Sadyovran`a

Dr.R.B.Gogte
GFAM, AVP

Sadyovran`a is defined as a recent traumatic wound. It could be due to trauma or due to a surgical procedure. This is also called Aagantu Vran`a. But Sadyovran`ais differentiated from Aagantu Vran`a due to its special property of healing within the seven days if it does not get infected, and it produces a burning sensation immediately after trauma, which is usually relieved I.e. by cold fomentation or the application of Ghritaand honey. If the patient comes suffering from Sadyovran`a, the first thing to see is whether he has developed any signs and symptoms of Marmaaghaata. If so, Marmaaghaata is to be treated first and then the other ailment, depending upon the type of injury.

Classification of Sadyovran`a:

Chhinna Vran`a Usually a type of cut injury where is slight trauma to the muscles and bones

Kshataja Vran`a This is a penetrating wound and is usually caused by sharp-pointed substances like horns of animals, knives and bullets.

After treating the Marmaaghaata, if present, the first thing is to see whether there is any infected or foreign material in the wound in the form of small stones nail, pieces of wood, bullets, grass etc, if they are present, they should be removed immediately. If there is any injury to muscles, fascia, or vessels, they are also to be repaired immediately. Torn lacerated skin or the fascia or the muscles are to be removed and sutured. After confirming that there is no internal hemorrhage, the wound is to be sutured layer-wise.

Now, this sutured wound is treated for 7 days as stated in the texts (A.H.Su.26-13)

If the wound is heavily infected, no immediate suturing should be done, till the wound becomes clean and then it can be sutured. This type of suturing is called secondary suturing.

In cases of all Non-surgical traumatic injuries, Aamapaachana Chikitsaa is essential, which includes all antibiotics and antiseptics according to modern medical science.

Even in a clean-sutured wound, if the patient develops redness, itching or pain at the site of suturing, immediately a few sutures should be removed to allow the infection to be drained and Aamapaachana Chikitsaa should be given.

Treatment for Non-Infected Sadyovran`a:

1. Dhoopana Chikitsaa Twice in a day as mentioned in the Shasht`hee Upakrama_s.
2. Avasechana by Yasht`imadhu Ghritaand Balaa Taila for seven days
3. Removal of sutures on the 7^th day and in case of the face, on the 5^th day

[The Tvachaa being the Upadhaatuof Maamsa Dhaatu, as per Dhaatu Utpatti Krama, it takes 5 to 7 days to heal]
C. Chi. 15-17 From Rasa Rakta Maamsa Meda Asthi Majjaa S`hukra
Days {1 5 10 15 20 25 30

{1 2 3 4 5 6 7

Aagantu Vran`a

This type of Vran`a is always produced due to different types of traumas. It also includes the traumas caused by heat, Kshaara, Teekshn`a Aushadhi, and Visha or poison. Aagantu Vran`a_s are supposed to be aseptic for 7 days, and that is why, the treatment for Aagantu Vran`a is different than the other types of Vran`a_s. Though this is true, in practice, many a times these wounds get infected due to Dusht`a Dosha_s already existing in the body before their entry from the environment. In such a condition, it is expected that the treatment prescribed for the Aagantu Vran`a be stopped and shifted to the Dusht`a Vran`a management. Aagantu Vran`a also includes Sadyovran`awhich is being caused by sharp object or incisions made by surgeons also. Aagantu Vran`a caused by heat (Dagdha Kshaara or Aushadhi are not sutured)

Ayurveda has classified these Aagantu Vran`aas Chhinna, Bhinna, Viddha, Kshata, Pichchita, Ghrisht`a. The physician Vaagbhat`aclassifies it as Ghrisht`a, Avakrutta, Vicchina, Pravilambita, Patita, Viddha, Bhinna, and Vidalita.

Asht`aanga Samgraha classifies it as Ghrisht`a, Avakrita, Vichchhinna, Vilambita, Patita.

