A STUDY OF THE EFFECT OF HARITAKYADI LEHYAM IN ARSHOROGADISSERTATION SUBMITTED IN PARTIAL FULFILMENT FOR THE DEGREE OFDOCTOR OF AYURVEDIC MEDICINE – M.D. (AYURVEDA) BY DR.Ch.SADANANDAM GUIDE Dr.V.VIJAYA BABU M.D. (Ay.) READER, KAYACHIKITSA, P.G. UNIT DEPARTMENT OF KAYACHIKITSA, P.G. UNIT DR.B.R.K.R.GOVERNMENT AYURVEDIC COLLEGE / HOSPITAL HYDERABAD AFFILIATED TO Dr. N.T.R. UNIVERSITY OF HEALTH SCIENCES, VIJAYAWADA 2007
NTR UNIVERSITY OF HEALTH SCIENCES VIJAYAWADA, A.P. DEPT. OF KAYA CHIKITSA POST GRADUATE UNIT Dr.B.R.K.R. GOVT. AYURVEDIC COLLEGE / HOSPITAL ERRAGADDA, HYDERABAD, A.P. ; INDIA Date: 14.05.2007 Place: Hyderabad CERTIFICATE This is to certify that Dr.Ch.Sadanandam, student of Dept. ofKayachiktsa M.D. (Ayurveda) has worked for the dissertation on the topic“A Study of the effect of HARITAKYADI LEHYAM in ARSHOROGA”as per the requirements of the ordinances laid down by the University ofHealth Sciences, Vijayawada, for the purpose. The topic is duly approved bythe Academic council of the University. I am fully satisfied with his work and hereby forward thisdissertation for evaluation of the adjudicators. Dr. Prakash Chander M.D.(Kayachikitsa) Prof. & Head of the Dept. of Kayachikitsa, Post-Graduate Unit Dr.B.R.K.R.Govt. Ayurvedic College Erragadda, Hyderabad
NTR UNIVERSITY OF HEALTH SCIENCES VIJAYAWADA, A.P. DEPT. OF KAYA CHIKITSA POST GRADUATE UNIT Dr.B.R.K.R. GOVT. AYURVEDIC COLLEGE / HOSPITAL ERRAGADDA, HYDERABAD, A.P. ; INDIA Date: 14.05.2007 Place: Hyderabad CERTIFICATE This is to certify that Dr.Ch.Sadanandam, student of Dept. ofKayachiktsa M.D. (Ayurveda) has worked for the dissertation on the topic“A Study of the effect of HARITAKYADI LEHYAM in ARSHOROGA”as per the requirements of the ordinances laid down by the University ofHealth Sciences, Vijayawada, for the purpose. The topic is duly approved bythe Academic council of the University. I am fully satisfied with his work and hereby forward thisdissertation for evaluation of the adjudicators. Dr.V.Vijaya Babu M.D.(Kayachikitsa) Reader, Dept. of K.C., P.G.Unit Dr.B.R.K.R.Govt. Ayurvedic College Erragadda, Hyderabad
ACKNOWLEDGEMENTS At the outset, I would like to express my thankfulness to Dr.PrakashChander, Profesor and Head of the Department of Kaya chikitsa,P.G.Unit, for his guidance and co-operation. The satisfaction and euphoria that accompany the successfulcompletion of any work would be incomplete without mentioning thosepeople who made it possible with their constant guidance andencouragement crowned my efforts with success. I would like to express mygratitude to my Guide Dr.V.Vijaya Babu, Reader, Department ofKayachikitsa, P.G. Unit, for his valuable guidance and co-operationextended during the clinical study, without which it is impossible tocomplete this dissertation work. I would like to thank Dr.V.A.S.Chary I/c Professor and H.O.D.Dept of Shalya, for his co-operation, and I am especially thankful toDr.S.Sarangapani, Asst. Professor for his guidance and timely suggestionsin M.O.T. I am also thankful to B.Satyanarayana, Technical Assistant forhis help. Words carry no meaning when it comes to acknowledge the help andsupport I got from my teachers Dr.M.Srinivassulu, Professor,Dr.M.L.Naidu, Reader, Dr.S.Jayaprakash, Professor, Dr.BhaswantaRao, Dr.B.Venktaiah, Reader, Dept.of Shalakya, Dr.Philip Anandkumar, Reader, Dept.of Dravyaguna, Dr.V.R.K.Murthy, Asst.Professor,Dr.K.Ravinder, Asst.Professor, Dr.E.Anilkumar, Asst.Professor,
Dr.Ramalingeshwar Rao, Technical Assistant and Dr.P.Raghupathigoud they were there to help me out from many intricacies that used to propup in my mind during this dissertation work My grateful acknowledgements to our Principal Dr.M.Sadasiva Raoand Hospital Superintendent Dr.L.R.K.Murthy, for providing excellentworking atmosphere. I am thankful to all my friends & colleagues who supported andencouraged in every way to get away from some bitter experience andboosted my confidence. Special thanks to Dr.N.Sridhar Sarma,Dr.M.Surya Prakash, Dr.Ch.Ravi Kumar, Dr.D.Rama Gopal andDr.Binod Kumar Singh. I avail this opportunity to express my deepest love to my familymembers, my wife Sunitha and my children Sujith Chakra, Shilpa Chakraand Shirish Chakra. They have always been my pillar to my strength andsupport. I am also very much thankful to the librarians of college and researchlibraries for their cooperation. And last but not the least are my patients without whom the work willnot be completed, for which I am very much indebted to all of them. Dr.Ch.Sadanandam
INDEXName of the chapter Page NoSECTION I DISEASE PROFILE1. Introduction 12. Review of Sareeram 73. Classification 254. Nidanam 305. Poorva Roopam 386. Roopam 407. Samprapti 558. Rugvinischayam 579. Sadhya-Asadhyata 6010. Upadravas 6111. Chikitsa 6212. Pathya-Apathyas 72SECTION II DRUG REVIEW13. Haritakyadi Lehyam 73SECTION III CLINICAL STUDY14. Material and Methods 9015. Observation and Results 9216. Discussion and Conclusion 9817. Summary 10318. Special Case sheet19. Bibliography
1 INTRODUCTION Ayurveda is the “Science of Life” that is which helps in achieving alonger life span by preventing the occurrence of diseases as well as curing itto the possible extent if occurred. Thus it is established that maintenance of‘Swasthya’ or health is the aim of Ayurveda. The condition other than ‘swasthya’ is ‘vyadhi’ i.e. disease (dis-ease).Susrutha1 mentioned ‘Ashtamaha Vyadhis’ viz. vata vyadhi, prameha,kushta, arshas, bhagandaram, asmari, mudhagarbha and udara. Vagbhata2also mentions Ashtamaha gadas, differeing from Susrutha, that he mentionsGrahani instead of Mudhagarbha. The reason for these being considered as aspecial category is the intensity of suffering caused by them and thedifficulty in treating them, hence the term ‘Mahagadas’. The paryayas of vyadhi are all attributable to these Ashta mahagadasi.e. vyadhi = it causes vividha dukhas; amaya = generally caused due to ama;gada = which is caused due to aneka karanas; atanka = krichra jeevana dueto dukha i.e. sorrowful, miserable life; yakshma = roga samuha; jwara =causes tapa of both deha and manas; vikara = a state in which panchagnanendriyas, pancha karmendriyas and manas are all diverted from theirnatural activities; roga = ruja yuktata i.e. painfulness; papma = papasamudbhavam; dukham = upatapakatwam, i.e. uneasiness; abadham = peedaof kaya and manas.3,4 It is not only that the above mentioned vyadhis are themselves painfulbut they are also causative factors to many other vyadhis as well ascomplications or upadarvas.
2 Arshas is one of these and the incidence of the disease is on the risedue to Specific life style and aetiological factors like – heredity, worktimings, irregular food habits, spicy foods, controlling urges (vega dharana),excess sexual indulgence, etc. Therefore this disease is selected for special study. Susrutha samhitha advocates the management of Arshas under fourheadings – Oushadha, Kshara, Agni and Shastra Chikitsas. Of these four thefirst and foremost is the Oushadha chikitsa and the remaining are to beconsidered when it is out of range of medicines. It is also true that a caseselected for surgery will also be advised medical regimen to avoidrecurrence of the disease. Charaka specially mentions that Oushadha chikitsa is being described because there is chance of relapse of arshas treated in other three ways, ‘Punarviruho rudhanam’ is the term he uses. Susrutha samhitha also mentions that ‘oushadha can be tried even in a case where surgery is advised, but surgery should not be the option when the vyadhi is oushadha sadhya’. This sutra holds good for all the times. The yogam ‘Haritakyadi Lehyam’ is selected for the study. It is taken from the texts ‘Bhava Prakasha’5 and ‘Bhaishajya Ratnavali’6. Ayurveda mentions ‘aptopadesha’ as the first step of gaining knowledge and Bhava Prakasha and Bhaishajya Ratnavali are famous Ayurvedic text full of excellent ‘Gem’ like yogas.
