Introduction

Ayurveda, the science of life, is a comprehensive system of health based on experiential knowledge and grown with perpetual additions. Our life style is changing, so as nature, which has great reflection in our health.

The symptoms of fissure-in-ano are pain in the anorectum, bleeding, spasm that corelate with Parikartika. Fissure is defined as a longitudinal ulcer and when this ulcer occurs in the anal skin it is termed as fissure- in-ano. There are two varieties in fissure in ano one is anterior and another is posterior fissure in ano. On the basis of the clinical symptoms the disease Fissure in ano has been classified in two varieties Acute and Chronic. In acute fissure there is inflammation of anal mucosa is present with cutting and burning pain while in chronic fissure along with fissure groove there is any external or internal hemorrhoid or sentinel tag may be present. [1]

In Ayurveda literature regarding Parikartika is found in very scattered manner. In Samhitas the description of Parikartika available is very short. Kashyap has described Parikartika (fissure in ano) in topic of “Garbhini Vyapada”, Kashyap has also described its treatment. In Kashyap Samhita the Parikartika described in view of a pregnant woman and described the disease according to involvement of Doshas. In Charak Samhita in Siddhishtana Charak has mentioned Parikartika as a complication of Virechana [2] and Niruha Basti.[3] Description of Parikartika also found as a complication of various diseases like Vataj Pakwa Atisar,[4] Kaphaja Arsha,[5] Udavarta [6] in Garbhini, [7] Unlawful use of purgatives [8] Sahaj Arsha,[9] Vataj Jwara [10] Arsha Purvarupa.[11] In similar manner Acharya Kashyap has described it in three types viz. Vataja, Pittaja, Kaphaja. Acharya Sushrut while describing the symptoms of Parikartika he has mentioned the features like cutting or burning pain in anus, penis, umbilicus and neck of bladder with cessation of flatus whereas Charak has described the features like pricking pain in groins and sacral region, scanty constipated stools and frothy bleeding from anus.

According to Acharya Charak the people living in Jangama Pradesha are having Ruksha Prakruti because of the climate and they have dry food that vitiates Vata and produces Vibandha or constipation.

Aim and objective- Detailed Ayurvedic review of Parikartika Vyadhi (Fissure in Ano)

Material & method: References regarding Parikartika and its Chikitsa were collected from Bruhatrayi, Laghutrayi Modern textbooks and Research articles and analysed them.

Review of Literature:

Definition of Parikartika:

Parikartika denotes ‘Kartanvat Vedana’ i.e., cutting type of pain around the Guda region. According to Dalhan there is cutting and tearing type of pain everywhere. [12] While Jejjata[13] mentioned that there is cutting type of pain of the Guda which is localized up to a particular area. Kashyap has also supported the above definition of Parikartika.

Hetu of Parikartika

The Doshas in state of Chayavastha progress to Prakopam due to etiological factors described in Sarvaroganudana. Thus, Vata Dosha vitiates due to dietary factors including Tiktaushana Kashayalpa Bhojana, Shodhana therapy, diurnal and seasonal variations. The causes for Pitta Dosha vitiations are Katu, Amla, Lavana Ahara, Vidahi Ahara etc. Vihara such as Kopa (anger) is also due to diurnal and seasonal variations. Kapha Dosha get vitiates due to dietary factors such as Svadu, Amla, Lavana Ahara, etc. Vihara such as sleeping in day time etc.

We can divide accordingly as below:

1. Vyadhinimittaja: produced after a disease or during the stage of disease.

2. Vaidyanimittaja: produced by Vaidya due to wrongful conduction of therapy or medicine as mentioned by Sushruta. [14]

Rupa of Parikartika:

The prodromal symptom in the word of Sushruta, is the pain of sharp cutting nature in the Guda. Acharya Sushuta further described in chapter Vaman-Virechan Vyapada, there is sort of cutting pain, sawing pain in the anus, penis, umbilical region and the neck of urinary bladder. The emission of the flatus is arrested the Vayu is incarnated in the abdomen relish for the food vanishes. Constipation may be habitual or due to disease. Vaghbhat has described same sign and symptoms as described by Charak and Sushrut. Vrana is an essential symptom of Parikartika having Deerghakruti shape. A Strava resembling may be present.

