पञ्चदशोऽध्यायः । अथातो मूढगर्भचिकित्सितं व्याख्यास्यामः, यथोवाच भगवान् धन्वन्तरिः।।१।।
Now we shall discourse on the (surgical and medical) treatment of the cases of difficult malpresentation of the foetus and of difficult labour (Mudha-Garbha ). As stated by Lord Dhanvantari. 1
नातः कष्टतममस्ति यथा मूढगर्भशल्योद्धरणम् । अत्र हि योनियकृत्प्लीहान्त्रविवरगर्भाशयानां मध्ये कर्म कर्त्तव्यं स्पर्शेन । उत्कर्षणापकर्षणस्थानापवर्त्तनोद्वर्त्तनोत्कर्त्तनभेदनच्छेदनपीडनर्जूकरणदारणानि चैकहस्तेन गर्भं गर्भिणीं वाऽहिंसता । तस्मादधिपतिमापृच्छच परञ्च यत्नमास्थायोपक्रमेत ॥ २ ॥
The extraction of a foetus, acting (in the womb) as an obstructing Salya (foreign matter lodged in the body), is the most difficult of all surgical operations, in as much as actual contact or actual manipulation is the only means accessible to a surgeon in the region of the pelvic cavity, the spleen, the liver, the intestines and the uterus. All surgical acts in respect of the foetus or the enceinte, such as lifting up, drawing down, changing of postures ( version), excision, incision, the cutting of limbs and section, pressure, the straightening and the perforating of the abdomen, could not be done otherwise than by actual contact of the hand, avoiding injury to the pregnant woman and to the foetus. Therefore after due permission from the king all procedures should be carried out with utmost care.
तत्र समासेनाष्टविधा मूढगर्भगतिरुद्दिष्टा; स्वभावगता अपि त्रयः सङ्गा भवन्ति, शिरसो वैगुण्यादंसयोर्जघनस्य वा । जीवति तु गर्भे सूतिकागर्भनिर्हरणे प्रयतेत । निर्हर्त्तुमशक्ये च्यावनान् मन्त्रानुपशृणुयात्, तान् वक्ष्यामः २॥
We have stated before that the foetus is generally presented in cases of difficult labour in eight different postures or forms. The obstruction of the child in the passage of parturition (Garbha-Sanga) may be effected in three different ways, owing to its head, shoulders or hips being presented in a wrong way and held fast in the passage. Every care should be taken and no pains spared to bring a child alive into the world, which is not already dead in the womb. The sacred verses (Mantras), possessing of the virtue of bringing out the foetus, should be recited in the hearing of the enciente in the case of a failure in the first attempt at effecting parturition. The mantras are as follows. 2
सोमश्च चित्रभानुश्च भामिनि । इहामृतञ्च उच्चैःश्रवाश्च तुरगो मन्दिरे निवसन्तु ते।। ३।।
इदममृतमयां समुद्धृतं वै तव लघु गर्भमिमं प्रमुञ्चतु स्त्रि । तदनलपवनार्कवासवास्ते सह लवणाम्बुधरैर्दिशन्तु शान्तिम् ॥ ४॥
सूर्येण पशोर्विपाशाश्च मुक्ता: सर्वभयाद् गर्भ एह्येहि रश्मयः विरमावितः ।। ५ ।॥ मुक्ताः मुक्तः
Metrical Texts : “O thou beautiful damsel, may the divine ambrosia and the Moon god with Citra bhanu and the celestial horse Uccaih-Sravas take their residence in thy room; may this waterbegotten nectar, help thee, O lady, in swiftly casting off thy wombMay the Sun, the Vasavas and the Wind-god (Pavana) in the company of the saline Ocean give thee peace. The incarcerated beasts have been freed from their fastenings and binding chords. The Sun god has freed his rays of light Freed from all danger, come, O, come, O child, and rest in peace in these precincts.” 3-5
औषधानि च विदध्याद् यथोक्तानि । मृते चोत्तानाया आभुग्नसक्थ्या वस्त्राधारकोन्नमितकट्या धन्वननगवृत्तिकाशाल्मलीमृत्स्नघृताभ्यां प्रक्षयित्वा हस्तं योनौ प्रवेश्य गर्भमुपहरेत् ॥ ६॥
Proper and useful medicinal remedies should also be employed for the delivery of the child.
