PROGNOSIS OF MADHU MEHA (DIABETES MELLITUS)
Ancient Ayurvedic scholars have grouped Madhumeh (Diabetes mellitus) under one among the 20 Prameha (urinary disorders); particularly one of the kind of vatic disorder. Also, any of the prameha (urinary disorder) if neglected ultimately it ends up in madhumeh due to nature of the illness. This is evident in the verses of Acharya Sushruta -
सर्व एव प्रमेहास्तु कालेनाप्रतिकारिणः ।
मधुमेहत्वं आयांति तदा असाद्यता भवन्ति हि ॥ (सु. नि. ६)
WHO BECOMES VICTIM OF TYPE 2 DIABETES MELLITUS
Anyone may get to be the victim of T2DM and especially in the modern day lifestyle; none of us are spared from getting T2DM And in ayurveda people who don’t stop the mithya ahaar vihar (the foods which are not good for them and not doing any physical exercise) have the tendency.
- Syasukham – Comfortable seating (luxury, sedentary lifestyle, lack of physical activities and exercise).
- Svapnasukham – comforts of sleeping, excess sleeping.
- Kapha krut cha sarvam – All foods and lifestyle activities which increase Kapha.
- Sahaja (inherited factor).
- Chinta (stress)
- Shoka (grief).
- Bhaya (fear).
- Deergha roga (long standing illness).
- Alasya (sedentary life).
FOOD AND DRINKS THAT CAUSE DIABETES
- Dadheeni – Excessive consumption of Curds and its preparations.
- Gramya-oudaka-anupa mamsa – flesh or meat soup of animals living in water and marshy regions.
- Payamsi – Excessive consumption of milk, its derivatives and preparations.
- Navaanna panam – Food, drinks and dishes prepared from new grains etc.
- Guda vaikruti – Jaggery, its derivatives and dishes made out of it.
- Guda (jaggery).
- Ikshurasa (sugar cane).
- Madhura Ahara (sweet substances).
- Pishta Ahara (carbohydrate rich food).
- Adyashana (repeated food intake).
- Adhikashana (excess food intake).
- Ahitashana (unwholesome diet).
- Guru ahara (heavy food).
- Samashana (improper diet) .
HIGHEST RISK GROUP ARE THOSE WHO (MODERN) ARE
- Above 45 years.
- Obese / overweight.
- Family history of T2DM.
- Do not exercise.
- Have low HDL or high triglycerides.
- Have high BP.
- Have had Gestational Diabetes.
- High fat and carbohydrate diet.
- High alcohol intake.
- Are older people.
- Ahitashana (unwholesome diet).
- Guru ahara (heavy food).
- Women having PCOS.
CHARACTERISTIC FEATURE OF MADHUMEHA AS PER AYURVEDA :
Madhumeha is a disease in which urine of the patient is sweet like honey and quantitatively increased as well as astringent, pale and rough in quality and the whole body of madhumeha becomes sweet.
ORIGIN OF DIABETES :
Acharya Vagbhata explained the Patho-physiology of Madhumeha as below -
Ojus – The essence of all dhatus (tissues) and the main entity of immunity is spread all over the body. It is frothy, clear, unctuous, sweet, thick, heavy, cold and slimy in nature. Due to the relative causes of the disease Madhumeha, imbalanced Doshas (especially Kapha and Pitta in association with Vata) block the channels related to Meda (adipose tissue / fat tissue) and Mamsa (muscle).Due to obstruction of Vata, it transforms sweet ojas into astringent mixed sweet taste like honey. Thus, it discharges in the urine. Thus, the condition Madhumeha is resulted. Any of the prameha if neglected or treated improperly, it leads to Madhumeha which is the terminal stage of urinary disorders.As described in pathogenesis of Diabetes mellitus though the Kapha is the primary ( arambhaka dosha) (in the Samprapti (pathogenesis) of Madhumeha (diabetes), Pitta and Vata play an important role in complicating the disease. It is worthwhile to note that Madhumeha will occur after when, if the prameha left untreated for some time. It is better to note that Madhumeha is a tridoshaja vyadhi.
Hence the following nidanas that are explained in the texts are to be studied carefully - Vihara sambadhi- Ati atapa sevana (excess sunbath), Ati santapa (excess irritability), Shrama (excess labour), Krodha (anger).
Vataja prameha nidana the causes for aggravation of Vata can be mainly grouped into two categories - margavarana and dhatu kshaya.
- Ahara sambandhi - Katu, kashaya, tikta rasa ahara atisevena; Laghu ruksha, sheeta guna ahara atisevana. .
