RGUHS Nat. J. Pub. Heal. Sci Vol No: 10 Issue No: 1 eISSN: pISSN: 2249-2149
Gulma is one among the eight diseases described in nidana sthana of Charaka samhita with a symptom complex consisting of complaints that are commonly encountered in clinical practice such as shula (pain) and shotha (swelling). Yet, a diagnosis of gulma is rarely made by clinicians owing to confusions and misconceptions that prevail in the understanding of this disease. A clearer insight into gulma is essential to utilize the textual descriptions of this obscure disease and its treatment in clinical practice. Hence, a detailed analysis of the Ayurvedic description of gulma is made here along with an attempt to identify conditions related to various stages or varieties of the disease from modern science.
Gulma is defined as a granthi (lump) between hridaya (cardiac region) and basti (pelvic region).1 Vitiated vata is an invariable causative factor for all types of gulma, and the disease cannot occur without the involvement of vata. 2 The term gulma literally means ‘a bush- an assemblage of creepers in a compact form’ similar to which vayu remains in a compact form and appears as a solid lump in the disease.3 Gulma is a vedanapradhana vyadhi (characterized by pain) and the specific nature of pain serves as the main diagnostic factor.4
This conceptual study is based on literature review of classical information, published research work and modern literature. The possible correlation has been made between collected information and has been presented in a systemic way. Objectives of the study is to critically study and to analyse the disease gulma and to draw plausible relation of the disease in contemporary science.
Vyadhi adhishtana- Koshta is the abode of all types of gulma.5 Koshta is known in scriptures as mahasrotas (the great channel), sarira madhya (central portion of body), mahanimna (deepest part of the body), and amapakvashaya (stomach and intestines); and it constitutes the abhyantara rogamarga (internal path of disease).6 The term ‘koshta’ includes amashaya (stomach), pakvashaya (intestines), mutrashaya (bladder), rudhirashaya (liver & spleen), hrdaya (heart), unduka (caecum) and phupphusa (lungs).7 While pittagulma and kaphagulma occurs only in amashaya, vatagulma can also occur in other parts of koshta such as basti. 8 If the gulma undergoes paka (suppuration) while it is located in the koshta itself, it is called antastha/ antarmargaja gulma (interior variety)and if the gulma grows and protrudes to the external surface, is called bahistha/ bahirmargaja gulma (external variety).
Vedana adhishtana- The sites of manifestation of gulma are confined to five regions, namely- hrdaya (heart), nabhi (umbilicus), basti (bladder) and dve parshve (lateral region). 9 These can be interpreted as the regions of abdomen corresponding to the location of these structures by go-bali varda nyaya (word which is selected among group of words suitable to the context), shabda vrtti nyaya (according to the situation, the meaning of the same shabda varies and provides different meaning) and lakshana vrtti nyaya (secondary meaning of a shabda instead of primary meaning e.g. gangaya ghosha- meaning is hut in the river but the most accepted meaning is hut on the bank of the river ganga). 10, 11, 12
The gulma is having kundalyakara or granti form. This granti is having aneka vidha akara (different types of shapes) as deergha (elongated), vrutta (round) & sthula (broad).
Types of gulma
There are five types of gulma – vatagulma, pittagulma, shleshmagulma, nicayagulma and shonitagulma.
Difference in number of types of Gulma mentioned in Nidana and Chikitsa Sthana is due to the principle of Prakriti Sama Samaveta (Prakriti Sama Samaveta where the effect is exactly in accordance of the cause) and Vikriti Vishama Samaveta (Vikriti Vishama Samaveta where the effect may not be exactly in accordance of the cause). In Nidana Sthana, three Prakriti Sama Samaveta Dwandwaja Gulma have not been mentioned, because their causes as well as treatment can be estimated in accordance to the individual Humours involved in the pathogenesis. But in Chikitsa Sthana, other three Vikriti Vishama Samaveta Dwandwaja Gulma have been counted separately, because their causes, signs & symptoms and treatment cannot be assumed on the basis of individual Humours.
Gulma- samanya hetu
As vata is the primary dosha involved, gulma is basically a vataroga which occurs in koshta. Here, vatakopa can occur by two distinct mechanisms: i) by independent vatakopa, and ii) due to margavarana by other dosha. Vatika gulma is caused by independently aggravated vata in koshta (koshtagatavata). This aggravated vata can provoke kapha and pitta which are in their normal states (ashayapakarsha), leading to various manifestations of vatika gulma.
