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MADHUMEHA: - keynote address by - Prof. C.P. SHUKLA
Ex. Head of the Kayachikitsa Dept. Institute of P.G.T. & R. & Emeritus Prof., JAMNAGAR (Gujarath) (Key note address in seminar on prameha 1988 Ayurveda Academy Bangalore

Historically speaking Madhumeha or Diabetes mellitus is known from Vedic Times. Even in Puranas and Kavyas the description of Madhumeha and its treatment are given. In Raghuvamsa, which is considered to be one of the best great poems (Mahakavya), an indirect narration of Madhumeha is found. It seems to be Metaphor (Rupak). The cause and treatment of sterility of king Dilip, the Great Grand Father of Lord Rama, is suggestive of the treatment of Diabetes mellitus. The story runs like this the King Dilip has no issue. So he consulted his preceptor Great Saint Vasistha Maharshi. Maharshi said that you have forgotten to bow down and serve the cow Kamadhenu and due to the curse of Kamadhenu you have got no issue. So he advised to start the Seva (service) of the cow. Thereupon king Dilip whole-heartedly serves the cow and in the end due to the blessings of the cow, Kamadhenu, kind Dilip gets a son through Queen Sudesna. Here also a description of Devdaru is given. According to the above description the following-facts can be inferred:

(i) In old times, everybody was required to serve cows. That is why a cow is called kamadhenu i.e. cow is the source of health, wealth and prosperity (ii) The whole-hearted service of the cow is the preventive and curative treatment of certain metaholic disorders like Madhumeha and others. (iii) The treatment of Madhumeha is possible with Devdaru i.e. (Cedrus Deodara).

Compare this treatment with Shushruta treatment of Madhumeha Shushruta says: महाधनोवा श्यामाकनीवारवृत्तिरामलककपित्थतिन्दुकाश्मन्तकफलाहारो मृगे सहवसेत तन्मूत्रशकृत् भक्ष्यः सततमनुव्रजेत् मृगाः सु.चि.11.12
A religious ceremony viz. Gotrivit or (Gotrat is being performed in the beginning of monsoon i.e. in the month of Ashadha. The lady, who wants Saubhagya i.e. long life of her husband, performs this ceremony. She feeds a cow about 1 kg of Yava (barley) and the barley which comes out with the faeces of the cow are collected. They are then thoroughly washed. These barley are to be eaten by the lady for 3 days. This religious ceremony resembles the treatment of Prameha according to Charaka. Charaka Says- खरास्वगोह सपृषद्भूतानां तथा यवानां विविधाश्च भक्ष्याः च.चि.6.34.
Yava are to be given for eating etc animals like donkey, horse, cow, bear etc. and are to be collected from their faceal matter. They are to be consumed in the form of different types of food.
From the above, it may very easily be inferred that our Acharyas have combined religion with Ayurveda and our religious ceremonies are meant for curative and preventive treatment of certain diseases.
CLASSIFICATION OF MADHUMEHA (DIABETES MELLITUS)
Madhumeha is classified by the Acharyas in different ways as under: -
सहज  Congenital or Juvenile and  acquired.   
स्थूल प्रमेहि (Obese diabetes)  and  कृश प्रमेहि Asthenic type
आवृत वात जन्य Due to obstruction of channels  and  शुद्ध वात (Due to Shuddha Vata )
स्वतन्त्र (Independent)  and परतन्त्र (As a result of ether urinary disorders)
The above classification is based on the classification done by -Maharshi Charaka. If required, other classifications can also be made. But according to my opinion the above T classification is a complete one in all respects. Even the most advanced modern medical science has nothing to add in the above classification. The modern science classifies diabetes mellitus according to the above.

The Samprapti of Madhumeha
The Samprapti comprises of five components (factors They are dosha, dushya, srotas/ ama and Agni, in madhumeha the components of pathogenesis are as under: -

