“ayurveda vachaspati”
TRANSCRIPT
“A CLINICAL STUDY OF YASHTIMADHU GHRITHA PICHU IN THE
MANAGEMENT OF PARIKARTIKA w. s. r. to FISSURE-IN-ANO ”
BY
DR.VEERESH .B. SATTIGERI
Dissertation submitted to
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore
In partial fulfillment Of the requirements for the degree of
“AYURVEDA VACHASPATI”
(M.S. AYURVEDA)
In
SHALYA TANTRA
Under the Guidance of
DR. CHETAN KARDALE
M.S (AYU)
READER OF P G STUDIES IN SHALYA TANTRA
DEPARTMENT OF POST GRADUATE STUDIES IN SHALYA TANTRA RAJIV GANDHI EDUCATION SOCIETY’S AYURVEDIC MEDICAL COLLEGE, HOSPITAL; P.G.STUDIES
AND RESEARCH CENTER, RON-5822O9 DIST:-GADAG (KARNATAKA-582114)
2014-2015
CERTIFICATE BY THE GUIDE
This is to certify that the Dissertation entitled “A CLINICAL
STUDY OF YASHTIMADHU GHRITHA PICHU IN THE MANAGEMENT OF
PARIKARTIKA w. s. r. to FISSURE-IN-ANO ” is a bona fide research work done by
Dr.VEERESH SATTIGERI in partial fulfilment for the degree of Ayurveda
Vachaspati, Master of Surgery (Ayurveda) in Shalya tantra of the Rajiv Gandhi
University of Health Sciences, Bengaluru.
I recommend this dissertation for the above degree to the
University for Assessment and approval.
Signature of the Guide
Dr .CHETAN CARDALE
M S (Ayu)
Reader
Department of Post Graduate Studies in Shalya tantra
Rajivgandhi educational societies’s Ayurvedic medical
College & pg research centre, ron - 582209
Date :
Place :
ENDORSEMENT BY THE HOD,
PRINCIPAL/HEAD OF THE INSTITUTION
This is to certify that the Dissertation entitled “A CLINICAL STUDY OF
YASHTIMADHU GHRITHA PICHU IN THE MANAGEMENT OF PARIKARTIKA
w. s. r. to FISSURE-IN-ANO” is a bona fide research work done by Dr. VEERESH
SATTIGERI under the guidance of Dr.CHETAN CARDALE Reader Department
of Postgraduate Studies in Shalya tantra, RAJIVGANDHI EDUCATIONAL
SOCIETIES’S AYURVEDIC MEDICAL COLLEGE & PG RESEARCH CENTRE,
RON - 582209
Signature of the Guide
Dr.CHETAN KARDALE (Ayu) Reader Department of Post Graduate Studies in Shalya tantra Rajiv Gandhi educational societies’ ayurvedic medical
College & pg research centre, Ron - 582209
Signature of the Principal
RAJIVGANDHI EDUCATIONAL SOCIETIES’S
AYURVEDIC MEDICAL COLLEGE & PG RESEARCH
CENTRE, RON - 582209
Date: Date:
COPYRIGHT
Declaration by the candidate
I hereby declare that the Rajiv Gandhi University of health Sciences,
Karnataka shall have the rights to preserve, use and disseminate this dissertation in
print or electronic format for academic/ research purpose.
Signature of the candidate
Dr. VEERESH .B .SATTIGERI
Date: Place:
© Rajiv Gandhi University of Health Sciences, Karnataka
LIST OF ABBREVIATIONS USED
SYMBOLES USED IN MASTER CHART
AT AFTER TREATMENT
BT BEFORE TREATMENT
P PROBABILITY
SD STANDERD DEVIATION
T T TEST
> MORE THEN
< LESS THEN
0,1,2,3 GRADE OF SEVERITY
AB -ASTANGA SANGRAHA BP -BHAVA PRAKASHA BR -BAISHAJA RATNAVALI CS -CHARAKA SAMHITA CD -CHAKRA DATTA SU -SUTRA STHANA CHI -CHIKISTASTHANA NI -NIDANA STHANA SH -SHAREERA STHANA CK -CHAKRAPANI DL -DALANA HS -HARITA SAMHITHA GN -GADANIGRAHA
ACKNOWLEDGEMENT
It is because of God’s grace that the work could be completed as per my expectation. I
bow my head to Lord Ganesh and Lord Dhanvantari for his divine inspiration and
support.
Words are not enough to express my gratitude and indebt to the sacrifices of my
beloved Late Shri Veerupakshappa & Smt. Iramma and respected parents Shri
Basavraj Smt. Neelamma, my family members Shri Ashok sattigeri (Advocate) ,
smt surekha and other family members for supporting, blessing, praying and standing
by me in all situations of my life.
It is my inexplicable pleasure to offer my salutations to Shri . G S PATIL ,m l a govt
of Karnataka founder of this institution for his blessings, which made me to complete
my thesis without any hurdles High on the list to which I owe my indebtedness, it
gives me immense pleasure and proudness to offer profound gratitude to my beloved
principal Dr.Iranna kotturashetter for his love, motherly care, benevolent guidance
and encouragement ensured the successful completion of the work.
I am extremely thankful to Prof. Dr.Ravikumar Arahunasi dept of
kayachikista Research Studies, R G E A M C H Ron for his valuable suggestions and
timely guidance. Mere words would not be enough for the deep sense of gratitude and
respect I hold for my esteemed tanks to Dr.Ravikumar Arahunasi their inspiration,
guidance, encouragement and expertise throughout my career.
I would like to express my deep sense of gratitude to DR.Subbaraju , Professor &
H.O.D., Dept. of P.G. studies in Shalya Tantra, R G E A M C H Ron, who became a
source of light and provided necessary fuel for my innovative thoughts I am deeply
indebted for his blessings, guidance, advice, broadmindedness and encouragement
placed me where I am today.
The inspiring force throughout this research work was my guide Dr.Chetan kardale
Reader., Department of P.G.Studies in Shalya TantraR G E A M C H Ron , for his
scholarly guidance and suggestions to complete this work.I extend my thanks to
DR.KUMAR for their co-operation encouragement and timely suggestions provided
to me. Nevertheless I am grateful to each one of them I cannot forget the guidance of
Dr. M R Hunagundi and Dr.Shivakumar patil.. which gave me confidence to get
along my work. I am thankful to my classmates, seniors & juniors Co-operation and
support It would be invidious to name a few friends, when many have helped me
DR.VEERESH SATTIGERI
ABSTRACT
“A CLINICAL STUDY OF YASHTIMADHU GHRITHA PICHU IN THE
MANAGEMENT OF PARIKARTIKA w. s. r. to FISSURE-IN-ANO ”
The research work was aimed to evaluate the efficacy of Yashtimadu Ghrita picchu
and Yashtimadu-Ghrita picchu and Abhayarista,Gandaka rasayana in the management
of Parikartika (Fissure – In -Ano).
It was comparative clinical study .The age limitation was 20 – 60 years. 40 patients
were taken for the study, 20 patients in each group A & B. Both the groups were
advised strict fiber rich diet, exercise and plenty of fluid intakes.
The study period was 7 days and follow up for 2 months Observations were recorded
in the concerned proforma on every month Observations were statistically analyzed
with pairedt- test. Group A showed statistically highly significant result as in both the
Group B also have same effect.but there is no significant result of constipation This
study concludes that in Parikartika (Fissure – in - ano), Yashtimadu Ghrita appears to
be effective in reducing signs & symptoms in both Groups And is cost effective, easy
to prepare and without any adverse effect.
Key words: - Yashtimadu Ghrita picchu,Abhayarista,Gandaka rasayana , Parikartika
TABLE OF CONTENTS SL NO CONTENTS PAGE NO
1 INTRODUCTION 01 to 03
2 OBJECTIVES 04
3 REVIEW OF LITERATURE 05 to 67
4 DRUG REVIEW 68 to 85
5 MATERIALS & METHODS 86 to 92
6 OBSERVATIONS & RESULTS 93 to 122
7 DISCUSSION 123 to 136
8 CONCLUSION 137 to 139
9 SUMMARY 140 to 143
10 REFERENCES AND BIBLIOGRAPHY 156 to 167
11 ANNEXURE( CASE SHEET PERFORMA) 144 to 155
LIST OF TABLES
SL
NO
LIST OF TITAL PAGE NO
1 Relation of Anal canal 5 to 14
2 Chemical composition of wet 100gms Yashtimadu contains 71
3 Pharmacological properties & Action of Yashtimadu 71 to 72
4 Pharmacological properties & Action of Gruthamurchana drugs 73 to 79
5 Pharmacological properties & Action of Go-gritha 79 to 81
6 Age wise distribution 93 to 94
7 Sex wise distribution 94 to 95
8 Socio economic status wise distribution 96
9 Diet wise distribution
97
10 Religion wise distribution 98
11 Occupation wise distribution 99 to 100
12 Incidence of Habitat 101
13 Distribution of patients in relation to Previous Surgery 101 to 102
14 Bleeding per rectum wise distribution 103
15 Constipation wise distribution 103 to 104
16 Pain wise distribution 105
17 Burning sensation wise distribution 106 to 107
18 Size of the ulcer in anal region wise distribution 108
19 Sphincter spasm wise distribution 109
20 Proctitis wise distribution 110
21 Distribution of patients in relation to Associated Lesions 106 to 107
22 Distribution of patients in position of fissure in ano. 107
Group A
23 Assessment of Sign & symptom before treatment & after
treatment
108 to 109
24 Assessment of Sign & symptom before treatment & after fallow up
110 to 101
Group B
25 Assessment of Sign & symptom before treatment & after treatment
112
26 Assessment of Sign & symptom before treatment & after
fallow up
115
27 Evaluation of pain between two groups 115 to 116
28 Evaluation of bleeding between two groups 117 to 118
29 Evaluation of burning sensation between two groups 119 to 119
30 Evaluation of constipation between two groups 120
31 Evaluation of ulcer between two groups 121
32 Evaluation of sphincter spasm between two groups 122
33 Evaluation of proctitis between two groups 122
LIST OF GRAPHS
LIST OF FIGURES
Sl no Tital of page Page no
1 Guda Valli and Spaces 37
2 Interior of anal canal 38
3 Musculature of anal canal 38
4 C.S. Rectum and anal canal 41
5 Blood supply 42
6 Venous supply 43
7 Before treatment 84
8 After treatment 85
Sl no Title page Page no
1 Age wise distribution 94
2 Sex wise distribution 95
3 Diet wise distribution 96
4 Occupation wise distribution 97
5 Religion wise distribution 100
6 Habitat wise distribution 101
7 Distribution of patients in relation to Previous Surgery 102
8 Bleeding per rectum wise distribution 103
9 Pain wise distribution 105
10 Burning sensation wise distribution 106
11 Constipation wise distribution 104
12 Size of Ulcer in anal region wise distribution 107
13 Sphincter spasm wise distribution 108
14 Proctitis wise distribution 109
15 Distribution of patients in position of fissure in ano 107
16 Overall effect of therapy wise distribution 116 to 122
Introduction.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 1
INTRODUCTION
Health is a precious possession. Wisdom and art, strength and wealth are of no use if
health is lacking. The surgeon must therefore strive to maintain or to restore his
patient’s health. Experience is of the utmost value but limits are imposed upon
medical skill. The best surgeon is who can distinguish the possible from the
impossible and avoid surgery. In the era of fast food, there is change or irregularity in
diet and diet timings and alsosedentary life style. In addition to change in diet and life
style, one is always under tremendous mental stress. All these causes disturb in
digestive system which results in to many diseases amongst them ano-rectal disorder
constitute an important group.
On the basis of the clinical symptoms the disease fissure-in-ano has been
classified into two varieties; viz. acute fissure-in-ano and chronic fissure-in ano.
Either acute or chronic, pain or bleeding is the two main symptoms of this condition;
pain is sometimes intolerable. In long standing cases it may be associated with
haemorrhoids or a sentinel tag. Pruritis ani may be another symptom of this condition.
On the basis of symptoms, the disease fissure-in-ano can be compared to the disease
Parikartika according to Ayurveda, Parikartika / Fissure in ano is very common and
painfulcondition.
Acharaya Dalhana has described the term Parikartika as a condition of Guda
in which there is cutting pain and tearing pain. Similarly Jejjata and Todara have
clearlydescribed Parikartika as a condition which causes cutting pain in anorectum.
Introduction.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 2
The factors responsible for causation of Parikartika as found in various texts are
Vamana- Virechana-Vyapat, Bastikarma Vyapat, Atisara, Grahani, Arsha, Udavarta
etc. In the similar manner it has been described of three type’s viz. Vata, Pitta and
Kapha. Sushruta while describing the symptoms of the disease speaks of the features
like; cutting or burning pain in anus, penis, umbilical region and neck of urinary
bladder with cessation of flatus. Whereas Charaka has described the features like:
pricking pain in groins and sacral area, scanty constipated stools and frothy bleeding
per rectum.
Fissure-in-ano occurs most commonly in midline posteriorly. In males, usually
occur in midline posteriorly – 90%, and less common anteriorly – 10%. In females in
Midline posteriorly - 60% and anteriorly – 40%An alarming rise in the incidence of
the disease fissure-in-ano and no known satisfactory remedies evolved so far has
given an impetus to find out a suitable solution, with altogether better effects, from
amongst the treatments advocated by the classics. This is the reason that sufficient
work is going on in this direction in many institutes throughout the country.
According to Ayurvedic literature, there are several methods of treatment i.e.
Bhaişaja – Kshara – Śhastra Karma etc. Among them Bhaişaja Karma – medicinal
treatment is the first line of treatment. Now a day, various topical remedies are
available for local application for wound healing in the market including for fissure-
in-ano. In the present study, an effort was made to derive a standard and easily
accessible treatment for fissure-in-ano from classical resources.
Introduction.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 3
Yashtimadu Ghŗita is having ingredients with Vraņa Śodhana and Ropaņa
properties which can help the Vraņa (wound) to heal rapidly (BR. Su.36/16). Its base
is yashtimadu which itself is having Samskara Anuvarti and healing properties.
Yashtimadu Ghŗita is economic by virtue of less number of easily available
ingredients and a time tested classical formulation. Hence, it was selected for the
clinical evaluation in the present study.
Aims and objectives.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 4
AIMS
To evaluvate effect of yeastimadu grith picchu in the management of
parikartika
OBJECTIVES
To review the literature of parikartika in Ayurvedic classics.
To review about fissure in ano in modern literature.
To evaluate efficacy of yashtimadhu ghritha pichu in parikartika.
. Review of literature
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 5
REVIEW OF AYURVEDIC LITERATURE
Ayurveda deals with the maintenance of health and relief from the diseases.
Sushruta defines the healthy state1 as one who’s Dosha; Agni and functions of Dhatu
and Malas are in the state of equilibrium and who has cheerful mind, intellect and
sense organs is termed as Svastha (healthy).
World Health Organization (WHO) also supports this definition which shows
the eternity of Ayurvedic description. Charaka has mentioned this in Vimana Sthana
as Dhatusamya.
Ancient literature including Vedas has a rich description of various diseases
and their management, but ‘Parikartika’ is not described in Vedas. Then comes the era
of the Samhitas where Ayurveda, actually developed as a medical science. But even
though there is detailed description about various diseases and their management but
Parikartika is the one that has not been emphasized upon.
The reason for this may be that, Parikartika was as neglected condition by
doctors and patients both as it is today. Also other strong reason may be that, there
might be a very less incidence of the disease, due to overall well being of the people,
better food quality, less stressful life, and balanced life style.
Acharya of Bruhatrayi has mentioned about this entity ‘Parikartika’ though not
as a separate disease but as a complication of various conditions viz. Vatika Jvara and
Vatika Atisara, as complication of purgatives or enemas. Kashyapa Samhita has given
. Review of literature
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 6
details of the disease, according to which Parikartika is of three types according to the
predominance of the Dosha and their treatment is to be done accordingly.
Before moving towards better understanding of the disease, it is inevitable to
go through a critical study of the part affected, in its structural and functional aspects
as told by the ancient Acharya. Here Parikartika is studied with special reference to
fissure-in-ano i.e. the one occurring in the Guda. Thus a detailed description of Guda
follows:
GUDA
The term Guda is consequent from, means the organ which excretes the Apana
Vayu and Mala is called as Guda. Here, term Guda can be used to indicate end part of
digestive system. According to Ayurvedic Shabdakosha, the word Guda means, i.e.
the organ which evacuates the Apana Vayu is known as Guda. In various Ayurvedic
texts, the term Guda is used to denote the ano-rectum. Almost all the Acharyas have
used this term to refer to an organ which performs the actual function of defaecation.
They have even described the embryological derivation and development of Guda,
and other body organs in Sharira Sthana.2It shows their ingenuity and depth of study
of the human body and its organs in those days when facilities were lacking.
. Review of literature
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 7
Synonyms:
Amarkosa: Aapanam, Payu
Jatadharam: Guhyam, Gudavartma
Vijayaraksita: Apanah, Mahatsrotas
Gangadhara: Bradhanam
Vachaspati: Vitmarga
Other words that are mentioned in contact to Guda various Acharyas are
Charaka: Uttaraguda, Adharaguda, Sthulaguda, 3, 4 Gudamukha
Sushruta: Gudamandala, Gudavalaya, Payuvalaya, Gudaustha.
Vagbhatta: Gudamarga
Dalhana : Gudantram
ANATOMY OF GUDA
Guda has been enumerated one among with fifteen Koshtangas (hollow
viscera) of the body by Acharya Charaka and having two parts vis. Uttara Guda and
Adhara Guda5 explains that former is the seat of faecal material collection whereas
later helps in the evacuation.6 This seems to indicate that Charaka has mentioned
Uttara Guda up to pelvic colon at least and Adhara Guda forms the part of anorectum
. Review of literature
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 8
because no sooner the faecal matter enters in ampula of rectum, the reflexes start
resulting into desire to defecate.
Guda is one among the Praņanayatan.7 It has also been included in
Sadyopraņahara Marma.8 Acharya Sushruta, who was basically a surgeon had
described that Guda is a terminal portion of large intestine (Sthulantra) in vicinity to
Basti (urinary bladder). It excretes the faeces and flatus9, which is also grouped under
Bahya Srotasa (external openings) 10
Origin of Guda:
In Suśhruta Samhita, it has been mentioned that parts like Peshi (muscles),
Rakta (blood), Meda (adipose tissue), Majja (bone marrow), Stana (breast), Nabhi
(navel), Yakŗt (liver), Plihā (spleen), Antra (intestine), Guda (anus) are ‘Matŗja’ in
origin 11,12 According to Acharya Suśhruta, it is Sara of Rakta and Kapha digested by
Pitta along with the active participation of Vayu.13 While Acharya Vagbhatta says that
Guda, Rakta and Mamsa are Maternal in origin.
Relation of Guda:
In the context of anatomy of Basti, Sushruta said that Basti is situated in
between Nabhi, Prushtha, Kati, Muska, Guda, Vankshaņa and Shephas having single
opening downward related to one another with Basti Sira (bladder neck), Paurusha
Granthi (prostate), Vrushana (Testis), Guda (ano-rectum) and placed in
Gudāsthivivara (pelvic cavity). He directed to put a finger into anus during the
. Review of literature
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 9
operation of vesicle calculus for fixation in perianal region thus quite justified that
Guda is an organ which is terminal part of large intestine situated in pelvic cavity
anterior to Gudasthi (sacrum) and posterior to Basti (bladder).
Parts of Guda:
Acharya Sushruta says that Gudaustha is situated at a distance of half Yava
away from the hair line and one finger interior to the last Vali i.e. Samvarņi.
According to Acharya Charaka, Guda is one of the fifteen organs belonging to
Koshta. Further, he has divided it into two parts viz., Uttar Guda and Adhara Guda.
But according to Ayurvedic text, it is difficult to make a line of demarcation between
the Uttar Guda and Adhar Guda. The words like Sthula Guda and Gudaustha are also
used in Ayurvedic texts. Acharya Charaka has considered Sthula Guda as a root of
Purishvaha Srotasa.14
Measurement of Guda:
Acharya Sushruta and Vagbhatta15, 16 have described that the total length of
Guda is 4½ Angula only. Dalhaņa considered one Angula is maximum width of
thumb. Practically, the width of the thumb may be taken as 2 cm. In this regard, the
length of Guda is about 9 cm (4½ Angula). The total length of anal canal is between 3
–4 cm and the total length of ano-rectal canal from recto sigmoid junction to anal
verge is 16.5 cm. Thus Guda includes anal canal plus distal 5 – 6 cm of rectal segment
. Review of literature
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 10
that means up to middle houstan valve. Vagbhatta had also told measurement of Guda
as Atmapanitala (palm of hand) 17
Internal Structure of Guda:
Acharya Sushruta and Vagbhaţţa have described the presence of three Valis
(fold, wrinkles) from proximal to distal named as Pravahini, Visarjani and Samvaraņi.
