Visarpa, Nadi Vrana & Stana Roga in the Sushruta Samhita: The Creeping Fire, the Hidden Channel and the Classical Reading of Mother's Milk (Nidana Sthana Chapter 10)

📖 24 min read · Classical text: Sushruta Samhita, Nidana Sthana, Chapters IX–X (Bhishagratna’s English translation), with the commentarial notes it preserves

One Chapter, Three Subjects: Visarpa, Nadi Vrana, Stana Roga

Every so often the Sushruta Samhita gathers into a single chapter a set of diseases that no modern textbook would shelve together — and the grouping itself turns out to be the lesson. The tenth chapter of the Nidana Sthana is the finest example in the whole section. Its announced subjects are three: Visarpa (the spreading disease the West calls erysipelas), Nadi Vrana (the sinus, a pus-discharging channel hidden under the skin) and Stana Roga (diseases of the breast). One creeps across the surface of the body; one burrows beneath it; one strikes the organ that feeds the next generation. What could they share?

Read closely, the chapter answers: all three are diseases of movement along tissue — of the way vitiated doshas and fluids travel, spread, burrow and pool. Visarpa is lateral spread through skin (tvak), blood, and flesh. The nadi is vertical spread — a track bored downward by neglected pus. And the breast, in Sushruta’s reading, is the terminus of the body’s most refined movement of all: the long journey of rasa, the nutrient essence, which in a mother becomes stanya — milk. The same physician who maps how disease travels closes the chapter by mapping how nourishment travels, and tests it in a bowl of water.

Because the cursor of our daily reading falls where it falls, this close reading also gathers the last verses of the ninth chapter — three small masterpieces the abscess chapter saves for its end: Makkalla, the abscess of the newly delivered mother; the celebrated Gulma-versus-Vidradhi distinction, argued by way of a water bubble; and Asthigata Vidradhi, the abscess that reaches the bone. The abscess chapter’s main doctrine — the six types, the internal abscess and its visceral map — has its own full study here; today we complete it, then walk into Chapter X.

Where We Stand in the Nidana Sthana

The Nidana Sthana is the Sushruta Samhita’s book of diagnosis — sixteen chapters that march disease by disease through the great categories of classical medicine. Our series has walked it steadily: the sixteen-chapter survey first, then the deep dives — Arsha (Chapter II), Ashmari (Chapter III), Kushtha (Chapter V), Prameha (Chapter VI), Udara (Chapter VII) and Vidradhi (Chapter IX). Chapter X carries the march onward.

Two habits of the text are worth carrying into these pages. First, Sushruta is the tradition’s surgeon — the author of Shalya Tantra — and his diagnostic chapters constantly anticipate the knife: which swelling will ripen, which channel hides a foreign body, which case must be declined. Second, the text we read comes to us through Kaviraj Kunja Lal Bhishagratna’s English translation, which preserves not only the verses but the arguments of the commentators around them — and in this chapter that margin comes alive: we will meet the commentator Gayadasa striking out a whole class of sinuses as spurious, and a variant reading on the colour of a fatal Visarpa. Classical medicine was a living argument, and these pages let us hear it.

The Nidana Sthana at work — the diagnostic chapters of the surgical classic, where every description anticipates a decision

Makkalla: The Abscess of the Newly Delivered Mother

Before Chapter X opens, the abscess chapter closes with a case the text treats with special care. In verses 20–21 of Chapter IX, Sushruta describes an abscess that arises “in the Kukshi (in the iliac region) of a safely delivered woman owing to the presence of the unexpelled blood-clots.” Blood that should have left the body after childbirth, and did not, gathers instead — and the gathering, the text warns, has a clock: “such an abscess, if not absorbed in the course of a week, is sure to suppurate.” This is the Raktaja Vidradhi of the postpartum woman, and the tradition gives it its own name: Makkalla.

Notice what the naming does. The six abscesses of the chapter’s main doctrine are classified by dosha — Vataja, Pittaja, Kaphaja and the rest. Makkalla alone is classified by circumstance: it belongs to a particular body at a particular moment, the week after delivery, when the tissues are open, the blood is in motion and the ordinary rules are suspended. A medical tradition reveals its priorities in the cases it singles out, and classical Ayurveda consistently singles out the mother — a thread that runs from Charaka’s six factors of the embryo to the stanya doctrine waiting at the end of this very chapter. The one-week watch on the Makkalla is bedside medicine of a very recognisable kind: observe, count the days, and know in advance which way the case will turn.

