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Year : 2022  |  Volume : 1  |  Issue : 2  |  Page : 70-78

Vipareeta Vrana Vijnaaneeyam chapter of Sushruta Sutra Sthana: An explorative study

Department of Kaya Chikitsa, R. B. Ayurvedic Medical College and Hospital, Agra, Uttar Pradesh, India

Date of Submission19-Dec-2022
Date of Acceptance19-Apr-2023
Date of Web Publication26-Sep-2023

Correspondence Address:
Dr. Kshama Gupta
Department of Kaya Chikitsa, R. B. Ayurvedic Medical College and Hospital, Agra, Uttar Pradesh 283126
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jahas.jahas_22_22

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Sushruta Samhita, written by Maharshi Sushruta, is one of the oldest Ayurvedic texts dedicated to surgical procedures along with other medical disciplines. Prognostic knowledge is documented in the 28th to 33rd chapters of Sutra Sthana of Sushruta Samhita (SSS). Vipareeta Vrana Vijnaaneeyam (VVV) is the 28th chapter of SSS, and it consists of 21 verses that deal with the prognostic assessment of wounds. The present work is aimed to provide a comprehensive and critical analysis of the contents of VVV chapter with the help of contemporary prognostic literature available on the wounds. Elaborate description is available regarding the prognostic assessment of wounds based on various parameters such as wound odor, color, pain, temperature, shape, size, location, granulation tissue, associated complications, underlying systemic diseases, etc., in VVV chapter. Gas chromatography-ion trap mass spectrometry or e-nose could be used to analyze various wound odors (Vrana Gandha). Red, Yellow & Black classification tool could be incorporated to standardize Vrana Varna (wound color). Various wound microenvironment indices, such as local pH, uric acid, glucose, lactic acid, etc., could be incorporated in standardizing Vrana Rasa (taste-related indices of wound). Wound, wound bed, and periwound temperatures can be used for understanding Vrana Sparsha (touch-related indices of wounds). Smartphones and digital wound measurements could be used to standardize Vrana Aakriti (shape and size of the wound). Most of the conditions described in VVV chapter denote various infectious, ischemic, chronic, and nonhealing ulcers associated with complications and underlying systemic diseases.

Keywords: Maharshi Sushruta, nonhealing ulcers, prognosis, Sushruta Samhita, Vrana, wound

How to cite this article:
Gupta K, Mamidi P. Vipareeta Vrana Vijnaaneeyam chapter of Sushruta Sutra Sthana: An explorative study. J Ayurveda Homeopath Allied Health Sci 2022;1:70-8

How to cite this URL:
Gupta K, Mamidi P. Vipareeta Vrana Vijnaaneeyam chapter of Sushruta Sutra Sthana: An explorative study. J Ayurveda Homeopath Allied Health Sci [serial online] 2022 [cited 2023 Dec 10];1:70-8. Available from: http://www.dpujahas.org/text.asp?2022/1/2/70/386301

  Introduction Top

Maharshi Sushruta (belongs to 600 BC) invented and developed many surgical procedures, and he is known as the father of plastic surgery. Sushruta Samhita (SS) had written by Maharshi Sushruta in the Sanskrit language many centuries ago and mainly deals with various surgical procedures along with other medical specialties. SS is considered one of the Brihatrayee (three major classical texts of Ayurveda), along with Charaka Samhita and Ashtanga Hrudaya.[1] Prognostic knowledge (Arishta Vignaana) is documented in the 28th–33rd chapters of Sushruta Sutra Sthana (section of Ayurvedic fundamental principles) (SSS).[2] Clinical implication and prognostic utility of the contents of Avaaraneeya Adhyaya (33rd chapter)[3] and Swabhava Vipratipatti Adhyaya (32nd chapter)[4] of SSS have been explored by the previous works. Vipareeta Vrana Vijnaaneeyam (VVV) is the 28th chapter of SSS, and it consists of 21 verses. According to Bhanumati commentary written by Chakrapani, the name of the 28th chapter of SSS is Vipareeta Vrana Vijnaaneeyam, whereas it is Vipareetaavipareeta Vrana Vijnaaneeyam according to Nibandha Sangraha commentary written by Dalhana. Wounds or ulcers (Vrana) that are associated with poor prognosis are explained in VVV chapter. Description of various abnormal (Vipareeta) wound (Vrana) characteristics such as color (Varna), shape, odor (Gandha), sounds (Shabda), etc., accompanied with fatal outcome (Arishta) is the main theme of VVV chapter of SSS.[5],[6]

Detailed, systematic, and scientific information regarding wounds, their pathogenesis and management are available in SS. Maharshi Sushruta has quoted many verses regarding Vrana or wound or an ulcer. Shashti Upakramas (60 remedial measures) are indicated for the management of wounds.[7] Though there is sufficient data available on wound management, according to Ayurveda, studies on prognostic assessment of wounds have been lacking. No published works are available on VVV chapter of SSS till date, as per our search and understanding. The present work is aimed to provide a comprehensive and critical analysis on the contents of VVV chapter by using contemporary prognostic literature on wounds. The present narrative review may provide new insights and may become a torchbearer for future works on the prognostic estimation of wounds according to Ayurveda.

