A Narrative Review on Healing Wisdom: Unveiling the Power of Pathya-Apathya in Wound Recovery

Ayurveda’s distinctiveness lies in its use of Ahara-Vihara (dietic and daily regimes) as a therapeutic method. Sixty therapeutic protocols for wound healing have ahara (food) as one of the approach. Wound healing is a multifactorial mechanism where food plays a significant role in terms of micro and macro nutrients. In clinical practice, understanding Pathya Kalpana (conducive practises) is crucial as it considered as half of the treatment, Ardha Chikitsa (Partial Treatment) and it also stabilises digestive and metabolic fires (jataragni and dhatwagni). Prescribing medicines and ignoring a proper lifestyle and diet changes serve no purpose as it only defeats the symptoms of the disease without attending the root causative factors of a disease, as Apathya (non conducive practices) are the major causative factors of pathogenesis. Even a treatment protocol which can hit the bull’s eye would fail, when a patient has inappropriate diet and indulges in improper activities of routine. The knowledge of influence of shadrasa (six tastes) in healing, method of eating, conducive and non conducive foods and regimes given in scriptures, properties and effects of the wholesome foods and its indications is beneficial for establishing a structured treatment protocol. Various types of wounds and different phases of wound healing can be approached by a specifically designed diet and regimes.

Ahara,Shashti upakrama,Vrana ropana,Vrana shodana

Wound healing is a dynamic and multifactorial dependent concern in surgical practice. Postoperative wound healing, healing of traumatic wounds and wounds due to multifactorial involvement like systemic and extrinsic factors like arterial, venous, diabetic ulcers, burn wounds, infections are the various spheres where wound healing is given prime importance [1]. In the current era of modernisation with rapid and poor lifestyle, the importance of knowing conducive and non conducive food habits and daily routines is a very essential and significant part of surgical practice [2]. Even a treatment protocol which can hit the bull’s eye would fail, when a patient has inappropriate diet and indulges in improper activities of routine [3]. Pathya, which refers to a wholesome diet and lifestyle, is characterised by foods and habits that nourish both the body and mind, clear the body’s microchannels (Pantha/Marga/Srotas), and promote overall well-being and happiness. In contrast, Apathya denotes an unwholesome diet and lifestyle that fails to provide these benefits [4]. The concept of good pathya (conducive) and apathya (unwholesome) regimes with a well detailed management approach would be a double edged sword for the wound healing as it can accelerate the treatment as well as eradicate the causative factors of pathogenesis. Acharya Charaka defines the ahara (diet) and vihara (lifestyle regimes) which is more beneficial and valuable to the body and also gives clarity and happiness to the mind as Pathya (wholesome) and opposite to that as Apathya (unwholesome) [5]. Contraindicated food items, if consumed by the wounded person may cause much suppuration and delayed healing. This concept works on shareerika (physical) and as well manasika aspects (mental levels) and accelerates the balance of tridoshas (three humours-vata, pita, kapha) required for optimum wound healing. Aahara (food) is called as Mahabhaishajya (superior medicine) in the Kashyapa Samhita (A Textbook by Acharya Kashyapa) [6]. Acharya Sushruta included ahara in shasti upakrama (60 types of treatment) as a treatment protocol to signify the role of food in wound healing [7]. There are general factors include poshaka tatwa (Nutrients), vaya (Age), and the diseases like paandu (Anemia) madhumeha (Diabetes), and local factors include shalya vastu (foreign bodies), twak sthaan (Position of skin) and bhoota sanghaata (Infection) affecting wound healing [8]. The Aahara Rasa (essence of food) will get distributed in the body, where Rasa Dhatu (primary product of digested food) will be nourished then followed by Rakta (Blood tissue), Mamsa (muscle tissue), Meda (fat tissue), Asthi (bone tissue), Majja (bone marrow) and finally Sukra (essence of all dhatus) will get the required nourishment. This is the pathway nourishment of the Dhatu (tissues) [9]. The six tastes of food and the specific action of each food on dosha (humours), dhatu (tissues) and agni (metabolic fire) is the prime importance of dietic and routine regimes in Ayurveda [10]. By utilising the knowledge of treating the wound and its healing process together with appropriate provision of nutrition, one can decrease the morbidity and associated mortality tagged with chronic natured wounds, and also reduces their treatment cost and social impact [11].

