Changes

==== Contemporary understanding of ''gulma'' ====

==== Contemporary understanding of ''gulma'' ====

In Ayurveda, a comprehensive description is given for abdominal swellings. While the generalized swellings have been described under the heading of udara roga (ascites), localized inflammatory swellings are described under the heading of vidradhi. However, there are other varieties of localized abdominal lumps which are non inflammatory in nature and are considered primarily under the heading of gulma.

In Ayurveda, a comprehensive description is given for abdominal swellings. While the generalized swellings have been described under the heading of ''udara roga'' (ascites), localized inflammatory swellings are described under the heading of ''vidradhi''. However, there are other varieties of localized abdominal lumps which are non inflammatory in nature and are considered primarily under the heading of ''gulma''.

On analyzing the features described by Charaka, it appears that the vataja gulma are irregular, mobile swellings of waxing and waning nature and are associated with pain of different characters. Such features can be seen in conditions like chronic intestinal obstructions of various etiology, intestinal tuberculosis, pyloric stenosis, mobile caecum etc. The treatment modalities like snehan, swedana and basti/vamana help in alleviating the symptoms by elimination of faeces and flatus as well as improving the gut motility.

On analyzing the features described by Charaka, it appears that the ''vataja gulma'' are irregular, mobile swellings of waxing and waning nature and are associated with pain of different characters. Such features can be seen in conditions like chronic intestinal obstructions of various etiology, intestinal tuberculosis, pyloric stenosis, mobile caecum etc. The treatment modalities like ''snehana, swedana'' and ''basti/vamana'' help in alleviating the symptoms by elimination of feces and flatus as well as improving the gut motility.

Pittaja gulma have been described as tender abdominal lumps associated with fever, thirst, burning sensation etc. which usually progress through various stages of inflammation i.e. ama-avastha and pachyaman avastha and finally suppurate.  

''Pittaja gulma'' have been described as tender abdominal lumps associated with fever, thirst, burning sensation etc. which usually progress through various stages of inflammation i.e. ''ama-avastha'' and ''pachyamana avastha'' and finally suppurate.  

It is mentioned that the pittaja gulma situated in antarbhag (inside i.e. intra-abdominal) can produce swelling in the hrid pradesh (upper abdomen) and when suppurate, may penetrate into the adjacent mahasrotas i.e. gastrointestinal tract and burst open culminating with discharge of pus either through oral or rectal route. The discharge of pus may usually continue for a couple of weeks (ten to twelve days) during which, no aggressive measure should be taken except that the nutritional status of the patient should be managed by proper diet.  

It is mentioned that the ''pittaja gulma'' situated in ''antarbhaga'' (inside i.e. intra-abdominal) can produce swelling in the ''hrid pradesha'' (upper abdomen) and when suppurate, may penetrate into the adjacent ''mahasrotas'' i.e. gastrointestinal tract and burst open culminating with discharge of pus either through oral or rectal route. The discharge of pus may usually continue for a couple of weeks (ten to twelve days) during which, no aggressive measure should be taken except that the nutritional status of the patient should be managed by proper diet.  

On examining these features, these can be correlated with clinical condition like empyema of gall bladder which may adhere and penetrate into the adjacent organs like stomach, duodenum or colon and may burst open into the lumen leading to the discharge of pus either through oral or rectal route. Similarly, a subphrenic abscess or liver abscess may rupture into the pleural cavity and may result into discharge of pus during coughing. In addition, suppurative pathologies of pelvic organs leading to pelvic abscesses and a diverticular abscess may erode into rectal lumen and result into pus discharge through rectum.

On examining these features, these can be correlated with clinical condition like empyema of gall bladder which may adhere and penetrate into the adjacent organs like stomach, duodenum or colon and may burst open into the lumen leading to the discharge of pus either through oral or rectal route. Similarly, a subphrenic abscess or liver abscess may rupture into the pleural cavity and may result into discharge of pus during coughing. In addition, suppurative pathologies of pelvic organs leading to pelvic abscesses and a diverticular abscess may erode into rectal lumen and result into pus discharge through rectum.

   

   

The other variants of gulma that is bahistha (externally located) may present with a visible swelling over the surface of abdomen usually in the flanks. These inflammatory pathologies seem to be located extraperitoneally or in the wall of abdomen. Ileopsoas or iliac abscess, perinephric abscess are some of the examples. Some other clinical conditions like infected urachal cyst or infected vitellointestinal duct cysts may also resemble with bahistha pittaja gulma.

The other variants of ''gulma'' that is ''bahistha'' (externally located) may present with a visible swelling over the surface of abdomen usually in the flanks. These inflammatory pathologies seem to be located extraperitoneally or in the wall of abdomen. Ileopsoas or iliac abscess, perinephric abscess are some of the examples. Some other clinical conditions like infected urachal cyst or infected vitellointestinal duct cysts may also resemble with ''bahistha pittaja gulma''.

