Uttar Basti

Role Of Uttar Basti In Various Gynecological Disorders

There are two routes for the administration of Basti described in the classics, viz. Basti (through the anal canal) & Uttara Basti (through the urogenital tract). The Basti Yantra is also used to inject medicines through the urinary and vaginal passage, for which the term Uttara Basti is given. The Uttara Basti deals with both males and females. But the following discussion is carried out taking females in view only, as required here.

CLASSICAL UTTARABASTI:

  • Uttara Basti as a Vishesa Chikitsa:

विधिमुत्तरबस्त्यन्तंकुर्यादार्तवशुद्धये ||

Acharya Sushruta has mentioned: After applying five Shodhana Karma, Uttara Basti should be given repeatedly for Artava Shuddhi. Acharya Charaka has also advised in Siddhisthana: ‘The woman, who is not able to conceive (due to Vata Dosha) should be treated by Basti because Basti is the best Chikitsa for this type of woman.

  • Definition:

            There are three reasons behind this terminology –

  1. It is administered after Niruhabasti (Niruhat Uttarena)

        (Niruhat Uttaro Yasmat Tasmat Uttarsamgyakah.

  • It is administered in the superior organ (upper passage)

(Uttarena Va Margena Deeyat),(Uttarmarga deeyamantaya.

  • It is superior as it does Snehanam like Anuvasanabasti and Shodhana like Niruhabasti. (Shreshtthagunatva)
  • Indications of Uttarabasti
  • For conception (GarbhamYonih Tada)
  • To pacify Vata (JiteVayuh)
  • For urinary bladder disease (Bastijeshu Vikareshu)
  • Diseases caused by prolapse (Yonivibhramshajeshu Cha)
  • Severe Pelvic pain (Yonishuleshu Tivreshu)
  • Gynecological disorders (Yonivyapada, Yonivyadhim)
  • Menometrorrhagia (Asrigdara)
  • Retention of urine (AprasravatiMutre, Mutraghata)
  • Incontinence of urine (BindumBindumSravatyapi)
  • Menstrual disorders (DushtamShonitam)
  • Menorrhagia (Pushpodrekam)
  • Pathological amenorrhoea(TasyaNasham)
  • Dysmenorrhoea (Kashtam)
  • Urinary diseases (Mutradosham)
  • Retention of the placenta (SamsathatimApara)
  • Urinary calculi (SharkaraAshamarim Cha)
  • Groin pain (Vamkshana Shula)
  • For all reproductive tract disorders (RogeshuNarinam Yoni Garbhashayeshu Cha)
    Contraindications
  • Not described in classics
  • The only contraindication given in classics is the genital tract in girls (Balanam Apatya Marge Na Diyat Iva)
    Time of administration

Uttarabasti should be given in Ritukala (just after a menstrual period) after purifying the body with two or three Asthapana Basti because Garbhashaya (Garbhashaiya or Yoni)[xiv] is prepared to soak up Sneha this time. Acharya Charaka & Vagbhata have given very correct rationalization for the choice of appropriate time by saying that all through menstruation, vaginal and uterine orifices open (Apaavrita yoni), so medicine is taken in a higher way.

  • Dose
  • Dose of Snehana type of Uttarabasti

Acharya Sushruta has given the quantity of Snehana (oleaginous) type of Uttarabasti for the urinary tract as one Prasrita (palm of an outstretched hand and hollowed it as to hold liquid, stuffed up to the Svangulimula i.e., the base of fingers). For cleansing (Vishodhana) of the uterus, it is doubled i.e., two Prasrita. Acharya has given this dose for extreme illness and strong patients (Paramvarga) and has left the decision of fixing individual doses on the knowledge of ShalyaChikitsaka (BuddhiVikalpitam). While commenting on the same, Acharya Dalhana again clarifies that the volume can also be half or less (as decided by the physician at his discretion), depending on the strength of the disease or the capacity of the patient. Acharya Chakrapani followed Sushruta and repeated the same.12

Acharya Sharangadhara and Bhava Mishra have considered this dose as:

  • In adult women: two Pala (96 ml) in the genital tract & one Pala (48 ml) in the urinary tract
  • In premature girls: two Karsha (24 ml)

Acharya Vagbhata has mentioned:

  • For adult women: one Prakumcha (Pala=48gms)
  • For girls: 1 Shakti (24 gms)

Aforesaid Matra is Madhyama as per Acharya Vagbhata. It should be increased gradually by half & one Karsha in the second & third Uttarabasti respectively.

  • Dose for Niruha Uttarabasti

If cleansing is needed by Uttarabasti:

  • For the genital tract reproductive age group of women (Nullipara or parous) – 2 Prasrita
  • For a urinary tract of reproductive age and girls of less than 12 years – 1 Prasrita

Duration: 

Day-night, a total of 2, 3, or 4 Basti should be given and the procedure should be continued for three nights gradual increase in the quantity of oleaginous substance

Interval

After giving rest for 3 days (Trayahmeva Cha Vishramya), the procedure was repeated for another 3 days.

