A STUDY OF THE EFFECT OF

HARITAKYADI LEHYAM IN ARSHOROGA

DISSERTATION SUBMITTED IN PARTIAL FULFILMENT FOR THE DEGREE OF

DOCTOR 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

C E R T I F I C A T E

This is to certify that Dr.Ch.Sadanandam, student of Dept. of

Kayachiktsa 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 of

Health Sciences, Vijayawada, for the purpose. The topic is duly approved by

the Academic council of the University.

I am fully satisfied with his work and hereby forward this

dissertation 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

C E R T I F I C A T E

This is to certify that Dr.Ch.Sadanandam, student of Dept. of

Kayachiktsa 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 of

Health Sciences, Vijayawada, for the purpose. The topic is duly approved by

the Academic council of the University.

I am fully satisfied with his work and hereby forward this

dissertation 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.Prakash

Chander, 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 successful

completion of any work would be incomplete without mentioning those

people who made it possible with their constant guidance and

encouragement crowned my efforts with success. I would like to express my

gratitude to my Guide Dr.V.Vijaya Babu, Reader, Department of

Kayachikitsa, P.G. Unit, for his valuable guidance and co-operation

extended during the clinical study, without which it is impossible to

complete 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 to

Dr.S.Sarangapani, Asst. Professor for his guidance and timely suggestions

in M.O.T. I am also thankful to B.Satyanarayana, Technical Assistant for

his help.

Words carry no meaning when it comes to acknowledge the help and

support I got from my teachers Dr.M.Srinivassulu, Professor,

Dr.M.L.Naidu, Reader, Dr.S.Jayaprakash, Professor, Dr.Bhaswanta

Rao, Dr.B.Venktaiah, Reader, Dept.of Shalakya, Dr.Philip Anand

kumar, 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.Raghupathi

goud they were there to help me out from many intricacies that used to prop

up in my mind during this dissertation work

My grateful acknowledgements to our Principal Dr.M.Sadasiva Rao

and Hospital Superintendent Dr.L.R.K.Murthy, for providing excellent

working atmosphere.

I am thankful to all my friends & colleagues who supported and

encouraged in every way to get away from some bitter experience and

boosted my confidence. Special thanks to Dr.N.Sridhar Sarma,

Dr.M.Surya Prakash, Dr.Ch.Ravi Kumar, Dr.D.Rama Gopal and

Dr.Binod Kumar Singh.

I avail this opportunity to express my deepest love to my family

members, my wife Sunitha and my children Sujith Chakra, Shilpa Chakra

and Shirish Chakra. They have always been my pillar to my strength and

support.

I am also very much thankful to the librarians of college and research

libraries for their cooperation.

And last but not the least are my patients without whom the work will

not be completed, for which I am very much indebted to all of them.

Dr.Ch.Sadanandam

INDEX

Name of the chapter Page No

SECTION I DISEASE PROFILE

1. Introduction 1

2. Review of Sareeram 7

3. Classification 25

4. Nidanam 30

5. Poorva Roopam 38

6. Roopam 40

7. Samprapti 55

8. Rugvinischayam 57

9. Sadhya-Asadhyata 60

10. Upadravas 61

11. Chikitsa 62

12. Pathya-Apathyas 72

SECTION II DRUG REVIEW

13. Haritakyadi Lehyam 73

SECTION III CLINICAL STUDY

14. Material and Methods 90

15. Observation and Results 92

16. Discussion and Conclusion 98

17. Summary 103

18. Special Case sheet

19. Bibliography

1

INTRODUCTION

Ayurveda is the “Science of Life” that is which helps in achieving a

longer life span by preventing the occurrence of diseases as well as curing it

to 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. Vagbhata2

also mentions Ashtamaha gadas, differeing from Susrutha, that he mentions

Grahani instead of Mudhagarbha. The reason for these being considered as a

special category is the intensity of suffering caused by them and the

difficulty in treating them, hence the term ‘Mahagadas’.

The paryayas of vyadhi are all attributable to these Ashta mahagadas

i.e. vyadhi = it causes vividha dukhas; amaya = generally caused due to ama;

gada = which is caused due to aneka karanas; atanka = krichra jeevana due

to dukha i.e. sorrowful, miserable life; yakshma = roga samuha; jwara =

causes tapa of both deha and manas; vikara = a state in which pancha

gnanendriyas, pancha karmendriyas and manas are all diverted from their

natural activities; roga = ruja yuktata i.e. painfulness; papma = papa

samudbhavam; dukham = upatapakatwam, i.e. uneasiness; abadham = peeda

of kaya and manas.3,4

It is not only that the above mentioned vyadhis are themselves painful

but they are also causative factors to many other vyadhis as well as

complications or upadarvas.

2

Arshas is one of these and the incidence of the disease is on the rise

due to Specific life style and aetiological factors like – heredity, work

timings, 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 four

headings – Oushadha, Kshara, Agni and Shastra Chikitsas. Of these four the

first and foremost is the Oushadha chikitsa and the remaining are to be

considered when it is out of range of medicines. It is also true that a case

selected for surgery will also be advised medical regimen to avoid

recurrence 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 and

Gudam – 8parts, which possess the dravya gunas said in chikitsa pada

chatushtayam, i.e. they are abundantly available, have many gunas, can be

made into various forms and are also cost effective. They are non-toxic

hence do not need any sodhana procedures; they are not drastic (teekshna)

too. The yogam is in ‘lehyam’ form which is palatable, hence can be given

to all age groups, and in the required ‘matra’ it is accepted from the patient’s

side. The ‘Oushadha guna kala avadhi’ i.e. shelf life for lehyas is said to be

one year. Therefore it can be prepared in bulk at once, preserved and used

throughout the year.

Paryayas and Niruktis

Arshas, Gudamkura, Gudakeela, Durnama (Rajanighantu),

Durnamakam (Amarakosam).

Arshas –

(1) “Arivat pranan srunoti hinasti iti arshas” i.e. the disease which

tortures 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 the

patient shrink as if a person in the hands of an enemy.7

(3) “Rupamiyarti udgachati iti arshas” i.e. that which makes the

patient 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 are

protrusions of mamsa which obstruct guda marga and torture the peson like

enemy.8

4

Gudankura – “ankyate lakshyate iti ankurah” i.e. that which is seen or

observed, having its own entity, like a sprout.9

Gudakeela – “Keela is a synonym of agni; keela bandhane, gati

nirodhane” i.e. this indicates the importance of vitiation of agni in this

vyadhi, as well as the symptom mala badhata caused by it.10

Durnama – “Paparogatvena prasiddhataya dushtam nama asya iti

durnamakam” i.e. it is considered as a dushta or neecha vyadhi because papa

is thought be the causative factor, therefore rogi cannot reveal its existence.11

Arsho Adhishthanam

Mainly the Arsho roga is originating in the valis of guda10. But other

than gudavalis arshas is formed in nasa, sira, shishna, karna, netra, gala,

yoni, mukha, talu, vartma and over the twak12. The arshas over twak is

called charma keela or adhimamsa. Arshas on shishna, yoni, garbhasaya are

called as lingarshas.

According to Vagbhata arshas is originating from the gudavali and

obstructs the pureeshavaha srotas giving disturbance in guda like enemy and

also arshas is formed at guda due to vitiated vatadi tridoshas along with the

vitiation of twak, mamsa and medas13.

Doshas in arshas

Panchatma Marutah, Pittam and Kapham – that all the panchavidha

vatas, panchavidha pittas and Panchavidha kaphas are involved in the

causation of the Mahavyadhi Arshas14.

5

Dushyas of arshas

Charaka as well as Madhava Nidana mentioned that the dushyas of

arshas are twak, mamsa and medas.15

Historical aspect

History starts from the vedic literature. In Rigveda there are

references about the manifestation and treatments for the disease originated

in guda. Reference of agnikarma in durnamaroga is also available in

Rigveda. Arshas is mentioned in Krishnayajurveda, which is related with

Vyshampayana descriptions about the diseases like arshas, sleepada,

hrudroga, kushta, sodha are mentioned in Krishnayajurveda. Reference

about ano-rectal disease and their management is specially described in

Atharvanaveda. The Garuda purana possesses knowledge about the systemic

disorders, in which arshas is also described. In the period of Lord Buddha,

kings have promoted ayurveda as a social science. Ayurvedic literature is

categorized as Samhita kalika, Sangrahakalika and recent one.16

The Brihattrayi: Charaka samhita, Susruta samhita and Astanga

Hrudaya are the good resources from the samhita kala.

As per the knowledge available, the earliest description about arshas

was given by Agnivesa in his Agnivesa tantra. Years later Charaka reset the

Agnivesa tantra into a detailed treatise in which he gave much importance

for oushadha chikitsa.

Between 600 and 1000BC Susrutha, The father of Surgery elaborated

fourfold chikista of arshas as oushadha, kshara, agni and shastra karmas.

6

Vagbhata, in his Astanga hrudaya made a compilation work from

Susruta samhita and Charaka samhita, which comprises more practical

aspects of the both.

The Laghu trayee: Madhava nidana, Sarangadhara samhita and Bhava

prakasa are the Laghutrayee followed the Brihatrayee, possessing literature

about arshas.

References about arshas are available in other texts such as Bhava

Prakasha, Bhaishajya ratnavali, Chakradatta, Rasaratna samuchhaya,

Gadanigraha, Yogaratnakra and Basava Rajeeyam.

According to Vagbhata arshas is originating from the gudavali and

obstructs the pureeshavaha srotas giving disturbance in guda like enemy and

also arshas is formed at guda due to vitiated vatadi tridoshas along with the

vitiation of twak, mamsa and medas.

7

REVIEW OF SAREERAM

The summary of the Ayurvedic descriptions regarding sareera aspect

of guda, is as follows –

Utpathi (origin) – Charaka says that Guda is a Mridu and Matruja

avayava 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 as

parts of the fifteen Koshtangas. Chakrapani’s vyakhya on this says that

Uttaraguda is where pureesha is stored and Adharaguda through which

pureesha 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 and

Mutra vaha Nadis.19

Vagbhata says that Guda is Sthulantra pratibaddha, through which

vata and pureesha move out and abhighata to it causes sadyomaranam.20

According to Susrutha – Guda, Vasti, Vasti shiras, Vrushans and

Pourusha 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), Ardha

panchangulam (four and half angulas in length), Adhi ardha angula trivalaya

sambhuta (formed with three valis, each one and half angula in length) and

namely Pravahini, Visarjini and Samvarani.23

8

Guda is Chaturangula ayata (four angulas in diameter), and has three

valis, all of which are tiryak, ekangula, ucchrita (lie horizontally, one above

the other, in one angula distance). They are like Sankha avartas (the spiral

grooves of a Conch), and are Gajatalunibha (like the palate of an Elephant in

colour). When seen externally, taking the romas (hair) located at guda

pradesha as criteria, from the ending line of romas, one ‘yava’ inside is

located the ‘Gudaoushtha’. From this Gudaoushtha one angula inside is the

first Vali, i.e Samvarani.24

Ashtanga Hridaya says Valis are three in number; the first is

Pravahani, 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 and

half anguli. The anguli has been standardised in BHU and it is fixed at about

2Cms. approximately. Thus the length of the guda includes the whole of the

anal canal and lowers 6Cm of the rectum, which extends upto the inferior

Houston’s valve roughly. The total length of the anorectal canal from the

anal margin to the recto sigmoid junction is known to be about 16.5Cm. Out

of which 3Cm. is the anal canal itself. Thus guda includes anal canal and a

part of rectum.

Susruta’s opinion about these three valis is anatomical as well as

physiological. Middle Houston’s valve, internal and external sphincters also

take important part in the complete act of defaecation.

Commentators on Susruta samhita come out through different ideas

about the valis. Dr.Ambikadatta Sastri has supposed Samvarani vali and

Visarjini vali as sphincter ani internal and sphincter ani external

9

respectively. According to vaidya Ranjeet Rai Desai, the piles are to occur ½

inch above the gudostha even though all the three valis are affected. He

found that vali thrayee are rather above to the folds described in modern

anatomy.26

The earlier work of Dr.V.S.Patil who enlightened on marma at BHU

has come out with a clear explanation that instead of Houston’s valves, the

lower part of the ampulla of rectum with internal and external sphincters

may be taken as three valis respectively, based on physiological importance

rather than structural importance.

According to B.G.Ghanekar the two peshis which are round in shape

and meant for closing of guda are called as samvarani vali and situated

externally.

Pravahani: This is the first vali and is situated in the proximal part of

gudanalika and is about 1½ inch above the Visarjinivali. Since it initiates the

vega 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 the

ampullary part of the rectum. The beginning or the proximal end is indicated

by the presence of the second Houston’s valve. The distance from the second

to the third houston’s valves is about 3 to 4cm. which is similar to the

Ayurvedic decription. The mucous membrane of this part of the rectum is

pale pink in colour, which is semi-transparent and branching radicles of the

superior rectal vessels are seen through it. The mucosa normally presents a

smooth velvetty appearance due to the myriads of tiny opening in to the

10

crypts of Leiberkuhn. In empty condition of the rectum the mucous

membrane presents a number of longitudinal folds, which are obliterated

when the rectum is distended and are the reason for the maximum diameter

of the ampullary part of the rectum, than any other part of the colon. The

blood supply is derived primarily from the superior rectal artery, which is

the continuation of the inferior mesenteric artery. Some supply is also

received from the middle rectal and median sacral arteries. The venous

drainage is through the superior rectal (Haemorrhoidal) veins, which drain

into the portal system via the inferior mesenteric vein. The superior, middle

and inferior rectal veins converge to form the internal rectal venous plexus

or haemorrhoidal plexus in the submucosa of the columns of Morgagni and

dilatation of this plexus gives rise to internal haemorrhoids.

The middle Houston’s valve which lies at the upper end of the rectal

ampulla and is the largest and the most constant one. Hence Ayurvedic

Acharyas had given it great importance and considered as a landmark.

The faecal matter is stored in the Sigmoid colon and at the time of

evacuation by mass peristaltic movements it enters the ampulla of the rectum

and the person feels the urge for defaecation and ‘Prvahanam’ or the effort

to defaecate occurs. Hence the name ‘Pravahani’.

Visarjini: This is the second vali situated between pravahini and samvarani

and is about 1½ inch and is in the middle portion of guda. It helps in moving

the 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 ampulla

of the rectum. Its beginning or proximal end is indicated by the third

Houston’s valve and the distal end by the ano-rectal ring, and its length is

about 3 to 4cm. and lies anterior to the tip of the coccyx bone and above the

pelvic diaphragm. This part is in continuation with Pravahani above and

Samvarani below. The mucous membrane of this part is pink in colour and

the tributaries of the superior and middle rectal vessels are seen through it.

The mucous membrane of this part contains longitudinal folds similar to

Pavahani. The blood supply and venous drainage are same as the Pravahani.

This is related – the base of the urinary bladder, terminal parts of the

ureters, seminal vesicles, vasa deferentia and prostate and in females with

vagina. This description correlates well with the Charaka’s and Susruta’s

description of Guda and its relations.

