अथातो भगन्दरप्रतिषेधं व्याख्यास्यामः । इति ह स्माहुरात्रेयादयो महर्षयः ।
We shall now expound the chapter Bhagandara pratisedha treatment of rectal fistula; thus said Atreya and other great sages.
Bhagandara Nidana-nirukti – causes and definition of rectal fistula
हस्त्यश्वपृष्ठगमनकठिनोत्कटकासनैः अर्शोनिदानाभिहितैपरैश्च निषेवितैः ॥ १ ॥
अनिष्टादृष्टपाकेन सद्यो वा साधुगर्हणैः । प्रायेण पिटिकापूर्वी योऽङ्गलो ह्यङ्गुलेऽपि वा ॥ २ ॥
पायोव्रणोऽन्तर्बाह्यो वा दुष्टासृड्मांसगो भवेत् । बस्तिमूत्राशयाभ्यासगतत्वात्स्यन्दनात्मकः ॥३॥
भगन्दरः स सर्वांश्च दारयत्यक्रियावतः । भगबस्तिगुदांस्तेषु दीर्यमाणेषु भूरिभिः ॥ ४ ॥
वातमूत्रशकृच्छुक्रं खैः सूक्ष्मैर्वमति क्रमात् । Riding on elephant, horse etc, for long period, sitting on hard seats, ones own heels (and such other troublesome postures) and indulging in unsuitable activies enumerated as the causes of arsas (piles / haemorrhoids), maturing of sinful acts of previous lives, effects of abusing ascetics-by these causes the blood and muscle tissues in the rectum become vitiated give rise to the formation of a vrana (ulcer) preceded by a pitaka ( eruption); one or two angula (deep), opening either to the interior or to the exterior; because of proximity to the urinary bladder, it is exudative (discharges urine, faecal matter etc), this diseases is Bhagandara. It is so named because it causes severe tearing pain in the pelvis, urinary bladder, rectum etc. if the patient is not treated properly and elimenates air, urine, faecal matter and semen through its small orifices. 1-5a.
दोषैः पृथग्युतैः सर्वैरागन्तुः सोऽष्टमः स्मृतः ॥ ५॥ It is of eight kinds, from each dosa seperately, in their combinations of two and all the three and from agantu (external agent) the eighth. 5b.
Pitika lakshana – features of the eruptions
अपक्कं पिटिकामाहुः पाकप्राप्तं भगन्दरम् । गूढमूलां ससंरम्भां रुगाढ्यां रूढकोपिनीम् ॥ ६ ॥
भगन्दरकरीं विद्यात् पिटिकां न त्वतोऽन्यथा |
The unripe stage is called as pitika (bhagandara pitika) and the ripe stage as bhagandara; the pitaka ( eruptions) which is deep seated, having great, swelling, severe pain and increased (recurring) even after healing, should be recognised as causing bhagandara (rectal fistula) whereas without theses features as a different disease. 6-7a.
तोदभेदस्फुरणरुक्करी ॥७॥
तत्र पिटिका रागिणी तनुरूष्माढ्या स्थिरा स्निग्धा महामूला पाण्डुः कण्डुमती कफात् ।
श्यावा ताम्रा सदाहोषा घोररुग् वातपित्तजा ॥ ९ ॥
पाण्डुरा किञ्चिदाश्यावा कृच्छ्रपाका कफानिलात् । पादाङ्गुष्ठासमा सर्वैर्दोषैर्नानाविधव्यथा ॥ १० ॥
श्यावाऽरुणा मारुतात् पित्तादुष्टग्रीवावदुच्छ्रिता । ज्वरधूमायनान्विता ॥ ८॥
शूलारोचकतृड्दाहज्वरच्छर्दिरुपद्रुता व्रणतां यांति ताः पक्काः प्रमादात्,
The pitika (bhagandara pitika) caused by maruta (vata) is blackish red with pricking, puncturing and throbbing kinds of pain; that caused by pitta is raised up like the neck of the camel, red, thin ( small ) with great warmth accompanid with fever and feeling of hot fumes coming out; that caused by kapha is static, unctuous, deep rooted; pale yellow and has itching; that caused by vatapitta is black, coppery with burning sensation, great warmth and severe pain; the caused by kaphavata is pale, slightly bluish and ripens with difficulty; that caused by all the dosas together resembles the big toe, has different kinds of pain, with secondary diseases such pain in the abdomen, loss of taste, thirst, burning sensation, fever and vomiting. These (pitika / eruptions) if neglected, lead to the formation of vrana ( ulcer).
