Gulma

gulma is a disease of Ayurveda and it is very controversial topic.

1. Critical study on Gulma and it’s surgical aspects in Ayurveda Dr. Alok Kumar M.S.(Ay.), Ph.D. Scholar P.G. Department Of Shalya Tantra , N.I.A. Jaipur

2. Gulma Meaning The word meaning of gulma is Lata i.e shrub or bush, another meaning is pindakara as per the chakrapani .

3. Nirukti of gulma गुपितानिलमूलत्वाद्गूढमूलोदयादपि गुल्मवद्वा विशालत्वाद्गुल्म इत्यभिधीयते निबन्धसङ्ग्रह व्याख्या (डल्हण कृत) अथ गुल्मनिरुक्तिमाह- गुपितानिलमूलत्वादित्यादि गुपितानिलमूलत्वात् आकुलीकृतवायुमूलत्वात्, एतेन सर्वगुल्मानां वायुः कारणम्| गूढमूलोदयादिति गूढमूलाः कन्दादयः,तेषामिवोदयादुत्पत्तेः; अन्ये तु गूढमूलो गुप्तकारण उदयो यस्य स तथा तस्मात्, मूलस्य वायोर्गूढत्वमावृतत्वमुच्यते तत्प्रकोपद्वैविध्यात्; तथा - च “ वायोर्धातुक्षयात् कोपो मार्गस्यावरणेन च”-इति |

4. The ways of understanding & concept of gulma according to our acharyas are different. The analogy, keen observation and the way of understand of the concept of gulma according to different acharyas concept helps a lot in our clinical practice.

5. According to acharya Charaka The word meaning of gulma is pindakara (round and hard mass) while explaining the vataja , pittaja , kaphaja , sannipataja , raktaja gulma lakshanas is unique as that of root meaning of gulma i.e pindakara - nodules or mass. So for the better understanding of cahrakokta gulma is tumours , the terms "mass" and "nodule" is often used synonymously with "tumor". Generally speaking, however, the term "tumor" is used generically, without reference to the physical size of the lesion. Tumor  is not synonymous with  cancer . While cancer is by definition malignant, a tumor can be benign ,  pre-malignant or  malignant or can represent a lesion without any cancerous potential what so ever.

6. According to shushrutha acharya हृद्बस्त्योरन्तरे ग्रन्थिःसञ्चारी यदि वाऽचलः | चयापचयवान् वृत्तः स गुल्म इति कीर्तितः || while explaining the lakshanas of vataja pittaja kaphaja , sannipatja , raktaja gulma they mention amurtha lakshanas . So, For the better understanding we concluded that shushrutokta gulma is Gastritis, in kannada we call it as Batti roga , in the batti roga or Gastritis around the umbilical region we can palpate as a round mass like structure, it is an pulsatile and moving around the abdomen and also other lakshanas like cathing & spasmodic pain in heart, parshwa (back of the chest), around the umbilicus, etc.

7. Ayurvedic scholars define it as the abdominal lump which is caused due to aggravation and encapsulation of Vata Dosha ( kupita Anila moodhatwat ) which does not give clue about its site of origin ( Goodha Gulmodaya ) which spreads widely like the shrubs ( Gulmavat vishalatwaat ). It is usually known as gaseous tumor of abdomen.

8. Gulma – Causative factors:   1. Excess intake of Vata aggravating foods  (dry, light, rough, spicy) 2. Constipation or improper bowel habit 3. Suppression of natural urges 4. Pressure exerted by external causes like injury, hit, compression etc 5. Excess food intake 6. Grief / stress 7. Improperly carried Panchakarma treatment

9. Gulma – Origin of the disease: The causative factors lead to severe aggravation of Vatadosha at the level of abdomen. This further vitiates Pitta and Kapha in the localized area and obstruct the passage of the channels. Due to the blockage of the morbid factor, they are stagnated and localized in abdominal organs like intestines, liver. According to the site and Dosha involvement, the features are exhibited. Usually, the condition is manifested in epigastrium , umbilicus, pelvic cavity and in lumbar/iliac regions.

