Basic learning of Prameha ( Diabetes mellitus) in Ayurveda

Prameha word consists of two words i.e., Pra (Upsarga-Prefix) and Meha. As Meha is derived from the root ‘Mih Sechane’ meaning to perfuse (watering), excessive quantity and frequency are 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 the patient passes a 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

Classification Of Madhumeha:

The clinicopathological status of the 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 the intake of a nutritious diet, which has 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. 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, and wetland 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.
• Their substances which increase meda,mutra &  kapha may cause prameha.
• Snigdha (unctuous), Medya (fatty) & Drava (liquid) type of food also

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, Madhumehi prefers standing to walking, sitting then standing, lying down to 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: The child excretes urine suddenly without any intention.
• Makshika Akranta Mutra: Flies get attracted towards the urine.
• Shveta & Ghana mutrata: Child passes urine having shweta color & turbidity.

Samprapti/Pathogenesis

Prameha is a group of diseases that establish in the body due to Santarpana. Charka in Nidanasthana mentioned the disease in detail.

The Nidana, Dosha (Vatadi tridosha), and Dushya (Rasadi dushyas) are responsible for the occurrence and non-occurrence of disease. If these three factors have less strength and are connected then 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 have all the signs and symptoms. Some important points in this concept are that natural Kapha does not have the 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 the 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 is in the Bahuabadhha form.

Pathogenesis of Madhumeha:

When Sadhya Roga changes into Krichrasadhya or Asadhya it can be called 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 that if all the Prameha are not treated first, they will gradually pass to the stage of Madhumeha.

Acharya Charaka has described Madhumeha vividly. Vagbhattacharya divides Madhumeha into two types, according to Samprapti. The Madhumeha is included in the Vataja type. If Vataprakopa occurs due to Sarvadhatukshya, it is called Dhatukshayajanya Madhumeha. And if Vataprakopa manifests as a result of Vatavarana, it is called Avaranjanya Madhumeha. Acharya Sushruta explains that if all the Pramehas are not treated initially, 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:

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 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, traveled 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. But the concepts & methods are different in different conditions, considering the Vyadhi Swabhava & Atura. Better to understand the Samprapti deeply before stepping to manage.

CHIKITSA SUTRA:

Charaka Acharya considers two types of patients, one is that with stout body structure & 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 the same to a major extent. After considering all the factors the two types of management emphasized are:

(1) Samshodhana Chikitsa [Elimination Therapy]

(2) Samshaman Chikitsa [Normalizing Therapy]

Just like with any disease, treating Meha involves first eliminating the factors responsible for its onset. By preventing further causative elements, Meha can be managed effectively. Although Madhumeha is incurable, it can still be treatable using this approach. Additionally, in Pratyakhyeya vyadhis, proper management provides symptomatic relief, offering a path to a better quality of life despite the diagnosis.

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 of Chandana, Aguru, Ela, etc. are advisable to use in kaphaja meha to reduce the increasing attitude of kleda, meda, and Kapha. [Cha. Chi. 6/50]

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 Acharya Charaka induces certain treatments in kaphapittanubandhi Vatika Meha.

According to Acharya Sushruta if we don’t treat Prameha properly on time, converts into Madhumeha. So, treatment is done as Vata Meha.

MADHUMEHA:

(i) Samshodhan Chikitsa:

To address Sthula and Krisha Pramehi, Samshodhan Chikitsa is exclusively for Sthula and Balvan Pramehi. Subsequently, Sarshapa, Nimba, Danti, Bibhitak, and Karanja Siddha Taila, or Trikantakadya Sneha (Ghrita or Taila, depending on the predominance of dosha) for Abhyantara Snehana. Here while explaining the Samshodhan, Charaka describes to use of the Malashodhan yogas from Kalpasthana.

Both Pitta & kapha eliminates 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 keep the dosha samyata.

Anuvasana with medicine oils & ghritas are usable in Madhumeha. After proper Shodhan Chikitsa, Charakacharya details to give santarpan chikitsa to the patients, to prevent 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 exposure 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. As Acharya Charaka & Vagbhatta say for Vata Meha, the kashaya yogas along with Sneha.

Typical Madhumeha Chikitsa:

According to Acharya Sushruta explains the intake of Shilajit 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.