LITERARY Abstract REVIEW Comparison of Madhumeha With Diabetes Mellitus *Dr. Gunjan Mangal, **Dr. Gopesh Mangal, ***Prof N. s. Chundavat Madhumeha "Richman's disease", since Vedic period, is familiar to mankind. Madhumeha is a disease in which mutra (Urine) of the patient attains similar property like those of madhu (Honey). It is documented as one among the twenty obstinate urinary disorders i.e. Prameha. It is also explained that, when the other Prameha are left untreated, this lead to the condition called Madhumeha. So Madhumeha can also be considered as an advanced condition or stage of Prameha. Diabetes Mellitus is a chronic disorder of carbohydrate metabolism, marked by hyperglycemia and glycosuria and resulting from inadequate production or use of insulin. Traditionally, Madhumeha can be equated with diabetes mellitus, as many similarities in view of their causative factors, pathogenesis, signs and symptoms, classification, complications and also in the treatment has been found. An attempt to provide the similarities or comparison between Madhumeha and Diabetes mellitus is made in this article. Key Words: Madhumeha, Prameha, Diabetes mellitus, madhu, DM, IDDM, NIDM, Typer, Typez ll~ I wfi"u qft ~ I ~ ~~CflR1 if ~ ~ ~I ll~ "&Ilf'1:l if ~ ll~ \i)"m ~ WrnT ~ I ll~ ~ >rcfir ifi ~ if ~ ~ 3th: ap;f ~ qft ~ f+.jfcflffii ";f m "tr -m ~ ~ ll~ "&Ilf'1:l mm ~ I slllaflfc:\j\ ~ ~ ~ ~ qr'ft ~ ~ I ~ ~ ~ ~~ Cfill 7.lT.~ mid ~ I ~ ~4i~1 ~ wcr if ~ -qr;ft \ffi"ffi ~ I aw:r ~ if ll~ qft slllaflfc:\j\ if "WAf qft \ffi"ffi ~ I -m CfiRUT, ~, ~8;l11T, VcfiR, ~ f+.jfcflffii ~ mpl -qr:n ~ ~ I ~ ~ if ll~ 3th: slllaflfc:\j\ qft "WRT ~ ~ mpl ~ ~ CfiT ~ ~ lfn ~I *M.D. Scholar, Deptt. of Swasthavritta, **M.D. Scholar, Deptt. of Panchakarma ***Prof. & H.O.D. P.G. Deptt. of Swasthavritta & Yoga, National Institute of Ayurveda, Jaipur 108
LITERARY REVIEW Comparison of Madhumeha With Diabetes Mellitus Dr. Gunjan Mangal, Dr. Gopesh Mangal, Prof N.S.Chundavat Introduction Madhumeha is a disease known to mankind since Vedic period and it is mentioned among the twenty types of Prameha. It is a disease in which patient passes the urine having similar with Madhu i.e. "Kashaya and Madhura taste, Pandu colour and Ruksha guna" or when the urine of the patient become sweet and resembles with honey in any type of Prameha and the whole body becomes sweet, it is to be named as Madhumeha. Diabetes Mellitus is a group of metabolic disorders characterized by hyperglycemia (abnormally increased content of glucose in the blood) with disturbance of carbohydrate, protein and fat metabolism resulting from defects in insulin secretion or insulin action or both. Traditionally, Madhumeha has been equated with Diabetes mellitus. Madhumeha is a disease in which certain pathological changes in urine are noted along with some other changes, the most important being the presence of madhuryata (sweetness), whicb can be taken as presence of sugar in the urine. Apart from this, tanu madhuryata is also mentioned, which can be taken as presence of sugar in the blood. Like this equation of Madhumeha with Diabetes mellitus is justifiable. Also in view of the similarity of causing factors, pathogenesis, signs and symptoms, classification, complications and also in the treatment, Madhumeha has been correlated with Diabetes mellitus. The correlations are discussed under following points: Nidana [Causative factors] Many similarities are found between causative factors for D.M. mentioned in modern science and nidana explained for Madhumeha in Ayurvedic science: 1. In modern science, over eating is considered as a predisposing factor for D.M., which is similar to excess consumption of madhura, guru and snigdha bhojana mentioned in Ayurveda. 109 Prameha roga IS included santharpanajanitha vyadhi. under 2. In modern science, sedentary habits are also considered as a predisposing factor for D.M. which is similar to asyasukham, swapnasukham i.e. atinidra, diwaswapna as mentioned in Ayurveda. 