Gulma (abdominal swelling) according to Caraka

Maharṣi Caraka discusses disease of Gulma and treatment of Phantom Tumour or Gulma-cikitsā. A palpable lump-like swelling in the abdominal region due to vitiated vāta is called "Gulma". According to Bhāvaprakāśa, a glandular or immobile spherical homogeneous substance is produced between the heart and the urinary bladder, which is sometimes enlarged, sometimes reduced, and is called a Gulma.

According to Ācārya Mādhavakara, a substance that grows or shrinks in the middle of the heart and navel, which is a circulating or motionless gland, is called a Gulma. The cause of the Gulma disease is: the vitiated Vāta provokes either Kapha or Pitta or both of them, and along with them, blocks the channels of circulation to cause pain in the regions of heart, umbilicus, sides of the chest, abdomen and urinary bladder. If dose not gets removed through the downward path because of obstructions. It remains confined to the colon, small intestine or stomach either independently or in association with other doṣas. It becomes palpable because of its round shape for which it is called ‘Gulma’.

The premonitory symptoms of all the five types of gulma are: loss of desire to take food, anorexia, indigestion, irregularity in the power of digestion, incomplete digestion of food, vomiting, eructation during the process of digestion without any specific cause, non-manifestation of the urges for doṣas, urination and defecation, even if such urges are manifested, there is no excretion or excretion occurs only in small quantity, colic pain due to vāta, meteorism, intestinal gurgling, horripilation, misperistalsis, loss of appetite, weakness and intolerance to heavy food^[1].

The five locations of manifestation of gulma are: urinary bladder, umbilicus, heart and two sides of the abdomen.

There are five types of Gulma, namely,

1. Vātajagulma,
2. Pittajagulma,
3. Śleṣmajagulma,
4. Sāṃnipātikagulma and
5. Raktajagulma.

Vātaja-gulma is caused by rough eating, extreme or excessive physical exertion, suppression of the manifested natural urges, grief, external injury and extreme weakness, and fasting for a long time. The following signs and symptoms of Vātajagulma are: momentary changes in the location, shape and intensity of pain; obstruction to the passage of the feces and flatus; dryness in the throat and mouth; grey and reddish coloration of the body; fever with cold; pain in the region of heart, lower abdomen, sides of the abdomen, scapula and head; aggravation of the disease after the food is digested and alleviation of the ailment by the intake of food. That gulma is called Vātajagulma because it is produced from vāyu. This gulma does not tolerate ununctuous, astringent, bitter and pungent substances. The following methods of treatment of Vātaja-gulma are used—Unction; sudation; enema -both ununctuous and unctuous enema; Emesis therapy used in excess Kapha; purgation therapy used in excess pitta.

Symptoms of Pittaja-gulma include: increased temperature of the body, thirst, increase in pain during digestion, severe pain on touching (as in abscess), burning sensation etc. The causes of gallstones are as follows—intake of pungent, sour, sharp, hot, vidāhī and ununctuous articles of diet; wrathful disposition; excessive intake of alcohol and exposure to sun as well as fire; affliction by ama and vitiation of blood. The treatment of gallstones is as follows: Kṣīra basti or enema with milk prepared with bitter drugs, purgation, rakta-mokṣaṇa or bloodletting, surgery is used, when the gulma has suppurated (Pakva), then follow the treatment of an internal abscess.

Symptoms of Śleṣmaja-gulma include: coldness of the body, fever beginning with cold, anorexia, indigestion, laziness, timidity, malaise, horripilation, heart disease, emesis, excessive sleep, heaviness and pain in the head. The causes of Śleṣmajagulma are as follows: intake of food in large quantity; intake of excessively unctuous, heavy, sweet and cold food; intake of pastry, preparations of sugar cane juice, milk, tilamāṣa and sugar candy; intake of immature curd and wine in excess; intake of Harītakī, the flesh of marshy, aquatic and domestic animals in excess; suppression of the manifested natural urges; intake of large quantity of water in the absence of appetite; and physical assault.

