Bhagandara Chikitsa in the Sushruta Samhita (Chikitsa Sthana 8): Five Types, Nine Named Cuts and the Thread in Chapter 17

इस लेख को हिंदी में पढ़ें: भगंदर चिकित्सा: सुश्रुत संहिता के पाँच प्रकार, नौ चीरे और क्षार सूत्र

📖 27 min read · Sushruta Samhita, Chikitsa Sthana 8, paragraphs 1–22, in Kaviraj Kunja Lal Bhishagratna's English translation (Volume II, printed pages 338–345), read beside Nidana Sthana 4

Sushruta Chikitsa Sthana 8: The Bhagandara Chikitsa Chapter

If you searched for the Sushruta Chikitsa 8th chapter, this is it: chapter 8 of the Chikitsa Sthana, the section of the Sushruta Samhita on therapeutics. Its closing line describes it as the chapter which deals with the treatment of Bhagandara, and its opening line glosses the Sanskrit word as Fistula-in-ano, etc. In Bhishagratna's translation it fills printed pages 338 to 345 of Volume II, in passages numbered 1 to 22.

Most of the chapter is a list of measures: what is done before a swelling ripens and after it, a set of steps for each type, a group of preparations and oils, and the after-care. We leave all of that out, for reasons given near the end. What is left is still worth a long read, because the chapter is built with unusual care for words. It names things after pictures. It tells the physician how to speak about a case that cannot end well. And it is assembled almost entirely out of references to other chapters.

We read it the way this series reads every Chikitsa chapter: beside its twin in the Nidana Sthana, the section on causes and signs, where the same condition has chapter 4 (printed pages 31 to 34). Three more texts join in where they speak to the same point: the Charaka Samhita, in Gabriel Van Loon's English handbook; Vagbhata's Ashtanga Hridaya, in Vidyanath's edition; and Celsus, a Roman writer on medicine of the first century, in W. G. Spencer's translation. The chapter before this one in the series is Ashmari Chikitsa, Chikitsa Sthana 7, on the stone.

Avaraniya Adhyaya: Sushruta's Eight Hard Conditions, in Order

Why does a chapter on bhagandara sit between the stone and kushtha? The answer is in the Sutrasthana, chapter 33, which Bhishagratna titles the chapter on incurable diseases (A'varaniya-madhyayam) (Volume I, printed page 298). It names eight conditions that are, in the translation's words, by their very nature, extremely hard. In its order they are maha-vata-vyadhi, prameha, kushtha, arsha, bhagandara (printed there as "Vagandara"), ashmari, mudha-garbha and udara.

Now look at how the two later sections are laid out. The Nidana Sthana gives these same eight its first eight chapters. The Chikitsa Sthana answers them from chapter 4 to chapter 15, in exactly the Nidana's order. Some conditions get one chapter of measures and some get two or three, but the sequence never changes, and it is not the order of the Sutrasthana's list.

The chapter numbers come from this edition's own closing lines, the colophons that end every chapter. So bhagandara is the fourth of the eight in both later sections and the fifth in the Sutrasthana's list. Twelve chapters of measures for eight conditions: the Chikitsa Sthana's long middle stretch is, in effect, an answer to one list. This is the fourth chapter of that stretch we have read for this series, after vata-vyadhi in chapter 4, the great vata disorders in chapter 5 and the stone in chapter 7.

Pidaka, Then Bhagandara: A Name That Waits for the Stage

The Nidana chapter explains the name before it describes anything: The disease is so named from the fact that it bursts the rectum, the perineum, the bladder and the places beside them (Nidana Sthana 4.2). Read as Sanskrit, bhagandara joins bhaga, the region of the perineum, to dara, a tearing or bursting. That parsing is ours; the reason is the text's.

The same paragraph then makes the name wait for the stage: The pustules, which appear in this regions are called as Pidakas in their unsuppurated stage, while they are called Bhagandaram when they are in a stage of suppuration. A boil (pidaka) is not yet bhagandara; only the ripened form earns the name. Charaka, in the few lines he gives the condition, tells the same story in one sentence: it Initially appears externally as a boil in the side of the anus which is very painful and gradually suppurates and breaks open.