(i) Dosha -tridosha i.e. Vata, pitta, Kapha, Vata being most predominant. Vata may be provoked by obstruction or may be independently provoked
(ii) (ii) Dushya i.e. Dhatus (tissues)- generally all the Dhatus are vitiated in Madhumeha. Main Dhatus are बह्वबद्धमेदस् (surplus and unutilized fat or adipose Tissue. (2) मांस(Muscular tissue) (3) क्लेद (fluids of the body i.e. intracellular and extra cellular fluids शुक्र Semen) (5) रक्त (Blood) (6 वसा Muscle fat) 7 मज्जा Marrow tissue) (8) लसीका (Fluids & Plasma) (9) रस (Blood Plasma) (10) ओजस् (Vital substance or the Biochemical substances in the body meant for resistance or immunity). In the above, It is clear that all the body tissues are vitiated in Madhumeha i.e. Diabetes mellitus. This is a disease in which any of the tissues or organs may be damaged. The disease is not localized in any one organ of the body but may vitiate any of the important organs.
Another important thing to be marked in the above description is that Ayurveda gives maximum importance to the derangement of fat metabolism (etc) while the modern science considers this disease to be mainly due to the derangement of carbohydrate metabolism.
In diabetes mellitus not only the fat metabolism is disturbed but the fluid balance is also disturbed as suggested by derangement of कलेद, लसीका, रस etc.  The muscles and blood arc also damaged as can be seen from the production dermatitis, boils, carbuncles i.e. (thus Prameha manifests its effects in any part of tissue of the body.
SROTAS
The main Srotas i.e. system involved is mootravaha srotas and though other Srotas are not exempt. The type of pathological changes (vikruthi) of the Srotas may be Atipravriti (excessive flow) and (improper flow) (vimarga gamana)
Agni
Main Agni involved in this disease is Dhatvagni mandya i.e. loss functioning of hormones mainly (medo-Dhatvagni mandya). Here a short description regarding Agni and Ama is necessary. Agni's though many in the body, are classified in (1 ) Jatharagni (2) Dhatwagni's (3) and Bhutagni's. Thus totally there are 13 Agni's in the body, Useful for digestion, transformation, assimilation and utilization i) the nutrient material. By this description of Agni's, it may very well be said that all the enzymes, hormones are to be put under the heading of Agni. Those Agni's are vitiated in 3 ways, i.e. excessive functioning (teekshnagni) .under functioning (mandagni ) erratic functioning (vishamagni) functioning of Agni the body tissues are burnt off, and in -hypo functioning the nutrient material is not utilized or transformed properly, resulting there-by in accumulation or In Prameha mandagni at the level of Dhatwagni takes place.
AMA
As narrated above Dhatwagni Mandya results in the production of Ama. Ama is mainly of 3 types (1 Chyle (2,) mala sanchaya i.e. accumulation of undigested nutrient materiel and (3)Prathama dosha dusti i.e. the sudden and insidious beginning of vitiated Dosha. In diabetes mellitus the result of Ama is accumulation of waste matter in the body, that is why Acharyas have mentioned dantadeenam maldyatwam (collection of Sordes on tongue and on other parts of the body like ear, tongue, etc and "chikkanata " (stickiness on the skin and mucous membrane) as the Poorva rupas (prodromal) of Prameha.
Thus Prameha is a disease produced due AMA to resulting in the vitiation of any of the Dhatus (Tissues) mainly Medas (fat), Kleda (fluids of the body) and Mamas (Muscular tissue). It also vitiates blood and its components and results in decreased immunity or resistance i.e. Ojas-Kshaya.
The pathogenesis of Prameha in general and Madhumeha runs as under (1)-Firstly, Shleshma dusti is the primary factor in the production of Prameha. Dusta (vitiated) Shleshma circulates in the body. The Dhatus in the body are loose i.e. not impact i.e. unutilized. (2) Secondly, Meda (fat or adipose tissue) may be in excess, unbound and unutilized.
The Shleshma combines with this type of Medas because both Meda & Shleshma possess similar properties. The combination of vitiated Shleshma with the Medas produces vitiation of Medas.
Thirdly (3) both the vitiated medas and Shleshma come in contact with Mamsa Dhatu (Muscular tissues) and also with Kleda (fluids) in the body; and vitiates them. (4) If Mamsa is vitiated dermatitis and other skin diseases like Prameha Peedaka (carbuncles, boils, ringworm etc. are produced and (5) If kleda is vitiated, urine quantity is increased and the Dhatus are also flowing out with urine (6) In the long run the Mutravaha Srotas (Nephrons & tubules) are obstructed and Diabetic Kidney disorder (nephritis) takes place.
From the above pathogenesis it is seen that (1 ) Prameha is not the disease of only urinary tract. There is derangement of fat metabolism. That fat is surplus and unutilized. So it is necessary to assess at what level of the fat metabolism there is disturbance. Thirdly the Kleda i.e. fluid balance in the body or thrown out of the body with urine e.g. Sugar is in excess in the blood and though necessary as fuel during exercise and work, is excreted through urine. Thus the body cannot resist exercise, work or infection. Thus the working capacity is diminished. The modern science believes that carbohydrate metabolism is primarily deranged in diabetes mellitus, while Ayurveda believes the disease primarily to be due to the disturbance in the fat metabolism. The question is open for further research. Later on, the protein metabolism is also disturbed. Thus it is a chronic metabolic disorder in which all the three metabolisms i.e. carbohydrate, fat and protein metabolism like calcium, Iron etc. May also be disturbed. So the disease is considered to be Maha-Vyadhi or difficult to cure or incurable. Thus the disease Madhumeha is proceed due to Dhatu- Agni- Mandya i.e. decreased functioning of the Dhatu-Agni i.e. metabolism.
Prodromal Symptoms
There are many premonitory symptoms as the disease is a chronic one, they are sweet taste, excessive thirst and appetite, dryness in the mouth and throat j excessive accumulation of waste matter in the channels (srotas) thereby producing stickiness in the skin, hairs are also sticky to feather (keshanam jatilibhava). There is lethargy ( alasya ) drowsiness (tandra) or excessive sleep; either burning (daha) or hypo-sensitiveness (suptata) in the limbs, hand & feet; a typical odor in the urine and the urine becomes sweet so that the ants are attracted to the urine. These symptoms, though considered to be the premonitory symptoms (poorva roopa) are symptoms, which attract the attention of the patient to consult a doctor, who decides whether the patient is suffering from diabetes or not. Thus it may be said that in mellitus does not manifest any of the symptoms other than the symptoms of the urinary tract. Diabetes mellitus is diagnosed accidentally. The patient, well built in the body, consults a physician, with the complaints of debility or dermatitis or progressive myopia is diagnosed as a patient of diabetes mellitus(madumehi). The urine colour consistency are generally normal and show no abnormality by open eye observation, not any other type of pain etc. Thus the premonitory symptoms are really the symptoms of Madhumeha.
SIGNS & SYMPTOMS
The urine is kashaya (astringent) and sweet in taste, white in colour resembling Madhu. Madhu has 2 meanings (1) Honey (2) Alcohol . Honey is sweet & Astringent in taste, yellow or white in colour and has a typical odor. The same is the colour, taste of alcohol,. Moreover in alcohol there is fermentation. So also it is possible that the urine may undergo fermentation on preserving for a night or two.
COMPLICATIONS
Diabetes mellitus is a diseased of deranged metabolism and the Ojas (resistance power) undergoes kshaya i.e. it lowers the vitality. Thus the patient is susceptible to infection very easily and once there is infection, it is difficult to cure i.e. ( Kruchra sadyata) Sushruta, while describing the curability or otherwise ( ) or Vrana (ulcers) has said that the Vrana in a diabetic patient is very difficult to cure.
Prameha Pidaka are example of secondary infections. They are also Krichra - Sadhya or difficult to cure or Asadya. Due to the disturbance of metabolism, no body organ is exempt from undergoing Vikriti (pathological Change). Thus arteries undergo athero-sclerosis; Heart undergoes hypertrophy and enlargement. There is a possibility of damage in nervous system resulting in (neuritis) or Pakshaghata) (Hemiplegia). The mootravaha srotas also damaged resulting in Diabetic nephritis. Heart may be enlarged resulting in congestive cardiac failure. Thus any of the body organs may be damaged.
An another grave complication is sanyasa(coma). When accumulation of Ama Dosha takes place in blood and disturbs the brain, specially; the sensory centres of the brain, moorcha unconsciousness) and sanyasa (coma) takes place. In fact mada moorcha and sanyasa are three stages of loosing consciousness, The first stage is mada in which the patients gets giddiness, the second stage is moorcha, in which the patient gradually looses consciousness and in the third stage the patient passes in to coma etc sanyasa. This is due to the accumulation of ketone bodies, a side product of deranged fat and protein metabolism which may be compared with Ama-Dosha or Mala Sanchaya. Thus diabetes mellitus is a disease of deranged metabolism and leads to any or the grave complications.
TREATMENT
The principles of treatment in a diabetic patient may be classified as under
1. There are two types of -diabetics (1) obese (2 (asthenic type). In obese the treatment must be mainly based on proper utilization of excess fat i.e. he should be give: (i} shodhana (purificatory process) (ii) Apatarpa reduction in body weight by way of diet control or drugs), Vyaayama (exercise) etc.
2. In the (krusha) asthenic type the treatment should be mainly based on the line of increasing stamina and vitality by way of tonics (Brumhana) diet, drugs etc. The patient should never be given excessive Langhana or Apatarpana i.e. he should not be starved.
3. The patient, whether obese or Asthenic, suffers from the complications like gulma, Kshaya (Tuberculosis), pain in abdomen etc) he should always by given some food. A diabetic and an obese person generally suffer from excessive appetite and thirst and so some type of nutrition should always be given to them. I have come across a patient, who is Juvenile diabetic, kept on insulin, and other modern hypoglycemic drugs. He suddenly started discomfort in abdomen with gas etc, then severe pain in abdomen. Next day he got vomiting. The vomit contained the same food which was ingested the previous day i.e. 14 hours before. He was admitted in Irwin Hospital but no diagnosis could be done; then he consulted me. I diagnosed the case as Gulma and Alasaka i.e. pyloric spasm due to insulin. Then I stopped all hypoglycemic drugs and kept him only on garlic. The patient then never suffered from pain and his blood sugar has been normal gradually. He is having perfect health and free from diabetes.
The following are the articles of food which can be given to the diabetes