Chhinna Vran`a In Chhinna Vran`a, usually, the part gets amputated or it is treated in the form of straight or oblique incised, wound.

Bhinna Vran`a For the wound, which happens to be on a part which has one of the following e.g. urine, blood, undigested food or an abscess or a Vidradhi.

After the trauma on these parts, the contents that are inside are drained out, and that is why, it is called Bhinna. If it is on the Pakvaas`haya, it will drain faecalmaterial; if it is on Phuphphusa, it will drain air and if it is on Mootraas`haya, it will drain urine. Sometimes, Bhinna Vran`a is also produced by a simple trauma penetrating the peritoneal cavity without injuring the Kosht`hastha Avayava_s.

Although this Bhinna Vran`ais particularly related to Kosht`haanga_s, some signs and symptoms are common to all, which include fainting, retention of faeces and urine, Aadhmaana, S`hvaasa.

Sometimes it is accompanied by pain the chest.

Viddha Vran`a This is a penetrating wound where the external opening is almost invisible or very small, but the internal injury may be great.

This Viddha Vran`ais sub classified into

i. Anuviddha ii. Uttun`d`ita iii. Atividdha iv. Nirviddha v. Anubhinna vi. Bhinnottun`d`ita vii Atibhinna viii Nirbhinna.

Sometimes, we get a foreign body in different types of wounds e.g. A thorn, may remain inside even after making a Viddha Vran`a.

Kshataja Vran`a this falls between the Chhinna and Bhinna. The peculiarity is that this wound has an irregular surface.

Pichchita Vran`a This is always caused by the bilateral pressure or a trauma, if the extremity is fixed over a hard surface. Usually, the bones are affected in such types of injury. Many a times there is no external injury except loss of its normal contour. Such injury is usually flat.

Vaagbhat`as Viddha Vran`a is included under this category. This could be sub-classified as 1. Savran`a2. Avran`a.

Ghrisht`a Vran`a This is like a lacerated wound, where there is partial loss of skin. It is usually, accompanied by severe burning and a watery discharge.

Krita and Avakrita Vran`a This is a sub-variety of Ghrisht`a Vran`a where the subcutaneous tissue is also damaged.

Vicchinna Vran`a This is the next step of Vicchinna. The wound lies still deeper.

Pravilambita Vran`a Where the bone remains as it is, but the muscles, blood vessels, skin etc. are seen hanging.

Patita Vran`a In this Vran`a, part of the body gets separated from the body.

Vidalita Vran`a This is nothing but a synonym for Pichchita Vran`a.

Treatment:
The first line of treatment is related to Marmaaghaata, if noticed.
Control of bleeding if it exists.
Removal of foreign body, if inside
Total cleansing of the wound, if it is not of the Bhinna type.
If it is in relation to Kosht`haanga, exploration of the abdominal or thoracic cavity is indicated.
If it is of a superficial type, suturing can be done in the long cut wound.
In Pichchitaand Ghrisht`a Vran`a, S`heeta Lepa and Parisheka is indicated.
In the Ghrisht`a Vran`a, Avachoorn`ana is to be performed.
In the Avakritta Vran`a, Kalka_s are to be applied.
In the Vicchinna and Pravilambita Vran`a_s, Sevanaadi Upakrama_s are to be carried out.
In the Patita Vran`a, Sevana is indicated.
In general, for all types of wounds, there should be immediate sprinkling of Yasht`imadhu Ghritaor Balaa Taila.
In the Kshataja Vran`a, especially Lepa_s with Kashaaya, Madhura, S`heetaand Snigdha qualities to be applied
Good`haprahaaraabhighaata (Contusions / Sprains) these types of injuries are caused by lifting weights, fall from trees, twisting of limbs of due to a simple fall. This type of injury is usually presented as pain, burning sensation, and loss of consciousness. Sometimes, such types of symptoms are also produced due to heavy work or trauma on a Marma.

