Critical review of Surgical treatment of Mutrashmari according to Sushruta

REVIEW ARTICLE Nov-Dec 2019 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2019 | Vol. 4 | Issue 6 237 Critical review of Surgical treatment of Mutrashmari according to Sushruta Dr. Nitesh Patle 1 , Dr. Shilpa Dudhalwar 2 , Dr. Vinay Pandey 3 , Dr. Aparna Gade 4 , Dr. Priyanka Wate 5 1 Post Graduate Scholar, 2 Guide & Professor, Dept. of Shalyatantra, 3 Assistant Professor, Dept. of Roganidan Evum Vikruti Vigyan, 4 Associate Professor, 5 Assistant Professor, Dept. of Dravyaguna, M.S. Ayurveda Mahavidyalaya, Gondia, Maharashtra, INDIA. I NTRODUCTION Mutrashmari is a disease of urinary tract which causes problems in many ways including passage of urine [1] Charaka described the Ashmari in the chapter of Mutrakrichcha. He explains excessive physical exercise, strong and irritant medication (tikshna - ausadhi), riding on fast moving horses or vehicles, drinking of dry wine in excess, ingestion of flesh of wet land, fishes and other food staffs, eating before the digestion of previous meal (adhyasana) are the basic causes of eight varieties of Mutrakrichcha and Address for correspondence: Dr. Nitesh Patle Post Graduate Scholar, Dept. of Shalyatantra, M.S. Ayurveda Mahavidyalaya, Gondia, Maharashtra, INDIA. E-mail: sunder [email protected] Submission Date: 18/19/2019 Accepted Date: 22/12/2019 Access this article online Quick Response Code Website: www.jaims.in Published by Maharshi Charaka Ayurveda Organization, Vijayapur, Karnataka (Regd) under the license CCby-NC-SA and ultimately Ashmari. According to Sushruta, those who neglect the Samshodhana of internal channels and those who are engaged in unwholesome dietary habits become the victim of Ashmari [2] Mainly two types of Chikitsa are described in our Shastras for every disease viz [3] Samanya Chikitsa (General Rx) and Vishesha Chikitsa (Specific Rx). Here the Samanya Chikitsa is more of a supportive nature and does not cure the disease completely but gives a little relief, where as the Vishesha Chikitsa is advocated after knowing about the type of disease, Doshas involved, status of Dhatus etc. Nidana - Parivarjana' is the main method of keeping one self free from the disease. As Ashmari is kapha predominant dieseas, hence the measures aggravating kapha are to be avoided and the treatment to control Kapha is to be followed. The below said is the treatment of choice in Ashmari viz. 1 Aushadhi - Chikitsa 2 Basti Karama - Chikitsa 3 Kshara - Chikitsa 4 Shastra – Chikitsa A B S T R A C T The Mutravaha Samsthana (Urinary system) is meant for the formation and excretion of Mutra. Mutravaha stroto dushti causes Mutrakricchra, Mutraghata, Mutrashmari etc. Mutrashmari is one of the most common and distressing maladies among the group of urinary disorders. Acharya Sushruta, the pioneer in the art and science of surgery has described widely and comprehensively about the Mutrashmari with its classification, symptomatology, aetiology, pathology, complications and its management. This is the proof for the depth of knowledge of the Acharyas on the subject of urinary disorders as a whole. Ashmari is mentioned as one of Ashta Mahagadas, so it requires great attention for its cure. early detected Ashmari can be treated with medicines because of its recent origin and small size, while an Ashmari of long-time origin is difficult to cure and large Ashmari is also an indication for surgical treatment (Shalya Chikitsa). Key words: Mutrashmari, Mutravaha Strotas, Shalya Chikitsa, Sushruta.

