A Manifold Approach to Assuage the Management of Vishaja-Vrana - A Case Study

Introduction

The Vrana which are produced by different types of Visha such as Sthavara Visha, Jangama Visha and Kritima Visha are known as Vishaja Vrana. Vishaja Vrana has become a global burden in present era, produced by injury with poisonous substances or fang, teeth, nail, assault as well as due to poisonous contact and weapon. Acharya Sushruta elaborately described various types of Vrana and its management in Sushruta Samhitha¹ and also Vishaja Vrana has been exclusively mentioned in Kalpasthana.² Acharya Charaka discusses a similar approach to treating Vishas³ and Vrana⁴ in the Chikitsasthana, while Acharya Vagbhata contributed to the Uttarasthana⁵ with related concepts. Acharya Sushruta has voiced about Shasti Upakramas for the management of Vrana and the same can also be employed for Vishaja Vrana. ¹ Wound healing is a natural procedure, but in Vishaja Vrana it often remains in the inflammatory stage for prolonged duration because of exotoxins and bacterial colonization resulting in delayed healing. Complications of non-healing wound are vast and patients are at high risk for septicemia, toxic shock syndrome and amputations as well. So for the early and uncomplicated healing of Vrana, diagnosis and proper management is essential.

Patient Information

A 54-year-old married male presented with dog bite on the left lower leg 10 days back for which he consulted nearby hospital. He was suggested three doses of antirabies vaccination, antibiotics, anti-inflammatory drugs, and analgesics along with daily dressing (Patient couldn’t recall the medications he had taken). There was minimal improvement, and the wound became infected, causing severe pain. Consequently, he sought our hospital's assistance for further evaluation and management. There was no past surgical, medical or family history and all the family members were said to be healthy. No history of abnormal bowel, insomnia, appetite loss, abnormal bladder, and allergy were mentioned by the patient.

The vitals of the patients were: Blood pressure- 120/90 mmHg; Pulse- 72 bpm; Temp- 97o F; RR- 20 bpm; SpO2- 98%; Weight- 55 kgs; Height- 149 cm; BMI- 22.7 kg/m² . General examination revealed a moderate built, normal gait with absence of pallor, icterus, clubbing, cyanosis and lymphadenopathy. Systemic examination revealed normal CVS, RS, abdomen and CNS and the patient was conscious, well oriented to time, place and person. Clinical Findings, timeline of the events and investigations are presented in Table 1 and 2.

Therapeutic Interventions

Bahya Chikitsa

In the treatment process, wound debridement was performed initially, followed by daily dressing, which involved Vrana Prakshalana using Triphala Kashaya. Subsequently, the wound was dressed with a combination of Gomutra and Tankana Bhasma.

Additionally, two sessions of Jalaukavacharana, a leech therapy, were conducted in close proximity to the wound site. One session took place after Shuddha Vrana Lakshana, and following this, wound dressing was carried out using Jatyadi Thaila.

Abhyanthara Chikitsa

Patient was advised following medications for one month.

• Manjishtadi Kashaya 10 -0 -10 mL B/F with 20 mL luke warm water

• Tab. Triphala Guggulu 2-0-2 A/F

• Tab. Bilwadi Gutika 2-0-2 A/F 

Follow up and outcomes

• Anterior aspect (Figure 1- Day 0, Day 30, Day 50 and Day 60- Healed ulcer)

• Posterior aspect (Figure 2 - Day 0, Day 25, and Day 45- Healed ulcer)

Discussion

Although healing is a natural process, it faces inhibition from various factors making Vishaja Vrana a clinical challenge with room for improvement. Therefore, before commencing treatment, it is crucial to assess factors such as toxicity, Dosha predominance, Dushya involvement, Vrana location and size, and the treatability (Sadhyaasadhyata) of the wound. Achieving complete wound healing primarily involves eliminating Visha and its associated complications. Vrana Ropana, hinges on mitigating inflammation 'Shotha' as a key clinical aspect. While inflammation plays a vital role in early-stage wound healing, its persistence can impede the overall healing process.