3 Haritakyadi Lehyam - The yoga contains simple dravyas – Haritaki– 7parts, Sunthi – 6parts, Nimba beeja – 5parts, Karanja beeja – 4 parts,Indrayava – 3 parts, Chitramula – 2parts, Saindhava lavana – 1part andGudam – 8parts, which possess the dravya gunas said in chikitsa padachatushtayam, i.e. they are abundantly available, have many gunas, can bemade into various forms and are also cost effective. They are non-toxichence do not need any sodhana procedures; they are not drastic (teekshna)too. The yogam is in ‘lehyam’ form which is palatable, hence can be givento all age groups, and in the required ‘matra’ it is accepted from the patient’sside. The ‘Oushadha guna kala avadhi’ i.e. shelf life for lehyas is said to beone year. Therefore it can be prepared in bulk at once, preserved and usedthroughout the year.Paryayas and Niruktis Arshas, Gudamkura, Gudakeela, Durnama (Rajanighantu),Durnamakam (Amarakosam).Arshas – (1) “Arivat pranan srunoti hinasti iti arshas” i.e. the disease whichtortures like enemy. The word arshas is derived from the ‘SRU - himsayam”dhatu.7 (2) “Arivat praninam syati tanu karoti it arshas” i.e. it makes thepatient shrink as if a person in the hands of an enemy.7 (3) “Rupamiyarti udgachati iti arshas” i.e. that which makes thepatient appear ugly (because of the complications of impaired agni).7 (4) “Arivat pranino mamsa kilaka visasanti yat, Arshamsi tasmaduchyante guda marga nirodhatah” i.e. arshas areprotrusions of mamsa which obstruct guda marga and torture the peson likeenemy.8
4 Gudankura – “ankyate lakshyate iti ankurah” i.e. that which is seen orobserved, having its own entity, like a sprout.9 Gudakeela – “Keela is a synonym of agni; keela bandhane, gatinirodhane” i.e. this indicates the importance of vitiation of agni in thisvyadhi, as well as the symptom mala badhata caused by it.10 Durnama – “Paparogatvena prasiddhataya dushtam nama asya itidurnamakam” i.e. it is considered as a dushta or neecha vyadhi because papais thought be the causative factor, therefore rogi cannot reveal its existence.11Arsho Adhishthanam Mainly the Arsho roga is originating in the valis of guda10. But otherthan gudavalis arshas is formed in nasa, sira, shishna, karna, netra, gala,yoni, mukha, talu, vartma and over the twak12. The arshas over twak iscalled charma keela or adhimamsa. Arshas on shishna, yoni, garbhasaya arecalled as lingarshas. According to Vagbhata arshas is originating from the gudavali andobstructs the pureeshavaha srotas giving disturbance in guda like enemy andalso arshas is formed at guda due to vitiated vatadi tridoshas along with thevitiation of twak, mamsa and medas13.Doshas in arshas Panchatma Marutah, Pittam and Kapham – that all the panchavidhavatas, panchavidha pittas and Panchavidha kaphas are involved in thecausation of the Mahavyadhi Arshas14.
5Dushyas of arshas Charaka as well as Madhava Nidana mentioned that the dushyas ofarshas are twak, mamsa and medas.15Historical aspect History starts from the vedic literature. In Rigveda there arereferences about the manifestation and treatments for the disease originatedin guda. Reference of agnikarma in durnamaroga is also available inRigveda. Arshas is mentioned in Krishnayajurveda, which is related withVyshampayana descriptions about the diseases like arshas, sleepada,hrudroga, kushta, sodha are mentioned in Krishnayajurveda. Referenceabout ano-rectal disease and their management is specially described inAtharvanaveda. The Garuda purana possesses knowledge about the systemicdisorders, in which arshas is also described. In the period of Lord Buddha,kings have promoted ayurveda as a social science. Ayurvedic literature iscategorized as Samhita kalika, Sangrahakalika and recent one.16 The Brihattrayi: Charaka samhita, Susruta samhita and AstangaHrudaya are the good resources from the samhita kala. As per the knowledge available, the earliest description about arshaswas given by Agnivesa in his Agnivesa tantra. Years later Charaka reset theAgnivesa tantra into a detailed treatise in which he gave much importancefor oushadha chikitsa. Between 600 and 1000BC Susrutha, The father of Surgery elaboratedfourfold chikista of arshas as oushadha, kshara, agni and shastra karmas.
6 Vagbhata, in his Astanga hrudaya made a compilation work fromSusruta samhita and Charaka samhita, which comprises more practicalaspects of the both. The Laghu trayee: Madhava nidana, Sarangadhara samhita and Bhavaprakasa are the Laghutrayee followed the Brihatrayee, possessing literatureabout arshas. References about arshas are available in other texts such as BhavaPrakasha, Bhaishajya ratnavali, Chakradatta, Rasaratna samuchhaya,Gadanigraha, Yogaratnakra and Basava Rajeeyam. According to Vagbhata arshas is originating from the gudavali andobstructs the pureeshavaha srotas giving disturbance in guda like enemy andalso arshas is formed at guda due to vitiated vatadi tridoshas along with thevitiation of twak, mamsa and medas.
7 REVIEW OF SAREERAM The summary of the Ayurvedic descriptions regarding sareera aspectof guda, is as follows – Utpathi (origin) – Charaka says that Guda is a Mridu and Matrujaavayava and is formed from the uthama sara bhaga of rakta and kapha,digested by the pitta and vayu, giving it a hollow or tubular structure.17 Sthana (location) - Charaka mentions Uttara guda and Adhara guda asparts of the fifteen Koshtangas. Chakrapani’s vyakhya on this says thatUttaraguda is where pureesha is stored and Adharaguda through whichpureesha passes out i.e. excreted.18 Charaka in the context of Uttara Vasti, describes the location of Vasti– Vasti is located between Mushkas, Sthula guda, Sevani and Sukra andMutra vaha Nadis.19 Vagbhata says that Guda is Sthulantra pratibaddha, through whichvata and pureesha move out and abhighata to it causes sadyomaranam.20 According to Susrutha – Guda, Vasti, Vasti shiras, Vrushans andPourusha granthi are Eka sambandhi and are related to Gudasthi vivara21;there are Dwa trimsat22 (32) siras in Sroni supplying Guda and Medhra;Guda is Sthulantra pratibaddha (joined proximally with Sthulantra), Ardhapanchangulam (four and half angulas in length), Adhi ardha angula trivalayasambhuta (formed with three valis, each one and half angula in length) andnamely Pravahini, Visarjini and Samvarani.23
8 Guda is Chaturangula ayata (four angulas in diameter), and has threevalis, all of which are tiryak, ekangula, ucchrita (lie horizontally, one abovethe other, in one angula distance). They are like Sankha avartas (the spiralgrooves of a Conch), and are Gajatalunibha (like the palate of an Elephant incolour). When seen externally, taking the romas (hair) located at gudapradesha as criteria, from the ending line of romas, one ‘yava’ inside islocated the ‘Gudaoushtha’. From this Gudaoushtha one angula inside is thefirst Vali, i.e Samvarani.24 Ashtanga Hridaya says Valis are three in number; the first isPravahani, in between is the Visarjini and externally lays the Samvarani,from where Gudaoushtha is one angula externally.25 Susruta and Vagbhata mentioned the length of the guda as four andhalf anguli. The anguli has been standardised in BHU and it is fixed at about2Cms. approximately. Thus the length of the guda includes the whole of theanal canal and lowers 6Cm of the rectum, which extends upto the inferiorHouston’s valve roughly. The total length of the anorectal canal from theanal margin to the recto sigmoid junction is known to be about 16.5Cm. Outof which 3Cm. is the anal canal itself. Thus guda includes anal canal and apart of rectum. Susruta’s opinion about these three valis is anatomical as well asphysiological. Middle Houston’s valve, internal and external sphincters alsotake important part in the complete act of defaecation. Commentators on Susruta samhita come out through different ideasabout the valis. Dr.Ambikadatta Sastri has supposed Samvarani vali andVisarjini vali as sphincter ani internal and sphincter ani external
9respectively. According to vaidya Ranjeet Rai Desai, the piles are to occur ½inch above the gudostha even though all the three valis are affected. Hefound that vali thrayee are rather above to the folds described in modernanatomy.26 The earlier work of Dr.V.S.Patil who enlightened on marma at BHUhas come out with a clear explanation that instead of Houston’s valves, thelower part of the ampulla of rectum with internal and external sphinctersmay be taken as three valis respectively, based on physiological importancerather than structural importance. According to B.G.Ghanekar the two peshis which are round in shapeand meant for closing of guda are called as samvarani vali and situatedexternally.Pravahani: This is the first vali and is situated in the proximal part ofgudanalika and is about 1½ inch above the Visarjinivali. Since it initiates thevega of pureesha pravartana (sensation of expulsion) and pushes (pravahana)the pureesha downwards, it is called Pravahani. ‘Pravahanyastu pravahanam’ – Dalhana27 This is the middle one third of the rectum or the upper half of theampullary part of the rectum. The beginning or the proximal end is indicatedby the presence of the second Houston’s valve. The distance from the secondto the third houston’s valves is about 3 to 4cm. which is similar to theAyurvedic decription. The mucous membrane of this part of the rectum ispale pink in colour, which is semi-transparent and branching radicles of thesuperior rectal vessels are seen through it. The mucosa normally presents asmooth velvetty appearance due to the myriads of tiny opening in to the
10crypts of Leiberkuhn. In empty condition of the rectum the mucousmembrane presents a number of longitudinal folds, which are obliteratedwhen the rectum is distended and are the reason for the maximum diameterof the ampullary part of the rectum, than any other part of the colon. Theblood supply is derived primarily from the superior rectal artery, which isthe continuation of the inferior mesenteric artery. Some supply is alsoreceived from the middle rectal and median sacral arteries. The venousdrainage is through the superior rectal (Haemorrhoidal) veins, which draininto the portal system via the inferior mesenteric vein. The superior, middleand inferior rectal veins converge to form the internal rectal venous plexusor haemorrhoidal plexus in the submucosa of the columns of Morgagni anddilatation of this plexus gives rise to internal haemorrhoids. The middle Houston’s valve which lies at the upper end of the rectalampulla and is the largest and the most constant one. Hence AyurvedicAcharyas had given it great importance and considered as a landmark. The faecal matter is stored in the Sigmoid colon and at the time ofevacuation by mass peristaltic movements it enters the ampulla of the rectumand the person feels the urge for defaecation and ‘Prvahanam’ or the effortto defaecate occurs. Hence the name ‘Pravahani’.Visarjini: This is the second vali situated between pravahini and samvaraniand is about 1½ inch and is in the middle portion of guda. It helps in movingthe fecal matter forward by its expansion and aids in its expulsion. “Tasam antaramadhya Visarjini” (Vagbhata)28 “Visrujateeti Visarjini” (Dalhana)29
