Sushruta Samhita Nidanasthana Chapter 2 Arshas Nidanam (Haemorrhoids)

The 2nd chapter of Nidanasthana of Sushruta Samhita is named as Arshasam Nidanam Adhyaya. This chapter deals with Diagnosis of Hemorrhoids.

अथातोऽर्शसां निदानं व्याख्यास्यामः ।।१ ।।
यथोवाच भगवान् धन्वन्तरिः ।।२ ।।
We will now expound the diagnosis of arshas (piles) ; as revealed by the venerable Dhanvantari .

arshas bheda: Kinds of piles

षडांसि भवन्ति वातपित्तकफशोणितसन्निपातैः सहजानि चेति ।।३ ।।

arshas is of six types and are as below mentioned –

• Vataja arshas
• Pittaja arshas
• Kaphaja arshas
• Sonitaja / Raktaja arshas
• Sannipataja arshas – piles caused by aggravation of all three doshas and
• Sahaja arshas – congenital piles

Nidana-samprāpti: Causes and Pathogenesis

तत्रानात्मवतां यथोक्तैःप्रकोपणैर्विरुद्धाध्यशनस्त्रीप्रसङ्गोत्कटुकासनपृष्ठयानवेग विधारणादिभिर्विशेषैः प्रकुपिता दोषा एकशो द्विशः समस्ताः शोणितसहिता वा यथोक्तं प्रसृताः प्रधानधमनीरनुप्रपद्याधो गत्वा गुदमागम्य प्रदूष्य गुदवलीमा॑सप्ररोहाञ्जनयन्ति विशेषतो मन्दाग्नेः , तथा तृणकाष्ठोपललोष्ठवस्त्रादिभिः शीतोदकसंस्पर्शनाद्वा कन्दाः परिवृद्धिमासादयन्ति , तान्यर्शांसीत्याचक्षते ||4||

Causes – Excessive indulgence in etiological factors of below mentioned types would cause aggravation of doshas mainly in persons who are not self-controlled and indulge in things which aggravate doshas –

• Incompatible foods,
• Excessive consumption of foods,
• Excessive indulgence in copulation,
• Sitting on heels for prolonged time
• Too much riding on animals,
• Regularly suppressing the urges of the body

Pathogenesis – Due to the above said causes, the doshas get aggravated either individually or in combination of two or all the three doshas together or the three doshas along with blood. These doshas spread out and travel through the main dhamanis – blood vessels / arteries. Through the dhamanis, they move in the downward direction and reach the guda – rectum and anus region. On reaching the mentioned places i.e. rectum and anal region, the doshas would produce sprouts of muscles in the gudavali i.e. folds of the rectum, mainly in those who have weak digestive fire.
When they come into contact with materials like grass, sticks, stone pebbles and lumps of clothes etc. or with cold water, these sprouts grow in size. These sprouts are called arshas.

Gudavali: Folds of the rectum

तत्र स्थूलान्त्रप्रतिबद्धमर्धपञ्चाङ्गुलं गुदमाहुः, तस्मिन् वलयस्तिस्रोऽध्यर्धाङ्गुलान्तर संभूताः प्रवाहणी विसर्जनी संवरणी चेति चतुरङ्गलायताः; सर्वास्तिर्यगेकाङ्गुलोच्छ्रिताः ।।५ ।।
शङ्खावर्तनिभाश्चापि उपर्युपरि संस्थिताः ।।
गजतालुनिभाश्चापि वर्णतः संप्रकीर्तिताः ।।
रोमान्तेभ्यो यवाध्यर्धो गुदौष्ठः परिकीर्तितः ||६||
प्रथमा तु गुदौष्ठादङ्गुलमात्रे ।।७ ।।
Guda / rectum – measures five and half angula (9.9 cm). It is the portion of guda which is attached to the large intestine.
There are three folds in the Guda and these folds are called Valis. Each of the three valis are separated from the immediate next vali by a distance of one and half angula (2.7 cm). The total length of all the three valis together is four and half angula (8.1 cm). These valis are situated one angula (1.8 cm) above the anus.
The names of the Guda Valis are

• Pravahani
• Visarjani and
• Samvarani

Shape of the valis – The folds of the rectum resemble the spirals of the conch and are situated one above the other. They resemble the palate of an elephant in color.
Gudostha or Guda Ostha – lip of the anus (opening of the anal canal outwards) – It is an area of one and half yava or half angula (0.9 cm) above the line of hairs.

