Varicose veins

Varicose veins are veins that have become enlarged and twisted. The term commonly refers to the veins on the leg,
although varicose veins can occur elsewhere. Veins have pairs of leaflet valves to prevent blood from flowing backwards (retrograde flow or venous reflux). Leg muscles pump the veins to return blood to the heart (the skeletal-muscle pump), against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work (valvular incompetence). This allows blood to flow backwards and they enlarge even more. Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing. Besides being a cosmetic problem, varicose veins can be painful, especially when standing. Severe long-standing varicose veins can lead to leg swelling, venous eczema, skin thickening (lipodermatosclerosis) and ulceration. Life-threatening complications are uncommon, but varicose veins may be confused with deep vein thrombosis, which may be life-threatening.
Non-surgical treatments include sclerotherapy, elastic stockings, leg elevation and exercise. The traditional surgical treatment has been vein stripping to remove the affected veins. Newer, less invasive treatments which seal the main leaking vein are available. Alternative techniques, such as ultrasound-guided foam sclerotherapy, radiofrequency ablation and endovenous laser treatment, are available as well. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10% of the total blood of the legs, can usually be removed or ablated without serious harm.
Secondary varicose veins are those developing as collateral pathways, typically after stenosis or occlusion of the deep veins, a common sequel of extensive deep venous thrombosis (DVT). Treatment options are usually support stockings, occasionally sclerotherapy and rarely, limited surgery.
Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency,[6] by the size and location of the veins. Many patients who suffer with varicose veins seek out the assistance of physicians who specialize in vein care or peripheral vascular disease. These physicians include vascular surgeons, phlebologists or interventional radiologists.
Signs and symptoms :-
Aching, heavy legs (often worse at night and after exercise).
Appearance of spider veins (telangiectasia) in the affected leg.
Ankle swelling, especially in evening.
A brownish-yellow shiny skin discoloration near the affected veins.
Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema, because of waste products building up in the leg.
Cramps may develop especially when making a sudden move as standing up.
Minor injuries to the area may bleed more than normal or take a long time to heal.
In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard.
Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency.
Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophie blanche.
Complications:-
Most varicose veins are reasonably benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.
Pain, tenderness, heaviness, inability to walk or stand for long hours, thus hindering work
Skin conditions / Dermatitis which could predispose skin loss
Skin ulcers especially near the ankle, usually referred to as venous ulcers.
Development of carcinoma or sarcoma in longstanding venous ulcers. Over 100 reported cases of malignant transformation have been reported at a rate reported as 0.4% to 1%.
Severe bleeding from minor trauma, of particular concern in the elderly.
Blood clotting within affected veins, termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins, becoming a more serious problem.
Acute fat necrosis can occur, especially at the ankle  of overweight patients with varicose veins. Females are more frequently affected than males.
Causes:-
 
Varicose veins are more common in women than in men, and are linked with heredity.  Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury and abdominal straining. Varicose veins are unlikely to be caused by crossing the legs or ankles.   Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction or incontinence, venous and arteriovenous malformations
More recent research has shown the importance of pelvic vein reflux (PVR) in the development of varicose veins. Hobbs showed varicose veins in the legs could be due to ovarian vein reflux  and Lumley and his team showed recurrent varicose veins could be due to ovarian vein reflux.
 Whiteley and his team reported that both ovarian and internal iliac vein reflux causes leg varicose veins and that this condition affects 14% of women with varicose veins or 20% of women who have had vaginal delivery and have leg varicose veins.  In addition evidence suggests that failing to look for, and treat pelvic vein reflux can be a cause of recurrent varicose veins.
There is increasing evidence for the role of incompetent Perforator veins (or "perforators") in the formation of varicose veins.
and recurrent varicose veins.

The roots of ancient Indian surgery

The roots of ancient Indian surgery go back to more than 4000 years ago. Sushruta, one of the earliest surgeons of recorded history (600 B.C.) is believed to be the first individual to describe Rhinoplasty. The detailed description of the Rhinoplasty operation by Sushruta is amazingly meticulous, comprehensive and relevant today.

The historical evidences suggest that plastic surgery originated in India more than two millennia ago and the oldest plastic surgery operation probably relate to nasal reconstruction. Sushruta, an ancient Indian surgeon in 600 BC. is believed to be the first individual to describe Rhinoplasty.

