EVALUATION OF AYURVEDIC THERAPY FORARSHA (HAEMORROIDS) MANAGEMENT - A THERAPEUTIC STUDY

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1 J.R.A.S. Vol. XXXI, No.1, Jan.-March 10 pp EVALUATION OF AYURVEDIC THERAPY FORARSHA (HAEMORROIDS) MANAGEMENT - A THERAPEUTIC STUDY M.Mruthyumjaya Rao I, Anukul Chandra Kar 2, P.Bhattacharya J and Jayram Hazra 4 (Received on ) Abstract In order to evaluate the efficacy of different drug combinations for the management of Arsha, a randomized single blind clinical study was carried out in three different groups at A no-rectal Clinic, Central Research Institute (Ay.), Kolkata during the periodfrom May 1999 to March This trial was conducted on 659 patients of A rsha as per the proforma designed by CCRA S, New Delhi III group -1, outo{247 cases, percent patients got complete relief,"27.12 percent patients got marked relief," percent patients got moderate relief," 4.04 percent patients got mild relief, 1.61 percent patients got No reliefwhile percent patients were dropped out. III group - 2, out of230 cases, percent cases got complete relief,"26j)8 percent got marked relief,' percent got moderate reliefand 6.52 percent got mild relief,' while percent of.cases were dropped out. III group - 3, Out of 182 cases, percent cases got complete relief,' percent got marked relief," percent got moderate relief,' 1.09 percent got mild relief,"0.54 percent go No reliefwhile percent were dropped out. After analyzing the results it was observed that the differences in the improvement among the three groups were minimal and negligible and hence it is concluded that the drug combination o{all the groups are similarly effective in the management ofarsha. l.asst.director (Ay.) Central Research Institute(Ay.) Unit-I, Bhubaneswar, 2. Research Officer(Ay.) CCRAS, New Delhi,3.Research Officers (Ay.) & 4,Assist Director I/C, Central Research Institute CAy.)Kolkata. 29

2 M. Mruthyumjaya Rao et al. Introduction Piles, or Haemorrhoids, are areas in the anal canal where the tissue, which contains lots of blood vessels, has become swollen. Piles are common in pregnant women, but are rare in children. The exact cause of piles is controversial but it may be linked to excess pressure in the anus and lower rectum. This pressure can have one or more of several different causes: Straining to empty the bowels when constipated. Chronic diarrhoea. Pregnancy - the weight of the foetus on the abdomen and the increased blood flow, as well as the effect of hormones on the blood vessels. Childbirth - pushing during childbirth increases the pressure in the veins. Straining to pass urine, especially in men with prostate problems. Cancer or growths in the pelvis or bowel, which may exert pressure in a similar way to a pregnancy. Fam iiy history - piles can run in families and are potentially hereditary, perhaps because of weak veins in the anal area. Obesity. Varicose veins-many people with these also develop piles, although piles are not varicose veins. 30 They can be internal, occurring inside the anus, or external, when they can be seen and felt on the outside of the anus. When visible they look like round pink swellings, the size of a pea or a grape. They are classified according to their position. First-degree piles remain inside the rectum or anal canal. Seconddegree piles protrude (or prolapse) from the anus when the bowels are opened, but return of their own accord afterwards. Third-degree piles are similar, but only return inside when pushed back. Fourthdegree piles hang permanently outside the anus. Most people affected have internal piles and may not have any symptoms at all. The earliest symptom is often bleeding offresh, red blood from the anal passage when the bowels are opened. There may be itching around the anal area. Third and fourth degree piles may be more painful and tend to produce a slimy discharge of mucous that leaks from the exposed lining of the pile. The patients who complain of piles may have one or more of a number of individual problems, that no single treatment method can be advised for all patients and that several different methods may achieve actually good result. Their size, shape and details of anatomical configuration vary in the population who do not complain of any local problems. But any classification of clinical disease must be based on patients' symptoms assigning from or caused by ill defined derangement of anal canal function.