The first fold or vali of the guda is situated at one angula (1.8 cm) above the gudostha.

Notes – Among the three folds,

1. Pravahani – the first from above downwards or innermost (Abhyantara) is Pravāhani – that is responsible for straining to expel the Feces.
2. Visarjani – Next, below it (Pravahani) or middle (Madhyama) fold is called Visarjani since it expels the feces.
3. Samvarani – The next fold beneath Visarjani – the third fold or external (Bāhya) fold is called Samvaraņi since it constricts or closes the rectal orifice.
   Gudoștha (anal lip) is below the last fold. Pile masses develop in all the three folds. Though the ancients have called these as Māmsāñkura (sprouts of muscles), strictly speaking these are Sirā añkura (engorged veins) protruding out of the rectal wall.

Pūrvarūpa: Premonitory symptoms

तेषां तु भविष्यतां पूर्वरूपाणि – अन्नेऽश्रद्धा कृच्छ्रात् पक्तिरम्लीका परिदाहो विष्टम्भः पिपासा सक्थिसदनमाटोपः कार्यमुद्गारबाहुल्यमक्ष्णोःश्वयथुरन्त्रकूजनं गुदपरिकर्तनमाशङ्का पाण्डुरोगग्रहणीदोषशोषाणां कासश्वासौ बलहानिर्धमस्तन्द्रा निनेन्द्रियदौर्बल्यं च ।।८ ।।
जातेष्वेतान्येव लक्षणानि प्रव्यक्ततराणि भवन्ति ।।९ ।।
The following are the premonitory symptoms of arshas (piles) developing later –

• lack of desire for food,
• digestion (of food) with difficulty,
• sour belching,
• burning sensation inside,
• long stasis of food,
• severe thirst,
• debility of the thighs,
• gurgling sounds in the abdomen / flatulence,
• emaciation,
• too many belching,
• swelling around the eyes,
• sounds from the intestines,
• cutting pain in the anus (rectum),
• doubt of the presence of anemia and duodenal disease,
• consumption, cough and dyspnoea;
• loss of strength,
• giddiness,
• stupor,
• more of sleep and
• weakness of sense organs

The same premonitory symptoms would become well manifest as the symptoms of the disease, after the disease develops or progresses into the next stage.

Rupa: Signs and symptoms

Vataja arshas

तत्र मारुतात् परिशुष्कारुणविवर्णानि विषममध्यानि कदम्बपुष्पतुण्डिकेरीनाडी मुकुलसूचीमुखाकृतीनि च भवन्ति ; तैरुपद्रुतः सशूलं संहतमुपवेश्यते , कटीपृष्ठपार्श्वमेढ़गुद नाभिप्रदेशेषु चास्य वेदना भवन्ति , गुल्माष्ठीलाप्लीहोदराणि चास्य तन्निमित्तान्येव भवन्ति , कृष्णत्वङ्नखनयनदशनवदनमूत्रपुरीषश्च पुरुषो भवति ।।१० ।।
In piles produced by aggravated vata the below mentioned signs and symptoms will be seen,
Appearance of pile mass –

• dry
• color – slightly red or will have many colors
• irregular in their middle part,
• resemblance – the masses appear like flowers of Kadamba and tundikeri, nadi, mukula – flower bud or suci mukha – eye or orifice of the needle in shape
  Symptoms – The person –
• expels hard feces with pain,
• feels pain in the waist, back, flanks, penis, anus and area of the umbilicus;
• becomes a patient of abdominal tumor, prostate enlargement and splenomegaly
• will have blackish coloration of skin, nails, eyes, teeth, mouth, urine and feces because of this (piles) only

