Arsha (Piles) in the Sushruta Samhita: The Six Types of Haemorrhoids in Ayurveda's Nidana Sthana

📖 22 min read · By Ayurveda Hub

Arsha in the Sushruta Samhita: How Ayurveda Frames Piles

Piles — the swollen, often painful masses in and around the anal canal that modern medicine calls haemorrhoids, and which much of India still calls bawaseer — are one of the oldest documented human complaints. Ayurveda's name for them is Arsha, and the description we have is anything but vague. In the Sushruta Samhita, the foundational text of Indian surgery attributed to Acharya Sushruta, an entire chapter of the Nidana Sthana is given over to Arsha: its causes, its anatomy, its varieties and its outlook. The word arsha itself is often explained as "that which torments like an enemy" (ari), a fitting name for a condition the text treats with real seriousness.

It helps to know where in the text we are. The Sushruta Samhita is organised into sections called sthanas, and the Nidana Sthana is the one concerned with nidana — the study of the causes, the mechanism and the diagnostic picture of disease, as distinct from its treatment (chikitsa). The chapter just before our subject deals with disorders of Vata and the nervous system, closing with a hard mass called Pratyashthila that obstructs the downward passage of stool, urine and flatus — a neat bridge into the Guda (ano-rectal) region. Then comes Nidana Sthana, Chapter 2: the Nidanam of Arsas, which opens with a clean classification: "Haemorrhoids may be divided into six classes." That single sentence is the seed of everything that follows, and the heart of this guide. (For the bird's-eye view of how this chapter sits among all sixteen Sushruta Nidana chapters, see our overview of the Sushruta Samhita's Nidana Sthana and its sixteen disease groups.)

The Sushruta Samhita devotes a whole chapter of its Nidana Sthana — the section on the causes and diagnosis of disease — to Arsha (piles)

One thing to settle at the outset: this article stays on the side of nidana — understanding and classifying the condition — rather than treatment. The Sushruta Samhita does describe an elaborate, four-fold approach to managing Arsha in its Chikitsa Sthana (Chapter 6): bheshaja (medicines and diet), kshara (the application of a caustic alkali paste), agni (thermal cautery, agnikarma) and shastra (surgical excision). These are serious clinical procedures, not home remedies, and the gentler, food-and-formula side of classical care is covered separately in our companion guide to Chakradutta's classical remedies for bawaseer (Arsha). Here, our task is to read Sushruta's diagnostic chapter closely — to understand what Ayurveda actually saw when it looked at piles.

The Guda and Its Three Folds: Pravahini, Visarjani and Samvarani

What is remarkable about Sushruta's account is how anatomical it is. Before describing the disease, the text describes the place. The lower end of the large intestine that passes into the rectum, it says, is called the Guda — literally the channel of faecal matter — and it measures about four-and-a-half fingers in length. Its interior, Sushruta writes, is "provided with three spiral grooves," each lying a finger-and-a-half apart, like ring-shaped muscles set one above the other.

These three folds (valis) are named, and the names are functional:

• Pravahini — the groove of out-flow, associated with bearing down and the propulsive effort of passing stool.
• Visarjani — the groove of defecation proper, the release.
• Samvarani — the groove of closure, what we would today call the sphincter (the text says sphincter ani), the muscle of continence.

Sushruta likens the three grooves of the Guda to "the involuted indentures of a conch shell," set one above the other — an image of the rectum's coiled, ringed inner structure

Then comes one of those similes that make the classical texts so vivid. The grooves, Sushruta says, are "like the involuted indentures of a conch shell, situated one above the other, coloured like the palate of an elephant." The outermost rim, where the canal meets the outer hairy margin, is called the Gudoushtha (the "lip" of the Guda). For a text many centuries old, this is a careful, layered map of the ano-rectal canal — and it matters for what follows, because Sushruta will later use exactly this anatomy to grade how serious a case of Arsha is, depending on which of the three grooves the growth sits in.

Nidana: The Ayurvedic Causes of Arsha

True to a nidana chapter, Sushruta is specific about how Arsha comes about. The doshas — chiefly the deranged Vayu (Vata), along with Pitta, Kapha and the blood — become "enraged by their specific aggravating causes," dislodged from their natural seats, and carried down into the descending colon, where they lodge and "give rise to growths of polypi or fleshy condylomata, which are known as piles." Crucially, the text adds that these growths "chiefly appear in persons suffering from impaired digestion (Agni)." Weak digestive fire, Agnimandya, is the soil in which Arsha takes root — a point Charaka stresses even more strongly in his own Arsha chapter (Charaka Samhita, Chikitsa Sthana, Chapter 14).

