Arsha Nidanam – 5th Chapter of Madhav Nidana

Abstract

Arsha is one of the important ano-rectal disorders described in Ayurveda affecting the health and quality of life of an individual. Madhava Nidana systematically describes Arsha Nidana with causative factors, clinical signs and symptoms and pathogenesis. According to Ayurveda principles, this condition is caused by improper dietary habits, unhealthy lifestyle practices and vitiation of Doshas. Disease is explained on the basis of involvement of Doshas, Dushya, Agni and site of involvement. An accurate knowledge of Nidana (etiological factors), Purvarupa (prodromal features), Rupa (clinical signs and symptoms) and Samprapti (pathogenesis) is very important for its assessment. . This article aims to present a concise review of Arsha Nidana according to Madhava Nidana and highlight its significance in Ayurvedic clinical practice.

Arsha Nidanam – 5th Chapter of Madhav Nidana

Introduction

The term – Arsha is used in the past to denote growths in the anal region which can cause pain, bleeding and discomfort during defecation This condition has been described in detail in classical Ayurvedic texts, with discussions on its causes, clinical features and progression of the disease. The manifestation of it can be understood by the involvement of dosha imbalance, impaired Agni and disturbances in normal functioning of the affected tissues . Madhava Nidana is a very important Ayurvedic text which systematically describes diseases giving special emphasis to Nidana (causative factors) and Lakshana (clinical features). A useful account of the etiological factors, characteristic signs and symptoms and different classifications of the disease is given in the chapter on Arsha Nidana. The knowledge of these classical descriptions provides a sound basis for the Ayurvedic assessment of Arsha.The review is to emphasize the significance of classical Ayurvedic knowledge for the understanding of the disease and its importance in the contemporary Ayurvedic clinical practice.

Types Of Arsha

1. Based On Dosha Predominance

Vataja Arsha (वातज अर्श)
Pittaja Arsha (पित्तज अर्श)
Kaphaja Arsha (कफज अर्श)
Sannipataja Arsha (सन्निपातज अर्श)
Raktaja Arsha (रक्तज अर्श)

2. Based On Prognosis (Sadhya–Asadhyata)

Sadhya Arsha — curable.
Yapya Arsha — manageable or palliable.
Asadhya Arsha — difficult or incurable.

3. Based On Site Of Occurrence

Bahirvalaya Arsha — external piles, situated outside the anal canal.
Antarvalaya Arsha — internal piles, situated within the anal canal.

Definition Of Arsha

दोषास्त्वङ्मांसमेदांसि संदूष्य विविधाकृतीन्।
मांसाङ्कुरानपानादौ कुर्वन्त्यर्शांसि ताञ्जगुः॥ २॥ (Madhava Nidana Arshonidana, Shloka 2)

When the Doshas vitiate the Twak (skin), Mamsa (muscle tissue), and Medas (fat tissue), they produce fleshy projections of different shapes in the Apana region (anal region). These growths are known as Arsha.

Samprapti Of Arsha

According to the Ayurvedic description of Arsha Nidana in Madhava Nidana, the disease develops through the following stages:

Nidana Sevana: Excessive intake of incompatible, heavy, or unsuitable food and unhealthy lifestyle practices contribute to Dosha vitiation.
Agni Dushti: Impairment of Jatharagni affects the proper digestion of food and contributes to disturbances in normal bowel function.
Dosha Prakopa: The vitiated Doshas, particularly Vata, Pitta, and Kapha, disturb the normal functioning of the gastrointestinal tract.
Sthana Samshraya: The vitiated Doshas affect the Guda region and its associated tissues.
Arsha Utpatti: The Doshas vitiate Twak (skin), Mamsa (muscle tissue), and Medas (fat tissue), leading to the formation of fleshy growths of different shapes, known as Arsha.