Treatment:
Tub bath of oil or lukewarm water.
Abhyanga and Mardana
Fomentation
Local fomentation by heated pulp of coconut core, mixed with Bhallataka and Haridraa
The same is to be retained there for one night.

Diet Easily digestible, Balya and if possible, it should be supplemented with a non-vegetarian diet.

Special treatment of different types of Bhinna Vran`as:

• Trauma to the Alimentary tract, especially the small intestines after the trauma over abdomen, sometimes the small intestines come out through the wound with or without injury to the intestines.

1. If it is without any injury, if the abdominal wound is sufficiently larger after application of Ghrita, the intestines are to be replaced in the abdominal cavity and suturing should be carried out.
2. If the abdominal wound is small, then it is to be extended upwards or downwards and the intestines are to be replaced in the abdominal cavity and other parts are also to be examined for injury.
3. If the intestines come out with the injury to the lumen of the intestines, then such type of wound on the intestines is to be sutured. The suturing material that is used is black Pippilikaa (black big ants). Approximate the wound on the intestines and apply the ants, as soon as they take a bite, cut off the ants body from the head.
   
   This is the first non-absorbable material belonging to the arthropodecategory. The author himself applied this technique on the stomach of frogs and the healing was very satisfactory.
   
   If the wound and abdominal cavity is contaminated by mud, grass particles etc., then the whole abdominal cavity (Udaraguhaa) and viscera are to be washed with milk and then only to be replaced inside. So, the concept of peritoneal lavagewas not new to Ayurveda during that era also.
4. If the patient reports to you after a long time, then before putting the intestines inside, they should be fully bathed with ghee and milk till their dryness goes off. Then they are to be replaced inside. This is nothing but similar to draping up the small intestines with saline soaked towels. After suturing the abdomen, a diet is to be worked out gradually. Water with milk, only milk, semisolid, and full diet; or water, non-veg, soup, semi-non-vegdiet and the non-vegdiet. To prevent constipation, castor oil with ghee should be given internally.

• If the testes protrude outside after a trauma on the scrotum, they are to be washed with milk if contaminated; if not, they are to be put in the Mushka Kosha (Scrotal pouch) and the Mushka is to be sutured.
• After an abdominal injury, sometimes, Medovarti(Omentum) comes out of the abdominal wound. If such a thing happens and if it is not infected, then the powder of Arjuna is to be applied, the Medovarti is ligatedat its base and a red-hot knife cuts the part, which has protruded.

This concept of cutting the Omentum with a red-hot knife is nothing but to achieve the haemostasis, as the omentumhas many free vessels that are likely to bleed. The second purpose of cutting the Omentum with red-hot knife is to prevent infection. After doing this procedure, the abdominal wall is to be sutured. In this particular condition, the patient is put on defatted milk diet. Usually after this surgery a severe burning pain is present; to alleviate this, sugar mixed water along with Yasht`imadhu and castor is given orally.

• If there is trauma over skull with our without a foreign body inside, the following procedure is to be adopted.
  

1. Remove the foreign body. After its removal usually Mastulunga (cerebro-spinal fluid) (Straava) outflow starts. If it comes out in excess, death may be the outcome. In order to prevent this complication, a big bunch of hair is inserted inside the wound and as the wound goes on healing, the hair is removed one by one gradually.
2. If it is without foreign body, simple bunch is inserted.
   a. If there is only a cut wound over the scalp, then the wound is to be sutured.
   b.    If accompanied by depressed fracture, the skull bone is elevated and the wound sutured.
   c.     If the injury is up to the meningeal coverings with oozing of CSF, the treatment given above is to be followed
   d.    If the injury is up to the Mastulunga (brain matter), and if the Mastulunga is damaged, then no treatment is required, as death follows.
   e.    If the eyeball comes out of the socket of orbit with its attachments intact, then after application of Ghrita, it is to be put back in its socket with the use of a tender leaf, preferably that of lotus and then, other treatments of Sadyovran`a will follow.

