Concept of Awram (swellings) in Greco-Arab medicine: A Review Abstract: Hippocrates, Galen, Avicenna and other Greco-Arab physicians have described shout waram (swelling) in their literatures. In Greco-Arab medicine oedema, tumours and cancers etc. are considered to be sucht swellings which result from a variety of morbid matiers. Whenever excess influx or production of ‘morbid matter in an organ occurs and tabiar (physisinature) is unable to deal with the matter due to its ‘weakness or excess amount of matter, the morbid matter may accumulate in affected organ. The morbid ‘matter accumulates in whichever organ, causes structural damage as well as enlargement of the organ resulting in formation of swelling. Swellings may be hotorcold according to quality of causative matter. Present work is an attempt to systematize relevant available literary information regarding swelling. Key words: waram, swelling. falghamuni, hamra, sagirus, ozima Introduction: Waram is a partial or complete excess due to accumulation of morbid matter in an organ ‘or surface. Warum is a compound disease as all the three gencra of the simple disease ic. sue mizaj (disturbances of temperament), sue tarkib (disturbances of structure) and tajarrug dtesal (loss of contiguity) are found in it, Thus there is sue mizaj because no swelling can occur without sue mizaj associated with maticr. Sue farkib is also present in it because no swelling can occur without a defect in organ’s structure like form, size etc, And itis accompanied by loss of contiguity, because there can be no swelling without loss of contiguity. There is no doubt that contiguity is lost with accumulatioa/influx of morbid matter in the affected organ 2! Causes of swellings: ‘There are six types of matters which ean cause swelling. These are four humours ie. dam (sanguine), balgham (phlegm), safra (bile) sawda (black bile) and ma (water) as well as rh (air) !"*! Morbid matter may originate in affected organ itself or may influx into the affected organ from some ‘other organ of the body! 4) Because of strong expulsive faculty. organ disposed its morbid matter towards weak organ. 411) Because of weakness, the recipient organ accepts the disposed matter. QI) Sometimes organ is susceptible to swelling structurally orby its nature or is situated in the way or below. QV) Injury, heat and lack of dissolution are responsible for accumulation or absorption of morbid matter atthe site! ‘Types of swellings: Depentiing on the nature of matter swellings may be hot such as swellings caused by sanguine, bile oF putreficd matter or cold swellings that result from phlegm, black bile, water and air.!""1Cold swellings arc usually endogenous whereas in hot swellings mostly matter is influxed." 1. Hot swellings: (Davi awram (sanguineous swellings): Purely sanguincous influxed swellings are termed as falhamuni which occur in response to various ‘external and internal stim like injury. fracture, burn and Jmiela (congestion) ctc.'Mlas n matter of fact ‘normal humours do not produce swelling. Infact humours become abnormal.on stagnation as happens in waran. The affected organ is swollen, painful (if organ is sensitive otherwise not), tender, red, hot and tense"! Cutaneous sanguineous swellings result from accumulation of thin sanguine whereas‘muscular hot swellings result from viscous sanguine. Sanguineous swellings confined to flesh are more painful and tender in comparison to those of skin.!* Sanguincous swellings are classified according to site involved as:!4 Site Meningies 2. | Barsam (ghaphragritisy Diaphragms 3.__| Dhar al- Ri‘a (pneumonia) Langs. | Dhar ai=janb (pleurisyy Pleura 5. | Ramad/Ashob-i- chashm (acute conjunctivitis) Conjunctiva 6. | Dakhis (paronychia/whitlow) Nail 7__[ Ta'wn (plague) Lymph nodes S| Mashra (erysipelasy Head (especially face) Unnamed sanguincous swellings are known as falghamuni mulag. A falghamuni with suppuration 1s Known as kturaj (abscess). Jadri (Chicken pox) is also an example of sanguineous cutaneous swelling!45 (2)Safrawi Avram (Bilious swelling): In general bilious swellings are known ax hamra*4 Sometimes being hot and thin, sanguine too acquires bilious nature and may give rise Aamra. Is red, bot and painful as well as of pitting type." Pain is lesser than falghamuni and its redness is like saffron. Burning sensation in hamra is more than falghamuni.'! ‘Because of thinness of bile, most common site of involvement is skin." However, it may involve other sites too, Ismail Jurjani has classified biious swelling according to site involved. He is of view that ‘cutaneous swelling caused by bumt bile is known as mashra (erysipclas) whereas bilious swellings occurring under the skin and in the muscles are known as amra.!* ‘Nama is an example of bilious swelling produced by excessive hot and thin bile. Those swellings Which are produced by mixture of sanguine and bile are known as hamra murakkaba."! These are also named as hamva falghamuni or falghamuni hamra." 41 When giving the name, prefix of the dominant humour is used.!"