“ADVANCES IN WOUND HEALING- AN AYURVEDIC

PERSPECTIVE”By

Dr K.K.ThakralRetd. Director,

Ayurvedic & Unani Services, U.P.

HUMAN EVOLUTION FROM QUADRIPED TO BIPED

Normal repair in a wound in humans follows an orderly sequence of cellular events which is initiated by injury and results in new connective issue formation.

Definition of wound i.e. VRANA:-

Surgeons in ancient India defined the wound as:-

“Vrana Gatra Vichoorney, Vranayetey itee Vrana” Su.ch.1/6

i.e. The solution of the continuity of the skin is known as VRANA (Wound).

ANOTHER DEFINITION was also given based on the presence

of resultant scar after healing of the wound as:-

“Vrinoti Yasmat roodhe api Vrana Vastu Na Nashytee

Aadeh Dhaarnat Tasmat Vrana

itee Uchytey Budhaiyee”. Su.Su.21/40  

Vrana is so called by the wise Vaidyas, since it covers and also because the VRANA VASTU i.e. (scar/ cicatrix formed later) does not disappear even after healing and remains till the body survives.

Based on the injury to tissues the Vrana is classified into two

types viz.

Dwaoo Vranaoo Bhavatah:- Shareer, Agantushch.

That it is of two type’s i.e. 1) Bodily or endogenous (Shareer

Vrana) and 2) External or exogenous

(Agantuj or Sadyovrana)

SHAREER VRANA: - - are caused by

aggravation of Vata, Pitta Kapha Rakta and Sannipata. It will include all types of infections, infestations, carcinogenic factors and others which produce ulcers.

AGANTUJ VRANA: -

are caused by assault or injury inflicted by human beings or animals or by falling from heights and all type of weaponry

It shall also include clean wounds produced by surgeons under aseptic conditions and sutured, such as EARPLASTY and RHINOPLASTY described by Sushruta.

Though wound formation is common in both these situations yet in view of different kinds of causes and effects it has been classified to be of two types.

  The response of the body to this

situation in the form of wound healing process is same in both types.

SHAREER VRANA is the ultimate explosion of

underlying pathological structures such as in a case of abscess and passes through six stages i.e.

“Sanchayam cha Prakopam cha Prasaram Sthan Sanshrayam

Vyaktibhedham cha yo veti Doshanam sa Bhaved Bhishak”. Su.Su. 22/36.

SIX STAGES Sanchya (Accumulation) Prakopa (Aggravation) Prasara (Spread) Sthan Sanshraya (Localisation) Vyakti (Manifestation) and Bheda (Chronicity)

For practical purposes any of such conditions passes through 3 stages viz.

“Amam Vipachyamanam cha Samyak Pakvam cha yo Bhishak

Janeeyat sa Bhave Vaidya sheshastaskar Vrittya.”Su.Su.17/6

Amavastha (Unripe stage) Pachyamanavastha (Ripening

Stage )and Pakvavastha (Ripe)

AMAVASTHA

PACHYAMANAVASTHA

WOUND FORMATION

PAKVAVASTHA The Pakvavastha

results in either FRUSTE FORME LESION or Intentional Opening, so the skin continuity is lost and now is called a VRANA.

Because this wound has all the features of a SEPTIC

WOUND so it has been termed as a Dushta Vrana and to heal

it has to pass through 4 clinically appreciable stages:- Dushta Vrana (A SEPTIC WOUND) Shudh Vrana (A CLEAN Wound) Roohyamana Vrana (A Healing

Wound) and Roodha Vrana (Healed Wound)  

Dushta Vrana:- “Pooti Gandhan Vivarnashch Bahu Sravan

Maha ruja Vran ashudhan Vigyaye Shodhanaiyee

Samupacharet”

(Charak) The features are; - Smells bad, has

various colours, different type of discharges and is painful.

The treatment is PROPER CLEANING.

Shudh Vrana (A Clean Wound);- “Tribhir doshayee Na Akranta Shyav Aushtha Pidki Samah Avedno Nirasravo Vrana Shudh eho Uchyatey” Su.Su.23/18   The features are;- There is no more invasion of Tridoshas i.e.

there is no more infection, the edges become bluish in color (an indication of activity of Fibroblasts), the surface of wound is filled with small eruptions i.e. granulation tissues, it is painless and also no discharge of any kind.