3. Obesity is mentioned as a major causative factor for D.M. as it causes I.R. In Ayurvedic literature, it is similar to sthoulya, which is mentioned as a nidanarthakararoga for Prameha. 4. In modern science, genetic and hereditary factors are explained for D.M., which is similar to Beejadosha and Kulajadosha, mentioned in Ayurveda. Modern science says that there is a specific gene for every specific enzyme within a cell. When that gene is lost or altered, the corresponding enzyme is also lost or altered. In D.M. abnormality of gene, which codes for the enzyme glucokinase on chromosome 7 and gene coding for hepatic nuclear factor 1 Alfa and 4 Alfa are responsible. The same factor has been told by our acharyas. As told earlier, Acharya Charaka says that if particular bhaga or bhaga avayava of beeja is affected then the garbha formed will be having abnormality either having structural or functional of that particular organ concerned. By the above explanation, we can say that even Ayurvedic acharyas had the knowledge of genetics in those days. In modern science, hereditary factor is concerned as an important factor to D.M. It would appear then that diabetes is present from birth in the form of inherently defective carbohydrate mechanism, which can be triggered in a variety of ways. The defect may remain in latent form for many years but it may be brought to light by stress of pregnancy, corticotrophin therapy, Cushing's syndrome, or even by over eating. Prameha is
Journal of Ayurveda considered as Adi-bala Pravritta vyadhi. Term "Adi" signifies the transmission of the disease from either mother or father to the garbha through sonita and sukra at the time of their sammurchana in garbhashaya. Vol.IV No.3 Jul-Sep 2010 Thus, we can say that causative factors of D.M. explained in modern science are almost similar to that of nidana of Madhumeha mentioned in Ayurveda. They can be summarized as- Table no.1 Madhumeha Diabetes Mellitus Nidana Kapha vardhaka ahara-vihara like Excessive intake of sweet, oily food madhura, snigdha, guru bhojana and Over eating Sayya-asana-swapna sukha Sedentary life style Sthoulya Obesity Beejadosha and Kulajadosha Genetic and Hereditary factors Samprapti [Pathogenesis] A partial attempt can be made to correlate the pathogenesis of Madhumeha with that of D.M. explained in modern science in following way: 1. Acharya has given more importance to medovaha srotas in the pathogenesis of Madhumeha. Vapavahana as its moolasthana gets affected. Vapavahana can be compared to pancreas. Acharya Charaka has explained it as udarasthanga and its shape is just like a tailavarti. Therefore, based on this physioanatomical similarity in the description we can consider vapavahana as pancreas. This description gives a clue that our acharyas might know the involvement of pancreas in the pathogenesis of Madhumeha. Adding to this Kloma is also considered as pancreas by some authors. Pipasa is also mentioned as a lakshana in the antharvidradhi of kloma. This also indicates the involvement of pancreas. 2. Insulin resistance and relative insulin deficiency are the major step in the pathogenesis of D.M. in obese individuals. Not all obese individuals will suffer from diabetes unless pancreas remains healthy and secretes insulin to combat Insulin resistance. To explain Insulin resistance in term of Ayurveda is very difficult. However, we can say that not all the sthoola persons will suffer from Madhumeha until they have healthy vapavahana and do not afflicted by beeja or kuladosha. 110 3. Insulin may correlated to medhodhatvagni. But for the exact correlation of it, substantial evidence in this regard is needed. In Ayurveda agni has been given more importance in the disease process of Madhumeha. Due to the dhatvagni mandya, dosha and dushya will be in aparipakwavastha. It indicates metabolic impairment in Madhumeha. 