming mixed diet.

Data Related to Disease: A) Subjective Parameter:

Table No 11: Showing Incidence of pain in 30 patients:

Sl. No Incidence of pain Total No. of patient Percentage

1 Present 30 100%

2 Absent 00 00

Out of 30 patients, all patients were suffering from pain (100%).

Table No 12: Showing Incidence of Severity of pain in 30 patients:

Vedana (Pain) Group A Group B Group C Total %

No pain 0 0 0 0 0

Mild pain 3 0 3 6 20%

Discomforting pain 6 5 6 17 56.67%

Distressing pain 1 4 1 6 20%

Horrible pain 0 1 0 1 3.33%

Excruciating pain 0 0 0 0 0


Observations 88

Out of 30 subjects, 06 subjects were having Mild pain (20%), 17 subjects were

having Moderate pain (56.67%), 06 subjects were having Distressing pain (20%) and

01 subjects had Horrible Pain (3.33%).

PAIN SCORE: Group A (Ashwa Bala)

Table No 13: Showing McGill Pain Index Score:

Patient No Pain score on 1st Day Pain score on 7th Day

1. 2 0

2. 3 0

3. 2 0

4. 2 0

5. 2 0

6. 1 0

7. 1 0

8. 1 0

9. 2 0

10. 2 0

Table No14: Showing Average McGill Pain Index Score:

1st Day 7th Day

1.8 00

The average McGill pain index score on day 1 in Group A was 1.8 and at the

end of 7 days patients experienced no pain.


Observations 89

PAIN SCORE: Group B (Guduchi Snayu) Table No 15: Showing McGill Pain Index Score:


1. 3 0

2. 2 0

3. 2 0

4. 2 0

5. 3 0

6. 2 0

7. 2 0

8. 4 0

9. 3 0

10. 2 0

Table No 16: Showing Average McGill Pain Index Score:

1st Day 7th Day

2.7 00

The average McGill pain index score on day 1 in Group B was 2.7 and at the



Observations 90

PAIN SCORE: Group C (Cotton Thread no 10) Table No 17: Showing McGill Pain Index Score:


1. 3 0

2. 2 0

3. 1 0

4. 1 0

5. 2 0

6. 2 0

7. 2 0

8. 2 0

9. 2 0

10. 1 0

Table No 18: Showing Average McGill Pain Index Score:

1st Day 7th Day

1.8 00

The average McGill pain index score on day 1 in Group C was 1.8 and at the



Observations 91

B) Objective Parameter

a) Post Seevana /Suture Sankramana (Infection)

Table No 19: Showing Incidence of Sankramana:

Sankramana Group A Group B Group C Total %

No Infection 9 8 6 23 76.67

Mild 1 1 1 3 10

Moderate 00 1 2 3 10

Severe 00 1 1 3.33

23 (76.67%) subjects had no infection, 03 (10%) subjects had Mild infection, 03

(10%) subjects had Moderate infection and 01 (3.33%) subjects had severe infection.

b) Post Ropana Kala (Healing time):

Table No 20: Showing Incidence of Ropana Kala:

Ropana Kala Group A Group B Group C Total %

0-7 days 3 3 2 8 26.67

8-14 days 7 7 8 22 73.33

15-21 days 00 00 00 00 00

Ropana Kala (Healing time) seen in all the subjects in all the three groups. 08

(26.67%) subjects healing time were within 7 days and 22 (73.33%) subjects healing

time were within 14 days.


Observations 92

c) Post Vrana chinha (Scar) formation:

Table No 21: Showing Incidence of Vrana chinha:

Vrana chinha Group A Group B Group C Total %

No Scar 0 0 0 0 0

Small Scar 8 4 7 19 63.33

Medium Scar 2 6 3 11 36.67

Big Scar 0 0 0 0 0

Vrana chinha (Scar formation) seen in all the subjects in all the three groups.

In 19 (63.33%) subjects Scar formation was Small scar, 11 (36.67%) subjects Scar

formation was Medium scar.


Observations 93

Graphs Graph No. 1

Age incidence wise Distribution:

0

2

4

6

8

10

0‐10 11‐20 21‐30 31‐40 41‐50 51‐60

Group A

Group B

Group C

Total

Graph No. 2 Sex incidence wise Distribution:

0

5

10

15

20

25

Male Female

Group A

Group B

Group C

Total

Graph No. 3

Religion wise Distribution:

0

5

10

15

20

25

30

Hindu Muslim

Group A

Group B

Group C

Total


Observations 94

Graph No. 4

Marital Status wise Distribution:

0

5

10

15

20

Married Unmarried

Group A

Group B

Group C

Total

Graph No. 5

Education wise distribution:

0

5

10

15

20

Uneducated Primary Secondary Graduate Post Graduate

Group A

Group B

Group C

Total

Graph No. 6 Occupation wise distribution

0

2

4

6

8

10

12

14

16

18

Labour Business Agriculture Service House Wife Student

Group A

Group B

Group C

Total


Observations 95

Graph No. 7

Socio-Economic status wise distribution:

Graph No. 8

Dietary Habit wise Distribution:

0

5

10

15

20

25

Vegetarian Mixed

Group A

Group B

Group C

Total

Graph No. 9

Incidence of Pain:


Observations 96

Graph No. 10

Severity of Pain:

Graph No 11:

Incidence of Sankramana

0

5

10

15

20

25

No Infection Mild Moderate Severe

Group A

Group B

Group C

Total

Graph No. 12

Incidence of Ropana Kala:

0

5

10

15

20

25

0‐7 days 8‐14 days 15‐21 days

Group A

Group B

Group C

Total


Observations 97

Graph No. 13

Incidence of Vrana chinha:

0

5

10

15

20

No Scar Small Scar Medium Scar Big Scar

Group A

Group B

Group C

Total

Size of the wound: The average size of the vrana observed in all the three Groups is as follows Table No 22: Showing Average Size of the Vrana:

Sr. no Group A Group B Group C

1 2.2 cm 2.8 cm 4.2 cm

2 2.5 cm 3 cm 3.5 cm

3 2 cm 3.5 cm 2.8 cm

4 3.2 cm 4 cm 3 cm

5 1.8 cm 2.5 cm 3.8 cm

6 2.5 cm 3 cm 3.5 cm

7 3 cm 2.8 cm 3 cm

8 2.6 cm 3 cm 4.6 cm

9 2 cm 2.7 cm 2.6 cm

10 2.5 cm 3.5 cm 4 cm

Total 24.3 cm 30.8 cm 35 cm

Average 2.43 cm 3.08 cm 3.5 cm


Observations 98


Observations 99


Observations 84

OBSERVATIONS: -

30 Subjects who were fulfilling the Inclusion criteria were randomly selected

and were taken for the present study. Subjects were divided into three groups as

Group A, Group B and Group C with each group having 10 subjects. Data was

collected as:

1) Demographic Data

2) Data related to disease

i) Subjective parameters.

ii) Objective Parameters.

Details of the data have been presented in the following tables.

1) Demographic Data: Age incidence

Table No 3 Showing Age wise distribution:

Age (in yrs.) Group A Group B Group C Total %

0-10 1 2 3 6 20

11-20 2 4 3 9 30

21-30 4 2 2 8 26.67

31-40 2 2 2 6 20

41-50 1 00 00 1 3.33

51-60 00 00 00 00 00

06 (20%) subjects were in the age group 0-10 yrs, 09 (30%) subjects were in

age group 11-20yrs, 08 (26.67%) subjects were in 21-30 yrs, 06 (20%) subjects were

in age group 31-40 yrs of age and 01 (3.33%) subjects were in age group 41-50 yrs of

age.


Observations 85

Sex incidence

Table No 4 Showing Sex wise distribution:

Sex Group A Group B Group C Total %

Male 9 7 5 21 70

Female 1 3 5 9 30

21 (70%) subjects in the study were males while 09 (30%) subjects were females.

Religion

Table No 5 Showing Religion wise distribution:

Religion Group A Group B Group C Total %

Hindu 9 8 9 26 86.67

Muslim 1 2 1 4 13.33

A Maximum number of study subjects i.e. 26 (86.66%) subjects were Hindu and 04

(13.33%) subjects were Muslim.

Marital status

Table No 6 Showing Marital Status wise Distribution:

Status Group A Group B Group C Total %

Married 6 4 3 13 43.33

Unmarried 4 6 7 17 56.67

13 (43.33%) subjects were married while 17 (56.67%) subjects were unmarried.

