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{{#seo:

|title=Gulma Nidana

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|keywords=Gulma, mahasrotas, koshtha, dhatukshaya, avarana, abdominal lumps, intra-abdominal swellings, tumors", Ayurveda, Indian system of medicine, charak samhita.

|description=Nidana Sthana Chapter 3. Diagnosis and etio-pathogenesis of Abdominal lumps

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|image=http://www.carakasamhitaonline.com~~/mediawiki-1.32.1~~/resources/assets/ogimgs.jpg

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|image=http://www.carakasamhitaonline.com/resources/assets/ogimgs.jpg

|image_alt=carak samhita

|type=article

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<big>'''Nidana Sthana Chapter 3. Diagnosis and etio-pathogenesis of Abdominal lumps '''</big>

{{Infobox

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|data4 = [[Sutra Sthana]], [[Vimana Sthana]], [[Sharira Sthana]], [[Indriya Sthana]], [[Chikitsa Sthana]], [[Kalpa Sthana]], [[Siddhi Sthana]]

|label6 = Translator and commentator

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|data6 = Sahu M., Fatmi U., Deole Y. S.

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|data6 = Sahu M., Fatmi U., [[Yogesh Deole|Deole Y. S.]]

|label7 = Reviewer

|data7 = Kar A.C., Gadgil D.

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|label8 = ~~Editor~~

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|label8 = Editors

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|data8 = Khandel S.K., Godatwar P.

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|data8 = Khandel S.K., Godatwar P., [[Yogesh Deole|Deole Y.S.]], [[Gopal Basisht|Basisht G.]]

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|label9 = ~~Date~~ of publication

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|label9 = Year of publication

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|data9 = ~~December 17, 2018~~

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|data9 = 2020

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|label10 = ~~DOI~~

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|label10 = Publisher

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|data10 =

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|data10 = [[Charak Samhita Research, Training and Skill Development Centre]]

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|~~header3~~ =

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|label11 = DOI

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|data11 = [https://doi.org/10.47468/CSNE.2020.e01.s02.004 10.47468/CSNE.2020.e01.s02.004]

}}

<big>'''Abstract'''</big>

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<p style="text-align:justify;">The third chapter describes the etiology, pathogenesis, clinical features and therapeutics of lumps in abdomen. Gulma, a (stable or transitory) growth that could occur anywhere in the body is primarily caused by a vitiated [[vata]]. The description given in the text cannot be correlated with any single entity of conventional medicine, but denotes localized intra-abdominal swellings of multiple origin in terms of their cause, site, features etc. In patients weakened by or recuperating from diseases or cleansing therapies ([[vamana]], etc.), or suffering from very stressful conditions, [[vata]] gets vitiated and enters the mahasrotas (gastrointestinal tract) causing the formation of gulma. Amongst the five types of gulma, sannipatika gulma is incurable whereas remaining can be managed according to [[dosha]] involvement. </p>

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<~~div~~ style="text-align:justify;">The third chapter describes the etiology, pathogenesis, clinical features and therapeutics of lumps in abdomen. Gulma, a (stable or transitory) growth that could occur anywhere in the body is primarily caused by a vitiated vata. The description given in the text cannot be correlated with any single entity of conventional medicine, but denotes localized intra-abdominal swellings of multiple origin in terms of their cause, site, features etc. In patients weakened by or recuperating from diseases or cleansing therapies (vamana, etc.), or suffering from very stressful conditions, vata gets vitiated and enters the mahasrotas (gastrointestinal tract) causing the formation of gulma. Amongst the five types of gulma, sannipatika gulma is incurable whereas remaining can be managed according to dosha involvement. </~~div~~>

'''Keywords''': ''Gulma, mahasrotas, koshtha, dhatukshaya, avarana'', abdominal lumps, intra-abdominal swellings, tumors.

