Last updated on: September 8th, 2017
Diabetes in Ayurveda
Diabetes is a chronic metabolic disease condition involving the disorder of carbohydrate metabolism. You can find a lot of information on diabetes in various books, journals and on the internet. In this article, I will focus more on what Ayurveda describes diabetes by the term Prameha or madhumeha, its history, types, symptoms and treatment. In short, we can say this article is all about diabetes in Ayurveda. The clinical condition is similar to that of Madhumeha described in Ayurveda under Prameha Roga. Diabetes is a long-term disease with variable clinical manifestation and progression.
The word, Prameha is derived from the root ‘mih sechane’ meaning ‘watering’. In reference to disease of human beings, many have a meaning of passing urine, qualified by prefix ‘Pra’ meaning excess in both frequency and quantity.
Historical Aspects of Madhumeha
The majority of the description available in the context of Prameha such as Nirukti, samanya Nidana (general causes), Samanya samprapti (pathogenesis) suits Madhumeha if we compare diabetes in Ayurvedic contexts. As Madhumeha is one among 20 types of Pramehas and all the pramehas in due course, if neglected or not treated attain the stage of Madhumeha. Considering all the above points, the description of prameha will also be made along with Madhumeha. Many types of research done so far on Madhumeha in various Ayurvedic centres have equated it to Diabetes Mellitus. So a very brief description of Diabetes Mellitus will be made along with the description of Prameha and Madhumeha in particular.
Mythological Review of Prameha
- Daivika Yuga- The Adhya Devata Lord Gajanana (Ganesha) suffered from this disease. He had suffered from the disease because of his dietary and working habits. He used to consume the excess of sweets (Modaka) and work continuously in sitting position and his body was also obese. After the attack of this disease, he started to take Kapittha, Jambuphala and Shiva Gutika on the advice by his father Lord Shiva. (As described in Chakradutta Rasayana).
Literary Reviews of Prameha
- Vedic period- In Atharva Veda (2500 BC) the disease is mentioned as Ashravam, which means Mutra Atisara i.e. excessive urination (polyuria).
- Samhitha Period- Charaka has described the disease madhumeha in the chapters of sutra stana 17th, Nidanastana 4th, and Chikitsasthana 6th. Sushruta Samhita describes it as Kshaudra Meha in which one passes urine, which resembles honey. It is described in the chapters of Nidana Sthana 6thand chikitsa sthana 11th, 12th and 13th. An exclusive chapter for Madhumeha Chikitsa is available only in Sushruta Samhita In Ashtanga Hridayam, the descriptions of Madhumeha are available in Nidanasthana chapter 10th and Chikitsasthana chapter 12th. In Astanga Sangraha the descriptions of madhumeha are available in the chapters of Nidanasthana 10th and Chikitsasthana 14th, same as Charaka and Sushruta with slight modifications.
Diabetes Mellitus in Modern Medical History
- Madhumeha can be literally translated as diabetes mellitus as both of them mean honey urine. Diabetes is derived from a Greek word, which means ‘to siphon through’ Mellitus a latin word which means‘Honey’. It had been known to Chinese as a wasting thirst decrease for many centuries and they observed that the urine was so sweet that it attracted dogs.
- Abrus papyrus- An Egyptian medical compilation (1000 bc) has referred to a condition called polyuria.
- Celsus (2ndAD) - first clinical clear description of diabetes was given.
- Aratars of Cappadocia (150AD) - Has mentioned polyuria and thirst. He rightly quoted “mysterious affection not very frequent among man, being a melting down of flesh and limbs into urine, life is short, disgusting and painful, thirst unquenchable, death is inevitable”
- Thomas Willis (1670AD) - First mentioned the sweet taste of diabetic urine.
- Mathew Dobson (1776AD) - Demonstrated sugar in urine.
- Johan Leonard (1682AD) - First thought that pancreas was the cause of polyuria. He experimented on dogs to prove this.
- Claude Bernard (1813AD -1878AD) - First said about Diabetes. He punctured the 4thventricle of dog’s brain and produced glycosuria.
- Paul Langerhans (1869AD) - Identified Islets of Langerhans.
- Kunhana & Lea (1893AD) - Discovered anti-diabetic hormones.
Nirukti (Etymology) of Prameha and Madhumeha
- Prameha - is derived form Pra + Miha. A condition characterised by the excessive outflow of urine (Acc. To Shabda Kalpadruma).
