The deranged Váyu, Pittam, Kaphah and Sannipátah (a simultaneous derangement of the three bodily Doshas) and extraneous causes (such as a blow etc.) give rise to the types of Bhagandaram known as Sataponaka, Ushtragriva, Parisrávi, Samvukávarta 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 Pidakás in their unsuppurated stage, while they arc called Bhagandaram when they arc 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.

The Sataponakah Type

The Váyu, 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 (Váta) and semen arc emitted through these sieve-like holes. This type of fistula is called Sataponakah (Sieve-like fistula in ano). 3.

The Ushtra-Grivah Type

The enraged Pittamcarried down by the Váyu (into the rectum) finds lodgmeit 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 emits a hot, fetid discharge. Jets of urine, flatus (Váta), fecal matter and semen flow out of the ulcer in the event of it not being healed up with proper medicinal remedies. This type is called Ushtragrivah. 4.

The Parisrávi Type

The enraged Kaphah, carried down by the Váyu (jnto the rectum) and lodged therein, gives rise to a white, hard, 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.

The Samvukávartah Type

The enraged Váyu, in conjunction with the aggravated Pittam and Kapham, 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 body of a river or fresh water mollusc. This is called Samvukávartah. 6.

The Unmárgi 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 Apána Váyu (into the rectum), thus scratching or abrading 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, 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 (Váyu) are found to gush out of these holes. This type of Bhagandaram is called Unmárgi. 7.

Authoritative Verses On The Subject

A pustule, appearing about the region of the anus and characterised by a slight pain and swelling, and spontaneously 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 Fistula-pustule crops up within a space of two fingers' width of the Payu proper (distal end of the .5 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 Bhagandaram. 8 - 9.

Prognosis: - Almost all the types of this disease (Fistula in ano) yield to medicine after a prolonged course of treatment, and are hard to cure, except the Sannipatah and traumatic ones, which are incurable. 10.

Thus ends the fourth Chapter of the Nidana Sthanam in the Sushruta Samhita, which treats of the Nidanam of Fistula in ano (Bhagandaram).