Gulma vs Vidradhi: The Water-Bubble Distinction

Then comes one of the most quietly brilliant passages in the Nidana Sthana. A student’s question shapes verses 22–24: the internal tumour called Gulma and the internal abscess called Vidradhi arise, says the text, from the same deranged doshas. Why then does the abscess ripen and burst with pus, while the Gulma almost never does?

Sushruta’s answer is a lesson in what we would now call pathological reasoning. A Vidradhi, he explains, forms in tissue: the deranged doshas seize on flesh and blood, and “the diseased flesh and blood of a locality are themselves transformed into an abscess.” There is organic matter at its root, and organic matter can ripen, break down and become pus. A Gulma, by contrast, has no such anchor. The text reaches for an image any villager would know: an internal tumour is “like a water bubble floating and moving about within a cavity of the body, without any fixed root of its own.” No captured flesh, no captured blood — therefore nothing to suppurate. The swelling is real, but it is a swelling of wind and pressure, not of transformed tissue.

Bhishagratna’s notes preserve the discussion’s finer grain: the little word api (“also”) in the verse, the commentators observe, quietly admits the exception — a Gulma that has entangled itself with local flesh may indeed suppurate; and Charaka’s Gulma chapter (Chikitsa Sthana, Chapter V) is cited for the signs that ripening has begun — colic, fever with sleeplessness, distaste for food, a sense of oppression. Two thousand years before histology, physicians were distinguishing masses by what they are made of, arguing the borderline cases, and citing each other across schools. That is the discipline of differential diagnosis, fully formed.

Asthigata Vidradhi: When Disease Reaches the Bone

The abscess chapter’s last word (IX.25–26) is its darkest and most precise. Some suppurations, the text says, are to be declined: an internal abscess ripening “about the heart, the bladder or the umbilicus,” or one of the Tridosha type, “should be given up as incurable” — the honest triage that runs through the whole Nidana Sthana. And then the deepest case of all: the suppuration that “generally affects the underlying bone, and is sometimes found to affect the marrow.”

The description that follows is unforgettable. The suppurated marrow, “failing to find an outlet on account of the compactness of the local flesh and bone, produces a sort of burning sensation confined to the bone, like a blazing fire” — a piercing torment, the text adds, that wears the patient down “for a considerable length of time.” Only an incision into the affected bone reveals the truth: a discharge unlike any other — “thick, white, cold and glossy,” fat-like to the eye. This, say “men learned in the knowledge of the Medicinal Shastras,” is Asthighata-Vidradhi (the reading Asthigata — “gone to the bone” — is the familiar form), an affliction of all three doshas, each contributing its own signature of pain.

What the passage records — deep bone pain of a burning, imprisoned character; a long indolent course; a thick pale discharge reached only by opening the bone — is a portrait of deep bone suppuration drawn entirely from observation, centuries before imaging. It belongs beside the goat’s-liver prescription for night-blindness and the fluid-thrill sign of the Udara chapter in the ledger of classical bedside observations that still read true. And with it Chapter IX closes — “Thus ends the ninth Chapter of the Nidana Sthanam in the Sushruta Samhita” — its study of the abscess complete.

Visarpa: The Disease Named for Its Movement

Chapter X opens with a definition built, like the best classical definitions, out of a verb. The deranged doshas — Vayu, Pitta and Kapha — “having recourse to, and affecting the Tvaka (skin), blood and flesh, speedily give rise to a sort of shifting, elevated swelling (Shotha)” whose signs follow whichever dosha leads. And then the etymology, given in the text itself: “The disease is called Visarpa from the fact of its extending or swiftly shifting character” — from the Sanskrit root srip, to creep, to glide, to go. Visarpa is, literally, the creeper: the swelling that will not stay where it began, that “tends to extend all over the body.”

Here is a small marvel of the history of medicine. Half a world away, Greek physicians watched the same clinical picture — a hot, raised, angry redness of the skin advancing at a visible margin — and named it erysipelas, “red skin,” a name whose folk descendants (“the rose,” “St. Anthony’s fire”) chase the same spreading flame. Two traditions, no contact we can prove, one identical act of naming-by-behaviour: the Sanskrit tradition named the movement, the Greek named the colour, and both were describing the fact that this disease travels. When Bhishagratna glosses Visarpa as “erysipelas,” he is joining two bedside observations across two millennia and five thousand kilometres.

