Sushruta Samhita Sutrasthana Chapter 22: Vrana Srava Vijnaniya Adhyaya (Knowledge of Exudates of the Wound)

The 22nd chapter of Sutrasthana of Sushruta Samhita is named as Vrana Srava Vijnaniya Adhyaya. This chapter deals with the Knowledge of Exudates of the Wound.

अथतोव्रणास्रावज्ञानीयमध्यायं व्याख्यास्यामः ॥१॥
यथोवाच भगवान् धन्वन्तरिः ॥२॥

Now, we all expound the chapter called Vranasrava vijnaniya- knowledge of exudates of the wound, as revealed by the venerable Dhanvantari.

 Vranavastu: Seats of wounds

त्वङ्मांससिरास्नाय्वस्थिसन्धिकोष्ठमर्मानीत्यष्टौ व्रणवस्तूनि। अत्र सर्वव्रणसन्निवेशः ॥३॥

Below mentioned are the eight vrana vastus (seats, dwelling places of wounds / ulcers) –

• Twak – skin,
• Mamsa – muscles,
• Sira – veins,
• Snayu – ligaments,
• Asthi – bones,
• Sandhi – bony joints,
• Kostha – abdominal viscera, and
• Marma – vital spots, vital organs.

In these (seats) all kinds of wounds happen.

Prognosis of wounds located in vrana vastu

तत्र, आद्यैकवस्तुसन्निवेशी त्वग्भेदी व्रणः सूपचरः, शोषाः स्वयमवदीर्यमाणा दुरुपचाराः ॥४॥

Twak Bhedi Vrana – It is the wound / ulcer which occurs in the first seat of the wound i.e. skin. It causes tears in the skin only. This is the reason that it is easily treatable. On the other hand, the remaining kinds of vranas residing in other tissues and which would burst out all by themselves are difficult to treat.

Vranakriti: Different shapes of wounds

तत्रायतश्चतुरस्रो वृत्तस्त्रिपुटक इति व्रणाकृतिसमासः, शोषास्तु विकृताकृतयो दुरुपक्रमा भवन्ति ॥५॥

Below mentioned are the shapes of wounds in brief, they are –

–   Ayata – broad
–   Chaturasra – rectangular
–   Vritta – round and
–   Triputaka – triangular

Wounds having other abnormal shapes are difficult to treat.

Prognosis of wounds based on the physician treating the wounds

सर्व एव व्राणाः क्षिफ्रं संरोहन्त्यात्मवतां सुभिषग्भिश्चोपक्रान्ताः; अनात्मवतामज्ञैश्चोपक्रान्ताः प्रदुष्यन्ति,  प्रवृद्धद्दोषाणाम् ॥६॥

All kinds of vranas – wounds heal quickly –

–       in persons who are very disciplined and consume healthy foods and follow the instructions of the physician, and
–       in patients who are treated by good, intelligent and experienced physician

On the other hand, the vranas would lead to great abnormality and do not heal easily because of a great increase of the doshas in those patients who are undisciplined and are treated by ignorant physicians.

Dusta Vrana Laksana: Features of bad (septic) wound

तत्रातिसंवृतोऽतिविवृतोऽतिकठिनोऽवसन्नोऽतिमृदुरुत्सन्नोऽवसन्नोऽविशीतोऽत्युष्णः कृष्णरक्तपीशुक्लादीनां वर्णानामन्यतमवर्णो भैरवः पूतिपूयमांसससिरास्नायुप्रभृतिभिः पूर्णः पूतिपूयास्राव्युन्मार्ग्युत्सङ्ग्चमनोज्ञदर्शनगन्धोऽत्यर्थं वेदनावान् दाहपकरागकण्डूशोफपिडकोपद्रुतोऽत्यर्थं दुष्टशोणितास्रावी दीर्घकालानुबन्धी चेति दुष्टव्रणलिङ्गानि। तस्य दोषोच्छ्रायेण षत्त्वं विभज्य यथास्वं प्रतीकारे प्रयतेन ॥७॥

