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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 177-184

Comparative study of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra in the management of Bhagandar (Fistula-in-Ano)


1 Department of Shalyatantra, Mahatma Gandhi Ayurved College Hospital and Research Centre (MGACH & RC), Salod, Maharashtra, India
2 Department of Rasa Shastra and Bhaishajya Kalpana, Mahatma Gandhi Ayurved College Hospital and Research Centre (MGACH & RC), Salod, Maharashtra, India

Date of Submission06-May-2020
Date of Decision20-May-2020
Date of Acceptance08-Oct-2020
Date of Web Publication11-Nov-2020

Correspondence Address:
Dr. Dhananjay D Deshmukh
Department of Shalyatantra, Mahatma Gandhi Ayurved College Hospital and Research Centre (MGACH & RC), Salod, Wardha 442001, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISM.JISM_30_20

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  Abstract 

The term Bhagandhar is a condition that causes Daran (cutting) of Bhag (vulva), Guda (anus), and Bastipradesh (perianal region) at first, it is present as Pidika in Apakwa or un-suppurated condition and when it becomes Pakwa or suppurated, it is called as Bhagandar.It is correlated with fistula-in-ano, as described in modern medical science. Fistula-in-ano is defined as an inflammatory tract that is lined by unhealthy granulation tissue, having its external opening in the perianal region and internal opening in the anal canal or rectum. Various surgical as well as parasurgical treatments are in rage to treat anal fistula but they have certain limitations and risk of recurrence. In this study, an effort was made to derive a standard and easily accessible treatment for fistula-in-ano. Snuhi Ksheer Sutra application is a proved effective treatment for Bhagandhar, but Snuhi creates many problems during the preparation of the thread. Nyagrodha Ksheer was used in the present research work, as it is available in abundance and in all seasons and its latex can be easily extracted. Nyagrodha Ksheer possesses Vranaropak and Krimighna properties and it acts on the basis of its Shodhan (wound cleaning) property. By comparing the advantages of Nyagrodha Ksheer Sutra with those of Snuhi Ksheer Sutra, it can be concluded that Nyagrodha Ksheer Sutra may be used as a good alternative of Snuhi Ksheer Sutra in the management of Bhagandar.

Keywords: Bhagandar, Fistula-in-Ano, Ksheer Sutra, Nyagrodha, Snuhi


How to cite this article:
Deshmukh DD, Khandare KB, Shrivastav PP, Chavhan NS. Comparative study of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra in the management of Bhagandar (Fistula-in-Ano). J Indian Sys Medicine 2020;8:177-84

How to cite this URL:
Deshmukh DD, Khandare KB, Shrivastav PP, Chavhan NS. Comparative study of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra in the management of Bhagandar (Fistula-in-Ano). J Indian Sys Medicine [serial online] 2020 [cited 2020 Dec 3];8:177-84. Available from: https://www.joinsysmed.com/text.asp?2020/8/3/177/300488




  Introduction Top


The earliest description of Bhagandar was given in 1000 BC by Acharya Sushrut, the father of Indian Surgery; however, before Sushrut we do not find much about this disease. He has included Bhagandar as one among the Ashtamahagada (eight dreadful diseases).[1] According to Acharya Sushrut, that which causes Daran (cutting) of Bhag (vulva), Guda (anus), and Bastipradesh (perianal region) is known as Bhagandar; at first, it is present as Pidika (boil) in Apakwa or un-suppurated condition and when it becomes Pakwa or suppurated it is called Bhagandar.[2]Acharya Charak has made a very short and passing reference to Bhagandar in Shwayathu Chikitsa Adhyay. He has described the treatment of Bhagandar through Kshar Sutra (medicated seton).[3]Acharya Vagbhat said that when Pidika gets Pakwa Awastha or gets suppurated it is called Bhagandar.[4] In Madhav Nidan, it is stated that a painful boil that is between two fingers of the anal verge and that bursts is known as Bhagandar.[5]Bhagandar is correlated with fistula-in-ano, as described in modern medical science. Fistula-in-ano is an abnormal track or cavity with an external opening in the perianal area that communicates with the rectum or anal canal by an identifiable internal opening.[6] Most fistulas are believed to arise as a result of cryptoglandular infection, with resultant perianal abscess. An abscess represents an acute inflammatory event, whereas a fistula is representative of the chronic process.[7] Ayurved has a unique way of treating fistula-in-ano.

