Sushruta Samhita Nidanasthana Chapter 2 Arshas Nidanam (Haemorrhoids)

The 2nd chapter of Nidanasthana of Sushruta Samhita is called as Arshasam Nidanam Adhyaya. This chapter offers with Analysis of Hemorrhoids.

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

arshas bheda: Sorts of piles

षडांसि भवन्ति वातपित्तकफशोणितसन्निपातैः सहजानि चेति ।।३ ।।

arshas is of six varieties and are as beneath talked about –

• Vataja arshas
• Pittaja arshas
• Kaphaja arshas
• Sonitaja / Raktaja arshas
• Sannipataja arshas – piles attributable to 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 – Extreme indulgence in etiological elements of beneath talked about varieties would trigger aggravation of doshas primarily in individuals who are usually not self-controlled and take pleasure in issues which worsen doshas –

• Incompatible meals,
• Extreme consumption of meals,
• Extreme indulgence in copulation,
• Sitting on heels for extended time
• An excessive amount of using on animals,
• Recurrently suppressing the urges of the physique

Pathogenesis – As a result of above stated causes, the doshas get aggravated both individually or together of two or all of the three doshas collectively or the three doshas together with blood. These doshas unfold out and journey via the principle dhamanis – blood vessels / arteries. Via the dhamanis, they transfer within the downward path and attain the guda – rectum and anus area. On reaching the talked about locations i.e. rectum and anal area, the doshas would produce sprouts of muscle groups within the gudavali i.e. folds of the rectum, primarily in those that have weak digestive fireplace.
Once they come into contact with supplies like grass, sticks, stone pebbles and lumps of garments and so forth. or with chilly water, these sprouts develop in measurement. These sprouts are referred to as 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 5 and half angula (9.9 cm). It’s the portion of guda which is hooked up to the massive gut.
There are three folds within the Guda and these folds are referred to as Valis. Every of the three valis are separated from the speedy subsequent vali by a distance of 1 and half angula (2.7 cm). The full size of all of the three valis collectively is 4 and half angula (8.1 cm). These valis are located one angula (1.8 cm) above the anus.
The names of the Guda Valis are

• Pravahani
• Visarjani and
• Samvarani

Form of the valis – The folds of the rectum resemble the spirals of the conch and are located one above the opposite. They resemble the palate of an elephant in colour.
Gudostha or Guda Ostha – lip of the anus (opening of the anal canal outwards) – It’s an space of 1 and half yava or half angula (0.9 cm) above the road of hairs.

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

Notes – Among the many three folds,

1. Pravahani – the primary from above downwards or innermost (Abhyantara) is Pravāhani – that’s answerable for straining to expel the Feces.
2. Visarjani – Subsequent, beneath it (Pravahani) or center (Madhyama) fold is named Visarjani because it expels the feces.
3. Samvarani – The following fold beneath Visarjani – the third fold or exterior (Bāhya) fold is named Samvaraņi because it constricts or closes the rectal orifice.
   Gudoștha (anal lip) is beneath the final fold. Pile plenty develop in all of the three folds. Although the ancients have referred to as these as Māmsāñkura (sprouts of muscle groups), strictly talking these are Sirā añkura (engorged veins) protruding out of the rectal wall.

Pūrvarūpa: Premonitory signs

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 next are the premonitory signs of arshas (piles) creating later –

• lack of need for meals,
• digestion (of meals) with issue,
• bitter belching,
• burning sensation inside,
• lengthy stasis of meals,
• extreme thirst,
• debility of the thighs,
• gurgling sounds within the stomach / flatulence,
• emaciation,
• too many belching,
• swelling across the eyes,
• sounds from the intestines,
• reducing ache within the anus (rectum),
• doubt of the presence of anemia and duodenal illness,
• consumption, cough and dyspnoea;
• lack of power,
• giddiness,
• stupor,
• extra of sleep and
• weak spot of sense organs

The identical premonitory signs would develop into nicely manifest because the signs of the illness, after the illness develops or progresses into the following stage.

Rupa: Indicators and signs

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 beneath talked about indicators and signs might be seen,
Look of pile mass –

• dry
• colour – barely crimson or could have many colours
• irregular of their center half,
• resemblance – the plenty seem like flowers of Kadamba and tundikeri, nadi, mukula – flower bud or suci mukha – eye or orifice of the needle in form
  Signs – The particular person –
• expels arduous feces with ache,
• feels ache within the waist, again, flanks, penis, anus and space of the umbilicus;
• turns into a affected person of stomach tumor, prostate enlargement and splenomegaly
• could have blackish coloration of pores and skin, nails, eyes, tooth, mouth, urine and feces due to this (piles) solely

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 beneath talked about indicators and signs could also be seen,
Look of pile mass –

• colour – blue on the tip, yellowish or liver-like in colour
• skinny
• spreading
• look – resembles parrot tongue in form, the plenty are bulged within the center portion like barley or just like the mouth of the leech
• there may be exudation from the plenty
  Signs – The particular person –
• expels liquid feces combined with blood;
• develops fever, burning sensation, extreme thirst and fainting as issues;
• could have yellow coloration of his pores and skin, nail, eyes, tooth, 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 beneath talked about indicators and signs could also be seen,
Look of pile mass –

• white in colour
• deep rooted
• motionless
• spherical
• unctuous
• pale
• resemble Karira, Panasa asthi or Gostana in form
• the plenty don’t burst open
• there is no such thing as a exudation of fluids from the plenty
• has extreme itching

