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Evaluation of the efficacy of BHUNIMBADI YOGA IN THE MANAGEMENT OF “MADHUMEHA” By Ashok Akki, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL ...

Evaluation of the efficacy of BHUNIMBADI YOGA IN THE MANAGEMENT OF “MADHUMEHA” By Ashok Akki, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, Gadag - 582 103

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    Madhumeha kc035 gdg Madhumeha kc035 gdg Document Transcript

    • Evaluation of the efficacy ofBHUNIMBADI YOGA IN THE MANAGEMENT OF “MADHUMEHA” By Ashok Akki Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfilment of the degree of Ayurveda Vachaspati M.D. In Kayachikitsa Under the Guidance of Prof. Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)] Department of KayachikitsaPost Graduate Studies & Research CentreD.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG 2008
    • D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTRE GADAG - 582 103 This is to certify that the dissertation entitled EVALUATION OF THE EFFICACY OFBHUNIMBADI YOGA IN THE MANAGEMENT OF “MADHUMEHA” is a bonafide researchwork done by Ashok Akki in partial fulfillment of the requirement for the post graduationdegree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajiv Gandhi University of HealthSciences, Bangalore, Karnataka. Date: Prof. Dr. SHIVA RAMA PRASAD KETHAMAKKA Place: Gadag M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)] Guide PROFESSOR IN KAYACHIKITSA (PG) DGMAMC, PGS&RC, Gadag
    • J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTRE GADAG, 582 103 Endorsement by the H.O.D, Principal/ head of the institution This is to certify that the dissertation entitled EVALUATION OF THE EFFICACY OFBHUNIMBADI YOGA IN THE MANAGEMENT OF “MADHUMEHA” is a bonafide researchwork done by Ashok Akki under the guidance of Prof. Dr. SHIVA RAMA PRASADKETHAMAKKA, M.D. (Ayu) (Osm) M.A. (Jyotish), Ph.D (Jyotish), Professor in Kayachikitsa,DGMAMC, PGS&RC, Gadag, in partial fulfilment of the requirement for the post graduationdegree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev Gandhi University of HealthSciences, Bangalore, Karnataka.. (Dr. G. B. Patil) Professor & HOD Principal, Dept. of Kayachikitsa DGM Ayurvedic Medical College, PGS&RC Gadag Date: Date: Place: Gadag Place:
    • Declaration by the candidateI here by declare that this dissertation / thesis entitled EVALUATION OF THE EFFICACY OFBHUNIMBADI YOGA IN THE MANAGEMENT OF “MADHUMEHA” is a bonafide andgenuine research work carried out by me under the guidance of Dr. SHIVA RAMA PRASADKETHAMAKKA, M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)], Reader in Kayachikitsa,DGMAMC, PGS&RC, Gadag. Date Place (Ashok Akki)
    • Copy right Declaration by the candidate I here by declare that the Rajiv Gandhi University of Health Sciences,Karnataka shall have the rights to preserve, use and disseminate this dissertation/thesis in print or electronic format for the academic / research purpose.DatePlace (Ashok Akki) © Rajiv Gandhi University of Health Sciences, Karnataka
    • Ayurveda is simply translated as "Science of Life" and more comprehensively as "the knowledge that teaches us which substances and activities are beneficial or harmful to life".
    • Acknowledgement With the blessings of lord Dhanvantari, I am thankful to the people who supported me tocomplete my research as without seeds crops cannot be grown. I take great pleasure to record mygratitude to all the concerned persons who have undertaken pains willingly for consummatingthis work. I am here to express my sincere and deepest respect and gratitude to my guide Prof. Dr.Shiva Rama Prasad Kethamakka, M.D. (Ayu) (Osm) M.A. (Jyotish), [Ph.D (Jyotish)], Headof the Department of Post-Graduate Studies in Kaya Chikitsa, D.G. Melmalagi AyurvedicMedical College Gadag, for encouragement and valuable guidance showered upon me for thesuccessful completion of this research work. I wish to express my earnest and personal respect and thankfulness to my former guideand H.O.D. Kayachikitsa Prof. Dr. V. Varadacharyulu, M.D. (Ayu) (Osm) for stimulation andvaluable guidance showered upon me for the successful completion of this research work. I am ever grateful to Dr. R.V. Shettar, Asst. Prof, Kayachikitsa, D.G.M. AyurvedicMedical College, Gadag, for persistent help rendered to me during selecting Diabetic patientsfrom the Hospital. I am immensely indebted to Dr. G. B. Patil, Principal, Post Graduate Studies ResearchCentre, D.G. Melmalagi Ayurvedic Medical College, Gadag, for his constant support andmeticulous guidance. His perspectives and suggestions are reflected in this work. I take this opportunity to thank my colleagues and well wishers M. C. Patil, Dr. SantoshBelawadi, Dr. Kuber Sankh, Dr. G.N. Danappagoudar, Dr. Miss. Yasmeen Dr. G.S.Hiremath, Dr. B.G. Swami, Dr. K.S. Paraddi, Dr. U.V. Purad, Dr. S.B. Govindappanavar,Dr. V.M. Sajjan, Dr. S.A. Patil, Dr. C.S. Kudarekonnur, Dr. S.S. Avvanni. Dr. S.H.Raddar, Dr. V.M. Malagoudar, Dr. Aiholli, Dr. Dr. B.S. Patil, and one and all of D.G.M.Ayurvedic Medical College, Gadag, and to all other teaching staff who extended their valuablesuggestions, co-operation and support throughout the research work. I am ever grateful to Shri Dr. S.D. Yerigeri, Physician, D.G.M. Ayurvedic MedicalCollege, Gadag, for unflinching help rendered to me during selecting Diabetic patients from theHospital. I extend my thanks to Shri Nandakumar, Statistician, for his kind co-operation inproviding the statistical data systematically and in stipulated time.
    • I am thankful to Shri Shankar Belwadi, who took personal care by all means. I amequally thankful to Librarian Shri. V. M. Mundinamani, and Shri. B.S. Tippanagoudar LabTechnician, who helped me lot by providing the timely help at the dissertation completion. I owe my heartedly thanks to Dr. B.B. Hunagund, Asst Prof, & Prof. Dr. A.M. Wali,for their constant encouragement and helped lot in the success of my endeavour. It is beyond the reach of my language to inscribe the profound respect and devotion towards my beloved mother Smt. Annapurna for her blessings to me in each and every stage. Iexpress my due sense of love and gratitude to my wife Smt. Sumangala and my beloved sonKumar Anup and my daughter Smt. Kadambari who efficiency shouldered my responsibilitiesfor fulfilling the research work. My special thanks to my beloved student Miss. Jayashree Karenavar, who always stoodlike a friend and enhanced my interest through inspiring & arousing me with encouraging wordsthose made me to complete this thesis work in time. I express my due sense of thanks to Smt.Savita Padashetty, who helped me in collecting the more information during research tenure. And also my whole hearted thanks to my students, Mr.Santosh Metri, Mr.GopalDhulgond, Mr.Deepak Koundal, Miss.Tejashwini Ghadge, Miss. Amrita Herkal, Miss.Navita Kumari, Miss.Priyanka, Miss.Shwetambari Ghadge, Miss.Swati Beble, Miss.AsmitaKhandagale, Miss. Prajakta Jawale & Miss.Manjula Karlwad for their timely help renderedduring the research work on Madhumeha. I avail this situation to utter my sincere thanks al the staff of the college & hospital thathave helped me directly or indirectly during the course of research time. Lastly, I am thankful to my classmates for their co-operation during dissertation work andalso to my juniors who have directly or indirectly helped in completing this responsibility. (Dr.Ashok I. Akki)
    • Contents of“Evaluation of the efficacy of Bhunimbadi yoga in the management of “Madhumeha” By - Ashok AkkiChapter Content Pages 1 Introduction 1 to 6 2 Objectives 7 to 8 3 Literary Review 9 to 51 4 Methods 52 to 60 5 Results 61 to 82 6 Discussion 83 to 109 7 Conclusion 110 to 111 8 Summary 112 to 112 9 Bibliographic References i to ix 10 Annex 1 – Master Charts Data of trial i to x 11 Annex 2 – Case sheet 1 to 6
    • Tables of “Evaluation of the efficacy of Bhunimbadi yoga in the management of “Madhumeha”SN TITLE OF TABLE PAGE1 General Nidana of Prameha /Madhumeha 252 Vishesha nidana of Madhumeha 263 Showing the poorva roopa of Madhumeha 274 Lakshana of Madhumeha 315 Madhumeha Roopa (symptoms) 336 Symptomatic evaluation of differential diagnosis in Madhumeha 347 Madhumeha upadrava 368 Age distribution in Bhunimbadi Yoga protocol of A & B groups 629 Gender distribution in Bhunimbadi Yoga protocol of A & B groups 6310 Religion distribution in Bhunimbadi Yoga protocol of A & B groups 6411 Occupation distribution in Bhunimbadi Yoga protocol of A & B 64 groups12 Economic status distribution in Bhunimbadi Yoga protocol of A & B 66 groups13 Diet status distribution in Bhunimbadi Yoga protocol of A & B groups 6714 Validation of presenting complaint distribution in Bhunimbadi Yoga 69 protocol of A & B groups15 Validation of associated complaint distribution in Bhunimbadi Yoga 70 protocol of A & B groups16 Validation of Ahara Nidana distribution in Bhunimbadi Yoga protocol 72 of A & B groups17 Validation of Vihara/Anya Nidana distribution in Bhunimbadi Yoga 73 protocol of A & B groups18 Validation of Poorva roopa distribution in Bhunimbadi Yoga protocol 74 of A & B groups
    • 19 Validation of Sroto dusti lakshana distribution in Bhunimbadi Yoga 75 protocol of A & B20 Validation of Family history distribution in Bhunimbadi Yoga protocol 76 of A & B21 Validation of Parameter Group A in Bhunimbadi Yoga protocol 7722 Validation of Parameter Group B in Bhunimbadi Yoga protocol 7823 Validation of Parameter comparison of Group A and B in Bhunimbadi 79 Yoga protocol of A & B groups24 Result of the Bhunimbadi Yoga of A & B groups 81
    • Figures and Photos of ““Evaluation of the efficacy of Bhunimbadi yoga in the management of “Madhumeha”SN TITLE OF FIGURES AND PHOTOS PAGE1 Illustrating Samprapti of Sthaulya and its role in causing Madhumeha 22 Schematically2 Ingredients of Bhunimbadi Yoga 443 Age distribution in Bhunimbadi Yoga protocol of A & B groups 624 Gender distribution in Bhunimbadi Yoga protocol of A & B groups 635 Occupation distribution in Bhunimbadi Yoga protocol of A & B groups 656 Economic status distribution in Bhunimbadi Yoga protocol of A & B 67 groups7 Diet status distribution in Bhunimbadi Yoga protocol of A & B groups 688 Validation of presenting complaint distribution in Bhunimbadi Yoga 70 protocol of A & B groups9 Validation of associated complaint distribution in Bhunimbadi Yoga 71 protocol of A & B groups10 Validation of Ahara Nidana distribution in Bhunimbadi Yoga protocol 72 of A & B groups11 Validation of Vihara/Anya Nidana distribution in Bhunimbadi Yoga 73 protocol of A & B groups12 Validation of Family history distribution in Bhunimbadi Yoga protocol 76 of A & B13 Result of the Bhunimbadi Yoga of A & B groups 82
    • Abstract of Evaluation of the efficacy of Bhunimbadi yoga in the management of “Madhumeha By Ashok AkkiKey words: Madhumeha, Avarana, GIT glucose absorption inhibition Among Indian population approximately 6 Crores of Madhumeha (DM) patients aredetected as so far. The Prameha (Madhumeha) which is prevalent all over the globe ismisunderstood, as a disease dependent upon mere Insulin and pancreas. Finally it is necessary toconquer “The triumph of sugar over diabetes” as said by George Jean Nathan 1882–1958 by thepresent trial drug “Bhunimbadi Yoga”. To understand the aetiology, patho-physiology, complications and management methodsis necessary to emphasize the disease Madhumeha. The word Madhumeha consists of two words,“Madhu” and “Meha”. Sayana highlighted the vatic nature of this ailment Madhumeha.In Charaka Samhita, described Nirupasthambha Madhumeha but also the AvaranjanyaMadhumeha which is a unique contribution of this Samhita. Susruta typically mentioned thedecoctions according to each type of Prameha and mentioned the body constitution andsymptoms related to Sahaja and Apathyanimittaja Prameha and used Ksaudrameha synonym toMadhumeha in Nidana 6th chapter. The results are not much variant as the time schedule for the research is quite minimaland sample size is also marginal. There is a response to the drug is found and the purpose ofunderstanding glucose metabolism in this protocol is successful. Group A patients 47% notresponded and Group B patients 60% not responded to the treatment. The responses in the bothgroups are marginal and 27% of Group A and 40% of Group B are responded for theBhunimbadi yoga. Only 7% in Group A patients are regulated and 20% of Group A arePalliative. Statistically the study is significant.
    • Chapter 1 Introduction I am of the opinion that the kidneys too are affected in the rare disease which some people call chamber pot dropsy, others again diabetes (‘the siphon’) or violent thirst. Quoted by Folke Henschen in Medical History 1969 Wellcome Historical Library XIII, No. 2:190 Galen AD 130-200- Roman physician ‘What fuel is to an engine, Glucose is to the body’, as fuel provides mechanical energy tothe engine, Glucose provides Physical energy to the body. When the practicality is to beachieved, contemporary medical practitioners are unable to understand the pathogenesis of theMadhumeha (Diabetes mellitus) in total. Thus it is required to analyze and emphasize the diseasein total and assure with non-chemotherapy by the modern Ayurvedists. Among Indian population approximately 6 Crores of Madhumeha (DM) patients aredetected as so far. And it is also estimated that at the end of 2020 this number may increase up to57 Million. As per present available data 10% of population are found in City and 3-4% in ruralareas 1. The Prameha (Madhumeha) which is prevalent all over the globe is misunderstood, as adisease dependent upon mere Insulin and pancreas 2. It is the need of the day to explain theoriginal Ayurvedic understanding of pathogenesis and management applied from ancient days tocombat the dreadful metabolic disease of the present day world. Research is necessary for thesake of early management of the disease, as samprapti vighatana (breakdown or reversal ofpathogenesis) is the Chikitsa (treatment) 3. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 1
    • In the classics, when the pathology of Prameha is discussed with a special reference toMadhava Nidana, by Madhavakara, who followed a specific pattern and kept this (metabolic)disorder before to Medoroga (Obesity) and after the Ashmari (Urinary caliculi), which isdeveloped from Vasti or Mootrashaya (bladder). The chapter of prameha consists of pramehapitika (boils) at the end as the complications of Prameha 4. There are total twenty pramehasexplained, out of which 4 are vataja, 6 pittaja and 10 kaphaja. Because of Tulya dosha dooshyata(Homologous etiologic factors of vitiation of doshas and dooshyas) in kaphaja mehas areaccessible to treatment, where as vataja becomes difficult for the same reason. The medoroga issaid to be the Nidanarthakara vyadhi for Prameha pitika other than that of Prameha 5.Prevalence Madhumeha has become a global problem in spite of much advancement in modern 6.medicine The World Health Organization stated in 1998 that a 122 % rise in the number ofadults with diabetes is projected by 2005, to reach 300 million adults worldwide. There are fourreasons for this two-fold global increase: Firstly, we are living longer; over-nutrition and lack ofexercise are prevalent; the disease being transmitted in a hereditary fashion; such transformationshave taken place within the Indian population also. In India, it is estimated that 19 million casesoccurred in 1995, rising to a projected 57 million by the year 2025 (1/6th of the world total).According to recent epidemiological studies there has been a 40% increase in diabetesprevalence amongst urban during the last five years 7. Even the NIDDM a commonest form ofDM is most common accounting for 85-99% of the patient depending on geography andethnicity, occurs in adults, more so over 35 years of age 8. The prevalence of NIDDM is on therise more alarmingly in the developing nations, ranked 7th among leading cause of death. It hasbeen rated 3rd when all its micro vascular, macro vascular, neuropathic complications 9 is taken Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 2
    • into account. The cost of treating diabetes an associated complication exceeds $ 100 billion peryear 10. Diabetes mellitus and its complications are clinical conditions of growing importanceboth from the clinical as well as epidemiological standpoint. The relevance of diabetes at clinicaland individual level is given by its life threatening acute complications and, especially, by itschronic complications affecting several organs and systems, with increased risk for ocular, renal,cardiac, cerebral, nervous and peripheral vascular diseases. The high prevalence of diabetes inmany developed countries or in special ethnic groups, entailing premature disability andmortality, points to its relevance at population level. It is, therefore, mandatory for both thespecialist and the practitioner to be acquainted with the patho-physiological mechanisms, clinicalmanifestations and, above all, therapy of diabetes mellitus 11. Thus it is clear; the Madhumeha (Diabetes mellitus) is a disorder pertained to the lipidmetabolism. Today when we observe the patients, many of them are non-insulin dependent andvery few are insulin dependent. In fact many of the patients those who are having Madhumeha,secret more insulin (hyper insulinemia) than that of normal and still the glucose levels are high(hyperglycemia). It suggests clearly in insulin dependent patients, there are other causes otherthan that of insulin, to begin with, develop the dependency later. Madhumeha is the madhuryataof mootra (renal glycosuria) where glomerular filtration gets impaired. Madhumeha occurs if thebody cannot produce Insulin (type I), or if it unable to use the insulin produced (type II); in eithercase, the ultimate result is hyperglycemia and impaired glucose transport. Type I diabetes is characterized by a genetic predisposition manifested in one of severalhuman leukocyte antigens. Recent research suggests that the genetic predisposition, coupled withan unknown factor, trigger an ongoing autoimmune process that systematically destroys the beta Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 3
    • cells in the pancreas, there interfering with the body’s ability to produce Insulin. Type II diabetesinvolves either a defect in the insulin release sites in the pancreas or resistance to the action ofInsulin stemming from a decrease in the number of receptor sites in the peripheral tissues. Andusually this type II of DM is often associated with Obesity. In both types of DM the result is interference with glucose transport across cellmembranes in peripheral muscle and adipose tissue, Meda, Mamsa, Shareer and Kleda leading tofaulty oxidation and energy production where aqueous contents of the body is involved 12. Metabolism of Carbohydrates (Shareer kleda), Proteins (Mamsa) and Fats (Medas) areimpaired as the storage of Glycogen i.e. Rasa in the muscle and liver is impaired. As a resultunrestrained gluconeogenic and glycogenolytic process in the liver cause overproduction ofglucose. In mean time blood glucose level rises, renal tubules fail to reabsorb all the glucose thatproduces as Mutra Madhuryata (glycosuria). Thus the condition Prameha becomesMADHUMEHA with the involvement of Vata and Ojus 13. “In diabetes the thirst is greater for the fluid dries the body . . . For the thirst there is need of a powerful remedy, for in kind it is the greatest of all sufferings, and when a fluid is drunk, it stimulates the discharge of urine”. Therapeutics of chronic diseases II, Ch. II, 485-6 Aretaeus of Cappadocia ad 120-180 - Greek physician Until 1997, the classification and diagnosis of diabetes were based on the criteriadeveloped by an international work group, sponsored by the National Diabetes Data Group(NDDG) of the American National Institute of Health, and published in 1979. The World HealthOrganization (WHO) Expert Committee on Diabetes in 1980 and the WHO Study Group onDiabetes mellitus in 1985 adopted the recommendations of the NDDG with slight alterations. In Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 4
    • 1995, an International Expert Committee was established (sponsored by the American DiabetesAssociation) with the aim to review the scientific literature since 1979 and to decide the adequatechanges in the classification and diagnostic criteria of diabetes. The committee work culminatedin a document published in 1997, divided into four sections (definition and description ofdiabetes, classification of diabetes, diagnostic criteria and testing for diabetes), which wesummarize in this chapter 14. The main and obligatory principle in the management of Diabetes Mellitus is maximumcompensation of the disturbed metabolic processes, one of the most easily determinable indicesof which is the normalization of blood sugar content and correction of Mutra Madhuryata(glycosuria) along with the Rakta Madhuryata (Hyperglycemia). The principle therapeutic is Diettherapy, Exercise, Yoga, Insulin therapy and oral hypoglycemic agents. The ideal managementfor diabetes should allow the patient to lead a complete normal life, to remain not onlyasymptomatic but with positive good health 15.Purpose of the study More than 200 Ayurvedic thesis/ works were conducted all over India on Madhumeha inthe form of shodhana and shamana line of treatment. In shamana Chikitsa different formulationshave been used so for, in the form of kashaya, vati etc. The critical analysis of the resultsobtained is the works are not available in general to every physician. No matter of theavailability of the drug and its efficacy is for discussion. The conclusions drawn from thisclinical study is not listed in any where. As the Madhumeha is Kapha Vata pradhana Vyadhi, Bhunimbadi yoga seems to be veryeffective. It contains Bhunimba, Katuki, Musta, Triushana, Indrayava, Chitramoola and Vatsakatwak. All these drugs are Kapha and Vata Shamana property with Ushna virya. Thus in the Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 5
    • present study an attempt is made to “Evaluation of the efficacy of Akulyadi Yoga”, with a viewto find out a therapeutically efficacious, safer, cost effective and easily available drugs. 16 The present study with Bhunimbadi yoga refers to the principles from Ayurvedatreatises and makes ailed to review positive health with Madhumeha hara prabhava (anti diabeticproperties) and on modern prevalence to know its Hypoglycemic and Lipidolytic effects. Finallyit is assessed that this compound can be exhibiting good Normoglycemic and Normolipidicproperties.The study description The study description of EVALUATION OF THE EFFICACY OF BHUNIMBADIYOGA IN THE MANAGEMENT OF “MADHUMEHA” consists of the headings accordingto the RGUHS protocol followed from 2nd chapter. Finally it is necessary to conquer “Thetriumph of sugar over diabetes” as said by George Jean Nathan 1882–1958 by the present trialdrug “Bhunimbadi Yoga”. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 6
    • Chapter 2 Objectives Physicians are faced daily with disease, illness, suffering, and death. The medicalprofession aims to help cure, treat, comfort, and save the lives of those who seek help. Mostphysicians must also personally face illness at some time in their lives or care for a loved onewho is ill. Whether professionally, personally, or with family, when illness comes allpractitioners want basically the same thing–rapid, gentle treatment that can cure us or at leastallay our fears and alleviate our suffering. In 1996, an international group of health scholars andpractitioners reclarified the traditional goals of all medicine (1). These goals are: 1. The prevention of disease and injury and promotion and maintenance of health. 2. The relief of pain and suffering caused by maladies. 3. The care and cure of those with a malady, and the care of those who cannot be cured. 4. The avoidance of premature death and the pursuit of a peaceful death 17 Madhumeha/DM is the present burning issue alarming the world. Madhumeha is adisease known to the mankind since Vedic period and it is mentioned as one of the 20 obstinate 18.urinary disorders, where “Prabhoota Mootrata” i.e. polyuria is as the cardinal symptomMadhumeha and its management through various methods are possible viz. shodhana, Lekhanaand Apatarpana Chikitsa. Considering the Chikitsa sutra the Akulyadi yoga as a shamanaChikitsa is under taken for the trial that has almost all of these therapeutic effects is opted for thisstudy 19. The present study intended to focus on the disease evaluation i.e. Madhumeha vis-à-vis.Diabetes Mellitus and the management with Bhunimbadi yoga as a shamana Chikitsa. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Objectives 7
    • Bhunimbadi yoga ingredients are collected form local and prepared under GMP conditions,weighing 500mg capsule form. Hypothetically evaluated therapeutic efficacy on the Madhumehavis-à-vis Diabetes Mellitus is tested through the test under the following objectives. In thisregard the objectives proposed in the study are – i. To evaluate the Hypoglycemic effect of the of Bhunimbadi yoga in control of blood sugar levels in Madhumeha. ii. To evaluate the Lipidolytic properties of Bhunimbadi yoga in the assessment of Madhumeha. The check the above said hypoglycaemic and lipidolytic effects are effectivefundamentally as the disease involves the glucose and lipid cycles along with citrus acid cycle inthe causation of the Madhumeha. The ingredients of the Bhunimbadi Yoga Kiratatikta andIndrayava have a specific effect to act over the prevention by restricting the absorption ofglucose from the intestine and to act to produce pro-insulin. Thus the present study,EVALUATION OF THE EFFICACY OF BHUNIMBADI YOGA IN THEMANAGEMENT OF “MADHUMEHA” has importance to find out the proper methods ofMadhumeha management. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Objectives 8