All types of fistula-in-ano respond well to different types of Kshar Sutra as well as to the Ksheer Sutra procedure. Kshar Sutra and Ksheer Sutra comprise a medicated seton.[8] Mechanical action of the threads and the chemical action of the drugs coated on the thread together do the work of cutting, curetting, draining, and cleaning the fistulous track, thus promoting healing of the track. Apamarga (Achyranthus aspera) Kshar Sutra is considered the standard Kshar Sutra; although this Apamarga Kshar Sutra has been a landmark success, it has certain drawbacks such as pain, burning sensation, and itching associated to it. Even Snuhi Ksheer is used in Apamarga Kshar Sutra and it creates many problems during the preparation of thread. Snuhi Ksheer Sutra application is a proven effective treatment for Bhagandar.[9] However, Snuhi (Euphorbia nerifolia) creates many problems during the preparation of thread, for instance, a very small quantity is collected after the incision of the stem, it coagulates if not used early, and collection becomes more difficult in summer. Therefore, to overcome such problems associated with Snuhi Ksheer, Nyagrodha Ksheer was used in the current research work as it is available in abundance and in all seasons and its latex can be easily extracted. Different research scholars have conducted investigations to find out other varieties of thread that can minimize pain and other undesired effects.[10] The objective of this study was to evaluate the comparative efficacy of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra in the management of Bhagandar (Fistula-in-Ano) when applied continuously for seven days.


  Material and Methods Top


Materials: Patients reported to the outpatient department and inpatient department of Shalyatantra Department and also those from the peripheral camps were enrolled in this study.

Method: The study was started after obtaining approval from the Institutional ethics committee (Ref. number.

DMIMS (DU)/IEC/2017–18/6391) on 30/3/2017.

Type of study: Interventional

Study design: Randomized control clinical trial

Sample size and grouping: Two groups each with a minimum of 15 patients who fulfilled the inclusion and exclusion criteria were selected.

Period of study: Five weeks

Inclusion Criteria

  1. Patients within the age group of 18 to 70 years


  2. Patients with clinical features of Bhagandar will be included after screening.


  3. All patients, regardless of sex, occupation, and economic status, will be included.


Exclusion Criteria

  1. Subjects suffering with systemic disorders such as diabetes mellitus, tuberculosis, HIV, and hepatitis


  2. Subjects having:
    • Multiple fistula-in-ano,


    • Fistula-in-ano associated with fissure-in-ano,


    • Fistula-in-ano associated with hemorrhoids, and


    • Malignancy will be excluded.


Assessment of results

Ksheer Sutra in both the groups was changed after every seven days, and assessment was done on the basis of the following subjective and objective parameters for five weeks (first, second, third, fourth, and fifth).

Subjective Parameters

  1. Pain


  2. Discharge


  3. Itching


  4. Tenderness


Objective Parameters

  1. Cutting rate per week (CRW)


Grading of Objective Parameters

  1. CRW:



Overall Assessment of Clinical Improvement

Maximum improvement: More than 75% improvement of the clinical signs and symptoms.

Moderate improvement: 50%–75% improvement of the clinical signs and symptoms.

Poor improvement: 25%–50% improvement of the clinical signs and symptoms.

No improvement: 0%–25% improvement of the clinical signs and symptoms

Observations and Results

Age

Overall, 40% of the patients in Group A and 26.67% of the patients in Group B belonged to the age group of 21 to 30 years, 13.33% of the patients in Group A and 46.67% of the patients in Group B belonged to the age group of 31 to 40 years, 26.67% of the patients in Group A and 13.33% of the patients in Group B belonged to the age group of 41 to 50 years, and 20% of the patients in Group A and 13.33% of the patients in Group B belonged to the age group of 50 to 60 years, respectively.