Education Table No 7 Showing Education wise distribution:

Education Group A Group B Group C Total %

Uneducated 1 0 0 1 3.33 Primary 4 7 6 17 56.67

Secondary 3 3 2 8 26.67 Graduate 2 0 2 4 13.33

Post Graduate 00 00 00 00 00


Observations 86

17 (56.67%) subjects were up to Primary education, 08 (26.67%) subjects

were educated up to secondary, 04 (13.33%) subjects were graduates and 01(3.33%)

subjects were uneducated.

Occupation

Table No 8 Showing Occupation wise distribution:

Occupation Group A Group B Group C Total %

Labour 4 3 1 8 26.67 Business 2 0 0 2 6.67

Agriculture 00 00 00 00 00 Service 1 0 0 1 3.33

House Wife 1 1 1 3 10 Student 2 6 8 16 53.33

08 (26.67%) subjects belonged to Labour class, 02 (6.67%) subjects belonged

to Business class, 01 (3.33%) subjects Service classes each, 03 (10%) subjects were

House wives and 16 (53.33%) subjects were students.

Socioeconomic status

Table No 9 Showing Economic status wise distribution:

Socio-economic

status

Group A Group B Group C Total

%

Poor 2 0 1 3 10 Middle 8 10 9 27 90

Rich 00 00 00 00 00

A Maximum number of subjects i.e. 27 (90%) subjects were of middle class

and 03 (10%) subjects belonged to poor class.


Observations 87

Dietary habits

Table No 10 Showing Dietary Habit wise Distribution:

Diet Group A Group B Group C Total %

Vegetarian 3 3 2 8 26.67

Mixed 7 7 8 22 73.33

08 (26.67%) subjects were vegetarians while 22 (73.33) subjects were

consuming mixed diet.

Data Related to Disease: A) Subjective Parameter:

Table No 11 Showing Incidence of pain in 30 patients:

Sl. No Incidence of pain Total No. of patient Percentage

1 Present 30 100%

2 Absent 00 00

Out of 30 patients, all patients were suffering from pain (100%).

Table No 12 Showing Incidence of Severity of pain in 30 patients:

Vedana (Pain) Group A Group B Group C Total %

No pain 0 0 0 0 0

Mild pain 3 0 3 6 20%

Discomforting pain 6 5 6 17 56.67%

Distressing pain 1 4 1 6 20%

Horrible pain 0 1 0 1 3.33%

Excruciating pain 0 0 0 0 0


Observations 88

Out of 30 subjects, 06 subjects were having Mild pain (20%), 17 subjects were

having Moderate pain (56.67%), 06 subjects were having Distressing pain (20%) and

01 subjects had Horrible Pain (3.33%).

PAIN SCORE: Group A (Ashwa Bala)

Table No 13 Showing McGill Pain Index Score:


1. 2 0

2. 3 0

3. 2 0

4. 2 0

5. 2 0

6. 1 0

7. 1 0

8. 1 0

9. 2 0

10. 2 0

Table No14 Showing Average McGill Pain Index Score:

1st Day 7th Day

1.8 00

The average McGill pain index score on day 1 in Group A was 1.8 and at the



Observations 89

PAIN SCORE: Group B (Guduchi Snayu) Table No 15 Showing McGill Pain Index Score:


1. 3 0

2. 2 0

3. 2 0

4. 2 0

5. 3 0

6. 2 0

7. 2 0

8. 4 0

9. 3 0

10. 2 0

Table No 16 Showing Average McGill Pain Index Score:

1st Day 7th Day

2.7 00

The average McGill pain index score on day 1 in Group B was 2.7 and at the



Observations 90

PAIN SCORE: Group C (Cotton Thread no 10) Table No 16 Showing McGill Pain Index Score:


1. 3 0

2. 2 0

3. 1 0

4. 1 0

5. 2 0

6. 2 0

7. 2 0

8. 2 0

9. 2 0

10. 1 0

Table No 17 Showing Average McGill Pain Index Score:

1st Day 7th Day

1.8 00

The average McGill pain index score on day 1 in Group C was 1.8 and at the



Observations 91

B) Objective Parameter

a) Post Seevana /Suture Sankramana (Infection)

Table No 18 Showing Incidence of Sankramana:

Sankramana Group A Group B Group C Total %

No Infection 9 8 6 23 76.67

Mild 1 1 1 3 10

Moderate 00 1 2 3 10

Severe 00 1 1 3.33

23 (76.67%) subjects had no infection, 03 (10%) subjects had Mild infection, 03

(10%) subjects had Moderate infection and 01 (3.33%) subjects had severe infection.

b) Post Ropana Kala (Healing time):

Table No 19 Showing Incidence of Ropana Kala:

Ropana Kala Group A Group B Group C Total %

0-7 days 3 3 2 8 26.67

8-14 days 7 7 8 22 73.33

15-21 days 00 00 00 00 00

Ropana Kala (Healing time) seen in all the subjects in all the three groups. 08

(26.67%) subjects healing time were within 7 days and 22 (73.33%) subjects healing

time were within 14 days.


Observations 92

c) Post Vrana chinha (Scar) formation:

Table No 20 Showing Incidence of Vrana chinha:

Vrana chinha Group A Group B Group C Total %

No Scar 0 0 0 0 0

Small Scar 8 4 7 19 63.33

Medium Scar 2 6 3 11 36.67

Big Scar 0 0 0 0 0

Vrana chinha (Scar formation) seen in all the subjects in all the three groups.

In 19 (63.33%) subjects Scar formation was Small scar, 11 (36.67%) subjects Scar

formation was Medium scar.


Observations 93

Graphs Graph no. 1

Age incidence wise Distribution:

0

2

4

6

8

10

0‐10 11‐20 21‐30 31‐40 41‐50 51‐60

Group A

Group B

Group C

Total

Graph no. 2 Sex incidence wise Distribution:

0

5

10

15

20

25

Male Female

Group A

Group B

Group C

Total

Graph no. 3

Religion wise Distribution:

0

5

10

15

20

25

30

Hindu Muslim

Group A

Group B

Group C

Total


Observations 94

Graph no. 4

Marital Status wise Distribution:

0

5

10

15

20

Married Unmarried

Group A

Group B

Group C

Total

Graph no. 5

Education wise distribution:

0

5

10

15

20

Uneducated Primary Secondary Graduate Post Graduate

Group A

Group B

Group C

Total

Graph no. 6 Occupation wise distribution

0

2

4

6

8

10

12

14

16

18

Labour Business Agriculture Service House Wife Student

Group A

Group B

Group C

Total


Observations 95

Graph no. 7

Socio-Economic status wise distribution:

Graph no. 8

Dietary Habit wise Distribution:

0

5

10

15

20

25

Vegetarian Mixed

Group A

Group B

Group C

Total

Graph no. 9

Incidence of Pain:


Observations 96

Graph no. 10

Severity of Pain:

Graph No 11:

Incidence of Sankramana

0

5

10

15

20

25

No Infection Mild Moderate Severe

Group A

Group B

Group C

Total

Graph no. 12

Incidence of Ropana Kala:

0

5

10

15

20

25

0‐7 days 8‐14 days 15‐21 days

Group A

Group B

Group C

Total


Observations 97

Graph no. 13

Incidence of Vrana chinha:

0

5

10

15

20

No Scar Small Scar Medium Scar Big Scar

Group A

Group B

Group C

Total

Size of the wound: The average size of the vrana observed in all the three Groups is as follows

Sl no Group A Group B Group C

1 2.2 cm 2.8 cm 4.2 cm

2 2.5 cm 3 cm 3.5 cm

3 2 cm 3.5 cm 2.8 cm

4 3.2 cm 4 cm 3 cm

5 1.8 cm 2.5 cm 3.8 cm

6 2.5 cm 3 cm 3.5 cm

7 3 cm 2.8 cm 3 cm

8 2.6 cm 3 cm 4.6 cm

9 2 cm 2.7 cm 2.6 cm

10 2.5 cm 3.5 cm 4 cm

Total 24.3 cm 30.8 cm 35 cm

Average 2.43 cm 3.08 cm 3.5 cm


Observations 98


Observations 99


Results 100


RESULTS

Effect of Seevana Karma on different parameters such Vedana (Pain),

Sankramana (Infection), Ropana Kala (Healing Time) and Vrana Chinna (Scar

Formation) were recorded after the treatment and subjected to statistical analysis. The

results obtained were subjected to statistical analysis. The results are tabulated in the

following tables

Table No 23: Showing the comparative reduction in Pain at the end of the

treatment in all the groups based on McGill’s Pain Index score.