- Madhumeha is a compound word made up of Madhu and Meha.
- Madhu - The word ‘Madhu’ is derived from the root ‘Mana’ and meaning ‘manae bodhane’- which gives Psychic contentment.
- Meha - The word ‘Meha’ is derived form the root ‘Miha’ which is employed in the sense of sinchana (to moisten), ksharana to flow, prasrava - excessive excretion.
Definition of Madhumeha
Madhumeha is a disease in which urine of the patient is sweet like honey and quantitatively increased as well as astringent, pale and rough (ruksha guna) in quality and the whole body of madhumehi becomes sweet. Many Acharyas also opines the same (Ashtanga Sangraha, Nidana- 10/14; Ashtangahridayama, Nidana- 10/18, 21; Charaka Samhita, Nidana- 4/44; Sushruta Samhita, Nidana- 6/14; Madhava Nidana- 33/26).
Synonyms of Prameha
- Prameha- Means ‘ Prakarshena Mehati’ - excessive urine outflow.
- Meha- is referred to as Prameha by Amarakosha.
- Mootradosha- A urinary disorder.
- Bahumootrata- a disease where here is excessive urination.
- Madhumeha- Excess urination resembling honey either in colour or taste.
- Kshaudrameha- Kshaudra is a synonym of madhu (honey).
- Ojomeha- Ojas is considered as Tejas or essence of all dhatus, which is a casualty in Madhumeha.
- Definition- Sir William Osler in his book ‘The Principles & Practice of Medicine’ published in 1923 defined Diabetes Mellitus as “a disorder primarily of carbohydrate and secondarily of fat and protein metabolism due to the failure of the system to burn sugar and dependent on the deficiency or absence of internal secretion of pancreas resulting from functional or organic disease of islet cells of Langerhans.
- According to WHO - A state of chronic hyperglycemia (i.e. a state of having an excessive concentration of glucose in the blood) which may result from many environmental & genetic factors often acting jointly. For more details on diabetes, you may visit WHO website.
Incidence & prevalence of Diabetes
Of late, India has seen a substantial rise in the number of diabetic patients.
- In the year 1984- 4 million diabetes cases.
- In the year 1999 – 30 million diabetes cases.
Besides this, there was 1.02 lakh diabetes-related deaths in India in 1999-2000. According to an ICMR survey, it is estimated that between 1995 & 2005, India will name 3.2 crore diabetics.
The prevalence of non-insulin dependent diabetes mellitus is seen in pima Indians where obesity is common. Obesity has a major role in the pathogenesis of diabetes mellitus. About 25% of over weight has a 3 fold risk and 50% of over weight has a 12 fold increased the risk of developing diabetes compared to normal weight individual.
For Country specific and regional data on diabetes, you may consider visiting WHO report.
Nidana (causes) of Madhumeha
The only Charaka explains specific Nidanas for Madhumeha. The samanya Nidanas of pramehas and Vataja prameha may attribute to Madhumeha, as it is one of the types of Vataja prameha.
Samanya nidana of Madhumeha
The key words in samanya nidana of prameha are the hetus (causes), which cause Kapha vriddhi. It becomes contextual here to take note of the fact that kapha is the main dosha involved in prameha and hence all the hetus that cause kapha vriddhi, automatically become the hetus for prameha.
Ahara sambandhi hetu (Causes related to food habit)
- Adhyashana (intake of food without digestion of previously taken food)
- Excessive intake of Guru, Snigdha, Sheeta, Manda, Shlakshna, Sandra, Sthira and Pichchhila Guna ahara.
- Excessive intake of Madhura, Amla, and Lavana Rasa ahara.
- Excessive intake of Navanna (new grains).
- Excessive intake of Gudavikara (jaggery based food items).
- Excessive intake of Dadhi(curd).
- Excessive intake of Anupa, Oudaka, Gramya mamsa (meat).
- Excessive intake of Medovardhaka ahara (high-calorie diet).
- Excessive intake of Kaphakara ahara.
These nidana increases Kapha in turn affects meda and kleda leading to Madhumeha due to avaran (Charaka Samhita, Sutra- 17/79; Charaka Samhita, Chikitsa- 6/4; Sushruta Samhita, Nidana- 6/2; Ashtangahridayam, Nidana- 10/1, 2, 3; Ashtanga Samgraha, Nidana- 10/3).
