Prameha and Diseases of Udakavaha Srotas
(Part-7)

Prof. Muralidhar Sharma
based on the lecture available at–Prameha and Diseases of Udakavaha Srotas

“षोभाद्भयाच्छ्रमादपि शोकात्क्रोधाद्विलङ्घनान्मद्यात्|
क्षाराम्ललवणकटुकोष्णरूक्षशुष्कान्नसेवाभिः||
धातुक्षयगदकर्षणवमनाद्यतियोगसूर्यसन्तापैः|
पित्तानिलौ प्रवृद्धौ सौम्यान्धातूंश्च शोषयतः||
रसवाहिनीश्च नालीर्जिह्वामूलगलतालुकक्लोम्नःl
संशोष्य नृणां देहे कुरुतस्तृष्णां महाबलावेतौ|
पीतं पीतं हि जलं शोषयतस्तावतो न याति शमम्|
घोरव्याधिकृशानां प्रभवत्युपसर्गभूता  सा||
Ch.Chi22/4,5,6,7

Trishna is considered to be disease of Udakvah srotas and its literal translation  suggests thirst . Thirst is not a disease. When the word Trishna indicates thirst when translated as it is. Thrishna is not disease but when to consider it as disease and when to consider it as symptom is debating issue. I would just say that whenever there is a gross fluid and electrolyte imbalance,

It is to be consider as Trishna Vyadhi.

Vataja Trishna: Hyponatremia

शुष्कास्यता मारुतसम्भवायां तोदस्तथा शङ्खशिरःसु  चापि |

स्रोतोनिरोधो विरसं च वक्त्रं शीताभिरद्भिश्च विवृद्धिमेति ||Su. Ut 48/8

Signs described by Sushruta are exactly similar with signs of dehydration. Management of the dehydration is simply identification of the cause and of course providing water in the form of Sheet Panak or Manth or oral rehydration solution. Charka has suggested Prachardhan, but it is odd issue, it could be beneficial in very sever condition

In a patient typical of that hypernatremia, there are certain conditions where patients requires prolonged treatment. Particularly in patients with renal abnormalities tend to develop hyponatremia. Incidence of the hypernatremia is increasing very rapidly these days. Since past five years I have come across patients of hyponatremia more than what I have seen in the past 35 years. I don’t know the reason. But many of the patients particularly patient who is admitted in the hospital with drowsy sensorium their serum electrolytes report suggests hypornatremia. When serum sodium falls below the 120mmol/lit then it is difficult to manage it with oral medicine, it has to be managed with intravenous supplements. In the last five years I have given intravenous injections more than what I have been in the last 35 years. I don’t know the real reason but there is some dramatic change in the total presentation of chronic disorders. Any other a disease, any stroke patients or any other severely ill patient  is developing hypernatremia very significantly. But beyond that kind of hyponatremia of chronically ill patients, chronic adrenal deficiency patients developing hyponatremia, also called as Washer man syndrome. It is seen very occasionally but it can be managed with Raj Yapan Basti and Madiphal Rasayan.

Madiphala Rasayana

Rajayapana basti

 That’s the sequel of Vataprakopa and can be managed with Madiphala Rasayana and Rajayapana basti.  There would be very few number of patients, but some of the other day they have to come to Ayurvedic treatment because there is no other satisfactory treatment elsewhere. Madiphala Rasayana is treatment of Kaphavritta Vata.

Pittaja Trishna – Hypokalemia

मूर्च्छाप्रलापारुचिवक्त्रशोषाः पीतेक्षणत्वं प्रततश्च दाहः |

शीताभिकाङ्क्षा मुखतिक्तता च पित्तात्मिकायां परिधूपनं च ||Su.Ut 48/9

  It has almost every feature of the hypokalemia. The potassium level being reduced being reduced is the exact clinical symptom of the Pittaja Trishna. When potassium levels reduced to critical level that is below 3, then it has to be replaced by potassium supplements. Potassium replacement is not very critical issue, need to give intravenously and can be replaced well with oral route.  So I don’t say that I have a good experience with Ayurveda formulations in cases of hypokalaemia. But certain of the patients who tend to have a persistent hypokalaemia along with the potassium when Sariva is given then it show some benefit. It is about the Rakta dushti lakshnas. It’s from that point of view.  In Pittaja and Raktaja vyadhi ‘Sariva’ is better, Sariva show some resilience. In certain of patients even after providing potassium orally for sustained period, they tend to develop hypokalaemia. There are very few number of patients found in this category .In such cases Sarivadyasav along potassium supplements is useful.