11 This is the last one third of the rectum or the lower half of the ampullaof the rectum. Its beginning or proximal end is indicated by the thirdHouston’s valve and the distal end by the ano-rectal ring, and its length isabout 3 to 4cm. and lies anterior to the tip of the coccyx bone and above thepelvic diaphragm. This part is in continuation with Pravahani above andSamvarani below. The mucous membrane of this part is pink in colour andthe tributaries of the superior and middle rectal vessels are seen through it.The mucous membrane of this part contains longitudinal folds similar toPavahani. The blood supply and venous drainage are same as the Pravahani. This is related – the base of the urinary bladder, terminal parts of theureters, seminal vesicles, vasa deferentia and prostate and in females withvagina. This description correlates well with the Charaka’s and Susruta’sdescription of Guda and its relations.Samvarani: This is the third vali situated below visarjini and 1 inch abovethe gudaousshtha and is the last vali. Its function is to open when faecalmatter comes from above and to close the guda after its expulsion. “Samvaranateeti samvarani” (Dalhana)30 This part is the anal canal with internal and external anal sphincters. Itis in continuation with the rectum above and is marked by the Ano-rectalring. Anal canal is the terminal portion of the large intestine. It begins at theano-rectal ring and terminates at the anal verge. The length of the anal canalis approximately 3cm and the diameter is also 3cm laterally it is surroundedby ischio-rectal fossa around the sphincters and over its whole length it issurrounded by sphincter ani muscles. The upper half of anal canal is lined bymucous membrane and is in ‘Plum’ colour owing to the blood in thesubjacent internal venous plexus. The blood supply is from superior and
12inferior rectal arteries of which the superior rectal arteries supply the analcanal and the inferior rectal arteries supply the sphincter muscles and theischio-retcal fossae. The venous drainage is into Internal and External rectalvenous plexuses which communicate with each other and inturn drain intosuperior and inferior rectal veins. Veins in the three anal columns, situated at3, 7 and 11 o’clock positions as seen in the lithotomy position, are large andconstitute the potential sites for primary internal piles. Anal veins arearranged radially around the anal margin. They communicate with theinternal rectal plexus and the inferior rectal veins. Excessive straining duringdefaecation may rupture on of these veins, forming the subcutaneousperianal haematoma known as ‘External piles’. The internal anal sphincter is involuntary and the external analsphincter is under voluntary control. Both of these open for defaecation andclose after passing out of the faecal matter, hence the name ‘Samvarani’.MODERN ASPECTAnatomy of rectum and anal canal The embryonic proctoderm provides the lining of the anal canal. Thislining being ectodermal in origin is described to form anal skin. The rectumis derived from the hindgut. Hence the mucosal lining of the rectum isendodermal in origin.Rectum: The rectum constitutes the terminal segment of the colon. It’slength varies from 12 to 15 cm and possesses a larger lumen than any otherportion of the colon. It begins at the level of the third sacral vertebra andending at the anal canal i.e. from the recto-sigmoid junction above to thedentate line below. The rectum is having total three convex curves; two of
13the curves to the right side and one convex curve at the left. The rectumfrom its origin comes down following the concavity of the sacrum andcoccyx forming an antero-posterior curve which is called as sacral flexure ofthe rectum. First it passes downwards and backwards then downwards andlastly forwards to become in continuation with anal canal by passing throughthe pelvic diaphragm. Above it’s junction with the anal canal it passesthrough the pelvic floor, which is formed by levator ani muscle. In additionto the antero posterior curve the rectum deviates from the midline at threelateral curves. The upper one is convex to right, the middle one is moreconvex to left and the lower one is again convex to right. The diameter of the upper part of the rectum in empty state is 4 cm. asat the sigmoid colon but its lower part is distended to the widest portionknown as ampulla of rectum. Peritoneum is related with rectum only to theupper two thirds of it. The upper one third is covered is by peritoneumanteriorly and laterally, the middle one third is covered anteriorly only. Inmales the peritoneum reflects on the bladder and forms recto-vesical pouchwhere as in females it reflects upon vagina and uterus which is recto-uterinepouch or the “pouch of Douglas”. The lower portion of the rectum is devoid of peritoneum and iscovered by fibrous sheath, which is derived from the true pelvic fascia. Inempty condition of the rectum the mucous membrane of its lower partpresents a number of longitudinal folds which affect the distension of therectum.Houston’s valves: These are nothing but three spiral foldings of the mucosaland submucosal layers which are found with in the rectum. The lowest valveis seen in the left, the middle one in the right and the upper most one on the
14left. Each valve arises gradually at one end for the rectal valve extendinginto lumen of the gut. It then recedes at its other end into the rectal valve.The Houston valves can be seen through the sigmoidoscopy. The rectal mucosa normally presents a smooth velvetty appearancedue to the myriads of tiny opening in to the crypts of Leiberkuhn. Themucous membrane of the lower part of the rectum is pale pink in colour,which is semi-transparent and branching radicles of the superior rectalvessels are seen through it.Ano-rectal junction: The junction of anal canal and rectum is about two tothree cm. in front of and slightly below the tip of the coccyx. In males at thislevel opposite to this there is the apex of the prostrate gland. At the ano-rectal junction the folding back of the gut is known as the perineal flexure.Anal canal: Anal canal is the terminal portion of the large intestine. It beginsat the ano-rectal ring and terminates at the anal verge. The length of the analcanal is approximately 4 cm. and the diameter is 3 cm. The junction isindicated by the pectinate line (anal valves). It provides voluntary andinvoluntary sphincters at the outlet of the rectum. The external opening ofthe anus is situated in the midline, posterior to the perineal body. The emptylumen is puckered into longitudinal folds, the columns of Morgagni and theyare 5-10 or 8-12 in number. Posteriorly it contacts with a mass of fibrous andmuscular tissue known as ano-coccygeal ligament, which separates the analcanal from the tip of the coccyx. Anteriorly, it is separated from the perinealbody, by the membranous part of the urethra and the bulb of penis in themale and lower end of the vagina in the female. Laterally it is surrounded byischio-rectal fossa around the sphincters over its whole length it issurrounded by sphincter muscles.
15 The upper half of anal canal is lined by mucous membrane and itscolour is plum owing to the blood in the subjacent internal venous plexus.The epithelium in the region is variable in character. The mucous membranein this part has 6-10 vertical folds, the anal columns. Each column contains aterminal radicle in these three sites constitute primary internal haemorrhoids.The line along with the anal valves are situated is termed as pectinate line.Sometimes small epithelial projections (anal papilli) are present on the edgesof the anal valves. The succeeding part of the anal canal extends for about 15mm below the anal valves and is known as “transitional zone of pecten”.This zone ends narrow and wavy known as White line or Hilton’s line.Below the Hilton’s line the lower 8 mm or so of the anal canal are lined bytrue skin which contains sweat glands and sebaceous glands.Musculature of anal canal:External anal sphincter: It is under voluntary nerve control, made up ofstriated muscle and supplied by inferior rectal and perineal branch of fourthsacral nerves. It surrounds the whole length of the anal canal and has threeparts - subcutaneous, superficial and deep. The subcutaneous part lies belowthe level of internal sphincter and surrounds the lower part of anal canal as aflat band about 15mm broad. It has no bony attachment. The superficial partis elliptical in shape and arises from posterior surface of the terminalsegment of coccyx as the ano-coccygeal ligament.Internal anal sphincter: It is involuntary in nature, formed by the thickened,circular muscle coat of the gut and surrounds the upper ¾ (3cm) of the analcanal, lies above the subcutaneous part and deep to the superficial and deepparts of the external sphincter, and ends below at the Hilton’s white line.
16Conjoint longitudinal coat: It is formed by the fusion of puborectalis withthe longitudinal muscle coat of rectum at the ano-rectal junction, betweenthe external and internal sphincters. Soon it becomes fibro elastic and at thelevel of the white line it breaks up into a number of fibro elastic septa whichspread out fan wise, pierce the subcutaneous part of external sphincter andare attached to the skin around the anus. The most lateral septum forms theperianal fascia and the most medial are the anal inter muscular septum that isattached to the white line. In addition, some strands pierce obliquely theinternal sphincter and end in the sub mucosa below the anal valves.Ano-rectal ring: It is a muscular ring of the ano-rectal junction, formed bythe fusion of the pubo-rectals, deep external sphincter and the internalsphincter. It is easily felt by a finger in the anal canal. Surgical division ofthis ring results in rectal incontinence. The ring is less marked anteriorlywhere the fibers of puborectalis are absent.Surgical spaces: The tissue spaces are filled with cutaneous tissue andimportant from the surgical point of view because they are the possible sitesof infection. The surgical spaces are as follows.1. Ischio-rectal space: It is a pyramidal space and comprises of the upper 2/3 of ischiorectal fossa. This space is crossed by the inferior haemorrhoidal vessels and nerves. Morgagni has showed that the ischiorectal space is liable to become filled with pus in high anal fistula and ischiorectal abcesses. Countrey described that this space connects with the opposite ischiorectal space through the subsphincteric space and is an important avenue of existence of infection.