Postures of the Foetus: In the case of the foetus being dead in the womb, the enciente should be made to lie on her back with her thighs flexed down and with a pillow of rags under her waist so as to keep it a little elevated. Then the physician should lubricate his (own) hand with a compound consisting of earth, clarified butter and (the compressed juice of) Sallaki, Dhanvana and Salmati and inserting it into the passage of parturition (Yoni) should draw out the dead foetus (downward with the hand). 6
तत्र सक्थिभ्यामागतमनुलोममेवाञ्छेत् । एकसकथना प्रतिपन्नस्येतरसक्थि प्रसार्यापहरेत् । स्फिग्देशेनागतस्य स्फिग्देशं प्रपीडयोर्ध्वमुत्क्षिप्य सक्थिनी प्रसार्यापहरेत् । तिर्यगागतस्य परिघस्येव तिरश्चीनस्य पश्चादर्धमूर्ध्वमुत्क्षिप्य पूर्वार्धमपत्यपथं प्रत्यार्जवमानीयापहरेत् । पार्श्वापवृत्तशिरसमंसं प्रपीड्योर्ध्वमुत्क्षिप्य शिरोऽपत्यपथमानीयापहरेत् । बाहुद्वयप्रतिपन्नस्योर्ध्वमुत्पीडयोर्द्धवशिरोऽनुलोममानीयापहरेत् । द्वावन्त्यावसाध्यौ मूढगर्भी। एवमशक्ये शस्त्रमवचारयेत् ॥ ७ ॥
In the case of a leg-presentation (Sakthi), the foetus should be drawn downward by pulling its legs. In case where a single leg (Sakthi) is presented, the other leg of the foetus should be expanded and then it should be drawn downward.
In the case of the presentation of the buttocks (sphik) (breech presentation), the buttocks should be first pressed and lifted up and then the foetus should be drawn downward by extending the legs. In the case of a transverse presentation (the child coming stretched crosswise) like a belt and arrested in the passage, its lower extremities should be pushed upward with the hand and the child should be drawn out with its upper part (viz, the head, etc.), thus pointed downward, and brought straight into the passage of parturition. In a case of the head being hung back a little on one side, the shoulder should be lifted up by pressing it (with the hand) after chafening it, so as to bring the head at the door of the passage and the child should be drawn straight downward. Similarly in the case of the presentation of the two arms, the shoulder should be lifted up by pressing it (with the hand) and, the head being brought back to the passage, the child should be drawn downward. The remaining two kinds of mal presentation (Mudhagarbha) previously described (in the eighth Chapter of the Nidana Sthana) should be considered as irremediable. The applications of instruments (Sastra) should be the last resort when such manipulatory measures would fail. 7
सचेतनञ्च शस्त्रेण न कथञ्चन दारयेत् । दार्यमाणो हि जननीमात्मानञ्चैव घातयेत् ॥ ८ ॥
Metrical Text : But even in such irremediable (Asadhya) cases, surgical operations should not be made if the foetus could be detected alive in the womb, as such a course (as the cutting of the foetus, etc.) would fatally end both the child and its mother. 8
अविषह्ये विकारे तु श्रेयो गर्भस्य पातनम् ।
न गर्भिण्या विपर्यासः प्राप्तकालं न हापयेत् ।। ९ ।।
In case it is not possible to correct the mal presentation it is better to terminate the pregnancy. In no case, however, time should not be lost, so that the mother’s life may not be put in danger.
