Virechana madhumeha pk006-gdg


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CLINICAL EVALUATION OF VIRECHANA KARMA IN MADHUMEHA (NIDDM), Febin. K. Anto. Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103.

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Virechana madhumeha pk006-gdg

  1. 1. Clinical Evaluation of Virechana Karma InMadhumeha(NIDDM) By Febin. K. Anto.Dissertation Submitted to the Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. In partial fulfillment of the requirements for the degree of AYURVEDA VACHASPATHI M.D. (PANCHAKARMA) In PANCHAKARMA Under the guidance of Dr. G. Purushothamacharyulu, M.D. (Ayu) And co-guidance of Dr. Shashidhar.H. Doddamani, M.D. (Ayu) Post graduate department of Panchakarma, Shri D. G. Melmalagi Ayurvedic Medical College, Gadag – 582103. 2005.
  2. 2. Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore. DECLARATION BY THE CANDIDATE I hereby declare that this dissertation / thesis entitled “ClinicalEvaluation of Virechanakarma in madhumeha (NIDDM)” is a bonafideand genuine research work carried out by me under the guidance of Dr. G.Purushothamacharyulu, M.D. (Ayu), Professor and H.O.D, Post-graduate de-partment of Panchakarma and co-guidance of Dr. Shashidhar. H. Doddamani,M.D.(Ayu) , Assistant Professor, Post graduate department of Panchakarma.Date:Place: Febin. K. Anto.
  3. 3. CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “Clinical Evalua-tion of Virechanakarma in madhumeha (NIDDM)” is a bonafide researchwork done by Febin. K. Anto. in partial fulfillment of the requirement for thedegree of Ayurveda Vachaspathi. M.D. (Panchakarma).Date:Place: Dr. G. Purushothamacharyulu, M.D. (Ayu). Professor & H.O.D Post graduate department of Panchakarma.
  4. 4. ENDORSEMENT BY THE H.O.D AND PRINCIPAL OF THE INSTITUTION This is to certify that the dissertation entitled “Clinical Evalua-tion of Virechanakarma in madhumeha (NIDDM)” is a bonafide researchwork done by Febin. K. Anto. under the guidance of Dr.G.Purushothamacharyulu, M.D. (Ayu), Professor and H.O.D, Postgraduate de-partment of Panchakarma and co-guidance of Dr. Shashidhar.H. Doddamani,M.D. (Ayu), Assistant Professor, Post graduate department of Panchakarma.Dr. G. Purushothamacharyulu, M.D. (Ayu) Dr. G. B. Patil. Professor & H.O.D, Principal.Post graduate department of Panchakarma.
  5. 5. CERTIFICATE BY THE CO- GUIDE This is to certify that the dissertation entitled “Clinical Evalu-ation of Virechanakarma in madhumeha (NIDDM)” is a bonafide researchwork done by Febin. K. Anto. in partial fulfillment of the requirement forthe degree of Ayurveda Vachaspathi. M.D. (Panchakarma).Date: Dr. Shashidhar.H. Doddamani, M.D. (Ayu).Place: Assistant Professor, Post graduate Department of Panchakarma.
  6. 6. COPYRIGHT Declaration by the candidate I hereby declare that the Rajiv Gandhi University of HealthSciences, Karnataka shall have the rights to preserve, use and dissemi-nate this dissertation / thesis in print or electronic format for academic /research purpose.Date: Febin. K. Anto.Place:© Rajiv Gandhi University of Health Sciences, Karnataka.
  7. 7. I Acknowledgement “Many hands make light work”. This work carries some memories toexpress and record about some distinguished personalities with whom I had inspiredduring the course of this thesis. I express my obligation to my honorable H.O.D and Guide Dr. GPurushothamacharyulu M.D (Ayu), in the P.G Department of Panchakarma, P.G.S&R,D.G.M.A.M.C, Gadag for his critical suggestions and expert guidance for the completionof this work. I am extremely grateful and obliged to my co-guide Dr. Shashidhar.H.Doddamani, Asst. Professor, P.G.S.&R, D.G.M.A.M.C, Gadag for his guidance andencouragement at every step of this work. I express my deep gratitude to Dr .G.B Patil, Principal, D.G.M.A.M.C,Gadag, for his encouragement as well as providing all necessary facilities for thisresearch work. I express my sincere gratitude to Dr.Shivaramudu M.D (Ayu), AssistantProfessor and Dr. Santhosh. N.Belavadi MD (Ayu), Lecturer for their sincere advices andassistance. I express my sincere gratitude to Dr. V. Varadacharyulu M.D (Ayu),Dr.M.C.Patil M.D (Ayu), Dr. Mulgund M.D (Ayu), Dr. K.S.R Prasad M.D (Ayu), Dr.Dilip Kumar M.D (Ayu), Dr. R.V. Shetter M.D (Ayu), Dr. Kuber Sankh M.D (Ayu),Dr.G.Danappa Gowda M.D (Ayu) for their constant encouragement. I also express my sincere gratitude to Dr.B.G.Swamy, Dr.V.M.Sajjan,Dr.U.V.Purad, Dr.Mallagowder, Dr.K.S.Paraddi, Dr.G.Yargeri, Dr.S.H.Radder and otherundergraduate teachers for their support in the clinical work. I thank to Shri. Nandakumar (Statistician), Dr. Arun Baburao Biradar ,Shri. V.M. Mundinamani (Librarian), Shri. B.S. Tippanagoudar (lab technician), Shri.Basavaraj (X-Ray technician) and other hospital and office staff for their kind support inmy study. I express my sincere thanks to my colleagues and friends Dr. Satheesh. R.Warrier, Dr. Subin Vaidyamadham, Dr. Renjith. P. Gopinath, Dr. Shajil. N, Dr. ShyjuOllakode, Dr. Sreenivasa Reddy, Dr. Hadimani, Dr. C. S. Hanumanta Gouda, Dr.Sankadal, Dr. Vanitha, Dr. Naveen, Dr. Santhosh. L. Y, Dr. Varsha. S. Kulkarni, Dr. P.Chandramouleeswaran, Dr. Uday Kumar, Dr. K. Krishnakumar, Dr. Ashwini Dev, Dr.Ratna Kumar, Dr. Jayaraj Basarigidad, Dr. Kendadamath, Dr. V. M. Hugar, Dr. Shyla. B,Dr. Suresh Hakkandi, Dr. Manjunath Akki, Dr. L. R. Biradar, Dr. Vijay Hiremath, andother post graduate scholars for their support.
  8. 8. II I take this opportunity to remember my late ancestors Shri. PouloseVaidyan, Shri. Francis Vaidyan and Shri. Pathrose Vaidyan whose lives have inspired meto take Ayurveda as my profession. I acknowledge Mrs. Annam Poulose, Mr. Renil Anto, Mrs. Lidiya Renil,Mr. Vinil Anto, Master. Andrews Renil for their inspiration and whole-hearted support. Ialso acknowledge Dr. Jose Kandamkulathy, Dr. Wilson Kandamkulathy, Dr. DavisKandamkulathy, Mr. Wilson Kandamkulathy (Managing Director, Pathrose Vaidyan’sKandamkulathy Vaidyasala), Dr. Rose Marry Wilson and Mr. Dipu Karuthedath for theirinspiration and moral support. I would like to mention the support and inspiration provided by Dr.R.Ramabhadran, Director (ISM, Kerala) and Dr. P. S. Gopi, Retd. DMO (ISM, Kerala). Ialso acknowledge the support and inspiration provided by my teachers Dr. K.P.Muralidharan, Principal, S.J.S. Ayurveda College, Chennai, Dr. S. Swaminathan, H.O.D.,Samhita & Siddhanta, S.J.S. College, Dr. S. Venugopal, Reader in Sanskrit, Dr.Vasudevareddy H.O.D. Shalya department and Dr. Ramdas Maganti, H.O.D., Kayachikitsa, S.J.S. College. I also thank Shri. C. S. Bhatt and family and Shri. Prasad and family forthe support and encouragement provided during my stay at Gadag. I acknowledge my patients for their wholehearted consent to participate inthis clinical trial. I express my thanks to all the persons who have helped me directly andindirectly with apologies for my inability to identify them individually. Finally I dedicate this work to my respected parents Mr. AntoKandamkulathy and Mrs. Rosily Anto, for their wholehearted inspiration and support tofulfill this dream.Date : Signature of the candidatePlace : Febin. K. Anto.