In paittika and kaphaja gulma, pitta and kapha respectively get aggravated independently by their own causative factors, and cause obstruction to vata (margavarana). In sannipatika gulma, both kapha and pitta are independently aggravated, and they get provoked by vayu to cause gulma.
Svatantra and paratantra gulma
In pathogenesis of all types of gulma, vata invariably plays a primary role. Vatadosha is primarily located in pakvashaya. In vatika gulma, aggravated vata in pakvashaya manifests the disease, independent of other dosha. Hence, this is called svatantra gulma.
Pittashaya and kaphashaya are primary abodes of pitta and kapha respectively. Hence, in the manifestation of gulma in these organs, vayu becomes dependent on other dosha. Hence, such gulma is called parasamshraya.
Paka in gulma
According to Sushruta, gulma grows within itself like a bubble in water and does not undergo paka as it is devoid of mamsa and rakta, as opposed to vidradhi which is sheegrapaki due to abundance of mamsa and rakta.13 Dalhana comments that this description applies only to vatika gulma. Other types of gulma which stay in raktadi dhatu can undergo suppuration.
Charaka samhita describes paka of gulma. According to Chakrapani, gulma which is not embedded in tissues (akrtavastuparigraha) does not get suppurated, whereas the one that gets embedded in tissues (krtavastuparigraha) becomes a vidradhi and can get suppurated. Hence, gulma can undergo paka when it is krtavastuparigraha, but this stage of the disease is better termed as vidradhi. So, the difference in opinion regarding paka in gulma is merely terminogical.
- Charaka - gulma and shula are associated phenomena i.e., mass predominant by pain only.
- Sushrutha - gulma is a vyadhi and shula is an upadrava i.e., mass lesion and pain
- Vagbhata - gulma is an upadrava and shula is a purvarupa i.e., pain is preminority symptom followed by mass.
Udgarabahulya (excessive belching), pureesha bandha (constipation), trupti (dislike towards food), akshamatva (not being able to work), antravikujana (sounds in the abdomen-increased intestinal motility), atopa (borborygmus), adhmana (flatulence), apaktishakti (indigestion), agnivaishamya (disturbed metabolism) are the features which indicate the occurrence of gulma in near future.14
Gulma samanya rupa
Aruchi (anorexia), krchra vinmutravata (difficulty in passing faeces, urine and flatus), antravikujana (sounds in the intestine), anaha (flatulence), urdhwavata (over belching) are the features seen in all types of gulma.
Vataja gulma Nidana - ruksha annapana (dry food and drinks), vishama atimatra vicheshtana (excessive and abnormal physical behaviour), vegavinigraha (supression of natural urges), shoka (grief), abhighata (affliction by injury), atimalakshaya (excessive loss of impuritiesexcessive purgation therapy) and nirannata (lack of food) are the causes for vataja type of gulma.
Lakshana – In vataja gulma, vikalpa (variation) in sthana (location), samsthana (signs and symptoms) and ruja (pain) is observed
- Sthanavikalpa- the location of gulma keeps changingsometimes appears in nabhi, sometime in parshwa pradesha etc.
- Samsthanavikalpa- variable appearance - round, elongated, broad etc.
- Rujavikalpa- variable degrees of pain
Vidvatasanga (constipation of faeces and flatus), gala vaktra shosha (dryness of throat and mouth), shyava (blackish red color in the body), shishirajwara (diurnal fever with night sweat) and hrithkukshiparshwamsa shiroruja (pain in the heart, stomach, flanks, scapular region and head).
Anupashaya (aggravating factors) - jeerne (after digestion), ruksha (dry), kashaya (astringent), tiktha (bitter), katu (spicy).
Upashaya (relieving factors)- bhukte (intake of food)
Nidana – consuming katu (pungent), amla (sour), teekshna (like alkali), ushna (hot), vidahi (producing burning sensation), ruksha bhojana (food stuffs which are devoid of fat), krodha (anger), ati madya pana (excess use of alcoholic drinks) and arkasevana (excess exposure to sunlight), amabhighata (where dushta rasa is produced due to vidagadhajeerna) or due to abhighata (injury) and rakta dushti (vitiation of blood).
