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Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus) By SHIVALEELA. S. KALYANI, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC ...

Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus) By SHIVALEELA. S. KALYANI, Department of Kayachikitsa, Post graduate studies and research center D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, Gadag - 582 103

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  • Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus) By SHIVALEELA. S. KALYANI Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore In partial fulfillment of the degree of Ayurveda Vachaspati M.D. In Kayachikitsa Under the Guidance of Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm), C.O.P. (German) M.A., [Ph.D] (Jyotish) Department of KayachikitsaPost Graduate Studies & Research CenterD.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG 2005-2008
  • D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER GADAG, 582 103 This is to certify that the dissertation “Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus)” is a bonafide research work done by Shivaleela. S. Kalyani in partial fulfillment of the requirement for the post graduation degree of “Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev Gandhi University of Health Sciences, Bangalore, Karnataka.Date: GuidePlace: Prof. Dr. Shiva Rama Prasad Kethamakka M.D. (Ayu) (Osm), C.O.P (German), M.A., [Ph.D] (Jyotish) Professor in Kayachikitsa DGMAMC, PGS&RC, Gadag
  • J.S.V.V. SAMSTHE’S D.G.M.AYURVEDIC MEDICAL COLLEGE POST GRADUATE STUDIES AND RESEARCH CENTER 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 ofAkulyadi yoga in Madhumeha (Diabetes Mellitus)” is a bonafide research work done byShivaleela. S. Kalyani under the guidance of Prof. Dr. Shiva Rama PrasadKethamakka, M.D. (Ayu) (Osm), C.O.P (German), M.A., [Ph.D] (Jyotish), Professor inKayachikitsa in partial fulfillment of the requirement for the post graduation degree of“Ayurveda Vachaspati M.D. (Kayachikitsa)” Under Rajeev Gandhi University of HealthSciences, Bangalore, Karnataka.. (Dr. V. Varadacharyulu) (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 candidate I here by declare that this dissertation / thesis entitled “Evaluation of the efficacy ofAkulyadi yoga in Madhumeha (Diabetes Mellitus)” is a bonafide and genuine researchwork carried out by me 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.DatePlace Shivaleela. S. Kalyani
  • Copy right Declaration by the candidate I here by declare that the Rajiv Gandhi University of Health Sciences, Karnatakashall have the rights to preserve, use and disseminate this dissertation/ thesis in print orelectronic format for the academic / research purpose.DatePlace Shivaleela. S. Kalyani© Rajiv Gandhi University of Health Sciences, Karnataka
  • Acknowledgement First and foremost, I salute almighty God who is omnipresent, omniscient andomnipotent. He is the possessor of the ocean of knowledge and wisdom-to which I wouldlike to contribute a drop in the form of my dissertation. As it is said, each and every dropgoes to make an ocean; this is my humble endeavor towards its goal of wisdom. It givesme in expressible pleasure to offer my sincere thanks to all who have rendered theirwholehearted support, guidance and co-operation in completing the thesis work. I am extremely happy to express my deepest sense of gratitude to my beloved andrespected guide Prof. Dr. K. Shiva Rama Prasad, M.D., C.O.P. (German), M.A., [Ph.D.](Jyotish), Department of Kayachikitsa (PG), for his guidance and timely help. I express my gratitude to Dr. V.V.Varadacharyulu M.D. (Ayu), Professor andH.O.D of Kayachikitsa (PG) for his advice and encouragement in every step of this work. I am sincerely gratefulness to Dr.G.B.Patil, Principal, for his encouragement andproviding all necessary facilities for this research work. I extend my gratitude to Dr. R.V.Shettar, Dr.Mulki Patil, Dr. Shankaragouda,Dr.P. Shivaramudu, Dr. G. Purushottamacharyulu, Late Dr. Dhilip, Dr.M.C. Patil, Dr. G.Danappagoudar, Dr.S.H. Doddamani, Dr.S.N. Belawadi, Dr. Nedugundi, Dr. Samudri,Dr, Kuber sankh. Dr.Mulgund, Dr.J.Mitti, Dr. Yasmin A.P. and all my U.G. Lecturers fortime-to-time help offered by them. I express my immense gratitude to my statistician Nandakumar, librarian V.B.Mundinamani and assistant Sureban for facilitating me in collection and production ofmy thesis. I take this opportunity to thank Dr. Shrinivas. Vadeyar M.D (Ayu). PvamanPharmacy, Bijapur, for the preparation of Akulyadi Yoga in the form of tablet. I would like to thank my family members who have given love and care duringmy studies. My deep sense of gratification is due for my Father Sangappa. B. Kalyani andmy mother Kalavati. S. Kalyani who are the architects of my career. The culture,discipline and perseverance, which I could imbibe, are solely because of theirpainstaking, upbringing and strong moral support. I express my deep gratitude to my
  • Father-in law Prof. Revanneppa. R. Honawad. And mother-in law, Shakuntala. R.Honawad for their inspiration and valuable suggestions. I express my heartfelt gratitude to my brother, Mahantesha and my Sisters,Geetanjali. Savita, Sujata for constant help and encouragement to move ahead. Mydeepest gratitude to my husband Dr. Chandrashekhar. R. Honawad for enormous loveand moral support. I feel proud in expressing my gratitude to my best friends Dr. Seema, Dr. Neeta.Dr. Radha, Dr. Mahantaleela, Dr. Prasad Shakti, Dr. Shivananda., Who not only helpedme but stood by during hours of stress and dejection. I take this moment to express my thanks to all my Post gratude colleagues, Dr.Kalmath, Dr. Ratnakumar, Dr. Venkareddy, Dr.Udaya, Dr. Umesha, Dr. G. G. patil, Dr.Sarvi, Dr. Shaila, Dr. Sunita, Dr. Veena. Kotrashetter. Dr. Krishna, Dr. Ashoka, Dr.Kamalaxi, Dr. Sulochana, Dr. prasann. Joshi, Dr. Sanjeeva, Dr.Neeraj, Dr. Veena.Jigalur, Dr. Vijayalakshmi, Dr. Shivaleela. Kudari, Dr. Shalini. Sharma, Dr. Kataraki, Dr.Ashwini, Dr. Rudrakshi, Dr. Jayashree, Dr. Kattimani, Dr. Suma Dr. Madhushree, Dr.Kalmesha, Dr. Muttu, Dr. Seeba, Dr. Prasanna kumar, Dr. Mukta. Hiremath, Dr.Sarvamangala, Dr. Anupama, Dr. Mukta. Arali Dr. UdayaGanesha, Dr. Adarsha, Dr.Nataraj, Dr. Shaileja, Dr. Kavita Dr. Kalavati, Dr. Jaya, Dr.Savita, Dr. Shivakumar. Finally I am thankful to all those who helped directly or in directly for thecompletion of this work. (Shivaleela S. Kalyani)
  • Abstract of “Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus)” by Shivaleela. S. KalyaniKey words:Madhumeha, Prabhoota, Avila, Akulyadi yoga, Hypoglycemia, Hyperglycemia, DM, FBS, PPBS The advancement of industrialization and communication is contributing towardssedentary life styles; in turn causing chronic non-communicable diseases like Madhumeha vis-à-vis Diabetes Mellitus, etc. in fact Ayurveda is the first life science, which identified, diagnosedand managed Madhumeha. Madhumeha/DM is the present burning issue alarming the world.Madhumeha is a disease characterized by Prabhoota, avila mootrata, Tanu and Mootramadhuryata. Susruta only mentioned that in Madhumeha Sweda becomes Sweet in nature.Abnormal bi-fold digestion causes aggravation of Vata in turn involves Dushya and metabolicwaste to form Madhumeha. The Madhumeha vis-à-vis diabetes mellitus has many theories ofoccurrence, even the recent viral influence studies on diabetes. Madhumeha has Kapha Dosha isthe key factor along with Vata. The present study intended to focus on the disease evaluation i.e.Madhumeha vis-à-vis. Diabetes Mellitus management with Akulyadi yoga as a ShamanaChikitsa. Akulyadi yoga ingredients are hypoglycemic agents collected form local area andprepared under GMP conditions, weighing about 500mg tablet form. Patients of Madhumehafulfilling the criteria of diagnosis were selected in the present study. The male female ratio in thestudy is approximately 3:2 patients and 75% patients were recorded with sedentary life styles. Inthe present study 60% patients had family history and rest of the 40% patients had no familyhistory of Madhumeha. Apart from the symptoms which show high significance in the study thekey parameters to assess “glycemic” condition of Madhumeha exhibit, FBS with a meandifference of 48.605mg and PPBS with mean difference of 117.18mg for after to before data.This is strong evidence to state that the Akulyadi yoga is good hypoglycemic agent combinationof Ayurveda.
  • Contents of “Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus)” By Shivaleela. S. KalyaniCHAPTER CONTENT PAGES 1 Introduction 1 to 5 2 Objectives 6 to 7 3 Review of literature 8 to 66 4 Methods 67 to 75 5 Results 76 to 93 6 Discussion 94 to 104 7 Conclusion 105 to 106 8 Summary 107 to 108 9 Bibliographic References 1 to 6 10 Annex – data of trial 1 to 9 11 Annex – Case sheet 1 to 6 -1-
  • Tables of “Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus)” By Shivaleela. S. KalyaniSN Title of Table Page1 Showing the Vihara Nidana of Madhumeha 162 Showing the Ahara Nidana of Madhumeha 173 Types of kaphaja Prameha 364 Types of pittaja Prameha 365 Types of vataja Prameha 366 Showing Prognosis of Madhumeha 377 Showing the poorva roopa of Madhumeha 428 Lakshana of Madhumeha 459 Madhumeha upadrava 5410 Results by Age in Madhumeha with Akulyadi yoga 7711 Results by Gender in Madhumeha with Akulyadi yoga 7812 Results by Religion in Madhumeha with Akulyadi yoga 7913 Results by Occupation in Madhumeha with Akulyadi yoga 8014 Results by Economic status in Madhumeha with Akulyadi yoga 8115 Results by Diet in Madhumeha with Akulyadi yoga 8216 Distribution of patients by presenting complaints 8417 Distribution of patients by Associated features 8518 Ahara Nidana observed in the study 8619 Vihara Nidana observed in the study 8620 Distribution of patients by Anya Nidana 87 -2-
  • 21 Distribution of patients by Poorva roopa lakshana 8722 Distribution of patients by Sroto dusti lakshana 8823 Data of Family history in the study 8924 Assessment of Subjective parameters 8925 Assessment of Objective parameters 9026 Result of Akulyadi yoga in Madhumeha 9127 Statistical analysis of Akulyadi yoga 92 Figures and Photos of “Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus)” By Shivaleela. S. KalyaniSN Title of Figures and photos Page1 Madhumeha Samprapti 312 Composition of Akulyadi Yoga 643 Results by Age in Madhumeha with Akulyadi yoga 774 Results by Gender in Madhumeha with Akulyadi yoga 785 Results by Religion in Madhumeha with Akulyadi yoga 796 Results by Occupation in Madhumeha with Akulyadi yoga 807 Result Distribution of patients by Economic status 828 Results by Diet in Madhumeha with Akulyadi yoga 839 Distribution of patients by presenting complaints 8410 Distribution of patients by Associated features 8511 Result of Akulyadi yoga in Madhumeha 91 -3-
  • Chapter - 1 Introduction Ayurveda the heritage of Indian civilization is not only a medical system but also afull-fledged science, consisting of all medical and ailed branches essential to lead a healthylife. Being a science Ayurveda believes in supreme power. The Ayurveda has attracted the attention of global population specially the developedcountries since ages. The main reason behind this was the holistic approach of Ayurveda,humanitarian approach, simplicity of the procedures, cure of chronic and incurable diseasesafer and non-toxic herbal resources1. The purpose of Ayurveda is to maintain health and to treat diseases, in order toachieve the ultimate goal. It is applicable in every fact of human life, with its own unique. Aprinciple in understanding any disease by either preventive or curative wedge is necessary.This may be the fact due to which this science is persisting through centuries beginning fromtime immemorial2. Scientific and technological progress has made man highly sensitive and critical;there by giving rise to different types of health problems. The advancement ofindustrialization and communication is contributing towards sedentary life styles; in turncausing chronic non-communicable diseases like diabetes mellitus, etc. in fact it is the firstlife science, which identified diagnosed and managed diabetes. In spite of all sorts ofadvancement of science man is not able to stay himself in the boat of happy and healthy life.So it is disadvantage rather than an asset. Madhumeha is a disease known to mankind since vedic period and it is mentioned asone of the 20 obstinate urinary disorders. It is the present burning issue alarming the world. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 1
  • With synonym of ‘Richman’s disease’, particularly because a person who is able to enjoy thepleasure of life without any perceptible exercise is usually affected with this disease3. Madhumeha is a chronic metabolic disorder and the symptom appears in relation withmootravaha samsthana. Diabetes mellitus is a chronic metabolic endocrinal disorder, whichhas similar pathogenesis as the Madhumeha. Thus the comparison between Madhumeha andDM is justifiable4. In Ancient treatise we find a vivid description of the disease solely attributed tometabolic derangement along with genetic predisposition. Madhumeha subtype of VatajaPrameha due to involvement of vital elements causes alarming health instability with higherprevalence. Vata is the conductor of healthy life and vitality supporter of all the embodiedbeings and sustains long life free of disorders5. Susruta emphasized that Vyanavata and Apanavata vitiation cause Sukra Dosha andPrameha. Vyanavata because of its potential to perform the functions related to each andevery body element and Apanavata due to its potential related with excretion. When weexploit Madhumeha we cannot deny their credibility in the pathogenesis. This superiorconsideration of Susruta proved to be essential before profound treatment modality6. Changing life style, lack of exercise, fast foods, improper unbalanced diet, andsedentary life are showing upward trend in India. This has lead to the emergence of DiabetesMellitus in the region. Iatrogenic or genetic predisposition and degenerative changes provedfatal in diabetes mellitus7.Purpose of the study The prevalence of diabetes is approximately twice in the urban than in rural areas. Itis suggested that the increase in the occurrence of this disease is possibly due to changing life Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 2
  • style. Lack of exercise, fast foods, improper unbalanced diet, and sedentary life are showingupward trend in India. This has lead to the emergence of diabetes mellitus in the region. In spite of using oral hypoglycemic agents and insulin modern medicine is leastbother about the sedentary life style and improper diet, so struggling to provide bettermanagement to counteract the complications and to provide better health. So many research works have been carried out in relation to shamana treatment asmentioned in classics and their therapeutic effect is proved. Present research work is intendedto evaluate the effect of herbal combinations used as different line of treatments.Prevalence Madhumeha has become a global problem in spite of much advancement in modernmedicine8. 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 arefour reasons for this two-fold global increase: Firstly, we are living longer; over-nutrition andlack of exercise are prevalent; the disease being transmitted in a hereditary fashion; suchtransformations have taken place within the Indian population also. In India, it is estimatedthat 19 million cases occurred in 1995, rising to a projected 57 million by the year 2025 (1/6thof the world total). According to recent epidemiological studies there has been a 40%increase in diabetes prevalence amongst urban during the last five years9. Even the NIDDM acommonest form of DM is most common accounting for 85-99% of the patient depending ongeography and ethnicity, occurs in adults, more so over 35 years of age10. The prevalence ofNIDDM is on the rise more alarmingly in the developing nations, ranked 7th among leadingcause of death. It has been rated 3rd when all its micro vascular, macro vascular, neuropathic Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 3
  • complications11 are taken into account. The cost of treating diabetes an associatedcomplication exceeds $ 100 billion per year12. It has long been recognized that drugs represents only part of the management ofMadhumeha and other intervention such as education, modification of diet and promotion ofphysical health play a crucial role. If the dietary control and exercise programmes do notimprove the condition then the medication is added. Many of patients won’t have patiencefor long term therapies, complicated therapies like exercise etc13. The OHA viz.Sulfonylurea, Bigunides have associated with adverse effect like nausea, vomiting, lacticacidosis, hypersensitivity etc. After long term administration their action declines, up to 50%patients of NIDDM initially treated with OHA ultimately need insulin. Hence we find nosatisfactory remedies for Madhumeha in contemporary medical science.Previous research literatures 1. Bramachari M.D and Augusti K.T (1961) hypoglycemic agents from Indian medicinal plants. Dried seeds of Eugenia jumbalana and dried bark of Ficus bengalensis j. pharma, pharmacy. 13,181-2. 2. Chandala H.M Tripathi S.M and Udupa K.M (1980); effect of Tamala on plasma insulin vis-à-vis blood sugar in patients of D.M-JRAS 1,345-357. 3. Gupta S.S and Variyar M.C (1963); effect of Gymnema sylvestre and Pterocurpus marsapium glucose tolerance in albino-rats Indian J. Med. Sci. 17,501. 4. Lal. B.M and Chaudhary K.D (1968); observation on Mimordica charanita and Eugenia jambalana as oral anti diabetic remedies. J. Res. Indian. Med. 2 (2), 161-4 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 4
  • About concept The word Madhumeha in terms of ‘Diabetes Mellitus’ it is the present burning issuealarming the world. With synonym of Richman’s disease,’ Madhumeha is a chronicmetabolic disorder and the symptom appears in relation with a mootravaha samsthana.Diabetes mellitus is a chronic metabolic endocrinal disorder, which has similar pathogenesisas the Madhumeha. Thus the comparison between Madhumeha and DM is justifiable14. The present study was designed as ‘Evaluation of the efficacy of Akulyadi Yoga’.Medicinal plants since time immemorial have been used virtually in all cultures as a sourceof medicine. Several herbs have been described in Ayurvedic treasure of therapeutics, whichhave a beneficial effect in the management of Madhumeha. Akulyadi Yoga is one such acombination which acts as mootra sangrahaneeya and also reduces the high blood glucose15. As the Madhumeha is Kapha Vata pradhana Vyadhi Akulyadi yoga seems to be veryeffective. It contains Akuli, Amalaki and Haridra. All these drugs are Kapha and VataShamana property with Ushna virya. Thus in the present study an attempt is made to“Evaluation of the efficacy of Akulyadi Yoga”, with a view to find out a therapeuticallyefficacious, safer, cost effective and easily available drugs.The study description The study description consists of the headings according to the RGUHS protocolfollowed from 2nd chapter. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Introduction 5
  • Chapter - 2 Objectives Ayurvedic science, a boon in today’s world, describes Swastha parayanata, whichmeans maintenance of health in the one hand and treatment of disease on the other. It hasbeen described in Ayurveda that it is not rational treatment where the medicine modifies onedisease; on the other hand it provokes new complications. So here, we are putting our stepforward to find safe and effective oral hypoglycaemic agent. Madhumeha is a disease known to the mankind since Vedic period and it ismentioned as one of the 20 obstinate urinary disorders, where “Prabhoota Mootrata” i.e.polyuria is as the cardinal symptom16. Madhumeha/DM is the present burning issue alarmingthe world. Madhumeha and its management through various methods are possible viz.shodhana, Lekhana and Apatarpana Chikitsa. Considering the Chikitsa sutra the Akulyadiyoga as a shamana Chikitsa is under taken for the trial that has almost all of these therapeuticeffects is opted for this study17. The present study intended to focus on the disease evaluation i.e. Madhumeha vis-à-vis. Diabetes Mellitus and the management with Akulyadi yoga as a shamana Chikitsa.Akulyadi yoga ingredients are collected form local and prepared under GMP conditions,weighing about 500mg tablet form. Hypothetically evaluated therapeutic efficacy on theMadhumeha vis-à-vis Diabetes Mellitus is tested through the test under the followingobjectives. In this regard the objectives proposed in the study are –Objectives 1) To evaluate the efficacy of Akulyadi Yoga in the management of Madhumeha 2) To evaluate the efficacy of hypoglycaemic activity of Akulyadi Yoga in Madhumeha Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Objectives 6