Nidana (Causative Factors) Of Vataja Arsha

कषाय-कटु-तिक्तानि रूक्ष-शीत-लघूनि च।
प्रमिताल्पाशनं तीक्ष्णं मद्यं मैथुनसेवनम्॥ ३॥
लङ्घनं देश-कालौ च शीतौ व्यायामकर्म च।
शोकः वातातपस्पर्शो हेतुः वातातिसारिणाम्॥ ४॥ (Madhava Nidana Arshonidana, Shloka 3-4)

The causative factors of Vataja Arsha include excessive consumption of foods having Kashaya (astringent), Katu (pungent), and Tikta (bitter) tastes, along with Ruksha (dry), Sheeta (cold), and Laghu (light) qualities. Insufficient food intake, excessive fasting, consumption of strong alcoholic beverages, and excessive sexual activity are also described as contributing factors. Furthermore, exposure to cold environments and seasons, excessive physical exertion, grief, and contact with wind and sunlight may aggravate Vata Dosha. These factors are considered to disturb the normal functioning of Vata, contributing to the pathogenesis of Vataja Arsha. This classical description highlights the importance of dietary habits, lifestyle, environmental conditions, and psychological factors in the Ayurvedic understanding of the disease.

Nidana (Causative Factors) Of Pittaja Arsha

कट्वम्ललवणोष्णानि व्यायामाग्न्यातपप्रभाः।
देशकालावशिशिरौ क्रोधो मद्यमसूयनम्॥
विदाहि तीक्ष्णमुष्णं च सर्वं पानान्नभेषजम्।
पित्तोल्बणानां विज्ञेयः प्रकोपे हेतुरर्शसाम्॥ (Madhava Nidana Arshonidana, Shloka 5-6)

The causative factors of Pittaja Arsha include excessive consumption of foods that are Katu (pungent), Amla (sour), Lavana (salty), and Ushna (hot) in nature. Excessive physical exertion, exposure to the heat of fire and sunlight, and residence in places or seasons that are not cold may further aggravate Pitta Dosha. Other contributing factors include anger (Krodha), alcohol consumption (Madyapana), and envy or jealousy (Asuya). Intake of food, drinks, and medicines possessing Vidahi (causing burning or irritation), Tikshna (sharp), and Ushna (hot) properties is also described as a cause of Pitta aggravation. According to Ayurvedic principles, these factors contribute to the development of Pittaja Arsha.

Nidana (Causative Factors) Of Kaphaja Arsha

मधुर-स्निग्ध-शीतानि लवणाम्ल-गुरूणि च।
अव्यायामो दिवास्वप्नः शय्यासनसुखे रतिः॥ ७॥
प्राग्वत्सेवा शीतौ च देश-कालावचिन्तनम्।
श्लेष्मिकाणां समुद्दिष्टमेतत् कारणमर्शसाम्॥ ८॥ मधुर-स्निग्ध-शीतानि लवणाम्ल-गुरूणि च।
अव्यायामो दिवास्वप्नः शय्यासनसुखे रतिः॥ ७॥
प्राग्वत्सेवा शीतौ च देश-कालावचिन्तनम्।
श्लेष्मिकाणां समुद्दिष्टमेतत् कारणमर्शसाम्॥ ८॥ (Madhava Nidana Arshonidana, Shloka 7-8)

Kaphaja Arsha is associated with the aggravation of Kapha Dosha due to inappropriate dietary and lifestyle practices. Sweet, sour, and salty foods, as well as those that are cold, oily, or difficult to digest, consumed on a daily basis can lead to this. A lack of regular exercise, reduced physical movement, sleeping during the day, and spending excessive time in sedentary postures, such as sitting or lying down, may also contribute to the development of the condition.

Furthermore, exposure to cold climatic conditions and the habitual adoption of Kapha-promoting practices may disturb the normal balance of Doshas. According to Ayurvedic principles, these factors contribute to Kapha predominance and play a role in the pathogenesis of Kaphaja Arsha.

Nidana (Causative Factors) Of Dvandvaja And Tridoshaja Arsha

पृथग्दोषैः समस्तैश्च शोणितात् सहजानि च।
अर्शांसि षट् प्रकाराणि विद्याद् गुदवलित्रये॥ १॥ (Madhava Nidana Arshonidana, Shloka 9)

Dvandvaja Arsha develops due to the combined vitiation of any two Doshas – Vata and Pitta, Vata and Kapha, or Pitta and Kapha. Its clinical features reflect the involvement of both Doshas.

Tridoshaja Arsha arises from the simultaneous vitiation of all three Doshas — Vata, Pitta, and Kapha. It is associated with a combination of features corresponding to all three Doshas.

