Sushruta Samhita, volume 4: Cikitsasthana
Chapter VI - The medical treatment of Hemorrhoids
The remedial measures in hemorrhoids may be grouped under four subheads; namely, the employment of (active) medicinal remedies, the application of an alkali (into the seat of the disease), actual cauterization (of the polypii) and surgical operation. A case of recent origin involving the action of the Doshas to a slight degree and uncomplicated with any grave or dangerous symptom and complication may prove amenable to medicine alone. Deep-seated polypii, which are soft to the touch and markedly elevated and extended (external—D. R.), should be treated with alkaline applications, while those which are rough, firm, thick and hard should be cauterized with fire. Polypii which are raised, exuding and slender at the roots should be surgically treated. Hemorrhoids which are held amenable to medicine and are not visible (to the naked eye) should be treated with the help of medicines alone. Now, listen to the procedure to be adopted in the treatment of Arshas which would require alkaline applications, a cauterization, or a surgical operation. 2.
Application of Kshara:—
The body of the patient suffering from hemorrhoids, in the event of possessing sufficient strength, should be anointed and duly fomented. He should be made to eat warm but demulcent food (Anna) in a fluid state (of a gruel-like consistency) to alleviate the excessive pain incidental to the action of the deranged Vayu. In a season neither too hot nor too cold, and when the sky is cloudless, he should be placed in a raised up position in a clean and well-equipped place on a plain slab or on a clean bed with his head resting on the lap of an attendant and the anal region exposed to the sun. In this position the waist should be made to elevate a little and to rest on a cushion of cloths or blankets. The neck and the thighs of the patient should be drawn out, and then secured with trappings and held fast by the attendants so as not to allow him to move. Then a straight and slender-mouthed instrument (somewhat like the modern rectal speculum), lubricated with clarified butter, should be gently inserted into the rectum and the patient should be asked to strain down gently at the time. After seeing the polypus (through the speculum), it should be scraped with an indicator and cleansed with a piece of cotton or linen after which an alkali should be applied to it. The exterior orifice of the instrument should be closed with the palm of the hand after this application and kept in that manner for a period that would be required to utter a hundred words.
Then after having cleansed the polypus, a fresh application should be made according to the strength of the alkali and the intensity of the aggravated Doshas involved in the case. Further application of the alkali should be stopped and the polypus washed with fermented rice-gruel (Dhanyamla), curd-cream, Sukta, or the juice of acid fruits, in the event of its having been found to have become a little flabby, bent down, and to have assumed the colour of a ripe Jambu fruit. After that it should be cooled with clarified butter mixed with Yashti-Madhu, the trappings should be removed and the patient should be raised up and placed in a sitting posture in warm water and refreshed with sprays of cold water, or, according to some authorities, with warm water. Then the patient should be made to lie in a spacious chamber, not exposed to the blasts of cold winds (specially), and advised as regards his diet and regimen Each of the remaining polypii, if any, should be cauterized with the alkaline application at an interval of seven days. In case of a number of polypii, those on the right side should be first cauterized and then those on the left, and after that those on the posterior side; and lastly those that would be found to be in front. 3.
Polypii, having their origin in the deranged Vayu and Kapha, should be cauterized with fire or alkali; while those, which are the outcome of the deranged Pitta and vitiated blood should be treated with a mild alkali alone. A perfect and satisfactory cauterization (Samyag- dagdha) of a polypus should be understood from such symptoms as, restoration of the bodily Vayu to its normal condition, relish for food, keenness of the appetite, lightness of the body and improvement in strength, complexion and pleasure. An over-cauterized (Ati- dagdha) polypus gives rise to such symptoms as, cracking of the region of the anus, a burning sensation (in the affected locality), fainting, fever, thirst, and profuse hemorrhage (from the rectum), and consequent complications; while an insufficiently cauterized (Hina- dagdha) polypus is known by its tawny brown colour, smallness of the incidental ulcer, itching, derangement of the bodily Vayu, discomforts of the cognitive organs and a non-cure of the disease. 4.
A large polypus, appearing in a strong person, should be clipped off (with a knife) and cauterized with fire. As regards an external polypus full of extremely aggravated Doshas (Vayu, Pitta, Kapha and blood) no Yantra should be used, but the treatment should consist of fomentation, anointing, poulticing, immersion, plastering, evacuating measures (Visrava), cauterization with fire and alkali and a surgical operation. Measures laid down under the head of Rakta-pitta should be resorted to in cases of hemorrhage (from the seat of affection). Remedies mentioned in connection with dysentery (Atisara) should be employed in cases of a looseness of the bowels; whereas in cases of constipation of the bowels oily purgatives should be administered, or the remedies for Udavartta should be adopted. These rules shall hold good in the cases of treating (cauterization, etc.) a polypus occurring in any part of the body whatsoever. 5.