10. Types 1.  Vataja 2.  Pittaja 3. Kaphaia 4. Tridoshic 5. Raktaja (in female, refers to uterine fibroids)

11. Stages of Gulma : 1. Immature (recent onset) tumors: Tumors are heavy, hard, situated beneath the muscles, without change or color and fixed firmly. 2. Maturing tumours : The Tumors are burning, painful, causing agony, loss of sleep, irritation, and fever. 3. Matured (suppurated) gaseous tumors: The tumors are burning, bluish red in color, palpable like bladder and severe painful in nature.

12. Specific features of gulma : 1.Vatik Gulma : Obstruction of flatus, dryness of the throat and mouth, shivering, fever, pain in heart and abdominal sides, shoulder and head, aggravates on empty stomach and relieved on ingestion of food; the condition is worsened by dry-astringent-bitter and pungent substances. 2.  Pittaja gulma : In the condition, fever, thirst, redness of the face, pain, sweating, burning and tenderness are complained by the patients. 3. Kaphajagulma : This produces inertia, shivering, fever, body ache, nausea, cough, tastelessness, heaviness, and hard elevated non inflammatory masses.

13. 4. Dwidoshaja and sannipataja : According to the dosha involvement mixed features are observed. 5. Raktaja gulma : Menstruating women indulging in fasting or using excess of dry food, facing the fearsome events, suppressing the natural urges, subjecting to therapies which arrest the free outgoing of blood and vomiting, suffering from uterine dysfunction etc, cause the vitiation of menstrual blood. This, in turn lead to the occurrence of Raktaja gulma (fibroid). Here, pulsating tumor, gradually taking the shape of the round mass, with pain and producing the features or pregnancy (like amenorrhoea , pigmented nipples, morning sickness etc). Acharya Ksharapani stated that Raktaj gulma may found in men also. Often this produces this pain and burning sensation with the features of Pittaja Gulma . Raktaj gulma is easly treatable after 10 months as per Acharya charak .

14. Treatments Vataj वातगुल्मार्दितंस्निग्धंयुक्तंस्नेहविरेचनैः| उपाचरेद्यथाकालंनिरूहैःसानुवासनैः ||१६ Su.U Pittaj पित्तगुल्मार्दितंस्निग्धंकाकोल्यादिघृतेनतु | विरिक्तं मधुरैर्योगैर्निरूहैःसमुपाचरेत् ||17 Su.U Kaphaj श्लेष्मगुल्मार्दितंस्निग्धंपिप्पल्यादिघृतेनतु |तीक्ष्णैर्विरिक्तंतद्रूपैर्निरूहैःसमुपाचरेत् ||18 Su.U

15. Treatment : Surgical Aspects Raktamokshana सशूले सोन्नतेऽस्पन्दे दाहपाकरुगन्विते ||52|| गुल्मे रक्तं जलौकोभिःसिरामोक्षेण वा हरेत् |53| Su.U Shashtra karma in pakva gulam by Acharya charak . Acharya Baghbhatta also discribes a type of raktamokshan technique in kaphaj gulam known as Ghati yantra , A type of cupping therapy. He describe the procedure as a hot pot of soil placed on gulma site , after saome time whem gulma come inside the pot then , gulma is dissolved by hands or some instruments like Vimarga , Ajpad , Adarsh . For the bhedan of gulma Acharya Sushruta advised some medicated varti made from different preprations .

