चतुर्थोऽध्यायः । अथातो भगन्दराणां निदानं व्याख्यास्यामः, यथोवाच भगवान् धन्वन्तरिः ।। १ ।।
Now we shall discourse on the Nidana of Bhagandara (fistula in ano and fistular ulcers). 1
वातपित्तश्लेष्मसन्निपातागन्तुनिमित्ताः शतपोनकोष्ट्रग्रीवपरिस्राविशम्बूकावर्त्तोन्मार्गिणो यथासंख्यं पञ्च भगन्दरा भवन्ति । ते तु भगगुदबस्तिप्रदेशदारणाच्च ‘भगन्दरा ‘इत्युच्यन्ते । अपक्व पिडकाः, पक्वास्तु भगन्दराः । तेषान्तु पूर्वरूपाणि-कटीकपालवेदना कण्डूर्दाहः शोफश्च गुदस्य भवति । ॥ २ ॥
The deranged Vayu, Pitta, Kapha and Sannipata (a simultaneous derangement of the three bodily Dosas) and extraneous causes (such as a blow etc.) give rise to the types of Bhagandara known as Sataponaka, Ustragriva, Parisravi, Sambukavarta and Unmargi. The disease is so named from the fact that it bursts the rectum, the perineum, the bladder and the place adjoning to them (thus setting up a mutual communication between them). The pustules, which appear in this regions are called as Pidakas in their unsuppurated stage, while they are called Bhagandara when they are in a stage of suppuration. A pain about the sacral bone and an itching about the anus, accompanied by a swelling and burning sensation, are the premonitory symptoms of this disease. 2
तत्रापथ्यसेविनां वायुः प्रकुपितः सन्निवृत्तः स्थिरीभूतो गुदमभितोऽङ्गुले द्वयङ्गुले वा मांसशोणिते प्रदूष्यारुणवर्णां पिडकां जनयति । साऽस्य तोदादीन् वेदनाविशेषान् जनयति; अप्रतिक्रियमाणा च पाकमुपैति, मूत्राशयाभ्यासगतत्वाच्च व्रणः प्रक्लिन्नः शतपोनकवदणुमुखैश्छिद्वैरापूर्यते, तानि च छिद्राण्यजस्र मच्छं फेनानुविद्धमधिकमास्रावं स्रवन्ति, व्रणश्च ताड्यते भिद्यते छिद्यते सूचीभिरिव निस्तुद्यते, गुदञ्चावदीर्यते, उपेक्षिते च वातमूत्रपुरीषरेतसामप्यागमश्च तैरेव छिद्रैर्भवति; तं भगन्दरं शतपोनकमित्याचक्षते ।। ३ ।।
The Sataponaka Type: The Vayu, excited, condensed, and rendered motionless by a course of unwholesome food, gives rise to a pustule within one or two fingers’ length from the rectum (anal region, –Guda), by vitiating the flesh (areolar tissue) and blood (of the locality). It assumes a vermilion colour and is characterised by a variety of pricking, piercing pain. If neglected at the outset, the pustule runs into suppuration. Owing to its vicinity to the bladder, the abscess or the suppurated pustule exudes a kind of slimy secretion and becomes covered with hundreds of small sieve-like holes, through which a constant frothy discharge is secreted in large quantities. The ulcer, thus formed, seems as if it is being thrashed with a rod, pierced with a sharp instrument, cut with a knife, and pricked by needles. The region of the anus cracks and bursts, and jets of urine, fecal matter, flatus (Vata) and semen are emitted through these sieve-like holes. This type of fistula is called Sataponaka (Sieve-like fistula in ano). 3
पित्तुन्तु प्रकुपितमनिलेनाधः प्रेरितं पूर्ववदवस्थितं रक्तां तन्वीमुच्छ्रिता मुष्ट्रग्रीवाकारां पिडकां जनयति । साऽस्य चोषादीन् वेदनाविशेषान् जनयति; अप्रतिक्रियमाणा च पाकमुपैति, व्रणश्चाग्निक्षाराभ्यामिव दह्यते, दुर्गन्थमुष्णम् आस्रावं स्रवति, उपेक्षितश्च वातमूत्रपुरीषरेतांसि विसृजति; तं भगन्दरमुष्टुग्रीवमित्याचक्षते ।। ४ ।।
The Ustra-griva Type : The enraged Pitta, carried down by the Vayu (into the rectum) finds lodgment therein, and there gives rise to a small, raised, red pustule, which resembles the neck of a camel in shape, and is characterised by a varied kind of pain, such as sucking etc. The pustule, not medicinally treated at the beginning, runs into suppuration. The incidental ulcer seems as if it is being burnt with fire or alkali, and enits a hot, fetid discharge. Jets of urine, flatus (Vata), fecal matter and semen flow out of the ulcer in the event of it not being heald up with proper medicinal remedies. This type is called Ustragriva.