  1. Cereals:- Yava (Barley) are the best, different preparations of food, prepared from Barley can be given e.g. Mantha, Odana, Appopa, bread, Roti etc. This is the subject of pharmaceutics and food stuffs. So the method of preparations of barley is not dealt with here. Wheat (godooma) can also be given.  
  2. Rice: - This is controversial, Ayurveda prescribed old rice,(purana shali) as one Of the cereals, which can be prescribed to the diabetic patients. While according to the modern science Rice due to starch and carbohydrate, are considered to be increasing diabetic and obesity. I would like to draw here the attention and also ask the scientists working in the field of nutrition, the percentage of diabetics and obese persons staying in the area, where the people are mainly rice eaters e.g. Bengal , Assam , Bihar and Tamilnadu, Kerala and other South Indian provinces and compare with the provinces where rice is either rarely taken or not taken e.g. Punjab Rajasthan etc. A survey should be done in this filed also. So far I know, the percentage of obesity is much less in south Indian States and eastern states as compared with Rajasthan, Punjab and some parts of U.P. where Rice is readily taken. This proves that old rice can be prescribed to the diabetics and the modern concept requires to be reassessed.
  3. Plusses: Mung (Green grams), Chanaka (Bengal Grams), Matha,- Adhaki etc, can be taken vegetables: All types of bitter vegetables (tikta shaka) e.g. Kerala methi etc. should be given
  4. Adjutants: Oils-best is Mustard oil (sarshapa taila) f The preparations of food are many and they are not mentioned here. But according to Ayurveda one should start with light diet(laghu bhaksha, laghu ahara) and then gradually increase the quantity of food. It is a rule that one should keep complete attention on the condition of Agni i.e. digestion, Diabetes, being a disease of deranged metabolism, special attention should be kept on the condition of digestion and metabolism.

