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A CLINICAL STUDY ON THE EFFECT OF ‘ELADI QWATH’ IN THE MANAGEMENT OF ‘MUTRASMARI’ (UROLITHIASIS ), Y. Ratna Priyadarsini, Department of Kayachikitsa, PG unit Dr.BRKR Govt. Ayurvedic College, ...

A CLINICAL STUDY ON THE EFFECT OF ‘ELADI QWATH’ IN THE MANAGEMENT OF ‘MUTRASMARI’ (UROLITHIASIS ), Y. Ratna Priyadarsini, Department of Kayachikitsa, PG unit Dr.BRKR Govt. Ayurvedic College, HYDERABAD



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  • Dr. NTR UNIVERSITY OF HEALTH SCIENCES VIJAYAWADA, A.P. POST GRADUATE DEPARTMENT OF KAYA CHIKITSA Dr. B.R.K.R. G0VT. AYURVEDIC COLLEGE / HOSPITAL HYDERABAD, A.P., INDIA 2007 CERTIFICATE This is to certify that Dr. Y. Ratna Priyadarsini, final year PostGraduate Scholar, Dept. of Kaya Chikitsa has submitted her dissertation workentitled “A CLINICAL STUDY ON THE EFFECT OF ‘ELADI QWATH’ INTHE MANAGEMENT OF ‘MUTRASMARI’ (UROLITHIASIS )” UnderOur direct supervision. We are satisfied with the work carried out by her and recommend thesame for the acceptance and approval of the adjudicators. H.O.D. Dr. Prakash Chander, M.D. (Ay) Professor Dept. of Kaya Chikitsa, P.G. Unit Dr. B.K.K.R. GOVT. Ayurvedic College / Hospital, Hyderabad.Date:Place:
  • Dr. NTR UNIVERSITY OF HEALTH SCIENCES VIJAYAWADA, A.P. POST GRADUATE DEPARTMENT OF KAYA CHIKITSA Dr. B.R.K.R. G0VT. AYURVEDIC COLLEGE / HOSPITAL HYDERABAD, A.P., INDIA 2007 CERTIFICATE This is to certify that the present thesis of Dr. Y. Ratna Priyadarsini,entitled by “A CLINICAL STUDY ON THE EFFECT OF ‘ELADI QWATH’IN THE MANAGEMENT OF ‘MUTRASMARI’ (UROLITHIASIS)” hasbeen completed by the candidate herself under our direct supervision. She hasdevoted the required time for the purpose and her work has been checkedperiodically. This originality of the work holds good of its kind to enlightenthe branch of Kaya Chikitsa. Guide: Dr. M.L. Naidu, M.D. (Ay) Reader Dept. of Kaya Chikitsa, P.G. Unit Dr. B.K.K.R. GOVT. Ayurvedic College / Hospital, Hyderabad.Date:Place:
  • A CLINICAL STUDY ON THE EFFECT OF‘ELADI QWATH’ IN THE MANAGEMENT OF “MUTRASMARI” (UROLITHIASIS) Thesis Submitted in Partial Fulfillment for the Degree of Doctor of Medicine (AYURVEDA) in KAYA CHIKITSA BY Dr. Y. Ratna Priyadarsini GUIDE: Dr. M.L. Naidu,. MD (Ay) READER Dept. of Kayachikitsa, P.G. UnitPOST GRADUATE DEPARTMENT OF KAYACHIKITSADr. B.R.K.R. G0VT. AYURVEDIC COLLEGE / HOSPITAL HYDERABAD Affiliated to Dr. N.T.R. University of Health Sciences Vijayawada, A.P. 2007
  • “Namami Dhanvantarimadi Devam Surasurairvandita Padapadmam | Loke Jararugbhaya Mrutyunasham, Datarmisham Vividhoushadhinam ||”
  • BT – Before TreatmentAT – After TreatmentS - Sex: M – Male, F – FemaleR- Religion: H – Hindi, M – Muslim, C – ChristianOcc – Occupation: Te – Teacher, W – Worker, E – Employeem, St – Student, Bu – Business,Hw – House WifeS.E. – Socio Economic Status: Lc – Lower Class, Mc – Middle Class, Uc – Upper ClassDI – Diet: M – Mixed, V – VegetarianCh – Chronicity: Y – Years, M – Months, D – DaysLOS – Location of Stone : R – Renal, U – Ureteric, U.V. – Uretero Vesicular JunctionNOS: No. Of Stones, M – MultipleSide: BL – Bi lateral, Lt – Left, Rt – RightPra – Prakriti: V – Vata, P – Pitta, K – Kapha, V.P. – Vata Pitta, V.K. – Vata Kapha, P.K. –Pitta KaphaF/R – Fresh / Recurrence: F – Fresh, R – RecurrenceWI – Water Intake: L – Less, S – SufficientPain: No Pain – 0, Mild – 1, Moderate – 2, Severe – 3B.M – Burning Micturition: Present – 1, Absent – 2.SOS - State of Stone : P – Passed, R – Reduced, D – Dislodged, S – Still PersistingL.P. - Location of Passed StoneUrine Analysis: Pcl - Pus Cell, CRCL - Crystals, Ep cells - Epithelial Cells, ac – acidic, ak –alkaline, A – Absent, P – PresentF&V – Frequency and Volume, inc. – Increased, nc – No change. 136
  • LIST OF TABLES1 Table Showing Regulation of Glomerular Filteration2 Table Showing Substances Filtered, Re-absorbed, and Excreted in Urine3 Table Showing Characteristics of Normal Urine4 Table Showing Organic Constituents5 Table Showing In-Organic Constituents6 Table Showing Rupa of Asmari according to different authors7 Table Showing Asmari Lakshanas and Bhedas8 Table Showing Ingradients of “Eladi Qwatha”9 Table Showing Gunas of Silajith10 Table Showing Dried extracts of Silajith11 Table Showing Organic Constituents of Silajith12 Table Showing Mineral Constituents of Silajith13 Table Showing Age Incidence14 Table Showing Sex Incidence15 Table Showing Religion Incidence16 Table Showing Occupation Incidence17 Table Showing Socio Economic Status Incidence18 Table Showing Diet Incidence19 Table Showing Chronicity Of Disease20 Table Showing No. of Calculi21 Table Showing Incidence of Calculi in Kidney22 Table Showing Habitat23 Table Showing Prakriti24 Table Showing Habits25 Table Showing Degree of Pain26 Table Showing Signs and Symptoms27 Table Showing Water intake28 Table Showing Reccurance / Fresh29 Table Showing Relief of Pain30 Table Showing Response in Pain before and after treatment31 Table Showing Response in Burning Micturition32 Table Showing Response in Burning Micturition before and after treatment33 Table Showing Frequency and Volume of Urine34 Table Showing State of Stone after Treatment35 Table Showing No. of Patients with Calculi before and after treatment36 Table Showing Calculi present at different sites of Urinary system before and after treatment37 Table Showing Lab investigation before and after treatment38 Table Showing Position from which the Calculi were passed39 Table Showing Statistical Analysis of Data40 Table Showing Individual Drugs action on Mutravaha Srotas
  • Introduction INTRODUCTION ‘Asmari’ comprises of two words ‘Asma’ and ‘Ari’ .’Asma’ means stone or agravel and ‘ari’ means enemy. Asmari is a disease in which there is formation of stone,exerting great suffering to man like an enemy. Ayurveda considered Asmari mainly as ‘Mutra asmari’ (Urolithiasis), which isemerging as a sequel to deranged mutra pravritti leading to deterioration in urinesecretion and micturition. Mutrasmari is a disease of Mutravaha srotas and consideredas one of the ‘Astamaha gadas’ i.e. one of the deadly diseases. The symptoms of mutrasmari like excruciating pain over nabhi, vasti, or atsevani, medra during micturition, sudden stoppage of urine flow, blood stained urine,twisting and slitting of urine, aggravation of pain during running, jolting etc., go on inaccordance with symptoms of urolithiasis of modern science. Hence urolithiasis canbe co-related with the mutrasmari mentioned in ayurveda. Urolithiasis is the state describing the presence of calculi with in the urinarysystem. It is estimated to afflict 2% of the total worlds population but are particularlycommon in some geographic locales such as in parts of the United states, South Africa,India, South East Asia. Men are more affected than women with the ratio of 3:1. Initialpresentation predominates in the third and fourth decades. Intrinsic factors in the genesis of stone are related to inherit, biochemical oranatomical make up of the individual. Endocrine abnormality may also be the cause forstone formation. Environmental, temperature, water intake, diet, social class, geniticalpredisposition and occupation play major role in the formation of the renal calculi. Geographical factors contribute to the development of renal calculi. Areas ofhigh humidity and elevated temperatures appear to be contributing factors, and theincidence of symptomatic ureteral stone is greatest during the hot summer months. Study on the effect Eladi Quath in the management of Mutrasmari 1
  • Introduction In the modern arena, surgical procedures remain the only treatment of choiceand are not conducive enough as they hold the disadvantages of high expenditure, sideeffects and disease recurrence. It is in this dire situation, the desperate need to findconservative medicine which is an inexpensive, effective and appropriate medicine totreat Mutrasmari which has very less disadvantages. Even though this disease is kasta saadhya to treat, all our acharyas have clearlymentioned many lines of treatment for the same. Hence by adopting the principles inwhich the line of treatment is not only elimination or to remove the disease but alsomeanwhile avoid the recurrence by prakriti vighatana. In ayurvedic classics there areplenty of medicinal preparations referred in different forms for the treatment ofmutraasmari. This dissertation work is an attempt to manage mutrasmari by medicalmanagement. The proposed treatment is having reference in Sarangadhara samhitha.The trial medicine is a compound called “Eladi kwatham”. This is mentioned to haveLithotriptic (Asmarighna) property and relieve Burning micturition (Mutrakrichra). Ifound it as a simple composition of drug`1s having Mutrala, Vasthisodhana,Mutravirechaniya, Asmaribhedana etc., properties. It is economical and does notrequire hospitalization and the ingredients are easily available. I felt this compound need a scientific investigation and research to be broughtinto mainstream and establish as a remedy for urolithiasis. Study on the effect Eladi Quath in the management of Mutrasmari 2
  • Review of History REVIEW OF HISTORY The need for proper and perfect evaluation of disease is very required forgetting a proper line of treatment for which we may have to go deeper into our ancientpeople’s work, i.e. in their literature, so as for the disease ‘Asmari’. The study of ‘Asmari’ can be seen right from the ancient period, in the medievalperiod and still going on in this modern era of medicine.VEDA KALA: Even though we don’t find any direct reference in Vedas regarding the Asmaridisease. We find some related information in Rigveda1, Yajurveda2 which are theoldest literatures available. In Vedic period a prayer was performed to Lord ‘Varuna’asking to strengthen kidneys, so that they perform with skill and function each day tokeep body and mind so pure thus enabling us good health to ensure. This indicates theawareness and importance of good health and long life related to every system of bodyin particular, urinary system in this context. In Atharva veda3 we find references regarding Asmari in relation with muthraavarodha. Here healthy flow of urine is compared with a lake which flows freely whenobstructed bank is relieved and also with an ‘arrow’ that goes off from its bow, whichexplains the necessity of free drainage of urine from body that removes toxins anddoshas. Similar explanation supporting the above said hymn is found in ‘koushikasutra’. In Rgveda4 and Atharvaveda5 we find some anatomical description regardingurinary organs as ‘Matasnabhyam’, ‘Plesa’, ‘Gavinika’. In Atharvaveda we also findsome drugs which have the divine power to relieve diseases related to muthra vahasrotas as muthra marga sodha, nirbhalatha, kriya mandata, avarodha avastha. They are‘varuna’, ‘sara’, their mother being ‘Pruthvi’ and father being ‘Akasa’. There weredifferent ancient practices which help in relieving retention of urine or obstructiveuropathy. Study on the effect of Eladi Quath in the management of Mutrasmari 3
  • Review of History Yogi’s used to practice ‘vajrailee’6 with an instrument like a metal cathetermade of iron silver and gold, which is thin, long having bulb at the end. With this theypass water or milk into bladder and cleansed it. They used to believe this type ofpractice would not only strengthen the urinary track but also the genital system.SAMHITHA KALA: When coming to the Samhitha kala which we consider as golden period ofAyurveda. we find detailed description of anatomy, physiology, etiology, pathology,classification, signs, symptoms management and complications etc. regarding urinarysystem in classical texts of ayurvedic system of medicine which dates back to 4th and3rd millennium B.C. viz. Charaka samhita, Susruta samhita, Astanga sangraha etc.others like Bhela, Haritha, Kasyapa samhitas have also explained in a scientific formCharakacharya though not paid much attention to the description of disease, in hisChikitsa Stana has explained the conservative line of management for Asmari. Although all acharyas have explained Asmari and its management,Susruthacharya has given much importance to the disease and explained in detail inNidana and Chikitsa stanas. ‘Darunatva’ complexity of Asmari Vyadhi has beenmentioned in Susrutha stana 7th chapter, with its similarity with Lord Yama who takesaway the life of man as the ‘Asmari’ does. He also advices surgical removal of Asmariwhen other measures fail. Bhela and Haritha have also devoted separate chapters for Asmari, whereharitha even says Asmari may be hereditary. In Astanga sangraha sutra stana 3rd chapter while explaining muthraavarodhajanya vikaras, vagbhata indicates asmari as one of them. At other place whileexplaining Mutrakricchram, Asmari is said to be one of its eight types. it was alsomentioned as the cause for mutrakricchram. Study on the effect of Eladi Quath in the management of Mutrasmari 4
  • Review of History Most of the literary works like Sarangadhara samhita Yoga ratnakaramChakradutta, Madhava nidanam, Gada nigraham, Bhava prakasa, have all explainedabout ‘Asmari’.MODERN HISTORY: Cutting for stone was the only primitive surgery completely free from religious,ritual or superstitious conations and possibly most ancient operation undertaken forspecific disorder. Anthropologic history provides evidence that urinary calculus existed as earlyas 7000 years ago and perhaps before. In long run different varieties of stones wererecognized and which in turn resulted in development of various medical treatments. Riches (1968) refers to that is formed in pelvis (presumably) bladder ofEgyptian skeleton estimated to be 7000 years old a boy sixteen years age buried atAmarah dated about 4,800 B.C. In the modern period very less has been undertaken by Ayurvedic scholars,where as acharyas of the past have discussed with high privilege. Western medical field did a lot of search work in the field of urinary calculi andeven in surgical line of treatment for the same. The causes were also discussed aftermany years of research and have proposed many hypothesis which include the role ofdiet, hypercalcuria hormonal changes, hereditary causes and metabolic factors. Thedetermination of urinary crystalloids and colloids along with composition of differenttypes of stones was also introduced. Many discoveries and inventions have taken placein fields of anatomy, physiology, pathology, surgery etc. which lead to thedevelopment of nephrology. Some of the evidences are . The specialty of urologic surgery was even recognized by Hippocrates, who inhis famous oath for physicians stated “I will not cut, even for the stone but leave suchprocedures to practitioners of craft” (calendaring 1942) Study on the effect of Eladi Quath in the management of Mutrasmari 5
  • Review of History Hippocrates (460-370 B.C) observed patients having urinary calculi had sandysediments in urine and suggested that infection of muddy river water /water containinglime caused stone formation. After Christ, a Roman physician Celsus described the lateral lithotomy forremoval of bladder stones. Galen (181-201 AD), a Roman physician who wrote aboutthe formation of stone and recognized risk factors like hereditary, race, climate, diet,Drinking water, alcohol, incidence of gout, rheumatism and metabolic abnormalities. A Tibetan medical document (650 AD) has portrayed the site of kidney andmentioned a few urinary affections. Jean Baptist Van Helmont 1571-1644 was the first to suggest that stoneformation is resulted from the excretion of abnormal material in urine. The necessaryurinary factors according to him were 1) the spirit of urine (uric acid). 2) Coagulatingspirit alcohol and 3) ferment causing deposition of urine. First treatise on disease ofkidney, bladder, urethra was written by Francisco Diaz, a Spanish surgeon in 1588. Marcello Malpighi Italian anatomist, described tuft of blood vesselssurrounded by the expanded uniferous tubules, recorded in 1666. Known as renalcorpuscle and ‘malpighian corpuscle of kidney’. He also discovered renal pyramidcalled ‘malpighian pyramid’. Urinary calculi consists of calcium phosphate, magnesium ammoniumphosphate, calcium oxalate, uric acid or mixture of these, demonstrated by William,Hyde, Wollaston, in 1797. Celsius Franco and Cheselden was great contributors for development ofimproved lithotomy techniques. Civiate and Bigelow developed instrumental lithotrity and lithopaxy techniquesthat are still used. Lithotrite for crushing the calculi in the urinary bladder is known asBigelow‘s lithotrite. Lithotrite word was coined and introduced by Jean Civiate. Study on the effect of Eladi Quath in the management of Mutrasmari 6
  • Review of History Artificial production of kidney stone in Guinea pigs by intermittent obstructionof urine, by injecting parathyroid extract was done by Felix Mandl, Austrian surgeonin 1892. Urine formation theory which holds that the kidney glomeruli filter a diluteprotein free urine which is concentrated by re absorption of water while passingthrough the tubules was proposed by W.Luduig, a German physiologist in 1843 called‘Luduig’s Filtration theory’. By 1950, investigators began to report some significant physiologicalobservations that were associated with production of urinary calculi. This included theimportance of diet, especially in association with uric-acid bladder-calculi. Hypercalcuria was defined as one factor contributing to the formation ofcalcium calculi (Flocks 1939) and hypercalciuria due to hyperparathyroidism wasidentified and seperated form idiopathic hyper calciuria (Albright and Renfenstein,1948) The importance of nucleation of stones in kidney was studied intensively byRandall (1937) who described his Randall’s Plaques Urinary crystals and colloids were described and their composition of all stoneswas determined by Wesson, 1935. Study on the effect of Eladi Quath in the management of Mutrasmari 7
  • Rachana Sareera RACHANA SAREERA OF MUTRAVAHA SROTASIntroduction: Even though the disease Mutraasmari is explained in all the classical texts, thematter is scattered with the controversial explanations when compared todays science.We find vast references in relation with anatomical structures of the urinary systemlike vasti, mutravahini siras, mutravaha srotas,mehana, vankshana etc., even thephysiology of formation of urine has been explained with references to the structures,contrary of comparing the anatomy and physiology in today’s well exposed sciencestill remains puzzle with difference in opinions.Mutram: “Mutram Prasraavaha: Mutrayati prasavati mutram prasravascha”7The one which flushes out and gets secreted by is called mutram. In other words theone which is secreted in the body and there by takes away the (liquid) waste productsfrom the body is called mutram. “Kittamannamasya Vinmutram” Mutram is considered as malam (wasteproduct) derived from annam (ingested good). “Mutram” ‘Mu +’tra’:‘Mu’ derived from ‘Mav’ and ‘Miv’ means ‘Mimavate’To bind/to tie/to fix etc. ‘Tra’derived from ‘Trai’ means ‘protecting’‘Mu’ + ‘Trai’ means the one which protects the binding or integrating force.Now the question comes that how and in what way the meaning of mutram as the‘protector of integrity’ will be applicable to the conduct of health since where mutramis considered as an excretory (waste product of the body) Body is made of 5 bhutas and 3 doshas which are responsible for bodilyactivities in health and disease by virtue of their regulating and supporting properties.Sleshma being one of tridoshas, combines hridayadi different angas with integrity sothat they work in coordination with each other and make all bodily functions be carriedout without hindrance by its ‘slistatwam’ (Amarakosa)8 Mutram being a liquidwaste/excretory product of the body regulate/check the ‘slistatam’of sleshma and Study on the effect of Eladi Quath in the management of Mutrasmari 8
  • Rachana Sareerasubsequently ensures thereby maintains the integrity of the body. That may be thereason why acharyas considered urine as ‘Mutram’ is the provider of the bodyintegrity protection and also ‘sareera vikleda karakan’ the one which see the body be inproper hydrated condition related to motravaha srotho avayavas.Mutravaha srotas: The word Mutravaha srotas can be correlated with urinary system. Here weshall deal with the organs related to Mutravaha srotas in the light of Ayurvedicliterature. As per the definition of srotas (sravanath srothamsi) any upper structure whichpermits the liquid media for ‘sravana’ (mobility) is considered as srotas. So, these canbe correlated to all the micro and macro structures including the intercellularconnectors. Thus this view with reference to mutravahna whatever tubular structureswhich can come in formation, secretion and excretion can be learned as ‘mutravahsrotas’ may fall with in physiological limits. But, by referring various classical texts the anatomical structures in differentcontexts may be summarized as Vasti, Mutravaha siras, Mutravaha snayus Mutravahadhamanis, Vrikka, Gavini and Mutra prasekas .Mutravaha sroto Mulam: According to susrutha samhita – Vasti and Medra9. In Charaka Samhitha10 and Astanga Hridayam–Vasti and Vankshana11. Mula as such explained by Chakrapani states that it is the ‘prabhava sthama’which can also be taken as the site of formation or utpatti of pertained sroto dravya12.Mutravaha – Srotas – Nadis – Siras and Dhamanis: There exists a considerable amount of controversy over the fixation of the‘mutravaha Srotamsi’ in light of the various other terms Nadis, Siras, Dhamanisetc.,which at one place or the other meaning simulating ‘Mutra srotamsi’ descriptiionas found in the literature differ with different authority. Susrutha describes ‘Mutra vaha srotamsi’ as a paired structure with urinarybladder (vasti) and penile urethra (Medhra) Study on the effect of Eladi Quath in the management of Mutrasmari 9
  • Rachana Sareera As we go through different volumes of Ayurvedic literature we find thatdifferent authors make use of different terms for apparently the same structure as it wascustomary in those imminent days to give a word, number of synonyms and then makeuse of those in verse making, so much so that the same author some times useddifferent terms at different places to denote the same structure. There is a lot of controversy between number of terms as noted above whichhave similar structure and functions viz., Srotas ,Nadis, Dhamanis and Siras. Itbecomes more so, when all the visible or invisible hollow conductors and channelsof the ‘dhatus’ (tissues) of the body13.Therefore it becomes imperative in light ofabove description that the terms viz., Srotamsi, Siras, Nadis and Dhamanis may beconsidered in connection with urinary system. The main avayavas which come across the entire explanation available in regardwith urinary system and the pertained disorders are:a) Charaka - Mutravaha Srotamsi, Mutravaha nadib) Susrutha - Mutravaha nadis, Dhamanies, Vasti, Medrac) Vagbhata - Vasti, Mutravaha srotas, Nadid) Atharvaveda- GaviniMutravaha Nadi: While explaining the urine formation, Susrutha says that the mutravaha nadisare plenty in number and situated between amasaya and pakwasya with thousands ofopenings which are inappreciable by naked eyes on account of their minute structurescarry the Mutram and replenish the bladder continuously . This is compared with‘Sagara’ (sea) which is continuously poured by many number of ‘sarithas’(river)14. Charaka has also used the term ‘Nadis’ to denote urine carrying and secretingstructures15.Mutravaha Dhamanis: In ‘Dhamani vyakarana sareeram’ chapter Susrutha explains how the main 24dhamanis that emerge from nabhi, nourishes the body. Adhogami dhamanis areresponsible for carrying vata, mutra, purisha, sukra and aarthava. These dhamanisdivide into 30 branches between amasaya and pakwasaya and are responsible forseparation of mutra, purisha and sweda from kitta bagha of ahara. Among these 30 Study on the effect of Eladi Quath in the management of Mutrasmari 10
  • Rachana Sareeraadhogami dhamanis, which are coarsing down, two of them are called ‘Mutravahadhamanis’. Dhalhana says even though the mula dhamanies are two they are divided intohundreds and thousands of inumerable branches16. Charaka has not used the term ‘mutra vaha dhamani’. Later some acharyas likeBhavamisra and Sarangadhara have used the terms dhamanis to mean the urinecarrying and secreting channels. Bhavamisra provides identical description to that ofsusrutha in regard to dhamani17 still at the other places he gives all credit to ‘siras’forthe formation of urine18 .Mutravaha Siras: The term ‘Siras’ has been used by acharyas like Bhavamisra and Sarangadhara.They give all the credit to the mutravahasiras for the formation of mutra. Whileexplaining the paachanakarma, formation of urine has been brought into light19 .Thesummary of the explanation says that ‘saaraheena mala drava’ of food that comesthrough siras and reaches the basti is called as mutram20. The same explanation was given by susrutha21 in nidanasthana that themutravaha nadi does perform the transportation of mutra from pakwasaya to vasti. Thus the difference in opinion of mutravaha nadis and mutravaha siras can besoughted out by taking both the entities under the single terminology. That is why theterm used in different texts cause a great controversy in understanding, in spite of theirexplanations being unaltered. Gudhartha deepika commentary on sarangadhara samhitha says that transport of‘aharajala’ is the function of siras which are connected to vrikkas for purpose.Vastyasrita Snayu: In ‘Sareera sankhya vyakarana sareeram’ chapter susrutha has explainedimportant structural components of the body in which he mentioned about 900 snayusspread among different organs viz., Pratanas in sakhas (limbs), Vrithas in sandhi(joints), Sushiras in amapakwasaya, antra , vasti and Pruthu in sirah (head) urah(chest). Vagbhatacharya mentioned that there are 5 Sushira snayus in relation to vasti22. Study on the effect of Eladi Quath in the management of Mutrasmari 11