  • Method of Uttarabasti

Yantra (Instruments): Pushpanetra & Bastiputaka

  • Pushpa Netra:

The Netra or nozzle of Uttarabasti is termed as Pushpanetra;

In nutshell, the parameters of Pushpanetra can be summarized as follows:

  • Should be made of silver, gold, brass, bell metal, tin, or lead
  • It must be smooth, tapering like a cow’s tail
Age Passage Length Circumference of nozzle Size of lumen
Girl Urinary 10 fingers The flower stalk of Malati Size of a mustard seed
Adult women Urinary 10 fingers Size of the urethral meatus Size of Mudga seed
Adult women Vaginal 10 fingers Index finger Size of Mudga seed
  • Uttarabasti Pustaka
  • Not mentioned specifically in classics
  • Can be made on the same pattern as mentioned for Guda (anal) Basti, but smaller in dose /quantum.
  • Uttarbasti putaka should be made from soft material, light like the skin of an animal and in case they are unavailable skin of birds, one-fourth portion of a leather bag or any other soft leather can be used.
  • Position (Sthiti)

The woman should be placed in a supine position with flexed thighs and elevated knees (Uttanaya Shayanaya Samyak Samkochya Sakthini Urdhvajanve Striye Dadyat Uttanaye)

  • Procedure (Vidhi)

The nozzle should be inserted in the urinary or vaginal passage slowly with steady hands, following the direction of passage.

  • Pratyavartana (Returning)
  • Pratyavartana of Snehana is considered essential for Uttarabasti.
  • Acharya Charaka has mentioned the administration of PippalyadiVarti (suppositories) if Basti does not return.
  • Acharya Dalhana has given a very specific description of the Pratyavartana of Sneha. These measures are –Yoni Varti, GudaVarti, Sphika – Tadana & Eshana, etc.

UTTARABASTI IN PRACTICE

Now a day, Uttarabasti referred to as classic is being practiced after making several modifications. Everything has been extensively modified from its indications to contraindications, and instruments to the method, and only the Snehana type of Uttarabasti is in practice.

  • Method
  • Poorva Karma
  • The patient is asked to evacuate the bladder & rectum.
  • Yoni Prakshalana – by some Kwatha of antiseptic property
  • Snehana (Abhyanga) of the local abdomen, back, thigh, and legs
  • Svedana especially Nadi Sveda on the back and lower abdomen
  • Pradhana Karma

The instruments used for the Uttarabasti are Posterior Vaginal Speculum, Anterior Vaginal Wall retractor, Allis’ forceps & Uttarabasti cannula fitted with a disposable syringe. Uttarbasti is done under perfect aseptic precautions. It can be given intravaginally or intrauterine. In Intrauterine Uttarbasti– The genital parts are prepared and the medicine should be autoclaved or heated and cooled at room temperature. The drug can be instilled when slightly warm but not beyond 95°F.

The routine disposable syringe is used and not more than 5 ccs of medicine (usually Snehadravya) is used in one sitting. Rubin’s cannula, Uttarbasti canula, IUI canula or butterfly needle with the needle cut off and only the tube is used. The patient is taken to the dorsal lithotomy position, and cleaned with the antiseptic solution is done. Expose the cervix with instruments (By Speculum). Before inserting the medicine, one should ensure that there are no air bubbles in the syringe or the tube and then the medicated oil is gradually pushed in, while the anterior lip of the cervix is held with Allis’ forceps and the patient is kept in head low position.

Once the speculum is withdrawn the patient may be asked to lie in the left lateral position for 15-20 mins and then shifted toward. The patient is kept in a head low position for at least 2 hours for better absorption of the drug from the vagina and to prevent any vasovagal shock.

  • Pashchata Karma
  • Complete rest in head low position for at least 2 hours.
  • Abdominal hot fomentation with hot water bag.
  • Light diet.
  • Indications
  • Yoni shuShulaavartaYonivyapada
  • Rajodosha
  • Asrigdara
  • Vandhyatwa
  • Artavadosha
  • Premature ovarian failure
  • Yonivyapada
  • Tubal Block
  • Gulma
  • Granthi, Arbuda

2.3. Contraindications

Contraindications being considered these days can be divided into two categories –

  • Absolute contraindications: Pregnancy and in-situ contraceptive device
  • Relative contraindications: vaginitis, cervicitis, endometritis, endometriosis, and carcinoma.

2.4. Period of Uttarabasti

The best period is from the 6th to 12th12th-days of menstruation, as it will lead to a well-formed Bija and facilitate conception.

PROBABLE MODE OF ACTION OF UTTARABASTI

The mode of action of Uttarabasti lies not only in the Pradhana Karma but also in its Poorva Karma-

  • Mode of action of Poorva Karma in Uttara Basti:
  • Though classics have not specifically emphasized much upon Snehana and Svedana before Uttarabasti, this method looks to be genuine and appropriate.
  • Uttarabasti deals generally with the Apana Vayu, as the close-by situated organs are its seat. Snehana and Swedana before Utttarabasti do its Anulomana and thus, Uttarabasti becomes more efficacious.
  • Besides this, the chances of any type of complication are also less, if Vatanulomana is done before the procedure.
  • Besides, Snehana and Swedana (just before Uttarabasti) relax the abdominal muscles. Good relaxation is very important for Uttarabasti, so that uterus does not get irritated by the instillation of medicine from outside. If it is not relaxed adequately, it may contract at once and may not retain any of the medicine.
  • Snehana and Svedana (before Uttarabasti) also lessen the ache all through and after the procedure.
  • Yoni Prakshalana carried out before Uttarabasti with Kwatha of antiseptic property nullifies the possibility of any kind of infection as a complication.

