Prameha Chikitsa

Prameha Chikitsa

Section/Chapter	Chikitsa Sthana Chapter 6
Preceding Chapter	Gulma Chikitsa
Succeeding Chapter	Kushtha Chikitsa
Other Sections	Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Kalpa Sthana, Siddhi Sthana

(Chikitsa Sthana Chapter 6, Chapter on the Management of Obstinate Urinary Disorders)

Abstract

Prameha is a set of complex clinical disorders characterized by frequent abnormal micturition, with the etiology involving genetic predisposition as well as improper diet and lifestyle. The clinical conditions described in prameha have much in common with diabetes mellitus. In the chapter dealing with the treatment for the alleviation of prameha following topics have been discussed: Etiology of the disease; doshas and dushyas involved in the pathogenesis of the disease; Curability and incurability of the disease; Signs and symptoms of the disease; Two types of prameha patients; Three categories of therapy; viz. samshodhana (elimination therapy), samshamana (alleviation therapy) and nidana parivarjana (avoiding causative factors); Disadvantages of over depletion; Eatables prepared of barley, mantha (thin gruel) and decoctions for the cure of prameha.

Treatment of prameha includes, medicated oil, medicated ghee, various recipes of linctus, food preparations; good quality asavas (fermented drinks) having known therapeutic utility; and different methods of exercise, baths, unctuous and fragrant applications. Though prameha is widely accepted as description of diabetes, it covers various types of urinary disorders.

Keywords: Sthula Pramehi, Krisha Pramehi, Chikitsa, Diabetes Mellitus, obstinate urinary disorders

Introduction

The word Prameha literally means urinary disorders with increased quantity of urine with turbidity in it. In the last chapter of Nidana Sthana, prameha is said to have originated from excess consumption of ghee. This chapter deals with the detail etio-pathogenesis, clinical features, classification and management of prameha. It is widely considered as diabetes mellitus. However, prameha covers various types of obstinate urinary disorders under its umbrella. The key to management of prameha roga is to attempt to stop its pathogenesis for which the etiological factors responsible for the origin of the disease are identified. These etiological factors include both faulty dietary habits and life style that cause imbalance between energy consumption and energy expenditure and ultimately cause obesity. Indulgence in high calorie diet including refined carbohydrate and bad fat associated with sedentary life style causes excessive storage of fatty tissue in body to disturb the body mass index. The disturbed body mass index reflects as obesity causing disturbed lipid metabolism and assimilation (FFAs, TG, HDL and VLDL) that in turn causes insulin resistance and produces type-2 DM.

It is interesting to note that the ancient acharyas (preceptors, teachers) were aware of the fact that insulin resistance is secondary to the dyslipidemia. Therefore, the patients of prameha are classified as sthula pramehi and krisha pramehi which can be identified based on body mass index. All those factors, that cause vitiation of kapha will cause prameha. At the end of the chapter, it is mentioned that jatah/ kulaja (hereditary) prameha and madhumeha are incurable. Prameha is also classified as (1) jatah pramehi (hereditary) and (2) sthula pramehi (acquired). Further justification that acquired type of prameha (apathyanimmitaja) occurs only in obese persons i.e. obesity is the root cause for insulin resistance. But in addition to that it is stated that genetic predisposition is also required for the development of disease. There is difference of opinion within the Ayurvedic community on equating prameha with diabetes mellitus. Though it is not always feasible to accurately/exactly correlate or map Ayurvedic terms with modern medical concepts (e.g., there are no accurate medical terms to explain the concepts of gulma or prameha), Ayurveda provides insights that can prove to be invaluable in exploring effective ways of the management of various chronic diseases, including diabetes. The medical community of today believes that raised FFAs cause insulin resistance leading to diabetes mellitus along with hypertension and atherogenic dislipidemias. It is assumed that targeting FFA will help in mitigating insulin resistance more than using only hypoglycemic drugs. This chapter clearly depicts that the Ayurvedic approach for the management of prameha by apatarpana chikitsa (depleting therapy), drugs as well as diet that are helpful in lowering both fat as well as glucose such as yava (barley), triphala etc.

The chapter also gives the detailed description of urinalysis for the diagnosis, classification and assessment of prognosis of the disease. Distinctive description of raktameha and siktameha correlates with current method of microscopic examination of urine.

Description of Sahaja prameha and role of genetic predisposition in the development of disease clears all the dout about the scientific validity of Ayurveda.

Sanskrit text, Transliteration and English Translation

अथातः प्रमेहचिकित्सितं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

athātaḥ pramēhacikitsitaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

athAtaH cikitsitaM vyAkhyAsyAmaH||1||

iti ha smAha bhagavAnAtreyaH||2||

We shall now expound the chapter on the treatment of Prameha. Thus, said Lord Atreya. [1-2]

निर्मोहमानानुशयो निराशः पुनर्वसुर्ज्ञानतपोविशालः| कालेऽग्निवेशाय सहेतुलिङ्गानुवाच मेहाञ्शमनं च तेषाम्||३||

nirmōhamānānuśayō nirāśaḥ punarvasurjñānatapōviśālaḥ| kālē'gnivēśāya sahētuliṅgānuvāca mēhāñśamanaṁ ca tēṣām||3||

nirmohamAnAnushayo nirAshaH punarvasurj~jAnatapovishAlaH| kAle~agniveshAya sahetuli~ggAnuvAca Meha~jshamanaM ca teShAm||3||

Punarvasu who is free from delusion, ego, hatred and attachment, and who has attained magnanimity because of his knowledge and penance, described the etiology, signs and symptoms, and treatment of meha (prameha) to Agnivesha at proper time (when query was asked).[3]

Etiology of prameha

आस्यासुखं स्वप्नसुखं दधीनि ग्राम्यौदकानूपरसाः पयांसि| नवान्नपानं गुडवैकृतं च प्रमेहहेतुः कफकृच्च सर्वम्||४||

āsyāsukhaṁ svapnasukhaṁ dadhīni grāmyaudakānūparasāḥ payāṁsi| navānnapānaṁ guḍavaikr̥taṁ ca pramēhahētuḥ kaphakr̥cca sarvam||4||

AsyAsukhaM svapnasukhaM dadhIni grAmyaudakAnUparasAH payAMsi| navAnnapAnaM guDavaikRutaM ca PramehahetuH kaphakRucca sarvam||4||

Over-indulgence in the pleasure of sedentary habits, excess sleep, curds, soup of the meat of domesticated and aquatic animals and animals inhabiting marshy land, milk and its preparations, freshly harvested food articles, freshly prepared drinks, preparations of jaggery and all kapha- aggravating factors are responsible for the causation of prameha. [4]

Dushya (vitiated factors) and pathogeneis

मेदश्च मांसं च शरीरजं च क्लेदं कफो बस्तिगतं प्रदूष्य| करोति मेहान् समुदीर्णमुष्णैस्तानेव पित्तं परिदूष्य चापि||५||

क्षीणेषु दोषेष्ववकृष्य बस्तौ धातून् प्रमेहाननिलः करोति| दोषो हि बस्तिं समुपेत्य मूत्रं सन्दूष्य मेहाञ्जनयेद्यथास्वम्||६||

mēdaśca māṁsaṁ ca śarīrajaṁ ca klēdaṁ kaphō bastigataṁ pradūṣya| karōti mēhān samudīrṇamuṣṇaistānēva pittaṁ paridūṣya cāpi||5||

kṣīṇēṣu dōṣēṣvavakr̥ṣya bastau dhātūn pramēhānanilaḥ karōti| dōṣō hi bastiṁ samupētya mūtraṁ sandūṣya mēhāñjanayēdyathāsvam||6||

Medashca mAMsaM ca sharIrajaM ca kledaM kapho bastigataM pradUShya| karoti Mehan samudIrNamuShNaistAneva pittaM paridUShya cApi||5||

kShINeShu doSheShvavakRuShya bastau dhAtUn pramehananilaH karoti| doSho hi bastiM samupetya mUtraM sandUShya Meha~jjanayedyathAsvam||6||

Aggravated kapha vitiates medas, mamsa and kleda of the body located in basti (bladder and urinary system) and causes different types of kapha dominant meha.

