E-ISSN:2456-3110

Research Article

Dushta Vrana

Journal of Ayurveda and Integrated Medical Sciences

2023 Volume 8 Number 12 December
Publisherwww.maharshicharaka.in

A comparative study of Apamarga Kshara Lepa and Jaloukavacharana in the management of Dushta Vrana

Pouse P1*, Resmi KK2, Manjunatha B3
DOI:10.21760/jaims.8.12.8

1* Poulose Pouse, Associate Professor, Dept of Shalakya Tantra, Netra Chikitsa Ayurved College, Amreli, Gujarat, India.

2 K K Resmi , Assistant Professor, Dept of Swasthavritta, Mandsaur Institute of Ayurveda and Research, Mandsaur, Madya Pradesh, India.

3 Bhatt Manjunatha, 3Professor and Head of Department, PG Dept of Shalya Tantra, Alva’s Ayurveda Medical College, Moodbidri, Karnataka, India.

Wound healing is a challenge faced in the medical field since the time of Vedas. Though surgical debridement, chorion graft, etc. which are practiced in modern era gives effectiveness in treating non-healing ulcers, these procedures have certain limitations such as, limited centres and high cost of treatment. The present study is to compare the effect of Apamarga Kshara Lepa and Jaloukavacharana in the management of Dushta Vrana. The main aim of study is intended to evaluate the efficacy in healing the ulcer. The subjects reported at Outpatient department of Shalyatantra were allocated into two groups of 20 subjects each. The Group A patients received Apamarga Kshara Lepa as treatment and the Group B patients received Jalaukavacharana as treatment. The subjects were assessed by analysing their biochemical parameters, subjective and objective parameters. Marked improvements were noted in both groups.

Keywords: Apamarga Kshara Lepa, Jaloukavacharana, Dushta Vrana, Kshara Karma, Non-Healing Ulcer

Corresponding Author How to Cite this Article To Browse
Poulose Pouse, Associate Professor, Dept of Shalakya Tantra, Netra Chikitsa Ayurved College, Amreli, Gujarat, India.
Email: 		Pouse P, Resmi KK, Manjunatha B, A comparative study of Apamarga Kshara Lepa and Jaloukavacharana in the management of Dushta Vrana. J Ayu Int Med Sci. 2023;8(12):54-59.
Available From
https://jaims.in/jaims/article/view/2852

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2023-10-13 2023-10-19 2023-10-28 2023-11-07 2023-11-24
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None declared. Nil yes 14.43 None

© 2023by Pouse P, Resmi KK, Manjunatha Band Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Ulcers are often associated with a great deal of suffering and pain to the patient and their successful management is a great challenge to the surgeons. Acharya Susrutha has explained various types of Vrana and explains Dustavrana as those with great accumulation of Doshas.[1] The frequency of injuries is more common than any other disease. There are certain conditions where the normal wound converted in to non-healing wound which needs immense care. Classics of Ayurveda has emphasized at various places to take care of wounds which occurs either as a result of vitiated Doshas or of traumatic in origin. Ayurveda also give their prime attention in wound management.

In Dushta Vrana there will be delay or no healing of ulcer and if it’s not treated effectively it may lead to long standing inflammation, pain, suppuration, gangrene and even may progress up to malignancy. Sushrutaacharya elaborated Shasti-Upakrama[2] especially to manage different stages of Vrana. These include medical therapy, Panchakarma therapies, surgical therapies and Parasurgical therapies.

Among the Para surgical measures, Kshara Karma is having supreme place due to its tremendous properties in curing diseases. Acharya Sushruta specifically mentioned that the Mamsa which are Utsanna, Katina, Kandu, Chirothidham and ulcers which are of Dusadhya should be cleaned by Kshara Karma.[3] Acharya Sushruta has also mentioned Jalaukavacarana Vidhi[4] is one of the most important treatment methodology mentioned in Shalya Tantra under Vrana Chikitsa and also mainly in Sthaanika Doshas. In Dushta Vrana which is Katina, Vivarna, Vedananuvidda, Vishayukta the Dushta Rakta should be drained using leeches.[5] In the present study, Apamarga Kshara Lepana and Jaloukavacharana are tried to evaluate the comparative action in the management of Dushta Vrana.

Methodology

All the Ayurvedic texts, contemporary Ayurvedic literatures, internet sources about the disease, drugs, and procedure is reviewed and documented for the intended study. Drugs are prepared in Alvas Pharmacy, Mijar and leeches were collected from the

leech lenders and certified by experts. The study was planned as a randomized comparative clinical trial with 40 subjects with complaints of Dushtavrana reported at the OPD of Alva’s Ayurveda Medical College, Moodbidri.

Group A of 20 subjects were administered with Jaloukavacharana and Group of 20 subjects were administered with Kshara Karma.

