Anatomical and Preventive Approach of Arbuda in Relation to Tvak

Introduction

“Skin is the mirror of the soul” and also the first barrier between the whole body and its environment. Skin is constantly submitted to mechanical, physical, chemical, and oxidative attacks resulting from the breath, metabolism, or external factors such as ultraviolet exposure, which may lead to disturbance of homeostasis within body cells and organs, that reflects itself on the surface of the skin, sometimes in many drastic ways. Skin may develop more than 1000 different ailments and conditions. Skin disorders are mainly either due to viral, bacterial, or some type of yeast infections. Skin conditions like skin cancer and burns are less common but far more dangerous.  

Skin is the body’s largest organ in surface area and weight. In adults, the skin covers an area of about 2 sq. meters and weighs 4.5-5 kg, about 16% of total body weight. Structurally, skin can be divided into two main parts. The superficial, thinner portion, that is composed of epithelial tissue, is the epidermis. The deeper, thicker connective tissue part is the dermis. Skin protects the body against heat, sunlight, injury, and infection. Skin also helps maintain the body temperature and stores water, fat, and vitamin D. Skin cancer usually develops in the epidermis - the outer layer of the skin; thus, it can often be spotted and treated in time. Skin cancer most commonly occurs in areas exposed to sunlight, such as the face, neck, hands, and arms, and even can occur anywhere on the body.¹

Acharya Charaka explained six layers of Tvak in the body, such as Udakadhara (that which holds the water) - the outer layer. The second layer is Raktadhara (which holds the blood). The Tritiya layer is seat of origin of Sidhma (a type of dermatitis) and Kilasa (leucoderma). The Chaturtha layer is the seat of origin of Dadru (ringworm), and Kustha (leprosy including other skin disorders). The Panchami layer is a seat for Alaji and Vidradhi. The Shashti layer is that which if cut, causes loss of consciousness, the person feels as if entering in to the dark like blind and it is the seat of origin of Aarumshi (small boils) developing over joints, having blackish red colour, thick roots and are difficult to treat (hardly curable).²

Acharya Sushurta explained seven layers of Tvak, deposited on the rapidly transforming product of the combination of Sukra and Sonita. This impregnated matter undergoes metabolism along with the individual soul, which forms seven layers Tvak, in the same manner as the layers of cream formed on the surface of boiling milk after heating. Among them, the first layer is called Avabhasini (reflecting). It is the external layer and it imparts color and luster in the body. The thickness of this layer measure 1/18^th of a Vrihi (rice grain) and skin diseases such as Sidhma, Padmakantaka etc. can occur in this layer.

The second layer is called Lohita. It measures 1/16th of a Vrihi and is the seat for skin diseases like Tilakalaka, Nyachcha, and Vyanga etc.

The third layer is called Shveta, which measures 1/12_th of Vrihi in thickness and forms the seat for skin diseases like Ajagallika, Carmadala and Mashaka etc

The fourth layer is called Tamra, measuring 1/8^th of Vrihi and the diseases which manifest in this layer are different types of Kilasa and Kustha etc. 

The fifth layer is Vedini, measuring 1/5^th of Vrihi and manifests diseases like Kustha, Visarpa etc. 

The sixth layer is Rohini, having equal thickness of Vrihi and forms the seat for Granthi, Apaci, Arbuda, Slipada and Galaganda etc.

The seventh layer is called Mamsadhar. It has thickness as twice of a Vrihi and the diseases like Bhagandhara, Vidradhi, Arsa manifests in this layer.³

Dalhana interpreted ‘Vrihi’ as Yava (barley) instead of paddy or rice and further said, “the length of a barley grain should be divided first into twenty parts; out of these, eighteen, sixteen, twelve, eight and five parts taken together is the thickness of the layer of skin respectively.” There is a great similarity between the ancient and present day description of the skin. Descriptions found in modern texts on anatomy are furnished herein for comparison.

Skin or integument is a protective covering over the entire exterior of the body. It varies greatly in thickness, from 0.5 mm (on the eyelids etc.) to about 6 mm (on palms, soles, back etc.) and on an average, is 1 to 2 mm thick. It consists of two distinct layers, viz 1. Epidermis- External layer; further composed of five layers, i.e. Stratum corneum, Stratum lucidum, Stratum granulosum, Stratum spinosum, Stratum germinatum. 2. Dermis- Internal layer; again is divided into two layers i.e. papillary layer and Reticular layer.

