Basic learning of Prameha ( Diabetes mellitus) in Ayurveda

Prameha word consists of two words i.e., Pra (Upsarga-Prefix) and Meha. Meha is derived from the root ‘Mih Sechane’ meaning to perfuse (watering), Excessive quantity and frequency is indicated by the prefix (pra).

Acharya Vagbhatta described Prameha as frequent and copious urine with turbidity; i.e., Prabhut Avil Mutrata while Madhumeha is a clinical entity in which patient passes large quantity of urine similar to Madhu having kashaya & Madhura taste, Ruksha texture & Honey like color and thus body attains sweetness. (A.H.Ni.10/18, Cha. Ni.4/44)

Synonyms- Ojomeha, Kshaudrameha, Paushpameha.

Classification of Parmeha

Based on Dosha

Entity	Kaphaja	Pittaja	Vataja
Prognosis	Sadhya (Treatable)	Yapya (Continues on treatment)	Asadhya (Non-treatable)
Physical Appearance	Sthula (Obese)	Usually not much obese	Krisha (Asthenic)
Origin	Apthyanimittaja (Acquired)	Acquired	Sahaja(hereditary)

Classification Of Madhumeha:

The clinicopathological status of disease has an invariable relation with the physical constitution of the body in Madhumeha. [Cha.Chi.6/15] [Su.Chi.11/3]

• Sthula or Krisha
• Sahaja [Heriditary] or Apathyanimittaja [Acquired] [Su.Chi.11/3]

Sahaja: Due to Beejadosha i.e., genetic origin. [Su.Chi.11/3]

Apathyanimittaja: Occurs due to Ahitahara/ Dietary factor.

(B)According to etiological factors:

• Santarpanjanya & Apatarpanjanya:

Santarpanjanya Madumeha is directly due to intake of a nutritious diet, which are having kaphavardhaka properties. The excess intake of such substances will primarily lead to the vitiation of Kapha, pitta, Meda & Mansa, which in turn cause Madhumeha by doing Avarana of Vata. [Cha. Su.17/78-81] If the substances which deplete the dhatu & aggravate Vata are consumed then it leads to Apatarpanjanya Prameha. They act through vitiation of Vata which in turn leads to the manifestation of madhumeha.

Nidana

Sahaja:

Abnormality in Stri & Pumbeeja (Ovum & Sperm) which is said to be Matrupitru Beejadoshakrita will cause Sahaja Prameha. Or in other words, it is being received from hereditary trends. Charaka stated that indulgence of Madhura rasa by parents is the chief cause of changes & damages in the sperm & ovum. Excessive intake of Madhura Rasa during pregnancy is depicted as a major cause.

Apathyanimittaja:

Etiological Factors of General Prameha [Cha.Chi.6/4]

• Asyasukham
• Swapnasukham
• Excessive indulgence in Dadhini i.e., Various preparation of curd.
• Gramya, Audaka ,Anupa Mamsa i.e. Meat of domestic, aquatic, wet land animals.
• Payamsi i.e., excessive use of milk & its preparation
• Navannapanam i.e., new grains & drinks
• Guda vaikrutam i.e., various preparation of sugar & jaggery.
• ther substances which increases meda,mutra &  kapha may cause prameha.
• Snigdha (unctuous), Medya (fatty) & Drava (liquid) type of food also