Different treatments for Śleṣmajagulma are applied -fasting, emesis, intake of ghee processed with pungent and alkali, purgation, therapeutic enema, application of alkali, use of fermented drinks or Ariṣṭa and thermal cautery or agni karma.

The Sāṃnipātika-gulma is incurable inasmuch as there is a sort of mutual contradiction involved in its treatment. The contradiction in treatment is because of the abnormal heterogenous combination of the three dosas. In cases, where there is no abnormal heterogenous combination of dosas as in a type of Sāṃnipāta-Jvara the disease may not be taken as incurable.

Symptoms of Sāṃnipātikagulma are: excruciating pain; excessive burning sensation; stone like compactness and elevation of the affected part; quick sloughing, seriousness of the condition; and disappearance of the strength of the mind, body and digestion as well as metabolism. The following medicines are used to treat this disease-Tryūṣaṇādi ghṛta, Hiṅgūsauvarcalādi ghṛta, Pippalyādi ghṛta, Ṣaṭpala ghṛta, Dantīharītakī, Hiṅgvādi powder or tablets, Laśuna Kṣīra, taila pañcaka, Dantī Harītakī, Śilājatu, Nīlinyādi ghṛta, Vasā ghṛta, Bhallātakādya ghṛta.

Raktaja-gulma form in a woman's uterus. Therefore, it belongs to the woman. Doctors call it an ovarian tumour. Symptoms of Raktajagulma are: remaining without food during the period of fertility; fear, intake of excessively un-unctuous food and suppression of the manifested natural urges; improper administration of astringent and emetic therapies and morbidity of genital organs. The cause of ovarian tumours is collection of menstrual blood, features similar to that seen in pregnancy. In the Kāśyapa Saṃhitā or Vṛddha-Jīvakatantra. In the chapter titled ‘Raktagulmaviniścaya’ in the Khilasthāna, this is discussed. Here are the differential symptoms described as follows:

Table 1: Vibhedaka Symptoms of Raktagulma^[2]

Raktagulma	Sahajagarbha
niraṅgaḥ vṛttaḥ	aṅga-pratyaṅgavāna
avyāviddhaṃ vivarttate	vyāviddhaṃ parivarttate
manduṃ manduṃ vivardhate	ahanyahani vardhate

(Source: Caraka-Samhita–Vol. II)

All these symptoms develop after three months of the patient. Treatment of Raktagulma is as follows: Treated only after tenth months, purgation (sneha Virecana), intake of Palāśa kṣāra, vaginal douche, disintegrating the swelling, with measures like enema of Daśamūla with kṣāra, Cow’s urine. In addition, Snehapāna is regarded to be the best treatment for gulma above the umbilicus. Also, the use of Basti is regarded to be the best treatment for gulma in Pakvāśaya and Jaṭhara^[3].

Footnotes and references:

[1]:

anannābhilaṣaṇam, arocakāvipākau, agnivaiṣamyaṃ vidāho bhuktasya, pākakāle cāyuktayā chard्yudgārau, vātamūtrapurīṣavegānāṃ cāprādurbhāvaḥ, prādurbhūtānāṃ cāpravṛttirīṣadāgamanaṃ vā, vātaśūlāṭopāntrakujanāpariharṣaṇāti vṛttapurīṣatāḥ, abubhukṣā, daurbalyaṃ, sauhitasya cāsahatvamiti | (C. Nidānasthāna–III.15); R. K. Sharma & Bhagwan Dash (eds.), Caraka Saṃhitā–Vol. II, Varanasi, Chowkhamba Sanskrit Series Office, 2017, p. 51.

[2]:

Baidyacharya Kalikinkar Sensarma & Ayurbedacharya Satyasekhar Bhattacharya (eds.), Caraka- Samhita–Vol. II, trans. Kabiraj Jasodanandan Sirkar, Kolkata, Deepayan Publication, 2013, p. 277.

[3]:

C. Cikitsāsthāna–V.4-182; Caraka Saṃhitā -Vol. II with elaborated Vidyotini Hindi Commentary, trans. Kasinatha Pandey & Gorakha Natha Chaturvedi, Varanasi, Chaukhambha Bharati Academy, 2015, pp. 199-227.