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

(Chikitsa Sthana Chapter 14, Chapter on Treatment of 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:

1. Congenital
2. 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:

1. The wrong diet and regimen of parents (father/mother)
2. 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:

1. 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.
2. 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.
3. The stool color differs, having white, pale yellow, green, yellow, red, thin, dense, slimy, having bad odor like dead tissue and associated with ama.
4. The patient suffers from severe colicky pain in umbilicus, region of urinary bladder, pelvic region and anus.
5. 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.
6. 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.
7. He has frequent cough, dyspnea, bronchial asthma, morbid thirst, nausea, vomiting, anorexia, indigestion, chronic rhinitis and sneezing.
8. He gets fits of fainting and headache; his voice is weak, broken, of low pitch, impeded and has hoarseness.
9. He may suffer from ear diseases, gets swelling around the eyes, suffers from fever, malaise and pain in all the joints and bones.
10. Patient gets stiffness in chest, abdomen, region of urinary bladder, cardiac region, back and lumber region.
11. He has persistent giddiness and is extremely lazy.
12. 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-gurumadhurashItAbhiShyandividAhiviruddhAjIrNapramitAshanAsAtmyabhojanAdgavyamAtsyavArAhamAhiShAjAvikapishitabhakShaNAtkRushashuShkapUtimAMsapaiShTikaparamAnnakShIradadhimaNDatilaguDavikRutisevanAnmAShayUShekShurasapiNyAkapiNDAlukashuShkashAka-shuktalashunakilATatakrapiNDakabisamRuNAlashAlUkakrau~jcAdanakasherukashRu~ggATakatarUTavirUDhanavashUkashamI-dhAnyAmamUlakopayogAdguruphalashAkarAgaharitakamardakavasAshiraspadaparyuShitapUtishItasa~gkIrNAnnAbhyavahArAnmanda-kAtikrAntamadyapAnAdvyApannagurusalilapAnAdatisnehapAnAdasaMshodhanAdbastikarmavibhramAdavyAyAmAdavyavAyAddivAsvapnAtsukhashayanAsanasthAnasevanAccopahatAgnermalopacayo bhavatyatimAtraM,tathotkaTakaviShamakaThinAsanasevanAdudbhrAntayAnoShTrayAnAdativyavAyAdbastinetrAsamyakpraNidhAnAdgudakShaNanAdabhIkShNaMshItAmbusaMsparshAccelaloShTatRuNAdigharShaNAt 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:

1. Intake of heavy, sweet, cold, abhishyandi (food that causes obstruction in the channels of circulation), vidahi (that causes burning sensation) and viruddha ( mutually contradictory ) food; intake of food before the previous meal is digested; intake of a small quantity of food; and intake of unwholesome food;
2. Excessive intake of the meats of cattle, fish, pig, buffalo, goat and sheep;
3. Meat of emaciated animals, dried meat and putrefied meat.
4. Excessive intake of pastries, paramanna (preparation of milk, rice and sugar), milk, dadhimanda (whey), preparations of sesame seed and jaggery-based products;
5. 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;
6. 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).
7. Intake of mandaka (immature curds) and wrongly (excess) fermented wines.
8. Drinking of polluted and heavy water, excess intake of sneha (oleation therapy), non-use of Panchakarma (elimination therapies), improper basti karma (enema therapy)
9. 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:

1. Use of rough, irregular and hard seats
2. Use of vehicles carried by improperly trained animals or vehicles carried by camels
3. Excessive indulgence in sexual act;
4. Improper insertion of enema nozzle and frequent injury in the anal region.
5. Frequent application of cold water.
6. Use of rags, clods of grass, etc. for rubbing the anus
7. Continued and excessive strain
8. Forcible attempts for passing flatus, urine and stool
9. Suppression of natural urges
10. 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 udders), 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:

1. 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.
2. The mass of hemorrhoids is associated with pain, cramps toda (piercing pain), itching, numbness and tingling sensation in excess.
3. Unctuous and hot things give relief in this condition.
4. The patient suffers from dysentery, abdominal distension and stiffness of genitals, testicles, urinary bladder, pelvis and cardiac region; he also suffers from malaise and palpitation in excess.
5. His flatus, urine and stool are constantly obstructed.
6. 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)
7. 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) itching, pain in the nose, ears and temporal region, and impairment of the voice.
8. 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 follows:

1. Habitual intake of astringent, pungent, bitter, ununctuous, cold and light food;
2. 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.
3. 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 arsha:

1. The pile mass is soft, flabby, delicate and tender to touch
2. The color of hemorrhoids is red, yellow, blue or black
3. The hemorrhoids is associated with excessive sweating and sticky discharge
4. The discharge from the hemorrhoids mass is visra (smelling like raw-meat), thin, yellow or red
5. There is bleeding from the hemorrhoids
6. The hemorrhoids are associated with burning sensation, itching, pain, pricking pain and suppuration.
7. Cold things relief the symptoms
8. The stool of the patient is loose, yellow or green
9. The urine and stool are voided in large quantities, yellow in color and the smell is like raw meat.
10. The patient suffers from morbid thirst, fever, asthma, fainting and disliking for foods
11. 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 follows:

1. Intake of pungent, hot, salty and alkaline food,
2. Excess exercise and exposure to the heat of fire and Sun
3. Living in a place and season which are not cold, intake of alcohol and envy;
4. 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 arsha:

1. The hemorrhoids are large in size, swollen, smooth, painless to touch, 2. The hemorrhoids are unctuous, white, pale white, slimy, having stiffness, heavy, rigid, benumbed, having consistent oedema and excessive of itching. 3. The discharge from the hemorrhoids is excess and continuous having white or red in colour with slimyness. 4. Urine and stool of the patient are heavy, slimy and white 5. Ruksha (un-unctuous) and hot therapies gives relief from symptoms 6. The patient has an excessive desire to pass stool with tenesmus and distension in the lower pelvic region 7. The patient suffers from burning pain in anus, nausea, excessive spitting, cough, anorexia, cold, heaviness, vomiting, dysuria; lethargy, edema, anemia. 8. 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), 9. The disease becomes chronic condition. So, digestive power gets suppressed and causes impotency 10. They are associated with acute diseases caused by ama (product of improper digestion and metabolism). 11. 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 1. Sweet, unctuous, cold, salty, sour and heavy food 2. Lack of exercise, sleeping during day time and indul¬gence in the pleasure of beds and seats (excess sleeping and sitting) 3. Direct exposure to wind 4. 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: 1. 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 )2. 3. Pottali prepared of the cake of the sesame seed 4. Pottali containing husk of paddy. 5. 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] 6. Pinda containing sattu (roasted corn flour) and added with unctuous substances, like oil and ghee 7. Pinda containing the pulp of dry radish 8. Pinda containing karshnagandhika 9. Pinda containing rasna (Pluchea lanceolata) 10. 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]

Recipes for sitz-bath: मूलक त्रिफलार्काणां वेणूनां वरुणस्य च| अग्निमन्थस्य शिग्रोश्च पत्राण्यश्मन्तकस्य च||४५|| जलेनोत्क्वाथ्य शूलार्तं स्वभ्यक्तमवगाहयेत्| कोलोत्क्वाथेऽथवा कोष्णे सौवीरक तुषोदके||४६|| बिल्वक्वाथेऽथवा तक्रे दधिमण्डाम्लकाञ्जिके| गोमूत्रे वा सुखोष्णे तं स्वभ्यक्तमवगाहयेत्||४७|| mūlaka triphalārkāṇāṃ veṇūnāṃ varuṇasya ca| agnimanthasya śigrośca patrāṇyaśmantakasya ca||45|| jalenotkvāthya śūlārtaṃ svabhyaktamavagāhayet| kolotkvāthe’thavā koṣṇe sauvīraka tuṣodake||46|| bilvakvāthe’thavā takre dadhimaṇḍāmlakāñjike| gomūtre vā sukhoṣṇe taṃ svabhyaktamavagāhayet||47|| mUlakatriphalArkANAM veNUnAM varuNasya ca| agnimanthasya shigroshca patrANyashmantakasya ca||45|| jalenotkvAthya shUlArtaM svabhyaktamavagAhayet| kolotkvAthe~athavA koShNe sauvIrakatuShodake||46|| bilvakvAthe~athavA takre dadhimaNDAmlakA~jjike| gomUtre vA sukhoShNe taM svabhyaktamavagAhayet||47|| If there is pain in hemorrhoidal mass, then it should be well smea¬red with medicated oil and sitz-bath should be given with the help of decoction prepared by leaves of radish, triphala [Haritaki (Terminalia Chebula Roxb.), bibhitaka (Terminalia belerica Roxb.) and amalaka (Emblica officinalis Gaertn.)], arka (Calotropis procera Ait.), venu varuna (crataeva nurvala Buch-Ham), agnimantha (Clerodendrum phlomidis Linn.), shigru (Moringa oleifera Lam.) and ashmantaka. The patient can also be given sitz-bath with the decoction akola (Alangium salviifolium Linn.) or sauviraka or tushodaka or decoction of bilva (Aegle marmelos Carr.) or butter¬milk or dadhi manda (whey) or sour kanjika or cow's urine. Before sitz-bath, medicated oil should be applied on the hemorrhoids mass and the decoction should be warm. [45-47]

Recipes for smearing and fumigation: कृष्ण सर्प वराहोष्ट्र जतुकावृषदंशजाम्| वसामभ्यञ्जने दद्याद्धूपनं चार्शसां हितम्||४८|| नृकेशाः सर्पनिर्मोको वृषदंशस्य चर्म च| अर्कमूलं शमीपत्रमर्शोभ्यो धूपनं हितम्||४९|| तुम्बुरूणि विडङ्गानि देवदार्वक्षता घृतम्| बृहती चाश्वगन्धा च पिप्पल्यः सुरसा घृतम्||५०|| वराहवृषविट् चैव धूपनं सक्तवो घृतम्| कुञ्जरस्य पुरीषं तु घृतं सर्जरसस्तथा||५१|| kṛṣṇa sarpa varāhoṣṭra jatukāvṛṣadaṃśajām| vasāmabhyañjane dadyāddhūpanaṃ cārśasāṃ hitam||48|| nṛkeśāḥ sarpanirmoko vṛṣadaṃśasya carma ca| arkamūlaṃ śamīpatramarśobhyo dhūpanaṃ hitam||49|| tumburūṇi viḍaṅgāni devadārvakṣatā ghṛtam| bṛhatī cāśvagandhā ca pippalyaḥ surasā ghṛtam||50|| varāhavṛṣaviṭ caiva dhūpanaṃ saktavo ghṛtam| kuñjarasya purīṣaṃ tu ghṛtaṃ sarjarasastathā||51|| kRuShNasarpavarAhoShTrajatukAvRuShadaMshajAm| vasAmabhya~jjane dadyAddhUpanaM cArshasAM hitam||48|| nRukeshAH sarpanirmoko vRuShadaMshasya carma ca| arkamUlaM shamIpatramarshobhyo dhUpanaM hitam||49|| tumburUNi viDa~ggAni devadArvakShatA ghRutam| bRuhatI cAshvagandhA ca pippalyaH surasA ghRutam||50|| varAhavRuShaviT caiva dhUpanaM saktavo ghRutam| ku~jjarasya purIShaM tu ghRutaM sarjarasastathA||51|| 1. The fat black variety of cobra, pig, camel, jatuka and cat should be applied on the piles mass and also used for fumigation of piles.[48] 2. Fumigation should be done with the help of human hair, serpent's slough, cat's skin, root of Arka (Calotropis procera Ait.) and leaf of shami. [49] 3. Fumigation should be given with tumbi, vidang (Embelia ribes), devadaru (Cedrus deodaru) and akshat (rice) mixed with ghee. Brahati (Solanum indicum), ashvagandha (Withania somnifera), pippali (Piper longum) and surasa/tulasi (Ocimum sanctum) mixed with ghee can be used for fumigation.[50] 4. Saktu (roasted corn-flour) and ghee should be used for fumigation. Fumigation with sarjarasa mixed with ghee is also used for hemorrhoids. [51]

Ointment recipes: हरिद्रा चूर्ण संयुक्तं सुधा क्षीरं प्रलेपनम्| गोपित्त पिष्टाः पिप्पल्यः सहरिद्राः प्रलेपनम्||५२|| शिरीष बीजं कुष्ठं च पिप्पल्यः सैन्धवं गुडः| अर्क क्षीरं सुधा क्षीरं त्रिफला च प्रलेपनम्||५३|| पिप्पल्यश्चित्रकः श्यामा किण्वं मदन तण्डुलाः| प्रलेपः कुक्कुट शकृद्धरिद्रा गुडसंयुतः||५४|| दन्ती श्यामाऽमृतासङ्गः पारावतशकृद्गुडः| प्रलेपः स्याद्गजास्थीनि निम्बो भल्लातकानि च||५५|| प्रलेपः स्यादलं कोष्णं वासन्तकवसायुतम्| शूलश्वयथुहृद्युक्तं चुलूकीवसयाऽथवा||५६|| आर्कं पयः सुधाकाण्डं कटुकालाबुपल्लवाः| करञ्जो बस्तमूत्रं च लेपनं श्रेष्ठमर्शसाम्||५७|| haridrā cūrṇa saṃyuktaṃ sudhā kṣīraṃ pralepanam| gopitta piṣṭāḥ pippalyaḥ saharidrāḥ pralepanam||52|| śirīṣa bījaṃ kuṣṭhaṃ ca pippalyaḥ saindhavaṃ guḍaḥ| arka kṣīraṃ sudhā kṣīraṃ triphalā ca pralepanam||53|| pippalyaścitrakaḥ śyāmā kiṇvaṃ madana taṇḍulāḥ| pralepaḥ kukkuṭa śakṛddharidrā guḍasaṃyutaḥ||54|| dantī śyāmā’mṛtāsaṅgaḥ pārāvataśakṛdguḍaḥ| pralepaḥ syādgajāsthīni nimbo bhallātakāni ca||55|| pralepaḥ syādalaṃ koṣṇaṃ vāsantakavasāyutam| śūlaśvayathuhṛdyuktaṃ culūkīvasayā’thavā||56|| ārkaṃ payaḥ sudhākāṇḍaṃ kaṭukālābupallavāḥ| karañjo bastamūtraṃ ca lepanaṃ śreṣṭhamarśasām||57|| haridrAcUrNasaMyuktaM sudhAkShIraM pralepanam| gopittapiShTAH pippalyaH saharidrAH pralepanam||52|| shirIShabIjaM kuShThaM ca pippalyaH saindhavaM guDaH| arkakShIraM sudhAkShIraM triphalA ca pralepanam||53|| pippalyashcitrakaH shyAmA kiNvaM madanataNDulAH| pralepaH kukkuTashakRuddharidrAguDasaMyutaH||54|| dantI shyAmA~amRutAsa~ggaH pArAvatashakRudguDaH| pralepaH syAdgajAsthIni nimbo bhallAtakAni ca||55|| pralepaH syAdalaM koShNaM vAsantakavasAyutam| shUlashvayathuhRudyuktaM culUkIvasayA~athavA||56|| ArkaM payaH [6] sudhAkANDaM kaTukAlAbupallavAH| kara~jjo bastamUtraM ca lepanaM shreShThamarshasAm||57|| The following recipes should be used in the form of ointments in the management of hemorrhoids: 1. Turmeric powder (Curcuma longa) mixed with latex of snuhi (Euphorbia nerifolia) paste should be applied on hemorrhoids. 2. The paste of turmeric powder (Curcuma longa) mixed with the fruits of pippali (Pipper longum) and cow's bile. [52] 3. The paste prepared with the seeds of shirisha (Albizzia lebbeck), kushtha (Sausserea leppa), pippali (Piper longum), saindhava, jaggery, latex of arka (Calotropis procera Ait.) and snuhi (Euphorbia nerifolia) and triphala.[53] 4. The paste prepared of pippali (Piper longum), chitraka (Plumbago zeylanica Linn.), shyama, kinva (yeast), fruit pulp of madana (Randia spinosa), turmeric (Curcuma longa) and jaggery. [54] 5. The paste of danti (Baliospermum montanum), shyama amjtasaga and jaggery. 6. The paste prepared of elephant bone, nimba (Azadirecta indica) and bhallataka (Semecarpus anacardium) [55] 7. The luke¬warm paste prepared of hartala mixed with the fat of camel should be applied. It cures pain and edema in the hemorrhoids mass. [56] 8. The paste of the latex of arka (Calotropis procera Ait.), stem of snuhi (Euphorbia nerifolia), leaf of bitter variety of alabu (bottle guard), karanja (Pongamia pinnata) and urine of goat is excellent in treatment of hemorrhoids. [57] अभ्यङ्गाद्याः प्रदेहान्ता य एते परिकीर्तिताः| स्तम्भ श्वयथु कण्ड्वर्ति शमनास्तेऽर्शसां मताः||५८|| abhyaṅgādyāḥ pradehāntā ya ete parikīrtitāḥ| stambha śvayathu kaṇḍvarti śamanāste’rśasāṃ matāḥ||58|| abhya~ggAdyAH pradehAntA ya ete parikIrtitAH| stambhashvayathukaNDvartishamanAste~arshasAM matAH||58||

All above mentioned recipes started with abhyanga (recipes for smearing) and ending with pradeha (local application of ointment) are useful in management of hemorrhoids associated with stiffness, edema, itching and pain. [58] प्रदेहान्तैरुपक्रान्तान्यर्शांसि प्रस्रवन्ति हि| सञ्चितं दुष्टरुधिरं ततः सम्पद्यते सुखी||५९|| pradehāntairupakrāntānyarśāṃsi prasravanti hi| sañcitaṃ duṣṭarudhiraṃ tataḥ sampadyate sukhī||59|| pradehAntairupakrAntAnyarshAMsi prasravanti hi| sa~jcitaM duShTarudhiraM tataH sampadyate sukhI||59||

The vitiated blood which is accumulated in the hemorrhoids mass, oozes out by local application of the above mentioned recipes and ointments which ultimately give relief to the patients of hemorrhoids. [59]

Raktamokshana (bloodletting): शीतोष्णा स्निग्ध रूक्षैर्हि न व्याधि रुपशाम्यति| रक्ते दुष्टे भिषक् तस्माद्रक्तमेवावसेचयेत्||६०|| जलौकोभिस्तथा शस्त्रैः सूचीभिर्वा पुनः पुनः| अवर्तमानं रुधिरं रक्तार्शोभ्यः प्रवाहयेत्||६१|| śītoṣṇā snigdha rūkṣairhi na vyādhi rupaśāmyati| rakte duṣṭe bhiṣak tasmādraktamevāvasecayet||60|| jalaukobhistathā śastraiḥ sūcībhirvā punaḥ punaḥ| avartamānaṃ rudhiraṃ raktārśobhyaḥ pravāhayet||61|| shItoShNAsnigdharUkShairhi na vyAdhirupashAmyati| rakte duShTe bhiShak tasmAdraktamevAvasecayet||60|| jalaukobhistathA shastraiH sUcIbhirvA punaH punaH| avartamAnaM rudhiraM raktArshobhyaH pravAhayet||61||

If the disease is not relieved by the application of cold, hot, unctuous and ununctuous types of treatment then such disease is likely to be caused by vitiation of rakta (blood). In such condition raktamokshana (bloodletting) procedure should be administered. [60]

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. [61]

Churna (powder formulations): गुद श्वयथु शूलार्तं मन्दाग्निं पाययेत्तु तम्| त्र्यूषणं पिप्पलीमूलं पाठां हिङ्गु सचित्रकम्||६२|| सौवर्चलं पुष्कराख्यमजाजीं बिल्वपेषिकाम्| बिडं यवानीं हपुषां विडङ्गं सैन्धवं वचाम्||६३|| तिन्तिडीकं च मण्डेन मद्येनोष्णोदकेन वा| तथाऽर्शोग्रहणीदोषशूलानाहाद्विमुच्यते||६४|| पाचनं पाययेद्वा तद्यदुक्तं ह्यातिसारिके| guda śvayathu śūlārtaṃ mandāgniṃ pāyayettu tam| tryūṣaṇaṃ pippalīmūlaṃ pāṭhāṃ hiṅgu sacitrakam||62|| sauvarcalaṃ puṣkarākhyamajājīṃ bilvapeṣikām| biḍaṃ yavānīṃ hapuṣāṃ viḍaṅgaṃ saindhavaṃ vacām||63|| tintiḍīkaṃ ca maṇḍena madyenoṣṇodakena vā| tathā’rśograhaṇīdoṣaśūlānāhādvimucyate||64|| pācanaṃ pāyayedvā tadyaduktaṃ hyātisārike| gudashvayathushUlArtaM mandAgniM pAyayettu tam| tryUShaNaM pippalImUlaM pAThAM hi~ggu sacitrakam||62|| sauvarcalaM puShkarAkhyamajAjIM bilvapeShikAm| biDaM yavAnIM hapuShAM viDa~ggaM saindhavaM vacAm||63|| tintiDIkaM ca maNDena madyenoShNodakena vA| tathA~arshograhaNIdoShashUlAnAhAdvimucyate||64|| pAcanaM pAyayedvA tadyaduktaM [7] hyAtisArike|