Similarly, pitta aggravated by hot things vitiates those elements and causes different types of pitta dominant meha. When other two doshas are in a relatively diminished state, the aggravated vayu draws tissues elements (viz. ojas, majja, and lasika) into the urinary tract and vitiates them to cause vata dominant pramehas. Different doshas having entered the urinary tract in vitiated condition give rise to the respective types of meha with their own dominance. [5-6]

Classification and Prognosis

साध्याः कफोत्था दश, पित्तजाः षट् याप्या, न साध्यः पवनाच्चतुष्कः|| समक्रियत्वाद्विषमक्रियत्वान्महात्ययत्वाच्च यथाक्रमं ते||७||

sādhyāḥ kaphōtthā daśa, pittajāḥ ṣaṭ yāpyā, na sādhyaḥ pavanāccatuṣkaḥ| samakriyatvādviṣamakriyatvānmahātyayatvācca yathākramaṁ tē||7||

sAdhyAH kaphotthA dasha, pittajAH ShaT yApyA, na sAdhyaH pavanAccatuShkaH| samakriyatvAdviShamakriyatvAnmahAtyayatvAcca yathAkramaM te||7||

Kaphaja pramehas are of ten types and they are curable because of their compatibility of the therapies meant for their cure (samakriyatvata).

Pittaja pramehas are of six types and they are only palliable (yapya) because of their incompatibility of the therapies meant for their treatment.

Vatika pramehas are of four types and they are incurable because of their incompatibility with therapies and dreadful nature of vata leading to complications. [7]

Vitiating factors involved in pathogenesis

कफः सपित्तः पवनश्च दोषा मेदोऽस्रशुक्राम्बुवसालसीकाः| मज्जा रसौजः पिशितं च दूष्याः[१] प्रमेहिणां, विंशतिरेव मेहाः||८||

kaphaḥ sapittaḥ pavanaśca dōṣā mēdō'sraśukrāmbuvasālasīkāḥ| majjā rasaujaḥ piśitaṁ ca dūṣyāḥ [3] pramēhiṇāṁ, viṁśatirēva mēhāḥ||8||

kaphaH sapittaH pavanashca doShA medo~asrashukrAmbuvasAlasIkAH| majjA rasaujaH pishitaM ca dUShyAH pramehiNAM, viMshatireva MehaH||8||

Doshas like kapha, pitta and vata, and dushyas like medas, rakta, shukra, ambu (body fluid), vasa (muscle fat), lasika (lymph), majja, rasa, ojas and mamsa are responsible for the causation of prameha which is of twenty types. [8]

Twenty types of dosha dominant prameha

जलोपमं चेक्षुरसोपमं वा घनं घनं चोपरि विप्रसन्नम्| शुक्लं सशुक्रं शिशिरं शनैर्वा लालेव वा वालुकया युतं वा||९||

विद्यात् प्रमेहान् कफजान् दशैतान् क्षारोपमं कालमथापि नीलम्| हारिद्रमाञ्जिष्ठमथापि रक्तमेतान् प्रमेहान् षडुशन्ति पित्तात्||१०||

मज्जौजसा वा वसयाऽन्वितं वा लसीकया वा सततं विबद्धम्| चतुर्विधं मूत्रयतीह[१] वाताच्छेषेषु धातुष्वपकर्षितेषु||११||

jalōpamaṁ cēkṣurasōpamaṁ vā ghanaṁ ghanaṁ cōpari viprasannam| śuklaṁ saśukraṁ śiśiraṁ śanairvā lālēva vā vālukayā yutaṁ vā||9||

vidyāt pramēhān kaphajān daśaitān kṣārōpamaṁ kālamathāpi nīlam| hāridramāñjiṣṭhamathāpi raktamētān pramēhān ṣaḍuśanti pittāt||10||

majjaujasā vā vasayā'nvitaṁ vā lasīkayā vā satataṁ vibaddham| caturvidhaṁ mūtrayatīha [4] vātācchēṣēṣu dhātuṣvapakarṣitēṣu||11||

jalopamaM cekShurasopamaM vA ghanaM ghanaM copari viprasannam| shuklaM sashukraM shishiraM shanairvA lAleva vA vAlukayA yutaM vA||9||

vidyAt pramehan kaphajAn dashaitAn kShAropamaM kAlamathApi nIlam| hAridramA~jjiShThamathApi raktametAn pramehan ShaDushanti pittAt||10||

majjaujasA vA vasayA~anvitaM vA lasIkayA vA satataM vibaddham| caturvidhaM mUtrayatIha vAtAccheSheShu dhAtuShvapakarShiteShu||11||

Ten varieties of kaphaja meha have the following characteristic features:

1. The urine resembling water (udaka meha)
2. The urine resembling sugar cane juice (iksu- valika meha)
3. Dense urine (sandra meha)
4. Low density urine with transparent upper layer (Sandra prasad meha)
5. The urine having white colour (shukla meha)
6. The urine containing seminal fluid (shukra meha)
7. The urine having cold touch (shita meha)
8. The urine passing out slowly (shanaih meha)
9. The urine containing slimy material like saliva (lala meha) and
10. The urine containing sand like substance (sikata meha).

Six varieties of pittaja meha have following characteristic features:

1. The urine resembling alkali solution (kshara meha)
2. The urine having black color (kala meha)
3. The urine having indigo color (nila meha)
4. The urine having yellow color like turmeric (haridra meha)
5. The urine having reddish color like that of manjistha (manjishtha meha) and
6. The urine having blood in it (rakta meha).

Four varieties of vatika meha have the following characteristic features:

1. The urine mixed with majja (majja meha)
2. The urine mixed with ojas (oja meha )
3. The urine mixed with muscle fat (vasa meha)
4. The urine mixed with lympha (lasika meha)

Diminution of other dhatus or tissue elements (besides those described above) is responsible for the causation of the above mentioned four varieties of vatika prameha. [9-11]

Criteria for diagnosis

वर्णं रसं स्पर्शमथापि गन्धं यथास्वदोषं भजते प्रमेहः| श्यावारुणो वातकृतः सशूलो मज्जादिसाद्गुण्यमुपैत्यसाध्यः||१२||

varṇaṁ rasaṁ sparśamathāpi gandhaṁ yathāsvadōṣaṁ bhajatē pramēhaḥ| śyāvāruṇō vātakr̥taḥ saśūlō majjādisādguṇyamupaityasādhyaḥ||12||

varNaM rasaM sparshamathApi gandhaM yathAsvadoShaM bhajate PramehaH| shyAvAruNo vAtakRutaH sashUlo majjAdisAdguNyamupaityasAdhyaH||12||

Different types of prameha are characterized by the color, taste, touch and smell of the respective dosha. Vatika varieties of prameha are characterized by grayish or reddish coloration of the urine, pain and attributes of majja, etc. These types of vatika prameha are incurable. [12]

Premonitory signs and symptoms

स्वेदोऽङ्गगन्धः शिथिलाङ्गता च शय्यासनस्वप्नसुखे रतिश्च| हृन्नेत्रजिह्वाश्रवणोपदेहो घनाङ्गता केशनखातिवृद्धिः||१३||

शीतप्रियत्वं गलतालुशोषो माधुर्यमास्ये करपाददाहः| भविष्यतो मेहगदस्य रूपं मूत्रेऽभिधावन्ति पिपीलिकाश्च||१४||

svēdō'ṅgagandhaḥ śithilāṅgatā ca śayyāsanasvapnasukhē ratiśca| hr̥nnētrajihvāśravaṇōpadēhō ghanāṅgatā kēśanakhātivr̥ddhiḥ||13||

śītapriyatvaṁ galatāluśōṣō mādhuryamāsyē karapādadāhaḥ| bhaviṣyatō mēhagadasya rūpaṁ mūtrē'bhidhāvanti pipīlikāśca||14||

svedo~a~ggagandhaH shithilA~ggatA ca shayyAsanasvapnasukhe ratishca| hRunnetrajihvAshravaNopadeho ghanA~ggatA keshanakhAtivRuddhiH||13||

shItapriyatvaM galatAlushoSho mAdhuryamAsye karapAdadAhaH| bhaviShyato Mehagadasya rUpaM mUtre~abhidhAvanti pipIlikAshca||14||

Sweating, body odor, flabbiness of the body, liking for constantly lying on the bed, sitting, sleeping and leading an easy life, a feeling as if the cardiac region is covered with extraneous material, exudation of excreta from eyes, tongue and ears, corpulence of the body, excessive growth of hair and nails, liking for cold things, dryness of throat and palate, sweet taste in the mouth, burning sensation in hands and legs and swarming of ants on the urine- these are the premonitory signs and symptoms of prameha. [13-14]

Principles of management

स्थूलः प्रमेही बलवानिहैकः कृशस्तथैकः परिदुर्बलश्च| सम्बृंहणं तत्र कृशस्य कार्यं संशोधनं दोषबलाधिकस्य||१५||