Lakshana - Jwara (fever), pipasa (thirst), vadana & anga raaga (redness of face & body), shulam mahajjeryati bhojane cha (severe pain during digestion of food), sweda (sweating), vidaha, vranavat sparsha asahatva (burning sensation resembling ulcer and tenderness)
Nidana– consuming food which is sheeta (cold), guru (hard to digest) & snigda (fatty), acheshtana (having no physical exercise), sampuranam (over eating), and prasawapanam diwa (sleeping during day time).
Lakshana- Staimitya (feeling as if covered with a wet cloth), sheeta jwara (fever associated with feeling of cold or mild fever), gatra sada (prostration), kasa (cough), aruchi (anorexia), gaurava (heaviness), Shaityam (cold in touch), rugalpa (mild pain) katina (hardness) and unnata (marked elevation) of gulma.
Gulma where tridosha are equally involved in causing the disease will show features like maha ruja (great pain), daha (severe burning sensation), ashmavad ghana unnatam (appearance of gulma as big and hard like stone), darunam (fatal in nature), mana shareera agni balapaharinam (it diminishes the strength of mind, body and digestive fire) and it is asadhya (incurable) in nature.
Due to extreme asadhyatva, this gulma is called as nicaya gulma.
In the woman who suppress their natural urges due to paratantryath (dependence), avaisharadhyath (ignorance) or sathatam upacharanurododhath (constant attendance to service of others), who indulges in vata prakopaka dravyas soon after abortion, delivery or during menstruation, taking ahita bhojana (unwholesome diet) just after delivery or who aborts ama garbha (fetus before completion of gestation), during ritukala (ovulation period) if a woman does fasting or takes dry food items or indulges in fear, then it results in vata dushti and obstructs the menstrual blood resulting in gulma along with ruja (pain) and daha (burning sensation) similar to pittaja gulma. Here, gulma does not behave like fetus but its similarity of appearance makes the woman to think psychologically and perform actions just as the activity of a woman during pregnancy.21 Experts say that this gulma occurs in females due to obstruction of arthava and this raktaja gulma will be having ekapinda rupa (a solitary mass without any appendages as for fetus) with uniform spandana (quivering) without any movements of body parts as in garbha. The spandana occurs in a large interval along with shula and as this happens only in females, it is considered as arthava rupa raktaja gulma.
Dhaturupa raktaja gulma occurs in males as well as in females, as gulma is a samanyaja vikara and also a raktapradoshaja vikara, where dushta rakta involved will be having similar nidana and lakshana, as pittaja gulma with raktatisara presentation and its treatment is similar to raktatisara. 22, 23, 24, 25
The prime pathological event in gulma is the obstruction to the course of vata, which can be due to causes like inflammation, stricture, tumor etc. The disease is characterized by pain and palpable mass. But not all cases of gulma are associated with a palpable mass as some gulma never attain a palpable size, and others may not be palpable in its initial stages.
The modern correlation of gulma can be done as follows based on various forms of disease presentation
I. Gulma with only shula and shotha (pain and inflammation), without a palpable mass.
II. Gulma, as various stages of an inflammatory swelling.
III. Gulma with pindakara shotha (a mass) which is sparshopalabhya (palpable).
Gulma with shula and shotha (antastha gulma)
Acute intestinal obstruction, is a condition that can occur due to adhesive bands or internal hernias or may be sometimes secondary to previous abdominal surgery or from external hernias, which is similar to abhighata nidana of vataja gulma. Here, mechanical intestinal obstruction is characterized by cramping mid abdominal pain, which tends to be more severe the higher the obstruction. The pain occurs in paroxysms and patient becomes relatively comfortable in the interval between the pains, which is similar to ruja vikalpa of vatika gulma. Audible borborygmi (antrakujana) are often noted by the patient simultaneously with paroxysms of pain. When the obstruction is complete, obstipation and failure to pass gas by rectum (vid vata sanga) are invariably present.
In early stage of intestinal obstruction, diagnosis is marked mainly based on colicky pain with features of obstruction, which can be considered as a shula and shotha pradhana abhyantara vataja gulma.
