Parsva Shula Causes, Symptoms, Pathogenesis, Treatment, Modern View

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Parsva / Parshva = side, flank, ribs – sides of thorax or ribcage (chest) / sides of abdomen (belly) in this context. Shula = pain, colic
Synonyms: Parshvashoola, Parshvashoola, Parshvashula, Parsvashula,

Though Parshva means both ‘sides of chest wall and belly’ the condition is often considered as ‘urah parshva shula’ i.e. pain in the sides of the chest region. But Master Sushruta has magnified the version of parsva shoola and has also included pain in both regions i.e. sides of the chest and belly in his explanation of pathogenesis and symptoms of the disease.

But in the same context Master Sushruta has also explained Kukshi shula which means pain in the abdomen. Here the pain cannot be manifested in only the central region of the abdomen but in fact would cover the sides of the abdomen also. If pain in the sides of the chest and also abdomen is manifested in parsva shula then what was the need of explaining kukshi shula immediately after parshwa shoola?
Read – Shoola Types, Symptoms, Treatment, Medicines, Remedies

Causes of parshva shoola

Foods and activities which cause vitiation of kapha are the primary causes of parsva shula.

Pathogenesis

• Due to the consumption in excess of incompatible foods and getting exposed to the activities and seasons which cause vitiation of kapha, the kapha gets aggravated.
• This aggravated kapha moves towards the sides of the body i.e. sides of the chest (and belly) and gets lodged therein.
• This kapha blocks the pathways of vata thus obstructing its free movements.
• This vata blocked by vitiated kapha causes distension of chest (and abdomen) in quick time and also causes sounds in the chest (gurgling sounds in the abdomen).
• It also causes pricking pain in the flanks i.e. sides of both chest and abdomen.
• This disease caused by vitiated kapha and vata is called parsva shula.
  Read – Kapha Dosha – General introduction

Symptoms of Parsva Shula

Adhmana – distension of chest / abdomen
Gudagudayanam – abnormal sounds in the chest / gurgling sounds in the abdomen
Suchibhiriva nistodam – pain as if pricked by pins and needles in the flanks i.e. sides of the chest and abdomen
Krichra uchchvasa – difficulty in breathing
Annam na vanchati – lack of desire to eat food
Na nidram upaiti – lack of sleep / insomnia

Why should we consider parsva shula as ‘pain in the sides of the chest’ alone?

• It is a popular notion and belief in Ayurveda clinical practice that parsva shula is ‘pain in the sides of the chest’ and not ‘pain in the sides of the abdomen’. This is because –
• Kukshi shula which has been explained immediately after parsva shula encompasses pain in not only the tummy but also the pain in its sides
• Parsva Shula mentioned as one of the symptoms of Rajayakshma disease, its symptoms and treatment (by Master Charaka) clearly defines and explains ‘pain in the sides of the chest wall’
• The abdominal symptoms and sleeplessness mentioned among the symptoms of parsva shula may be manifested as an effect of the pain in the sides of the chest over the abdomen
• It is wise to understand the terms adhmana, gudagudayanam, suchibhiriva nistodam (which are usually used with abdominal diseases) as applicable to the chest and not for the abdomen.
  Read – Parinama Shoola : Definition, Types, Treatment, Medicines

Sanskrit Verses

Treatment of Parsva Shula

Principles

Master Charaka charts out common treatment principles and formulations for 6 conditions associated with rajayakshma i.e. rhinitis, headache, cough, hoarseness of voice, dyspnea and pain in the sides of the chest cavity.

Considering these principles the below mentioned treatments can be considered to combat parsva shula.

The below mentioned may be skillfully administered –
Sudation – poultice, steaming, tubular, showering etc forms of sweating therapies
Massage with herbal oils
Fumigation
Anointments over the head
Showering of medicinal liquids
Tub bath / immersion
Food prepared with barley
Read – Annadrava Shoola: Definition, Treatment, Remedies

Shodhana / Panchakarma measures

When the doshas are accumulated in excess and are ready to get expelled, cleansing therapies should be administered in the form of therapeutic emesis and therapeutic purgation.