These are situated one over the other inside Guda at a distance of 1½ Angula from
each other and all of them obliquely projectile in one Angula spiral like conch
(Sankhavartanibha) and resembling colour of palate of elephant (Gajatalu) as reddish
black. Gudausţha (anal verge) is situated at a distance of 1½ Yava from Romānta
(hairy margin). The first Vali is at a distance of one Angula from the anal verge18, 19
Dalhaņa while dealing with the above context clarified that three Yavas are equal to
one Angulas length and specified that Gudaustha distance is about 1½ Yava i.e. ½
Angula from Romanta. Now the entire description of Valis can be interpreted in the
light of present day knowledge. Some authors have translated these Valis as
sphincters (Singala et al, 1972). Gaņanathasen has assumed the distal two houstan
valves are Pravahini and Visarjini, the area of external and internal sphincters
collectively as Samvaraņi.
Muscles of Guda:
Acharya Sushruta has described the presence of three muscles in the Guda region20
. Review of literature
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 11
1) Pravahani is one which compresses and pushes the stool downwards as spiral
movements of middle houstan valve.
2) Visarjani which relaxes and initiating the reflex of defacation in the presence of
rich stretch nerve ending in ampula of rectum and region of ano-rectal junction.
3) Samvarani which is sphincteric continence under the control of reflex mechanism
by presence of external and internal sphincter which is opening and closing in passage
of feces and flatus. Guda has also other functions. It is a place where Vayu can be
controlled easily by its chief site. Charaka and others have advocated the Basti Karma
for amelioration of Vatika disorder.
Guda as a Marma:
Acharya Sushruta has described Guda is one of Sadyopraņahara Marma
(results instantaneous death) which is situated in terminal part of Sthulantra (large
intestine) and categorized under ‘Mamsa Marma.’21 Vagbhatta has mentioned Guda as
Dhamani Marma.22 He has also said that Guda is attached to Sthulantra and functions
as evacuator of faeces and flatus. Injury to this would lead to immediate death.23
Blood Supply of Guda:
Like Sira, Dhamani, Srotasa etc. various words have been described in
Ayurveda which are the Srotasa (channels) carrying Dosha, Dhatu and Mala in the
body and are the essential components of every Avayava (organ). According to the
different commentators, Sira denotes only work of Sarana i.e. presumabling the flow
. Review of literature
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 12
is maintained slowly. Dhamani denotes work of Sarana with Dhamana i.e. flow
through this channel is maintained with pulsatile movement. Srotasa means the
structure through Sravaņa takes place. There are eight Siras present in middle part of
Shroni (pelvis) which supply to Guda and Medhra24 and two Dhamani are supplying
to Guda in downward direction25 Regarding Srotasa there are two Srotasa which
pertain fecal matter namely, Pakvashaya and Guda, the later one also having external
opening and named as one among Navasrotamsi.26
Importance of Guda:
(1) Marma: Guda is a Mamsa Marma27contradicting to this Vagbhatta includes it in
the Dhamani Marma. Similarly Acharya Sushruta has considered Guda as Udara
Marma28 while Vagbhatta has included it in Koshta Marma.29 Both Acharyas opines
that Guda is a Sadyapraņahara Marma and it is of four Angula size. Injury to it causes
obstruction of Apana Vayu, Mala and loss of moment in Sthulantra (paralytic ileus)
and patient dies instantaneously.
(2) Prananayatan: Praņanayatan are so enlisted because their proper functioning is
very-very important for proper functioning of the body. Guda is one of such
‘Praņanayatan’.
(3) Srotasa: Guda is a Bahirmukha Srotasa. Acharya Charaka has put Sthula Guda as
the root of the Purişhavaha Srotasa and Acharya Sushruta has mention Guda as the
same.30 it is an important ‘Chidra’ of the body and thus a valuable part too.
. Review of literature
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 13
(4) Karmendriya: While enlisting the Indriyas Guda is categorized under
Karmendriya group and the function designated to it is defecation and releasing of
flatus.
Physiological Function of Guda:
All the ancient authors have mentioned the functions of Guda as to dispose of
excreta from the body. Guda is included among 9 Bahya Srotasa and among 10
Randhras by Sharangadhara. The opening is terminal part of Purishavaha Srotasa and
serves as an excretory channel for excretion of faeces and flatus. According to
Acharya Charaka and Sushruta, Purishavaha Srotasa has two Mula e.g. Pakvashaya
and Guda which serves as a storage and excretion of feces respectively. The presence
of Purishadhara Kala in Koshta serves as to separate Mala from Ahara Rasa. Guda is
also included under Panchakarmendriya and the ancient Acharya expressed these
activities are maintained by Vayu. Vayu has five varieties which are located in their
specific sites and contribute towards integration and maintenance of body by virtues
of their physical as well as mental characteristics. Karma of Guda is chiefly done by
Apana Vayu, and Samana Vayu contributes functions of gastrointestinal tract like
digestion, absorption, separation of nutritional assimilated material from wastage and
finally to move the waste products for excretion.31 When Apana Vayu gets vitiated it
becomes the cause for occurrence of Guda and Basti Roga like Parikartika, Arsha,
Bhagandara etc. On critical analysis, Vayu resembles the activities of nervous system.
The Apana Vayu is one which is responsible for action of defecation and may be
. Review of literature
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 14
compared as sacral plexus. In Ayurveda, excretory mechanism has been described in a
lucid manner. The three Gudavalis are playing key role in the mechanism of
defecation. As their names:
1) Pravahani is one which compresses and pushes the stool downwards as spiral
movements of middle houstan valve.
2) Visarjani which relaxes and initiating the reflex of defacation in the presence of
rich stretch nerve ending in ampula of rectum and region of ano-rectal junction.
3) Samvarani which is sphincteric continence under the control of reflex mechanism
by presence of external and internal sphincter which is opening and closing in passage
of feces and flatus.32 Guda has also other functions. It is a place where Vayu can be
controlled easily by its chief site. Charaka and others have advocated the Basti Karma
for amelioration of Vatika disorder.
. Nirukti.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 15
PARIKARTIKA
The present study is aimed towards studying of the ailment Parikartika. In
various Ayurvedic literatures, it has been described as a complication of Virechana,
Basti and also Vamana Karma. But the fact that the occurrence of Parikartika as a
sequel of Atisara, Jvara, Garbha etc. was also known to ancient authors may seem
incredible to the modern man.
Definition:
It refers to a condition in which patient experiences a sensation of pain as if
the Guda is being cut around with scissors. It is derived from Sanskŗit word ‘Parikŗ’
which denotes ‘all around’ and ‘Kartanam’. It means that excessive cutting pain
around the anus is seen in Parikartika.
Synonyms:
Kshata Payu and Kshata Guda are the synonyms in this disease. Pain is most
accepted and important clinical symptoms in this disease.
Nirukti:
Acharya Kashyapa says that the one having cutting and tearing pain.33, 34 means
cutting and tearing pain everywhere as said by Dalhana. Jejjata has anticipated about
the condition and opined in a very pin pointed way specific Vatika pain is present all
around in a specific area of Guda, is Parikartika.35
. Nidana
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 16
Nidana:
Parikartika though is not that uncommon still has slipped from the due attention of
the Acharyas of Ayurveda. A properly classified documentation of Nidana,
Samprapti, and Rupa etc. of Parikartika is not available at any single place. Even then
many Nidana that may produce Parikartika are described by Acharya which are
scattered in the text. Thus a general assumption can be drown from Sarvaroga Nidana
Adhyaya that those Dosha that are in a Sancaya Avastha get to Prakopa Avastha in
presence of etiological factors and produce the disease.36 In Parikartika, Vata is the
leading or the primary Dosha, this is because of the fact that Guda is actual site of
Vata especially Apana Vayu. Vata vitiation factors are Tikta, Ushņa, Kashaya, Alpa
Bhojana, Vegadharana, Udiraņa, excessive Shodhana therapy; diurnal and seasonal
variations37. The second predominant Dosha that seems to play important part is Pitta.
The factors vitiating it are Katu, Amla, Lavana, Ahara, Krodha; diurnal and seasonal
variations 38 Kapha Dosha, though not predominantly present for triggering the
condition, but still it plays a role many ways. The factors vitiating Kapha are: Swadu,
Amla, Lavana, Adhyasana, Sita, Guru Bhojana, Divaswapna and diurnal and seasonal
variations.39 Other than the three Doshas, Acharya Sushruta has paid utmost attention
to Rakta Dhatu, up to the extent that he says that Rakta is the 4th Dosha. He also says
that as Vayu unites with blood Vrana is formed. In Parikartika, Vrana produced is
mostly Nija in origin and Acharya Charaka in Chikitsasthana Dwivraneeya Adhyaya40
has explained that when Doshas take site in Bahya Roga Marga, they produce Vrana
. Nidana
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 17
likewise Prakupita Vata and Pitta especially the causes of Parikartika. As told by
Acharya Sushruta, the Nidana of Parikartika can be divided in to three types.
1. Nija Nidana (Endogenous).
2. Nidanarthakari Roga (Complications)
3. Agantuja Nidana (Exogenous).
(1) Nija Nidana:
The Nidana that vitiate Apana Vayu, Rakta are the Nija Nidana41, 42
Consumption of the causative factors for Apana Vikrti are Ruksha Anna and Guru
Anna, holding the natural urges of micturition and defecation, too much of traveling
by vehicles, traveling repeatedly at various places by walking. Sushruta has given few
more reasons of Parikartika. He says that “Due to excessive accumulation of Mala in
Pakvashaya, it obstructs the normal passage of Vayu and produces Vibandha with
cutting like pain. Due to this the Snehamsa (unctuous portion) gets absorbed rapidly
and eliminates dry faeces with pain.43 By excessive intake of astringent, bitter,
pungent and dry articles of diet, by the suppression of natural urge of Mala Pravrutti,
by excessive indulgence in eating and sex, the Apana Vata is provoked in the colon;
growing stronger it causes obstruction in the lower part of the alimentary tract and
produces retention of feaces, flatus and urine and thus produces very serious disorders
of misperistalsis.44Acharya Sushruta has said that due to consumption of Kashaya,
Tikta and Ushna and Ruksha substances Vayu enters into Koshta of a person and
. Nidana
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 18
along with abstained urges of defecation, produces Atopa, Shula and Parikartika as
sequel to Vitasanga.45,46
Nidanarthkari Roga Nimittaja.:
Nidanarthkari Roga Nimittaja are such disorders that are produced due to any
pre-existing diseases.47 the chief Roga is Udavarta that produces Parikartika.48,49,50
Acharya Charaka has described this condition as a Lakshana of Atisara.51 ,52
Acharya Charaka and Vagbhatta have mentioned ‘Parikartika’ as a symptom
in Vataja Atisara, who is suffering from Vatik Atisara and has complaints of scanty,
watery or hard rounded motions, soon develops Parikartika53,54
Sushruta while explaining the prodromal features of Arsha, has not mentioned
the word Parikartika but has documented a very similar symptom, 55 the symptom here
is Guda ‘Parikartanam’ i.e. there is cut in the anus and cutting pain. This is nothing
else but Parikartika and it is explained here as a prodromal symptom of Arsha. The
shape of the Vatika Arsha is like ‘arrow’ and is pointed which is similar to sentinel
tag. Acharya Charaka has said that in Sahaja Arsha56 there is severe pain in
Gudavallaya. In Vatika Arsha, the symptoms that he has described57 very much
similar to those found in Parikartika viz. pain in anus, penis, abdomen, umbilcal
region and so on. Also in Kaphaja Arsha he has said that there is Parikartika, nausea
etc.58, 59
. Nidana
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 19
(3) Vaidya Nimittaja:
By Pancakarma like Virechana, Basti and Vamana, Parikartika 60 as complication
Virechana Vyapad: Sushruta both have mentioned one important complication
‘Parikartika’, if ingests Tikshna, Ushna and Ruksha drugs for Virechana 61,62 .
Basti Vyapada: If Ruksha Basti containing Tikshna and Lavana drugs is
administered in heavy dose; it may produce Parikartika 63, 64
Basti Netra Vyapada: Due to inappropriate administration of Basti Netra and
defect in Basti Netra it may cause this disease.65
Excessive use of Yapana Basti: It may lead to Parikartika along with other
diseases66
. Rupa....
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 20
RUPA
Vikrta Vata gets localized in Guda67 It produces retention of faeces, urine and
flatus, colic pain and flatulence and Śarkara (fecolith).68 Along with these the
prodromal symptoms of Parikartika, in the words of Sushruta, is pain of sharp cutting
nature in Guda.69 Acharya Sushruta has described is absolutely correct because in
modern medicine also for anal fissure same clinical symptoms are described as cutting
or burning pain in anus, pain in umbilical region and radiated pain in penis and thigh
also. Constipation may be habitual or due to disease because patient is apprehensive
to relax the sphincters and defaecate so wind is not passed and constipation develops70
, Further, he has quoted that the symptoms like pricking pain in the sacrum, groins,
below the naval region and passage of scanty stools and constipation are present in
one who is suffering from Parikartika.71
Acharya Vagbhatta has also described same signs and symptoms as described by
Acharya Charaka and Sushruta.72 Vraņa is an essential symptom of Parikartika which
is having Dirghakriti shape or Triputakakrti73 and a Srava may be present.74 The
Vraņa surface appears more Rukşha. Features of Vata Pittaja Vraņa and also Dushta
Vrana like Samvritatwam, Vivitatwam, Kathinya, Mŗduta, etc. can be found 75.
. Samprapthi...
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 21
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. If proper Dinacharya and Ritucharya are observed, the vitiation of the
Doshas can be brought to normal limit. When Asatmya Indriyartha Samyoga,
Prajnaparadha and Parinama influence this imbalance of Dosha, a morbidization
process begins and it undergoes six stages known as Kriyakala.
They are Sanchaya, Prakopa, Prasara, Sthanasamsraya, Vyakti and Bheda
during these stages disease is manifested.76The Samprapti of Parikartika and Arsha
shows close similarities. It is evident from the fact that both these conditions are
manifested in the same Srotasa i.e. Purişhavaha Srotasa.
The role of specific etiological factors and site of manifestation of disease
further strengthens this theory. In this disease Vata Prakopa is predominant with
associated Pitta. The localization of Doshas occurs particularly in Guda Pradesh.
As a result of the pathogenesis, Twak becomes Ruksha and shows tendency to
crack. Sushruta and Vagbhatta have clearly stated that similar changes occur in skin
when Vata vitiates from the skin.77 When Ksham and Mridu Koshta person indulges
Ruksha, Tikshna Ahara and Ruksha Aushadha it produces Agnidushti, which in term
leads to Vata- Pitta Prakopa. Due to Daurbalya of Duşhya i.e. Mamsa and Twak,
particularly of Purişavaha Srotasa, Kha-vaiguņya takes place. Because of this Kha-
vaiguņya, Sthana Samşhraya of aggravated Vata and Pitta Dosha takes place in
. Samprapthi...
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 22
Purişhavaha Srotasa which leads to Dosha Dushya Sammurcchana. This produces
Twak Māmsa Duşhti specifically in Guda Pradesha. This Twak Mamsa Dushti or
Vrana results in frequent defeacation associated with pain. This ultimately leads to
Parikartika.
The second kind of Samprāpti is that the diseases like Atisara, Grahani etc.
are if not treated properly and patient continues to indulge Aharaja Nidana then
preexisting pathology leads to Guda Vikŗti and later on Parikartika occurs. The third
type of Samprapti is due to Agantuja Nidana where there is wound formation in first
stage and then the Doshas get sited in the Vrana, producing further symptoms. When
the wound is produced simultaneously there is vitiation of Doşa which in term leads
to Parikartika.
. Bheda.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 23
BHEDA:
Acharya Charaka and Sushruta both have described two types of Doshas in
Parikartika viz. Vata and Pitta. In almost all Ayurvedic texts, no detailed descriptions
about classification of disease, its Samprapti and symptomatology have been
specified, but Acharya Kashyapa has described the involvement of all the three
Doshas e.g. Vata, Pitta and Kapha in the Adhyaya of Garbhini Chikitsa while giving
the detailed Chikitsa of the disease Parikartika.79
This classification is chiefly emphasized on the character of pain, shooting,
cutting or pricking pain in Vata predominance, burning pain in Pitta and dull ache
type in Kapha predominance.
Since it is a known fact that Kashyapa Samhita is incomplete work and it
might be possible that he might have considered the Nidana Panchaka of Parikartika
in detail in some of lost portion over a period, but later on given a brief description of
it in relation to a Gravid woman.
. Sadhya Asadhyata.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 24
SADHYA ASADHYATA
Sadhyasadhyata of a disease is decided by considering all the factors which
are likely to influence the curability and incurability of a disease. It is essential to
consider the Sadhyasadhyata before administering any forms of Chikitsa
(treatment).80 any type of Vrana can be cured easily, provided the patient is with good
Satva, Mamsa Dhatu, and Agni and if he is in his younger age.81
Also Vrana occurs in Guda can be cured easily82 if a Vrana is left untreated,
the Sadhyatva, as a consequence may lead to Yapyatva stage and finally leading to
Asadhyatva stage.83
Parikartika which affects the superficial layer of the Twak (analskin) is easily
curable. Therefore it can be included in the Sadhyata group. If it affects the deeper
layers, it shows relectance to heal.
Therefore it can be included in Kŗcchrasadhya group. If it is associated with
Kushta, Vishadushti and Shosha, the healing of Vrana will be delayed.84 If Parikartika
is associated with Sanniruddhaguda, it is considered as Yapya.
. Chikista of parikartika.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 25
CHIKITSA OF PARIKARTIKA
Parikartika as a disease has been considered very briefly by Sushruta and other
successive authors. They have described the treatment of Parikartika in most brief
manner. Kashyapa has mentioned its management according to Doshika
predominance, others have not considered as Doshika type of classification, but it is a
fact that none of them has described surgical management, thereby showing that there
was no need of surgery as the disease was completely cured by the use of medicinal
preparations only, and they were satisfied with management. According to route of
administration the medicines are divided into two categories viz. 1) Sodana and 2)
Shamana
Sodana Chikista:
This local treatment is nothing but only Basti Karma. Basti is prepared in
Ghrita, Taila and milk with the help of other different drugs. Most of the drugs, which
are used in Basti Karma, are VataShamaka, Vraņa Shodhana - Ropaka and
Pittashamaka. There are three types of Bastis described by Sushruta and other
Ayurvedic authors viz.
(i) Anuvasana Basti (ii) Piccha Basti and (iii) Sital Basti. Remedy consists in
employing a Picchā Basti with Yashtimadhu and Sesamum pasted together and
dissolved in clarified butter and honey. And patient should be kept on Anuvasana
Basti, (in cases of Pittapredominance) Basti should be employed with the cream of
clarified butter and in case of Vata predominance with Taila cooked with
. Chikista of parikartika.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 26
Yashtimadhu 85 Charaka has also advocated both types of medicines which have been
advocated by the Sushruta. He says Sheeta Basti consisting of drugs having Madhura
and Kashaya properties (Piccha and Anuvasana Basti) prepared by Madhuyaşti
powder and kwatha should be used.86
Kashyapa has also advised for the Anuvasana Basti. In this type of Basti the
base is milk, oil or Ghŗita87 these are either Vatashmaka or Pittashamaka. In many
compositions so many drugs have been used they have Vata and Pittashamaka
properties and Madhuyasti is many times used. Because it has property of cooling,
Vata- Pitta-Raktashamaka and widely it has been advocated by Sushruta for treatment
of traumatic wounds, Pittaja Vrana, fractures, Bhagandara, Upadansa and ulcer etc.
Both the Acharya Charaka and Sushruta have advocated Piccha Basti with
Madhuyaşti, Madhu and Taila for treatment of Parikartika.
Shamana chikista:
The oral preparation have many-fold objectives some drugs are used to correct
the anorectal disorders other are used as laxative and few more as to correct the
Agniduşhti. They have advised drugs as the Tridoşhashamaka. Sushruta has advised
for cold water bath and milk for oral administration.88
In this disease the main problem is that of constipation and pain only. If one
corrects the constipation part of disease and alleviates the pain the disease may
disappear to a great extent within few days. Pain due to Vata and Pitta vitiation and
constipation due to two reasons 1) Habitual constipation and 2) Due to fear of pain
. Chikista of parikartika.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 27
patient does not go for the defaecation. Acharya Charaka has also written about the
oral treatment in Parikartika and advised for only milk drinking.89
Acharya Charaka has also advised to take Amla Dravya because it has the
property of Vatashamaka and increases the digestive fire. According to Charaka, if
there is Parikartika present with fever, patient should drink the gruel prepared with the
heart shaped leaves of seed, fruits of Kokam, butter tree, sour jujube, then painted
leaved ureria and yellow barried night shade mixed with Beal fruit.90 In Kashyapa
Samhita the treatment has been given according to predominance of Dosha.