Exogenous wounds are caused by trauma which further manifests because of tridosha (three humours) and rakta (blood). Vata, kapha and pitta (the three humours) when vitiated by their respective aetiologies get accumulated in external passage and produces endogenous ulcers [12]. Accumulation of vitiated doshas (humours) in Sanchaya Avastha (stage of accumulation), their prokapa (aggravation) and prasara (spread) to the wound location happens due to improper and faulty habits of diet and regimes, way of living and the seasonal variations [12]. The vitiated dosha (humours), after a sequale of pathological events (shada-kriyakala) get accumulated at a particular place resulting in the formation of vrana (wound). Eight locations of wounds are blood vessels (sira), skin (Twak), fat (Meda), flesh (mamsa), ligament (sanyu), bones (asthi), viscera (Kostha) and vital parts (Marma) [13].

The various stages of wound include Amawastha (early phase of inflammation), Pachyamanawastha (actual inflammatory phase) and Pakwawastha (suppurative phase), respectively [14]. Based on the degree of vitiation of Dosha (humours), Sushruta has classified VranaShopha (wound inflammation) into Vatika, Kaphaja and Paittika (dependent on each of the three humours independently) Shonita (blood), Sannipattaja (combined state of all the three humours) and Agantuja (exogenic) which later attains suppuration due to pitta (heat) and rakta (blood) [15]. Ruhyamana vrana is the ulcer in healing phase while ruda vrana is the wound in healed phase [16].

Wound healing requires repair at cellular levels mediated by tridosha (three humours). After the digestion of ingested food by Jatharagni (digestive fire), tissue metabolism happens due to Bhutagni Paka (tissue level metabolic fire), it is absorbed and distributed throughout the body [17]. The Dhatu-paka (metabolic conversion of tissues) continues the chemical conversion into tissues at micro level which is important for wound healing [18]. At the level of the Dhatwagnipaka (tissue metabolism), the Prasaada-bhaga (essential part) contributes to the Dhatu formation (tissues), i.e., Sthayi Dhatu (stable tissues) and Upadhatu (subordinate tissues) while the Kittabhaga (non essential part) leads to the formation of the Dhatu Malas (metabolic wastes) [19]. The nutrient portion of the Dhatus (tissues), provides nourishment to the successive other Dhatus (tissues). The nourishment of all Dhatu (tissues) is the primary function of Aahara Rasa (essence of food). These are nourished in a sequalae one after the other like Rasa (first level of tissues) nourishes Rakta (second level of tissues), Mamsa (third level of tissues) etc. The combination essence of all the dhatus (tissues) nourishes Sukra dhatu (the seventh level of tissues), which is followed by Ojas (vital force of the body) [20]. Wound healing requires proper nourishment of the seven levels of tissues, strong metabolic fire at tissue levels without which chronic non healing wounds will fail to heal. The superficial wounds, involving skin only, heal easily and early in comparison to those extending to the other Vrana vastu (deeper tissues).

Defects causing the faulty mechanism of wound healing are known to be 24 according to aetiological factors which are as follows: excessive moisture in ligaments, increased fluid in blood vessels, more depth of the wound, influence of maggots, involvement of bones, lodging of foreign body, toxin accumulation, spreading natured, traumatic tearing with nails or other objects, friction of skin and body hair over wound, improper bandage application, excessive local application of unctuous substance over wound, excessive emaciation of patient due to over dose, indigestion of food, over-eating before digestion, incompatible food consumption, unsuitable food habits, anger, grief, excessive day-sleep, sexual intercourse, physical exercise, and sedentary life and inactivity. These factors cause delay in the wound healing process. Ulcers with impurity are difficult to treat due to presence of excessive discharges, foul odors, major defects and multiple complications [Table/Fig-1] [21].

Rasa of the food ingested an outcome of Jatharagni and Bhutagni Paka, is absorbed from Adho-Amasaya and distributed throughout the body by Dhamanis. This process of absorption of Annarasa in the body is described under the concept of Dhatvagni Paaka or Dhatvagnivyapara. In the term Dhatvagni Paaka, two terms are important to discuss that is Agni and Paaka. Paaka was seen to stand for chemical transformations both reversible and non reversible.