The layer just underneath the dermis is known as Hypodermis, subcutaneous tissue or superficial fascia. Hypodermis is thicker than the dermis; it binds the dermis to the underlying muscles and bones. It contains more of fat, sweat glands, hair follicles, blood vessels and lymphatics traverse through it.⁴ 

Thus, skin layers described by Acharya Sushruta and by modern anatomists can be correlated roughly as:

Avabhasini and Lohita - Stratum corneum,

Shveta - Stratum lucidum,

Tamra - Stratum granulosum and Stratum spinosum,

Vedini - Papillary layer,

Rohini - Reticular layer

Mamsadhara - Hypodermis of the skin.⁴

Ayurvedic classics mentioned about Arbuda, which can be compared to cancer. Acharya Charaka described Arbuda in the context of Sopha/ Svayathu (inflammatory and non–inflammatory swellings).⁵

Cancer cells possess unique characteristics, that their proliferation is unregulated and they have the capacity to invade surrounding tissues and penetrate the walls of blood vessels and lymphatics to spread to different sites of the body. Oncogenesis is a multistage process which often begins with a somatic mutation in a single cell, resulting in growth advantage. Numerous other triggering causes includes toxic environment, denatured and processed foods, sedentary lifestyle, and lack of spiritual purpose or effort in life, hormones, occupations, cigarette smoking, inflammatory diseases, radiation etc.⁶ 

Methodology

Literature has been collected from Samhitas (classical texts), Medicine and Surgery text books and journals. 

Anatomical Approach of Arbuda in Relation to Tvak 

Skin cancers originate from the epidermis and malignant tumours of the dermal appendages are very rare. A single injury or insult to the skin may determine the development of cancer; though long continued exposure to irritation is the more potent cause. A combination of irritant effects is more carcinogenic than a single agent. Skin cancer is relatively benign and easily curable, if treated early and efficiently. But malignant tumours are characterized by local destruction, infiltrative growths, recurrence after removal and have tendency to local or distant metastases.⁷

*Squamous cell carcinoma (SCC) is the non-melanoma type of skin cancer arising from the squamous cell (Keratinocytes). Squamous cell carcinoma may occur from pre-existing skin lesion such as actinic or solar keratosis, actinic chelitis, long-standing leg ulcers, burn scars (marjolin’s ulcers), ulcerative lichen planus of lip and oral mucosa, lupus vulgaris. 

*Basal cell carcinoma (BCC) is the most commonly occurring non-melanoma skin cancer in humans. BCC typically affects adults of fair complexion, who have had chronic sun exposure. It is uncommon in Indian skin. Its clinical behavior is different from that of other malignancies; it is locally invasive, does not metastasize and hence, carries good prognosis. It is thought to arise from embryonic crests of pluripotent basaloid cells (germ cells), which retain ability to develop into different types of cell line in the adult.

*Malignant melanoma is a type of melanoma skin cancer arising from melanocytes and is a potentially serious condition. Melanoma can occur in adults of any age, but is very rare in children. All melanomas initially spread out within the epidermis called radial growth. At this stage, as the melanoma cells are confined to the epidermis, it is referred as melanoma in situ. When the malignant cells have grown through the basement membrane, invade deep into the dermis, it is known as invasive melanoma and this phase is called vertical growth phase and is more dangerous.⁸

Acharya Sushruta explained the development of Arbuda in the sixth layer of the skin ‘Rohini’.⁴ Ayurvedic classics explained the fundamental cause for Arbuda as ‘Rohini’, which gets vitiated due to improper foods habits, bad hygiene. These habits results in the vitiation of Dosha, which causes pathological injuries to this layer in muscular tissues and blood vessels (Dhatu i.e. Rakta or Mamsa or Medas).

