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MUTRASHMARI

Ayurvedic review Ayurveda the science of life and an upanga of Atharvaveda has described many diseases related to Basti. The learned Ayurvedic Acharyas have described in detail about various bodily systems in relation to their Anatomy, Physiology and Pathology etc. The Mutravaha Samsthana (Urinary system) is one of them, and meant for the formation and excretion of Mutra. The following is the short description of Mutravaha Samsthana given in ancient classics : Basti Vrikka Gavini Mutrapraseka Mutravaha Srotansi Mutravaha Nadies Mutravaha Dhamanis Mutravaha Siras. Basti The word Basti Its different meanings are, to cover, base, store house and reservoir.

Synonyms Mutrashaya Mutrabasti Mutradhara

Mutraputa Mutraputaka.
(Su. Sa. 6/26, Su. Ni. 3/20)

Definition In Ayurvedic texts though no clear cut definition of Basti has been given, it can be defined as a store house which acts as a reservoir of urine. Embryological development According to the fundamental principles of Ayurveda the human body is constituted on the basis of the Five Mahabhutas and the Tridosha at the time of combination of Shukra and Shonita. These eight factors are responsible for the production of each and every organ during the foetal life. The Basti is a hollow structure made by the Vayu entering in the combination of essence of Rakta, Kapha and Pitta.

It has been said by all the Acharyas that Basti is derived from Matrija Bhava- the maternal constituents
(Su. Sa. 4/26).

Situation

Basti has been accepted one among the Kosthangas by all the Acharyas Sushruta states that Basti is surrounded by Nabhi, Kati, Muska, Guda, Vakshanas and Sepha (Su. Ni. 3/18). Structure The Basti is Alabu shaped and is fixed on all sides by Siras and Sanayus according to Sushruta. Basti is thin called and has a single out let directed downwards. Vagbhatta has mentioned the shape of Basti as Dhanurvakra i.e. a curve like a bow with a downward opening. Basti has been counted as one of the vital parts i.e. Marmas of the body. It is of the Snayu Marmas type with area of four fingers. (Su. Sa. 6/7) Vrikka Synonyms : Vikka Vrikka No direct reference of Vrikka's relation to urine formation is found in either of the Ayurvedic classics. Vrikka are two in numbers and are situated in the lumbar regions on either side in the posterior abdominal wall in Kostha.
(Su. Ni. 9/18 Dalhana)

Like Basti Vrikka is also a maternal contribution derived from essence of Rakta and Meda.
(Su. Sa. 4/30)

Sarangdhara has considered the Vrikka's as the nourishers of the abdominal fats.

Gavini They are two in number, situated one on each side of Basti, receiving Mutra from the antras and sending it further to the Mutrashaya. (Atharvaveda 1/3/6) Mutrapraseka Synonyms : Mutrapatha Mutramarga Mutrasrota It is one among the eight important organs, which are to be protected from any injury at the time of performing surgery for Mutrashmari. (Su. Chi. 7/38) It is the outlet of the Basti, Which is two Angulas in females and Twelve Angulas in males.

In male it carries both Mutra and Shukra, while in female only Mutra.
(Su. Sa. 4/22)

Mutravaha Srotas According to Charaka the word Srotas is 'Sravanat Srotamsi' which means, where from something oozes out. This way the channels which carry Mutra. Charaka says that Mutravaha Srotas has its origin from Basti and two Vankshanas. Sushruta believes Basti and Medhra as the roots of Mutravaha Srotas.

Any trauma to this Mutravaha Srotamsi leads to acute retention of urine, distension of urinary bladder and painful erection of the penis, ultimately leading to death of the patients. (Su. Sa. 9/12)

Mutravaha Nadis Sushruta in Ni 3rd chapter says that these are thousand in number and are situated in between Pakvashaya and Basti and their main function is to carry the Mutra from Pakvashaya to Basti, like the rivers fill the ocean with water. Mutravaha Dhamanis Sushruta termed as 'Adhogami Dhamani' which are meant for Sara-Kitta Vibhajana and to transport Mutra, Purisha Sukra, Artava, Apana Vata etc. downwards.
(Su. Ni. 3/21-23)

These same Dhamanis taking part in the Sarakitta vibhajana process the functions of which stated are Dharana and Yapan of Mutra and Basti.