A balanced approach of inculcating Shadrasa (six tastes) in diet is ideal for wholesome health whereas wound healing phase needs a more considerate approach of the six rasas [23]. Madhura rasa (sweet taste) is dominant in Prithvi and jala mahabhuta (earth and water elements), increases kapha (phlegm humour) and has sandhanakara (binding) and bal-krita (strengtheneing) actions, while amla rasa (sour taste) is dominant in Prithvi (earth element) and agni Bhuta (fire element), increases kapha (phlegm humour) and pitta (bile humour) and forms puya (pus) causing vidaha (burning sensation) in the wound. Lavana rasa (salt taste) made of predominantly jala (water element) and agni mahabhuta (fire element) increases kapha (phlegm humour) and pitta dosha (bile humour), due to vishleshan (breaking down) and lekhana karma (scrapping action), performs the role of vrana shodhana (wound cleaning) and katu rasa (pungent taste) possesses qualities like vrana shodhana (wound cleaning), kushtaghna (skin disease eradicating), krimighana (anti-microbial), and lekhana (scraping actions). Katu rasa (pungent taste) is vayu (air element) and agni (fire element) dominant and increases vata (air element). Tikta rasa (bitter taste) made of vayu (air element) and akasha (ether element) strengthens twak (skin) and mamsa dhatu (muscle tissues) and dries up kapha (discharge), increases vata (air humour) while kashaya rasa (astringent taste) made of vayu (air element) and Prithvi (earth element), increases vata (air humour), possesses kleda shoshaka (dries up discharge), vrana shodhana (wound cleaning) and ropana (wound healing) properties [11]. Tikta Rasa (bitter taste) in considered supreme for wound healing and all the vrana shodana (wound cleaning) and ropana (wound healing) drugs are predominantly tikta (bitter) in rasa (taste) It helps for platelets migration and binding to the site of injury and its proliferation because of the dominent Vata Dosha (one of the humour) function and also enhances proper division of cells respectively. Release of target chemicals & activation of fibrin and its subsequent transformation is the work of Pitta Dosha (one of the humour). Formation of platelet plug and clot for hemostasis sequence is related to the attributes of Kapha Dosha (one of the humour). It also helps in scavenging of tissue debris and pathogens because of its dry and cold nature and attribute of lesser weight [Table/Fig-2] [24,25].

Along with the quantity of diet and the quality of food, the way of food consumption too plays a vital role in the maintenance of health. The process of digestion, nutrient absorption, and assimilation of digested food are complex procedures where social, physical, emotional and physiological factors contribute a vital role. For obtaining optimum benefits of food, a person should practise certain rules and regulations according to Ayurveda regarding what to consume, when and where to eat, and how the food should be taken. Classification of food according to age, purpose, benefits, seasons, constitution, foods which are daily consumable and non consumable, helps in achieving the balanced diet for one’s constitution according to age and seasonal variations. The complete beneficial assimilation of food takes place when these rules for consumption of food are followed and this is known as Ahara vidhi Vidhana [26]. One should consume food that is warm in state except in diseases dominant in pitta (one of the humour) and rakta (blood) vitiation. Consuming food in warm state helps in retaining the maximum taste of food, stimulates the digestive fire, and undergoes easy digestion. Unctuous food is advised except in kapha (phlegm humour) and medho dhatu (adipose tissue) vitiation, because it will increase the subdued power of digestion in a similar manner that ghee ignites fire. It will strengthen the sense organs and will enhance growth, strength, and complexion of the body. The quantity of food taken that gets digested in proper time without affecting the normalcy of the body is called as Maatra or the measure of proper quantity [27]. The next diet should be taken only after the proper digestion of previous food. If, taken otherwise, the improperly digested Ahararasa (primary product of digestion) of the previous meal gets mixed up with Ahararasa (product of digestion) of the newly taken food and instantaneously aggravates all Doshas (humours) [28]. One should consume food that is non contradictory in Virya (potency). Food should be consumed in a beautiful and auspicious place that is devoid of Vaastu Dosha (Unpropitious land) and unwanted people, having a pleasant smell, and that is well covered in order to provide protection from dust and other organisms [29]. One should not consume food in haste to prevent entry of food in the wrong passage resulting in asphyxiation of food. One should not consume food very slowly as it prevents satisfaction or satiation, leading to over eating. Food becomes cold leading to improper digestion. The food consumed while talking, laughing, or with a distracted mind produces complications due to vata vitiation. Food should be always consumed with due consideration to oneself, knowing well about the suitability or the unsuitability of the food components to the self. Thus, one should consume food only after proper self-consideration [30].

Anupana is explained as a liquid, which can be taken after the intake or along with the Aushada (medicine) or Ahara (food) [31]. The term Sahapana is defined as the medicine administration by mixing it with another liquid substance which can result in easy disintegration of food, absorption and uniform optimum assimilation of medicine completely in the body [32]. Appropriate administration of adjuvants with foods facilitates energising the body quickly, helps in required digestion resulting in the benefits of promotion of longevity and strength. Adjuvants softens and liquefies the hard food. The food which is non wholesome or heavy in nature, or when taken in excessive quantity undergoes easy digestion by the action of the adjuvants. When a small quantity of water is consumed between a meal, the food remains moist, instead of becoming dry and difficult for digestion. Therefore, Anupana (co-administers with medicine) has its importance in diet regimes [33]. Drugs with wound healing properties can be taken and infused along as adjuvants in the early phase of wound healing and strength promoting foods can be used for chronic wound patients.