ततः स्त्रियमाश्वास्य मण्डलाग्रेणाङ्गलीशस्त्रेण वा शिरो विदार्य शिरः कपालान्याहृत्य शङ्कना गृहीत्वोरसि कक्षायां वाऽपहरेत् । अभिन्ने शिरसि चाक्षिकूटे गण्डे वा, अंससंसक्तस्यांसदेशे बाहुं छित्त्वा, दृतिमिवाततं वातपूर्णोदरं वा विदार्य निरस्यान्त्राणि शिथिलीभूतमाहरेत् । जघनसक्तस्य वा जघनकपालानीति ॥ १० ॥
Operations involving destruction of the Foetus–Craniotomy : In cases where there would be any necessity of using an instrument for the purpose of delivery, the enciente should be encouraged (with hopes of life) before making the surgical operation. The head or skull of the child in such cases should be severed with the knife known as the Mandalagra or the Anguli-sastra; then having carefully taken out the particles of the skull-bone (Kapala), the foetus should be drawn out by pulling it at its chest or at the shoulder with a Sanku (forceps). Where the head would not be punctured and smashed, the foetus should be drawn out by pulling it at the cheeks or the eye-sockets. The hands of the foetus should be severed from the body at the shoulders, when they (the shoulders) would be found to have been obstructed in the passage and then the foetus should be drawn out. The abdomen of a child, dead in the womb, should be pierced and the intestines drawn out, in event of the former being swollen into a flatulent (Vata) distension like a leather bag (for holding water), as such a procedure would remove the stiffness of its limbs, and then it should be drawn out. The bones of the thighs (Jaghana-kapala) should be first cut out and removed, where the foetus would be found to have adhered fast to the passage with its thighs (Jaghana). 9-10
यद् यदङ्गं हि गर्भस्य तस्य सज्जति तद् भिषक् । सम्यग्विनिर्हरेच्छित्त्वा रक्षेन्नारीञ्च यत्नतः गर्भस्य
गतयश्चित्रा तत्रानल्पमतिर्वैद्यो वर्त्तेत ।। ११ ।।
जायन्तेऽनिलकोपतः । नोपेक्षेत मृतं गर्भ मुहूर्त्तमपि विधिपूर्वकम् ।। १२ ।।
पण्डितः ।स ह्याशु जननीं हन्ति निरुच्छ्वासं पशुं यथा || १३ ||
मण्डलाग्रेण कर्त्तव्यं छेद्यमन्तर्विजानता । वृद्धिपत्रं हि तीक्ष्णाग्रं नारीं हिंस्यात् कदाचन ॥ १४ ॥
Metrical Texts: In short, that part of the body of the foetus should be severed and removed which prevents its (foetus) withdrawal from the womb and the life of the mother should be saved with all care. The different types of false-presentations should be ascribed to the abnormal coursing of the deranged Vayu (in the uterus), and hence an intelligent physician should adopt, after careful considerations, proper remedies (for its pacification). An intelligent physician should not waste a single moment in drawing out the foetus, as soon as it would be found to be dead in the womb, since neglect in such case leads to the instantatneous death of the mother, like an animal dying of suffocation. An erudite physician, well-versed in anatomy, should use in such cases a Mandalagra instrument for the purpose of cutting out (the foetus), since a sharpe-edged Vruddhi-patra may sometimes hurt the mother during the operation. 11-14
अथापतन्तीमपरां पातयेत् पूर्ववद् भिषक् । हस्तेनापहरेद् वाऽपि पार्श्वभ्यां परिपीडच वा ।। १५ ।।
धुनुयाच्च मुहुर्नारीं पीडयेद वांऽसपिण्डिकाम् । तैलाक्तयोनेरेवं तां पातयेन्मतिमान् भिषक् ॥ १६ ॥