Kaphaja Prameha [Cha.Ni.4/5]:	Pittaja Prameha Nidana [Cha.Ni.4/24]	Vataja Prameha Nidana [Cha.Ni.4/36]
Frequent & Excessive intake of fresh corns like Hayanak, Yavaka, Chinaka, Uddalaka, Naishdha, Itkata,	Intake of Ushna,Amla Lavana, Kshara & Katura Dravyas.	Excessive intake of Dravyas having predominantly kashaya, katu,tikta rasa,Ruksha,Laghu & Sheeta veerya
Intake of pulses like fresh harenu & Masha with ghee	Intake of food before the digestion of the previous meal	Excessive indulgence in sex & physical exercise.
Intake of the meat of domestic, marshy & aquatic animals.	Exposure to excessively hot sun,heat of the fire, physical exertion & anger	Excessive administration of emesis, purgations, asthapana & shirovirechana.
Intake of vegetables, tila, palala, pishtanna, payasa (a type of milk preparation), krishara,Vilepi & preparations of sugarcane.	Intake of mutually contradictory food articles.	Resorting to suppression of the manifested urges, fasting, assault, exposure to sun, anxiety, grief, Excessive bloodletting, Keeping awake at night & irregular posture of the body.
Intake of milk, fresh wine, immature curd & curd which are mostly liquid, Sheeta & immature in nature.
Avoidance of unction & physical exercise
Indulgence in sleep, bed rest & sedentary habits
Restoring to even such regimens which produce more of kapha, fat & urine.

Signs/Symptoms

Specific Symptomatology of Madhumeha:

Urine Characteristics:

Madhumehi passes urine having Kashaya & Madhura taste, Pandu varna & Ruksha quality. According to Sushruta, the urine of Madhumehi resembles that of honey.

Psychological manifestation:

The special manifestation related to the behavioral pattern is depicted by Sushruta that, Madhumehi prefers standing to walk, sitting then standing, lying down than sitting, & sleeping then lying down.

General Symptomatology:

• Urine Characteristics:
• Prabhuta Mutrata (excess urine Quantity)
• Avila Mutrata (Turbid urine):
• Pichhila Mutrata (viscus in Consistency):
• Akasmata Mutra Nirgama: Child excretes urine suddenly without any intention.
• Makshika Akranta Mutra: Flies get attracted towards the urine.
• Shveta & Ghana mutrata: Child passes urine having shweta colour & turbidity.

Samprapti/Pathogenesis

Prameha is a group of diseases which are established in the body due to Santarpana. Charka in Nidanasthana mentioned the disease in detail.

The Nidana, Dosha (Vatadi tridosha), Dushya (Rasadi dushyas) are responsible for occurrence and non-occurrence of disease. If these three factors are having less strength and connected with each other than the establishing disease will not have all the signs and symptoms. If they are complete & with full strength, and their connection is strong then the disease produced will be having all the signs and symptoms. Some important points in this concept are, Natural kapha is not having quality of ‘Bahudravatva’. In the normal state it is in bounded form. Here in Prameha samprapti it loses its bounded form due to some specified causes and changes to bahudravatva (liquid) form. Dravata(Liquid nature) is high in the acharya’s concept and it is stressed by the term ‘Bahu’. The dushyas included are, meda, mamsa, Sharir kleda,Shukra, Shonita,Vasa, Majja, Lasika,Rasa and Oja. The special characteristic feature of the Dushyas in the Bahuabadhha form.

Pathogenesis of Madhumeha:

When Sadhya Roga changes into Krichrasadhya or Asadhya it can be called as Vidhi Samprapti. It commonly occurs in the untreated condition. As far as Madhumeha is concerned, we can partly include it in Vidhi Samprapti. Acharya Sushruta explains it as if all the Prameha are not treated first, they will gradually pass to stage of Madhumeha.

Acharya charaka has described Madhumeha vividly. Vagbhattacharya divides Madhumeha into two types, according to Samprapti. The Madhumeha is included in Vataja type. If Vataprakopa occurs due to Sarvadhatukshya, it is called Dhatukshayajanya Madhumeha. And if Vataprakopa manifests as result of Vatavarana, it is called Avaranjanya Madhumeha. Acharya Sushruta explains it as if all the Pramehas are not treated intially, they will gradually pass the stage of Madhumeha.

Upadrava/complications

(1) General Complications [Cha.Ni.4/48]:

Trishna, Atisara, Daha, Daurbalya, Arochaka, Avipaka, Putimamsa Pidaka, Alaji, Vidradhi etc.