Samvarani: This is the third vali situated below visarjini and 1 inch above

the gudaousshtha and is the last vali. Its function is to open when faecal

matter 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. It

is in continuation with the rectum above and is marked by the Ano-rectal

ring. Anal canal is the terminal portion of the large intestine. It begins at the

ano-rectal ring and terminates at the anal verge. The length of the anal canal

is approximately 3cm and the diameter is also 3cm laterally it is surrounded

by ischio-rectal fossa around the sphincters and over its whole length it is

surrounded by sphincter ani muscles. The upper half of anal canal is lined by

mucous membrane and is in ‘Plum’ colour owing to the blood in the

subjacent internal venous plexus. The blood supply is from superior and

12

inferior rectal arteries of which the superior rectal arteries supply the anal

canal and the inferior rectal arteries supply the sphincter muscles and the

ischio-retcal fossae. The venous drainage is into Internal and External rectal

venous plexuses which communicate with each other and inturn drain into

superior and inferior rectal veins. Veins in the three anal columns, situated at

3, 7 and 11 o’clock positions as seen in the lithotomy position, are large and

constitute the potential sites for primary internal piles. Anal veins are

arranged radially around the anal margin. They communicate with the

internal rectal plexus and the inferior rectal veins. Excessive straining during

defaecation may rupture on of these veins, forming the subcutaneous

perianal haematoma known as ‘External piles’.

The internal anal sphincter is involuntary and the external anal

sphincter is under voluntary control. Both of these open for defaecation and

close after passing out of the faecal matter, hence the name ‘Samvarani’.

MODERN ASPECT

Anatomy of rectum and anal canal

The embryonic proctoderm provides the lining of the anal canal. This

lining being ectodermal in origin is described to form anal skin. The rectum

is derived from the hindgut. Hence the mucosal lining of the rectum is

endodermal in origin.

Rectum: The rectum constitutes the terminal segment of the colon. It’s

length varies from 12 to 15 cm and possesses a larger lumen than any other

portion of the colon. It begins at the level of the third sacral vertebra and

ending at the anal canal i.e. from the recto-sigmoid junction above to the

dentate line below. The rectum is having total three convex curves; two of

13

the curves to the right side and one convex curve at the left. The rectum

from its origin comes down following the concavity of the sacrum and

coccyx forming an antero-posterior curve which is called as sacral flexure of

the rectum. First it passes downwards and backwards then downwards and

lastly forwards to become in continuation with anal canal by passing through

the pelvic diaphragm. Above it’s junction with the anal canal it passes

through the pelvic floor, which is formed by levator ani muscle. In addition

to the antero posterior curve the rectum deviates from the midline at three

lateral curves. The upper one is convex to right, the middle one is more

convex 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. as

at the sigmoid colon but its lower part is distended to the widest portion

known as ampulla of rectum. Peritoneum is related with rectum only to the

upper two thirds of it. The upper one third is covered is by peritoneum

anteriorly and laterally, the middle one third is covered anteriorly only. In

males the peritoneum reflects on the bladder and forms recto-vesical pouch

where as in females it reflects upon vagina and uterus which is recto-uterine

pouch or the “pouch of Douglas”.

The lower portion of the rectum is devoid of peritoneum and is

covered by fibrous sheath, which is derived from the true pelvic fascia. In

empty condition of the rectum the mucous membrane of its lower part

presents a number of longitudinal folds which affect the distension of the

rectum.

Houston’s valves: These are nothing but three spiral foldings of the mucosal

and submucosal layers which are found with in the rectum. The lowest valve

is seen in the left, the middle one in the right and the upper most one on the

14

left. Each valve arises gradually at one end for the rectal valve extending

into 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 appearance

due to the myriads of tiny opening in to the crypts of Leiberkuhn. The

mucous membrane of the lower part of the rectum is pale pink in colour,

which is semi-transparent and branching radicles of the superior rectal

vessels are seen through it.

Ano-rectal junction: The junction of anal canal and rectum is about two to

three cm. in front of and slightly below the tip of the coccyx. In males at this

level 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 begins

at the ano-rectal ring and terminates at the anal verge. The length of the anal

canal is approximately 4 cm. and the diameter is 3 cm. The junction is

indicated by the pectinate line (anal valves). It provides voluntary and

involuntary sphincters at the outlet of the rectum. The external opening of

the anus is situated in the midline, posterior to the perineal body. The empty

lumen is puckered into longitudinal folds, the columns of Morgagni and they

are 5-10 or 8-12 in number. Posteriorly it contacts with a mass of fibrous and

muscular tissue known as ano-coccygeal ligament, which separates the anal

canal from the tip of the coccyx. Anteriorly, it is separated from the perineal

body, by the membranous part of the urethra and the bulb of penis in the

male and lower end of the vagina in the female. Laterally it is surrounded by

ischio-rectal fossa around the sphincters over its whole length it is

surrounded by sphincter muscles.

15

The upper half of anal canal is lined by mucous membrane and its

colour is plum owing to the blood in the subjacent internal venous plexus.

The epithelium in the region is variable in character. The mucous membrane

in this part has 6-10 vertical folds, the anal columns. Each column contains a

terminal 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 edges

of the anal valves. The succeeding part of the anal canal extends for about 15

mm 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 by

true skin which contains sweat glands and sebaceous glands.

Musculature of anal canal:

External anal sphincter: It is under voluntary nerve control, made up of

striated muscle and supplied by inferior rectal and perineal branch of fourth

sacral nerves. It surrounds the whole length of the anal canal and has three

parts - subcutaneous, superficial and deep. The subcutaneous part lies below

the level of internal sphincter and surrounds the lower part of anal canal as a

flat band about 15mm broad. It has no bony attachment. The superficial part

is elliptical in shape and arises from posterior surface of the terminal

segment 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 anal

canal, lies above the subcutaneous part and deep to the superficial and deep

parts of the external sphincter, and ends below at the Hilton’s white line.

16

Conjoint longitudinal coat: It is formed by the fusion of puborectalis with

the longitudinal muscle coat of rectum at the ano-rectal junction, between

the external and internal sphincters. Soon it becomes fibro elastic and at the

level of the white line it breaks up into a number of fibro elastic septa which

spread out fan wise, pierce the subcutaneous part of external sphincter and

are attached to the skin around the anus. The most lateral septum forms the

perianal fascia and the most medial are the anal inter muscular septum that is

attached to the white line. In addition, some strands pierce obliquely the

internal 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 by

the fusion of the pubo-rectals, deep external sphincter and the internal

sphincter. It is easily felt by a finger in the anal canal. Surgical division of

this ring results in rectal incontinence. The ring is less marked anteriorly

where the fibers of puborectalis are absent.

Surgical spaces: The tissue spaces are filled with cutaneous tissue and

important from the surgical point of view because they are the possible sites

of 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.

17

2. 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 is

situated about 4cms below and in front of the tip of the coccyx in the cleft

between the buttocks.

Surgical anal canal lining: The surgical anal canal is lined above by mucosa

and below by anoderm which is modified skin. The anal crypts are in the

upper 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 of

Morgagni, which overline the internal haemorrhoidal plexus. Intermediately

18

above 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 is

known as Hilton’s line named by its founder.

Anal sphincter: The anal sphincter has three distinct “U” shaped loops which

have specific mechanism.

1st Loop: In this top loop the deep portion of the external sphincter and the

puborectalis are fixed into one muscle. This attaches to the lower part of the

symphysis pubis and loops around the upper part of the anal canal with the

downward inclination.

2nd Loop: This intermediate loop is the superficial external sphincter which

arises from the tip of the coccyx as a tendon and gives rise to strong muscle

bundles passing forward to encircle the anal canal below the top loop.

3rd Loop: The third or base loop is the subcutaneous external sphincter. It

attaches anteriorly to the perianal skin in the mid line and passes backward

with an upward inclination to loop around the lower part of the anal canal.

Anal Glands: Anal Glands are vestegial structures lined by stratified mucus

secreting columnar epithelium and squamous epithelium. Normally there are

six to ten glands in the circumference of the anus. Each gland has a duct and

discharges into the anal crypt at the dentate line.

19

Arterial Supply of the Rectum and Anal Canal

1. 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 the

rectum and the upper part of the anal canal into the portal system via the

inferior mesenteric vein. Primarily the middle rectal veins drain the lower

part of the rectum and the upper part of the anal canal. They accompany the

middle rectal artery and terminate in internal iliac veins. The inferior retcal

20

veins, following the corresponding arteries drain the lower part of the anal

canal via the internal pudendal veins, which empty into the internal iliac

veins. Dilatation of the inferior rectal veins leads to external haemorrhoids.

The superior, middle and inferior rectal veins converge to form the

internal rectal (haemorrhoidal) plexus in the submucosa of the columns of

Morgangi. Dilatation of this plexus gives rise to internal haemorrhoids.

Venous Plexuses

1) Internal rectal venous plexus:

It lies in the submucosa of the anal canal. It drains mainly into

superior rectal vein but communicates freely with the external plexus and

thus with the middle and inferior rectal veins. The plexus therefore is an

important site of communication between the portal and systemic veins. This

is a series of dilated pouches connected by transverse branches around the

anal canal.

2) External rectal venous plexus:

It lies outside the muscular coat of the rectum and the anal canal and

communicates freely with the internal plexus and is drained by the inferior

rectal vein into the internal pudendal vein; the middle part by the middle

rectal vein, into the internal iliac vein, and the upper part of the superior

rectal vein which continues as the inferior rectal vein which further

continues as the inferior mesenteric vein.

3) Anal veins:

These are arranged radially around the anal margin. They

communicate with the internal rectal plexus and the inferior rectal veins.

21

Excessive 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 just

above 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 the

bifurcation of the Superior rectal artery.

2. Middle rectal lymph nodes:

These lie along the lateral ligament of rectum close to the middle

rectal vessels. From here they pass to the lymph nodes around the internal

iliac artery.

3. Inguinal lymph nodes:

The lower portion of the anal canal and the anus are drained by

lymphatics, which pass to the inguinal nodes.

Above the pectinate line the lymphatics drain with those of the rectum

into the internal iliac nodes. Below the pectinate line the lymphatics drain

into the medial group of the superficial inguinal nodes.

Nerve Supply of Rectum and Anal canal

Sympathetic innervation:

Rectum and the upper half of the anal canal derive their sympathetic

supply from the lumbar part of the trunk and the superior hypogastric plexus

by means of the plexus on the branches of the inferior mesenteric artery. The

sympathetic nerves to the rectum and upper part of the anal canal pass

22

mainly along the inferior mesenteric and the superior rectal arteries and

partly via the superior and inferior hypogastric plexuses. The latter

supplying the lower part of the rectum and internal sphincter.

Para sympathetic innervation:

This is derived from pelvic splanchnic nerves; for these the fibres pass

as long strands from sacral nerves to join the inferior hypogastric plexuses

which enter on the sides of rectum, being motor to the musculature of the

rectum and inhibitory to internal sphincter. The external sphincter is

supplied by the inferior rectal branch of the pudendal nerve (S2, S3) and the

perineal branch of the fourth sacral nerve. Afferent impulses underlying

sensations of physiological distension are conveyed by the para sympathetic

nerves, while pain impulses are conducted by both sympathetic as well as

para sympathetic nerves supplying the rectum and upper part of the anal

canal.

Importance of Guda

Charaka includes Guda in Dasa Pranayatanas31 and Susrutha in

Marmas; Guda is a Mamsa and Sadyo pranahara marma.32

Vata is controller of all the sareerika kriyas, which is divided into five

types depending upon the site it occupies. Thus ‘Apana vata’ is the one

which occupies below the nabhi in general and pakwashaya in vishesha.

Apana vayu prakopa produces diseases at guda and vasti pradesha, like

Arshas, Ashmari, Bhagandara, etc.33

23

According to Charaka, Pakwashaya and Sthula guda are the moolas

for Pureesha vaha srotas.34 Thus it is understood that the function of the

Guda is Pureesha dharana and Visarjana.

Seated in the pakwashaya the apana vata does the function of ‘adho

nayana’ or bringing downwards of vata, mutra, pureesha, artava, retas and

garbha 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 is

subjected jatharagni and its pachana takes place after which sara kitta

vibhajana occurs. The sara bhaga is absorbed and the kitta bhaga or

‘pureesha’ is pushed forward to the end part of pakwasaya i.e. guda (uttara

guda) where it is stored until its elimination. Therefore it is said that

pakwashaya (uttara guda) and guda (adho guda) are the sthanas of pureesha

vaha srotas. When the pureesha accumulates in sufficient quantity (the

pramana of pureesha is seven anjalis), the desire for defaecation occurs.

When the desire for defaecation is being felt by an individual, there

occurs propulsion of faecal column beyond the Pravahini. At this stage

Visarjini relaxes and accommodates the advancing faecal column, which

progresses onwards by induction of pressure of Pravahini, by the individual.

The column of the fecal material thus passes through the relaxed internal

sphincter (ano-rectal ring) and the external sphincter to the outside.

Samvarani comes into action when sufficient column has advanced beyond

the external opening and by contraction cuts the fecal column and releases it

to be dropped out. Hence physiologically these three levels are very

important during the act of defaecation.

24

The important function of guda is defaecation. Dalhana comments on

Susrutha regarding the function of the Valis, by which they get their name

i.e. Pravahana, Visarjana and Samvarana are the functions or actions of

Pravahani, Visarjini and Smavarani respectively. These are the different

actions exhibited by the Guda for pureesha visarjana.

Mechanism of Defaecation

Defaecation means process of passing faeces from the anus. It is a

reflex mechanism, which is under voluntary control in the normal condition

of the life. Usually the rectum remains empty and faeces are stored in pelvic

colon. The urge for defaecation occurs when the faecal matter enters the

rectum on increase of the intraluminal pressure of the rectum from 20 to 25

mm of water. Faecal matter does not collect elsewhere if defaecation is

regular, however, if defaecation is long deferred; the descending colon

becomes filled when pelvic colon can hold no more. As a result of mass

movement, some faeces enters the rectum when the desire to defaecate

occurs 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 to

defaecate may be induced by straining effort, which may raise the abdominal

pressure to as much as 200mm. of mercury and forces faecal matter into the

rectum.

The process of defaecation includes the action of voluntary and

involuntary muscles, which are highly susceptible to emotional stimuli. The

reflex centres for defaecation have been located in the hypothalamus, in

lower lumbar and upper sacral segments of the spinal cord and ganglionic

plexuses of the gut.

25

CLASSIFICATION OF ARSHAS

Ayurvedic classification

Arshas can be broadly classified in to five types –

1. Utpathi bhedena

2. Dosha bhedena

3. Anubandha bhedena

4. Adhishthana bhedena

5. Sadhyasadhya bhedena

Utpathi bhedena

According to Utpathi arshas are classified into Sahajanma and

Utharothana or Jatasyottara kalaja.36

Dosha 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 while

describing the lakshanas mentions ‘Dwandwaja arshas’. Though they

mentioned Raktaja type separately, in the description they says that, it has

Pitta lakshanas.

Anubandha bhedena

Charaka in the context of chikitsa mentioned Vatanubandha and

Kaphanubandha Raktarsho lakshanas40 are also mentioned.

Vagbhata mentions that Raktaja arshas may have Vata or

Kaphanubandha.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 which

rakta (or) pitta (or) raktapitta dushti is more, they were termed as ‘Ardra or

Sravi’ arshas. Again Charaka described the Sravi43 arshas to be of two types

according to anubandha, i.e. Vata and Kapha anubandha.

Adhishthana bhedena

According Adhishthana Bheda arshas is of 13 types, i.e. it can be

occur 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.Asadhya

arshas. Sadhya arshas is again subdivided into Kruchra sadhya and Sukha

sadhya arshas. Asadhya arshas are of two varieties. They are Yapya and

Pratyakhyeya arshas.45

Regarding arshas, Vagbhata classified based on Susruta’s and

Charaka’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 six

varieties of arshas. Madhava Nidana also has the same classification which

is based on the Charaka and Susruta.

