REVISIT OF AYURVEDA A NEED OF EVIDENCEBASED DOCUMENTS

PROF. J.N. MISHRA (Ph.D.)

EX. HEAD POST GRADUATE DEPT. OF RACHNA SHRIRFACULTY OF AYURVEDALUCKNOW UNIVERSITY,U.P, INDIA

HOLISTIC ?

• HOLISTIC HEALTH : is physical, mental, emotional and spiritual wellbeing.

• HOLISTIC MEDICIE: Several ancient healing traditions.

HISTORICAL BACKRGOUND

• SOCRATIES

Promoted a holistic approach.

469-399 BC

PLATO

HYPOCRATES

Advocated holism.

Emphasised the body’s ability to heal itself.

424-348 BC

460-370 BC

AYURVEDA

Treats the man not the disease. Thus keeps the body and soul together.It prefers to deal with vitality than immunity and believes in ‘Prevention is better than cure.’

ABOUT 1000 BC

Why world’s anxiety for A.M ? Iatrogenic illness due to OM treatment is now recognized as a

health hazard of global proportion and its detrimental effect is so extensive that it is termed “Iatroepidemic” (Review of Respiratory diseases 1987)

180,000 people die in US each year partly as a result of iatrogenic injury (J.A.M. 1994)

There were more than 12000 death’s in a year due to over sight and investigations for unwanted surgery. (USA Today, October 31, 1983)

OM is contravening the basic concept of Hippocrates oath- First, do not harm.

People horrified of side effects of synthetic drugs, dissatisfaction of O.M. Diseases that can not be cured by O.M and more expectations and attention from O.M

Therefore we are knocking at the door of A.M.

HISTORICAL BACKGROUND OF DIFFERENT MEDICAL CULTURES

• CHINESE medicine claims to be the first organised body of medical knowledge (2700 BC)- Excellence of Acupuncture anaesthesia.

• Ayurveda originated in India about 5000 BC back and propagated theory of TRIDOSH (Vata, Pitta,Kafa)

Sushrut is first to introduce Rhinoplasty

• Egyptian Medicine believed that disease is due to putrefaction of blood and formation of pus.

• The Greek theory of Humours- Blood, Phlegm yellow Bile and Black bile is similar to Tridosh theory of Ayurveda.

MARMA ?

• There are certain points on the surface of the body which are vulnerable due to specific underlying structures and trauma causes definite sequelae as compared to non vital areas. (Asth. Hrid 7; sush shar 6:2-3)

(Marma is recognized by any trauma on an area causing morbidity or mortality.)

Extreme result of high-tech trauma

Vital points on the surface of the body- Sushrut

• Rig veda (5000BC) is knowledge from divine source refers trauma of soldiers and its management by skilled surgeons (Rigveda commentry by Marsyanacharya, Volume I –X; 1:8-116-15)

Illustration from Mahabharat

WOUNDS OF ANCIENT TIME The wounds of ancient times were predominately caused by

stabs, cuts, pierce etc. (Illustrations from Ramayan and Mahabharat)

They are caused by low velocity missile and path is guided by its tail attached to it.

There is a decline in morality rate in successive wars, since innovation in management and invention of new surgical conditions such as arterioveneous fistula and false aneurism in Vietnam and Korean War. (Mortality rate from 15% in 1846 to 2.7% in 1961)

However trauma showed major civil problems due to automobile and firearm injuries

Wide spread use of automobile and the frank use of firearm have lead to trauma epidemic. (First automobile accident took place in 1899 and fire arm was introduced in Europe in 14 centaury)

TRAUMA OF NEW ERA

TRAUMA MANAGEMENT OF NEW GENERATION

• In era of advancement of surgical skill and management, the instant fatal injuries have been replaced by recovery. This questions the significance of Marma ?

• But progress in severity of trauma is not static and parallel race between fatal techniques and repair management is simultaneously going on.

G.S.I of thigh Intensive Care

• Inspite of progress in trauma management the post traumatic conditions still depend upon; A. The site of traumaB. The kind of inflecting object C. The intensity of traumaD. The amount of tissue lossE. The narrow time between trauma and managementF. The quality of medical services availableNote: The factors from A-D are not under controll of surgical

development; the only factors E-F are likely to be improved, therefore marma still retains its significance and may not loose in future too.

PROGNOSTIC STATUS OF MARMA

SUBJECT OF STUDY

•Two marmas - URVI and LOHITAKSHA have been subjected for evidence based study .

•Sushrut’s observations of URVI and LOHITAKSHA

Description URVI LOHITAKSHA

Surface anatomy Centre of thigh Root of the limb below hip joint

Structure Sira (Vessel) Sira (Vessel)

Post traumatic effect Wasting of limb Palsy and wasting of limb

Cause Hemorrhage Hemorrhage

LACUNA IN THE KNOWLEDGE

•There are diversified views regarding their structure location and subsequent post traumatic sequelae due to lack of documentation.