Sataponaka
तत्र वातजा ॥ ११ ॥
चीयतेऽणुमुखैश्छिद्रैः शतपोनकवत् क्रमात् । अच्छं स्त्रवद्भिरास्त्रावमजस्त्रं फेनसंयुतम् ॥ १२ ॥ शतपोनकसंज्ञोऽयम्
The vrana (bhagandara-rectal fistula) caused by vata slowly develops with small multiple orifices resembling a sataponaka (seive) exudes clear, thin frothy, fluid constantly. This is known as sataponaka. 12-13a.
Ustragriva and parisravi
उष्ट्रग्रीवस्तु पित्तजः ।
बहुपिच्छापरिस्त्रावी परित्रावी कफोद्भवः ॥ १३ ॥
Ustragriva is caused by pitta, Parisravi is by kapha and exudes large amount of slimy fluid. 13b.
Pariksepi
वातपित्तात्परिक्षेपी परिक्षिप्य गुदं गतिः । जायते परितस्तत्र प्राकारं परिखेव च ॥ १४ ॥
Pariksepi is of vatapitta origin, forms a circular fistula around the anus like the moat (pit) around the fort. 14.
Rju
ऋजुर्वातकफादृज्व्या गुदो गत्याऽत्र दीर्यते ।
Rju is of vatakapha origin, forms a straight fistula, causing a tear in the rectum. 15a.
Arso bhagandara
कफपित्ते तु पूर्वोत्थं दुर्नामाश्रित्य कुप्यतः ॥ १५ ॥
अर्शोमूले ततः शोफः कण्डूदाहादिमान् भवेत् ।
स शीघ्रं पक्कभिन्नोऽस्य क्लेदयन्मूलमर्शसः ॥ १६ ॥ स्त्रवत्यजस्त्रं गतिभिरयमर्शोभगन्दरः ।
Kapha and pitta invading the prevaiously existing haemorrhoids, give rise to swelling, itching and burning sensation, very soon ripens, forms a fistula by softening, the roots of the pile mass begins to eliminate fluid constantly through its sinuses. This codition is Arsobhagandara. 15b-17a.
Sambukavarta
सर्वजः शम्बुकावर्तः शम्बुकावर्तसन्निभः ॥ १७॥ गतयो दारयन्त्यस्मिन् रुग्वेगैर्दारुणैर्गुदम् ।
Sambukavarta is caused by all the dosas and resembles the shell of a snail in its sinuses, causes severe pain and laceration of the rectum by its multiple sinuses. 17b-18a.
Unmargi or ksataja
अस्थिलेशोऽभ्यवहृतो मांसगृद्ध्या यदा गुदम् ॥ १८ ॥
क्षिणोति तिर्यड्निर्गच्छन्नुन्मार्ग क्षततो गतिः । स्यात्ततः पूयदीर्णायां मांसकोथेन तत्र च ॥ १९ ॥
जायन्ते कृमयस्तस्य खादन्तः परितो गुदम् । विदारयन्ति नचिरादुन्मार्गी क्षतजश्च सः ॥ २०॥
In persons who eat mutton with great relish, pieces of bone swallowed along with it, while passing out the rectum cause tear in its passage. This wound undergoes suppuration and worms (bacteria etc.) grow in it and away the rectum soon. This small of eat is known as Unmargi or ksataja (bhagandara). 18b-20.
तेषु रुग्दाहकण्डादीन् विद्याद् व्रणनिषेधतः । षट् कृच्छ्रसाधनास्तेषां निचयक्षतजौ त्यजेत् ॥ २१ ॥
प्रवाहिणीं बलीं प्राप्तं सेवनीं वा समाश्रितम् । “
In these (all kinds of bhagandara ) the nature of pain, burning sensation, itching etc. should be learnt from vrana pratisedha (chapter 25); out of these, six ( three from individual dosa and three from their combination in twos) are difficult to cure, that caused by all the dosas and that by ksata should be refused; so also if the fistula is localised in the pravahini vali (inner most fold of rectum) or in the sevani (vesicorectal raphae). 21-22a.
Bhagandara Chikitsa – treatment of rectal fistula
अथास्य पिटिकामेव तथा यत्नादुपाचरेत् ॥ २२ ॥ शुद्ध्यसृक्स्स्रुतिसेकाद्यैर्यथा पाकं न गच्छति ।
During the pitika ( eruption ) stage only, effective treatment should be done so that it does not undergo ripening (suppuration, ulceration) by administering purificatory therapies, blood letting, bathing the leison with decoctions and such others. 22b-23a.