Ambikadatta Sastry explained that Sushka arshas are Vata or Kapha

or Vatakapha predominant. If there is vata or kapha or vatakapha there will

be 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 rakta

and pitta which are always bleeds are called as ‘Sravi arshas’ or Rakta

arshas.

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 CLASSIFICATION

The 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

28

Internal Haemorrhoids

These are exaggerated vascular cushions involving the superior

haemorrhoidal veins, normally located above the dentate line and are

covered by mucous membrane of the rectum or anal canal. These are

classified into three varieties depending on their prolapse, viz. First, Second

and 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 by

squamous epithelium (skin). These are mainly the dilated venules of inferior

haemorrhoidal plexus.

These are classified into two groups:

a) True external haemorrhoids

These are rare and nothing but small skin tags. These are generally

associated with internal haemorrhoids and anal fissures. The skin tag is an

area of fibrous connective tissue covered by skin.

b) Perianal haematoma

It is nothing but small haematoma arising from rupture of the external

haemorrhoidal plexus. A thrombosed haemorrhoid is that in which blood has

clotted both intra-vascularly and to some degree extra-vascularly.

29

Interno-external Haemorrhoids

This is a combination of internal and external haemorrhoids.

Symptomatic Haemorrhoids

Symptomatic piles may appear in condition where the problem or

disease 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 them

situated in the cushions of upper anal canal at right anterior, right posterior

and the third at left lateral position. The new structures between or nearer to

these segments are called accessory or secondary piles.

30

NIDANA

The 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 the

factor which indicates as well as confirms the disease’. Here it is used in a

broader 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 unitedly

give the knowledge of the disease. But, in general usage the word Nidana is

used in specific sense and it means only the first one of the Pancha lakshana

nidana, 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 disease

are 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 by

the Madhukosa commentary which says – ‘if nidana is not known then how

its avoidance is possible?’ Hence it is necessary to study the nidana

individually.

31

Nidana according to Ayurveda

Charaka has dealt with the Nidanas in an elaborated manner. Firstly

he described nidana of Sahaja arshas, then Samanya nidana of arshas, then

the individual nidanas of Vataja, Pittaja and Kaphaja arshas and finally

Dwandwaja and Sannipataja arshas in a line. He did not mention Raktaja

arsho nidanam. Susrutha mentioned them very briefly and Madhavakara has

taken the nidanas for Vata, Pitta, Kapha, Dwandwa and Sannipataja arshas,

from Charaka. Eventhough both Susrutha and Madhavakara have mentioned

Raktaja arshas as one of the types of arshas and described its lakshanas, they

did not mention individual nidana for it, which supports the Charaka’s

opinion of considering Raktaja arshas as a part Pittaja arshas. The nidanas

are as follows:

Nidana of Sahaja arshas

According to Charaka ‘Guda vali beeja upataptam’56 is the nidana for

Sahaja arshas. This again occurs by two ways, one is ‘Matru pitru krita

apachara’ and the second is the ‘purva karma’. This Nidana has to be

attributed to all Sahaja vikaras says Charaka.

Susrutha in the Nidana sthana mentioned that – Sahaja arshas are due

to ‘Dushta sonita sukra nimittani’.57

Modern science also accepts this concept of congenital weakness of

the vessels of the anal region in persons whose parents have similar history

and are more and easily prone to piles.

‘The condition is so frequently seen in members of the same family

that there must be a predisposing factor, such as a congenital weakness of

the vein walls or an abnormally large arterial supply to the rectal plexus’ –

Bailey & Love – Short Practice of Surgery.58

32

Samanya nidana

The Samanya nidanas mentioned by Charaka can be classified into

Ahara, 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, Sukha

sayana asana upasevanat, Ratha, Utkatuka – Vishama – kathina Asana

sevanat, Udbhranta yanat, Ushtra yana, Vata – Mutra – Pureesha vega

udeeranat, Samudeerna vega vinigrahat, Abhikshnam Seetambu

samsparshat, Chela – Loshta – Trina adi gharshanat, Streenam ama garbha

bhramsat, 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 can

be nidanas for one another says Charaka.

33

Susrutha briefly mentioned that – the karanas attributed for dosha

prakopa, and Viruddhasana, Adhyasana, Stree prasanga, Utkatuka aasana,

Prishta yana and Vega vidharana to be the nidana for arsho vhadhi and says

that the Parivruddhi of ‘Guda Kandas’ occurs due to Trina, Kashtha, Upala,

Loshtha, Vastra, etc.60

Vagbhata mentioned same as Susrutha and Madhavakara did not

mention any Samanya nidana.

After this Charaka has mentioned the Vishesha nidanas or individual

nidanas which are as follows –

Vataja arsho nidanam61, 62

Ahara karanas – Kashaya, Katu, Ruksha, Sheeta and Laghu, Pramita

Alpashana and Teekshna madyam

Vihara karanas – Langhanam, Maithunam, Vyayamam, Seeta Desha

and 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 Kalaeeta

Kaphaja arsho nidanam65, 66

Ahara karanas – Madhura, Snigdha, Seeta, Guru, Teekshna, Lavana,

Amla aharas.

Vihara karanas – Avyayama, Diwaswapna, Shayana sukha, Asana

sukha, Pragvata sevana, Seeta Desha and Seeta Kala sevana and achintana.

34

Dwandwaja arsho nidanam67, 68

The nidanas which cause prakopa of two dosahs, if join together cause

Dwandwa or Samsargaja arshas.

Sannipataja arsho nidanam69, 70

The nidana which cause sarva dosha prakopa i.e. prakopa of all the

three 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 Symptomatic

Hereditary

The condition is so frequently seen in the members of the same family

that there must be a predisposing factor, such as a congenital weakness of

the 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 of

venous blood from the rectum. Consequently venous valves are not required.

In man the weight of the column of blood unassisted by valves produces a

high venous pressure in the lower rectum, unparalleled in the body. Except

in a few fat old dogs, haemorrhoids are exceedingly rare in animals.

35

Anatomical

(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 over

purgation is considered to be a potent cause of haemorrhoids. Less often the

diarrhoea of enteritis, colitis, or the dysenteries aggravates latent

haemorrhoids. In instances, descent and swelling of the anal cushions is a

prominent feature.

Symptomatic haemorrhoids

Haemorrhoids may be symptomatic of some other condition in the

body 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.

36

c) 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 + - ”

37

Table showing the Pittaja arsho nidanas

Nidana

Charaka

Susrutha

Madhava Nidana

Katu + - Same as Charaka Amla + - ” Lavana + - ” Kshara + - ” Vyayama + - ” Agni + - ” Atapa + - ” Sisira Desha + - ” Sisira Kala + - ” Krodha + - ” Madyam

+ - ”

Asuya + - ” Vidahi + - ” Teekshna + - ” Ushna + - ”

Table showing the Kaphaja arsho nidanas

Nidana

Charaka

Susrutha

Madhava Nidana

Madhura + - Same as Charaka Snigdha + - ” Seeta + - ” Lavana + - ” Amla + - ” Guru + - ” Avyayama + - ” Divasvapna + - ” Sayya sukha + - ” Asana sukha + - ” Pragvata seva + - ” Seeta Desha + - ” Seeta Kala + - ” Avachintana + - ”

38

POORVA ROOPAM

When Dosha dooshya sammurchana takes place in sthana samsraya

kala the Poorva roopa takes place. The lakshanas of the disease will be

alpabala and swalpa lakshanas and invisible. Sometimes the lakshanas of the

disease are strong.

Regarding Poorva roopa some of Acharyas said the prakupitha doshas

when takes stana samsraya then the vyadhi bodhaka lakshanas clearly

visible.

These lakshanas are vyadhi bodhakas that’s way Acharyas said as

Poorva roopa lakshanas.

The Poorva roopa is two types72 –

1. Samanya poorva roopa and

2. Vishesha poorva roopa

According to Charaka –

Anna vistamba (Avipakam), Atopa, Karshya, Daurbhalya, Mandagni,

Udgara bhavulyata, Alpamala pravruthi and Grahani dosha, Pandu roga

shanka 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 of

Akshi, Antra koojanam, Gudaparikartanam, Paridaha, Amlika, Bhrama,

Tandra, Nidra and Ashanka of Pandu roga, Grahani dosha or Sosha, Kasa,

Swasa, Balahani and Indriya dourbalyam.74

39

Vagbhata followed Susruta while Madhavakara mentioned the same

poorva roopas which were mentioned by Charaka.75

Table showing the Poorva Roopas of Arshas

Poorva roopa

Charaka

Sushruta

As.Hrudayam

Madhava Nidana

Anna vistamba + + + + Atopa + + + + Karshya + + + + Daurbhalya + + Mandagni + + Udgara bahulyata + + + + Alpamala pravruthi + + Grahani dosha shanka + + + + Pandu roga shanka + + + + Anna asraddha + + Kruchra pachanam + + Amlika + + Paridaha + + Saktisadana + + Pipasa + + Akshi swayathu + + Antra koojanam + + Guda parikartanam + + Bhrama + + Tandra + + Nidra + + Ashanka of Pandu roga

+ +

Ashanka of Gahani dosha

+ +

Ashanka of Sosha + + Kasa + + Swasa + + Balahani + + + Indriya dourbalyam + +

40

ROOPAM

This is the stage in which the lakshanas of a vyadhi have become

prominenent and present according to the doshas. Again Charaka gives a

detailed description of the lakshanas of Sahaja arshas, samanya lakshanas of

arshas, then vataja, pittaja and kaphaja arsho lakshanas, and finally

Dwandwaja and Sannipataja arsho lakshanas but did not mention Raktaja

arsho lakshanas. Susrutha and Madhavakara dealt with Sahaja arsho

lakshanas in a line and also mentioned Raktaja arsho lakshanas along with

doshaja 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 according

to 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, Kunapa

gandha, Ama pureesha; Prachura parikartika in Nabhi, Vasthi and Vankshna;

Guda sula, Pravahika, Pariharsha (roma harsha), Prameha, Vishtambha,

Antrakujana, Udavarta, Hrydaya indriya upalepa, Prachura vibaddha tikta

amla 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

41

Parswa, Kukshi, Vasthi, Hrudaya,Prishtha, Trika graha; Pradhyanapara,

Parama alasa.

Susrutha78 mentions that the lakshanas of Gudankuras in Sahaja arshas

are according to the dosha but still vishesha lakshanas are like –

Durdarshanani, Parusha, Pandu varna, Daruna, Antarmukha; and the rogi is

Krusha and Alpabhukta; suffers with Upadravas like – Aruchi, Alpagni, Sira

santata 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.79

Samanya roopa

Samanya Swaroopa of Vata, Pitta and Kaphaja arshas according to

Charaka80 – Sarshapa, Masoora, Masha, Mudga, Makushtaka, Yava, Kalaya,

Pindi, Tintikera, Kharjura, Karkanthu, Kakanantika, Bimbi, Badara, Kareera,

Udumbara, Jambava, Gostana, Angushtha, Kaseruka, Srungataka; and

appearance 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 or

pakwa, whose varna is pandu, haridra, harita or rakta.

42

Vishesha roopa

Charaka, Susrutha and Vagbhata mentioned Vishesha roopa as

doshaja lakshanas. Madhavakara followed the description of Vagbhata. They

are 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 and

Vasthi; 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 leading

to 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,

43

Karkanthu phala, Karpasa phala, Kadamba pushpa abha, Siddharthaka

upama; causing vyatha of Shira, Parswa, Kati, Uru, Vankshna; having

Kshavathu, Udgara, Vishtambha, Hirdgraha, Arochaka, Kasa, Swasa, Agni

Vaishamya, Karnanada, Bhrama; and passes mala – Grathita, Stoka,

Sashabda, Sapravahika, Ruk, Phena, Pichhanugata, and Vibaddha; Krishnata

of Twak, Nakha, Vit, Mutra, Netra and Vaktra; Gulma, Pleeha, Udara and

Ashtheela may be caused by Vatarshas.

Pittaja arshas

According to Charaka85 – the Gudankuras are – Mridu, Sithila,

Sukumara, Sparsha asaha, Rakta, Peeta, Neela, Krishna, Sweda Upakleda

bahulani, Visra gandha, Srava is Tanu, Peeta, Rakta; Daha, Kandu, Soola,

Nistoda, paka, Upasaya with Sisira ahara viharas, Sambhinna Peeta harita

Varchas, 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, Visarpa

guna, 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 Nayana

Dashana 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 Suka

jihwa, 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, Netra

and Vaktra are in Harita, Peeta and Haridra varnas.

44

Sleshmaja 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 Sweta

Rakta Piccha srava; Mutra and Pureesha are Guru, Picchila and Sweta;

Upasaya with Ruksah Ushna ajhara viharas, Pravahika, Atimatra vankshna

anaha, 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, Deergha

kala anupasayani, Atimatra – agnimardava, klaibya kara; Amavikara

prabala, 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 Sparshana

priya; Na sravanthi, Na bhidyante; their akruthi – Kareera, Panasa asthi

abha, gostana sannibha; Pureesha is Vasaabha, Kapha yukta, and Pureesha

pravruthi 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, and

Ama praya vikaras; Twak, Nakha, Vit, Mutra, Netra and Vaktra are Pandu

and Snigdha.

45

Raktaja arshas

According to Susrutha91 they are – Nyagrodha praroha, Vidruma,

kakanantika phala sadrusha; Pitta lakshanayukta, at the time of Avagadha

mala tyaga, sahasa, atyartha, dushta, analpa asruk srava, atipravruthi of rakta

causes 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, Heena

varna bala utsaha, Hatouja, Kalushendriyas, Sonita kshaya sambhava dukha

Peedita, and has Pitta lakshanas.

The upadravas of sonita atipravruthi are – Siro abhitapam, Andhyam,

Adhimantham, Timira, Dhatu kshaya, Akshepaka, Pakshaghata, Ekanga

vikaram, Trishna, Daha, Hikka, kasa, Swasa, Panduroga, Maranam – Sonita

varnaneeya adhyaya.93

Vata anubandha Raktarshas

According to Charaka94 - Mala is in Syava varna, Kathina and

Ruksha; Adhovayu na vartate; Asruk from arshas is Tanu, Aruna varna and

Phenila; Rogi is seen with Kati–Uru–Guda Sula and Adhika dourbalya; and

if the Hetu is Rukshanam – then it should be understood as Vatanubandha

Raktarshas.

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 and

Picchilam; Guda sthana is Sapiccham and Sthimitam; and if the Karanas are

46

Guru and Snigdha gunas, then it should be understood as Kaphanubandha

Raktarshas.

Same is the description of Madhavakara.97

Dwandwaja Arshas

In these the lakshanas of dwandwa ulbana doshas are seen.98

Sannipataja arshas

According to Charaka99, Susruta100, Vagbhata101 and Madhavakara102

Tridosha Lakshanas are seen in Sannipataja and Sahaja Arshas.

THE SIGNS AND SYMPTOMS OF HAEMORRHOIDS

INTERNAL 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 between

these three primary haemorrhoids there may be smaller secondary

haemorrhoids.

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 of

the superior rectal artery. Very occasionally there is a haemangiomatous

condition of this artery – an ‘arterial pile’ – which leads to ferocious

bleeding at operation.

Clinical features

Bleeding – As the name haemorrhoid implies, bleeding is the principal and

the earliest symptom. At first the bleeding is slight; it is bright red and

occurs during defaecation (a ‘splash in the pan’), and it may continue

intermittently thus for months or years. Haemorrhoids that bleed but do not

prolapse out side the anal canal are called first degree haemorrhoids.