  • Rachana Sareera On the other hand Charakacharya mentions that snayus are 900 in number andcan only be seen by tarkam(imagination/consideration/demonstation). Susrutacharya says that these snayus are important structures of the body, theycombine different related organs together so that they carry their function withouthindrance 23.Vasti: Vasti is one term that receives a major description wherever there is mentionabout the urinary disease, it is said to be the main seat of all most of all urinarydiseases described in Ayurvedic literature. The ancient authors have imparted so muchimportance to this organ that some of the modern commentators take it granted for thecomplete urinary apparatus as we may call it while going to textual description aboutits location, shape and structure.Utpatti: The word ‘vasti’ is derived from ‘vas’ dhatu which means ‘to say’ ‘to live’ ‘tocover’Paryayas: Vasti, Basti, Mutrasaya, Mutraputa, Mutravasti, Vastiputa, Mutradhara. In Atharvaveda and Rgveda, there is a mention of term “Plase”which wasexplained by acharya Sresta as ‘Mutrasaya’24. Vasti term is used for one of the chikitsas and its different types Eg.VranaVasthi, Sirovasthi, Uttaravasti. Vasti is considered to be very important organ in the body wherevastyasritamarma, one of the ‘trimarmas’25 is present. It is also kostasritha,Sadyopranahara, Snayumarma, one in number and there has been given primeimportance to avoid any injuries, Susrutha has mentioned to take precautions and careduring the extraction of Asmari (as one is operating on a marma). Charaka has given the superiority to this organ by explaining under a separateheading which is pertained to three pradhana marmas in which Trimarmeeya siddi andchikitsa for the same has been dealt. It is composed from the essence of raktha, kapha. From the view point ofembryology it is derived from ‘Matruja Bhava’ (maternalcontribution)25Vagbhatacharya says Vasthimarma resembles ‘Dhanus ’(Dhanurvakra)26,27. It is Study on the effect of Eladi Quath in the management of Mutrasmari 12
  • Rachana Sareeraemphasized by all acharyas that if injured one side it forms an ulcer which cures withdifficulty. The injury may be due to asmari/asmari sastrakarma or by other mean28. Vasti is considered as ‘Mulaadhara’ and ‘Pranayatana’ which supports life andis comprised of ‘Alpamamsa and Sonitham29 It is one of Sapthasayas30 in females it is situated by side of Garbhasaya31surrounded by nabhi, prista,- kati, muskha, gudha, vankshana and sepha. Charakasexplanations are similar and theme being the same. He says that vasti is placed inbetween stoola gudha, muskha, sevani, sukravaha srothas and mutravaha nadis32 andone of Kostangas33 . The location of Vasti is mentioned as below nabhi34.Vrikka : Nirukti: ‘Vrsu sesane’ dhatu ‘Varsti iti vrikka ‘35Means organ which drops off water. Utpatti: Vruka is derived from the word ‘vrikadna’ means ‘to take’ or toreceive.36 In Rgveda37 and Atharva veda there is a word mentioned ‘Matsnaabhyam’ forwhich Sri Brahmamuni has considered them as two vrikkas/kidneys. They have beenmentioned right from the vedic period until now, though its function in the samhithaperiod is an obscure specification for the modern commentators. ‘Vrikau’ have always been mentioned in ayurvedic literature as two in number38They are classified under Kostangas and Pratyang39 . They are composed of mamsa, one on right side and the other on left40. Roundin shape and situated at kukshi pradesa41 . According to Charaka they are classified 42embryologically under Maatrujabhaavas . They are formed by prasada bhaga ofAsrik and Mala. As per susrutha Medovha srotas have their root in kati and vrikka43 As per Chakara Medovaha srotas have their root in vrikka and vapa44 As per Vagbhata Vrikkas are considered to be root of medovaha srotas and arerelated to mamsa dhatu45 . Adhamalla while commenting on sarangadhara , says That vrikau are roots forthe siras which carry aharajala (aharjalavaha siras)46 Study on the effect of Eladi Quath in the management of Mutrasmari 13
  • Rachana Sareera In Ayurvedic texts the term vasti includes urinary system i.e., kidneys tobladder. Kidney is also termed as ‘vasti sirah’ i.e., head of urinary system. Whileexplaining renal colic it was mentioned that pain radiates from vasti sirah to penis (lointo groin region) ‘Loin’ where the kidney lies. So, by the above explanation we canconsider ‘kidney’ as ‘vasti sirah’. The controversies which confuse any student who is having the present dayknowledge of kidneys is that vrikkas have not been mentioned in the context withregard to urinary system. Though the anatomical structure have clear explanation,which suggests that vrikkas are non other than kidneys. The continual structures likethe pelvis, ureter and the additional structures like supra renal glands have not beendealt anywhere in spite of being macroscopic structures. If we come to ‘vrikka as mula of medovaha srotas’ and go through the detailedanatomy explained in our Ayurvedic classics they indicate that sages have notrecognized or identified the adrenal glands. But identified only the vrikkas with regardto Medodhatu. It is necessary to look into the action of a harmone produced by adrenalgland in the fat metabolism, cortisol, glucocorticosteroid produced by the cortex of theadrenal gland causes a moderate degree of fatty acid metabolism from the adipose tissue. A dangerous pathological state may develop due tomorbidity of Medodhatu and result in Annaja (sneha vyapat,and dhatuja medovyapat)which occur due to an abnormality of dhatuparinama (Dalhana) . This condition iscommon in secure obesity, diabetes mellitus, nephrotic syndrome etc. ‘Sarangadhara’said that Jatarastha meda is related with vrikka. However it is a fact that Renin isexcessively secreted by the kidneys in nephrotic syndrome. Renin stimulate theadrenal cortex to produce more glucocorticoids and aldosterone, which are capable ofmobilizing the fatty acids from fat depots leading to medovyapat . This can beconsidered as connection between the kidneys and the fat mobilisation.Similarlyedema which does not pit on pressure and thrist sign shows that the link betweenmedovaha srotas and kidney disorders especially seen in the case of prameha so it isproved that vrikka is a mula of medovaha srotas. Study on the effect of Eladi Quath in the management of Mutrasmari 14
  • Rachana SareeraGavini: Gavinis have been termed in the Atharvaveda and its commentary written bysayanacharya in which it has described that gavinis are the tubular structures (nadis)which are situated on either side of the mutra and render it to mutrasaya47. Thesestructures can be directly compared to ureters.Mutra praseka: As per susrutha this is situated at the Vastimukha and has been termed 48singularly through its occurrence that it can be compared with the proximal part ofurethra linked with the urinary bladder. This is also involved one among theAstamarmas. Caution the surgeon not to injure these marmas namely, sevani,shukravaha, guda, mutrapraseka, basti during the surgery. The length of the urinary passage in male according to Charaka is 6 inches49.Saragadhara quotes ‘Medhra’ is a channel for sukra and mutra. Study on the effect of Eladi Quath in the management of Mutrasmari 15
  • Anatomy ANATOMY OF URINARY SYSTEM The urinary system consists of two kidneys, two ureters, one urinary bladder,and one urethra. After the kidneys filter blood plasma, they return most of the waterand solutes to the bloodstream. The remaining water and solutes constitute urine,which passes through the ureters and is stored in the urinary bladder until it is excretedfrom the body through the urethra. Nephrology is the scientific study of the anatomy,physiology and pathology of the kidneys. The branch of medicine that deals with themale and female urinary systems and the male reproductive system is Urology.Anatomy and Histology of the kidneys: The paired kidneys are reddish, kidney-bean-shaped organs located just abovethe waist between the peritoneum and the posterior wall of the abdomen. Becausetheir position is posterior to the peritoneum of the abdominal cavity, they are said to beretroperitoneal. The kidneys are located between the levels of the last thoracic andthird lumbar vertebrae, a position where they are partially protected by the eleventhand twelfth pairs of ribs. The right kidney is slightly lower than the left.External anatomy of the kidneys: A typical kidney in an adult is 10-12 cm (4-5in) long, 5-7 cm (2-3 in) wide, and3 cm (l in) thick and has a mass of l35-l50g. The concave medial border of eachkidney faces the vertebral column. Near the center of the concave border is a deepvertical fissure called the renal hilus through which the ureter emerges from the kidneyalong with blood vessels, lymphatic vessels and nerves. Three layers of tissue surround each kidney. The deep layer, the renal capsuleis a smooth, transparent sheet of dense irregular connective tissue that is continuouswith the outer coat of the ureter. It serves as barrier against trauma and helps maintainthe shape of the kidney. The middle layer, the adipose capsule, is a mass of fatty tissuesurrounding the renal capsule. It also protects the kidney from traumaand holds it firmly in place within the abdominal cavity. The superficial layer, therenal fascia, the another thin layer of dense irregular connective tissue that anchors thekidney to the surrounding structures and to the abdominal wall. On the anteriorsurface of the kidneys, the renal fascia is deep to the peritoneum. Study on the effect of Eladi Quath in the management of Mutrasmari 16
  • AnatomyInternal anatomy of the kidneys: A frontal section through the kidney reveals two distinct regions: a superficial,smooth-textured reddish area called the renal cortex aand a deep, reddish-brown innerregion called the renal medulla. The medulla consists of 8 to 18 cone-shaped renalpyramids. The base (wider end) of each pyramid faces the renal cortex, and its apex(narrower end) called a renal papilla, points toward the renal hilus. The renal cortex isthe smooth-textured area extending from the renal capsule to the bases of the renalpyramids and into the spaces between them. It is divided into an outer cortical zoneand an inner juxtamedullary zone. Those portions of the renal cortex that extendbetween renal pyramids are called renal columns. A renal lobe consists of a renallpyramid, its overlying area of renal cortex, and one-half of each adjacent renal column. Together, the renal cortex and renal pyramids of the renal medulla constitute theparenchyma (functional portion) of the kidney. Within the parenchyma are thefunctional units of the kidney—about I million microscopic structures called nephrons. Urine formed by the nephrons drains into large papillary ducts which extend throughthe renal papillae of the pyramids. The papillary ducts drain into cuplike structurecalled minor and major calyees Each kidney has 8 to 18 minor calyees and 2 to 3major calyees. A minor calyx receives urine from the papillary ducts of one renalpapilla and delivers it to a major calyx. From the major calcyees, urine drains into asingle large cavity called the renal pelvis and then out through the ureter to the urinarybladder. The hilus expands into a cavity within the kidney called the renal sinus, whichcontains part of the renal pelvis, the calyees, and branches of the renal blood vesselsand nerves. Adipose tissue helps stabilize the position of these structures in the renalsinus.The Nephron: Nephrons are the functional units of the kidneys. Each nephron consists of twoparts; a renal corpuscle, where blood plasma filtered fluid passes. The twocomponents of a renal corpuscle are the glomerulus (capillary network) and theglomerular (Bowman’s) capsule, a double-walled epithelial cup that surrounds theglomerular capillaries. Blood plasma is first filtered in the glomerular capsule, and thenthe filtered fluid passes into the renal tubule, which has three main sections. Study on the effect of Eladi Quath in the management of Mutrasmari 17
  • Anatomy In the order that fluid passes through them, the renal tubule consists of a (1)proximal convoluted tubule (2) loop of Henle (nephron loop) and (3) distal convolutedtubule. The renal corpuscle and both convoluted tubules lie with the renal cortex,whereas the loop of Henle extends into the renal medulla, makes a hairpin turn andthen returns to the renal cortex. The distal convoluted tubules of several nephrons empty into a singlecollectingduct. Collecting ducts then unite and coverage until eventually there are onlyseveral hundred large papillary ducts, which drain into the minor calyces. Thecollecting ducts and papillary ducts extend from the renal cortex through the renalmedulla to the renal pelvis. Although one kidney has about 1 million nephrons, it has amuch smaller number of collecting ducts and even fewer papillary ducts. In a nephron, the loop of Henle connects the proximal and distal convolutedtubules. The first part of the loop of Henle dips into the renal medulla, where it iscalled the descending limb of the loop of Henle. It then makes the hairpin turn andreturns to the renal cortex as the ascending limb of the loop of Henle. About 80-85%of the nephrons are cortical nephrons. Their renal corpuscles lie in the outer portion ofthe renal cortex, and they have short lops of Henle.Juxtamedullary nephrons: The renal corpuscles lie deep in the cortex, close to the medulla and they have along loop of Henle that extends into the deepset region of the medulla. Long loops ofHenle receive their blood supply from peritubular capallaries and from the vasa rectathat arise from efferent arteries . In addition the ascending limb of the loop of Henle ofjuxtamedullary nephrons consists of two portions ; a thin ascending limb followed bya thick ascending limb. The lumen of the thin ascending limb is the same as in otherareas of the renal tubule; it is only the epithelium that is thinner. Nephrons with longloops of Henle enable the kidneys excrete very dilute or very concentrated urine. Study on the effect of Eladi Quath in the management of Mutrasmari 18
  • AnatomyUreters: Each of the two ureters transports urine from the renal pelvis of one kidney tothe urinary bladder. Peristaltic contraction of the muscular walls of the ureters pushurine towards the urinary bladder, but hydroastic pressure and gravity also contribute.Peristaltic waves that pass from the renal pelvis to the urinary bladder vary infrequency from one to five per minute depending on how fast urine is being formed. The ureters are 25-30 cm (l0-12 in) long and are thick-walled, narrow tubes thatvary in diameter from lmm to 10mm along their course between renal pelvis and theurinary bladder. The coats of tissue from the wall of the ureters. The deepest coat or mucosa, isa mucous membrane with transitional epithelium and an underlying lamina propria ofareolar connective tissue with considerable collagen, elastic fibers and lymphatictissue. Thoughout most of the length of the ureters, the intermediate coat, themuscularis is composed of inner longitudinal and outer circular layers of smoothmuscle fibers. This arrangement is opposite to that of the gastrointestinal tract. Thesuperficial coat of the ureters is the adventitia, a layer of areolar connective tissuecontaining blood vessels , lymphatic vessels and nerves that serve the muscularis andmucosa. The adventitia blends in with surrounding connective tissue and anchors theureters in place.Urinary bladder: The urinary bladder is hollow, distensible muscular organ situated in the pelviccavity posterior to the public symphysis. In males it is directly anterior to the rectum;in female it is anterior to the vagina and inferior to the uterus. Folds of the peritoneumhold the urinary bladder in position. The shape of the urinary bladder depends on howmuch urine it contains. Empty, it is collapsed; when slightly distended it becomesspherical. As urine volume increase it becomes pear-shaped and rises into theabnormal cavity. Urinary bladder capacity averages 700-800 ml. It is smaller infemales because the ureters occupies the space just superior to the urinary bladder.Anatomy and histology of the urinary blader: In the floor of the urinary bladder it is small triangular area called the trigone.The two posterior corners of the trigone contain the two ureteral openings whereas the Study on the effect of Eladi Quath in the management of Mutrasmari 19
  • Anatomyopening into the urethra, the internal urethral orifice lies in the anterior corner.Because it mucosa is firmly bound to the muscularies, the trigone has a smoothappearance. Three coats make up the wall of the urinary bladder. The deepest is the mucosa,a mucous membrane composed of transitional epithelium and an underlying laminapropia similar to that of the ureters. Rang (the flods in the mucosa) are also present topermit expansion of the urinary bladder. Surrounding the mucosa is the intermediatemuscularis, also called the detrusor muscle which consists of three layers of smoothmuscle fibers; the inner longitudinal, middle, circular and outer longitudinal layers.Around the opening to the urethra the circular fibers from the internal urethralsphincter; inferior to it is the external urethral sphincter, which is composed of skeletalmuscle and is a modification of the urogenital disphagm muscle . The most superficialcoat of urinary bladder on the posterior and inferior surfaces is the adventitia, a layer ofareolar connective tissue that is continuous with that of the ureters. Over the superiorsurface of the urinary bladder is the serosa, a layer of visceral peritoneum.Urethra: The urethra is a small tube leading from the internal urethral orifice in the floorof the urinary bladder to the exterior of the body. In both males and females, theurethra is the terminal portion of the urinary system and the passageway fordischarging urine from the body. In males, it discharges seman (fluid and containssperm) as well In females, the urethra lies directly posterior to the public symphysis, is directedobliquely inferiorly and anteriorly and has a length of 4 cm (l.5in) The opening of theurethra to the exterior, the external urethral orfice is located between the clitoris andthe vaginal opening. The wall of the female urethra consists of a deep mucosa and asuperificial muscularis. In males, the urethra also extends from the internal urethral orifice tothe exterior but its length and passage through the body are considerably different thanin females The male urethra first passes through the prostate, then through the urogentialdiphragm, and finally through the penis, a distance of 15-20 cm (6-8 in) Study on the effect of Eladi Quath in the management of Mutrasmari 20
  • Anatomy The male urethra which also consists of a deep mucosa and a superficialmuscosa and a superficial muscularies, is subdivided itno three anatomical regions. 1)The prostatic urethra passes through the prostate (2) The membranous urethra, theshortest portion, passes through the penis. The muscularis of the prostatic urethra is composed of mostly circular smoothmuscle fibers sjuperificial to the lamina propria; these circular fibers help from theinternal urethral sphincter of the urinary bladder. The muscularies of the membranousurethra consists of circularly arranged skeletal muscle fibers of theurogenital diaphragm that help from the external urethral sphincter of the urinarybladder. Several glands and other structures associated with reproduction deliver theircontents into the male urethra. The prostatic urethra contains the openings from (1)ducts from transport secretions from the prostate and from (2) the seminal vesicles andductus (vas) deferens, which deliver sprem into the jurethra and provide secretions thatboth neutralize the actidity of the female reproductive tract and contribute to spermmotility and viability. The openings of the ducts of the bullbo-urethral (Cowper;s)glands empty into the spongy urethra. They deliver an alkaline substance beforeejaculation to neutralize the acidity of the urethra.Blood Supply Of the urinary System:Kidneys: Because the kidneys remove wastes from the blood and regulate its volume andionic composition, it is not surprising that they are abundantly supplied with bloodvessels. Although the kidneys constitute less than 0.5% of total body mass, theyreceive 20-25% of the resting cardiac output via the right and left renal arteries .and the accessory arteries with their branches.Ureter: Supplied by branch of lower segmental artery of the kidney and also from thederivative branches of the abdominal aorta, testicular (ovarian in females), commoniliac, internal iliac, vesical and uterine vesical. Study on the effect of Eladi Quath in the management of Mutrasmari 21
  • AnatomyBladder : Supplied by superior and inferior arteries derived from anterior trunk of theinternal iliac artery, small branches of obturator and inferior glutial arteries.In femalesan additional branch of vaginal artery supply the bladder.The venous drainage is to internal iliac vein through the complicated plexus of theinferiolateral vein.Nerve Supply of the Urinary System:Kidneys: These are supplied by both the sympathetic and the parasympathetic nerves ofthe autonomic nervous system, and the renal nerves which contain the afferent andefferent nerve fibres.Ureter: These are supplied by the ureteric nerves which are derived from the renal,aortic, superior and inferior hypogastric plexus, which are derived from the lower 3thoracic , L1 and S2-4 segments of the spinal chord.Bladder: It is supplied by the vesical plexus which consists of both sympathetic andparasympathetic components which consists of both afferent and efferent fibres .Thevesical plexus come from the anterior branch of the inferior hypo gastric plexus. Sympathetic preganglionic nerves in the plexus arch from the lower twothoracic and upper two lumbar final segments, synapsing with neurons scattered in thesuperior and inferior hypogastric plexus and the vesical wall. The parasympathetic preganglionic efferent fibers come from S2-4.Urethra: It is supplied by the perennial branches of the pudendal nerve (S2,3and 4) it isvoluntary after infancy. Study on the effect of Eladi Quath in the management of Mutrasmari 22
  • AnatomyLymphatic Drainage of the Urinary System :Kidney: Renal lymphatics begin in three plexus 1)Around the renal tubule 2)Under the renal capsule 3)Under the peri renal fat connecting freely with the lymphatics under the renalcapsule.Collecting vessels under the intra renal plexusfrom 4or 5 trunks following therenal vein to end in the lateral aortic nodes.Ureteric: Vessels begin in the sub mucosal,intra muscular and adventecial plexus whichinter communicate .The proximal part drain directly into aortic nodes near the origin ofthe gonadal artery. Those from the lower abdominal part go to the common iliac nodes and thosefrom the pelvic part end in common, external and internal iliac nodes.Vesical: Lymphatics begin in mucosal, inter muscular and serosal plexus, collectingnearly all ending in ilieac nodes in three sets.Urethral: These are two sets1) Vessels from the prostratic and membranous urethra in males and whole of urethrain females drain to external ileac nodes.2) Vessels from the male spongiose urethra drain to the vessels accompanying theglans penis which end in the deep inguinal nodes. some may end even in thesuperficial nodes or in the external ileac nodes. Study on the effect of Eladi Quath in the management of Mutrasmari 23
  • Kriya Sareera KRIYA SAREERA OF MUTRAVAHA SROTASFormation of urine The concept of urine formation described in Ayurvedic classics is based on day-to-day observations. All the scholars of Ayurveda have same opinion that productionof Mutra (urine) is ultimately related with ingested Ahara and Mutra is waste excretoryproduct (Mala or Kitta) of Ahara along with Purisha. Pachaka pitta, Samana Vayu andPurishdara Kala play prominent role in this process of Mutra Nirmana and Pakwashayais said to be the seat of urine formation. But there is some difference of opinion amongthe scholars of Ayurveda regarding the structures involved in the transportation ofMutra from Pakwashaya to Vasti. On perusal of reference found in Atharvaveda, it is clear that Mutra (urineformation) takes place in Antra (large intestine) and then Mutra, traversing through theGavinies (ureters) reaches Vasti50. According to Charaka, food material after digestion converts into two formsviz., prasadakhya and Malakhya. Later on the prasadakhya ie., essence part isconverted into Rasa while the Malakhya i.e., inert waste part is known as Kitta andserves as a nutrient to the final shaping of different Malas of body such as Sweda(sweat) Mutra (urine) Purisha (faces) Vata Pitta and Kapha (the three Doshas). ThisMalakhya Kitta maintains all these Malas in appropriate quantity through out of thelife51 Sushruta referred that Pachaka Pitta (Antragni/digestive enzyme) which ispresent in between Amashaya (stomach) and Pakwashaya (intestines) digests all thefour types of food and separates into Rasa, Mutra and Purisha52 . This separation ofRasa, Mutra and Purisha is further extended by Adhogami Dhamanies. Thisdescription of Adhogami Dhamanies is given by Susruta while enumerating thirtyAdhogami Dhamanies, among them two Dhamanies carry the Mutra to Vasti andtermed as Mutravaha Dhamanies. If we see in the light of modern science theyindicate towards right and left ureters 53. Dalhana, while commenting on the above, clarified that the Ahara which is tobe digested and separated into Rasa, Mutra and Purisha in Pittashaya will not remainin the same form of Anna as it was. It has undergone some change to some Study on the effect of Eladi Quath in the management of Mutrasmari 24
