Sushruta Samhita Chikitsasthana Chapter 8 Bhagañdara Cikitsitam (Treatment of Fistula-in-Ano)

The 8th chapter of Chikitsasthana of Sushruta Samhita is named as Bhagañdara Cikitsitam Adhyaya. This chapter deals with Treatment of Fistula-in-Ano.

अथातोभगन्दराणांचिकित्सितंव्याख्यास्यामः।।१।।
यथोवाचभगवान्धन्वन्तरिः।।२।।

We will now propound Bhagañdara cikitsita – treatment of Fistula-in-ano; as revealed by the venerable Dhañvañtari.

पञ्चभगन्दराव्याख्याताः,तेष्वसाध्यःशम्बूकावर्तःशल्यनिमित्तश्च; शेषाःकृच्छ्रसाध्याः।।३।।

In chapter 5 of Nidana Sthana section of the same treatise five kinds of Bhagandara have been described. Among these five types, Sambukavarta or Tridosaja Bhagandara and Salya Nimittaja or Ksataja Bhagandara are incurable. The remaining (three types of Bhagandara) are curable with difficulty.

Sāmañya Cikitsā – general treatment

तत्रभगन्दरपिडकोपद्रुतमातुरमपतर्पणादिविरेचनान्तेनैकादशविधेनोपक्रमेणोप-क्रमेतापक्वपिडकं,पक्वेषुचोपस्निग्धमवगाहस्विन्नंशय्यायांसन्निवेश्यार्शसमिवयन्त्रयित्वा,भगन्दरंसमीक्ष्यपराचीनमवाचीनंवा,ततःप्रणिधायैषणीमुन्नम्यसाशयमुद्धरेच्छस्त्रेण;अन्तर्मुखेचैवंसम्यग्यन्त्रंप्रणिधायप्रवाहमाणस्यभगन्दरमुखमासाद्यैषणींदत्त्वाशस्त्रंपातयेत्;आसाद्यवाऽग्निंक्षारंचेति;एतत्सामान्यंसर्वेषु।।४।।

Bhagandara Pidaka is an eruption which occurs earlier to the formation of Bhagandara i.e. fistula and is unripe in nature. The patients having Bhagandara Pidaka should be administered with all the eleven therapies commencing from Apatarpana i.e. fasting and ending with Virecana i.e. purgation which have been enumerated in Chikitsa Sthana section, Chapter 1 of the same treatise.

Mild oleation and fomentation by Avagaha method i.e. tub bath should be given when the pidaka i.e. eruption of Bhagandara is ripe. After this, the patient is made to lie on a cot and is restrained / prevented from doing anything.

The surgeon should next inspect and find out if the opening of Bhagandara is outwards or inwards.

Bhagandara with opening inward – In this condition, the patient should be restrained and the surgeon should search for the opening of the fistula. At the same time, the patient is advised to strain (bear down) all the while.

Once the opening is found, it should be cut (incised) by a sharp instrument i.e. lancet. If incising is not possible in the given condition, it should be touched by agni – a heated rod etc. (branding by fire) or by ksara – caustic alkali.

This treatment is common for all varieties of Bhagandara.

Sataponaka Bhagañdara Cikitsä

नाड्यन्तरेव्रणान्कुर्याद्भिषक्तुशतपोनके।।
ततस्तेषूपरून्डेषुशेषानाडीरूपाचरेत्।।५।।

There are multiple fistulae in the Sataponaka variety of Bhagandara. In the middle of one of the fistulae, the surgeon should make a wound. After it gets healed, the remaining fistulae should be treated.

गतयोऽन्योन्यसंबद्धाबाह्याश्छेद्यास्त्वनेकधा।।
नाडीरनभिसंबद्धायश्छिनत्त्येकधाभिषक्।।६।।
सकुर्याद्विवृतंजन्तोणंगुदविदारणम्।।
तस्यतद्विवृतंमार्गविण्मूत्रमनुगच्छति।।७।।
आटोपंगुदशूलंचकरोतिपवनोभृशम्।।
तत्राधिगततन्त्रोऽपिभिषमुह्येदसंशयम्।।८।।
तस्मान्नविवृतःकार्योव्रणस्तुशतपोनके।।

Incisions should be made at many places when many fistulae are interconnected.