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The word ''gulma'' is derived from the Sanskrit root ''gud'', literal meaning encircling or surrounding. Therefore the word ''gulma'' stands for an entity that encircles, envelops or covers something. According to mythological concepts described in this text, people fleeing from the wrath of Lord Shiva, when he was dismantling Daksha’s holy sacrifice, were afflicted with this disease. This legend is symbolic, since situations such as panic, stress, or grief, usually accompanying such a chaotic, cataclysmic event would lead to vitiation of ''vata'' causing the appearance of ''vata''-dominant diseases like ''gulma'', etc. In [[Ayurveda]], ''gulma'' has been defined as large palpable, rounded, intra- abdominal swellings between ''hridaya'' (upper abdomen) and the ''basti'' (bladder) regions, which develop due to accumulation of ''~~doshas~~'' with predominance of ''vata''. Such swellings are either transitory or static, and display the properties of spontaneous regression and reappearance. ''Gulmas'' are usually non-suppurative and are separate entities from other intra-abdominal swellings such as ''antar vidradhi'' (internal abscesses) where suppuration is often found.

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The word ''gulma'' is derived from the Sanskrit root ''gud'', literal meaning encircling or surrounding. Therefore the word ''gulma'' stands for an entity that encircles, envelops or covers something. According to mythological concepts described in this text, people fleeing from the wrath of Lord Shiva, when he was dismantling Daksha’s holy sacrifice, were afflicted with this disease. This legend is symbolic, since situations such as panic, stress, or grief, usually accompanying such a chaotic, cataclysmic event would lead to vitiation of ''[[vata]]'' causing the appearance of ''[[vata]]''-dominant diseases like ''gulma'', etc. In [[Ayurveda]], ''gulma'' has been defined as large palpable, rounded, intra- abdominal swellings between ''hridaya'' (upper abdomen) and the ''basti'' (bladder) regions, which develop due to accumulation of ''[[dosha]]s'' with predominance of ''[[vata]]''. Such swellings are either transitory or static, and display the properties of spontaneous regression and reappearance. ''Gulmas'' are usually non-suppurative and are separate entities from other intra-abdominal swellings such as ''antar vidradhi'' (internal abscesses) where suppuration is often found.

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The vitiated ''vata'', in conjunction with other ''~~doshas~~'', gets into the ''mahasrotas'' and get lodged either in the ''amashaya'' (stomach), ''pittashaya'' (gallbladder), ''pakwashaya'' (cecum) or in other regions like ''hridaya'' (epigastric), ''basti'' (bladder) and ''nabhi'' (umblicus) leading to formation of deep-rooted shrub-like mass. Here a new term has been introduced i,e, ''mahasrotas'', that could be explained as viscera including organs of the gastrointestinal tract. However, commentators have suggested that it stands for all of abdominal viscera, including the kidneys. Thus it is evident that under the definition of ''mahasrotas'' all the organs in abdomen are included. As mentioned earlier, ''gulma'' afflicts the gastrointestinal region between the heart and the bladder. Depending upon the region it afflicts, it can be classified into four general types common to males and females:

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The vitiated ''[[vata]]'', in conjunction with other ''[[dosha]]s'', gets into the ''mahasrotas'' and get lodged either in the ''amashaya'' (stomach), ''pittashaya'' (gallbladder), ''pakwashaya'' (cecum) or in other regions like ''hridaya'' (epigastric), ''basti'' (bladder) and ''nabhi'' (umblicus) leading to formation of deep-rooted shrub-like mass. Here a new term has been introduced i,e, ''mahasrotas'', that could be explained as viscera including organs of the gastrointestinal tract. However, commentators have suggested that it stands for all of abdominal viscera, including the kidneys. Thus it is evident that under the definition of ''mahasrotas'' all the organs in abdomen are included. As mentioned earlier, ''gulma'' afflicts the gastrointestinal region between the heart and the bladder. Depending upon the region it afflicts, it can be classified into four general types common to males and females:

*''Hridaya'' (epigastric region),

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Besides these, there is a fifth type afflicting only women - ''shonitaja gulma'' of the ''yoni'' region i.e. in the ''garbhashaya'' or uterus region. Such ''gulma'' shows a progressive increase in size and thus requires a special attention to differentiate it from pregnancy.

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While there are ''gulma'' variants like ''paittika'' and ''kaphaja gulma'' caused by an excess of ''pitta'' and ''kapha'' respectively, it is essentially a ''vata'' disorder. ''Sannipatika gulma'' is caused due to the vitiation of all the three ''~~doshas~~''. Since abdominal organs have ''~~mamsadhatu~~'' as the main component, all the ''siragranthi'' (glandular/tumorous) types of ''srotodushti'' (vitiation of channels carrying body components) of abdominal viscera have also been covered under ''gulma''. This chapter also covers obstruction and inflammation of viscera having no swelling.

