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CLINICAL EVALUATION OF VATSAKADI QWATHA IN THE MANAGEMENT OF MADHUMEHA W.S.R TO DIABETES MELLITUS (NIDDM), SRIKRISHNA H.A, PG Studies in Kayachikitsa, A.L.N. Rao Memorial Ayurvedic Medical College and P. G. Centre, Koppa.

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Madhumeha kc009 kop

  1. 1. CLINICAL EVALUATION OF VATSAKADI QWATHAIN THE MANAGEMENT OF MADHUMEHA W.S.R TO DIABETES MELLITUS (NIDDM) BY Dr. SRIKRISHNA H.A BAMS (RGUHS) Dissertation submitted to theRajiv Gandhi University of Health sciences, Karnataka, Bangalore In partial fulfillment Of the requirements for the degree of Ayurveda Vachaspati” M.D. [Ayurveda] In KAYACHIKITSA GUIDE Dr. SURESH R.D M.D. (Ayu), MS (C&P), CYS.DEPARTMENT OF POST GRADUATE STUDIES IN KAYACHIKITSA A.L.N.RAO MEMORIAL AYURVEDIC MEDICAL COLLEGE KOPPA – 577126, CHIKMAGALUR DISTRICT KARNATAKA, INDIA NOVEMBER - 2010
  2. 2. Department of Post graduate A.L.N.Rao Memorial AyurvedicStudies in KAYACHIKITSA Medical College Koppa – 577126 Dist: Chikmagalur Declaration I hereby declare that this dissertation entitled “Clinical Evaluation Of Vatsakadi Qwatha In The Management Of Madhumeha W.S.R To Diabetes Mellitus (NIDDM).” is a bonafide and genuine research work carried out by me under the guidance of DR.SURESH.R.D. Department of Post Graduate Studies in KAYACHIKITSA, A.L.N. Rao Memorial Ayurvedic Medical College P. G. Centre, Koppa Date: DR.SRIKRISHNA H.A Place: Koppa P.G.SCHOLAR, Dept. of Kayachikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126
  3. 3. Department of Post graduate A.L.N.Rao Memorial AyurvedicStudies in KAYACHIKITSA Medical College Koppa – 577126 Dist: Chikmagalur Certificate This is to certify that the dissertation entitled “Clinical Evaluation Of Vatsakadi Qwatha In The Management Of Madhumeha W.S.R To Diabetes Mellitus (NIDDM).” is a bonafide research work done by DR. SRIKRISHNA H.A, in partial fulfillment of the requirement for the degree of Ayurveda Vachaspati (MD) in KAYACHIKITSA of Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka. Date: DR SURESH R.D Place: Koppa M.D (Ayu), MS (C&P), CYS GUIDE & ASSISTANT PROFESSOR Post graduate Department of Kayachikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126Department of Post graduate A.L.N.Rao Memorial AyurvedicStudies in KAYACHIKITSA Medical College Koppa – 577126 Dist: Chikmagalur
  4. 4. Certificate This is to certify that the dissertation entitled “Clinical Evaluation Of Vatsakadi Qwatha In The Management Of Madhumeha W.S.R To Diabetes Mellitus (NIDDM).” is a bonafide research work done by DR. SRIKRISHNA H.A, in partial fulfillment of the requirement for the degree of Ayurveda Vachaspati (MD) in KAYACHIKITSA of Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka. Date: DR. DEBAJIT BHATTACHARYA Place: Koppa M.D. (Ayurveda) H.O.D. & PROFESSOR Post Graduate Department of Kayachikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126Department of Post graduate A.L.N.Rao Memorial AyurvedicStudies in KAYACHIKITSA Medical College Koppa – 577126 Dist: Chikmagalur
  5. 5. EndorsementThis is to certify that the dissertation entitled “Clinical Evaluation Of VatsakadiQwatha In The Management Of Madhumeha W.S.R To Diabetes Mellitus(NIDDM).” is a bonafide research work done by DR. SRIKRISHNA.H.A,in partial fulfillment of the requirement for the degree of Ayurveda Vachaspati (MD)in KAYACHIKITSA of Rajiv Gandhi University of Health Sciences, Bangalore,Karnataka.Date: Prof. DR.SANJAYA.K.S. B Sc, MD (Ayurveda)Place: Koppa PRINCIPAL, A.L.N.Rao Memorial Ayurvedic Medical College, Koppa –577126
  6. 6. COPYRIGHT I hereby declare that the Rajiv Gandhi University of Health Sciences,Karnataka shall have the rights to preserve, use and disseminate this dissertation inprint or electronic format for academic/research purpose.Date: DR.SRIKRISHNA.H.A P.G.Scholar,Place: Koppa Dept. of Kayachikitsa A.L.N. Rao Memorial Ayurvedic Medical College, Koppa – 577 126© Rajiv Gandhi University of Health Sciences, Karnataka
  7. 7.   ACKNOWLEDGEMENT Salutations and surrenderence of this whole work under thelotus feet of his highness and holiness Sri Sri Sri RangapriyaMahadesikan and his highness and holiness Sri Sri SriSwayamprakasha Sachidananda Saraswathi Mahaswamiji. Salutations and surrenderence to the self within belovedparents, Sri.H.S.Ananthashayanam (Retired Manager, ING VYSYABANK and Smt.M.S.Vedavalli (Retired Headmistress), innateselfmate Mr. Srinidhi H.A and sister-in-law Smt Dr Janaki, SriSitaram Bhat and Smt. Nagaratna and all my other family memberswhose constant blessings through true - love, support, sacrifice,encouragement and inspiration has sculptured this whole worktowards its smooth and successful completion. Salutations and surrenderence to the self within beloved greatteachers Dr Rangapriya Mahadesikan, Dr.N. Shivarama Gayathri,Dr. Shobha. G. Hiremath, Dr Geetha Bhai, Dr Ahalya who taught andwill be teaching the essential lessons of Ayurveda for lifetime. Salutations and surrenderence to the self within beloved andrespected Guide Dr. Suresh. R. D, M.D (Ayu), MS (C&P), , P.G Dept. of CYSKayachikitsa, A. L. N. Rao Memorial Ayurvedic Medical CollegeKoppa for his blessings through high esteemed standards of guidance,meticulous supervision, timely advices, motivation, inspiration and co-operation throughout the successful completion of this dissertationwork. Salutations and surrenderence to the self within beloved andrespected Sri. Aroor Ramesh Rao, President, A.L.N. Rao MemorialAyurvedic Medical College, Koppa for giving an opportunity topursue post-graduate study in his esteemed and prestigious institution. Salutations and surrenderence to the self within beloved andrespected Dr.Sanjaya.K.S M.D , Principal, A.L.N Rao Memorial (Ayu)Ayurvedic Medical College, Koppa for his immense help and supportin completing this work. Salutations and surrenderence to the self within beloved andrespected Dr. Debajith Bhattacharya M.D (Ayu) , HOD and Professor, P.GDepartment of Kayachikitsa and Prof. Dr P.K. Mishra M.D (Ayu) , 
  8. 8.  Department of Kayachikitsa for their blessings through great heartyinspiration. Salutations and surrenderence to the self within beloved andrespected P.G staffs in the Dept. of Kayachikitsa; Dr.Prasanth G.S M.D , Dr.C.B.Singh(Ayu),PhD M.D (Ayu) , Dr. Rita Singh M.D (Ayu) , Dr. Srinivas M.D (Ayu) ,Dr. Shobha Shetty M.D (Ayu) , Dr.Niranjan, M.D (Ayu), Dr.Smitha Manoj M.D , Dr Usha Rani(Ayu) M.D (Ayu) Dr Triveni M.D (Ayu) and Dr. Shobha. R. ItnalM.D (Ayu) . Salutations and surrenderence to the self within beloved andrespected Prof. T.K.Mohanta M.D, PhD (Ayu) and Prof. R.R. Mishra, , M.D (Ayu)for their substratal constructive suggestions during the successfulcompletion of this Dissertation work. Salutations and surrenderence to the self within beloved andrespected Prof. Dr D.K.Mishra , HOD of Bhaishajya Kalpana & M.D (Ayu)Assistant Principal of P.G faculty and Prof. Dr Vidyasagar M.D (Ayu) ,HOD of Dravyaguna for their constant encouragement and valuablesuggestions. Salutations and surrenderence to the self within beloved andrespected Dr. Prashanth Kumar Jha DIM, CIPR, PGDEE, MSc, Ph.D . Head, QualityControl Laboratories, for his guidance and support for Phyto ChemicalAnalysis without which the study would have been incomplete. Salutations and surrenderence to the self within beloved andrespected Prof. Dr H.R.Pradeep M.D (Ayu) Assistant Principal of U.Gfaculty and other P.G. faculty of Dravyaguna Department;Dr.Ilanchezhian , Dr.Harivenkatesh M.D (Ayu) M.D (Ayu) , Dr Vinayak BhatM.D (Ayu) and Dr.Bhanu M.D (Ayu) for their extensive help in the drugreview. Salutations and surrenderence to the self within beloved andrespected Dr.Mathapati M.D (Ayu) , Dr. Milind Hukkeri , Dr. Roshy M.D (Ayu)M.D (Ayu) , Dr. Harikrishnan M.D (Ayu) , Dr. Abdul Kareem M.D (Ayu) , Dr. ShubhaShastry M.D (Ayu) and Dr. Sandeep Sarode M.D , Department of (Ayu)Bhaishajya Kalpana for their guidance in the preparation ofmedicine. Salutations and surrenderence to the self within beloved andrespected Dr. Suryakumar, M.D (Ayu) , Dr Basavaraj M.D (Ayu) , Dr VidyavatiM.D (Ayu) from the Department of Shalakya Tantra, Dr. Laxmikanth M.D 
  9. 9.  (Ayu) , Dr. Vikram M.D (Ayu) , Dr. Mithun M.D (Ayu) and Dr. Satish M.D (Ayu),from the Department of Shalaya Tantra for their support in thedissertation work. Salutations and surrenderence to the self within beloved andrespected Dr. Suhas Shetty, , for his kind inspirational attitude M.D (Ayu)and meticulous guidance in statistical work. Salutations and surrenderence to the self within beloved andrespected Dr. Ram Mohan, and Dr. Shanbhag, Consultant Physiciansof this bonafide Ayurvedic college and hospital for their supportduring various stages of this work. Salutations and surrenderence to the self within Dr. Sandhya,M.D (Ayu) , Dr. Elizabath, , Dr. Sonmankar, M.D (Ayu) M.D (Ayu) , Dr. Basavaraj,M.D , Dr. Moharar (Ayu) M.D (Ayu), Dr. Rashmi Sharma M.D , Dr. (Ayu)Saraganachary M.D (Ayu) and Dr. Prashanth.K , for their moral M.D (Ayu)support during the study tenure. Salutations and surrenderence to the self within the treasurest,the sweetest reminiscences of loving and affectionate sharing andcaring attitude shown by our dear seniors Dr. Nagendra M.D (Ayu) , Dr.Sreejith , by dear loving batchmates Dr. Bejoy, Dr. Lovelin M.D (Ayu)eralil, Dr. Krishnaveni, Dr. Thulya, Dr. Sriparvathi, Dr. Deepa, Dr.Ananda Bhairavi, Dr. Pallavi, Dr. Katyayani, Dr. Kiran, Dr.Jagadish Mayya, Dr. Narappa Reddy, Dr Vaishnavi, by dear lovingjuniors Dr. Suresh, Dr. Sudev, Dr. Subin, Dr. Jayakrishnan, Dr.Neelakantan, Dr. Divya Khare, Dr. Dhanyamurali, Dr. Soumitkumar, Dr. Parag, Dr. Kanchan kulkarani whose warmth hearty andintellectual memories will always be cherished as the ei-force, besidesjust being the e & i forces for the successful completion of this work. Salutations and surrenderence to the self within all the patientswho were included and excluded during the study for being theprimordial ei-force for the present and the future endeavours. Salutations and surrenderence to the self within all the hospitalstaff, pharmacy staff and especially for Ms. Amrutha and Mr.Mohana, the Lab technicians for their immense hearty andintellectual support for the successful completion of this work.Koppa, Nov. 2010. Dr. Srikrishna.H.A 