172. Peri-anal space: It surrounds the anal canal below the white line. It contains the subcutaneous external sphincter, the external rectal venous plexuses, and the terminal branches of the vessels and nerves.3. Sub-mucous space: Sub-mucousa of the anal canal lies above the white line between the mucous membrane and the internal sphincter. It contains the internal rectal venous plexus and lymphatics.4. Peri-rectal space: This space is a potential space which lies between the pelvic peritoneal floor and levator ani muscle.5. Intermuscular space: Its medial boundary is internal anal sphincter and external anal sphincter. This space was described by Eisen Hammer.6. Ischio rectal fossa: It lies between the sidewall of the pelvic and the anal canal and the lower part of the rectum. The apex is above and base is below formed by the perianal skin. Milliganetal described the ischiorectal fossa as being divided into two spaces by a horizontal fascia i.e., perianal space and ischiorectal space.Anal Orifice or Anus: The anus is the lower aperture of the anal canal and issituated about 4cms below and in front of the tip of the coccyx in the cleftbetween the buttocks.Surgical anal canal lining: The surgical anal canal is lined above by mucosaand below by anoderm which is modified skin. The anal crypts are in theupper part of the anoderm. A line at the level of the crypts is the pectinate line or dentate line.Above this line there are number of vertical mucosal folds, the columns ofMorgagni, which overline the internal haemorrhoidal plexus. Intermediately
18above the dentate line or dentate line is an important landmark for surgeons.At the lower part of the anal canal, this line is wavy, whitish, which isknown as Hilton’s line named by its founder.Anal sphincter: The anal sphincter has three distinct “U” shaped loops whichhave specific mechanism.1st Loop: In this top loop the deep portion of the external sphincter and thepuborectalis are fixed into one muscle. This attaches to the lower part of thesymphysis pubis and loops around the upper part of the anal canal with thedownward inclination.2nd Loop: This intermediate loop is the superficial external sphincter whicharises from the tip of the coccyx as a tendon and gives rise to strong musclebundles passing forward to encircle the anal canal below the top loop.3rd Loop: The third or base loop is the subcutaneous external sphincter. Itattaches anteriorly to the perianal skin in the mid line and passes backwardwith an upward inclination to loop around the lower part of the anal canal.Anal Glands: Anal Glands are vestegial structures lined by stratified mucussecreting columnar epithelium and squamous epithelium. Normally there aresix to ten glands in the circumference of the anus. Each gland has a duct anddischarges into the anal crypt at the dentate line.
19Arterial Supply of the Rectum and Anal Canal1. The superior rectal or Haemorrhoidal artery: It is the continuation of the inferior mesenteric artery and descends posteriorly to the rectum, where it bifurcates to supply the rectum and upper portion of the anal canal.2. The middle rectal or haemorrhoidal arteries: These arise from the internal iliac artery on each side and enter the lower portion of the rectum antero laterally at the level of levator ani muscle. They do not enter lateral stalks as previously believed. The arteries anastomose with the branches of the superior rectal artery.3. The inferior rectal or haemorrhoidal arteries: These arise on each side from the internal pudendal artery, a branch of the internal iliac artery and traverse the ischio-rectal fossa on each side to supply the anal sphincter muscles. There is no evidence of anastomosis between the superior and inferior rectal arteries.4. The middle sacral artery: It provides an insignificant amount of blood supply to the rectum. It arises posteriorly just above the bifurcation of aorta, descends over the lumber vertebrae, sacrum and coccyx, and gives only small branches to the posterior wall of the lower portion of the rectum.Venous Drainage of Rectum and Anal canal Return of the blood from the rectum and anal canal is via two systems– Portal and Systemic. The superior rectal (Haemorrhoidal) veins drain therectum and the upper part of the anal canal into the portal system via theinferior mesenteric vein. Primarily the middle rectal veins drain the lowerpart of the rectum and the upper part of the anal canal. They accompany themiddle rectal artery and terminate in internal iliac veins. The inferior retcal
20veins, following the corresponding arteries drain the lower part of the analcanal via the internal pudendal veins, which empty into the internal iliacveins. Dilatation of the inferior rectal veins leads to external haemorrhoids. The superior, middle and inferior rectal veins converge to form theinternal rectal (haemorrhoidal) plexus in the submucosa of the columns ofMorgangi. Dilatation of this plexus gives rise to internal haemorrhoids.Venous Plexuses1) Internal rectal venous plexus: It lies in the submucosa of the anal canal. It drains mainly intosuperior rectal vein but communicates freely with the external plexus andthus with the middle and inferior rectal veins. The plexus therefore is animportant site of communication between the portal and systemic veins. Thisis a series of dilated pouches connected by transverse branches around theanal canal.2) External rectal venous plexus: It lies outside the muscular coat of the rectum and the anal canal andcommunicates freely with the internal plexus and is drained by the inferiorrectal vein into the internal pudendal vein; the middle part by the middlerectal vein, into the internal iliac vein, and the upper part of the superiorrectal vein which continues as the inferior rectal vein which furthercontinues as the inferior mesenteric vein.3) Anal veins: These are arranged radially around the anal margin. Theycommunicate with the internal rectal plexus and the inferior rectal veins.
21Excessive straining during defaecation may rupture one of these veins,forming subcutaneous perianal haematoma, known as external piles.Lymphatic Drainage of Rectum and Anal canal Mainly there are three sets of lymphatic channels –1. Superior rectal lymph nodes: These run with the Superior rectal vessels. A special group lies justabove the Levator ani and close to the rectal wall in the region of ampulla.They are the para rectal nodes of the aorta. These are larger nodes at thebifurcation of the Superior rectal artery.2. Middle rectal lymph nodes: These lie along the lateral ligament of rectum close to the middlerectal vessels. From here they pass to the lymph nodes around the internaliliac artery.3. Inguinal lymph nodes: The lower portion of the anal canal and the anus are drained bylymphatics, which pass to the inguinal nodes. Above the pectinate line the lymphatics drain with those of the rectuminto the internal iliac nodes. Below the pectinate line the lymphatics draininto the medial group of the superficial inguinal nodes.Nerve Supply of Rectum and Anal canalSympathetic innervation: Rectum and the upper half of the anal canal derive their sympatheticsupply from the lumbar part of the trunk and the superior hypogastric plexusby means of the plexus on the branches of the inferior mesenteric artery. Thesympathetic nerves to the rectum and upper part of the anal canal pass
22mainly along the inferior mesenteric and the superior rectal arteries andpartly via the superior and inferior hypogastric plexuses. The lattersupplying the lower part of the rectum and internal sphincter.Para sympathetic innervation: This is derived from pelvic splanchnic nerves; for these the fibres passas long strands from sacral nerves to join the inferior hypogastric plexuseswhich enter on the sides of rectum, being motor to the musculature of therectum and inhibitory to internal sphincter. The external sphincter issupplied by the inferior rectal branch of the pudendal nerve (S2, S3) and theperineal branch of the fourth sacral nerve. Afferent impulses underlyingsensations of physiological distension are conveyed by the para sympatheticnerves, while pain impulses are conducted by both sympathetic as well aspara sympathetic nerves supplying the rectum and upper part of the analcanal.Importance of Guda Charaka includes Guda in Dasa Pranayatanas31 and Susrutha inMarmas; Guda is a Mamsa and Sadyo pranahara marma.32 Vata is controller of all the sareerika kriyas, which is divided into fivetypes depending upon the site it occupies. Thus ‘Apana vata’ is the onewhich occupies below the nabhi in general and pakwashaya in vishesha.Apana vayu prakopa produces diseases at guda and vasti pradesha, likeArshas, Ashmari, Bhagandara, etc.33
23 According to Charaka, Pakwashaya and Sthula guda are the moolasfor Pureesha vaha srotas.34 Thus it is understood that the function of theGuda is Pureesha dharana and Visarjana. Seated in the pakwashaya the apana vata does the function of ‘adhonayana’ or bringing downwards of vata, mutra, pureesha, artava, retas andgarbha in time.35 “Ahara sambhavam vastu deho hi ahara sambhavah” says Charaka.The body is made from ahara and is also maintained by it. This ahara issubjected jatharagni and its pachana takes place after which sara kittavibhajana occurs. The sara bhaga is absorbed and the kitta bhaga or‘pureesha’ is pushed forward to the end part of pakwasaya i.e. guda (uttaraguda) where it is stored until its elimination. Therefore it is said thatpakwashaya (uttara guda) and guda (adho guda) are the sthanas of pureeshavaha srotas. When the pureesha accumulates in sufficient quantity (thepramana of pureesha is seven anjalis), the desire for defaecation occurs. When the desire for defaecation is being felt by an individual, thereoccurs propulsion of faecal column beyond the Pravahini. At this stageVisarjini relaxes and accommodates the advancing faecal column, whichprogresses onwards by induction of pressure of Pravahini, by the individual.The column of the fecal material thus passes through the relaxed internalsphincter (ano-rectal ring) and the external sphincter to the outside.Samvarani comes into action when sufficient column has advanced beyondthe external opening and by contraction cuts the fecal column and releases itto be dropped out. Hence physiologically these three levels are veryimportant during the act of defaecation.
24 The important function of guda is defaecation. Dalhana comments onSusrutha regarding the function of the Valis, by which they get their namei.e. Pravahana, Visarjana and Samvarana are the functions or actions ofPravahani, Visarjini and Smavarani respectively. These are the differentactions exhibited by the Guda for pureesha visarjana.Mechanism of Defaecation Defaecation means process of passing faeces from the anus. It is areflex mechanism, which is under voluntary control in the normal conditionof the life. Usually the rectum remains empty and faeces are stored in pelviccolon. The urge for defaecation occurs when the faecal matter enters therectum on increase of the intraluminal pressure of the rectum from 20 to 25mm of water. Faecal matter does not collect elsewhere if defaecation isregular, however, if defaecation is long deferred; the descending colonbecomes filled when pelvic colon can hold no more. As a result of massmovement, some faeces enters the rectum when the desire to defaecateoccurs while the usual stimulations are – taking food, a glass of warm water,a cup of coffee or tea or smoking may have the same effects. The desire todefaecate may be induced by straining effort, which may raise the abdominalpressure to as much as 200mm. of mercury and forces faecal matter into therectum. The process of defaecation includes the action of voluntary andinvoluntary muscles, which are highly susceptible to emotional stimuli. Thereflex centres for defaecation have been located in the hypothalamus, inlower lumbar and upper sacral segments of the spinal cord and ganglionicplexuses of the gut.