Gender

Overall, 80% of the patients in Group A and 93.33% of the patients in Group B were males and 20% of the patients in Group A and 6.67% of the patients in Group B were females.

Habitat

Overall, 53.33% of the patients in Group A and 46.67% of the patients in Group B belonged to rural areas and 46.67% of the patients in Group A and 53.33% of the patients in Group B belonged to urban areas, respectively.

Marital status

When stratified according to their marital status, it was revealed that 66.67% of the patients in Group A and 73.33% of the patients in Group B were married and 33.33% of the patients in Group A and 26.67% of the patients in Group B were unmarried, respectively.

Economic status

The distribution of patients according to their economic status reveals that 33.33% of the patients in Group A and 66.67% of the patients in Group B were poor, 20% of the patients in Group A and 73.33% of the patients in Group B belonged to the middle class, and 6.67% of the patients in Group B were wealthy.

Educational status

Overall, 66.67% of the patients in Group A and 86.67% of the patients in Group B were literate and 33.33% of the patients in Group A and 13.33% of the patients in Group B were illiterate.

Nature of work

The distribution of patients according to their nature of work shows that 40% of the patients in Group A and 53.33% of the patients in Group B performed sedentary work, 20% of the patients in Group A and 33.33% of the patients in Group B performed moderate work, and 40% of the patients in Group A and 13.33% of the patients in Group B performed strenuous types of work.

Sleep

Overall, 93.33% of the patients in Group A and 80% of the patients in Group B had disturbed sleep and 6.67% of the patients in Group A and 20% of the patients in Group B had sound sleep.

Diet

Overall, 13.33% of the patients in Group A and 6.67% of the patients in Group B consumed a vegetarian diet and 86.67% of the patients in Group A and 93.33% of the patients in Group B consumed a mixed diet.

Bowel habit

Overall, 26.67% of the patients in Group A and 13.33% of the patients in Group B had regular bowel habits; 73.33% of the patients in Group A and 86.67% of the patients in Group B had irregular bowel habits.

Hygiene

Overall, 73.33% of the patients in Group A and 80% of the patients in Group B experienced poor hygienic conditions; 26.67% of the patients in Group A and 20% of the patients in Group B experienced good hygienic conditions.

Addiction

Overall, 26.67% of the patients in Group A and 13.33% of the patients in Group B were addicted to alcohol, 6.67% of the patients in Group A and 20% of the patients in Group B had the habit of kharra, 26.67% of the patients in Group A and 13.33% of the patients in Group B had multiple habits, 6.67% of the patients in Group A and 40% of the patients in Group B had the habit of smoking, and 13.33% of the patients in Group A and 0% of the patients in Group B had the habit of tobacco, respectively.

Height and weight

The mean height of the patients in Group A was 167.66cm, whereas that of the patients in Group B was 170.73cm. The mean weight of the patients in Group A was 60.66kg, whereas that of the patients in Group B was 65.73kg.

Psychological condition

According to their psychological condition, it was revealed that 80% of the patients in Group A and 66.67% of the patients in Group B were worried, 20% of the patients in Group A and 26.67% of the patients in Group B were depressed, and 6.68 of the patients in Group B were irritative.

Builtup

Overall, 93.33% of the patients in Group A and 93.33% of the patients in Group B had a normal build, 6.67% of the patients in Group A and 6.67% of the patients in Group B were slim, and 0% of the patients in Group A and 0% of the patients in Group B were obese.


  Results Top


Statistical analysis was conducted on the changes seen in subjective parameters by using the Mann–Whitney U test, and it was conducted on the changes seen in objective parameters by using the Student’s unpaired t test.