Prolapse – This is a much later symptom. In the beginning the protrusion is

slight and occurs at stool, and reduction is spontaneous. As time goes on the

haemorrhoids do not reduce themselves, but have to be replaced digitally by

the patient. Haemorrhoids that prolapse on defaecation but return or need to

be replaced manually and then stay reduced are called second degree

haemorrhoids. Still later, prolapse occurs during the day, apart from

defaecation, often when the patient is tired or exerts himself. Haemorrhoids

that are permanently prolapsed are called third degree haemorrhoids. By

now the haemorrhoids have become as a source of great discomfort and

cause a feeling of heaviness in the rectum but are not usually acutely painful.

Discharge – A mucoid discharge is a frequent accompaniment of prolapsed

haemorrhoids. It is composed of mucus from the engorged mucous

membrane, sometimes augmented by leakage of ingested liquid paraffin.

Pruritus will almost certainly follow this discharge.

48

Pain – is absent unless complications supervene. For this reason any patient

complaining 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 from

the haemorrhoids.

On inspection – there may be no evidence of internal haemorrhoids. In

more advanced cases, redundant folds or tags of skin can be seen in the

position of one or more of the three primary haemorrhoids. When the patient

strains, internal piles may come into view transiently, or if they are of the

third degree they remain prolapsed.

By Digital examination, internal haemorrhoids cannot be felt unless they

are thrombosed.

By Proctoscopy – they can be seen bulging into the lumen of the

proctoscope, just below the anorectal ring.

Complications

Profuse haemorrahge – is not rare. Most often it occurs in the early stage

of the second degree. The bleeding occurs mainly externally, but it may

continue internally after the bleeding haemorrhoid has retracted or has been

returned. In these circumstances, the rectum is found to contain blood.

Strangulation – one or more of the internal haemorrhoids prolapse and

become gripped by the external sphincter. Further congestion follows

because the venous return is impeded. Second degree haemorrhoids are most

often complicated in this way. Strangulation is accompanied by considerable

49

pain, 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 dark

purple or black and feel solid. Considerable oedema of the anal margin

accompanies thrombosis. Once the thrombosis has occurred, the pain of the

strangulation largely passes off, but tenderness persists.

Ulceration – superficial ulceration of the exposed mucous membrane often

accompanies strangulation with thrombosis.

Gangrene – occurs when strangulation is sufficiently tight to constrict the

arterial supply of the haemorrhoid. The resulting sloughing is usually

superficial and localized. Occasionally, a whole haemorrhoid sloughs off,

leaving an ulcer which heals gradually. Very occasionally massive gangrene

extends to the mucous membrane within the anal canal and rectum and can

be the cause of spreading anaerobic infection and portal pyemia.

Fibrosis – after thrombosis, internal haemorrhoids sometimes become

converted into fibrous tissue. The fibrosed haemorrhoid is at first sessile, but

by repeated traction during prolapse at defaecation, it becomes pedunculated

and constitutes a fibrous polypus that is readily distinguished by its white

colour from an adenoma, which is bright red. Fibrosis following transient

strangulation commonly occurs in the subcutaneous part of a primary

haemorrhoid. Fibrosis in an external haemorrhoid favours prolapse of an

associated internal haemorrhoid.

50

Suppuration – is uncommon. It occurs as a result of infection of a

thrombosed haemorrhoid. Throbbing pain is followed by perianal swelling,

and a perianal or submucous abscess results.

Pylephlebitis (Portal pyaemia) – theoretically, infected haemorrhoids should

be a potent cause of portal pyaemia and liver abscesses. Although cases do

occur from time to time, this complication is surprisingly infrequent. It can

occur 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 a

conglomerate group of distinct clinical entities.

a) A thrombosed external haemorrhoid – this is commonly termed a

perianal haematoma. It is a small clot occurring in the perianal

subcutaneous connective tissue, usually superficial to the corrugator cutis

ani muscle. The condition is due to backpressure on a venule consequent

upon straining at stool, coughing, or lifting a heavy weight.

The condition appears suddenly and is very painful, and on

examination a tense, tender swelling which resembles a semi-ripe

blackcurrant is seen. The haematoma is usually situated in a lateral region of

the anal margin. Untreated it may resolve, suppurate, fibrose, and give rise

to a cutaneous tag, or burst and extrude the clot, or continue bleeding.

In the majority of cases resolution or fibrosis occurs. Indeed, this

condition is called ‘a 5-day, painful, self-curing lesion’.

51

Provided it is seen within 36 hours of the onset, a perianal haematoma

is best treated as an emergency. Under local anaesthesia the haemorrhoid is

bisected and the two halves are excised together with 1.25cm of adjacent

skin. This leaves a pear-shaped wound, which is allowed to granulate. The

relief of pain is immediate and a permanent cure is certain. On the rare

occasions in which a perianal haematoma is situated anteriorly or

posteriorly, it should be treated conservatively because of the liability of a

skin wound in this region is said to be an anal fissure.

b) Dilatation of the veins of the external anal verge - This becomes

evident only if the patient strains, when a bluish, cushion-like ring appears.

This variety of external haemorrhoids is almost a perquisite of those who

lead a sedentary life. The only treatment required is an adjustment of the

patient.

c) Sentinel Pile – A thickening of the mucous membrane at the lower end of

a fissure of the anus.

52

Table showing the Vataja Arsho Lakshanas

Charaka Susrutha As.Hru. Ma. Ni.Sushka Parisushka + Same

as Mlana + As.Hru.Kathina Parusha + Ruksha Syava + Teekshna agra + Vakra + Sphutita mukha + Vishama Vistruta Sula Akshepa Toda Sphurana Chimichima + Samharshana Snigdha Ushna Upasaya

Visadrusa

Aruna Aruna Vivarna Stabdha Vishama Madhya Visada Kadamba pushpa + Tundikeri Bimbi Nadi Kharjura Mukula Karkanthu Suchi mukha Karpasi phala Khara Siddharthaka

upama

53

Table showing the Pittaja Arsho Lakshanas Roopam Charaka Susrutha Vagbhata Madhava

Nidana Mrudu + Neela agra + Sithila + Tanu Sukumara + Visarpa Sparsha asaha + Peeta avabhasa Rakta + Yakrut prakasa + Peeta + Suka jihva

sadrusa +

Neela + Yava Madhya + Krishna + Jalouka vaktra

sadrusa Asita

Sveda bahulya + Praklinna Upakleda bahulya

+

Visra gandha + + Tanu peeta rakta srava

+ +

Daha + Kandu + Soola + Nistoda + Paka + Sisira upasaya + + Slatha + Sukajihwa Jalouka

vaktra

Yava Madhya

54

Table showing the Kaphaja Arsho Lakshanas Roopam Charaka Susrutha Vagbhata Madhava

Nidana Pramana + Sveta Ghana Upachita + Maha

moola Mahamoola

Slakshna + Sthira Mandaruja Sparsha saha + Vrutta Utsanna Sveta + Snigdha Upachita Pandu + Pandu Snigdha Picchila + Kareera Stabdha Stabdha + Panasa

asthi Vrutta

Guru + Gostana Guru Stimita + Na

bhidyante Sthira

Supta sputa + Na sravanti Picchila Sthira + Stimita Svayathu + Slakshna Kandu bahula + + Kandu adhya Pinjara, Sveta, Rakta, Piccha Srava

+ Sparshana priya

Ruksha, Ushna Upasaya

+ Karira

+ Panasa asthi + Gostana + Na sravanti + Na bhidyanti Table showing the Raktaja Arsho Lakshanas

Charaka Susrutha Vagbhata Madhava Nidana Nyagrodha praroha Vata praroha Vidruma Gunja Kakanantika phala Vidruma Pitta lakshanani Rakta srava Pitta laksjhnanai

55

SAMPRAPTI (PATHOGENESIS)

According to Charaka Samprapti103 of Arshas (1) by intake of various

specific nidanas (aggravating causes) agnimandya takes place and leads

excessive accumulation of mala (faeces) (2) due to specific aggravating

causes the apanavata accumulated in guda valis leads to arshas.

Vagbhata104 explained the samprapti in brief. The aggravated dosha

vitiates twak, mamsa, medas of guda region and forms mamsa ankura of

various types, and they are called as arshas.

Madhavakara105 had the same opinion.

As per Sushruta106 doshas by their aggravating factors splits from their

normal seat alone or together including Rakta, which reaches the guda

marga through pradhana dhamanis and causes the vitiation of valis of guda

which results into production or formation of mamsa ankuras specifically in

mandagni person an irritation of guda by trina, kastha, upala (stone), lostha

(soil lump), vastra and shitodaka sparsha. These mamsankuras further

aggravate to result into arshas.

Dalhana in his commentary on Sushruta explained pradhana dhamani

as purisha vaha dhamani. Dr.Ghanekar’s commentary on Sushruta also gives

the idea about the pradhana dhamani is one of the adhogami dhamani which

goes downwards from the ridaya and arshas are described as the ‘Vikruti of

malashaya siras’ since dhamanis and siras are synonyms. Sushruta’s school

of thought seems to be correct. His opinion is absolutely relevant and which

has considered even by the scientific thinkers, because varicosity of the

rectal veins is called Haemorrhoids.

56

Modern aspect

The anal canal receives a rich blood supply from the superior, middle

and inferior rectal arteries, whose branches reach the anal submucosa and

forms the venous plexuses, being surrounded by smooth muscle under the

anal submucosa. Straining during defaecation and the passage of hard and

small volume stools results in the engorgement of anal cushions. This may

cause injury to the mucous membrane resulting in bright red bleeding from

the capillaries of the lamina propria. With repeated straining, the anal

cushions are damaged so that the normal supports are stretched and tendency

to prolapse outside the anal canal develops. Early in the evolution of the

disease, the normal rectal mucosa above the anal cushions eventually is

dragged with the prolapsing anal cushions, so that it adds to the bulge.

Prolapse of anal cushion and its supporting frame work by the straining at

stools and constricting pecten bands produces piles, obstructing stool

passage causing the venous congestion.

Anal infection is also a cause of piles; the infectious material (stool) is

trapped into anal crypts and directed into anal glands at the time of

defaecation. There the infection takes place and causes inflammation and

vascular tension is developed in rectal plexuses which leads to haemorrhoids

and their protrusion.

57

RUGVINISCHAYAM

Arshas has to be diagnosed based on the Darshana pariksha with the

help of Arsho darshana nadi yantram or a Proctoscope and Sparshana

pariksha i.e. digital examination. Raktaja arshas has to be differentiated from

Raktatisara and Raktapitta. They are described as follows:

Rectal Examination

Position of the patient: Lithotomy position, left lateral (Sim’s) position and

knee-elbow position are advised, where as the lithotomy position is more

convenient for the examination.

Digital examination – In lithotomy position stretching the buttocks aside

and inspecting the anal region, it is to be noted that whether any eruption,

external piles, etc. are present. Fit a finger stall to the right forefinger and

smear it with a lubricant. Massage the anus for a moment with the finger and

then press gently with the pulp of the finger till it enters the anus directing it

straightly forwards. Once the anal canal is passed, direct the finger slightly

downwards directly towards umbilicus. Feel the mucous membrane for pile

masses, polyps, ulcers and malignant neoplasm. Haemorrhoids are not

palpable unless thrombosed. On withdrawing the finger, examine the finger

for the presence of mucous, blood, etc.

Proctoscopy – The patient should be in left lateral or ‘knee-elbow’ position.

The proctoscope should be made warm and lubricated and should be gently

inserted into the rectum. The instrument should be introduced at first in the

direction of the axis of the anal canal i.e. upwards and forwards towards the

patient’s umbilicus until the anal canal is passed. The instrument is then

directed posteriorly to enter into the rectum properly. Now the obturator is

58

withdrawn and the interior of the rectum and anal canal is seen with the help

of a light. The internal piles, fissures, ulcer and growth can be seen if

present. The piles will prolapse into the proctoscope as the instrument is

being withdrawn. Note the position of the piles. They are generally

positioned according to the main branches of the superior haemorrhoidal

vein. The main three branches are situated in the left lateral, right anterior

and right posterior positions. When then patient is in the lithotomy position

these positions will correspond to 3, 7 and 11 o’clock positions respectively,

if a watch is imagined to be held against the anus. These are called ‘primary

piles’. A few secondary piles (4-5) may frequently develop in between the

primary ones. Chronic fissure is often situated on the midline posteriorly. By

proctoscope one can also find inner opening of fistula and biopsy can also be

taken from a growth or an ulcer through a proctoscope.

Table showing the differences between Raktarshas and Rakta pitta

Raktarshas

Rakta pitta

History of arshas present History absent Bleeding is only per rectum Bleeding can occur from other sites also, like

nose, mouth, genitals, etc. Digital examination reveals masses

Digital examination does not reveal any masses

Bleeding is before or after defaecation

Bleeding can occur irrespective of defaecation

Pain during defaeceation present

Pain is absent

Generally constipation is seen

Constipation not necessary

Dog or crow will take blood mixed food

They do not accept the blood mixed food

Vastra ranjana absent Vastra ranjana present Blood quantity is comparatively less

Bleeding is more

59

Differences between Raktarshas and Rakta atisaram

Raktarshas

Rakta atisaram

History of arshas present History of arshas absent

Digital examination reveals of masses No masses

Bleeding is before or after defaecation, as

abrasion occurs during defeacation

Blood mixed with stool

Stool mass is hard and solid Normal or loose stools

60

SADHYA-ASADHYATA

Arshas is said as a ‘Maha vyadhi’ and by prakruti itself it is

Duschikitsyam i.e. difficult to treat.107 According to Charaka108 - Arshas

involves pancha vidha vatas, pancha vidha pittas, pancha vidha kaphas and

Guda vali trayam; hence they are said to be dukhaani, bahu vyadhikaraani,

sarva dehopataapini and prayah krichhratamani. But still depending on the

vali in which they have originated and the kala avadhi they are classified as

Sukhasadhya, Krichrasadhya and Asadhya.

Sukhasadhya arsho lakshanas

According to Charaka109 and Madhavakara110 Bahya valijata, Eka

dosholbana and na chirotpatitani are said to be Sukhasadhya.

Kricchrasadhya arsho lakshanas

According to Charaka111 and Madhavakara 112 Dwidoshajas, Dwitiya

vali janita and Eka samvatsara purana are said to be Krichhrasadhyas.

Asadhya arsho lakshanas

According to Charaka113 and Madhavakara114 Sahaja, Tridoshaja,

Abhyantara valijanita arshas are said as Asadhyas.

Yapya arsho lakshanas

A rogi with Asadhya Arshas having Ayush sesha, Deepta kayagni and

Chatushpadopapathi, can be considered as Yapya and a rogi not possessing

these turns to be Pratyakhyeya.115, 116

According to Susruta117 – Arshas occurring on Bahya and Madhyama

valis are sadhyas and those occurring on antara vali are asadhays.

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UPADRAVAS

Some Upadravas are also mentioned for Arshovyadhi, the presence of

which in a rogi indicates Pratyakhyeyatva. They are – Sotha of hasta, pada,

mukha, guda and Vrushanas; Hrit parswa sula, Sammoha, Chardi, Angaruk,

Jwara, Trishna, Gudapaka, Arochaka, Ati prasruta sonita and Atisara. It is

said that arshas with these upadravas will definitely kill the rogi.

62

ARSHO CHIKITSA

Charaka and Susrutha, both have described the chikitsa of arshas in a

detailed manner, but differing in orientation, i.e. Oushadha pradhana and

Shastrakarma pradhana. Even then Susrutha has mentioned Oushadha at

first, which shows the importance of Oushadha chikitsa.

