Gulma Chikitsa
Chikitsa Sthana Chapter 5.Management of Gulma
| Section/Chapter | Chikitsa Sthana Chapter 5 |
|---|---|
| Preceding Chapter | Raktapitta Chikitsa |
| Succeeding Chapter | Prameha Chikitsa |
| Other Sections | Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Kalpa Sthana, Siddhi Sthana |
| Translator and commentator | Singh G. |
| Reviewer | Bhagwat M., Tripathi J.S., Gadgil D. |
| Editors | Baghel M.S., Deole Y.S., Basisht G. |
| Year of publication | 2020 |
| Publisher | Charak Samhita Research, Training and Skill Development Centre |
| DOI | 10.47468/CSNE.2020.e01.s06.006 |
Abstract
Gulma is defined as large palpable, rounded, intra- abdominal swellings between hridaya (cardiac region) and the basti (bladder) regions, which develop due to excess accumulation of doshas with predominance of vata. Such swellings are either transitory or static, and display the properties of spontaneous regression and reappearance. This chapter on the treatment of gulma (abdominal lumps) first describes its general etiological factors and pathogenesis along with five places in the abdomen where the swelling occurs. The treatment of vata gulma includes snehana (oleation), swedana (sudation), brimhana (repletion), basti with ghee, virechana, vamana and preparations in the form of powders, pills and medicated ghrita and as a last resort bloodletting. For the treatment of pitta gulma, the ghrita prepared with bitter (tikta) drugs, virechana, recipes for niruha basti, blood-letting (raktamokshana), use of milk, counseling (ashvasana) and oral recipes have been elaborated. Upanaha (poultice), shodhana and surgical measures for suppurated and internally ruptured gulma have also been described.
For kapha gulma snehana, swedana, bhedana (puncturing), langhana (lightening therapy), vamana, virechana, medicated ghee, basti, pills, powder, arishta, and kshara are described. Bloodletting followed by cauterization of the gulma as a last resort is explained. A surgical procedure for rakta gulma, which occurs only in women is also described.
Wholesome (pathya) food and drinks, avoidance of etiological factors, continuous protection of digestive power (agni) and the instructions for a patient who undergoes snehana are discussed in detail.
Keywords: Gulma (abdominal lumps), Pathya (whole some), Raktamokshana (bloodletting), Apathya (unwholesome)
Introduction
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) 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.
Gulma is defined as a palpable round compact lump in the abdomen. Thus, all the localized palpable masses in the abdomen are classified under gulma, but they are named depending upon the dominance of dosha or the place. Its four types belong to dosha i.e. three of single dosha and one of a combination of all the three dosha and the fifth one is rakta gulma which occurs only in females in uterine cavity (garbhashayashroni). Sannipata Gulma has been given synonym as nichaya-gulma.
Sanskrit text, Transliteration and English Translation
Management of Gulma (abdominal lumps)
Now we shall expound the chapter "Gulma Chikitsa" (Management of abdominal lumps and other diseases) . Thus said Lord Atreya. [1-2]
सर्वप्रजानां पितृवच्छरण्यः पुनर्वसुर्भूतभविष्यदीशः|
चिकित्सितं गुल्मनिबर्हणार्थं प्रोवाच सिद्धं वदतां वरिष्ठः||३||
Punarvasu the fatherly figure for all, who has knowledge of past and future, who is the best among the exponents, describes the treatment for the complete eradication of gulma [3]
Etio-pathogenesis of gulma
विट्श्लेष्मपित्तातिपरिस्रवाद्वा तैरेव वृद्धैः परिपीडनाद्वा|
वेगैरुदीर्णैर्विहतैरधो वा बाह्यभिघातैरतिपीडनैर्वा||४||
रूक्षान्नपानैरतिसेवितैर्वा शोकेन मिथ्याप्रतिकर्मणा वा|
विचेष्टितैर्वा विषमातिमात्रैः कोष्ठे प्रकोपं समुपैति वायुः||५||
Following are the general causative factors of gulma:
- Excessive excretion of feces, kapha and pitta or due to pressure exerted by their excessive aggravation,
- Suppression of downward natural urges (like feces, flatus and urine),
- Physical trauma,
- By excessive pressure (on abdomen),
- By taking food articles and drinks having excessive dry property,
- Excessive grief,
- Improper implementation of Panchakarma procedures,
- Excessive wrongful body activities,
Due to the above mentioned factors vata gets aggravated in koshtha i.e. thoraco-abdominal cavity [4-5]
General Pathogenesis of gulma
कफं च पित्तं च स दुष्टवायुरुद्धूय मार्गान् विनिबद्ध्य ताभ्याम्|
हृन्नाभिपार्श्वोदरबस्तिशूलं करोत्यथो याति न बद्धमार्गः||६||
The provoked vata takes out kapha and pitta from their sites and in turn gets blocked its own passage by them. Thus, blocked vata is unable to move properly leading to pain in the regions of heart, umbilicus, both sides of abdomen and urinary bladder [6]
Cardinal Signs of Gulma
पक्वाशये पित्तकफाशये वा स्थितः स्वतन्त्रः परसंश्रयो वा|
स्पर्शोपलभ्यः परिपिण्डितत्वाद्गुल्मो यथादोषमुपैति नाम||७||
Formation of a palpable mass in colon, gall-bladder or stomach which may be independent or associated with other dosha is known as gulma. It is named according to the dosha involved. [7]
Five sites of gulma
बस्तौ च ना भ्यां हृदि पार्श्वयोर्वा स्थानानि गुल्मस्य भवन्ति पञ्च|
पञ्चात्मकस्य प्रभवं तु तस्य वक्ष्यामि लिङ्गानि चिकित्सितं च||८||
Five places of gulma are urinary bladder (hypogastric region), umbilical region (nabhi), cardiac region (hridi) and two flanks (parshva). Henceforth I will explain the causes, symptoms and the treatment of these five types of gulma [8]
Causative factors of vata dominant gulma
रूक्षान्नपानं विषमातिमात्रं विचेष्टितं वेगविनिग्रहश्च|
शोकोऽभिघातोऽतिमलक्षयश्च निरन्नता चानिलगुल्महेतुः||९||
Excessive use of dry articles of food and drinks, excessive or wrong body activities, suppression of natural urges, excessive grief, too-much diminution of feces, trauma and excessive fasting are the causes of vata-gulma [9]
Symptoms of vata gulma
यः स्थानसंस्थानरुजां विकल्पं विड्वातसङ्गं गलवक्त्रशोषम्|
श्यावारुणत्वं शिशिरज्वरं च हृत्कुक्षिपार्श्वांसशिरोरुजं च||१०||
करोति जीर्णेऽभ्यधिकं प्रकोपं भुक्ते मृदुत्वं समुपैति यश्च|
वातात् स गुल्मो न च तत्र रूक्षं कषायतिक्तं कटु चोपशेते||११||
Frequent change in the site, shape and pain of the lump along with obstruction of feces and flatus, dryness in throat and mouth, dusky-red color of body, fever with chills, pain in the cardiac, umbilical, flanks and shoulder regions and headache are the sign and symptoms of vata gulma. The symptoms decrease on taking of food but increase on completion of digestion as well as by taking dry substances or having astringent, bitter and pungent tastes [10-11]
Causative factors and pathogenesis of pitta dominant gulma
कट्वम्लतीक्ष्णोष्णविदाहिरूक्षक्रोधातिमद्यार्कहुताशसेवा|
आमाभिघातो रुधिरं च दुष्टं पैत्तस्य गुल्मस्य निमित्तमुक्तम्||१२||
Taking of food articles having pungent and sour tastes and piercing, hot, irritant (vidahi) and dry properties; excessive wines; exposure to sun and heat; indulgence in anger, affliction by ama and vitiation of rakta are the causative factors of pitta-gulma [12]
Symptoms of pitta-gulma
ज्वरः पिपासा वदनाङ्गरागः शूलं महज्जीर्यति भोजने च|
स्वेदो विदाहो व्रणवच्च गुल्मः स्पर्शासहः पैत्तिकगुल्मरूपम्||१३||
Fever, thirst, redness of mouth and other organs, excessive pain during digestion, sweating, burning sensation and tenderness in the lesion like that of ulcer are the signs and symptoms of pitta-gulma [13]
Causative factors of kapha-gulma and nichaya-gulma
शीतं गुरु स्निग्धमचेष्टनं च सम्पूरणं प्रस्वपनं दिवा च|
गुल्मस्य हेतुः कफसम्भवस्य सर्वस्तु दिष्टो निचयात्मकस्य||१४||
Excessive intake of food articles having cold, heavy and unctuous properties and excessive eating, sedentary life style and day-sleep are the causative factors of kapha-gulma.