- Vihara sambandhi- vyavaya atiyoga, vyayama ati yoga, vamana ati yoga, virechana atiyoga, asthapana ati yoga, shirovirechana atiyoga, anashana, abhighata, atapa atisevana, udvega, shoka, ratri jagarana, vegasandharana.
- Charaka mentions the samprapti of Madhumeha due to shudda vata. Due to Vata kara nidana, vata dosha provocated leading to kshaya of other two doshas and sarabhoota dhatus like vasa, majja, lasika and oja. Due to kshaya of dhatus vata further gets provocated. This highly provocated vata draws oja towards basti and leads to madhumeha. This is asadhya to treat due to its arambhaka dosha vata and resultant further provocation due to dhatukshaya (Charaka Samhita, Chikitsa- 6/34).
SAMPRAPTI OF MADHUMEHA (PATHOGENESIS OF DIABETES IN AYURVEDA)
Madhumeha is considered as mahagada and as anushangi vyadhi. This is because, in Madhumeha, vyadhikshamatva (immunity) is a major casualty. Bala derived from Ojas characterises vikara vighata bhava and its deficiency characterises vikar avighata abhava. Hence, the study of the involvement of ojas in the disease warrants a top priority.
Ojas – Oja plays an active part as dushya in the samprapti of Madhumeha. Sushruta has mentioned that oja is a supreme extract of all the dhatu and strength of the body (Sushruta Samhita, Sutra - 14/11). Charaka mentions that life depends on Oja and therefore without Oja, one can’t live. Such oja remains in the heart and called as shareera rasa sneha (ch su 30/4). In the commentary, Chakrapani has described two varieties of oja i.e. para and apara oja. Para oja is a supreme and remains in the, while its pramana is ashta bindu (8 drops). Apara oja is of ardha anjali pramana, which is also called as shleshmika in nature and not the para oja kshaya. Pathological conditions regarding oja are 3 types.
- Oja visramsa – sandhi vishlesha, gatra sada, dosha chyavana, kriyasannirodha.
- Ojavyapth – sthabda gurugatrata, vatashopha,varna bheda, glani, tandra, nidra.
- Ojokshaya – murcha, mamsa kshaya, moha, pralapa, marana (su su 15/24).
In Madhumeha, oja is excreted through the urine leading to oja kshaya, so the symptoms of ojakshaya like murcha, mamsa kshaya, moha may manifest. Vagbhata has mentioned some additional symptoms of oja kshaya like bibheti (excessive fear), abhiksna daurbalya (excessive weakness, vyathita indriya, rukshata etc. (Ashtangahridayam, Sharira- 11/40).
- In madhumeha, though the pathology regarding oja is of kshaya nature, the other two pathological conditions may also be met with, if the samprapti remain unbroken for prolonged time with continuous nidana sevana or due to improper treatment.
- Madhumeha originated from suddha vata may manifest any of the above pathological conditions very easily. Hence the pathological aspect of the oja is very necessary to be observed to know the severity of the disease.
- Any vikara is a mutual interaction of nidana, dosha and dushya under the influence of prakriti, desha, kala, bala and vaya. The extent of this dosha dushya sammurchana is dependent on the vikara vighata bhava and its abhava. Ojas is an important vikar vighatakara bhava and one of the main dushya in Madhumeha which is eliminated through mutra leading to dhatu kshaya. Hence Madhumeha is also called “Ojomeha”.
- The patient who has the specific body tendency for premeha onset which means it may be due to genetic predisposition, prakruti manifestation or sedentary habit have the specific meda bahulyata preferably with abaddhatva. If these patients consume excessive vata provocative ahara, vihara or mano abhigatkara bhava, then vata gets provocated. This vata further gets implicated by meda. Now this provocated meda complex leads to transfer of vasa, majja, lasika, oja to mutravaha srotas. When oja due to influence for vata adopts kshaya and ruksha guna and excrete through urinary treat is termed as Madhumeha.
DHATUKSHAYA JANYA MADHUMEHA SAMPRAPTI
The kshya of gambhira and sarabhuta dhatus like majja, vasa, oja and lasika leads to vata prakopa vata dosha gets vitiated leading to ksharana of sarabhuta dhatus through mutra pravritti in such a quantity that this ksharana of sarabhuta dhatus itself acts as etiological factor again for vata prakopa hence this vicious circle goes on. But due to ashukaritva of vata all the stages of samprapti proceeds so fast that, it leads to asadhya stage of the disease very quickly.