Below mentioned are the symptoms of dusta vrana (vitiated / septic wound) –

–       either has small opening or large opening, (greatly covered and slightly exposed or greatly exposed and slightly covered),
–       excessively hard or very soft,
–       elevated or depressed,
–       excessively cold or excessively warm / hot,
–       having any one among black, red, yellow or white colors,
–       terrifying (by appearance),
–       filled with / associated with putrefying (foul smelling) pus, blood, muscles, veins, ligaments etc,|-       exuding putrefying pus and exudates moving in abnormal paths.
–       wound raised up,
–       having unpleasant look (ugly in appearance) and smell (foul smelling);
–       accompanied with severe pain, burning, suppuration, redness, itching, swelling, eruptions and such other complications greatly;
–       exuding 
–       vitiated blood and persisting for long time

Dushta Vrana shall be classified into six kinds mainly on the basis of dosha predominance in them. Later, appropriate treatments shall be administered in each kind, with all efforts.

Srava Lakshanas: Features of the exudates

अत ऊर्ध्वं सर्वस्रावान् वक्ष्यामः- तत्र घृष्टासु छित्रासु वा त्वक्षु स्फोटे भिन्ने विदारिते वा सलिलप्रकाशो भवत्यास्त्रावः किंचिद्विस्रः पीतावभासश्च; मांसगतः सर्पिःप्रकाशः सान्द्रः श्वेतः पिच्छिलश्च ;सिरगतः सद्यश्छिन्नसु  सिरातु रक्तातिप्रवृत्तिः  पक्वासु च तोयनाडीभिरिव  तोयागमनं पूयस्य,

आस्रावश्चात्र तनुर्विंच्छिन्नः पिच्छिलोऽवलम्बी श्यावोऽवश्यायप्रतिमश्च; स्नायुगतःस्निग्धो घनः सिंघाणकप्रतिमः सरक्तश्च; अस्थिगतोऽस्थान्यभिहते स्फुटिते  भिन्ने दोषावदारिते वा दोषभक्षितत्वादस्थि निःसारं शुक्तिधौतमिवाभाति,  आस्रावश्चात्रमज्जमिश्रः सरूधिरः स्निग्धश्च; संधिगतः

पीड्चमनो न प्रवर्तते, आकुञ्चनप्रसारणोन्नमनविनमनप्रधावनोत्कासनप्रवाहणैश्च स्रवति;  मर्मगतस्त्वगादिष्ववरुद्धत्वान्नोच्यते। तत्र त्वगादिगतानामास्रावाणां यथाक्रम्ं पारुष्यश्यावावश्यायदधिमस्तुक्षारोदकमांसधावनपुलाकोदकसन्निभत्वानि मारुताद्भवन्ति; पित्ताद्रोमेदकगोमूत्रभस्मशङ्खकषायोदकमाध्वीकतैलसन्निभत्वानि; पित्तवद्रक्तादतिविस्रत्वं च ;कफान्नवनीतकासीसमज्जपिष्टतिलनालिकेरोदकवराहवसासन्निभत्वानि; सन्निपातान्नालिकेरोदकैर्वारुकरसकाञ्जिकप्रासादारुकोदकप्रियङ्गुफलयकृन्मुद्रयूषसवर्णत्वानीति ॥८॥

After this, the features of all types of exudates will be described –

1. Wound type – Ghrsta – abrasion, Chinna – cut or incised, Sphote Bhinna – burst open, Vidarita – tearing of vesicles

Nature of exudates –

–       water like,
–       with slight bad smell,
–       yellow in colour

2. Wound type – Mamsagata Vrana – Wounds caused in and residing in the muscles

Nature of exudates –

–       resembles ghee
–       thick
–       white
–       slimy

3. Wound type – Siragata Vrana – Wounds occurring in veins, caused by accidental cuts will cause severe bleeding. When these wounds suppurate, they would produce pus i.e. exudates.