The definition also quietly fixes the disease’s address: skin, blood, flesh — tvak, rakta, mamsa. In the seven-dhatu architecture of the body, Visarpa is a disease of the outer and middle stations — which is exactly why it can be seen to creep, and why the chapter that studies it can afford such confident visual detail.

Srip — to creep: the vine’s advance across the stone is the exact image inside the word Visarpa, the disease named for its movement

Vataja, Pittaja and Kaphaja Visarpa

As everywhere in the Nidana Sthana, the disease then refracts through the doshas — and the three portraits (X.3–5) are drawn with the economy of a field guide.

The Vataja Visarpa is rough and dusky: the swelling “is rough and assumes a black colour, attended with an aching pain in the limbs and a piercing pain in the affected locality,” the whole picture “marked by all the usual symptoms of Vatika fever.” The text adds its first triage note at once: a case in which the vitiation runs to extremes — where “flame-coloured bulbs,” vesicles, erupt on the part — “should be given up as incurable.”

The Pittaja Visarpa is the fire-form: it “rapidly extends over the body, attended with fever, a burning sensation, severe suppuration and the destruction of the local flesh and veins,” while “a large number of vesicles appears on the skin” and a great spot spreads “blood-red in colour.” It is the closest of the five to the picture that made Greek physicians reach for the word “fire.”

The Kaphaja Visarpa moves in the opposite tempo: it “extends slowly,” its suppuration “is tardy,” and the affected part “becomes white, glossy and swollen, marked by a slight pain and excessive itching” — heaviness and slowness, the Kapha signature, written on the skin. But slowness is not safety: when Kapha and Pitta together run to the extreme and the swelling takes on “a collyrium-like black colour,” that case too is to be regarded as incurable. Speed, colour, pain, itch, temperature — five observable axes, and each type sits at its own coordinates. This is the same diagnostic grammar our series has met in the eighteen kushthas and the twenty pramehas — the classical conviction that if you observe finely enough, the dosha announces itself.

Sannipatika and Kshataja Visarpa: The Grave Forms

Two forms remain, and both belong to the chapter’s shadowed side. The Sannipatika Visarpa — the Tridoshaja type — is “deep-seated,” “assumes all colours, and is attended with all sorts of pain peculiar to the three aforesaid types.” In its suppurating stage “the local flesh and veins are destroyed,” and the verdict is unflinching: it “should be looked upon as incurable.” When every dosha speaks at once, the text hears a case beyond its own medicine — the same honest triage the tradition applies everywhere, from the abscess seats to the fatal sinus we will meet below.

The fifth form is the surgeon’s own: the Kshataja Visarpa, the visarpa of a wound. In a person whose Pitta is extremely aggravated, the text says, the disease may take its start from an injury — the swelling “assumes a reddish-brown colour,” is “covered with black vesicles the size of Kulattha pulse,” and comes on “with high fever and a burning sensation.” That a breach in the skin can open the door to a rapidly spreading, fevered redness around it is a clinical sequence every modern reader recognises at once; Sushruta not only records it but gives it separate standing as a named type. The prognosis verse (X.8) then rules across all five with a symmetry the tradition loves: the Vataja, Pittaja and Kaphaja are curable; the Sannipatika and Kshataja are unfavourable — and any Visarpa that “attacks the vital parts (Marmas) of the body can be cured only with the greatest difficulty.” Bhishagratna’s margin preserves one more voice: a variant reading in the commentaries holds that a Visarpa of golden-yellow colour, born of deranged Pitta, is likewise beyond help — the living argument again, disputing even the colours of death.

Nadi Vrana: How Neglect Digs a Channel

The chapter’s second subject begins with a small moral tale hidden inside a definition (X.9–10). A swelling has suppurated; the pus is ripe. And then — nothing is done. The patient, “dubious of its being so conditioned,” hesitates, “or even neglects to open a fully suppurated abscess.” The pus, denied its outlet, makes one: it “burrows into the affected part,” boring a track through the tissues. The result is a wound with a hidden interior — called Gati Vrana, the “wound with a passage,” from its excessive infiltration of pus, “and it is also called a Nadi-vrana owing to the presence of a large number of recesses or cavities in its inside.”