Pittaja arshas

पित्तान्नीलाग्राणि तनूनि विसmÉÏïणि पीतावभासानि यकृत्प्रकाशानि शुकजिह्वा संस्थानानि यवमध्यानि जलौकोवक्त्रसदृशानि प्रक्लिन्नानि च भवन्ति ; तैरुपद्रुतः सदाहं सरुधिरमतिसार्यते , ज्वरदाहपिपासामूर्छाश्चास्योपद्रवा भवन्ति , पीतत्वङ्नखनयनदशनवदनमूत्र पुरीषश्च पुरुषो भवति ।।११ ।।
In piles produced by aggravated pitta the below mentioned signs and symptoms may be seen,
Appearance of pile mass –

• color – blue at the tip, yellowish or liver-like in color
• thin
• spreading
• appearance – resembles parrot tongue in shape, the masses are bulged in the middle portion like barley or like the mouth of the leech
• there is exudation from the masses
  Symptoms – The person –
• expels liquid feces mixed with blood;
• develops fever, burning sensation, severe thirst and fainting as complications;
• will have yellow coloration of his skin, nail, eyes, teeth, mouth, urine and feces

Kaphaja arshas

श्लेष्मजानि श्वेतानि महामूलानि स्थिराणि वृत्तानि स्निग्धानि पाण्डूनि करीर पनसास्थिगोस्तनाकाराणि , न भिद्यन्ते न स्रवन्ति कण्डूबहुलानि च भवन्ति ; तैरुपद्रुतः सश्लेष्माणमनल्पं मांसधावनप्रकाशमतिसार्यते , शोफशीतज्वरारोचकाविपाकशिरोगौरवाणि चास्य तन्निमित्तान्येव भवन्ति , शुक्लत्वङ्नखनयनदशनवदनमूत्रपुरीषश्च पुरुषो भवति ।।१२ ।।
In piles produced by aggravated kapha the below mentioned signs and symptoms may be seen,
Appearance of pile mass –

• white in color
• deep rooted
• immobile
• round
• unctuous
• pale
• resemble Karira, Panasa asthi or Gostana in shape
• the masses do not burst open
• there is no exudation of fluids from the masses
• has severe itching

Symptoms – the person –

• has diarrhea, with feces mixed with Kapha, large in quantity , resembling mutton wash;
• suffers from swelling, cold fever (with chills), loss of taste, improper digestion and heaviness of the head – which develop only because of this (piles)
• will have whitish coloration of his skin, nails, eyes, teeth, mouth, urine and feces

Raktaja arshas

रक्तजानि न्यग्रोधप्ररोहविद्रुमकाकणन्तिकाफलसदृशानि पित्तलक्षणानि च , यदाऽ वगाढपुरीषपीडितानि भवन्ति तदाऽत्यर्थं दुष्टमनल्पमसक् सहसा विसृजन्ति , तस्य चातिप्रवृत्तौ शोणितातियोगोपद्रवा भवन्ति ।।१३ ।।
In piles produced by aggravated rakta the below mentioned signs and symptoms may be seen,
Appearance of pile mass –

• resembles the sprouts of Nyagrodha, coral, fruit of Kakanantika / Gunja
• will have features of pile masses caused by pitta
  Symptoms – the person –
• expels feces along with large quantity of vitiated blood suddenly when the feces becomes hard
• develops complications / secondary diseases arising from too much loss of blood when this bleeding becomes too much

Tridoshaja Arshas

सन्निपातजानि सर्वदोषलक्षणयुक्तानि ।।१४ ।।
The symptoms of all the doshas mentioned above will be present in mixed proportions in the piles caused by simultaneous aggravation of all the three doshas.