• Many a times, there is no external injury over the abdominal wall; there is no cut or piercing injury over the intestines or other viscera. But the trauma itself causes contusions over the intestines. These contusions lead to micro haemorrhagesin the whole gastro-intestinal tract. This has been compared in Ayurveda to water oozing from a mud pot. This is called as Klinna Aantra Bheda.

Diagnostic measures, which were used by Ayurveda in the case of Bhinna Vran`aon the gastro-intestinal tract are as follows As soon as the patient reports to you for treatment of the abdominal wound, watch for the type of discharge. If it is faecalmatter, it is likely to be small intestine and if it is frothy slimy yellow or green material coming out with or without food particles, it is likely to be gastric.

Vran`opadrava

[Complications of wound or ulcer]

The manifestations occurring or developing during the healing process of a Vran`aor even after its healing are called Vran`opadrava. They may be in the form of another disease. These can occur after surgical procedures also, as a result of the either the surgeons error or as a sequel of diseases condition itself. Generally these Upadrava_s subside as soon as the original wound heals. But this is not always the case; many times, Upadrava_s becomes more troublesome than the original wound and hence require quick treatment. They are classified as follow-

1. Vran`opadrava (I.e. Abnormal changes at the site of injury). This includes itching, redness, excessive pain, abnormal discharge or development of maggots etc. in the wound itself.
2. The second type of Upadrava is that which the patient develops, also called as Vran`itasya Updrava. They are namely, according to Sus`hruta Jvara, Atisaara, Moorchhaa,, Chhardi, Hikkaa, Arochaka, Shvaasa, Kaasa, Avipaaka, Trishn`aa. According to Charaka Jvara, Atisaara, Chhardi, Shvaasa, Kaasa, Trishn`aa, Visarpa, Pakshaaghaata, Sira–Stambha, Apataanaka, Moha, Unmaada, Vran`a–Vedanaa, Vepathu.

The most troublesome amongst these Vran`opadrava_s is Apataanaka, which is nothing but intermittent contractions and relaxations of body muscles causing intense movements of the body resulting in fatigue. If this Apataanaka continues, it leads to Dand`aapataanaka, where the body becomes rigid and bent internally and externally.

Internal curving of body is known as Dhanusht`ambha / Antaraayaama and external bending as Bahiraayaama.

Vaagbhat`a has called this as Vran`aayama, while Maadhava Nidaana classifies it as Aptantraka and Apataanaka as the Avasthaa of Aakshepaka. This is mainly due to the effects of Vaatavaha Naad`i_s.

According to Dosha, they are classified as

1. Kaphaanvita Vaataja
2. Pittaanvita Vaataja
3. Keval Vaataja
4. Abhighaataja

Some people also classify them as

1. Apataanaka
2. Sanshrisht`a Aakshepaka (Kaphaanvita Vaataja)
3. Keval Aakshepaka (Keval Vaataja)
4. Abhighaataja

Sometimes this Aakshepaka results in difficulty in respiration, deglutition, and sometimes fracture of the bones of limbs, ribs or pelvis.

According to modern science, this condition is put under the heading of tetanus. The causative organism of this condition is an anaerobic bacillus called claustridium tetani. As this is caused by anaerobic organisms, it is more common in Viddha or sutured injuries or if the wound is contaminated with horse dung.

The symptoms may start after injuries from 48 hrs to 6 months. This is usually caused by the presence toxins on the nerve endings. The earlier onset of signs and symptoms, the graver is the prognosis. The early onset of lock-jaw, the more grave the prognosis. Lock jaw is produced due to the spasm of the facial muscles, especially the muscles of mastication. The look on the face is very peculiar, which is comparable to moneys face and hence called rhesus sardonicus. This condition is also common especially after abortion, delivery as the woman is Vran`ita or in the newborn babies due to infection of the umbilicus.