Mutravaha Siras There is no reference available with Brihattrayee about Mutravaha Siras. Sharangadhara describes that the Maladrava of digested food i.e. Mutra is transported to Basti by Siras. Adhamalla in his commentary on Sharangadhara says that the Siras are concerned with Aharajala transported to Basti through Mutravaha Siras. That above stated organs take an active part in the transportation of urine in one or the other way. So we find that mutravaha nadi, dhamani and siras have close relation with the urinary system. Mutranirmana Prakriya Ingested food Digestive process starts Saman Vayu action Digestive process completion
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SARA (PRASADA) Nourishes the body

KITTA Dravamsa Mutra Sandra Purisha

Now according to Sushruta this Mutra goes into the Basti from the several minute pores, as a new pitcher gets filled up with water from the minute pores, when it is kept in water upto its mouth.
(Su. Ni.3/23)

Introduction 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, etiology, 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.

Etymology

"Ashmanam Rati Dadati iti Ashmari" means the formation and presentation of a substance like stone. "Ashma" means "stone" "Rati" means "to present" Definition No satisfactory definition of the Ashmari is available in either of the Ayurvedic texts, "Ashmari Mutra Krichhra Syat " (Amarakosha) "Ashmari Mutra Krichhra bheda" (Ayu. Shabdhakosha) Ashmari - Stone, gravel, strangury (M. Williams) Synonyms * Sanskrit - Ashmari, Ashmarih * Hindi - Pathari

* English - Stone, Gravel, Calculus, Vesical - Calculi. * Latin - Calculus (singular) Calculi (Pleural) Description of Disease Nidana Panchaka a) Nidana According to Sushruta, Who neglect the Samshodhana of internal channels

Who are engaged in unwholesome dietary habits become the victim of Ashmari. Acharya Charaka has not given separate chapter for the disease but explained it under the "Mutrakricchra". Hence the nidanas of both Mutrakrichhra & Ashmari can be taken as same. They are : Practice of excessive exercise Strong medicines Ruksha Madyapana Excessive intake of anupa - mamsa Adhyashana Ajeerna-bhojana

Matsya sevana

(Ch. Chi. 26/32)

According to Vagbhata, the Nidanas are Intake of heavy, fatty & sweet food excessively. Day sleep Ajeerna-bhojana Adhyashana

According to Kashyapa Bhar vahana on Kati and Skandha. b) Samprapti Samprapti can be defined as, it is the process which starts from 'Sanchayavastha' of Doshas to the 'Vyadhi Vayktavastha'. It is possible through Samprapti to assess the Doshas, Dushyas, Srotodusti or Khavaigunya, Agni etc. It is also helpful because proper treatment is only fruitful if it is applied according to Samprapti of disease. As said 'Samprapti Vighatanama eva Chikitsa'. Different views have been put forth regarding the Samprapti which are as below :Sushruta's View Apathya Asamshodhan Sheela Shleshma Mixes with Mutra Dushti Urinary bladder Attains shape of gravel Ashmari
(Su. Ni. 3/4 & 3/24)

Sushrata's examples for clear understanding of the mechanism of stone formation :10

A new pitcher filled with clear water can also show settling down of muddy particles in due course of time. In the same way the calculi are formed in Basti. (Su. Ni. 3/25) As air & fire of electricity in the sky consolidate water (to form hail storms) similarly Pitta located in the bladder, along with Vayu consolidates Kapha to form calculi. (Su. Ni. 3/26).