Sahaja arshas

सहजानि दुष्टशोणितशुक्रनिमित्तानि, तेषां दोषत एव प्रसाधनं कर्तव्यं, विशेष तश्चैतानि दुर्दर्शनानि परुषाणि पांसूनि दारुणान्यन्तर्मुखानि; तैरुपद्रुतः कृशोऽल्पभुक् सिरासन्त तगात्रोऽल्पप्रजः क्षीणरेताः क्षामस्वर; क्रोधनोऽल्पानिप्राणः परमलसश्च तथा घ्राणशिरोऽक्षिना साश्रवणरोगी , सततमन्त्रकूजाटोपहृदयोपलेपारोचकप्रभृतिभिः पीड्यते ।।१५ ।।
Sahaja arshas means congenital piles. It is caused due to the vitiation of sonita – ovum (menstrual blood) and sukra – sperm (semen). This condition shall be treated in accordance to the symptoms caused by predominant doshas only.
Appearance of pile masses –

• they are located deep inside and are difficult to see
• coarse
• color – dark brown
• bent inwards
• troublesome
  Symptoms –
• the patient eats less food being afflicted by this condition
• visible prominent network of veins all over the body
• the person has less progeny
• has less semen
• has feeble voice
• is always angry
• suffers from weak digestive fire and digestion
• has poor strength
• is very lazy
• suffers from diseases of nose, head, eyes and ears
• has flatulence and intestinal gurgling
• experiences a feeling of something being coated in the region of the heart
• loss of taste etc.

Prognosis of piles depending on the folds in which they manifest

भवति चात्र
बाह्यमध्यवलिस्थानां प्रतिकुर्याद्भिषग्वरः ।।
अन्तर्वलिसमुत्थानां प्रत्याख्यायाचरेत् क्रियाम् ।।१६ ।।
One more verse here-
The physician should treat the arshas present in the external and middle valis – folds because they are curable. On the other hand, while treating the pile masses located in the interior fold, the physician should intimate the relatives of the patient about its incurability and should treat considering it incurable.

Anya sthāna arshas, piles at other places

प्रकुपितास्तु दोषा मेढ्रमभिप्रपन्ना मांसशोणिते प्रदूष्य कण्डूं जनयन्ति, ततः कण्डूयनात् क्षतं समुपजायते, तस्मिंश्च क्षते दुष्टमांसजाः प्ररोहाः पिच्छिलरुधिरस्राविणो जायन्ते कूर्चकिनोऽभ्यन्तरमुपरिष्टाद्वा, ते तु शेफो विनाशयन्त्युपघ्नन्ति च पुंस्त्वं; योनिमभिप्रपन्नाः सुकुमारान् दुर्गन्धान् पिच्छिलरुधिरस्राविणश्छत्राकारान् करीराञ्जनयन्ति, ते तु योनिमुपघ्नन्त्यार्तवं च; नाभिमभिप्रपन्नाः सुकुमारान् दुर्गन्धान् पिच्छिलान् गण्डूपदमुखसदृशान् करीराञ्जनयन्ति; त एवोर्ध्वमागताः श्रोत्राक्षिघ्राणवदनेष्वर्शांस्युपनिर्वर्तयन्ति; तत्र कर्णजेषु बाधिर्यं शूलं पूतिकर्णता च, नेत्रजेषु वर्त्मावरोधो वेदना स्रावो दर्शननाशश्च, घ्राणजेषु प्रतिश्यायोऽतिमात्रं क्षवथुः कृच्छ्रोच्छ्वासता पूतिनस्यं सानुनासिकवाक्यत्वं शिरोदुःखं च; वक्रजेषु कण्ठौष्ठतालूनामन्यतमस्मिंस्तैर्गद्गदवाक्यता रसाज्ञानं मुखरोगाश्च भवन्ति ||१७||
arshas occurring in the penis
The aggravated doshas reach the penis and get lodged therein. They vitiate the muscles and blood of the penis and cause itching therein.
Due to itching, the person keeps scratching the penis.
As a result of repeated scratching, an ulcer is formed on the penis.
Sprouts of vitiated muscles develop from that ulcer. These sprouts discharge slimy blood.
The mass might go into the depth of the muscles of the penis or even remain on the surface itself and cause itching.
They not only destroy the penis, but also masculinity.

arshas occurring in the vagina
The aggravated doshas reach the vagina and get lodged therein. These doshas give rise to the pile masses in the vagina.
The pile masses are soft and discharge foul smelling blood which is also slimy.
The sprouts resemble an umbrella in shape.
They not only destroy the vagina but also the menstrual blood / ovum.

arshas occurring in the umbilical region
The aggravated doshas reach the umbilicus and get lodged therein. These doshas, in later part of time, would give rise to sprouts which are tender. They emit a bad smell, are slimy and resemble the mouth of an earthworm in shape.