All the causative factors mentioned for all the above three types of dosha gulma are also of nichaya (tridosha)-gulma [14]
Symptoms of kapha dominant gulma
स्तैमित्यशीतज्वरगात्रसादहृल्लासकासारुचिगौरवाणि|
शैत्यं रुगल्पा कठिनोन्नतत्वं गुल्मस्य रूपाणि कफात्मकस्य||१५||
Feeling as covered by wet cloth, fever with chills, exhaustion of limbs, nausea, cough, anorexia, heaviness, cold and mild pain with palpable hard and protruded mass are the signs and symptoms of kaphaja-gulma [15]
Dvi-doshaja gulma
निमित्तलिङ्गान्युपलभ्य गुल्मे द्विदोषजे दोषबलाबलं च|
व्यामिश्रलिङ्गानपरांस्तु गुल्मांस्त्रीनादिशेदौषधकल्पनार्थम्||१६||
Three types of dvi-doshaja gulma (vata-pitta, vata-kapha and kapha-pitta) are produced by the mixture of causative factors of two involved dosha. These gulma manifest the signs and symptoms of two involved dosha. These varieties are mentioned here for the purpose of the treatment which can be planned on the basis of degree of provocation of each dosha [16]
Signs and symptoms of tri-doshaja gulma
महारुजं दाहपरीतमश्मवद्घनोन्नतं शीघ्रविदाहि दारुणम्|
मनःशरीराग्निबलापहारिणं त्रिदोषजं गुल्ममसाध्यमादिशेत्||१७||
The symptoms of tri-dosha gulma include agonizing pain and excessive burning sensation, elevated mass, stony hard and quick to mutilate. It is a very serious condition and leads to diminution of strength of body, mind and digestion. It is incurable [17]
Causative factors of rakta gulma
ऋतावनाहारतया भयेन विरूक्षणैर्वेगविनिग्रहैश्च|
संस्तम्भनोल्लेखनयोनिदोषैर्गुल्मः स्त्रियं रक्तभवोऽभ्युपैति||१८||
During ritu-kala (ovulation period) if a woman does fasting or takes dry food articles or indulges in fear and suppression of natural urges; or misuses styptic (stambhana) drugs i.e. try to stop the menstrual bleeding; improper conduction of vomiting therapy and disorders of genital organs, all these may lead to formation of rakta gulma in women [18]
Symptoms of rakta gulma
यः स्पन्दते पिण्डित एव नाङ्गैश्चिरात् सशूलः समगर्भलिङ्गः|
स रौधिरः स्त्रीभव एव गुल्मो मासे व्यतीते दशमे चिकित्स्यः||१९||
The lump slowly grows in the form of round mass which has pulsation as a whole but not in its part. It is associated with acute pain and signs and symptoms mimicking pregnancy. Raktaja gulma occurs only in women and should be treated after the completion of ten months [19]
क्रियाक्रममतः सिद्धं गुल्मिनां गुल्मनाशनम्|
प्रवक्ष्याम्यत ऊर्ध्वं च योगान् गुल्मनिबर्हणान्||२०||
Now onward first the successful line of treatment shall be described for the cure of gulma. Thereafter, the remedies and recipes for its cure shall be described [20]
Treatment of vata-gulma
As vata gulma is produced due to excessive dryness and exercise and is associated with severe pain and retention of feces and flatus, therefore in the beginning snehana (unctuous) therapy should be prescribed [21]
Snehana for vata-gulma
Snehana is performed by administration of unctuous substances in the form of food and drink, oil massage and anuvasana basti along with niruha basti. After proper snehana, physician should subject the patient to swedana therapy [22]
Benefit of swedana therapy for vata-gulma
स्रोतसां मार्दवं कृत्वा जित्वा मारुतमुल्बणम्|
भित्त्वा विबन्धं स्निग्धस्य स्वेदो गुल्ममपोहति||२३||
Swedana therapy administered to a patient who has already undergone oil massage produces softness in the channels leading to alleviation of vata. Thus by breaking the obstruction and opening the channels the vata-gulma is cured [23]
Mode of Administration of sneha according to sites of vata gulma
Oral administration of unctuous substances is beneficial in vata gulma particularly if it is situated above the umbilicus i.e. in stomach. Anuvasana (unctuous) basti is beneficial if gulma is situated in colon and both oral administration of unctuous substances and unctuous basti are beneficial if it is situated in the middle of jathara i.e. in small intestine [24]
दीप्तेऽग्नौ वातिके गुल्मे विबन्धेऽनिलवर्चसोः|
बृंहणान्यन्नपानानि स्निग्धोष्णानि प्रयोजयेत्||२५||
In vata gulma if the retention of feces and flatus is present but digestion is good then unctuous, hot and nourishing (brimhana) diet and drinks should be given [25]
Repeated basti in vata gulma
In vata gulma repeated use of unctuous drink and alternative use of anuvasana (unctuous) and niruha (un-unctuous) basti are advised in taking care of kapha and pitta [26]
कफो वाते जितप्राये पित्तं शोणितमेव वा|
यदि कुप्यति वा तस्य क्रियमाणे चिकित्सिते||२७||
यथोल्बणस्य दोषस्य तत्र कार्यं भिषग्जितम्|
आदावन्ते च मध्ये च मारुतं परिरक्षता||२८||
During the treatment when vata has almost subsided but kapha, pitta or rakta gets provoked, then routine treatment of these provoked dosha should be done. In this condition, the treatment should be according to the predominance of dosha but care should be taken to protect vata in the beginning, middle and at the end of the treatment [27-28]
Vamana in vata gulma
वातगुल्मे कफो वृद्धो हत्वाऽग्निमरुचिं यदि|
हृल्लासं गौरवं तन्द्रां जनयेदुल्लिखेत्तु तम्||२९||
In vata gulma if kapha gets increased, it causes diminution in digestion leading to anorexia, nausea, heaviness and sleepiness; such condition should be treated with vamana therapy [29]
In vata-kapha dominant gulma if there is acute pain, distension of abdomen and constipation then it should be treated with suppositories, pills and powders which are prepared from vata and kapha pacifying drugs [30]
Virechana in vata gulma
पित्तं वा यदि संवृद्धं सन्तापं वातगुल्मिनः|
कुर्याद्विरेच्यः स भवेत् सस्नेहैरानुलोमिकैः||३१||
In vata gulma if increased pitta causes burning sensation then virechana should be done with laxative drugs mixed with unctuous substances [31]
Blood-letting in vata gulma
If gulma does not subside even after proper treatment of vata etc. mentioned above then bloodletting is advised to cure it [32]
Treatment of pitta dominant gulma
स्निग्धोष्णेनोदिते गुल्मे पैत्तिके स्रंसनं हितम्|
रूक्षोष्णेन तु सम्भूते सर्पिः प्रशमनं परम्||३३||
If pitta gulma is caused by indulging in unctuous and hot substances then virechana is beneficial. But if it is caused by indulging in dry and hot substances then ghee is a choice of drug [33]
पित्तं वा पित्तगुल्मं वा ज्ञात्वा पक्वाशयस्थितम्|
कालविन्निर्हरेत् सद्यः सतिक्तैः क्षीरबस्तिभिः||३४||
पयसा वा सुखोष्णेन सतिक्तेन विरेचयेत्|
भिषगग्निबलापेक्षी सर्पिषा तैल्वकेन वा||३५||
If pitta or pitta-gulma is situated in colon, the physician expert in proper and timely treatment should eliminate it by giving kshira-basti mixed with bitter drugs immediately. The physician aiming to increase the digestive power should perform virechana with milk mixed with bitter drugs or with tilvaka ghrita [34-35]
Blood-letting in pitta dominant gulma
The patient of pitta-gulma if having thirst, fever, burning sensation, pain, perspiration, impaired digestion and anorexia is treated with bloodletting [36]
छिन्नमूला विदह्यन्ते न गुल्मा यान्ति च क्षयम्|
रक्तं हि व्यम्लतां याति, तच्च नास्ति न चास्ति रुक्||३७||
Provoked rakta is responsible for inflammation (vidaha) which is removed by bloodletting; thus when root-cause is removed then there will be no inflammation resulting in vanishing of swelling and pain [37]
Diet after blood-letting
The patient may become weak due to elimination of vitiated blood; hence he should be nourished by the diet comprising of meat soup of wild animals and comforted. To pacify the remaining complaints, he should be prescribed the medicated ghee again [38]
In case of excessive increase of pitta and rakta or due to unavailability of proper treatment, if suppuration occurs then surgery should be performed by the surgeon [39]
Apakva gulma (intial non-suppurative stage)
Immovable lump of gulma which is deeply situated under the flesh and hard and heavy to palpate and whose color remains unchanged is considered as apakva i.e. non-suppurative [40]
Symptoms of suppurating (vidahamana) gulma
The gulma with symptoms of burning sensation, much pain, very much irritation and discomfort, loss of sleep and fever indicates that it is about to suppurate. In this condition upanaha (poultice) is indicated. [41]
Symptoms of suppurated gulma
विदाहलक्षणे गुल्मे बहिस्तुङ्गे समुन्नते|
श्यावे सरक्तपर्यन्ते संस्पर्शे बस्तिसन्निभे||४२||
निपीडितोन्नते स्तब्धे सुप्ते [४] तत्पार्श्वपीडनात्|
तत्रैव पिण्डिते शूले सम्पक्वं गुल्ममादिशेत्||४३||
If gulma protrudes pointing toward outside and skin over the lesion becomes stiff and numb and its color changes to dusky with red margins. On palpation, the lump resembles as bladder filled with water, pitting on pressure, but on pressing from side the mass becomes tense with mild pain, otherwise it feels compressed mass with acute pain; all these signs and symptoms indicate that the gulma has suppurated [42-43]
The suppurated gulma requires surgical intervention such as incision, cleansing and healing therefore it should be treated by a surgeon [44]
अन्तर्भागस्य चाप्येतत् पच्यमानस्य लक्षणम्|
हृत्क्रोडशूनताऽन्तःस्थे [५] बहिःस्थे पार्श्वनिर्गतिः||४५||
The above mentioned symptoms also occur in suppurating (pachyamana) internal gulma. Only difference is that in the internal gulma there is swelling in cardiac region of the abdomen while exterior gulma protrudes towards sides of abdomen [45]
Management of pus discharging gulma
पक्वः स्रोतांसि सङ्क्लेद्य व्रजत्यूर्ध्वमधोऽपि वा|
स्वयम्प्रवृत्तं तं दोषमुपेक्षेत हिताशनैः [६] ||४६||
दशाहं द्वादशाहं वा रक्षन् भिषगुपद्रवान्|
