The eighth chapter of Chikitsasthana of Sushruta Samhita is called as Bhagañdara Cikitsitam Adhyaya. This chapter offers with Therapy of Fistula-in-Ano.
अथातोभगन्दराणांचिकित्सितंव्याख्यास्यामः।।१।।
यथोवाचभगवान्धन्वन्तरिः।।२।।
We are going to now propound Bhagañdara cikitsita – remedy of Fistula-in-ano; as revealed by the venerable Dhañvañtari.
पञ्चभगन्दराव्याख्याताः,तेष्वसाध्यःशम्बूकावर्तःशल्यनिमित्तश्च; शेषाःकृच्छ्रसाध्याः।।३।।
In chapter 5 of Nidana Sthana part of the identical treatise 5 sorts of Bhagandara have been described. Amongst these 5 varieties, Sambukavarta or Tridosaja Bhagandara and Salya Nimittaja or Ksataja Bhagandara are incurable. The remaining (three sorts of Bhagandara) are curable with problem.
Sāmañya Cikitsā – common remedy
तत्रभगन्दरपिडकोपद्रुतमातुरमपतर्पणादिविरेचनान्तेनैकादशविधेनोपक्रमेणोप-क्रमेतापक्वपिडकं,पक्वेषुचोपस्निग्धमवगाहस्विन्नंशय्यायांसन्निवेश्यार्शसमिवयन्त्रयित्वा,भगन्दरंसमीक्ष्यपराचीनमवाचीनंवा,ततःप्रणिधायैषणीमुन्नम्यसाशयमुद्धरेच्छस्त्रेण;अन्तर्मुखेचैवंसम्यग्यन्त्रंप्रणिधायप्रवाहमाणस्यभगन्दरमुखमासाद्यैषणींदत्त्वाशस्त्रंपातयेत्;आसाद्यवाऽग्निंक्षारंचेति;एतत्सामान्यंसर्वेषु।।४।।
Bhagandara Pidaka is an eruption which happens earlier to the formation of Bhagandara i.e. fistula and is unripe in nature. The sufferers having Bhagandara Pidaka needs to be administered with all of the eleven therapies commencing from Apatarpana i.e. fasting and ending with Virecana i.e. purgation which have been enumerated in Chikitsa Sthana part, Chapter 1 of the identical treatise.
Delicate oleation and fomentation by Avagaha methodology i.e. tub tub needs to be given when the pidaka i.e. eruption of Bhagandara is ripe. After this, the affected person is made to lie on a cot and is restrained / prevented from doing something.
The surgeon ought to subsequent examine and discover out if the opening of Bhagandara is outwards or inwards.
Bhagandara with opening inward – On this situation, the affected person needs to be restrained and the surgeon ought to seek for the opening of the fistula. On the similar time, the affected person is suggested to pressure (bear down) all of the whereas.
As soon as the opening is discovered, it needs to be reduce (incised) by a pointy instrument i.e. lancet. If incising just isn’t attainable within the given situation, it needs to be touched by agni – a heated rod and many others. (branding by fireplace) or by ksara – caustic alkali.
This remedy is frequent for all kinds of Bhagandara.
Sataponaka Bhagañdara Cikitsä
नाड्यन्तरेव्रणान्कुर्याद्भिषक्तुशतपोनके।।
ततस्तेषूपरून्डेषुशेषानाडीरूपाचरेत्।।५।।
There are a number of fistulae within the Sataponaka number of Bhagandara. In the midst of one of many fistulae, the surgeon ought to make a wound. After it will get healed, the remaining fistulae needs to be handled.
गतयोऽन्योन्यसंबद्धाबाह्याश्छेद्यास्त्वनेकधा।।
नाडीरनभिसंबद्धायश्छिनत्त्येकधाभिषक्।।६।।
सकुर्याद्विवृतंजन्तोणंगुदविदारणम्।।
तस्यतद्विवृतंमार्गविण्मूत्रमनुगच्छति।।७।।
आटोपंगुदशूलंचकरोतिपवनोभृशम्।।
तत्राधिगततन्त्रोऽपिभिषमुह्येदसंशयम्।।८।।
तस्मान्नविवृतःकार्योव्रणस्तुशतपोनके।।
Incisions needs to be made at many locations when many fistulae are interconnected.
