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Gulma Nidana (view source)

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=== Abstract ===

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The third chapter of [[Nidana Sthana]] titled [[Gulma Nidana]] describes the etiology, pathogenesis, clinical features and therapeutics effective in treating ''gulma''. ''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 modern 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.

'''Keywords''': ''Gulma, mahasrotas, koshtha, dhatukshaya, avarana'', abdominal lumps.

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=== Introduction ===

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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 [https://en.wikipedia.org/wiki/Ayurveda 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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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.

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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===Sanskrit Text, Transliteration and English Translation===

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gulmanAM visheShamabhijAnImahe; nahyavisheShavidrogANAmauShadhavidapi bhiShak

prashamanasamartho bhavatIti||4||

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After Lord Atreya said this, Agnivesha asked, “Sir, How can we know the specific characteristics of these five ''gulmas''? Because without this knowledge, such patients cannot be successfully treated by a physician even though he is well versed in the selection and usage of drugs.”[4]

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तमुवाच भगवानात्रेयः-

समुत्थानपूर्वरूपलिङ्गवेदनोपशयविशेषेभ्यो विशेषविज्ञानं गुल्मानां भवत्यन्येषां च रोगाणामग्निवेश! तत्तु खलु गुल्मेषूच्यमानं निबोध||५||

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anyadvA ki~jcidevaMvidhaM viShamamatimAtraM vyAyAmajAtamArabhate,

tasyApacArAdVataH prakopamApadyate||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]

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स प्रकुपितो वायुर्महास्रोतोऽनुप्रविश्य रौक्ष्यात्

कठिनीभूतमाप्लुत्य पिण्डितोऽवस्थानं करोति हृदि बस्तौ पार्श्वयोर्नाभ्यां वा; स शूलमुपजनयति ग्रन्थींश्चानेकविधान्,

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plIhATopAntrakUjanAvipAkodAvartA~ggamardamanyAshiraHsha~gkhashUlabradhnarogAshcainamupadravanti; kRuShNAruNaparuShatva~gnakhanayanavadanamUtrapurIShashca

bhavati, nidAnoktAni cAsya nopasherate, viparItAni copasherata iti VatagulmaH||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]

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

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Taireva tu karshanaiH karshitasyAmlalavaNa kaTukakShAroShNatIkShNashuktavy ApannamadyaharitakaphalAmlAnAM vidAhinAM ca shAkadhAnyamAMsAdIn AmupayogAdajIrNAdhyashanAdraukShyAnugate cAmAshaye vamanamativelaM

sandhAraNaM Vatatapau cAtisevamAnasya pittaM saha mArutena prakopamApadyate||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]

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तत् प्रकुपितं मारुत आमाशयैकदेशे संवर्त्य तानेव वेदनाप्रकारानुपजनयति,

य उक्ता वातगुल्मे; पित्तं त्वेनं विदहति कुक्षौ

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haritahAridratva~gnakhanayanavadanamUtrapurIShashca bhavati; nidAnoktAni

cAsya nopasherate, viparItAnyupasherata iti pittagulmaH||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]

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

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piShTekShukShIratilamAShaguDavikRutisevanAnmandakamadyAtipAnAddharitakAtipraNanayAdAnUpaudakagrAmyamAMsAtibhakShaNAt sandhAraNAdabubhukShasya cAtipragADhamudapAnAt sa~gkShobhaNAdvA sharIrasya shleShmA saha mArutena

prakopamApadyate||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]

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तं प्रकुपितं मारुत आमाशयैकदेशे संवर्त्य तानेव वेदनाप्रकारानुपजनयति

य उक्ता वातगुल्मे; श्लेष्मा त्वस्य शीतज्वरारोचकाविपाकाङ्गमर्द हर्षहृद्रोगच्छर्दिनिद्रालस्यस्तैमित्यगौरवशिरोभितापानुपजनयति, अपि च गुल्मस्यस्थैर्यगौरवकाठिन्यावगाढसुप्तताः, तथाकासश्वासप्रतिश्यायान् राजयक्ष्माणं चातिप्रवृद्धः, श्वैत्यं त्वङ्नखनयनवदनमूत्रपुरीषेषूपजनयति, निदानोक्तानि चास्य नोपशेरते, विपरीतानि चोपशेरत इति श्लेष्मगुल्मः||११||

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tva~gnakhanayanavadanamUtrapurISheShUpajanayati, nidAnoktAni cAsya nopasherate,

viparItAni copasherata iti shleShmagulmaH||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]

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==== ''Tridosha'' dominant ''gulma'' ====

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Amagarbhe vA~apyacirapatite~athavA~apyaciraprajAtAyA Rutau vA

VataprakopaNAnyAsevamAnAyAH kShipraM VataH prakopamApadyate||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]

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स प्रकुपितो योनिमुखमनुप्रविश्यार्तवमुपरुणद्धि, मासि मासि तदार्तवमुपरुध्यमानं |कुक्षिमभिवर्धयति|

तस्याः शूलकासातीसारच्छर्द्यरोचकाविपाकाङ्गमर्दनिद्रालस्यस्तैमित्य कफप्रसेकाः समुपजायन्ते, स्तनयोश्च स्तन्यम्, ओष्ठयोः

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api ca yonyA daurgandhyamAsrAvashcopajAyate, kevalashcAsyA

gulmaH piNDita eva spandate, tAmagarbhAM garbhiNImityAhurmo UDhAH||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]

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==== Prodormal symptoms ====

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VatashUlATopAntrakUjanApariharShaNAtivRuttapurIShatAH,

abubhukShA, daurbalyaM, sauhityasya cAsahatvamiti||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]

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

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gurUnupadravAMstvaramANashcikitsejjaghanyamitarAn|

tvaramANastu visheShamanupalabhamAno gulmeShvAtyayike karmaNi VatacikitsitaM praNayet, snehasvedau Vataharau snehopasaMhitaM ca mRudu virecanaM bastIMshca; amlalavaNamadhurAMshca rasAn yuktyA~avacArayet| mArute hyupashAnte svalpenApi prayatnena shakyo~anyo~api doSho niyantuM gulmeShviti||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 ''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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भवति चात्र-

गुल्मिनामनिलशान्तिरुपायैः सर्वशो विधिवदाचरितव्या|

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

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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.