स्निग्धस्य योगा विविधाः प्रयोज्याः कल्पोपदिष्टा मलशोधनाय[१] | ऊर्ध्वं तथाऽधश्च मलेऽपनीते मेहेषु सन्तर्पणमेव कार्यम्||१६||

गुल्मः क्षयो मेहनबस्तिशूलं मूत्रग्रहश्चाप्यपतर्पणेन| प्रमेहिणः स्युः, परितर्पणानि[२] कार्याणि तस्य[३] प्रसमीक्ष्य वह्निम्||१७||

sthūlaḥ pramēhī balavānihaikaḥ kr̥śastathaikaḥ paridurbalaśca| sambr̥ṁhaṇaṁ tatra kr̥śasya kāryaṁ saṁśōdhanaṁ dōṣabalādhikasya||15||

snigdhasya yōgā vividhāḥ prayōjyāḥ kalpōpadiṣṭā malaśōdhanāya [5] | ūrdhvaṁ tathā'dhaśca malē'panītē mēhēṣu santarpaṇamēva kāryam||16||

gulmaḥ kṣayō mēhanabastiśūlaṁ mūtragrahaścāpyapatarpaṇēna| pramēhiṇaḥ syuḥ, paritarpaṇāni [6] kāryāṇi tasya [7] prasamīkṣya vahnim||17||

sthUlaH pramehI balavAnihaikaH kRushastathaikaH paridurbalashca| sambRuMhaNaM tatra kRushasya kAryaM saMshodhanaM doShabalAdhikasya||15||

snigdhasya yogA vividhAH prayojyAH kalpopadiShTA malashodhanAya| UrdhvaM tathA~adhashca male~apanIte meheShu santarpaNameva kAryam||16||

gulmaH kShayo MehanabastishUlaM mUtragrahashcApyapatarpaNena| pramehiNaH syuH, paritarpaNAni kAryANi tasya prasamIkShya vahnim||17||

Patients suffering from prameha are classified into two categories, viz. (1) those who are obese and strong, and (2) those who are emaciated and weak.

Patients belonging to the latter category should be given nourishing therapy. Patient of the former category who are strong and who have more doshas in the body should be treated with elimination therapy.

For this purpose, the oleated patient should be given various recipes described in Kalpa Sthana with a view to eliminating metabolic waste products through both upward and downward tracts. After the waste products (excess metabolic bi-products) are eliminated from his body, the patient should be given santarpana or nourishment therapy. Because apatarpana (depletion) therapy in this condition may produce gulma, consumption, pain in phallus and urinary bladder including kidneys and retention of urine. Such patients should be given santarpana therapy depending upon their power of digestion. [15-17]

Samshamana ( pacification therapy)

संशोधनं नार्हति यः प्रमेही तस्य क्रिया संशमनी प्रयोज्या| मन्थाः कषाया यवचूर्णलेहाः प्रमेहशान्त्यै लघवश्च भक्ष्याः||१८||

ये विष्किरा ये प्रतुदा विहङ्गास्तेषां रसैर्जाङ्गलजैर्मनोज्ञैः| यवौदनं रूक्षमथापि वाट्यमद्यात्[१] ससक्तूनपि चाप्यपूपान्||१९||

मुद्गादियूषैरथ तिक्तशाकैः पुराणशाल्योदनमाददीत| दन्तीङ्गुदीतैलयुतं प्रमेही तथाऽतसीसर्षपतैलयुक्तम्||२०||

सषष्टिकं स्यात्तृणधान्यमन्नं यवप्रधानस्तु भवेत् प्रमेही| यवस्य भक्ष्यान् विविधांस्तथाऽद्यात् कफप्रमेही मधुसम्प्रयुक्तान्||२१||

निशिस्थितानां त्रिफलाकषाये स्युस्तर्पणाः क्षौद्रयुता यवानाम्| तान् सीधुयुक्तान् प्रपिबेत् प्रमेही प्रायोगिकान्मेहवधार्थमेव||२२||

ये श्लेष्ममेहे विहिताः कषायास्तैर्भावितानां च पृथग्यवानाम्| सक्तूनपूपान् सगुडान् सधानान् भक्ष्यांस्तथाऽन्यान् विविधांश्च खादेत्||२३||

खराश्वगोहंसपृषद्भृतानां तथा यवानां विविधाश्च भक्ष्याः| देयास्तथा वेणुयवा यवानां कल्पेन गोधूममयाश्च भक्ष्याः||२४||

saṁśōdhanaṁ nārhati yaḥ pramēhī tasya kriyā saṁśamanī prayōjyā| manthāḥ kaṣāyā yavacūrṇalēhāḥ pramēhaśāntyai laghavaśca bhakṣyāḥ||18||

yē viṣkirā yē pratudā vihaṅgāstēṣāṁ rasairjāṅgalajairmanōjñaiḥ| yavaudanaṁ rūkṣamathāpi vāṭyamadyāt [8] sasaktūnapi cāpyapūpān||19||

mudgādiyūṣairatha tiktaśākaiḥ purāṇaśālyōdanamādadīta| dantīṅgudītailayutaṁ pramēhī tathā'tasīsarṣapatailayuktam||20||

saṣaṣṭikaṁ syāttr̥ṇadhānyamannaṁ yavapradhānastu bhavēt pramēhī| yavasya bhakṣyān vividhāṁstathā'dyāt kaphapramēhī madhusamprayuktān||21||

niśisthitānāṁ triphalākaṣāyē syustarpaṇāḥ kṣaudrayutā yavānām| tān sīdhuyuktān prapibēt pramēhī prāyōgikānmēhavadhārthamēva||22||

yē ślēṣmamēhē vihitāḥ kaṣāyāstairbhāvitānāṁ ca pr̥thagyavānām| saktūnapūpān saguḍān sadhānān bhakṣyāṁstathā'nyān vividhāṁśca khādēt||23||

kharāśvagōhaṁsapr̥ṣadbhr̥tānāṁ tathā yavānāṁ vividhāśca bhakṣyāḥ| dēyāstathā vēṇuyavā yavānāṁ kalpēna gōdhūmamayāśca bhakṣyāḥ||24||

saMshodhanaM nArhati yaH pramehI tasya kriyA saMshamanI prayojyA| manthAH kaShAyA yavacUrNalehAH PramehashAntyai laghavashca bhakShyAH||18||

ye viShkirA ye pratudA viha~ggAsteShAM rasairjA~ggalajairmanoj~jaiH| yavaudanaM rUkShamathApi vATyamadyAt sasaktUnapi cApyapUpAn||19||

mudgAdiyUShairatha tiktashAkaiH purANashAlyodanamAdadIta| dantI~ggudItailayutaM pramehI tathA~atasIsarShapatailayuktam||20||

saShaShTikaM syAttRuNadhAnyamannaM yavapradhAnastu bhavet pramehI| yavasya bhakShyAn vividhAMstathA~adyAt kaphapramehI madhusamprayuktAn||21||

nishisthitAnAM triphalAkaShAye syustarpaNAH kShaudrayutA yavAnAm| tAn sIdhuyuktAn prapibet pramehI prAyogikAnMehavadhArthameva||22||

ye shleShmamehe vihitAH kaShAyAstairbhAvitAnAM ca pRuthagyavAnAm| saktUnapUpAn saguDAn sadhAnAn bhakShyAMstathA~anyAn vividhAMshca khAdet||23||

kharAshvagohaMsapRuShadbhRutAnAM tathA yavAnAM vividhAshca bhakShyAH| deyAstathA veNuyavA yavAnAM kalpena godhUmamayAshca bhakShyAH||24||

If the patient of prameha is not eligible for samshodhana or elimination therapy, samshamana or alleviation therapies should be given. [18]

Diet

The patient suffering from prameha should be given the following food:

1. Manthas (flour of different types of corn mixed with water), kashayas (decoctions), barley powder, linctus prepared of barley and other light- eatables;
2. Yavaudana (cooked barley) without adding any unctuous articles, vatya (barley porridge), saktu (roasted corn flour) and apupa (pancakes) mixed with the meat soup of gallinaceous and pecker birds and animals inhabiting arid land;
3. Old shali rice cooked and mixed with the soup of mudga etc., and preparations of bitter vegetables; and
4. Cooked shashtika rice and trina dhanyas mixed with the oil of danti, ingudi, atasi and sarshapa.

Shashtika rice with shyamaka etc., truna dhanya with yava as predominant food is advised for prameha patients.

Various food recipes of yava with honey are indicated in kapha dominant prameha.

