E-ISSN:2456-3110

Case Report

Chedana Karma

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 8 AUGUST
Publisherwww.maharshicharaka.in

Management of Dustavrana by Chedana Karma and application of Madhu - A Case Study

Jangamshetti L1*, L Manonmani2, Bhat MZ3
DOI:10.21760/jaims.9.8.50

1* Lavesh Jangamshetti, Post Graduate Scholar, Dept. of Shalya Tantra, TMAES Ayurvedic Medical College and Hospital, Hospete, Karnataka, India.

2 L Manonmani, Principal and HOD, Dept. of Shalya Tantra, TMAES Ayurvedic Medical College and Hospital, Hospete, Karnataka, India.

3 Mohd Zahoor Bhat, Post Graduate Scholar, Dept. of Shalya Tantra, TMAES Ayurvedic Medical College and Hospital, Hospete, Karnataka, India.

Dusta Vrana management is most complicated problem encountered by medical practitioner all over the globe, that is non-healing, rapidly growing, disturb the day to day activities of patients, without early and optimal intervention it may ends with amputation of affected limb to save the life, This study reveals that Chedan (debridement) of necrotic patches followed by application of Madhu gives tremendous result in healing of ulcers, As per Sushruta Samhita, Lakshana of Dusta Vrana are Dourganda, Putisrava, Twak Mamsadi Kotha etc., In this case we had Lakshanas like Twak Kotha, Dourganda, Atiputisrava, Kandu etc. In Sushruta Samhita, Chikitsa Sthana 1st chapter Sushruta describes Shasti Upakrama for Vrana Chedana and Madhu Lepana is one among them. Chedana is mainly indicated for Dustavrana, Kotha etc., Honey has properties like Vrana Shodana, Vrana Ropana, Vvrana Sandhaniya. A 45 year male patient with wound over lateral aspect of thigh, knee joint and over lateral aspect of tibia associated with pain, itching fever since 1 week. Patient also had a history of admission in allopathic hospital under diagnosis of cellulitis, where in fasciotomy / fasciectomy was done. As the patient didn’t get relief so he approached our hospitals Shalya Tantra OPD. Patient had no comorbidity like diabetic mellitus, hypertension and patient was treated with Chedana Karma and application of Madhu along with Shamana Aushadi which has been discussed here.

Keywords: Chedana, Madhu, Dustavrana, Infected wound, Honey

Corresponding Author How to Cite this Article To Browse
Lavesh Jangamshetti, Post Graduate Scholar, Dept. of Shalya Tantra, TMAES Ayurvedic Medical College and Hospital, Hospete, Karnataka, India.
Email: 		Jangamshetti L, L Manonmani, Bhat MZ, Management of Dustavrana by Chedana Karma and application of Madhu - A Case Study. J Ayu Int Med Sci. 2024;9(8):317-321.
Available From
https://jaims.in/jaims/article/view/3540

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-07-13 2024-07-23 2024-08-03 2024-08-13 2024-08-25
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 12.32

© 2024by Jangamshetti L, L Manonmani, Bhat MZand 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

Vrana Gatra Vichurnane can be better understood in terms of discontinuity of skin, Vranayati Gatram Vivarnam Vaivarnyam Karoti Iti Vrana (Dalhana), it says that there is discoloration at the site of Vrana after healing. Sushruta says Sasta Vrana Moola (Vata, Pita, Kapha, Rakta, Sannipata, Agantuja), Astapariga (Twak, Mamsa, Sira, Snayu, Sandhi, Asthi, Kostha and Marma), Panchalakshana (Aakruti, Vedana, Varna, Gandha, Srava) and Shasti Upakarma. Vrana classified into two types[1]

  • Nija Vrana
  • Agantuja Vrana

Nija Vrana occurs due to vitiation of Vata, Pita , Kapha and Rakta Doshas. It is subdivided into 15 types according to Dosha Vitiation, were as Agantuja Vranais caused by an assault, hit, injury by fire, alkalis, poison, horn of animal etc.

Sushruta explains 4 stages of Vrana viz.[2]

  • Dusta Vrana (Infected wound)
  • Shudha Vrana (Clean wound)
  • Ruhyamana Vrana (Healing wound)
  • Rudha Vrana (Healed wound)

Dusta Vrana

After getting a Nija Vrana, those individuals who don’t have control over Indriyas or who don’t follow Pathya Ahara Vihara and those who have Nija Vrana which is left untreated results in condition called Dusta Vrana because of severe vitiation of Nija Vrana. It said to be Krucha Sadhya i.e., difficult to treat.

