Charaka Udara Roga Chikitsa – 13th Chapter

13th Chapter of Charaka Samhita Chikitsa Sthana deals with treatment of Udara. The disease Udara encompasses many diseases including ascites, intestinal obstruction, gaseous distension of abdomen etc. We shall now expound the chapter on the treatment of Udara.

Agnivesha’s query

Agnivesha’s query to Atreya Punarvasu:

Thus, said Lord Atreya [1-2]
Once upon a time, Lord Punarvasu was dwelling on mount Kailasa which was the abode of the Siddhas and Vidyadhars and which was charming like Nandana (celestial garden). Punarvasu was dazzling with the practice of severe penance and looking like incarnate. He was the original propounder of the science of medicine, and he was the first and foremost of the physicians proficient in the science of the life, having full control over his senses.

Agnivesha inquired with Atreya as below
‘O Lord! People are seen suffering with maladies of Udara (abdomen) having
Shushka vaktra – dryness of mouth,
Krusha Gatra – emaciation of the body, weight loss
Adhmana Udara Kukshayaha – distension of the abdomen and pelvis
Pranashta Agni, Bala, Ahara – Loss of digestion fire, appetite and strength
Incapability of doing any work;

They are helpless for want of effective remedy and they are breathing their last breath like an orphan. For the welfare of all living beings, I want to hear about the causative factor, types, premonitory signs and symptoms, manifested signs and symptoms and effective therapies of this malady as appropriately instructed by my preceptor like you”.
Being thus asked by the disciple, the sage initiated his discourse as follows for the welfare of living beings. [3-8]

Udara Samprapti

Agnidosha – defective digestion strength and
Mala Vruddhi – increase in waste products / morbid matter – These two are the reasons for diseases like Udara (abdominal diseases including ascites).
If there is suppression of Agni (power of digestion and metabolism), and if  the person takes Polluted food, this leads to indigestion as a result of which Doshas get accumulated.
This causes vitiation of Prana (a variety of Vata Dosha), Agni (digestive enzymes) and Apana (another variety of Vata, related to expulsion of faeces, flatus, urine etc) and obstruction to the upward and downward channels of circulation.
Thereafter, the vitiated Doshas get lodged between the skin and the muscle tissue and cause extensive distension of lower part of abdomen.
This gives rise to Udara (obstinate abdominal diseases including Ascites). Now, hear the causative factors, signs and symptoms of this ailment [9-11]

Udara Nidana – Causes

1. Intake of excessively hot, saline, Alkaline, Vidahi (which causes burning sensation), sour and poisonous food and drinks (Gara visha)
2. Mithya Samsarjana – Improper Samsarjana krama( diet, drinks and other regimens given to the patient after the administration of Pancha karma therapy)
3. Rooksha, Viruddha, Ashuchi Bhojana – Intake of dry, mutually contradictory and unclean food
4. Pleeha Arsha Grahani Dosha Karshana – Emaciation as a consequence of diseases, like Pliha (Splenic disorders), Arsas (piles) and Grahani Dosha (sprue syndrome)
5. Improper administration of Pancha Karma therapy, namely emesis, purgation etc.
6. Negligence of treatment of diseases, like Pliha Roga (splenic disorder) and the consequential unctuousness in the body.
7. Karma Vibhramaat – Suppression of the manifested natural urges
8. Vitiation of the channels of circulation
9. Continued presence of Ama (product of improper digestion and metabolism) in the body
10. Intake of irritating food and drinks
11. Over nourishment
12. Obstruction by piles, hair and hard stool masses
13. Ulceration and perforation of intestines
14. Excessive accumulation of vitiated Doshas and
15. Indulgences in serious sinful acts.
Because of the above mentioned factors, different varieties of Udara are manifested, especially in those having Mandagni (low digestion strength) [12-15]

Poorvaroopa

Udara Poorvaroopa: Premonitory Signs and Symptoms
1. Khsut Nasha – Low digestion strength
2. Belated digestion of food, which is sweet, excessively unctuous and heavy
3. Vidaha (burning of indigestion) of all the food and drinks taken by the patient
4. Inability to determine between the digestion and indigestion of the food
5. Inability to tolerate a little excess of food
6. Slight swelling in the legs
7. Constant loss of strength
8. Shortness of breath even with slight exercise
9. Excessive accumulation of stool because of unctuousness and Udavarta (bloating, upward movement of the wind in the abdomen)
10. Pain and Adhmana (distension) in the Basti- Sandhi (lower part of abdomen)
11. Even if the patient takes food in small quantity, the size of his abdomen considerably increases. The patient experience bursting pain and the abdomen becomes considerably distended.
12. Raji Janma – Appearance of network of veins and
13. Vali nasha – Disappearance of folds in the abdomen and creases due to swelling [16-19]

Samprapti

Udara Samprapti: Pathogenensis
Accumulated Doshas obstruct the channels of sweat and water (Ambuvaha srotas and Swedavaha Srotas) and vitiate Prana Vata, Agni (power of digestion and metabolism) and Apana Vayu, as a result of which Udara (obstinate abdominal diseases including ascites) is manifested in human beings [20]

General symptoms, types

Udara Samana Lakshana – General Symptoms:
Kukshe adhmana – Distension in the side of the abdomen,
Aatopa – gurgling sound
Pada shopha – oedema in the leg and hands,
Suppression of the power of digestion,
Slakshna gandatva – smoothness of the chin and
Karshya – emaciation [21]

Udara Bheda – Types:
8 types –
Vatodara
Pittodara
Kaphodara
Sannipatikodara
Plihodara
Baddhodara
Kshatodara and
Udakodara (Jalodara).
Signs and symptom of each of these varieties will hereafter be described. [22]

Vatodara

Vatodara – Nidana, Samprapti
Vataja Udara causes and pathogenesis:
Vata gets aggravated because of the intake of dry food, less quantity of food,
Ayasa – exertion,
Vega – suppression of natural urges,
Udavarta (upward movement of the wind in the abdomen) and emaciation (fasting , etc which are responsible for emaciation).
This aggravated Vayu, while passing through Kukshi (sides of the abdomen), cardiac region, urinary bladder and anus, suppresses digestion strength and stimulates Kapha.
The Kapha arrests the movement of Vata Dosha, as a result of which the latter gets located between the skin and the muscle tissue of the abdomen and causes swelling of the abdomen. [23-24]

Vatodara Lakshana:
Signs and symptoms of Vatodara:
The following are the signs and symptoms of Vatika type of Udara
1. Kukshi, Pani, pada vrshana svayathu – Swelling in sides of the abdomen, hands, legs and scrotum
2. Udara vipatanam – Appearance of cracks in the abdomen
3. Increase and decrease of the swelling in the abdomen without any appreciable cause
4. Kukshi parshva shoola -Colic pain in the sides of the abdomen and in the sides of the chest
5. Udavarta (upward movement of wind in the abdomen)
6. Anga marda, Parva bheda, Sushka kasa , Karshya, Daurbalya, Arochaka, Avipaka – Malaise, cracking pain in the phalanges, dry cough, emaciation, weakness, anorexia and indigestion
7. Adho gurutvam – Heaviness in the lower part of the abdomen
8. Vata varcho mutra sanga – Non- elimination (blockage) of flatus, stool and urine
9. Shyava aruna cha nakha nayana vadana tvak mutra varchas – Greyish and reddish discolouration of nails, eyes, face, skin, urine, and stool
10. Appearance of thin and black net- work of veins over the abdominal wall
11. The best of the abdomen sounds like the beat of an inflated leather bag and
12. Movement of Vayu upwards, downwards and sideways along with colic pain and sound. [25]