Charaka describes oushadha chikitsa in detail but still mentions very

briefly regarding Kshara, Agni and Shastra karmas saying that ‘some people

say that arshas are to be treated with Kshara, some say Shastra, and some

say Agnikarma. For performing these, the Vaidya should have wide

knowledge and should have seen many times, these chikitsas being done by

expert surgeons, because these treatments if improperly done, may lead to

complications like Pumstva upaghata, Swayathu of Guda, Vega vinigraha,

Adhmanam, Daruna Soola, Vyatha, Rakta ati pravruthi, Guda kleda, Guda

bhramsa, Punarviroha of rudhas (recurrence of the gudankuras, which

have subsided) or even Marana120. Therefore a treatment which is Sukha,

Adaruna and Alpa bhramsam will be described for the Samula nivruthi of

arsho vyadhi.’121 This shows the importance given to Oushadha chikitsa,

compared to others.

Susruthokta Arsho Chikitsa

Susrutha says ‘Sankshepatah Kriya yogo nidana parivarjanam’, i.e.

nidana parivarjana itself is the treatment, in brief. So it has to be followed

first, without which all the treatments will remain unfruitful.

The chikitsa of arshas is said to be of four types122, the names and the

conditions in which they are indicated are as follows –

63

• Oushadha sadhyas - Achira kala jatani, Alpa dosha, Alpa linga, Alpa

upadrava yukta, and Adrushya arshas.

• Kshara sadhyas – Mridu, Prasruta, Avagadha and Ucchrita.

• Agni sadhyas – Karkasha, Asthira, Prithu and Kathina.

• Shastra sadhyas – Tanu moola, Ucchritani and Kledayukta.

According to dosha of arshas also these chikitsas are indicated123 –

• Agni and Kshara karmas in Vataja and Sleshmaja arshas

• Mridu Kshara in Pittaja and Raktaja arshas

Susrutha cautions that these Kshara, Agni and Shastra chikitsas are to

be done with utmost care, as Vibhrama of these chikitsas leads to Shandyam,

Sopha, Daha, Mada, Murcha, Atopa, Anaha, Atisara, Pravahana or even

Marana124.

Mandagni is the cause for arshas and all the chikitsas are aimed at

Agni vruddhi and Agni Samrakshana.125

The general outlines of Oushadha chikitsa126 – in Vataja arshas –

Sneha, Sweda, Vamana, Virechana, Asthapana and Anuvasana; in Pittaja

arshas – Virechanam; in Raktaja arshas – Samshamanam; in Kaphaja arshas

– Anulomana, Vibandha hara oushadhas and in Sarva doshaja arshas Sarva

dosha hara oushadha like oushadha sidha payah.

Bhallataka prayoga127 is specially mentioned along with some other

yogas. Two single drugs, Vrukshaka (Kutaja) and Arushkara (Bhallataka)128

have been highlighted, saying that they can cure all types of arshas,

comparing them with two other single drugs Khadira and Beejaka

64

(Vijayasara) in the cure of Kushthas. Similarly Kshara and Agni129 prayogas

have been emphasized to cure all types all types of arshas, comparing with

Haridra prayoga, which can cure sixteen types of pramehas.

Finally emphasizes Nidana parivarjana, Agni samrakshana, and

Anuloma oushadha sevana.130

Charakokta Arsho Chiktsa

Before starting chikitsa Charaka mentions Sadhya asadhya lakshanas,

the intention is to look for them and handle the case accordingly.

Importance of early treatment - Arshas should be treated as early as

possible, because it may cause obstruction to Guda, which may lead Baddha

gudodaram.131

Charaka’s opinion regarding Ksharadi chikitsas is already mentioned.

It is said that there may be recurrence with these chikitsas, hence Oushadha

chikitsa is stated to be uttama.

Arshas has been categorized into Sushka and Prasravi or Ardra

varieties, which are Vata Sleshma and Pitta Rakta adhikya janyas

respectively.

Chikitsa for Sushka arshas with Bhinna Shakrut

For Stabdha arshas, Abhyanga should be done with Chitraka kshara or

Bilwa taila or with any taila or sarpi and then Swedana should be done with

oushadha siddha pottali or pinda. Avagaha and Sechana is done with

Kashayas, Gomutra, Souvira or Tushodaka Madyas, Takra, Dadhi manda,

Amla kanjika, etc. which are sukhoshna. This is followed by Dhoopana,

65

which is done with Vasas of different animals, human hairs, Skins or

Arkamoola, Tumburu, etc. Lepas are advised for rogi with soola, sotha and

hridroga.

The aim of these bahya chikitsas is to reduce the Stabdhata,

Swayathu, Kandu and Vedana and the Dushta rakta accumulated in them

drains out and give relief.

Rakta mokshana132 – when rakta dushti is present, seetha, ushna,

snigdha or rooksha chikitsas will not give relief. Then Rakta mokshana

should be done again and again with Jaluka, Shastra or Suchi, to let out

dushta rakta.

After these bahya chikitsas abhyantara oushadha prayoga is done.

“yad vayoranulomyaya yad agni bala vruddhaye,

anna pana oushadha dravyam tat sevyam nityam arshasaih”133

Mandagni has been considered as the important nidana for arsho roga.

Hence Arsho rogi is advised to take always, Anna, Pana and Oushadha

dravyas, which causes Vatanulomana and Agni bala vruddhi. Hence all the

treatments are aimed at these two.

Tryushana, Patha, Hingu, Chitraka, Saindhava lavana, etc. are given

with Manda, Madya or Ushnodaka, which will relieve from Guda swayathu,

Soola and Mandagni.

Abhaya with Guda is advised to be taken as Pourva bhakta i.e. before

bhojana, which causes arsho sankshayam.

66

Taktra134 has been highlighted to be one of the best arshohara dravya.

It is of three types – Ruksham i.e. navaneeta fully removed, Ardha

uddhrutam i.e. navaneeta half removed and Sneham i.e. navaneeta not

removed. These are given according to agni bala of rogi i.e. alpabala,

madhyama bala and uttama bala accordingly. Takra can be taken alone or

prepared with other oushadha dravyas, mixed with oushadha dravyas or

annam. Sushka Arshas cured by Takra prayoga will not relapse just like the

Truna which is dagdha with takra poured on ground. Takra causes Sroto

suddhi, with which pushti, bala, varna and praharsha are gained. Hundred

varieties of vata kapha vaydhis are curable with Takra and nothing is better

than Takra for kapha vata vyadhi samana. ‘Takrarishta’135 is a special

preparation which is very effective in arshas.

Varieties of Peya, Khada and Yushas are mentioned. Rakta Shali,

Maha Shali, Kalama, Jangala, Sarada and Shashthika are varieties of

dhanyas which can be used as Pathya by an arsho rogi.

Chikitsa for Sushka arshas with Gadha Shakrut

Madira, Seethu, Souvirakam, Prasanna and other yogas prepared with

various oushadhas, with Ghrita and Lavana are mentioned which cause Vata

anulomana and Varcho anulomana, which should be taken as Pourva

bhaktika i.e. before food.

Ghrita yogas prepared with pippali, nagara, kshara, dhanyaka, jeeraka,

phanita, phalamla, pippalimoola, chitramoola, chavya, dadima, patha,

tumburu, yamani, lavana, bilwa, abhaya, swadanshtra, changeri, dadhi, etc.

in different combinations are mentioned which are Vatanulomana, Vibandha

hara, Kapha vata hara, and also useful in pravahika, guda bhramsa, mutra

67

kricchram, parisravam, guda soola, vankshna soola, grahani dosha, etc.

Pippalyadi ghrita is a special yoga mentioned in this context.

Haritaki (ghrita bharjita) and taken with guda and pippali or trivrut

and danti is advised which is Varcho Vata Kapha Pitta anulomaka and

causes Arsho prasamana and Agnideepana.136

Mamsa rasas prepared with different birds and animals are mentioned

which are useful in Pureesha bandha and as Vata shamaka.

Shakas advised as Pathyas – Trivrut, Danti, Palasha, Changeri,

Chitraka, Upodika, Tanduleeyaka, Veera, Vastuka, Suvarchala, Salonika,

Yava, Avalguja, Kakamachi, Ruha patram, Maha patram, Amlika, Jeevanthi,

Sathi, Grinjana are advised to be taken prepared with Dadhi, Dadima,

Yamaka sneha, Dhanya, Nagara, etc.137

Anupanam – Madira, Shaarkara, Seethu, Takram, Tushodakam

Arishtam, Dadhimandam, Sruta seeta jala or jala sruta with Kantakari, or

Nagara and Dhanyaka should be given as anupanas for a arsho rogi with

Vatadhikyata, Rukshata and Deeptagni for causing Vatanulomana and

Varcho anulomana.138

Vasti karma - Anuvasana vasti – snehas prepared with different vata

hara oushadhas are advised for Anuvasana vasti for ati virukshita arsho rogi

suffering with Kandu yukta and Stabdha arshas and also in Udavarta,

Viloma vata, Kati soola, Guda soola, Guda sopha, anaha, Dourbalyam,

Pavahika, Mutra kricchram, etc. Niruha vasti can be given with Ksheera

prepared with Dasamoola, Mutra, Sneha, Lavana and Phala kalkas.

68

Shoucha karma is advised to be done with Ushnodaka and Kashayas

prepared with different patras.

Chikitsa for Sravi (Rakta sravi) arshas

In Vatanubandha, Kaphanubandha, Pitta Kaphadhika and Dushta

rakta srava yukta arshas, Snigdha – Seeta, Ruksha – Seeta, Sodhana and

Upeksha or Langhana chikitsas respectively are advised.139

If the Dushta rakta srava from arshas is stopped, it causes Rakta pitta,

Jwara, Trishna, Agni nashana, Arochakam, Kamala, Swayathu, Guda and

Vankshna Soola, Kandu, Kotha, Pidaka, Kushtha, Pandu, Vata mutra

pureesha vibandha, Sirassula, Staimityam, Guru gatrata, and other Raktaja

gadas. Therefore Rakta sangrahana should be done after complete dushta

rakta srava.140 Vaidya having knowledge of Hetu, Lakshana, Kala, Bala,

Sonita varna, etc. should wait till the dushta rakta srava is complete. Tikta

dravyas are advised for Agni deepana, Rakta sangrahana and Dosha

pachana. If Rakta srava is there in rogi with dosha kshaya and vatolbana, to

him Sneha should be given as Pana, Abhyanga and Anuvasana. Rakta srava

occurring in Ushna kala, which is Pittolbana and without Vata

kaphanubandha, should be stopped immediately. Preparations with Kutaja

twak, Dadima twak, Nagara, Chandana, Kirata tikta, Darvi twak, Useera,

Nimba, Ativisha, Kutaja beeja, and Rasanjana are advised as Rakta

sangrahakas. Kutajadi Rasakriya, Nilotpala prayoga, some ghritas and peyas

are mentioned in this context.

Shakas useful in raktarshas – Kasmari, Amalaki, karbdara, Dadima,

Grunjana, Salmali niryasa, Chukrika, Nyagrodha sunga and Kovidara

pushpa given with dadhi sara (Creamy layer on Dadhi).141

69

Palandu, navaneeta, Ghrita, Chaga mamsa, Shashtika dhanya, Shali

dhanya, Taruna Sura and Taruna Sura manda are very useful as Rakta

sangrahakas. Seetala upacharas like, Parisheka, Avagaha, Udaka dhara, and

Pratisarana are also advised.

Picchavasti is a vishesha yoga mentioned in this context.142

Abhayarishta, Dantyarishta, Phalarishta, Sharkarasava, Kanakarishta

Pippalyadi Ghritam, Hriberadi Ghritam and Changeri Ghritam are the

vishesha yogas mentioned in the context of arshas.

Since Mandagni is the nidana for arshas, agni bala vruddhi causes

ksheena of vyadhi and agni bala ksheena causes vruddhi of vyadhi; hence

Agni bala samrakshana is emphasized at all the times and by all means.

70

MODERN METHODS OF MANAGEMENT OF HAEMORRHOIDS143

Non-operative or Conservative treatment

Small asymptotic first degree piles, which are found incidentally, may

be left alone. If the patients have constipation and difficulty with

defaecation, they require advice about fluid intake and high-residue diet or

the use of laxatives to ensure a regular, easy bowel movement without

excessive straining. Symptomatic piles are to be treated accordingly, along

with laxatives, external lubricant ointments and suppositories and if

necessary by surgery or injection.

Injection therapy

First-degree internal piles with bleeding are advised to have injection

therapy. A Gabriel syringe is filled with sclerosant (5% phenol in almond

oil) and using a proctoscope, 3-5 ml is injected into the pedicle of each pile

at or just above the ano-rectal ring. This produces submucosal fibrosis in the

upper anal canal and lower rectum, constricting vascular spaces within the

pile and decreasing mucosal mobility.

Banding treatment

This is advised in cases with second-degree piles, which are too large

and cannot be handled by injections. The principle of elastic band ligation is

to apply a tight elastic band above the internal haemorrhoid and the mucosa

above it. Not only does this some of the redundant mucosa but also fixes it at

the site of banding to the underlying muscle by scar tissue, thereby

preventing the haemorrhoid from sliding down the anal canal. Banding is not

applicable to piles covered with skin or associated skin tags.

71

Third degree piles, failure of non-operative treatments of second-

degree piles, fibrosed piles and interno-external piles are not suitable

injection or banding treatmetns.

Cryosurgery

The application of liquid nitrogen (–196oC), the extreme cold of

which causes coagulation necrosis of the piles which subsequently separate

and drop off. The procedure is painless and can be done in the Outpatient

department. The technique tends to cause troublesome mucus discharge,

which is the limiting factor for its use. This technique is suitable for internal

haemorrhoids.

Photocoagulation

The application of infra-red coagulation by a specially designed

instrument is advocated for piles that do not prolapse. This is an effective

and painless method.

Manual Anal Dilatation

Manual anal dilation is used to disrupt the tight unyielding sphincter

and reduce the activity of the internal anal sphincter. This can be done as an

O.P. case and postoperative regime of a regular bulk laxative and the

passage of an anal dilator are recommended.

Haemorrhoidectomy

Third degree piles, failure of non-operative treatments of second-

degree piles, fibrosed piles and interno-external piles are not suitable

injection or banding treatments. These are indications for

haemorrhoidectomy.

72

PATHYA-APATYHAS

‘If pathya is followed what is the necessity of chikitsa and

if pathya is not followed what is the use of chikitsa’

– This is what a vaidyakeeya subhashitam says, which indicates that

Pathyapathyas play an important role in the chikitsa of any vyadhi.

Dhanyas: Rakta Shali, Maha Shali, Kalama, Jangala, Sarada and Shashthika

varieties of dhanyas.

Shakas: Trivrut, Danti, Palasha, Changeri, Chitraka, Upodika,

Tanduleeyaka, Veera, Vastuka, Suvarchala, Salonika, Yava, Avalguja,

Kakamachi, Ruha patram, Maha patram, Amlika, Jeevanthi, Sathi, Grinjana,

Chukrika, Nagara, Kovidara pushpa, Nyagrodha sunga. Palandu is specially

mentioned as Rakta sangrhaka.

Phalas: Kasmari, Amalaki, Karbudara, Dadima.

Mamsas: Chaga, Barhi, Tittira, Lava, Daksha.

