Ashtanga Hridayam Nidanasthanam Chapter 12:  Udara Nidanam Adhyaya (Diagnosis of enlargement of the abdomen)

The 12th chapter of Nidanasthanam of Ashtanga Hridayam is named as Udara Nidanam Adhyayah. This chapter deals with the explanation of ‘diagnosis of enlargement of the abdomen’.

The topics covered in this chapter include –

–       Udara Nidana – causes of enlargement of abdomen
–       Samprapti (pathogenesis)
–       Types and general symptoms of udara
–       Purvarupa – premonitory symptoms
–       Rupa – Clinical features
–       Vatodara, Pittodara, Kaphodara, Sannipatodara\
–       Plihodara – Yakrutodara (enlargement of spleen and liver)
–       Baddhodara – obstruction of abdomen (abdominal viscera)
–       Kshatodara – abdominal enlargement caused due to trauma
–       Jalodara – ascites
–       Sadhyasadhyata (prognosis)

Pledge by the author(s)

अथात उदरनिदानं व्याख्यास्याम: ।
इति ह स्माहुरात्रेयादयो महर्षय: ।
After having offered prayers to the God, henceforth we are going to explain the chapter pertaining to the explanation of ‘diagnosis of enlargement of the abdomen’. Thus say (pledge) atreya and other sages.

Udara Nidana: Causes of enlargement of abdomen

रोगाः सर्वेऽपि मन्देऽग्नौ सुतरामुदराणि तु ।
अजीर्णान् मलिनैश्चान्नैर्जायन्ते मलसञ्चयात् ॥ १ ॥
Generally all diseases are produced by mandagni (weak digestion strength) especially so the udara – enlargement of the abdomen;Udara disease can also be caused due to indigestion, due to contaminated foods, or due to accumulation of malas – aggravated doshas and waste products.

Samprapti (Pathogenesis)

ऊर्ध्वाधो धातवो रुद्ध्वा वाहिनीरम्बुवाहिनीः ।
प्राणाग्न्यपानान् सन्दूष्य कुर्युस्त्वङ्मांससन्धिगाः ॥ २ ॥
आध्माप्य कुक्षिमुदरम्
Dhatus – doshas-vata, pitta and kapha getting aggravated, obstruct the channel of ambu (water related body channels) both at the top and bottom,bring about abnormalities in the prana (division of vata), agni (digestive activity) and apana (division of vata),causes accumulation of water in between the layers of skin, and musclesand produce udara, by enlarging the abdomen.

Types and general symptoms of udara

अष्टधा तच्च भिद्यते ।
पृथग्दोषैः समस्तैश्च प्लीहबद्धक्षतोदकैः ॥ ३ ॥
तेनार्ताः शुष्कताल्वोष्ठाः शूनपादकरोदराः ।
नष्टचेष्टाबलाहाराः कृशाः प्रध्मातकुक्षयः ॥ ४ ॥
स्युः प्रेतरूपाः पुरुषा
It is of eight kinds;from each dosha separately, by all of them together,by pliha (enlargement of the spleen), baddha (obstruction of the intestine), ksata- perforation of the intestines and udaka accumulation of fluid.Affected by this disease, the persons have dryness of the palate and lips,swelling of the feet, hands and abdomen;loss of activeness, strength and desire for food;emaciation, severe flatulenceand appear like a cadaver.

Purvarupa: Premonitory symptoms

भाविनस्तस्य लक्षणम् ।
क्षुन्नाशोऽन्नं चिरात्सर्वं सविदाहं च पच्यते ॥ ५ ॥
जीर्णाजीर्णं न जानाति सौहित्यं सहते न च ।
क्षीयते बलतः शश्वच्छ्वसित्यल्पेऽपि चेष्टिते ॥ ६ ॥
वृद्धिर्विषोऽप्रवृत्तिश्च किञ्चिच्छोफश्च पादयोः ।
रुग्वस्तिसन्धौ ततता लघ्वल्पाभोजनैरपि ॥ ७ ॥
राजीजन्म वलीनाशो जठरे
The premonitory symptoms (of enlargement of abdomen are) loss of hunger, food takes a very long time undergo digestion, digestion is accompanied with burning sensation, the person cannot decide whether the food is digested or not, and also can not tolerate satiety, has loss of strength, does not breath (has shortness of breath) even after mild activity, there is increase in the quantity of feces but there is constipation, slight swelling of the feet, pain in the joints on either sides of the urinary bladder, and distention even with easily digestible and little quantity of food and by not eating food also, appearance of white lines and disappearance of folds over the abdomen (because of stretching of abdominal skin due to distention).