25 CLASSIFICATION OF ARSHASAyurvedic classification Arshas can be broadly classified in to five types – 1. Utpathi bhedena 2. Dosha bhedena 3. Anubandha bhedena 4. Adhishthana bhedena 5. Sadhyasadhya bhedenaUtpathi bhedena According to Utpathi arshas are classified into Sahajanma andUtharothana or Jatasyottara kalaja.36Dosha bhedena According to Charaka it is of six types37 – Sahaja, Vataja, Pittaja,Kaphaja, Dwandwaja and Sannipataja. According Susrutha38 and Madhavakara39 it is of six varieties –Vataja, Pittaja, Kaphaja, Raktaja, Sannipataja and Sahaja. Vagbhata whiledescribing the lakshanas mentions ‘Dwandwaja arshas’. Though theymentioned Raktaja type separately, in the description they says that, it hasPitta lakshanas.Anubandha bhedena Charaka in the context of chikitsa mentioned Vatanubandha andKaphanubandha Raktarsho lakshanas40 are also mentioned. Vagbhata mentions that Raktaja arshas may have Vata orKaphanubandha.41
26 Charaka again mentioned two types of arshas according to chikitsa –Sushka and Ardra arshas42. The arshas in which vata (or) kapha (or)vatakapha dushti is more, is called as ‘Sushka’ arshas and those in whichrakta (or) pitta (or) raktapitta dushti is more, they were termed as ‘Ardra orSravi’ arshas. Again Charaka described the Sravi43 arshas to be of two typesaccording to anubandha, i.e. Vata and Kapha anubandha.Adhishthana bhedena According Adhishthana Bheda arshas is of 13 types, i.e. it can beoccur at 13 sthanas, viz. guda valis, siras, nasa, netra, karna, nabhi, gala,talu, oshtha, kantha, mukha, vartma and twak44, 45.Sadhyasadhya bhedena These are mainly of two types:- 1.Sadhya arshas and 2.Asadhyaarshas. Sadhya arshas is again subdivided into Kruchra sadhya and Sukhasadhya arshas. Asadhya arshas are of two varieties. They are Yapya andPratyakhyeya arshas.45 Regarding arshas, Vagbhata classified based on Susruta’s andCharaka’s concepts. In Arsha nidana he describes the types of arshas as 1. Sahaja 2. Janmottarothana and Sushka arshas and Sravi arshas. But while describing the samprapti and lakshanas he narrated sixvarieties of arshas. Madhava Nidana also has the same classification whichis based on the Charaka and Susruta. Ambikadatta Sastry explained that Sushka arshas are Vata or Kaphaor Vatakapha predominant. If there is vata or kapha or vatakapha there willbe no bleeding or secretion and it is dry and painful. They are called as
27‘Bahya Arshas’. Ardra arshas are predominant of rakta or pitta or both raktaand pitta which are always bleeds are called as ‘Sravi arshas’ or Raktaarshas.Table showing Arsho bhedas according to Different Achayras Arsho bheda Charaka Susruta Vagbhata Madhava nidana Sahaja + + + + Janmothara + Vataja + + + + Pittaja + + + + Kaphaja + + + + Sannipataja + + + + Raktaja Sravi + + + - Vatanubandha + + - Kaphanubandha + + Dwandwaja + + + Sushka + + Ardra (Sravi) + +MODERN CLASSIFICATIONThe modern science classifies Anal protrusions47 as follows - 1. Internal haemorrhoids – First, Second and Third Degree 2. External haemorrhoids 3. Interno external haemorrhoids 4. Symptomatic piles 5. Secondary or accessory piles
28Internal Haemorrhoids These are exaggerated vascular cushions involving the superiorhaemorrhoidal veins, normally located above the dentate line and arecovered by mucous membrane of the rectum or anal canal. These areclassified into three varieties depending on their prolapse, viz. First, Secondand Third Degree haemorrhoids. – Haemorrhoids that bleed but do not prolapse out side the anal canal are called first degree haemorrhoids. – Haemorrhoids that prolapse on defaecation but return or need to be replaced manually and then stay reduced are called second degree haemorrhoids. – Haemorrhoids that are permanently prolapsed are called third degree haemorrhoids.External Haemorrhoids External piles are located below the dentate line and are covered bysquamous epithelium (skin). These are mainly the dilated venules of inferiorhaemorrhoidal plexus. These are classified into two groups:a) True external haemorrhoidsThese are rare and nothing but small skin tags. These are generallyassociated with internal haemorrhoids and anal fissures. The skin tag is anarea of fibrous connective tissue covered by skin.b) Perianal haematomaIt is nothing but small haematoma arising from rupture of the externalhaemorrhoidal plexus. A thrombosed haemorrhoid is that in which blood hasclotted both intra-vascularly and to some degree extra-vascularly.
29Interno-external Haemorrhoids This is a combination of internal and external haemorrhoids.Symptomatic Haemorrhoids Symptomatic piles may appear in condition where the problem ordisease is specific and the piles are secondary viz. carcinoma of rectum,pregnancy, straining at micturition and from chronic constipation.Secondary or Accessory Haemorrhoids Superior rectal vein has three main branches out of these two of themsituated in the cushions of upper anal canal at right anterior, right posteriorand the third at left lateral position. The new structures between or nearer tothese segments are called accessory or secondary piles.
30 NIDANAThe word ‘Nidana’ is described as follows – ‘Nischitya deeyate pratipadyate vyadhiraneneti nidanam’ – Jejjata48 ‘Nirdisyate vyadhiraneneti nidanam’ – Gadadhara49 ‘Vyadhi nischaya karanam nidanam’ – Vararuchi50 ‘Hetulakshana nirdesat nidanani’ – Susruta51 The meaning of the above quotations is – ‘nidana is the karana or thefactor which indicates as well as confirms the disease’. Here it is used in abroader sense and should be understood as ‘Pancha lakshana nidana’ or‘Nidana panchaka’ which comprises of Nidana, Poorva roopa, Roopa,Upasaya and Samprapti, because each of these individually and also unitedlygive the knowledge of the disease. But, in general usage the word Nidana isused in specific sense and it means only the first one of the Pancha lakshananidana, which is described as follows – ‘Nidanam karanam ityuktam agre’ – Charaka52 ‘Nidanam rogotpadako hetuh’ – Madava nidana53 ‘Seti kartavyatako rogotpadaka heturnidanam’ – 54 i.e. the causative factors which aid in the production of the diseaseare said as Nidanam. ‘Sankshepatah kriya yogo nidana parivarjanam’55 Susruta mentioned the importance of this nidanam and said that‘avoiding the causative factors it is chikitsa in brief’. This is supported bythe Madhukosa commentary which says – ‘if nidana is not known then howits avoidance is possible?’ Hence it is necessary to study the nidanaindividually.
31Nidana according to Ayurveda Charaka has dealt with the Nidanas in an elaborated manner. Firstlyhe described nidana of Sahaja arshas, then Samanya nidana of arshas, thenthe individual nidanas of Vataja, Pittaja and Kaphaja arshas and finallyDwandwaja and Sannipataja arshas in a line. He did not mention Raktajaarsho nidanam. Susrutha mentioned them very briefly and Madhavakara hastaken the nidanas for Vata, Pitta, Kapha, Dwandwa and Sannipataja arshas,from Charaka. Eventhough both Susrutha and Madhavakara have mentionedRaktaja arshas as one of the types of arshas and described its lakshanas, theydid not mention individual nidana for it, which supports the Charaka’sopinion of considering Raktaja arshas as a part Pittaja arshas. The nidanasare as follows:Nidana of Sahaja arshas According to Charaka ‘Guda vali beeja upataptam’56 is the nidana forSahaja arshas. This again occurs by two ways, one is ‘Matru pitru kritaapachara’ and the second is the ‘purva karma’. This Nidana has to beattributed to all Sahaja vikaras says Charaka. Susrutha in the Nidana sthana mentioned that – Sahaja arshas are dueto ‘Dushta sonita sukra nimittani’.57 Modern science also accepts this concept of congenital weakness ofthe vessels of the anal region in persons whose parents have similar historyand are more and easily prone to piles. ‘The condition is so frequently seen in members of the same familythat there must be a predisposing factor, such as a congenital weakness ofthe vein walls or an abnormally large arterial supply to the rectal plexus’ –Bailey & Love – Short Practice of Surgery.58
32Samanya nidana The Samanya nidanas mentioned by Charaka can be classified intoAhara, Vihara, Vyadhi and Pancha karma vyapat.59 Ahara karanas – Guru, Madhura, Seeta, Abhishyandi, Vidahi,Viruddha aharas; Ajeerna, Pramitasana (alpa matra), Asatmya bhojana;Gavya – Matsya – Varaha - Mahisha – Aja – Avika – Pishita Bhakshana;Krusha, Sushka, Puti mamsa, Pyshtika, Paramanna, Ksheera modaka,Dhadhi, Tila, Guda vikruti sevana; Masha, Yusha, Ikshurasa, Pinyaka,Pindaluka, Sushka saka, Sukta, lasuna, Kilata, Pindaka, Bisa, Mrinala,Saluka, Krounchadana, Kaseruka, Srungataka, Taruna, Virudha,Navadhanya, Ama mulaka upayogat; Guru Phala, Saka, Raga, Haritaka,Mardaka, Vasa, Siraspada, Paryushita-Puti-Sankeerna anna Abhyavaharanat;Mandaka, Atikranta Madyapana, Vyapanna – Guru Salila pana. Vihara karanas – Ati vyavaya, Avyavayat, Diva swapnat, Sukhasayana asana upasevanat, Ratha, Utkatuka – Vishama – kathina Asanasevanat, Udbhranta yanat, Ushtra yana, Vata – Mutra – Pureesha vegaudeeranat, Samudeerna vega vinigrahat, Abhikshnam Seetambusamsparshat, Chela – Loshta – Trina adi gharshanat, Streenam ama garbhabhramsat, Garbha utpeedanat, Bahu and Vishama Prasutis. Pancha karma vyapat karanas - Ati snehanat, Ati Samsodhanat,Vastikarma vibhramat, Vasti netra asamyak pranidhanat, Guda kshananat Vyadhi karanas – Arshas, Grahani dosha and Atisara – these three canbe nidanas for one another says Charaka.