  10. 10.   ABSTRACT Madhumeha is a term considered for the condition of all types of Prameha and specifically for one among the Vatika Prameha as elucidated by Acharya Chakrapani in Charaka Samhita and is characterized by Prabhuta and Avila Mutrata as the Samanya Lakshana. With specific Madhumeha lakshanas, some Ayurvedic scholars correlate Madhumeha with Diabetes Mellitus, which is a metabolic disorder characterized by hyperglycemia with or without Glycosuria resulting from an absolute or conditional deficiency of insulin. Madhumeha which has been correlated with Diabetes Mellitus has become a global health threat inspite of advances in conventional science; while, India has been projected by W.H.O as the country with the fastest growing population of Diabetic patients. Recent studies have estimated that in the year 2000, 171 million people had diabetes and are expected to double by 20301. So, in an attempt for early diagnosis and to combat this disease condition effectively; a formulation, Vatsakadi Qwatha mentioned in Sharangadhara Samhitha, Qwatha Kalpana Adhyaya in the context of Mehagna qwatha, has been selected for the present study based on the hypothesis that the drugs like Vatsaka, Triphala, Daruharidra, Musta and Bijaka having Tikta Kashaya as the Pradhana Rasa and Mehagna property are potent enough to combat this disease condition and are also easily available. OBJECTIVES:• To evaluate the efficacy of the formulation, Vatsakadi Qwatha in the management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM).• To assess the merits and demerits of the trial drug, Vatsakadi Qwatha.
  11. 11.  • Detailed study of the disease covering classical and modern literatures.• To evaluate the Diabetic Quality of life. METHODS: Cases presenting with classical sign and symptom of Madhumeha were selected. The preparation Vatsakadi Qwatha had been given to a group of 20 patients. The symptoms of Madhumeha like Prabhutamutrata, Avilamutrata, Pipasa, Kshudha etc had been assessed before and after the treatment. The duration of the study was 45 days with 90 days follow up study with assessment of results at the interval of 15 days. RESULTS: The drug Vatsakadi Qwatha showed significant results in combating the symptoms of the disease Madhumeha during treatment period. The follow up results were insignificant. CONCLUSION: The Polyherbal formulation Vatsakadi Qwatha was effective in the management of Madhumeha during treatment period and was not effective enough during the follow up period. The ingredients of the formulation are easily available; needs constant discrete observation over the subject by the treating physician and has a wide scope for further studies. KEYWORDS: Madhumeha, Diabetes Mellitus, Vatsakadi Qwatha.
  12. 12. CONTENTSSL. NO. TOPIC PAGE 1. Chapter- I INTRODUCTION 1 2. Chapter- II OBJECTIVES 4 3. Chapter- III REVIEW OF LITERATURE a) HISTORICAL REVIEW 5 b) DISEASE REVIEW 11 c) DRUG REVIEW 90 4. Chapter- IV METHODOLOGY a) MATERIALS & METHODS 99 b) OBSERVATIONS 110 5. Chapter- V RESULTS 128 6. Chapter- VI DISCUSSION 139 7. Chapter- VII CONCLUSION 164 8. Chapter- VIII SUMMARY 166 9. REFERENCE 10. BIBLIOGRAPHY 11. ANNEXURE
  13. 13.   ABBREVIATIONS 1. A.Hr Ashtangahrudayam 2. A.Sa Ashtangasangraham 3. Cha.Sam CharakaSamhitha 4. Su.Sam Susrutha Samhita 5. Ma.Ni Madhava Nidanam 6. Sha.Sam Sharangadhara Samhitha 7. Ka.Sam Kashyapa Samhitha 8. Ha.Sam Harita Samhitha 9. Bha.Pra Bhavaprakasam 10. Y.R Yogaratnakaram 11. H.P.I.M Harrisson’s Principles of Internal Medicine 12. D.P.P.M Davidson’s Principles and Practice of Medicine 13. Ni Nidanasthanam 14. Chi Chikitsasthanam 15. In. Indriyasthanam 16. Vi Vimanasthanam 17. U. Utharardham 18. R.V Rig-Veda 19. S.B Shayana Bhashya 20. C.D Chakradutta 21. R.P Robbins-Pathology 22. K.V.K.C.M Clinical Medicine - K.V.Krishnadas 23. Chak Chakrapani 24. Ni.Sam Nibandha Sangraha 
  14. 14. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) INTRODUCTION || िन या: ूाणभृतां दे हे वात प कफा य: । वकृ ताः ूकृ ितःथा वा तान ् बुभु सेत प डतः ॥ - च.सू.१८/४८ In an attempt to dig out the secrets of healing within the asylum of diseases;the therapeutic pearls of wisdom in the form of aphorisms delivered by our AncientAyurvedic Seers several thousand decades ago is now still on the verge of greatdiscoveries and achievements, under the sacred healing hands of the present dayAyurvedic Professionals of varied specialties. The Prime Eternal Objective Instinct of these professionals being the Quest Ofthree fundamental humors in relationship with the elan vital governing both Healthyand Non-Healthy state of the Human Body, Mind and Soul, thus guiding them to thegreatest heights of professional success by fulfilling the four essential pursuits of life1. Thus, literally, the word Ayurveda cannot be restricted to be defined as only –Science of Life but, it would be wise enough to be extended as the Most ScientificEternal Divine Coded Medical Language which teaches the value of being healthyand the means to achieve it through our day to day activities of life. This is achieved by the Ayurvedic professionals with the help of the fouressential limbs of therapeutics like the Bhishak, Dravya, Upastha and Rogirespectively, termed as Bhishak Chatushpada by the ancient seers. The present 21stcentury is gradually and drastically changing the attitude ofevery individuals of the society towards every aspect of life by guiding and promptingthem towards a weird quality of day to day physical and mental activities and finallymaking them to lead an obsessive, erratic lifestyle which in turn has led to an healthcrisis of various lifestyle disorders. One among those lifestyle disorders isMadhumeha vis a vis Diabetes Mellitus, which is now becoming a major health threatin both developed and developing countries. Statistically, India is now considered as ‐ 1 - 
  15. 15. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)the diabetic capital and is sure to double from the 2010 - 171 million diabetics by2030. Acharya Charaka has quoted “as the birds are attracted towards the treewhere their nests lies, similarly Madhumeha affects people who are voracious eatersand have aversion to physical exercise. The disease Madhumeha, its definition,etiology, clinical features and principles of treatment appear to be similar with thedisease “Diabetes Mellitus”, which is considered as “Ice Berg” disease in the presentera1. Our classics have termed Madhumeha1 as Asadya keeping in terms of VatajaPrameha and also as a Kulaja Vikara - Jataja but, the term here in the present study istaken in accordance to the opinion of Acharya Chakrapani where Meha Samuha canalso be termed as Madhumeha and by the timely intervention with appropriateOushadha, Pathya and Vyayama for the same both the short-term and long-termcomplications can be effectively managed and prevented by breaking the viciouscycle of pathology and thereby enhance the Quality Of Life of the patient. If it is notdone so; then, the disease pathology progresses enough to gain a strong chronicity andbecomes Asadya. Ayurveda proposes number of Herbal and Herbo-mineral formulations for themanagement of Madhumeha. Here a sincere attempt has been made to provide abetter management of this dreadly condition, Madhumeha. The present research workundertaken is entitled as “Clinical Evaluation of Vatsakadi Qwatha in theManagement of Madhumeha With Special Reference to Diabetes Mellitus” basedon the hypothesis that the formulation Vatsakadi Qwatha11 mentioned inSharangadhara Samhita, Madhyama khanda, 2nd Chapter- Qwatha Kalpana Adhyaya-Mehagna context, with its ingredients Vatsaka1, Haritaki, Amalaki, Vibhitaki, ‐ 2 - 
  16. 16. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Daruharidra, Musta and Bijaka have Tikta Kashaya Rasa Pradhanata andMehagna property. The present work also includes theoretical aspects of Madhumeha, briefhistorical review, Nirukti and Paribhasha, Nidana Panchaka, Bheda, Sapeksha Nidana,Chikitsa, Upadrava, Sadhya Asadhyatha as explained by different Ayurvedic classicsand also its modern parlance. Random selection of patients for clinical study, case study, adopted treatmentand its methods with respective subjective and objective parameters, resultsdiscussion and conclusion are dealt at the end in detail. Thus the entire work has been strategized chapter wise in the followingmanner: Chapter I Introduction Chapter II Objectives Chapter III Review of literature Chapter IV Methodology Chapter V Observation Chapter VI Results Chapter VII Discussion Chapter VIII Conclusion Chapter IX Summary Bibliography Annexure ‐ 3 - 