Sushruta (also known as the ‘‘Father of Indian surgery'‘ and ‘‘Father of Indian plastic surgery'‘) authored famous ancient encyclopaedic treatise Sushruta Samhita' (Sushruta's compendium) and vividly described the technique of Rhinoplasty. ‘Sushruta Samhita' is onsidered to be the most advanced compilation of surgical practices prevalent in India around two thousand millennia ago.

In‘Sushruta Samhita', Sushruta emphasized all the basic principles of plastic surgery and vividly described numerous operations in various fields of surgery with significant contributions to Plastic Surgery.

The notable contributions in Plastic Surgery are technique of pedicle flap, repair of ear lobe defects ,repair of traumatic and congenital clefts of the lip, classification of burns ,description of sharp (20 types) and blunt (101 types)instruments, practice of mock operations, cadveric dissection ,use of wine to dull the pain of surgical incisions, code of ethics; however the Rhinoplasty remains the greatest highlight of Sushruta's surgery.

The nose in Indian society has remained a symbol of dignity and respect throughout antiquity. In ancient times, amputation of nose was frequently done as a punishment for criminals, war prisoners or people indulged in adultery. The practice of Rhinoplasty slowly started as a result of the need to reconstruct the external nose and later developed to the full fledged science.

Sushruta is considered as the innovator of the Rhinoplasty technique practised since 600 B.C.The detailed description of the Rhinoplasty operation in the Sushruta Samhita is amazingly precise and comprehensive.

The English translation of Sushruta's original Sanskrit description of the method is as follows : -

“The portion of the nose to be covered should be first measured with a leaf. Then a piece of skin of the required size should be dissected from the living skin of the cheek, and turned back to cover the nose, keeping a small pedicle attached to the cheek. The part of the nose to which the skin is to be attached should be made raw by cutting the nasal stump with a knife. The physician then should place the skin on the nose and stitch the two parts swiftly, keeping the skin properly elevated by inserting two tubes of eranda (the castor-oil plant) in the position of the nostrils, so that the new nose gets proper shape. The skin thus properly adjusted, it should then be sprinkled with a powder of liquorice, red sandal-wood and barberry plant. Finally, it should be covered with cotton, and clean sesame oil should be constantly applied. When the skin has united and granulated, if the nose is too short or too long, the middle of the flap should be divided and an endeavor made to enlarge or shorten it.”

The Sanskrit text of 'Sushruta Samhita' was later translated in Arabic by Ibn Abi Usaybia (1203-1269 AD). As the historical pages started opening up, the knowledge of Rhinoplasty spread from India to Arabia and Persia and from there to Egypt. However, it took centuries for the principles and the technique of Rhinoplasty to travel to Europe and other parts of the world. In the 15th century, Gaspare Tagliacozzi from Italy documented similar technique of nasal reconstruction. He successfully reconstructed the nose by using the skin of the upper arm. The principle of Italian procedure was precisely the same as of the pedicle flap which was described two millennia ahead by Sushruta. Ackernecht aptly observed “There is little doubt that plastic surgery in Europe which flourished in medieval Italy is a direct descendant of classical Indian surgery”.

The classical cheek flap Rhinoplasty of Sushruta was later modified by using a rotation flap from the adjacent forehead, The Traditional Indian Method of Rhinoplasty. This technique was kept a secret for centuries in India, and practiced by Marathas of Kumar near Poona, certain Nepali families and Kanghairas of Kangra (Himachal Pradesh) .

The resurgence of Indian method began in the 1700s when British surgeons working for the East India Company saw the work done by Indian surgeons. During Mysore War of 1792 between Tipu Sultan and the British. Cowasjee, a cart-driver with the British and four other native sepoys were captured by the Sultan's soldiers. Their noses and a hand each were cut off by the Mysore army. After a year without a nose, he and four of his colleagues submitted themselves to treatment by a man who had a reputation for nose repairs. The operations were witnessed by Thomas Cruso and James Findlay ,surgeons at the British Residency in Poona. They appear to have prepared a description of what they saw and diagrams of the procedure. The technique used for Rhinoplasty was a modification of the ancient Rhinoplasty described by Sushruta. Sushruta's version has the skin flap being taken from the cheek; Cowasjee's was taken from the forehead. A photo feature on the sensational surgery was published in the Madras Gazette. Subsequently, the details and an engraving from the painting were reproduce (Figure-1, 2)









