द्वितीयोऽध्यायः । अथातोऽर्शसां निदानं व्याख्यास्यामः, यथोवाच भगवान् धन्वन्तरिः ।। १ ।।
Now we shall discourse on the Nidana of Arsas (Haemorrhoids). 1
षडशसि भवन्ति वातपित्तकफशोणितसन्निपातैः सहजानि चेति ॥ २॥
Haemorrhoids may be divided into six classes viz. (i) Vataja (due to the action of the deranged (Vayu), (ii) Pittaja ( due to the action of deranged Pitta), (iii) Kaphaja (due to the action of deranged Kapha, (iv) Raktaja (due to the action of the vitiated blood), (v) Sannipataja (due to the concerted action of the deranged Vayu, Pitta and Kapha and (vi) Sahaja (congenital ). 2
तत्रानात्मवतां यथोक्तैः प्रकोपणैर्विरुद्धाध्यशनस्त्रीप्रसङ्गोत्कटुकासनपृष्ठयानवेगविधारणादिभिर्विशेषैः प्रकुपिता दोषा एकशो द्विशः समस्ताः शोणितसहिता वा यथोक्तं प्रसृताः प्रधानधमनीरनुप्रपद्याधो गत्वा गुदमागम्य प्रदूष्य गुदवलीर्मांसप्ररोहान् जनयन्ति विशेषतो मन्दाग्नेः, तथा तृणकाष्ठोपललोष्ठवस्त्रादिभिः शीतोदकसंस्पर्शनाद् वा कन्दाः परिवृद्धिमासादयन्ति, तान्यर्शासीत्याचक्षते ।। ३ ।।
Pathology: The deranged Vayu, Pitta, etc. enraged by their specific aggravating causes, or by such acts or conduct as partaking of food composed of incompatible substances, eating before the previous meal has been digested, inordinate sexual intercourse, sitting on the haunches, excessive riding, and the voluntary suppression of any natural urging of the body, either severally or in combination of two or three Dosus, or vitiating the blood of a person, who observes no moderation in food and drink & c., become dislodged from their natural seats in the body (according to the law of Prasaranam (expansion and change of place by a deranged organic principle)] and are carried down through the large intestine (Pradhana Dhamani) into the descending colon and getting lodged therein, give rise to growths of polypi or fleshy condylomata, which are known as piles. These growths chiefly appear in persons suffering from impaired digestion ( Agni), and gain in size through friction with the wearing apparel, and weeds. wood, lumps of clay or stone, or by contact with cold water. 3
तत्र स्थूलान्त्रप्रतिबद्धमर्धपञ्चाङ्गुलं गुदमाहुः । तस्मिन् वलयस्तिस्रोऽध्यर्धाङ्गलान्तरसंभूता: प्रवाहणी विसर्जनी संवरणी चेति चतुरङ्गुलायताः; सर्वास्तिर्यगेकाङ्गुलोच्छ्रिताः।। ४।।
The lower end of the large intestine, which passes into the flexure of the rectum and measures four and a half fingers in length, is called the Guda (lit–the channel of fecal matter), the interior of which is provided with three spiral grooves. Each of these grooves or ring-like muscles lie a finger and a half apart, and are respectively known as Pravahani, Visarjani and Samvarani or the grooves of out-flow, defecation and closure of the anus (sphincter ani), covering a space of four fingers and having laterally an elevation of one finger’s width. 4
शङ्खावर्तनिभाश्चापि उपर्युपरि संस्थिताः । गजतालुनिभाश्चापि वर्णतः संप्रकीर्त्तिताः ॥ ५ ॥
रोमान्तेभ्यो यवाध्यर्धो गुदौष्ठः परिकीर्त्तितः । तु प्रथमा गुदौष्ठादङ्गुलमात्रे ।। ६ ।।
Metrical Texts: These grooves are like the involuted indentures of a conch shell, situated one above the other, coloured like the palate of an elephant. A part of the channel, half a finger’s width in length as it is usually measured from the outer hairy orifice of the rectum, is called the anus (Gudaustha ) 5-6
तेषान्तु भविष्यतां पूर्वरूपाणि अन्ने न श्रद्धा कृच्छ्रात् पक्तिरम्लीका ( परिदाहो विष्टम्भः पिपासा) सक्थिसदनमाटोप: कार्यमुद्गारबाहुल्यमक्ष्णोः श्वयथुरन्त्रकूजनं गुदपरिकर्तनमाशङ्का पाण्डुरोगग्रहणीदोषशोषाणां कासश्वासौ बलहानिर्भ्रमस्तन्दा निद्रेन्द्रियदौर्बल्यञ्च । जातेष्वे तानि रूपाणि प्रव्यक्ततराणि भवन्ति । ॥ ७ ॥
