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International Journal of Trend in Scientific Research and Development (IJTSRD) Volume 5 Issue 4, May-June 2021 Available Online: www.ijtsrd.com e-ISSN: 2456 – 6470 @ IJTSRD | Unique Paper ID – IJTSRD43736 | Volume – 5 | Issue – 4 | May-June 2021 Page 1683 Management of A Rūksha Dagdha Vrana by Treatment Procedures used in Rajasekara Tradition - A Case Study Charitha. L. Muthukuda1, Padmasiri Rajasekara2 1National Institute of Traditional Medicine, Department of Ayurveda, Nawinna, Maharagama, Sri Lanka 2Rajasekara Ayurveda Burn Hospital, Gorakadeniya, Yakkala, Sri Lanka ABSTRACT Burn injuries are most devastating and painful condition causing major physical, mental, emotional and social trauma. In Sri Lanka, ∼10 000 injuries and 100 deaths are burn related annually. Affected patients may lead into post burn complications like contractures, pigmented scar and keloid formation. This study was done in search of more effective, eco-friendly and cost effective way to treat burns and to avoid post burn complications. A case report of second degree burn has been presented here. A male patient of 43 years of age presented with complaints of burns over both upper limbs and face due to a burst gas stove. He was associated with pain, burning sensation and slight discharge. The patient was treated with polyherbal internal and external medications used in Rajasekara tradition for a period of 21 days. Changes in subjective and objective parameters were observed during treatments and for a follow up period of 2 weeks. Pain and burning sensation were completely relieved on day 14. Oedematous red coloured wound presented at the beginning was minimal with the treatments. Appearance of healthy granulation tissue was present at the end of treatments. No post burn complications like contractures of the skin and keloid formation were identified during follow up period of 2 weeks. Sulahara, vedanasthapana and ushna guna of ingredients in formulations might support in subsiding pain while sheeta virya benefited in relieving burning sensation. Kasaya rasa, vranaropaka, vranashodana, snehana, krimihara, tvagdosahara, varnya, bhutaghna, lekhana guna facilitated in proper burn wound healing without post burn complications. KEYWORDS: Rūksha dagdha vrana, Post burn complications, Traditional medicine How to cite this paper: Charitha. L. Muthukuda | Padmasiri Rajasekara "Management of A Rūksha Dagdha Vrana by Treatment Procedures used in Rajasekara Tradition - A Case Study" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456- 6470, Volume-5 | Issue-4, June 2021, pp.1683-1687, URL: www.ijtsrd.com/papers/ijtsrd43736.pdf Copyright © 2021 by author (s) and International Journal of Trend in Scientific Research and Development Journal. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) (http: //creativecommons.org/licenses/by/4.0) 1. INTRODUCTION Burns are a significant cause of morbidity and mortality worldwide. Fire-related burns account for 10 million disability-adjusted life-years lost worldwide annually (WHO, 2003). The impact of physical disfigurement due to burns is far reaching, as social stigma may lead to isolation and other psychological impairments limiting one's productivity (WHO, 2008). In Sri Lanka, ∼10 000 injuries and 100 deaths are burn related, costing US$1 million annually (Lau, 2006). Sri Lanka developed its own medical system based on a series of prescriptions handed down the generations to generation over a period of 3000 years. Indigenous medicine of Sri Lanka called Desiya chikitsa wasbefore 8000 – 10 000 years ago (Samaranayaka, 2017). Rajasekara tradition of burn treatments is such a generation in Sri Lanka which are continuing their special field of deshiya chikitsa even today. Rajasekara tradition treats both physical and mental condition of the patient. They treat for psychology by chanting mantras which has influence on the relief of the symptoms. Speciality of this tradition is curing the burnt individual without any post burn deformities using their timely proven treatment modalities. Word Dewum pilissum has two different meanings. Dewum means touching the skin with heated objects. Damage only to the first layer of the skin. In Pilissum, damage occurs in more