The operation was described as follows:

“A thin plate of wax is fitted to the stump of the nose so as to make a nose of good appearance; it is then flattened and laid on the forehead. A line is drawn around the wax, which is then of no further use, and the operator then dissects off as much skin as it had covered, living undivided a small slip between the eyes. This slip preserves the blood circulation till a union has taken place between the new and the old parts. The cicatrix of the stump of the nose is next paired off, and immediately behind the new part, an incision is made through the skin which passes around both alae, and goes along the upper lip. The skin, now brought down from the forehead and being twisted half around, is inserted into this incision, so that a nose is formed with a double hold above and with its alae and septum below fixed in the incision. A little Terra Japonica (pale-catechu) is softened with water and being spread on slips of cloth, five or six of these are placed over each other to secure the joining. No other dressing but this cement is used for four days. It is then removed, and cloths dipped in ghee are applied. The connecting slip of skin is divided about the twentieth day, when a little more dissection is necessary to improve the appearance of the new nose. For five or six days after the operation, the patient is made to lie on his back, and on the tenth day, bits of soft cloth are put into the nostrils to keep them sufficiently open. This operation is always successful. The artificial nose is secured and looks nearly as well as the natural nose, nor is the scar on the forehead very observable after a length of time.”

This story encouraged Carpue, an English surgeon, to study the details and soon he recognized the immense potential of the operation. Carpue successfully performed the first Rhinoplasty operation (37 minutes) on October 23, 1814 followed by a second successful operation7. Subsequently, through the publication of these successful operations by Carpue in 1816, the use of Indian technique gained popularity amongst British and European surgeons. By 1897, at least 152 rhinoplasties had been performed in Europe.

One of the earliest European descriptions of Indian rhinoplasty is as follows :

The surgeons belonging to the country cut the skin of the forehead above the eyebrows, and made it fall down over the wounds on the nose. Then, giving a twist so that a live flesh might meet the other live surface, by healing applications, they fashioned for them other imperfect noses. There is left above, between the eyebrows, a small hole, caused by the twist given to the skin to bring the two live surfaces together. In a short time the wounds heal up, some obstacle being placed beneath to allow of respiration. I saw many persons with such noses, and they were not so disfigured as they would have been without any nose at all.” (Storia do Mogor 1653-1708 AD).

These Rhinoplasties were widely appreciated as the 'Indian Nose' and generated tremendous interest in the medical fraternity paving way for corrective Rhinoplasty in Europe , United states and other part of the world. Later, with the dissemination and refinement of the technique it became an established procedure worldwide. Though today the technique has received few modifications but the basic principles laid down by Sushruta still remains true. Today, the world acknowledges India as the cradle of Rhinoplasty and the contemporary use of the “Indian flap” for nasal reconstruction testifies to its practicality and success for more than 2500 years.

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KSHAR AND KSHARSUTRA

Kshara

Kshara is a kind of medication described in Ayurveda Texts for the management of various disorders . The word Kshara(क्षार) is derived from the root Kshar(क्षर्), means to melt away or to perish (क्षर् स्यन्दने). Acharya Sushruta defines as the material which destroys or cleans the excessive/the morbid doshas (Kshyaranat Kshyananat va Kshara). According to the preparation we can consider it to be caustic materials, obtained from the ashes after distillation and are mostly alkaline in nature.

Contents

            1 Types of Kshara

• 2 Drugs Used
• 3 Method of Preparation
• 4 Kshara Sutra
  • 4.1 Method of preparation
• 5 Mode of Action
• 6 Types of Kshar Sutra
• 7 References

Types of Kshara

According to the administration it is of two type 1. Paniya Kshara(for internal Medication) and 2.Pratisaraniya Kshara'(external application). The Paniya Kshara is mostly used for the treatment of diseases like artificial poison, abdominal lump, indigestion, calculus etc. The Pratisaraniya Ksara is used to apply on tumors, piles, fistula in ano, skin diseases etc.

1. ^ Sabda Kalpadrima
2. ^ Susruta Samhita 3/11
3. ^ Susruta Samhita 11

 Drugs Used

Many drugs have been advised by Sushruta and other Ayurvedic texts for the preparation of Kshara. The important among them are - Palasa- Butea monosperma, Erythrina indica, Terminalia belerica, Cassia fistula , Plumbago zeylanica, Holarrhena antidysenterica etc.