Suppurated gulma on softening of the passage discharges the pus upwards or downwards. In case of gulma starts discharging at its own then the physician should wait and watch for ten or twelve days while taking care that no complication occurs [46]
अत ऊर्ध्वं हितं पानं सर्पिषः सविशोधनम्||४७||
शुद्धस्य तिक्तं सक्षौद्रं प्रयोगे सर्पिरिष्यते|४८|
Oral administration of ghee with cleansing of the discharging ulcer with shodhana drugs are beneficial. After the cleansing, medicated ghee prepared with bitter drugs should be given with honey [48]
Management of kaphaja gulma
Indications of langhana
शीतलैर्गुरुभिः स्निग्धैर्गुल्मे जाते कफात्मके||४८||
अवम्यस्याल्पकायाग्नेः कुर्याल्लङ्घनमादितः|
Kapha-gulma if caused by indulgence in cold, heavy and unctuous diet and in those not eligible for vamana, langhana (depletion) therapy should be prescribed in the beginning. [48]
Indications of vamana
Vamana is indicated in a patient of gulma who is having low digestion, anorexia, nausea and mild pain, heaviness and stiffness in abdomen [49]
After the treatment with vamana and langhana, the patient should be given hot (ushna) therapy and food mixed with pungent and bitter substances [50]
सानाहं सविबन्धं च गुल्मं कठिनमुन्नतम्||५१||
दृष्ट्वाऽऽदौ स्वेदयेद्युक्त्या स्विन्नं च विलयेद्भिषक्|
If the gulma is hard and protruded accompanied with constipation and distension of abdomen then physician should give sudation locally to dissolve it [51]
After performing langhana, vamana and swedana therapies when digestion is improved, the patient of kapha gulma should be given ghee prepared with bitter substances and kshara (alkali preparation) at the proper time [52]
By the above treatments when kapha gulma dislodges from its place, the patient should be given virechana for purification. Anuvasana basti with oil prepared with dashamula drugs can also be given for this purpose [53]
मन्देऽग्नावनिले मूढे ज्ञात्वा सस्नेहमाशयम्||५४||
गुटिकाचूर्णनिर्यूहाः प्रयोज्याः कफगुल्मिनाम्|
In the condition when digestion is low and dysfunction of vata, after proper oleation of the affected site (ashaya), the drugs in the form of pills, powder or decoction are administered to the patient of kapha gulma [54]
If kapha-gulma has a deep root and is large in size, hard in consistency and heavy, then the patient should be treated with alkali preparation-kshara, arishta and agni karma (cauterization) [55]
दोषप्रकृतिगुल्मर्तुयोगं बुद्ध्वा कफोल्बणे||५६||
बलदोषप्रमाणज्ञः क्षारं गुल्मे प्रयोजयेत्|
एकान्तरं द्व्यन्तरं वा त्र्यहं विश्रम्य वा पुनः||५७||
शरीरबलदोषाणां वृद्धिक्षपणकोविदः|
A physician expert in assessing the degree of strength of patient as well as of dosha should prescribe alkali preparation–kshara to the patient of kapha gulma by considering its dosha and nature as well as prevailing season. The expert physician should use kshara treatment on alternate day or at the interval of two or three days depending on the increase or decrease in the strength of the body and dosha [56-57]
श्लेष्माणं मधुरं स्निग्धं मांसक्षीरघृताशिनः||५८||
छित्त्वा छित्त्वाऽऽशयात् क्षारः क्षरत्वात क्षारयत्यधः|
Kapha is sweet and unctuous, so it is increased by indulging in the diet comprising of excessive meat, milk and ghee. Alkali preparation-kshara has an action of erosion (ksharana) due to which it erodes the gulma and tickles it down from its habitat [58]
मन्देऽग्नावरुचौ सात्म्ये मद्ये सस्नेहमश्नताम्||५९||
प्रयोज्या मार्गशुद्ध्यर्थमरिष्टाः कफगुल्मिनाम्||
The diminution in digestion and loss of appetite occur in a patient of kapha gulma due to excessive indulgence in unctuous diet, therefore for the purification of the channels medicated fermented preparation-arishta should be given provided the patient is habituated of taking alcohol [59]
Daha karma and raktamokshana in kapha gulma
लङ्घनोल्लेखनैः स्वेदैः सर्पिःपानैर्विरेचनैः||६०||
बस्तिभिर्गुटिकाचूर्णक्षारारिष्टगणैरपि|
श्लैष्मिकः कृतमूलत्वाद्यस्य गुल्मो न शाम्यति||६१||
तस्य दाहो हृते रक्ते शरलोहादिभिर्हितः|
If the kapha gulma does not subside by langhana, vamana, swedana, oral administration of medicated ghee, virechana, basti, pills, powder, kshara and arishta due to its firm root in the body, then first bloodletting should be done and then cauterization with such means as arrow head should be done [61]
औष्ण्यात्तैक्ष्ण्याच्च शमयेदग्निर्गुल्मे कफानिलौ||६२||
तयोः शमाच्च सङ्घातो गुल्मस्य विनिवर्तते|
The fire heat due to its hot and sharp properties relieves kapha and vata in gulma, which in turn leads to dissolving the mass of gulma [62]
Cauterization comes under the purview of the surgeon and the use of kshara is the field of specialist in kshara karma [63]
व्यामिश्रदोषे व्यामिश्र एष एव क्रियाक्रमः||६४||
If the gulma is due to two dosha then the mix treatment of the involved two dosha should be done [64]
सिद्धानतः प्रवक्ष्यामि योगान् गुल्मनिबर्हणान्|
Now the specific preparations for the cure of gulma will be described [64 ½]
Tryushanadi-ghritam
त्र्यूषणत्रिफलाधान्यविडङ्गचव्यचित्रकैः||६५||
कल्कीकृतैर्घृतं सिद्धं सक्षीरं वातगुल्मनुतिति त्र्यूषणादिघृतम् |
Ghee prepared with a paste of trayushna (dry ginger, black and long pepper), triphala, coriander, vidanga, chavya and chitraka by adding milk is known as tryushanadighritam. It is curative of vata gulma; thus described trayushanadighritam [65]
Parama trayushanadighritam
एत एव च कल्काः स्युः कषायः पाञ्चमूलिकः ||६६||
द्विपञ्चमूलिको वाऽपि तद्घृतं गुल्मनुत् परमिति त्र्यूषणादिघृतमपरम्
Above mentioned paste if prepared with decoction of brihat panchamula or dashamula is known as parama tryushanadighritama. It is very much effective in curing gulma; thus described parama tryushanadighritama [66]
(षट्पलं वा पिबेत् सर्पिर्यदुक्तं राजयक्ष्मणि)||६७||
(shatpalam ghrita described for the treatment of rajayakshma may also be used orally) [67]
In place of milk in above preparation of tryushanadighritam, ghrita can also be prepared with prasanna wine, sura wine, pomegranate juice or cream of yogurt (curd). It also cures vata gulma [68]
Hingusauvarchaladya ghrita
हिङ्गुसौवर्चलाजाजीबिडदाडिमदीप्यकैः|
पुष्करव्योषधन्याकवेतसक्षारचित्रकैः||६९||
शटीवचाजगन्धैलासुरसैश्च विपाचितम्|
शूलानाहहरं सर्पिर्दध्ना चानिलगुल्मिनाम्||७०||
इति हिङ्गुसौवर्चलाद्यं घृतम्
A ghrita prepared with paste of asafoetida, rock salt, cumin, Vit-salt, pomegranate, ajwan, pushkaramula, trikatu, coriander, vetas, yavakshara, chitraka, shati, vacha, ajagandha, cardamom and holy basil by adding curd/yogurt is known as hingusauvarchaladyam ghritam. It cures vata gulma, acute pain and distension of abdomen due to retention of gases (anaha). Thus hiṅgusauvarchaladyam ghritam is described [69-70]
Hapushadya ghritam
हपुषाव्योषपृथ्वीकाचव्यचित्रकसैन्धवैः|
साजाजीपिप्पलीमूलदीप्यकैर्विपचेद्घृतम्||७१||
सकोलमूलकरसं सक्षीरदधिदाडिमम्|
तत् परं वातगुल्मघ्नं शूलानाहविमोक्षणम्||७२||
योन्यर्शोग्रहणीदोषश्वासकासारुचिज्वरान्|
बस्तिहृत्पार्श्वशूलं च घृतमेतद्व्यपोहति||७३||
इति हपुषाद्यं घृतम्
Ghee prepared with a paste of hapusha, trikatu, cardamom, chavya, chitraka, rock salt, cumin, root of long pepper and ajwain along with juice of jujubes, radish and pomegranate, by adding milk and curd is known as hapushadyam ghritam. It is best drug to cure vata gulma, abdominal pain and distension of abdomen. It also provides relief in gynecological disorders, piles, grahani (assimilation disorders), dyspnea, cough, anorexia, fever and pain in hypogastric, epigastric and flanks regions of the abdomen. Thus, hapushadyam ghritam is described [71-73]
Pippalyadyam ghritam
पिप्पल्या पिचुरध्यर्धो दाडिमाद्द्विपलं पलम्|
धान्यात्पञ्च घृताच्छुण्ठ्याः कर्षः क्षीरं चतुर्गुणम्||७४||
सिद्धमेतैर्घृतं सद्यो वातगुल्मं व्यपोहति|
योनिशूलं शिरःशूलमर्शांसि विषमज्वरम्||७ ५||
इति पिप्पल्याद्यं घृतम्
Ghee prepared with paste of one and half part of long pepper, eight parts of pomegranate seeds, four parts of coriander and one part of dry ginger in 20 parts of ghee and 80 parts of milk is known as pippalyadyam ghritam. It provides quick relief in vata gulma, pain in vagina, headache, piles and irregular fever. Thus pippalyadyam ghritam is described [74-75]
The drugs mentioned in the above ghrita preparations may also be used in form of powders, suppositories or decoctions for the treatment of gulma [76]
Peya (liquid gruel)
The liquid gruel prepared from jujube, pomegranate, warm water, supernatant liquid of sura(wine) (sura manda), sour kanji or citron juice relieves abdominal pain and distension of abdomen [77]
Or prepare the suppositories and pills by impregnating the powders of the above drugs in the juice of pomelo (matulunga) and use them for providing relief in gulma, distension of abdomen and discomfort [78]
Hingvadi churna and gutika
हिङ्गु त्रिकटुकं पाठां हपुषामभयां शटीम्|
अजमोदाजगन्धे च तिन्तिडीकाम्लवेतसौ||७९||
दाडिमं पुष्करं धान्यमजाजीं चित्रकं वचाम्|
द्वौ क्षारौ लवणे द्वे च चव्यं चैकत्र चूर्णयेत्||८०||
चूर्णमेतत् प्रयोक्तव्यमन्नपानेष्वनत्ययम्|
प्राग्भक्तमथवा पेयं मद्येनोष्णोदकेन वा||८१||
पार्श्वहृद्बस्तिशूलेषु गुल्मे वातकफात्मके|
आनाहे मूत्रकृच्छ्रे च शूले च गुदयोनिजे [९] ||८२||
ग्रहण्यर्शोविकारेषु प्लीह्नि पाण्ड्वामयेऽरुचौ|
उरोविबन्धे हिक्कायां कासे श्वासे गलग्रहे||८३||
भावितं मातुलुङ्गस्य चूर्णमेतद्रसेन वा|
बहुशो गुटिकाः कार्याः कार्मुकाः स्युस्ततोऽधिकम्||८४||
इति हिङ्ग्वादिचूर्णं गुटिका च |
Make fine powder of equal parts of asafoetida, trikatu, patha, hapusha, haritaki, shati, ajamoda, ajagandha, tintidika, amlavetas, pomegranate, pushkaramula, coriander, cumin, chitraka, vacha, two types of kshara, two types of salt and chavya. It is known as hingvadichurnam.
