The 28th chapter of Uttara Sthanam of Ashtanga Hridayam is named as Bhagandara Pratishedha. This chapter deals with the explanation of ‘Treatment of ano-rectal fistula’.

The topics covered in this chapter include –

• Nidana, Nirukti – causes and definition
• Types
• Pitika Lakshana – features of the eruptions
• Vataja Pitika – Shataponaka
• Ustragriva and Parisravai
• Parikshepi
• Ruju
• Arsho Bhagandara
• Shambukavarta
• Unmargi or Kshataja
• Prognosis of different kinds of Bhagandara
• Cikitsa – treatment
• Treatment of ripening ulcer
• Treatment of fistula opening to the exterior
• Treatment of Shataponaka
• Treatment of Parikshepi
• Treatment of Arshobhagandara
• Treatment in presence of multiple sinuses
• Types of incision
• Treatment of orifices exuding fluids
• Koshta Shodhana – purification
• Lepa
• Jyotishmatyadi Taila
• Madhukadi Taila
• Vidangasaradi Churna
• Amritadi Guggulu
• Magadhikadi Churna
• Guggulu pancha palam
• Uttamadi Churna Yoga
• Vrana Cikitsa in Bhagandara
• Avoidable things in Bhagandara

Pledge by the author(s)

अथातो भङ्गदरप्रतिषेधं व्याख्यास्याम: ।
इति ह स्माहुरात्रेयादयो महर्षय: ।
After having offered prayers to the God, henceforth we are going to explain the chapter pertaining to the explanation of ‘Treatment of rectal fistula’. Thus, say (pledge) Atreya and other sages.

Nidana, Nirukti: Causes and definition

हस्त्यश्वपृष्ठगमनकठिनोत्कटकासनैः ।
अर्शोनिदानाभिहितैरपरैश्च निषेवितैः ॥ १ ॥
अनिष्टादृष्टपाकेन सद्यो वा साधुगर्हणैः ।
प्रायेण पिटिकापूर्वो योऽङ्गुले द्व्यङ्गुलेऽपि वा ॥२॥
पायोर्व्रणोऽन्तर्बाह्यो वा दुष्टासृङ्मांसगो भवेत् ।
बस्तिमूत्राशयाभ्यासगतत्वात्स्यन्दनात्मकः ॥ ३ ॥
भगन्दरः स सर्वांश्च दारयत्यक्रियावतः ।
भगबस्तिगुदांस्तेषु दीर्यमाणेषु भूरिभिः ॥ ४ ॥
वातमूत्रशकृच्छुक्रं खैः सूक्ष्मैर्वमति क्रमात् ।
Riding on elephant, horse etc. for long periods, sitting on hard seats, one’s own heels (and such other troublesome postures) and indulging in unsuitable activities enumerated as the causes of Arshas (piles / haemorrhoids), maturing of sinful acts of previous lives or current life, of abusing ascetics; by these causes the blood and muscle tissue in the rectum become vitiated, give rise to the formation of a vrana (ulcer), probably preceded by a pitaka (eruption); one angula 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, fecal matter etc.), this disease is called Bhagandara. Because it causes tearing of all parts (mentioned below), in a person who does not follow proper diet (or has done sins) due to severe tearing in the pelvis, urinary bladder, rectum etc. there is gradual elimination of air, urine, faecal matter and semen though its small orifices.

Types

दोषैः पृथग्युतैः सर्वैरागन्तुः सोऽष्टमः स्मृतः ॥ ५ ॥
It is of eight types, from each dosha separately, in their combinations of two and all the three and from agantu (external agent) the eighth.

Pitika Lakshana: Features of the eruptions

अपक्वं पिटिकां आहुः पाकप्राप्तं भगन्दरम् ।
गूढमूलां ससंरम्भां रुगाढ्यां रूढकोपिनीम् ॥ ६ ॥
भगन्दरकरीं विद्यात्पिटिकां न त्वतोऽन्यथा ।
The unripe stage is called as Pitika (Bhagandara Pitika) and the ripe stage as Bhagandara; the Pitika (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 this feature as a difficult disease.