In the inflammatory phase of wound healing, ahara (food) with tikta (bitter) and kashaya rasa (astringent taste), Madhura vipaka (sweet taste post digestion) and cold potency should be the choice to control inflammation. In proliferative stage Madhura-kashayarasa (sweet and astringent taste) and cold potency should be the choice of food as astringent taste has wound contraction activities and Madhura rasa (sweet tatse) helps in tissue regeneration and cold potency has sthambana (retaining) action [34]. In remodelling phase, Madhura rasa (sweet taste) and sheeta virya (cold potency) and Madhura vipaka (sweet taste post digestion) foods should be preferred as Madhura rasa (sweet taste) attributes to wound strength and also increases tissue granulation [34,35]. The observations revealed that the plants mentioned under Kakolyadi, Nyagrodhadi, Lakshadi, Aaragvadhadi, Surasadi, Arkadi and Priyanguambasthadi Gana (group) have significant properties of Vrana-Shodhana (wound cleansing) and Vrana-Ropana (wound healing) [Table/Fig-3] [34-40].

Vegetables like Karavellaka (bitter gourd) and patola (pointed gourd) are included in Aragwadadhi Gana. Both are bittery and pungent in taste, light and dry in nature, has pungent effect post digestion, kapha pitta hara (reduces humours) and can be used in diets of patients with non healing wounds. Bitter gourd has antimicrobial action, it can be used in diet of infected wound patients. KarkotaMomardica dioica (spiny gourd) has similar properties of bittergourd [41]. Pointed gourd is carminative and is loaded with vitamin C and it reduces and balances all the three doshas (humours) [42]. Vartaka (brinjal) reduces ama (metabolic tissue) is very light to digest and kindles digestive fire. It slightly balances excess kapha and vata dosha (humours) [43]. Baala-mulaka (immature radish) is included in pippalyadi and surasadi gana by Acharya Sushruta. Its attributes are similar to that of pointed gourd. It is highly condusive as it redcues and balances all the thre humours [44]. Vaastuka (Green leafy vegetable- Chenopodium album) is sweet in taste, light and hot in potency and has pungent effect after digestion. It balances all the three humours, has anti-microbial action and also relieves pain [45]. Tanduleeyaka (A type of Amaranth) is sweet in taste and reduces inflammation and bleeding and is anti-poisonous and Jeevanthi shaka is one among the drug in Kakolyadi gana, Kashaya varga and Shakavarga and is considered the best vegetable for consumption [46,47].

Dadima (Pomegranate) is sweet and astringent in taste, light and unctuous in properties, has a neutral potency, sweet and sour after digestion taste and balances all the three doshas. It is light for digestion, absorbent, carminative increases body strength and burning sensation [48]. Amalaki has five tastes namely, sour, astringent, bitter, pungent and sweet in taste where sour and astringent tastes are predominant [49]. It is slightly heavy, dry, has mild cold potency. The taste developed through digestion is sweet. It alleviates all the three dosha and is considered the best of the Ayurvedic rejuvenative herbs as it rejuvenates all of the tissues in the body and builds Ojas (the essence of immunity) [50].

Mudga (Vigna Radiata) belongs to pulses, and is one of the Sarva Prani Pathya Ahara Varga, a set of food items regarded as both among the finest and dietary items suitable for all animals and is considered Nityasevaneeya, or food that should be consumed every day to maintain good health as it is light to digest, mildly dry in nature and gives nourishment, enhances physical strength and builds the tissues [51]. Yava (Barley) is astringent and sweet in taste rasa is carminative, builds stability and strength. It enhances skin repair too. It can be used in patients of chronic wounds and diabetic wounds [52].

Vilepi (porridge) is made by boiling rice and water in the ratio 1:4. The rice is boiled till it becomes soft and it consists more solid portion. It is refreshing, satiating, strength increasing, wholesome, sweet, light, stimulates digestive power, and allays hunger and thirst. It subside pitta (one of the humour) [53]. Mamsa rasa (meat soup) is of two types. Kruta Mamsarasa is prepared by adding ghee/oil, salt and mild spices, whereas akruta mamsarasa is prepared without additions. It is Oja Vardhaka (improves vitality), Brumhana (nutritive) and gives preenana (nourishment) [Table/Fig-4] [54-56].