Vihara sambandhi hetu (causes related to daily and seasonal regimen)
The following viharas have been implicated as Kapha-medo kara (which increases Kapha and Meda)-
- Divasvapna (day sleep)
- Avyayama (lack of exercise)
- Aasya atisukha (foody)
- Alasya (lazyness)
- Chinta tyaga (a person who does not worry at all)
- Samshodhana varjana (not undergoing detoxification processes)
These ahara and viharas that aggravate kapha dosha are to be considered as Madhumeha nidana. Above factors are explained in the text are considered for prameha in general. The same factors are held responsible for the causes of Madhumeha also. Above said nidanas can be classified under Apathyanimitaja Madhumeha (Sushruta Samhita, Chikitsa- 11/3).
- Apathya Nimittaja is believed to be acquired later in life due to habits such as over indulgence in food or sweets. Maharishi Bhela termed this as "swa krittaja'.
- Vagbhatta describes the nidana of prameha as which increases the bodily Medas, Mutra and Kapha. Such as navadhanya (new grains), sura (an alcoholic beverage), anupa mamsa (specific meat), ikshu (sugarcane) and guda (jaggery). (Ashtanga Samgraha Nidana 10/3).
- Asya sukham (satisfying tongue - the sense of taste) vitiates sleshma and meda. Shayyanam vidhivajitam as put forward by Vagbhata means sleeping in the daytime, even in ritus other than grishma (summer).
- Diwasvapna (habit of day sleep) is Kapha Pitta kara and Snigdha.
- Vyayama (exercise) is necessary for all at least chankramana (brisk walk) which is deepana, ayushya and vatanulomana. So avyayama (lack of exercise) will contribute to the manifestation of Madhumeha (premeha).
- Tyakta chinta (devoid of worries) is another nidana suggested by Charaka i.e. achinta has the property of brumhana (increase heaviness property of body).
Vishesha nidana of Madhumeha
Though the Kapha is the arambhaka dosha (primary) in the Samprapti (pathogenesis) of Madhumeha (diabetes), Pitta and Vata play an important role in complicating the disease. It is worthwhile to note the textual reference that Madhumeha will occur after when, if the prameha are untreated at the same time. It is better to note that Madhumeha is a tridoshaja vyadhi. Hence the following nidanas that are explained in the texts are to be studied carefully-
Kaphaja prameha nidana
These are as the same as explained in the samanya nidana.
Pittaja prameha nidana
- Ahara sambandhi- More intake of Ushna guna ahara (warm or hot potency food) atisevana, Amla (sour), lavana (salty), katurasa (acrid), Ajeernashana (taking meal without considering digestion of previous meal), Vishama ahara sevana (intake of food items which are non-similar in quality and not recommended to take together).
- Vihara sambadhi- Ati atapa sevana (excess sunbath), Ati santapa (excess irritability), Shrama (excess labour), Krodha (anger).
Vataja prameha nidana
The causes for aggravation of Vata can be mainly grouped into two categories - margavarana and dhatu kshaya.
- Ahara sambandhi- Katu, kashaya, tikta rasa ahara atisevena; Laghu ruksha, sheeta guna ahara atisevana.
- Vihara sambandhi- vyavaya atiyoga, vyayama ati yoga, vamana ati yoga, virechana atiyoga, asthapana ati yoga, shirovirechana atiyoga, anashana, abhighata, atapa atisevana, udvega, shoka, ratri jagarana, vegasandharana.
Sushruta has categorised the existence of sthula (obese) and krisha (thin) varieties of pramehis (diabetic) and Charaka has prescribed different lines of treatment for the sthula and krisha pramehis. He has also asserted that whenever a patient presents with madhupama mutra, a wise physician should always consider the possibilities of madhumeha due to vata as a result of ksheenata of doshas and Madhumeha due to kapha as a result of santarpana.
It is very clear from Charaka’s explanation that Madhumeha in krisha occurs in the event of a relative vata vridhi in comparison to the other doshas. These persons may have been sthula in beginning but would have become krusha due to dhatu kshaya.
On the other hand, krusha madhumehis are usually rogis with beejadosha (congenital/ genetic disorder). Hence when such a rogi consumes nidanas of vatavridhi, he develops Madhumeha sooner than a sthula rogi who always indulges in tarpana ahara.