  • 1) To evaluate the efficacy of Akulyadi Yoga in the management of Madhumeha The Madhumeha is a disease manifested from Mamsa, Meda and Shareera kleda withthe vitiation of the Kapha and Vata18. The Madhumeha vis-à-vis diabetes mellitus has manytheories of occurrence, recent viral influences studies on diabetes. This viral influence tocause the DM is a new trend apart from the interventions of the pancreas and the metabolicdisturbences. The ingredients of the Akulyadi yoga are with Kapha Vata Doshahara and areof Katu, Tikta Rasa predominance to pacify the Dosha. All ingredients of the yoga are ofUshna veerya and also do the Kapha Vata shamana along with the gunas like Laghu,Rookasha, Teekshna and Snigdha. Akulyadi yoga basically acts as Agni vardhaka, tonormalize the Agni is the motto of Kayachikitsa and also as it has the Krimihara Dravya andRasayana dravya the actions of such are helping the disease regulations. The Krimiharatwa interms of antiretroviral action over the causative organisms probably thought by the ancientresearchers thus the “Akulyadi Yoga” with such combination is used at the management ofthe Madhumeha19. By observing all these characteristics of drugs Akulyadi yoga seems to bevery much beneficial in the management of Madhumeha which could be clinically observedto understand such Krimihara and Mehahara actions.2) To evaluate the efficacy of hypoglycaemic activity of Akulyadi Yoga in Madhumeha As the Akulyadi yoga is hypothetically capable of inducing the hypoglycemicactivity, is evaluated through Blood Glucose testing. An attempt is made to measure theBlood sugar, urine sugar at different times of relation to meal. The evidential estimations ofthe blood sugars with corresponding urine sugars are recorded before and after the inductionof trial drug to estimate the hypoglycemic action of the test drug. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Objectives 7
  • Chapter - 3 Review of Literature Madhumeha is the disease of having merely metabolic derangement and geneticpredisposition related with each constituent of the body with systemic consideration though itis a subtype of vataja Prameha having more prevalence in the society20. Susruta has used theword Kshaudrameha. ‘Madhu’ and kshaudra are literally synonyms of each other, whichmean honey21. But he placed a different chapter for management of the ‘Madhumeha’ in hisChikitsa. He has accredited Madhumeha to be a stage of complications of appearing inPrameha22. When literal meaning of the word ‘Madhumeha’ is compared to the contemporaryDiabetes Mellitus, it exactly fits in the frame work. General etiology of Prameha coincides with that of Madhumeha of Charaka, with itsaetio-pathogenesis dealt in Susruta and Vagbhata, who are at the common opinion of that allPrameha left untreated or not properly treated leads to Madhumeha23. Two types of Pramehanamely Sahaja and Apathyanimittaja, can be compared to insulin dependent and non-insulindependent diabetes respectively. Whatever be the type of Madhumeha, as it is MadhyamaRogamarga (Vasti – Marma) associated becomes incurable and needs very long activemanagement strategy. To understand the etiology, patho-physiology, complications and managementmethods, first it is merely necessary to emphasize the disease Prameha as a whole andMadhumeha in particular. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 8
  • Etymological DerivationsNirukti of Prameha The word ‘Prameha’ consists of two words, i.e. “pra” and “meha”. The word meha isderived from the root ‘miha sechane by adding ‘Lue’ pratyaya to it ‘mehati sinchatimutraretansi’ which means to excrete. Rigveda mentioned this word first is mehanadthanamkaranallium. The commentator of Rigveda, Sayana interpreted the word mehana as medhra,which denotes to shishna (penis). In Sanskrit literature the ‘mih’ is used to denote, to makewater, to wet to emit semen. So this root ‘mih’ is added to prefix ‘pra’ the word becomes‘Prameha’. In regard to above explanation we can easily understand that the disease Pramehais resulted because of excessive excretion of urine24.Nirukti of Madhumeha Chakrapani opines that both words are used for each other. Madhu means honey orsweet and Meha is passing urine. The word ‘madhu’ is derived from the root ‘mana’ and themeaning as “manava bhodane” i.e., which gives the psychic contentment (vachaspathyeem); itrefers to the 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(honey), in colour, smell and taste25. 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 untreatedbecomes “Madhumeha”, the generalization of Madhumeha is applied to all ‘Prameha’. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 9
  • Definition of Madhumeha So the meha word here mainly related with excessive excretion of urine. So thedefinition is a clinical entity in which the patients’ voids the urine having comparison withmadhu i.e. of Kashaya and madhura rasa, ruksha texture and honey like colour, and at thisstage even the body acquires sweetness is called as Madhumeha. From above definitions wecan easily diagnose the disease and understand its progression26. 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 getconverted in to Madhumeha and especially he emphasized that the disease Prameha alongwith pideka should termed as Madhumeha27. Susruta and Vagbhata opine, if the patients of Prameha are not treated properly, all ofthem reach to the stage of ‘Madhumeha’, which is asadhya28. It is natural history of thedisease that, every patient of kaphaja leads to pittaja and then to vataja stage. But Susruta saysthat, the progression of the disease is not only time-oriented, it also depends on themanagement of the disease. If the patients are properly managed well in time, the progressionof the disease can be slowed down. If not managed properly, of course-it may reach the stageof Madhumeha quickly and becomes asadhya29. In 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 andpittaja Prameha. Thus all the types of Prameha lead to the stage of Madhumeha, which isconsidered as a vataja Prameha. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 10
  • Paryaya of Madhumeha Kshoudrameha – Susruta used this term instead of Madhumeha30. Ojomeha – Charaka31 and Vagbhata32 mentioned that, Vata changes the madhura rasa, snigda guna of oja in to kashaya & ruksha. Pushpameha – In Anjananidana, the word pushpa has been narrated as synonym for Madhumeha where the Pushparasa means – madhu33. All above synonyms postulates unanimously that, the urine concordant with madhu orsweet taste is Madhumeha.HISTORICAL REVIEW Study of sequential evaluation is foremost step in the research field. History study isimportant to know about the systematic development and progress of the subject to determinethe future plans for further establishment and research designing history of medicine startsfrom the very moment when the human being come into existence that’s why the ancienttreatise are full with description of diseases and their treatment. Here the present reviewrelated to Madhumeha is explained.Pre-vedic and Vedic Period The evolution of Madhumeha can be traced from Vedas but in rudimentary form,when we go through the Atharvaveda there is a reference related to the disease Asrava alongwith its management. Sayanacharya opined that Asrava means Mutraatisara the Englishtranslator Whitney (1962) interpreted it as flux and Griffith (1962) as morbid flow, WhileLeman has translated the meaning of Asarva as Diabetes Mellitus. Sayanacharya highlightedthe vatic nature of this ailment34. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 11
  • Samhita Period:(1) Charaka Samhita In Charaka Samhita, ancient treatise of medical science, Charaka explained theetiology, pathogenesis, symptomatology, complications and treatment. Even he not onlydescribed Nirupasthambha Madhumeha but also the Avaranjanya Madhumeha which is aunique contribution of this Samhita35.(2) Susruta Samhita Susruta also explained the Madhumeha in elaborative manner with separate chapter onits management36. He used Ksaudrameha synonym to Madhumeha inNidana6thchapter. Hetypically mentioned the decoctions according to each type of Prameha and mentioned thebody constitution and symptoms related to Sahaja and Apathyanimittaja Prameha.(3) Astanga Hridaya Vagbhata categorized the Madhumeha as Mootra Atipravrttijja and explained twotypes of Madhumeha i.e. Dhatu kshyaja and Avartpathat. He further added Sweda as theDushysa37.(4) Harita Samhita Harita mentioned Madhumeha as Papajanya and enumerated 13 types of Prameha withnomenclature different than Brihatrayi treatise viz. Puyameha, Ghrtameha etc38.(5) Bhela Samhita Bhela described Prameha is of two types i.e. Swakrita and Parakrita meha39.(6) Kasyapa Samhita Kashyapa mentioned the symptoms of Pramehi child in Vedanadhyaya and noted thedisease as Chirakari40. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 12
  • Medieval Period In this period 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.(1) Madhava Nidana Madhavakara collectively retold the description of Charaka, Susruta and Vagbhata41.(2) Sarangadhara Samhita Sarangadhara enumerated the Prameha bheda as 20 types. He further described themany medicines at the context of different forms of the medicines conversation42.(3) Bhavaprakasa Bhavamishra described Prameha and Madhumeha along with some new herbo-mineralpreparations added to the old treasure43.(4) Yogaratnakar Yogaratnakara explained Prameha and Madhumeha along with treatment in general44.Nidana – Aetiology Nidana of the Prameha are expressed as general those are common for all kinds ofPrameha. Specific Nidana manifests the particular kind of Prameha such as Madhumeha. Inclassics only Charaka has explained the specific Nidana for Madhumeha45. 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 Kapha46. By the above views, allnidanas of Prameha are considered for Madhumeha. All ancient treatise mentioned thecommon etiological factors of Prameha but Charaka mainly narrated the etiological factors Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 13
  • according to Dosha he also mentioned the specific etiological factors of Madhumeha. This isthe unique contribution. Thus the causative factors of Madhumeha can be discussed as -Sahaja (Hereditary) and Apathyaja (Acquired) 47.1) Sahaja (Hereditary) nidanas: Charaka48 and Susruta49 have agreed that beejadosha (genetically devoid) is also acause for Madhumeha. Acharyas are explained, ‘Kulaja vikaras’, Madhumeha is one amongthis. Susruta has included Madhumeha, in adibala pravritaja vyadhis. While telling the vikrita Garbha caused by beejadosha, Charaka says that, if thatportion of beeja is defective, the body part developing from that portion of beeja will bedefective50. The term beeja has been considered as shukra and shonita. Hence it can beunderstood that, the child born to Madhumehi, may or may not suffer from Madhumeha. Itdepends on the beejabhagavayava, which is defected. It is caused, because of the vitiatedvatadi doshas present in the shukra and shonita of parents51.2) Apathyaja (Acquired) causes: It can be classified in to two types viz. Samanyaja (General) and Vishesha (Accordingto dosha).Vishesha Nidana for Prameha Except Charaka other authors have explained the common causative factors and theyhave particularly stressed on the factors, which affects the Kapha, medas and mutra. Charakaexplained nidanas specific to the doshas concerned but he too has equally voiced on thosefactors, which vitiate Kapha and medas. As the Kapha Prameha Nidana is equally importantas that of the Prameha thus the Kapha Prameha Nidana is enumerated here under. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 14
  • a) KAPHAJA PRAMEHA NIDANA 52Ahara Nidanas: - A) Rasa – Madhura padartha atisevana B) Guna – Drava taruna dravya atisevana C) Dravyas – i) Dhanya’s – Hanyaka, Chanak, Uddalaka, Naishada, Mukundaka, Mahavrihi, Pramodaka, Sugandhaka, Sarpishmati, Masha etc ii) Mamsa: - gramya, Oudaka, Anupa, Mamsa, Rasa iii) Others – Shakas, Tila, Pistanaa, Payasa, Ksheera, Vilepi kshoudra, Mandaka, Dadhi etc.Vihara Nidanas - • Swapna prasanga • Shaya prasanga • Asana prasanga • Vyayama vruja varjana • Anya kapha meda mutra and • Vridhikara Viharasb) PITTAJA PRAMEHA NIDANA53: -Ahara Nidana - A) Rasa – Amla, Lavana, Katuadhika sevena B) Guna – Ushna kshara adhika sevena C) Anya – Ajeerna dravyas and VishamaharamVihara Nidana - • Ati teekshna atapa sevena • Agni Santapa • Shrama • Krodha Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 15
  • c) VATAJA PRAMEHA NIDANA54: - Ahara Nidana’s A) Rasa – Kashaya, Katu rasa Ati sevena B) Guna – Rooksha laghu sheeta Ati sevena C) Anya – Anashana Vihara Nidana’s Vyavaya, ativyayama Shonita ati seka Udvega Abhighata Shodhana atiyoga Ratri Jagarana Atishoka Atapa Sevana Vega sandharana Vishama Shareera Nasyam1) Samanyaja (General) Along with the Nidana mentioned below which effect individual Dosha to vitiate the other factors, which affect the Kapha and Vata Dosha, are to be considered as Madhumeha Nidana. Table – 1 Showing the Vihara Nidana of Madhumeha 55 S.no. Nidana Charaka Susruta Vagbhata 1 Swapna Sukham + 2 Diva Swapnam + 3 Avyayamam + 4 Alasyam + 5 Chinta Tyaga 6 Swapna prasanga + 7 Shayana prasanga + 8 Asana prasanga + Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 16
  • Table – 2 Showing the Ahara Nidana of Madhumeha 56SN Ahara Nidana CS SS AH MN BS BP YR1 Dadhi + + + +2 Gramya, Oudaka, Mamasa + + + +3 Anupa Mamsa + + + + + +4 Payaha + +5 Navanna pana + + + +6 Guda vikara + + + + +7 Sheeta, Snigdha, Madhura + + Madya sevena8 Dravannapana sevena +9 Swadu, Amla, Lavana, Snigdha, + + Pichhila, Shutala ahara10 Sura sevana +11 Ikshu rasam + + +12 Adhyasana13 Medovardhaka AharaAtiSevena In general the factors pronounced here are self explanatory at the context, which aretabulated in the table differentiated as Ahara and Vihara, are for Prameha in general and alsospecific to the Madhumeha. Apart from the mentioned many factors are held responsible forthe causation of Madhumeha.Madhumeha Nidana 57 Charaka affirms direct or specific Nidana responsible for the production of Madhumeha, which are narrated is as follows – • Guru, snigdha, lavana rasatmaka dravya atisevana • Navanna and pana • Atinidra • Asya sukham Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 17
  • • Achinta • Avyayama • Asamshodhana These factors contribute to the vikriti of the Kapha, Pitta, meda and mamsa. Thesevitiated factors cause avarodha to normal Vata gati, which in turn carries the ojas to vasti thusresulting in Madhumeha.ETIOLOGY OF DIABETES MELLITUS58: - 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 Bloodvessels.Genetic factors: - Genetic factors are even more important than Types I diabetes. Amongidentical twins the concordance rate is 60% to 80% in first-degree relatives with type IIdiabetes the risk of developing disease is 20% to 40%. The two main defects thatcharacterized in type II diabetes are – a) derangements in the beta cell secretion of Insulin andthe b) decreased response of peripheral 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 insulinresistance. In Ayurveda, sthoulya is mentioned as a Nidanarthaka roga for prameha, and thisprameha falls under 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. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 18
  • Sedentary life: - People with sedentary life style are more likely to have diabetes arecompared to those who lead an active life. It is believed that exercise and physical activityincrease the effect of insulin on the cells.Hereditary: - Warren and Le Compet , a famous Diabetalogist, when both the parents havediabetes, all the children may expect to develop the disease, if they live long enough. Whenone parent has diabetes and the other is diabetic carrier, 40% of their children may developthe disease. If a diabetic or a carrier marries an individual who neither has diabetes nor adiabetic carrier none of the 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 predisposingfactors for diabetes mellitus.Samprapti of Prameha The process of manifestation of disease is called Samprapti or pathogenesis. Itincludes various stages as disease progresses. The detailed knowledge of 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 Dhatukshayatmaka59. Susruta not mentioned the detailed Samprapti, he just informs that; if allPrameha ill-treated or ignored get terminated in to Madhumeha60. Charaka explained thepathogenesis in an elaborative manner. Charaka enumerated the general Samprapti in Chikitsa sthana. He narrated that due toover indulgence of etiological factors, Kapha along with meda, mamsa and Kleda get vitiatedand results into formation of metabolic waste which carried towards basti resulting Prameha. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 19
  • In the same manner Pitta get vitiated resulting pittaja Prameha. Where in the Vata is provokedin turn causes depletion of Dhatu due to the depletion of other two Dosha by which theexcretion of sweet urine resulting vataja Prameha61. In Nidana Charaka described pathogenesis according to the type, where as the concisepathogenesis further described in Chikitsa in regard to Doshic predominance i.e. Clinico-pathological descriptions.(1) Kaphaja prameha Charaka narrated important explanation related to extent of nexus between Dosha,Dushya and Nidana in the disease manifestation. When we understand the above factors andtheir nexus we can easily diagnose the disease. We can understand the nature of the diseaseand we can profound the prognosis too62. The above assertion is very important in Pramehapathogenesis. An etiological factor first causes the provocation of Kapha because closeresembles to the related hetu. This provoked Kapha spreads all over the body quickly becauseof the Sharira shaithilya (weak assemblage in between tissues). While spreading it get mixedwith meda dhatu, which is excess in quantity and Abadha and having more properties withKapha. That’s why get vitiated first. This annexation of vitiated meda and Kapha comes incontact with sharira kleda and mamsa, which are already in excess quantity resultingPutimamsa pidaka On the other hand the vitiated Kleda get converted into Mutra. The Kaphaalong with meda and kleda covers the openings of mutravaha strotas resulting into Prameha63.Susruta narrated dushya in each doshic type of Prameha. He narrated vitiation of Kapha alongwith Vata, Pita and Meda in Kaphaja Prameha64. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 20
  • (2) Pittaja Prameha: Provoked Pitta due to its etiological factors manifests as pittaja Prameha Here samepathogenesis occurs as described in kaphaja Prameha65. Susruta66 narrated Sonita along withVata, Kapha and Meda in the pathogenesis of Pittaja Prameha More or less similar pathologyis described by Ashtanga sangraha and Ashtanga Hridaya67.(3) Vataja Prameha: Susruta narrated the typical dusya sangraha according to dosha. He explained that, InVataja Prameha, Kapha, Pitta, meda, vasa and majja takes part in pathogenesis68. DetailedSamprapti of Vataja prameha is described by Charaka as - Aggravated Vata because of itsown etiological factors draws out Sarabhuta dhatus from the body and carries them towardsVasti resulting into four types of vataja Prameha69. Another pathogenesis of vataja prameha is narrated in Chikitsa sthana is that, theprovoked Vata due to depletion of other two Dosha carries vital dhatus towards basti,resulting into vataja Prameha70.Pathogenesis of Madhumeha According to the Vagbhata two types of pathogenesis get precipitate because of thetwo types of etiological factors viz. (1) Dhatu ksaya janya, (2) Avarana janya and the thirdtype also persists is Kalaprabhavaja71.(1) Dhatu ksaya: Due to depletion of the vital dhatus, the Pathogenesis in this regard can beexplained is as follows. (a) Sahaja Prameha: Susruta mentioned that Sahaja Prameha precipitate because of defect in beeja72. Same thing explained by Charaka is that the Sahaja Madhumeha is a Kulaja Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 21
