Clinical Approach to Vrana Shopha w.s.r. to Inflammatory Swelling

[Find the meaning and references behind the names: Manoj Kumar, Sri, Manoj, Fatima, Kumar, Ama, Vishwanath, Swamy, Afreen]

ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2018 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2018 | Vol. 3 | Issue 4 148 Clinical Approach to Vrana Shopha w.s.r. to Inflammatory Swelling Dr. Sumera Afreen Fatima, 1 Dr. Vishwanath, 2 Dr. Manoj Kumar 3 1,3 Post Graduate Scholar, 2 Reader, Dept. of Shalya Tantra, Sri Kalabyraveshwara Swamy Ayurvedic Hospital and Research Center, Bengaluru, Karnataka, INDIA. I NTRODUCTION Vrana Shopha has been documented in Brihatrayee between 1500 BC and 600 AD and in Madhava Nidana around 700 AD. Vrana Shopha is a localised swelling explained by Acharya Sushruta which develops in relation with Twak and Mamsa , ultimately leading to the formation of Vrana if not treated in time. Inflammatory swellings of skin and subcutaneous tissues which leads to suppuration can be considered under the term Vrana Shopha . Inflammation has been dealt as a disease, as a Address for correspondence: Dr. Sumera Afreen Fatima Post Graduate Scholar, Dept. of Shalya Tantra, Sri Kalabyraveshwara Swamy Ayurvedic Hospital and Research Center, Bengaluru, Karnataka, India. E-mail: sanjeevani.life@yahoo.in Submission Date : 08/06/2018 Accepted Date: 24/07/2018 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.v 3 i 4.13301 symptom and also as a complication of diseases. From the time, Celsus (30 BC - 38 AD) characterised Inflammation by Four Cardinal Signs - Rubor (redness), Calor (raised temperature), Tumour (swelling), Dolar (pain), Functio laesa (loss of function ) the fifth sign was added by Virchow [1] Shopha described by Sushruta is analogous to inflammatory swelling in many respects. Shopha is antecedent phase of Vrana (wound) as it is similar to inflammatory process which leads to formation of anabscess. It can be clinically noticed as boil, furunculosis, cellulitis, erysipelas etc. Acharya Madhava for first time introduced the new entity of Vrana Shotha as inflammation as a separate chapter. According to Charaka when vitiated Vata comes in contact with vitiated Rakta, Pitta and Kapha , it brings them to the periphery then the Srotas (channels) get obstructed to develop Shotha in and around the skin and the flesh but it is not limited to part of body [2] Classification and clinical presentation of Shopha Achayra Sushruta classified Shopha on the basis of clinical observation into six types; Vatika, Pittaja, Kaphaja, Shonitaja, Sannipataja, Agantuja [3] A B S T R A C T Inflammation in Ayurveda is known by different names in different contexts namely Shotha , Shopha , Svayatu , Utsedha and Samhata . Chronic inflammation is a cardinal sign of chronic degenerative disorders. Inflammation and oedema associated with it is duly recognised in Ayurveda as a pathological manifestation. While modern medicine considers inflammation as a symptom or rather as a healing response of the body in wounds. Ayurveda treats the concept of inflammation as symptom of a disease, an independent disease and complication of diseases. Degenerative diseases share a common pathological feature of inflammation. The disturbances in micro channel circulation in inflammation are due to Srotodushti (clogging of channels) by Aama (toxic waste of metabolism). The proper clinical approach to Vrana Shopha with Modern concept is an key role in management and preventing complication of Vrana Shopha. Key words: Aama, Degenerative Diseases, Inflammation, Shopha, Srotodushti.

