अष्टमोऽध्यायः । अथातो भगन्दराणां चिकित्सितं व्याख्यास्यामः, यथोवाच भगवान् धन्वन्तरिः ॥ १ ॥
Now we shall discourse on the medical treatment of Fistula-in ano, etc.. (Bhagandara). 1
पञ्च भगन्दरा व्याख्याताः, तेष्वसाध्याः शम्बूकावर्त शल्यनिमित्त• श्चेति; शेषाः कृष्छ्रसाध्याः ।। २ ।।
The disease admits of being divided into five different groups, of which the two, known as Sambukavarta (Tridosaja) and Salyaja (traumatic), should be regarded as incurable, and the rest as extremely difficult to cure. 2
तत्र भगन्दरपिडकोपद्रुतमातुरमपतर्पणादिविरेचनान्तेनैकादशविधेनोपक्रमेणोपक्रमेतापक्वपिडकम् । पक्वेष चोपस्निग्धमवगाहस्विन्नं शय्यायां सन्निवेश्यार्शसमिव यन्त्रयित्वा भगन्दरं समीक्ष्य पराचीनमवाचीनं वा, ततः प्रणिधायैषणीमुन्नम्य साशयमुद्धरेच्छस्त्रेण । अन्तर्मुखे चैवं सम्यग्यन्त्रं प्रणिधाय प्रवाहमाणस्य भगन्दरमुखमासाद्यैषणीं दत्त्वा शस्त्रं पातयेत् । आसाद्य वाऽग्निक्षारञ्चेत्येतत् सामान्यं सर्वेषु ॥ ३ ॥
The General Treatment: The even¹ kinds of remedial measures commencing with Apatarpana up to purgatives ( as described under
1. Aputarpama, Alepa, Pariseka, Abhyanga, Sveda, Vimlapana, Upanaha, Pacana, Visravana, Sneha, and Vamana. the treatment of Dvi-vrana) should be employed as long as any fistular ulcer would remain in an unsuppurated stage. The patient should be soothed by the application of medicated oil, etc., and his body should be fomented by immersing him in a receptacle of warm water, etc. as soon as suppuration would set in (and even after the ulcer had burst). Then having laid him on a bed and bound his hands and thighs with straps as described under the treatment of Haemorrhoid, the surgeon should examine closely as whether the mouth of the fistula is directed. outward or inward, and whether the ulcer itself is situated, upward or downward. Then the whole cavity or receptacle of pus (sinus) should be raised up and scraped out with an Esani (indicator or probe). In a case of inter-mouthed fistula, the patient should be secured with straps (as before described) and asked to strain down. An incision should then be made by first directing the indicator when its mouth would become visible from the outside. Cauterization with fire or alkali is a general remedial measure which may be resorted to in all types of this disease. 3
विशेषतस्तु – नाड्यन्तरे व्रणान् कुर्याद् भिषक् तु शतपोनके । शेषा नाडीरुपाचरेत् । बाह्याश्छेद्यास्त्वनेकधा ।। ४ ।।
ततस्तेषूपरूढेषु गतयोऽन्योन्यसम्बद्धा नाडीरनभिसम्बद्धा स कुर्याद् विवृतं यश्छिनत्त्येकधा भिषक् ।
जन्तोव्रणं गुदविदारणम् । तस्य तद् विवृतं मार्ग विण्मूत्रमनुगच्छति ।। ५ ।।
आटोपं गुदशूलञ्च करोति पवनो भृशम् । तत्राधिगततन्त्रोऽपि भिषङ् मुह्येदसंशयम् ।। ६ ।। शतपोनके ।। ७ ।। तस्मान्न विवृतः कार्यो व्रणस्तु