3 EVALUATION OF AYURVEDIC. Since the Haemorroids problem is not a threat to life excepting few conditions, the least invasive procedure/treatment is most desirable. Several cal/conventional therapies are now in practice depending upon condition of Haemorroids like sclerotherapy, rubber band ligation, anal dilatation, photo coagulation, cryosurgery, Haemorroidectomy etc. This increasing number of therapies themselves proves that there is no universally acceptable technique in the management ofhaemorroids. Sushruta (800 B.C.), the father of ancient surgery, has described 'Arsha' one among of the Mahagadas and methodologically classified the disease, and recommended different drug regimens, which are widely acceptable and practicable even today. They are Aushadha Chikitsa (Employment of medicinal remedies) Kshara Chikitsa (Application of Kshara (alkali) i.e. chemical cauterization). Agnikarma (Thermal cauterization) Sashtrakarma (Surgical management). Out of four therapeutic regimens, the Kshara & Agni Karmas are regarded as para-surgical procedures, which can be carried out without much preparation. In Sushrut Samhita, we can also see some external applications apart from some oral remedies. Based on the treatment descriptions given by Sushruta, the present drug regimen is kept on trial on 724 patients selected as per the selection / exclusion criteria laid down by the Council and the results were analyzed and assessed on various parameters. Material and Methods The study was conducted at Anorectal clinic ofc.r.i.(ay.), Kolkata using specially devised protocol & proforma, designed as per both Ayurvedic and modem parameters. Essentially, the trial aimed to evaluate an effective Ayurvedic drug combination in terms of the days taken to check the bleeding as well as alleviation of associated symptoms and to see the recurrence of bleeding & other symptoms even after complete healing. A) Selection of cases: A total no. of 659 patients with complains of bleeding per rectum during andlor after the defecation with or without other symptoms like, itching, discharge, constipation, with lor without pain were examined per-rectally and confirmed by proctoscopic examination were admitted for the study. The cases of strangulated pile masses, and Haemorroids associated with malignancy were excluded from the study. The cases were randomly selected irrespective of age, sex, chronicity, Prakriti and type of Haemorroids and follow-up was made at interval of7 days during the study period of 21 days and at interval of 15 days up to 6 weeks thereafter. 31

4 M Mruthyumjaya Rao et al. B. Drug Group- I Ka s e e sa d i Taila-IO ml to be administered per rectally half an hour before defaeeation daily once in the morning with the help of syringe and plain rubber catheter no. 7. Kankayana Vati mg. daily three times with warm water after food. Triphala Churna - 5 gm. at bed time with warm water. Group- II Kas e e sa d i Taila-IO ml to be administered per rectally half an hour before defaecation daily once in the morning with the help of syringe and plain rubber catheter no. 7. Kravyadi Rasa mg. daily three times with warm water after food. Triphala Churna -5 gm. at bed time with warm water. Group-III Kaseesadi Tail a - 10 ml to be administered per rectally half an hour before defaecation daily once in the morningwiththehelpofsyringe and plain rubber catheter no. 7. Kankayana Vati - daily three times with warm water after food. Kravyadi Rasa - daily three times with warm water after food. Abhayarishtam - 25 ml twice daily with luke warm water Triphala Churna -5 gm. at bed time with warm water. C. Diet To be taken: Ghee, milk, rice and plenty ofliquids. To avoid: Non-veg. and spicy foods. D. Criteria adopted for assessment of the response oftherapy Since the bleeding is the mam symptom in the bleeding haemorrhoids, the days taken to arrest the bleeding is noted along with alleviation of other associated symptoms and the result was assessed in the following manner. Complete relief - when the bleeding is checked completely within 7 days of therapy and complete disappearance of associated symptoms if any and no recurrence up to 6 weeks of the followup. Marked relief - When the bleeding is checked after 7 days but Before 14 days of therapy and complete disappearance of associated symptoms if any and no recurrence up to 6 weeks of the follow up. 32

5 EVALUATION OF AYURVEDIC. Moderate relief -Arrest of bleeding after 14 days but before 21 days of the therapy and complete disappearance of associated symptoms if any and no recurrence up to 6 weeks of follow-up. Mild relief - Arrest of bleeding after 21 days but before 30 days and complete disappearance of associated symptoms if any and no recurrence up to 6 weeks of follow-up. No relief - No checking of blood before 30 days or checked after 30 days and/or recurrence even after complete recovery from the symptoms. Drop out/lama 1. Discontinuation of the treatment during the trial 2. Development of any serious complications. 3. Aggravation of the disease. Results / Conclusions a) Condition of patients on admission: (Summarized in table -I) A. Out of 659 patients admitted for clinical trial, 490 (74.35%) were males and 169 (25.64%) were females. Maximum number of (169) patients belong to the age group of yrs while minimum of 75 cases belong to below 20 yrs. B. Out of 659 cases about percent of patients reported to be of Pitta Prakriti, about percent of Vata Prakriti while minimum of about 8.8 percent of Kapha Prakriti. C. About percent of patients had constipated bowel habits which is the main reason for the bleeding per rectum in those cases while minimum of about 8.34 percent had regular bowel habits. D. Among 659 cases about percent were non - vegetarians while remaining were vegetarians. b) The characteristic of Arsha / Haemorroids on admission: (Summarized in Table- II). a) About percent of patients had the disease for at least one year while minimum number of patients (5.46%) had the duration of illness above three yrs. and 48 percent patients had acute onset. b) About 9.3 percent of patients had previous history of anal surgery; about percent of patients had taken medicines for this purpose while percent of cases were reported as afresh. c) The type of Haemorroids was recorded maximum as internal in about percent of patients while minimum number of cases (8.64%) was found with external type of Haemorroids A maximum no. of percent of Arsha was found to be of Pittaja type followed by Raktajaa with the incidence of about percent while minimum 33