Triphala Kashaya Prakshalana serves a dual role in Vrana cases, acting as both Shodhana and Ropana. This is due to its rich content of active compounds, including gallic acid, chebulinic acid, ellagic acid, flavonoids, tannins, and various polyphenols such as Aringin, Quercetin, Homoorientin, Isorhamnetin, Hypaconitine, and Acaciin, which contribute to its potent immunostimulatory and immunomodulation properties.⁶

The use of 5% Tankana Bhasma in Gomutra Arka accelerates slough removal with targeted precision, enhancing the overall recovery rate. Tankana, a component of the Kshara Traya, has a long history of use in Ayurveda, demonstrating versatility in treating various conditions such as Vrana, Shvasa and more.⁷

Jalukavacharana yielded remarkable results in ulcer healing. The leech's saliva components promoted healing by increasing blood flow through vasodilation, reducing platelet aggregation, mitigating thrombogenic effects, and exhibiting both immune-stimulating and immune-modulating effects. Additionally, Hyaluronidase facilitated the penetration of active healing substances.⁸

Jatyadi Thaila, primarily Tikta and Kashaya Rasa, has Pitta Kapha-alleviating properties and is known for its Shodhana, Ropana, Pootihara, and Vedanasthapana qualities. Jaati contributes antibacterial, anti-inflammatory, and anti-fungal effects due to the presence of salicylic acid. Nimba contains active compounds like nimbine and margosin, which offer anti-inflammatory, analgesic and antibacterial benefits. Yastimadhu has active ingredient that promotes wound healing, while turmeric provides anti-inflammatory, antimicrobial, and antibacterial properties. Tuttha aids in Lekhana Karma, and Tila Taila serving as the base enhances tissue repair. The combined effects of these ingredients synergistically contribute to the overall healing effect.⁹

In addition to this, internal medications such as Majishtadi Kashaya, Triphala Guggulu, and Bilwadi Gutika play a significant role. Manjishtadi Kashaya contains potent Vatahara herbs rich in antioxidants like Rubia cordifolia, Cedrus deodar, Hemidesmus indicus, Tinospora cordifolia, Zingiber officinale, Sidarhombifolia, Triphala, and more. This antioxidant-rich combination makes it valuable in the treatment of Vrana.¹⁰

Triphala Guggulu is composed of Amalaki, Haritaki, Vibhitaki, Pippali, and Guggulu. Its constituents exhibit Tikta, Kashaya, Madhura Rasa, Ushna Virya, Katu Vipaka, Laghu, Ruksha, Ushna, Tikshna Gunas, Tridoshahara and Shothahara properties. It alleviates Kapha Dosha through Tikta, Kashaya Rasa, Laghu and Ruksha Guna, while reducing Vata and Kapha Dosha with Ushna Virya. Pitta Dosha is pacified by its Tikta, Kashaya and Madhura Rasa. Triphala Guggulu also enhances Agni due to its Ushna Virya, Laghu and Ruksha Guna, and it prevents Srotorodha through its Ushna, Tikshna, Laghu Guna and Ushna Virya. ¹¹

Bilwadi is effective in treating venomous bites, based on specific signs and symptoms. Its Ushna Virya, Katu Vipaka and Kashaya, Tikta Rasa make it suitable for managing pain and swelling. Furthermore, it exhibits anti-venom, anti-inflammatory, cardio-protective and wound-healing properties.¹²

After an in-depth examination of Vishaja Vrana Chikitsa, it was discovered that all the Vrana treatment approaches were consolidated within the Shashti Upakramas. In this particular case study, Prakshalana, Rakthamokshana, Shodhana, and Ropana Upakramas were employed for managing Vishaja Vrana. Vishaja Vrana continues to pose clinical challenges due to its non-healing nature. Therefore, following the treatment modalities recommended by our Acharyas facilitates its management by promoting healing and reducing complications.

Patient perspective

During my first visit to hospital, I was suffering with severe pain over left leg and was worried about the wound healing. Once the ayurvedic line of treatment started, I noticed gradual reduction in my pain and discharge, along with gradual improvement of wound each day. The wound healed completely without much residual scar or pain. Informed consent Informed consent was taken prior to all procedures.

Conflict of interest

None