This powder is to be given with food and drinks or it may be taken before meal as drink mixed with wine or hot water. This has no harmful effect.
It is useful in vata-kapha gulma, pain in hypogastric, epigastric and hypochondric regions of the abdomen, distension of abdomen, dysuria, pain in anus and vagina, assimilation disorders, piles, spleen disorders, anemia, anorexia, tightness of chest, hiccup, cough, dyspnoea and sore-throat.
The pills may also be prepared by repeatedly impregnating the above mentioned powders in juice of citron, which is more effective than administration of the simple powders. Thus hingvadichurnam and gutika have been described [79-84]
Mix asafoetida, pomegranate and bid and rock salts in juice of citron and take with supernatant fluid of surā wine. It cures pain of vata gulma [85]
Shatyadi churnam and gutika
शटीपुष्करहिङ्ग्वम्लवेतसक्षारचित्रकान्|
धान्यकं च यवानीं च विडङ्गं सैन्धवं वचाम्||८६||
सचव्यपिप्पलीमूलामजगन्धां सदाडिमाम्|
अजाजीं चाजमोदां च चूर्णं कृत्वा प्रयोजयेत्||८७||
रसेन मातुलुङ्गस्य मधुशुक्तेन वा पुनः|
भावितं गुटिकां कृत्वा सुपिष्टां कोलसम्मिताम्||८८||
गुल्मं प्लीहानमानाहं श्वासं कासमरोचकम्|
हिक्कां हृद्रोगमर्शांसि विविधां शिरसो रुजम्||८९||
पाण्ड्वामयं कफोत्क्लेशं सर्वजां च प्रवाहिकाम्|
पार्श्वहृद्बस्तिशूलं च गुटिकैषा व्यपोहति||९०||
Mix fine powders of shati, pushkaramula, asafoetida, amlavetasa, kshara, chitraka, coriander, ajwain (yavani), vidanga, rock-salt, vacha, chavya, pippalimula, ajagandha, pomegranate, ajaji and ajamoda. It may be used in powder form or in the form of pills made of size of jujube by impregnating these powders in juice of citron or vinegar of honey by rubbing well.
This pill cures gulma, spleen disorders, distension of abdomen, dyspnea, anorexia, hiccup, heart diseases, piles, various types of headache, anemia, excessive of secretions (kaphotklesha), all types of dysenteries and pain in hypogastric, epigastric and hypochondric regions of the abdomen [86-90]
Nagara preparation
नागरार्धपलं पिष्ट्वा द्वे पले लुञ्चितस्य च|
तिलस्यैकं गुडपलं क्षीरेणोष्णेन ना पिबेत्||९१||
वातगुल्ममुदावर्तं योनिशूलं च नाशयेत्|
Make paste of 25 gm of dried ginger, 100 gm pealed sesame and 50 gm of jaggery and administer to the patient with warm milk. It cures vata gulma, udavarta ( disorder due to improper direction of vata) and pain in vagina [91½]
पिबेदेरण्डजं तैलं वारुणीमण्डमिश्रितम्||९२||
तदेव तैलं पयसा वातगुल्मी पिबेन्नरः|
श्लेष्मण्यनुबले पूर्वं हितं पित्तानुगे परम्||९३||
The patient of vata gulma associated with kapha dominance, then should take castor oil with supernatant of varuni wine and if pitta is associated then take castor oil with milk [92-93]
Lashuna-kshiram
साधयेच्छुद्धशुष्कस्य लशुनस्य चतुष्पलम्|
क्षीरोदकेऽष्टगुणिते क्षीरशेषं च ना पिबेत्||९४||
वातगुल्ममुदावर्तं गृध्रसीं विषमज्वरम्|
हृद्रोगं विद्रधिं शोथं साधयत्याशु तत्पयः||९५||
इति लशुनक्षीरम् |
Take 160 gm of dried and peeled garlic, add to it 640 ml of milk and 640 ml of water and boil on slow fire till only milk remains. It is known as lashuna kshiram and its oral administration provides quick relief in vata gulma, udavarta, sciatica, irregular fever, heart disease, abscess and inflammation [94-95]
Taila panchakam
तैलं प्रसन्ना गोमूत्रमारनालं यवाग्रजम्|
गुल्मं जठरमानाहं पीतमेकत्र साधयेत्||९६||
इति तैलपञ्चकम् |
The mixture of castor oil, prasanna wine, cow’s urine, aranala (sour kanji) and yavakshara is known as tailapanchakam. Its oral administration cures gulma, gastric disorders and distension of abdomen [96]
shilajatu-prayoga
पञ्चमूलीकषायेण सक्षारेण शिलाजतु|
पिबेत्तस्य प्रयोगेण वातगुल्मात् प्रमुच्यते||९७||
इति शिलाजतुप्रयोगः |
Taking of shilajatu with kshara and decoction of panchamula cures vata gulma. Thus administration of shilajatu is described [97]
Vatyam or barley preparation
Taking of barley meal mixed with unctuous substances along with soup of long pepper or juice of radish, provides relief in vata gulma and udavarta [98]
Swedana
If the patient of vata gulma is also having the complaints of distension of abdomen and constipation then swedana therapy should be given in the form of nadi (cattle sudation), prastara (stone slab sudation) and sankara (mix sudation) sweda as described in Swedadhyaya [99]
Basti karma
बस्तिकर्म परं विद्याद्गुल्मघ्नं तद्धि मारुतम्|
स्वे स्थाने प्रथमं जित्वा सद्यो गुल्ममपोहति||१००||
तस्मादभीक्ष्णशो गुल्मा निरूहैः सानुवासनैः|
प्रयुज्यमानैः शाम्यन्ति वातपित्तकफात्मकाः||१०१||
गुल्मघ्ना विविधा दिष्टाः सिद्धाः सिद्धिषु बस्तयः|
Basti Karma is the best treatment of gulma because it first conquers vata at its natural site and then cures gulma quickly. Therefore niruha and anuvasana basti should be administered repeatedly for cure of vata, pitta and kapha gulma. Various types of basti for the cure of gulma shall be described in Basti Siddhi [100-101]
Medicated oils
गुल्मघ्नानि च तैलानि वक्ष्यन्ते वातरोगिके||१०२||
तानि मारुतजे गुल्मे पानाभ्यङ्गानुवासनैः|
प्रयुक्तान्याशु सिध्यन्ति तैलं ह्यनिलजित्परम् [१२] ||१०३||
The various types of medicated oil useful for gulma will be described in Vatavyadhi Chikitsa. The medicated oils are used for oral administration, massage and anuvasana basti. As oil is best therapy for vata therefore it cures vata gulma quickly [102-103]
Accumulated feces of the patient of vata gulma should be eliminated by giving earlier mentioned ghrita mixed with powder nilini.[104]
Nilinyadyam ghritam
The ghee prepared with nilini, trivrita, danti, haritaki and kampillaka along with bid-salt and kshara should be given for shodhana [105]
Nilinyadyam ghritam
नीलिनीं त्रिफलां रास्नां बलां कटुकरोहिणीम्|
पचेद्विडङ्गं व्याघ्रीं च पलिकानि जलाढके||१०६||
तेन पादावशेषेण घृतप्रस्थं विपाचयेत्|
दध्नः प्रस्थेन संयोज्य सुधाक्षीरपलेन च||१०७||
ततो घृतपलं दद्याद्यवागूमण्डमिश्रितम्|
जीर्णे सम्यग्विरिक्तं च भोजयेद्रसभोजनम्||१०८||
गुल्मकुष्ठोदरव्यङ्गशोफपाण्ड्वामयज्वरान्|
श्वित्रं प्लीहानमुन्मादं घृतमेतद्व्यपोहति||१०९||
इति नीलिन्याद्यं घृतम्
Take 50 gm each of nilini, triphala, rasna, bala, katuki, vidanga and kantakari and add to it 2.5 litres of water and prepare the decoction by reducing it to one-fourth. Add to it 640 ml of ghee, 640 ml of curd and 50 ml of latex of snuhi and prepare ghee as per method of sneha-paka. Its 40 ml mixed with manda (liquid obtained by filtering the boiled rice) should be given for virechana. When the patient is well purged and the drug is digested then meat soup is given in diet.