A non-falling placenta (Apara) should be extracted in the way indicated before or the enciente should be firmly pressed and the placenta extracted with the hand. Her body should be constantly shaken or her shoulders constantly rubbed at the time (of extracting the placenta after lubricating the passage of parturition with oil. 15-16
एवं निर्हतशल्यान्तु सिञ्चेदुष्णेन वारिणा । ततोऽभ्यक्तशरीराया योनौ स्नेहं निधापयेत् ।
एवं मृद्वी भवेद् योनिस्तच्छूलञ्चोपशाम्यति ।। १७ ।।
कृष्णातन्मूलशुष्ठचेला हिङ्गभार्गी: सदीप्यकाः । वचामतिविषां रास्नां चव्यं संचूर्ण्य पाययेत् ।। १८ ।।
स्नेहेन दोषस्यन्दार्थं वेदनोपशमाय च। क्वाथञ्चैषां तथा कल्कं चूर्णं वा स्नेहवर्जितम् ।। १९ । ।
शाकत्वग्घिङ्ग्वतिविषा-पाठाकटुकरोहिणीः । तथा तेजोवतीञ्चापि पाययेत् पूर्ववद् भिषक् ।। २० ।।
त्रिरात्रं पञ्चसप्ताहं ततः स्नेहं पुनः पिबेत् । पाययेद्वाऽऽसवं नक्तमरिष्टं वा सुसंस्कृतम् ॥ २१ ॥
शिरीषककुभाभ्याञ्च तोयमाचमने हितम् । उपद्रवाश्च येऽन्ये स्युस्तान् यथास्वमुपाचरेत् ॥ २२ ॥
After-measures : Thus having extracted the Salya (foetus). the body of the mother should be washed with warm water and anointed with oil, etc. Oil should also be copiously applied to the passage of parturition, as it would soften the Yoni and alleviate the pain therein. After that, powdered Pippali, Pippali-roots. Sunthi, Ela, Hingu, Bhargi, Dipyaka, Vaca, Ativisa, Rasna and Cavya should be given in a Sneha ( clarified butter, etc.), for the ( proper) discharge (i.e.. purification) of the Dosas (lotia) and for the alleviation of the pain. A plaster, or a decoction, or a pulversided compound of the said drugs without the addition of any Sneha (clarified butter, etc.) may also be
1. The oil should be introduced into the vaginal canal by means of Picu i.e.. cotton plugs soaked in oil, etc. given to her. As an alternative, the physician should ask the parturient woman to take Saka-bark, Hingu, Ativisa, Patha, Katu-rohini and Tejovati prepared and administered in the preceding manner. Then for three, five or seven days, Sneha ( clarified butter, etc.) should again be given; or the patient should be asked to take well prepared Asavas and Aristas at night time: decoction of the bark of Sirisa and Kakubha should be used for sipping (Acamana¹) purposes and the other supervening distresses (i.e. complications) should be remedied with proper medicines. 17-22
सर्वतः परिशुद्धा च स्निग्धपथ्याल्पभोजना। स्वेदाभ्यङ्गपरा नित्यं भवेत् क्रोधविवर्जिता ।। २३ ।।
पयो वातहरैः सिद्धं दशाहं भोजने हितम् । रसं दशाहं शेषे तु यथायोगमुपाचरेत् ।। २४ ।।
व्युपद्रवां विशुद्धाञ्च ज्ञात्वा च बलवर्णिनीम्। ऊर्ध्वं चतुर्भ्यो मासेभ्यो विसृजेत् परिहारतः ।। २५ ।।
योनिसन्तर्पणेऽभ्यङ्गे पाने बस्तिषु भोजने । बलातैलमिदञ्चास्यै दद्यादनिलवारणम् ।। २६ ।।
Diet and regimen of conduct: The mother should always be neat and clean and subjected to a course of a small quantity of wholesome and emollient diet and to daily anointments and fomentations; and she should be advised to renounce all anger. Milk cooked with the Vayusubduing drugs should be used for the first ten days. Then the meatsoup should be prescribed for another such period, after which a diet should be prescribed according to the patient’s health and nature. This regimen should be observed for a period of four months, after which when the patient would be found to have regained her health, strength and glow of complexion, having no any complications, then the medical treatment, etc., should be discontinued.