Premonitory Symptoms : A non-relish for food, a tardy and difficultdigestion of food (brought into the stomach), acid eructations, burning pain, fulness of abdomen, thirst, a sense of weakness in the thighs, meteorism emaciation of the body, frequent eructations, swellings around the eyes, a croaking sound in the intestines, cutting pain in the rectum (Guda), apparent indications of an attack of phthisis, jaundice, dysentery, cough, dyspnoea, vertigo, somnolence, excessive sleep, weakness of the organs (Indriya), are indications which predict the advent of this disease, and which become more marked with its progress. 7
तत्र मारुतात् परिशुष्कारुणविवर्णानि विषममध्यानि कदम्बपुष्पतुण्डिकेरीनाडीमुखसूचीमुखाकृतीनि च भवन्ति । तैरुपद्रुतः सशूलं संहतमुपवेश्यते कटीपृष्ठपार्श्वमेढ्रगुदनाभिप्रदेशेषु चास्य वेदना भवन्ति, गुल्माष्ठीलाप्लीहोदराणि चास्य तन्निमित्तान्येव भवन्ति, कृष्णत्वङ्नखनयनदशनवदनमूत्रपुरीषश्च पुरुषो भवति ।। ८ ।।
The Vataja Type: Piles, due to the action of the aggravated Vayu, are non-exuding, rose-coloured, and uneven in their surface. They resemble the Kadamba flowers in structure and are either tubular or sharp-pointed like a needle, sometimes assuming the shape of the wild Tundikeri flower. The stool of a haemorrhoid patient of this type becomes excessively hard, and can be evacuated only in a sitting posture, with the greatest pain and difficulty. An excruciating pain is experienced in the regions of the waist, back, sides, anus, umbilicus and the genitals. Symptoms similar to Gulma, Asthila, enlarged spleen and abdominal dropsy add to the distress of the patient, whose skin, nails, eyes, teeth, face, urine and stool also assume a dark black colour. 8
पित्तान्नीलाग्राणि तनूनि विसर्पीणि पीतावभासानि यकृत्प्रकाशानि शुकजिह्वासंस्थानानि यवमध्यानि जलौकोवक्तूसदृशानि प्रक्लिन्नानि च भवन्ति, तैरुपद्रुतः सदाहं सरुधिरमतिसार्यते, ज्वरदाहपिपासामूर्च्छाश्चास्योपद्रवा भवन्ति, पीतत्वङ्नखनयनदशनवदनमूत्रपुरीषश्च पुरुषो भवति ।। ९ ।।
The Pittaja Type : Piles, brought on through the action of the deranged Pitta, are slender, blue-topped, shifting in their nature, yellowish in their hue, or are coloured like shreds of liver, resembling in shape the tongue of the Suka bird. They are thick at middle, like barley grains, or resemble the mouth of leeches and secrete a sort of slimy exudation. The stool is marked with blood, and the patient complains of a painful, burning sensation (in the rectum) at the time of defecation. Fever, with a burning sensation and thirst, and epileptic fits, supervene. The skin, nails, eyes, face, teeth, stool, and urine of the patient assume a yellow hue. 9
श्लेष्मजानि श्वेतानि महामूलानि स्थिराणि वृत्तानि स्निग्धानि पाण्डूनि करीरपनसास्थिगोस्तनाकाराणि न भिद्यन्ते न स्रवन्ति कण्डूबहुलानि च भवन्ति, तैरुपद्रुतः सश्लेष्माणमनल्पं मांसधावनप्रकाशमतिसार्यते, शोफशीतज्वरारोचकाविपाकशिरोगौरवाणि चास्य तन्निमित्तान्येव भवन्ति शुक्लत्वङ्नखनयनदशनवदनमूत्रपुरीषश्च पुरुषो भवति ।। १० ।।
The Kaphaja Type : Piles, due to the action of the deranged Kapha, become white, are sunk about their roots, and are hard, round and glossy. They assume a greyish hue and resemble the teats of a cow or the stones of the Karira, or of a Panasa fruit. These piles do not burst, nor do they exude any sort of secretion. The patient feels an irresistible tendency to itch the excresconces. The stools become copious in quantity and are charged with mucous (Slesma), resembling the washings of meat. Oedema, fever with shivering (Sita-jvara), and heaviness of the head and with a non-relish for food are the symptoms which become manifested with the progress of the disease. The skin, finger nails, eyes, teeth, face, stool and urine of the patient also assume a white colour. 10
रक्तजानि न्यग्रोधप्ररोहविद्रुमकाकणन्तिकाफलसदृशानि पित्तलक्षणानि च, यदाऽवगाढपुरीषप्रपीडितानि भवन्ति तदात्यर्थं दुष्टमनल्पमसक् सहसा विसृजन्ति, तस्य चातिप्रवृतौ शोणितातियोगोपद्रवा भवन्ति ।। ११ ।।