In the inflammatory phase of wound healing food with excessive sour, pungent and salty taste is avoided. Food with hot potency like curd, alcohol and other vidahi (burning foods) increases the duration and extent of inflammation. These also delay the wound healing phase. Dry foods increases vata (one of the humour) and affect the quality of granulation and wound healing. Sugarcane and jaggery processed foods, aquatic animals meat increases kapha (one of the humour) and gurutwam (heaviness) and reduces the metabolic fire leading to reduced nourishment to successive tissues hampering the wound healing mechanism. Mutually contraindicated foods (virudhanna) are also avoided for the same reason [57].

The patient should not sleep during day as it increases kapha and pitta and cause itching in the wound, swelling, feeling of heaviness of the body, pain, redness and exudation. The wounded person should not indulge in standing, sitting, walking for long period and sleeping during day, though he is strong as too much indulgence produces pain in the body parts due to aggravation of väta (one of the humours) [58].

According to Ayurveda, patients having strong psychological status have a good compliance and thus respond better to the treatment. The person who cannot control his/her anger or remains under fear may redevelop the wounds at the same site. Even many more psychological factors have been elaborated by our ancient scientists in the reference of wound. There is evidence that greater mental stress prior to surgery results with poorer outcomes, including postoperative complications, delayed healing, higher rates of re-hospitalisation, and poor wound healing rate [59]. After surgery, recovery phase is greatly influenced by psychological factors like stress and anger. Patient should avoid sexual activities to preserve bala (strength) and ojas (vitality). One should never have too much exposure to breeze, dust, sunlight, smoke, dew, mist, eating excess quantity food, use of unliked foods, the feeling of fear, jealousy, grief, anger, worry, staying awake at night, eating incompatible foods, irregular sleep schedules, fasting, speaking at a loud voice and strenuous physical activities. One should also avoid roaming in forbidden places. When the wounded person, troubled by the above causes, and patients who have weak constitution with excessive muscle and blood depletion, the ingested food does not get digested. Indigestion will cause great aggravation of all the three humours which produce pain, swelling, exudation, pus formation and burning sensation. A wounded patient should avoid the use of spirituous liquors such as Asava, Mairaya, Arishta, Sura and Sidhu (alcoholic preparations). A wound may develop into malignancy through the use of alcoholic preparations which is acidic in taste, sharp, dry with hot potency, or is followed by almost instantaneous intoxication [60].

Person who regularly consumes Hita Ahara (Beneficial food) and does Hita Vihaara (beneficial regmies) becomes disease free thus establishing Pathya (wholesomeness) to be a primary principle in the treatment [61]. Tikta Rasa (bitter taste) pacifies Kapha dosha (one of the humour) because it is opposite natured which is considered to be beneficial in the mechanism of wound healing [62]. If, one approaches diet considering the state of tridosa (three humours), prakriti (bodily constitution), satmya (condusiveness) of person as well as panchabhautik (five elemental) composition of food. Pathya (wholesome) regimen is explained elaborately in Ayurveda which plays a foremost important role in prevention as well as cure of different diseases. Due consideration is given to the atmosphere of place, psychological condition of the person, status of health and digestion of the person. The diet should also be based on the age, seasonal changes, habitat and habit of the person. Consumption of medicines without prescribed food and lifestyle regimes changes serve no purpose as it merely tackles the symptoms of a disease without terminating the root aetiology of a Vyadhi (disease) [63]. Apathya (unwholesome) as a Nidana (aetiological factor) for a Vyadhi (disease). No treatment is helpful without counteracting the aetiology of the ailment/Apathya. Hence, thorough understanding of sequalae of pathophysiology and aetiopathogenesis is very important to approach diseases [29]. Optimum quantity of porridge cooked from old rice served in unctuous and warm state with little water, and meat of animals of arid regions when consumed regularly helps in healing of the wound quickly. Soups, saktu (paste of flour), vilepi (thick gruel), kulmasa (cooked pulses) and boiled water may by consumed [65]. The wounded patient who adheres to the wholesome regimes gets timely and ideal healing.

Ahara is very aptly placed in the sixty therapeutic approaches for wound healing. Food when rightly consumed can work par with a medicine in healing a patient. The right choice of food, the right combination, the right quantity, the right proportions and the right method and time to eat is a knowledge which has to be imparted by the doctor, to achieve optimum healing of the disease, prevention and also to improve the quality of living. Behavioural regimes when followed help in achieving a mental balance which in turn aids in the physiological healing.

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