In brief, the madhura rasa, sneha dravya etc. along with the sedentary habits are having the direct bearing on the provocation of kapha dosha, which attains ‘aparipakva avastha’ which in turn affects meda and kleda leading to cause Madhumeha due to avarana.
Samprapti of Madhumeha (Pathogenesis of Diabetes in Ayurveda)
Madhumeha is considered as mahagada and as anushangi vyadhi. This is because, in Madhumeha, vyadhikshamatva (immunity) is a major casualty. Bala derived from Ojas characterises vikara vighata bhava and its deficiency characterises vikar avighata abhava. Hence, the study of the involvement of ojas in the disease warrants a top priority.
Ojas- Oja plays an active part as dushya in the samprapti of Madhumeha. Sushruta has mentioned that oja is a supreme extract of all the dhatu and strength of the body (Sushruta Samhita, Sutra- 14/11). Charaka mentions that life depends on Oja and therefore without Oja, one can’t live. Such oja remains in the heart and called as shareera rasa sneha (ch su 30/4). In the commentary, Chakrapani has described two varieties of oja i.e. para and apara oja. Para oja is a supreme and remains in the heart, while its pramana is ashta bindu (8 drops). Apara oja is of ardha anjali pramana, which is also called as shleshmika in nature and not the para oja kshaya. Pathological conditions regarding oja are 3 types.
- Oja visramsa – sandhi vishlesha, gatra sada, dosha chyavana, kriyasannirodha.
- Ojavyapth – sthabda gurugatrata, vatashopha,varna bheda, glani, tandra, nidra.
- Ojokshaya – murcha, mamsa kshaya, moha, pralapa, marana (su su 15/24).
In Madhumeha, oja is excreted through the urine leading to oja kshaya, so the symptoms of ojakshaya like murcha, mamsa kshaya, moha may manifest. Vagbhata has mentioned some additional symptoms of oja kshaya like bibheti (excessive fear), abhiksna daurbalya (excessive weakness, vyathita indriya, rukshata etc. (Ashtangahridayam, Sharira- 11/40).
- In madhumeha, though the pathology regarding oja is of kshaya nature, the other two pathological conditions may also be met with, if the samprapti remain unbroken for prolonged time with continuous nidana sevana or due to improper treatment.
- Madhumeha originated from suddha vata may manifest any of the above pathological conditions very easily. Hence the pathological aspect of the oja is very necessary to be observed to know the severity of the disease.
- Any vikara is a mutual interaction of nidana, dosha and dushya under the influence of prakriti, desha, kala, bala and vaya. The extent of this dosha dushya sammurchana is dependent on the vikara vighata bhava and its abhava. Ojas is an important vikar vighatakara bhava and one of the main dushya in Madhumeha which is eliminated through mutra leading to dhatu kshaya. Hence Madhumeha is also called “Ojomeha”
- The patient who has the specific body tendency for premeha onset which means it may be due to genetic predisposition, prakruti manifestation or sedentary habit have the specific meda bahulyata preferably with abaddhatva. If these patients consume excessive vata provocative ahara, vihara or mano abhigatkara bhava, then vata gets provocated. This provocated vata further gets implicated by meda. Now this provocated meda complex leads to transfer of either vasa, majja, lasika, oja to mutravaha srotas. When oja due to influence for vata adopts kshaya and ruksha guna and excrete through urinary treat is termed as Madhumeha.
Samprapti of Madhumeha due to shuddha Vata
Charaka mentions the samprapti of Madhumeha due to shudda vata. Due to Vata kara nidana, vata dosha provocated leading to kshaya of other two doshas and sarabhoota dhatus like vasa, majja, lasika and oja. Due to kshaya of dhatus vata further gets provocated. This highly provocated vata draws oja towards basti and leads to madhumeha. This is asadhya to treat due to its arambhaka dosha vata and resultant further provocation due to dhatukshaya (Charaka Samhita, Chikitsa- 6/34).