Otherwise in classical hypokalemia , oral supplements of potassium are cheap, easily available  and  easy to give orally.

Kaphaja Trishna – Dehydration

कफावृताभ्यामनिलानलाभ्यां कफोऽपि शुष्कः प्रकरोति तृष्णाम्  |

निद्रा गुरुत्वं मधुरास्यता च तयाऽर्दितः  शुष्यति चातिमात्रम् ||

कण्ठोपलेपो मुखपिच्छिलत्वं शीतज्वरश्छर्दिररोचकश्च |

कफात्मिकायां गुरुगात्रता च शाखासु शोफस्त्वविपाक एव |

एतानि रूपाणि भवन्ति तस्यां तयाऽर्दितः काङ्क्षति नाति चाम्भः ||Su.ut 48/10,11

There is not much of a complex issue of the treatment, not as complex as mentioned in our samhita and comparatively the whole treatment is simpler. Occasionally you may have to use intravenous   fluids also.

 Udara

रुद्ध्वा स्वेदाम्बुवाहीनि दोषाः स्रोतांसि सञ्चिताः|

प्राणाग्न्यपानान् सन्दूष्य जनयन्त्युदरं नृणाम्||

कुक्षेराध्मानमाटोपः शोफः पादकरस्य च|

मन्दोऽग्निः श्लक्ष्णगण्डत्वं कार्श्यं चोदरलक्षणम्||

पृथग्दोषैः समस्तैश्च प्लीहबद्धक्षतोदकैः|

सम्भवन्त्युदराण्यष्टौ तेषां लिङ्गं पृथक् शृणु|| Ch.chi13 /20,21,22

Basically Ambuvaha Srotas is involved in development Udara. Among all abdominal Udaras it’s mainly the Jalodara where Udakvah srotas is involved.

Vataja Udara – Intestinal colic

सङ्गृह्य पार्श्वोदरपृष्ठनाभीर्यद्वर्धते कृष्णसिरावनद्धम् ||

सशूलमानाहवदुग्रशब्दं सतोदभेदं पवनात्मकं तत् |Su. Ni 7/8,9

It is basically about unspecified abdominal pain. Unspecified pain is standard clinical diagnosis which is accepted by international code of diagnosis, ICD 10 –R10.9. One of the standard diagnosis is unspecific abdominal pain which is quite common and it’s like it could be around 30% in Children and 10% in adults.  Vataja Udar is not undiagnosed condition. It’s often considered abdomen as Pandora’s Box. Even after all the investigations, you’ll have plenty of patients where abdominal pain is persistent but the real causes not known.  Many times it is considered as psychosomatic and so on. But there are certain conditions where causes are not found and need to have a symptomatic treatment. In such condition my treatment would be Nabhi vati, Jeerkadyarishta with Ajamodarka. Any unspecified abdominal pain is to be considered as Vataja Udar, only when all the other possibilities of abdominal pain are ruled out.  Once a specific condition is idedentified  , naturally treatment would be different.

Treatment Of Vataja Udara – Nabhi vati

Jeerkadyarishta + Ajamodarka

Key points:

• ICD 10 –R10.9 Unspecified abdominal pain
• Incidence -30 % in children,10% in adults

(Incidence of non-specific abdominal pain in children during school term: population survey based on discharge diagnoses Nigel Williams, Di Jackson, Paul C Lambert, J Michael Johnstone BMJ. 1999 May 29; 318(7196): 1455)

Pittaja Udara – Peritonitis

यच्चोषतृष्णाज्वरदाहयुक्तं पीतं सिरा भान्ति च यत्र पीताः ||

पीताक्षिविण्मूत्रनखाननस्य पित्तोदरं तत्त्वचिराभिवृद्धि | Su. Ni 7/9,10

In Pittaja Udara signs described in texts resembles with signs of peritonitis. Peritonitis cannot be managed only with Ayurvedic treatment virtually there is no scope for Ayurveda treatment in case of peritonitis.

