AETIOPATHOLOGY OFMADHUMEHA

I sivarama prq!94 I(ETHAMAKI4

When the pathology of Prameha is discussed inMadhava Nidana, Madhavakara, who followed a

specific pattern has kept this (metabolic) disorderbelore l\fiedoroga (Obesity) and after the Ashmari(Urinary caliculi). The chapter of prameha consistsof prameha pidika (boils). at the end as thecomplications of prameha. There are twentypramehas explained, out of which 4 are vataia, 6pittaja and 10 kaphaja

Because of Tulya dosha dooshyata(Homologous etiologic factors ofvitiation of doshas and dooshyas)kaphaja mehas are amenable totreatment, where as vataja becomedifficult for the same reason. Themedoroga is said to be thenidanarthakara vyadhi for pramehapidika'other than that of prameha.

Thus it is clgar, madhumeha -

Diabetes mellitus, -is a disorderpertained to the lipid metabolism.Today when we observe the patients,

many of them are non-insulindependent and very few are insulindependent. ln fact many of thepatients those who are havingmadhumeha, secrete more insulin(hyper insulinemia) than that ot

normal and still the glucose levels are

high (hyperglycemia). lt suggestsclearly, in insulin dependent patients,

there are other causes other than thatof insulin. Madhumeha literally meansmadhuryata of mootra (r:enalglycosuria).

SCAN:

When we look in to the pathogenesisof meha vis a vis prameha it givespriority for medas (fat?) as dooshyaalong. with mamsa (muscle) andshareera kleda (fluid contents"of thebody). The seat of accumulation offluid is vasti (bladder). ln the categoryof shareera kleda, the other dooshyas(vitiated tissues) are rakta (blood),sukra(semen), ambu (fluids), vasa(adipose tissue), lasika (lymph?),

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majja (bone marrow), rasa (plasma)and ojas (essence of body tissues).When we are analyzing thepathogenesis, along witfr the dosha,the sequencei of dooshya involvementis to be followed.

It is explained in medoroga, howthe medagni gets the ama samjnaand dustamedas is accumulated inthe body. For the accurnulation ofthe medas in the bodymedovahasrotas avritatva(encircling /covering), vatavitiation, jathara$ni vriddi andkapha medovardhaka nidana isnecessary. lt is a fact that, the obesepersons have the tendency ofdeveloping prameha or madhumeha.ln both prameha and medorogakapha rnedodusti appears in thebody.

Etiology:The etiology includes intake ofnavanna (newly harvested paddy)which is rich of carbohydrates alongwith the gudavikriti (items made ofjaggery and sugar), Payamsi, dadhini(diary products) which have lactoseand less" number of carbohydratechains and are easily metabolized,gramyaanupa rasa (meat and fleshof the water and land animals) arerigh in proteins and lipids/tats, Thefood which is ingested getsassirnilated and'ulilized by jatharagni

and this gets impaired to begiri with.Thus free glucose increases in theblood which collects the seven water

molecules for one.glncose moleculeand eicreted through, mootravahasrotas (kidney, ureter, :bladder) andullirnately accumulates in vasti(bladder), where re-absorptionmechanism fails (in Henley's loop)and sweet urine or glycosuria iswitnessed ultimately in all mehas.

Ama auto corrective mechanism :

ln the process of pathogenesis firstjatharagni dowrbalyata is seen withthe above said etiology. lnitiallykaphavriddhi makes the Agni vitiationwith its seeta and guru gunas. Theagni dusthi leads to varieties ofAjeerna according to the predominantdosha associated. The Agnidisturbances follow with,Arna, inpachakagni and spreads to Rasa, theinitial dhatu. lt further gets rooted inthe successive dhatui where firstthree make one set and rear threemake another. ln between of thesetwo groups the Medas is notaccessible for treatment. Here theAuto corrective mechanism:of thebody as protective mechanism act(su.su.21l28) and makes therectification of Ama in uttana dhatus(Rasa, Rakta and Mamsa). This canbe under the neural or secretarycontrol, or of'even both. But theMedas is not going to be getcorrected by auto rectification,

Ojas in pathogenesis :

ln the nidana of pranieha, the causewhich increases sleshma, mootra. andmeda with a special reference to

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sleshma, which is abundantly watery(Bahudrava sleshma), is discussed.Specificalty Madhumeha appearswhen ojodusti.is seen a.nd becausethe sweetness in Ojas gets depletedby vata and reaches'the vasti, whicliis the cause of the cardinal symptom,sweet urine.: .

Browse the symptoms :

Among the lakshanas mentioned in

Madhumeha the following are seenas valuable for analysis.

.' Prabhootivila : mootrata(polyuria) : Sweda vaha srotoavarodhata causes increasedurinary output with turbidig

+ Madhuratwa ln mootra :

Glycosuria (explained later inSamprapti)

* Dantadinam mala sanchaya:Becayge of ,Arra. depositions areseen in mouth.

.' Pani pada daha: Abundance ofglucose ayailable in the blood isnot utilized by body tissue causesdisturbance in the equillibrium ofdhatus and doshas. lt gives rise topada pani daha (burning sensationof feet and palm).

