Difference between revisions of "Arsha Chikitsa"

Arsha Chikitsa
Section/Chapter	Chikitsa Sthana Chapter 14
Preceding Chapter	Udara Chikitsa
Succeeding Chapter	Grahani Chikitsa
Other Sections	Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Kalpa Sthana, Siddhi Sthana

Revision as of 14:08, 9 April 2019

Chikitsa Sthana Chapter 14, Chapter on management of Arsha (Hemorrhoids)

Abstract

This chapter of Chikitsa Sthana exclusively deals with the treatment of guda arsha (piles/hemorrhoids). Congenital and acquired types, their causes, clinical features of dosha dominance and management are elaborated. The usual treatment of hemorrhoids is surgical, but if proper treatment is received it can be best managed with medicinal treatment. The disease arsha is mentioned in the Ashtomahagada (group of eight diseases that are difficult to cure).

Recurrence rate of hemorrhoids is high, even after surgical intervention. Sushruta has mentioned that any disease, if can be cured with the medicine is not required to be treated with shodhana and shastrakarma (surgical intervention). So, every attempt should be made to treat hemorrhoids with medicinal treatment, diet and lifestyle changes. Different medicinal formulations for conservative management and local applications, soothing therapy, sitz bath, fumigation, and sprinkling with the herbs are some of the modes of treatment prescribed to relieve the local inflammation, bleeding and maintain the peri-anal hygiene to control the disease. The principal of treatment is to avoid the nidana (causative factors), with diet being one of them. Digestive power of the person should be strong, which can be maintained with the consumption of different types of thin and thick gruels. Anuvasana basti is used for management of constipation, the root cause of arsha. Raktamokshana (bloodletting), in cases of vitiation of rakta, is advised. Finally, it is evident that treatment of hemorrhoids is multifocal and no single modality is effective including surgery.

Keywords: Arsha, anuvasana basti, raktamokshana, hemorrhoids, shodhana chikitsa, soothing therapy, sitz bath, fumigation, asava, arishta, churna, vati

Introduction

This chapter is followed by udara roga because the causative factors for both the diseases are similar like vitiation of tridosha. Both the diseases are related to the same system i.e. gastrointestinal tract. Further, arsha is one of the causative factors of udara roga (Boddhagudedara- intestinal obstruction) Therefore the chapter dealing with arshas (hemorrhoids) follows the chapter on the treatment of udara (obstinate abdominal disorders).

The chapter describes types of arsha (such as congenital or acquired), sites of manifestation other than the ano-rectal region, doshic signs and symptoms, etio-pathogenosis, etiology of the doshaja arsha, and prognosis along with the symptoms of curable and incurable hemorrhoids. Hemorrhoids can be shushka (dry or non-bleeding) and sravi (wet or bleeding) with different modes of treatment for each of these. In the bleeding type hemostatic management is essential while in non- bleeding type hemostatic treatment is not needed.

The dry hemorrhoids can be correlated with the external hemorrhoids where protrusion of mucosal folds occur, without bleeding. Local treatment includes, fomentation, sitz bath, sprinkling, smearing and fumigation and topical medicament. The need of proper hygiene of the peri-anal area is important. Raktamokshana (bloodletting) was advised as one of the para-surgical procedure and in cases of vitiation of rakta and predominance of pitta dosha. Oral intake of the herbal powders, takraarishta, abhayaarishta, dantyaarishta, phalaarishta are described along with their method of preparation. In pathya the recipes like thick gruel, curd, buttermilk, leafy vegetables for vegetarian and meat as well as meat soup for non-vegetarian was advised in cases of constipated bowel. It proves that along with the other causative factors constipation is an important cause. The role of haritaki with jaggery is one of the requirements for deepana and pachana because the cause of arsha is depressed digestive power. The other recipes like ghrita, preparations like pippalyadi ghrita, chavyadi ghrita, nagaradi ghrita in constipated patients. The anuvasana basti is advisable with medicated taila in the management of dry or external hemorrhoids.

The wet hemorrhoids have the predominance of kapha along with vata and can be correlated with internal hemorrhoids which are usually bleeding in nature. The line of treatment as per predominance of vata or kapha has been described. In initial stage the bleeding should not be stopped as the vitiated blood should be let out. Later on kutajadi rasakriya for hemostatis, thick and thin gruel remedies were explained. Cooling therapy, sprinkling therapy with different herbal preparations, warm and cold water sitz bath was advised in the cases of bleeding. Recipes of curds and rice in the diet are also recommended. For local treatment external application of cold leaves, soothing ointment, rubbing recipes and topical application in the bleeding hemorrhoids are described.

Sanskrit text, Transliteration and English Translation

अथातोऽर्शश्चिकित्सितं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

athāto’rśaścikitsitaṃ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātreyaḥ||2||

athAto~arshashcikitsitaM vyAkhyAsyAmaH||1||

iti ha smAha bhagavAnAtreyaH||2||

We shall now expound the treatment of hemorrhoids. Thus said Lord Atreya. [1-2]

आसीनं मुनिमव्यग्रं कृतजाप्यं कृतक्षणम्|

पृष्टवानर्शसां युक्तमग्निवेशः पुनर्वसुम्||३||

प्रकोप हेतुं संस्थानं स्थानं लिङ्गं चिकित्सितम्|

साध्यासाध्य विभागं च तस्मै तन्मुनिरब्रवीत्||४||

āsīnaṃ munimavyagraṃ kṛtajāpyaṃ kṛtakṣaṇam|

pṛṣṭavānarśasāṃ yuktamagniveśaḥ punarvasum||3||

prakopa hetuṃ saṃsthānaṃ sthānaṃ liṅgaṃ cikitsitam|

sādhyāsādhya vibhāgaṃ ca tasmai tanmunirabravīt||4||

AsInaM munimavyagraM kRutajApyaM kRutakShaNam|

pRuShTavAnarshasAM yuktamagniveshaH [1] punarvasum||3||

prakopahetuM saMsthAnaM sthAnaM li~ggaM cikitsitam|

sAdhyAsAdhyavibhAgaM ca tasmai tanmunirabravIt||4||

To Punarvasu (Lord Atreya), who was in calm pose after having completed his religious rituals, Agnivesha inquired about the etiology, aggravating factors, shape, size, location, clinical features, treatment and prognosis of arsha (hemorrhoids). Then Lord Atreya responded. [3-4]

Types of hemorrhoids

इह खल्वग्निवेश! द्विविधान्यर्शांसि- कानिचित् सहजानि, कानिचिज्जातस्योत्तरकालजानि|

तत्र बीजं गुदवलि बीजोप तप्तमायतनमर्शसां सहजानाम्|

तत्र द्विविधो बीजोपतप्तौ हेतुः- मातापित्रोरपचारः, पूर्वकृतं च कर्म; तथाऽन्येषामपि सहजानां विकाराणाम्|

तत्र सहजानि सह जातानि शरीरेण, अर्शांसीत्यधिमांसविकाराः||५||

iha khalvagniveśa! dvividhānyarśāṃsi- kānicit sahajāni, kānicijjātasyottarakālajāni|

tatra bījaṃ gudavali bījopa taptamāyatanamarśasāṃ sahajānām|

tatra dvividho bījopataptau hetuḥ- mātāpitrorapacāraḥ, pūrvakṛtaṃ ca karma; tathā’nyeṣāmapi sahajānāṃ vikārāṇām|

tatra sahajāni saha jātāni śarīreṇa, arśāṃsītyadhimāṃsavikārāḥ||5||

iha khalvagnivesha! dvividhAnyarshAMsi- kAnicit sahajAni, kAnicijjAtasyottarakAlajAni|

tatra bIjaM gudavalibIjopataptamAyatanamarshasAM sahajAnAm|

tatra dvividho bIjopataptau hetuH- mAtApitrorapacAraH, pUrvakRutaM ca karma; tathA~anyeShAmapisahajAnAM vikArANAm|

tatra sahajAni saha jAtAni sharIreNa, arshAMsItyadhimAMsavikArAH||5||

O Agnivesha!, The arsha is of two types:

Congenital
Acquired (manifested after the birth).

Congenital hemorrhoids are caused by the vitiation of the beeja dosha (deformity in sperm and ovum), specially the part of the anal canal or anal sphincters. This vitiation of the beeja dosha is caused by two groups of factors:

The wrong diet and regimen of parents (father/mother)
The sinful acts of the past life of individuals.