1. Vatika Parikartika:
Brihati, Beal and Ananta are used which all have the Vatashamaka property.93
2. Paittika Parikartika:
Such drugs like Madhuyaşti, Hanspatti, Dhaniya, Madhu etc. are useful for
Pittashamana and have also property to correct abdominal trouble with its laxative
effect91
3. Kaphaja Parikartika:
In this he has used the drugs which have the property of Kaphaśhāmaka and
Vatashamaka also as Kantakari, Pippal, Gokshura and salt.95 Further he has given the
treatment for Gravid Stri who is suffering from Parikartika is milk prepared with
. Chikista of parikartika.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 28
drugs which have Madhura Rasa and mixed with Madhu, Sharkara, Tila Taila and
Madhuyaşti in this way, all the treatment is based on following factors.
1. To allevitate the Vata and Pitta.
2. To correct the abdominal trouble because in this disease Vata and Pitta are vitiated.
Most of the patients come with burning type of pain. So keeping these
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 29
MODERN ANATOMICAL CONSIDERATION
From the surgical point of view organs and structures of the body must be
known by a surgeon as to their anatomy and physiology for complete understanding
and thoroughness including the diagnosis and performing a good job at operation
table. Moreover, the diseases of the ano-rectal area are few of the commonest
pathological conditions of the terminal part of Gastro-intestinal tract and present very
complex conditions, in their management, both from the patients as well as from the
surgeon’s point of view. The basic understanding and knowledge of modern surgical
or applied anatomy of the anal canal and rectum is undoubtedly provided by Milligan
and Morgan (Milligan, 1942; Milligan and Morgan1934, 1937; Morgan, 1936).
Though Thompson (1899) has also dwelt upon the subject in his historic monograph
entitle, “mycology of the pelvic floor”. The former authors actually performed the
various operations and gave their histological findings too.
In fissure–in-ano mainly there is a need for either fissurectomy or
sphincterotomy. Therefore, it is very important that to have a good and thorough
knowledge of its anatomy and recognition of the sphincters, anal canal and rectum.
The ano-rectum, as the term suggest, can be described under two heads; viz. Rectum
and Anal Canal.
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 30
DEVELOPMENTAL ANATOMY OF RECTUM AND ANAL CANAL
The development of rectum and anal canal is associated with the growth of the
tail told. Further it is intimately associated with that of the bladder and other elements
of the urogenital system.
ANATOMY OF RECTUM:
The rectum is about 5 inches (13 cm) long and begins in front of the third
sacral vertebra as a continuation of the sigmoid colon. It follows the curvature of
sacrum and coccyx and ends 1 inch (2.5 cm) in front of the tip of the coccyx by
piercing the pelvic diaphragm and becoming continuous with the anal canal. The
lower part of the rectum that lies immediately above the pelvic diaphragm is dilated to
form the rectal ampulla. It develops partly from hindgut and partly from cloaca both
being endometrial in origin.
CURVES OF THE RECTUM:
1. Anteroposterior curves - Sacral flexure and perineal flexure
2. Lateral curves -Upper, middle and lower, lateral curves
PERITONEAL RELATIONS:
The peritoneum covers the anterior and lateral surface of the first third of the
rectum and only the anterior surface of the middle, leaving the lower third devoid of
peritoneum.
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 31
VISCERAL RELATIONS:
(a) Anteriorly -
In males the upper 2/3 of the rectum is related to rectovesical pouch with coils
of intestine and sigmoid colon. Where as lower 1/3 of rectum related to the base of
urinary bladder, vas deferens and prostate.
In females the upper 2/3 of rectum is related to recto uterine pouch with coils
of intestine and sigmoid colon and lower 1/3 of rectum is related to the lower part of
vagina.
(b) Posteriorly –
The rectum is in contact with sacrum and coccyx, ano-coccygeal ligament,
piriformis, coccygeus, levator ani, the sacral plexus and the sympathetic trunks.
Mucosal folds:
The mucous membrane of an empty rectum shows two types of folds. They are,
1. Longitudinal folds
2. Transverse or Horizontal folds
1. Longitudinal folds -
These are transitory and are present in the lower part of an empty rectum and
obliterated by distension.
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 32
2. Transverse or Horizontal folds -
(Houston's valves or plica transversalis)
These are permanent and most marked in distended rectum. Folding of
mucous membrane continuing circular and some times longitudinal muscle coats
forms them.
a) The upper fold lies near the upper end of rectum and projects from the right or
the left wall. Sometimes it may encircle and partially constrict the lumen.
b) The middle fold that is largest and most constant lies at the upper end of rectal
ampulla and projects from the anterior and right wall.
c) The lower fold that is inconstant lies 2.5 cms below the middle fold and
projects the left wall.
Supports of the rectum:
Waldeyer's fascia
Denonvillier's fascia
Lateral ligaments of endopelvic fascia
Pelvic floor.
ANATOMY OF ANAL CANAL:
The anal canal is the terminal portion of the intestinal tract; it begins at the
anorectal junction, is 3-4 cms in length and terminates at the anal verge. The
anatomical anal canal extends from the anal verge to dentate line. But the surgical
anal canal, extending from the anal verge to the anorectal ring. It passes downwards
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 33
and backwards from the perineal flexure. It has greatest surgical importance both
because of its role in the mechanism of rectal continence and because it is prone to
certain diseases.
In the normal living subject, the anal canal is completely collapsed owing to
the tonic contraction of the anal sphincters, and the anal orifice is represented by an
anteroposterior slit in the anal skin.
Table No. 1
Shows Relations:-
Anterior Posterior Lateral
Both
sexes
Perineal body Ano coccygeal
ligament
Ischiorectal
fossa
Males Membranous
urethra
Bulb of penis
Tip of Coccyx
Female Lower end of
Vagina
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 34
Interior of the Anal Canal:
This can be divided into 3 parts,
(a) Upper Part -
It extends from ano-rectal ring to the pectinate line and about 15 mm long. it is
lined by columnar epithelium of endodermal origin. The mucous membrane shows
anal columns of morgagni, anal valves, anal sinuses, anal papillae and pectinate line.
Anal glands are 4-8 in number and each has a direct opening into apex of anal crypt
and occasionally two glands open into same crypt.
(b) Middle Part –
It lies between the pectinate line above and white line of Hilton below and
about 15 mm long. This part of anal canal is lined by a stratified squamous
epithelium, which is thin pale and glossy and is devoid of sweat glands. The Hilton's
white line is situated at the level of interval between the subcutaneous part of anal
sphincter and the lower border of internal anal sphincter.
c) Lower Part –
It is about 8 mm long and is lined by true skin containing the sweat and
sebaceous glands.
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 35
Musculature of the Anal Canal:
A. Anal Sphincters:
Internal Sphincter:
It is formed by the thickened (5-8 mm) circular muscle coat and is involuntary
in nature. It lies above the subcutaneous part and deep to the superficial and deep
parts of the external sphincter and ends below at the white line of Hilton.
External Sphincter:
It is made up of striated muscle and is under voluntary control. It surrounds
the whole length of anal canal and consists of three parts.
(a) Subcutaneous Part - Which encircles the lower end of the anal canal and has
no bony attachments.
(b) Superficial Part - Which is attached to the coccyx behind and the perianal
body in front.
(c) Deep Part - Which surrounds the upper part of internal sphincter and is fused
with the puborectalis.
B. Ano-rectal Ring:
The term was coined by Milligan and Morgan to denote the functionally
important ring of muscle which surrounds the junction of rectum and anal canal. This
is composed of the upper borders of the internal and external sphincters, which
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 36
completely encircles the junction and on the posterior and lateral aspect, by the strong
puborectalis sling. As a consequence, the ring is stronger posteriorly and laterally than
it is anteriorly, and its definition on the posterior aspect is accentuated by the forward
angulation of the bowel at this level.
Recognition of the anorectal ring is of paramount importance in the treatment
of abscesses and fistula in the anal region, for its complete division inevitably results
in rectal incontinence, while its preservation, despite the sacrifice of all the rest of the
sphincter musculature, at least ensures that there will be no gross lack of control,
though minor degrees of incontinence may result.
FIGURE – 1
GUDA VALI & SPACES
Pravahani
Visarjini
Samvarani
Perianal space
Ischiorectal space
Supralevator space
Submucous space
Intersphincteric space
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 37
Surgical Spaces
These are potential spaces surrounding the anorectal canal and are sites for collection
of pus that might result in the formation of abscesses and fistulae.
i. Ischiorectal spaces - There is a fossa situated on both sides of anal canal. It is
situated on the pelvic diaphragm. Its base is towards surface and apex upwards.
Apart from these, there is a thin band of tissue intervening between the
ischiorectal fossa posteriorly, which is still a weaker point and permits entry of
Figure -3 Figure -2
MUSCULATURE OF
ANAL CANAL INTERIOR OF ANAL CANAL
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 38
pus from one fossa to the other, there by producing a horseshoe abscess in the
posterior perianal region.
ii. Pelvirectal spaces - It is made up of loose connective tissue above levator ani. It
is divided into anterior and posterior regions of lateral ligament of rectum.
These spaces can hold good account of pus.
iii. Submucous space - It is situated above the white line of Hilton between the
mucous membrane and internal sphincter.
iv. Perianal space - It surrounds the anal canal below the white line. It extends from
white line of Hilton medially to pudendal canal laterally.
v. Retrorectal space - It lies in the forward concavity of the sacrum. It is bounded
anteriorly by rectal wall, posteriorly by prevertebral fascia of sacrum, superiorly
by peritoneal reflexion, inferiorly by pelvic diaphragm, laterally by lateral
ligaments of rectum.
(D) Pelvic Diaphragm
It is formed by levator ani muscle. It is thin sheath of muscle on each side
forming major portion of pelvic diaphragm except anterior part. Each levator ani is
divided into three parts. They are pubococcygeus, puborectalis and iliococcygeus.
Pelvic diaphragm fixes pelvic viscera and acts as support for increased abdominal
pressure during exertion.
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 39
BLOOD SUPPLY OF RECTUM AND ANAL CANAL
1. Superior rectal artery -
It is the continuation of inferior mesenteric artery. The left and right
branches of superior rectal artery supply the upper and middle rectum.
2. Middle rectal artery –
It arises at anterior division of iliac artery and supply the lower part of
the rectum and upper part of the anal canal.
3. Inferior rectal artery -It supplies external and internal sphincters below the
pectinate line.
4. Median sacral artery -It supplies to the posterior wall of anorectal junction
and anal canal.
VENOUS SUPPLY OF RECTUM AND ANAL CANAL
1. Superior rectal veins -The upper and middle rectums are drained by superior
rectal veins which enter the portal system via inferior mesenteric vein.
2. Middle rectal veins -It drains the lower rectum and upper anal canal, which
open into the internal iliac veins and then into canal system.
3. Inferior rectal veins -It begins from the external rectal plexus and drains the
lower part of anal canal.
4. Internal rectal venous plexus (Haemorrhoidal Plexus)- It lies in the
submucosa of anal canal and drains mainly into the superior rectal vein, but
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 40
communicates freely with the external plexus and thus with middle and
inferior rectal veins.
5. External rectal venous plexus - It lies outside the muscular coat of the
rectum and anal canal and communicates freely with the internal plexus.
6. Anal veins - These are arranged radially around the anal margin. They
communicate with the internal rectal plexus and inferior rectal veins.
FIGURE – 4
C.S. RECTUM & ANAL CANAL
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 41
FIGURE – 5
BLOOD SUPPLY
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 42
LYMPHATIC SUPPLY OF RECTUM AND ANAL CANAL:
1. Lymphatics from more than the upper half of the rectum pass along the
superior rectal vessels to the inferior mesenteric nodes.
2. Lymphatics from the lower half of the rectum pass along the middle rectal
vessels to the internal iliac nodes.
3. Above the pectinate line, the lymphatics drain with those of the rectum into
the internal iliac nodes.
FIGURE –6
VENOUS SUPPLY
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 43
4. Below the pectinate line, the lymphatics drain into the median group of
superficial inguinal nodes.
NERVE SUPPLY OF RECTUM AND ANAL CANAL:
1. The rectum is supplied by both sympathetic (L1, L2) and parasympathetic (S2,
3, 4) nerves through superior rectal and inferior hypogastric plexuses.
2. Above the pectinate line - The anal canal is supplied by autonomic nerves,
both sympathetic (inferior hypogastric Plexus L1,L2) and parasympathetic ( S2,
3, 4).
3. Below the pectinate line - It is supplied by somatic (inferior rectal S3, 4) nerves.
4. Anal Sphincters - The internal sphincter contracts by sympathetic nerves and
relaxes by the parasympathetic nerves. The inferior rectal and perineal branch
of fourth sacral nerve supplies external sphincter.
PHYSIOLOGY OF THE RECTUM AND ANAL CANAL
The junction of the anorectal canal has to store and evacuate the fecal matter.
The interval of the defecation varies from a day to 4-5 days, depending upon the
nature of food taken. In majority of the people, this occurs once in a day. There are
two reflexes which initiate peristalsis.
(1) Orthocolic reflex. - This occurs when a person awakes from sleep assuming the
erect position.
Modern Anatomical Consideration.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 44
(2) Gastrocolic reflex. –This occurs when the person is moving and taking food and
liquids. The increased intra rectal pressure causes the relaxation of anal sphincters
which is counteracted by voluntary contraction of external sphincter permits the act to
proceed. If the delay is prolonged, a temporary reduction in the intensity of the urge
may occur.
FISSURE –IN –ANO
SYNONYMS:
Anal ulcer
Anal fissure
Ulcer –in –ano
Chronic ulcer
Faecal ulcer
Definition of fissure
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 45
DEFINITION:
The term “fissure” generally denotes a crack or a split or a cleft or a groove.
The anal fissure (or fissure-in-ano) has been described as an acute superficial break in
the continuity of the anoderm (anal skin) usually in the posterior midline of the anal
margin. 1. “An anal fissure appears to be a longitudinal crack in the anal skin, but in
reality it is a true ulcer of the skin of the wall of the anal canal” (Nesselrod).
2. “An elongated ulcer in the long axis of the anal canal”96
3. “The squamous mucosa of the lower half of the anal canal is prone to superficial
ulceration, which present clinically as an anal fissure. It is a linear ulcer, usually
situated in the posterior commissure of the canal” (Devis Christopher)
AGE:
It is usually encountered in young or middle aged adults, but sometimes seen
at other ages including infancy and early childhood (Bennet). It is disease mainly of
middle life (R.Madevan). Hamilton says that “Fissure-in-ano is not uncommon in
children, and probably because the condition is not even thought of, in young child
the diagnosis is frequently missed.
SEX:
Definition of fissure
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 46
Anterior fissure is more common in women than in men, and accounts for
some 40%of all fissures in that women as contrasted with only 10% in men
(Goligher). Posterior fissure is 90% in men, 60%in women.
LOCATION:
It is mostly found on the midline posteriorly. The next frequent situation is the
mid line anteriorly 97 Page 46 of 163 - 46 -Goligher say that it is nearly always in the
midline of the posterior wall of the anal canal or immediately towards one or other
side of it, occasionally it occurs in middle of the anterior anal wall and exceptionally
it is found elsewhere on the circumference of the anus. Fissures are always single but
rarely two or more fissures co-exist.
Aetiology.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 47
AETIOLOGY:
According to Davis,”main aetiology of anal fissure is anal infection”. Boyd
says that there are only two reasons by which anal fissures occur.
1. Trauma by the passage of a thick column of hard stool and,
2. Loss of elasticity due to chronic infection and fibrosis.
Further he says that at least 95% of these lesions are situated in the posterior
commissure, because the fibres of eternal sphincter which encircle the anus fuse much
more completely in front than behind. So that mucosa of the posterior aspect of anal
canal is less strongly supported and more easily torn. Fissure-in-ano is end result of a
tear of mucous membrane at 6 o’clock position of the anus or of anal valve by a hard
scybala in a constipated patient. Bailey and Love have said that the cause of anal
fissure, particularly the reason why the midline posteriorly is frequently involved is
not completely understood. Probability is that posterior wall of the rectum curves
forwards from hollow of the sacrum to join the anal canal, which turns sharply
backwards. During defaecation the presence of hard faecal mass is mainly on the
posterior ano- rectal angle in which event the overlying epithelium is greatly stretched
and being relatively unsupported by muscle, is placed in a vulnerable position when a
scabalous mass is being expelled. Possibilities in some cases are due to tearing down
of an anal valve of ball.
Modern classification.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 48
CLASSIFICATION:
For all practical purposes, the fissure can be classified into two groups:
1. Primary or Idiopathic
2. Secondary or such fissures
Which develop in those patients who have undergone anal operation, such as
haemorrhoidectomy or lying open of a low anal fistula, where the resulting wound is
situated anteriolry or posteriorly. Considering the large number of minor anal
operations which are regularly performed the secondary anal fissure are not
uncommon.
TYPES:
1. Acute
2. Chronic.
1. Acute.: This ulcer is often a mere crack in the epithelial surface, but may, never the
less, cause severe pain and spasm.
2. Chronic: This has thickened margin edges, the skin at the lower edges of the fissure
is often odematous, hypertrophied and undermined, producing the so called sentinal
tag. In the base of the ulcer some times see the fibres of the external sphincter
crossing transversely.
Pathology..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 49
PATHOLOGY
This condition is nearly always in the midline of the posterior wall of the anal
canal or immediately left or right side of it, occasionally it occurs in middle of the
anterior anal wall, and of exceptionally it is found elsewhere on the circumference of
the anus. Anterior fissures are more common in woman than in man. Fissures are
always single but rarely two or more fissures are encountered simultaneously. The
situation of the fissure in the vertical axis of anal canal is also a very constant. It lies
in the cutaneous portion of anal lining between the level of the anal valve and the anal
orifice. In this portion it is situated superficial to the lower most quarter or one third
of the internal sphincter muscle. Initially it is separated from the sphincter by the thin
layer of longitudinal muscle spread on the inner
An alternative view advanced by Miles (1919-39) was that pale tissue exposed
by a chronic fissure was not sphincter muscle at all but instead a condensation of
fibrous tissue in the submucous space of the anal canal, forming a ring of fibrosis
which is “Paten band” and which he believed played an important part in the
aetiology of anal fissure. The work of Eisenhammer (1953), Goliher, Leacock and
Brossy (1955) and Thomson (1956) however, leaves no doubt that the tissue
underlying a fissure-in-ano is the internal sphincter muscle that the structure identified
by Miles as the ‘Paten band’ is simply the prominent lower edge of this sphincter, and
that at no stage the external sphincter is in direct contact with an anal fissure.
Pathology..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 50
SECONDARY CHANGES:
In its early stages fissure is a simple slit in the skin of the anal canal but there
soon developed in connection with it certain secondary changes. One of the most
important points is the swelling of the skin at the lower end of the fissure, actually at
the level of the anal orifice, so that it forms a tag like swelling the so-called sentinel
tag. This is due to low grade infection and lymphatic oedema, and after the tag has
undergone very inflammed, tense and oedematous appearance, it may go into fibrosis
later on and persist as a permanent fibrous skin tag even after the fissure has healed.
When the fissure is relatively superficial the sphincter usually undergoes a tight
spasm, but when the fissure deepens and bares sphincter fibres thus becomes even
more pronounced. The external sphincter may also have to some extent in the
contraction of the anal musculature associated with the pain of the fissure, but it does
not undergo the intense persistence contraction and eventual fibrosis seen so often in
the internal sphincter.
PATHOGENESIS:
According to Devis (1960) and Nesselrod (1970) has said that chief cause of
anal fissure is anal infection and it occurs in three stages:
Stage 1: The infectious material is trapped or lodged in one or more of the anal crypts
and is carried to the anal glands via the anal ducts. Thus, the crypts serve as funnels
Pathology..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 51
through which the infectious material from the intestinal tract is directed into the anal
ducts and glands.
Stage 2: The second stage of anal infection is initiated by the so-called invasion of the
surrounding tissues by the infectious material. This can occur directly due to breaks in
the continuity of gland or duct.
Stage 3: If the infectious material localieses itself superficially in the subcutaneous
tissue of the anal wall, usually the posterior one, a dissolution of the anal skin results
in the formation of an ulcer of the anal skin, more commonly known as an anal
fissure.
CLINICAL FEATURES.
Pain:
The story of the condition is very much suggestive in cases of active anal
fissure. Acute anal pain is associated with and following stool. The pain starts with
the act of defaecation and is described as a sharp/ cutting or tearing; which
subsequently continues as a burning or gnawing discomfort for several hours (3 to 4
hours) following stool. To some patients the pain is so agonizing that they tend to
become constipated rather than go through the agony of defaecation. The reason of
pain following stool can be understood on the basis of pathophysiology of nervous
involvement of anorectal region. During defaecation the anal tissues are stretched and
the margins of the anal ulcer are separated. The first victim of anal fissure is the anal
integument /skin of the anal canal. The anal skin has somatic sensory nerve- supply
Pathology..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 52
further the sensitive nerve conveys its influence from the surface of the ulcer to the
spinal marrow, and the motor branch conveys the motor power from the spinal
marrow to the sphincter muscle thus the irritation engenderaed at the ulcer is
conveyed to the spinal marrow, thereby producing reflected effects upon the sphincter
muscle, leading to painful contraction, which continues until the muscle becomes
fatigued and at that time the patient feels relief. Hence the spasm of the muscle results
in pain, whereas, the fatigue results in relief.