The classical causes (nidana) of Arsha read like a portrait of modern sedentary life: heavy, incompatible food, weak digestion, prolonged sitting and the habit of suppressing natural urges

What aggravates the doshas in the first place? Sushruta's list is strikingly modern in its logic:

• Incompatible foods (Viruddha Ahara) — "partaking of food composed of incompatible substances." Wrong combinations and habitually unsuitable eating disturb digestion and the doshas. We explore this whole idea in our guide to Viruddha Ahara, Ayurveda's wrong food combinations.
• Eating before the previous meal is digested — adhyashana, piling food on undigested food, which the text names directly. The classical correction is to respect both the timing and the quantity of meals, the theme of our piece on Ahara Matra, Vagbhata's rule for how much to eat.
• Prolonged, hard sitting — "sitting on the haunches" and excessive riding, the postural and pressure causes. A sedentary day on a hard seat is, in this light, a genuine aggravating factor.
• Inordinate sexual activity — named among the depleting, Vata-aggravating habits.
• Suppressing natural urges (Vegadharana) — "the voluntary suppression of any natural urging of the body." Holding back the urge to pass stool or wind disturbs the downward Apana Vayu and is a classic precursor. Ayurveda is emphatic about this, as we cover in Vegadharana, the thirteen urges you should never suppress.

Sushruta even names the mechanics. The dislodged doshas travel "according to the law of Prasaranam" — expansion and displacement — down through the large intestine (the Pradhana Dhamani) and lodge in the descending colon, where the growths form and then "gain in size through friction" with rough clothing, hard seats, or contact with cold water. The picture is coherent: weak Agni plus a Vata-deranging, pressure-laden, urge-suppressing lifestyle, acting on a precisely described canal.

Purvarupa: The Premonitory Signs Sushruta Lists

One hallmark of Ayurvedic diagnosis is the idea of purvarupa — the premonitory signs that appear before a disease declares itself fully, giving a watchful person (and physician) the chance to act early. For Arsha, Sushruta lists them carefully. They include a non-relish for food, a tardy and difficult digestion, acid eructations (sour belching), a sense of weakness in the thighs, a rumbling or croaking sound in the intestines, gradual emaciation, frequent belching, and swellings around the eyes.

He goes further, noting that the premonitory phase may carry "apparent indications" of conditions such as phthisis (wasting), jaundice, dysentery, cough, dyspnoea (breathlessness), vertigo and excessive sleepiness — a reminder that a long-standing derangement of digestion and Apana casts a wide shadow over health. "These," the text says, "are indications which predict the advent of this disease, and which become more marked with its progress."

Read today, the message is one of early attention rather than alarm. Persistent poor appetite, sluggish digestion, sour belching and abdominal rumbling are exactly the kind of low-grade digestive disturbance that Ayurveda would urge you to address at the level of Agni and routine — long before anything more serious sets in. (If chronic acidity and sour belching are familiar to you, our guide to Amlapitta, the Ayurvedic view of acidity, follows the same thread.)

The Six Types of Arsha (Shad Arsha)

Now to the core of the chapter. Sushruta divides Arsha into six classes — the Shad Arsha — according to which dosha (or which inheritance) is chiefly responsible: (i) Vataja (deranged Vayu), (ii) Pittaja (deranged Pitta), (iii) Kaphaja (deranged Kapha), (iv) Raktaja (vitiated blood), (v) Sannipataja (all three doshas together), and (vi) Sahaja (congenital). Each has its own appearance, sensation and associated symptoms — classical Ayurveda's way of "typing" a single condition by its underlying imbalance, so that understanding (and, in the treatment texts, management) can be tailored.

Sushruta classifies Arsha into six types — Vataja, Pittaja, Kaphaja, Raktaja, Sannipataja and Sahaja — each defined by the dosha or inheritance behind it

1. Vataja Arsha

Piles arising from aggravated Vayu are, Sushruta says, "non-exuding, rose-coloured, and uneven in their surface." They are dry rather than discharging, and may be tubular or sharp-pointed "like a needle," sometimes resembling the Kadamba flower or the wild Tundikeri flower in structure. The defining theme is dryness and pain: the stool becomes excessively hard, is passed only with the greatest difficulty, and the patient feels "excruciating pain" across the waist, back, sides, anus, umbilicus and groin. Vata being the dosha of dryness, cold and movement, its piles are the hard, painful, constipated kind.

2. Pittaja Arsha

When deranged Pitta is the cause, the piles are "slender, blue-topped, shifting in nature, yellowish in hue," sometimes coloured like shreds of liver and resembling the mouth of a leech. The signature is heat, bleeding and burning: the stool is marked with blood, defecation brings a burning sensation, and the patient may run a fever with thirst. In keeping with Pitta's nature, the skin, nails, eyes and urine may take on a yellow tinge. These are the inflamed, bleeding, hot-natured piles.