If the patient suffers from edema and pain in the peri-anal region, and if there is suppression of the digestive power, then he should be treated with the combination of powder of trikatu [(Sunthi (Zingiber officinale), pippali (Piper longum)and maricha (Piper nigrum)], pippalimool (Piper longum), patha (Cissampelos parrira), hingu (Ferula narthex), chitraka (Plumbago Zylanica), sauvarchala (one kind of salt), pushkarmool(Inula racemosa), jeera (Cuminum cyminum), Pulp af bilva (Aegle marmelos), bidlavan, ajwyan (Trachyspermum ammi), hauber, vavding (Embalia ribes), saindhava (one kind of salt), vacha (Acorus calamus) and tintidika along with whey, alcoholic drink or hot water. This recipe also cures hemorrhoids, grahani (sprue syndrome), colic pain and flatulence.[62-64]

The recipes for pachana (which help in the digestion of undigested food), which are described for the treatment of atisara (diarrhea) should be given to the patients of hemorrhoids.[65]

Other Recipes: गुडामभयां वाऽपि प्राशयेत् पौर्वभक्तिकीम्||६५|| पाययेद्वा त्रिवृच्चूर्णं त्रिफलारससंयुतम्| हृते गुदाश्रये दोषे गच्छन्त्यर्शांसि सङ्क्षयम्||६६|| गोमूत्राध्युषितां दद्यात् सगुडां वा हरीतकीम्| हरीतकीं तक्रयुतां त्रिफलां वा प्रयोजयेत्||६७|| सनागरं चित्रकं वा सीधुयुक्तं प्रयोजयेत्| दापयेच्चव्ययुक्तं वा सीधुं साजाजिचित्रकम्||६८|| सुरां सहपुषापाठां दद्यात् सौवर्चलान्विताम्| दधित्थ बिल्व संयुक्तं युक्तं वा चव्यचित्रकैः||६९|| भल्लातक युतं वाऽपि प्रदद्यात्तक्रतर्पणम्| बिल्व नागर युक्तं वा यवान्या चित्रकेण च||७०|| चित्रकं हपुषां हिङ्गुं दद्याद्वा तक्रसंयुतम्| पञ्चकोल युतं वाऽपि तक्रमस्मै प्रदापयेत्||७१|| saguḍāmabhayāṃ vā’pi prāśayet paurvabhaktikīm||65|| pāyayedvā trivṛccūrṇaṃ triphalārasasaṃyutam| hṛte gudāśraye doṣe gacchantyarśāṃsi saṅkṣayam||66|| gomūtrādhyuṣitāṃ dadyāt saguḍāṃ vā harītakīm| harītakīṃ takrayutāṃ triphalāṃ vā prayojayet||67|| sanāgaraṃ citrakaṃ vā sīdhuyuktaṃ prayojayet| dāpayeccavyayuktaṃ vā sīdhuṃ sājājicitrakam||68|| surāṃ sahapuṣāpāṭhāṃ dadyāt sauvarcalānvitām| dadhittha bilva saṃyuktaṃ yuktaṃ vā cavyacitrakaiḥ||69|| bhallātaka yutaṃ vā’pi pradadyāttakratarpaṇam| bilva nāgara yuktaṃ vā yavānyā citrakeṇa ca||70|| citrakaṃ hapuṣāṃ hiṅguṃ dadyādvā takrasaṃyutam| pañcakola yutaṃ vā’pi takramasmai pradāpayet||71|| saguDAmabhayAM vA~api prAshayet paurvabhaktikIm||65|| pAyayedvA trivRuccUrNaM triphalArasasaMyutam| hRute gudAshraye doShe gacchantyarshAMsi [8] sa~gkShayam||66|| gomUtrAdhyuShitAM dadyAt saguDAM vA harItakIm| harItakIM takrayutAM triphalAM vA prayojayet||67|| sanAgaraM citrakaM vA sIdhuyuktaM prayojayet| dApayeccavyayuktaM vA sIdhuM sAjAjicitrakam||68|| surAM sahapuShApAThAM dadyAt sauvarcalAnvitAm| dadhitthabilvasaMyuktaM yuktaM vA cavyacitrakaiH||69|| bhallAtakayutaM vA~api pradadyAttakratarpaNam| bilvanAgarayuktaM vA yavAnyA citrakeNa ca||70|| citrakaM hapuShAM hi~gguM dadyAdvA takrasaMyutam| pa~jcakolayutaM vA~api takramasmai pradApayet||71||

1. Haritaki churna along with jaggery should be given before meal. 2. Trivrita (operculina terpenthum) powder along with triphala decoction should be given which eliminates accumulated doshas through anal region and get relief from symptoms. 3. Haritaki (Terminalia Chebula) soaked overnight should be given along with jaggery 4. Haritaki (Terminalia Chebula) along with butter-milk 5. Triphala along with butter-milk 6. Chitraka (Plumbago Zylanica) and nagara (Zingiber officinale) along with sidhu (a type of alcoholic drink) 7. Chitraka (Plumbago Zylanica) and chavya (Piper retrofractum) along with sidhu 8. Shatapushpa (Anethum Sowa) and patha (Cissampelos parrira) mixed with sauvarchala (kind of salt) should be given mixed with sura (a type of alcoholic drink). 9. Bilva (Aegle marmelos) churna, dadhitva mixed with sura. 10. Decoction of bilva (Aegle marmelos), nagar (Zingiber officinale), ajvayan (Trachyspermum ammi), and chitraka (Plumbago Zylanica) or bhallataka (Semecarpus anacardium) mixed with tarpana (refreshing drink prepared of roasted corn-flour) 11. Chitraka(Plumbago Zylanica), hapushpa and hingu mixed with Butter-milk 12. Panchakola [(Sunthi (Zingiber officinale)pippali (piper longum), pippali moola, chavya (Piper retrofractum) and chitraka (Plumbago Zylanica)) should be given with butter-milk. [65-71]

Takraarishta: हपुषां कुञ्चिकां धान्यमजाजीं कारवीं शटीम्| पिप्पलीं पिप्पलीमूलं चित्रकं हस्तिपिप्पलीम्||७२|| यवानीं चाजमोदां च चूर्णितं तक्रसंयुतम्| मन्दाम्लकटुकं विद्वान् स्थापयेद्धृतभाजने||७३|| व्यक्ताम्लकटुकं जातं तक्रारिष्टं मुखप्रियम्| प्रपिबेन्मात्रया कालेष्वन्नस्य तृषितस्त्रिषु||७४|| दीपनं रोचनं वर्ण्यं कफवातानुलोमनम्| गुद श्वयथु कण्ड्वर्तिनाशनं बलवर्धनम्||७५|| इति तक्रारिष्टः| hapuṣāṃ kuñcikāṃ dhānyamajājīṃ kāravīṃ śaṭīm| pippalīṃ pippalīmūlaṃ citrakaṃ hastipippalīm||72|| yavānīṃ cājamodāṃ ca cūrṇitaṃ takrasaṃyutam| mandāmlakaṭukaṃ vidvān sthāpayeddhṛtabhājane||73|| vyaktāmlakaṭukaṃ jātaṃ takrāriṣṭaṃ mukhapriyam| prapibenmātrayā kāleṣvannasya tṛṣitastriṣu||74|| dīpanaṃ rocanaṃ varṇyaṃ kaphavātānulomanam| gudaśvayathukaṇḍvartināśanaṃ balavardhanam||75|| iti takrāriṣṭaḥ| hapuShAM ku~jcikAM dhAnyamajAjIM kAravIM shaTIm| pippalIM pippalImUlaM citrakaM hastipippalIm||72|| yavAnIM cAjamodAM ca cUrNitaM takrasaMyutam| mandAmlakaTukaM vidvAn sthApayeddhRutabhAjane||73|| vyaktAmlakaTukaM jAtaM takrAriShTaM mukhapriyam| prapibenmAtrayA kAleShvannasya tRuShitastriShu||74|| dIpanaM rocanaM varNyaM kaphavAtAnulomanam| gudashvayathukaNDvartinAshanaM balavardhanam||75|| iti takrAriShTaH The powder of hapusha, kunchika, dhanyaka (Coriandrum sativum), jeera (Cuminum Cyminum), karavi (Foeniculum Vulgare), kachur, pippali (Piper longum), pippali mula ( root of Piper longum), chitraka (Plumbagoylanica) gajapippali (Scindapsus officinalis Schoott.), yavani (Trachyspermum ammi) and ajamoda (Carum roxburghianum) (in equal quantity) should be taken in a jar which is smeared with ghee, butter-milk. The paste of the ingredients to be kept in the jar will be slightly sour and pungent. When it is well fermented, the sour and pungent tastes become well manifested. This is called takraarishta, which is very delicious in taste. This drink should be taken in apropriate dose during the beginning, middle and end of meals, to overcome thirst. It also stimulates digestion, improves appetite, promotes complexion, helps in downward movement of kapha and vayu, cures swelling, itching and pain in anus and promotes strength. [72-75]

Benefits of curd and butter-milk: त्वचं चित्रक मूलस्य पिष्ट्वा कुम्भं प्रलेपयेत्| तक्रं वा दधि वा तत्र जातमर्शोहरं पिबेत्||७६|| वातश्लेष्मार्शसां तक्रात् परं नास्तीह भेषजम्| तत् प्रयोज्यं यथादोषं सस्नेहं रूक्षमेव वा||७७|| सप्ताहं वा दशाहं वा पक्षं मासमथापि वा| बलकालविशेषज्ञो भिषक् तक्रं प्रयोजयेत्||७८|| अत्यर्थमृदुकायाग्नेस्तक्रमेवावचारयेत्| सायं वा लाजशक्तूनां दद्यात्तक्रावलेहिकाम्||७९|| जीर्णे तक्रे प्रदद्याद्वा तक्रपेयां ससैन्धवाम्| तक्रानुपानं सस्नेहं तक्रौदनमतः परम्||८०|| यूषैर्मांसरसैर्वाऽपि भोजयेत्तक्रसंयुतैः| यूषै रसेन वाऽप्यूर्ध्वं तक्रसिद्धेन भोजयेत्||८१|| कालक्रमज्ञः सहसा न च तक्रं निवर्तयेत्| तक्रप्रयोगो मासान्तः क्रमेणोपरमो हितः||८२|| अपकर्षो यथोत्कर्षो न त्वन्नादपकृष्यते| शक्त्यागमनरक्षार्थं दार्ढ्यार्थमनलस्य च||८३|| बलोपचयवर्णार्थमेष निर्दिश्यते क्रमः| रूक्षमर्धोद्धृतस्नेहं यतश्चानुद्धृतं घृतम्||८४|| तक्रं दोषाग्निबलवित्त्रिविधं तत् प्रयोजयेत्| हतानि न विरोहन्ति तक्रेण गुदजानि तु||८५|| भूमावपि निषिक्तं तद्दहेत्तक्रं तृणोलुपम्| किं पुनर्दीप्तकायाग्नेः शुष्काण्यर्शांसि देहिनः||८६|| स्रोतःसु तक्रशुद्धेषु रसः सम्यगुपैति यः| तेन पुष्टिर्बलं वर्णः प्रहर्षश्चोपजायते||८७|| वातश्लेष्मविकाराणां शतं चापि निवर्तते| नास्ति तक्रात् परं किञ्चिदौषधं कफवातजे||८८|| tvacaṃ citraka mūlasya piṣṭvā kumbhaṃ pralepayet| takraṃ vā dadhi vā tatra jātamarśoharaṃ pibet||76|| vātaśleṣmārśasāṃ takrāt paraṃ nāstīha bheṣajam| tat prayojyaṃ yathādoṣaṃ sasnehaṃ rūkṣameva vā||77|| saptāhaṃ vā daśāhaṃ vā pakṣaṃ māsamathāpi vā| balakālaviśeṣajño bhiṣak takraṃ prayojayet||78|| atyarthamṛdukāyāgnestakramevāvacārayet| sāyaṃ vā lājaśaktūnāṃ dadyāttakrāvalehikām||79|| jīrṇe takre pradadyādvā takrapeyāṃ sasaindhavām| takrānupānaṃ sasnehaṃ takraudanamataḥ param||80|| yūṣairmāṃsarasairvā’pi bhojayettakrasaṃyutaiḥ| yūṣai rasena vā’pyūrdhvaṃ takrasiddhena bhojayet||81|| kālakramajñaḥ sahasā na ca takraṃ nivartayet| takraprayogo māsāntaḥ krameṇoparamo hitaḥ||82|| apakarṣo yathotkarṣo na tvannādapakṛṣyate| śaktyāgamanarakṣārthaṃ dārḍhyārthamanalasya ca||83|| balopacayavarṇārthameṣa nirdiśyate kramaḥ| rūkṣamardhoddhṛtasnehaṃ yataścānuddhṛtaṃ ghṛtam||84|| takraṃ doṣāgnibalavittrividhaṃ tat prayojayet| hatāni na virohanti takreṇa gudajāni tu||85|| bhūmāvapi niṣiktaṃ taddahettakraṃ tṛṇolupam| kiṃ punardīptakāyāgneḥ śuṣkāṇyarśāṃsi dehinaḥ||86|| srotaḥsu takraśuddheṣu rasaḥ samyagupaiti yaḥ| tena puṣṭirbalaṃ varṇaḥ praharṣaścopajāyate||87|| vātaśleṣmavikārāṇāṃ śataṃ cāpi nivartate| nāsti takrāt paraṃ kiñcidauṣadhaṃ kaphavātaje||88|| tvacaM citrakamUlasya piShTvA kumbhaM pralepayet| takraM vA dadhi vA tatra jAtamarshoharaM pibet||76|| vAtashleShmArshasAM takrAt paraM nAstIha bheShajam| tat prayojyaM yathAdoShaM sasnehaM rUkShameva vA||77|| saptAhaM vA dashAhaM vA pakShaM mAsamathApi vA| balakAlavisheShaj~jo bhiShak takraM prayojayet||78|| atyarthamRudukAyAgnestakramevAvacArayet| sAyaM vA lAjashaktUnAM dadyAttakrAvalehikAm||79|| jIrNe takre pradadyAdvA takrapeyAM sasaindhavAm| takrAnupAnaM sasnehaM takraudanamataH param||80|| yUShairmAMsarasairvA~api bhojayettakrasaMyutaiH| yUShai [9] rasena vA~apyUrdhvaM takrasiddhena bhojayet||81|| kAlakramaj~jaH sahasA na ca takraM nivartayet| takraprayogo mAsAntaH krameNoparamo hitaH||82|| apakarSho yathotkarSho na tvannAdapakRuShyate| shaktyAgamanarakShArthaM dArDhyArthamanalasya ca||83|| balopacayavarNArthameSha nirdishyate kramaH| rUkShamardhoddhRutasnehaM yatashcAnuddhRutaM ghRutam||84|| takraM doShAgnibalavittrividhaM tat prayojayet| hatAni na virohanti takreNa gudajAni tu||85|| bhUmAvapi niShiktaM taddahettakraM tRuNolupam| kiM punardIptakAyAgneH shuShkANyarshAMsi dehinaH||86|| srotaHsu takrashuddheShu rasaH samyagupaiti yaH| tena puShTirbalaM varNaH praharShashcopajAyate||87|| vAtashleShmavikArANAM shataM cApi nivartate| nAsti takrAt paraM ki~jcidauShadhaM kaphavAtaje||88||

The paste of the root-bark of Chitraka (Plumbago Zeylanica) should be smeared inside earthen jar and in this jar, curd or butter-milk should be prepared which relieves hemorrhoids. [76] There is no medicine better than butter-milk 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).[77]

The butter-milk should be given for either one week or for ten days or for fifteen days or for a month according to strength of the patient and season. [78]

If the kayagni (digestive power and metabolism) of the patient is very weak, then only butter¬milk should be advised for morning and evening. Otherwise takra avalehik (linctus prepared by adding butter-milk to the flour of fried paddy) should be given in the evening. [79]

If butter¬milk given in the morning then takrapeya, a thin gruel prepared by adding butter-milk along with rock-salt should be given in the evening. Thereafter, Takra audana (rice mixed with butter-milk) added with oil should be given along with butter-milk as Anupan. [80] Vegetable soup or meat soup along with butter-milk should be given and alternatively, vegetable soup and meat soup prepared with butter¬milk can be given as diet. [81] The physician acquainted with the time (kala) and procedure of administration (karma) should not discontinue butter-milk all of a sudden. Butter-milk should be administered up to one month, and thereafter, it should be gradually withdrawn. [82]

Takra should be withdrawn gradually in the same quantity in which it was increased. While reducing butter-milk, the patients total food intake should not be reduced. Adop¬tion of this procedure will promote and maintain his energy, maintain the strength, digestive power and promote the strength, plumpness as well as complexion. Butter-milk is of three types: 1. From which fat is completely removed 2. From which half of the fat is removed 3. From which fat is not at all removed. [83-84]

The physician acquainted with the nature of the dosha involved in the causation of the disease, agni (power of diges¬tion and metabolism) of the patient and his strength should administer any of the above mentioned three types of butter¬milk appropriately.[85] Hemorrhoids once cured by the administration of butter-milk, do not recur. The butter milk burns all the grass sprinkled over the ground, let alone the dry type of hemorrhoids in a patient whose agni (digestive power and meta¬bolism) has been kindled through this therapy.[86] Butter-milk cleanses the channels of circulation as a result of which rasa (end product of the food after digestion) reaches [the tissue elements] appropriately. This produces proper nourishment, strength, complexion and exhilaration, and cures one hundred diseases including those caused by vayu (80) and kapha (20). There is no medicine, better than butter-milk, for the treat¬ment of hemorrhoids caused by vitiation of vayu and kapha. [87-88]

Other Recipes: पिप्पलीं पिप्पलीमूलं चित्रकं हस्तिपिप्पलीम्| शृङ्गवेरमजाजीं च कारवीं धान्यतुम्बुरु||८९|| बिल्वं कर्कटकं पाठां पिष्ट्वा पेयां विपाचयेत्| फलाम्लां यमकैर्भृष्टां तां दद्याद्गुदजापहाम्||९०|| एतैश्चैव खडान् कुर्यादेतैश्च विपचेज्जलम्| एतैश्चैव घृतं साध्यमर्शसां विनिवृत्तये||९१|| pippalīṃ pippalīmūlaṃ citrakaṃ hastipippalīm| śṛṅgaveramajājīṃ ca kāravīṃ dhānyatumburu||89|| bilvaṃ karkaṭakaṃ pāṭhāṃ piṣṭvā peyāṃ vipācayet| phalāmlāṃ yamakairbhṛṣṭāṃ tāṃ dadyādgudajāpahām||90|| etaiścaiva khaḍān kuryādetaiśca vipacejjalam| etaiścaiva ghṛtaṃ sādhyamarśasāṃ vinivṛttaye||91|| pippalIM pippalImUlaM citrakaM hastipippalIm| shRu~ggaveramajAjIM ca kAravIM dhAnyatumburu||89|| bilvaM karkaTakaM pAThAM piShTvA peyAM vipAcayet| phalAmlAM yamakairbhRuShTAM tAM dadyAdgudajApahAm||90|| etaishcaiva khaDAn kuryAdetaishca vipacejjalam| etaishcaiva ghRutaM sAdhyamarshasAM vinivRuttaye||91|| Peya (thin gruel) should be prepared by cooking with pippali (piper longum), pippalimoola (root of piper longum), chitraka (Plumbago Zylanica), gaja pippali(Scindapsus officinalis Schoott.), shringvera (Zingiber officinale), ajqji (Cuminum Cyminum), karavi (Foeniculum vulgare), dhanyak (Coriandrum sativum), tumburu (Coriandrum sativum), bilva (Aegle marmelos), karkataka and patha (Cissampelos parrira). Intake of this peya (thin gruel) by adding sour fruits and sizzled with ghee and oil cures hemorrhoids. [89-90] With the above mentioned ingredients, khada (a type of sour drink) should be prepared and given to the patient. Ghee boiled with the above ingredients is useful in. [91] Thick gruel: शटी पलाश सिद्धां वा पिप्पल्या नागरेण वा| दद्याद्यवागूं तक्राम्लां मरिचैरवचूर्णिताम्||९२|| śaṭī palāśa siddhāṃ vā pippalyā nāgareṇa vā| dadyādyavāgūṃ takrāmlāṃ maricairavacūrṇitām||92|| shaTIpalAshasiddhAM vA pippalyA nAgareNa vA| dadyAdyavAgUM takrAmlAM maricairavacUrNitAm||92|| Thick gruel prepared by pippali (Piper longum) and nagara (Zingiber officinale) made sour by adding buttur-milk and sprinkled with the powder of maricha (Piper nigrum) is useful. [92]