  9. 9. III ABSTRACT Panchakarma is the popular term for shodhana chikitsa, among that virechana isan important one. Virechana is the therapy by which the doshas are made to pass throughthe adhomarga i.e. Gudamarga. In virechana the doshas even from the amasaya are takento the pakvashaya and they are removed through gudamarga. In the treatment of Sthoola Madhumcha Virechana therapy has great importanceaccording to Ayurveda. In the modern system of medicine Madhumcha can be compairedto diabetes mellitus. And it can be classified as insulin dependent, non insulin dependent,malnutrition related and other types of diabetes mellitus associated with certainconditions and syndromes. Among these non-insulin dependent diabetes mellitusconstitutes 85 % or more of all cases of diabetes. Diabetes has become the disease of themasses. Over 20 million people are reported to be suffering from this “Sweet Disease”.Between 1995 and 2005 India will have about 2-3 crore diabetic patients. Even though the scientific world has conducted extensive studies but couldn’tfind a safe and effective therapy or medicine for this disease. In Ayurveda we can offerseveral treatment modalities among that virechana therapy is a good, result oriented andeconomical therapy which can control the blood sugar level and prevent furthercomplications without any side effects. Virechana Karma is advised in Madhumeha patients having good body strengthand those who are sthoola in nature. The objective of this study was to assess the efficacyof virechana in such patients. The study was designed as a prospective clinical trial and30 patients were selected and given classical Virechana karma.
  10. 10. IV The treatment contains the following steps. 01. Deepana pachana by Trikatu Choorna. 02. Shehapana by Thrikandakadyam Ghritam. 03. Abhyanga and mridu sweda by Moorchita tila taila and ushnajala snana. 04. Virechana by Vidanga Tanduladi choorna. 05. Samsarjana krama. 06. Follow-up for one month. As a result of the proper administration of Virechana karma it was noted that, itgives immediate and lasting results, both in sugar levels as well as in other complaints.Among the 30 patients taken for the study, 17 patients (56.6%) responded good, 11patients (36.6%), responded moderately and 2 patient’s (6.6%) response was poor. Aclose perusal of observation and inference that can be drawn leads to the conclusionssuch as, Virechana is an effective treatment in Sthoola Madhuneha and it also showslasting results. In mild and moderate type of Sthoola Madhumeha classical Virechanaalone is enough to control it. Even though only Virechana was administered in this study,it was also noted that along with Virechana karma, administration of pathya ahara viharaand shamanoushadis might help more. Also administration of repeated virechana maygive lasting results.Key words – Shodhana karma ; Virechana karma ; Sthoola Madhumeha ; Prameha ; Diabetesmellitus ; Insulin resistance ; Obesity; Vidangatanduladi churna ; Thrikandakadyamghritam ; Blood sugar.
  11. 11. V LIST OF ABBREVIATION USED⇒ Ch. – Charaka Samhita.⇒ G. R. – Good response.⇒ M. R. – Moderate response.⇒ P. R. – Poor response.⇒ Su. – Sushruta Samhita.⇒ Vag. – Ashtanga Hridaya.
  12. 12. VI TABLE OF CONTENTSChapters Page No.1. Introduction 1-32. Objectives 43. Review of literature 5-724. Methodology 73-925. Results 93-1236. Discussion 124-1367. Conclusion 1378. Summary 138-1399. Bibliography 140-15310. Annexure
  13. 13. VII LIST OF TABLES Page No.Table No. 01. Historical milestones in the field of Diabetes mellitus. 8Table No. 02. Showing the virechana yogyas. 12Table No. 03. Showing the virechana ayogyas. 15Table No. 04. showing the samyak snigdha lakshanas. 17Table No. 05. Showing the virechana dravya jeeranoushadha and ajeeranoushadha lakshanas. 19Table No. 06. Showing the vega nirnaya. 20Table No. 07. Showing the ayoga and atiyoga 21Table No. 07a. Showing the samanya nidana of prameha. 43Table No. 08. Showing the poorvaroopa of prameha 48Table No. 08a. Showing are the Prameha according to the major classics. 60Table No. 09. Showing the Vyavachedaka nidana. 67Table No. 10. Upadravas of prameha according to Vagbhata and Sushruta on dosha basis. 69Table No. 11. Showing the properties of the ingredients of Trikatu churna 74Table No. 12. Showing the properties of the ingredients of Thrikandya ghritam. 75Table No. 13. Showing the properties of the ingredients of Moorchhita tila taila. 79Table No. 14. Showing the properties of drugs used in Vidangataduladi churna. 80Table No. 15. Showing the grades of the blood sugar level. 88Table No. 16. Showing the demographic data. 94Table No. 17. Showing the data related to disease. 95Table No. 18. Showing the data of parameters. 96Table No. 19. Showing the treatment protocol and observation. 97Table No. 20. Showing the age group incidence and response. 98Table No. 21. Showing the Sex group incidence and response. 99Table No. 22. Showing the incidence of religion and response. 100Table No. 23. Showing the incidence of occupation and response. 101Table No. 24. Showing the Socioeconomic Status and response. 102Table No. 25. Showing the food habits and response. 103Table No. 26. Showing the chronicity and response. 104Table No. 27. Showing the treatment history and response. 105Table No. 28. Showing the family history and response. 106Table No. 29. Showing the nature of koshta and response. 107Table No. 30. Showing the Status of agni and response. 108Table No. 31. Showing the nature of malapravritti in the patient and response. 109Table No. 32. Showing the habits of the patient and response. 110Table No. 33. Showing the prakriti of the patient and response. 111Table No. 34. Showing the nidana status and response. 112Table No. 35. Showing the days of deepana pachana and response. 113Table No. 36. Showing the days of snehapana and response. 114Table No. 37. Showing the incidence of samyak snigdha lakshanas and response. 115Table No. 38. Showing the incidence of samyak virechana lakshanas and response.117Table No. 39. Showing the number of vegas attained by patient and response. 119Table No. 40. Showing the incidence of antaki and response. 120Table No. 41. Showing the incidence of manaki and response. 121Table No. 42. Showing the Overall assessment. 122Table No. 43. Showing the Statistical results. 123
  14. 14. VIIILIST OF FIGURES, PHOTOGRAPHS AND GRAPHS Title Page No. 1) Figure showing digestive system 26 2) Photo showing the drugs used in the study 73 3) Photo showing Vidangatanduladi churna and ingredients 80 4) Graph showing the age group incidence and response. 98 5) Graph showing the Sex group incidence and response. 99 6) Graph showing the incidence of religion and response. 100 7) Graph showing the incidence of occupation and response. 101 8) Graph showing the Socioeconomic Status and response. 102 9) Graph showing the food habits and response. 103 10) Graph showing the chronicity and response. 104 11) Graph showing the treatment history and response. 105 12) Graph showing the family history and response. 106 13) Graph showing the nature of koshta and response. 107 14) Graph showing the Status of agni and response. 108 15) Graph showing the nature of malapravritti in the patient and response. 109 16) Graph showing the habits of the patient and response. 110 17) Graph showing the prakriti of the patient and response. 111 18) Graph showing the nidana status and response. 112 19) Graph showing the days of deepana pachana and response. 113 20) Graph showing the days of snehapana and response. 114 21) Graph showing the incidence of samyak snigdha lakshanas and response. 115 22) Graph showing the incidence of samyak virechana lakshanas and response.117 23) Graph showing the number of vegas attained by patient and response. 119 24) Graph showing the incidence of antaki and response. 120 25) Graph showing the incidence of manaki and response. 121 26) Graph showing the Overall assessment. 122
  15. 15. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” Ayurveda the heritage of Indian civilization is not only a medical pathy but also afull-fledged Science, consisting of all medical and allied branches essential to lead ahealthy life. Being a Science Ayurveda believes in supreme power. This concept isessential to know the limitations of human efforts and to accept the existence of thingsbeyond the perception of our sense. Ayurveda considers the prime living principle i.e.atma and the importance of which is now accepted by all. The purpose of Ayurveda is to maintain health and to treat diseases, in order toachieve the ultimate goal i.e. distraction from worldly things. Ayurveda is consisting oftwo words ayu and veda. Ayu means life, which is a proper combination of body, mind,sense organs and soul. Veda means knowledge. Preservation of health and its maintenance are the main aim of Ayurveda. Itsattainment is due to personal, social and moral hygiene, which is very sophisticated andhighly developed. The regimens of day, night and seasons, if observed properly lead topositive health. The disease is manifested when extrinsic factors provoke the bodilydoshas and this provocation is the stage proceed by accumulation and followed bypacification and the provoked doshas are eliminated in fixed particular seasons byemetics, purgatives etc. This application prohibits the recurrence of disease. The Panchakarma therapy is an important part of Ayurveda. The procedures ofPanchakarma therapy have thrown new light on the management of diseases and haveprovided effective weapons against many of them. The Panchakarma therapy or five-fold purification procedures include, Vamana,Virechana, Basthi, Nasya and Raktamokshana. This entire group of purification producesis based up on promoting the body’s natural methods of elimination of unwanted 1 Introduction