    • Chapter 3 Literary Review To understand the aetiology, patho-physiology, complications and management methodsis necessary to emphasize the disease Madhumeha. Diabetes mellitus is a clinical syndromecharacterised by hyperglycaemia due to absolute or relative deficiency of insulin. This can arisein many different ways but is most commonly understood by the contemporary system are - dueto autoimmune type 1 diabetes or to adult-onset type 2 diabetes. Lack of insulin affects the metabolism of carbohydrate, protein and fat, and can cause asignificant disturbance of water and electrolyte homeostasis. Death may result from acutemetabolic decompensation, while long-standing metabolic derangement is frequently associatedwith functional and structural changes in the cells of the body, with those of the vascular systembeing particularly susceptible. These changes lead to the development of clinical complicationsof diabetes which characteristically affect the eye, the kidney and the nervous system 20. Diabetes can affect almost every system in the body. In routine clinical practice,examination of the patient with diabetes (Madhumeha) is focused on examination of the hands, 21blood pressure, eyes and feet. General aetiology and pathology of Charaka Prameha is 22compared with that of Susruta Madhumeha and also to Vagbhata 23, who are at the commonopinion of that all Prameha left untreated or not properly treated leads to Madhumeha. Two typesof Prameha namely Sahaja and Apathyanimittaja, can be compared to insulin dependent and non-insulin dependent diabetes respectively. Whatever be the type of Madhumeha, as it is MadhyamaRogamarga (Vasti – Marma) associated becomes incurable and needs very long activemanagement strategy. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 9
    • Madhumeha is a disease of having metabolic derangement and genetic predispositionrelated with each constituent of the body, especially Kapha constituents with systemicconsideration though it is a subtype of vataja Prameha having more prevalence in the society 24.Susruta has used the word Kshaudrameha. ‘Madhu’ and kshaudra are literally synonyms of each 25other, which mean honey . But he placed a different chapter for management of the‘Madhumeha’ in his Chikitsa. He has legitimated Madhumeha to be a stage of complications of 26appearing in Prameha . When literal meaning of the word ‘Madhumeha’ is compared to thecontemporary Diabetes Mellitus fits exactly in the frame work.Etymological Derivations The meha word here mainly related with excessive excretion of urine. So the definition isa clinical entity in which the patients’ voids the urine having comparison with madhu i.e. ofKashaya and madhura rasa, ruksha texture and honey like colour, and at this stage even the bodyacquires sweetness is called as Madhumeha. From above definitions we can easily diagnose thedisease and understand its progression 27. The word Madhumeha consists of two words, “Madhu” and “Meha”. The former isreplica of the honey and the second denotes the “Sechana” i.e. excessive urination. Term ‘meha’is attributed to ‘Madhu’ is the relativity and as the all Prameha delayed are untreated becomes“Madhumeha”, the generalization of Madhumeha is applied to all ‘Prameha’. Chakrapani opines that both words are used for each other. Madhu means honey or sweetand Meha is passing urine. The word ‘madhu’ is derived from the root ‘mana’ and the meaningas “manava bhodane” i.e., which gives the psychic contentment (vachaspathyeem); it refers tothe meaning honey, kshoudra, Madhya, pushpoarasa, jala and madhuranasa. Thus theMadhumeha is a disease, in which the person passes the urine, which is similar to madhu Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 10
    • (honey), in colour, smell and taste 28. The word ‘Prameha’ consists of two words, i.e. “pra” and“meha”. The word meha is derived from the root ‘miha sechane by adding ‘Lue’ pratyaya to it‘mehati sinchati mutraretansi’ which means to excrete. Rigveda mentioned this word first is mehanadthanam karanallium. The commentator ofRigveda, Sayana interpreted the word mehana as medhra, which denotes to shishna (penis). InSanskrit literature the ‘mih’ is used to denote, to make water, to wet to emit semen. So this root‘mih’ is added to prefix ‘pra’ the word becomes ‘Prameha’. In regard to above explanation wecan easily understand that the disease Prameha is resulted because of excessive excretion ofurine. Susruta 29 opines, if the patients of Prameha are not treated properly, all of them reach tothe stage of ‘Madhumeha’, which is asadhya. It is natural history of the disease that, everypatient of kaphaja leads to pittaja and then to vataja stage. But Susruta says that, the progressionof the disease is not only time-oriented, it also depends on the management of the disease. If thepatients are properly managed well in time, the progression of the disease can be slowed down. Ifnot managed properly, of course-it may reach the stage of Madhumeha quickly and becomesasadhya. Susruta narrated the term in place of Madhumeha is kshaudrameha, ksudramehanothing but subtype and synonym of madhu (honey). So it is undoubtedly resembles withMadhumeha. Further he asserted that when all the Prameha illustrated or neglected get convertedin to Madhumeha and especially he emphasized that the disease Prameha along with pidakashould termed as Madhumeha 30. In the initial stage of Prameha, Kapha is in excess quantity but there is Kapha kshaya atlater stage. Similarly, there is excess of Pitta particularly in pittaja prameha, later, which alsoleads to Pitta kshaya. So, ultimately there is Vata vriddi in the terminal stage of kaphaja and Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 11
    • pittaja Prameha. Thus all the types of Prameha lead to the stage of Madhumeha, which isconsidered as a vataja Prameha. The W.H.O. gave its second report on Diabetes mellitus (DM) in which it has defined“DM as a chronic disease caused by inherited and/or acquired deficiency in production of insulinby the pancreas, or by the ineffectiveness of the insulin produced. Such a deficiency results inincreased concentrations of glucose in the blood, which in turn damage many of the bodyssystems, in particular the blood vessels and nerves”. Sir William Osler in his book The Principles& Practice of medicine published in 1923, defined DM as a disorder primarily of carbohydrate &secondarily of fat & protein metabolism due to the failure of the system to burn sugar anddependent on the deficiency or absence of internal secretion of pancreas resulting fromfunctional or organic disease of islet cells of Langerhans, the definition is held valid to present 31.HISTORICAL REVIEW History study makes the sequential evaluation of study which is foremost step in theresearch field. It is important to know about the systematic development and progress of thepresent subject Madhumeha to determine the future plans for further establishment and researchdesigning. History of medicine starts from Stone Age human who struggle to exist and how theancient treatises are utilized with description of diseases and their management. Presenthistorical review related to Madhumeha explains the observations of centuries. Sayana opined that Asrava means Mutraatisara the English translator Whitney (1962)interpreted it as flux and Griffith (1962) as morbid flow, While Leman has translated themeaning of Asarva as Diabetes Mellitus. Sayana highlighted the vatic nature of this ailment 32Madhumeha . The evolution of Madhumeha can be traced from Vedas but in rudimentary Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 12
    • form, when we go through the Atharvaveda there is a reference related to the disease Asravaalong with its management even. In Charaka Samhita, described Nirupasthambha Madhumeha but also the Avaranjanya 33Madhumeha which is a unique contribution of this Samhita . Susruta typically mentioned thedecoctions according to each type of Prameha and mentioned the body constitution andsymptoms related to Sahaja and Apathyanimittaja Prameha and used Ksaudrameha synonym toMadhumeha in Nidana 6th chapter 34. Vagbhata explained Madhumeha as Mootra Atipravrttijjaand classified as two types i.e. Dhatu kshyaja and Avartpathat. Vagbhata states that the Sweda isone of Dushysa in causation of Madhumeha 35. According to Harita Madhumeha is a PapajanyaVyadhi and enumerated 13 types of Prameha with nomenclature different than Brihatrayi treatiseviz. Puyameha, Ghrtameha etc 36. Bhela classified Prameha in different way as it is of two types 37i.e. Swakrita and Parakrita meha . Kashyapa includes the description of a Pramehi child inVedanadhyaya and noted the disease as Chirakari i.e. long association 38. In later periods validations and compilers of the ancient literature are more than theoriginal contributions. Many commentaries are entertained; out of them contents are merecollection of thoughts from previous authors added fewer experiences along with. 39 Madhavakara collectively retold the description of Charaka, Susruta and Vagbhata .Sarangadhara enumerated the Prameha bheda as 20 types. He further described the many 40medicines at the context of different forms of the medicines conversation . Bhavamishradescribed Prameha and Madhumeha along with some new herbo-mineral preparations added to 41the old treasure . Yogaratnakara explained Prameha and Madhumeha along with treatment ingeneral 42. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 13
    • Some of inventive landmarks about the DM: (1) Areatus (Christian era): Firstly he mentioned the disease as diabetes. (2) William Cullen (1709 AD): Added suffix mellitus to the diabetes. (3) Mathew Dobson (1775 AD): He found that sweetness of urine is due to sugar. (4) Thomas Cowley (1781 AD): He suggested that pancreas may be the cause of diabetes. (5) Poul Langarhans (1869 AD): Name itself suggests that he described the group of cells in pancreas. (6) Gusteve Edouard Laguosse (1893 AD): Named after Langerhans as islets of langerhans (7) Opie (1901 AD): He put forth the hypothesis that, diabetes is due to alteration in the islets of langerhans. (8) FG Babting and Charles best (1922 AD): Discovered insulin.Paryaya (Synonyms) of Madhumeha 1. Prameha: Means Prakarshena mehati – excessive urine out flows 2. Meha: Is referred to as Prameha by Amara kosha. 3. Mootradosha: A urinary disorder. 4. Bahumootrata: A disease where there is excessive urination. 5. Madhumeha: A condition characterized by excess urination, resembling honey either in colour or taste. This word has been used synonymously with Prameha. 6. Kshoudrameha: Kshoudra is a synonym of Madhu 43 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 14
    • 7. Ojomeha: Ojas is considered as Tejas or essence of all Dhatus, which is a casualty in Madhumeha hence Ojomeha has been used by Charaka to describe this disease 44,45. 8. Paushpameha: Narrated in Anjana Nidana. Paushparasa is again resembles with Madhu 46. From above synonyms, we can postulate that unanimously all Acharyas mentioned theurine culture concordant with Madhu 47.Samprapti of Prameha The Samprapti is a process of manifestation of disease or pathogenesis. It includesvarious stages as disease progresses. The detailed knowledge of process pathogenesis is verynecessary to find of the extent of Dosha vitiation, involvement of dusya, avayava and srotusalong with the nature and prognosis of the disease. Vagbhata narrated pathogenesis ofMadhumeha very concisely, indicating two types i.e. Dosha avaranatmaka and Dhatu 48kshayatmaka . Susruta not mentioned the detailed Samprapti, he just informs that; if allPrameha ill-treated or ignored get terminated in to Madhumeha 49. Charaka narrated that due to over indulgence of etiological factors, Kapha along withmeda, mamsa and Kleda get vitiated and results into formation of metabolic waste which carriedtowards basti resulting Prameha. In the same manner Pitta get vitiated resulting pittaja Prameha.Where in the Vata is provoked in turn causes depletion of Dhatu due to the depletion of othertwo Dosha by which the excretion of sweet urine resulting vataja Prameha 50. Summarization ofthe authors obtains the following Samprapti factors for evaluation. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 15
    • SAMPRAPTI GHATAKAS: -Dosha Kapha pradhana Tridosha Pitta is in Vriddhavastha Vata – AvritaDushya Kleda (mootra), Meda, Mamsa, Lasika, Oja, Rakta, Majja, Sukra, Rasa, SwedaSrotas Medavaha, Mutravaha, Mamsavaha, Swedavaha and UdakavahaDusti Prakara Atipravritti, Sanga, VimargagmanaAgni Vaishamyata and Dhatwagni mandhyaAma Aparipakwa DhatuUdbhava Sthana Amashaya (Medovaha srotomoola – vapavahana)Sanchara Sthana Sarva Shareera, (through Rasayani and Mootravahinis)Adhisthana VastiVyakta Sthana Sarva Shareera, Mootravaha srotasVyadhi Swabhava ChirakariPathogenesis of Madhumeha According to the Vagbhata two types of pathogenesis get precipitate because of the twotypes of etiological factors viz. (1) Dhatu ksaya janya, (2) Avarana janya and 51 (3) Third type also persists is Kalaprabhavaja . Other wise it is understood as Dhatukshaya and Apathyanimittaja are reclassified. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 16
    • (i) Dhatu ksaya: Due to depletion of the vital dhatus - the ingredients of Pathogenesis in this regard can beexplained is as follows for various classifications. (a) Sahaja Prameha: Charaka 52 and Susruta 53 have agreed that beejadosha (genetically devoid) is also a cause for Madhumeha. The term Sahaja means congenital, that is vertical transmission from beeja dosha of mother’s or father’s or both, the genetic factors. The organs which are responsible to produce Madhumeha i.e. vapaavahana udakavaha srothas, mootravahasrothas etc. are deformed from birth and are susceptible to get the disease and is aggravated by external causes. It can be explained as selective discrimination of these systems to Madhumeha appearing from birth as a result of defective beeja. Over intake of Madhura rasa by mother during pregnancy is also likely to induce Madhumeha more and more. Acharyas further told, ‘Kulaja vikaras’, where Madhumeha is one among of them. Susruta has included Madhumeha, in Adibala pravritaja vyadhis. Here the patient is prone to Dhatu kshaya because of above discussed factors which cause the Madhumeha. (b) Madhumeha due to Dhatu kshaya Charaka explained the pathogenesis of Madhumeha in Nidana as it is due to specific etiological factors vitiate Vata and draws out the entire liquid vital dhatus and carries them towards vasti resulting into Madhumeha. Here the Vata vitiation is because of its own etiological factors that cause diminution of Dhatu. So this classification is called as the Samprapti visishta of Anilatmaka Madhumeha. In this the pathogenesis is a genetic predisposition where the patient makes him self prone to get Madhumeha (Tathavidhasarire) 54. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 17
    • Madhumeha due to Sudha Vata: Charaka enumerated that due to depletion of Kapha and Pitta doshas, Vata get aggravatedand cause the excretion of dhatus in excess through urine resulting into Madhura mootrata i.e. 55Madhumeha . One thing here to observe is that the Vata is not aggravated by other Doshaetiological factors by any means. By observing above pathogenic processes, we can enlist thefollowing factors: (a) Dhatu kshaya is the main factor present in each pathogenesis. (b) The etiological factors mainly related to Vata. (c) Vata provoked by its own etiological factors or by depletion of other Dosha and dhatus. This in turn aggravates the Vata. (d) Such types of pathogenesis occur in those patients, which are prone to this disease because of genetic predispositions.ii) Apathyanimithaja Madhumeha: It can be classified in to two types viz. Samanyaja (General) and Vishesha (According toDosha). The etiology of the disease is dealt in various angles by Ayurvedic authors, consideringdifferent classifications. Among them one classification is bahya hetu janya and Abyanthara hetujanya. The bahya hetus are nothing but the ahara, achaara etc the extrinsic causative factors,which are discussed in this chapter.(2) Avaranjanya Madhumeha: Though Vagbhata narrated the cause of Avarana janya Madhumeha type but notexplained the pathogenesis elaborately. Charaka emphasized pathogenic process in wellelaborative manner. Here, due to excessive indulgence of heavy, unctuous, salty and sour diet,Avoidance of worry, an exercise and purification measure, the Kapha and Pitta get provoked and Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 18
    • vitiates meda and mamsa. All are in excess quantity at this juncture. They in turn causeobstruction to the normal pathway of Vata, which is intended to move freely all over the body.This obstructed or redirected Vata get aggravated and draws out the apara ojas from all over thebody and carries it towards vasti resulting Madhumeha. In this Avarana janya Madhumeha, theprovocation of Vata is precipitated because of the Kapha Pitta etiological factors, especiallyVyanavata and Apanavata.(3) Kalaprabhavaja Madhumeha: This type of Madhumeha is described by Susruta. There is no direct mention of thepathogenesis but narrated that, when all types of Prameha if ignored or ill treated, all of them getend into Madhumeha. This is not a separate pathogenesis classification but can be said as it asthe later stage or further progression of kaphaja and pittaja Prameha or complicate stage of thedisease 56. Without the ‘Kaarana ‘, Karya cannot exist. Cause is the etiological factors for thedisease Madhumeha, either precipitated by the usage of irregular dietetics or appears as aninherited factor by parents. For better understanding of the causative factors a focus on theclassification done by different authors is essential to note. Susruta has classified it into two maingroups i.e. Sahaja and Apathyanimithaja 57. 58 59 Charaka used the word Jaatha Pramehi for Sahaja (Prameha) Madhumeha . EvenBhela termed these two as Prakrithija and Swakrutaja. Charaka said the disease Prameha as 60Santarpana janya Vyadhi. It is the same as Susruta “Apatharpana janya” diseases. Vagbhatahave mentioned two types of Madhumeha viz. Dhathukshaya janya and Margaavaranajanya. Sobasically causes of Madhumeha are divided into two types as sahaja and apathyanimithaja. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 19
    • Madhumeha is considered as Mahagada and an Anushangi Vyadhi.This is becasue inMadhumeha, Vyadhikshamatva is a major casualty. This explains why Charakacharyaintroduced the concept of Vikara Vighata Bhava Abhava Vishesha in Prameha Nidana. Baladerived from Ojus Characterizes Vikara Vighata Bhava and its deficiency characterizes VikaraVighata Abhava. Hence the study of the involvement of Ojas in the disease warrants a toppriority.Ojas: Oja plays an active part as Dushya in the Samprapti of Madhumeha. Susruta has 61mentioned that Oja is a supreme extract of all the Dhatu & strength of the body . Charakamentions that life depends on Oja and therefore without Oja one cannot live. Such Oja remainsin the heart and called as Shareera Rasa Sneha 62. In the commentary Chakrapani has describedtwo varieties of Oja i.e., Para and Apara Oja. Para Oja is supreme and remains in the heart, whileits Pramana is Ashta Bindu. Apara Oja is of Ardha Anjali Pramana which is also called asShleshmika Oja i.e. Shareera Bala 63. Further Chakrapani explained that, in Madhumeha AparaOja Kshaya occurs, which is Sleshmika in nature, and not the Para Oja Kshaya 64. Pathologicalconditions regarding Oja are of 3 types. 1) Ojovisramsa – Sandhi Vishlesha, Gatra Sada, Dosha Chyavana, Kriyaasannirodha 2) Ojovyapath – Sthabda Gurugatrata, Vatashopha, Varna Beda, Glani, Tandra, Nidra. 3) Ojokshaya – Murcha, Mamsa Kshaya, Moha, Pralapa, Marana 65. In Madhumeha Oja is excreted through the Urine leading to Oja Kshaya, so thesymptoms of Oja Kshaya like Murcha, Mamsa Kshaya, Moha may manifest. Vagbhata hasmentioned some additional symptoms of Oja Kshaya like Bibheti (excessive fear) AbhikshnaDaurbalya (excessive weakness), Vyathita Indriya, Rukshata etc 66. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 20
    • SAMPRAPTI OF STHAULYA AND ITS ROLE IN CAUSING MADHUMEHA: Sthaulya can be caused by Tarpana (Nourishing diet) as well as Beeja Dosha. TheNidanas 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 identifiedby an abnormal bulk especially of Sphik, Udara and Stana and has the 8 Doshas as characteristicfeatures 67. LAKSHANA CAUSE1) Ayushohrasa Medhoupachaya2) Javoparodha Shaithilyath Soukumaryath Guruthvath Cha Medasaha3) Kruchra Vyavayatha Shukra Abhahutvath Medhasavrutha Margathvat4) Dourbalya Asamathvat Dhatunam5) Svedabadha Medhasah Sleshma Samsargat Vishyanditvat Bhahutvat Gurutvat Vyayama Asahatvat6) Dourgandya Medo Doshat Medhasah Svabhavat Svedanatvat Cha7) Kshuda Atimatram Teekshagnitvat Prabhoota Koshta Vayutvat Cha8) Pipasa Ati Yoga Teekshagnitvat Prabhoota Koshta Vayutvat Cha Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 21
    • Figure – 1Illustrating Samprapti of Sthaulya and its role in causing Madhumeha Schematically Nidana Sevana Beeja Svabhava (Ahara, Vihara, Manasika) Kostagni Dusti Madhuratara Anna Rasa Utpatti Ama Medo Dhatvagni Mandyata Ati Sneha Utpatti Meda Dhatu Ati Upachaya Ati Meda Avarana Ati Vrudha Meda Dhatu causes Anya Dhatu Margavarodha Vata Vrudhi in Kosta Jataragni Ati Sandhukshana Anya Dhatu Asamyak Upachaya Ati Ahara Sevana Pre disposing factors Sthaulya MADHUMEHA Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 22
    • SAMPRAPTI OF MADHUMEHA IN THE LIGHT OF KRIYA KALA1st Kriya Kala – Sanchaya Avastha In this stage the Samhati Roopa Vriddhi of Kapha occurs in Svasthana i.e., Amashaya,presenting with the following symptoms.a) Agni Mandyab) Gauravac) Alasya These are as a result of Guru and Manda Guna of Kapha. The occurrence of thesesymptoms has been inferred after studying the Poorva Roopa and Roopas of Madhumeha.2nd Kriyakala – Prakopa Avastha In the event of the patient continuing with the Nidana Sevana, disease proceeds toPrakopa Avastha where the Kapha under goes Vilayana Roopa Vriddhi and can be understood aspresenting with the following symptoms.a) Annadvesha Due tob) Hridayotklesha Ama Roopi Kapha3rd Kriya Kala – Prasara Avastha If unhindered, the Prakupita Doshas attain Prasaravastha where the Unmarga GamanaKapha along with the other two Doshas from the Svasthana occurs. The Doshas pervade thebody and it can be inferred that the following symptoms are presented.a) Arochaka due to Kaphab) Avipaka along with Vata and Pittac) Angasada Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 23
    • The importance of first 3 Kriyakalas in preventing Madhumeha – Any disorders in these3 stages often goes unrecognized, 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 perto Madhumeha in these 3 stages. By suitable modification in the Ahara and Vihara in the formof Laghu Ahara Sevana and Vyayama etc, we can control as well as prevent the onset ofMadhumeha.4th Kriyakala – Sthana Samshraya Avastha By repeated Nidana Prakupita Doshas lodges in the Srotas where Khavaigunya exists.The Medhovaha Sroto Vaigunya in the Vapavahana due to Apathya Sevana or Beeja Upatapacauses the Dusti of Kapha and Vata and attains Sthanasamshraya initiating the process of DoshaDushya Sammurchana. The Poorva Roopas manifest in this Kriyakala.5th Kriyakala – Vyakta Avastha Dosha Dushya Sammurchana takes place actively during this Kriyakala. The PratyatmaLakshanas of Madhumeha i.e., Prabhoota Mutrata and Avila Mutrata along with SarvadaihikaLakshanas manifest during this stage. Prabhuta Mutrata is a result of Vriddhi Svaroopa KledaDushti and Avila Mutrata is one of the symptoms of Kleda Dushti.6th Kriyakala – Bheda Avastha In this stage Madhumeha is no more new. It would have attained sub acute or chronicstage. The disease proceeds into more severe forms in the event of increasing Dhatukshaya. Italso starts manifesting the Pittaja and Vataja Lakshanas rendering the disease Yapya. The diseaseessentially attains Asadhyatha in this stage; hence forth, Upadrava and Arishta Lakshanas startappearing. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 24
    • Saamaanya Nidana 68, 69, 70, 71: All those factors which increases generally Kapha and Madas, increases the Mootramalaand common causative factors of Madhumeha. The abyantra hetus are the Dosha, dooshyas andthe intrinsic causative factors, are discussed later in Samprapti. Table – 1 General Nidana of Prameha /Madhumeha AHARA Ch. Su. A.Sn. A.Hr. Dadhi + - - + Gramya, Anupa, Audaka Mamsa + - - + Payah + - - + Nava Pana + - - + Nava Anna + - - + Guda Vikrti + - - + Shleshmajanaka Ahara + - + + Sheeta dravya - + - + Madhura dravya - + - + Amla lavana rasa + - - - Snigdha dravya - + - + Drava Anna pana - + - + Guru dravya - - - + Picchila dravya - - - + Mootrajanaka dravya - - + + Tikta, Katu, Kashaya rasa - - - + VIHARA Asya Sukham + - - + Svapna Sukham + - - - Diva Svapna - + - - Avyayama - + - - Alasya - + - - MANAS Tyakta Chinta + - + + Shoka/Vishada + + + + Bija Dosha + + + + Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 25
