Dvivraniya Chikitsa acc to Charaka Samhita w.s.r. wounds

Vol.01, Issue-06, December 2024

Author: Dr. Manish Singh Tomar, MD, PhD Ayurveda

Abstract

Dvivraniya Chikitsa, or the treatment of two types of wounds, is a significant topic in Ayurveda, extensively detailed in the classical text Charaka Samhita. This article explores the Ayurvedic understanding of wounds (Vranas), their classification into Nija (endogenous) and Agantuja (exogenous) types, clinical features, prognosis, and therapeutic approaches as outlined by Acharya Charaka. By correlating these ancient principles with modern wound management and healing processes, we aim to provide a comprehensive overview that bridges traditional wisdom with contemporary medical science. This integrative approach underscores the relevance of Ayurvedic concepts in modern healthcare, offering holistic strategies for effective wound care.

Introduction

Wound management is a critical aspect of healthcare, given the potential for complications like infections, delayed healing, and chronic wounds. In modern medicine, wound care involves understanding the types of wounds, the healing process, and appropriate interventions to promote optimal recovery.

Ayurveda, the ancient Indian system of medicine, offers a profound understanding of wound healing under the term Vrana Chikitsa. The Charaka Samhita, one of the foundational texts of Ayurveda, dedicates considerable attention to this topic, particularly in the chapter on Dvivraniya Chikitsa (treatment of two types of wounds). Acharya Charaka classifies wounds into two main categories—Nija Vrana (endogenous wounds) and Agantuja Vrana (exogenous wounds), providing detailed descriptions of their etiology, pathogenesis, and management.

This article delves into Dvivraniya Chikitsa as presented by Acharya Charaka, examining the Ayurvedic principles of wound classification, assessment, and treatment. By correlating these insights with modern medical knowledge on wound care, we aim to highlight the relevance and potential applications of Ayurvedic practices in contemporary healthcare.

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Understanding Vrana (Wounds) in Ayurveda

Classification of Wounds

Acharya Charaka classifies wounds into two primary types:

1. Nija Vrana (Endogenous Wounds):
   • Originating from internal factors, particularly the imbalance of the three Doshas—Vata, Pitta, and Kapha.
   • These wounds are caused by inherent bodily dysfunctions.
2. Agantuja Vrana (Exogenous Wounds):
   • Resulting from external factors such as trauma, burns, bites, and injuries caused by weapons or accidents.
   • These wounds are inflicted upon the body from outside sources.

Sanskrit References:

• “Nijaḥ śarīradōṣōttha āganturbāhyahētujaḥ.” (Verse 6)
• “Vadhabandhaprapatanād-daṁṣṭrād-anta-nakhakṣatāt, āgantavo vraṇās-tadvat viṣa-sparśāgni-śastra-jāḥ.” (Verses 7)

Etiology of Wounds

Nija Vrana (Endogenous Wounds)

• Vataja Vrana: Caused by the aggravation of Vata Dosha.
• Pittaja Vrana: Due to the aggravation of Pitta Dosha.
• Kaphaja Vrana: Resulting from the aggravation of Kapha Dosha.

Sanskrit Reference:

• “Yathāsvair hētubhir duṣṭā vātapittakaphā nr̥ṇām, bahirmārgaṁ samāśritya janayanti nijān vraṇān.” (Verse 10)

Agantuja Vrana (Exogenous Wounds)

• Caused by external injuries such as:
  • Trauma: Blunt force leading to contusions or lacerations.
  • Burns: From fire, chemicals, or radiation.
  • Bites and Stings: From animals, insects, or venomous creatures.
  • Surgical Incisions: Wounds resulting from surgical procedures.

Characteristics of Dosha-specific Wounds

Vataja Vrana (Vata Predominant Wounds)

• Symptoms:
  • Dryness and stiffness.
  • Severe pain with a pricking or throbbing sensation.
  • Wound color: Dark or bluish-black.
  • Minimal discharge.

Sanskrit Reference:

• “Stabdhaḥ kaṭhina-saṁsparśo manda-srāvō’ti-tīvraruk, tudyatē sphurati śyāvō vraṇō māruta-sambhavaḥ.” (Verse 11)

Pittaja Vrana (Pitta Predominant Wounds)

• Symptoms:
  • Inflammation with burning sensation.
  • Pus formation with foul odor.
  • Wound color: Reddish or yellowish.
  • Excessive discharge.

Sanskrit Reference:

• “Tr̥ṣṇā-mōha-jvara-svē(klē)da-dāha-duṣṭyavadāraṇaiḥ, vraṇaṁ pitta-kr̥taṁ vidyād gandhaiḥ srāvaiśca pūtikaiḥ.” (Verse 13)

Kaphaja Vrana (Kapha Predominant Wounds)

• Symptoms:
  • Swelling with heaviness.
  • Wound is cold to touch and pale.
  • Excessive exudation, thick and sticky discharge.
  • Delayed healing.