Nature of exudates –

–       resemble water coming out from a tube / sinus
–       thin
–       discontinuous
–       slimy
–       adhering
–       black
–       resembling dew drops

4. Wound type – Snayugata Vrana – Wounds occurring in the ligaments

Nature of exudates –

–       unctuous,
–       thick
–       resembling nasal discharges
–       mixed with blood

5. Wound type – Asthigata Vrana – Wounds occurring in the bones caused due to injury such as splitting, dividing or getting damaged and cracked by aggravated doshas. It may also be caused due to the bone tissue getting eaten or destroyed by worms or microorganisms. The bones become poor in strength and weight.

Nature of exudates –

–       resembles water with which oyster shells have been washed – shining white
–       unctuous
–       mixed with marrow and blood

6. Wound type – Sandhisthita Vrana – Wounds are present in the bony joints.

Nature of exudates –

–       will not flow out even on pressing over the joints
–       would flow out during various movements like flexion, extension, elevation, depression, running, coughing and straining
–       slimy
–       appear like streaks of syrup hanging down just like saliva dribbles from the corner of the mouth,
–       mixed with froth, pus and blood

7. Wound type – Kosthagata Vrana – Wounds are present in the abdomen (viscera).

Nature of exudates –

–       there will be exudation of blood
–       exudation of urine, feces and pus
–       exudation of water – serous fluid

8. Wound type – Marmagata Vrana – Wounds are present in the vital spots.

Nature of exudates –

–       not described separately, this is because these are included under skin etc. i.e. the exudation will be similar to those explained in cases of wounds located in the skin etc. above

Now, the features of discharges / exudates coming from the wounds occurring in the skin, muscles, ligaments, veins etc. structures depending on the doshas involved will be explained in respective order as follows –

Vata symptoms – When vata is involved in the wounds, the discharges produced therein (depending on from which vrana vastu – seat of wound the exudates is flowing) are-

–       rough – in exudates of skin
–       black (blackish blue) – in exudates of muscles
–       dew drop – in exudates of veins
–       whey – in exudates of ligaments
–       alkali solution – in exudates of bones
–       mutton wash – in exudates of joints
–       boiled rice wash (gruel) – in exudates of abdominal viscera

Pitta symptoms – When pitta is involved in the wounds, the discharges produced therein (depending on from which vrana vastu – seat of wound the exudates is flowing) are-

–       gomedaka – in exudates of skin
–       cow’s urine – in exudates of muscles
–       conch – in exudates of veins
–       solution of ash – in exudates of ligaments
–       decoction – in exudates of bones
–       madhvika – in exudates of joints
–       taila / oil – in exudates of abdominal viscera

Rakta symptoms – are similar to those of pitta along with too much of bad smell in the exudates.

Kapha symptoms – When kapha is involved in the wounds, the discharges produced therein (depending on from which vrana vastu – seat of wound the exudates is flowing) are-

–       butter – in exudates of skin
–       kasisa / ferrous sulfate – in exudates of muscles
–       marrow – in exudates of veins
–       flour – in exudates of ligaments
–       sesame – in exudates of bones
–       coconut water – in exudates of joints
–       boar fat – in exudates of abdominal viscera

Sannipata symptoms – when all the three doshas are involved in the wounds, the exudates coming from them will be similar in color of coconut water, juice of ervaru (cucumber), scum of gruel, juice of  Aruka (bhallataka), fruit of Priyangu, Yakrti( liver) and soup of Mudga (green gram) in exudates of skin, muscles, veins, ligaments, bones, joints and abdominal viscera respectively.

Exudates coming from various organs

श्लोकौ चात्र भवत:-
पक्वाशयादसाध्यस्तु पुलाकोदकसन्निभः ॥
क्षारोदकनिभःस्रवो वर्यो रक्ताशयात्स्रवन् ॥९॥
आमाशयात् कलायाम्भोनिभश्च  त्रिकसन्धिजः ॥
स्रावानेतान् परीक्ष्यादौ ततः कर्माचरोद्भिषक ॥१०॥

Two more verses here:-

The exudates coming out from different organs should be firstly examined by the physician and later he should plan and administer suitable treatments. Example of exudates from different organs are –