Samprapti:

The structural and functional integrity of the human body is maintained by Tridoshas in their state of equilibrium. But they are always susceptible to imbalance and vitiation. When Asatmendriya Sanyoga, Pragnaparadha and Parinama influence this imbalance of Doshas, a Morbidisation process begins and it undergoes six stages known as Kriyakala. They are Chaya, Prakopa, Prasara, Sthansanshraya, Vyakti and Bheda. During this stage’s disease is manifested. The Dosha undergoes Chaya as normal physiological response to various endogenic and exogenic stimuli. When the person continues to use the specific etiological factors mentioned for the vitiations of the Doshas, they undergo vitiations and Agni-Vaishamya also occurs, which causes Avipaka and Malasanchaya, resulting in vitiations of Apana Vayu. This progress to subsequent stage Prasaravastha and the Doshas migrates throughout the body through Pradhansiras. At this condition when the person uses Nidana, the small strotas of Gudavalis undergoes pathologic changes and Dosha Dushya Sammoorchana localizes here and further changes occurs. During this process disease manifestation occurs.

In this disease Vatakopa is predominant with associated pitta. The localization of Doshas occurs in Twak between Payudwaram and Gudaustha. As a result of the pathogenesis, the Twak becomes Ruksha and shows tendency to crack. Sushrut and Vagbhat have vitiates from the skin. The peculiar anatomical structure of this area also plays an important role in the manifestation of this disease. The Twak over this area is devoid of hairs, sebaceous gland and sweat glands which are normally present in the skin. This indicates that, this area is more Ruksha in normal individuals, which is further aggravated during the pathology predominant to Vata.

Types of Parikartika:

The detailed description of Parikartika has not been found in Ancient Ayurvedic Samhitas except Kashyap Samhita. Acharya Kashyap has described the three types of Parikartika. This classification is based upon the character of pain which is prominent feature of the Parikartika.

The classification is as follows:

1. Vatika Parikartika: In this type patient complaining shooting, cutting or pricking type of pain due to Vata predominance. [15]

2. Paittika Parikartika: In this type patient complaining burning type of pain due to predominance of pitta. [16]

3. Kaphaja Parikartika: Due to predominance of Kapha patient complaining of itching type of pain. [17]

Sadhyasadhyata

Generally, Vrana in Payu is easily curable.[18] If a Vrana is left untreated, as a consequence it may lead to Yapyatwa stage and finally leading to Asadhyatwa stage. Parikartika which affects the superficial layer of the Twak (anal skin) are easily curable in short time. Therefore, it can be included in the Sukhasadhya group. If it affects the deeper layers, it deals wound healing. If it is associated with Madhumeha, Kustha, Vishodusti and Sosha, the healing of Vrana will be delayed. If Parikartika is associated with Sanniruddha Guda, it is considered as Yapya.[18] In Astanga Samgraha some Arista Lakshana mentioned in relation to Parikartika [19]

a) When Parikartika is formed due to Amashaya cause and associated with severe thirst and Sakrutabheda.

b) When Parikartika is formed due to Pakvashaya cause and associated with severe thirst and Gudagraha.

Treatment of Parikartika:

Ancient Ayurvedic Acharayas described Parikartika as a disease in a very short manner. They have described its treatment in brief. Only Acharya Kashyap has described its treatment along with Doshik type of classification. It is interesting to note that none of the ancient authors have mentioned its surgical management. They may be treating this disease by the use of medicinal preparations only. According to Modern science the fissure-in-ano is cured by the surgical management. But this type of management sometimes leads to other complications. According to Ayurveda there are various drugs of different properties which will be useful for treating the diseases. According to the uses of medicines it is further divided in two parts.

Local i.e., Sthanik and General i.e., Abhyantara

1. Local or Sthanik Chikitsa: According to Ayurveda this type of treatment is Basti karma (enemas). These Bastis are particularly prepared in Ghrita and milk with the help of other different drugs. The drugs used in preparing basti are mostly Vata- Pitta Shamak and Vrana Ropaka properties. Acharya Sushruta and other Samhitakar described three types of Basti i.e., Anuvasana Basti, Pichha Basti and Sheetal Basti.

The Pichhabasti is prepared mainly from mixing of Yashtimadhu and paste of Sesamum and dissolved in clarified butter and honey. Anuvasanabasti containing Ghrita and cream of clarified butters should be given in predominance of Pitta Dosha. The Basti employed with oil cooked with Yashtimadhu.