Signs – the particular person –

• has diarrhea, with feces combined with Kapha, massive in amount , resembling mutton wash;
• suffers from swelling, chilly fever (with chills), lack of style, improper digestion and heaviness of the top – which develop solely due to this (piles)
• could have whitish coloration of his pores and skin, nails, eyes, tooth, 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 beneath talked about indicators and signs could also be seen,
Look of pile mass –

• resembles the sprouts of Nyagrodha, coral, fruit of Kakanantika / Gunja
• could have options of pile plenty attributable to pitta
  Signs – the particular person –
• expels feces together with massive amount of vitiated blood instantly when the feces turns into arduous
• develops issues / secondary ailments arising from an excessive amount of lack of blood when this bleeding turns into an excessive amount of

Tridoshaja Arshas

सन्निपातजानि सर्वदोषलक्षणयुक्तानि ।।१४ ।।
The signs of all of the doshas talked about above might be current in combined proportions within the piles attributable to simultaneous aggravation of all of 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’s triggered because of the vitiation of sonita – ovum (menstrual blood) and sukra – sperm (semen). This situation shall be handled in accordance to the signs attributable to predominant doshas solely.
Look of pile plenty –

• they’re situated deep inside and are tough to see
• coarse
• colour – darkish brown
• bent inwards
• troublesome
  Signs –
• the affected person eats much less meals being stricken by this situation
• seen distinguished community of veins everywhere in the physique
• the particular person has much less progeny
• has much less semen
• has feeble voice
• is at all times offended
• suffers from weak digestive fireplace and digestion
• has poor power
• may be very lazy
• suffers from ailments of nostril, head, eyes and ears
• has flatulence and intestinal gurgling
• experiences a sense of one thing being coated within the area of the center
• lack of style and so forth.

Prognosis of piles relying on the folds through which they manifest

भवति चात्र
बाह्यमध्यवलिस्थानां प्रतिकुर्याद्भिषग्वरः ।।
अन्तर्वलिसमुत्थानां प्रत्याख्यायाचरेत् क्रियाम् ।।१६ ।।
Yet one more verse here-
The doctor ought to deal with the arshas current within the exterior and center valis – folds as a result of they’re curable. Then again, whereas treating the pile plenty situated within the inside fold, the doctor ought to intimate the relations of the affected person about its incurability and may deal with contemplating it incurable.

Anya sthāna arshas, piles at different locations

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 within the penis
The aggravated doshas attain the penis and get lodged therein. They vitiate the muscle groups and blood of the penis and trigger itching therein.
Because of itching, the particular person retains scratching the penis.
On account of repeated scratching, an ulcer is shaped on the penis.
Sprouts of vitiated muscle groups develop from that ulcer. These sprouts discharge slimy blood.
The mass may go into the depth of the muscle groups of the penis and even stay on the floor itself and trigger itching.
They not solely destroy the penis, but additionally masculinity.

arshas occurring within the vagina
The aggravated doshas attain the vagina and get lodged therein. These doshas give rise to the pile plenty within the vagina.
The pile plenty are mushy and discharge foul smelling blood which can be slimy.
The sprouts resemble an umbrella in form.
They not solely destroy the vagina but additionally the menstrual blood / ovum.

arshas occurring within the umbilical area
The aggravated doshas attain the umbilicus and get lodged therein. These doshas, in later a part of time, would give rise to sprouts that are tender. They emit a foul scent, are slimy and resemble the mouth of an earthworm in form.

The aggravated doshas attain the higher components of the physique and get localized in ears, eyes, nostril, mouth or face and produce arsa ankuras i.e. sprouts / pile-like plenty in these areas.

Charmakila

व्यानस्तु प्रकुपितः श्लेष्माणं परिगृह्य बहिः स्थिराणि कीलवदर्शासि निर्वर्तयति, तानि चर्मकीलान्यासीत्याचक्षते ।।१८ ।।
The aggravated vyana vata together with kapha getting lodged within the pores and skin would give rise to peg-like sprouts that are immovable, within the exterior a part of the pores and skin. This situation is named Carmakila or arshas of the pores and 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-
Beneath talked about are the dosha associated signs in Charmakila –

• vata – causes pricking ache
• pitta and rakta collectively – trigger dryness, black colour, smoothness and profound hardness
• kapha – causes – colours of the sprouts and tumor like growths

अर्शसां लक्षणं व्यासादुक्तं सामान्यतस्तु यत् ।।
तत्सर्वं प्राग्विनिर्दिष्टात्साधयेद्भिषजां वरः ।।२१ ।।
Till now, the signs of arshas have been described elaborately. The widespread signs for every kind of arshas had been described earlier. The doctor ought to start the remedy of arshas solely after having understood these signs and indicators clearly.

Samsargaja arshas

अर्श: सु दृश्यते रूपं यदा दोषद्वयस्य तु ।।
संसर्गं तं विजानीयात् संसर्गः स च षड्विधः ।।२२ ।।
One ought to perceive the samsarga i.e. involvement of mixture of two doshas within the causation of piles when the signs of two doshas are evident in arshas. Such mixtures might be of six varieties.

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 attributable to involvement of all three doshas having few and delicate signs is taken into account to be yapya i.e. manageable.
Krchchra Sadhya arshas – These produced by mixture of any two doshas, these located within the second fold, and people that are a couple of yr previous must be thought-about as krchrasadhya (tough to treatment).
Varjya / Asadya arshas – The piles that are produced by the mixture of all of the three Doshas and that are congenital must be rejected.
The particular person in whom all of the folds of the rectum have developed piles, Apana Vata getting obstructed in its downward motion by the pile plenty, strikes upwards and on combining with vyana vata diminishes the warmth (heat of the physique) of the particular person (and kills him).

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