4. Madhumeha is caused because of the invariable vitiation of kaphadosha. Kaphadosha is predominant of prathvi and apamahabhoota. Madhura rasa and snigdha dravyas generally help in building kapha dosha in the body and kapha is having with similar qualities. In normal state kapha promotes sthiratwa, dardya, utshaha, vrishata, gyana and buddhi and it is also called as bala and ojas. By this description, we may correlate kapha with glucose. In Madhumeha due to bahudravatha, it will not able to nourish the body and when this bahudrava shleshma travels all over the body with rasa dhatu, it produces tanumadhuryatha. It is nothing but hyperglycemic state in D.M. This can be understood by testing blood glucose. I have tried to correlate the pathogenesis of Madhumeha with pathogenesis of D.M. precisely by the available references. It can be summarized as-
Vol.IV No.3 Jul-Sep 2010 Journal of Ayurveda Table no.2 Madhumeha Diabetes Mellitus Samprapti Dhatwagni mandya Metabolic impairment Medodhatwagni Insulin Medodhatwagni-mandya Insulin deficiency kapha dosha Glucose Rupa [Signs & Symptoms] A majority of the lakshana explained in Ayurveda for Madhumeha is described in the modern counterpart too. An attempt to correlate the same is made here. 1. Prabhoot-avila mutrata is considered as a pratyatma lakshana of Prameha. Bahudrava kapha along with other kleda pradhana dushya in the basti is the cause for prabhoot-avila mutrata. The same reason has been given in the modern science for Polyuria that the osmotic diuretic effect of glucose in the kidney tubules. 2. Madhusama mutra or madhura mutra, explained in Ayurveda can be taken as glycosuria. As ojas or bahudrava, kapha (glucose) is excreted through mutra and produce the above symptom. Whenever the quantity of glucose entering the kidney tubules in the glomerular filtrate rises above 22smg/min, a significant proportion of the glucose begins to spill into the urine and produces glycosuria. 3. Tanu madhuryata explained in Ayurveda can be taken as high sugar level in blood or hyperglycemic state. pipasa is a symptom included by Acharya Shushruta in the Sahaja Madhumeha. 6. Krisha body has been mentioned as a lakshana in the Sahaja Madhumeha the same is mentioned in modern science in term of lean body or weight loss. 7. Klama may be correlated with weakness. As aparipakwa, dhatus will not nourish the body properly and hence causes klama. Modern science describes that weakness is caused by the failure of glucose utilization, loss of electrolytes and loss of body protein. 8. Shushruta has mentioned different conditions for delayed healing. Out of which Madhumeha is one among them and commentator Chakrapani says "Dustadushya" are responsible for them. Even in modern science, delayed healing of wounds has been mentioned as a symptom and the reasoning they give is the deficient formation of granulation tissues. Majority of the lakshana mentioned in both the science with their reasoning can be correlated and understood in above said manner. They can be summarized as- 4. Bahu akankshi has been mentioned as a lakshana in the Apathya Nimittaja Madhumeha the same is mentioned in modern science in term of polyphagia. S. Polydipsia is mentioned as one of the symptom related to hyperglycemia. In Ayurveda, pipasa is not mentioned as a lakshana but included under purva rupa. As it is explained that most of the purva rupa mentioned in Ayurveda are the rupa of Madhumeha. So pipasa can be said as a symptom, which is similar to polydipsia. Bhrish 111