  • Kriya Sareeraextent, but not to the final state of its excretable form. It is the middle product ofdigested food which is the out of separation of Rasa and that after reaching Vasti, getsits name as Mutra54. At another place, while commenting on Asmari-Nidana, Dalhana has elaboratedthat the two Mutravaha Dhamanies divide into ten hundred, thousands and so on(branches). These branches are not visible due to their minuteness55. On the basis ofDhalhan’s concept, it may be interpreted that these dhamanies are nothing but the rightand left renal artery and invisible branches are nephron and the middle product ofdigested food before urine formation enters into these two Mutravaha Dhamanies andthen to their small branches where the Nishyandana takes place. Besides the above, in the chapter of Ashamari-Nidana, Sushruta has depictedanother view of urine formation with excellent example that Mutravaha Nadiesconstantly drain urine into Vasti and keep it moist or filled with urine in the samemanner as rivers drain their water to ocean. (These Nadies are originating formPakwashaya (large intestine) from thousand of very minute opening which are notvisible due to their minuteness and are sustained in between Amashaya(stomach/intestine) and Mutrashaya (urinary bladder) These Nadies carry on the function of Mutra-Nisyandana (urine filtration)continuously even in the state of awakening or sleep, just as a new earthen pot(pithcer) which is immersed up to its mouth in the water, will fill through its lateralpores in the wall by the process of transduction constantly56. Vagbhatta, very briefly confirmed the above view of Susruta. He mentionedthat though Vasti is placed with its mouth directed downwards, it is being constantlyfilled by the process of transduction through numerous lateral opening of MutravahiSiras (Mutravahisiramukhei)57. Sharangadhar also gave a short description about urine formation that Sara(essence of Aharas called Rasa and the inert portio i.e., (Sarahina part of the digestedfood) is Mala Drava. The aqueous part of Mala Drava is carried by Sira (channels) toVasti which afterwards is known as Mutra 58. Study on the effect of Eladi Quath in the management of Mutrasmari 25
  • Kriya Sareera It is important to mention here that most of Samhitakar has given anatomicaldescription of Vrikka but none of them has given any role of Vrikka in urineformation. However Gananatha Sen has tried to establish the role of Vrikka in Mutra-Nirmana. He accepted that the available texts of Ayurveda are not the original one asmany of the Pathasudhi Karta (editor of textual error) has changed the text according totheir own views. According to Gananth Sen at the place of Mutram in the verse ofSushruta Nidna Sthana 3/21 it was Vrikkam; because it is the Vrikka only which canbe Tarpita by Mutravaha Dhamanies, not the Mutra. Hence, if his view is correct,there is a definite role of Vrikka in Mutra-Nirmana as these are the tubules of kidney(Vrikka) only which are invisible due to their minuteness and carry on the function offiltration continuously (Gananth Sen) There exists an indirect relationship (through the medium of blood (RaktaRasa) between the urinary tract and gastrointestinal tract as if is mentioned in modernliterature that the kidney filtrate about 170 lit / 24 hrs but the net urine formation rate isabout 1.5 lit/24 hrs. This means that the whole fluid absorbed from the GIT passthrough the kidney as said in Ayurveda that the absorbed fluid is transportedby two Mutravaha dhamanis divided into thousands branches and then reaches to Vasti(urinary bladder) via two Mutravaha Dhamani/Nadi/and termed as (Mutrra) urine.Sushruta has also used word Vritekam Tarpita by Mutravaha Dhamanies (renalarteries) 59. This indicates that Vrikka (kidney) has definite role in urine formation After perusal of the all above facts the whole process of urine formation may besummarized as: When food is completely digested by Pachaka Pitta (digestive enzyme) initiatedby Samana Vayu (neural factors) it is separated into two parts:1) Sarabhaga (useful part)2) Kittabhaga (useless part) The liquid portion of Kittabhaga is separated from its solid form in thePakwashaya by Purisdhara Kala (mucosa of large intestine) under the control ofSamana Vayu. This separated portion is Poshaka Dhatu (precursor) of Mutra and Study on the effect of Eladi Quath in the management of Mutrasmari 26
  • Kriya Sareeraafter being absorbed from Pakwashaya, it gets into the circulation by AdhogamiDhamanies and ultimately reaches the Vrikka (kidney) through the two MutravahaDhamanies. These Mutravaha Dhamanies divided into large number of smallercapillaries i.e., Mutravaha Nadies, which filter the urine. The urine, thus formed, iscarried by a pair of Gavini (ureters) to Vasti (urinary bladder) for storage, from whereit is ultimately passed out by the Mutrapraseka (urethra) under the control of ApanaVayu.Mutrotsargam: Mutram is one of the three main excretory products of the body. All acharyashave given much importance to the timely excretion of all waste products from thebody. It is said that the act of mutrotsargam (excretion of urine) is under the control ofapana vayu which is situated in Pakwashaya60. This apanavayu excrete mutra purisha,sukram etc. However, the activities of apanavayu are clearly interrelated with 4 typesof vata. Mutravega is one of the vegas, which should not be suppressed. It is also saidthat when mutravega which is on one should not take anything by mouth, should notdo coitus since they vitiate mutravaha srotas and cause many related diseases. Mutra vega dharana is considered as etiological factor for many diseases likeUdawarta, Mutrasmari, Rajayakshma, Mutrakrichra etc.Mutra karma: Mutra does vastipurana and maintains Kledatwa of shareera (Mutra doesKledavahana) 61.Mutra kshaya lakshanas: In susrutha samhitha, Kshaya lakshanas are vasti toda and alpa mutrata62.According to Vagbhata Alpamutratwa, Mutra krichrata, Vivarnata, Rakta yuktamutrata, Vasti toda, Mukha sosha63.Mutravriddhi lakshanas: Sushrutha quotes muhur muhur mutra pravritti, Vasti toda and adhmana64.Vagbhata quotes as Mutradikya, Krite api akruta sangata. Study on the effect of Eladi Quath in the management of Mutrasmari 27
  • Kriya SareeraMutravegadharana janya vyadhi: Charaka says dhaarana of motravegas leads to Vasti, Medhra soola, Mutrakrichra, Siroruja and Vankshana sodha66. Mutravega dhaarama leads to angabhanga, asmari, vasti, vankshana vedana67.Mutravaha sroto dusti nidana: According to Charaka mutravaha srotas are affected due to use of water, foodand coitus during urge for micturition, suppression of urge for micturition68.Mutravaha sroto dusti lakshana: Charaka quotes as excessive exertion, excessive obstruction or suppression,vitiated, diminished or frequent thick urine with pain indicate the morbidity ofmutravaha srotas69.Vrikka karma: According to Sarangadhara Vrikka nourishes the jatarastha meda70.Dhamani karma: According to Sushrutha Dhamani does mutra vahana to Vasti71.Dhaarana and Yaapana of Mutra and Vasti72 .Vasti karma: As per Susrutha,Vasti is the place for Mutra and is the seat of Prana73. As perCharaka reservoir of mutra where all the Ambuvaha srotas end.74Mutra praseka karma: According to Sushrutha it does excretion of Mutra from Vasti75.Mutravaha sroto karma: Since all the srothas does the function of ‘sravana’ the mutrasroto karma is themain function of Mutravahana srotas. Study on the effect of Eladi Quath in the management of Mutrasmari 28
  • Physiology PHYSIOLOGY OF THE URINARY SYSTEMOverview of kidney functions: The kidneys do the major work of the urinary system. The other parts of thesystem are mainly passageways and storage areas. Functions of the kidneys include• Regulating blood ionic composition: The kidneys help regular the blood levels of several ions, most importantly sodium ions (Na+) patassium ions (K+) calicum ions(Ca2+) chloride ions (CI-) and phosphate ions (HPO42)• Regulating blood Ph: The kidneys excrete a variable amount of hydrogen ions (H+) into the urine and conserve bicarbonate ions (HCO3) which are an important buffer of H+ in the blood. Both of these activities help regulate blood pH• Regulating blood volume: The kidneys adjust blood volume by conversing or eliminating water in the urine. Also, an increase in blood volume increase blood pressure whereas a decrease in blood volume decrease blood pressure.• Regulating blood pressure: Beside adjusting blood volume, the kidneys help regulate blood pressure by secreting the enzyme renin, which activates the reninangiotensin - aldosterone pathway Increased renin causes an increase in blood pressure.• Maintaining blood osmolarity: By separately regulating loss of water and loss of solutes in the urine, the kidneys maintain a relatively constant blood osmolarity close to 290 milliosmoles per liter.• Producing hormones: The kidneys produce two hormones. Calcitriol the active form of vitamin D, helps regulate calcium homeostasis and erythropoietin stimulates production of red blood cells.• Regulating blood glucose level : Like the liver, the kidneys can use the amino acid glutamine in gluconegenesis, the synthesis of new glucose molecules. They can then release glucose into the blood to help maintain a normal blood glucose level. Study on the effect of Eladi Quath in the management of Mutrasmari 29
  • Physiology• Excreting wastes and foreign substances. By forming urine the kidneys help excrete wastes—substances that have no useful function in the body. Some wastes excreted in urine result from metabolic reactions in the body. These include ammonia and urea from the deamination of amino acids; bilirubinfrom the catabolism of hemoglobin; creatine from the breakdown of creatine phosphatein muscle fibers; and uric acid from the catabolism of nucleic acids. Other wastesexcreted in urine are foreign substances from the diet, such as drugs and environmentaltoxins.Overview of renal physiology:To produce urine, nephrons and collecting ducts perform three basic processes—glomerular filtration, tubular secretion and tubular re-absorption1. Glomerular filtration: In the first step of urine production, water and most solutes in blood plasma move across the wall of glomerular capillaries into the glomerular capsule and then into the renal tubule.2. Tubular re-absorption: A filtered fluid flows along the renal tubule and through the collecting duct, tubule cells reabsorb about 99% of the filtered water and many useful solutes. The water and solutes return to the blood as it flows through the peritubular capillaries and vasa recta. Note that the term re-absorption refers to the return of substance to the bloodstream. The term absorption by contract means entry of new substances into the body as occurs in the gastrointestinal tract.3. Tabular secretion: As fluid flows along the tubule and through the collecting duct the tubule and duct cells secrete other materials, such as waste, drugs and excess ions, into the fluid. Notice that tubular secretion removes a substance from the blood. In other instances of secretion—for instance secretion of hormones—cells release substances into interstitial fluid and blood Solutions in the fluid that drains into the renal pelvis remain in the urineand are excreted. The rate of urinary excretion of any solute is equal to its rate ofglomerular filtration, plus its rate of secretion, minus its rate of re-absorption.By filtering, reabsorbing and secreting, nephrons help, maintain homeostasis ofthe blood’s volume and composition Study on the effect of Eladi Quath in the management of Mutrasmari 30
  • Physiology REGULATION OF GLOMERULAR FILTRATION RATE (GFR),Table No.1 Type of Regulation Major Stimulus Mechanism and Site Action Effect on GFR Renal Autoregulation Increased stretching of smooth Stretched smooth muscle muscle fibers in afferent fibers contract, thereby Myogenic mechanism Decrease arteriole walls due to increased narrowing the lumen of the blood pressure. afferent arterioles. Decreased release of nitric Rapid delivery of NA and CI to oxide (NO) by the Tubuloglomerular feed the macula densa due to high juxtaglomedular apparatus Decrease back systematic blood pressure. causes constriction of afferent arterioles. Constriction of afferent Increase in level of activity of arterioles through activation Neural Regulation renal sympathetic nerves Decrease of a1 receptors and increased releases norepinephirne. release of renin. Decreased blood volume or Hormonal Regulation Constriction of both afferent blood pressure stimulates Decrease Angiotensin II and efferent arterioles production of angiotensin II Relaxation of mesangial cells Stretching of the atria of the Atrial natriuretic in glomerulus increases heart stimulates secretion of Increase peptide (ANP) capillary surface area ANP available for filtration SUBSTANCES FILTERED, REABSORBED, AND EXCRETED IN URINE, Table No2 Filtered* (Enters Reabsorbed (Returned Urine (Excreted Substance Glomerular Capsule per to Blood per Day) per Day) Day)Water 180 liters 178-179 liters 1-2 litersProteins 2.0 g 1.9 g 0.1 gSodium ions (Na+) 579 g 575 g 4gChloride ions (Cl-) 640 g 633.7 g 6.3 gBicarbonate ions (HCO3-) 275 g 275 g 0.03 gGlucose 162 g 162 g 0. gUrea 54 g 24 g 30 gPotassium ions (K+) 29.6 g 29.6 g 2.0 gUric acid 8.5 g 7.7 g 0.8 gCreatinine 1.6 g 0. g 1.7 g Study on the effect of Eladi Quath in the management of Mutrasmari 31
  • Physiology CHARACTERISTIC OF NORMAL URINE, Table No.3CHARACTERISTIC DESCRIPTIONVolume One to two liters in 24 hours but varies considerably. Yellow or amber but varies with urine concentration and diet. Color is due to urochrome (pigment produced from breakdown of bile) and urobilinColour (from breakdown of hemoglobin). Concentrated urine is darker in colour. Diet (reddish-coloured urine from beets), medications, and certain diseases affect colour. Kidney stones may produce blood in urine. Transparent when freshly voided but becomes turbid (cloudy) uponTurbidity standing. Mildly aromatic but becomes ammonia-like upon standing. Some people inherit the ability to form methymercaptan from digested asparagus thatOdor gives urine a characteristic odor. Urine of diabetics has a fruity odour due to presence of ketone bodies. Range between 4.6 and 8.0; average 6.0; varies considerably with diet.PH High – protein diets increase acidity; vegetarian diets increase alkalinity. Specific gravity (density) is the ratio of the weight of a volume of a substance to the weight of an equal volume of distilled water. In urine, itSpecific Gravity ranges from 1.001 to 1.035. The higher the concentration of solutes, the higher the specific gravity. Study on the effect of Eladi Quath in the management of Mutrasmari 32
  • Physiology NORMAL CONSTITUENTS OF URINEA.ORGANIC CONSTITUENTS, Table No.41. Nitrogen (total) 25-35g2 Urea 25-30g3. Creatine 60-150g (appx)4. Creatinine 1.4g (1.2-1.7g)5. Ammonia 0.7g (0.3-1.0g)6. Uric Acid 0.7g (0.5-0.8g)7. Hippuric Acid 0.1-1.0g8. Oxalic Acid 10-30mg9. Amino Acid (amino acid nitrogen) 150-200mg10. Allantonin Small quantity11. Vitamins, Harmones & Enzymes Small quantityB.INORGANIC CONSTITUENTS, Table No.51. Chloride 6-9g2. Chloride as NaCl 10-15g3. Phosphate as P 0.8-1.3g4 Sulphate (total Sulphur) 0.8-1.4g (AVG-1.0g)5. Potassium 2.5-3.5g6. Sodium 4-5g7. Calcium 0.1-0.3g8. Magnesium 0.1-0.2g9. Iodine 50-250mcg10. Arsenic 50mcg11. Lead 50mcg Study on the effect of Eladi Quath in the management of Mutrasmari 33
  • Review of the Disease REVIEW OF THE DISEASEUROLITHIASIS Urolithiasis or formation of urinary calculi at any level of the urinarytract is a common condition. Urinary calculi are worldwide in distributionbut are particularly common in some geographic locales such as in parts ofthe united states, South Africa, India and South East Asia, It is estimatedthat approximately 2% of the population experiences stone disease at sometime in their life with male female ratio 3:1, in their 2nd and 3rd decades oflife.CONCEPT OF ASMARI IN AYURVEDA The word “Asmari” means “stone”. In ayurveda the word Asmari is mainly usedfor Urinary calculi and can be considered as “Mutrasmari”(Urolithiasis). There is distributed description of Mutra rogas in our classics.Vagbhataclassified these entities in Mutraghata nidana adhyaya into two groups76. a) Mutra atipravritti janya vikra – prameha and its types b) Mutra apravritti janya vikaras i) Mutra krichra ii) Mutra ghata Mutra atipravrittija rogas mainly features poly-urea and prameha being theclassical example, Apravrittijanya rogas include Mutra ghata, Mutrkrichra, Asmariwhich presents with oliguria and dysuria . Mutrasmari comes under Mutrakrichra according to susrutha77. Mutrasmari comes under Mutra ghata according to vagbhata.78 The symptoms of mutrasmari like excruciating pain over nabhi, vasti, or atsevani, medra during micturition, sudden stoppage of urine flow, blood stained urine,twisting and slitting of urine, aggravation of pain during running ,jolting etc., go on in Study on the effect of Eladi Quath in the management of Mutrasmari 34
  • Review of the Diseaseaccordance with symptoms of urolithiasis of modern science. Hence urolithiasis canbe co-related with the mutrasmari mentioned in ayurveda. UTPATTI AND NIRUKTI1. Uthpatti: Asmari : Asmann am Raati Dadati Ya79 ; Asam + Raa+ka+Gavraditwal+nip1) The word Asmari is derived from the root word ‘Asman’ Ra is suffixed by ka and Gavradiwal nip2) Here ‘Raati’ means ready or favourable or to give. The disease that involves the formation of stone is called as ‘Asmari’3) Asma – ‘Arman’ means a stone2. Nirukti: “Asmarateeti Asmari” Which has got stone like structure is called as Armari – Dalhana CommentaryAsmari is the stone formed in the srotas/channels especially the mutramarga 80 The meaning of ‘Asma’ as in Amarakosa is stone and the term ‘Asmari’ isconsidered as disease with the presence of stone. Study on the effect of Eladi Quath in the management of Mutrasmari 35
  • Review of the Disease NIDANA Coming to Dashavidha Pariksha like Prkruthitaha, Vikruthitaha, etc., we canconsider the etiology of the diseases in many aspects. Asmari is the Tridoshaja Vyadhibut predominant with vata and kapha doshas, thus the person with prakruthi ofpredominance with vata and kapha. In vikruthitah we can consider the individualetiological factors which are responsible to aggravate vata and kapha as nidanas, but atthe same time it should be clear that the disease is tridoshaja vyadhi and thus casativefactors must be effecting all the tridoshas simultaneously along with dushana of themutra. These can be classified under sannikrusta and viprakrusta karanas:Sannikrusta Karanas : 1). Different causes for Mutrakricchra as per charaka. a) Teekshna Oushada sevana b) Ruksha madhyapana. c) Anupa matsyasevana. d) Adhyasana. e) Ajeerna bhojana. f) Ati vyayama. g) Aswa asana.81 2) Apathya sevana and Divaswapna82. 3) Pitara matara dosha, according to Haritha83.Viprakrusta Karanas :It includes the etiological factors capable of aggravating individual doshas such as, 1) Madhura, Seetha, Snigdha, Guru, Mandaahara. Divaswapna for kapha. 2) Ruksha, Laghu, Seetha, Aahara for vata84. 3) Teekshna, Ushna, Laghu Aahara for Pitta. 4) Desa. 5) Prakruthi. 6) Asama sodhana seelasya as per susrutha85. 7) Mutravegadharana86. Study on the effect of Eladi Quath in the management of Mutrasmari 36
  • Review of the Disease Thus all the Nidana can be brought in to these headings, but kapha isascertained to be the prime dosha which can be told as Arambaka karana or Upadanakarana for all the Asmaris except Sukrasmari. In Sukrasmari sukra it self is told asUpadana karana87. Regarding Pitruja and Matruja doshas, it can be explained in terms of reasons forkhavygunyatha for the formation and development of the stone. Thus the knowledgeof congenital cause in the disease was being well understood in a better way whichshows the depth of knowledge of our great ancient acharyas. In the above context Asamasodhanaseelasya is used which can be taken in twoways they are:• Improper Purifactory methods which result in the excessive accumulation of kapha in vasti and has the influence on vata due to heenayoga, ayoga, mithyayoga and atiyoga.• Not at all performing sodhana therapy even though being advised which lead to aggravation of doshas. Summing up the Nidanas explained: 1) Haritha - Pitru Matruja doshas. 2) Vagbhata - Mutravegadharana. 3) Susrutha - Asmasodhaseelasya and apatyakaranas. 4) Charaka individual causative factors for aggravating dhosas. Nidana for Mutrakricchra have to be considered as Nidana even for Asmari roga astold by Vijaya Rakshita and other Acharayas.Jotishya (Horoscope):- Accroding to Jotishya sastra, if Mercury (Budha) situated in the house of Jupiter(Guru) and in addition is vitiated by Sun, i.e. Ravi, the person suffers from Asmari,Mutraghata, and Prameha of various types88. Study on the effect of Eladi Quath in the management of Mutrasmari 37
  • Review of the Disease ETIOLOGY Causes of renal stone formation is not yet fully understood but in the majority ofcases multiple factors are involved. The important factors which influence theformation and growth of urolith are as follows. However the epidemiological factorsalso play an important role in formation of urolith along these etiological factors.Causes of urolith may be metabolic abnormalities, anatomical abnormalities infectionand may be dietetic factors. To understand the etiology of the urolith various theorieshave been put forth, such causes are summarized below under various headings.A) HYPERSECRETION OF RELATIVELY INSOLUBLE URINARYCONSTITUENTS:Oxalate: 70% of renal stones. Cabbage, Rhubarb, Spinach, Tomatoes, Black tea and Coca Contain largeamount of oxalate, ingestion of ascorbic acid and orange juice cause more oxalateexcretion. A) Primary hyper oxaluria, a genetic disorders affecting metabolism of glyolic acid, which forms oxalate rather than other soluble end products due to deficiency of enzymes ,Type I ketoglutarate glyoxylate carboligiase and Type II glyceric dehydrogenase, important cause for nephrolithiasis in children. B) Secondary or acquired hyper oxyluria forms include pyridoxine deficiency, ethylene glycol poisoning, small bowel disease with hyper absorption of dietary oxalate and methoxyflurane anesthesia.Calcium: 1) Hyper calciuric - (>200 mg/24h:>4 mg/ kg/24 h) can be caused by absorptive,resorptive and renal disorders a) Absorptive hyper calcuria: Secondary to increased absorption of calcium at thelevel of small bowel, predominantly in jejunum can be further sub divided into I, II andIII Types. Study on the effect of Eladi Quath in the management of Mutrasmari 38
  • Review of the DiseaseType I: It is independent of calcium intake, there is increased Urinary calcim on a regular or calcium restricted diet .Type II: Absorptive hyper calciuria is diet dependent. Decrease of calcium intake by 50% will decrease the hypercalciuria to normal .Type III: Secondary to renal phosphate leak. This results in increased vitamin ‘D’ synthesis and secondarily increased small bowel absorption of calcium. b) Resorptive hyper calcuria: Secondary to hyperparathyroidism, Hyper calcemia, hypo phostamia, hyper calciuria and elevated pH vlue are found. c) Renal hypercalcuria: Occurs when the renal tubules are unable to efficiently reabsorb filtered calcim and hyper calciuria results.2) Hyperuricosuric calcium: Secondary to dietary excess or uricacid metabolismdefects.3) Hyperoxaluric calcium: Usually due to primary intestinal disorders. History ofchronic diarrhea, inflammatory bowel disease or steatorrhoea. Increased bowel fatcombines with intraluminal calcium to form soap like product. Calcium is thereforeunavailable to bind to oxalate, which is freely and rapidly absorbed. A small increasein oxlate absorption will significantly increase stone formation.4) Hypocitraturic calcium: Secondary to chronic diarrhea, Type I renal tubularacidosis, chronic hydrochlorothiazide treatment or in rare cases idiopathic (Citrateappears to bind calcium in solution, thereby decreasing available calcium for stoneformation.Uric acid: Gout, after chemotherapy, dehydration, idiopathic hyper uricorsuria with or without hyper uricamia (eg Primary or secondary Gout), myeloproliferative disordersmalignancy with increased uric acid production, abrupt and dramatic weight loss anduricosuric medications.Cystine: Genetically determined defect in cystime transport. Study on the effect of Eladi Quath in the management of Mutrasmari 39
  • Review of the DiseaseDrug induced: In rare cases the long term use of magnesium trisilicate in the treatment ofpeptic ulcer has produced radio opaque silicon stones.B) PHYSICAL CHANGES IN URINE: 1) Urinary pH: The mean urinary pH is 5.85. if urine is infected by urea splittingbacteria e.g., proteus mirabilis it makes the urine strongly alkaline by liberatingammonia. The in inorganic salts calcium phosphate and magnesium ammoniumphosphate stones (Triplephosphate) are insoluble and form urinary stones. Uric acidstone forms in consistently low urinary pH. 2) Colloid content: Colloids in urine allow the crystalloids to be held insupersaturated state. But the importance of this has been questioned recently. 3) Decreased concentration of crystalloids: Due to low fluid intake excessivewater loss in febrile disease, hot climates, excessive perspiration, vomiting, diarrhea. 4) Urinary magnesium/calcium ratio: This ratio influence the stone formation.Acetazanamide cause hyper calcuria and decrease in ratio and thiazides, preventsrecurrence of stone formation, increase this ratio.C) ALTERED URINARY CRYSTALLOIDS AND COLLOIDS Crystalloids – oxalates, calcium, cystine, uric acid. Colloids – Mucin, chrodraiolin sulphuric acid.a) When there is an increase in crystalloid level and fall in colloid level urinary stones may be formed.b) If there is any modification of the colloids e.g., they lose their solvent action and adhesive property urinary stone may develop.D) DECREASED OUT PUT OF CITRATE: Presence of citrate in urine keeps relatively insoluble calcium phosphate andcarbonate in solution. Study on the effect of Eladi Quath in the management of Mutrasmari 40
  • Review of the DiseaseE) VITAMIN DEFICIENCY: Deficiency of vitamin A causes desquamation of the epithelium. The desquamated cells form nidus for stone formation; this is more applicable in bladder stones.F) URINARY INFECTIONS: Association of stone with infection is very intimate. Infection disturbs colloid content of urine, also causes abnormality in the colloids which may cause the crystalloid to be precipitated changes urinary pH and also increases crystalloid concentration, all these factors may influence stone formationG) URINARY STASIS: Stones are more prone to occur when there is obstruction to free passage of urine. a) Urinary stasis provides a fertile field for bacterial growth. b) Shifts the pH to alkaline side. c) Predisposes urinary infection. d) Allows crystalloids to precipitate.H) NIDUS OR NUCLEATION OF STONE FORMATION: Salt added to water continues to dissolve until no more will do so, this is thesaturation concentration, which is measured by the solubility product of theconcentration of ions making up the salt. In urine a metastable solution forms which does not precipitate crystals, eventhrough the saturation concentration has been exceeded, unless the solution is leftundisturbed for a long time. If the concentration exceeds that of the metastable regioncrystals precipitate to make their own nuclei-nucleation. The metastable state isinfluenced by temperature, presence of colloids, rate off flow of urine, theconcentration of the solutes and the presence of any thing which can act as a nucleus,e.g., dead papillae, necrotic carcinoma, non-absorbable suture, a fragment of catheter,or a previously existing fragment of stone. Study on the effect of Eladi Quath in the management of Mutrasmari 41