Chapter 8 starts exactly at that line. Its first general measure covers the time as long as any fistular ulcer would remain in an insuppurated stage (Chikitsa Sthana 8.3–4), and for that time it borrows The eleven kinds of remedial measures commencing with Apatarpana up to purgatives from chapter 1. Those are the measures Sushruta gives a swelling (shopha) before it ripens, and our page on Dvivraniya, Chikitsa Sthana 1 counts twelve names between the first and the last, under chapter 1's own heading of eleven.

Chapter 8 adds a third way of making eleven. Bhishagratna's footnote here lists the measures by name, Apatarpana, Alepa, Parisheka, Abhyanga, Sveda, Vimlapana, Upanaha, Pachana, Visravana, Sneha, and Vamana, and so stops at vamana, one name short of virechana, the purgatives his own main sentence gives as the last. The main text and the footnote of the same page count the eleven differently, and neither says which name is dropped.

Shataponaka to Unmargi: Five Types, Five Pictures

The Nidana chapter names five types and gives each a cause: vata alone, pitta, kapha, all three doshas together, and a cause from outside. But the names do not say "the vata type" or "the pitta type". Four of them are pictures, and the fifth is a direction.

A sieve with hundreds of holes and a snail shell's inward whorl: the pictures inside two of the five names, shataponaka and shambukavarta.

Shata is "a hundred", and Bhishagratna gives the first name as Sieve-like fistula in ano. Ushtra is a camel and griva a neck. Parisravi, which he glosses (exuding), flows all round. Shambuka is a small water snail and avarta a whorl, so the name keeps the turn of a coiled shell. Unmargi, which the edition leaves untranslated, is "going off the path", and it fits its own description, in which something swallowed comes down the wrong way. The glosses for the last two names are ours; the pictures in the quotations are the text's. They are not a guide to symptoms, and we have kept each to a phrase.

Now read the causes again: vata has a part in all five. It acts alone in the first. In the second and third it is the carrier: The enraged Pittam, carried down by the Vayu (into the rectum) and The enraged Kaphah, carried down by the Vayu (into the rectum) lodge where it takes them. In the fourth all three doshas come down together. Even the fifth, the type from outside, travels by it: the swallowed fragments of bone are carried down with the hard and constipated stool by the Apana Vayu, the downward-moving vayu. Charaka says the same about vata in general in his own vata chapter, where vata, being subtle, carries the other two doshas elsewhere; we read that line on our page on Charaka's Chikitsa Sthana 28. In Sushruta's account of this one condition, the carrier is named in every row.

Sadhya and Asadhya: Two Types Given Up, Six Names Between Them

The Nidana chapter ends on the outlook (4.10): Almost all the types of this disease (Fistula in ano) yield to medicine after a prolonged course of treatment, it says, except the Sannipatah and traumatic ones, which are incurable. The Chikitsa chapter opens on it (8.2): The disease admits of being divided into five different groups, of which the two, known as S'ambukavarta and S'alyaja (traumatic), should be regarded as incurable, and the other three as extremely difficult.

Set side by side, the two sentences move one way. The Nidana says three types give way to medicine over a long course; the Chikitsa calls the same three "extremely difficult". The Sutrasthana puts the whole condition among the eight that are hard by nature. Nowhere does the outlook grow softer from one section to the next. The sorting is the classical one into sadhya, what can be brought round, and asadhya, what cannot.

The two types given up also change their names on the way. The fourth is Shambukavarta in both lists of types, Sannipatah in the Nidana's outlook and Tridoshaja in the Chikitsa's heading for it (8.11–12). The fifth is Unmargi in the Nidana, Shalyaja in 8.2 and Agantuka in its own heading (8.10). The six names come in two kinds. Shambukavarta and Unmargi describe what the thing looks like or how it goes. Sannipata, Tridoshaja, Shalyaja and Agantuka name what caused it: all three doshas at once, a shalya or foreign body, or something from outside. A reader who meets only one of these names in a later book can be sure, from these two chapters, which type is meant.

One note we repeat on every page like this: a prognosis in an old text is not a prognosis for anyone today. The surgery of this condition has changed beyond recognition since these lines were written, and only a doctor who has examined a person can say anything about that person.

Asadhya Is Not Silence: Acting Without Promising

If two types are given up, why does the chapter go on to set out measures for both? For the type from outside it gives its steps without comment (8.10), among them the measures laid down in connection with the extraction of a Salya from the body. For the three-dosha type it adds an instruction about speech. Such a case should be treated without holding out any hope of recovery to the patient's people, or should be given up as hopeless (Chikitsa Sthana 8.11–12).