Diagnostic Criteria was made based on classical signs and symptoms of Dushta Vrana like those that are slightly exposed, very hard or soft, elevated or depressed, very cold or warm, having colours of black, yellow, and white, filled with pus, blood, muscles, vein etc.

Foul smelling, pain, burning sensation, redness, itching, swelling, eruptions, and such other complication persisting for a long time are considered for this study.

Subjects fulfilling at least one of the diagnostic criteria of Dusthavrana, age group between 16-70 years irrespective of gender, occupation, socio-economic and marital status and participant who signed written informed consent were included.

Those with bleeding disorders, on anti-coagulant drugs, Rakthamokshaanarhas, Kshara Karma Anarhas and diabetic ulcer subjects were excluded.

Assessment criteria includes subjective parameters like pain, itching, burning sensation, Objective parameters includes size of ulcer, discharge, tenderness, floor of the ulcer, surrounding area of ulcer.

Group A:

Apamarga Kshara Lepa was administered and the following materials were required like Apamarga Kshara, NimbuSwarasa, Madhu, Moorchita Grita, Kshara Karma Shalaka, Sterile Cotton Swab, Pad and Gauze.

The Poorva Karma done by taking consent of the subject then made the subject to lie down later the Vrana Sthana and surrounding area were cleaned with distilled water.

The Pradhana Karma is confirmation of Dosha predominance in Vrana then later in Vatapradhana sight Lekhana Karma[6] was done with sterile gauze.

In Pitta Pradhana Vrana, Gharshana is done with


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sterile cotton and in case of Kapha Pradhana Vrana; Prachaana was done with sterile needle.

The Teekshna Apamarga Kshara was applied with a Shalaka over the Vrana, waited for 100 Maathrakaala.

Then Kshara was wiped with cotton and Vrana was washed with Nimbuswarasa. Observation was made for the Krishna Varnata of Varna.[7]

If the Krishna Varnatha of Vrana did not appear properly the procedure was repeated.

The Paschath Karma was carried out by applying a paste of Madhu with Moorchita Grita on the area of Kshara Karma after that the dressing is done with bandage.[8]

The duration of treatment was for 28 days in which Kshara Lepa was done on 1st day and the assessment was carried out on 7th, 14th, 21st and 28th day. Follow up was done on the 45 days and 60 days after treatment.

Group B:

Jalaukavacharana was administered and the following materials were required like Jalauka, Saindhava Lavana Choorna, Haridra, Sarshapa Choorna, Thandula Choorna, Sterile Cotton Swab, Needle, Pad and Gauze.

The Poorva Karma done by taking the consent of the subject and later the subject was made to lie down.

The leaches have been anointed with the paste of Sarshapa Choorna and Haridra Choorna mixed with water and is placed in a water pot for a while for refreshment of the leach for making it active.[9]

The Pradhana Karma started by putting Jaloukas at the site of Dushta Vrana after cleaning the area with distilled water.

If the Jalouka doesn’t bite the site then a sterile needle prick was made on the area. When the Jalauka starts sucking the blood it was covered with a wet piece of cotton.[10]

Paschat Karma includes by applying Haridra Churna over the bitten area, after that the dressing was done for proper haemostasis.[11]

The duration of treatment was 28 days with 4 sitting for leech therapy, once in seven days. Jaloukavacharana was done on 1st, 7th, 14th and

.

21st day.

Assessment was done on 7th, 14th, 21st and 28th day. Follow up was done on the 45 days and 60 days after treatment.

Figure 1: Materials used for Jaloukavacharana

Figure 2: Materials used for Apamarga Ksharalepa

Figure 3: Purvakarma done before doing Apamarga Kshara Lepa


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Figure 4: Apamarga Kshara applied

Figure 5: Dushta Vrana was washed with Nimbu Swarasa
jaims_2852_08.JPG

Figure 6: After doing Apamarga Kshara Lepa

Figure 7: Jalaukavacharana done on Varicose Ulcer

Result and Discussion

Table 1: Assessment of pain

Group AGroup B
Assessment dayM.DS.DPAssessment dayM.DS.DP
7th day0.9000.447S7th day0.9000.447S
14th day1.4000.598S14th day1.2500.444S
21st day1.9000.553S21st day1.6000.503S
28th day2.3000.470S28th day2.1500.587S

Table 2: Assessment of burning sensation

Group AGroup B
Assessment dayM.DS.DPAssessment dayM.DS.DP
7th day1.1000.553S7th day1.1000.447S
14th day1.3500.489S14th day1.4500.510S
21st day1.8000.616S21st day1.8000.523S
28th day2.4500.605S28th day2.4000.503S

Table 3: Assessment of Itching

Group AGroup B
Assessment dayM.DS.DPAssessment dayM.DS.DP
7th day1.6000.489S7th day0.9000.553S
14th day1.4500.470S14th day1.3500.489S
21st day0.9000.587S21st day1.8000.523S
28th day0.3000.605S28th day2.1000.553S

Table 4: Assessment of discharge

Group AGroup B
Assessment dayM.DS.DPAssessment dayM.DS.DP
7th day0.9500.394S7th day0.8000.696S
14th day1.3000.470S14th day1.0500.605S
21st day1.7000.470S21st day1.6500.587S
28th day2.4500.686S28th day2.0000.725S

The subjective parameters like pain, burning sensation, discharge, itching has statistically significant improvement noted in both Group A and Group B.