Journal' of Ayurveda VoLIV No.3 Jul-Sep 2010 Table no.3 Madhumeha Diabetes Mellitus Rupa Prabhuta-avila mutrata Polyuria and turbidity of urine Tanu madhuryata Mutra madhuryata Pipasa Klama Vrana Krichena Sidyanti Krish body in Sahaja Madhumeha Hyperglycemia Glycosuria Polydipsia Weakness Delayed healing of wounds Lean body in Juvenile Diabetes (Typer) Bahu akankshi & Shayya-Asana- Polyphagia and laziness in Maturity Swapnasheela in Apathya-nimittaja onset diabetes(type 2) Madhumeha Bheda [Classification] Classification of Madhumeha in Ayurvedic literature is similar to D.M. in modern science. An attempt to correlate the same is made here. 1. Beeja dosha and kulaja dosha are mentioned in the causative factor of Sahaja Prameha. Such patients are said to krisha (emaciated), ruksha (dry body texture), Bhrish pipasa (excessive thirst), Alpashi (consumes less food or loss of appetite) and are required to be treated with a nourished diet. Modern science explains that due to genetic and hereditary factors, patients are weak, lean and emaciated. Such patients are juvenile diabetic and require a nourish diet. Therefore, Sahaja Prameha and juvenile diabetes (Type 1) can be correlated. 2. Apathyanimittaja Prameha is caused by excess indulge in sweet, unctuous and heavy preparations. Such patients are sthoola (obese), balavana (strong,) snigdha (unctuous body texture) and afflicted with bahu akankshi (Voracious eater), Shayya-Asana-Swapnasheela (excess sleep and laziness). The maturity onset diabetes tends to overeat and patients are lazy. Thus, Apathyanimittaja Prameha and maturity onset diabetes (Type 2) may be correlated. 3. The Sthoola and Krisha classification is similar to Obese and Non- Obese division. Classification mentioned in both the science with their reasoning can be correlated and understood in above said manner. It can be summarized as- Table no.4 Madhumeha Diabetes Mellitus Bheda Sahaja Madhumeha Juvenile Diabetes (Type 1) Apathya-nimittaja Madhumeha Maturity onset diabetes(type 2) Sthoola and Krisha patients Obese and Non-Obese patients Updrava [Complications] Ayurvedic acharyas used to observe the patient and used to write. Likewise they observed many updrava in madhumehi and many of them are correlated to that of complication of D.M. mentioned in modern science. 1. Udavarta, aruchi, avipaka, atisara, baddha purish explained in Ayurveda can be incluced in 112
VoLIV No.3 Jul-Sep 2010 "gastrointestinal autonic neuropathy" in which abdominal fullness, nausea, vomiting, dysphagia, diarrhea or constipation may be seen. 2. Trishna, bhrama, tama, shoola, and shwasa can be correlated to diabetic ketoacidosis, in which thirst, weakness, blurring vision, abdominal pain, air hunger etc. are seen. These symptoms even correlated with the clinical features of hypoglycemia also. 3. Kampa is a symptom correlated with 'trembling', which is present in hypoglycemia. Journal of Ayurveda 4. Shoola can be correlated to abdominal or chest pain, which is present in reticulopathy, a variety of diabetic neuropathy. It is a sensory syndrome in which, pain occurs over the distribution of one or more spinal nerves usually in the chest wall or abdomen. 5. Prameha pidika can be correlated to carbuncles. Majority of the complications mentioned in both the science with their reasoning can be correlated and understood in above said manner. They can be summarized as- Table no.5 Madhumeha Diabetes Mellitus Updrava Kampa Trembling in hypoglycemia Shoola Abdominal or chest pain in reticulopathy, Udavarta, aruchi, avipaka, atisara, Abdominal fullness, nausea, baddha purish vomiting, dysphagia, diarrhea or constipation etc. in gastrointestinal autonic neuropathy. Trishna, bhrama, tama, shoola, shwasa Thirst, weakness, blurring vision, abdominal pain, air hunger etc. in hypoglycemia. Prameha pidika Carbuncles Chikitsa [Treatment] Treatment of Madhumeha in Ayurvedic literature is similar to D.M. in modern science. An attempt to correlate the same is made here. 1. Aptarpana Chikitsa is indicated in Margavaranajanya or Apathyanimittaja Madhumeha, which is similar to restricted diet, exercise and oral hypoglycemic (sometimes insulin also) given in Type! (IDDM). 2. Santarpana Chikitsa is mentioned in Dhatukshayajanya Madhumeha, similar to that of insulin therapy in Typez (NIDDM). Thus, treatment mentioned III both the science can be correlated and understood in above said manner. It can be summarized as- Table no.6 Madhumeha Diabetes Mellitus Chikitsa Aptarpana Chikitsa in Margavarana Restricted diet, exercise and oral -janya Madhumeha hypoglycemic (sometimes insulin also) in Type! (IDDM). Santarpana Chikitsa in Dhatukshaya insulin therapy in Typez (NIDDM) -janya Madhumeha 113