3. Kaphaja Arsha

Piles of Kapha origin "become white, are sunk about their roots, and are hard, round and glossy," greyish, likened to a cow's teat or the stone of certain fruits. Their theme is heaviness, mucus and itching: they do not burst or exude readily, the patient feels an irresistible tendency to scratch, and the stools are copious and charged with mucus (Sleshma), "resembling the washings of meat." Indigestion, a heaviness of the head and a non-relish for food accompany them — the slow, sticky, oversized piles.

4. Raktaja Arsha

Where the blood (Rakta) is vitiated, the piles "resemble the sprouts of the Vata tree in shape and are of the colour of red coral," or the dark-red seeds of the Gunja berry. They share many features of the Pittaja type, but their hallmark is bleeding: pressed by hard, constricted stool on its way out, they "suddenly give rise to a haemorrhage of vitiated blood," and the symptoms of excessive bleeding then follow. These are the classically bleeding piles — and, in the text's own logic, the type most likely to lead to anaemia and weakness if neglected.

5. Sannipataja Arsha

The Sannipataja type arises "due to the concerted action of the deranged Vayu, Pitta and Kapha," and in it "symptoms characteristic of each of these types manifest themselves in unison." It is the mixed, complicated presentation — and, as we will see, the hardest to treat. Sushruta also recognises an intermediate Samsargaja form, due to the combined action of two doshas, of which six distinct sub-varieties are counted in practice.

6. Sahaja Arsha (Congenital)

Finally, Sahaja Arsha — congenital piles — which Sushruta ascribes "to defects in the semen and ovum of one's parents," in other words to inheritance. Here the growths are hardly visible, rough and yellowish, their faces turned inward, and they are "extremely painful." The person, the text says, grows thinner over time despite eating little, with prominent veins, irritability, a feeble voice and impaired digestion. It is the deepest-seated and most stubborn class — and, as the prognosis section makes clear, the one held to be beyond cure.

This six-fold scheme is shared, with minor variations, across the classical canon: Charaka classifies Arsha along the same doshic lines in his Chikitsa Sthana (Chapter 14), and Vagbhata follows suit in the Ashtanga Hridaya (Nidana Sthana, Chapter 7). The consistency across these independent authorities is part of what gives the classification its authority. (If you are new to the doshas themselves, our complete guide to the Tridosha — Vata, Pitta and Kapha is the place to start.)

Apana Vayu: The Engine Behind Arsha

Sushruta closes the chapter with a piece of physiology that ties the whole picture together, and it centres on Apana Vayu — the downward-and-outward moving sub-type of Vata that governs elimination, the very force that should carry stool, urine and wind out of the body. In a rectum "overrun with such polypus growths," the text says, the Apana Vayu "tries to pass out through the anus, but is driven back upward, being obstructed in its passage by the vegetations." Blocked from its natural downward course, it then "mixes with his Vyana Vayu, thus impairing the five-functioned fire (Pittam) in his body."

This is an elegant account of a vicious circle. The growths obstruct Apana; obstructed Apana moves the wrong way and disturbs the other vital airs and the digestive fire; weakened fire and deranged Vata then favour still more growths. It is why classical management of Arsha leans so heavily on restoring the downward flow of Apana and rekindling Agni — and why Basti (medicated enema), the chief therapy for Vata disorders, features so prominently in the treatment texts. We explore that therapy in our guide to Basti, the Panchakarma enema and the master treatment for Vata. The role of the vital airs more broadly is the subject of our piece on the five pranas and vayus of Ayurveda, and the deeper story of deranged Vata as the "king of diseases" is told in Vata Vyadhi, from Sushruta's Nidana Sthana.

Sadhya and Asadhya: The Classical Prognosis

Perhaps the most clinically mature part of the chapter is its prognosis — the honest grading of cases into sadhya (curable), yapya (manageable but not fully curable) and asadhya (incurable). Sushruta does not promise that everything can be fixed, and that restraint is itself a mark of a careful physician.

His grading runs roughly like this. Piles due to the concerted action of all three doshas (Sannipataja), but only partially developed, "may be temporarily checked" — that is, made Yapya, kept in hand rather than truly cured. Cases of more than a year's standing, those due to two combined doshas (Samsargaja), or those "situated in the middle groove of the rectum," "may be cured but with the greatest difficulty." And cases of the Sannipatika (full three-dosha) or congenital (Sahaja) types "should be given up as incurable." Position mattered too: a growth at the outer or middle groove was held amenable to treatment, but, in Sushruta's words, "a polypus appearing about the innermost ring or groove of the rectum should be treated without holding out any definite hope of cure to the patient."

It is worth pausing on how responsible this is. The same chapter that confidently classifies the disease also tells the physician when not to promise a cure — an ethic of honesty that modern medicine would recognise. Sushruta's detailed treatment of the curable cases (the four-fold bheshaja, kshara, agni, shastra) lives in the Chikitsa Sthana; the gentler dietary and home-care side of the tradition is the subject of our companion guide to Chakradutta's classical remedies for piles.

Beyond Arsha: Charmakila and Related Growths

For completeness, the chapter also notes that the same deranged doshas can raise other kinds of fleshy growths elsewhere. Sushruta describes hard papillomatous skin growths he calls Charmakila (literally "skin-warts," papillomata) — produced when an excited Vyana Vayu unites with aggravated Kapha — and notes, in a footnote of the translation, that Charmakila "may crop up on the skin of any part of the body." Such growths, the text says, may be dry, black or white, knotty, or the colour of the surrounding skin, depending on the doshas involved.

The takeaway for a modern reader is simple and important: Ayurveda recognised that abnormal growths in this region (and on the skin generally) are a varied family, not a single thing. That is precisely why self-diagnosis is unsafe. What looks or feels like a simple pile can be something else entirely, and only an examination by a qualified professional can tell the difference. Skin growths in particular should always be shown to a doctor.

Protecting Agni: The Ayurvedic Logic of Prevention

If there is one practical thread running through the whole chapter, it is this: Arsha grows where Agni is weak and Apana is disturbed. So the classical logic of prevention is to keep digestion strong and elimination easy and regular — which, pleasingly, is ordinary good living rather than anything exotic. None of what follows is a treatment for piles or any condition; it is simply the everyday wisdom the texts attach to a healthy Guda.

Triphala — Haritaki, Vibhitaki and Amalaki — is Ayurveda's best-loved support for easy, regular elimination and a balanced Vibandha (constipation) tendency

• Guard against Vibandha (constipation). Hard, strained stool is the single thread that runs through the Vataja and Raktaja descriptions. A fibre-rich diet, enough warm water, and the gentle, classical support of Triphala (the three fruits Haritaki, Vibhitaki and Amalaki) are Ayurveda's age-old answer for easy elimination. See our guides to Triphala for digestion and relieving gas and bloating the Ayurvedic way.
• Never suppress the urge. The text names Vegadharana directly. When the body calls, answer it — holding back disturbs Apana Vayu. More in the thirteen urges never to suppress.
• Eat for your Agni. Avoid heavy, incompatible meals and eating before the last meal has digested; favour warm, simple, well-cooked food in a sensible quantity. Takra (buttermilk) is the classics' single most celebrated food for the Guda, and our guides to the Ayurvedic diet and cow's ghee, the king of healing fats follow the snigdha (unctuous) principle that keeps stool soft.
• Move, and sit less. Sushruta blamed "sitting on the haunches" and long hours of pressure. Regular movement and a daily rhythm — the spirit of Dinacharya, the Ayurvedic daily routine — keep Apana flowing downward as it should.

A warm, unctuous, fibre-friendly diet — buttermilk (takra), ghee, soft rice or khichdi and greens — is the classical foundation of a strong Agni and easy elimination

When to See a Doctor (Please Read This)

The Sushruta Samhita itself models this caution. Its prognosis section tells the physician exactly when a case is too advanced or too deep to promise a cure, and its treatments — kshara (caustic application), agni (cautery) and shastra (surgery) — are skilled clinical procedures performed only by a trained hand. Nothing in this chapter was ever meant for self-treatment at home. The right modern reading of Sushruta is not "here is how to fix piles," but "here is how thoughtfully a great clinical tradition understood them — now go and be examined properly."

Used wisely, the classical view is genuinely empowering: it points you toward the everyday habits — strong digestion, easy elimination, never suppressing urges, moving more, eating warm and simple — that keep the Guda healthy in the first place, while sending every real symptom to the people qualified to assess it.

Frequently Asked Questions

This article is educational and rooted in a classical Ayurvedic text — the Sushruta Samhita, Nidana Sthana, Chapter 2 (the Nidanam of Arsas), covering the six types of Arsha, the anatomy of the Guda and its three folds, the causes, premonitory signs, the Apana-Vayu mechanism and the classical prognosis — with corroborating reference to the Charaka Samhita (Chikitsa Sthana, Chapter 14) and the Ashtanga Hridaya of Vagbhata (Nidana Sthana, Chapter 7). It explains how a classical tradition understood a medical condition; it is not medical advice and does not diagnose or treat any disease. Piles and any rectal bleeding require assessment by a qualified doctor. Ayurvedic products are wellness preparations, not medicines for any specific condition. Consult a qualified physician for any health concern.