Lakshana (Symptoms) Of Vataja Arsha

गुदाङ्कुरा बह्वनिलाः शुष्काश्चिमचिमान्विताः।
म्लानाः श्यावारुणाः स्तब्धा विशदा: परुषाः खराः॥ १०॥
मिथो विसदृशा वक्रास्तीक्ष्णा विस्फुटिताननाः।
बिम्बी-खर्जूर-कर्कन्धू-कार्पासिफलसन्निभाः॥ ११॥
केचित् कदम्बपुष्पाभाः केचित् सिद्धार्थकोपमाः।
शिरः-पार्श्वांसि-कट्यूरु-वङ्क्षणाध्यधिकव्यथाः॥ १२॥
क्षवथूद्गार-विष्टम्भ-हृद्ग्रहारोचकप्रदाः ।
कास-श्वासाग्निवैषम्य-कर्णनाद-भ्रमावहाः ॥१३॥
तैरार्तो ग्रथितं स्तोकं सशब्दं सप्रवाहिकम् ।
रुक्फेन-पिच्छानुगतं विबद्धमुपवेश्यते ॥१४॥
कृष्णात्वङ्नख-विण्मूत्र-नेत्र-वक्त्रश्च जायते ।
गुल्म-प्लीहोदराष्टीलासंभवस्तत एव च ॥१५॥ (Madhava Nidana Arshonidana, Shloka 10-15)

Madhava Nidana says that Vataja Arsha presents rough, hard and rigid piles that can prick or tingle. Vataja Arsha piles are usually pale, dusky red or blackish, irregular in shape, curved, pointed and cracked at their tips and Vataja Arsha piles have no discharge. Vataja Arsha looks like the fruits of Bimbi, date palm, Karkandhu or cotton and Vataja Arsha can also look like Kadamba flowers or mustard seeds. Vataja Arsha can bring pain to the head, flanks, shoulders, waist, thighs and groin. Vataja Arsha can also make passing stools difficult cause constipation, abdominal swelling, frequent sneezing or belching pain, near the heart loss of appetite, cough, breathlessness, digestion ringing in the ears and dizziness.Defecation may be painful and difficult, with scanty, hard, fragmented stools passed with straining and noise; the stools may also be frothy or mixed with mucus. The skin, nails, urine, eyes and face may become dark or blackish. Classical descriptions also mention possible associated conditions such as Gulma, enlargement of the spleen and abdominal disorders

Lakshana (Symptoms) Of Pittaja Arsha

पित्तोत्तरा नीलमुखा रक्तपीतासितप्रभाः।
तन्वस्रस्राविणो विस्रा स्तनवो मृदवः श्लथाः॥ १६॥
शुकजिह्वा यकृत्खण्ड जलौकोवक्त्रसन्निभाः।
दाहपाकज्वरस्वेदतृण्मूर्च्छारुचिमोहदाः॥ १७॥
सोष्माणो द्रवनिलोष्णपीत रक्तामवर्चसः।
यवमध्या हरित्पीतहरिद्रत्वङ्नखादयः॥ १८॥ (Madhava Nidana Arshonidana, Shloka 16-18)

Pittaja Arsha is characterized by predominance of Pitta dosha and hemorrhoidal masses. These masses have bluish tips and can be of red, yellowish or dark color. These are usually few in number, soft, loose, and associated with the discharge of thin, foul-smelling blood. They look like a parrot’s tongue (Śuka-jihvā), a bit of liver (Yakṛt-khaṇḍa) or the mouth of a leech (Jalauka-vaktra). Symptoms associated with it are burning sensation (Dāha), inflammation or suppuration (Pāka), fever (Jvara), excessive sweating (Sveda), thirst (Tṛṣṇā), fainting (Mūrchā), loss of appetite (Aruci) and confusion (Moha). The patient may have loose stools that are bluish, yellowish or reddish in color and may contain undigested material. The skin and nails may become greenish-yellow or turmeric-yellow in color. These features are described in Ayurveda as the specific lakshanas of Pittaja Arsha.