Features[3]

  • Atisamvrutha (Too narow)
  • Ativivrutha (Too wide)
  • Atikathina or Mrudu (Extremely Hard/ Soft)
  • Utsanna or Avasanna (Extremely elevated/Depressed)
  • Atishita or Ushana (Too hot/cold)
  • Having one of the colours Krishna, Rakta, Peeta, Shukla etc.
  • Bhairava (Exhibits unusual and strange features)
  • Moving in oblique track (Unmargi)
  • Having Amanoghna Darshana(Unfavourable Sight)
  • Atigandha (Foul odour)
  • Vedanayukta (Painful)
  • Associated with Daha, Paaka, Raga, Kandu, Shopha Pidaka
  • Discharging excessively Dushta Shonitha Dheerga, Kaalanubandha
  • Filled with putrid and sloughing flesh and fetid pus

Sushruta was quite aware about management of Dushta Vrana as he explains Shastiupakrama[4] i.e., 60 treatment modalities for Vrana (wound), Chedana[5] and application of Madhu is one among Shashti Upakarma. Chedana is mainly indicated for Snayu, Twak Mamsadi Kotha which indirectly helps to make Dusta Vrana to Shudha Vrana. On other hand Madhu has Vrana Ropana, Vrana Lekhana, VranaShodhana, Tridoshagna effects.[6]Patient was also given internal medicines (Shamana Aushadhi) in form of Kaishore Guggulu and Gandhak Rasayan.

Patient Information

A 45 year male patient came with complaint of ulcer over lateral aspect of thigh, knee joint and lateral aspect of tibia of left lower limbassociated with pain, Kandu (itching), Atipootisrava (Excessive Puss discharge) since 15 days, not know case of diabetic mellitus,hypertension etc. Patient was apparently healthy1 monthback. He had history of small injury over left lower limb while doing work. Graduallyover next few days swelling developed in area followed by fever, blisters, skin discoloration and day by day swelling elevated upto thigh region so he went to see a local surgeon who performed fasciotomy and gave IV antibiotics but patient didn’t get any relief so he approached to Shalya Tantra department ofTMAE Ayurvedic Medical College and P G Research Centre Hospet, for further wound management.

Clinical Findings

Inspection: Swelling of left lower limb, necrotic patches were noted over lateral aspect of left lower limb and dorsum of foot, incision line (fasciotomy) noted on lateral surface of thigh, below the knee joint and dorsum of foot.

Palpation: Pain and Tenderness of whole lower limb, redness, pitting oedemanoted, restricted limb movement due to pain.


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Laboratory Findings:

Hb: 11.2 gm/dl

RBC: 4.48 million/mm3

WBC: 10, 650 cells/mm3

PLT: 1.84 Lakh /mm3

RBS: 126 mg/dl

HIV & HBsAg, HCV: Negative

Serum Creatinine: 0.9

Treatment:

Pre Anaesthetic test dose for lignocaine was given which remained uneventful.

Patient was asked to lie-down in supine position. Under all aseptic condition part was painted with 10% betadine solution and draped,

Local anaesthesia (Inj. lignocaine) infiltrated along the margins of necrotic patches. By using 23 no surgical blade, debridement of necrotic patches was done. Nimba Kwath was poured on the wound while it was simultaneously cleaned by using sterile swabs. After cleaning Madhu (Honey-Dabur India Ltd) was applied on woundin adequate quantity and wound was closed using sterile surgical pads, loose bandage were done. Similarly on every 2nd day dressing was done with Nimba Kwatha Prakshalana followed by application of Madhu. Patient was also given internal medicines (Shamana Aushadhi) in form of Kaishore Guggulu 2 Tabs BD and Gandhak Rasayan 250mg 2 Tabs BD.

Result

The clinical features ofVrana started improving by the beginning of 3rd week, Healthy granulation started to develop after 3rd weekof debridement.

Putiganda, Puyasrava etc. decreased day by day.

jaims_3540_01.JPG

jaims_3540_02.JPG
Figure 1: Original and After Chedana

jaims_3540_03.JPG
Figure 2: After 3 weeks

jaims_3540_04.JPG
Figure 3: After 6 weeks

jaims_3540_05.JPG
Figure 4: After 12 weeks

jaims_3540_06.JPG

Pain

GradePain
0No pain
1Mild pain (1-3)
2Moderate pain (4-6)
3Severe pain (7-9)
4Worst pain (10)

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Wound Healing Scale (WHS)[7]