Pittodara

Pittodara Nidana, Samprapti:
Etiology and Pathogenesis of pittodara:
Pitta gets immediately and excessively accumulated because of intake of
Katu-pungent, Amla – sour, Lavana -saline, Ati ushna and Tiksna ahara -excessively hot and sharp food,
Atapa sevana – exposure to the heat of the fire and sun,
Intake of Vidahi (which causes burning sensation) type of food and intake of food before the previous meal is digested.
Having reached the locations of Vata and Kapha, it supreme the Agni (power of digestion and metabolism) in the stomach as a result of which Pitta type of Udara is manifested. [26-27]

Signs and symptoms of Pittodara:
The following are the signs and symptoms of Paittika type of Udara:
1. Daha – Burning sensation, jwara -fever, Trushna – thirst, Murcha -fainting, Atisara -diarrhoea and Bhrama – giddiness
2. Katukasyatvam – Pungent taste in the mouth
3. Harita haridratvam cha nayana, vadana, tvak mutra varchasam – Green and yellowish discolouration  of nails, eyes, face, skin, urine and stool
4. Nila pita harita tamra raji sira on Udara – Appearance of the net- work of vein with blue, Haridra (yellowish like the colour of turmeric), green and coppery colour
5. Daha – Burning sensation, Duyate -sensation of pain as of smoke is coming out, Dhupyate -heating sensation, Usmayate – perspiration, Svidyate – stickiness and Klidyate-softness to touch and
6. The condition gets converted to Jalodara (Ascites) because of swiftness (Kshiprapaka). [28]

Kaphodara

Etiology and Pathogenesis of kaphodara:
Kapha gets excessively aggravated
Avyayama – owing to lack of exercise
Diva swapna – sleep during day time
Svadati snigdha picchila – intake of sweet, unctuous and slimy food
Dadhi, dugdha Anupa mamsa sevana – curd, milk, and aquatic meat of animals inhabiting marshy land in excess
This aggravated Kapha obstructs the channels of circulation as a result of which Vayu located in the exterior of the intestines gets obstructed. This Vata on its part exercises pressure on Kapha as a result of which [kaphaja type of] Udara is manifested. [29-30]

The following are the signs and symptoms of Kaphaja type of Udara:
1. Gaurava – Heaviness, aruchi- anorexia, Avipaka -indigestion and Anga marda -Malaise
2. Supti – Numbness
3. Pani pada mushka sopha – Appearance of swelling in hands, legs, scrotum
4. Utklesha -Nausea, Ati nidra -excessive sleep, Kasa – cough and Shwasa -dyspnoea
5. Suklatvam of nakha,nayana,vadana, tvak and mutra varchas- Whiteness of nails, eyes, face, skin, urine and stool
6. Udaram sukla raji sira santatam – Appearance of the net- work of veins white in colour and
7. Guru – The abdomen becomes heavy, Stimita (timid or fixed), Sthira -immobile and Kathinam -hard. [31]

Sannipatodara

Etiology and Pathogenesis of Sannipatodara:
All the 3 Doshas, namely Vata, Pitta and Kapha get simultaneously aggravated because of the following
1. When a person with a weak power of digestion indulges in unwholesome, uncooked, mutually contradictory and heavy food.
2. When unwholesome ingredients, like menstrual blood, hair, stool, urine, bone, nails etc. Are administered by women etc and
3. Slow poisoning
These 3 Doshas get accumulated gradually in the Kostha (viscera of the alimentary tract) as a result of which [Sannipatika type of] Udara (obstinate abdominal disease) is caused. [32-33]

Signs and symptoms of Sannipatodara:
The following are the signs and symptoms of Sannipatika type of Udara :
1. Appearance of signs and symptoms of all the 3 Doshas
2. Affliction of nails etc, with all the types of colour described in respect of the Udaras caused by all 3 Doshas and
3. Appearance of net- work veins over the abdomen having varieties of colours (described in respect of Vatodara, Pittodara and Kaphodara ) [34]

Etiology and Pathogenesis of Plihodara:
Spleen which is located in the left side [of the abdomen] gets displaced and enlarged because of intake of-
excessively irritating food, travelling in excess, riding a vehicle,
strenuous exercise, over indulgence in sex, lifting heavy weight, walking a long distance and emaciation caused by excessive administration of emetic therapy or by suffering from chronic diseases.
Spleen also gets enlarged because of increase in the quantity of blood as a result of increase in the quantity of Rasa (chyle) etc.
The spleen becomes stony- hard in the beginning of the process of enlargement and [on palpation] feels like a tortoise.
If the treatment of this condition is neglected, it gradually puts pressure and expands over the Kukshi (sides and lower abdomen) and Agni Adhisthana (pancreas) as a result of which Pihodara is manifested. [35-37]

Pleehodara, Yakrutodara

Signs and symptoms of Plihodara (splenic enlargement) and Yakrutodara (liver enlargement):
1. Daurbalya -Weakness, Aruchi -anorexia,
Vipaka-indigestion, Varcha mutra graha – retention of stool and urine,
Tamah pravesha – entering into darkness,
Pipasa -excessive thirst, Anga marda -malaise,
Chardi -vomiting, Murchha -fainting,
Anga sada- prostration, Kasa -cough,
Shwasa-dyspnoea, Mrudu jwara -mild fever,
Anaha (immobility of wind in the abdomen),
Agni nasha -loss of the power of digestion,
Karshya – emaciation, Aasya vairasya – distaste in the mouth,
Parva bheda -pain in finger joints, Kostha vata shula -distension of alimentary tract by wind and colic pain.
2. Shyava aruna udara -Redness or discolouration of the abdomen and
3. Appearance of net-work of veins having blue, green or yellow colour
Similarly signs and symptoms are manifested by the enlargement of liver (Yakrddalyudara) which is located in the right side of abdomen. Since its etiology, signs and symptoms and treatment are similar to those of Plihodara (splenic enlargement), it is included in the description of the latter.
Thus, the ailment Plihodar (splenic enlargement) is described [38]

Baddhagudodara

Etiology and Pathogenesis of Baddhagudodara – intestinal obstruction
Vata gets aggravated as a result of obstruction in the passage of the rectum because of:
1. Intake of small hair, like eye-lashes along with food
2. Udavarta – upward movement of the wind in the abdomen
3. Arshas – Piles
4. Antra sammurcchana (Intussusception) or intrusion of the intestine into its lumen and
5. Obstruction to the passage of Apana vayu (flatus)
This aggravated Vayu suppresses Agni (activities of enzymes responsible for digestion and metabolism and obstructs the movement of faeces, Pitta and Kapha as a result of which Baddhagudodara (abdominal swelling caused by obstruction in the intestines) is manifested. [39-40]