These two categories of causative factors are also responsible for all the other congenital disorders in the human body. Sahaja means the disorder which is manifested along with the appearance of the body parts since birth. Arsha (hemorrhoids) is characterized by morbid growth in the muscle tissue. [5]

Locations of hemorrhoids

सर्वेषां चार्शसां क्षेत्रं- गुदस्यार्ध पञ्चमाङ्गुलावकाशे त्रिभागान्तरास्तिस्रो गुदवलयः क्षेत्रमिति; केचित्तु भूयांसमेव देशमुपदिशन्त्यर्शसां- शिश्नमपत्यपथं गल तालु मुख नासिका कर्णाक्षि वर्त्मानि त्वक् चेति|

तदस्त्यधि मांस देशतया, गुदवलिजानां त्वर्शांसीति सञ्ज्ञा तन्त्रेऽस्मिन्|

सर्वेषां चार्शसामधिष्ठानं- मेदो मांसं त्वक् च||६||

sarveṣāṃ cārśasāṃ kṣetraṃ- gudasyārdha pañcamāṅgulāvakāśe tribhāgāntarāstisro gudavalayaḥ kṣetramiti; kecittu bhūyāṃsameva deśamupadiśantyarśasāṃ- śiśnamapatyapathaṃ gala tālu mukha nāsikā karṇākṣi vartmāni tvak ceti|

tadastyadhi māṃsa deśatayā, gudavalijānāṃ tvarśāṃsīti sañjñā tantre’smin|

sarveṣāṃ cārśasāmadhiṣṭhānaṃ- medo māṃsaṃ tvak ca||6||

sarveShAM cArshasAM kShetraM- gudasyArdhapa~jcamA~ggulAvakAshe tribhAgAntarAstisro gudavalayaHkShetramiti; kecittu bhUyAMsameva deshamupadishantyarshasAM- shishnamapatyapathaMgalatAlumukhanAsikAkarNAkShivartmAni tvak ceti|

tadastyadhimAMsadeshatayA, gudavalijAnAM [1] tvarshAMsIti sa~jj~jA tantre~asmin|

sarveShAM cArshasAmadhiShThAnaM- medo mAMsaM tvak ca||6||

The hemorrhoids are located in the space of four and half angulas (or approximately 8-10 cm) in the lower part of rectum and anal canal. This area has three sphincters dividing the space into three parts (guda vali). There are other locations of arshas (hemorrhoids) in the body in which excessive and unnatural growth of the muscle tissue also takes place, such as, pudendum, female genital tract, throat, palate, mouth, nose, ears, eyelids and skins. However, in this chapter the arsha occurring in the anal region are only considered as arsha (hemorrhoids). The adhishthana (involved morbid tissue elements) of all the types of arsha are medas (fatty tissue), mamsa (muscular tissue) and tvaka (skin and mucous membrane). [6]

Forms of congenital hemorrhoids

तत्र सहजान्यर्शांसि कानिचिदणूनि, कानिचिन्महान्ति, कानिचिद्दीर्घाणि, कानिचिद्ध्रस्वानि, कानिचिद्वृत्तानि, कानिचिद्विषमविसृतानि, कानिचिदन्तःकुटिलानि, कानिचिद्बहिःकुटिलानि, कानिचिज्जटिलानि, कानिचिदन्तर्मुखानि, यथास्वं दोषानुबन्धवर्णानि||७||

tatra sahajānyarśāṃsi kānicidaṇūni, kānicinmahānti, kāniciddīrghāṇi, kāniciddhrasvāni, kānicidvṛttāni, kānicidviṣamavisṛtāni, kānicidantaḥkuṭilāni, kānicidbahiḥkuṭilāni, kānicijjaṭilāni, kānicidantarmukhāni, yathāsvaṃ doṣānubandhavarṇāni||7||

tatra sahajAnyarshAMsi kAnicidaNUni, kAnicinmahAnti, kAniciddIrghANi, kAniciddhrasvAni, kAnicidvRuttAni,kAnicidviShamavisRutAni, kAnicidantaHkuTilAni, kAnicidbahiHkuTilAni, kAnicijjaTilAni,kAnicidantarmukhAni, yathAsvaM doShAnubandhavarNAni||7||

Among the congenital hemorrhoids, some are small, some are large, some are long, some are short, some are round, some are irregularly spread, some are curved internally, some are curved externally, some are matted together, and some are introverted. Their characteristics or forms are as per the doshas involved in their formation. [7]

Signs and symptoms of congenital hemorrhoids

तैरुपहतो जन्म प्रभृति भवत्यतिकृशो विवर्णः क्षामो दीनः प्रचुर विबद्ध वात मूत्र पुरीषः शर्कराश्मरीमान्, तथाऽनियतविबद्धमुक्तपक्वामशुष्कभिन्नवर्चा अन्तराऽन्तरा श्वेत पाण्डु हरित पीत रक्तारुण तनु सान्द्र पिच्छिल कुणपगन्ध्याम पुरीषोपवेशी, नाभि बस्ति वङ्क्षणोद्देशे प्रचुर परिकर्तिकान्वितः, सगुदशूल प्रवाहिका परिहर्ष प्रमेह प्रसक्त विष्टम्भान्त्रकूजोदावर्त हृदयेन्द्रियोपलेपः प्रचुर विबद्ध तिक्ताम्लोद्गारः, सुदुर्बलः, सुदुर्बलाग्निः, अल्पशुक्रः, क्रोधनो, दुःखोपचारशीलः, कास श्वास तमक तृष्णा हृल्लास च्छर्द्यरोचका विपाक पीनस क्षवथु परीतः, तैमिरिकः, शिरःशूली, क्षामभिन्नसन्नसक्तजर्जरस्वरः, कर्णरोगी, शून पाणिपाद वदनाक्षिकूटः, सज्वरः, साङ्गमर्दः, सर्व पर्वास्थि शूली च, अन्तराऽन्तरा पार्श्व कुक्षि बस्ति हृदय पृष्ठ त्रिकग्रहोपतप्तः, प्रध्यानपरः, परमालसश्चेति; जन्म प्रभृत्यस्य गुदजैरावृतो मार्गोपरोधाद्वायुरपानः प्रत्यारोहन् समानव्यानप्राणोदानान् पित्तश्लेष्माणौ च प्रकोपयति, एते सर्व एव प्रकुपिताः पञ्च वायवः पित्तश्लेष्माणौ चार्शसमभिद्रवन्त एतान् विकारानुपजनयन्ति; इत्युक्तानि सहजान्यर्शांसि||८||

tairupahato janma prabhṛti bhavatyatikṛśo vivarṇaḥ kṣāmo dīnaḥ pracura vibaddha vāta mūtra purīṣaḥ śarkarāśmarīmān, tathā’niyatavibaddhamuktapakvāmaśuṣkabhinnavarcā antarā’ntarā śveta pāṇḍu harita pīta raktāruṇa tanu sāndra picchila kuṇapagandhyāma purīṣopaveśī, nābhi basti vaṅkṣaṇoddeśe pracura parikartikānvitaḥ, sagudaśūla pravāhikā pariharṣa prameha prasakta viṣṭambhāntrakūjodāvarta hṛdayendriyopalepaḥ pracura vibaddha tiktāmlodgāraḥ, sudurbalaḥ, sudurbalāgniḥ, alpaśukraḥ, krodhano, duḥkhopacāraśīlaḥ, kāsa śvāsa tamaka tṛṣṇā hṛllāsa cchardyarocakā vipāka pīnasa kṣavathu parītaḥ, taimirikaḥ, śiraḥśūlī, kṣāmabhinnasannasaktajarjarasvaraḥ, karṇarogī, śūna pāṇipāda vadanākṣikūṭaḥ, sajvaraḥ, sāṅgamardaḥ, sarva parvāsthi śūlī ca, antarā’ntarā pārśva kukṣi basti hṛdaya pṛṣṭha trikagrahopataptaḥ, pradhyānaparaḥ, paramālasaśceti; janma prabhṛtyasya gudajairāvṛto mārgoparodhādvāyurapānaḥ pratyārohan samānavyānaprāṇodānān pittaśleṣmāṇau ca prakopayati, ete sarva eva prakupitāḥ pañca vāyavaḥ pittaśleṣmāṇau cārśasamabhidravanta etān vikārānupajanayanti; ityuktāni sahajānyarśāṃsi||8||

tairupahato janmaprabhRuti bhavatyatikRusho vivarNaH kShAmo dInaHpracuravibaddhavAtamUtrapurIShaH sharkarAshmarImAn,tathA~aniyatavibaddhamuktapakvAmashuShkabhinnavarcA antarA~antarAshvetapANDuharitapItaraktAruNatanusAndrapicchilakuNapagandhyAmapurIShopaveshI,nAbhibastiva~gkShaNoddeshe pracuraparikartikAnvitaH,sagudashUlapravAhikApariharShapramehaprasaktaviShTambhAntrakUjodAvartahRudayendriyopalepaHpracuravibaddhatiktAmlodgAraH, sudurbalaH, sudurbalAgniH, alpashukraH, krodhano,duHkhopacArashIlaH,kAsashvAsatamakatRuShNAhRullAsacchardyarocakAvipAkapInasakShavathuparItaH, taimirikaH,shiraHshUlI, kShAmabhinnasannasaktajarjarasvaraH, karNarogI, shUnapANipAdavadanAkShikUTaH,sajvaraH, sA~ggamardaH, sarvaparvAsthishUlI ca, antarA~antarApArshvakukShibastihRudayapRuShThatrikagrahopataptaH, pradhyAnaparaH, paramAlasashceti;janmaprabhRutyasya gudajairAvRuto mArgoparodhAdvAyurapAnaH [1] pratyArohansamAnavyAnaprANodAnAn pittashleShmANau ca prakopayati, ete sarva eva prakupitAH pa~jca vAyavaHpittashleShmANau cArshasamabhidravanta etAn vikArAnupajanayanti; ityuktAni sahajAnyarshAMsi||8||

The person suffering with congenital hemorrhoids has the following signs and symptoms:

Right from the birth he is lean and thin, pale, emaciated, weak, excessive or obstructed flatus, urine and stool. He has gravels and stone in the urinary system.
Irregular bowel habit- sometimes constipation and sometimes normal; sometimes stool is pakva (free from ama) and sometimes it is associated with ama (mucus or products of improper digestion); sometimes stool is dry and sometimes it is liquid.
The stool color differs, having white, pale yellow, green, yellow, red, thin, dense, slimy, having bad odor like dead tissue and associated with ama.
The patient suffers from severe colicky pain in umbilicus, region of urinary bladder, pelvic region and anus.
Patient suffers from dysentery, horripilation, prameha (obstinate urinary disorders including diabetes), constipation, gurgling sound in the intestine, abdominal distension and a feeling of covering on the heart and the sense organs.
Patient gets excessive eructation associated with bitter and sour taste, extreme weakness, weak digestive power; he has very little semen; he is irritable and is difficult to treat.
He has frequent cough, dyspnea, bronchial asthma, morbid thirst, nausea, vomiting, anorexia, indigestion, chronic rhinitis and sneezing.
He gets fits of fainting and headache; his voice is weak, broken, of low pitch, impeded and has hoarseness.
He may suffer from ear diseases, gets swelling around the eyes, suffers from fever, malaise and pain in all the joints and bones.
Patient gets stiffness in chest, abdomen, region of urinary bladder, cardiac region, back and lumber region.
He has persistent giddiness and is extremely lazy.
Right from the birth, his apana vayu gets obstructed by the hemorrhoid-mass and moves upwards leading to aggravation of samana vayu, vyana vayu, prana vayu, udana vayu, pitta and kapha. When all these five types of vayu, pitta and kapha get aggravated the individual suffers from above mentioned morbidities of congenital hemorrhoids.[8]

Etiology and pathogenesis of acquired arsha (hemorrhoids)

अत ऊर्ध्वं जातस्योत्तरकालजानि व्याख्यास्यामः- गुरु मधुर शीताभिष्यन्दि विदाहि विरुद्धाजीर्ण प्रमिताशना सात्म्य भोजनाद्गव्य मात्स्य वाराह माहिषा जाविक पिशित भक्षणात् कृश शुष्क पूतिमांस पैष्टिक परमान्न क्षीर दधि मण्ड तिलगुड विकृति सेवनान्माषयूषेक्षुरस पिण्याक पिण्डालुक शुष्क शाक- शुक्तल शुन किलाट तक्र पिण्डक बिस मृणाल शालूक क्रौञ्चादन कशेरुक शृङ्गाटकतरूट विरूढ नव शूक शमी- धान्याममूलकोपयोगाद्गुरु फल शाक राग हरितक मर्दक वसा शिरस्पद पर्युषित पूति शीत सङ्कीर्णान्नाभ्यवहारान्मन्द- कातिक्रान्त मद्यपानाद्व्यापन्न गुरु सलिलपानादति स्नेहपानादसंशोधनाद्बस्तिकर्म विभ्रमाद व्यायामाद व्यवायाद्दिवास्वप्नात् सुख शयनासन स्थान सेवनाच्चोपहताग्नेर्मलोपचयो भवत्यतिमात्रं, तथोत्कटक विषम कठिनासनसेवनादुद्भ्रान्तयानोष्ट्रयानादति व्यवायाद्बस्तिनेत्रा सम्यक्प्रणिधानाद्गुदक्षणनाद भीक्ष्णं शीताम्बु संस्पर्शाच्चेललोष्ट तृणादि घर्षणात् प्रतताति निर्वाहणाद्वातमूत्रपुरीषवेगोदीरणात् समुदीर्ण वेग विनिग्रहात् स्त्रीणां चामगर्भभ्रंशाद्गर्भोत्पीडनाद्विषमप्रसूतिभिश्च प्रकुपितो वायुरपानस्तं मलमुपचितमधोगमासाद्य गुदवलिष्वाधत्ते, ततस्तास्वर्शांसि प्रादुर्भवन्ति||९||

ata ūrdhvaṃ jātasyottarakālajāni vyākhyāsyāmaḥ- guru madhura śītābhiṣyandi vidāhi viruddhājīrṇa pramitāśanāsātmyabhojanādgavyamātsya vārāha māhiṣājāvika piśita bhakṣaṇāt kṛśa śuṣka pūtimāṃsa paiṣṭika paramānna kṣīra dadhi maṇḍa tilaguḍa vikṛti sevanānmāṣayūṣekṣurasa piṇyāka piṇḍāluka śuṣka śāka- śuktalaśunakilāṭa takra piṇḍaka bisa mṛṇāla śālūka krauñcādana kaśeruka śṛṅgāṭakatarūṭa virūḍha navaśūkaśamī- dhānyāmamūlakopayogādguruphalaśāka rāga haritakamardakavasāśiraspadaparyuṣitapūtiśītasaṅkīrṇānnābhyavahārānmanda- kātikrāntamadyapānādvyāpannagurusalilapānādatisnehapānādasaṃśodhanādbastikarmavibhramādavyāyāmādavyavāyāddivāsvapnāt sukhaśayanāsanasthānasevanāccopahatāgnermalopacayo bhavatyatimātraṃ, tathotkaṭakaviṣamakaṭhināsanasevanādudbhrāntayānoṣṭrayānādati vyavāyādbastinetrā samyakpraṇidhānādgudakṣaṇanādabhīkṣṇaṃ śītāmbu saṃsparśāccelaloṣṭa tṛṇādi gharṣaṇāt pratatāti nirvāhaṇādvātamūtrapurīṣavegodīraṇāt samudīrṇavegavinigrahāt strīṇāṃ cāmagarbhabhraṃśādgarbhotpīḍanādviṣamaprasūtibhiśca prakupito vāyurapānastaṃ malamupacitamadhogamāsādya gudavaliṣvādhatte, tatastāsvarśāṃsi prādurbhavanti||9||

ata UrdhvaM jAtasyottarakAlajAni vyAkhyAsyAmaH-gurumadhurashItAbhiShyandividAhiviruddhAjIrNapramitAshanAsAtmyabhojanAdgavyamAtsyavArAhamAhiShAjAvikapishitabhakShaNAtkRushashu- ShkapUtimAMsapaiShTikaparamAnnakShIradadhimaNDatilaguDavikRutisevanAnmAShayUShekShurasapiNyAkapiNDAlukashuShkashAka-shuktalashunakilATatakrapiNDakabisamRuNAlashAlUkakrau~jcAdanakasherukashRu~ggATakatarUTavirUDhanavashUkashamI-dhAnyAmamUlakopayogAdguruphalashAkarAgaharitakamardakavasAshiraspadaparyuShitapUtishItasa~gkIrNAnnAbhyavahArAnmanda-kAtikrAntamadyapAnAdvyApannagurusalilapAnAdatisnehapAnAdasaMshodhanAdbastikarmavibhramAdavyAyAmAdavyavAyAddivAsvapnAtsukhashayanAsanasth- AnasevanAccopahatAgnermalopacayo bhavatyatimAtraM,tathotkaTakaviShamakaThinAsanasevanAdudbhrAntayAnoShTrayAnAdativyavAyAdbastinetrAsamyakpraNidhAnAdguda- kShaNanAdabhIkShNaMshItAmbusaMsparshAccelaloShTatRuNAdigharShaNAt pratatAtinirvAhaNAdvAtamUtrapurIShavegodIraNAt samudIrNavegavinigrahAt strINAMcAmagarbhabhraMshAdgarbhotpIDanAdviShamaprasUtibhishca prakupito vAyurapAnastaM malamupacitamadhogamAsAdya gudavaliShvAdhatte,tatastAsvarshAMsi prAdurbhavanti||9||

The causes of acquired hemorrhoids : In a person whose power of digestion is afflicted, mala (waste products) gets accumulated in excess due to the following reasons:

Intake of heavy, sweet, cold, abhishyandi (food that causes obstruction in the channels of circulation), vidahi (that causes burning sensation) and viruddha ( mutually contra¬dictory ) food; intake of food before the previous meal is digested; intake of a small quantity of food;and intake of unwholesome food;
Excessive intake of the meats of cattle, fish, pig, buffalo, goat and sheep;
Meat of emaciated animals, dried meat and putrefied meat.
Excessive intake of pastries, paramanna (preparation of milk, rice and sugar), milk, dadhimanda (whey), preparations of sesame seed and jaggery-products;
Excessive intake of masha, sugarcane juice, oil cake, pindaluka, dry vegetables, vinegar, garlic, kilat (cream of milk) takra-pindaka (cream of curd), bisa (thick lotus stalk ), naktamala (thin lotus stalk) shaluka, kraunchodana, kasheruka, shringataka, tarut, germinated corns and pulses, freshly harvested corns and cereals and tender radish;
Intake of heavy fruits, vegetables, pickles, hantaka (uncooked vegetables), mardaka, vasa (muscle fat), meat of head and legs of animals, stale, putrid and sankeerna anna (food prepared by the mixture of different items, like rice and meat).
Intake of mandaka (immature curds) and wrongly (excess) fermented wines.
Drinking of polluted and heavy water, excess intake of sneha (oleation therapy), non-use of panchakarma (elimination therapies), improper basti karma (enema therapy)
Lack of exercise, avayaya (lack of sexual activity) or adhivayaya (excess sexual activity), sleep during day time; and habits to pleasant beds, seats and location.

Similarly, the following factors are responsible for the aggravation of apana vayu.