पाके पुनरुपस्निग्धं स्वेदितं चावगाहतः ॥ २३ ॥
यन्त्रयित्वाऽर्शसमिव अर्वाचीनं पश्येत्सम्यग्भगन्दरम । पराचीनमन्तर्मुखबहिर्मुखम् ॥ २४ ॥
If ripening, the ulcer should be slightly anointed with oil and fomentation given by immercing the part (buttocks) in medicated warm water, the physician should then inspect the rectum by using the rectal speculum and note whether the fistula is nearer or farther, opening inside or opening outside. 23b-24.
अथान्तर्मुखमेषित्वा सम्यक् शस्त्रेण पाटयेत् । बहिर्मुखं च निःशेषं ततः क्षारेण साधयेत् ॥ २५ ॥
अग्निना वा भिषक् साधु क्षारेणैवोष्ट्रकन्धरम् ।
That fistula which opens to the interior should be explored by the probe and then cut with knife; that which opens to the exterior should also be probed, cut without leaving any remnent and then treated either with ksara (caustic alkali) or agni (fire); ustragriva bhagandara should be treated with application of ksara ( alkali) only. 25-26a.
नाडीरेकान्तराः कृत्वा पाटयेच्छतपोनकम् ॥ २६ ॥
तासु रूढासु शेषाश्च, मृत्युर्दी गुदेऽन्यथा |
Sataponaka should also be cut with the knife, one sinus after the other, after healing of the earlier one, otherwise death may occur if the rectum is greatly injured. 26b-27a.
परिक्षेपिणि चाप्येवं नाड्युक्तैः क्षारसूत्रकैः ॥ २७ ॥
In pariksepi also the same treatment, in additionksarasutra (thread soaked in alkaline juices may be used)
अर्शोभगन्दरे पूर्वमशसि प्रतिसाधयेत् । त्यक्त्वोपचर्यः क्षतजः शल्यं शल्यवतस्ततः ॥ २८ ॥
आहरेच्च तथा दद्यात् कृमिघ्नं लेपभोजनम् । पिण्डनाड्यादयः स्वेदाः सुस्निग्धा रुजि पूजिताः ॥ २९ ॥
In case of Arsobhagandara, arsas (piles) should be treated after having refused treatment, if the foreign body is present in the wound it should be removed, then application of paste of drugs and foods which kill the worms should be adopted. Fomentation by pinda ( hot balls of drugs ) nadi (tubes emitting steam) etc. after lubrication are beneficial when there is pain. 28-29.
सर्वत्र च बहुच्छिद्रे छेदानालोच्य योजयेत् । गोतीर्थसर्वतोभद्रदललाङ्गललाङ्गलान् ॥३०॥
In case of multiple sinuses and openings, the appropriate type of incision should be selected after careful consideration, such as gotirtha, sarvatobhadra, dala, ardhalangala and langalaka. 30.
पार्श्व गतेन शस्त्रेण छेदो गोतीर्थको मतः ।
सर्वतः सर्वतोभद्रः पार्श्वच्छेदोऽर्धलाङ्गलः ॥ ३१ ॥ पार्श्वद्वये लाङ्गलकः
Gotirtha is incision made from the sides by using the knife, sarvatobhadra is that made from all the sides, ardhalangala incision from one of the sides and langalaka is incision from both the sides. 31.
Notes: The description of the shape of the incisions have also been furnished by other commentators like Dalhana (in Susruta Samhita), Indu (in Astanga sangraha) but none of them are clear. Modern surgical techniques can be adopted as and now found appropriate.
समस्तांश्चाग्निना दहेत् ।
आस्त्रावमार्गान्निः शेषं नैवं विकुरुते पुनः ॥ ३२ ॥
All the orifices exuding fluids should be cut open and burnt by fire ( thermal cautery), only the wound does not recur again. 32.
यतेत कोष्ठशुद्धौ च भिषक् तस्यान्तराऽन्तरा |
The physician should also try to purify the alimentary tract, often and on. 33a.
लेपो व्रणे विडालास्थि त्रिफलारसकल्कितम् ।। ३३ ।।
For application to the wound, paste made of bones of a cat, mecerated with the decoction of triphala is best suited. 33b.
ज्योतिष्मतीमलयुलाङ्गलिशेलुपाठाकुम्भाग्निसर्ज ( र्जि ) करवीरवचासुधार्कैः ।
अभ्यञ्जनाय विपचेत भगन्दराणां तैलं वदन्ति परमं हितमेतदेषाम् ॥ ३४ ॥
Medicated oil prepared with jyotismati, malayu, langali, selu, patha, kumbha, agni, sarja, karavira, vaca, sudha and arka and used for anointing the rectal fistula is said to be highly beneficial for it. 34.