Sanskrit Reference:

• “Bahupicchō guruḥ snigdhaḥ stimitō mandavēdanaḥ, pāṇḍu-varṇō’lpa-saṅklēdaś cirakārī kapha-vraṇaḥ.” (Verse 15)

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Assessment and Classification of Wounds

Twenty Types of Wounds

Acharya Charaka further classifies wounds into twenty types based on various characteristics:

1. Kritya: Incised wound.
2. Utkrita: Excised wound.
3. Dushta: Infected wound.
4. Adushta: Clean wound.
5. Marma Sthita: Located over vital points.
6. Non-Marma Sthita: Not involving vital points.
7. Samvrta: Closed wound.
8. Daruna: Severe wound.
9. Sravi: Discharging wound.
10. Savisha: Poisonous wound.
11. Vishama Sthita: Irregular wound.
12. Utsangin: Elevated wound.
13. Utsanna: Depressed wound.
14. Others: Based on combinations of these features.

Sanskrit Reference:

• “Yau vraṇau pūrvamuddiṣṭau nijaś cāgantureva ca.” (Verse 5)
• “Iti nānātvabhēdēna niruktā viṁśatir vraṇāḥ.” (Verse 21)

Three Methods of Examination (Pariksha)

1. Darshana (Inspection): Visual examination of the wound.
2. Sparshana (Palpation): Assessing the wound through touch.
3. Prashna (Inquiry): Gathering information from the patient.

Sanskrit Reference:

• “Darśana-praśna-saṁsparśaiḥ parīkṣā trividhā smr̥tā.” (Verse 22)

Assessment Parameters

• Color of the Wound: Indicative of Dosha involvement.
• Discharge: Quantity, quality, color, and smell.
• Depth and Location: Superficial or deep, involving vital structures.
• Pain and Sensation: Type and intensity of pain.

Prognosis

• Sukha Sadhya (Easily Curable):
  • Wound in healthy individuals.
  • Located in non-vital areas.
  • Clean with minimal contamination.
• Kricchra Sadhya (Difficult to Cure):
  • Wounds with significant Dosha involvement.
  • Located over vital points or joints.
  • Associated with complications.
• Asadhya (Incurable):
  • Wounds with extensive tissue damage.
  • Accompanied by severe complications.
  • In individuals with poor vitality.

Sanskrit References:

• “Tvaṅ-māṁsajaḥ sukhē dēśē taruṇasyānupadravaḥ, dhīmatō’bhinavaḥ kālē sukha-sādhyaḥ smr̥tō vraṇaḥ.” (Verse 36)
• “Sarvair vihīnō vijñēyaḥ tv-asādhyo nirupakramaḥ.” (Verse 37)

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Ayurvedic Management of Wounds

General Principles

1. Dosha Assessment: Identify the predominant Dosha involved.
2. Wound Cleaning: Early cleansing to prevent infection.
3. Promote Healing: Use of herbs and formulations that enhance tissue regeneration.
4. Prevent Complications: Address symptoms and prevent progression.

Sanskrit Reference:

• “Vraṇānām āditaḥ kāryaṁ yathāsannaṁ viśōdhanam.” (Verse 38)

Specific Treatment Modalities

Acharya Charaka outlines 36 treatment measures for wound management, which can be categorized as follows:

1. Shodhana (Cleansing)

• Use of herbal decoctions and antiseptic solutions to clean the wound.
• Herbs like Triphala, Neem, and Turmeric are used for their antimicrobial properties.

Sanskrit Reference:

• “Triphalā khadiraḥ dārvī nyagrōdhādir balā kuśaḥ, nimba-kōlaka-patrāṇi kaṣāyāḥ śōdhanā matāḥ.” (Verse 84)

2. Ropana (Healing and Regeneration)

• Application of herbs that promote granulation and epithelialization.
• Use of medicated oils and ghee infused with healing herbs.

Sanskrit References:

• “Candanaṁ padma-kiñjalkaṁ dārvī-tvaṅ-nīlam-utpalam, mēdē mūrvā samaṅgā ca yaṣṭyāhvaṁ vraṇa-rōpaṇam.” (Verse 88)
• “Prapauṇḍarīkaṁ jīvantī gōjihvā dhātakī balā, rōpaṇaṁ satilaṁ dadyāt pralēpaṁ sa-ghr̥taṁ vraṇē.” (Verse 89)

3. Shastra Karma (Surgical Procedures)

• Types of Surgical Interventions:
  • Chedana (Excision): Removal of dead or infected tissue.
  • Bhedana (Incision): To drain abscesses or relieve pressure.
  • Lekhana (Scraping): For cleaning ulcers.
  • Vedhana (Puncturing): To release accumulated fluids.
  • Eshana (Probing): To explore the depth and pathways of wounds.