  17. 17. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)   OBJECTIVES The study is based on the following aims and objectives.1) To assess the efficacy of ‘Vatsakadi Qwatha’ in the management of Madhumeha.2) To assess the merits and demerits of the drug.3) Detailed study of the disease covering classical and modern literature.4) To evaluate the Diabetic Quality Of Life. HYPOTHESIS  1. Null Hypothesis: Vatsakadi Qwatha does not have any effect in the management of patients suffering from Madhumeha.2. Alternative Hypothesis: Vatsakadi Qwatha do have effective role in the management of patients suffering from Madhumeha. ‐ 4 ‐   
  18. 18. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) HISTORICAL GLIMPSES Study of sequential evolution of an event forms the fremost step in the field ofresearch. Study of history is of great important to know about the systematic development andprogress of the subject to determine the future plans for further establishment and researchdesigning. History of Medicine starts from the very moment when the human beings cameinto existence. Among the various ancient treatises, Ayurveda provides an extensive andemeritus description of diseases and their treatment. Here an attempt to review all theAyurvedic and Modern Treatises providing information related to historical background ofMadhumeha has been made. The evolution of Madhumeha can be traced right back from Vedas but, inrudimentary form. When we go through the Atharvaveda there is a reference related to thedisease Asrava along with its management. Sayana Acharya in his Sayana Bhashya revealsthat Asrava means Mutraatisara, the English translator Whitney (1962) interpreted it as fluxand Griffith (1962) as morbid flow, while leeman has translated the meaning of Asrava asDiabetes Mellitus. Sayanacharya has highlighted the vatic nature of this ailment.(A) Samhita Period: Elaborative description of the disease Meha viz-a-viz Prameha- Madhumeha has beenfound during Samhita period.(1) Charaka Samhita: Ref Cha. Ni. 4, Cha. Chi. 6 In this ancient treatise of medical science, Charaka has explained the Etiology,Pathogenesis, Prodromal Symptoms, Clinical Features, expected Complications anddescriptive therapeutic procedures with discretion – Sutra Sthana 17th chapter, Nidana Sthana4th chapter, Chikitsa Stana 6th chapter. -5- 
  19. 19. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)(2) Sushruta Samhita: Ref. Su. Ni. 6, Su. Ni. 11, 12,13. Acharya Sushruta has contributed that the disease Prameha which when not treated atappropriate time gets transformed into Madhumeha in Nidana Sthana – 6th chapter, the wholedisease and its therapeutic purview in Prameha – Pramehapidaka – Madhumeha in ChikitsaSthana – 11th, 12th, 13th chapters successively. The distinct feature is the usage of KsaudraMeha instead of Madhu Meha in vatic variety in Nidana Sthana 6th chapter, Specificdecoctions for specific type Prameha and mentioned the Specific Dietary Pattern whichshould be avoided and to be used accordingly in Chikitsa Sthana.(3) Vagbhata Samhita: Ref. A.Hr. ni.10,A.Hr.12 Vagbhata has mentioned 2-3 types of underlying cause leading to Madhumeha i.e.Dhatukshaya and Avrutapatha or even both and added Sveda as one among the Dushya inNidana Sthana 10th chapter.(4) Harita Samhita: Ref Ha.Sam. II sthana 1/9 Acharya Harita has mentioned the cause as Papajanya and enumerated 13 types ofPrameha with nomenclature different than above treatise like, Puyameha, Ghrutameha etc.(5) Bhela Samhita: He described Prameha is of two type i.e. Svayamkruta and Prakruta Meha.(6) Kashyapa Samhita: He has mentioned the symptoms of juvenile diabetes clinical findings in VedanaAdhyaya and noted the disease as Chirakari. -6- 
  20. 20. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)(B) MEDIEVAL PERIOD: In this period commentaries mainly written, but most of them content only thecollection of thoughts from previous authors.(1) Madhavanidana: Ref. Ma. Ni. 33 He collectively repeated the description of Charaka, Susruta and Vagbhata.(2) Gayadasa: Ref. Nyaya Chandrika Su. Ni.6/6 He has explained that the Samalatva of the Mutra is due to the presence of Dusya inMutra.(3) Sharangadhara Samhita: Ref. Sha. Ma.11 He has mentioned the 20 types of Prameha in Prathama Khanda 7th chapter, while wefind various scattered references with respect to the disease and the respective formulationsfor the latter in different forms. The Polyherbal formulation for the present study has beenselected from Qwatha Kalpana Adhyaya of the present treatise mentioned in MadhyamaKhanda. Meha Prakarana.(4) Bhavaprakasa: Ref Bha. Ni. Ma. Kha. 38 He describes Prameha and Madhumeha along with some new Herbo-Mineralpreparations.(5) Yogaratnakar: He has explained Prameha and Madhumeha along with its respective treatment. -7- 
  21. 21. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) MODERN REVOLUTION AND THERAPEUTIC LANDMARKS:Some of emeritus inventive landmark about the Diabetes Mellitus:(1) Areatus (Christian era) : Firstly he mentioned the disease as Diabetes.(2) William Cullen - 1709 A.D : Added suffix mellitus to the diabetes.(3) Mathew Dobson L-1775 A.D : Found that sweetness of urine is due to sugar.(4) Thomas Cowley -1781 AD : Pancreas as the possible cause of the disease.(5) Paul Langerhans -1869 AD : Group of cells in Pancreas.(6) Gusteve Edward -1893 AD : Group of cells as Islets of Langerhans.(7) Opie -1901 AD : Hypothesis- Islets Of Langerhans dysfunction.(8) Babting and Charles -1922 AD : Discovered Insulin. -8- 
  22. 22. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) NIRUKTHI AND PARIBHASHA In Ayurveda, Madhumeha is a term used for all the 20 types of Prameha andalso as a sub type of Vatika Prameha which is Asadya. In this present study sinceMadhumeha is taken in terms of Meha Samuha but not restricted to the terms ofVatika Prameha hence understanding its literal Derivation is quite important forproper understanding of the intricacies in the usage of the term Madhumeha1.ETYMOLOGY:Meha: The word Meha is derived from the root ‘Mih Sechane’ by adding lyu’Pratyaya to it, gives the meaning watering. - Shabda Kalpadruma. Mehayati Sinchati Mutraretamsi iti mehaha - Halayudha Kosha Mehayati mutrayati iti arthaha - Su. Ni. 9/10This term is suppose to be used for all types of Meha either it is Prameha orMadhumeha- according to Acharya Chakrapani. The first and the foremost Vedic reference for the word Meha is found in theYakshma Nashana Suktha – 5th Verse, 163rd Suktha of 10th Mandala of Rigveda.Shayana Bhashya21 interpretes the word Mehana as Medr, which means Shishnya i.e.Penis on the above mentioned reference. 1. Prameha1 - The word Prameha is composed of two sub-words. i.e. Pra + MehaAccording to the the above verses, it means to excrete urine and semen profusely. In Sanskrit literatures, the word Mih is used to denote - to make water, to wet,to ejaculate semen. When the prefix “Pra” is added to the root word Mih, the wordbecomes Prameha. ‘Pra’ suggests excess or profuse in both Frequency and Quantity. -9- 
  23. 23. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)So, the word Prameha can be understood as increase in both frequency and quantity ofurine. “Prakarshena Mehayati Yasmin Roge” - Su. Ni. 6/10 This derivation of word is again substantiated with the Common ClinicalFeatures of Prameha described as Prabhutamutrata and Avilamutrata. Su.ni.6/6,A.Hr.ni.10/7. 2. Madhumeha: - The word Madhumeha is derived from two words Madhu and Meha. The word Madhu is derived from the root “Manyante Viseshena Jananti JanahYasmin”. In Sanskrit literature Madhu word is used with various synonyms in variouscontexts like Kshaudram, Kusumasavam, Madhyama, Makarandah, Makshikam,Madhura Rasa, Jalam, Pushparasa, Kshiram etc - ArunaduttaSo, Madhumeha is a disease in which the excretion of urine possesses the qualitysimilar to that of Madhu (honey) in its colour, taste, smell and consistency. -Madhavakara. It means ‘Madhumeha’ is a disease in which a patient passes sweet urine andexhibits sweetness all over the body i.e in sweat, mucus, breath and blood etc.PARIBHASHA OF MADHUMEHA: With the above literary background for the term “Madhumeha”, it can bedefined as a clinical entity in which subject passes large quantity of urine withKashaya, Madhura rasa and Ruksha quality similar to the characteristics of honey andthus body attains sweetness – Acharaya Charaka and Vagbhata. -10- 
  24. 24. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) Acharya Sushruta has narrated the term “Kshaudrameha” in place ofMadhumeha .The “Kshaudra” is one of the varieties of Madhu which is Kapila(tawny) in colour and hence considered as a synonym to the word Madhu as well. So,it is clear that Kshaudrameha resembles Madhumeha. As per Sushruta all the varietiesof Prameha; if neglected, get transformed into the pathological streak of Madhumeha.SYNONYMS: Few of the synonyms of Madhumeha mentioned in the ancient classics arefollows: OJOMEHA: This is one among the four sub-types of Vataja Prameha.Vitiated Vata dosha causes diminution of Ojas through which, the urine along withthe change in its taste and texture finally results in Ojomeha. KSHAUDRAMEHA: This term has been used by Sushruta because of itsclose resemblance with Madhu – Acharya Sushruta. PAUSHPAMEHA: In Anjana Nidana, the word Paushpameha has been usedin place of Madhumeha. In Sanskrit literature, Paushpameha means Madhu.ETYMOLOGY OF DIABETES MELLITUSThe word diabetes is originated from the French word named “Jiyabatis” whichmeans punctured pitcher or pitcher with leak, so that water sprinkles out of it.Diabetes– Parashuram Shastry.The word diabtes mellitus contains two words i.e diabetes and mellitus. In GreekDiabetes means to run through a siphon and the term Mellitus means honey.WHO APPROVED DEFINITION OF DIABETES MELLITUS: -11- 