[Find the meaning and references behind the names: Krishna, Pandu, Kala, Aruna]

Dr. Sumera Afreen Fatima et.al. Clinical Approach to Vrana Shopha w.s.r. to Inflammatory Swelling ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2018 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2018 | Vol. 3 | Issue 4 149 Vataja Shopha It has fallowing features. Varna - Krishna, Aruna. Sparsha - Parusha, Mrudu. Toda and Anavasthita Pittaja Shopha It has fallowing features Varna - Piita, Aruna. Sparsha - Mrudu. Osha and Sheeghraanusari. Kaphaja Shopha It has fallowing features Varna - Pandu. Sparsha - Kathina, Sheeta, Snigdha. Kandu, Vedana and Mandaanusari. Raktaja Shopha “ Pittavatshonitajoatikrushna ” Similar features as that of Pitta but has Varna - Atikrushna Agantuja Shopha Has combined features of all above and has Lohitaavabhasa. Aetiopathogenesis of Shopha As it is well known that the imbalanced state of Doshas lead to pathogenesis of diseases. Aetiopathogenesis of Shopha is much resembled to inflammation in modern medical science. Acharya Sushruta said that the pathogenesis of Shopha has definite sequential pattern, distributed over Shatkriya Kala [4] These Shatkriya Kala has been mentioned as follows: Sanchaya - accumulation of physiological active Doshas . Prakopa - excitation of the previously cumulated and imbalanced Doshas . Prasara - excited Doshas leave there original space and over flow.

Dr. Sumera Afreen Fatima et.al. Clinical Approach to Vrana Shopha w.s.r. to Inflammatory Swelling ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2018 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2018 | Vol. 3 | Issue 4 150 Sthaanasamshraya - localisation of the imbalanced Doshas at a particular site ( Khavaigunya ) Vyakti - manifestation of Doshas in the form of disease with signs and symptoms. Bhedaavastha - definite termination of the pathological lesion, eg - abscess. Avasthas or Stages of Vrana Shopha 1. Aamaavstha 2. Pachyamaanaavastha 3. Pakwaavastha Amaavastha - (early stage of inflammation) In this condition Kaphadosha may be predominant due to which swelling is produced, hence it has symptoms as follows; [5] Sparsha - Manda, Ushma. Twaksavarnata. Shitashopha, Alpashopha. Sthira Manda Vedana Pachyamaanaavastha - (Stage of Inflammation) If Amaavastha is not treated this leads to next stage formation that is Pachyamaanaavastha , here Prakupita Pitta will act on the Dushya to produce disintegration and produces symptoms like; [6] Suchibhirivanistudyate Dashyatevapippiilikaabhiva Chiddyateivashastrena Bhidyatevashaktibhihi Taadyateivadandena Piidyateivapaanina Ghatyateiva Cha Angulya Dahyatepachyateva Cha Agnikshaarabyam Osha Choshaparidahashcha Twakvaivarnyashophaabhivruddhi Jwara, Daaha, Pipaasa, Aruchi. Pakwaavastha - (stage of suppuration) If Pachyamanavastha is not treated it results in progression of next stage, here there is involvement of Vayudosha leading to these symptoms; [7] Vedanopashanti Panduta Alpashophata Twakpariputana Bastavivodakasancharana Muhurmuhutoda And Kandu Vyadhiupadrava Shanty Dosha Sambandha Dosha Sambandha says about involvement and importance of each Dosha in Vrana Shopha ; [8] Vata is responsible for - Ruja Pitta is responsible for - Paaka Kapha is responsible for - Puya Rakta is responsible for - Varna Saadhya Asadhyata of Vrana Shopha “Alpomahaanvakriyaayavinaayahasamuchritahapaak amupaitishophaha| Vishaalamulovishamamvidagdhahasakruchratamyaat yavagaadhadoshaha ||” [9] Management of Vrana Shopha The Vrana Shopha should be managed in early stage to avoid suppuration and more tissue harm as described under Shatkriya Kala. Two types of Upakramas have been mentioned for the management of Vrana Shopha ; Saptopakrama Ekaadashaupakrama Saptopakrama: For the management of Vrana Shopha seven Upakramas have been said by Acharya

