Chapter CLXI - The Nidanam of Ascited etc

Dhanvantari said:—Hear me, O Sushruta, now discourse on the Nidanam of Udaram (Ascites). AH diseases are but the offspring of impaired digestion, and it is but superfluous to add that Udaram has its origin in the deranged condition of the digestive function. An accumulation of feces in the intestines may give rise to indigestion or to any other form of dyspepsia or disease, and the deranged up-coursing and down-coursing Vayus of the system, being obstructed in their course, make the intestines (Prabahini) inoperative. The Prana Vayu (nerve-force of the respilatory centre)

brings about the derangement of the Apana Vayu (pneumo-gastric nerveforce), and keeps them incarcerated in the union of the skin and flesh (faces), thus giving rise to a distended condition of the abdomen, which is called Udara-Ruga (Roga?) (Ascites.)

The disease admits of being divided into eight types according as it is engendered through the several, or concerted action of the morbific principles of the deranged Vayu, Pittam, and Kapham, or through the enlargement of the spleen, or abdominal glands, etc., or is produced as the outcome of a wound in the abdomen, or is ushered in through an accumulation of serous fluid in the abdominal cavity. Dryness of the lips and palate, distension of the abdomen, diminution of strength and appetite, incapacity for all kinds of work, bulging out of the abdomen, and a cadaverous look are the premonitory symptoms of Ascites. Loss of appetite with a non-relish for food, which, if retained in the stomach, gives rise to an acid reaction are the further characterestics of ascites during its period of incubation. He, who does not experience a proper digestion of his ingested food, should do well to live on a wholesome diet. The strength of the patient is diminished, every day, and he feels tired after the least exertion. He becomes incapable of fixing his attention to any definite subject, and the least thinking distresses his mind. The limbs becomes emaciated, and the patient feels despondent and complains of a breaking pain in the pelvis, even after the scantiest meal. Somnolence, lassitude, loose motions of the bowels, fondness for seclusion, impaired digestion with a burning sensation in the body, anasarca, and tympanites are the symptoms, which indicate the accumulation of water (serous fluid) in the abdomen. A case of Ascites invariably ends in death, and it is futile on the part of the patient's relations to mourn his death under the circumstance. A rumbling sound is heard in the intestines, and the surface of the abdomen becomes chequered with a net-work of veins. The intestines and the region of the umbilicus becomes stuffed (with wind) in this disease, and an urging towards defication (dedication) vanishes as soon as it is experienced. In this Vataja type, the patient experiences a pain in the groins, heart, and other parts of the body, as well as about the waist, anus, and umbilicus. Flatus is often emitted with a loud report, and urine becomes scanty. All desire for food vanishes in this type of the disease, and the patient complains of a bad taste in his mouth. (Edematous swelling of the face, abdomen, and extremities, a breaking pain in the abdomen, or about the waist, sides, back, or other parts of the body, dry cough, pain in the limbs, heaviness of the nether regions of the body, suppression of stool, varied taste in the mouth, and a reddish or blackish colour of the skin are the further characteristics of the Vataja type of Ascites. A breaking, piercing, pain is likewise experienced in the abdomen in this type, and the surface of the abdomen becomes covered over with a fret-work of blue or black veins. The abdomen gets distended, and a variety of sound is heard within its cavity. The deranged bodily Vayu, which courses all through the organism, gives rise to various sounds and and diverse kinds of pain in the different parts of the body.

Fever, epileptic fits, a bitter taste in the mouth, and a burning sensation in the body, vertigo, dysenteric stools, yellowness of the skin, and greenness of the skin of the distended abdomen are the symptoms, which mark the Pittaja type of Ascites. Yellow or copper-coloured veins appear on the skin of the patient, who imagines as if fumes are escaping out of his body, and complains of constant vanishings of sight. Perspiration becomes copious which does not relieve the intolerable burning sensation in the body. The abdomen is felt soft to the touch and speedily supperates in this (Pittaja) type of Ascites.

Lassitude of the body, perspiration, œdematous swelling of the limbs, heaviness of the body, somnolence with a non-relish for food, dyspnœa, cough and whiteness of the skin and conjunctivæ are the features, which mark the Kaphaja type of Ascites. The skin of the protruded abdomen becomes glossy, and fretted with messes of black or white veins. On the excessive accumulation of water (serous fluid) in the abdominal cavity, the abdomen becomes hard, heavy, immoveable, and cold to the touch. In the Tridoshaja type the symptoms peculiar to each of the three aforesaid types manifest themselves in unison.