Dairy products: Ksheera (for vasti), Dadhi, Dadhi sara, Takram, Navaneetam

and Ghritam. Navaneetam and Takram specially mentioned.

Madyas: Madira, Shaarkara, Seethu, Tushodakam, Arishtakam, Taruna Sura

and Taruna Sura manda.

Anupanam – Madira, Shaarkara, Seethu, Takram, Tushodakam Arishtam,

Dadhimandam, Sruta seeta jala should be given as anupanas for causing

Deepana, Pachana, Vatanulomana, Varcho anulomana, Anahahara,

Soolahara, Laghavakara.

TYPES OF ARSHAS

UTPATHI DOSHA ANUBANDHA ADHISHTHANA SADHYASADHYA Sahajanma 1. Vataja 1.Siras 7.Gala 2. Pittaja 2.Nasa 8.Oshtha Uttarothana 3. Kaphaja Sushka Ardra 3.Netra 9.Kantha Sadhya Asadhya 4. Raktaja 4.Karna 10.Mukha 5. Sannipataja 5.Nabhi 11.Vartma 6. Sahaja 6.Talu 12.Twak Sukha Sadhya Kichra sadhya Yapya Pratyakhyeya

CLASSIFICATION OF HAEMORRHOIDS

Internal haemorrhoids External Interno-external Symptomatic Secondary or Accessory Haemorrhoids Haemorrhoids Piles Piles First degree Second degree Third degree

Table showing Lakshnas of Arshas according to Dosha

Dosha

Vata

Pitta

Kapha

Rakta

Vata Rakta

Kapha Rakta

Sannipataja

Varna (colour)

Syava varna Neelamukha, Rakta, Peeta, Asita, prabha

Sita Vata praroha

Aruna varna

Panduni

Akruti (shape)

Bimbi, Kharjura, Karkanthu,

Karpasi

Sukajihwa, Yakrut khanda, Jalouka

vaktra

Karira, Panasa asthi, Gostana

Gunja, Vidruma

Antarmukhani

Parimana (size)

Kadamba puhpa, Siddharthaka

upama

Sukshma Mahamula, Utsanna, Upachita

Irregular

Srava (discharge)

Anila, Sushka, Mlana

Tanu srava, durgandha

Arik Tanu,

Phenila

Asrik Ghana, Tantumat,

Pandu, Picchila

Sparsha (nature)

Stabdha, Vishada, Khara,

Mitho Visadrusa, Vakra,

Teekshna, Visphutita

Mrudu, Slatha, Paka

Snigdha, Stabdha, Vrutta,

Guru, Sthira, Picchila, Sthimita, Slakshna,

Sparshana priya

Daruna, Parusha,

Durdarshana

Mala (stool)

Frothy mucous discharge

Bloody stool Mucous pus discharge

Gadha Sweta, Peeta, Snigdha

Irregular

Vedana (pain)

Adhika vedana (irregular)

Dahayukta vedana Mild pain with itching

Nabhi, Vasti, Vankshna

73

DRUG REVIEW

The oushadha yoga selected for the present study is Hareethakyadi

Lehyam, selected from Bhava Prakasha and Bhaishajya Ratnavali. The

ingredients of the yoga and their proportions are as follows –

1. Haritaki - 7 parts (2100gms)

2. Shunti - 6 parts (1800gms)

3. Nimba beeja - 5 parts (1500gms)

4. Karanja beeja - 4 parts (1200gms)

5. Indrayava - 3 parts (900gms)

6. Chitramulam - 2 parts (600gms)

7. Saindhava lavanam - 1 part (300gms)

8. Gudam - 8 parts (2400gms)

Lehya preparation: Take the drugs from 2 to 7 and make them into a fine

powder and mix them well and keep aside. Take Guda and Saindhava lavana

in wide mouthed vessel and heat slowly till they melt and then they are

mixed well. Now the mixture of the fine powders of the above mentioned

drugs is slowly added to the molten Guda and Saindhava lavana, mixing it

with a darvi. When it reaches the lehya paka stage, the vessel is taken down

from the stove and when moderately hot Ghrita and Madhu are added to it

and allowed to cool to room temperature and preserved in an airtight

container.

Matra : 5gm – twice daily

Anupana : Jalam

74

Hareetaki

Botanical name : Terminalia chebula

Family : Combretaceae

Synonyms

Sanskrit : Abhaya, Pathya, Amrutha, Kayastha, Haimavathi, Siva,

Cetaki, Sreyasi, Vayastha, Vijaya, Jivanti, Rohini,

Putana

Telugu : Karakkaya

English : Chebulic myrobalan

Hindi : Hara, Harara, Harad

Assam : Shilikha

Bengal : Haritaki

Gujarati : Hirdo, Himaja, Pulo – harda.

Kannada : Alalekai

Kashmiri : Halela

Malayalam : Kathikka

Marathi : Hirda, Haritaki, Harda, Hireda

Orissa : Harida

Punjabi : Halela, Harar

Urdu : Halela

Ganas:

• Jwaraghna, Arshoghna, Kasaghna, Kushtaghna,Prajasthapana (Charaka)

• Amalakyadi, Parushakadi, Triphala (Susruta)

• Triphala, Hareetakyadi varga (Bh.Pr.)

Brief description of the plant: It grows wildly and is seen throughout India,

especially in the Sub-Himilayan regions from Ravi River to West Bengal

75

and Assam. It grows to a height of 50 to 80ft. The flowering occurs in the

months of April and May and the fruits are seen during winter. The fruit is

yellowish brown, ovoid, wrinkled and ribbed longitudinally. The useful part

is the phala twak or pericarp, which is fibrous, non-adherent to the seed.

Bhava Prakasha mentions seven varieties of Hareethaki viz. Vijaya,

Rohini, Putana,Amrutha, Abhaya, Jeevanthi and Chetaki. This classification

might be based on the desha and guna karmas. In general usage it is said to

of three varieties Bala Hareetaki, Peeta Hareetaki and Hareethaki i.e. purna

pakwa phala. These are nothing but the fruits collected during different

stages.

The pericarp contains Tannins of which the important are Chebulagic

acid, Chebulinic acid and Corilagin. It also contains Chebulic acid,

Gallotanic acid, Gallic acid, Sorbitol, anthraquinones and polyphenolic

compounds.

Prayojyangas: Phala

Matra: 3-6gm

Gunas:

Rasa : Kashaya pradhana (pancharasa alavana)

Guna : Laghu, Ruksha

Veerya : Ushna

Vipaka : Madhura

Prabhava : Tridoshahara, Rasayanam

76

Karmas:

Tridoshahara, Rasayana, Yogavahi, Deepana, Pachana, Medhya,

Cakshushya, Brimhana, Anulomana, Lekhana, Hridya, Lekhana, Vrushya,

Smrutikara, Buddhida, Vayasthapana, Buddhi Indriya Bala prasadanam,

Vedanahara, Mootrala, Rakta shodhaka, Sroto vibandha. Useful in Hikka,

Swasa, Kasa, Prameha, Arshas, Kushta, Sopha, Udara, Krimi, Visarpa,

Grahani roga, Vibandha, Vishama jwara, Gulma, Vrana, Kantha –

Hridamaya, Kamala, Yakrut – Pleehodbhava soola, Asmari, Mootra

kricchra, Mutra ghata, Jwara, Atisara, Asyapaka, Hanti Santarpana krita

rogan.

Vijaya and Jeevanthi are Sarvarogahara.

77

Sunthi

Botanical Name : Zinziber officinale

Family : Zinziberaceae

Synonyms

Sanskrsit : Ardraka, Ardrika,Visva, Visvam, Visvausadham, Visva

bhesajam, Mahaushadham, Nagaram, Katu bhadram,

Sringaveram, Usanam, Katugranthi, Katushanam,

Souparnam

Telugu : Sonthi

English : Dried Ginger

Hindi : Sunth

Tamil : Chukku

Malayalam : Chukku

Bengali : Shunta, Shunti

Gujarati : Shunthya, Sunta, Soontha.

Kannada : Shunti, Shonthi, Onsuthi, Venam Shutti.

Marathi : Suntha

Punjabi : Sunda

Urdu : Sonth, Zanjabeel

Ganas:

• Triptighna, Arshoghna, Dipaniya, Shula prasamana, Trishna nigrahana

(Ch)

• Pippalyadi, Trikatu (Susruta)

• Panchakola, Shadushan, Hareethakyadi varga (Bhav Prakasha)

Brief description of the plant: A slender perennial rhizomatous herb. The

rhizomes are white to yellowish brown in colour, irregularly branched. The

surface is smooth and if broken a few fibrous elements of the vascular

78

bundles project out from the cut ends. It grows wildly in hot and humid

climates; found extensively in Western Ghats and is also cultivated through

India.

Indian Ginger contains the active principles Gingerin and Shogaol,

some starch, and an aromatic volatile oil containing Camphene, Phelladren,

Zinziberine, Oleo-resins; proteins, calcium, phosphorous, iron and vitamins

A, B, and C and some fat and fiber.

Parts used: Kanda (Rhizome)

Matra: Ardraka swarasa – 5 to 10ml; Sunthi churna – 1to2gm

Gunas:

Rasa : Katu

Guna : Ardraka – Guru, Ruksha, Teekshna

Sunthi – Laghu, Snigdha

Veerya : Ushna

Vipaka : Ardraka – Katu; Sunthi – Madhura

Karma : Kapha Vatahara, Deepana, Pachana, Rechana, Balya, Vrishya

Grahi, Swaryam, Vatanulomana, Truptighna, Sheeta prashamana,

Vedanasthapana, Nadiuthejhaka, Hridyathejak, Raktha shodhaka, Mala

Sangrahi; useful in – Udara, Sleepada, Pandu, Amavata, Katisula, Siroruja,

Vibandha, Anaha, Sotha, Arshas, Chardi, Sula, Kasa, Swasa, Jwara, etc.

79

Nimba (Beeja)

Botanical Name : Azadirachta indica A.Juss (Melia azadirachta. Linn)

Family : Meliaceae

Synonyms

Sanskrit : Tiktaka, Paribhadra, Pichumarda, Hinguniryasa,

Arishta, Sarvatobhadra.

Telugu : Vepa, Konda vepa

English : Neem tree, Margosa tree, Indian lilac

Hindi : Nim, Nimba

Bengali : Nim

Marathi : Kadu nimb

Gujarathi : Leemdo

Tamil : Vembu, Vempu

Punjabi : Nimb

Malayalam : Vempu

Ganas:

• Kandughna, Tiktaskandha (Charaka)

• Aragwadhadi, Guduchyadi, Lakshadi (Susruta)

• Guduchyadi varga (Bh.Pra.)

Brief description of the plant: This grows from about 25 –50 ft. high. Found

extensively throughout India. Flowering occurs from February to March and

fruits are seen from April onwards.

The parts used are Twak, Moola twak, Patram, Pushpam, Phalam,

Beejam, Tailam and Niryasam. There are many active principles of which

important ones are Nimbin, Nimbidin, Nimbinin, Nimboesterol, Margosine,

80

etc. All the parts of the plant and active principles and extracts possessed a

lot of significant pharmacological properties and uses as – antiseptic,

analgesic, antibacterial, antiprotozoal, antiviral, antihelminthic, in skin

diseases, gastric ulcers, snake bite, scorpion sting, etc. Sulphur is present in

considerable amounts, which is the reason for many of the effects.

Neem oil, Nimbin and Nimbidin were found to possess anti-

inflammatory property. Nimbin was to found to possess analgesic and

antipyretic effect. Nimbin and Nimbidin have significant effect on gastric

and peptic ulcers in experimental models; produced antiulcer activity against

various types of gastro duodenal lesions in animals; exhibited healing effect

on peptic ulcer without any side effects. Alcoholic extracts possessed

potentiality on scabies, ringworm, acute eczema and also very effective in

helminthiasis. An unsaponifiable matter from oil of seeds exhibited

antibacterial property against S. aureus, Proteus Sp., E.coli and B.subtilis in

particular. It cured ringworm infection in 4-8 days applied in the form of

lotion. Dramatic action exhibited in 2 days of application. Lotion of neem

leaves applied externally twice a day for 3 consecutive days found highly

effective on scabies. It also exhibited cure for eczema (weeping, acute and

chronic).

Prayojyangas : Twak, Moola twak, Patram, Pushpam, Phalam, Beejam,

Tailam and Niryasam

Matra : Twak churna – 2 to 4gm; Patra swarasa – 10 to 20ml;

Tailam – 5 to 10 drops; Beeja churnam – 1 to 2gm

81

Gunas:

Rasa : Tikta, Kashaya

Guna : Laghu, Ruksha

Veerya : Seeta

Vipaka : Katu

Karmas:

Twak - Kapha Pitta hara, Ahrudya, Grahi, Vedanahara, Varnya,

Twakrogahara, Vrana shodhana and Vrana ropana, Yakruduttejaka;

useful in Srama, Trishna, Kasa, Jwara, Aruchi, Krimi, Vrana, Chardi,

Hrillasa, Kushta, Meha, Sotha;

Patra – Netryam; Raktapitta, Kapha, Krimi, and Visha hara, Vatalam,

katupakam, Arochaka and Kushta hara; Salaka (Rachis of the leaf) is

Kasa swasahara, Sreshta Krimihara, Kushtha jwarahara

Phalam – Tikta rasa, katu paka, Laghu guna, Bhedanam, Aruksham,

Ushnam, Gulma, Krimi, Meha hara

Pakwa phalam – Madhura tikta rasa, Snigdham, Guru, Picchilam; useful

in Sonita pitta, kapha, Nayanamayas, Kshtaksheena

Niryasa – Guru, Picchila, Bhedana, Krimi, Kushta, Sothaharas

Pushpam – Chakshushyam, Krimi, Pitta, Vishahara

Tailam – Laghu, Teekshna, Sara; Katu Rasa; Katu Vipaka;Ushna Veerya;

Vata Kaphahara; useful in Krimi, Kushta, Siro roga

82

Karanja (Beeja)

Botanical Name : Pongamia pinnata

Family : Leguminosae

Synonyms

Sanskrit : Karanja, Naktamala, Guchha pushpaka, Ghritapua,

Snigdha patra, Prakeerya, Pushpa manjari

Telugu : Kanuga, Kalukranuga, Ganuga

English : Indian beech

Hindi : Dithouri

Marathi : Karanja

Gujarathi : Karanja, Kanajhi

Bengali : Dahar Karanja

Tamil : Pongum

Malayalam : Ponnam

Kannada : Honge

Ganas:

• Kandughna, Virechana, Katuka skandha, Tikta skandha (Charaka)

• Aragvadhadi, Varunadi, Arkadi, Syamadi, Sirovirechana, Kapha

samsamana (Susrutha)

• Guduchyadi varga (Bhava prakasa)

Brief description of the plant: This is a mid sized tree growing about 25 – 50

ft. high. It is found throughout India especially in South India and coastal

regions. Flowering occurs from May to June and fruits in December and

January. The parts used are Twak, Patra and Beeja. The oil extracted from

the seeds called Pongamia oil, is bitter and dark couloured active principle

83

called Karanjin which is very good antibacterial. Root bark contains

alkaloids like Kanugin, Demethoxy kanugin, etc.

Prayojyangas: Twak, Patra and Beeja, Tailam

Matra: Swarasa of twak/patra – 10 to 20 ml;

Beeja churna – 1 to 3 gm.

