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Chapter 35 – Udara Nidanam

The chapter 35 of Madhava Nidana is Udara Nidanam which deals with Enlargement of Stomach.

Etiology —

रोगाः सर्वे अपि मन्दे अग्नौ सुतरामुदराणि च |
अजिर्णान्मलिनैश्चान्नैर्जायन्ते मलसञ्चयात् || १ ||

rōgāḥ sarvē api mandē agnau sutarāmudarāṇi ca |
ajirṇānmalinaiścānnairjāyantē malasañcayāt || 1 ||

The poor digestive activity (mandagni) produces several diseases, particularly the disease of the enlargement of the stomach (Udara Roga). The diseases of stomach also arise due to indulgence in uncooked, dirty, or spoiled eatables and accumulation of waste products in the body. 1

Pathogenesis —

रुद्ध्वा स्वेदाम्बुवाहीनि दोषाः स्रोतांसि सञ्चिताः |
प्राणाग्न्यपानान् संदूष्य जनयन्त्युदरं नृणाम् || २ ||

ruddhvā svēdāmbuvāhīni dōṣāḥ srōtānsi sañcitāḥ |
prāṇāgnyapānān sandūṣya janayantyudaraṁ nr̥ṇām || 2 ||

The accumulated doshas producing obstruction in the sweat and water – carrying channels excite prana, apana and pitta (agni) and generate various diseases of the stomach (udara roga). 2

General Clinical Features —

आध्मानं गमने अशक्तिदौर्बल्यं दुर्बलाग्निता |
शोथः सदनम अङ्गानां सङ्घो वात – पुरीषयोः || ३ ||
दाहस्तन्द्रा च सर्वेषु जठरेषु भवन्ति हि | 

ādhmānaṁ gamanē aśaktidaurbalyaṁ durbalāgnitā |
śōthaḥ sadanama aṅgānāṁ saṅghō vāta – purīṣayōḥ || 3 ||
dāhastandrā ca sarvēṣu jaṭharēṣu bhavanti hi |

Symptoms of Udara Roga include the following:

  • Distension of the stomach with gas,
  • Inability to walk,
  • Weakness,
  • Poor digestion,
  • Inactivity,
  • Oedema, and
  • Debility of the extremities,
  • Obstructed movement of flatus and faeces.

Moreover, there is a feeling of burning sensation and stupor. 3

The Eight types of abdominal enlargements —

पृथग्दोषैः समस्तैश्च प्लीह – बद्ध – क्षतोदकैः || ४ ||
सम्भवन्त्युदराण्यष्टौ तेषां लिङ्गं पृथक् शृणु |

pr̥thagdōṣaiḥ samastaiśca plīha – baddha – kṣatōdakaiḥ || 4 || sambhavantyudarāṇyaṣṭau tēṣāṁ liṅgaṁ pr̥thak śr̥ṇu |

 There are eight types of Udara Rogas; one from each dosha, one from their combination; Plihodara, baddhodara, ksatodara and udakodara. Now please listen to their specific clinical features. 4 

Vatodara —

तत्र वातोदरे शोथः पाणि – पान्नाभि – कुक्षिषु || ५ ||
कुक्षि – पार्श्वोदर – कटि – पृष्ठरुक् पर्वभेदनम् |
शुष्ककासो अङ्गमर्दो अधो गुरुता मलसंग्रहः || ६ ||
श्यावारुणत्वगादित्वमकस्माद्वृद्धिह्रासवत् |
सतोद – भेदमुदरं तनु – कृष्णसिराततम् ||७||
आध्मातदृतिवच्छब्दमाहतं प्रकरोति च |
वायुश्चान्न सरुक्शब्दो विचरेत् सर्वतोगतिः || ८ ||

tatra vātōdarē śōthaḥ pāṇi – pānnābhi – kukṣiṣu || 5 ||
kukṣi – pārśvōdara – kaṭi – pr̥ṣṭharuk parvabhēdanam |
śuṣkakāsō aṅgamardō adhō gurutā malasaṅgrahaḥ || 6 || śyāvāruṇatvagāditvamakasmādvr̥ddhihrāsavat |
satōda – bhēdamudaraṁ tanu – kr̥ṣṇasirātatam ||7||
ādhmātadr̥tivacchabdamāhataṁ prakarōti ca |
vāyuścānna sarukśabdō vicarēt sarvatōgatiḥ || 8 ||