Barley soaked in the decoction of triphala and kept overnight should be mixed with honey. It is a refreshing (tarpana) diet. It should be taken by the patient suffering from prameha regularly to overcome the disease. Barley should be soaked separately with each of decoctions prescribed for the treatment of kaphaja prameha and taken by the patient in the form of saktu (roasted flour), apupa (pancake), dhana (roasted barley) and other types of eatables along with jaggery.

Various eatables prepared from the barley or bamboo seed or wheat previously eaten by asses, horses, cows, swans and deer and collected from their dung should be given to the patient suffering from prameha. [18-24]

Specific Therapies

संशोधनोल्लेखनलङ्घनानि काले प्रयुक्तानि कफप्रमेहान्| जयन्ति पित्तप्रभवान् विरेकः सन्तर्पणः संशमनो विधिश्च||२५||

saṁśōdhanōllēkhanalaṅghanāni kālē prayuktāni kaphapramēhān| jayanti pittaprabhavān virēkaḥ santarpaṇaḥ saṁśamanō vidhiśca||25||

saMshodhanollekhanala~gghanAni kAle prayuktAni kaphaPramehan| jayanti pittaprabhavAn virekaH santarpaNaH saMshamano vidhishca||25||

Purificatory therapies including specifically emesis and fasting therapies, administered at the appropriate time, cure kaphaja types of prameha. Similarly, pittaja types of prameha are overcome by purgation, santarpana (refreshing therapy) and alleviation therapies. [25]

Various recipes

दार्वीं सुराह्वां त्रिफलां समुस्तां कषायमुत्क्वाथ्य पिबेत् प्रमेही| क्षौद्रेण युक्तामथवा हरिद्रां पिबेद्रसेनामलकीफलानाम्||२६||

dārvīṁ surāhvāṁ triphalāṁ samustāṁ kaṣāyamutkvāthya pibēt pramēhī| kṣaudrēṇa yuktāmathavā haridrāṁ pibēdrasēnāmalakīphalānām||26||

dArvIM surAhvAM triphalAM samustAM kaShAyamutkvAthya pibet pramehI| kShaudreNa yuktAmathavA haridrAM pibedrasenAmalakIphalAnAm||26||

The patient suffering from prameha should take the decoction of darvi, surahva, triphala and musta mixed with honey. He may also take haridra along with the juice of amalaki. [26]

Decoctions for kaphaja prameha

हरीतकीकट्फलमुस्तलोध्रं पाठाविडङ्गार्जुनधन्वनाश्च| उभे हरिद्रे तगरं विडङ्गं कदम्बशालार्जुनदीप्यकाश्च||२७||

दार्वी विडङ्गं खदिरो धवश्च सुराह्वकुष्ठागुरुचन्दनानि| दार्व्यग्निमन्थौ त्रिफला सपाठा पाठा च मूर्वा च तथा श्वदंष्ट्रा||२८||

यवान्युशीराण्यभयागुडूचीचव्याभयाचित्रकसप्तपर्णाः| पादैः कषायाः कफमेहिनां ते दशोपदिष्टा मधुसम्प्रयुक्ताः||२९||

harītakīkaṭphalamustalōdhraṁ pāṭhāviḍaṅgārjunadhanvanāśca| ubhē haridrē tagaraṁ viḍaṅgaṁ kadambaśālārjunadīpyakāśca||27||

dārvī viḍaṅgaṁ khadirō dhavaśca surāhvakuṣṭhāgurucandanāni| dārvyagnimanthau triphalā sapāṭhā pāṭhā ca mūrvā ca tathā śvadaṁṣṭrā||28||

yavānyuśīrāṇyabhayāguḍūcīcavyābhayācitrakasaptaparṇāḥ| pādaiḥ kaṣāyāḥ kaphamēhināṁ tē daśōpadiṣṭā madhusamprayuktāḥ||29||

harItakIkaTphalamustalodhraM pAThAviDa~ggArjunadhanvanAshca| ubhe haridre tagaraM viDa~ggaM kadambashAlArjunadIpyakAshca||27||

dArvI viDa~ggaM khadiro dhavashca surAhvakuShThAgurucandanAni| dArvyagnimanthau triphalA sapAThA pAThA ca mUrvA ca tathA shvadaMShTrA||28||

yavAnyushIrANyabhayAguDUcIcavyAbhayAcitrakasaptaparNAH| pAdaiH kaShAyAH kaphamehinAM te dashopadiShTA madhusamprayuktAH||29||

The following ten decoctions should be mixed with honey and given to patients suffering from kaphaja prameha:

1. Decoction of haritaki, katphala, musta and lodhra;
2. Decoction of patha, vidanga, arjuna and dhanvana;
3. Decoction of haridra, daruharida, tagar and vidanga;
4. Decoction of kadamba, shala, arjuna and dipyaka;
5. Decoction of darvi, vidanga, khadira and dhava;
6. Decoction of surahva, kushtha, aguru and chandana;
7. Decoction of darvi, agnimantha, triphala and patha;
8. Decoction of patha, murva and shvadamshtra;
9. Decoction of yavani, ushira, abhaya and guduchi; and
10. Decoction of chavya, abhaya, chitraka and sapta parna.

Decoctions for pittaja prameha

उशीरलोध्राञ्जनचन्दनानामुशीरमुस्ता मलकाभयानाम्| पटोलनिम्बामलकामृतानां मुस्ताभयापद्मकवृक्षकाणाम्||३०||

लोध्राम्बुकालीयकधातकीनां निम्बार्जुनाम्रातनिशोत्पलानाम्| शिरीषसर्जार्जुनकेशराणां प्रियङ्गुपद्मोत्पलकिंशुकानाम्||३१||

अश्वत्थपाठासनवेतसानां कटङ्कटेर्युत्पलमुस्तकानाम्| पैत्तेषु मेहेषु दश प्रदिष्टाः पादैः कषाया मधुसम्प्रयुक्ताः||३२||

uśīralōdhrāñjanacandanānāmuśīramustāmalakābhayānām| paṭōlanimbāmalakāmr̥tānāṁ mustābhayāpadmakavr̥kṣakāṇām||30||

lōdhrāmbukālīyakadhātakīnāṁ nimbārjunāmrātaniśōtpalānām| śirīṣasarjārjunakēśarāṇāṁ priyaṅgupadmōtpalakiṁśukānām||31||

aśvatthapāṭhāsanavētasānāṁ [11] kaṭaṅkaṭēryutpalamustakānām| paittēṣu mēhēṣu daśa pradiṣṭāḥ pādaiḥ kaṣāyā madhusamprayuktāḥ||32||

ushIralodhrA~jjanacandanAnAmushIramustAmalakAbhayAnAm| paTolanimbAmalakAmRutAnAM mustAbhayApadmakavRukShakANAm||30||

lodhrAmbukAlIyakadhAtakInAM nimbArjunAmrAtanishotpalAnAm| shirIShasarjArjunakesharANAM priya~ggupadmotpalakiMshukAnAm||31||

ashvatthapAThAsanavetasAnAM kaTa~gkaTeryutpalamustakAnAm| paitteShu meheShu dasha pradiShTAH pAdaiH kaShAyA madhusamprayuktAH||32||

The following ten decoctions should be mixed with honey and given to patients suffering from pittaja prameha:

1. Decoction of ushira, lodhra, arjuna, lalachandana
2. Decoction of ushira, musta, amalaka and abhaya;
3. Decoction of patola, nimba, amalaka and amrita;
4. Decoction of musta, abhaya, padmaka and vrikshaka;
5. Decoction of lodhra, ambu, kaliyaka and dhataki;
6. Decoction of nimba, arjuna, amrita, nisha and utpala;
7. Decoction of shirisha, sarja, arjuna and keshara;
8. Decoction of priyangu, padma, utpala and kimshuka;
9. Decoction of ashvattha, patha, asana and vetasa; and
10. Decoction of katankateri (daruharidra), utpala and mustaka. [30-32]

Decoctions for all types of prameha

सर्वेषु मेहेषु मतौ तु पूर्वौ कषाययोगौ विहितास्तु सर्वे| मन्थस्य पाने यवभावनायां स्युर्भोजने पानविधौ पृथक् च||३३||

सिद्धानि तैलानि घृतानि चैव देयानि मेहेष्वनिलात्मकेषु| मेदः कफश्चैव कषाययोगैः स्नेहैश्च वायुः शममेति तेषाम्||३४||

sarvēṣu mēhēṣu matau tu pūrvau kaṣāyayōgau vihitāstu sarvē| manthasya pānē yavabhāvanāyāṁ syurbhōjanē pānavidhau pr̥thak ca||33||

siddhāni tailāni ghr̥tāni caiva dēyāni [12] mēhēṣvanilātmakēṣu| mēdaḥ kaphaścaiva kaṣāyayōgaiḥ snēhaiśca vāyuḥ śamamēti tēṣām||34||

sarveShu meheShu matau tu pUrvau kaShAyayogau vihitAstu sarve| manthasya pAne yavabhAvanAyAM syurbhojane pAnavidhau pRuthak ca||33||

siddhAni tailAni ghRutAni caiva deyAni meheShvanilAtmakeShu| medaH kaphashcaiva kaShAyayogaiH snehaishca vAyuH shamameti teShAm||34||

Two recipes of decoction are described for the treatment of all varieties of prameha. These decoctions can be used for the preparation of mantha (a drink prepared of roasted corn flour mixed with water), for the impregnation of barley and for the preparation of different kinds of food and drinks.