Nadi is one of Sanskrit’s great words — the tube, the pipe, the reed, the channel; the same word the tradition uses for the body’s subtle conduits and the pulse a physician reads at the wrist. Its use here is exact and grim: the sinus is a pipe, a false channel the disease has plumbed into the body, discharging at the surface while its root lies out of sight. And the aetiology carries an unmistakable lesson in responsibility: this disease is not sent by season or constitution alone — it is, in the paradigm case, manufactured by delay. The Nidana Sthana rarely moralises, but here cause and character meet: hesitation, doubt and neglect are listed among the true nidanas of the sinus. A surgeon’s chapter, indeed — written by the tradition that taught, in its operative sections, exactly when boldness is the safer path.

Nadi — the reed, the pipe, the channel: the sinus is a false pipe the disease plumbs into the body, and the thorn on the dish is the chapter’s final culprit

The Five Sinuses of the Sushruta Samhita

The classification follows (X.11–15), and by now the reader of this series could almost write it unaided — yet each portrait carries a detail worth pausing on, and one of them hides a genuine bedside subtlety: the sinuses are distinguished not only by the look of their discharge but by its timetable.

The Vataja sinus is “rough and short-mouthed,” aching within, and exudes a frothy secretion “which becomes greater at night.” The Pittaja announces itself with thirst, lassitude, heat and piercing pain; fever attends it from the first, and it discharges “a large quantity of hot and yellow-coloured secretion which is more by day than by night.” The Kaphaja grows hard, itches, hurts only dully, and secretes “a copious quantity of thick, shiny, white-coloured pus which becomes greater at night.” Day-worse or night-worse, thin froth or thick white, hot yellow or cold glossy — the physician is being taught to diagnose a hidden channel by sitting with it through a day and a night. It is diagnosis by rhythm, in a tradition that elsewhere reads the whole year’s rhythm into the body.

Then the margin speaks. The text as received describes the Dvandvaja sinuses — those born of two doshas in concert — but Bhishagratna’s notes record that the commentator Gayadasa would have none of it: he “rejected as spurious” the two-dosha types, reading the chapter as giving five sinuses only. A classical commentator, weighing manuscript against doctrine and striking a whole class of disease from the canon — textual criticism practised on a medical text, a thousand years and more before the word “philology.” The Tridoshaja sinus, by contrast, stands undisputed and dreadful: exhibiting the marks of all three types, “attended with fever and a burning sensation, difficult breathing, dryness of the mouth and syncope,” it “should be regarded as fatal, casting around the gloom of death.” The gloom is not rhetoric; it is the same honest boundary-drawing that closed the Visarpa section.

Salyaja: The Splinter the Body Cannot Forget

The fifth sinus (X.16) belongs entirely to the surgeon, and it may be the most quietly prescient passage in the chapter. A Salyaja Nadi-vrana arises when “foreign matter (Salya) — such as dirt, bone, a splinter of wood — lodged within the body, invisible to the eye, tends to burst open the skin of the locality along the channel of its insertion and gives rise to a type of sinus.” Its character: “a constant pain,” and a discharge that comes “suddenly and rapidly — hot, blood-tinged, agitated, frothy.”

Salya — the dart, the arrow, the thorn, the foreign body — is the word from which Sushruta’s whole discipline, Shalya Tantra, takes its name; extraction of what does not belong in the body was the founding act of the classical surgeon. And here that founding insight is stated as diagnostic doctrine: a discharging track that will not close has a cause hidden inside it — something retained, invisible, still working. Modern surgery teaches its students the very same rule about sinuses that persist: look for what remains within — retained material of any kind — because until the hidden cause is found and removed, the channel it feeds will keep discharging. A first-year surgical trainee today, asked why a wound track refuses to close, is expected to give Sushruta’s answer. The observation sits comfortably in the same ledger as the goat’s-liver night-blindness prescription and the water-drum sign — classical bedside conclusions that the centuries have only underlined.

Stana Roga: The Breast Enters the Ledger

The chapter’s third movement opens with an economy that tells us the hard classificatory work is already done: the diseases of the breast, says the text (X.17–19), “may be divided into as many types as the aforesaid Nadi-Vrana, and are caused by the same exciting factors.” The forms of disease repeat; what is new is the terrain — and it is in describing the terrain that the passage becomes remarkable.