The Raktaja Type : Piles (haemorrhoids), having their origin in the vitiated condition of the blood resemble the sprouts of the Vata tree in shape and are of the colour of red coral, or the seeds (dark red) of Gunja berry. They exhibit all the symptoms, which are similar to the Pittaja type of this disease. Pressed hard by the constricted faeces in their passage through the anus, they suddenly give rise to a haemorrhage of vitiated (venous) blood, and symptoms characteristic of excessive bleeding are found to supervene. 11
सन्निपातजानि सर्वदोषलक्षणयुक्तानि ।। १२ ।।
The Sannipataja Type : In a case of haemorrhoids due to the concerted action of the deranged Vayu, Pitta and Kapha, symptoms characteristic of each of these types manifest themselves in unison. 12
सहजानि दुष्टशोणितशुक्रनिमित्तानि, तेषां दोषत एवं प्रसाधनं कर्त्तव्यम् । विशेषतश्चैतानि दुर्दर्शनानि परुषाणि पाण्डूनि दारुणान्यन्तर्मुखाणि, तैरुपद्रुतः कृशोऽल्पभुक् सिरासन्ततगात्रोऽल्पप्रजः क्षीणरेताः क्षामस्वरः क्रोधनोऽल्पाग्निप्राणः परमलसश्च, तथा घ्राणशिरोऽक्षिनासाश्रवणरोगवान् सततमन्त्रकूजाटोपहृदयोपलेपारोचकप्रभृतिभिः पीड्यते।।१३।।
The Congenital Type: Congenital haemorrhoids (Sahaja Arsas ) are usually ascribed to defects in the semen and ovum of one’s parents and should be medicinally treated with an eye to the special deranged Dosas involved in the case. The polypi (in this type) are hardly visible and are rough and yellowish, with their faces turned inward. They are extremely painful. A person suffering from this type of piles gets thinner and thinner every day and eats very little. Large veins (Sira) appear on the surface of the body. The patient becomes irritable, the semen decreases in quantity, making the procreation of a small number of children possible only by him. The voice becomes feeble, the digestion is impaired, weak vitality, excessive lethargy and disorders affecting the head, nose, ears and eyes follow. A continuous croaking sound is heard in the intestines, attended with a rumbling in the abdomen. All relish for food vanishes and the region of the heart seems to be smeared with a kind of sticky paste (of mucous), etc. 13
भवति चात्र बाह्यमध्यवलिस्थानां प्रतिकुर्याद् भिषग्वरः । अन्तर्वलिसमुत्थानां प्रत्याख्यायाचरेत् क्रियाम् ॥ १४ ॥
Auhoritative verse on the subject : A qualified physician should undertake the medical treatment of haemorrhoids which occur either about the outer or the middle groove of the rectum, (in as much as they prove amenable to medicine). A polypus, appearing about the innermost ring or groove of the rectum, should be treated without holding out any definite hope of cure to the patient. 14
प्रकुपितास्तु दोषा मेढ्रमभिप्रपन्ना मांसशोणिते प्रदूष्य कण्डूं जनयन्ति, ततः कण्डूयनात् क्षतं समुपजायते, तस्मिंश्च क्षते दुष्टमांसजा: प्ररोहाः पिच्छिलरुधिरस्राविणो जायन्ते कूर्चकिनोऽभ्यन्तरमुपरिष्टाद् वा, ते तु शेफो विनाशयन्त्युपघ्नन्ति च पुंस्त्वम्, योनिमभिप्रपन्नाः सुकुमारान् दुर्गन्धान् पिच्छिलरुधिरस्राविणश्छत्राकारान् करीराञ्जनयन्ति, ते तु योनिमुपघ्नन्त्यार्तवञ्च; 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 सानु – नासिकवाक्यत्वं शिरोदुःखञ्च, वक्तूजेषु कण्ठौष्ठतालूनामन्यतमस्मिस्तैर्गद्गदवाक्यता रसाज्ञानं मुखरोगाश्च भवन्ति । व्यानस्तु प्रकुपितः श्लेष्माणं परिगृह्य बहिः स्थिराणि कीलवदर्शासि निर्वर्तयति, तानि चर्मकीलान्यर्शासीत्याचक्षते ।। १५ ।।
Lingarsas (Fig warts or condylomatous growths about the genitals) : The deranged and aggravated Vayu etc., finding lodgment in the genitals, vitiate the local flesh and blood, giving rise to an itching sensation in the affected localities. The parts become ulcerated (through constant scratching) and the ulcers become studded with sprout-like vegetations of flesh ( warts), which exude a kind of slimy, bloody discharge. These growths, or excrescences generally appear on the inner margin, or on the surface of the glans penis, in the form of soft. slender vegetations of skin, resembling the hairs of a small brush (Kurcaka). These vegetations ultimately tend to destroy the penis and the reproductive faculty of the patient.