Signs and symptoms of Baddhagudodara (intestinal obstruction)
1. Trushna – Morbid thirst, Daha -burning sensation, Jwara -fever,
Mukha talu sosha – dryness of mouth and Palate,
Uru sada -prostration in the thighs,
Kasa – cough, Shwasa – dysponea,
Daurbalya -weakness, Aruchi -anorexia, Vipaka – indigestion,
Varcho mutra sanga – stoppage of excretion of stool and urine,
Adhmana ( abdominal distension ), Chardi – vomiting, Kshavathu -sneezing
Shiro shola -headache and Hrut Guda shoola – colic pain in the regions of the heart, umbilicus and anus.
2. Mudha vata in udara – Absence of peristaltic movement in the abdomen.
3. Appearance of stable and blue net-work of veins and
4. Appearance of an elongated swelling of the size and shape of the tail of a cow over the umbilical region.
This is called Baddhagudodara (abdominal swelling caused by obstruction in the intestines) [41]

Chidrodara

Etiology and Pathogenesis of Chidrodara: Intestinal perforation
The intestine gets perforated because of following-
1. Piercing of the intestine by the intake of sand, grass, pieces of wood, bone or nails along with food.
2. Yawning (deeply) and
3. Intake of food in large quantity
The wound in the intestine, thus caused, gets suppurated, and from the wounds the juice (thin paste of food) comes to the exterior of the intestine. The rectum and the intestines get filled up with this juice as a result of which Chidrodara (acute abdominal swelling caused by intestinal perforation) is manifested. [42-43]

Signs and symptoms of Chidrodara:
The following are the signs and symptoms of Chidrodara (acute abdominal swelling caused by intestinal perforation):
1. The abdomen gets swollen generally below the Umbilical region; it subsequently grows to cause Udakodara (Ascites)
2. Manifestation of the signs and symptoms of Doshas according to the nature of their affliction
3. Passing of food stool which is either red, blue, yellow slimy or having the odour of a dead body and
4. Manifestation of hiccup, dyspnoea, cough, excess thirst, Prameha (obstinate urinary disorders), anorexia, indigestion and weakness.
This condition is called Chidrodara (acute abdominal swelling caused by intestinal perforation). [44]

Udakodara

Etiology and Pathogenesis of Udakodara (Ascites):
Agni (digestion strength) loses its power because of excessive intake of water after administration of Snehana treatment (oleation) or by a person suffering from Mandagni (suppressed power of digestion) or by an individual who is suffering from Rajayakshma or excessively emaciated.
As a result of this, Vayu located in Kloman (viscera located adjacent to the heart, i.e right lung) gets interrupted with Kapha and Udaka Dhatu (a liquid element of the body) increases the quantity of that water in the obstructed channels of circulations. The vitiated Kapha and Vayu from their own locations assist in increasing this water as a result of which Udakodara (ascites) is caused. [45-46]

Signs and Symptoms of Udakodara (Ascites):
The following are the signs and symptoms of Udakodara (Ascites):
1. Loss of appetite, morbid thirst, discharge from the anus, colic pain, Dyspnoea, cough and general debility
2. Appearance of net-work of veins having different colours over abdomen and
3. In percussion and Palpation, the physician feels as if the abdomen is like a leather bag filled with water.
This is called Udakodara (Ascites). [47]

Prognosis

The physician should immediately treat this condition before the appearance of complications and before water accumulates in the abdomen.
If the treatment is neglected, then the vitiated Doshas get displaced and become liquefied as a result of Paripaka (maturation), causes stiffness in the joints and channels of circulation and divert sweat from the external channels. The water element moves sideways (Tiryak). It collects in the abdominal cavity. This zigzag- moving sweat adds to the quantity of water already accumulated in the abdomen.
The appearance of this sticky liquid makes the abdomen dull in percussion and soft to touch. The abdomen becomes dull in percussion and soft to touch. Thereafter, the net-work of veins disappears.
During this period, the umbilical region is primarily afflicted, and from there the disease spreads in the remaining parts of the abdomen. Thereafter, states accumulating in the abdomen.
The signs and symptoms of this condition are as follows:
1. Excessive enlargement of the sides of the abdomen
2. Disappearance of the network of the veins and
3.On palpation and percussion, the physician feels as if the abdomen is like a leather sack filled with water. [48]

Upadrava – Complications

Thereafter, the patient gets afflicted with complications, like
Chardi -vomiting, Atisara – diarrhoea,
Tamaka type of Asthma, Trushna – Morbid thirst, shwasa – dyspnoea, Kasa – cough, Hikka- hiccup, Daurbalya- debility, Parshva shoola – pain in the sides of the chest, Aruchi -anorexia, Svara bheda -hoarseness of voice and Mutra sanga—anuria (suppression of urine). A patient with these complications is incurable. [49]

Thus, it is said: of the 6 types of Udara, Viz
Vatodara
Pitodara
Kaphodara
Plihodara
Sannipatodara and
Udakodara, the subsequent ones are more and more difficult for treatment than the previous ones.
After a fortnight, Baddhagudodara (abdominal swelling caused by the obstruction in the intestine) becomes incurable.
Udakodara (ascites) in its Jata Udaka stage (when water accumulates in the abdomen) and Chidrodara (acute abdominal swelling caused by intestinal perforation) are generally incurable right from the beginning [50-51]

Bad Prognosis

Shoonakshi – Swollen eyes,
Kutila Upastha – curved pudendum, sticky and thin skin and diminished strength, blood, muscle tissue as well as Agni (Power of digestion and metabolism) – appearance of these signs and symptoms indicate the incurability of the condition [even if the patient is otherwise curable].
Occurrence of complications, like swelling in all the vital organs, dyspnoea, hiccup, anorexia, morbid thirst, fainting, vomiting and diarrhoea lead to the death of the patient suffering from Udara (obstinate abdominal disease).
All varieties of Udara, right from the time of their manifestation, are generally considered difficult to cure; however it can be cured with adequate care soon after its appearance. If the patient is otherwise strong and if water has not started accumulating in the abdomen [52-54]

Ajatodaka Stage

Signs and symptoms of Ajatodaka Stage of Udara – Ascites
Ajata means not yet appeared, Udaka means water.
Signs and symptoms indicating Ajatodaka (non-appearance of water) stage of Udara Roga
1. There will be either no swelling or less Swelling in the abdomen and legs
2. The colour of the abdomen will be reddish
3. There will be tympanic sound on percussion
4. The abdomen is not very heavy
5. Always having gurgling sound in the abdomen
6. The abdomen will be covered with the network of veins
7. There will be movement of wind from rectum to the umbilicus and distension of the umbilical region; it will be suppressed after the elimination of stool and flatus
8. There will be colic pain in each of the heart region, umbilicus, inguinal region, lumber region and anus
9. Flatus will be eliminated with force
10. The power of the digestion of the patient will not be very weak
11. Because of excessive salivation, there will be imperceptibility of taste in the mouth and
12. There will be scanty urine and hard stool
The above mentioned signs and symptoms indicate Ajatodaka (non-appearance of water in the abdomen) stage of Udara Roga.
Having ascertained it with care, the physician well acquainted and the time of the treatment, should initiate remedial measures for the patient. [55-58]

Treatment of Vatodara

If the patient is suffering from Udara Roga caused by the aggravation of Vayu, and if he is strong, then in the beginning, he is given
Snehana – oleation therapy followed by
Swedana – sweating treatment and
Snigdha virechana – Purgation by oils such as castor oil.

After the Doshas (morbid matter are removed by Virechana treatment, the abdomen of the patient becomes flaccid. Then the abdomen is tightly wrapped with the help of a cloth, so that the Vayu (wind), in view of the empty space in the abdomen, may not cause distension again.