Lakshana (Symptoms) Of Kaphaja Arsha

श्लेष्मोल्बणा महामूला घना मन्दरुजः सिताः।
उत्सन्नोपचितस्निग्धस्तब्धवृत्तगुरुस्थिराः॥१९॥
पिच्छिलाः स्तिमिताः श्लक्ष्णाः कण्डवाद्यः स्पर्शनप्रियाः।
करीरपनसाभास्तथा गोस्तनसन्निभाः॥२०॥
वङ्क्षणानाहिनः पायु-बस्ति-नाभिविकर्षिणः।
सश्वास-कास-हृल्लास-प्रसेकारुचि-पीनसाः॥२१॥
मेहकृच्छ्रशिरोजाड्यशिशिरज्वरकारिणः।
क्लैब्याग्निमार्दवच्छर्दिरामप्रायविकारदाः॥२२॥
वसाभसकफप्रायपुरिषाः सप्रवाहिकाः।
न स्रवन्ति न विदीर्यन्ते, पाण्डुवर्णत्वं स्निग्धत्वं च त्वचि दृश्यते ॥२३॥ (Madhava Nidana Arshonidana, Shloka 19-23)

As per Madhava Nidana, Kaphaja Arsha is defined as a disease of anal region with hemorrhoidal masses due to predominance of Kapha dosha. These masses are deep, large, hard, white, smooth, rounded, heavy, firm and relatively painless. They are slimy, moist, glossy and are associated with severe itching. The patient may get some relief or comfort from touching or scratching them. It looks like a bamboo shoot (Karira), or a jack fruit (Panasa), or a cow’s teat. Associated symptoms are distension of the groin, dragging sensation in anal region, urinary bladder and umbilicus, breathlessness, cough, nausea, excessive salivation, loss of appetite and running of the nose. Other features may include difficulty in urination, heaviness of the head, fever with chills, reduced sexual function, reduced digestive capacity and vomiting. The stool is like fat and contains mucus, and there is straining during defecation. Usually the pile masses do not bleed or produce mucus. The skin can turn pale and greasy.

Lakshana (Symptoms) Of Tridoshaja Arsha (Sannipataja Arsha)

सर्वैः सर्वात्मकान्याहुर्लक्षणैः सहजानि च ।
रक्तोल्बणा गुदे कीला: पित्ताकृतिसमन्विताः ।
वटप्ररोहसदृशा गुञ्जाविद्रुमसन्निभाः ॥
ते अत्यर्थं दुष्टमुष्णं च गाढविट्कप्रपीडिताः ।
स्रवन्ति सहसा रक्तं तस्य चातिप्रवृत्तितः ॥ (Madhava Nidana Arshonidana )

In Madhava Nidana, the Tridoshaja Arsha (Sannipataja Arsha) means the concomitant vitiation of Vata, Pitta and Kapha doshas. It is mentioned in the classical that all the features of all three doshas may coexist. The features of Sahaja Arsha as mentioned in verse 24, contains all three doshas. The following verses 25 to 26 on rakta Arsha can not be equally hastily inflicted upon the Tridoshaja Arsha: all pile masses have maximal affinity for blood, they resemble the tender sprouts of a banyan tree, Gunja seeds or coral and bleed severely on pressing by hard stool.

Lakshana (Symptoms) Of Raktaja Arsha

सर्वैः सर्वात्मकान्याहुर्लक्षणैः सहजानि च ।
रक्तोल्बणा गुदे कीलाः पित्ताकृतिसमन्विताः ॥२४॥
वटप्ररोहसदृशा गुञ्जाविद्रुमसन्निभाः ।
तेऽत्यर्थं दुष्टमुष्णं च गाढविट्कप्रपीडिताः ॥२५॥
स्रवन्ति सहसा रक्तं तस्य चातिप्रवृत्तितः ।
भेकाभः पीड्यते दुःखैः शोणितक्षयसंभवैः ॥२६॥ (Madhava Nidana Arshonidana, Shloka 24-26)

Raktaja Arsha is a type of arsha characterised by prominent bleeding, which has similar signs and symptoms as Pittaja Arsha, while the growth is similar to the young sprouts of the banyan tree, gunja seed and coral. During passing of stool, the pressure exerted on these arshas and associated bleeding profusely, while the nature of bleeding is classicically described as hot and vitiated blood. Advanced bleeding may cause pallor and emaciation, diminished energy, loss of strength and memory, and weaken the sensory faculties. The classical text describes a frog like appearance of the patient due to intermittent and profuse bleeding