Symptoms of Vatodara include the following:

  • Oedema of the hands, feet, umbilicus and lower stomach;
  • Pain in the stomach, flanks, waist, back and joints;
  • Dry cough and
  • Body aches

Moreover, there is

  • Feeling of heaviness in the lower parts of the body,
  • Accumulation of waste products in the body,
  • Bluish or brownish discoloration of skin and the like,
  • Enlargement or decrease of size of the stomach without any apparent reason,
  • pricking and other types of pain.

In addition, there is

  • Appearance of thin, black network of veins on the stomach,
  • Highly resonant sound elicited on percussion and
  • there is movement of gas with gurgling noise and
  • Pain inside the stomach. 5-8

Pittodara —

पित्तोदरे ज्वरे मूर्च्छा दाहस्तृट् कटुकास्यता |
भ्रमो अतिसारः पीतत्वं त्वगादावुदरं हरित् || ९ ||
पीत – ताम्रसिरानद्धं सस्वेदं सोष्म दह्यत् |
धूमायते मृदुस्पर्शं क्षिप्रपाकं प्रदूयते || १० ||

pittōdarē jvarē mūrcchā dāhastr̥ṭ kaṭukāsyatā |
bhramō atisāraḥ pītatvaṁ tvagādāvudaraṁ harit || 9 ||
pīta – tāmrasirānaddhaṁ sasvēdaṁ sōṣma dahyat |
dhūmāyatē mr̥dusparśaṁ kṣiprapākaṁ pradūyatē || 10 ||

Symptoms of Pittodara include the following:

  • Fever,
  • Fainting
  • Burning sensation,
  • Thirst,
  • Bitter taste in the mouth,
  •  Giddiness,
  • Diarrhoea,
  • Yellow discoloration of skin and the like,
  • Appearance of network of veins of green, yellow or red colour on the stomach,
  • Perspiration,
  •  Feeling of heat and
  • Burning as though by movement of warm smoke;
  • Stomach turning soft to touch and painful.

To sum up, as Jalodara the condition is quickly progressive. 9-10

Shleshmodara —

श्लेष्मोदरे अङ्गसदनम् स्वापः श्वयथु – गौरवम् |
निद्रोत्क्लेशो अरुचिः श्वासः कासः शुक्लत्वगादिता || ११ ||
उदरं स्तिमितं स्निग्धं शुक्लराजीततं महत् |
चिराभिवृद्धं कठिनं शीतस्पर्शं गुरु स्थिरम् || १२ ||

ślēṣmōdarē aṅgasadanam svāpaḥ śvayathu – gauravam |
nidrōtklēśō aruciḥ śvāsaḥ kāsaḥ śuklatvagāditā || 11 ||
udaraṁ stimitaṁ snigdhaṁ śuklarājītataṁ mahat |
cirābhivr̥ddhaṁ kaṭhinaṁ śītasparśaṁ guru sthiram || 12 ||

Symptoms of Kaphodara or Shleshmodara include the following:

  • Debility,
  • Loss of activity,
  • Oedema, and
  • Heaviness of body parts,
  • Too much of sleep,
  • Nausea,
  • Loss of appetite,
  • Difficulty in breathing,
  • Cough,
  • Whiteness of the skin and the like.
  • Softness of the stomach, having white striae.

In addition,

  • Stomach of the patient enlarges and it becomes hard, cold to touch, heavy and static.

