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→Vidhi Vimarsha
=== ''Vidhi Vimarsha'' ===
=== ''Vidhi Vimarsha'' ===
A comprehensive effort has been made in Ayurveda to describe different types of swellings occurring in the body e.g. ''gulma, udara roga, vriddhi roga, granthi, arbuddha, shopha,'' and ''vidradhi'' etc. They can be distinguished from each other according to their specific characteristics as written in different classics of Ayurveda. Generalized abdominal swellings have been described under the heading of ''udara roga'' (abdominal diseases including ascitis), while localized, non-suppurated swellings are ''gulmas''. Other localized swellings, such as ''vriddhi roga'' (hernia and hydrocele), have also been described by ancient authors but such swellings are in regions other than the gastro-intestinal region, or in parts of the body such as the scrotal and inguinoscrotal region. ''Shopha'' is a localized inflammatory swelling. ''Vidradhi'' (abscess) are also localized but large suppurative lesions and are deep - rooted that may develop either from external surfaces or internal body cavities. ''Granthi'' (cyst) and ''arbuda'' (tumor) are also localised, progressively increasing knotty lesions and are primarily non suppurative in nature. Such swellings may arise in any part of the body and are commonly known as neoplastic lesions.
A comprehensive effort has been made in Ayurveda to describe different types of swellings occurring in the body e.g. ''gulma, udara roga, vriddhi roga, granthi, arbuddha, shopha,'' and ''vidradhi'', etc. They can be distinguished from each other according to their specific characteristics as written in different classics of Ayurveda. Generalized abdominal swellings have been described under the heading of ''udara roga'' (abdominal diseases including ascitis), while localized, non-suppurated swellings are ''gulmas''. Other localized swellings, such as ''vriddhi roga'' (hernia and hydrocele), have also been described by ancient authors but such swellings are in regions other than the gastro-intestinal region, or in parts of the body such as the scrotal and inguinoscrotal region. ''Shopha'' is a localized inflammatory swelling. ''Vidradhi'' (abscess) are also localized but large suppurative lesions and are deep - rooted that may develop either from external surfaces or internal body cavities. Granthi (cyst) and arbuda (tumor) are also localized, progressively increasing knotty lesions and are primarily non suppurative in nature. Such swellings may arise in any part of the body and are commonly known as neoplastic lesions.
==== Etiopathogenesis of ''gulma'' ====
==== Etiopathogenesis of ''gulma'' ====
In [[Charaka Samhita]], vitiated ''vata dosha'' is considered as major aetiological factor for the development of any type of ''gulma''. Amongst the five types of ''vata'' mentioned in [[Charaka Samhita]], vitiated ''apana'' and/or ''samana vata'' seem to be the primary etiological factors of ''gulma'', since these are mainly responsible for the normal physiological functions of ''mahastrotas''. The prodromal symptoms of ''gulma'' also point towards these two e.g. aversion to food, anorexia, and diminished urge to pass flatus, urine and feces.
In [[Charaka Samhita]], vitiated ''vata dosha'' is considered as major etiological factor for the development of any type of ''gulma''. Among the five types of ''vata'' mentioned in [[Charaka Samhita]], vitiated ''apana'' and/or ''samana vata'' seem to be the primary etiological factors of ''gulma'', since these are mainly responsible for the normal physiological functions of ''mahastrotas''. The prodromal symptoms of ''gulma'' also point towards these two e.g. aversion to food, anorexia, and diminished urge to pass flatus, urine and feces.
In [[Chikitsa Sthana]], Charaka states that ''vata'' gets vitiated by two basic means i.e. ''dhatukshaya'' (tissue wasting) and ''margavarana'' (obstruction)<ref> CH Chi 28/58 </ref>. The etiology given in this chapter could also include excess consumption of food with ''ruksha guna'', trauma and faulty ''shodhana'' procedures, excessive loss of ''mala'' and ''dhatu'' responsible for ''dhatukshaya'' and various other factors that vitiate ''doshas'' and ''mala'' causing obstruction of different channels, further aggravating ''vata''.
In [[Chikitsa Sthana]], Charaka states that ''vata'' gets vitiated by two basic means i.e. ''dhatukshaya'' (tissue wasting) and ''margavarana'' (obstruction). The etiology given in this chapter could also include excess consumption of food with ''ruksha guna'', trauma and faulty ''shodhana'' procedures, excessive loss of ''mala'' and ''dhatu'' responsible for ''dhatukshaya'' and various other factors that vitiate ''doshas'' and ''mala'' causing obstruction of different channels, further aggravating ''vata''.