Udara Roga is caused because of excessive accumulation of Doshas (morbid matter) in the gastro- intestinal tract and also because of the obstruction to the opening of channels of circulation (Srotas).

Therefore, the patient is given purgation therapy every day.
After the body is cleansed, the patient is given Samsarjana Krama (administration of heavier diet gradually). Thereafter, he is made to drink milk for the promotion of strength.

If milk is given continuously for a long time, then the patient is likely to get nausea. Therefore, after he has regained strength and prior to the occurrence of nausea, milk is withdrawn.
The patient is then be given vegetable soup or meat soup added with small quantities of sour and salt foods to promote his appetite. If he gets flatulence, then again oleation and fomentation (swedana) therapies are administered. This is followed by Asthapana (decoction enema)

If the patient has itching sensation, cramps, pain in joints, bones, sides of the chest, back and lumbar region, if he has strong power of digestion; and if there is retention of stool and flatus, then even without oleation therapy, the patient is given Anuvasana type of enema (fat enema)

For the purpose of Niruha and Asthapana Basti, the decoction of Dashamoola and such other drugs having Teekshna (sharp) qualities are used.
For the purpose of Anuvasana Basti, castor oil or Sesame oil boiled with sour drugs which help in the alleviation of Vata is used.
If the patient is not suitable for Virechana, if he is weak, old, too young or of tender nature; if there is slight aggravation of Doshas, and if Vayu is aggravated much in excess, then the wise physician should treat home with alleviation therapies. Such a patient is given medicated ghee, vegetable soup and meat soup along with rice, and he should be given massage therapy, anuvasana type of enema and milk (boiled with Vata balancing herbs) [59-67]

Treatment of Pittodara

If the patient is suffering from Paittika type of Udara Roga and if he is strong, then in the beginning, he is given Virechana – purgation therapy.
If he is weak, then he is given elimination therapies, like Anuvasana Basti or medicated enema prepared by boiling drugs with milk (Ksheera Basti).
After the patient regains his strength, and after the promotion of his digestion strength, he is again given Snehana followed by Virechana therapy for which the following recipes is used:
1. Milk boiled with the paste of Trivrit and castor seed
2. Milk boiled with Satala and Trayamana
3. Milk boiled with fruit- pulp of Aragvadha (Cassia fistula)
4. If Udara Roga is caused by Kapha and Pitta, then for the purpose of purgation, milk is used with cow’s urine and
5. If Udara Roga is caused by Pitta and Vata Dosha, then for the purpose of purgation, Tiktaka Ghrita (vide Cikista 7: 140- 150) added with Trivrit etc. is administered.
6. The patient is given milk, medicated enema and purgation therapy repeatedly. The Paittika type of Udara Roga can be certainly cured by Virechana treatment. [68-71]

Treatment of Kaphodara

The patient with Kaphaja type of Udara Roga is given Snehana, Swedana, Vamana treatment. Thereafter, Samsarjana Krama (administration of lighter to heavier food gradually) is given by adding pungent drugs and alkalies to cereals.
He is then given other Kapha mitigating herbs, Ayaskriti (special preparations of iron) and medicated oils added with Alkalies. These therapies alleviated Udara Roga caused by Kapha. [72-73]

Treatment of Sannipatodara

If the patient is suffering from Sannipatik Udara (caused by vitiation of all 3 Doshas) then all the therapies prescribed above for the treatment of Vatodara, Pittodara and Kaphodara are to be suitably employed. If this condition is associated with complications, then the patient is treated keeping in view the incurability of the condition. [74]

Treatment of Pleehodara and Yakruddalyudara

Plihodara splenomegaly with Vata Dosha dominance exhibits Udavarta (bloating, upward movement of wind in the abdomen), pain and Anaha (abdominal distension).
Pleehodara with Pitta dominance exhibits – burning sensation, unconsciousness, thirst and fever
With Kapha dominance, heaviness, anorexia as well as hardness.
Based on the dominance of Dosha and with keeping blood vitiation in mind, suitable treatment is adopted.

The patient is given oleation, fomentation, purgation, Niruha Basti, and Anuvasana Basti, as suitable.
The patient can also be given Siravyadha treatment (blood letting) on the left arm.

The patient is given the following recipes:
1. Shatpala Ghrita ( vide Cikitsa 5: 147 – 148)
2. Pippali Rasayana
3. Abhaya (Terminalia chebula) mixed with Jaggery and
4. Recipes of Kshara and Aristas (Alcoholic Preparations) which are described later below, and in chapter 14 and 15.

The following herbal blends are useful in Pleehodara:
1. 1 part Powder of each of Long pepper, Ginger, Danti, Chitraka, 2 parts of Haritaki and 1 part of Vidanga is given to the patient with hot water.
2. Vidanga – Embelia ribes, Chitraka – Plumbago zeylanica, Sunthi – Ginger, Ghee, Rock-salt and Vacha (Acorus calamus Linn.)- All these herbs are taken in equal quantities, kept over an earthen plates, covered with another earthen plate and the joints is sealed. This is placed over fire to reduce the ingredients into ashes. Intake of this with milk cures Gulma (tumour) and Plihodar (splenic enlargement).

3. Stems of Rohitaka are cut into small pieces. To this, the crushed pulp of Haritaki is added. These ingredients is soaked in adequate quantity of either water or cow’s urine and followed to ferment for 7 nights. Intake of this liquid cures Kamala (Jaundice), Gulma (tumour), Meha (urinary diseases including diabetes), Arsha (piles), Plihodara ( splenic enlargement), all the remaining type of Udara rogas and Krimi Roga (parasitic infestation) after this portion is digested, the patient is given the soup of meat of animals inhabiting arid zone, (Jangala mamsarasa).

4. 25 Palas of bark of Rohitaka and 2 Prasthas Kala is boiled with [8 times of] water [and reduced to 1/4th]. To this, 1 pala paste of pippali – Piper longum 1 Pala Pippali Mula, 1 Pala Ginger 5 Palas of the bark of Rohitaka and 1 Prastha (768 g) ghee is added and cooked this medicated ghee instantaneously cures Pleeha(splenic enlargement), Gulma (Phantom tumour), Udara (obstinate abdominal disorder), Asthma, Krimi (Parasitic infestation), Pandu(anaemia) and Kamala (jaundice).
If there is predominance of aggravated Vayu and Kapha in the patient suffering from splenic enlargement then Agni Karma (cauterisation therapy) is administered. If Pitta is aggravated then Jeevaneeya Ghrita, Ksheera, blood- letting, elimination therapies, light purgation therapy and intake of milk are useful.
Such a patient is given food mixed with vegetable soup and meat soup prepared by boiling with digestive stimulants.
In Yakrdudara (enlargement of liver), all the therapies prescribed for plihodara (enlargement of spleen) is administered because of the similarity between these 2 conditions.