Ghrtapana – One should take large quantities of ghee after food for few days to get relieved from pain in flanks. The below mentioned ghee are useful –
Dashamuladhya Ghrta
Bala Ghrta
Rasna Ghrta
Jivantyadi Ghrta
Duralabha Ghrta

Use of Shatphala Ghrta (Sushruta)
Shatphala Ghrta mentioned in the context of ‘treatment of Plihodara – enlargement of spleen and liver’. Should be used mixed with powder of purified asafetida.

Use of Ghrta (Sushruta)
Pure ghee should be given for oral consumption mixed with powder of pure asafetida.
Read – Oleation – Snehakarma Dose, Benefits, Side Effects, Management

Leha – medicated confections
Kharjuradi Leha – Confection prepared with the below mentioned ingredients is useful –
Dates
Pippali – Long pepper
Raisins
Pathya – Terminalia chebula
Karkatasringi – Pistacia integerrima
Duralabha – Fagonia cretica

Shuntyadi Leha – confection prepared with below mentioned ingredients should be used –Ginger
Chitraka – Plumbago zeylanica
Parched grain
Pippali – Long pepper
Amalaki – Emblica officinalis
Jaggery

Churnas
Talisadhya Churnam
Sitopaladi Churnam
Pushkaramuladi Churnam (Sushruta)

Powder prepared with equal quantity of the below mentioned ingredients should be taken –
Pushkaramula – root of Inula racemosa
Purified asafetida
Sauchal salt
Vid salt
Rock salt
Coriander
Haritaki – Terminalia chebula

The powder should be taken along with decoction of barley.

Benefits – This formulation cures pain in the sides of the chest, pain in the heart and pain in the urinary bladder.

Use of Eranda Taila (Sushruta)
Castor oil (oil of Ricinus communis) should be administered mixed with any one of the below mentioned vehicles taking into consideration the constitution, disease and time period or stage of disease –
Madhya – wine
Mastu – supernatant layer of curds
Milk
Meat soup

When the person feels hungry he should be served with food along with milk or meat soup of animals and birds living in desert-like regions.
Read – Castor Oil Benefits, Research, Side Effects, How To Use, Dose

Use of Bijapura (Sushruta)
Seeds of Bijapura fruit – Citrus medica or its freshly extracted juice should be boiled and processed with milk. This milk should be consumed.

Dietetic inclusions

Meat soup of quail, grey francolin, partridge, cock, prepared with ghee added with lemon juice, pepper powder and rock salt should be served fresh and hot.
Food prepared with rice, barley or wheat should be served with soup of radish or horse gram.
For people who are used to drinking wine, a supernatant layer of the wine by the name Varuni should be given to drink.
Water processed with Laghu Panchamula group of herbs should be given for drinking.

External measures

Applications – These pastes may be applied over the afflicted part / painful part of the chest –

1. Baladi Pradeha – Paste of the below mentioned should be applied mixed with ghee –
Bala – Sida cordifolia
Rasna – Pluchea lanceolata
Sesame seeds
Licorice
Blue variety of lotus / water lily

2. Guggulvadi Pradeha – Paste of the below mentioned should be applied mixed with ghee –Guggulu – Commiphora mukul
Devadaru – Cedrus deodara
Sandalwood
Nagakesara – Mesua ferrea

3. Shatapushpadi Lepa – Paste of the below mentioned should be applied mixed with ghee –
Shatapushpa – Anethum sowa
Licorice
Kushta – Saussurea lappa
Tagara – Valeriana wallichii
Sandalwood

For massage – the below mentioned medicaments may be used –
Chandanadi Taila
Shatadhauta Ghrta

Showering of liquids – one of the below mentioned shall be used –
Fresh milk of cow
Decoction of Licorice
Freshly collected rain water
Water boiled and prepared with Chandanadi group of herbs

Other useful formulations
Balajeerakadi Kashayam
Dashamula Kaduthrayam Kashayam
Nayopayam Kashayam
Punarnavadi Kashayam
Rasonadi Kashayam
Vidaryadi Kashayam