तत्र श्यावारुणा तोदभेदस्फुरणरुक्करी ॥ ७ ॥
पिटिका मारुतात्पित्तादुष्ट्रग्रीवावदुच्छ्रिता ।
रागिणी तनुरूष्माढ्या ज्वरधूमायनान्विता ॥ ८ ॥
स्थिरा स्निग्धा महामूला पाण्डुः कण्डूमती कफात् ।
श्यावा ताम्रा सदाहोषा घोररुग्वातपित्तजा ॥ ९ ॥
पाण्डुरा किञ्चिदाश्यावा कृच्छ्रपाका कफानिलात् ।
पादाङ्गुष्ठसमा सर्वैर्दोषैर्नानाविधव्यथा ॥ १० ॥
शूलारोचकतृड्दाहज्वरच्छर्दिरुपद्रुता ।
व्रणतां यान्ति ताः पक्वाः प्रमादात्
The Pitika (Bhagandra Pitika) caused by 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 accompanied 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 Vata and Pitta is black, coppery with burning sensation, has great warmth and severe pain; those caused by Kapha and Vata is pale, slightly bluish and ripens with difficulty; that caused by all the doshas together resembles the big toe, has different kinds of pain, with secondary diseases such as pain in the abdomen, loss of taste, thirst, burning sensation, fever and vomiting. These (Pitika/ eruption) if neglected, get suppurated and lead to the formation of Vrana (ulcer).

Vataja Pitika: Shataponaka

त्तत्र वातजा ॥ ११ ॥
चीयतेऽणुमुखैश्छिद्रैः शतपोनकवत्क्रमात् ।
अच्छं स्रवद्भिरास्रावमजस्रं फेनसंयुतम् ॥ १२ ॥
शतपोनकसञ्ज्ञोऽयम्
The Vrana (Bhagandara-rectal fistula) caused by Vata, slowly develops with small multiple orifices resembling a Shataponaka (sieve); exudes clear, thin, frothy fluid constantly. This is known as Shataponaka.

Ustragriva and Parisravai

उष्ट्रग्रीवस्तु पित्तजः ।
बहुपिच्छापरिस्रावी परिस्रावी कफोद्भवः ॥ १३ ॥
Ustragriva is caused by Pitta, Parisravi is by Kapha and exudes large amounts of slimy fluid.

Parikshepi

वातपित्तात्परिक्षेपी परिक्षिप्य गुदं गतिः ।
जायते परितस्तत्र प्राकारं परिखेव च ॥ १४ ॥
Parikshepi is of Vata-Pitta origin, forms a circular fistula around the anus like the moat (pit) around the fort.

Ruju

ऋजुर्वातकफादृज्व्या गुदो गत्यात्र दीर्यते ।
Ruju is of Vata-Kapha origin, forms a straight fistula, causing a tear in the rectum.

Arsho Bhagandara

कफपित्ते तु पूर्वोत्थं दुर्नामाश्रित्य कुप्यतः ॥ १५ ॥
अर्शोमूले ततः शोफः कण्डूदाहादिमान् भवेत् ।
स शीघ्रं पक्वभिन्नोऽस्य क्लेदयन् मूलमर्शसः ॥१६॥
स्रवत्यजस्रं गतिभिरयमर्शोभगन्दरः ।
Kapha and Pitta invading the previously existing hemorrhoids and getting vitiated, give rise to swelling, itching and burning sensation at the roots of the pile masses, very soon ripens, forms a fistula by softening, the roots of the pile mass begins to eliminate constantly through its sinuses. This condition is Arshobhagandara.

Shambukavarta

सर्वजः शम्बुकावर्तः शम्बूकावर्तसन्निभः ॥ १७ ॥
गतयो दारयन्त्यस्मिन् रुग्वेगैर्दारुणैर्गुदम् ।
Shambukavarta is caused by all the doshas and resembles the shell of a snail in its sinuses, causing severe pain and laceration of the rectum by its multiple sinuses.

Unmargi or Kshataja

अस्थिलेशोऽभ्यवहृतो मांसगृद्ध्या यदा गुदम् ॥ १८ ॥
क्षिणोति तिर्यङ्निर्गच्छन्नुन्मार्गं क्षततो गतिः ।
स्यात्ततः पूयदीर्णायां मांसकोथेन तत्र च ॥ १९ ॥
जायन्ते कृमयस्तस्य खादन्तः परितो गुदम् ।
विदारयन्ति न चिरादुन्मार्गी क्षतजश्च सः ॥ २० ॥
In a person who eats meat with great relish, small pieces of bone swallowed along with it, while passing out of the rectum in an obliquely abnormal course, causes tear and this injury gives rise to sinuses in its passage. Later there is discharge of pus and decaying of muscles in the passage of the rectum. This leads to growth of worms (bacteria etc.) in it and they eat away the rectum and cause tears therein soon, this is known as Unmargi or Kshataja (Bhagandara).

