Charaka Samhita Chikitsa Sthana 14 – Arsha Chikitsa

14th chapter of Charaka Samhita Chikitsa Sthana is Arsha Chikitsa, explains in detail about causes, types, signs and symptoms and treatment of haemorrhoids.

We shall now expound the chapter on the treatment of Arsas (piles). Thus said Lord Atreya [1-2]

To Punarvasu, who was seated without any anxiety after completing his religious and secular duties, Agnivesha inquired about various aspects of Arshas (haemorrhoids) [3]

Topics covered in this chapter:
Lord Punarvasu explained to Agnivesha, the following topics relating to Arsha:
1. Causative and aggravating factors
2. Different forms (Samsthana)
3. The places of manifestation
4. Signs and symptoms
5. Treatment and
6. Classification of the disease depending upon its curability and incurability [4]

Classification

Types of haemorrhoids as per Ayurveda:
O Agnivesha! Piles are of 2 types;
Sahaja Arsas – congenital or hereditary
Jatasya Uttara Kalaja Arsas – acquired which are manifested after birth.

Sahaja Arsha

Kshara Application on Arshas
By Dr Ashwin Shetty B.A.M.S., M.S. (Ayu)
Easy Ayurveda Hospital
Click to Consult Dr Ashwin

Sahaja Arsha – Congenital Piles:
Caused by vitiation of seeds (sperm and ovum), specially the part of the seed responsible for the formation of the anal sphincters,
The cause for Sahaja Arshas are –
(i) wrong diet and regimen of father and mother, and
(ii) Sinful acts of past life.
These two categories of causative factors are applicable to all the other hereditary diseases also.
Sahaja means which is manifested (Jata) along with (Saha) the appearance of body (birth)
Arshas is a disease characterised by Adhimamsa Vikara – morbid growth in the muscle tissue [5]

Locations of Piles – Utpatti Kshetra:                                                                    All types of piles are located in the space of 4 ½ Angulas (8-10 cm. approx) in the lower part of the colon. This area has 3 sphincters dividing the space into 3 parts- Guda valaya.
According to some other physicians, Arshas has several other locations in the body, like pudendum, female genital tract, throat, palate, mouth, nose, ears, eyelids and skins because in the above mentioned locations, excessive and unnatural growth of the muscle tissue also take place. However, in the present text, those occurring in the anal region are specifically considered as Arshas.

Arsha Adhishtana: Tissues involved:
Medas – fat tissue
Mamsa – muscle tissue and
Tvak – skin including mucous membrane [6]

Forms and structures of Congenital Piles
Among the congenital piles, some are small, some are large, some are long, some are short, some are round, some are irregularly spread, some are curved internally, some are curved externally, some are matted together, and some are introverted. Their characteristic colours are based on Dosha aggravation. [7]

Signs and symptoms of Congenital Piles:
Person afflicted with congenital piles has the following signs and symptoms- birth, he is lean and thin, discoloured, emaciated, weak, having flatus, urine and stool in excessive quantity and sometimes having their obstruction, and having urinary gravels and stone in the urinary tract.

2. His stool is irregular- sometimes it is constipated and sometimes it is normal; sometimes it is Pakva (free from Ama) and sometimes it is associated with Ama (Mucus or products of improper digestion) and sometimes it is dry and sometimes it is loose;
3. His stool, at times, is white, pale, yellow, green, reddish, thin, dense, slimy, having the smell of dead body and associated with Ama( Mucus or products of improper digestion)
4. He suffers severe type of sawing pain in umbilicus, urinary bladder region and pelvis
5. He suffers from pain in anus, dysentery, horripilation, Prameha (urinary disorders including diabetes), continuous constipation, gurgling sound in the intestine, abdominal distension and a feeling as if the heart and the sense organs are covered with sticky material. (Hrudaya Indriya Upalepa)
6. He gets excessive eructation, which are often obstructed and associated with bitter and sour taste
7. He is extremely weak and has a very weak digestion strength, he has very little semen; he is irritable and he is difficult to treat.
8. He frequently gets cough, dyspnoea, asthma, morbid thirst, nausea, vomiting, anorexia, indigestion, chronic rhinitis and sneezing
9. He gets fits, fainting and headache
10. His voice is weak, broken of low pitch, impeded and hoarse
11. He suffers from fever, Malaise and pain in all the joints and bones
12. Occasional chest stiffness, stiffness in the sides of the abdomen, region of urinary bladder, cardiac region, back and lumber region.
13. Dizziness and extremely lazy
14. Right from the birth, his Apana Vayu gets obstructed by the piles- mass. Because of this obstruction to the passage, the Apana Vayu moves upwards and causes aggravation of Samana Vayu, Prana Vayu, Vyana Vayu, Pitta and Kapha. When all these 5 varieties of Vayu, pitta and Kapha get aggravated the individual succumbs to the above mentioned symptoms.
Thus ends the description of the congenital type of piles. [8]

Jatasya Uttara Kalaja Arsha

Etiology and Pathogenesis of Acquired Piles:
Haemorrhoids which occur after birth (acquired):
In a person whose power of digestion is afflicted, Mala (waste products) get accumulated in excess because of the following:
1. Intake of heavy, sweet, cold, Abhisyandi (which causes obstruction in the channels), Vidahi (causes burning sensation) and Viruddha (mutually contradictory) food; intake of food before the previous meal is digested; intake of small quantity of food and intake of unwholesome food.
2. Excess intake of flesh of cattle, fish, pig, buffalo, goat and sheep
3. Intake of the meat of emaciated animals, dried meat and spoilt milk; Excess intake of pastries, Paramanna or Payasa (a preparation of milk, rice and sugar), milk, Dadhimanda (whey) preparations of sesame seed and jaggery- products.
4. Excess intake of Masha (black gram), sugarcane juice, oil cake, Pindaluka, dry vegetables, vinegar, garlic, Kilata (cream of milk), butter milk, Pindaka (cream of curd), Bisa (thick lotus stalk), Mrinala (thin lotus Stalk), Shaluka, Kraunchadana, Kasheruka (Scripus grossus), Sringataka, Taruta, germinated corns and pulses, freshly harvested corns and cereals and tender radish;
5. Intake of heavy fruits, vegetables, pickles, haritaka (vegetables used uncooked), Mardaka, Vasa (muscle fat), meat of head and legs of animals, stale, putrid and sankeerna anna (food prepared by the mixture of different items, like rice and meat)
6. Intake of Mandaka (immature, thick curds) and wrongly fermented alcohol preparations;
7. Drinking of polluted and heavy water
8. Excess intake of Sneha (oleation therapy)
9. Non-use of elimination of Basti Karma (enema therapy)
10. Wrong application of Basti Karma (enema therapy)
11. Lack of exercise
12. Avyavaya or Ativyavaya (lack of sexual act or excess of it)
13. Sleep during day time and
14. Habitually resorting to pleasant beds, seats and location.

Apana Vayu aggravating factors

Following factors are responsible for the aggravation of Apana Vayu:
1. Use of rough, irregular and hard seats
2. Use of vehicles carried by improperly trained animals or vehicles carried by camels
3. Excessive indulgence in sex
4. Improper insertion of enema nozzle and frequent injury in the anal region
5. Frequent application of cold water.
6. Use of rags, colds of grass etc , for rubbing [ the anus]
7. Continuous and excessive straining during defecation
8. Forcible attempt for passing flatus, urine and stool
9. Suppression of manifested strain / urges
10. Miscarriage, pressure of the pregnant uterus and abnormal delivery in case of women.
The Apana Vayu aggravated by the above-mentioned factors, brings down the accumulated waste products [reasons for their accumulations are already described above] and so afflict the anal sphincters. Because of this, piles are manifested in the sphincters. [9]

Shapes of piles

Different Shapes of the Piles:
Piles have different shapes in as much as they look like mustard, Masura, Masha (black gram), Makustha – Phaseolus aconitifolius, Yava – Barley, Kalaya – green pea, Pindi, Tintikera (fruit of Karira), Kebuka, Tinduka, Karkandhu Kakanantika, Bimbi –Coccinia indica, Badara – (ber fruit), Kareera, Udumbara – Ficus racemosa, Kharjura- Phoenix sylvestris, Jambu (Jamun fruit), Gostana (cow’s udder), Thumb, Kaseruka – Scripus grossus, Sringataka, Srungi, beaks or tongues of cock, peacock or parrot, and buds of lotus or Karnika(ra).