Medicated oils and medicated ghee prepared by cooking with these decoctions should be administered to patients suffering from vatika prameha. These decoctions correct the vitiated medas and kapha, and the aggravated vayu in these patients gets alleviated by the unctuous ingredients (viz., oil and ghee) included in these recipes. [33-34]

Formulations for kaphaja and pittaja prameha

कम्पिल्लसप्तच्छदशालजानि बैभीतरौहीतककौटजानि| कपित्थपुष्पाणि च चूर्णितानि क्षौद्रेण लिह्यात् कफपित्तमेही||३५||

पिबेद्रसेनामलकस्य चापि कल्कीकृतान्यक्षसमानि काले| जीर्णे च भुञ्जीत पुराणमन्नं मेही रसैर्जाङ्गलजैर्मनोज्ञैः||३६||

kampillasaptacchadaśālajāni baibhītarauhītakakauṭajāni| kapitthapuṣpāṇi ca cūrṇitāni kṣaudrēṇa lihyāt kaphapittamēhī||35||

pibēdrasēnāmalakasya cāpi kalkīkr̥tānyakṣasamāni kālē| jīrṇē ca bhuñjīta purāṇamannaṁ mēhī rasairjāṅgalajairmanōjñaiḥ||36||

kampillasaptacchadashAlajAni baibhItarauhItakakauTajAni| kapitthapuShpANi ca cUrNitAni kShaudreNa lihyAt kaphapittamehI||35||

pibedrasenAmalakasya cApi kalkIkRutAnyakShasamAni kAle| jIrNe ca bhu~jjIta purANamannaM mehI rasairjA~ggalajairmanoj~jaiH||36||

Powder of kampillaka, barks of saptachchada, bibhitaka, rohitaka and kutaja and flower of kapittha should be added with honey, made to a linctus and taken by patients suffering from kaphaja and pittaja prameha. One aksha of the paste of above mentioned drugs should be mixed with the juice of amalaki and given at the appropriate time to patients suffering from kaphaja and pittaja types of prameha. After the digestion of this potion, the patient should be given to eat old rice cooked and mixed with the delicious soup of the meat of animals living in arid land.[35-36]

Formulations for vata association in kaphaja and pittaja prameha

दृष्ट्वाऽनुबन्धं पवनात् कफस्य पित्तस्य वा स्नेहविधिर्विकल्प्यः| तैलं कफे स्यात् स्वकषायसिद्धं पित्ते घृतं पित्तहरैः कषायैः||३७||

त्रिकण्टकाश्मन्तकसोमवल्कैर्भल्लातकैः सातिविषैः सलोध्रैः| वचापटोलार्जुननिम्बमुस्तैर्हरिद्रया[१] पद्मकदीप्यकैश्च||३८||

मञ्जिष्ठया चागुरुचन्दनैश्च सर्वैः समस्तैः कफवातजेषु| मेहेषु तैलं विपचेद्, घृतं तु पैत्तेषु, मिश्रं त्रिषु लक्षणेषु||३९||

फलत्रिकं दारुनिशां विशालां मुस्तां च निःक्वाथ्य निशां सकल्काम्| पिबेत् कषायं मधुसम्प्रयुक्तं सर्वप्रमेहेषु समुद्धतेषु||४०||

dr̥ṣṭvā'nubandhaṁ pavanāt kaphasya pittasya vā snēhavidhirvikalpyaḥ| tailaṁ kaphē syāt svakaṣāyasiddhaṁ pittē ghr̥taṁ pittaharaiḥ kaṣāyaiḥ||37||

trikaṇṭakāśmantakasōmavalkairbhallātakaiḥ sātiviṣaiḥ salōdhraiḥ| vacāpaṭōlārjunanimbamustairharidrayā [13] padmakadīpyakaiśca||38||

mañjiṣṭhayā cāgurucandanaiśca sarvaiḥ samastaiḥ kaphavātajēṣu| mēhēṣu tailaṁ vipacēd, ghr̥taṁ tu paittēṣu, miśraṁ triṣu lakṣaṇēṣu||39||

phalatrikaṁ dāruniśāṁ viśālāṁ mustāṁ ca niḥkvāthya niśāṁ sakalkām| pibēt kaṣāyaṁ madhusamprayuktaṁ sarvapramēhēṣu samuddhatēṣu||40||

dRuShTvA~anubandhaM pavanAt kaphasya pittasya vA snehavidhirvikalpyaH| tailaM kaphe syAt svakaShAyasiddhaM pitte ghRutaM pittaharaiH kaShAyaiH||37||

trikaNTakAshmantakasomavalkairbhallAtakaiH sAtiviShaiH salodhraiH| vacApaTolArjunanimbamustairharidrayA१] padmakadIpyakaishca||38||

ma~jjiShThayA cAgurucandanaishca sarvaiH samastaiH kaphavAtajeShu| meheShu tailaM vipaced, ghRutaM tu paitteShu, mishraM triShu lakShaNeShu||39||

phalatrikaM dArunishAM vishAlAM mustAM ca niHkvAthya nishAM sakalkAm| pibet kaShAyaM madhusamprayuktaM sarvaprameheShu samuddhateShu||40||

If vayu is secondarily aggravated along with either kapha or pitta, then the patient should be administered unctuous preparations. For the kapha aggravation, medicated oil should be processed with the decoction of kapha alleviating drugs. .For the pitta aggravation, medicated ghee should be processed with the decoction of pitta alleviating drugs. Trikantaka, ashmantaka, somavalka, bhallataka, ativisha, lodhra, vacha, patola, arjuna, nimbi, musta, haridra, padmaka, dipyaka, manjishtha, aguru and chandana- all these drugs together should be used in the preparation of medicated oil for the treatment of kaphaja prameha which is associated with secondarily aggravated vayu. In case of pitta dominance, ghee shall be processed with above mentioned drugs.

If the signs and symptoms of all the three doshas are manifested, then with all the above mentioned drugs together, ghee and oil both in a mixed form should be cooked and given to the patient.

Recipe for all types of prameha:

The decoction of triphala, darunisha, vishala and musta should be mixed with the paste of haridra and honey. Intake of this potion cures all types of prameha even when these are manifested in acute form. [37-40]

Madhvasava

लोध्रं शटीं पुष्करमूलमेलां मूर्वां विडङ्गं त्रिफलां यमानीम्| चव्यं प्रियङ्गुं क्रमुकं विशालां किराततिक्तं कटुरोहिणीं च||४१||

भार्ङ्गीं नतं चित्रकपिप्पलीनां मूलं सकुष्ठातिविषं सपाठम्| कलिङ्गकन् केशरमिन्द्रसाह्वां नखं सपत्रं मरिचं प्लवं च||४२||

द्रोणेऽम्भसः कर्षसमानि पक्त्वा पूते चतुर्भागजलावशेषे| रसेऽर्धभागं मधुनः प्रदाय पक्षं निधेयो घृतभाजनस्थः||४३||

मध्वासवोऽयं[१] कफपित्तमेहान् क्षिप्रं निहन्याद्द्विपलप्रयोगात्| पाण्ड्वामयार्शांस्यरुचिं ग्रहण्या दोषं किलासं विविधं च कुष्ठम्||४४||