This ghrita cures gulma, kushtha, udara roga, vyanga (freckles), swellings, anemia, fever, leukoderma, splenomegaly and psychic disorders (unmada). Thus nilinyadi ghritam is described [106-109]
Pathya in vata gulma
कुक्कुटाश्च मयूराश्च तित्तिरिक्रौञ्चवर्तकाः|
शालयो मदिरा सर्पिर्वातगुल्मभिषग्जितम्||११०||
हितमुष्णं द्रवं स्निग्धं भोजनं वातगुल्मिनाम्|
समण्डवारुणीपानं पक्वं वा धान्यकैर्जलम्||१११||
Hot, liquid and unctuous diet is beneficial for the patient of vata gulma. Red rice, wine and ghee; meats of chicken, peacock, partridge (tittara), krauncha (demoiselle) and quail (vartaka) are beneficial for the patient of vata gulma.
Similarly a potion of varuni wine with manda (supernatant fluid of boiled rice) or water boiled with coriander is beneficial [110-111]
Protection of agni
मन्देऽग्नौ वर्धते गुल्मो दीप्ते चाग्नौ प्रशाम्यति|
तस्मान्ना नातिसौहित्यं कुर्यान्नातिविलङ्घनम्||११२||
With decrease in digestive-power (agni) the gulma is aggravated, while on augmentation of the digestion (agni) the gulma is pacified. Therefore, to the patient of gulma neither excessive nutritional food nor excessive fasting or light food/treatment should be prescribed [112]
Oleation therapy
सर्वत्र गुल्मे प्रथमं स्नेहस्वेदोपपादिते|
या क्रिया क्रियते सिद्धिं सा याति न विरूक्षिते||११३||
In all types of gulma, only that successive treatment is fruitful which is given after subjecting first the patient to snehana and then swedana, but it never success if given after un-unctuous (ruksha) treatment [113]
Management of pitta gulma
Physician while dealing with pitta gulma should know that it requires immediate treatment (atyayika). Pitta gulma patient should be given ghee prepared with purgative and bitter drugs [114]
Rohiṇyadya ghritam
रोहिणीकटुकानिम्बमधुकत्रिफलात्वचः|
कर्षांशास्त्रायमाणा च पटोलत्रिवृतोः पले||११५||
द्वे पले च मसूराणां साध्यमष्टगुणेऽम्भसि|
शृताच्छेषं घृतसमं सर्पिषश्च चतुष्पलम्||११६||
पिबेत् सम्मूर्च्छितं तेन गुल्मः शाम्यति पैत्तिकः|
ज्वरस्तृष्णा च शूलं च भ्रमो मूर्च्छाऽरुचिस्तथा||११७||
इति रोहिण्याद्यं घृतम्
Take 10 gm each of katuka, neem, liquorices, triphala and trayamana; 40 gm each of patola and trivrita; 80 gm of lentil (masura) and add to it 8 times water; boil on low fire till it reduces to 160 ml. Add to it equal quantity of ghee i.e. 160 ml and administer it to the patient orally. It alleviates pitta gulma, fever, thirst, abdominal pain, giddiness, fainting and anorexia. Thus rohinyadi ghrita is described [117]
Trayamaṇadi ghritam
जले दशगुणे साध्यं त्रायमाणाचतुष्पलम्|
पञ्चभागस्थितं पूतं कल्कैः संयोज्य कार्षिकैः||११८||
रोहिणी कटुका मुस्ता त्रायमाणा दुरालभा|
कल्कैस्तामलकीवीराजीवन्तीचन्दनोत्पलैः||११९||
रसस्यामलकानां च क्षीरस्य च घृतस्य च|
पलानि पृथगष्टाष्टौ दत्त्वा सम्यग्विपाचयेत्||१२०||
पित्तरक्तभवं गुल्मं वीसर्पं पैत्तिकं ज्वरम्|
हृद्रोगं कामलां कुष्ठं हन्यादेतद्घृतोत्तमम्||१२१||
इति त्रायमाणाद्यं घृतम्
Make decoction by adding 10 times of water to 160 gm of trayamana and reducing it to one fifth. To this decoction add 10 gm paste of katuka, mustaka, trayamana and duralabha; 10 gm paste of tamalaki, veera, jivanti, chandana and lotus; add to it 320 ml juice of amalaki, milk and ghee. From all these, prepare ghrita as per method of sneha pāka. It is best ghrita to cure pitta and rakta-gulma, visarpa, pitta jwara, heart disease, jaundice and kushtha. Thus trayamanadi ghritam is described [118-121]
Amalakadi ghritam
रसेनामलकेक्षूणां घृतपादं विपाचयेत्|
पथ्यापदं पिबेत्सर्पिस्तत्सिद्धं पित्तगुल्मनुत्||१२२||
इत्यामलकाद्यं घृतम्
Prepare ghrita with four parts of juice of amalaki and sugarcane juice, one-fourth part of paste of haritaki and one part of ghee. It is to be taken orally to cure pitta gulma. Thus amalakadyam ghritam is described [122]
Drakshadi ghritam
द्राक्षां मधूकं खर्जूरं विदारीं सशतावरीम्|
परूषकाणि त्रिफलां साधयेत्पलसम्मितम्||१२३||
जलाढके पादशेषे रसमामलकस्य च|
घृतमिक्षुरसं क्षीरमभयाकल्कपादिकम्||१२४||
साधयेत्तद्घृतं सिद्धं शर्कराक्षौद्रपादिकम्|
प्रयोगात् पित्तगुल्मघ्नं सर्वपित्तविकारनुत्||१२५||
इति द्राक्षाद्यं घृतम्
Take 40 gm each of raisin, madhuka (mahva), date, vidari, shatavari, parushaka and triphala and add to it 2560 ml of water and boil till reduced to one-fourth. To this decoction add 640 gm each of ghee, sugar-cane juice, juice of amalaki and milk and its one fourth part of paste of haritaki; and prepare ghrita as per method of sneha-paka. Take this ghee by adding one fourth quantities of sugar and honey. It cures pitta-gulma and all types of pitta disorders. Thus drakshdyam ghritam is described [123-125]
Vasaghr̥itam
वृषं समूलमापोथ्य पचेदष्टगुणे जले|
शेषेऽष्टभागे तस्यैव पुष्पकल्कं प्रदापयेत्||१२६||
तेन सिद्धं घृतं शीतं सक्षौद्रं पित्तगुल्मनुत्|
रक्तपित्तज्वरश्वासकासहृद्रोगनाशनम्||१२७||
इति वासाघृतम्
Take whole plant of vasa including its root and make decoction by adding to it eight times water and reducing to one-eighth. Add to the decoction, paste of its flower and ghee and prepare the ghrita. It is to be taken with honey which cures pitta gulma, piles, fever, dyspnea, cough and heart disease. Thus vasaghritam is described [126-127]
द्विपलं त्रायमाणाया जलद्विप्रस्थसाधितम्|
अष्टभागस्थितं पूतं कोष्णं क्षीरसमं पिबेत्||१२८||
पिबेदुपरि तस्योष्णं क्षीरमेव यथाबलम्|
तेन निर्हृतदोषस्य गुल्मः शाम्यति पैत्तिकः||१२९||
Take 80 gm of trayamana and make decoction by adding 1.280 litre of water and reducing to one-eighth and filter it. Take it by adding equal quantity of warm milk and thereafter take as much milk as one can digest. This preparation eliminates the toxic substances and thus cures pitta gulma [128-129]
द्राक्षाभयारसं गुल्मे पैत्तिके सगुडं पिबेत्|
लिह्यात्कम्पिल्लकं वाऽपि विरेकार्थं मधुद्रवम्||१३०||
In patient of pitta gulma the virechana can be performed by administration of decoction of raisins and haritaki with jaggery or by licking powder of kampillaka with honey [130]
Massage
For relieving burning sensation in the patient of gulma, massage with ghee or chandanadi taila or medicated oil prepared with madhuka should be done [131]
Kshira-basti for pitta gulma
ये च पित्तज्वरहराः सतिक्ताः क्षीरबस्तयः|
हितास्ते पित्तगुल्मिभ्यो वक्ष्यन्ते ये च सिद्धिषु||१३२||
Kshira-basti comprising of bitter drugs described for pitta fever as well as which will be described in Siddhi Sthana are also beneficial for curing pitta gulma [132]
Pathya for pitta gulma
शालयो जाङ्गलं मांसं गव्याजे पयसी घृतम्|
खर्जूरामलकं द्राक्षां दाडिमं सपरूषकम्||१३३||
आहारार्थं प्रयोक्तव्यं पानार्थं सलिलं शृतम्|
बलाविदारीगन्धाद्यैः पित्तगुल्मचिकित्सितम्||१३४||
Red rice, meat of wild animals, milk and ghee of cow and goat, dates, grapes, pomegranates, amalaki and parushaka are wholesome diet articles for eating and water boiled with bala-vidarigandhadi drugs for drinking for the patient of pitta gulma [133-134]
Management of ama associated gulma
आमान्वये पित्तगुल्मे सामे वा कफवातिके|