Mode of action of Pradhana Karma in Uttarabasti:

The mode of action of Uttarabasti can be understood in two ways –

  • Local effect of Uttarabasti
  • The effect of Uttarabasti will depend on various things; like method, instrument, drug user, etc. If the medicine is put in the cervical canal, it may act more on the cervical factors. For the factors like cervical stenosis, a Katu – Ushna Taila-based medication is more useful, while for increasing the secretion of mucous from cervical glands, a nutritive like Madhura-Sheeta Ghrita-based medicine will be more efficacious.
  • In the same way, drug selection for an ovulatory and tubal factor will be different from each other. On the ovary, the effect of the drug will be after absorption and then by promoting the Hypothalamus-Pituitary-Ovarian axis, while in the tubal block, Uttara Basti acts locally. In ovulation, a drug with Snehan property can be good while for tubal block, a drug with Lekhana Karma will be better.
  •  The advantage of intrauterine instillation of oil is proved in modern science also as it is said that approximately 30% of the patients who have normal hysterosalpingography, conceive over the following 6 months and it is thought to be a characteristically oil-based contrast medium.
  • Apart from this, Uttara Basti may also stimulate certain receptors in the endometrium, leading to the correction of all the physiological processes of the reproductive system. It may also help in the rejuvenation of the endometrium.

Thus, the mode of action of Uttara Basti can be understood in the following ways –

  • Intra-vaginal Uttara Basti helps in removing infections. (If given with antiseptic drugs)
  • Intra Intra-vaginal – Basti may also facilitate the absorption of the drug, as the posterior fornix has a very rich blood supply and it may also act as a reservoir of the drug (when the patient is lying down in a head low position after Uttara Basti).
  • Intra-cervical Uttara Basti with oil-based drug helps to remove cervical stenosis and to restore the function of the cervix in conception and helps to treat dysmenorrhoea caused by stenosis.
  • In cervical Uttara Basti with Bhrimhana drugs may stimulate the secretion of cervical mucous leading to an ascent of sperms in the uterine cavity.
  • Intrauterine Uttarabasti with Ghrita-based Snehana & Brimhana drugs helps in the rejuvenation of endometrium, especially where apart from regular ovulation, poor endometrium is causing infertility or scanty menstruation.
  • In cases of menorrhagia due to endometrial hyperplasia, Intra uterine Uttarabasti with Lekhana Dravyas may help.
  • For a tubal factor of infertility, a high intra intra-uterine Basti with Lekhana & Ropana Dravya acts in two ways. Lekhana Dravyas removes the blockage of the tubal lumen by directly acting on obstruction mechanically and Ropana Dravyas restores the normal function of tubal cilia by stimulating it. As endometrial covering is continuous in the tubes too, its scraping and regeneration also lead to the normalization of tubal functions.
  • The systemic effect of Uttar Basti after absorption: –
  • Ayurveda had a very clear approach to the oral and parenteral route of drug administration from the very beginning. Thus, Acharyas have described the administration of drugs from almost all the open organs and have considered the Basti (rectal administration) the most efficacious.
  • In the same pattern, Uttarabasti can also act after getting absorbed from the rich blood circulation of the uterus and posterior fornix. Then, it may act on the whole body system and can act as a parenteral route.
  • The systemic effect of Uttarabasti can also be understood with the help of the system biology concept. System biology is the latest concept emerging and getting accepted in modern science. This concept believes in the artistic approach similar to as advocated in Ayurveda from the very beginning. It considers the need for a standard shift of modern science from reductionist to holistic. It believes that all bodily systems and organs are interconnected at the molecular level. This concept is the first step of modern science towards the concept of Mahabhuta and Tridosha. Ayurveda also considers whole the body as one unit on the Mahabhautic level. Still, Tridosha and Mahabhuta are something broader, but more abstract than molecules, which will be explored in modern science too in the coming future. It is now clear that ‘whatever may the effect Uttarabasti drugs have on the physiology of the reproductive system, it will involve the physiological functions and corrections of other systems.
  • Thus, Uttarabasti can be taken as a parenteral route of administration for reproductive diseases, as it can act, locally as well as systemically.

About Author

Dr. Ankit K. Garg

M.S (Ayu) OBGY

Former resident ITRA, Jamnagar

Address-Ridhi-Sidhi Bhawan bedal road Falna Dist.-Pali, (Raj).306116 Phone -8302463471

Prameha

Best Way To manage Diabetes mellitus / Prameha in Ayurveda

Prameha word consists of two words i.e., Pra (Upsarga-Prefix) and Meha. Meha is derived from the root ‘Mih Sechane’ meaning to perfuse (watering), Excessive quantity and frequency are indicated by the prefix (pra).

Acharya Vagbhatta described Prameha as frequent and copious urine with turbidity; i.e., Prabhut Avil Mutrata while Madhumeha is a clinical entity in which a patient passes a large quantity of urine similar to Madhu having kashaya & Madhura taste, Ruksha texture & Honey like color and thus body attains sweetness. (A.H.Ni.10/18, Cha. Ni.4/44)

Synonyms- Ojomeha, Kshaudrameha, Paushpameha.