  16. 16. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”substances. Thus the Panchakarma therapies of Ayurveda form a unique system oftherapy, which not only aims at physical correction and rehabilitation, but also aim atimparting local medication and transdermal nourishment of the tissues. Among the panchakarmas, virechana is an important one, which had greatimportance. At the same time it is a highly effective therapy, which gives tremendousresults. It is a process by which the doshas are made to pass through the adhomarga i.e.Guda. Virechana is a specific treatment for pitta dosha, and pitta samsarga doshas. It isalso the treatment for kapha and vata doshas. In the process of virechana, the person willnot have that much amount of trouble and exhaustions as in normal purgation, as he hasbeen subjected to snehana, swedana etc. Madhumeha is a disease known to mankind since vedic period. Ayurvedicclassics consider madhumeha among the twenty obstinate urinary disorders. Thedevelopment of modern science has revolutionized the approach to this disease and it’smanagement. Traditionally madhumeha is correlated with diabetes mellitus, which is known as“Richman’s disease”, particularly because a person who is able to enjoy the pleasure oflife without any perceptible exercise is usually affected with this disease. The importanceof over nutrition is shown by the fact that, over the age of 40 some 80 percent of patientsdeveloping diabetes are considerably over weight. Obesity is considered to be a important risk factor for diabetes mellitus. In factAyurveda considers sthoulya as a nidanarthakara roga for madhumeha. 2 Introduction
  17. 17. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”INCIDENCE AND PREVALENCE Diabetes has become the disease of the masses. Over twenty million people arereported to be suffering from this “sweet disease”. It is projected that by another twentyyears the number would rise to 60 million in India. In the past 16 years our populationhas roughly doubled from about 68 million to the 1 billion mark and the number ofdiabetics has increased by more than 7 fold. According to I.C.M.R. survey, it isestimated that between 1995 and 2005, India will have about 2-3 crore diabetic patients. 3 Introduction
  18. 18. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”Need For Study : The modern management of diabetes inspite of many advances still remainsunsatisfactory. Drug intolerance, hypersensitivity, resistance to insulin, the danger ofacute and chronic complications, the fear of hypoglycemic episodes make it all the moreimportant to search out safe, effective and cheaper remedies. Such remedies could beexplored form the huge wealth of Ayurveda. Among that virechana is one of the jewel,which gives tremendous results in many diseases including sthoola madhumeha.Objectives : Even though many research works are conducted on the effect of some indigenousdrugs on Madhumeha, only few have been conducted on samshodhana karma. So far onlyless studies are conducted on the effect of virechana on sthoola madhumehi. So theobjective of this study is “Clinical evaluation of virechana karma in sthoolamadhumeha (NIDDM)” in order to evaluate its effect. 4 Objectives of the study
  19. 19. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”HISTORICAL REVIEW Madhumeha is one of the ancient diseases and is as old as humanity and thisdisease is well known to vedic period also.Vedic Period : Vedas are the oldest literature of civilization. Atharva veda is having closerelation to Ayurveda. In Vedas we find two words Asrava and Prameha. In Atharvaveda asrava vyadhis are mentioned in which nasasrava, atimootra and atisara areincluded1. The term asrava is formed from A-Srava means to flow. Whitney (Atharvaveda translated and commented) interpreted this as “Flux” and Griffith (also translatedand commented) as “Morbid flow” 2. In Koushika sutra of the Atharvanaveda we find reference of the work Prameha3. In Atharvaveda 6/44/3 Visanaka drug is indicated in vatavyadhi. Kesavacommenting on this, explained “Vaikruta nasani” as “Vaikruta asravya nasani”,means it is indicated in asrava vyadhis. In the Manthra 23-1-3 of Atharvanaveda, the drugs emerged from valmika areindicated in atisara, atimootra and nadivranam4. This clearly indicates the prevalence of this disease with its remedy in the vedicperiod.Samhita Period : It is a point of historical importance that Charaka samhita mentions the loss ofsweet substance from urine5. Charaka also mentioned in sutrasthana that the Madhumeha occurs due toavritatwa of vayu6. 5 Historical review
  20. 20. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” Charaka also mentioned the importance of ojus in Madhumeha samprapti7. Bhela samhita which is contemporary to Charaka samhita describes the two typesof Madhumeha i.e. prakruta (congenital) and swakrita (acquired) 8. The most notable contribution of Sushruta was to devote a separate chapter for themanagement of Madhumeha and he mentioned some specific preparations of mineral andvegetables. He has also given more importance to Shilajatu9. Further he also described aseparate chapter for the management of Carbuncles, which are the upadravas ofMadhumeha10. After Sushruta, Vagbhata has given great contribution to Indian medicine. Hecompiled the existing knowledge and added some new preparations and ideas to thiscontext. He mentioned two types of Madhumeha on the basis of pathogenesis, one isDhatukshayajanya and another is Avaranajanya11. Arthashastra of Koutilya (321 – 296 BC) mentions a method to produce Pramehain the section dealing with the means to injure the enemy. The spot obtained fromburning Chanclion (Krukalaka) and house lizard (Gruha Goulika) together with theintestines of mottled frog (Chitra Bheka) and honey, if administered causes Prameha.This evidently points the existence of diabetogenic technique in the ancient times12.Medieval Period : This period of history of Indian medicine is known as a period of commentators. Madhavakara (9th century A.D.) in his book Madhava nidana compiled thethoughts of his earlier authors without adding any thing new to the knowledge onMadhumeha13. 6 Historical review
  21. 21. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” Gayadasa (11th Century A.D.) commentator of Sushruta samhita elucidated thatavilatva of urine in Prameha is due to the presence of some components of dooshya i.e.meda, mamsa, etc14. Dalhana, another commentator of Sushruta samhita (12th century) contributed amyth that females do not suffer from Madhumeha15. Sharangadhara (13th century A.D.) prescribed some new recipes for themanagement of Prameha16. Bhavamishra (16th century A.D) contributed to the history of prameha by addingsome new vegetables and metallic preparations for the management of prameha. Ayurvedic physicians even three thousand years ago were aware of the extent towhich all the body tissues are involved in the pathogenesis of Prameha. Claims have beenmade by China, Egypt and India as the home of discovery of this vast disease. But allevidences points to the fact that, it is in ancient Sanskrit texts that the earliest referenceare found. These Sanskrit texts in turn were translated to Latin and became the source ofEuropean medicine. Three outstanding physicians of Ayurveda, Charaka, Sushruta and Vagbhatabetter known as the Holy Triad made the earliest reference to diabetes as a “diseasedflow of urine” and “honey urine”. Charaka mentions that ants are attracted by Person’surine afflicted with this disease. Sushruta specifically mentions that the urine of thediabetic person is sweet nature. It seams, during this period no Greco-Roman physicians were acquainted withsymptoms of abnormal urine. 7 Historical review
  22. 22. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”Historical milestones in the field of Diabetes Mellitus The relationship between the pancreas, an organ lying behind the upper intestinesand diabetes are firmly established by “Von Mering” and “Minkouski” in 1889. It wason the mid night of July 30,1921, that a pancreatic extract produced in this manner wasinjected to a depancreatised diabetic dog on the verge of coma and one hour later bloodsugar came down and urine sugar disappeared, Insulin was born!.Table No.01. Historical milestones in the field of Diabetes mellitus17.Sl. Invention Name Period01. Clinical description document Eberus papyrus 1500 BC02. Clinical description, noted sweetness in urine Charaka 600 BC and role of hereditary03. Clinical description, noted sweetness in chine Sushruta 400 BC and role of hereditary04. Clinical description Celsus 30 BC - 38 AD05. Name diabetes Aretaus 30 - 90 AD06. Introduce the term diarrhoea of urine Galan 132 - 201 AD07. Evaporated specimen of Urine of patient and Jaques Dubois 1478 – 1555 discovered a residue which was almost sylvanus Glucose08. Dietary regulation for diabetes Arnatus 1511 – 1568 Luritanus09. Role of heredity in diabetes Mortan Richard 1637 – 169810. Role of hereditary in diabetes Mortan Richard 1637 – 1698 8 Historical review
