Diva Bali Shvayathu / Shotha: Swellings predominant during ‘Morning Time’

Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa S, B.A.M.S

Meaning

Diva = morning / day time

Bali = strong, predominant, evident

Shvayathu / Shotha = swelling, edema

Note – Shvayathu is a synonym of Shotha.

Divabali Shvayathu/Shotha

Moving, thin skin, harsh, red, black, with sleep, joy, pain, without cause
It subsides, it rises, it is oppressed, and the divabali, the white fever, from the breeze||

Ref – Charaka Chikitsa Sthana, Chapter 12, Verse 12

Divabali Shvayathu / Shotha is a swelling which is predominantly seen during day-time i.e. in the morning hours. So, Vataja Shotha is Divabali Shotha and Divabali Shotha is Vataja Shotha.

Causes – Vata predominance in Shotha. Nidanas of Shotha and Nidanas for Vata Aggravation.

Symptoms of Divabali or Vataja Shotha –

– Chala – the swelling is movable

– Tanu Twak – the skin over the swelling is thin

– Parusha – the swelling is rough / dry / coarse on touch

– Aruno, Asitaha – the colour of the skin is either reddish brown / dawn red / dusky brown or black

– Prasupti – feeling of numbness

– Harsha – horripilation

– Arati – discomfort or pain

– Prashamyati Animittatah – the swelling subsides without any reason

– Pronnamati Prapidito – the swelling disappears on pressing it, but it reappears and comes back to its normal position immediately (after the pressure has been released)

– Divabali – the swelling is predominant during morning time i.e. it increases during the day time and often subsides without any appreciable reason

Modern view of ‘Morning Swelling’

Daytime or Morning time swellings are generally caused due to edema or overnight fluid redistribution. In these conditions, the fluid in the body settles in the face, around the eyes or hands. The mechanism has occurred while we have slept due to lying down flat for several hours.

Many times these swellings are harmless and are temporary in nature. In such conditions, they depict some lifestyle factors. When these swellings occur regularly or as a pattern, it is a point of concern and they reflect the underlying medical conditions. It is time to see the doctor.

Features of Morning Swelling – When the swelling or edema (fluid accumulation in the tissues) is more in the morning time, it usually involves – face swelling (mainly eyelids), swelling of hands or fingers and sometimes generalized puffiness.

Mechanism – When we lie down overnight, the fluid in the body redistributes from legs to face and upper body. Due to reduced gravity, more fluid accumulates in the loose tissues like eyelids. So, morning swelling often indicates systemic causes and not just local issues.

Main causes for morning swelling

1. Overnight Fluid Accumulation – Fluids, mainly lymph, do not get drained from the face and head while we are sleeping. This will result in puffiness around the eyes and cheeks and are evident when we wake up. Such swellings disappear once we wake up and are upright.
2. High Salt or Sodium Intake – When we are habituated to consume foods rich in sodium, mainly in the evening or night, the body learns to retain water. This retention reflects in the form of visible swelling in the hands, feet and or face in the morning.
3. Sleeping Position – Fluids can increasingly pool around your face if you are habituated to sleeping on your belly or with your head elevated too little.
4. Pregnancy – Swelling in the hands and face is common during pregnancy due to increased fluid volume. The woman should however be evaluated for high blood pressure.
5. Sleep Related Factors – Poor Sleep Posture, excessive intake of salt at night, consumption of alcohol before bed – these factors might cause temporary fluid retention which leads to manifestation of morning puffiness.
6. Certain Medications – Steroids, Calcium channel blockers, Non-Steroidal Anti-inflammatory Drugs – can cause ‘morning swelling’.

Common Underlying Medical Conditions for ‘Morning Swelling’

1. Kidney Issues – Kidney disorders are the most classic causes for morning swellings, usually nephrotic syndrome and glomerulonephritis. Key features would be – puffy face, especially eyelids, frothy urine due to protein loss and reduced urine.

Low protein leads to fluid leaks into tissues and that fluid collects in the face overnight.

Kidney Damage → protein leak into urine → fluid accumulation → swelling around the eyes (periorbital edema).