Key points

Thorough evaluation is necessary

Majority of conditions require hospitalization and acute care.

Kaphaja Udara – Intra-abdominal masses and lesions

यच्छीतलं शुक्लसिरावनद्धं गुरु स्थिरं शुक्लनखाननस्य ||

स्निग्धं महच्छोफयुतं ससादं कफोदरं तत्तु चिराभिवृद्धि |Su,Ni 7/10,11

 It is about intra-abdominal masses and lesions. Abdominal masses also is one of the areas where ethically you have you have to have a thorough evaluation and a protocol of management will be as to be followed in the contemporary situation. We may not have much of a scope from Ayurveda point of view.

Dooshi Udara – Nonspecific mesenteric lymphadenitis

स्त्रियोऽन्नपानं नखरोममूत्रविडार्तवैर्युक्तमसाधुवृत्ताः ||

यस्मै प्रयच्छन्त्यरयो गरांश्च दुष्टाम्बुदूषीविषसेवनाद्वा |

तेनाशु रक्तं कुपिताश्च दोषाः कुर्वन्ति घोरं जठरं त्रिलिङ्गम् ||

तच्छीतवाताभ्रसमुद्भवेषु  विशेषतः कुप्यति दह्यते च स चातुरो मूर्च्छति सम्प्रसक्तं पाण्डुः कृशः शुष्यति तृष्णया च ||प्रकीर्तितं दूष्युदरं तु घोरं … | Su.Ni 7/11,12,13,14

 That’s the cumulative toxicity issues. I will consider that as usually chronic colitis conditions. You need all the other investigational tools to make the diagnosis. My usual prescription would be particularly for nonspecific lympheniditis. Nonspecific lympheniditis mimics like appendicitis. Patient may have all the clinical signs of appendicitis but there may not be tenderness at iliac fossa. This condition does not require surgery, rather surgery can complicate it. My prescription would be Agnitundi, Anandabhairava and Jeerkadyarishta

Key points

 Vague abdominal pain

Reduced appetite

Weight loss

USG – to confirm the diagnosis

Pleehodara – Splenomegaly

It is complex issue, causes could be many and thorough clinically evaluation is necessary.

Virtually we have a very little scope for Ayurveda management. The major work is to rule out the exact cause has to be assessed and majority of those causes may require more energetic treatment.

Key points

Clinical algorithm of assessment of splenomegaly

Cause specific management

Baddha gudodara – Intestinal obstruction

प्लीहोदरं कीर्तयतो निबोध |

विदाह्यभिष्यन्दिरतस्य जन्तोः प्रदुष्टमत्यर्थमसृक् कफश्च ||१४||

प्लीहाभिवृद्धिं सततं करोति प्लीहोदरं तत् प्रवदन्ति तज्ज्ञाः |

वामे च पार्श्वे परिवृद्धिमेति विशेषतः सीदति चातुरोऽत्र ||१५||

मन्दज्वराग्निः कफपित्तलिङ्गैरुपद्रुतः क्षीणबलोऽतिपाण्डुः |Su.Ni 7/14,15,16

 It requires a surgical evaluation or conservative management may be needed.

Parisravi udara – Visceral perforation

 

ततः परिस्राव्युदरं निबोध |

शल्यं यदन्नोपहितं तदन्त्रं भिनत्ति यस्यागतमन्यथा वा ||

तस्मात् स्रुतोऽन्त्रात् सलिलप्रकाशः स्रावः स्रवेद्वै गुदतस्तु भूयः |

नाभेरधश्चोदरमेति वृद्धिं निस्तुद्यतेऽतीव विदह्यते च ||

एतत् परिस्राव्युदरं प्रदिष्टं… |Su. Ni 7/19,20,21

It is an surgical emergency condition.