All the morbific principles of the body, in combination with the vitiated blood and accumulated fecal matter, find lodgment in the cavity of the abdomen, giving rise to vertigo, Epilepsy, and emaciation in a form of Ascites in which symptoms peculiar to the three morbific diathises of Vayu, Pittam, and Kaham are combinedly developed; and suppuration sets in early in the distended abdomen. The disease shows signs of aggravation in cold and windy days, and is extremely hard to cure.

The spleen, which is situated in the left side of the abdominal cavity, is disloged (hangs down) from its seat through the ingestion of inordinate quantities of food, mental anxiety, or excessive riding or drinking, or through the abuse of emetics (excessive emisis).

In the alternative, the spleen may increase in bulk through the accumulation of fat or engorgement of blood in its body. It becomes hard and raised like the back of a tortoise, and gradually fills a greater part of the abdominal cavity, bringing on dyspnœa, cough, thirst, fever with a bad taste in the mouth, distension of the abdomen, yellowness of the skin, epileptic fits, vomiting, fainting, and a burning sensation in the body in its train. In abdominal dropsy due to enlargement of the spleen, nets of red, blue, or yellow veins are found to appear on the skin of the abdomen, and tympanites with suppression of stool and flatus, vertigo, and fever with a burning sensation in the region of the heart are found to supervene.

Similarly, the liver, which is situated in the upper part of the right side of the abdominal cavity, is pressed down from its natural position either through a voluntary and constant repression of any natural urging of the body, or through the heaviness of any of the surrounding appendages, or through eating without any relish for food, or in reason of its own indurated condition, gives rise, like the spleen, to a peculiar form of abdominal dropsy, which is called Yakritodaram (lit Dropsy of the enlarged liver). The feces remain obstructed in the rectum of the patient as soon as the process of suppuration is established in the liver, producing dyspnœa, tympanites, etc. The enraged and aggravated Vayu, in this disease, arrests the secretion of bile, and those of the glands of the intestimes, thus obstructing the expulsion of the feces. The Apana Vayu, thus incarcerated in the abdominal cavity, brings on fever attended with cough, dyspnœa, a gone feeling in the thighs, headache, an aching pain at the sides, in the limbs, or about the umbilicus, constipation of the bowels, vomiting and a non-relish for food. The enraged bodily Vayu should be regarded as the principal agent in engendering this, as well as every other, form of abdominal dropsy. Blue or red veins are found to appear permanently on the skin of the dropsical abdomen, and the dropsy extends in the form of a cow’s tail transvesely above the umbilicus, marked by crow-feet marks.

The visceras of the abdominal cavity supparate in the event of any bone or foreign matter being pricked into the cavity of the abdomen. The abdominal dropsy engendered in consequence thereof is called Chhidrodara or Parisravyodara (Peritonites) according to others The Vayu and Kapham in the system of an emaciated person, or of one of impaired digestive function or addicted to the habit of drinking large quantities of water, become enraged through such injudicious conduct, and arrest the discharge of the acid secretions of the stomach, giving rise to an accumulation of water in the abdomen. Thirst, prolapsus ani, pain, cough, and dyspnœa with a non relish for food, are the symptoms which are exhibited during the extremely aggravated stage of this disease. The surface of the distended abdomen becomes covered over with a net work of veins. The abdomen is found to fluctuate under pressure, and is iclt soft to the touch. In some cases the abdomen is felt to be firm and glossy like the abdomen of a heron, and the disease is found to invade the intestines. The patient suffers from alternate fits of heat and rigor. In all types of Dropsy, neglect at the outset leads to the further liquefication of the serous accumulations of the abdomen, which are diffused all through the organism, causing œdamatous swelling of the face, joints etc., and facilitating the accumulation of serous fluid in the vessels of the body.

An obstruction of the ducts of the body that carry perspiration may help the accumulation of water in the abdomen. Purging or loose motions of the bowels precede an attack of this type of Ascites. The dropsy becomes firm, heavy, and spherical, and does not give the characteristic sound under percussion. The patient gets weaker, every day, and the disease becomes incurable as soon as it invades the internal vessels of the abdomen. A case of Ascites, in which the appearance of veins on the surface of the bulged out abdomen is obliterated, should be regarded as of a Sannipatika origin.

Of the different types of dropsy such as, the Vataja, Pittaja, Kaphaja, Plihaja (Pihaja?) (Dropsy of the enlarged spleen) and Sannipatika (due to the concerted action of the deranged Vayu Pittam, and Kapham), and Dakodara (Ascites), each preceding one should be regarded as more difficult to cure than the one immediately following it in the order of enumeration. All types of Dropsy, attended with the symptoms of obstructed (flow), become incurable after a fortnight from the date of their attack. A case of congenital Ascites invariably proves fatal.