6 M. Mruthyumjaya Rao et at. number (4.4%) found to be of Sahaja a type ofarshas. e) About percent ofhaemorroids was positioned at 3 clock followed by 11, 5 & 7 clock positions with the incidences of %,44.15% & % respectively. c) Clinical findings noticed on admission (Summarized in Table - III) All patients had bleeding per rectum and Prolapse in percent, percent had pruritis, percent had discomfort at peri-anal region, percent had pain during/after defecation, and percent had mucous discharge. d) Haemoglobin levels recorded on admission (Summarized in Table - IV) In Group-l About percent had the mean hemoglobin of 6.5 gm%., about percent had the mean Hb% of 9.8 gm% percent while remaining patients (7.69%) had either mild anemia or normal level of hemoglobin with mean of 11.5 gm%. About 41.7 percent had moderate bleeding, about percent and percent had mild and profuse bleeding per rectum respectively. InGroup-2 About percent had the mean hemoglobin of 6.8 gm%, about percent had the mean Hb% of 8.5 gm% percent while remaining patients (38.69%) had either mild anemia or normal level of hemoglobin with mean of 10.8 gm%. About percent had moderate bleeding; about 9.13 percent and percent had mild and profuse bleeding per rectum respectively. InGroup-3 About 10 percent had the mean hemoglobin of 4.5 gm.%, about percent had the mean Hb% of 7.2 gm% percent while remaining patients of percent had either mild anaemia or normal level of haemoglobin with mean of 10.3 gm%. About 44.5 percent had moderate bleeding; about percent and 43.4 percent had mild and profuse bleeding per rectum respectively. d) The speed of recovery from bleeding and other associated symptoms (Summarized in Tables fromvtox) (Table- V) InGroup-l Healing took place in 211 patients with varying degree of duration starting from one week to four weeks. Out of247 cases 33 patients were dropped out from the study. About percent patients had healing (complete relief) by Ist week, percent had (marked relief) by two weeks, percent had (moderate relief) by three weeks and about 4.04 percent had (mild relief) by four weeks. But after four weeks 0.61 percent had the recovery but all of them (04 patients) had the recurrence within 30 days. InGroup-2 Healing took place in 195 patients 34

7 EVALUATION OFAYURVEDIC. with varying degree of duration starting from one week to four weeks. Out of230 cases 35 patients were dropped out from the study. About percent patients had healing (complete relief) by 1st week, percent had (marked relief) by two weeks, percent had (moderate relict) by three weeks and about 6.52 percent had (mild relief) by four weeks. In Croup - 3 Healing took place in 149 patients with varying degree of duration starting from one week to four weeks. Out of 182 cases 29 patients were dropped out from the study. About 3 I percent patients had healing (complete relief) by 1st week, percent had (marked rei iet) by two weeks, percent had (moderate reliet) by three weeks and about 1.09 percent had (mild relief) by four weeks. (Table- VI) In Croup-l Out of 106 cases who had complete relief, 37 patients fall under the age group yrs, 31 cases under yrs while minimum of 07 cases up to the age of 20 yrs.. Out of 67 cases who had marked relief, maximum cases (20) were in the yrs. age group, while minimum (07) up to the age of 20 yrs. Out of 27 cases who had moderate relief, the number was almost equally distributed in all the age groups. Out of 4 patients who were under No response category, two were in the group up to 20 yrs and one each under & yrs. Relief was found in all of them but recurrence had observed in four cases. InGroup-2 Out of 86 cases who had complete relief, 13 patients fall under the age up to the age of 20, 32 cases under yrs while minimum of 10 cases under the age of 50 & above. Out of 60 cases that had marked relief, maximum cases (25) were in the yrs. age group, while minimum (07) up to the age of 50 & above. Out of27 cases who had moderate relief, the number was maximum (17) in the age group 41-50, while minimum (2) in the group 51 & above. Out of 15 patients who were under mild response category, 09 were in the group 51 & above and three each under & 41-50yrs. InGroup-3 Out of 60 cases who had complete relief, 09 patients fall under the age up to the age of 20, 20 cases under yrs while minimum of 07 cases under the age of yrs. Out of 53 cases who had marked relief, maximum cases (21) were in the yrs. age group, while minimum (03) up to the age of20. Out of 37 cases who had moderate relief, the number was maximum of 11 each in the age groups of & 51 and above while minimum (2) in the group upto to 20 yrs. Out of 2 patients who were under mild response category, 0 I each in the group of 5 I and above and Table-VII InGroup-l Data shows maximum of the Pittaja type of Arsha (47) had complete relief followed by Raktajaa (16) and Kaphajaa 35