Bleeding:
Bleeding may be present or may not be present. Usually the bleeding is quite
slight and amounts to little more than a streaking of the motion.
Swelling:
A large sentinal tag at the anus and may complain of having painful external
piles.
Discharge and Purities:
If there is much discharge this may lead to soiling of the underclothes, and to
increase moisture of the peri-anal skin with resulting pruritis around the anus.
Urinary symptoms:
Some times patients have developed disturbances of micturation by reflex
mechanism and C/O either dysuria and retention or increased frequency.
Pathology..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 53
Bowel habit:
The patient can quickly make out that is either initiated or aggravated by
defecation. So there is tendency to defer going to stool, thereby the normal bowel
habit is gradually taken over by the constipation.
Nervous Manifestation:
In stable individuals there may be no systemic reaction. Where as in less stable
persons there may be abdominal discomfort, digestive disturbances, headache,
irritability and extreme nervousness. There may be marked changes in the personality.
Differential Diagnosis..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 54
DIFFERENTIAL DIAGNOSIS:
Most of the conditions presenting with anal pain, swelling, bleeding can be
easily differentiated by examination. Thus haematoma, prolapsed haemorrhoids,
various types of abscesses in the anal region can be easily identified. However a few
ulcerative lesions which produce fissures in the anal skin such as carcinoma,
ulcerative colitis, Crohn’s disease, syphilitic ulcers, gonorrhoea requires more careful
discrimination.
ANAL ABRASION AND PRURITUS WITH SUPERFICIAL
CRACKS:
Anal abrasion is caused by passage of hard stools and it is usually found in
infants and children. These are superficial cracks which heal easily under proper anal
hygiene. In pruritus-ani several superficial cracks extending radially from anus are
found. Both these conditions are limited to superficial layer of skin and the
characteristic features of fissure in ano such as tenderness, spasm of internal sphincter
etc are absent. Thus these conditions can be differentiated from fissure in ano.
ULCERATIVE COLITIS:
Fissure-in-ano can be found in some types of ulcerative colitis in which
ulcerative lesions are a prominent feature. In this disease ulcers occur in large
intestine. Fissure-in-ano is a rectal manifestation of this disease and they are
extremely painful and become broad deep and very septic so that they readily lead to
Differential Diagnosis..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 55
abscess and fistula formation. They are often situated in the midline and may be
multiple in numbers. When ulcerative colitis involves the greater part of large
intestine, the diarrhoea and some constitutional symptoms are also manifested. If
proctocolitis is confined to the rectum and lower part of the sigmoid colon then the
patient may develop mild diarrhoea and little general disturbances with painful
fissures. Usually these fissures are inflamed.
Crohn’s disease:
Anal fissures can be found in Crohn’s disease affecting the large or small
intestine. The fissure appears grosser than idiopathic fissures and more similar to that
seen in ulcerative colitis. But it is more extensive than the latter. Histological
examination of the tissue obtained by biopsy confirms the disease. Sigmoidoscopy
may reveal disease in the rectum, but rarely rectal mucosa appears normal when the
intestinal lesion is situated at a higher level in the bowel.
Associated with carcinoma:
A > Squamous cell carcinoma of the anus.
b > Adenocarcinoma of rectum.
In both these conditions, the anal skin is involved and shows fissures
resembling chronic idiopathic fissures. There will be more induration than a simple
fissure. In chronic cases, these fissures form the lower most part of the more extensive
lesion of anal canal or rectum. These will be severe pain on defaecation. The inguinal
Differential Diagnosis..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 56
glands may become hard and enlarged. Histological examination of the tissue
obtained by biopsy confirms the diagnosis.
Phiranga Roga Anubandha (Associated with syphilis)
This infectious disease was more prevalent in Phiranga Desha hence the
disease was named as Phiranga. The mode of spreading is through contact with the
infected patient. Therefore it is considered as an aquired disease. There are three types
(1)Bahya (external) (2)Abhyantara (internal) (3) Bahyabhyantara (mixed).
Bahyabhyantara is characterized by painless ulcers. Triponema pallidium is the
causative organism. Fissures due to syphilis may either be primary chancre or
condylomas (secondary). A classic primary chancre is typically a single painless
papule which quickly erodes to from an ulcer with smooth base and firm raised
borders. These ulcers are usually painless. But there may be rectal pain, tenesmus, and
difficulty during defaecation and rectal discharge. The presence of symmentrical
lesions in either side of the anal canal will raise suspection. Anal condyloma affects
anal orifice as well as perianal skin. The anal region is moist and pruritic. The
presence of multiple superficial ulcers should raise the possibility of syphilis.
Secondary lesions and mucous patches are also present in the mouth. Dark ground
illumination of the sample of the discharge from the ulcer for spirochetes can confirm
the diagnosis. TPHA test and VDRL test are also used to diagnose the disease.
Differential Diagnosis..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 57
Tuberculosis:
Yakshma or Tuberculosis is an infectious communicable bacterial disease
caused by Mycobacterium tuberculosis. Rarely tuberculous ulcers can occur in anal
region. Early stages of this disease may present with a simple fissure and later shows
the characteristic undermined edge. Histological examination of the tissue obtained
from the ulcer edge will confirm the diagnosis.
HIV Infection:
With emerge of HIV infection it becomes an essential step to differentiate and
identify this condition, as it poses diagnostic and therapeutic problems. Recent studies
show that there is clear association between HIV seroposativity and ulcerative lesions.
Immuno compromised patients are susceptible to a wider range of diseases caused by
human immunodeficiency virus or other organisms such as bacteria, fungus, virus,
protozoa etc. ELISA test and western blot tests are the available tests to detect HIV
infection. Latest report says that it is possible to isolate the organism from the
materials obtained from the ulcerative lesions. In the HIV positive patient, benign
fissure and idiopathic AIDS ulcers are distinct processes. Ano-receptive intercourse
and diarrhoeal; illnesses predisposes the HIV positive homosexual to the development
of anal fissures which are typical in appearance and response to treatment. Idiopathic
anal ulcers are characterized by persistent gnawing pain, location above the dentate
line, a broad base, deep invasion, a patulous anus and AIDS. Debridement, excision
with mucosal advancement and Depo-Medrol injection has been successful.
Differential Diagnosis..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 58
AGRANULOCYTIC ANGINA:
The anal lesions of agranulocytic angina may appear first to resemble a typical
anal fissure. Usually this lesion fails to respond to normal treatment and then a
differential blood study show decreased leucocyte count and a low percentage of
granulocyte. Similar lesions can be found in mouth and throat. Thus the condition can
be differentiated from idiopathic benign fissure.
Associated with Gonorrhoea:
Pooyameha or Gonorrhoea is an infection caused by Neisseria Gonorrhoea.
Catteral in described a patient with a slightly erethematous rectal mucosa and small
ulceration at the anorectal junction. Lebedeff DA, Hochmann EB in described
superficial ulcerations and fissures in rectal gonorrhoea. However, high proportions of
rectal gonococcal infections are asymptomatic or produce mild symptoms including
constipation anorecatal discomfort, tenesmus or a mucopurulent discharge. A
diagnosis can be made by gram stain of rectal exudates obtained through anoscope
and culture of material obtained from biopsy.
Chancroid:
Chancroid is a genital ulcerative disease caused by Haemophillus ducreyi. The
anorectal manifestations of the disease have been described by carman. M.L.in 1984.
An errythematous tender papule develops at the site of inoculation and within a few
days it becomes pustular and develops into a painful ulcer. These ulcers have poorly
Differential Diagnosis..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 59
demarcated borders and a characteristic necrotic irregular base covered by
mucopurulent exudates. This is no surrounding erythema or induration, but there may
be associatd painful inguinal lymphadenopathy. Culture of material obtained from an
enlarged lymphnode for the H. ducreyi suggests a diagnosis.
Lymphogranuloma vernerum:
L. G.V. is caused by chalamydia trachomatis unilateral tender erythematous
lymphadenopathy will develop 2-3 weeks of the skin lesions. Fever malaise, hepatitis,
meningitis and conjunctivitis are the systematic disturbances manifested at this stage
of disease. Rectal involvement is manifested by rectal discharge and peri-rectal
fistulae or abscess cryptitis. Progressive stricture can cause sanniruddha guda / rectal
stricture in the absence of these symptoms in untreated cases. Culture of the organism
from the lesions and enlarged lymph nodes confirms the diagnosis.
Proctalgia fugax:
The characteristic feature of this disease is the intermittent attack of cramp like
severe pain in the rectum unrelated with organic disease. Pain often occurs at night
when the patient is in bed, usually lasts only a few minutes and disappears
spontaneously. The pain may be due to the segmental cramp of puborectalis muscle.
Ectropion:
Ectropion in reference to Ano- Rectal terminology means growth of rectal
mucosa distal to the former level of the dentate margin, where a portion of the wall of
Differential Diagnosis..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 60
the canal becomes lined by rectal mucous membrane instead of the anal skin. Careful
examination will reveal the smooth, velvety appearance of mucosa, no pain or spasm.
But constant mucoid discharge resulting in a soggy, macerated anal and perianal skin.
Pruritus ani with superficial cracks of anal skin:
Many cases of anal fissure develop pruritus ani due to irretation of perianal
skin by the discharge. In case of primary pruritus the skin shows superficial cracks
extending radially from the anus. There is no true anal spasm or tenderness in
thesecases.
Coccydynia:
The complaint of the patient is severe pain during defaecation. There is a history of
injury or fracture of the coccyax, which causes the contraction of levator ani, whiles
various movements. Whereas in some cases there is no history of fracture or injury
and such a condition is known as “COCCYDYNIA” of unknown aetiology. Rectal
examination reveals local tenderness and occasionally deformity.
COMPLICATIONS
Main complications are:
1. Abscess and fistula.
2. Sentinel tag.
3. Enlarged papilla
Differential Diagnosis..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 61
4. Anal contracture.
Treatment..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 62
TREATMENT
Most of the superficial fissure heals spontaneously often in 3 or 4 weeks, which have
short history of pain. On the other hand chronic fissures do not heal on the
conservative line of treatment. They may produce less symptoms but trouble may
recur frequently. To avoid trouble to the patient one should be anxious for a quick
judgment whether there is need of conservative line of treatment or surgical
intervention. Thus there could be two types of treatment for fissure-in-ano.
1. Medical or Conservative Treatment.
2. Surgical Treatment.
1. Medical Treatment:
(i) Palliative
(ii) Injection treatment
Palliative:
In this treatment warm sit bath, hot packs, careful cleaning of the anal outlet
following the passage of stools. (Anal Hygiene) and application of ointment and use
of laxative is common. In this treatment the laxatives play a major role to some extent.
Avoidance of Constipation:
This is most important point in the medical treatment for fissure-in ano.
Fric.L. has suggested for olive oil enema to avoid the constipation. John Wilson has
Treatment..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 63
advised to regularization of bowel habits with mineral oils or other stool softness and
Senna suppositories twice daily. If fissure is healed, care should be taken for
regularizing the bowel habits and constipation must be avoided. If this care is not
taken by the patient, there are more chances to recurrence of fissure.
Nitric oxide - has been identified as the chemical messenger of the intrinsic
nonadrenergic, non- cholinergic pathway mediating relaxation of the internal anal
sphincter. Topical application of nitroglycerin, a nitric oxide donor, causes a transient
lowering of resting anal pressure and an increase in anodermal blood flow.
Botulinum Toxin: Botulinum toxin has been injected into the external and internal
sphincters and, with short term follow up, healing rates of 80% have been achieved.
This approach is expensive and invasive compared to nitroglycerin.
Injection of long acting local anaesthetics: Sensory nerve supply to the skin in the
region of an anal fissure is divided from the inferior rectal nerves, and blocking of
these nerves by long acting anaesthetics injection can give relief from pain of fissure-
in-ano. These anaesthetics are prepared in sterile oily media, the object of which is to
delay the absorption of the anaethetics agents and prolong its local action. Well
known preparation Nupercaine and Proctocaine and so many other preparations are
available in the market now days.
Technique of Injection: Taking proper aseptic care the injection should be injected
producing a wheal of ½% lignocaine in the skin 2.5 cm. Behind the anal verge and
needle being injected at this part, 5-10 ml drug may be injected immediately behind
Treatment..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 64
the anus, deep to the fissure, and skin should be sealed with Tr.Iodine, Second
injection should not be given in less than 3 months, and it is probably unwise for this
treatment to be repeated within period of one year.
Use of the Anaesthetic ointment:
Now a day’s local anaesthetic are used as an ointment for relieving. The pain
and spasm of the fissure very frequently. This treatment is adopted by every
proctologist and every physician; popular preparations are 3% Decicaine
(amethocaine). Percailol or lignocaine 5%. The best time for application is before
defaecation and after defaecation, it can be used by the help of finger or by any
nozzle, but it should not touch the peri-anal skin because it produces local dermatitis
and pruritis (Goligher). Now day’s similar ointments with cortisone are also used.
Use of Anal Dilators:
Goligher suggested producing local anaesthesia by applying the local
anaesthetics and dilatation can be performed digitally.
Method: Under general anaesthesia with the patients in lithotomy position, the
lubricated, gloved index finger is inserted as far as the ano-rectal line and with the
palmer surface against the anal wall the muscle is stretched by firm pressure applied
in a rotatory motion. The index finger of the other hand is then introduced beside the
first, and firm pressure is made in opposite directions about the circumference of the
anus. This procedure should be carried out slowly, several minutes being consumed in
doing so.
Treatment..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 65
COMPLICATION OF THE MEDICAL TREATMENT:
The medical treatment is liable for so many complications, that this has gone
into disrepute. Regular use of such ointments cause local dermatitis and retard the
natural healing of the ulcer rather than promoting it,. Similarly in the injection
therapy, there are more chances of abscess formation and subsequent fistulae may
develop.. It may also produce incontinence due to paralysis of the sphincter, because
it has been seen that higher doses of these local anaesthetics definitely produce the
paralysis of anal sphincters by which the relief from pain is achieved. Moreover, in
anal dilatation there is the need of general anaesthesia and during dilatation there may
be profuse bleeding by an enthusiastic surgeon.
OPERATIVE TREATMENT:
There is correction of spasm and contraction of internal sphincter muscle by
stretching or by partial or complete division or excision of the fissure, so as to provide
a wide external wound in which the discharges cannot stagnate.
1. Stretching of the anal sphincter: It is simple operation and there is no need
of many instruments and other surgical accessories. Only by the help of fingers
this operation can be performed. Not only a surgeons but junior staff without
special equipment can also perform it easily. Thus this operation was made
popular by the surgeon for treating the cases of fissure-in-ano.
2. Technique: This operation can be performed even under local anaesthesia, but
it is better done under general anaesthesia preferably with a relaxant. With the
Treatment..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 66
patient in lithotomy or left lateral position, the anus is stretched by the help of
index and middle finger of the both hands. During this the forearms are fully
pronated so as to stretch the posterior wall of the anal canal. Better stretching is
obtained in male patients by using the sagittal rather than the transverse plane as
this avoids the fingers coming in contact, with the ischial tuberosities. This
problem does not arise in woman because of their wider pelvis.
3. Complication: Within few hours of stretching patients developed painful
perianal oedema.
4. Excision of Anal Fissure: Excision of broad triangle of skin of perianal region
along with the main lesion itself very important and provides relief, The advantage
of so doing, was that the apical part of the wound corresponding to the site of the
former fissure was given a chance to epithelization, so that there was little
prospect of being left with an unhealed area of granulation in the posterior wall of
the anal canal, so healing will not be impaired.
5. Excision of anal fissure with immediate Skin Grafting: In this technique
split thickness skin graft to the wound after the excision of the fissure, but there is
problem of Hospitalization and bowels must be confined for 5-6 days.
6. Division of the Internal Sphincter:
This technique is performed under general anaesthesia. By a short
longitudinal incision in the lining of the posterolateral part of canal it can be
obtained.
Treatment..
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 67
7. Technique of Open Posterior Internal Sphincterotomy.
This operation can be performed under a local anaesthetic blocker of the
inferior rectum nerves. For the actual operation patient should be turned on his left
lateral side. This technique should be done under general anaesthesia, because this
is much painful condition and after anaesthesia. it will be more convenient to do
operation in lithotomy position and then by the help of No. 7 Bard Parker knife
carrying a small no. 10 blade, this operation should be performed.
Complications:
There may be anal incontinence in the post-operative period another functional
defect is found that is faecal staining of the underclothes. The physiology of the
internal anal sphincter and its disturbance by internal sphincterotomy. It seemed
that faecal matter and flatus could leak down by this groove. The possibility that
lateral sphincterotomy has less prominent furrow on the anal canal than the
posterior sphincterotomy.
Complication:
Faecal Soiling of the underclothes and anal region in mid posterior
sphincterotomy.
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 68
DRUG REVIE
Ayurvedic treatises speak about the importance of drugs as ‘Nothing in world exists
which does not have the therapeutic utility.’ Taking this fact into consideration
Ayurvedic physicians have formulated single as well as compound drug for cure as
well as prevention of various ailments.
Selection of Drug:
In the present clinical research work, Yashtimadu gritha102 indicated for treatment of
Parikartika. Ingredients of Yashtimadu gritha also have sulaharaanulomana
,krimignaand Ropaņa properties that can help the wound to heal rapidly. Yashtimadu
Ghŗita is Sneha Kalpana and based on Ghŗita. Property of Ghŗita has been mentioned
as Vata-Pitta Shamaka, Madhura, Sheeta, Vişhahara, Ropaņa103, 104 Ghŗita is having
also soothing properties. It forms a thin layer over the wound and allows early
epithelization, also protects from invasion of any microbes. Ghŗita is also Samskara
Anuvarti 105
Ayurveda discriminates their particular features also and recommends the Go-Ghŗita
(cow Ghee) as best and the Ghŗita of choice for both, food and medicinal purposes and
in Ayurvedic Yoga if not specified, the Ghŗita always applies to Go-Ghŗita (Cow
Ghee).The present study was aimed towards providing easily accessible economic
treatment fo the common ailments fissure-in-ano. Yashtimadu Ghŗita is used for local
application. It is a simplest and easy formula.
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 69
To compare the effect of these therapies a control group of patients is
studied. Drug of the control drug is generally used in the patients of fissure-in-ano. As
a result of such for the better option for the standard control group – Yashtimadu Ghrita
and oral medication like abhayarista,gandaka rasayana is selected. Its Vraņa Ropaņa
and Śhodhana properties are well known and unanimously accepted, due to its dramatic
action on Vraņa like conditions. And it is obviously best option because it removes the
accumulated secretion in the fissure bed and also reduces thechances of secondary
infection thus, it reduces the pain. By application of these Ghrita, accelerates the wound
healing process.
YASHTIMADU GHRITA
YASHTI(GLYCYRRHIZA GLABRA LINN):
Glycyrrhiza glabra linn, is commonly known as ‘yashti in Ayurveda. It is also known as
‘liqarice in ’ in English ; ‘mulethi ’ in hindi ; ‘Kannada : Jestamadu,
Madhuka,Jyeshtamadhu longitudinally wrinkled, with occasional small buds and
encircling scale leaves,smoothed transversely, cut surface shows a cambium ring about
one-third of radius from outer surface and a small central pith, root similar without a pith,
fracture, coarsely fibrous in bark andsplintery inwood, odour, faint and characteristic,
taste,sweetish.
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 70
Chemical composition of wet 100gms yashtimadu contains.
Table No. 3
Shows Pharmacological properties & Action:-
Special Yogas: yashtimadu churna, yashtimadu Ghrita and Taila.
Glycyrrhizin
Asparagine, Starch
Glycyrrhizic acid
Sugars
Glycyrrhetinic acid,
Resin
Guna - Guru,Singda Rasa - Madhura.
Vipaka - Madhura. Veerya - Sheeta.
Doshagnata - Balya choksusha, Vrana Shodhaka.vrsya
Rakta Shodhaka,Raktaprasadana Ropaka, Varnya ,vatapittajith,
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 71
Haritaki:
Haritaki consists of the pericarp of mature fruits of Terminalia chebula Retz.
(Fam.Combretaceae)
Chemical composition:
Tannins, anthraquinones and polyphenolic compounds
Table No. 4
Pharmacological properties & Action:-
Guna -Laghu, Rooksha, Rasa – Madura,amla ,tikta,Katu,kashaya
Vipaka - Madura Veerya - Ushana
Doshagnata - caksusya,hrdya,dipana, Medya,sarvadoshaprasamanna
Pachana,rasayana ,anulomana Rakta Stambhaka.,
Useful parts: - Phala beeja. a)Macroscopic
Intact fruit yellowish-brown, ovoid, 20-35 mm long, 13-25 mm wide, wrinkled and
ribbed longitudinally, pericarp fibrous, 3-4 mm thick, non-adherent to the seed,taste,
astringent.