OBJECT OF STUDY

•To find out the vascular structure responsible for Abhighat Parnam (Post traumatic result).

•To verify the cause of post traumatic result stated by Sushrut.

•To evaluate the status of Marma in present scenario of high-tech management.

MATERIAL AND METHOD

• Ayurveda has three modes to approach the subject of application- APTODESH (written document/narration), ANUMAN (circumstantial evidence) and PRATYAKSHA (Eye witness)

In present study APTODESH and ANUMAN- PRAMAN have been used to evaluate Sushrut’s version about traumatic result of URVI and LOHITAKSHA Marma.

• According to Sushrut Urvi and Lohitaksha Marma are sira (vessel) Marma (Sush. Shar 6:10). URVI Marma is situated in middle of thigh and trauma causes wasting of the muscles due to hemorrhage (Sush Shar 6:31). The LOHITAKSHA Marma situated at the root of the limb and below hip joint, trauma causes palsy and wasting of muscles due to hemorrhage (Sush Shar 6:31)

• The surgical records of index cases published in different journals were used to verify and evaluate the Marmas.

CONTINUE…

APTODESH PRAMAN

ANUMAN PRAMAN

Observations• A 28 yrs old man in a road traffic accident on 2nd June

2003 received a deep ulceration of about 4cm at the left groin region with multiple ragged tears on the left common femoral vein. Post repair healing left with EPCILATERAL LYMPHODEMA which remained non progressive till last seen in Jan, 2004. (by Onahlfeani and Onumeagbu, national orthopedic hospital, Enugu)

Post traumatic repair of femoral vein left the residue.

• In a study of 109 acute common femoral arterial injuries, more than one half of them were lacerated; the following observations were in iatrogenic injuries associated with catheterization of the common femoral artery at Walter Reed Medical Centre.

A. Autogeneous Graft Repair About 57%B. End-to End anastomoses About 25%C. Lateral suture repair About 10%D. Complication rate 28.3%E. Amputation rate 13.2%F. Mortality rate 2.8%

(J. Trauma, 1975; 15 (8): 628-37)

Note: Iatrogenic invasive investigation on femoral artery also claims morbidity and mortality.

Observation of femoral vessels injuries in modern warfare since Vietnam

S.R No.

Place with reference

% of Fem. Artery injury

% of Fem. Vessel Injury

Management Given

% of Amputaio

n

% of Mortalit

y

1 Vietnam 351 (35.15%) - - 27 -

2 Vietnam(Mc Mara et

al)

82 (28) - Saph Vein graft

41 (53)

12 -

3 Beirut Dajani et al

- 150 (18) (60) g.s.i

sharpnel(35)

Saph Vein Graft (40)

3.3 6 (4)

4 Sfeir et al 141 (36.37) 111 (28.63) 152 grafting repair and

ligation

8 10

5 Crotia Osijek

University

41 (43) Different methods

2 10

6 Somalia Mabry et al

- - - 1 Blast injury

14

http:/findarticles.com/p/articles/m_903912/is_200309/ai_n9255794/

Note: Inspite of high technology of management post traumatic threat could not be ruled out – approves Sushrut’s Observation

• In northern Ireland a unique series of lower femoral vascular injuries caused by low velocity missile/bullets. (Groman, J.F., Camat arterial trauma analysis of 106 limb threatening injuries. Arch surgery 58,1969,160-164)

• Following observations were noted.A. Limb Amputation 5B. Amputation 1

(After 15 months)C. Poor limb function 9

Following revascularization

Note: The best vascular trauma management is not free from limb amputation/poor limb function

• Femoral neuropathy causes weakness predominantly of the quadriceps muscles difficulty with ambulation due to direct trauma compression. The nerve can be compressed anywhere along the course but it is particularly susceptible within the body of the psoas muscle, at the iliopsoas groove and at the inguinal ligament. (Former SS, Carpenter J.P Fireman RM, Velazquez OC, Mitchell ME . Femoral neuropathy following retroperitoneal hemorrhage: case serial and review of the literature. Ann. Vasc. Surg. Jul 2006; 20(4):536-40 medline)

Note: Sushrut conceived femoral neuropathy due to trauma compression on femoral nerves due to hemorrhage.

Discussion• URVI marma lies beneath the apex of the

femoral triangle in the lower limb being most vulnerable area of front of the thigh (femoral triangle). The trauma commonly produces Shakti Sosha (wasting of the limb) due to hemorrhage or pressure by hematoma from outside. The arterial insufficiency may produce motor paralysis and disuse atrophy of muscles and later on may lead to dry gangrene.