Mean Groups

B.T. A.T. %

Relief S.D. S.E. ‘t’ ‘p’ Remarks

Group A (n=10) 1.8 0.5 72.2% 0.105 0.033 8.51 <0.001 H.S.

Group B (n=10) 2.6 1 61.53% 0.228 0.072 7.23 <0.001 H.S.

Group C (n=10) 1.8 0.6 66.67% 0.116 0.037 4.81 <0.001 H.S.

Group A showed 72.2% relief of pain in the post operative period which was

statistically Highly significant at the level of p <0.001 (t = 8.51) where as Group B

showed relief of pain of 61.53% which was statistically highly significant at the level

of p < 0.001 (t = 7.23) and Group C showed 66.67% relief of pain of which was

statistically highly significant at the level of p < 0.001 (t = 4.81) at the end of

treatment of 7 days in Group A, Group B and Group C.

Results 101


Table No 24: Showing Overall Relief of Pain at the end of 7 days of treatment in

Group A, Group B and Group C after Seevana Karma by McGill’s Pain Index

score.

Groups Mean B.T. Mean A.T. % Relief of pain

Group A 1.8 0.5 72.2%

Group B 2.6 1 61.53%

Group C 1.8 0.6 66.67%

At the end of 7 days, Group A showed relief in the intensity of pain 72.2%

over B.T. Mean of 1.8 where as Group B in the same duration had relief of pain of

61.53% over B.T. Mean of 2.6 and Group C had relief of pain of 66.67% over B.T.

Mean of 1.8 in patients who had undergone Seevana karma, post operatively.

Table No 25: Showing Comparison between Group A and Group C in Relief of

Pain at the end of 7 days of treatment on McGill’s Pain Index score.

Groups S.D. S.E. ‘t’ ‘p’ Remarks

Group A

Group C 0.65 0.29 0.34 >0.1 N.S.

(n1 = 10) (n3 = 10)

The intensity of pain experienced by patients of Group A and Group C was equal in

reduction of Pain which was statistically insignificant at the level of p > 0.1 (t = 0.34).

Table No 26: Showing Comparison between Group B and Group C in Relief of

Pain end of 7 days of treatment according to McGill’s Pain Index score.


Group B

Group C 0.74 0.33 1.2 >0.1 N.S.

(n2= 30) (n3 = 30)

The intensity of pain experienced by patients of Group B and Group C was equal in


Results 102


Table No 27: Showing the Comparison between Group A and Group B in Relief

of Pain end of 7 days of treatment according to McGill’s Pain Index score.


Group A

Group B 0.55 0.24 -4.8 >0.1 N.S.

(n1= 30) (n2 = 30)

The intensity of pain experienced by patients of Group A and Group B was equal in


Sankramana (Infection) after Seevana Karma: Table No 28: Showing Sankramana (Infection) after Seevana Karma

Group A Group B Group C No of Patients

Sankramana No of Patients

Sankramana No of Patients

Sankramana

1 0 1 1 1 0 2 0 2 0 2 1 3 0 3 0 3 0 4 1 4 0 4 1 5 0 5 0 5 0 6 0 6 1 6 0 7 0 7 0 7 1 8 0 8 0 8 0 9 0 9 0 9 1

10 0 10 0 10 0

Total 1 Total 2 Total 4

10% of subjects in group A presented with mild infection , in group B 20% of

subjects presented with mild to moderate infection and in group C 40% of the

subjects presented with moderate to severe infection at the end of 7 days of treatment.

Results 103


Ropana Kala (Healing Time):

Table No 29: Showing Ropana Kala:

Number of Days

Group A Group B Group C No of Patients

Ropana Kala

No of Patients

Ropana Kala

No of Patients

Ropana Kala

1 7 1 9 1 10 2 9 2 8 2 12 3 8 3 10 3 7 4 7 4 9 4 9 5 9 5 11 5 10 6 10 6 7 6 8 7 8 7 8 7 10 8 7 8 10 8 7 9 9 9 7 9 9

10 8 10 7 10 9

Total 82 Total 86 Total 91

Average 8.2 8.6 9.1

Average healing time in group A was 8.2 days and group B 8.6 was days and

in group C was 9.1 days.

Vrana Chinna (Scar Formation): Table No 30: Showing Vrana Chinna Formation:

Group A Group B Group C

No of Patients

Vrana Chinna

No of Patients

Vrana Chinna

No of Patients

Vrana Chinna

1 1 1 1 1 1 2 2 2 2 2 2 3 1 3 1 3 1 4 1 4 2 4 1 5 1 5 1 5 1 6 1 6 1 6 1 7 2 7 1 7 2 8 1 8 2 8 1 9 1 9 2 9 2

10 1 10 1 10 1

Results 104


Vrana Chinna (Scar) in Group A: In Group A, 8 subjects (80%) had small scar, 2

subjects (20%) had medium scar formation.

Vrana Chinna (Scar) in Group B: In Group B, 6 subjects (60%) had small scar, 4


Vrana Chinna (Scar) in Group C: In Group C 7 subjects (70%) had small scar, 3


Table No 31: Showing overall effect of therapy in 10 patients who have

undergone Seevana Karma in Group A based on McGill Pain Score Index.

Sr. No. Relief No. of Patients Percentage

1 Complete relief 10 100%

2 Marked Relief - - 3 Moderate relief - - 4 Mild relief - - 5 No relief - - Total No. of Patients. 10 100%

The overall effect of therapy in Group A treated with Ashwa Bala and

Triphala Guggulu had complete relief in 10 patients (100%)


undergone Seevana Karma in Group B based on McGill Pain Score Index.



2 Marked Relief - - 3 Moderate relief - - 4 Mild relief - - 5 No relief - - Total No. of patients. 10 100%

The overall effect of therapy in Group B treated with Guduchi Snayu and

Triphala Guggulu had complete relief in 10 patients (100%).

Results 105



undergone Seevana Karma in Group C based on McGill Pain Score Index.



2 Marked Relief - - 3 Moderate relief - - 4 Mild relief - - 5 No relief - - Total No. of patients. 10 100%

The overall effect of therapy in Group C treated with Cotton Thread No. 10

and Triphala Guggulu had complete relief in 10 patients (100%)

Discussion 106

DISCUSSION

The present clinical trial was conducted to establish an effective Ayurvedic

suture material in the management of Kshataja Vrana. This work includes the literary

review of Kshataja Vrana, Seevana Dravya and Seevana Karma, as described in

Ayurvedic and Modern Medical Sciences. So the discussion of the present study,

apart from the clinical study, includes discussion on conceptual study too. Hence the

discussion of the present work is made on the following headings as,

1. Discussion on literary review.

2. Discussion on materials and methods.

3. Discussion on observations and results.

4. Discussion on overall effect of therapy.

1. DISCUSSION ON LITERARY REVIEW:

The knowledge of the past decides the attitude to perform better in present and

aims towards a bright future. Hence an overview into the history is always fruitful.

Wounds are one of first Health problems faced by man since his very existence.

Hence there arises man’s need to have an effective, easily, available good suture

materiel for closing the wounds.

Sushruta has explained in detail, the various types of wounds and their

management including complications. While describing the definition of shalyatantra

Sushruta, apart from mentioning Yantra, Shastra, Kshara, Agni etc as subjects of

Shalya tantra, he has also described that shalyatantra is related to diagnosis and

management of wounds. Sushruta’s elaborate description regarding Vrana includes on

variety of Agantuja vrana. This vrana is further classified in to six types. This

category of vruna can be compared with Traumatic wound. The comparison of


Discussion 107

Agantuja vruna types and types of Traumatic wounds of Modern Medical Science, as

follows,

Chinna : Excised wound

Bhinna : Incised wound

Viddha : Punctured wound

Kshata : Lacerated wound

Pichhita : Contused wound

Ghrustha : Abrasions

As long as humans have treated the wounds, we have to look for a way to

close them, which urges us to find more sophisticated suture material. This has

resulted in different kinds of suture materials we use today.

When an ideal suture material is to be prepared it should possess following

basic requirements,

Good Tensile strength

It should have easy knotting and holding properties.

It should glide through tissue easily.

It should remain in the tissue till that time as required for it.

It can be employed in infected sites.

It should be cost effective.

It should have uniform Diameter.

Easy sterilization

It should be freely available.

It should not provide a medium for bacterial growth.


Discussion 108

Healing by first intention - Healing by primary intention is that which follows

surgical wound closure with sutures. In the primary intention method, surgical wound

closure facilitates the biological event of healing by joining the wound edges.

Surgical wound closure directly opposes the tissue layers, which serves to minimize

new tissue formation within the wound. However, remodeling of the wound does

occur, and tensile strength is achieved between the newly apprised edges.