  23. 23. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”Sl. Invention Name Period11. Removed pancreas from the dogs and found Burunner J.C. 1653 – 1727 that they developed thirst and polyurea12. First to add mellitus to diabetes Cellura William 1712 – 179013. First to separate diabetes incipidus from Johanu Frank 1745 – 1821 mellitus14. Described pathology of pancreas Cawley 178815. Liver’s role in diabetes Von Noorden 1858 – 194416. Described pancreatic Islets Langerhan paul 196917. Sugar storage in liver as glucagons and Clande Bernad 1870 elevated blood sugar in diabetes18. Experimental diabetes after removal of Von Mering and 1889 pancreas Minkovasski19. Insulin almost discovered Zulger, Panlaski 1910 – 192020. Insulin from dog pancreas Banting and 1921 - 1922 Best21. Transplant of beta cells Downwards 1970 Mervin and Gliedman22. Artificial pancreas Liebel selden 1974 - 1975 9 Historical review
  24. 24. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”VIRECHANA KARMANirukti And Paribhasha Virechana18 : - Virehana shabda is formed by the root “Rich” dhatu and “Vi”upasasga. “Nich and “Lout” pratyaya are also take part in the derivation of the wordvirechana. “Visheshena rechateeti” “Vi + rich + Nich + Lyu.”Virechana karma Panchakarma is the popular term for shodhana chikitsa, and among that virechanais an important one. Virechana is a process by which the doshas are made to pass throughthe adhomarga i.e. Guda21. Its general meaning is to remove the doshas from the body,but in Ayurveda removal of the doshas from the body trough guda is called as virechana. Virechana is a specific therapy for pitta dosha and pitta samsarga doshas. It isalso the treatment for kapha in the pittasthana. Virechana is also useful in vata dosha assneha, sweda and mridu virechana are the main upakramas of vata dosha22.Virechana karma In Major Classics In the treatment of madhumeha virechana therapy has great importance. All theBrihathrayies of Ayurveda has mentioned about Madhumeha and other classis likeBhavaprakasha, Bhaishajya ratnavali, Yogaratnakara and Vangasena mentioned aboutthis disease and the importance of virechana in this condition23. All the classics have given detailed description regarding Virechanakarma. InCharaka samhita we can get the explanation of different virechana dravyas and kalpas inkalpasthana and in sutrasthana. In siddhi sthana he explained the importance ofVirechana in different diseases, yogyas, ayogyas, siddhis, vyapats and pariharas etc. indetail24. Virechana karma
  25. 25. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” In Sushrutasamhita sutrasthana he gives explanation regarding adhobhagaharadravyas in detail. Also in the sutrasthana he explains virechana pradhanani dravyas. Inchikitsasthana acharya gives information regarding method of application of virechana,oushadha panavidhi, dosha nirharana karma, samyakyoga, atiyoga, vyapats, and theirchikitsa in detail25. Vagbhata acharya in Ashtanga Hridaya Kalpasthana gives explanation ofvirechana dravyas and their different kalpas. Apart from this in Sutrasthana, he givesexplanation of virechana vidhi, yogyas, ayogyas, etc. in detail26. In the same way other acharyas like Yogaratnakara, Bhavaprakasha,Sharangadhara, Vangasena, all gives explanations regarding Virechanakarma.Types of Adhobhagahara Karma Sharangadhara has explained 4 types of adhobhagahara karmas, they are27 01. Anulomana 02. Sramsana 03. Bhedana 04. Rechana Among these, rechana karma expels pakva or apakva mala in drava form which isconsidered as more good.Virechana Dravyas Virechana dravyas will have all the properties of vamana dravyas i.e., ushna,teekshna, sookshma, yogavahi, vikashi etc. These drugs consisting of pritvi and jalamahabhootas. Virechana dravyas have a specific property of removing the doshas fromthe lower part of body i.e. Adhobhaga28. Virechana karma
  26. 26. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”Virechana Vidhi As a first step one has to observe whether the patient is fit for virechanakarma ornot. For this in classics criterias are given such as virechana yogyas, virechana ayogyasetc. Those who are fit for virechana should only be given with virechana other wise itwill lead to lot of complications. At the same time one has to see whether the patient isfit for snehana and swedana also, as they are the poorvakarmas of virechanakarma.Table No. 02. Showing the Virechana Yogyas29.Sl. Virechya Charaka Susruta Vagabata01. Jwara + + +02. Kushta + + +03. Prameha + + +04. Urdvaga raktapitta + + +05. Bhagandara + + +06. Arsha + + +07. Pleeha dosha + + +08. Gulma + + +09. Arbuda + + -10. Galaganda + + -11. Grandhi + + +12. Gara + + +13. Vishoochika - + +14. Alasaka + + -15. Mootraaghhata + + +16. Krimikoshta + + + Virechana karma
  27. 27. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”17. Visarpa + + +18. Pandu + + +19. Sirashoola + + daha +20. Parshva shoola + - -21. Udaavartha + - -22. Netra daha + + -23. Aasya daha + + -24. Hridroga + + -25. Vyanga + - +26. Neelika + - -27. Aruchi + + -28. Netrasrava + - -29. Nasasrava + - -30. Haleemaka + - +31. Swasa + - +32. Kasa + - +33. Kamala + - +34. Apachi + - +35. Apasmara + - -36. Unmada + - -37. Vata rakta + + +38. Yonidosha + + +39. Retodosha + - +40. Timira + + + Virechana karma
  28. 28. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”41. Udara + + +42. Avipaka + - -43. Chardi + + +44. Visphota + + +45. Pakwashaya ruja - + +46. Vibhanda - + +47. Vidradhi - + +48. Shvayadhu + + +49. Shastra ksheena kshara agni dagdha - + -50. Dushta Vrana - + +51. Akshipaka - + -52. Abhishyanda - + +53. Kaacha - + +54. Guda daha - + -55. Medhra daha - + -56. Nasa Karna daha - + -57. Aanaha - + -58. Shleepada - - -59. Stanyadosha - - +60. Hrullasa + - + Virechana karma
  29. 29. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”Table No. 03. Showing the Virechana Ayogyas30.Sl. Avirechya Charaka Susruta Vagbata01. Subhaga + - -02. Kshataguda + - +03. Bhuktaanala + - -04. Adhoga vaktapitta + + +05. Langhita + - -06. Durbalendriya + - -07. Alpagni + + +08. Niruda + - +09. Kamadi vyagra + - -10. Ajeerna + + +11. Nava jwara + + +12. Madatyaya + + +13. Aadhmana + - +14. Shalyardita + - +15. Abhighata + - +16. Atisnigdha + + +17. Atirooksha + + +18. Daruna Koshta + + -19. Kshata ksheena + + +20. Atisthoola + + +21. Atiruksha + - + Virechana karma
  30. 30. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”22. Bala, Vrudha + + +23. Durbala + + +24. Shranta + + -25. Pipasita + + -26. Karma, bhara Advahana + - -27. Upavasita + + -28. Maithunaprasakta + - -29. Adhyayana Prasakta + - -30. vyayama Prasakta + - -31. Chinta prasakta + - -32. Kshama + - -33. Garbhini + + +34. Nava prasuti - + +35. Nava pratishyaya - + +36. Rajayakshma - - -37. Atisara - - -38. Kshudhita + - +39. Nitya dukhita - - +40. Hrudrogi, Bhayabhoota - - + Compared to other karmas like vamana, vasthi, nasya and raktamokshana,virechana is less complicated and easy to administer, if administered in proper way.Before the administration of virechana, the patient is made to undergo snehana andswedana. Before the above two karmas i.e., snehana and swedana, deepana pachana Virechana karma
  31. 31. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”should be administered in order to get niramata. After getting niramata patient should begiven shehana in arohana krama till he attains samyak snigdha lakshana, normally till 7days. The sneha should be vyadyanuroopa and vyadyanukoola.Table No. 04. Showing the Samyak Snigdha Lakshanas31.Sl. Lakshanas Charaka Susruta Vagbata01. Agnideepthi + + +02. Snehodvega + - +03. Asamhata varcha + + +04. Anga laghava + + -05. Gatra mardava + + -06. Gatra snigdhata + +` +07. Pureesha snigdhata + + +08. Twak snigdhata - + -09. Vatanuloma + - +10. Adhomarga sneha srava - + +11. Klama - + +12. Shaithilya - + - As a next step, patient should be given swedana till samyak swinna lakshanas.After attaining swinnata, he should be given Virechana dravya. Before this a proper doseand form should be fixed for the Virechana dravya and the total body condition shouldalso be assessed carefully in order to avoid further complications. For Virechana dravya, uttama, madyama and alpamatras are mentioned, from thatone dose suitable to the patient should be selected. Also vaidya has to see whether any Virechana karma