Dushya - rasa, rakta, mamsa, meda, majja, vasa, shukra, oja, lasika, kleda (Charaka Samhita, Nidana- 4/4) and sweda (Ashtangahridayam, Nidana- 10/4).
Srotas - annavaha, mutravaha, udakavaha, medovaha srotas.
Srotodushti - atipravritti, sanga, vimarga gamana.
Agni - vaishamya in all agnis.
Ama - in Madhumeha the amaroopi kapha causes samata of medodhatu first, leading to increased kledata subsequently, this result in saamata of other dhatus as well including the ojas.
Hence dushyas are presenting in the form of ama in Madhumeha.
Udbhavasthana - amashaya.
Sanchara Sthana - sarva shareera.
Adhisthana - basti.
Vyakta Sthana - mootravaha shrotas and sarva shareera.
Vyadhi Swabhava - chirakari Madhumeha is a kapha vata dosha pradhana vyadhi in which the vata dushti occurs in two different pathologic mechanism.
SAMPRAPTI OF MADHUMEHA
1) KRIYA KALA – SANCHAYA AVASTHA -In this stage the samhathi roopa vriddhi of kapha occurs in svasthana i.e. amashaya, presenting the following symptoms.
1. Agnimandya (lack of digestive fire).
2. Gaurava (heaviness).
3. Alasya (laziness).
These are as a result of guru and manda guna of kapha. The occurrence of these symptoms has been inferred after studying the poorva roopa and roopas of Madhumeha.
2) KRIYAKALA – PRAKOPA AVASTHA -In the event of the patient continuing with the nidana sevana, disease proceeds to prakopa avastha where the kapha undergoes vilayana roopa vriddhi and can be understood as presenting with the following symptoms.
1. Annadvesha (anorexia).
2. Hridayotklesha (nausea or unpleasant feeling) - due to amaroopi kapha.
3) KRIYAKALA – PRASARA AVASTHA -If unhindered, the prakupitha doshas attain prasaravastha where the unmarga gamana kapha along with the other two doshas from the svasthana occurs. The doshas pervade the body and it can be inferred that the following symptoms are presented.
3. Angasada - due to kapha along with vata and pittaThe importance of first 3 kriyakalas in preventing Madhumeha – any disorders in these 3 stages often goes unrecognised, as these symptoms are mild enough for the patient to ignore.Moreover, the symptoms are so vague and varied that it becomes difficult to ascribe them as per to Madhumeha in these 3 stages. By suitable modification in the ahara and vihara in the form of laghu ahara sevana and vyayama etc, we can control as well as prevent the onset of Madhumeha.
4) KRIYAKALA – STHANA SAMSHRAYA AVASTHA - By repeated nidana prekupita doshas lodges in the srotas where khavigunya exists. The medhovaha sroto vaigunya in the vapavahana due to apathya sevana or beeja upatapa causes the dusti of kapha and vata & attains sthana ssamshraya initiating the process of dosha dushya sammurchana. The poorva roopas manifest in this kriyakala.
5) KRIYAKALA – VYAKTA AVASTHA - Dosha dushya sammurchana takes place actively during this kriyakala. The pratyatma lakshanas of Madhumeha i.e. prabhoota mutrata and aavila mutrata along with sarvadaihika lakshanas manifest during this stage.
6) KRIYAKALA – BHEDA AVASTHA - In this stage, Madhumeha is no more new. It would have attained sub acute or chronic stage. This disease proceeds into more severe forms in th event of increasing dhatukshaya. It also starts manifesting the pittaja and vataja lakshanas rendering the disease yapya. The disease essentially attains asadhyatha in this stage. Hence forth, upadrava and arishta lakshas start appearing.
1. VISHISHTA ANILATMAKA MADHUMEHA SAMPRAPTI
“Sa prakupita thathavida shareera visarpan -
Ojaha punar madhura swabhavam tadyadaroukshyatvayuh kashayatvena abhisamsrujya mutrashaye abhivahati tada madhumeham karothi.
Thatha vida shareere – bahudrava sleshma, bahuabdh meda, bahu kleda yukta shareera( chakrapani on ch ni 4/37).
The patient who have the specific body tendency for premeha onset which means it may be due to genetic predisposition, prakruti manifestation or sedentary habit have the specific meda bahulyata preferably with abaddhatva. If these patients consume excessive vata provocative ahara, vihara or mano abhigatkara bhava, then vata gets provocated. This provocated vata further gets implicated by meda. Now this provocated meda complex leads to transfer of vasa, majja, lasika, oja to mutravaha srotas. When oja due to influence for vata adopts kshaya and ruksha guna and excrete through urinary treat is termed as Madhumeha.
2. SAMPRAPTI OF MADHUMEHA DUE TO SHUDDHA VATA
Charaka mentions the samprapti of Madhumeha due to shuddavata
“ksheeneshu doshaeshvavakrshya basthav dhatoon pramehaananila karothi || (chi 6/6)
Due to vatakara nidana, vatadosha provocated leading to kshaya of other two doshas and sarabhoota dhatus like vasa, majja, lasika and oja.due to kshaya of dhatus vata further gets provocated. This highly provocated vata draws oja towards basti and leads to madhumeha. This is asadhya to treat due to its arambhaka dosha vata and resultant further provocation due to dhatukshaya (ch.chi 6/34).
3. DHATUKSHAYA JANYA MADHUMEHA SAMPRAPTI :
Apakarshitheshwithi ksheeneshu, kshayasthesham prameha arambakena vatenaiva
upaposhanadhibih karshanad va kriyate (chakrapani on ch chi 6/11)
The kshaya of gambhira and sarabhuta dhatus like majja, vasa, oja and lasika leads to vata prakopa vata dosha gets vitiated leading to ksharana of sarabhuta dhatus through mutra pravritti in such a quantity that this ksharana of sarabhuta dhatus itself acts as etiological factor again for vata prakopa hence this vicious circle goes on. But due to ashukaritva of vata all the stages of samprapti proceeds so fast that, it leads to asadhya stage of the disease very quickly.
4. APRATHIKARITHA VATANU BANDITA MADHUMEHA SAMPRAPTI :
This type of Madhumeha is actually not a separate entity but it is the further stage of kaphaja or pittaja prameha due to deerga kalanu bandha or this may be called as ignored stage of prameha due to lack of proper treatment. Kaphaja and pittaja prameha which are present from quite longer period they do get anubandha of vata to chronicity i.e. they get converted into vataja prameha (ch ni 4/37).
5. AVARANA JANYA MADHUMEHA SAMPRAPTI :
The descriptionof avarana janya samprapti of madumeha is a unique contribution of charaka to the clinical medical knowledge. Here one can see that nidana is same as that of kaphaja prameha but still the resulting disease in Madhumeha. Guru snigdhadi ahara, avyayamadi vihara etc. leads to provocation of kapha and pitta dosha inturn increases in quantity of meda and mamsa. All these increased factors obstruct the gati of vata leading to provocation of vata.This provocated vata withdraws oja from the body and takes it towards basti and leads to Madhumeha, which is krichra sadya for treatment due to its origin from kapha and pitta doshas.
Initially vata dosha remains innocent in the pathology. The vata, pitta and kapha doshas start manifesting their symptoms intermittently depending on their extent of dushti. Subsequently pitta and kapha attain kshayavastha compared to vata due to kshaya of dhatus. This process of margavarana of vata due to kapha and pitta occurs in two kinds of people. First in those who are sthula and secondly in those who are not sthula but have indulged in kapha medokara ahara and vihara. If the nidana for pitta are significant then it also gets dushti. In sthula people, the sthaulya is the result of two reasons. First it is due to excess indulgence in kaphakara ahara viha. If the nidana for pitta are significant then it also gets dushti. In sthula people, the sthulya is the result of two reasons. First it is due to excess indulgence in kaphakara ahara vihara and second is due to beeja dushti. In the former case, the upachaya of medas occurs due to the nidana sevana, where as in the later case, the medo upachaya occurs even in the absence of kapha medokara ahara vihara.
SAMPRAPTI OF STHAULYA AND ITS ROLE IN CAUSING MADHUMEHA
Sthaulya can be caused by tarpana (nourishing diet) as well as beeja dosha. The nidanas for sthaulya are same as those described for Madhumeha as “kapha krit cha sarvam” (all those which cause an abnormal increase in kapha dosha). A sthula rogi can be identified by an abnormal bulk especially to sphik, udara and stana and has the 8 doshas as characteristic features (ch su 21/4).
STAGES OF THE ILLNESS : A SPECIAL REFERENCE
The text Vaidya sara sangraha quotes 10 stages for Diabetes in succeeding order :
1. Vasti bheda (pricking pain in bladder).
2. Murtra peedana (pain during micturition).
3. Vata prakopa (features of aggravated vata in urine).
4. Sannipata dosha prakopa (multiple dosha involvement/tissue damage).
5. Dhatu nasha (tissue necrosis/systemic effect).
6. Daha-moha (burning and hallucination).
7. Mootratisara (severe urination).
8. Mootra granthi/mootra sada (dysuria or controlled urine).
9. Ati trishna (severe thirst).
10. Mrityu (death).
CLINICAL FEATURES OF MADHUMEHA :
1. Atimutrata (excess urination).
2. Avila mutrata (turbid urine).
3. Madhu tulya (urine similar to honey- sweetish astringent).
4. Panduta (pallor of the body).
5. Rukhsata (dryness of the body).
6. Dourbalya (debility).
7. Ratisu anasakti (loss of sexual urge).
8. Dourgandhya (bad body odor).
9. Dhatu kshaya (emaciation) etc.
CURABILITY OF MADHUMEH :
Madhumeha is a palliative disease. It cannot be completely cured; but, can be controlled by food and medicine. In rare cases, if it is originated due to any secondary cause or stress or medicine etc, on cure of the main illness or on withdrawal of the medicine, it will be subsided by its own.
AYURVEDIC TREATMENT CONCEPT FOR DIABETES :
Depending on the physical constitution or body type (prakriti), or the health status of an individual, ayurvedic classics advocate two different types of therapy schedules for diabetics. They are : Apatarpana – de-nourishment treatment – useful in obese diabetic patients, usually in Kapha body type patients.
Santarpana – Nourishing treatment – useful in lean diabetic patients, usually in Vata or Pitta body type patients.
1. Apatarpana (de-nourishment) and Samshodhana (cleansing): This treatment is prescribed if you are obese and heavily built. In this, along with anti-diabetic herbal medicines, importance is given on de-nourishment of fats and elimination of toxins by way of
- various exercises.
- fasting therapies – such as juice fasting, water fasting etc.
- Cleansing therapies –called panchakarma (five fold therapies viz. emesis, purgation, oil enema, decoction enema and nasal drops instillation).
2. Santarpana (replenishment) and Brumhana (body bulk promotion): This is prescribed if you are chronically ill, with low immunity and underweight due to the draining of essential nutrients. This therapy helps in providing the easily acceptable nutrients and micronutrients to rebuild body tissues and help strengthen the defence mechanism without increasing circulating blood sugar and fat tissue. This prevents further damage and ensures enhanced healing and repair. This is achieved by
- Oil enema therapies (Anuvasana Basti).
- Oil massage.
Administration of nourishing Ayurvedic herbs such as Ashwagandha (Withania somnifera), Vidari (Pueraria tuberose), Shatavari (Asparagus racemosus), Aloe vera, pomegranate, nuts etc. Read more about nourishing treatments of Ayurveda
CLASSICAL AND HOME REMEDIES :
Guduchi Kwatha : Decoction or juice of Tinospora cordifolia mixed with honey.
Nisha kalka : Paste of Nisha (Curcuma longa) mixed with juice of Amalaki (Emblica officinalis).
Nisha-triphala Yoga : The powders of the below said should be kept in water over night and should be strained through a sterile cloth or sieve in the morning. It should be consumed mixed with honey.
- Nisha – Curcuma longa.
- Daruharidra – Berberis aristata.
- Haritaki – Terminalia chebula.
- Bibhitaki – Terminalia bellirica.
- Amalaki – Emblica officinalis.
HERBS RECOMMENDED IN MADHUMEHA
Asana – Pterocarpus marsupium Linn.
Nimba – Azadirachta indica A. Juss.
Bilva – Bael tree – Aegle marmelos.
Haridra – Turmeric.
Lodhra – Symplocos racemosa Roxb.
Jambu – Jamun seeds.
Saptaparna – Alstonia scholaris R. Br.
Meshashringi – Gymnema sylvestre R. Br.
Kathaka – Strychnos potatorum Linn.
Khadira – Acacia catechu Willd.
Guggulu – Commiphora mukul (Hook. Ex. Stocks.) Engl.
Mamajjaka – Enicostemna littorale Linn.
Shilajatu – Asphaltum punjabinum.
FORMULATIONS RECOMMENDED IN MADHUMEHA
USEFUL AYURVEDIC MEDICINES FOR DIABETES
1. Dhatri Nisha : A combination of Turmeric powder and Amla powder and has to be taken early morning and is especially useful in Diabetic eye problems (diabetic retinopathy).
2. Triphala : A simple combination of three fruits – Terminalia chebula, Terminalia bellirica, Emblica officinalis. Apart from reducing blood sugar levels, it also relieves constipation, provides eye care. It is a very good source of anti oxidants.
3. Asanadi Kashayam : useful in diabetes associated with obesity, non healing wounds, diabetic carbuncles.
4. Chandraprabha vati : Useful in diabetes associated with recurrent urinary tract infection and diabetic nephropathy.
5. Pathyakshadhatryadi Kashaya : rich in anti oxidants.
6. Shilajatu vati : useful in diabetes associated with premature ejaculation, erectile dysfunction etc.
7. Panchanimba churna : useful in diabetes associated with repeated skin infection disorders.
Madhumeha is a burning problem of the whole universe. People are eagerly waiting for a quick and permanent cure.
ARISHTA LAKSHANA OF MADHUMEHA - LETHAL FEATURES
A few references regarding the Arishta Lakshana of Madhumeha and Prameha can be found. If the Bala and Mamsa of Madhumeha Rogi is severely deteriated then he should be considered as Achikitsya (not advisable for treatment), I am not listing them as they will demoralize the patients. If will power of any patient is good and positive he can take care of himself.
CURABILITY OF MADHUMEH
Madhumeha or prameha has been described as anushangi which means it is punarbhavi in other words once a madhumehi will be so always throughout his life. Therefore one should make all efforts to prevent and control it. As described earlier Madhumeha passes through 3 stages of severity based on involvement of dhatus accordingly the sadhya asadhyata has been described.
The above interpretations indicate the fatality of the disease, where all th dhatus including the gambhira dhatus undergo nasha, kshaya, sravana and apakarshana.
This process involves multiple srotases producing upadravas and is hence mahavyapathikara, which means that the disease is much too fatal to sustain life. Moreover it is ashukari and sheegrakari which indicates the rapidity of the fatality in the patient, which is why the author’s advice the physician not to bother much in handling the patient as disease transcends all boundaries of management.
Virudhopakramatvat: the chikitsa of vataja prameha involves virudhopakrama which means there is a mutual contradiction in the treatement modalities as use of snigdha etc are pathya for vata but apatya for medas. Hence the disease is asadhya.
Sadhyata of kaphaja meha attains Asadhyata when associated with all poorvaroopa. Yapyata of pittaja meha attains Pratyak hyeyata when associated with poorvaroopa.
The principles of chikitsa can be studied under
a) Nidana parivarjana.
c) Prakriti Vighatana.
SAMANYA CHIKITSA SIDDHANTA
Nidana Parivarjana in Margvarana Janya Madhumehi
An apathyanimittaja Madhumehi is usually sthula, likes Abhyavaharana and hates chankramana. Here the patient should be made to avoid all kaphakara ahara vihara to prevent the occurrence or to cure the disease.
Nidana Parivarjana in dhatukshaya janya madhumehi (ch.chi 6/53).
Nidana parivarjana in such madhumehis is studied with special referance to sahaja Madhumeha. It lies entirely on the vata or pita so as to how best they act to prevent the occurance of the disease in them. They should avoid the beeja, beeja bhaga or beeja bhaga avayava upatapa leading to Madhumeha arambaka dosha dushti.
APAKARSHANA AND PRAKRITI VIGHATANA
The apakarshana of dhoshas are mainly done through samashodhana but only when roga and rogi bala are in pravaravastha and when either one or both are avara, then it is done through langhana and langhana pachana which constitutes samshamana chikitsa, in other words prakriti vighatana.
Apakarshana in margavarana janya Madhumeha: In sthula Madhumeha samshodhana is indicated and before starting this therapy snehana is advised. For snehana karma when there is predominame of kapha dosha along with vata then taila processed with kaphagna drugs should be used. When there is anubandha of pitta the ghritha processed with pittaghna drugs should be employed (ch.chi6/34, 37). Shodhana especially vamana should be preferred in a madhumehi if the dhatukshaya is minimum and kapha and medodushti lakshana are maximum.
If there is pittaja lakshana and dhatukshaya but virechana is not contraindicated then virechana can be performed. Similarly, if the anubandha vata lakshana are more and the patient is samashodhana arha then basti can be performed.
Madhumeha is a svedana anasha vyadhi(su.chi 12/7) but niragni sveda in the form of vyayama is indicated. The selection of yoga for samshodhana should be selected as per the recipes prescribed in kalpa sthana. After shodhana, shamana chikitsa can be done by kapha medohara dravya.
APAKARSHANA AND PRAKRITI VIGHATANA
Dhatu Kshaya avastha is the result of Beeja dushti in sahaja Madhumeha and due to a state of Atikarshita dhatus as a result of continued dhatu kshaya, which in fact is the progressed stage of Marga varana Janya Madhumeha. Both the situations are considered samsodhana Anarha (chi chi 6/18). In such cases, samshamana chikitsa is adviced, whereas Madhumeha in both these cases are Asadhya (chi chi 6/52).
Not with standing this, the principles of chikitsa for vataja pramehas are for vata anubandha doshatva, which is still dependent on the Kapha and pitta doshas and not for Vata Anubandhya Dosha janya Madhumeha characterised by Atishaya karshana of dhatus. Hence samshamana chikitsa should be appropriatly adopted in such patients.
AVASTHA ANUSARA CHIKITSA OF MADHUMEHA (SU CHI 12/4)
Sushrutha in the chapter of prameha pidaka chikitsa has identified the stages of Madhumeha and accordingly advised the treatment, which can be discussed as follows;
Stage I : chikitsa in poorvaroopavastha.
Stage II : chikitsa in vyaktavastha.
Stage III : chikitsa in Upadrava Avastha.
Stage IV : chikitsa in pravrudha Upadrava Avastha.
Stage V : chikitsa in asadhya Avastha.
Stage I : Is the poorvaroopa Avastha where the dosha dushya sammurchana has just begun, then the disease should be treated with Apatarpana, Vanaspathi Kashaya and chaga mutra. If left untreated, Madhumeha proceeds to the II stage.
Stage II :this is the vyakta avastha of Madhumeha where, due to continued madhura ahara sevana, the sveda, Mutra and sleshma attain Madhura bhava and hence should be treated with ubhaya samshodhana i.eVamana, virechana and Basti. If left untreated, the disease progresses to Stage III.
Stage III :in this stage, the Mamsa and Shonita undergoes pravruddha dushti causing shopha and other Upadravas and these should be appropriately treated as mentioned accordingly, like siramokshana in shopha. If left untreated, the disease progresses to stage IV.
Stage IV :in this stage, the upadravas like shopha would have attained Ativruddha Avastha manifesting symptoms like ruja and Vidaha, where shastra chikitsa and Vranakrija should be performed. If neglected the disease proceeds in to Asadhya Avastha which is the V and final stage.
Stage V :In the Asadhya Avastha, the Upadravas become Mahantha and makes the disease Asadhya, like here when the Puya of Pidakas attain Abhyantaraprapti and become utsanga.
Analysis : Though explained as Prameha pidaka Avastha chikitsa, description of stagewise progession of the disease and the treatment has been done by sushruta on the pretext of explaining prameha pidaka chikitsa.
This description seems to be chikitsa in case of Apathyanimittaja Madhumeha, the course of this illness has been discussed already under samprapti and accordingly in the poorvaroopavastha, sushrutha advices Apatarpana and other shamana dravyas, as there is alpa dosha and alpa dhatu dushty. Hence unless the need arises, samshodhana is not the treatment of choice and as the lakshana are predominently due to kapha, kaphahara chikitsa should be done and this seems to be the logic behind prescribing Apatarpana and Tikshana dravyas like chaga mutra. Whereas in Vyakta avastha there is bahu dosha and relatively Alpa dusti of dhatu like medas and Rakta which wants shodhana, accordingly Vamana, Virechana and basti have been advised as the rogi is still Balavan and Stula so, shodanarha.
In the next stages, there is a progressive dhatu kshaya and production of upadravas. The patient is shodhana Anarha and there is Vata pradhanyata. Hence, only shamana chikitsa and respective upadrava chikitsa should be done. Sushruta has stressed the importance of timely intervention in Madhumeha because in case of negligence, the disease progresses involving gambhira dhatus and the upadravas pervade entire body making it Asadhya.
SANTARPANA APATARPANA CHIKITSA IN MADHUMEHA
Madhumeha has been described as santarpanodha vyadhi as well as Apatarpanodha vyadhi. The former is Apathya nimithya Madhumeha and later is sahaja Madhumeha i.e. Madhumeha due to dhatu karshna due to long lasting prameha. Acordingly, two forms of madhumehis are encountered one who is sthula and balavan for whom apatarpana is the best and other who is krusha and paridurbala for whom santarpana is the best line of treatment.
APATARPANA CHIKITSA (CHI CHI 6/51) :– is done in the form of langhana, langhana pachana and doshavasechana (ch.vi 4/43). Langhana is done in Alpadoshavastha where only upavasa, pipasa, maruta, atapa, sevana (ch su 22/10). Rooksha udvartana, pragadha vyayama, nishijagarana & so on, which are kapha medohara, are helpful. Langhana pachana is done in madhyama doshavastha where along with langhana; amapachana is done with Tikshna, ushna dravyas. Doshavasechana is done in bahu doshavastha where the shodhana of doshas is done from ubhaya margas.