Classification of Parmeha

Based on Dosha

Entity Kaphaja Pittaja Vataja
Prognosis Sadhya (Treatable) Yapya (Continues on treatment) Asadhya (Non-treatable)
Physical Appearance Sthula (Obese) Usually not much obese Krisha (Asthenic)
Origin Apthyanimittaja (Acquired) Acquired Sahaja(hereditary)

Classification Of Madhumeha:

The clinicopathological status of the disease has an invariable relation with the physical constitution of the body in Madhumeha. [Cha.Chi.6/15] [Su.Chi.11/3]

  • Sthula or Krisha
  • Sahaja [Hereditary] or Apathyanimittaja [Acquired] [Su.Chi.11/3]

Sahaja: Due to Beejadosha i.e., genetic origin. [Su.Chi.11/3]

Apathyanimittaja: Occurs due to Ahitahara/ Dietary factor.

(B)According to etiological factors:

  • Santarpanjanya & Apatarpanjanya:

Santarpanjanya Madumeha is directly due to the intake of a nutritious diet, which are having kaphavardhaka properties. The excess intake of such substances will primarily lead to the vitiation of Kapha, pitta, Meda & Mansa, which in turn causes Madhumeha by doing Avarana of Vata. [Cha. Su.17/78-81] If the substances which deplete the dhatu & aggravate Vata are consumed then it leads to Apatarpanjanya Prameha. They act through the vitiation of Vata which in turn leads to the manifestation of madhumeha.

Nidana

Sahaja:

Abnormality in Stri & Pumbeeja (Ovum & Sperm) which is said to be Matrupitru Beejadoshakrita will cause Sahaja Prameha. Or in other words, it is being received from hereditary trends. Charaka stated that indulgence of Madhura rasa by parents is the chief cause of changes & damages in the sperm & ovum. Excessive intake of Madhura Rasa during pregnancy is depicted as a major cause.

Apathyanimittaja:

Etiological Factors of General Prameha [Cha.Chi.6/4]

  • Asyasukham
  • Swapnasukham
  • Excessive indulgence in Dadhini i.e., Various preparation of curd.
  • Gramya, Audaka, Anupa Mamsa i.e. Meat of domestic, aquatic, and wetland animals.
  • Payamsi i.e., excessive use of milk & its preparation
  • Navannapanam i.e., new grains & drinks
  • Guda vaikrutam i.e., various preparation of sugar & jaggery.
  • the substances which increase meda,mutra &  Kapha may cause prameha.
  • Snigdha (unctuous), Medya (fatty) & Drava (liquid) types of food also
Kaphaja Prameha [Cha.Ni.4/5]: Pittaja Prameha Nidana [Cha.Ni.4/24] Vataja Prameha Nidana [Cha.Ni.4/36]
Frequent & Excessive intake of fresh corn like Hayanak, Yavaka, Chinaka, Uddalaka, Naishdha, Itkata, Intake of Ushna, Amla Lavana, Kshara & Katura Dravyas. Excessive intake of Dravyas having predominantly kashaya, katu,tikta rasa, Ruksha, Laghu & Sheeta very
Intake of pulses like fresh harenu & Masha with ghee Intake of food before the digestion of the previous meal Excessive indulgence in sex & physical exercise.
Intake of the meat of domestic, marshy & aquatic animals. Exposure to excessively hot sun, the heat of the fire, physical exertion & anger Excessive administration of emesis, purgations, asthapana & shirovirechana.
Intake of vegetables, tila, palala, pishtanna, payasa (a type of milk preparation), krishara, Vilepi & preparations of sugarcane. Intake of mutually contradictory food articles. Resorting to suppression of the manifested urges, fasting, assault, exposure to sun, anxiety, grief, Excessive bloodletting, Keeping awake at night & irregular posture of the body.
Intake of milk, fresh wine, immature curd & curd which are mostly liquid, Sheeta & immature.    
Avoidance of unction & physical exercise    
Indulgence in sleep, bed rest & sedentary habits    
Restoring to even such regimens which produce more Kapha, fat & urine.    

Signs/Symptoms

Specific Symptomatology of Madhumeha:

Urine Characteristics:

Madhumehi passes urine having Kashaya & Madhura taste, Pandu varna & Ruksha quality. According to Sushruta, the urine of Madhumehi resembles that of honey.

Psychological manifestation:

The special manifestation related to the behavioral pattern is depicted by Sushruta, Madhumehi prefers standing to walking, sitting then standing, lying down to sitting, & sleeping then lying down.

General Symptomatology:

  • Urine Characteristics:
  • Prabhuta Mutrata (excess urine Quantity)
  • Avila Mutrata (Turbid urine):
  • Pichhila Mutrata (viscus in Consistency):
  • Akasmata Mutra Nirgama: The child excretes urine suddenly without any intention.
  • Makshika Akranta Mutra: Flies get attracted to urine.
  • Shveta & Ghana mutrata: Child passes urine having Shweta color & turbidity.