The mean pain on Day 1 in Group A was 4 and that in Group B was also 4; on comparing the mean pain, no statistically significant result was obtained. The mean pain during Week 1 in Group A was 3.80 and that in Group B was 3.73; on comparing the mean pain, no statistically significant result was obtained. The mean pain during Week 2 in Group A was 2.86 and that in Group B was 2.73; on comparing the mean pain, no statistically significant result was obtained. The mean pain during Week 3 in Group A was 1.93 and that in Group B was 1.73; on comparing the mean pain, no statistically significant result was obtained. The mean pain during Week 4 in Group A was 1 and that in Group B was 0.80; on comparing the mean pain, no statistically significant result was obtained. The mean pain during Week 5 in Group A was 0.26 and that in Group B was 0.20; on comparing the mean pain, no statistically significant result was obtained [Table 1].
Table 1: Comparison of mean difference pain in two groups

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The mean discharge on Day 1 in Group A was 3.20 and that in Group B was 3.46; on comparing the mean discharge, no statistically significant result was obtained. The mean discharge during Week 1 in Group A was 3.00 and that in Group B was 3.13; on comparing the mean discharge, no statistically significant result was obtained. The mean discharge during Week 2 in Group A was 2.06 and that in Group B also was 2.06; on comparing the mean discharge, no statistically significant result was obtained. The mean discharge during Week 3 in Group A was 1.06 and that in Group B was 1.00; on comparing the mean discharge, no statistically significant result was obtained. The mean discharge during Week 4 in Group A was 0.20 and that in Group B was 0.13; on comparing the mean discharge, no statistically significant result was obtained. The mean discharge during Week 5 in Group A was 0.20 and that in Group B was 0.00; on comparing the mean discharge, no highly statistically significant result was obtained [Table 2].
Table 2: Comparison of mean difference discharge in two groups

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The mean itching on Day 1 in Group A was 3.00 and that in Group B was 2.86; on comparing the mean itching, no statistically significant result was obtained. The mean itching during Week 1 in Group A was 2.80 and that in Group B was 2.53; on comparing the mean itching, no statistically significant result was obtained. The mean itching during Week 2 in Group A was 1.86 and that in Group B was 1.46; on comparing the mean itching, no statistically significant result was obtained. The mean itching during Week 3 in Group A was 0.93 and that in Group B was 0.53; on comparing the mean itching, no statistically significant result was obtained. The mean itching during Week 4 in Group A was 0.00 and that in Group B also was 0.00; on comparing the mean itching, no statistically significant result was obtained. The mean itching on Week 5 in Group A was 0.00 and that in Group B also was 0.00; on comparing the mean itching, no highly statistically significant result was obtained [Table 3].
Table 3: Comparison of mean difference in itching score in two groups

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The mean tenderness on Day 1 in Group A was 3.00 and that in Group B was 2.86; on comparing the mean tenderness, no statistically significant result was obtained. The mean tenderness during Week 1 in Group A was 2.80 and that in Group B was 2.53; on comparing the mean tenderness, no statistically significant result was obtained. The mean tenderness during Week 2 in Group A was 1.86 and that in Group B was 1.46; on comparing the mean tenderness, no statistically significant result was obtained. The mean tenderness during Week 3 in Group A was 0.93 and that in Group B was 0.53; on comparing the mean tenderness, no statistically significant result was obtained. The mean tenderness during Week 4 in Group A was 0.00 and that in Group B also was 0.00; on comparing the mean tenderness, no statistically significant result was obtained. The mean tenderness during Week 5 in Group A was 0.00 and in Group B also it was 0.00; on comparing the mean tenderness, no highly statistically significant result was obtained [Table 4].
Table 4: Comparison of mean difference in tenderness score in two groups

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  Discussion Top


Acharya Sushrut has included Nyagrodha in Nyagrodhadi Gana; in Bhagandar Chikitsa, he explained that Nyagrodhadi gana Dravya are Bhagandar Nashak.[2]Nyagrodha has Kashay Rasa (astringent), Katu (bitter) Vipak (postdigestive), Sheeta (cold), Virya (potency), Guru and Ruksha Guna, and Kapha-Pitta Shamak; it has Vranavikar and Krimighna properties as well.[11] The pH value of prepared Nyagrodha Ksheer Sutra is found to be 5.28.