That sentence keeps apart two things a modern reader often runs together: whether to act, and what to promise. The surgeon may act, but must not let the family expect recovery; or the surgeon may decline. What the sentence leaves no room for, as far as we read it, is a third course, acting while letting the family hope.

Sutrasthana 33 makes the same demand from the other side. After its list of eight, it says that A physician with any regard to professional success should abandon a patient laid up with any of the preceding diseases, marked by complications, and it then describes, condition by condition, the signs of a case beyond help, which we leave out. Our page on the stone found the same care in another form, where the operation waits for the king's permission. In these chapters a hard case is first of all a matter for plain speaking.

Agni and Kshara: Fire Refused to the Burning Type

Fire (agni) and alkali (kshara) are the two cauteries of Sushruta's surgery, and chapter 8 gives them a general place: Cauterization with fire or an alkali is a general remedial measure which may be resorted to in all the types of this disease (8.3–4). Vagbhata's chapter on the two, which we read on our page on Kshara Agnikarma Vidhi, also names bhagandara among the conditions fit for cautery of the flesh.

Yet the chapter refuses fire twice. The first time is for a type. In the camel's-neck type, the one the Nidana gives to pitta, To remove all sloughed off or sloughing flesh and membranes cauterization with fire is forbidden (8.6); the alkali is still allowed. This is the type whose sore, the Nidana says, seems as if it is being burnt with fire or alkali (4.4). Pitta is the fiery dosha, and the type that already feels burnt is the one denied the fire. The chapter gives no reason, so the connection is ours, but it is the logic of opposites that runs through the whole tradition.

The second time is for a person, and we come to it below: for an infant, both cauteries are refused together.

Langalaka to Avangmukha: Nine Cuts Named After a Plough, a Ford and the Moon

The chapter names nine shapes of cut, and here too the names are pictures. Four belong to the sieve type. The text first warns that its many small openings must not be allowed to run into one another and become one wide one, and adds: Such a case is enough to confound even a well-read and experienced physician. (8.5). For a sieve type with many openings it then names the Langalaka, Ardha-Langalaka, Sarvatobhadraka and the Gotirthaka.

A cow's ford is the worn slope where cattle go down to drink. Gotirthaka, the cow's-ford cut, is one of the four shapes named in paragraph 5.

Langala is the plough, so the first two are the plough cut and the half-plough. Sarvatobhadra means good on every side. Go-tirtha is a cow's ford, the worn slope where cattle walk down to the water to drink. Bhishagratna translates these by their geometry, not their meaning, as in the Langalaka (curvilineal) and the Gotirthaka (longitudinal); the everyday meanings are ours from the Sanskrit. We name the shapes as words only: where and how any of them is made is withheld, and nothing here is anything anyone should imitate.

Five more shapes come with the exuding type (8.7): Kharjura-patra (leaf of the date-palm), Ardha-chandra (half-moon), Chandra-chakra (moon's disc), Suchi-mukha (needle's mouth), or Avammukha (with downward mouth). These five the translator glosses himself. A palm leaf, the moon at half and at full, a needle's mouth and a downward turn: with the plough and the cow's ford, the vocabulary of this chapter's cuts comes from the field, the sky and the sewing basket. A student who had never seen the work done could still picture every shape, and we suspect that is the point of naming them this way.

A full moon rising between two palms. Chandra-chakra, the moon's disc, is one of the five shapes named in paragraph 7; the half-moon is another.

The Timid, the Delicate and the Bala: Whom the Chapter Worries About

The chapter's hardest words are not only about types. One sentence is about the person: A case of the Sataponaka type occurring in a person of timid disposition or of delicate constitution, is extremely difficult (8.5). The chapter weighs the person as well as the type.

One passage is about age: 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 (8.8–9). Every forceful measure of the chapter is ruled out at once for a child (bala), in favour of what the text calls Medicinal remedies calculated to be mild, though keen in their efficacy. The preparation it then names is withheld here, and the rule is not a guide for anyone. A child with any swelling or discharge in this region belongs with a paediatrician, at once.

Hold on to the timid person. Nine chapters later the timid come back, and with them the one tool chapter 8 never names.