Preventive measures include total aseptic precautions, injection of tetanus toxoidprior to surgery and immediately after trauma with ulcer. If tetanus sets in, Anti-Tetanus serum is indicated intravenously. The dose that varies from 5 Lacto 10 LacI.U. sometimes, intra-spinal penicillin helps in improving the condition. The supportive treatment is IV fluids for nutrition, and drugs like paraldehyde, magnesium sulphateto stop convulsions.

If the patient is unable to swallow anything, feeding is done through a rylestube. If the patient undergoes respiratory difficulties, tracheostomyor artificial respiration is indicated. The other things that are to be done in this patient is to avoid pricks, especially intra-muscularly, to keep him away from noise and keep in a dark room with eyes covered to prevent the glare of a powerful light. The wound should be opened, if it is of the closed type and irrigation with hydrogen peroxide (H2O2) should be done followed by instillation of anti-toxic serum.

According to Ayurveda, Snehana and Svedana is done followed by Teekshn`a Nasya. Then, Vidaarigandhaadi Ghritaor Trivrita Ghrita should be used for Avagaaha, Abhyanga, Paana, Bhojana, Anuvaasana and Nasya. Vaatahara Dravya–Siddha milk should be given and Vaatahara Dravya–Siddha Snehbasti should be given. During convulsion, care should be taken that the patient does not injure himself.

Visarpa:
Etymology The oedema, which spreads all around the wound of trauma are called Visarpa (cellulitis).
Classification:
Sus`hruta Vaataja ( Vaata–Pittaja), Pittaja (Pitta–Kaphaja), Kaphaja (Kapha–Vaataja), Saannipaatika and Kshataja.
Charaka Vaataja, Pittaja, Kaphaja, Saannipaataja, Agnisarpa (Vaata–Pittaja), Granthivisarpa (Kapha–Vaataja), and Kardama Visarpa (Kapha–Pittaja).
Maadhava Nidana Charakas 7 + Kshataja Visarpa should be included under Pittaja Visarpa
Vaagbhat`a adds Abhighaataja Visarpa
Charaka has classified it as Bahyas`hrita (S`haakhaas`hrita), Antahs`hrita (Kosht`haas`hrita), and Ubhayaas`hrita. By gradation they are serious.
Sus`hruta describes Visarpa as a constantly spreading, not much elevated swelling appearing quickly, which should be treated as Visarpa.
Dosha: All Dosha, Dhaatu, Upadhaatu Tvachaa, Maamsaand Rakta
Charaka: All Dosha, + Rakta, Lasikaa, Tvachaaand Maamsa.
General signs and symptoms slightly elevated swelling above the skin with margin and spreading oedema, usually accompanied by Temperature, Arati etc.
Sometimes, there is development of blisters and if they burst, serum (Lasikaa) comes out.

Signs and Symptoms
Vaataja The inflammation is blackish, hard and rough to touch, accompanied by Jvara, Bheda, Toda etc.
Pittaja Speedily spreading inflammation, red in color with blisters accompanied by Jvara, Daaha, and Paaka
Kaphaja Color is red spreading, gradually with very little pain. There is much itching and Oedema is with blisters. Pus formation is very slow.
Tridoshaja Mixed manifestations
Kshataja It is after injury in a Tridoshaja Prakriti patient. Pitta and Rakta get vitiated resulting into a blackish colored, red inflammatory oedemaand resulting in the blisters of blackish or Kulattha color.
Atisaara, burning pain and suppuration are also present.

Granthi Visarpa:
Dosha Kapha and Vaata
Dushya Tvachaa, Siraa, Snaayu, Maamsa. Usually red blisters are present and they appear like woven pearls. Accompanied by pain, fever, Shvaasa, Kaasa, Atisaara, Hikkaa, Chhardi, Moha, Vaivarn`ya, Angabhanga, Angasaada

Few commentators put this under Apachi.