शुष्क मूलक यूषं वा यूषं कौलत्थमेव वा| दधित्थ बिल्व यूषं वा सकुलत्थमकुष्ठकम्||९३|| छागलं वा रसं दद्याद्यूषैरेभिर्विमिश्रितम्| लावादीनां फलाम्लं वा सतक्रं ग्राहिभिर्युतम्||९४|| रक्तशालिर्महाशालिः कलमो लाङ्गलः सितः| शारदः षष्टिकश्चैव स्यादन्नविधिरर्शसाम्||९५|| इत्युक्तो भिन्नशकृतामर्शसां च क्रियाक्रमः|९६| śuṣka mūlaka yūṣaṃ vā yūṣaṃ kaulatthameva vā| dadhittha bilva yūṣaṃ vā sakulatthamakuṣṭhakam||93|| chāgalaṃ vā rasaṃ dadyādyūṣairebhirvimiśritam| lāvādīnāṃ phalāmlaṃ vā satakraṃ grāhibhiryutam||94|| raktaśālirmahāśāliḥ kalamo lāṅgalaḥ sitaḥ| śāradaḥ ṣaṣṭikaścaiva syādannavidhirarśasām||95|| ityukto bhinnaśakṛtāmarśasāṃ ca kriyākramaḥ|96| shuShkamUlakayUShaM vA yUShaM kaulatthameva vA| dadhitthabilvayUShaM vA sakulatthamakuShThakam||93|| chAgalaM vA rasaM [11] dadyAdyUShairebhirvimishritam| lAvAdInAM phalAmlaM vA satakraM grAhibhiryutam||94|| raktashAlirmahAshAliH kalamo lA~ggalaH sitaH| shAradaH ShaShTikashcaiva syAdannavidhirarshasAm||95|| ityukto bhinnashakRutAmarshasAM ca kriyAkramaH|96| Vegetable soup prepared from dried radish or kulattha (Dolichous biflorus) or combination of kapittha (Limonia acidissima), bilva (Aegle marmelons), Kulattha (Dolichous biflorus) and makushtka (Vigna aconitifolia) is useful for hemorrhoids. These soups can be added with the soup of goat-meat. The soup of the meat of lava, etc. added with the juice of sour fruit, butter-milk should be given to such a patient. [93-94]

Rakta shali, mahashali, kalama, langala, sita, sharad and jshasthik types of rice can be given as food to the patient suffe¬ring from hemorrhoids. Thus, the therapeutic measures for the patients of hemorrhoids having loose motions are described. [95-96]

Treatment of hemorrhoids with constipated bowels: येऽत्यर्थं गाढशकृतस्तेषां वक्ष्यामि भेषजम्||९६|| सस्नेहैः शक्तुभिर्युक्तां प्रसन्नां लवणी कृताम्| दद्यान्मत्स्यण्डिकां पूर्वं भक्षयित्वा सनागराम्||९७|| गुडं सनागरं पाठां फलाम्लं पाययेच्च तम्| गुडं घृत यव क्षार युक्तं वाऽपि प्रयोजयेत्||९८|| यवानीं नागरं पाठां दाडिमस्य रसं गुडम्| सतक्र लवणं दद्याद्वातवर्चोऽनुलोमनम्||९९|| दुःस्पर्शकेन बिल्वेन यवान्या नागरेण वा| एकैकेनापि संयुक्ता पाठा हन्त्यर्शसां रुजम्||१००|| प्राग्भक्तं यमके भृष्टान् सक्तुभिश्चावचूर्णितान्| करञ्ज पल्लवान् दद्याद्वातर्चोऽनुलोमनान्||१०१|| मदिरां वा सलवणां सीधुं सौवीरकं तथा| गुड नागरसंयुक्तं पिबेद्वा पौर्वभक्तिकम्||१०२|| ye’tyarthaṃ gāḍhaśakṛtasteṣāṃ vakṣyāmi bheṣajam||96|| sasnehaiḥ śaktubhiryuktāṃ prasannāṃ lavaṇī kṛtām| dadyānmatsyaṇḍikāṃ pūrvaṃ bhakṣayitvā sanāgarām||97|| guḍaṃ sanāgaraṃ pāṭhāṃ phalāmlaṃ pāyayecca tam| guḍaṃ ghṛta yava kṣāra yuktaṃ vā’pi prayojayet||98|| yavānīṃ nāgaraṃ pāṭhāṃ dāḍimasya rasaṃ guḍam| satakra lavaṇaṃ dadyādvātavarco’nulomanam||99|| duḥsparśakena bilvena yavānyā nāgareṇa vā| ekaikenāpi saṃyuktā pāṭhā hantyarśasāṃ rujam||100|| prāgbhaktaṃ yamake bhṛṣṭān saktubhiścāvacūrṇitān| karañja pallavān dadyādvātarco’nulomanān||101|| madirāṃ vā salavaṇāṃ sīdhuṃ sauvīrakaṃ tathā| guḍa nāgarasaṃyuktaṃ pibedvā paurvabhaktikam||102|| ye~atyarthaM gADhashakRutasteShAM vakShyAmi bheShajam||96|| sasnehaiH shaktubhiryuktAM prasannAM lavaNIkRutAm| dadyAnmatsyaNDikAM pUrvaM bhakShayitvA sanAgarAm||97|| guDaM sanAgaraM pAThAM phalAmlaM pAyayecca tam| guDaM ghRutayavakShArayuktaM vA~api prayojayet||98|| yavAnIM nAgaraM pAThAM dADimasya rasaM guDam| satakralavaNaM dadyAdvAtavarco~anulomanam||99|| duHsparshakena bilvena yavAnyA nAgareNa vA| ekaikenApi saMyuktA pAThA hantyarshasAM rujam||100|| prAgbhaktaM [12] yamake bhRuShTAn saktubhishcAvacUrNitAn| kara~jjapallavAn dadyAdvAtarco~anulomanAn||101|| madirAM vA salavaNAM sIdhuM sauvIrakaM tathA| guDanAgarasaMyuktaM [13] pibedvA paurvabhaktikam||102|| Now, recipes for the treatment of patients suffering from hemorrhoids and having excessive constipation are as follows: 1. The patient should be given matsyandika (a preparation of sugar-cane juice) along with sunthi (Zingiber officinlis) and then prasanna (a type of alcoholic drink) mixed with saktu (roasted corn-flour) and salt.[97] 2. Drink of jaggery along with nagara/ dry ginger (Zingiber officinlis), patha (Cesalpinia pareira) and juice of sour fruit and jaggery mixed with ghee and yava ksara (alkali preparation of barley) should be given. [98] 3. Ajvayan (Apium graveolens), nagara (Zingiber officinlis), patha (Cesalpinia pareira), pomegranate juice and jaggery along with butter-milk and salt should be used which helps in the downward movement of flatus and stool. [99] 4. Paatha (Cesalpinia pareira), along with either duralabha (Fegonia critica) or bilva (Aegle marmelons) or yavani (Trachyspermum ammi) or nagara (Zingiber officinlis), cures pain in the hemorrhoids. [100] 5. Leaves of karanja (Pongamia pinata) fried with ghee and oil, and sprinkled with the powder of saktu (roasted corn¬ flour) should be given before food which helps in the downward movement of flatus and stool.[101] 6. Madira (a type of alcohol) along with salt should be taken before food; and along with sidhu (a type of alcohol) or sauvira ( a type of vinegar ) along with jaggery and nagara ( dry ginger). [102]

Pippalyadi ghrita: पिप्पली नागर क्षार कारवी धान्य जीरकैः| फाणितेन च संयोज्य फलाम्लं दापयेद्घृतम्||१०३|| pippalī nāgara kṣāra kāravī dhānya jīrakaiḥ| phāṇitena ca saṃyojya phalāmlaṃ dāpayedghṛtam||103|| pippalInAgarakShArakAravIdhAnyajIrakaiH| phANitena ca saMyojya phalAmlaM dApayedghRutam||103|| Phanita (penidium) prepared with and juice of sour fruits and ghee added with pippali (Piper longum), nagara (Zingiber officinalis), kshara, karavi, dhanya (Coriandrum sativum), jiraka (Cuminum cyminum) should be given in cases of hemorrhoids. [103] पिप्पली पिप्पलीमूलं चित्रको हस्तिपिप्पली| शृङ्गवेरयवक्षारौ तैः सिद्धं वा पिबेद्घृतम्||१०४|| pippalī pippalīmūlaṃ citrako hastipippalī| śṛṅgaverayavakṣārau taiḥ siddhaṃ vā pibedghṛtam||104|| pippalI pippalImUlaM citrako hastipippalI| shRu~ggaverayavakShArau taiH siddhaM vA pibedghRutam||104|| Ghee cooked with pippali (Piper longum), pippalimoola, chitraka (Plumbego zylanicum), gajapippali, shringavera, yavakshara should be given in hemorrhoids. [104]

Recipes of medicated ghee: चव्य चित्रक सिद्धं वा गुड क्षार समन्वितम्| पिप्पलीमूल सिद्धं वा सगुडक्षार नागरम् ||१०५|| cavya citraka siddhaṃ vā guḍa kṣāra samanvitam| pippalīmūla siddhaṃ vā saguḍakṣāra nāgaram ||105|| cavyacitrakasiddhaM vA guDakShArasamanvitam| pippalImUlasiddhaM vA saguDakShAranAgaram [14] ||105|| Ghee cooked with the paste of chavya (Piper retrofractum) and chitraka (Plumbego zeylanicum) and added with jaggery, kshara and nagara (Zingiber officinalis) should be given in hemorrhoids. Ghee cooked with the paste of pippali moola and added with jaggery, kshara (alkali) and nagara (Zingiber officinalis) should be given in hemorrhoids. [105]

Pippalyadi ghrita: पिप्पली पिप्पलीमूल दधि दाडिम धान्यकैः | सिद्धं सर्पि र्विधातव्यं वात वर्चो विबन्धनुत्||१०६|| pippalī pippalīmūla dadhi dāḍima dhānyakaiḥ | siddhaṃ sarpi rvidhātavyaṃ vāta varco vibandhanut||106| pippalIpippalImUladadhidADimadhAnyakaiH [15] | siddhaM sarpirvidhAtavyaM vAtavarcovibandhanut||106|| Ghee cooked with the paste of pippali (Piper longum), pippalimoola and dhanyaka (Coriandrum sativum) and curd should be given to patient of hemorrhoids. It helps in the movement of flatus and stool. [106]

Chavyadi ghrita: चव्यं त्रिकटुकं पाठां क्षारं कुस्तुम्बुरूणि च| यवानीं पिप्पलीमूलमुभे च विडसैन्धवे||१०७|| चित्रकं बिल्वमभयां पिष्ट्वा सर्पिर्विपाचयेत्| शकृद्वातानुलोम्यार्थं जाते दध्नि चतुर्गुणे||१०८|| प्रवाहिकां गुदभ्रंशं मूत्रकृच्छ्रं परिस्रवम्| गुदवङ्क्षणशूलं च घृतमेतद्व्यपोहति||१०९|| cavyaṃ trikaṭukaṃ pāṭhāṃ kṣāraṃ kustumburūṇi ca| yavānīṃ pippalīmūlamubhe ca viḍasaindhave||107|| citrakaṃ bilvamabhayāṃ piṣṭvā sarpirvipācayet| śakṛdvātānulomyārthaṃ jāte dadhni caturguṇe||108|| pravāhikāṃ gudabhraṃśaṃ mūtrakṛcchraṃ parisravam| gudavaṅkṣaṇaśūlaṃ ca ghṛtametadvyapohati||109|| cavyaM trikaTukaM pAThAM kShAraM kustumburUNi ca| yavAnIM pippalImUlamubhe ca viDasaindhave||107|| citrakaM bilvamabhayAM piShTvA sarpirvipAcayet| shakRudvAtAnulomyArthaM jAte dadhni caturguNe||108|| pravAhikAM gudabhraMshaM mUtrakRucchraM parisravam| gudava~gkShaNashUlaM ca ghRutametadvyapohati||109|| Ghee should be cooked with the paste of chavya (Piper retrofractum), trikatu, patha (Cesalpinia pareira), kshara, kustumbaru (dhanyaka (Coriandrum sativum)), yavani, pippali moola, vida, saindhava (rock-salt). chitraka (Plumbego zeylanicum), bilva (Aegle marmelons) and abhaya (Terminalia chebula). To this, well fermented curd (four times the quantity of ghee) should be added while cooking. It helps in the downward movement of stool and flatus, and also cures pravahika (amoebic dysentery), prolapsed of rectum, dysuria, and pain in perianal and pelvic region. [107-109] Nagaradi ghirta: नागरं पिप्पलीमूलं चित्रको हस्तिपिप्पली| श्वदंष्ट्रा पिप्पली धान्यं बिल्वं पाठा यवानिका||११०|| चाङ्गेरीस्वरसे सर्पिः कल्कैरेतैर्विपाचयेत्| चतुर्गुणेन दध्ना च तद्घृतं कफवातनुत्||१११|| अर्शांसि ग्रहणीदोषं मूत्रकृच्छ्रं प्रवाहिकाम्| गुदभ्रंशार्तिमानाहं घृतमेतद्व्यपोहति||११२|| nāgaraṃ pippalīmūlaṃ citrako hastipippalī| śvadaṃṣṭrā pippalī dhānyaṃ bilvaṃ pāṭhā yavānikā||110|| cāṅgerīsvarase sarpiḥ kalkairetairvipācayet| caturguṇena dadhnā ca tadghṛtaṃ kaphavātanut||111|| arśāṃsi grahaṇīdoṣaṃ mūtrakṛcchraṃ pravāhikām| gudabhraṃśārtimānāhaṃ ghṛtametadvyapohati||112|| nAgaraM pippalImUlaM citrako hastipippalI| shvadaMShTrA pippalI dhAnyaM bilvaM pAThA yavAnikA||110|| cA~ggerIsvarase sarpiH kalkairetairvipAcayet| caturguNena dadhnA ca tadghRutaM kaphavAtanut||111|| arshAMsi grahaNIdoShaM mUtrakRucchraM pravAhikAm| gudabhraMshArtimAnAhaM ghRutametadvyapohati||112||

Ghee should be cooked with the paste of nagara (Zingiber officinalis), pippali moola, chitraka (Plumbego zeylanicum), gaja pippali, shvadanshtra, pippali (Piper longum), dhanyak (Coriandrum sativum), bilva (Aegle marmelons), patha (Cissampelos Pareira) and yavani (Trechyspermum ammi), juice of changeri (Oxalis corniculata) (four times the quantity of ghee) and curd (four times the quantity of ghee). This medicated ghee alleviates kapha and vayu and cures hemorrhoids, grahani, dysuria, pravahika (amoebaisis), prolapse of rectum, pain in the anal region and flatulence. [110-112]

Pippalyadi ghrita: पिप्पलीं नागरं पाठां श्वदंष्ट्रां च पृथक् पृथक्| भागांस्त्रिपलिकान् कृत्वा कषायमुपकल्पयेत्||११३|| गण्डीरं पिप्पलीमूलं व्योषं चव्यं च चित्रकम्| पिष्ट्वा कषाये विनयेत् पूते द्विपलिकं भिषक्||११४|| पलानि सर्पिषस्तस्मिंश्चत्वारिंशत् प्रदापयेत्| चाङ्गेरीस्वरसं तुल्यं सर्पिषा दधि षड्गुणम्||११५|| मृद्वग्निना ततः साध्यं सिद्धं सर्पिर्निधापयेत्| तदाहारे विधातव्यं पाने प्रायोगिके विधौ||११६|| ग्रहण्यर्शोविकारघ्नं गुल्महृद्रोगनाशनम्| शोथप्लीहोदरानाहमूत्रकृच्छ्रज्वरापहम्||११७|| कासहिक्कारुचिश्वाससूदनं पार्श्वशूलनुत्| बलपुष्टिकरं वर्ण्यमग्निसन्दीपनं परम्||११८|| pippalīṃ nāgaraṃ pāṭhāṃ śvadaṃṣṭrāṃ ca pṛthak pṛthak| bhāgāṃstripalikān kṛtvā kaṣāyamupakalpayet||113|| gaṇḍīraṃ pippalīmūlaṃ vyoṣaṃ cavyaṃ ca citrakam| piṣṭvā kaṣāye vinayet pūte dvipalikaṃ bhiṣak||114|| palāni sarpiṣastasmiṃścatvāriṃśat pradāpayet| cāṅgerīsvarasaṃ tulyaṃ sarpiṣā dadhi ṣaḍguṇam||115|| mṛdvagninā tataḥ sādhyaṃ siddhaṃ sarpirnidhāpayet| tadāhāre vidhātavyaṃ pāne prāyogike vidhau||116|| grahaṇyarśovikāraghnaṃ gulmahṛdroganāśanam| śothaplīhodarānāhamūtrakṛcchrajvarāpaham||117|| kāsahikkāruciśvāsasūdanaṃ pārśvaśūlanut| balapuṣṭikaraṃ varṇyamagnisandīpanaṃ param||118|| pippalIM nAgaraM pAThAM shvadaMShTrAM ca pRuthak pRuthak| bhAgAMstripalikAn kRutvA kaShAyamupakalpayet||113|| gaNDIraM pippalImUlaM vyoShaM cavyaM ca citrakam| piShTvA kaShAye vinayet pUte [16] dvipalikaM bhiShak||114|| palAni sarpiShastasmiMshcatvAriMshat pradApayet| cA~ggerIsvarasaM tulyaM sarpiShA dadhi ShaDguNam||115|| mRudvagninA tataH sAdhyaM siddhaM sarpirnidhApayet| tadAhAre vidhAtavyaM pAne prAyogike vidhau||116|| grahaNyarshovikAraghnaM gulmahRudroganAshanam| shothaplIhodarAnAhamUtrakRucchrajvarApaham||117|| kAsahikkArucishvAsasUdanaM pArshvashUlanut| balapuShTikaraM varNyamagnisandIpanaM param||118|| Decoction should be prepared with pippali (Piper longum), nagara (Zingiber officinalis), patha (Cissampelos Pareira), gokshur (Tribulus terrestris) and taken three palas of each add 160 palas of water and reduced to one fourth, i.e. 40 palas. In this decoction, the paste of gandira, pippalimoola; vyosha [sunthi (Zingiber officinalis), pippali (Piper longum) and maricha (Piper nigrum)], chavya (Piper retrofractum) and chitraka (Plumbego zylanicum), taken two palas of each, should be added. To this, 40 palas of ghee, 40 palas of the juice of changeri (Oxalis corniculata) and 240 palas of curd should be added and cooked over mild fire. This medicated ghee should be kept in a clean jar and used in food and as a drink regu-larly. It cures grahani (digestive system disorders), hemorrhoids, gulma (tumour), heart diseases, oedema, splenic disorders, flatulence, dysuria, febrile condition, cough, hiccup, anorexia, breathlessness and pain in the sides of the chest. It is an excellent promoter of strength, plumpness of the body, complexion and digestive and metabolic power. [113-118]

Administration of haritaki: सगुडां पिप्पली युक्तां घृतभृष्टां हरीतकीम्| त्रिवृद्दन्तीयुतां वाऽपि भक्षयेदानुलोमिकीम्||११९|| विड्वात कफ पित्तानामानुलोम्येऽथ निर्वृते| गुदेऽर्शांसि प्रशाम्यन्ति पावकश्चाभिवर्धते||१२०|| saguḍāṃ pippalī yuktāṃ ghṛtabhṛṣṭāṃ harītakīm| trivṛddantīyutāṃ vā’pi bhakṣayedānulomikīm||119|| viḍvāta kapha pittānāmānulomye’tha nirvṛte| gude’rśāṃsi praśāmyanti pāvakaścābhivardhate||120|| saguDAM pippalIyuktAM ghRutabhRuShTAM harItakIm| trivRuddantIyutAM vA~api bhakShayedAnulomikIm||119|| viDvAtakaphapittAnAmAnulomye~atha [17] nirvRute| gude~arshAMsi prashAmyanti pAvakashcAbhivardhate||120|| Haritaki (Terminalia chebula) fried in ghee along with either jaggery and pippali (Piper longum), or trivrita (Operculina terpenthum) and danti (Beliospermum montenum) should be given for the downward movement of vaju. Due to downward movement of stool, flatus, kapha and pitta and by their elimination, hemorrhoids are cured and improve the digestive power. [119-120]