Samprapti/Pathogenesis

Prameha is a group of diseases that are established in the body due to Santarpana. Charka in Nidanasthana mentioned the disease in detail.

The Nidana, Dosha (Vatadi tridosha), and Dushya (Rasadi dushyas) are responsible for the occurrence and non-occurrence of disease. If these three factors are having less strength and are connected then the establishing disease will not have all the signs and symptoms. If they are complete & with full strength, and their connection is strong then the disease produced will be having all the signs and symptoms. Some important points in this concept are, that Natural Kapha is not having the quality of ‘Bahudravatva’. In the normal state, it is in bounded form. Here in Prameha samprapti, it loses its bounded form due to some specified causes and changes to the bahudravatva (liquid) form. Dravata(Liquid nature) is high in the acharya’s concept and it is stressed by the term ‘Bahu’. The dushyas included are, meda, mamsa, Sharir kleda, Shukra, Shonita, Vasa, Majja, Lasika, Rasa, and Oja. The special characteristic feature of the Dushyas is in the Bahuabadhha form.

Pathogenesis of Madhumeha:

When Sadhya Roga changes into Krichrasadhya or Asadhya it can be called as Vidhi Samprapti. It commonly occurs in untreated conditions. As far as Madhumeha is concerned, we can partly include it in Vidhi Samprapti. Acharya Sushruta explains as if all the Prameha are not treated first, they will gradually pass to the stage of Madhumeha.

Acharya Charaka has described Madhumeha vividly. Vagbhattacharya divides Madhumeha into two types, according to Samprapti. The Madhumeha is included in the Vataja type. If Vataprakopa occurs due to Sarvadhatukshya, it is called Dhatukshayajanya Madhumeha. And if Vataprakopa manifests as a result of Vatavarana, it is called Avaranjanya Madhumeha. Acharya Sushruta explains as if all the Pramehas are not treated initially, they will gradually pass the stage of Madhumeha.

Upadrava/complications

(1) General Complications [Cha.Ni.4/48]:

Trishna, Atisara, Daha, Daurbalya, Arochaka, Avipaka, Putimamsa Pidaka, Alaji, Vidradhi etc.

(2) Specific Complications:

Kaphaja [Su.Ni.6/15] Pittaja Vataja
Makshikopasarpanam, Alasya, Mamsopachaya, Pratishyaya, Shaithilya, Arochaka, Avipaka, Kaphapraseka, Chhardi, Nidra, Kasa & Shwasa Vrushanayorvadaranam, Bastibheda, Medhra toda, Hridshula, Amlika, Jwara, Atisara, Arochaka, Vamathu, Paridhumayanam, Daha, Murchha, Pipasa, Nidranasha, Panduroga, Pittavidmutranetratva Hridgraha, Laulya, Anidra, Stambha, Kampa, Shula, Baddha purishatva & shosha, Kasa, shwasa

Complications of Madhumeha:

Pidaka-  Sharavika , Kacchhapika, Jalini, Sarshapi, Alaji, Vinata, Vidradhi, Putrini, Masurika, Vidarika

SADHYASADHYATA

Generally, the concept of prognosis in the case of prameha re given by all acharyas as,

Kaphaja Prameha-Sadhya

Pittaja Prameha-Yapya

Vataja Prameha-Asadhya when occurred due to dhatukshaya & Krichrasadhya when

established due to avarana.

PATHYA-APATHYA

Pathya:

(a) Aahara:

  • Shook Dhanya: Jeerna Shali, Shashtika, Kodrava, Yava, Godhuma, Uddalaka, Shyamaka
  • Shimbi Dhanya: Chanaka, Adhaki, Kulattha, Mudga
  • Shaka Varga: The leafy vegetables with a predominance of tikta-kashaya rasa, Patola, Karvellaka, Shigru
  • Phala Varga: Jambu, Dadima, Shringataka, Amalaki, Kapittha, Tinduka, Kharjura, Kalinga, Navina Mocha.
  • Mamsa Varga: Vishkira mamsa,Pratuda, Jangala mamsa
  • Taila Varga: Danti, Ingudi, Sarshapa , Atasi
  • Udaka Varga: Sarodaka, Kushodaka, Madhudaka
  • Kritanna Varga: Apupa, Saktu, Yavodana, Vatya, Yusha
  • Others: Madhu, Hingu, Saindhava, Maricha, Lasuna

(b) Vihara:

To have walked, traveled on elephants, horses, and different plays, a different forms of martial arts, and roamed in different places without chappal and umbrella.

Apathya:

(a) Aahara:

Jala, Milk, Ghee, Oils, Curd, Sugar, Different types of rice preparations, anupa, gramya, audaka mamsa, Ikshurasa, Pishtanna, and Navanna.

(b) Vihara:

Eksthana asana, Divaswapa, Dhoompana, Sweda, Raktamoksha, Mutravega dharana.

CHIKITSA

Chikitsa-sutra (principles of treatments) and Chikitsa (Management Proper) are the two divisions of this major part. Both these are described very well in the classics. But the concepts & methods are different in different conditions, considering the Vyadhi Swabhava & Atura. The Samprapti should be considered deeply before stepping to manage.

CHIKITSA SUTRA:

Charaka Acharya considers two types of patients, one with stout body structure & strength and the other without strength & krisha.