The features described in kaphaja gulma like a firm, fixed, elevated, non-tender lump are comparable to solid mass lesions of the abdomen. Charaka has also added that these lumps can be treated surgically and a detailed surgical procedure has been described as under.  

The features described in ''kaphaja gulma'' like a firm, fixed, elevated, non-tender lump are comparable to solid mass lesions of the abdomen. Charaka has also added that these lumps can be treated surgically and a detailed surgical procedure has been described as under.  

An earthen pitcher (ghati) of suitable size is taken and fire is put inside for a while. Once the fire is extinguished, the pitcher is placed over the gulma in upside down position. This creates a negative pressure inside the earthen pitcher resulting a part of the gulma to gradually move inside the pitcher. The pitcher is separated after a while. As the mass has risen above rest of the surface of abdominal wall sufficiently, a tourniquet is tied firmly at the narrow part i.e. the base of the gulma for further surgical procedure. Tying of tourniquet at the base of gulma facilitate proper holding as well as minimize bleeding during surgical procedure. An incision is made and the gulma is compressed firmly by vimarga yantra (a wooden instrument to apply pressure). The contents of gulma are removed by scrapping with the help of other yantras like ajpada and adarsha (ref. commentary by Yogindranath Sen). During this procedure, he has cautioned not to injure aantra (gut) or hridaya (vital organ).

An earthen pitcher (''ghati'') of suitable size is taken and fire is put inside for a while. Once the fire is extinguished, the pitcher is placed over the ''gulma'' in upside down position. This creates a negative pressure inside the earthen pitcher resulting a part of the ''gulma'' to gradually move inside the pitcher. The pitcher is separated after a while. As the mass has risen above rest of the surface of abdominal wall sufficiently, a tourniquet is tied firmly at the narrow part i.e. the base of the ''gulma'' for further surgical procedure. Tying of tourniquet at the base of ''gulma'' facilitate proper holding as well as minimize bleeding during surgical procedure. An incision is made and the ''gulma'' is compressed firmly by ''vimarga yantra'' (a wooden instrument to apply pressure). The contents of ''gulma'' are removed by scrapping with the help of other ''yantras'' like ''ajpada'' and ''adarsha'' (ref. commentary by Yogindranath Sen). During this procedure, he has cautioned not to injure ''aantra'' (gut) or ''hridaya'' (vital organ).

This surgical technique suggests that kaphaja gulma includes the benign lesions of the abdominal wall, epigastric or paraumbilical hernia containing extraperitoneal fat or omentum etc.

This surgical technique suggests that ''kaphaja gulma'' includes the benign lesions of the abdominal wall, epigastric or paraumbilical hernia containing extraperitoneal fat or omentum etc.

In addition to above varieties of gulma, a tridoshaja gulma is also described which is considered as incurable. The features described like an elevated, stony hard lump with excessive pain and burning sensation and loss of vitality suggest more towards a malignant tumor of the abdomen. Moreover, the bad prognostic characters defined for an incurable gulma viz. a gradually increasing, deep rooted, elevated hard mass like a turtle shell which is associated with visibly engorged vessels and poor general condition like generalized oedema, loss of appetite, cough, vomiting, persistent fever etc. point more towards an advanced malignant lesion of abdomen e.g. hepatoma or the metastatic involvement of liver or other solid malignant tumors of abdominal organs.

In addition to above varieties of ''gulma'', a ''tridoshaja gulma'' is also described which is considered as incurable. The features described like an elevated, stony hard lump with excessive pain and burning sensation and loss of vitality suggest more towards a malignant tumor of the abdomen. Moreover, the bad prognostic characters defined for an incurable ''gulma'' viz. a gradually increasing, deep rooted, elevated hard mass like a turtle shell which is associated with visibly engorged vessels and poor general condition like generalized edema, loss of appetite, cough, vomiting, persistent fever etc. point more towards an advanced malignant lesion of abdomen e.g. hepatoma or the metastatic involvement of liver or other solid malignant tumors of abdominal organs.

In conclusion, vataja gulma are mobile swellings of waxing and waning nature due to partial obstructive lesions of gut lumen. Pittaja gulma are intraperitoneal or extraperitoneal inflammatory or suppurative lesions of abdomen whereas the kaphaja gulma are non inflammatory benign lesions of abdominal wall. Tridoshaja gulma seems to be malignant intraabdominal lesions with poor prognosis.

In conclusion, ''vataja gulma'' are mobile swellings of waxing and waning nature due to partial obstructive lesions of gut lumen. ''Pittaja gulma'' are intraperitoneal or extraperitoneal inflammatory or suppurative lesions of abdomen whereas ''kaphaja gulma'' are non inflammatory benign lesions of abdominal wall. ''Tridoshaja gulma'' seems to be malignant intra-abdominal lesions with poor prognosis.

==== Sites of gulma ====

==== Sites of gulma ====