These are, in general the characteristic shapes of piles caused by excessive aggravation of vayu, Pitta and Kapha. [10]

Vataja Arshas

Vataja Arshas – Signs and symptoms:
Piles caused by the predominance of aggravated Vata Dosha:
1. The mass of piles is dry, wrinkled, hard, rough and greyish in colour; these masses have sharp tips; curved, have cracks, spread irregularly.
2. The pile is associated with pain, cramps, Toda (Piercing pain), itching, numbness and tingling sensation in excess.
3. Oily and hot things give relief to the patient
4. The patient suffers dysentery, abdominal distension and stiffness of genitals, testicles, the region of urinary bladder, pelvis and cardiac region; he also suffers from malaise and palpitation in excess.
5. His flatus, urine and stool are constantly obstructed – constipation and dysuria
6. He suffers from pain in thighs, lumbar region, back, Trika (Sacral region), Parshva (sides of the chest), Kukshi (sides of abdomen) and in the region of urinary bladder.
7. He has burning sensation in the heart; suffers from sneezing, coryza, cough, Udavarta, ( upward movement of wind in the abdomen), Ayama, Ayasa, oedema, fainting, anorexia, distaste in mouth, Timira (impairment of vision) itching pain in the nose, ears and temporal region, and impairment of the voice and
8. Greyish, reddish discolouration and roughness of nails, eyes, face, skin, urine and stool. [11]
Vataja Arsha Causes:
Etiology of Vatik type of Piles:
1. Intake of astringent, pungent, bitter, unctuous , cold and light food
2. Habitual intake of food in extremely small quantities ( Pramitashana) intake of less quantities of food, intake of alcoholic drinks having sharp quality and indulgence in sexual acts
3. Fasting, residing in cold climate, excess physical exercise and
4. Grief and exposure to sun and wind [ 12-13]

Pittaja Arshas

Pittaja Arsha Lakshana:
Signs and symptoms of Pittaja Arsh:
1. Pile mass is Mrudu – soft, Shithila – flabby, fragile, Sukumara -delicate and tender touch
2. Pile mass is Rakta – red, Pita – yellow, Neela – blue or Krishna – black in colour
3. The mass of piles is associated with Sweda upakleda – excessive sweating and sticky discharge
4. The discharges from the piles mass is Visra (smelling like raw- meat), thin, yellow or red
5. Blood discharge
6. Associated with burning sensation, itching colic pain, pricking pain and suppuration
7. There will be relief by resorting to cold things
8. The stool of the patient is loose yellow or green
9. Increased volume of urine and stool and these are yellow in colour and smell like raw meat
10. The individual suffers from excess thirst, fever Asthma, fainting and disliking for food
11. Nails, eyes , skin urine and stool of the patient are yellow in colour [14]

Pittaja Arsha Nidana:
Paittik piles is caused by the following:
1. Intake of pungent, hot, saline and alkaline food
2. Exercise in a place and season which are not cold
3. Intake of alcohol and envy, jealousy and
4. Intake of all types of drinks, food and drugs which are Vidahi (causing burning sensation), sharp and hot. [15-16]

Kaphaja Arshas

Kaphaja Arsha Lakshana:

Signs and symptoms of Kaphaja types of piles:
1. The mass of piles is large in size, swollen, smooth, painless to touch, unctuous, white, slimy, having stiffness, heavy, rigid, benumbed, having constant oedema with severe itching
2. Large and continuous discharge from the piles mass, reddish, white or red colour, slimy.
3. Urine and stool of the patient are heavy, slimy and white
4. The disease gets alleviated by dry and hot therapies
5. The patient has excessive desire to pass stool with gurgling sound
6. There is distension in the lower pelvic region
7. The patient suffers from sawing pain, nausea, excessive spitting, cough, anorexia, cold, heaviness, vomiting, dysuria, consumption, oedema, anaemia, fever associated with cold, stone and gravels in genitourinary tract, feeling as if the heart and sense organs are covered with sticky material, sweet taste in the mouth and Prameha (urinary disorders including diabetes)
8. Symptoms are chronic
9. Low digestion strength, impotence
10. Associated with acute disease caused by Ama (product of improper digestion and metabolism)
11. The nails eyes, skin, urine and stool are white in colour. [17]

Kaphaja Arsha Nidana:
Causes for Kaphaja type of Arsha:
1. Intake of Madhura – Sweet, Snigdha – unctuous, Shita – cold, Lavana – saline, Amla – sour and Guru – heavy food, Avyayama – lack of exercise, Diva swapna – sleeping during day time and Shayyana sukha – indulgence in the pleasure of beds and seats.
2. Prag vata sevana – Exposure to easterly wind
3. Shita desha kala – Residing in cold place and burning a cold season and
4. Chintanam – Mental inactivity [18-19]

Dwandwaja and Sannipataja Arshas

Dwandwaja and Sannipataja Arsha – Piles caused by aggravations of 2 Doshas and all the 3 Doshas:
Dvandvolbana types of Arshas (in which 2 doshas are predominantly aggravated) is caused by the combination of 2 types of etiological factors. Here, a combination of symptoms of the two Doshas are exhibited.

In Sannipataja Arshas, all the three Doshas are aggravated. The symptoms resemble Sahaja Arsha symptoms that have been explained above. [20]

Purvaroopa

Arsha Poorvaroopa – Primogenitor symptoms:
Vistambha – constipation,
Daurbalya – weakness
Kukshi aatopa – gurgling sound in the lower abdomen
Karshya – emaciation
Bahula udgara – frequent eructation,
Sakti sada – weakness in the thighs,
Alpa vit kata – voiding less of stool,
Grahani – sprue syndrome, IBS
Pandu – anaemia,
Udara shanka – apprehension of the manifestation of Udara Roga (abdominal disorders including ascites) [21-22]

Involvement of 3 Doshas:
Piles never occur without the aggravation of all the 3 Doshas. It is because of the predominance of one or all the Doshas that different types of piles are determined. [23]

Prognosis

Reason for bad Prognosis:
5 kinds of Vayu (Prana, Apana, Vyana, Udana and Samana)
Pitta and Kapha- all these morbid factors in their aggravated form afflict the 3 anal sphincters, as a result of which piles are manifested. Therefore these piles are painful and are associated with several complications. They afflict the entire body, and generally, these are difficult to cure. [24-25]

Prognosis: Arsha Upashaya
If the patient suffering from piles develops oedema in hands, legs, face, umbilicus, anus and testicles, and if he suffers from pain in cardiac region and in the sides of the chest, then he is incurable.
Pain in the cardiac region and sides of the chest, fainting vomiting, pain in the limbs, fever, excess thirst and inflammation of the anus- these complications lead to the death of the patient suffering from piles.

Hereditary piles caused by the simultaneous aggravation of all the three Doshas and piles located in the internal sphincter of the anus is incurable.
Considering residual life span, the piles may become palliative (Yapya) if all the four constituents of treatment (physician, drugs, attendants and patient) are in the state of their excellence and if the patient has strong Kayagni (powder of digestion and metabolism). Otherwise, such patient should not be entertained because they are incurable.

Kashta Sadhya: If piles are caused by the simultaneous vitiation of 2 Doshas (Dwandwaja), if they are located in second anal- sphincter and if these are one year old, then such patients are difficult of cure – Kashta Sadhya

Sukha Sadhya: If piles are located in the external anal sphincter, if they are caused by the dominance of one aggravated Dosha, and if they are not very chronic, then such a patient is easily curable. A wise physician should immediately take necessary steps for the cure of such patients. Otherwise, the piles mass will cause obstruction in the passage of the rectum. [25- 32]

Shastra, Kshara, Agnikarma indications

Indication of Shastra, Kshara and Agnikarma:
Some physicians advocate surgical excision of pile mass as a useful therapy. Some others recommended cauterization (Agnikarma) and some – application of alkalies (Kshara);
These 3 types of therapies are administered only by a physician who is wise and who has previous experience of performing such surgical operations. It there is any mistake in these operative processes, then the consequences can be serious.