(2) Specific Complications:

Kaphaja [Su.Ni.6/15]	Pittaja	Vataja
Makshikopasarpanam, Alasya, Mamsopachaya, Pratishyaya, Shaithilya, Arochaka, Avipaka, Kaphapraseka, Chhardi, Nidra, Kasa & Shwasa	Vrushanayorvadaranam, Bastibheda, Medhra toda, Hridshula, Amlika, Jwara, Atisara, Arochaka, Vamathu, Paridhumayanam, Daha, Murchha, Pipasa, Nidranasha, Panduroga, Pittavidmutranetratva	Hridgraha, Laulya, Anidra, Stambha, Kampa, Shula, Baddha purishatva & shosha, kasa, shwasa

Complications of Madhumeha:

Pidaka-  Sharavika , Kacchhapika, Jalini, Sarshapi, Alaji, Vinata, Vidradhi, Putrini, Masurika, Vidarika

SADHYASADHYATA

Generally, the concept of prognosis in the case of prameha re given by all acharyas as,

Kaphaja Prameha-Sadhya

Pittaja Prameha-Yapya

Vataja Prameha-Asadhya when occurred due to dhatukshaya & Krichrasadhya when

established due to avarana.

PATHYA-APATHYA

Pathya:

(a) Aahara:

• Shook Dhanya: Jeerna Shali, Shashtika, Kodrava, Yava, Godhuma, Uddalaka, Shyamaka
• Shimbi Dhanya: Chanaka, Adhaki, Kulattha, Mudga
• Shaka Varga: The leafy vegetables with a predominance of tikta-kashaya rasa, Patola, Karvellaka, Shigru
• Phala Varga: Jambu, Dadima, Shringataka, Amalaki, Kapittha, Tinduka, Kharjura, Kalinga, Navina Mocha.
• Mamsa Varga: Vishkira mamsa,Pratuda, Jangala mamsa
• Taila Varga: Danti, Ingudi, Sarshapa , Atasi
• Udaka Varga: Sarodaka, Kushodaka, Madhudaka
• Kritanna Varga: Apupa, Saktu, Yavodana, Vatya, Yusha
• Others: Madhu, Hingu, Saindhava, Maricha, Lasuna

(b) Vihara:

To have walked, traveling on elephants, horses, and different plays, a different forms of martial arts, roaming in different places without chappal and umbrella.

Apathya:

(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, Mutravega dharana.

CHIKITSA

Chikitsa-sutra (principles of treatments) and Chikitsa (Management Proper) are the two divisions of this major part. Both these are described very well in classics. But the concepts & methods are different in different conditions, considering the Vyadhi Swabhava & Atura. The Samprapti should be considered deeply before stepping to manage.

CHIKITSA SUTRA:

Charaka Acharya considers two types of patients, one is that with stout body structure & with strength and the other without strength & krisha.

Sushruta acharya also says that Sahaja Meha Rogi will be krisha & apathyanimittaja rogi will be sthula.

In the context of medoroga, the managements described are parallel to that of meha since the dosha & dushyas are same to major extent. After considering all the factors the two types of management emphasised 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 are if 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 Pratyakhyeya vyadhis, symptomatic relief can be given by proper management.

KAPHAJA PRAMEHA:

(i)Samshodhan Chikitsa:

• Shodhana
• Vamana
• Langhana
• For Bastichikitsa- Surasadi gana kwatha.

(ii)Samshaman Chikitsa:

• Charaka- combinations of 10 drugs
• Sushruta-Samshodhana with swarasa of Amalaki and Haridra powder with madhu.
• Vagbhatta- Three yogas
• Lodhrad i- Lodhra, Abhaya, Musta, Katphala
• Pathadi – Patha, Vidanga ,Arjuna,Dhanyaka
• Gayatrayadi – Khadirsara, Darvi, Vidanga, Vacha

Importance of Apatarpana:

Different types of vyayama, kshut, udvartana, Dhara & snana with churns made of Chandana, Aguru, Ela, etc. are advised to use in kaphaja meha to reduce the increasing attitude of kleda, meda, and kapha. [Cha. Chi. 6/50]

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PITTAJA PRAMEHA:

(i)Samshodhana Chikitsa:

• Virechan
• Asthapan Basti with Nyagrodhadi gana kwatha

(ii) Samshaman Chikitsa:

Acharya Charaka -Combinations of 10 drugs

Sushrutacharya -6 specific kwatha yogas for the specific type of Pittaja prameha. [Su.Chi.11/9]

Acharya Vagbhatta -The three kwatha yogas

(i) Ushiradi: Ushira, Lodhra, Arjuna, Chandana.