Dhatukshaya janya Madhumeha samprapti
The kshya of gambhira and sarabhuta dhatus like majja, vasa, oja and lasika leads to vata prakopa vata dosha gets vitiated leading to ksharana of sarabhuta dhatus through mutra pravritti in such a quantity that this ksharana of sarabhuta dhatus itself acts as etiological factor again for vata prakopa hence this vicious circle goes on. But due to ashukaritva of vata all the stages of samprapti proceeds so fast that, it leads to asadhya stage of the disease very quickly
Apratikarita vatanu-bandita Madhumeha samprapti
This type of Madhumeha is actually not a separate entity but it is the further stage of kaphaja or pittaja prameha due to deerga kalanu bandha or this may be called as ignored stage of prameha due to lack of proper treatment. Kaphaja and pittaja prameha which are present from quite longer period they do get anubandha of vata to chronicity i.e. they get converted into vataja prameha (Charaka Samhita, Nidana- 4/37).
Avarana janya Madhumeha samprapti
The description of avarana janya samprapti of madumeha is a unique contribution of charaka to the clinical medical knowledge. Here one can see that nidana is same as that of kaphaja prameha but still the resulting disease in Madhumeha. Guru snigdhadi ahara, avyayamadi vihara etc. leads to the provocation of kapha and pitta dosha inturn increases in quantity inside meda and mamsa. All these increased factors obstruct the gati of vata leading to the provocation of Vata. This provocated Vata withdraws Oja from the body and takes it towards basti and leads to Madhumeha, which is krichra sadya for treatment due to its origin from Kapha and Pitta doshas.
Initially, the Vata dosha remains innocent in the pathology. The vata, pitta and kapha doshas start manifesting their symptoms intermittently depending on their extent of dushti. Subsequently, Pitta and Kapha attain kshayavastha compared to vata due to kshaya of dhatus. This process of margavarana of vata due to kapha and pitta occurs in two kinds of people. First in those who are sthula and secondly in those who are not sthula but have indulged in kapha- medokara ahara and vihara. If the nidana for pitta are significant then it also gets dushti. In sthula people, the sthaulya is the result of two reasons. First, it is due to excess indulgence in kaphakara ahara viha. If the nidana for pitta are significant then it also gets dushti. In sthula people, the sthulya is the result of two reasons. First, it is due to excess indulgence in kaphakara ahara vihara and second is due to beeja dushti. In the former case, the upachaya of medas occurs due to the nidana sevana, where as in the later case, the medo upachaya occurs even in the absence of kapha medokara ahara vihara.
Samprapti of sthaulya (obesity) and its role in causing Madhumeha
Sthaulya can be caused by tarpana (nourishing diet) as well as beeja dosha (hereditary problem). The nidanas (causes) for sthaulya are same as those described for Madhumeha as “kapha krit cha sarvam” (all those which cause an abnormal increase in kapha dosha).
Samprapti Ghataka of Madhumeha
On the basis of various references the samprapti ghataka of Madhumeha is described as follows-
- Kapha- bahu and abaddha – in avaranjanya Madhumeha.
- Kapha- kshina in kshayajanya Madhumeha.
- Vriddha – in avaranajanya madhumeha.
- Kshina- in kshaya janya madhumeha.
- Avritta – in avaranajanya Madhumeha.
- Vriddha – in kshaya janya Madhumeha.
Dushya- rasa, rakta, mamsa, meda, majja, vasa, shukra, oja, lasika, kleda (Charaka Samhita, Nidana- 4/4) and sweda (Ashtangahridayam, Nidana- 10/4).
Srotas- annavaha, mutravaha, udakavaha, medovaha srotas.
Srotodushti- atipravritti, sanga, vimarga gamana.
Agni- vaishamya in all agnis.
Ama- in Madhumeha the amaroopi kapha causes samata of medodhatu first, leading to increased kledata subsequently, this results in saamata of other dhatus as well including the ojas. Hence dushyas are presenting in the form of ama in Madhumeha.
Sanchara Sthana- sarva shareera
Vyakta Sthana- mootravaha shrotas and sarva shareera.
Vyadhi Swabhava- chirakari
Madhumeha is a kapha vata dosha pradhana vyadhi in which the vata dushti occurs in two different pathologic mechanisms.
Samprapti of Madhumeha w.r.t. Kriyakala
1st Kriya kala – Sanchaya avastha- In this stage the samhathi roopa vriddhi of kapha occurs in svasthana i.e. amashaya, presenting the following symptoms
- Agnimandya (lack of digestive fire)
- Gaurava (heaviness)
- Alasya (laziness)
These are as a result of guru and manda guna of kapha. The occurrence of these symptoms has been inferred after studying the poorva roopa and roopas of Madhumeha.