  32. 32. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”avirechya diseases are manifested in the patient during the day of the virechana. Both thesneha used for the snehapana and the drug used for Virechana should be vyadhyanukoolaand vyadyanuroopa. Apart from the above factors like desha, kaala, bala, shareera, aharasaatmya, satva, prakriti and vayaha should be considered32. Pradhana Karma inVirechana vidhi consists of administration of Virechana dravya to till the stoppage ofvirechana vegas. The following ideas are necessarily kept in mind such as, 01. The administration of Virechana Yoga. 02. Deciding the Vegas. 03. Observation of the signs and Symptoms of samyak yoga, ayoga and atiyoga. 04. Examination of the patient who have undergone virechana therapy. 05. Vyapats if any, and their treatment. Vagbhata Says, the patient has to take Virechana dravya just after kapha kala. Assoon as the drug meant to produce Virechana is administered, in some sensitive patientsthere will be the sensation of nausea or vomiting. It is due to either bad taste of the drugor due to utkleshana leading to anorexia. The properties of emetics and purgatives willhave stimulating properties. Hence the Purgatives may sometimes produce vomiting. Assoon as the patient drinks the purgative drug the patients face must be sprinkled with coldwater and the mouth should be washed with hot water. The patient must also be made to lie on a bed and to allow him to take rest. Alittle hot water must be given to the patient to drink so that the vega must come properly.He must not allow touching even cold water up to last vega33. Virechana karma
  33. 33. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” In a proper Virechana the patient passes mutra, purisha, pitta, kapha etc. in asequence. When there is no purgation, then instantaneously the hot water must be givento drink and the hand must be made warm and sweda must be done on stomach. Vaidyamust observe the signs and symptoms of jeernoushadha and ajeernoushadha etc. that aregiven in the following table34.Table No. 05. Showing the Virechana dravya jeeranoushadha and ajeeranoushadhalakshanasSl. Jeernoushadha Lakshana Ajeernoushadha lakshana01. Vatanulomana Dourbalya02. Swasthya Daha03. Kshut Angasaada04. Pipasa Bhrama05. Mana prasannata Moorcha06. Indriya prasannata07. Shudha udgara, etc. Here ajeernoushadha lakshanas indicates that the virechanoushadha undergonepachana without doing its virechana effect. Apart from the above lakshanas the hrit dosha lakshana also should be taken intoconsideration. As told previously, in a proper virechana there will be expulsion of mala,pitta and kapha in sequence i.e. “kaphantam virechanam”. After this only vatanirgamana occurs. Also the appearance of dourbalyata and laghuta indicates that doshashave properly gone out35. Virechana karma
  34. 34. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” If ajeerna lakshanas are noted but ayoga of virechana happens, the patient shouldnever be given further dose of oushadha because it may lead to atiyoga. When theoushadha undergone pachana and there is no hrit dosha lakshanas, then he should begiven food and again virechana oushadha should be administered on next day. Even thenvirechana does not happen, after 10 days again virehana oushadha can be given afterproper snehana and swedana36.Vega Nirnaya For Veganirnaya the physician has to leave the first two three malayukta vegasand then counting should be done. By observing the vegiki, maniki, antaki and laingikilakshanas, one has to decide whether virechana is pravara, madhyama or avara.Table No.06. Showing the Virechana vega nirnaya37.Sl. Vega vishaya Pravara Madhyama Avara01. Vegiki lakshana 30 vega 20 vega 10 Vegas02. Miniki lakshana 4 Prastha 3 Prastha 2 Prastha.03. Antaki lakshana Kaphantam04. Laigiki lakshana General signs and symptoms of virechana A proper or well-performed Virechanakarma leads to samyak Virechanalakshanas. i.e. 38, Indriya prasannata. Shareera laghuta. Expulsion of vit, pitta, kapha and Agnideepti vata in sequence. Absence of atiyoga and ayoga Sroto shuddhi. virechana lakshanas. Vatanulomana. Virechana karma
  35. 35. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” Like the knowledge of virechana samyak lakshanas, the knowledge of ayoga andatiyoga lakshanas are also very essential39.Table No. 07. Showing the Virechana ayoga and atiyoga laxanas. Virechana ayoga lakshansa Virechana atiyoga lakshanas Lakshanas Ch. Su. Vag. Lakshanas Ch. Su. Vag.Kapha Praseka + + + Kapha Kshaya vikara + + -Pitta Prakopa + + + Pitta kshaya vikara + - -Vata Prakopa + - - Vata Kshaya vikaya + - -Agni mandya + + - Anga marda + - _Gaurava + + - Klama + - -Pratishyaya + - + Vepathu + - _Tandra + - _ Nidra + - -Chardi + - - Dourbalya + - -Aruchi + + + Tama pravesha + - -Vata pratilomata + - - Unmada + - -Daha - + + Hikka + - -Hridaya Ashudhi - + + Moorcha - - -Kukshi Ashudhi - + + Guda bhramsha - - -Kandu - + + Shoola - + -Vit sanga - - + Kapha pitta rahita, - - + sweta, lohita udaka + nissaranamMutra Sanga - + - Mamsa udaka srava - - +Pidaka - - + Medo gandhavat - - + srava Virechana karma
  36. 36. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” Trishana - - + Bhrama - - + Netra Praveshana - - + Ati vamana vyapat - - + Rakta kshaya vikara + - - Due to Kaphotklesha, aruchi and ajeernata, the virechanoushadha may producevamana. In such conditions, patient should be given snehana and swedana and againoushadha should be given. Even then virechana is not possible, if oushadha is not satmyato the patient and dravya is not producing any apriyata, once again oushadha can be givenfor attaining Virechana40. Soon after the samyak virechanakarma digestive power gets impaired. So thepeyadi samsarjana krama should be followed in order to bring back the normal agni41.Except in the following conditions, in others peyadi samsarjana karma can be done. They are, Pitta kapha parisrava Madatyaya Vata pitta prakriti In the above conditions tarpana can be administered. Improper conduction of Virechana leads to the vyapats (complication) Like42, Aadhmana Parisrava Stambha Jeevadana Anga graha Parikartika Hrit graha Vibhrama Klama Virechana karma
  37. 37. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”Sushruta has given 15 vyapaths (complications) of Virechana43, Vamana occurs with Virechana Vata ruk dravya and vise versa Parisrava Shesha oushadatwam Ayoga Jeerna oushadhatwam Pravahika Aadhmana Atiyoga Heena oushadha apahritatwam Hridyopasarana Jeevadhana Vibandha Parikartika As seen above, acharyas have clearly mentioned the ayoga, atiyoga and vyapats indetail and their treatment.Mode of Action of Virechana Drugs As explained earlier, the virechana dravyas have the properties like ushna,teekshna, sookshma, vyavayi and vikashi gunas. The drug having these properties willreach the heart by its potency and there by to the entire dhamanis. Also it reaches to bigsmall and minute srotases of the body. Due to the presence of ushna veerya, vishyandanais produced; teekshna guna produces chedana of dosha samoohas and brings it to thekoshta. From there due to prithvi and jala mahabhoota gunas and also due toadhobhagahara prabhava the doshas are get eliminated through guda marga. Bothvirechana and vamana oushadha having the same properties, but virechana drugsproduces virechana and vamana drugs produces vamana only and it is only because of itsprabhava. Virechana dravyas produce uttejana in the sotases, dhamanies, koshta andultimately on hridaya kendra. Sushruta added sara guna along with the ushnadi gunas andthis sara guna is helpful in anulomana procedure44. Virechana karma
  38. 38. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” Acharya Charaka says, the drugs acts not only due to its prabhava but also due toit’s dravyatwa prabhava, gunatwa prabhava and both dravyatwa and gunatwa prabhava.And the factors mentioned here may change based on conditions. The effect produceddue to above is called karma. The factor responsible for manifestation of effect isveerya45.Modern Concept of Purgatives46 The terms purgative, cathartic, laxative, and evacuant may be consideredsynonymous. They are medicines that promote defecation largely by reducing theviscosity of the contents of the lower colon. Purgatives may be classified as: 01. Bulk purgatives. 02. Osmotic Purgatives. 03. Fecal softeners. 04. Stimulants.01. Bulk purgatives : These comprise indigestible vegetable fiber and hydrophilic colloids. Bulkpurgatives act by increasing the volume and lowering the viscosity of intestinal contentsto promote a large soft, solid stool. The substances thus encourage normal reflex bowelactivity, rendering it more effective and generally acting within 1-3 hours. Dietary fibersare essentially the cell walls and supporting structures of vegetables and fruits.Increasingly reference is made to non-starch polysaccharide (NSP), which refers tocarbohydrates that are not digestible by human enzymes and which can be assayed. NSPcomprises most of the fiber in our diet. Virechana karma