8 M. Mruthyumjaya Rao et al. type. Under marked relief category maximum of 25 patients of pittaja type while minimum of 2 cases of Sahaja a type of Arsha. Under No response category 2 cases were found to be of Sanipataja and one each to be of Kaphajaa and Vatajaa type of Arsha. In Group-2 Data shows maximum ofthe Pittaja type of Arsha (37) had complete relief followed by Sannipataja (19) and Raktajaa (16) type. Under marked relief category maximum of 20 patients of pittaja type while minimum of2 cases of Sahaja a type of Arsha. Under moderate response category 10 cases were found to be Vatajaa, 06 in Raktajaa while 04 each to be of Kaphajaa and pittaja type of Arsha. InGroup-3 Data shows maximum of 24 cases of the Pittaja type of Arsha had complete relief followed by Raktajaa(l8) and Sannipataja (08) type. Under marked relief category maximum of 13 patients each of Sannipataja and Raktajaa type while minimum of 3 cases of Sahaja a type of Arsha. Under moderate response category 12 cases were found to be Sannipataja, 07 in Raktajaa while 06 each to be of Vatajaa, Kaphajaa and Pittaja type ofarsha. (iv) Table-VIII In Group-l Analysis was made about the response in reference to the duration of the disease and it shows the maximum number (81) who had complete relief (106) had the duration of illness less than one year. Out of 67 who had marked relief, 39 had illness less than one year followed by 22 cases up to 2 years. Out of 27 cases who had moderate relief, maximum number (17) had the illness less than one year. InGroup-2 The maximum number (61) who had complete relief (86) had the duration of illness less than one year. Out of 60 who had marked relief, 34 had illness less than one year followed by 17 cases up to 2 years. Out of34 cases who had moderate relief, maximum number 17 had the illness less than one year. In Group-3 The maximum number of 46 cases who had complete reliefhad the duration of illness less than one year. Out of 53 cases who had marked relief, 25 had illness less than one year followed by 21 cases up to 2 years. Out of 37 cases who had moderate relief, maximum number of 19 had the illness less than one year. Table-IX InGroup-t A maximum no. of 71 & 37 internal hemorrhoid cases had complete and marked relief respectively and a total of 80 of cases of intero-external hemorrhoids, 33 cases had complete, 23 had marked while minimum of 2 cases had no relief. InGroup-2 A maximum no. of 56 & 47 internal 36

9 EVALUATION OF AYURVEDIC. hemorrhoids cases had complete and marked relief respectively and a total of 63 of cases of intero-external hemorrhoids, 24 cases had complete, 09 had marked, 14 had moderate reliefwhile minimum of 04 cases had mild relief. In Group- 3 A maximum no. of27, 31 & 20 of internal haemorrhoid cases had complete, marked and moderate relief respectively and a total of 83 of cases of intero-external hacmorrhoids, 30 cases had complete, 20 had marked, 17 had moderate relief while minimum of 02 cases had mild relief. Table-X It has also been observed from the study that there is a significant improvement in hemoglobin levels after 45 days of the therapy in all the three groups. Table-I Condition of patients on admission S1.No Condition No. of patients A Age group(in yrs.) Male I Female I Total Upto & above Total 490(74.35) 169(25.64) 659(100.00) B Prakriti of patient No. of patients Vata 243(36.87) Pitta 358(54.32) Kapha 58(8.80) C Bowel habits No. of patients Regular 55(8.34) Constipated 541(82.09) Alternate bowel habits 63(9.55) D Dietary habit No. of patients Vegetarian 31(4.7) Non-vegetarian 628(95.29) 37

