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|title=Gulma Nidana

|title=Gulma Nidana

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

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

{{Infobox

{{Infobox

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

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

|label6 = Translator and commentator

|label6 = Translator and commentator

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

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

|label7 = Reviewer  

|label7 = Reviewer  

|data7  = Kar A.C., Gadgil D.

|data7  = Kar A.C., Gadgil D.

|label8 = Editors

|label8 = Editors

|data8  = Khandel S.K., Godatwar P., Deole Y.S., Basisht G.

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

|label9 = Year of publication  

|label9 = Year of publication  

|data9 =  2020

|data9 =  2020

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

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

 

<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>

<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.  

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

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

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

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.  

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.  

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''.

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]]''.

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.  

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.  

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'').

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'' ===

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

#''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.

#''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.

#''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''.

#''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''.

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

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

#''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.

#''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.

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

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

#''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.  

#''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'' ===

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

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. Tritiya Sthana, Chap 4, Gulma Chikista, Verse 2-4, In: Harihariprasad Tripati, Editor. Harita Samhita. 2nd ed. Varanasi: Chaukhambha Krishnadas Academy; 2009</ref>  

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:

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:

'''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 ''[[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.

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.

* [[Gulma Chikitsa]]

* [[Gulma Chikitsa]]

== References ==

== References ==