Review comments and Suggestions by Sabnis M.
Modifications needed in the present chapter
Overall the entire chapter has been elaborated very nicely. The expected meaning of the terms and the translations are good. The term lasika has been translated as lymph which could have been translated in other terms . Lasika has been explained as the fluid in between the muscles which is different than lymph.
लसीका मांसत्वगन्तरे उदकभागः| वक्ष्यति हि शारीरे- “यन्मांसत्वगन्तरे उदकं, तल्लसीकाशब्दं लभते” (शा.अ.७) इत्यादि| | [Chakrapani on Cha.Sa. Ni.4/37] Its very clearly mentioned as intra muscular fluid which is different than lymph. Regarding the doshas explained in the eighth sutra of this chapter the word Ambu has occurred, which is analogue to kleda. More scientific explanation is required in this context.
In the 11 th Sutra, मज्जौजसा वा वसयाऽन्वितं वा लसीकया वा सततं विबद्धम्| चतुर्विधं मूत्रयतीह वाताच्छेषेषु धातुष्वपकर्षितेषु||११||
It has been clearly elaborated that when dushyas other than Majja, oja, lasika and vasa becomes weak the person lands into Vataj Prameha. This sutra should we rightly explained. Here the word Vibaddha is very important. Chakrapani clearly mentions that abadhhatva occurs in Mamsa, meda, vasa and majja which is due to kleda . This abdhhatva is laxity in the tissues and decline in tissue functions. There is volumetric increase in rasa, rakta, shukra ,ambu oja, and lasika due to vitiated kleda. Chakrapani defines that the increase in the volume of these dushyas is due to vitiated kleda. It again becomes clear that ambu and kleda may be taken as different factors and not the same.
सन्तर्पणोत्थेषु गदेषु योगा मेदस्विनां ये च मयोपदिष्टाः| विरूक्षणार्थं कफपित्तजेषु सिद्धाः प्रमेहेष्वपि ते प्रयोज्याः||४९|| In kaphaja Prameha rukshan of the dhatus is indicated and the medicines which can create rukshan in the dushyas are indicated. Here the word rukshan indicates not literally drying of the dushyas but in broader way reducing laxity and increasing the strength of the dushyas and bring them to normalcy.
In the said sutra, व्यायामयोगैर्विविधैः प्रगाढैरुद्वर्तनैः स्नानजलावसेकैः| सेव्यत्वगेलागुरुचन्दनाद्यैर्विलेपनैश्चाशु न सन्ति मेहाः||५०|| The word udawartan has been translated unction which can be said as dry scrub. In Vidhi Vimarsha Certain medications are indicated for treating Premha. These medicines are mentioned according to the type of Prameha. In the chart the anupan which is mentioned is common for all and that is milk. Milk is one of the common causative dietary factor for Prameha. In this table anupan according to the doshik classification should be mentioned. The doses mentioned in the charts should be revised.
Significant differences/updates in classical texts other than Charak Samhita
The most important difference noted in other classical text and Charak Prameha Chikitsa is that , Charak has elaborated the management of Prameha with some classifications. Those Prameha which are due to the predominance of one or three doshas a complete management is elaborated and its prognosis has also been explained. Apart from the predominance of dosha , management of Prameha has also been classified depending on volume of body that is Sthula and Krusha Pramehi. While explaining the prognosis of Prameha Charak has very clearly differentiated into Jata Pramehi Bija dosha Pramehi Kulaja Pramehi. This classification regarding the prognosis also indicated three different types of Prameha that is Jata Pramehi that is having Prameha since birth irrespective of whether the parents are having Prameha or not. Bija Doshaja is that Pramehi patient which is born of parents having some defects in the shukra dhatu.
एवमेव  पुरुषस्य यदा बीजे बीजभागः प्रदोषमापद्यते  | बीजे इति शुक्रे| [Cha.Sa. Sharira 4/31]
and third is Kulaja which means patient born out of diabetic family where parents, grandparents and grand grandparents are diabetic The above classification is very important which shows very keen observation of Acharyas regarding involvement of genetics in metabolic disorders
This type of classification is very important in view of preventive care of patients where time of onset of disease, developing co morbidities and prognosis can be precisely explained. This type of classification regarding prognosis is not observed in other texts. Regarding the co morbidities of Prameha that is Prameha Pidaka Charak has handed over the subject to Shalya Chikitsa.Prameha Pidaka are not elaborated in Nidan or Chikitsa Sthan but are explained in Kiyanti Shiraseeya adhyaya. This also suggests that Prameha Pidakas are outcome of different type of Prameha which is more fatal than the doshik predominant Prameha which is explained in nidan and Chikitsa. Prameha Pidakas are surgically managed disorder and complication of Prameha were Sushrut have dedicated a separate chapter for the diagnosis and management of Prameha Pidaka.