Journal of Ayurveda Vol.IV No.3 Jul-Sep 2010 Discussion - Nidana [Causative factors] D Kapha vardhaka ahara-vihara like madhura, snigdha, guru bhojana and sayya-asana-swapna sukha, avyayam etc. can be correlated with over eating and sedentary life style D Sthoulya can be correlated with obesity is mentioned as a major causative factor for Diabetes mellitus, as it gives rise to insulin resistance. D Genetic and hereditary factors are explained for D.M. which is similar to Beejadosha and Kulajadosha. Samprapti [Pathogenesis] D In Ayurveda agnimandya & dhatwagni mandya has given more importance in the disease process of Madhumeha. It indicates metabolic impairment III Madhumeha.Some recent Ayurvedic scholars have correlated insulin with Medodhatwagni, as well as insulin deficiency to Medodhatwagni-mandya. D Madhumeha is caused because of the invariable vitiation of kaphadosha. Similarly in D.M., increased level of glucose is present. In some recent researches, kapha is correlated with glucose. D Vapavahana can be compared to pancreas of modern science, on the basis of physioanatomical si=rilarity in the description. Rupa [Signs & Symptoms] D Prabhut-avila mutrata can be correlated with Polyuria and turbidity of urine. D Madhusama mutra or madhura mutra and tanu madhryata is noted in the disease which can be taken as presence of sugar in the urine and blood respectively. D Pip as a or Polydipsia is mentioned in both sciences. Bheda [Classification] D Sahaja Madhumeha and Juvenile diabetes (Type 1) can be correlated D Apathyanimittaja Madhumeha may be correlated to Maturity onset diabetes (Type 2). D The Sthoola and Krisha classification is similar to Obese and Non-Obese division. 114 Updrava [Complications] D Udavarta, aruchi, avipaka, atisara, baddha purish can be included in "gastrointestinal autonic neuropathy". D Trishna, bhrama, tama, shoola, shwasa can be correlated to diabetic ketoacidosis D Shoola can be correlated to abdominal or chest pain, which is present in reticulopathy, a variety of diabetic neuropathy. D Prameha pidika can be correlated to carbuncles. Chikitsa [Treatment] D Aptarpana Chikitsa is indicated in Margavaranajanya or Apathyanimittaja Madhumeha, which is similar to restricted diet, exercise and oral hypoglycemic (sometimes insulin also) given in Type1 (IDDM). D Santarpana Chikitsa is mentioned in Dhatukshayajanya Madhumeha, similar to that of insulin therapy in Typez (NIDDM). Conclusion As Acharya says that Itershastra adhyana (other texts should be read) is useful to understand diseases. so it is important to compare both diseases according to modern and Ayurveda. On the similarity of nidana, samprapti, rupa, bheda, updrava and chikitsa, we can say that Madhumeha is similar to Diabetes mellitus or both are same diseases. References: 1. Charaka Samhita, Vidyotini comm. Vol. I & II, by Pt.K.N.Shastri and G.N.Chaturvedi, Chaukhamba Bharti Academy, Varanasi, Revised edition 1998. 2. Charaka Samhita, Charaka Chandrika Comm. Vol I & II, By Brahmananda Tripathi, Chaukhamba Surbharti Prakashana, Varanasi, Revised edition 2004 3. Charaka Samhita, Eng R.K. Sharma and Sanskrit Series Office, 4. Sushruta Samhita, Comm. Vol. I & II, Chaukhamba edition 200l. Sanskrit translation, YoU, II & III, Bhagwandas, Chaukhamba Varanasi, 3,d edition, 1998. Ayurvedatattva 5. Sushruta Samhita, Susratavimarshini Sandi pika Kaviraj Ambikadutta Shastri, Anant Ram Sharma, Chaukhamba Sansthan, Varanasi, 12th Prakashana, Varanasi, l't edition 2001 6. Sushruta Samhita, Eng translation, Vol. I, II & III, P.V.Sharma, Chaukhamba Visvabharti, Varanasi, l't edition 1999. Comm., Dr. Surbharti