Specific Measures — M. Texts: In cases of the Sataponaka (multiple fistula) type all the small Vranas about the anus should be first incisioned and the principal sinus in the locality should not be looked after until these small ones had been healed up. The connected abscesses should be respectively incisioned on the external side, while the unconnected ones should not be opened at the same time in order that they may not run into one another and be thus converted into a wide-mouthed ulcer. The urine and the faecal matter are found in each case to flow out of the cavity of such a wide-mouthed ulcer; and aching pains in the rectum and a rumbling sound in the abdomen, due to the action of the aggravated Vayu, are experienced. Such a case is enough to confound even a well-read and experienced physician. Hence the mouth of a fistula of the Sataponaka type should not be opened with a broad incision. 4-7
व्याधौ तत्र बहुच्छिद्रे भिषजा वै विजानता ।। ८ ।।
अर्द्धलाङ्गलकश्छेदः कार्यो लाङ्गलकोऽपि वा । सर्वतोभद्रको वाऽपि कार्यो गोतीर्थकोऽपि वा । सर्वतः स्त्रावमार्गांस्तु दहेद् वैद्यस्तथाऽग्निना ।। ९ ।।
Forms of incisions : An experienced surgeon should know that the Langalaka, Ardha-Langalaka, Sarvatobhadraka and the Gotirthaka forms of incisions should be the different shapes of incision, in a case of a many-mouthed Sataponaka. An incision equal in its two sides is called the Langalaka (curvilineal), while the one with one arm longer than the other is named the Ardha-Langalaka. An incision made in the region of the anus in the shape of a cross (crucial) and a little removed from the raphe of the perineum, is called the Sarvatobhadraka by men conversant with the shapes of surgical incisions. An incision made by inserting the knife in one side is called the Gotirthaka (longitudinal). All exuding (bleeding) channels in the affected region should be cauterized with fire by the surgeon. 8-9
सुकुमारस्य भीरोर्हि दुष्करः शतपोनकः । रुजास्त्रावापहं तत्र स्वेदमाशु प्रयोजयेत् ।। १० ।।
स्वेदद्रव्यैर्यथोद्दिष्टैः कुशरापायसादिभिः । ग्राम्यानूपौदकैर्मांसैर्लावाद्यैर्वाऽपि विष्किरैः ।। ११ ।।
वृक्षादनीमथैरण्डं बिल्वादिञ्च गणं तथा । कषायं सुकृतं कृत्वा स्नेहकुम्भे निषेचयेत् ।। १२ ।।
नाडीस्वेदेन तेनास्य तं व्रणं स्वेदयेद् भिषक् । तिलैरण्डातसीमाष-यवगोधूमसर्षपान् ।। १३ ।।
लवणान्यम्लवर्गञ्च स्थाल्यामेवोपसाधयेत् । आतुरं स्वेदयेत् तेन तथा सिध्यति कुर्वतः ॥ १४ ॥
स्विन्नञ्च पाययेदेनं कुष्ठञ्च लवणानि च । वचाहिङ्ग्वजमोदञ्च माकेनाथवाऽम्लेन वा ।
ततो मधुकतैलेन तस्य सिञ्चेद् भिषग् व्रणम् ।। १६ ।।
तैलैर्वातरुजापहैः । स्वमार्गमधिगच्छति ।। १७ ।।
परिषिञ्चेद् गुदञ्चास्य विधिनाऽनेन विण्मूत्रं अन्ये चोपद्रवास्तीव्राः सिध्यन्त्यत्र न संशयः ।
शतपोनक आख्यातः समभागानि सर्पिषा ।। १५ ।।
सुरासौवीरकेण ..उष्ट्रग्रीवे क्रियां शृणु ।। १८ ।।
A case of the Sataponaka type occurring in a person of timid disposition or of delicate constitution, is extremely difficult to cure. Medicinal fomentations endowed with the virtue of arresting secretion and alleviating pain, should be quickly applied (to the seat of the disease). Fomentations with Krsara, or Payasa (porridge), made with the aforesaid Svedaniya (diaphoretic) drugs with a decoction of the drugs constituting the Bilvadi group. Vriksadani and roots of the castor-plant mixed and boiled together with the flesh of the Lava, Vikskira (a kind of bird) and that of animals living in swampy or marshy land or aquatic in their habits or Gramya animals, and then kept in an