33 Susrutha briefly mentioned that – the karanas attributed for doshaprakopa, and Viruddhasana, Adhyasana, Stree prasanga, Utkatuka aasana,Prishta yana and Vega vidharana to be the nidana for arsho vhadhi and saysthat the Parivruddhi of ‘Guda Kandas’ occurs due to Trina, Kashtha, Upala,Loshtha, Vastra, etc.60 Vagbhata mentioned same as Susrutha and Madhavakara did notmention any Samanya nidana. After this Charaka has mentioned the Vishesha nidanas or individualnidanas which are as follows –Vataja arsho nidanam61, 62 Ahara karanas – Kashaya, Katu, Ruksha, Sheeta and Laghu, PramitaAlpashana and Teekshna madyam Vihara karanas – Langhanam, Maithunam, Vyayamam, Seeta Deshaand Seeta Kala sevana, Shoka, Vata and Atapa sevana.Pittaja arsho nidanam63, 64 Ahara karanas – Katu, Amla, Lavana, Ushna, Teekshna, Vidahi,Ksharam, Madyam Oushadha karanas – Vidahi, Teekshna and Ushna Oushadhas Vihara karanas – Krodha, Shishira Desha and Shishira KalaeetaKaphaja arsho nidanam65, 66 Ahara karanas – Madhura, Snigdha, Seeta, Guru, Teekshna, Lavana,Amla aharas. Vihara karanas – Avyayama, Diwaswapna, Shayana sukha, Asanasukha, Pragvata sevana, Seeta Desha and Seeta Kala sevana and achintana.
34Dwandwaja arsho nidanam67, 68 The nidanas which cause prakopa of two dosahs, if join together causeDwandwa or Samsargaja arshas.Sannipataja arsho nidanam69, 70 The nidana which cause sarva dosha prakopa i.e. prakopa of all thethree doshas leads to Sannipataja arshas.NIDANA ACCORDING TO MODERN SCIENCE71 The causative factors can be classified as follows – 1. Hereditary 2. Morphological 3. Anatomical and 4. Exciting causes 5. Other conditions or SymptomaticHereditary The condition is so frequently seen in the members of the same familythat there must be a predisposing factor, such as a congenital weakness ofthe vein walls or an abnormally large arterial supply to the rectal plexus.Varicose veins of the legs and haemorrhoids often occur concurrently.Morphological In quadrupeds, gravity aids, or any rate does not retard, return ofvenous blood from the rectum. Consequently venous valves are not required.In man the weight of the column of blood unassisted by valves produces ahigh venous pressure in the lower rectum, unparalleled in the body. Exceptin a few fat old dogs, haemorrhoids are exceedingly rare in animals.
35Anatomical (1) The collecting radicles of the superior haemorrhoidal vein lie unsupported in the very loose submucous connective of the anorectum. (2) These veins pass through muscular tissue and are liable to be constricted by its contraction during defaecation. (3) The superior rectal veins, being tributaries of the portal vein, have no valves.Exciting causes Straining accompanying constipation or that induced by overpurgation is considered to be a potent cause of haemorrhoids. Less often thediarrhoea of enteritis, colitis, or the dysenteries aggravates latenthaemorrhoids. In instances, descent and swelling of the anal cushions is aprominent feature.Symptomatic haemorrhoids Haemorrhoids may be symptomatic of some other condition in thebody like – a) In carcinoma of rectum – this by compressing or causing thrombosis of the superior rectal veins, gives rise to haemorrhoids sufficiently often to warrant examination of the rectum and the rectosigmoid junction for a neoplasm in every case of haemorrhoids. b) During pregnancy – pregnancy piles are due to compression of the superior rectal veins by the pregnant uterus and relaxing effect of the progesterone, F.S.H, prolactin and glucocorticoids on smooth muscles in the walls of veins.
36c) Straining at micturition due to enlarged prostate or stricture of the urethra.d) Large ovarian or uterine masses.e) Cirrhosis of the liver leads to portal obstruction and portal hypertension and cardiac weakness leads to tension within the haemorrhoidal plexus.f) Anal infection is also an important cause of piles. The infectious material (stool) is trapped into anal crypts and directed into anal glands at the time of defaecation leading to inflammation and vascular tension in the rectal plexuses, which leads to haemorrhoids and their protrusion.g) Lack of indigestible part in food like fiber and cellulose causes constipation, which leads into the piles. Table showing the Vataja arsho nidanas Nidana Charaka Susruta Madhava Nidana Kashaya + - Same as Charaka Katu + - ” Tikta + - ” Ruksha + - ” Seeta + - ” Laghu + - ” Pramita + - ” Alpasana Teekshna + - ” Madyam Maithuna + - ” Langhanam + - ” Seeta Desha + - ” Seeya Kala + - ” Vyayama + - ” Soka + - ” Vata sparsha + - ” Atapa sparsha + - ”
38 POORVA ROOPAM When Dosha dooshya sammurchana takes place in sthana samsrayakala the Poorva roopa takes place. The lakshanas of the disease will bealpabala and swalpa lakshanas and invisible. Sometimes the lakshanas of thedisease are strong. Regarding Poorva roopa some of Acharyas said the prakupitha doshaswhen takes stana samsraya then the vyadhi bodhaka lakshanas clearlyvisible. These lakshanas are vyadhi bodhakas that’s way Acharyas said asPoorva roopa lakshanas. The Poorva roopa is two types72 – 1. Samanya poorva roopa and 2. Vishesha poorva roopaAccording to Charaka – Anna vistamba (Avipakam), Atopa, Karshya, Daurbhalya, Mandagni,Udgara bhavulyata, Alpamala pravruthi and Grahani dosha, Pandu rogashanka can be seen in Arsho poorva roopa stage73.According to Sushrutha – Anna asraddha, Kruchra pachanam, Amlika, Paridaha, Vishtambha,Pipasa, Saktisadana, Atopa, Karshyam, Udgara bahulyam, Swayathu ofAkshi, Antra koojanam, Gudaparikartanam, Paridaha, Amlika, Bhrama,Tandra, Nidra and Ashanka of Pandu roga, Grahani dosha or Sosha, Kasa,Swasa, Balahani and Indriya dourbalyam.74
40 ROOPAM This is the stage in which the lakshanas of a vyadhi have becomeprominenent and present according to the doshas. Again Charaka gives adetailed description of the lakshanas of Sahaja arshas, samanya lakshanas ofarshas, then vataja, pittaja and kaphaja arsho lakshanas, and finallyDwandwaja and Sannipataja arsho lakshanas but did not mention Raktajaarsho lakshanas. Susrutha and Madhavakara dealt with Sahaja arsholakshanas in a line and also mentioned Raktaja arsho lakshanas along withdoshaja lakshanas.Sahaja arsho lakshnas According to Charaka they are as follows –Arsho swaroopam76 – Anu, Mahan, Deergha, Hraswa, Vrutta, Vishama,Visruta, Antah kutila, Bahih kutila, Jatila, Antarmukha and varna accordingto dosha.Rogi lakshans77 – Janma prabhruti ati krusha, Vivarnah, Kshama, Deena,Prachura vibaddha vata mutra pureesha, Sarkara peedita, Asmari peedita,Mala – aniyata, vibaddha, mukta, pakwa, ama, sushka, bhinna; Antarantara –Sweta, Pandu, Harita, Peeta, Rakta, Aruna, Tanu, Sandra, Picchila, Kunapagandha, Ama pureesha; Prachura parikartika in Nabhi, Vasthi and Vankshna;Guda sula, Pravahika, Pariharsha (roma harsha), Prameha, Vishtambha,Antrakujana, Udavarta, Hrydaya indriya upalepa, Prachura vibaddha tiktaamla udgara, Sudurbala, Sudurbalagni, Alpa sukra, Krodhano,Dukhopachara seela, Kasa, Swasa, tamaka, Trushna, Hrillasa, Chardi,Arochaka, Avipaka, Peenasa, Kshavathu, Timira, Sirassula, Swara –Kshama, Bhinna, Sakta, Jarjara; Karna rogi, Sula of Pani, Pada, Vadana,Akshikuta; Jwara, Angamarda, Sarva parva asthi soola, Antarantara graha of
41Parswa, Kukshi, Vasthi, Hrudaya,Prishtha, Trika graha; Pradhyanapara,Parama alasa. Susrutha78 mentions that the lakshanas of Gudankuras in Sahaja arshasare according to the dosha but still vishesha lakshanas are like –Durdarshanani, Parusha, Pandu varna, Daruna, Antarmukha; and the rogi isKrusha and Alpabhukta; suffers with Upadravas like – Aruchi, Alpagni, Sirasantata gatra, Ksheena reta, Alpa praja, Kshama swara, Krodha, Nasa-siro-netra-shrotra rogas, Satata antrakujana, Atopa, Hridaya pralepa, etc. Madhavakara says Sahaja and Sannipataja arsho lakshanas are alike.79Samanya roopa Samanya Swaroopa of Vata, Pitta and Kaphaja arshas according toCharaka80 – Sarshapa, Masoora, Masha, Mudga, Makushtaka, Yava, Kalaya,Pindi, Tintikera, Kharjura, Karkanthu, Kakanantika, Bimbi, Badara, Kareera,Udumbara, Jambava, Gostana, Angushtha, Kaseruka, Srungataka; andappearance like Tunda – Jihwa – Mukula – Karnika of Srungi, Daksha,Sikhi, Sukatunda. Vagbhata81 mentioned the Samanya lakshanas of arshas as follows –Agnimandya, Krusatha, Hatoutsaha, Deenata, Durbala, Ati nishprabha,Saraheena Guda vedana, Kasa, Trishna, Mukha vyrasya, Swasa, Peenasa,Klama, Angabhanga, Vamana, Kshavadhu, Sotha, Jwara, Kleebatha,Arochaka, Vedana in Parswasthi, Hrudaya, Nabhi, Payu and Vankshana;Pulakodaka sadrusa guda srava, and Pureesha is sushka or ardra, ama orpakwa, whose varna is pandu, haridra, harita or rakta.