(ii) Patoladi: Patola, Nimba, Amalaki, Amrita

(iii) Lodhradi: Lodhra, Ambu, Kaleyaka, Dhataki

VATAJA PRAMEHA:

Although vatika mehas are incurable still Acharya Charaka explains to induce certain treatment in kaphapittanubandhi Vatika Meha.

Acharya Sushruta has described that all types of Prameha if not treated properly in time, get converted into Madhumeha.

So, the treatment described for Vatika meha can be considered as the treatment of Madhumeha.

MADHUMEHA:

(i) Samshodhan Chikitsa:

Considering Sthula & krisha pramehi, Samshodhan Chikitsa should be administered only to the sthula & Balvan Pramehi. Sarshapa, Nimba, Danti, Bibhitak & Karanja siddha Taila or Trikantakadya Sneha (Ghrita or Taila according to dosha predominance should be used for Abhyantara Snehana. Here while explaining the Samshodhan, Charaka describes to use the Malashodhan yogas from Kalpasthana

Both Pitta & kapha are eliminated through shodhana. Either it may be vamana or virechana, because of; Pittantam Vamanam, Kaphantam Virechanam. In Virechana pitta is eliminated first, then Samyak lakshana of virechana is kaphadarshan, so both pitta & kapha doshas which are vitiated are eliminated. Then the described

Anuvasana & Asthapana Basti chikitsas are able enough to control the provocation of vata. Like this all the doshas are normalized to keep the dosha samyata.

Anuvasana with medicated oils & ghritas are prescribed in Madhumeha. After proper Shodhan Chikitsa, Charakacharya details to give santarpan chikitsa to the patients, to prevent the complications like Gulma, Bastishula etc.

(ii)Samshaman Chikitsa:

Samshaman Chikitsa includes mainly deepana (appetizers), Pachana, (enhancing digestion), Kshut (Hunger maintenance), Trit (Maintenance of thirst), Vyayama (Exercise), Atapa (Having exposed to sunlight) & Maruta (Exposing oneself to wind). According to the conditions of vitiated doshas & dushyas, vaidya has to suggest proper Shaman Chikitsa to the patient.

Acharyas introduces different tarpana upakramas in vatika mehas. It is due to the less strength of the patient. Acharya Charaka & Vagbhatta says that the kashaya yogas should be enriched with sneha and given to vatika Mehas.

Typical Madhumeha Chikitsa:

Acharya Sushruta explains that Shilajit should be taken after triturating with Salsaradi gana kwatha. After its digestion patient should take Jangalamamsarasayukta Anna. He prescribes to take 1 Tula of shilajatu.

Compound Preparations Used in Prameha:

Swarasa: Amalaki, Haridra, Nimbapatra, Bilwapatra, Guduchi

Kwatha: Vidangadi, Phalatrikadi, Mustadi, Manjishthadi, Pathadi

Churna: Triphaladi, Mustadi, Gokshuradi, Arkadi

Gutika: Chandraprabha, Indravati, Pramehantak Vati

Gugglu: Gokshuradi Guggulu

Modaka: Kastur Modaka

Avleha: kushavleha, Bangavleha

Paka: Pugapaka, Ashwagandhadi paka, Draksha Paka.

Asava Arishta: Lodhrasava, Dantyasava, Madhukasava, Devdarvyadiarishta, Lodhrarishta.

Ghrita: Dhanvantar ghrita, Trikantakadi ghrita, Sinhamrita ghrita, Dadimadi ghrita, Shalmali ghrita.

Rasaushadhi:Vasant kusumakar Rasa, Mehamudgar Rasa, Brihat Bangeshwar, Rasa, Prameha gajkesri Rasa, Tribanga Bhasma, Vasant tilaka Rasa.