Aqueous and ethanolic extracts of the stem bark of Ficus bengalensis help in destruction of unhealthy tissue and provides a healthy environment for healing purposes.[12] The aqueous chloroform and alcoholic extracts of the bark of Ficus benghalensis act on the inherent tissue damage of the area, thus reducing inflammation to a great extent.[12] The aqueous and ethanolic extracts of Ficus benghalensis created an antimicrobial path for faster healing; these also exhibit analgesic and antipyretic activity.[12] The aqueous extracts of the stem, bark, leaf, and root possess antifungal activity and they are also antipruritic,[12] which helps in the management of fistula-in-ano. All these properties of Ficus benghalensis help in the management of fistula-in-ano. When this Nyagrodha Ksheer Sutra was changed after every seven days, it had an additional effect in managing fistula-in-ano [Figure 1],[Figure 2]-[Figure 3].
Figure 1: Probing of fistulous track

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Figure 2: Changing Ksheer Sutra

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Figure 3: Ksheer Sutra in sit

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When the effect of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra on pain was statistically analyzed by using Wilcoxon signed-rank test, the result was found to be significant in the patients of both the groups. However, on comparing both the groups by using the Mann–Whitney U test, the result was found to be nonsignificant. On assessment of the application of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra, both the groups showed approximately equal analgesic activity. Percentage relief in the pain of Group A patients was 93% and in Group B it was 95% [Table 5] and [Table 6].
Table 5: Comparison of mean difference in CRW in two groups

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Table 6: Comparison of percentage of improvement in two groups

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Pain, discharge, itching and tenderness were accessed by specific gradation which are depicted in [Table 7],[Table 8],[Table 9],[Table 10]. When the effect of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra on discharge was statistically analyzed by using the Wilcoxon signed-rank test, the result was found to be highly significant in the patients of both the groups. However, on comparing the mean discharge in both the groups, by using the Mann–Whitney U test, a statistically nonsignificant difference was found. The percentage of relief in discharge of Group A patients was 100% and that in Group B was also 100%. From this, we can conclude that the changing of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra was equally effective in reducing discharge in both the groups.
Table 7: Grading of pain scale

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Table 8: Grading of discharge

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Table 9: Grading of itching

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Table 10: Grading of tenderness

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When the effect of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra on itching was statistically analyzed by using the Wilcoxon signed-rank test, the result was found to be highly significant in the patients of both the groups. However, on comparing the mean itching in both the groups, by using the Mann–Whitney U test, a statistically nonsignificant difference was found. The percentage of relief in itching of Group A patients was 100% and that in Group B patients was also 100%. From this, we can conclude that the changing of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra was equally effective in reducing itching in both the groups.

When the effect of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra on tenderness was statistically analyzed by using the Wilcoxon signed-rank test, the result was found to be significant in the patients of both the groups. However, on comparing the mean tenderness in both the groups, by using the Mann–Whitney U test, a statistically nonsignificant difference was found. The percentage of relief in the tenderness of Group A patients was 80% and that in Group B patients was 87%. From this, we can conclude that the changing of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra was equally effective in reducing tenderness in both the groups.

Discussion on CRW (in cm): The length of the track, cut by the Ksheer Sutra per weeks, was measured as the CRW. The CRW is the most quantitative and the principal objective of this study.

When the principal objective parameter CRW was considered, the mean CRW in Group A was found to be 0.396cm/week and that in Group B was 0.397cm/week. By using the Student’s unpaired t test, no statistically significant difference was found in mean CRW (in cm per week) in both the groups. Hence, we can say that the CRW in both Groups A and B is approximately the same. The cutting effect or Chhedana Karma of Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra is facilitated by its Vrana (ulcer) Shodhana (cleaning), Vrana Ropana (healing), Shothhara (anti-inflammatory), and Krimighna (anti-bacterial) Karma (action). It reduces inflammation by Shothahara Karma. With the help of the Vrana Shodhana property, it keeps the track clean, providing the Suddha (healthy) Vrana Avasthaa (stages) and only a Suddha Vrana can heal properly. Due to Vrana Ropana Karma of the Nyagrodha Ksheer Sutra and Snuhi Ksheer Sutra and mechanical action of the Sutra, healing and cutting processes occur simultaneously. As a whole, we can say that the Ksheer Sutra acts by gradual chemical excision of the Bhagandar (fistula-in-ano) with simultaneous healing.