42Vishesha roopa Charaka, Susrutha and Vagbhata mentioned Vishesha roopa asdoshaja lakshanas. Madhavakara followed the description of Vagbhata. Theyare as follows –Vataja arshas According to Charaka82 – Gudankuras are Sushka, Mlana, Kathina,Parusha, Rooksha, Syava, Teekshna agra, Vakra, Sphutita mukha, Vishama,and Visturta; vedana casused by gudankuras – Sula, Akshepa, Toda,Sphurana, Chimichima, Samharshana, Upasaya with Snigdha, Ushna aharas;Pravahika, Adhmana, Sisna, Vrushana, Vasthi, Vankshna, Hridgraha,Angamarda, Hridaya drava, Pratata vibaddha Vata, Mutra and Varcha,Kathina Varcha; Sula of Uru, Kati, Prishta, Trika, Parswa, Kukshi andVasthi; Siro Abhitapa, Kshavathu, Udgara, Pratisyaya, Kasa, Udavarta,Ayasa, Sosha, Sotha, Murcha, Arochaka, Mukha vairasya, Timira, kandu,Sula of Nasa, karna and Sankha,Swaropaghata; Nakha – Nnayana-VadanaTwak- Mutra- Pureesha are Syava, Aruna and Parusha. According to Susrutha83 the Gudankuras are – Parisushka, Aruna,Vivarna, Vishama Madhya, and their akruti like - Kadamba pushpa,Tundikeri, Nadi, Mukula and Suchimukha; Sasula Samhata mala tyaga,Vedana of Kati, Prishta, Parswa, Medhra, Guda and Nabhi; Arshas leadingto Gulma, Ashtheela, Pleeha and Udara; Krishnata of Twak, nakha, nayana,Vadana, Mutra, Pureesha. According to Madhavakara84 the Gudankuras are – Bahu, Sushka,Chimachimanvita, Mlana, Syava varna, Aruna varna, Stabdha, Vishada,Parusha, Khara, Visadrusha (akruti different from each other), Vakra,Teekshna, Visphutita anana; and in akrutis like Bimbi phala, Kharjura phala,
43Karkanthu phala, Karpasa phala, Kadamba pushpa abha, Siddharthakaupama; causing vyatha of Shira, Parswa, Kati, Uru, Vankshna; havingKshavathu, Udgara, Vishtambha, Hirdgraha, Arochaka, Kasa, Swasa, AgniVaishamya, Karnanada, Bhrama; and passes mala – Grathita, Stoka,Sashabda, Sapravahika, Ruk, Phena, Pichhanugata, and Vibaddha; Krishnataof Twak, Nakha, Vit, Mutra, Netra and Vaktra; Gulma, Pleeha, Udara andAshtheela may be caused by Vatarshas.Pittaja arshas According to Charaka85 – the Gudankuras are – Mridu, Sithila,Sukumara, Sparsha asaha, Rakta, Peeta, Neela, Krishna, Sweda Upakledabahulani, Visra gandha, Srava is Tanu, Peeta, Rakta; Daha, Kandu, Soola,Nistoda, paka, Upasaya with Sisira ahara viharas, Sambhinna Peeta haritaVarchas, peeta visragandha Pachura Vit Mutra, Pipasa, Jwara, Tamaka,Sammoha, Bhojana dwesha, Peeta – Nakha Nayana, Twak, Mutra Pureesha.According to Susrutha86 the Gudankuras are – Neela agra, Tanu, Visarpaguna, petra avabhasa, yakrut prakasa, Suka jihwa samsthana, Yava Madhya,Jalouka vaktra sadrusha, Praklinna, rogi is Sadaha – rudhira atisara,upadravas like Jwara daha pipasa murcha; Peeta - Twak Nakha NayanaDashana Vadana Mutra Pureesha. According to Madhavakara87 the Gudankuras are – Neela mukha;Rakta-Peeta-Asita prabha, Tanu (alpa sankhya), Mridu, Shlatha (hanging);Sparsha asaha; Srava is Asra, Tanu and Visra gandha; Akruthi like Sukajihwa, Yakrit khanda, Jalouka vaktra; Mala is Ushma yukta, Drava, Neela,Ushna, Peeta, Rakta, Amayukta; causing lakshanas like Daha, Paka, Jwara,Sweda, Trishna, Murcha, Aruchi, Moha; Twak, Nakha, Vit, Mutra, Netraand Vaktra are in Harita, Peeta and Haridra varnas.
44Sleshmaja arshas According to Charaka88 the Gudankuras are – Adhika Pramana,Upachita, Slakshna, Sparsha Saha, Sweta, Pandu, Picchila, Stabdha, Gurru,Stimita, Suptasupta, Sthira, Swayathu – kandu bahula, Pratata Pinjara SwetaRakta Piccha srava; Mutra and Pureesha are Guru, Picchila and Sweta;Upasaya with Ruksah Ushna ajhara viharas, Pravahika, Atimatra vankshnaanaha, Parikartika, Hrillasa, kapha nishtheeva, kasa, Arochaka, Pratisyaya,Gourava, Chardi, Mutra kricchra, Sosha, Sotha, pandu, Seeta jwara, Asmari,Sarkara, Upalepa of Hridaya and Indriyas, Asya Maturya, prameha, Deerghakala anupasayani, Atimatra – agnimardava, klaibya kara; Amavikaraprabala, Guru; Sukla – Nakha, Nayana, Vadana, Twak, Mutra, Pureesha. According to Susrutha89 – the Gudankuras are – Sweta, mahamula,Sthira, Vrutha, Snigdha, Pandu; Akara like kareera, Panasa astjhi, Gostana;Na bhidyate, Na sravanthi, kandu bahula; Sleshma yukta - analpa -mamsadhavana prakasa atisara, Sopha, Seeta jwara, Arochaka, Avipaka,Siro gourava, Sukla – Twak, Vnakha, Nayana, Dashana, Vadana, Mutra,Puresha. According to Madhavakara90 the Gudankuras are – Maha mula,Ghana, Mandaruja, Seeta, Utsanna, Upachita, Snigdha, Stabdha, Vrutha,Guru, Sthira, Picchila, Stimitha, Slakshna, Kandu adhya and Sparshanapriya; Na sravanthi, Na bhidyante; their akruthi – Kareera, Panasa asthiabha, gostana sannibha; Pureesha is Vasaabha, Kapha yukta, and Pureeshapravruthi is Sapravahika; causing lakshanas like Vankshna anaha, Payu-Vasthi- Nabhi vikarshana; Swasa, Kasa, Hrillasa, Praseka, Aruchi, Peenasa,Meha kricchra, Shiroruja, Sishira jwara, Klaibya, Agni mardava, Chardi, andAma praya vikaras; Twak, Nakha, Vit, Mutra, Netra and Vaktra are Panduand Snigdha.
45Raktaja arshas According to Susrutha91 they are – Nyagrodha praroha, Vidruma,kakanantika phala sadrusha; Pitta lakshanayukta, at the time of Avagadhamala tyaga, sahasa, atyartha, dushta, analpa asruk srava, atipravruthi of raktacauses Sonita atiyoga upadravas. According to Madhavakara92 the ankuras are - Pittakruti samanvita,Vata praroha sadrusha; Gunja Vidruma sannibha; Sravanthi sahasa raktam;Rogi is – Dushta, Ushna and Gadha vitka prapeeditah; Bhekabha, Heenavarna bala utsaha, Hatouja, Kalushendriyas, Sonita kshaya sambhava dukhaPeedita, and has Pitta lakshanas. The upadravas of sonita atipravruthi are – Siro abhitapam, Andhyam,Adhimantham, Timira, Dhatu kshaya, Akshepaka, Pakshaghata, Ekangavikaram, Trishna, Daha, Hikka, kasa, Swasa, Panduroga, Maranam – Sonitavarnaneeya adhyaya.93Vata anubandha Raktarshas According to Charaka94 - Mala is in Syava varna, Kathina andRuksha; Adhovayu na vartate; Asruk from arshas is Tanu, Aruna varna andPhenila; Rogi is seen with Kati–Uru–Guda Sula and Adhika dourbalya; andif the Hetu is Rukshanam – then it should be understood as VatanubandhaRaktarshas. Madhavakara95 also expressed the same opinion.Kaphanubandha Raktarshas According to Charaka96 – Mala is Sithila, Swetha and Peetha in varna;Asruk from Arshas is Snigdha, Guru, Seethala, Ghana, Tantumat, Pandu andPicchilam; Guda sthana is Sapiccham and Sthimitam; and if the Karanas are
46Guru and Snigdha gunas, then it should be understood as KaphanubandhaRaktarshas. Same is the description of Madhavakara.97Dwandwaja Arshas In these the lakshanas of dwandwa ulbana doshas are seen.98Sannipataja arshas According to Charaka99, Susruta100, Vagbhata101 and Madhavakara102Tridosha Lakshanas are seen in Sannipataja and Sahaja Arshas.THE SIGNS AND SYMPTOMS OF HAEMORRHOIDSINTERNAL HAEMORROIDS The primary haemorrhoids are generally arranged at three places i.e.at 3, 7 and 11 o’clock with the patient in the lithotomy position. In betweenthese three primary haemorrhoids there may be smaller secondaryhaemorrhoids. Each principal haemorrhoid can be divided into three parts: a) The Pedicle – This is situated at the anorectal ring. As seen through a proctoscope it is covered with pale pink mucosa and occasionally a pulsating artery can be felt in this situation. b) The Internal haemorrhoid, which commences just below the anorectal ring. It is bright red or purple and covered by mucous membrane and the size is variable. c) An external associated haemorrhoid lies between the dentate line and the anal margin. It is covered by skin, through which blue veins can seen, unless fibrosis has occurred. This associated haemorrhoid is present only in well-established cases.