Complications

Complications of Shastra, Kshara and AgniKarma:
Pumsatvahara – Impotency,
Shvayathu – swelling in the anus,
Vega vinigraha – lack of urge for defecation,
Adhamanam – abdominal distension,
Shoolam – excruciating pain,
Vyatha – feeling of discomfort,
Rakta ati vartanam – excessive bleeding,
Punar viho vruddhanam – recurrence of the piles mass after these are healed, sticky discharge,
Guda bhramsha – prolapsed of the rectum or
Maranam – even instant death.

Hence, alternative methods are explained below[33-37]

Classification of Piles

Piles are broadly classified into 2 groups, namely
(i) dry piles, which are caused by predominance of aggravated Vayu and Kapha, and
(ii) Exudation or wet piles, which are caused by predominance of aggravated Rakta (blood) and Pitta. [38]

Treatment of Dry Piles

Swedana Yogas:
Swedana for Arsha:
If there is numbness, oedema and pain in the piles, then first of all, the mass is smeared with oil prepared by boiling with Chitraka – Leadword – Plumbago zeylanica, Kshara and Bilva – Aegle marmelos.
Thereafter, Swedana (sweating) therapy is administered with below methods.
1. Pottali (medicines tied in a piece of clothing the form of a bolus) containing Yava – Barley, Black gram, Horse gram and and Pulaka (Tuccha dhanya).
2. Pinda (lump) containing the dung of cow, donkey or horse:
3. Pinda (Lump) prepared of the cake of the sesame seed
4. Pinda(Lump) of Vacha (Acorus calamus Linn.) and Shatahva
5. Pinda (Lump) containing husk of Paddy

The above mentioned recipes of Pottali and Pindas are tolerably warm and should be added with fat.
6. Pinda(Lump) containing the pulp of dry radish
7. Pinda(Lump) containing Saktu (Roasted corn flour) added with unctuous substances , like oil and ghee
8. Pinda(Lump) containing Krsnagandha (sobhanjana)
9. Panda( Lump) containing Rasna (Vanda roxburghi / Pluchea lanceolata)
10. Pinda (Lump) containing Hapusha.
The above mentioned recipes (nos. 6 – 10) should be luke- warm and is added with fat.
11. The piles mass should be smeared with oil prepared by boiling with Kushta – Saussurea lappa. Thereafter, it is fomented. With the help of a Pottali (medicines tied in a piece of cloth in the form of a bolus) containing brick powder, Kharahva (Ajamoda – Ajowan (fruit) – Trachyspermum roxburghianum) and the pulp of Grunjanaka. [39 ½ – ½ 44]

Recipe for Sprinkling – Sechana
The piles mass is sprinkled with decoction of the leaves of Vrusha (Adhatoda vasica), Arka – Calotropis gigantea, Castor and Bilva. [44 ½]

Recipes for Bath:
If there is pain in pile mass, then it is well smeared with medicated oil and the patient is given sitz- bath with the help of decoction prepared by boiling with leaves of
Radish, triphala (Haritaki, Bibhitaki, and Amalki), Arka – Calotropis gigantea, Venu, Varuna (Crataeva nurvala), Agnimantha – Clerodendrum phlomidis, Shigru – Moringa oliefera and Ashmantaka – Ficus rumphii.

The patient can also be given sitz bath with the decoction of Kola (ber) or Sauviraka or Tushodaka or decoction of Bilva or butter milk or Dadhimanda (Whey) or Sour kanjika or cow’s urine. Before giving sitz bath, the piles mass is well smeared with medicated oil, and the decoction should be tolerably by warm. [45-47]

Abhyanga and Dhoopana – Smearing and Fumigation:
The fat of Krishna Sarpa (black snake), pig, camel, Jatuki (Carma Catika) and cat is smeared over piles mass. These fats are used for fumigation of piles also.
Fumigation with human hair, serpent’s slough, cat’s skin, root of Arka – Calotropis gigantea and leaf of Shami – Prosopis cineraria is useful for piles.
Fumigation is given with Tumburu—Xanthoxylum alatum, Vidanga – Embelia ribes, Devadaru – Cedrus deodara and Aksata (Barley) mixed with ghee.
Brihati – Solanum indicum, Ashwagandha – Withania somnifera, Pippali – Long pepper fruit and Surasa (Tulsi) mixed with ghee is used for fumigation.
Dung of pig or goat, Saktu (roasted corn- flour) and ghee is used for fumigation.
Fumigation with the dung of elephant mixed with ghee and Sarjarasa is also useful for piles. [48-51]

Ointment recipes

The following recipes for is used as ointments in the treatment of piles:
1. Latex of Snuhi – Euphorbia nerifolia mixed with the powder of turmeric
2. Fruits of long pepper and turmeric made to a paste by adding cow’s bile
3. Paste prepared of the seeds of Sirisha (Albizzi lebbeck Benth.), Kushta – Saussurea lappa, Pippali – Long pepper fruit – Piper longum, Saindhava, Jaggery, latex of Arka – Calotropis gigantea and Snuhi – Euphorbia nerifolia and Triphala ( Haritaki – Terminalia chebula, Bibhitaka – Terminalia bellaerica and Amalaka – Embelica officinalis)
4. Paste prepared of Pippali – Long pepper fruit – Piper longum, Chitraka – Leadword – Plumbago zeylanica, Syamaka, Kinva (yeast), fruit Pulp of Madana – Randia dumetorum, droppings of cock, turmeric and jaggery
5. Paste of Danti – Baliospermum montanum, Shyama (Trivrit), Mrutasanga (Mayuratuttha – Copper sulphate) droppings of pigeon and jaggery
6. Paste prepared of elephant bone, Nimba – Neem (Azadirachta indica) and Bhallataka – Semecarpus anacardium.
7. Paste prepared of Ala (Haritala) mixed with the fat of camel or the fat of Culuki is applied when lukewarm. It cures pain and oedema in the piles mass and
8. Paste of the latex of Arka, stem of Snuhi – Euphorbia nerifolia, leaf of bitter variety of Alabu, and urine of goat is excellent for curing piles. [52-57]

All the recipes enumerated above beginning with Abhyanga (recipes for smearing) and ending with Pradeha (recipes for preparing ointment) are useful for curing piles associated with stiffness, oedema, itching and pain.[58]
By the application of the above recipes the vitiated blood which is accumulated in the pile mass oozes out which gives relief to the patient [59]

Raktamokshana – Blood letting:
If the disease doesn’t subside by the application of cold, hot and oily recipes, then it is determined to be caused by vitiated blood. To such patients, Raktamokshana therapy is administered.
In the case of Raktaja type of piles, if blood doesn’t come out on its own, then it is taken out by the repeated leech therapy or sharp edged instruments or needles. [60-61]

Trayushanadi Curna

If the patient suffers from oedema and pain in the anus, and if there is suppression of the power of the digestion, then he is given Trayushanadi Churna –
powder of Tryusana (Ginger, pepper and long pepper fruit), Pippali Mula, Patha – Cyclea peltata, Hingu – Asa foetida, Chitraka – Leadword – Plumbago zeylanica, Sauvarcala, Puskara – Inula racemosa, Ajaji – Nigella sativa, Pulp of Bilva – Aegle marmelos, Bida, Yavani – Carum copticum, Hapusa – Juniperus communis, Vidanga – Embelia ribes, Saindhava, Vacha (Acorus calamus Linn.) and Tintidika along with heavy, alcoholic drinks or hot water.
This recipe also cures piles, Grahani (Sprue syndrome), colic pain and Anaha (constipation).
The above mentioned patient can also be given recipes for Pachana (which help in the digestion of undigested food), which are described for the treatment of Atisara (Diarrhoea) in Chikitsa 19th chapter [62- ½ 65]