  • Review of the Disease INTERPRETATION OF MUTRASMARI NIDANATeekshna Oushada sevana is mentioned as the causative factor of mutrasmari.This would cause some local erosion and inflammation to the intestinal mucosaresulting in impairment of water absorption (inhibition of ion absorption) leading toless urine formation and increased concentration of urine ultimately leading to thecalculi formation.Ruksha Madhya sevana may cause altered Osmosis and finally leads to the lessurine formation.Anupa matsya sevana -SeaFood- Fish, Herring, Fish rhoe, Lobster, Crab, Prawns,Shrumps, Sardines etc. have high protein content and might increase the load on thekidney. Fish rhoe, Herring fish have high contents of Uricacid.Ajeerna bhojana also alter the absorption at the level of intestines ex:-Hyperuricosuric calcium, secondary to dietary excess.Athivyayama, Aswagaja asana are the activities of the body leading to highperspiration from the body ultimately leading to less urine formation.Apathya sevana, diet having more oxalates (e.g., Cabbage, rhubarb, spinach, coca,black tea), uric acid and calcium containing foods etc., if consumed more than therequirement of the body. There is no specific mentionof particularly the above mentioned diet in our classics. Even the modern medicalfield has not well established the role of diet in the formation of stone; they justsimply recommend to avoid this diet as they have rich oxalates, uric acid andcalcium according to the type of stone.Pitara and Matara dosha, according to Haritha can be compared with hereditary andgenetic factors. E.g., Primary Hyper Oxaluria, a genetic disorder, a defect inmetobolism of Glyolic acid, which form oxalate rather than other soluble endproducts due to deficiency of enzymes Type I Ketogluturic GlyoxylateCarboxyliase and Type II Glyaric dehydrogenase, important cause fornephrolithiasis in children. Geneticallydetermined defect in cystine transport.Desa, it is mentioned that persons living in Anupa desa are more prone tomutrasmari than any other desa may be because of the high humidity in theStudy on the effect of Eladi Quath in the management of Mutrasmari 42
  • Review of the Diseaseatmosphere leading to high perspiration of the body, high water loss and less urineformation ( more saturated urine).Asama sodhana seelasya means improper cleansing procedures. Athiyoga causedehydration and high concentrated urine formation. Ayoga and Mityayoga, causealtered osmolarity and defective absorption leading to mutrasmari.Not at all performing sodhana may lead to accumulation of doshas.Mutravegadharana leads to urinary stasis, stones are more prone to occur whenthere is obstruction to free flow of urine. Providefertile field for bacterial growth, shifts pH to alkaline, predisposes urinary infection,allows crystalloids to precipitate.Study on the effect of Eladi Quath in the management of Mutrasmari 43
  • Review of the Disease PURVARUPA Purvarupa are the pre monitoring signs and symptoms which appear in the stage ofdoshadushya sammurchana and sthana samshrayaavastha they suggest the probabledisease of the future. They differ from the stage of manifestation of the disease beingeither feeble or unclear in their manifestation.In purvarupa avastha of Asmari, according to Susrutha and Vagbhata, are :- Jwara, Vastipeeda, Arochaka, Mutrakricchra,Vedana in Vastishira, Mushkasepha, Krichravasada, bastagandhatwa( Mutra smells like goat)98. Adhmana in vasti and vedana in vasti pradesa, bastagandhatwa, Mutrakrichra,Jwara and aruchi99.Susrutha VagbhataJwara JwaraVastipeeda Adhmana in VastiArochaka ArochakaVedana in Vastisirah Mushka Sepha Vedana in Vasti pradesaMutrakrichra MutrakrichraBasta gandha Mutrata Basta gandha Mutrata Study on the effect of Eladi Quath in the management of Mutrasmari 44
  • Review of the Disease RUPA Rupa (Lakshanas) are the signs and symptoms presented at the actual stage ofmanifestation of the disease. These are presented particularly in vyakthavastha. The lakshanas may differ or show the combined symptoms as the diseaseprogresses. It is not necessary that all the lakshanas must be present in a particulartype of Mutrasmari as it may differ according to the dosha involved. These lakshanas as per our classical text books are mentioned as samanyalakshanas and vishistha lakshanas.Samanyalskshanas: _ Mehathivedana _ Sarudhiramutrata _ Pain in nadbhipradesa,vasti pradesa, sevani pradesa mehana Pradesa and even in other regions. (anythasmin ruk). _ Mutradharasanga _ Mutravikirana As explained in Sushruta Samhita100Table no.6 showing symptoms /rupa in mutrasmari according to different authors: Rupa Su.S Ch.S A.H 1. Nabhivasti sevani mehesh wanyata + + + masmin mehate vedana 2. Mutra dharasangam + + + 3. Sarudhiramutrata + + + 4. Mutravikirana + + + 5. Gomedhuka prakasamatyavilam + _ + 6. Sasikata + _ + 7. Muhussaskrin munchati mehatacha _ + _ 8. Mrudnati medram satu vedanarta _ _ + All these symptoms may increase on riding, fasting, swimming, taking longjourney on camel or horse or by any means. According to Vagbhata andBhavamishra.the person passes urine of colour resembling gomedhaka or reddish.Even according to Charaka, the person may pass blood mixed urine. Study on the effect of Eladi Quath in the management of Mutrasmari 45
  • Review of the Disease CLINICAL FEATURES Clinical features vary depending upon the site of the calculi. An urinarycalculus usually announces it presence with an acute episode of renal or ureteral colic.I. Renal Stone:A) Symptoms : Symptom wise cases can be divided into 4 groups. 1)Quesent Calculus: A few stones particularly the phosphate stones may liedormant for quite a long period. During this time stones gradually increase in size withdestruction of renal parenchyma. Such stones may be discovered accidentally in X-rayperformed for some other reasons or is first revealed with renal failure and uraemia.Sometimes such stones are also discovered due to symptoms of urinary infection. When the stone is still in the submucosal stage or adherent to parenchyma, itmay be symptomless. Even staghorn calculus may be asymptotic. Vaguegastrointestinal symptoms which stimulate the peptic ulcer or gall bladder disease orenteric syndrome may be found in few cases. 2) Pain : Pain is the leading symptom of renal calculus in majority of the cases(80%). These types of pain are usually noticed viz., fixed renal pain, ureteric colic, andreferred pain, of which last is very rare. a) Fixed renal pain: if the stone is free obstructs a calyx or uretero –pelvic junction. There will be dull flank pain due to capsular and parenchymal distension. Dull aching, a boring type of pain is also experienced in case of big phosphate calculus. The pain is situated in the renal posteriorly and in corresponding hypochondrium anteriorly. The pain characteristically gets worse on movement. b) Ureteric colic: This occurs when stone attempts to pass down the ureter or temporarily blocks the pelvi ureteric junction. It is an agonizing pain which radiates from loin to groin. The pain comes on suddenly during which the patient rolls about drawing up his knees towards the chest, tossing on the bed in agony. This colic is often accompanied by the profuse sweating, nausea and vomiting. The pulse quickness and temperature goes down below normal. The typical radiation of colicky pain is due to the iliohypogastric and ilioiguinal Study on the effect of Eladi Quath in the management of Mutrasmari 46
  • Review of the Disease nerves, which are the somatic nerves of the same segments, that supply the autonomic nervous system to the ureter (T11, T12, L1 ). Sometimes the pain is referred to the scrotum or labium majora or to the inner side of the thigh along the distribution of the genitofemoral nerve, when the stone is in the lower part of the ureter. When the stone in the intramural part of the ureter ‘Stranguary’ may occur. c) Referred pain: This is quite rare and is sometimes referred to all over the abdomen. Such pain may simulate peptic ulcer or gall bladder disease. Sometimes pain may be referred to the opposite kidney, which is known as renorenal reflex. 3) Hydronephrosis: Occasionally haematuria is the leading and only symptom.Haematuria usually occurs in small amount, to make the urine dirty or smoky during orafter an attack of pain. Infection of the kidney may occur due to stone which isrelatively symptomless. Patient represents with pus in the urine in varying amounts oropalescent urine.B) Physical Signs: in majority of cases characteristic physical signs are not present.The signs which may be present and should be looked for are; a) Tenderness: this is mostly present at the renal angle posteriorly. Tenderness is a more constant feature, when renal calculus is associated with infection. b) Muscles rigidity: this may be found over the kidney in a few cases. Rebound tenderness anteriorly can also be elicited particularly, if acute infection is associated with. c) Swelling: when there is hydronephrosis, Pyelonepl;hrosis with renal calculus then swelling may be felt in the flank. The characteristic features of renal swelling are: a) It is oval or reniform in shape. b) The swelling is almost fixed and cannot be moved as it is a retroperitonial swelling. c) A kidney lump is ballatable sometimes. d) The swellings slightly moves up and down with respiration. But much less than a liver swelling. Study on the effect of Eladi Quath in the management of Mutrasmari 47
  • Review of the Disease e) Fingers can be insinuated between the lump and costal margin. f) A band of resonance can be elicited anteriorly on percussion due to presence of colon, duodenum and coil of small intestine, in-front of the kidney according to the side. g) Abdominal distension: Distension of abdomen and visible peristalsis mayaccompany ureteric colic.II . Ureteral stonesA) Symptoms: 1. Pain: there are two types of Pain. a) Ureteric colic: When a stone enters the ureter and descends along it there is an attack of ureteric colic to hyper peristalsis of smooth muscles of the ureter, pelvis and calyces. The pain starts abruptly becomes severe within minutes. It repeats at longer or shorter intervals till the stone is ejected into the bladder or becomes impacted in the ureter. This colic becomes severe when the stone becomes arrested at the anatomical narrowings of the ureter. In case of ureteric colic there is radiation of pain, the position of which suggests the position of arrested stone in the ureter. When the stone is arrested high in the ureter the pain passes from loin to groin along the distribution of the iliohypogastric and ilioinguinal nerves. When the calculus is in the lower- third of the ureter, colic starts at a lower level and radiates to the testicles in the male, labium majora in the female and to the medial aspect of thigh, as the pain is referred along the two branches of the genitofemoral nerve. b) Ceasation of pain: when stone enters to the intramural part of the ureter the pain is referred to the penis in the male and stranguary in both sexes. c) Fixed pain: when ureteric calculus gets impacted ureteric colic passes off and replaced by a dull ache. The position of this dull ache depends upon the position of impaction of the ureteric caculus. Such pain is due to capsule tension and distention of the renal pelvis. This pain gets aggravated by exercise, movement, and is relieved by rest. This pain also varies in intensity. The ureteric stone often gets impacted in the pelvic part of the ureter and at that time dull ache is complained off at the iliac fossa. Study on the effect of Eladi Quath in the management of Mutrasmari 48
  • Review of the Disease 2. Heamaturia: some amount of heamaturia may be present, usually occursafter an attack of ureteric colic. It may last for a few hours to a day. At times it is soslight that it requires microscopic identification, but in 1/3rd of cases gross heamaturiais observed, even small clots may be passed. 3. Even in the absence of infection symptoms of urgency and frequency ofmicturition may be complained of when the stone is very near the bladder. 4. Gastrointestinal symptoms are sometimes associated with ureteric stone.Nausea/vomiting are often complained of. Abdominal distension due to paralytic ileusmay also be present. These symptoms may sometimes over shadow the renal andureteric pain. This may mimic intraperitoneal pathologies like peptic ulcer, urolithiasisor acute appendicitis.B) Physical Signs: The patient usually tosses on the bed as if nothing affords him relief. 1. The skin is cold and clammy and there may be other signs of mild shock. 2. Muscular rigidity due to spasm of abdominal muscles is felt at the region of tenderness. 3. Tenderness is marked over the part of the ureter where the ureteric calculus lies. This often gives difficulty in differentiating this condition from acute appendicitis when the right ureter is involved. 4. When the stone is in the lower end of the ureter, it may be felt by rectal or vaginal examination. 5. Percussion on renal angle posteriorly gives rise to pain with marked ternderness. 6. The abdomen may be distended and quiet on auscultation (Bowel sounds less prominent). 7. The corresponding scrotal skin may be hyperaesthetic if the stone lies in the lower part of the ureter. Study on the effect of Eladi Quath in the management of Mutrasmari 49
  • Review of the DiseaseIII. Vesical stones:A) Symptoms: 1. Increased frequency 2. Pain and discomfort at the end of micturition. 3. Heamaturia – Terminal heamaturia 4. Dysuria 5. Acute retention of urine.B) Signs : Only gaint calculi can be felt suprapubically.The bladder may be visiblepalpable or percussable. Rectal examination may demonstrate a refluxed analsphincter, enlarged or hard prostate and cystocoel may be noted.IV. Urethral calculiA) Symptoms: While urinating the patient with urethral calculus may experience a suddenstoppage and thereby unable to empty the bladder. Dribbling also occurs. Pain due to the stone in urethra may be rather severe and may radiate to thehead of the penis. When the calculus is lodged in the anterior urethra the pain may belocalized at the site of impaction and the patient will be aware of palpable mass.In females: The symptoms of urethral diverticulum with or without calculus are those ofinfection of lower urinaryh tract including frequency, dysuria, nocturia, pyuria, and inrare instances haematura, pain during coitus is a prominent symptom, occasionaldischarge of pus may occurV. Prostate and seminalvesicle calculiSymptoms: In many cases it is asymptomatic 1. Dull aching pain in the lower back, perineum and penis. 2. Difficulty in voiding, lack of force of stream and dribbling will occur. 3. Incase of seminal vesicle calculus symptoms are haematospermia, painful erections and perineal discomfort at the time of ejaculatuion. Study on the effect of Eladi Quath in the management of Mutrasmari 50
  • Review of the DiseaseVI. Preputial calculi Symptoms are those of Balanoprosthitis. A discharge from small opeing in theforeskin, oedema and later stages ulceration may present. Carcinomas also coexistwhen the calculus has been present for a long time.Complications:Renal Calculus: The size and position of the stone usually govern the development of secondarypathologic changes in the urinary tract.A.Same kidney 1.Obstruction: Partial obstruction leads to hydronephrosis. Complet obstruction leads to destruction of kidney. 2.Infection: Infection leadsto pyelitis,pyeloneplhritis,perinephricabscess etc. 3. Epithelium of the pelvis and calyces in relation to the stone gradually loses luster, become rough an d thickened. Parenchymal ischaemia may be caused by local pressure due to stone. 4. Sometimes due to presence of a stone in the lining epithelium of the renal pelvis it may undergo metaplasia which may initiate to malignancy of epidermoid nature (Epithelioma).B.Opposite Kidney: 1. Compensatory hypertrophy 2. Stone formation may be bilateral 3. Infection 4. calculus anuriaUreteral Stones: 1. Obstruction 3. Ulceration 2. Impaction 4. Diverticulum in the wall of the ureter Study on the effect of Eladi Quath in the management of Mutrasmari 51
  • Review of the DiseaseINTER PRETATION OF PURVARUPA AND RUPA OF MUTRASMARI The symptoms and signs which were explained by our Acharyas are similar to thatof explanation in ancient text books. If we go through purvarupa of mutrasmariVasthi peeda – pain in the urinary system(kidneys, ureter, bladder, urethra etc.)Mutrakrichra – burning micturition or dysuria, is a symptom of any infection in theurine. Predisposing cause to calculi formulation later on.Vasthisirah, Mushka, Sepha vedana – this is the order of the organs where radiatingpain starts and ends (loin to groin). Here vasthisirah means kidney.Bastagandha Mutrata – urine smells like goat, due to presence of dirty foulingconstituents in urine like pus cells, epithelial cells etc. due to infection.Jwara, Aruchi – urinary tract infections cause raise in temperature. Alkali urine, apredisposing factor for magnesium ammonium phosphate calculi. Rupa is considered as signs and symptoms of modern science. Symptomsexplained in mutrasmari by Acharyas are similar to that of urolithiasis.Muthradhara sangam – obstruction of urine flow by calculi in the urinary tract, maylead to hydronephrosis.Sarudhira Muthrata - compared with haematuria, when the spiky calculi is impactedin the tract and damage surrounding tissue causes bleeding, urine comes out mixedwith blood mainly seen in calcium oxalate crystals.Mutravikirana – dribbling of urine due to obstruction by gravels at the level ofurethra. Study on the effect of Eladi Quath in the management of Mutrasmari 52
  • Review of the DiseaseGomedhuka Prakasamatyavilam – urine is passed in light brown colour due toconcentration and mixture of red blood cells.Sasikata – gravels which break into small fragments coming out as in spermolith(sukrasmari) which are very delicate and break up easily by little pressure.Nabhi vasthi sevani anyatha masmin mehate vedana – generalized explanationabout areas of pain through out the urinary tract and their related areas. It can berelated with pain at the flank in renal calculi pain radiating from loin to groin as inuretric colic, pain radiating testicles in males and labia majora in females and to medialaspect of the thigh Even though Acharyas have explained so well in detail, the clinical manifestationof the disease mutrasmari, it is much generalized. They have not explained specificsymptoms in accordance with the site of calculi separately for renal, ureteric vesicularetc. Study on the effect of Eladi Quath in the management of Mutrasmari 53
  • Review of the Disease SAMPRAPTHI In case of the disease Mutrasmari elaborate explanation of the pathogenesis havebeen explained by Acharya Susrutha, Charaka and Vagbhata with similes. Theconcept is enriched by contribution of later coming authors like Bhavamisra,Sarangadhara and other commentators. To emphasize on the same as susrutha hasexplained Mutrasmari samprapthi in two concepts while charaka’s explanation differslightly with the opinion what Susrutha had. In one instance that is in Susrutha nidanathird chapter, he says the Kaphadosha gets aggravated due to the indulgence inKaphaja ahara and vihara. This aggravated kaphadosha comes to vasti along withmutra and result in the formation of mutraasmari. While same Susrutha in the other context of the same chapter explained in anelaborate form. It is described that as the mutra enter the vasti, thridoshas alsoaccompany it by the process of upasnehana89. After entering the vasti these doshascollectively result in the formation of asmari. This is characterized by the predominantdosha and thus possess the respective qualities. The opinion of Dalhana who is the commentator for Susrutha samhitha is that theprocess of upasneha is facilitated buy sameepakleda. Gayadasa, the othercommentator of Susrutha samhitha emphasis the role of each individual dosha in theformation of asmari. According to him kapha is considered as to be the predominantdosha since it is the upadanakarana or the material cause for asmari. Pitta isresponsible for its ghanathva or solidification, and vata is responsible for shoshana.The mass that is formed is again encoated by the vitiated doshas and further hardenedby vata90. Charaka samhitha also describes the similar samprapthi and explains that eventhough it is described to be a tridoshaja disorder the role of kapha as the material causeis of prime importance. This is also highlighted by the commentator Chakrapani. Therole of doshas specific to different varieties of asmari is also emphasized dependingupon the vitiated or responsible dosha. The formed asmari posess the similar nature.Thus mutraasmaris formed are of 4 types vatajaasmari, Pittajasmari, Sleshmasmari andSukrasmari91. Study on the effect of Eladi Quath in the management of Mutrasmari 54
  • Review of the Disease In vatasmari, vata is predominant dosha which is responsible for the ultimateformation of asmari by the virtue of its shoshana property (ruksha guna), where as inpitta asmari pitta plays the key role for the integration by the virtue to its ushnatha92 .Similarly in the sukrasmari it is with other dosha and sukra itself produces the asmariby the virtue of its snighdatha. Astanga Hridayakara,Vagbhata also has the same opinion in regard with theformation of asmari, he reciprokes the version of Charaka samhitha in different terms. The process of formation is better understood by the similes given by our greatAcharyas. Acharya Sushratha says ,As even clean water in a new pitcher ,gets muddyin due coarse of time in asimilar way calculi are formed.As air and fire of electricity inthe sky cosolidate water (to form hail stone),similarly pitta located in the bladder inconjunction with vayu consolidates kapha (to form calculi)93. The same is alsomentioned in the Astanga sangraha in different version ie kapha situated in the basthi isconsolidated by ushma of pitha and dried by the action of vata in the same way as thejalaamsa of the environment is dried away by heat and air inspite of its invisibility94. Charaka on the other hand explains the similar samprathi by quoting anothersimile. He writes that the formation of mutrasmari is similar to the formation ofgorochana by the gopitha95. After referring and going through all the available description of our Ayurvedicliteratures like the samhithas, commentaries and different opinions of well knownscholars it is possible to draw a clear picture of samprapthi in an uncomplicatedmanner for better and easy understanding. Here all scattered information are broughttogether to make a single picture. It is a known fact that all Acharyas have the same opinion in the doshasinvolved in the pathogenesis of asmari. i.e., the tridoshas. These tridosha gets vitiatedby their respective nidanas and then enter the vasti by the principles to upasneha vidhialong with mutra96. After getting lodged, it is in the basti where thedoshadushya sammurchana occurs. Thus vasti acts as an asaya for the dosha anddushya for a disease to manifest. The stage of sthanasamsraya is predisposed by khavaiguyatha of basthi probablybecause of hereditary cause as explained in terms of mathru pithruja beejadosha or dueto the srothovikara. Study on the effect of Eladi Quath in the management of Mutrasmari 55
  • Review of the Disease Thus the gradual deposition of the asmari forming components lead to the gradualformation and development of the stone. In the initial state despite of the predominantdosha, kapha plays the first role. Thus it is termed as the upadhanakarana inmutrasmari97. It initiates the formation of asmari by consolidation of the mutra fromits physical qualities like kleda and snigdha guna, later pitha produces the ghanathavaor the compactness by its ushnaguna ultimately apanavata dries the formed material byits rookshaguna. It also hardens the mass resulting in the formation of asmari. It can be concluded that kapha & Vata are given more importance in the processof pathogenesis which is evident by the fact that the nidana factor explained inmutrakricchra & mutragatha support the statement. Mutrasmari is a disease in which there is kostagnimandhya. As the kapha is theprimary dosha, the vitiation of kapha impairs the first stage of ahara paka. This impactis carried on to the further stages of digestion, ultimately resulting in jataragnimandhyaand the formation of ama. Regarding the udbhava sthana of the disease asmari it can be speculated that itoriginates from amapakvashaya as it is kaphavata predominant disorder. The sancharasthana of the disease can be considered as adhogami dhamanis, particularly mutravahadhamanis. The adhistana of asmari is undoubtly the vasti. The discription regarding theformation of asmari available in Susrutha samhitha is highly suggestive of bladdercalculi. However it is evident that asmari can occur in any part of the urinary system,but its formation in other parts of the system other than Vasti not separately describedin any Ayurvedic literatures. Hence it is convenient and logical to consider that theterm basthi mentioned here refers to the urinary system as discussed earlier.Bhedas:- Asmari is 4 types: 1) Vataja Asmari 3) Kaphaja asmari 2) Pittaja Asmari 4) Sukra asmari Study on the effect of Eladi Quath in the management of Mutrasmari 56
  • Review of the Disease Samprapti ghatakas Dosha Tridosha Dushya Mutra Agni Jataragnimandya Ama Jataragnimandyajanya ama Srotas Mutravaha srotas Udbhava sthana Amaasaya and pakavasaya Sanchara sthana Siras. Adhstana Mutravaha srotas and vasti Vyaktha sthana Mutravaha srotas and vasti Dustiprakara Sanga Rogamarga Madhyama Vyadhi swabhava Chirakari Sadhyaasadhyata Dusthara, Shasthrasadhya.Study on the effect of Eladi Quath in the management of Mutrasmari 57