Roohyamana Vrana (A Healing Wound);-

The feature are;- “Kapot varna Pratima Yasyanta Kleda

Varjita Sthirashch Pitikavanto rohity itee

Tmadishet”

Su.Su.23/19 The margins have the color of a wild

pigeon i.e. GREYISH HUE, is devoid of discharge at the edges, the surface is filled with healthy eruptions i.e. healthy granulation tissue.

ROODHA VRANA (A Healed Wound):-

The features are:- “Roodhavartmanam agranthim ashoonam arujam

vranam Twak Swaranam Samtalam Samyagroodham

Vinirdishet” Su.Su 23/20 A healed wound has no eruptions, no

swelling due to inflammatory process, no pain, and the color of scar is that of the skin and the level of the scar is even with the healthy skin, it is neither raised nor depressed.

White Skin

Brown Skin

Black skin

(2) EXTERNAL OR EXOGENOUS (Agantuj or Sadyovrana);

This is produced by injury and is of six types;-

Chhinna ( Excised ) Bhinna (Incised ) Viddha (Punctured ) Kshat (Crushed ) Picchit (Contused) and Ghrishta (Abrased).

A surgeon under aseptic conditions may produce such a

wound. This type of vrana is not

influenced by Humors for the first seven days of its life and after that if not properly taken care of then it may be affected by humours and so shall be considered as Shareer vrana.

SIXTY PROCEDURES To achieve wound healing SIXTY

PROCEDURES have been described by Sushruta.

(A) To remove the contamination of wound To bring the humours to an ideal balance To prepare the wound and the patient for

a definitive therapy = First 12 procedures.

(B) Surgical Intervention =

10 procedures ( C) Induction of Healing =

12 procedures (D) Vaikritapaha i.e. to remove

complications and Sequela. = 26 procedures.

An Ideal Wound Created by a Surgeon;- 

“Tatrayto vishalah samah suvibhakto

Nirashraya iti Vrana guna”

Su.Su.5/8 The vrana made by the surgeon

should be straight, appropriately long, even, well divided edges and no hollow space is left inside, is an ideal wound.

AN IDEAL WOUND It may be possible to make an

ideal wound if one should use an infinitely sharp knife,(Yada Sunishchitam shastram Romchhedi susanssthitam, Su.Su.8/14) protect the wound edge from water loss and close the wound primarily without sutures within a few seconds of its making. In such a case little surrounding tissue would have to be debrided before the conditions for repair would be suitable.

WOUNDS IN PRACTICE In practice wounds are not

made with infinitely sharp instruments, wound are exposed and contaminated and surgeons tend to leave islands of strangulated or coagulated tissues behind them.

2, WHAT IS THE DIFFERENCE BETWEEN CHANDSI TECHNIQUE AND KSHAR SUTRA TREATMENT

METHOD?

Chandsi technique is a traditional and unscientific technique under which untrained persons having no scientific knowledge of diagnosing the disease, treat the Piles and Bhagandra.

Railroad Technique

DAMAGED FACE OF THE WOUND

Before repair can occur, then, the damaged face of the wound must be removed. This process involves collagen lysis as well as removal of noncollagenous protein. This job is generally left to the MACROPHAGE.

MYSTERIES OF WOUND HEALING;-

The major mysteries of repair have always been and continue to be; 1) what in the injury stimulates repair, and 2) how does the wound recognize that it is no longer needed- that is why does healing stops?

ROLE OF BLOOD AND ITS COMPONENTS:-

Blood has been called both as Dhatu and Dosha.

“Ta Etye Shareer Dharnat Dhatwa iti Uchyante” Su.Su.14/20

Because they support (maintain) the body so they are called as Dhatu.

“Tatra Kshya Vriddhi Shonit Nimitte” Su.Su. 14/21

  Decrease and increase of these Dhatus is

caused by Shonit (Blood)

FUNCTIONS OF BLOOD “Rasas Tushtim preenanam Rakta

pushtim cha Karoti, Raktam Varna Prasadam Mamsa Pushtim

Jeevyati cha,”   Rasa dhatu provides satisfaction,

nutrition and supplies nourishment to Rakta (Blood)

Blood bestows color, nourishment to Mamsa and maintains life activities.