Dr. Nitesh Patle et al. Critical review of Surgical treatment of Mutrashmari according to Sushruta ISSN: 2456-3110 REVIEW ARTICLE Nov-Dec 2019 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2019 | Vol. 4 | Issue 6 238 Surgery has to be the ultimate treatment because even with expert surgeons success is uncertain. In these cases, operation should be considered last of all, when death is inevitable with non-operative treatment. It should be carried out by the wellmeaning persons after taking the consent of the authorities [4] Shastra Karma is indicated when the calculi not curable to treatment with Ghrita, Kshara, decoctions, milk preparations and Uttarbasti. A IM AND O BJECTIVE 1 To review the Mutrashmari management in Ayurvedic classics. 2 To review the Surgical treatment of Mutrashmari according to Sushruta. M ATERIALS AND M ETHODS A detailed review of the available literature on the Mutrashmari, such as classical text of Ayurveda Samhita was done. Data was collected from various books, papers published in the various national and international journals etc. Management of Ashmari As the Ashmari has been considered a grave disease and said to be as fatal as death. So, it is necessary to diagnose and treat the disease at the earliest. Acharya sushruta has advised to treat the disease in the Purvarupa stage itself. He has prescribed following medications depending upon the varieties of Ashmari Aushadha used by Sushruta for different types of Ashmari; Vataja [5] : Pashanbheda, Vasuka (Shweta Ark), Vasir (Gajpippal), Ashmantak (Changeri), Satavari, Yava, Kulatha, Bera, Nirmali, Gokharu, BrihatiKantakari, Khasa, Gunja, Shayonakghrita should be prepared from the decoction of the above substances in which the drugs of the Usakadi group should be added. This ghrita quickly destroys the calculi caused by vitiated Vata. Alkalies, gruels, soups, decoctions, milk preparations and food prepared from these lkataallaying groups of substances should also be administered. Pittaja [6] : Kusha, Kasha, Ikshumool, Pashanbheda, Satavari, Vidarikanda, Brihati, Gokharu Shayonak, Patala, hrita should be prepared from the decoction of the above substances in which silajatu, madhuka, seeds of indivara (blue lotus), trapusa, seeds of eravaruka, etc. should be added. This recipe quickly disintegrates the calculi caused by Pitta. Alkalies, gruels, soups, decoctions, milk preparations and food prepared from these Pittaailaying groups of substances should also be administered. Kaphaja [7] : Varunadi-Gana, Gugglu, Elaychi, Kutha, Devdaru, Haridra, Maricha, Dhanya should be processed with ghrita from goat's milk to which the drugs of usaka group should be added. Alkalies, gruels, soups, decoctions, milk preparations and food prepared from these Kapha-allaying groups of substances should also be administered. Basti Chikitsa Acharya Sushruta advised Uttarbasti in the management of bladder stone. He said that the decoction of latex trees administered through urethral douche flushes out the calculus immediately along with the blood collected in the bladder. Basti treatment in Ashmari is indicated by all the Acharyas. Kshara Chikitsa Acharya Sushruta has advocated preparing Kshara from the drugs mentioned above for preparing Ghrita. This Kshara destroys calculi, abdominal swelling and urinary gravel. In Kshara prepared from the paste of Tila, Apamarga, Kadali, Palasha and Yava should be taken with the sheep’s urine to destroy urinary gravel. Paneeyakshara mentioned in the treatment of Mootrashmari since it possess properties like Chedana, Bhedana, Lekhana, Krimighna, Shodhana, Ropana and Vilayana, these all qualities believed to offer beneficial effects in effective removal of Mutrashmari. Apamargkshara along with Yavakshara possess disintegration, dissolution, dislodging and expulsive property therefore recommended in mootrashmari.

Dr. Nitesh Patle et al. Critical review of Surgical treatment of Mutrashmari according to Sushruta ISSN: 2456-3110 REVIEW ARTICLE Nov-Dec 2019 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2019 | Vol. 4 | Issue 6 239 Shastra Chikitsa [8] a) Purvakarma: First, the patient should be given Snehana, his Doshas eliminated and body weight reduced a little. He should be massaged with oil, sedated and given a feed, then after having made sacrificial offerings (while the patients should) chant auspicious hymns text wishing welfare and collecting all things mentioned in Agropaharaniya chapter, he should be reassured. Positioning of the Patients: Then the patient who is strong enough and is not nervous, should lie down, with the upper part of his body resting on the lap of another person sitting on a knee high plank facing east the patient’s waist should be raised by cushions and his knees and ankles fixed and tied together by ropes or straps Pre-operative manipulation of the stone: Then, after massaging the left side of the well-oiled umbilical region, pressure should be applied by a fist below the navel until the stone comes down. The lubricated index and middle fingers should be introduced into the rectum and brought below the perineal raphe, thereafter with manipulation and force (the stones) should be brought between the rectum and penis. Keeping the bladder tense and distended so as to obliterate the folds, the stone should be pressed hard by fingers so that they become prominent like a tumour. b) Pradhana Karma: Then, an incision of about the size of the stone should be made one barley width away from the perineal raphe on the left side. Some prefer the incision on the right side for the sake of technical convenience. Precautions should be taken so that the stone does not get broken or crushed. Even if a small particle is left behind it again increases in size, hence it, should be removed completely by the Agravakra (curved forceps) Shastra. In female, as the uterus situated very near the urinary bladder posteriorly, the incision should be directed upward, if this rule is violated, urine discharging ulcer (Mutrasravi Vraņa) would occur. In males an injury to Mutrapraseka (trigone of the bladder) also