    • Table -2 Vishesha nidana of Madhumeha 72 AHARA VIHARA Excessive intake of Excessive indulgence in : 1. Guru 1. Nidra 2. Snigdha 2. Asyasukha 3. Amla 3. Tyakta Vyayama chinta 4. Lavana 4. Samshodhana Akurvatam 5. Nava Anna 6. Nava Pana For all types of Prameha especially Madhumeha, Kapha Dosha is the key factor and itcan be established by Gangadhara’s version. In that he says, Gulma is caused by Vata, Raktapitta by Pitta and Madhumeha caused invariably due to the Kapha 73. All tthese factors contributeto the vikriti of the Kapha, Pitta, meda and mamsa. These vitiated factors cause avarodha tonormal Vata gati, which in turn carries the ojas to vasti thus resulting in Madhumeha.Poorva roopa of Madhumeha The Symptoms, which are produced during the process of sthanasamshraya avastha, arecalled as poorva roopa, and the symptoms which appears prior to the manifestation of thedisease, are called poorvaroopa i.e. is “4th Kriyakala”. Premonitory symptoms are very muchimportant to diagnose the disease as early as possible that in turn helps for good prognosis. Inancient Ayurvedic treatises common premonitory symptoms are described but specialpremonitory symptoms of Madhumeha are not mentioned. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 26
    • Table - 3 Showing the poorva roopa of MadhumehaS.no Poorva roopa C.S S.S A.H A.S M.N B.P Y.R1 Kesha Jatilibhava + + +2 Asyamadhuryata + + + + + +3 Karapada daha +4 Karapada suptata +5 Mukha talu kantha gala shosha +6 Pipasa + + + + + +7 Alasya + +8 Kaye malam + +9 Angeshu paridaha +10 Anga suptata + +11 Shatapada Mutrashaya abhisarana + +12 Vishra shareera gandha + + +13 Atinidra +14 Tandra + + +15 Snigdha,Pichhila guru gatratam + + +16 Madhura shukla mutrala + +17 Durgandha swara + +18 Talu, gala, danteshu malotpathi +19 Nakhati vriddhi + + +20 Swedam + +21 Keshathi vruddhi +22 Sheetpriyatwan + + +23 Mootra abhidhavanti pipeelakasha +24 Ghanangata + +25 Angashaithilatwa + + By clean observation of above Premonitory sign and symptoms we can postulate theopinion that the disease having vast field of etio-pathology the patient shows very fewPremonitory sign and symptoms. So it is very hard to diagnose Prameha by means of above Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 27
    • description but Susruta makes it easy by narrating and shloka that a man with slight increase inthe urine output along with the premonitory symptoms showed is consider as the patient ofPrameha 74. Apart from above premonitory symptoms and signs only few of them are cardinal signand symptoms of Madhumeha. These are pipasa madhura mootrata, asyamadhurya, anga daha.There is no direct explanation of the poorva roopa of Madhumeha as such. But poorva roopa ofPrameha can be considered as poorva roopa of Madhumeha. In classics, Lakshana of Madhumeha are only ascribed to Mutra and Mutra Pravruttiwhich remains incomplete without the study of Sarvadaihika Lakshana explained in contexts ofApathyanimittaja and Sahaja Pramehas by Susruta. Hence the Lakshana of Madhumeha ismainly grouped under two categories, which is – 1) Mutra Sambandhi Lakshanas 2) Sarvadaihika Lakshanas.Lakshana (Roopa) of Prameha The vyakta or pradurbhoota lakshanas of the Vyadhi is seen in the 5th kriyakala. Thevyadhi bodhaka linga of all 20 types of Prameha is prabhoota and Avila mootrata. The prabhootamootrata can be considered in terms of increased volume of urine and frequency of micturition.Avila mootrata refers to increased turbidity of urine.Roopa means symptoms of the actual manifestation of disease. At this stage Dosha dushyasamoorchana would have been completed and the onset of the disease would have beencommenced. Madhavakara explains it as when symptoms in the stage of poorvaroopa becomefully or clearly manifested they are called roopa 75. Roopa is the prominent diagnostic key of a Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 28
    • disease and hence thorough knowledge of the various roopa of each disease essential for aphysician. Signs and symptoms of the disease are the diagnostic tool manifests when the pathologyof the disease is in full context. The symptomatalogy of Madhumeha is ascertained by Ayurvedain broad manner to understand them need to elaborate as follows. Susruta narrated that theperson should be diagnosed as pramehi when complete to partial prodromal symptoms ofPrameha accompanied by polyuria get manifested 76. In this regard Gayadasa opined that in this disease all prodromal symptoms get convertedinto rupa due to specific nature of the disease i.e. vyadhiprabhava. From above description wecan say that the prodromal symptoms along with chief symptoms get continued as the diseaseprogress.1) SAMANYA LAKSHANAS: - 77 Samanya Lakshanans of Madhumeha sited by Vagbhata are common those which areascribed to Prameha, they are i) Prabhoota mootrata and ii) Avila mootrata.Prabhoota mootrata: - The increase in quantity and frequency is known as prabhoota mootrata. It is manifesteddue to increase of sharreera kleda, the reasons for which are explained in the context ofSamprapti. The frequency is increased due to vitiation of Apanavata. Due to hyperglycaemia inmadhumeha, glycosuria manifests which in terms hampers the tubular absorption of waterleading to polyuria. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 29
    • Prabhoota mootrata means atipravrutti of mootra. It goes without mentioning that there isalso an increased frequency of micturition and Avila mootrata means Atyartha Kalusha Samalamor Malinam akulam which means that there is a considerable change in the quality of urine as perthe above mentioned factors. Considering these factors, it becomes contextual to enumerate theconditions where there is increased frequency of urine and abnormality in its quality. Most of thetimes these symptoms are associated with mootravaha srotodusti and other diseases wheredifferentiating Madhumeha is not a problem for evident reasons. It becomes relevant to considerthe following conditions where hyperglycaemia is common manifestation under the heading ofdifferential diagnosis.Avila mootrata: - Moorta avilata is nothing but the turbidity of mootra, which is manifested due to dravaand guru guna vriddhi of Kapha and medhas. This can be noticed by the increase in the specificgravity of the urine.VISHESHA LAKSHANAS In Madhumeha mootra is manifested with Kashaya, Madhura, Rooksha, Pandu andmadhu Sama lakshanas. Bhavaprakasha clarify the controversy of the word kashaya as kashayavarna. The implication of this term is still debatable. The presence of madhura rasa in mootra ismainly because of ojo visramsa into mootra, which can be easily understood by pipeelikaabhisarana and by qualitative analysis of urine test. Rooksha guna is due to vitiation of vata.Pandu varnata of mootra is because of kleda dusti which influences Kapha to attain more liquidstate. Madhusama mootra implies the colour, smell and taste of mootra similar to that of madhu.It has to be understood that along with the samanya lakshanas madhusama mootra is thepratyatmaka lakshanas of Madhumeha. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 30
    • Table - 4 Lakshana of Madhumeha 78-85SN Roopa C.S S.S A.H A.S M.Ni Y.R B.Ra G.Ni1 Kashaya + + + + + +2 Madhura + + + + + +3 Pandu +4 Rooksha + + + + + +5 Snigdha +6 Ojadhatu +7 Kshoudravat + + Madhviva8 Kshoudra rasa +9 Kshoudra varna + Madhumeha patient excretes urine having kasaya and madhura taste, panduta in colourand of ruksa quality commenting upon this assertion of Charaka, opines that natural madhurarasa of oja is replaced by kasaya rasa in vasti Chakrapani opines on assertion that Vata becauseof its prabhava converts madhura oja into kasaya rasa. Susruta mentioned the resemblance ofurine with honey as described above. Similar description in asserted. In Chikitsa sthana Susrutabefore propounding the treatment of Prameha, asserted two types of Prameha along with theirfeatures as follows 86.1) Sahaja Prameha (Krusha) • Rooksha • Alpashi • Bhrsa pipasa • Parisarana sheela Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 31
    • 2) Apathya nimittaja (Sthoola) • Bahu ashi • Snigdha • Shayyasana swapna sheelaThe Samprapti of Apathya Nimittaja madhumeha has been explained earlier. The vitiation ofKapha, Kleda, Medas is due to the indiscreet food habits. Thus leads to the medovaha Srotodustidue to medodhatwagni mandya. Thus the person develops sthoulya. The samana Vata avarodhain koshta is the reason for prabhuta agni from which the person desires and consumes more food.It has been said earlier that the meda sthana is the pitta sthana and hence the Vata in kosta isobstructed which later lead to the excessive secretions of Pitta in Amashaya which results in theabove said lakshanas. The affected person is termed as snigdha due to the karmataha vruddi ofKapha. Madhumeha is one among the 20 types of pramehas. So these may be present inmadhumehi.Madhumeha lakshana 87 Susruta gives explanation regarding the lakshanas of Madhumeha, as follows – • Gamanat sthananichati • Sthanat asananichati • Aasanat sayyamichati • Shayanat swapnamichati. Apart from the above lakshanas urine similar to honey in colour and taste are alsoattributed to Madhumeha. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 32
    • Table -5 Madhumeha Roopa (symptoms) Mutra Sambandhi Lakshanas Sarvadaihika Lakshanas Samanya Vishishta Apathyanimittaja SahajaPrabhuta Mutrata Madhusama Sthula KrushaAvila Mutrata Madhura Snigdha Rooksha Kashaya Bahvashee Alpashee Rooksha Shayyasana Svapna Pipaasu brusha Pandu Sheela Paribramana SheelaDifferential diagnosis for Madhumeha Proper diagnosis is the foundation to the success of a treatment because many diseasesaffecting a srotas have similar manifestations, enough to confuse a physician but picking upthreadbare with a little difference to clinch a diagnosis is an art aspired by all. Deep knowledgeand untiring practice are the means to perfection as Vagbhata has rightly mentioned “abhyasatprapyate dristihi karma siddhi prakashini”. Madhumeha is a mootra atipravruttaja vikara with prabhoota and avila madhusamamootrata as pratyatma lakshana. Although there are many diseases presenting with Atipravruttiof mootra, the diagnosis of Madhumeha is usually a straight forward proposition by differentialdiagnosis of the following with its sweet uriantion. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 33
    • Table – 6 Symptomatic evaluation of differential diagnosis in MadhumehaMootra lakshana (Pravartana Nimitta) Symptoms1) Abhikshnam (Muhurh muhurh, Punah Ashmari (C. Ci. 26/38)punah : Subahushah, vikiranam Mutratita (S. U. 58/12) Ushna vata (Ah. N. 9/36) Vatika mootrakrichra (C. Ci 26/32)2) Atipravrutti Ama jwara (C. Ci. 3/135) Amavata (M. N. 25/9) Arsha poorvaroopa (As. N. 7/7) Asadhya masurika (M. N. 54/27) Chidrodara (C. Ci. 13/44) Kaphaja arsha (C. Ci. 14/17) Mutra praseka (S. Ci 7/36) Sahaja arsha (C. Ci. 14/8) Upasthita prasava (S. Sa. 10/7) Moreover within the preview of the disease Madhumeha, the Kapha, Pitta and Vata havecharacteristic presentations, which have been described in such a way as not to leave any scopefor doubt. In other words, if a patient presents with mootra atipravrutti, lakshanas of Kapha, Pittaor Vata like shukla mootrata haridramootrata or vasa mootrata and if they are associated withPrameha poorvaroopas then the disease is per se Prameha or Madhumeha. Charaka explains thisconcept giving the example of a situation where one comes across a patient who is presenting Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 34
    • with haridra or rakta mootrata. Here the absence of Prameha poorva roopas will prove theexistence of rakta Pitta and exclude Prameha 88. In the presence of madhura and picchala lakshanas of Prameha, one should consider twopossibilities for differentiation whether the condition is anilatmaka due to Dosha ksheenata orkaphasambhava as a result of santarpana. As discussed earlier, here one should essentially consider Madhumeha as a consequenceof vata vruddhi as a result of dhatukshaya where Vata is the anubandhya Dosha and Madhumehaas a result of margavarana janya vata vruddhi where Vata is an anubandha dosha and is directlydependent upon Kapha, which has undergone vruddhi because of santarpana. The factors fordifferentiation are as follows – Madhumeha (anilatmaka) Madhumeha (Kapha sambhava)Rogi : Krusha SthoolaNidana a) Vatakara ahara vihara along Kaphakara ahara vihara with vata vruddhi as a result of chirakalina madhumeha b) Beeja uapatapaRogi avastha : Bala to madhyama vaya Madhyama to vruddhaRoopa : Vata pradhana Kapha pradhanaSamprapti : Madhumeharambhaka dosha Kaphamedodusti leads to Madhumeha dusti leading to vapavahana arambhaka dosha, dusti in vapavahana dusti especially in sahaja madhumehi ChirakariVyadhiswaroopa : Ashukari Sadhya in the beginningSadhyasadhyata : Asadhya Kapha pradhana upadravasUpadrava : Vata pradhana upadravas ApatarpanaChikitsa : Santarpana Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 35
    • Madhumeha is basically medovaha srotodustijanya vikara but its pratyatma lakshanasbecome vyakta in the mootravaha srotas with abnormal changes in the rasa, varna, gandha,sparsha of the mootra and it is characterized by prabhoota and avila mootrata.Upadrava related to Madhumeha Charaka mentioned the Sapta Pidaka 89 as complication, because of the negligence of theMadhumeha. Susruta mentioned Madhumeha along with upadrava Pidaka, develops because ofvitiated Meda and Vasa which in turn vitiate Tridosha. Susruta and Vagbhata mentioned 10Pidaka while Caraka mentioned only 7 Pidaka these are also follows. Table – 7 Madhumeha upadrava SN Pidaka Charaka Susruta Vagbhata 1 Saravika + + + 2 Kaccapika + + + 3 Jalini + + + 4 Vinita + + + 5 Alaji + + + 6 Masurika + + 7 Sarsapi + + + 8 Putrini + + 9 Vidarika + + 10 Vidrdhika + + + Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 36
    • Sadhyasadhyata of Madhumeha(1) Sadhya - Kaphaja Prameha Etiological factors are same to that of Dosha, Dushya and having same qualities and sameseat. So the treatment is same for both. That’s why Kaphaja Prameha is Sadhya. Charakaexplained few things about prognosis of the disease that Sthairya i.e. Sadhyata (Curability)results when Kapha get vitiated along with same quality dushya i.e. Prakrti bhutatvat. Asadhytaincurability results because the vitiation of Kapha that occurs along with different qualityDushya like Raktadi. The treatment proved to be Viruddha i.e. apposite to each other, Vikrtibhutatvat as said by Chakrapani 90.(2) Kruchrasadhya (Difficult to treat): Madhumeha resulted because of Avaranjanya pathogenesis is difficult treat i.e.Kruchrasadhya. Here the provocation of Vata results, but the etiological factors mainly related tothe Kapha and Meda. So we should have to consider both of them, there are very few measures,which act against the Vata and Kapha combined 91.(3) Yapya (palliative): Pittaja Prameha is palliative that means the disease needs continuous treatment. Once thetreatment stopped, suddenly disease get provoke because of the apposite treatment measures wehave to profound here i.e. Visama kriyatvat.(4) Asadhya (Incurable) Vataja Prameha is incurable because there is involvement of vital Dhatus like Majja, Ojain the pathogenesis and the treatment modalities quite apposite to Dosha and Dushya. Susrutamentioned that if Kaphaja and Pittaja Prameha or All types of Prameha if not treated properly orill-treated become Asadhya 92. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 37
    • (4) Prognosis related to Medodusya : Charaka described that if there is less extent vitiation of Meda dhatu in Kaphaja andPittaja Prameha then Pittaja Prameha becomes curable but when there is more vitiation of Medathen Kaphaja and Pittaja both Prameha become Asadhya. Charaka mentioned that Madhumehabecause of the Beeja Dosha i.e. genetic predisposition is incurable. Susruta mentioned thatMadhumeha in association with complication i.e. Pidaka is incurable 93.Madhumeha Chikitsa The eminent ancient physicians, Charaka, Susruta and Vagbhata are considering the bodyconstitution and strength of the body of the patient when dealing with the management aspect.Charaka considers two types of patients; one is that with stout body structure and with strengthand the other is thin and impaired strength. Susruta said that the sahaja meha (born diabetic) rogiwill be krusha (thin) and apathyanimittaja rogi will be sthula (stout). Chikitsa (ManagementProper) and Chikitsa sutra (principles of treatments) are the two divisions of diseasemanagement. Both are illustrated very well in Ayurveda. But the concepts of methods aredifferent in situ, considering the disease. The Samprapti i.e. pathogenesis, should be consideredstep by step deeply before stepping to management. Medoroga context spoken managements are parallel to that of meha since the Dosha anddushyas are same to major extent. After considering all the factors in the management types it isemphasized as: (1) Samshodhana Chikitsa (Elimination Therapy) (2) Samshaman Chikitsa (Normalizing Therapy) – are the common modalities of the Madhumeha management. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 38
    • Factors which are responsible for the production of the diseases are eliminated andcausative factors are prevented any disease doesn’t progress to offer complications. Even inMadhumeha is treated like in other disease. Madhumeha said to be treated for long way althoughit is described as incurable. Madhumeha and such Pratyakhyeya vyadhis, symptomatic relief canoffer better relief to patient along with proper management. The managements of the KaphaPrameha and Madhumeha in specific are enumerated here under.1) KAPHAJA PRAMEHA 94(i) Samshodhan Chikitsa Charaka describes that shodhana, Vamana and langhana done at the proper time lookingat the condition of the patient is able to cure kaphaja meha. For Vasti Chikitsa Vagbhatadescribes the utilization of Surasadi gana kwatha. After explaining the shodhana the palliativetreatment given is samshamana Chikitsa in all types of Madhumeha. It is better to treat thepatient with Vamana therapy as all Prameha are often with Kapha predominance.(ii) Samshaman Chikitsa: Charaka gives 10 combinations of drugs to all the mehas with Kapha predominance. According to Susruta, after proper samshodhana the patient should use swarasa of amalaki with Haridra powder with madhu. Susruta in this context explains single drug decoctions with separate indications in 5 types of kaphaja meha and combinations in other 5 types.Importance of Apatarpana: Prameha and especially Madhumeha is a santarpana janya vyadhi. Charaka explains thecause of Prameha as due to increasing attitude of kleda, meda, and Kapha. So he emphasizes therole of Apatarpana in kaphaja and Pittaja Prameha. Different types of vyayama, kshut, udvartana, Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 39
    • dhara & snana with churnas made of Chandana, Aguru, Ela etc. are advised to use in kaphajameha.2) PITTAJA PRAMEHA 95(i) Samshodhan Chikitsa Virechana is best in pittaja pramehas. The drugs which are sufficient to eliminate morbidPitta can be used with sheeta and other tikta, kashaya rasa in this. Nyagrodhadi gana kwatha isadvised for Asthapanbasti by Vagbhata. Susruta has described that due to spreading of medodhatu all over the body, Madhumehi subjects are durvirechya.(ii) Samshaman Chikitsa Charaka explains 10 pada yogas in this aspect to treat pittaja pramehas. Susruta hasdescribed 6 specific kwatha yogas for the specific type of pittaja Prameha.The three kwatha yogas explained by Vagbhata are 96-(i) Ushiradi : Ushira, Lodhra, Arjuna, Chandana.(ii) Patoladi: Patola, Nimba, Amalaki, Amrita(iii) Lodhradi : Lodhra, Ambu, Kaleyaka, Dhataki3) VATAJA PRAMEHA 97 Although vataja mehas are incurable still Charaka explains to induce certain treatment inKapha Pitta anubandhi Vatika meha. Susruta has described that all types of Prameha if nottreated properly in time, gets converted into Madhumeha. So the treatment described for vatikameha can be considered as treatment of Madhumeha. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 40
    • MADHUMEHA 98 Susruta has separately mentioned one chapter for the treatment of Madhumeha.(i) Samshodhan Chikitsa Considering Sthula and krusha pramehi, Samshodhan Chikitsa should be administeredonly to the sthula and Balvan Pramehi. Sarshapa, Nimba, Danti, Bibhitak & Karanja siddha Tailaor Trikantakadya Sneha (Ghrita or Taila according to Dosha predominance should be used forAbhyantara Snehana. Here while explaining the Samshodhan, Charaka describes to use theMalashodhan yogas from Kalpa sthana Both Pitta and Kapha are eliminated through shodhana. Itmay be vamana or virechana, because of Pittantam Vamanam, Kaphantam Virechanam. InVirechana Pitta is eliminated first, then Samyak lakshana of virechana is kaphadarshan, so bothPitta and Kapha doshas which are vitiated are eliminated. Then the described Anuvasana &Asthapana Basti chikitsas are able enough to control the provocation of Vata. Like this all thedoshas are normalized to keep the Dosha samyata. Anuvasana with medicated oils and ghritasare prescribed in Madhumeha. After proper Shodhan Chikitsa, Charaka details to give santarpanaChikitsa to the patients, to prevent the complications like Gulma, Bastishula etc.(ii)Samshaman Chikitsa Samshaman Chikitsa includes mainly deepana (appetizers) , Pachana, (enhancingdigestion), Kshut (Hunger maintenance), Trit (Maintenance of thirst), Vyayama (Exercise),Atapa (Having exposed to sunlight ) and Maruta ( Exposing oneself to wind).According to theconditions of vitiated doshas and dushyas , a physician has to suggest proper Shaman Chikitsa tothe patient. Acharyas introduces different tarpana upakramas in vatika mehas. It is due to the lessstrength of the patient. Acharya Charaka & Vagbhatta says that the kashaya yogas should beenriched with sneha and given to vatika mehas . Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 41
    • Typical Madhumeha Chikitsa Susruta explains that Shilajitu should be taken after triturating with Salsaradi ganakwatha. After its digestion patient should take Jangala mamsa rasayukta Anna. He prescribes totake 1 Tula of shilajatu.Compound Preparations Used In Prameha:Swarasa : Amalaki, Haridra, Nimbapatra, Bilwapatra, GuduchiKwatha : Vidangadi, Phalatrikadi, Mustadi, Manjishthadi, PathadiChurna : Triphaladi, Mustadi, Gokshuradi, ArkadiGutika : Chandraprabha, Indravati, Pramehantak VatiGugglu : Gokshuradi GugguluModaka : Kastur ModakaAvleha : kushavleha, BangavlehaPaka : Pugapaka, Ashwagandhadi paka, Draksha Paka.Asava Arishta: Lodhrasava, Dantyasava, Madhukasava, Devdarvyadiarishta, Lodhrarishta.Ghrita: Dhanvantar ghrita, Trikantakadi ghrita, Sinhamrita ghrita, Dadimadi ghrita, ShalmalighritaRasaushadhi: Vasant kusumakar Rasa, Mehamudgar Rasa, Brihat Vangeshwar Rasa, Pramehagajkesri Rasa, Trivanga Bhasma, Vasant tilaka Rasa.PATHYA-APATHYA 99 Those Aahara and vihara which are suitable to pramehi are called Pathya and those whichinduce Prameha are called Apathya. Pathya is having a key role in the management ofMadhumeha. Even in modern science also Diet & Exercise are included in diabetes management. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 42
    • So before stepping to manage we have to consider for the Pathya-Apathya. Pathya and ApathyaAharas and Viharas according to different Ayurvedic classics are as follows:Pathya in Madhumeha(a) Aahara:Shook Dhanya: Jeerna Shali, Shashtika, Kodrava, Yava, Godhuma, Uddalaka,ShyamakaShimbi Dhanya:Chanaka, Adhaki, Kulattha, MudgaShaka Varga: The leafy vegetables with a predominance of tikta-kashaya rasa, Patola,Karvellaka, ShigruPhala Varga: Jambu, Dadima, Shringataka, Amalaki, Kapittha, Tinduka, Kharjura, Kalinga,Navina Mocha.Mamsa Varga:Vishkira mamsa,Pratuda, Jangala mamsaTaila Varga: Danti, Ingudi, Sarshapa , AtasiUdaka Varga: Sarodaka,Kushodaka,MadhudakaKritanna Varga: Apupa,Saktu,Yavodana,Vatya,YushaOthers: Madhu, Hingu, Saindhava, Maricha, Lasuna(b) Vihara: To have walk, traveling on elephants, horses and different plays, different form ofmarshal arts, roaming in different places other than temples and umbrellaApathya in Madhumeha(a) Aahara: Jala, Milk, Ghee, Oils, Curd, Sugar, Different types of rice preparations, anupa,gramya and audaka mamsa, Ikshurasa, Pishtanna, Navanna.(b) Vihara: Eksthana asana, Divaswapa, Dhoompana, Sweda, Raktamoksha, Mutravegadharana. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Literray Review 43
    • Drug Review: Bhunimbadi yoga In Ayurveda, herbs play a major role in various kinds of therapeutic treatments -internally as well as externally. Bhunimbadi yoga is one of the first "Hypoglycemiccompounds" which is freely available in the market and provides extensive result among mostAyurvedic herbs. The composition and preparation of Bhunimbadi yoga is as follows –Composition of Bhunimbadi yoga: S.no Name of the Herb Latin name Proportion 1 Bhunimba 100-101 Andrographis paniculata 1 part 2 Katuki 102 Picrorhiza kurroa 1 part 3 Musta 103 Cyprus rotandus 1 part 4 Triushana 104 Equal parts of Piper longum, Piper 1 part nigram, Zingiber officinale 5 Indrayava 105 Holarrhena antidysenterica 1 part 6 Chitramoola 106 Plumbago zylanica 2 parts 7 Vatsaka twak 107 Bark of Holarrhena antidysenterica 16 partsPreparation of Medicine:Bhunimbadi yoga ingredients are well identified and collected from local areas. Goodmanufacturing practice will be followed for the preparation of Bhunimbadi yoga. Initially all theingredients are fortified with the kashaya of the Bhunimbadi yoga and dried to have improvedefficacy. Later these components are subjected to fine powder and capsulated to 500mg capsules.Filled capsules are packed and shelved in glass containers. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Drug Review 44