2. Hypothyroidism – Swelling in the face and hands is evident in cases of Hypothyroidism / underactive thyroid.

Puffy face & non-pitting edema, myxedema (thickened skin), weight gain, cold intolerance, fatigue and other symptoms of hypothyroidism may be evident. The fluid retention in the tissues may be due to mucin deposition.

3. Allergies – Puffiness of the face, itchy eyes or stuffy nose in the morning can also occur due to exposure to dust mites, laundry detergents or dander in the bedding. This happens due to the allergic reactions caused by these things.

Allergic reactions cause swelling when you are exposed to the allergens overnight. Allergic Rhinitis is one such common cause which presents with swelling of eyelids, itching, sneezing. Dust mites, pillows, bedding – as mentioned above are the triggers often.

4. Liver Diseases – would cause ‘morning swelling’, mainly Cirrhosis of the Liver. It would present with generalized swelling (anasarca), ascites and low albumin levels.

5. Sinus infection or congestion – Pain and swelling behind the nose, cheeks and eyes are common in sinusitis.

6. Arthritis – In Rheumatoid Arthritis, if the stiffness lasts more than half an hour, it might result in swelling of joints in the hands. It can occur in other forms of arthritis also.

7. Local Causes specific to the Eye – Conditions like Blepharitis, Conjunctivitis and Eye infections would cause morning swelling.

Uncommon condition –

Heart Failure – Due to fluid build up in the tissues when the heart does not work efficiently as a pump.

This is a less common condition which presents with morning swelling. It might be evident in cases of congestive heart failure. These conditions present with leg swelling in the evenings rather than facial swellings in the mornings. So, heart cause is less likely if the swelling is mainly in the morning. But it needs to be ruled out.

Simple tips to reduce morning swelling

1. Head elevation – One should use an extra pillow while sleeping. This will prevent fluid accumulation in the face.
2. Reducing Sodium and Alcohol consumption – To prevent excessive water retention, one should avoid sodium and salty snacks especially in the evenings and also alcohol consumption.
3. Cold Compress – Cold compress or a cold water splash on the face will reduce puffiness by constricting the blood vessels in the face.
4. Hydration – One should make sure of drinking enough water throughout the day. This will help in flushing out excess salts and toxins out of the body.
5. Massage – A gentle facial massage with upward strokes will encourage lymphatic drainage.
6. Night Meals – Avoid late night heavy meals.
7. Allergen Check – Identify the allergens troubling you. Check your bed for any allergens.

Right time to see the doctor / Red Flags of ‘Morning Swelling’

One should immediately see the doctor if the swelling is severe and is persistent i.e. when it does not go away during the day.

One should also seek immediate medical advice when swelling is accompanied by

– persistent daily swelling,

– breathing difficulty,

– sudden and rapid gain in weight,

– shortness of breath,

– high blood pressure

– reduced urine output

– painful swelling or

– a swelling which feels hot.

Evaluation of Morning Swelling

Doctors would need some basic tests to run so as to figure out the exact cause of morning swellings. They are – urine test for presence of protein or RBCs, kidney function tests (mainly to check urine creatinine values), thyroid profile, serum albumin and blood pressure.

Ayurveda Treatment Principles

Divabali Shvayathu should be treated on the lines of Shvayathu Chikitsa – treatment of swellings as enumerated in the Ayurveda texts. To be specific, these cases shall be treated on the lines of Vataja Shvayathu Chikitsa – treatment of swellings caused by predominant aggravated Vata.

Related Easy Ayurveda Articles – For Quick Glance and Preparation

1. Shota Chikitsa – Charaka Chikitsa, Chapter 12
2. Chikitsa Sutra – treatment principles of Shotha / Shvayathu – Charaka Samhita, Chikitsa Sthana – Chapter 12, Verses 16-19
3. Treatment of Doshaja-Shothas
4. Shotha – A Bird’s Eye View
5. Diagnosis of Shotha on the Basis of Dosha Predominance
6. Shvayathu Chikitsitam Adhyayam – Ashtanga Hridaya, Chikitsa Sthana – Chapter 17
7. Shotha Nidanam – Madhava Nidana, Chapter 36