Dosha Involvement In Raktarshas And Its Associated Clinical Manifestations

हीनवर्णबलोत्साहो हतौजाः कलुषेन्द्रियः ।
तत्रानुबन्धो द्विविधः श्लेष्मणो मारुतस्य च ॥ २७ ॥
तनु चारुणवर्णं च फेनिलं चासृगर्शसाम् ।
कट्यूरुगुदशूलं च दौर्बल्यं यदि चाधिकम् ॥ २८॥
तत्रानुबन्धो वातस्य हेतुर्यदि च रूक्षणम् ।
शिथिला, श्वेत-पीतवर्णा, स्निग्धा, गुरुः तथा शीतगुणयुक्ता विट्भवति ॥ २९॥
यद्यर्शसां घनं चासृक् तन्तुमत् पाण्डु पिच्छिलम् ।
गुदं सपिच्छं स्तिमितं गुरु स्निग्धं च कारणम् ।
श्लेष्मानुबन्धो विज्ञेयस्तत्र रक्तार्शसां बुधैः ॥ ३०॥ (Madhava Nidana Arshonidana, Shloka 27-30)

According to Madhava Nidana, the patient suffering from Raktarshas may experience a decline in complexion, physical strength, enthusiasm and vitality, along with disturbances in the normal functioning of the sense organs. The text further explains that the condition may be associated with either Vata or Kapha dosha. When Vata is involved, the blood discharged from the haemorrhoidal masses is described as thin, reddish and frothy, and the patient may experience pain in the waist, thighs and anal region, along with weakness. In contrast, when Kapha is associated, the blood may be thick, pale, stringy and slimy, while the anal region may exhibit heaviness, stickiness and increased unctuousness. These variations in the characteristics of blood and associated symptoms help explain the different dosha associations described in the classical Ayurvedic text.

Purvarupa Of Arsha

विष्टम्भोऽन्नस्य दौर्बल्यं कुक्षेराटोप एव च।
कार्श्यमुद्गारबाहुल्यं सक्थिसादोऽल्पविट्कता॥ ३१॥
ग्रहणीदोषपाण्ड्वर्तिप्रशङ्का चोदरस्य च।
पूर्वरूपं विनिर्दिष्टमर्शसामभिवृद्धये॥ ३२॥ (Madhava Nidana Arshonidana, Shloka 31-32)

As per the classical description, the purvarupa (prodromal symptoms) of Arsha are as follows-indigestion or obstruction of food (annasya vishtambha), general weakness (daurbalya), distension of the abdomen along with gurgling sounds (kuksher atopa), severe emaciation (karshya), frequent eructation (udgara-bahulya), heaviness or weakness of the thighs (sakthi-sada) and passage of small quantity of stool (alpa-vitkata). These symptoms may be associated with several other phenomena like abdominal pain and other indications pointing towards the (Grahani), anaemia (pandu) and abdominal pain and potential for abdominal disease; all before the appearance of typical haemorrhoidal swellings.

Prognosis Of Arsha

1. Sukha-Sadhya Arsha (Easily Curable)

बाह्यायां तु वलौ जातान्येकदोषोल्बणानि च ।
अर्शांसि सुखसाध्यानि न चिरोत्पतितानि च ॥ ३५ ॥ ॥ (Madhava Nidana Arshonidana, Shloka 35)

2. Krichhra-Sadhya Arsha (Difficult To Cure)

द्वन्द्वजानि द्वितीयायां वलौ यान्याश्रितानि च ।
कृच्छ्रसाध्यानि तान्याहुः परिसंवत्सराणि च ॥ ३६ ॥ ॥ (Madhava Nidana Arshonidana, Shloka 36)

Haemorrhoids caused by the combined aggravation of two doshas, situated in the middle anal fold, or persisting for approximately one year are described as difficult to cure. Their location, chronicity and combined dosha involvement make treatment more challenging.