Vol.IV No.3 Jul-Sep 2010 7. Astanga Hridya, Nirmala Comm., By Brahmananda Tripathi, Chaukhamba Sanskrit Pratishthan, Delhi, Revised edition 2003. 8. Astanga Hridya, Eng translation, Vol.I & II, K.R.Srikanthamurthy, Chaukhamba Krishnadas Academy, Varanasi, 2 nd edition 1997. 9. Astanga Samgrha, Saroj Comm., Sutra sthana, Dr. R.D. Tripathi, Chaukhamba Sanskrit Pratishthan, Delhi, Revised edition 1996. 10. Astanga Samgrha, Vol.! & II, Kaviraj Atridev Gupt, Chaukhamba Krishnadas Academy, Varanasi, Revised edition 2005. 11. Astanga Samgraha, Eng translation, Vol.I & II, K.R.Srikanthamurthy, Chaukhamba Orientalia, Varanasi, 3'd edition 2000. 12. Bhavaprakasha, Vidyotini Comm. Vol. II, Pt.Brahma Sankara Misra, Chaukhamba Sanskrit Sansthan, Varanasi, 7 th edition 2000. 13. Madhava Nidana, Madhukosha Comm. With Vidyotini Comm. Vol. II, Yadunandana Upadhyaya, Chaukhamba Sanskrit Bhawan, Varanasi, 31'h edition 2002. Bhavaprakasha, Vidyotini Comm. Journal of Ayurveda Vol. II, Pt.Brahma Sankara Misra, Chaukhamba Sanskrit Sansthan, Varanasi, 7'h edition 2000. 14. Madhava Nidana, Madhukosha Comm. With Vidyotini Comm. Vol. II, Yadunandana Upadhyaya, Chaukhamba Sanskrit Bhawan, Varanasi, 31th edition 2002. 15. Taber's Cyclopedic Madical Dictionary, Vol. I & II, Jaypee brothers medical publishers (P) Ltd., New Delhi, 18'h edition. 16. Davidson's Principles and Practice of Medicine, 19'h edition. 17. Cotran SR, Pathologic Basis of Disease, Chapter 20'h, 6 th edition. 18. Harrison's Principle of International Medicine, 14'h edition, 1998. 19. Human Physiology, C.C.Chatterjee, Medical Allied Agency, Calcutta, 10 th edition, 1995. 20. Hutchinson's Clinical Methods, Michael Swash, 20'h edition. 21. Medicine for Student, A.F.Golwalla & S.A.Golwalla. 22. Kumar & Klark, CD-Rom I. Ownership of the Journal The Journal of Ayurveda is the official publication of the National Institute of Ayurveda, Jaipur under Deptt. of AYUSH, Ministry of health & FW, New Delhi. It is published quarterly i.e. January-March, April-June, July-September and October-December. II. Authorship and Contributorship II.A. Byline Authors An "author" is generally considered to be someone who has made substantive intellectual contributions to a published study, and biomedical authorship continues to have important academic, social, and financial implications. (1) In the past, readers were rarely provided with information about contributions to studies from those listed as authors and in acknowledgments. (2) Some journals now request and publish information about the contributions of each person named as having participated in a submitted study, at least for original research. Editors are strongly encouraged to develop and implement a contributorship policy, as well as a policy on identifying who is responsible for the integrity of the work as a whole. Instructions for Authors 115 While contributorship and guarantorship policies obviously remove much of the ambiguity surrounding contributions, it leaves unresolved the question of the quantity and quality of contribution that qualify for authorship. The International Committee of Medical Journal Editors has recommended the following criteria for authorship; these criteria are still appropriate for those journals that distinguish authors from other contributors. Authorship credit should be based on 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3. When a large, multi-center group has conducted the work, the group should identify the individuals who accept direct responsibility for the manuscript (3). These individuals should fully meet the criteria for authorship defined above and editors will ask these individuals to complete journal-specific author and conflict of interest