  25. 25. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Diabetes Mellitus is a group of metabolic disorders characterized by chronichyperglycemia associated with disturbances of carbohydrates, fat and proteinmetabolism due to absolute or relative deficiency in insulin secretion and /or action23.SYNROME X or METABOLIC SYNDROME is a cluster of cardiovascular riskfactors that frequently coincides with insulin resistance and hyperglycemia. Themetabolic syndrome is a common condition, associated with genetic predisposition,sedentary lifestyle, obesity, and aging23. -12- 
  26. 26. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) NIDANA Nidana is the specific core pre-disposing factor of a disease. The cycle ofpathology and severity of the disease considerably revolves around the type andseverity of the predisposing factors in relation to the tridosha respectively. Ayurvedic classics elaborately describes about the general etiological factorsof Prameha at the same time it is the highness of discretion elucidated by AcharyaCharaka in relation to this disease which even though is Tridosha in origin but it isinfluenced by specific doshic etiologies which inturn decides the extent and strengthof the corresponding disease pathology leading to Madhumeha latter –Vikara VighataBhava Abhava Prativishesha. Hence, classical etiologies mentioned for Prameha canbe taken for Madhumeha also. Etiological factors of Prameha can be classified intoSahaja and Apathyanimittaja. I. Sahaja Prameha: Sahaja Prameha is further divided in to Kulaja and Garbhaja. A. Kulaja Prameha:It is due to defects in Stri & Pumbeeja (Ovum & Sperm) which is said to be Matru-Pitrukrita Beejadosha finally resulting in Sahaja Prameha. This Beeja Doshahighlights the relevance of Kulanupatini Prakruti and may have its origin from parentsof both father and mother i.e. it may be inherited from generation to generation andthus it is a unique example of hereditary disease. B. Garbhaja Prameha: Acharya Charaka opines that indiscrete excessive indulgence of Madhura Rasaby garbhini is the chief cause for the changes and damages in the foetus. Overindulgence in Madhura Rasa by mother during pregnancy is likely to induce Prameha. -13- 
  27. 27. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) Regarding Sahaja Prameha, genetic predisposition occurring in diabetes hasbeen well established based on various genome studies in conventional science. Studyfocus is mainly on β-cells of islets of langerhans and the blood vessels.Simultaneously, the metabolic functions leading to the rapid conversion of glucoseinto fatty acid forming the adipose tissue have been suspected to have genetic origin.These variations are due to variation of structure and function of chromosomes. Evenafter having genetic predisposition; the stage of overt diabetes may take time toprecipitate – highlighting the concept of Lakshya Nimita1. Hypothetically, indiscrete excessive intake of Madhura Rasa bring aboutchanges at the level of gene and thus provide a genetic pre-disposing condition in thesubject and again intake of excessive Madhura Rasa by the pre-diabetic subject in hisearly life also precipitates Prameha. Thus; Beeja Dosha and Apathya, both play acombined role in the causation of Sahaja Prameha. II. Apathyanimittaja Prameha: Various opinions regarding the discription of Apathyanimittaja Prameha by different Acharyas are described as follows,Charakoktha Apathyanimittaja Prameha Nidana:Asyasukham: Sedentory Sexual Habits and Sedentary Sitting Habits.Swapnasukham: Sedentary sleeping habits.Excessive indulgence in Dadhini: Curd and its various preparations.Gramya, Audaka, Anupa Mamsa: Meat of domestic, aquatic, wet land animals.Payamsi: Excessive use of milk and its preparationsNava Annapanam: Excessive use of new grains and drinks.Guda Vaikrutam: Jaggery and its various preparations. Along with the above etiological factors, all regimens which vitiate Kaphadosha should also be considered as the cause for Prameha. -14- 
  28. 28. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) Dravya Properties Dosha PrabhavaKoolachara (living at river Madhura Rasa & Vipaka Mutrala & Kaphaside) Eg. Gaja, Gavaya, etc. Sheeta Veerya, Snigdha Guna VardhakPlava (Birds which swim) Sheeta Veerya, Snigdha Mutrala & Kapha Guna,Eg. Hamsa, Kroucha etc. Vardhaka Madhura Rasa and vipakaKoshastha (Live in burrows) Madhura Rasa & Vipaka, Kapha VardhakaEg. Shanka, Shukti etc. Sheeta Veerya Snigdha GunaPadina (which have limbs) Balya MutralaEg. Koorma etc.Matsya Nadeya Madhura Rasa, Snigdha and Shleshma(Fishes of river) Guru GunaSamudra (Fishes of sea) Guru, Snigdha, Ushna, guna, Shleshma Madhura Rasa, and VipakaEg. Timingala, Kulisha etc. CHART: GRAMYA, OUDAKA AND ANUPA MAMSA RASASushrutoktha Apathyanimittaja Prameha Nidana: Acharya Sushruta opines in terms of Snigdha (unctuous), Medya (fatty) andDrava (liquid) type of food as the causative factors.Vagbhatoktha Apathyanimittaja Prameha Nidana: Acharya Vagbhata opines in terms of Madhura, Amla, Lavana Rasapredominant diet and sedentary habits which increase Medas, Mutra and Kapha as thecausative factors.DOSHANUSAARA NIDANA VISHESHA:Kaphaja Prameha Nidana The following are the etiological factors which help in the immediatemanifestation of Prameha due to Kapha dosha - Frequent and excessive intake offresh corns like Hayanaka, Yavaka, Chinaka, Uddalaka, Naishadha, Itkata, -15- 
  29. 29. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Mukundaka, Mahavrihi, Pramodaka and Sugandhaka; Intake of Pulses like freshHarenu and Masha with ghee; Intake of the meat of domestic, marshy and aquaticanimals; Intake of vegetables, Tila, Palala, Pishtanna, Payasa (a type of sweetpreparation), Krishara, Vilepi and preparations of sugarcane; Intake of milk, freshwine, Immature curd and its preparations; Avoidance of unction and physicalexercise; Resorting to inappropriate sleeping habit and sedentary habits; Resorting tosuch regimens which produce more of Kapha, fat and urine.Pittaja Prameha Nidana Intake of Ushna, Amla, Lavana, Kshara and Katura Dravyas; Intake of foodbefore the digestion of the previous meal; Exposure to excessively hot sun, heat ofthe fire, physical exertion and anger; Intake of mutually contradictory food articles.Vataja Prameha Nidana Excessive intake of Dravyas having predominantly Kashaya, Katu, Tikta Rasa,Ruksha, Laghu and Sheeta Veerya; Excessive indulgence in sex and physicalexercise; Excessive administration of Vamana, Virechana, Asthapana andShirovirechana; Resorting to suppression of the manifested urges, fasting, assault,exposure to sun, anxiety, grief, excessive blood letting, keeping awake at night andirregular postures of the body.Specific Etiology of Madhumeha: The person indulging in food substances having Guru, Snigdha qualities andexcessive indulgence of Amla and Lavana Rasa substances and Navannapana,excessive sleep, sitting in a same place for longer duration, avoiding exercises –physical and mental exercises and also not resorting to the Shodhana process at propertime or even resorting to the latter at improper time. -16- 
  30. 30. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) Acharya Sushruta has narrated that untreated Prameha in its initial stage, getsconverted into Madhumeha and becomes incurable. According to Acharya Vagbhata, the urine of Madhumehi will be simulatingwith that of Madhu. Two type of Vata vitiation has been mentioned, one is due toDhatukshaya and second due to Margavarana. According to Acharya bhela, this disease is of two types based on the specificetiologies like 1) Prakruthi Prabhaavam 2) Narasya SwakruthamEtiopathogenesis according to modern medicine: The etiology of Diabetes mellitus has yet to be understood in spite of theadvances made in the knowledge obtained with respect to various factors associatedwith the causation of Diabetes mellitus. Based on the etiological factors Diabetesmellitus can be classified into two main types namely, 1. Primary or Idiopathic Diabetes: Which is further subclassified intoType I Diabetes or IDDM and Type II Diabetes or NIDDM. 2. Secondary Diabetes Mellitus.Causes for Primary Diabetes Mellitus:A. Genetic Factors:a) Genetic susceptibility in IDDM: IDDM is a heterogenous disorder in wich several factors may play a role.IDDM tends to be a familial disorder and there is a 25-fold increase in the riskamongst the siblings than the general population. Its inheritance is strongly related toHLA loci on chromosome-6. It is seen that HLA B8, B15, B6, B21, BW3, DR3 andDR4 are associated with a higher risk of diabetes. In Indians and Japanese IDDM -17- 
