Critical analysis of Srava and Gandha of Vrana with special reference to...

[Full title: Critical analysis of Srava and Gandha of Vrana with special reference to Madhumehajanya Dusta Vrana vis-à-vis Diabetic Foot Ulcer]

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[Find the meaning and references behind the names: Nani, Patil, Prashanth, Kaya, Narayan]

REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 176 Critical analysis of Srava and Gandha of Vra n a with special reference to Madhumehajanya Du st a Vrana vis-à- vis Diabetic Foot Ulcer Narayan KR 1 , Siddanagouda A. Patil 2 , Prashanth AS 3 1 Ph.D. Scholar, Department of Shalya Tantra, Ayurveda Mahavidyalaya, Hubballi, Karnataka, India. 2 Professor, Department of Shalya Tantra, Ayurveda Mahavidyalaya, Hubballi, Karnataka, India. 3 Principal, Department of Kaya Chikitsa, Ayurveda Mahavidyalaya, Hubballi, Karnataka, India. I NTRODUCTION A wound is considered chronic when it fails to proceed in “an orderly and timely reparative process that results in sustained restoration of anatomic and functional integrity” [1] Madhumehajanya Dusta Vrana also comes under the umbrella of Chronic wound due to its delayed healing nature and complications Address for correspondence: Dr. Narayan K.R. Ph.D. Scholar, Department of Shalya Tantra, Ayurveda Mahavidyalaya, Hubballi, Karnataka, India. E-mail: danu.nani@gmail.com Submission Date: 05/11/2023 Accepted Date: 16/12/2023 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.1.25 associated with it and hence considered to be an archetypical of chronic wounds [2-4] Madhumehajanya Dusta Vrana can be broadly classified into two types. Viz, Nija and Agantuja . All the Aharaja and Viharaja Nidana resulting in Prameha/Madhumeha can be considered as the Nidana for the manifestation of Nija Madhumehajanya Dusta Vrana . Abhigata also plays an important role as Nidana in contributing to the manifestation as Agantuja Madhumehajanya Dusta Vrana . In case of a Nija Madhumehajanya Dusta Vrana, Vatadi Dosa Prakopa takes place prior to the formation of Vrana whereas in Agantuja Madhumehajanya Dusta Vrana , Vrana gets manifested first followed by Vatadi Dosa Prakopa . Eventually, as Madhumehajanya Dusta Vrana is Dirghakalanubandhi , even Agantuja Madhumehajanya Dusta Vrana after a period of 7 days A B S T R A C T Diabetes Mellitus is one of the major health concerns of India gradually gaining potential to become an epidemic. At present, India has a stunning population of people suffering from diabetes which goes up to 101 million and by the end of 2045 it is expected to be between 124 to 135 million. As per a Cohort study conducted by Diabetic Federation of India 2/3 rd of these diabetic patients suffer from Diabetic complications. When we consider these 2/3 rd of the diabetic population who suffer from Diabetic complications, majority of them tend to develop Diabetic Foot Ulcers in their lifetime due to uncontrolled glycemic status. Madhumehajanya Dusta Vrana vis-à-vis Diabetic Foot ulcers once formed does not only affect the patient physically but can significantly negatively impact a patient’s quality of life by its presentations. Due to the non-healing nature of Madhumehajanya Dusta Vrana and associated infection, it discharges multiple secretions from its floor which results in morbid moisture in the ulcer further adding to its non-healing nature. The present article is intended to understand the same in detail regarding the Srava and Gandha of Madhumehajanya Dusta Vrana in detail as per Ayurvedic and contemporary science point of view. Key words: Madhumehajanya, Dusta, Vrana, Srava, Gandha, Discharge, Odour, DFU.

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[Find the meaning and references behind the names: Debris, Nila, Krishna, Brown, Flora, Red]