Charaka Nidana Sevana Vata increases (Quantitatively & Qualitatively) Which associated with Shukra, Pitta, Kapha Gradually calculi formation i.e. Ashmari. Dries-up the urine in bladder

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Charaka explained the process of formation of Ashmari as similar to that of Gorochana (Gall stone) in the Pittashaya of cows. Both Kashyapa and Vagbhata accept the views of Charaka and further state that the increase or decrease in the Medodhatu is directly related to the size of Ashmari.

Disease Process According to Shatkriyakala Acharya Sushruta has very well mentioned the six stages of disease, which are called 'Shatkriya Kala' which gives the full idea of Samprapti of the disease and helpful in the diagnosis and treatment. Sushruta has given more stress towards these and further says that the exact knowledge of these stages is the only path to reach upto disease or treatment. In reference to the production of the disease Mutrashmari, following six stages are the proper time for the treatment :12

1. Sanchaya It is the stage when Doshas accumulate in their Ashayas more than the normal range due to various etiological factors and in case of Ashmari these excess accumulated Doshas develop the following symptoms : Discomfort in hypogastrium Anorexia Pyrexial feeling General debility Stiffness and fullness of abdomen Yellowish tinge of the skin Concentrated urine etc. Acharya Sushruta says that the treatment should start as soon as the symptoms of first Kriyakala i.e. Sanchaya develops, for the prevention of future disease. Prakopa It occurs when Sanchyavastha is neglected or proper corrective steps are not taken. All symtoms of Sanchyavastha with more prominence and in addition to them are :(Su. Su. 21/18)

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- Pain over the bladder region, anal region and testicular region. - Painful micturition with thickness - Thirst - Nausea etc.
(Su. Su. 21/27)

Prasara Prasara avastha is a progressive stage of Prakopa avastha. Following symptoms develop in this stage : Anaha Atopa Daha Burning micturition Anorexia etc. But the patient who suffer from Ashmari will complain of Frequent pain over the bladder area Dysuria

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Pain in the testicles along with previous symptoms.


(Su. Su. 21/32)

Sthanasanshraya This stage is also known as Dosha Dushya Sammurchchana. In the stage Dosha may finally settle down at a place where they find maximum favourable place (Khavaigunya). The following symptoms develop to a patient who is going to suffer from Ashmari : Fever Pain in the bladder region Dysuria Pain in the region of the bladder neck the scrotum & the penis. Goat like smell in urine Distaste of food etc. Vyakti Vyakti is the fifth stage and here the disease comes out with clear picture. hence called the Rupa Avastha. Following are the symptoms which patient feels at this stage: Excruciating pain in umblical region during micturition Pain in bladder, perineal raphe & penis Obstruction to the flow of urine Haematuria (Su. Su. 21/33)

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Turbid and sandy urine with a shining like Gomeda gem. Bheda Bheda Avastha has two natural courses Spontaneous subsiding Leading into chronicity This is the last stage of management and it is suggestive stage for the complications and the prognosis of the disease. In case of spontaneous recovery, the patient of Ashmari experiences gradual relief of all the symptoms and improvement in general health. If the disease leads to chronicity then the patient complains of obstruction of the urinary outflow with a complication involving the upper urinary system due to backward pressure i.e. involving the ureter and kidneys. Purvarupa The signs & symptoms which are indicative of a future disease are known as Purvarupa. Purvarupa play a very important role in the diagnosis and treatment of any disorder. It is a stage where the disease is reversible with very little residual damage. Different classics have mentioned about the prodromal signs and symptoms of Ashmari viz. S.No Purva-rupa Su. A.Hr. A.S. M.N. B.P. Y.R. G.N.
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1. Basti Pida 2. Aruchi 3. Mutrakricchra

+ + +

+ + + + + +

+ + + + + + + +

+ + + + + +

+ + + + + +

+ + + + + -

+ + + + + -

4. Bastisirovedana + 5. Mushka +

Vedana 6. Shepha Vedana + 7. Jwara 8. Avasada + +

9. Bastigandhatwa + 10. Sandra Mutra 11. Avila Mutra 12. Basti adhmana + + -

Rupa Signs & Symptoms when fully manifested are called Rupa. Different texts have mentioned the Rupas of Ashmari as shown in following table :S.N Rupas Su. Ch. A. A. H K. M.N. B.P. Y.R.