Acharya Charak has fully supported to Acharya Sushruta. He also described that cooling enema consisting of the drugs having Madhur and Kashaya properties prepared with Madhuyashti powder and Kwath (Decoction) should be used in Pichha and Anuvasanabasti. [20] He has also mentioned for the administration of cooling enema containing milk prepared with sweet and cooling drugs such as sugarcane etc. and it has been also mixed with liquorice, Ral, mud of Kamal and Raswat. He has also mentioned that the above all Basti Karma procedure should be done by expert Vaidya. If these procedures are not done by expert, then it is possible to give rise the complication such as Parikartika which have been mentioned already in the etiology of this disease. Acharya Sushrut has mentioned the Anuvasan basti containing Madhuyashti, Khusa, Gambhari, Kutki, Kamala, Chandan, Shyama, Padmaka, Zeemutak, Indrayava, Ateesh, Sugandh, BalaTail, Ghrita, Milk and decoction of Nyagrodhadigana for treating the Parikartika complications which are formed during Vaman- Virechan and Basti Karma.

Acharya Charak described the Basti which is prepared mainly from Kashaya Rasa Sheeta Virya and Madhur Vipaka drugs. [21] The all are mixed with Ghrita and milk and given to the patient. [22][23] Kashyap has also advised for the Anuvasana Basti in the treatment of Parikartika. [24][25] Thus, all the ancient Acharya mentioned the basti either Vata Shamak or pitta Shamak properties. In those combinations of basti they advised mainly for Madhuyashti, Ghrita and oil of Sesamum Kashaya rasa and sheeta virya drugs. Because all the drugs have the property of anti-bacterial, cooling, Vata, Pitta Shamak, anti-inflammatory and it has been advocated by Sushruta for the treatment of traumatic wounds, Doshjanaya Vrana, Asthibhagana, Updansha and Visarpa etc. Both Charaka and Sushruta have described Pichhabasti for the treatment of Parikartika containing Madhuyashti, Madhu and Til. Acharya Charaka has described Sheetalbasti or a cold enema containing Yashtimadhu, Vruntta, Shriparni, Kovid, and Kadamb should be prepared in milk with honey and sugar.

2. Abhyantar Chikitsa: In this type of treatment drugs are administered through oral route to treat the vitiated dosha, others are used as laxative and some drugs are used for increasing the Agni-deepan i.e., digestive fire. [26] They have also advised Tridosh-Shamaka as well as Shothahar drugs. In the case of Parikartika, pain and constipation are the main presenting symptoms. If someone corrects the constipation and subside the pain by using the oral preparation the disease may be cured in very short period. Pain is due to Vatta and Pitta Vitiation and Constipation is due to habitual or fear of pain during defaecation which results in constipation. Due to these above reasons Acharya Sushruta has advised cold water bath and milk for oral administration.Acharya Charak has also supported the above description and also mentioned that to take Amlarasa Pradhandravya because it has Vatashamaka property and also these drugs are useful in Agni deepan. Most of these Amla Rasa dravya are containing ascorbic acid which is vitamin ‘C’ and helpful in healing and increase the body resistance also. According to Acharya Charak if Parikartika present with Jwar, then patient should be given the Yusha containing heart shaped leaves of side, fruits of kokum, sour jujube, bel fruit etc.

Discussion

Because of location, nature of pathology and features, Parikartika can be correlated to Fissure-in-ano. The detail description about Hetu (etiology), Samprapti (pathogenesis), Rupa (symptoms) and Chikitsa (treatment) is mentioned in ancient literatures like Sushrut Samhita, Kashyap Samhita, Astanga Hridaya etc. There is detail description about Bahya and Abhyantar Chikitsa for Parikartika.

Conclusion

Improper dietary Habits and stressful life is found to have predisposed the high incidence observed today. Passage of constipated hard stools is the major cause of tear in the lower anal canal which results in agonizing (KARTANVAT PIDA) pain during and after defecation, the cardinal feature of Fissure-in-ano. There are various complications which arise after modern conventional treatment. Ayurvedic treatment is proved to be effective and it prevents the chances of conversion of acute fissure to chronic fissure. The main goal of Ayurveda treatment for Parikartika is to relieve the sphincter spasm, pain, associated burning sensation, bleeding and promote healing of fissure wound Ayurvedic preparations use in form of Bahya (Local) as well as Abhyantar Medications are all effective and these can cure fissure and regularize bowel in most of cases of acute fissures. These could always be offered to the patients who wants to go for conservative management only.