    • 1) Bhunimba Botanical: Andrographis paniculata Family name: Acanthaceae Sanskrit: Bhunimba, Kirata English: The Creat, The great king of bitters Hindi: Kalmegh, Kirayat Common names: Kaalamegha, Yavatikta, Shwetatikta, Shwetakunha, Shankini, Sookshmapushapa, Tiktaphala, Yavi, Yashaswni, Nilavempu Kalmegh, Bhuineem, Kalmegh, Kirayat Kalmegh, Kariyatu, Mahatita, Nelaberu, Kiriyattu, Nelaveppu, Olikiryata, Bhunimba, Nilavembu, Qusabhuva, Qasabuzzarirah, Chiretta Justicia paniculata Paryaya • Parvataha: Lives in mountains and hills. • Hemakandaha: Golden coloured stem. • Chardighnaha: Prevents vomiting. • Nidrari: Induces sleep. Parts used: • Whole plant Properties • Rasa: Tikta • Guna: Laghu, Rooksha • Veerya: Ushna • Vipaka: Katu • Prabhava: Jwaraghna Uses It is febrifuge, alterative, anthelmintic antipyretic, hepatic stimulant, blood-purifie, anodyne in nature. Good remedy for debility, diabetes, consumption, influenza, bronchitis, general debility, dysentery, liver and digestive ailments, colic pain, itching and piles. It has good affect on liver. It is a good medicine for Cholera. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Drug Review 45
    • 2) Katuki Botanical: Picrorhiza kurroa Family name: SCROPHULARIACEAE Sanskrit: Anjani, Arishta, Chakrangee, Katuka, Katavi, Katumbahara English: Hellebore, Picrorhiza Hindi: Katkea, Kuru Common names: Picrorrhiza Kurroa, Katuka, Katki Paryaya Ashokrohini, Ashoka, Chitrangi, Dwijangi Parts used: Dried rhizomes, Kutki rhizomes Properties • Rasa: Tikta • Guna: Laghu, Rooksha • Veerya: Sheeta • Vipaka: Katu Uses Excretory, female reproductive, digestive, circulatory, nervous. Small doses-bitter stomachic and laxative; large doses-cathartic; anti- periodic, cholagogue, used in epilepsy, paralysis, emmenagogue, emetic, skin problems, best remedy for liver disorders. Bottom of F. Its usefulness as a laxative, liver-stimulant, improving lactation, appetite stimulant, febrifuge and as beneficial in bronchial asthma. The plant and its formulations are widely used in therapy of epidemic jaundice. Clinical studies including double-blind trials have been carried out with the root powder of the plant in patients with viral hepatitis with significant improvement in symptoms like anorexia, nausea and vomiting. There was a concurrent improvement in liver functions. Open trials in bronchial asthma have given encouraging prophylactic response with prolonged administration. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Drug Review 46
    • 3) Musta Botanical: Cyprus rotandus Family name: CYPERACEAE Sanskrit: Ambuda, Bhadra, Bhadrakshi, Bhadramusta, Eraka English: Nutgrass, Coco grass Hindi: Musta Common names: Abdahullu, Jeekanagandha, Tungemusta Paryaya Ambudu, Bhadra, Ghana, gangeeya, Hima, Kachola Parts used: Rhizomes Properties • Rasa: Katu, Tikta, Kashaya • Guna: Laghu, Rooksha • Veerya: Sheeta • Vipaka: Katu • Prabhava: Balya Uses The decoction of the roots and tubers are excellent antidote to all poisons. A paste of the fresh tubers applied to the breasts acts as an effective galactagogue. The root is often used for developing high memory. This herb also harmonizes the liver, spleen, and pancreas. The grass is alteractive, anthelmintic, anti-fungal, anti-parasitic, anti- rheumatic, antispasmodic, aphrodisiac and astringent.4) Pippali Botanical: Piper longum, Family name: Piperaceae Sanskrit: Pippali English: Dried catkin, long pepper Hindi: Madadha, Peepar, Pipari, Pippalee Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Drug Review 47
    • Common names: Modi, Hippali, Kuma Paryaya Chanchala, Chapala, Granthika, Katubeeja, Krishna Parts used: Fruit, Root ,Stem, Long pepper Fruits, small pepper fruits Properties • Rasa: Katu • Guna: Laghu, Rooksha • Veerya: Anushna sheeta • Vipaka: Madhura • Prabhava: Deepana Uses Aromatic, stimulant, carminative ,good for constipation, for gonorrhea, paralysis of the tongue ,advised in diarrhea , cholera, scarlatina ,Chronic Malaria, Viral hepatitis.Piper Longum is most commonly used to treat respiratory infections such as stomachache, bronchitis, diseases of the spleen, cough, tumors, and asthma. When applied topically, it soothes and relieves muscular pains and inflammation. In Ayurvedic medicine, it is said to be a good rejuvenator. Piper Longum helps stimulate the appetite and it dispels gas from the intestines. An infusion of Piper Longum root is used after birth to induce the expulsion of the placenta.5) Maricha Botanical: Piper nigram Family name: Piperaceae Sanskrit: Maricha English: Black pepper, peppercorns Hindi: Chocamirchi, Gulmirchi, Habush, Kalimirchi Common names: Kaalu menasu, Karimenasu Paryaya Kola, Kolaka, Maleena, Maricha, Rooksha, shyama, Teekshna Parts used: Dried unripe fruits, usually known as peppercorns, Black pepper, peppercorns Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Drug Review 48
    • Properties • Rasa: Katu • Guna: Laghu, Teekshna • Veerya: Ushna • Vipaka: Katu • Prabhava: Deepana Uses Black pepper oil can be used to help in the treatment of pain relief, rheumatism, chills, flu, colds, increase circulation, exhaustion, muscular aches, physical and emotional coldness, nerve tonic and fevers. It furthermore increases the flow of saliva, stimulates appetite, encourages peristalsis, tones the colon muscles and is a general digestive tonic. Sometimes it is used in place of cubebs for gonorrhoea. As a gargle it is valued for relaxed uvula, paralysis of the tongue. On account of its stimulant action it aids digestion and is especially useful in atonic dyspepsia and torbid condition of the stomach. It will correct flatulence and nausea. It has also been used in vertigo, paralytic and arthritic disorders. It has also been advised in diarrhoea, cholera, scarlatina and in solution for a wash for tinea capititis.6) Sunthi Botanical: Zingiber officinale Family name: Zingiberaceae Sanskrit: Ardraka, Shunti English: Ginger Hindi: Ardrak, Ada, Sonta Common names: Calamus, sweet ginger, ginger root, sonth(dried) Paryaya Anupama, Gulmamoola, Kandara, Katubhadra, Vara Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Drug Review 49
    • Parts used: Fresh And Dried Fruit, Fresh Ginger , Dried ginger, Extract Properties • Rasa: Katu • Guna: laghu, Snigdha, Guru, Teekshna • Veerya: Ushna • Vipaka: Madhura • Prabhava: Grahi Uses Clinically proved as prophylactic of Nausea and vomiting associated with motion, sickness, sea sickness and pregnancy. Known for its gastrointestinal benefits and as an anti inflamatory and carminative7) Indrayava and Vatsaka twak Botanical: Holarrhena antidysenterica Family name: Apocynaceae Sanskrit: Indrayava, Kutaja English: Bitter oleander, connessi bark, kurchi bark, , dysentery rose bay, tellicherry bark Hindi: Dudhi, Karchi, Kadu, Kora Common names: Hale, Hirekodasige, Kodumuruka, Vatsaka Paryaya Girimallika, Indra, Kahi, Kalinga, Ksheeri Parts used: Bark, Seeds Properties • Rasa: Tikta, Kashaya • Guna: Laghu, Rooksha • Veerya: Sheeta • Vipaka: Katu Prabhava: Sthambhana Uses It is one of the best drug for Diarrhoea. In chronic diarrhoea & to check blood coming from stool,it should be given with Isobgol, caster oil or Indrayav. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Drug Review 50
    • According to Ayurveda, the bark is useful in treatment of piles, skin diseases and biliousness. The bark is used externally in case of skin troubles. The bark is mostly mixed with cow urine and apply it in affected parts. In treatment of urinary troubles, the bark is given with cow milk. The fresh juice of bark is considered good to check the diarrhoea. In Bleeding piles Decoction of Kutaj bark with sunthi checks mucus & blood. Application of this herb is useful in Rh. Arthritis & Oestioarthritis.8) Chitramoola Botanical: Plumbago zylanica Family name: Plumbaginaceae Sanskrit: Chitrak English: Ceylon lead root, leadwort, wild leadwort, lautafifi Hindi: Cheetah, Chitra, Chitawar, Safed chitra Common names: Bili chitramoola Paryaya Agni, Pavaka, Agnishikha, Anala, Bhari, Bhali Parts used: Flowers, Roots Properties • Rasa: Katu • Guna: Laghu, Rooksha, Teekshna • Veerya: Ushna • Vipaka: Katu • Prabhava: Deepana Uses Plumbago is acrid and stimulates sweating. It also promotes appetite and helps in digestion. It is used for dyspepsia, piles, and skin diseases. Roots have been used as abortifacient in some indigenous practices, internally or as an irritant to the os uteri. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Drug Review 51
    • Chapter 4 Methods The present clinical study is based on the classical explanations with scientific welldesigned research protocol, which details the patient before to administrate the trial drug to aftereffects in comparison.Criteria for selecting drugs 1. The above mentioned Bhunimbadi yoga 108, which are taken from the Saharayoga with Subodhini Vyakhya, Churna Prakarana 2. The pharmacological actions of the individual drugs are Madhumeha hara. 3. The trial drug, Bhunimbadi yoga is selected according to the pharmacological action and properties of individual drugs with in. 4. Bhunimbadi yoga is purely herbal and cheaper as easily available in the local market. 5. Bhunimbadi yoga is very easy to process and vati making 6. Bhunimbadi yoga is very easy to dispense. 7. The said combination Bhunimbadi yoga is hypothetically effective in reversal of Samprapti or the patho-physiological normalcy induction in Madhumeha.Criteria for quantity of the drug All the drugs which are selected has pharmacological action against Madhumeha withtherapeutic effects which are the equitant so it is considered to under take in equal quantity of theBhunimbadi yoga ingredients as said in the text.Methods followed in trail of Bhunimbadi yoga protocol1) Study design: Simple random sampling technique - dose control comparative clinical trial Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Methods 52
    • In spite of advanced medical research, it is still a burning problem for the society. Recentstudies reveal that the prevalence rate of type-2 diabetes is from 10-18% in the urban Indianadult population and also increasing in rural population too. At least 50% of all people are withMadhumeha are undiagnosed and noticed from a dentist. Madhumeha vis-à-vis Diabetes mellitusis a major health problem for the world of 21st century. Thus the Bhunimbadi yoga protocol is aSimple Random sampling technique dose control comparative clinical study.2) Sample size:A minimum of 15 patients in each group with dose control comparative clinical study isevaluated.3) Posology of Trial drugTwo groups are formed with different dose patterns for comparison. Group A: Receives the standard dose of 500mg TDS Bhunimbadi yoga. Group B: Receives 1 gm. TDS Bhunimbadi yoga. (Each capsule contains 500 mg Bhunimbadi yoga).3) Anupana of Trial drug Udaka is advised not to have any bios in study.4) Study duration of Trial drug Bhunimbadi yoga clinical study was conducted for 30 days. The medicine was dispensedfor every 7 days to all patients and advised to report for 7 days interval, noted the nature,frequency and other symptoms of their disease during their visits.5) Follow up of Trial drug Bhunimbadi yoga trail offered a further follow up 30 days. The effect of yoga wasanalyzed according to clinical and functional response before and after the treatment is compared Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Methods 53
    • to that of follow up data. In further the final declaration of the trail drug effect and result is doneon the basis of the follow up data.6) Source of data of Trial drug Diet control, exercise, oral hypoglycemic agents and insulin have tried and treated thispublic health threat, Madhumeha. In spite of this much of prevalence and increasing nature of thedisease all over the world, still researchers are struggling for a good, effective and harmlessremedial measure of Madhumeha. The data was collected from the patients suffering fromMadhumeha in the OPD of post graduation and research center DGM Ayurvedic medical collegeGadag. The method of the present study consists of following headings. a) selection of the patient b) examination of the patient c) criteria of assessmenta) Selection of the patient Patients of Madhumeha fulfilling the criteria of diagnosis were selected in the presentstudy. Patients were distributed based on preset inclusion and exclusion criteria in to two groups.Patients were excluded, if they are at discontinuous to treatment or unable to fulfil the studydesign. i) Inclusion criteria Patients between the age of 25 to 65 years Irrespective of sex Less than 5 years chronicity Non obese Patients other than that of Exclusive criteria Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Methods 54
    • Patient having clinical features of Madhumeha viz. • Excess urination • Turbid urination • Weakness - Dourbalya • Loss of weight - Shareera Bhaarahani • Muscular cramps - Janghamamsagraha • Burning feet and palm - Karapada Daha • Thirst - Pipasa • Excessive Hunger - Kshudhadhikyata ii) Exclusion criteria 109 Patients who are with known organic lesions. (Type II ) Insulin dependent. (Type I) Severe chronic disease Neoplasm Suffering from liver or ailments failure Suffering from Kidney or ailments failure Associated Cardiac diseases and Hypertension Obesity Pregnancyb) Examination of the patient Patient through examination is necessary to obtain clear picture of disease and also theeffect of trail drug – Bhunimbadi yoga. For that the following methods are obtained in the study.b-1) Physical signs of Madhumeha patients – A detailed medical history is under taken along with physical examination. Ayurvedicand contemporary clinical methods were observed clearly in the study. Patients are diagnosedaccording to diagnostic criteria given for Madhumeha vis-à-vis DM. A special case sheet isprepared incorporating all Madhumeha aspects, which is placed as annexure. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Methods 55
    • b-2) Diagnosis measurements The signs and symptoms of Madhumeha mentioned in Ayurveda and contemporaryscience were the main basis of diagnosis and criteria for assessing the response to the treatment.Assessments of results were made according to clinical and functional improvement observed inthe study. Clinical assessment was made on the basis of symptoms viz. prabhoota mootrata,kshudha etc., which are allotted grades according to their severity or to that of normalcy. Thegrades are followed as under. Grades of assessment1) Avila Mootrata (Turbidity) Grade 0 = Crystal clear fluids Grade 1 = faintly cloudy or hazy with slight turbidity Grade 2 = Turbidity clearly present but news print can be read through the tube. Grade 3 = More turbidity & news print can not be read.2) Dourbalya Grade 0 = No Dourbalya Grade 1 = occasionally noticed Grade 2 = periodically noticed Grade 3 = daily noticed Grade 4 = continuously noticed3) Janghamamsagraha Grade 0 = No Janghamamsagraha Grade 1 = occasionally noticed Grade 2 = periodically noticed Grade 3 = daily noticed Grade 4 = continuously observed6) Karapada Daha Grade 0 = No Karapada Daha Grade 1 = occasionally noticed Grade 2 = periodically noticed Grade 3 = daily noticed Grade 4 = continuously noticed7) Pipasa Grade 0 = No Pipasa Grade 1 = occasionally noticed Grade 2 = periodically noticed Grade 3 = daily noticed Grade 4 = continuously noticed8) Kshudhadhikyata Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Methods 56
    • Grade 0 = No Kshudhadhikyata Grade 1 = occasionally noticed Grade 2 = periodically noticed Grade 3 = daily noticed Grade 4 = continuously noticedb-3) Assessment measures and Laboratory-investigations The following investigations are under taken to fulfil the criteria of inclusions andexclusions. The effective parameters which are considered for the assessment are as under.a) Blood Sugar estimations Blood glucose is determined by using Gluzyme glucose reagent setProcedure A blood sample is collected from patient into a sterilized container. Serum is separatedfrom the cells at the earliest possible time (within 30 minutes), then the serum blood is mixedwith the reagent (working solution) and heated at 37°C for 15 minutes. The readings areobserved from colorimeter under 520 nm.Pipetting scheme for determination of blood sugar Blank Standard Test Working enzyme reagent (ml) 3.0 3.0 3.0 Distilled water (ml) 0.025 - - Standard ( ml) - 0.025 - Sample (ml) - - 0.025 Calculation Glucose in mg/ dl = Absorbance of sample x 100 Absorbance of standard The same procedure is applied for both FBS and PPBS. The FBS is done with emptystomach and on the same day the PPBS is calculated after 2 hours of food and the results arerecorded in case sheet. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Methods 57
    • b) Urine Sugar estimations A fresh urine sample is collected from the patient. 5 ml of Benedict solution is taken in atest tube and 5-6 drops of urine sample in put in that. Then the test tube is heated till until a boilin the solution and cooled at room temperature. The change is observed for the presence ofsugar.Observations Colour of test solution Urine sugar Blue Nil Green 0.5 % Yellow 1.0 % Orange 1.5 % Brick red 2.0 % The following are investigations were done prior to the study according to the need eitherto make an exclusion or inclusion in to the study, which are commonly undertaken for thepurpose of prognosis.c) Lipid profile The blood was taken from the patient randomly according to the advice of pathologist.The venous blood was collected in sterilized test tube that was not heparinized & allowed tosettle in vertical position for one hour. Then centrifuged at 3000 rpm for 30 min. & the serumseparated. Modified Allain’s method Cholesterol kit & GPO-PAP method triglyceride kit is usedfor lipid profile.Pipetting scheme for total cholesterol Blank Standard TestWorking enzyme reagent (ml.) 1.0 1.0 1.0Distilled water (ml.) 0.01 - -Cholesterol Standard (ml.) - 0.01 -Sample (ml.) - - 0.01 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Methods 58
    • Pipetting scheme for HDL cholesterol Blank Standard TestWorking enzyme reagent (ml.) 1.0 1.0 1.0Distilled water (ml.) 0.01 - -HDL cholesterol Standerd (ml.) - 0.01 -Supernatant from step 1 (ml.) - - 0.01Pipetting scheme for Triglyceride Blank Standard TestWorking enzyme reagent (ml.) 1.0 1.0 1.0Distilled water (ml.) 0.01 - -Cholesterol Standard (ml.) - 0.01 -Sample (ml.) - - 0.01 Mixed well & allowed at room temperature for 10 min. measured the absorbance of test& standard against Blank on a photocolorimeter with green filter. This procedure is followedseparately for total cholesterol, HDL & Triglycerides & reading is recoded.Calculations 1. Total cholesterol in mg % = A of (T) /A of (S) X 200. 2. HDL Cholesterol in mg % = A of (TH) /A of (S) X 50. 3. Triglycerides in mg % = A of (T) /A of (S) X 200. 4. VLDL Cholesterol = Triglyceride / 5. 5. HDL Ratio = HDL / Total Cholesterol – HDL The following are investigations were done prior to the study according to the need eitherto make an exclusion or inclusion in to the study, which are commonly undertaken for thepurpose of prognosis. a) Erythrocyte Sedimentation Rate b) Hemoglobin % c) Blood Differential Count Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Methods 59
    • c) Criteria of assessment Over all assessment of results are done considering the cumulative subjective and objective parameters assessments as shown in annex. As the disease is not totally curable in the scheduled time span of the study, the grades of assessments made for the results declaration are as follows - 1. Regulated – i. Patient relieved with symptoms clinically ii. PLBS controlled totally to normal with in schedule and continued even at Follow up period 2. Palliative – i. Incomplete Symptomatic relief for the patient clinically ii. Reduced PLBS at schedule to normal and fluctuated at Follow up period 3. Responded – i. Symptomatic relief for the patient is witnessed partially ii. Partial Reduction of PLBS at schedule and increased at Follow up period 4. Not responded i. None of the above conditions Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Methods 60
    • Chapter – 5 Results Present study registers 30 patients, out of 45 approached patients. The percentages ofpatients undertaken from the scrutinised are 66%. The 30 patients of Madhumeha viz. DiabetesMellitus, fulfilling the criteria of diagnosis and inclusive criteria were included in the studyrandomly in two groups with Bhunimbadi yoga viz. Group A (500 mg TDS) and Group B (1 gmTDS). Fasting and Postprandial blood sugar (FBS and PPBS) along with corresponding urinesugars (FUS and PPUS) are considered as an objective for the inclusion in the present study. All the patients were examined before and after the trail, according to the case sheetformat given in the annex. Both the subjective and objective criteria were recorded along withvalidation of disease state. The data recorded are presented under the following headings. A. Demographic data B. Validation of disease Data C. Statistical analysis and D. Result of the Bhunimbadi YogaA) Demographic data: The details of Age, Gender, Religion, and Occupation etc. of the 20 patients are asfollows.A1) Age distribution in Bhunimbadi Yoga protocol In this study an attempt is made to understand the male female responses to themanagement with respect to that of the age groups. An interval of 10 has considered from theages 25 to 65 as discussed in the methods. In the study it is recorded that Madhumeha is mostprevalent in 35 to 55 age groups. The tabulations are depicted as under. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 61
    • Table – 8 Age distribution in Bhunimbadi Yoga protocol of A & B groups Group –A Group - BAge Reg P Res NR T % Reg P Res NR T %25- 35 0 0 0 2 2 13 0 0 1 2 3 2035 – 45 1 1 3 3 8 53 0 0 1 4 5 3345 – 55 0 2 1 1 4 27 0 0 3 3 6 4055 – 65 0 0 0 1 1 7 0 0 1 0 1 7Total 1 3 4 7 15 100 0 0 6 9 15 100% 7 20 27 47 100 0 0 0 40 60 100 100 Results of Group A Figure -3 Age distribution in Bhunimbadi Yoga protocol Not 1 1 2 3 Re sponded 0 1 Re sponded 0 3 55 – 65 0 2 45 – 55 Palliative 1 0 35 – 45 0 25- 35 Re gulate d 1 0 0 1 2 3 4 Results of Group B Age distribution in Bhunimbadi Yoga protocol Not 0 3 2 4 Re sponded 1 3 Re sponded 1 1 55 – 65 00 45 – 55 Palliative 0 0 35 – 45 0 25- 35 Re gulated 0 0 0 1 2 3 4 5 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 62
    • A2) Gender distribution in Bhunimbadi Yoga protocol The male female ratio in the study is approximately 3.28:1 patients. The percentage of thedistribution may not show any gender differentiation to get this Madhumeha in specific, except asmall lean towards male population. The observations are of 23 Patients i.e. (76.66%) male and 7patients i.e. (23.34%) were female. The data is expressed in diagrammatic manner is as under. Table – 9 Gender distribution in Bhunimbadi Yoga protocol of A & B groups Group –A Group - BGender Reg P Res NR T % Reg P Res NR T %Male 2 0 3 7 12 80 0 0 5 6 11 73Female 1 1 1 0 3 20 0 0 1 3 4 27Total 3 1 4 7 15 100 0 0 6 9 15 100% 7 20 27 47 100 0 0 0 40 60 100 100 Figure -4 Results of Group B Results of Group A Gender distribution in Bhunimbadi Yoga protocol Gender distribution in Bhunimbadi Yoga protocol Regulated 7 Regulated 6 Palliative Palliative 6 Responded 8 5 7 Responded 5 Not Responded 7 Not Responded 6 4 3 5 3 4 3 3 2 2 1 2 1 1 1 1 1 0 0 0 0 0 0 0 0 Male Female Male Female Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 63
    • A3) Religion distribution in Bhunimbadi Yoga protocol of A & B groups Table – 10 Group –A Group - BReligion Reg P Res NR T % Reg P Res NR T % Hindu 1 3 4 7 15 100 0 0 6 9 15 100 Muslim 0 0 0 0 0 0 0 0 0 0 0 0Christian 0 0 0 0 0 0 0 0 0 0 0 0 Others 0 0 0 0 0 0 0 0 0 0 0 0 Total 1 3 4 7 15 100 0 0 6 9 15 100 % 7 20 27 47 100 0 0 0 40 60 100 100 All the patients belong to Hindu community as the trial area is with Hindu locality.A4) Occupation distribution in Bhunimbadi Yoga protocol of A & B groups Table – 11 Group –A Group - BOccupation Reg P Res NR T % Reg P Res NR T %Sedentary 0 0 0 2 2 13 0 0 0 2 2 13Active 1 3 4 4 12 80 0 0 4 5 9 60Labor 0 0 0 1 1 7 0 0 2 2 4 27Total 1 3 4 7 15 100 0 0 6 9 15 100% 7 20 27 47 100 0 0 0 40 60 100 100 At the results observed, out of Group A and B, 70% of Active category patientsinvolvement, strongly suggests that the Madhumeha is a disease of the stress patients. Group Aexhibit no response to the sedentary patients and also Labour. Out of 12 (80%) patients of active Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 64