  31. 31. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)appears to be associated more with HLABW21 and BW54. Among identical twinsonly 50% shows concordance for IDDM as against 100% for NIDDM.b) Genetic Susceptibility in NIDDM: Role of genetic factors in etiology of NIDDM has been appreciated ever sincethe recognition of the disease, but the pathogenesis is less well understood. Thedisease is not linked to any HLA genes as in Type I Diabetes. Though NIDDM occursin families, modes of inheritance are not known except for the variant termedMaturity Onset Diabetes of the Young (MODY), which is due to three different genemutations. MODY 1 gene is located on the long arm of chromosome 20 and that forMODY 3 is on the long arm of chromosome 12 while that of MODY 2 is due tomutation of glucokinase gene located on the short arm of chromosome 7. It is highlylikely that ordinary NIDDM is polygenic.B.Immunological Factors (Auto immunity): The pathogenesis of Diabetes Mellitus mainly depends on the factors insulinand its source, the β-cells. There is no evidence that Auto-immune mechanisms areinvolved in the manifestation of Type II Diabetes (NIDDM) where as IDDM is aslowly progressive T-cell mediated Auto-Immune disease. Hyperglyceamiaaccompanied by the classical symptom of Diabetes occurs only when 70-90% of β-cells have been destroyed. Islet cell antibodies can be detected before the clinicaldevelopment of type-1 Diabetes and disappear with increasing duration of diabetes.Presently these antibodies are neither used for screening nor for diagnostic purposes,but glutamic acid decarboxylase(GAD) antibodies may have a role in identifying late-onset type-1 Diabetes in middle-aged people(Latent Autoimmune Diabetes in Adults-LADA). -18- 
  32. 32. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) Although; recent studies reveal that approximately 10% of IDDM patients alsosuffer from other Organo-Specific Autoimmune Disorders like Graves’s disease,Addisions disease, Thyroiditis or Pernicious Anemia, there appears to be a broadspectrum derangement of immunoregulation in these patients. By the time OvertDiabetes develops, most of the insulin producing cells of the pancreas - β-cells will bedestroyed completely or will have disappeared.completely.C. Environmental Factors: The environment insult or factors may be the cause for manifestation ofDiabetes Mellitus. In many cases the environmental factor is believed to be a viralinfection of the beta cell. Epidemiological studies have linked viral infection withIDDM. A viral etiology was originally suggested by seasonal variations in the onsetof the disease and by what appeared to be more than a chance relationship betweenthe appearance of diabetes and preceding episodes of mumps, measles, and congenitalrubella, Coxsackie’s B virus, hepatitis, infectious mononucleosis. The isolation of aCoxsackie’s virus B 4 from pancreas of a previously healthy boy who died after anepisode of Ketoacidosis and induction of diabetes in animals inoculated with isolatedvirus, also suggests a viral etiology. Further the support for viral theory comes fromobservations that about 1/5th individuals with congenital rubella develop IDDM.Viruses may damage the beta cells by direct invasion or by triggering an auto immuneresponse. They may also persist with beta cells and cause long term interference withmetabolic and secretory functions. While viruses do not produce IDDM in all infectedindividuals, it is tempting to speculate that in susceptible individuals these infectiveagents trigger a host of immunological phenomena resulting in beta cell death. Theviral theory should be treated with considerable caution. Serologic studies seeking -19- 
  33. 33. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)evidence of recent viral infection in patients with new onset IDDM are in conclusiveat best.D. Diet: Circumstantial evidence supports the proposition that dietary factors may, atleast in certain circumstances, influence the development of Type I Diabetes. It hasbeen suggested that exposure to cow’s milk or milk products early in life predisposesto autoimmune Diabetes. The proposed environmental trigger is Bovine SerumAlbumin, operating through the mechanism of molecular mimicry. In the initial studydiabetic subjects were found to have antibodies to bovine albumin and an antibodysubset specific for a 17 amino acid epitope showed to the strongest association withthe disease. Exposure to cow’s milk in presumed to induce an immune response to 17amino acid fragment in some infants, and cross β cells expressing the P 69 antigen.This hypothesis has not received wide support. Various chemical agents like pentamidine, vacor (rodenticide) and variousNitrosoamines found in smoke and curried meat have been proposed as potentiallydiabetogenic factors.E. Age: It is also one of the important risk factor in manifestation of Type II Diabetes.Type II Diabetes is principally a disease of the middle aged and elderly (>40yrs).Recently age of onset of Type II Diabetes mellitus is decreasing and is seen inchildren and adolescents (i.e. <25 years- MODY) 29F. Obesity: Particularly central obesity and a change to western style are inevitableaccompaniment of modernization and it is one of the leading causes for manifestationof Diabetes Mellitus of Type II variety particularly in India. Obesity probably acts as -20- 
  34. 34. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)a Diabetogenic factor (through increasing resistance to the action of insulin) in thosegenetically predisposed to develop Type II Diabetes.G. Life Style: The sedentary life style with diminished physical activity combined withovereating and obesity is associated with development of Type II Diabetes Mellitus.H. Stress: Stress may be a possible link factor for Diabetes either through a direct effecton the Neuro-endocrine system by stimulating the secretion of counter regulatoryhormones and possibly by modulating immune activity or indirectly through the cycleof overeating and subsequent development of obesity that may be associated withstress 25.I. Malnutrition in utero: It is proposed that malnutrition in utero may programme beta cell developmentand metabolic function at a critical period, so predisposing to Type II Diabetes later inlife.Causes for Secondary Diabetes Mellitus:Pancreatic Disease: Acute and Chronic pancreatitis, Post Pancreatectomy, congenital pancreaticaplasia, pancreatic carcinoma, cystic fibrosis and Haemochromotosis are few of theconditions which manifests Secondary Diabetes Mellitus.Hormonal Abnormalities: The hormones such as Growth Hormone, Glucocorticoids, Catecholamines,Thyromine and Glucagon cause impaired Glucose Tolerance or even an overtDiabetes, as they have insulin antagonistic effect. Conditions such as Acromegaly,Cushing’s syndrome, and Phenochromocytoma can cause Diabetes, especially in -21- 
  35. 35. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)those persons who are prone. It may also arise due to therapeutic administration ofSteroidal Hormones. Stress hyperglycemia associated with severe burns, acutemyocardial infraction and other life threatening illness, is due to excessive release ofGlucagon and Catecholamines.Drugs and Chemical induced Diabetes: Drugs or Chemicals can either impair insulin action or damage the beta cellscausing decreasing in the insulin secretion. Drugs like pentamidine and vacor are betacytolytic, where as glucocorticoids and nicotinic acid increase the insulin resistance.Insulin Receptor Abnormalities: Rare conditions associated with mutation in the insulin receptor or the postreceptor pathway leads to manifestation of Diabetes mellitus. The individuals haveextreme degrees of insulin resistance and are associated with Acanthosis Nigrican’s,polycystic ovaries and rarely virilization. Leprenchaunism could be fatal and patientsdo not cross the infancy.Genetic Disorders: Many genetic syndromes are associated with Diabetes. Down’s syndrome,Klinefelter’s syndrome, Turner’s syndrome and Wolfram’s syndrome are someimportant ones.Role of Endocrine Glands:Pituitary Gland14: The pituitary hormones can influence the course of DiabetesMellitus. The growth Hormone of pituitary has the diabetogenic power.Administration of hormone leads to hydropic changes in beta cells associated with anearly reversible phase of Diabetes followed later by an irreversible phase withcomplete destruction of beta cells. Diabetes may be associated with Acromegaly. -22- 
  36. 36. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Adrenal Gland14: Adrenalectomy will arrest or modify the progress of experimentalDiabetes. The onset of Addisson’s disease has an ameliorating effect on the humanvariety. Adrenal Hyperplasia or tumors may be associated with Diabetes.Gestational Diabetes: Gestational Diabetes is defined as any degree of glucoseintolerance with onset or first recognition during pregnancy. During normalpregnancy, insulin sensitivity is reduced through the action of placental hormones andthis affects the glucose tolerance. The insulin secreting cells of the pancreatic isletsmay be unable to meet this increased demand in women genetically predisposed todevelop Diabetes. Repeated pregnancy may increase the likelihood of developingirreversible Diabetes, particularly in obese women. However the patient should beevaluated after six weeks after delivery and reclassified as either diabetic or nondiabetic.Nidana similarities of modern view with ayurveda: The atiological factors mentioned by modern medicine are also in concordancewith ayurvedic scholars. Both systems agree regarding genetic elements associatedwith DM. According to modern view and ayurvedic view sedentary life habits play animportant role. Both systems deal with Medo Dhatudushti Nidana as a cause for DM. -23- 