Closure can serve both functional and aesthetic purposes. These purposes include

elimination of dead space by approximating the subcutaneous tissues, minimization of

scar formation by careful epidermal alignment and avoidance of a depressed scar by

precise eversion of skin edges.

Uncomplicated healing by primary intention occurs with minimal edema, minimal

discharge and no bacterial infection. The tensile strength of the wound increases

significantly and the skin obtains approximately 85-90% of its tensile strength before

the wounding healing by primary intention is the most desirable to the surgeon.

SEEVAN KARMA:

According to Acharya Sushruta, Seevana Karma is the process of tying two

ends of thread for union of wound edges and is done with the help of needle and

appropriate suturing material.

Whereas Modern Medical Science are of opinion that, when two cut edges are

approximated either continuously or interruptedly it is called as suturing.

AIM OF SEEVAN KARMA:

The purpose of seevana karma is to approximate the wound edges for proper

and faster healing i.e. Vrana Sandhan. Aim is to unite, repair and support the injured

tissue until healing is completed. This will achieve complete haemostasis and normal

restoration of tissue function which is the ultimate aim of Modern Medical Science

also.


Discussion 109

Types of Seevana Karma:

Sushruta and Astanga Sangrahakar have explained four types of suturing techniques

which resemble exactly with the suturing techniques described by Modern Medical

Sciences.

1. Vellitaka : Continuous type suturing

2. Gophanika : Blanket type suturing

3. Tunnasevani : Subcuticular type suturing

4. Rujugranthi : Interrupted type suturing

‘Acharya Vagbhata had mentioned ‘Granthi’ instead of ‘Rujugranthi’.

Vellitaka –

Vellitaka i.e. Round. This is achieved by suturing continuously along the length of the

wound rapping the wound edges inside it. This can be correlated with Continuous

sutures.

Gophanika -

The vrana which are shaped as footprints of crow or are wide, they are sutured with

gophanika type of suturing. It can be correlated with Blanket sutures or Continuous

interlocking sutures.

Tunnasevani -

It is done as like as the torn up garments are sutured. It can be correlated with

Subcuticular sutures.

Rujugranthi –

In this needle is inserted in vrana margins and sutured, keeping some distance

between two stitches. This is Interrupted type of suturing.

SEEVAN DRAVYA:

As suturing was a known procedure to ancient India, the materials used for the

purpose were also well developed. In ancient India, advances in surgery took place


Discussion 110

through wars and battle wounds. Though the science and technology is developed at

its extreme level, still most of these materials are in use today.

Sushruta samhita is one of the Indian surgical texts which includes detail description

about different types of suture materials both vegetative and animal origin which are

either absorbable or non-absorbable. Sushruta had worked with many natural

materials like fine threads, flax of Ashmantak, Guduchi and Trinaushadhi like Shanaj

(a type of Grass), cotton threads, silk threads, horsehair and snayu

(tendons/ligaments). Modern Medical Sciences too resembles these types of suture

materials

Sushruta had used the heads of giant ants to effectively staple a wound over intestine

while performing surgery for perforations. The live creatures were affixed to the

edges of the wound, which they clamped shut with their pincers. Then the physician

cut the insects bodies off, leaving the jaws in place.

Classification of suture materials: -

1. Absorbable and nonabsorbable

2. Natural and synthetic

3. Monofilament and multifilament.

Absorbable suture material:

Natural:

Catgut

Collagen sutures

Cargile membrance

Fascia lata sutures

Kangaroo's tendons

Skin ribbon suture


Discussion 111

Synthetic:

Polyclycolic acid (Dexan)

Vicryl-(Polyglactin)

Polydioxinone suture (PDS)

Non absorbable suture material:

Natural

Cotton thread

Linen

Silk

Synthetic Nylon

Prolene

Polyamide (Ethilon)

Stainless steel wire

It can be concluded that Sushruta have described detailed knowledge of suture

materials, which are modified and still in practice today by Modern Medical Science.

SUCHI (NEEDLES):

Along with different suture materials Sushruta also explained the different types of

needles which have to be used for suturing the wounds over different parts of body.

Modern Medical Science had same resemblance.

1. Vritta Dyangula (Round body- two finger long): –

It can be co-related with round body needles. This used for vrana over

the organs with less mamsa.

2. Aayata Tryangula (Cutting - three finger long):-

It can be co-related cutting needles. It is used for vrana over the organs

having more mamsa


Discussion 112

3. Dhanurvkra (Curved):–

It can be co-related curved needles. It is used for wounds over marma

Sthana (vital organs), scrotum

These are three types of needles explained by Sushruta for suturing wounds, which

exactly resemble with needles used now days. So it can be concluded that Sushruta

have described detailed knowledge of suturing techniques.

Among the various Seevana dravya used for seevana karma in ancient days

Ashwa Bala and Guduchi Snayu was one among them. Suturing with Ashwa Bala was

routinely practiced in those days. The physical properties of Ashwa Bala and Guduchi

Snayu were explored in a well established factory of “MCO Hospital Aids Pvt. Ltd.

Hubli.

2. DISCUSSION ON MATERIALS AND METHODS:

Ashwa Bala:

Ashwa Bala from the tail of the horse was used for the seevana karma. Ashwa

Bala has got 0.18 mm of average diameter. As per USP standards this diameter

complies with the 4-0 sized standard suture material. Straight pull tensile strength of

Ashwa Bala was 0.48 kg and Knott pull tensile strength of was 0.45 kg which

complies with the non absorbable suture material of USP Standards. Seevana karma

done with Ashwa Bala had minimal infection because it is monofilament suture

material which is known for less infection and the scar formed is also minimal.

Pliability i.e. easy passage through tissue, easy tying and knot security were

graded better than, commonly used suture materials. But the disadvantage with the

Ashwa Bala is that it slips out of the eye of needles, therefore the handling

characteristic should be improved with needle attachment with eyeless needle.


Discussion 113

GUDUCHI SNAYU:

As we all know our Samhita provide us the knowledge which has to be

understood by reading between the lines. Using Guduchi Snayu as a suture material is

also a short description about the subject. It is not clearly mentioned exactly which

part of Guduchi should be taken, how much thickness should be taken, whether it

should be taken in wet form i.e. fresh or in dry form, if it has to taken in dry form then

how to preserve it. Guduchi snayu loses its tensile strength if it becomes dry. Hence

fresh Guduchi stems were used to obtain Guduchi snayu. The Guduchi snayu were

preserved in different materials such as Tila taila and Lysol (Benzalkonium chloride)

for sterilization. The average diameter was 0.78 mm. As per USP standards this

diameter complies with the 3 sized standard suture material. The average straight pull

tensile strength of Guduchi Snayu was 1.79 kg and Knott pull tensile strength of was

1.73 kg, which complies with the non absorbable suture material of USP Standards.

And the Guduchi Snayu stored in Lysol retains moisture of Guduchi Snayu which

ultimately helps to retain the tensile strength as compare to Tila taila. As Lysol is

irritant to the skin it was cleaned with spirit in order to remove Lysol from the surface

of Guduchi Snayu. Seevana karma done with Guduchi Snayu had minimal infection

because it is having tikta rasa which is antibacterial and helps to wound heal faster.

Guduchi Snayu doesn’t long lasting stitch impression and the scar formed is also

minimal.

COTTON THREAD NO 10:

Cotton thread no 10 is standard suture material which is oftenly used in

for suturing. The average diameter is 0.45 mm. The average straight pull tensile

strength was 1.95 kg and Knott pull tensile strength of was 1.93 kg. As per USP

standards it is a standardized no 10.This thread was autoclaved and used for suturing.


Discussion 114

Seevana karma by this thread showed infection in few cases. This may be due to the

thread being multi-braided in nature. Scar formed is minimal.

TRIPHALA GUGGULU:

The vati prepared out of triphala guggulu when taken internally cures vibandha and it

acts as vrana shodhaka & vrana ropaka.

Tab Triphala guggulu taken internally also relieves pain & swelling. It reduces

moisture, prevents paka and minimizes discharge & smell (Chakradatta vrana shotha

chikitsa).

Probable action of Triphala Guggulu:

Triphala by its kashaya rasa acts as vrana ropana, by tikta rasa acts as krimigna, by

madhura rasa acts as rasayana and helps in tissue repair, by amlarasa which is rich in

Vitamin C improves blood circulation. Haritaki having tridoshaghna property helps in

tridosha shamana & pippali by its katu rasa & tikshana guna acts as deepana &

pachana. Guggulu is a major component of this yoga it acts as vedana shamaka.