 Method of Preparation

According to the three types of Ksharas are prepared on the basis of their strength. 1. Mild - Mridu, 2. Moderate - Madhyama and 3. Strong - Tikshna .The general procedure can be narrated as - 'Mridu'Bhașmīkaraņa (conversion to ash) Adding to water(1:6 ratio) Filtration(21 times) Distillation(boiling the ksarajala still all water evaporates) collection (process called lixiviation) 'Madhyama' Here the procedure is same some extra powders of Katasarkara Bhasma sarkara Ksheerapaka, Samkhanabhi( gravels of lime and ash,oyester-shell & core of conch-shell) are added to the boiling ksharajala before distilling it. 'Tikshna' Similar to madhyama kshara here added is the powders of drugs like Chitraka, danti, vacha etc. inplace of the lime stones.

Kshara Sutra

"Kshar Sutra" (क्षारसूत्र) is a sanskrit phrase in which Kshar (क्षार) refers to anything that is corrosive or caustic; while Sutra(सूत्र) means a thread.It is described by many Ayurvedic texts which originated and flourished in India. It is one among popular Ayurvedic treatment modality in the branch of Salyatantra followed by Susruta.

The Ksharsutra was first mentioned by the "Father of Surgery" Sushruta in his text named SUSHRUT - SAMHITA for the treatment of Nadi Vrana(sinus), Bhagandara (fistula- in - ano), arbuda(excision of small benign tumour) etc..Although Brihattrayi- the chief three texts of Ayurveda mention the use of kshara sutra,there is no description of their preparation properly. It was Chakrapani Dutta in late eleventh century in his book Chakradatta ,first mentioned the method of preparation with a clear-cut indication of its use in bhagandara and arsha(haemorrhoid). In his book Chakradutta explains the method that by smearing a sutra (thread) repeatedly in the latex of snuhi() and haridra(turmeric) powder makes the kshara sutra. Later authors like Bhavamishra, Bhaisajyaratnavali etc. also mention the same method. But because of brevity of preparation and inadequate explanation of procedure of application, it lost its popularity among Ayurvedic surgeons. Later in Rasatarangini a better preparation procedure was introduced still the credit of making it practically in use goes to Prof. P.J.Deshpandey and his coworkers. They rediscovered and standardized the ksharasutra in the present era . The Dept. of Shalya- Shalakya, Faculty of Ayurveda, IMS, BHU should be credited for the abundant use and popularization of this technique.

1. ^ A hand book of Anorectal Disorders and their Ayurvedic Management, Dept. of Salyatantra , GAC, Tripunithura, Kerala

Method of preparation

The standard kshar sutra is prepared by repeated coatings of snuhi ksheera (latex of Euphorbia Nerrifolia), apamarg kshara (ash of Achyranthus aspera) and haridra powder over a surgical linen thread no. 20. This thread is spread throughout lengthwise in hangers. Each thread on the hanger is then smeared with snuhi latex with the help of gauze piece soaked in the latex. This wet hanger is transferred in kshara sutra cabinet.

The same process is repeated next day. Eleven such coatings with snuhi ksheera alone should be accomplished. The twelfth coating is done by first smearing the thread with ksheera and in wet condition thread is passed through the apamarg kshar. It is again transfer into the cabinet for drying. This process is repeated till seven coatings of snuhi ksheer and apamarg kshara are achieved. The final three coatings are completed with snuhi ksheera and fine powder of turmeric in the same fashion. Thus twenty-one coatings over the thread are completed.,

1. ^ A Handbook of Anorectal Disorders and their Ayurvedic Management, Dept. of Salyatantra, GAC, Tripunithura, Kerala
2. ^ Anal Fistula and KST, Pathak S.N., Chawkhamba Krishnadash Academy, Varanasi

 Mode of Action

Kshar Sutra is now a popular treatment modality in India for the management of fistula in ano. Many Clinical trials have done all over in different institutes to evaluate the action. In countries like Srilanka and Japan also many clinical trial has already done and established it. Precisely the action of Kshara sutra is thought to be due to its healing and cleansing effect according to Ayurveda. It can be suggested that due to the anti microbial action, and as a saton it allows the proper drainage of pus from the fistula, that leads to a proper healing. On the other hand the cutting effect of thread incises the skin gradually with out a surgical incision. Many studies confirms that it is more effective in the way of reducing hospital stay and less infection than the conventional seton therapy.Researches suggests that it is having the action of Excision, Scrapping, Draining Penetrating, Debridement , Sclerosing and Healing.it is Bactericidal and Bacteriostatic.