Gunas:

Rasa : Tikta, Katu, Kashaya

Guna : Laghu, Tikshna

Vipaka : Katu

Veerya : Ushna

Karmas:

Twak: Vata Kaphahara, Pitta vardhaka, Bhedana, Kriminasaka, Vrana

ropana, Vedanasthapana, Rakta doshahara; useful in Krimi, Sotha,

Kustha, Meha, Udara, Arshas, Yoni dosha, Gulma, Udavarta, Pleeham

Patra – Kapha vatahara, Pittalam, Deepana, Pachana, Bhedana, Sopha,

Visha, Arsha, Krimi, Kushtha

Phalam (Beeja) – Kapha vatathara, Meha, Arsha, Krimi, Kushtha, Jantujit

84

Indrayava (Kutaja beeja)

Botaical Name : Holerrhina antidysenterica

Family : Apocyanaceae

Synonyms

Sanskrit : Girimallika, Vatsaka, Vrukshaka, Kalinga, Indravruksha

Telugu : Kodisapala, Palakodisa, Kutaja

English : Kurchi

Hindi : Kutaj, Kuda

Bengali : Kurchi

Marathi : Kuda

Gujarathi : Kudo

Tamil : Veppalai

Kannada : Korchi

Urdu : Kherda

Punjabi : Kenar

Ganas:

• Arshoghna, Kandooghna, Stanya sodhana, Asthapanopaga,

Vamanaopaga (Charaka)

• Aragvadhadi, Pippalyadi, Lakshadi, Haridradi, Urdhwabhagahara

(Susrutha)

• Hareetakyadi varga (Bh.Pra.)

Brief description of the plant: This is a medium sized plant growing upto 30

ft. high. Distributed wildly throughout the country. Charaka has mentioned

two varieties namely – Stree and Pum Kutaja. Ayurvedic physicians of the

later period found two varieties – namely Swetha and Krishna. These are

correlated as – Swetha to be Pum Kutaja i.e. Holerrhina antidysenterica and

85

Krishna to be Stree Kutaja i.e. Wrightia tinctoria. The parts used are Twak

and Beeja. The bark and seeds contain many alkaloids like Kurchicine,

Conessin, Holerrhine, Kurchin, etc. of which ‘Conessin’ is the important

one. It is a well known remedy for diarrhoea and dysentery and has specific

action on E. histolytica.

Prayojyangas: Twak and Beeja

Matra: Twak Churna – 10 to 30 gm. (taken as Kashaya);

Beeja Churna – 3 to 6 gm.

Gunas:

Rasa : Tikta, Kashya

Guna : Laghu, Ruksha

Veerya : Seeta

Vipaka : Katu

Karmas:

Twak – Kapha Pitta hara, Trishnahara, Amahara, Sulahara, Deepana,

Grahi, Upashoshaka and useful in, Arshas, Krimi, Kushta, Atisara,

Raktapitta, Hridroga, Vatarakta and Visarpa.

Beeja – Tridoshaghna, and other gunas same as twak.

86

Chitraka

Botanical Name : Plumibago Zeylanica Linn.

Family : Plumbaginaceae

Synonyms

Sanskrit : Agni, Vahni, Jvalanakya, Dhana

Telugu : Chitramulam

English : Leadwort

Hindi : Cheetah, Chira, Chitra

Marathi : Chitraka

Bengali : Chita

Gujarati : Chitro

Tamil : Chittira

Urdu : Sheetras

Ganas:

• Deepaneeya, Truptighna, Shoola Prashamana, Bhedaneeya, Arshoghna,

Lekhaneya, Katukaskandha (Cha)

• Pippalyadi, Mustadi, Amalakyadi, Mushkakadi, Varunadi, Argwadhadi

(Su)

• Panchakola, Shadooshana, Hareetakyadi varga (Bha. Pra)

Brief description of the plant: It is a perennial shrub found throughout India,

distributed wildly and is also cultivated. Three varieties of Chitraka are

mentioned in the texts i.e Swetha (P. zeylanica), Rakta (P. indica) and Neela

(P. auriculata). Of these Swetha is the variety abundantly available and

generally used. The part used is root and it contains an alkaloid which is

yellow coloured, bitter in taste forming needle shaped crystals known as

Plumbagin.

87

Prayojyangas : Moola Twak

Matra : 1 – 2 gr. Of powder

Gunas:

Rasa : Katu

Guna : Laghu, Rusha, Ushna, Teeksha

Veerya : Ushna

Vipaka : Katu

Karmas:

Vata kapha haram, Pitta vardhanam, Deepanam, Pachanam, Grahi,

Rasayanam. Useful in Shoola, Grahani, Kustha, Shotha, Arshas, Krumi,

Kasa, Udara and Pandu.

Vishakta lakshanas (toxic symptoms): Excessive dosage produces –

• Kshobhaka and madak visha lakshanas- it produces burning sensation in

throat, stomach & whole body, vomiting and diarrhoea

• Mutrakruchram

• Pulse – low and irregular

• Coldness of skin

• Abortifacient

The condition should be treated with Pitta shamaka, snigdha-sheetala

dravya Prayogam.

88

Saindhava Lavanam

Latin name : Sodii chloridum

Synonyms

Sanskrit : Saindhava, Sheetashiva, Lavanottama, Sindhu lavana,

Pathya, Shivatmaja, Manibandha

Telugu : Saindhava lavanam

English : Sodium chloride

Hindi : Saidhavon

Bangali : Saidhavalanam

Gujarati : Sindhalun

Ganas : Lavana Panchakam, Hareetakyadi varga (Bh.Pra.)

Gunas:

Rasa : Lavana, Madhura

Guna : Laghu, Snigdha, Seeta, Sookshma

Veerya : Anushna

Vipaka : Madhura

Karmas:

Uttama Tridoshagnam, Deepanam, Pachanam, Ruchyam, Himam,

Vrushyam, Netryam, Hrudyam, Avidahi, Lavanothamam.

89

Gudam (Ikshurasa vikara)

Botanical name : Saccharum officinarum Linn.

Family : Graminae

Synonyms

Sanskrit : Ikshu, Dirghacchada, Bhurirasa, Asipatra, Madhutruna,

Gudamula

Telugu : Bellamu, Cheruku

English : Jaggery

Hindi : Gud

Ganas:

• Trina panchamoola (Su)

• Ikshu varga (Bh.Pra.)

Brief Description: Guda or Jaggery is prepared from Ikshurasa by the

‘Rasakriya’ process. It is a rich source of sugar and also contains Iron in

high quantities.

Prayojyanga: Moola, Rasa (made into Sarkara or Guda)

Gunas:

Rasa : Madhura

Guna : Guru, Snigdha

Veerya : Seeta

Vipaka : Madhura

Karmas: Vataghnam, Nati Pittakaram, Vrushya, Mutra sodhaka, Balyam,

Medovardhakam, Kaphavardhakam, Raktapittahara, Trishna prasamana,

Krimikara.

Table showing the Gunas of ingredients of Haritakyadi Lehyam.

Dravya

Rasa

Guna

Veerya

Vipaka Action on Doshas

Other actions

Harithaki Pancharasa, Alavana, Kashaya pradhana

Laghu, Ruksha Ushna Madhura Tridoshahara,

Rasayanam, Deepana, Pachana, Anulomana

Sunthi Katu Laghu, Snigdha Ushna Madhura Kapha Vatahara Deepana, Pachana, Rechana, Balya, Vrushya Vibandha Anaha

Nimba beeja Tikta, Kashaya Laghu, Ruksha Seeta Katu Kapha Vata hara Bhedana, Gulma, Krimi, Kushtha

Karanja beeja Tikta, Katu, Kashaya

Laghu, Teekshna Ushna Katu Kapha Vata hara Meha, Krimi

Indrayava Tikta, Kashaya Laghu, Ruksha Seeta Katu Tridoshaghna Deepana, Grahi, Arshohara

Chitramulam Katu Laghu, Ruksha, Ushna, Teekshna

Ushna Katu Vata Kaphahara Pitta vardhaka

Rasayanam, Deepana, Pachana

Saindhava Lavanam

Lavana, Madhura

Laghu, Snigdha, Seeta

Anushna Madhura Tridoshaghna Deepana, Pachana, Vrushya, Hrudya

Gudam Madhura Guru, Snigdha Seeta Madhura Vataghna, Nati Pittala Kaphakara

Vrushya Balya Rakta pittahara

90

MATERIAL AND METHODS

The present clinical study namely “A Study of the Effect of

Haritakyadi Lehyam in Arshoroga” is carried out at the O.P. wing of the

P.G. Unit of Kayachikitsa, Govt. Ayurvedic Hospital, Erragadda,

Hyderabad, spread over a period of Eighteen months during the years 2006 –

2007.

The cases were selected exclusively from the O.P. wing of the P.G.

Unit of Kayachikitsa. Patients of both the sexes and of all age groups were

taken. The cases were selected randomly and thoroughly examined. Patients

with carcinoma of the rectum were not taken for the study. Patients with

hypertension and diabetes were also taken for study. Finally 30 cases were

taken for the study.

All these patients were examined thoroughly as per the parameters

mentioned in Ayurveda as well as Modern medicine. All the details were

recorded in a special case sheet designed for this purpose. Then the trial drug

‘Haritakyadi Lehyam’ was given for a period of 40 days. Dietary regulations

mentioned for arsho rogi were explained and the patients were asked to

follow them to the possible extent.

The criteria taken into consideration for the assessment of results were

– Sex, Diet, Age group and Economic status, Dosha, Chronicity, Heredity,

Smoking and Alcoholism.

The parameters taken for assessment of result are Vedana, Daha,

Kandu, Sotha, Sravam, Rakta srava, Kharatva, Mala baddhata, Parimana and

Pandu, which were recorded from time to time.

91

Routine investigations like BP, Weight, Hb%, CBP, ESR, RBS, CUE

and special diagnostic procedure i.e. Proctoscopy were done in each and

every case. The necessary investigations were repeated at regular intervals

and the data was recorded carefully in a special case sheet.

Material: The trial drug is Haritakyadi Lehyam which is in the form of

Lehyam, whose ingredients are Haritaki, Sunthi, Nimba beeja, Karanja

beeja, Indrayava, Chitramulam, Saindhava Lavanam, and Gudam.

Matra : The dose of the drug is fixed to be 5gm, twice daily.

Kala : Morning and Night

Anupanam : Jalam

Assessment of Result: In the present clinical study the results were assessed

comparing the subjective and objective parameters, before starting the

treatment and after completion of course of treatment. Based on the

percentage of progress the results are categorized in to three groups –

Result Percentage of Progress

Good above 70%

Moderate 50% - 70%

Poor 30% - 50%

92

OBSERVATION AND RESULTS

The patients were classified according to Sex, Age and Diet,

Economic status, Heredity, Smoking, Habit of Alcohol, Chronicity and

Doshic predominance of Arshas.

Observation

1.Sex: The patients were classified on the basis of sex and the study

reveals that the affected males and females are 19 (63.3%) and 11 (36.7%)

respectively, i.e. the incidence in males is almost double than that in

females, which might be due to the fact that males are subjected more to the

nidanas than females.

Table showing the incidence of Arshas in Male and Female.

Sex No. of patients

Male 19

Female 11

Total 30

2. Age: The patients were classified according to their age and the

present study reveals that the incidence is highest among the age groups of

20-40 years age group i.e. including both 20-30 years age group and 30-40

years age group, whose number is 22 (73.3%), the number of patients in 40-

50 years age group is 6 (20%) and those in 50-60 years age group is 2

(6.7%). As the persons in the above mentioned age groups will be in the

93

stages of final education or early working and earning categories, hence it

can be said that the disease will have a considerable effect on the education

part or the earning part of the life which may affect their lively hood, hence

the necessity for a better treatment.

Table showing the incidence of Arsahs in different age groups.

Age group No. of patients .

21-30 11

31-40 11

41-50 6

51-60 2

Total 30

3. Diet: The patients were classified according to their dietary habit,

whether Vegetarian or Mixed diet. It is observed that the patients taking

mixed diet are more affected 25 patients (83.3%) compared to pure

vegetarian 5 patients (16.7%).

Table showing incidence of Arshas in Vegetarian and Mixed diet

patients.

Dietary habit No. of patients .

Vegetarian 5

Mixed 25

Total 30

94

4.Economic status: The patients were classified according to their

economic status (income), and the observation reveals that the incidence of

Arshas among higher, middle and lower income groups is 10% (3 patients),

56.7% (17 patients) and 33.3% (10 patients) respectively. The reason for the

number being least in higher income group may be the living conditions and

the timely and proper medication, which the people of other two groups are

deprived of.

Table showing the incidence of Arshas in different income groups.

Economic status No. of patients .

Higher income group 3

Middle income group 17

Lower income group 10

Total 30

5. Heredity: The present study reveals that the affected patients

having hereditary history are only 6 (20%) against the number of patients

having no hereditary history, whose number is 24 (80%). This indicates that

though heredity is an important factor, arshas occurring with out hereditary

history due to the severity of the nidanas is also more.

Table showing the incidence of Hereditary factor in arshas patients.

Hereditary history No. of patients .

Present 6

Absent 24

Total 30

95

6. Smoking: The patients are classified based on the habit of

smoking, whose number is 8 (26.7%) and the remaining 22 (73.3%) are non-

smoking. It is observed that in non-smoking category of patients, the relief is

observed early compared to smoking category.

Table showing the number of patients according to habit of Smoking.

Habit of smoking No. of patients .

Yes 8

No 22

Total 30

7. Habit of Alcohol: The patients were classified based on the habit

of consuming alcohol and 7 patients (23.3%) were found to be having the

habit and the remaining 23 (76.6%) were considered to be non-alcoholics. It

is observed that in non-alcoholic category of patients, the relief is observed

early compared to alcoholic category.

Table showing the number of patients according to habit of Alcohol.

Habit of Alcohol No. of patients .

Yes 7

No 23

Total 30

96

8. Chronicity: The patients were classified according to the

chronicity of the arshas. As mentioned in the nidana, history of arshas more

than one year is considered to be chronic and within a year is considered to

be non-chronic. 8 patients (26.7%) were chronic and 22 patients (73.3%)

were non-chronic. It was observed that in chronic cases relief is obtained

after longer duration compared to the other group and relief is also less and

in some cases relief was observed only while using the medicine and after

stopping the medicine the symptoms relapsed.

Table showing the number of patients according to Chronicity.

Chronicity No. of patients .

Chronic 8

Non-chronic 22

Total 30

9. Doshic predominance: The patients were classified according to the

predominance of Dosha and their numbers were found to be 23 (76.7%) in

Vata predominant category and 7 (23.3%) in Kapha predominant category.

Table showing the doshic predominance in arshas patients.

Doshic predominance No. of patients .

Vata 23

Kapha 7

Total 30

97

RESULT:

The result of the study is tabulated as follows:

Table showing the Result of the treatment

No. of patients Result of the treatment . Male Female Total

Good 9 7 16

Moderate 5 3 8

Poor 5 1 6

Total 19 11 30

‘Good’ result was observed in 16 patients (53.3%), most of them

responded in the first 10 days of treatment. Rakta srava, Malabaddhata and

Vedana were completely disappeared and the patients were able to do their

routine work without any disturbance.

‘Moderate’ result was observed in 8 patients (26.7%).

‘Poor’ result was observed in 6 patients (20%).

The results are presented in the form of a ‘Master Table’ and also

depicted in the form of ‘Graphs’.

98

DISCUSSION AND CONCLUSION

Though the modern medical and surgical wings developed vastly, still

there are many diseases, which are not amenable to the present day

management. In these conditions the attention of the patients as well as the

modern medicine is turning to alternate systems of medicine for a better

and permanent solution. The patients suffering with Arshas also belong to

the same category. They feel as if they do not have any cure for the

diseases and they develop some sort of desperate tendency.