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Dr. Sumera Afreen Fatima et.al. Clinical Approach to Vrana Shopha w.s.r. to Inflammatory Swelling ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2018 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2018 | Vol. 3 | Issue 4 151 Sushruta [10] The initial four procedures like Vimlapana, Avasechana, Upanaha, Patana, Patina helps in the management of Vranasopha and other three upakramas like Shodhana, Ropana, Vaikrutapaha is used in managing the wound. Ekaadashaupakrama: Acharya Sushruta in Chikitsasthana further explains about 11 types of Chikitsa for the management of Vrana Shopha [11] Apatarpana, Aalepa, Paisheka, Abhyanga, Swedana, Vimlapana, Upanaha, Paachana, Visravana, Vamana, Virechana. Inflammation and clinical examination of inflammation History 1. Duration: Those with shorter duration and pain - acute inflammatory swellings Those with longer duration and slight pain - chronic inflammatory swellings. 2. Mode of onset: If appeared just after a trauma or may have developed spontaneously and grown rapidly with severe pain - inflammatory condition. 3. Other symptoms associated: History of pain, fever. 4. Pain: Pain is an important and frequent complaint of inflammatory swellings. Nature of pain - Throbbing pain suggests inflammation, leading to suppuration. Site - localised to the site of swelling. Time of onset - It is important to know whether the pain preceded the swelling or the swelling preceded the pain. In case of inflammation - Pain always appears before the Swelling. 5. Progress of swelling: If swelling decreases in size then it is suggestive of inflammatory swelling. 6. Fever: If patient had temperature along with swelling then it is suggestive of inflammatory swelling. 7. Secondary changes: Inflammatory changes. 8. Impairment of function: Enquire about the nature of loss of movement and intensity of it and how much of it is due to swelling. Physical Examination 1. General Survey: Patient should be as a whole. Attitude of patient is very important. Abnormal attitude may be due to irritation at the site of the swelling. Local Examination A. Inspection 1 Colour – Colour sometimes gives definite hint to diagnosis. Redness suggestive of inflammatory swelling. 2 Skin over the swelling - Tense, Glossy, Red, oedematous, Dusky indurated - Suggestive of inflammatory swelling. B. Palpation 1 Temperature - Raised local temperature. 2 Tenderness - Inflammatory swellings are mostly tender. 3 Surface - May be Smooth, lobular with smooth bump, nodular irregular and rough. 4 Marginacute inflammatory swellings, ill-defined or indistinct margins Chronic inflammatory swellings - well defined margins. 5 Consistency - It varies from soft to hard. Sometimes the swelling pits on pressure. It means that there is oedematous tissue and most often the swelling is inflammatory one. 6 Fluctuation - Fluctuation test is positive in progressed stage.

[Find the meaning and references behind the names: Soma, Soman]