  37. 37. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) Table No: 1 Similarities of Nidana in Modern and Ayurveda MODERN VIEW AYURVEDIC VIEW Genetic susceptibility is identified. One variety of prameha is Sahaja due to Sukra and Artava Dosha. Sedentory life habits are a prime Ayurveda also mentioning the same like cause. Asyasukham, Swapna Sukham etc. Diabetis has been discribed as Charaka also describes Prameha as a complication of Obesity due to insulin Complication of Sthoulya. resistance caused by fat globules. Dietary factors influence development Indiscrete use of Cows milk, Gramya of type1 DM.Some Diabetogenic Mamsa, Anoopa Mamsa are considered factors like bovine serum albumin as major Nidana for Prameha by Charaka. found in cow’s milk, nitrosamines present in smoked and cured meat has been identified. Mental factors like stress have been Acharya Charaka explains as Krodha is a accepted as a principal atiology. predisposing factor for Pitha Prameha and mental strain like Udvega and Soka will cause Vataja Prameha. Environmental factors enhance viral Excessive Vata Pita Prakopa infections and leads to diabetes have environments like Atapa Sevana, Agni been described. Santapa etc have been described. -24- 
  38. 38. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) PURVARUPA Purvarupa are the most valuable prodromal signs and symptoms that signal theforth-coming disease. Every disease has its own characteristic Purvarupa and becomemanifested at the stage of Sthanasamshraya and it is one kind of warning signal to thesubject to restrain from those activities which triggers Prameha. As Madhumeha isclassified under the Vatika type of Prameha, Purvarupa of Prameha can be taken asPurvarupa of Madhumeha1. Table No 3. Purvarupa of Madhumeha, according to different Acharyas. Purvarupam Cha17 Su20 A.H27 A.S28 Ma.Ni29Kesheshu Jatilibhava + + - + -Asya Madhurya + - + + +Karapadadaha + + + + +Karapada Suptata + - - - -Mukha Talu KanthaShosha + - + + -Pipasa + + - + +Alasya + - - + -Kaye malam + - - + -Kaya Chhidreshu Upadeha + - - + -Paridaha Angeshu + - - - -Suptata Angeshu + -- - + -Shatpada Pipilika + - + + -MutrabhisaranamMutre Cha Mutra Dosham + - - - -Visra Sharir Gandha + + + + -Sarvakala Nidra + - - + -Sarvakala Tandra + + - + -Snigdha Gatrata - + - + -Pichhila & Guru Gatrata - + - - -Madhur Mutrata - + - - -Shukla Mutrata - + - + - ­25­ 
  39. 39. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Sada - + - + -Shwasa - + - + -Keshanakhativriddhi + + + - -Sheeta Priyata + - + + -Hridaya Netra Jihwa - - + - -ShravanopdehaSweda + - + + -Dehe Chikkanata - - - - + The manifestation of the above mentioned prodromonal symptoms can beunderstood in co-relation to the stage of Sthanasamshraya where the already vitiatedand dislodged bodily principles starts to find its substratum vide srotas and itsappendages for the development of further pathogenesis within the latter and finallyenabling the process of Atura Samvedhya and Vaidya Samvedhya Lakshanas whichinturn helps the physician to assess the srotas and its appendages afflicted and plan forappropriate therapeutic measures based on the Dushyadi Sameekshya Bhava9.Unexplained fatigue and weight loss has been clinically considered as prodromalsymptoms by modern physicians29. It is in the nature of this disease; Madhumeha, which withholds the globalsystemic illness within its claws that these above mentioned prodromal symptomsthemselves extend to become the cardinal clinical features of the disease. So for theearly diagnosis of this disease – Madhumeha, these prodromal symptoms mentionedfor Prameha - Madhumeha play a pivotal role in guiding and planning the furthercourse of therapeutic measures with the discretion of the physician based on theVikara Vighata Bhava Abhava Prativishesha1. ­26­ 
  40. 40. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) RUPA The manifesting symptom of a disease which bears its characteristic features iscalled Rupa. It represents the Vyakthavastha of Shatkriyakala. Acharya Gayadasaopines that in case of Prameha, Purvarupa will be manifested as Rupa. This type ofmanifestation is termed as Vyadhi Prabhava. According to Sushrutacharya, the person should be diagnosed as Pramehiwhen complete or partial prodromal symptoms of Prameha accompanied byPrabhoota mutrata get manifested.Important Samanya Lakshnas of Prameha w.s.r to the UrineCharacteristics:1) Prabhuta Mutrata (Quantity): It is considered as the cardinal sign of Prameha by all Acharyas. AcharyaGayadasa opines on Su.Ni.6/6 that excess urine quantity is because of liquefaction ofthe Dushyas and their mutual amalgamation. It may be suggested that the Prabhuta Mutrata is more akin to metabolicchanges. The excessive urination helps in the elimination of excessive accumulationof carbohydrate, protein and fat metabolites. The excessive urination is due to animproper metabolism of carbohydrates, proteins and fats resulting in water andelectrolytes imbalance.2) Avila Mutrata (Turbidity): Patient passes urine having hazy consistency. Gayadasa and Dalhana opinethat, the characteristic features of urine are because of the amalgamation betweenMutra, Dosha and Dushya. Avila Mutrata is more akin to urinary pathology. This Avila mutrata i.e.turbidity of urine occurs due to body reaction with the Doshas. This can be due to -27- 
  41. 41. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)presence of phosphates, sugar, sperm, acetone, silicates, albumin, chyle, bile pigmentsand salts, blood, pus or casts etc. in the urine. Observed facts contribute to the opinionthat quantity of the urine may remain normal or may be reduced in the later stage ofthis disease which in turn depends upon the habit of liquid intake. So, both thesymptoms have been considered as the Cardinal Clinical Features of this disease byAncient Seers.3) Pichhila Mutrata (Consistency): At the time of diagnosis, Charaka mentioned to consider the etiological factorsalso to assess the involved Dosha after knowing the character of urine like Pichhilathaand Madhurya. Acharaya Sushruta has described two types of Prameha along with theirmanifestations as followsSahaja Pramehi (Krisha-Asthenic)Ruksha (Dry body)Alpashi (Consumes less food)Bhrish Pipasa (Voracious thirst)Parisarpansheelata (Restless, always desires to wander)Apathyanimittaja (Sthula-Obese)Bahuashi (Voracious eater)Snigdha (Unctuous body texture)Shayyasanswapnasheela (Like to sit down & sleep always)Acharya Kashyapa has described the following Rupas for Prameha.(a) Akasmata Mutra Nirgama: Excretes urine suddenly without any intention.(b) Makshika Akranta Mutra: Flies get attracted towards the urine. -28- 
  42. 42. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)(c) Shweta and Ghana Mutrata: Passes urine having white colour and of turbid nature.Along with the above he has also narrated symptoms like Gaurava (Heaviness of thebody), Baddhata (tightness) and Jadata (Procrastination).Specific Lakshanas of Madhumeha: (Visesha Rupa)Urine Characteristics: Madhumehi passes urine having Kashaya and Madhura taste, Pandu Varnaand Ruksha quality. Gangadhara opines on this that the Madhura Rasa of Ojas isdisplaced by Kashaya Rasa. Chakrapani opines that Vata, because of its Prabhavaconverts Madhura Ojas into Kashaya Ojas. According to Sushruta, the urine of Madhumehi resembles with that of honey,as described above. Similar description is found in Ashtanga Hridaya and AshtangaSamgrahakara.CLINICAL FEATURES OF DIABETIS MELLITUS:Type I Diabetes Mellitus: Type I Diabetes Mellitus usually begins before age 40 years. This type ofDiabetes is characterized by a rapid onset, with symptoms such as Polydypsia,Polyuria, Polyphagia, weight loss associated with Random Plasma Glucose level ≥200 mg/dl. In the fulminating case, the most striking features are those of salt andwater depletion i.e. loose dry skin, furred tongue, cracked lips, tachycardia, andhypotension and reduced intraoccular pressure. Breathing may be deep and sighingdue to acidosis, the breath is usually fetid and the sickly sweet smell of acetone maybe apparent. Once the symptoms develop, Insulin therapy is required. Occasionally aninitial episode of Ketoacidosis is followed by a symptom free interval (the“honeymoon” period), during which no treatment is required. -29- 
  43. 43. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Type II Diabetes Mellitus: Type II Diabetes Mellitus usually begins in middle life or later. The typicalpatient is overweight. Symptoms begin gradually. Candidal vaginitis or Pruritisvulvae29 or balanitis is a common presenting symptom since the external genitalia areespecially prone to infection by fungi (Candida) which flourish on skin and mucousmembranes contaminated by glucose due to varied pH within the vaginal canal.Blurred or decreased vision due to retinopathy is found due to the prothrombotic andplatelet aggregation caused by the endothelial dysfunction. Depression or loss oftendon reflexes at the ankles and impaired perception of vibration sensation distally inthe legs indicate neuropathy caused due to the accumulation of AGEs which areneurotoxic in nature25. Hypertension and signs of atherosclerosis are common andmay include diminished or impalpable pulses in the feet, bruits over the carotid orfemoral arteries and gangrene of the feet. Signs of dehydration with associated alteredconsciousness are recently noted in cases with severe hyperglycemia. Clinical featurescan be classified as follows, TableNo.4 Clinical Features of Diabetes Mellitus29 SYMPTOMS TYPE – I TYPE – II Polyuria and thirst ++ + Weakness or fatigue ++ + Polyphagia with weight loss ++ - Ketoacidosis ++ + Impotency ++ + Nocturnal enuresis ++ - Recurrent blurred vision + ++ Vulvovaginitis /Pruritis Vulvae + ++ Peripheral Neuropathy + ++ Often asymptomatic - ++ -30- 