The following Bala-Taila should be used for applying into the Yoni (Vagina, etc.), for anointing the body and for drinking and eating purposes (i.e., along with other food) as well as for Basti-Karma, as the oil is highly efficacious in curbing the action of the deranged and aggravated bodily Vayu. 23-26
1. This decoction should be specially used for washing the uterus (Yoni).
दशमूलीशृ॒तस्य क्वाथस्य पयसस्तथा । अष्टावष्टौ शुभा भागास्तैलादेकस्तदेकतः ॥ २७ ॥
पचेदावाप्य मधुरं गणं सैन्धवसंयुतम् । तथाऽगुरुं सर्जरसं सरलं देवदारु च ।। २८ ।।
मञ्जिष्ठां चन्दनं कुष्ठमेलां कालानुसारिवाम् । मांसीं शैलेयकं पत्रं तगरं सारिवां वचाम् ॥ २९ ॥
शतावरीमश्वगन्धां शतपुष्पां पुनर्नवाम् । तत् साधुसिद्धं सौवर्णे राजते मृन्मयेऽपि वा ॥ ३० ॥
प्रक्षिप्य कलशे सम्यक् स्वनुगुप्तं निधापयेत् । बलातैलमिदं यथाबलमतो मात्रां ख्यातं सर्ववातविकारनुत् ।। ३१ ।।
सूतिकायै प्रदापयेत् । या च गर्भार्थिनी नारी क्षीणशुक्रश्च यः पुमान् ॥ ३२ ॥
वातक्षीणे मर्माहते मथितेऽभिहते तथा । भग्ने श्रमाभिपन्ने च सर्वथैवोपयुज्यते ।। ३३ ।।
एतदाक्षेपकादीन् वै वातव्याधीनपोहति । हिक्कां कासमधीमन्थं गुल्मं श्वासञ्च दुस्तरम् ॥ ३४॥
षण्मासानुपयुज्यैतदन्त्रवृद्धिमपोहति प्रत्यग्रधातुः पुरुषो भवेच्च स्थिरयौवनः ।। ३५ ।।
राज्ञामेतद्धि कर्त्तव्यं राजमात्राश्च ये नराः । सुखिनः सुकुमाराश्च धनिनश्चापि ये नराः ।। ३६ ।। बलामूलकषायस्य यवकोलकुलत्थानां
The Bala Taila : An adequate quantity of sesamum oil should be cooked with eight times as much of the decoction of each of the following; viz., Bala roots. Dashmula and the three combined drugs of Yava, Kola and Kulattha and with eight times as much of milk and (one-fourth as much of ) a paste (Kalka) compound of the drugs included in the Madhura group as well as with Saindhava-salt, Aguru,
1. Four seers of sesamun oil, thirty-two seers of the decoction of the Bala-roots. thirty-two seers of the decoction of Dasa-mula, thirty-two scers of the decoction of the drugs Yava, Kola and Kulattha taken together, thirty-two seers of milk and one seer of the paste compound (Kalka) should be taken in the preparation of the oil. Sarja-rasa, Sarala-Kastha, Deva-daru, Manjistha, Candana, Kustha, Ela, Kalanusariva, Mansi, Saileya, Teja-patra, Tagara, Sariva, Vaca, Satavari, Asva-gandha, Sata-puspa and Punarnava. After the completion of its cooking the oil should be kept carefully in a golden, silver, or earthen pitcher with its mouth well-stoppered. This oil is known as the Bala-Taila and proves curative in all diseases due to the action of the deranged Vayu. A newly delivered woman should use this oil in adequate doses, according to her physical condition. Women wishing conception and men with impotency should use this Taila (oil), which proves equally beneficial in cases of an emaciation of the body due to the action of the deranged Vayu, weariness of the body through hard labour, and also in cases of hurt or injury to any vital and vulnerable part of the body (Marma), in cases of fractured bones, convulsions, Vata – Vyadhi, hiccough, cough, Adhimantha, Gulma and dyspnoea. A case of hernia would likewise yield to the continuous use of this oil for six months. The essential and vital principles ( Dhatus) of the organism of a man are strengthered through its use and his youth will suffer no decay. It should be used alike by kings, king-like and wealthy persons, as well as by those of a delicate and ease-loving temperament. 27-36