It even continues to increase in size slowly. 11-12

Sannipatodara (Acute/ Chronic Peritonitis) —

स्त्रियो अन्नपानं नख – लोम – मूत्र – विडार्तवैर्युक्तमसाधुवृत्ताः |
यस्मै प्रयच्छन्त्यरयो गरांश्च दुष्ताम्बु – दूषिविषसेवनाद्वा || १३ ||
तेनाशु रक्तं कुपिताश्च दोषाः कुर्युः सुघोरं जठरं त्रिलिङ्गम् |
तच्छीतवाते भृशदुर्दिने च विशेषतः कुप्यति दह्यते च ||१४||
स चातुरो मुह्यति हि प्रसक्तं पाण्डुः कृशः शुष्यति तृष्णया च |
दूष्योदरं कीर्तितमेतदेव —

striyō annapānaṁ nakha – lōma – mūtra – viḍārtavairyuktamasādhuvr̥ttāḥ |
yasmai prayacchantyarayō garānśca duṣtāmbu – dūṣiviṣasēvanādvā || 13 ||
tēnāśu raktaṁ kupitāśca dōṣāḥ kuryuḥ sughōraṁ jaṭharaṁ triliṅgam |
tacchītavātē bhr̥śadurdinē ca viśēṣataḥ kupyati dahyatē ca ||14||
sa cāturō muhyati hi prasaktaṁ pāṇḍuḥ kr̥śaḥ śuṣyati tr̥ṣṇayā ca |
dūṣyōdaraṁ kīrtitamētadēva —

 

Causes for the increase in doshas include the following:

  • Ingestion of harmful substances containing nails, hairs, urine, faeces, menstrual blood and the like, administered by wicked women.

Doshas get vitiated also through indulgence in the eatable and drink offered by the foes, ingestion of polluted water, slow poison and the like. These factors vitiate rakta as well as doshas soon. They produce severe abdominal disorders having the features of all the three doshas together.

The disease is aggravated and it produces a burning sensation especially during extreme cold, windy and cloudy weathers. The patient faints repeatedly and becomes pale as well as emaciated; he feels his mouth to be dry due to thirst. This is also known as Dushyodara. 13-14

Plihodara (Splenomegaly) —

— प्लीहोदरं कीर्तयतो निबोध || १५ ||
विदाह्यभिष्यन्दिरतस्य जन्तोः प्रदुष्टमत्यर्थमसृक् कफश्च |
प्लीहाभिवृद्धिं कुरुतः प्रवृद्धो प्लीहोत्थमेतज्जठरं वदन्ति || १६ ||

— plīhōdaraṁ kīrtayatō nibōdha || 15 ||
vidāhyabhiṣyandiratasya jantōḥ praduṣṭamatyarthamasr̥k kaphaśca |
plīhābhivr̥ddhiṁ kurutaḥ pravr̥ddhō plīhōtthamētajjaṭharaṁ vadanti || 16||

Plihodara occurs in the following persons:

  • Who indulge in eatables like greasy materials which cause burning sensation during digestion and which block the tissue pores. Thus, the blood (rakta) and kapha undergo abnormal change and they, in turn, produce enlargement of spleen and generate Splenomegaly (Plihodara).

In this disease, stomach is enlarged mainly on the left side. The patient turns much debilitated. He develops a mild fever, poor digestion, and features of promoted kapha and pitta. Moreover, loss of strength and severe anemia are the additional symptoms of Plihodara. 15-16

Yakrddalyudara (Hepatomegaly) —

तद्वामपार्श्वे परिवृद्धिमेति विशेषतः सीदति चातुरो अत्र |
मन्दज्वराग्निः कफ – पित्तलिङ्गैरूपद्रुतः क्षीणबलो अतिपाण्डुः |
सव्यान्यपार्श्वे यकृति प्रवृद्धे ज्ञेयं यकृद्दाल्युदरं तदेव || १७ ||

tadvāmapārśvē parivr̥ddhimēti viśēṣataḥ sīdati cāturō atra |
mandajvarāgniḥ kapha – pittaliṅgairūpadrutaḥ kṣīṇabalō atipāṇḍuḥ |
savyānyapārśvē yakr̥ti pravr̥ddhē jñēyaṁ yakr̥ddālyudaraṁ tadēva || 17 ||

The pathological condition has been identified as hepatomegaly (yakrutodara) if there is an enlargement of the liver on the right side. 17

Symptomatology of Splenomegaly or Hepatomegaly —

उदावर्त – रुजानाहैर्मोह – तृड् – दहन – ज्वरैः |
गौरवारुचि – कठिन्यैर्विध्यात्तत्र मलान् क्रमात् || १८ ||

udāvarta – rujānāhairmōha – tr̥ḍ – dahana – jvaraiḥ |
gauravāruci – kaṭhinyairvidhyāttatra malān kramāt || 1 ||

Features of splenomegaly that has been produced through Vata include the following:

  • Upward movement of wind in stomach (that is udavarta),
  • Pain and
  • Distension of stomach with gas.