Recipes:
The patient of piles is given following recipes
1. Abhaya along with Jaggery is given before taking food
2. Powder of Trivrt along with decoction of Triphala (Haritaki, Bibhitaki and Amalaka)
With the above mentioned two recipes, the accumulated Doshas [in the anal region get eliminated as a result of which piles subside]
3. Haritaki – Terminalia chebula soaked over night. It is given along with Jaggery
4. Haritaki – Terminalia chebula along with buttermilk
5. Triphala (Haritaki, Vibhitaki and Amalaki) along with buttermilk
6. Chitraka – Plumbago zeylanica and Nagara – Zingiber officinale along with Sidhu (a type of alcoholic drink)
7. Ajaji – Nigella sativa, Chitraka – Leadword – Plumbago zeylanica and Chavya – Piper retrofractum along with Sidhu (a type of alcoholic drink)
8. Sura (a type of alcoholic drink) added with Hapusa – Juniperus communis and Patha –Cyclea peltata mixed with Sauvarcala salt.
9. Taphana (refreshing drink prepared of roasted corn- flour) mixed with butter- milk and added with either Kapitha and Bilva – Aegle marmelos or Chavya – Piper retrofractum and Chitraka – Leadword – Plumbago zeylanica or Bhallataka (Semecarpus anacardium Linn.) or Bilva – Aegle marmelos and Nagara or Chitraka – Leadword – Plumbago zeylanica
10. Chitraka – Plumbago zeylanica , Hapusa – Juniperus communis and Hingu mixed Butter- milk and
11. Butter added with Panchakola (Sunthi – Zingiber officinale, Pippali – Long pepper fruit – Piper longum, Pippali – Long pepper fruit – Piper longum Mula, Chavya – Piper retrofractum and Chitraka – Plumbago zeylanica. [65 ½ – 71]

Takrarishta

In a jar, the inside wall of which is smeared with ghee, butter- milk is kept. To this, the powder of Hapusa –Juniperus communis, Kuncika, Dhanya, Ajaji – Nigella sativa, Karavi, Shati – Hedychium spicatum, Pippali – Long pepper fruit – Piper longum mula – Long pepper fruit – Piper longum, Chitraka – Leadword – Plumbago zeylanica, Gajapippali, Yavani and Ajamoda – Ajowan (fruit) – Trachyspermum roxburghianum is added.
The paste of the ingredients to keep in jar will be slightly sour and pungent. When it is well fermented, the sour and pungent tastes become well manifested. This is called Takrarishta, which is very delicious. This drink is taken in appropriate dose during the beginning, middle and end of meals, to overcome thirst.
It stimulates digestion, improves appetite for food, promotes complexion, helps in downward movement of Kapha and Vayu, cures swelling, itching and pain in anus and promotes strength. [72-75]

Buttermilk for haemorrhoids

The inside wall of an earthen jar is smeared with the paste of the rootbark of Chitraka – Plumbago zeylanica, and in this Jar, curd is prepared. Intake of this curd or the butter milk prepared out of it cures piles.
There is no medicine, better then butter- milk for the cure of piles caused by the predominance of aggravated Vayu and kapha depending upon the Dosha involved, it is taken along with fat (for Vayu) or in an unctuous from(for Kapha).
The physician acquainted with the specifications of the strength of the patient as well as the nature of the season is given butter-milk for either on week or for 10 days or for 15 days or for a month.
If the Kayagni (power of digestion and metabolism) of the patient is very weak, then he is given only butter- milk [both morning and evening], other- wise Takravalehika (linctus prepared by adding butter- milk to the flour of fried paddy) is given in the evening. After the butter- milk (taken in the morning) is digested, [in the evening] the patient is given Takrapeya (thin gruel prepared by adding butter-milk) along with rock- salt, thereafter, Takraudana (rice mixed with butter- milk) added with fat is given and butter- milk is given to such a patient as post- prandial drink. As food, he may be given vegetable soup or meat soup along with butter- milk. Alternatively, vegetable soup and meat soup prepared by boiling with butter- milk can be given to him.
The physician acquainted with the time (Kala) and procedure of administration (Krama) is discontinuing butter- milk all of a sudden.
Butter milk is administered up to 1 month, and thereafter, it is gradually withdrawn. It is withdrawn gradually in the same quantity in which it was increased [in the beginning].
While reducing butter- milk, the patient total food intake is reduced. Adoption of this procedure will promote and maintain his energy, maintain the strength of his digestive powder and promote his strength, plumpness as well as complexion.
Butter- milk is of 3 types. Viz
1) From which fat is completely removed
2) From which half of the fat is removed and
3) From which fat is not at all removed.
The physician acquainted with the nature of the Doshas involved in the causation of the disease, Agni (power of digestion and metabolism) of the patient and his strength should administer any of the above mentioned 3 types of butter – milk appropriately.
Piles in the anus, once cured by the administration of butter- milk, do not recur. When sprinkled over the ground butter- milk burns all grass thereon let alone the dry type of piles in a patient who’s Agni (power of digestion and metabolism) has been kindled through this therapy.
Butter- milk cleanses the channels of circulation as a result of which Rasa (end product of the food after digestion) reaches [the tissue elements] appropriately. This produces proper nourishment, strength, completion and exhilaration, and cures 100 diseases including those caused by Vayu (80 in number) and Kapha (20 in number). There is no medicine better than butter- milk, for the treatment of piles caused by Vayu and Kapha. [76- 88]

Read more about buttermilk benefits as per Ayurveda

Recipes:
Peya (thin gruel) is prepared by cooking with Pippali – Long pepper fruit – Piper longum, Pippali Moola, Chitraka – Plumbago zeylanica, Gaja Pippali, Srngavera, Ajaji – Nigella sativa, Karavi, Dhanya, Tumburu – Xanthoxylum alatum, Bilva(unripe fruit), Karkataka and Patha – Cyclea peltata.
It is made sour by adding [the juice of] sour fruits and sizzled with ghee and oil. Intake of this Peya (thin gruel) cures piles.
With the above mentioned ingredients, Khada (a type of sour drink) is prepared and given to the patient. Water boiled with the above mentioned ingredients is useful for the patient suffering from piles. Ghee boiled with the above ingredients is also useful in curing piles [89-91]

Yavagu, Yusha

Yavagu (thick Gruel):
Yavagu (thick gruel) prepared by boiling with either Shati – Hedychium spicatum and Palasha – Butea monosperma or Pippali – Piper longum and Nagara – Zingiber officinale made sour by adding buttermilk and sprinkled with the powder of Maricha – Piper nigrum is useful for the patient suffering from piles. [92]

Yusha (Vegetable soup):
Vegetable soup prepared of dried radish or horse-gram or Kapittha, Bilva – Aegle marmelos, horse gram and Makustha – Phaseolus aconitifolius is useful for piles. This soup can be added with the soup of goat-meat. The soup of the meat of lava etc. added with the juice of sour fruit, butter milk or astringent drugs is given to such a patient.
Rakta Shali, Maha Shali, Kalama, Langala, Sita, Sarada and Sustika types of rice can be given as food to the patient suffering from piles.
Thus, the therapeutic measures for the patients of piles having loose motions are described. [93-96 1/2]

Treatment of piles with bulky Bowels:
Now, recipes for the treatment of patients suffering from piles and having excessively costive bowels will be described, these are as follows:
i) Prasanna (a type of alcoholic drink) mixed with Saktu (Roasted corn- flour) and salt before administering this potion, the patient is given matsyandika (a preparation of sugar-cane juice) along with Nagara ( dry ginger)
ii) Jaggery along with Nagara (dry Ginger), Patha – Cyclea peltata and Juice of sour fruit. this is given as a drink
iii) jaggery mixed with the ghee and Yava Ksara (Alkali preparation of Barley)
iv) Yavani – Carum copticum, Ginger, Patha – Cyclea peltata, Pomegranate juice and jaggery along with butter milk and salt (in adequate quantity to make it saline in taste). this potion helps in the downward movement of flatus and stool
v) Patha – Cyclea peltata along with either Duhsparsa or Bilva Yavani or Nagara.This cures pain in the piles.
vi) Tender leaves of Karanja – Pongamia pinnata fried with ghee and oil, and sprinkled with the powder of Saktu (Roasted corn flour). This is given before food. it helps in the downward movement of flatus and stool
vii) Madira (a type of alcohol) or Sauvira (a type of Vinegar) along with Jaggery and Nagara (dry ginger). This is administered before food. [96 ½ – 102]