would cause leakage of urine. When the wound is made for the removal of the stone, an injury to the urinary bladder is not likely to heal. Patients with calculi, whose bladder has been torn in two, never get well. An incision in the bladder, made at one place only for the removal of a stone. After removal of the stone the patient should be put in a tub of hot water sitz bath. Thus the bladder does not get filled with blood. However, if it does get filled up, it should be irrigated through a catheter using the decoction of the latex trees. The following verse is quoted here: “The decoction of the latex trees administered (as an irrigating fluid) through a catheter removes the stone and the blood from the bladder quickly”. c) Pashchata Karma: To purify the urinary tract (after operation) the patient should be given sufficient jaggery. Next, he should be taken out from the tub, Madhu and Ghrita applied to the wound and warm gruel processed with urine purifying substances should be administered with Ghrita twice daily for 3 nights (a night implies a 24 hours period). After 3 nights milk with jaggery and small quantities of well-cooked rice should be eaten for 10 nights (so that the urine and blood may be purified and the wound may remain moist). After 10 nights citrus fruits and juices prepared from wild animal’s meat should be given. Thereafter for 10 nights patients should carefully be given sudation therapy either by oils or by liquids. Then his wound should be washed by the decoction of latex trees. The pastes of Rodhra, Madhuka, Manjishtha and Prapaundarika should be applied to the wound also. Taila or Ghrita from the same substance along with Haridra should be anointed over the wound. For urinary fistula, the wound is to be cauterised. Excessive exercise and sexual intercourse should be avoided for an year after the operation. Patient should take light diet [9] Precautions The urinary passages, seminal passages, testicular channels, perineal raphe, vagina, rectum and urinary

Dr. Nitesh Patle et al. Critical review of Surgical treatment of Mutrashmari according to Sushruta ISSN: 2456-3110 REVIEW ARTICLE Nov-Dec 2019 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2019 | Vol. 4 | Issue 6 240 bladder should be avoided from injury during operation. If urinary passages are injured, death occurs due to the bladder becoming full of urine. If seminal passages are injured, death or impotency occurs. If testicular channels are injured, loss of erection occurs. Injury to the vagina and the perineal raphe gives rise to pain [10] Contra-indications If the stone is being caught hold of, the patient's eyes become protruding, he becomes unconscious, head droops down as if he is collapsed and becomes motionless like a dead person. Stones should not be removed from him in this condition and if they are removed, he may die. Efforts should be continued to remove the stones provided the patient does not present the above symptoms [11] Complications During operation there may be sign of shock, incomplete removal and recurrence. In female if the stone is delivered through anterior wall then urinary fistula may be formed. So, for removal of stone only one injury is permissible. Pathyapathya [12] Pathya in simple meaning is, that Ahara & Vihara which is always suitable to patient and aids in relief or cure of a disease without initiating other diseases. And those Ahara and Vihara , which cause complications and aggravate the same disease is known as Apathya . Basti, Vamana, Virechana, Langhana, Avagahasweda are useful in case of Mutrashmari. DISCUSSION The superiority of Ayurvedic explanation of this disease can be observed relating to the specificity of symptoms mentioned for each variety of Ashmari. Importance of medical and surgical management of this disease is not to be overlooked because, the principles of management designed by different Ayurvedic authorities, are not only selective but also effective. If the calculi are not amenable to treatment with ghritas, alkalies, decoctions, milk preparations and bladder washes, surgery is the ultimate treatment. Even with expert surgeons success is uncertain, in these cases, operation should be considered last of all [13] When death is inevitable with non-operative treatment and a doubt (in the inevitability of death) is raised by surgery, it should be carried out by the well meaning persons after taking the consent of the authorities. The disease is still an unsolved problem for the physicians and surgeons. The etiopathogenesis of this disease includes many multidirectional problems requiring multidirectional treatment. There are altered biochemical, physicochemical picture originating from metabolic or environmental disturbances requiring medical as well as surgical management to cure. Both the methods of treatment are complementary to each other. Dramatic surgical removal procedure is available but there is continuing need for medical diagnosis and prevention. Medical treatment is more superiorly placed over surgery because of the need of prevention of recurrence, prophylaxis (mediating through biochemical and physico-chemical pathways), reduction of colic pain and spontaneous passage of stone, reduced chance of stone removal, prevention of complications, easy availability of drug with low cost and obviously less or nontoxic. CONCLUSION Basti (urinary bladder) is the seat of urinary diseases including stone (Ashmari). Ashmari is formed by condensation of Kapha with the impact of Pitta and Vayu. Though now a day’s modern non-surgical management is available yet surgery is still widely practiced. Ayurvedic medical management includes internal and local therapy (Uttar Basti) by some drug decoctions. Ayurvedic surgical treatment for many diseases is mentioned in Sushruta Samhita. Scientific procedure of surgery indicates deep knowledge of Anatomy and physiology of system to Acharyas. REFERENCES 1 Prof. G.D. Singhal et al, editor, Sushruta Samhita With “English translation & Explanatory, Part-1, Chaukhambha Sanskrit Pratisasthan, Delhi, 2 nd Edition 2007. Pp-522.