Multiple incisions should not be done when the fistulae are not interconnected. If done, a wide wound with many openings is formed consequently causing tearing of the rectum / anus.

When this happens, faeces and urine start coming out of these sinuses. Vata also would get greatly aggravated giving rise to gurgling sounds in the abdomen and pain in the anus.

Even a learned physician who is well versed in science surely would get into confusion in these cases. Therefore, a wide wound should not be made in Sataponaka variety of Bhagandara.

व्याधौतत्रबहुच्छिद्रेभिषजावैविजानता।।९।।
अर्धलाङ्गलकश्छेदःकार्योलाङ्गलकोऽपिवा।।
सर्वतोभद्रकोवाऽपिकार्योगोतीर्थकोऽपिवा।।१०।।
सर्वतःस्नावमार्गास्तुदहेद्वैद्यस्तथाऽग्निना।।
सुकुमारस्यभीरोहिदुष्करःशतपोनकः।।११।।
In Bhagandara having multiple openings, the physician who clearly knows and has clearly determined them should make one of the below mentioned kinds of incisions as found appropriate –

–        ardhalangalika,

–        langalaka

–        sarvatobhadra or

–        gotirthaka

The surgeon should touch all the orifices exuding materials from inside with fire or materials heated in fire, like a metal rod (thermal cautery).

Sataponaka is difficult to cure in

–        persons who are of tender constitution and

–        in persons who are 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 should be given to the anus in order to quickly relieve pain and exudation.

Nadi Sweda should be provided by making use of herbs indicated for swedana therapy.

Alternatively it shall be done using –

–        krsara (boiled rice), payasa (milk pudding) or

–        meat of domestic animals or animals living in marshy regions or water or of birds of viskira group or

–        decoction of plants like Vrksadani, Eranda, herbs belonging to Bilvadi Gana / Brhat Pancamula group of herbs

All the above said ingredients are made into decoction in a pot. The steam which gets emitted is then made to pass through a pipe / tube to reach the wound in the anus.

Other recipe – Alternatively, the below mentioned ingredients may be boiled in the pot and the steam emitted is passed through a tube such that it reaches the anus –

–        tila

–        eranda

–        atasi

–        masa

–        yava

–        godhuma

–        sarsapa

–        lavana and

–        herbs belonging to amla varga – sour group

The powder of the below mentioned ingredients taken in equal quantities should be used mixed with ghee, mardvika (wine) or sour liquids such as sura, sauviraka etc. and given after having administered fomentation –

–        lavana – salts

–        vaca

–        hingu and

–        ajamoda

Madhuka Taila or any other medicated oil which can mitigate the pain caused by vata should be used for anointing the wound in the anus.

When all these treatments are methodically done, the urine and faeces will no longer come out of the fistula but will come out through their own channels. We can also observe that the other complications associated with this condition will also undoubtedly subside.

Thus, the treatment of Sataponaka Bhagandara was described.

Uștragrīva Bhagañdara Cikitsā

उष्टग्रीवेक्रियांशृणु॥
अथोष्टग्रीवमेषित्वाछित्त्वाक्षारंनिपातयेत्।।२०।।
पूतिमांसव्यपोहार्थमग्निरत्रनपूजितः।।
अथैनंघृतसंसृष्टैस्तिलैःपिष्टैःप्रलेपयेत्।।२१।।
बन्धंततोऽनुकुर्वीतपरिषेकंतुसर्पिषा।।
तृतीयेदिवसेमुक्त्वायथास्वंशोधयेद्भिषक्।।२२।।
ततःशुद्धंविदित्वाचरोपयेत्तुयथाक्रमम्।।

Next, the treatment of Ustragrīva Bhagañdara will be explained, listen to the same.

This Bhagandara contains decomposed and foul smelling muscles in it, which need to be removed first. In this direction, the fistula should be probed first and cut open. Now ksara – caustic alkali is placed into the opened Bhagandara so as to remove the decomposed muscles.

In this condition agnikarma i.e. use of fire (thermal cautery) is not desirable.

After this, paste of tila – sesame seeds should be added with ghrta – ghee and smeared over the anus.

The bandage and dressing should be removed on the third day. Following this, the wound should be cleansed in the usual manner. Later, treatments to heal the wound should be adopted.

उत्कृत्यास्रावमार्गस्तुपरिस्राविणिबुद्धिमान्।।२३।।
क्षारेणवास्त्रावगतिंदहेद्भुतवहेनवा।।सु
खोष्णेनाणुतैलेनसेचयेगुदमण्डलम्।।२४।।
उपनाहाःप्रदेहाश्चमूत्रक्षारसमन्विताः।।
वामनीयौषधैःकार्याःपरिषेकाश्चमात्रया।।२५।।
मृदुभूतंविदित्वैनमल्पस्त्रावरुगन्वितम्।।
गतिमन्विष्यशस्त्रेणछिन्द्यात्खजूरपत्रकम्।।२६।।
चन्द्रार्धंचन्द्रचक्रंचसूचीमुखमवाङ्मुखम्।।
छित्त्वाऽग्निनादहेत्सम्यगेवंक्षारेणवापुनः।।२७।।
ततःसंशोधनैरेवमृदुपूर्विशोधयेत्।।
An intelligent surgeon should cut open all the channels from which exudation is occurring in case of Parisrāvi bhagañdara. After cutting, he should burn all the channels with either ksara – caustic alkali or hutavaha – rod heated on fire.

In the follow up, the below mentioned treatments should be done to the area around the anus –

–        anointment with lukewarm Anu Taila

–        warm poultice

–        application of prepared with medicinal herbs added with urines of cow etc. and alkalies like yava ksara etc.

–        pariseka – pouring / showering medicinal liquids with decoction prepared from emetic herbs

The bhagandara should be probed once again and cut open once the surgeon learns that the area has become soft and the fistula still has small quantities of exudation and pain. The cut shall be done in kharjurapatraka, cañdrärdha, candravakra, sucimukha or avangmukha types.

After this, it is once again burnt with fire or caustic alkali. Once it becomes soft, it should be cleansed in the usual way.

बहिरन्तर्मुखश्चापिशिशोर्यस्यभगन्दरः।।२८।।
तस्याहितंविरेकाग्निशस्त्रक्षारावचारणम्।।
यद्यन्मृदुचतीक्ष्णंचतत्तत्तस्यावचारयेत्।।२९।।
Bhagandara in children should be treated with therapies like purgation. Burning by fire or alkali is not suitable for children and should not be done. Bhagandara should be treated with herbs / medicines which are soft and penetrating in nature.

आरग्वधनिशाकालाचूर्णमधुघृताप्लुतम्।।
अग्रवर्तिप्रणिहितंव्रणानांशोधनंहितम।।३०।।
योगोऽयंनाशयत्याशुगतिंमेघमिवानिलः।।
Wicks prepared with the below mentioned herbs mixed with honey and ghee inserted into the fistula would help in cleansing them –

–        äragvadha,

–        nisa and

–        kālā (ahimsrā)

Fistulas are quickly cured by this treatment just like the clouds are driven away by the wind.

Āgañtu Bhagañdara Cikitsa

आगन्तुजेभिषङ्नाडीशस्त्रेणोत्कृत्ययत्नतः।।३१।।
जम्ब्वोष्ठेनाग्निवर्णेन्तप्तयावाशलाकया।।
दहेद्यथोक्तंमतिमांस्तंव्रणंसुसमाहितः।।३२।।
कृमिघ्नंचविधिंकुर्याच्छल्यानयनमेवच।।
While treating Agantuja Bhagandara i.e. fistula caused due to extraneous causes, the surgeon should cut open the fistula vehemently. After cutting it, he should burn the place with Jambavostha (cylindrical stone used for conducting cauterization) or Salaka (iron rod used for cauterization) made red hot in the prescribed manner. Following this, treatments to remove foreign bodies and destroy krimis – microorganisms like bacteria etc. should be adopted.

प्रत्याख्यायैषचारभ्योवय॑श्चापित्रिदोषजः।।३३।।
एतत्कर्मसमाख्यातंसर्वेषामनुपूर्वशः।।

Tridoshaja Bhagañdara i.e. fistula produced by all the three doșäs is incurable. The surgeon should first inform the incurability of these types of Bhagandara to the patient and his well wishers and then start treating it or may even refuse treating it.

Thus, the treatments of all kinds of Bhagandara have been described in sequential order.

Rujähara karma — methods for relieving pain

एषांतुशत्रपतनाद्वेदनायत्रजायते।।३४।।
तत्राणुतैलेनोष्णेनपरिघेकःप्रशस्यते।।
वातघ्नौषधसंपूर्णोस्थालीछिद्रशराविकाम्।।३।।
स्नेहाभ्यक्तगुदस्तप्तामध्यासीतसबाधिकाम्।।
नाड्यावाऽस्याहरेत्स्वेदंशयानस्यरुजापहम्।।
उष्णोदकेऽवगाह्योवातथाशाम्यतिवेदना।।३६।।
Anu Taila is the best in the business and should be used for bathing the area when there is severe pain caused by cutting with sharp instruments while conducting surgery. After anointing the anus well with Anu Taila, the patient is made to sit on a plate / saucer with an opening on its top, filled with herbs which mitigate vata. Alternatively, the vata mitigating herbs are boiled in a pot and the steam emanating from it is allowed through the tube targeting the area where it needs to reach, while the patient is lying down. The patient may also be immersed in a tub of warm water.

कदलीमृगलोपाकप्रियकाजिनसंभृतान्।।
कारयेदुपनाहांश्चसाल्वणादीन्विचक्षणः।।३७।।
कटुत्रिकंवचाहिङ्गुलवणान्यथदीप्यकम्।।
पाययेच्चाम्लकौलत्थसुरासौवीरकादिभिः।।३८।।
Below mentioned should be applied on the painful part –

–        Salvana Upanāha and other poultices kept inside the hide;

–        Bands of leather of kadali mrga – a kind of aquatic animal-otter, lopika – jackal or priyanka – a kind of snake

The powder of the below mentioned ingredients should be consumed with fermented soup of Kulattha – horse gram, sura – beer, sauviraka – sour beverage and similar such things –

–        Katutrika / Trikatu,

–        Vaca,

–        Hingu,

–        Lavana;

–        Saindhava and

–        Dipyaka

Vrana Sodhana – cleansing the wound

ज्योतिष्मतीलाङ्गलकीश्यामादन्तीत्रिवृत्तिलाः।।
कुष्ठंशताह्वागोलोमीतिल्वकोगिरिकर्णिका।।३९।।
कासीसंकाञ्चनक्षीयौँवर्गःशोधनइष्यते।।
According to Master Dalhana, the group consisting of below mentioned herbs is the best for cleansing the wounds –

–        Jyotsmati,

–        Langalaki,

–        Syāmā,

–        Danti,

–        Trivrt,

–        Tila,

–        Kustha,

–        Satāhva,

–        Golomi,

–        Tilvaka,

–        Girikarņikā,

–        Kāsīsa,

–        Two kinds of kāñcanakşīri;

–        Kamkuştha and

–        Yavatiktā according to Dalhana

Utsadana – elevating the floor of the wound

त्रिवृत्तिलानागदन्तीमञ्जिष्ठापयसासह।।४०।।
उत्सादनंभवेदेतत्सैन्धवक्षौद्रसंयुतम्।।

Utsadana is a therapy in which the floor of the wound is elevated to the surface level. Below mentioned herbs macerated with milk and added with saindhava lavana and honey is applied on the wound with the purpose of causing utsadana –

–        Trivrt,

–        Tila,

–        Nagadanti and

–        Manjisthā

Recipes for Nadivrana (sinus wounds) and Vrana Sodhana (cleansing the wound)

रसाञ्जनंहरिद्रेद्वेमञ्जिष्ठानिम्बपल्लवाः।।४१।।
न्निवृत्तेजोवतीदन्तीकल्कोनाडीव्रणापहः।।
कुष्ठंत्रिवृत्तिलादन्तीमागध्यःसैन्धवंमधु।।४।।
रजनीत्रिफलातुत्थंहितंस्याव्रणशोधनम्।।
Recipe prepared with the below mentioned herbs cures wound related to Bhagandara –

–        Rasäñjana,

–        Two kinds of Haridrā,

–        Manjisthä,

–        Nimba Pallava,

–        Trivrt,

–        Tejovati and

–        Danti

Below mentioned are also ideal in clearing the wounds –

–        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 prepared with the below mentioned herbs –

–        Magadhi,

–        Madhuka,

–        Rodhra,

–        Kusthā,

–        Elā,

–        Hareņu,

–        Samañgā,

–        Dhātakī,

–        Sārivā,

–        Two kinds of Rajani,

–        Priyangu,

–        Sarjarasa,

–        Padmaka,

–        Padmakesara,

–        Sudhā, vacā,

–        Lāñgalaki,

–        Madhūcchista and

–        Saindhava

Tila Taila – sesame oil is added to this and medicated oil is prepared.

Benefits – It is best to heal the wound of scrofula and diabetic eruptions. It also cures fistula-in-ano.

न्यग्रोधादिगणश्चैवहितःशोधनरोपणे।।
तैलंघृतंवातत्पक्वंभगन्दरविनाशनम।।४७।।

For cleansing and healing wounds and also for curing bhagandara – fistula-in-ano, medicated oil or ghee prepared with herbs belonging to Nyagrodhadi Gana group of herbs is beneficial.

त्रिवृद्दन्तीहरिद्रार्कमूलंलोहाश्वमारकौ।।
विडङ्गसारंत्रिफलास्नुह्यर्कपयसीमधु।।८।।
मधूच्छिष्टसमायुक्तैस्तैलमेतैर्विपाचयेत्।।
भगन्दरविनाशार्थमेतद्योज्यंविशेषतः।।४९।।
Below mentioned herbs are boiled and medicated oil is prepared from it in the usual way –

–        Trivrt,

–        Danti,

–        Haridra,

–        Arkamula,

–        Loha;

–        Aguru,

–        Asvamāraka,

–        Vidangasava,

–        Triphalā,

–        Milky sap of Snuhi and Arka,

–        Madhu (honey),

–        Madhūccista and

–        Tila Taila

This oil is especially useful for curing anal fistula.

Visyañdana Taila

चित्रकामैत्रिवृत्पाठेमलपूंहयमारकम्।।
सुधांवचालाङ्गलकीसप्तपर्णंसुवर्चिकाम्।।५०।।
ज्योतिष्मतींचसम्भृत्यतैलंधीरोविपाचयेत्।।
एतद्धिस्यन्दनंतैलंभृशंदद्याद्भगन्दरे।।५१।।
Below mentioned herbs are collected, added with oil and medicated oil is prepared with it –

–        Citraka,

–        Arka,

–        Trivrt,

–        Pāthā,

–        Malapū,

–        Hayamāraka,

–        Sudhā,

–        Vacā,

–        Lāñgalaki,

–        Saptaparna,

–        Suvarcika and

–        Jyotishmati

This medicated oil is called Visyandana Taila. It is especially used in treatment of Bhagandara – anal fistula.

शोधनंरोपणंचैवसवर्णकरणंतथा।।
द्विव्रणीयमवेक्षेतव्रणावस्थासुबुद्धिमान्।।५२।।

After this, the wise physician / surgeon should adopt treatments meant for cleansing and healing the wounds and for restoring the colour of the skin. These should be applied on the area of the wound following their description as enumerated in Dvivraniya Chikitsita i.e. second chapter of Chikitsa Sthana.

छिद्रादूर्ध्वंहरेदोष्ठमयन्त्रस्ययन्त्रवित्।।
ततोभगन्दरेदद्यादेतदर्धेन्दुसन्निभम्।।५३।।

The ridge present above the slit on Arsoyantra i.e. anal speculum should be cut off by the surgeon having good knowledge of the instruments. After cutting it, he should make it resembling half moon in shape and use it for Bhagandara, for cutting / incising, applying ksara – caustic alkali, hot iron rod, medicinal pastes etc. in the course of treatment.

Varjya āhara vihāra

व्यायाममैथुनंकोपंपृष्ठयानंगुरूणिच।।
संवत्सरंपरिहरेदुपरूढव्रणोनरः।।५४।।

The patient of Bhagandara – fistula should avoid the below mentioned for a period of one year after the wound of fistula has been healed –

–        physical exercises,

–        copulation,

–        anger,

–        riding animals,

–        consumption of foods which are heavy / hard for digestion

इतिसुश्रुतसंहितायांचिकित्सास्थानेभगन्दरचिकित्सितंनामाष्टमोऽध्यायः।।८।।

Thus ends the eighth chapter by name Bhagañdara Cikitsita in Cikitsa Sthāna of Suśruta Samhita.