The aggravated doshas reach the upper parts of the body and get localized in ears, eyes, nose, mouth or face and produce arsa ankuras i.e. sprouts / pile-like masses in these regions.

Charmakila

व्यानस्तु प्रकुपितः श्लेष्माणं परिगृह्य बहिः स्थिराणि कीलवदर्शासि निर्वर्तयति, तानि चर्मकीलान्यासीत्याचक्षते ।।१८ ।।
The aggravated vyana vata along with kapha getting lodged in the skin would give rise to peg-like sprouts which are immovable, in the external part of the skin. This condition is called Carmakila or arshas of the skin.

भवन्ति चात्र
तेषु कीलेषु निस्तोदो मारुतेनोपजायते ।।
श्लेष्मणा तु सवर्णत्वं ग्रन्थित्वं च विनिर्दिशेत् ।।१९ ।।
पित्तशोणितजं रौक्ष्यं कृष्णत्वं श्लक्ष्णता तथा ।।
समुदीर्णखरत्वं च चर्मकीलस्य लक्षणम् ।।२० ।।
Some verses here-
Below mentioned are the dosha related symptoms in Charmakila –

• vata – causes pricking pain
• pitta and rakta together – cause dryness, black color, smoothness and profound hardness
• kapha – causes – colors of the sprouts and tumor like growths

अर्शसां लक्षणं व्यासादुक्तं सामान्यतस्तु यत् ।।
तत्सर्वं प्राग्विनिर्दिष्टात्साधयेद्भिषजां वरः ।।२१ ।।
Until now, the symptoms of arshas have been described elaborately. The common symptoms for all kinds of arshas were described earlier. The physician should begin the treatment of arshas only after having understood these symptoms and signs clearly.

Samsargaja arshas

अर्श: सु दृश्यते रूपं यदा दोषद्वयस्य तु ।।
संसर्गं तं विजानीयात् संसर्गः स च षड्विधः ।।२२ ।।
One should understand the samsarga i.e. involvement of combination of two doshas in the causation of piles when the symptoms of two doshas are evident in arshas. Such combinations will be of six types.

Sadhyāsādhyatā: Prognosis

त्रिदोषाण्यल्पलिङ्गानि याप्यानि तु विनिर्दिशेत् ।।
द्वन्द्वजानि द्वितीयायां वलौ यान्याश्रितानि च ।।२३ ।।
कृच्छ्रसाध्यानि तान्याहुः परिसंवत्सराणि च ।।
सन्निपातसमुत्थानि सहजानि तु वर्जयेत् ।।२४ ।।
सर्वाः स्युर्वलयो येषां दुर्नामभिरुपद्रुताः |
तैस्तु प्रतिहतो वायुरपानः सन्निवर्तते ||२५||
ततो व्यानेन सङ्गम्य ज्योतिर्मृद्नाति देहिनाम् ||२६||
Yapya arshas – arshas caused by involvement of all three doshas having few and mild symptoms is considered to be yapya i.e. manageable.
Krchchra Sadhya arshas – Those produced by combination of any two doshas, those situated in the second fold, and those which are more than one year old should be considered as krchrasadhya (difficult to cure).
Varjya / Asadya arshas – The piles which are produced by the combination of all the three Doshas and which are congenital should be rejected.
The person in whom all the folds of the rectum have developed piles, Apana Vata getting obstructed in its downward movement by the pile masses, moves upwards and on combining with vyana vata diminishes the heat (warmth of the body) of the person (and kills him).

इति सुश्रुतसंहितायां निदानस्थानेऽर्शोनिदानं नाम द्वितीयोऽध्यायः ||२||
Thus ends the second chapter by the name Arshasam Nidanam in Nidana Sthana of Sushruta Samhita.