After the administrations of therapies, the patient is given Samsarjana Krama (administration of lighter to heavier food gradually) with the help of food ingredients which are easily digestible [75- ½ 89]

Baddhodara Chidrodara treatment

Treatment of Baddhodara: Intestinal obstruction
To the patient suffering from Baddhodara (intestinal obstruction), fomentation therapy is given thereafter, Niruha (type of medicated enema) and Anuvasana (another type of medicated enema) is given adding cows urine drugs having Tiksna ( sharp) attributes, oil and Salt.
The patient is given such food as would help in the downward movement of Vayu in the abdomen. He is given strong purgative therapies indicated for the treatment of udavarta (upward movement of wind in the abdomen) and such other therapies which are responsible for alleviation of Vayu are administrated. [89 ½ – ½ 91]

Treatment of Chidrodara:
Chidrodara (abdominal swelling caused by the perforation of intestine) is treated on the lines suggested for Kaphodara (vide verses 72- 73) above. However, Swedana is not administered to the patient.
In the patient of Chidrodara suffers from morbid thirst, cough and fever; if there is depletion of his muscle tissue; if his power of digestion and the quantity of food intake are diminished; if he suffers from dyspnoea and colic pain; and if his sense organs become weak, then such a patient is not to be treated [91 ½ – ½ 93]

Treatment of Udakodara

In Udakodara (Ascites), the patient is given therapies to correct the defects of the liquid elements (Apam Doshaharani) in the beginning.
The patient is given therapies containing cow’s urine, drugs having Tiksna (sharp) attributes and different types of Alkalies. He is given food which is digestive stimulant and which alleviates Kapha. Gradually, the patient is prohibited to take water and other liquids [93 ½ – ½ 95]

Involvement of all the 3 Doshas
All the varieties of Udara are generally caused by the involvement of all the three Doshas. Therefore, therapies which cause alleviation of all the 3 Doshas are administered for the treatment of all the varieties of Udara. [95 ½ – ½ 96]

Diet and regimen

Since the abdomen is filled with vitiated Doshas, the power of digestion gets diminished. Therefore, the patient should take such food which is light to digest. (Laghu ahara)
He should take Rakhtashali – red rice, Barley, moong dal – green gram, meat of animals and birds inhabiting arid zone (Jangala mamsa), milk, cow’s urine, Asava (alcoholic preparation in which drugs are generally added without boiling), Arista (alcoholic preparation), honey, Seedhu (a type of alcohol) and Sura (another type of alcohol).
He may also take Yavagu (thick gruel) and boiled rice prepared by boiling with the decoction of Panchamula (roots of Bilva, Syonaka, Gambhari, Patali and Ganikarika) and added with slightly sour ingredients, unctuous substances, like ghee and oil, and pungent drugs along with vegetable soup or meat soup.
He should avoid aquatic meat and animals inhabiting marshy land; leafy vegetables; pastries, preparations of sesame seeds, exercise, walking long distance, and sleep during day time and travelling by fast moving vehicles.
He should also avoid hot, saline and sour things, ingredients which cause burning sensation (Vidahi) and heavy food. This type of patient should strictly avoid taking water. [96 ½ – ½ 101]

Buttermilk of Udara roga

Buttermilk, which is not very thick, which is sweet (not sour) and which is free from fat is useful for the patient suffering from Udara Roga.
If the patient is suffering from Sannipatika Udara Roga, then he should take buttermilk along with Tryusana (ginger, pepper, long pepper) Alkalies and Rock salt
The patient of Vatika type of Udara Roga should take
• Buttermilk along with Pippali – Piper longum and Rock- salt.
In Paittika type of Udara Roga, the patient should take
• Buttermilk which is freshly churned and sweet and added with sugar and the powder of Madhuka (licorice).
For the patient suffering from Kaphaja type of Udara Roga, buttermilk added with Yavani, Rock salt, cumin seeds and Trikatu (ginger, pepper and long pepper) and it should not contain much of fat.
The patient of Plihodara (abdominal swelling caused by the enlargement of spleen) should take
• Butter milk along with honey, oil and the powder of Vata, Sunthi, Shatahva (dill), Kustha and rock salt.
The patient suffering from Udakodara (Ascites) should take
• Buttermilk prepared of well formed curd along with the powder of Trikatu (ginger, pepper and long pepper).
For the patient suffering from Baddhodara (enlargement of abdomen because of intestinal strangulation), butter- milk added with Hapusha, Yavani, cumin seeds and rock salt is useful.
The patient suffering from Chidrodara (abdominal swelling caused by intestinal perforation) should take
• butter milk along with Pippali and honey
Butter milk is like nectar for people suffering from heaviness, anorexia, suppression of the power of digestion, diarrhoea and diseases caused by aggravated Vata and Kapha. [101 ½ – ½ 107]
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Use of milk

If the patient of Udara is suffering from oedema, Anaha (bloating, abdominal distension because of wind), pain, thirst and fainting, then camel milk is useful. After administration of Panchakarma treatment, when it has become emaciated, cow milk, goats milk and buffalo milk are useful [ 107 ½ – ½ 108]

Recipes for External Use

The paste of Devadaru – Cedrus deodara, Palasa – Butea monosperma, Arka – Calotropis procera, Gaja Pippali, Shigru—Moringa oliefera and Ashwagandha- Withania somnifera taken in equal quantities, prepared by triturating with cow’s urine is applied over the abdomen of the patient suffering from Udara Roga.
Vrushchikali, Vacha – Acorus calamus, Kustha – Sausserea lappa, Panchamula (Bilva – Aegle marmelos, Syonaka – Oroxylum indicum, Gambhari – Gmelina arborea, Patali, and Ganikarika), Punarnava – Boerhavia diffusa, Bhutika, Nagara – Zingiber officinale and Dhanyaka is boiled in water and this decoction is used for sprinkling over the abdomen of the patient suffering from Udara Roga.
Similarly the decoction of Palasa – Butea monosperma, Kattrna and Rasna is used for sprinkling [108 ½ -110]

Urine, ghees

Use of Urine
8 type of urine [described in Sutra 1/92-104] is used in sprinkling (over the abdomen) and drinking by the patient suffering from Udara Roga. [½ 111]

Use of Medicated Ghee
If the patient of Udara Roga has Ruksha-dryness and Bahu vata- excess of Vayu in his body, and if he needs elimination therapy, then medicated ghee which is stimulant of digestion and which cures Udara Roga is administered. These recipes will be described hereafter. [111 ½ – ½ 112]

Panchakola Ghirta:
2 Prasthas of ghee is cooked by adding the following:
1. Paste of ½ Pala each of Pippali – Piper longum, Pippali Mula, Chavya – Piper retrofractum, Chitraka – Plumbago zeylanica, Nagara – Zingiber officinale and Yavaksara
2. ½ Tula of the decoction of Dashamula (Bilva – Aegle marmelos, Syonaka – Oroxylum indicum, Gambhari – Gmelina arborea, Patali, Agnimantha – Clerodendrum phlomidis, prsniparni, Shalaparni, Brhati, Kantakari – Solanum surattense and Goksura – Tribulus terrestris) and
3. 1 Adhaka of Dadhimanda (liquid portion of the curd)
This medicated ghee cures Udara Rogas, oedema, Vatavistambha (immobility of wind in the abdomen), Gulma (Phantom tumour) and piles. [112 ½ – 114]

Read more about Panchakola ghrita
Nagara Ghruta
1 Prastha Ghee and 1Prastha til oil is cooked by adding [the paste of] Nagara and Triphala (Haritaki – Terminalia bellerica, Bibhitaka – Terminalia chebula and Amalaki – Phyllanthus emblica) [2 palas each] and 2 Adhakas of Mastu (thin butter- milk).
This medicated ghee cures all types of Udara rogas. It is also useful in the treatment of Gulma caused by the vitiation of kapha and vayu. [115 ½ – ½ 116]
Chitraka Ghrta
2 Prasthas Ghee, 8 Prasthas water, 4 prasthas cow’s urine, 1 Pala paste of Citraka and 1 Pala Yavaksara is cooked together.
This medicated ghee is used by the patient suffering from Udara Roga. [116 ½- ½ 117]