Use of rough, irregular and hard seats
Use of vehicles carried by improperly trained animals or vehicles carried by camels
Excessive indulgence in sexual act;
Improper insertion of enema nozzle and frequent injury in the anal region.
Frequent application of cold water.
Use of rags, clods of grass, etc. for rubbing the anus
Continued and excessive strain
Forcible attempts for passing flatus, urine and stool
Suppression of natural urges
Miscarriage, pressure of the pregnant uterus and abnormal delivery in the case of women.

The apana vayu aggravated by the above mentioned factors, brings down the accumulated waste products and so afflicts the anal sphincters and leads to acquired type of hemorrhoids. [9]

Shapes of the arsha (hemorrhoids)

सर्षप मसूर माष मुद्गमकुष्ठ कयव कलाय पिण्डिटिण्टिकेर केबुक तिन्दुक कर्कन्धु काकणन्तिका बिम्बी बदर करीरोदुम्बर- खर्जूर जाम्बव गोस्तनाङ्गुष्ठ कशेरु शृङ्गाटक शृङ्गीदक्ष शिखि शुकतुण्ड जिह्वा पद्ममुकुलकर्णिका संस्थानानि सामान्याद्वात पित्त कफ प्रबलानि||१०||

sarṣapa masūra māṣa mudgamakuṣṭha kayava kalāya piṇḍiṭiṇṭikera kebuka tinduka karkandhu kākaṇantikā bimbī badara karīrodumbara- kharjūra jāmbava gostanāṅguṣṭha kaśeru śṛṅgāṭaka śṛṅgīdakṣa śikhi śukatuṇḍa jihvā padmamukulakarṇikā saṃsthānāni sāmānyādvāta pitta kapha prabalāni||10||

sarShapamasUramAShamudgamakuShThakayavakalAyapiNDiTiNTikerakebukatindukakarkandhukAkaNantikAbimbIbadarakarIrodumbara-kharjUrajAmbavagostanA~gguShThakasherushRu~ggATakashRu~ggIdakShashikhishukatuNDajihvApadmamukulakarNikAsaMsthAnAnisAmAnyAdvAtapittakaphaprabalAni||10||

Hemorrhoids have different shapes and resemble mustard, masura, masha, mudga, kushtaka (Saussurea lappa CB. Clarke), yava (barley), kalaya (green pea), pindi, tundikeri (fruit of karira), kebuka, tinduka, karkandhu, kakanantika, bimbi badara, karira, udumbara (Ficus racemosa Linn), kharjura (Phoenix dactylifera) jambu (Syzygium cuminii (Linn.)), gostana (cow's breast), thumb, kasheruka, shringataka, shringi, beaks or tongues of a fowl, a peacock or a parrot, and buds of lotus or karyika. All above mentioned shapes are in general the characteristic shapes of hemorrhoids caused by excessive aggravation of vayu, pitta and kapha. [10]

Signs and symptoms of vataja arsha

तेषामयं विशेषः- शुष्कम्लान कठिन परुष रूक्ष श्यावानि, तीक्ष्णाग्राणि, वक्राणि, स्फुटित मुखानि, विषम विसृतानि, शूलाक्षेपतोदस्फुरण चिमिचिमासंहर्ष परीतानि, स्निग्धोष्णोपशयानि, प्रवाहिका ध्मान शिश्न वृषण बस्ति वङ्क्षण हृद्ग्रहाङ्गमर्द हृदय द्रव प्रबलानि, प्रतत विबद्ध वात मूत्र वर्चांसि, ऊरु कटी पृष्ठ त्रिक पार्श्व कुक्षि बस्ति शूल शिरोऽभिताप क्षवथूद्गार प्रतिश्याय कासोदावर्तायाम शोष शोथ- मूर्च्छारोचक मुखवैरस्य तैमिर्य कण्डू नासा कर्ण शङ्ख शूल स्वरोपघातकराणि, श्यावारुण परुष नख नयन वदन त्वङ्मूत्र पुरीषस्य वातोल्बणान्यर्शांसीति विद्यात्||११||

teṣāmayaṃ viśeṣaḥ- śuṣkamlāna kaṭhina paruṣa rūkṣa śyāvāni, tīkṣṇāgrāṇi, vakrāṇi, sphuṭita mukhāni, viṣama visṛtāni, śūlākṣepatodasphuraṇa cimicimāsaṃharṣaparītāni, snigdhoṣṇopaśayāni, pravāhikā dhmāna śiśna vṛṣaṇa basti vaṅkṣaṇa hṛdgrahāṅgamarda hṛdaya drava prabalāni, pratata vibaddha vāta mūtra varcāṃsi, ūru kaṭī pṛṣṭha trika pārśva kukṣi basti śūla śiro’bhitāpa kṣavathūdgāra pratiśyāya kāsodāvartāyāma śoṣa śotha- mūrcchārocaka mukhavairasya taimirya kaṇḍū nāsā karṇa śaṅkha śūla svaropaghātakarāṇi, śyāvāruṇa paruṣa nakha nayana vadana tvaṅmūtra purīṣasya vātolbaṇānyarśāṃsīti vidyāt||11||

teShAmayaM visheShaH- shuShkamlAnakaThinaparuSharUkShashyAvAni, tIkShNAgrANi, vakrANi, sphuTitamukhAni,viShamavisRutAni, shUlAkShepatodasphuraNacimicimAsaMharShaparItAni, snigdhoShNopashayAni,pravAhikAdhmAnashishnavRuShaNabastiva~gkShaNahRudgrahA~ggamardahRudayadravaprabalAni,pratatavibaddhavAtamUtravarcAMsi,UrukaTIpRuShThatrikapArshvakukShibastishUlashiro~abhitApakShavathUdgArapratishyAyakAsodAvartAyAmashoShashotha-mUrcchArocakamukhavairasyataimiryakaNDUnAsAkarNasha~gkhashUlasvaropaghAtakarANi,shyAvAruNaparuShanakhanayanavadanatva~gmUtrapurIShasya vAtolbaNAnyarshAMsIti vidyAt||11||

Hemorrhoids caused by the predominance of aggravated vata:

The mass of hemorrhoids is dry, wrinkled, hard, rough, ununctuous and greyish in color; these masses have sharp tips; these are curved and with cracks on the surface; and these are spread irregularly.
The mass of hemorrhoids is associated with pain, cramps toda (piercing pain), itching, numbness and tingling sensa¬tion in excess.
Unctuous and hot things give relief in this condition.
The patient suffers from dysentery, abdominal disten¬sion and stiffness of genitals, testicles, urinary bladder, pelvis and cardiac region; he also suffers from malaise and palpitation in excess.
His flatus, urine and stool are constantly obstructed.
He suffers from pain in thighs, lumber region, back, trika (sacral region), parshva (sides of the chest), kukshi (sides of the abdomen ) and in basti (urinary bladder)
He gets heat sensation in the head and suffers from, sneezing, eructation, coryza, cough, udavarta (mis-peristalsis), lethargy, edema, fainting, anorexia, distaste in mouth, timira (impairment of vision) it¬ching, pain in the nose, ears and temporal region, and impairment of the voice.
Greyish, reddishness and roughness of nails, eyes, face, skin, urine and stool. [11]

Etiology of vataja arsha hemorrhoids

भवतश्चात्र- कषाय कटु तिक्तानि रूक्ष शीत लघूनि च| प्रमिताल्पाशनं तीक्ष्ण मद्य मैथुन सेवनम्||१२|| लङ्घनं देशकालौ च शीतौ व्यायामकर्म च| शोको वातातपस्पर्शो हेतुर्वातार्शसां मतः||१३||

bhavataścātra- kaṣāya kaṭu tiktāni rūkṣa śīta laghūni ca| pramitālpāśanaṃ tīkṣṇa madya maithuna sevanam||12|| laṅghanaṃ deśakālau ca śītau vyāyāmakarma ca| śoko vātātapasparśo heturvātārśasāṃ mataḥ||13||

bhavatashcAtra- kaShAyakaTutiktAni rUkShashItalaghUni ca| pramitAlpAshanaM tIkShNamadyamaithunasevanam||12|| la~gghanaM deshakAlau ca shItau vyAyAmakarma ca| shoko vAtAtapasparsho heturvAtArshasAM mataH||13||

The causes of vataja arsha are as follow.