Ghrita formulations

Pippalyadi Ghrita:
Ghee added with Pippali—Piper longum, Nagara – Zingiber officinale, Ksara (alkali preparation), Karavi, Dhanya, Jiraka – Cuminum cyminum and Phanita (penidium) and juice of sour fruits is given [to the patient suffering from piles. [103]

Pippalyadya Ghruta:
Ghee cooked with Pippali – Piper longum, Pippali Mula, Chitraka – Plumbago zeylanica, Gaja Pippali, Srngavera and Yavaksara (Alkali preparation of Barley) is taken by the patient suffering from piles [104]
Recipes of Medicated Ghee:
Ghee cooked with the paste of Chavya – Piper retrofractum and Chitraka – Plumbago zeylanica and added (at the final stage of cooking) with jaggery, Kshara (Alkali preparation) and Nagara (Dry ginger powder) is given to the patient suffering from piles
Ghee cooked with the paste of Pippali Mula and added (at the final stage of cooking) with jaggery, Kshara (Alkali preparation) and Nagara (dry ginger powder) is given to the patient suffering from piles [105]

Pippalyadya Ghritham
Ghee cooked with the paste of Pippali – Piper longum, Pippali Mula, Dadima –Punica granatum and Dhanyaka – Oryza sativa and curd (which is to be used as liquid) is given to the patient suffering from piles. It helps in the movement of flatus and stool. [106]

Chavyadya Ghrita:

Ghee is cooked with the paste of Chavya – Piper retrofractum, Trikatuka (Sunthi – Zingiber officinale, Pippali – Long pepper fruit – Piper longum and Maricha – Black pepper fruit – piper nigrum), Patha – Cyclea peltata, Ksara( Alkali preparation), Dhanyaka, Yavani, Pippali Mula – Long pepper fruit – Piper longum, Vida, Saindhava( Rock- Salt) Chitraka – Leadword – Plumbago zeylanica, Bilva and Abhaya – Terminalia chebula. To this, well fermented curd (4 times the quantity of ghee) is added while cooking.
It helps in
Pravahika – downward movement of stool with tensmus,
Guda bhramsha – prolapse of rectum,
Mutra krchrra – dysuria,
Parisravam – incontinence of urine and
Guda vankshana shoolam – pain in the anus as well pelvic region [107-109]

Nagaradya Ghruta:
Ghee is cooked with the paste of Nagara – Zingiber officinale, Pippali – Long pepper fruit – Piper longum Mula, Chitraka – Leadword – Plumbago zeylanica, Gaja Pippali – Long pepper fruit – Piper longum, Svadamstra, Pippali – Long pepper fruit – Piper longum, Dhanya, Bilva – Aegle marmelos, Patha – Cyclea peltata and Yavani – Carum copticum, juice of Changeri (4 times the quantity of ghee)
This medicated ghee alleviates Kapha and Vayu and cures piles, Grahani Dosa (sprue syndrome), Dysuria, Pravahika (Passage of stool with Tenesmus), prolapsed of rectum, pain in the anal region and constipation. [110-112]

Pippalyadya Ghrita:
Decoction is prepared of Pippali – Long pepper fruit – Piper longum, Nagara – Zingiber officinale, Patha – Cyclea peltata and Svadamstra, taken 3 Palas of each (for the preparation of decoction, these drugs is boiled by adding 160 palas of water and reduced to 1/4th , i.e 40 Palas). In this decoction, the paste of Gandira, Pippali – Long pepper fruit – Piper longum Mula, Vyosa (Sunthi Pippali – Long pepper fruit – Piper longum and Maricha – Black pepper fruit – piper nigrum), Chavya – Piper retrofractum and Chitraka – Leadword – Plumbago zeylanica, taken 2 Palas of each, is added, to this, 40 Palas of ghee, 40 Palas of juice of Changeri and 240 Palas of curd is kept in kept in a clean jar and used in food and as a drink regularly.
It cures
Grahani (Sprue syndrome)
Arshas – piles
Gulma (Phantom tumour),
Hrd roga – heart diseases,
Shotha – Oedema,
Plihodara – splenic disorders,
constipation,
Mutra krchra – dysuria,
Jwara – fever,
Kasa – cough,
Hikka – hiccup,
Aruchi – anorexia,
Shvasa – asthma and
Parshva shoola – pain in the sides of the chest
It is an excellent promoter of strength, plumpness of the body, complexions and the power of digestion as well as metabolism [113- 118]

Administration of Haritaki

For the downward movement of Vayu, the patient is given Haritaki fried in ghee along with either Jaggery and Pippali – Long pepper fruit – Piper longum, or Trivrt – Operculina Turpethum and Danti. By the downward movement of stool, flatus, Kapha and Pitta and by their elimination, piles of the anal region are cured and the power of digestion is increased. [119-120]

Read more about Haritaki uses

Use of meat, vegetables

Meat Soup:
If there is obstructed to the movement of stool and flatus, then the patient is given the meat- soup of peacock, partridge, grey quail, cock and bustard quail. This meat soup is made sour and well sizzled. [121]

Leafy Vegetables:
[Leaves of] Trivrt – Operculina turpethum, Danti – Baliospermum montanum, Palasa – Butea monosperma, Changeri – Oxalis corniculata and Chitraka – Leadword – Plumbago zeylanica is fried with ghee and oil. This is given along with curd [to the patient suffering from piles].
[Leaves of] Upodika, Tanduliya, Vira, Vastuka, Suvarcala, Lonika, Yava – Barley (Hordeum vulgare), Avalguja, Kakamaci, Ruha Patra – Cinnamomum tamala Nees and Eberum. (Udagra Saka) Maha Patra – Cinnamomum tamala Nees and Eberum. (Syonaka), Amlika, Jivanti – Leptadenia reticulata, Sati and Grnjanaka is cooked with curd and fried with ghee as well as oil. This is given [to the patient suffering from piles] mixed with Dhanya and Nagara. [122- 125]

Other food ingredients
This meat soup of Godha, Lopaka, Marjara, Svavit, Ustro, cow Kurma and Sallaka is prepared on the line suggested above for leafy vegetables.
Along with this meat soup, red variety of Sali rice is given [to the patient suffering from piles] for the alleviation of Vayu.[ 126- ½ 127]

Anupana after drink

The patient having piles caused by the predominance of aggravated vayu, having unctuousness and having less power of digestion is given Madira (a type of alcoholic drink), buttermilk, Tusodaka (a type of Vinegar prepared of barley), Arista (recipes to be described in verses 138- 168), whey, boiled, and cooled water, decoction of Kantakari – Solanum xanthocarpum or decoction of Nagara – Zingiber officinale and Dhanyaka as Anupana (post prandial drink) for the downward movement of flatus and stool.
[127 ½ – 129]

Anuvasana basti

Anuvasana type of Enema
It is desirable to administer Anuvasana type of enema to the patient suffering from Udavarta (upward movement of wind in the abdomen), who is extremely devoid of unctuousness whose wind in the stomach moves in the opposite direction and who is suffering from colic pain. [130]

Pippalyadya Taila
Oil is cooked with the paste of pippali – Piper longum, Madana – Randia dumetorum, Bilva – Aegele marmelos, Satahva, Madhuka – Terminalia madhuca, Vaca—Acorus calamus, Kustha – Sausserea lappa, Sati – hedychium spicatum, Pushkaramula, Citraka – Plumbago zeylanica and Devadaru – Cedrus deodara by adding milk(taken in double the quantity of oil).
This is an excellent recipe for the administration of Anuvasana type of medicated enema for piles and Mudha Vata (immobility of wind in abdomen).
This cure:
Guda nissarana – prolapse of rectum,
Shoola – colic pain,
Mutra kruchra – dysuria,
Kati, uru, Prushta Daurbalya – distension in the pelvic region, thighs and back,
Pravahika -slimy discharge from the annual oedema,
Anaha – non- elimination of flatus and stool and
Vata varcho vinigraha – frequent desire for passing stool [131-134]

Paste for External Application
The above mentioned drugs ending with Devadaru – cedrus deodara (vide verse 131) is made to a paste.
This paste is mixed with fat, made luke-warm and applied over piles having numbness and pain. By its application, slimy Kapha along with blood will ooze out, and because of this pile will be free from itching, stiffness, pain and oedema [135-136]