इति मध्वासवः|

lōdhraṁ śaṭīṁ puṣkaramūlamēlāṁ mūrvāṁ viḍaṅgaṁ triphalāṁ yamānīm| cavyaṁ priyaṅguṁ kramukaṁ viśālāṁ kirātatiktaṁ kaṭurōhiṇīṁ ca||41||

bhārṅgīṁ nataṁ citrakapippalīnāṁ mūlaṁ sakuṣṭhātiviṣaṁ sapāṭham| kaliṅgakan kēśaramindrasāhvāṁ nakhaṁ sapatraṁ maricaṁ plavaṁ ca||42||

drōṇē'mbhasaḥ karṣasamāni paktvā pūtē caturbhāgajalāvaśēṣē| rasē'rdhabhāgaṁ madhunaḥ pradāya pakṣaṁ nidhēyō ghr̥tabhājanasthaḥ||43||

madhvāsavō'yaṁ [15] kaphapittamēhān kṣipraṁ nihanyāddvipalaprayōgāt| pāṇḍvāmayārśāṁsyaruciṁ grahaṇyā dōṣaṁ kilāsaṁ vividhaṁ ca kuṣṭham||44||

iti madhvāsavaḥ

lodhraM shaTIM puShkaramUlamelAM mUrvAM viDa~ggaM triphalAM yamAnIm| cavyaM priya~gguM kramukaM vishAlAM kirAtatiktaM kaTurohiNIM ca||41||

bhAr~ggIM nataM citrakapippalInAM mUlaM sakuShThAtiviShaM sapATham| kali~ggakan kesharamindrasAhvAM nakhaM sapatraM maricaM plavaM ca||42||

droNe~ambhasaH karShasamAni paktvA pUte caturbhAgajalAvasheShe| rase~ardhabhAgaM madhunaH pradAya pakShaM nidheyo ghRutabhAjanasthaH||43||

madhvAsavo~ayaM kaphapittaMehan kShipraM nihanyAddvipalaprayogAt| pANDvAmayArshAMsyaruciM grahaNyA doShaM kilAsaM vividhaM ca kuShTham||44||

iti madhvAsavaH|

Lodhra, shati, pushkaramula, ela, murva, vidanga, triphala, yamani, chavya, priyangu, kramuka, vishala, kiratatikta, katurohini, bharngi, nata, chitraka, pippalimula, kushtha, ativisha, patha, kalingaka, keshara, indravaruni, nakha, patra, maricha and plava- one karsha of each of these drugs should be boiled in one drona of water till one fourth remains. This decoction along with half its quantity of honey should be kept inside a ghee smeared jar for a fort night. This is called madhvasava. It instantaneously cures kaphaja and paittika types of meha when administered in a dose of two palas. It also cures pandu, arsha, aruchi, grahani dosha, kilasa and different types of kushtha.[41-44]

Dantyasava and bhallatakasava

क्वाथः स एवाष्टपलं च दन्त्या भल्लातकानां च चतुष्पलं स्यात्| सितोपला त्वष्टपला विशेषः क्षौद्रं च तावत् पृथगासवौ तौ||४५||

kvāthaḥ sa ēvāṣṭapalaṁ ca dantyā bhallātakānāṁ ca catuṣpalaṁ syāt| sitōpalā tvaṣṭapalā viśēṣaḥ kṣaudraṁ ca tāvat pr̥thagāsavau tau||45||

kvAthaH sa evAShTapalaM ca dantyA bhallAtakAnAM ca catuShpalaM syAt| sitopalA tvaShTapalA visheShaH kShaudraM ca tAvat pRuthagAsavau tau||45||

In the above mentioned decoction, eight palas of danti, eight palas of sugar and the same quantity of honey should be added and processed. Similarly, in the above mentioned decoction four palas of bhallataka, eight palas of sugar and the same quantity of honey should be added and processed. These two asavas (namely dantyasava and bhallatokusava) are useful in the treatment of prameha. [45]

Beneficial diet and drinks

सारोदकं वाऽथ कुशोदकं वा मधूदकं वा त्रिफलारसं वा| सीधुं पिबेद्वा निगदं प्रमेही माध्वीकमग्र्यं चिरसंस्थितं वा||४६||

मांसानि शूल्यानि मृगद्विजानां खादेद्यवानां विविधांश्च भक्ष्यान्| संशोधनारिष्टकषायलेहैः सन्तर्पणोत्थाञ् शमयेत् प्रमेहान्||४७||

भृष्टान् यवान् भक्षयतः प्रयोगाच्छुष्कांश्च सक्तून्न भवन्ति मेहाः| श्वित्रं च कृच्छ्रं कफजं च कुष्ठं तथैव मुद्गामलकप्रयोगान्||४८||

sārōdakaṁ vā'tha kuśōdakaṁ vā madhūdakaṁ vā triphalārasaṁ vā| sīdhuṁ pibēdvā nigadaṁ pramēhī mādhvīkamagryaṁ cirasaṁsthitaṁ vā||46||

māṁsāni śūlyāni mr̥gadvijānāṁ khādēdyavānāṁ vividhāṁśca bhakṣyān| saṁśōdhanāriṣṭakaṣāyalēhaiḥ santarpaṇōtthāñ śamayēt pramēhān||47||

bhr̥ṣṭān yavān bhakṣayataḥ prayōgācchuṣkāṁśca saktūnna bhavanti mēhāḥ| śvitraṁ ca kr̥cchraṁ kaphajaṁ ca kuṣṭhaṁ tathaiva mudgāmalakaprayōgān||48||

sArodakaM vA~atha kushodakaM vA madhUdakaM vA triphalArasaM vA| sIdhuM pibedvA nigadaM pramehI mAdhvIkamagryaM cirasaMsthitaM vA||46||

mAMsAni shUlyAni mRugadvijAnAM khAdedyavAnAM vividhAMshca bhakShyAn| saMshodhanAriShTakaShAyalehaiH santarpaNotthA~j shamayet pramehan||47||

bhRuShTAn yavAn bhakShayataH prayogAcchuShkAMshca saktUnna bhavanti MehaH| shvitraM ca kRucchraM kaphajaM ca kuShThaM tathaiva mudgAmalakaprayogAn||48||

The patient suffering from prameha should drink sarodaka (water boiled with the heart- wood of khadira etc.,), kushodaka (water boiled with kusha), madhudaka (water mixed with honey), triphala rasa (juice or decoction of triphala) or sidhu (a type of wine) which is properly fermented or madhvika (another type of wine) which is of superior quality and is prepared after fermenting for a long time.

Spit- roasted meat of animals and birds and different eatables prepared of barley should be given to the patient to eat. Different types of prameha caused by over-nourishment should be alleviated by the administration of elimination therapies, arishtas (a type of wine), decoctions and various types of linctus.

Persons habitually taking roasted barley, dry corn- flour, mudga and amalaka do not suffer from prameha, shvitra (leucoderma), mutrakrucchra (dysuria) and kaphaja kushtha. [46-48]

Indications of above treatment

सन्तर्पणोत्थेषु गदेषु योगा मेदस्विनां ये च मयोपदिष्टाः| विरूक्षणार्थं कफपित्तजेषु सिद्धाः प्रमेहेष्वपि ते प्रयोज्याः||४९||

santarpaṇōtthēṣu gadēṣu yōgā mēdasvināṁ yē ca mayōpadiṣṭāḥ| virūkṣaṇārthaṁ kaphapittajēṣu siddhāḥ pramēhēṣvapi tē prayōjyāḥ||49||

santarpaNottheShu gadeShu yogA medasvinAM ye ca mayopadiShTAH| virUkShaNArthaM kaphapittajeShu siddhAH prameheShvapi te prayojyAH||49||

Effective formulations for producing drying effect on obese patients while describing the management of diseases caused by over- nourishment are useful in the treatment of pramehas caused by kapha and pitta dominance. [49]

Various external applications

व्यायामयोगैर्विविधैः प्रगाढैरुद्वर्तनैः स्नानजलावसेकैः| सेव्यत्वगेलागुरुचन्दनाद्यैर्विलेपनैश्चाशु[१] न सन्ति मेहाः||५०||

vyāyāmayōgairvividhaiḥ pragāḍhairudvartanaiḥ snānajalāvasēkaiḥ| sēvyatvagēlāgurucandanādyairvilēpanaiścāśu [17] na santi mēhāḥ||50||

vyAyAmayogairvividhaiH pragADhairudvartanaiH snAnajalAvasekaiH| sevyatvagelAgurucandanAdyairvilepanaishcAshu na santi MehaH||50||

Pramehas get immediately cured by different types of exercises, unction, bath, sprinkling of water over the body and application of ointment made of sevya (ushira), tvak, ela, aguru, chandana etc. [50]