मधुकोरध्रकणात्रुटिरेणुकाद्विरजनीफलिनीपटुसारिवाः । कमलकेसरपद्मकधातकी मदनसर्जरसामयरोदिकाः ॥३५॥
सबीजपूरच्छदनैरेभिस्तैलं भगन्दरापचीकुष्ठमधुमेहव्रणापहम् विपाचितम् । ॥ ३६॥
Medicated oil should be cooked with madhuka, rodhra, kana, truti, renuka, the two rajani, phalini, patu, sariva, kamalakesara, padmaka, dhataki, madana, sarjarasa, amaya, rodika and bark of bijapura. This cures rectal fistula, goitre, ulcer of leprosy and diabetes mellitus. 35-36.
मधुतैलयुता विडङ्गसारत्रिफलामागधिकाकणाश्च लीढाः । भवन्ति ॥ ३७॥
कृमिकुष्ठभगन्दरप्रमेहक्षतनाडीव्रणरोपणा
Powder of vidanga sara, triphala, magadhika and kana licked with honey and oil heals the ulcers caused by worms, leprosy, rectal fistula, diabetes, injury, and sinus ulcers. 37.
अमृतात्रुटिवेल्लवत्सकं कलिपथ्यामलकानि गुग्गुलुः । क्रमवृद्धमिदं मधुद्रुतं पिटिकास्थौल्यभगन्दरान् जयेत् ॥ ३८ ॥
Amrta, truti, vella, vatsaka, kali, pathya, amalaka and guggulu increased by one part in their succeeding order (powdered well), soaked in honey and consumed cures eruptions, obesity and rectal fistula. 38.
मागधिकाग्निकलिङ्गविडङ्गैर्बिल्वघृतैः सवरापलषट्कैः ।
गुग्गुलुना सदृशेन समेतैः क्षौद्रयुतैः सकलामयनाशः ॥ ३९ ॥
Magadhika, agni, kalinga, vidanga, bilva and ghrta each one pala added with six pala of vara and equal quantity (six pala) of guggulu, powdered and consumed along with honey cures all diseases. 39.
गुग्गुलुपञ्चपलं पलिकांशा मागधिका त्रिफला च पृथक्स्यात् । मधुलीढं त्वक्त्रुटिकर्षयुतं कुष्ठभगन्दरगुल्मगतिघ्नम्
Five pala of guggulu, one pala each of magadhika and triphala, one karsa each of tvak and truti powdered and licked with honey cures leprosy, rectal fistula, abdominal tumour and sinus ulcers. 40.
शृङ्गबेररजोयुक्तं तदेव च सुभावितम् ।
क्वाथेन दशमूलस्य विशेषाद्वातरोगजित् ॥ ४१ ॥
The same drugs ( guggulu etc. mentioned above) added with powder of srngavera and well soaked in the decoction of dasamula cures diseases caused by vata especially. 41.
उत्तमाखदिरसारजं रजः शीलयन्नसनवारिभावितम् ।
हन्ति तुल्यमहिषाक्षमाक्षिकं कुष्ठमेहपिटिकाभगन्दरान् ॥ ४२ ॥
Powder of uttama (triphala) and khadirasara soaked in the decoction of asana, consumed mixed with addition of equal quantity of mahisaksi ( guggulu ) and maksika ( honey) cures leprosy, diabetes, eruptions and fistula of the rectum. 42.
भगन्दरेष्वेष विशेष उक्त: शेषाणि तु व्यञ्जनसाधनानि । व्रणाधिकारात् परिशीलनाच्च सम्यग्विदित्वौपयिकं विदध्यात् ॥ ४३ ॥
The procedure (therapies, recipes etc.) described here were especially for bhagandara; other methods of treatment which ever needed should be selected by going through the chapter on treatment of ulcers ( chapter 25 ) and administered properly. 43.
अश्वपृष्ठगमनं चलरोधं मद्यमैथुनमजीर्णमसात्म्यम् ।
साहसानि विविधानि च रूढे वत्सरं परिहरेदधिकं वा ॥ ४४ ॥
Riding on horse, suppression of urge of cala (vata) flatus, faeces, urine etc. indulgence in wine, copulation, uncooked things/indigestion, unaccustomed foods and different kinds of exertions should be avoided for one year or still more after healing (of the rectal fistula). 44.
इति श्रीवैद्यपतिसिंहगुप्तसूनुश्रीमद्वाग्भटविरचितायामष्टाङ्गहृदयसंहितायां
षष्ठे उत्तरस्थाने भगन्दरप्रतिषेधो नामाष्टाविंशोऽध्यायः ॥ २८ ॥
Thus ends the chapter-Bhagandara pratisedha-the twenty eighth in Uttarasthana of Astanga hrdaya samhita composed by Srimad Vagbhata, son of Sri Vaidyapati Simhagupta.