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While there are ''gulma'' variants like ''paittika'' and ''kaphaja gulma'' caused by an excess of ''[[pitta]]'' and ''[[kapha]]'' respectively, it is essentially a ''[[vata]]'' disorder. ''Sannipatika gulma'' is caused due to the vitiation of all the three ''[[dosha]]s''. Since abdominal organs have ''[[mamsa dhatu]]'' as the main component, all the ''siragranthi'' (glandular/tumorous) types of ''srotodushti'' (vitiation of channels carrying body components) of abdominal viscera have also been covered under ''gulma''. This chapter also covers obstruction and inflammation of viscera having no swelling.

</div>

==Sanskrit Text, Transliteration and English Translation==

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</div></div>

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There are five types of ''gulma''- ''vata'' dominant ''gulma'', ''pitta'' dominant ''gulma'', ''shleshma''/''kapha'' dominant ''gulma'', ''nichaya'' (''tridosha'' dominant) ''gulma'', and ''shonita gulma''.[3]

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There are five types of ''gulma''- ''[[vata]]'' dominant ''gulma'', ''[[pitta]]'' dominant ''gulma'', ''shleshma''/''[[kapha]]'' dominant ''gulma'', ''nichaya'' (''tridosha'' dominant) ''gulma'', and ''shonita gulma''.[3]

=== Agnivesha’s question ===

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Lord Atreya replied, “Agnivesha! Specific characteristics of the five ''gulma'' as well as other diseases are defined on the basis of their etiology, prodromal symptoms, clinical features with various types of pains, and therapeutic applicability.”[5]

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=== Etio-pathogenesis of ''vata''-dominant ''gulma'' ===

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=== Etio-pathogenesis of ''[[vata]]''-dominant ''gulma'' ===

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When a person of ''vatika'' constitution, particularly emaciated due to one of the debilitating factors like fever, emesis, purgation and diarrhoea, consumes ''vata''- aggravating food or excessively cold food, in excessive quantities, or is administered emesis or purgation without prior unction, he vomits profusely and holds up impelling urges of flatus, urine, bowel movement. Or if such a person, after consuming a heavy meal, drinks a lot of fresh water or travels by an excessively jerking vehicle, indulges in excessive sexual intercourse, intensive physical exercise, or drinks alcoholic drinks, or suffers from excessive anxiety, or is subjected to injury or uses uneven postures in sitting, sleeping, standing and walking, or starts some other similar sort of irregular and excessive physical exercises -''vata'' gets vitiated or aggravated. [6]

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When a person of ''vatika'' constitution, particularly emaciated due to one of the debilitating factors like fever, emesis, purgation and diarrhoea, consumes ''[[vata]]''- aggravating food or excessively cold food, in excessive quantities, or is administered emesis or purgation without prior unction, he vomits profusely and holds up impelling urges of flatus, urine, bowel movement. Or if such a person, after consuming a heavy meal, drinks a lot of fresh water or travels by an excessively jerking vehicle, indulges in excessive sexual intercourse, intensive physical exercise, or drinks alcoholic drinks, or suffers from excessive anxiety, or is subjected to injury or uses uneven postures in sitting, sleeping, standing and walking, or starts some other similar sort of irregular and excessive physical exercises -''[[vata]]'' gets vitiated or aggravated. [6]

</div>

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Such vitiated ''vata'', on entering the ''mahasrotas'', hardens due to dryness forming a mass or swelling localised in the regions of heart, urinary bladder, sides and the navel. The condition, ''gulma'' (or ''vata gulma''), is painful and can take the shape of a single swelling or multiple nodules of various types. It sometimes gets aggravated and enlarged, sometimes diminished, and causes mild or severe pain due to instability of ''vayu''. Sometimes there are tingling sensations like ants crawling on body and frequent onset and diminution of various types of painful sensations such as piercing, breaking, twitching, extension, contraction, numbness, hyperaesthesia, etc. These sensations could be accompanied by a rise in temperature usually in the evenings, dryness of mouth, difficulty in expiration, horripilation at the onset of pain and complications such as spleen (enlargement), distension and gurgling sound in the abdomen, indigestion, ''udavarta'' (upward movement of ''vata''), bodyache, pain in the lateral side of the neck, head and temple regions and ''bradhana'' (swellings of the inguinal region) with appearance of blackness, reddishness and roughness in skin, nails, eyes, face, urine and feces. The disease aggravates due to these etiological factors and pacifies due to opposite factors. These are characteristic features of ''vata gulma''. [7]