Indication of apatarpana treatment

क्लेदश्च मेदश्च कफश्च वृद्धः प्रमेहहेतुः प्रसमीक्ष्य तस्मात्| वैद्येन पूर्वं कफपित्तजेषु मेहेषु कार्याण्यपतर्पणानि||५१||

klēdaśca mēdaśca kaphaśca vr̥ddhaḥ pramēhahētuḥ prasamīkṣya tasmāt| vaidyēna pūrvaṁ kaphapittajēṣu mēhēṣu kāryāṇyapatarpaṇāni||51||

kledashca medashca kaphashca vRuddhaH pramehahetuH prasamIkShya tasmAt| vaidyena pUrvaM kaphapittajeShu meheShu kAryANyapatarpaNAni||51||

Aggravated kleda (liquid element of the body), medas (adipose tissue) and kapha are responsible for the causation of prameha. Keeping this in view, the physician, in the beginning, should administer depletion therapies to patients suffering with kapha and pitta dominant types of prameha. [51]

Vata dominant prameha

या वातमेहान् प्रति पूर्वमुक्ता वातोल्बणानां विहिता क्रिया सा| वायुर्हि मेहेष्वतिकर्शितानां कुप्यत्यसाध्यान् प्रति नास्ति चिन्ता||५२||

yā vātamēhān prati pūrvamuktā vātōlbaṇānāṁ vihitā kriyā sā| vāyurhi mēhēṣvatikarśitānāṁ kupyatyasādhyān prati nāsti cintā||52||

yA vAtaMehan prati pUrvamuktA vAtolbaNAnAM vihitA kriyA sA| vAyurhi meheShvatikarshitAnAM kupyatyasAdhyAn prati nAsti cintA||52||

Formulations described earlier for the vatika prameha are actually meant for vata dominant prameha where vayu is secondarily (subsequently) aggravated. If the vayu is primarily aggravated in prameha because of excessive depletion of tissue elements, then it is incurable and the physician need not make efforts to treat. [52]

Prevention of prameha

यैर्हेतुभिर्ये प्रभवन्ति मेहास्तेषु प्रमेहेषु न ते निषेव्याः| हेतोरसेवा विहिता यथैव जातस्य रोगस्य भवेच्चिकित्सा||५३||

yairhētubhiryē prabhavanti mēhāstēṣu pramēhēṣu na tē niṣēvyāḥ| hētōrasēvā vihitā yathaiva jātasya rōgasya bhavēccikitsā||53||

Yairhetubhirye prabhavanti MehasteShu prameheShu na te niShevyAH| hetorasevA vihitA yathaiva jAtasya rogasya bhaveccikitsA||53||

Etiological factors responsible for the causation of different types of prameha should be avoided even after prameha are manifested. The causative factors described shall be avoided during the treatment of those particular diseases (even after its manifestation). [53]

Differentiation between raktapitta and prameha

हारिद्रवर्णं रुधिरं च मूत्रं विना प्रमेहस्य हि पूर्वरूपैः| यो मूत्रयेत्तं न वदेत् प्रमेहं रक्तस्य पित्तस्य हि स प्रकोपः||५४||

hāridravarṇaṁ rudhiraṁ ca mūtraṁ vinā pramēhasya hi pūrvarūpaiḥ| yō mūtrayēttaṁ na vadēt pramēhaṁ raktasya pittasya hi sa prakōpaḥ||54||

hAridravarNaM rudhiraM ca mUtraM vinA pramehasya hi pUrvarUpaiH| yo mUtrayettaM na vadet pramehaM raktasya pittasya hi sa prakopaH||54||

If the color of the urine is yellow or if blood is excreted through the urine without the prior manifestation of premonitory signs and symptoms of prameha, such a person should not be diagnosed as a patient of prameha. He should be diagnosed as a case of rakta-pitta (a disease characterized by bleeding from different parts of body).[54]

Two types of prameha patient

दृष्ट्वा प्रमेहं मधुरं सपिच्छं मधूपमं स्याद्द्विविधो विचारः| क्षीणेषु दोषेष्वनिलात्मकः स्यात् सन्तर्पणाद्वा कफसम्भवः स्यात्||५५||

dr̥ṣṭvā pramēhaṁ madhuraṁ sapicchaṁ madhūpamaṁ syāddvividhō vicāraḥ| kṣīṇēṣu dōṣēṣvanilātmakaḥ syāt santarpaṇādvā kaphasambhavaḥ syāt||55||

dRuShTvA pramehaM madhuraM sapicchaM madhUpamaM syAddvividho vicAraH| kShINeShu doSheShvanilAtmakaH syAt santarpaNAdvA kaphasambhavaH syAt||55||

If the patient suffering from prameha passes urine which is sweet, slimy and honey-like, then there are two possibilities. It is caused either by the diminution of doshas having vata-dominant type or by over- nourishment having kapha dominant type. [55]

Prognosis

सपूर्वरूपाः कफपित्तमेहाः क्रमेण ये वातकृताश्च मेहाः| साध्या न ते, पित्तकृतास्तु याप्याः, साध्यास्तु मेदो यदि न प्रदुष्टम्||५६||

sapūrvarūpāḥ kaphapittamēhāḥ kramēṇa yē vātakr̥tāśca mēhāḥ| sādhyā na tē, pittakr̥tāstu yāpyāḥ, sādhyāstu mēdō yadi na praduṣṭam||56||

sapUrvarUpAH kaphapittaMehaH krameNa ye vAtakRutAshca MehaH| sAdhyA na te, pittakRutAstu yApyAH, sAdhyAstu medo yadi na praduShTam||56||

Kapha dominant and pitta dominant types of prameha, if preceded by their premonitory signs and symptoms, are incurable. Similarly, vatika prameha, where vayu is aggravated right from the beginning is incurable. Pitta dominant types of prameha are generally palliable. But they are curable if medas (adipose tissue) is not vitiated. [56]

In-curability of hereditary diseases

जातः प्रमेही मधुमेहिनो वा न साध्य उक्तः स हि बीजदोषात्| ये चापि केचित् कुलजा विकारा भवन्ति तांश्च प्रवदन्त्यसाध्यान्||५७||

jātaḥ pramēhī madhumēhinō vā na sādhya uktaḥ sa hi bījadōṣāt| yē cāpi kēcit kulajā vikārā bhavanti tāṁśca pravadantyasādhyān||57||

jAtaH pramehI madhumehino vA na sAdhya uktaH sa hi bIjadoShAt| ye cApi kecit kulajA vikArA bhavanti tAMshca pravadantyasAdhyAn||57||

Patients who suffer from prameha since birth (congenital) and those who are borne of prameha parents (hereditary) are not curable because of the morbidity in their bija (genes). Similarly, other hereditary (kulaja/familial) ailments are considered as incurable. [57]

Treatment of prameha pidaka

प्रमेहिणां याः पिडका मयोक्ता रोगाधिकारे पृथगेव सप्त| ताः शल्यविद्भिः कुशलैश्चिकित्स्याः शस्त्रेण संशोधनरोपणैश्च||५८||

pramēhiṇāṁ yāḥ piḍakā mayōktā rōgādhikārē pr̥thagēva sapta| tāḥ śalyavidbhiḥ kuśalaiścikitsyāḥ śastrēṇa saṁśōdhanarōpaṇaiśca||58||

pramehiNAM yAH piDakA mayoktA rogAdhikAre pRuthageva sapta| tAH shalyavidbhiH kushalaishcikitsyAH shastreNa saMshodhanaropaNaishca||58||

Seven types of prameha pidaka of patients suffering from prameha described in the quadrate on diseases (rogadhikara) are to be treated by expert surgeons with the help of shastras (surgical operations), samshodhana (cleansing) and ropana (healing therapies). [58]

Summary

तत्र श्लोकाः-

हेतुर्दोषो दूष्यं मेहानां साध्यतानुरूपश्च| मेही द्विविधस्त्रिविधं[१] भिषग्जितमतिक्षपणदोषः||५९||

आद्या यवान्नविकृतिर्मन्था मेहापहाः कषायाश्च| तैलघृतलेहयोगा भक्ष्याः प्रवरासवाः सिद्धाः||६०||

व्यायामविधिर्विविधः स्नानान्युद्वर्तनानि गन्धाश्च| मेहानां प्रशमार्थं चिकित्सिते दिष्टमेतावत्||६१||

tatra ślōkāḥ-

hēturdōṣō dūṣyaṁ mēhānāṁ sādhyatānurūpaśca| mēhī dvividhastrividhaṁ [18] bhiṣagjitamatikṣapaṇadōṣaḥ||59||