Pathogenesis of Arbuda

Acharya Sushruta provided more information on Arbuda, Granthi, Apachi, and Galaganda etc. Vata and other Dosha associated with Kapha, on getting aggravated, vitiate the Mamsa, Rakta and Meda Dhatu and produce a Vrutta (round), Unnatam (bulged) and Vigrathitam (hard swelling), which is called as Granthi (Benign tumour). Further, Acharya mentioned aggravated Dosha causing vitiation of the Mamsa Dhatu, produces muscular swelling in the body, which is Vrutta (round), Sthira (immovable) with Mandaruja (mild pain), Mahanta (big in size), Analpa Mulam (deep rooted), Chirvrudda (growing slowly), and Apakam (not ripening). Such disease should be called as Arbuda (Malignant tumour).⁹

Arbuda is a disease that often involves all three bodily humors (Vata, Pitta, Kapha), though it typically starts with vitiation or predominance of one of the Dosha. When an individual’s digestive fire or enzyme reserves are decreased, allowing a build-up of toxic substances in the body, this can develop an environment for cancer cells to grow. Therefore, in Arbuda, the mandagni i.e, decreased state of dhatwagni (deranged metabolism) results in the excessive abnormal growth of the dhatu (rakta or maimsa or medas). The cancer denotes a negative lifeenergy, something similar to a microorganism, which has been developed in the body.¹⁰

The aggravated Dosha compressing and contracting the Sira (vessels) and Rakta of the affected part, leading to suppuration and thus exuding tumour that is covered by the small peduncle and fleshy tubercles is called a Rakta Arbuda. This tumour quickly grows and exudes a constant flow of vitiated Rakta. This type is considered as incurable because of its origin in the Rakta. The patient becomes pale due to complications of bleeding. The Mamsa gets vitiated due to external blow etc. giving rise to swelling (tumour), which is called Mamsarbuda; occurs by the action of the Vayu that is aggravated. It is oily, painless, non-suppurating, hard like stone, fixed and of the same colour as the surrounding skin. Such a tumour appearing in a person addicted to meat diet becomes deep seated, owing to the consequent vitiation of the Mamsa and soon becomes incurable.¹¹

There is possibility of getting a view that Ayurveda has considered only the three Dosha as causative factors for all diseases. It is true that the three Dosha are the causes, but there may be several causes for the disturbance, vitiation or aggravation of Dosha in the body. After being affected, the Dosha in turn affects the bodily tissues and produces disease. While making a pot, mud is the inherent or innate cause, while the potter is Nimitta or efficient cause. Similarly, Dushya or Dhatu are inherent cause and Dosha are Nimitta cause (instrumental or efficient). Others like Ahara (food), Charya (regimen) are the supporting factors for causing diseases.¹²

From an Ayurvedic perspective, Arbuda formation is a condition of Vata-Kapha origin. Vata is responsible for the faulty division of cells and Kapha for their growth. Thus, Vata pushes Kapha out of balance resulting in formation of tumour. Kapha appearance is predominantly seen in benign tumors. Further, Pitta is also vitiated and the condition becomes Sannipatika in nature in malignancies. Later in this condition, the Agni of the affected tissue is increased, making it very aggressive to its surroundings, as it slowly digests the tissues of the body.¹³

While in the beginning, the interplay or involvement of the Dosha may not be clear; later, Vata imbalance predominates and the condition leads to severe wasting of the body tissues. As cancer begins, Ojas in the affected tissue is always hampered. The systemic Ojas decreases as the condition progresses. Ojas depletion is due to anger, hunger, constant thinking, grief, exertion etc., leading to phobias, loss of strength, excessive thoughts, sensory disturbances, loss of complexion, confusion, increased dryness of body and exhaustion.¹⁴

Preventive Approach of Arbuda in Relation to Tvak

The prevention of cancer can be described as active measures to decrease the risk of cancer. The environmental risk factors cause vast majority of cancer cases, and by adapting good dietary habits and lifestyle choices, the effect of these environmental factors is controllable.

Methods of preventing skin cancer

•  Avoiding risk factors
• Increasing protective factors 

Risk factors

•  Exposure to natural sunlight or artificial sunlight (such as from tanning beds) over long periods of time
• Fair complexion 
• Prolonged exposure to industrial chemicals and excess use of cosmetics 
• Past history of treatment with radiation 
• Possessing weak immune system 
• Skin that is prone to moles 
• Having a history of many blistering and sunburns as a child or teenager. 