Bhagarsas : The deranged Vayu etc. of the body, lodged in the vaginal region of a woman, gives rise to similar crops of soft polyp in the passage. They may crop up isolated at the outset, and (by coalescing) may assume the shape of a mushroom or an umbrella, secreting a flow of slimy, foul-smelling blood.
The deranged Vayu, etc. may further take an upward course, and finding a lodgment in the ears, nose, mouth and eyes may produce similar warts in those localities. Warts, which crop up inside the cavities of the ears, may bring on earache, dumbness, and a foul discharge from those organs, while those (cysts) cropping up in the eyes will obstruct the movement of the eye-lids, giving rise to pain and a local secretion and ultimately destroy the eye-sight. Similarly, such growths in the nostrils produce catarrh, excessive sneezing, shortness of breath, headache, nasal speech and the complaint known as Putinasya. Such vegetations cropping up in and about the lips, palate or the larynx, tend to make the speech confused and indistinct. When appearing in the mouth, they impair the faculty of taste, and diseases which affect the cavity of the mouth follow. The excited Vyana Vayu. united with the aggravated Kapha. produces a kind of hard papillomatous growths on the skin (about the anus) which are called the Carmakilas (papillomata).’ 15
भवन्ति चात्र तेषु कीलेषु निस्तोदो मारुतेनोपजायते । श्लेष्मणा तु सवर्णत्वं ग्रन्थित्वञ्च विनिर्दिशेत् ।। १६ ।।
पित्तशोणितजं रौक्ष्यं कृष्णत्वं शुक्लता तथा । समुदीर्णस्वरत्वञ्च चर्मकीलस्य लक्षणम् ।। १७ ।।
Authoritative verses on the subject: These Carmakilas may be attended with a kind of pricking pain through an excess of the deranged Vayu, whereas those which have their origin in the deranged Kapha (lymphatics) assume a knotty shape and become of the same colour as the surrounding skin. On the other hand, they become dry, black or white, and extremely hard through an exuberance of the deranged local blood and Pitta. 16-17
अर्शसां लक्षणं व्यासादुक्तं सामान्यतस्तु यत् । तत् सर्वं प्राग्विनिर्दिष्टात् साधयेद् भिषजां वरः ।। १८ ।।
अर्श:सु दृश्यते रूपं यदा दोषद्वयस्य तु । संसर्गं तं विजानीयात् संसर्गः स च षड्विधः । । १९ । ।
1. According to others, Carnakilas may crop up on the skin of any part of the body.
The symptoms of polypi, appearing in the neighbour-hood of the anus, have been described in full, while the general characteristics of those, which are found to crop up around the genitals, have been briefly discoursed upon. An intelligent physician should ponder over the two groups of symptoms while engaged in treating a case of piles. A case of piles exhibiting symptoms similar to the two deranged Dosas is called the Samsargaja. Six distinct types of Dwi-Dosaja piles are known in practice.¹ 18-19
त्रिदोषाण्यल्पलिङ्गानि याप्यानि तु विनिर्दिशेत् । द्वन्द्वजानि द्वितीयायां वलौ यान्याश्रितानि च ।। २० ।।
कृच्छ्रसाध्यानि तान्याहुः परिसंवत्सराणि च । सन्निपातसमुत्थानि सहजानि तु वर्ज्जयेत् ।। २१ ।।
सर्वाः स्युर्वलयो येषां दुर्नामभिरुपद्रुताः। प्रतिहतो वायुरपानः सन्निवर्त्तते । तस्तु
ततो व्यानेन सङ्गम्य ज्योतिर्मृनाति देहिनाम् ।। २२ । ।
Prognosis: A case of piles due to the concerted action of the three deranged Dosas of the body, (with its characteristic symptoms) but partially developed, may be temporarily checked (Yapya). Cases, which are of more than a year’s standing, as well as those in which the haemorrhoids are due to the concerted action of the two Dosas (Sansargaja), or are situated in the middle groove of the rectum, may be cured but with the greatest difficulty. Cases of the Sannipatika or congenital (Sahaja) types should be given up as incurable. The Apana Vayu, in a person whose rectum is overrun with such polypus growths, tries to pass out through the anus, but is driven back upward, being obstructed in its passage by the vegetations, and then mixes with his Vyana Vayu, thus imparing (the five-functioned) fire (Pitta) in his body. 20-22
इति सुश्रुतसंहितायां निदानस्थानेऽशनिदानं नाम द्वितीयोऽध्यायः || २ ||
Thus ends the second Chapter of the Nidanasthana in the Susruta Samhita which deals with the Nidana of piles.