Modern correlation

The below mentioned conditions might cause pain in the flanks, mainly in the sides of the thoracic cavity / chest cavity and hence may be included in correlated study with parsva shula. They are –
Pleurisy
Pleurodynia
Intercostal neuralgia

Parsva shula is caused by kapha and vata. If this condition is compared to pleurisy –
Kapha predominant parsva shula can be considered as ‘pleurisy with effusion wherein there will be expansion of chest cavity (ayama).
Vata predominant parsva shula can be considered as ‘dry pleurisy’ wherein there will be constriction of chest cavity (sankocha)

Depending on the site of lesion the pain can be on one side or both sides of the chest cavity. Severe pain in the side of the chest cavity is the predominant symptom of dry pleurisy. In this condition the pain would increase when the patient breathes or coughs. The movement of the chest is reduced on the afflicted side. At the same time the movement of the abdomen will increase during breathing. The person will also find it difficult to breathe easily. There may also be an accompanying fever. Fever will not be seen in conditions of pleurodynia and intercostal neuralgia. These conditions also will fit into the differential diagnosis of parsva shula.

Pleurisy Causes, Symptoms, Prevention And Treatment

Pleura are the thin tissues that line lungs and chest wall. Putting it the other way, the lining or outer covering of the lungs are called pleura. Pleurae are plural and include coverings of both lungs. Each lung is covered by 2 pleura separated by a space filled with a lubricant fluid. The inner layer close to the surface of the lung is called visceral pleura and the outer layer is called parietal pleura. The pleurae rub against each other while breathing. This usually doesn’t generate any friction since the tissue is satiny and there is sufficient lubrication. But when there is infection in these tissues, they become irritated and swollen. This causes significant pain in region of lungs. This condition is called pleurisy or pleuritis. It causes sharp chest pain ‘pleuritic pain’ that worsens during breathing.

It is not a common condition any more. It is successfully treated with antibiotics over the past few years. Antibiotics have also helped in preventing bacterial infections which cause pleurisy. Recent day pleurisy is due to viral infections. On the other hand pleurisy related deaths are rare.
Read – Dyspnoea – Difficulty in breathing: Causes, Pathophysiology, Diagnosis

Symptoms of Pleurisy

Main symptom – Sharp and stabbing pain in the chest, in the region of lungs when you breathe is the chief symptom of pleurisy.

Relieving factors – The pain may ease when you apply pressure on the most painful area of the chest or when you hold your breath.

Aggravating factors – Pain will worsen when you breathe, cough, sneeze or move about. Pain might worsen with movement of the upper body. The pain can also radiate to the back or shoulders.

Associated symptoms –
Pain on one side of the chest, back and in shoulders
Shortness of breath-
Shallow breathing (defense mechanism to avoid feeling the pain)
Muscle aches
Cough
Fever
Headache
Chills
Joint pain
Loss of appetite
Fluid buildup around the lungs (pleural effusion)
Read – Atelectasis Causes, Symptoms, Treatment, Ayurveda Concept

Pleurisy will be accompanied by one or more of the below mentioned conditions – Pleural Effusion / fluid around the lungs – In some cases of the disease, fluid will build up in the space between the pleurae and impart pressure on the lungs. The lungs will not work properly. This effusion may initially act like a cushion and will make the chest pain disappear because the layers of pleura do not rub against each other so as to cause the pain.

Atelectasis / collapse of lung – When a large amount of fluid is present in the pleural space it would create pressure. This will compress the lung to a great extent that partial or complete collapse of the lung occurs and this is called atelectasis. This will lead to difficulty in breathing. The patient might also develop a cough.

Empyema – The extra fluid which has become infected around the lungs can often get infected. This results in accumulation of pus. This is called empyema. This condition is often accompanied by fever, chills and dry cough.
Read – Emphysema – Causes, Symptoms, Treatment, Prognosis, Ayurvedic Understanding

Causes

The most common cause of pleurisy is viral infections. Viruses cause infections in the lungs. This leads to pleurisy.
Other causes –
Bacterial infection / Bacterial pneumonia
Fungal / parasitic infections
Tuberculosis
Bronchitis
Wounds in the chest / blunt trauma (to the chest wall)
Fractures of ribs / rib trauma
Chest / lung tumors
Pulmonary emboli
Immune / Autoimmune disorders (SLE, RA etc)
Complications of heart surgery
Lung cancer
Sickle cell anemia
Lymphoma / mesothelioma
Certain medications