oily pitcher and applied in the way of a Nadi-Sveda (fomentation through Nadi or pipe), should be at once applied to the seat of the ulcer. Sesamum, castor-seeds, linseed, Masa-pulse, barley, wheat, mustard-seeds, salts and the Amla-Varga (see Rasa Vijnaniya chapter) should be boiled in a saucer and the affected part or ulcer should be fomented therewith. After being fomented, the patient should drink ( a potion consisting of ) Kustha, salts (the five official kinds of salts) Vaca, Hingu and Ajamoda taken in equal parts and mixed with (an adequate quantity of) clarified butter, grape-wine (Mardvika) Kanjika (Amla), Sura or Sauviraka. Subsequent to that, the ulcer should be wetted with the Madhuka-oil and the rectum should be washed with medicated oils which would alleviate pain due to the action of the deranged and aggravated Vayu. The preceding medicinal remedies tend to bring about the outflow or evacuations of stool and
1. By the use of this potions the digestive power is increased. urine through their natural channels or courses, and undoubtedly alleviate all acute and supervening distresses which specifically mark the progress of the disease. We have described the treatment of a case of fistula-in-ano of the Sataponaka ( sieve ) type; now listen to me about the treatment of the Ustragriva (camel’s neck) type of the disease. 10-18
निपातयेत् ।। १९ ।। पूजितः । अथैनं घृतसंसृष्टैस्तिलैः पिष्टैः प्रलेपयेत् ।। २० ।।
बन्धं ततोऽनुकुर्वीत परिषेकन्तु सर्पिषा | तृतीये दिवसे मुक्त्वा यथास्वं शोधयेद् भिषक् ।
ततः शुद्धं विदित्वा च रोपयेत् तु यथाक्रमम् ।। २१ । । अथोष्ट्रग्रीवमेषित्वा छित्त्वा क्षारं पूतिमांसव्यपोहार्थमग्निरत्र
Treatment of Ustra-griva: The ulcer should first be searched with a probe or director and, after an operation, an alkali should be applied to it. To remove all sloughed off or sloughing flesh and membranes cauterization with fire is forbidden. [ The flssures of pus (sinuses) and sloughed off flesh should be first drawn out ] A plaster of clarified butter and pasted sesamum should then be applied to it, and the ulcer is duly bandaged. Clarified butter should be constantly applied over the bandage which should be removed on the third day. Cleansing or disinfecting (Sodhana) measures should then be used by the surgeon, according to the Dosas involved in the ulcer, and the successive healing (Ropana) measures resorted after its being properly purified (Sodhana). 19-21
उत्कृत्यास्त्रावमार्गस्तु परित्राविणि बुद्धिमान् । क्षारेण वा स्रावगतिं दहेद्धुतवहेन वा । सुखोष्णेनाणुतैलेन सेचयेद् गुदमण्डलम् ।। २२ ।।
उपनाहा: प्रदेहाश्च मूत्रक्षारसमन्विताः । वामनीयौषधैः कार्या: परिषेकाश्च मात्रया ||२३||
विदित्वैनमल्पस्त्रावरुगन्वितम् । मृदुभूतं गतिमन्विष्य शस्त्रेण छिन्द्यात् खर्जूरपत्रकम् । चन्द्रार्धं चन्द्रचक्रञ्च सूचीमुखमवाङ्मुखम् ॥ २४ ॥
छित्त्वाऽग्निना दहेत् सम्यगेवं क्षारेण वा पुनः । संशोधनैरेव मृदुपूर्वैर्विशोधयेत् ॥ २५ ॥ ततः