ādyā yavānnavikr̥tirmanthā mēhāpahāḥ kaṣāyāśca| tailaghr̥talēhayōgā bhakṣyāḥ pravarāsavāḥ siddhāḥ||60||

vyāyāmavidhirvividhaḥ snānānyudvartanāni gandhāśca| mēhānāṁ praśamārthaṁ cikitsitē diṣṭamētāvat||61||

Tatra shlokAH-

heturdoSho dUShyaM MehanAM sAdhyatAnurUpashca| mehI dvividhastrividhaM bhiShagjitamatikShapaNadoShaH||59||

AdyA yavAnnavikRutirmanthA MehapahAH kaShAyAshca| tailaghRutalehayogA bhakShyAH pravarAsavAH siddhAH||60||

vyAyAmavidhirvividhaH snAnAnyudvartanAni gandhAshca| MehanAM prashamArthaM cikitsite diShTametAvat||61||

Here are the recapulatory verses:

The causes, dosha, dushya, curability, characteristics of urine in prameha, two types of patients, three modes of treatment, disadvantages of excess depletion therapy, various food items of yava, mantha, various decoctions used in treatment of prameha, medicated oils, ghee preparations, linctuses, diet articles, fermented preparations like asava, various exercises, baths, massage, fragrant applications all these are described in the management of prameha. [59-61]

Thus, ends the sixth chapter dealing with the treatment of prameha of Chikitsa Sthana of Agnivesha’s work as redacted by Charaka.[6]

Tattva Vimarsha

• Excess intake of curds, soup of the meat of domesticated, aquatic animals and animals inhabiting marshy land, milk and its preparations, freshly harvested food articles, freshly prepared drinks, preparations of jaggery and all kapha- aggravating factors are responsible for the causation of prameha.
• Over-indulgence in the pleasure of sedentary habits, excess sleep are lifestyle factors leading to prameha.
• Aggravated kapha vitiates medas, mamsa and kleda of the body located in basti (bladder and urinary system) and causes different types of kapha dominant meha.
• Similarly, pitta aggravated by hot things vitiates those elements and causes different types of pitta dominant meha.
• When other two doshas are in a relatively diminished state, the aggravated vayu draws tissues elements (viz. ojas, majja, and lasika) into the urinary tract and vitiates them to cause vata dominant pramehas. Different doshas having entered the urinary tract in vitiated condition give rise to the respective types of meha with their own dominance.
• Doshas like kapha, pitta and vata, and dushyas like medas, rakta, shukra, ambu (body fluid), vasa (muscle fat), lasika (lymph), majja, rasa, ojas and mamsa are responsible for the causation of prameha which is of twenty types. Prameha is classified on the basis of characteristics of urine as observed. Indeed the classification depends upon response of urinary system towards internal imbalance of cellular metabolism. This depends upon waste products excreted through urine after interaction of aggravated dosha and dushya.
• Different types of prameha are characterized by the color, taste, touch and smell of the respective dosha.
• Patients suffering from prameha are classified into two categories, viz. (1) those who are obese and strong, and (2) those who are emaciated and weak. The clinical presentation and treatment is different for both categories. Patients belonging to the latter category should be given nourishing therapy. Patient of the former category who are strong and who have more doshas in the body should be treated with elimination therapy.
• After elimination therapy, nourishment therapy shall be prescribed to the patient. If nourishment therapy is not done, then the aggravated vata dosha leads to complications of prameha.
• The food preparations like yava (barley) which have dry, light to digest and hot properties are predominantly indicated in prameha.
• Aggravated kleda (liquid element of the body), medas (adipose tissue) and kapha are responsible for the causation of prameha. Considering this aggravation, apatarpana (depletion therapies) is the first principle of treatment in kapha and pitta dominant types of prameha.
• If vata is primarily aggravated in prameha because of excessive depletion of tissue elements, then it is incurable. If vata is associated and secondarily aggravated, then it is treatable upto some extent.
• Persistently avoiding etiological factors after manifestation of disease and during treatment of disease are important principles of management of disease.
• The curability of kapha and pitta dominant prameha depends upon intensity of involvement of meda dhatu.
• Patients who suffer from prameha since birth (congenital) and those who are borne of prameha parents (hereditary) are not curable because of the morbidity in their bija (genes). Similarly, other hereditary (kulaja/familial) ailments are considered as incurable.

Vidhi Vimarsha

Role of kapha dominant diet

In prameha, kapha is the main culprit both as dosha as well as dushya. Diet having high contents of bad fat and carbohydrates like curd (Fat= 3g/ 100g, carbohydrate= 7.8g/100g, Protein= 5.25g, calories= 63), meat soup (calories= 902), jaggery (Fat= 0g/ 100g, carbohydrate= 97.2 g/100g, Protein= 0.5g/100g, calories= 367), newly harvested grains that are having high calories than old one (If dry grains are held for only a few months, minimum nutritional changes will take place, but if the grains are held with a higher amount of moisture, the grain quality can deteriorate because of starch degradation by grain and microbial amylases) etc., causes prameha. All the causative factors are in diet that have high content of bad fat like saturated fats and no good fats like polyunsaturated or monounsaturated fats (which are mostly present in plant originated dietary products). It is advisable that maximum percentage of daily fat consumption should come from plant origin to lower the risk of dyslipidemia.

Optimum levels of fat in the diet are given below: • Less than 10 percent of calories should come from saturated fat. • An average of 30 percent of calories or less should come from total fat. • Dietary cholesterol intake should be less than 300 mg a day. Thus the causative factors can be categorized as (1) those related to high fat and refined carbohydrate diet that provide high calories by liberating high and instant energy (jaggery, meat soup, etc.) and (2) those related to sedentary life style that causes low energy expenditure (lack of exercise, etc). These two factors cause an imbalance between energy consumption and energy expenditure and ultimately cause obesity.

Role of obesity and pathogenesis in sthula prameha

Excessive consumption of fats and sedentary life style causes obesity. Obesity causes derangement in lipid metabolism and storage which in turn leads to prameha as shown in the following chart:

Diagnosis of prameha based on characteristics of urine

Different categories of prameha are described to possess the color, taste, touch, and smell of the respective doshas. For example, in kaphaja prameha, the urine is characterized by white color, sweet taste; cold touch and ama gandha (smell like that of flesh). In the same way, the characteristic features of pittaja prameha are to be determined. Vayu itself is colorless. Therefore, different varieties of vata dominant prameha are characterized by grayish or reddish color of urine as a result of the prabhava (specific action) of the vayu.

Vata dominant prameha is already described to be incurable (asadhya). Again repeating the statement regarding its incurability implies that the presence of several symptoms including the grayish and reddish coloration of urine right from the origin of disease is incurable; and if these signs and symptoms appear at later stage, then the condition is incurable. In the latter type, attributes of majja etc., need not to be present. Alternatively, it can be explained that when at a later stage, any type of prameha gets associated with vayu and characterized by grayish and reddish coloration of urine, and then it also becomes incurable. In addition when kaphaja and pittaja types of prameha are associated with the passage of majja etc., in the urine, they become incurable. It is stated, “All types of prameha, if not treated in time, leads to madhumeha and become incurable” (Sushruta : Nidana 6).

1. Kaphaja prameha (progressive stage from pre-diabetic to diabetes mellitus type-2)

• Udakameha – Osmotic diuresis (having characteristic similar to that of water)
  • Pre-diabetic stage - hyperglycemia causes decrease reabsorption of water and excessive loss of water through urine.
• Ikshumeha – Alimentary glycosuria (having characteristic similar to sugarcane juice)
  • Pre-diabetic stage when liver is unable to metabolize excessive glucose due to hepatic insulin resistance and thus presence of glucose in urine.
• Sandra meha, and
• Sandraprashada meha – (layered urine: 3 layers: a top layer of chylomicrons, a middle layer rich in protein, and a bottom layer containing fibrin clots and cellular debris)
  • Intermediary stage between pre-diabetic and diabetic mellitus start with the involvement of kidneys.
• Lalameha – Albuminuria (heavy whitish foam in urine)
  • Progressive stage of diabetes mellitus type-2 which may show the presence of albumin.
• Shuklameha- (urine having white colour like that of pasted flour)
  • Progressive stage of diabetes mellitus type-2 with the further derangement in the functioning of nephrons (proteinuria).
• Shanaimeha – Reduced urinary flow (reduced urinary flow with increased frequency)
  • Stage of diabetes involving advanced nephropathy. Infective and reduced urinary flow.
• Shitameha-(the patient gets frequent micturition which is exceedingly sweet and cold)
  • