Chapter II - Diagnosis of haemorrhoids

Now we shall discourse on the Nidana of Arshas (Hemorrhoids). 1.

Hemorrhoids may be divided into six classes viz:—

1. Vataja (due to the action of the deranged Vayu),
2. Pittaja (due to the action of deranged Pitta),
3. Kaphaja (due to the action of deranged Kapha),
4. Raktaja (due to the action of the vitiated blood),
5. Sannipataja (due to the concerted action of the deranged Vayu, Pitta and Kapha)
6. and Sahaja (congenital).

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 Doshas, or vitiating the blood of a person, who observes no moderation in food and drink etc., become dislodged from their natural seats in the body [according to the law of Prasarana (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, weeds, wood, lumps of clay or stone, or by contact with cold water. 3.

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 Pravahini, 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.

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 (Gudoushtha). 5—6.

The first of the aforesaid grooves or rings lies about a finger’s width apart from the orifice of the anus.

Premonitory Symptoms:—

A non-relish for food, a tardy and difficult digestion of food (brought into the stomach), acid eructations, a sense of weakness in the thighs, a rumbling sound in the intestines, 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, dyspnea, 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.

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 hemorrhoid 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 peculiar to Gulma, Ashthila, 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.

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 Shuka 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.

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 scratch the excrescences. The stools become copious in quantity and are charged with mucous (Sleshma), resembling the washings of meat. Indigestion, fever with shivering (Shita-jvara), and heaviness of the head and edema with a non-relish for food are the symptoms which become manifest 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.

The Raktaja Type:—

Piles (hemorrhoids), 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 peculiar to the Pittaja type of this disease. Pressed hard by the constricted feces in their passage through the anus, they suddenly give rise to a hemorrhage of vitiated (venous) blood, and symptoms characteristic of excessive bleeding are found to supervene. 11.

The Sannipata Type:—

In a case of hemorrhoids due to the concerted action of the deranged Vayu, Pitta and Kapha, symptoms characteristic of each of these types manifest themselves in unison. 12.

The Congenital Type:—

Congenital hemorrhoids (Sahaja Arshas) 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 Doshas 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 but very little. Large veins (Shira) 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, and disorders affecting the head nose, ears and eyes follow. A 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.

Auhoritative verse on the subject:—

A qualified physician should undertake the medical treatment of hemorrhoids 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.

Lingarshas (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 (Kurchaka). These vegetations ultimately tend to destroy the penis and the reproductive faculty of the patient.

Bhagarshas:—

The deranged Vayu etc. of the body, lodged in the vaginal region of a woman, gives rise to similar crops of soft polypi 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 dis- charge 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).^[1] 15.

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.

The symptoms of polypi, appearing in the neighbourhood 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 peculiar to the two deranged Doshas is called the Samsargaja. Six distinct types of bio-Doshaja piles are known in practice.^[2] 17.

Prognosis:—

A case of piles due to the concerted action of the three deranged Doshas 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 hemorrhoids are due to the concerted action of the two Doshas (Samsargaja), 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. 18-19.

 

Thus ends the second Chapter of the Nidanasthana in the Sushruta Samhita which deals with the Nidana of piles.

Footnotes and references:

[1]:

According to others, Carmakilas may crop up on the skin of any part of the body.

[2]:

Such as (1) the one due to the concerted action of the deranged Pitta and Kapha, (2) the one incidental to the simultaneous derangement of the Vayu and the Kapha, (3) the one brought about through the disordered condition of the Vayu and blood, (4) the one due to the combination of the deranged Pitta and Kapha, (5) the one produced by the concerted action of the deranged Pitta and blood, (6) the one which results from the combined action of the deranged Kapha and blood.