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Such vitiated ''[[vata]]'', on entering the ''mahasrotas'', hardens due to dryness forming a mass or swelling localised in the regions of heart, urinary bladder, sides and the navel. The condition, ''gulma'' (or ''[[vata]] gulma''), is painful and can take the shape of a single swelling or multiple nodules of various types. It sometimes gets aggravated and enlarged, sometimes diminished, and causes mild or severe pain due to instability of ''[[vayu]]''. Sometimes there are tingling sensations like ants crawling on body and frequent onset and diminution of various types of painful sensations such as piercing, breaking, twitching, extension, contraction, numbness, hyperaesthesia, etc. These sensations could be accompanied by a rise in temperature usually in the evenings, dryness of mouth, difficulty in expiration, horripilation at the onset of pain and complications such as spleen (enlargement), distension and gurgling sound in the abdomen, indigestion, ''udavarta'' (upward movement of ''[[vata]]''), bodyache, pain in the lateral side of the neck, head and temple regions and ''bradhana'' (swellings of the inguinal region) with appearance of blackness, reddishness and roughness in skin, nails, eyes, face, urine and feces. The disease aggravates due to these etiological factors and pacifies due to opposite factors. These are characteristic features of ''[[vata]] gulma''. [7]

</div>

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=== ''Pitta''-dominant ''gulma'' ===

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=== ''[[Pitta]]''-dominant ''gulma'' ===

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If a person, weakened by ailments or various etiological factors (as mentioned above in verse 6), uses sour, salty, pungent, and alkaline substances with hot and sharp potency, vinegar, improperly prepared or denatured alcoholic drinks, salads, sour fruits and acidic vegetables, grains, meat etc., takes food during indigestion, is administered emesis when ''amashaya'' is dry (or not properly oleated), suppresses natural urges for long, or is exposed excessively to the sun and wind, his ''pitta'' along with ''vata'' gets vitiated or aggravated. [8]

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If a person, weakened by ailments or various etiological factors (as mentioned above in verse 6), uses sour, salty, pungent, and alkaline substances with hot and sharp potency, vinegar, improperly prepared or denatured alcoholic drinks, salads, sour fruits and acidic vegetables, grains, meat etc., takes food during indigestion, is administered emesis when ''amashaya'' is dry (or not properly oleated), suppresses natural urges for long, or is exposed excessively to the sun and wind, his ''[[pitta]]'' along with ''[[vata]]'' gets vitiated or aggravated. [8]

</div>

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Aggravated ''vata'', along with vitiated ''pitta'', gets (completely or partially) collected in the ''amashaya'' and produces the same types of pain as mentioned for ''vata gulma''. Due to aggravation of ''pitta'' in certain cases, the patient feels a burning sensation (with hyperacidity) in the belly, cardiac region, chest and throat while letting out smoky and sour eructations at the same time. In the location of ''gulma'', there is burning sensation, pain, sensations of fuming, sweating and moistening, laxity, tenderness and slight horripilation. The patient could exhibit symptoms such as fever, giddiness, burning pain, thirst, dryness of throat, palate and mouth, fainting and diarrhea, and develops greenish or yellowish discoloration of skin, nails, eyes, face, urine and feces. The disease aggravates due to these etiological factors and pacifies due to opposite factors. This variant of ''gulma'' is called ''pitta gulma''. [9]

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Aggravated ''[[vata]]'', along with vitiated ''[[pitta]]'', gets (completely or partially) collected in the ''amashaya'' and produces the same types of pain as mentioned for ''[[vata]] gulma''. Due to aggravation of ''[[pitta]]'' in certain cases, the patient feels a burning sensation (with hyperacidity) in the belly, cardiac region, chest and throat while letting out smoky and sour eructations at the same time. In the location of ''gulma'', there is burning sensation, pain, sensations of fuming, sweating and moistening, laxity, tenderness and slight horripilation. The patient could exhibit symptoms such as fever, giddiness, burning pain, thirst, dryness of throat, palate and mouth, fainting and diarrhea, and develops greenish or yellowish discoloration of skin, nails, eyes, face, urine and feces. The disease aggravates due to these etiological factors and pacifies due to opposite factors. This variant of ''gulma'' is called ''[[pitta]] gulma''. [9]