  39. 39. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”02. Osmotic laxatives : These are but little absorbed and increases the bulk and reduces viscosity ofintestinal contents to promote a fluid stool. Some inorganic salts retain water in theintestinal lumen or, if given as hypertonic solution withdrawn it from the body. Lactuloseis a synthetic disaccharide, taken orally, it is unaffected by small intestinal disaccharides,is not absorbable and this acts as an osmotic laxative.03. Fecal softeners (emollient) : The softening purposes of these agents are useful in the management of analfissures and hemorrhoids. In this the feces is softened by lowering the surface tension offluids in the bowel, which allows more water to remain in the feces.04. Stimulant purgatives (contact laxatives) : These increase intestinal motility by various mechanisms. They may causeabdominal cramps and should not be used where there is intestinal obstruction.After giving the explanation of virechana karma along with its modern aspects, it isnecessary to narrate the normal anatomical and physiological activities that are going onin the stomach, small intestine, large intestine and rectum, which are given below. Virechana karma
  40. 40. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”SHAREERAStomach 47 The stomach has the shape of an expanded “J”. The stomach performs 4 majorfunctions. Viz. 01. The bulk storage of the ingested food. 02. Disruption of chemical bonds in chemical materials through the action of acids and enzymes. 03. Mechanical breakdown of ingested food. 04. Production of intrinsic factor, a glycoprotein whose presence in the digestive tract is required for the absorption of the vitamin B12.Regulation of Gastric phase – The CNS, regulated by the short reflexes coordinated in the wall of stomach andregulated by the digestive tract hormones can control the production of acids andenzymes by the gastric mucous.01. The cephahlic phase – Function – Prepare stomach for arrival of food. Duration – short. (minutes) Mechanism – Neural via preganglionic fibers in vagus nerve and synapse insubmucosal plexus (by seeing, smell, taste or thoughts of food) Actions – Primary – Increased volume of gastric juice by stimulatingmucous, enzyme and acid production. Secondary – Stimulation of gastrin release by G cells. 26 Shareera
  41. 41. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”02. Gastric phase – Enhance secretion started in cephalic phase, homogenizes and acidify the chyme.It initiates the digestion of proteins by pepsin. Duration of the phase is long i.e. 3-4 hours. Mechanism – Neural – Short reflexes triggered by stimulation of stretch receptors as stomach fills. There is also stimulation of chemo-receptors as PH increases. Hormonal – Stimulation of gastrin release by G cells byparasympathetic activity and presence of peptide and amino acids in chyme. Also therelease of histamine by mast cells as stomach fills. As a result there is an increased acidand pepsinogen production, increased motility and initiation of mixing waves. Themixing waves occur several times per minute and they gradually increase in intensity.After an hour, the material with in the stomach is churning like the clothing in thewashing machine.03. Intestinal phase – The main function of this phase is controlled rate of chyme entry into duodenum.The duration of this process is long. i.e. hours. Mechanism – Neural – short reflexes (entero-gastric reflex) triggered by the extension of duodenum. Hormonal – Primary – Stimulation of CCK, GIP, and secretin release by presence of acid, carbohydrate and lipids. 27 Shareera
  42. 42. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” Secondary – Release of gastrin stimulated by presence of undigestedproteins and peptides and finally there is feed back inhibition of gastric acid andpepsinogen production, reduction of gastric motility. The intestinal phase of gastric secretion begins when chyme starts to enter thesmall intestine. The intestinal face generally starts after several hours of mixingcontractions, when the wave of contraction begins sweeping down the length of thestomach. Each time the pylorus contracts, a small quantity of chyme squits through thepyloric sphincter. The purpose of intestinal phase is to control the rate of gastricemptying and ensure that the secretary, digestive functions of the small intestine canproceed with reasonable efficacy. The arrival of chyme in the small intestine also triggersother neural and hormonal events that co-ordinate the activities of intestinal tract,pancreas, liver, and gall bladder.Small Intestine48 The stomach is a holding tank where food is saturated with gastric juices andexposed to stomach acids and the digestive effects of pepsin. These are the primary steps,for most of the digestive and absorption functions occur in the small intestine, where theproducts of digestion are absorbed. The mucosa of the small intestine produces only a few of the enzymes involved.The pancreas provides digestive enzymes as well as buffers that assist in theneutralization of acidic chyme. The liver and the gall bladder provide bile, a solution thatcontains additional buffers and bile salts, compounds that facilitates digestion andabsorption of lipids. 28 Shareera
  43. 43. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” The small intestine averages 6 m. in length and has a diameter ranging from 4 cmat the stomach and about 2.5 cm at the junction to the large intestine. It accompanies allabdominal regions except the right and left hypochondriac regions. It has 3 subdivisions.duodenum, jejunum and ileum.Intestinal Movements After chyme has arrived in the duodenum weak peristaltic contractions move itslowly towards the jejunum. These contractions are mesenteric reflexes not under CNScontrol. Their effects are limited to with in a few centimeters of the site of the originalstimulus. These short reflexes are controlled by motor neurons in the submucosal andmesenteric plexus. In addition, some of smooth muscle cells contract periodically evenwithout stimulation, establishing a basic contractile rhythm that then spreads from cell tocell. The stimulation of the parasympathetic system increases the sensitivity of thesemesenteric reflexes and accelerates both local peristalsis and segmentation. Moreelaborate reflexes coordinate activities along the entire length of small intestine. Tworeflexes are triggered by the stimulation of the stretch receptors in the stomach as it fills.The gastro-enteric reflexes stimulates motility and secretion along the entire length of thesmall intestine, the gastro-ilial reflex triggers the relaxation of the iliocecal valve. The netresult is that, the materials pass form small intestine to the large intestine. Thus thegastro-enteric and the gastro-ilial reflexes accelerate movements along with smallintestine, the opposite effect of the entero-gastric reflex. Hormones released by thedigestive tract can enhance or suppress reflex responses. 29 Shareera
  44. 44. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”Large Intestine 49 The horseshoe shaped large intestine begins at the end of the ilium and ends at theanus. The large intestine lies inferior to the stomach and liver and almost completelyframes the small intestine. The major functions are – 01.Absorption of water and compactness of intestinal contents into faeces. 02. Absorption of important vitamins liberated by the bacterial action. 03. Storing of fecal material before defecation. It has the following parts – 01. Caecum 02. Colon 03. RectumMovements of large intestine The gastro-ilial and gastro-enteric reflexes move materials into the caecum atmealtime. Movement form the caecum to the transverse colon occurs very slowly,allowing hours for water absorption to convert the already thick material into a sludgypaste. Peristaltic waves move material along the length of colon. Movements from thetransverse colon through the rest of the large intestine results form powerful peristalticcontractions called “Mass movements” which occur a few times each day. The stimulus is distention of the stomach and the duodenum and the commandsare relayed over the intestinal nerve plexus. The contractions force the fecal materialsinto the rectum and produce the conscious urge to defecate. 30 Shareera
  45. 45. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”Defecation The rectal chamber is usually empty except when one of those powerful peristalticcontractions forces fecal material out of the sigmoid colon. Distention of the rectal wallthen triggers the defecation reflex. The defecation reflex involves two positive feed back loops both are triggered bystretch receptor stimulation in the walls of the rectum. The first loop is a shorter reflexthat triggers a series of peristaltic contractions in the rectum that moves the feces towardsthe anus. The second loop is a long reflex coordinated by the sacral parasympatheticsystem. This reflex stimulates mass movements that push the fecal material to the rectumfrom the descending colon and the sigmoid colon. Rectal stretch receptors also trigger two reflexes important to the voluntarycontrol of defecation. 01. Visceral reflex – Mediated by the parasympathetic innervations with in the pelvic nerves. Thisreflex causes the relaxation of the internal anal sphincter, a smooth muscle sphincter thatcontrols the movements of the feces into the anorectal canal. 02. Somatic reflex – That stimulates the immediate contraction of the external anal sphincter. Theelimination of the feces requires that both the internal and external anal sphincter to berelaxed, but these reflexes open the internal sphincter and close the external sphincter.The urge to defecate usually develops when rectal pressure reaches about 15 mm of Hg.When it exceeds 55 mm of Hg external sphincter will relax and the defecation occurs. Diabetes mellitus is a chronic disease due to the disordered carbohydratemetabolism and results due to deficiency of insulin secreted by the beta cells of Islets of 31 Shareera