यवागूभिः खडैर्यूषैः सन्धुक्ष्योऽग्निर्विलङ्घिते||१३५||
Pitta gulma or kapha-vata gulma if associated with ama, first it should be subjected to langhana and then given cooked rice (yavagu) and vegetable or pulse soup to enhance the digestion [135]
Importance of agni
Equilibrium or provocation of all the dosha depend upon the condition of agni (digestion and metabolism), hence one should always take its care and avoid such causes which disturb it [136]
Treatment of kaphaja gulma
Vamana in kaphaja gulma
वमनं वमनार्हाय प्रदद्यात् कफगुल्मिने|
Vamana karma should be done in kapha gulma provided the patient is fit for it [136½]
Surgical treatment of kapha gulma
स्निग्धस्विन्नशरीराय गुल्मे शैथिल्यमागते||१३७||
परिवेष्ट्य प्रदीप्तांस्तु बल्वजानथवा कुशान्|
भिषक्कुम्भे समावाप्य गुल्मं घटमुखे न्यसेत्||१३८||
सङ्गृहीतो यदा गुल्मस्तदा घटमथोद्धरेत्|
वस्त्रान्तरं ततः कृत्वा भिन्द्याद्गुल्मं प्रमाणवित्||१३९||
विमार्गाजपदादर्शैर्यथालाभं प्रपीडयेत्|
मृद्नीयाद्गुल्ममेवैकं न त्वन्त्रहृदयं स्पृशेत्||१४०||
First make the kapha gulma loose (shaithilya) by snehana and swedana therapies then following operation should be performed on the patient:
Cover the brim of gulma with a piece of cloth and on the inner portion of the brim put an earthen lid containing ignited balvaja or small sacrificial grass (kusha). Then place the mouth of an inverted empty pot on it in such a way so that it covers and fit on the brim. Due to negative pressure produced inside the pot by the fire, the mouth of the pot will strongly adhere to the brim and the lump will be pulled into the pot. Then remove the pot and tightly tie the bottom of this bulged portion of the gulma and then puncture it. Thereafter, with the help of any available instruments such as vimarga, ajapada and adarsha, only the gulma part is squeezed or compressed, without touching the intestines and heart. This operation should be done only by the expert surgeon in the technique [137-140]
Post-operative measures
After the above operation apply the paste made from sesame, castor seed, linseeds and mustard seeds on the gulma and do its sudation through bearable hot iron pot [141]
Dashamuli ghrita
सव्योषक्षारलवणं दशमूलीशृतं घृतम्|
कफगुल्मं जयत्याशु सहिङ्गुबिडदाडिमम्||१४२||
इति दशमूलीघृतम्|
Prepare a medicated ghee with decoction of dashamula, paste of trikatu, yavakshara, salt, asafoetida, bid-salt and pomegranate, and ghee. Its oral use quickly subsides kapha gulma. Thus dashamuli-ghritam is described. [142]
Bhallatakadi ghritam
भल्लातकानां द्विपलं पञ्चमूलं पलोन्मितम्|
साध्यं विदारीगन्धाद्यमापोथ्य सलिलाढके||१४३||
पादशेषे रसे तस्मिन् पिप्पलीं नागरं वचाम्|
विडङ्गं सैन्धवं हिङ्गु यावशूकं बिडं शटीम्||१४४||
चित्रकं मधुकं रास्नां पिष्ट्वा कर्षसमं भिषक्|
प्रस्थं च पयसो दत्त्वा घृतप्रस्थं विपाचयेत्||१४५||
एतद्भल्लातकघृतं कफगुल्महरं परम्|
प्लीहपाण्ड्वामयश्वासग्रहणीरोगकासनुत्||१४६||
इति भल्लातकाद्यं घृतम्
Take coarse powder of 80 gm of bhallataka, 40 gm of laghu panchamula and 40 gm of vidarigandhadi and prepare a decoction by adding 2.5 liters of water and reducing to one-fourth. To this decoction add paste made of 10 gm each of long pepper, dry ginger, vacha, vidanga, rock and bid salts, asafoetida, yavakshara, chitraka, shati, liquorices and rasna; 640 ml each of milk and ghee and make ghrita as per method of sneha paka. Oral use of bhallatakadyam ghritam is best for providing cure to kapha gulma. It also provides relief in spleen disorders, anemia, asthma, assimilation disorders and cough. Thus bhallatakadyam ghritam is described [143-146]
Kshiraṣhaṭpalaka ghritam
पिप्पलीपिप्पलीमूलचव्यचित्रकनागरैः|
पलिकैः सयवक्षारैर्घृतप्रस्थं विपाचयेत्||१४७||
क्षीरप्रस्थं च तत् सर्पिहन्ति गुल्मं कफात्मकम्|
ग्रहणीपाण्डुरोगघ्नं प्लीहकासज्वरापहम्||१४८||
इति क्षीरषट्पलकं घृतम्
Make a paste of 40 gm each of fruits and roots of long pepper, chavya and chitraka, yavakshara and dried ginger and add to it 640 gm each of ghee and milk, and prepare a medicated ghee. This ghrita cures kapha gulma, grahani (chronic assimilation disorders), anemia, spleen disorders, cough and fever. Thus kshirashatpalakam ghritam is described [147-148]
Mishraka sneha
त्रिवृतां त्रिफलां दन्तीं दशमूलं पलोन्मितम्|
जले चतुर्गुणे पक्त्वा चतुर्भागस्थितं रसम्||१४९||
सर्पिरेरण्डजं तैलं क्षीरं चैकत्र साधयेत्|
स सिद्धो मिश्रकस्नेहः सक्षौद्रः कफगुल्मनुत्||१५०||
कफवातविबन्धेषु कुष्ठप्लीहोदरेषु च|
प्रयोज्यो मिश्रकः स्नेहो योनिशूलेषु चाधिकम्||१५१||
इति मिश्रकः स्नेहः
Prepare a decoction of 40 gm each of trivrita, triphala, danti and dashamula by adding four times of water and reducing to one-fourth. In this decoction add ghee, castor oil and milk and prepare medicated ghee. This mishraka sneha taken orally by adding honey cures kapha gulma. It also provides relief in constipation due to kapha and vata, kushtha (chronic skin disorders), spleen disorders and udara-roga (generalized enlargement of abdomen) and especially useful in vaginal pain. Thus mishraka sneha is described [149-151]
Virechana in kapha gulma
यदुक्तं वातगुल्मघ्नं स्रंसनं नीलिनीघृतम्|
द्विगुणं तद्विरेकार्थं प्रयोज्यं कफगुल्मिनाम्||१५२||
सुधाक्षीरद्रवे चूर्णं त्रिवृतायाः सुभावितम्|
कार्षिकं मधुसर्पिभ्यां लीढ्वा साधु विरिच्यते||१५३||
Nilini-ghrita already described as laxative for the cure of vata gulma should be used in double the dose for virechana in the patient of kapha gulma.
10 gm powder of trivrita well impregnated with latex of snuhi taken with ghee and honey may also be used to produce a good virechana [152-153]
Danti-haritaki
जलद्रोणे विपक्तव्या विंशतिः पञ्च चाभयाः|
दन्त्याः पलानि तावन्ति चित्रकस्य तथैव च||१५४||
अष्टभागावशेषं तु रसं पूतमधिक्षिपेत्|
दन्तीसमं गुडं पूतं क्षिपेत्तत्राभयाश्च ताः||१५५||
तैलार्धकुडवं चैव त्रिवृतायाश्चतुष्पलम्|
चूर्णितं पलमेकं तु पिप्पलीविश्वभेषजम्||१५६||
तत् साध्यं लेहवच्छीते तस्मिंस्तैलसमं मधु|
क्षिपेच्चूर्णपलं चैकं त्वगेलापत्रकेशरात्||१५७||
ततो लेहपलं लीढ्वा जग्ध्वा चैकां हरीतकीम्|
सुखं विरिच्यते स्निग्धो दोषप्रस्थमनामयम्||१५८||
गुल्मं श्वयथुमर्शांसि पाण्डुरोगमरोचकम्|
हृद्रोगं ग्रहणीदोषं कामलां विषमज्वरम्||१५९||
कुष्ठं प्लीहानमानाहमेषा हन्युपसेविता|
निरत्ययः क्रमश्चास्या द्रवो मांसरसौदनः||१६०||
इति दन्तीहरीतकी
Prepare a decoction of 25 haritaki and 50 gm each of danti and chitraka in 10 liters of water by reducing it to one-eighth. Add jaggery equal to quantity of danti to the decoction and filter again and add to it haritaki, 80 ml of sesame oil, 160 gm of trivrita powder and 40 gm each of long pepper and dry ginger and by heating made into constituency of the jam. On cooling add 80 gm of honey, 40 gm powder of cinnamon, cardamom, tamalapatra and keshara. Administer its 40 gm with one haritaki daily to a person who has already been prepared with snehana and swedana for a good virechana. It will remove 640 gm of morbid material (dosha prastha) without producing any side effect.