Treatment of Parisravi : In a case of the Parisravi ( exuding ) type, where there is bleeding and secretion from the ulcer, the sinus and the cavities of pus should be first removed and then cauterized with an alkali or with fire by an intelligent surgeon. The region of the anus should then be kept wet by the sprinkling of luke-warm water and Anutaila (described in the chapter on Vata-vyadhi) Warm plasters, or poultices, mixed with Yavakshara and the urine (of a cow) should then be applied. Decoction of the emetic drugs as the seeds of Madana, etc.), should also be sprinkled slightly on the affected part. The ulcer when found to be softened and having little pain and secretion (owing to the preceding measures) should be searched with a probe and the principal sinus should be cut open and again completely cauterized with fire or with an alkali. The incisions should be made in the shape or form of a Kharjura-patra (leaf of the date-palm), Ardha-candra (half-moon), Candra-cakra (moon’s disc ) , Suci-nmukha (needle’s mouth), or Avammukha (with downward mouth). After that the ulcer should be purified with milk cleansing or disinfecting remedies (as described above). 22-25
बहिरन्तर्मुखश्चापि शिशोर्यस्य भगन्दरः । तस्याहितं विरेकाग्नि-शस्त्रक्षारावचारणम् ॥ २६ ॥
यद् यन्मृदु च तीक्ष्णञ्च तत्तत् तस्यावचारयेत् ॥ २७ ॥
आरग्वधनिशाकाला चूर्णं मधुघृताप्लुतम् । अग्रवर्तिप्रणिहितं व्रणानां शोधनं हितम् । योगोऽयं नाशयत्याशु गतिं मेघमिवानिलः ।। २८ । ।
In the case of an infant cauterization with fire or with an alkali, the use of strong purgatives and surgical operations are forbidden in the case of the disease (Bhagandara), whether outer mouthed or intermouthed. Medicinal remedies calculated to be mild, though keen in their efficacy, should be used in such cases. A plug or a Varti in the shape of a wick and made of powdered Aragvadha, Haridra and Kala, mixed with honey and clarified butter, should be inserted into the ulcer for purifying purposes. This medicinal compound speedily brings about the healing of a sinus, just as the wind will drive away a cloud. 26-28
आगन्तुजे भिषङ्नाडीं शस्त्रेणोत्कृत्य यत्नतः । जम्ब्वोष्ठेनाग्निवर्णेन तप्तया वा शलाकया ॥ २९ ॥
दहेद् यथोक्तं मतिमांस्तं व्रणं सुसमाहितः । कृमिघ्नञ्चविधिं कुर्याच्छल्यानयनमेव च ।। ३० ।।
Treatment of Agantuka Bhagandara: The sinus in a fistula of traumatic origin should be carefully cut open by a surgeon (with a knife) and cauterized, according to the rules laid down, with a red-hot Jamvostha (instrument) or with a red-hot director (Salaka). Vermifugal remedies should be applied to it, and measures laid down in connection with the extraction of a Salya from the body should be carefully resorted to. 29-30
प्रत्याख्यायैष चारभ्यो वर्ज्यश्चापि त्रिदोषजः । एतत् कर्म समाख्यातं सर्वेषामनुपूर्वशः । ॥ ३१ ॥
एषान्तु शस्त्रपतनाद् वेदना यत्र जायते। तत्राणुतैलेनोष्णेन परिषेक: प्रशस्यते ।। ३२ ।।
वातघ्नौषधसम्पूर्णां स्थाल छिद्रशराविकाम् । स्नेहाभ्यक्तगुदस्तप्तामध्यासीत सवाष्पिकाम् ।। ३३ ।।
नाड्या वाऽस्याहरेत् स्वेदं शयानस्य रुजापहम्। उष्णोदकेऽवगाह्यो वा तथा शाम्यति वेदना ॥ ३४ ॥
कदलीमृगलोपाक-प्रियकाजिनसंभृतान् 1 कारयेदुपनाहांश्च शाल्वणादीन् विचक्षणः ॥ ३५ ॥
कटुत्रिकं वचाहिङ्ग-लवणान्यथ दीप्यकम्। पाययेच्चाम्लकौलत्थ -सुरासौवीरकादिभिः ।। ३६।।