Types of Kshar Sutra

In the textual reference of Chakradatta and Rasatarangini we get only indication of the thread made up of Snuhi, apamarga and Turmeric. Susruta describes about many kind of Kshars like Karaveera, Palasa, Kadali etc. in Susruta Samhita. So many studies have already carried out with variations in the Kshara and the latex. The most remarkable are Guggulu Ksharasutra, Udumbara KS, Gomutra KS, Papaya KS, KS with Ficus carica latex etc.

1. ^ Shukla, N.K. Narang, R. Nair, N.G.K., Radhakrishna, S., Satyavati, G.V.: Multicentric randomized controlled clinical studies of Kshara-sootra in management of fistula-in-ano. Indi J. Med. Res. (B), 177-185, 1994
2. ^ Thakur abhiram at al , Kshara sutra therapy a new dimension, souvenir-Anusastra 2008, Dept. of Salyatantra, GAC, Tripunitura, Kerala
3. ^ Ghanekar BG , Susruta Samhita, Sutra sthana 11, ML Publication, New Delhi,1998

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medical director,chief ayurveda consultant,ayurmangalam hospital ·Jul 2003 to present · Jhansi

ayurmangalam hospital and research centre,

• specialist of ayurved chikitsa, yoga ,panchakarma and naturopathy

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OUTLINE OF FRACTURES

OUTLINE OF FRACTURES
• classification of fractures- caused by sudden injury, fatigue or stress fracture, pathological fractures
• Closed fracture, open fracture with & without wound
• Pattern of fracture- transverse, oblique, spiral, comminuted, impacted, compressed, greenstickoccurs below 10
• Repair phases- stage of hematoma> stage of proliferation> stage of calus> stage of consolidation> stageof remodeling
• Rate of union is high in children & slow as get older
• Sites of stress fracture -metatarsal, tibia & fibula
• Common causes of pathological fracture - cancer, bone cyst, paget’s disease
• Clinical features of fracture- deformity, swelling, visible bruises, local tenderness, impairment of function, abnormal motility.
• Treatment of fracture- reduction, immobilization, rehabilitation
• Reduction- manipulative, mechanical reduction, operative reduction
• Internal fixation- plates & screws, bone graph, compression screw plate, circumferential wires & bands
• Open fracture- contaminated & non contaminated
• Complications of fractures- infection, mom union, mal union, a vascular necrosis, shortening
• Nerve injury- neuropraxia, axonotmesis, neurotmesis
• post traumatic ossification= myositis ossificants
• Post traumatic osteodistrophy = reflux sympathetic dystrophy syndrome
• Growth occurres away from the elbow & towards the knee
• Fracture of capitulum of humerrus may lead to non union even in children
• Avulsion injury does not cause premature union of epiphysis
• Dislocation can’t occur without ligament injury
• Strain - incomplete rapture of ligament
• Sprain- acute ligament injury
• In extension subluxations of spine, anterior longitudinal ligament is ruptured
• Automatic emptying of urinary bladder when full after3 months of cord injury- automatic bladder
• Commonest fracture - collie’s fracture
• In shoulder dislocations- anterior dislocation is common
• Rotator cuff include- supra spinous, infra spinous, sub scapularis
• Immobilization is not needed if fracture of humerous is impacted
• Volkmann’s ischemic contracture occurs if supracondylar fracture block brachial artery
• Montegia fracture- fracture of upper end of ulna with radial head dislocation
• Galeazzy fracture- fracture of radial shaft with inferior radio ulnar dislocation
• Collies fracture- fracture of lower end of radius -fracture occurres 2 cm below the articular surfaces lower end displaced backwards reverse to colli - Smith fracture
• Scaphoid fracture is most complicated fracture in it, proximal part is prone to a vascular necrosis
• Rapture of urethra in hip fracture is on the membranous part
• Pott’s fracture- fracture of bones relates to ankle
• Ankle sprain - injury to medial & lateral ligament of ankle