Yavadi Ghruta
Ghee cooked with the decoction of Yava, Kola, Kulattha and Panchamula (Bilva – Aegle marmelos, Syonaka – Oroxylum indicum, Gambhari – Gmelina arborea, Patali and Agnimantha – Clerodendrum phlomidis) and Sura (a type of alcohol) as well as Savira (a type of vinegar) is useful for a patient suffering from udara Roga ( obstinate abdominal disorders) 117 ½- ½ 118]

Virechana – Purgation Therapy

By the administration of the above mentioned recipes of medicated ghee, the patient becomes oleated; he regains strength; aggravated Vayu in his body gets alleviated and the adhesiveness of the Doshas in various Ashayas (visceras) is diminished. Thereafter, the patient of Udara Roga is given purgation therapy described in Kalpa section. [118 ½ – ½ 119]

Patoladi Churna
1 Karsa Root of Patola, 1 Karsa Rajani, 1 Karsa Vidanga – Embelia ribes, 1 Karsa fruit Pulp of Haritaki, 1 Karsa fruit Pulp of Amalaki, 2 Karsas Kampillaka, 3 Karsa Nilini and 4 Karsas Trivrt all these drugs is made to powders and given to the patient along with 1 Musti (Pala) of cow’s urine.
This causes purgation.
Thereafter, the patient is given light diet along with meat soup of animals inhabiting arid zone.
For 6 days, thereafter, depending upon the power of digestion, the patient is given Manda (exceedingly thin gruel) or Peya (thin gruel) along with milk boiled by adding Trikatu (Sunthi, Pippli and Marica).

The above mentioned powder is given again and again.
It cures all types of Udara Rogas even in their Jatodaka Stage (when water starts accumulating in the abdomen). It is also useful in the treatment of Jaundice, anaemia and oedema.
This is called Patoladya churna, and it is very effective in the treatment of all types of udara Rogas. [119 ½ – ½ 124]
Read more about Patoladi Choornam

The patient of Udara Roga should take the powder of Gavaksi, Sankhini (Sveta Bhallataki), Danti, Bark of Tilvaka and Vacha – Acorus calamus along with Cow’s urine, decoction of Draksa – Vtis vinfera, juice of Kola, Juice of Karkandhu or Sidhu (a type of alcoholic preparation). [124 ½ – ½ 125]

Narayana Churna

Yavani, Hapusa, Dhanya, Triphala, (Haritaki –Terminalia chebula, Bibhitaka – Terminalia belerica and Amalaki – Phyllanthus emblica), Upakuncika (Krsna Jiraka), Karvi (small variety of Jiraka), Pippali Mula, Ajagandha [see commentary], Shati – Hedychium spicatum, Vacha – Acorus calamus, satahva, Jiraka ( large variety of Jiraka), Trikatu (Sunthi – Zingiber officinale, Pippali- Piper longum and Marica – Piper nigrum), Svarnaksiri, Chitraka – Plumbago zeylanica, Yavaksara, Svarajiksara,Puskaramula, Kustha – Sauussera lappa, Lavana Panchaka (Sauvarcala, Saindhava, Vida,Audmula, Kustha, Lavana Pancaka (Sauvarcala, Saindhava, Vida, audbhida and Samudra) and Vidanga – all taken one part each, Dani ( three parts), Trivrt – Operculina turpethum(2 parts), Visala (2 Parts) and Satala( 4 parts) is made to a powder. This is called Narayana Churna. Like Lord Narayana, the destroyer along with the following Anupanas depending on the nature of the diseases concerned:
Disease Vehicle
1. Udara Roga Butter Milk
2. Gulma ( Phantom Tumour) Juice of Badara
3. Anaddhavata ( Immobility of wind in the abdomen) Sura (alcoholic drink)
4. Diseases caused by Vayu Prasanna (another type of alcoholic drink)
5. Vidsanga ( faecal obstruction) Dadhimanda ( water which is squeezed out of the curd
6. Piles Juice of Dadima
7. Parikartika (sawing pain in the abdomen) Vrksamla
8. Indigestion Hot water
In Bhagandara (fistula- in- ano) Pandu Roga (anaemia), Asthma, bronchitis, Galagraha( obstruction in the throat), heart diseases, sprue syndrome, Kustha ( obstinate skin diseases including leprosy), suppression of the pow
er of digestion, fever, Damstra visa( biting by an animal having poisonous teeth), Mula Visa ( root poisons) Garavisa ( a type of Poison artificially prepared by combining different ingredients), and Krtrima Visa ( artificial Poison), the patient should first of all be given oleation therapy followed by this recipes for the purpose of purgation [124 ½ – ½ 113]

Hapushadya Churna

Hapusa, Kancanaksiri, Triphala (Haritaki – Terminalia chebula, Bibhitaki – Terminalia chebula, and Amalaki – Phyllanthus emblica), Katurohini, Nilini, Trayamana, Satala, Trivrt – Operculina turpethum, Saindhava, Kala lavana (Bida Lavana) and Pippali – Piper longum is made to powder.
This powder is taken along with juice of Dadima – Punica granatum, Decoction of Triphala, meat soup, cow’s urine or hot water.
It is useful in the treatment of all types of Gulma (phantom tumour), Plihodara (splenic enlargement), all other forms of Udara roga, Svitra (leucoderma), Kustha (obstinate skin diseases including leprosy), Visamagni (irregular power of digestion) associated with pain and flatulence, Shotha – oedema, Arsha -piles, Pandu – anemia, Kamala – Jaundice and Halimaka (A serious type of Jaundice) by causing purgation, this recipe instantaneously corrects aggravated Vayu, Pitta and kapha. [133 ½ – ½ 137]

Nilinyadya Curna:
Nilini, Nicula, Trikatu (Sunthi – Zingiber officinale, Pippali –Piper longum and Maricha – Piper nigrum), Yava, Ksara, Svarjiksara, Pancha Lavana (Sauvarcala, Saindhava, Vida, Audbhida and Samudra) and Chitraka – Plumbago zeylanica is made to a powder.
Intake of this potion along with ghee cures Udara (obstinate abdominal disorders including ascites) and Gulma (Phantom tumour) [137 ½ – ½ 138]