</div>

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=== ''Kapha''-dominant ''gulma'' ===

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=== ''[[Kapha]]''-dominant ''gulma'' ===

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If a person weakened by diseases or aforesaid factors (in verse 6) takes too much unctuous, heavy, sweet and cold things, habitually takes preparations of (rice) flour, sugarcane, milk, sesame, black gram and coarse, unrefined sugar (jaggery), uses excessively immature curd, alcoholic drinks, salads, eats meat of marshy, aquatic and domesticated animals in excessive quantities, suppresses natural urges, drinks too much water when hungry, or is subjected to excessive shaking of the body (caused by travelling on rough roads, etc.), his ''kapha'' along with ''vata'' gets vitiated or aggravated. [10]

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If a person weakened by diseases or aforesaid factors (in verse 6) takes too much unctuous, heavy, sweet and cold things, habitually takes preparations of (rice) flour, sugarcane, milk, sesame, black gram and coarse, unrefined sugar (jaggery), uses excessively immature curd, alcoholic drinks, salads, eats meat of marshy, aquatic and domesticated animals in excessive quantities, suppresses natural urges, drinks too much water when hungry, or is subjected to excessive shaking of the body (caused by travelling on rough roads, etc.), his ''[[kapha]]'' along with ''[[vata]]'' gets vitiated or aggravated. [10]

</div>

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Such aggravated ''vata'' along with vitiated ''kapha'', when accumulated in the ''amashaya'' (upper part of abdomen) region or a part of it, causes the same types of painful symptoms as mentioned for ''vata gulma''. ''Kapha'' causes fever accompanied with cold sensation, anorexia, indigestion, bodyache, horripilation, heart disease, vomiting, excess sleep, lassitude, sweating, and a feeling of heaviness and distress in the head. In the region where the ''gulma'' is located, there is fixity, heaviness, hardness, and numbness. Complications could occur such as cough, dyspnoea, coryza and even tuberculosis in much advanced stages. In terms of physical appearance, the patient develops whiteness in skin, nails, face, urine and feces. The disease aggravates due to these etiological factors and pacifies due to opposite factors. This variant of ''gulma'' is called ''kapha gulma''. [11]

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Such aggravated ''[[vata]]'' along with vitiated ''[[kapha]]'', when accumulated in the ''amashaya'' (upper part of abdomen) region or a part of it, causes the same types of painful symptoms as mentioned for ''[[vata]] gulma''. ''[[Kapha]]'' causes fever accompanied with cold sensation, anorexia, indigestion, bodyache, horripilation, heart disease, vomiting, excess sleep, lassitude, sweating, and a feeling of heaviness and distress in the head. In the region where the ''gulma'' is located, there is fixity, heaviness, hardness, and numbness. Complications could occur such as cough, dyspnoea, coryza and even tuberculosis in much advanced stages. In terms of physical appearance, the patient develops whiteness in skin, nails, face, urine and feces. The disease aggravates due to these etiological factors and pacifies due to opposite factors. This variant of ''gulma'' is called ''[[kapha]] gulma''. [11]

</div>

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</div></div>

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When the symptoms of three ''~~doshas~~'' are exhibited, a ''gulma'' patient is said to be ailing from ''sannipatika gulma''. This condition is incurable. [12]

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When the symptoms of three ''[[dosha]]s'' are exhibited, a ''gulma'' patient is said to be ailing from ''sannipatika gulma''. This condition is incurable. [12]

=== ''Shonita gulma'' ===

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''Shonita'' or ''raktagulma'' occurs specifically only in women and not in men because of presence of uterus and menstrual flow in the former. In woman, who suppress their natural urges because of dependence, ignorance or a constant attendance to service of others or uses ''vata'' aggravating substances soon after abortion, delivery or during menstruation, ''vata'' gets vitiated or aggravated quickly. [13]