Sanskrit Reference:

• “Pāṭanaṁ vyadhanaṁ caiva chēdanaṁ lēpanaṁ tathā, pracchanaṁ sīvanaṁ caiva ṣaḍvidhaṁ śastra-karma tat.” (Verse 55)

4. Kshara Karma (Application of Alkaline Substances)

• Use of herbal alkalis to debride necrotic tissue and promote healing.
• Appropriate for chronic, non-healing wounds.

5. Agni Karma (Cauterization)

• Thermal cauterization to stop bleeding, remove unhealthy tissue, and prevent infection.
• Used cautiously, considering the patient’s condition.

Sanskrit Reference:

• “Rōga-dōṣa-balāpēkṣī mātrā-kālāgni-kōvidaḥ, śastra-karma-agnikr̥tyēṣu kṣāramapyavacārayēt.” (Verse 107)

6. Bandhana (Bandaging)

• Proper dressing techniques to protect the wound and promote healing.
• Use of clean, medicated cloths or materials.

Sanskrit Reference:

• “Bandhaś ca dvividhaḥ śastō vraṇānāṁ savya-dakṣiṇaḥ.” (Verse 96)

7. Aushadha (Medications)

• Internal medications to balance Doshas and support healing.
• Herbal formulations for anti-inflammatory and immunomodulatory effects.

8. Dhupana (Fumigation)

• Use of medicated smoke to disinfect wounds.
• Herbs like Guggulu, Neem, and Turmeric are used.

Sanskrit Reference:

• “Kaṭhinatvaṁ vraṇā yānti gandhaiḥ sāraiś ca dhūpitāḥ.” (Verse 108)

9. Upanaha (Poultices)

• Application of warm, medicated poultices to alleviate pain and swelling.
• Ingredients include Sesame seeds, Flax seeds, and Herbal pastes.

Sanskrit Reference:

• “Upanāhaś ca kartavyaḥ sa-tilō mudga-pāyasaḥ, rug-dāhayōḥ praśamanō vraṇēṣv eṣa vidhir hitaḥ.” (Verse 79)

10. Diet and Lifestyle Management

• Consumption of appropriate foods to support healing.
• Avoidance of activities that may aggravate the wound or Doshas.

Sanskrit References:

• “Varjayēt anna-pānāni vraṇī maithunam eva ca.” (Verse 97)
• “Annapānaṁ vraṇa-hitaṁ hitaṁ cāsvapanaṁ divā.” (Verse 98)

Management Based on Dosha

Vataja Vrana

• Therapies:
  • Use of Snigdha (unctuous) and Ushna (warm) treatments.
  • Application of warm oil massages and poultices.
  • Swedana (Sudation Therapy) to alleviate stiffness.
• Medications:
  • Medicated oils like Dashamoola Taila.
  • Internal use of herbs like Ashwagandha and Bala.

Sanskrit Reference:

• “Sampūraṇaiḥ snēha-pānaiḥ snigdhaiḥ svēdōpanāhanaiḥ, pradēhaiḥ pariṣēkaiś ca vāta-vraṇam upācarēt.” (Verse 12)

Pittaja Vrana

• Therapies:
  • Cooling and soothing treatments.
  • Application of cold compresses and pastes.
• Medications:
  • Use of Ghee infused with Madhura (sweet) and Tikta (bitter) herbs.
  • Herbs like Neem, Sandalwood, and Guduchi.

Sanskrit Reference:

• “Śītalair madhuraiḥ tiktaiḥ pradēha-pariṣēcanaiḥ, sarpiṣ-pānaiḥ virēkaiś ca paittikaṁ śamayēd vraṇam.” (Verse 14)

Kaphaja Vrana

• Therapies:
  • Ruksha (Dry) and Ushna (Hot) treatments.
  • Lepana (Application of dry powders) to absorb excess moisture.
• Medications:
  • Herbs with Katu (pungent) and Tikta (bitter) tastes.
  • Use of Haridra (Turmeric) and Trikatu (combination of Ginger, Black Pepper, and Long Pepper).

Sanskrit Reference:

• “Kaṣāya-kaṭu-rūkṣōṣṇaiḥ pradēha-pariṣēcanaiḥ, kapha-vraṇaṁ praśamayēt tathā laṅghana-pācanaiḥ.” (Verse 16)

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Modern Medical Correlation

Types of Wounds

1. Incised Wounds: Caused by sharp objects, clean edges.
2. Lacerations: Tear-like wounds, irregular edges.
3. Abrasion: Superficial wounds caused by friction.
4. Puncture Wounds: Deep, narrow wounds from pointed objects.
5. Avulsion: Tissue is torn away from the body.
6. Burns: Caused by heat, chemicals, electricity, or radiation.