The features of pitta induced splenomegaly are such as —

  • Delusion, and Thirst,
  • Feeling of burning sensation and
  • Fever.

Similarly, the features of kapha induced Splenomegaly include the following:

  • Feeling of heaviness,
  • Loss of appetite and
  • Hardness of the stomach.

In both these conditions, these symptoms should be kept in view. 18

Baddhagudodara (Intestinal obstruction) —

यस्यान्त्रमन्नैरूपलेपिभिर्वा बालाश्मभिर्वा पिहितं यथावत् |
संचीयते तस्य मलः सदोषः शनैः शनैः सङ्करवच्च नाल्याम् || १९ ||
निरुध्यते तस्य गुदे पुरीषं निरेति कृच्छ्रादपि चाल्पमल्पम् |
ह्रुन्नाभिमध्ये परिवृद्धिमेति तस्योदरं बद्धगुदं वदन्ति || २० ||

yasyāntramannairūpalēpibhirvā bālāśmabhirvā pihitaṁ yathāvat |
sañcīyatē tasya malaḥ sadōṣaḥ śanaiḥ śanaiḥ saṅkaravacca nālyām || 19 ||
nirudhyatē tasya gudē purīṣaṁ nirēti kr̥cchrādapi cālpamalpam |
hrunnābhimadhyē parivr̥ddhimēti tasyōdaraṁ baddhagudaṁ vadanti ||20||

When food, slimy substances, hair or small stones, etc. block (the lumen of) the intestines of the patient, the faeces along with the doshas gradually accumulate there like garbage in a drain. The faecal matter then is obstructed in the rectum and even when it is passed; it is passed through enormous difficulty and in very small amounts. It distends the stomach between the pericardium (epigastrium) and umbilicus. This condition is called Baddhagudodara. 19-20

Parisravyudara or Ksatodara (Intestinal perforation) —

शल्यं तथा अन्नोपहितं यदन्त्रं भुक्तं भिनत्त्यागतमन्यथा वा |
तस्मात्स्रुतो आन्त्रात्सलिलप्रकाशः स्रावः स्रवेद्वै गुदतस्तु भूयः || २१ ||
नाभेरधश्चोदरमेति वृद्धिं निस्तुध्यते दाल्यति चातिमात्रम् |
एतत् परिस्राव्युदरं प्रदिष्टं —

śalyaṁ tathā annōpahitaṁ yadantraṁ bhuktaṁ bhinattyāgatamanyathā vā |
tasmātsrutō āntrātsalilaprakāśaḥ srāvaḥ sravēdvai gudatastu bhūyaḥ |21||
nābhēradhaścōdaramēti vr̥ddhiṁ nistudhyatē dālyati cātimātram |
ētat parisrāvyudaraṁ pradiṣṭaṁ —

Sometimes, there is a condition in which the intestines are perforated by sharp foreign bodies ingested along with eatables or due to other causes also; Moreover, there is exudation of watery material from inside and subsequent enlargement of the stomach below the umbilicus with pricking pain and apparent fluid movement. This condition has been identified as intestinal perforation and peritonitis. (Parisravi Udara). 21

Jalodara or Dakodara (Ascites) —

— दकोदरं कीर्तयतो निबोध || २२ ||
यः स्नेहपीतो अप्यनुवासितो वा वान्तो विरिक्तो अप्यथवा निरुढः |
पिबेज्जलं शीतलमाशु तस्य स्रोतांसि दूष्यन्ति हि तद्वहानि || २३ ||
स्नेहोपलिप्तेष्वथवा अपि तेषु दकोदरं पूर्ववदभ्युपैति |
स्निग्धं महत्तत्परिवृत्तनाभि समाततं पूर्णमिवाम्बुना च |
यथा दृतिः क्षुभ्यति कम्पते च शब्दायते चापि दकोदरं तत् || २४ ||