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 72
b) Microscopic
Transverse section of pericarp shows epicarp consisting of one layer of epidermalcells
inner tangential and upper portions of radial wall thick, mesocarp, 2-3 layers
ofcollenchyma, followed by a broad zone of parenchyma in which fibres and
sc1ereids ingroup and vascular bundles scattered, fibres with peg like out growth and
simple pittedwalls, sclereids of various shapes and sizes but mostly elongated, tannins
and raphides inparenchyma, endocarp consists of thick-walled sclereids of various
shapes and sizes, mostly elongated, epidermal surface view reveal polygonal cells,
uniformly thickwalled,several of them divided into two by a thin septa, starch grains
simple rounded or 62 oval in shape, measuring 2-7 µ in diameter, found in plenty in
almost all cells of mesocarp.
BIBITAKI:
Table No. 5
Pharmacological properties & Action:-
Guna - Laghu, Rooksha Rasa – Kashaya
Vipaka -Madura Veerya - Ushana
Doshagnata - caksusya,kaphapittajit kesya.
Bedaka ,kriminasahara, Kasahara,vibanda ,sarvabeda
Latin Name: Terntinalia belerica Roxb.
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 73
DESCRIPTION
a) Macroscopic
Fruit nearly spherical to ovoid, 2.5-4.0 cm in diameter, fresh ripe fruits Slightly
silvery or with whitish shiny pubescent surface, mature fruits grey orgrayish brown
withslightly wrinkled appearance, rind of fruit shows variationin thickness from 3-5
mm, taste, astringent.
b) Microscopic
Transverse section of fruit shows an outer epicarp consisting of a layer of epidermis,
most of epidermal cells elongate to form hair like protuberance with swollen
base,composed of a zone of parenchymatous cells, slightlytangentially elongated and
irregularly arranged, intermingled with stone cells of varying shape and size,elongated
stone cells found towards periphery and spherical in the inner zone of mesocarp in
groups of 3-10, mesocarp traversed in various directions by numerous vascular
strands, bundles collateral, endarch, simple starch grains and some stone cells found
in most of mesocarp cells, few peripheral layers devoid of starch grains, rosettes of
calcium oxalate 33 and stone cells present in parenchymatous cells, endosperm
composed of stone cells running longitudinally as well as transversely.
CONSTITUENTS - Gallic acid, tannic acid and glycosides.
IMPORTANT FORMULATIONS - Triphal churna, Triphaladi Taila,
Lavanagadi Vati.
THERAPEUTIC USES - Chardi, Kasa, K¤miroga, Vibandha, Svarabheda, Netraroga
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 74
DOSE - 3-6 g of the drug in powder .
USED PART:Seeds,root ,
AMALAKI:
Table No. 6
Pharmacological properties & Action:-
Guna - Laghu, Rooksha Rasa – Madura,amla,katu,tikta, Kashaya
Vipaka -Madura Veerya - sheeta
Doshagnata - caksusya,tridoshajit Vrsya,rasayana
Rakthapittanasana,amlapittanashana Rasayana
Amalaki consists of pericarp of dried mature fruits of Emblica officinalis Gaertn.Syn.
Phyllanthus emblica Linn.
DESCRIPTION
a) Macroscopic
Drug consists of curled pieces of pericarp of dried fruit occuring either asseparated
single segment; 1-2 cm long or united as 3 or 4 segments; bulk colourgrey toblack,
pieces showing, a broad, highly shrivelled and wrinkled external convex surface to
somewhat concave, transversely wrinkled lateral surface, external surface show s a
few whitish specks, occasionally some pieces show a portion of stony testa (which
should be removed before processing); texture rough, cartilaginous, tough; taste,
sourand astringent.
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 75
IMPORTANT FORMULATIONS – Cyavanaprasa, Dhatri, Lauha, Dhatryadi Ghuta,
Triphala churna.
THERAPEUTIC USES - Raktapitta, Amlapitta, Premeha, Daha.
DOSE - 3-6 g of the drug in powder form.8
MUSTA:
Musta consists of dried rhizome of Cyperus rotundus Linn. (Fam. Cyperaceae)
occurring throughout the country, common in waste grounds, gardens and roadsides,
upto an elevation of 1800 m.
Table No. 7
Pharmacological properties & Action:-
Guna - Laghu, Rooksha Rasa – katu ,tikta, Kashaya
Vipaka -Katu Veerya - sheeta
Doshagnata -sotahara,dipana pachana Grihi ,krimigna ,vishagna
Pittakaphahara,sthoulyahara Trsnanirgarana ,tvakdoshahara,jvaragna.
DESCRIPTION -
a) Macroscopic
Drug consists of rhizome and stolon having a number of wiry roots, stolon 10-20cm
long having a number of rhizomes, crowded together on the stolons, rhizomes bluntly
conical and vary in size and thickness, crowned with the remains of stem and leaves
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 76
forming a scaly covering, dark brown or black externally, creamish-yellow
internally;odour, pleasant.
b) Microscopic:
Rhizome shows single layered epidermis, followed by 2-6 layers,
suberisedsclerenchymatous cells; epidermis and outer sclerenchymatous layers filled
with dark brown content; ground tissue of cortex consists of circular to oval, thin-
walled, parenchymatous cells with small intercellular spaces; a few fibro-vascular
bundles present in this region; endoderm is distinct and surrounding the stele; wide
central zonebeneath endodermis,
CONSTITUENTS - Volatile Oil
IMPORTANT FORMULATIONS –
Musakarista, Mustakadi Kvatha, Ashokarista, Mustakadi churna, Mustakadi Lehyaetc
THERAPEUTIC USES - Agnimandya, Ajerna, Jvara Kasa, Mutrakucchra, Vamana,
Stanyavikara, Sutikaroga,Atisara, Ëmavata, Krimiroga
DOSE - 3-6 g. (Powder).20-30 ml. (Kwatha).
HARIDRA:
Haridra consists of the dried and cured rhizomes of Curcuma longa Linn.
(Fam.Zingiberaceae), a perennial herb extensively cultivated in all parts of the country,
crop is harvested after 9-10 months when lower leaves turn yellow rhizomes carefully
dug up with hand-picks between October-April and cured by boiling and dried.
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 77
Table No. 8
Pharmacological properties & Action:-
Guna - Rooksha Rasa – katu ,tikta,
Vipaka -Katu Veerya - ushna
Doshagnata -krimigna,kushagna Vranya,vishagna
Kaphapitantu Pramehanashaka
DESCRIPTION
a) Macroscopic
Rhizomes ovate, oblong or pyriform (round turmeric) or cylindrical, often short
branched (long turmeric), former about half as broad as long, latter 2-5 cm long and
about 1-1.8 cm thick, externally yellowish to yellowish-brown with root scars and
annulations of leaf bases, fracture horny, fractured surface orange to reddish
brown,central cylinder twice as broad as cortex: odour and taste characteristic.
b) Microscopic
Transverse section of rhizome shows epidermis with thick-walled, cubical cells Of
various dimensions, cortex characterised by the presence of mostly thin-walled
rounded parenchyma cells scattered collateral vascular bundles, a few layers of cork
developed under epidermis and scattered oleo-resin cells with brownish contents;
cork generally composed of 4-6 layers of thin-walled, brick-shaped parenchyma, cells
of ground tissue contain starch grains of 4-15 µ in diameter, oil cell with suberised
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 78
walls containing 60.either orange-yellowglobules of volatile oil or amorphous
resinous matter, vessels mainly spirally thickened, a few reticulate and annular.
CONSTITUENTS - Essential oil and a colouring matter (curcumin).
IMPORTANT FORMULATIONS – Haridra Khanda
THERAPEUTIC USES - Pandu, Prameha, Vrana, Visavikara, Kstha, Tvagroga
raktapitta pachana
DOSE - 1-3 g of the drug in powder .
MATULUNGA:
Table No. 9
Pharmacological properties & Action:-
Guna - Lagu Rasa – Mdura
Vipaka -Madura Veerya - shita
Doshagnata - vata pittanashaka Pidanashaka
Swasa kasahara Amlapittanashaka
GO – GHŖITA
Latin Name: Butyrum departum
Gaņa: Mahasneha (Su. Ca.)
Vernacular Names:
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 79
Sanskrit: Ghŗita English: Clarified butter
Hindi: Ghee Gujarati: Ghee
Synonyms: Aajya, Havis, Snehottama, Varasneha, Sarpi
Pharmacodynamics:
Rasa: Madhura Guņa: Guru, Snigdha, Mŗidu
Virya: Sheeta Vipaka: Madhura
Doshakarma: Vata- Pittahara
Actions and Uses: Ghee is the clarified butter fats. It promotes Agni, Sukra and
lengthens the life span. Attributes of Ghee i.e. unctuousness and coldness are
antagonistic to those ofVata and Pitta like dryness, lustreless, roughness and heat
respectively. Moreover, boilinwith Kapha antagonist drugs (like pungent, bitter taste),
prepared medicated Ghee caninhibit the action of deranged Kapha due to its
assimilating properties.
According to Bhavapraksha, Suśhruta, Charaka and almost all Acharya Go-Ghrita is
also beneficial for visual acuity by oral as well as local use. It also improves Dhi, Dhŗti
and Smŗti. It is good for complexion, voice and in Kşhatakşhiņa, Visarpa, toxins,
Unmada etc
. (A. H. Su. 5/37-39)
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 80
Chemical Constituents:
Go – Ghrita contains carotene in the amount of 3.2 – 7.4 g/g, vitamin A in the amount
of 19 – 34 I.U./g and Tocopherol (vitamin E) in the amount of 26 – 48 g in it. It also
contains vitamin D and K. (Source: Milk products of India by Srinivasan and
Anantakrishnan)
The principal contents are triglycerides or neutral fats. Fatty acid contents in
percentage by weight of different fatty acids is as follows: saturated – c14, below 3.0
palmitic (c10) 29, stearic (c18)21, c20 and above 1.0; monounsaturated – palmitoleic
(c16)3, oleic (c18) 41; polyunsaturated; linoleic (c18: 2)2, arachidonic (c20: 4) and c22
and higher in trace.
(Beaton G. H. McHenry W. E. 1964)
PREPARATION OF YASHTIMADU GHRITA:
Ingredients: - Yashtimadu gritha .
Kalka Dravyas: - 1 part (Amalaki,vibitaki,Haritaki,Hridra,Musta,matulunga swarasa)
Snehana Dravya: Murcchita Ghrita – 1 part ( 4 .1/2 liters)
Drava Dravya - Jala 4parts.
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 81
Method of preparation:
Taken 1 part of kalka dravyas,and 1 part of sneha dravyas,4 part of drava
dravyas taken in a big vessel heated on moderate flame till only ghee part remains. after
snehasiddi lakshanas remove preparation from heat. Filter the yashtimadu gritha and
stored in steel container104.
Mode of Action:
Yeashtimadu Ghŗita is having properties like sulahara ,anulomana, dipana,
krimign pachana Shodhana, Vraņa Ropaņa, Shothahara, Thus it removes the
accumulated secretions in the fissure bed; it promotes healing and also reduces probable
secondary infections.
Method of Administration:
Yashtimadu Ghrita Pichu in Guda-Marga
Indication: - Vrana Shodhaka, Vrana Ropaka, Pittaja Vrana, Nadi Vrana and Dust
Vrana. In this study Ghrita preparations were used because Ghrita preparations are said to
be coolantsand Vata Pittaharas. Ghee which is the base for the preparation of yashtimadu
Ghrita It accelerates the process of healing; reduce sphincter spasm of the Vrana when
applied locally.
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 82
Drug review.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 83
PREPARATION OF GRITHA
Yastimadu churna Murchitha ghritha
Adding churna to grithaAdding matulunga
swarasa
Heating mixture of all drugs
Pure yeashtimadu gritha
Materials and methods.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 84
MATERIALS AND METHODS:
SOURCE OF DATA
a) LITERARY SOURCE:
The source of parikartika is collected from the various classical texts of Ayurveda &
Modern Science, updated with journals and internet.
b) CLINICAL SOURCE:
Patients suffering from parikartika as per Ayurvedic classics, will be selected from the
OPD and IPD of RGES Ayurvedic Medical College and Hospital, RON
c) Drugs: The trial drug “yastimadhu” is collected from the local area and certified by
the Dravya Guna department.
Preparation of Yashtimadhu ghritha
Yashtimadhu ghritha preparation as per Bhaishajya Kalpana Ayurvedic text12
METHOD OF COLLECTION OF DATA:
The patients who are presenting with the features of Parikartika which can be
correlated with Fissure-in-ano in modern science, symptoms like excruciating pain in
anal region during and after defecation, constipation, bleeding per anum i.e. stools
streaked with blood, burning sensation in anal region, presence of longitudinal tear in
the anal region and sphincter spasm shall be selected for study.
Materials and methods.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 85
A. INCLUSION CRITERIA:
Patients having classical features of Fissure-in-ano namely excruciating pain in anal
region during and after defecation, bleeding per anum, constipation, burning
sensation, presence of sphincter spasm and with a longitudinal ulcer in the anal region
will be selected.
Acute solitary fissures will be included.
Patients suffering from parikartika as per Ayurvedic classics will be selected.
B. EXCLUSION CRITERIA:
Patients suffering from any other ano rectal diseases.
Patients suffering from systemic disorders like HTN, DM etc
Patient suffering from infectious disease like HIV, tuberculosis etc
DIAGNOSTIC CRITERIA
Signs & Symptoms
Pain in anal region
Constipation
Bleeding per anum i.e. stools streaked with blood
Burning sensation in anal region.
STUDY DESIGN:
A Compairitive clinical study with pre test and post test design.
Materials and methods.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 86
SAMPLE SIZE:
20 cases of each group (group A and group B) either sex and age group of 20 to 60
years suffering from Parikartika are randomly selected and submitted for clinical
trial.
GROUP-A
(CONTROL GROUP)
Patient treated with Yashtimadhu ghritha pichu
Aabhayarishta (3 tsf, t i d daily ) + Gandhaka
Rasayana(1 tab. t i d daily) and advised sitz bath twice
daily.
GROUP-B
(TRIAL GROUP)
Patient treated with Yashtimadhu ghritha pichu +
DURATION OF TREATMENT: Seven days
FOLLOW UP: - up to 2 months.
SOURCE OF FORMULATION:
Yashtimadhu ghritha will be prepared in the Rasa Shastra & Bhaishajya kalpana
Dept. of R G E S Ayurvedic Medical College, Hospital PG Studies & Research
centre, Ron, according to the classical references.
Materials and methods.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 87
ASSESSMENT OF RESULTS
Depending upon subjective & objective parameters, assessment of response will be
made based on Gradation Index mentioned below.
Statistical analysis will be made using unpaired‘t’ test.
PARAMETERS OF STUDY:-
The improvement provided by therapy will be assessed on the basis of classical signs
and symptoms. All the signs and symptoms will be assigned with a score depending
upon their severity to assess the effect of the drugs objectively.
CRITERIA FOR ASSESMENT:
Assessment will be done based on the following parameter:-
GRADING FOR THE ASSESSMENT CRITERIA:-
FOR SUBJECTIVE PARAMETERS:
Pain;
No pain - 0
Mild -1
Moderate -2
Severe -3
Constipation:
No constipation - 0
Mild -1
Moderate -2
Severe -3
Materials and methods.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 88
Bleeding:
No -0
Mild -1
Moderate -2
Severe -3
Burning sensation:
No -0
Mild -1
Moderate -2
Severe -3
b. Objective parameters:
Ulcer healing
Sphincter spasm.
Proctitis
Ulcer healing
Size of the ulcer is measured in mm and filled in the digits.
Materials and methods.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 89
Sphincter spasm
Symptoms Normal Spasmodic
Grading 0 1
Proctitis:
Proctitis Absent Present
Grading 0 1
7.3) Does the study require any investigations or interventions to be conducted on
Patients or other humans or animals? If so please describe:
Yes
Study will be a human observational study. No animal experimentation will be
conducted.
INVESTIGATIONS:
HB
TC
DC,ESR
HIV, HBsAg
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
YES (Copy Enclosed)
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 90
The efficacy of Yashtimadu Ghrita and control group has been studied in 20
patients of Parikartika (Fissure-In-Ano). These patients were divided into two group’s
viz. Control group internal medication (Abhayarista, gandaka rasayana) and
Yashtimadu Ghritha Pichu Group A and Yashtimadu Ghrita Pichu Group B . Each
group comprises of 20 patients.
All the patients of Parikartika were analyzed for their age, sex, socio-economic status,
religion, diet, etc. The details of these observations were as follows:
Age: The age wise distributions of 20 patients showed that maximum number of
patients i.e. 55% belonged to age group of 20-30 years, followed by 27.5% patients to
31-40 years and 12.5% patients to 41 – 50 years. Lastly 5 % patients belonged to age
Group of 51 - 60 years. (Table-10, Graph No.1)
Table- 10
Age wise distribution of 40 patients of Fissure-in-Ano
Age
Group A Group B Total
No % No. % No. %
20 – 30 12 60% 10 50% 22 55%
31 – 40 04 20% 07 35% 11 27.5%
41 – 50 03 15% 02 10% 05 12.5%
51 – 60 01 5% 01 5% 02 05%
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 91
Sex: Among 40 patients, in Group A 75 % were male, 25 % were female.