बलाकषायपीतेभ्यस्तिलेभ्यो वाऽप्यनेकशः
तैलमुत्पाद्य निवाते निभृतागारे प्रयुञ्जीत यथाबलम् । जीर्णेऽस्मिन् पयसा स्निग्धमश्नीयात् षष्टिकौदनम् ॥ ३८ ॥
अनेन विधिना द्रोणमुपयुज्यान्नमीरितम् । भुञ्जीत द्विगुणं कालं बलवर्णान्वितस्ततः ।। ३९ ।।
सर्वपापैर्विनिर्मुक्त: शतायुः पुरुषो भवेत् । शतं शतं तथोत्कर्षो द्रोणे द्रोणे प्रकीर्तितः ॥ ४० ॥ तत्क्वाथ-शतपाककृतं शुभम् ॥ ३७॥
The Bala-Kalpa: Seeds of sesamum should be successively soaked a number of times in a decoction of Bala roots¹ and then dried (in the manner of a Bhavana saturation). The oil pressed out of such sesamum should be successively cooked a hundred times with the
1. Bala would be the Kalka in this oil, says Dalhana. But he also says that some authorities hold that the Kalkas used in the Bala-Taila should be used as the Kalka in this oil as well. decoction of Bala-roots. This having been done, the oil should be poured into an earthen pitcher and the patient, while taking it in adequate doses, should live in a lonely chamber protected from the wind. After its digestion, the patient should partake of milk and boiled Sastika rice. A Drona measure of the oil, should in this way, be gradually taken and the regimen of diet (milk and Sastika rice cooked in Ghrita) should be observed for double of that period. This oil is efficacious in improving one’s strength and complexion and adds a century (of years) to the duration of one’s life, and at the same time absolves him from all sins. It is said that the use of each successive Drona measure of this oil adds a century to one’s days on earth. 27-40
बलाकल्पेनातिबला गुडूच्यादित्यपर्णिषु । सैरेयके वीरतरौ शतावर्या त्रिकण्टके | तैलानि मधुके कुर्यात् प्रसारिण्याञ्च बुद्धिमान् ॥ ४९ ॥
Oils may similarly be prepared with each of Ativisa, Guduci, Aditya-parni, Saireyaka, Virataru, Satavari, Tri-kantaka, Madhuka and Prasarani and may be prescribed by an experienced and erudite physician. 41
नीलोत्पलं वरीमूलं गव्ये क्षीरे विपाचयेत् । शतपाकं ततस्तेन तिलतैलं पचेद् भिषक् ॥ ४२ ॥
बलातैलस्य कल्कांस्तु सुपिष्टांस्तत्र दापयेत् । सर्वेषामेव जानीयादुपयोगं चिकित्सकः । बलातैलवदेतेषां गुणांश्चैव विशेषतः ॥ ४३ ॥
Nilotpala and Satavari should be cooked in cow’s milk. The milk thus prepared should be again cooked with sesamum oil successively a hundred times and a paste of all the drugs used as a paste in the Bala-Taila should be added to it at the time of cooking. The clinician should employ this oil also like Bala Tail. The therapeutic virtues of all these oils are the same as those of the Bala-Taila and the same regimen of diet and conduct should be observed in all such cases. 42-43
इति सुश्रुतसंहितायां चिकित्सितस्थाने मूढगर्भचिकित्सितं नाम पञ्चदशोऽध्यायः ॥ १५ ॥
Thus ends the fifteenth Chapter of the Chikitsa Sthana in the Susruta Samhita which deals with the medical treatment of Mudha-garbha.