Habitual intake of astringent, pungent, bitter, ununctuous, cold and light food;
Habitual intake of pramitashana ( food measured in extremely small quantities), intake of less quantity of food, intake of excess alcoho¬lic drinks and indulgence in sexual acts.
Fasting, living in cold country and cold season, physical exercise, grief and exposure to sun and wind. [12-13]

Signs and symptoms of pittaja arsha

मृदु शिथिल सुकुमाराण्य स्पर्शसहानि, रक्त पीत नील कृष्णानि, स्वेदोपक्लेद बहुलानि, विस्र गन्धि तनु पीत रक्त स्रावीणि, रुधिरवहानि, दाह कण्डू शूल निस्तोद पाकवन्ति, शीतोपशयानि, सम्भिन्नपीत हरित वर्चांसि, पीत विस्रगन्धि प्रचुर विण्मूत्राणि, पिपासा ज्वर तमक सम्मोह भोजन द्वेषकराणि पीत नख नयन त्वङ्मूत्र पुरीषस्य पित्तोल्बणान्यर्शांसीति विद्यात्||१४||

mṛdu śithila sukumārāṇya sparśasahāni, rakta pīta nīla kṛṣṇāni, svedopakleda bahulāni, visra gandhi tanu pīta rakta srāvīṇi, rudhiravahāni, dāha kaṇḍū śūla nistoda pākavanti, śītopaśayāni, sambhinnapīta harita varcāṃsi, pīta visragandhi pracura viṇmūtrāṇi, pipāsā jvara tamaka sammoha bhojana dveṣakarāṇi pīta nakha nayana tvaṅmūtra purīṣasya pittolbaṇānyarśāṃsīti vidyāt||14||

mRudushithilasukumArANyasparshasahAni, raktapItanIlakRuShNAni, svedopakledabahulAni,visragandhitanupItaraktasrAvINi [1] , rudhiravahAni, dAhakaNDUshUlanistodapAkavanti, shItopashayAni,sambhinnapItaharitavarcAMsi, pItavisragandhipracuraviNmUtrANi,pipAsAjvaratamakasammohabhojanadveShakarANi pItanakhanayanatva~gmUtrapurIShasyapittolbaNAnyarshAMsIti vidyAt||14||

The following are the signs and symptoms of Pittaja Arshas:

The pile mass is soft, flabby, delicate and tender to touch
The color of hemorrhoids is red, yellow, blue or black
The hemorrhoids is associated with excessive swea¬ting and sticky discharge
The discharge from the hemorrhoids mass is visra (smelling like raw-meat), thin, yellow or red
There is bleeding from the hemorrhoids
The hemorrhoids are associated with burning sensa¬tion, itching, pain, pricking pain and suppura¬tion.
Cold things relief the symptoms
The stool of the patient is loose, yellow or green
The urine and stool are voided in large quantities, yellow in colour and the smell is like raw meat.
The patient suffers from morbid thirst, fever, asthma, fainting and disliking for foods
The nails, eyes, skin, urine and stool become yellow in color. [14]

Etiology of pittaja arsha

भवतश्चात्र- कटूष्ण लवण क्षार व्यायामाग्न्यातप प्रभाः | देश कालावशिशिरौ क्रोधो मद्यमसूयनम्||१५|| विदाहि तीक्ष्णमुष्णं च सर्वं पानान्नभेषजम्| पित्तोल्बणानां विज्ञेयः प्रकोपे हेतुरर्शसाम्||१६||

bhavataścātra- kaṭūṣṇa lavaṇa kṣāra vyāyāmāgnyātapa prabhāḥ | deśa kālāvaśiśirau krodho madyamasūyanam||15|| vidāhi tīkṣṇamuṣṇaṃ ca sarvaṃ pānānnabheṣajam| pittolbaṇānāṃ vijñeyaḥ prakope heturarśasām||16||

bhavatashcAtra- kaTUShNalavaNakShAravyAyAmAgnyAtapaprabhAH [2] | deshakAlAvashishirau krodho madyamasUyanam||15|| vidAhi tIkShNamuShNaM ca sarvaM pAnAnnabheShajam| pittolbaNAnAM vij~jeyaH prakope heturarshasAm||16||

The causes of pittaja arsha are as follow:

Intake of pungent, hot, salty and alkaline food,
excess exercise and exposure to the heat of fire and Sun
Living in a place and season which are not cold, intake of alcohol and envy;
Intake of drinks, food and drugs having vidahi (causing burning sensation), sharp and hot properties. [15-16]

Signs and symptoms of kaphaja arsha

तत्र यानि प्रमाणवन्ति, उपचितानि, श्लक्ष्णानि, स्पर्शसहानि, स्निग्ध श्वेत पाण्डु पिच्छिलानि, स्तब्धानि, गुरूणि, स्तिमितानि, सुप्त सुप्तानि, स्थिर श्वयथूनि, कण्डू बहुलानि, बहुप्रतत पिञ्जर श्वेतरक्त पिच्छा स्रावीणि, गुरु पिच्छिल श्वेत मूत्र पुरीषाणि, रूक्षोष्णोपशयानि, प्रवाहिकातिमात्रोत्थानवङ्क्षणानाहवन्ति, परिकर्तिका हृल्लास निष्ठीविका कासारोचक प्रतिश्याय गौरव च्छर्दि मूत्रकृच्छ्र शोष शोथ- पाण्डु रोग शीतज्वराश्मरी शर्करा हृदयेन्द्रियोपलेपास्य माधुर्य प्रमेहकराणि, दीर्घकालानुबन्धीनि, अतिमात्रमग्निमार्दव क्लैब्यकराणि, आम विकार प्रबलानि, शुक्ल नख नयन वदन त्वङ्मूत्रपुरीषस्य श्लेष्मोल्बणान्यर्शांसीति विद्यात्||१७||

tatra yāni pramāṇavanti, upacitāni, ślakṣṇāni, sparśasahāni, snigdha śveta pāṇḍu picchilāni, stabdhāni, gurūṇi, stimitāni, supta suptāni, sthira śvayathūni, kaṇḍū bahulāni, bahupratata piñjara śvetarakta picchā srāvīṇi, guru picchila śveta mūtra purīṣāṇi, rūkṣoṣṇopaśayāni, pravāhikātimātrotthānavaṅkṣaṇānāhavanti, parikartikā hṛllāsa niṣṭhīvikā kāsārocaka pratiśyāya gaurava cchardi mūtrakṛcchra śoṣa śotha- pāṇḍu roga śītajvarāśmarī śarkarā hṛdayendriyopalepāsya mādhurya pramehakarāṇi, dīrghakālānubandhīni, atimātramagnimārdava klaibyakarāṇi, āma vikāra prabalāni, śukla nakha nayana vadana tvaṅmūtrapurīṣasya śleṣmolbaṇānyarśāṃsīti vidyāt||17||

tatra yAni pramANavanti, upacitAni, shlakShNAni, sparshasahAni [3] , snigdhashvetapANDupicchilAni,stabdhAni, gurUNi, stimitAni, suptasuptAni, sthirashvayathUni, kaNDUbahulAni,bahupratatapi~jjarashvetaraktapicchAsrAvINi, gurupicchilashvetamUtrapurIShANi,rUkShoShNopashayAni, pravAhikAtimAtrotthAnava~gkShaNAnAhavanti,parikartikAhRullAsaniShThIvikAkAsArocakapratishyAyagauravacchardimUtrakRucchrashoShashotha-pANDurogashItajvarAshmarIsharkarAhRudayendriyopalepAsyamAdhuryapramehakarANi,dIrghakAlAnubandhIni [4] , atimAtramagnimArdavaklaibyakarANi, AmavikAraprabalAni,shuklanakhanayanavadanatva~gmUtrapurIShasya shleShmolbaNAnyarshAMsIti vidyAt||17||

The following are the signs and symptoms of kaphaja arshas

The hemorrhoids are large in size, swollen, smooth, painless to touch,
The hemorrhoids are unctuous, white, pale white, slimy, having stiffness, heavy, rigid, benumbed, having consistent oedema and excessive of itching.
The discharge from the hemorrhoids is excess and continuous having white or red in colour with slimyness.
Urine and stool of the patient are heavy, slimy and white
Ruksha (un-unctuous) and hot therapies gives relief from symptoms
The patient has an excessive desire to pass stool with tenesmus and distension in the lower pelvic region
The patient suffers from burning pain in anus, nausea, excessive spitting, cough, anorexia, cold, heaviness, vomiting, dysuria; lethargy, edema, anemia.
Patient suffer from fever associated with cold, stone and gravels in genito¬urinary tract, a feeling as if the heart and sense organs are covered with sticky material, sweet taste in the mouth and prameha (obstinate urinary disorders including diabetes),
The disease becomes chronic condition. So, digestive power gets suppressed and causes impotency
They are associated with acute diseases caused by ama (product of improper digestion and metabolism).
The nails, eyes, face, skin, urine and stool are become white in color. [17]

Etiology of kaphaja arsha

भवतश्चात्र- मधुर स्निग्ध शीतानि लवणाम्ल गुरूणि च| अव्यायामो दिवास्वप्नः शय्यासनसुखे रतिः||१८|| प्राग्वातसेवा शीतौ च देशकालावचिन्तनम्| श्लैष्मिकाणां समुद्दिष्टमेतत् कारणमर्शसाम्||१९||

bhavataścātra- madhura snigdha śītāni lavaṇāmla gurūṇi ca| avyāyāmo divāsvapnaḥ śayyāsanasukhe ratiḥ||18|| prāgvātasevā śītau ca deśakālāvacintanam| ślaiṣmikāṇāṃ samuddiṣṭametat kāraṇamarśasām||19||

bhavatashcAtra- madhurasnigdhashItAni lavaNAmlagurUNi ca| avyAyAmo divAsvapnaH shayyAsanasukhe ratiH||18|| prAgvAtasevA shItau ca deshakAlAvacintanam| shlaiShmikANAM samuddiShTametat kAraNamarshasAm||19|| The causes of kaphaja arsha (hemorrhoids) are as follow

Sweet, unctuous, cold, salty, sour and heavy food
Lack of exercise, sleeping during day time and indul¬gence in the pleasure of beds and seats (excess sleeping and sitting)
Direct exposure to wind
Living in cold place and exposure to cold season and mental inactivity. [18-19]