In Group B 75 % were male, 25 % were female. (Table-11, Graph No2)
Table-11
Sex wise distribution of 40 patients of Fissure-in-Ano
sex
Group A Group B Total
No. % No. % No. %
Female 5 25 % 5 25% 10 25
Male 15 75 % 15 75 % 30 75
0
5
10
15
20
25
No % No. % No. %
Group A Group B Total
Age wise distribution
20 – 30
31 – 40
41 – 50
51 – 60
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 92
Socio- Economic Status: Among 40 patients, in Group A 30% patients were in lower
class 65% patients in middle class and 5% patients in high class. In Group B 5 %
patients were in lower class ,90% patients in middle class and 5% patients in high
class (Table-12 graph- 3 )
No. % No. % No. %
Group A Group B Total
525%
525%
10
25
15
75%
15
75%
30
75
Sex wise distributionFemale Male
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 93
Table- 12
Socio economic status wise distribution of 30 patients of Fissure-in-Ano
Socio economic
status
Group
A(Control)
Group
B(trail ) Total
No. % No. % No. %
Lower class 06 30 % 1 5% 7 17.5%
Middle class 13 65% 18 90% 31 77.5%
High class 01 5 % 1 5 % 2 5%
0
5
10
15
20
25
30
35
No. % No. % No. %
Group A(Control) Group B(trail ) Total
Socio economic status
Lower class
Middle class
High class
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 94
Diet: While observing the nature of diet, in Group A- it was found that mixed diet
patients were majority in number i.e. 100% and vegetarian diet patients were 0%. In
Group B 100 % patients were mixed diet and 0 % patients were vegetarian diet (Table
No 13 Graph No.4)
Table- 13
Diet Habit wise distribution of 40 patients of Fissure-in-Ano
Diet habit
Group A Group B Total
No. % No. % No. %
Vegetarian 0 0 0 0 0 00
Mixed 20 100 20 100 40 100
No. % No. % No. %
Group A Group B Total
0 0 0 0 0 020
100
20
100
40
100
Diet Habit Vegetarian Mixed
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 95
Religion: Cases were analysed in view of their religion, out of 40 cases, in Group A
100% were Hindus and 0 % was Muslim. In Group B 95 % patients were Hindu 5%
Muslim (Table No14)
Table-14
Religion wise distribution of 40 patients of Fissure-in-Ano
No. % No. % No. %
Group A Group B Total
20
100
19
95
39
97.5
0 0 1 5 1 2.5
Religion wise Hindu Muslim
Religion
Group A Group B Total
No. % No. % No. %
Hindu 20 100 19 95 39 97.5
Muslim 0 0 1 5 1 2.5
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 96
Occupation: Among 40 patients, in Group A 50% patients were in Job holder , 10%
patients students and 20% patients were agriculture 4% house wife. In Group B 30%
patients were in Job holder, 20% patients were Student and 40% patients were
Agriculture 10% House wife(Table-15, Graph No 4
Table-15
Occupation wise distribution of 40 patients
of Fissure-in-Ano
Occupation
Group A Group B Total
No. % No. % No. %
Job holder 10 50 % 06 30% 16 40
Students 2 10 % 04 20 % 6 15
Agricultures
04 20 % 08 40 % 12 30
House wife 4 20% 02 10% 6 15
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 97
Habitat: Patients were analyzed in view of their habitat. Out of 40 patients of
Parkirtika in Group A. 80 % patients were reported from rural area and 20 % patients
from urban area. In Group B 40 % patients were reported from rural area and 60 %
patients to urban area. (Table No16)
Table No.16
Incidence of Habitat of 40 patients Of Fissure-in-Ano
Habit
Group A Group B Total
No. % No. % No. %
Rural 16 80 8 40 24 60
Urban 4 20 12 60 16 40
0
5
10
15
20
25
30
35
40
No. % No. % No. %
Group A Group B Total
Occupation wise
Job holder
Students
Agricultures
House wife
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 98
Previous surgery: Patients were classified into two groups on the basis of surgical
treatment reported (recurrent) and non-operated (fresh) cases. Out of 40 patients, in
Group A 0 % were reported as operated and 20 % were non-operated. In Group B,
15% patients were reported as operated and 85% patients were non-operated. (Table-
17 Graph No5)
Rural Urban
164
80
208 12
40
60
2416
60
40
Incidence of Habitat Group A No. Group A % Group B No. Group B % Total No. Total %
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 99
Table No-17
Distribution of patients in relation to Previous Surgery of
40 patients of Fissure-in-Ano
Surgery
Group A Group B Total
No. % No. % No. %
Operated 0 0 3 15% 3 7.5%
Non-operated 20 100% 17 85% 37 92.5%
Bleeding per rectum: Out of 40 patients, in Group A 50% patients were having
bleeding per rectum,50% patient not having bleeding & in Group B also 60% patients
were having bleeding per rectum.40% patient not having bleeding (Table-18, Graph-
6)
05
10152025303540
No. % No. % No. %
Group A Group B Total
Relation to Previous Surgery
Operated
Non-operated
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 100
Table-18
Bleeding per rectum wise distribution of 40 patients of Fissure-in-Ano
Bleeding per rectum
Group A Group B Total
No. % No. % No. %
Present 10 50% 14 70% 24 60%
Absent 10 50% 06 30% 16 40%
Vibandha: Out of 40 patients, in Group A 100 % patients were having Vibandha
00% patients were reported normal stool habit. In Group B 100% % patients were
having Vibandha and (Table-19)
No. % No. % No. %
Group A Group B Total
10
50%
14
70%
24
60%
10
50%
6
30%
16
40%
Bleeding per rectum Present Absent
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 101
Table-19
Vibandha (constipation) wise distribution of 40 patients of
Fissure-in-Ano
Vibandha
Group D Group G Total
No. % No. % No. %
Present 20 100% 20 100% 40 100%
Absent 00 00% 00 00% 00 00%
Pain (burning sensation): In Group D, 20% patients were reported having moderate
pain but 80% patients were reported having severe pain. In Group G, 26.7% patients
were reported having moderate pain but 73.3% patients were reported having severe
pain. (Table-16, Graph- 7)
No. % No. % No. %
Group D Group G Total
20
100%
20
100%
40
100%0 0% 0 0% 0 0%
Vibandha (constipation)Present Absent
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 102
Table-20
Pain (Burning sensation) wise distribution of
40 patients of Fissure-in-Ano
Distribution of patients in relation to Associated Lesions: Out of 40 patients in
both the groups, No case was observed of having any associated disease (Table-17)
0
5
10
15
20
25
30
35
No. % No. % No. %
Group A Group B Total
Pain (Burning sensation)
No pain
Mild
Moderate
Severe
Pain
Group A Group B Total
No. % No. % No. %
No pain 00 0 00 00 00 00
Mild 01 05% 02 10% 03 7.5%
Moderate 16 80% 18 90% 34 85%
Severe 03 15% 00 00% 03 7.5%
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 103
Table No. 21
Distribution of patients in relation to Associated Lesions of 40
patients of Fissure-in-Ano
Associated Lesions
Group A Group B Total
No. No. No. %
Piles 0 0 0 0
Sentinel tag 0 0 0 0
Abscess 0 0 0 0
Prolapse 0 0 0 0
Malignancy 0 0 0 0
Total 0 0 0 0
Position of Fissure-in-Ano: In Group A 50 % patients were recorded to have
posterior fissure, 35% patients were recorded to have anterior fissure and 15 %
patients had both anterior & posterior fissure in ano. Whereas in Group B, 45%
Piles Sentinel tag Abscess Prolapse Malignancy Total
0 0 0 0 0 00 0 0 0 0 00 0 0 0 0 00 0 0 0 0 0
Relation to Associated Lesions Group A No. Group B No. Total No. Total %
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 104
patients were reported having posterior fissure, 40% patients were reported having
anterior fissure and 15% patients had both anterior & posterior fissure in ano. (Table-
22)
Table No-22
Distribution of patients in position of fissure in ano of
40 patients of Fissure-in-Ano
Position
Group A Group B Total
No. % No. % No. %
Posterior 10 50% 09 45% 19 47.5%
Anterior 07 35% 08 40% 15 37.5%
Both 03 15% 03 15% 06 15%%
Posterior Anterior Both
0
107
30 50% 35% 15%0
9 8
30 45% 40% 15%0
19
15
6
Position of Fissure in AnoGroup A Group B Total
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 105
EFFECTS OF THE THERAPIES
In thise series 40 patients of Parikartika (Fissure-In-Ano) were treated in 2
groups each comprising of 20 patients. The patients of one group were applied Pichu
of yeashtimadu Ghrita and internal medication(Gandaka rasayana,abhayarista)
(Group A) and patients of other group were applied the Pichu of Yeashtimadu Ghrita
(Group B). The results obtained are being described under the heading of each group.
EFFECTS OF YASHTIMADU GHRITA PICCHU AND ORAL
MEDICATION
As mentioned above a group of 20 patients suffering from Parikataka was
treated with local application of Pichu dipped in Yashtimadu Ghrita (Group A) two
times a day for 7 days. Its effect on the various signs and symptoms were as follow:
1. Effect of yashtimadu Ghrita and oral medication Treatment for 7 Days:
Guda Shoola: The initial mean score of the symptom Shoola was 3.00 which was
reduced to 1.75 at the end of 7th day. Its statistical analysis shows highly significant
result at <0.001 level.
Rakta Srava: The initial mean score of the symptom Rakta Srava was 2.00. This was
reduced to 1.15 at the end of 7th day. It was statistically highly significant result at
<0.001 level
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 106
Viband: The initial mean score of the symptom Vibanda was 3.00. This was reduced
to 1.85 by 38% at the end of 7th day. It was statistically highly significant result at
<0.001 level
Gudadaha(burning sensation): The initial mean score of the symptom gudatapa was
2.0 This was reduced to 1.0 by 50 % at the end 7th day. It was statistically highly
significant result at <0.001 level
Size of Ulcer: The initial mean score of the size of ulcer was 2.00 which was reduced
to 0.80 (60%) at the end of 7th day. Its statistical analysis shows highly significant
result at <0.001 level
Sphincter spasm : The initial mean score of the symptom sphincter spasm was 1.00
which was increased to 0.85 by 15% at the end of 7th day. It shows statistically highly
significant result at <0.001 level
proctitis : The initial mean score of the symptom proctitis was 1.00 which was
increased to 0.9 by 10% at the end of the 7th day. It shows statistically highly
significant result at <0.001 level.
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 107
TABLE-23
ASSESSMENT OF SIGN & SYMPTOMS BEFORE
TREATMENT AND AFTER TREATMENT
Signs & Symptoms
Mean BT
Mean AT
% of Change
SD ()
SE () t* P
Shoola 3.00 1.75 41.66 0.44 0.09 17.61 <0.001
Rakta
Srava 2.00 1.15 42.5 1.13 0.25 4.52 <0.001
Vibanda 3.00 1.85 38.0 0.48 0.10 16.9 <0.001
Gudadaha 2.00 1.00 50 0.56 0.12 15.9 <0.001
Size of
ulcer 2.00 0.80 60 0.52 0.11 6.83 <0.001
Sphincter
spasm
1.0 0.9 10 0.30 0.06 13.0 <0.001
Proctitis 1.0 0.9 10 0.30 0.06 13.0 <0.001
ASSESSMENT OF SIGN & SYMPTOMS BEFORE TREATMENT AND
AFTER FU:
Guda Shoola: The initial mean score of the symptom Shoola was 3.00 which reduced
to 0.1.67 at the end of the follow up. This 44.33% reduction in pain was statistically
highly significant at P<0.001 level.
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 108
Raktasrava: The initial mean score of the symptom Rakta Srava was 2.00. This was
reduced to 1.40 by 30% at the end of follow up. It was statistically highly significant
result at <0.001 level
Viband: The initial mean score of the symptom Vibanda was 3.00. This was reduced
to 1.50 by 50% at the end of follow up. It was statistically highly significant result at
<0.001 level
Gudatapa(burning sensation): The initial mean score of the symptom gudatapa was
2.00. This was reduced to 1.40 by 30% at the end of follow up. It was statistically
highly significant result at <0.001 level
Size of Ulcer: The initial mean score of the size of ulcer was 2.00 which was reduced
to 1.13 (33.5%) at the end of follow up Its statistical analysis shows highly significant
result at <0.001 level
Sphincter spasm : The initial mean score of the symptom sphincter spasm was 1.00
which was increased to 0.75 by 25 % at the end of follow up. It shows statistically
highly significant result at <0.001 level (Table-23).
proctitis : The initial mean score of the symptom proctitis was 1.00 which was
increased to 0.75 by 2 5% at the end of follow up. It shows statistically highly
significant result at <0.001 level (Table-23).
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 109
TABLE No. 24
ASSESSMENT OF SIGN & SYMPTOMS BEFORE
TREATMENT AND AFTER FU
Signs & Symptoms
Mean BT Mean AF % of
Change SD ()
SE () t* P
Shoola 3.00 1.67 44.33 0.49 0.13 10.58 <0.001
Rakta
Srava 2.00 1.40 30 0.51 0.13 4.58 <0.001
Vibanda 3.00 1.50 50 0.52 0.13 4.58 <0.001
Gudatapa 2.00 1.40 30 0.51 0.13 4.58 <0.001
Size of
ulcer 2.00 1.13 43.5 0.35 0.09 6.53 <0.01
Sphincter
spasm 1.00 0.75 25 0.26 0.07 9.33 <0.001
Proctitis 1.00 0.75 25 0.26 0.07 10.0 <0.001
EFFECTS OF YASHTIMADU GRITHA
A group of 20 patients suffering from Parikataka was treated with local application of
Pichu dipped in Yashtimadu gritha (Group B) two times a day for 7 days. Its effect
on the various signs and symptoms were as follow:
1. Effect of Yashtimadu gritha Treatment for 7 Days:
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 110
Guda Shoola: The initial mean score of the symptom Shoola was 3.00 which were
reduced to 1.8(40%) After treatment. Its statistical analysis show significant result at
<0.001 level.
Raktasrava: The initial mean score of the symptom Rakta Srava was 2.00. This was
reduced to 1.40(30%) after the treatment. It was statistically significant result at <0.01
level
Viband: The initial mean score of the symptom Vibanda was 3.00. This was reduced
to 0.1 by 96 % at the end of after the treatment. It was statistically highly not
significant result at >0.05 level
Gudatapa(burning sensation): The initial mean score of the symptom gudatapa was
3.00. This was reduced to 1.85 by 38% at the end of after treatment. It was
statistically highly significant result at <0.001 level
Size of Ulcer: The initial mean score of the size of ulcer was 2.00 which was reduced
to 0.9 (55%) at the end of after the treatment. Its statistical analysis shows highly
significant result at <0.001 level
Sphincter spasm : The initial mean score of the symptom sphincter spasm was 1.00
which was increased to 0.8 by 20% at the end of after the treatment. It shows
statistically highly significant result at <0.001 level
proctitis : The initial mean score of the symptom proctitis was 1.00 which was
increased to 0.95 by 5% at the end after the treatment. It shows statistically highly
significant result at <0.001 l
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 111
TABLE- 25
ASSESSMENT OF SIGN & SYMPTOMS BEFORE TREATMENT AND AFTER TREATMENT
Signs & Symptoms
Mean BT Mean AT % of
Change SD ()
SE () t* P
Shoola 3.00 1.8 40.0 0.49 0.09 19.6 <0.001
Rakta
Srava 2.00 1.40 30 0.88 0.19 7.09 <0.001
Vibanda 3.00 0.1 96.6 0.30 0.06 1.4 >0.05
Gudatapa 2.0 1.00 50 0.36 0.08 22.5 <0.001
Size of
ulcer 2.00 0.9 55 0.55 0.124 7.28 <0.001
Sphincter
spasm
1.0 0.95 5. 0.22 0.05 19.0 <0.001
Proctitis 1.0 0.95 5. 0.22 0.05 19.0 <0.001
ASESSMENT OF SIGN & SYMPTOMS BEFORE TREATMENT AND
AFTER FALLOW UP:
Guda Shoola: The initial mean score of the symptom Shoola was 3.00 which were
reduced to 1.67 (44.33%) at the end of fallow up. Its statistical analysis shows
significant result at <0.001 level.
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 112
Rakta-Srava: The initial mean score of the symptom Rakta Srava was 2.00. This was
reduced to 1. 40(30%) at the end of fallow up. It was statistically significant result at
<0.001 level
Viband: The initial mean score of the symptom Vibanda was 3.00. This was reduced
to 0.1 by 96 % at the end of fallow up. It was statistically not significant result at
>0.05 level
Guda daha (burning sensation): The initial mean score of the symptom gudatapa
was 2.00. This was reduced to 1.40 by 30% at the end of fallow up. It was statistically
highly significant result at <0.001 level
Size of Ulcer: The initial mean score of the size of ulcer was 2.00 which was reduced
to 1.13 (30%) at the end of fallow up. Its statistical analysis shows highly significant
result at <0.001 level
Sphincter spasm : The initial mean score of the symptom sphincter spasm was 1.00
which was reduced to 0.75 by 25% at the end of the fallow up. It shows statistically
highly significant result at <0.001 level (Table-25).
proctitis : The initial mean score of the symptom proctitis was 1.00 which was to
1.75 by reduced 25% at the end of the fallow up. It shows statistically highly
significant result at <0.001 level (Table-26)
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 113
TABLE- 26
ASSESSMENT OF SIGN & SYMPTOMS BEFORE
TREATMENT AND AFTER TREATMENT
Signs & Symptoms
Mean BT Mean AF % of
Change SD ()
SE () t* P
Shoola 3.00 1.67 44.33 0.49 0.13 10.58 <0.001
Rakta
Srava 2.00 1.40 30 0.51 0.13 4.58 <0.001
Vibanda 3.00 0.1 96 0.308 0.069 1.4 >0.05
Gudatapa 2.00 1.40 30 0.51 0.13 4.58 <0.001
Size of ulcer 2.00 1.13 43.5 0.35 0.09 6.53 <0.01
Sphincter
spasm 1.00 0.75 25 0.26 0.07 9.33 <0.001
Proctitis 1.00 0.75 25 0.26 0.07 10.0 <0.001
Overall effect
Evaluation of pain between two groups: Group A showed a Complete relief in pain
during therapy at the end of 7th day 80 % patients got relieved, and at the end of 2
months 90 % patients got relieved which was statistically highly significant at the
level of p <0.001
Group B showed relief in pain during therapy at the end of 7th day 80% patient got
relieved, which was statistically significant and at the end of 2 months 85 % patients
got relieved which was statistically significant at the level of p <0.001
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 114
Table- 27
Evaluation of pain between two groups
Evaluation of bleeding between two groups:
Group A showed a Complete relief in bleeding during therapy at the end of 7th
day 95 % patients got relieved, and at the end of 2 months 95 % patients got relieved
which was statistically highly significant at the level of p <0.001
Study
period Group
No.of
patients
Pain (shoola)
P value No
pain Mild Moderate Severe
Before
treatment
Group A 20 00 03 15 02 -
Group B 20 00 01 18 01 -
After
Treatment
Group A 20 16 04 00 00 <0.001
Group B 20 16 04 00 00 <0.001
After
fallow
Up
Group A 20 18 02 00 00 <0.001
Group B 20 17 03 00 00 <0.001
Over all
out come
Group A 20 18 02 00 00 <0.001
Group B 20 17 03 00 00 <0.001
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 115
Group B showed relief in bleeding during therapy at the end of 7th day patient
got 90% relieved, which was statistically significant and at the end of 2 months 95 %
patients got relieved which was statistically not significant at the level of p <0.001
Table-28
Evaluation of bleeding between two groups
Evaluation of constipation between two groups: Group A showed a Complete relief
in Constipation during therapy at the end of 7th day 85 % patients got relieved, and at
Study
period Group
No.of
patie
nts
BLEEDING
P value No
bleeding Mild Moderate Severe
Before
treatment
Group A 20 09 01 07 03 -
Group B 20 05 02 13 00 -
After
Treatment
Group A 20 19 01 00 00 >0.001
Group B 20 18 02 00 00 >0.001
After
fallow
Up
Group A 20 19 01 00 00 >0.001
Group B 20 19 01 00 00 >0.001
Over all
out come
Group A 20 19 00 00 00 >0.001
Group B 20 00 00 00 00 >0.001
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 116
the end of 2 months 100% patients got relieved which was statistically highly
significant at the level of p <0.001
Group B showed Not relief in Constipation during therapy at the end of 7th day
100% patient got no relieved, which was statistically not significant and at the end of
2 months 100% patients got relieved which was statistically not significant at the
level of p >0.001
Table- 29
Evaluation of CONSTIPATION between two groups
Study
period Group
No.o
f
pati
ents
CONSTIPATION (VIBANDA)
P value No
constipation Mild Moderate Severe
Before
treatment
Group A 20 00 02 16 02 -
Group B 20 00 01 18 01 -
After
Treatment
Group A 20 17 03 00 00 <0.001
Group B 20 00 01 18 01 >0.001
After
fallow
Up
Group A 20 20 00 00 00 <0.001
Group B 20 00 01 18 01 >0.001
Over all
out come
Group A 20 20 00 00 00 <0.001
Group B 20 00 01 18 01 >0.001
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 117
Evaluation of Gudadaha(Burning sensation) between two groups: Group A
showed a Complete relief in Burning sensation during therapy at the end of 7th day
95% patients got relieved, and at the end of 2 months day 95 % patients got relieved
which was statistically highly significant at the level of p <0.001
Group B showed relief in Burning sensation during therapy at the end of 7th day
95% patient got relieved, which was statistically significant and at the end of 2
months 95% patients got relieved which was statistically significant at the level of
p <0.001 Table – 30
Evaluation of BURNING SENSATION between two groups
Study
period Group
No.of
patie
nts
BURNING SENSATION
(GUDADAHA)
P value No
burning
sensation
Mild Moderate Severe
Before
treatment
Group A 20 00 01 16 03 -
Group B 20 00 02 18 00 -
After
Treatment
Group A 20 19 01 00 00 <0.001
Group B 20 19 01 00 00 <0.001
After fallow
Up
Group A 20 19 01 00 00 <0.001
Group B 20 19 01 00 00 <0.001
Over all out
come
Group A 20 19 01 00 00 <0.001
Group B 20 19 01 00 00 <0.001
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 118
Evaluation of Size of the ulcer between two groups: Group A showed a
Complete relief in Size of Ulcer during therapy at the end of 7th day 70% patients got
relieved, and at the end of 2 months 90 % patients got relieved which was statistically
highly significant at the level of p <0.001
Group B showed relief in Size of Ulcer during therapy at the end of 7th day 70%
patient got relieved, which was statistically significant and at the end of 2 months
85 % patients got relieved which was statistically significant at the level of p <0.001
Table- 31 Evaluation of SIZE OF THE ULCER between two groups
Study
period Group
No.o
f
pati
ents
Size of the ulcer
P
value No
ulcer Mild Moderate Severe
Before
treatme
nt
Group A 20 00 05 14 01 _
Group B 20 00 04 14 02 _
After
Treatme
nt
Group A 20 00 20 00 00 <0.01
Group B 20 00 20 00 00 <0.01
After
fallow
Up
Group A 20 18 02 00 00 <0.01
Group B 20 17 03 00 00 <0.01
Over all
out
come
Group A 20 18 02 00 00 <0.01
Group B 20 17 03 00 00 <0.01
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 119
Evaluation of Spincter spasm between two groups: Group A showed a Complete
relief in Spincter spasm during therapy at the end of 7th day 100% patients got
relieved, and at the end of 2 months 100% patients got relieved which was statistically
highly significant at the level of p <0.001
Group B showed relief in Spicter spasm during therapy at the end of 7th day patient
100% got relieved, which was statistically significant and at the end of 2 months
100% patients got relieved which was statistically not significant at the level of p
<0.001 Table- 32
Evaluation of spincter spasm between two groups
Study
period Group
No.
of
pati
ents
Spincter spasm
P value No
pain Mild Moderate Severe
Before
treatment
Group A 20 03 17 00 00 _
Group B 20 04 16 00 00 _
After
Treatment
Group A 20 20 00 00 00 <0.001
Group B 20 20 00 00 00 <0.001
After fallow
Up
Group A 20 20 00 00 00 <0.001
Group B 20 20 00 00 00 <0.001
Over all out
come
Group A 20 20 00 00 00 <0.001
Group B 20 20 00 00 00 <0.001
Effect of the therapies .