  Review Methodology Top

We have conducted a literature search in different databases and search engines, including Web of Science, PubMed, Scopus, EMBASE, and Google Scholar, with various keywords related to Ayurveda and contemporary prognostic literature on wounds. We did not consider any time limitations, but articles or abstracts published in the English language only were considered during database searching. SS with Nibandha Sangraha and Bhanumati commentary and other Ayurvedic texts such as Charaka Samhita, Ashtanga Samgraha, Ashtanga Hrudaya, Bhela Samhita, and Kashyapa Samhita have been referred. No search filters and Boolean operators have been used while searching different databases. Published articles that failed to describe the factors of interest for the present study were excluded. Articles that have either contradicting or supportive findings to the present work have been included. Data obtained from these studies are compiled, interpreted, and presented as a narrative review.

  Discussion Top

Vrana is the most significant surgical entity, and the surgeon is expected to have sufficient skill in its effective management. Maharshi Sushruta was a popular surgeon of his time, and he had expertise in the diagnosis and management of Vrana.[8] A detailed description of wound care that includes various types of wounds, their systematic classification, etiopathogenesis, and management is available in SS. Sixty treatment modalities (Shashti Upakrama) are mentioned for the management of wounds in SS.[9] The word Arishta denotes fatality; Arishta Lakshans means fatal signs and symptoms; their presence indicates an imminent death. Many Ayurvedic texts have a separate section called Indriya Sthana that consists of a few chapters describing various Arishta Lakshanas (AL). Indriya Sthana is not present in SS, instead of that Maharshi Sushruta has dedicated six chapters (from 28th to 33rd chapters) to describe various AL in Sutra Sthana (a section that deals with fundamentals of Ayurveda). VVV is the 28th chapter that deals with the description of AL related to Vrana, and the remaining chapters (from the 29th to 33rd chapters) deal with various AL related to some other medical and surgical conditions. VVV chapter of SSS consists of 21 verses. The initial verses deal with the definition of AL and their classification with examples followed by various fatal signs and symptoms related to Vrana.[5],[6] Critical analysis with the interpretation of each and every verse of VVV chapter by using contemporary prognostic literature related to wounds in the following sections [Tables 1,2].

Athaato Vipareetaavipareeta: Rishtaani Panchataam (verse 1–3)

The current chapter (VVV) deals with the good (Avipareeta) and the bad (Vipareeta) prognostic features of wounds (Vrana). A detailed description is provided in the following sections. Similar to the manifestation of flowers (Pushpa), smoke (Dhooma), and clouds (Ambuda) before fruits (Phala), fire (Agni), and rain (Vrishti), AL precede death (Panchataam). The manifestation of Arishta Lakshnas indicates an imminent death.[5],[6]Dalhana (commentator of Nibandha Sangraha commentary on SS) has classified AL into two groups, i.e., Niyata (definite) and Aniyata (indefinite). Both Niyata and Aniyata Arishta Lakshanas are explained with examples of fire & smoke, flower & fruit, and clouds & rainfall. Examples such as flower & fruit and clouds & rainfall are Aniyata, whereas fire & smoke are Niyata. The effects of Aniyata Arishta Lakshanas are uncertain, just like nonflowring plants that bear fruits and clouds without rain. Niyata Arishta Lakshanas definitely precedes death, like the association between fire and smoke is certain. Chakrapani (written Bhanumati commentary on SS and Ayurveda Dipika commentary on Charaka Samhita) has mentioned Kaala Mrutyu (timely or certain death) and Akaala Mrutyu (untimely or uncertain death) with or without the precedence of AL.[2]

The odds ratio (OR) measures the strength of an association between two events (in the present context, the association between AL and death [D]). OR greater than 1 denotes AL and D are associated or correlated (Niyata Arishta Lakshnas like fire & smoke), whereas OR less than 1 indicates AL and D are negatively correlated (Aniyata Arishta Lakshnas like flower & fruit, and clouds & rainfall). A positive OR does not establish that AL causes D or that D causes AL; it denotes only the strength of association (correlation doesn’t imply causation). Hence, Niyata and Aniyata Arishta Lakshanas could be better explained with the help of OR (>1 or <1).[10]

Taani Saukshmyaat: Dhruvam tu Maranam Rishthe (verse 4)