Rupa: Clinical features

जठरेषु तु ।
सर्वेषु तन्द्रा सदनं मलसङ्गोऽल्पवह्निता ॥ ८ ॥
दाहः श्वयथुराध्मानमन्ते सलिलसम्भवः ।
सर्वं त्वतोयमरुणमशोफं नातिभारिकम् ॥ ९ ॥
गवाक्षितं सिराजालैः सदा गुडगुडायते ।
नाभिमन्त्रं च विष्टभ्य वेगं कृत्वा प्रणश्यति ॥ १० ॥
मारुतो हृत्कटीनाभिपायुवङ्क्षणवेदनाः ।
सशब्दो निश्चरेद्वायुर्विड्बद्धा मूत्रमल्पकम् ॥ ११ ॥ नातिमन्दोऽनलो लौल्यं न च स्याद्विरसं मुखम् ।
In all types of jathara (Udara) there is stupor, debility, accumulation of wastes-especially the feces, poor digestion strength, burning sensation, swelling, at the terminal stages, flatulence and collection of fluid – in the abdomen. In all the types of Udara, before the collection of fluid, the abdomen is of slight red color there will not be swelling and heaviness of abdomen. Abdomen covered with the network of veins, air or gas moves inside producing constant sound, vata causes obstruction of the umbilicus and intestines, the symptoms arise and then subside; there is pain in the region of the heart, waist, umbilicus, rectum and groins, the flatus comes out with great sound, faeces is obstructed and the urine is expelled little in quantity; the digestive capacity is not very dull, there is neither increased desire for food nor bad taste in the mouth.

Vataja Udara

तत्र वातोदरे शोफः पाणिपान्मुष्ककुक्षिषु ॥ १२ ॥
कुक्षिपार्श्वोदरकटीपृष्ठरुक् पर्वभेदनम् ।
शुष्ककासोऽङ्गमर्दोऽधोगुरुता मलसङ्ग्रहः ॥ १३ ॥
श्यावारुणत्वगादित्वमकस्माद्वृद्धिह्रासवत् ।
सतोदभेदमुदरं तनुकृष्णसिराततम् ॥ १४ ॥
आध्मातदृतिवच्छब्दमाहतं प्रकरोति च ।
वायुश्चात्र सरुक्शब्दो विचरेत्सर्वतोगतिः ॥ १५ ॥
In vatodrara –abdominal enlargement due to vata there is, swelling of the hands, feet, scrotum and upper abdomen; pain in the upper abdomen, flanks, central abdomen, waist and back, cutting pain in the inter-phalangeal joints (small joints of the fingers), dry cough, body ache, heaviness of the lower parts of the body, accumulation of wastes, dark brown and reddish brown discoloration of skin etc. sudden increase and sudden decrease in the size of abdomen, pricking and piercing pain in the abdomen, appearance of thin black veins on the abdomen; the abdomen produces sound when tapped similar to an inflated lather bellow vayu – air / gas moves in all places – inside the abdomen accompanied with pain and noise.

Pittaja Udara

पित्तोदरे ज्वरो मूर्छा दाहस्तृट् कटुकास्यता ।
भ्रमोऽतीसारः पीतत्वं त्वगादावुदरं हरित् ॥ १६ ॥
पीतताम्रसिरानद्धं सस्वेदं सोष्म दह्यते ।
धूमायति मृदुस्पर्शं क्षिप्रपाकं प्रदूयते ॥ १७ ॥
In pittodara, there is fever, fainting, burning sensation, thirst, pungent feeling in the mouth, dizziness, diarrhea, yellow color in the skin etc. the abdomen has green, yellow, or coppery red veins appearing everywhere; excess sweating, feeling of warmth as though being scorched by fire, feeling as though emitting hot fumes; is soft to touch undergoes quick ripening with quick collection of fluid.