  44. 44. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) We can find more similarities between ayurvedic and modern perception overthe clinical features of Madhumeha vis a vis Diabetes Mellitus like Polyuria -Prabhutamutrata, Polydipsia - Pipasa Adhikata, Polyphagia – Kshudha Adhikataetc. They have been discussed as follows,TableNo.5 Similarities of symptoms in Modern and Ayurvedic views: MODERN VIEW AYURVEDIC VIEW Polyuria Prabhutamutrata Polydipsia Pipasa Adhikata Weakness and fatigue Dourbalya Polyphagia Kshudha Adhikata Glycosuria Avila mutrata - Mutramadhurya Lassitude Alasya Increased turbidity and specific gravity Avilamutrata of urine. -31- 
  45. 45. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) SAMPRAPTI Samprapti of a disease can be literally understood as the process of obtainingthe complete purview of a disease by bridging the discipline of basic fundamentalprinciples with the clinical observation by studying the specific patterns of vitiationrelated to the doshas and dushyas underlying a disease due to its variety of Nidanaand its successive sequential events through the mode of Prasara andSthanasamshraya in to various parts or visceras of the body upto the ultimateexpression of the diseased condition and its complications. This indeed due to thetechnological advances has become more exciting scientifically and also gained moreimportance in relation to the selection of medicine especially in our stream ofmedicine – Ayurveda, since all therapeutic modalities are aimed at breaking up thisvicious cycle of pathogenesis -“Samprapti Vighatanameva Chikitsa.” For the manifestation of any disease condition in the body, the important threeinter-connected factors are Nidana, Dosha and Dushya. Likewise; when these threefactors are not well established within the body, then the occurrence of the diseasewill be questionable. The Nidana - Gurvadi, Dosha - Vatadi, and Dushya - Rasadi areresponsible for the manifestation or non-manifestation of the disease. If the Inter-relationship or Paraspara anubandha of the above three factors are of Hina Bala andare not connected to each other; then, the chances of manifestation of the disease willbe of considerably low. If these three factors are having less strength and connectedwith each other then the manifested disease will not have all the signs and symptoms.If they are complete and with full strength and their inter-connection is strong enough;then, the disease occurrence and manifestation can be termed as the Status Ultimatumwith complete clinical manifestation of the disease. However, this in relation to the -32- 
  46. 46. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Diabetes Mellitus is termed as Overt Diabetes and possibly can be related to theAsadya state of the disease Madhumeha. Prameha vis a vis Madhumeha is included in the group of diseases which areestablished in the body due to Santarpana. Charaka Acharya has well established thesequential events occuring in the process of establishment of the disease by explainingthe Dosha Dushyadi Samprapthi Ghatakas in detail. For better understanding ofMadhumeha Samprapti it is worthy enough to discuss in detail regarding variouspatterns of Prameha Samprapti since the other facet of this condition Madhumehaincludes as a category of Vatika Prameha. Some important points in this concept are natural Kapha in the PrakrutaAvastha is responsible for the existence of Apara Ojas and its corresponding function.Here in Prameha Samprapti it gets disturbed due to respective preceding etiologicalfactors mentioned for the vitiation of the dosha, particularly Kapha Dosha. The Dushya Sangraha is Meda, Mamsa, Shareera Kleda, Shukra, Shonita,Vasa, Majja, Lasika, Rasa and Ojas. The special characteristic features of theseDushyas are elicited to be Bahvabadha form. Due to Nidana Sevana Kapha Pradhana Tridosha Prakopa occurs and AparaOjas in Bahudrava Kapha form vitiates Shareera Kleda, Meda, and Mamsa etc. Itfurther vitiates to reach the Sthanasamsraya stage within Basti along with the Dushyasand produce Kaphaja Meha. When Kapha Kshaya occurs it will began to vitiate PitaDosha and its Anubandha Dushya. As a result Pitha Kshaya occurs and lastly VataPradhana Dosha Dushti occurs and results in Vataja Prameha. These abovedescriptions are liable for discretion based on Vyapadeshastu Bhuyasa rule. -33- 
  47. 47. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) ChartNo.1 SAMPRAPTI OF MADHUMEHA - VARIETY 1 Dushana of Kapha by Nidana Sahaja Prameha Apathya Nimitaja Bahudrava Kapha Dushana of Meda, Kleda, Mamsa etc Bastiprapti of Dosha and Dushya Kapha Prameha Pitha Prameha Vata Prameha The above mentioned pattern is the gradual development of the Madhumehaeither through Avarana or Dhatu Kshaya. In other words the Samprapti of Meha canbe discreted according to the Dushyas involved and the dominating Dosha involved.The possible streak of pathology from Kaphaja Meha to Vatika Meha based on theGati and Pradhanata of Dosha, Dushya Samurchana can be explained as follows in thetable. TableNo.6 Ashraya Ashrayi Bhava9 Dosha Prakopa Dushya Meha produced Kapha Rasa, Mamsa, Meda, Ojas Kaphaja Pitta Rakta Pitaja Vata Remaining Pradhana Dhatus Vataja (Vasa, Majja, Lasika,) -34- 
  48. 48. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Samprapti of Kaphaja Prameha: After giving a clear picture of these common factors, Acharya Charaka beginswith the causative factors of Kaphaja Meha. With the specification of some Aharasand Viharas which lead to Kapha Vrudhi, he concludes them by saying that all thosefactors which lead to the Vrudhi of Kapha Meda and Mutra are included in theNidanas of Kaphaja Meha. Due to Nidana Sevana the Kapha Dosha undergoes provocation andMedomamsadi Dushyas are getting vitiated. When these two events occur the KupitaKapha – Apara ojas spreads easily and this spreading of Dosha is supported by OjoVisramsa and Ojo Vyapath Lakshanas. The affinity of Kapha Dosha towards thefactors of same quality plays an important role here. The liable Medo Vikruthi havingSamanya Bhava with Kapha Dosha combines together. Kapha Dosha due to itsvitiated nature vitiates Medo Dushya also. The further course of these combo factors in the body is to vitiate the ShareeraKleda, Mamsa and Vasa due to few Samanya Bhava, this further lead to Vrudhi ofSharira Kleda and Mamsa dushti. Within this stage of Mamsa Dushti, Rakta Dhatuand its appendages gets afflicted due to the varied involvement of vitiated pita doshawhich in combination with the above combo factors are responsible for vitiation ofSveda and Medas in the body successively to create a sufficient amount of MalaSanchaya within the disturbed Koshta. All these together inclines towards theacquisition of Samalatva form of Mutra which is guided towards the correspondingMutravaha Srotas to establish the Samanya Lakshana of this condition.Samprapti of Pitaja Prameha: Basically the Samprapti of Pitaja Meha is same as that of Kaphaja but theNidana which directly provocate Pita Dosha, the latter dosha pita and the affinity -35- 
  49. 49. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)towards the respective Dushya Dushti with the predominance of pita dosha andassociated with the kapha and vata dosha in establishing varied degrees of clinicalmanifestation.Samprapti of Vatika Prameha: When an individual who’s Mamsa, Meda, Kleda are already vitiated isexposed to the Nidanas of Vata Dosha Prakopa, it directly lead to Vatika Prameha.The Nidana are those which affect Sharira Bala very much like Ativyayama, improperShodhana Chikitsa, Atiyoga, Shoka, Bhaya etc. This is the condition when VataDosha undergoes provocation. Then the Kupita Vata Dosha attracted towards theremaining important Dushyas like Vasa, Majja, Lasika and Ojas. These vitiatedfactors reach basti and are eliminated in Mutra form.Samprapti of Madhumeha1: Acharya Sushruta opines that if Prameha vis a vis Madhumeha is not treated intime, they gradually pass to Asadya stage of Madhumeha. Acharya Charaka hasdescribed Madhumeha vividly based on the Vikara Vighata Bhava AbhavaPrativishesha principle. Vagbhata divides Madhumeha into two types, according toSamprapti. The Asadya variety of Madhumeha is included in Vataja type. If VataPrakopa occurs due to Sarvadhatukshaya, it is called Dhatukshayajanya Madhumeha.And if Vata prakopa manifests as result of Avarana, it is termed as AvaranajanyaMadhumeha.Different mode of Samprapti of Madhumeha: The pathogenesis of Madhumeha is explained in Charaka Samhita,Nidanasthana 4th chapter. Due to causative factors in the person susceptible forPrameha, Vatakopa occurs. This Kupita Vata Dosha attracts the vital and deep seatedDhatus like Vasa, Majja, Lasika and Oja to Basti. The Vata Dosha is having -36- 
  50. 50. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Rukshatva and it again changes the Madhura Rasa of Oja into Kashaya Rasa. ThisKashaya Oja is excreted through urinary tract later. Chart No.2 – SAMPRAPTI OF MADHUMEHA - VARIETY 2a) Madhumeha Due to Kevala Vata: Due to the Kapha and Pita Kshaya, and with the Kshaya of Vasa, Majja,Lasika and Ojas, Vata Dosha gets aggravated and draws Ojas towards basti leading toMadhumeha.b) Dhatukshayajanya Madhumeha: The Kshaya of vital dhatus Vasa, Majja, Lasika and Ojas leads toVataprakopa. This vitiated vata further makes Ksharana of these dhatus throughMutravaha srotas resulting in Vasameha, Majjameha, Hastimeha and Madhumeharespectively. When Kapha and Pita gets depleted Vata gets provocated and it leads todepletion of Dhatus. -37- 