Niruha basti

Niruha Type of Enema:
Enema should contain milk, decoction of Dashamula(Bilva – Aegle marmelos, syonaka, Gambhari – Gmelina arborea, Patali, Ganikarika, Shalaparni, Prsniparni, Brhati – Solanum indicum, Kantakari – Solanum surattense and Goksura – Tribulus terrestris), cow’s urine, fat, salt and the paste of Madana Phala – Randia dumetrom, etc( vide Sutra 4:13). [137]

Arishta formlulations

Abhayarista:
½ Prastha Haritaki—Terminalia chebula, 1 Prastha Amalaki – Phyllanthus emblica, 10 Palas Kapittha – Limonia acidissima ,5 Pala Indra Varuni – Citrullus colocynthis, 2 Palas Vidanga – Embelia ribes, 2 Palas Pippali – Piper longum, 2 Palas Lodhra – Symplocos racemosa, 2 Palas Maricha – Piper nigrum and 2 Palas Elavaluka is added with 8 Dronas of water and boiled till 2 Dronas remain.
The decoction is filtered and allowed to cool. To this, 200 Palas of Jaggery is given in an appropriate dose depending upon the strength of the patient.
By the regular intake of this Arista, Piles get cured. This effective recipe is called Abhayarista.
It cures
Grahani dosha (sprue syndrome)
Pandu – anaemia,
Hrudi roga – heart diseases,
Pliha – splenic disorders,
Gulma – Tumours of the abdomen (Phantom tumour),
Udara – ascites, enlargement of the abdomen (obstinate abdominal diseases including Ascites),
Kustha (obstinate skin diseases including leprosy),
Shotha – oedema,
Aruchi-Anorexia
Kamala – Jaundice
Leucoderma,
Krmi – infestation with intestinal parasites,
Granthi (adenitis) Tumour
Vyanga – discoloured patch on face (Freckles),
Raja yakshma – Tuberculosis and
Jwara – fever.
It promotes strength, complexion and the power of digestion [ 138-143]

Dantyarista
Roots of Danti – Baliospermum montanum, Chitraka – Plumbago zeylanica and Dashamula (Bilva – Aegle marmelos, Syonaka, Gambhari—Gmelina arborea, Patali, Ganikarika, Sala parni, Prsni Parni, Brhati – Solanum indicum, Kantakari and Goksura – Tribulus terristeris), taken 1 pala each is boiled by adding 2 Dronas of water.
To this, fruits pulp of Triphala (3 Palas in total) is added.
It is boiled till 1/4th remains. The decoction is strained through a cloth and cooled.
To this, 1 Tula of Jaggery is added and kept in a ghee smeared jar for 15 days. Regular intake of this in appropriate dose makes a person free from piles. This is called Dantyarista and it cures Grahani (sprue syndrome) and Pandu – Anaemia, initial stages of liver disorders.
It helps in the downward movement of flatus and stool.
It stimulates the power of digestion and cures anorexia [144-147]

Phalarista:
Fruits pulp of 1 Prastha Haritaki – Terminalia chebula, 1 Prastha Amalaki – Phyllanthus emblica; 2 Palas Visala, 2 Palas Kapittha, 2 Palas Patha – Cissampelos parriera and 2 Palas Root of Chitraka – Plumbago zeylanica is added with 4 Dronas of water and boiled till 1/4th remains.
The decoction is then stained out through a cloth. To this, 1 Tula of jaggery is added and kept in ghee.
It cures
Grahani (sprue syndrome),
Arshas – piles,
Hrt roga – heart diseases,
Pliha roga – splenic this obstruction to the passage of stool, urine and flatus, low power of digestion,
Kasa – cough,
Gulma – Phantom Tumour and
Udavarta – bloating (upward movement of wind in the abdomen),.
It stimulates the power of digestion.
It called Phalarista, and is propounded by the sage Krsuatreya. [148- 152]

Duralabharishta – Phalarista (second Recipe)
1 Prastha of Duralabha – Fagonia cretica / Alhagi pseudalhagi and 2 Palas of each of Chitraka – Plumbago zeylanica, Ursa, Haritaki – Terminalia chebula, Amalaki – Phyllanthus emblica, Patha – Cissampelos pariera, Nagara – Zingiber officinale and Danti – Baliospermum montanum is added with 2 Dronas of water and boiled till 1/4th remains.
The decoction is strained out through a cloth and cooled. To this, 100 Palas of Sugar is added. It is kept in a jar 15 days. The inside wall of the jar is smeared with the paste containing Pippali – Piper nigrum, Chavya, Priyangu, honey and ghee.
This preparation of sugar (Sarkara) is taken in appropriate dose depending upon the strength of the patient.
It cures-
Arshas – Piles,
Grahani – Malabsorption syndrome, Irritable Bowel Syndrome (sprue Syndrome), Udavarta – bloating upward movement of wind in the stomach,
Arochaka – anorexia,
Sakrt anila mutra udgara – obstruction to the movement of stool, urine, flatus and eructation,
Agni mandya – low power of digestion,
Hrud roga – heart diseases and
Pandu – Anaemia, initial stages of liver disorders (anaemia) [153-157]

Kanakarista
1 Tula of freshly collected Amalaki – Phyllanthus emblica is coarsely pounded. To this, 4 Palas of each Pippali – Piper nigrum, Vidanga – Embelia ribes and Maricha – Piper nigrum, 1 Pala of each of Patha – Cissampelos parieira, Pippali Mula, Kramuka (Puga or Pattika Lodhra) Chavya – Piper retrofractum, Chitraka – Plumbago zeylanica, Manjistha –Rubia cordifolia, Elvauka and Lodhra –Symplocos racemosa ,
½ Pala of each of Kustha—Sausserea lappa, Daruharidra – Berberis aristata, Surahva (Goraksa Karkatika), Sariva – Hemidesmus indicus, Krsna sariva, indrahva and bhadramusta, and 4 Palas of freshly collected Naga Puspa is added. To this, two Dronas of water is added and boiled till 1/4th remains.
The decoction is strained out through a cloth and collected honey and the powder of Tvak, Ela, Plava patra, Ambu, Sevya, Karmuka and Kesara, taken in the quantity of 1 Karsa each, is added. This is kept in a clean and ghee smeared and fumigated with sugar and Aguru. After 15 days, the recipe is filtered out.
This is called Kanakarista. This drink is sweet in taste and cardiac tonic.
It produces relish in the food and cures
Arshas – piles,
Grahani – Malabsorption syndrome, Irritable Bowel Syndrome (Sprue syndrome),
Anaha (flatulence),
Udara – Ascites (obstinate abdominal diseases including ascites),
Jwara – fever,
Hrud roga – heart diseases,
Pandu – Anaemia, initial stages of liver disorders,
Shotha – Oedema,
Gulma – abdominal tumour, distension (Phantom tumour), Obstruction to the Passage of Stool,
Kasa – cough and other diseases caused by Kapha.
Vali (Appearance of wrinkles in the body),
Palita (appearance of Premature grey hair) and
Khalitya caused by the vitiation of Doshas. [158-168]

Water for Washing
For cleansing the anus, the patient of piles should use the decoction of leaves (which are curative of piles) or warm water. Thus, the effective treatment for dry type of piles is described [169]

Treatment of bleeding piles

Thereafter, the effective treatment of bleeding piles will be described. In this type of piles, kapha or Vayu remain aggravated secondarily [170]

Signs of Bleeding Piles Associated with Vayu
One should determine the bleeding associated with the secondarily aggravated Vayu if unctuous food and regimens are its causative factors and if the following signs and symptoms are manifested:
(i) Greyish colour, hardness and unctuousness of tract,
(ii) non-elimination of the flatus through the downward tract,
(iii) the blood which exudes from the piles is thin, reddish in colour and foamy,
(iv) pain in the lumber region, thighs and anus and
(v) Excessive weakness. [171- 172]

Signs of bleeding Piles associated with Kapha
One should determine the bleeding piles as secondarily associated with Kapha if food and regimens which are heavy and unctuous are the causative factors and if the following signs and symptoms are manifested:
(i) stool is loose, white, yellow, unctuous, heavy and cold,
(ii) the blood which exudes from the piles is dense, therapy, pale yellow and slimy and
(iii) The anus is smeared with slimy material and there is numbness in that region. [173-174]