Treatment of Tridosaja Bhagandara : A case of Bhagandara, due to the concerted action of the three Dosas, should be treated after informing little hope of recovery to the patient’s people, or should be given up as hopeless. The measures and remedies mentioed above should be adopted in succession in all types of Bhagandara. In the event of there being any pain in it, owing to the insertion of a knife or to any other surgical operation, luke-warn Anu-taila (oil) should be applied. As an alternative, the drugs possessed of the virtue of subduing the deranged Vayu (Bhadra-darvadi and Erandadi groups) should be boiled in a pot covered by a lid having a hole or aperture on its top; then the patient with his rectum anointed with oil, etc., should be made to sit in such a way over the said covered pot that the seat of the disease may be fomented with the warm fumes escaping through that aperture; or Nadi-sveda should be applied to the affected region through a pipe in a recumbent posture to alleviate the pain. As an alternative, a hot bath should be prescribed for the alleviation of the pain. Salvana Upanaha (described in connection with the treatment of Vata-vyadhi and that with the skins of the Kadali Mrga, Lopaka and Priyaka, should be applied to the affected locality to subdue the pain. A potion of the drugs or substances such as Trikatu Vaca, Hingu, salt (five kinds of salt) and Dipyaka, should be administered with wine, Kanjika, Sauviraka and Kulattha-Soup. etc. 31-36
ज्योतिष्मतीलाङ्गलकी- श्यामादन्तीत्रिवृत्तिलाः कुष्ठ शताह्वा गोलोमी तिल्वको गिरिकर्णिका ।
कासीसं काञ्चनक्षीय वर्ग: शोधन इष्यते ।। ३७ ॥
त्रिवृत् तिला नागदन्ती मञ्जिष्ठा पयसा सह । उत्सादनं भवेदेतत् सैन्धवक्षौद्रसंयुतम् ।। ३८ ।।
रसाञ्जनं हरिद्रे द्वे मञ्जिष्ठानिम्बपल्लवाः । त्रिवृत्तेजोवतीदन्तीकल्को नाडीव्रणापहः ।। ३९ ।।
कुष्ठं त्रिवृत् तिला दन्ती मागध्यः सैन्धवं मधु । रजनी त्रिफला तुत्थं हितं स्याद् व्रणशोधनम् ॥ ४० ॥
Jyotismati, Laangalaki, Syama Danti, Trivrt Tila, Kustha, Satahva, Golomi, Tilvaka, Giri-karnika, Kasisa and the two kinds of Kancana-ksiri, compose the group which is possessed of the virtue of purifying (a fistula sore). (The decoction of these substances should be applied for the purification of the ulcer). The sore of a fistula may be filled (healed) up by the application of (a compound of) Trivrt, Tila, Nagadanti, Manjistha and rock-salt pasted together with milk and honey. A plaster (Kalka) consisting of Rasanjana, turmeric, Daruharidra, Manjistha, Nimba leaves, Trivrt, Tejovati and Danti proves curative in a case of sinus. The drugs known as Kustha, Trivrt, Tila, Danti, Pippali, Saindhava, honey, turmeric, Triphala and sulphate of copper (Tuttha), are efficacious in purifying an ulcer. 37-40
मागध्यो मधुकं रोध्रं कुष्ठमेला हरेणवः । समझा धातकी चैव सारिवा प्रियङ्गवः सर्जरस: पद्मकं रजनीद्वयम् पद्मकेशरम् ।। ॥ ४९ ॥
सुधा वचा लाङ्गलकी मधूच्छिष्टं ससैन्धवम् ॥ ४२ ॥ एतत् संभृत्य सम्भारं तैलं धीरो विपाचयेत् । एतद् वै गण्डमालासु मण्डलेष्वथ मेहिषु । रोपणार्थं हितं तैलं न्यग्रोधादिगणश्चैव तैलं घृतं वा तत्पक्वं हितः भगन्दरविनाशनम् ॥ ४३ ॥