  46. 46. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”Langer Hans of pancreas. But the hormones of pituitary and adrenal glands are alsointimately related to the development of this state. Apart form this liver had its own rolein the manifestation of this disease, because it stores the glucose in the form of glycogenunder the influence of insulin. Any alteration in this leads to diabetes. So following arethe glands involved in the pathology of manifestation of the diabetes mellitus – 01. Pancreas 02. Pituitary 03. Adrenal 04. LiverPancreas50 The pancreas lines within the abdomino-pelvic cavity in the ‘J’ shaped loopbetween the stomach and the small intestine. It is a slender, plane organ with a nodularconsistency. The adult pancreas is 20 –25 cm long and weights about 80 gms. The broadhead of the pancreas lines within the loop formed by the duodenum as it leaves thepylorus. The slender body extends transversely towards the spleen and the tail is shortand bluntly rounded. The pancreas is retroperitonal and is firmly bound to the posteriorwall of abdominal cavity. The surface of the pancreas has a lumby, lobular texture. A thin, transparentconnective tissue capsule wraps the entire organ. You can see the pancreatic lobules,associated blood vessels and excretory ducts through the anterior capsule and theoverlying layer of peritoneum. Arterial blood reaches the pancreas by way of branches of the splenic, superiormesenteric and common hepatic arteries. The pancreatic arteries and Pancreaticoduodenalarteries are the major branches from these vessels. Splenic vein and its branches drain thepancreas. 32 Shareera
  47. 47. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” The pancreas is primarily an exocrine organ producing digestive enzymes andbuffers. The large pancreatic duct delivers these secretes to the duodenum. A smallaccessory duct, or duct of Sanforini, may branch from the Pancreatic duct. The Pancreaticduct extends within the attached mesentery to reach the duodenum, where it meats thecommon bile duct from the liver and gall bladder. The pancreas has two distinct functions, one endocrine and other exocrine. Theexocrine pancreas roughly 99 percent of the pancreatic volume consists of clusters ofgland cells, pancreatic acini, and their attached ducts. Together the gland and duct cellssecrete large quantities of an alkaline, enzyme rich fluid. This secretion reaches thelumen of the digestive tract by traveling along a network of secretary ducts. The endocrine pancreas consists of small groups of cells scattered among theexocrine cells. The endocrine clusters are known as pancreatic Islets, or the Islets ofLanger Hans. Pancreatic islets account for only about 1 percent of the pancreatic cellpopulation. Nevertheless, a typical pancreas contains roughly 2 million pancreatic Islets. Each Islet contains four different cell types. 01. Alpha cells – Produce the hormone Glucagon. Glucagon raises blood glucose levels byincreasing the rates of glycogen break down and glucose release by the liver. 02. Beta cells – Produce the hormone insulin. Insulin lowers blood glucose by increasing the rateof glucose uptake and utilization by most body cells and increasing glycogen synthesis inskeletal muscles and the liver. Beta cells also secrete amylin, a recently discoveredpeptide hormone whose role is uncertain. 33 Shareera
  48. 48. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” 03. Delta cells – Produce a peptide hormone identical to somatostatin, a hypothalamic regulatoryhormone. Somatostatin produced in the pancreas suppresses glucagon and insulin releaseby other islet cells and slows the rates of food absorption and enzyme secretion along thedigestive tract. 04. F cells – Produce the hormone pancreatic polypeptide. It inhibits gallbladder contractionsand regulates the production of some pancreatic enzymes. It may help to control the rateof nutrient absorption by the digestive tract. Here focus is made on insulin and glucagon, the hormones responsible for theregulation of blood glucose concentrations, which are given below. These hormonesinteract to control blood glucose levels. When blood glucose levels rise, beta cells secreteinsulin, which then stimulates the transport of glucose across cell membranes. Whenblood glucose levels decline, alpha cells secrete glucagon, which stimulates glucoserelease by the liver.Insulin Insulin is a peptide hormone released by beta cells when glucose levels rise abovenormal levels (70 to 110 m/c). Elevated levels of some amine acids, including arginineand leucine, also stimulate insulin secretion. Insulin exerts its effects on cellularmetabolism in a series of steps that begins when insulin binds to receptor proteins on thecell membrane. Binding heads to the activation of the receptor which functions as akinease and attaches phosphate groups to intracellular enzymes. Phosphorylation ofenzymes then produces Primary and secondary effects within the cell, the biochemicaldetails remain unresolved. 34 Shareera
  49. 49. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” One of the most important effects is the enhancement of glucose absorption andutilization. Insulin receptors are present in most cell membranes. Such cells are calledinsulin-dependent. However, cells in the brain and kidneys, cells in the lining of thedigestive tract, and red blood cells lack insulin receptors. These cells are called insulinindependent, because they can absorb and utilize glucose without insulin stimulation.Effects of insulin on its target cells –01. Acceleration of glucose up takes This effect results from an increase in the number of glucose transport proteins inthe cell membrane. These proteins transport glucose into the cell by facilitated diffusion.02. Acceleration of glucose utilization and enhanced ATP production This effect occurs for two reasons – (a) The rate of glucose use is proportional to its availability. when more glucose enters the cells, more is used. (b) Second messengers activate a key enzyme involved in the initial steps of glycolysis.03. Stimulation of glycogen formation (skeletal muscles and Liver cells) When excess glucose enters these cells, it is stored in the form of glycogen.04. Stimulation of amino acid absorption and protein synthesis05. Stimulation of triglyceride formation in adipose tissues Insulin stimulates the absorption of fatty acids and glycerol by adipocytes. Theadipose cells then store these components as triglycerides. Adipocytes also increase theirabsorption of glucose; excess glucose is used in the synthesis of additional triglycerides. As a whole (summary) insulin secreted when glucose is abundant and thishormone stimulates glucose utilization to support growth and the establishment of 35 Shareera
  50. 50. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”carbohydrate (glycogen) and lipid (tryglyceride) reserves. The accelerated use of glucosesoon brings circulating glucose levels with in normal limits.Glucagon When glucose concentrations fall below normal, alpha cells release glucagons,and energy reserves are mobilized. When glucagons binds to a receptor in the cellmembrane; it activates adenylate cyclase, and cAMP acts as a second messenger thatactivates cytoplasmic enzymes. The primary effects of glucagons are – 01. Stimulation of glycogen breakdown in skeletal muscle and liver cells. 02. Stimulation of triglyceride breakdown in adipose tissues. 03. Stimulation of glucose production at the liver. The liver cells absorb amino acids from blood steam, convert them to glucose,and release the glucose into the circulation. This process of glucose synthesis in the liveris called gluconeogenesis. The results are a reduction in glucose use and the release of more glucose into theblood steam consequently; blood glucose concentrations soon rise towards normal levels. Pancreatic alpha cells and beta cells monitor blood glucose concentrations, andthe secretion of glucagon and insulin occur without endocrine or nervous instructions.Yet, because the alpha cells and beta cells are very sensitive to changes in blood glucoselevels, any hormone that affects blood glucose concentrations will indirectly affect theproduction of both insulin and glucagon. Insulin production is also influenced byautonomic activity. Parasympathetic stimulation inhabits it. 36 Shareera