As previously said in the historical aspect, Yava (Barley) collected from the faces of cow are the best FS food. They are pre-digested and contain some of the enzymes of the cows and other beasts and might be helping in substituting enzymes or might produce some enzymes which may be necessary for proper metabolic functions. Other preparations of Barley can also be prescribed. Exercise Hard exercise are prescribed for diabetics and obese persons. This is meant for proper utilisation of the fat and consumes the glucose () in. the body. The methods can be-changed in the present times according to the habitat (desha) and time (kala). But the exercises are very necessary.  Some of the hard, productive exercises prescribed by Shushruta are as under:-

  1. Vyayarna (exercises) (2) niyuddha (fighting) -(3) Kreeda (games) (4) gajacharya, turagacharya, rathacharya, padacharya to ride an elephant, horse etc. and walking etc. Over and above the above mentioned heavy exercises, there are other exercises according to the financial position and also according to their community. They are (1) for poor class, the diabetic should walk about 100 miles, bore footed, not staying more than one night in the settle place should eat only the things available by begging and keeping restraint on his sense organs. (Muni iva smyattatma)  
  2. For rich diabetics- they should oat only Shyamaka, Kodrava etc., Amalaka, Kapitha Etc. and reside with the cattle. The food stuff for them should be Ruksha (free from fat) or they may stay with the cows and eat the above with the urine and faeces of the cow Compare this with the metaphor in Raghuvamsha.
  3. For other either farming or digging a well etc. From the above, it will be seen that the exercise prescribed by the Acharyas are very hard and productive. In short for diabetics exercise serves the purposes of (1) Utilising the fat and (2) Metabolizing sugar fat and carbohydrates, and also proteins. In the present day civilisation , when these types of exercise are not possible, one should regularly play some out- door games, do some productive labour, or the best is different type yogic exercises.
  4. Yoga now-a-days has attracted the attention of Western people. The greatest drawback in our country is that we cannot appreciate the Indian things, customs or literature in the beginning but we ready to accept, when we here the same from the Western Countries. IN Yoga, also the same- things has happened. Then our Acharya's and yogi's propagated Yoga in america and other countries, they were accepted there and they did research work,. But our Indian research workers were not only criticizing the yoga but they discarded yoga to be humbug and propagated yoga as only for yogies and was not accepted as a scientific method. But when the same yoga was scientifically studied in the Western Countries, our research scholars now-a-days are working on yoga even in India .
  5. Yoga improves all sorts of metabolism in the body. So diabetics should perform different types of yoga. Yoga will definitely cure diabetes mellitus