Meat soup: बर्हि तित्तिरि लावानां रसानम्लान् सुसंस्कृतान्| दक्षाणां वर्तकानां च दद्याद्विड्वातसङ्ग्रहे||१२१|| barhi tittiri lāvānāṃ rasānamlān susaṃskṛtān| dakṣāṇāṃ vartakānāṃ ca dadyādviḍvātasaṅgrahe||121|| barhitittirilAvAnAM rasAnamlAn susaMskRutAn| dakShANAM vartakAnAM ca dadyAdviDvAtasa~ggrahe||121|| The meat-soup of peacock, partridge, grey quail, cock and bustard quail which is sour and well sizzled relieves obstruction of stool and flatus. [121] Leafy vegetables: त्रिवृद्दन्तीपलाशानां चाङ्गेर्याश्चित्रकस्य च| यमके भर्जितं दद्याच्छाकं दधि समन्वितम्||१२२|| उपोदिकां तण्डुलीयं वीरां वास्तुक पल्लवान्| सुवर्चलां सलोणीकां यव शाकमवल्गुजम्||१२३|| काकमाचीं रुहापत्रं महापत्रं तथाऽम्लिकाम्| जीवन्तीं शटिशाकं च शाकं गृञ्जनकस्य च||१२४|| दधि दाडिम सिद्धानि यमके भर्जितानि च| धान्य नागर युक्तानि शाकान्येतानि दापयेत्||१२५|| trivṛddantīpalāśānāṃ cāṅgeryāścitrakasya ca| yamake bharjitaṃ dadyācchākaṃ dadhi samanvitam||122|| upodikāṃ taṇḍulīyaṃ vīrāṃ vāstuka pallavān| suvarcalāṃ saloṇīkāṃ yava śākamavalgujam||123|| kākamācīṃ ruhāpatraṃ mahāpatraṃ tathā’mlikām| jīvantīṃ śaṭiśākaṃ ca śākaṃ gṛñjanakasya ca||124|| dadhi dāḍima siddhāni yamake bharjitāni ca| dhānya nāgara yuktāni śākānyetāni dāpayet||125|| trivRuddantIpalAshAnAM cA~ggeryAshcitrakasya ca| yamake bharjitaM dadyAcchAkaM dadhisamanvitam||122|| upodikAM taNDulIyaM vIrAM vAstukapallavAn| suvarcalAM saloNIkAM yavashAkamavalgujam||123|| kAkamAcIM ruhApatraM mahApatraM tathA~amlikAm| jIvantIM shaTishAkaM ca shAkaM gRu~jjanakasya ca||124|| dadhidADimasiddhAni yamake bharjitAni ca| dhAnyanAgarayuktAni shAkAnyetAni dApayet||125||

The leaves of trivrit (Operculina terpentum), danti (Beliospermum montenum), palash (Butea monosperma), changari (Oxalis corniculata) and chitraka (plumbego Zylanicum) should be fried with ghee and oil. This should be given along with curd to the patient of hemorrhoids. The leaves of upodika, tanduliya, vira, vastuka, suvarchala (one kind of salt) yava, avalguja, kakamachi (Solanum nigrum), ruhupatra, mahapatra, amlika, jivanti (Leptadenia reticulata), shati (Hedychium spicatium) and gunjanaka (Abrus pricatorius) should be cooked with curd and fried with ghee as well as oil. This should be given to the patient suffering from hemorrhoids mixed with dhaniya (Coriandrum sativum) and nagara (Zingiber officinalis). [122-125]

Use of meat: गोधालोपाक मार्जार श्वाविदुष्ट्रगवामपि| कूर्म शल्लकयोश्चैव साधयेच्छाकवद्रसान्||१२६|| रक्त शाल्योदनं दद्याद्रसैस्तैर्वात शान्तये|१२७| godhālopāka mārjāra śvāviduṣṭragavāmapi| kūrma śallakayoścaiva sādhayecchākavadrasān||126|| rakta śālyodanaṃ dadyādrasaistairvāta śāntaye|127| godhAlopAkamArjArashvAviduShTragavAmapi| kUrmashallakayoshcaiva sAdhayecchAkavadrasAn||126|| raktashAlyodanaM dadyAdrasaistairvAtashAntaye| The meat-soup of godha, lopaka, mnrjara, svavidu, ushtra, cow, kurma and sallaka should be prepared on the line suggested above for leafy vegetables. Along with this meat soup, red variety of sali rice should be given in patients of mandagni and vata predominant hemorrhoids. [126-127]

Anupana: ज्ञात्वा वातोल्बणं रूक्षं मन्दाग्निं गुदजातुरम्||१२७|| मदिरां शार्करं जातं सीधुं तक्रं तुषोदकम्| अरिष्टं दधिमण्डं वा शृतं वा शिशिरं जलम्||१२८|| कण्टकार्या शृतं वाऽपि शृतं नागरधान्यकैः| अनुपानं भिषग्दद्याद्वातवर्चोऽनुलोमनम्||१२९|| jñātvā vātolbaṇaṃ rūkṣaṃ mandāgniṃ gudajāturam||127|| madirāṃ śārkaraṃ jātaṃ sīdhuṃ takraṃ tuṣodakam| ariṣṭaṃ dadhimaṇḍaṃ vā śṛtaṃ vā śiśiraṃ jalam||128|| kaṇṭakāryā śṛtaṃ vā’pi śṛtaṃ nāgaradhānyakaiḥ| anupānaṃ bhiṣagdadyādvātavarco’nulomanam||129|| j~jAtvA vAtolbaNaM rUkShaM mandAgniM gudajAturam||127|| madirAM shArkaraM jAtaM sIdhuM takraM tuShodakam| ariShTaM dadhimaNDaM vA shRutaM vA shishiraM jalam||128|| kaNTakAryA shRutaM vA~api shRutaM nAgaradhAnyakaiH| anupAnaM bhiShagdadyAdvAtavarco~anulomanam||129|| Madira (wine), butter-milk, tushodaka (a type of vinegar prepared of barley ), arishta ( recipes to be described in verses 138-168 ) should be given to the patient having hemorrhoids caused by the predominance of aggravated vayu, having ununctuousness and having less digestive power. Whey, boiled, and cooled water, decoction of kantakari (Solanum xanthocarpum) or decoction of nagara (Zingiber officinalis) and dhanyaka (Coriandrum sativum) as anupana (post-prandial drink) for the downward movement of flatus and stool. [127-129]

Anuvasana basti: उदावर्त परीता ये ये चात्यर्थं विरूक्षिताः| विलोमवाताः शूलार्तास्तेष्विष्टमनुवासनम्||१३०|| udāvarta parītā ye ye cātyarthaṃ virūkṣitāḥ| vilomavātāḥ śūlārtāsteṣviṣṭamanuvāsanam||130|| udAvartaparItA ye ye cAtyarthaM virUkShitAH| vilomavAtAH shUlArtAsteShviShTamanuvAsanam||130||

Anuvasana type of enema should be administered to the patient suffering from udavarta (upward movement of wind in the abdomen), who is extremely devoid of unctuousness, whose wind moves in the opposite direction and having colic pain. [130]

Anuvasana basti with pippayadi taila: पिप्पलीं मदनं बिल्वं शताह्वां मधुकं वचाम्| कुष्ठं शटीं पुष्कराख्यं चित्रकं देवदारु च||१३१|| पिष्ट्वा तैलं विपक्तव्यं पयसा द्विगुणेन च| अर्शसां मूढवातानां तच्छ्रेष्ठमनुवासनम्||१३२|| गुदनिःसरणं शूलं मूत्रकृच्छ्रं प्रवाहिकाम्| कट्यूरुपृष्ठदौर्बल्यमानाहं वङ्क्षणाश्रयम्||१३३|| पिच्छास्रावं गुदे शोफं वातवर्चोविनिग्रहम्| उत्थानं बहुशो यच्च जयेत्तच्चानुवासनात्||१३४|| pippalīṁ madanaṁ bilvaṁ śatāhvāṁ madhukaṁ vacām| kuṣṭhaṁ śaṭīṁ puṣkarākhyaṁ citrakaṁ dēvadāru ca||131|| piṣṭvā tailaṁ vipaktavyaṁ payasā [18] dviguṇēna ca| arśasāṁ mūḍhavātānāṁ tacchrēṣṭhamanuvāsanam||132|| gudaniḥsaraṇaṁ śūlaṁ mūtrakr̥cchraṁ pravāhikām| kaṭyūrupr̥ṣṭhadaurbalyamānāhaṁ vaṅkṣaṇāśrayam||133|| picchāsrāvaṁ gudē śōphaṁ vātavarcōvinigraham| utthānaṁ bahuśō yacca jayēttaccānuvāsanāt||134||

pippalIM madanaM bilvaM shatAhvAM madhukaM vacAm| kuShThaM shaTIM puShkarAkhyaM citrakaM devadAru ca||131|| piShTvA tailaM vipaktavyaM payasA [18] dviguNena ca| arshasAM mUDhavAtAnAM tacchreShThamanuvAsanam||132|| gudaniHsaraNaM shUlaM mUtrakRucchraM pravAhikAm| kaTyUrupRuShThadaurbalyamAnAhaM va~gkShaNAshrayam||133|| picchAsrAvaM gude shophaM vAtavarcovinigraham| utthAnaM bahusho yacca jayettaccAnuvAsanAt||134||

The ingredients like pippali (Piper longum), madan (Randia spinosa), bilva (Aegle marmelons), shatavha, madhuka, kushtha (Saussurea lappa) shati (Hadychium spicatium), pushkarmoola (Inula racemosa), chitrak (Plumbego zylanicum), devadaru (Cedrus deodara) made in paste, added sesame oil 4 times to kalka then added milk 2 times more the oil and prepare the medicated oil as per standard procedures. This oil should be used in patients having obstruction of flatus for anuvasan basti. Rectal prolapse, pain in ano, dysurea, amoebaisis, weakness in back, thigh, flatulence, mucous discharge through rectum, peri-anal inflammation, obstruction in flatus, and feces and increased frequency of defecation or unsatisfactory defecation in all above disorders or symptoms should be treated with anuvasan basti with above ingredients should be given. [131-134]

Topical application of paste: आनुवासनिकैः पिष्टैः सुखोष्णैः स्नेहसंयुतैः| दार्वन्तैः स्तब्ध शूलानि गुदजानि प्रलेपयेत्||१३५|| दिग्धास्तैः प्रस्रवन्त्याशु श्लेष्म पिच्छां सशोणिताम्| कण्डूः स्तम्भः सरुक् शोफः स्रुतानां विनिवर्तते||१३६|| ānuvāsanikaiḥ piṣṭaiḥ sukhoṣṇaiḥ snehasaṃyutaiḥ| dārvantaiḥ stabdha śūlāni gudajāni pralepayet||135|| digdhāstaiḥ prasravantyāśu śleṣma picchāṃ saśoṇitām| kaṇḍūḥ stambhaḥ saruk śophaḥ srutānāṃ vinivartate||136|| AnuvAsanikaiH piShTaiH sukhoShNaiH snehasaMyutaiH| dArvantaiH [19] stabdhashUlAni gudajAni pralepayet||135|| digdhAstaiH prasravantyAshu shleShmapicchAM sashoNitAm| kaNDUH stambhaH saruk shophaH srutAnAM vinivartate||136||

The 11 ingredients ending with devadaru (in verse 131) should be mixed with oil and ghee and applied in the dry and painful type of hemorrhoids after application of medicament the hemorrhoids discharge the mucous and blood and relieve pain, itching and swelling of dry hemorrhoids. [135-36] Niruha basti in dry hemorrhoids: निरूहं वा प्रयुञ्जीत सक्षीरं दाशमूलिकम्| समूत्र स्नेह लवणं कल्कैर्युक्तं फलादिभिः||१३७|| nirūhaṃ vā prayuñjīta sakṣīraṃ dāśamūlikam| samūtra sneha lavaṇaṃ kalkairyuktaṃ phalādibhiḥ||137|| nirUhaM vA prayu~jjIta sakShIraM dAshamUlikam| samUtrasnehalavaNaM kalkairyuktaM phalAdibhiH||137||

The ingredients used in niruha enema are milk, decoction of dashamoola, , cow's urine, sneha, salt and the paste of madanaphala (Randia spinosa), etc.[137]

Abhayarishta: हरीतकीनां प्रस्थार्धं प्रस्थमामलकस्य च| स्यात् कपित्थाद्दशपलं ततोऽर्धा चेन्द्रवारुणी||१३८|| विडङ्गं पिप्पली लोध्रं मरिचं सैलवालुकम्| द्विपलांशं जलस्यैतच्चतुर्द्रोणे विपाचयेत्||१३९|| द्रोणशेषे रसे तस्मिन् पूते शीते समावपेत्| गुडस्य द्विशतं तिष्ठेत्तत् पक्षं घृतभाजने||१४०|| पक्षादूर्ध्वं भवेत् पेया ततो मात्रा यथाबलम्| अस्याभ्यासादरिष्टस्य गुदजा यान्ति सङ्क्षयम्||१४१|| ग्रहणी पाण्डु हृद्रोग प्लीह गुल्मोदरापहः| कुष्ठ शोफारुचिहरो बलवर्णाग्निवर्धनः||१४२|| सिद्धोऽयमभयारिष्टः कामलाश्वित्रनाशनः| कृमिग्रन्थ्यर्बुद व्यङ्ग राजयक्ष्म ज्वरान्तकृत्||१४३|| इत्यभयारिष्टः| harītakīnāṁ prasthārdhaṁ prasthamāmalakasya ca| syāt kapitthāddaśapalaṁ tatō'rdhā cēndravāruṇī||138|| viḍaṅgaṁ pippalī lōdhraṁ maricaṁ sailavālukam| dvipalāṁśaṁ jalasyaitaccaturdrōṇē vipācayēt||139|| drōṇaśēṣē rasē tasmin pūtē śītē samāvapēt| guḍasya dviśataṁ tiṣṭhēttat pakṣaṁ ghr̥tabhājanē||140|| pakṣādūrdhvaṁ bhavēt pēyā tatō mātrā yathābalam| asyābhyāsādariṣṭasya gudajā yānti saṅkṣayam||141|| grahaṇīpāṇḍuhr̥drōgaplīhagulmōdarāpahaḥ| kuṣṭhaśōphāruciharō balavarṇāgnivardhanaḥ||142|| siddhō'yamabhayāriṣṭaḥ kāmalāśvitranāśanaḥ| kr̥migranthyarbudavyaṅgarājayakṣmajvarāntakr̥t||143|| ityabhayāriṣṭaḥ

harItakInAM prasthArdhaM prasthamAmalakasya ca| syAt kapitthAddashapalaM tato~ardhA cendravAruNI||138|| viDa~ggaM pippalI lodhraM maricaM sailavAlukam| dvipalAMshaM jalasyaitaccaturdroNe vipAcayet||139|| droNasheShe rase tasmin pUte shIte samAvapet| guDasya dvishataM tiShThettat pakShaM ghRutabhAjane||140|| pakShAdUrdhvaM bhavet peyA tato mAtrA yathAbalam| asyAbhyAsAdariShTasya gudajA yAnti sa~gkShayam||141|| grahaNIpANDuhRudrogaplIhagulmodarApahaH| kuShThashophAruciharo balavarNAgnivardhanaH||142|| siddho~ayamabhayAriShTaH kAmalAshvitranAshanaH| kRumigranthyarbudavya~ggarAjayakShmajvarAntakRut||143|| ityabhayAriShTaH

Haritaki (Terminalia chebula) (1 prastha), amalaki (Embilica officinalis) (one prastha), kapittha (10 pala), indrayan (5 pala) vidanga (Embilia ribes) (two pala), pippali (Piper longum) (two pala), lodhra (Symplocus racemosa) (two pala), maricha (Piper nigrum) (two pala) and elavaluka (two pala) should be added with eight dronas of water and boiled till two dronas remained. The decoction should be filtered and allowed to cool. To this, two hundreds palas of jaggery should be added and kept in a ghee-smeared jar for a fort-night.

Thereafter, it becomes suitable for adminis¬tration as a drink. It should be given in an apropriate dose depending upon the strength of the patient. By the regular intake of this arista, hemorrhoids get cured. This effective recipe is called abhayarishta. It cures grahani, pandu (anemia), heart diseases, spleen disorders, gulma (abdominal lumps ), udara (obstinate abdominal diseases including ascites), kushtha (obstinate skin diseases including leprosy), edema, anorexia, jaundice, leucoderma, krimi (worm infestation with intestinal parasites), granthi (benign swellings), arbuda (tumours), vyanga (freckles), tuberculosis and fever. It promotes strength, complexion and digestive power. [138-143]

Dantyarishta: दन्ती चित्रक मूलानामुभयोः पञ्चमूलयोः| भागान् पलांशानापोथ्य जलद्रोणे विपाचयेत्||१४४|| त्रिपलं त्रिफलायाश्च दलानां तत्र दापयेत्| रसे चतुर्थ शेषे तु पूते शीते समावपेत्||१४५|| तुलां गुडस्य तत्तिष्ठेन्मासार्धं घृतभाजने| तन्मात्रया पिबन्नित्यमर्शोभ्यो विप्रमुच्यते||१४६|| ग्रहणी पाण्डु रोगघ्नं वातवर्चोऽनुलोमनम्| दीपनं चारुचिघ्नं च दन्त्यरिष्टमिमं विदुः||१४७|| इति दन्त्यरिष्टः| dantī citraka mūlānāmubhayoḥ pañcamūlayoḥ| bhāgān palāṃśānāpothya jaladroṇe vipācayet||144|| tripalaṃ triphalāyāśca dalānāṃ tatra dāpayet| rase caturtha śeṣe tu pūte śīte samāvapet||145|| tulāṃ guḍasya tattiṣṭhenmāsārdhaṃ ghṛtabhājane| tanmātrayā pibannityamarśobhyo vipramucyate||146|| grahaṇī pāṇḍu rogaghnaṃ vātavarco’nulomanam| dīpanaṃ cārucighnaṃ ca dantyariṣṭamimaṃ viduḥ||147|| iti dantyariṣṭaḥ| dantIcitrakamUlAnAmubhayoH pa~jcamUlayoH| bhAgAn palAMshAnApothya jaladroNe vipAcayet||144|| tripalaM triphalAyAshca dalAnAM tatra dApayet| rase caturthasheShe tu pUte shIte samAvapet||145|| tulAM guDasya tattiShThenmAsArdhaM ghRutabhAjane| tanmAtrayA pibannityamarshobhyo vipramucyate||146|| grahaNIpANDurogaghnaM vAtavarco~anulomanam| dIpanaM cArucighnaM ca dantyariShTamimaM viduH||147|| iti dantyariShTaH Roots of danti (Baliospermum montanum), chitraka (Plumbego zylenicum) and dasamoola should be taken one pala each, should be boiled by adding two dronas of water. To this, fruit pulp of triphala, (three palas) should be added. It should be boiled till one fourth remains. The decoction should be strained through a cloth and cooled. To this, one pala of jaggery should be added and kept in a ghee-smeared jar for fifteen days. This is called dantyarishta and it cures hemorrhoids, grahani and pandu (anemia). It helps in the downward movement of flatus and feces and also stimulates the digestive power and cures anorexia. [144-147| Phalarishta: हरीतकी फलप्रस्थं प्रस्थमामलकस्य च| विशालाया दधित्थस्य पाठाचित्रकमूलयोः||१४८|| द्वे द्वे पले समापोथ्य द्विद्रोणे साधयेदपाम्| पादावशेषे पूते च रसे तस्मिन् प्रदापयेत्||१४९|| गुडस्यैकां तुलां वैद्यस्तत् स्थाप्यं घृतभाजने| पक्षस्थितं पिबेदेनं ग्रहण्यर्शोविकारवान्||१५०|| हृत्पाण्डुरोगं प्लीहानं कामलां विषमज्वरम्| वर्चोमूत्रानिलकृतान् विबन्धानग्निमार्दवम्||१५१|| कासं गुल्ममुदावर्तं फलारिष्टो व्यपोहति| अग्निसन्दीपनो ह्येष कृष्णात्रेयेण भाषितः||१५२|| इति फलारिष्टः| harītakī phalaprasthaṃ prasthamāmalakasya ca| viśālāyā dadhitthasya pāṭhācitrakamūlayoḥ||148|| dve dve pale samāpothya dvidroṇe sādhayedapām| pādāvaśeṣe pūte ca rase tasmin pradāpayet||149|| guḍasyaikāṃ tulāṃ vaidyastat sthāpyaṃ ghṛtabhājane| pakṣasthitaṃ pibedenaṃ grahaṇyarśovikāravān||150|| hṛtpāṇḍurogaṃ plīhānaṃ kāmalāṃ viṣamajvaram| varcomūtrānilakṛtān vibandhānagnimārdavam||151|| kāsaṃ gulmamudāvartaṃ phalāriṣṭo vyapohati| agnisandīpano hyeṣa kṛṣṇātreyeṇa bhāṣitaḥ||152|| iti phalāriṣṭaḥ| harItakIphalaprasthaM prasthamAmalakasya ca| vishAlAyA dadhitthasya pAThAcitrakamUlayoH||148|| dve dve pale samApothya dvidroNe sAdhayedapAm| pAdAvasheShe pUte ca rase tasmin pradApayet||149|| guDasyaikAM tulAM vaidyastat sthApyaM ghRutabhAjane| pakShasthitaM pibedenaM grahaNyarshovikAravAn||150|| hRutpANDurogaM plIhAnaM kAmalAM viShamajvaram| varcomUtrAnilakRutAn vibandhAnagnimArdavam||151|| kAsaM gulmamudAvartaM phalAriShTo vyapohati| agnisandIpano hyeSha kRuShNAtreyeNa bhAShitaH||152|| iti phalAriShTaH