10 M. Mruthyumjaya Rao et al. Table-II Characteristics of Arsha / Haemorroids on admission SI.No Incidence I Characteristics No. of patients a) Duration of disease (yr) No. of patients <1 371( 56.29) (27.92) (10.31) >3 36(5.46) b) H/O previous treatment Medical 382(57.96) Surgical 61(9.25) FreshINone 216(32.77) c) Type of Haemorrhoids External 57(8.64) Internal 376(57.05) lntero external 226(34.29) d) Type of Arsha Vatajaa 85(12.89) Pittaja 212(32.16) Kaphajaa 67(10.1 6) Sannipataja 129(19.57) Raktajaa 137(20.78) Sahajaa 29(4.4) e) Position of Haemorrhoids (0' clock) 30 clock 373(56.60) 50 clock 291(44.15) 70 clock 237(35.96) 11 0 clock 308(46.73) 38

11 EVALUATION OF AYURVEDIC... Table-III Clinical features (signs & symptoms) noticed on Admission SI. Symptom Percentage A. Bleeding (659=100%) Profuse/ severe 207(31.41) Moderate 323(49.01) Mild 129(19.57) B. Prolapse of pile masses 246(37.32) C. Itching/ Pruritis 246(37.32) D Discomfort 417(63.27) E. Pain 155(23.52) F. Discharge (mucous) 228(34.59) Table-IV Haemoglobin levels recorded on Admission S1. No G AnaemiafHb levels Severe (Hb%<7 gm.%) Moderate (Hb% 7-10gm) Mild / normalcy (Hb%>10gm%) No. of Patients (%) with mean hemoglobin level Group - 1 I Group - 2 I Group (29.14) 27(12.14) 18(9.89) (mean Hb (mean Hb (mean Hb gm %=6.5) gm %=6.8) gm %=4.5) 156(63.15) 114(49.56) 97(53.29) (meanhb (mean Hb (meanhb gm %=9.8) gm% =8.5) gm %=7.2) 19(7.69) 89(38.69) 67(36.81) (meanhb (meanhb (meanhb gm %=11.5) gm %=10.8) gm %=10.3) 39

12 M. Mruthyumjaya Rao et al. Table-V Speed of Recovery from bleeding and other associated symptoms 51. Result/ No. of patients No Recovery Group - 1 I Group - 2 I Group - 3 Total 1 Complete relief 106 (42.91) 86(37.39) 60(32.96) 252(38.23) by 1 week 2 Marked relief 67(27.12) 60(26.08) 53(29.12) 180(27.31) by 2 weeks 3 Moderate relief 27(10.93) 34(14.78) 37(20.32) 98(14.87) by 3 weeks 4 Mild relief 10(4.04) 15(6.52) 02(1.09) 27(4.09) by 4 weeks 5 No relief 04(0.61) 00(00.00) 01(0.54) 05(0.75) after 4 weeks 6 Drop out / 33(13.36) 35(15.21) 29(15.93) 97(14.71 ) Recurrence 7 Total 247(100.00) 230(100.00) 182(100. '",100.00) CR - Complete Relief, MR - Marked Relief, MDR - Moderate Relief, l'v NR - No Relief, D.O. - Drop out. :v1ild Relief, J Table-VI Speed of recovery according to Age Age Results of the treatment (Percentage) group -.i (in yrs.) CR MR MDR MLR NR DO Total Up to 20 7(2.83) 7(2.83) 3(1.21) 0(00) 2(0.80) 6(2.42) 25(10.12) (14.97) 10(4.04) 6(2.42) 2( (0.00) 3(1.21) 58(23.48) (12.55) 13(5.26) 8(3.23) 1(0.04) 1(0.04) 10(4.04) 64(25.91) 18(7.28) 20(8.09) 7(2.83) 3(1.21) 1(0.04) 7(2.85) 56(22.67) 13(5.26) 17(6.88) 3(1.21) 4(1.61) 0(0.00) 7(2.85) 44(17.81) 106(42.91) 67(27.12) 27(10.93) 10(4.04) 4(0.61) 33(13.36) 247(100.00) 40