Etiology and symptoms of dwandaja and sannipataja type of arsha hemorrhoids

हेतु लक्षण संसर्गाद्विद्याद्द्वन्द्वोल्बणानि च| सर्वो हेतुस्त्रिदोषाणां सहजैर्लक्षणैः समम्||२०||

hetu lakṣaṇa saṃsargādvidyāddvandvolbaṇāni ca| sarvo hetustridoṣāṇāṃ sahajairlakṣaṇaiḥ samam||20||

hetulakShaNasaMsargAdvidyAddvandvolbaNAni ca| sarvo hetustridoShANAM sahajairlakShaNaiH samam||20||

The dwandaja arsha (in which two doshas are predo¬minantly aggravated) is caused by the combination of two types of etiological factors and clinical features of two doshas. If the causative factors of all the doshas are combined together, then tridosaja type of hemorrhoids (in which all the three doshas are simultaneously aggravated) is manifested. The signs and symptoms of hemorrhoids are similar to those described for hereditary type of hemorrhoids- (vide verses 7 and 8 above). [20]

Purvaroopa (premonitory) signs and symptoms of hemorrhoids

विष्टम्भोऽन्नस्य दौर्बल्यं कुक्षेराटोप एव च| कार्श्यमुद्गारबाहुल्यं सक्थिसादोऽल्पविट्कता||२१|| ग्रहणीदोषपाण्ड्वर्तेराशङ्का चोदरस्य च| पूर्वरूपाणि निर्दिष्टान्यर्शसामभिवृद्धये||२२||

viṣṭambho’nnasya daurbalyaṃ kukṣerāṭopa eva ca| kārśyamudgārabāhulyaṃ sakthisādo’lpaviṭkatā||21|| grahaṇīdoṣapāṇḍvarterāśaṅkā codarasya ca| pūrvarūpāṇi nirdiṣṭānyarśasāmabhivṛddhaye||22||

viShTambho~annasya daurbalyaM kukSherATopa eva ca| kArshyamudgArabAhulyaM sakthisAdo~alpaviTkatA||21|| grahaNIdoShapANDvarterAsha~gkA codarasya ca| pUrvarUpANi nirdiShTAnyarshasAmabhivRuddhaye||22||

Delayed digestion of the food, weak¬ness, gurgling sound in the lower abdomen, emaciation, fre¬quent eructation; pain in thighs, voiding less stool, anemia, apprehension of the manifestation of udararoga (obstinate abdominal disorders including ascites)-these are the premonitory signs and symptoms in the development of hemorrhoids. [21-22]

Involvement of three doshas

अर्शांसि खलु जायन्ते नासन्निपतितैस्त्रिभिः| दोषैर्दोषविशेषात्तु विशेषः कल्प्यतेऽर्शसाम्||२३||

arśāṃsi khalu jāyante nāsannipatitaistribhiḥ| doṣairdoṣaviśeṣāttu viśeṣaḥ kalpyate’rśasām||23||

arshAMsi khalu jAyante nAsannipatitaistribhiH| doShairdoShavisheShAttu visheShaH kalpyate~arshasAm||23||

Hemorrhoids never manifest without the aggravation of all the three doshas. It is evident that the predominance of one or all the doshas determine the type of hemorrhoids. The nomenclature of doshaja arsha is given according to the predominance of dosha e.g. if vata dosha is predominat then that hemorrhoid is said to be vataja arsha. [23]

Aggravation of tridosha in arsha

पञ्चात्मा मारुतः पित्तं कफो गुदवलित्रयम्| सर्व एव प्रकुप्यन्ति गुदजानां समुद्भवे||२४|| तस्मादर्शांसि दुःखानि बहुव्याधिकराणि च| सर्वदेहोपतापीनि प्रायः कृच्छ्रतमानि च||२५||

pañcātmā mārutaḥ pittaṃ kapho gudavalitrayam| sarva eva prakupyanti gudajānāṃ samudbhave||24|| tasmādarśāṃsi duḥkhāni bahuvyādhikarāṇi ca| sarvadehopatāpīni prāyaḥ kṛcchratamāni ca||25||

pa~jcAtmA mArutaH pittaM kapho gudavalitrayam| sarva eva prakupyanti gudajAnAM samudbhave||24|| tasmAdarshAMsi duHkhAni bahuvyAdhikarANi ca| sarvadehopatApIni prAyaH kRucchratamAni ca||25||

Five types of vayu (prana, apana, vyana, udana and samana), pitta and kapha - all these morbid factors in their aggravated state afflict the three anal sphincters at ano-rectum and lead to hemorrhoids. These hemorrhoids are painful and are usually associated with several complications. These hemorrhoids affect the whole body and so they are difficult to cure with conservative measures. [24-25]

Symptoms of incurable arsha

हस्ते पादे मुखे नाभ्यां गुदे वृषणयोस्तथा| शोथो हृत्पार्श्वशूलं च यस्यासाध्योऽर्शसो हि सः||२६|| हृत्पार्श्वशूलं सम्मोहश्छर्दिरङ्गस्य रुग् ज्वरः| तृष्णा गुदस्य पाकश्च निहन्यर्गुदजातुरम्||२७|| सहजानि त्रिदोषाणि यानि चाभ्यन्तरां वलिम्| जायन्तेऽर्शांसि संश्रित्य तान्यसाध्यानि निर्दिशेत्||२८|| शेषत्वादायुषस्तानि चतुष्पादसमन्विते| याप्यन्ते दीप्तकायाग्नेः प्रत्याख्येयान्यतोऽन्यथा||२९|| द्वन्द्वजानि द्वितीयायां वलौ यान्याश्रितानि च| कृच्छ्रसाध्यानि तान्याहुः परिसंवत्सराणि च||३०|| बाह्यायां तु वलौ जातान्येकदोषोल्बणानि च| अर्शांसि सुखसाध्यानि न चिरोत्पाततानि च||३१|| तेषां प्रशमने यत्नमाशु कुर्याद्विचक्षणः| तान्याशु हि गुदं बद्ध्वा कुर्युर्बद्धगुदोदरम्||३२||

haste pāde mukhe nābhyāṃ gude vṛṣaṇayostathā| śotho hṛtpārśvaśūlaṃ ca yasyāsādhyo’rśaso hi saḥ||26|| hṛtpārśvaśūlaṃ sammohaśchardiraṅgasya rug jvaraḥ| tṛṣṇā gudasya pākaśca nihanyargudajāturam||27|| sahajāni tridoṣāṇi yāni cābhyantarāṃ valim| jāyante’rśāṃsi saṃśritya tānyasādhyāni nirdiśet||28|| śoṣatvādāyuṣastāni catuṣpādasamanvite| yāpyante dīptakāyāgneḥ pratyākhyeyānyato’nyathā||29|| dvandvajāni dvitīyāyāṃ valau yānyāśritāni ca| kṛcchrasādhyāni tānyāhuḥ parisaṃvatsarāṇi ca||30|| bāhyāyāṃ tu valau jātānyekadoṣolbaṇāni ca| arśāṃsi sukhasādhyāni na cirotpātatāni ca||31|| teṣāṃ praśamane yatnamāśu kuryādvicakṣaṇaḥ| tānyāśu hi gudaṃ baddhvā kuryurbaddhagudodaram||32||

haste pAde mukhe nAbhyAM gude vRuShaNayostathA| shotho hRutpArshvashUlaM ca yasyAsAdhyo~arshaso hi saH||26|| hRutpArshvashUlaM sammohashchardira~ggasya rug jvaraH| tRuShNA gudasya pAkashca nihanyargudajAturam||27|| sahajAni tridoShANi yAni cAbhyantarAM valim| jAyante~arshAMsi saMshritya tAnyasAdhyAni nirdishet||28|| shoShatvAdAyuShastAni catuShpAdasamanvite| yApyante dIptakAyAgneH pratyAkhyeyAnyato~anyathA||29|| dvandvajAni dvitIyAyAM valau yAnyAshritAni ca| kRucchrasAdhyAni tAnyAhuH parisaMvatsarANi ca||30|| bAhyAyAM tu valau jAtAnyekadoSholbaNAni ca| arshAMsi sukhasAdhyAni na cirotpAtatAni ca||31|| teShAM prashamane yatnamAshu kuryAdvicakShaNaH| tAnyAshu hi gudaM baddhvA kuryurbaddhagudodaram||32||

If the patient of hemorrhoids develops edema in upper and lower extremities, face, umbilicus, anus and scrotum, and if he suffers from pain in the cardiac region and lateral parts of chest, then such types of patients became incurable. [26]

Pain in the cardiac region and lateral parts of the chest, fainting, vomiting, pain in the limbs, fever, thirst and perianal swelling - these complications lead to the death of the patient suffering from hemorrhoids. [27]

Congenital/hereditary hemorrhoids caused by aggravation of three doshas and hemorrhoids located in the internal sphincter of the anus are also considered as incurable. [28]

In the presence of above incurable symptoms, if all four aspects of treatments like physician, drugs, attendant and patient are in the state of their excellence and if the patient has strong kayagni (power of digestion and metabolism) the disease may become yapya (palliative). Otherwise the disease became incurable. [29]

If the hemorrhoids are caused by vitiation of two doshas, and are located in the second anal- sphincter and if these are more than one year old, then these are difficult of cure. If the hemorrhoids are located in the external anal sphincter with vitiation of one dosha, and are not chronic then patient is said to be curable. A wise physician/surgeon should treat the patient early otherwise the enlarged hemorrhoids can obstruct the anal canal and lead to baddha-gudodara (obstruction in the passage of the ano-rectum). [30-32]

Treatment of hemorrhoids

तत्राहुरेके शस्त्रेण कर्तनं हितमर्शसाम्| दाहं क्षारेण चाप्येके, दाहमेके तथाऽग्निना||३३|| अस्त्येतद्भूरितन्त्रेण धीमता दृष्टकर्मणा| क्रियते त्रिविधं कर्म भ्रंशस्तत्र सुदारुणः||३४|| पुंस्त्वोपघातः श्वयथुर्गुदे वेगविनिग्रहः| आध्मानं दारुणं शूलं व्यथा रक्तातिवर्तनम्||३५|| पुनर्विरोहो रूढानां क्लेदो भ्रंशो गुदस्य च| मरणं वा भवेच्छीघ्रं शस्त्रक्षाराग्निविभ्रमात्||३६|| यत्तु कर्म सुखोपायमल्पभ्रंशमदारुणम्| तदर्शसां प्रवक्ष्यामि समूलानां विवृत्तये||३७||

tatrāhureke śastreṇa kartanaṃ hitamarśasām| dāhaṃ kṣāreṇa cāpyeke, dāhameke tathā’gninā||33|| astyetadbhūritantreṇa dhīmatā dṛṣṭakarmaṇā| kriyate trividhaṃ karma bhraṃśastatra sudāruṇaḥ||34|| puṃstvopaghātaḥ śvayathurgude vegavinigrahaḥ| ādhmānaṃ dāruṇaṃ śūlaṃ vyathā raktātivartanam||35|| punarviroho rūḍhānāṃ kledo bhraṃśo gudasya ca| maraṇaṃ vā bhavecchīghraṃ śastrakṣārāgnivibhramāt||36|| yattu karma sukhopāyamalpabhraṃśamadāruṇam| tadarśasāṃ pravakṣyāmi samūlānāṃ vivṛttaye||37||

tatrAhureke shastreNa kartanaM hitamarshasAm| dAhaM kShAreNa cApyeke, dAhameke tathA~agninA||33|| astyetadbhUritantreNa [5] dhImatA dRuShTakarmaNA| kriyate trividhaM karma bhraMshastatra sudAruNaH||34|| puMstvopaghAtaH shvayathurgude vegavinigrahaH| AdhmAnaM dAruNaM shUlaM vyathA raktAtivartanam||35|| punarviroho rUDhAnAM kledo bhraMsho gudasya ca| maraNaM vA bhavecchIghraM shastrakShArAgnivibhramAt||36|| yattu karma sukhopAyamalpabhraMshamadAruNam| tadarshasAM pravakShyAmi samUlAnAM vivRuttaye||37||

In the management of arsha,some physicians/surgeons advise excision of the hemorrhoids by sharp instruments, while others recommend cauterization with ksharakarma (alkalies) and agnikarma (thermal cauterization). These procedures should be administered only by a physician/surgeon who is well trained in the field.

Any mistake during these (surgical or para-surgical) procedures could result in serious consequencwes and complications, such as impotency, ano-rectal swelling, obstruction in defecation, abdominal distension, excruciating pain, excessive bleeding and recurrence of hemorrhoids. On healing stricture may form and chronic sticky /pus discharge, prolapse of the rectum can occur. Above complications may develop due to improper surgery, ksharakarma and agnikarma.

Now the treatment which involve less of risk and which are not painful will be described for the eradication of hemorrhoids. [33-37]

Classification of arsha

वातश्लेष्मोल्बणान्याहुः शुष्काण्यर्शांसि तद्विदः| प्रस्रावीणि तथाऽऽर्द्राणि रक्तपित्तोल्बणानि च||३८||

vātaśleṣmolbaṇānyāhuḥ śuṣkāṇyarśāṃsi tadvidaḥ| prasrāvīṇi tathā”rdrāṇi raktapittolbaṇāni ca||38||

vAtashleShmolbaNAnyAhuH shuShkANyarshAMsi tadvidaH| prasrAvINi tathA~a~ardrANi raktapittolbaNAni ca||38||

Hemorrhoids caused by aggrava¬tion of vayu and kapha are called dry hemorrhoids. Whereas those with excess discharge(bleeding) and wetness are caused by aggravation of rakta and pitta. [38]

Treatment of dry hemorrhoids

तत्र शुष्कार्शसां पूर्वं प्रवक्ष्यामि चिकित्सितम्| स्तब्धानि स्वेदयेत् पूर्वं शोफशूलान्वितानि च||३९||

tatra śuṣkārśasāṃ pūrvaṃ pravakṣyāmi cikitsitam| stabdhāni svedayet pūrvaṃ śophaśūlānvitāni ca||39||

tatra shuShkArshasAM pUrvaM pravakShyAmi cikitsitam| stabdhAni svedayet pUrvaM shophashUlAnvitAni ca||39||

Dry, hard, inflamed and painful hemorrhoids should be first treated with fomentation. [39]

Recipes for fomentation

चित्रक क्षार बिल्वानां तैलेनाभ्यज्य बुद्धिमान्| यव माष कुलत्थानां पुलाकानां च पोट्टलैः||४०|| गोखराश्वशकृत्पिण्डैस्तिलकल्कैस्तुषैस्तथा| वचाशताह्वापिण्डैर्वा सुखोष्णैः स्नेहसंयुतैः||४१|| शक्तूनां पिण्डिकाभिर्वा स्निग्धानां तैलसर्पिषा| शुष्कमूलकपिण्डैर्वा पिण्डैर्वा कार्ष्णगन्धिकैः||४२|| रास्नापिण्डैः सुखोष्णैर्वा सस्नेहैर्हापुषैरपि| इष्टकस्य खराह्वायाः शाकैर्गृञ्जनकस्य वा||४३|| अभ्यज्य कुष्ठतैलेन स्वेदयेत् पोट्टलीकृतैः|

citraka kṣāra bilvānāṃ tailenābhyajya buddhimān| yava māṣa kulatthānāṃ pulākānāṃ ca poṭṭalaiḥ||40|| gokharāśvaśakṛtpiṇḍaistilakalkaistuṣaistathā| vacāśatāhvāpiṇḍairvā sukhoṣṇaiḥ snehasaṃyutaiḥ||41|| śaktūnāṃ piṇḍikābhirvā snigdhānāṃ tailasarpiṣā| śuṣkamūlakapiṇḍairvā piṇḍairvā kārṣṇagandhikaiḥ||42|| rāsnāpiṇḍaiḥ sukhoṣṇairvā sasnehairhāpuṣairapi| iṣṭakasya kharāhvāyāḥ śākairgṛñjanakasya vā||43|| abhyajya kuṣṭhatailena svedayet poṭṭalīkṛtaiḥ|

citrakakShArabilvAnAM tailenAbhyajya buddhimAn| yavamAShakulatthAnAM pulAkAnAM ca poTTalaiH||40|| gokharAshvashakRutpiNDaistilakalkaistuShaistathA| vacAshatAhvApiNDairvA sukhoShNaiH snehasaMyutaiH||41|| shaktUnAM piNDikAbhirvA snigdhAnAM tailasarpiShA| shuShkamUlakapiNDairvA piNDairvA kArShNagandhikaiH||42|| rAsnApiNDaiH sukhoShNairvA sasnehairhApuShairapi| iShTakasya kharAhvAyAH shAkairgRu~jjanakasya vA||43|| abhyajya kuShThatailena svedayet poTTalIkRutaiH|

The pile mass should be smeared with the help of the oil prepared by boiling chitraka (Plumbago zeylanica Linn.), alkalies and bilva (Aegle marmelos Carr.). Fomen¬tation should be done with the help of the following formulations:

Pottali (medicines tied in a piece of cloth in the form of a bolus) containing yava (Hordeum vulgare Linn.), masha, kulattha (Vigna unquiculata (Linn.) walp and pulaka (tucchadhnnya )
Pottali prepared of the cake of the sesame seed
Pottali containing husk of paddy.
Pottali of vacha (Acarus calamus Linn.) and satahva (Anethum sowa Roxb.)

The above mentioned recipes of pottali and pindas should be tolerably warm and should be added with fat. [40-41]

Pinda containing sattu (roasted corn flour) and added with unctuous substances, like oil and ghee
Pinda containing the pulp of dry radish
Pinda containing karshnagandhika
Pinda containing rasna (Pluchea lanceolata)
Pinda containing hapusha

The above mentioned recipes (no. 6 to 10) should be luke-warm and should be added with fat. The hemorrhoids mass should be smeared with oil prepared by boiling with rasna (Pluchea lanceolata). Thereafter, it should be fomented, with the help of a potalli containing brick powder, kharahva (Ajamoda/Apium leptophyllum (Pers.)) and the pulp of gunjanaka (Abrus precatorius Linn.). [39-43]

Recipe for Sprinkling

वृषार्कैरण्डबिल्वानां पत्रोत्क्वाथैश्च सेचयेत्||४४||

vṛṣārkairaṇḍabilvānāṃ patrotkvāthaiśca secayet||44||

vRuShArkairaNDabilvAnAM patrotkvAthaishca secayet||44||

The hemorrhoids mass should be sprinkled with decoction of the leaves vasa (Adhatoda zeylanica Medic.), arka (Calotropis procera Ait.), eranda (Ricinus communis Linn.) and bilva (Aegle marmelos Carr.) [44]