    • group express 1 regulated, 3 palliative, 4 responded and 4 patients of not responded to thetreatment. Group B exhibit no response to the 60% of patients. and also Labour. Out of 9 activegroup patients 4 patients responded and 5 not responded. Out of 4 labour group patients each 2 ofthem responded and not responded respectively. The data is expressed in diagrammatic manneris as under. Results of Group A Occupation distribution in Bhunimbadi Yoga protocol Figure -5 Regulated Palliative 4.5 4 Responded 4 4 Not Responded 3.5 3 3 2.5 2 2 1.5 1 1 1 0.5 0 0 0 0 0 0 0 Sedentary Active Labor Results of Group B Occupation distribution in Bhunimbadi Yoga protocol 6 Regulated Palliative 5 5 Responded Not Responded 4 4 3 2 2 2 2 1 0 0 0 0 0 0 0 0 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 65
    • A5) Economic status distribution in Bhunimbadi Yoga protocol of A & B groups Table – 12 Group –A Group - BEconomic Reg P Res NR T % Reg P Res NR T %statusPoor 0 1 1 2 4 27 0 0 2 3 5 33Middle 1 2 3 4 10 67 0 0 4 6 10 67Higher 0 0 0 1 1 7 0 0 0 0 0 0MiddleHigher 0 0 0 0 0 0 0 0 0 0 0 0Total 1 3 4 7 15 100 0 0 6 9 15 100% 7 20 27 47 100 0 0 0 40 60 100 100 At the results observed in Group A, out of 4 of poor patients, two are not responded andone each has shown as palliative and responded. Out of 10 of Middle class patients 4 are notresponded and 1 palliative, 1 responded and 1 regulated with the treatment. One patient recordedin higher middle expressed as not responded. At the results observed in Group B, out of 5 of poorpatients, 3 are not responded and 2 are responded. Out of 10 of Middle class patients 6 are notresponded and 4 responded with the treatment. The data is expressed in diagrammatic manner isas under. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 66
    • Results of Group A Occupation distribution in Bhunimbadi Yoga protocol Regulated Palliative 4.5 4 4 Responded 4 Not Responded 3.5 3 3 2.5 2 Figure -6 2 1.5 1 1 1 0.5 0 0 0 0 0 0 0 Sedentary Active Labor Results of Group B Occupation distribution in Bhunimbadi Yoga protocol 6 Regulated Palliative 5 5 Responded 4 4 Not Responded 3 2 2 2 2 1 0 0 0 0 0 0 0 0 Sedentary Active LaborA6) Diet status distribution in Bhunimbadi Yoga protocol of A & B groups Table – 13 Group –A Group - BDiet Reg P Res NR T % Reg P Res NR T %Vegetarian 0 1 1 6 8 53 0 0 1 5 6 40Mixed diet 1 2 3 1 7 47 0 0 5 4 9 60Total 1 3 4 7 15 100 0 0 6 9 15 100% 7 20 27 47 100 0 0 0 40 60 100 100 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 67
    • As the results observed, out of 30 patients in both groups recorded 14 (65%) vegetariansand 16 (35%) mixed diet patients. The results can not be attributed to the diet variances by anymeans in the present study. The data is expressed in diagrammatic manner is as under. Results of Group A Diet distribution in Bhunimbadi Yoga protocol Vegetarian 7 Mixed diet 6 6 5 4 3 3 2 2 1 1 1 1 1 0 0 Regulated Palliative Responded Not Responded Results of Group B Diet distribution in Bhunimbadi Yoga protocol 6 Vegetarian 5 5 5 Mixed Diet 4 4 3 2 1 1 0 0 0 0 0 Regulated Palliative Responded Not Responded Figure -7 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 68
    • B) Validation of disease DataB1) Validation of presenting complaint distribution in Bhunimbadi Yoga protocol of A & B Table – 14 Group A Group B Presenting complaints Pts % Pts % Excess urination 15 100 15 100 Turbid urination 0 0 0 0 Weakness - Dourbalya 13 87 14 93 Loss of weight - Shareera Bhaarahani 1 7 0 0 Muscular cramps - Janghamamsagraha 7 47 10 67 Burning feet and palm - Karapada Daha 10 67 11 73 Thirst - Pipasa 15 100 15 100 Excessive Hunger - Kshudhadhikyata 13 67 14 93 Almost all the symptoms of the presenting complaints enumerated in the study areobserved here to understand the disease entity. Prabhoota mootrata (30 patients), Dourbalya (27patients), loss of weight (1 patient), janghamamsagraha (17 patients), karapadadaha (21 patients),Pipasa (30 patients) and Kshudha adhikyata (27 patients) are observed stating the cardinalsymptoms as polyuria, polydipsia and polyphasia. The graph for the above tabulation is shown asbelow. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 69
    • Results of Group A & B Presenting complaints distribution in Bhunimbadi Yoga protocol Figure -8 Group A Group B 16 15 15 15 15 14 14 13 14 13 12 11 10 10 10 8 7 6 4 2 0 1 0 0 0 Excess Turbid Weakness Loss of Muscular Burning Thirst Excessive urination urination weight cramps feet and Hunger palmB2) Validation of associated complaint distribution in Bhunimbadi Yoga protocol of A & B Table – 15 Group A Group B Presenting Associated features Pts % Pts % Numbness of hands / feet - Kara/Pada suptata 6 40 5 33 Fatigue - Klama 13 87 10 67 Stupor - Tandra 6 40 4 40 Lethargic - Alasya 10 67 10 67 Heaviness - Gurugatratatwam 5 33 3 20 Dryness of mouth - Mukha/Talu shosha 8 53 9 60 Almost all the associated symptoms of the presenting disease enumerated in the study areobserved here to understand the disease entity. Numbness of hands / feet - Kara/Pada suptata (11 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 70
    • patients), Fatigue – Klama (23 patients), Stupor – Tandra (10 patients), Lethargic – Alasya (20patients), Heaviness – Gurugatratatwam (8 patients) and Dryness of mouth - Mukha/Talu shosha(17 patients) are observed in the study as depicted in table and graph. Figure -9 Results of Group A & B Associated complaints distribution in Bhunimbadi Yoga protocol Group A Group B 14 13 12 10 10 10 9 10 8 8 6 5 6 5 6 4 3 4 2 0 Gurugatratatwam Numbness of Lethargic - Alasya Fatigue - Klama Stupor - Tandra Dryness of mouth hands / feet - Kara/Pada - Mukha/Talu suptata Heaviness - shoshaB3) Validation of Ahara Nidana distribution in Bhunimbadi Yoga protocol of A & B Ayurveda texts offered many factors of aetiology, especially in regard with food. TheGuda, Dadhi and Snigdha padartha are said as causes are observed maximum in the study. Theother factors also observed in the study are tabulated below. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 71
    • Table – 16 Group A Group B Ahara Nidana Pts % Pts %Guda 12 80 14 93Navanna 5 33 3 20Dugdha 7 47 4 27Gramya 6 40 9 60Anoopa 0 0 1 7Auduka 3 20 3 20Snigdha 14 93 15 100Dadhi 10 67 10 67Sheeta 12 80 14 93 Figure -10 Results of Group A & B Ahara Nidana distribution in Bhunimbadi Yoga protocol Group A Group B 16 15 14 14 14 14 12 12 12 10 10 10 9 8 7 6 6 5 4 4 3 3 3 2 1 0 0 Guda Navanna Dugdha Gramya Anoopa Auduka Snigdha Dadhi Sheeta Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 72
    • B4) Validation of Vihara/Anya Nidana distribution in Bhunimbadi Yoga protocol of A & B Table – 17 Group A Group B Vihara / Anya Nidana Pts % Pts %Avyayama 12 80 9 60Diwaswapna 2 13 4 27Swapna sukham 0 0 0 0Sukhaaseenatwam 0 0 0 0Manishika- Chinta 9 60 7 47Krimi 0 0 0 0Vegavarodha 1 7 1 7Panchakarma Vibhramsha 0 0 0 0Sthoulya 0 0 0 0 Re sults of Group A & B Vihara/Anya Nidana distribution in Bhunimbadi Yoga protocol Figure -11 G ro up A G ro up B 14 12 12 9 9 10 7 8 6 4 4 2 1 1 2 0 0 0 0 0 0 0 0 0 0 0 sukham Manishika- Sukhaaseenatw Panchakarma Avyayama Diwaswapna Swapna Sthoulya Vegavarodha Krimi Vibhramsha Chinta am Results of Group A & B Vihara/Anya Nidana distribution in Bhunimbadi Yoga protocol Group A Group B 14 12 12 9 9 10 7 8 6 4 4 2 1 1 2 0 0 0 0 0 0 0 0 0 0 0 Manishika- Avyayama Sthoulya Panchakarma Swapna sukham Sukhaaseenatwa Diwaswapna Krimi Vegavarodha Vibhramsha Chinta m Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 73
    • Many regimens are told in Ayurveda, out of which Avyayama and Diwaswapna alongwith Chinta and Vegarodha are observed here in the study. The vihara /Anya nidana aretabulated here under.B5) Validation of Poorva roopa distribution in Bhunimbadi Yoga protocol of A & B groups Table – 18 Group A Group B Poorva roopa Pts % Pts % Dantadeenam Malatvam 0 0 0 0 Pada daha 6 40 11 73 Pani daha 4 27 8 53 Deha chikkanata 3 20 5 33 Shareera durgandha 2 13 0 0 Mutra madhurata 0 0 2 13 Mutra shuklata 1 7 0 0 Mukha madhurta 2 13 2 13 Talu kloma shosha 3 20 1 7 Kesh jatilata 0 0 0 0 Nakha vriddhi 0 0 0 0 Alasya 6 40 8 53 Tandra 8 53 7 47 Nidra 2 13 0 0 Trishna 13 87 13 87 Maldhikyata in bahya chidra 1 7 0 0 Swedadhikya 3 20 8 53 Sheeta iccha 6 40 6 40 Swasa 0 0 0 0 Shitalangata 0 0 2 13 The Poorva roopa mentioned in Ayurveda are observed here in the study. Paada Dahaand Trishna are observed more. The rest of the symptoms observed are tabulated here along withpercentage. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 74
    • B6) Validation of Sroto dusti lakshana distribution in Bhunimbadi Yoga protocol of A & B Out of different srotas included in the study explicit new dimensions. Out of Udakavahasrotas – Pravruddha Pipasa, Jihwa and talu sosha, in Mootravaha srotas – Adhika Mootrata, inMedovaha srotas the Pipasa are observed in the study. It conform the involvement of thesesrotases. The enlisted symptoms are at above table. Table – 19 Group A Group B Sroto dusti lakshana Pts % Pts % Jihwa shosha 12 80 11 73 Talu shosha 7 47 6 40 Udakavaha Osta shosha 0 0 1 7 Kloma shosha 0 0 0 0 Pravruddha pipasa 13 87 11 73 Alpalpa mootrata 0 0 0 0 Mootravaha Mootara rodha 0 0 0 0 Adhika mootra 15 100 15 100 Sashoola mootra 0 0 0 0 Basti stabdhata 0 0 0 0 Arbuda 1 7 0 0 Mamsavaha Arsha 0 0 0 0 Mamsa shosha 0 0 0 0 Shira granthi 0 0 0 0 Sweda 5 33 10 67 Medovaha Snigdhanagata 0 0 0 0 Sthulashophata 0 0 0 0 Pipasa 14 93 14 93 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 75
    • B7) Validation of Family history distribution in Bhunimbadi Yoga protocol of A & B The Madhumeha observed as familial by researcher prove in study with 60% familyhistory. The rest of 40% show the instantaneous expression of the disease. Table – 20 Group A Group B Total Family history Pts % Pts % Pts % Present 5 33 8 53 13 43 Absent 10 67 7 47 17 57 Total 15 100 15 100 30 100 Figure -12 Family history distribution in Bhunimbadi Yoga protocol Present Absent Absent , 17, 57% Present , 13, 43% Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 76
    • C) Statistical analysisC1) Validation of Parameter Group A in Bhunimbadi Yoga protocol Table – 21Parameter Group A Mean SD SE t value P value RemarkDourbalya 0.7852 0.892 0.2303 3.411 <0.01 HSJanghamamsa graham 0.2 0.414 0.106 1.88 >0.05 NSKarapada daha 0.333 0.723 0.186 1.79 >0.05 NSPipasa 0.8 0.676 0.1745 4.58 <0.001 HSKshudhadhikyata 0.4 0.632 0.1632 2.450 <0.02 HSPrabhoota mootrata 0.52 0.3028 0.0782 6.6496 <0.001 HSShareera bharahani 1.4 0.828 0.2138 6.548 <0.001 HSFBS 14.933 12.109 3.127 4.775 <00.1 HSPPBS 31.066 25.647 6.623 4.490 <0.001 HSS Cholesterol 6.666 5.789 1.495 4.458 <0.001 HSS Triglycerides 10.8 13.66 3.527 3.062 <0.01 HSFUS 0.1666 0.308 0.0795 2.0955 >0.05 NSPPUS 0.2 0.253 0.0653 3.0627 <0.01 HS Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 77
    • C2) Validation of Parameter Group B in Bhunimbadi Yoga protocol Table – 22Parameter Group B Mean SD SE t value P value RemarkDourbalya 1.133 3.0 0.774 1.146 >0.05 NSJanghamamsa 0.4 0.632 0.163 2.453 <0.05 HSgrahamKarapada daha 0.6 0.632 0.163 3.680 <0.01 HSPipasa 0.7333 0.7988 0.266 3.559 <0.01 HSKshudhadhikyata 0.4 0.6324 0.163 2.453 <0.05 HSPrabhoota mootrata 0.7266 0.4934 0.1274 5.703 <0.001 HSShareera bharahani 1.8666 0.8338 0.2153 8.666 <0.001 HSFBS 13.666 11.653 3.009 4.5417 <0.001 HSPPBS 21.8 18.3349 4.735 4.604 <0.001 HSS Cholesterol 12.733 19.969 5.157 2.469 <0.05 HSS Triglycerides 12.2 17.259 4.457 2.737 <0.05 `HSFUS 0.366 0.2968 0.0766 4.778 <0.001 HSPPUS 0.433 0.258 0.0666 4.501 <0.001 HS Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 78
    • C3) Validation of Parameter comparison of Group A and B in Bhunimbadi Yoga protocol of A& B groups Table – 23Parameter Group Gr Mean SD SE PSE t value P value RemarkcomparisonDourbalya A 0.933 0.798 0.206 0.2566 0.5206 >0.05 NS B 1.0666 0.593 0.153Janghamamsa A 0.733 0.883 0.228 0.298 0.445 >0.05 NSgraham B 0.8666 0.7432 0.1919Karapada daha A 1.066 0.9611 0.2482 0.3303 0.1998 >0.05 NS B 1.0 0.8451 0.218Pipasa A 2.0 0.7559 0.1952 0.2736 1.7068 >0.05 NS B 1.533 0.743 0.1918Kshudhadhikyata A 1.933 1.2227 0.3157 0.4246 - - - B 1.933 1.0997 0.284Prabhoota mootrata A 3.353 0.5232 0.135 0.185 0.6108 >0.05 NS B 3.24 0.4939 0.127Shareera bharahani A 58.2 5.646 1.458 2.125 1.505 >0.05 NS B 55.0 5.988 1.546FBS A 198.46 57.193 14.77 18.784 0.038 >0.05 NS B 197.73 44.937 11.605PPBS A 248.2 63.5117 16.4028 20.275 1.125 >0.05 NS B 271.0 46.15 11.918S Cholesterol A 202.8 29.655 7.658 13.045 0.2044 >0.05 NS B 200.13 40.893 10.561S Triglycerides A 197.66 37.97 9.806 13.081 0.036 >0.05 NS B 198.13 33.53 8.659FUS A 0.7 0.492 0.127 0.1757 0.569 >0.05 NS B 0.6 0.4705 0.1215PPUS A 1.366 0.6114 0.1579 0.1906 0.8706 >0.05 NS B 1.2 0.414 0.1069 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 79
    • • To compare the mean affect of the treatment in the present protocol, the statistical analysis is carried out by un-paired “t” test.• By assessment the mean affect of the drug is same in both groups the treatment.• Here all parameters show no significance.• The parameter kshudhadhikyata the mean affect of the treatment is same in both groups.• The mean effect of Trushna is same in both groups.• Dorbalya parameter expresses the mean affect of the group B is more with less deviation.• Karapada daha mean effect of group B in comparison to group A reflects more variation after the treatment.• Analyzing the objective parameters in group B, the parameters viz. Fasting Blood Sugar and S.Cholesterol shows less mean with less variation than the group A after the treatment.• The shareera bharahani exhibit more improvement on group B with more variation.• To study the affect of the drug with in the group the statistical analysis is done by using paired ‘t’ test.• By assessing the drug has no responsible changes in the readings of observation before and after the treatment.• In group – A, the parameters Viz. Janghamamasa Graha, Karapadadaha and fasting Urine Sugar and all other parameter show high significance (p>0.05).• In the group B only the parameter dorbalya shows no significance but rest of all other show high significance. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 80
    • • In the parameters Janghamamasa Graha, Karapadadaha, Kshudhahikyata, sharer bharahani, FUS, PPUS are highly significant in group B than the group A (by comparing t value). • But the parameter pipasa probhoota mootrata and FBS show high significance in group A and parameter PPBS shows equal high significance in both the groups (by comparing t value). • Over the entire group B is highly significant than the group A after the treatment (by comparing ‘p’ value). D) Result of the Bhunimbadi Yoga of A & B groups Table – 24 Group –A Group - B Result Patients Percentage Patients Percentage Regulated 1 7 0 0 Palliative 3 20 0 0 Responded 4 27 6 40 Not Responded 7 47 9 60 Total 15 100 15 100 The results are not much variant as the time schedule for the research is quite minimaland sample size is also marginal. There is a response to the drug is found and the purpose ofunderstanding glucose metabolism in this protocol is successful. The results are depicted heretabulation are expressed in graphical below. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 81
    • Figure -13 Results of Group A in Bhunimbadi Yoga protocol Not Regulated , 1, Responded, 7, 7% Palliative , 3, 46% 20% Responded, 4, 27% Results of Group B Regulated in Bhunimbadi Yoga protocol Palliative Responded Not Responded Regulated , 0, Palliative , 0, 0% 0% Responded, 6, Not 40%Responded, 9, 60% Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Results 82
    • Chapter 6 Discussion In the classics, when the pathology of Prameha discussed with a special reference toMadhava Nidana, by Madhavakara, followed a specific pattern and kept this (metabolic) disorderbefore to Medoroga (Obesity) and after the Ashmari (Urinary caliculi), which is developed fromVasti or Mootrashaya (bladder). The chapter of prameha consists of prameha pitika (boils) at theend as the complications of prameha. There are total twenty pramehas are explained; out of fourare vataja, six pittaja and ten kaphaja. Tulya dosha dooshyata (Homologous etiologic factors ofvitiation to doshas and dooshyas because of similar qualities) in kaphaja mehas leads to easyaccessibility and treatment where as vataja becomes difficult for the same region. The medorogais said to be the nidanardhakara vyadhi for prameha pitika other then that of prameha. Thus it isclear, the Madhumeha - Diabetis melitus (prameha) is a disorder pertained to the lipidmetabolism but not in concern to the pancreas or insulin dependent. Today when we observe thepatients, many of them are of non insulin dependent and very few are of insulin dependent. Infact many of the patients those who are having Madhumeha, secrets more insulin (hyperinsulinemia) then that of normal and still the glucose levels are high (hyperglycemia) in theblood. It suggests clearly involvements of insulin dependent patients are with other causes otherthen that of insulin, developed the dependency later. In Ayurveda Madhumeha is with themadhuryata (sweetness) of mootra (glycosuria) where glomerular filtration gets impaired 110. When the practicality is to be achieved, it is required to analyze the samprapti(pathogenesis) of the disease. In that, the Madhumeha, which is prevalent and misunderstood bythe other system of medicines as a disease dependent upon the Insulin and pancreas, needs toexplain the original Ayurvedic thought of pathogenesis, for the sake of easy treatment of the Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 83
    • disease, as samprapti vighatana (breakdown or reversal of pathogenesis) is the chikitsa(treatment). Though the disease is of Tridosha predominant but Avrutta Vata and the BahudravaShlesma are the main ailments. Madhumeha is the subtype of Vataja Prameha. Vata is theoriginator and executor of the bio-motor functions. Vyanavata mainly pervades swiftly throughthe body, effective transport and circulation is dependent upon him. Apanavata related to thefunctions of Pakwashaya. In Madhumeha both are get vitiated leading to the abnormal pathwayand excessive elimination respectively. Kapha is the basis of structural integrity of the bodyprovides steadiness and strength in the body, keeping together various structures. All these function of Kapha get hampered in the Madhumeha. When Kapha get vitiated itundoubtedly vitiates the body elements like Rasa Mamsa, Meda, Vasa, Lasika, Oja etc. they inturns diminish the structured body integrity by providing excess of metabolic waster because offaulty bi-fold digestion. The present clinical study was planned in dose control comparative clinical study tomanage the problem by trial drug Bhunimbadi yoga. The subjects were treated with Bhunimbadiyoga for duration of 30 days and the yoga possesses Tikta, Kasaya Rasa predominance withVatakaphahara and Pramehaghna.Discussion on disease Diabetes mellitus (DM) comprises a group of common metabolic disorders that share thephenotype of hyperglycemia. Several distinct types of DM exist and are caused by a complexinteraction of genetics, environmental factors, and life-style choices. Depending on the etiologyof the DM, factors contributing to hyperglycemia may include reduced insulin secretion,decreased glucose usage, and increased glucose production. The metabolic dysregulation Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 84
    • associated with DM causes secondary pathophysiologic changes in multiple organ systems thatimpose a tremendous burden on the individual with diabetes and on the health care system. In theUnited States, DM is the leading cause of end-stage renal disease, nontraumatic lower extremityamputations, and adult blindness. With an increasing incidence worldwide, DM will likelycontinue to be a leading cause of morbidity and mortality for the foreseeable future 111. The description of pathogenesis from Susruta Nidana 6-4 states “Pravrittasyaparipakwa”for which Dalhana comments as “Aparipakwa Ama”. It refers both Amadosha and Amadooshyaas pravritti of becoming. In further said as other wise “Medascha Aparipakwam” pertaining tothe dooshya only. As Amaya is synonym for Vyadhi, in the process of pathogenesis Amatwa willbe generated in doshas also. Thus it is not necessary to spell it once again. There by Amatwa indooshyas specifically medas, is the meaning out of it. Gayadasa explains it as “medaschaaparinama miti asamyakparinatam”, in this the process of formation of medas is not interruptedbut impaired, with the qualities of ama; “ Ama rasavadati snigdham” , snigdhatwa will be inmedas by virtue, but here it will become pichilatwa with atidravatwa. “Cha” usage indicates notonly medas but also other dooshyas in the pathogenesis as explained by Charaka. And Gayadasain his commentary said it is in stanasamshritavasta, in which amalakshana in medas and otherdooshyas are visualized. As Susruta reefers to the pathogenesis, impaired jatharagni anddhatwagnis pertaining to dosha dooshyas of prameha are making non properly metabolizedtissues (metabolic) in which “Ama” causes the atidravatwa for the dooshyas of prameha and asin doshadooshya sammurchana, dosha union with dooshyas, which are vitiated with their owncausatives are going to get the “Ama sanjna”. They mix with the medas and other dooshyas,dragged or excreted through mootra vaha srotas, seats in vasti 112. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 85
    • In general any non-metabolized is for execration and pureesha, mootra and sweda vahasrotases are ment for it. “Mootrasya kledavahanam”, there by liquefied waste/ non properlymetabolized or Ama/ Amadooshyas are excreted by mootravaha srotas and its seat is vasti, a 113place of accumulation of liquid. Chakrapani comments as dravatwa to kapha dosha. Whenkapaha dosha is in abundent liquefied form then only capable of generating the prameha, bymixing with the medas which is further liquefied and liquefy the medas in association with amalakshana. Importance of drava ahara/ pana in liquefying kapha and medas along with the otherdooshyas are to be noticed. One thing here, not a single kapha dosha is capable of making theprameha roga with out pitta and vata. The dooshyas are said to be 114 medas, rakta, sukra, ambu 115 116(sareera kleda), vasa, lasika (said as rasamala by Hemadri and chakrapani as a part ofapadravya capable of coagulation) majja, rasa, ojas and medas in chronological order. Initially it was discussed the states of agni responsible in the presence of medoroga,creates udara lambana, shareera gowrava etc. For that mainly jatharagni is responsible. As it isthe supportive for other agnis. As in medoroga rasa, rakta and mamsagnis are normal andcapable, where as medoagni is vitiated or fat metabolism is impaired. As medoagni is notcapable of assimilation of astayee mamsa, the agni of it is diverted. Another area of kayagniamshas which are responsible for catabolic activity in the tissues is diminished. The dhatus aresubjected for increase. Here not only jatharagni vriddhi but also kayagni amshas of medodhatuksheenata is expected. As a result of blockage of medovaha srotas, increased agni (jatharagni/pachakagni) and decreased medo amshagnis causes the medoroga. In the etiology of medo rogamadhuryata of ahara or ahara rasa getting madhura vipaka in association with snigdhaguna ahara,medas is aggravated. A similarity for prameha to medoroga in etiology is with the factorscapable of making kapha vriddhi like madhura rasa, snigdha guna dravyas. The process of Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 86
    • metabolism of fats in different stages gives rise either medoroga or prameh(santarpanothavikara). Even in lakshanas of medoroga consists of durgandha, expressed inprameha as chikkanata deha because of more sweetness even in sweat because of ama withspecific lakshana as pichilatwa or atisnigdhata (more stickiness) 117. Amarakosha explains "miha sechana”, indicates prabhoota mootrata or polyuria.Adhamalla comments "prakarshene medo mamsa shareea kledadi mehateeti prameha" thatprabhoota mootra is because of fat, muscle and body fluids dragged to and excreted out throughvasti. Sudarshanacharya on Madhava nidana comments "prakarshena prabhootam- prachuramvaram varam va mehati mootratyagam-karoti yasmin roge prameha”, denotes not onlyprabhoota mootrata even muhurmootrata or repeated urination also said as prameha. Thepolyurea is one of the symptoms in Madhumeha. Arunadatta explains "mootrati pravrittija"- asmuch urination in quantity or for repeated times as pramehas, which is always in connection withmadhuryata can be said as madhumeha, which ultimately comes from various etiologic factorsunder doshik predominance as vataja etc. Out of the lakshanas mentioned for Madhumeha thefollowing are seen as valuable for analysis. Prabhootavila mootrata (polyuria): Sweda vaha sroto avarudhata causes increased urinary output with turbidity Madhuratwa in mootra: Glycosuria Dantadinam mala sanchaya: Because of Ama in dhatu more secretions in the oral cavity ultivated there by more depositions are seen in mouth. Pani pada daha: Abundant of glucose available in the blood is not utilized by body tissue, as it is not in the state of proper reception cause depletion in Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 87