47 Entering the pedicle of an internal haemorrhoid may be a branch ofthe superior rectal artery. Very occasionally there is a haemangiomatouscondition of this artery – an ‘arterial pile’ – which leads to ferociousbleeding at operation.Clinical featuresBleeding – As the name haemorrhoid implies, bleeding is the principal andthe earliest symptom. At first the bleeding is slight; it is bright red andoccurs during defaecation (a ‘splash in the pan’), and it may continueintermittently thus for months or years. Haemorrhoids that bleed but do notprolapse out side the anal canal are called first degree haemorrhoids.Prolapse – This is a much later symptom. In the beginning the protrusion isslight and occurs at stool, and reduction is spontaneous. As time goes on thehaemorrhoids do not reduce themselves, but have to be replaced digitally bythe patient. Haemorrhoids that prolapse on defaecation but return or need tobe replaced manually and then stay reduced are called second degreehaemorrhoids. Still later, prolapse occurs during the day, apart fromdefaecation, often when the patient is tired or exerts himself. Haemorrhoidsthat are permanently prolapsed are called third degree haemorrhoids. Bynow the haemorrhoids have become as a source of great discomfort andcause a feeling of heaviness in the rectum but are not usually acutely painful.Discharge – A mucoid discharge is a frequent accompaniment of prolapsedhaemorrhoids. It is composed of mucus from the engorged mucousmembrane, sometimes augmented by leakage of ingested liquid paraffin.Pruritus will almost certainly follow this discharge.
48Pain – is absent unless complications supervene. For this reason any patientcomplaining of ‘painful piles’ must be suspected of having another condition(Possibly serious) and examined accordingly.Anaemia – can be caused very rarely by persistent profuse bleeding fromthe haemorrhoids.On inspection – there may be no evidence of internal haemorrhoids. Inmore advanced cases, redundant folds or tags of skin can be seen in theposition of one or more of the three primary haemorrhoids. When the patientstrains, internal piles may come into view transiently, or if they are of thethird degree they remain prolapsed.By Digital examination, internal haemorrhoids cannot be felt unless theyare thrombosed.By Proctoscopy – they can be seen bulging into the lumen of theproctoscope, just below the anorectal ring.ComplicationsProfuse haemorrahge – is not rare. Most often it occurs in the early stageof the second degree. The bleeding occurs mainly externally, but it maycontinue internally after the bleeding haemorrhoid has retracted or has beenreturned. In these circumstances, the rectum is found to contain blood.Strangulation – one or more of the internal haemorrhoids prolapse andbecome gripped by the external sphincter. Further congestion followsbecause the venous return is impeded. Second degree haemorrhoids are mostoften complicated in this way. Strangulation is accompanied by considerable
49pain, and is often spoken of by the patient as an ‘acute attack of the piles’.Unless the internal haemorrhoids can be reduced with in an hour or two,strangulation is followed by thrombosis.Thrombosis – the affected haemorrhoid or haemorrhoids become darkpurple or black and feel solid. Considerable oedema of the anal marginaccompanies thrombosis. Once the thrombosis has occurred, the pain of thestrangulation largely passes off, but tenderness persists.Ulceration – superficial ulceration of the exposed mucous membrane oftenaccompanies strangulation with thrombosis.Gangrene – occurs when strangulation is sufficiently tight to constrict thearterial supply of the haemorrhoid. The resulting sloughing is usuallysuperficial and localized. Occasionally, a whole haemorrhoid sloughs off,leaving an ulcer which heals gradually. Very occasionally massive gangreneextends to the mucous membrane within the anal canal and rectum and canbe the cause of spreading anaerobic infection and portal pyemia.Fibrosis – after thrombosis, internal haemorrhoids sometimes becomeconverted into fibrous tissue. The fibrosed haemorrhoid is at first sessile, butby repeated traction during prolapse at defaecation, it becomes pedunculatedand constitutes a fibrous polypus that is readily distinguished by its whitecolour from an adenoma, which is bright red. Fibrosis following transientstrangulation commonly occurs in the subcutaneous part of a primaryhaemorrhoid. Fibrosis in an external haemorrhoid favours prolapse of anassociated internal haemorrhoid.
50Suppuration – is uncommon. It occurs as a result of infection of athrombosed haemorrhoid. Throbbing pain is followed by perianal swelling,and a perianal or submucous abscess results.Pylephlebitis (Portal pyaemia) – theoretically, infected haemorrhoids shouldbe a potent cause of portal pyaemia and liver abscesses. Although cases dooccur from time to time, this complication is surprisingly infrequent. It canoccur when patients with strangulated haemorrhoids are subjected to ill-advised surgery, and have even been reported to follow banding.EXTERNAL HAEMORRHOIDS Unlike internal haemorrhoids, external haemorrhoids comprise of aconglomerate group of distinct clinical entities.a) A thrombosed external haemorrhoid – this is commonly termed aperianal haematoma. It is a small clot occurring in the perianalsubcutaneous connective tissue, usually superficial to the corrugator cutisani muscle. The condition is due to backpressure on a venule consequentupon straining at stool, coughing, or lifting a heavy weight. The condition appears suddenly and is very painful, and onexamination a tense, tender swelling which resembles a semi-ripeblackcurrant is seen. The haematoma is usually situated in a lateral region ofthe anal margin. Untreated it may resolve, suppurate, fibrose, and give riseto a cutaneous tag, or burst and extrude the clot, or continue bleeding. In the majority of cases resolution or fibrosis occurs. Indeed, thiscondition is called ‘a 5-day, painful, self-curing lesion’.
51 Provided it is seen within 36 hours of the onset, a perianal haematomais best treated as an emergency. Under local anaesthesia the haemorrhoid isbisected and the two halves are excised together with 1.25cm of adjacentskin. This leaves a pear-shaped wound, which is allowed to granulate. Therelief of pain is immediate and a permanent cure is certain. On the rareoccasions in which a perianal haematoma is situated anteriorly orposteriorly, it should be treated conservatively because of the liability of askin wound in this region is said to be an anal fissure.b) Dilatation of the veins of the external anal verge - This becomesevident only if the patient strains, when a bluish, cushion-like ring appears.This variety of external haemorrhoids is almost a perquisite of those wholead a sedentary life. The only treatment required is an adjustment of thepatient.c) Sentinel Pile – A thickening of the mucous membrane at the lower end ofa fissure of the anus.
55 SAMPRAPTI (PATHOGENESIS) According to Charaka Samprapti103 of Arshas (1) by intake of variousspecific nidanas (aggravating causes) agnimandya takes place and leadsexcessive accumulation of mala (faeces) (2) due to specific aggravatingcauses the apanavata accumulated in guda valis leads to arshas. Vagbhata104 explained the samprapti in brief. The aggravated doshavitiates twak, mamsa, medas of guda region and forms mamsa ankura ofvarious types, and they are called as arshas. Madhavakara105 had the same opinion. As per Sushruta106 doshas by their aggravating factors splits from theirnormal seat alone or together including Rakta, which reaches the gudamarga through pradhana dhamanis and causes the vitiation of valis of gudawhich results into production or formation of mamsa ankuras specifically inmandagni person an irritation of guda by trina, kastha, upala (stone), lostha(soil lump), vastra and shitodaka sparsha. These mamsankuras furtheraggravate to result into arshas. Dalhana in his commentary on Sushruta explained pradhana dhamanias purisha vaha dhamani. Dr.Ghanekar’s commentary on Sushruta also givesthe idea about the pradhana dhamani is one of the adhogami dhamani whichgoes downwards from the ridaya and arshas are described as the ‘Vikruti ofmalashaya siras’ since dhamanis and siras are synonyms. Sushruta’s schoolof thought seems to be correct. His opinion is absolutely relevant and whichhas considered even by the scientific thinkers, because varicosity of therectal veins is called Haemorrhoids.
56Modern aspect The anal canal receives a rich blood supply from the superior, middleand inferior rectal arteries, whose branches reach the anal submucosa andforms the venous plexuses, being surrounded by smooth muscle under theanal submucosa. Straining during defaecation and the passage of hard andsmall volume stools results in the engorgement of anal cushions. This maycause injury to the mucous membrane resulting in bright red bleeding fromthe capillaries of the lamina propria. With repeated straining, the analcushions are damaged so that the normal supports are stretched and tendencyto prolapse outside the anal canal develops. Early in the evolution of thedisease, the normal rectal mucosa above the anal cushions eventually isdragged with the prolapsing anal cushions, so that it adds to the bulge.Prolapse of anal cushion and its supporting frame work by the straining atstools and constricting pecten bands produces piles, obstructing stoolpassage causing the venous congestion. Anal infection is also a cause of piles; the infectious material (stool) istrapped into anal crypts and directed into anal glands at the time ofdefaecation. There the infection takes place and causes inflammation andvascular tension is developed in rectal plexuses which leads to haemorrhoidsand their protrusion.