New research updates
Diabetes mellitus which can be said to be analogue to Prameha is multi factorial, low grade inflammatory disorder. In such types of disorders dyslipidaemia along with insulin resistance is observed in majority of patients. Auto antigenicity is also present in type 1 Diabetes. Apart from the above mentioned factors certain dietary factors are elaborated which are to be focused and explored nicely which can aggravate the pathology and can be the cause of Genetic expression in diabetes. Oxidative stress and mitochondrial dysfunction at all dushyas level are also two important factors responsible for the laxity or shithilata in dushyas which declines the function of the tissues. Medicine and the dietary factors which are advised in the management of Prameha are not essentially hypoglycemic in action. This type of management should be explored for its effects on Gut flora, low grade inflammation, oxidative stress which can have an ultimate effect to reduce insulin resistance.
When Sanshodhan and sanshaman treatments are discussed , these types of management should also be revealed in the context of improvement at dushya or tissue level which can harmonize the bio chemical changes occurred in the tissues. If the pathology at the level of dushyas is addressed correctly there are many chances that the prognosis of the disease can change significantly.
Important concepts in the chapter
Nidan and Chikitsa Chapter of Prameha explained by Charak is very important in the context of Prameha as well as all the metabolic disorders. Charak has clearly emphasised that disorders like Prameha are all life style disorders and inactivity or sedentary life style leads to number of syndromes landing the person into dreadful diseases. The dietary causes like newly harvested grains, milk and soups of domestic animals aggravates the pathology of Diabetes is a very unique concept which is not found in current medical system. Though the disease is classified as per the doshik predominance the treatment and management has been explained in two ways. One is as per the dosha prevalence and second as per corpulence and leanness of the body. It is clearly indicated that certain type of Prameha patients where the doshas are very very weak should not be subjected to shodhan chikitsa and for them shaman chikitsa is nicely explained. After advocating shodhan chikitsa optimum nourishment of dhatus is advised, this can restrict further weakness in the dhatus. The use of barley and its recipes is one of the unique advice. Barley has very low glycemic index and is rich in fibres. The use of barley not only in diabetes but in all santarpan vyadhis has proven useful. Charak has indicated use of Ingudi and Atasi tail in cooking which is high in Omega fatty acids. Oils rich in omega fatty acids are highly anti-inflammatory and are beneficial to restrict low grade chronic inflammation.
It is observed that many a times the dietary causes mentioned by Charak are not advised by the physician nor are followed by the patients. Substances like milk, newly harvested grains are regularly used in the society. Charak has explained the importance of Barley and Sattu in Prameha which is not in practice in present modern world. Majority of Obese people are diabetic and they maintain their weight while taking hypoglycemic drugs. No serious advice is given to the patients to reduce weight neither the patients at large are subjected for weight reduction treatments. It has been advised to have dry scrub regularly for the patients of Prameha . This regular scrubbing with powder ( Udavartan ) can relive micro angiopathy. Such type of practises are not found in patients of Prameha neither they are advised. The use of Atsi oil (flax seed oil ) is indicated but very few Pramehi patients are found to use this type of Oil. The regular use of barley, Moong and Amla can help to relive the progress In the samprapti of Prameha. Unfortunately such type of diets is never advised by dietician or by physician. The use of Burshta anna ( Roasted grains) is advised which is not in use.
Key research areas in the chapter
The key research area in this subject of Prameha is to make use of Ayurvedic concepts and restrict the pathology which can lead to fatal disorders. The effect of medicine not only on blood sugar level should be observed but the scope of these medicines and management should be increased. These management and medicines should be explored in the light of epigenetics, where the food and life style has an impact on genetic down regulation in diabetes and metabolic syndrome. The effect of medicines on cellular inflammation, insulin resistance, its effects on GLUT hormones, auto antigenicity should be explored.
It should be also observed that the diet which has been advised in Prameha management has some impact on dietary AGEs and RAGEs.