A polypus should be caught hold of and an alkali should be applied thereto with a Darvi, or a brush (Kurcha), or an indicator (Shalaka). In a case of a prolapsus of the anus, cauterization should be made without the help of any Yantra (speculum).
In all types of hemorrhoids, the diet should consist of wheat barley, Shashtika rice or Shali rice, (boiled) and mixed with clarified butter, to be taken with milk, Nimba-soup, or Patola-soup. The patient should be advised to take (his meal) with Vastuka, Tanduliyaka, Jivanti, Upodika, Ashva-vala, tender Mulaka, Palanka, Asana, Chilli, Chuccu, Kalaya, Valli, or any other Shakas (pot-herbs), according to the nature of the Doshas involved in the case Any other oleaginous, diuretic, laxative and appetising (Dipana) diet possessing the virtue of curing piles should also be prescribed. 6.
After the cauterization of the polypus, as well as in a case where no cauterization would be necessary, the body of the patient should be anointed with clarified butter and oil, etc., and measures both general and specific (mentioned below and in accordance with the Dosha or Doshas involved) should be employed for the purpose of improving the digestive powers and to alleviate any aggravation of the Vayu. He should be made to drink a potion consisting of clarified butter cooked with the Vayu-subduing and appetising (Dipana) drugs (Kalka and Kvatha) mixed with the powders of Hingu, etc., (described in the treatment of Maha-Vata- vyadhi, chapter. V). In a case of Pittaji-Arshas, clarified butter prepared by cooking it with the drugs of the Pippallyadi and Bhadra-darvadi groups, should again be cooked with the decoction of Prithakparnyadi group and the Kalka of the Dipaniya (Pippallyadi) group, and given as a potion to the patient. In a case of hemorrhoid due to the action of the deranged blood (Raktarshas), the clarified butter should be cooked with a decoction of Manjishtha, Murungi, (D. R. Surangi), &c., while in a case of one due to the action of the deranged Kapha, the clarified butter should be cooked with a decoction of the drugs constituting the Surasadi group. The supervening distresses should be alleviated by the remedial measures peculiar to each of them. 7.
Cauterization with fire or with an alkali or any surgical operation in the present disease should be effected by introducing the Yantra (speculum) into the rectum (with the utmost care, inasmuch as an error happening in any of these cases may bring on impotency, swelling (Sopha), a burning sensation, epilepsy, rumbling in the intestines, retention of stool and urine, dysentery, diarrhea, or may ultimately end in death. 8.
Now we shall describe the dimensions of the Yantras (and the materials of which they are made of). The instrument may be made of iron, ivory, horn or wood. It should be made to resemble the teat of a cow. In the case of a male patient, it should be four fingers in length and five fingers in circumference; whereas in the case of a female patient, the length should be commensurate with that of the palm of the hand (of the same length as before—D. R.) and six fingers in circumference. The instrument should be provided with two separate apertures in its inside, one for seeing the interior of the rectum and the other for applying an alkali, or actual cautery (Agni) to the polypus, since it is impossible to apply fire and alkali through the same aperture. The circumference of the aperture in the upper three fingers of the instrument should be like that of a thumb. There should be a bulb-like protrusion of the same width, at the bottom, and above it a space of half a finger’s width. Thus we have briefly described the shape of the instrument. 9–10.
Now we shall describe the plasters to be applied to the hemorrhoids (to cause their spontaneous dropping off). The first consists of pulverised turmeric mixed with the milky exudation of the Snuhi tree. The second contains of the cock- evacuations and pulverised Gunja, turmeric and Pippali pasted with the urine and bile of a cow. The third is compounded of Danti, Chitraka, Suvarchika and Langali pounded together and made into a paste with cow’s bile. The fourth consists of Pippali, rock-salt, Shirisha- seeds and Kushtha pasted with the milky juice of an Arka, or Snuhi plant. An oil cooked in combination with Kasisa (sulphate of iron), Haritala (yellow orpiment), rock-salt, Ashvamaraka, Vidanga, Putika, Kritavedhana, Jambu, Arka, Uttamarani, Danti, Chitraka, Alarka and Snuhi -milk, and used as an unguent, leads to the falling off of the polypus, 11.