Duodenitis Due to excessive action of enzyme pepsin and hydrochloric acid, typically inflammation develops in stomach and duodenum (beginning of small intestine). This is because of indulging in alcohol consumption (acidic drinks), medications and smoking, along with the chronic usage of medications like NSAID (NonSteroidal Anti-Inflammatory Drugs) (katu, teekshna, ushna, amla and vidahi ahara vihara similar to pittaja gulma nidana), which leads to reduction in prostaglandin secretion and its cytoprotective effects in gastric mucosa. The pain of duodenitis is described as burning or gnawing discomfort. In duodenitis, discomfort may actually be precipitated by food as in pittaja gulma (shulam mahajjeryati bhojane cha). In 20% of patients, pain may be found to the right of the midline. There may be dyspeptic history with pain occurring often at night with periodic symptoms. All these symptoms are oriented towards shula and shotha pradhana abhyantara variety of pittaja gulma. Further, duodenitis condition may end up in duodenal ulcer as a complication.
The lower oesophageal sphincter (LES) is a muscular ring that closes off the oesophagus from the stomach due to impaired oesophageal body peristalsis and incomplete lower oesophageal sphincter relaxation. Long standing achalasia is characterized by progressive dilatation and sigmoid deformity of esophagus with hypertrophy of lower oesophageal sphincter. Clinical manifestations may include dysphagia, regurgitation, chest pain and weight loss. Most patients report solid and liquid food dysphagia. Patients with advanced achalasia are at risk for bronchitis, pneumonia or lung abscess from chronic regurgitation and aspiration. These symptoms point towards kaphaja gulma, where arochaka, avipaka, hridroga, chardi can be observed and kasa, shwasa, pratishyaya and rajayakshma is noted in advanced conditions. Here the manifestation is abhyantara in nature.
Gulma - an inflammatory swelling with various stages
Inflammatory swelling has different stages in the disease such as, stage of inflammation, stage of suppuration and phlegmonous stage. As gulma is arising in kundali akara/ gudaka akara/ grinti of different shapes, in appendages of intestine and its inflammatory conditions like diverticulitis, appendicitis could be included under gulma. As Charaka says, when a pittaja gulma vitiates rakta, there will be paka (suppuration) of structures surrounding the gulma. Sushrutha has clarified the involvement of tridosha in the process of paripaka (process of suppuration), as there is no vedana (pain) without vata, no paka (suppuration) without pitta and no puya (pus formation) without kapha dosha.26
Vataja gulma - Early acute appendicitis where appendix gets swollen with hyperemia. This round mass at times gets inflated and at times gets decreased (muhuhu adhamati). Due to this irregularity, there will be acute and migratory pain (muhuhu alpatwa mapadhyate) from umbilicus to right iliac fossa.
Pittaja gulma - Acute suppurative appendicitis spreading diffuse inflammatory process with suppurative or purulent exudate or pus. Here, patient will present with nausea, vomiting and vague periumbilical pain, to migration of pain to right lower quadrant, to low-grade fever.
Kaphaja gulma - Phlegmonous stage, where appendix will increase in size with dull serous membrane, hyperemic, covered with fibrinous coating. The walls of the appendix are thickened, stable, heavy and hard, similar to kaphaja lakshana as gaurava, sthairya, katinya and it is filled with purulent matter which sometimes may become diffuse.
Diverticula are the outpouchings or herniations of the mucosa and submucosa of the colon through the muscle wall
Vataja gulma – A pericolic abscess confined by the mesentery of the colon (vayu mahasroto anupravishya… pindito avastaanam karoti). This means, there are inflammatory masses or abscesses in the fat surrounding the colon or the folds of the small intestine.
Pittaja gulma – A pelvic abscess resulting from local perforation of a pericolic abscess. This abscess may be walled off by colon, mesocolon, omentum, small bowel, uterus, fallopian tubes and ovaries, and /or pelvic peritoneum leading to abdominal tenderness, fever, nausea or vomiting (muhuhu adhamati).