Fruit pulp of haritaki (Terminalia chebula) (one prastha), amalaki (Embelica officinalis) (one prastha), visala (Cirullus colocunthis) (two palas), kapittha (Limonia acidissima) two palas), patha (Cesalpinia pareira) (two palas) and root of chitraka (Plumbego zylenicum) (two palas) should be added with four dronas of water and boiled till one fourth remains. The decoction should then be strained out through a cloth. To this, one tula of jaggery should be added and kept in a ghee-smeared jar for fifteen days. Intake of this recipe cures grahani, hemorrhoids, heart diseases, spleen dis¬orders, jaundice, visamajwara (malarial fever), obstruction to the passage of stool, urine and flatus, low power of digestion, cough, gulma and udvarta (upward movement of wind in the abdomen ). It stimulates the power of digestion. It is called phaldrista, and is propoun¬ded by the sage Krishnaatreya. [148-152] Phalarishta (Second recipe): दुरालभायाः प्रस्थः स्याच्चित्रकस्य वृषस्य च| पथ्यामलकयोश्चैव पाठाया नागरस्य च||१५३|| दन्त्याश्च द्विपलान् भागाञ्जलद्रोणे विपाचयेत्| पादावशेषे पूते च सुशीते शर्कराशतम्||१५४|| प्रक्षिप्य स्थापयेत् कुम्भे मासार्धं घृतभाविते| प्रलिप्ते पिप्पली चव्य प्रियङ्गु क्षौद्र सर्पिषा||१५५|| तस्य मात्रां पिबेत् काले शार्करस्य यथाबलम्| अर्शांसि ग्रहणीदोषमुदावर्तमरोचकम्||१५६|| शकृन्मूत्रानिलोद्गारविबन्धानग्निमार्दवम्| हृद्रोगं पाण्डुरोगं च सर्वमेतेन साधयेत्||१५७|| इति द्वितीयफलारिष्टः | durālabhāyāḥ prasthaḥ syāccitrakasya vṛṣasya ca| pathyāmalakayoścaiva pāṭhāyā nāgarasya ca||153|| dantyāśca dvipalān bhāgāñjaladroṇe vipācayet| pādāvaśeṣe pūte ca suśīte śarkarāśatam||154|| prakṣipya sthāpayet kumbhe māsārdhaṃ ghṛtabhāvite| pralipte pippalīcavyapriyaṅgukṣaudrasarpiṣā||155|| tasya mātrāṃ pibet kāle śārkarasya yathābalam| arśāṃsi grahaṇīdoṣamudāvartamarocakam||156|| śakṛnmūtrānilodgāravibandhānagnimārdavam| hṛdrogaṃ pāṇḍurogaṃ ca sarvametena sādhayet||157|| iti dvitīyaphalāriṣṭaḥ | durAlabhAyAH prasthaH syAccitrakasya vRuShasya ca| pathyAmalakayoshcaiva pAThAyA nAgarasya ca||153|| dantyAshca dvipalAn bhAgA~jjaladroNe vipAcayet| pAdAvasheShe pUte [20] ca sushIte sharkarAshatam||154|| prakShipya sthApayet kumbhe mAsArdhaM ghRutabhAvite| pralipte pippalIcavyapriya~ggukShaudrasarpiShA||155|| tasya mAtrAM pibet kAle shArkarasya yathAbalam| arshAMsi grahaNIdoShamudAvartamarocakam||156|| shakRunmUtrAnilodgAravibandhAnagnimArdavam| hRudrogaM pANDurogaM ca sarvametena sAdhayet||157|| iti dvitIyaphalAriShTaH [21] Duralabha (Fagonia criteca) (one prastha) and chitraka (Plumbego zylenicum), vasa (Adhatoda vasika), haritaki (Terminalia chebula), amalaki (Embelica officnalis), patha (Cesalpinia pareira), nagara (Zingiber officinalis) and danti (each two pala) should be added with two dronas of water and boiled till one fourth remains. The decoction should be strained out through a cloth and cooled then added 100 palas of sugar. It should be kept in a jar for fifteen days. The inside wall of the jar should be smeared with the paste containing pippali (Piper longum), chavya (Piper retrofractum), priyangu (Callicarpa macrophylla), honey and ghee. This preparation should be taken in apropriate dose depending upon the strength of the patient. It cures hemorrhoids, grahani, udavarta, anorexia, obstruction to the movement of stool, urine, flatus and eructation, low power of digestion, heart diseases and pandu (anemia). [153-157]

Kanakarishta: नवस्यामलकस्यैकां कुर्याज्जर्जरितां तुलाम्| कुडवांशाश्च पिप्पल्यो विडङ्गं मरिचं तथा||१५८|| पाठां च पिप्पली मूलं क्रमुकं चव्य चित्रकौ| मञ्जिष्ठैल्वालुकं लोध्रं पलिकानुपकल्पयेत्||१५९|| कुष्ठं दारुहरिद्रां च सुराह्वं सारिवाद्वयम्| इन्द्राह्वं भद्रमुस्तं च कुर्यादर्धपलोन्मितम्||१६०|| चत्वारि नागपुष्पस्य पलान्यभिनवस्य च| द्रोणाभ्यामम्भसो द्वाभ्यां साधयित्वाऽवतारयेत्||१६१|| पादावशेषे पूते च शीते तस्मिन् प्रदापयेत्| मृद्वीकाद्व्याढकरसं शीतं निर्यूहसम्मितम्||१६२|| शर्करायाश्च भिन्नाया दद्याद्द्विगुणितां तुलाम्| कुसुमस्य रसस्यैकमर्धप्रस्थं नवस्य च||१६३|| त्वगेलाप्लवपत्राम्बुसेव्यक्रमुककेशरान्| चूर्णयित्वा तु मतिमान् कार्षिकानत्र दापयेत्||१६४|| तत् सर्वं स्थापयेत् पक्षं सुचौक्षे घृतभाजने| प्रलिप्ते सर्पिषा किञ्चिच्छर्करागुरुधूपिते||१६५|| पक्षादूर्ध्वमरिष्टोऽयं कनको नाम विश्रुतः| पेयः स्वादुरसो हृद्यः प्रयोगाद्भक्तरोचनः||१६६|| अर्शांसि ग्रहणीदोषमानाहमुदरं ज्वरम्| हृद्रोगं पाण्डुतां शोथं गुल्मं वर्चोविनिग्रहम्||१६७|| कासं श्लेष्मामयांश्चोग्रान् सर्वानेवापकर्षति| वलीपलितखालित्यं दोषजं च व्यपोहति||१६८|| इति कनकारिष्टः| navasyāmalakasyaikāṃ kuryājjarjaritāṃ tulām| kuḍavāṃśāśca pippalyo viḍaṅgaṃ maricaṃ tathā||158|| pāṭhāṃ ca pippalī mūlaṃ kramukaṃ cavya citrakau| mañjiṣṭhailvālukaṃ lodhraṃ palikānupakalpayet||159|| kuṣṭhaṃ dāruharidrāṃ ca surāhvaṃ sārivādvayam| indrāhvaṃ bhadramustaṃ ca kuryādardhapalonmitam||160|| catvāri nāgapuṣpasya palānyabhinavasya ca| droṇābhyāmambhaso dvābhyāṃ sādhayitvā’vatārayet||161|| pādāvaśeṣe pūte ca śīte tasmin pradāpayet| mṛdvīkādvyāḍhakarasaṃ śītaṃ niryūhasammitam||162|| śarkarāyāśca bhinnāyā dadyāddviguṇitāṃ tulām| kusumasya rasasyaikamardhaprasthaṃ navasya ca||163|| tvagelāplavapatrāmbusevyakramukakeśarān| cūrṇayitvā tu matimān kārṣikānatra dāpayet||164|| tat sarvaṃ sthāpayet pakṣaṃ sucaukṣe ghṛtabhājane| pralipte sarpiṣā kiñciccharkarāgurudhūpite||165|| pakṣādūrdhvamariṣṭo’yaṃ kanako nāma viśrutaḥ| peyaḥ svāduraso hṛdyaḥ prayogādbhaktarocanaḥ||166|| arśāṃsi grahaṇīdoṣamānāhamudaraṃ jvaram| hṛdrogaṃ pāṇḍutāṃ śothaṃ gulmaṃ varcovinigraham||167|| kāsaṃ śleṣmāmayāṃścogrān sarvānevāpakarṣati| valīpalitakhālityaṃ doṣajaṃ ca vyapohati||168|| iti kanakāriṣṭaḥ| navasyAmalakasyaikAM kuryAjjarjaritAM tulAm| kuDavAMshAshca pippalyo viDa~ggaM maricaM tathA||158|| pAThAM [22] ca pippalImUlaM kramukaM cavyacitrakau| ma~jjiShThailvAlukaM lodhraM palikAnupakalpayet||159|| kuShThaM dAruharidrAM ca surAhvaM sArivAdvayam| indrAhvaM bhadramustaM ca kuryAdardhapalonmitam||160|| catvAri nAgapuShpasya palAnyabhinavasya ca| droNAbhyAmambhaso dvAbhyAM sAdhayitvA~avatArayet||161|| pAdAvasheShe pUte ca shIte tasmin pradApayet| mRudvIkAdvyADhakarasaM shItaM niryUhasammitam||162|| sharkarAyAshca bhinnAyA dadyAddviguNitAM tulAm| kusumasya rasasyaikamardhaprasthaM navasya ca||163|| tvagelAplavapatrAmbusevyakramukakesharAn| cUrNayitvA tu matimAn kArShikAnatra dApayet||164|| tat sarvaM sthApayet pakShaM sucaukShe ghRutabhAjane| pralipte sarpiShA ki~jciccharkarAgurudhUpite||165|| pakShAdUrdhvamariShTo~ayaM kanako nAma vishrutaH| peyaH svAduraso hRudyaH prayogAdbhaktarocanaH||166|| arshAMsi grahaNIdoShamAnAhamudaraM jvaram| hRudrogaM pANDutAM shothaM gulmaM varcovinigraham||167|| kAsaM shleShmAmayAMshcogrAn sarvAnevApakarShati| valIpalitakhAlityaM doShajaM ca vyapohati||168|| iti kanakAriShTaH Freshly collected amalaki (one tula) should be coarsely pounded added pippali (Piper longum), vidanga (Embelia ribes) and maricha (Piper nigrum) (4 pala each), one pala of each patha(Cissampelos Pareira ), pippalimoola, kramuka chavya (Piper retrofractum), chitraka (Plumbego zylanicum), manjishta (Rubia cordifolia), elvaluka and half pala of each of kushta (Sassurea lappa), daruharidra (Berberis aristata), suraha, sariva (Hemidesmus indicus), indrahva (Holarrhina antidysenterica) and bhadramusta and four pala of freshly collected nagapushpa should be added. To this two drona of water should be added and boiled till one fourth remains. The decoction should be strained out through a cloth and cooled. To this, two adhakas of the cooled decoction of madhuka, two tulas of pounded sugar, half prastha of freshly collected honey and the powder of tvak, ela, plava, patra, ambu, sevya, kramuka and kehra taken in the quantity of one karsha each, should be added. The inside wall of the clean jar should be smeared with ghee and fumigated with sugar and Aguru. This should be kept for fifteen days. After fifteen days, the recipe should be filtered out. This is called kanakarishta which is sweet in taste and is cardiac tonic. It produces relish in the food and cures hemorrhoids, grahani, flatulence, udara, fever, heart diseases, pandu (anemia), edema, gulma (tumour), obstruction to the passage of stool, cough and other diseases caused by kapha. It also cures vali (appearance of wrinkles in the body), palita (appearance of premature grey hair) and khalitya (alopecia) caused by the vitiation of doshas. [158-168] Cleanliness of peri-anal region: पत्रभङ्गोदकैः शौचं कुर्यादुष्णेन वाऽम्भसा| इति शुष्कार्शसां सिद्धमुक्तमेतच्चिकित्सितम्||१६९|| patrabhaṅgōdakaiḥ śaucaṁ kuryāduṣṇēna vā'mbhasā| iti śuṣkārśasāṁ siddhamuktamētaccikitsitam||169|| patrabha~ggodakaiH shaucaM kuryAduShNena vA~ambhasA| iti shuShkArshasAM siddhamuktametaccikitsitam||169|| The patient of hemorrhoids should use the decoction of leaves which are curative of hemorrhoids) or warm water for cleansing of per anal region. Thus, the effective treatment for dry type of hemorrhoids is described. [169] Treatment of bleeding hemorrhoids: चिकित्सितमिदं सिद्धं स्राविणां शृण्वतः परम् | तत्रानुबन्धो द्विविधः श्लेष्मणो मारुतस्य च||१७०|| cikitsitamidaṃ siddhaṃ srāviṇāṃ śṛṇvataḥ param | tatrānubandho dvividhaḥ śleṣmaṇo mārutasya ca||170|| cikitsitamidaM siddhaM srAviNAM shRuNvataH param [23] | tatrAnubandho dvividhaH shleShmaNo mArutasya ca||170|| Now after treatment of dry hemorrhoids the treatment of bleeding hemorrhoids is mentioned further which are associated with vitiated vayu and kapha. [170]

Signs and symptoms of bleeding hemorrhoids associated with vayu:

विट् श्यावं कठिनं रूक्षं चाधो वायुर्न वर्तते| तनु चारुणवर्णं च फेनिलं चासृगर्शसाम्||१७१|| कट्यूरुगुदशूलं च दौर्बल्यं यदि चाधिकम्| तत्रानुबन्धो वातस्य हेतुर्यदि च रूक्षणम्||१७२||

viṭ śyāvaṃ kaṭhinaṃ rūkṣaṃ cādho vāyurna vartate| tanu cāruṇavarṇaṃ ca phenilaṃ cāsṛgarśasām||171|| kaṭyūrugudaśūlaṃ ca daurbalyaṃ yadi cādhikam| tatrānubandho vātasya heturyadi ca rūkṣaṇam||172|| viT shyAvaM kaThinaM rUkShaM cAdho vAyurna vartate| tanu cAruNavarNaM ca phenilaM cAsRugarshasAm||171|| kaTyUrugudashUlaM ca daurbalyaM yadi cAdhikam| tatrAnubandho vAtasya heturyadi ca rUkShaNam||172|| The color of hemorrhoids is gray, hard to feel and ununctuousness of the stool, flatulent, blood which exudes from the hemorrhoids is thin, reddish and foamy, pain in the lumber region, thighs and peri-anal region with excessive weakness. [171-172]

Signs and symptoms of bleeding hemorrhoids associated with kapha: शिथिलं श्वेतपीतं च विट् स्निग्धं गुरु शीतलम्| यद्यर्शसां घनं चासृक् तन्तुमत् पाण्डु पिच्छिलम्||१७३|| गुदं सपिच्छं स्तिमितं गुरु स्निग्धं च कारणम्| श्लेष्मानुबन्धो विज्ञेयस्तत्र रक्तार्शसां बुधैः||१७४||

śithilaṃ śvetapītaṃ ca viṭ snigdhaṃ guru śītalam| yadyarśasāṃ ghanaṃ cāsṛk tantumat pāṇḍu picchilam||173|| gudaṃ sapicchaṃ stimitaṃ guru snigdhaṃ ca kāraṇam| śleṣmānubandho vijñeyastatra raktārśasāṃ budhaiḥ||174||

shithilaM shvetapItaM ca viT snigdhaM guru shItalam| yadyarshasAM ghanaM cAsRuk tantumat pANDu picchilam||173|| gudaM sapicchaM stimitaM guru snigdhaM ca kAraNam| shleShmAnubandho vij~jeyastatra raktArshasAM budhaiH||174||

The following signs and symptoms are manifested in bleeding hemorrhoids secondarily associated with kapha. Stool is loose, white, yellow, unctuous, heavy and cold, the blood which exudes from the hemorrhoids is dense, pale yellow and slimy, the anus is smeared with slimy material and there is numbness in that region. [173-174]

Line of treatment as per dosha: स्निग्धशीतं हितं वाते रूक्षशीतं कफानुगे| चिकित्सितमिदं तस्मात् सम्प्रधार्य प्रयोजयेत्||१७५|| पित्तश्लेष्माधिकं मत्वा शोधनेनोपपादयेत्| स्रवणं चाप्युपेक्षेत लङ्घनैर्वा समाचरेत्||१७६|| snigdhaśītaṃ hitaṃ vāte rūkṣaśītaṃ kaphānuge| cikitsitamidaṃ tasmāt sampradhārya prayojayet||175|| pittaśleṣmādhikaṃ matvā śodhanenopapādayet| sravaṇaṃ cāpyupekṣeta laṅghanairvā samācaret||176|| snigdhashItaM hitaM vAte rUkShashItaM kaphAnuge| cikitsitamidaM tasmAt sampradhArya prayojayet||175|| pittashleShmAdhikaM matvA shodhanenopapAdayet| sravaNaM cApyupekSheta la~gghanairvA samAcaret||176||

Unctuous and cold things should be used if vitiation of vayu in bleeding hemorrhoids. In case of vitiation of kapha in bleeding hemorrhoids ununctuous and cold-things are useful. Therefore, therapies should be administered after considering these points . If there is predominance of pitta and kapha dosha, the patient should be administered shodhan (elimination) therapies. However, bleeding should not be stopped immediately anyone should wait for appropriate time. The patient can be given fasting therapy. [175-176]

Complications of immediate hemostasis therapy: प्रवृत्तमादावर्शोभ्यो यो निगृह्णात्यबुद्धिमान्| शोणितं दोषमनिलं तद्रोगाञ्जनयेद्बहून्||१७७|| रक्तपित्तं ज्वरं तृष्णामग्निसादमरोचकम्| कामलां श्वयथुं शूलं गुद वङ्क्षण संश्रयम्||१७८|| कण्ड्वरुःकोठपिडकाः कुष्ठं पाण्ड्वाह्वयं गदम्| वात मूत्र पुरीषाणां विबन्धं शिरसो रुजम्||१७९|| स्तैमित्यं गुरुगात्रत्वं तथाऽन्यान् रक्तजान् गदान्| तस्मात् स्रुते दुष्टरक्ते रक्तसङ्ग्रहणं हितम्||१८०|| हेतु लक्षण कालज्ञो बल शोणित वर्णवित्| कालं तावदुपेक्षेत यावन्नात्ययमाप्नुयात्||१८१|| pravṛttamādāvarśobhyo yo nigṛhṇātyabuddhimān| śoṇitaṃ doṣamanilaṃ tadrogāñjanayedbahūn||177|| raktapittaṃ jvaraṃ tṛṣṇāmagnisādamarocakam| kāmalāṃ śvayathuṃ śūlaṃ gudavaṅkṣaṇasaṃśrayam||178|| kaṇḍvaruḥkoṭhapiḍakāḥ kuṣṭhaṃ pāṇḍvāhvayaṃ gadam| vātamūtrapurīṣāṇāṃ vibandhaṃ śiraso rujam||179|| staimityaṃ gurugātratvaṃ tathā’nyān raktajān gadān| tasmāt srute duṣṭarakte raktasaṅgrahaṇaṃ hitam||180|| hetulakṣaṇakālajño balaśoṇitavarṇavit| kālaṃ tāvadupekṣeta yāvannātyayamāpnuyāt||181|| pravRuttamAdAvarshobhyo yo nigRuhNAtyabuddhimAn| shoNitaM doShamanilaM tadrogA~jjanayedbahUn||177|| raktapittaM jvaraM tRuShNAmagnisAdamarocakam| kAmalAM shvayathuM shUlaM gudava~gkShaNasaMshrayam||178|| kaNDvaruHkoThapiDakAH kuShThaM pANDvAhvayaM gadam| vAtamUtrapurIShANAM vibandhaM shiraso rujam||179|| staimityaM gurugAtratvaM tathA~anyAn raktajAn gadAn| tasmAt srute duShTarakte raktasa~ggrahaNaM hitam||180|| hetulakShaNakAlaj~jo balashoNitavarNavit| kAlaM tAvadupekSheta yAvannAtyayamApnuyAt||181|| If the blood vitiated by doshas, which comes out from the hemorrhoids is arrested in the beginning then it may lead to several complications like raktapitta (a disease characterized by bleeding from various parts of the body ), fever, morbid thirst, suppre¬ssion of digestive power, anorexia, jaundice, edema, pain in the anus and pelvic region, urticaria and pimples in the lumber region and thighs, kushtha, pandu (anemia), obstruction in flatus, urine and stool, headache, staimitya (a feeling as if the body is covered with a wet cloth ), heaviness of the body and other diseases caused by vitiated blood. Therefore, only after elimination of vitiated blood hemostatic measures are useful. The physician should be well known with 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. [177-181]

Use of bitter drugs: अग्नि सन्दीपनार्थं च रक्त सङ्ग्रहणाय च| दोषाणां पाचनार्थं च परं तिक्तैरुपाचरेत्||१८२|| agni sandīpanārthaṃ ca rakta saṅgrahaṇāya ca| doṣāṇāṃ pācanārthaṃ ca paraṃ tiktairupācaret||182|| agnisandIpanArthaM ca raktasa~ggrahaNAya ca| doShANAM pAcanArthaM ca paraM tiktairupAcaret||182||