AL are generally uninterpretable or unidentifiable (Na Gruhyante) because of their subtle nature (Saukshmyaat), due to the untrained eyes or lack of prognostication skills (Agnai) or decrement in vigilance (Pramaadaat) of the physicians and due to their remitting-relapsing nature or fluctuating or inconsistent nature (Aashu Vyatikramaat). AL definitely (Dhruvam) precedes death (Maranam).[5],[6] Clinical signs (AL) that have very high specificity rates (Dhruvam) for impending death (Maranam) have been identified. As AL are fluctuating or inconsistent or remitting-relapsing in nature, they may confuse the physician (Na Gruhyante Udgataani Agnai) and may ultimately lead to clinical decision-making errors (Na Gruhyante). AL are variable qualitatively and quantitatively, and they are innumerable. AL might be hidden or subtle or invisible (Saukshmyaat) sometimes. Prognostic factors (AL?) may evolve and vary (Saukshmyaat & Aashu Vyatikramaat) according to the stage of disease, and they could be tested on various statistical parameters such as specificity, sensitivity, negative & positive predictive values, false negatives & false positives, etc. Most clinical predictions made by physicians are based on subjective assessments of complex situations or clinical intuition that is fallible and may lead to biases (Na Gruhyante Udgataani Agnai). Physicians’ accuracy in estimating the mortality risk of patients has been variable, and the exact time of death cannot be predicted with certainty (due to Saukshmyaat & Aashu Vyatikramaat). Life expectancy estimates and prognosis carries a high degree of uncertainty (Aniyata), and that can be reduced by improving the accuracy of prognostic estimates. A physician will become confident with the thorough knowledge of AL or prognostication. Experienced physicians have performed better than others.[11] According to Chakrapani, Aashu Vyatikramaat means the quick disappearance of AL after their manifestation, just like thunder (Vidyut). As per Dalhana, Aashu Vyatikramaat means death that occurs immediately after the manifestation of AL.[2]

Brahmanaistat: Nivaryate (verse 5)

Death could be warded off (even after the manifestation of AL) (Nivaryate) by the blessings of holy Brahmanas (a particular community involved in spiritual practices), who are of unblemished character (Amalai) or free from various unethical or abnormal practices (Amalai), and are also accustomed to practice the meditation and other religious penances (Tapa); who regularly practice meditation (Japa), prayers and consume Rasayana (nutraceuticals or regenerative or restorative or antiaging) medicines.[5],[6] The present verse explains the exceptional conditions in which death could be warded off even after the appearance of AL (Aniyata?). Maharshi Bhela has explained some personality traits that are associated with longevity in the Ayurlakshaneeyam chapter of Bhela Samhita Indriya Sthana. Personality traits such as Dharma (conscientiousness) & Satya Vakya (honesty/righteousness), and Rasayana Prayoga are positively associated with longevity. Longevity is associated with conscientiousness, emotional stability, and activeness. Religiosity/Spirituality beliefs and doctrines support human virtues such as honesty, dependability, courage, generosity, altruism, forgiveness, humility, self-discipline, patience, and social relationships. Rasayana comprises the use of Ayurvedic medicines, diet, lifestyle, and self-discipline to achieve the optimum state of health. Rasayana Prayoga delays the aging process and prevents the manifestation of diseases. Rasayana drugs may achieve this purpose through various pharmacological activities such as antiaging, cognitive-enhancing, antioxidant, adaptogenic, nootropic, and immunomodulatory effects.[12] The present verse highlights the role of various spiritual or religious, or virtuous practices and the extraordinary effects of Rasayana drugs in preventing death.

Nakshatra Peedaa: Bruvate Bahavo Janaa (verse 6)

Ill effects (Arishta) of abnormal or bad astrological birth charts and abnormal position of starts/planets in astrological charts (Nakshtra Peeda) often manifest themselves at a specific time (Yatha Kaalam Vipachyate). Bad omens are followed by their fatal consequences (Arishta Paakam) in due course of time (Yatha Kaalam Vipachyate), as opined by many (Bahavo Janaah). The present verse denotes the fatal consequences due to the abnormal planetary positions in astrological birth charts.[5],[6] Astrology deals with the estimation of the influence of the planets or stars (Nakshatra Peeda) on human affairs. Astrologer guides for consuming and collecting medicinal herbs at suitable times to achieve maximum benefits. With the help of astrology, account of bad and good deeds during previous lives and in this life, their consequences of ill health (Arishta Paakam), etc., could be predicted.[13] For an individual’s family welfare, a physician, an astrologer, and a Hindu priest were consulted simultaneously in ancient India.[14] The 12 Zodiac signs, the 7 planets, and the 12 houses of heaven are considered while casting a horoscope.[15] Some research works suggest that there is an association between a predisposition to severe mental illness and astrological factors.[16] Implementing the principles of medical astrology in prognostication is a unique contribution of Maharshi Sushruta, and further retrospective or prospective cohort studies are required to authenticate these claims.

Asiddhimaapnuyaalloke: Kushalo Bhishak (verse 7)

The physician (Bhishak), who attempts to treat (Pratikurvan) incurable or poor prognostic or fatal conditions (Gataayusha), will definitely get reputational damage (Asiddhimaapnuyaat). Hence, the wise physician (Kushalo Bhishak) should be alert in identifying and avoiding (Yatnena Lakshayet) fatal conditions (Arishta).[5],[6] Similar verse is available in the Varna Swareeyam chapter of Indriya Sthana of Charaka Samhita and according to which treating incurable conditions leads to defamation, financial losses, social harm, reputational damage, and even legal punishments to the physician.[11]

Gandha Varna: Pakwa Lakshanam (verse 8)

The appearance of abnormality (Vaikrutam) in the specific natural characters (Swabhavata), with regard to the smell (Gandha), color (Varna), taste (Rasa), etc., of the wound (Vrana), prognosticates death (Pakwa Lakshanam) of the wounded (Vranina).[5],[6] Wounds having abnormal appearance (Rupa), smell/odor (Gandha), color, sounds (Shabda), and other characteristics such as abnormal wound texture, shape, size, etc., will indicate an imminent death (Arishta) of the wounded. According to Maharshi Sushruta, the examination of Vrana should incorporate the parameters based on the perception of Indriyas (sense organs). According to Dalhana, the word Adi in the present verse includes Shabda (sound) and Sparsha (touch). The word Vaikrutam denotes pathological features, whereas the word Swabhavata represents normal characteristics of wounds.[2] In the following verses (verses 9–21), the description of some abnormal wound odors, sounds, colors, etc., those are fatal are explained. Prognostication of wounds based on their odors, colors, appearance, etc., is a unique contribution of Maharshi Sushruta.

Katu Teekshnashcha: Bhumi Gandhaashcha Garhita (verses 9–12)

An ulcer (Vrana) emits a pungent (Katu), sharp (Teekshna), or raw meat-like or musty or fishy smell (Visra Gandha) and metallic or smells like iron under the respective influences of the deranged Vata, Pitta, Kapha (the three bodily humors) and Rakta (blood). Deranged Vata, Pitta, and Kapha together will produce an odor that is characterized by the distinctive features of each of them (a combination of Katu, Teekshna, and Visra Gandha). Deranged Vata & Pitta, Vata & Kapha, and Pitta & Kapha will emit odors similar to that of fried or parched grains (Laaja), linseed oil (Atasi), and sesamum oil (Tila Taila), respectively. All these odors, marked by a somewhat fishy or raw meat-like character (Visra Gandha), should be deemed the natural odors (Prakruta Gandha) of ulcers, and any other odors should be considered as contrary or fatal one (Vaikruta Gandha or Gandha Vaikrutam). An ulcer emitting an odor similar to that of wine (Madya Gandha) or agarwood (Aguru Gandha) or clarified-butter (Aajya Gandha) or Jasmine flower (Sumana) or lotus flower (Padma) or sandalwood (Chandana) or Champaka flower (Magnolia Champaka) or any celestial flower (Divya Gandha), should be regarded as the precursor of death (Mumurshaanaam). Odors are similar to that of a dog (Shva), horse (Vaaji), rat (Mushika), crow (Dhwaanksha), dry and putrid meat (Puti Vallura), bedbug (Matkuna), clay (Panka) and earth (Bhumi) should be considered fatal (Garhita) in an ulcer patient (Vranina).[5],[6]Chakrapani interpreted Prakruta Gandha as it has a relation with Vata. Matkunah is Ungasa (bugs) according to Chakrapani.[2]

Wound odor

Wound odor (Vrana Gandha) has a significant impact on a patient’s quality of life (Arishta?/Garhita?); however, the available information is scarce on it.[17] An offensive malodor (Vaikruta Gandha) is caused by anaerobic bacteria in various types of chronic wounds, such as ulcerated malignant tumors, infected and necrotic wounds (Garhita?). Devitalized tissue is a conducible environment for the growth of microbes. Biosurgical debridement that incorporates the use of maggots (Matkuna?) is effective in the treatment of both necrotic and infected wounds (Garhita Vrana?).[18],[19] Based on the causative organism, purulent discharge produces a strong odor (Puti Vallura Gandha), such as in venous stasis wounds.[20] Malodorous wounds (Vaikruta Gandha) are distressing and are associated with negative quality of life outcomes (Arishta or Garhita). Unpleasant or repulsive wound odors (Vaikruta Gandha) may generate feelings of disgust. Fungating wounds (Arishta?) are associated with malodor (Vaikruta Gandha).[21] Various questionnaires, evaluation scales, and objective instruments such as e-nose, identification of volatile organic compounds (VOCs), gas chromatography, etc., and odor-sensing devices could be used for the identification or for analysis or for measuring the intensity of various wound odors.[22]

An unpleasant odor (Vaikruta Gandha) is often found in chronic wounds (Arishta or Garhita Vrana?). Venous leg ulcers, foot ulcers of diabetes mellitus patients, infected and necrotic wounds, and ulcers due to vascular diseases are associated with wound malodor (Vaikruta Gandha). Necrotic tissues and bacteria produce the fetid odor (Vaikruta Gandha) in some wounds (Vrana). Various anaerobic and aerobic bacterial species are responsible for wound odor (Gandha). Cadaverine and putrescine produces a severe acrid smell (Shva or Dwaanksha or Mushika Gandha?). Unpleasant wound odors (Vaikruta Gandha?) are described as foul (Shva or Mushika or Dwaanksha?), putrid (Puti Vallura?), sweet (Madya or Aajya?), acrid, pungent (Teekshna?), and offensive (Visra?) by the clinicians and patients. Particular species of bacteria generate a specific type of odor (Gandha).[22]Matkuna denotes maggots and their manifestation represents a necrotic wound. Maggot infestation debrides wounds quickly, effectively, and without damaging viable tissues. Maharshi Bhela has described a condition that is similar to that of Myiasis in the Mumurshiyam chapter of Bhela Indriya Sthana.[23] The present verse denotes normal and abnormal wound odors and malodorous wounds that are associated with various fatal consequences.