Tattva Vimarsha

The arsha is of two types viz. congenital and acquired (manifested after the birth).
The congenital hemorrhoids are caused by the vitiation of the beeja dosha (deformity in sperm and ovum), specially the part of the anal canal or anal sphincters. This vitiation of the beeja dosha is caused by either wrong diet, lifestyle regimen of parents (father/mother) or by sinful acts of the past life of patient. These are also causes for all other congenital disorders.
Arsha (hemorrhoids) is characterized by morbid growth in the muscle tissue. The adhishthana (involved morbid tissue elements) of all the types of arsha are medas (fatty tissue), mamsa (muscular tissue) and tvaka (skin and mucous membrane).
Characteristics or forms of all hemorrhoids are as per the doshas involved in their formation.
In pathophysiology of arsha, apana vayu gets obstructed by the hemorrhoid-mass and moves upwards leading to aggravation of samana vayu, vyana vayu, prana vayu, udana vayu, pitta and kapha dosha. When all these five types of vayu, pitta and kapha get aggravated the individual suffers from morbidities of hemorrhoids.
The causes of vataja arsha include habitual intake of astringent, pungent, bitter, ununctuous, cold and light food; habitual intake of pramitashana (food measured in extremely small quantities), intake of less quantity of food, intake of excess alcoholic drinks and indulgence in sexual acts; fasting, living in cold country and cold season, excess physical exercise, grief and exposure to sun and wind.
The causes of pittaja arsha include intake of pungent, hot, salty and alkaline food; excess exercise and exposure to the heat of fire and Sun; living in a place and season which are not cold, intake of alcohol and envy; Intake of drinks, food and drugs having vidahi (causing burning sensation), sharp and hot properties.
The causes of kaphaja arsha (hemorrhoids) include sweet, unctuous, cold, salty, sour and heavy food; lack of exercise, sleeping during day time, excess sleeping and sitting; direct exposure to wind, living in cold place and exposure to cold season and mental inactivity.
Hemorrhoids always include aggravation of all the three doshas. Predominance of one or all the doshas determine the type of hemorrhoids.
Five types of vayu (prana, apana, vyana, udana and samana), pitta and kapha - all these morbid factors in their aggravated state afflict the three anal sphincters at ano-rectum and lead to hemorrhoids.
Excision of the hemorrhoids by sharp instruments, cauterization with ksharakarma (alkalies) and agnikarma (thermal cauterization) are three modalities in the management of arsha.
Hemorrhoids caused by aggravation of vayu and kapha are ‘dry hemorrhoids’. Whereas those with excess discharge (bleeding) and wetness are caused by aggravation of rakta and pitta.
Dry, hard, inflamed and painful hemorrhoids should be first treated with fomentation in the form of avagaha (sitz bath in medicated decoction), abhyanga (local massage with medicated oils), sprinkling of medicated water, fumigation, ointment and external application. Then the vitiated blood shall be removed out by blood letting therapy. Bloodletting with the help of application of leeches or sharp instruments or needles should be done in raktaja arsha, if blood doesn't come out on its own. Simultaneously with this localized treatment, generalized treatment to correct the agni is advised to patients.
Butter-milk is the best medicine for the treatment of hemorrhoids caused by aggravation of vayu and kapha. Butter-milk should be taken along with fat (for vayu) or in an ununctuous form (for kapha). It can be given in various forms, at different times depending upon the state of disease.
Anuvasana basti (unctuous enema) is best treatment for arsha associated with dysfunction of vata.
The bleeding hemorrhoids shall be treated after assessment of association with vata dominance and kapha dominance in its patho-physiology. Unctuous and cold things should be used in cases of vitiation of vayu in bleeding hemorrhoids. In case of vitiation of kapha in bleeding hemorrhoids, ununctuous and cold-things are useful.
If there is predominance of pitta and kapha dosha, shodhana (elimination) therapies are indicated.
Bleeding should not be stopped immediately by giving hemostatic therapies. One should wait for appropriate time till the vitiated blood goes out and the patient can be given fasting therapy.
If the blood vitiated by doshas, which comes out from the hemorrhoids is arrested in the beginning then it may lead to several other complications. Therefore, only after elimination of vitiated blood hemostatic measures are useful. The physician should be well aware of the etiology, signs and symptoms, nature of the time, strength and color of the blood and should wait for appropriate time before administering hemostatic therapies unless there is an emergency.
Bitter drugs should be given for stimulation of the digestive power, hemostasis and pachana (metabolic transformation).
In hemorrhoids with predominance of vayu, if bleeding continues even after the aggravated doshas are eliminated, then the patient should be given unctuous therapies in the form of drinks, massage and anuvasana basti.
In summer season, pitta predominant hemorrhoids without secondary predominance of vayu and kapha, should be treated with hemostatic therapies immediately to stop bleeding.
In case of excessive bleeding, the arsha becomes vata dominant. Even if pitta and kapha are predominantly vitiated, then also predominance of vata shall be considered in excessive bleeding.
If there is predominance of rakta and pitta and there is less of the signs and symptoms of aggravated kapha and vayu, then the patient should be given cooling remedies.
If bleeding continues in spite of the above mentioned remedies and cooling therapies, then a wise physician should administer at the appropriate time, meat-soup which is unctuous and hot. Patient should be given medicated ghee which is administered, prior to taking food. His anus should be massaged with lukewarm ghee or oil, or the hemorrhoid mass should be fomented with lukewarm milk, ghee or oil. These remedies should be administered quickly.
If bleeding doesn't stop and there is aggravation of vayu then the patient should be given anuvsana type of enema with the help of lukewarm ghritamanda (upper portion of the ghee). He should be given the effective piccha basti (recipe of which is described below) at the appropriate time.
The power of digestion should always be preserved in the patients of hemorrhoids by giving sometimes cold articles and sometimes hot articles, sometimes sweet or sour taste drugs or food having opposite characters.
Arsha (hemorrhoids), atisara (diarrhea) and grahani these three diseases are interdependent. In all patients of these three diseases, if the digestive power is low then disease gets aggravated and if digestive power is strong then relief occurs.
The foods that lead to downward movement of vayu and promote digestive power should be daily consumed by patients of hemorrhoids. Those foods having opposite properties and those described in the etiology of hemorrhoids should never be used by the patients.

Vidhi Vimarsha

In modern surgery, the primary hemorrhoids are located at 3, 7, and 11' 0 clock position while secondary hemorrhoids are located in other positions as well. The sizes of the hemorrhoids differ from patient to patient as well as duration of disease.

The symptoms described for the incurable hemorrhoids develop due to severe bleeding in third and fourth grade of hemorrhoids and secondary complications may develop due to severe anemia and became incurable. But in the present era this type of condition rarely develops and can be managed with the help of blood transfusion. So, any kind of hemorrhoid is curable in present era except one associated with ano-rectal carcinoma.

Bhallataka (Semecarpus anacardium) is strong medicine and if given as single drug in oil form it leads to ulceration in mouth so refreshing drink should be added to dilute and to avoid the complication.

Charaka mentioned in most of the verses the effect of the formulation like dantyarishta helps in the downward movement of flatus and feces and stimulates the digestive power. It shows that the main cause of the disease is agnimandya and constipation.

In recent studies the sitz bath is advised with warm water in all kind of hemorrhoids or ano-rectal disorders. Charaka mentioned sitz bath with warm and cold water. The warm water should be used in cases of vataja and kaphaja type of hemorrhoids while cold water sitz bath should be given in cases of pittaja or rakataja predominant hemorrhoids.

Color atlas of various conditions of arsha

Fig 1: Rectal polyp (sahaja arsha)
Fig.2: Vataja arsha
Fig.3: Vataja arsha
Fig.4: Pittaja arsha
Fig.5: Pittaja arsha
Fig.6: Kaphaja arsha
Fig.7: Kaphaja arsha
Fig.8: External Piles
Fig.9: External Piles
Fig.10: Internal Piles
Fig.11: Internal Piles

Current Clinical Management

Type	Medicine	Dosage	Time	Anupana
Shushka (Dry)	Kankayana Guti	500-1000 mg	Before Meals	Butter and sugar
	Bhallatakvaleha	10-15 gms	After meals	Milk and ghee
	Abhayarishta	10-25 ml	After meals	Water
Wet	Nagakeshara mixture	125-250 mg	Between two meals, three times	Milk
Wet	Samasharkara mixture	200-400 mg	Between two meals, three times	Butter and sugar/Milk and sugar

Surgical Management

Ksharasutra is the widely accepted effective method.

@@ Line 576: / Line 576: @@
 # Pottali (medicines tied in a piece of cloth in the form of a bolus) containing yava (Hordeum vulgare Linn.), masha, kulattha (Vigna unquiculata (Linn.) walp and pulaka (tucchadhnnya )
 # Pottali prepared of the cake of the sesame seed
-    #Pottali containing husk of paddy.
+#Pottali containing husk of paddy.
-   #Pottali of vacha (Acarus calamus Linn.) and satahva (Anethum sowa Roxb.)
+#Pottali of vacha (Acarus calamus Linn.) and satahva (Anethum sowa Roxb.)
-    The above mentioned recipes of pottali and pindas should be tolerably warm and     should be added with fat. [40-41]
+The above mentioned recipes of pottali and pindas should be tolerably warm and     should be added with fat. [40-41]
 #Pinda containing sattu (roasted corn flour) and added with unctuous substances, like oil and ghee
 # Pinda containing the pulp of dry radish