ISCHAEMIA VERSUS HAEMOSTASIS

While performing EARPLASTIES Sushruta noted that healing was not achieved in ISCHAEMIC situations

pinna is dry( Shushka), Pinna is very small ( Alp Pali) Its muscle is absent (Ksheen Mamsa) Ear lobe is thin ,irregular and short

(Tanu,Visham,Alp ) Ear lobe has nodules and static network of

veins ( Grathit Mamsa and Stabdh sira) All indicating towards ISCHAEMIA.

and the result is “Badheshvapi tu Shofa Raag

Paak Pidika Srava Yukta Na Siddham Upyanti” Even if performed with dexterity

they develop swelling, burning sensation, red color, ulceration suppuration, exudative eruptions and so become unsuccessful.

So instead of Ischemia he suggests for complete Haaemostasis by the

following four methods. Sandhan (joining the edges of the

wound) Skandan ( promoting clotting by cooling) Pachan (Promoting clotting by

application of drugs) Dahan (By thermal cautery)

IN VIVO EXPERIMENTS;- Based on this fact described

by Sushruta that blood is both a dhatu and a Dosha, experiments were planned at the Wound Healing laboratory, University of California, Medical School, San Francisco, U.S.A. under the guidance of Prof.Thomas Knight Hunt.

BLOOD COMPONENTS TRIED

Different components of blood such as whole blood, Serum, Plasma, blood clot, Macrophages, Platelets, Fibrin were assayed for their angiogenetic capacity. These were injected or placed in a small pocket made in the cornea of the same rabbits

RESULTS Our results demonstrated

that activated platelets and activated macrophages have the capacity to initiate angiogenesis in vivo. So there is a platelet derived growth factor as well as a macrophage derived growth factor, which supports to their role as initiator of the healing process.

angiogenesis

angiogenesis

A schematic representation of the edge of wound just after

injury

Developing Granulation Tissues (Sthir Pitika)

A New functioning Capillary Loop has developed

DISORDERS OF REPAIR;- The general surgeon thinks of disorders

of repair in terms of wound dehiscence (Uchttan, anastmotic leaks (Vrana Srava) or wound infection (Doshic involvement).

The plastic surgeon thinks of them as hypertrophic scars, keloid formation and contracture (Aakunchan). Urologists and Gastroenterologists concerns are strictures of the esophagus, Duodenum, ureter, urethra and obstruction of the bowel due to adhesions.

SCAR OR STRICTURE All of these belong to the same spectrum

of disorders, which in a broader view, includes occlusion of arteries due to arteriosclerosis, deformation of heart valves due to valvulitis and scar or stricture of the trachea due to injury or prolonged intubation. Restriction of joint motion by arthritis is a common cause of disability (Vaikalykar Marma ). As a last example, the major cause of blindness is corneal scarring.

a Scar is a Scar This grouping may seem diverse at first

sight but they are known for their ultimate result and others for their anatomical location. But they are all scars. However, a Scar is a Scar whether its cause is a club, a knife or an immune or chemical reaction (DOSHIC AFFECT) – and whether it is located in the skin, a joint or the cornea or vascular endothelium.

CONFUSION In practice it is difficult

to decide just what normal repair is. We often confuse that which is abnormal with that which simply is undesirable.

DESIRE OF A SURGEON;-   The general surgeon desires strong

union of soft tissues in an acceptable time. The hand surgeon wants union of tendons, but union is useless, unless the healed tendon can glide and flex within its sheath. The neurosurgeon repairing a peripheral nerve wants as little connective tissue repair as possible, whereas the orthopedist setting a fracture usually wants as much connective tissue repair as possible.

MODIFICATION OF REPAIR Each of these surgeons has his own ways

of modifying results of repair. Some attempt to modify repair with microscopic surgical technique, others with immobilization, still others with physical therapy, Nutrition, necessary drugs, traction and pressure. All these have been dealt with in the SIXTY PROCEDURES described in Sushruta Samhita.