Dr. Sumera Afreen Fatima et.al. Clinical Approach to Vrana Shopha w.s.r. to Inflammatory Swelling ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2018 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2018 | Vol. 3 | Issue 4 152 By seeing and examining these conditions one can know the progress and can correctly diagnose the stages and give the treatment accordingly [14] DISCUSSION Concept of Vrana Shopha has been explained by different Acharyas but Acharya Sushruta’s concept is approachable in clinical practice. Agantuja being one of the causes for Vranashopha is substantiated by the fact that trauma is one of the causes for the manifestation of Cellulitis, Erysipeloid disease, Actinomycosis, Madura foot and Necrotising fasciitis. Involvement of Twak and Mamsa can be substantiated by understanding the etiopathogenesis of Boils, Abscess, Cellulitis, Necrotising fasciitis etc. Though the process of inflammation begins in Amavastha , inflammatory signs are clearly evidenced from Pachyamanaavastha . Involvement of Pitta Pradhana Tridosha during Paripaakakaala of Vrana Shopha can be substantiated by the presence of cardinal signs of inflammation. Rubor - Rakta Dolor - Vata Functio laesa - Vata Tumor - Kapha Calor - Pitta Hence consideration of Vrana Shopha as inflammatory origin is done based on the presence of above cardinal signs. Treatment modalities like Apatarpana, Abhyanga, Aalepa, Vimlapana, Parisheka and Upanaha are indicated in Amavastha which is helpful in arresting the ongoing process by doing Doshaprashamana and subsides the symptoms. Upanaha and Pachana are employed in Pachyamana Avastha to bring about Paaka . Decision for interventions like Darana / Patana in Pakwavastha is done based on patient’s Satvabala, Vaya, Sthana and Pakaavastha of Vrana Shopha . When Pakwa and Apakwaavastha of Vrana Shopha is wrongly interpreted and mismanaged, it leads to the manifestation of other disorders [13] CONCLUSION All inflammatory swellings do not undergo suppuration, hence only those Shopha which undergoes Paaka , if untreated turns to Vrana can be considered as Vranashopha . Prakupita Doshas are to be eliminated in initial stage itself, if not they would become more potent, progressing to the Upadrava Avastha making the condition a bad prognosis. Therefore Vaidya should rightly diagnose the condition and necessary steps should be taken for managing the Vrana Shopha at its earlier stage so as to prevent further progression and complications. Appropriate treatment modality has to be choosen in specific Avasthas considering the Dosha and Lakshanas based on Yukti of Vaidya . Along with the detail history taking, critical analysis of the Vranashopha based on Dosha , Dushya ( Vranavasthu ), Avastha , thorough examination and required investigations are the necessary components to rule out the underlying pathology, associated disorders and to arrive at the accurate diagnosis. REFERENCES 1 Soman Das, A concise text book of surgery, 9 th edition, 2016, chpter 7, pp-1374,p 78. 2 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Sutrasthana, chapter 17/3, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.71. 3 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Sutrasthana, chapter 17/4, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.71. 4 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Sutrasthana, chapter 21/36, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.106. 5 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Sutrasthana, chapter 17/5, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.71. 6 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Sutrasthana, chapter

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Dr. Sumera Afreen Fatima et.al. Clinical Approach to Vrana Shopha w.s.r. to Inflammatory Swelling ISSN: 2456-3110 REVIEW ARTICLE July-Aug 2018 Journal of Ayurveda and Integrated Medical Sciences | July - Aug 2018 | Vol. 3 | Issue 4 153 17/5, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.71. 7 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Sutrasthana, chapter 17/6, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.72. 8 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Sutrasthana, chapter 17/7,8, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.72. 9 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Sutrasthana, chapter 17/14, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.76. 10 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Sutrasthana, chapter 17/18, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.77 11 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Chikitsastha, chapter 1/8, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.77 12 Somen Das, A manual on clinical surgery, 12 th edition, 2016, chapter no 3, pp 648, p-21-48. 13 Kaviraja Ambikadutta Shastri, Sushruta Samhita edited with Ayurveda Tattva Sandipika, Sutrasthana, chapter 17/9, Chaukhamba Sanskrit Sansthan, Varanasi, reprint 2007.p.79. ******************************* How to cite this article: Dr. Sumera Afreen Fatima, Dr. Vishwanath, Dr. Manoj Kumar. Clinical Approach to Vrana Shopha w.s.r. to Inflammatory Swelling. J Ayurveda Integr Med Sci 2018;4:148-153. http://dx.doi.org/10.21760/jaims.v 3 i 4.13301 Source of Support: Nil, Conflict of Interest: None declared.

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Dosha, Pandu, Vata, Pitta, Kapha, Sushruta-samhita, Ama, Vaidya, Rakta, Vrana, Shopha, Shrota, Sushruta, Agantuja, Inflammation, Clinical examination, Inflammatory swelling, Modern concept, General survey, Cardinal sign, Acharya Sushruta, Local examination, Clinical presentation, Acharya Madhava, Degenerative disease, Degenerative disorder, Clinical approach, Saptopakrama, Vrana Shopha, Shatkriya kala, Vrana (wound), Dosha sambandha, Key-word, Vata, Pitta, Srotas (channels), Pitta, Kapha.