Why, the text asks implicitly, does the breast sicken when it does? The answer is an anatomical observation about the milk-carrying ducts. In a woman who has not borne a child, “the milk-carrying ducts remain closed,” barring the doshas’ descent into the organ’s depth. In the mother, “such ducts open and expand of their own accord” — and with the opening comes vulnerability, “thus making possible the advent of the diseases peculiar to the breast.” Open channels nourish; open channels also admit. The clinical shadow of this verse is familiar to every modern reader — it is around childbirth and feeding, when the ducts are open and working, that the breast’s troubles cluster — and the classical explanation, argued purely from the logic of channels (srotas), lands on the same association by observation alone.

Note also what the passage is doing in the architecture of the book. Sushruta has spent nine chapters on diseases that afflict any body. Here, for a moment, the Nidana Sthana turns to the female body specifically — not as an afterthought but with its own aetiology, its own anatomy of risk, and, in the verses that follow, the tradition’s most careful writing about the substance that makes the breast what it is.

Stanya: Milk as the Finest Essence of Rasa

What is milk? The text’s answer (X.20) is a miniature of the whole classical physiology: “The sweet essence of the digested food, drawn from the whole body where it courses, is ultimately concentrated in the breast of a mother, which is called milk.” Milk, that is, is rasa — the nutrient fluid, first and subtlest of the seven dhatus, the body’s distillation of everything eaten — gathered, refined and redirected outward as nourishment for another body. The mother’s food becomes the mother’s essence becomes the child’s food: a three-step chain that makes the kitchen the first nursery, and explains at a stroke why the tradition’s milk doctrine and food doctrine take nursing mothers as a special case throughout.

Then a subtler question: if milk is made from the body’s whole essence, where is it before it flows? The text’s answer (X.21) reaches for the tradition’s standard example of a substance really present yet nowhere visible: milk’s character, it says, “lies hidden and invisible in the organism, like semen, permeating it in a subtle or essential form.” Shukra and stanya — the generative essence and the nourishing essence — are the classical pair of vyapi substances: pervading the whole body, condensing to visibility only at their moment and their gate. One may smile at the physiology, but the question it answers is a real one — and the doctrine of a pervasive essence summoned to a location is the tradition’s honest account of a genuinely puzzling everyday fact: that milk is not stored like water in a jar, but arrives.

The terminus of rasa — in the classical reading, the mother’s kitchen and the mother’s milk are two stations of one journey of nourishment

The Verse of the Mother’s Love

And what summons it? Here the chapter delivers its most beautiful verse (X.21–22), and it deserves to be quoted at length. Just as the emotions of a man are the cause of the emission of his generative essence, says the text, “so the fondest love of a mother for her children brings about the secretion of her breast-milk. The milk is dislodged and flows out at the sight, touch, or recollection — the very thought — of the child.”

Read that again, slowly. The claim is precise: the trigger for the flow of milk is not suckling pressure, not fullness, not will — it is the mother’s feeling for the child, operating through sight, through touch, and even through memory alone. Every nursing mother knows the phenomenon; modern physiology has given it a name — the let-down reflex — and an account: the sight, sound, touch or mere thought of the infant can set off the cascade that releases the stored milk, which is why the reflex famously fires when a mother simply hears a baby cry in another room. The mechanism belongs to modern science; the observation — that milk answers to love and to the thought of the child, sight unseen — sits complete in a Sanskrit verse some two thousand years old. It is, of all the classical anticipations our series has gathered, the most humane: not a surgical insight or a chemical one, but a piece of exact attention paid to mothers — by a medical text patient enough to watch one, and honest enough to write down what actually happens.

The verse also completes the chapter’s hidden design. Visarpa taught how disease travels; the nadi taught how neglect travels; and stanya teaches how care travels — from feeling, through the body’s subtlest channels, to another person. The physician who began the chapter watching a redness creep across skin ends it watching love move milk. That is the Nidana Sthana’s range in eight pages.

Stanya Pariksha: Reading Milk in a Bowl of Water

From the lyrical, the text turns instantly practical (X.23–24): if milk is the child’s whole food, its quality must be knowable — and the instrument the tradition reaches for is a bowl of clear water. Drop the milk in, and watch.