13 EVALUATION OF AYURVEDIC... 2 Up to 20 13(5.65) 08(3.47) 0(0.00) 0(0.00) 0(0.00) 06(2.60) 27(11.73) (13.91) 9(3.91) 5(2.17) 3(1.30) 0(0.00) 4(1.73) 53(23.04) (6.52) 25(10.86) 10(4.34) 0(0.00) 0(0.00) 5(2.17) 55(23.91) (6.95) 11(4.78) 17(7.39) 3(1.30) 0(0.00) 1(0.43) 48(20.43) 51 & 10(4.34) 7(3.04) 2(0.86) 9(3.91) 0(0.00) 19(826) 47(20.43) above Total 86(37.39) 60(26.08) 34(14.78) 15(6.52) 0(0.00) 35(15.21) 230(100.00) 3 Up to 20 9(4.94) 3(1.64) 2(1.09) 0(0.00) 0(0.00) 9(4.94) 27(14.83) (3.84) 14(7.69) 11(6.04) 1(0.54) 0(0.00) 3(1.64) 53(29.12) (10.98) 21(11.53) 5(2.74) 0(0.00) 1(0.54) 4(2.19) 45(24.72) (7.69) 7(3.84) 8(4.39) 0(0.00) 0(0.00) 2(1.09) 48(26.37) 51 & 10(5.49) 8(4.39) 11(6.04) 1(0.54) 0(0.00) 11(6.04) 35(19.23) above Total 60(32.96) 53(29.12) 37(20.32) 2(1.09) 1(0.54) 29(15.93) 182(100.00) Table-VII Speed of recovery according to type of Arsha Group Type of Results of the treatment (Percentage) Arsha CR MDR I ~R I I MLR I NR Total DHO I I A B C E F G I Vatajaa 9(3.64) 5(2.02) 8(3.23) 3(1.21) 1(0.04) 4(1.61) 30(12.14) 1 Pittaja 47(19.02) 25(10.12) 6 (2.42) 1(0.04) 0(00) 12(4.85) 91(36.84) Kaphaiaa 14(5.66) 9(3.64) 2 (0.80) 0(0.00) 1(0.04) 0(0.00) 26(10.52) Sannipataja 10(4.04) 11(4.45) 4 (1.61) 5(2.020) 2(0.80) 9(3.64) 41(16.59) Raktaiaa 16(6.47) 15(6.07) 7 (2.83) 1(0.04) 0(00) 6(2.42) 45(18.21) Sahaja a 10(4.04) 2(0.80) 0(0.00) 0(0.00) 0(0.00) 2(0.08) 14(5.66) Total 106(42.91) 67(27.12) 27(10.93) 10(4.04) 4(0.61) 33(13.36) 247(100.00) A I B C D E F G H I 2 Vataja 5(2.17) 5(2.17) 10(4.34) 4(1.73) 0(0.00) 4(1.73) 28(12.17) Pittaja 37(16.07) 20(8.69) 4(1.73) 6(2.60) 0(0.00) 6(2.60) 73(31.73) Kaphaia 7(3.04) 12(5.21) 4(1.73) 01(0.43) 0(0.00) 0(0.00) 24(10.43) Sannipataja 19(8.26) 5(2.17) 8(3.47) 01(0.43) 0.(0.00) 14(6.08) 47(20.43) Raktaja 16(6.95) 16(6.95) 6(2.60) 01(0.43) 0(0.00) 9(3.91) 48(20.86) Sahaja 2(0.86) 2(0.86) 2(0.86) 2(0.86) 0(0.00) 2(0.86) 10(4.":'4). - Total 86(37.39) 60(26.08) 34(14.78) 15(6.52) 0(0.00) 35(15.21) 230(100.lJe 3 Vataja 5(2.74) 6(3.29) 6(3.29) 1(0.54) 1(0.54) 8(4.39) 27(14.83) Pittaja 24(13.18) 8(4.39) 6(3.29) 0(0.00) 0(0.00) 8(4.39) 48(26.37) Kaphaja 3(1.64) 10(5.49) 6(3.29) 0(0.00) 0(0.00) 0(0.00) 17(9.34) Sannipataja 8(4.39) 13(7.14) 12(6.59) 1(0.54) 0(0.00) 7(3.84) n(22.52) Raktaja 18(9.89) 13(7.14) 7(3.84) 0(0.00) 0(0.00) 6(3.29) 44(24.17) Sallaja 2(1.09) 3(1.64) 0(0.00) 0(0.00) 0(0.00) 0(0.00) 5(2.74) Total 60(32.96) 53(29.12) 37(20.32) 2(1.09) 1(0.54) 29(15.93) 182(100.00) 41