Sushruta acharya also says that Sahaja Meha Rogi will be krisha & apathyanimittaja rogi will be sthula.

In the context of medoroga, the managements described are parallel to that of meha since the dosha & dushyas are the same to a major extent. After considering all the factors the two types of management emphasized are:

(1) Samshodhana Chikitsa [Elimination Therapy]

(2) Samshaman Chikitsa [Normalizing Therapy]

Like every disease, those factors which are responsible for the production of the diseases are eliminated and if further, causative factors are prevented Meha can also be treated. Madhumeha can be treated in this way although it is described as incurable. In Pratyakhyeya vyadhis, symptomatic relief can be given by proper management.

KAPHAJA PRAMEHA:

(i)Samshodhan Chikitsa:

  • Shodhana
  • Vamana
  • Langhans
  • For Bastichikitsa- Surasadi gana kwatha.

(ii)Samshaman Chikitsa:

  • Charaka- combinations of 10 drugs
  • Sushruta-Samshodhana with swarasa of Amalaki and Haridra powder with Madhu.
  • Vagbhatta- Three yogas
  • Lodhrad i- Lodhra, Abhaya, Musta, Katphala
  • Pathadi – Patha, Vidanga ,Arjuna,Dhanyaka
  • Gayatrayadi – Khadirsara, Darvi, Vidanga, Vacha

Importance of Apatarpana:

Different types of vyayama, kshut, udvartana, Dhara & snana with churns made of Chandana, Aguru, Ela, etc. are advised to use in kaphaja meha to reduce the increasing attitude of kleda, meda, and Kapha. [Cha. Chi. 6/50]

PITTAJA PRAMEHA:

(i)Samshodhana Chikitsa:

  • Virechan
  • Asthapan Basti with Nyagrodhadi Gana kwatha

(ii) Samshaman Chikitsa:

Acharya Charaka -Combinations of 10 drugs

Sushrutacharya -6 specific kwatha yogas for the specific type of Pittaja prameha. [Su.Chi.11/9]

Acharya Vagbhatta -The three kwatha yogas

(i) Ushiradi: Ushira, Lodhra, Arjuna, Chandana.

(ii) Patoladi: Patola, Nimba, Amalaki, Amrita

(iii) Lodhradi: Lodhra, Ambu, Kaleyaka, Dhataki

VATAJA PRAMEHA:

Although Vatika mehas are incurable still Acharya Charaka explains induces certain treatments in kaphapittanubandhi Vatika Meha.

Acharya Sushruta has described that all types of Prameha if not treated properly in time, get converted into Madhumeha.

So, the treatment described for Vatika meha can be considered as the treatment of Madhumeha.

MADHUMEHA:

(i) Samshodhan Chikitsa:

Considering Sthula & krisha pramehi, Samshodhan Chikitsa should be administered only to the sthula & Balvan Pramehi. Sarshapa, Nimba, Danti, Bibhitak & Karanja Siddha Taila or Trikantakadya Sneha (Ghrita or Taila according to dosha predominance should be used for Abhyantara Snehana. Here while explaining the Samshodhan, Charaka describes using the Malashodhan yogas from Kalpasthana

Both Pitta & Kapha are eliminated through shodhana. Either it may be Vamana or virechana, because of; Pittantam Vamanam, Kaphantam Virechanam. In Virechana pitta is eliminated first, then Samyak Lakshana of virechana is kaphadarshan, so both pitta & Kapha doshas which are vitiated are eliminated. Then the described

Anuvasana & Asthapana Basti chikitsas are able enough to control the provocation of Vata. Like this, all the doshas are normalized to keep the dosha samyata.

Anuvasana with medicated oils & ghritas is prescribed in Madhumeha. After proper Shodhan Chikitsa, Charakacharya details to give santarpan chikitsa to the patients, to prevent the complications like Gulma, Bastishula, etc.

(ii)Samshaman Chikitsa:

Samshaman Chikitsa includes mainly deepana (appetizers), Pachana, (enhancing digestion), Kshut (Hunger maintenance), Trit (Maintenance of thirst), Vyayama (Exercise), Atapa (Having exposure to sunlight) & Maruta (Exposing oneself to wind). According to the conditions of vitiated doshas & dushyas, the vaidya has to suggest proper Shaman Chikitsa to the patient.

Acharyas introduce different tarpana upakramas in Vatika mehas. It is due to the less strength of the patient. Acharya Charaka & Vagbhatta says that the kashaya yogas should be enriched with Sneha and given to Vatika Mehas.

Typical Madhumeha Chikitsa:

Acharya Sushruta explains that Shilajit should be taken after triturating with Salsaradi Gana kwatha. After its digestion patient should take Jangalamamsarasayukta Anna. He prescribes taking 1 Tula of shilajit.

Compound Preparations Used in Prameha:

Swarasa: Amalaki, Haridra, Nimbapatra, Bilwapatra, Guduchi

Kwatha: Vidangadi, Phalatrikadi, Mustadi, Manjishthadi, Pathadi

Churna: Triphaladi, Mustadi, Gokshuradi, Arkadi

Gutika: Chandraprabha, Indravati, Pramehantak Vati

Gugglu: Gokshuradi Guggulu

Modaka: Kastur Modaka

Avleha: kushavleha, Bangavleha

Paka: Pugapaka, Ashwagandhadi paka, Draksha Paka.