 

SUTURE MATERIAL;-

Choosing suture material is one of the “arts” of surgery. The use of non-absorbable and absorbable suture material along with the use of ANT HEADS to suture the ruptured intestines so that no stricture is formed or leaking takes place is mentioned. The best surgeon can often compensate for the worst suture and the worst surgeon can defeat the best suture.

NEEDLES;-

Skin sutures create a micro wound and small cysts may appear at the mature wound. The use of cutting, round body and atraumatic needles has been advised.

INCISIONS;- Various incisions such as

straight, circular, semicircular, zigzag and various others should be used according to the anatomical site to avoid bleeding and minimize postoperative complications.

LINEAR INCISION ( AYATAKAR)

RECTANGULAR INCISION (Sarvatobhadra)

SURGEON VERSUS GRANULOCYTE

“Tatah Shastram Avcharya,, Samantat Paripeedya Angulya,Vranam Abhimridya, Prakshalaya Kshayen, Proten Odakam Adaye” Su.Su.5/17

That after surgery the entire area should be kneaded by fingers and massaged mildly, washed with decoction of drugs so that materials such as pus, blood, dead tissues etc are removed and liquid remaining be removed by swabbing.

POWER OF SURGEON Surgeon has this power

to minimize the dead tissue and thus he has in his hands a major means of preventing infection. The granulocytes and macrophages remove debris and kill bacteria. They “clean up” after the surgeon.

DEHISCENCE, WOUND SEPERATION

“Na Ati Doorey Nikrishtey va soochi Karmani Patyet

Doorad Rujo Vran Aushthasye Sannikrishte Avlunchnam” Su.Su.25/26

While using the suture needle, punctures should be made neither very far nor very near. If the punctures are far apart that will give rise to pain in the edges and if very near the edges will get torn because they get strangulated.

PROPER SUTURING

PROPER SUTURING

ROLE OF GOOD HEALTH “Tatra vyasthanam Dridhanam

Pranvattam Sattvavattam cha Suchkitsya Vrana.”

Su.Su.23/3 Wounds of persons who are youth,

strong built, valiant, of strong mind and will power and can control their senses their wounds heal easily.

 

ROLE OF BAD HEALTH “Ta Ev Vipreet Guna Vridh

Kirsch Alp- prana Bheerushu Drishtavya”

People with opposite qualities of the above i.e. who are old, emaciated, not valiant and are fearful their wounds heal with difficulty.

ASSOCIATED DISEASES “Kushthinam Vishjushtsnam Shoshinsm

Madhumehinam Vrana Krichhren Sidhyantee Yesham

chaapi Vrane Vrana” Su.Su 23/7 Extensive survey conducted by the then

surgeons and over a experience of many years they concluded that persons suffering from Leprosy, affected by poison, consumption, diabetes mellitus and in those who again have injury in the previous wounds heal with difficulty.

OTHER FACTORS Many other situations have also

been described. The role of Prakriti,

bandaging (Loose, Mild, Tight), Multifunctional dressing materials (oily, powders, pastes) and many other factors have been described.

Role of Rasayan

CONCLUSION Sushruta concludes that;- “Shanmoolo Ashtparigrahi Panch Lakshan

LakshitaShashthya Vidhanair Nirdishtai Chaturbhi

Sadhyte Vrana” A wound has six causes, eight seats in the

human body(SKIN,FLESH,BLOOD VESSELS, SINEWS, BONES,JOINTS,INTERNAL ORGANS OF CHEST & ABDOMEN,VITAL STRUCTURES), five type of symptoms, should be treated with sixty kind of procedures and has four pillars in the form of 1,Vaidya, 2,Patient, 3, Paricharak and 4, Aushadhi.

AYURVEDIC PERSPECTIVE;- The major lesson is that

wound repair is a delicate and easily confounded “ecosystem” in which unthinking meddling of man may have disastrous consequences. That repair often requires aid and that it frequently responds to modification.

CONTRIBUTION OF THE SURGEON

The major contribution the surgeon makes to the healing of wounds is in his technical skill. If he is gentle, clean , uses cautery and sutures with appropriate restraint, if he does not fuss with tissues, picking it up and dropping it, if he does not rub it, dry it or kill it with clamps , he and his patients will be rewarded.

Thank you

Thank you