Even though Nyagrodha has been presented by Acharya Sushruta as Bhagandar Nashak, till date no study has been conducted on its efficacy in Ksheer Sutra in the management of Bhagandar. Hence, the findings of the current study justify the clinical claim made by Acharya Sushruta on the efficacy of Nyagrodha.


  Conclusion Top


The current study recommends that Nyagrodha Ksheer Sutra is equally effective when compared with Snuhi Ksheer Sutra. By comparing the advantages of Nyagrodha Ksheer Sutra with Snuhi Ksheer Sutra, it can be concluded that Nyagrodha Ksheer Sutra may be used as a good alternative of Snuhi Ksheer Sutra in the management of Bhagandar.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shastri AD Sushrut Samhita. Vol I. Sutrasthan. Avarniya Adhyaya 33/4–5. Varanasi, India: Chaukhambha Sanskrit Sansthan; 2013. p. 163.  Back to cited text no. 1
    
2.
Shastri AD Sushrut Samhita. Vol I. Nidansthan. Bhagandar Nidan Adhyaya 4/5. Varanasi, India: Chaukhambha Sanskrit Sansthan; 2013. p. 317.  Back to cited text no. 2
    
3.
Shukla V, Tripathi R Charak Samhita Vol II. Chikitsasthan. Kshwayathu Chikitsa. -12/96. Varanasi, India: Chaukhambha Bharti Publication; 2010. p. 288.  Back to cited text no. 3
    
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Gupta A Ashtang Hrudayam of Vagbhat. Uttarsthan. Bhagandar Pratishedh. 28/5. Varanasi, India: Chaukhambha Sanskrit Sansthan; 1995. p. 551.  Back to cited text no. 4
    
5.
Murthy K Madhav Nidanam: Rog Vinischaya of Madhavkara. Part 1, 8th ed. Bhagandar Nidan 46/4. Varanasi, India: Chaukhambha Orientalia; 2007. p 152.  Back to cited text no. 5
    
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Belliveau P Anal Fistula. Current Therapy in Colon and Rectal Surgery. Philadelphia, PA: BC Decker; 1990. p. 22-7.  Back to cited text no. 6
    
7.
Williams N, Bulstrode C, Connell P Bailey & Love’s Short Practice of Surgery. 25th ed. London: Edward Arnold Ltd; 2008. p. 1264.  Back to cited text no. 7
    
8.
Deshmukh DD, Khandare KB, Shrivastav PP A case report on management of recurrent anal fistula by Nyagrodha Ksheer Sutra. J Indian Sys Med 2019;7;51-5.  Back to cited text no. 8
    
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Lobo SJ, Bhuyan C, Gupta SK, Dudhamal TS . A comparative clinical study of Snuhi Ksheera Sutra, Tilanala Kshara Sutra and Apamarga Kshara Sutra in Bhagandara (Fistula in Ano). AYU2012;1:85-91.  Back to cited text no. 9
    
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Bhaskarao M, Lavekar GS Recent Advances in Kshar Sutra: Kshar Sutra in the Light of Contemporary Medicine with a Critical Review. New Delhi, India: Chaukhamba Publication; 2009. p. 77.  Back to cited text no. 10
    
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Rastogi RP, Mehrotra BN Compendium of Indian Medicinal Plants, Vol. II, New Delhi, India: Central Drug Research Institute and Publications & Information Directorate; 2007. p. 187.  Back to cited text no. 11
    
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Ahirwar SK, Singh A, Singh PK, Bijauliya RK. AN updated review of pharmacological studies on Ficus benghalensis Linn. Int J Pharmacogn2018;5:546-62.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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