Kunkuma Dhyaama: Taan Parivarjayet (verses 13–15)

If a Pitta predominant ulcer displays the colors (Varna) of saffron (stamens of Crocus sativus flower—Kunkuma) or slightly blackish (Dhyaama) or Callicarpa macrophylla (Shyaama or Priyangu) flower color or the fresh yellow latex color of Argemone Mexicana Linn (Kankushta) in the absence of (Na) either burning (Dahyante) or sucking (Chushyante) type of pain, such an ulcer denotes an imminent death and physician (Bhishak) should not attempt to treat those patients (Taan Parivarjaytet). Kapha predominant ulcer associated with itching (Kandumanta), hard or immotile (Sthira), white in color (Shweta), and unctuousness (Snigdha) with burning pain (Duyante Vaapi Dahyante) should also be considered as fatal (Taan Parivarjaytet). Vata predominant ulcer is characterized by a complete lack of pain (Swalpaam Api Na Rujam Kurvanti), having a blackish hue (Krishna) and a thin secretion or oozing (Tanu Sraava), invades or located at the vital parts of the body (Marma Taapina), should not be treated by the physician (Taan Parivarjaytet Bhishak). The present verse describes various wound colors and associated features, along with their fatal consequences.[5],[6]

Wound color

Healthy granulation tissue indicates healing of a wound, and it is pink in color, whereas granulation tissue that is unhealthy is characterized by dark red color (Kunkuma Varna?) and may indicate wound infection. Chronic wounds covered by white (Shweta) or yellow shiny fibrinous tissue (Kankushta Varna?) indicate avascularity (Arishta?). The wound bed is covered with necrotic tissue, cream (Shweta?) or yellow colored (Kankushta Varna?) slough, or eschar (black, dry, hard necrotic tissue—Shyaama? or Krishna Varna). Such tissue impedes healing (Arishta).[24] Wound slough is characterized by yellow (Kankushta Varna), gray (Shyaama or Dhyaama), and necrotic tissue (Krishna Varna), usually thin, wet, and stringy (Tanu Sraava). Eschar is characterized by black (Krishna Varna), brown (Shyaama or Dhyaama), and dry, necrotic tissue, usually thicker and hard (Sthira). Epithelial tissue of the wound is characterized by deep pink or pearly pink, or light purple (the flower color of Priyangu).[25] RYB (Red, Yellow & Black) classification is a tool to assess the tissue nature in a wound bed. The red color (Kunkuma Varna) of the wound denotes healthy granulation tissue and normal healing. Yellow color (Kankustha Varna) indicates a film of fibrin, whereas black color (Krishna Varna) indicates necrosis.[25]

Wound pain

Pain (such as Dahyante or Duyante or Chushyante or Ruja) or its alteration is usually associated with wound infection. Wound-related pain is a subjective experience, and it is negatively associated with the quality of life of patients.[26] The nature of pain (Dahyante or Duyante or Chushyante or Ruja) the patient is experiencing depends on the wound type (Vataja, Pittaja, and Kaphaja Vrana). Intermittent claudication or ischemic rest pain and aching or deep muscle pain are seen in the peripheral arterial occlusive disease. Primary hyperalgesia (Duyante Vaapi Dahyante?) is an increased sensitivity in the wound area, whereas Allodynia describes an intense pain response that is out of proportion to the stimulus (Duyante Vaapi Dahyante?). Pain perception may depend on either expectations or anticipation (Dahyante or Duyante or Chushyante or Ruja?) of a patient. Psychology plays an important role in the experience of pain sensations (Dahyante or Duyante or Chushyante or Ruja?).[27] Moderate to severe pain is associated with wound types, baseline pain, and anxiety.[28]