than one layer of the skin. Ruksa dagdha are burn injuries with dry maters; gunpowder, lightening, electricity, explosives. Drava dagdhaare burn injuries with hot water, warm honey, warm gruel, tar, warm oil. In traditional system of medicine stages of burns are classified as dva dagdha, mamsa dagdha, shira dagdha, snayu dagdha, sendhi dagdha, marma dagdha, indriya dagdha. Burn injury involves complex pathology. Burn patients are more predisposed for infection due to suppressed immunity. Burn wound is a fertile land for the growth of various microorganisms. Due to more or less destruction of microcirculation in the burnt area, systemic antibiotics are not very much effective in treating local wound infections. Also the rise of antibiotic resistant organisms, is posing a great problem in use of systemic antibiotics. (Dhrubajyoti&Kumar, 2018). Affected patients may land into post burn complications like keloid formation, contractures, hypo or hyper pigmented cars (Vishwas et al, 2016).Hence there is always a space for more effective, eco-friendly and cost effective way to treat burn injuries avoiding post burn complications. Thel kira and medicinal oil are two formulations of herbal preparations used by Rajasekara tradition for all types of dry heat burn wounds over the generations. Thel kira is a IJTSRD43736 International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470 @ IJTSRD | Unique Paper ID – IJTSRD43736 | Volume – 5 | Issue – 4 | May-June 2021 Page 1684 composition of Amu kaha (Curcuma longa), Dan (Syzygium cumini), king coconut (Cocos nucifera). Medicinal oil composed of pokuru vada (Hibiscus rosa sinesis), kaluduru (Nigella sativa), Amu kaha (Curcuma longa), tila taila (Sesame oil), cow's milk. Decoction used has venivelgeta, kottamalli, beli mul and vee pori. These polyherbal internal and external medications are having both sodhana and ropana actions which in turn results in proper healing of the wound without complications. The case reported here with the informed consent of the second degree burnt patient was observed for the effect of treatment procedures used in Rajasekara tradition. 1.1. Aims and objectives To study the effect of thel kira, herbal oil preparation and decoction used in Rajasekara tradition in the management of Rūksha Dagdha Vrana. 2. MATERIALS AND METHODOLOGY 2.1. Case report A male patient of 43 years of age came with complaints of burns over both upper limbsand face due to burst gas stove in the morning. Patient was having pain, burning sensation and a slight discharge at wounds. Past history- patient was not having a history of diabetes, hypertension, dyslipidaemia. On examination- There was blister formation on both upper limbs and face. Mild discharge was present over the wound. No purulent discharge was seen. All other systemic examinations are intact. 2.2. Preparation of thel kira Barks of Dan (Syzygium cumini) – 2 pounds Amu Kaha (Curcuma longa) – 1 pound king coconut (Cocos nucifera) – 2 nutsAll the collected drugs were made authenticated for its identity and genuinity by Dr. Rajasekara.All the materials were weighed and cleaned properly.Amu kaha (Curcuma longa) were grounded and put into another vessel.2 nuts of king coconut were scraped and juice was collected. Fresh juices of these three ingredients were mixed well. The mixture was kept under sunlight for 1 day. The oil is ready to use from the following day. This is known as thel kira. 2.3. Preparation of the oil to be applied. Pokuru vada (Hibiscus rosa-sinensis) - 1 pound kaluduru (Nigella sativa), - 2 kalan Amu kaha (Curcuma longa) – 250g Tila taila (sesame oil) – 1 bottle Cow's milk – 1 bottle All the collected drugs were made authenticated for its identity and genuinity by Dr.Rajasekara. All the materials were weighed and cleaned properly. Fresh turmeric was chopped and cold extract was taken. Buds of Hibiscus were added to 1500 ml of boiled water and filtered. Cow's milk, sesame oil, cold extract of turmeric was added to the filtration. This mixture was heated in mild flame. The heating was continued by adding kaluduru until the whole mixture comes to khara paka. 2.4. Treatment given Patient was advised to admit to Rajasekara burn hospital for the treatments. 