Changes

The word ''gulma'' stands for an entity that encircles, envelops or covers something. Situations such as panic, stress, or grief, usually associated with chaotic, cataclysmic event would lead to vitiation of ''vata'' causing the appearance of ''vata''-dominant diseases like ''gulma'', etc. The vitiated ''vata'', in conjunction with other ''doshas'', gets into the ''mahasrotas'' and get lodged either in the ''amashaya'' (stomach), ''pittashaya'' (gall bladder), ''pakwashaya'' (cecum) or in other regions like ''hridaya'' (epigastric), ''basti'' (bladder) and ''nabhi'' (umblicus) leading to formation of deep-rooted shrub-like mass. 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: ''vata gulma'', ''pitta gulma'', ''kapha gulma'', and ''sannipatik gulma''.

The word ''gulma'' stands for an entity that encircles, envelops or covers something. Situations such as panic, stress, or grief, usually associated with chaotic, cataclysmic event would lead to vitiation of ''vata'' causing the appearance of ''vata''-dominant diseases like ''gulma'', etc. The vitiated ''vata'', in conjunction with other ''doshas'', gets into the ''mahasrotas'' and get lodged either in the ''amashaya'' (stomach), ''pittashaya'' (gall bladder), ''pakwashaya'' (cecum) or in other regions like ''hridaya'' (epigastric), ''basti'' (bladder) and ''nabhi'' (umblicus) leading to formation of deep-rooted shrub-like mass. 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: ''vata gulma'', ''pitta gulma'', ''kapha gulma'', and ''sannipatik gulma''.

Since ''gulma'' can occur as complication of ''raktapitta'' (bleeding disorders) Charaka describes this chapter after the ''raktapitta'' chapter. ''Jwara'' is the disease of ''rasavah srotas'' whereas, ''raktapitta'' is a disease of ''raktavah srotas'', in that sequence ''gulma'' is a disease of ''mansavah srotas'' and further ''prameha'' is of ''medavah srotas''. However, this chapter seems to be designed with greater implication and term ''mahasrotasa'' has been used because manifestation of disease is in the viscera/ organs up to uterus. Even then the involvement of ''vata dosha'' and ''mamsa dhatu'' is predominant in final manifestation of disease ''gulma''.

Since ''gulma'' can occur as complication of ''raktapitta'' (bleeding disorders) Charak describes this chapter after the ''raktapitta'' chapter. ''Jwara'' is the disease of ''rasavah srotas'' whereas, ''raktapitta'' is a disease of ''raktavah srotas'', in that sequence ''gulma'' is a disease of ''mansavah srotas'' and further ''prameha'' is of ''medavah srotas''. However, this chapter seems to be designed with greater implication and term ''mahasrotasa'' has been used because manifestation of disease is in the viscera/ organs up to uterus. Even then the involvement of ''vata dosha'' and ''mamsa dhatu'' is predominant in final manifestation of disease ''gulma''.

It should also be noted that the same pathogenesis route and treatment procedure should be kept in mind for the disease of the ''mahasrotasa'' occurring without the true manifestation of growth/tumor. Hence peptic ulcer and ulcer dyspepsia should be treated like ''pitta gulma'' etc.

It should also be noted that the same pathogenesis route and treatment procedure should be kept in mind for the disease of the ''mahasrotasa'' occurring without the true manifestation of growth/tumor. Hence peptic ulcer and ulcer dyspepsia should be treated like ''pitta gulma'' etc.

gulmacikitsitaM nAma pa~jcamo~adhyAyaH||5||

gulmacikitsitaM nAma pa~jcamo~adhyAyaH||5||

Thus fifth chapter named [[Gulma Chikitsa]] in [[Chikitsa Sthana]] in the treatise compiled by Agnivesha and revised by Charaka is completed [5]

Thus fifth chapter named [[Gulma Chikitsa]] in [[Chikitsa Sthana]] in the treatise compiled by Agnivesha and revised by Charak is completed [5]

=== ''Tattva Vimarsha'' ===

=== ''Tattva Vimarsha'' ===

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 ''snehana, swedana'' and ''basti/vamana'' help in alleviating the symptoms by elimination of feces and flatus as well as improving the gut motility.

On analyzing the features described by Charak, 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 ''pachyamana 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.  

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. Charak 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).

#Bhāvaprakāsha: Bhāvaprakāsha . Published by Chaukhamba Sanskrit Series office Banaras. Cikitsa Prakarana  

#Bhāvaprakāsha: Bhāvaprakāsha . Published by Chaukhamba Sanskrit Series office Banaras. Cikitsa Prakarana  

#Charaka: Charaka Samhita, Edited by Yadavaji T. Acharya. Niranaya sagar Press, Bombay.  

#Charak: Charak Samhita, Edited by Yadavaji T. Acharya. Niranaya sagar Press, Bombay.  

#Madhava: Madhava Nidana; published by Chaukhamba Samskrit series office, Varanasi,

#Madhava: Madhava Nidana; published by Chaukhamba Samskrit series office, Varanasi,

#Sushruta:  Sushruta Samhita. Edited by Yadavaji T. Acharya. Niranaya sagar Press, Bombay.  

#Sushruta:  Sushruta Samhita. Edited by Yadavaji T. Acharya. Niranaya sagar Press, Bombay.