Since Arshas occurs due to various nidanas and has many sites,

though treated by surgical way still there are chances of recurrence of the old

ones, as well as new ones may also develop as long as the nidanas are not

taken care of, hence the emphasis on Oushadha chikitsa by Charaka and

Susrutha.

In classics there are many number of medicines prescribed for the

treatment of Arshas. Each and every medicine has its own role of action and

specification. It is needed to evolve a simple and effective medicine among

them, which suits Arshas of all types. This work is a trial for evaluation of

one such medicine at random in the cases of Arshas.

The analysis of the data obtained from the present study gives very

valuable information about the disease which is as follows.

The affected number of males with Arshas is more than that of

females. This can be explained as due to the hard working i.e. laborious jobs,

food habits, habits like smoking and alcohol, altered bowel habits, etc.

99

People in the Age groups of 21 to 30 and 31 to 40 years are more

affected, because it is the prime phase of working hard and earning or to say

the ‘productive period of an individual’, and the people in these age groups

are more exposed to the said causative factors of Arshas and hence the

incidence.

Diet plays an important role as a nidana of Arshas. The people with

mixed dietary habit are more affected than pure vegetarians. This is due to

the less quantity of fiber available in fleshy food stuffs as well as the spicy

nature of them without which people don’t relish them and hence is a must.

The Mamsa ahara and the spicy nature of the food come under the category

of Rajoguna vardhaka ahara, which is considered as Dosha prakopaka and

the nature of the persons taking such ahara are also Rajoguna pradhana. It is

not that the people with other Gunas (Satwa and Tamo) do not take such

food but they may follow the ‘Matra, Kala and Anupana, which are the key

factors behind the menace.

The data about the economic status suggests that the number of

patients in the higher income group is less when compared to the other two

groups. This is because of the working conditions they have, the quality of

the food they can get, the flexibility of time to have timely food and last but

not the least is the proper place to take food. It has been observed in many

cases that people hesitate to carry their own/home made food because they

don’t get proper place to have it and have to resort to the food available

outside. Some people, who are in jobs like marketing, do not have a fixed

schedule, and even take back their lunch boxes because of some or other

reason. Thus ‘proper place to have food’ also stands to be an important

factor. The number of patients in the lower economic group is comparatively

100

less because of their unawareness about Ayurvedic medicine and the false

beliefs about Pathya-apathyas.

Hereditary factor stands to be of moderate concern because the

number of patients with hereditary history is only one fifth of the total

number and the result of the treatment was better in this group because of

the strict adherence to the other regimen advised to them. Hence it can be

said that though Heredity is an important factor, Mithya ahara viharas are of

much more importance both in causation as well as in the treatment aspect.

Smoking and Alcoholism are also important factors as Nidana and

also as Apathya. It was observed that relief was obtained earlier in the

nonsmoking and non-alcoholic category of patients compared to those with

smoking and/or alcohol habit.

Chronicity has its effect on the result of the treatment, perhaps a case

turns to be chronic only if proper attention is not paid and proper care is not

taken of in the aspect of both treatment and Pathya-apathyas. Therefore it is

clearly mentioned in the sadhya-asadhyata aspect that these cases belong to

the ‘Yapya’ category.

Doshic predominance has got its own impact as a nidana factor. If

Arshas itself was considered as a Pitta pradhana vyadhi, Vata is observed to

be anubandha dosha having predominance compared to Kapha. This is

expressed as the lakshanas, of which Rukshata is important one. Therefore

stress was laid on the vatanulomana and snigdha aharas in the chikitsa

aspect.

101

Action of the drug:

The action of the drug can be explained on the basis of its Rasa, Guna,

Veerya, Vipaka and Prabhava and those of HARITHAKYADI LEHYAM

are tabulated below.

Rasa: Madhura rasa is Pitta, Vata samaka, Rakta sangrahaka, Gouravakara

and Anulomana. Lavana rasa is Vata samaka, Ama pachaka, Deepana,

Anulomana and Kledakara. Katu rasa is Vata Kapha samaka, Deepana,

Pachana, Kledakara, Anulomana and Rechana. Tikta rasa is Kapha Pitta

samaka, Ama pachaka, Rakta sangrahaka. Kashaya rasa is Pitta Kapha

samaka, Gouravakara, Rakta sangrahaka, Anulomana. By all these gunas the

drug acts as Tridosha samaka, Deepana, Pachana, Rakta sangrahaka,

Kledakara, Anulomana and Mridu Rechana.

Guna: Laghu and Ruksha gunas are Kapha samaka, Deepana, Pachana,

Rakta sangrahaka. Guru guna is Vata samaka, Kapha vardhaka,

Gouravakara, Anulomana. Snigdha guna is Vata samaka, Mardavakara

Gouravakara, Anulomana. Ushna and Teekshna gunas are Vata Kapha

samaka, Deepana, Pachana, Anulomana, Rechana, etc. Thus by the above

gunas the drug acts as Vata Kapha samaka predominantly, Deepana,

Pachana, Anulomana, Rakta sangrahaka, Rechaka, etc.

Veerya: Seetha veerya acts as Pitta Kapha samaka, Rakta sangrahaka,

Anulomana, etc. Ushna veerya acts as Vata samaka, Deepana, Pachana,

Kledakara, Anulomana, Rechana, etc. Thus the drug acts as Vata Kapha

samaka predominantly, and also Deepana, Pachana, Kledakara, Anulomana,

and Rechana.

Vipaka: Madhura Vipaka is Pitta Vata samaka and Kapha vardhaka. Katu

vipaka is Vata Kapha samaka and Pitta vardhaka. The drug is

102

predominanltly Vata Kapha samaka, Deepana, Pachana, Anulomana and

Rechana.

Prabhava: Rasayana prabhava is possessed by Harithaki, Saindhava lavana

and Chitramula.

By all the above mentioned properties of the individual drugs the

compound drug ‘Harithakyadi Lehyam’ exhibits the actions of Vata Kapha

samana, Deepana, Pachana, Rakta sangrahana, Mardavakara, Kledana,

Anulomana, Mridu rechana, etc. and improvement was seen in all types of

Arshas cases. Pandu condition was also improved by virtue of Gudam. Thus

it can be said that the drug is very effective in all the types of Arshas.

CONCLUSION: The results of the present study are encouraging. Good result was

obtained in 16 cases (53.3%) and Moderate result was seen in 8 cases

(26.7%) and Poor result was obtained in 6 cases (20%). Patients suffering

with severity of the symptoms were also relieved with in first ten days of

treatment. In chronic or Yapya category of cases also relief was observed as

long as the medicine was taken in the dosage and timing as prescribed. All

these facts prove the drug to be very effective in all types of Arshas.

103

SUMMARY

Disease profile

• General introduction of the disease, drug and their selection criteria are

discussed.

• Synonyms, derivations and definitions of the word Arshas are discussed.

• Classification of the Arshas is discussed in detail.

• Anatomical aspect of Guda, Valis with their correlation in modern aspect

is discussed.

• Importance of Guda and process of mala visarjana is discussed.

• Nidana aspect is discussed in detail considering all the types of Arshas.

• Poorva Roopa and Roopa aspects are discussed in detail considering all

the types of Arshas and the Roopa (lakshanas) is given in a tabular form

which serves as a ready reckoner of the lakshanas of all the types of

Arshas.

• Vyadhi vyavachedaka nidanam or differential diagnosis is described.

• Sadhya-asadhayta is discussed.

• Chikitsa part is discussed in detail including principles of treatment,

general line of treatment, and the important drugs, single and compound,

were mentioned.

• Pathya-apathyas are described accordingly.

Drug Review

• In the Drug review part the composition and preparation of the lehyam,

its dosage and description of the individual drugs in detail are mentioned.

104

Clinical Study

• The Methods and Material, Parameters taken for the diagnosis and

assessment of progress in the patients are described.

• In the Observation and Results part, the data obtained in the study is

tabulated and also presented in the form of graphs for easy

understanding.

• In the Discussion and Conclusion part discussion regarding the data

obtained and the derivations done based on the data as well as the

explanation on the mode of action of the drug are given in detail and the

Conclusion is made.

• Finally summary is given.

BIBLIOGRAPHY

A Text Book Of pathology – William Boyd

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Bailey and Love – A short text book of Surgery

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Charaka Samhita with commentaries of Chakrapani and Jajjata – Edited by

Sri Hari Datta Sastry, Chowkhamba publiacation

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Clinical Methods of Ayurveda – Prof. K.R. Srikantha Murthy

Differential Diagnosis – Dr.Gupta and Gupta

Dravya Guna Vignan – Acharya Priya Vrat Sharma

Human Anatomy – B.D.Chaurasia

Human Physiology – C.C.Chatterjee

Hutchison’s Clinical Methods

Indian Materia Medica – Dr.K.M.Nadkarni

Indian Medicinal Plants – Orient Longman

Introduction to Kayachikitsa – Dr.C.Dwarakanath

Madhava Nidanam – Deevi Gopalacharyulu

Madhava Nidanam with Madhukosa Vyakhya– Chokhamba publication

Parishadyam Sabdartha Saareeram – Baidyanath

Principles in Surgery – K.Das & S..Das……..

Principles of Anatomy and Physiology - Gerard J. Tortora

Raja Nighantu – Krishna Das Academy, Chowkhamba Publication

Rasa Ratna Samucchayam – Chivukula Satyanarana Sastry

Sareera Kriya Vignanamu – A.P. Ayurvedic Lit. Improvement Trust

Susrutha Samhita – Ambika Datta Sastry - Chowkhamba Publication

Tridosha Theory – V.V.Subrahmanya Sastry

Vedon me Ayurved – Ram Gopal Sastry

REFERENCES

1. Su.Su.33/45 2. As.Hru.Ni. 8/30 3. Ch.Ni. 1/1-5 4. As.Hru.Ni. 1/1 5. 5th - Arsho adhikara 6. 9th – Arsho adhyaya 7. Amarakosa, 2/6/54 8. As.Hru.Ni.7 9. Amarakosa, 2/4/4 10. Amarakosa 1/1/56 11. Amarakosa 2/6/54 12. Ch.Chi.14/6 13. Ch.Chi.14/6 14. A.Hru.Ni. 15. Ch.Chi.1/25 16. Vedon me Ayurved,

Ramgopal Sastry 17. Ch.Sa.3/6 18. Ch.Sa.7/13 19. Ch.Si.9/3 20. As.San.Sa.7/18 21. Su.Ni.3/19 22. Su.Sa.7/23 23. Su.Ni.2/5 24. Su.Ni.2/6-8 25. As.Hru.Ni.7 26. A.D.Sastry on Su.Ni.2/6 27. Dalhana on Su.Ni.2/5 28. As.Hru.Ni.7 29. Dalhana on Su.Ni.2/5 30. Dalhana on Su.Ni.2/5 31. Ch.Su.29/3 32. Su.Sa.6/9 33. Ch.Su.12/8 34. Ch.Vi.5/4 35. Ch. 36. Ch.Chi.14/5 37. Ch.Chi.14/5 38. Su.Ni.2/3 39. Ma.Ni.5/1 40. Ch.Chi.14/171-174

41. As.Hru.Ni.7 42. Ch.Chi.14/38 43. Ch.Chi.14/170 44. Ch.Chi.14/6 45. Ma.Ni.5/43 46. Ch.Chi.14/26-31 47. Bailey and Love, 48. Ma.Ni.5 49. Ma.Ni.5 50. Ma.Ni.5 51. Su.Su.3 52. Ch.Ni.1/7 53. Ma.Ni.1 54. Madhukosa on Ma.Ni.1 55. Su.Ni.1 56. Ch.Chi.14/4-5 57. Su.Ni.2/16 58. Bailey and Love 59. Ch.Chi.14/9-10 60. Su.Ni.2/4 61. Ch.Chi.14/14 62. Ma.Ni.5/3-4 63. Ch.Chi.14/17 64. Ma.Ni.5/5-6 65. Ch.Chi.14/19 66. Ma.Ni.5/7-8 67. Ch.Chi.14/20 68. Ma.Ni.5/9 69. Ch.Chi.14/20 70. Ma.Ni.5/9 71. Bailey and Love 72. Ma.Ni.1.Madhukosa 73. Ch.Chi.14/22 74. Su.Ni. 2/9 75. Ma.Ni.5/31-32 76. Ch.Chi.14/7 77. Ch.Chi.14/8 78. Su.Ni.2/16 79. Ma.Ni.5/9 80. Ch.Chi.14/11 81. As.Hru.Ni.7 82. Ch.Chi.14/12 83. Su.Ni.2/11

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MASTER CHART

Sl. No.

Name

Age In

Yrs

Sex

Occupation

Diet

Smoking

Alcohol

Economic

Status

Hereditary

History

Anubandha

Dosha

Chroni

-city

Result

1 Narahari 53 M Carpenter M Yes Yes MIG No Kapha + Poor 2 A.Srinivas 25 M Student M No No MIG No Vata --- Good 3 A.Balaji 40 M Software M Yes Yes MIG Yes Vata + Moderate 4 S.Mahitha 26 F Student M No No MIG No Vata --- Good 5 Y.Hari babu 26 M Student M No No MIG No Vata --- Good 6 B.Venkatesh 27 M Security Guard M Yes Yes LIG No Kapha --- Moderate 7 Smitha 45 F Housewife V No No HIG Yes Vata + Moderate 8 Venkatesh 35 M Employee M No No MIG No Kapha --- Good 9 D.Jyothi 23 F Housewife M No No MIG No Vata --- Good

10 K.Hanumantha Rao 25 M Taxi driver M Yes Yes LIG No Vata --- Good 11 H.Raju 22 M Auto driver M Yes Yes LIG No Vata --- Poor 12 Lakshmi 28 F Research scholar M No No MIG No Kapha --- Good 13 R.Shivaji 27 M Employee M No No LIG No Vata --- Moderate 14 K.Narsing Rao 45 M Employee V No No HIG Yes Vata + Poor 15 Rajesh 35 M Business M No No MIG No Vata --- Good 16 Balamma 40 F Green grocery M No No LIG No Vata --- Moderate 17 Kalavathi 45 F Housewife M No No MIG No Vata --- Good 18 Mangala 35 F Housewife V No No HIG No Vata --- Good 19 Govind 35 M Office boy M Yes Yes LIG No Kapha --- Good 20 Buchaiah 50 M Business M No No MIG Yes Vata + Moderate 21 Nagaiah 50 M Employee M No No MIG No Vata --- Poor 22 Bharathi 45 F Housewife M No No LIG No Vata --- Good 23 Suguna 45 F Employee M No No MIG Yes Vata + Moderate 24 Santhosh 40 M Attender M No No LIG No Vata --- Good 25 Khajauddin 55 M Auto driver M Yes No LIG Yes Kapha + Poor 26 Balabhaskar 42 M Employee M No No MIG No Vata --- Good 27 R.Srinivasa rao 28 M Teacher V No No MIG No Vata --- Good 28 Archana Joshi 32 F Employee V No No MIG No Vata --- Good 29 Ameeruddin 27 M Hamali M Yes Yes LIG No Kapha + Moderate 30 Sumathi 33 F Housewife M No No MIG No Vata --- Poor

ABBREVATIONS:

Diet: V-Vegetarian; M-Mixed

Economic status: LIG – Low Income Group; MIG – Middle Income Group; HIG – Higher Income Group

Chronicity: ‘+’ More than a year; ‘–’ Less than a year