16. Abdominal lump Abdominal aortic aneurysm Bladder distention Cholecystitis (an inflammation of the gallbladder) Colon cancer Crohn's disease Bowel obstruction Diverticulitis Gallbladder tumor Hydronephrosis (fluid-filled kidney) Kidney cancer (including renal cell carcinoma) Liver cancer Hepatomegaly (Liver enlargement) Neuroblastoma Ovarian cyst Pancreatic abscess Pancreatic pseudocyst Splenomegaly (Spleen enlargement) Stomach cancer Uterine leiomyoma (fibroids) Volvulus (twisted piece of the gastrointestinal tract) Uretero -pelvic junction obstruction

17. Migratory abdominal lump Torsion of the Wandering Spleen, Seen as a Migratory Abdominal Mass A case report published in in RSNA Radiology April 1977 Volume 123, Issue 1 DOI: http://dx.doi.org/10.1148/123.1.36 Abstract : Torsion of the wandering spleen is an unusual cause of an acute abdomen, rarely diagnosed preoperatively. The authors describe a case which was suspected prior to surgery and confirmed by radionuclide imaging. Radiographic findings include an extrinsic mass on barium-enema examination and absence of the splenic shadow in the left upper quadrant. Wandering spleen (or Pelvic spleen ) is a rare medical disease caused by the loss or weakening of the ligaments that help to hold the spleen stationary

18. Abdominal tuberculosis Indian J Med Res 120, October 2004, pp 305-31 Ileocaecal tuberculosis Patients complain of colicky abdominal pain, borborygmi and vomiting. Abdominal examination may reveal no abnormality or a doughy feel. A well defined, firm, usually mobile mass is often palpable in the right lower quadrant of the abdomen. Associated lymphadenitis is responsible for the presence of one or more lumps which are mobile if mesenteric nodes are involved and fixed if para -aortic or illiac group of nodes are enlarged.

19. Ind. J. Tub. 2000, 47, 101 ISOLATED TUBERCULOUS MESENTERIC ABSCESS -A CASE REPORT D. Vijaya1, T.K. Lakshmi Kanth1*, S.I.S. Khadri1*, H.C. Suresh Chandru3* and A. Malini4 Local examination revealed a firm mobile mass measuring 7x5 cms with defined margin in the right iliac and lu.nbar regions. Sputum and urine were negative for acid fast bacilli. Mantoux test was positive. Clinical diagnosis of appendicular a Laparotomy showed a spherical 8 cm isolated mass medial to the caecum , in the root of mesentry . All other organs were normal. There was no mesenteric lymphadenitis. Pus aspirated from the abscess cavity was sent to the Microbiology bscess / ileocaecal tuberculosis was made. mesenteric cold abscess might be secondary to symptomless pulmonary tuberculosis which probably spread to the mesentery after swallowing sputum. This report emphasizes the diverse clinical features of abdominal tuberculosis and the need for a high index of suspicion for the proper management of such cases.

20. 1230 Proc. roy . Soc. Med. Volume 62 December 1969 Clinical Features and Surgical Management of Ileocecal Tuberculosis

21. Uterine fibroid Signs and symptoms Fibroids, particularly when small, may be entirely asymptomatic. Symptoms depend on the location and size of the fibroid. Important symptoms include abnormal uterine bleeding, heavy or painful periods, abdominal discomfort or bloating , painful defecation , back ache, urinary frequency or retention , and in some cases, infertility. There may also be pain during intercourse, depending on the location of the fibroid. During pregnancy they may also be the cause of miscarriage, bleeding, premature labor, or interference with the position of the fetus Location and classification a= subserosal fibroids b=intramural fibroids c= submucosal fibroid d= pedunculated submucosal fibroid e=fibroid in statu nascendi f= intraligamental fibroid

22. Treatments Most fibroids do not require treatment unless they are causing symptoms. After menopause fibroids shrink and it is unusual for them to cause problems. In those who have symptoms uterine artery embolization and surgical options have similar outcomes with respect to satisfaction. Symptomatic uterine fibroids can be treated by: medication to control symptoms medication aimed at shrinking tumors ultrasound fibroid destruction myomectomy or radio frequency ablation hysterectomy uterine artery embolization

23. Conclusion It is very difficult to correlate the gulma with a single entity in modern context. Gulma has various presentation. There is no definite etiology. Various condition having suppurated or nonsuppurated abdominal mass with or without association of other sign/ symptoms may include in gulma . Medicinal management was preferred by acharyas . Raktamokshan is the common procedure advocated by most of the acharyas .