Asava Arishta: Lodhrasava, Dantyasava, Madhukasava, Devdarvyadiarishta, Lodhrarishta.

Ghrita: Dhanvantar ghrita, Trikantakadi ghrita, Sinhamrita ghrita, Dadimadi ghrita, Shalmali ghrita.

Rasaushadhi:Vasant kusumakar Rasa, Mehamudgar Rasa, Brihat Bangeshwar, Rasa, Prameha gajkesri Rasa, Tribanga Bhasma, Vasant tilaka Rasa.

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Fissure

Basic Fundamentals of Fissure in Ano as per Ayurveda

Fissure

Fissure is described in Sushrut Samhita. It is described in the complications of Garbini (pregnant lady) in the Kashyap Samhita, Khilasthana. Parikartika resembles a fissure‑in‑ano having cutting and burning pain at Guda. Acharya Sushruta mentioned it as one of the complications in the Virachanaa (purgation therapy) and Vasti karma (enema therapy). Acharya Charaka described it in vyapad of vaman-virechan and Basti Vyapad (a complication of medicated enema), and Bastinetra Vyapad (a complication of medicated enema tube).

DEFINITION:

Parikartika or Parikartana. Vyutpatti: The word Parikatika consists of two words. Pari- around, about; Kartana- the act of cutting off; Krintati– clip, cut off. Nirukti: Unbearable cutting type of pain all around Guda, Bastishiras, and Nabhi is termed Parikartika.

ETIOLOGY :

 Diet-related etiology :

Diet plays a very important role in Parikartika which is evident from references. Vagbhata and Kashyapa have explained that intake of Mudga, Kodrava, Chanaka, and other pulses and Rooksha charas which is water absorbent in nature (Sangrahi) lead to constipation. Apanavata gets aggravated in its seat (Pakwashaya) which blocks the adhovaha srotas, dries them up (of their moisture), and produces obstruction to the movement of feces, flatus, and urine by which Parikartika occurs 8&9. As per modern science intake of nonfibrous food will lead to the hardening of stools and cause Fissure-in-ano.

            When Vata is covered with feces, the stool is constipated, the patient suffers from severe pain and passes hard stools with difficulty, and evacuation is delayed. This causes Parikartana leading to Parikartika. If a person is debilitated with Mridukoshta or Mandagni, the ingestion of Atirooksha, Atiteekshna, Atiushna, Atilavana Sahara causes Dushana of Pitta and Anila and produces parikartika.

 Disease-Related etiology :

  • Udavarta (Purisajaudavartaor Purisavrta Vata)
  • Arsha (Prodromal features and symptoms of Vatika and Kaphaja Arsha) – Abnormality of the internal sphincter predisposes the patient to the formation of both hemorrhoids and fissures.
  • Jirnajwara
  • Vatika Atisara
  • Vatika Grahani

Physician related etiology :

  1. Vairocana Vyapada – A person having Mrudu Kostha and Alpa Bala ingest Tiksna, Ushna, and Ruksa drugs for Virechana, then this disease results.
  2. Vasti Vyapada (niuruha)- If Ruksa Vasti containing Tiksna and Lavana drugs is administered in heavy doses; it may produce Parikartika.
  3. Excessive use of Yapana Vasti – It may lead to Parikartika along with other diseases.
  4. Vasti Netra Vyapada – Due to inappropriate administration of the enema nozzle and defects in the enema nozzle itself may cause this disease.

SAMPRAPTI :

In the concerned disease, the predominant vitiated Dosha is Vata. Dushya is Twak, Rakta, and Mamas, specifically in Guda Pradesh, which affects gradually according to the progress of the disease. The Vyana Vayu when obstructed by the pathway of Apana Vayu led to the formation of Parikartika associated with Udavarta. Due to the etiological factor, there is Dusti of Purisavaha Srotas. When Purusha is obstructed the natural way of Apana Vata also causes vitiation of Vayu. As a result of the pathogenesis, when Vata localizes in Twak, it becomes Ruksa and shows a tendency to crack. As the disease progress, the vitiated Vayu is localized in Rakta, and the formation of an ulcer takes place. Thereafter when it localizes in Mamsa forming knotty swelling or tags and pain. Though there is a predominance of Vayu, it is associated with Pitta (according to Acharya Sushruta) and Kapha (according to Acharya Kasyapa)

Another Samprapti is due to Agantuja Nidana where there is wound formation in the first stage and then the Doshas get sited in the Vrana, producing further symptoms. When the wound is produced simultaneously there is vitiation of Dosha which in term leads to Parikartika.

LAKSHANA/SYMPTOMS:

The terminology Parikartika is itself representing the symptom, which is the intensity of pain. It is a sharp cutting or sawing type of pain. It’s severe pain with bloody mucous discharge associated discomfort in the perianal region as per Charaka. The pain persists before and after defecation mentioned by Susruta. There is vitiation of Vayu mainly the Purisavrta Vata. The involvement of Dushya as a disease concern will be Twak, Rakta, and Maṃsa. When vitiated Vayu affects the following Dhatus, symptoms become more relevant as per disease concern.