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''Shonita'' or ''raktagulma'' occurs specifically only in women and not in men because of presence of uterus and menstrual flow in the former. In woman, who suppress their natural urges because of dependence, ignorance or a constant attendance to service of others or uses ''[[vata]]'' aggravating substances soon after abortion, delivery or during menstruation, ''[[vata]]'' gets vitiated or aggravated quickly. [13]

</div>

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This vitiated ''vata'' gets into the cervico-vaginal canal and checks the menstrual flow. If this continues for a prolonged period, the menstrual blood being obstructed accumulates and enlarges the abdomen. The patient consequently suffers from pain, cough, diarrhea, vomiting, anorexia, indigestion, bodyache, excess sleep, lassitude, dampness, and excessive salivation. There occurs appearance of milk in breasts, dark coloration of lips and areolar region, excessive heaviness in eyes, fainting, nausea, longing for certain food articles as seen during pregnancy, swelling in feet, dilatation of the vaginal orifice and foul smelling discharge from the vagina. There is pulsation in the entire mass of ''gulma'', confusing the patient (or her attendants) into thinking that she is pregnant. [14]

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This vitiated ''[[vata]]'' gets into the cervico-vaginal canal and checks the menstrual flow. If this continues for a prolonged period, the menstrual blood being obstructed accumulates and enlarges the abdomen. The patient consequently suffers from pain, cough, diarrhea, vomiting, anorexia, indigestion, bodyache, excess sleep, lassitude, dampness, and excessive salivation. There occurs appearance of milk in breasts, dark coloration of lips and areolar region, excessive heaviness in eyes, fainting, nausea, longing for certain food articles as seen during pregnancy, swelling in feet, dilatation of the vaginal orifice and foul smelling discharge from the vagina. There is pulsation in the entire mass of ''gulma'', confusing the patient (or her attendants) into thinking that she is pregnant. [14]

</div>

=== Prodormal symptoms ===

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These five types of ''gulma'' have the following prodormal symptoms just prior to occurring: aversion to food, anorexia and indigestion, disturbed metabolism, burning sensation after taking meals, vomiting and unusual eructations, reduced urge for flatus, urine and bowel movements, pain, distension, gurgling sound, horripilation and diarrhea due to ''vata'', loss of appetite, debility, and inability to endure satiety. [15]

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These five types of ''gulma'' have the following prodormal symptoms just prior to occurring: aversion to food, anorexia and indigestion, disturbed metabolism, burning sensation after taking meals, vomiting and unusual eructations, reduced urge for flatus, urine and bowel movements, pain, distension, gurgling sound, horripilation and diarrhea due to ''[[vata]]'', loss of appetite, debility, and inability to endure satiety. [15]

</div>

=== Prognosis and general principles of management ===

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As is evident from the descriptions of ''gulma'', no variant is caused without vitiation of ''vata''. Amongst these variants, ''sannipatika'' ''gulma'' is incurable and should not be treated. The variant caused by just one ''dosha'', should be treated with suitable therapeutics prescribed for respective ''dosha''. Those caused by a combination of two ''~~doshas~~'' (''vata – pitta'' or ''vata – kapha'') should be managed with the general therapeutic measures applicable to ''dwidoshic'' ailments. The measures that are not contrary to the ''dosha'' can be applied according to severity of complications. In case of emergency situations, the measures applicable in treatment of ''vata gulma'', such as ''vata''-alleviating unction, fomentation, mild unctuous purgation, enema, and use of sweet, sour and salty substances should be administered. If ''vata'' is pacified, then the disease can be cured even with little efforts and other types of ''gulma'' can also be treated. [16]

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As is evident from the descriptions of ''gulma'', no variant is caused without vitiation of ''[[vata]]''. Amongst these variants, ''sannipatika'' ''gulma'' is incurable and should not be treated. The variant caused by just one ''[[dosha]]'', should be treated with suitable therapeutics prescribed for respective ''[[dosha]]''. Those caused by a combination of two ''[[dosha]]s'' (''[[vata]] – [[pitta]]'' or ''[[vata]] – [[kapha]]'') should be managed with the general therapeutic measures applicable to ''dwidoshic'' ailments. The measures that are not contrary to the ''[[dosha]]'' can be applied according to severity of complications. In case of emergency situations, the measures applicable in treatment of ''[[vata]] gulma'', such as ''[[vata]]''-alleviating unction, fomentation, mild unctuous purgation, enema, and use of sweet, sour and salty substances should be administered. If ''[[vata]]'' is pacified, then the disease can be cured even with little efforts and other types of ''gulma'' can also be treated. [16]