Line of Treatment
If Vayu is secondarily vitiated in this type of (bleeding) piles, then unctuous and cold things are useful. If however, Kapha is secondarily vitiated, then unctuous and cold things are useful. Therefore, therapies are administered keeping these points in view.
If there is predominance of Pitta and kapha, the patient is administered elimination therapies: However, bleeding is not stopped immediately and one should wait for appropriate time. The patient can be given “fasting “therapy.[ 175-176]

Complications of immediate Hemostasis

If the bleeding containing material polluted by Doshas, which comes out from the piles is arrested in the beginning by an unwise physician, then it gives rise to several other diseases, viz, Rakta Pitta (a diseases characterised by bleeding from various part of the body), Jwara – fever, Trushna – morbid thirst, Suppression of the power of digestion, Aruchi -Anorexia, Kamala – Jaundice, Shotha – Oedema, colic pain in the Anus and pelvic region, urticaria and pimples in the lumer region , kustha(obstinate skin diseases including leprosy), Pandu – Anaemia, initial stages of liver disorders, (arrest of the flatus, urine and stool, headache, Staimitya( a feeling as if the body is covered with a wet cloth), heaviness of the body and other diseases caused by vitiated blood. Therefore, only after the polluted blood is eliminated, homeostatic measures are useful.
The physician well acquainted with the causative factors, signs and symptoms, nature of the time, strength and colour of the blood should await an appropriate time before administering homeostatic therapies unless is an emergency. [177-181]

Administration of Bitter Drugs

The patient is given bitter drugs for stimulation of the power of digestion, homeostasis and Pachana (metabolic transformation) of Doshas. [182]

Use of Sneha
If in the Piles having predominance of Vayu, bleeding continues even after the aggravated Doshas are eliminated then the patient is given unctuous therapies in the form of Drinks, massage and Anuvasana type of enema. [183]

Indication for Hemostatic Therapy
If Vayu and Kapha are not secondarily predominant, if piles are caused by the exclusive predominance of Pitta and if it occurs in summer, then hemostatic therapies is administered immediately to stop bleeding. [184]

Hemostatic Recipes

The decoction of the bark of Kutaja mixed with the powder of Nagara – Zingiber officinale stops exudation of unctuous blood. Similarly, the decoction of the bark (of stem or fruit) of Dadima along with the power of Nagara and the decoction of Candana along with the powder of Nagara are hemostatic.
Decoction of Chandana – Santalum album, Kiratatikta, Dhanvayasa and Nagara – Zingiber officinale, and the decoction of darvi, Tvak, Aguru – Aquallaria agallocha Usira and nimba are alleviated of piles caused by the vitiation of blood (bleeding piles).
Bark and fruits of Kutaja – Hollarhena dysentrica along with Ativisa and Rasanjana is mixed with honey and used as a hemostatic. If the patient is suffering from morbid thirst, then this potion is given along with Tandulodaka (rice- wash). [185- 187]

Kutajadi Rasakriya
100 Palas of the freshly collected bark of Kutaja – Hollarhena dysentrica is boiled with 1 Drona rain water till the entire essence of the bark comes to water ( i.e till 1/8th remains).
This decoction is then strained out through a cloth. To this, the powders of 1 Pala Mocarasa, 1 Pala Samanga 1 Pala Phalini and 3 Palas seeds of Kutaja is added and boiled again till it becomes semi- solid extract, administered in appropriate dose and time, stops bleeding, depending upon the strength of the patient, this recipe is administered along with goat- milk
It instantaneously cures rakta arsha – bleeding piles, Atisara -diarrhoea with bleeding, blood- diseases and serious types of Urdhvaga Raktha Tracts of the body) as well as Adhoga Rakta Pitta (a disease characterised by bleeding from downward tract of the body). [188-192]

Recipes for Piles
Powder of Nilotpala, Samanga, Mocarasa, Chandana – Santalum album, Tila and Lodhra is taken along with goat- milk. Thereafter, the patient should eat Shali type of rice along with goat milk [193]
Intake of the juice of Vastuka along with goat- milk stops bleeding. The soup of the meat of birds and animals inhabiting arid zone is taken without any sour ingredient or with small quantity of sour drugs, which is useful for bleeding piles.

The powder of Patha—Cissampelos parriera, seed of Kuthaja – Hollarhena dysentrica, Rasanjana, Nagara – Zingiber officinale, Yavani and Bilva – Aegle marmelos is taken in the form of a drink if there is pain in piles.[195]
If there is excessive bleeding and pain in the piles, then medicated ghee is administered.
If bleeding – piles are associated with pain, then ghee cooked with the paste of the fruits and barks of Kutaja – Hollarhena dysentrica, Kesara, Nilotpala, Lodhra and Dhataki – Woodfordia floribunda is administered by the physician.
Ghee cooked with the juice of Dadima – Punica granatum and Yava Ksara (Alkali prepared of barley) instantaneously cures bleeding and piles.
Ghee cooked with Nidigdhika and Dugdhika, similarly, cures bleeding and pain in the piles instantaneously. [196 ½- 198]

Recipes of Peya (Thin Gruel)

Peya (thin gruel) of Laja (fried paddy) prepared by adding Cukrika, Kesara and Nilotpala, or Bala and Prsniparni instantaneously cures bleeding in piles.
Peya (thin gruel) prepared by adding the decotion of Haridra, Bilva – Aegle marmelos and Nagara – Zingiber officinale, added with butter and made sour by adding Vrksamula, Amalika and Kola cures raktatisara (diarrhoea with bleeding), colic pain, Pravahika( dysentery) and oedema.
Similarly, Peya (thin Gruel) prepared by adding Grnjanaka and Sura (a type of alcohol), and sizzled with ghee and oil is taken for the cure of Raktatisara (Diarrhoea with bleeding), colic pain, Pravahika (dysentery ) and oedema.[199-201]

Recipes of Curds

Cream of Curds boiled with the piles of the following recipes is given if there is excessive bleeding:
i) Kasmari, Amalaka, Karbudara and sour fruits
ii) Grnjanaka and Shalmali – Salmalia malabarica
iii) Kstrini and Cukrika
iv) adventitious roots of Nyagrodha and
v) Flowers of Kovidara

Diet
To stop bleeding, the patient is given onion cooked with butter-milk, Upodika along with Badaramla) sour vinegar prepared of Badara) or the soup of Masura made sour by adding butter- milk. [204]
The patient of bleeding piles should take the food containing Sali rice, Syamaka and Kodrava along with the boiled milk or the soup of Masura, Mudga, Adhaki and Makustha, and added with sour ingredients. [205]

The patient suffering from bleeding piles should take food along with the meat of Sasa, Harina, Lava, Kapinjala and Ena.
He can add sour or slightly sweet ingredients to his food or sprinkle powder of Marica on his food [206]
If there is excessive bleeding from the piles and if there is excessive aggravation of Vayu in the body of the patient, then he should take food along with the soup of cock, peacock, Tittiri bird, camel and Jackal. This meat soup should be suitably with sweet and sour ingredients. [207]

Yusha of Onion
Onion taken alone or along with Rasa (meat soup), Khada (a sour and pungent drink), Yusa (vegetable soup) and Yavagu (thick gruel) cures excessive bleeding and aggravated Vayu. [208]

The truck of a young goat along with its blood is well cooked by adding large quantity of Onion. It is given by adding alternatively, sweet and sour ingredients if there is diminution of stool and blood. [209]

Bleeding piles gets cured by the habitual intake of the following recipes:
I) Navanita(Butter) and Tila (sesame seed)
II) Kesara , Navanita (Butter) and Sharkara (sugar) and
III) The cream of curd after churning [210]

Bleeding stops if the patient takes freshly collected ghee from butter, goat meat, Sastika or Sali types of rice, the scum of freshly fermented Sura (a type of alcoholic drink) or freshly fermented Sura [211]

Predominance of Vayu
Even if Pitta and Kapha are predominantly vitiated, the piles become generally, predominant of aggravated Vayu, if there is excessive bleeding. [212]