  • Vikara, because of the defect in beeja i.e. either Sperm or ovum73. Here the patient isprone to Dhatu kshaya because of above discussed factors which cause theMadhumeha.(b) Madhumeha due to Dhatu kshaya Charaka explained the pathogenesis in Nidana is that, due to specificetiological factors provocated Vata draws out the vital dhatus and carries themtowards vasti resulting into Madhumeha74. Here the provocation of Vata is because ofits own etiological factors causes diminution of Dhatu, so it is called that as theSamprapti visishta Anilatmaka Madhumeha. In this the pathogenesis is a geneticpredisposition in that patient makes him prone to get Madhumeha75(Tathavidhasarire).Madhumeha due to Sudha Vata: Charaka enumerated that due to depletion of Kapha and Pitta Vata getaggravate and causes the excretion of dhatus through urine resulting intoMadhumeha76. By observing above pathogenic processes, we can enumerate thefollowing things:(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 anddhatus. This in turn aggravates the Vata.(d) Such types of pathogenesis occur in those patients, which are prone to this diseasebecause of genetic predispositions.Remember here Vata is not aggravated by other Dosha etiological factors. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 22
  • (2) Avaranjanya Madhumeha: Though Vagbhata narrated the cause of Avarana janya Madhumeha type but notexplained the pathogenesis elaborately. Charaka emphasized this pathogenic process in wellelaborative manner. Due to excessive indulgence of heavy, unctuous, salty and sour diet,Avoidance of worry, an exercise and purification measure, the Kapha and Pitta get provokedand vitiates meda and mamsa. All are in excess quantity. They in turn cause obstruction to thenormal pathway of Vata. This obstructed Vata get aggravated and draws out the apara ojasfrom all over the body and carries it towards vasti resulting Madhumeha. One thing to be veryclear here that the provocation of Vata is precipitated because of the Kapha Pitta etiologicalfactors. Here mainly Vyanavata and Apanavata get aggravated.(3) Kalaprabhavaja Madhumeha: This type of Madhumeha is described by Susruta. He does not mention the directpathogenesis but narrated that, when all types of Prameha if ignored or ill treated. They getterminate into Madhumeha. This is not a separate entity but we can say that this is the laststage or further progression of kaphaja and pittaja Prameha or complicate stage of thedisease78.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 mandhya Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 23
  • Ama Aparipakwa DhatuUdbhava Sthana Amashaya (Medovaha srotomoola – vapavahana)Sanchara Sthana Sarva Shareera, (through Rasayani and Mootravahinis)Adhisthana VastiVyakta Sthana Sarva Shareera, Mootravaha srotasVyadhi Swabhava Chirakari All these factors responsible for the Madhumeha can be discussed in detail with eachfactor associations in the fallowing way.a) Dosha involvement • Kapha – having peculiar nature i.e., bahu drava described by Charaka. So we can easily understand the ‘shaithilya’ manifestation in this disease. So this bahudravatva of vitiated Kapha causes disruption in the assemblage of body elements and provide ground for the accumulation of marbid matter in the tissues. • Kapha having normal function as sthiratva, Chakrapani commented upon the word sthiratva means ashaithilya79 • Again Kapha Dosha is the dominant factor in the pathogenesis of Madhumeha. It gets vitiated primarily and causes the vitiation of concordant body elements like meda, mamsa, kleda, rasa, vasa, lasika etc. • The vitiation of Kapha here mainly is of excessive type. That’s why the following symptoms manifest in Madhumeha. These are shaithilya, alasya, atinidra, gaurava, etc. • Charaka clearly mentioned and Chakrapani opined that Kapha Dosha is dominant and primarily vitiated because of its close resembles with the etiological factors80. Pitta Dosha is not so dominant factor in the pathogenesis of Prameha. By the vitiation of Pitta, avaranjanya Samprapti of Madhumeha resulted. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 24
  • Rakta, sweda, lasika and rasa are the seats of Pitta Dosha so when Pitta get provoked, it undoubtedly causes the vitiation of above dushyas. That’s why the symptoms manifests are sweda vruddhi indirectly Agni vaishyam too. Here mainly the symptoms manifests because of vruddhi of Pitta Dosha (trusna, daha, ksudha and trunshavruddhi) 81 Pitta is in kshaya avastha in the vataja Prameha pathogenesis as compared to Vata. Vata is the main predominant Dosha in the pathogenesis of Madhumeha here Vata get aggravated either because of its own etiological factors or because of avarana caused by Kapha, Pitta and meda. This provoked Vata carries the vital constituents of the body like Vasa, majja and ojas towards vasti and excretes them outside through urine resulting depletion of the dhatus. Thus due to severe depletion of Dhatu, the symptom manifests are karsya, daurbalya, angasuptata and parisaranasheela nature. Charaka narrated that Dhatu gati is the function of normal Vata. Chakrapani opined that this gati is related with the transfer of rasa etc. towards poshya i.e. main dhatus. Thus these functions of Vata in bi fold digestion get hampered causing imbalance in Dhatu formation and their transformation in the body82.b) Dushya Involvement All authors narrated dushya sangraha and their involvement in the pathogenesis but Charaka specially enumerated a group and named it as a dushya vishesa again he mentioned them in Chikitsa also83. Susruta also narrated the dushya but he typically mentioned them along with the dosic type but he commonly included meda in each type84. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 25
  • Only Vagbhata mentioned sweda as a dushya along with the above dushyas85.Rasa Dhatu: This is one of the Dhatu mainly vitiates. Here because of its close resemblancewith Kapha qualitatively. If Kapha get vitiate rasa also get vitiate, that’s why having samesymptomatalogy related to vruddhi. This is mentioned by Vagbhata i.e., “rasoapislesmavat86.” Susruta emphasized that sthaulya and karshya results due to vitiation of rasaDhatu and practically we can found both conditions in the Madhumeha87. So the role of rasaDhatu is very much important in the precipitation of the disease. Vitiated rasa showsmanifestations like alasya, gaurava, krushangata, klaibya and Agni nasa in context toMadhumeha.Rakta Dhatu: Rakta Dhatu having not much involvement in the precipitation of theMadhumeha. It is mainly get vitiated prominently causing complication like pideeka, vidradhialasi88.Mamsa Dhatu: One of the main dushya described by Charaka he narrated it especially inkaphaja Prameha and avaranjaneya Madhumeha. Mamsa and Kapha have same qualities.They both give strength to the body. When get vitiated, mamsa losses its normal consistencyand develops shaithilya and provide space in between for the accumulation of morbid matter.Thus in turn results into the putimamsa pidaka89.Meda Dhatu: Meda vitiation is common and dominant dushya in the pathogenesis ofMadhumeha. Kapha and meda having close resemblance in regard to functions as well asqualitative parameters, thus both are getting vitiated more or less by same etiological factors.In Madhumeha vitiation of meda results by two ways as either Qualitative – abadha(asamhatam) normal function of meda is to produce unctuousness in the body along with Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 26
  • drahdhatva i.e., compactness so this abadhatva causes derangement in the structure of medaproducing shaithilya in the body. The second is Quantitative as bahu, here in the pathogenesis meda is in excessquantity. This medodhatu is aparipakva90. It obstructs the path of Vata along with Kapha. Thisprovoked Vata increases the Agni so patient unnecessary eats more and more food causingexcessive deposition of Aparipakva meda. This in turn cause severe depletion of the otherdhatus and produces various sign and symptoms. In Astanga sangraha, Vagbhata mentionedthat along with Prameha purvarupa excessive meda can cause diseases of sleshma, rakta andmamsa. Thus from above description it is clear that vitiated meda plays vital role in theprogress of pathogenesis and affects the normal physiology of various body elements.Arundadatta comments it as it is necessary to occur vitiation in meda when Madhumehaprecipitates. So this deranged meda produces following signs and symptoms. These aredescribed as medo Dosha91. Ayushor-hasa- life expectancy is get decrease because other dhatus could not get nourished properly Javoparodha – early manifestation of ageing Kruchra vyavayata – difficulty to perform sexual act and impotency, this again related with depletion of sukra i.e., abahutvat Dourbalya – this results because of the deranged metabolism occurring to malnourishment of the dhatus Dourgandhya – bad smelling is results due to excessive sweating and combustion of meda Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 27
  • Swedabadha – excessive sweating results because of the excessive meda and Kapha, patient is intolerable to exercise. Atikshuda and pipasa – excessive appetite and thrust because of the increased digestive power and Vata vitiation. By observing above description undoubtedly we can asser that, in Madhumeha pathogenesis meda plays leading role.Majja Dhatu: Majja is not vitiated in maximum extent but Vata causes its khsaya i.e.,depletion. Thus vitiated majja produces clinically symptoms like, netra gaurava and angagaurava in Madhumeha patient92.Sukra Dhatu: Sukra also get vitiated in the pathogenesis produces symptoms like durbalyaand kruchra vyavayata, because normal functions of sukra is to maintain deha bala. It alsoplays role in the precipitation of sahaja Prameha. Susruta narrated that sukra Dosha andPrameha get precipitate because of the vitiation of Vyanavata and Apanavata93. Thus one caneasily understand the close relation of sukra dushti in Prameha and Madhumeha.Vata cause depletion of shukradhatu and cause shukrameha.Ojus: – oja as dushya mainly involved in vataja Prameha i.e., ojomeha (Madhumeha).Provoked Vata due to its own etiological factors or due to avarana carries oja towards vastiand excrete outside through urine94, so the symptoms of oja ksaya manifests, like guru gatrataNidra, tandra and daurbalya95. Charaka narrated ruksta i.e., related to ruksa shareera so onecan easily understand the manifestations of krusa pramehi or sahaja pramehi of course thevitiation of apara oja occurs here. Hence it is prime concern to find out the oja vitiation in thepathogenesis to assert the extent of severity.Kleda: – The literary meanings of kleda are wetness. Moisture and dampness etc. thephysiology of kleda is mainly related with mutra and sweda along with meda. Thus when Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 28
  • kleda is involved then it directly affects the above factors. There is no direct referenceregarding to the function of kleda in the body but Arundatta commented that, if kleda is notpresent then there is manifestation of dryness in the body. So indirectly we can say that thekleda proper in quantity is important to maintain the unctuousness in between the tissues. Innormal physiology mutra and sweda maintain the balance of kleda. Especially sweda holds itin the body and mutra excrete it outside the body96. According to the body condition andrequirement, if this kleda is get vitiated it directly affects the physiology of mutra and swedadisrupts the assemblage of bodily elements causing shaithilya. Thus the symptoms manifestsdue to kleda vitiation are prabhuta mutrata, sweda vruddhi, saithilya, daurgandhya andavilumootrata.Sweda – this is mentioned by Vagbhata, as Sweda is mainly related with meda and kleda.When the Sweda vaha srotodusti occurs due to vitiation of meda and kleda., the normalphysiology of Sweda get disturbed resulting in manifestations like Sweda vruddhi,dourgandhya, picchila gatrata, snigdha gatrata, etc. Susruta mentioned that even the Swedabecomes sweet in nature97.Vasa: Charaka described it as a subtype of vataja Prameha i.e. vasameha. Vasa is theupadhatu of mamsa and the unctuousness present in the mamsa Dhatu is called vasa. Thus wecan easily understand that in Prameha mamsa is one of the main dooshya so in turns vasa tooget vitiate98.Lasika: This is one of the liquid materials of body, present just beneath the skin. Lasika alsoget vitiated by vata resulting lasikameha. There is no direct reference related to vasa andlasika dushti99. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 29
  • Srotas involvement Madhumeha is the disease mainly of systemic consideration. In the pathogenesis thereis involvement of each and every constituent of the body. In the pathogenesis there isreference of sroto dushti only related to mutravaha srotas. When we observe the pathogenesisand symptomatalogy of Madhumeha, we can easily understand the involvement of medovahamamsavaha, swedavaha and udakavaha srotas too. In the pathogenesis we can found the twotypes of srotodusti – Atipravrutti and Vimargagamana.Thus we can find out the srotas involvement according to the symptoms observed is follows - Purvarupa of Prameha – medovahasrotas dusti Putimamsapidaka – mamsavaha srotodusti Trsna mukha talu sosha – udakavaha srotodusti Atisrusta abhiksna mutrapravrutti – mutravahasrotodustiAgni and Ama There is no direct reference related to the Agni condition but both Agnimandya andtikshna Agni conditions present in the pathogenesis again without Ama it is impossible toprecipitate the pathogenesis of Madhumeha that’s why Susruta narrated that, aparipakvacondition of Dhatu is related with Ama mainly. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 30
  • Figure – 1 Madhumeha Samprapti Avarana janya Apathyanimittaja Sahaja Madhumeha Madhumeha Madhumeha Nidana sevana Beeja Dosha Vikruta bahudrava Kapha Travels all over the body because of shareera shithilata Medo dhatwagni mandya Sthoulya Medovaha srotas vitiation Bahu abaddha medas Kapha Pitta Meda Mamsa Dosha dushya sammurchana Ativruddhi Bahudrava sleshma with bahu abaddha meda Obstruction of Vata due to Vitiation of other dushya avarana by vitiated Kapha Pitta and Meda Adhika kledata of DhatuSqueezing of Ojas in to vasti Vasti Madhumeha Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 31
  • Manifestation of DM 100 Diabetes mellitus is characterized by glucose concentrations that are high enough toover whelm the reapportion capabilities of the kidneys. Glucose appears in urine and urineproduction generally become excessive. Other metabolic products, such as fatty acids andother lipids are also 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.Life style clearly plays a role and clearly evident when obesity is considered. Genetic factorsare even more important than in type I diabetes. The two metabolic defects that characterizetype II diabetes are – 1) Deranged beta cell secretion of insulin and 2) Decreased response ofperipheral tissues 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 maybe observed, attributed to beta cell hyper responsiveness to physiologic elevations in bloodglucose. With the development of overt disease, the pattern of insulin secretion exhibits asubtle change. Early in the course of type II diabetes, insulin secretion appears to be normaland plasma insulin levels are not reduced. However normal pattern of insulin secretion is lostand the rapid first phase of insulin secretion triggered by glucose is obtunded. Collectivelythis and other observations suggest derangements in beta cell responses to hyperglycemiaearly in type 2 diabetes rather than deficiencies in insulin synthesis. A mild to moderate deficiency of insulin develops later in the course of type IIdiabetes that is less severe than the- type I. The reason for this is not clearly known butirreversible beta cell damage appears to be present. According to one view, all the somatic Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 32
  • cells of predisposing individual including pancreatic beta cells are genetically vulnerable toinjury, leading to accelerated cell turnover and premature aging and finally to reduction inbeta-cells mass. Chronic hyperglycemia may exhaust the ability of beta cells to function(called glucose toxicity), as a consequence of persistent beta cell stimulation.b) Insulin Resistance Insulin deficiency is present in the course, of type II diabetes. Reducedresponsiveness of peripheral tissues i.e. insulin resistance, is a major factor in thedevelopment of type II diabetes. In obesity it is very much prominent or clear. The molecularbasis of insulin resistance is not clear. There may be a decrease in the number of insulinreceptors and more important post receptor signaling by insulin is impaired. Also the insulinresistance 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 pathogenesisof the diabetes mellitus on obese individuals. If the pancreas is healthy and if it secretessufficient insulin even this obese people will also won’t get diabetes mellitus. There is noexplanation regarding insulin resistance in Ayurveda. Even in some recent literary worksmedo dhatwagni is correlated with insulin. But, no proves are available for exact co-relation.If we see the pathology, we can see that the concept of Agni plays a great role i.e. Agnimandya is considered to play key role in the formation of aparipakwa Dosha and dushyaswhich is the main defect behind Madhumeha. The other factors responsible for manifestation of the DM are - Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 33
  • 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 pathogenesisof Madhumeha. In classics it is mentioned that vapavahana is the moola sthana of medovahasrotas, and which can be considered as pancreas. But there is no much description inAyurvedic classics regarding vapavahana. Charaka has explained that the vapa vahana is anudarasthaanga and he also says, it is having the shape of taila varti. So on the basis of thisphysio-anatomical similarity, we can co-relate the vapavahana with pancreas. But kloma alsoconsidered as pancreas by some authors of Ayurveda. As pipasa mentioned as a kloma vikritilakshana, which is the main characteristics of the Madhumeha, here it can also co-relate withthe 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 byatrophy of the normal tissue, particularly Islet epithelial cells. In more advanced lesions, theIslet is more or less converted to amyloid and the reduction in the number of insulin secretingcell is more pronounced than that of glucagons-secreting cells. Heavy deposition of amyloiditself is rare without diabetes. In normal state sthiratwa, dardya, utasaha, vrishada, buddhi, etc are contributed bykapha, which is also known as bala or oja. By seeing this we can co-relate this Kapha withglucose. In Madhumeha the Kapha which is vitiated and which is in bahu dravata form travels Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 34
  • all over the body in rasa produces tanu madhuryata, which can be taken as hyperglycemia i.e.increased blood 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 aresituated in 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 inAyurveda and in modern science. To prove the above ideas correctly, further studies areneeded.Classification of Prameha Knowledge of classification will helps in proper understanding of the disease and toformulate an effective treatment protocol. In classics various types of Prameha had beendescribed based on many factors. Though Prameha is stated to be a condition due to thevitiation of all the three doshas, the disease is mainly divided in to 3 groups101 Kaphaja Pramehas - 10 Pittaja Prameha - 06 Vataja Prameha - 04Though there is a similarity in the opinion of Brihatrayes regarding the numbers of pramehasin each group. But they seem to be different in the nomenclature used by them. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 35
  • Table - 3 TYPES KAPHAJA PRAMEHASl Names Charaka Susruta Vagbhata Madhava1 Udaka meha + + + +2 Ikshu meha + + + +3 Sandra meha + + + +4 Sandraprasada Meha + Sura meha Sura meha Surameha5 Sukla meha + Pista meha Pista meha Pistameha6 Sikata meha + + + +7 Sita meha + Lavanameha + +8 Shanair meha + + + +9 Lala meha + Phena meha Lala meha Lala meha10 Shukra meha + + + + Table - 4 TYPES OF PITTAJA PRAMEHASl Names Charaka Susruta Vagbhata Madhava1 Kshara meha + + + +2 Kala meha + Amla meha + +3 Nila meha + + + +4 Lohit meha + Ahinitameha Rakta meha Rakta meha5 Manjishtha meha + + + +6 Haridra meha + + + + Table - 5 TYPES OF VATAJA PRAMEHA Sl Names Charaka Susruta Vagbhata Madhava1 Vasa meha + - + +2 Majja meha + Sarpi meha + +3 Hasti meha + + +4 Madhu meha + Kshaudra + + meha Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 36