Kshara Sutra: The Thread That Is Not in Chapter 8

Many readers come to this chapter looking for the kshara sutra, the thread coated with alkali, which writing about this condition often attaches to Sushruta's name. We read every paragraph of chapter 8 for it, and it is not there: in this translation the chapter mentions no thread, no string and no sutra at all. The thread is in chapter 17, on sinuses (nadi-vrana), under a heading of its own (Chikitsa Sthana 17.16, printed page 423):

An erudite surgeon should open a sinus, occurring in any of the Marmas, or in a weak, timid, or emaciated person with an alkalined string (Kshara-Sutra), and not with a surgical knife.

A few lines on, after the method, which we withhold, comes the sentence that ties it to this condition: The surgeon should know that the same procedure may be as well adopted in cases of fistula-in-ano. So in Sushruta the thread reaches bhagandara by a cross-reference from the sinus chapter, where it is offered first for a sinus in a marma, a vital spot, and for a weak, timid or emaciated person. The timid person of 8.5, whose case the fistula chapter calls extremely difficult, is one of the people the sinus chapter names for the thread instead of the knife. Whether Sushruta meant that link we cannot tell from the English; the shared word is in the text.

Raw flax twisted into thread. Sushruta's chapter 17 and Charaka name a thread with alkali, Celsus a linen one; chapter 8 names none.

Charaka, who gives the condition no chapter of its own, puts the thread straight into his few lines on it. They sit in his Chikitsa Sthana 12, on swellings (shotha), inside the run of verses that Van Loon marks 12.75–102 (Volume II, printed page 1017), and among the measures they list is the application of well-prepared ksara-sutra (alkaline thread). And a thread for this condition is not only Indian. Celsus, in the seventh book of his De Medicina, writes of fistulas that Special consideration is required in the case of those in the anus, and uses a linen thread for them (7.4.4), plain flax with no alkali on it.

Today the thread is a procedure done by surgeons, and nothing on this page describes it or judges it. Whether any procedure suits any person is a decision for a qualified surgeon after an examination.

Arsha Yantra to Bhagandara Yantra: One Instrument, One Bulb Removed

The chapter's last paragraph begins with an instrument, and it does not invent a new one. It takes the speculum of the arsha chapter and changes it: The bulb-like protrusion above the hole of the instrument (speculum), mentioned in connection with the treatment of Ars'as, should be removed and the instrument, now in the shape of a half-moon, should be used (8.21–22).

The original is in chapter 6 (6.9–10), where the arsha speculum is to be made to resemble the teat of a cow, with a bulb-like protrusion at its lower end. We leave its measurements out. Chapter 8 takes the bulb away and the instrument ends in the shape of a half-moon: one more half-moon, beside the half-moon of the list of cuts.

Vagbhata, a later author, keeps the same relation in one line of his chapter on instruments (Ashtanga Hridaya, Sutrasthana 25): Bhagandara yantra should not have any ridge above the slit. His arsha instrument has the same shape as Sushruta's: They are hollow and tapering at the end and are in the shape of the teat of a cow. Two texts written far apart agree that the fistula instrument is the piles instrument with one part taken away. Our page on Yantra Vidhi, Ashtanga Hridaya Sutrasthana 25 reads Vagbhata's whole list.

Atikranta-vekshana: Eight Pointers, All Looking Back

Count the places where chapter 8 sends the reader elsewhere and you find eight, to five different chapters. Four are in the text's own sentences: the position as described under the treatment of Haemorrhoid (chapter 6, in 8.3–4); the measures laid down in connection with the extraction of a Salya from the body (Sutrasthana 27, in 8.10); the procedure laid down under the treatment of Dvi-Vrana (chapter 1, in 8.20); and the speculum mentioned in connection with the treatment of Ars'as (chapter 6 again, in 8.21–22). Vagbhata's own chapter on taking out a shalya is read on our page on Shalyaharana Vidhi.

Four more sit inside round brackets: the eleven measures (as described under the treatment of Dvi-vrana) in 8.3–4, a group of sour things (see Rasa-Vijnaniya chapter) in 8.5, and two items described in the chapter on Vata-vyadhi and described in connection with the treatment of Vata-vyadhi in 8.7 and 8.11–12. The translator's preface explains his brackets: he inserted within brackets explanatory clauses, where a strictly literal translation of texts would not convey their true meaning. So the bracketed four may be his explanations rather than Sushruta's words. The edition does not mark each case, and the split into four and four is ours.