Panchavalkala churna:

The stem barks of Ksheeri vraksha viz Nyagroda, Udumbara, Ashwattha,

Pareesha, and Plaksha are called as Panchavalkala. Pancha valkala drugs comprise of

Kashaya, Madhura rasa, Sheeta Veerya, and Katu Vipaka (except pareesha-Madhura

Vipaka). Among the properties of Panchavalkala enlisted by Bhavaprakash, vrana and

Shopha harana are very much concerned. ‘Tannin’ is the main chemical constituent

characterized by astringent action on mucous membrane, thus exerts protective action

and arrests bleeding. Avchurna with Panchavalkala churna reduces pain, cleans the

local area and may acts as local antiseptic.


Discussion 115

The Comparative Assessment of Seevana Karma by Ashwa Bala, Guduchi Snayu

and Cotton thread no 10.

Table No 34:

Sr. No Factors Ashwa Bala Guduchi Snayu Cotton thread no 10

1 Availability Easy Easy Easy

2 Cost Cheap Cheap Cheap

3 Performance of procedure

Easy Easy Easy

4 Diameter 0.183 mm 0.78 mm 0.45 mm

5 Straight pull

tensile strength 0.48 kg 1.79 kg 1.95 kg

6 Knott pull

tensile strength 0.45 kg 1.73 kg 1.93 kg

7 Sterilization Easy Easy Easy

8 Post operative

pain Less Less Moderate

9 Healing time Avg 8.2 days Avg 8.6 days Avg 9.1 days

10 Post operative

infection Rare Rare More chances

11 Scar formation Minimal Minimal Minimal

3. DISCUSSION ON OBSERVATIONS AND RESULTS:

Discussion related to demographic data:

Age:

The age wise distribution in 30 subjects of Kshataja Vrana shows that 9 (30%)

subjects were in age group 11-20yrs. In this period more action and physical work

goes on. And it also shows that accidental injuries are common in above age group.

Sex:

The sex wise distribution shows that male subjects were more in number i.e.

21(70%) than females which were 9 (30%). The findings are on conclusions.


Discussion 116

Religion:

Religion wise incidence of the disease states that, the prevalence was more

seen in Hindu religion i.e. 26 (86.67%) subjects and 04 (13.33%) subjects were

Muslim. But, it can’t be concluded on this basis, that the Hindus are more affected by

this disorder. The people of all religion are susceptible to this disease. This may be

due to the geographical distribution of communities in and around Hubli. This data

doesn’t give any specific conclusion.

Marital status:

13(43.33%) subjects were married while 17 (56.67%) subjects were

unmarried. These findings are inconclusive in the present study.

Education:

17 (56.67%) subjects were up to primary education, 8(26.67%) subjects were

educated up to secondary, 4(13.33%) subjects were graduates and 1 subject (3.33%)

was uneducated. These findings are inconclusive in the present study.

Occupation:

Occupation wise students were more in number i.e. 16 (53.33%) than other

classes. More incidences may be due to playing and other activities, they are more

prone for Kshataja Vrana.

Socio-economic status:

There were maximum 27 (90%) subjects in middle class followed by 03 (10%)

subjects in poor class. Rich class subjects use to attend the private hospital because of

good financial condition hence there were no subjects in rich class.

Dietary habits:

8(26.67%) subjects were vegetarians while 22(73.33) subjects were

consuming mixed diet. These findings are inconclusive in the present study


Discussion 117

Discussion related to Disease:

Effect of Seevana Karma on Vedana (Pain):

Out of 30 subjects, all subjects were suffering from pain (100%).

Vedana (Pain):-

Group A: It showed 72.2% relief of pain in the post suture period which was

statistically highly significant at the level of p <0.001 (t = 8.51) at the end of 7 days of

treatment.

Group B: It showed 61.53% relief of pain in the post suture period which was

statistically highly significant at the level of p < 0.001 (t = 7.23) at the end of 7 days

of treatment.

Group C: It showed 66.67% relief of pain in the post suture period of which was

statistically highly significant at the level of p < 0.001 (t = 4.81) at the end of 7 days

of treatment.

All the three groups had shown significant relief in pain; this may be because of the

combined effect of Tab Triphala Guggulu and Panchavalkala Avachurna which acts

as Shothahara, Vedanasthapak, Vranashodhan, and Vranaropana.

Effect of Seevana Karma on Sankramana (Infection):

Out of 30subjects, 23 (76.67) subjects had no infection. In Group A only 01

subject had infection. In Group B, 02 subjects had infection and in Group C 04

subjects had infection.

Sankramana (infection):-

Group A: 1 (10%) subject had mild infection. This may be by chance due to the

subject’s negligence towards the wound. Otherwise Ashwa Bala is not known for

infection as it is monofilament in nature.


Discussion 118

Group B: 2 (20%) subjects had mild to moderate infection. This may be due to

inflammatory response of the wound towards healing.

Group C: 4 (40%) subjects had moderate to severe infection, this is because cotton

thread is polyfilament in nature and it is also known for its tissue reaction,

Effect of Seevana Karma on Ropana Kala (Healing Time):

In 22 (73.33%) subjects, Ropana kala was 8-14 days and rests of 8 (26.67%)

subjects Ropana kala was within 7 days.


Group A: Average healing time was 8.2 days. As the maximum numbers of subjects

were in the age group of 11-30 years in which healing capacity of the body is in its

best form and the average size of the wound was 2.43 cm, as the wound size is

smaller healing will be faster. Also Tab Triphala Guggulu and Avachurna by

Panchavalkala churna have contributed in wound healing.

Group B: Average healing time was 8.6 days. As the maximum numbers of subjects

were in the age group of 11-30 years in which healing capacity of the body is in its

best form and the average size of the wound was 3.08 cm, as the wound size is

smaller healing will be faster. Also Tab Triphala Guggulu and Avachurna by

Panchavalkala churna have contributed in wound healing.

Group C: Average healing time was 9.1 days. This is because cotton thread is

polyfilament in nature and it is also known for its tissue reaction, which might had

cause delay in wound healing. The average size of the wound was 3.5 cm, as the

wound size is bigger healing will be delayed. Also Tab Triphala Guggulu and

Avachurna by Panchavalkala churna have contributed in wound healing.


Discussion 119

Effect of Seevana Karma on Vrana Chinna (Scar Formation):

Scar Formation usually depends upon size of the Vrana and Seevana Dravya

used for Seevana Karma. If the diameter of the suture material is less the scar

formation will also be small. So in Group A and Group C subjects had small scar

formation comparatively than Group B.

Vrana Chinna (scar formation):-

Vrana chinna (scar) in Group A: 8 (80%) subjects had small scar, 2 (20%) subjects

had medium scar.

Vrana chinna (scar) in Group B: 6 (60%) subjects had small scar, 4 (40%) subjects

had medium scar.

Vrana chinna (scar) in Group C: 7 (70%) subjects had small scar, 3 (30%) subjects

had medium scar.

4. Discussion on overall effect of Therapy:

The clinical study with the title ‘A critical study of indigenous suture material with

special reference to management of Kshataja vrana’ was undertaken to assess the

efficacy of Ashwa Bala, Guduchi snayu and cotton thread no. 10. The overall effect of

the therapy in all the three groups with respect to Vedana are, Group A showed 72.2%

relief of pain in the post operative period, Group B showed 61.53% relief of pain in

the post operative period and Group C showed 66.67% relief of pain in the post

operative period.

The overall effect of the therapy in all the three groups with respect to Sankramana

are Group A 10% subjects had mild infection, Group B 20% subjects had mild to

moderate infection and Group C 40% subjects had moderate to severe infection.


Discussion 120

The overall effect of the therapy in all the three groups with respect to Ropana kala

are Group A had Average healing time of 8.2 days, Group B had Average healing

time of 8.6 days and Group C had Average healing time of 9.1 days.

The overall effect of the therapy in all the three groups with respect to Vrana Chinna

are Group A had small scar formation, Group B and Group C had medium scar

formation.


Conclusion 121

CONCLUSION

Depending on the observations obtained and detailed discussion on these

observations, following conclusions can be drawn.

Conclusions on Literary review:

The review of available literature of Agantuja vrana and Traumatic wound has

lot of similarity.

The review of literature of Seevana karma and Suture procedures too

possesses same principles.

The types of seevana karma and Types of sutures can be correlated without

any ambiguity.

In spite of lack of manufacturing and synthetic development of suture

materials, ancient’s scholars had profound knowledge about, how to utilize

natural materials for wound closures which are available anytime around us.

The Modern description of Suturing and suture material is most advanced.