1st week: Sufficient quantity of thel kira was applied using a feather of a hen. Then medicinal oil was applied over the wound every morning and evening. And ensured that it spreads uniformly all over the surface of the wounds. After the application of thel kira and medicinal oil over the wound, patient was advised to keep the wound uncovered but not to expose the wound to dirty surroundings or contact with any materials like soil, dust etc. Wounds were fumigated with hal dummala. At 6 am/ 6 pm; He was given the decoction made with venivelgeta, kottamalli, vee pori, beli mul. Decoction has to be prepared by taking 2 kalan of each ingredient and boil 4 parts of water into 2 parts. Patient was asked to take ½ parts once in 3 hours. At 10am / 4pm; 1 teaspoonful of Talisadi curna with bee honey was given to lick. Patient was advised to have patya ahara and viharana. 2nd week: Tel kira and medicinal oil were applied and fumigated with hal dummala in every morning and evening. At 6 am/ 6 pm; She was given the decoction made with venivelgeta, kottamalli, vee pori, beli mul. 3rd week: Application of tel kira, medicinal oil and fumigation were continued. As his wounds got cured he was discharged from the hospital and asked him to visit the physician for further follow up. Observations on the subjective and objective changes with the treatment were made for 3 weeks. Furthermore, patient was observed for a follow up period of 2 weeks. During these period he was advised to have patya ahara and viharana as follows. patya aharaviharana - porridge processed with rice, vegetable soup, Rice with gravy, Fresh fruit juice Advised to drink luke warm water. Apatya aharaviharana- prawn, cuttlefish, lobster, tuna, pickles, tomatoes, breadfruit. Criteria for the assessment of result Subjective Parameters 1. Pain The changes in the pain with the treatment were considered as follows. The pain which was intolerable, constant and makes to seek medical help as early possible was considered as severe and denoted as- III Constant, tolerable pain and subject can wait even for some days in seeking medical help was considered as moderate and denoted as –II The pain which was tolerable, negligible considered as mild and was denoted as –I The absence of pain is considered as nil and denoted as – 0 2. Burning sensation The change in the burning sensation during the treatment was considered as follows. International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470 @ IJTSRD | Unique Paper ID – IJTSRD43736 | Volume – 5 | Issue – 4 | May-June 2021 Page 1685 The burning sensation which was intolerable, constant and makes the patient seek medical help as earlier possible is considered as severe and denoted as -III The burning sensation which was constant and tolerable and subject can even for some days in seeking medical help is considered as moderate and denoted as- II The burning sensation which was tolerable, negligible is considered as mild and denoted as-I The absence of burning sensation is considered as nil and denoted as – 0 Objective parameters Discharge at the wound Oedema and redness around the wound. Colour of base of the wound 3. RESULTS AND OBSERAVATIONS Table 1- Assessment of subjective criteria Before treatments On day 14 On day 21 Pain III 0 0 Burning sensation III 0 0 Table 2- Assessment of objective criteria Before treatments On day 14 On day 21 Discharge at the wound Slight discharge not purulent No discharge No discharge Oedema and redness around wound Significant oedematous edges. Oedema was minimal showing epithelium Absence Appearance Quantity and colour of wound base Redness & presence of raw surface of wound Appearance of granulation tissue Healthy granulation tissue and signs of epithelization of margins No post burn complications like contractures of the skin and keloid formation were identified during follow up period of 2 weeks. 