Prognosis of different kinds of Bhagandara

तेषु रुग्दाहकण्ड्वादीन् विद्याद्व्रणनिषेधतः ।
षट् कृच्छ्रसाधनास्तेषां निचयक्षतजौ त्यजेत् ॥ २१ ॥
प्रवाहिणीं वलीं प्राप्तं सेवनीं वा समाश्रितम् ।
In these (all kinds of Bhagandara), the nature of pain, burning sensation, itching etc. should be learnt from Vrana Pratishedha (chapter 25). Out of these, six (there from individual dosha and three from their combination in twos) are difficult to cure, that caused by all the doshas and that by injury should be refused; so also, if the fistula is in the pravahini layer of the rectum or if it is in the sevani (vesico-rectal raphae).

Chikitsa: Treatment

अथास्य पिटिकामेव तथा यत्नादुपाचरेत् ॥ २२ ॥
शुद्ध्यसृक्स्रुतिसेकाद्यैर्यथा पाकं न गच्छति ।
During the Pitika (eruption) stage only, effective treatment should be done with effort by administering purificatory therapies, bloodletting, bathing the lesion with decoction and such others, so that it does not undergo ripening (suppuration, ulceration).

Treatment of ripening ulcer

पाके पुनरुपस्निग्धं स्वेदितं चावगाहतः ॥ २३ ॥
यन्त्रयित्वाऽर्शसमिव पश्येत्सम्यग्भगन्दरम् ।
अर्वाचीनं पराचीनमन्तर्मुखबहिर्मुखम् ॥ २४ ॥
If the pitaka ripens, the ulcer should be slightly anointed with oil and fomentation given by immersing the part (buttocks) in medicated warm water, the physician should then inspect the rectum by using the rectal speculum just like visualizing the piles, properly and note whether the fistula is nearer or farther, opening inside or opening outside.

Treatment of fistula opening to the exterior

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 the knife properly; that which opens to the exterior should also be probed, cut without leaving any remnant and then treated either with kshara (caustic alkali) or agni (fire); Ustragriva Bhagandara should be treated with application of kshara (alkali) only by the physician.

Treatment of Shataponaka

नाडीरेकान्तराः कृत्वा पाटयेच्छतपोनकम् ॥ २६ ॥
तासु रूढासु शेषाश्च मृत्युर्दीर्णे गुदेऽन्यथा ।
Shataponka should 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.

Treatment of Parikshepi

परिक्षेपिणि चाप्येवं नाड्युक्तैः क्षारसूत्रकैः ॥ २७ ॥
In Parikshepi also, the same treatment explained for nadi, in addition, ksharasutra (thread soaked in alkaline juice may be used).

Treatment of Arshobhagandara

अर्शोभगन्दरे पूर्वमर्शांसि प्रतिसाधयेत् ।
त्यक्त्वोपचर्यः क्षतजः शल्यं शल्यवतस्ततः ॥ २८ ॥
आहरेच्च तथा दद्यात्कृमिघ्नं लेपभोजनम् ।
पिण्डनाड्यादयः स्वेदाः सुस्निग्धा रुजि पूजिताः॥२९॥
In case of Arshobhagandara, Arshas (piles) should be treated first; after having refused treatment, if the wound contains foreign body, that foreign body should be removed, then application of paste of herbs and foods which kill the worms should be adopted. Fomentation by pinda (hot balls of herbs), nadi (tubes emitting steam) etc. after lubrication are beneficial when there is pain.

Treatment in presence of multiple sinuses

सर्वत्र च बहुच्छिद्रे छेदान् आलोच्य योजयेत् ।
गोतीर्थसर्वतोभद्रदललाङ्गललाङ्गलान् ॥ ३० ॥
In case of multiple sinuses and openings, the appropriate type of incision should be selected after careful consideration of every aspect, such as Gotirtha, Sarvatobhadra, Dala, Ardhalangala and Langalaka.

Types of incision

पार्श्वं 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, Ardhalangalaka is incision from one side and incision made from both sides is called Langalaka.