    • equilibrium of Dhatu. It gives rise the pada pani daha (burning sensation of feet and palm), a condition of deficiency (B complex). Chikkanata (stickiness): (explained later in Samprapti) Trishna (thirsts - polydipsia): In the process of lypolysis more water is utilized. It results in to activation of thirst center and Thirst. Swadasyata : More circulating sugars as excreted in to oral cavity as saliva, sweetness is witnessed in mouth.Manifestation of DM 118 Diabetes mellitus is characterized by glucose concentrations that are high enough to overwhelm the reapportion capabilities of the kidneys. Glucose appears in urine and urine productiongenerally become excessive. Other metabolic products, such as fatty acids and other lipids arealso present in abnormal concentrations. While much has been learned in the recent years, the pathogenesis of type II diabetesremains enigmatic. There is no evidence that autoimmune mechanisms are involved in this. Lifestyle clearly plays a role and clearly evident when obesity is considered. Genetic factors are evenmore important than in type I diabetes. The two metabolic defects that characterize type IIdiabetes are – 1) Deranged beta cell secretion of insulin and 2) Decreased response of peripheraltissues to respond to insulin (insulin resistance).a) Deranged beta cell secretion of Insulin In populations at risk for developing type II diabetes, a modest hyperinsulinemia may beobserved, attributed to beta cell hyper responsiveness to physiologic elevations in blood glucose.With the development of overt disease, the pattern of insulin secretion exhibits a subtle change.Early in the course of type II diabetes, insulin secretion appears to be normal and plasma insulin Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 88
    • levels are not reduced. However normal pattern of insulin secretion is lost and the rapid firstphase of insulin secretion triggered by glucose is obtunded. Collectively this and otherobservations suggest derangements in beta cell responses to hyperglycemia early in type 2diabetes rather than deficiencies in insulin synthesis. A mild to moderate deficiency of insulin develops later in the course of type II diabetesthat is less severe than the- type I. The reason for this is not clearly known but irreversible betacell damage appears to be present. According to one view, all the somatic cells of predisposingindividual including pancreatic beta cells are genetically vulnerable to injury, leading toaccelerated cell turnover and premature aging and finally to reduction in beta-cells mass. Chronichyperglycemia may exhaust the ability of beta cells to function (called glucose toxicity), as aconsequence of persistent beta cell stimulation.b) Insulin Resistance Insulin deficiency is present in the course, of type II diabetes. Reduced responsiveness ofperipheral tissues i.e. insulin resistance, is a major factor in the development of type II diabetes.In obesity it is very much prominent or clear. The molecular basis of insulin resistance is notclear. There may be a decrease in the number of insulin receptors and more important postreceptor signaling by insulin is impaired. Also the insulin resistance leads to - 1) The inability of circulating insulin to properly direct the disposition of glucose 2) A more persistent hyperglycemia 3) More Prolonged stimulation of the pancreatic beta cell Insulin resistance and relative insulin deficiency are the major step in the pathogenesis ofthe diabetes mellitus on obese individuals. If the pancreas is healthy and if it secretes sufficientinsulin even this obese people will also won’t get diabetes mellitus. There is no explanation Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 89
    • regarding insulin resistance in Ayurveda. Even in some recent literary works medo dhatwagni iscorrelated with insulin. But, no proves are available for exact co-relation. If we see thepathology, we can see that the concept of Agni plays a great role i.e. Agni mandya is consideredto play key role in the formation of aparipakwa Dosha and dushyas which is the main defectbehind Madhumeha. The other factors responsible for manifestation of the DM are -i) Obesity Obesity is an extremely important environmental factor in the formation of type IIdiabetes. Approximately 80% of type II debates are obese. In this, the impaired binding is aresult of decrease in the number of insulin receptors. Ayurveda authors have given importance to the medovaha srotas in the pathogenesis ofMadhumeha. In classics it is mentioned that vapavahana is the moola sthana of medovaha srotas,and which can be considered as pancreas. But there is no much description in Ayurvedic classicsregarding vapavahana. Charaka has explained that the vapa vahana is an udarasthaanga and healso says, it is having the shape of taila varti. So on the basis of this physio-anatomical similarity,we can co-relate the vapavahana with pancreas. But kloma also considered as pancreas by someauthors of Ayurveda. As pipasa mentioned as a kloma vikriti lakshana, which is the maincharacteristics of the Madhumeha, here it can also co-relate with the pancreas.ii) Amylin Among the pathological changes, which are happening in type II diabetes, the mostconsistent of these changes is probably deposition of amyloid, which is accompanied by atrophyof the normal tissue, particularly Islet epithelial cells. In more advanced lesions, the Islet is moreor less converted to amyloid and the reduction in the number of insulin secreting cell is more Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 90
    • pronounced than that of glucagons-secreting cells. Heavy deposition of amyloid itself is rarewithout diabetes. In normal state sthiratwa, dardya, utasaha, vrishada, buddhi, etc are contributed by kapha,which is also known as bala or oja. By seeing this we can co-relate this Kapha with glucose. InMadhumeha the Kapha which is vitiated and which is in bahu dravata form travels all over thebody in rasa produces tanu madhuryata, which can be taken as hyperglycemia i.e. increasedblood glucose condition. Also in the Samprapti we can see the word vasti. In Ayurveda it has been used indifferent contexts in different meaning i.e. as bladder, whole urinary tract and also kidney.Sushrutaacharya says nabhi prishta madhyaha vasti. Anatomically kidney and ureters are situatedin this region. Also he says, the term “vastau” which indicates the plural sense i.e. two kidneys.So, here an attempt is made to co-relate the pathogenic factors mentioned in Ayurveda and inmodern science. To prove the above ideas correctly, further studies are needed.ETIOLOGY OF DIABETES MELLITUS 119 A defective or deficient insulin secretary response, which translates in to impairedcarbohydrate use, is a characteristic feature of diabetes mellitus and resulting intohyperglycemia. The chronic hyperglycemia of diabetes in associated with long-term damage,dysfunction and failure of various organs like Eyes, Kidney’s, Nerves, Heart and Blood vessels.Genetic factors: - Genetic factors are even more important than Types I diabetes. Among identical twins theconcordance rate is 60% to 80% in first-degree relatives with type II diabetes the risk ofdeveloping disease is 20% to 40%. The two main defects that characterized in type II diabetes Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 91
    • are – a) derangements in the beta cell secretion of Insulin and the b) decreased response ofperipheral tissues to respond to Insulin.Obesity: - Among the initiating events, which are proposed for type II diabetes. Obesity is anextremely important environmental factor. Approximately 80% of type II diabetes is obese.Obesity is one of the major causative factors for diabetes mellitus as it causes insulin resistance.In Ayurveda, sthoulya is mentioned as a Nidanarthaka roga for prameha, and this prameha fallsunder the santarpanajanya vyadhis.Age: - As the age advances the number of beta cells in pancreas, which produce insulin getsreduced. So the risk of diabetes increases with age especially after 40 years.Sedentary life: - People with sedentary life style are more likely to have diabetes are compared tothose who lead an active life. It is believed that exercise and physical activity increase the effectof insulin on the cells.Hereditary: - Warren and Le Compet , a famous Diabetalogist, when both the parents have diabetes, allthe children may expect to develop the disease, if they live long enough. When one parent hasdiabetes and the other is diabetic carrier, 40% of their children may develop the disease. If adiabetic or a carrier marries an individual who neither has diabetes nor a diabetic carrier none ofthe children with have diabetes. Madhura, Snigdhadi, Bhojana are the main Nidana’s for Madhumeha, in contemporaryscience it is explained that the excess eating and sedentary life style are the predisposing factorsfor diabetes mellitus. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 92
    • CLASSIFICATION OF DIABETES MELLITUS 120 The current expert committee of American diabetes association has proposed changes to the NDOG/WHO classification scheme. The revised Etiologic classification of diabetes mellitus is as follows -I) Primary Diabetes Type I: - Beta-cell destruction, usually leading to absolute insulin Primary deficiency. a) Immune mediated b) IdiopathicII) Type II diabetes (may range from predominantly insulin resistance with relative deficiency toa predominantly secretary defect with insulin resistance. Under this type II again 2 types can be seen 1) None obese NIDDM 2) Obese NIDDM Genetic defects of beta cell function including maturity on set diabetes of young known as MODYIII) Other specific types A) Genetic defect of beta cell function a) Chromosome 12, HNF – 1 Alpha (MODY S) b) Chromosome 07 Glucokinse (MODY 2) c) Chromosome 20 HNF 4 Alpha (MODY 1) d) Mitochondral DNA e) Others B) Genetic defects in insulin action: - Type 4 insulin resistances, Lepsechaunism, Rabson Mendenhall Syndrome. Lipoatrophic diabetes and others. B) Disease of exocrine pancreas: - Pancreatic pathology Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 93
    • a) Pancreatitis b) Hemochromatosis c) Fibrocalculous d) Neoplastic Disease e) Pancreactetomy f) Cystic fibrosis and others. D) Iaotrogenic: - Drug induced or chemical induced. a) Glucocorticoids b) Thiazides c) Alpha – Intrferon d) Thyroid Hormone. F) Endocrinopathies: - Endocrine disease induced. a) Cushing’s Syndrome b) Acromegaly c) Thyrotoxicosis d) Phaeoc hromocytoma e) Glucogonoma. G) Infections: - • Congenital rubella • Cytomegalo virus and others H) Other genetic syndromes sometimes associated with diabetes. a) Dawn’s syndrome, b) Klenefelter’s syndromes etc. I) Gestational Diabetes Mellitus (GDM)Etiologic Classification of Diabetes MellitusI. Type 1 diabetes (β-cell destruction, usually leading to absolute insulin deficiency) A. Immune-mediated B. IdiopathicII. Type 2 diabetes (may range from predominantly insulin resistance with relative insulin deficiency to a predominantly insulin secretory defect with insulin resistance) Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 94
    • III. Other specific types of diabetes A. Genetic defects of β-cell function characterized by mutations in: 1. Hepatocyte nuclear transcription factor (HNF) 4α (MODY 1) 2. Glucokinase (MODY 2) 3. HNF-1α (MODY 3) 4. Insulin promoter factor (IPF) 1 (MODY 4) 5. HNF-1β (MODY 5) 6. Mitochondrial DNA 7. Proinsulin or insulin conversion B. Genetic defects in insulin action 1. Type A insulin resistance 2. Leprechaunism 3. Rabson-Mendenhall syndrome 4. Lipoatrophic diabetes C. Diseases of the exocrine pancreas⎛pancreatitis, pancreatectomy, neoplasia, cystic fibrosis, hemochromatosis, fibrocalculous pancreatopathy D. Endocrinopathies⎛acromegaly, Cushings syndrome, glucagonoma, pheochromocytoma, hyperthyroidism, somatostatinoma, aldosteronoma E. Drug- or chemical-induced⎛Vacor, pentamidine, nicotinic acid, glucocorticoids, thyroid hormone, diazoxide, β-adrenergic agonists, thiazides, phenytoin, α-interferon, protease inhibitors, clozapine, beta blockers F. Infections⎛congenital rubella, cytomegalovirus, coxsackie G. Uncommon forms of immune-mediated diabetes⎛"stiff-man" syndrome, anti-insulin receptor antibodies H. Other genetic syndromes sometimes associated with diabetes⎛Downs syndrome, Klinefelters syndrome, Turners syndrome, Wolframs syndrome, Friedreichs ataxia, Huntingtons chorea, Laurence-Moon-Biedl syndrome, myotonic dystrophy, porphyria, Prader-Willi syndromeIV. Gestational diabetes mellitus (GDM) Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 95
    • Apart from many classifications - Susruta 7 fold classification has much importance tounderstand the disease Madhumeha. Adibala Pravrutta Janmabala Pravrutta Doshabala Pravrutta Sanghatabala Pravrutta Kalabala Pravrutta Daivabala Pravrutta Swabhavabala Pravrutta Matruja Madhumeha – probably developed because of Matruja beeja avayava Medo vikruti – kostanga – kloma (Pancreas-?) Pitruja Madhumeha – Asthi beeja avayava – Acetylcholine – citrus acid cycle disturbance – neo glycolysis - ketone bodies Genetically influenced Madhumeha – where Beeja – Beeja bhaaga avayava are influenced to give rise MM child The genetics and involvement of Genes are even though not new – medically to treat a patient of Shisava MM is not possible. But “Eugenics” – is provided by the Ayurveda to combat the disease to eradicate or to avoid “predominance” of Beeja – Pumsavana - sadvrutta etc. Apart from this the colonial prophylaxis management as – Atulya Grotriya is followed. Rasakruta (Apatarpanajanaya MM) & Douhrudapacharaja (Santarpanajanya MM) Rasakruta MM is, where mother irregular food habits or lack of food or incapacities of taking food leaves an impression over the baby to develop accumulation of food for Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 96
    • future use habituated to develop as Juvenile DM. – 2nd World war impression overGerman populationDouhrudapacharaja literally mother’s deviated habits influence the baby for derangedsegregations of Shareera Kleda (Blood Sugar) to develop JDM as result of impairedmetabolic functionsAmashaya Samutha MM & Pakwashaya Samutha MMWe always behind the Dosha and Dhatu, which are altering all the time to target for anyillness in the body. Off course the Dosha are dependent over the food and digestion.The pre digestive manifested MM and post digestive manifested MM has to bedifferentiated before treatmentShastra (armed fight) and Vyala (animal) should be concerned to exogenous causes ofMMViral DM is said to be a new invention in contemporary but the Krimija MM even thoughnot classified, its existence is proved through usage of Anti retroviral management inMM.Seasonal influences are common in manifestation of disease. This cause Agnidisturbances. The MM of seasonal variations dependent on food habits which are ofexternal causes implies influence on shareera kleda to cause Amashaya samutha MMwith apakwa rasa kleda. In some seasons sugar levels alters to high and low even – as wesee in summer hypoglycemia – so as the usage of madhura rasaIn it Vidud-ashanikruta – is said to be any external shock referred to execute electricalimpulses that disturb the body environment and cause Hyper or Hypoglycemia Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 97
    • Pishacha once again fingers towards the infectious origins - which could be sudden or communicated viral or Bacterial origins could occur either by contact or epidemiological or transfusion In this the diseases manifested during the un time/time schedule routine course pathological conditions are discussed – like gestational DM etc which may ultimately leads to precipitate MM/DM permanently as marker In the old age hypoglycemia (Vata) and children with hyperglycemia (Kapha) are common Sahaja MM is Krusha – Rooksha – Alpashi – Always Parisarana sheela (hyperactive) - is not indicated with any elimination but to treat with “Samskruta Annpana” pathya – transformed food regulations and Samshamana chikitsa – palliative management – along with diseases or conditions associated to even treat is indicated. Apathya nimitta MM is Sthoola – snigdha – wants comforts of food and sleep – is to be treated with Apatarpana Chikitsa – Samshodhana following the “Samutha Vishesha” as either with Vamana in case of Amashaya samutha and Virechana fro Pakwashaya samutha MM A comparative statement of Madhumeha and DMMadhumeha Diabetes Mellitus1) Margavarana Janya madhumehi NIDDM patient is obese, so diet exerciseis sthoola & balavan so apatarpana and oral hypoglycemics (sometimes insulinchikitsa in the form of langhana & also)Nidana parivarjana2) Dhatu Kshaya Janya madhumehi is IDDM – patient is thin so insulin therapyKrusha & durbala hence santarpanaChikitsa. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 98
    • Clinical Features of DM The classical triad of diabetes symptoms is polyuria, polydipsia and polyphagia, whichare, respectively, frequent urination; increased thirst and consequent increased fluid intake; andincreased appetite. Symptoms may develop quite rapidly (weeks or months) in type 1 diabetes,particularly in children. However, in type 2 diabetes the symptoms develop much more slowlyand may be subtle or completely absent. Type 1 diabetes may also cause weight loss (despitenormal or increased eating) and irreducible fatigue. These symptoms can also manifest in type 2diabetes in patients whose diabetes is poorly controlled 121. When the glucose concentration in the blood is raised beyond the renal threshold,reabsorption of glucose in the proximal renal tubuli is incomplete, and part of the glucoseremains in the urine (glycosuria). This increases the osmotic pressure of the urine and inhibits thereabsorption of water by the kidney, resulting in increased urine production (polyuria) andincreased fluid loss. Lost blood volume will be replaced osmotically from water held in bodycells, causing dehydration and increased thirst. Prolonged high blood glucose causes glucose absorption, which leads to changes in theshape of the lenses of the eyes, resulting in vision changes. Blurred vision is a commoncomplaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of rapidvision change whereas type 2 is generally more gradual, but should still be suspected. Patients (usually with type 1 diabetes) may also present with diabetic ketoacidosis(DKA), an extreme state of metabolic dysregulation characterized by the smell of acetone on thepatients breath; a rapid, deep breathing known as Kussmaul breathing; polyuria; nausea;vomiting and abdominal pain; and any of many altered states of consciousness or arousal (suchas hostility and mania or, equally, confusion and lethargy). In severe DKA, coma may follow, Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion 99
    • progressing to death. Diabetic ketoacidosis is a medical emergency and requires hospitaladmission. A rarer but equally severe possibility is hyperosmolar nonketotic state, which is morecommon in type 2 diabetes and is mainly the result of dehydration due to loss of body water.Often, the patient has been drinking extreme amounts of sugar-containing drinks, leading to avicious circle in regard to the water loss. It is very difficult to sketch with brevity the diverse clinical presentation of diabetesmellitus. Only a few characteristic patterns will be presented. The type II (NIDDM) diabetespresent with polyuria, polydipsia but unlike type I diabetes patients are often older andfrequently obese. Some times weakness or weight loss also noted. Apart from these featuresothers like, polyphagia, pruritis vulvae, glycosuria, infections, delayed healing of wounds,impotency, are also noted. Polyuria is due to the osmotic diuretic effect of glucose in kidney tubules. The glycosuriainduces an osmotic diuresis and thus polyuria, causing a profound loss of water and electrolytes. The obligatory renal water loss combined with the hyper osmolarity resulting from theincreased levels of glucose in the blood tends to deplete intracellular water, triggering theosmoreceptors of the thirst centers of the brain. In this manner intense thirst (polydipsia)appears. The catabolism of proteins and fat tends to induce a negative energy balance, which inturn leads to increasing appetite, i.e. polyphagia. Despite the increased appetite, catabolic effectsprevail, resulting in weight loss and muscle weakness. Frequently, however the diagnosis madeafter routine blood or urine testing mainly in asymptomatic persons. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion100
    • Whenever the quantity of glucose entering the kidney tubules in the glomerular, filtrate risesabove approximately 225 mg/min, a significant proportion of the glucose begins to spill in to theurine and when the quantity increases above about 325 mg/min, which is tubular maximum forglucose. All the excess, above this is lost in to urine (Glycosuria) 122. A comparative study of madhumeha lakshanas with the Diabetes mellitus explained inthe modern science reveals a lot of similarities between them. Prabhoota avila mootrata isconsidered as a prathyatma lakshana of Prameha. In this the bahudrava Kapha along with otherdooshyas mainly kleda pradhana dooshyas in the vasti is the cause for prabhoota mootrata. Thesame reason has been given in modern science for polyuria that the osmotic diuretic affects ofglucose in the kidney tubules. Glycosuria explained in the modern science can be taken as madhusama mootra. Thereason for this madhusama mootra is bahudrava kapha or ojus (Glucose), which is excretedthrough moootra. Pipasa or polydipsia mentioned in both sciences. Depletion of intracellular watertriggering the osmoreceptors of thirst center of brain and thirst is noted which is similar to pipasaof Ayuredic science, here due to excessive loss of the urine; pipasa is noted. Bahukankshata has been mentioned as a lakshana in apathya nimittaja madhumeha, thesame in modern science in terms of polyphagia. In modern science the condition weakness is due to lack of glucose utilization, loss ofelectrolyte and protein loss. In Ayurveda this same condition is due to aparipakwa dhatus i.e.,lack of proper nourishment of dhatus. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion101
    • By considering the above similarities, we can come to a conclusion that Madhumehaexplained in Ayurvedic science and the diabetes mellitus mentioned in the modern science arealmost similar condition. Patients with diabetes mellitus commonly complain of gastrointestinal symptoms,including chronic abdominal pain and bowel dysfunction, for which there is no structural cause124-134. It is now widely recognized, although only relatively recently, that complicationsinvolving the gastrointestinal tract represent an important cause of morbidity in patients with 135-136diabetes mellitus . However, epidemiological studies of these problems remain sparse andthe data are conflicting. In addition, aspects of quality of life have attracted increased interest inthe past few years, as it has been shown that gastrointestinal problems can impair well-being anddaily life in diabetes.COMPLICATION OF DIABETES MELLITUS 137 Some upadravas can be correlated to some of the complications of modern sciences fore.g.- thrishna, bhrama, shoola, tamapravesha, swasa etc with that of the ketoacidosis in which allthese symptom are seen and even in hypoglycemic condition also. It can be classified into twogroups 1) Acute complications: - a) Metabolic – Ketoacidosis, Hyper Osmolar non Ketotic coma, lactic acidosis b) Infective apisodes of RIT, UTI, Skin etc., c) Surgical complications – Gangrene, Carbuncles 2) Chroni Complications: - a) CVS – Premature altheroma, Ischaemic or CHD – Thromibosis, HT, Claudication etc Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion102
    • b) Nervous System – CVD, Peripheral neuropathey, Sensory and motor neuropathises. c) Excretory System – Recurrent UTI, RF, Chronic polynephritis d) Eyes – Cataracts, Retinopathy e) Respiratory System – Pulmonary kocks f) Digestive System – Stomatitis, Dental sepsis, fatty filtration of lives g) Bones and Joints – Osteoporosis, Frozen shoulder on, Neuropathic joints h) Skin – Monitial infections, trophic ulcers, carbuncles i) Gonad possible hormon changes.Epidemiologic Determinants and Risk Factors of Type 2 DiabetesGenetic factors Genetic markers, family history, "thrifty gene(s)"Demographic characteristics Sex, age, ethnicityBehavioral and lifestyle-related risk factors Obesity (including distribution of obesity and duration) Physical inactivity Diet Stress Westernization, urbanization, modernizationMetabolic determinants and intermediate risk categories of type 2 diabetes Impaired glucose tolerance Insulin resistance Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion103