$ Chikkanata (stickiness):(explained later in Samprapti)

* Trishna (thirst - polydipsia): ln theprocess of lypolysismore water isutilized. lt results in to activationof thirst center and Thirst.

s Swadasyata : Sweetness isexperienced in the mouth due toincrease in the sugar level.

Samprapti (Aetiopathology)

The description of pathogenesis in

Susruta Nidana 614 states"Pravrittasyapaiipakwa" for whichDalharra commenls as. AparipakwaAma". lt refers both Amadosha andAmadooshya. Further it is said as'Medascha Aparipakwam' pertaining

to the dooshya alone. There byAmatwa in dooshyas specificallymedas, isthe.meaning of "Medascha

Aparipakwamn.

Gayadasa explains it as "medascha

aparinama mili asamyakparinatam",in this the process of formation ofmedas is not interrupted but impaired,with the qualities of ama; " Amarasavadati snigdham" , snigdhatwawill be in medas by virtue, but here it

will become pichhilatwa withatidravatwa. "Cha" usage indicatesnot only medas but also otherdooshyas in the pathogenesis asexplained by Charaka. And Gayadasain his commentary said il is instanasamshritavasta, in whichamalakshana in medas and otherdooshyas are visualized. lmpairedjatharagni and dhatwagnis causesthe atidravatwa of the dogshyas ofprameha. These draveebhoothadhatus get dragged and excretedthrough mootra vaha srotas.

" lt/ootrasya kledavahanam", there byliquef ied waste/ non properlymetabolized or Ama/ Amadooshyasdre excreted through mootravahasrotas and its seat"is vasti, a place

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Table - 1

Showing auto rectification of Agni giving rise increased Medas

/ Aulo\. rectilication

Mithya ahara and vihara '

Kaphaja Ahara

Jatharagni dourbalya

Ama in Jatharagni

Ama in Rasa, Rakta,Mamsa and Meda

Non restrictedMedo ama

Medoroga

, SamanavataNirama

Dhatu and Agni

Medodeposition

KindlingJatharagni

ExcessiveMetabollsm

'1 , Prabhoota mootrata3. Madhura mootrata5. Panipada daha7. Trishna

2. Avil mootrata4. Dantani mala sanchaya6. Chikkanata8. Abhishyanna deha

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Table - 2 Sweet urine genesis - Polyglycosuria

Kapha kara Ahara-->

+Kapha

Vi

iMedovilayaRaBreak down of thel-ligher level ofmolecules to.lowerlevel molecules

Table -3 lnterference of fat metabolism developing Diabetes mellitus

Oxidised.f Iavoproteinstimulates in Mitochondria

iRed,.rced f lavoprotein, Alpha,

Beta unsaturated fatty acid CoA

Hyperketonemia

Vatavriddhi

@1

Carnitine deficiency

HypoketonemiaHypoglycemia

Adversity or active production of Hyperglycemia

Beta oxidation of fatty acids .,-----\will produce Hyperglycemia /OtneefeS\(fatty aeid synthesis slops WIELLITUS/

when the chains in Aminoacids -----'zare more then 16 Carbon atoms long)

Defective-.r^ ..)lGarnnrne rncreaseY

Reaction inside outside of Mitochondriain the presence of Carnitine (Lysine derivative)

Helps iJcrossingMitochondrial membrane

With the interaction ofLiver and acelyl CoA

gives rise betahydroxy butyrate +Acetone along with

Ketqne bodies

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for accumulalion of urine. Chakrapanion Cha.Ni.4/6comments as dravatwato kapha dosha. When kapha doshais in abundant liquefied form thenonlycapable of generating the prameha,.by mixing with the medas which isfuriher liquefied and liquefy themedas in association with amalakshana. lmportance of drava ahara/pana in liquefying kapha and medasalong with lhe other dooshyas are tobe noticed. Kapha dosha is notcapable of causing the prameha rogawithout pitta or vata. The dooshyasare said to be medas, rakta, sukra,ambu (sareera kleda), vasa, lasikamajja, rasa and ojas in chronological.order.

ln medoroga rasa, rakta andmamsagni's are normal, where asmedagni is Vitiated orfat metabolismis impaired: As medagni" is notcapable of assimilation of astayeetrnamsa, this agni is diverted. The

kayagni amshas, which areresponsible lor catabolic activity in thetissues, are also diminished. The.dFiatus are subjected to increase.Here not only jatharagni vriddhi butalso kayagni amshas of medodhatuksheenata is expected. As a result ofblockage of medovaha srotas,increased agni (jatharagni/pachakagni) and decreased medoamshagnis cause the medoroga.Lastly, there is a similarity betweenprarneha and medoroga in etiologywith the factors capable ol causingkapha vriddhi like madhura rasa,snigdha guna dravyas. The processof metabolism of fats in differentstages gives rise either medoroga orprameha (santarpanothavikara).Even in lakshanas of medoroga, wesee similarity with pramehalakshanas.

Theflowcharts given will give clearinsight about the discussed topics.

The author is Reader in Kayachikitsa,Department of PG Sfudr'es, DGM Ayurvedic medical college,

Gadag, Karnatala

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