Dr. Nitesh Patle et al. Critical review of Surgical treatment of Mutrashmari according to Sushruta ISSN: 2456-3110 REVIEW ARTICLE Nov-Dec 2019 Journal of Ayurveda and Integrated Medical Sciences | Nov - Dec 2019 | Vol. 4 | Issue 6 241 2 Prof. K.R. Srikantha Murthy editor. 1 st ed, Susruta Samhita, Nidansthan, Chapter 3, Verse 4. Vol-II. Varanasi: Chaukhamba Orientalia, 2001;pg 262 3 Shukla V, editor, (2 nd ed.). Charaka Samhita of charak, Chikitstasthan: Chapter 26, Verse 32. Varanasi: Chowkhambha Sanskrit Series, 2002; 325. 4 Shashtri AD, editor,(1 sted.).Sushrut Samhita of sushrut, Sutrasthan: Chapter 7, Verse 33. Varanasi: Chowkhambha Sanskrit Series, 2009;423 5 AD. Shastri, editor,: Susruta Samhita, part I, ChikitsaSthana,. AshmariChikitsa, Chapter 7, Verse 5-8, Chaukhambha Sanskrit Sansthan, Varanasi, 9 th ed., 1995, 418 6 AD. Shastri, editor,: Susruta Samhita, part I, ChikitsaSthana,. AshmariChikitsa, Chapter 7, Verse 9- 13, Chaukhambha Sanskrit Sansthan, Varanasi, 9 th ed., 1995,419 7 AD. Shastri, editor,: Susruta Samhita, part I, ChikitsaSthana,. AshmariChikitsa, Chapter 7, Verse 14- 16, Chaukhambha Sanskrit Sansthan, Varanasi, 9 th ed., 1995, 419 8 AD. Shastri, editor,: Susruta Samhita, part I, ChikitsaSthana,. AshmariChikitsa, Chapter 7, Verse 30, Chaukhambha Sanskrit Sansthan, Varanasi, 9 th ed., 1995,421 9 AD. Shastri, editor,: Susruta Samhita, part I, ChikitsaSthana,. AshmariChikitsa, Chapter 7, Verse 35, Chaukhambha Sanskrit Sansthan, Varanasi, 9 th ed., 1995, 423 10 AD. Shastri, editor,: Susruta Samhita, part I, ChikitsaSthana,. AshmariChikitsa, Chapter 7, Verse 36, Chaukhambha Sanskrit Sansthan, Varanasi, 9 th ed., 1995, 423 11 AD. Shastri, editor,: Susruta Samhita, part I, ChikitsaSthana,. AshmariChikitsa, Chapter 7, Verse 31- 32, Chaukhambha Sanskrit Sansthan, Varanasi, 9 th ed., 1995, 422. 12 Charaka Samhita of Agnivesha with Ayurveda Dipika Commentary of Cakrapanidatta and with Vidyotini Hindi Commentary by Sastri, K.(PartI), Vimana Sthana, ed. Pandeya,G.S. Chapter 5, Verse 20, Chaukhambha Sanskrit Sansthan,Varanasi, 4 th ed.,1994. 342. 13 AD. Shastri, editor,: Susruta Samhita, part I, ChikitsaSthana,. AshmariChikitsa, Chapter 7, Verse 28, Chaukhambha Sanskrit Sansthan, Varanasi, 9 th ed., 1995, 421. ******************************* How to cite this article: Dr. Nitesh Patle, Dr. Shilpa Dudhalwar, Dr. Vinay Pandey, Dr. Aparna Gade, Dr. Priyanka Wate. Critical review of Surgical treatment of Mutrashmari according to Sushruta. J Ayurveda Integr Med Sci 2019;6:237-241. Source of Support: Nil, Conflict of Interest: None declared.

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Sushruta-samhita, Shastrakarma, Pradhana-karma, Sushruta, Ashmari, Purvakarma, Pathyapathya, Shastrachikitsa, Shalya-chikitsa, Excessive physical exercise, Surgical treatment, Urinary passage, Urinary bladder, Surgical management, Contra-indication, Well-meaning person, Urinary tract, Acharya Sushruta, Mutrashmari, Samanya Chikitsa, Pashchata karma, Basti Chikitsa, Kshara chikitsa, Ashta Mahagada, Kapha predominant, Aushadhi Chikitsa, Non-operative treatment, Internal channel, Urinary disorder, Urinary gravel, Scientific procedure, Vishesha Chikitsa, Acharya Sushruta advised, Perineal raphe.