Recipes of Snuhi ksheera Ghrita
2 Dronas of Cow’s milk and 1 Prastha milky latex of Sunhi is mixed together and converted into curd.
It is churned and the ghee that comes out of it is appropriately cooked by adding Trivrt – Operculina turpethum
2 Prasthas of Cow’s ghee and 16 Prasthas cow’s milk is cooked by adding the paste prepared of 1 Pala of the milky latex of Snuhi and 6 Palas of Trivrt.
The above mentioned 2 recipes are useful in the treatment of Gulma (Phantom tumour), poisoning by artificially poisons and Udara Rogas (obstinate abdominal disorders including ascites).
2 Prasthas of Ghee is cooked along with 2 Adhakas of Dadhimanda (water squeezes out of curd) and 1 pala paste of the milky latex of Snuhi. This is taken by the patient in appropriate dose for the cure of Udara Roga (obstinate abdominal disorders including ascites).
After the intake of these recipes, either
Peya (thin gruel) or
Milk or
Juice of sweet fruits (Kapha, Pitta and Vayu respectively) is taken as post – prandial drink.
When the ghee is digested and the purgation is over, the patient is given luke- warm water boiled with ginger (prepared according to the procedure laid down for Sadanga Paniya (vide Cikitsa 1: 3: 145).
Thereafter, the patient is given Peya or thin gruel (on the second day) and soup of Kulattha (on the third day). If necessary, these food ingredients can be given for a longer period the Patient will, thus, become  Ruksa (unctuous and dry). The course of medicated ghee along with the food preparations prescribed above is administered to him repeatedly by an expert physician.
These cures:
Gulma (Phantom Tumour),
Poisoning by artificial poisons and
Udara Rogas (obstinate abdominal disorders including ascites) (138 ½ – ½ 145)

Other recipes of Medicated Ghee
Ghee cooked with the paste of Pilu cures anaha (abdominal distension).
Nilini Ghrta (Nilinyadya Ghrta- vide Cikitsa 5: 105- 109) cures Gulma (Phantom Tumour). The patient of Udara (obstinate abdominal disorders including ascites) may also take Misraka Sneha- vide Cikitsa 5: 149: 151. [145 ½ – 146 ½]

Other medicines

After the vitiated Doshas are gradually eliminated, the patient is given the meat of animals inhabiting arid zone. For the elimination of the residual Doshas, following recipes is administered to the patient:
1. The paste of Devadaru – Cedrus deodara along with milk is taken for 1 month
2. The powder of Gajapippali and Sunthi along with milk
3. Milk boiled with 1 Kola each of Vidanga – Embelia ribes, Chitraka – Plumbago zeylanica, Danti, Chavya – Piper retrofractum and Trikatu (Sunthi – zingiber offcinale, Pippali – Piper longum and Marica – Piper nigrum); intake of this medicated milk cures an acute form of Udara (obstinate abdominal disorders including Ascites) for the preparation of this recipe, the powder of above mentioned drugs is boiled by adding 8 Palas of milk and 32 Palas of water)
4. Decoction of Triphala (Haritaki – Terminalia chebula, Bibhitaka – Terminalia bellerica and Amalaki—Phyllanthus emblica), Danti and Rohitaka along with Trikatu(Sunthi – Zingiber offcinale , Pippali – Piper longum, and Marica -Piper nigrum) and Yavaksara take food along with the soup of meat of animals inhabiting arid zone
5. Meat along with the recipes of Sudhaksira Ghrta or Snuhiksira Ghrta- vde verses 138- 145 above;
6. Harithaki along with cow’s urine followed by milk as post prandial drink; the patient should not take any cereal while taking this recipe.
7. Buffalo – urine; this should be taken for one week; during this period the patient should not take any cereal
8. Buffalo milk, to be taken for 1 week; during this period the patient should not eat any cereal.
9. Camel- milk along with the powder of Trikatu (Sunthi – Zingiber offcinale, Pippali – Piper longum and Marica – Piper nigrum) to be taken for 1 month.
10. Goat- milk along with the powder of trikatu (sunthi, Pippali and Marica) to be taken for 3 months.
11. 1000 fruits of haritaki (to be taken according to the procedure prescribed for Pippali Vardhamana Rasayana- (vide Cikitsa 1: 3: 36-40).
12. Shilajitu along with milk
13. Guggulu according to the procedure prescribed above for Silajatu, i.e along with milk
14. Juice of green ginger along with milk
15. Til oil cooked with ten times of ginger- juice
16. Oil of the fruits of Danti and Dravanti ; this is useful in Dusodara(sannipatika Udara); if there is Colic Pain, abdominal distension and constipation, then this oil should be taken along with Mastu (thin butter- milk) vegetable soup, meat soup etc
17. Oils collected from the seeds of Sarala, Madhusigru and Mulaka; these are useful for massage as well as for taking internally; these oils cure colic pain in the patient suffering from Vatodara;
18. Arishtas ( alcoholic preparations) these recipes are useful if there is Staimitya (a feeling as if a person is covered with a wet cloth or leather), anorexia and nausea; if there is suppression of the power of digestion,
and if the patient is accustomed to alcoholic drinks
19. Ksharas (Alkaline preparations); these recipes are useful if kapha become thick and sticky in the patient suffering from Udara Roga it liquefies the Kapha;
20. [Pippalyadi Ksara] Pippali – Piper longum, Tilvaka, Hingu, Sunthi – Zingiber officinale, Gajapippali, Bhallataka – Randia dumetrum, fruit of Sigru – Moringa oliefera, Triphala (Haritaki – Terminalia chebula , Bibhitaki – Terminalia bellerica and Amalaki – Phyllanthus emblica), katurohini, Devadaru – Cedrus deodara, Haridra, Daruharidra — Berberis aristata, Sarala, Ativisa, Dhava, Vida, Audbhida and samudra) – all these drugs are mixed with curd, ghee, muscle fat, bone marrow and oil and burnt over the fire[ the quantity of curd, etc. Should be such that the powders of drugs are enable to take the shape of bolus; this bolus is kept in an earthen vessel and covered with an earthen plate; the joint between the earthen vessel and earthen plate is sealed with the help of mud smeared cloth; this is placed over fire for reducing the ingredients into ashes. 1 Karsa of this powder is taken after food along with Madira (alcoholic drink), Dadhimanda (water squeezed out of curd), hot water, Arishta (a type of alcoholic preparation), Sura (alcohol) and Asava (another type of alcoholic preparation). It cures heart disease, oedema, Gulma, (Phantom tumour), enlargement of spleen, piles, various types of Udara Rogas, Visucika (choleric diarrhoea), Udavarta upward movement of wind) and Vatasthila (stone like growth in the abdomen caused by vayu).
21. Kshara Vatika- Stool of the goat is burnt, reduced to ashes, diluted with 6 times cow’s urine and strained through a cloth for twenty one times to prepare Kshara (Alkaline preparation). This Alkaline preparation is cooked till it becomes thick in consistency. To this , Pippali – Mula, panca lavana (Sauvarcala, Saindhava, Vida, Audbhida and Samudra), Pippali, Chitraka –Plumbago zeylanica, Sunthi, Triphala(Haritaki, Bibhitaka and Amalaki), Trivrt, Avca, Yavaksara, Svarjiksara, Satala, Danti, Svarnaksiri and Visanika – 1 Karsha each is added and cooked (the quantity of liquid Kshara should be eight times of the powder). From out of this paste, pills of 1 Kola each are prepared. Intake of this pill along with Sauvira ( a type of vinegar) cures oedema, indigestion and acute form of jalodara oedema, indigestion and acute form of Jalodara ( Ascites)
22. Shastika type of rice is impregnated with cow’s urine. This rice is cooked with milk and given to the patient as much as he could take. Thereafter, he is given sugar- cane juice which cures Udara Rogas. By the administration of this recipe, the aggravated Vayu, Kapha and Pitta get restored to their own locations
23. To the patient having costive bowels, vegetables preparation of the leaves of Sankhini, Snuhi, Trivrt, Danti Cirabilva etc. is given before food. By the administration of this recipe, the stool becomes soft and the physician well versed in medical texts should administered milk along with cow’s urine for the elimination of the residual Doshas
24. If the patient suffer from Sula (pain in the sides of the chest) Hrdgraha (stiffness and pain in the cardiac region) because of aggravate Vayu, then he is given oil cooked with Bilva Ksara( fruits of Bilva should be burnt for the preparation of kshara or Alkali preparation and the oil is cooked with this Kshara preparation