  • From above classification it is very necessary to find out the basic ideology behindthis. Vagbhata clearly narrated that these types result because of the nexus between Dosha,Dushya and their specific combination according to concordance. That’s why in each subtypespecific urine is voided102 Charaka put forth his theory that all these types and theirnomenclature is because of the specific qualities and their combinations with each other but,the nomenclature is mainly based apoun the predominance of one quality103. Chakrapani also commented that the nomenclature is because close resembles of urinewith particular quality (guna) i.e. Sitameha, Suklameha etc. When we go through in detailwith this classification we can easily understand the Dosha predominance, Again dushyainvolvement, again nature of urine voiding and we also can find out the etiological factors,State of the disease and progression.Classification According to Prognosis Table – 6 Showing Prognosis of Madhumeha Sadhya (curable) Yapya (Palliative) Asadhya (incurable)Kaphaja Pittaja VatajaSthoulya Usually not much obese KrushaAcquired Acquired HereditaryEarly stage Acute stage Advance stageWithout complications With complications With complicationsClassification of Madhumeha Madhumeha is one of the subtypes of Vataja Prameha, can result with variousetiological factors mainly. It can be classified according to the build related with geneticpredisposition. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 37
  • (1) Based upon the etiological factor(i) Sahaja (Hereditary) (a) Etiology - Charaka and Susruta narrated Jata pramehi because of beeja Dosha emphasized it as Kulaja Vikara. It is said as incurable. Defect in beeja i.e. in sperm / ovum or defect in beeja Avayava i.e. in chromosome. This theory mainly supported by the modern science too104. (b) Body constitution: Susruta along with etiology narrated the body constitution of Sahaja Prameha / Madhumeha; Charaka mentioned the word Krusha especially for easy understanding of the same along with the treatment.(ii) Apathya nimittaja: (Acquired) Susruta etiological factors denote the subtype Apathya Nimittaja. It can be againclassified into following manner, related with etiology and Patho-physiology105.(a) Avarana janya and Dhatu apakarsanjanya This type of classification mainly related with etiology and patho-physiology. In this,Avarana janya pathogenesis is due to the etiological factors mainly corresponding with Kaphaand Pitta where the vitiation of Vata occurs due to avarana. Dhatu apakarshana janyapathology occurs due to depletion of dhatus because of the vitiated Vata106.(b) Santarpanjanja and Apatarpanjanya This classification mainly narrated by Charaka when describing the treatment of thePrameha. Classification mainly based apoun the overnutrition and undernutrition. SoSantarpanajanya Madhumeha can be correlated with Avaranjanya Madhumeha andApartarpanjanya can be correlated with Dhatuapakarshanjanya Madhumeha107. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 38
  • (c) Anilatmaka and Kaphasambhava Charaka mentioned that when we observed the urine of the patient Picchila, madhuraand Madhusamam. Then we should have to consider two factors i.e. this Madhumeha is eitherof Vatatmaka or either of Kaphasamphava. Here what literally missed is the Pitta role, fromthis description we can postulate the theory that in Madhumeha is mainly due to the Vata andKapha predominance though the disease is said as Tridosha janya.CLASSIFICATION OF DIABETES MELLITUS 108 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 deficiencyto a 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 Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 39
  • 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 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 othersH) Other genetic syndromes sometimes associated with diabetes. a) Dawn’s syndrome, b) Klenefelter’s syndromes etc.I) Gestational Diabetes Mellitus (GDM) Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 40
  • 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. In classics the classification of a disease made it clear that for the sahaja Pramehabeeja Dosha have been mentioned as causative factors. Such patients are said to be weakemaciated. Suffering from thirst, loss of appetite and are required to be treated with anourishing diet. In contemporary science the genetic and hereditary factors are mentioned as causativefactor. Such patients are weak emaciated and they are asthenia. The above-mentioned patientis juvenile diabetes and requires a nourishing diet, so sahaja Prameha can be consider asjuvenile diabetes.Poorva roopa of Madhumeha The Symptoms, which are produced during the process of sthanasamshraya avastha,are called 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. In Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 41
  • ancient Ayurvedic treatises common premonitory symptoms are described but specialpremonitory synmptoms of Madhumeha are not mentioned. Table - 7 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 abovedescription but Susruta makes it easy by narrating and shloka that a man with slight increase Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 42
  • in the urine output along with the premonitory symptoms showed is consider as the patient ofPrameha 109. Apart from above premonitory symptoms and signs only few of them are cardinal signand symptoms of Madhumeha. These are pipasa madhura mootrata, asyamadhurya, angadaha. There is no direct explanation of the poorva roopa of Madhumeha as such. But poorvaroopa of Prameha can be considered as poorva roopa of Madhumeha.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. Theprabhoota mootrata can be considered in terms of increased volume of urine and frequency ofmicturition. Avila mootrata refers to increased turbidity of urine. Roopa means symptoms of the actual manifestation of disease. At this stage Doshadushya samoorchana would have been completed and the onset of the disease would havebeen commenced. Madhavakara explains it as when symptoms in the stage of poorvaroopabecome fully or clearly manifested they are called roopa110. Roopa is the prominent diagnostickey of a disease and hence thorough knowledge of the various roopa of each disease essentialfor a physician. Signs and symptoms of the disease are the diagnostic tool manifests when thepathology of the disease is in full context. The symptomatalogy of Madhumeha is ascertainedby Ayurveda in broad manner to understand them need to elaborate as follows. Susrutanarrated that the person should be diagnosed as pramehi when complete to partial prodromalsymptoms of Prameha accompanied by polyuria get manifested111. In this regard Gayadasaopined that in this disease all prodromal symptoms get converted into rupa due to specific Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 43
  • nature of the disease i.e. vyadhiprabhava. From above description we can say that theprodromal symptoms along with chief symptoms get continued as the disease progress.1) SAMANYA LAKSHANAS 112: - Samanya Lakshanans of Madhumeha are those which are ascribed to Prameha, theyare i) Prabhoota mootrata and ii) Avila mootrata.i) Prabhoota mootrata: - The increase in quantity and frequency is known as prabhoota mootrata. It ismanifested due to increase of sharreera kleda, the reasons for which are explained in thecontext of Samprapti. The frequency is increased due to vitiation of apana vayu. Due tohyperglycenia in madhumeha, glycosuria manifests which in terms hampers the tubularabsorption of water leading to polyuria.ii) 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 thespecific gravity of the urine.2) VISHESHA LAKSHANAS 113 In Madhumeha mootra is manifested with Kashaya, Madhura, Rooksha, Pandu andmadhu Sama lakshanas. Bhavaprakasha clarify the controversy of the word kashaya askashaya varna. The implication of this term is still debatable. The presence of madhura rasa inmootra is mainly because of ojo visramsa into mootra, which can be easily understood bypipeelika abhisarana and by qualitative analysis of urine test. Rooksha guna is due to vitiationof vata. Pandu varnata of mootra is because of kleda dusti which influences Kapha to attainmore liquid state. Madhusama mootra implies the colour, smell and taste of mootra similar to Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 44
  • that of madhu. It has to be understood that along with the samanya lakshanas madhusamamootra is the pratyatmaka lakshanas of Madhumeha. Table – 8 Lakshana of MadhumehaSN 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 Vatabecause of its prabhava converts madhura oja into kasaya rasa. Susruta mentioned theresemblance of urine with honey as described above. Similar description in asserted. In Chikitsa sthana Susruta before propounding the treatment of Prameha, asserted twotypes of Prameha along with their features as follows114.1) Sahaja Prameha (Krusha) Rooksha Alpashi Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 45
  • Bhrsa pipasa Parisarana sheela2) Apathya nimittaja (Sthoola) Bahu ashi Snigdha Shayyasana swapna sheela Asana, Swapnasheela the Samprapti of Apathya Nimittaja madhumeha has beenexplained earlier. The vitiation of Kapha, Kleda, Medas is due to the indiscreet food habits.Thus leads to the medovaha Srotodusti due to medodhatwagni mandya. Thus the persondevelops sthoulya. The samana Vata avarodha in koshta is the reason for prabhuta agni fromwhich the person desires and consumes more food. It has been said earlier that the medasthana is the pitta sthana and hence the Vata in kosta is obstructed which later lead to theexcessive secretions of Pitta in Amashaya which results in the above said lakshanas. Theaffected person is termed as snigdha due to the karmataha vruddi of Kapha. Madhumeha isone among the 20 types of pramehas. So these may be present in madhumehi.Madhumeha lakshana 115 Susruta gives explanation regarding the lakshanas of Madhumeha, as follows – a) Gamanat sthananichati b) Sthanat asananichati c) Aasanat sayyamichati d) Shayanat swapnamichati.Apart from the above lakshanas urine similar to honey in colour and taste are also attributedto Madhumeha. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 46
  • Clinical Features of DM 116 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. Theglycosuria induces an osmotic diuresis and thus polyuria, causing a profound loss of waterand 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, cataboliceffects prevail, resulting in weight loss and muscle weakness. Frequently, however thediagnosis made after routine blood or urine testing mainly in asymptomatic persons. Whenever the quantity of glucose entering the kidney tubules in the glomerular,filtrate rises above approximately 225 mg/min, a significant proportion of the glucose beginsto spill in to the urine and when the quantity increases above about 325 mg/min, which istubular maximum for glucose. All the excess, above this is lost in to urine (Glycosuria). Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 47
  • 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 withother dooshyas mainly kleda pradhana dooshyas in the vasti is the cause for prabhootamootrata. The same reason has been given in modern science for polyuria that the osmoticdiuretic affects of glucose 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 topipasa of Ayuredic science, here due to excessive loss of the urine; pipasa is noted. Bahukankshata has been mentioned as a lakshana in apathya nimittaja madhumeha,the same 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. 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. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 48
  • Differential 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. Deepknowledge and untiring practice are the means to perfection as Vagbhata has rightlymentioned “abhyasat prapyate dristihi karma siddhi prakashini”. Madhumeha is a mootra atipravruttaja vikara with prabhoota and avila madhusamamootrata as pratyatma lakshana. Although there are many diseases presenting withAtipravrutti of mootra, the diagnosis of Madhumeha is usually a straight forward propositionby differential diagnosis of the following with its sweet uriantion.Mootra lakshana (Pravartana Nimitta) Symptoms1) Abhikshnam (Muhurh muhurh, Punah a) Ashmari (C. Ci. 26/38)punah : Subahushah, vikiranam b) Mutratita (S. U. 58/12) c) Vatika mootrakrichra (C. Ci 26/32) d) Ushna vata (Ah. N. 9/36)2) Atipravrutti a) Amavata (M. N. 25/9) b) Arsha poorvaroopa (As. N. 7/7) c) Sahaja arsha (C. Ci. 14/8) d) Kaphaja arsha (C. Ci. 14/17) e) Mutra praseka (S. Ci 7/36) f) Upasthita prasava (S. Sa. 10/7) g) Chidrodara (C. Ci. 13/44) h) Asadhya masurika (M. N. 54/27) i) Ama jwara (C. Ci. 3/135) Moreover within the preview of the disease Madhumeha, the Kapha, Pitta and Vatahave characteristic presentations, which have been described in such a way as not to leave anyscope for doubt. In other words, if a patient presents with mootra atipravrutti, lakshanas ofKapha, Pitta or Vata like shukla mootrata haridramootrata or vasa mootrata and if they areassociated with Prameha poorvaroopas then the disease is per se Prameha or Madhumeha.Charaka explains this concept giving the example of a situation where one comes across a Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 49
  • patient who is presenting with haridra or rakta mootrata. Here the absence of Prameha poorvaroopas will prove the existence of rakta Pitta and exclude Prameha 117. In the presence of madhura and picchala lakshanas of Prameha, one should considertwo possibilities for differentiation whether the condition is anilatmaka due to Doshaksheenata or kaphasambhava as a result of santarpana. As discussed earlier, here one should essentially consider Madhumeha as aconsequence of vata vruddhi as a result of dhatukshaya where Vata is the anubandhya Doshaand Madhumeha as a result of margavarana janya vata vruddhi where Vata is an anubandhadosha and is directly dependent upon Kapha, which has undergone vruddhi because ofsantarpana. The factors for differentiation 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 Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 50
  • 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. Prabhoota mootrata means atipravrutti of mootra. It goes without mentioning thatthere is also an increased frequency of micturition and Avila mootrata means AtyarthaKalusha Samalam or Malinam akulam which means that there is a considerable change in thequality of urine as per the above mentioned factors. Considering these factors, it becomescontextual to enumerate the conditions where there is increased frequency of urine andabnormality in its quality. Most of the times these symptoms are associated with mootravahasrotodusti and other diseases where differentiating Madhumeha is not a problem for evidentreasons. It becomes relevant to consider the following conditions where hyperglycemia iscommon manifestation under the heading of differential diagnosis.Differential diagnosis 1181) Diabetes mellitus & Endocrine disorders:a) Pituitary gland 1) Pituitary diabetes due to growth hormone 2) Acromegaly 3) Diabetes insipidusb) Adrenal Cortex 1) Cushing’s Syndrome 2) Steroid diabetes due to administration of steroids 3) Primary Hyperaldosteronismc) Adrenal Medulla 1) Phaeochromocytoma 2) Addison’s disease 3) Adrenalectomy Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 51
  • d) Thyroid 1) Hyperthyrodism 2) Myxoedema2) Pancreatic Diabetes 1) Acute pancreatitis 2) Mumps (rarely) 3) Chronic pancreatitis 4) Haemochromatosis 5) Total pancreatectomy 6) Carcinoma of pancreas3) Diabetes liver 1) Cirrhosis of liver 2) Gall Stones4) Drugs & diabetes Thiazide, Chlorthalidone, frusemide, oestrogen containing oral contraceptives, β blockers & catacholaminergic drugsV Miscellaneous 1) Type I glycogen storage disease 2) Down’s syndrome 3) Turner’s Syndrome 4) Huntington’s chorea 5) BurnsConditions of polyuria Polyuria should not be confused with prostratic hypertrophy or cystitis because here itis only increased frequency of micturition & not increased quantity. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 52
  • 1) Polyurea due to water diuresis Cranial or neurogenic diabetes insipidus: This is due to an identifiable lesion in thehypo thalamus pituitary or both leading to failure of A.D.H. Nephrogenic diabetes insipidus:Familial form seen in males only also as an accompaniment of Fanconi syndrome.Psychogenic polydipsia or compulsive water drinking this is a hysterical condition. There isclinically marked fluctuation here.2) Polyurea due to increased solute load Diuretic therapy Chronic renal failureUpadravas Charaka enumerated the general complications while Susruta and Vagbhata describedaccording to the Dosha predominance.(1) Samanya Upadrava These are Trsna, Atisara, Jwara, Daha, Daurbalya, Arocaka, Avipaka,Putimamsapidaka, Alaji and Vidrdhi. Chakrapani opined that these complications manifestbecause of the long term Anubandha of Prameha disease119.(2) Vishesha Upadrava (a) Kaphajameha Janmanam: Makshikopasarpanam, Alasya, Mamsopacaya, Pratisyaya, Shaithilya ,Arocaka, Avipaka, Kaphapraseka, Ccardi, Nidra, Kasa and Swasa 120. (b) Pittajameha Janmanam: Vrsandaavadaran, Bastibheda, Medhratoda, Hrdisula, Amlika, Jwara, Atisara, Arocaka, Vamathu, Paridhupanam, Daha, Murcca, Pipasa, Nidranasa, Panduroga, Pitvidmutranetratva and Vidbheda 121. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 53
  • (c) Vatajameha Janmanam: Hrdgraha, Laulyam, Anidra, Stambha, Kampa, Sula, Badhapurisatvam, Sosa, Kasa and swasa122.When we observe the above complications, only few of them are looking fetal like, Moorcha,Hrudgraha, otherwise all other complications seem to be associated symptoms or signs in thedisease progression.Upadrava related to Madhumeha Charaka mentioned the Sapta Pidaka as complication, because of the negligence ofthe Madhumeha123, while Susruta mentioned that Madhumeha along with Pidaka is Asadhya,He quoted that these Pidaka causes because of the Tridosha and because of the vitiated Medaand Vasa. Susruta and Vagbhata mentioned 10 Pidaka while Caraka mentioned only 7 Pidakathese are also follows. Table – 9 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 + + + Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 54
  • COMPLICATION OF DIABETES MELLITUS 124 Some upadravas can be correlated to some of the complications of modern sciencesfor e.g.- thrishna, bhrama, shoola, tamapravesha, swasa etc with that of the ketoacidosis inwhich all these symptom are seen and even in hypoglycemic condition also. It can beclassified into two groups 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 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.Sadhyasadhyata of Madhumeha(1) Sadhya - Kaphaja Prameha Etiological factors are same to that of Dosha, Dushya and having same qualities andsame seat. So the treatment is same for both. That’s why Kaphaja Prameha is Sadhya125.Charaka explained 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 Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 55
  • bhutatvat. Asadhyta incurability results because the vitiation of Kapha that occurs along withdifferent quality Dushya like Raktadi. The treatment proved to be Viruddha i.e. apposite toeach other, Vikrti bhutatvat as said by Chakrapani126.(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 relatedto the Kapha and Meda. So we should have to consider both of them, there are very fewmeasures, which act against the Vata and Kapha combined127.(3) Yapya (palliative): Pittaja Prameha is palliative that means the disease needs continuous treatment. Oncethe treatment stopped, suddenly disease get provoke because of the apposite treatmentmeasures we have to profound here i.e. Visama kriyatvat.(4) Asadhya (Incurable) Vataja Prameha is incurable because there is involvement of vital Dhatus like Majja,Oja in the pathogenesis and the treatment modalities quite apposite to Dosha and Dushya128.Susruta mentioned that if Kaphaja and Pittaja Prameha or All types of Prameha if not treatedproperly or ill-treated become Asadhya129.(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 ofMeda then Kaphaja and Pittaja both Prameha become Asadhya. Charaka mentioned thatMadhumeha because of the Beeja Dosha i.e. genetic predisposition is incurable. Susrutamentioned that Madhumeha in association with complication i.e. Pidaka is incurable130. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 56