Diagnosis

The physician will diagnose the condition after thorough examination of the patient, case recording and conducting the necessary tests. Initially the location and cause of inflammation shall be determined. The below mentioned tests might be recommended so as to make a precise diagnosis –
Blood Tests – will help to determine infections and cause of infection. They will also help in revealing disorders related to the immune system if any.
Chest X-rays – will help to check if there is inflammation in the lungs. It also help to find if lungs are completely inflating or not and also determine if there is air or fluid in between the lungs and ribs.
Decubitus X-ray – is an X-ray taken while lying on side. This will confirm if there is any fluid buildup around the lungs.
CT scan – will give a detailed picture of the inside of chest and a closer look at the irritated tissue. These are cross sectional images of chest which help the doctor find out abnormalities in the chest. The detailed images available from the scan will show the condition of the pleura and also if there are other causes of pain including blood clot in the lung.
Ultrasound – will help in finding out inflammation or fluid buildup related to pleurisy (effusion).
Biopsy – help in determining the cause of pleurisy.
ECG / EKG – Used to rule out certain heart problems as causal for chest pain.

Procedures used to remove fluid and tissue from pleural space for testing them –Thoracentesis – the fluid around the lungs will be removed and analyzed for the presence of infections. Removal of the fluid will also help you breathe better.
Thoracoscopy / pleuroscopy – helps in looking into the pleural space, to locate the irritated area and to collect tissue samples for analysis. It will also be advised if TB or cancer is suspected to be causal for your pleurisy.

When to see a doctor?

You need to see a doctor if there is unexplained chest pain which is severe and when it happens when you breathe.

Lifestyle changes, Home remedies

These measures help in relieving symptoms though they may not cure the disease –

Taking medications regularly
Get good rest – the patient needs to find a proper position to sleep and rest. The position should be such that it should provide you with least discomfort.
No smoking – Smoking is harmful for lungs and might worsen the irritation in pleurisy.

Treatment of Pleurisy

Treatment is mainly dependent on the underlying cause. Example – antibiotics will be prescribed if bacterial pneumonia is the cause. Pleurisy may resolve on its own if virus is the cause.
Good rest is needed for comprehensive healing.
One should lie on the side having excessive pain. The pressure exerted on the painful side by sleeping on that side would make the pain go away.

Other treatment –
Antibiotics which would help in dealing with the infection
Aspirin, ibuprofen, NSAIDs – to combat pain related pleurisy
Pain and cough medication
Medications to break up any blood clots
Medicines to remove pus and mucus
Bronchodilators / inhaler devices
Fluid drain – If there is excessive fluid accumulation in and around the lungs i.e. pleural effusions the doctors may advice you to get hospitalized for fluid drain.

Outlook

This disease can have severe long term implications. Early diagnosis and treatment are the key strategies for comprehensive cure. Seeking medical help and treatment and strictly following the course of treatment as advised by the doctors will yield positive results. Identification of underlying causes will help in good and effective recovery.

Research

A study conducted on 254 patients to determine the age at which tuberculous pleurisy / tuberculous pleural effusions occur it was found that about 62.2% of patients were younger than 35 years of age. (A)

A comparative study was done on diagnostic tools in tuberculous pleurisy and thoracoscopy was found to be the most accurate yet most expensive tool for establishing the diagnosis of tuberculous pleurisy. (B)

Ayurveda Understanding

Pleurisy can be closely correlated and studied with a condition named and explained as ‘parsva shula’ by Master Sushruta.
Pleurisy should also be treated on the lines of –
Shwasa Chikitsa – when there is shortness of breath and shallow breathing
Kasa Chikitsa – when cough predominates the picture of pleurisy
Jwara Chikitsa – when fever, body pains, headache, chills, joint pains and loss of appetite are present
Udakavaha sroto dushti / Shotha Chikitsa – in presence of pleural effusion

Click to Consult Dr Raghuram Y.S. MD (Ayu)