4. DISCUSSION 4.1. Discussion Rūksha dagdha vranawas managed by combination of tropical and systemic agents. Local application of medicine has a great role in burn wound management. Thel kira and medicinal oil perform various roles in the process of healing the wound. Probable mode of action of each ingredient are as follows. The probable action due to which pain was reduced in patient could be because thel kira and medicinal oil have usna (hot), and sulahara (pain relieving) properties. Kaluduru, amu kaha and tila taila have usna guna.At the same time Kaluduru, Amu kaha and tila taila have sulahara and vedanastapaka properties1 (Ayurveda pharmacopoeiaAP, 1979). Regression of pain may be also due to presence of sneha dravya in the preparation. Tila taila and cow's milk 1AP- Ayurveda pharmacopoeia have snehana guna(AP, 1979).Sheeta (cooling) virya of dan, king coconut, Hibiscus, cow's milk could have reduced daha (burning sensation) in dagdha vrana (AP, 1979). Discharge of dagdha vrana could have subsided due to ruksha, sthanmbhana properties. Kaluduru, Hibiscus, amu kaha, dan have ruksa guna (AP, 1979). Sthambhaka guna of dan, tila taila, cow's milk might have helped to reduce discharge at the wound. The likely action due to which floor reduced in patients could be because of ruksha (dry), krimihara (anti-microbial), tvagdosahara properties which might have lessened the slough in wound. Kaluduru, Hibiscus, Amu kaha and dan are said to be ruksha in property. Dan, amu kaha and dan possesses tvagdosaharaguna (AP, 1979). Varnya property of amu kaha and tila taila might have assisted in deducting the discoloration of vrana. Similarly, the potential action due to which healing took place in patient could be because of Vranaropaka (healing), Sandhankara, Bhutaghna (anti-microbial) and snigdha (moisturising) properties. Amu kaha, tila taila have vrana sodhana action (AP, 1979). Amu kaha, tila taila, cow's milk and king coconut are vrana ropanain action (AP, 1979). Kasaya and lekhana properties are removing dead, necrosed tissue from burn wound and facilitate formation of granulation tissue. Dan (Syzygium cumini), Hibiscus rosa sinesis have kasaya rasa2(Aushadhiya shaka sangrahayaASS, 2001). Kaluduru and amu kaha have lekhana properties (AP, 1979). Decoction is made of venivelgeta, kottamalli, beli mul and vee pori. Venivelgeta is having raktha sodhaka properties which promote wound healing. Kottamalli has usna, snigdga guna which subsides vata, kasaya, madhura, tikta properties which subsides pitta and tikta, katu, usna properties which subsides kapha which in turn has tridosa samaka dosa karma(AP, 1979). Usna guna of beli relieves vata and ruksha, laghu, kasaya, tikta properties relieve kapha (AP, 1979). Vitiated pitta is responsible for paka kriya which by vitiating rakta forms puya. Pitta samaka dravya control upon the paka kriya, which results in subsidence of srava. Absence of srava, suggestive of the wound is devoid of infection. Oil is non polar hydrophobic, insoluble in water and floats on water. It may prevent fluid loss from burn wound and lubricate the surface of wound. Oil layer prevents the entry of germs acting as a covering layer. Various fatty acids in it have better healing property and good absorption. The natural essential fatty acids in formulation easily penetrate into cell membrane to enhance drug penetration. As cell membrane is a phospholipid bilayer, it is non polar and hydrophobic. So non polar ingredients can easily penetrate the cell membrane (Courteny&Daniel, 2015). Wound healing property of major phytoconstituents; flavonoids, Tannins and anthraquinones present in herbs augments healing process. Flavonoids and phytosterols in herbs promote epithelialization for wound healing process with increased capillary formulation and fibroblast proliferation enhancing the rate of epithelization (Norman &Christoper, 2008). Antioxidants act as a scavenger and probably helped to remove free radicals as well as inhibited further generation 2ASS -Aushadhiya shaka sangrahaya International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470 @ IJTSRD | Unique Paper ID – IJTSRD43736 | Volume – 5 | Issue – 4 | May-June 2021 Page 1686 of free radicals (Faten et al, 2012). Anti-microbial activity which have the ability to disinfect and destroy microorganisms and to break biofilms which are formed by microorganisms. They reduce wound infection due to bactericidal action of drug (Kumar et al, 2007). In view of such results it can be said that thelkira, medicinal oil and decoction show equally encouraging results in proper wound healing without post burn complications 4.2. Conclusion This case study reveals that burn wound treatment protocols used by Rajasekara tradition provide good and faster wound healing. It can help in minimizing post burn complications like contractures, keloid formation, hyper pigmentation and hypopigmentation. 