  • Review of the Disease PATHOLOGY Among the various causes mentioned earlier any of he etiological factors mayprovoke the formation of urinary stones. So, next question arises, how the inductiondoes and growth of stones occur in the urinary stones. To understand this concept orpathology, various theories are mentioned here.Different stages of stones are as follows: 1. Saturation 2. Super saturation 3. Crystal nucleus 4. Crystal growth 5. Crystal aggregation 6. Epitaxy.Saturation: If increasing amount of substances capable of crystallizing are added to purewater, at certain pH and temperature, eventually a high enough concentration reachedfor crystals to form. When crystals begin to form, we say that the solution has becomesaturated with the substances. There is a specific limit to amount of solids that can behold in solution. When this limit is exceeded crystals must form crystallization of asingle substance, such as cystine and uric acid will occur, when enough of substance isadded to water at given ph and temperature to saturate the solution. When two or moresubstances are combined to form crystal as is the case of table salt (sodium chloride) orcalcium oxalate, the level of saturation is governed by byproduct of concentrations oftwo(or more) substances. The point at which the saturation is reached andcrystallization begins is referred to as solubility product .It is defined as “the product ofmolar concentration of the two substances at the point, at which ht saturation isreached”. Note that pH and temperature are always specified for any crystallizationprocess. Since urine varies widely in pH, this factor must be considered in allexplanation of urolithiasis. Saturation and solubility product are easy to define in water, but urine is a muchmore complex solution. In urine, concentration of a substance reaches when the pointat which saturation would occur water, crystallization does not occur as expected.Urine has the ability to hold more solute in solute than pure water. Although all Study on the effect of Eladi Quath in the management of Mutrasmari 58
  • Review of the Diseaseelements and molecules in urine are suspended in water, the mixture of manyelectrically active ions in urine causes interaction, that change the solubility of theirelements. Such a solution is called pyloric and the definition of saturation or solubilityproduct. Of a given substance in this type of solution becomes very complex anddifficult. In addition many organic chemicals and molecules such as urea, uric acid,citrate and the complex mucoprotiens of the urine all mutually effect the solubility ofother substances. For example, citrate is known to combine with calcium to form asoluble complex. It therefore prevents some calcium from combining with oxalate orphosphate and becoming crystalline. Many researchers have reported that deficiencyin urinary citrate is one of many factors found in urine of stone former.Electrical attraction or repulsion of ions in biologic solutions is also involved in thestone forming crystallization process. Electrical fields of urine like solutions and theeffects of various additives on the electrical attraction of urinary substances. This typeof biologic electrical activity is called “Zeta Potential”. It is however important to stress that the presence of such a large number ofionically active substances does change the solubility of any given element orsubstance in urine.Super Saturation: The most significant and beneficial effect of these ionic and protein elementalinteractions is to increase the solubility of various substances that otherwise mightcrystallize in the concentrations present in urine. Hence if a given amount of calciumand oxalate that would crystallize, when placed in a solution of water at a given PHand temperature is placed in urine, it will be held in solution. If the amount of calciumand oxalate is increased progressively in the same volume of urine, at constant pH andtemperature, the calcium and oxalate will stay in solution even through thesolubility product has exceeded. In doing this we are actually creating super saturationis called the metastable region. The amount of substance in urine can be increased to apoint at which urine will no longer hold it in solution. Then spontaneous nucleation ofcrystals begins. The area of super saturation between the solubility product andspontaneous urinary crystallization is the metastable region of a given substance. The point at which spontaneous nucleation of crystals occurs is known as theformation product of for urine. This means that although urine contains multiple and Study on the effect of Eladi Quath in the management of Mutrasmari 59
  • Review of the Diseasecomplex solubilizing factors for that particular crystal, the amount of substance inurine may eventually become so great that is capable of crystallizing in spite of thesolubilizers and inhibitors that are present.Crystal nucleation: Nucleation of crystals occurs when active ions and molecules in a solution nolonger flow randomly in a completely dissociated fashion but cluster together closelyenough to from the earliest crystal structure that will not dissolve. This structure hasthe form of lattice that is characteristic of that crystal. If this process occursspontaneously in a pure solution, that process is called homogenous nucleation. Butpure solutions are difficult to create. Dust particles, glass chips and other contaminantsmay enter the solution and serve as nuclei. The analogy is that of a chemical catalystother particles that start nucleation catalyze the process. This type of secondarynucleation is probably most likely to occur in urine and is referred to as heterogeneousnucleation. No matter what type of nucleation is probably most likely to occurs, itrequires energy to “push” the crystal nucleus together, the energy required fornucleation is higher than that required for simple crystal growth, and is provided whenthe amount of super saturation is high enough (metastable ) to cause nucleation Thephysical factors that tend to control nucleation are those of interfacial energy, thetemperature and the frequency of collision. Frequency of collision increases as supersaturation increases and therefore, enough energy is ultimately created to allownucleation once satisfactory energy has been achieved nucleation may occur in one ofseveral fashions as noted above.Crystal growth: Once nucleation has occurred in the complete solution known as urine, certainnuclei may continue to grow if the urine remains super saturated. Not only will suchnuclei continue to grow in the zone above the formation product (the zone that permitsspontaneous nucleation) they will continue to grow in the zone above the formationproduct (the zone that permits spontaneous nucleation) they will continue to grow evenif the saturation of urine falls into the metastable zone between solubility product andformation product. The concept of increasing the urine concentration to the level where the formationproduct is exceeded is critical to certain theories of urinary stone formation in which Study on the effect of Eladi Quath in the management of Mutrasmari 60
  • Review of the Diseasehomogeneous nucleation is critical event. In other theories however, saturation isrequired only to the range of metastable super saturation. It is postulated that adequateheterogeneous nuclei are already created by biologic processes in the kidney. These two concepts of nucleation may be further separated into the freeparticles theory and fixed particle theory. In free particle nucleation multiple crystalsare formed simultaneously in the upper urinary system when the formation product ofa substance is exceeded. One concept of free particle nucleation allows for the factthat urine probably contains multiple, previously formed microliths in the kidneypapillae that are subsequently excreted and may then serve as nuclei for other ions. To confirm this theory, however, these particles must float freely in urine and mustserve as nuclei for further growth or aggregation of crystals. In the theory of fixedparticle nucleation, it is suggested that because of excessive concentration of certainions in certain areas of kidney, precipitation of crystals or spherules may occur in therenal papillae either within the tubular lumina or beneath. However these nuclei cangrow and may come close enough to each other to be bounded together by variouschemical forces. Therefore nuclei or larger growing crystals may aggregate to formlarge crystal masses. Should these become large enough to become lodged in agiven position in the urinary tract they may then continue to grow by one of the twoprocess. They may add additional crystals to their surfaces by the process ofaggregation or they may grow by adding new crystal masses to their surfaces. It islikely that both processes are important in the creation of urinary calculi.Epitaxy One other aspect of crystallization that received considerable attention is epitaxy.If crystal has pattern or organization of ions of that is regular and predictable, thisstructure is called a lattice. This surface lattice may resemble very closely to that ofsecond but different types of crystals. Depending upon the closeness of resemblance,the second type of crystal may actually be able to grow upon the surface of the first.For example, let us suppose that urine is super saturated for a period of time with uricacid. For some reason, such dehydration combined with the intake of meal containinga large amount of uric acid, the concentration of uric acid goes up markedly. Theformation product for uric acid is exceeded, and a number of uric acid crystals formby the “free nucleation” process. When these nuclei form they ‘pull’ uric acid out of Study on the effect of Eladi Quath in the management of Mutrasmari 61
  • Review of the Diseasesolution, and the concentration of free uric acid in the urine decreases. Since multiplenuclei of uric acid are already present in the urine, however, calcium oxalate mayactually grow more easily upon the previously formed uric acid crystals calciumoxalate and uric acids do have crystals lattice that are similar to permit this process ofepitaxy or the deposit of one type of crystal upon the surface of another. In fact it isnot unusual to find that urinary calculi have a nucleus of uric acid and a surfacecovering of calcium oxalate. The degree to which epitaxy may be important in theformation of a particular crystal depends upon the relationship between the amount ofsuper saturation for that for the crystal that forms on its surface by epitaxy.Matrix Extensive research showed that matrix as derivative of several of thismucoproteins of urine. Matrix content of a given stone varies but most solid urinarycalculi have a matrix content of about 3 % by weight. Matrix may inhibit crystalgrowth, interfere with crystal aggregation and even enhance stone growth. At thepresent time the uromucoid of normal persons is thought to be beneficial inhibitor ofcrystallization and stone formation. Where as the matrix of stone formers representuromucoid with some qualitative defect that alters its ability to inhibit crystallization oreven causes it to promote stone formation.Lack of Inhibitor Super saturation alone does not completely explain even these three major types ofcalculi and certainly not calcium phosphate or calcium oxalate stone formation. Manynormal persons have urinary super saturation with the substances mentionedpreviously. They will form crystals but the crystals remain small and passed easily.Neither super saturation theory nor inhibitor theory can stand alone. It seemsnecessary to combine both. Robertson and colleague’s study show that for calciumcalculi, an index of super saturation versus inhibition can be determined for anindividual, and that stone formers have higher incidences that is, stone formers showgreater super saturation and less inhibition of crystallization and stone formation.To summarize 1. Renal function must be adequate for the excretion of excess amounts of crystalliziable substances. Study on the effect of Eladi Quath in the management of Mutrasmari 62
  • Review of the Disease2. The kidney must be able to adjust the pH , excretion to confirm to that required to crystallize the substance.3. The Urine must have a complete or relative absence of a number of inhibitors of crystallization of the crystallizable components.4. Crystal mass must reside in the urinary system for a time sufficient to allow growth or aggregation of crystal to a size large enough to obstruct the urinary passage through which it is proceeding.Study on the effect of Eladi Quath in the management of Mutrasmari 63
  • Review of the Disease INTERPRETATION OF SAMPRAPTI Sushrutha has explained samprapthi of mutrasmari at two different instances witha slightly varying concept. 1. In Su.Ni.3, Kapha dosha gets aggravated due to the indulgence of kaphaja ahara and vihara.this comes to vasti along the mutra resulting Mutrasmari.This may be compared with the pathology at the level of pakwasaya, i.e.defective absorption of fluids or hyper absorption of ions at the level of intestines. Deficiency of enzymes,Type I Ketogluturic Glyoxylate Carboxyliase and Type II Glyaric dehydrogenase,affecting metabolism of Glyolic acid forming oxalate, leading to hyper oxyluria. Absorptive Hyper Calcuria,here calcium is more absorbed Hyper uricosuric calcium-dietary excess or uric acid metabolism. 2. Susrutha in same chapter explains the other concept of samprapti for mutrasmari. After entering vasti all the Tridoshas collectively result in formation of Mutrasmari. This is characterized by predominant dosha and thus posses the respective qualities. All this can be compared to the pathology and etiological factors at the level of urinary system i.e. Nephrons and kidneys. High concentrates of urine due to different factors comprising of different doshas reach the urinary system where the crystallization, nucleation, stone formation occurs. High urinary pH Stasis of urine Urinary infections Resorptive hyper calciuria Renal hyper calciuria ( renal tubules are unable to efficiently reabsorb calcium ) Hyper citraturic calcium (citrate appears to bind calcium in solution there by decreasing available calcium for stone formation ) Decreased concentrates of crystalloids Altered urinary magnesium-calcium ratio etc. Study on the effect of Eladi Quath in the management of Mutrasmari 64
  • Review of the Disease Among the various causes mentioned etiological factors may provoke theformation urinary stones. So, next question arises how the induction does and thegrowth of stone occurs. To understand this concept or pathology our Acharyas haveproposed various similes regarding Asmari formation in Vasthi, i.e. urinary system,with, Residue in a long standing earthen pot (susrutha) and formation of Gorochana incow (charaka).By the above similes pathology can be understood in the following way: In urine, a metastable solution form, which does not precipitate crystals eventhough saturation concentration has been exceeded unless solution is left un disturbedfor long time. This is in Prakrutha (normal) condition there is a specific limit to amountof solids that can be hold in solution. When this limit is exceeded crystals must formcrystallization of a single substance, such as cystine and uric acid will occur, whenenough of substance is added to water at given ph and temperature to saturate thesolution. If the concentration exceeds that of the metastable region crystals precipitateto make their own nuclei-nucleation. The metastable state is influenced bytemperature, presence of colloids, rate off flow of urine, the concentration of thesolutes. Vikruthi of thridoshas can be explained in the following way: 1. Temperature – pitta 2. Nucleus (dead papilla, fragments of stones etc.), colloids etc.- kapha 3. Rate of flow of urine, saturation of urine - under the control of vata. May be compared with the above conditions leading to calculi formation. If thisconditions still persists cause saturation, super saturation, crystalisation, crystalgrowth, crystal aggregation etc. finally calculi of many layers is formed. This explanation justify the Charaka’s simile to Gorochana, a final form of calculiand as a residue at the bottom of the earthen pot which is formed by the abovementioned process. Kapha is considered as the pradhana dosha because colloids andcrystalloids ratio and nucleus/ nidus place major role than the otherfactors. Study on the effect of Eladi Quath in the management of Mutrasmari 65
  • Review of the Disease BHEDAS&VISHISTA LAKSHANAS Vishistalakshanas are the signs and symptoms presented by the patient after themanifestation of the complete disease. This is once again characterized by thecharacteristics of the individual dosha. These depend on the nidana factors for which aparticular dosha gets aggravated and leads to that type of mutrasmari.These include. • Vatajasmari Lakshanas • Pittajasmari Lakshanas • Slesmaja asmari Lakshanas & • Sukrajaasmari Lakshanas.Susrutha has explained the lakshanas of different types of Mutra asmari as followsVatajasmari Lakshanas: The clinical symptoms presented by a person who issuffering from vatajasmari will have 101 . • Severe pain during micturition (mutrapratigathath teevravedana). • Clinches his teeth (dantha Khadayathi). • Pain at the umbilical region (nabhim Peedayathi) • Touches his scrotal region ( medram mrudhnathi) • Shouts loudly (visardhathe) • Feels burning sensation all over the body (Vidahathe) • Passes vata, mutra and purisha with high difficulty.The passed asmari will posses the following qualities. Colour - Syavavarna Surface- Parusha & Khara Edges - Vishama Simile - Resemble kadamba pushpa kantaka.Pittasmari Lakshanas: The person suffering from pittasmari will present withfollowing signs and symptoms102. • Different kind of burning sensations like Chooshana, Dahana, Pachana. • Symptoms of ushnavatha will be seen. Study on the effect of Eladi Quath in the management of Mutrasmari 66
  • Review of the Disease The pittasmari will posses the following characters. • Colour -Rakta varna or Peetavarna or Krishnavarna madhuvarna. • Simile - Resembles Ballathaka Asthi.Sleshmajaasmari Lakshanas: The person suffering from sleshmajasmari willpresent with following signs and symptoms103. • Heaviness at the vasti region. • Feeling of coldness at the vasti region. • Different types of pain i.e., Pricking & Cutting like (nisthudyathe and Bidyathe) The Kaphaja asmari will posses the following characteristic. • Colour - White( Madhukapushpavarna). • Size - Big (Mahath) • Surface - Smooth (Snigdha) • Simile - Resembles Kukkutanda.Sukrajaasmari Lakshana: Though this is a bit difficult to find, it can be compared with seminalconcretions or the spermolith, which are of course not seen in ultrasonography or X-ray but are very fragile in nature and can be crushed by fingers. Even the site of painalso differs being mainly at the path of vas deference. According to the Ayurvedic classics the asmari formed due to sukra inassociation with mutra and thridosha produce the disease sukrasmari104. But at the same time it is said that children wont suffer from sukrasmari asshukra is not secreted and hence there is no formation of asmari in relation with sukrain the basthi. Thus the persons who suffer from the same will have the followingcharacteristic. • Difficulty in micturition (Mutrakrichra) • Pain in the vasti pradesha. • Swelling in the testicular region (Vrushanayoho sopha) Table No.7 The lakshanas can also be brought under subjective and objectiveclassifications which make the diagnosis depending upon the Asmari involved. Study on the effect of Eladi Quath in the management of Mutrasmari 67
  • Review of the Disease Vataja Pittaja Kaphaja Sukraja Mutra Prathigatha Mutra Tivra Vedana Chooshyathe Biddyathe Krichrum Dantha Khadayathi Dhahyathe Nisthyudyathe Basthi Vedana Nabhim Peedyathi Dhooshyathe Vastir Gurutha Vrishanayoh Svayathu S Medrum Pachyathe Vastir Sitata Not found in the U Mrudhnathi children B Payum Sparshayathi J E C Vata, Purisha T Mutra Krichrena I Nisarathi V E O B Syava in colour Rakta varna Swetha J Parusha Peetabha Snigdha E Vishama Krishna Mahathi C Khara Madhuvarna Madhuka Pushpavarna T Kadamba Ballathakasthi Kukkutanda Prathima I pushpavath Prathima V EStudy on the effect of Eladi Quath in the management of Mutrasmari 68
  • Review of the Disease TYPES OF RENAL CALCULUS:Basically the renal stones can be divided into two major groups. 1.Primary stones 2. Secondary stones1. PRIMARY STONES Primary stones are those which appear in apparently healthy urinary tract without any antecedent inflammation. These stones are usually formed in acid urine andusually consist of calcium oxalate, uric acid, urates, cystine, xanthine or calciumcarbonate.a) Oxalate Calculus (Calcium Oxalate): This type of stone is usually single and is extremely hard. It is dark in Colour dueto staining with altered blood precipitated on its surface. It is spiky that means it iscovered by sharp projections, which cause bleeding due to injury to the adjacenttissues. This stone popularly known as Mulberry stone. On section it shows wavyconcentric laminae that means it is formed by deposition of layers of calcium oxalateon a nidus. The peculiarities of this stone are : i. It is often impacted in the ureter. ii. It causes bleeding due to its rough surface. iii. There may be deposits of secondary phosphate on its surface caused by infection, leading to formation of mixed stone. iv. Due to high calcium content it casts an exceptionally good shadow radiologically (radio-opaque). The rough surface may also be evident in Skiagramb) Uric Acid and Urate Calculi: Pure uric acid calculi are rare and are not visible in x-ray (not – radio opaque). Themajority contains urates and enough calcium oxalate to render such calculi radio-opaque. These stones usually occur in multiples and so are typically faceted. The stonesare of , moderate hardness. Their colour varies from yellow to dark brown. On sectionthe stones display wavy concentric marking. The surfaces of these are usually smooth.These stones usually occur in acid urine. Study on the effect of Eladi Quath in the management of Mutrasmari 69
  • Review of the Disease In children, stones of ammonium and sodium urate are some times found. Thesestones are yellow , soft and friable. But unfortunately if these do not contain someimpurities like calcium oxalate, they do not become radio-opaque ,so may not bevisible on straight x-ray.c) Cystine calculi: These stones usually appear in patients with cystinuria. Such cystinuriasometimes occurs in young girls. Cystine is an amino acid rich in sulphur, and cystinecalculi usually occur in multiple. These calculi are soft and yellow or pink in colour.When these are exposed outside, the hue gradually changes to green pure cystinecalculi are not radio opaque, but as they contain sulphur they are usually radio-opaque.Such stones also occur in acid urine. Cystinuria is usually caused by diminished re-absorption of cystine by therenal tubules. Some time excessive cystine appears in urine due to inborn error inmetabolism. The condition is often familial and such cystine is not converted intosulphate, cystine crystals which are found in urine in cystinuria are usually hexagonal,white and translucent. These usually appear in acid urined)Xanthine Calculi: These are extremely rare. These are smooth, round and brick red in colour. OnCut surface it shows lamellar appearance.e) Indigo calculi: They are so uncommon that these are merely academic curiosities. These areblue in colour and are derived from indican, formed by decomposition of tryptophan inthe intestine and found in the urine. Study on the effect of Eladi Quath in the management of Mutrasmari 70
  • Review of the Disease2. SECONDARY STONES:a)Phosphate Calculus: Majority of theses stones are composed of calcium phosphate, though a few arecomposed of ammonium magnesium phosphate, known as triple phosphate’. Suchcalculus is usually smooth, soft and friable. It is usually dirty white in colour. Thistype of calculus usually occurs in infected urine and so is a secondary calculus. Urineis often alkaline. Such stone enlarges rapidly and gradually fills up pelvis and renalcalyces to take up the shape of staghorn calculus. As this stone gives little symptomsdue to its smooth surface, it enlarges rapidly. Triple phosphate usually results fromliberation of ammonium carbonate from urea brought about by urea splittingorganisms. While majority of such stones are made up of calcium phosphate, a few aremade up of mixture of calcium phosphate and triple phosphate. On cut section itshows usually radio-opaque as these contain calcium. But it is also due to its large sizerather than density that it is radio opaque.b)Mixed Stones: Phosphate stone may occur as covering of a primary stone. Such stones areknown as ‘mixed stones’ the primary stone is often the calcium oxalate stone. Whenthe urine becomes infected, deposits of phosphate occur on the rough surface ofcalcium oxalate stones. Such stones also occur in alkaline urine. Study on the effect of Eladi Quath in the management of Mutrasmari 71
  • Review of the Disease Comparative Morphology of Asmari and CalculusVataja: Calcium Oxalate:1. Dusky colour 1. Black or Dusky2. Parusha Rough 2. Rough Surface3. Hard 3. Very hard 4. Uneven 5. Faceted 6. NodularPittaja: Uric Acid Calculus1. Red, Yellowish Black 1. Reddish brown, Black2. Smooth 2. Smooth3. Hard 3. Hard 4. FacetedKaphaja: Phosphatic Calculus:1. White, Light yellow 2. Dirty White2. Smooth 3. Smooth3. Large sized 4. GlossySukrasmari: Spermolith: Study on the effect of Eladi Quath in the management of Mutrasmari 72