For stimu¬lation of the digestive power, hemostasis and pachana (meta¬bolic transformation) bitter drugs should be given. [182]

Use of sneha: यत्तु प्रक्षीणदोषस्य रक्तं वातोल्बणस्य च| वर्तते स्नेहसाध्यं तत् पानाभ्यङ्गानुवासनैः||१८३|| yattu prakṣīṇadoṣasya raktaṃ vātolbaṇasya ca| vartate snehasādhyaṃ tat pānābhyaṅgānuvāsanaiḥ||183|| yattu prakShINadoShasya raktaM vAtolbaNasya ca| vartate snehasAdhyaM tat pAnAbhya~ggAnuvAsanaiH||183||

In hemorrhoids having predominance of vayu, 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. [183]

Indications for hemostatic therapy: यत्तु पित्तोल्बणं रक्तं घर्मकाले प्रवर्तते| स्तम्भनीयं तदेकान्तान्न चेद्वातकफानुगम्||१८४|| yattu pittolbaṇaṃ raktaṃ gharmakāle pravartate| stambhanīyaṃ tadekāntānna cedvātakaphānugam||184|| yattu pittolbaNaM raktaM gharmakAle pravartate| stambhanIyaM tadekAntAnna cedvAtakaphAnugam||184|| In summer season pitta predominant hemorrhoids without secondary predominance of vayu and kapha hemostatic therapies should be administered immediately to stop bleeding. [184] Hemostatic recipes: कुटज त्वङ्निर्यूहः सनागरः स्निग्ध रक्त सङ्ग्रहणः| त्वग्दाडिमस्य तद्वत् सनागरश्चन्दनरसश्च||१८५|| चन्दन किराततिक्तक धन्वयवासाः सनागराः क्वथिताः| रक्तार्शसां प्रशमना दार्वीत्वगुशीर निम्बाश्च||१८६|| सातिविषा कुटज त्वक् फलं च सरसाञ्जनं मधुयुतानि| रक्तापहानि दद्यात् पिपासवे तण्डुलजलेन||१८७|| kuṭaja tvaṅniryūhaḥ sanāgaraḥ snigdha rakta saṅgrahaṇaḥ| tvagdāḍimasya tadvat sanāgaraścandanarasaśca||185|| candana kirātatiktaka dhanvayavāsāḥ sanāgarāḥ kvathitāḥ| raktārśasāṃ praśamanā dārvītvaguśīra nimbāśca||186|| sātiviṣā kuṭaja tvak phalaṃ ca sarasāñjanaṃ madhuyutāni| raktāpahāni dadyāt pipāsave taṇḍulajalena||187|| kuTajatva~gniryUhaH sanAgaraH snigdharaktasa~ggrahaNaH| tvagdADimasya tadvat sanAgarashcandanarasashca||185|| candanakirAtatiktakadhanvayavAsAH sanAgarAH kvathitAH| raktArshasAM prashamanA dArvItvagushIranimbAshca||186|| sAtiviShA kuTajatvak phalaM ca sarasA~jjanaM madhuyutAni| raktApahAni dadyAt pipAsave taNDulajalena||187|| The decoction of kutaja (Holarrhina antidysenterica) bark mixed with the powder of nagara (Zingiber officinalis) stops exudation of unctuous blood. The decoction of the dadima (Punica granatum), bark along with the powder of nagara and the decoction of chandana (Santalum album), mixed with the powder of nagara (Zingiber officinalis) are hemostatic in bleeding hemorrhoids. [185] Decoction of chandana (Santalum album), kiratatikta (Swetia chirayita), dhanvyavasa (Fagonia criteca) and nagara (Zingiber officinalis), and the decoction of darvi (Berberis aristata), tvak (Cinnamomum zeylinicum), agaru (Aqularia agallocha), ushira (Vetiveria zizanioidis) and nimba (Azadirecta indica) are alleviators of hemorrhoids caused by the vitiation of blood (blee¬ding hemorrhoids) [186] Bark and fruits of kutaja (Holarrhina antidysenterica) along with ativisha (Aconitum heterophylum) and rasanjana should be mixed with honey and used as a hemostatic in hemorrhoids. If the patient is suffering from morbid thirst tandulodaka (thin rice gruel), should be given. [187] Kutajadi rasakriya: कुटज त्वचो विपाच्यं पलशतमार्द्रं महेन्द्रसलिलेन| यावत्स्याद्गतरसं तद्द्रव्यं पूतो रसस्ततो ग्राह्यः||१८८|| मोचरसः ससमङ्गः फलिनी च समांशिकैस्त्रिभिस्तैश्च | वत्सकबीजं तुल्यं चूर्णितमत्र प्रदातव्यम्||१८९|| पूतोत्क्वथितः सान्द्रः स रसो दर्वीप्रलेपनो ग्राह्यः| मात्राकालोपहिता रसक्रियैषा जयत्यसृक्स्रावम्||१९०|| kuṭaja tvaco vipācyaṃ palaśatamārdraṃ mahendrasalilena| yāvatsyādgatarasaṃ taddravyaṃ pūto rasastato grāhyaḥ||188|| mocarasaḥ sasamaṅgaḥ phalinī ca samāṃśikaistribhistaiśca | vatsakabījaṃ tulyaṃ cūrṇitamatra pradātavyam||189|| pūtotkvathitaḥ sāndraḥ sa raso darvīpralepano grāhyaḥ| mātrākālopahitā rasakriyaiṣā jayatyasṛksrāvam||190|| kuTajatvaco vipAcyaM palashatamArdraM mahendrasalilena| yAvatsyAdgatarasaM taddravyaM pUto rasastato grAhyaH||188|| mocarasaH sasama~ggaH phalinI ca samAMshikaistribhistaishca [24] | vatsakabIjaM tulyaM cUrNitamatra pradAtavyam||189|| pUtotkvathitaH sAndraH sa raso darvIpralepano grAhyaH| mAtrAkAlopahitA rasakriyaiShA jayatyasRuksrAvam||190|| Kutaja (Holarrhina antidysenterica) bark (100 palas) should be boiled with rain water (one drona) till the entire essence of the bark comes to water (i.e. till 1/8th remains). This decoction should then be strained out through a cloth. To this, the powders of mocharasa, (one pala), samanga (one pala) Phalini (one pala) and seeds of kutaja (Holarrhina antidysenterica) (three palas) should be added and boiled again till it becomes semi-solid and till it sticks to the stirring spoon. This rasakriya (semi- solid extract) stops bleeding in hemorrhoids if administered in appropriate dose and time. This rasakriya should be administered along with goat-milk depending upon the strength of the patient. [188-190]

Peyamanda (thin gruel): छगली पयसा पीता पेयामण्डेन वा यथाग्निबलम्| जीर्णौषधश्च शालीन् पयसा छागेन भुञ्जीत||१९१|| रक्तार्शांस्यतिसारं रक्तं सासृग्रुजो निहन्त्याशु| बलवच्च रक्तपित्तं रसक्रियैषा जयत्युभयभागम् ||१९२|| इति कुटजादिरसक्रिया| chagalī payasā pītā peyāmaṇḍena vā yathāgnibalam| jīrṇauṣadhaśca śālīn payasā chāgena bhuñjīta||191|| raktārśāṃsyatisāraṃ raktaṃ sāsṛgrujo nihantyāśu| balavacca raktapittaṃ rasakriyaiṣā jayatyubhayabhāgam ||192|| iti kuṭajādirasakriyā| chagalIpayasA pItA peyAmaNDena vA yathAgnibalam| jIrNauShadhashca shAlIn payasA chAgena bhu~jjIta||191|| raktArshAMsyatisAraM raktaM sAsRugrujo nihantyAshu| balavacca raktapittaM rasakriyaiShA jayatyubhayabhAgam [25] ||192|| iti kuTajAdirasakriyA After the digestion of above rasakriya, the patient should be given shashtika shali (one type of rice) along with goat-milk to eat. It instantaneously cures bleeding hemorrhoids, diarrhea with bleeding, blood-diseases and serious types of urdhvaga as well as adhoga Rraktapitta [191-192]

Recipes for hemorrhoids: नीलोत्पलं समङ्गा मोचरसश्चन्दनं तिला लोध्रम्| पीत्वा च्छगलीपयसा भोज्यं पयसैव शाल्यन्नम्||१९३|| nīlotpalaṃ samaṅgā mocarasaścandanaṃ tilā lodhram| pītvā cchagalīpayasā bhojyaṃ payasaiva śālyannam||193|| nIlotpalaM sama~ggA mocarasashcandanaM tilA lodhram| pItvA cchagalIpayasA bhojyaM payasaiva shAlyannam||193|| Powder of nilotpala (Nelumbo nucifera), samanga, mocharasa, chandan (Santalum album),, tila (Sesamum indicum) and lodhra (Symplocus racemosa) should be taken along with goat-milk. Thereafter, the patient should eat shali type of rice along with goat-milk. [193] छागलि पयः प्रयुक्तं निहन्ति रक्तं सवास्तुकरसं च| धन्व विहङ्ग मृगाणां रसो निरम्लः कदम्लो वा||१९४|| chāgali payaḥ prayuktaṃ nihanti raktaṃ savāstukarasaṃ ca| dhanva vihaṅga mṛgāṇāṃ raso niramlaḥ kadamlo vā||194|| chAgalipayaH prayuktaM nihanti raktaM savAstukarasaM ca| dhanvaviha~ggamRugANAM raso niramlaH kadamlo vA||194||

Intake of the juice of vastuka along with goat-milk, the soup of the meat of birds and animals inhabi¬ting arid zone should be taken without any sour ingredient or with small quantity of sour drug, which is useful for bleeding hemorrhoids. [194] पाठा वत्सकबीजं रसाञ्जनं नागरं यवान्यश्च| बिल्वमिति चार्शसैश्चूर्णितानि पेयानि शूलेषु||१९५|| pāṭhā vatsakabījaṃ rasāñjanaṃ nāgaraṃ yavānyaśca| bilvamiti cārśasaiścūrṇitāni peyāni śūleṣu||195|| pAThA vatsakabIjaM rasA~jjanaM nAgaraM yavAnyashca| bilvamiti cArshasaishcUrNitAni peyAni shUleShu||195|| If there is pain in bleeding hemorrhoids then the powder of patha (Cissampelos pareria), seed of vastak (Holerrhina antidysentrica), rashanjana, nagara (Zingiber officinalis), yavini (Trachyspermum ammi) and bilva (Aegle marmelos) should be taken in the form of a drink. [195]

दार्वी किराततिक्तं मुस्तं दुःस्पर्शकश्च रुधिरघ्नम्| dārvī kirātatiktaṃ mustaṃ duḥsparśakaśca rudhiraghnam| dArvI kirAtatiktaM mustaM duHsparshakashca rudhiraghnam|

The powder of darvi (Berberis aristata), kiratatikta (Swetia chirayata), musta (Cyperous rotendus) and duspharshka stops the bleeding- [196] रक्तेऽतिवर्तमाने शूले च घृतं विधातव्यम्||१९६|| कुटजफल वल्क केशर नीलोत्पल लोध्र धातकी कल्कैः| सिद्धं घृतं विधेयं शूले रक्तार्शसां भिषजा||१९७|| सर्पिः सदाडिमरसं सयावशूकं शृतं जयत्याशु| रक्तं सशूलमथवा निदिग्धिकादुग्धिकासिद्धम्||१९८|| rakte’tivartamāne śūle ca ghṛtaṃ vidhātavyam||196|| kuṭajaphala valka keśara nīlotpala lodhra dhātakī kalkaiḥ| siddhaṃ ghṛtaṃ vidheyaṃ śūle raktārśasāṃ bhiṣajā||197|| sarpiḥ sadāḍimarasaṃ sayāvaśūkaṃ śṛtaṃ jayatyāśu| raktaṃ saśūlamathavā nidigdhikādugdhikāsiddham||198|| rakte~ativartamAne shUle ca ghRutaM vidhAtavyam||196|| kuTajaphalavalkakesharanIlotpalalodhradhAtakIkalkaiH| siddhaM ghRutaM vidheyaM shUle raktArshasAM bhiShajA||197|| sarpiH sadADimarasaM sayAvashUkaM shRutaM jayatyAshu| raktaM sashUlamathavA nidigdhikAdugdhikAsiddham||198|| Ghee cooked with the paste of the fruits of kutaja (Holarrhina antidysenterica), nagkeshar (Mesua ferrea), nilkamal (Nelumbo nucifera), lodhara (Symplocus racemosa) and dhataki (Woodfordia fruticosa) should be administered in bleeding hemorrhoids associated with pain. [197] Bleeding and pain in the hemorrhoids relieved with medicated ghee cooked with the juice of dadima (Pongamia granatum) and yavakshara as well as ghee cooked with nidigdhika (Solanum surratense) and dugdhika (Euphrbia thymifolia).[198]

Recipes of peya (thin gruel): लाजापेया पीता सचुक्रिका केशरोत्पलैः सिद्धा| हन्त्याश्वस्रस्रावं तथा बला पृश्निपर्णीभ्याम्||१९९|| ह्रीवेर बिल्व नागर निर्यूहे साधितां सनवनीताम्| वृक्षाम्ल दाडिमाम्लामम्लीकाम्लां सकोलाम्लाम्||२००|| गृञ्जनकसुरासिद्धां दद्याद्यमकेन भर्जितां पेयाम्| रक्तातिसार शूल प्रवाहिका शोथ निग्रहणीम्||२०१|| lājāpeyā pītā sacukrikā keśarotpalaiḥ siddhā| hantyāśvasrasrāvaṃ tathā balā pṛśniparṇībhyām||199|| hrīvera bilva nāgara niryūhe sādhitāṃ sanavanītām| vṛkṣāmla dāḍimāmlāmamlīkāmlāṃ sakolāmlām||200|| gṛñjanakasurāsiddhāṃ dadyādyamakena bharjitāṃ peyām| raktātisāra śūla pravāhikā śotha nigrahaṇīm||201|| lAjApeyA pItA sacukrikA kesharotpalaiH siddhA| hantyAshvasrasrAvaM tathA balApRushniparNIbhyAm||199|| hrIverabilvanAgaraniryUhe sAdhitAM sanavanItAm| vRukShAmladADimAmlAmamlIkAmlAM sakolAmlAm||200|| gRu~jjanakasurAsiddhAM dadyAdyamakena bharjitAM peyAm| raktAtisArashUlapravAhikAshothanigrahaNIm||201|| Peya (thin gruel) prepared form changeri (Oxalis corniculata), nagkeshar (Mesua ferrea), nilkamal (Nelumbo nucifera), bala (Sida cordifolia), prashniparni (Uraria picta) instantaneously cures bleeding hemorrhoids. Peya prepared by adding the decoction of hribera (Sugandhabala), bilva (Aegle marmelos) and nagara (Zingiber officinalis), added with butter and made sour by adding vrakshamala (Garcinia indica), dadima (Pongamia granatum), amlika and kola cures raktatisara (diarrhea with bleeding). Peya prepared by adding gunjanaka and sura (a type of alcohol), sizzled with ghee and oil cures of raktatisara, colic pain, pravahika (dysentery) and edema. [199-201]

Recipes of curds: काश्मर्यामलकानां सकर्बुदारान् फलाम्लांश्च| गृञ्जनक शाल्मलीनां क्षीरिण्याश्चुक्रिकायाश्च||२०२|| न्यग्रोध शुङ्गकानां खण्डांस्तथा कोविदार पुष्पाणाम्| दध्नः सरेण सिद्धान् दद्याद्रक्ते प्रवृत्तेऽति||२०३|| kāśmaryāmalakānāṃ sakarbudārān phalāmlāṃśca| gṛñjanaka śālmalīnāṃ kṣīriṇyāścukrikāyāśca||202|| nyagrodha śuṅgakānāṃ khaṇḍāṃstathā kovidāra puṣpāṇām| dadhnaḥ sareṇa siddhān dadyādrakte pravṛtte’ti||203|| kAshmaryAmalakAnAM sakarbudArAn [26] phalAmlAMshca| gRu~jjanakashAlmalInAM kShIriNyAshcukrikAyAshca||202|| nyagrodhashu~ggakAnAM khaNDAMstathA kovidArapuShpANAm| dadhnaH sareNa siddhAn dadyAdrakte pravRutte~ati||203|| In cases of excessive bleeding in hemorrhoids, the cream of curd boiled with pieces of the following should be given [202-203] 1. Kashmarya, amalaka, karbudara and sour fruits 2. Gunjanaka and shalmali (Shalmalia malabarica) 3. Fruit of dugdhika (Uuphrbia thymifolia). 4. Roots of nyagrodha (ficus bengalensis) and flowers of kovidara (Borrhavia diffusa)

Diet in bleeding hemorrhoids: सिद्धं पलाण्डुशाकं तक्रेणोपोदिकां सबदराम्लाम्| रुधिरस्रवे प्रदद्यान्मसूरसूपं च तक्राम्लम्||२०४|| siddhaṃ palāṇḍuśākaṃ takreṇopodikāṃ sabadarāmlām| rudhirasrave pradadyānmasūrasūpaṃ ca takrāmlam||204|| siddhaM palANDushAkaM takreNopodikAM sabadarAmlAm| rudhirasrave pradadyAnmasUrasUpaM ca takrAmlam||204|| Onion cooked with butter-milk or upodika along with badaramla (sour vinegar prepared of badara) or the soup of masura made sour by adding butter-milk should be given in bleeding hemorrhoids. [204] पयसा शृतेन यूषै र्मसूर मुद्गाढकीमकुष्ठानाम् | भोजनमद्यादम्लैः शालि श्यामाक कोद्रवजम्||२०५|| payasā śṛtena yūṣai rmasūra mudgāḍhakīmakuṣṭhānām | bhojanamadyādamlaiḥ śāli śyāmāka kodravajam||205|| payasA shRutena yUShairmasUramudgADhakImakuShThAnAm [27] | bhojanamadyAdamlaiH shAlishyAmAkakodravajam||205|| The patient of bleeding hemorrhoids should take the food containing shali rice, shyama rice and kodrava rice along with, boiled-milk or soup of masura, mudga, arhar, and makushtha. [205] शश हरिण लाव मांसैः कपिञ्जलैणेयकैः सुसिद्धैश्च| भोजनमद्यादम्लैर्मधुरैरीषत् समरिचैर्वा||२०६|| śaśa hariṇa lāva māṃsaiḥ kapiñjalaiṇeyakaiḥ susiddhaiśca| bhojana madyādamlair madhurairīṣat samaricairvā||206|| shashahariNalAvamAMsaiH kapi~jjalaiNeyakaiH susiddhaishca| bhojanamadyAdamlairmadhurairIShat samaricairvA||206|| The food along with the meat of shasha (rabbit), harin, lava, gouraiya and ena should be taken in bleeding hemorrhoids. He can add sour or slightly sweet ingredients to his food, or he should sprinkle his food with the powder of maricha (Piper nigram). [206] दक्ष शिखि तित्तिरि रसैर्द्विककुदलो पाकजैश्च मधुराम्लैः| अद्याद्रसैरतिवहेष्वर्शःस्वनिलोल्बणशरीरः||२०७|| dakṣa śikhi tittiri rasairdvikakudalo pākajaiśca madhurāmlaiḥ| adyādrasairativaheṣvarśaḥsvanilolbaṇaśarīraḥ||207|| dakShashikhitittirirasairdvikakudalopAkajaishca madhurAmlaiH| adyAdrasairativaheShvarshaHsvanilolbaNasharIraH||207|| If there is excessive bleeding from the hemorrhoids and aggravated symptoms, then patient should take food along with the soup of fowl, pea¬cock, tittiri bird, camel and jackel. This meat soup should be suitably added with sweet and sour ingredients. [207] रस खड यूष यवागू संयोगतः केवलोऽथवा जयति| रक्तमतिवर्तमानं वातं च पलाण्डुरुपयुक्तः||२०८|| rasa khaḍa yūṣa yavāgū saṃyogataḥ kevalo’thavā jayati| raktamativartamānaṃ vātaṃ ca palāṇḍurupayuktaḥ||208|| rasakhaDayUShayavAgUsaMyogataH [28] kevalo~athavA jayati| raktamativartamAnaM vAtaM ca palANDurupayuktaH||208|| Onion taken alone or along with meat soup, khada (pungent drink), yusha (vegetable soup) and yavngu (thick gruel) cures excessive bleeding and aggravated vayu. [208] छागान्तराधि तरुणं सरुधिरमुपसाधितं बहु पलाण्डु| व्यत्यासान्मधुराम्लं विट्शोणितसङ्क्षये देयम्||२०९|| chāgāntarādhi taruṇaṃ sarudhiramupasādhitaṃ bahu palāṇḍu| vyatyāsānmadhurāmlaṃ viṭśoṇitasaṅkṣaye deyam||209|| chAgAntarAdhi taruNaM sarudhiramupasAdhitaM bahupalANDu| vyatyAsAnmadhurAmlaM viTshoNitasa~gkShaye deyam||209|| Large quantity of onion cooked with the trunk of a young goat should be given by adding alternatively, sweet and sour ingredients if there is diminution of stool and blood. [209] नवनीत तिलाभ्यासात् केशर नवनीत शर्कराभ्यासात्| दधि सर मथिताभ्यासादर्शांस्यपयान्ति रक्तानि||२१०|| navanīta tilābhyāsāt keśara navanīta śarkarābhyāsāt| dadhi sara mathitābhyāsādarśāṃsyapayānti raktāni||210|| navanItatilAbhyAsAt kesharanavanItasharkarAbhyAsAt| dadhisaramathitAbhyAsAdarshAMsyapayAnti raktAni||210|| The bleeding hemorrhoids get cured by the habitual intake of the following recipes 1. Butter and sesame seed 2. Keshara, butter and sugar 3. The cream of curd after churning. [210] नवनीतघृतं छागं मांसं च सषष्टिकः शालिः| तरुणश्च सुरा मण्डस्तरुणी च सुरा निहन्त्यस्रम्||२११|| navanītaghṛtaṃ chāgaṃ māṃsaṃ ca saṣaṣṭikaḥ śāliḥ| taruṇaśca surāmaṇḍastaruṇī ca surā nihantyasram||211|| navanItaghRutaM chAgaM mAMsaM ca saShaShTikaH shAliH| taruNashca surAmaNDastaruNI ca surA nihantyasram||211|| Bleeding stops if the patient takes freshly prepared ghee from butter, goat-meat, shashtika types of rice, freshly fermented sura (a type of alcoholic drink). [211]