While analyzing the definition given by various Acharyas regarding ''gulma'' it can be stated that it is the clinical condition in which only solidification of ''doshas'' give rise to ''gulma''. It is believed that, for the development of any other disease, vitiated ''dosha''(s), together with ''dushya'' need to accumulate at a specific site leading to development of the disease. Therefore for the development of any disease, a combination of ''dosha'' and ''dushya'' is critical. However for ''gulma'', only vitiated ''doshas'' are responsible and there is no involvement of ''dushya''. This is a unique feature of pathogenesis of ''gulma''. Sushruta has explained further that just as water bubbles appear and disappear when rain drops fall on water, ''gulmas'' appear and disappear. Also, in the absence of any ''dushya'' (''dhatu'' and ''mala''), these swellings are commonly non-suppurative in nature<ref> Su Utt 42/6-7 </ref>. There are, however, some cases where suppuration may take place. For example, in [[Chikitsa Sthana]], Charaka has mentioned that suppuration may takes place in ''pittaja'' ''gulma'' and further elaborates the various stages of suppuration of ''gulma'' i.e. ''ama'' (immature or initial stage), pachyamana (intermediary stage) and pakwa awastha (final mature stage) etc. similar to the stages seen in various suppurative conditions like ''vidradhi''. Chakrapani commented that when the ''pitta gulma'' is not treated timely, ''pitta dosha'' and ''rakta dhatu'' get aggravated (together or separately), and involves the deeper structure (''kritmulam'').
While analysing the definition given by various Acharyas regarding gulma it can be stated that it is the clinical condition in which only solidification of doshas give rise to gulma. It is believed that, for the development of any other disease, vitiated dosha(s), together with dushya need to accumulate at a specific site leading to development of the disease. Therefore for the development of any disease, a combination of dosha and dushya is critical. However for gulma, only vitiated doshas are responsible and there is no involvement of dushya. This is a unique feature of pathogenesis of gulma. Sushruta has explained further that just as water bubbles appear and disappear when rain drops fall on water, gulmas appear and disappear. Also, in the absence of any dushya (dhatu and mala), these swellings are commonly non-suppurative in nature. There are, however, some cases where suppuration may take place. For example, in Chikitsasthana, Charaka has mentioned that suppuration may takes place in pittaja gulma and further elaborates the various stages of suppuration of gulma i.e. ama (immature or initial stage), pachyamana (intermediary stage) and pakwa awastha (final mature stage) etc. similar to the stages seen in various suppurative conditions like vidradhi. Chakrapani commented that when the pittagulma is not treated timely, pitta dosha and rakta dhatu get aggravated (together or separately), and involves the deeper structure (kritmulam).
Shadkriyakala (lifecycle) of Gulma:
a. Sanchaya- Vata accumulates in vatasthana (pakwashaya, or the intestines) with the consumption of vatika food and activities such as excessive exercise, suppressing emergent urges etc., further aggravating it.
b. Prakopa- Consumption of ruksha, khara and sheeta food for prolonged periods of time reduces the snigdha quality of strotas while stimulating excess vata to overflow from its sthana.
c. Prasara-In this stage aggravated vata dislodges from its accumulated site and spreads all over the body.
d. Sthanasanshraya- This is the stage in which the dosha stays at a particular locus and comes in contact with dushya. In case of gulma, the mahastrotas are the principal loci, with an absence of dushya in their formation. The vitiated vata and other doshas have an affinity towards specific loci such as hridaya, nabhi, basti etc. to get lodged there. Prodromal symptoms of gulma such as anorexia, aversion for food, weakness etc. also become apparent at this stage.
e. Vyakti- Clinical features of different types of gulma manifest at this stage so management can be done depending upon specific dosha characteristics.
f. Bheda-When the gulma is not treated at the fourth and fifth stage, complications like bradhna roga (inguinal swellig), jwara (fever), vidbheda (loose stools/diarrhoea), and suppuration (in case of pittaja gulma ) occur where surgical intervention could be necessary.
Location of gulma :
With respect to the adhishthana (location) of gulma, five major sites have been mentioned , including the hridaya, nabhi, basti, and parshwadwaya (flanks). In the context of this chapter, hridaya should be taken as the upper part of the abdominal cavity rather than the thoracic cage as described in Sharirasthana. Vata gulma most commonly occurs in basti, while pittagulma occurs most commonly in the nabhi region, and kaphagulma in the hridaya and parshwadwaya regions. The yakrita gulma occurs in the region of hridaya, ashtheela gulma in the region of kukshi (hypogastrium), pleeha gulma in the Madhya (central) region, chandravivardhaka gulma in the region of basti , and granthi gulma afflicts the region of nabhi.
The pathogenesis of pittaja and kaphaja gulma takes place in amashaya that lies in the region between hridaya and basti. Thus these two variants of gulma (i.e., pittaja and kaphaja) cannot occur in basti. The five sites of gulma can be mapped to the following anatomical sites of the abdomen:
Types of gulma Adhisthana Anatomical site Charaka Sushruta Vagbhat Harita
Vataja Basti lower abdomen Does not specify Does not specify Same Not mentioned
Pittaja Nabhi mid Abdomen Does not specify Does not specify same Not mentioned
Kaphaja hridaya upper abdomen Does not specify Does not specify same Not mentioned
parshwadwaya (dakshin parshwa and vama parshwa) right and left flank
Shonitaja garbhashaya and yoni uterus and vagina Same same same Not mentioned
Sannipataja Not specified Not specified Not specified Not specified Not specified Not mentioned
Yakrita gulma hridaya upper abdomen Not mentioned Not mentioned Not mentioned Same
Ashtheela gulma Kukshi mid abdomen Not mentioned Not mentioned Not mentioned Same
Pleeha gulma Madhya bhaga mid abdomen Not mentioned Not mentioned Not mentioned Same
Chandravivardhaka gulma Basti lower abdomen Not mentioned Not mentioned Not mentioned same
Granthi gulma Nabhi umbilical region Not mentioned Not mentioned Not mentioned Same
Prognosis –''Sannipatika gulma'' is incurable, rest four are curable when treated timely.