This decoction for virechana will cure gulma, swellings, piles, anemia, anorexia, heart disease, chronic assimilation disorders, jaundice, irregular fever, kushtha, spleen disorders and distension of abdomen. The therapy does not produce any complication. During this therapy liquid diet and rice with meat soup are given to eat. Thus dantiharitaki is described [154-160]
Basti in kapha gulma
सिद्धाः सिद्धिषु वक्ष्यन्ते निरूहाः कफगुल्मिनाम्|
अरिष्टयोगाः सिद्धाश्च ग्रहण्यर्शश्चिकित्सिते||१६१||
The most effective niruha basti for kapha gulma will be described in Siddhi Sthana and most effective medicated wines (arishta) will be described in the chapter on Grahani Chikitsa and Arsha Chikitsa [161]
Powders and pills
यच्चूर्णं गुटिका याश्च विहिता वातगुल्मिनाम्|
द्विगुणक्षारहिङ्ग्वम्लवेतसास्ताः कफे हिताः||१६२||
Powder and pills which are described for the treatment of vata gulma should also be used for kapha gulma but added with double the quantity of mixture of kshara, asafoetida and amlavetasa [162]
Kshara and daha karma
य एव ग्रहणीदोषे क्षारास्ते कफगुल्मिनाम्|
सिद्धा निरत्ययाः शस्ता दाहस्त्वन्ते प्रशस्यते||१६३||
Kshara preparations mentioned in Grahani Chikitsa are also beneficial for kapha gulma without any side effect. If above mentioned treatment does not cure kapha gulma then cauterization should be done as a last resort [163]
Pathya for kapha gulma
प्रपुराणानि धान्यानि जाङ्गला मृगपक्षिणः|
कौलत्थो मुद्गयूषश्च पिप्पल्या नागरस्य च||१६४||
शुष्कमूलकयूषश्च बिल्वस्य वरुणस्य च|
चिरबिल्वाङ्कुराणां च यवान्याश्चित्रकस्य च||१६५||
More than one year old grains, meat of wild animals and birds, soup of horse-gram (kulattha) or green gram (mudga), long pepper, dry ginger, dry radish, bilva, varuna, sprouts of chirabilva, yavani and chitraka are beneficial diet articles for the patient of kapha gulma [165]
Citron, asafoetida, amlavetas, kshara, pomegranate, butter milk, oil and ghee preparations are also wholesome for kapha gulma [166]
Water boiled in laghu panchamula or old varuni or old honey wine should be given to drink on getting the thirst to the patient of kapha gulma [167]
Taking of butter milk mixed with yavani (ajwain) and salted with bid-salt acts as a digestive stimulant and the regulator of flatus, urine and kapha [168]
Signs and symptoms of incurable gulma
सञ्चितः क्रमशो गुल्मो महावास्तुपरिग्रहः|
कृतमूलः सिरानद्धो यदा कूर्म इवोन्नतः||१६९||
दौर्बल्यारुचिहृल्लासकासवम्यरतिज्वरैः |
तृष्णातन्द्राप्रतिश्यायैर्युज्यते न स सिध्यति||१७०||
The gulma which gradually goes on increasing, spreading over a large area, has taken firm root, is covered by veins, has convex surface like that of tortoise, and which is accompanied with weakness, anorexia, thirst, nausea, vomiting, fever, cough, coryza and drowsiness is considered as incurable [169-170]
Signs and symptoms of bad prognosis
The patient of gulma accompanied with fever, dyspnea, vomiting and diarrhea along with edema in the epigastric and umbilical regions and on hands and feet indicate that the patient is approaching to death [171]
Treatment of rakta gulma
The treatment of rakta gulma should be under taken only after completion of normal period of gestation i.e. 10 months. The patient should be given unctuous virechana after preparing with snehana and swedana [172]
पलाशक्षारपात्रे द्वे द्वे पात्रे तैलसर्पिषोः|
गुल्मशैथिल्यजननीं पक्त्वा मात्रां प्रयोजयेत्||१७३||
Make a semisolid preparation by heating 5 Kg of palasha-kshara with 5 kg each of ghee and oil. Administer it in sufficient dose to make the gulma soft/loose. [173]
प्रभिद्येत न यद्येवं दद्याद्योनिविशोधनम् |
क्षारेण युक्तं पललं सुधाक्षीरेण वा पुनः||१७४||
आभ्यां वा भावितान् दद्याद्योनौ कटुकमत्स्यकान्|
वराहमत्स्यपित्ताभ्यां लक्तकान् वा सुभावितान्||१७५||
अधोहरैश्चोर्ध्वहरैर्भावितान् वा समाक्षिकैः|
किण्वं वा सगुडक्षारं दद्याद्योनिविशोधनम्||१७६||
If the above mentioned treatments do not break the rakta gulma then the preparations which cleans vagina should be used locally. A swab well saturated with one of the following pastes may be inserted in the vagina:
- Sesame paste mixed with kshara or latex of snuhi or
- Pungent fish impregnated with both kshara and latex of snuhi
- Bile of hog or fish or emetic or purgative drugs or with honey
Or yeast mixed with jaggery and honey may be used for cleansing the vagina [174-176]
रक्तपित्तहरं क्षारं लेहयेन्मधुसर्पिषा|
लशुनं मदिरां तीक्ष्णां मत्स्यांश्चास्यै प्रदापयेत्||१७७||
Kshara which cures raktapitta may be licked with honey and ghee. Or garlic mixed with strong wine and fish may be given in diet [177]
Basti prepared with milk, cow’s urine, kshara and decoction of dashamula should be given. Even after all these treatments, if blood does not flow from vagina then surgical intervention is required [178]
When blood starts flowing through vagina then rice with meat soup should be given to eat. Massage with ghee or oil is done and for drink new wine may be given [179]
In case of excessive bleeding, the measures curative of raktapitta should be prescribed. If the patient gets vata type of pains then all the remedies curative of vata are given [180]
घृततैलावसेकांश्च तित्तिरींश्चरणायुधान्|
सुरां समण्डां पूर्वं च पानमम्लस्य सर्पिषः||१८१||
प्रयोजयेदुत्तरं वा जीवनीयेन सर्पिषा|
अतिप्रवृत्ते रुधिरे सतिक्तेनानुवासनम्||१८२||
Effusion with ghee and oil should be performed. Meat of partridge (tittara) and rooster (charanayudha), sura (wine) along with its upper fluid (manda) and ghee prepared with sour drugs may be given in diet.
Uttara basti with ghee prepared with jivaniya drugs should be given. In case of the excessive blood flow, anuvasana basti with ghee/oil prepared with bitter drugs should be given [181-182]
Summary
तत्र श्लोकाः-
स्नेहः स्वेदः सर्पिर्बस्तिश्चूर्णानि बृंहणं गुडिकाः|
वमनविरेकौ मोक्षः क्षतजस्य च वातगुल्मवताम्||१८३||
सर्पिः सतिक्तसिद्धं क्षीरं प्रस्रंसनं निरूहाश्च|
रक्तस्य चावसेचनमाश्वासनसंशमनयोगाः||१८४||
उपनाहनं सशस्त्रं पक्वस्याभ्यन्तरप्रभिन्नस्य|
संशोधनसंशमने पित्तप्रभवस्य गुल्मस्य||१८५||
स्नेहः स्वेदो भेदो लङ्घनमुल्लेखनं विरेकश्च|
सर्पिर्बस्तिर्गुटिकाश्चूर्णमरिष्टाश्च सक्षाराः||१८६||
गुल्मस्यान्ते दाहः कफजस्याग्रेऽपनीतरक्तस्य|
गुल्मस्य रौधिरस्य क्रियाक्रमः स्त्रीभवस्योक्तः||१८७||
पथ्यान्नपानसेवा हेतूनां वर्जनं यथास्वं च|
नित्यं चाग्निसमाधिः स्निग्धस्य च सर्वकर्माणि||१८८||
हेतुर्लिङ्गं सिद्धिः क्रियाक्रमः साध्यता न योगाश्च|
गुल्मचिकित्सितसङ्ग्रह एतावान् व्याहृतोऽग्निवेशस्य||१८९||
In this chapter, sneha, sweda, sarpi-basti, churna, brimhana, gudika, vamana, virechana and raktamokshana for the patient suffering from vata-gulma have been described.
For the treatment of pitta gulma, sarpi prepared with tikta drugs, kshira, samshamana-niruha basti, bloodletting, counseling (ashvasana), samshamana(preparations) have been described.
For pakva (suppurated) gulma, surgical procedure and poultice (upanaha) are described and for that which is ruptured internally the purification (samshodhana) and palliative (samshamana) treatments are mentioned.
For kapha gulma, snehana, swedana, bhedana, langhana, vamana, virechana, sarpirbasti, gutika, churna, arishta, kshara, bloodletting followed by cauterization of the gulma as a last resort have been described. Line of treatment for [[]rakta]]-guma occurring in women has also been described.
Use of wholesome (pathya) eats and drinks, avoidance of the respective etiological factors, continuously protection of digestive power (agni), the instruction for the patient who has undergone snehana are described.
Etiological factors, signs and symptoms, successful line of treatment, curability and otherwise and therapeutic measures are described in concise form in this chapter of Gulma Chikitsa as described by Agnivesha [183-189]
इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते चिकित्सितस्थाने
गुल्मचिकित्सितं नाम पञ्चमोऽध्यायः||५||
Thus fifth chapter named Gulma Chikitsa in Chikitsa Sthana in the treatise compiled by Agnivesha and revised by Charak is completed [5]
Tattva Vimarsha (Fundamental Principles)
- Gulma occurs predominantly due to excessive excretion of feces, kapha and pitta or due to pressure exerted by their excessive aggravation and other causes leading to vitiation of vata dosha.
- Cavities like that in urinary bladder (hypo gastric region), umbilical region (nabhi), cardiac region (hridi) and two flanks (parshva) are susceptible sites for gulma.
- All gulma are treated after consideration of dosha dominance, stage, site and strength of patient.
- Internal administration of sneha (unctuous substance) in various modes like oral administration, massage, unctuous enema is the principle of management of vata dominant gulma.
- If pitta gulma is caused due to unctuous and hot substances, then virechana shall be administered. If it is caused by dry and hot substances, then ghee shall be administered.