SADHYASADHYATA/PROGNOSIS :

Generally, Vrana in Payu is easily curable. If a Vrana is left untreated, as a consequence it may lead to the Yapyatwa stage and finally leading to the Asadhyatwa stage. Parikartika which affects the superficial layer of the Twak (anal skin) is easily curable in a short time. Therefore it can be included in the Sukhasadhya group. If it affects the deeper layers, it deals with wound healing. And if it is associated with Madhumeha, Kustha, Vishodusti, and Sosha, the healing of Vrana will be delayed. If Parikartika is associated with Sanniruddha

Guda, is considered as Yapya.

In Astanga Samgraha some Arista Lakshana is mentioned about Parikartika.

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

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

CHIKITSA/TREATMENT :

The Mandagni is a most important factor in Parikartika as well as in Arsha, Atisara, and Grahani. So increasing and maintaining the Agni in an equilibrium state is necessary. Up to 70 % of acute fissures resolve with conservative medicine, if not they progress to form a chronic fissure. However, Ayurvedic preparations are used in the primary stage of the disease the chance of progression in chronic one can be minimized. The main aim of treatment is to relieve sphincter spasms and heal fissure wounds, soothe the anal canal, and relieve the agonizing pain and associated burning sensation and bleeding.

  1. Nidana Parivarjana (removal of etiology)- It is the first step of treatment.
  2. Avagahana-sweda (Hot fomentation- Sitz bath): Sitting in a warm/hot water tub after each bowel movement soothes the pain and relaxes the spasm of the internal sphincter for some time.
  3. Local application of Durvadya tail–  Main ingredient of Durvadya tail is Durva (Cynodondactylon), Kampillaka (Mallotus philippensis), Daruharidra (Berberis aristata), and Til tail (sesame oil).
  4. Matra Basti (type of Anuvasana Basti): It acts as a retention enema and helps in the easy voiding of stools, by this Vatanulomana occurs and it cures the diseases caused by aggravated Vata as Parikartika is Vata dominate Vyadhi. By giving Matrabasti local Snehan occurs, the spasm will also be relieved and thus brings down the pain. It softens the stools, lubricates the anal canal, and provides an easy evacuation.
  5. High fiber diet: The rate of intestinal passage of food depends on the nature of the diet and its fluidity. The greater the indigestible residue and water content, the more rapidly it reaches the rectum and produces its distension and thereafter evacuation. Hence patients should take daily fiber-rich food and plenty of fluids to improve digestion and regularize their bowels. These are hygroscopic, which allows them to expand and become mucilaginous. These fibers are a complex carbohydrate, which binds with water in the colon creating larger, softer, stools. Larger, softer, stools stretch and relax the sphincter muscles helping the blood to flow and it also requires little pressure to pass.
  • In the Jwara Chikitsa, Acharya Charaka has also mentioned that in Jwarita person, there are chances of having Parikartika. He should consume Peya of red rice made from decoction of Vrakshamala, Badara, Pithivana, and Kantakāri with powder of unripe fruit of Bela’s cortex.
  • About Garbhini Chikitsa, Acharya Kasyapa classified the disease into three categories and gave specific treatment according to the Doshic involvement.
  • Taila/Ghrita Pichu: It forms a protective layer over the fissure wound, it smooths the anal canal and relieves pain by releasing sphincter tone and cleaning the wound thus helping in the healing of ulcers.

CHIKITSA FOR SHUSHKARSH / BAHYARSH :

In Ayurvedic text information available on Shushkarsha, Bahyarsha can be correlated with Sentinel Piles. Acharya Sushruta mentioned four modalities of management

1) Bheshaja (conservative line of management)

2) Kshara

 3) Agni 

4) Shastra. 

In kshar chikitsa, kshar sutra ligation was done to sentinel piles. of this themselves they may fall within a few days. Also can use as Lepa of  Pratisaraneeya kshara is done over the (Chronic fissure-in-ano) ulcer surface, by lekhan karma of Kshara, this reduces the excess fibrous tissue present over the ulcer surface and the ulcer heals & sphincter relaxation occurs simultaneously.

DISCUSSION :

Based on location, nature of pathology, and features, Gudaparikartika can be correlated to Fissure-in-ano. The detailed description of Nidana (etiology), Samprapti (pathogenesis), Lakshana (symptoms) & Chikitsa (treatment) is mentioned in Sushruta Samhita, Kashyapa Samhita, Astanga Hridaya, etc. There is a detailed description of conservative and surgical treatment for Fissure-in-ano.

CONCLUSION :

  • Improper dietary regimens and stressful life are found to have influenced the high incidence observed today. 
  • Passage of hard constipated stools is the prime cause of tears in the lower anal canal which results in excruciating pain during and after defecation, the cardinal feature of Fissure-in-ano.
  • Ayurvedic preparations are all effective & these can cure fissures and regularize bowel in up to 90% of cases of acute fissures. These could always be offered to patients who are not willing to operative procedures such as cardiac patients or patients with diabetes, AIDS, or Hepatitis B where healing is difficult after the operation.
  • Kshara is used in different forms like Kshara Lepa, and Ksharasutra ligation in treating Parikartika (Chronic Fissure-in-ano).