Vrana Vedana: Kinds of pains in the wounds:-

अत ऊर्वं  सर्वव्रणदेना वक्ष्यामः- तोदनभेदनताडनच्छेदनायामनमन्थनविक्षोपणचुमुचुमायननिर्दहनावभञ्जनस्फोटनविदारणोत्पाटनकम्पनविविधशूलविश्लेषणविकिरण स्तम्भनपूरणस्वप्राकुञ्चनाङ्कुशिकाः संभवन्ति, अनिमित्तविविधवेदनाप्रादुर्भावो वा मुहुर्मुहुर्यत्रागच्छन्ति वेदनाविशेषास्तं वातिकमिति विद्यात् ;  ओषचोषपरिदाहधूमायनानि यत्र गात्रमङ्गारावकीर्णमिव पच्यते यत्र चोष्माभिवृद्धिः क्षते क्षारवसिक्तवञ्च वेदनाविशेषास्तं पैत्तिकमिति विद्यात् ; पित्तवद्रक्तसमुत्थं जानीयात् ; कण्डूर्गरुत्वं सुप्तत्वमुपदेहोऽल्पवेदनत्वं स्तम्भः  शैत्यं च यत्र तं श्लेष्मिकमिति विद्यात्; यत्र सर्वांसां वेदनानामुत्पत्तिस्तं सान्निपातिकमिति  विद्यात् ॥११॥

From here, different kinds of pains of the wounds shall be described –

Pains caused by Vata predominance in the wounds –

–       piercing, tearing, hitting, cutting, dilating, churning, seizing, tingling, type of pains
–       burning, crushing, breaking (blasting), tearing, plucking (as if de-rooted, plucked), trembling and various kinds of pain,
–       splitting (as if separating or tearing into two),
–       as if being thrown away in all directions,
–       filling,
–       stiffness,
–       numbness (absence of pain or sensation),
–       absence of pain (numbness),
–       shrinking / sucking (as if flexing or withdrawing),
–       pain as if pierced by hooks etc. and
–       various kinds of pains developing without any apparent cause, and
–       various kinds of pain appearing and disappearing frequently

If these symptoms are present it should be understood that they are caused by aggravated vata.

Pains caused by Pitta predominance in the wounds –

–       local burning sensation and also burning sensation experienced all over the body,
–       sucking pain,
–       feeling as if hot fumes are coming out from inside the body
–       feeling as though the body is covered with burning red hot coal,
–       ulceration,
–       increase of temperature – either localized or generalized
–       severe pain in the wounds as if alkali has been applied over the wounds,

Pains caused by Rakta (blood) predominance in the wounds – Symptoms are similar to those caused by pitta, as explained above.

Pains caused by Kapha predominance in the wounds –

–       itching,
–       heaviness in the body or around the wounds,
–       numbness,
–       feeling as if something is sticking or a feel of something being coated on the body,
–       mild pain,
–       stiffness
–       coldness

Pains caused by predominance of all three doshas in the wounds – In this condition all kinds of pains as caused by all three individual doshas are collectively present.

 Vrana varna: Colour of wounds

 अत ऊर्ध्वं व्रणवर्णान् वक्ष्यामः- भस्मकपोतास्थिवर्णः परुषोऽरुणः कुष्ण इति मारुतजस्य; नीलः पीतो हरितः श्यावः कॄष्णो रक्तः पिङ्गलः कपिल इति रक्तपित्तसमुत्थयोः;श्वेतः स्निग्धः पाण्डुरिति श्लेष्मजस्यल् सर्ववर्णोपेतः सान्निपातिक  इति ॥१२॥

Next, the color of the wounds as caused by dosha aggravation in them is explained –

One verse here:-

 न केवलं व्र णेषूक्तो वेदनावर्णसंग्रहः ॥
सर्वशोफविकारेषु व्रणवल्लक्षयेद्भिषक ॥१३॥

Many kinds of pains and colors are mentioned in the above contexts. They are not limited to the wounds only. These should be considered for diagnosing all kinds of diseases manifesting with swelling.

इति श्रीसुश्रुतसंहितायां सूत्रस्थाने व्रणास्रावविज्ञानीयो नाम द्वाविंशतितमोअध्यायः ॥२२॥

Thus ends the twenty second chapter by name Vranasrava vijnaniya in Sutra sthana of Susrutha samhita.