  • CHIKITSA IN MADHUMEHA Chikitsa sutra (principles of treatments) and Chikitsa (Management Proper) are thetwo divisions of this major part. Both these are described very well in classics. But theconcepts & methods are different in different conditions, considering the Vyadhi swabhava &Atura. The Samprapti should be considered deeply before stepping to manage. The eminent ancient ayurvedists, Charaka, Susruta and Vagbhata are considering thebody constitution and strength of the body of the patient when dealing with the managementaspect. Charaka considers two types of patients; one is that with stout body structure & withstrength and the other without strength and krusha. Sushrutacharya also says that sahaja meharogi will be krusha & apathyanimittaja rogi will be sthula. In the context of medoroga, the managements described are parallel to that of mehasince the Dosha and dushyas are same to major extent. After considering all the factors thetwo types of management emphasized are: (1) Samshodhana Chikitsa (Elimination Therapy) (2) Samshaman Chikitsa (Normalizing Therapy)Like every disease, those factors which are responsible for the production of the diseases areif eliminated and if further, causative factors are prevented meha can also be treated.Madhumeha can be treated in this way although it is described as incurable. In Pratyakhyeyavyadhis, symptomatic relief can be given by proper management.1) KAPHAJA PRAMEHA 131(i) Samshodhan Chikitsa It is better to treat the patient with Vamana therapy. Charaka describes that shodhana,vamana and langhana done at the proper time looking at the condition of the patient is able to Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 57
  • cure kaphaja meha. For vasti Chikitsa Vagbhata describes the utilization of Surasadi ganakwatha. After explaining the shodhana the palliative treatment given is samshamana Chikitsain all types of Madhumeha.(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 amalakiwith Haridra powder with madhu. Susruta in this context explains single drug decoctions withseparate indications in 5 types of kaphaja meha and combinations in other 5 types. Vagbhatadescribes three yogas in this aspect. They are as follows;(i) Lodhradi- Lodhra, Abhaya, Musta, Katphala(ii) Pathadi - Patha ,Vidanga ,Arjuna,Dhanyaka(iii) Gayatrayadi - Khadirsara, Darvi, Vidanga ,VachaImportance of Apatarpana: Charaka explains the cause of Prameha as due to increasing attitude of kleda, meda,and Kapha. So he emphasizes the role of Apatarpana in kaphaja & Pittaja Prameha. Differenttypes of vyayama, kshut, udvartana, dhara & snana with churnas made of Chandana, Aguru,Ela etc. are advised to use in kaphaja meha.2) PITTAJA PRAMEHA 132(i) Samshodhan Chikitsa Virechana is best in pittaja pramehas. The drugs which are sufficient to eliminatemorbid Pitta can be used with sheeta and other tikta, kashaya rasa in this. Nyagrodhadi ganakwatha is advised for Asthapanbasti by Vagbhata. Susruta has described that due to spreadingof medo dhatu all over the body, Madhumehi subjects are durvirechya. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 58
  • (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 133-(i) Ushiradi : Ushira, Lodhra, Arjuna, Chandana.(ii) Patoladi: Patola, Nimba, Amalaki, Amrita(iii) Lodhradi : Lodhra, Ambu, Kaleyaka, Dhataki3) VATAJA PRAMEHA 134 Although vataja mehas are incurable still Charaka explains to induce certain treatmentin Kapha 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 forvatika meha can be considered as treatment of Madhumeha.MADHUMEHA 135 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 siddhaTaila or Trikantakadya Sneha (Ghrita or Taila according to Dosha predominance should beused for Abhyantara Snehana. Here while explaining the Samshodhan, Charaka describes touse the Malashodhan yogas from Kalpa sthana Both Pitta and Kapha are eliminated throughshodhana. It may be vamana or virechana, because of Pittantam Vamanam, KaphantamVirechanam. In Virechana Pitta is eliminated first, then Samyak lakshana of virechana iskaphadarshan, so both Pitta and Kapha doshas which are vitiated are eliminated. Then the Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 59
  • described Anuvasana & Asthapana Basti chikitsas are able enough to control the provocationof Vata. Like this all the doshas are normalized to keep the Dosha samyata. Anuvasana withmedicated oils and ghritas are prescribed in Madhumeha. After proper Shodhan Chikitsa,Charaka details to give santarpana Chikitsa to the patients, to prevent the complications likeGulma, 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 Chikitsato the patient. Acharyas introduces different tarpana upakramas in vatika mehas. It is due tothe less strength of the patient. Acharya Charaka & Vagbhatta says that the kashaya yogasshould be enriched with sneha and given to vatika mehas .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 prescribesto take 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 Guggulu Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 60
  • Modaka : 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,Prameha gajkesri Rasa, Trivanga Bhasma, Vasant tilaka Rasa.MANAGEMENT OF DIABETES MELLITUS 136 Management, rather than treatment, is the appropriate term in Diabetes mellitus, andinvolves diet, exercise, insulin, oral hypoglycemic, patient education and counseling. Insulinand oral drugs are discussed here and the other aspects of management in subsequentchapters.INSULIN: Insulin is required for treatment of all patients with IDDM & many patients withNIDDM. No single standard exists for patterns of administration of insulin and treatmentplans vary from physician to physician. With a given physician for different patients threetreatment regimes will be described. Viz. Conventional, Multiple subcutaneous injections(MSI) and Continuous subcutaneous insulin infusion (CSII).Conventional Insulin Therapy: Conventional therapy involves administration of one or two injections a day ofintermediate acting insulin such as zinc insulin (NPH insulin) with or without the addition ofsmall amounts of regular insulin. This practice is based on the concept that regular insulin Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 61
  • lowers the plasma glucose level rapidly after which more slowly absorbed insulin maintainsthe lowered level. Here patients should be taught to decrease insulin when extra exercise isanticipated.Multiple subcutaneous insulin injection technique (MSI): Most commonlyinvolves administration of intermediate or long acting insulin in the evening as a single dosetogether with regular insulin prior to each meal. Continuous subcutaneous insulin infusion (CSII): This involves the use of a smallbattery driven pump that delivers insulin subcutaneously into the abdominal wall.Adjustments in dosage are made in response to measured capillary glucose values, as in MSI.Though CSII provides better Diabetic control, there is a higher risk of Hypoglycaemia andDiabetic Ketoacidosis.ORAL AGENTS: Sulphonyl ureas: NIDDM that cannot be controlled by diet & exercise often responds to sulphonyl ureas. Sulphonylureas, like Chlorpropamide & Tolbutamide, act primarily by stimulating release of insulin from β cell, but are useful only in patients with relatively mild disease. Second generation drugs such as Glipizide & Glyburide are effective in smaller doses and differ little from Sulphonylureas. Hypoglycemia occurs less often with oral agents than with insulin. But when it occurs it tends to be severe & prolonged. Biguanides: Metformin is useful in NIDDM patients who are not responsive to diet & exercise. The primary action is thought to be inhibition of hepatic gluconeogenesis & it also may enhance glucose disposal in muscle & adipose tissue. Melformin does not cause hypoglycemia unlike sulphonylureas, metformin can cause lactic acidosis hence should not be given in patients with renal disease. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 62
  • Thiazolidinedione derivatives: Such as troglitazone, lower blood levels of glucose, free fatty acids & triglycerides and appears to reduce insulin resistance. Troglitazone is approved for use in obese patients with NIDDM who are poorly controlled on insulin.PATHYA-APATHYA 137 Those Aahara and vihara which are suitable to pramehi are called Pathya and thosewhich induce Prameha are called Apathya. Pathya is having a key role in the management ofMadhumeha. Even in modern science also Diet & Exercise are included in diabetesmanagement. So before stepping to manage we have to consider for the Pathya-Apathya.Pathya and Apathya Aharas and Viharas according to different Ayurvedic classics are asfollows: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,Yusha Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 63
  • Others: Madhu, Hingu, Saindhava, Maricha, Lasuna(b) Vihara: To have walk, traveling on elephants, horses and different plays, different formof marshal 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.TRIAL DRUG (AKULYADI YOGA) REVIEW Medicine is the prime concern when disease manifests. Madhumeha is the diseaseprimarily of metabolic derangement includes vitiation of various body elements. Excessiveformation or deranged Meda, Kleda, Vasa and Lasika along with the depletion of vital Dhatuslike Oja and Majja cause the Vata provocation and ultimately Madhumeha. Thus line oftreatment should be to reverse the pathogenesis with the help of Samana as well as Sodhana.The medication should posses, as discussed in Chikitsa, Tikta and Kasaya Rasa along withKapha Vata hara, Medo hara, Kledaghna and Prameha hara properties. Thus the selectedcombination – Akulyadi yoga is of the drug of choice for the present clinical trial.Combination of Akulyadi Yoga 138SN Drugs Name Latin Name Proportion1 Akuli 139 Cassia auriculeta 1 Part2 Amalaki140 Embilica officinalis 1 Part3 Haridra141 Curcuma longa 1 Part Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 64
  • Name & Latin name Akuli – Cassia auriculeta 142Gana Guduchyadi varga 143Parts used MukulaRasa Kashaya ,TiktaGuna Laghu ,RookshVeerya SheetaVipaka KatuPrabhava Grahi, RechakaDoshaghnata Kapha Pitta shamaka,Karma Pramehaghna, Atisarahara, Raktapitta haraChemical constituents Emodin, Rubradin, Festinidols*Name & Latin name Amalaki – Embilica officinalis 144Gana Vayasthapana145, Virechanopaga146Parts used PhalaRasa Madhura, Amla, Katu, Tikta, KashayaGuna Laghu, rukshaVeerya SheetaVipaka AdhuraPrabhava RasayanaDoshaghnata TridosaghnaKarma Raktapitta, Krimighna, Prameha haraChemical constituents Gallic acid Tannic acid, and Vit – C* Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 65
  • Name & Latin name Haridra – Curcuma longa 147Gana Lekhaneeya148, Kustaghna149, Krimighna150Parts used KandaRasa Tikta, KatuGuna Rooksha, LaghuVeerya UshnaVipaka KatuDoshaghnata Kapha Vata haraKarma Pramehaghna, Kustaghna, KrimighnaChemical constituents Curcumene, Curcumenone, Camphor All the ingredients of the Akulyadi yoga are well identified and collected from localarea; good manufacturing practice will be followed for preparation. Even though above yogamentioned in “churna kalpa” for easy administration it is tabulated after 3 times fortification.The prepared drug is preserved in glass jars to protect the shelf life of the medicine. Later atthe time of distribution requisite quantity of the medicine is packed and given to patients. Theindividual components of the composition are as follows under specified headings. Akulyadi yoga in Madhumeha (Diabetes Mellitus) – Literary Review 66
  • Chapter - 4 Methods The clinical study is based on the classical explanations with scientific welldesigned research protocol, which enumerates the patient before to administrate the trialdrug to after effects in comparison.Criteria for selecting drugs 1. The above mentioned Akulyadi yoga, which are taken from the Yogaratnakara Pramehadhikara. 2. The pharmacological actions of the individual drugs are Pramehahara. 3. The trial drug, Akulyadi yoga is selected according to the pharmacological action and properties of individual drugs with in. 4. Akulyadi yoga is purely herbal; they are cheaper and easily available as in the local market. 5. Akulyadi yoga is very easy to process and vati making 6. Akulyadi yoga is very easy to dispense. 7. The said combination Akulyadi 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 Madhumehawith therapeutic effects which are the equitant so it is considered to under take in equalquantity of the Akulyadi yoga ingredients as said in the text. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Methods 67
  • Methods followed in trail1) Method of Research design Madhumeha vis-à-vis Diabetes mellitus is a major health problem for the world of21st century. At least 50% of all people are with Madhumeha are undiagnosed and noticedfrom a dentist. In spite of advanced medical research, it is still a burning problem for thesociety. Recent studies reveal that the prevalence rate of type-2 diabetes is from 10-18% inthe urban Indian adult population and also increasing in rural population too.Thus the trailis Simple Random sampling technique clinical study. In this Patients were taken inrandomized selection.2) Posology of Trial drug Internally: 3000 mg / 24hrs in divided two doses or 50mg /Kg body weight distributed in equal doses3) Anupana of Trial drug Madhodaka is undertaken as it is stipulated for the medicine.4) Study duration of Trial drug Akulyadi yoga Simple Random sampling technique clinical study was conductedfor 21 days. The medicine was dispensed for 7 days to all patients and advised to report forevery 7 days interval, noted the nature, frequency and other symptoms of their diseaseduring their visits.5) Follow up of Trial drug Akulyadi yoga trail offered a further follow up 21 days. The effect of yoga wasanalyzed according to clinical and functional response before and after the treatment is Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Methods 68
  • compared to that of follow up data. In further the final declaration of the trail drug effectand result is done on the basis of the follow up data.6) Source of data of Trial drug In spite of this much of prevalence and increasing nature of the disease all over theworld, still researchers are struggling for a good, effective and harmless remedial measureof Madhumeha. Diet control, exercise, oral hypoglycemic agents and insulin have tried andtreated this public health threat, Madhumeha. The data was collected from the patientssuffering from Madhumeha in the OPD of post graduation and research center DGMAyurvedic medical college Gadag. The method of the present study consists of followingheadings. 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 thepresent study. Patients were distributed based on preset inclusion and exclusion criteria.Patients were excluded, as they are discontinuous at the treatment or unable to fulfill thestudy design. i) Inclusion criteria Patients with symptoms of Madhumeha are included with classical symptoms enumerated at the classical texts under the lime light of contemporary medical context along with criteria of inclusion. The symptoms of inclusion are as under. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Methods 69
  • • All patients other than that of exclusive criteria are included • Age of patients between 25-65 years • Irrespective of gender • Non-insulin dependent diabetes mellitus • Patient having clinical features of Madhumeha viz. 1. Prabhoota Mootrata 2. Avila Mootrata 3. Dourbalya 4. Shareera Bhaarahani 5. Janghamamsagraha 6. Karapada Daha 7. Pipasa 8. Kshudhadhikyata ii) Exclusion criteria Patients other than exclusion criteria are included in the present study. The specified exclusions are as under with their causes. i. Insulin dependent D.M Vis-à-vis Madhumeha ii. Patients who develops complication with other systemic disease iii. Juvenile diabetes iv. Malnutrition D.M v. Gestational D.Mb) Examination of the patient Patient through examination is necessary to obtain clear picture of disease and alsothe effect of trail drug – Akulyadi yoga. For that the following methods are obtained in thestudy. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Methods 70
  • b-1) Physical signs of Madhumeha patients – For diagnosis, a detailed medical history is taken and physical examination alsoundertaken in detail according to Ayurvedic and contemporary clinical methods. Patientsare diagnosed according to diagnostic criteria given for Madhumeha vis-à-vis DM. Aspecial case sheet is prepared incorporating all Madhumeha aspects, which is placed asannexure.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 thetreatment. Assessments of results were made according to clinical and functionalimprovement observed in the study. Clinical assessment was made on the basis ofsymptoms viz. prabhoota mootrata, kshudha etc., which are allotted grades according totheir severity or to that of normalcy. The grades are followed as under. Grades of assessment 1) Prabhoota Mootrata Grade 0 = 1000 – 1500 ml/ 24 hrs Grade 1 = 1500 – 2000 ml/ 24 hrs Grade 2 = 2000 – 2500 ml/ 24 hrs Grade 3 = 2500 – 3000 ml/ 24 hrs Grade 4 = 3000 – above ml/ 24 hrs 2) 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. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Methods 71
  • 3) Dourbalya Grade 0 = No Dourbalya Grade 1 = occasionally noticed Grade 2 = periodically noticed Grade 3 = daily noticed Grade 4 = continuously noticed4) Shareera Bhaarahani Grade 0 = No Bhaarahani Grade 1 = occasionally noticed Grade 2 = periodically noticed Grade 3 = regularly noticed5) 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 noticed Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Methods 72
  • 8) Kshudhadhikyata 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 fulfill 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 isseparated from the cells at the earliest possible time (within 30 minutes), then the serumblood is mixed with the reagent (working solution) and heated at 37°C for 15 minutes. Thereadings are observed 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) - - 0.025Calculation Glucose in mg/ dl = Absorbance of sample x 100 Absorbance of standard Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Methods 73
  • The same procedure is applied for both FBS and PPBS. The FBS is done withempty stomach and on the same day the PPBS is calculated after 2 hours of food and theresults are recorded in case sheet.b) Urine Sugar estimations A fresh urine sample is collected from the patient. 5 ml of Benedict solution istaken in a test tube and 5-6 drops of urine sample in put in that. Then the test tube is heatedtill until a boil in the solution and cooled at room temperature. The change is observed forthe presence of sugar.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 needeither to make an exclusion or inclusion in to the study, which are commonly undertakenfor the purpose of prognosis. a) Erythrocyte Sedimentation Rate b) Hemoglobin % c) Blood Differential Countc) Criteria of assessment Over all assessment of results are done considering the cumulative subjective and objective parameters assessments. As the disease is not Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Methods 74
  • 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 period2. Palliative – i. Incomplete Symptomatic relief for the patient clinically ii. Reduced PLBS at schedule to normal and fluctuated at Follow up period3. Responded – i. Symptomatic relief for the patient is witnessed partially ii. Partial Reduction of PLBS at schedule and increased at Follow up period4. Not responded i. None of the above conditions Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Methods 75
  • Chapter - 5 Results Present study registers 20 patients, out of 55 approached patients. The percentages ofpatients undertaken from the scrutinised are 36.36%. The 20 patients of Madhumeha viz.Diabetes Mellitus, fulfilling the criteria of diagnosis and inclusive criteria were included inthe study. Fasting and Postprandial blood sugar (FBS and PPBS) along with correspondingurine sugars (FUS and PPUS) are considered as an objective for the inclusion in the presentstudy. 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. Result of the Akulyadi yoga and D. Statistical analysisA) Demographic data: The details of Age, Gender, Religion, and Occupation etc. of the 20 patients are asfollows.A1) distribution of patients by Age Here 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 revealed that Madhumeha is eventhough thought that starts from the ages of 25 onwards and the fact found is not suggestive. At Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 76
  • the older age group of 55-65, 5 (25%) patients reported suggest the chronicity of the disease.Where in 45-55 and 35-45 age groups reported with 9 (45%) and 6 (30%) patients in eachgroup respectively. It is interested to note that the active age group patients of 35-45 agegroups reported only 6 (30%) patients. Out of the 45-55 ages a maximum (7) patientsregulated the disease. The tabulations are depicted as under. Table- 10 Results by Age in Madhumeha with Akulyadi yogaAge Regulated Palliative Responded Not Responded Total %25- 35 0 0 0 0 0 035 – 45 3 0 3 0 6 3045 – 55 7 0 2 0 9 4555 – 65 1 1 3 0 5 25Total 11 1 8 0 20 100% 55 5 40 0 100 * Figure – 3 Results by Age in Madhumeha with Akulyadi yoga Results by Age in Madhumeha with Akulyadi yoga 0 3 55 – 65 1 1 0 2 45 – 55 0 7 0 3 35 – 45 0 Not Responded 3 Responded 0 Palliative 25- 35 00 0 Regulated 0 2 4 6 8 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 77