*! Abbas Majusi is of view that hamera murakkaba has a bad prognosis. IL Cold Swellings: ‘These types of swellings are produced by cold matter like sada (black bile) bulgham (phlegm), ma’ (water) oF rile (aie). 221 (1)Balghami Awram (Phlegmatic swellings): The swellings produced by phlegm are of two kinds: (a) diffused, and (b) localised. The later are often discrete and covered with capsule. Diffused swellings are often widespread" Swellings which appear during winter are mostly phlegmatic."! Excessive use of those nutriments and drugs which are capable of producing phlegm result in phlegmatic swellings" Phlegmatic swellings vary according to the consistency of the phlegm, and may thus resemble with ‘savedlawi and rift swellings.""51 (a)Ocima: It is a diffuse type of swelling produced by balgham-e-muiaffin (puirefied phlegm) of ‘moderate consistency." It is white in colour, painless and of pitting type."*!Commonly these are due to influx of phlegm but sometimes may be endogenous. (b) Sal'a (Tumour): These are also known as rasofi "lor batadi "! and produced by viscous phlegm ‘encapsulated in a sheath." When Tabiat is strong enough it tries to localise the morbid matter by forming a capsule around the same. Usually their shapes are round but size may vary from gram to watermelon. These are movable! On the basis of resemblance of contained matter with fatty substances, honey. wheat and milk these are divided into four types: (@ Sal‘a Shahmia: In this type of sal‘a the contained matter resembles with the fat in colour as well as in consistency. It is greasy/smooth to touch and slippery. It does not yield to pressure 41(Gi) Sal‘a Astiya: In this type of sal‘a contained matter is like honey. It occurs when phlegm gets ‘muctafin (putrified). This type of sala does not yield to pressure. It feels like a bag full of honey." (ii) Sala Ardakaliya: In this type of sala the contained matter resembles with ardhala i a semi solid preparation made up of wheat flour and ghee. "¥ (iv) Sel‘a Shiraziva: In this type of sal‘a contained mattcr resembles with boiled viscous milh.!**1 (©) Khanazir (Lymphadenopathy): It is ike saf‘a!*4l It involves lymph nodes, mainly cervical. tis named so because (a) this discase is common in Kincir (pig). (b) Some physicians are af view that this disease involves multiple lymph nodes just like sows have multiple piglets in one delivery. It is produced by mixture of viscous phlegm and black bile 1 “The difference between the sal‘at, Khanazir and sarian (carcinoma) are thal the sal‘atare free, Kianazir| are attached with the underlying © or overlying structures and sarian infiltrates in surrounding. structures, Majusi has considered saleel a type of phlegmatic swelling.! Whereas, other physicians are of view that causative matter of safeel is black bile!" (2)Sawdawi Awram (Black Bilious Swellings): These swellings are produced by black bile. Production ‘of black bile increases because of excessive use of cold and dry nutriments, predominance of cold and ‘dry or hot and dry temperament on the organ etc "1 ‘These swellings are classified into: (a) Waram sulb (sclerosis) It is also known as sagirus.59 It is eaused by accumulation of normal black bile in an organ! This normal black bile becomes abnormal on retention and produces sagirus (hard swelling). It isa slowly growing painless swelling which does not harm adjacent structures, 3% (b) Sartan (carcinoma): Sarian means crab. This swelling is named so because (a) it sticks to the affected organ stubbornly like a crab and (b) In this swelling the vessels on the sides of the affected ‘organ are engorged due to accumulation of thick black bilious matter giving appearance ofa crab. It is ‘caused by excess of sawida-e-mohtarga (bumt black bile)! Cancer isa hard, spreading. rapid growing and painful swelling which later gets ulcerated"! It has roots entangled inside the organs. Initially it does not interfere with sensation and is painful but Iater it destroys the tissues and becomes painless"! According to Bugrat sartan is generally incurable and paticnt dies during treatment. Tabri ‘explains that sartan is treated by cauterization/burning and during the process, causative matter reaches to the vital organs causing death. However, sartam affecting the peripheral parts of the body like arms and legs can be cured by surgical removal Jucam (leprosy) is produced when sartani matter ie. burt black bile spread throughout the body that is why itis also known as sardan-e-aam_4#! Dawali (varicose veins) and Da'al-il(elephantiasis) are also the examples of sawfawi avram. Dawali may be caused by normal as well as burnt black bile. On contrary Da‘al-fil is caused by normal black bile only. (3)Ma'i Awram (Watery swellings): These types of swellings are considered cold because these swellings contain watery mattcr in them" It is a fact that water is coldest!" The watery fluid present in these swellings transude from the linings of organ as eceur in gila maiva {hydrocele) and istisga (ascites) ete." (Rihi Awram (Airy