श्लेष्मा तु प्रकुपितः समीरणेनाधः प्रेरितः पूर्ववदवस्थितः शुक्लावभासां स्थिरां कण्डूमतीं पिडकां जनयति । साऽस्य कण्ड्वादीन् वेदनाविशेषान् जनयति, अप्रतिक्रियमाणा च पाकमुपैति, व्रणश्च कठिनः संरभ्भी कण्डूप्रायः पिच्छिलमजस्रमास्त्रावं स्रवति, उपेक्षितश्च वातमूत्रपुरीषरेतांसि विसृजति; तं भगन्दरं परिस्राविणमित्याचक्षते ।। ५ ।।
The Parisravi Type : The enraged Kapha, carried down by the Vayu (into the rectum ) and lodged therein. gives rise to a whitish stable, itching pustule in that locality, characterised by a variety of itching pains, etc. If neglected at the outset, it soon runs into suppuration. The incidental ulcer becomes hard and swollen, marked by excessive itching and a constant secretion of slimy fluid. Jets of urine, fecal matter, flatus and semen are emitted through the ulcer in the event of it not being well cared for at the outset. This type is called Parisravi. 5
वायुः प्रकुपितः प्रकुपितौ पित्तश्लेष्माणौ परिगृह्याधो गत्वा पूर्ववदवस्थितः पादाङ्गुष्ठाग्रप्रमाणां सर्वलिङ्गां पिडकां जनयति, साऽस्य तोददाहकण्ड्वादीन् वेदना विशेषान् जनयति, अप्रतिक्रियमाणा च पाकमुपैति, व्रणश्च नानाविधवर्णमास्रावं स्रवति, पूर्णनदीशम्बूकावर्तवच्चात्र समुत्तिष्ठन्ति वेदनाविशेषाः; तं भगन्दरं शम्बूकावर्तमित्याचक्षते ।। ६॥
The Sambukavarta Type : the enraged Vayu, in conjunction with the aggravated Pitta and Kapha, is carried down, and finds lodgment (in the region of the rectum), giving rise to a pustule of the size of the first toe, and characterised by a piercing pain, and burning, itching sensations etc. Such a pustule, neglected at the outset, speedily suppurates, and the incidental ulcer exudes secretions of diverse colours, characterised by a kind of whirling pain, which revolves about, in the direction of the involuted indentures (within the grooves of the rectum) such as are found within the full stream of a river or fresh water mollusc. This is called Sambukavarta. 6
मूढेन मांसलुब्धेन यदस्थिशल्यमन्नेन सहाभ्यवहृतं यदाऽवगाढपुरीषोन्मिश्रमपानेनाधः प्रेरितमसम्यगागतं गुदमपक्षिणोति, तदा क्षतनिमित्तः कोथ उपजायते, तस्मिंश्च क्षते पूयरुधिरावकीर्णमांसकोथे भूमाविव जलप्रक्लिन्नायां किमय: संजायन्ते, ते भक्षयन्तो गुदमनेकधा पार्श्वतो दारयन्ति, तस्य तैमार्गैः क्रिमिकृतैर्वातमूत्रपुरीषरेतांस्यभिनिःसरन्ति; तं भगन्दरमुन्मार्गिणमित्याचक्षते ।। ७ ।।
The Unmargi Type : Particles of bones, eaten with (cooked) meat by an imprudent, greedy, gluttonous person, may be carried down with the hard and constipated stool by the Apana Vayu (into the rectum), thus scratching or abraising the margin of the anus, or burrowing into the rectum in the event of their being evacuated in improper directions through (transverse or horizontal postures). The scratch or abrasion is soon transformed into a fetid and putrid ulcer, associated with pus and scattered blood infested with worms and parasites, as a plot of miry ground will soon swarm with a spontaneous germination of similar parasites. These worms and parasites eat away the sides of, or largely burrow into, the region of the anus, and jets of urine, fecal matter and flatus (Vayu) are found to gush out of these holes. This type of Bhagandara is called Unmargi. 7
भवन्ति चात्र । उत्पद्यतेऽल्परुक् शोफा (तू) क्षिप्रञ्चाप्युपशाम्यति । पायवन्तदेशे पिडका सा ज्ञेयाऽन्या भगन्दरात् ।। ८ ।।
पायोः स्याद् द्व्यङ्गुले देशे गूढमूला सरुगुज्वरा भगन्दरी तु विज्ञेया पिडकाऽतो यानयानान्मलोत्सर्गात् पायुर्भवेद्वजः विपर्ययात् ।। ९ ।।
कण्डूरुग्दाहशोफवान् । पूर्वरूपं कटयां भगन्दरे ।। १० ।।
Authoritative verses on the subject : A pustule, appearing about the region of the anus and characterised by a slight pain and swelling and immediately subsiding, should be regarded as a simple pustule, which is of a quite different nature from a fistula in ano, which has contrary features (i.e., invariably found to be attended with a violent pain and swelling etc., and takes a long time to heal). A Fistulapustule crops up within a space of two fingers’ width of the Payu proper (distal end of the rectum), is sunk at its root, and attended with pain and febrile symptoms. Pain, itching and burning sensations are experienced about the anus after a ride in a carriage, or after defecation. The anus becomes swollen, and the waist painful in the premonitory stages of Bhagandara. 8-10
घोराः साधयितुं दुःखा: सर्व एव भगन्दराः |
तेष्वसाध्यस्त्रिदोषोत्थः क्षतजश्च भगन्दरः ।। ११ ।।
Prognosis : Almost all the types of this disease (Fistula in ano) yield to medicine after a prolonged course of treatment, and are difficult to cure, except the Sannipata and traumatic ones, which are incurable. 11
इति सुश्रुतसंहितायां निदानस्थाने भगन्दरनिदानं नाम चतुर्थोऽध्यायः ।। ४ ।।
Thus ends the fourth Chapter of the Nidana Sthana in the Susruta Samhita, which treats of the Nidana of Fistula in ano (Bhagandara).