Predominance of vayu: प्रायेण वात बहुलान्यर्शांसि भवन्त्यतिस्रुते रक्ते| दुष्टेऽपि च कफ पित्ते तस्मादनिलोऽधिको ज्ञेयः||२१२|| prāyeṇa vāta bahulānyarśāṃsi bhavantyatisrute rakte| duṣṭe’pi ca kapha pitte tasmādanilo’dhiko jñeyaḥ||212|| prAyeNa vAtabahulAnyarshAMsi bhavantyatisrute rakte| duShTe~api ca kaphapitte tasmAdanilo~adhiko j~jeyaH||212||

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. [212]

Cooling Therapy: दृष्ट्वा तु रक्तपित्तं प्रबलं कफ वात लिङ्गमल्पं च| शीता क्रिया प्रयोज्या यथेरिता वक्ष्यते चान्या ||२१३|| dṛṣṭvā tu raktapittaṃ prabalaṃ kapha vāta liṅgamalpaṃ ca| śītā kriyā prayojyā yatheritā vakṣyate cānyā ||213|| dRuShTvA tu raktapittaM prabalaM kaphavAtali~ggamalpaM ca| shItA kriyA prayojyA yatheritA vakShyate cAnyA [29] ||213|| 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 which are already described and some of which are to be described later. [213]

Sprinkling in bleeding hemorrhoids: मधुकं सपञ्चवल्कं बदरीत्वगुदुम्बरं धवपटोलम्| परिषेचने विदध्याद्वृषककुम यवास निम्बांश्च||२१४|| madhukaṃ sapañcavalkaṃ badarītvagudumbaraṃ dhavapaṭolam| pariṣecane vidadhyādvṛṣakakuma yavāsa nimbāṃśca||214|| madhukaM sapa~jcavalkaM badarItvagudumbaraM dhavapaTolam| pariShecane vidadhyAdvRuShakakumayavAsanimbAMshca||214||

To stop bleeding, hemorrhoids should be sprinkled with the decoctions of madhuka, panchavalka [barks of nyagrodha (ficus bengalensis), udumbara (ficus glomeruta), ashwatha (ficus religiosa), parisha (thespesia populnea) and plaksha (ficus lacor)], bark of badar, udumbara (ficus glomeruta), dhava (Anogeissus latifolia) and patola (Tricosanthes dioica) or vasa (Adhatoda vasika), kakubha,Yavasaka (Alhagi camelorum) and nimba (Azadiracta indica). [214]

Warm water sitz-bath in bleeding hemorrhoids: रक्तेऽतिवर्तमाने दाहे क्लेदेऽवगाहयेच्चापि| मधुक मृणाल पद्मक चन्दन कुश काश निष्क्वाथे||२१५|| rakte’tivartamāne dāhe klede’vagāhayeccāpi| madhuka mṛṇāla padmaka candana kuśa kāśa niṣkvāthe||215|| rakte~ativartamAne dAhe klede~avagAhayeccApi| madhukamRuNAlapadmakacandanakushakAshaniShkvAthe||215|| The patient should be given warm water sitz bath with the decoction of madhuka, nifnala, padmaka, chandana (Santalum album), kusha (Desmospachya bipinnata) and kasha (Saccharum spontaneum) in cases suffering from bleeding, burning sensation and stickiness. [215]

Cold water sitz-bath in bleeding hemorrhoids: इक्षुरस मधुक वेतस निर्यूहे शीतले पयसि वा तम्| अवगाहयेत् प्रदिग्धं पूर्वं शिशिरेण तैलेन||२१६|| ikṣurasa madhuka vetasa niryūhe śītale payasi vā tam| avagāhayet pradigdhaṃ pūrvaṃ śiśireṇa tailena||216|| ikShurasamadhukavetasaniryUhe shItale payasi vA tam| avagAhayet pradigdhaM pUrvaM shishireNa tailena||216||

The peri-anal area of the patient should be first anointed with cold oil and then sitz bath should be given with sugar-cane juice and the decoctions of madhuka and vetasa mixed with cold water in excessive bleeding. [216]

Hemostatic douche: दत्त्वा घृतं सशर्करमुपस्थदेशे गुदे त्रिकदेशे च| शिशिर जल स्पर्श सुखा धारा प्रस्तम्भनी योज्या||२१७|| dattvā ghṛtaṃ saśarkaramupasthadeśe gude trikadeśe ca| śiśira jala sparśa sukhā dhārā prastambhanī yojyā||217|| dattvA ghRutaM sasharkaramupasthadeshe gude trikadeshe ca| shishirajalasparshasukhA dhArA prastambhanI yojyA||217||

To stop bleeding in hemorrhoids the genitals, anus and lumber region should be smeared with ghee and sugar then douche of cold water should be applied to stop bleeding. [217]

External application of cold leaves: कदलीदलैरभिनवैः पुष्करपत्रैश्च शीतजलसिक्तैः| प्रच्छादनं मुहुर्मुहुरिष्टं पद्मोत्पलदलैश्च||२१८|| kadalīdalairabhinavaiḥ puṣkarapatraiśca śītajalasiktaiḥ| pracchādanaṁ muhurmuhuriṣṭaṁ padmōtpaladalaiśca||218|| kadalIdalairabhinavaiH puShkarapatraishca shItajalasiktaiH| pracchAdanaM muhurmuhuriShTaM padmotpaladalaishca||218|| Hemorrhoid mass should be covered with the leaves of banana, and puskara sprinkled with cold water. Similarly, covering these masses with the leaves of padma (Nelumbo nucifera) and utpala is useful. [218]

Soothing Ointment: दुर्वाघृतप्रदेहः शतधौतसहस्रधौतमपि सर्पिः| व्यजनपवनः सुशीतो रक्तस्रावं जयत्याशु||२१९|| durvāghr̥tapradēhaḥ śatadhautasahasradhautamapi sarpiḥ| vyajanapavanaḥ suśītō raktasrāvaṁ jayatyāśu||219|| durvAghRutapradehaH shatadhautasahasradhautamapi sarpiH| vyajanapavanaH sushIto raktasrAvaM jayatyAshu||219||

External application of durvaghrita, shatadhauta ghrita and sahasradhauta ghrita, and fanning of cold air stops bleeding. [219]

Topical application or rubbing: समङ्गा मधुकाभ्यां तिल मधुकाभ्यां रसाञ्जनवृताभ्याम्| सर्जरस घृताभ्यां वा निम्बघृताभ्यां मधुघृताभ्यां वा||२२०|| दार्वीत्वक्सर्पिर्भ्यां सचन्दनाभ्यामथोत्पलघृताभ्याम्| दाहे क्लेदे च गुदभ्रंशे गुदजाः प्रतिसारणीयाः स्युः||२२१|| samaṅgā madhukābhyāṃ tila madhukābhyāṃ rasāñjanavṛtābhyām| sarjarasa ghṛtābhyāṃ vā nimbaghṛtābhyāṃ madhughṛtābhyāṃ vā||220|| dārvītvaksarpirbhyāṃ sacandanābhyāmathotpalaghṛtābhyām| dāhe klede ca gudabhraṃśe gudajāḥ pratisāraṇīyāḥ syuḥ||221|| sama~ggAmadhukAbhyAM tilamadhukAbhyAM rasA~jjanavRutAbhyAm| sarjarasaghRutAbhyAM vA nimbaghRutAbhyAM madhughRutAbhyAM vA||220|| dArvItvaksarpirbhyAM sacandanAbhyAmathotpalaghRutAbhyAm| dAhe klede ca gudabhraMshe gudajAH pratisAraNIyAH syuH||221|| If there is prolapse of rectum, burning sensation or sticki¬ness in the anus, then the following recipes should be gently rubbed over the anus. [220-221] 1. Samanga and madhuka 2. Tila and madhuka 3. Rasanjana and ghee 4. Sarjarasa and ghee 5. Nimba (Azadirachta indica) and ghee 6. Honey and ghee 7. Bark of darvi (Berberis aristata) and ghee 8. Chandana (Santalum album) and rakta-chandana 9. Utpala (Nelumbo nucifera) and ghee Topical application in continuous bleeding: आभिः क्रियाभिरथवा शीताभिर्यस्य तिष्ठति न रक्तम्| तं काले स्निग्धोष्णैर्मांसरसैस्तर्पयेन्मतिमान्||२२२|| अवपीडक सर्पिर्भिः कोष्णै र्घृत तैलिकैस्तथाऽभ्यङ्गैः| क्षीर घृत तैल सेकैः कोष्णैस्तमुपाचरेदाशु||२२३|| कोष्णेन वातप्रबले घृतमण्डेनानुवासयेच्छीघ्रम्| पिच्छाबस्तिं दद्यात् काले तस्याथवा सिद्धम्||२२४|| ābhiḥ kriyābhirathavā śītābhiryasya tiṣṭhati na raktam| taṃ kāle snigdhoṣṇairmāṃsarasaistarpayenmatimān||222|| avapīḍaka sarpirbhiḥ koṣṇai rghṛta tailikaistathā’bhyaṅgaiḥ| kṣīra ghṛta taila sekaiḥ koṣṇaistamupācaredāśu||223|| koṣṇena vātaprabale ghṛtamaṇḍenānuvāsayecchīghram| picchābastiṃ dadyāt kāle tasyāthavā siddham||224|| AbhiH kriyAbhirathavA shItAbhiryasya tiShThati na raktam| taM kAle snigdhoShNairmAMsarasaistarpayenmatimAn||222|| avapIDakasarpirbhiH koShNairghRutatailikaistathA~abhya~ggaiH| kShIraghRutatailasekaiH koShNaistamupAcaredAshu||223|| koShNena vAtaprabale ghRutamaNDenAnuvAsayecchIghram| picchAbastiM dadyAt kAle tasyAthavA siddham||224||

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 luke warm ghee or oil, or the hemorrhoid mass should be fomented with luke-warm 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 luke-warm ghritamanda (upper portion of the ghee). He should be given the effective piccha basti (recipe of which is described below) at the appropriate time. [222-224] Piccha basti: यवास कुश काशानं मूलं पुष्पं च शाल्मलम्| न्यग्रोधोदुम्बराश्वत्थ शुङ्गाश्च द्विपलोन्मिताः||२२५|| त्रिप्रस्थं सलिलस्यैतत् क्षीरप्रस्थं च साधयेत्| क्षीरशेषं कषायं च पूतं कल्कैर्विमिश्रयेत्||२२६|| कल्काः शाल्मलि निर्यास समङ्गा चन्दनोत्पलम्| वत्सकस्य च बीजानि प्रियङ्गुः पद्मकेशरम्||२२७|| पिच्छाबस्तिरयं सिद्धः सघृतक्षौद्रशर्करः| प्रवाहिका गुदभ्रंश रक्तस्राव ज्वरापहः||२२८|| प्रपौण्डरीकं मधुकं पिच्छाबस्तौ यथेरितान्| पिष्ट्वाऽनुवासनं स्नेहं क्षीरद्विगुणितं पचेत्||२२९|| इति पिच्छाबस्तिः|` koṣṇena vātaprabale ghṛtamaṇḍenānuvāsayecchīghram| picchābastiṃ dadyāt kāle tasyāthavā siddham||224|| yavāsa kuśa kāśānaṃ mūlaṃ puṣpaṃ ca śālmalam| nyagrodhodumbarāśvattha śuṅgāśca dvipalonmitāḥ||225|| triprasthaṃ salilasyaitat kṣīraprasthaṃ ca sādhayet| kṣīraśeṣaṃ kaṣāyaṃ ca pūtaṃ kalkairvimiśrayet||226|| kalkāḥ śālmali niryāsa samaṅgā candanotpalam| vatsakasya ca bījāni priyaṅguḥ padmakeśaram||227|| picchābastirayaṃ siddhaḥ saghṛtakṣaudraśarkaraḥ| pravāhikā gudabhraṃśa raktasrāva jvarāpahaḥ||228|| prapauṇḍarīkaṃ madhukaṃ picchābastau yatheritān| piṣṭvā’nuvāsanaṃ snehaṃ kṣīradviguṇitaṃ pacet||229|| iti picchābastiḥ|` yavAsakushakAshAnaM mUlaM puShpaM ca shAlmalam| nyagrodhodumbarAshvatthashu~ggAshca dvipalonmitAH||225|| triprasthaM salilasyaitat kShIraprasthaM ca sAdhayet| kShIrasheShaM kaShAyaM ca pUtaM kalkairvimishrayet||226|| kalkAH shAlmaliniryAsasama~ggAcandanotpalam| vatsakasya ca bIjAni priya~gguH padmakesharam||227|| picchAbastirayaM siddhaH saghRutakShaudrasharkaraH| pravAhikAgudabhraMsharaktasrAvajvarApahaH||228|| prapauNDarIkaM madhukaM picchAbastau [30] yatheritAn| piShTvA~anuvAsanaM snehaM kShIradviguNitaM pacet||229|| iti picchAbastiH Two palas each of yavasa, kusha, kasha, flowers of semul and adventitious roots of nyagrodha, udumbara and ashwattha should be added in six prasthas of water, two prasthas of milk and boiled till two prasthas remain. This should be strained through a cloth, and to this, the paste of the resin from shalmali (Mocharas), majishtha, chandana, utpala, seeds of kutaja, priyangu and padmakarira should be added. This effective recipe is called piccha basti and it should be admini¬stered along with ghee, honey and sugar. It cures dysentery, prolapsed of rectum, bleeding and fever. [225-228]

Anuvasana basti in bleeding hemorrhoids Prapaundarika and madhuka along with the drugs described in piccha basti should be made to a paste. This paste should be added to oil and double the quantity of milk, and cooked. [This medicated oil should be used for anuvasana type of medicated enema for the patients suffering from hemorrhoids. [229] Hriveradi Ghrita: ह्रीवेरमुत्पलं लोध्रं समङ्गा चव्य चन्दनम्| पाठा सातिविषा बिल्वं धातकी देवदारु च||२३०|| दार्वी त्वङ् नागरं मांसी मुस्तं क्षारो यवाग्रजः| चित्रकश्चेति पेष्याणि चाङ्गेरीस्वरसे घृतम्||२३१|| ऐकध्यं साधयेत् सर्वं तत् सर्पिः परमौषधम्| अर्शोतिसार ग्रहणी पाण्डुरोगे ज्वरेऽरुचौ||२३२|| मूत्रकृच्छ्रे गुदभ्रंशे बस्त्यानाहे प्रवाहणे| पिच्छास्रावेऽर्शसां शूले योज्यमेतत्त्रिदोषनुत्||२३३|| इति ह्रीवेरादिघृतम्| hrīveramutpalaṃ lodhraṃ samaṅgā cavya candanam| pāṭhā sātiviṣā bilvaṃ dhātakī devadāru ca||230|| dārvī tvaṅ nāgaraṃ māṃsī mustaṃ kṣāro yavāgrajaḥ| citrakaśceti peṣyāṇi cāṅgerīsvarase ghṛtam||231|| aikadhyaṃ sādhayet sarvaṃ tat sarpiḥ paramauṣadham| arśotisāra grahaṇī pāṇḍuroge jvare’rucau||232|| mūtrakṛcchre gudabhraṃśe bastyānāhe pravāhaṇe| picchāsrāve’rśasāṃ śūle yojyametattridoṣanut||233|| iti hrīverādighṛtam| hrIveramutpalaM lodhraM sama~ggAcavyacandanam| pAThA sAtiviShA bilvaM dhAtakI devadAru ca||230|| dArvItva~g nAgaraM mAMsI mustaM kShAro yavAgrajaH| citrakashceti peShyANi cA~ggerIsvarase ghRutam||231|| aikadhyaM sAdhayet sarvaM tat sarpiH paramauShadham| arshotisAragrahaNIpANDuroge jvare~arucau||232|| mUtrakRucchre gudabhraMshe bastyAnAhe pravAhaNe| picchAsrAve~arshasAM shUle yojyametattridoShanut||233|| iti hrIverAdighRutam The paste of ingredients like hribera, utpala, lodhra, majitha, chavya chandana, patha, atisa, bilva, dhataki, devadaru, bark of daruharidra, nagaramotha, jatamamsi, musta, yavakshara and chitraka should be made then added 4 times juice of changeri and cooked with ghee as per ghrita siddha. It is an excel¬lent remedy for hemorrhoids, diarrhea grahani, pandu (anemia), fever, anorexia, dysuria, prolapsed rectum, distension in the region of urinary bladder, dysentery, voiding of slimy material and pain in the hemorrhoids. It alleviates all the three aggravated doshas. [230-233]

Sunnishannak changeri ghrita: अवाक्पुष्पी बला दार्वी पृश्निपर्णी त्रिकण्टकः| न्यग्रोधोदुम्बराश्वत्थशुङ्गाश्च द्विपलोन्मिताः||२३४|| कषाय एषां पेष्यास्तु जीवन्ती कटुरोहिणी| पिप्पली पिप्पलीमूलं नागरं सुरदारु च||२३५|| कलिङ्गाः शाल्मलं पुष्पं वीरा चन्दनमुत्पलम् | कट्फलं चित्रको मुस्तं प्रियङ्ग्वतिविषास्थिराः||२३६|| पद्मोत्पलानां किञ्जल्कः समङ्गा सनिदिग्धिका| बिल्वं मोचरसः पाठा भागाः कर्षसमन्विताः||२३७|| चतुष्प्रस्थे शृतं प्रस्थं कषायमवतारयेत्| त्रिंशत्पलानि प्रस्थोऽत्र विज्ञेयो द्विपलाधिकः||२३८|| सुनिषण्णकचाङ्गेर्योः प्रस्थौ द्वौ स्वरसस्य च| सर्वैरेतैर्यथोद्दिष्टैर्घृतप्रस्थं विपाचयेत्||२३९|| एतदर्शःस्वतीसारे रक्तस्रावे त्रिदोषजे| प्रवाहणे गुदभ्रंशे पिच्छासु विविधासु च||२४०|| उत्थाने चातिबहुशः शोथशूले गुदाश्रये| मूत्रग्रहे मूढवाते मन्देऽग्नावरुचावपि||२४१|| प्रयोज्यं विधिवत् सर्पिर्बलवर्णाग्निवर्धनम्| विविधेष्वन्नपानेषु केवलं वा निरत्ययम्||२४२|| इति सुनिषण्णकचाङ्गेरीघृतम्| avākpuṣpī balā dārvī pṛśniparṇī trikaṇṭakaḥ| nyagrodhodumbarāśvatthaśuṅgāśca dvipalonmitāḥ||234|| kaṣāya eṣāṃ peṣyāstu jīvantī kaṭurohiṇī| pippalī pippalīmūlaṃ nāgaraṃ suradāru ca||235|| kaliṅgāḥ śālmalaṃ puṣpaṃ vīrā candanamutpalam | kaṭphalaṃ citrako mustaṃ priyaṅgvativiṣāsthirāḥ||236|| padmotpalānāṃ kiñjalkaḥ samaṅgā sanidigdhikā| bilvaṃ mocarasaḥ pāṭhā bhāgāḥ karṣasamanvitāḥ||237|| catuṣprasthe śṛtaṃ prasthaṃ kaṣāyamavatārayet| triṃśatpalāni prastho’tra vijñeyo dvipalādhikaḥ||238|| suniṣaṇṇakacāṅgeryoḥ prasthau dvau svarasasya ca| sarvairetairyathoddiṣṭairghṛtaprasthaṃ vipācayet||239|| etadarśaḥsvatīsāre raktasrāve tridoṣaje| pravāhaṇe gudabhraṃśe picchāsu vividhāsu ca||240|| utthāne cātibahuśaḥ śothaśūle gudāśraye| mūtragrahe mūḍhavāte mande’gnāvarucāvapi||241|| prayojyaṃ vidhivat sarpirbalavarṇāgnivardhanam| vividheṣvannapāneṣu kevalaṃ vā niratyayam||242|| iti suniṣaṇṇakacāṅgerīghṛtam| avAkpuShpI balA dArvI pRushniparNI trikaNTakaH| nyagrodhodumbarAshvatthashu~ggAshca dvipalonmitAH||234|| kaShAya eShAM peShyAstu jIvantI kaTurohiNI| pippalI pippalImUlaM nAgaraM suradAru ca||235|| kali~ggAH shAlmalaM puShpaM vIrA candanamutpalam [31] | kaTphalaM citrako mustaM priya~ggvativiShAsthirAH||236|| padmotpalAnAM ki~jjalkaH sama~ggA sanidigdhikA| bilvaM mocarasaH pAThA bhAgAH karShasamanvitAH||237|| catuShprasthe shRutaM prasthaM kaShAyamavatArayet| triMshatpalAni prastho~atra vij~jeyo dvipalAdhikaH||238|| suniShaNNakacA~ggeryoH prasthau dvau svarasasya ca| sarvairetairyathoddiShTairghRutaprasthaM vipAcayet||239|| etadarshaHsvatIsAre raktasrAve tridoShaje| pravAhaNe gudabhraMshe picchAsu vividhAsu ca||240|| utthAne cAtibahushaH shothashUle gudAshraye| mUtragrahe mUDhavAte mande~agnAvarucAvapi||241|| prayojyaM vidhivat sarpirbalavarNAgnivardhanam| vividheShvannapAneShu kevalaM vA niratyayam||242|| iti suniShaNNakacA~ggerIghRutam