swellings); These swellings are produced by rie!" Here one should not confuse sir with the elemental air. Production of this zit occurs in the organs by two ways: (a) weakness of digestive faculty of the organ (b) the matter itself is such that produces rile ‘These are considered cold swellings because coldness of the body protects ri (air) from its dissolution ‘whereas heat favours its dissolution.” ‘These swellings are of two types: (a) Tahabbuj (puffiness): When sh is infused in interstices of the organ then it is known as sahabbuj. thas a soft feel (b) Nafkh (distension): When rih is collected /entrapped in a cavity then itis known as nfl. I is tense!Stages of swelling: ‘There are four siages in swelling-" (1) Fotida (Onset): The initial stage of the swelling is when the influx of morbid matter starts at the site. It becomes evident. In this stage the role of faba (physiv/nature) is not much apparent. (2) Tazayued (Growth): In this stage, swelling keeps growing due tocontinuous influx of morbid matter. Interaction of tabiat ane matter becomes evident. (3) Intiha (Peak): In this stage, swelling has reached its maximum and stops to increase further. There is a fight between tabiat and swelling. (4) Inhetat (Decline): When tabiat overcomes the swelling then it results in either dissolution oF formation of pus. Every swelling completes its all four stages unless intervened, in other words, when swelling is completely entrusted to tabiat Fate of swellings: A swelling has one of the three following fate"? (2) Dissolution: When tabiat is strong enough and morbid matter is small in quantity then tabi predominates over and causes dissolution of the matter. It is best fate. (2) Formation of pus: Formation of pus in a swelling indicates complet: concoction of morbid matter“! With this all acute symptoms subside #1 ‘There are some factors like thin consistency of morbid matter, strong body faculties, hot temperament, adulthood, summer season and essence of affected organ e.g. muscles which favour the process of pus formation (3) Transformation into hard swelling: Sometimes sanguincous and phlegmatic swellings may transform into hard swellings because of following two reasons: (a) Overuse of mohallilat (resolvent) causes dissolution of thin content of the morbid matter leaving. behind viscous content only. This occurs mainly in sanguincous swellings. (b) Overuse of mubarridar (refrigerant) solidifies the morbid matter. It occurs mainly in phlegmatic swelling. ‘Transformed hard swellings are painful contrary to thase hard swellings produced by the black bile. Discusion: \Waram is classified on the basis of matter involve but sanguincous and bilious swellings are further ‘classified on the basis of site involve by Abbas Majusi and Ismail Jurjani respestively.! Jurjani is of view that mashra is bilious swelling of skin whereas Majusiand Mohammed Tabri are of view that mash is the sanguincous swelling of face. It can be inferred that Majusi and TTabri are more specific about the site of mashra. But the difference in opinions of these physicians lies into causative ‘matter. The possible explanation is that sometimes sanguine becomes very hot and thin and acquires biliows nature. That is the reason Jurjani considered it bilious swelling ## According to Majusi_sanguineous swelling with suppuration is known as kiuvayf whereas Surjani and Ibn Sina generalise this term with any hot swelling (sanguincous or bilious) with supparation "4 MBajusi has considered salee! under phlegmatic swelling whereas llbn Sina considered it a growth on the skin caused by black bile." He further added that at times excessive dry phlegm acquires the nature ‘of black bile and produces saleel." Rabban Tabri is af view that when viscous black bile mixes with blood it causes saleef.? The difference in opinion of Majusi and other pirysicians is in causative matter ‘of saleed and can be explained on the basis of Ibn Sina's view of production of saleel by excessive dry phlegm that actually acquires the nature of black bile." Conclusion: Greco-Amab physicians have a very broad concept of waram: (swelling) that includes oedema, tumour and cancer etc. On the basis of type of matter involve in the swelling. they have explained each one ofthem in detail from causes to pathogenesis and symptoms etc. in a very systematize manner. Understanding the concept of various types of swellings would be helpful in diagnosis as well as in their treatment. Reference 1Llbn Sina. Al Qanooa fit Tibi. New Delhi: Idara Kitab-us-Shifa; YNM. 2.lbn Sina. Kulliyate Qanoon. New Delhi: Aijaj publication house; YNM_ 3.Baghdadi IH. Kitab-al-Mukbtarat Fit Tibb. Vol.1, New Delhi: CCRUM; 2005. 4.Majoosi AHBA. Kamil-us-Sana, New Delhi: Idara Kitab-useShifa; 2010. 5.Masihi AFIQ. Kitab al-umda fil Jarahat. Vol. I.New Delhi: OCRUM:1986 6.Rushd AWL Kitab-ul-Kulliyat. New Dethi: CCRUM: 1987. 7 Jurjani 1. Zakhira khwarizam Shahi. New Delhi: Idara kitab-us-Shifa; 2010, 8Tabri AABSR. Firdaus-ul-Hikmat. 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