Narayan KR et al. Critical analysis of Srava and Gandha of Vrana ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 177 becomes Nija Madhumehajanya Dusta Vrana due to Doshopaplava. [5] The Laksana of Madhumehajanya Dusta Vrana are included under the heading of Dusta Vrana itself by all the Acarya . Apart from most of the Samanya Dusta Vrana Laksana following Laksana can be specifically attributed to Madhumehajanya Dusta Vrana - viz; Susruta [6] ▪ Krsna Rakta Pita Sukla Varnanam Anyatama Varna - The wound can be black, red, yellow or white or any other colours. ▪ Putipuya Mamsa Sira Snayu Prabhrti - The wound is filled with purulent pus discharge, putrefied muscle tissue, blood vessels and tendons. ▪ Bhairava ▪ Putipuya Srava - Purulent discharge ▪ Amanojna Darsana and Amanojna Gandha - The wound has offensive appearance and odour. ▪ Pi ḍ akopadruta - Formation of papule ▪ Dirghakalanubandhi - Chronic in nature Charaka [7] ▪ Avasanna Vartma - Depression in the margin of the Vrana ▪ Atisthula Vartma - Excessive thickness of the margin of the Vrana ▪ Atipi ḍ aka Vrana - Excess Pidaka over the Vrana ▪ Atipinjara - Colour of the Vrana being excessively reddish yellow, Similar to the colour of Haratala ▪ Nila - Bluish colour of the Vrana ▪ Syava - Blackish brown colour of the Vrana ▪ Rakta - Reddish colour of the Vrana ▪ Krsna - Blackish colour of the Vrana ▪ Atiputika - Excess pus discharge from the wound ▪ Ropya - Recurrence of the Vrana ▪ Kumbhimukha - Vrana with completely pus-filled cavity having a small opening outside. Srava from Madhumehajanya Dusta Vrana - Discharge from Diabetic Foot Ulcer Discharge from wound is a sequel to the local host response to the microorganisms and dissemination of microorganisms in viable tissue of the ulcer as they try to outcompete the host natural immune system. Nonviable tissues due to infection, microorganism and leucocyte debris forms the components of the discharge along with various proteins and other metabolites released during this process. Formation of different kinds of discharge in a diabetic foot ulcer is a complex process that involves a lot of significant factors like microbial contamination, Glucose laid tissues, associated vascular pathologies like micro and macro angiopathy. All these factors cumulatively lead to the formation of a discharge in the ulcer which varies from ulcer to ulcer depending on the changes in the above mentioned factors. Microbial contamination refers to the effect exerted by different colony of bacteria that usually affect the ulcer floor and resulting infection in the ulcer floor, which eventually leads to discharge in the ulcer. This microbial contamination may come from either endogenous or exogenous sources. Endogenous flora includes the bacterial growth seen on patient’s skin and mucous membranes. The most common endogenous causative organisms are S. aureus, coagulase-negative staphylococci, Enterococcus, and Escherichia coli. Improper wound hygiene and uncontrolled blood glucose levels that result in glucose loaded tissues are some factors that result in Bacterial contamination due to endogenous factors. Exogenous flora may come from the theatre room, including air, instruments, materials, and staff members. The most common exogenous organisms are staphylococci and streptococci. Also, the number and the virulence of the organism are major risk factors. Improper dressing and not maintaining adequate aseptic precautions during dressing are some

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[Find the meaning and references behind the names: Sita, Green, Aruna]

Narayan KR et al. Critical analysis of Srava and Gandha of Vrana ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 178 factors that result in Bacterial contamination due to exogenous factors. Although diabetics are particularly vulnerable to bacterial infections, DFUs have a complex and highly organized polymicrobial community that frequently contributes to undesirable outcomes in DFU-affected individuals [8] This microbiota – biofilm over the ulcer bed in a diabetic ulcer comprises of symbiotic bacteria, yeast and fungal loads. So, discharge from DFU can be a resultant of an infection varying from bacterial to viral and yeast infestation. Description of Vrana Srava as per Acharya Sushruta: Varna Srava Description As per contemporary science Lasika Discharge of Lymph like fluid Serous discharge from the wound Jala Watery discharge Serous discharge from the wound Pooya Pus discharge Purulent discharge from the wound Asrk / rakta Blood discharge Sero- Sanguinous discharge from the wound Haridra Discharge which is yellow like turmeric The whitish-yellow, yellow, yellow-brown color of pus is the result of an accumulation of dead neutrophils. Aruna Discharge which is red in color Sanguinous discharge from the wound Pinjara Discharge which is mixture of red and yellow color Mixture of Sanguinous and Purulent discharge from the wound – Resultant of a chronic infection in the ulcer floor Kasaya Discharge which is brownish black in color Discharge appears brownish black in colour due to presence of dried and senile blood cells in the discahrge. Nila Discharge which is blue in color Some strains of Pseudomonas Bacteria result in blue colored discharge Harita Discharge which is green in color Pus can sometimes be green because some white blood cells produce a green antibacterial protein called myeloperoxidase. A bacterium called Pseudomonas aeruginosa (P. aeruginosa) produces a green pigment called pyocyanin, which results in green color pus. Snigdha Discharge which is unctous in nature Unctous discharge in the ulcer is an indicative of chronic bacterial infection Ruksha Discharge which is dry in nature Serous discharge Sita Discharge which is white in color Purulent discharge Asita Discharge which is black in color Black discharge can be an indicative of Bacterial and Yeast/Fungal infection For the practical purpose of understanding and assessment of the ulcer discharge, it can be categorized as following types: Classification of Srava Description No discharge Dressing is Dry Minimal Discharge The gauze is slightly moist Mild Discharge The gauze is completely wet - noticed after opening the bandage Moderate Discharge The gauze is completely wet - noticed even before opening the bandage Severe Discharge The gauze and the bandage are completely soaked - Within 24 hours Gandha from Madhumehajanya Dusta Vrana - Odour from Diabetic Foot Ulcer Among all the distressing outcomes in patients with Diabetic Foot Ulcer, Foul smelling odor stands first because it not only affects the patient but also the people surrounding the patient with its offensive and repulsive nature. This also leads to a negative psychological effect on the patient and leads to social isolation of the patient as even the close family