Kardama Visarpa:
Dosha Kapha Pitta. Dushya Tvachaa, Maamsa, Siraa, Snaayu. Usually, this type of inflammatory oedemaresults in slough formation. It is accompanied by decomposition of Tvachaa, Siraa, Snaayu, and Maamsa

As soon as the inflammatory oedemasets in, blisters of red, yellow, white color start erupting the concerned area becomes hot, but there is little pain. Finally it results in the slough formation with a foul smell.

It is accompanied by Jvara, Vedanaa, Stambha, Pralaapa, Bhrama, Moorchchhaa, Loss of sensation and memory. If these things are severe, it should be treated as Asaadhya; if not it is curable.

Agnivisarpa:
This type possesses the whole body, with a burning sensation like the fiery heat of a flame. The inflammation spreads to Marmasthaana.
General signs and symptoms are body ache, loss of sensation, Chhardi, Atisaara, and giddiness, burning Jvara, Tamakas`hvaasa, sleepiness. The color of the inflammatory oedemabecomes blackish bright red. If Marma_s get involved, it becomes Asaadhya and hence is not treatable.

Saadhyaasaadhyatva:
Vaataja Pittaja Kaphaja Saadhya
Granthi Kardama and Agnivisarpa (unless there is Marmasthaanas involvement)
Krichchhrasaadhya
Sannipaatika and Kshataja Asaadhya

Treatment:

1. Vamana, Virechana or Basti according to the Dosha involved.
2. Raktamokshan`a and Varun`aadi Gan`a medicines for internal and external medication
3. For inflammatory Oedema, Doshapratyanika Chikitsaa of Lepa, Seka, Siddha Ghritaand Siddha Taila
4. Other treatments according to Avasthaa

Vaayu Kot`ha (Gas Gangrene)
This condition is produced by the infection of the clostridium velchii. We get multiple vesicles at the site of the trauma, which spreads rapidly. The pulse is fast with high temperature. If the infection is heavy, death occurs soon.

Treatment: Excision of dead tissue. If necessary, amputation of the limb. Administration of anti-gas gangrene serum (05 Lacunits). Other antibiotics to control secondary infection.

Jalasantraasa (Hydrophobia):
This is caused by the dog bite already infected with rabdovirus. The route of entry is through the saliva of the dog during bite. Even the contaminated saliva on the skin could also produce this condition.

After the infection, constant painful contractions of muscles of deglutition starts and the patient fears drinking water and hence the name hydrophobia.

The incubation period is 1 to 3 months. Earlier onset on record is 10 days and as late as 1 year. The period depends on the place of bite, load of virus, type of animal (dog, monkey, rat, cat etc.) and the time spent for treatment.

Bite on Face, skull or neck 34 days
Forearm 46 days
Legs 78 days
The virus enters the brain through the circulating blood and develops nigribodies.
Signs and Symptoms: bodyache, headache, temperature, itching and pain at the site of injury; cannot tolerate light or cold breeze. Excessive perspiration, salivation, contraction of muscles, watering from eyes, irritability and difficulty in deglutition. Lastly, the noise of water or word water induces spasm of the muscles of deglutition. Patient develops convulsions or paralysis and lastly death occurs as the final and inevitable outcome.
Saadhyaasaadhyatva: Nobody survives

Treatment: Cleaning of the wound by carbolisation(application of Carbolic acid)
Preventive treatment

1. No suturing
2. Confirmation of madness of the dog

Death occurs within 10 days from setting up of the symptoms
Antirabies vaccine 3,7,10, or 14 injections.

Human Antirabiesvaccine 3,5 injections
Local oedema, redness, tenderness, headache, and allergic rash are common after injection.

Dr. R. B. Gogte
Ex – Professor and H.O.D. Department of Shalya

Last updated on March 3rd, 2021 at 08:58 am