SANTARPANA CHIKITSA :– laghu santarpana chikitsa is prashastha for krusha and durbala rogis. The following can be administered in madhumehi. a) mantha b) kashaya c) yava d) churna e) lehya f) laghu bhakshya. These formulations should be prepared such that they cause santarpana without causing vriddhi of kapha and medas. Among all these yava is considered as best for madhumehi.
SHAMANA CHIKITSA :– Sushruta as described to select drugs, which are having bitter, pungent, astringent taste, katuvipaka, ushna veerya and shoshaka, chedana properties in the treatment of Madhumeha (su chi 13/8). Shilajathu guggula, loharaja are the best medicines in madhumeha, either in krusha or sthula, as they are virukshana and chedaneeya, which is good for kapha, as well as rasayana, which is good for dhatukshaya & vata vriddhi. Sushruta as described some medicinal remedies for all types of prameha and advised to use after purification therapy.
1. Extracted juice of amalaka mixed with haridra powder and honey.
2. A decoction of triphala vishala, devadaru and musta.
3. Tola kalka of shala, kampillka, mustaka, sweetened with honey and extracted juice of amalaka should be taken together.
4. Powders of the flower of kutaja, rohitha, kapittha and vibhitaka should be taken together with honey, haridra and extracted juice of amalaka.
5. Decoction of roots, leaves, barks, flowers and fruits of nimba, aragvadha, saptaparna, murva, kutaja, somavriksha, palasha should be given to the patients (su chi 11/8).
The decoction of chitraka, triphala and indrayava mixed with honey. Extracted juice of guduchi mixed with extracted juice of amalaka fruit and honey.
PATHYA APATHYA OF MADHUMEHA :–
Pathya :Nidana parivarjana is the first and prime pathya for Madhumeha. In sthula Madhumeha there is margavarodha of vata by vridha kapha and meda hence to rectify the imbalance of doshas and to reduce to the meda, usage of jangala mamsa rasa of vishkira, pratuda and vihanga varieties, shyamaka, uddalaka, kodrava, godhuma, chanaka, adhaki tikta rasa pradhana shakas grown in jangala desha, yavanna, madhu, kulatta purana dhanya sevana, puranashali, laja sevana is also beneficial (ch chi 6/19, 20, 21).
Sushrutha mentioned vyayama and ratri jagarana are beneficial (su ch 12). Tikta rasa dravyas are beneficial in madhumeha because tikta is laghu and ruksha where as kapha is guru and snigdha. Tikta rasa helps in decreasing kapha, shareera kleda and meda, which are known as the important factors involved in Madhumeha. It helps in reducing the dravatva of mutra in term decrease the saratva hence the frequency of mutra will be reduced. Karavella, bhumyamalaki etc are to be used for this purpose. Yava is ruksha & laghu, helps in bringing kapha dosha to normalcy. Yava, mantha, vishkira mamsa, pratuda mamsa are the pathya beneficial for krusha madhumehi.
Sahaja Madhumeha and Madhumeha with Dhatu Kshaya have Vata as anubhandhya dosha. Since the beginning, but in margavarana Janya Madhumeha Vata is only Anubhandha to pitta by Sleshma and therefore the chikitsa for vataja prameha have been designed keeping in mind the Anubhandhavata and not the Anubandhyavata because in the later case it has been categorically stated that even thinking about managing this condition is a futile exercise. Where as in the former case the status of Vata can be controlled through the treatment, as it is still dependent on the status of Sleshma and pitta. In this case the amenability of vata to the treatment becomes less and less depending on with what severity the poorvaroopas are associated.
In other words, in case of Anubandha vata if the prameha were having to been Avastha Sadhya, it would become Asadhya even if associated with Asamartha poorvroopas as vataja pramehas are Asadhya by svabhava. Hence the degree of Asadhyata in stages of vataja prameha worsens with the degree of association of poorvaroopas.
1. Jatha Madhumeha is Asadhya due to Beeja dosha as there is irreversible madhumeharambaka dosha dusti since the birth itself.
2. Madhumeha with pidaka is Asadhya.
3. Madhumehi who has Bala mamsa Kshaya can be left untreated.
4. All pramehas if left untreated terminate into Madhumeha which is Asadhya.
5. Prameha with upadravas and Atiprasuta mutra is Asadhya.
6. Pramehas with arista lakshanas is Asadhya.
7. A patient who hates hygienic habits like snana, chankramana and one who has Manda Utsaha, who is Atisthula, Snigda and Mahashana dies of prameha.
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