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 120
Evaluation of proctitis between two groups: Group A showed a Complete relief in
Proctitis during therapy at the end of 7th day 100% patients got relieved, and at the
end of 2 months day 100% patients got relieved which was statistically highly
significant at the level of p <0.001
Group B showed relief in Proctitis during therapy at the end of 7 day patient 100%
got relieved, which was statistically significant and at the end of 2 months 100%
patients got relieved which was statistically not significant at the level of p <0.01
Table- 33 Evaluation of proctitis between two groups
Study
period Group
No.of
patie
nts
Proctitis
P value No
Proctitis Mild Moderate Severe
Before
treatment
Group A 20 02 18 00 00 _
Group B 20 01 19 00 00 _
After
Treatment
Group A 20 20 00 00 00 <0.001
Group B 20 20 00 00 00 <0.001
After
fallow
Up
Group A 20 20 00 00 00 <0.001
Group B 20 20 00 00 00 <0.001
Over all
out come
Group A 20 20 00 00 00 <0.001
Group B 20 20 00 00 00 <0.001
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 121
DISCUSSION
Fissure-in-ano is the ailment that does not have any direct correlation in the
Ayurvedic text. ‘Parikartika’ is a condition occurring due to improper administration
of Virechana and Basti can be compared with fissure-in-ano, since both the conditions
occur in Guda and have similar clinical manifestations. Thus fissure-in-ano can be
compared with Parikartika as follows:
1. Parikartika is characterized by Kartanavat and Chedanavat Shoola in Guda,
Basti and Nabhi. Similarly fissure in ano is also characterized by sharp cutting pain
in anal region.
2. In Parikartika Guda-Kshata is result of Virechana Atiyoga uyapad Kshanana
implies injured tissue. In the same way fissure in ano is evident by the
3. longitudinal tear in the anal canal.
Since the location, nature of pathology and the predominant clinical feature
aresame, it can be said that the condition Parikartika is the clinical condition known
in current surgical practice as fissure in ano. In this study Yashtimadu Ghrita was
selected to evaluate its role in the management of Parikartika because it has
VraņaRopaņa, Shothahara, Varņa Prasadana and Shulahara properties along with
Tridoşahara, Rakta Stambhaka in actions.Yeashtimadu Ghritan and
GandakaRasayana,Abayarista was taken as control drug because the base of
Yeashtimadu Ghrita and Gandaka Rasayana, Abayarista which is also having
Vrana Ropana ,Vatanulomana ,Virechana,Vibandanashaka ,properties. For this
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 122
purpose 40 patients of Parikartika were divided into two grouconsisting of 20 patients
each. In group A, the patients were managed with application of
Yashtimadu -Ghrita Pichu per rectally, gandaka rasayana, Abhayarista twice a day
oraly for 21 days. Patients were managed with application of Yashtimadu Ghrita
Pichu per rectally twice a day for 21 days.In group B the main aim of management of
fissure in ano is to relieve the agonizing pain, to relieve the sphincter spasm, to heal
the ulcer and to reduce burning sensation and to stop bleeding,proctitis Significant
clinical observations recorded in this study were as follows:
Age:
Group A: Among 20 patients 55% patients were in the age group of 20 –30 years.
20% patients in the age group of 31-40 years,15% patients in the age group of 41-50
years, 5% patients in the group of 51-60 years.
Group B: Among 20 patients 50% patients were in the age group of 20 –30 years 35
% patients in the age group of 31-40 years, 10% patients in the age group of 41-50
years, 5% patients in the group of 51-60 years.
Both group: Among 40 patients In both group patients are seen in age group between
20-30 years 55% probably because of improper dietary habits, sedentary life style,
and nature of work and withholding of urges. The incidence is less in old age group
due to the muscular atony.
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 123
Sex:
Group A: Among 20 patients 75 % were male and patients 25 % were female
safering from fissure in ano.
Group B: Among 20 patients 75 % were male and 25 % were female safering from
fissure in ano.
Both group: The anatomical difference in the structure of the pelvic cavity between
male and female patients due to the presence of uterus and enough space for child
bearing may also be responsible for the difference in the incidence of fissure in the
both sexes. The description given in Sushruta Samhita regarding the circumference of
the ano-rectal canal suggests that it is wider in females than in males. This may also
be responsible for less incidence of fissure in females.
Occupation:
Group A: Among 20 patients were as Job holder 50% ,students were as
10%,agriculture were as 20%,house wife were as 20%.safering from fissure in ano.
Group B : Among 20 patients job holder were as 30%,students were as
20%,agriculture were as 40%,house wife were as 10% .safering from fissure in ano.
Both group: Among 40 patients. 40 % respectively were from job holders, who
ultimately lead to the development of fissure-in-ano due to sedentary lifestyle and
continuous sitting in same posture and stressful life style.
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 124
Socio-Economic Status:
Group A: Among 20 patients were from lower class 30%, middle class were as 65%,
high class were from 5% safering from fissure in ano.
Group B: Among 20 patients were as lower class 5%, middle class were as 90%.high
class were as 5%.
Both groups:
Among 40 patients in group a 65% were from middle class. In group B, 90 %
patients were from middle class. Due to habit of taking excess spicy and oily meals
once or twice a day may be the cause of Parikartika in the middle class families.
Diet:
Group A : While discussing the nature of diet, in group A- it was found that mixed
diet patients were majority in number (100%).
Group B: 100 % patients were on mixed diet. Hence the patients with mixed dietary
habits are more susceptible due to low fiber content and spicy non- vegetarian diet.
Both groups:
Among both group from 100% patient having mixed diet form non vegetarian food its
incresess the vata and pitta prakopa that’s why mixed diet patients having fissure in
ano more in number.
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 125
Religion:
Group A: Among 20 patients group were Hindus are 100% .muslims are 0% safering
from fissure in ano while taking the cases for clinical study.
Group B : Among 20 patients was Hindus are 95% Muslims are 5% safering from
fissure in ano while taking the cases for clinical study.
Both groups:
Among 40 patients Hindus are more in number. but Even though muslims are taking
more low fibers diet and more non vegetarian here the stastical data shows more
hindus patients are suffering with fissure in ano.based on this we can not conclude
that hindu are more sufer with this diseas.based on less number of samples droing the
conclusion is much more difficult.
Habitate:
Group A Among 20 patients were as 80% from rural area .20% from urban area
patients are safering from fissure in ano.
Group B: Among 20 patients were as 60% from rural. And 40% from urban areas so
that patients are safering from fissure in ano.
Both group : more patients are from rural area this may be due to the our college is in
rural area.so we are getting more rural patients rather than the urban.but fissure in ano
will be observed in both the area.
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 126
GROUP A
Effect Guda Shoola: The initial mean score of the symptom Shoola was 3.00 which
was reduced to 1.75(41.66%) after treatment. Its statistical analysis shows highly
significant result at P <0.001 level.
Effect on Rakta Srava: The initial mean score of the symptom Rakta Srava was
2.00. This was reduced to 1.15(42.5%) after treatment. It was statistically highly
significant result at P<0.001 level
Effect on Viband: The initial mean score of the symptom Vibanda was 3.00. This
was reduced to 1.85 by 38% after treatment. It was statistically highly significant
result at P<0.001 level
Effect on Gudadaha (burning sensation): The initial mean score of the symptom
gudatapa was 2.0 this was reduced to 1.0 by 50 % after treatment. It was statistically
highly significant result at <0.001 level
Effect on Size of Ulcer: The initial mean score of the size of ulcer was 2.00 which
was reduced to 0.80 (60%) after treatment. Its statistical analysis shows highly
significant result at <0.001 level
Effect on Sphincter spasm: The initial mean score of the symptom sphincter spasm
was 1.00 which was increased to 0.85 by 15% after treatment. It shows statistically
highly significant result at <0.001 level
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 127
Effect on proctitis: The initial mean score of the symptom proctitis was 1.00 which
was increased to 0.9 by 10% after treatment. It shows statistically highly significant
result at <0.001 level
GROUP B
Effect on Guda Shoola: The initial mean score of the symptom Shoola was3.00
which were reduced to 1.8(40%) after treatment. Its statistical analysis show
significant result at <0.001 level.
Effect on Raktasrava: The initial mean score of the symptom Rakta Srava was 2.00.
This was reduced to 1.40(30%) after treatment. It was statistically significant result at
<0.01 level
Effect on Viband: The initial mean score of the symptom Vibanda was 3.00.This was
reduced to 0.1 by 96 % after treatment. It was statistically highly not significant result
at >0.05 level
Effect on Gudatapa(burning sensation): The initial mean score of the symptom
gudatapa was 3.00. This was reduced to 1.85 by 38% after treatment. It was
statistically highly significant result at <0.001 level
Effect on Size of Ulcer: The initial mean score of the size of ulcer was 2.00 which
was reduced to 0.9 (55%) after treatment. Its statistical analysis shows highly
significant result at <0.001 level
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 128
Effect on Sphincter spasm : The initial mean score of the symptom sphincter spasm
was 1.00 which was increased to 0.8 by 20% after treatment. It shows statistically
highly significant result at <0.001 level
Effect on proctitis : The initial mean score of the symptom proctitis was 1.00 which
was increased to 0.95 by 5% after treatment. It shows statistically highly significant
result at <0.001 level
COMPAIRITIVE DISSCUSSION OF BOTH GROUP (Group A and Group B)
Effect Guda Shoola:
The compairitive effect on gudashoola as in group A was 41.66% and group B was
40% improvement were observerd after the treatment. Here both groups which shows
stasticaly highly significant in nature but slight variation as1.66% is more in group A
due to internal medication.
Effect Rakta Srava:
The compairitive effect on Rakta Srava in group A was 42.5% and group B was30%
improvement were observerd ofter the treatment here both group wich shows
stasticaly highly significant in nature but slight variation as12.% is more in group A
due to internal medication.
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 129
Effect on Vibanda:
The compairitive effect on vibanda in group A was 1.85% and group B was
0.1(>0.05%) improvement were observerd after the treatment here group A which
shows stasticaly highly significant were as In group B there is nochangein vibanda
because there is internal medicine in group B to act on constipation.
Effect on Gudadaha:
The compairitive effect on Gudadaha in group A was 50% and group B was 38 %
improvement were observerd after the treatment. Here both groups shows stasticaly
highly significant in nature but slight variation as12.% is more ingroup A due to
internal medication which act as pitta shamaka and vatanulomaka.
Effect on Size of ulcer:
The compairitive effect on Size of ulcer in group A was 60 % and group B was 55%
improvement were observered after the treatment. here both group wich shows
stasticaly highly significant in nature but slight variation as 5 % is more in group A
due to internal medication which helps in vibhanda nashaka and further avoiding of
laceration.
Effect on Spincter spasm:
The compairitive effect on Spincter spasm in group A was 15 % and group B was 20
% improvement were observerd ofter the treatment here both group wich shows
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 130
stasticaly highly significant in nature but slight variation as 5 % is more in group B
due to Yeastimadu gritha is helps for vata shamana so act as spincter relaxant.
Effect on proctitis:
The compairitive effect on proctitis in group A was 10 % and group B was 5 %
improvements were observered after the treatment. here both groups shows statisticaly
highly significant in nature but slight variation as 5 % is more in group A due to Oral
medication act as vatanulomaka, vibhanda nashaka and pittashamak.
Over all Effects of Therapies: In control group A, 95 % patients got complete
remission, 05% patients had marked improvement. On the other hand in Yashtimadu
group B 93 % patients got complete remission and 5 % patients had marked
improvement and 2 % patients had moderate improvement.in constipation there is no
improvement It is obvious from the above results that the over all effects of
Yashtimadu Ghrita in providing the over all relief to the patients of fissure inano after
looking all the observational study and statistical analysis it can be come to the
conclusion that both group have the good response in treating fissure in ano expect the
vibanda laxanas that is controle group shows good result on vibanda due to the
internal medication like abhayarista,gandaka rasayana were as in trail drug the result
was similar after the treatment also becose there is no internal medication which are
on viband.
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 131
Significant Effects of Group A
(Yashtimadu Ghrita picchu and Abhayarista,gandaka rasayana):
7 days local application of Pichu of Yastimadu Ghrita provided significantly relief in
Guda Shula (90%), bleeding per rectum (95%), vibanda (100%) burning sensation
(95%) healed the ulcer (90%) and increased the sphincter Spasm (100%) proctitis
(100%). In this group there is no patients have complete remission 18 patients got
markly improvement 2 patients are mode rate improvement,0 patients mild changes
and 00 patients are unchanged in fissure in ano.
Significant Effects of Group B (Yashtimadu-Ghrita):
7 days local application of Pichu of yastimadu Gritha provided significantly relief in
Guda Shula (85%), bleeding per rectum (95%),constipation(100% P>0.01)burning
sensation(95%) healed the ulcer (85%) and decreases the sphincter spasm (100%)
proctitis(100%). In this group there is no patients have complete remission 17 patients
got markly improvement 3 patients are moderate improvement,0 patients mild
changes and 00 patients are unchanged in fissure in ano.
Comparison of the Effects of controle group and Yashtimadu Ghrita:
Comparison the effect obtained in both the groups showed that local application of
Pichu provided significantly better relief in Guda Shoola, Bleeding per rectum,
healing the ulcer, spicter spasm and proctitis.but its not help for the constipation
coparison to controle group.
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 132
Probable Mode of Action: As mentioned earlier the healing of fissure is different
from the healing of any other ulcer because in the former there is constant
contamination of the wound by faeces and its frequent friction with the mucosa while
there is continuous spasm of the sphincteric muscle. They are the important factors
which keep a fissure away from normal healing. In such situation a drug which
produces a soothing effect, Vata-Pittahara, Vedna Sthapana, Vrana Ropana and
influences reduction of inflammation will be more suitable than drug which may act
as the best healer of ulcer on other parts of the body. Yashtimadu Ghrita probably has
these properties. But as far as main symptoms are concerned pain (Burning and
Cutting) may be relieved due to the action of Vedna Sthapana, Dahaprashamana and
Vata Pittahara. It’s well known fact that the Vata and Pitta Doshas are predominant in
pain as well as in fissure. According to modern pharmacological action of drugs
patient as anti inflammatory and steroidal activity. Other drugs also have been
reported to have a similar type of property but our clinical experience suggests that its
activity is less as compared to that of Yashtimadu Ghrita. It is the amount of
inflammation and spasm which is responsible for producing the agonizing pain in
cases of fissure-in-ano. Yashtimadu Ghrita probably is able to counteract these two
factors more efficiently than the other drugs. The relief of severe pain within 24 hours
is something remarkable about this drug although the ulcer takes as with in weeks for
complete healing.
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 133
After the completion of treatment in group A shows over all result of highly
significant where as in group B shows over all result of statistically significant. It
shows Group A is highly significant And Group B Also have same result with out
oral medication expect constipation.group B is better then group A.
Sitz bath
Sitz bath its directly acts on local vascular bed of the ano rectal region may leads to
Vasodilatation. It warks by keeping the affected area clean and incressing the flow of
blood to it.so that which directly helps for wound healing mechanisum.
CRITERIA FOR OVERALL EFFECT OF THERAPHY
Result Percentage of parameters Patients in
group A
Patients in
group B
Complete
Remission
100% relief in the subjective and
objective parameter.
00 00
Markly
Improvement
More than 75% in the subjective
and objective parameter.
18 17
Moderate
Improvement
50 to 74% relief in the subjective
and objective parameter.
02 03
Mild
Improvement
25 to 49% relief in the subjective
and objective parameter.
00 00
Unchanged Result below 25% was consider as
unchanged.
00 00
Discussion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 134
Group A
Group B
0% 0%
90%
10%
0%
Patients in
Complete Remission 100% relief in the subjective and objective parameter.
Markly Improvement More than 75% in the subjective and objective parameter.
Moderate Improvement 50 to 74% relief in the subjective and objective parameter.
Mild Improvement 25 to 49% relief in the subjective and objective parameter.
Patients in
Complete Remission 100% relief in the subjective and objective parameter.
Markly Improvement More than 75% in the subjective and objective parameter.
Moderate Improvement 50 to 74% relief in the subjective and objective parameter.
Mild Improvement 25 to 49% relief in the subjective and objective parameter.
Conclusion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 135
CONCLUSION
The clinical study was carried out to evaluate the efficacy of in between two group in
which one group selected as controle group here adviced Yashtimadu gritha picchu
along with bhayarista, gandaka rasayana and isecond group adviced only Yashtimadu
gritha picchu in the management of Guda Parikartika, On the basis of Ayurvedic texts,
views of ancient scholars, facts and observations done in the present clinical research
work some points can be concluded like –
The site of Parikartika is Guda, which is similar to the site of fissure-in-ano.
Vata and Pitta Doşha have dominancy in the development of the disease
Parikartika, but Vata is predominant.
Sedentary life style and hard work and stressful life like businessmen, in the
modern era, is having a key role in occurrence of the disease Parikartika
(fissure-in-ano).
Fissure-in-ano was present commonly at 6 o’clock position and most of the
time it is a single fissure only. However the fissure at 12 o’clock or at other
site may also be found either alone or in combination.
Excessive consumption of Lavaņa, Katu, Tikta, Rukşha, Uşhņa,lagu Ahara
and irregular diet and diet timings are the main precipitating factors of this
condition.
For the management of fissure in ano pichu of Yashtimadu Ghrit along with
and oral medication and only Yashtimadu Ghrita pichu were adapted.
Conclusion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 136
The most evident symptom present i.e. pain and spasm of anal sphincter can
be relieved much earlier in both the groups shows similar result so that only
pichu can helps to controle the pain and spincter spasm.
In the cases of Rakta Srava, (bleeding) in fissure-in-ano even thow both the
group showes good control also controle group showes slightly better than the
trail drug.
In the cases of ulcer size in fissure-in-ano in the both the groups showed
effective results in healing and good control after 7 days.
In the cases of sphincter spasm, during therapy at the end of 7 day patients got
Complete relieved in both group where it provides same relief.
In the follow up study, it was observed that the results achieved in both the
groups are effective and stable and was showed constant relief on pain,
burning sensation, bleeding, and ulcer, spasm of sphincter, constipation and
proctitis but in group B upon constipation were there is no result was
observed.
Expect the constipation in the present study it can be concluded that both the
group was same effect and observed after treatment. as well as after treatment
and after fallow up in group B Pichu never shows the result upon the
constipation and constipation is the main cause ot trigger back once again to
the fissure-in-ano (Parikartika).
Yashtimadu Ghrita was found more effective in relieving the feature of disease
Parikartika (fissure-in-ano).
Conclusion.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 137
Yashtimadu Ghrita is easily applicable, cost effective and can be widely used
in general practice.
SUGGESTION
As chronic conditions may need long term therapy for achieving better results
and to avoid reoccurrence so, in future same topic should be taken for further
research to overcome some lacunas if found, for better results more numer of
samples.
Summary.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 138
SUMMARY
Ayurveda is an age old science of health which emphasize on the health than
to cure disease. The fissure-in-ano is very common and painful condition still there is
no satisfactory method of treatment, medical or surgical. On the basis of symptoms,
the disease fissure-in-ano can be compared to the disease Parikartika described in to
Ayurveda.
According to Tridoşha theory, Parikartika has been mentioned under the
Vatika disease along with Pitta Doşha. Guda is the site of Apana Vayu and severe
pain and burning sensation in the ano-rectal area the two major symptoms are due to
Vata and Pitta Doşha only. No detailed description of Parikartika (fissure-in-ano) is
available in the Ayurveda. Though, Acharya Kashyapa has made an effort but detailed
description was not given by him also. However, Kashyapa had mentioned this
condition in relation to a pregnant woman which is quite logical.
It was decided to conduct the present clinical research work entitled “Effect of
Yashtimadu Ghrita in the management of Parikartika (Fissure-In-Ano).
The main objective of selecting this study was to find out efficacious and cost
effective treatment for the patients of Parikartika from the treasure of Ayurveda. In
the Āyurvedic text, few references are found to a condition Parikartika and its
management. Most of the Acharyas have indicated chiefly Ghŗita, Madhu, Tila Kalka
and Yaşhtimadhu for this condition.
Summary.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 139
Yashtimadu Ghrita has been described as a drug for Vraņa which are having
lakshana like Raktasrava, Daha, etc. Hence the present work is an attempt to assess
the efficacy of this preparation for treatment of the disease Parikartika.
Here, Yashtimadu Ghrita is having Vraņa Shodhana, Vraņa Ropaka, Vedanā
Sthāpana and Vata- Pittahara properties and it has been advocated in Ayurvedic
literature by Acharya Sushruta for the management of Vraņa.
Therefore, it has been chosen for the present research work. Total 40patients
were selected, diagnosed and randomly divided into two groups.In group A, 20
patients were given Yashtimadu Ghrita Picchu and abhayarista gandaka rasayana
internally twice a day for 7 days, while in group B, 20 patients were given plain
Yashtimadu Ghrita Picchu twice a day for 7 days, and assessed 7thday during
treatment period.fallow up to 2 months.
All the patients in both the groups were given Picchu application in anal route
being followed at RGEAMC & H for patients of ano rectal disoders.
So, here on the basis of this study the following observations can be drawn –
In group A and group B both groups shows 55 % patients were of the age
group of 18 –28 years.
In total group A and group B 25 % patients were females.And group A 75%
Male in group B 75% male total 75% male its shows more male patients
40% patients were job holders in both the groups .
Summary.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 140
40% patients from urban area 60% patients more from rural area while
clinical study.
97.5% patients are from hindus while clinical study.