Patients are unable to feel pain (Swalpaam Api Na Rujam Kurvanti) due to the lack of sensation in neuropathic ulcerations. Neuropathic ulcers (diabetic) are associated with prolonged healing time, increased morbidity (Marma Taapina), and occasional mortality (hence Taan Parivarjaytet Bhishak). Diabetic foot ulcers are associated with the risk of amputation, various other complications (Marma Taapina), and a bad prognosis (Arishta).[29] The vegetative variant of Pyoderma gangrenosum is characterized by a superficial painless ulcer (Swalpaam Api Na Rujam Kurvanti) with undermined edges.[30] Venous leg ulcers (VLUs) are associated with chronic venous insufficiency, and pain is not the important clinical feature (Swalpaam Api Na Rujam Kurvanti) of these ulcers. VLUs can cause disability and serious complications (Marma Taapina).[31] Sensory neuropathy is characterized by loss of sensation in hands and feet (Swalpaam Api Na Rujam Kurvanti) and leads to ulceration (Vrana). The ulceration (Vrana) in leprosy is due to nerve damage and cutaneous anesthesia.[32] Painless ulcers (Swalpaam Api Na Rujam Kurvanti) can be seen in cutaneous leishmaniasis.[33] The ulcers (Vrana) of primary syphilis (syphilitic chancre) are usually painless (Swalpaam Api Na Rujam Kurvanti). Anogenital ulcers (Vrana) may be painful (Duyante Vaapi Dahyante?) or painless (Swalpaam Api Na Rujam Kurvanti).[34] Pulmonary tuberculosis patients may present with painless (Swalpaam Api Na Rujam Kurvanti) ulcers (Vrana) on the tongue.[35]

Both Dalhana and Chakrapani have supported the view of Maharshi Sushruta regarding the mandatory knowledge of Prakruta Awastha (normal characteristics of wound) and its comparison with Vaikrta Awastha (abnormal characteristics of wounds) as an indicator of prognosis. The word Dhyaama is described as Ishat Krishna (slightly blackish) by Dalhana, whereas Chakrapani has described it as Gandhatruna Varna (dark brick color). Wounds having clinical features that are incongruent to the Doshic predominance, i.e., Kaphaja Vrana with the burning type of pain (Dahyante), painless (Swalpaam Api Na Rujam Kurvanti), Vataja Vrana, etc. should be considered fatal. Kashaya (astringent), Katu (pungent), and Madhura Rasas (sweet taste) should be considered normal for Vataja, Pittaja, and Kaphaja Vranas’, respectively. Vrana Rasa (predominant taste of the wound) could be assessed indirectly by observing the insect-attracting (Pipilikadi Upasarpana) or insect-repelling (Pipilikadi Apasarpana) properties of the wounds according to Dalhana.[2]

Kshwedanti Ghurghurayante: Atyartha Vedana (verse 16)

Wounds (Vrana) that make rattling sounds (Kshwedanti) or crepitations (Ghurghurayante), blackish in color (Jwalanteeva), restricted to the muscles and skin (Twak Maamsastha), produce gas (Pawanam) and emit (Visrujati) sounds (Sa Shabdam) should be discarded (not to be treated) (Arishta). The wounds (Vrana) that are not situated on vital spots (Marmasu Asambhuta) and are associated with extreme pain (Atyartha Vedana) should also be discarded.[5],[6] The present verse is similar to the condition of Gas gangrene. Gas gangrene is an infection that spreads quickly and is associated with the collection of gas (Pawanam) in the subcutaneous tissue and muscles (Twak Maamsastha). It is caused by  Clostridium perfringens Scientific Name Search r Clostridium welchii. The word Kshwedanti represents sounds such as Khat Khat or a hissing sound. Ghurghurayante represents whistling sounds or panting or gasping-like sounds. Crepitations or crackle sounds are produced (Visrujanti) from the wounds due to the presence of gas (Pawanam). Jwalanteeva denotes the burnt appearance or blackish color of wounds due to necrosis of the muscles (Maamsastha) caused by Clostridial infection. The muscles (Maamsastha) in gas gangrene are blackish (Jwalanteeva) due to the action of sulfurated hydrogen on iron that comes from broken-down muscle hemoglobin. Gas gangrene carries a considerable mortality rate (Arishta).[36] Severe painful ulcers (Atyartha Vedana) though they are not situated on vital parts of the body (Marmasu Asambhuta), are considered fatal (Arishta).[5],[6]

Dahyante Cha Antaratyartham: Antashcha Sheetala (verse 17)

Excessive (Atyartham) burning type of pain (Dahyate) or temperature (Dahyate) in wound (Antar) or wound bed (Antar) associated with cold (Sheetala) periwound (Bahi) or general body temperature (Bahi); low wound or wound bed temperature (Antashcha Sheetala) with excessive (Atyartham) periwound (Bahi) or general body temperature (Dahyante) denote an imminent death (Arishta).[5],[6] The word Bahi denotes either periwound or general body, whereas Antar denotes either wound bed or wound. Wound temperature and its prognostic significance have been described in this verse by Maharshi Sushruta.[5],[6]