25. Similarly, oil cooked with the Kshara( Alkali preparation) of either agnimantha, Syonaka, Palasa, Stems of Tila, Bala, Kadali or Apamarga should be given to the patient for the cure of Udara Rogas( obstinate abdominal disorders) by the administration of this medicated oil, Hrdgaha) stiffness and pain in the cardiac region caused by vayu in the patient suffering from Udara Roga gets subsided
26. If Kapha gets occluded (Avrtta) either by Vayu or by Pitta and if Vayu gets afflicted (Avrtta) by Kapha and Pitta, then castor oil added with Drugs appropriate for the alleviation of the respective Doshas is administered.
27. If the patient gets flatulence even after proper purgation, then he is given Niruha basti( a type of enema prepared of Unctuous, sour and saline drugs) and
28. If the patient suffers from flatulence and there is occlusion of Vayu, then he is given medicated enema therapy prepared of Tiksna (having sharp attributes) drugs, alkalies and cow’s urine. [ 145 ½- ½ 175]

Administration of Snake- venom

If the Udara Roga caused by the simultaneous vitiation of all the 3 Doshas does not yield to the above mentioned treatment, then the physician should call for patient’s relatives, friends, wife ,Brahmanas, the kin(authorities of the state) and preceptors, and inform them of his doubts about the curability of the disease in normal course they should also be informed that patient will certainly die if the risk of toxic therapy is not permit, after this statement, if the friends, etc, of the patient permit, then he is given snake- venom mixed with his food and drinks.
A (Cobra) snake should be enraged and made to bite a fruit to ejaculate its venom the physician after due consideration, should ask the patient to eat that fruit.
The snake- venom is Pramathi [ the drug which by its own potency drains out the accumulated Doshas from the channels of circulation is called Pramathi) because of this, the compact Doshas which are stabilized and completely submerged in the tissues and which have gone astray to channels other than their own, get instantaneously separated from tissues and come out .
When the aggravated Doshas are eliminated, then the patient is sprinkled with cold water and the physician should give him either milk or Yavagu (thick gruel) inadequate quantity depending upon his strength.
Then for 1 month, the patient should not take any cereal and depend upon the leaves of Trivrit – Operculina turpethum, Mandukaparni – , Barley, Vastuka and Kalasaka. These leafy vegetables can be either boiled or taken in unboiled form.
No sour drug, salt or fat is added to these vegetables. These are to be prepared along with the own juice or by adding water.
If during this 1 month, the patient feels thirsty , then he is given the juice of above mentioned plants, specially or Kalasaka to drink.
Intake of these leafy vegetables will eliminate the accumulative Doshas, and after 1 month, the patient who has already become weak is given camel- milk to restore his vitality. [175 ½ – 183 ½]

Surgical Measures

The following surgical measures are performed by the physician having practical experience for the removal/ correction of Shalya (foreign bodies including perforation etc).
An expert surgeon should do an incision in the left pelvic region below the umbilicus leaving 4 fingers breadth of space (from the level of the umbilicus) with the help of an appropriate surgical instrument.
After opening the abdomen, the physician should carefully examine the intestines for strangulation and perforation. The afflicted part is anointed with ghee and foreign bodies, like hair etc, is removed from the intestine. Thereafter, the afflicted are put in its appropriate place.
If there is morbidity in the intestine,then it is made to be Biten by big- black- ants (Pipilikas). Having ascertained the cut off then these intestines is placed back into their appropriate place and the incised abdominal skin is sutured with the help of a needle. [184 ½- 188]

Abdominal Tapping
If liquid is already accumulated in the abdomen(Jatodaka stage) in all types of Udara – Ascites Rogas, the physician should tap in the left side of the abdomen below the umbilicus (with the help of torchar and canula), later, with the help of the canula all the fluid by applying pressure, the abdomen is tied tightly with the help of a cloth- bandage, the retraced abdomen is required to be similarly tied with the help of a cloth- bandaged after the administration of enema or purgation therapy and after similar other measures. [189- 190]

Diet
After the fluid from the abdomen is drained out, the patient is made to fast and thereafter, he is given (thin gruel) which is prepared without adding fat and salt. Thereafter, for 6 months, the patient should live only on milk.
Thereafter, for 3 months, the patient should take Peya (thin Gruel) prepared of milk. For 3 months, thereafter, he is given cereals like Syamaka or Koradusa along with milk. These are light for digestion and no salt is given to the patient during this period.
Thus, the patient having reached the Jatodaka stage of ascites should overcome the ailment in 1 year. [191- ½ 193]

Utility of Milk
After the administration of all therapies, the patient should invariably be given milk to take for maintaining the harmony of Doshas and for promoting strength as well as stability in the body.
By the administration of different therapies, the body of the patient becomes emaciated and all the tissue elements in his body get diminished.
For such patient, milk is very useful. It is as good as the ambrosia for the gods. [193 ½- 194]
Thus it is said:-

In this chapter dealing with the treatment of Udara Rogas the Sage Atreya has described in brief as well as in detail the following topics.
1. Causative factors
2. Premonitory signs and symptoms
3. Signs and symptoms of eight varieties of Udara Roga ( obstinate abdominal diseases including ascities) in detail as well as in brief;
4. Complications and their seriousness
5. Curability and incurability
6. Signs and symptoms of Jatodaka( where fluid has started accumulating in the abdomen) and Ajatodaka abdomen) stages of this disease and
7. Treatment [195- 196]

Thus, ends the 13th chapter dealing with the treatment of Udara Roga (obstinate abdominal disorders including ascites) in the section on therapeutics of Agnivesha’s work as redacted by Charaka, restored by Drudhabala.

Yogas mentioned in Sahasra yoga text book

1. Mahodarahara kashaya
2. Tiktaka Gritha
3. Mahatiktaka gritha
4. Indukantam gritha
5. Sukumara gritham
6. Dhanvantari gulika
7. Varunadi gritha
8. Khandasama choorna
9. Naracha choorna
10. Hapushadi choorna
11. Nilini choorna
12. Jati Lavangadi choorna
13. Mahavahni vajra
14. Trilavana Pasugandhadi choorna
15. Ayorajo Nagaradi choorna
16. Pippalyadi choorna
17. Snuhi pippali choorna
18. Sindhuttha jeerakadi choorna
19. Indrasani choorna
20. Agnimukha choorna
21. Soolari choorna
22. Modakadi choorna
23. Kalyana kshara
24. Abhayarishta
25. Dasmoolarishta
26. Parpadadyarishta
27. Dantyarishta
28. Duralabharishta
29. Pippalyasava
30. Punarnavasava
31. Kumaryasava
32. Manibhadra guda
33. Danti haritakyavaleha
34. Bahusala Guda
35. Dasamoola Hareetaki Lehya
36. Chithraka Guda
37. Kaisora Guggulu
38. Yogaraja guggulu
39. Kittadi Gutika
40. Marichadi Gutika
41. Anthrakuthara Rasa
42. Taviramadi kashaya
43. Ardrakadi Ghritam