Wound Healing Process

1. Hemostasis Phase:
   • Immediate response to injury.
   • Blood clot formation to stop bleeding.
2. Inflammatory Phase:
   • Removal of debris and pathogens by immune cells.
   • Signs include redness, heat, swelling, and pain.
3. Proliferative Phase:
   • Granulation tissue formation.
   • Angiogenesis (new blood vessel formation).
   • Re-epithelialization.
4. Maturation Phase:
   • Collagen remodeling.
   • Scar tissue formation.

Modern Wound Management Principles

1. Wound Assessment:
   • Evaluate size, depth, location, and contamination.
   • Identify underlying conditions affecting healing.
2. Wound Cleaning:
   • Use of sterile saline or antiseptics.
   • Debridement to remove necrotic tissue.
3. Infection Control:
   • Application of antibiotics if necessary.
   • Use of antimicrobial dressings.
4. Moist Wound Healing:
   • Maintaining optimal moisture levels to promote healing.
   • Use of occlusive or semi-occlusive dressings.
5. Nutrition and Supportive Care:
   • Adequate protein and nutrient intake.
   • Control of blood glucose levels in diabetic patients.
6. Advanced Therapies:
   • Negative Pressure Wound Therapy.
   • Growth Factors and Skin Grafts.
   • Hyperbaric Oxygen Therapy.

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Discussion

Correlation of Ayurvedic and Modern Concepts

1. Wound Classification:
   • Ayurveda’s classification into endogenous and exogenous wounds parallels modern understanding of wounds caused by internal factors (e.g., vascular ulcers) and external trauma.
2. Dosha Involvement and Wound Characteristics:
   • The symptoms described for Vataja, Pittaja, and Kaphaja wounds correspond to clinical features of wounds with varying levels of inflammation, exudate, and healing tendencies.
3. Herbal Antimicrobials and Anti-inflammatory Agents:
   • Ayurvedic herbs like Neem, Turmeric, and Triphala have documented antimicrobial and anti-inflammatory properties, supporting their use in wound care.
4. Surgical Interventions:
   • Procedures like debridement, incision, and drainage are common to both Ayurveda and modern surgery.
5. Moisture Balance:
   • Ayurvedic practices of applying medicated oils and ghee can maintain moisture and provide a protective barrier, similar to modern moist wound healing techniques.
6. Nutritional Support:
   • Emphasis on diet and nourishment in Ayurveda aligns with the modern understanding of nutrition’s role in wound healing.

Potential Integration

• Use of Herbal Preparations:
  • Incorporating Ayurvedic formulations as adjunct therapies for wound healing.
• Holistic Approach:
  • Addressing the patient’s overall health, including mental well-being, to promote healing.
• Preventive Measures:
  • Educating patients on lifestyle factors that affect wound healing, such as diet, hygiene, and activity levels.

Challenges and Considerations

• Scientific Validation:
  • Need for clinical studies to establish efficacy and safety of Ayurvedic treatments.
• Standardization of Herbal Medicines:
  • Ensuring consistency in preparation and dosage.
• Integration with Conventional Care:
  • Coordinated approach between Ayurvedic practitioners and modern healthcare providers.

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Conclusion

Dvivraniya Chikitsa, as detailed by Acharya Charaka, offers a comprehensive framework for the management of wounds. The Ayurvedic approach emphasizes individualized treatment based on Dosha assessment, the use of natural remedies, and holistic care to promote optimal healing.

By correlating these ancient principles with modern wound management practices, we can appreciate the depth of Ayurvedic knowledge and its potential contributions to contemporary healthcare. Integrating Ayurvedic concepts with modern medicine may enhance wound care strategies, improve patient outcomes, and promote overall well-being.

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References

1. Charaka Samhita, Chikitsa Sthana, Chapter 25: Dvivraniya Chikitsa.
2. Sharma, P. V. (1981). Charaka Samhita: Text with English Translation. Chaukhambha Orientalia.
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6. Sen, C. K., et al. (2009). Human skin wounds: A major and snowballing threat to public health and the economy. Wound Repair and Regeneration, 17(6), 763-771.
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8. World Health Organization (WHO). (2018). Guidelines on Wound Care in the Management of Skin Conditions.
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10. Tiwari, S., & Pratyush, D. D. (2012). Microbiological and clinical characteristics of diabetic foot infections in northern India. Journal of Infection in Developing Countries, 6(4), 329-332.