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[Find the meaning and references behind the names: Don]

Narayan KR et al. Critical analysis of Srava and Gandha of Vrana ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 179 members tend to avoid coming close to the patient due to the offensive nature of the ulcer odor. Odor in the ulcer can vary from barely noticeable to offensive and foul smelling, which also indicates the nature of the wound healing. Offensive smell indicates an infected wound which causes delayed healing and vice versa. An ulcer develops odor as a result of abnormal metabolic processes occurring at the ulcer site, which involves microbial proliferation, polymorphonuclear infiltration, cellular and tissue death at the ulcer and aerobic-anaerobic metabolic processes that happens at the tissue level in the ulcer. A chronic ulcer like a Diabetic Foot Ulcer gives a suitable substratum for the growth of microbes over the ulcer leading to infection and odor formation. These microbes, specifically that affect the DFU can be aerobes - that require oxygen for metabolic processes and anaerobes - that don’t require oxygen for metabolic processes. Majority of the times odor in the ulcer is caused by anaerobes like Prevotella, Bacteroides fragilis, Fusobacterium nucleatum, Clostridium, Beta-hemolytic Streptococci, Porphyromonas and clostridium perfringens that release foul-smelling compounds called Cadaverine, Putrescine and Sulphur due to tissue degradation as a part of putrefaction process of the tissues. Also, various other volatile metabolites such as short-chain fatty acids including n-butyric, n-valeric, n-caproic, nhaptonic, and caprylic acids also result in intense acrid smell. As Ulcer odor is an objective criterion in the assessment of the ulcer, there are no standard categorization methods of ulcer odor, as it can vary from person to person based on their sensitivity to smell. Description of Vrana Gandha as per Acharya Sushruta : Gandha Description As per contemporary science Sarpi Similar to the smell of Ghee Foul smelling discharge due to Pseudomonas infection Taila Similar to the smell of Oil Foul smelling discharge due to Clostridium infection Vasa Similar to the smell of Fat Pungent smelling discharge due to various Bacterial infections Puya Similar to the smell of Pus Foul smelling discharge usually noticed in gangrenous wounds Rakta Similar to the smell of Blood Foul smelling discharge due to Sero-Sanguinous discharge Shyava Similar to the smell that emanates when curd is rubbed over copper Some Acharya also consider it as Shava Gandha – which is similar to the smell of a dead body Foul smelling discharge usually noticed in gangrenous wounds and Ulcers affected by anaerobic bacteria Amla Similar to the smell of Sour substances Foul smelling discharge usually noticed in gangrenous wounds Pooti Similar to the smell of Putrid substances. Foul smelling discharge usually noticed in gangrenous wounds For the practical purpose of understanding and assessment of the ulcer odor it can be categorized as following types: Classification of Odor Description Very Strong Malodor / Offensive Malodor This is immediately perceived on entering a room with a patient with a wound. The offensive smell can be detected at a distance of 6-10 feet, even with the wound completely wrapped in a dressing. Strong Malodor A strong smell can be detected at a distance of 6-10 feet only when the dressing is removed, or the wound is partially exposed. Moderate Malodor The odor is only noticeable close to the wound with a dressing intact. Slight Malodor This is similar to a moderately odorous wound however it can only

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[Find the meaning and references behind the names: Davis, Nil, Med, Prakashan, Jan]