  • Review of the DiseaseUpadravas: The upadravas for the disease mutrasmari which are mentioned in the classics are105 • Dourbalya, anga sadhana, aruchi and trishna • Karshya, kukshishoola, and pandutha • Vamana • And even the ushnavataAristha lakshanas: As per Sushruta106, if the patients Nabhi and Vrishanas are inflamed, severepain and obstruction of urine and the Asmari associated with Sarkara or sikata kills thepatient quickly.Sadhyaasadhyatha: The disease mutraasmari is a daruna vyadhi as explained by our ancientAcharyas. As per susrutha; the recent formed stones can be managed by conservativeor palliative methods where in the well developed asmari which has already progressedcan be treated by surgical intervention107 But as with the consideration of vasti, being marma, pranayathana seat oftridoshas, the disease mutrasmari is generally considered as asaadhya which is directlypointed by quoting mutraasmari as one in Ashtamahagadhas. With the references available the asmari which has led the upadravas swellingin nabhi and vrushana, sikathmeha etc is considered as asaadhya and it may even causedeath108. A surgical operation should be considered a remedy that has little to recommenditself. The death of the patient is almost certain without surgery and the result to bederived from it is also uncertain. Hence a skilled surgeon should perform suchoperation only with the permission of the king. Study on the effect of Eladi Quath in the management of Mutrasmari 73
  • Review of the DiseaseVyavachchedaka nidana: This has to be done in between: • Mutraghata109 • Mutrakrichra109 • Mutrasarkara111 • Mutraghata - The cardinal feature of Mutraghata is Avarodha • Mutrakrichra - In this condition there will be marked Mutrakrichra and minimal vibandha • Mutrasharkara - In this condition gravels will be passed through urine. Study on the effect of Eladi Quath in the management of Mutrasmari 74
  • Review of the Disease INVESTIGATIONSRenal calculi :1. Blood examination: This is to be done for urea creatinine, uric acid, total count, serum calcium and phosphate.2. Urine analysis: i. Physical Examination: This is to be done for gross haematuria, smoky appearance or opalescence. ii. Chemical examination : Should be one for protein cystine and for pH values iii. Microscopic examination: Microscopy of urine should be done for the presence of RBC’s , Pus cells, Epithelial cells, and for the presence of any casts and crystals. iv. Bacterial examination: This is highly important including cultural and sensitivity test. If the pH increase, the urea splitting organisms present. v. Renal function tests: this should be always performed in calculus cases. The PSP may be normal even in presence of bilateral staghorn stones or in chronic unilateral obstruction due to stone.3. Radiography A. Straight X-Ray: An X-ray of kidney, ureter and baldder region is to be taken after thorough bowelpreparation and is watched for any opacities. B. Ultra sonograplhy This is useful to distinguish between opaque and non-opaque stones. This ischeap, painless procedure, and no dangerous radiation present. The size of the kidney,and thickness of the cortex can be estimated. Other useful finding are presence ofcysts, Calculi and its size, any obstructions and hydronephrosis C.Intravenous Urogram (IVU) Study on the effect of Eladi Quath in the management of Mutrasmari 75
  • Review of the Disease4. Instrumental Examination Cystoscopy: Cystoscopy is useful in diagnosing the urethral stricture orobstruction, as the cause of stone formation.Ureteric calculi: 1. Examination of blood 2. Urine analysis 3. Straight X-ray of KUB region 4. Excretory urography 5. CystoscopyProstate & Seminal vesicle calculi: 1. Penendoscopic examination 2. Urethroscopic study 3. Roentgen graphic studyUrethral Calculi: 1. Penendoscopic examination 2. Roentgenography Study on the effect of Eladi Quath in the management of Mutrasmari 76
  • Review of the Disease CHIKITSA OF MUTRASMARI In Ayurvedic classics various aspects of the management of the Asmari hasbeen dealt. Broadly it can be divided into medical and surgical due to its associationwith one of the most important trimarmas and one of the Jeevitha staanas. Vasti isconsidered as one of the vital area and the vyadhi occurring in this area may be veryserious and some times fatal also. In early stages it can be managed with medicines,but in later stages surgery is the treatment of choice. While explaining complicationsof different diseases in Avaraniyam Adyayam Susrutha acharya considered as one ofthe eight mahavyadhis. In view of the seriousness of the diseases, treatment has been classified into twomain groups 1). Medical Treatment 2). Surgical TreatmentChikista: After knowing the balaabala of roga as well as rogi in due regard with desha,kaala, the line of treatment can be selected. The main aim of the treatment beingNidana parivarjana, Prakruthi vighathana and Apakarshana are adopted.Nidaana Parivarjana: For any disease it is must that the etiological factors must be kept at bay. If notinspite of giving the best of available treatment the chances of reccurence orsuccumbing to the disease is more, unless this is done the disease become furthereaggravated. In the early stage (initially) when the asmari formation has begun, by followingnidana parivarjana and adopting the pathyapathya objectives one can be treatedsuccessfully eventhough the disease is dharuna vyadhi.Prakruthi Vighathana: This is the line of treatment which does the environment not suitable for theformation or progression of the disease by regularizing the deformity and enhancingthe performance of the effected part. This is achieved by the expulsion of shodhanaand shamana line of therapies. This is achieved by the expulsion of the vitiatedshleshmadhi doshas which can be termed in other words as rogarambaka prakruthi. Study on the effect of Eladi Quath in the management of Mutrasmari 77
  • Review of the Disease Similarly shamana chikitsa also causes the destruction of factors responsible forthe manifestation of a disease. The principles adopted in the treatment of mutrasmari are listed below: 1) According to the statement of Susratha snehadi procedures can be adopted fortreatment in the persons who are presenting with the purvarupa lakshnas. Bheshajachikitsa is adopted in the initial stage of the disease. In pravarthaavastha of mutrasmarithe sastra karma has to be employed112. 2) According to charaka in general, the chikitsa principles of kaphaja and vathajamutra krichra are to be adopted in the management of mutrasmari113. Apart frommutrakricchra chiktsa the other specific treatment mentioned for asmari include on 1)Asmari Bhedana. 2).Asmari Patana114. One more note worthy and beneficial aspect that charakacharya mentioned in themanagement of asmari is the utilization of physical exercise as a supportive measure ofasmari patana chiktsa thus charakacharya though not given detailed information aboutasmari but mentioned measures and medical treatment for it. 3)Astangahridhayakara Vagbhata opines that principles of treatment used forsannipathaja MutraKrichra are to be utilized based on the predominance of doshas115Shodhana line of Treatment: It is imperative to the principles, to adopt the snehadi karma in the purvarupastage of asmari. Snehadi is interpreted as sneha, swedha, vamanadhi by Arunadatta,the commentator of Astanga hridaya. As asmari is a tridoshaja vyadhi whatevershodhana therapy is advised in mutrakrichra is to be adopted according to the doshicpredominance.Eg.In vatajasmari, the therapy advised in vatajamutrakrichra is to beadopted, where in abyanga by vatahara thailas, niruha vasti, uttara vasti, upanaha,parisheka, with vatahara thailas or kwathas are carried out. Management of asmari with shodhana therapy in the stage of purvarupa helpsin checking the manifestation an aggravation of disease during thedosha dooshya sammurchana stage itself. During this stage asmari is neither solidified Study on the effect of Eladi Quath in the management of Mutrasmari 78
  • Review of the Diseasenor hardened hence the shodhana chikitsa is beneficial by the process of elimination ofmorbid doshas. Once asmari is formed and hardened the related doshic nature in it alsochanges. There is no positive effect of shodhana on asmari which is already formed,even if the doshas are brought to the kosta and efforts are made to expel them out.Shamana line of Treatment : This line of treatment has to be followed along with nidana parivarjana,particularly after shodhana therapy. The administered drug must possess bhedhana,asmarighna properties to disintegrate the formed stone. It also should have the mutravirechaneeya properties to expel the stone out. Apart from all these Charakacharya mention some regimen to follow for theexpulsion like, raiding on camel or horse or doing vigerous exersise on takingmadhyapana etc. These all aim at the function of apanavata which helps to expel themutra, there by expelling the asmari present in it.SHASTRA CHIKITSA: As per Susrutha the surgical line of treatment must be employed in Asmari ofpravradhavasta, and if all the measures previously mentioned gets failed116. Susrutha was the first person to mention the surgical management in the context ofmutrasmari. During his explanation he has elaborately dealt the consequences andcomplications faced after surgery. He has explained the pre-operative, operative andpost-operative procedures with actual techniques and instruments. Indications, contraindications, and complications are also dealt in chikitsa stana 7th chapter of susruthasamhitha. Study on the effect of Eladi Quath in the management of Mutrasmari 79
  • Review of the Disease MANAGEMENT OF UROLITHIASIS A Urinary calculus announces its presence with an acute episode of renal orureteric colic that is severe abdominal pain (may be radiating) with urologicalsymptoms. If Uroliths get loose and lodged in renal pelvis or get so big that they cannotpossibly go down the ureter, they create problems in patients, only when they becometrapped in some segment in one of the five positions of the urinary tract. After thorough clinical examination one should diagnose and management is tobe planned under various steps.I. Medical Management A. Management of acute episode: a. The majority of patients with urolithiasis require prompt therapy of for pain relief. b. Most patients get relief from the intramuscular injection of 50 to 100mg of merperidine or 10 to 15 mg of morphine depending upon the body weight and severity of pain. c. Other drugs recommended are pethidine, buprenorphine, prostaglandin systhetic inhibitors such as indomethacin, ketoprofen or diclofenac. The latter group of drugs may be given orally, or by suppository or by intravenous infusion. d. Antispasmodics, have little effects on pain and are not now used routinely. Antiemetic drugs are often necessary to combat the nausea of disease itself or that induced by pethidine. e. To alleviate spasm, a dose of probanthin may be required, but repeated doses should be avoided as it may produce retention of urine by paralyzing the detrusor muscle of the bladder. Atropine 0.8 mg subcutaneously is also an effective antispasmodic drug. f. In some cases hospitalization may be necessary, for those individuals who have too much of gastrointestinal upset that they cannot retain fluids or food. In addition they may become exhausted by the loss of sleep and other discomfort created by stone disease. Study on the effect of Eladi Quath in the management of Mutrasmari 80
  • Review of the DiseaseB) Conservative Management Not all patients with renal stones require surgery. When the stones aresufficiently small, these can be naturally eliminated and expectant policy is bestadopted in these cases. Chemical dissolution of renal stones requires indwelling ureteral catheters forconstant through and through irrigation with renacidin or G solution. In elderly risk patients coraliform stone is best left alone unless it causessignificant symptoms. After management of acute episode, one should know about the size of thecalculi, because 80% of the calculi, below 7mm pass spontaneously. It is an almost universal adage in urology that fluid must be forced upon thestone patient, whether given intravenously or orally. Studies in urodynamics indicatethat an increase in diuresis generally decreases the rate of ureteral peristalsis. If so,one wonders whether forced water drinking serves to propel the stone through theurinary system or to decrease peristalsis and there by inhibits. Most of the patients after management of acute attack can be treated in outpatient department. Since majority of urinary calculi are less that 4 to 5 mm in size,majority of these pass spontaneously. Such patients should be treated with analgesic &emphasized to the patient that it is to be recovered in case of any calculus or gravel thatis passed. Whether one should wait for 2 days or 2 months to decide the duration ofobservation following factors are to be considered. 1. All the stones measuring less that 5-7 mm size 2. Stone weighing less than 100 mg & Smaller diameter is less than 4 mm 3. Stone is not increasing in size. 4. Minimal hydronephrosis, hydroureterosis and obstruction. 5. If there is no infection of urine. 6. If stone is obstructing solitary kidney or bilateral obstruction is not present. 7. If patient is elderly, risk patient, coraliform stone is left best alone. 8. Calyceal stone, seldom cause any problem and can be kept under observation 9. Ureterial stones, without much repeated attacks of colicky pain. Study on the effect of Eladi Quath in the management of Mutrasmari 81
  • Review of the Disease In general – A small uretral stone accompanied by infrequent attacks of colickybut not associated with infection or progressive hydronephrosis may be observed in thehope that the stone will pass spontaneously. But this is important that in all aboveconditions the progress of hydronephrosis, hydroureterosis, obstruction, size ofcalculus, should be assessed on in 4-6 weeks intervals by repeated urograms.II Surgical /Instrumental Stone removalThe light of fact is that the technological revolution over the last decade has enabled asout patient procedure or with minimal hospital stay. 1. Extracorporeal shock wave lithotripsy. 2. Percutaneous nephrolithotomy. 3. Ureterorenoscopy.Operations for Urolithiasis: 1.Pyelolithotomy 2.Nephrolithotomy 3.Nephrectomy 4.Nephrostomy 5.Pyelonephrolithotomy. Study on the effect of Eladi Quath in the management of Mutrasmari 82
  • Calcium Oxalate Uric Acid Brushite Carbonate Apatite Monohydrate deposited over Silica Calcium Oxalate Silica (Canine) Struvite Uric Acid Monohydrate Calcium Oxalate Calcium Oxalate Calcium Oxalate Stuvite with staple Monohydrate with Monohydrate Dihydrate superficial Dihydrate Calcium Oxalate Monohydrate (coated Xanthine Brushite Struvite (Ferret) with Triamterene)Tricalcium Phosphate & Calcium Carbonate Uric Acid Dihydrate Struvite (Feline) Apatites Calcium Oxalate Calcium OxalateMonohydrate deposited Monohydrate partially Struvite Carbonate Apatite over Apatite encrusted w/ Dihydrate Calcium Oxalate Cholesterol (Biliary) Cystine Struvite Monohydrate
  • Patya & Apatya PATYA & APATYA Ahara and vihara i.e., diet and life style are two main factors which influencethe person leading to health or disease. Patya ahara or vihara which were explained inthe classics not only prevent disease but also relieves the existing one so as the patyaahara and vihara described for asmari in this context. As mutrakricchra leads to Asmari and both are interrelated diseases, so thepathya and apathyas of mutrakricchra can be incorporated for Asmari vyadhi. Summing up the contents mentioned by different acharyas following are117PATHYA:-Ahara: Purana salianna, lohitha Sali dhanya, Godhuma, Mudga Annadi Kulvtta,Tandulvya, Yava, Seetala anna.Mamsa: Jangala mamasa, dhanvanda sambhava rasa.Dravyas: Pashana bheda, yavakshara, Madhura, Gokrhura, Varuna Sakha, Kushmanada phala and its latha, Ardrakam, Renuka, Salaparni, Patola, Mahardraka, Kumari, Kharjura, Narikela, Talamajja, Haritaki, Kusa, Ela,.Pana: Gokshur, Gritha, Dadhi, Mudgarasa, Nadijala, Seetala Pana, Vari swana.Vhara: Varti, Virechana, Vamana, Langhana, AvagahaswedanAPATHYA:-Ahaara: Sushka, Ruksha, Pistanna sewana, Amla, Vistambakara.Pana: Madhya sewana.Mamsa: Matsya (Anupa).Dravyas: Lavana, Taila Bharjitha, Hingu, Tila, Sarshapa, Masha, Karera.Vihara: Mutra and sukra vega nirodham, parisrama, Stree Sambhoga, Gajayana, Diva swapna. Study on the effect of Eladi Quath in the management of Mutrasmari 84
  • Patya & Apatya DIETIC FACTORS IN UROLITHIASIS i. Intake of Fluids Dr. Stanely Goldforb,M.D. et. al reported that the persons who are mainly to drink more fluids had no signs of new kidney stone growth over the next five years. ii. Avoid Meat Eating animal protein can drive up urine levels of the stones raw material i.e., calcium oxalate and uric acid multiplying the chances of stone formation. Eating normal amounts of animal protein can stimulate abnormally high levels of urinary calcium in some individuals, for unknown reason. Consumption of most protienecious diet boosts their chances of kidney stones by one third.iii. Vegetarians are less prone to have renal calculus Vegetarians have only one third as many kidney stones as meat eaters. Such vegetarians also eat twice as much fiber recognized as an antidote to kidney stones, and they excrete less calcium. Studies show that vegetarians, when put on meat diets have increases of calcium in their urine.iv. Salt and protein restriction It is found in the studies conducted by Dr. Wasserstain that the restriction of sodium and protein intake by stone formers, their excretion of urinary calcium dropped by 35 percent. Dr. Wasserteen advises stone formers with high urinary calcium not to use salt at the table or in cooking, and avoid high sodium processed foods such as bacon and other processed meats, olives, canned soups. v. Avoid rich oxalate containing foods Consumption of rich oxalate foods may help boost urinary oxalate, which can combine with calcium to form stones. Studies do show high urinary oxalate in stone patients who eat lots of oxalate-rich foods, such as spinach, rhubarb, peanuts, chocolate and tes According to Richard W. Norman eating up to 180 mg of oxalate a day is harmless but more may lead to a marked increase in urinary oxalate. Study on the effect of Eladi Quath in the management of Mutrasmari 85
  • Patya & ApatyaIn take of calcium containing diet : After studying the diets of 45,619 men for four years by Dr. Gary Curhan et.Al reported that men who ate more calcium were less prone to kidney stones (34percent lower risk) than men who restricted calcium. The study also revealed that men who drank two or more glasses of skimmedmilk a day had a nearly 40 percent lower risk of kidney stones compared with menwho drank only one glass per day.Consumption of water intake : Drinking lots of water blunts the potential damage from calcium, oxalate andevery other stone forming mineral in the urine as the water dilutes concentrations ofminerals that can crystallize into stones. Studies show that people who excrete less than one liter of urine a day are muchmore likely to have kidney stones than those who put out twice that much. The bare minimum drinking of fluids/water should be eight glasses spreadthrough out the day, and twice that much is sometimes recommended, especially in hotweather when it is sweated off. Dr. Stanley Godfarb, a professor of Medicine, university of Pennsylvaniaschool of Medicine prescribed water for recurring of kidney stones. He advised todrink water of 2 glasses for every four hours – at 8 am, 12 Noon, 4PM, 8PM andbefore bed time.Consumption of high fibre diet : Janey Hughes a dietician said that the fiber may be especially beneficial forpeople at risk of forming calcium stones. It is reported in the studies, 182 calciumstone –formers who ate 10 gms of rice bran twice a day for an average five years hadabout a six fold drop in kidney stone recurrence.Un whole some diet (Apathya ahaara):The food that contains high oxalate content. i) Palaka ii) Tomatoes iii) Amla iv) Chickoo v) Cashewnuts vi) Cucumber Study on the effect of Eladi Quath in the management of Mutrasmari 86
  • Patya & ApatyaThe food that contain high uric acid/Purine Content i) Cauliflower ii) Pumpkin iii) Mushroom v) BrinjalWhole some diet:1) Barley : It has good diuretic action and has rich stone inhibitors.2) Bananas : It has rich Vitamin ‘B’ which break down oxalic acid in the body thereby preventing stone formation3) Almond : Rich sources of Mg and K which are known stone inhibitors.4) Carrots : Rich sources of Pyrophosphatase and plant acids which act as stone inhibitors5) Coconut water : Inhibits the initial mineral phase formation, and act as stone inhibitors.6) Corn silk tea : Very good source of tartrates acting as good inhibitors of stone formation7) Kulutha dal : Stone inhibitor as well as stone disintegrator by producing acidic media.8) Karela : Due to presence of stone inhibitors like Mg, phosphorus etc. Study on the effect of Eladi Quath in the management of Mutrasmari 87
  • Drug Review DRUG REVIEW In the modern arena, surgical procedures remain the only treatment of choiceand are not conducive enough as they hold the disadvantages of high expenditure, sideeffects and disease recurrence. It is in the dire situation, the desperate need ofconservative medicines is fulfilled by some formulations mentioned in our classics. In this regard my present study proceeds in ascertaining the efficacy of “EladiQwatham” a compound preparation selected from Sarangadhara samhita acomprehensive and contemporary text of 13th century. This Compound preparation “Eladi qwatham”has been described inSarangadhara samhita, madhyama khanda, qwatha kalpaadhyaya 105, 106.Eladiqwatha was also cited in Bhaishajya ratnavali a standard text book of compilation fromdifferent modalities of ayurveda The effect of compound is premonitorily as the individual drugs explains theiralleviating effect on vitiated doshas and sodhana effect on mutravaha srotas, ultimatelydisintegrating the formed asmari viz.madhura, tikta, katu rasas, mutralamutrakricchrahara, kapha vata samaka are the important therapeutic properties of theingredients which bring out the specific effect in breaking, migrating and quickerdisposal of the asmari, apart from healing the associated symptomatology. Study on the effect of Eladi Quath in the management of Mutrasmari 88
  • Drug ReviewIngredients of Eladi Qwatham explained in different texts: Table No.8 Sarangadhara Bhaishajya samhitha ratnavali Latin name Part usedEla Ela Elettaria cardomomum FruitKrishna Upakulya Piper longum FruitRenuka Renuka Vitex anguscastus SeedsAsmabheda Asmabheda Aerva lanata Whole plantGokantaka Swadamstra Tribulus terresteris Whole plantVasaka Kounthi Adathoda vasica FlowersEranda Urubuka Ricinus communis RootsMadhuka Madhuka Glycyrrhiza glabra RhizomePreparation of the Drug:All the above mentioned dried drugs are taken in equal quantity, made into coarsepowder. In 2tolas ( 20 gms) of powder , 32 tolas ( 320 ml) of water is poured andboiled until it becomes ¼,in this decoction add 4 ratti (500mg) of Sudh Silajith and 2tolas(20 gms) of Sarkara or 1tola ( 10 gms) of Honey .This decoction is made to drinkby the patient. Dosage : 80 ml Mode of administration : Before food with empty stomach, twice, daily. Duration of treatment : 40 days Silajith powder, when exposed to air becomes sticky and it is difficult to divide theexact dose by the patient so, for the convenience of usage to the patient suddhasilajithpowder 500mg is filled in a capsule and given. This capsule is advised to have alongwith the prepared decoction. Study on the effect of Eladi Quath in the management of Mutrasmari 89
  • Drug Review ELABotanical Name : Elettaria Cardamomum.Family : Zingeberaceae.English Name : Lesser cardomam.Synonyms : Triputi, Sukshma, Dravidi, Upakunchika, Hima, ChandraVermacular Names : Hindi- Choti elaichi; Kannada-Elakki; Mala- Elem; Tam- Illays; Tel-Elakulu.Ganas : Charaka: Swasahara, Katuskandha, Angamardaprasamana, Sirovirechana. Susruta : Eladi.Morphology : Perennial herb 3mt ht, Root stock, Woody and stem branching. Leaves- Subsessile, oblong,lanceolate, Corolla Lip is white,Capsule is Subglabrous, Marked with many fine Verticle cups and seeds 15-20.Chemical composition: Cineol, Terpineol.Gunas : Rasa : Katu, Madhura. Guna : Laghu, Singdha, Sugandhi. Veerya : Seetha. Vipaka : Madhura Karma : Vatahara, Deepana, Rochana, Hridya.Parts Used : Phala, BheejamAction on Mutravahasamsthan : Angamardaprasamana(charaka), Mutrakrichra hrut(Bha pra), Mutrakrichraghn ( , Mutra Asmarihara(Ni.ra),Mutrakrichraapaha (,Mutrakrichra Nivaranam( Study on the effect of Eladi Quath in the management of Mutrasmari 90
  • Drug Review KRISHNABotanical Name : Piper Longum Linn.Family : Piperaceae.English Name : Long pepper.Synonyms : Pippali, Magadhi, Kana, Chapala, Ushana, Teekshna, Tandula, Upakulya, Vaidehi, Kola, Syama, Megadodhbhava.VernacularNames : Hindi-pippali; Kan-Hippali; Mala-Tippali; Tam-Tipil; Tel- Pippallu.Ganas : Charaka: Kasahara, Deepaniya, Hikka nigraha, Sirovirechana, vamana, Triptighna, Sulaprasamana. Susruta: Pippalyadi,Urdhvabhagahara,Sirovirechana.Morphology : Perennial Twinner , Leaves- Lower- Broadly ovate, cordate, Upper- oblong, Spikes- Solitary, Pedenculate,. Fruits- Small ovoid flesh spike.Chemical compositiona: Peperine.Gunas : Rasa : Katu. Guna : Laghu, Snigdha, Teekshna. Veerya : Anushna. Vipaka : Madhura. Karma : Kaphavatahara, Rechana, Vrushya, Medhya.Parts Used : PhalaAction on Mutravahasamstan: Sulanasam,(ma.Ni),Kaphavatasamakam( Peperine showed that it interacts with lipid environment to produce effects whichlead to increased permeability of intestinal cells (Bio chem, pharmocol, 1992, 43,142). Bio availability: A study on the scientific evidence on the role of the Ayurvedicherbals on Bio availability of drugs, like Trikatu, specially Piper longum. Suggestedthat it has the capacity to increase the bio availability either by promoting rapidabsorption from the gastro intestinal tract, or by protecting the drug from beingmetabolized or by a combination of these two mechanisms.(J Ethnophamocology , Regional Research Laboratory, Jammu Tawi). Study on the effect of Eladi Quath in the management of Mutrasmari 91