Wound, wound bed, and periwound temperature

Wound bed (Antar) temperature (Dahyate) comes in between the range of 30.2–33.0°C. Wound bed temperature less than (Antashcha Sheetala) core body temperature (Dahyate Bahi) indicates delayed healing (Arishta).[37] The local temperature of wounds (Dahyate Antar) is associated with infection (Arishta). A wound temperature of less than 33°C (Antashcha Sheetala) indicates hindrances in wound repair (Arishta). Wound temperature higher than 37°C (Dahyate Antar Atyartham) indicates congestion and inflammation. A sudden rise in wound temperature (Dahyate Antar Atyartham) denotes a Gram-positive bacterial infection (Arishta). The difference between the local wound temperature and general body temperature (Dahyate Antar Atyartham Bahi Sheetala) is due to the “lag” required for bacteria to break the boundary and to reach the blood.[38] A lower (Sheetala) periwound (Bahi) temperature is indicative of latent necrosis (Arishta). Higher wound bed temperature (Dahyate Antar Atyartham) denotes delayed wound healing (Arishta). Temperature fluctuations of the wound bed (Antar), periwound skin (Bahi), and normal skin (Bahi) are common during wound healing. Wound bed temperature (Antar) or periwound (Bahi) skin temperature is higher (Atyartham) in infected wounds (Arishta).[39] Incongruence or discordance between wound/wound bed temperature and periwound/core body temperature are considered fatal, according to Maharshi Sushruta.

Shakti Dhwaja Rathaa: Anavachurnita (verses 18 and 19)

An ulcer (Vrana) should be regarded as fatal (Arishta) that is shaped (Aakriti) like (Avabhaaseran), a sword (Shakti), a spear (Kunta), or like a banner (Dhwaja), chariot (Ratha), horse (Vaji), or an elephant (Vaarana), or like a cow (Go), an ox (Vrisha), a temple or a palace (Praasaada). An ulcer (Vrana) that appears (Bhaanti) to have been dusted over (Avakeerna) with a sort of pulverized crust or powder (Churna) though it’s not (Anavachurnita) should be considered fatal (Arishta).[5],[6]Maharshi Sushruta has explained the prognostic significance based on the shape of an ulcer.

Wound shape

Wound healing trajectory can be different for various wound shapes such as elongated cut, round, rectangular and complex shapes (Vaji, Vaarana, Go, Vrisha, Praasaada, Kunta, etc.). The wound healing time is dependent on the width of the wound (Vrana). The shape of the wound and wound perimeter determines wound healing dynamics. The shape of the wound also affects the epithelialization rate.[40] Wounds vary greatly in size and shape (Vaji, Vaarana, Go, Vrisha, Praasaada, Kunta, etc.). To quantify the shape of the wounds, a ratio of width to length (W/L) is useful. A W/L ratio of 1 indicates circular wounds, and W/L decreases as the wound becomes more oblong.[41] Various available wound measurement methods need to be reliable, accurate, and feasible to implement in evaluating the wound healing processes.[42] Wound shapes such as Vaji, Vaarana, Go, Vrisha, Praasaada, Kunta, etc., are big in size and complex in shape; hence they may be associated with poor wound healing dynamics, as mentioned in the present verse by Maharshi Sushurta.

Granulation tissue

The word Churna Avakeerna (wound that is covered with a powder or dust-like substance) may denote the granulation tissue of the wound. Granulation tissue (Churna Avakeerna) is a crucial component in the wound (Vrana) healing process, and it can be seen in chronic wounds (Arishta?). Healthy granulation tissue is painless, appears pink to red, soft, moist, and appears as bumpy (Churna Avakeerna Iva). Unhealthy granulation tissue is painful, darker red in color, easily bleeds, and is covered by yellow or shiny white fibrous avascular tissue (Churna Avakeerna Iva Bhaanti), impeding healing (Arishta). Excess and unhealthy granulation tissue (Churna Avakeerna Iva Bhaanti) is seen in chronic wounds. Necrosis, poor perfusion, nutrition, metabolism, angiogenesis, and underlying conditions are the sources of chronic wounds (Arishta) and persistent granulation tissue (Churna Avakeerna Iva Bhaanti Cha Anavachurnita). Causes of hypergranulation (excess granulation tissue) (Churna Avakeerna) are wound infection, foreign body, excess inflammation, and physical irritation.[43] Hence, Churna Avakeerna Iva Bhaanti Cha Anavachurnita may denote either the presence of unhealthy granulation tissue or the absence of healthy granulation tissue; both conditions will impede wound healing.

Prana Maamsa Kshaya: Aatmano Yasha (verses 20 and 21)

A wise physician (Praagna), with any regard (Samrakshan) to his own (Aatmano) reputation (Yasha), should abandon a patient (Varjayet) who has been suffering from sarcopenia or disease (wound)-related muscle loss (Maamsa Kshaya) and strength (Prana Kshaya), dyspnea (Shwasa), cough (Kasa), and aversion to food or anorexia (Arochaka). An ulcer (Vrana) that is situated on vital parts of the body (Marmasu) secretes a copious quantity (Pravruddha) of pus (Puya) and blood (Rudhira), and refuses to be healed (Na Siddhyanti) even after providing authentic (Samyagaarabdha) treatment (Kriyabhi), should be considered as fatal.[5],[6]Maharshi Sushruta has explained the prognostic significance based on the wound's site, complications of the wound, and poor prognosis of chronic and nonhealing ulcers in the present verses.