Avakpushpi, balamoola, daruharidra, pithavana, gokshuru and adventitious roots of nyagrodha, udumbara and ashvattha (2 pala each drug) these drugs should be added and boiled till one prastha of water remains. This decoction should be strained through a cloth. In this decoction jivanti, kutaki, pippali, pippalimoola, nagara, devadaru, indrajava, Flower of shalmali, shatavari, rakta chandana, utpala, katphala, chitraka, musta, priyangu, ativisha, sarivan, pollens of padma, utpala, majitha bhatakataiya, bilva, mocharasa and patha. All these drugs should be taken in the quantity of one karsha each and made to a paste. The juice of changari in the above recipe should be added four times the quan¬tity of ghee because this portion does not contain any other liquid sunishanyaka changeri ghrita. The above mentioned decoction and paste should be added with the juice of sunijannaka and changeri, two prasthas of each and one prastha of ghee, and cooked. This medicated ghee cures hemorrhoids, diarrhea, bleeding caused by the aggravation of all the three doshas, dysentery, voiding of different types of slimy material, prolapsed rectum, urge for motion, edema and pain in anal region, suppression and anorexia. This medicated ghee helps in the promotion of strength, complexion and digestive power. This medicated ghee is harmless, and it can be administered alone or along with different types of food for digestion and strength. [235-242] Different foods in arsha: भवन्ति चात्र- व्यत्यासान्मधुराम्लानि शीतोष्णानि च योजयेत्| नित्यमग्निबलापेक्षी जयत्यर्शःकृतान् गदान्||२४३|| bhavanti cātra- vyatyāsānmadhurāmlāni śītoṣṇāni ca yojayet| nityamagnibalāpekṣī jayatyarśaḥkṛtān gadān||243|| bhavanti cAtra- vyatyAsAnmadhurAmlAni shItoShNAni ca yojayet| nityamagnibalApekShI jayatyarshaHkRutAn gadAn||243|| Thus it is said, depending upon the power of digestion, the patients of hemorrhoids should be given some time cold article and sometimes hot articles sometimes sweet or sour taste drugs or food should be given having opposite characters to keep digestive power normal. [243]

Interdependence of diseases and protection of agni in hemorrhoids: त्रयो विकाराः प्रायेण ये परस्परहेतवः| अर्शांसि चातिसारश्च ग्रहणीदोष एव च||२४४|| एषामग्निबले हीने वृद्धिर्वृद्धे परिक्षयः| तस्मादग्निबलं रक्ष्यमेषु त्रिषु विशेषतः||२४५|| trayo vikārāḥ prāyeṇa ye parasparahetavaḥ| arśāṃsi cātisāraśca grahaṇīdoṣa eva ca||244|| eṣāmagnibale hīne vṛddhirvṛddhe parikṣayaḥ| tasmādagnibalaṃ rakṣyameṣu triṣu viśeṣataḥ||245|| trayo vikArAH prAyeNa ye parasparahetavaH| arshAMsi cAtisArashca grahaNIdoSha eva ca||244|| eShAmagnibale hIne vRuddhirvRuddhe parikShayaH| tasmAdagnibalaM rakShyameShu triShu visheShataH||245||

Hemorrhoids, diarrhea and grahani these three diseases are interdependent. In all patients of above three diseases if the digestive power is low then disease gets aggravated and if digestive power is strong then relief occurs. So, the digestion power should be maintained in these three diseases to overcome them. [244-245]

Treatment in General: भृष्टैः शाकै र्यवागूभिर्यूषैर्मांसरसैः खडैः| क्षीर तक्र प्रयोगैश्च विविधैर्गुदजाञ्जयेत्||२४६|| bhṛṣṭaiḥ śākai ryavāgūbhiryūṣairmāṃsarasaiḥ khaḍaiḥ| kṣīra takra prayogaiśca vividhairgudajāñjayet||246|| bhRuShTaiH shAkairyavAgUbhiryUShairmAMsarasaiH khaDaiH| kShIratakraprayogaishca vividhairgudajA~jjayet||246|| The physician should overcome hemorrhoids by the use of diffe¬rent types of fried vegetables, thick gruel, vegetable soup, meat soup, khada (a sour preparation), milk and curd. [246] Pathya (diet regimen) in hemorrhoids: यद्वायोरानुलोम्याय यदग्निबलवृद्धये| अन्नपानौषधद्रव्यं तत् सेव्यं नित्यमर्शसैः||२४७|| यदतो विपरीतं स्यान्निदाने यच्च दर्शितम्| गुदजाभिपरीतेन तत् सेव्यं न कदाचन||२४८|| yadvāyorānulomyāya yadagnibalavṛddhaye| annapānauṣadhadravyaṃ tat sevyaṃ nityamarśasaiḥ||247|| yadato viparītaṃ syānnidāne yacca darśitam| gudajābhiparītena tat sevyaṃ na kadācana||248|| yadvAyorAnulomyAya yadagnibalavRuddhaye| annapAnauShadhadravyaM tat sevyaM nityamarshasaiH||247|| yadato viparItaM syAnnidAne yacca darshitam| gudajAbhiparItena tat sevyaM na kadAcana||248|| 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 patient suffering from this disease. [247-248] Summary of the chapter: तत्र श्लोकाः- अर्शसां द्विविधं जन्म पृथगायतनानि च| स्थान संस्थानलिङ्गानि साध्यासाध्यविनिश्चयः||२४९|| अभ्यङ्गाः स्वेदनं धूमाः सावगाहाः प्रलेपनाः| शोणितस्यावसेकश्च योगा दीपनपाचनाः||२५०|| पानान्न विधिरग्र्यश्च वातवर्चोऽनुलोमनः| योगाः संशमनीयाश्च सर्पींषि विविधानि च||२५१|| बस्तयस्तक्रयोगाश्च वरारिष्टाः सशर्कराः| शुष्काणामर्शसां शस्ताः स्राविणां लक्षणानि च||२५२|| द्विविधं सानुबन्धानां तेषां चेष्टं यदौषधम्| रक्त सङ्ग्रहणाः क्वाथाः पेष्याश्च विविधात्मकाः||२५३|| स्नेहाहार विधिश्चाग्र्यो योगाश्च प्रतिसारणाः| प्रक्षालनावगाहाश्च प्रदेहाः सेचनानि च||२५४|| अतिवृत्तस्य रक्तस्य विधातव्यं यदौषधम्| तत्सर्वमिह निर्दिष्टं गुदजानां चिकित्सिते||२५५|| tatra ślokāḥ- arśasāṃ dvividhaṃ janma pṛthagāyatanāni ca| sthāna saṃsthānaliṅgāni sādhyāsādhyaviniścayaḥ||249|| abhyaṅgāḥ svedanaṃ dhūmāḥ sāvagāhāḥ pralepanāḥ| śoṇitasyāvasekaśca yogā dīpanapācanāḥ||250|| pānānna vidhiragryaśca vātavarco’nulomanaḥ| yogāḥ saṃśamanīyāśca sarpīṃṣi vividhāni ca||251|| bastayastakrayogāśca varāriṣṭāḥ saśarkarāḥ| śuṣkāṇāmarśasāṃ śastāḥ srāviṇāṃ lakṣaṇāni ca||252|| dvividhaṃ sānubandhānāṃ teṣāṃ ceṣṭaṃ yadauṣadham| rakta saṅgrahaṇāḥ kvāthāḥ peṣyāśca vividhātmakāḥ||253|| snehāhāra vidhiścāgryo yogāśca pratisāraṇāḥ| prakṣālanāvagāhāśca pradehāḥ secanāni ca||254|| ativṛttasya raktasya vidhātavyaṃ yadauṣadham| tatsarvamiha nirdiṣṭaṃ gudajānāṃ cikitsite||255|| tatra shlokAH- arshasAM dvividhaM janma pRuthagAyatanAni ca| sthAnasaMsthAnali~ggAni sAdhyAsAdhyavinishcayaH||249|| abhya~ggAH svedanaM dhUmAH sAvagAhAH pralepanAH| shoNitasyAvasekashca yogA dIpanapAcanAH||250|| pAnAnnavidhiragryashca vAtavarco~anulomanaH| yogAH saMshamanIyAshca sarpIMShi vividhAni ca||251|| bastayastakrayogAshca varAriShTAH sasharkarAH| shuShkANAmarshasAM [32] shastAH srAviNAM lakShaNAni ca||252|| dvividhaM sAnubandhAnAM teShAM ceShTaM yadauShadham| raktasa~ggrahaNAH kvAthAH peShyAshca vividhAtmakAH||253|| snehAhAravidhishcAgryo yogAshca pratisAraNAH| prakShAlanAvagAhAshca pradehAH secanAni ca||254|| ativRuttasya raktasya vidhAtavyaM yadauShadham| tatsarvamiha nirdiShTaM gudajAnAM cikitsite||255||

Following points are discussed in detail in this chapter of treatment of hemorrhoids. 1. The disease arsha is produced by two different causes like congenital and acquired. 2. Different locations, appearance, size, shape and signs as well as symptoms were described in detail. 3. The prognosis of the arsha in the form of curable and non-curable. 4. Different recipes for massage, fomentation, fumigation, sitz bath, external or topical application, blood-letting and digestive stimulation and laxatives. 5. The most useful modes of taking different herbal herbo-mineral drinks and prepared food for patients of arsha; 6. Many recipes for the downward movement of flatus and stool to control the vitiation of vata dosha. 7. Dosha alleviating recipes as per doshic involvement. 8. Different types of medicated ghee. 9. Recipes of medicated enemas 10. The use of butter-milk and its importance in mandagni patients. 11. Excellent arishtas including sharkaraarishta (arishta adding sugar instead of jaggary). 12. The wholesome regimens for dry type of hemorrhoids. 13. The signs and symptoms of bleeding hemorrhoids. 14. Two different types of anubandhas (secondary aggravation of doshas) and their appropriate remedies; 15. Hemostatic decoctions to stop bleeding in hemorrhoids. 16. Preparation and uses of different types of pastes for local application in hemorrhoids. 17. Excellent modes of giving oleation therapy and food. 18. The different recipes used for rubbing on the hemorrhoids mass. 19. Many recipes for washing or local cleaning of perianal region, sitz bath, ointment and sprinkling on hemorrhoids. 20. The remedies in cases of excessive bleeding in hemorrhoids. [249-255] Colophon: इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते चिकित्सास्थानेऽर्शश्चिकित्सितं नाम चतुर्दशोऽध्यायः||१४|| ityagniveśakṛte tantre carakapratisaṃskṛte cikitsāsthāne’rśaścikitsitaṃ nāma caturdaśo’dhyāyaḥ||14|| ityagniveshakRute tantre carakapratisaMskRute cikitsAsthAne~arshashcikitsitaM nAma caturdasho~adhyAyaH||14||

Thus ends of the 14th chapter which deals with the treat¬ment of hemorrhoids (arshas) in the section on therapeutics of Agnivesha's work as redacted by Charaka.

Tattva Vimarsha

• The arsha is of two types viz. congenital and acquired (manifested after the birth). • The congenital haemorrhoids 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 adhishthan (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 alcoho¬lic 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 aggrava¬tion 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 haemorrhoids 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, shodhan (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 stimu¬lation of the digestive power, hemostasis and pachana (meta¬bolic 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 luke warm ghee or oil, or the hemorrhoid mass should be fomented with luke-warm 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 luke-warm 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 vataj and kaphaj type of hemorrhoids while cold water sitz bath should be given in cases of pittaja or rakatj predominant hemorrhoids. Colour 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 and 9 External piles

Fig.10 and 11 Internal piles Current clinical management: Type Medicine Dose Time Anupana Shushka(Dry) Kankayana guti 500-1000 mg Before meals Butter and sugar Bhallatakvaleha 10-15 grams After meals Milk and ghee Abhayarishta 10 to 25 ml After meals With water Wet (bleeding) Nagakeshara mixture 125-250 mg Between two meals three times Milk Samasharkar mixture 200-400 mg Between two meals three times Butter and sugar, milk and sugar

Surgical management: Ksharasutra is the widely accepted effective method.

Further reading

1. Dudhamal TS, Gupta SK, Bhuyan C, Singh K. Clinical study of kutaja and palasha Kshara in the management of Arsha. Indian Journal of Ancient Medicine and Yoga (IJAMY) 2009; 2(2):117-22. 2. Bhuyan C, Gupta SK, Dudhamal TS. Importance of Ksharasutra in the management of Arsha (A study of 3586 cases). AYU International Research Journal of Ayurved. 2009;30(2):232-35. 3. Dudhamal TS, Gupta SK, Bhuyan C, Singh K. The role of Apamarga Kshara in the management of Arsha. AYU 2010;31(2): 232-35. 4. Tomar V, Dudhamal TS, Mahanta VD, Gupta SK. Review of Researches conducted on Arsha (Hemorrhoids) at Institute for Post Graduate Teaching and Research in Ayurveda, Jamnagar. Asian Resonance 2013;2(4): 118-124. 5. Dudhamal TS, Gupta SK, Solanki Milan. Effect of Arshohara Malahara and Adjuvant Drugs in the management of Arsha (1st and 2nd Degree hemorrhoids). Ayurlog; National Journal of Research in Ayurveda Science 2013; 2(3): 1-10. 6. Das BS, Gupta SK, Dudhamal TS, Mahanta VD. Ksharasutra ligation in Arsha (second degree intero-external piles)-A Case Report. PunarnaV 2014; 2(4): 1-7. 7. Gupta SK, Dudhamal TS, Baghel MS, Patil PD. Clinical Efficacy of Arshonyt Tablet and Ointment in hemorrhoids & Fissure-in-ano. Annals of Ayurvedic Medicine (AAM) 2014;3(3-4):81-87. 8. Rao MM, Kar AC, Bhattacharya P. A clinical study on the effect of Kankayan Vati, Kaseesadi Taila Vasti and Triphala Churna in the management of Arsha (haemorrhoids). Journal of Research in Ayurveda and Siddha. 2004;25( 3-4): 9-21 9. Rao MM, Kar AC, Bhattacharya P, Devidas KV. A clinical study on the effect of Kravyadi Rasa, Kaseesadi Taila Vasti and Triphala Churna in the management of arshas (haemorrhoids). Journal of Research in Ayurveda and Siddha 2004;25(1-2) : 1-10 10. Rao MM, Kar AC, Bhattacharya P. A clinical study on the management of Arsha (haemorrhoids) by ayurvedic drug regimen. Journal of Research in Ayurveda and Siddha 2006;27(3-4):48-58 11. Pathak A, Hemantha K. P. A case discussion on effect of Apamarga Pratsaraneeya Kshara in the management of Ardra Arshas w.s.r to histopathological examination. International Journal of Ayurvedic Medicine. 2012; 3(4):193-195. 12. Reddy RG, Mangal A, Jadhav AD, Tathed PS. A case study of thrombosed haemorrhoids treated with leech application. Journal of Research in Ayurveda and Siddha. 2010; 31( 4) :101-112. 13. Mehra M, Makhija R, Vyas N. A clinical study on the role of indigenous formulation on Arsha (piles). Journal of Ayurveda 2010;4(1): 15-22 14. Mehra M, Makhija R, Vyas N. A clinical study on the role of ksara Vasti and Triphala Guggulu in Raktarsha (bleeding piles). AYU 2011;32(2):192-195 15. Reddy RG, Mangal A, Jadhav AD, Tathed PS Venkateshwarlu G. A clinical evalution of efficacy of certain Ayurvedic formulations in the management of Arsha (haemorrhoids). Journal of Research in Ayurveda and Siddha. 2011; 32 3(4) : 31-46. 16. Borkar KM, Shekokar AV, Patange V. A clinical study of Kankayan Vati in the management of Arshas (piles) International Journal of Ayurvedic Medicine.2012; 3 ( 3):177-181. 17. Pal A,Sharma PP, Mukherjee PK. A clinical study of kutaja (Holarrhena antidysenterica wall) on Shonitarsha. AYU .2009; 30(4):369-372. 18. Rao MM, Kar AC, Bhattacharya P, Hazra J. A comparative clinical study on the effect of some compound Ayurvedic preparations in the management of Arsha (haemorrhoids). Journal of Research in Ayurveda and Siddha .2010; 31(3): 1-14 19. Singh R, Ramesh C Arya RC, Minhas SS, Dutt A. A comparative study of barron's rubber band ligation with Ksharsutra ligation in hemorrhoids. International Journal of Ayurveda Research. 2010;1(2):73-81. 20. Singh R, Ramesh C Arya RC, Minhas SS, Dutt A. A comparative study of Guggul Based Apamarga Kshar Sutra ligation with barron s rubber band ligation in haemorrhoids. Journal of Pharmacy Research. 2009; 2(3): 514-523. 21. Shekokar AAV, Borkar KM. A comparative study of Ksharkarma and cryo surgery in the management of Arsha (haemorrhoids). International Journal of Ayurvedic Medicine. 2012;3(3):186-192. 22. Reddy RG, Mangal A, Jadhav AD,Venkateshwarlu GV, Lavekar GS. A single blind clinical study to evaluate the efficacy of herbo-mineral formulation in the treatment of Arsha (haemorrhoids). Journal of Research in Ayurveda and Siddha 2010; 31(4):85-100. 23. Anant Kumar V. Shekokar , 2.Kanchan M. Borkar, 3.Pratik Raut A study on clinical efficacy of nagaradi Modak in the management of Arsha w.s.r to piles. International Journal of Ayurvedic Medicine. 2013;4(1): 72-76. 24. Prasad N, Dash NC, Das BK. A study on medicinal management (Bhesaja Cikitsa) of piles with a patent medicine Pilosap. Journal of Research in Ayurveda and Siddha.2004;25(1-2):11-27. 25. Dongargaon TN, Emmi SV, Wali AA, Kulkarni YS. A unique nonsurgical management of internal hemorrhoids by Jimutaka lepa. Ancient Science of Life. 2014 ;33(3) :176-181 26. Bhagat PJ Raut SY, Lakhapati AM.Clinical efficacy of Jalaukawacharana (leech application) in thrombosed piles. AYU.2012; 33(2): 261-263. 27. Yousefi M etal, Clinical evaluation of commiphora mukul, a botanical resin, in the management of hemorrhoids: a randomized controlled trial. Pharmacognocy Magazine. 2013; 9(36):350-356. 28. Vendateshwarlu G, Pushpalatha H, Sridhar BN. Clinical evaluation of herbo mineral formulations in the management of Arsas (haemorrhoids). Aryavaidyan. 2009; 22(3):153-157. 29. Rao BM. Comparative clinical evaluation of Kshara injection technique in the management of internal hemorrhoids. Ancient Science of Life.1999;19(1 & 2): 39-45. 30. Gupta ML, Gupta SK, Bhuyan C. Comparative clinical evaluation of Kshara Sutra ligation and hemorrhoidectomy in Arsha (hemorrhoids). AYU.2011;32(2): 225-229. 31. Pathak A, Hemantha KP. Comparative study of Apamarga Pratisaraniya Kshara and palasha Pratisaraniya Kshara in the management of Ardra Arsha. 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