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o 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Nabhi Vedana Basti Vedana Sevani Vedana Mehana + + + + + + + + + + =

Hr S. ar S. . + + + + + + + + + + + + + + + -. + + + + + + + + + + + + + + + + + + + + + + + -

Vedana Mutra Dhara + Sanga Mutra Vikirana Gomeda Prakasha Atyavilam Sasiktam Dhavan, Plavan etc. Vishirna Dhara Sarudhira Mutra Mrudanti Medhra Makusakaran Munchati Mehana Mutrarodha Atimutratram Pratatam roditi Kasamana + + + + + + -

15 16 17 18

+ -

+ -

+ + +

+ + -

+ -

+ 18

Upashaya Anupashaya The factors which relieve the signs and symptoms of disease are called upashaya, while the factors which aggravate the disease are called anupshaya. None of the ayurvedic texts have mentioned about upashaya anupashaya in relation to mutrashmari. Main factor involved in ashmari formation is kapha dosha. All the measures leading to control of kapha are considered as upashaya and those which vitiate kapha are anupashaya of ashmari. Classification of Ashmari All the Acharyas except Charaka have classified the disease Mutrashmari into four types. i.e. Shleshmaja Ashmari Pittaja Ashmari Vataja Ashmari Shukraja Ashmari Acharya Charaka has considered Mutrashmari as a variety under Mutrakrichhra and classified it into Mridu Ashmari and Kathina.

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Different varieties of Ashmari,according to different Acharyas are as in under mentioned table :S.No Ashmari 1 2 3 4 5 6 Shleshmaja Pittaja Vataja Shukraja Mridu Kathina Su. + + + + Ch. + + A.Hr . + + + + A.S. M.N B.P + + + + + + + + + + + + Sha. Y.R. + + + + + + + + -

Laxanas of different Ashmari 1. Shleshmaja : Heavy & cold sensation in bladder area Cutting, incising, pricking pain. Pittaja : Burning hot sensation and inflammatory changes in urinary tract. Vataja : * Severe bladder pain, umblical pain and pain in the anus * Frequent passage of flatus * Urethral burning * Dysuria * Difficulty in defecation.
(Su. Ni. 3/10)

( Su. Ni. 3/8).

(Su. Ni. 3/9)

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Shukraja :* Dysuria * Scrotal swelling *Lower abdominal pain * Special characterstic feature is, it can be crushed into powder by pressure. Features of Ashmari are 1. Shleshmaja - White, slimy, big like Kukkutanda - Colour - Madhuka Pushpavat - Heavy in weight 2. Pittaja :- Reddish / Yellowish - black or honey like in colour. - Resembles Bhallataka seed. 3. Vataja : - Dusty coloured - Hard - Irregular - Rough - Nodular like Kadambapushpa Sadhyasadhyata In our classics Acharyas have described about 'Ashta Mahagadas' and these Mahagadas are not easy to treat and they are not having good prognosis.
(Su. Ni. 3/10) (Su.Ni. 3/9) (Su. Ni. 3/8) (Su. Ni. 3/12)

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As Ashmari is mentioned as one of them, so it requires great attention for its cure.

In children because of the smaller space occupying lesion and less fat in subcutaneous and perinephric region the prognosis is better.

Similarly 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. should be avoided.
(Su. Chi. 7/3)

Ashmari associated with complications and Arishta Lakshanas Upadrava No particular Upadravas of Ashmari are mentioned in Ayurvedic classics except Mutra sharkara, described by Acharya Sushruta. It is nothing but the disintegrated particles of Ashmari, passes along with the stream of urine. Laxanas of Upadrava *. Pain in the pericardium * Weakness of lower limbs * Pain in the flanks and shivering * Thirst * Blackish discoloration of body * Dislike for food and indigestion * Pale appearance of the body etc. ************** (Su. Ni. 3/15)

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