    • Pregnancy-related determinants (parity, gestational diabetes, diabetes in offspring of women with diabetes during pregnancy, intrauterine malnutrition or overnutrition) 138PHYSICAL FINDINGS & CLINICAL PRESENTATION 1) Physical examination varies with the presence of complications and may be normal in early stages. 2) Diabetic retinopathy: a. Nonproliferative (background diabetic retinopathy): (1) Initially: microaneurysms, capillary dilation, waxy or hard exudates, dot and flame hemorrhages, AV shunts (2) Advanced stage: microinfarcts with cotton wool exudates, macular edema b.Proliferative retinopathy: characterized by formation of new vessels, vitreal hemorrhages, fibrous scarring, and retinal detachment 3. Cataracts and glaucoma occur with increased frequency in diabetics. 4. Peripheral neuropathy: patients often complain of paresthesias of extremities (feet more than hands); the symptoms are symmetric, bilateral, and associated with intense burning pain (particularly during the night). a. Mononeuropathies involving cranial nerves III, IV, and VI, intercostal nerves, and femoral nerves are also common. b. Physical examination may reveal: 1. Decreased pinprick sensation, sensation to light touch, and pain sensation. 2. Decreased vibration sense. 3. Loss of proprioception (leading to ataxia). 4. Motor disturbances (decreased DTR, weakness and atrophy of interossei muscles); when the hands are affected, the patient has trouble picking up small objects, dressing, and turning pages in a book. 5. Diplopia, abnormalities of visual fields. 5. Autonomic neuropathy: a. GI disturbances: esophageal motility abnormalities, gastroparesis, diarrhea (usually nocturnal) b. GU disturbances: neurogenic bladder (hesitancy, weak stream, and Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion104
    • dribbling), impotence. c. Orthostatic hypotension: postural syncope, dizziness, lightheadedness 6. Nephropathy: pedal edema, pallor, weakness, uremic appearance. 7. Foot ulcers: occur frequently and are usually secondary to peripheral vascular insufficiency, repeated trauma (unrecognized because of sensory loss), and superimposed infections. 8. Neuropathic arthropathy (Charcot’s joints): bone or joint deformities from repeated trauma (secondary to peripheral neuropathy). 9. Necrobiosis lipoidica diabeticorum: plaquelike reddened areas with a central area that fades to white-yellow found on the anterior surfaces of the legs; in these areas the skin becomes very thin and can ulcerate readily . 139In a nut shell - Ahara consumed -• Prabhoota (more than 4 Anjali - Dushya dravibhootata) – Avila (Samala) - Madhura (Kleda- Ojas) Mootra as common symptoms are developed due to – Shareera kleda (blood sugar) added to urine as – glycosuria is “Pratyatma Niyata Lakshana” requires management• Usually the MM patient is with – impaired Agni where in pathology has transformed meda as mootra and the tejas of it augment Kleda with Abhishyanna Deha – Drava Pradhana deha• Absorbed from Amashaya (Madhura rasa ahara) = Amashaya samutha MM = Vamana indicated• Food absorbed and transformed at Pakwashaya (Madhura vipaka ahara) = Pakwashaya samutha MM = Virechana indicated• Rasa nimittaja or santarpana janya or Apathya nimittaja MM is pathological state of excess rasa in shareera as (Dhatu vruddhi) understood as intracellular glucose excess (many times we are not considering this condition) Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion105
    • • Excess is mala always – so the excess rasa from the dhatu is brought in to system (interstitial glucose excess) to name as – Shareera Kleda (Blood glucose) • Shareera kleda along with “Apdhatu” is filtered by Mootravaha srotas to get Madhura Mootra where the re-absorption capacities of “Vrukka” or Shareera is failed • Excess kleda (glucose) attracts 16 molecules of water so as to get Prabhoota and Avila Mootra in MM – thus the Baddhamootra drvaya along with Amedaskara as palliative managementDiscussion on demographic data Because of decrease in beta cells the risk of diabetes increases as age advances;especially after 40 years. It is well recorded fact that, the NIDDM occurs only after 3rd decade oflife. In this study, the above factors were proved, as all the patients were between the age groupof 30 to 62, suggestive of the age relation stress advancements and comforts at age advancementsto cause the Madhumeha. This reveals that maximum prevalence of the disease is at Madhyamavayastha because at this stage of age there is natural aggravation of Vata started and normaldigestion / metabolism going to hamper. These findings were related to the recent statistical data,which shows that the onset of type II diabetes mellitus in the forties is most common. Majority of the patient in the present study belongs to Hindu community i.e. 100%, but itdoes not mean that Hindus are prone to this disease. This may be due to the local dominance ofHindu religion. Susruta had said that women would not get Madhumeha; because their body gets cleanedevery month by the raja pravrutti. But it is seems as a controversial dialogue as women alsogetting Madhumeha and they are also at high risk of getting diabetes compared to men after Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion106
    • 30years, especially after the pregnancy or at the time of pregnancy. In this study a majority of thepatients were male when compared to female, as shown in results chapter. Majority numbers of patients were Active type of occupation. In sedentary type ofoccupation physical activities are very less, it is clearly mentioned that people with sedentary lifestyles more prone to diabetes mellitus or Madhumeha. But in the present study majority ofpatients were recorded with active life styles. In the present study 43% patients had family history and rest of the 57% patients had nofamily history of Madhumeha. Even though hereditary factor is a well proven subject, here thefamily history has equal distributions in comparison with no family history. In the manifestation of Madhumeha food habits had great importance. If we check theNidana aspects we can see the importance of food habits. At the same time lot of foods are alsomentioned which are helpful in controlling Madhumeha. In the present study majority patientswere mixed diet practitioners. From these we can see that high calorie intake is the main riskfactor for diabetes. Economics makes ones to susceptible for comforts. Majority of patients belongs tomiddle and upper middle class, exhibiting richness. In these classes the people indulge in verystress life along with much physical activities and ultimately remain to anxiety life styles to getthe a Madhumeha vis-à-vis Diabetes Mellitus.Discussion on diseases components Almost all the symptoms of the presenting complaints enumerated in the study areobserved here to understand the disease entity. Prabhoota mootrata (30 patients), Dourbalya (27patients), loss of weight (1 patient), janghamamsagraha (17 patients), karapadadaha (21 patients), Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion107
    • Pipasa (30 patients) and Kshudha adhikyata (27 patients) are observed stating the cardinalsymptoms as polyuria, polydipsia and polyphasia. Almost all the associated symptoms of the presenting disease enumerated in the study areobserved here to understand the disease entity. Numbness of hands / feet - Kara/Pada suptata (11patients), Fatigue – Klama (23 patients), Stupor – Tandra (10 patients), Lethargic – Alasya (20patients), Heaviness – Gurugatratatwam (8 patients) and Dryness of mouth - Mukha/Talu shosha(17 patients) are observed in the study. Ayurveda texts offered many factors of aetiology, especially in regard with food. TheGuda, Dadhi and Snigdha padartha are said as causes are observed maximum in the study. Manyregimens are told in Ayurveda, out of which Avyayama and Diwaswapna along with Chinta andVegarodha are observed here in the study. The Poorva roopa mentioned in Ayurveda areobserved here in the study. Paada Daha and Trishna are observed more. Out of different srotasincluded in the study explicit new dimensions. Out of Udakavaha srotas – Pravruddha Pipasa,Jihwa and talu sosha, in Mootravaha srotas – Adhika Mootrata, in Medovaha srotas the Pipasaare observed in the study. It conform the involvement of these srotases.Effect of Bhunimbadi yoga in Madhumeha The drugs selected for the trial mainly having Tikta, Kasaya, Katu Rasa Usna Veerya andLaghu, Ruksa Guna, Katu Vipaka and Kaphavatahara properties and each one is indicated inPrameha Cikitsa. Thus Usna Veerya and Tikta Kasaya Rasa helps to normalise the function ofJathragni and Dhatwagni. That in turn helps to form the Dhatus in proper proportion withSamyak qualities. Laghu Ruksa Guna helps for the Sosan of Bahudrava Shlesma and reductionof vitiated Meda Kleda. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion108
    • Thus once these factors get normalized in the body they in turn make clear the Path ofVata which stops the depletion of vital Dhatus and restore normal physiology. Thus diseaseMadhumeha get Alleviate. The result of the Bhunimbadi yoga is representing the efficiency of the drug with itsembedded qualities in group A i.e. (Receives the standard dose of 500mg TDS Bhunimbadiyoga) as - is 1 (7%) Regulated, 3 (20%) palliative, 4 (27%) responded and 7 (47%) notresponded in the trial. The result of the Bhunimbadi yoga is representing the efficiency of thedrug with its embedded qualities in group B i.e. (Receives 1 gm. TDS Bhunimbadi yoga) as - is 6(40%) responded and 9 (60%) not responded in the trial. There are neither palliative norregulated patients in Group B. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Discussion109
    • Chapter 7 Conclusion• When the practicality is to be achieved, contemporary medical practitioners are unable to understand the pathogenesis of the Madhumeha (Diabetes mellitus) in total.• Among Indian population approximately 6 Crores of Madhumeha (DM) patients are detected as so far. The Prameha (Madhumeha) which is prevalent all over the globe is misunderstood, as a disease dependent upon mere Insulin and pancreas.• The World Health Organization stated in 1998 that a 122 % rise in the number of adults with diabetes is projected by 2005, to reach 300 million adults worldwide. The cost of treating diabetes an associated complication exceeds $ 100 billion per year.• Finally it is necessary to conquer “The triumph of sugar over diabetes” as said by George Jean Nathan 1882–1958 by the present trial drug “Bhunimbadi Yoga”.• To understand the aetiology, patho-physiology, complications and management methods is necessary to emphasize the disease Madhumeha.• The word Madhumeha consists of two words, “Madhu” and “Meha”. Sayana highlighted the vatic nature of this ailment Madhumeha.• In Charaka Samhita, described Nirupasthambha Madhumeha but also the Avaranjanya Madhumeha which is a unique contribution of this Samhita.• Susruta typically mentioned the decoctions according to each type of Prameha and mentioned the body constitution and symptoms related to Sahaja and Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Conclusion110
    • Apathyanimittaja Prameha and used Ksaudrameha synonym to Madhumeha in Nidana 6th chapter.• The results are not much variant as the time schedule for the research is quite minimal and sample size is also marginal. There is a response to the drug is found and the purpose of understanding glucose metabolism in this protocol is successful.• Group A patients 47% not responded and Group B patients 60% not responded to the treatment. The responses in the both groups are marginal and 27% of Group A and 40% of Group B are responded for the Bhunimbadi yoga. Only 7% in Group A patients are regulated and 20% of Group A are Palliative.• Statistically the study is significant. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Conclusion111
    • Chapter 8 Summary• The word Madhumeha consists of two words, “Madhu” and “Meha”. Sayana highlighted the vatic nature of this ailment Madhumeha.• In Charaka Samhita, described Nirupasthambha Madhumeha but also the Avaranjanya Madhumeha which is a unique contribution of this Samhita.• Bhunimbadi yoga is one of the first "Hypoglycemic compounds" which is freely available in the market and provides extensive result among most Ayurvedic herbs. The composition and preparation of Bhunimbadi yoga is as follows – S.no Name of the Herb Latin name Proportion 1 Bhunimba Andrographis paniculata 1 part 2 Katuki Picrorhiza kurroa 1 part 3 Musta Cyprus rotandus 1 part 4 Triushana Equal parts of Piper longum, Piper 1 part nigram, Zingiber officinale 5 Indrayava 1 Holarrhena antidysenterica 1 part 6 Chitramoola Plumbago zylanica 2 parts 7 Vatsaka twak Bark of Holarrhena antidysenterica 16 parts• Group A patients 47% not responded and Group B patients 60% not responded to the treatment. The responses in the both groups are marginal and 27% of Group A and 40% of Group B are responded for the Bhunimbadi yoga. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Summary112
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    • 90. Rajeshwaradatta Sastri, Charaka Samhita, Part 1, sutra 17/80-81, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp 352-353 91. Ambikadatta shastri ed, Susruta Samhita, Part-I, Nidana, 6/27, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-255 92. Ravidatta Tripati ed, Charaka Samhita, Chikitsa, 6/47, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 177 93. Ravidatta Tripati ed, Charaka Samhita, Chikitsa, 6/16-18, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 171 94. Yadunandan Upadhyaya, Astanga Hridaya, Chikitsa, 12/8, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-372 95. Yadunandan Upadhyaya, Astanga Hridaya, Chikitsa, 12/8, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-372 96. Ravidatta Tripati ed, Charaka Samhita, Chikitsa, 6/37, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 174 97. Ambikadatta shastri ed, Susruta Samhita, Part-I, Chikitsa, 13/1-34, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-65-67 98. Ambikadatta shastri ed, Susruta Samhita, Part-I, Chikitsa, 11/6, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-6099. M.A.Iyengar, Study of Crude drugs, revised and enlarged 9th edition, 1999, PP38100. K.M.Nadkarni, Indian Materia Medica, 2nd edition, 1982, Published by Popular Prakashan Bombay, PP 101101. Ibid, 953102. Ibid, 428103. Bramha Shankar Mishra edited, Vidyotini commentary on Bhavaprakasha, Poorva Khanda 5/Hareetakyadi varga, sloka 60-61, Kashi Sanskrit series –130, Chaukhambha Sanskrit Sansthan, Varanasi, 2nd edition104. K.M.Nadkarni, Indian Materia Medica, 2nd edition, 1982, Published by Popular Prakashan Bombay, PP 643105. Ibid, 990106. Ibid, 634 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Bibliographic Referances vii
    • 107. Vempati Koteswara Shastri, Saharayoga (Telugu) with Subodhini Vyakhya, Churna Prakarana/ 114 sloka, 1st edition,1961, published by Andhra Ayurveda Parishat, Vijayawada, PP 139108. Cristofer Haslett, Adwin R. Chilvers et.al. Davidson’s Principles of Practice of Medicine, 19th edition, 2002; Daibetes mellitus by B.M. Frier, B.M. Fisher, PP 641109. Shiva Rama Prasad Kethamakka, Aetio-Pathology of Madhumeha, Ayurmedline, July- December 2000, PP 11-16110. Alvin C. Powers, Harrison medicine 333 chapter. DIABETES MELLITUS -111. Shiva Rama Prasad Kethamakka, Aetio-Pathology of Madhumeha, Ayurmedline, July- December 2000, PP 11-16112. Ravidatta Tripati ed, Charaka Samhita, nidana, 4/6, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, Chakrapani113. Ibid, Chikitsa 6/8114. Hemadri on A.H,.Su.12/2115. Ravidatta Tripati ed, Charaka Samhita, sutra, 20/8, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, chakrapani116. Shiva Rama Prasad Kethamakka, Aetio-Pathology of Madhumeha, Ayurmedline, July- December 2000, PP 11-16117. Cotran SR, Basic Pathology, 6th ed. 2003, Philadelphia Saunders, pp 913118. Davidson Stanely, Principles and practice of medicine, 1995, Churchill Livingstone, London, pp 728119. Cotran SR, Basic Pathology, 6th ed. 2003, Philadelphia Saunders, pp 913120. Diabetes mellitus, From Wikipedia, the free encyclopedia, ast modified 21:47, 21 November 2007121. Cotran SR, Basic Pathology, 6th ed. 2003, Philadelphia Saunders, pp 913-916122. Gastrointestinal Function in Diabetes Mellitus. Edited by Michael Horowitz and Melvin Samsom 2004 John Wiley & Sons, Ltd ISBN: 0-471-89916-X, pp1-2123. Katz LA, Spiro HM. Gastrointestinal manifestations of diabetes. N Engl J Med 1966; 275: 1350–61.124. Goyal RK, Spiro HM. Gastrointestinal manifestations of diabetes mellitus. Med Clin N Am 1971; 55: 1031–44. Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Bibliographic Referances viii
    • 125. Taub S, Mariani A, Barkin JS. Gastrointestinal manifestations of diabetes mellitus. Diabetes Care 1979; 2: 437–47.126. Feldman M, Schiller LR. Disorders of gastrointestinal motility associated with diabetes mellitus. Ann Intern Med 1983; 98: 378–84.127. Atkinson M, Hosking DJ. Gastrointestinal complications of diabetes mellitus. Clin Gastroenterol 1983; 2: 633–50.128. Yang R, Arem R, Chan L. Gastrointestinal tract complications of diabetes mellitus. Arch Intern Med 1984; 144: 1251–6.129. Niakan E, Harati Y, Comstock JP. Diabetic autonomic neuropathy. Metabolism 1986; 35: 224–34.130. Nompleggi D, Bell SJ, Blackburn GL, Bistrian BR. Overview of gastrointestinal disorders due to diabetes mellitus: emphasis on nutritional support. J Parent Ent Nutr 1989; 13: 84–91.131. Rothstein RD. Gastrointestinal motility disorders in diabetes mellitus. Am J Gastroenterol 1990; 85: 782–5.132. Locke GR III. Epidemiology of gastrointestinal complications of diabetes mellitus. Eur J Gastroenterol Hepatol 1995; 7: 711–16.133. Talley NJ, Hammer J, Giles N, Jones MP, Horowitz M. Measuring gastrointestinal symptoms in diabetes: development and validation of the Diabetes Bowel Symptom Questionnaire. Gastroenterology (abstr) 2001 (in press).134. Horowitz M, Fraser R. Disordered gastric motor function in diabetes mellitus. Diabetologia 1994; 37: 543–51.135. Horowitz M, Wishart JM, Jones KL, Hebbard GS. Gastric emptying in diabetes: an overview. Diabet Med 1996; 13: S16–22.136. Davidson Stanely, Principles and practice of medicine, 1995, Churchill Livingstone, London, pp 754-757137. Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001; 414:782787138. Ferris Clinical Advisor 2004: Instant Diagnosis and Treatment 6th edition (June 2003) By Fred F. Ferri By Mosby Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) – Bibliographic Referances ix
    • SPECIAL CASE SHEET FOR “Evaluation of the efficacy of Bhunimbadi Yoga in Madhumeha (Diabetes Mellitus)” POST GRADUATE STUDIES AND RESEARCH CENTER (KAYACHIKITSA) SHRI. D.G.M.AYURVEDIC MEDICAL COLLEGE, GADAGGuide: Dr. V.Varadacharyulu Scholar:Co - Guide: Dr. K. Shiva Rama Prasad Ashok I. Akki1) Name of the Patient Sl.No2) Gender Male Female OPD No3) Age Years IPD No4) Religion Hindu Muslim Christian Other5) Occupation Sedentary Active Labor6) Economical status Poor Middle Higher middle Higher class7) Address Pin8) Birth data Place of Birth AMDate Month Year Time Hours Minutes PM9) Selection Included Gr A Gr B Excluded10) Schedule dates Initiation Completion / Discontinuation11) Result Regulated Palliative Responded Not Responded INFORMED CONSENTI Son/Daughter/Wife of amexercising my free will, to participate in above study as a subject. I have been informed to mysatisfaction, by the attending physician the purpose of the clinical evaluation and nature of thedrug treatment. I am also aware of my right to opt out of the treatment schedule, at any timeduring the course of the treatment. EzÀÄ £Á£ÀÄ ²æÃ/²æêÀÄw _________________________________________________ £À£Àß ¸ÀéEZÀÑ ¬ÄAzÀ PÉÆqÀĪÀ aQvÁì ¸ÀªÀÄäw. ¥Àæ¸ÀÄÛvÀ £ÀqÉ¢gÀĪÀ aQvÁì ¥ÀzÀÞw0iÀÄ §UÉÎ £À£ÀUÉ aQvÀìPÀjAzÀ ¸ÀA¥ÀÇtð ªÀiÁ»w zÉÆgÉwzÀÄÝ ªÀÄvÀÄÛ 0iÀiÁªÁUÀ¯ÁzÀgÀÄ aQvÀì¬ÄAzÀ »AwgÀÄUÀ®Ä ¸ÁévÀAvÀæ÷å «zÉ JAzÀÄ w½¢gÀÄvÀÛ£É. gÉÆÃV0iÀÄ gÀÄdÄ / Patients Signature Bhun imbadi Yoga in Madhum eha (D iab e te s Mellitus) 1
    • 12) CHIEF COMPLAINTS WITH DURATION (Subjective Parameters) Complaints - Lakshana Duration Remarks1 Excess urination2 Turbid urination3 Weakness - Dourbalya4 Loss of weight - Shareera Bhaarahani5 Muscular cramps - Janghamamsagraha6 Burning feet and palm - Karapada Daha7 Thirst - Pipasa8 Excessive Hunger - Kshudhadhikyata13) ASSOCIATED COMPLAINTS Associated Complaints – Duration Remarks Anubandha Lakshana1 Numbness of hands / feet - Kara/Pada suptata2 Fatigue - Klama3 Stupor - Tandra4 Lethargic - Alasya5 Heaviness - Gurugatratatwam6 Dryness of mouth - Mukha/Talu shosha14) Occupational History (if any)15) PERSONAL HISTORYFood habits Vegetarian Mixed dietTaste preferred Sweet Sour Salty Pungent Bitter AstringentAgni Sama Vishama Manda TeekshnaKosta Mrudu Madhyama KruraNidra Day Night Sound DisturbedAddictions Tobacco Alcohol DrugsBowel habits Normal Loose ConstipatedMenstrual History Regular Irregular Amenorrhea MenopauseTreatment Other system medicationshistory (if any)GynaecologicalHistory (if any)History of pastillness (if any) Bhun imbadi Yoga in Madhum eha (D iab e te s Mellitus) 2
    • Family history – Specify if any has the same disease Brother Patient Sister Brother Father Sister Brother Mother Sister Grandfather Grandmother Grandfather Grandmother16) HISTORY OF PRESENT ILLNESSMode of detection Accidental / suspicious / At Regular check-upFrequency of Micturition 3-4 times / 5-6 times /7-8 times /9-10 times /Above 10 /17) Madhumeha Nidana Ahara Vihara AnyaMadhura Guda Avyayama Manishika- Chinta Navanna Diwaswapna Krimi Dugdha Swapna sukham VegavarodhaMamsa Gramya Sukhaaseenatwam Panchakarma Vibhramsha Anoopa AudukaSnigdha Nidanarthakara VyadhiDadhi SthoulyaSheeta18) Madhumeha PoorvaroopaDantadeenam Malatvam Mukha madhurta TrishnaPada daha Talu kloma shosha Maldhikyata in bahya chidraPani daha Kesh jatilata SwedadhikyaDeha chikkanata Nakha vriddhi Sheeta icchaShareera durgandha Alasya SwasaMutra madhurata Tandra ShitalangataMutra shuklata Nidra19) EXAMINATION(a) VitalsTemperature ºF Pulse / min Respiration rate / minHeight Cms Weight Kg Blood pressure mm Hg Bhun imbadi Yoga in Madhum eha (D iab e te s Mellitus) 3
    • (b) Examination of srotasUdakavaha Mootravaha Mamsavaha MedovahaJihwa shosha Alpalpa mootrata Arbuda SwedaTalu shosha Mootara rodha Arsha SnigdhanagataOsta shosha Adhika mootra Mamsa shosha SthulashophataKloma shosha Sashoola mootra Shira granthi PipasaPrawridha Basti stabdhatapipasa (c) Astasthana PareekshaNadi Dosha Mutra Pravrutti Gati Varna Purnata Gandha Spandana KathinyaJihwa Ardra Sushka Mala Sama Nirama Lepa NirlepaShabda Sparsha Sheeta UshnaDrik Akruti(d) Systemic Examination: (if any)20) Upashaya and AnupashayaUpashaya AnupashayaShita iccha UshnaMadhurrahit ahara Madhuara aharavyayama Diwa swapana21) UpadravasLakshanas LakshanasPrameha pidika AvipakaAtisara ChardiJwara KasaDaha pratishyayaArochaka22) INVESTIGATIONS Investigations for screeningUrine Routine Albumin Sugar Microscopic Bhun imbadi Yoga in Madhum eha (D iab e te s Mellitus) 4
    • 23) Assessment of Trail1) Subjective parameters Before After Follow-up Difference BA1 Avila Mootrata2 Dourbalya3 Janghamamsagraha4 Karapada Daha5 Pipasa6 Kshudhadhikyata2) Objective parameters1 Fasting Blood Sugar2 Post prandial Blood sugar3 Fasting Urine Sugar4 Post prandial Urine sugar5 Serum cholesterol6 Serum triglycerides7 Prabhoota Mootrata in ml8 Shareera Bhaarahani in Kg24) Treatment schedule (Group – A = 500mg TDS / Group – B = 1gm TDS) Day Date Investigator’s NoteDay 1Day 11Day 21Day 31Follow upDay 60Investigators Note Signature of Guide Signature of Scholar (Dr. K. Shiva Rama Prasad) (Ashok I. Akki) Bhun imbadi Yoga in Madhum eha (D iab e te s Mellitus) 5
    • Grades of assessment1) Avila Mootrata (Turbidity)Grade 0 = Crystal clear fluidsGrade 1 = faintly cloudy or hazy with slight turbidityGrade 2 = Turbidity clearly present but news print can be read through the tube.Grade 3 = More turbidity & news print can not be read.2) DourbalyaGrade 0 = No DourbalyaGrade 1 = occasionally noticedGrade 2 = periodically noticedGrade 3 = daily noticedGrade 4 = continuously noticed3) JanghamamsagrahaGrade 0 = No JanghamamsagrahaGrade 1 = occasionally noticedGrade 2 = periodically noticedGrade 3 = daily noticedGrade 4 = continuously observed6) Karapada DahaGrade 0 = No Karapada DahaGrade 1 = occasionally noticedGrade 2 = periodically noticedGrade 3 = daily noticedGrade 4 = continuously noticed7) PipasaGrade 0 = No PipasaGrade 1 = occasionally noticedGrade 2 = periodically noticedGrade 3 = daily noticedGrade 4 = continuously noticed8) KshudhadhikyataGrade 0 = No KshudhadhikyataGrade 1 = occasionally noticedGrade 2 = periodically noticedGrade 3 = daily noticedGrade 4 = continuously noticed Bhun imbadi Yoga in Madhum eha (D iab e te s Mellitus) 6
    • MS01A - Demographic Data of Bhunimbadi YogaSNo OPD Gender Religion Occupation Economical Result V/Mx Food Age No Condition M F H M C O S A L P M Hg Hc1 4050 + 43 M + + + Responded2 4136 + 60 V + + + NotResp3 4138 + 40 V + + + Responded4 4166 + 52 V + + + NotResp5 4288 + 48 M + + + Palliative6 4290 + 40 V + + + NotResp7 4292 + 31 V + + + NotResp8 4367 + 48 V + + + NotResp9 4369 + 46 M + + + Palliative10 4397 + 45 M + + + Regulated11 4592 + 44 M + + + NotResp12 4694 + 36 V + + + Palliative13 4697 + 48 M + + + Responded14 4691 + 40 M + + + Responded15 4696 + 43 V + + + NotRespTotal 15 MS01B - Demographic Data of Bhunimbadi YogaSNo OPD Gender Religion Occupation Economical Result V/Mx Food Age No Condition M F H M C O S A L P M Hg Hc1 3963 + 42 M + + + NotResp2 4049 + 50 V + + + NotResp3 4062 + 50 M + + + NotResp4 4137 + 50 M + + + Responded5 4150 + 52 M + + + Responded6 4287 + 32 M + + + NotResp7 4289 + 35 M + + + NotResp8 4291 + 40 V + + + NotResp9 4368 + 47 V + + + NotResp10 4378 + 59 M + + + Responded11 4403 + 53 M + + + Responded12 4692 + 42 M + + + Responded13 4695 + 35 V + + + Responded14 4690 + 38 V + + + NotResp15 4693 + 38 V + + + NotRespTotal NotResp Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Master charts i