Now we shall describe the remedial measures which bring about the falling off of the invisible (internal) hemorrhoids. The patient should take Haritaki with treacle every morning; or a hundred Haritakis should be boiled in a Drona measure of cow’s urine and the patient, observing a strict continence, should take with honey every morning as many of them as suit his constitution; or he should be made to take every day a paste made of the roots of Apamarga with the washings of rice and with honey. Shatavari pasted with an adequate quantity of milk or a Karsha measure of) the powders of Chitraka mixed with a copious quantity of good Sidhu wine, or a gruel (Mantha) (neither extremely thick nor thin), or powdered barley or wheat mixed with Takra and Bhallataka powder, should be administered without any salt. A quantity of Takra should be kept in an earthen pitcher, plastered inside with a paste of Chitraka roots, and given to the patient in food and drinks whether fermented or not. A Takra should also be separately prepared as in the preceding manner with Bhargi, Asphota, barley, Amalaka and Guduchi and administered similarly this is called the Takra-kalpa (butter-milk compound). 12.
A medicated Takra should also be prepared with Pippali, Pippali-mula, Chavya, Chitraka, Vidanga, Shunthi and Haritaki, in the manner described above, (and given to the patient), who should abstain from taking any solid food, but live only on (this) Takra for a period of one full month; or he should be given milk boiled with a decoction of Shringavera, Punarnava and Chitraka, or a condensed decoction (Phanita) of the bark of Kutaja roots mixed with an after-throw of the powdered drugs of the Pippalyadi group and honey. The patient should be made to partake of the medicinal compound known as the Hingvadi-churna, described in the chapter on Maha-Vata-vyadhi, and be made to live either on milk, or on Takra. As an alternative, he should take Kulmasha boiled in Ksharodaka (alkaline water) prepared from Chitraka -roots and made saline with a liberal after-throw of Yava-kshara; or he should take milk boiled with the Ksharodaka (alkaline water) prepared from Chitraka- roots, or Kulmasha boiled with the alkaline water prepared from the ashes of burnt Palasa; or he should drink frequent potions of clarified butter mixed with the alkali made of the ashes of either Patola, Apamarga, Vrihati, or Palasa wood; or drink Takra mixed with the Kalka of the roots of Kutaja and of Vandaka; or take the alkaline water of Putika mixed with a Kalka of Chitraka, Putika and Nagara; or use the clarified butter boiled in an alkaline solution with the powdered drugs of the Pippalyadi group, added to it by way of an after-throw; or he should take every morning one or two Palas of black sesamum (according as required), with cold water. These measures prove remedial in cases of hemorrhoids and tend to improve the digestion. 13.
A Tula weight (twelve seers and a half) of the following drugs, viz., Dasha-mula, Danti, Chitraka and Haritaki should be boiled with four Drona measures of water till reduced to one quarter part (one Drona). The decoction, thus prepared, should be cooled down, filtered, mixed with a Tula measure of treacle and preserved into a receptacle which formerly contained clarified butter, which should then be kept buried for a month in a heap of unthrashed barley At the close of this period an adequate dose of this preparation should be given to the patient every morning. This medicine proves beneficial in cases of hemorrhoids, chronic diarrhea (Grahani), jaundice, obstinate constipation of the bowels (Udavartta) and in an aversion to food. It is also a good stomachic agent.
Two Pala weight of each of the following drugs, viz., Pippali, Mancha, Vidanga, Elavaluka and Lodhra, five Pala weight of Indra - varuni, ten Pala weight of the inner pulps of the Kapittha fruit, half a Prastha measure (one Prastha is equal to two seers) of Haritaki and one Prastha weight of Amalaki, boiled together with four Drona measures of water until reduced to one quarter of its quantity. This decoction should be filtered (through a piece of linen) and cooled down, after which two Tula weight of treacle should be added to it. The whole preparation should be then kept in a receptacle which formerly contained clarified butter, and be kept buried half a month in a heap of unthrashed barley. After the lapse of the said period, the patient should be made to drink (an adequate quantity of) this preparation every morning according to his strength. This Arishta proves curative in cases of an enlarged spleen, impaired digestion, chronic diarrhea (Grahani), Arshas, heart-disease, jaundice, cutaneous affection, ascites, Gulma, oedema (Shopha), and worms in the intestines, and improves the strength and complexion of the body. 14
Anointing (Sneha-karma), fomentation, use of emetics and purgatives and the application of Anuvasana and asthapana measures should be employed in cases of hemorrhoids due to the action of the deranged Vayu. The use of purgatives is recommended in the Pittaja type; soothing or pacifying (Samsamana) measures in the Raktaja type; and Shringavera and Kulattha in the type caused by the action of the deranged Kapha. All the preceding remedies should be combinedly employed when the concerted action of all the Doshas would be detected. As an alternative, milk boiled with the proper drugs may be administered in every case. 15.