• LOHITAKSHA marma is situated at the inguinal ligament below the hip joint at the root of the limb. Trauma generally causes the palsy of the muscles or wasting of the limb due to ischemia and hemorrhage. (Shu. Shas 6:10,31)

• The exposure of the muscles due to blunt violence to the groin revealed dark blue colored, swollen and non pulsatile with complete occlusion of lumen. These vessels were unsuitable for thrombectomy for direct repair and bypass principles were mandatory. (East Cott. H.N.G., Antennal Surgery pitman, London 246, 1969)

• In unique series of lower femoral vascular injuries caused by low velocity bullets, limb amputaion, poor limb function following revascularization, severe calf muscle wasting due to ischemic necrosis were found.

(Surgical and pathological evaluation of vascular injuries in Vietnam, J trauma 9,279-291;1969)

Note: Sushrut made the similar observation.

• Femoral vein injury is commonly seen in association with femoral artery but occurs less frequently.(Cargile JS, Hunt JL, Panduc GF. Acute trauma of the Femoral Artery and vein J Trauma, march 1992;32(3):364-370)(Dajani OM, Hadded FF, Hajj HA, Sfeir RE, Khoury GS, Injury to the femoral vessels - The Lebanese was Experience Eur.J.Vasc.Surg, 1988 Oct, 2(5):293-296)

• Missile injury is the common aetiology in the military. Isolated femoral vein injury is the least frequent than femoral vessel injuries.

(Hobson RW 2nd, Yeager RA,Lynch TG,Lee BC, Jain K, Jamil Z, Padberg FT Jr. Femoral Venous trauma “ Techniques for surgical management and early result. Am J. Surg. Aug, 1983- 146(2):220-224)

• Life saving amputation has been also educated by Sushrut.(Sush. Shar 6:43)

Note: Cause of high tech trauma could not defy Sushrut.

• Life saving amputation may occasionally be done where artery is severed but where possibly repair of both the vessels are done. In these circumstances vein ligation is an option if repair is precluded. Morbidity is high with venous ligation in presence of arterial injury.(Blumaff R L, Powell T, Johnson G Jr. Femoral venous trauma in a university referral centre. J Trauma August 1982: 22(8):703-705)

• Early edema, lymph ischemia, compartment syndrome and its sequelae may occur. Transient lymph leak has also been noted following femoral vascular repair, lymphodema and late chronic leg ulceration from venous insufficiency.(Goffjm, Gillespie DL, rich NM. Long term follow up of a superficial femoral vein injury: a case report from the Vietnam vascular registry. J Trauma Jan 1998; 44(1):209-211)

• The incident of lower extremity injuries is high in modern warfare; however the mortality rate from injuries is low. Despite of overall low mortality of lower extremity injury, many deaths in modern conflicts are due to femoral vessel injury. Despite the advances in modern body armor, the groin is left unprotected. A strategy to help minimizes US casualty in modern warfare may be method of field homeostasis specifically designed for femoral vessel injury.(http://findarticles.com/p/articles/mi_903912/is_200309/ai_n9255794/)

• In spite of advances in vascular surgery, the result of repair of lower femoral artery may remain poor.(Forman JF, Rich NM, Baugh C et al. Surgical and pathological evaluation of vascular injury in Vietnam, J Trauma 1969; 9:279-291)

Conclusion

• Sushrut has highlighted two femoral vascular ends in femoral triangle one at inguinal ligament and other at apex of the triangle encouraging the injury to the vessels by any projectile but rest of the part of the vessel is mobile and usually escapes from injury.

• Femoral vein repair in spite of best surgical skill and methods leaves post traumatic residue as compared to artery. Sushrut has also upheld the importance of Sira in comparison to artery by naming this Marma Sira predominant.

• Autogenous grafting is done with the help of vein, and again importance of vein is highlighted in modern scenario approving Sushrut’s findings regarding significance of veins. Best management of femoral arterial trauma does not guarantee 100% residue free healing which validates the Urvi and Lohitaksha Marma.

• Femoral arterial hemorrhage is the important factor for surgeons to avoid hemorrhagic complications as noted by Sushrut too.

• The mortality is very rare in femoral vascular trauma and sushrut has also ruled out this possibility and therefore kept this Marma under vaikalyakar(post traumatic morbidity)

• Pakshaghata (Paralysis) is common in upper extremities due to its relative anatomy for concealed hemorrhage as compared to lower extremities threatening open hemorrhage causing ischemic limb or venous insufficiency leading to Shakthisosha (Atrophy). Sushrut also observed general observation of Pakshaghata and Shakthisosha as post traumatic complication of these Marma including limb salvage due to hemorrhage which still stands well today.

ResultRevisit of Ayurveda through classical

views (Aptodesh) and references of published work by different workers on femoral vascular trauma and management brought URVI and LOHITAKSHA marma more on surface. These marmas of Sushrut enjoy the same status even in present scenario of high-tech management and enormously reduced time between trauma and management. This evidence based subject of Ayurveda on URVI and LOHITAKSHA are still held vulnerable.

MessageThe present talk on Revisit of

Ayurveda- A need of evidence based document certainly brings Ayurveda to scientific platform for debate to claim best among all as alternative medicine