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→Tattva Vimarsha
Thus ends of the 14th chapter which deals with the treat¬ment of hemorrhoids (arshas) in the section on therapeutics of Agnivesha's work as redacted by Charaka.
Thus ends of the 14th chapter which deals with the treat¬ment of hemorrhoids (arshas) in the section on therapeutics of Agnivesha's work as redacted by Charaka.
=== Tattva Vimarsha ===
=== ''Tattva Vimarsha'' ===
*The arsha is of two types viz. congenital and acquired (manifested after the birth).
*The congenital haemorrhoids are caused by the vitiation of the beeja dosha (deformity in sperm and ovum), specially the part of the anal canal or anal sphincters. This vitiation of the beeja dosha is caused by either wrong diet, lifestyle regimen of parents (father/mother) or by sinful acts of the past life of patient. These are also causes for all other congenital disorders.
*Arsha (hemorrhoids) is characterized by morbid growth in the muscle tissue. The adhishthan (involved morbid tissue elements) of all the types of arsha are medas (fatty tissue), mamsa (muscular tissue) and tvaka (skin and mucous membrane).
*Characteristics or forms of all hemorrhoids are as per the doshas involved in their formation.
*In pathophysiology of arsha, apana vayu gets obstructed by the hemorrhoid-mass and moves upwards leading to aggravation of samana vayu, vyana vayu, prana vayu, udana vayu, pitta and kapha dosha. When all these five types of vayu, pitta and kapha get aggravated the individual suffers from morbidities of hemorrhoids.
*The causes of vataja arsha include habitual intake of astringent, pungent, bitter, ununctuous, cold and light food; habitual intake of pramitashana (food measured in extremely small quantities), intake of less quantity of food, intake of excess alcoho¬lic drinks and indulgence in sexual acts; fasting, living in cold country and cold season, excess physical exercise, grief and exposure to sun and wind.
*The causes of pittaja arsha include intake of pungent, hot, salty and alkaline food; excess exercise and exposure to the heat of fire and Sun; living in a place and season which are not cold, intake of alcohol and envy; Intake of drinks, food and drugs having vidahi (causing burning sensation), sharp and hot properties.
*The causes of kaphaja arsha (hemorrhoids) include sweet, unctuous, cold, salty, sour and heavy food; lack of exercise, sleeping during day time, excess sleeping and sitting; direct exposure to wind, living in cold place and exposure to cold season and mental inactivity.
*Hemorrhoids always include aggravation of all the three doshas. Predominance of one or all the doshas determine the type of hemorrhoids.
*Five types of vayu (prana, apana, vyana, udana and samana), pitta and kapha - all these morbid factors in their aggravated state afflict the three anal sphincters at ano-rectum and lead to hemorrhoids.
*Excision of the hemorrhoids by sharp instruments, cauterization with ksharakarma (alkalies) and agnikarma (thermal cauterization) are three modalities in the management of arsha.
*Hemorrhoids caused by aggrava¬tion of vayu and kapha are ‘dry hemorrhoids’. Whereas those with excess discharge (bleeding) and wetness are caused by aggravation of rakta and pitta.
*Dry, hard, inflamed and painful hemorrhoids should be first treated with fomentation in the form of avagaha (sitz bath in medicated decoction), abhyanga (local massage with medicated oils), sprinkling of medicated water, fumigation, ointment and external application. Then the vitiated blood shall be removed out by blood letting therapy. Bloodletting with the help of application of leeches or sharp instruments or needles should be done in raktaja arsha, if blood doesn't come out on its own. Simultaneously with this localized treatment, generalized treatment to correct the agni is advised to patients.
*Butter-milk is the best medicine for the treatment of hemorrhoids caused by aggravation of vayu and kapha. Butter-milk should be taken along with fat (for vayu) or in an ununctuous form (for kapha). It can be given in various forms, at different times depending upon the state of disease.
*Anuvasana basti (unctuous enema) is best treatment for arsha associated with dysfunction of vata.
*The bleeding haemorrhoids shall be treated after assessment of association with vata dominance and kapha dominance in its patho-physiology. Unctuous and cold things should be used in cases of vitiation of vayu in bleeding hemorrhoids. In case of vitiation of kapha in bleeding hemorrhoids, ununctuous and cold-things are useful.
*If there is predominance of pitta and kapha dosha, shodhan (elimination) therapies are indicated.
*Bleeding should not be stopped immediately by giving hemostatic therapies. One should wait for appropriate time till the vitiated blood goes out and the patient can be given fasting therapy.
*If the blood vitiated by doshas, which comes out from the hemorrhoids is arrested in the beginning then it may lead to several other complications. Therefore, only after elimination of vitiated blood hemostatic measures are useful. The physician should be well aware of the etiology, signs and symptoms, nature of the time, strength and color of the blood and should wait for appropriate time before administering hemostatic therapies unless there is an emergency.
*Bitter drugs should be given for stimu¬lation of the digestive power, hemostasis and pachana (meta¬bolic transformation).
*In hemorrhoids with predominance of vayu, if bleeding continues even after the aggravated doshas are eliminated, then the patient should be given unctuous therapies in the form of drinks, massage and anuvasana basti.
*In summer season, pitta predominant hemorrhoids without secondary predominance of vayu and kapha, should be treated with hemostatic therapies immediately to stop bleeding.
*In case of excessive bleeding, the arsha becomes vata dominant. Even if pitta and kapha are predominantly vitiated, then also predominance of vata shall be considered in excessive bleeding.
*If there is predominance of rakta and pitta and there is less of the signs and symptoms of aggravated kapha and vayu, then the patient should be given cooling remedies.
*If bleeding continues in spite of the above mentioned remedies and cooling therapies, then a wise physician should administer at the appropriate time, meat-soup which is unctuous and hot. Patient should be given medicated ghee which is administered, prior to taking food. His anus should be massaged with luke warm ghee or oil, or the hemorrhoid mass should be fomented with luke-warm milk, ghee or oil. These remedies should be administered quickly.
*If bleeding doesn't stop and there is aggravation of vayu then the patient should be given anuvsana type of enema with the help of luke-warm ghritamanda (upper portion of the ghee). He should be given the effective piccha basti (recipe of which is described below) at the appropriate time.
*The power of digestion should always be preserved in the patients of hemorrhoids by giving sometimes cold articles and sometimes hot articles, sometimes sweet or sour taste drugs or food having opposite characters.
*Arsha (hemorrhoids), atisara (diarrhea) and grahani these three diseases are interdependent. In all patients of these three diseases, if the digestive power is low then disease gets aggravated and if digestive power is strong then relief occurs.
*The foods that lead to downward movement of vayu and promote digestive power should be daily consumed by patients of hemorrhoids. Those foods having opposite properties and those described in the etiology of hemorrhoids should never be used by the patients.
=== Vidhi Vimarsha ===
=== Vidhi Vimarsha ===