- If kapha-gulma is caused by indulgence in cold, heavy and unctuous diet and in those not eligible for vamana, langhana (depletion) therapy should be prescribed in the beginning. Vamana is indicated in a patient of gulma who is having low digestion, anorexia, nausea and mild pain, heaviness and stiffness in abdomen.
- Kapha gulma is treated with langhana, agni dipana, swedana, vamana, snehana, kshara karma and agni karma.
- If kapha-gulma has a deep root and is large in size, hard in consistency and heavy, then the patient should be treated with alkali preparation-kshara, arishta and agni karma (cauterization).
- With decrease in digestive-power (agni) the gulma is aggravated, while on augmentation of the digestion (agni) the gulma is pacified. Therefore, to the patient of gulma neither excessive nutritional food nor excessive fasting or light food/treatment should be prescribed (112).
- Pitta gulma requires immediate treatment (atyayika) and the patient should be given ghee prepared with purgative and bitter drugs (114).
- Equilibrium or provocation of all the dosha depend upon the condition of agni (digestion and metabolism), hence one should always take its care and avoid such causes which disturb it.
- Vamana karma should be done in kapha gulma provided the patient is fit for it.
- The excessively increased stage of gulma needs surgical intervention.
- The gulma which gradually goes on increasing, spreading over a large area, has taken firm root, is covered by veins, has convex surface like that of tortoise, and which is accompanied with weakness, anorexia, thirst, nausea, vomiting, fever, cough, coryza and drowsiness is considered malignant and as incurable.
- Rakta gulma should be treated only after observation for 10 months. This waiting period is essential for achieving a stage suitable for intervention. The patient should be given unctuous virechana after preparing with snehana and swedana.
Vidhi Vimarsha (Applied Inferences )
Contemporary understanding 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 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. It is mentioned that the pittaja gulma situated in antarbhaga (inside i.e. intra-abdominal) can produce swelling in the hrid pradesha (upper abdomen) and when suppurate, may penetrate into the adjacent mahasrotas i.e. gastrointestinal tract and burst open culminating with discharge of pus either through oral or rectal route. The discharge of pus may usually continue for a couple of weeks (ten to twelve days) during which, no aggressive measure should be taken except that the nutritional status of the patient should be managed by proper diet.
On examining these features, these can be correlated with clinical condition like empyema of gall bladder which may adhere and penetrate into the adjacent organs like stomach, duodenum or colon and may burst open into the lumen leading to the discharge of pus either through oral or rectal route. Similarly, a subphrenic abscess or liver abscess may rupture into the pleural cavity and may result into discharge of pus during coughing. In addition, suppurative pathologies of pelvic organs leading to pelvic abscesses and a diverticular abscess may erode into rectal lumen and result into pus discharge through rectum.
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. 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).
This surgical technique suggests that kaphaja gulma includes the benign lesions of the abdominal wall, epigastric or paraumbilical hernia containing extraperitoneal fat or omentum etc.
In addition to above varieties of gulma, a tridoshaja gulma is also described which is considered as incurable. The features described like an elevated, stony hard lump with excessive pain and burning sensation and loss of vitality suggest more towards a malignant tumor of the abdomen. Moreover, the bad prognostic characters defined for an incurable gulma viz. a gradually increasing, deep rooted, elevated hard mass like a turtle shell which is associated with visibly engorged vessels and poor general condition like generalized edema, loss of appetite, cough, vomiting, persistent fever etc. point more towards an advanced malignant lesion of abdomen e.g. hepatoma or the metastatic involvement of liver or other solid malignant tumors of abdominal organs.
In conclusion, vataja gulma are mobile swellings of waxing and waning nature due to partial obstructive lesions of gut lumen. Pittaja gulma are intraperitoneal or extraperitoneal inflammatory or suppurative lesions of abdomen whereas kaphaja gulma are non inflammatory benign lesions of abdominal wall. Tridoshaja gulma seems to be malignant intra-abdominal lesions with poor prognosis.
Sites of gulma
Five regions of the abdomen where gulma occurs are hrid (epigastric), nabhi (umbilical), basti (hypogastric) and two parshva (right and left flanks). If both flanks are further subdivided into three urdhva (upper), madhya (middle) and adho (lower), then whole abdomen is divided into 9 parts which is similar to the modern clinical method where abdomen is also divided into nine parts as shown in Table-1. Some of the organs situated in these regions as mentioned by Warner (1964) are also depicted therein and on that basis exact location of the Gulma can be traced.
Table1. Nine divisions of the abdomen, according to Ayurveda and allopathic medicine
| Region and Organs | Right section, with organs situated therein | Middle section, with organs situated therein | Left section, with organs situated therein |
|---|---|---|---|
| Region | Dakshina Urdhva Parshva (Right Hypochondriac) | Hrid (Epigastric) | Vama Urdhva Parshva (Left Hypochondriac) |
| Organs | Right lobe of liver, gall-bladder, part of duodenum, hepatic flexure of colon, part of right kidney, right suprarenal gland | Pyloric end of stomach, duodenum, pancreas, aorta & part of liver | Stomach, spleen, tail of pancreas, splenic flexure of colon, upper part of left kidney, part of the left lobe of liver (some time) |
| Region | Dakshina Madhya Parshva (Right Lumbar) | Nabhi (Umbilical) | Vama Madhya Parshva (Left Lumbar) |
| Organs | Ascending colon, lower part of right kidney & part of duodenum and jejunum | Omentum, transverse colon, lower part of jejunum & ileum | Descending colon, lower half of left kidney & portions of jejunum and ileum |
| Region | Dakshina Adho Parshva (Right Iliac) | Basti (Hypogastric) | Vama Adho Parshva (Left Iliac) |
| Organs | Caecum, appendix, lower end of ileum, right ureter, right spermatic cord in male & right ovary in female | Ileum, bladder, gravid pregnant uterus | Sigmoid colon, left ureter, left spermatic cord in male & left ovary in female |
Differential diagnosis of gulma
Ayurveda is a clinical science; therefore, the diseases are classified in such a way so that they can be systematically diagnosed on the basis of the symptoms. Gulma is a good example for it.
Mainly three resembling diseases occur in the abdominal cavity viz. udara roga, gulma and pliha dosha which require differential diagnosis. Udararoga comprises of eight diseases which cause general enlargement of the abdomen. Five types of gulma have protruding and palpable localized swellings related to the abdominal organs and appendages. Under pliha dosha benign enlargement of spleen or liver occurs [1]. Therefore, on the basis of these clear demarcations, it may not be difficult to differentiate these three kinds of diseases clinically.
Chikitsa sutra (principles of management) of gulma
Principles:
- Anulomana
- Pachana
Main drugs:
- Bhallataka
- Lashuna
- Castor oil
- Tamra bhasma
Internal Medicines
| Type | Medicine | Dose | Time of Administration | Anupana |
|---|---|---|---|---|
| Vata dominant | Lashunadi Vati | 500 to 1000 mg | Before meals, two times | Lemon water |
| Vata vidhvansa | 250 to 500 mg | Before meals, two times | Lemon water | |
| Chukra oil | 20 to 40 drops | Before meals, two times | Milk | |
| Pitta dominant | Praval panchamritam | 250 to 500 mg | Before and after meals, four times | Milk and sugar |
| Shatavari-trina panchamula decoction | 20 to 40 ml | Before two meals, two times | Milk | |
| Shatavari mandura | 500 to 1000 mg | Before meals, two times | Milk | |
| Kapha dominant | Svarna vasant | 250 to 500 mg | After meals | Milk |
| Bhallataka oil | 5 to 10 drops | Before meals, two times | Milk | |
| Arogya kshara mixture | 500 to 1000 mg | Before meals, two times | Kumaryasava | |
| Raktaja | Shatavari-truna panchamula decoction | 20 to 40 ml | Between meals, two times | Milk |
| Loha parpati mixture | 500 to 750 mg | Before meals, two times | Honey | |
| Sannipatika | Varunadi kwatha | 20 to 40 ml | Between two meals, two times | Honey |
Panchakarma
| Type | Medicine | Dose | Time of Administration | Anupana |
|---|---|---|---|---|
| Virechana | Castor Oil | 20-40 ml | Morning, one time | Milk |
| Virechana decoction | 20-40 ml | Morning, one time | Milk | |
| Niruha | Dashamula decoction | 320 ml | Morning, one time | - |
| Anuvasana | Sahachara decoction | 40 to 70 ml | Morning, one time | - |
| Anulomana | Triphala mixture | 1 to 3 grams | Frequently | Honey |
| Blood Letting | - | 100 to 150 ml | - | - |
Related Chapter
Further reading
- Charak. Charak Samhita. Edited by Jadavaji Trikamji Aacharya. 1st ed. Varanasi: Krishnadas Academy;2000. p.--.
- Madhavakara. Madhava Nidanam (Roga vinischaya). Translated from Sanskrit by K. R. Srikantha Murthy. 8th ed. Varanasi: Chaukhambha orientalia;2007.pp--
- Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005. p.--.
- Vagbhata. Ashtanga Hridayam. Edited by Harishastri Paradkar Vaidya. 1st ed. Varanasi: Krishnadas Academy;2000.p.--.
- Bhavamishra. Bhavaprakasha -Volume I. Translated from Sanskrit by K.R. Srikantha Murthy. 1st ed. Varanasi: Krishnadas academy;2000.pp.-
- Warner E. C. (1964): Savill's System of clinical medicine. Orient Longmans Ltd.New Delhi, 14th Edition p.341
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References
- ↑ Bhavamishra. Bhavaprakasha -Volume I.Chikitsa-Prakarana chapter 33, Translated from Sanskrit by K.R. Srikantha Murthy. 1st ed. Varanasi: Krishnadas academy;2000.pp.-