Conclusions on Ashwa Bala:

In the present study Ashwa bala is used for suturing of superficial cut wounds.

Ashwa Bala is a natural material, easily available and very cost effective. It

will cut off the cost of suturing to a great extent.

Monofilament sutures are always superior to multifilament sutures with regard

to the incidence of wound infection. As the Ashwa Bala is monofilament, it

will not provide a medium for bacterial growth thus reduce chances of

infection.

Considering the diameter and tensile strength of the Horse hair, it is useful in

external suturing especially cosmetically important areas like face, neck,


Conclusion 122

extremities etc, where delicacy is the need while suturing and the wound

healing is expected with minimum scar.

In plastic and reconstructive surgery Horsehair can be used as suturing

material as it produces minimal scar.

Sterilization method of Ashwa Bala is very easy so it can be very easily used

in general practice and is cost effective.

Handling with Horsehair is quite comfortable. The knot security can be

achieved with three square knots.

No allergic reaction was noted with the experimental suture.

The experimental study did not reveal any significant differences in tissue

reaction between specimen and standard cotton thread no 10. Both the sutures

exerted least reaction in the tissues.

Clinical Study reveals that wounds sutured with Ashwa Bala heals with least

chances of infection and with minimal scar formation.

Conclusions on Guduchi Snayu: In the present study Guduchi snayu is used for suturing of superficial cut

wounds.

The use of Guduchi Snayu as seevana dravya as mentioned in Ayurveda can

be considered as Herbal suture material.

The study showed that suturing with Guduchi Snayu produces less pain,

infection and no discoloration at suture site which may be due to anti

inflammatory and anti bacterial activity of Guduchi Snayu.

Guduchi snayu heals the wound by primary intention not only by

approximation of wound edges but also by its medicinal properties.


Conclusion 123

Sterilization method of Guduchi Snayu is very easy, so it can be very easily

used in general practice and is cost effective.

The knots taken by Guduchi Snayu are well secured and require only 2-3

knots. The knot doesn’t get slipped for 7-10 days.

Therefore considering the cost and availability of Guduchi Snayu as herbal

suture material may prove excellence suture material in general practice.

Conclusions on Cotton thread:

In the present study cotton thread No 10 was used to suture superficial cut

wounds.

The cotton thread has been already proved as the best suture material.

The present study also supports this view.

Recommendations for further Studies

The use of Indigenous Suture materials by Ayurvedic surgeons has to be

encouraged.

Further research studies are to be undertaken to prove the efficacy of

Indigenous suture materials.

The sterilization methods of Ashwa Bala and Guduchi snayu are to be

standardized.

An eyeless needle attachment to Ashwa Bala and Guduchi Snayu strands

should be tried.

Multibraided Ashwa Bala and Guduchi Snayu should be tried to increase the

tensile strength.

The study should be carried out with larger sample size and for Deep cut

wounds.


Summary 124


SUMMARY

The present clinical study entitled as “A CRITICAL STUDY OF


KSHATAJA VRANA” was completed with a clinical trial. The introductory part

gives the brief picture of the contents and the approach towards the study of this

dissertation.

Research requires the thorough literary review, before it could be worked

upon. During the study, the available literature in the Ancient and Modern medical

books with regard to Seevana Karma, Seevana Dravya, Suturing and Suture Materials

were compiled and critically analyzed.

The present study aims at comparative efficacy of Indigenious Suture

materials in Kshataja vrana. In this study the various materials required for the study

along with their descriptions and method of suturing are explained. The study plans

along with assessment criteria are also dealt.

Patient with clinical features of Kshataja Vrana and fulfilling the criteria of

selection, of the present study were selected. The patients were subjected for detail

clinical examination and investigations as per the specially designed proforma. The

present clinical study comprises of 30 patients. They were divided into three groups as

Group-A, Group-B and Group-C each having 10 patients.

The Group-A patients were sutured with Ashwa Bala, Group-B patients were sutured

with Guduchi Snayu and Group-C patients were sutured with Cotton Thread no 10. In

all three groups internally Tab Triphala Guggulu tid and externally Panchavalakala

Avachurna was done.

Summary 125


The criteria of assessment were based on “McGill pain index score” and self-

assessment. Regular dressing was done on 3rd, 5th and 7th day. Suture removal was

done on 7th and 9th after the wound was completely healed.

The study design that was prepared with the consideration of inclusion /

exclusion criteria, materials, methods, follow ups and assessment criteria is recorded

in the second part of the dissertation, along with observations, results and discussion,

which includes the reasoning for the observations and results, that are obtained.

Among the selected 30 patients, the following observations were made like

majority 09 (30%) patients were in age group 11-20yrs, 21 (70%) were males, 17

(56.67%) patients were married, 16 (53.33%) patients were students. It was also

observed 27 (90%) patients were of were middle socio-economic status.

On the basis of McGill pain index score, it was observed that Group A showed

72.2% relief of pain in the post operative period which was statistically Highly

significant at the level of p <0.001 (t = 8.51) where as Group B showed relief of pain

of 61.53% which was statistically highly significant at the level of p < 0.001 (t = 7.23)

and Group C showed 66.67% relief of pain of which was statistically highly

significant at the level of p < 0.001 (t = 4.81) at the end of 7 days of treatment.

Assessment of infection was done on self scoring index and 10% of patients

in group A presented with mild infection , in group B 20% of patients presented with

mild to moderate infection and in group C 40% of the patients presented with

moderate to severe infection at the end of 7 days of treatment.

Average healing time in group A was 8.2 days and group B 8.6 was days and in group

C was 9.1 days.

Vrana Chinna in Group A, (80%) patients had small scar, (20%) patients had

medium scar formation. In Group B, (60%) patients had small scar, (40%) patients

Summary 126


had medium scar formation. In Group C, (70%) patients had small scar, (30%)

patients had medium scar formation.

The overall effect, which was assessed as complete relief, marked relief,

moderate relief, mild relief and no relief. Comparative analysis of overall effect of the

clinical study statistically reveals that Seevana Karma done by Ashwa Bala showed

very minimal scar formation, rare chance of infection. Seevana Karma done by

Guduchi Snayu showed medium scar formation, rare chance of infection.

Seevana Karma done by Cotton Thread no 10 showed medium scar formation and

very high chances of infection.

List of References & Bibliogrophy 127


REFERENCES

1 Rigveda 116/15 22 Shabda kalpadruma -page 225

2 Rigveda 1.112.10 23 Shabda kalpadruma –page 555

3 Valmiki Ramayana.Sut 74/33. Mahabharata 699/56-57 24 Su.Chi. 1/6

4 Garud purana, dhanwntari samhita. (ref. G.P./Dh. S. 171th Chapter). 25 Su.Sut.21/40

5 Su. Chi. 2/19-20. 26 Su.Chi. 2/20

6 Su. Su. 5/5 27 Vangasen.Chi.55/1

7 Su. Su. 25/16. 28 Su.Sut.22/8

8 Su. Chi. 1/8,45 29 Su.Chi 1/6, Ast.Sang.Ut. 31/11

9 Ca. Chi. 25/55. 30 Su.Sut.18/29

10 Bhel.Chi. 27/15 31 Su.Sut. 22/7

11 Vangasen.Chi.55/2,12 32 Su.Sut.23/18

12 A.Sang. Sut. 38/37,38 33 Su.Sut.23/19

13 A.Sang.Ut. 3/3 34 Su.Sut.23/20

14 Ast.Hr.Sut. 26/28 35 Su.Sut.5/5

15 Ast.Hr.Sut. 29/49-56 36 Shabda kalpadruma Vol-2, page 896

16 Ma. Ni. 43/12 37 Shabda kalpadruma Vol-3, page 542.

17 Kashyapa Samhita Chi.Sthana. 11/7, 8, 9. 38 Shabda kalpadrumaVol-4, page

228 18 Yog.R. Sadhyo Vrana Chikitsa 28th

Shloka 39 Shabda kalpadruma Vol-1, page no 299.