Narayan KR et al. Critical analysis of Srava and Gandha of Vrana ISSN: 2456-3110 REVIEW ARTICLE January 2024 Journal of Ayurveda and Integrated Medical Sciences | January 2024 | Vol. 9 | Issue 1 180 be detected near a partially exposed wound or one without a dressing. No Malodor No odor even when close to a open wound Role of BIOFILM in manifestation of Vrana Srava and Gandha A biofilm is composed of living, reproducing microorganisms, such as bacteria, that exist as a colony, or community. A biofilm forms when certain microorganisms adhere to the surface of some object in a moist environment and begin to reproduce. The microorganisms form an attachment to the surface of the object by secreting a slimy, glue-like substance called as an Extracellular Polymeric Substance Matrix (EPS). This EPS, along with different microorganisms consists of various other materials depending on the surface they are attached to. In DFU, the biofilms are composed primarily of microbial cells and EPS and biofilm community usually consists of a single kind of microorganism, but in DFU biofilms almost always consist of mixtures of many species of bacteria, as well as fungi, algae, yeasts, protozoa, and other microorganisms, along with non-living cellular debris and other metabolic products. The cells produce strands of EPS and are held together by these strands, allowing them to develop complex, three-dimensional, attached communities that are resistant to attacks that would destroy individual cells not part of a biofilm colony. As this microbiota biofilm over the ulcer bed in a diabetic ulcer comprising of symbiotic organisms are submerged in EPS complex, the ulcer becomes resistant to external treatments and also the threedimensional structure of the Biofilm complex does not respond easily to any antibiotic therapy resulting in the non-healing nature of the DFU. The resulting Non- Healing DFU, due to increased load of microorganisms and resistance to the treatments offered by the Biofilm leads to excessive discharge and odor from the ulcer bed. So, eradicating the biofilm becomes an integral part in the management of DFU to control Vrana Srava and Vrana Gandha . REFERENCES 1 Lazarus GS, Cooper DM, Knighton DR, Percoraro RE, Rodeheaver G, Robson MC. Definitions and guidelines for assessment of wounds and evaluation of healing. Wound Repair Regen. 1994 Jul;2(3):165 – 70. 2 Stupin VA, Gabitov RB, Sinelnikova TG, Silina EV. Biological mechanisms of chronic wound and diabetic foot healing: the role of collagen. Serbian J Exp Clin Res. 2018 Dec 26;19(4):373 – 82. 3 Posnett J, Franks PJ. The burden of chronic wounds in the UK. Nurs Times. 2008 Jan 22 – 28;104(3):44 – 5. 4 Lazaro J, Izzo V, Meaume S, Davies AH, Lobmann R, Uccioli L. Elevated levels of matrix metalloproteinases and chronic wound healing: an updated review of clinical evidence. J Wound Care. 2016 May;25(5):277 – 87. 5 Su s ruta. Su s ruta Sa ṃ hit a . Nibandhasaṅgraha commentary of s r i Dalhan a ch a rya and Ny a yachandrik a pañjik a of S r i Gayad as a ch a rya on Nid a nasth a na. Edited by Vaidya j a davji trik a mji a ch a rya and N a r a ya n r a m a ch a rya k a vyat i rtha. Reprint edition. Varanasi: Chaukhambha surbharati prakashan. 2012; Cikits a sth a na, 1 st adhy a ya. 3 rd s loka. 6 Su s ruta. Su s ruta Sa ṃ hit a . Nibandhasaṅgraha commentary of s r i Dalhan a ch a rya and Ny a yachandrik a pañjik a of S r i Gayad as a ch a rya on Nid a nasth a na. Edited by Vaidya j a davji trik a mji a ch a rya and N a r a ya n r a m a ch a rya k a vyat i rtha. Reprint edition. Varanasi: Chaukhambha surbharati prakashan. 2012; S u tra sth a na, 22 nd adhy a ya. 7 th s loka. Page no: 108. 7 Agnive s a, Caraka, D r ḍ habala, Caraka Saṃhit a . A yurvedad i pik a commentary by S r i Cakrap an idatta. Edited by Vaidya Yadavji trik a mji acharya. Reprint edition. Varanasi: Chaukhambha surbharati prakashan. 2012; Cikits a sth a na, 25 th adhy a ya. 24 th – 25 th s loka. Page no 593. 8 Peleg AY, Weerarathna T, McCarthy JS, Davis TM. Common infections in diabetes: pathogenesis, management and relationship to glycaemic control. Diabetes Metab Res Rev. 2007 Jan;23(1):3 – 13 How to cite this article: Narayan KR, Siddanagouda A. Patil, Prashanth AS. Critical analysis of Srava and Gandha of Vrana with special reference to Madhumehajanya Dusta Vrana vis-à-vis Diabetic Foot Ulcer. J Ayurveda Integr Med Sci 2024;1:176-180. http://dx.doi.org/10.21760/jaims.9.1.25 Source of Support: Nil, Conflict of Interest: None declared.

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