Treatment of orifices exuding fluids

समस्तांश्चाग्निना दहेत् ।
आस्रावमार्गान्निःशेषं नैवं विकुरुते पुनः ॥ ३२ ॥
All the orifices exuding fluids should be cut open completely and burnt by fire (thermal cautery), only then the wound does not recur again.

Koshta Shodhana: Purification

यतेत कोष्ठशुद्धौ च भिषक् तस्यान्तरान्तरा ।
The physician should also try to purify the alimentary tract, repeatedly with time gaps.

Lepa

लेपो व्रणे बिडालास्थि त्रिफलारसकल्कितम् ॥ ३३ ॥
For application to the wound, paste made of bones of a cat, macerated with the decoction of triphala is best suited.

Jyotishmatyadi Taila

ज्योतिष्मतीमलयुलाङ्गलिशेलुपाठाकुम्भाग्निसर्जकरवीरवचासुधार्कैः ।
अभ्यञ्जनाय विपचेत भगन्दराणां तैलं वदन्ति परमं हितमेतदेषाम् ॥ ३४ ॥
Medicated oil prepared with jyotiṣmatī – Celastrus paniculatus, malayu – Psoralea corylifolia, lāṅgali – Gloriosa superba, śelu – Cordia dichotoma, pāṭhā – Cissampelos pareira, kumbha – Operculina turpethum, agni – Plumbago zeylanica, sarja – Veteria indica, karavīra – Nerium indicum, vacā – Acorus calamus, sudhā – Euphorbia neriifolia, arkaiḥ – Calotropis gigantea and used for anointing the rectal fistula is said to be highly beneficial for it.

Madhukadi Taila

मधुकलोध्रकणात्रुटिरेणुकाद्विरजनीफलिनीपटुसारिवाः ।
कमलकेसरपद्मकधातकीमदनसर्जरसामयरोदिकाः ॥३५॥ सबीजपूरच्छदनैरेभिस्तैलं विपाचितम् ।
भगन्दरापचीकुष्ठमधुमेहव्रणापहम् ॥ ३६ ॥
Medicated oil should be cooked with madhuka – Glycyrrhiza glabra, lodhra – Symplocos racemosa, kaṇā – Piper longum, truṭi – Elettaria cardamomum, reṇukā – Vitex agnus-castus, dvirajanī – the two Rajani- Haridra – Curcuma longa and Daruharidra – Berberis aristata, phalinī – Callicarpa macrophylla, salt, sārivāḥ – Hemidesmus indicus, kamala kesara – Nelumbo nucifera, padmaka – Prunus cerasoides, dhātakī – Woodfordia fruticosa, bee wax, sarjarasa – resin of Vateria indica, āmaya – Saussurea lappa, rodikāḥ – Mimosa pudicaand bark of Citrus medica. This cures rectal fistula, goitre, ulcers of skin disease and diabetes mellitus.

Vidangasaradi Churna

मधुतैलयुता विडङ्गसारत्रिफलामागधिकाकणाश्च लीढाः ।
कृमिकुष्ठभगन्दरप्रमेहक्षतनाडीव्रणरोपणा भवन्ति॥३७॥
iḍaṅgasāra – Powder of sara of Embelia ribes, triphalā – Triphala-
Haritaki – Terminalia chebula
Vibhitaki – Terminalia bellerica
Amalaki – Emblica officinalis,
māgadhikā – Piper longum, and kaṇāśca – Piper longum licked with honey and oil heals the ulcers caused by worms, skin disease, rectal fistula, diabetes, injury and sinus ulcers.

Amritadi Guggulu

अमृतात्रुटिवेल्लवत्सकं कलिपथ्यामलकानि गुग्गुलुः ।
क्रमवृद्धमिदं मधुद्रुतं पिटिकास्थौल्यभगन्दराञ्जयेत् ॥३८॥
amṛtā – Tinospora cordifolia, truṭi – Elettaria cardamomum, vella – Embelia ribes, vatsakaṃ – Holarrhena antidysentirica, kali – Terminalia bellirica, pathyā – Terminalia chebula, āmalakāni – Emblica officinalis, and gugguluḥ – Commiphora mukul, increased by one part in their succeeding order (powdered well), soaked in honey (and consumed) cures eruptions, obesity and rectal fistula.