19 Bhaisajya.Ratnavali. 49/6 40 Shabda kalpadruma Vol-1, page no 199.

20 Su.Chi. 2/8-22 41 Shabda kalpadruma Vol-5, page no 361.

21 Ast.Hr. Ut. 26/2 42 Cha.Chi.25/55



43 Ast.Hr.Sut.26/28,29 65 Text Book Of Pathology by Harsh Mohan, page no 167

44 Su.Sut.25/20,21 66 Manipal Manual of Surgery, chapter 1, page no 2, 3.

45 Su.Chi.1/45 67 Text Book Of Pathology by Harsh Mohan, page no169, 170,171.

46 Su.Sut. 25/16 68 www.wikipidia.freeenclyclopidia.com

47 Ast.Sang.Ut.31/33 69 SRB’S Manual of Surgery, page no 775.

48 Ca.Chi. 25/60 70 A Practical Guide to Operative Surgery, S Das. Chapt.3, page no 17, 18, 19.

49 Su.Sut. 25/18, 19. 71 Ward Procedure by Mansukh Patel, Chapter 3, page no 25-51.

50 Su.Sut. 25/18, 72 Bailey and Love’s, chapter 42, page no 639.

51 Ast.Sang.Sut. 38/30 73 Su.Sut.25/21,22

52 Su.Sut. 25/18, 19. 74 Su.Sut. 25/21,

53 Su.Sut. 25/21,22 75 22Ward Procedure by Mansukh Patel, Chapter 3, page no 34, 35.

54 Su.Sut. 25/20 76 Yog. Ratnakara page no 89.

55 Su.Chi. 14/17 77 Bhavaprakash. Vatadi varga 15-17th Shloka, page no 519

56 Su.Chi. 2/56,57 78 Su.Sut. 7/16

57 Ca.chi 13/184-188 79 Su.Sut. 8/18

58 Su.Sut.16/17 80 Ast.Sang.Ut.31/32

59 Su.Sut. 25/23,24,25 81 Su.Sut.27/15

60 Su.Chi. 17 82 www.interscience.com, www.animalhair.com.

61 Ast.Hr. Sut.26/20,21 83 Su.Ut.16/3-6.

62 SRB’S Manual of Surgery chapter 1, page no 9 84 American Journal of Gastro-entrology,

2003, Vol-98 No-3, page no 691. 63 Bailey and Love’s, chapter 2,

page no 11. 85 Ayurvedic Pharmacopeia of India

64 Manipal Manual of Surgery, chapter 1, page no 1.

http://www.wikipidia.freeenclyclopidia.com/



BIBLIOGROPHY

Sushrutha, Sushrutha Samhitha, Dalhana commentary, edited by Vaidya

Yadavaji Trikamji Acharya, Chaukhambha Sanskrit Sansthan.

Agnivesha, Charaka Samhita, Chakrapani, 48th edition reprint 2004, edited by

Vaidya Yadavaji Trikamaji, Choukambha Publication.

Vagbhata, Ashtanaga Hridaya, Sarvanga Sunadri commentary by Arunadatta,

6thedition, edited by Pandit Hari Sada Shivashastri, Choukambha

Surabharati Prakashana.

Vagbhata, Ashtanaga Hridaya, Dr.Anna Moreshwar Kunte, Choukambha

Surabharati Prakashana.

Srimad Vriddha Vagnhata, Ashtanga Samgraha 10th edition by Dr.Ravidatt

Tripthi, Chaukhambha Sanskrit Sansthan.

Madhavakara, Madhava nidana, with madhukosha sanskrit commentary by

shri Vijayarakshita and Srikanthadatta, with vidyittini hindi commentary by

shri Sudarshan shastri, 30th ed, edited by sri yadunandan upadhyaya; varanasi,

Chaukhambha Orientalia Publishers.

Sir Williams Monier, Sanskrita English Dictionary first Publiser Oxford

University 1899, edition; reprent 1993 at Delhi.

Bhavamishra, Bhavaprakasha, Hindi commentary by Dr K.C.Chunekar, reprint

edition, edited by Dr G.C Pandey, Chaukhambha Brahati Academy.

Vangasena, Hindi commentary by Kavivar Sri shaligram, 1st ed, Khemaraj

Krishnadas Prakashan.

Bhaishajya Ratnavali, of Govindadas, edited with Hindi commentary by

Kaviraja Sri Ambikadatta Shastri, 13th edition,Choukamba Sanskrit Samsthan.

Dravyaguna Vidnyana, prof. P.V.Sharma, vol-ii, 17th edition, Chaukhambha

Brahati Academy.



Shabda Kalpadrum, Raja Raha kantadeva, third edition 1967, Publisher

Choukhamba Sanskrit Sansthan.

Das.S, A Concise Text Book of Surgery, 2nd Edition Calcutta 1999, Pp 1234.

Das.S, A Practical guide to Operative Surgery, 4th Edtn 1994, Pp 465.

Bailey And Love’s, Short Practice Of Surgery, Edited By Charles V Mann,

22nd Edition, Chapmann And Hall, London, 1995 Pp- 1041,Page No 639-640.

Sahasrayoga, Dr. Ramnivas Sharma and Dr. Surendra Sharma, Choukhamba

Orientalia Publishers, 3rd edition.

Mansukh B Patel and Yogesh P Upadhyaya, Ward procedure: fourth edition

by reed elsevier, India private limited Publishers, 2005, Pp-434.

Yogaratnakara, With Vidyottini Hindi Commentary By Vaidya Lakshmipati

Shastri, Edited By Bhisagratna Brahmasankar Shastri, fifth edition, Varanasi,

Chaukhambha Orientalia Publishers, 1993, Pp -504.

Case Sheet i

A CRITICAL STUDY OF INDIGENIOUS SUTURE MATERIALS W.S.R TO MANAGEMENT

A CRITICAL STUDY OF INDIGENOUS SUTURE MATERIALS W.S.R TO MANAGEMENT OF KSHATAJA VRANA

Guide: Dr. S. K. BANNIGOL Co-Guide: DR. S A. PATIL M.D (Ayu.) M.S. (Ayu.) Candidate: Dr. RAVINDRA G. VARMA

M.S. Scholar

PATIENT CONSENT FORM

I ____________________________________________________

Exercising my free of choice, hereby give you my complete consent to be include as a subject in the Clinical trail on “A Critical Study of Indigenous Suture Material W.S.R To Management of Kshataja Vrana”. I have been inform to my satisfaction by attending Doctor, the purpose of clinical trail and nature of drug treatment, therapeutic procedures, follow-up and probable complications. I m also ready to undergo necessary Laboratory Investigations to monitor and safeguard my body functions.

I am also aware of my right to opt out of the trial at any time during the

course of the trial without having to give the reasons for doing so.

Signature of the Candidate Signature of the Patient / Guardian (Dr.RAVI G. VARMA)

M.S. Scholar

Signature of the guide Signature of the co-guide (DR. S. K. BANNIGOL) (DR.S A. PATIL)

M.D. (Ayu) M.S. (Ayu)

OF KSHATAJA VRANA

Case Sheet ii


A CRITICAL STUDY OF INDIGENIOUS SUTURE MATERIALS W.S.R TO MANAGEMENT OF KSHATAJA VRANA

Guide: Dr. S. K. BANNIGOL Co-Guide: DR. S A. PATIL M.D. (Ayu) M.S. (Ayu)

Candidate: Dr. RAVINDRA G. VARMA M.S. Scholar

CASE SHEET

Name: _________________________________ Clinical Trial No.: - ________

Age: ___________________________________ O.P.D. No: - ________

Sex: ___________________________________ I.P.D.No: - ________

Occupation______________________________ Date: - ________

Religion________________________________ D.O.A.: - ________

Marital Status: ___________________________ D.O.D.: - ________

Habitat__________________________________ Diagnosis: - ________

Socio Economical Status____________________

Educational status_________________________

Address: ________________________________

________________________________________

________________________________________

Ph.No ____________________

E-Mail ____________________

CLINICAL TRIAL INFORMATION

Group A Ashwa Bala

Group B Guduchi Snayu

Group C Cotton Thread no 10

Date of Procedure Done

Date of Complete Recovery

OF KSHATAJA VRANA

Case Sheet iii


PRADHANA VEDANA: Kala Prakarsha:

Vedana:

Raktasrava:

ANUBANDHI VEDANA: Kala Prakarsha:

DETAILS OF LAKSHANA: Vedana - Present / Absent

Duration -

Mode of Onset -

Aggravating factor -

Relieving factor -

Raktasrava - Present / Absent Mode of Onset -

Severity - Mild / Moderate / Severe

ADYATAN VYADHI VRUTANTA:

POORVA VYADHI VRUTTANTA:

KULA VRITTANTA:

OF KSHATAJA VRANA

Case Sheet iv


VAIYAKTIKA VRUTTANTA:

1. Aharaja - Vegetarian / Mixed

Pradhana Rasa -

Guna -

2. Vihara -

3. Nidra -

4. Vyasana - Tobacco chewing /Smoking/Alcohol/Gutka

/Others/Nil

5. Mala pravrutti -

6. Mootra pravrutti - Frequency-Day -------- / Night ------ --

VYAVASAYA VRUTTANTA: Nature of Work - Sedentary /Moderate /Laborious /Traveling /Sitting /H/W