  51. 51. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)c) Avaranajanya Madhumeha: Aharas with the predominance of Guru, Snigdha, Amla and otherKaphapitakara Nidana leads to the provocation of Kapha and Pita doshas. This in turnvitiates Medas and Mamsa. These increased dosha-dushya cause avarana dosha bywhich normal gati of Vata Dosha is disturbed. Finally vitiated vata carry thecirculating Ojas towards basti resulting in the Madhumeha condition.d) Apratikarita Madhumeha8: Acharya Sushruta has described that all types of Prameha - Madhumeha, if nottreated in time, gets converted into Madhumeha. This is the later stage of disease.SAMPRAPTI GHATAKAS:a) Dosha: All the three doshas are responsible in producing Prameha- Madhumeha,based on Vyapadeshastu Bhuyasa rule - Kapha, Pita and Vata respectively.(i) Kapha: A. Bahu and Abadha in Avaranjanya Madhumeha B. Kshina in Dhatukshayajanya Madhumeha Kapha Dosha- Apara Ojas has the status as dominant dosha in either type ofSamprapti. The first vitiated dosha is kapha - . Acharya Charaka while describing theNidana has used the term ‘Kaphakrut cha sarvam’. It indicates the importance ofKapha Dosha Dushti and the subsequent Ojas disturbance in Meha. Ojo VyapatLakshanas are well appreciated clinically.(ii) Pita: A. Vrudha-in Avaranjanya Madhumeha B. Kshina- in Dhatukshayajanya Madhumeha -38- 
  52. 52. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM) Status of Pita Dosha is Vrudha in Avaranjanya Madhumeha. In this state dueto respective Nidana, Vrudhi Lakshanas will be manifested. In DhatukshayajanyaMadhumeha, Vata dosha is in the Kupitha state, So lakshanas related to Pita DoshaVikruthi and Vata Dosha are quite evident clinically. Kshudha Adhikata, Atisweda etc. like Pita Vrudhi lakshanas are evident inAvaranajanya Madhumeha and Mandagni, Prabhahani etc. like Pita Kshaya lakshanasare found in Dhatukshayajanya Madhumeha.(iii) Vata: A. Avruta- in Avaranjanya Madhumeha B. Vrudha-in Dhatukshayajanya Madhumeha It possesses Gati and Yogavahi Svabhava. In Madhumeha the provocation ofthis dosha occurs in two ways i.e. Margavarodha and Dhatukshaya .This vitiateddosha then carries the vital dhatus like Vasa, Majja, Lasika and Oja to basti andresults Madhumeha.Role of Vyana and Apana: In Su.Ni.1/20, it is described that Vyana and Apana are the main culprits inPrameha- Madhumeha. Vyana being pervaded all over the body and Apana inVankshana, Vyana acts as the collector of Kleda and Apana as Excretor. Theprovoked vata carries the dushyas like Vasa, Majja and Ojas towards Basti andexcretes through urine. Again the excretion of dushyas exaggerates vata provocationand hence the vicious cycle goes on.b) Dushyas: Nidana, Dosha and Dushyas are the three factors responsible for themanifestation of every disease. But when they are having Anukulatva diseaseestablishes in its way. So Anukulatva of these factors is important in Madhumeha. -39- 
  53. 53. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)The ten Dushyas described in Madhumeha are Rasa, Rakta, Mamsa, Meda, Majja,Vasa, Lasika, Oja, Shukra and Ambu38. Vagbhata Acharya includes Sveda asadditional.39 Citation - Charakasamhita Chikitsasthana, Kleda has been referred to asAmbu. Acharya Sushruta also have considered the above factors. Meda is common dushya in all Prameha Samprapti. While considering thePurvarupa at the Sthanasamshraya level, Keshanakhati Vrudhi mentioned refers to themala as a result of Asthi Dhatu. Thus almost all the dhatus are involved in this diseasewhich leads to either Asadhyatva or Krichrasadhyatva.Rasa: Rasa is the seat of Kapha Dosha. At the same time, the Prakupita Avasta isconsidered as mala of Rasadhatu. So vitiation of Kapha is the result of vitiation ofRasadhatu. The symptoms like Alasya, Gaurava and Karshya are produced as a result.Rakta: Mainly connected dushya in Pitaja Meha Samprapti. The symptoms and signsdue to its involvement are Daha, Pidaka, and Vidradhi etc.Mamsa: It is a seat of Kapha Dosha. The vitiated Meda combines with it and resultsin Putimamsa pidakas.Meda: It is the dominant dushya in all types of Pramehas. Both quantitatively andqualitatively it is vitiated. Abadhatva is qualitative and Bahutwa is quantitativevitiation. Shareera Shaithilya is produced by Abadha Meda and Bahutwa of Medaleads to Dhatwagnimandya. Dhatwagnimandya leads to Medo Vrudhi in turn.Majja: In the Samprapti of Madhumeha, Majja gets depleted as a result ofVataprakopa. The provoked vata draws Majja towards Basti and excretes throughMutravaha srotas leading to Majjameha which signifies the highest degree ofvitiation. -40- 
  54. 54. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Shukra: Shukra is having an important role in Sahaja Prameha. Prameha is a KulajaVikara and occurs as result of Beeja dosha. Vyana and Apana are the causative factorsfor Shukra dosha and Prameha. Vata causes depletion of Shukra Dhatu and causesShukra Meha.Ojas: Apara Oja is the one disturbed initially which later in Vataja type of Pramehavis a vis Madhumeha alters its quality and carries towards basti and excretes throughurine. The manifestations like Gurugatrata, Nidra, and Tandra are the result of OjaVisramsa and Vyapat which finally at the highest degree of vitiation draws the ParaOjas to cause death.Kleda: Kleda itself is an important dushya in Prameha. It makes other dushyassusceptible for the progression of the Samprapti. Kleda promotes analogy betweenDosha and Dushya. The increased Kleda with Bahudrava Sleshma and BahvabadhaMeda amalgamates with vitiated Doshas and Dushyas resulting in increased amountand frequency of the urine along with adding Samalatva to it thus altering itsturbidity, specific gravity and transparency.Vasa: Vasa, the Upadhatu of Mamsa has been described as the predominant dushyaaffected in Vataja Prameha. Vasameha is one type of Vataja Prameha which signifiesthe highest degree of vitiation.Lasika: Lasika is one type of body fluid described as - its dushti will be predominantin Hastimeha.Sweda: Sweda has been described as dushya by Acharya Vagbhata. Atisweda andVisra shareergandha occurs as a result of Sveda dushti along with other dushyas.(c) Srotas: (Medovaha, Mutravaha, Udakavaha) Mutravaha srotas is mainly involved in this disease. Medovaha, MamsavahaSrotodushti also occurs in Madhumeha. Prabhuta Avila mutrata is a result of -41- 
  55. 55. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Mutravaha Srotodushti. Purvarupa of Prameha mentioned like, Kaye Malam, SnigdhaGatrata, and Pichila Gatrata is the manifestations of Medovaha Srotodushti.Udakavaha Srotodushti produces symptoms like Pipasa Adhikata, Mukha-Talu-KantaShosha. Sharavika, Kachapika etc. like pidakas gets manifested when MamsavahaSrotodushti occurs.d) Role of Agni and Ama: Madhumeha is a metabolic disorder which is the result of Dhatwagnimandya.In Ayurvedic concept Pachana tatvas are Jataragni, Bhutagni and Dhatvagni. Whentaken food materials are properly digested it can be absorbed for further building upof the body. Otherwise a non absorbable form is produced after semi digested stage.This concept is applicable not only to the food ingested by the individual but also canbe applied to the cellular level. The food which is in the semidigested form is notcapable of entering to the Srotomukhas due to pichila, Guru Guna and can be termedas Ama. In the case of Dhatvagni it helps in the Parinama of dhatus from rasa toshukra. When it loses its potency or when it is less, it leads to Dhatuvrudhi and viceversa. Due to specific nidanas, Agnimandya occurs and it further leads to BahudravaKapha and Bahvabadha Meda. Kleda and mamsa also increases within the same stage. The concept of Agnimandya is the same in case of Avaranjanya Madhumehaalso. Agnimandya occurs in a same way and it leads to the improper digestion ofexcessive dhatus and is not assimilated properly leading to the vitiation of the specificDhatu. This vitiated dhatu obstructs gati of vata. Due to Kupita vata, Jataragniincreases and it requires more and more food. This further leads to the tendency totake more food which in turn leads to Medovrudhi- impaired lipid and proteinmetabolism. Samprapti Ghatakas had been summarized as follows. -42- 
  56. 56. Clinical Evaluation of Vatsakadi Qwatha in the Management of Madhumeha w.s.r to Diabetes Mellitus (NIDDM)Dosha : Kapha Arambhaka TridoshajaDushya: Meda, Mamsa, Shareera Kleda, Shukra, Lasika, Vasa, Majja, Rasa, Raktaand Ojas1.Mala: Sveda, Mutra, Kesha, Nakha.Agni: Jataragni, DhatvagniAma: As the Mandagni leads to formation of Aparipakva Ahara rasa.Srotas: Medovaha, Svedovaha, Rasavaha, Raktavaha, Annavaha, Mutravaha andUdakavaha.Srothodushti: Sanga and Atipravruti.Udbhavasthana: Amasaya.Adhishtana: Vapavahana and Vrukkas.Sanchara Sthana: Mutravaha SamsthanaVyaktha Sthana: Basti.Vyadhi Svabhava: Chirakari, Anushangi.Rogamarga: Bahya Rogamarga as Rasa, Rakta and Mamsa dhatus are involved.Abhyantara Rogamarga is also involved in the disease as Koshtangas like Amasaya, ,Pakvashaya, Vrukka etc. are affected – signifying the Global Systemic Affliction. SAMKHYA SAMPRAPTI OF PRAMEHA (CLASSIFICATION) Classification of a disease is mainly done for the purpose of properunderstanding of the disease and to formulate an effective treatment protocol. In thispoint of view various types of classification of Prameha including Madhumeha hasbeen described by the ancient Ayurvedic scholars. This has been elaborated asfollows. -43- 

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