</div>

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</div></div>

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In the case of ''gulma'', all the measures for pacification of ''vata'' should be administered properly because after ''vayu'' is controlled over, other aggravated ''~~doshas~~'' can be alleviated even with small remedies. [17]

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In the case of ''gulma'', all the measures for pacification of ''[[vata]]'' should be administered properly because after ''vayu'' is controlled over, other aggravated ''[[dosha]]s'' can be alleviated even with small remedies. [17]

=== Summary ===

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== Tattva Vimarsha (Fundamental Principles) ==

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*''Gulma'' is a disease of the ''mahastrotas'' (gastro-intestinal tract/abdomen) and is caused due to predominance of ''vata''. It is of five types depending upon its location (limited to the gastro-intestinal region between the heart and the bladder). Four types of ''gulma'' are common to both males and females while the fifth, ''raktaja gulma'', is a condition limited to females.

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*''Gulma'' is a disease of the ''mahastrotas'' (gastro-intestinal tract/abdomen) and is caused due to predominance of ''[[vata]]''. It is of five types depending upon its location (limited to the gastro-intestinal region between the heart and the bladder). Four types of ''gulma'' are common to both males and females while the fifth, ''raktaja gulma'', is a condition limited to females.

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*''Gulmas'' also vary by the vitiation of other ~~doshas~~ besides ''vata''. The ''sannipitaka gulma'', caused by vitiation of all three ''~~doshas~~'', is said to be incurable.

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*''Gulmas'' also vary by the vitiation of other [[dosha]]s besides ''[[vata]]''. The ''sannipitaka gulma'', caused by vitiation of all three ''[[dosha]]s'', is said to be incurable.

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*A primary feature of ''gulma'' is obstruction to the path of ''vata'', which can be due to causes like tumor, stricture, inflammation, tuberculosis, parasites, etc.

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*A primary feature of ''gulma'' is obstruction to the path of ''[[vata]]'', which can be due to causes like tumor, stricture, inflammation, tuberculosis, parasites, etc.

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*''Gulma'' with acute symptoms should have urgent relief of ''vata'' obstruction.

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*''Gulma'' with acute symptoms should have urgent relief of ''[[vata]]'' obstruction.

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*Treatment of ''vata gulma'' includes ''vata''-alleviating unction, fomentation, mild unctuous purgation, enema, and use of sweet, sour and salty substances. If ''vata dosha'' is pacified in ''gulma'' disease, then other two ''dosha'' can also be controlled.

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*Treatment of ''[[vata]] gulma'' includes ''[[vata]]''-alleviating unction, fomentation, mild unctuous purgation, enema, and use of sweet, sour and salty substances. If ''[[vata dosha]]'' is pacified in ''gulma'' disease, then other two ''[[dosha]]'' can also be controlled.

== Vidhi Vimarsha (Applied Inferences) ==

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=== Etiopathogenesis of ''gulma'' ===

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In [[Charak Samhita]], vitiated ''vata dosha'' is considered as major etiological factor for the development of any type of ''gulma''.[Cha.Sa.[[Chikitsa Sthana]] 28/58] Among the five types of ''vata'' mentioned in [[Charak 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.

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In [[Charak Samhita]], vitiated ''[[vata dosha]]'' is considered as major etiological factor for the development of any type of ''gulma''.[Cha.Sa.[[Chikitsa Sthana]] 28/58] Among the five types of ''[[vata]]'' mentioned in [[Charak 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.

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In [[Chikitsa Sthana]], Charak 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''.

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In [[Chikitsa Sthana]], Charak 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 ''[[dosha]]s'' and ''[[mala]]'' causing obstruction of different channels, further aggravating ''[[vata]]''.

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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.

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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 ''[[dosha]]s'' 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 ''[[dosha]]s'' 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.

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Also, in the absence of any ''dushya'' (''dhatu'' and ''mala''), these swellings are commonly non-suppurative in nature.~~[Su~~.Sa.~~Uttar Tantra~~ 42/~~6-7]~~ There are, however, some cases where suppuration may take place. For example, in [[Chikitsa Sthana]], Charak 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'').