    • MS02A - Subjective Statistical Assessment Data of Bhunimbadi YogaS.No OPD Avilamootrata Dourbalya Jangamamsa Karapada daha Pipasa Kshudhadhikyata graham B A B A B A B A B A B A1 4050 0 0 1 0 1 1 1 1 3 2 2 32 4136 0 0 3 1 2 1 0 0 3 2 2 23 4138 0 0 4 2 1 1 1 1 3 2 1 14 4166 0 0 0 0 0 0 0 0 3 2 0 05 4288 0 0 1 0 1 1 0 0 1 1 3 26 4290 0 0 1 1 3 3 3 3 3 2 4 37 4292 0 0 1 1 0 0 2 2 3 2 3 38 4367 0 0 2 1 1 1 1 1 3 2 3 39 4369 0 0 3 1 0 0 1 1 2 2 0 010 4397 0 0 3 1 0 0 3 1 3 1 1 111 4592 0 0 0 0 0 0 1 1 3 2 1 112 4694 0 0 1 1 0 0 0 0 4 2 3 213 4697 0 0 1 1 0 0 3 1 1 1 1 114 4691 0 0 1 1 3 2 3 3 3 3 4 415 4696 0 0 1 3 0 1 0 1 4 4 1 3Total 0 0 23 14 12 11 19 16 42 30 29 29Mean 0 0 1.53 0.93 0.8 0.73 1.26 1.06 2.8 2 1.93 1.93SD 0 0 1.18 0.79 1.08 0.88 1.22 0.96 0.87 0.75 1.33 1.22 MS02B - Subjective Statistical Assessment Data of Bhunimbadi YogaS.No OPD Avilamootrata Dourbalya Jangamamsa Karapada Pipasa Kshudhadhikyata graham daha B A B A B A B A B A B A1 3963 0 0 3 1 1 1 1 1 3 1 4 32 4049 0 0 4 1 0 0 1 1 3 2 3 33 4062 0 0 3 1 1 1 0 0 3 3 3 34 4137 0 0 1 1 1 1 3 2 3 3 4 45 4150 0 0 1 1 1 1 0 0 3 1 2 26 4287 0 0 3 1 0 0 0 0 3 1 4 37 4289 0 0 2 1 0 0 3 1 1 1 3 28 4291 0 0 3 1 3 1 3 2 1 2 1 19 4368 0 0 1 1 0 0 2 1 1 1 0 010 4378 0 0 3 1 2 1 3 2 1 1 2 211 4403 0 0 0 0 1 1 1 0 1 1 1 112 4692 0 0 3 1 0 0 1 1 3 2 1 113 4695 0 0 1 1 3 2 3 2 1 1 3 114 4690 0 0 2 1 3 2 3 2 2 1 1 115 4693 0 0 3 3 3 2 0 0 3 2 1 2Total 0 0 33 16 19 13 24 15 32 23 33 29Mean 0 0 2.2 1.06 1.26 0.86 1.6 1 2.13 1.53 2.2 1.93SD 0 0 1.14 0.59 1.22 0.74 1.29 0.84 0.99 0.74 1.32 1.09 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Master charts ii
    • MS03A - Objective Statistical Assessment of Bhunimbadi YogaS.No OPD Prabhuta Shareera FBS PPBS SCh STg FUS PPUS mootrata Bharahani (L) B A B A B A B A B A B A B A B A1 4050 4 3 70 68 201 190 260 200 180 160 142 138 0.5 0 1 0.52 4136 3.5 2.5 50 49 190 198 240 240 180 180 140 190 1 1 1.5 1.53 4138 3.8 3.5 51 51 198 195 218 200 190 180 160 146 1 0 1.5 1.54 4166 4.5 4 60 58 198 210 220 270 175 175 136 140 1 1 1.5 25 4288 4 3 60 58 180 190 340 230 198 195 200 200 1 1 2 26 4290 3.5 3 56 56 156 160 270 298 208 200 190 210 1 1 1.5 1.57 4292 4 4 58 57 190 198 280 288 198 198 198 189 0.5 0.5 1.5 1.58 4367 3 3 55 54 168 170 254 280 205 200 210 206 0.5 1 1.5 1.59 4369 3.5 3 62 60 148 120 200 138 200 205 191 190 0 0 1 0.510 4397 3 2.5 55 53 115 79 197 107 216 200 190 180 0 0 0.5 011 4592 4 3.5 70 67 190 206 225 250 260 250 200 230 0.5 0.5 1 112 4694 4 3.5 58 57 296 290 340 298 226 216 210 210 1.5 1 2 1.513 4697 4.5 4 60 58 233 205 297 290 285 281 260 260 1 1 1.5 214 4691 4.5 4 68 67 280 286 340 310 201 197 200 210 1.5 1.5 2 215 4696 3 3.5 61 60 240 280 298 324 210 205 260 266 1 1 1.5 1.5Total 56.8 50 894 873 2983 2977 3979 3723 3132 3042 2887 2965 12 10.5 21.5 20.5 3.78 3.35 59.6 58.2 198.86 198.46 265.26 248.2 208.8 202.8 192.4 197.6 0.8 0.7 1.43 1.36Mean 0.52 0.52 6.1 5.64 47.7 57.19 49.77 63.51 29.66 29.65 37.31 37.97 0.45 0.49 0.41 0.61SD MS03B - Objective Statistical Assessment of Bhunimbadi YogaS.No OPD Prabhuta Shareera FBS PPBS SCh STg FUS PPUS mootrata Bharahani B A B A B A B A B A B A B A B A1 3963 4 3.5 52 50 254 210 310 280 154 140 110 180 1.5 1 2 1.52 4049 3.5 3.5 56 53 208 200 272 260 212 136 152 176 1 1 2 1.53 4062 4 3.5 70 68 230 235 286 280 240 200 170 160 1 1 2 1.54 4137 3 2 56 55 205 196 220 200 210 200 156 150 0.5 0 1 15 4150 4.5 3 58 56 210 178 240 210 300 290 178 168 1 0 1.5 16 4287 4 3 50 47 120 117 270 260 201 196 190 186 0 0 1 07 4289 4 3 60 57 206 198 315 302 180 175 198 196 1.5 1 2 1.58 4291 4 3 57 55 215 200 370 360 200 195 205 200 1.5 1 2 1.59 4368 4 3.5 60 58 153 160 240 249 180 178 205 210 0.5 0 1 110 4378 3.5 3 54 53 107 105 319 290 198 196 198 210 0 0 1.5 111 4403 4 4 65 65 223 228 284 260 207 206 269 270 1 1 1.5 1.512 4692 4 3.8 58 56 280 270 370 340 290 279 280 266 1.5 1 2 1.513 4695 4 3 48 46 210 189 280 200 205 200 200 198 1 0.5 1.5 114 4690 4 3 51 49 260 240 310 298 201 198 198 198 1.5 1 2 1.515 4693 4 3.8 58 57 256 240 300 288 215 213 210 204 1 0.5 1.5 1Total 58.5 48.6 853 825 3137 2966 4386 4077 3193 3002 2919 2972 14.5 9 24.5 18 3.9 3.24 56.8 55 209.13 197.73 292.4 271.8 212.8 200.13 194.6 198.13 0.96 0.6 1.63 1.2Mean 0.33 0.49 5.7 5.98 49.3 44.93 42.92 46.15 38.43 40.89 42.01 33.53 0.51 0.47 0.39 0.41SD Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Master charts iii
    • MS04A - Chief & Associated complaints of Bhunimbadi Yoga Complaints 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 T1 Prabhoota 2 1 2 2 2 1 2 1 2 1 2 2 3 3 1 * Mootrata2 Avila Mootrata 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 *3 Dourbalya 1 3 4 0 1 1 1 2 3 3 0 1 1 1 1 *4 Shareera 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 * Bhaarahani5 Janghamamsagra 1 2 1 0 1 3 0 1 0 0 0 0 0 3 0 * ha6 Karapada Daha 1 0 1 0 0 3 2 1 1 3 1 0 3 3 0 *7 Pipasa 3 3 3 3 1 3 3 3 2 3 3 4 1 3 4 *8 Kshudhadhikyata 2 2 1 0 3 4 3 3 0 1 1 3 1 4 1 * Associated Complaints1 Kara/Pada + + + + + + 6 suptata2 Klama + + + + + + + + + + + + + 133 Tandra + + + + + + 64 Alasya + + + + + + + + + + 105 Gurugatrata + + + + + 56 Mukha/Talu + + + + + + + + 8 shosha MS04B - Chief & Associated complaints of Bhunimbadi Yoga Complaints 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 T1 Prabhoota 2 1 2 1 3 2 2 2 2 1 2 2 2 2 2 * Mootrata2 Avila Mootrata 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 *3 Dourbalya 3 4 3 1 1 3 2 3 1 3 0 3 1 2 3 *4 Shareera 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 * Bhaarahani5 Janghamamsagra 1 0 1 1 1 0 0 3 0 2 1 0 3 3 3 * ha6 Karapada Daha 1 1 0 3 0 0 3 3 2 3 1 1 3 3 0 *7 Pipasa 3 3 3 3 3 3 1 1 1 1 1 3 1 2 3 *8 Kshudhadhikyata 4 3 3 4 2 4 3 1 0 2 1 1 3 1 1 * Associated Complaints1 Kara/Pada + + + + + 5 suptata2 Klama + + + + + + + + + + 103 Tandra + + + + + + 64 Alasya + + + + + + + + + + 105 Gurugatrata + + + 36 Mukha/Talu + + + + + + + + + 9 shosha Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Master charts iv
    • MS05A - Upashaya/Anupashaya of Madhumeha Poorvaroopa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 T Upashaya1 Shita iccha + + + + + + + + + + + + + + + 152 Madhurrahit ahara 03 vyayama 0 Anupashaya1 Ushna 02 Madhuara ahara 03 Diwa swapana 0 MS05B - Upashaya/Anupashaya of Madhumeha Poorvaroopa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 T Upashaya1 Shita iccha + + + + + + + + + + + + + + + 152 Madhurrahit ahara 03 vyayama 0 Anupashaya1 Ushna 02 Madhuara ahara + + 23 Diwa swapana 0 MS06A - Poorvaroopa of Madhumeha Poorvaroopa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 T1 Dantadeenam 0 Malatvam2 Pada daha + + + + + + 63 Pani daha + + + + 44 Deha chikkanata + + + 35 Shareera durgandha + + 26 Mutra madhurata 07 Mutra shuklata + 18 Mukha madhurta + + 29 Talu kloma shosha + + + 310 Kesh jatilata 011 Nakha vriddhi 012 Alasya + + + + + 613 Tandra + + + + + + + + 814 Nidra + + 215 Trishna + + + + + + + + + + + + + 1316 Maldhikyata in bahya + 1 chidra17 Swedadhikya + + + 318 Sheeta iccha + + + + + + 619 Swasa 020 Shitalangata 0 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Master charts v
    • MS06B - Poorvaroopa of Madhumeha Poorvaroopa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 T1 Dantadeenam 0 Malatvam2 Pada daha + + + + + + + + + + + 113 Pani daha + + + + + + + + 84 Deha chikkanata + + + + + 55 Shareera durgandha 06 Mutra madhurata + + 27 Mutra shuklata 08 Mukha madhurta + + 29 Talu kloma shosha + 110 Kesh jatilata 011 Nakha vriddhi 012 Alasya + + + + + + + + 813 Tandra + + + + + + + 714 Nidra 015 Trishna + + + + + + + + + + + + + 1316 Maldhikyata in bahya 0 chidra17 Swedadhikya + + + + + + + + 818 Sheeta iccha + + + + + + 619 Swasa 020 Shitalangata + + 2 MS07A - Upadrava of Madhumeha Poorvaroopa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 T1 Prameha pidika 02 Atisara 03 Jwara 04 Daha + 15 Arochaka 06 Avipaka 07 Chardi 08 Kasa 09 pratishyaya 0 MS07B - Upadrava of Madhumeha Poorvaroopa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 T1 Prameha pidika 02 Atisara 03 Jwara + 14 Daha + + + 35 Arochaka 06 Avipaka 07 Chardi + 18 Kasa 09 pratishyaya 0 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Master charts vi
    • MS08A - Examination of srotas Sroto Lakshana 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 T Udakavaha1 Jihwa shosha + + + + + + + + + + + + 122 Talu shosha + + + + + + + 73 Osta shosha 04 Kloma shosha 05 Prawridha pipasa + + + + + + + + + + + + + 13 Mootravaha1 Alpalpa mootrata 02 Mootara rodha 03 Adhika mootra + + + + + + + + + + + + + + + 154 Sashoola mootra 05 Basti stabdhata 0 Mamsavaha1 Arbuda + 12 Arsha 03 Mamsa shosha 04 Shira granthi 0 Medovaha1 Sweda + + + + + 52 Snigdhanagata 03 Sthulashophata 04 Pipasa + + + + + + + + + + + + + + 14 MS08B - Examination of srotas Sroto Lakshana 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 T Udakavaha1 Jihwa shosha + + + + + + + + + + + 112 Talu shosha + + + + + + 63 Osta shosha + 14 Kloma shosha 05 Prawridha pipasa + + + + + + + + + + + 11 Mootravaha1 Alpalpa mootrata 02 Mootara rodha 03 Adhika mootra + + + + + + + + + + + + + + + 154 Sashoola mootra 05 Basti stabdhata 0 Mamsavaha1 Arbuda 02 Arsha 03 Mamsa shosha 04 Shira granthi 0 Medovaha1 Sweda + + + + + + + + + + 102 Snigdhanagata 03 Sthulashophata 04 Pipasa + + + + + + + + + + + + + + 14 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Master charts vii
    • MS09A - History of present IllnessS.No OPD Mode of detection Frequency of Micturition Family history 1 2 3 1 2 3 4 5 Present Absent1 4050 + + +2 4136 + + +3 4138 + + +4 4166 + + +5 4288 + + +6 4290 + + +7 4292 + + +8 4367 + + +9 4369 + + +10 4397 + + +11 4592 + + +12 4694 + + +13 4697 + + +14 4691 + + +15 4696 + + +Total 9 4 2 0 10 5 0 0 5 10 MS09B - History of present IllnessS.No OPD Mode of detection Frequency of Micturition Family history 1 2 3 1 2 3 4 5 Present Absent1 3963 + + +2 4049 + + +3 4062 + + +4 4137 + + +5 4150 + + +6 4287 + + +7 4289 + + +8 4291 + + +9 4368 + + +10 4378 + + +11 4403 + + +12 4692 + + +13 4695 + + +14 4690 + + +15 4693 + + +Total 7 4 4 2 5 8 0 0 8 7 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Master charts viii
    • MS10A - Ahara NidanaS.No OPD Guda Navanna Dugdha Gramya Anoopa Auduka Snigdha Dadhi Sheeta Mamsa Mamsa Mamsa Ahara Ahara1 4050 + + + + +2 4136 + + +3 4138 + + + +4 4166 + + + +5 4288 + + + + + +6 4290 + + + + +7 4292 + + +8 4367 + + +9 4369 + + + + +10 4397 + + + + +11 4592 + + + + +12 4694 + + + + +13 4697 + + + + +14 4691 + + + + + + +15 4696 + + + +Total 12 5 7 6 0 3 14 10 12 MS10B - Ahara NidanaS.No OPD Guda Navanna Dugdha Gramya Anoopa Auduka Snigdha Dadhi Sheeta Mamsa Mamsa Mamsa Ahara Ahara1 3963 + + + + + +2 4049 + + + +3 4062 + + + + +4 4137 + + + + +5 4150 + + + +6 4287 + + + + +7 4289 + + + + + + +8 4291 + + + + +9 4368 + + + +10 4378 + + + + + +11 4403 + + + +12 4692 + + + +13 4695 + + + +14 4690 + + + + +15 4693 + + + + +Total 14 3 4 9 1 3 15 10 14 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Master charts ix
    • MS11A - Vihara /Anya Nidana Vibhramsha Avyayama Manishika avarodha Sthoulya Swapna sukham swapna Krimi Diwa Vega S.No OPD PK1 4050 + + +2 4136 +3 4138 +4 4166 + +5 4288 + +6 4290 +7 4292 +8 4367 + +9 4369 + +10 4397 +11 4592 + +12 4694 +13 4697 +14 4691 + +15 4696 + +Total 12 2 0 9 0 1 0 0 MS11B - Vihara /Anya Nidana Vibhramsha Avyayama Manishika avarodha Sthoulya Swapna sukham swapna Krimi Diwa Vega S.No OPD PK1 3963 + + +2 4049 +3 4062 +4 4137 +5 4150 +6 4287 +7 4289 +8 4291 +9 4368 +10 4378 + +11 4403 + +12 4692 +13 4695 + +14 4690 + +15 4693 +Total 9 4 0 7 0 1 0 0 Bhunimbadi yoga in Madhumeha (Diabetes Mellitus) - Master charts x
    • RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA Proforma for Registration of subject for Dissertation 1) Name of the Candidate and : Dr. ASHOK AKKI Address (in block letters) SRI SAI CLINIC, BEHIND VASAVI TALKIES, NEAR WATER TANK, BAGALKOT – 587101, KARNATAKA 2) Name of the Institute : Sri D.G. Melmalagi Ayurvedic Medical College, Post graduate studies and Research Center, Gadag - 582103 3) Course of study and subject : AYURVEDAVACHASPATHI (M.D.) KAYACHIKITSA 4) Date of Admission : March 2004 5) Title of the Topic : “EVALUATION OF EFFICACY OF BHUNIMBADI YOGA IN THE MANAGEMENT OF MADHUMEHA”6) Brief Review of Intended work:6.1) Need for the study: ‘What fuel is to an engine, Glucose is to the body’, as fuel provides mechanical energy to the engine, Glucose provides Physical energy to the body. When it is vitiated subjects to ailment, such as “Madhumeha” 1. When the practicality is to be achieved, modern medical persons are failing to understand the pathogenesis of the Madhumeha (Diabetes mellitus) in total. Thus it is required to analyze and emphasize the disease in total and assure with non-chemotherapy by the modern Ayurvedists. 2 The Prameha (Madhumeha) which is prevalent all over the globe is misunderstood, 3-4-5-6-7 as a disease dependent upon mere Insulin and pancreas . It is the need of the day to explain the original Ayurvedic understanding of pathogenesis and management applied from 1
    • ancient days to combat the dreadful metabolic disease of the present day world. Research is necessary for the sake of early management of the disease, as samprapti vighatana (breakdown or reversal of pathogenesis) is the Chikitsa (treatment) 8. Among Indian population approximately 6 Crores of Madhumeha (DM) patients are detected as so far. And it is also estimated that at the end of 2020 this number may increase up to 57 Million. As per present available data 10% of population are found in City and 3-4% in rural areas 9. Present study is derived to evaluate the Madhumeh-haratwa properties of Bhunimbadi Yoga 10 on modern prevalence to know its Hypoglycemic and Lipidolytic effects.6.2) Review of Literature: In the classics, when the pathology of Prameha is discussed with a special reference to Madhava Nidana, by Madhavakara, who followed a specific pattern and kept this (metabolic) disorder before to Medoroga (Obesity) and after the Ashmari (Urinary caliculi), 11 which is developed from Vasti or Mootrashaya (bladder) . The chapter of prameha consists of prameha pitika (boils) at the end as the complications of prameha 12. There are total twenty pramehas explained, out of which 4 are vataja, 6 pittaja and 10 13-14-15 kaphaja . Because of Tulya dosha dooshyata (Homologous etiologic factors of vitiation of doshas and dooshyas) in kaphaja mehas are accessible to treatment, where as vataja 16 becomes difficult for the same reason . The medoroga is said to be the Nidanarthakara vyadhi for Prameha pitika other than that of prameha. Thus it is clear, the Madhumeha (Diabetes mellitus) is a disorder pertained to the lipid metabolism. Today when we observe the patients, many of them are non-insulin dependent and very few are insulin dependent. In fact many of the patients those who are having Madhumeha, secret more insulin (hyper insulinemia) than that of normal and still the glucose levels are high (hyperglycemia). 2
    • It suggests clearly in insulin dependent patients, there are other causes other thanthat of insulin, to begin with, develop the dependency later. Madhumeha is the madhuryata ofmootra (renal glycosuria) where glomerular filtration gets impaired. Madhumeha occurs if thebody cannot produce Insulin (type I), or if it unable to use the insulin produced (type II); ineither case, the ultimate result is hyperglycemia and impaired glucose transport. Type I diabetes is characterized by a genetic predisposition manifested in one ofseveral human leukocyte antigens. Recent research suggests that the genetic predisposition,coupled with an unknown factor, trigger an ongoing autoimmune process that systematicallydestroys the beta cells in the pancreas, there interfering with the body’s ability to produceInsulin. Type II diabetes involves either a defect in the insulin release sites in the pancreas orresistance to the action of Insulin stemming from a decrease in the number of receptor sitesin the peripheral tissues. And usually this type II of DM is often associated with Obesity. In both types of DM the result is interference with glucose transport across cellmembranes in peripheral muscle and adipose tissue, Meda, Mamsa, Shareer and Kledaleading to faulty oxidation and energy production where aqueous contents of the body isinvolved17. Metabolism of Carbohydrates (Shareer kleda), Proteins (Mamsa) and Fats (Medas)are impaired as the storage of Glycogen i.e. Rasa in the muscle and liver is impaired. As aresult unrestrained gluconeogenic and glycogenolytic process in the liver causeoverproduction of glucose. In mean time blood glucose level rises, renal tubules fail toreabsorb all the glucose that produces as Mutra Madhuryata (glycosuria). Thus the conditionPrameha becomes MADHUMEHA with the involvement of Vata and Ojus 18. The main and obligatory principle in the management of Diabetes Mellitus ismaximum compensation of the disturbed metabolic processes, one of the most easilydeterminable indices of which is the normalization of blood sugar content and correction ofMutra Madhuryata (glycosuria) along with the Rakta Madhuryata (Hyperglycemia). The 3
    • principle therapeutic is Diet therapy, Exercise, Yoga, Insulin therapy and oral hypoglycemic agents. The ideal management for diabetes should allow the patient to lead a complete normal life, to remain not only asymptomatic but with positive good health 19. The present study with Bhunimbadi yoga refers to the principles from Ayurveda treatises and makes ailed to review positive health with Madhumeha hara prabhava (anti diabetic properties) and it is assessed that this compound can be good Normoglycemic and Normolipidic properties. The composition of the Bhunimbadi yoga explained in detail with preparation in column 7.16.3) Objective of the study: i. To evaluate the Hypoglycemic effect of the of Bhunimbadi yoga in control of blood sugar levels in Madhumeha. ii. To evaluate the Lipidolytic properties of Bhunimbadi yoga in the assessment of Madhumeha.7) Materials and methods: 7.1) Source of data: a) Patients suffering from Madhumeha will be selected from Dept. of Kayachikitsa, P.G.S. & R.C., O.P.D. of Shri D.G.M.A.M.C. & H., Gadag by present inclusion criteria and exclusion criteria. b) Literary aspect of the study will be collected from classical Ayurvedic and Modern texts and updated with recent medical journals. c) Trail Drug: Bhunimbadi yoga – The composition and preparation of Bhunimbadi yoga is as follows – 4
    • d) Composition of Bhunimbadi yoga: S.no Name of the Herb Latin name Proportion 1 Bhunimba 20-21 Andrographis paniculata 1 part 2 Katuki 22 Picrorhiza kurroa 1 part 3 Musta 23 Cyprus rotandus 1 part 4 Triushana 24 Equal parts of Piper longum, Piper 1 part nigram, Zingiber officinale 5 Indrayava 25 Holarrhena antidysenterica 1 part 6 Chitramoola 26 Plumbago zylanica 2 parts 7 Vatsaka twak 27 Bark of Holarrhena antidysenterica 16 parts e) Preparation of Medicine: Bhunimbadi yoga ingredients are well identified and collected from local areas. Good manufacturing practice will be followed for the preparation of Bhunimbadi yoga.7.2) Method of collection of Data: a. Study design: Simple random sampling technique - dose control comparative clinical trial b. Sample size: A minimum of 20 patients in each group c. Groups: Two groups are formed with different dose patterns for comparison. Group A: Receives the standard dose of 500mg TDS Bhunimbadi yoga. Group B: Receives 1 gm. TDS Bhunimbadi yoga. (Each capsule contains 500 mg Bhunimbadi yoga.). 5
    • a. Exclusive criteria 28: Patients who are with known organic lesions. (Type II ) Insulin dependent. (Type I) Severe chronic disease Neoplasm Suffering from liver or ailments failure Suffering from Kidney or ailments failure Associated Cardiac diseases and Hypertension Obesity Pregnancyb. Inclusive criteria : Patients between the age of 25 to 65 years Irrespective of sex Less than 5 years chronicity Non obese Patients other than that of Exclusive criteriac. Criteria of diagnosis : 1) The clinical features of Madhumeha (Diabetes Mellitus) mentioned in classics are the basis of diagnosis. 2) Hyper glycemia.d. Posology: Group A: Receives the dose of 500mg TDS Bhunimbadi yoga before the food. Group B: Receives 1 gm. TDS Bhunimbadi yoga before the food.h) Study duration: 30 days.i) Follow up: 30 days. 6
    • j) Assessment of results: Subjective and objective parameters to the base line data is compared with after treatment data. k) Subjective parameters: As designed in the classical Ayurvedic and Modern texts. l) Objective parameters: 1. Fasting blood sugar and corresponding Urine sugar. 2. Post lunch blood sugar and corresponding Urine sugar. 3. Serum Triglyceride 4. Serum Cholesterol 5. Serum H.D.L. Cholesterol 6. Serum L.D.L. Cholesterol 7. Serum V.L.D.L. Cholesterol m) Investigations: 1. Fasting blood sugar and corresponding Urine sugar. 2. Post lunch blood sugar and corresponding Urine sugar. 3. Serum Triglyceride 4. Serum Cholesterol 5. Serum H.D.L. Cholesterol 6. Serum L.D.L. Cholesterol 7. Serum V.L.D.L. Cholesterol 8. Erythrocyte Sedimentation Rate 9. Hemoglobin %01.2 Ethical clearance: Obtained and enclosed 7
    • 08. List of References:1 Dr. N. Kapanipathaiah, Diabetes Mellitus; published by Janapad Prakashan, Bangalore2 Kaviraj Ramaraksha Pathak Kaya Chikitsa Choukhamba Orientalia Varanasi, 6th Edition1993 ,Volume II Part I, Lakshanas of Madumeha; P 284.3 E. babsky, B. Khodorov, G. Kositsky etal., Human Physiology-Volume I, 1st edition, SecondPrint 1975, MIR Publishers Moscow, Nutrition & Energy Exchange, Lipid Metabolism; P 286,Pancreas, PP 379.4 J.C. David, V Iswariah, M.N. Guruswami, P. Varadachary and Company 3rd edition 1959,Pharmocology and Phormoco-Therapeutics, Insulin;, P 445.5 Martin Dunitz- Tylor and Francis Group; Diabetes: from Research to Diagnosis andTreatmen; ,First Indian Reprint, Edited by Itamar Raz, Jay S. Skyler, Eleazar Shafrir; JaypeeBrother Medical Publishers (P) Ltd, New Delhi, 20036 Robert G. Petersdorf, Raymond D. Adms etal., Harrison’s principles of Internal Medicine,International Book Company, 10th edition 1983. Intermediary Metabolism of Carbohydrates,Lipids and Proteins; by Daniel W. Foster and J. Denis McGarry; P 490. Diabetes mellitusby Denial W. Foster, P 661.7 Sir. John Conybeare and W.N. Mann; Text book of Medicine, 12th edition, E &S Livingstone Ltd., Edinburgh & London-1957, Diabetes Mellitus; P 242-257.8 Shiva Rama Prasad Kethamakka, Aetio-Pathology of Madhumeha, Ayurmedline, July-December 2000, PP 11-169 Editorial, Vaidya Mitra – Weekly heath magazine, September 2004,10 Vempati Koteswara Shastri, Saharayoga (Telugu) with Subodhini Vyakhya, ChurnaPrakarana/ 114 sloka, 1st edition,1961, published by Andhra Ayurveda Parishat, Vijayawada,PP 13911 Yadunandan Upadhyaya edited, Madhava Nidana 33rd chapter, Madhukosha commentary,Kashi Sanskrit series –158, published by Chaukhambha Sanskrit Sansthan, Varanasi, 26thedition 199612 Ibid, 33/34-3613 Yadavji Trikamji Acharya edited, Charaka Samhita Chikitsa, 6th chapter, ChakrapaniAyurveda Deepika, Chaukhambha Ayurvijnana Grandhamala - 34, published byChaukhambha Surabharathi Prakashan, Varanasi, reprint 1992 8
    • 14 Ibid, Nidana, 4th chapter15 Yadavji Trikamji Acharya edited, Susruta Samhita Nidana, 6th chapter, Dalhana NibandhaSangraha, Chaukhambha Ayurvijnana Grandhamala - 42, published by ChaukhambhaSurabharathi Prakashan, Varanasi, reprint 199416 Yadavji Trikamji Acharya edited, Charaka Samhita Chikitsa, 6/5, Chakrapani AyurvedaDeepika, Chaukhambha Ayurvijnana Grandhamala - 34, published by ChaukhambhaSurabharathi Prakashan, Varanasi, reprint 199217 Mosby’s Medical encyclopedia, The learning company inc., CD publication, 199718 Yadunandan Upadhyaya edited, Madhava Nidana 33/4, Madhukosha commentary, KashiSanskrit series –158, published by Chaukhambha Sanskrit Sansthan, Varanasi, 26th edition199619 Dr. Virendra Keshav Saha, Diabetes Mellitus in Indian Medicine; 1st edition-1995,Chukhamba Orientalia, Varanasi, PP 7320 M.A.Iyengar, Study of Crude drugs, revised and enlarged 9th edition, 1999, PP3821 K.M.Nadkarni, Indian Materia Medica, 2nd edition, 1982, Published by Popular PrakashanBombay, PP 10122 Ibid, 95323 Ibid, 42824 Bramha Shankar Mishra edited, Vidyotini commentary on Bhavaprakasha, Poorva Khanda5/Hareetakyadi varga, sloka 60-61, Kashi Sanskrit series –130, Chaukhambha SanskritSansthan, Varanasi, 2nd edition25 K.M.Nadkarni, Indian Materia Medica, 2nd edition, 1982, Published by Popular PrakashanBombay, PP 64326 Ibid, 99027 Ibid, 63428 Cristofer Haslett, Adwin R. Chilvers et.al. Davidson’s Principles of Practice of Medicine,19th edition, 2002; Daibetes mellitus by B.M. Frier, B.M. Fisher, PP 641 9
    • 9) Signature of the candidate: (Dr. Ashok I. Akki)10) Remarks of Guide : This dissertation topic on Madhumeha and chosen medicament Bhunimbadi yoga for the research will certainly help the ailed and can uphold good values for the Ayurvedic concepts.11) Name and designation:11.1) Guide : DR. VANGEEPURAM VARADACHARYULU, M.D. (Ayu) (Osm) Professor and H.O.D, Dept. of Kayachikitsa, PGSRC, DGMAMC, Gadag.11.2) Signature :11.3) Co- guide : Dr. SHIVA RAMA PRASAD KETHAMAKKA M.D.(K.C)(Osm), M.A.(Jyo), C.O.P(German){Ph.D.(Astromed)} READER IN KAYACHIKITSA DGMAMC, PGSRC, Gadag11.4) Signature :11.5) Head of the Department : Dr.VANGEEPURAM VARADACHARYULU, M.D. (Ayu) (Osm) Professor and H.O.D, Dept. of Kayachikitsa, PGSRC, DGMAMC, Gadag.11.6) Signature :12) Remarks of Chairman & Principal: The above synopsis is scrutinized by postgraduate studies and research committee and submitted for the registration of subject for dissertation.12.1) Signature: Dr. G.B.Patil Principal/ C.M.O. 10