The 46th chapter of Madhava Nidana is Bhagandara Nidanam which deals with Fistula in Ano. A fistula-in-ano is an abnormal hollow tract or cavity that is lined with granulation tissue and that connects a primary opening inside the anal canal to a secondary opening in the perianal skin; secondary tracts may be multiple and can extend from the same primary opening.
Definition —
गुदस्य द्वयङ्गुले क्षेत्रे पार्श्वतः पिडका आर्तिकृत् |
भिन्ना भगन्दरो ज्ञेयः स च पञ्चविधो मतः || १||
gudasya dvayaṅgulē kṣētrē pārśvataḥ piḍakā ārtikr̥t |
bhinnā bhagandarō jñēyaḥ sa ca pañcavidhō mataḥ || 1||
Bhagandara means a papule developing on the either side of the anus, within a radius of two angulis along with pain and exudation. There are 5 types of Bhagandara. 1
Vatika (Shataponaka) Fistula – in – Ano —
कषाय – रुक्षैस्त्वतिकोपितो अनिलस्त्वपानदेशे पीडकां करोति याम् |
उपेक्षणात् पाकमुपैति दारुणं रुजा च भिन्ना अरुण फेनवाहिनी || २ ||
तत्रागमो मूत्र – पुरीष – रेतसां व्रणैरनेकैः शतपोनकं वदेत् |
kaṣāya – rukṣaistvatikōpitō anilastvapānadēśē pīḍakāṁ karōti yām |
upēkṣaṇāt pākamupaiti dāruṇaṁ rujā ca bhinnā aruṇa phēnavāhinī || 2 ||
tatrāgamō mūtra – purīṣa – rētasāṁ vraṇairanēkaiḥ śatapōnakaṁ vadēt |
Vata is excessively aggravated due to the use of astringent and dry (non fatty food) articles that in turn generate a papule in the anus. By its neglect, it undergoes suppuration, bursts out. This condition is known as Shataponaka. In this condition, several small ulcers are created all around, through that crimson coloured froth, urine, faeces and semen come out accompanied with severe pain. 2
Paittika (Ushtragriva) Fistula in ano —
प्रकोपणैः पित्तमतिप्रकोपितं करोति रक्तां पिडकां गुदाश्रिताम् || ३||
तदा आशुपाका अहिमपूतिवाहिनीं भगन्दरं तूष्त्रशिरोधरं वदेत् |
prakōpaṇaiḥ pittamatiprakōpitaṁ karōti raktāṁ piḍakāṁ gudāśritām || 3||
tadā āśupākā ahimapūtivāhinīṁ bhagandaraṁ tūṣtraśirōdharaṁ vadēt |
Pitta, excessively aggravated by its vitiating factors, produces a red boil in the anal region that undergoes suppuration quickly and gives rise to a warm and foul smelling discharge; it is called as fistula – in – ano named Ushtrashirodhara (or ushtragriva). 3-4
Kaphaja (Parisravi) Fistula -in – ano
कण्डूयनो घनस्रावि कठिनो मन्दवेदनः |
श्वेताभासः कफजः परिस्रावि भगन्दरः || ५ ||
kaṇḍūyanō ghanasrāvi kaṭhinō mandavēdanaḥ |
śvētābhāsaḥ kaphajaḥ parisrāvi bhagandaraḥ || 5 ||
The fistula in ano that has such following symptoms as
- itching
- Thick exudate,
- Hard,
- Slightly painful, and
- White in colour and
- is caused by excess of Kapha is identified as the Parisraavi Bhagandara. 5
Sannipatika (Shambukaavarta) Fistula in ano —
बहुवर्ण – रुजास्रावा पिडका गोस्तनोपमा |
शम्बूकावर्तवन्नाली शम्बूकावर्तको मतः || ६ ||
bahuvarṇa – rujāsrāvā piḍakā gōstanōpamā |
śambūkāvartavannālī śambūkāvartakō mataḥ || 6 ||
The fistula in ano that is caused by a morbid excess of all the three doshas together and that has pustules of different kinds of colours and exudates is known as Shambukaavarta. It resembles the teat of the cow and creates spiral sinuses resembling a seashell inside the same. 6
Unmargi (fistula in ano due to trauma/ foreign body) —
क्षताद् गतिः पायुगता विवर्धते ह्युपेक्षणात् स्युः क्रिमयो विदार्य ते |
प्रकुर्वते मार्गमनेकधा मुखैर्व्रणैस्तदुन्मार्गि भगन्दरं वदेत् || ७ ||
kṣatād gatiḥ pāyugatā vivardhatē hyupēkṣaṇāt syuḥ krimayō vidārya tē |
prakurvatē mārgamanēkadhā mukhairvraṇaistadunmārgi bhagandaraṁ vadēt || 7 ||
If a minor injury that has been caused by thorns and the like at the anus, is neglected it would form sinuses. Due to infestation by germs, the condition subsequently generates a number of small ulcers. This pathological condition is known as Unmargi Bhagandara. 7
Prognosis —
घोराः साधयितुं दुःखाः सर्व एव भगन्दराः |
तेष्वसाध्यस्त्रिदोषोत्थः क्षतजश्च विशेषतः || ८ ||
ghōrāḥ sādhayituṁ duḥkhāḥ sarva ēva bhagandarāḥ |
tēṣvasādhyastridōṣōtthaḥ kṣatajaśca viśēṣataḥ || 8 ||
It is difficult to cure all types of fistula. On the other hand, the cases of fistula that have been caused by all the three doshas and injury are simply incurable. 8
The Untreatable Fistulae —
वात मूत्र पुरीषाणि क्रिमयः शुक्रमेव च |
भगन्दरात् स्रवन्तस्तु नाशयन्ति तमातुरम् || ९ ||
vāta mūtra purīṣāṇi krimayaḥ śukramēva ca |
bhagandarāt sravantastu nāśayanti tamāturam || 9 ||
The case of fistula that discharges gas, urine, faeces, worms, and semen is plainly fatal for the patient. 9
इति श्री माधवकरविरचिते माधवनिदाने भगन्दरनिदानं समाप्तम् || ४६ ||
iti śrī mādhavakaraviracitē mādhavanidānē bhagandaranidānaṁ samāptam || 46 ||
Thus concludes the Chapter on Bhagandara.
Source —
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