3. Asadhya Arsha (Incurable)

सहजानि त्रिदोषाणि यानि चाभ्यन्तरां वलिम् ।
जायन्ते अर्शांसि संश्रित्य तान्यसाध्यानि निर्दिशेत् ॥ ३७ ॥॥ (Madhava Nidana Arshonidana, Shloka 37)

Haemorrhoids that are congenital, involve all three doshas and are situated in the innermost anal fold are classified as incurable in the classical Ayurvedic description.

4. Yapya Arsha (Manageable Or Palliable)

शेषत्वादायुषस्तानि चतुष्पादसमन्विते ।
याप्यन्ते दीप्तकायाग्नेः प्रत्याख्येयान्यतो अन्यथा ॥ ३८ ॥॥ (Madhava Nidana Arshonidana, Shloka 38)

According to the text, such patients may be managed when they have sufficient remaining lifespan, good digestive capacity (Agni) and the necessary four components of treatment: the physician, medicines, attendant and patient. If these favourable conditions are absent, the text advises against undertaking treatment.

5. Additional Signs Of Incurability

हस्ते पादे मुखे नाभ्यां गुदे वृषणयोस्तथा ।
शोथो हृत्पार्श्वशूलं च यस्यासाध्योऽर्शसो हि सः ॥ ३९ ॥
हृत्पार्श्वशूलं सम्मोहश्छर्दिरङ्गस्य रुग्ज्वरः ।
तृष्णा गुदस्य पाकश्च निहन्युर्गुदजातुरम् ॥ ४० ॥॥ (Madhava Nidana Arshonidana, Shloka 39-40)

Swelling of the hands, feet, face, umbilical region, anal region, and scrotum along with pain in the cardiac region or flanks is said to be a symptom of untreatable Arsha Severe. Pain in the cardiac region and flanks, confusion, vomiting, body pain, fever, excessive thirst and suppuration of the anal region are described as grave signs that may threaten the patient’s life.

Lingaja Arshas

मेढ्रादिष्वपि वक्ष्यन्ते यथास्वं नाभिजान्यपि ।
गण्डूपदास्यरूपाणि पिच्छिलानि मृदूनि च ॥ ५२ ॥ (Madhava Nidana Arshonidana, Shloka 42)

According to Madhava Nidana, Arsha-like growths may occur in other body parts, including the genital organ (Medhra) and the umbilical region (Nabhi). Their features depend on the respective dosha involvement. The growths are described as resembling the mouth of an earthworm (Gandupada-asya), with a soft consistency (Mridu) and a slimy or mucus-like surface (Picchila). This description indicates that the classical text recognizes Arsha-like lesions beyond the anal region.

Charmakila

व्यानो गृहीत्वा श्लेष्माणं करोत्यर्शस्त्वचो बहिः ।
कीलोपमं स्थिरखरं चर्मकीलं तु तद्विदुः ॥ ४३॥
वातेन तोदपारुष्यं पित्तादसितवक्त्रता ।
श्लेष्मणा स्निग्धता चास्य ग्रथितत्वं सवर्णता ॥ ४४ ॥ (Madhava Nidana Arshonidana, Shloka 43-44)

Madhava Nidana describes Charmakila as a firm, rough, wart-like projection arising on the skin. When Vata predominates, the growth may be associated with pricking pain and roughness. When Pitta is involved, its tip may become blackish. When Kapha predominates, the growth tends to be smooth, oily, nodular and similar in colour to the surrounding skin. These features illustrate how the classical text differentiates Charmakila according to dosha involvement.

Conclusion

Arsha Nidana, as described in Madhava Nidana, provides a detailed understanding of Arsha by explaining its causes, premonitory symptoms, clinical features, types, dosha involvement and prognosis. The classical descriptions highlight how the predominance of Vata, Pitta and Kapha influences the appearance of haemorrhoidal growths and the symptoms experienced by the patient. By identifying the early signs and understanding the differences between the various types of Arsha, Ayurveda emphasizes the importance of timely recognition and appropriate management. The discussion of Raktarsha, Charmakila and other related conditions further broadens the understanding of anorectal disorders described in the text. Overall, the study of Arsha Nidana in Madhava Nidana remains valuable for Ayurvedic students and practitioners, as it connects classical diagnostic principles with a systematic approach to understanding disease and patient care. Integrating this traditional knowledge with appropriate clinical examination and modern medical evaluation can help support safe and effective patient management.