Working hours -

RAJA PRAVRUTI VRUTANTA:

Raja pravrutti - Regular / Irregular

Menarche -

Menopause -

Others -

SAMANYA PAREEKSHA:

Nadi Jihva Drik Dehoshma

Mala Shabdha Akruti Raktachapa

Mootra Sparsha Bhara Shwasavega

OF KSHATAJA VRANA

Case Sheet v


SYSTEMIC EXAMINATIN:-

*R.S. - *Urinary -

*C.V.S. - *Genital -

*C.N.S. - *G.I System-

DASHAVIDHA PAREEKSHA:-

1. Prakruti -V / P / K / VP / VK / PK / Tridoshaja

2. Vikruti -Dosha - V / P / K / VP / VK / PK / Tridoshaja

-Dushya-Rasa/Rakta/Mamsa/Meda/Asthi/Majja/Sukra

3. Sara -

4. Samhanana -Pravara / Madhyama / Avara

5. Pramana -Pravara / Madhyama / Avara

6. Satwa -Pravara / Madhyama / Avara

7. Satmya -

8. Ahara Shakti -Abhyvaharana – P / M / A

-Jarana – P / M / A

9. Vyayama Shakti - Pravara / Madhyama / Avara.

10. Vayataha -Bala / Madhyama / Vradha

OF KSHATAJA VRANA

Case Sheet vi


STHANIKA PAREEKSHA: I) Inspection:

Site - Size - Shape - ovoid/pear /kidney/irregular shaped Surface -

Edge - indistinct/sessile Number - II) Palpation:

Tenderness - present /absent Extent -

III) Auscultation:

Laboratory Investigation:

Specimen Name of Test Observed value

1. BLOOD Hb%

B.T

C.T

R.B.S

HIV 1 and 2

HbsAg

OF KSHATAJA VRANA

Case Sheet vii


INTERPRETATION: 1. Hetu:

2. Poorva roopa:

3. Roopa:

4. Upashaya / Anupashaya:

5. Samprapti:

Samprapti Ghataka:

a. Dosha -

b. Dushya -

c. Agni -

d. Ama -

e. Srotas -

f. Dusti prakara -

g. Udbhava sthana -

h. Vyakta sthana -

i. Adhisthana -

j. Roga marga -

Vyadhi vinischaya:

OF KSHATAJA VRANA

Case Sheet viii


TREATMENT PROCEDURE:

Poorva Karma: Pradhana Karma: Paschat Karma:

OF KSHATAJA VRANA

Case Sheet ix


OVERALL ASSESSMENT AND RESULTS: PARAMETERS AND OBSERVATION:

VEDANA -- McGill PAIN INDEX SCORE BEFORE TREATMENT

DURING TREATMENT (IN DAY’S) 1ST 2ND 3RD 4TH 5TH 6TH 7TH

AFTER TREATMENT

0 - No pain 1 - Mild pain

2 - Discomforting pain 3 - Distressing pain 4 - Horrible pain

5 - Excrutiating pain

SANKRAMANA (INFECTION)

BEFORE TREATMENT

DURING TREATMENT (IN DAY’S) 1ST 2ND 3RD 4TH 5TH 6TH 7TH AFTER TREATMENT

ROPANA KALA (HEALING TIME) BEFORE TREATMENT

DURING TREATMENT (IN DAY’S) 1ST 2ND 3RD 4TH 5TH 6TH 7TH AFTER TREATMENT

OF KSHATAJA VRANA

Case Sheet x


VRANA DHRUDHATA (TENSILE STRENGTH OF WOUND)

BEFORE TREATMENT

DURING TREATMENT (IN DAY’S)

1ST 2ND 3RD 4TH 5TH 6TH 7TH AFTER TREATMENT

VRANA CHINHA (SCAR FORMATION) BEFORE TREATMENT

DURING TREATMENT (IN DAY’S) 1ST 2ND 3RD 4TH 5TH 6TH 7TH AFTER TREATMENT CRITERIA FOR ASSESSMENT:

Assessment

a. For Symptoms:

* Complete relief - 100%

* Marked relief - 75 – 100%

* Moderate relief - 50 – 75%

* Mild relief - 25 – 50%

* No relief - < 25%

Signature of the Candidate Signature of the guide Signature of the co-guide (Dr.RAVI G. VARMA) (DR. S. K. BANNIGOL) (DR.S A. PATIL)

M.S. Scholar M.D(Ayu) M.S(Ayu)

OF KSHATAJA VRANA

Master Chart xi

Group ASl.No Name OPD No Age Religion Marital status Education Occupation Ecnomic status Food habit

1 Mr.Mahdevappa 638 23 Hindu Unmarried Graduate Student Middle Vegterian

2 Miss Renuka 2008 15 Hindu Unmarried Secondary Student Middle Mixed

3 Mrs.Uma 3741 40 Hindu Married Primary H.Wife Middle Mixed

4 Miss Sunita 4263 8 Hindu Unmarried Primary Student Poor Mixed

5 Mr.Parshuram 4344 22 Hindu Married Graduate Student Middle Mixed

6 Mr.Raghu 5022 13 Hindu Unmarried Primary Student Middle Mixed

7 Mrs. Kamla 6783 33 Hindu Married Secondary Labour Middle Mixed

8 Mrs.Aman 8442 7 Muslim Unmarried Primary Student Middle Mixed

9 Mr.Sreyas 10472 9 Hindu Unmarried Primary Student Middle Mixed

10 Mr.Dhruva 12103 12 Hindu Unmarried Primary Student Middle Vegterian

Group BSl.No Name OPD No Age Religion Marital status Education Occupation Ecnomic status Food habit

1 Mr.Krisna 1620 12 Hindu Unmarried Primary Student Middle Vegterian2 Mr.Veerangoda 2784 16 Hindu Unmarried Secondary Student Middle Mixed3 Mr Guru J 3729 32 Hindu Married Primary Labour Middle Mixed4 Miss Neelu K 4335 10 Muslim Unmarried Primary Student Middle Mixed5 Mrs Suvarna 4459 36 Hindu Married Primary H.Wife Middle Mixed6 Mr.Basu G H 5378 27 Hindu Married Primary Labour Middle Mixed7 Mr.Dhiraj 6799 29 Hindu Married Secondary Labour Middle Mixed8 Mrs.Heena 9488 14 Muslim Unmarried Secondary Student Middle Vegterian9 Mr.Vivek 10658 16 Hindu Unmarried Primary Student Middle Mixed

10 Mr.Pratik 12146 5 Hindu Unmarried Primary Student Middle Vegterian Group C

Sl.No Name OPD No Age Religion Marital status Education Occupation Ecnomic status Food habit1 Mr Y G Patil 1166 28 Hindu Married Graduate Business Middle Vegterian2 Mr.Kalmesh 3278 15 Hindu Unmarried Secondary Student Middle Mixed3 Mr.Babanna 3873 34 Hindu Married Primary Labour Middle Mixed4 Mr. Rakesh 4339 36 Hindu Married Illitarate Labour Poor Mixed5 Mr.Varun 4731 9 Hindu Unmarried Primary Student Poor Mixed6 Mr.Yogesh 5938 26 Hindu Unmarried Primary Business Middle Mixed7 Mr.Vasudev 7308 18 Hindu Unmarried Secondary Labour Middle Mixed8 Mrs.Padma 8799 41 Hindu Married Secondary H.Wife Middle Vegterian9 Mr.Nabib 11898 27 Muslim Married Primary Labour Middle Mixed

10 Mr.Amresh 11958 27 Hindu Married Graduate Service Middle Vegterian


Master Chart xi


INTRODUCTION

OBJECTIVES OF THE STUDY

HISTORICAL REVIEW

AYURVEDIC REVIEW

MODERN REVIEW

DRUG REVIEW

METHODOLOGY

RESULTS

DISCUSSION

OBSERVATIONS

BIBLIOGRAPHIC REFERENCES

SUMMARY

ANNEXURES

List of Graphs

LIST OF GRAPHS

Graph No. Name of the Graph Page No 1 Age 93

2 Sex 93

3 Religion 93

4 Marital status 93

5 Education status 94

6 Occupation 94

7 Socio-Economic status 94

8 Dietary habit 95

9 Incidence of Pain 95

10 Severity of Pain 95

11 Incidence of Sankramana 96

12 Incidence of Ropana Kala 96

13 Incidence of Vrana Chinna 96


a critical study of indigenious suture materials w.s.r …

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