2nd Kriyakala – Prakopa avastha- In the event of the patient continuing with the nidana sevana, disease proceeds to prakopa avastha where the kapha undergoes vilayana roopa vriddhi and can be understood as presenting with the following symptoms
- Annadvesha (anorexia)
- Hridayotklesha (nausea or unpleasant feeling) - due to amaroopi kapha
3rd Kriyakala – Prasara avastha- If unhindered, the prakupitha doshas attain prasaravastha where the unmarga gamana kapha along with the other two doshas from the svasthana occurs. The doshas pervade the body and it can be inferred that the following symptoms are presented.
- Angasada- due to kapha along with vata and pitta
The importance of first 3 kriyakalas in preventing Madhumeha – any disorders in these 3 stages often goes unrecognised, as these symptoms are mild enough for the patient to ignore.
Moreover, the symptoms are so vague and varied that it becomes difficult to ascribe them as per to Madhumeha in these 3 stages. By suitable modification in the ahara and vihara in the form of laghu ahara sevana and vyayama etc, we can control as well as prevent the onset of Madhumeha.
4th Kriyakala – Sthana samshraya avastha- By repeated nidana prekupita doshas lodges in the srotas where khavigunya exists. The medhovaha sroto vaigunya in the vapavahana due to apathya sevana or beeja upatapa causes the dusti of kapha and vata & attains sthana ssamshraya initiating the process of dosha dushya sammurchana. The poorva roopas manifest in this kriyakala
5th Kriyakala – Vyakta avastha- Dosha dushya sammurchana takes place actively during this kriyakala. The pratyatma lakshanas of Madhumeha i.e. prabhoota mutrata and aavila mutrata along with sarvadaihika lakshanas manifest during this stage.
6th Kriyakala – Bheda avastha- In this stage, Madhumeha is no more new. It would have attained sub acute or chronic stage. This disease proceeds into more severe forms in th event of increasing dhatukshaya. It also starts manifesting the pittaja and vataja lakshanas rendering the disease yapya. The disease essentially attains asadhyatha in this stage. Hence forth, upadrava and arishta lakshas start appearing.
Madhumeha Chikitsa (Treatment of Diabetes in Ayurveda)
The principles of treatment of diabetes in Ayurveda can be studied under-
- Nidana parivarjana (Avoid the causative factors)
- Prakriti Vighatana
These principles of treatment are to be studied separately with respect to Dhatu Kshaya Janya Madhumeha and marga Varana Janya Madhumeha (Charaka Samhita, Vimana- 7/ 28-29).
Sushruta has described to select drugs, which are having bitter, pungent, astringent taste, katuvipaka, ushna veerya and shoshaka, chhedana properties in the treatment of Madhumeha (Sushruta Samhita, Chikitsa- 13/8). Shilajatu, guggula, loharaja are the best medicines in madhumeha, either in krusha or sthula, as they are virukshana and chedaneeya, which is good for kapha, as well as rasayana, which is good for dhatukshaya & vata vriddhi. Sushruta has described some medicinal remedies for all types of prameha and advised to use after purification therapy (Panchakarma).
Following are some herbs and Ayurvedic medicines which are used to treat diabetes -
- Extracted juice of amalaka mixed with haridra powder.
- A decoction of triphala, vishala, devadaru and musta.
- Powders of the flower of kutaja, rohitha, kapittha and vibhitaka should be taken together with haridra and extracted juice of amalaki.
- Decoction of roots, leaves, barks, flowers and fruits of nimba, aragvadha, saptaparna, murva, kutaja, somavriksha, palasha should be given to the patients (Sushruta Samhita, Chikitsa- 11/8).
- The decoction of chitraka, triphala and indrayava.
- Extracted juice of guduchi mixed with extracted juice of amalaka fruit and honey (Ashtanga Hridayam, Chikitsa- 2/5, 6).
- Few effective preparations for the management of Madhumeha have been recommended by sharngdhara are- Amruta swarsa, triphala churna, nyagrodhadi kashaya, Dhatriswarasa, tryushnadi churna, lavangadi churna, Kalyanaka ghrita, vasant kusumakara rasa, Manduradi vatika, Chandraprabha vati, Yogaraja guggulu, Kaishora guggulu, Gokshuradi guggulu.
- Bhavaprakasha recommended – phalatrikadi kwatha, trikatukadhya modaka, nygrodhadi churna, lodhradi churna, guduchi swarasa.
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