  • A2) Distribution of patients by Gender Table- 11 Results by Gender in Madhumeha with Akulyadi yogaGender Regulated Palliative Responded Not Responded Total %Male 6 0 6 0 12 60Female 5 1 2 0 8 40Total 11 1 8 0 20 100% 55 05 40 0 100 * The male female ratio in the study is approximately 3:2 patients. The percentage of thedistribution does not show any gender differentiation to get this Madhumeha in specific,except a small lean towards male population. The observations are 12 Patients i.e. (60%) maleand 8 patients i.e. (40%) were female. Figure - 4 Results by Gender in Madhumeha with Akulyadi yoga Male Female 60.00% 40.00% Results by Gender in Madhumeha with Akulyadi yoga Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 78
  • A3) distribution of patients by Religion For the convenience of the study, the religion groups are noted as Hindu, Muslim,Christian and Others. The maximum number of patients are noticed from the Hinducommunity as the ratio of community at the study area is more i.e. 16 (80%) along withMuslim patients 4 (20%). Table- 12 Results by Religion in Madhumeha with Akulyadi yogaReligion Regulated Palliative Responded Not Responded Total % Hindu 8 0 8 0 16 80 Muslim 3 1 0 0 4 20Christian 0 0 0 0 0 0 Others 0 0 0 0 0 0 Total 11 1 8 0 20 100 % 55 5 40 0 100 * Figure – 5 Results by Religion in Madhumeha with Akulyadi yoga Muslim Others Hindu Christian 20.00% 0.00% 80.00% 0.00% Results by Religion in Madhumeha with Akulyadi yoga Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 79
  • At the results observed, out of 16 (80%) of Hindu patients, 8 (40%) patients regulatedand 8 (40%) patients fall under responded category. On the other hand the results observed atMuslim community are, out of 4 (20%), 3 (15%) patients fall under the category of regulatedand one has palliative response. The tabulation and graphical representation is as under.A4) Distribution of patients by Occupation Table- 13 Results by Occupation in Madhumeha with Akulyadi yogaOccupation Regulated Palliative Responded Not Responded Total %Sedentary 6 1 8 0 15 75Active 2 0 0 0 2 10Labor 3 0 0 0 3 15Total 11 1 8 0 20 100% 55 5 40 0 100 * Figure - 6 Results by Occupation in Madhumeha with Akulyadi yoga Labour 15.00% Active 10.00% Sedentary 75.00% Results by Occupation in Madhumeha with Akulyadi yoga Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 80
  • At the results observed, out of 15 (75%) of sedentary patients, strongly suggests thatthe Madhumeha is a disease of the sedentary patients, out of which 6 (30%) patientsregulated, 1 (5%) patient is palliative responded and 8 (40%) patient were responded to thetreatment. At the active group, out of 2 (10%) patients all two are regulated. At the results areobserved, out of 3 (15%) of Labour all three are regulated in the treatment. The pictorialrepresentation is as above.A5) Distribution of patients by economic status At the results observed, out of 2 (10%) of poor patients, all two are regulated. Out of2 (10%) of Middle class patients all are regulated. From higher middle class 8 (40%) patientsreported and out of them 3 (15%) patients are regulated, 1 (5%) patient have palliativeresponse and 4 (20%) patients are responded. 8 (40%) patients are reported from the higherclass of classification, show 4 (20%) regulated and the rest 4 (20%) responded. The tabulationand pictorial graph is expressed as here. Table- 14 Results by Economic status in Madhumeha with Akulyadi yogaEconomic Not Respondestatus Regulated Palliative Responde Total % d dPoor 2 0 0 0 2 10Middle 2 0 0 0 2 10Higher Middle 3 1 4 0 8 40Higher 4 0 4 0 8 40Total 11 1 8 0 20 100% 55 5 40 0 100 * Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 81
  • Figure - 7 Result Distribution of patients by Economic status Results by Economic status in Madhumeha with Akulyadi yoga 4.5 4 4 4 4 3.5 3 3 2.5 2 2 2 1.5 1 1 0.5 0 0 0 0 0 0 0 0 0 0 0 Patients Poor Middle Higher Middle HigherA6) Distribution of patients by diet Table- 15 Results by Diet in Madhumeha with Akulyadi yogaDiet Regulated Palliative Responded Not Responded Total %Vegetarian 6 0 7 0 13 65Mixed diet 5 1 1 0 7 35Total 11 1 8 0 20 100% 55 5 40 0 100 * The vegetarian and mixed diet ratio in the study is approximately 2:1 patients. Thepercentage of the distribution does not show any diet differentiation to get this Madhumeha adisease in specific, except a small lean towards vegetarian population. The observations are13 Patients i.e. (65%) vegetarian and 7 patients i.e. (35%) were mixed diet practitioners. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 82
  • Figure - 8 Results by Diet in Madhumeha with Akulyadi yoga Mixed diet Vegetarian 35.00% 65.00% Results by Diet in Madhumeha with Akulyadi yoga As the results observed, out of 13 (65%) vegetarians, 7 (35%) patients are Respondedand 6 (30%) patients Regulated to the management. As the results observed in mixed dietpopulation, out of 7 (35%), 5 (25%) patient are regulated response, 1 (5%) patient respondedpalliative and 1 (5%) patient responded to the treatment.B) Data related to the disease.B1) Distribution of patients by presenting complaints Almost all the symptoms selected as the presenting complaint as analyzed reflects thesaid complaints of the text and Prabhoota mootrata (20 patients), Dourbalya (20 patients),Kshudha adhikyata (18 patients) and Pipasa (17 patients) are observed stating the cardinalsymptoms as polyuria, polydipsia and polyphasia. The graph and tabulations are shown asbelow. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 83
  • Table –16 Distribution of patients by presenting complaintsPresenting complaints Patients %Prabhoota Mootrata 20 100Dourbalya 20 100Kshudhadhikyata 18 90Pipasa 17 85Karapada Daha 16 80Avila Mootrata 15 75Shareera Bhaarahani 13 65Janghamamsagraha 13 65 Figure - 9 Distribution of patients by presenting complaints 25 Dourbalya, 20 20 Pipasa, 17 Avila Mootrata, 15 Janghamamsag 15 raha, 13 10 5 0 Prabhoota Kshudhadhiky Karapada Shareera Mootrata, 20 ata, 18 Daha, 16 Bhaarahani, 13 Distribution of patients by presenting complaints Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 84
  • B2) Distribution of patients by Associated features Mukha talu sosha is said as associated symptom for Madhumeha, which is observedhere at the maximum. 11 each patients observed with Karapada spuptata and Sandhi Shoola.Alasya is observed by the 50% of the patients. This study observes the rest of the associatedcomplaints enumerated in the table below along with the graph. Table – 17 Distribution of patients by Associated features Presenting Associated features Patients Percentage Mukha/Talu shosha 19 95 Kara/Pada suptata 11 55 Sandhi Shula 11 55 Alasya 10 50 Gurugatrata 9 45 Klama 7 35 Tandra 5 25 Shithilangata 4 20 Figure – 10 Distribution of patients by Associated features 20 18 16 Kara/Pada 14 suptata, 11 12 Alasya, 10 10 8 Klama, 7 Shithilangata, 6 4 4 2 0 Mukha/Talu Sandhi Shula, Tandra, 5 shosha, 19 11 Gurugatrata, 9 Distribution of patients by Associated features Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 85
  • B3) Distribution of patients by Ahara Nidana Table – 18 Ahara Nidana observed in the study Ahara Nidana Patients Percentage Guda 20 100 Dadhi 20 100 Snigdha 17 85 Dugdha 16 80 Navanna 14 70 Sheeta 13 65 Gramya 5 25 Anoopa 4 20 Auduka 4 20 Ayurveda offered many causes especially in regard with food. The Guda and Dadhisaid as causes are observed 100% in the study. The other factors also observed in the studyare tabulated above.B4) Distribution of patients by Vihara Nidana Many regimens are told in Ayurveda, out of which Diwaswapna is observed 100% andAvyayama 90% and swapna sukham for 50% of patients. The vihara tabulated are here under. Table – 19 Vihara Nidana observed in the study Vihara Nidana Patients Percentage Diwaswapna 20 100 Avyayama 18 90 Swapnasukham 10 50B5) Distribution of patients by Anya Nidana The other Nidana told in texts are very less observed here. Only Sthoulya is observedfor 50% of patients. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 86
  • Table – 20 Distribution of patients by Anya Nidana Anya Nidana Patients Percentage Sthoulya 10 50 Manishika- Chinta 7 35 Krimi 0 0 Vegavarodha 0 0 Panchakarma Vibhramsha 0 0B6) Distribution of patients by Poorva roopa lakshana Table – 21 Distribution of patients by Poorva roopa lakshana Poorva roopa Patients Percentage Mutra madhurata 20 100 Trishna 20 100 Talu kloma shosha 19 95 Swedadhikya 17 85 Shitalangata 16 80 Sheeta iccha 15 75 Nidra 14 70 Nakha vruddhi 13 65 Maldhikyata in bahya chidra 12 60 Shareera durgandha 11 55 Kesh jatilata 10 50 Alasya 10 50 Deha chikkanata 9 45 Mukha madhurta 9 45 Pada daha 8 40 Pani daha 8 40 Dantadeenam Malatvam 7 35 Tandra 7 35 Swasa 6 30 Mutra shuklata 5 25 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 87
  • The Poorva roopa mentioned in Ayurveda are observed here in the study. Mutramadhuryata and Trishna are 100% and Talu kloma sosha is observed for 95%. The rest of thesymptoms observed are tabulated here along with percentage.B7) Distribution of patients by Sroto dusti lakshana Table – 22 Distribution of patients by Sroto dusti lakshana Sroto dusti lakshana Patients Percentage Jihwa shosha 20 100 Talu shosha Udakavaha 20 100 Osta shosha 14 70 Kloma shosha 18 90 Pravruddha pipasa 20 100 Alpalpa mootrata 0 0 Mootravaha Mootara rodha 0 0 Adhika mootra 20 100 Sashoola mootra 4 20 Basti stabdhata 0 0 Arbuda 0 0 Mamsavaha Arsha 0 0 Mamsa shosha 0 0 Shira granthi 0 0 Sweda 12 60 Medovaha Snigdhanagata 6 30 Sthulashophata 1 05 Pipasa 20 100 Out of different srotas included in the study explicit new dimensions. Out ofUdakavaha srotas – Pravruddha Pipasa, Jihwa and talu sosha, in Mootravaha srotas – Adhika Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 88
  • Mootrata, in Medovaha srotas the Pipasa are observed 100% in the study. It conform theinvolvement of these srotases. The enlisted symptoms are at above table.B8) Family history Table – 23 Data of Family history in the study Family history Patients Percentage Present 12 60 Absent 8 40 Total 20 100 The Madhumeha observed as familial by researcher prove in study with 60% familyhistory. The rest of 40% show the instantaneous expression of the disease.C) Result of the Akulyadi yogaC1) Assessment of Subjective parameters Table – 24 Presenting complaints relieved Patients Patients Patients Before After % %Dourbalya 20 100 2 10 18 % 90Shareera Bhaarahani 12 60 3 15 9 75Janghamamsagraha 13 65 3 15 10 77Karapada Daha 17 85 3 15 14 82.3Pipasa 17 85 7 35 10 58.8Kshudhadhikyata 16 80 6 30 10 62.5 The assessments of the symptoms which are presented as the chief complaints are thesubjective parameters of the study observed initially Dourbaly as 100% is witnessed reducedfor 90% in the study. The Shareera bharahani initially for 60% of patients later observed it as Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 89
  • weight gain in 75% of patients. In the same way the Jangha mamsa graham initially observed65%, the control rate observed as 77% at the completion of study. Karapada Daha is for 85%of patients’ initially recorded 82.3% relief. Pipasa initially for 85% of patients exhibit the58.8% of relief. Another major symptom Kshudhadhikyata is seen in 80% patients at the startbecome reduced 62.5% in the study.C2) Assessment of Objective parameters Table - 25 Presenting complaints relieved Patients Patients Patients Before After % % %Prabhoota Mootrata 20 100 3 15 17 85Avila Mootrata 9 45 1 05 8 88.88Fasting Blood Sugar 20 100 8 40 12 60Post prandial Blood sugar 20 100 10 50 10 50Fasting Urine Sugar 13 65 5 25 8 61.5Post prandial Urine sugar 17 85 7 35 10 58.8 The objectives are very much important to assess a study. Here in the study Mootraprabhootatva is reduced 85% and Avila mootrata for 88.88%. The FBS and PPBS exhibit60% and 50% differences in the study, where in the FUS and PPUS show the 61.5% and58.8% variances from the base line data.C3) Results of the Akulyadi yoga The result is based upon the cumulative effect of the subjective and objectiveparameters together assessed. The result is drawn in four categories viz. Regulated, Palliative,Responded and not responded. In the study at the follow up, if any increase of PPBS isobserved the patient is brought one step down to the declared result. The result of the Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 90
  • Akulyadi yoga declared is representing the efficiency of the drug with its embedded qualities.The tabulation is as below along with the graph. Table - 26 Result of Akulyadi yoga in Madhumeha Result Number of patients Percentage Regulated 11 55 Palliative 1 5 Responded 8 40 Not Responded 0 0 Total 20 100 Figure - 11 Result of Akulyadi yoga in Madhumeha Not Responded Regulated Responded 0% 55% 40% Palliative 5% Result of Akulyadi yoga in Madhumeha Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 91
  • D) Statistical analysis To compare the effectiveness of a drug before and after the treatment the statisticalanalysis paired t-test, by assuming that the drug is not responsible for changes in the readingbefore and after the treatment. The conclusion drawn is as highly significant if P <0.05. Table – 27 Statistical analysis of Akulyadi yogaParameter Mean SD SE t value P value RemarkDourbalya 2.45 1.145 0.256 9.57 <0.001 HSShareera bharahani 1.1 1.165 0.260 4.23 <0.001 HSJanghamamsa 0.95 1.05 0.234 4.059 <0.001 HSgrahamKarapada daha 1.4 0.94 0.21 6.666 <0.001 HSPipasa 2.2 1.281 0.286 7.69 <0.001 HSKshudhadhikyata 2.05 1.356 0.303 6.76 <0.001 HSPrabhoota mootrata 3.2 0.894 0.2 16.0 <0.001 HSAvila mootrata 0.5 0.606 0.135 3.703 <0.001 HSFBS 48.605 30.41 6.80 7.147 <0.001 HSPPBS 117.18 46.42 10.38 11.289 <0.001 HSFUS 0.325 0.293 0.0656 4.954 <0.001 HSPPUS 0.63 0.476 0.1066 5.9099 <0.001 HS Among the subjective parameters dourbalya, pipasa, Kshudhadhikyata shows morehighly significant than other parameters. (Comparing p values) the parameters shareerabharahani and jangamamsa graha are having almost equal effect before and after the treatment(by comparing t-values). The parameters dourbalya having more net mean effect where as theparameter jangamamsa graha is having less mean effect (comparing mean value) the variationin the parameter karapada daha is less, where as in the parameter Kshudhadhikyata is more. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 92
  • Among all the objective parameters all the parameters shows significant but in theparameter prabhoota mootrata, PPBS, FBS are shows more highly significant (comparing p-values). The parameters PPBS are having more net mean effect with more variation where asin FUS having less mean effect will less variation (comparing mean and variations). Among the subjective parameters the percentage improvement is in between 82% to92%, which means that the percentage of improvement lies between these two values. Whereas in the objective parameter the more percentage improvement in the prabhoota mootrata(94.1%) and where as in the parameter PPBS is least percentage improvement (14.312%). Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Results 93
  • Chapter - 6 Discussion A retrospective analysis of resource material reveals that various references relevant tothe topic are available under broad heading Prameha in the classics. The classical Ayurvedicliterature is sufficient with plenty of description of the disease and discussion regarding topatho-physiology, symptomatology and the treatment modalities. Physiological andpathological aspects of Dosha and Dushya regarding Madhumeha are available in detail.Various pathological processes regarding Dosha and etiological factors defined in the classicsare under taken by various research studies carried out to find out the exact pathogenesis ofMadhumeha and its 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 swiftlythrough the body, effective transport and circulation is dependent upon him. Apanavatarelated to the functions of Pakwashaya. In Madhumeha both are get vitiated leading to theabnormal pathway and excessive elimination respectively. Kapha is the basis of structuralintegrity of the body provides steadiness and strength in the body, keeping together variousstructures. All these function of Kapha get hampered in the Madhumeha. When Kapha getvitiated it undoubtedly vitiates the body elements like Rasa Mamsa, Meda, Vasa, Lasika, Ojaetc. they in turns diminish the structured body integrity by providing excess of metabolicwaster because of faulty bi-fold digestion. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion 94
  • Pitta a somatic humour mainly related with the digestion and metabolism here due toetiological factors Pitta also get vitiated it in turns affect the normal functions of Jathragni andDhatwagni leading to the excessive formation of deranged quality of Rasa, Mamsa, Meda,Kleda etc. Thus in Madhumeha because of the above discussed patho-physiologicalprocesses; i.e. Dushya obstructs the normal pathway of Vata causing Avarana to it that inturns aggravate the Vyanavata leads to the transport of vital Dhatu Oja towards vasti wherealready aggravated Apanavata excretes out it from the body resulting depletion of Dhatus andgenerate disease Madhumeha. This pathogenesis mainly described by Charaka. Thusaggravation of Vata excess of Dushya and metabolic waste due to abnormal bi-fold digestioncauses Madhumeha. Avarana is the essential part of any Vataja Samprapti. Anotherpathogenesis of Madhumeha described in Ayurveda mainly related with the vitiation of Vatadue to its own etiological factors and genetics predisposition this entity is incurable mentionedby Ayurveda because here severe diminution of Dhatus occurs. Thus Madhumeha having twoetiological factors one Santarpankara and second Apatarpankara. Excess of derangedShlesma, Meda ,Kleda, Vasa, Lasika etc. aggravated vata produces variouspahthophysiological changes in the body producing symptoms like Prabhata mootrata,Avilamootra, Pipasa, Daurbalya, Alasaya etc, leads to the structural as well as functionalabnormalities in the body. In the pathogenesis more or less every body element is getinvolved. The present clinical study was planned in single group to manage the problem by trialdrug Akulyadi yoga. The subjects were treated with Akulyadi yoga for duration of 21days andthe yoga possesses Tikta, Kasaya Rasa, Vatakaphahara and Pramehaghna. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion 95
  • Discussion 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 decadeof life. In this study, the above factors were proved, as all the patients were between the agegroup of 30 to 62, suggestive of the age relation stress advancements and comforts at ageadvancements to cause the Madhumeha. This reveals that maximum prevalence of thedisease is at Madhyama vayastha because at this stage of age there is natural aggravation ofVata started and normal digestion / metabolism going to hamper. These findings were relatedto the recent statistical data, which shows that the onset of type II diabetes mellitus in theforties is most common. Majority of the patient in the present study belongs to Hindu community i.e. 80%, butit does not mean that Hindus are prone to this disease. This may be due to the local ratio ofdifference religion. The patients were selected incidentally. Susruta had said that women would not get Madhumeha; because their body getscleaned every month by the raja pravrutti. But it is seems as a controversial dialogue aswomen also getting Madhumeha and they are also at high risk of getting diabetes compared tomen after 30years, especially after the pregnancy or at the time of pregnancy. In this study amajority of the patients were male when compared to female, as shown in results chapter. Majority numbers of patients were sedentary type of occupation. In sedentary type ofoccupation physical activities are very less, it is clearly mentioned that people with sedentarylife styles more prone to diabetes mellitus or Madhumeha. In the present study 75% patientswere recorded with sedentary life styles. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion 96
