Chapter VIII - The medical treatment of Fistula-in-ano

Now we shall discourse on the medical treatment of Fistula-in-ano, etc., (Bhagandara). 1.

The disease admits of being divided into five different groups, of which the two, known as Shambukavarta and Shalyaja (traumatic), should be regarded as incurable, and the rest as extremely difficult to cure. 2.

The General Treatment:—

The eleven^[1] kinds of remedial measures commencing with Apatarpana up to purgatives (as described under the treatment of Dvi-vrana) should be employed as long as any fistular ulcer would remain in an insuppurated 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 Hemorrhoid, the surgeon should examine closely as to where 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 Eshani (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 an alkali is a general remedial measure which may be resorted to in all the types of this disease. 3–4.

Specific Measures—M. Texts:—

In cases of the Shataponaka 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 fecal 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 Shataponaka type should not be opened with a broad incision.

Forms of incision:—

An experienced surgeon should know that the Langalaka, Ardha-Langalaka, Sarvatobhadraka and the Gotirthaka forms of incision should be the different shapes of incision, in a case of a many-mouthed Shataponaka. 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.

A case of the Shataponaka 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 Krishara, or Payasa (porridge), made with the aforesaid Svedaniya (diaphoretic) drugs with a decoction of the drugs constituting the Vilvadi group, Vrikshadani and roots of the castor-plant mixed and boiled together with the flesh of the Lava, Vishkira (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, Maska- 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) Kushtha, salts (the five officinal 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.^[2] 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 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 Shataponaka (sieve) type; now listen to me about the treatment of the Ushtragriva (camel’s neck) type of the disease. 5.

Treatment of Ushtra-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 fissures 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 duly bandaged. Clarified butter should be constantly applied over the bandage which should be removed on the third day. Cleansing or disinfecting (Shodhana) measures should then be used by the surgeon, according to the Doshas involved in the ulcer, and the successive healing (Ropana) measures resorted after its being properly purified (Shodhana). 6

Treatment of Farisravi:—

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 lukewarm Anu-toila (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 nearly free from 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-chakra (moon’s disc), Suchi-mukha (needle’s mouth), or Avammukha (with downward mouth). After that the ulcer should be purified with mild cleansing or disinfecting remedies (as described above) 7.

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 inter-mouthed. 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. 8–9

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 Jambvoshtha (instrument) or with a red- hot director (Shalaka). 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. 10.

Treatment of Tridoshaja Bhagandara:—

A case of Bhagandara, due to the concerted action of the three Doshas, should be treated without holding out any hope of recovery tot he patient’s people, or should be given up as hopeless. The measures and remedies mentioned 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-warm Anu-taila 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. Shalvana Upanaha (described in connection with the treatment of Vata-vyadhi and that with the skins of the Kadali Mriga, 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. 11-12.

Jyotishmati, Langalaki, Shyama, Danti, Trivrit, Tila, Kushtha, Shatahva, Golomi, Tilvaka, Giri-karnika, Kasisa and the two kinds of Kancana-kshiri, compose the group which is possessed of the virtue of purifying (a fistular 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) Trivrit, Tila, Nagadanti, Manjishtha and rock-salt pasted together with milk and honey. A plaster (Kalka) consisting of Rasanjana, turmeric, Daru-haridra, Manjishtha, Nimba leaves, Trivrit, Tejovati and Danti proves curative in a case of sinus. The drugs known as Kushtha, Trivrit, Tila, Danti, Pippali, Saindhava, honey, turmeric, Triphala and sulphate of copper (Tuttha) are efficacious in purifying an ulcer. 13-16.

Oil^[3] cooked (slowly) with Pippali, Yashti-madhu, Lodhra, Kushtha, Ela, Harenu, Samanga (Baraha-kranta), Dhataki flower, Sariva, the two kinds of Haridra, Priyangu, Sarja-rasa, Padmaka, Padma-keshara, Sudha, Vaca, Langalika, wax, and Saindhava should be regarded as a potent remedy in healing up the ulcer and curing fistula-in-ano. This remedy proves beneficial in cases of scrofula (Ganda-mala), 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 Trivrit, Danti, Haridra, and Arka, as well as with Vidanga, Triphala, milk of both Snuhi and honey and wax should be applied, as it is specifically efficacious in a case of Bhagandara. 17-19.

Syandana Taila:—

Oil slowly cooked and prepared (in the manner aforesaid) with Citraka, Arka Trivrit, Patha, Malapu (Kakodumbara), Karavira, Sudha (Snuhi), Vaca, Langalaki, Saptaparna, Suvar- chika and Jyotishmati, 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. 20.

The bulb-like protrusion above the hole of the instrument (speculum), mentioned in connection with the treatment of Arshas, should be removed and the instrument, now in the shape of a half-moon, 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 heavy and indigestible articles of food for a full period of one year even after the healing up of the ulcer in a Bhagandara. 21—22.

 

Thus ends the eighth Chapter of the Chikitsita Sthana of the Sushruta-Samhita which deals with the treatment of Bhagandara.

Footnotes and references:

[1]:

Apatarpana, Alepa, Parisheka, Abhyanga, Sveda, Vimlapana, Upanaha, Pacana, Visravana, Sneha, and Vamana.

[2]:

By the use of this potion the digestive power is increased.

[3]:

Four seers of oil, one seer of the drugs and sixteen seers of water should be taken at the time of preparation.