Prognosis –Sannipatika gulma is incurable, rest four are curable when treated timely.
Management- All the four types of gulma can be managed according to the prevalent doshas. In emergency conditions if there is no time to diagnose the type of gulma, vata dosha should be managed first as it is prevalent in all types of gulma.
Management- All the four types of ''gulma'' can be managed according to the prevalent ''doshas''. In emergency conditions if there is no time to diagnose the type of ''gulma, vata dosha'' should be managed first as it is prevalent in all types of ''gulma''.
Considering the various clinical features of gulma it can be said that the majority of gulmas are non-inflammatory and non-malignant intra-abdominal swellings. But some gulmas show indications of inflammatory swellings, some benign while some show the characteristics of malignant growths.
Vataja gulma-
Vataja gulma are mostly irregular, transitory swellings. These are accompanied with different intensities of colicky pain. Complications like inguinal swelling (bradhna roga) gurgling sound in the intestines (antrakoojana), fever/elevated temperature in the evenings, splenomegaly (pleehavriddhi), difficulty in breathing, bodyache (angamarda), and headache are commonly in the advanced stages of gulma. The above clinical features can be seen in chronic intestinal obstruction, intestinal tuberculosis, pyloric stenosis and in mobile caecum. Intestinal tuberculosis is a chronic condition with common symptoms including transitory nodules of varying sizes occuring due to partial intestinal obstruction, often accompanied with gurgling sounds from the abdomen, poor appetite, and evening fevers, as seen in the advanced stages of vatika gulma. Mobile upper abdominal lump, with nausea and breathing difficulty are the features present in the case of pyloric stenosis. In mobile caecum there is also chronic progressive pain in the right flank and in the lower abdomen.
Pittaja gulma-
They are painful abdominal lumps characterised with fever, sweating, thirst, burning sensations and burning eructations. These features are suggestive of inflammatory and suppurative changes in the intra-abdominal lump. In due course of time, pittaja gulma develops yellow discoloration of nail, eyes and skin, fever, and vertigo as an added complication. These features can be seen in obstructive biliary tract.
Kaphaja gulma-
These are fixed, solid abdominal lumps associated with heaviness, vomiting, mild pain and poor appetite. Further, if the exposure to etiological factors is continued, the patient may develop cough, breathing difficulty and rajayakshma (tuberculosis) etc. Such swellings can be compared with solid tumours of the abdomen which may or may not be associated with obstructive features of the gastrointestinal tract.
Sannipataja gulma –
These swellings are progressively increasing in size, fixed, deep rooted, covered with prominent veins, bulged out, and associated with weakness, nausea, vomiting, fever and thirst. Such features can be seen in malignant abdominal tumours.
Raktaja gulma-
These exhibit symptoms similar to those of pregnancy, so it is essential to differentiate them from the point of view of treatment:
Raktaja gulma Garbha (Pregnancy)
Slight movement may be present in later stage
Some movement is present throughout all trimesters
Size increases progressively and it remains localized Progressive change in size
It may be associated with fever, cough, pain etc. Presence of other constitutional features of pregnancy, including bodily changes
The features of Hydatidiform mole and chorionic carcinoma closely resemble the features of raktaja gulma.
A study was conducted in 50 patients of abdominal swellings, gulmas were analysed using clinical tests and radio-imaging techniques such as plain X ray abdomen, Barium studies, USG, intra-operative findings and HPE of the lumps.
o The study showed that vataja gulma has chronic obstructive lesions associated with gastrointestinal tract as in the cases of intestinal tuberculosis, pyloric obstruction due to carcinoma of the stomach, etc.
o Pittaja gulma includes nonspecific inflammatory lesions such as cholecystitis presenting as mucocele or empyema of gall bladder, appendicitis , etc.
o Kaphaja gulma includes benign lesions such as ovarian cyst, lipoma etc. Some are of specific chronic inflammatory types such as tubercular mesenteric lymphadenopathy.
o Tridoshaja gulma includes most of the malignant lesions of different organs of abdomen, adenocarcinoma of gall bladder, carcinoma ovary etc.
o Raktaja gulma features are found in hydatidiform mole and chorio-carcinoma.
The features of Hydatidiform mole and chorionic carcinoma closely resemble the features of ''raktaja gulma''.
A study was conducted in 50 patients of abdominal swellings, ''gulmas'' were analyzed using clinical tests and radio-imaging techniques such as plain X ray abdomen, Barium studies, USG, intra-operative findings and HPE of the lumps.
=== Table showing different features of gulma ===
=== Table showing different features of gulma ===