*''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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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:

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{| class="wikitable"

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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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These exhibit symptoms similar to those of pregnancy, so it is essential to differentiate them from the point of view of treatment:

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{| class="wikitable"

! rowspan="1"| Raktaja gulma

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==== Study of abdominal swellings ====

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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.

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• Basti (phonetic Basti Sanskrit बस्ति); bladder

• Apacayam (phonetic Apacayam Sanskrit अपचयम) Decrease, get shrink, not nourishing; The term signifies decrease of the body constituents which are abnormally increased.

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=== Table showing different features of gulma ===

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~~Symptoms vātagulma pittagulmaḥ ślēṣmagulma~~

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~~sa muhurādhamati (sometimes aggravates) avipāka (indigestion)~~

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~~Muhuralpatvamāpadyatē~~

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~~(sometimes is diminished) sthairya (non movable)~~

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~~kāṭhinya (hardness)~~

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~~Aniyata vipula aṇuvēdanaśca (having unstable severe and mild pain) vidahyamāna staimitya gaurava~~

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~~Pain/ vedana muhuḥ pipīlikā sampracāra ivāṅgēṣu~~

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~~(sensation of ants crawling) vidahati kukṣau hr̥dyurasi kaṇṭhē (burning sensation in belly cardiac region, chest and throat)~~

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~~aṅgamarda (body ache)~~

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~~gaurava (heaviness)~~

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~~avagāḍha (deep-seated and numbness)~~

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~~Tōda (piercing)~~

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~~Bhēda (breaking)~~

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~~sphuraṇ (twitching)~~

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~~āyāma (extension),~~

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~~saṅkōca (contraction) supti (numbness)~~

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~~harṣa (hyperaesthesia)~~

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~~harṣa (horripilation)~~

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~~suptatāḥ~~

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~~pralayōdayabahulaḥ~~

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~~patient feels pierced with sūcyēva (needle)~~

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~~śaṅkunēva (nail) Sa dhūmam ivōdgāram~~

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~~udgiraty~~

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~~amlānvitaṁ~~

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~~(emits out smoky and sour eructations) hr̥drōga (heart disease)~~

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~~cchardi ( vomiting)~~

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~~nidrā (excess sleep)~~

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~~ālasya (lassitude) śirōbhitāpa (heaviness and distress in head)~~

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~~Divasāntē Jvaryatē (evening rise of temperature) gulmāvakāśaścāsya~~

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~~dahyatē(burning sensation)~~

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~~dūyatē (pain)~~

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~~dhūpyatē(sense of fuming)~~

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~~ūṣmāyatē(warmness)~~

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~~svidyati (sweating)~~

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~~klidyat (moistening)~~

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~~śithila (laxity) Śītajvara (fever beginning with cold)~~

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~~śuṣyati cāsyāsyam,~~

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~~(dryness of mouth) ārōcaka (anorexia)~~

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~~Ucchvāsaścōparudhyatē~~

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~~hr̥ṣyanti cāsya rōmāṇi~~

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~~vēdanāyāḥ (horripilation at the onset of pain) Sparśāsaha (tenderness)~~

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~~ō'lparōmāñcaśca (slight horripilation)~~

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~~Upadrava plīhā (spleen enlargement)~~

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~~āṭōpa (distension)~~

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~~āntrakūjana (gurgling sound in abdomen)~~

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~~avipāka (indigestion)~~

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~~udāvarta (upward movement of Vata)~~

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~~aṅgamarda (body ache) manyāśiraḥśaṅkhaśūla (pain in lateral side of neck, head and temporal area)~~

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~~bradhnarōgā (swellings of inguinal region) jvara fever~~

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~~bhrama giddiness~~

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~~davathu (burning pain)~~

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~~pipāsā (thirst)~~

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~~gala tālu mukha śōṣa (dryness of throat, palate and mouth)~~

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~~pramōha (fainting)~~

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~~viḍbhēdāśca,(diarrhea) kāsa (cough)~~

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~~śvāsa (dyspnoea) pratiśyāyān (coryza)~~

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~~rājayakṣmāṇaṁ cātipravr̥ddhaḥ, (phthisis may also complicate)~~

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~~Varna / colour of tvak (skin)~~

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~~nakha (nails) nayana ( eyes) vadana (face ) mūtra( urine) purīṣaśca (faeces)~~

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~~kr̥ṣṇa (blackness)~~

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~~aruṇa (reddishness)~~

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~~paruṣatvaṅ (roughness)~~

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~~Harita (greenish)~~

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~~hāridra (yellowish)~~

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~~śvaityaṁ (whiteness)~~

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~~Upasaya/ Anupasaya nidānōktāni cāsya nōpaśēratē, viparītāni~~

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~~cōpaśērata (unsuitability towards the etiological factors and suitability to the contrary ones) nidānōktāni~~

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~~cāsya~~

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~~nōpaśēratē,~~

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~~viparītānyupaśērata~~

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~~nidānōktāni~~

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~~cāsya~~

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~~nōpaśēratē,~~

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~~viparītāni~~

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~~cōpaśērata~~

=== References ===

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