Wound site

The ultimate time course and outcome (Arishta?) of wound are determined by the wound's nature, location (Marmasu?), depth, size, and type.[44] Wound site (Marmasu?) may aid diagnosis; diabetic foot ulcers occur on the plantar and lateral aspect of toes and foot; venous ulcers on the gaiter area of the leg; pressure ulcers on greater trochanter, sacrum, and heel; arterial ulcers on the dorsum of the foot; basal and squamous cell carcinoma on sun-exposed areas. Non-healing ulcers (Vrana Na Siddhyanti) may occur in unusual sites (Marmasu?) sometimes, and they should prompt consideration of malignancy (Arishta).[24]Maharshi Sushruta might have noticed fatal consequences of ulcers that are located on vital parts of the body.

Wound complications and nonhealing ulcers

Systemic diseases interfere with the wound-healing process. Cachexia (Maamsa Kshaya) is a manifestation of chronic systemic diseases such as neoplasms (Na Siddhyati?), chronic heart failure, and chronic obstructive pulmonary disease (Kasa & Shwasa). Cachexia is associated with inflammation, reduced appetite (Arochaka), and skeletal muscle wasting (Maamsa Kshaya). Anorexia (Arochaka) in cachectic states (Maamsa Kshaya) is frequently associated with malnutrition (causes Prana Kshaya?). Malnutrition causes impaired healing (Vrana Na Siddhyati).[45] Chronic, nonhealing ulcers (Vrana Na Siddhyati) cause severe distress and discomfort to the patient, and also they drain the medical system by consuming an enormous amount of resources (hence Taan Varjayet Praagna).[44] Nonhealing wounds (Vrana Na Siddhyati) pose a serious financial and social cost to both the health system and to patients (hence Taan Varjayet Praagna). Malignancy (Arishta?) is one of the important etiological factors of nonhealing wounds (Vrana Na Siddhyati).[46] Pus (Puya) and contact bleeding (Rudhira) are predictors of wound infection.[47]

Even with the implementation of best practices (Samyagaarabdha), some treatment options (Kriyabhi) may not serve the best interests of patients (Vrana Na Siddhyati). Non-healing wounds (Vrana Na Siddhyati) may be due to inadequate vasculature, immunocompromised status, or critically-ill status such as life-threatening conditions (Prana Maamsa Kshaya, Kasa, Shwasa & Arochaka). Among patients who are dying (Arishta), nonhealing or palliative wounds (Vrana Na Siddhyati) may pose complications.[48] The wise physician (Praagna), to protect (Samrakshan) and his reputation (Yasha), should avoid treating (Varjayet) the patients (Taan) who have been suffering from nonhealing ulcers (Vrana Na Siddhyati). Treating chronic, nonhealing ulcers (Vrana Na Siddhyati) may create false hopes in patients' minds’ and becomes an excessive burden on limited healthcare resources (hence Taan Varjayet Praagna). It has been found that intensive care unit patients may die even when they receive the best treatment (Samyagaarabdha Kriyabhi Na Siddhyati).[49]Maharshi Sushruta has clearly mentioned that surgeons should avoid treating nonhealing ulcers associated with the above-said complications.

The initial verses of VVV chapter have dealt with the definition, classification, and characteristic features of AL (verses 1–7). Various normal and abnormal wound odors (Vrana Gandha) explained in VVV chapter can be assessed or analyzed by using gas chromatography-mass spectrometry. Various VOCs emitted by the wounded person can be analyzed by using either gas chromatography-ion trap mass spectrometry or e-nose. RYB classification tool could be incorporated to assess or analyze or standardize Vrana Varna (wound color). Various wound microenvironment indices, such as glucose, local pH, uric acid, lactic acid, etc., could be incorporated into standardizing Vrana Rasa. Wound, wound bed, and periwound temperatures can be measured and used for understanding Vrana Sparsha (touch-related indices of wounds). Smartphones and digital wound measurements, such as digital planimetry, etc., could be used to assess or analyze or standardize Vrana Aakriti (shape and size of the wound), Sthana (location of the wound), etc. Most of the conditions described in VVV chapter denote various infectious, ischemic, chronic, nonhealing ulcers associated with complications and underlying systemic diseases.

  Conclusion Top

Prognostic aspects of the wounds have been dealt with within the 21 verses of the Vipareeta Vrana Vijnaaneeyam chapter of SS Sutra Sthana. The definition, classification, and characteristic features of AL are explained in the initial verses of the chapter. Prognostic assessment of wounds based on various parameters such as wound odor, color, pain, temperature, shape, size, location, granulation tissue, associated complications, underlying systemic diseases, etc., are explained in this chapter. It seems that Maharshi Sushruta had developed a wound microenvironment monitoring system by incorporating various monitoring indicators such as wound odor, color, pain, etc. Further development in this area by including these entire wound parameters will play an important role in the prognostic assessment of wounds and also leads to the development of a novel Ayurvedic wound management model.

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