The disease admits of being divided into five different groups, of which the two, known as S'ambukávarta and S'alyaja (traumatica should be regarded as incurable, and the rest as extremely difficult to cure. 2.

The General Treatment

The eleven * kinds of remedial measures commencing with Apatar-pana 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 Haemorrhoid, 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,

* Apatarpana, Alepa, Parisheka, Abhyanga, Sveda, Vimlapana, Upanáha, Páchana, Visrávana, Sneha, and Vamana.

Specific Measures - M. Texts: In cases of the Sataponaka 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 faecal 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 Váyu, are experienced. Such a case is enough to confound even a well-read and experienced physician. Hence the mouth of a fistula of the Sataponaka type should not be opened with a broad incision.

Forms Of Incision

An experienced surgeon should know that the Lángalaka, Ardha-Lángalaka, Sarvatobhadraka and the Gotirthaka forms of incision should be the different shapes of incision, in a case of a many-mouthed S'ataponaka. An incision equal in its two sides is called the Lángalaka (curvilineal), while the one with one arm longer than the other is named the Ardha-Lángalaka. 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 Sitaponaka 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 Kris'ará, or Páyasa (porridge), made with the aforesaid Svedaniya (diaphoretic) drugs with a decoction of the drugs constituting the Vilvádi group, Vrikshádani 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 Grámya animals, and then kept in an oily pitcher and applied in the way of a Nádi-Sveda (fomentation through Nádi or pipe), should be at once applied to the seat of the ulcer. Sesamum, castor-seeds, linseed, Másha-pulse, barley, wheat, mustard-seeds, salts and the Amla-Varga (see Rasa Vijnániya 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) Vachá, Hingu and Ajamoda taken in equal parts and mixed with (an adequate quantity of) clarified butter, grape-wine (Márdvika), Kánjika (Amla), Sura or Sauviraka * Subsequent to that, the ulcer should be wetted with the Madhnka-oil and the rectum should be washed with medicated oils which would alleviate pain due to the action of the deranged and aggravated Váyu. 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 treat-merit of a case of fistula- in-ano of the Sataponaka (sieve) type; now listen to me about the treatment of the Ushtragriva (camel's neck) type of the disease. 5.

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