14 M. Mruthyumjaya Rao et al. Table-VIII Speed of recovery according to the duration of the illness Group Duration Results of the treatment ( Percentage) of illness CR MR MDR MLR NR DO Total (in yrs.) Upto1 81(32.79) 39(15.78) 17(6.88) 4(1.01) 1(0.40) 8(3.23) 150(60.72) (7.28) 22(8.9) 7(2.83) 4(1.61) 2(0.80) 9(3.67) 62(25.10) 2-3 3(1.21) 3(1.21) 2(0.80) 2(0.80) 0(0.00) 15(6.07) 25(10.12) 3& above 4(1.61) 3(1.21) 1(0.40) 0(0.00) 1(0.40) 1(0.40) 10(4.04) Total 106(42.91) 67(27.12) 27(10.93) 10(4.04) 4(0.61) 33(13.36) 247(100.00) 2 Upto1 62(26.95) 34(14.76) 17(7.39) 4(7.39) 0(0.00) 4(1.73) 121(52.60) (6.95) 17(7.39) 9(3.91) 7(3.04) 0(0.00) 16(6.95) 65(28.26) 2-3 4(1.73) 5(2.17) 6(2.60) 3(1.30) 0(0.00) 8(3.47) 25(10.86) 3& 4(1.73) 4(1.73) 2(0.86) 1(0.43) 0(0.00) 7(3.04) 19(8.26) above Total 86(37.39) 60(26.08) 34(14.78) 15(6.52) 0(0.00) 35(15.21) 130(100.00) Upto1 46(25.27) 25(13.73) 19(10.43) 0(0.00) 0(0.00) 10(5.49) 100(54.94) (6.04) 21(11.53) 16(8.79) 0(0.00) 1(0.54) 8(4.39) 57(31.31) 2-3 2(1.09) 5(2.74) 2(1.09) 1(0.54) 0(0.00) 4((2.19) 18(9.89) 3& 1(0.54) 2(1.09) 0(0.00) 1(0.54) 0(0.00) 4(2.19) 7(3.84) above Total 60(32.96) 53(29.12) 37(20.32) 2(1.09) 1(0.54) 29(15.93) 182(100.00) Table-IX Speed of recovery according to the type of Haemorroids Group Type of Results of the treatment (Percentage) haemorroid CR 1 MR -, MDRl MLR' NR, DO, Total External 2(0.80) 7(2.83) 6(2.42) 1(0.40) 1(0.40) 10(4.04) 27(10.93) 1 Internal 71(28.79) 37(14.97) 15(6.07) 4(1.61) 1(0.40) 12(4.85) 140(56.68) Intero-ext. 33(13.36) 23(9.31) 6(2.42) 5(2.02) 2(0.80) 11(4.45) 80(32.88) Total 106(42.91) 67(27.12) 27(10.93) 10(4.04) 4(0.61) 33(13.36) 247(100.00) External 6(2.60) 4(1.73) 2(0.86) 2(0.86) 0(0.00) 6(2.60) 20(8.69) 2 Internal 56(24.34) 47(20.43) 18(7.83) 9(3.91) (7.39) 147(63.91) Intero-ext. 24(10.43) 9(3.91) 14(6.08) 4(1.73) (5.21) 63(27.39) Total 86(37.39) 60(26.08) 34(14.78) 15(6.52) 0(0.00) 35(15.21) 130(100.00) 42

15 EVALUA TlON OF A YURVEDIC... External 3(1.04) 2(1.09) 0(0.00) 0(0.00) 0(0.00) 5(2.74) 10(5.49) 3 Internal 27(14.83) 31(17.03) 20(10.98) 0(0.00) 1(0.54) 9(4.94) 89(48.90) Intero-ext. 30(16.48) 20(10.98) 17(9.34) 2(1.09) 0(0.00) 15(8.24) 83(45.60) Total 60(32.96) 53(29.12) 37(20.32) 2(1.09) 1(0.54) 29(15.93) 182(100.00) Table-X Improvement in the Hemoglobin level Group Level of Hemoglobin gm % on After 30 days After 45 days. Hbgm% admission Hbgm % Hbgm% <7gm.% 72(29.14) IS( 6.07) 4(1.61) (mean=6.s) (mean=6.8) (mean=6.2) 7-10gm.% IS6(63.1S) 193 (78.13) 138(SS.87) (mean=9.8) (mean=9.6) (mean=9.4) >10gm.% 19 (12.S) 39 (IS.78) I OS(42.S1) (mean=ii.s) (mean=11.01) (mean=i1.3) <7gm.% 27(12.14)) 20(8.69) 14(6.08) (mean=6.8) (mean=6.9) (mean=6.2) 7-10gm.% 114(49.S6) 112 (48.69) 87(37.82)) (mean=8.s) (mean=8.9) (mean=8.7) >10 gm.% 89 (38.69) 98 (42.60) 129(S6.08) (mean= 1O.S) (mean=1o.3 ) (mean=10.8) <7gm.% 18(9.89) 12(6.S9) 7(3.84) (mean=4.s) (mean=s.8 ) (mean=6.9) 7-10gm.% 97(S3.29) 138(7S.82)) 161(88.46) (mean=7.2) (mean=8.s) (mean=9.8) >10 gm.% 67(36.81 ) 32(17.S8) 14(7.69) (mean=10.3) (mean= 11.00) (mean=13.s) Discussion The diagnosis of Arsha is simple but the choice of treatment is difficult, because one therapy can not be said to be applicable to all the type of ArshalHaemorroids, which is capable to cure the disease. The disease itself has diverse manifestations and accordingly the treatment has got to be based on individual merits. 'Burkitt' (1977) conducted an epidemiological study and reported that "when traditional diet in a community gives way to more refined foods; the incidence of haemorrhoids always rises before that of varicose veins". In the present study also it was found about 95.29% patients were non-vegetarians and were very fond of spicy, fast foods etc. Secondly, the Hemorrhoids are 43