Every one of the eight points backwards, to a chapter already passed: chapters 1, 4 and 6 of this section and chapters 27 and 42 of the Sutrasthana. The Sushruta Samhita's own list of thirty-two devices of composition has a name for the move, atikranta-vekshana, "this has already been said"; our pages on the tantra yuktis and on chapter 1 explain it. Chapter 8 is short because it can be. Nearly everything it needs, the swelling measures, the wound measures, the oils, the instrument and the position, was set out earlier, and it simply points.

A Full Year: Chikitsa Sthana 8.21–22 Beside Chapters 6 and 7

The chapter ends with a rule for the year after. Apart from one item we leave out, the person is to keep away from 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 (8.21–22). The two chapters before it end the same way, and the three lists are worth setting together.

Riding is in all three lists, and so is the item we leave out; food is in all three too. Only chapter 8 names a feeling: anger. The ride is also one of this series' small threads, and our page on the stone followed one jolting ride through four jobs. Here it does three. In Charaka's lines it is a cause: riding a horse closes his list of what brings the condition on. In Sushruta's Nidana it is a sign before the condition shows, which comes after a ride in a carriage, or after defecation (4.8–9). And in chapter 8 it is something to give up for a year after the sore has closed.

A cart at rest. Riding is a cause in Charaka's lines, a sign in Sushruta's Nidana and, in chapter 8, something to give up for a full year.

Charaka's list of causes has one more echo worth a sentence. It opens with gradual decay of bones by organisms, and Sushruta's fifth type begins with fragments of bone swallowed with meat, in a sore the Nidana says becomes infested with worms and parasites (4.7). Both accounts tie the condition to bone and to small living things. Van Loon's line is too short to show whether Charaka meant the same swallowed fragments, so we note the echo and leave it there.

Reading Bhagandara Chikitsa Today

What does a modern reader take from chapter 8? Not its measures: they belong to a surgery that has changed completely, and they are not reproduced here. What travels well is the way it is written. It names each form after something you can picture, so that a student can hold five types and nine shapes in mind. It refuses to soften a hard outlook, and it keeps acting apart from promising. It worries about the person as well as the type: the timid, the delicate, the infant. And it builds on what came before instead of saying it twice.

If you have a symptom in this region, none of that is a reason to wait. A swelling, a discharge, bleeding or pain near the anus needs a doctor's examination, and a fever with it needs one quickly. Nothing on this page should be read as a sign to look for in yourself.

What This Page Withholds, and Why

A shop's website should not read like an advertisement for a medicine, and Indian law restricts how medicines for many conditions may be advertised. So this page keeps to the chapter's words, its order and its arguments, and withholds everything that could be read as a measure to try:

• every preparation, ingredient, oil and quantity in chapter 8, including the whole of paragraphs 13 to 20, and the one preparation it names for an infant;
• every procedure: where and how each named cut is made, the steps for each type, the use of the two cauteries, the method of the thread in chapter 17, and the measurements of the instrument;
• the Nidana chapter's signs, apart from a word or two, and the Sutrasthana's signs of a case beyond help;
• one item in each of the three after-care lists.

The quotations above are the text's own words, chosen to show how it is built. They are not instructions.

What We Could Not Settle

• Which of the twelve names between apatarpana and virechana the "eleven" leaves out. Chapter 1 and the footnote to chapter 8 count differently, and neither says.
• Whether the four bracketed pointers are Sushruta's or Bhishagratna's. His preface says his brackets hold explanations; it does not mark each one.
• Whether the chapter means a reason when it refuses fire to the pitta type. The link to pitta's heat is ours.
• Whether Charaka's "decay of bones by organisms" is Sushruta's swallowed bone. Van Loon's line is too short to say.
• The everyday meanings we give for langalaka, sarvatobhadraka, gotirthaka, shambukavarta and unmargi are read from the Sanskrit words; the translator gives shapes for the first three and leaves the last two untranslated.
• Why the thread is taught in the sinus chapter and only pointed to this condition from there. The English cannot tell us whether that is Sushruta's plan or a later editor's.

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The series continues with chapter 9 of the Chikitsa Sthana, on kushtha. The chapter before this one is Ashmari Chikitsa.

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