Kaphodara (Shleshmodara)

श्लेष्मोदरेऽङ्गसदनं स्वापः श्वयथुगौरवम् ।
निद्रोत्क्लेशारुचिश्वासकासशुक्लत्वगादिता ॥ १८ ॥
उदरं स्तिमितं श्लक्ष्णं शुक्लराजीततं महत् ।
चिराभिवृद्धि कठिनं शीतस्पर्शं गुरु स्थिरम् ॥ १९ ॥
In kaphodara, there is debility of the body, loss of tactile sensation, swelling, feeling of heaviness, excess sleep, nausea, loss of taste and appetite; dyspnea, cough, white discoloration of the skin etc (and other organs such as nails, tongue etc), the abdomen is static –without any movement / feel as if abdomen is covered with wet cloth, is smooth, has white lines everywhere, increasing slowly in size, over long period of time;  hard cold to touch, heavy and stable.

Sannipatodara

त्रिदोषकोपनैस्तैस्तैः स्त्रीदत्तैश्च रजोमलैः ।
गरदूषीविषाद्यैश्च सरक्ताः सञ्चिता मलाः ॥ २० ॥
कोष्ठं प्राप्य विकुर्वाणाः शोषमूर्छाभ्रमान्वितम् ।
कुर्युस्त्रिलिङ्गमुदरं शीघ्रपाकं सुदारुणम् ॥ २१ ॥
बाधते तच्च सुतरां शीतवाताभ्रदर्शने ।
By indulgence in food and activities that cause increase of all the three doshas simultaneously; because of contamination of menstrual blood, excreta etc. administered by women – in order to kill or seduce, due to ingestion of artificial poison –administered by others to kill and of dusivia – poison which are weak to kill but can cause diseases, the accumulated malas dosha along with rakta, get aggravated, become localized in the abdomen and gives rise to abnormalities; emaciation, fainting, dizziness and produce enlargement of the abdomen, having the features of all the doshas; it undergoes ripening – collection of fluid quickly and the condition is severe, gives utmost trouble and discomfort, when expsosed to cold wind and clouds.

Plihodara: Yakrutodara (Enlargement of spleen and liver)

अत्याशितस्य सङ्क्षोभाद्यानयानादिचेष्टितैः ॥ २२ ॥
अतिव्यवायकर्माध्ववमनव्याधिकर्शनैः ।
वामपार्श्वाश्रितः प्लीहा च्युतः स्थानाद्विवर्धते ॥ २३ ॥
शोणितं वा रसादिभ्यो विवृद्धं तं विवर्धयेत् ।
सोऽष्ठीलेवातिकठिनः प्राक् ततः कूर्मपृष्ठवत् ॥ २४ ॥
क्रमेण वर्धमानश्च कुक्षावुदरमावहेत् ।
श्वासकासपिपासास्यवैरस्याध्मानरुग्ज्वरैः ॥ २५ ॥
पाण्डुत्वमूर्छाछर्दीभिर्दाहमोहैश्च संयुतम् ।
अरुणाभं विवर्णं वा नीलहारिद्रराजिमत् ॥ २६ ॥
उदावर्तरुजानाहैर्मोहतृड्दहनज्वरैः ।
गौरवारुचिकाठिन्यैर्विद्यात्तत्र मलान् क्रमात् ॥ २७ ॥
In persons who consume large quantity of food habitually, by exhaustion, excess travelling in vehicles, riding on animals and such other activates, over-indulgence in sexual intercourse, physical activities, long distance walk, excess vomiting, and by weakness due to diseases, pliha – the spleen situated on the left side of abdomen gets displaced from its place and becomes enlarged; increased, vitiated the blood, rasa-plasma and other tissues also bring about its enlargement of spleen; spleen, getting enlarged becomes very hard like the cobbler’s stone in the beginning, later resembles the tortoise shell, gradually the abdomen increases in size and occupies the entire abdomen starting from its upper portion and producing abdominal enlargement, accompanied with dyspnoea, cough, severe thirst, bad taste in the mouth, flatulence, pain, fever, and associated with pale appearance, fainting episodes, vomiting, burning sensation, and delusion (loss of consciousness) the abdomen is either slightly red or discolored, with blue, or deep yellow lines appearing on it. Predominance of the mala (dosha) should be determined by the presence of udavarta – upward movement of vata, pain and flatulence, these three are produced by vata; delusion, thirst, burning sensation and fever – these are caused by pitta, feeling of heaviness, loss of taste/appetite and hardness- of the abdomen caused by kapha respectively.