4.3. Suggestions Traditional burn treatments mention a lot of preparations for burn wound care over the generations. These medicines had been used in ancient times and pre-antibiotic era most probably with success. So there is a need of revalidating these preparations in terms of modern parameters and thus making them acceptable, accessible and available for thecommunity. BIBLIOGRAPHY [1] Aushadhiya shaka sangrahaya, vol III, (2001), Department of Ayurveda. [2] Ayurveda pharmacopoeia, vol I part 3, (1979), Department of Ayurveda. [3] Courteny M., Daniel A., pocket companion to Sabiston text book of surgery; 17th edition, New Delhi, 2015. [4] Faten, R., Ghaffar, A., El-Elaimy, I., (2012). In-vitro, antioxidant and scavenging activities of Hibiscus rosa- sinensis crude extract, J App Pharm Sci. 2:51–58. [5] Kumar, G. S., Jayaveera, K. N., Ashok, C. K., Umachigi, P., Sanjay, BM., Swamy, V., Kishore, D. V. K., 2007. Antimicrobial effects of Indian medicinal plants against acneinducing bacteria, Tropical Journal of Pharmaceutical Research, 6(2), 717-723. [6] Lau, Y. S., An insight into burns in a developing country: A Sri Lankan experience, 2006. Public Health, vol. 120 10 (pg. 958-65). [7] Norman, S., Christoper, J. K., 2008. Belly and Loves short practice of surgery; 25th edition, India. [8] Samaranayaka, G. V. P., Pushpakumara, A. A. J., 2017. A literary review on traditional medical system for boils, wounds and cancer in Sri Lanka, Journal of Ayurveda herbal medicine and innovative research. [9] Dhrubajyoti, T., Kumar, B. P., 2018. A Review of Burn Injury and its Management in Ayurvedic System of Medicine: A Comparative Study for Local Wound Care. International Journal of Ayurveda and Pharma Research; 6(4):29-36). [10] Vishwas, H., Vidhate, B. N., Banarase, M., Bhosale, P., 2016. Management of burn wound with local application of jeerakghrita. J Biol Sci Opin;4(2):29-32. [11] World Health Organization, A WHO plan for burn intervention and care, 2008. [12] World Health Organization The injury chart book: a graphical overview of the global burden of injuries, 2002. Figure 1- Burn wounds on the first visit Figure 2- Burn wounds after treatments International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470 @ IJTSRD | Unique Paper ID – IJTSRD43736 | Volume – 5 | Issue – 4 | May-June 2021 Page 1687 Venivelgeta(Coscinium fenestratum) (AP, 1979) Kottamalli (Corriandrum sativum) (AP, 1979) Beli mul (Aegle marmelos) (AP, 1979) Rasa tikta, kasaya Madhura, katu, tikta, kasaya kasaya, tikta Guna laghu, ruksha laghu, snigdha ruksa, laghu Virya Usna Usna usna Vipaka Katu Madhura katu Dosa karma kapha pittahara tridosa samaka kapha vata samaka Table 3- Rasa, guna, virya, vipaka, dosa karma of decoction Hibiscus rosa sinesis (ASS, 2001) Kaluduru (Nigella sativa) (AP, 1979) Curcuma longa (AP, 1979) Tila taila (AP, 1979) Cow's milk (AP, 1979) Rasa Kasaya, tikta Katu, tikta Tikta, katu Madhura Madhura Guna Laghu, ruksha Laghu, ruksa, tiksna Ruksa, laghu Guru, snigdha Guru, snigdha Virya Sita Usna Usna Usna Sita Vipaka Katu Katu Katu Madhura Madhura Prabhava Kesya Dosa karma Kapha pitta samaka Kaphavata samana, pit vardhaka Kapha vata samaka, pitrecaka Vata samana Vata pitta nasaka, kapha vardhaka Bahya karma Lekhana, sotahara, vedanastapana Sotahara, vedana stapana, varnya, kustaghna, vrana sodhana, vrana ropana, lekhana Snehana, vedana stapana, sandhaniya, vrana sodhana, vrana ropana Snehana, sandhaniya,ropana Table 4- Rasa, guna, virya, vipaka, dosa karma of medicinal oil Table 5- Rasa, guna, virya, vipaka, dosa karma of thel kira Dan (Syzygium cumini) (AP, 1979) Kingcoconut (Cocos nucifera) (AP, 1979) Amu kaha (Curcumin longa)(AP, 1979) Rasa Kasaya, madhura, amla Madhura Tikta, katu Guna Laghu, ruksha Guru, snigdha Ruksha, laghu Virya Sita Sita Usna Vipaka Madhura Madhura Katu Prabhava Kesya Dosa karma Kapha pitta samana vatapitta samana Kaphavata samaka Bahya karma sthambhana, tvagdosahara, daha prasamana. varnya, dahanasaka, kustaghna, vrana ropana sotahara, vedana stapaka, varnya, kustaghna, vrana sodana, vrana ropana, lekhana