ItemAssessmentBase line3rd Week6th Week12th Week
Size 1  = Length x width <4 sq cm
2  = Length x width 4--<16 sq cm
3  = Length x width 16.1--<36 sq cm
4  = Length x width 36.1--<80 sq cm
5  = Length x width >80 sq cm		5541
1.Necrotic tissue amount 1 = None visible
2 = White/grey non-viable tissue &/or non-adherent yellow slough
3 = Loosely adherent yellow slough
4 = Adherent, soft, black eschar
5 = Firmly adherent, hard, black eschar		3211
2.Exudate amount 1 = None, dry wound
2 = Scant, wound moist but no observable exudate
3 = Small
4 = Moderate
5 = Large		4321
3.Granulation tissue 1 = Skin intact or partial thickness wound
2 = Bright, beefy red; 75% to 100% of wound filled &/or tissue overgrowth
3 = Bright, beefy red; < 75% & > 25% of wound filled
4 = Pink, &/or dull, dusky red &/or fills < 25% of wound
5 = No granulation tissue present		4321
4.Colour 1 = Pink or normal for ethnic group
2 = Bright red &/or blanches to touch
3 = White or grey pallor or hypopigmented
4 = Dark red or purple &/or non blanched
5 = Black or hyperpigmented		3221

Consolidated Score

ParametersBefore Treatment3rd Week6th Week12th week
Pain (VAS)1221
WHS1915115
Total2017136

Discussion

As per assessment of the wound based on the WHS and VAS scales, the pain increased after Chedhana which started receding after 6th Week of treatment as the wound started healing.

WHS indicated a receding score from 19 to 5 by 12th Week of treatment. Madhu has Vranaropak properties as per the principles of the sixty Upakramas of Vrana management described in the Sushruta Samhita. Madhu acts as Tridoshahara, i.e., pacification of Vata, Pitta and Kapha by multiple actions attributable to its Madhura (Sweet) Rasa, Kashaya (Astringent) Uparasa, Ruksha (Dry) Guna, Sheeta (cold) Virya, Madhura Vipaka, and Sukshma Marga Anusari (Ability to permeate in micro-channels) Prabhava. Madhura Rasa gives nutrition to the tissue, which helps in granulation tissue formation, while Kashaya Rasa provides Lekhana (scraping) that helps in desloughing, preparing the wound for healing.[7]

Thus, Madhu has excellent properties to heal the wound by virtue of its Sodhana (purification), Ropana (healing), and Sandhana (union) actions.

Honey is hygroscopic in nature, with a pH of 3.2–4.5. It prevents colonization and bacterial growth in tissues due to this acidic nature. Most of microorganisms do not grow in pure honey because of its low water activity (aw) of 0.6, It has antibacterial properties due to presence of hydrogen peroxide.[8] The mode of treatment was found to be cost-effective, safe, and easy to implement.

Conclusion

This case study reveals that local application of Madhu was found to be very effective in the management of Dusta Vrana. All the ingredients of Madhu have collective potential of anti-inflammatory, wound cleaning, wound healing properties as well as antioxidant vascularization activity which helped for perfect wound healing in Dusta Vrana.Though this treatment provides an Insite of cost effective and OPD based treatment of Dusta Vrana with a promising prospectus of Shashti Upakrama but further evaluation on a larger group of patients is needed to establish efficacy of Chedana Karma and application of Madhu in management of Dusta Vrana.

References

1. Charaka Samhitha, by Vaidya Yadavajitrikamji, Chikitsa Sthana, Chapter- 26, Sholaka No- 6 Page no 592, Pulished by Chaukhambha Subharti Prakash, Varanasi


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2. A text book of Shalya Tantra, Vol- 1 by Dr Mohasin Kadegaon, Page No-306-308 Published by Chaukhambha Orientalia- 2022
3. Sushrutha Samhita, Sutrastahana, by K R Srikanth Murthy-2017, Vol- 1, Chapter no- 22, Sholaka No- 7, Page No – 166
4. Sushrutha Samhita of Sushrutha with Nibandhasangraha commentry of Sri Dalhanacharaya edited by Vaidya Yadavajitrikamji Pulished by Chaukhambha Subharti Prakashan, Varanasi, Chikitsa Sthana, Chapter no-1, Sholaka No- 8, Page No – 397.
5. Sushrutha Samhita of Sushrutha with Nibandhasangraha commentry of Sri Dalhanacharaya edited by Vaidya Yadavajitrikamji Pulished by Chaukhambha Subharti Prakash, Varanasi, Chikitsa Sthana, Chapter no-1, Sholaka No- 33, Page No – 400.
6. Astangahrdaya of Vagbhata Annotated by Dr Anna Moreswar Kunte and Krsna Ramachandra Sastri Navre Edited by Pt. Hari Sadashiv Sastri Paradakara Bhisagacaya, Edition 2023 Published by Chaukhambha Subharti Prakashan, Varanasi, Sutrasthana, Chapter No- 5, Sholaka No- 52, Page No-76
7. https://www.hmpgloballearningnetwork.com/site/wmp/content/a-clinically-relevant-wound-assesment-method-monitor-healing-progression
8. Role of honey (Madhu) in the management of wounds (Dushta Vrana) https://www.ncbi.nlm.nih.gov/pmc /articles/PMC3059452/


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