  51. 51. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”Pituitary Gland 51 This is an important ductless gland with lot of functions, including the control ofthe other ductless glands and of body growth. This gland measures 1.5 cm in the coronalplane, 1 cm in the sagittal plane and 0.75 cm in vertical form. It lies within the cellatarsica of the sphenoid bone and the posterio-superior to the sphenoid air sinuses, belowthe optic chiasma. It is flattened ovoid lying the hypophysial fossa and connected to theinferior surface of the hypothalamic part of the brain by the infundibulum. Structurally the gland can be divided into 2 main parts – 01. Anterior lobe – Which is composed of adenohypophyseas tissue. 02. Posterior lobe – Which is neurohypophyseas. Posterior lobe of the hypophysis is the expanded end of the infundibulum and isdeveloped from the brain. The anterior lobe is much larger than the posterior lobe andconsists of three parts, which partly surrounds that lobe and the infundibulum. The distalpart forms most of the anterior lobe. It is separated from the posterior lobe by the thinseat of glandular tissue applied to the posterior lobe. The infundibular part is a narrowupward projection of the distal part. The anterior lobe develops from the ectoderm andhas only vascular connection with brain. Anterior lobe is the master gland of the endocrine system, because it producesprotein tropic hormones, which affects the other ductless glands. In this secretions twohormones are having direct action on carbohydrate metabolism. If any disturbance, whichleads to hyperglycemia or hypoglycemia. The two hormones are – 01. Growth Hormone or Somatotrophic hormone – (GH or STH) 02. Adrenocorticotrophic hormone (ACTH) 37 Shareera
  52. 52. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” The pituitary effect of STH on carbohydrate metabolism is to stimulate itsstorage. Administration of growth hormone in the animal or in man producehyperglycemia and glycosuria. The high blood glucose level leads to its exhaustion andatrophy. So the growth hormone has diabetogenic effect especially in man. The hormoneis however increase the glycogen content of cardiac muscles. Administration of ACTH produces similar effects as induced by growth hormone.Both STH and ACTH increase gluconeogenesis and diminish the rate of oxidation ofglucose. Thus the anterior pituitary has a diabetogenic role. GH is also known asSomatotrophin and somatotrophic hormone causes cells to grow and multiply and itincreases the rate of protein synthesis. GH accelerates the rate at which glycogen storedin the liver is converted to the glucose and released in the blood. GH raises blood glucoselevel and the raise in the glucose, triggers insulin secretion. ACTH by stimulatingsecretion of gluco-corticoids brings about hyperglycemia and also directly stimulates therelease of GHIF and inhibits the secretion of insulin. One stimulus that inhibits GHsecretion is hyperglycemia. An abnormally high blood sugar level stimulates thehypothalamus to secret the regulating factor GHIF and it inhibits the release of GHAFand thus the secretion of GH. As a result blood sugar level decreases.Adrenal Gland 52 Adrenal glands are situated on the upper poles of the kidneys. Each gland weightsabout 4 gms. A distinct connective tissue capsule surrounds the parenchyma of the gland. Beneath the capsule the cortex is arranged in three layers – 01. Zona glomerulosa – Secretes mainly aldeosterone and small amount of gluco-corticoids and sexhormones. 38 Shareera
  53. 53. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” 02. Zone fasciculata – Secretes mainly gluco-corticoide. 03. Zona reticularis – Secretes sex hormone and small amount of the glucocorticoids, All the three zones of the adrenal gland can synthesis the gluco-corticoids. Thechief action of the gluco-corticoids is to increase glyconeogenesis in the liver andstimulates formation of glycogen in the liver and muscles. The adrenal cortex also assertsdiabetogenic affects. Proteins are converted into carbohydrates i.e. glyconeogenesis occurthrough the action of gluco-corticoids. Therefore, constant production of carbohydrates and the insulin is required tometabolize the excess of carbohydrates. The excessive glyconeogenesis exerts continuedstrain upon the cells of Islets leads to hyperglycemia. When it is severe, causes damage tobeta cells and permanent insulin deficiency results. The adrenal action however dependsupon the action of anterior pituitary.Liver 53 The liver is the largest gland in the body. The greater part of the liver lies underthe covering of the ribs and costal cartilage. The liver is a dark brown highly vascular softorgan. It is approximately 1/50th of the body weight in the adults, but larger in thenewborn. The liver lies normally in the right hypochondrial and epigastric regions. Thesurrounding organs determine the shape of the liver; it retains the shape of a blunt wedge.It has two surfaces – diaphragmatic surface and visceral surface.Lobes of liver – The main lobes of liver right and left are demarcated form one another above andin front by the falciform ligament and below and behind by the fissures for theligamentum teres and ligamentum venosum. The right lobe includes two subsidiary lobes. 39 Shareera
  54. 54. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” Important functions of liver with the special attention to carbohydrate metabolismare - 01. Glycogen storage 02. Conversion of galactose and fructose in the glucose. 03. Gluconeogenesis 04. Formations of many important chemical components from the intermediate products of carbohydrate metabolism. The liver is especially important for maintaining a normal blood glucoseconcentration. For instant storage of glycogen allows the liver to remove excess glucoseform blood, store it and return it to the blood when the blood glucose concentrationbegins to fall too low. This is called Glucose buffer function of the liver.Gluconeogenesis in the liver is also concerned with maintaining a normal blood glucoseconcentration. Gluconeogenesis occurs to a significant extend only when the glucoseconcentration begins to fall below normal. In such a case large amounts of amino acidsare converted into glucose, there by helping to maintain a relatively normal blood glucoseconcentration. 40 Shareera
  55. 55. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)”DISEASE REVIEW Meha19 - It is a pum-Linga vachana formed by “Mih + Ghaj” “Mehati Ksharati Shukratiranena iti” Prameha : - It is also a masculin vachana formed by “Pra + Miha” “Ksharane + Karane Khaj.” It is a roga vishesha. Its paryayas are “Meha” as a mutra dosha by Raja Nighnatuand as bahumutrata by Hemachandra. Diabetes is derived from a Greek word whichmeans “To siphon through” and mellitus a Latin word which means “Honey” 20.Nidana Nidana means the factor responsible for producing disease i.e. etiologicalfactors54. According to this any factor, which has a tendency or capacity to produce diseasecan be considered as Nidana. In classics only Charaka explains specific nidana formadhumeha55. Among the prameha nidanas that are mentioned in our classics samanya pramehanidanas and kaphaj prameha nidanas can be considered as nidana for Madhumeha insthoola. For all types of Prameha especially madhumeha, kapha dosha is the key factor,and it can be established by Gangadhara’s version. In that he says, Gulma is caused byvayu, raktapitta by pitta and madhumeha caused invariably due to the vitiation of kaphadosha56. In case of sthoola the madhumeha is due to doshavarana. And in this type ofdoshavrita janya madhumeha, vataprakopa is due to avarana caused mainly by thevitiation of kapha. If we take sthoulya here also kapha vardhaka factors are the mainfactors behind57. 41 Disease Review
  56. 56. “Clinical Evaluation of Virechana Karma In Madhumeha (NIDDM)” Though kapha is the arambhaka or main dosha in the samprapti of madhumeha,pitta and vata also play an important role in complicating the disease58. It is worthwhileto note the textual reference, that madhumeha will occur in due coarse, if Pramehas areuntreated and at the same time, it is better to note that madhumeha is a tridoshajavyadhi59. In view of the above, all Prameha nidanas should be assessed clearly whileconsidering, the madhumeha. Hence the nidanas of various pramehas are discussed belowcan be grouped under 2 main varieties60. 01.Sahaja (Hereditary) 02.Apathyaja (Acquired).01. Sahaja (Hereditary Causes) Charaka and Sushruta have agreed that beeja dosha is also a cause formadhumeha. Sushruta has included madhumeha in the adibala pravritaja category ofdisease. The term beeja has been considered as shukra and shonita61. If beejas are vitiatedwith dosha responsible for causation of prameha, they will produce a jatha pramehapatient. Jatha pramehi has also been considered as a kulaja vikara. The diseases includedunder this category are kushta, arsha, mehas, kshaya, etc.02. APATHYAJA (ACQUIRED CAUSE) Apathyaja causes of prameha can be further classified in to two groups 01. Samanya (General) 02. Vishesha (According to dosha) 42 Disease Review