Kaphaja gulma – General purulent peritonitis resulting from the rupture of either a pericolic or pelvic abscess into the free peritoneal cavity
The pindakara shotha (bahya gulma)
Characteristic feature of vataja gulma i.e., roukshyath katineebhootam (loss of unctuousness, dryness) can be considered as hypertrophy, hyperplasia and tumor like growth.27
Abdominal distension is the hallmark of all forms of intestinal obstruction caused due to either stricture or adhesive bands. It is least marked in cases of obstruction in the small intestine and most marked in colonic obstruction. In early obstruction of small and large intestine, tenderness and rigidity are usually minimal. In contrast, the pain is severe in chronic conditions as obstruction goes on increasing. The presence of a palpable abdominal mass usually signifies a closed loop, strangulated bowel. Here, palpable lesion per abdomen observed is the tense fluid filled loop. Along with obstruction and palpable abdominal mass, there will be powerful peristaltic waves in the bowel which is hypertrophied and dilated, accompanying progressive constipation and distension as in pleeha atopa antrakujana of vataja gulma. This can be considered as sparshopalabhya pindakara vataja gulma.
Pancreatic endocrine tumors (PET’s)-
Functional pancreatic endocrine tumors usually present clinically with symptoms due to the hormone excess state. Only late in the course of the disease does the tumor per se cause prominent symptoms such as abdominal pain. In contrast, all the symptoms due to non-functional PET’s are due to the tumor per se. The overall result of this is that, some functional PET’s may present with severe symptoms with a small or undetectable primary tumor, whereas non-functional tumors usually present late in the disease course with large tumors, which are usually metastatic. Under this, one of the syndromes is Zollinger Ellison Syndrome, a gastrinoma and a neuro endocrine tumor that secrets gastrin, where the resultant hypergastrinemia causes gastric acid hypersecretion resulting in severe ulcer disease as well as diarrhoea along with common presenting symptoms such as abdominal pain, gastro oesophageal reflux disease. This is similar to piitaja gulma which presents with features like shula, vid bheda, vidahati kukshau hrid urasi kante. Here, the tumor may or may not be palpable based on severity of disease. Still in advanced conditions, it may be observed as a palpable pittaja gulma.
About 85% of stomach cancers are adenocarcinoma, with 15% due to lymphomas, gastrointestinal stromal tumors and leiomyosarcomas. The intestinal type of gastric adenocarcinomas is characterized by cohesive neoplastic cells that form gland like tubular structure (granti form). Gastric cancer when superficial and surgically curable, usually produce no symptoms (alpa ruk). As the tumor becomes more extensive, patients may complain of an insidious upper abdominal discomfort, varying in intensity from a vague post prandial fullness to a severe steady pain. Anorexia often with slight nausea is very common but is not the usual presenting complaint. Weight loss may eventually be observed. Nausea and vomiting are particularly prominent with tumors of pylorus. Dysphagia and early satiety may be the major symptoms caused by diffuse lesions. A palpable abdominal mass indicates long standing growth and predicts regional extension. All these symptoms resemble kaphaja gulma which will advance into a sparshopalabhya gulma form.
Raktaja gulma in female
Molar pregnancy (Carneous mole and Hydatiform mole)-
Initially, there will be amenorrhea due to obstruction to menstrual blood and there will be features of early pregnancy. Due to associated infection, there may be fever and foul vaginal discharge. All these features result in a suspicion of pregnancy but here fetal body parts are not felt and there will be absence of fetal heart sound. Vomiting with varying degree of abdominal pain may be there and patient looks more ill.
In this condition, there will be shedding of endometrium and menstrual blood is formed but it fails to come out due to obstruction in the passage of genital tract. This also results in haematometra and haematosalpinx. Further, there will be periodic pain in the lower abdomen with uniformly enlarged uterus. But it can be differentiated from pregnancy through abdominal examination, which can disclose it as actual uterine mass and not fetus.
In this condition, there will be all signs and symptoms of pregnancy such as enlarged abdomen, amenorrhea, weight gain and morning sickness. This is because of psychological disturbance where there is a desire in women for having pregnancy.
All these conditions are comparable to raktaja gulma in female, which causes confusion of garbha resulting due to obstruction to arthava
Dhatu rupa Raktaja gulma- In both male and female
Hemorrhagic colonic diverticulum
The dhaturupa raktaja gulma occurs in both male and female. Clinical presentations of iron deficiency anemia and of occult blood in the stool in both sexes mandates a search for an occult gastrointestinal tract lesion. One such example is hemorrhagic colonic diverticulum. It is the most common cause of hematochezia in patients of > 60 years, yet only 20% of patients with diverticulosis will have GI bleeding. It also presents with fever, anorexia, left lower quadrant abdominal pain and obstipation.