  • Drug Review RENUKA (Nirgundi beeja)Botanical Name : Vitex anguscastus.Family : Verbanaceae.English Name : Fine Leaved Chaste Synonyms : Renuka, Hrenuka, Raja putri,Nandini, Kpila, Dvija, Bhasma ganda, Pandu putri, Kounti. Seeds: Renuka, HarenukaVernacular Names : Hindi- Sambhalu ka bheej, Renuk, Renuka;Guj :Harin ; Irani: Panjangustha.Ganas : Rasa : Tikta, katu,. Guna : Laghu, Veerya : Ushna(kinchit). Vipaka : Katu. Karma : Pachana,Kapha vata samaka,Pittala.Chemical Composition: Starch, Tannins, Castines.Parts Used : Patra Mula, Beeja, Panchanga.Action on Mutravahasamstan: Sodaghna,Anulomaka, Mutrajanana(Bh,pra- Chunekar).RESEARCH : Anti tumour and antibacterial substances are reported(Lin et al 1973). The ethyle acetate extract at a dose of 50mg /kg orally produced definite antiinflammatory affect against Carrageenin, 5HT and Bradykinin inducededema(CCRIMH,1977,78). Decoction of fruits is used as stimulant, diuretic and alternative (Indian MateriaMedica,A.K.Nadkarni). Study on the effect of Eladi Quath in the management of Mutrasmari 92
  • Drug Review ASMABHEDHABotanical Name : Aerva lanata linnjuss ex shuttesFamily : AmranthaceaeEnglish name : ---Synonyms : Bhadra, Bhadrika, Gorakshaganja , Sweta pushpi.VernaucularNames : Hindi-Gorraksha;kan-Bilihidisoppee; Mala-Cherupula;Tam-cherupula;Tel-Kondapindichettu.Ganas : ----Morphology : Errect Prostrate Shrub Leaves - Simple, Alternate, Short Petioled. Flowers - SmallSessile, Bisexual, Hairywhite colour. Fruit - Green, Round Compressed- Utricle Seeds - Kidney Shaped, Coriaceous testa.Gunas : Rasa : Tikta. Guna : Laghu. Veerya : Ushna Veerya. Vipaka : katu Karma : Vasti Sodhana, Bhedana, KaphapittasamakaParts Used : Mula, Panchanga.Action on Mutravahasamstan: Asmari nasani(Dr. Gu. Vig). Both ‘ Indian Medicinal Plants ` and Nadkarni ‘s ‘Materiamedica` give sanskritname “Asmabheda” to “Aerva lanata”.RESEARCH : The aqueous extracts had some diuretic effect in rats and significant Anti-Lithicactivity male rats. (Mourya Study on the effect of Eladi Quath in the management of Mutrasmari 93
  • Drug Review GOKANTAKABotanical Name : Tribulus terresteris linnEnglish Name : CaltropsSynonyms : Swadamstra, Swadukantaka, Trikantaka, Chandramsu, Ikshugandha, Chanadruma, Kshuraka, Vanasringataka, Duschakra.Vernacular Names : Hindi – Gokhru ; Kan-Negalu; Mala-Neringil; Tam- Neringi; Tel-Palleru.Family : ZygophyllaceaeGanas : Charaka:- Mutravirechaneeya, Sothahara, Krimigna, Anuvasanopaga. Susrutha: Vidarigandhadi,Veeratharvadi, Laghupanchamula,Kantakapanchamula,Asmaribedhana.Morphology : A Procumbent Herb, Stem Branches are thin soft hair Leaves - Opposite, Pinnate, Stipules are lanceolate, Hairy, leaf let -6 Pairs oblong. Flowers - Axillary, Solitary, Bisexual,, Stamens to, ovary bristly, Seeds have Spines.ChemicalComposition: Fixed Oils, Volatile Oils, Tannins, Nitrates, Saponine.Varieties ; Laghu & Brihat Gokshura.Gunas: Rasa : Madhura Guna : Guru, Snigdha. Veerya : Seetha Vipaka : Madhura Karma : Deepana,Vrushya,Vastisodhna, Vataghna, PittasamakaAction on MutravahaSamstan : Mutravirechaniya, Mutrakrichraanilaharam(charaka) Asmaribhedana (susruta), Mutrakrichra hara (,Vastisodhana Asmarihara ( .Mutrakrichra, Srotovisodha (, Mutralam,Krichra nasam(A.S), Mutrakrichra, UshnaAsmarinasam(Sa.sam). Study on the effect of Eladi Quath in the management of Mutrasmari 94
  • Drug ReviewRESEARCH:Neprhro protective activity: Evaluated in Gentamicin caused nephrotoxicity induced rats was reversed bytreating ,a formulation containing T.terresteris&Silajith (Samiulla& Harish 2001)Lithotriptic activity: An ethanolic extract from fruits showed significant dose dependent productionagainst (deposition calculogenic material) Urolithiasis induced by glass beadimplanted albino rats. (Indian J Exp .Biol.1994) Aqueous extract was tested in hyperoxyluria induced male rats.24 hr urinaryoxalate excretion reversed to normal.Diuresis : The aqueous extract elicited positive diuresis in addition it had evoked contractileactivity on guinea pig’s ileum ,indicating that it has the potential of propelling urinarystones and merits further pharmacological studies(J Ethnopharmacol,2003 ).Effect on smooth muscle: Saponin micture has caused a significant decrease on peristaltic movement ofisolated sheep ureter and rabbit jejunum i.e. saponin mixture may be useful ion smoothmuscle or colic pains (Bollchinn Farm, 1998, Dec,). Study on the effect of Eladi Quath in the management of Mutrasmari 95
  • Drug Review VASAKABotanical Name : Adothoda vasica.Family : Acanthaceae.English Name : Malabar nut.Synonyms : Vasika, Kounthi, Simhasya, Vajidantha, Vrushaba, Atarusha, Simbi, Bhishagmata, Panchamukhi, Matruka, Simhaparna.Vernacular Names : Hindi- Adusa; Kan-Adusoga; Mala- Attalotakam; Tam- Edathoda; Tel- Addsaramu.Ganas : Charaka: Tikataskandha. Bhavaprakasa: Durvadigana.Morphology : Perennial dense shrub, long opposite ascending branching. Leaves: Elliptic, Lenceolate, Acuminate, pubeseant when young and glabrous when mature. Flowers – Complete, Bisexual Hypogamousdense axillary,pedunculate. Corolla-White , 2lipped Calyx-5, shortly companulated imbricate, Ovary-2celled, tomentose. Fruit-Capsule.Chemical Composition: Vasicine and adathodic acidGunas : Rasa :Tikta, Kashaya Guna :Laghu, Ruksha Veerya:Seetha Vipaka:Katu Karma:Kaphapittahara, SwaryaPartsUsed : Mula, pushpa, patra,.Action on Mutra vahasamsthan: Flowers have Mutra janana affect (Bha.pra-Chunekar)RESEARCH: Relaxation of smooth muscle: Relaxation producing activity of dl–vasicinone on isolated guinea pig tracheal muscle (Nature,1962, 196 ,1217) . Haemostatic activity : Haemostatic activity of the A.vasa is reported (Atal et al.19) Study on the effect of Eladi Quath in the management of Mutrasmari 96
  • Drug Review ERANDABotanical Name : Ricinus communis.Family : EuphorbiaceaeEnglish Name : Castor.Synonyms : Gandharvahasta, Panchangula, Vardhamana, , Chitraka, Vatari, Uthanapatraka, Vyaghrapuchi, Chanchu, Vyadambara, Urubuka, Amanda, karaparna.VernacularNames : Hindi-Erandi; Kan-Haralu; Mala-Amamdam Tam- Akmanakkuu; Tel-Amudamu.Ganas : Charaka: Bhedaneeya, Madhuraskandha, Swedopaga, Angamardaprasamana. Susrutha:Vidarikandadi,Vatasamsamana, Adobhagahara.Morphology : Tall glabrous annual Shrub grows upto 6mt ht Root is sweetish. Leaves-Alternate, Palmately lobed, Serrate margin Flowers- Monoecious, Fruits- Prickly capsule. Seeds- Oblong albumin fleshy.Chemical Composition : Ricin, Palmidin, Slianin.Varieties : Two according to Bh. Prakash-Rakta, Sweta.Gunas : Rasa : Madhura, Katu, Kashaya, Tikta. Guna : Guru, Snidha, Teekashna & Sukshma. Veerya : Ushna Vipaka : Katu. Karma : Vata Kapha hara, Vrushya, TwachyaParts Used : Mula, Patra, Beeja, Tila.Action on Mutra vahasamstan: Sula,,udavartanasa, Margasodhana (,Mutrakrichraharam,Vastisulaharam,Sulaanilaapaham(Bha.pra),Vastisulaharam(, Marga sodhanam,Vastisiroruji hara, Mutradoshan jayedapi,Vasti sulam ,Asma nasam( : Anti inflammatory effects of root extract was investigated against corrageenin, 5-HT, dextron, bradikinin and PGE-1 induced rats. Study on the effect of Eladi Quath in the management of Mutrasmari 97
  • Drug Review MADHUKABotanical Name : Glycyrrhiza glabra linn.Family : Leguminaceae, Papilionaceae.English Name : Liquorice.Synonyms : Madhuka, Yastimadhu, Kleetaka.Verncular Names : Hindi-Muleti; Kan- Atimadhu; Mala- Irathimadhumam; Tam- Atimadhuram; Tel- Atimadhuram.Ganas : Charaka: Kantya, Varnya, Kandughna, Vamanopaga, Jeevaniya,Sandhaniya, Mutra virajaniya, Sonita stapana, Snehopaga,Vamanopaga, Asthanopaga. Susruta: Kakolyadi, Anjanadi, Sarivadi,.Morphology : Tall Perennial Plant. Rizhome spread long in ground. Leaves- 4-7 pairs oblong, acute. Inflorescence- Racemose. Flowers-Pale voilet colour, sessile, complete, bisexual. Fruit- Pod, oblong, achenate, glandular.Chemical Composition : Glycyrrhizin, Asperagin, Sugars, Starch and Tannins.Gunas : Rasa : Madhura Guna : Snigdha Guru. Veerya: Seetha. Vipaka: Madhura. Karma: Vatapittahara, Chakshushya, Balya, Varnya, Kesya.Parts Used : Root.Action on Mutravahasamstan : Mutra virajaneeya (charaka), Vranapaham(,Sadyo vranam nasayet(, Vrana sodharopanam( : The anti inflammatory activity of the glycyrretic acid and its diacetate was similarto that of hydrocortisone on formalin induced albino rats.(Tanri Glycyrrhiza glarbr posseses aprotective affect against both heart and kidneys inrat’s .This benificial effect may be attributed, at least in part to its antioxidant activity.(Phytother Res .2005 Mar). Study on the effect of Eladi Quath in the management of Mutrasmari 98
  • Drug Review SILAJITHScientific Name : AsphaltumSynonyms : Silajith, Saileya, Silaja, Siladhatu, Silamaya, Sila sweda, Silaniryasa, Asmaja, Asmajatuka, Girija, Adrija, Asmotha, Asmathada, GoureyaVernacular Names : San- Silajith, Silaras; Eng- Asphalt, Mineral pitch, Jewspitch,; Arab-Hajar-ul- musa; Hindi-Ral-yahudi.Source : Rock exudates, Ejected out of rocks in the hot weather i.e. sukra(jesta), suchi(ashada) months in the lower Himalayas, Vindhyas and other mountain tracts, containing metals like Gold, Silver, Bronze, Iron etc.Place of Origin : Nepal (Large quantities imported from Katmandu)Chemical coposition :Varieties : 4 types : Swarnam, Rajatam, Tamram, Loham (Ra.Ta) 6 types : Swarna, Rajatha, Tamra, Loham, Trapusa, Seesa. (Su) 2 types : Gomutra, Karpoora & Sasatwa, Nisatwa.(R.R.S) 2types : Girisambhava (Gomutra), Ksharabhumisambhava(karpoora)(Ay.Pra).Gunas : Table No.9 Swarna Rajatha Tamra LohaRasa Madhura,tikta, Katu Tikta Tikta, lavana katu kashayaGuna Seetam Seetam Ushna,Teekshna Seeta, snighda.guruVarna JapaPushpa Panduram Mayurakantabha, Krishna NilabhaVipaka Katu Madhura KatuKarma Vata pitta hara Sleshmapittahara Kaphanasak TridoshasamakaChemical Analysis:Description -Dark Brown colour, Dry powderPurified Silajith in water extraction medium: Loss of Drying -4.82% Water soluble extractives -96.32% pH -5.75% Study on the effect of Eladi Quath in the management of Mutrasmari 99
  • Drug Review It does not contain any compound of the nature of alkaloid. The following table no.10 shows the percentage of dried extracts after distillingoff the solvent: Solvent Crude silajith amount Purified Silajith amount dissolved in % dissolved in%Chloroform 2.15% 5.88%(crystal)Ethyle Acetate 1.2% 1.37%Alcohol 29.25% 30.81%(crystal) Table No.11, The result of analysis shows that silajith is composed of the followingsubstances: Organic Contents Crude Silajith % Purified Silajith%1. Moisture 12.54 29.032. Benzoic acid 6.82 8.583. Hippuric acid 5.53 6.134. Fatty acids 2.01 1.365. Resin and waxy matter 3.28 2.446. Gums 15.59 17.327. Albuminoids 19.61 16.128. Vegetable matter & sand etc 28.52 2.15 Table No.12 The Mineral Constituents are obtained from the ash by incineration of thesubstance at red heat, are also appended in the following table:- Mineral Contents Crude silajith Pure silajith%1. Moisture 12.54 29.032. Loss of Ignition 64.8 52.633. Ash 22.88 18.344. Silica 4.60 2.695. Iron(Fe2 O3 ) 0.51 0.646. Aluminium(Al2O3 2.26 2.617. Lime(CaO) 6.83 4.828. Magnesia(MgO) 1.29 1.209. Sulphurous acid(SO3) 0.64 0.97.10. Chloride(HCl) 0.26 0.5711. Phosphoric acid (P2 O5) 0.28 0.2412. Nitrogen 3.64 3.36Method Of Purification : Different methods of purification of Silajith were mentioned in our classics,there are:- i. Boiling and washing in triphala Kwatham (Ra.ta). ii. Washing in Ksharodak, Amlarasa, and Gomutra. (R.R.S).iii. Washing in Bringaraja swaras (Ra.ta). Study on the effect of Eladi Quath in the management of Mutrasmari 100
  • Drug Review The sample of Silajith which is used by me in this Clinical Trial was purchasedfrom pharmacy, CHEMILOIDS. They have purified it in the following way which issimilar to that of the above mentioned 1st method.Procedure: Take 100 kg Silajith raw material and 30kg Triphala raw material into a reactor.Boil with the help of steam for 4-5 hrs, till the Silajith completely dissolves. Take theextract and filter through a cora cloth. Continue the same process for further fourtimes. Concentrate the filtered extract under vaccum to a thick paste form. Dry thepaste in a vaccum dryer collect the dry flakes and pulverize the material in amicropulverizer in a dehumified room. Sieve through required mesh and pack.Tests for Pure Silajith: Doesn’t exit fumes when put on burning coal .Becomes lingakar (dome shaped) while burning. It tastes Katu and Tikta when put on tongue. When put on water it floats and melts slowly thread like solutes downwardsThe Silajith sample has satisfied all the above mentioned tests.Dosage : 2-8 RattiAction on Mutra vaha Samsthan: Asmarihara, Mutrakrichrahara (Ra.ta). Charaka says “There is hardly any curable disease which cannot be controlledor cured with the aid of Silajith. Specially employed genito-urinary diseases, Renal and Bladder calculi , anuriaetc. Under the influence of Silajith thirst, Polyuria Burning sensation and exhaustiondisappear quickly. Its Antispasmodic effects in colics of all forms and spasms ofmuscular tubes may be attributed due to free bezoic acid which it contains.(Nadkarni,The Indian MeteriaMedica). The Indigenous practitioners also used silajith as a diuretic andlithotriptic, Similar properties were attributed to benzoic acid in westernmedicine. (Chopras “I.D of I” pp-437-438). Study on the effect of Eladi Quath in the management of Mutrasmari 101
  • Drugs in Eladi kwatham Piper longum Trebulus terresterisRicinus communis Adathoda vasica
  • Elleteria cardamomum Glycerrhiza glabra Aerva lanata Vitex anguscastu
  • Ingredients of Eladi kwathamGokshura(panchanga) pashana bheda(panchanga) Ela(Phala)Pippali(Phala) Nirgundi(beeja) Yastimadhu(Moola)Vasa(pushpa) Shudhasilajith(powder)Eladi Kwatha churna Silajith (capsulated) Eladi kwatha churnam
  • Clinical Study CLINICAL STUDY The study was planned to evaluate the efficacy of ‘Eladi Kwatham’ in themanagement of Mutraasmari (Urolithiasis). A total of 30 patients fulfilling theinclusion criteria were selected mainly from O.P.D of Govt. Ayurvedic Hospital,Erragadda, Hyderabad.MATERIALS AND METHODS: 1. Source of Data : 30 patients of urinary calculi attending the O.P.D. of Govt. Ayurvedic Hospital were considered for study. 2. Method of Collection of Data: Open trail with a pre test and post test design with 30 patients of either sex withage group between 10 –60yrs suffering from renal calculus were selected randomlyand allocated into a single group.A special proforma was taken with all the points of history taking and examination,based on criteria mentioned in Ayurvedic classics and Ultrasonography &Urineanalysis was adopted to confirm the diagnosis.A) Inclusion criteria: Renal, ureteric and vesicular calculi Calculi measuring 1-20 mm in size Patients aged between 10 – 60 years.B) Exclusion criteria: Pregnant and lactating women Patients with systemic illness Patients with history of diabetes Patients with big calculi (Above 20mm) are excluded. Study on the effect of Eladi Quath in the management of Mutrasmari 102
  • Clinical StudyC) Investigations and Interventions: The study was only Human Clinical study. No animal experimentation wasconducted.I) Investigations: a) Routine haematological investigation. b) Urine routine and microscopic analysis. c) X-ray KUB d) Ultrasonography KUB abdomen. Clinical diagnosis was confirmed by ultrasonography. Size and position of thecalculi was assessed before and after treatment.2) Interventions: Drug- Eladi kwatham Dose- 80ml twice daily, before food. Route- Oral Treatment- 40 days Observation period- before and after treatment (40 days) The parameters of signs, symptoms and investigations were categorized on thebasis of standard methods of statistical analysis. The signs, symptoms andinvestigations mainly Ultrasonography and Urine analysis before and after treatmentwere compared and the efficacy of the drug were analyzed with the help of theobtained data.OBSERVATIONS AND RESULTS:Observations: For any research work, the data should be collected systematically and must bepresented in such a way that the reader can understand the things in a better way. Herethe data is presented in Tabulations, Graphs and Pictograms, as these are selfexplanatory descriptions. And are given wherever required. Study on the effect of Eladi Quath in the management of Mutrasmari 103
  • Clinical StudyTable no.13 showing Age Incidence: Age group No. of cases Percentage 10- 20 2 6.6% 21-30 10 33.3% 31-40 11 36.6% 41-50 6 20% 51-60 1 3.3 Total 30 100% The age group incidence of the patients suffering from mutrasmari revealsmaximum number were in between 30-40 yrs i.e. 36.6%, followed by patients of 20-30yrs i.e. 33%. 20% in 40-50yrs. The above incidence is in accordance with themodern literature that this disease is more seen in 3rd and 4th decades.Table no. 14 Showing Sex Incidence: Sex No. of cases Percentage Male 26 86.6 Female 4 13.3 Total 30 100% Sex incidence reveals 86.6% in males and only 13.3% in females justify thestatement that males are more prone to Urolithiasis than females.Table no. 15 Showing Religion Incidence: Religion No. of cases Percentage Hindu 23 76.6% Muslim 4 13.3% Christian 3 10% Total 30 100% Religion incidence with relation to mutrasmari shows that Hindus are with76.6% followed by 13.3%of Muslims and then Christians. May be this is in accordancewith the density of the population of respective communities.Table no. 16 Showing Occupation Incidence: Study on the effect of Eladi Quath in the management of Mutrasmari 104
  • Clinical StudyOccupation No .of cases PercentageHouse wife 3 10%Student 3 10%Business 7 23.3%Labor 8 26.6%Clerk 2 6.6%Sales boy 1 3.3%Farmer 1 3.3%Teacher/Lecturer 3 10%Lab technecian 1 3.3%Church Father 1 3.3%Total 30 100%Table no.17 Showing Socio Economic Incidence: The lower, middle and upper class - groups are divided into three categoriesbasing on their nature of work, financial status number of family members andpercapita income. i. Lower class- below Rs.5,000/month ii. Middle class- Rs. 5,000-20,000/month iii. Upper class – Rs.20,000 and aboveSocio economic status No. of cases PercentageUpper Class 1 3.3%Middle Class 12 41.1%Lower Class 17 56.6%Total 30 100% The lower socio-economic group people are more prone to the diseaseurolithiasis. Followed by middle class with observations in this study also justifies thestatement .Having lower class group with highest percentage of 56.6%, followed by41.1%, and very less in upper class with only 3.3%. Study on the effect of Eladi Quath in the management of Mutrasmari 105
  • Clinical StudyTable no.18 Showing Diet Incidence:Diet No. Of cases PercentageVegetarian 3 10%Mixed 27 90%Total 30 100% It is observed that more number of patients were consuming mixed diet (Non-vegetarians i.e.90% and less were the vegetarians with only 10%.Table no.19 Showing Chronicity of disease:Chronicity No. of cases Percentage 0-1M 5 16.6%1M-6M 6 20%7M-1Y 5 16.6%2Y-3Y 6 20%4Y-9Y 8 26.6% Total 30 100% The patient’s disease chronicity was graded .Different persons with variedperiod of chronic and acute phases were noted.Table no.20 Showing Location of Calculi:Location of Calculi No. of cases PercentageRenal 23 76.6%Ureteric 5 16.6%Vesiculo Ureteric junction 3 9% It is observed that 76.6% i.e more incidence of renal calculi (may be due tokidney being the origin of calculi formation) followed by ureteric, 16.6% and a less of9% of vesiculo ureteric junction.Table no.21 Showing No of Calculi: Study on the effect of Eladi Quath in the management of Mutrasmari 106
  • Clinical StudyNo. Calculi No. of cases PercentageSingle 14 46.6%Multiple 15 50%No Calculi 1 3.3%Total 30 100% Among the patients with Urolithiasis it is observed that nearly half, 50% werewith multiple calculi (more than one) and 46.6% with single calculi (one) and onepatient with no calculi.Table no.22 Showing Incidence of calculi in the Kidney:Incidence in the Kidney No. of cases PercentageLeft Kidney 11 37.9%Right Kidney 7 24.1%Bilateral 11 37.9%Total 29 100% There are patients with calculi in Left Kidney 37.9%, in Right kidney with24.1%, and Bilateral with 37.9%, showing nothing much relation to the side of kidneyTable no. 23 Showing Habitat:Habitat No. of cases PercentageTown 25 83.3%Village 5 16.6%Total 30 100% The observation show more people dwelling in the town, 83.3% were havingthe disease than people dwelling in village i.e 16.6%.Table no.24 Showing Prakriti : Study on the effect of Eladi Quath in the management of Mutrasmari 107
  • Clinical StudyPrakriti No. of cases percentageVata 6 20%Pitta 9 30%Kapha 11 36.6%Vatapitta 2 6.6%Vatakapha 1 3.3%Pitta kapha 1 3.3%Sannipata 30 100% The prime samprapti gatakas being kapha and vata doshas there is contributionof all doshas in stone formation including pitta .Even all the prakriti persons may havethe chance of developing mutrasmari, here in this present study it is observed thatkapha prakriti persons 36.6% were the sufferers, followed by pitta with 30% and vatawith 20%.Table no. 25 Showing Habits:Habits No. of cases PercentageTea/coffee 24 80%Smoking 15 50%Alcohol 13 43.3%No habits 3 10%It was observed in the study that majority of the patients have different habitsTable no.26 Showing Degree of pain:Degree of pain No. of cases PercentageMild 10 33.3%Moderate 6 20%Severe 11 36.6%No pain 3 10%Total 30 100% Study on the effect of Eladi Quath in the management of Mutrasmari 108
  • Clinical Study It is observed that patients were having a varied degree of pain depending onposition of stone in the urinary tract .some of them were quesent ones with nosymptom of pain.Table no.27 Showing Signs and Signs and Symptoms No. of cases Percentage1. Pain 27 90%2. Vomiting 0 0%3. Fever 0 0%4. Burning micturition 21 70%5. Dribbling/obstructed urine flow 1 3%6. Haematuria 6 20%7. Murphys kidney punch 5 16.6% (tenderness)8. Other changes in urine 5 16.6%9. Hydronephrosis 4 13.2% As per the signs and symptoms exhibited by the reported patients diagnosed asthe mutrasmari .Vedana and Mutra krichra were main complaints of all where inassociated symptoms were very less in number.Table no.28 Showing Water Intake:Water intake No. of cases PercentageLess 20 66.6%Sufficient/more 10 33.3%Total 30 100% By the observations seen in this study, the persons who consumed less waterday to day were more in incidence with 66.6% and who cosumed more or sufficientwater were only 33.3%, This indicates less water intake may precipitate the calculiformation. Study on the effect of Eladi Quath in the management of Mutrasmari 109
  • Clinical StudyTable no. 29 Showing Reccurance/Fresh:Reccurance/fresh No. of cases PercentageReccurance 14 46.6%Fresh 16 53.3%Total 30 100% In the modern literature it is stated that, Urolithiasis is more with reccurancerate. In ths present study it is observed that nearly half 46.6% of patients came withreccurance of disease and 53.3% with fresh complaint. Study on the effect of Eladi Quath in the management of Mutrasmari 110
  • Clinical Study RESULTS After the administration of the drug ‘Eladi kwatham’ for 40 days, the followingresults were obtained and they are assessed accordingly.Table no. 30 Showing Relief of Relief of pain No.of cases Percentage1. 1-10 days 2 7.1%2. 11-20 days 4 14.2%3. 21-30 days 4 14.2%4. 31-40 days 5 17.8%5. Pain reduced 5 17.8%6. Still persisting 8 28.4%7. Total 28 100% Among 28 patients 15, 53% got complete relief of pain by 40 days coarse oftreatment.2 were already not having pain symptom. Pain, not relieved in 8 and severityof pain was reduced in 5 patients.Table no.31 showing response in pain before treatment and after Response in Before.Tt Percentage After Tt Percentage pain1. No pain 2 6.6% 17 56.6%2. Mild pain 10 3.33% 4 13.3%3. Moderate 6 20% 1 3.3%4. Severe pain 11 36.6% 8 28.4%Table no.32 Showing Response in Burning micturition: Study on the effect of Eladi Quath in the management of Mutrasmari 111
  • Clinical Burning micturition No.cases Percentage1. 1-10 days 5 2.85%2. 11-20 days 13 61%3. 21-30 days 5 14.2%4. 31-40 days 0 05. Still persisting 0 06. Total 21 100% It shows out of 21 patients having symptom burning micturition 5 i.e 23.8% gotrelief by 10 days and 13 patients, 61% got relief by 20 days and 3 by 30 dayscompletely.Table no.33 showing response in Burning micturition before and after Burning Before Tt Percentage After Tt Percentage micturition1. Present 21 70% 0 0%2. Absent 9 30% 30 100%There were almost nill patients with persisting burning micturition.after treatment.Table no. 34 Showing Frequency and Volume of Frequency of urination No.of cases Percentage1. Increased 20 66.6%2. Decreased O 0%3. Normal 10 33.3%4. Total 30 100%.By the administration of the drug it is observed that 66.6% i.e 2/3rd of patients havenoticed increased volume and frequency of urine flow, may be because of the diuriticaction , the drug has.Table no.35 Showing State of Stone after Treatment: Study on the effect of Eladi Quath in the management of Mutrasmari 112
  • Clinical State of stone after treatment No. of cases Percentage1. Passed 10 33.3%2. Reduced 0 0%3. Dislodged 1 3.3%4. Still Persisting 15 50%5. Passed & persisting 4 13.3%6. Total 30 !00% It is observed that among 30 patients 10 i.e 33.3% have passed off the stonescompletely. No one has showed the reduced size of the stone. After treatment, onepatient with dislodged stone (from lower pole to middle pole the outer way).15patients, 50% have still persisting stones.4 patients have passed 1or 2stones among themultiple stones and still having some with in.Table no. 36 showing patients with calculi before and after treatment:S.n Calculi in patients Before Percentage After Percentageo treatment Treatment1. Present 29 96.6% 15 50%2. Absent 1 3.3% 11 36.6%3. Pesisting and passed 0 0% 4 13.3%Table no. 37 showing no.of stones passed from different levels of Urinary Passed stones No.of stones Percentage1. Renal 7 50%2. Ureteric 4 28.5%3. Vesiculo ureteric 3 21.4% junction4. Total 14 100%Table no.38 showing no. of calculi present at different sites of urinary systembefore and after treatment: Study on the effect of Eladi Quath in the management of Mutrasmari 113
  • Clinical StudyS .no Site of stone Before Tt Percentage After Tt Percentage1. Renal 23 76.6% 16 53%2. Ureteric 5 16.6% 1 3.3 %3. Uretero vesicular 3 9% 0 0% jnt. It is observed that out of 23 renal stones only 7 were passed out, and from 5ureteric stones 4 were passed out and no single stone is persisting which were atvesiculo ureteric junction.Table no. 39 showing lab Investigations before and after Lab investigations Before Percentage After Percentage treatment Treatment1. Alkaline urine 6 20% 4 13.3%2. Acidic urine 24 80% 26 36.6%3. Pus cells 18 60% 2 6.6%4. Crystals 9 30% 1 3.3%5. Epithelial cells 19 63.3% 5 16.6%6. R.B.C 9 30% 1 3.3% It is observed that patients were with 20% alkaline and 80% with acidicurine.There is no much change in the pH of the urine after intervention.There are 18patients with pus cells, 9 with crystals, 19 with epithelial cells and 9 with R.B.C in theurine But after treatment all of them were reduced to marked extent.Table no.40 showing the position from which the calculi have Passed Stones No. of calculi Percentage1. Renal 7 50%2. Ureter 3 21.4%3. Vesiculo Ureteric Junction 4 28.5%4. Total 14 100% Out of 14 patients who have passedaway the stones from the urinary tract 7were renal, 4were ureteric and 3 were vesiculo-ureteric junction calculi. Study on the effect of Eladi Quath in the management of Mutrasmari 114