Jalodara – Ascitis

दकोदरं कीर्तयतो निबोध |

यः स्नेहपीतोऽप्यनुवासितो वा वान्तो विरिक्तोऽप्यथवा निरूढः ||

पिबेज्जलं शीतलमाशु तस्य स्रोतांसि दुष्यन्ति हि तद्वहानि |

स्नेहोपलिप्तेष्वथवाऽपि तेषु दकोदरं पूर्ववदभ्युपैति ||

स्निग्धं महत् सम्परिवृत्तनाभि भृशोन्नतं पूर्णमिवाम्बुना च |

यथा दृतिः क्षुभ्यति कम्पते च शब्दायते चापि दकोदरं [तत् ||Su. Ni 7/21,22,23

 

   Huge variety of the causes are seen and a thorough evaluation is necessary. The list of causes of ascites enlisted below is not complete. List of causes mentioned under section of good scope for Ayurvedic management where we can have definite results.

अन्ते सलिलभावं हि भजन्ते जठराणि तु |

सर्वाण्येव परीपाकात्तदा तानि  विवर्जयेत् || Su. Ni 7/25

Summarized list of common  causes of ascites
Less scope for Ayurvedic management	Good scope for Ayurvedic management
Acute Liver Failure	Alcoholic Hepatitis
Biliary Disease	Cirrhosis
Budd-Chiari Syndrome	Dilated Cardiomyopathy
Familial Mediterranean Fever	Nephrotic Syndrome
Hepatocellular Adenoma	Viral Hepatitis
Hepatorenal Syndrome
Hepatocellular Adenoma
Portal Hypertension
Primary Biliary Cirrhosis
Protein-Losing Enteropathy
Restrictive Cardiomyopathy

 

.

Ayurvedic management of particular conditions is given in following table.

Hepatic pathology Pittaja , Pittakapahaja	Nephrotic syndrome Kaphaja	Cardiomyopathy Vatakaphaja
Arogyavardhini Punarnavamandoora Kumari Asava Gomutra + Triphala choorna	Chandraprabha vati Mrityunjaya Rasa /Punarnava mandora Amritarishta /Punarnavasava Saptaprna quatha	Prabhakara vati Punarnavamandoora Arjunarishta / Punarnavasava

If fresh and best quality Gomutra is used, it produces fantastic results in case of ascites particularly in alcoholic hepatitis patients. Gomutra arka doesn’t produce the same results.

So when I prescribe Gomutra I will always keep the patient in the ward for one week to observe if there is any peritonitis is developing or not . Peritonitis developing in patient of ascites can be very critical and many times fatal, so you have to be careful. In the patient who doesn’t develop peritonitis and continued with Gomutra for a quite a long period, there are many patients who have shown dramatic results. Unbelievable changes can be observed where by the whole shape and clinical picture has become total altered and sustained for years together, many times lifetime. So there is no question of the complete cure in that. But with Arogyavardhini, Punarnavamandoora,Kumari selective patients can show dramatic results. But at the same time, there are certain conditions where the patient may worsen immediately after starting Gomutra. So it’s always better to keep the patient under observation at least for week once started  on Gomutra. If patient would develop symptoms of peritonitis like abdominal pain, vomiting then it is better to stop Gomutra.

Nephrotic syndrome:

Thorough treatment of Nephrotic syndrome has been already discussed in previous section. Brief details are provided in the above table.

Cardiomyopathy:

In this patients primary contemporary drugs have to be maintained. Along with that Prabhakar Vati, Poonarnava mandoor. If patient is having severe dyspnoea I prefer Arjunarishta and if patient has oedema I prefer Punarnavasava. Patient can be managed satisfactorily with drugs but other primary drugs have to be maintained.

Carry home points

• To name diabetes mellitus as Madhumeha is technically a mis nomenclature
• So called famine genes are a myth
• Indian heritage is of spartan living
• Diabetes mellitus is preventable
• Complications of DM can be effectively managed with Ayurvedic regime.
• Gestational diabetes to be assessed with a different outlook.
• Trishna are fluid and electrolyte imbalances.
• Practical assessment and management of Udara Vyadhi