Discussion on Pain

Group A: The mean score reduced from 3.150 to 1.000 after treatment. This may be probably due to the Daarana, Krimighna, Tridoshaghna properties of Kshara.Group B: The mean score reduced from 3.100 to 0.800 after treatment. This may be probably because Rakthamokshana by Jalaukavacharana remove the vitiated blood that removes the locally increased Doshas, by that it reduced Vrana Vedana. The leech saliva has an anesthethetic agent that will also help in reducing the pain.


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Discussion on Burning sensation

Group A: The mean score reduced from 3.050 to 0.650 after treatment. The removal of slough by Tridoshaghna, Vilayana properties of Kshara improves the circulation to the ulcer area and reduces the burning sensation.

Group B: The mean score reduced from 2.950 to 0.500 after treatment. This may be probably due to the Sheeta, Snigdha and Slakshana Guna and Pittahara property of Jalauka that will reduce the burning sensation.

Discussion on Discharge

Group A: The mean score reduced from 3.050 to 0.650 after treatment. The removal of slough by Tridoshaghna, Vilayana properties of Kshara improves the circulation to the ulcer area and reduces the burning sensation.

Group B: The mean score reduced from 2.950 to 0.500 after treatment. This may be probably due to the Sheeta, Snigdha and Slakshana Guna and Pittahara property of Jalauka that will reduce the burning sensation.

Discussion on Itching

Group A: The mean score reduced from 2.600 to 0.850 after treatment. This may be probably due to the Daarana, Kandughna, Lekhana and Shodhana property of Kshara breaks up the concealed pus pockets present in the base or surrounding area of the ulcer, Kshara kills the infective organisms by Krimighna property and there be reduces the itching.

Group B: The mean score reduced from 2.900 to 0.300 after treatment. This may be probably due to the Rakthamokshana by Jalaukavacharana remove the vitiated blood which removes the locally increased Doshas, by that it reduced Vrana Kandu and leech produce an antihistaminic protease and bacteria-inhibiting substances which will also help in reducing itching.

Probable mode of action of Apamarga Pratisaraneeya Kshara

Drug Apamarga having Katu Tikta Rasa, Ushna Veerya, Katu Vipaka and Laghu, Teekshna Gunas, which helps in maturation of Vrana Shotha, reduces inflammation, cleanses the Dushta Vrana and promotes the healing of Vrana.

Kapha Vata Hara property of Apamarga may help to remove Kapha Vataja features of Dushta Vrana like Athi Shaityata, Vata predominant features like Athisamvritha, Athikatina, Avasanna, Athyartha Vedana, Krishna Varna, Kapha predominant feature like Kandu etc. For Apamarga Pratisaraneeya Kshara preparation, along with Apamarga ash, Lime, Prakshepaka Dravyas like Vacha, Chitraka was added to increase its Theekshna Guna. Lime (CaCO3) comes under Sudha Varga. The properties mentioned in Ayurvedic texts are Shweta, Kshariya, Deepana, and Pachana. Drug Apamarga, Lime, Prakshepaka Dravyas like Vacha, and Chitraka were having similar qualities like that of Kshara, which helps to improve the potency of Kshara. For Vacha the properties mentioned in Ayurvedic texts are Chedana, Deepana, Pachana, Krimighna, Shoolaprashamana, Vatakaphahara and for Chitraka the properties mentioned are Sothahara, Shoolahara, Deepana, Pachana, Kaphavatahara that will enhance the potency of Apamarga Pratisaraneeya Kshara. Application of Apamarga Kshara removes devitalized tissues present over the wound provides chemical debridement and thus vascularity of wound surface is enhanced. Removal of unhealthy granulation tissue promotes the process of wound healing.