  • In the present study 60% patients had family history and rest of the 40% patients hadno family history of Madhumeha. It is a well proven factor that family history had main rolein the manifestation of Sthoola Madhumeha. 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 arealso mentioned which are helpful in controlling Madhumeha. In the present study 65%patients were vegetarians and 35% patients were mixed. From these we can see that highcalorie intake is the main risk factor for diabetes. Economics makes ones to susceptible for comforts. Majority of patients belongs toupper middle and higher class, exhibiting richness. In these classes the people indulge in veryless physical activities and ultimately remain to sedentary life styles to get the a santarpanothaVyadhi, Madhumeha vis-à-vis Diabetes Mellitus.Discussion on diseases components Most of the Nidana mentioned in the classics were elicited in this study by detailedquestioning. Among general Nidana, all patients used to take snigdha and guru aharasexcessively. Among the viharas, Swapanasukham (10patients), Avyayama (18 patients) andmanasika karana (7patients) were also noted. From this we can say that snigdha ahara dravyasand swapna sukhadi viharas had key role among the nidanas. In ancient Ayurvedic treatises common premonitory symptoms are described butspecial premonitory symptoms of Madhumeha are not mentioned. The disease having vastfield of etio-pathogenesis only few of them are cardinal sign and symptoms of Madhumeha.These are pipasa, madhura mootrata, Asymadhurya, Panidaha, Padadaha. All patients shown100% history of mutra madhurata and Talu kloma shosha observed almost all patients i.e. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion 97
  • 95% Swedhadhikyata observed as 85%, Shithilangata is observed as 80% and sheeta iccha isobserved as 75%. Prabhoota mootrata is observed as 100% in the study. This is a cardinal sign describedby all authors for Madhumeha. Vagbhata mentioned Prameha as disease of mootraatipravruttaja. Avilamootrata is observed as 45%, for that Vagbhata emphasized that thisturbidity of the urine because of its annexation with the Dhatu. Charaka enumerated the general Samprapti as it is due to over indulgence ofetiological factors, Kapha along with meda, mamsa and Kleda get vitiate and results intoformation of metabolic waste which carried towards vasti resulting Prameha. In same mannerPitta get vitiated resulting pittaja Prameha. While Vata is due to depletion of other two Doshaget provocative in turns causes depletion of dhatus by excrete them through urine resultingvataja Prameha. Susruta mentioned that Sahaja Prameha precipitate because of defect in beeja. This iseven explained by Charaka that Sahaja Madhumeha is a Kulaja Vikara, because of the defectin beeja (Sperm / ovum). Here the patient is prone to Dhatu kshaya because of above factor.Charaka explained the pathogenesis is due to specific etiological factors which vitiate Vatadraws out the vital dhatus and carries them towards vasti resulting into Madhumeha. Charaka enumerated that due to depletion of Kapha and Pitta Vata get aggravate andcauses the excretion of dhatus through urine resulting into madhumeha. Though Vagbhatanarrated the cause of this type of Madhumeha but not explained the pathogenesis. Charakaemphasized this pathogenic process in well elaborative manner. This is the uniquecontribution of Charaka. Due to excessive indulgence of heavy, unctuous, salty and sour diet,Avoidance of worry, exercise and purifying measures. Kapha and Pitta get provoked and Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion 98
  • vitiates meda and mamsa. All are in excess quantity. They in turn cause obstruction to thenormal pathway of Vata. This obstructed Vata get aggravated and draws out the apara ojafrom all over the body and carries it towards vasti resulting Madhumeha. Majority of the patients shown symptoms and signs like Atisweda, Daurbalya, Alasya,Arochaka, data suggestive of Vata dusti and Kapha dusti also present, medodosha were alsopresent here. Majority subjects shown Rasadusti, Medodusti, Kleda. Data suggestive thatmedodusti is always present in Madhumeha and relevant to the quotation of Susruta thatsthaulya i.e. medoroga is because of Rasadusti, ojodusti suggestive of Dhatu depletion. Kapha have peculiar nature i.e. Bahudrava described by Charaka. So it is easilyunderstand that the Shaithily manifestation in this disease, as Kapha normally cause Sthiratvain the body. Cakrapani commented upon the word Sthiratva means Ashaithilya. So thisbahudravatva of vitiated Kapha causes disruption in the assemblage of body elements andprovide ground for the accumulation of morbid matter in the tissues. Again Kapha Dosha is the dominant factor in the pathogenesis of Madhumeha. It getsvitiated primarily and causes the vitiation of concordant body elements like Meda, Mamsa,Kleda, Rasa, Vasa, Lasika etc. The vitiation of Kapha here mainly is of excessive type. That’sway the following symptoms manifests in madhumeha. These are shaithilya, Alasya, Atinidra,Gaurava, etc. Charaka clearly mentioned and Cakrapani opined that Kapha Dosha is dominantand primarily vitiated because of its close resembles with the etiological factors. Thisexcessive Kapha can be correlated with functions of growth hormone, which is antagonistic toinsulin, one of the causative factors for the precipitation of type- 2 Diabetes Mellitus. Pitta Dosha is not so dominant factor in the pathogenesis of Prameha. By the vitiationof Pitta, Avaranganya Samprapti of Madhumeha resulted. Rakta, Sweda, Lasika and Rasa are Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion 99
  • the seats of Pitta Dosha so when Pitta get provoked, It undoubtedly causes the vitiation ofabove Dusyas. That’s why the symptoms manifests are Sweda vruddhi, visra sharira gandha,panidaha, pipasa and sosha indirectly Agni vaisyama too. This is the main predominant Dosha in the pathogenesis of Madhumeha here is Vataget aggravated either because of its own etiological factors or because of Avarana caused byKapha Pitta and Meda. This vitiated Vata carries the vital constituents of the body like Vasa,majja, and oja towards vasti and excretes them outside through urine resulting depletion of thedhatus. Thus due to severe depletion of Dhatu, the symptom manifests are Karsya, Daurbalya,Angasuptata and Parisaransheela nature. All authors narrated dushya sangraha and their involvement in the pathogenesis, butcaraka specially enumerated a group and named it as a Dushya visesa. Again he mentionedthem in Cikitsasthana also. Susruta also narrated the Dushyas but he typically mentioned themalong with the doshic type, but he commonly included meda in each type. Only Vagbhatamentioned sweda as a dushya along with above dushyas. This is one of the Dhatu mainly vitiates. Here because of its close resemblance withKapha qualitatively Again Rasa is one of the seats of Kapha Dosha and Pitta Dosha. So ifKapha get vitiate Rasa also get vitiate. That’s why having same symptoms related to Vruddhias mentioned by Vagbhata i.e. Rasoapi Slesmavat. Susruta emphasized that Sthaulya and Karshya results due to vitiation of Rasa Dhatuand practically we can found both conditions in the Madhumeha. So the role of Rasa Dhatu isvery much important in the precipitation of the disease. Vitiated Rasa shows manifestationslike Alasya, Gaurava, Krsangata, Klaibya and Agninasa in context to Madhumeha. RaktaDhatu have no much involvement in the manifestation of the Madhumeha. It is mainly getting Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion100
  • vitiated in pittaja Prameha. Not initially but in later stage Rakta also get vitiated prominantlycausing complications like Pidaka, Vidrdhi, Alasi. One of the main Dushya described by Charaka is Mamsa. He narrated it especially inKaphaja Prameha and Avaranjanya Madhumeha, as Mamsa and Kapha have same qualities.They both give strength to the body. When get vitiated, Mamsa losses its normal consistencyand develops Shaithilya and provide space in between for the accumulation of morbid matter.That in turn results into the Putimamsa Pidika. Medas vitiation is common and dominant Dushya in the pathogenesis of Madhumeha.Kapha and Meda have close resemblance in regard to functions as well as qualitativeparameters. Both are getting vitiated more or less by same etiological factors. Meda vitiationin Madhumeha appears in two ways i.e. the former is Qualitative - Abadha (Asamhatum)Normal function of Meda is to produce unctuousness in the body along with Dradhatva i.e.compactness. So this Abadhatva causes derangement in the structure of Meda producingShaithilya in the body. This can be well correlate with FFA excess. The later is Quantitative -Here in the pathogenesis, Meda is in excess quantity. This Medo Dhatu is Aparivakva. Itobstructs the path of Vata along with Kapha. This provoked Vata increases the Agni sopatient unnecessary eats more and more food causing excessive deposition of AparipakvaMeda. This in turns causes severe depletion of the other Dhatus and produces various sign andsymptoms. In Ashtanga Sangraha, Vagbhata mentioned that along with Prameha Purvarupaexcessive Meda can causes diseases of Slesma, Rakta and Mamsa. Thus from abovedescription it is clear that vitiated Meda plays vital role in the progress of pathogenesis andaffects the normal physiology of various body elements. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion101
  • Majja Dhatu is not vitiated in maximum extent but Vata causes its Ksaya i.e.Depletion. Thus the vitiated Majja producing symptoms like, Netragaurava, Angagaurava inMadhumehi patient clinically. Shukra also get vitiated in the pathogenesis produces symptoms like daurbalya andKruchra vyavayata, because normal functions of Sukra is to maintain. Dehabala, it also playsrole in the precipitation of Sahaja Prameha. Susruta narrated that Sukra Dosha and Pramehaget precipitate because of the vitiation of Vyanavata and Apanavata. With this it is understandthat the relation of Sukra dushti as a component of Prameha formation. Sexual impotency andtesticular hypo functions have been reported in Diabetes Mellitus by Moses et.al .1979. Oja as Dushya mainly involved in Vataja Prameha i.e. Ojomeha i.e. Madhumeha.Provoked Vata due to its own etiological factors or due to Avaran carries Oja towards vastiand excrete outside through urine so the symptoms of Ojaksaya manifests, like Gurugatrata,Nidra, Tandra and Daurbalya. Charaka mentioned Ruksta i.e. related to Ruksa Sharira, so onecan easily understand the manifestations of Krusapramehi or Sahaja Pramehi. This is one of the body component mainly involved in the pathogenesis. The literarymeanings of Kleda are wetness, moisture and dampness etc. The physiology of Kleda ismainly related with Mutra and Sweda along with Meda. Thus when Kleda is involved then itdirectly affects the above factors. There is no direct reference regarding to the function ofKleda in the body but Arundatta commented that. According to his opinion, If Kleda is notpresent then there is manifestation of dryness in the body, so indirectly we can say that theKleda proper in quantity is important to maintain the unctuousness in between the tissues. Innormal physiology Mutra and Sweda maintain the balance of Kleda. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion102
  • Especially Sweda holds it in the body and Mutra excrete it outside the body.According to the body condition and requirement, if this Kleda is get vitiated it directlyaffects the physiology of Mutra and Sweda and disrupts the assemblage of bodily elementscausing Shaithilya. Thus the symptoms manifests due to Kleda vitiation are Prabhuta mutrata,Sweda vruddhi, Saithilya, Daurgandhya and Avila mutrata. This dooshya is separately mentioned by Vagbhata. Sweda is mainly related withMeda and Kleda. When the Swedavaha Strotodusti occurs due to vitiation of Kleda and Meda,the normal physiology and Sweda get disturbed resulting in manifestations like, Swedavruddhi, Daurgandhya. Picchila gatrata, Snigdha gatrata etc. Susruta only mentioned that inMadhumeha Sweda becomes Sweet in nature. Charaka described it as a subtype of Vataja Prameha i.e. Vasameha. “Vasa” is anUpadhatu of Mamsa and the unctuousness present in the Mamsa Dhatu is called Vasa. Thuswe can easily understand that in Prameha Mamsa is one of the Main Dushya so in turns Vasatoo get vitiate. This is one of the liquid components present just beneath the skin. Lasika also getvitiated by Vata resulting Lasika meha. There is no direct reference related to Vasa andLasika Dushti. Madhumeha is the disease mainly of systemic consideration. In the pathogenesis thereis involvement of each and every constituent of the body. In the pathogenesis there isreference of strotodushti only related to Mutravaha strotas. But when we observe thepathogenesis and symptoms, we can easily understand the involvement of Medovaha,Mamsavaha, Svedavaha and Udakavaha Strotas too. We can find out the strotas involvement according to the symptoms as follows - Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion103
  • (1) Purvarupa of Prameha - Medovahastrotus Dusti.(2) Putimamsapidaka - Mamsavaha Srotusdusti.(3) Trsna, Mukhatalu Kanthasosa - Udakavaha Srotusdusti.(4) Atisrsta Abhiksna Mutrapravrti - Mutravaha Srotusdusti. There is no direct reference related to the Agni condition but both Agnimandya andTiksnagni conditions present in the pathogenesis Again without Ama it is impossible toprecepitate the pathogenesis of Madhumeha that’s why Susruta narrated that,Effect of Akulyadi yoga in Madhumeha The drugs selected for the trial mainly having Tikta, Kasaya, Katu Rasa Usna Veeryaand Laghu, Ruksa Guna, Katu Vipaka and Kaphavatahara properties and each one is indicatedin Prameha Cikitsa. Thus Usna Veerya and Tikta Kasaya Rasa helps to normalise the functionof Jathragni 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 andreduction of vitiated Meda Kleda. 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 Akulyadi yoga declared is representing the efficiency of the drugwith its embedded qualities, is 11 (55%) Regulated, 1 (5%) palliative and 8 (40%) patientsresponded in the trial. The conclusion drawn statistically for the present trial is as highlysignificant as P <0.05. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Discussion104
  • Chapter - 7 ConclusionMadhumeha is a disease characterized by Prabhoota avila mootrata, Tanumadhuryata & Mootra madhuryata.The terms Prameha and Madhumeha are synonymous. They indicate the samecondition where in the former refers to Prabhoota and Avila mootrata (illunderstood) & the latter refers to Tanu & Mootra madhuryata.Dhatu apakarshana & Sarva dhatu sara – Ojo dushti is a invariable manifestationof the disease.Aparipakva ojas is directly responsible for the Madhuryata of Tanu and MootraKapha is the Arambhaka dosha & Vata is the Preraka.Margavarana janya Madhumeha & Dhatukshaya janya Madhumeha are the twoforms of the disease. Apathya nimittaja Madhumeha & Sahaja Madhumeha arethe two independent forms of presentations, coming under the above classificationrespectively.Sadhyasadhyata of Madhumeha is directly dependent upon Dhatu apakarshana &Vata anubandha anubadhyatva & Sahaja karana.The Kaphaja, Pittaja & Vataja Pramehas are nothing but the range of variedsymptomatology of Madhumeha manifesting depending upon association offavorable Nidanas for the respective Dosha during the course of the illness. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Conclusion105
  • Sahaja Madhumeha can manifest in the Balya avastha also & Apathya nimittajaMadhumeha manifests in the Madhyama to Vriddha avastha.Madhumeha with Kapha pradhana lakshana and Anati dushta dhatu is Sadhya inthe sense that it is Sadhya until under continuous medication; otherwise it recursjustifying the term Anushangi meaning Punarbhavi.Diet and exercise helps only in patients who comply fully and compliance is thetoughest part in the management of Madhumeha.The significant improvement which was seen in subjective and objectivesymptoms.Blod glucose and urine sugar measurement is a useful tool to detect Mootramadhuryata & Tanu madhuryata in Madhumeha. The advantage being inidentifying the disease before the manifestation of symptoms so pronounced as toattract Pipeelikas, thus providing the physician an opportunity to prevent or curethe disease before the patient develops complications.The result of the Akulyadi yoga declared is representing the efficiency of the drugwith its embedded qualities, is 11 (55%) Regulated, 1 (5%) palliative and 8 (40%)patients responded in the trial.The conclusion drawn statistically for the present trial is as highly significant as P<0.05. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Conclusion106
  • Chapter - 8 SummaryThe advancement of industrialization and communication is contributing towardssedentary life styles; in turn causing chronic non-communicable diseases likeMadhumeha vis-à-vis Diabetes Mellitus, etc. in fact Ayurveda is the first lifescience, which identified, diagnosed and managed Madhumeha.Madhumeha/DM is the present burning issue alarming the world. Madhumeha isa disease characterized by Prabhoota, avila mootrata, Tanu and Mootramadhuryata.Madhumeha is a chronic metabolic or endocrinal disorder and the symptomappears in relation with sweet urine excreting Dhatu in it. In normal physiologyMutra and Sweda maintain the balance of Kleda. Especially Sweda holds in thebody and Mutra excrete it outside the body. Sweda is mainly related with Medaand Kleda. Susruta only mentioned that in Madhumeha Sweda becomes Sweet innature. Lasika also get vitiated by Vata resulting Lasika (lymph) meha which isnot substantiated even by the contemporary medicine. Abnormal bi-fold digestioncauses aggravation of Vata in turn involves Dushya and metabolic waste to formMadhumeha.Madhumeha is a subtype of Vataja Prameha, could appear either by Avarana orDhatu kshaya janya (degenerative changes). Apart from these Iatrogenic andgenetic dispositions are also recorded. The Madhumeha vis-à-vis diabetes mellitus Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Summary107
  • has many theories of occurrence, even the recent viral influence studies ondiabetes.Madhumeha has Kapha Dosha is the key factor along with Vata. Generally themanagement, rather than treatment, is the appropriate term in Diabetes mellitus,and involves diet, exercise, insulin, oral hypoglycemic, patient education andcounseling.The present study intended to focus on the disease evaluation i.e. Madhumeha vis-à-vis. Diabetes Mellitus management with Akulyadi yoga as a Shamana Chikitsa.Akulyadi yoga ingredients are hypoglycemic agents collected form local area andprepared under GMP conditions, weighing about 500mg tablet form. Present trialis a Simple Random sampling technique clinical study was conducted for 21 days.Patients of Madhumeha fulfilling the criteria of diagnosis were selected in thepresent study. Patients were selected on preset inclusion and exclusion criteria.The male female ratio in the study is approximately 3:2 patients and 75% patientswere recorded with sedentary life styles.In the present study 60% patients had family history and rest of the 40% patientshad no family history of Madhumeha.Apart from the symptoms which show high significance in the study the keyparameters to assess “glycemic” condition of Madhumeha exhibit, FBS with amean difference of 48.605mg and PPBS with mean difference of 117.18mg forafter to before data.This is strong evidence to state that the Akulyadi yoga is good hypoglycemicagent combination of Ayurveda. Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Summary108