शोधनरोपणे । त्रिवृद्दन्तीहरिद्रार्कमूलं विडङ्गसारं त्रिफला स्नुह्यर्कपयसी भगन्दरविनाशनम् ॥ ४४ ॥
लोहाश्वमारकौ । मधु ॥ ४५ ॥
मधूच्छिष्टसमायुक्तैस्तैलमेतैर्विपाचयेत् भगन्दरविनाशार्थमेतद् योज्यं विशेषतः ।। ४६ ॥
Oil cooked (slowly) with Pippali, Yasti -madhu, Rodhra, Kustha, Ela, Harenu, Samanga (Baraha-kranta), Dhataki flower, Sariva, the two kinds of Haridra, Priyaigu, Sarja-rasa, Padmaka, Padmakesara, Sudha, Vaca, Langalika. wax and Saindhava should be regarded as a potent remedy in healing up the ulcer and curing fistulain-ano. This remedy proves beneficial in cases of scrofula (Gandamala), Meha, ulcers and in the Mandala type of cutaneous affections as well. The drugs which constitute the Nyagrodhadi group are efficacious in disinfecting (Sodhana) and healing up an ulcer. A medicated oil or Ghrita prepared with the preceding drugs proves curative in a case of fistula in-ano. Similarly a medicated oil duly cooked and prepared with the roots of Trivrt, Danti, Haridra, and Arka, Aguru, Asyamaraka as well as with Vidanga, Triphala, milk of both Snuhi and Arka, honey and wax should be applied, as it is specifically efficacious in a case of Bhagandara. 41-46
चित्रका त्रिवृत्पाठे मलपूं हयमारकम् । सुधां वचां लाङ्गलकीं सप्तपर्णं सुवर्चिकाम् ॥ ४७ ॥
1. Four seers of oil, one seer of the drugs and sixteen seers of water should be taken at the time of preparation.
ज्योतिष्मतीञ्च संभृत्य तैलं धीरो विपाचयेत् । एतद्धि स्यन्दनं तैलं भृशं दद्याद् भगन्दरे ॥ ४८ ॥
शोधनं रोपणञ्चैव सवर्णकरणं तथा । द्विव्रणीयमवेक्षेत व्रणावस्थासु बुद्धिमान् ॥ ४९ ॥
Syandna Taila : Oil slowly cooked and prepared (in the manner aforesaid) with Citraka, Arka, Trivrt, Patha, Malapu (Kakodumbara). Karavira, Sudha, Vaca, Langalaki, Saptaparna, Suvarcika and Jyotismati, is called the Syandana-Taila and should be constantly applied in a case of Bhagandara. It is efficacious in purifying, healing and imparting a natural skin-colour to the cicatrix. A learned and experienced physician should adopt the remedial measures for this disease according to the procedure laid down under the treatment of Dvi Vrana, when there is any ulcer (Vrana) in existence. 47-49
छिद्रादूर्ध्वं हरेदोष्ठमर्शोयंत्रस्य यन्त्रवित् । ततो भगन्दरे दद्यादेतदर्धेन्दुसन्निभम् ।। ५० ।।
व्यायामं मैथुनं कोपं पृष्ठयानं गुरूणि च । संवत्सरं परिहरेदुपरूढव्रणो नरः ।। ५१ ।।
The bulb-like protrusion above the hole of the instrument ( speculuin) mentioned in connection with the treatment of Arsas, should be removed and the instrument, now in the shape of a halfmoon, should be used by an experienced surgeon in the treatment of a case of fistula-in-ano. The patient should refrain from sexual intercourse, physical exercise, riding, anger, and the use of heavyand indigestible of food for a full period of one year even after the healing up of the ulcer in a Bhagandara. 50-51
इति सुश्रुत संहितायां चिकित्सितस्थाने भगन्दरचिकित्सितं नामाष्टमोऽध्यायः ।।८।।
Thus ends the eighth Chapter of the Chikitsa Sthana of the Susruta-Samhita which deals with the treatment of Bhagandara.