Increasing protective factors

• The regular application of sunscreen that protects against UV radiation 
• Not staying out in the sun for long periods of time, especially when the sun is at its strongest 
• Wearing long sleeve shirts, long pants, sun hats, and sunglasses when outdoors 
• Chemo preventive agents like beta carotene, selenium and nicotinamide 
• Counseling and protecting the skin¹⁵

The American Cancer Society suggests that each person should examine their skin regularly for any new moles and changes in the skin pigment. A better way to examine your skin is to follow ABCD rule.

1.  Asymmetry - there is no match between two sides of the pigmented spot or mole. 
2. Border irregularity – the lesion exhibits indentations at the borders. 
3. Colour - the pigmented region contains different colours. 
4. Diameter- the diameter of spot is larger than 6 mm.¹⁶ 

Discussion

Ayurveda considers Tvak as one of the Jnanendriya and seat for the Sparshnendriya. Tvak is the Avayava derived from Matruja Bhava and is composed of Panchmahabhutas, specially Vayu mahabhuta in predominance .

Ayurveda believes the derangement of the three Dosha to be the cause of any disease and even diseases like Arbuda. The lifestyle errors, unhealthy food, poor hygiene and unhealthy habits results in disequilibrium of the three Dosha, which may lead to the formation of the tumours. The factors which are responsible for vitiation of the Dosha are: Vata aggravating factors – taking Katu (bitter), Tikta (pungent), Kashya (astringent), Ruksha (dry) Ahara in excess and living under stressful conditions. Pitta aggravating factors – taking Amla (sour), Lavana (salty), Vidahi (fried foods) in excess and excessive anger in behavior. Kapha aggravating factors – taking Madhur (sweet), Snigdha (unctuous) food in excess and sedentary life style habits. Rakta aggravating factors – taking Amla (acidic) or Kshara (alkaline) food stuffs in excess, Vidaahi (fried and roasted foods), Madya (alcoholic beverages) are the stuff that aggravates the Raktadhatu. Excessive temper or emotional disturbances, working under sun rays, near fire or very heated environment are some other causes. Mamsa aggravating factors – taking foods like Matsya (fish), Mamsa (meat), Dadhi (yoghurt), Ksheer (milk) and cream in excess. Divaswapna (sleep during day) and Adhyashana (overeating) are the causes which lead to dushti in Mamsa Dhatu and of course in three Dosha. Meda aggravating factors – use of excess of Sneha (oily foods), Madhura rasa (sweet), Madhya (alcohol) and Alasya (lazy attitude) leads to deranged Dosha.

These factors disturb the equilibrium of the body by disturbing the Dosha and causes the vitiation of Rasa Dhatu and Rakta Dhatu and then moves to the tvak, causing the risk of Arbuda in tvak, which may generate into skin cancers. Thus, avoiding these Dosha aggravating factors and inclusion of herbal drugs like Haridra, Aswagandha, Lasuna, which are having anticancer properties and regular use of foods such as fish, beans, carrots, curd, pumpkin, cabbage, broccoli, and vegetables containing beta-carotene and vitamin C may also help protect skin.¹⁷

Since UV radiation is the central causative carcinogen, to prevent the development of non-melanoma skin cancer, protection from excessive single doses as well as high cumulative doses of UV is the most important measure. This should include avoidance of the sun at peak times, wearing long sleeved clothing and hats that protect neck and ears as well (textile UV protection), and application of topical sun cream lotions protecting from both UVB and UVA. In this regard, not only the DNA damaging effects of UVA and UVB play a role, but it has also been shown that oxidative DNA damage plays an important role in skin carcinogenesis. Therefore, not only mere protection from UVA and UVB appears sensible, but also anti-oxidative strategies. Anti-oxidants can be applied topically or orally.¹⁸  

Conclusion

In this modernized world, skin cancer remains a major threat to the society. Skin is important presentable organ which carries many important functions of body. It has a definite role in one’s personality. Thus, disorders of skin affect not only at somatic level, but also at psychological level. Through proper anatomical knowledge of Tvak Shareera and by adopting Dinacharya, Rutucharya, Sadvrutta Acharana and seasonal Panchakarma procedures, we can prevent skin cancer to a certain extent. Ayurveda is a treasure of profound knowledge which must be rediscovered. By proper application of its principles in our daily life, it may one day bring an end to suffering, thereby preventing and treating many diseases by nature itself.