100 % patients were in group A and 100 % patients were in group B of mixed
diet
77.5 % patients from middle class from both groups.
100% %patients were in group A and 85 % patients were in group B belongs
to non-operated category
50 % patients were suffering from bleeding per rectum in group A .70%
patients from group B.
100% patients suffered from constipation in group A where as 100 % patients
suffered from constipation in group B
15% patients suffered from severe pain and 80 % patients from moderate pain
mild pain 05%in group A where as in group B 73.3 % patients suffered from
severe pain 7.5% and patients from moderate pain 85% and 7.5% mild pain
Discharge observed in b groups.
No cases were observed in having any associated diseases in both the groups.
In group A out of 20 patients, 10(50 %) patients were reported having
posterior fissure, 5 (33.3%) patients were reported having anterior fissure and
10 (50 %) patients had both anterior & posterior fissure in ano. Where as in
group B out of 20 patients, 9 (45%) patients were reported having posterior
fissure, 8 (40 %) patients were reported having anterior fissure and 03(15%)
Summary.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 141
patients had both anterior & posterior fissure in ano. Hence maximum patients
suffered from posterior fissure in ano.
In group A Yashtimadu Ghrita group Piccchu and oral medication Patients
found completely cured where as In Group B Yashtimadu gritha Piccchu also
have same effect expect constipation showed improvement in signs and
symptoms of Parikartika.
So, from the above mentioned facts, thoughts, data and results it can be
summarized that controle group i.e. group A can be good for relieving
cardinal symptoms, general symptoms and quick healing of ulcer in the
patients of Parikartika (fissure-in-ano) and even economical also to the
patients.
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 142
POST GRADUATE DEPARTMENT OF SHALYATANTRA CASE
PROFORMA OF RAJIVE GANDHI AYURVEDIC MEDICAL COLLEGE
RON
FOR
“A CLINICAL STUDY OF YASHTIMADHU GHRITHA PICHU IN THE
MANAGEMENT OF
PARIKARTIKA w. s. r. to FISSURE-IN-ANO
GUIDE : Dr. Chetan kardale
CO-GUIDE :Dr.kumar kantimata
P.G SCHOLAR : Dr. VEERESH SATTIGERI
CASE NO.: DATE :
NAME: MARITAL STATUS: Marred /Unmarried
AGE: ECONOMICAL STATUS: Low / Middle High
SEX: OPD NO:
ADDRESS: IPD NO :
RELIGION D.O.A :
OCCUPATION: D.O.D : PLACE:
\
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 143
CHIEF COMPLAINTS:
HISTORY OF PRESENT ILLNESS:
PAST HISTORY
1. Whether patient has similar complaints --- YES / NO.
earlier than the present episode
2. History of any systemic illness --- YES / NO.
3. History of any other Medical treatment --- YES / NO.
4. History of any surgeries undergone --- YES / NO.
5. Obstetric and gynecological history ---
6. Gynecological history
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 144
PERSONAL HISTORY
1. Nature of food --- Vegetarian Non vegetarian
Spicy Non spicy
2. Nature of work--- Strenuous Moderate Sedentary
3. Bowel habit --- Regular / lose / constipated
If Constipated : mild / moderate / severe.
4. Micturation --- Frequency / 24 hrs
5. Sleep ---
6. Habits ---
FAMILY HISTORY
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 145
GENERAL EXAMINATION
Conjunctiva:
Nails :
Tongue :
Odema :
Lymphadenopathy :
Cyanosis :
Clubbing :
Pallor :
Prakriti – Vata Pitta Kapha Vatapitta Vatakapha Pittakapha Sannipataja
Saara – Pravara / Madyama / Avara
Samhana - Pravara / Madyama / Avara
Satva : – Pravara / Madyama / Avara
Satmya : – Pravara / Madyama / Avara
State of agni – Tikshana Manda Vishama Sama
Bala – Pravara / Madyama / Avara
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 146
VITAL DATA
BLOOD PRESSURE ---
PULSE RATE ---
TEMPERATURE ---
RESPIRATORY RATE ---
SYSTEMIC EXAMINATION
CVS. ---
R.S. ---
CNS. ---
P/A ---
Clinical features:
1. Pain in anal region : mild/moderate/severe/unbearable
2. constipation : No Vibandha Mild Moderate Severe
3. Pruritis: Mild Moderate Severe
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 147
4. Anilasanga (flatus passed): Effortlessly / with difficulty.
5. Pain –duration (after defecation in min) : 15 / 30 / 60 / >60
i) During defecation = No pain Mild Moderate Severe
ii) After defecation = No pain Mild Moderate Severe
6. Size of the ulcer (in m m ):
7. Bleeding : Present / Absent
Amount of Blood = Mild Moderate Severe
Relation with defecation = Blood after defecation
Mixed with faces
On the surface of faces
Bleeding occur at some other time than
defecation
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 148
LOCAL EXAMINATION
ON INSPECTION:
1. Fistula ---
2. Haemorhhoids ---
3. Prolapse ---
ON P/R EXAM:
INVESTIGATIONS
HB % ---
TC ---
DC ---
ESR ---
RBS ---
Other investigations, if required ---
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 149
SPECIFIC EXAMINATION - ASSESMENT CRITERIA
Date of starting therapy ( day 1 ) :
Date of first follow-up ( day 8 ) :
A.SUBJECTIVE CRITERIA --
1. Pain –nature :
Pain- nature
Day 1 Day 8 Follow-up (every 15 days )
1 2 3 4 5 6 7 8 9 10 11 12
Pain- nature
Symptoms Grading
Absent O
Mild 1
Moderate 2
Severe 3
Unbearable
4
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 150
2. Constipation :
Constipation
Day 1 Day 8 Follow-up (every 15 days )
1 2 3 4 5 6 7 8 9 10 11 12
Constipation
Motion passed Grading
Every day 0
Once in 2 days Mild 1
Once in 2-3days Moderate 2
Once in 3 or more days Severe 3
3.Bleeding :
Bleeding
Day 1 Day 8 Follow-up (every 15 days )
1 2 3 4 5 6 7 8 9 10 11 12
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 151
Bleeding
Symptoms Grading
Absent 0
One streak Mild 1
2-3 streaks Moderate 2
>3 streaks/ drops Severe 3
4. Buning sensation:
Burning sensation
Day 1 Day 8 Follow-up (every 15 days)
1 2 3 4 5 6 7 8 9 10 11 12
Burning sensation
Symptoms Grading
Absent O
Mild 1
Moderate 2
Severe 3
Objective criteria :
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 152
1.spincter spasm :
Spincter spasm
Day 1 Day 8 Follow-up (every 15 days)
1 2 3 4 5 6 7 8 9 10 11 12
Symptoms Normal Spasmodic
Grading 0 1 (Not
allowed)
2.Size of the ulcer (in mms.) :
Size of the ulcer (in mms.)
Day 1 Day 8 Follow-up (every 15 days)
1 2 3 4 5 6 7 8 9 10 11 12
Size of ulcer in mm
Symptoms Grading
0mm to 2 mm 1
2mm to 4mm 2
4mm to 6mm 3
2. Proctitis
Case sheet froforma.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 153
proctitis
Day 1 Day 8 Follow-up (every 15 days )
1 2 3 4 5 6 7 8 9 10 11 12
Proctitis
Symptoms Grading
Absent O
Present 1
RESULT
CURED
IMPROVED
UNCHANGED
NOT FOLLOW - UP
Bibliography.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 154
BIBLIOGRAPHY AND REFRENCES
1. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 15/4
2. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 4/26
3. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Vimana Sthana 5/4
4. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 9/3
5. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Sharira Sthana 7/10
6. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Sharira Sthana 7/10
7. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Sharira Sthana 7/9
8. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Sharira Sthana 6/9
9. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 6/26
10. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 5/10
11. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 3/31
Bibliography.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 155
12. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 4/26
13. Vagbhata; Astanga Hridaya with Sarvaga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Sharira Sthana 3/8
14. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Sharira Sthana 5/7
15. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Nidana Sthana 4/26
16. Vagbhata; Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Nidana Sthana 7/ 4-6
17. Vagbhata; Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Sharira Sthana 45/61
18. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Nidana Sthana 2/ 5-8
19. Vagbhata; Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Nidana Sthana 7/4-5
20. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 5/47
21. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 6/7
22. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Sharira Sthana 4/42
Bibliography.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 156
23. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Sharira Sthana 4/10
24. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 7/7
25. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 9/7
26. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 9/12
27. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 6/7
28. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 6/7
29. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Sharira Sthana 4/1
30. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sharira Sthana 5/10
31. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Sutra Sthana 12/8-9
32. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Nidana Sthana 2/6-8
33. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002Chikitsa Sthana 34/16
Bibliography.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 157
34. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 3/156
35. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Nidana Sthana 1/16-18
36. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Nidana Sthana 1/14-15
37. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Nidana Sthana 1/16
38. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Nidana Sthana 1/17-18
39. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 25/10
40. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 28/70
41. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Nidana Sthana 16/27
42. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995.Nidana Sthana 16/40
43. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 26/5
44. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Uttara Sthana 55/37
Bibliography.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 158
45. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 28/24
46. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Uttara Sthana 55/8
47. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 26/5
48. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Uttara Sthana 55/8
49. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995Sutra Sthana 4/3
50. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 19/ 5
51. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 3/186
52. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 19/ 5
53. Vagbhata; Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995. Nidana Sthana 8/57
54. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Nidana Sthana 2/9
55. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 14/8
Bibliography.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 159
56. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 14/11
57. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 14/17
58. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 15/62
59. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/3-6
60. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 6 /61
61. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/16
62. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 7/56
63. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 36/37
64. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 5/5
65. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 12/30
66. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 28/26-27
Bibliography.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 160
67. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/15
68. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/16
69. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 7/54
70. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 7/55
71. Vagbhata, Astanga Hridaya with Sarvaga Sundara Commentary, Krishnadas
academy, Varanasi 1995. Nidana Sthana 8/5-7
72. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 22/5
73. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 22/8
74. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 25/7-8
75. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 21/36
76. Vagbhata, Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995. Nidana Sthana 15/9
77. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 34/16
Bibliography.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 161
78. Kashyapa Samhita, Nepal Rajguruna Pandit Hemraj Sharma, 1938 Khil
Sthana 10/101-105
79. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 23/3
80. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 23/4
81. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 23/9
82. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 23/7
83. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 23/8
84. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/16
85. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 6/67
86. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 10/35
87. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/16
88. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Siddhi Sthana 6 /67
Bibliography.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 162
89. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/16
90. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/16
91. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 34/16, 38/ 85
92. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Chikitsa Sthana 14/228
93. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 37/27-29
94. Gray’s Anatomy : Edited by Williams P.L.ELBS, 38th edition , 1995
95. Bailey and Love’s short practice of surgery, Londan by R.C.G. Russell,
Norman. S. Williams and Christopher J.K Bulstrode, 24th edition, 2004, page
no -1252-1253 and page no 1522
96. Bhaisajya Ratnavali- Varna Shotha Chikitsa Adhyaya- by Ambikadutt
Shashtri edited by Rajeshwardutt Shastri printed by Chaukhamba Sanskrit
Samsathana,14th edition 2001,47/80
97. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Sutra Sthana 45/ 96-97
98. Vagbhata; Astanga Hridaya with Sarvanga Sundara Commentary, Krishnadas
academy, Varanasi 1995. Sutra Sthana 5/38
99. Agnivesa, Charaka Samhita with Ayurveda Dipika Commentary,
Choukhamba Sanskrit series .Varanasi.1994.Nidana Sthana 1/ 40
Bibliography.
A Clinical Study of Yashtimadu Ghritha Pichu in the management of parikartika Page 163
100. Sushruta, Sushruta Samhita with Nibandha Sangraha Commentary
Choukhamba Sanskrit series 2002.Chikitsa Sthana 45/97
101. The chikitsa explained in the Sushruta Samhita commentary choukhamba
Sanskrit sutrasthana chapter 5th sloka-42 page no-19.
102. Kashyapa Samhita- chapter no -2 sloka- 1 page no- 163
103. Charaka Samhita,chikitsa sthana chapter -34th sloka- 16th page no –595.
104 Baishaja kalpana shoba hiremath text English translation chapter 9 page no
230
SL.NO
OPD / IPD NO
PATIENT NAME AGE
SEX M/F
OCCUPATION
RELEGION H / M / C
RURAL OR URBUN- R / U
MARRIED / UNMARRIED
ECONOMICAL STATUS L/M/H
EDUCATIONAL STATUS
HABBITSMOOKER/ALCOHOL/TOBACO
VEGITARION / MIXED
1 26713 Sri.shekarappa u 45 M Driver H R M M PUC Smook M 2 27733 Smt. Ratnavva.k. 23 F Housewife H R M M SSLC - M 3 28376 Sri Basavara pattar 35 M Farmar H U M M PUC Tobaco M 4 29995 Sri.Mahesh guttannavar 35 M Driver H R M M BA T/A M 5 30835 Smt. Renuka 28 F Housewife H R M M PUC - M 6 30596 Sri Saranappa 28 M Driver H R M L PUC T/Al M 7 30598 Smt. Kariyavva madar 30 F Housewife H R M M PUC - M 8 30597 Sri.Subbanna.D 32 M Contracter H R M M BA - M 9 32008 Sri. Basappa kavadikai 60 M Farmar H R M L PUC T/A M
10 38568 Sri.Irappa hosalli 43 M Farmar H R M L PUC Alcohol M 11 33333 Sri Nagaraj rotti 22 M Student H U U M B.com - M 12 33369 Sri Anand javar 26 M Teacher H R M L B.SC Tobocco M 13 23979 Sri.satish p 30 M Driver H R M L SSLC - M
14 24213 Sri.Siddanagouda p 23 M Contrter H R M L PUC Alcohol M 15 26386 Sri.Vinay belagankar 50 M Farmar H R M M BA Tobaco M 16 26521 Sri Andaneshwar.k. 27 M Teacher H R M M TCH - M 17 27717 Smt.Renuka katali 40 F Teacher H U M M B.SC - M 18 29595 Sri.Hnumanth .k. 28 M Driver H R M M SSLC - M 19 29597 Sri. Iranna hadali 22 M Student H R U M BA - M 20 29598 Smt.Neelavathi.l. 20 F Housewife H U M H PUC - M 21 29594 Sri.Prakash.H. 40 M Farmar H U M M SSLC - M 22 29593 Smt. Laxmi.G. 20 F Student H R U M BA - M 23 29596 Sri. Basanagoda.C. 50 M Contracter H R M L BA Alcohol M
24 29599 Sri.Nazeer sultan 22 M Warker M U U M SSLC - M 25 29734 Sri.Rajath sing 22 M Student H U U M BAMS Alcohol M 26 29732 Sri. Manju ugalat 26 M Farmar H R M M BA - M 27 29737 Sri. Basalingappa.S. 45 M Farmar H R M M SSLC - M 28 29904 Smt Sujatha.J. 26 F Student H U U M BA - M 29 29905 Sri.Pramod .S. 29 M Student H U M M MA T/A M 30 33820 Sri.Siddappa .N. 55 M Farmer H R M M SSLC - M 31 33821 Sri.Devappa.K. 35 M Farmar H R M M PUC Tobaco M 32 29906 Sri. Suresh.G. 32 M Farmar H U M M SSLC - M 33 36580 Sri.Muttu kolli 26 M Farmar M U M M Un edc Tobacco M 34 36590 Sri.Sngappa patil 35 M Frmar H R M M PUC T/A M 35 36660 Dr.Turbeen 38 M Lecturer H U M H MD - M 36 36670 Smt. Radika.C. 36 F Housewife H U M M Un.edc - M 37 36900 Sri.Praveen.N. 28 M Nursing H U M M GNM - M 38 37921 Smt. Prameela .P. 28 F Teacher H U M M TCH - M 39 37927 Smt.Mahalxmi.P. 29 F Housewife H U M M PUC - M 40 38008 Sri. Subhas.D. 32 M Contracter H R M M B.Com Tobacco M
SUBJECTIVE CRITERIA OBJECTIVE CRITERIA
SL NO
OPD/IPD NO
PATIENT NAME PAIN-IN NATURE
CONSTIPATION
BLEEDING
BURNING SENSATION
SPINCTER SPASM
SIZE OF ULCER PROCTITIS
BT AF BT AT BT AT BT AT BT AT BT AT BT AT
1 26713 Sri.shekarappa u 3 1 3 1 3 1 3 1 1 0 2 1 1 0
2 27733 Smt. Ratnavva.k. 2 0 2 0 0 0 2 0 1 0 2 1 1 0
3 28376 Sri Basavara . p. 2 0 2 0 0 0 2 0 1 0 2 1 1 0
4 29995 Sri.Mahesh.G. 2 0 1 0 0 0 2 0 1 0 2 1 1 0
5 30835 Smt. Renuka 2 0 2 0 2 0 2 0 1 0 2 1 0 0
6 30596 Sri Saranappa 3 1 2 1 3 0 3 0 1 0 2 1 1 0
7 30598 Smt. Kariyavva 2 0 2 0 2 0 2 0 1 0 1 1 1 0
8 30597 Sri.Subbanna.D 1 0 1 0 0 0 1 0 1 0 1 1 0 0
9 32008 Sri. Basappa ka. 2 0 3 0 2 0 3 1 1 0 2 1 1 0
10 38568 Sri.Irappa hosalli 1 0 2 0 0 0 2 0 0 0 2 1 1 0
11 33333 Sri Nagaraj rotti 1 0 2 0 0 0 2 0 0 0 1 1 1 0
12 33369 Sri Anand javar 2 0 2 1 0 0 2 0 0 0 2 1 1 0
13 23979 Sri.satish p 2 0 2 0 2 0 2 0 1 0 2 1 1 0
14 24213 Sri.Siddanagoud 2 1 2 0 1 0 2 0 1 0 2 1 1 0
15 26386 Sri.Vinay.B. 2 0 2 0 o 0 2 0 1 0 1 1 1 0
16 26521 Sri Andaneshwar 2 1 2 0 0 0 2 0 1 0 1 1 1 0
17 27717 Smt.Renuka .K. 2 0 2 0 2 0 2 0 1 0 2 1 1 0
18 29595 Sri.Hnumanth .k. 2 0 2 0 2 0 2 0 1 0 2 1 1 0
19 29597 Sri. Iranna hadali 2 0 2 0 2 0 2 0 1 0 2 1 1 0
20 29598 Smt.Neelavathi.l. 2 0 2 0 3 0 2 0 1 0 3 1 1 0
21 29594 Sri.Prakash.H. 2 0 2 2 0 0 2 0 0 0 2 1 0 0
22 29593 Smt. Laxmi.G. 2 1 2 2 1 0 2 0 1 0 2 1 1 0
23 29596 Sri. Basanagoda. 2 0 2 2 1 0 1 0 1 0 2 1 1 0
24 29599 Sri.Nazeer sultan 2 0 2 2 2 0 2 0 0 0 2 1 1 0
25 29734 Sri.Rajath sing 2 0 2 2 2 0 2 0 1 0 2 1 1 0
26 29732 Sri. Manju ugalat 2 0 2 2 2 0 2 0 1 0 2 1 1 0
27 29737 Sri. Basalingapp 2 1 2 2 2 0 2 1 0 0 2 1 1 0
28 29904 Smt Sujatha.J. 2 0 2 2 2 0 2 0 1 0 2 1 1 0
29 29905 Sri.Pramod .S. 2 0 2 2 0 0 2 0 1 0 2 1 1 0
30 33820 Sri.Siddappa .N. 2 0 2 2 0 0 2 0 1 0 1 1 1 0
31 33821 Sri.Devappa.K. 2 0 2 2 2 0 2 0 1 0 2 1 1 0
32 29906 Sri. Suresh.G. 2 0 3 3 2 0 2 0 1 0 2 1 1 0
33 36580 Sri.Muttu kolli 2 0 2 2 2 0 2 0 1 0 2 1 1 0
34 36590 Sri.Sngappa patil 2 0 2 2 2 0 2 0 1 0 1 1 1 0
35 36660 Dr.Turbeen 2 0 2 2 2 0 2 0 1 0 2 1 1 0
36 36670 Smt. Radika.C. 2 0 2 2 0 0 2 0 1 0 1 1 1 0
37 36900 Sri.Praveen.N. 2 0 2 2 2 0 2 0 1 0 2 1 1 0
38 37921 Smt. Prameela .P 2 1 2 2 2 0 2 0 1 0 3 1 1 0
39 37927 Smt.Mahalxmi.P 1 0 1 1 0 0 1 0 0 0 1 1 0 0
40 38008 Sri. Subhas.D. 3 1 2 2 2 0 2 0 1 0 3 1 1 0
DEDICATED TO
MY
Parents
INTRODUCTION
OBJECTIVES
REVIEW OF
LITERATURE
DRUG REVIEW
OBSERVATIONS
&RESULTS
MATERIALS AND
METHODS
CONCLUSION
SUMMARY
BIBLIOGRAPHY
&
REFERENCES
ANNEXURE
DISCUSSION
MASTER
CHART