Plihodara: Yakrutodara (enlargement of spleen and liver)

प्लीहवद्दक्षिणात्पार्श्वात् कुर्याद्यकृदपि च्युतम् ।
Similar to the plihodara, the yakritodara (with liver enlargement) gets replaced from the right side, causing enlargement of the abdomen.

Baddhodara: Obstruction of abdomen (abdominal viscera)

पक्ष्मवालैः सहान्नेन भुक्तैर्बद्धायने गुदे ॥ २८ ॥
दुर्नामभिरुदावर्तैरन्यैर्वान्त्रोपलेपिभिः ।
वर्चःपित्तकफान् रुद्ध्वा करोति कुपितोऽनिलः ॥ २९ ॥
अपानो जठरं तेन स्युर्दाहज्वरतृट्क्षवाः ।
कासश्वासोरुसदनं शिरोहृन्नाभिपायुरुक् ॥ ३० ॥
मलसङ्गोऽरुचिश्छर्दिरुदरं मूढमारुतम् ।
स्थिरं नीलारुणसिराराजीनद्धमराजि वा ॥ ३१ ॥
नाभेरुपरि च प्रायो गोपुच्छाकृति जायते ।
By ingestion of eyelashes, hair along with food, by severe obstruction of the rectum bloating of abdomen – upward movement of vata or by other reasons which form a coating inside the intestines, aggravated apana vata, by obstructing feces, pitta and kapha, produces Udara – abdominal enlargement; from that arises, burning sensation, fever ,thirst, excessive sneezing, cough, dyspnea, weakness of the thighs, headache, pain in the region of the heart, umbilicus and rectum, constipation, anorexia, vomiting; abdominal enlargement, with no movement of vata – flatus in the abdomen, abdomen is static, covered with lines of blue or light red, veins or not having lines; probably enlargement resembling the tail of cow (broad at the top and small at bottom) appears above the umbilicus.

Kshatodara: Abdominal enlargement caused due to trauma

अस्थ्यादिशल्यैः सान्नैश्चेद्भुक्तैरत्यशनेन वा ॥ ३२ ॥
भिद्यते पच्यते वान्त्रं तच्छिद्रैश्च स्रवन् बहिः ।
आम एव गुदादेति ततोऽल्पाल्पं सविड्रसः ॥ ३३ ॥
तुल्यः कुणपगन्धेन पिच्छिलः पीतलोहितः ।
शेषश्चापूर्य जठरं जठरं घोरमावहेत् ॥ ३४ ॥
वर्धयेत्तदधो नाभेराशु चैति जलात्मताम् ।
उद्रिक्तदोषरूपं च व्याप्तं च श्वासतृड्भ्रमैः ॥ ३५ ॥
छिद्रोदरमिदं प्राहुः परिस्रावीति चापरे ।
By ingestion of bone and other sharp foreign bodies along with food or consuming large quantity of food, the intestines get perforated or ulcerated; the undigested food material flows out (through the hole / ulcer). Rasa – fluids, in small quantities, is expelled out of rectum, mixed with feces feces becomes foul smelling like that of a dead body, slimy, yellowish-red in color. Gradually fills up the abdomen, causing its enlargement, which increases in size, below the umbilicus; it soon changes into collection of fluid in the abdomen; presenting symptoms of the predominant—causative dosha and associated with dyspnoea, thirst and dizziness; this disease is called as Chidodara and as parisravi udara by some others (also known as Kshatodara).