Now we shall describe the mode of using Bhallataka in cases of hemorrhoids. A ripe and fresh Bhallataka should be cut into two, three or four pieces and a decoction should be made of them in the usual way. The patient should be made to drink four Tola weight of this cold every morning after lubricating or anointing his tongue, palate and lips with clarified butter, and should take his chief meal with milk and clarified butter in the afternoon. The number of Bhallatakas in preparing the decoction should be increased by one every day till the fifth day, (and the quantity of the decoction to be drunk by the patient should be similarly increased). After that, the number of Bhallatakas (and consequently the quantity of the decoction to be taken) should be increased by five every day. This method should be followed till the number of the Bhallatakas reaches seventy, after which it should be decreased every day by five until it is reduced to five Bhallatakas only (and five Shukti measures of the decoction). Subsequently the number of Bhallataka (and the dose) should be diminished by one (and one Shukti measure respectively) every day,until it is reduced to the original one (and one Shukti measure). By taking a thousand Bhallatakas in this manner, one may get rid of an attack of any kind of Kushtha and Arshas, and, having become strong and healthy, may live for one hundred years. 16.
Other forms of Bhallataka-yoga:—
The oil extracted from or pressed out of Bhallatakas, in the manner laid down in the chapter on Dvi-vrana, should be taken in a dose of one Shukti (four Tolas) every morning. The patient, as in the preceding case, should take his meal (of boiled rice, milk and clarified butter) after the digestion of the oil with a similar good effect. As an alternative, oil should be extracted from the marrow of Bhallatakas and the patient, after cleansing his system with emetics and purgatives, etc., and regulating his diet in the order of Peya, etc. should enter into a spacious chamber, protected from the blasts of the winds and take two Palas, or one Pala weight of the oil according to his strength A meal of boiled rice, milk and clarified butter, etc., should be taken after the oil had been fully digested. The oil should be continued, in this way, for a month, the regimen of diet should be strictly observed for a period of three months and the patient should abstain from anger, etc, during this period. The use of this oil, in the above mentioned way, not only ensures a radical cure of the disease with all its complications, but would increase the duration of life to a hundred years with the glow of youth and health and with an increment in the powers of memory, retention and wisdom. The application of this oil for every one month will extend ones life for a period of one hundred years. In the same way a continuous use for ten months would enable him to live for a thousand years. 17.
Vrikshaka (Kutaja) and Bhallataka prove as much curative in cases of all kinds of hemorrhoids, as Kshadira and Vijaka are effective in cases of cutaneous affections (Kushtha). Cauterization with fire, or with an alkali, proves as much palliative in cases of external hemorrhoids as turmeric proves soothing in those of Prameha. 18–19.
Medicated Ghritas, appetising drugs, electuaries, medicinal wines, Ayaskriti and asava should be prescribed in cases of hemorrhoids, according to the nature and intensity of the Doshas involved therein. Voluntary suppression of any natural urgings of the body, sexual intercourse, riding on horse-back, etc., sitting on the legs and such diets as would aggravate the Doshas, should be avoided in cases of hemorrhoids. 20-21.
Thus ends the sixth Chapter in the Chikitsita Sthana of the Sushruta Samhita which deals with the medical treatment of Arshas.
Such as the decoction of the drugs of the Bhadra-darvadi (Vayu- subduing) and Pippalyadi (Dipaniya) groups. This Ghrita should be prescribed in a Vataja Arshas.2.
The epithet “Bhadra-darvadi-pippallyadi” in the phrase “Bhadra- darvadi-pippallyadi-sarpih” seems to be included into the body of the text through an accident. In our opinion, it is only an annotation of the phrase “Dipaniya-Vata-hara-siddha” occurring in the last sentence.—Ed.3.
The Kalkas of the Pippallyadi group should also be taken in the preparation of the two kinds of medicated clarified butter to be used in Raktarshas, and Pittarshas.—Dallana.4.
In a preponderance of Vayu and Kapha, Takra should be taken as diet; whereas milk should be taken in a case of the preponderance of vitiated blood.5.
During the period when the above mentioned alkaline preparations are used, the diet of the patient should consist of clarified butter, milk and meat-soup for fear of the loss of the Ojo-Dhatu.6.
Some are of opinion that one Tula weight of each of the drugs should be taken; but Gayadasa does not say so.7.
Charaka also reads this under the name of Abhayarishta.8.
Experienced physicians recommend two and a half Pala weight of Indra-Varuni in lieu of five Palas for its astringent taste. Charaka, however, recommends only “half a Pala.”9.
Some are of opinion that the Rishis do not read this line. But as Gayadasa explains it, so Dallana, he tells us, also does the same.10.
A physician should apply this medicine after a due consideration and according to the physical condition of the patient.11.
Boiled with sixteen times of water in the event of the Bhallataka being dry, otherwise with eight times of water only.
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