Probable mode of action of Jalaukavacharana

In wounds that are non-healing as a result of circulatory problems lead to the tissue’s inability to heal the leeches improve microcirculation and stimulating the immune system that in turn helps to clean and heal the wound. Raktamokshana by Jalaukavacharana removes the Rakta vitiated by Pitta which removes the Stanika Doshas. The Jalauka is having Sheeta, Snigdha and Shlakshna Guna and has Pittahara property. The leech’s saliva contains enzymes and compounds that act as an anticoagulation agent. The most prominent of these anticoagulation agents is hirudin, which binds itself to thrombins, thus, effectively inhibiting coagulation of the blood. Another compound that prevents coagulation is calin. This, on the other hand, works as an anticoagulant by prohibiting the von Willebrand factor to bind itself to collagen, and it is also an effective inhibitor of platelet aggregation caused by collagen. The saliva of the leeches also contains Factor Xa inhibitor which also blocks the action of the coagulation factor Xa. The action of destabilase is to break up any fibrins that have formed.


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It also has a thrombolytic effect, which can also dissolve clots of blood that have formed. Bdellins is a compound in the leech’s saliva that acts as an anti-inflammatory agent by inhibiting trypsin as well as plasmin. It also inhibits the action of the acrosin. Another anti-inflammatory agent is the eglins. There are three compounds in the leeches’ saliva that act as a vasodilator agent, and they are the histamine-like substances, the acetylcholine, and the carboxypeptidase A inhibitors. All these acts to widen the vessels, thus, causing inflow of blood to the site. The saliva of leeches also contains anaesthetic substances which deaden pain on the site and also bacteria-inhibiting substances which inhibit the growth of bacteria. By all these properties of Jalaukavacharana reduces infection and facilitate wound healing.

Conclusion

Management of Dushta Vrana by using Jalaukavacharana is more effective since markedly improvement (> 75%) and scar tissue formation was seen in 33 % of cases in comparison with Apamarga Kshara Lepa where 13% cases got markedly improved relief. Apamarga Kshara Lepa shows better result in healing abscess and Jalaukavacharana was found to be more effective in healing varicose ulcer. Jalaukavacharana and Apamarga Kshara Lepa is a simple cost effective OPD procedure which have miraculous effect on Dushta Vrana. No adverse effects were observed during the treatment in both groups. Statistically both groups are showing comparatively similar effects on Dushta Vrana, at the same time Jalaukavacharana showed much better effect on discharge and itching.

References

1. Sharma PV, editor and translator. Sushruta Samhita with English translation of text and Dalhana commentary. 1st edition. Varanasi: Chaukhambha Samskuta Samsthana; 1999. Utter Pradesh Chikitsa Sthana, Chapter 1, Verse 8.

2. Sharma PV, editor and translator. Sushruta Samhita with English translation of text and Dalhana commentary. 1st edition. Varanasi: Chaukhambha Samskuta Samsthana; 1999. Utter Pradesh Chikitsa Sthana, Chapter 1, Verse 22.

3. Sharma PV, editor and translator. Sushruta Samhita with English translation of text and Dalhana commentary. 1st edition. Varanasi: Chaukhambha Samskuta Samsthana; 1999. Utter Pradesh Chikitsa Sthana, Chapter 1, Verse 88.

4. Acharya VT, Acharya NR, editors. Sushruta Samhita with Nibandhasara Samgraha commentary of Dalhana Acharya and Nyaya Chandrikakhya Panjika Vyakhya of Sree Gayadasacarya. 6th edition. Varanasi: Chaukhambha Samskuta Samsthana; 1997. Sutra Sthana, Chapter 13, Verse 3.

5. Gupta KA, editor. Acharya Vagbhata. Ashtanga Hridaya, Uttara tantra, Chapter 25, Verse 2-4. Varanasi: Chaukhambha Prakashan; 2008.

6. Sharma PV, editor and translator. Sushruta Samhita with English translation of text and Dalhana commentary. 1st edition. Varanasi: Chaukhambha Samskuta Samsthana; 1999. Sutra Sthana, Chapter 11, Verse 18.

7. Gupta KA. Astanga Sangraha, Sutra Sthana. Varanasi: Chaukhamba Krishnadas Academy; Chapter 39, Verse 8.

8. Sharma PV, editor and translator. Sushruta Samhita with English translation of text and Dalhana commentary. 1st edition. Varanasi: Chaukhambha Samskuta Samsthana; 1999. Sutra Sthana, Chapter 11, Verse 19.

9. Sharma PV, editor and translator. Sushruta Samhita with English translation of text and Dalhana commentary. 1st edition. Varanasi: Chaukhambha Samskuta Samsthana; 1999. Sutra Sthana, Chapter 13, Verse 11.

10. Sharma PV, editor and translator. Sushruta Samhita with English translation of text and Dalhana commentary. 1st edition. Varanasi: Chaukhambha Samskuta Samsthana; 1999. Sutra Sthana, Chapter 13, Verse 19.

11. Sharma PV, editor and translator. Sushruta Samhita with English translation of text and Dalhana commentary. 1st edition. Varanasi: Chaukhambha Samskuta Samsthana; 1999. Sutra Sthana, Chapter 13, Verse 22.


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