— dakōdaraṁ kīrtayatō nibōdha || 22 ||
yaḥ snēhapītō apyanuvāsitō vā vāntō viriktō apyathavā niruḍhaḥ |
pibējjalaṁ śītalamāśu tasya srōtānsi dūṣyanti hi tadvahāni || 23 ||
snēhōpaliptēṣvathavā api tēṣu dakōdaraṁ pūrvavadabhyupaiti |
snigdhaṁ mahattatparivr̥ttanābhi samātataṁ pūrṇamivāmbunā ca |
yathā dr̥tiḥ kṣubhyati kampatē ca śabdāyatē cāpi dakōdaraṁ tat || 24 ||

Factors responsible to genesis of Dakodara include the following:

  • Drinking cold water by the patient who has been recently administered therapies like application of oil on the body, oil enema, emesis, and purgation or decoction enema; or by anyother means.

Moreover, when the channels of fluids in the body get obstructed by oily materials, it results in appearance of dakodara. In this condition, the stomach is greatly enlarged with the umbilicus protruding out, turning smooth and hard to touch. There appears a sound and a movement as if a leather bag has been filled with water. This condition is known as ascites, enlargement of the stomach with fluid (dakodara).23-24

Prognosis of Udara Diseases —

जन्मनैवोदरं सर्वं प्रायः कृच्छ्रतमं मतम् |
बलिनस्तदजाताम्बु यत्नसाध्यं नवोत्थितम् || २५ ||
पक्षाद्वद्धगुदं तूर्ध्वं सर्वं जातोदकं तथा |
प्रायो भवत्यभावाय च्छिद्रान्त्रं चोदरं नृणाम् || २६ ||

janmanaivōdaraṁ sarvaṁ prāyaḥ kr̥cchratamaṁ matam |
balinastadajātāmbu yatnasādhyaṁ navōtthitam || 25 ||
pakṣādvaddhagudaṁ tūrdhvaṁ sarvaṁ jātōdakaṁ tathā |
prāyō bhavatyabhāvāya cchidrāntraṁ cōdaraṁ nr̥ṇām || 26 ||

Even at their onset, all kinds of udara rogas are difficult to cure, generally. In persons of strong constitution, before formation of fluid and if it is of a recent onset, an udara roga can be cured with great efforts. All old cases of intestinal obstruction of more than fortnight duration, as well as those cases with accumulation of fluid and cases of intestinal perforation are usually fatal. 25 – 26

शूनाक्षं कुटिलोपस्थमुपक्लिन्न – तनुत्वचम् |
बल – शोणित – मांसाग्निपरिक्षीणं च वर्जयेत् || २७ ||
पार्श्वभङ्गान्नविद्वेष – शोथातीसारपीडितं |
विरिक्तं चाप्युदरिणं पूर्वमाणं विवर्जयेत् || २८ ||

śūnākṣaṁ kuṭilōpasthamupaklinna – tanutvacam |
bala – śōṇita – mānsāgniparikṣīṇaṁ ca varjayēt || 27 ||
pārśvabhaṅgānnavidvēṣa – śōthātīsārapīḍitaṁ |
viriktaṁ cāpyudariṇaṁ pūrvamāṇaṁ vivarjayēt || 28 ||

The wise physicians should avoid those patients of udara who have developed oedema of the eyes, curvature of the pubic region, and a smooth and thin skin. One should also not try to treat a patient manifesting loss of strength, loss of blood, muscles and digestive incapacity, those who have pricking pain in the flanks, aversion to eatables, oedema , diarrhoea and have tendencies to accumulate fluids quickly in spite of purgation. 27 – 28

इति श्रीमाधवकरविरचिते माधवनिदाने उदरनिदानं समाप्तम् || ३५ ||
iti śrīmādhavakaraviracitē mādhavanidānē udaranidānaṁ samāptam |35||

Thus concludes the chapter on Udara.