  • Bibliographic Refarences1) Baghel MS, Ayurvedic Education – Global perspective, International Congress on Ayurvedic Concepts and Treatment of Neurological Disorders, 2002, SDM College of Ayurveda and Hospital, Udupi, pp 252) Bhagawan Das, Charaka Samhita sutra, vol-1, 6th ed, 1999, Chaukhambha Sanskrit series, Varanasi, pp-6003) Swami DS, Evaluation of efficacy of Madhutailika Vasti in the management of Madhumeha, 2005, PGSRC, dept. of Panchakarma, DGM Ayurvedic Medical College, Gadag, pp24) Mahesh Udup, Comprehensive Kayachikitsa and principles of Ayurveda, 1st ed. 2004, Laveena publication, Bangalore, pp 11235) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Nidana 4/39, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-6386) Ambikadatta shastri ed, Susruta Samhita, Part-I, Nidana 1/20, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-2307) Pawar Anand N, A comparative study on the role of vasti therapy and pramehaghna drugs in the management of Madhumeha (Diabetes mellitus), L-2857, pp8) Khan weir, Joslins Diabetes mellitus, 13th ed. 1994, Pennsylvania USA, Lea and Febiger, pp 1949) Sahshikala Bani, Evaluation of efficacy of Avartaki in Madhumeha, 2005, PGSRC, dept. of Dravyaguna, DGM Ayurvedic Medical College, Gadag, pp 110) Sainani GS ed, API textbook of medicine, 6th ed, 1994, Association of Physicians of India, Mumbai, pp 98611) Khan weir, Joslins Diabetes mellitus, 13th ed. 1994, Pennsylvania USA, Lea and Febiger, pp 21612) Sainani GS ed, API textbook of medicine, 6th ed, 1994, Association of Physicians of India, Mumbai, pp 98613) AS Fauci, Harrison principles of internal medicine, Vol-2, 15th ed. 2001 Mcgraw Hill co, New York USA, pp 212914) Mahesh Udup, Comprehensive Kayachikitsa and principles of Ayurveda, 1st ed. 2004, Laveena publication, Bangalore, pp 112315) Bramhashankar Sastri ed, Yoga ratnakara, Uttarardha, Prameha Chikitsa, 4th ed, 1988, Choukhambha Sanskrit Samsthan, Varanasi, pp85-8616) Yadunandan Upadhyaya, Astanga Hridaya, Nidana 10/6, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-25417) Bramhashankar Sastri ed, Yoga ratnakara, Uttarardha, Prameha Chikitsa, 4th ed, 1988, Choukhambha Sanskrit Samsthan, Varanasi, pp85-8618) Ravidatta Tripati ed, Charaka samhita, Chikitsa, 6/5, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 16719) Bramhashankar Sastri ed, Yoga ratnakara, Uttarardha, Prameha Chikitsa, 4th ed, 1988, Choukhambha Sanskrit Samsthan, Varanasi, pp85-8620) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Nidana 4/39, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-63821) Ambikadatta shastri ed, Susruta Samhita, Part-I, Nidana 6/14, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-25222) Ibid, part 2, Chikitsa, 13/3-34, pp 65-67 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Bibliographic References 1
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  • 78) Ambikadatta shastri ed, Susruta Samhita, Part-I, Nidana 6/30, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-255 79) Yadunandan Upadhyaya, Astanga Hridaya, Sutra 11/3, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-85 80) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Nidana 4/8, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-633 81) Yadunandan Upadhyaya, Astanga Hridaya, Sutra 11/7, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-86 82) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Sutra 18/49, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-384 83) Ibid, Nidana, 4/7, pp 632 84) Ambikadatta shastri ed, Susruta Samhita, Part-I, Nidana 6/11, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-253 85) Yadunandan Upadhyaya, Astanga Hridaya, Nidana 10/4, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-253 86) Ibid, sutra, 11/8, pp 86 87) Ambikadatta shastri ed, Susruta Samhita, Part-I, Sutra 15/37, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-62 88) Ravidatta Tripati ed, Charaka Samhita, Nidana, 4/48, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 511 89) Ibid, sutra, 17/82, pp 267 90) Ambikadatta shastri ed, Susruta Samhita, Part-I, Nidana, 6/4, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-252 91) Yadunandan Upadhyaya, Astanga Hridaya, Nidana, 10/41, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-250 92) Ambikadatta shastri ed, Susruta Samhita, Part-I, Sutra,15/19, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-60 93) Ibid, Nidana, 1/20, pp230 94) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Sutra 17/78, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-352-353 95) Yadunandan Upadhyaya, Astanga Hridaya, Sutra, 11/40, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-89 96) Ibid, 11/5, pp 86 97) Ambikadatta shastri ed, Susruta Samhita, Part-I, Chikitsa,12/4, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-62 98) Ravidatta Tripati ed, Charaka Samhita, Chikitsa, 6/11, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 170 99) Ibid, 6/8, pp 168-169100) Cotran SR, Basic Pathology, 6th ed. 2003, Philadelphia Saunders, pp 913101) Ravidatta Tripati ed, Charaka Samhita, Chikitsa, 6/7, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 168102) Yadunandan Upadhyaya, Astanga Hridaya, Nidana, 10/7, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-254103) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Nidana 4/9, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-633104) Ambikadatta shastri ed, Susruta Samhita, Part-I, Chikitsa,11/3, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-59105) Ibid106) Yadunandan Upadhyaya, Astanga Hridaya, Nidana, 10/19, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-255 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Bibliographic References 4
  • 107) Ravidatta Tripati ed, Charaka Samhita, Chikitsa, 6/15, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 170108) Cotran SR, Basic Pathology, 6th ed. 2003, Philadelphia Saunders, pp 913109) Ambikadatta shastri ed, Susruta Samhita, Part-I, Nidana,6/25-26, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-255110) Yadunandan Upadhyaya ed. Madhava Nidanam, Part-2, 1/7, 9th ed, 2004, Chaukhambha Sanskrit Sansthan, Varanasi, pp-38111) Ambikadatta shastri ed, Susruta Samhita, Part-I, Nidana,6/25-26, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-255112) Yadunandan Upadhyaya, Astanga Hridaya, Nidana, 10/7, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-254113) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Nidana 4/44, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-639114) Ambikadatta shastri ed, Susruta Samhita, Part-I, Chikitsa, 11/3, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-59115) Ibid, Nidana, 6/28, pp 258116) Cotran SR, Basic Pathology, 6th ed. 2003, Philadelphia Saunders, pp 913-916117) Ravidatta Tripati ed, Charaka Samhita, Chikitsa, 6/54, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 176118) 8888119) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Nidana 4/48, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-640120) Ambikadatta shastri ed, Susruta Samhita, Part-I, Nidana, 6/15, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-254121) Ibid,122) Ibid123) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Sutra 17/105-106, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-362124) Davidson Stanely, Principles and practice of medicine, 1995, Churchill Livingstone, London, pp 754-757125) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Nidana 4/11, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-634126) Ibid, 4/8, pp 633127) Ibid, sutra 17/80-81, pp 352-353128) Ibid, Nidana, 4/38, pp 638129) Ambikadatta shastri ed, Susruta Samhita, Part-I, Nidana, 6/27, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-255130) Ravidatta Tripati ed, Charaka Samhita, Chikitsa, 6/47, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 177131) Ibid, 6/16-18, pp 171132) Ibid, 6/25-26, pp 173133) Yadunandan Upadhyaya, Astanga Hridaya, Chikitsa, 12/8, 1st ed, Reprint, 2007, Chaukhambha Prakashan, Varanasi, pp-372134) Ravidatta Tripati ed, Charaka Samhita, Chikitsa, 6/37, 2nd ed. 2001, Choukhambha Sanskrit Pratistan, Varanasi, pp 174135) Ambikadatta shastri ed, Susruta Samhita, Part-I, Chikitsa, 13/1-34, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-65-67136) AS Fauci, Harrison principles of internal medicine, Vol-2, 15th ed. 2001 Mcgraw Hill co, New York USA, pp 2112 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Bibliographic References 5
  • 137) Ambikadatta shastri ed, Susruta Samhita, Part-I, Chikitsa, 11/6, 6th ed. 1987, Chaukhambha Sanskrit Sansthan, Varanasi, pp-60138) Bramhashankar Sastri ed, Yoga ratnakara, Uttarardha, Prameha Chikitsa, 4th ed, 1988, Choukhambha Sanskrit Samsthan, Varanasi, pp85-86139) Srinivasacharyulu Yetur ed, Yogaratnakaram (Tel), Vol 2, Prameha Nidanam, 80, 1st ed. 1940, Swatantra Printers, Nellore, pp 142140) Pande GS, Bhavaprakasha, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-10-11141) Ibid, 114-116142) K. M. Nadkarni, Indian Materia Medica, Vol-I, 3rd ed, 1976, Popular Prakashan, Bombay, pp-284143) Narahari, Raja Nighantu, Guduchyadi varga, 2nd ed. 1998, Krishnadas Academy, Varanasi, pp 58144) K. M. Nadkarni, Indian Materia Medica, Vol-I, 3rd ed, 1976, Popular Prakashan, Bombay, pp-480145) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Sutra 4/50, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-98146) Ibid,4/24, pp 85147) K. M. Nadkarni, Indian Materia Medica, Vol-I, 3rd ed, 1976, Popular Prakashan, Bombay, pp-414148) Rajeshwaradatta Sastri, Charaka Samhita, Part 1, Sutra 4/3, 1st ed. Reprint, 1998, Chaukhambha Bharati Academy, Varanasi, pp-72149) Ibid,4/13, pp 81150) Ibid, 4/15, pp 82 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Bibliographic References 6
  • MS01 - Demographic Data of Akulyadi YogaSNo OPD Gender Religion Occupation Economical Result V/Mx Food No Age Condition M F H M C O S A L P M Hg Hc1 4773 + 40 Mx + + +2 4775 + 50 V + + +3 5068 + 35 V + + +4 6013 + 58 Mx + + +5 6016 + 43 Mx + + +6 6021 + 62 V + + +7 325 + 59 V + + +8 333 + 46 V + + +9 362 + 54 V + + +10 409 + 50 Mx + + +11 412 + 55 V + + +12 418 + 62 V + + +13 419 + 40 Mx + + +14 442 + 38 V + + +15 526 + 49 Mx + + +16 629 + 58 V + + +17 790 + 46 V + + +18 834 + 52 V + + +19 835 + 54 V + + +20 873 + 43 Mx + + +Total 12 8 16 4 0 0 15 2 3 2 2 8 8 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Master charts i
  • MS02 - Subjective Statistical Assessment Data of Akulyadi YogaS.No OPD Dourbalya Shareera Jangamamsa Karapada Pipasa Kshudhadhikyata Bharahani graham daha B A B A B A B A B A B A1 4773 1 0 0 0 0 0 1 0 3 1 3 02 4775 3 1 3 1 2 1 1 0 3 2 3 13 5068 1 0 0 0 1 0 0 0 3 2 4 24 6013 1 0 1 0 2 1 2 0 3 0 4 05 6016 4 0 2 0 0 0 1 0 3 0 3 06 6021 4 0 3 1 0 0 0 0 3 0 4 17 325 3 0 1 1 1 0 2 1 4 1 3 28 333 2 0 3 0 1 0 3 0 4 1 4 09 362 3 0 2 0 1 0 3 0 4 0 3 010 409 4 0 0 0 4 0 3 1 3 0 0 011 412 2 0 1 0 1 0 2 0 4 0 3 012 418 3 0 2 0 1 0 2 0 3 0 3 113 419 1 0 0 0 0 0 1 0 0 0 0 014 442 4 0 0 0 0 0 4 1 0 0 0 015 526 3 0 3 0 3 0 1 0 3 1 3 016 629 3 0 1 0 1 0 1 0 3 0 3 017 790 1 0 0 0 0 0 1 0 0 0 0 018 834 1 1 0 0 1 0 0 0 2 1 3 219 835 3 0 3 0 3 1 2 0 3 0 1 020 873 3 0 0 0 0 0 1 0 2 0 3 0Total 50 2 25 3 22 3 31 3 53 9 50 9Mean 2.5 0.1 1.25 0.15 1.1 0.15 1.55 0.15 2.65 0.45 2.5 0.45SD 1.147 0.307 1.25 0.366 1.165 0.366 1.099 0.366 1.26 0.686 1.432 0.759 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Master charts ii
  • MS03 - Objective Statistical Assessment of Akulyadi YogaS.No OPD Prabhuta Avila FBS PPBS FUS PPUS mootrata mootrata B A B A B A B A B A B A1 4773 3 0 0 0 198.4 110 240 142 0.5 0 1 02 4775 4 2 2 1 320 112 350 134.5 0.5 0 1 0.53 5068 4 0 0 0 235 113 347 165 1 0.5 1.5 14 6013 4 0 2 0 216 124 341 162 1.5 0.5 0.5 0.55 6016 3 1 0 0 188 120 305 216 1.5 1 0.5 06 6021 4 0 0 0 181 110 221 163 1 0.5 1.5 07 325 4 1 1 0 152 130 330 225 0.5 0.5 1 18 333 3 0 1 0 132 110 223 140 0 0 0.5 19 362 3 0 1 0 174 120 228 130 0 0 0.5 010 409 4 0 1 0 151.6 110 277.6 145 0.5 0 1 011 412 3 0 0 0 148 120 209 161 0 0 0.5 012 418 4 0 1 0 158.6 110.3 240 130 0.5 0 1.5 013 419 3 0 0 0 145.1 125 280.1 164 0.5 0 1.5 014 442 2 0 0 0 126.4 110 225.1 140 0 0 0.5 015 526 4 0 0 0 194 120 312 142 0.5 0 1 016 629 4 0 1 0 146.3 118 310.7 166 0 0 1 017 790 3 0 0 0 142 110 225 140 0 0 0.5 0.518 834 1 0 0 0 178 112 341 162 0.5 0 0 019 835 4 0 0 0 140 120 227 140 0 0 1 120 873 4 0 1 0 160 116 210 132 0.5 0 1 0Total 68 4 11 1 3486.4 2320.3 5442.5 3099.5 9.5 3 17.5 5.5Mean 3.4 0.2 0.55 0.15 164.62 116.015 272.15 154.97 0.475 0.5 0.86 0.255SD 0.82 0.523 0.686 0.223 30.411 6.13 52.34 25.811 6.472 0.285 0.444 0.411 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Master charts iii
  • MS04 - Chief & Associated complaints of Akulyadi Yoga Complaints 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 T1 Prabhoota Mootrata + + + + + + + + + + + + + + + + + + + + 202 Avila Mootrata + + + + + + + + + + + + + + + 153 Dourbalya + + + + + + + + + + + + + + + + + + + + 204 Shareera Bhaarahani + + + + + + + + + + + + + 135 Janghamamsagraha + + + + + + + + + + + + + 136 Karapada Daha + + + + + + + + + + + + + + + + 167 Pipasa + + + + + + + + + + + + + + + + + 178 Kshudhadhikyata + + + + + + + + + + + + + + + + + + 18 Associated Complaints1 Kara/Pada suptata + + + + + + + + + + + 112 Klama + + + + + + + 73 Tandra + + + + + 54 Sandhi Shula + + + + + + + + + + + 115 Alasya + + + + + + + + + + 106 Gurugatrata + + + + + + + + + 97 Shithilangata + + + + 48 Mukha/Talu shosha + + + + + + + + + + + + + + + + + + + 19 MS05 - Upashaya/Anupashaya of Madhumeha Poorvaroopa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 T Upashaya1 Shita iccha + + + + + 52 Madhurrahit ahara + + + + + + + + + + + + + + + + + + + + 203 vyayama + + + + + + + + + + + + + + + + + + + + 20 Anupashaya1 Ushna + + + 32 Madhuara ahara + + + + + + + + + + + + + + + + + + + + 203 Diwa swapana + + + + + + + + + + + + + + + + + 17 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Master charts iv
  • MS06 - Poorvaroopa of Madhumeha Poorvaroopa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 T1 Dantadeenam + + + + + + + 7 Malatvam2 Pada daha + + + + + + + + 83 Pani daha + + + + + + + + 84 Deha chikkanata + + + + + + + + + 95 Shareera durgandha + + + + + + + + + + + 116 Mutra madhurata + + + + + + + + + + + + + + + + + + + + 207 Mutra shuklata + + + + + 58 Mukha madhurta + + + + + + + + + 99 Talu kloma shosha + + + + + + + + + + + + + + + + + + + 1910 Kesh jatilata + + + + + + + + + + 1011 Nakha vriddhi + + + + + + + + + + + + + 1312 Alasya + + + + + + + + + + 1013 Tandra + + + + + + + 714 Nidra + + + + + + + + + + + + + + 1415 Trishna + + + + + + + + + + + + + + + + + + + + 2016 Maldhikyata in bahya + + + + + + + + + + + + + 12 chidra17 Swedadhikya + + + + + + + + + + + + + + + + + 1718 Sheeta iccha + + + + + + + + + + + + + + + 1519 Swasa + + + + + + 620 Shitalangata + + + + + + + + + + + + + + + + 16 MS07 - Upadrava of Madhumeha Poorvaroopa 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 T1 Prameha pidika + + 22 Atisara + + 23 Jwara + + + + + 54 Daha + + + + + + + + 85 Arochaka + + + + + + + + + + + 116 Avipaka + + + + + + + + + 97 Chardi + 18 Kasa + + + 39 pratishyaya + + + 3 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Master charts v
  • MS08 - Examination of srotas Sroto Lakshana 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 T Udakavaha1 Jihwa shosha + + + + + + + + + + + + + + + + + + + + 202 Talu shosha + + + + + + + + + + + + + + + + + + + + 203 Osta shosha + + + + + + + + + + + + + + 144 Kloma shosha + + + + + + + + + + + + + + + + + + 185 Prawridha pipasa + + + + + + + + + + + + + + + + + + + + 20 Mootravaha1 Alpalpa mootrata2 Mootara rodha3 Adhika mootra + + + + + + + + + + + + + + + + + + + + 204 Sashoola mootra + + + + 45 Basti stabdhata Mamsavaha1 Arbuda2 Arsha3 Mamsa shosha4 Shira granthi Medovaha1 Sweda + + + + + + + + + + + + 122 Snigdhanagata + + + + + + 63 Sthulashophata4 Pipasa + + + + + + + + + + + + + + + + + + + + 20 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Master charts vi
  • MS09 - History of present IllnessS.No OPD Mode of detection Frequency of Micturition Family history 1 2 3 1 2 3 4 5 1 21 4773 + + +2 4775 + + +3 5068 + + +4 6013 + + +5 6016 + + +6 6021 + + +7 325 + + +8 333 + + +9 362 + + +10 409 + + +11 412 + +12 418 + + +13 419 + + +14 442 + + +15 526 + + +16 629 + + + +17 790 + + +18 834 + + +19 835 + + +20 873 + + +Total 5 2 13 1 1 4 10 4 12 8 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Master charts vii
  • MS10 - Ahara NidanaS.No OPD Guda Navanna Dugdha Gramya Anoopa Auduka Snigdha Dadhi Sheeta Mamsa Mamsa Mamsa Ahara Ahara1 4773 + + + + + + +2 4775 + + + + + +3 5068 + + + + + + +4 6013 + + +5 6016 + + + + + +6 6021 + + + + +7 325 + + + + + + +8 333 + + + + +9 362 + + + +10 409 + + + + + + +11 412 + + + +12 418 + + + + + +13 419 + + + + + + +14 442 + + + + +15 526 + + + + + + +16 629 + + + +17 790 + + + + + +18 834 + + + + + +19 835 + + + + + +20 873 + + + + +Total 20 14 16 5 4 4 17 20 13 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Master charts viii
  • MS11 - Vihara /Anya NidanaS.No OPD Avyaya Diwaswa Swapnas Manishik Krimi Vegavar Panchak Sthoulya ma pna ukham a odha arma Vibhram sha1 4773 + + +2 4775 + + + +3 5068 + +4 6013 + + +5 6016 + + + +6 6021 + + +7 325 + + +8 333 + + +9 362 + + +10 409 + +11 412 + + + +12 418 + + +13 419 + + + +14 442 + +15 526 + + +16 629 + + +17 790 + + + +18 834 + + + +19 835 + + + +20 873 + + + +Total 18 20 10 7 10 Akulyadi yoga in Madhumeha (Diabetes Mellitus) - Master charts ix
  • SPECIAL CASE SHEET FOR “Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus)” POST GRADUATE STUDIES AND RESEARCH CENTER (KAYACHIKITSA) SHRI. D.G.M.AYURVEDIC MEDICAL COLLEGE, GADAGGuide: Scholar:Dr. K. Shiva Rama Prasad Shivaleela. S. Kalyani1) Name of the Patient Sl.No2) Sex 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 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 0iÀiÁªÁUÁzÀÄgÀÄ aQvÀì¬ÄAzÀ »AwgÀÄUÀ®Ä ¸ÁévÀAvÀæ÷å «zÉ JAzÀÄ w½¢gÀÄvÀÛ£É. gÉÆV0iÀÄ gÀÄdÄ / Patients Signature Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus) 1
  • 12) CHIEF COMPLAINTS WITH DURATION (Subjective Parameters) Complaints - Lakshana Duration Remarks1 Prabhoota Mootrata2 Avila Mootrata3 Dourbalya4 Shareera Bhaarahani5 Janghamamsagraha6 Karapada Daha7 Pipasa8 Kshudhadhikyata13) ASSOCIATED COMPLAINTS Associated Complaints – Duration Remarks Anubandha Lakshana1 Kara/Pada suptata2 Klama3 Tandra4 Sandhi Shula5 Alasya6 Gurugatrata7 Shithilangata8 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) Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes 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 Anya Nidanarthakara VyadhiMadhura Guda Avyayama Manishika- Chinta Sthoulya Navanna Diwaswapna Krimi Dugdha Swapnasukham VegavarodhaMamsa Gramya Panchakarma Vibhramsha Anoopa AudukaSnigdhaDadhiSheeta18) 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 Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes 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) Systemic Examination: 1. Respiratory 2. Cardiovascular 3. Gastro-Intestinal 4. Genito-Urinary(d) Dashavidha pareekshaNadi V P K VP VK PK VPKPrakruti V P K VP VK PK VPKSara Pravara Avara MadhyamaSamhanana Susamhita Asamhita Madhyma samhitaPramana Height in Cms Weight in KgsSatmya Ekarasa Sarvarasa Ruksha SnehaSatwa Pravara Avara MadhyamaAhara Shakti Abhyavaharana JaranaVyayam Shakti Pravara Avara MadhyamaVaya Balya Yauvana Vardhakya(e) Astasthana PareekshaNadi Dosha Mutra Pravrutti Gati Varna Purnata Gandha Spandana KathinyaJihwa Ardra Sushka Mala Sama Nirama Lepa NirlepaShabda Sparsha Sheeta UshnaDrik Akruti20) Upashaya and AnupashayaUpashaya AnupashayaShita iccha UshnaMadhurrahit ahara Madhuara aharavyayama Diwa swapana Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus) 4
  • 21) UpadravasLakshanas LakshanasPrameha pidika AvipakaAtisara ChardiJwara KasaDaha pratishyayaArochaka22) INVESTIGATIONS Investigations for screeningErythrocyte Sedimentation RateHb%Differential count Lymphocytes Neutrophils Eosinophils Basophils MonocytesUrine Routine Albumin Sugar Microscopic23) Assessment of Trail1) Subjective parameters Before After Follow-up Difference BA1 Dourbalya2 Shareera Bhaarahani3 Janghamamsagraha4 Karapada Daha5 Pipasa6 Kshudhadhikyata2) Objective parameters1 Prabhoota Mootrata2 Avila Mootrata3 Fasting Blood Sugar4 Post prandial Blood sugar5 Fasting Urine Sugar6 Post prandial Urine sugar Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus) 5
  • 24) Treatment schedule Day Date Investigator’s NoteDay 1Day 7Day 14Day 21Follow upDay 42 Grades of assessment1) Prabhoota Mootrata 5) JanghamamsagrahaGrade 0 = 1000 – 1500 ml/ 24 hrs Grade 0 = No JanghamamsagrahaGrade 1 = 1500 – 2000 ml/ 24 hrs Grade 1 = occasionally noticedGrade 2 = 2000 – 2500 ml/ 24 hrs Grade 2 = periodically noticedGrade 3 = 2500 – 3000 ml/ 24 hrs Grade 3 = daily noticedGrade 4 = 3000 – above ml/ 24 hrs Grade 4 = continuously observed2) Avila Mootrata (Turbidity) 6) Karapada DahaGrade 0 = Crystal clear fluids Grade 0 = No Karapada DahaGrade 1 = faintly cloudy or hazy with slight Grade 1 = occasionally noticedturbidity Grade 2 = periodically noticedGrade 2 = Turbidity clearly present but news Grade 3 = daily noticedprint can be read through the tube. Grade 4 = continuously noticedGrade 3 = More turbidity & news print can 7) Pipasanot be read. Grade 0 = No Pipasa3) Dourbalya Grade 1 = occasionally noticedGrade 0 = No Dourbalya Grade 2 = periodically noticedGrade 1 = occasionally noticed Grade 3 = daily noticedGrade 2 = periodically noticed Grade 4 = continuously noticedGrade 3 = daily noticed 8) KshudhadhikyataGrade 4 = continuously noticed Grade 0 = No Kshudhadhikyata4) Shareera Bhaarahani Grade 1 = occasionally noticedGrade 0 = No Bhaarahani Grade 2 = periodically noticedGrade 1 = occasionally noticed Grade 3 = daily noticedGrade 2 = periodically noticed Grade 4 = continuously noticedGrade 3 = regularly noticedInvestigators Note Signature of Guide Signature of Scholar (Dr. K. Shiva Rama Prasad) (Shivaleela. S. Kalyani) Evaluation of the efficacy of Akulyadi yoga in Madhumeha (Diabetes Mellitus) 6