A number of incisions shouldn’t be finished when the fistulae will not be interconnected. If finished, a large wound with many openings is shaped consequently inflicting tearing of the rectum / anus.
When this occurs, faeces and urine begin popping out of those sinuses. Vata additionally would get vastly aggravated giving rise to gurgling sounds within the stomach and ache within the anus.
Even a discovered doctor who’s nicely versed in science certainly would get into confusion in these instances. Due to this fact, a large wound shouldn’t be made in Sataponaka number of Bhagandara.
व्याधौतत्रबहुच्छिद्रेभिषजावैविजानता।।९।।
अर्धलाङ्गलकश्छेदःकार्योलाङ्गलकोऽपिवा।।
सर्वतोभद्रकोवाऽपिकार्योगोतीर्थकोऽपिवा।।१०।।
सर्वतःस्नावमार्गास्तुदहेद्वैद्यस्तथाऽग्निना।।
सुकुमारस्यभीरोहिदुष्करःशतपोनकः।।११।।
In Bhagandara having a number of openings, the doctor who clearly is aware of and has clearly decided them ought to make one of many beneath talked about sorts of incisions as discovered applicable –
– ardhalangalika,
– langalaka
– sarvatobhadra or
– gotirthaka
The surgeon ought to contact all of the orifices exuding supplies from inside with fireplace or supplies heated in fireplace, like a metallic rod (thermal cautery).
Sataponaka is tough to treatment in
– individuals who’re of tender structure and
– in individuals who’re afraid
रुजात्रावापहंतत्रस्वेदमाशुप्रयोजयेत्।।
स्वेदद्रव्यैर्यथोहिष्टैःकशरापायसादिभिः।।१२।।
ग्राम्यानूपौदकांसावाद्यैर्वाऽपिविष्किरैः।।
वृक्षादनीमथैरण्डबिल्वादिंचगणंतथा।।१३।।
कषायंसुकृतंकृत्वास्नेहकुम्भेनिषेचयेत्।।
नाडीस्वेदेनतेनास्यतंवर्णस्वेदयेद्भिषक्।।१४।।
तिलैरण्डातसीमाषयवगोधूमसर्षपान्।।
लवणान्यम्लवर्गचस्थाल्यामेवोपसाधयेत्।।१५।।
आतुरंस्वेदयेत्तेनतथासिध्यतिकुर्वतः।।
स्विन्नंचपाययेदेनंकुष्ठंचलवणानिच।।१६।।
वचाहिङ्ग्वजमोदंचसमभागानिसर्पिषा।।
मार्दीकेनाथवाऽम्लेनसुरासौवीरकेणवा।।१७।।
ततोमधुकतैलेनतस्यसिझेद्धिषग्व्रणम्।।
परिषिञ्चेद्दंचास्यतैलैर्वातरुजापहैः।।१८।।
विधिनाऽनेनविण्मूत्रंस्वमार्गमधिगच्छति।।
अन्येचोपद्रवास्तीवाःसिध्यन्त्यत्रनसंशयः।।१९।।
शतपोनकआख्यात
Nadi Sweda – tubular fomentation needs to be given to the anus in an effort to shortly relieve ache and exudation.
Nadi Sweda needs to be offered by making use of herbs indicated for swedana remedy.
Alternatively it shall be finished utilizing –
– krsara (boiled rice), payasa (milk pudding) or
– meat of home animals or animals residing in marshy areas or water or of birds of viskira group or
– decoction of crops like Vrksadani, Eranda, herbs belonging to Bilvadi Gana / Brhat Pancamula group of herbs
All of the above mentioned substances are made into decoction in a pot. The steam which will get emitted is then made to move by way of a pipe / tube to achieve the wound within the anus.
Different recipe – Alternatively, the beneath talked about substances could also be boiled within the pot and the steam emitted is handed by way of a tube such that it reaches the anus –
– tila
– eranda
– atasi
– masa
– yava
– godhuma
– sarsapa
– lavana and
– herbs belonging to amla varga – bitter group
The powder of the beneath talked about substances taken in equal portions needs to be used combined with ghee, mardvika (wine) or bitter liquids reminiscent of sura, sauviraka and many others. and given after having administered fomentation –
– lavana – salts
– vaca
– hingu and
– ajamoda
Madhuka Taila or every other medicated oil which may mitigate the ache attributable to vata needs to be used for anointing the wound within the anus.
When all these therapies are methodically finished, the urine and faeces will not come out of the fistula however will come out by way of their very own channels. We are able to additionally observe that the opposite issues related to this situation can even undoubtedly subside.
Thus, the remedy of Sataponaka Bhagandara was described.
Uștragrīva Bhagañdara Cikitsā
उष्टग्रीवेक्रियांशृणु॥
अथोष्टग्रीवमेषित्वाछित्त्वाक्षारंनिपातयेत्।।२०।।
पूतिमांसव्यपोहार्थमग्निरत्रनपूजितः।।
अथैनंघृतसंसृष्टैस्तिलैःपिष्टैःप्रलेपयेत्।।२१।।
बन्धंततोऽनुकुर्वीतपरिषेकंतुसर्पिषा।।
तृतीयेदिवसेमुक्त्वायथास्वंशोधयेद्भिषक्।।२२।।
ततःशुद्धंविदित्वाचरोपयेत्तुयथाक्रमम्।।
Subsequent, the remedy of Ustragrīva Bhagañdara will likely be defined, hearken to the identical.
This Bhagandara comprises decomposed and foul smelling muscle tissues in it, which must be eliminated first. On this course, the fistula needs to be probed first and reduce open. Now ksara – caustic alkali is positioned into the opened Bhagandara in order to take away the decomposed muscle tissues.
On this situation agnikarma i.e. use of fireside (thermal cautery) just isn’t fascinating.
After this, paste of tila – sesame seeds needs to be added with ghrta – ghee and smeared over the anus.
The bandage and dressing needs to be eliminated on the third day. Following this, the wound needs to be cleansed within the typical method. Later, therapies to heal the wound needs to be adopted.
उत्कृत्यास्रावमार्गस्तुपरिस्राविणिबुद्धिमान्।।२३।।
क्षारेणवास्त्रावगतिंदहेद्भुतवहेनवा।।सु
खोष्णेनाणुतैलेनसेचयेगुदमण्डलम्।।२४।।
उपनाहाःप्रदेहाश्चमूत्रक्षारसमन्विताः।।
वामनीयौषधैःकार्याःपरिषेकाश्चमात्रया।।२५।।
मृदुभूतंविदित्वैनमल्पस्त्रावरुगन्वितम्।।
गतिमन्विष्यशस्त्रेणछिन्द्यात्खजूरपत्रकम्।।२६।।
चन्द्रार्धंचन्द्रचक्रंचसूचीमुखमवाङ्मुखम्।।
छित्त्वाऽग्निनादहेत्सम्यगेवंक्षारेणवापुनः।।२७।।
ततःसंशोधनैरेवमृदुपूर्विशोधयेत्।।
An clever surgeon ought to reduce open all of the channels from which exudation is happening in case of Parisrāvi bhagañdara. After reducing, he ought to burn all of the channels with both ksara – caustic alkali or hutavaha – rod heated on fireplace.
Within the comply with up, the beneath talked about therapies needs to be finished to the realm across the anus –
– anointment with lukewarm Anu Taila
– heat poultice
– utility of ready with medicinal herbs added with urines of cow and many others. and alkalies like yava ksara and many others.
– pariseka – pouring / showering medicinal liquids with decoction ready from emetic herbs
The bhagandara needs to be probed as soon as once more and reduce open as soon as the surgeon learns that the realm has grow to be mushy and the fistula nonetheless has small portions of exudation and ache. The reduce shall be finished in kharjurapatraka, cañdrärdha, candravakra, sucimukha or avangmukha varieties.
After this, it’s as soon as once more burnt with fireplace or caustic alkali. As soon as it turns into mushy, it needs to be cleansed within the typical manner.
बहिरन्तर्मुखश्चापिशिशोर्यस्यभगन्दरः।।२८।।
तस्याहितंविरेकाग्निशस्त्रक्षारावचारणम्।।
यद्यन्मृदुचतीक्ष्णंचतत्तत्तस्यावचारयेत्।।२९।।
Bhagandara in kids needs to be handled with therapies like purgation. Burning by fireplace or alkali just isn’t appropriate for youngsters and shouldn’t be finished. Bhagandara needs to be handled with herbs / medicines that are mushy and penetrating in nature.
आरग्वधनिशाकालाचूर्णमधुघृताप्लुतम्।।
अग्रवर्तिप्रणिहितंव्रणानांशोधनंहितम।।३०।।
योगोऽयंनाशयत्याशुगतिंमेघमिवानिलः।।
Wicks ready with the beneath talked about herbs combined with honey and ghee inserted into the fistula would assist in cleaning them –
– äragvadha,
– nisa and
– kālā (ahimsrā)
Fistulas are shortly cured by this remedy identical to the clouds are pushed away by the wind.
Āgañtu Bhagañdara Cikitsa
आगन्तुजेभिषङ्नाडीशस्त्रेणोत्कृत्ययत्नतः।।३१।।
जम्ब्वोष्ठेनाग्निवर्णेन्तप्तयावाशलाकया।।
दहेद्यथोक्तंमतिमांस्तंव्रणंसुसमाहितः।।३२।।
कृमिघ्नंचविधिंकुर्याच्छल्यानयनमेवच।।
Whereas treating Agantuja Bhagandara i.e. fistula brought about resulting from extraneous causes, the surgeon ought to reduce open the fistula vehemently. After reducing it, he ought to burn the place with Jambavostha (cylindrical stone used for conducting cauterization) or Salaka (iron rod used for cauterization) made crimson sizzling within the prescribed method. Following this, therapies to take away overseas our bodies and destroy krimis – microorganisms like micro organism and many others. needs to be adopted.
प्रत्याख्यायैषचारभ्योवय॑श्चापित्रिदोषजः।।३३।।
एतत्कर्मसमाख्यातंसर्वेषामनुपूर्वशः।।
Tridoshaja Bhagañdara i.e. fistula produced by all of the three doșäs is incurable. The surgeon ought to first inform the incurability of these kinds of Bhagandara to the affected person and his nicely wishers after which begin treating it or could even refuse treating it.
Thus, the therapies of every kind of Bhagandara have been described in sequential order.
Rujähara karma — strategies for relieving ache
एषांतुशत्रपतनाद्वेदनायत्रजायते।।३४।।
तत्राणुतैलेनोष्णेनपरिघेकःप्रशस्यते।।
वातघ्नौषधसंपूर्णोस्थालीछिद्रशराविकाम्।।३।।
स्नेहाभ्यक्तगुदस्तप्तामध्यासीतसबाधिकाम्।।
नाड्यावाऽस्याहरेत्स्वेदंशयानस्यरुजापहम्।।
उष्णोदकेऽवगाह्योवातथाशाम्यतिवेदना।।३६।।
Anu Taila is the most effective within the enterprise and needs to be used for bathing the realm when there’s extreme ache attributable to reducing with sharp devices whereas conducting surgical procedure. After anointing the anus nicely with Anu Taila, the affected person is made to sit down on a plate / saucer with a gap on its high, full of herbs which mitigate vata. Alternatively, the vata mitigating herbs are boiled in a pot and the steam emanating from it’s allowed by way of the tube focusing on the realm the place it wants to achieve, whereas the affected person is mendacity down. The affected person may be immersed in a bathtub of heat water.
कदलीमृगलोपाकप्रियकाजिनसंभृतान्।।
कारयेदुपनाहांश्चसाल्वणादीन्विचक्षणः।।३७।।
कटुत्रिकंवचाहिङ्गुलवणान्यथदीप्यकम्।।
पाययेच्चाम्लकौलत्थसुरासौवीरकादिभिः।।३८।।
Under talked about needs to be utilized on the painful half –
– Salvana Upanāha and different poultices stored contained in the cover;
– Bands of leather-based of kadali mrga – a type of aquatic animal-otter, lopika – jackal or priyanka – a type of snake
The powder of the beneath talked about substances needs to be consumed with fermented soup of Kulattha – horse gram, sura – beer, sauviraka – bitter beverage and related such issues –
– Katutrika / Trikatu,
– Vaca,
– Hingu,
– Lavana;
– Saindhava and
– Dipyaka
Vrana Sodhana – cleaning the wound
ज्योतिष्मतीलाङ्गलकीश्यामादन्तीत्रिवृत्तिलाः।।
कुष्ठंशताह्वागोलोमीतिल्वकोगिरिकर्णिका।।३९।।
कासीसंकाञ्चनक्षीयौँवर्गःशोधनइष्यते।।
In response to Grasp Dalhana, the group consisting of beneath talked about herbs is the most effective for cleaning the injuries –
– Jyotsmati,
– Langalaki,
– Syāmā,
– Danti,
– Trivrt,
– Tila,
– Kustha,
– Satāhva,
– Golomi,
– Tilvaka,
– Girikarņikā,
– Kāsīsa,
– Two sorts of kāñcanakşīri;
– Kamkuştha and
– Yavatiktā in line with Dalhana
Utsadana – elevating the ground of the wound
त्रिवृत्तिलानागदन्तीमञ्जिष्ठापयसासह।।४०।।
उत्सादनंभवेदेतत्सैन्धवक्षौद्रसंयुतम्।।
Utsadana is a remedy during which the ground of the wound is elevated to the floor degree. Under talked about herbs macerated with milk and added with saindhava lavana and honey is utilized on the wound with the aim of inflicting utsadana –
– Trivrt,
– Tila,
– Nagadanti and
– Manjisthā
Recipes for Nadivrana (sinus wounds) and Vrana Sodhana (cleaning the wound)
रसाञ्जनंहरिद्रेद्वेमञ्जिष्ठानिम्बपल्लवाः।।४१।।
न्निवृत्तेजोवतीदन्तीकल्कोनाडीव्रणापहः।।
कुष्ठंत्रिवृत्तिलादन्तीमागध्यःसैन्धवंमधु।।४।।
रजनीत्रिफलातुत्थंहितंस्याव्रणशोधनम्।।
Recipe ready with the beneath talked about herbs cures wound associated to Bhagandara –
– Rasäñjana,
– Two sorts of Haridrā,
– Manjisthä,
– Nimba Pallava,
– Trivrt,
– Tejovati and
– Danti
Under talked about are additionally ideally suited in clearing the injuries –
– Kustha,
– Trivrt,
– Tila,
– Danti,
– Māgadhi,
– Saindhava,
– Madhu,
– Honey,
– Rajani,
– Triphalā and
– Tuttha
Ropana Taila
मागध्योमधुकंरोधंकुष्ठमेलाहरेणवः।।४३।।
समझाधातकीचैवसारिवारजनीद्वयम्।।
प्रियङ्गवःसर्जरसःपद्मकंपद्मकेसरम्।।४४।।
सुधावचालाङ्गलकीमधूच्छिष्टंससैन्धवम्।।
एतत्संभृत्यसंभारंतैलंधीरोविपाचयेत्।।४५।।
एतद्वैगण्डमालासुमण्डलेष्वथमेहिषु।।
रोपणार्थहितंतैलंभगन्दरविनाशनम्।।४६।।
Decoction and paste is ready with the beneath talked about herbs –
– Magadhi,
– Madhuka,
– Rodhra,
– Kusthā,
– Elā,
– Hareņu,
– Samañgā,
– Dhātakī,
– Sārivā,
– Two sorts of Rajani,
– Priyangu,
– Sarjarasa,
– Padmaka,
– Padmakesara,
– Sudhā, vacā,
– Lāñgalaki,
– Madhūcchista and
– Saindhava
Tila Taila – sesame oil is added to this and medicated oil is ready.
Advantages – It’s best to heal the wound of scrofula and diabetic eruptions. It additionally cures fistula-in-ano.
न्यग्रोधादिगणश्चैवहितःशोधनरोपणे।।
तैलंघृतंवातत्पक्वंभगन्दरविनाशनम।।४७।।
For cleaning and therapeutic wounds and in addition for curing bhagandara – fistula-in-ano, medicated oil or ghee ready with herbs belonging to Nyagrodhadi Gana group of herbs is helpful.
त्रिवृद्दन्तीहरिद्रार्कमूलंलोहाश्वमारकौ।।
विडङ्गसारंत्रिफलास्नुह्यर्कपयसीमधु।।८।।
मधूच्छिष्टसमायुक्तैस्तैलमेतैर्विपाचयेत्।।
भगन्दरविनाशार्थमेतद्योज्यंविशेषतः।।४९।।
Under talked about herbs are boiled and medicated oil is ready from it within the typical manner –
– Trivrt,
– Danti,
– Haridra,
– Arkamula,
– Loha;
– Aguru,
– Asvamāraka,
– Vidangasava,
– Triphalā,
– Milky sap of Snuhi and Arka,
– Madhu (honey),
– Madhūccista and
– Tila Taila
This oil is particularly helpful for curing anal fistula.
Visyañdana Taila
चित्रकामैत्रिवृत्पाठेमलपूंहयमारकम्।।
सुधांवचालाङ्गलकीसप्तपर्णंसुवर्चिकाम्।।५०।।
ज्योतिष्मतींचसम्भृत्यतैलंधीरोविपाचयेत्।।
एतद्धिस्यन्दनंतैलंभृशंदद्याद्भगन्दरे।।५१।।
Under talked about herbs are collected, added with oil and medicated oil is ready with it –
– Citraka,
– Arka,
– Trivrt,
– Pāthā,
– Malapū,
– Hayamāraka,
– Sudhā,
– Vacā,
– Lāñgalaki,
– Saptaparna,
– Suvarcika and
– Jyotishmati
This medicated oil is named Visyandana Taila. It’s particularly utilized in remedy of Bhagandara – anal fistula.
शोधनंरोपणंचैवसवर्णकरणंतथा।।
द्विव्रणीयमवेक्षेतव्रणावस्थासुबुद्धिमान्।।५२।।
After this, the smart doctor / surgeon ought to undertake therapies meant for cleaning and therapeutic the injuries and for restoring the color of the pores and skin. These needs to be utilized on the realm of the wound following their description as enumerated in Dvivraniya Chikitsita i.e. second chapter of Chikitsa Sthana.
छिद्रादूर्ध्वंहरेदोष्ठमयन्त्रस्ययन्त्रवित्।।
ततोभगन्दरेदद्यादेतदर्धेन्दुसन्निभम्।।५३।।
The ridge current above the slit on Arsoyantra i.e. anal speculum needs to be reduce off by the surgeon having good data of the devices. After reducing it, he ought to make it resembling half moon in form and use it for Bhagandara, for reducing / incising, making use of ksara – caustic alkali, sizzling iron rod, medicinal pastes and many others. in the midst of remedy.
Varjya āhara vihāra
व्यायाममैथुनंकोपंपृष्ठयानंगुरूणिच।।
संवत्सरंपरिहरेदुपरूढव्रणोनरः।।५४।।
The affected person of Bhagandara – fistula ought to keep away from the beneath talked about for a interval of 1 12 months after the wound of fistula has been healed –
– bodily workout routines,
– copulation,
– anger,
– using animals,
– consumption of meals that are heavy / onerous for digestion
इतिसुश्रुतसंहितायांचिकित्सास्थानेभगन्दरचिकित्सितंनामाष्टमोऽध्यायः।।८।।
Thus ends the eighth chapter by identify Bhagañdara Cikitsita in Cikitsa Sthāna of Suśruta Samhita.