The design of the test rewards a moment’s admiration. Water gives the examiner three readouts at once — density (float, sink, or blend), colour (the streaks against a clear ground) and texture (thin, thick, slimy) — and the three doshic signatures land neatly on the three axes: light Vayu floats, sharp Pitta stains, heavy Kapha sinks. Healthy milk is defined not by any spectacular sign but by unremarkableness — it simply merges, sweet and faintly grey, with nothing to report. The same doshic grammar that read the visarpas by colour and the sinuses by timetable here reads a fluid by its behaviour in water; one diagnostic language, applied without strain to skin, wound and nourishment alike. The text adds a last, sober cause to the list: an external blow or hurt (Abhighata), too, may vitiate the milk — even here, the surgeon’s eye for trauma. The Kashyapa Samhita, the classical tradition’s pediatric compendium, would go on to make stanya-pariksha and the correction of vitiated milk one of its great themes — the bowl of water standing at the head of a whole classical literature of infant nutrition.

Stanya pariksha — pure milk, says the text, “instantly mixes with water”: density, colour and texture read in one vessel

The Breast Abscess: Five of the Six

The chapter closes (X.25) by joining its third subject back to the ninth chapter, with a precision that is easy to read past. The bodily doshas, “having recourse to the breasts of a woman, whether filled with milk or not, and vitiating the local flesh and blood, give rise to mammary diseases” — and of the six abscesses catalogued in the Vidradhi chapter, “all the types excepting the one called Raktaja are found to attack the mammae, their symptoms identical with those of external abscesses.”

Five of the six — and the excepted one is telling. The Raktaja Vidradhi, in this chapter’s own doctrine, is the abscess of vitiated blood whose paradigm case is the Makkalla of the newly delivered mother, seated low in the body where the unexpelled blood pools. The classification declines to duplicate it in the breast: each disease keeps its proper seat, each seat its proper diseases. It is a small verse, but it shows the system’s joints working — chapters cross-referencing each other, categories imported wholesale where they fit and trimmed where they do not. “Thus ends the tenth Chapter of the Nidana Sthanam in the Sushruta Samhita” — its record of the aetiology and signs complete: three subjects, one grammar of channels, and a bowl of water at the centre.

What This Chapter Is — and What It Is Not

A close reading owes its reader honesty about categories. Visarpa is not simply “erysipelas” in the modern chart-heading sense: the classical category is wider, organised by dosha and behaviour rather than by cause, and Bhishagratna’s gloss is a translator’s bridge, not an identity. The same holds for the sinus and for the breast conditions of these verses: the classical and modern maps overlap without coinciding, and this article walks the classical map only — as scholarship and the history of medicine, never as diagnosis.

And one thing must be said plainly, precisely because this chapter’s diseases still exist. A hot redness of the skin that spreads — especially with fever; a wound or track that keeps discharging; any new lump, pain, redness or warmth of the breast — these belong today to urgent, qualified modern medical care, where the outcomes are excellent in exact proportion to how early they are sought. The classical texts themselves would endorse the instruction: their entire triage doctrine — curable, difficult, to be declined — is a two-thousand-year argument for going early, while the case is simple. Nothing in this article, and no product anywhere, replaces that. If any sign in this paragraph describes you or someone near you, please see a doctor now.

Twak and Snana: Ordinary Care of Ordinary Skin

Step back from the chapter’s dramas, and what remains for daily life is the terrain they all crossed: twak, the skin — the surface the Nidana Sthana reads like a page. The tradition’s everyday counsel for that surface lives not in its disease chapters but in its gentlest ones: the food doctrines that nourish from within, and the snana — the unhurried daily bath — that cleanses without punishing: cool water, mild earths, rose, a soft cloth, and regularity above all. Ordinary, intact, healthy skin asks only for ordinary kindness — cleansing that respects it, a little care after, and attention paid in the classical spirit: noticing early, so that small things stay small.

Snana — the daily bath of the classical routine: mild earth, rose and clean water, the unhurried care of ordinary skin

That is the whole, honest place for any of this: a few small, ordinary comforts within a well-kept day. The chapter above is classical surgical scholarship; the products are everyday cosmetic care, offered with no medical claim of any kind.

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