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Also, in the absence of any ''[[dushya]]'' (''[[dhatu]]'' and ''[[mala]]''), these swellings are commonly non-suppurative in nature.<ref>Sushruta. Uttara Tantra, Cha.42 Gulmapratisheda Adhyaya verse 6. In: Jadavaji Trikamji Aacharya, Editors. Sushruta Samhita. 8th ed. Varanasi: Chaukhambha Orientalia;2005.</ref> There are, however, some cases where suppuration may take place. For example, in [[Chikitsa Sthana]], Charak 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'').

=== ''Shadkriyakala'' (lifecycle) of ''Gulma'' ===

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#''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.

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#''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.

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#''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''.

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#''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''.

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#''Prasara''-In this stage aggravated ''vata'' dislodges from its accumulated site and spreads all over the body.

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#''Prasara''-In this stage aggravated ''[[vata]]'' dislodges from its accumulated site and spreads all over the body.

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#''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.

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#''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 ''[[dosha]]s'' 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.

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#''Vyakti''- Clinical features of different types of ''gulma'' manifest at this stage so management can be done depending upon specific ''dosha'' characteristics.

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#''Vyakti''- Clinical features of different types of ''gulma'' manifest at this stage so management can be done depending upon specific ''[[dosha]]'' characteristics.

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#''Bheda''-When the ''gulma'' is not treated at the fourth and fifth stage, complications like ''bradhna roga'' (inguinal swelling), ''jwara'' (fever), ''vidbheda'' (loose stools/diarrhea), and suppuration (in case of ''pittaja gulma'') occur where surgical intervention could be necessary.

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#''Bheda''-When the ''gulma'' is not treated at the fourth and fifth stage, complications like ''bradhna roga'' (inguinal swelling), ''[[jwara]]'' (fever), ''vidbheda'' (loose stools/diarrhea), and suppuration (in case of ''pittaja gulma'') occur where surgical intervention could be necessary.

=== Location of ''gulma'' ===

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With respect to the ''adhishthana'' (location) of ''gulma'', five major sites have been mentioned [Cha.Sa. [[Chikitsa Sthana]] 5/8], 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 [[Sharira Sthana]]. ''Vata gulma'' most commonly occurs in ''basti'', while ''~~pittagulma~~'' occurs most commonly in the ''nabhi'' region, and ''~~kaphagulma~~'' in the ''hridaya'' and ''parshwadwaya'' regions.<ref>Vagbhata. Sutra Sthana, Cha.11 Vidradivriddhigulmanidana verse 41. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000. </ref> 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''.<ref> Harita, Harita ~~samhita~~ Gulma ~~nidana~~</ref>

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With respect to the ''adhishthana'' (location) of ''gulma'', five major sites have been mentioned [Cha.Sa. [[Chikitsa Sthana]] 5/8], 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 [[Sharira Sthana]]. ''[[Vata]] gulma'' most commonly occurs in ''basti'', while ''[[pitta]] gulma'' occurs most commonly in the ''nabhi'' region, and ''[[kapha]] gulma'' in the ''hridaya'' and ''parshwadwaya'' regions.<ref>Vagbhata. Sutra Sthana, Cha.11 Vidradivriddhigulmanidana verse 41. In: Harishastri Paradkar Vaidya, Editors. Ashtanga Hridayam. 1st ed. Varanasi: Krishnadas Academy;2000. </ref> 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''.<ref>Harita, Harita Samhita. Tritiya Sthana, Chap 4, Gulma Chikista, Verse 2-4, In: Harihariprasad Tripati, Editor. Harita Samhita. 2nd ed. Varanasi: Chaukhambha Krishnadas Academy; 2009</ref>

The pathogenesis of ''pittaja'' and ''kaphaja gulma'' takes place in ''amashaya'' that lies in the region between ''hridaya'' and ''basti'' [Chakrapani on Cha.Sa.[[Nidana Sthana]] 03]. 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:

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'''Prognosis''' –''Sannipatika gulma'' is incurable, rest four are curable when treated timely.

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'''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''.

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'''Management'''- All the four types of ''gulma'' can be managed according to the prevalent ''[[dosha]]s''. 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.

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* [[Gulma Chikitsa]]

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