Gastro intestinal stromal tumors
Most gastro intestinal stromal tumors (GISTs) develop within the wall of the stomach or intestine. These tumors generally grow into empty space inside the gastrointestinal tract because of which they might not produce any symptoms initially, unless they reach a certain size. These tumors will be usually fragile, they tend to bleed easily. Signs and symptoms of this bleeding depend on how fast it occurs and where the tumor is located. If there is brisk bleeding into the large intestine, it is likely to turn the faecal matter into red with visible blood.
All these conditions resemble raktatisara presentation. A pittaja gulma showing shonita pravrutti can also be considered as dhaturupa raktaja gulma.
Nichaya gulma is a sannipataja gulma, located in dakshina parshwa of abdomen. Apart from tridosha involvement, it is also formed from purisha, lasika and rakta and the affected part appears as sirajala parichanna (covered with network of sira) i.e., enveloped by sirajala (peritoneum). Clinically, daha (burning sensation), raga (redness), jwara (fever), kurmavath ghana (hard as much as back of tortoise) and rakta paryanata (the border has redness) is observed and it is said as difficult for management.
Upastambha is an avastha bheda in gulma, either improper treatment or no treatment at right time results in progression of illness and hence called as upastambha. Just like the milk that becomes curd by adding sour, gulma also becomes contained and localized. The impediment caused in ambuvaha srotas, can be considered as localized exaggerated inflammatory response. Kurmavat could be guarding of the abdomen, rakta paryanta are peri appendicitis, or peri cholecystitis.
Gulma always occurs in hollow spaces such as hollow intestinal structures. In sannipataja gulma, it is the severity of the symptoms that are presented, site of manifestation cannot be the indicator. When diseases like appendicitis, diverticulitis etc. advances and involves infection with peritoneum, it leads to sepsis and death and can be considered as nichaya gulma.
Faecal peritonitis resulting from the free perforation of a diverticulum, leading to acute abdominal pain, fever, sinus tachycardia, intestinal paralysis.
This condition can be understood through –
Advanced stages of inflammation
Tissue destruction and necrosis are central features of most forms of advanced stages of inflammatory lesions. This is brought about by activated macrophages which release a variety of biologically active substances and it will be associated with fever, anemia, leukocytosis, elevation of ESR etc.
Advanced stages of carcinoma
Patients will suffer from severe pain, depression and anxiety, shortness of breath, fatigue and weakness, loss of appetite, weight changes, nausea and vomiting, constipation, ascites etc
Obstructions to paralytic ileus
Here, the obstructions can cut-off the blood supply to the intestine and lack of blood supply causes tissue necrosis and death. The symptoms associated during obstruction are moderate to severe, diffuse abdominal pain, constipation, abdominal distension, vomiting of bilious fluid.
Diverticulitis (stage IV)
Here, there will be faecal peritonitis resulting from the free perforation of a diverticulum, leading to acute abdominal pain, fever, sinus tachycardia, intestinal paralysis, shock and death.
Any medical condition that is causing compression or obstruction, if gets advanced, will surely end up in irreversible situation and becomes fatal to life, which shows the asadhya nature of nichaya gulma.
Gulma is a self-contained, shrub like conglomeration of provoked vata dosha, located superficially or deep inside thoracoabdominal cavity which may or may not be palpable. The basic pathogenesis of gulma is shotha and cardinal symptom is shula. Tissues may get involved in later stage of its pathogenesis. Extremely deranged status of agni and exceeding emaciation are specific causes in generation of gulma. Vikriti Vishama Samaveta types of Dwandwaja Gulma requires specific treatment when compared to Prakriti Sama Samaveta type.
Koshta is the abode of all types of gulma which have been divided into five regions of manifestation, where gulma can manifest as svatantra or paratantra. Here, gulma can also undergo paka except vatika gulma. Gulma is having its own purvarupas, rupas and vishesha lakshanas whose knowledge helps to analyse different correlations in modern science. The gulma types were related with different forms of obstruction, ulcer formation and benign neoplastic tumor growths, but this is not the end. There are many other diseases which come under the purview of gulma, that can be analysed further for the better diagnosis and treatment.
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