16 M. Mruthyumjaya Rao et aj. regarded as a surgical disease. The fact that so many operative and para-surgical techniques now-a- days are in vague themselves prove that there is no standard treatment procedure available in the treatment of Arsha. Kaseesadi Taila for per rectal application will help in producing a soothing effect and will help easy descent of the faecal column. This process should be carried out half an hour before defecation daily irrespective of whether the patient moves his bowels once or twice. The main ingredient is Kaseesa (Cu SOJ and due to its Vrana Ropana & Sodhana properties, it heals the eroded portion of the haemorroid vessels and facilitates & promotes quick healing. Both Kankayan Vati and Kravyadi Ras improves the digestive fire, reduces the Ama formation. Since the root cause of the disease mentioned in Ayurveda is Ama or metabolic disturbances, Kanakayana Vati was selected in order to eliminate or treat the basic cause i.e. amadosha to achieve the ultimate/better results of the treatment. Some drug is needed to take care of patients evacuatory process especially who have chronic or habitual constipation which is regarded as one of the major causes for the disease, hemorrhoid bleeding. So Triphala Churna was selected for its laxative action on the bowel. Since the earlier studies revealed the refined foods, fast foods and non veg. diet rises the incidence of haemorroid bleeding, the patients were kept on Milk, rice diet and plenty of liquids which also helps in the prevention of the recurrence. On the basis of the results of this single blind clinical trial in all the groups, the results were shown in Group - I & 2 appears better than that of Group - 3, which clearly indicates that adding more medicines keeping the symptomatology or the aetiopathogenesis in mind makes no difference but expensive and difficult to take all the medicines. The study gives an impression that even using either Kankayana Vati or Kravyadi Rasa orally apart from local application of Kaseesadi Taila and a laxative may not be having additional benefit. The difference in results among the both groups i.e group - 1 & 2 were very minimum and negligible and hence it is concluded that the drug combination tried in both the groups were similarly effective in the management of Arsha. Acknowledgement The authors are highly indebted to the Director, CCRAS, New Delhi for his financial and technical support. We are also thankful to the patients who gave their consent to can)' out the study. 44

17 EVALUATION OF AYURVEDIC. References Anderson H.G Burkitt 1972 Fielding L.P. Sharma S.K. et al: Sharma B. N 1999 Stanely.M.Goldburg 1980 Susruta, Susruta Samhita Watts,J.M The after results of the operative treatment of Hemorrhoids pre.med.j.2: Varicose vein, Deep Vein thrombosis and Hemorrhoids (Epidemiology and Suggested Etiology,) Br.MJ.2,556 Management of patients with symptomatic Hemorrhoids an introduction - (page ) "Kshara sutra.therapy in Fistula-in-Ane and other Ano rectal diseases" Rastreeya Ayurveda Vidyapeeth publication, New Delhi Ayurvedic management of Arsha (Hemorrhoids) - CCRAS publication Rob & Smith- Operative surgery Lippin cott company-4th edition. Annals ofano - Rectal Surgery, J.P. publication (commentary by Ambika dutta Sastri), Chawkamba Sanskrit Series Office, Varanasi. A controlled study of pain after different forms of Haemorrhoidectomy, Surg,gynoec, obstet.120:

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