Jalodara: Ascites

प्रवृत्तस्नेहपानादेः सहसामाम्बुपायिनः ॥ ३६ ॥
अत्यम्बुपानान्मन्दाग्नेः क्षीणस्यातिकृशस्य वा ।
रुद्ध्वाम्बुमार्गाननिलः कफश्च जलमूर्छितः ॥ ३७ ॥
वर्धयेतां तदेवाम्बु तत्स्थानादुदराश्रितौ ।
ततः स्यादुदरं तृष्णागुदस्रुतिरुजान्वितम् ॥ ३८ ॥
कासश्वासारुचियुतं नानावर्णसिराततम् ।
तोयपूर्णदृतिस्पर्शशब्दप्रक्षोभवेपथु ॥ ३९ ॥
दकोदरं महत्स्निग्धं स्थिरमावृत्तनाभि तत् ।
In a person who always drinks water without boiling, during the course of therapies such as oleation etc, drinking large quantity of water by those who have poor digestive capacity, who are debilitated – by depletion of tissues and who are very emaciated – by chronic diseases, vata and kapha get aggravated together and block the water channels of the body, mixed with the body-water, causes increase of water / fluids, displaces it from its place and cause water accumulation in the abdomen; it is called Udara disease associated with thirst, exudation from the rectum, and pain, cough, dysponea and loss of taste/ appetite the abdomen has veins of many colors appearing all over, resembles a bag filled with water for touch, sound, movement and tremors, large in size, unctuous, static, less movement, with bulged umbilicus. This disease is called Daakodara – Udakodara or Jalodara.

Jalodara: Ascites

उपेक्षया च सर्वेषु दोषाः स्वस्थानतश्च्युताः ॥ ४० ॥
पाकाद्द्रवा द्रवीकुर्युः सन्धिस्रोतोमुखान्यपि ।
स्वेदश्च बाह्यस्रोतःसु विहतस्तिर्यगास्थितः ॥ ४१ ॥
तदेवोदकमाप्याय्य पिच्छां कुर्यात्तदा भवेत् ।
गुरूदरं स्थिरं वृत्तमाहतं च न शब्दवत् ॥ ४२ ॥
मृदु व्यपेतराजीकं नाभ्यां स्पृष्टं च सर्पति ।
तदनूदकजन्मास्मिन्कुक्षिवृद्धिस्ततोऽधिकम् ॥ ४३ ॥
सिरान्तर्धानमुदकजठरोक्तं च लक्षणम् ।
By neglecting quick and effective treatment in all kinds of udara, the doshas getting displaced from their own sites due to digestion the doshas get liquefied and make more fluid to accumulate in the channels of the joints and tissues; the sweat obstructed in its outer opening, begins to move in all directions (oblique, sideward direction), gets mixed with the body-water causes stickiness, sliminess, it collects in the abdomen, which becomes heavy, static, round, not producing sound when tapped, soft, and absence of veins; the fluid spreads to other parts when the umbilicus is pressed; gradually accumulation of fluid in the abdomen occurs, leading to great increase in the size of the abdomen, causes disappearance of veins and other symptoms of udakodara.

Sadhya asadhyata (Prognosis)

वातपित्तकफप्लीहसन्निपातोदकोदरम् ॥ ४४ ॥
कृच्छ्रं यथोत्तरं पक्षात्परं प्रायोऽपरे हतः ।
सर्वं च जातसलिलं रिष्टोक्तोपद्रवान्वितम् ॥ ४५ ॥
जन्मनैवोदरं सर्वं प्रायः कृच्छ्रतमं मतम् ।
बलिनस्तदजाताम्बु यत्नसाध्यं नवोत्थितम् ॥ ४६ ॥
Udara- abdominal enlargement caused by vata, pitta, kapha, plihahodara –splenomegaly, sannipata – all the three doshas together and udakodara – ascites are difficult to cure in their successive order; other kinds usually kill the patient by a fortnight, udara all types after the formation of fluid and accompanied with complications or secondary diseases bad omens and fatal signs enumerated in the chapter on arista – chapter 5 of sharira sthana. All kinds of udara are by their very onset, are probably said to be very difficult to cure, those occurring in persons who are strong, which have not reached the stage of fluid formation and those of recent onset may get cured by great effort.

इति श्री वैद्यपति सिंहगुप्तसूनु श्रीमद्वाग्भटविरचितायामष्टाङ्गहृदयसंहिताया तृतीये निदानस्थाने उदरनिदानं नाम द्वादशोऽध्याय: ॥१२॥
Thus ends the chapter Udara – Nidana- the twelfth in the Nidana sthana of Astangahrudaya samhita composed by Srimad Vagbhata, son of sri Vaidyapathi Simhagupta.