  • Clinical StudyTable no.41 showing Statistical Analysis of the Data: Mean Mean Mean Std. Std. ‘t’ ‘p’ Remark B.T A.T Diff. Dev. Err Value ValueBurning 1.3 0 1.3 1.055 0.832 6.7468 0.00 SignificantmicturitionPain 1.933 1.00 0.933 1.015 3.0804 0.0031 SignificantState of 1.933 1.133 0.800 0.635 0.832 5.0655 0.0004 SignificantCalculi Study on the effect of Eladi Quath in the management of Mutrasmari 115
  • Discussion DISCUSSIONDiscussion on clinical Study: The present study was under taken to find an alternate and a better therapy forthis common disorder, Urolithiasis . A lot of work has been carried out on the samedisease with various compounds. The aim of the present study is to assess the efficacyof the drug,”Eladi Qwatham” in the management of Mutrasmari. In this present study ultrasonography and urine analysis were used as diagnostictools. Ultrasonography was adopted as it is a non-invasive investigation and detectsradiolucent calculi as well. From the study it was observed that mutrasmari is more seen in the age group30-40yrs (46.6%, n=30) and it is common in males (86.6%, n=30). Mixed diet has alsoshowed its role in causation of disease with (90%, n=30). In occupation category(66.6%), consuming very less amount of water and lower socio-economic persons aremore in percentage (56-6% n=30).All these explains , less intake of fluids andperspiration work is generally seen in lower socio-economic group of people, leadingto cause Urolithiasis. Only 4 out of 30 patients were having history of hereditary urolithiasis. Noconclusion can be drawn from this but, the statement in Haritha samhitha regardingMatruja and pitruja bhavas proves to be right.Probable mode of action of the compound Eladi Quatham: The compound ’Eladi Quatham’ constitutes all together eight herbal drugs andone mineral drug. All of them have been mentioned in classics to posses action on theMutravahasrotas in one way or the other, which help in alleviating the diseaseMutrasmari and its symptomatic manifestations. Study on the effect of Eladi Quath in the management of Mutrasmari 116
  • DiscussionTable No.40 Mode of action of the individual drugs Eladi Quatham on Mutrasmariaccording to different authors is being listed here as Drug Properties Refernce1. Ela Mutrasmari hara -Ni.ra Mutrakrichrahrit;;; Pippali Sula nasam Kapha vata haram -Kai.ni3. Madhuka Mutravirajaneeya -Charaka Vranapaham Sadyovranam nasayet Vrana sodhana Ropana -So.ni4. Eranda Sula hara, Margasodhana, Vranapaha, Mutrakrichrahara, Vasti sulahara, Sula anilapaham Vastisula hara Margasodhana,Vastisirorujihara, Mutradoshamjayet, Vastsula, Asmanasam.5 Vasa Flowers-Mutrajanana -Bh.pr6. Renuka Sothagna, Anulomaka, Mutrajanana -Bh.pr7. Asma bheda Asmari nasani Gokshura Mutravirechaneeya, Mutakrichra anilahara, -Charaka Asmari bhedana -Susruta Mutrakrichrahara Vastisodhaka, Asmarihara, -Bh.pra Asmarihara Mutrakrichrahara, Srotavsodhana -A.S Mutralam, krichranasa, Mutrakrichrahara, Ushna anilahara9. Silajith Mutrakrichra, Asmarihara -Ra.ta These drugs are also proved to have action on the disease Urolithiasisscientifically. Some of the research work is enumerated here.1. Asma bheda - Diuretic, Anti lithic activity2. Yastimadhu - Anti 9 , Antioxidant and protective against kidney damage.3. Nirgundi - Anti tumor, Antimicrobial, Anti inflammatory. Study on the effect of Eladi Quath in the management of Mutrasmari 117
  • Discussion4. Pippali - Bio-availability, increased permeability of intestines. Antispasmodic, Anti inflmmatory.5. Eranda - Anti inflammatory.6. Gokshura - Nephro protective activity, Lithotriptic, Diuretic, Action on smooth muscle.7. Vasa - Smooth muscle relaxation, Haemostatic activity.8. Silajith - Diuretic, Lithontriptic, antispasmodic. Pippali one of the ingredients has the property of increasing the permeability ofthe intestines, might have helped for good absorption of the drug from the gut andreach the level of urinary system without altering its therapeutic properties itsBioavailability. Many ingredients of this compound have the actions like, Mutrala,Mutravirechaniya, Mutrajanana, Vastisodhana, Margasodhana, Srtovisodhana,Anulomaka, Mutrakrichra hara properties. Because of these which are acting as theDiuretics (Production of more urine , Excretion of more urine, Flushing out of alldoshas/ disease causing factors like decreasing the formation and saturation of theurine, Restoring the optimum Crystalloid – Colloid ratio and finally inhibit nucleationand Calculi formation). This may also flush out the already existing calculi, and alsodecreases Dysuria and Burning micturition. May be this is the reason why many patients (66-6%) have noticed increasedflow, frequency and volume of urine during the treatment and got relief from dysuriaand burning micturition. Vasa has Haemostatic activity (Rakta pitta hara),Yasti madhu withVranasodhana ropana activity. In cases of haematuria, there will be underlying damageto the tissue (Ulceration) of the urinary tract by impregnated calculi. Vasa andYastimadhu would work by healing the ulcer and haemostasis. Pippali has the properties of Sulahara, and Eranda has Sula anilaapaha,Vastirujihara and Vastisulahara (Vasti sirah-Kidney, Vasti –Entire urinary system). Bytheir effect, vedana of the vasti, sepha, mushka etc. and vastisirah vedana would berelieved. In addition gokshura, pippali, vasa have anti spasmodic action, which wouldalso have affected in reducing the intensity of the colicky pain of the ureter. Study on the effect of Eladi Quath in the management of Mutrasmari 118
  • Discussion Yastimadhu, Eranda, Pippali, Nirgundi have the properties like Antiinflammatory, Anti microbial by which local inflammation in the urinary tract due toimpaction of the stone and infections due to microbes may be relieved. Ela, silajith, Gokshura, Pashana bheda have important properties of Asmaribheda / Asmari hara, Mutrakrichrahara. They are mentioned to have Diuretic andLithontriptic action in modern literature also. Many Research works has beenconducted on these drugs and was proved to posses these properties. They would actby disintegrating, dislodging or flushing out the urolith from the urinary tract or createcertain circumstances which would disturb the nucleation and the crystal formation orby decreasing the size of the stone ,ceasing further growth of the stone. Gokshura has Nephro protective activity and Yastimadhu with Antioxidant andprotective against Kidney damage. This would help the kidney further by ill effects ofthe calculi and enhance speedy recovery. For the formation of any stone,’Kapha’ is the essential as its basic quality is‘slish alingane’ that act as the nidus. Here Asmari bhedana, Kaphavataghna,Vastisodhaka etc. karmas of individual drugs had acted over the compactmolecules distructing the bondage of the kapha . More over by the Mutrajanana,Mutrala, Mutravirechaniya etc. properties would have flushed out the disintegratedstones or the stone as it is, and also decreased burning sensation. Discussion on the Releif obtained in these 30 patients in Subjective andObjective Symptomatologies: Response in Relief of pain: After the administration of the drug, it is observed that 53.3% of patients werecompletely relieved from pain, 17.8% were partially relieved and 28.4% with no reliefof pain. 4 patients had severe colicky pain episodes during the course of treatment.This may be because of the flushing out of the stone, coming out of the narrow tract ofureter causing ureteric colic. Patients were not able to bare the pain even byadministering Eladi Quatham. They were advised to have Antispasmodics andanalgesics to overcome the emergency episode. The over view suggests that more than half i.e.53.3% patients had complete Study on the effect of Eladi Quath in the management of Mutrasmari 119
  • Discussionrelief and 17.8% were partially relieved by decreased intensity of pain in spite of beingunable to manage the acute phase of pain. Response in Burning Micturition: 100% of patients were completely relieved from burning micturition (occasionalalso) by 30 days of treatment only. Drug proves to have good diuretic effect by causingincreased flow, frequency and volume of urine which would have flushed away theinfection causing factors. Response to the Urine analysis Findings: There is no much marked change in the pH of urine before and after treatment.Pus cells, Crystals, Epithelial cells, R.B.C, in urine found in very less no. of patientswith a gross reduction after treatment. Passage of Stones in Response to Treatment: The presence or absence stone was assessed basing on the report of theUltrasonography (K U B) before and after treatment. By the treatment given 14(46-6%) patients passed stones in which 4 have passed out, 1or 2 among multiple calculi,having some more still persisting stones. But there was no change/ response in15(50%) patients Regarding the size of the stones which were passed out 2mm- 14mm also werepresent. In one patient it was noted that calculi in the lower pole has reached the midpole, to way out after treatment. In no. of stones passed, only 7 out of 23 renal calculi, 4 out of 5 ureteric calculiand 3 out of 3 calculi from uretero vesicular junction were passed out. This implies thatstones at Ureteric and Vesciculo ureteric junction are flushed out easily with goodsuccess rate. But, renal stones were passed out in a very less number comparatively Study on the effect of Eladi Quath in the management of Mutrasmari 120
  • Conclusion CONCLUSION In the present study, evaluating the Efficacy of Eladi Quatham in Mutrasmari, itis observed that, 46.6% patients passed out stones, 53.3% had completely relievedfrom pain and 100% relieved from burning micturition .By the result it is concludedthat effect of drug on pain and passage/disintegration of stones is only to some extent.But, had good effect on burning micturition. While assessing the treatment and the result obtained, it shows that thecompound Eladi Quatham has proved its diuresis by its flushing out action, which hadhelped the patient to get rid of severe pain and burning micturition. But could notestablish the lithotriptic action properly. It is observed that, the administered Drug had not produced any adverse effectsin the patients. Probably by adopting the Sodhanakarma before the administration of medicinewould have given more successful results. In this study 30 patients were analyzed treating with Eladi Quatham. Thisnumber is not sufficient for statistical viability, but taken for pilot study. Though the number of patients were very less, Critical analysis is made on thepatients as well as the role of the drug, to establish the clinical management by a drugof choice. To evaluate the exact action of the drug, deeper work is needed. Further workcan be taken up by enthusiastic scholars with a big sized sample and still morestandard parameters. Study on the effect of Eladi Quath in the management of Mutrasmari 121
  • Summary SUMMARY The study was under taken to evaluate the “Efficacy of Eladi Quatham” in themanagement of Mutrasmari (Urolithiasis) is mainly based on clinical observationconducted at Dr.B.R.K.R Govt Ayurvedic College – Hospital, O.P.D, under theguidance of Dr. M.L.Naidu. The drug was selected from the references available inSarangadhara Samhita and Bhaishajya Ratnavali. A separate Proforma was made in regard with complaints of Urolithiasis inO.P.D. basis. The present study was done in three sections as followsSECTION -I: Reveals the Literary aspects available in Ayurveda and Modern medicinerelated to Mutrasmari or Urolithiasis. History, Etiology(Nidana), Prodromal Symtomatology(Purvarupa), Signs andSymptoms(Rupa), Types and Characteristics(Bhedas), Prognosis(Sadhyasdhyata),Complications(Upadravas), Management(Chikitsa), Dietic Factors(Patyapatya) areexplained in detail. It also comprehences with the additional review of Anatomy andPhysiology of both sciences related with urinary System and MutravahaSrotas. DrugReview is also included. Thorough review of both Modern and Ayurvedic literaturehas been done. The Ayurvedic literature which is very scattered in different Vedas &Classical texts has been collected and arranged in a sequence. A brief discussion is alsomade in correlating Ayurvedic and Modern sciences in respective areas.SECTION –II: Includes information about the Clinical Trail undertaken, Materials andMethods, Observations, Results and Discussion on the same.SECTION –III: Conclusion and Suggestions for further study is mentioned. The study was an observational study with pretest and posttest design .All the cases of Asmari were selected randomly, with a sample size of 30 cases satisfying the inclusion and exclusion criteria. They were assessed thoroughly. Study on the effect of Eladi Quath in the management of Mutrasmari 122
  • SummaryRoutine suggested investigations were done and diagnosis was done on thebasis of signs and symptoms mentioned in both sciences.Patients are advised to take the drug Eladi Quatham 80ml, twice daily, emptystomach, for 40 days.The assessment of the treatment was done by follow-up for every consecutive10 days basing on subsidal of signs and symptoms.The confirmation of the relieved disease (Mu rasmari) was done by done bypassing the stone in urine or by Ultrasonography(KUB).From the study it is observed that Mutrasmari is mainly seen in the age group30-40yrs and more common in Males, may be because of more exertional workand less intake of fluids. Mixed diet has also shown its role in causation ofdisease.Many patients have one or the other habits in their daily life with a stressfuloccupation, all the patients were doing one or the other Apathya sevanafrequently like adhyasana, rookshahara, Teekshnaahara, vishamasana,vegadharana. None of them had undergone Sodhana terapy earlier.In the aspect of complaints presented during the visit, pain and burningmicturition were predominately seen associated with few symptoms likevomiting haematuria, fever etc.After administration of Eladi Quatham 56.6% of patients had complete relief ofpain 100% of subjects showed relief from burning micturition .Where as 46.6%expelled the calculi out completely and 13.3% expelled 1or 2 calculi out ofmultiple calculi.In spite of being unable to manage acute pain episode and less success rate inexpelling the renal calculi, drug has proved to have good diuretic action whichhelped in flushing out the small sized stones from the urinary tract and relief ofpain Study on the effect of Eladi Quath in the management of Mutrasmari 123
  • References REFERENCES1. Rgveda (10-163-3)2. Yajurveda (19-85)3. Athervaveda (Pr.Khanda/Pr .Anuka,Pr.sukta 11-9)4. Rgveda (10-163)5. Athervaveda (1-11-5,2-33, 20-96)6. Athervaveda Ayurveda SubhodaBhashya7. Amarakosa8. Amarakosa9. Su.Sa. -9/1210. Cha.Vi- 5/811. A..H -6/5812.Chakrapani on Cha.Vi.-5/3813. Cha.Vi -5/914. Su.Ni -3/21-2415. Cha si-9/416. Su.Sa -9/6717. Bha.Pra.Ma-503/36418. Bha.Pra.Ma-509/17219. Cha.Su.-28/4; Cha.Vi-15/1820. Sa.Sa.Pu-9/1921.Su.Ni-3/922. A..S.Sa-5/8123. A..V.2nd K.33-4& R.V10-163-324. Su.Sa.5/42,4325. Cha.Chi- 16/626. Cha.Sa-3/1227. A.S.Sa-7/2028. A.H-4/10-1129. A.S Sa-7/1930. Su.Sa-5/8 Study on the effect of Eladi Quath in the management of Mutrasmari 124
  • References31. Su.Chi-7/3332. Cha.Si-9/433. Cha.Sa-7/1034. Cha.Chi-7/1135. Sabda Kalpadruma36. Sabda Kalpadruma37. R.V-10-163-3& A..V-2-33-338. Dhalhana on Su.Sa -939. A.H.Sa 3/2; Cha. Su-7/7; Su.Sa-5/540. Su.Ni.1/1841. Su.Sa.4/3042. Cha.Sa-17/1043. Su.Sa-9/1244. Cha.Vi.-5/845. A..S.Su-6/2646. Sa.Pu-5/4547.A.V.1-11-648. Dalhana on Su.Chi-7/1349. Cha.Vi-8/11750. A.V.1-3-651. Cha.Su-28/452. Su.Sa-21/453. Su.Sa-9/754. Dalhana on Su.Sa-9/1155. Dalhana on Su.Ni-3/21-2456. Su.Ni. -3/21-2357. A.H.Ni-9/258. Sa.Pu.-6/759. Su.Ni-21/360. Su.Ni-1/1961. A.H.Su-19/562. Su.Su.-15/563. A.H.Su-19/2 Study on the effect of Eladi Quath in the management of Mutrasmari 125
  • References64. Su.Su.-15/2865. A.H.Su-19/1366. Cha.Su.-7/667. A.H.Su-5/468. Cha.Vi-5/2069. Cha.Vi-5/270. Sa.Pu-5/4771. Su.Sa-9/672. Su.Sa -9/773. Su.Ni-3/2074. Cha.Si-9/975. Su.Chi-7/3376. A.H.Ni-9/4077. Su.U-58/78. A.H.Ni-9/2079. Sabda KalpaDruma80. Ayurvediya Sabda Kosa81. Cha-Chi.26/3282. Sa.Ma-3/483. H.Sa-31/184. Cha.Chi.26/3285. Su.Ni-3/486. A.S.Su-5; Ni.Ra.As.Chi.Pr87. Dalhana on Su.Ni-3/388. Ni.Ra89. Su.Ni-3/23-2490. Gayadas on Su.Ni-3/391. Su.Ni-3/2; Bh.Pr-37/292. Chakrapani on Cha.Chi-26/3693. Su.Ni-3/25-2694. A..S.Chi-9/695. Cha.Chi-26/3696. Su.Ni-3/4 Study on the effect of Eladi Quath in the management of Mutrasmari 126
  • References97. Bha.Pra.37/198. Su Ni.3/599. A.H-9/7-8100. Su.Ni-3/7101. Su.Ni-3/10102. Su.Ni-3/11103. Su.Ni-3/12104. Su.Ni-3/13105. Su.Ni-3/16-17106. Ma.Ni-32/16107. Su.Su-32/12108. Su.Su-33/5109. Su.Su-32/12110. Su.Ut-58/36111. Su.Chi-7/12112. Su.Chi-7/34113. Cha.Chi-26/56114. Cha.Chi.26/68115. A.H.Chi-11/15116. Su.Chi.7/27117. Cha.Chi-1/3,26/76; Bha.Pra.36/70-72; Ha.Sa.Tri 31/17-19. Study on the effect of Eladi Quath in the management of Mutrasmari 127
  • Bibliography BIBLIOGRAPHY1) Sabda Kalpa Druma, Bahadur, Raja,RadhaKantha Deva, Nag Publishers,Delhi, (1998).2) Amarakosa; Tanslation and Edition by Pandit Viswanath Jha, motilal Banarasidas,Varanasi.3) Athervaveda-Pandit Sripada Dhamodhar Satvaleker ,Sahitya vachaspathi, Swaadhyaya Mandali.4) Susruta Samhita,of Susrthaacharya, with commentaries, ‘Nibanda sangraha’ of dalhana and ‘Nyaya chandrika’ of Gayadas ;Vaidya Yadav Trikamji Acharya, ‘Kavya tirtha’, Reprint 7th Edition (2001) Krishnadas Academy, Varanasi.5) Susrutha Samhitha, English translation of text and Dalhana commentary along with critical notes by P.V.Sharma,Chowkhamba Orientalia.6) Susrutha Samhitha, Telugu, Published by Vavilla Ramasastry and Sons. (1958).7) Charaka Samhita, of Agnivesa, Text book with English Translation and Critical Exposition based on Chakrapani dattas ‘Ayurveda Dipika’ by R.K. Sharma, Bhagawan Dash. Chowkhamba Orientalia,Vranasi.8) Charaka Samhitha, Telugu, Vavilla Ramasastry and Sons, published by Vavilla Press, 1941.9) Astanga Hridayam, of Vaghbhatacharya, Prof. k.R.Srikantamurthy, Chowkhamba Krishna das Academy, Varanasi, 5th Edition .10) Astanga Sangraham of Vagbhatachaya, Kavi Raj Atrideva Gupta, Reprinted Edition 1993, Krishna Das Academy, Varanasi.11) Madhavanidana of Madhvakara,’Madhukosa Vyakhya’. Commentary by Sudarshan Shastry.Edited by Sri Yadudunandanopadhyaya,Chowkhamba Sanskrit Series , Varanasi.12) Yoga Ratnakaram, (1999), Anonymous, ‘Vidyotini’ Hindi commentary by Lakshmipathy Sastry Vaidya, Chowkhamba Sanskrit Series, Varanasi.13) Bhava Prakasa of Bhava Misra ‘Vidyotini’ Hindi commentary by Sri Brahmasankar Misra and Roopalalji Vaisya; 8th Edition, Kashi Sanskrit Series, Chowkhamba Sanskrit Sansthan, Varanasi (1993).14) Bhava Prakasa Nighantu, commentary by Dr.K.C.Chunekar.Edited by G.S.Pandey, 5th edition Chowkhamba Sanskrit Sansthan, Varanasi.1979. Study on the effect of Eldi Quath in the management of Mutrasmari 128
  • Bibliography15) Haritha Samhitha, Srimadaatreya Mahrshi Haritha Muni Samvadhitarupa, by Kshema Raja Sri krishnada, Sri Venkateswara Mudranalaya16) Sarangadhara Samhitha of Sarangadhara. English Translation by Dr.P.Himasagara Chandramurthy, Chowkhamba Sanskrit Series, Varanasi.(2001), 1st edition.17) Bhaishajya Ratnavali, GovindaDas.,’Vidyotini’ AmbikaDatta Sastry, 18th Edition, (2005) , Chowkhamba Sanskrit Series, Varanasi .18) Rasa Tarangini, Sadanand Sharma, Motilal Banaras Publications, Delhi, (1979).19) Rasa Ratna Samucchaya, Rasa Prabha Vyakhya by Indra Deva Tripati, Chowkhamba Orientalia,Vranasi.20) Ayurveda Prakasa, of Sri Acharya Madhava, Upakhya Sri GulRaja Sharma Misra Chowkhamba Bharathi Academy (1999).21) Indian Medicinal Plants, Orient Longmans ltd Publications (1997).22) Indian Materia Medica, Nadkarni.K.M, A.K.Nadkarni, Revised 3rd Edition, Popular Prakasan , Bombay.23) Indian Medicinal Plants , R.Kriyikar and Basu, 1975, 2nd Edition, Jayed Press, Delhi-624) Dravya Guna Vignana, P.V.Sharma Chowkhamba Bharathi Academy (1999).25) Dravya Guna Vignana, J.L.N.Shastry 1st Edition 2004, Chowkhamba Orientalia.26) Urology In Ayurveda (Basti Vignana), V.B.Athavale, 2nd Revised Edition, 2004, Chowkhamba Sanskrit Pratistan, Delhi.27) Rasa ShastraVignanam , Dr.K.Nisteshwar, A.P.Ayurvedic Literature Improvement trust, Hyderabad, 2nd Edition, 2005.28) Ayurvedic Scientific Seminar on Kidney-Urinary Disorders, Research Papers,26-27, March- 2003.Rashtriya Ayurveda Vidya Peeth, National Academy of Ayurveda.29) PhytoPhram May 2006, Feature article, Tribulus Tereteris, by Nandan KumarJha, et al.Herbal Information Center, New Delhi.30) Sanskritandhra Nighantu-by Vetsa Venkata Seshayya,1st Edition (1873)31) Current Medical Diagnosis and Treatment, 2006, LANGE, 45th Edition. Study on the effect of Eldi Quath in the management of Mutrasmari 129
  • Bibliography32) A.P.I Text Book of Medicine, 7th Edition, 2007.Published by Association of Physicians of India, Mumbai.33) A Concise Text book of Surgery, Somen Das, 2nd Edition, 1999, published by S.Das, 13, Old Mayer Kolkata.34) Short Practice of Surgery, Baley and Love, 18th Edition.35) Robbins Pathologic Basis of Disease , 5th Edition 1994, Published by Prism Book Pvt Ltd36) Principles of Anatomy and Physiology, 10th Edition, Tortora & Grabowski, Harper Collins College Publishers.37) Campbells Urology, Harrison,Gitles, Perlmuther, Staney Walsh.Vol.I,4th Edition, W.B.Saunders Company, Pheladelphia, London, Toronto.38) Clinical Die tics and Nutrition, By F.P.Antia and Philip Abraham, 4th Edition, 2003.Oxford University press.39) Text Book of Renal Disease, Edited by Juditha.A, WhitWorth, J.R.Lawrence. Churchill Living Stone, Medical Division of Long Mans Group. III rd Edition.1994.40) Infections Complications of Renal Disease, Edited By Paul Sweny. Oxford University Press , 2003.Ist Edition.41) Lecture Notes on Urology, Jhon Blandy, 5th Edition 1998, Black Well Science Limited.42) Urology, The Core Text Book, 2nd Edition. Stephen.N Rous, MD,MS,.(Urology).1996.Black Well Science ., Ltd. Study on the effect of Eldi Quath in the management of Mutrasmari 130
  • Annexure POST GRADUATE DEPARTMENT OF KAYACHIKITSA Dr.B.R.K.R. GOVT. AYURVEDIC COLLEGE/HOSPITAL ERRAGADDA-HYDERABAD-38 SPECIAL CASE SHEET FOR MUTRASMARIS.No : Regd.No:Name : Age/Sex :Occupation : Religion :Address : DOA : DOD :1. Chief Complaint with Duration: -2. Associated symptoms:PAIN:- Intensity :No Pain/Mild/Moderate/Severe (0/1/2/3) Onset : Duration : Nature : Progress :a) Renal : Dull constant ache in renal angleb) Ureteric : Gripping pain ,loin to groin (to the base of the pennies ,scrotum/l, majora and to inner side of the tigh ) 1) Upper : pain radiating to testicles 2) Middle : pain at the Mc burneys point 3 )Lower : vesicular irritability, pain in the inner side of the thighc) vescical : strangury,pain reffered to tip of the pennies,haematuia +/-BURNING MICTURITION: Presnet/Absent (1/0)3. History of present illness:4. History of past illness:5. Personal history: a) Hobby : b) Addiction : c) Diet : d) Any others :6. Family history:7. Dasa vidha pariksha: prakriti vikriti satvam satmyam aahara sakti vyayama sakti samhanana saram pramana vayah8.Asta staana pariksha:AstaStaanas Vata Pitta KaphaNadi Kapotha gathi Mandukagathi SarpagathiMutraMala Phenila AshrukJihwa Arochaka Dahayukta ArochakaSabhaSparsa Ruksha Nrudu SnigdhaDrik Krishna Peeta Sweta Study on the effect of Eladi Quath in the management of Mutrasmari 131
  • AnnexureAkruti Krusha Moderately built Weell9. Sroto pariksha: Mutra vaha srotas10. General examination: Appetite Sleep C.V.S Respiration Thyroid B.P Tongue11. Local Examination Inspection: Palpation : a) Bimanual b) Renal angle test Percussion:12. Poorva rupas: Jwara Bastipeeda Arochaka Mutrakrichra Bastisiro, muska, sepha – vedana Krichravasada Basta ganda mutrata13. Rupas (Samanya lakshnas) Lakshanas +/- 1st Visit 2nd Visit 3rd Visit 4th VisitNabhi,bastisevanimehaneshvanyatasminMehate vedanaMutra dhara sangamSarudhira mutratwaGomedhuka prakasamatyavilamDhaava,langhana,Palavana,Pristayana,ushnaadhavagamanaischa Vedana bhavati Study on the effect of Eladi Quath in the management of Mutrasmari 132
  • Annexure14. Lakshanas of Vividha Asmari Dosha Vata Pitta Kapha Sukra Tivravedana, Chushyate Dhaalyate Mutrakrichra tadatyardhan Dahyate Bidyate Vastivedana pidyamano Pachyate Nistodyate Vrishanayoscha dantam kadhati Svayathu Nabhi peedyate, Medram pramrudnati, Payum sprusathi, Visardhate, vidahatiVastiguna Ushna Guru, sitaAsmari guna Syava, parusha, Sarakthapeetabh Swetha, snigdha Vishama, khara a, Mahathi KrishnaAsmari Kadamba Bhallatakasti Kukkutandapratika Pidyamatrechalakshana pushpa pratima, m pravilayam vat Madhuvarna Madhuka pushpa kantakaschita varna15. Investigations Before Tt After Tta) Urine: 1. C.U.E 2. pH 3. Sediments 4. Any othersb) Blood: C.B.P - Hb % R.B.C W.B.C B L E M N B L E M N E.S.R Blood Urea Serum creatinine Uric acidc) Radiological Findings X-Ray (KUB) Ultra sound (KUB) IVP16. Treatment:- Eladikwatha choornam Study on the effect of Eladi Quath in the management of Mutrasmari 133
  • Annexure Decoction off eladikwath choornam with silajith capsule bid for 40 dayswith kanda sarkara – empty stomach, before food- 6 Am- 6Pm17. Dietary instructions: Patyas Apatyas Vari sevana Mutra sukra vegadharana Yava Ruksha,guru,aahara Kulutta Viruddahara-asana Puranasalyanna Hingu Purana kushmandaphala Tila Ardrakam Sarshapa Narikela Tambula Kharjura Matsya Keera Takra,paya,dadhi18. Coarse of treatment and issue of medicines:Visit Date Result Complications if any1st Visit2nd Visit3rd Visit4th VisitResult19. Special Assessment and Discussion: Signature Signature SignatureP.G.Scholar Co-supervisor Supervisor Study on the effect of Eladi Quath in the management of Mutrasmari 134