Drugs
As regards drugs, there are so many drugs and formularies but the main drugs are either bitter (Tikta) or astringent ( kashaya) in taste. They improve the fat and carbohydrate metabolism. Some of the medicines are given below;
Kwatha (decoction)
(1) Darvi, Surahwa, Triphala, Musta.
(2) Triphala, darvi, Vishala, Musta.
The above two decoctions are different only in one drug. The first contains Surahwa (Devadaru) and the second contains Vishala. Vishala is drastic purgative and so can be used in constipated persons.
The author of this paper has assessed the hypoglycemic action of the above two decoctions. 
The effect is (1) Hypoglycemic (2) and long lasting. About 20 cases of Diabetes mellitus, were studied. Their blood sugar was estimated, G.T.T. done and the results were found to be promising. The article has been published in Ayu the authentic quarterly of Gujarat Ayurveda University .
As mentioned above, garlic is also worth trying. One of my students, who was accidentally diagnosed as severe diabetic suffered from Gulma and Alasaka (Pyloric spasm) as a result of improper use of Insulin and other modern oral hypoglycemic drugs was given only garlic paste (lashuna kalka) with 10 ml. of ground nut oil. All modern anti-diabetic drugs were stopped. The blood sugar level gradually decreased and at present he is having normal blood sugar, though he eats everything including rice. The author then tried garlic in other patients also. All of them have got reduction in blood sugar level. This suggests that garlic might be producing insulin and other hormones. According to Ayurveda, garlic is digestive, tonic, bacteriocidal, wormicide and tonic.
It may be pointed out here that Lasuna(garlic) has not been mentioned as a remedy for diabetic mellitus or prameha. It is possible that the hypoglycemic action of Lasuna might be due to the action on digestion and metabolism. Ayurveda, as already narrated previously; believes Diabetes mellitus is a disease of Mandagni at Dhatwagni level i.e. a disease of deranged metabolism. Lasuna might have acted on the Agni. There is a vast scope of research on this drug alone. The other medicines are all the bitter drugs, diet e.g. Guduchi (Tinospora Cordifolia), Methi, Karvellaka etc. The juice of all these drugs can be used as hypoglycemic. It is possible that the action may not be as quick as insulin or other modern hypoglycemic drugs. But they definitely act on diabetes.
RASAYANA
Rasayana (Rejuvenators) drugs are very useful in all diseases, specially in chronic diseases. Rasayana means that line of treatment which maintains- (1) the flow of Rasa Dhatu (nutrient material) properly (2) maintains good health (3) delays old age (4) stops decay and degeneration (5) prevents and cures diseases. There are so many varieties of Rasayana drugs e.g. some are Karshana Rasayanas (for obese persons), some are Brimha (for lean & thin persons for increasing weight), some are digestive e.g. Pippli (long peper) etc, some are acting on maintaining cholesterol at normal level e.g. Guggulu, In short, Rasayana therapy is meant for maintaining normal biochemical values, production of hormones necessary for maintenance of good health. Here it is necessary to decide which type of Rasayana may be useful for diabetics. The drug of choice is (1) Shilajatu (2) -Guggulu and (3) Haritaki (myrobalan) and Amalaki. Shilajatu is useful in this disease. For obese persons Guggulu may also be used as Guggulu has been proved as hypo-cholesterimic drug.
Thus for the treatment of Diabetes Mellitus, Ahara (diet) Achara (Daily regimen), Vyayarna (exercise), Drugs (hypoglycemic drugs), Rasayana therapy (Rejuvenation therapy) may be properly prescribed for long time. I am sure that by the prolonged use of the above treatment, the patient will not only be free from Diabetes Mellitus but can live a long ( deergha jeevana) life, healthy ( sukhayu ) and will be useful to the society (hitayu).