Cooling therapy
If there is predominance of Rakta and Pitta, and there is less of the signs and symptoms of aggravated Kapha as well as Vayu, then the patient should be given cooling remedies which are already described and some of which are to be described later. [213]

Sprinkling
To stop bleeding in piles, these are sprinkled with the decoctions of Madhuka – Salmalia madhuca, Pancavalka (barks of Nyagrodha – Ficus bengalensis, Udumbara –Ficus racemosa, Asvattha, Parisha and Plaksa), Bark of Badari, Udumbara – Ficus racemosa, Dhava and Patola or Vasa – Adhathoda vasica, Kakubha, yavasaka (Duralabha) and Nimba.[ 214]

Bath
If there is Rakta ativartamaane – excessive bleeding, Daha – burning sensation and Kleda – stickiness, then the patient is given bath with the decoction of madhuka, Mrnala, padmaka, Chandana – Santalum album, Kusa and Kasa.
If there is excessive bleeding the anus of the patient is first of all anointed with cold oil and then he is given sitz bath with sugar- cane juice and the decoctions of Madhuka and Vetasa or with cold water. [285- 216]

Hemostatic Douche
External application of Leaves
To stop bleeding, the mass is frequently covered with the tender leaves of banana, and leaves of Puskara sprinkled with cooled water. Similarly, covering these mases with the leaves of Padma and Utapala is useful. [218]

Rubbing
If there is prolapse of rectum, burning sensation or stickiness in the anus, then the following recipes is gently rubbed over the anus:
i) Samanga and Madhuka
ii) Tila and Madhuka
iii) Rasanjana and Ghee
iv) Sarjarasa and Ghee
v) Neem and ghee
vi) Honey and Ghee
vii) Bark of Darvi and Ghee
viii) Sandalwood and red sandalwood and
ix) Utpala and Ghee
x) Shata dhauta ghrita

Management of Continuous Bleeding
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.
Such a patient is given Avapidaka Sarpis (medicated ghee which is administered prior to taking food or which is administered in large quantity). Then anus is massaged with luke- warm milk, ghee or oil. These remedies are administered instantaneously. [222-223]

Piccha Basti

If bleeding doesn’t stop and there is aggravation of Vayu, then the patient is given instantaneously Anuvasana type of enema with the help of Luke- warm Ghrtamanda (Upper portion of the ghee). He is given the effective piccha basti (recipe of which is described below) at the appropriate hour.
In 6 prasthas of water, 2 Prasthas of milk and 2 Palas each of Duralabha, kusa, Kasa, roots and flowers of Salmali – Salmalia malabaricaand adventitious roots of Nyagrodha, udumbara and Asvattha is added and boiled till 2 prasthas remain. This is strained through a cloth, and to this, the paste of the resin from Salmali, Samanga, Chandana, utpala, seeds of kutaja – Holarrhena dysentrica, Priyangu and padmakesara is added. This effective recipe is called piccha basti and it is administered along with ghee, honey and sugar. It cures dysentery, prolapsed of rectum, bleeding and fever.
Prapaundarika and madhuka along with the drugs described in piccha basti (in verse no 227) is made to a paste.
The paste is added to oil and double the quantity of milk, and cooked. This medicated oil is used for anuvasan type of medicated enema for the patients suffering from piles. [224- 229]

Hriveradi Ghrita

Ghee is cooked by adding the paste of Hrivera,Utpala, lodhra, Samanga,Chavya, Chandana – Santalum album, Patha – Cisampelos parriera, Ativisa – Aconitum heterophyllum, Bilva – Aegle marmelos, Dhataki – Woodfordia floribunda, Devadaru – Cedrus deodara, bark of Daru Haridra – Berberis aristata, Nagara – Zingiber officinale, jatamamsi, Musta – Cyperus rotundus, Yavaksara and Chitraka – Plumbago zeylanica and the juice of Changeri.
It is an excellent remedy for Arshas – (piles), Atisara – (diarrhoea), Grahani (sprue syndrome),Pandu(anemia) Jwara-(fever), Aruchi – (anorexia), Mutra krchhra- (dysuria), Guda bhramsha – (Prolapse of rectum), Basti anaha – (distension in the region of urinary bladder), tenesmus, voiding of slimy material and pain in the piles. It alleviates all the three aggravated Doshas [230-233]

Suni Sannaka-cangeri- ghrita

Avakpuspi (Adhah Puspi), Bala, Darvi, Prsniparni, Goksura and adventitious roots of Nyagrvodha, udumbara and Asvattha these drugs is added an boiled till 1 Prastha of water remains. This decoction is strained through a cloth. In the context of preparation of the decotion, 32 palas constitute 1 prastha.
Jivanti, Katurohini, pippali – piper longum, pippali mula, Nagara – zingiber officinale , devadaru, Kalinga, flower of Salmali, Vira,Chandana, Utpala, Katphala, Chitraka – Plumbago zeylanica, Musta – Cyperus rotundus, priyangu, Ativisa – Aconitum heterophyllum, Sthira, pollens of Padma and utpala, Samanga, kantakari, Bilva – Aegle marmelos, mocarasa and Patha- these drugs is taken in the quantity of karsa each and made to a paste.
The above mentioned decoction and paste is added with the juice of Sunisannaka and Changeri, 2 Prasthas of each and 1 Prastha of ghee and cooked. This medicated ghee cures Arshas-piles, Atisara – diarrhoea, bleeding by the simultaneous aggravation of all the 3 Doshas, tenesmus, prolapsed of rectum, voiding of different types of slimy material, excessive and frequent urge for motion, oedema and pain in the anus, anuria, immobility of wind in the abdomen, suppression of the power of digestion and anorexia.
Appropriate administration of this medicated ghee helps in the
Promotion of strength,
Complexion and
Agni – The power of digestion
This medicated ghee is harmless, and it can be administered alone or along with different type of food and drinks. [234-242]
Thus it is said
Depending upon the power of digestion and the strength, the patient is given alternatively sweet as well as sour, and cold as well as hot therapies. This cures the ailments caused by piles. [243]

Inter dependents of Diseases

Arshas – Piles, Atisara – diarrhoea and Grahani – Malabsorption syndrome, Irritable Bowel Syndrome (sprue syndrome) – these 3 diseases are interdependent in as much as one of them can cause the other. They get aggravated if there is reduction in the power of digestion is increased, they get cure. Therefore, Agni (Enzymes responsible for digestion) is protected specifically for (keeping) these 3 ailments under control [244-245]

Treatment in General

The physician should overcome piles by the use of different
Bhrsta shaka – types of fried vegetables
Yavagu – thick gruel
Yusha – vegetable soup,
Mamsa rasa – meat soup,
Khada – as sour preparation
Kshira – milk and
Takra – butter- milk. [246]
Treatment in Brief                                                                                               Food ingredients and drugs which cause downward movements of Vayu and which are the promoters of the power of digestion are all invariably useful for piles. Those having opposite properties and those described in the etiology of piles should never be used by the patient suffering from this diseases. [247- 248]

Summary

In this chapter on “The treatment of piles” all the following points pertaining to piles are discussed:
i) 2 different way in which this diseases is produced
ii) Location, appearance and signs as well as symptoms
iii) Determination of curability and incurability
iv) Recipes for massage, fomentation, fumigation, bath external application, blood- letting and digestive stimulation and of carminatives.
v) Most useful modes of taking drinks and food
vi) Recipes for the downward movement of flatus and stool
vii) Alleviating recipes
viii) Different types of medicated ghee
ix) Recipes for medicated Enemas and butter- milk
x) Excellent Aristas including Sarkararista
xi) Wholesome regimes for dry piles
xii) Signs and symptoms of bleeding piles
xiii) 2 different types of Anubandhas( secondary aggravations of Doshas) and their appropriate remedies
xiv) Hemostatic decoctions
xv) Pastes of different types
xvi) Excellent modes of giving oleation therapy and food
xvii) Recipes for rubbing over the piles mass
xviii) Recipes for washing, bath, ointment and sprinkling over piles and
xix) Remedies for excessive bleeding in piles. [249- 255]

Thus, ends the 14th chapter dealing with the treatment of Arshas in Chikitsa Sthana of Agnivesha’s work as redacted by Charaka.