Magadhikadi Churna

मागधिकाग्निकलिङ्गविडङ्गैर्बिल्वघृतैः सवरापलषट्कैः ।
गुग्गुलुना सदृशेन समेतैः क्षौद्रयुतैः सकलामयनाशः ॥ ३९ ॥
māgadhikā – Piper longum, agni – Plumbago zeylanica, kaliṅga – Holarrhena antidysenterica, viḍaṅgai: – Embelia ribes, bilva – Aegle marmelosand ghee each one pala (48 grams) added with six pala (288 grams) of varā – Vara and equal quantity (six pala – 288 grams) of guggulunā – Commiphora mukul, powdered and consumed along with honey cures all diseases.

Guggulu Panchapalam

गुग्गुलुपञ्चपलं पलिकांशा मागधिका त्रिफला च पृथक् स्यात् ।
त्वक्त्रुटिकर्षयुतं मधुलीढं कुष्ठभगन्दरगुल्मगतिघ्नम् ॥४०॥
Five pala (240 grams) of guggulu – Commiphora mukul, one pala (48 grams) each of māgadhikā – Piper longum and triphalā ca – triphala-

• Haritaki – Terminalia chebula
• Vibhitaki – Terminalia bellerica
• Amalaki – Emblica officinalis, individually one karsha (12 grams) each of tvak – Cinnamomum zeylanica and truṭi – Elettaria cardamomum powdered and licked with honey cures skin disease, rectal fistula, abdominal tumorand sinus ulcers.

शृङ्गवेररजोयुक्तं तदेव च सुभावितम् ।
क्वाथेन दशमूलस्य विशेषाद्वातरोगजित् ॥ ४१ ॥
The same herbs (Guggulu – Commiphora mukul etc. mentioned above) added with powder of śṛṅgavera – Zingiber officinale and well soaked in the decoction of daśamūlasya – Dashamula-

• Bilva – Aegle marmelos
• Agnimantha – Premna mucronata
• Shyonaka – Oroxylum indicum
• Patala – Stereospermum suaveolens
• Gambhari – Gmelina arborea
• Shalaparni – Desmodium gangeticum
• Prishniparni – Uraria picta
• Brihati – Solanum indicum
• Kantakari – Solanum xanthocarpum
• Gokshura – Tribulus terrestris cures diseases caused by Vata especially.

Uttamadi Churna Yoga

उत्तमाखदिरसारजं रजः शीलयन्नसनवारिभावितम् ।
हन्ति तुल्यमहिषाक्षमाक्षिकं कुष्ठमेहपिटिकाभगन्दरान् ॥ ४२ ॥
Powder of uttamā – Uttama (triphala)-

• Haritaki – Terminalia chebula
• Vibhitaki – Terminalia bellerica
• Amalaki – Emblica officinalis) and khadira sārajaṃ – sara of Acacia catechu continuously soaked asana vāri – in the decoction of Pterocarpus marsupium, consumed mixed with addition of equal quantity of mahiṣākṣa – (Guggulu) Commiphora mukul and honey cures skin disease, diabetes, eruptions and fistula of the rectum.

Vrana Chikitsa in Bhagandara

भगन्दरेष्वेष विशेष उक्तः शेषाणि तु व्यञ्जनसाधनानि ।
व्रणाधिकारात्परिशीलनाच्च सम्यग्विदित्वौपयिकं विदध्यात् ॥ ४३ ॥
The procedure (therapies, recipes etc.) described here especially in Bhagandara; other methods of treatment whichever needed should be selected by properly going through the chapter on treatment of ulcers (chapter 25) and administered properly and appropriately.

Avoidable things in Bhagandara

अश्वपृष्ठगमनं चलरोधं मद्यमैथुनमजीर्णमसात्म्यम् ।
साहसानि विविधानि च रूढे वत्सरं परिहरेदधिकं वा ॥४४॥
Riding on horse, suppression of urge of (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).

इति श्री वैद्यपति सिंहगुप्तसूनु श्रीमद्वाग्भटविरचितायामष्टाङ्गहृदयसंहितायां षष्ठे उत्तरस्थाने भगन्दरप्रतिषेधो नामाष्टाविंशोऽध्याय: ॥ २८ ॥
Thus, ends the chapter- Bhagandara pratishedha- the twenty-eight in Uttarasthana of Astanga Hridaya Samhita composed by Srimad Vagbhata, son of Sri Vaidyapati Simhagupta.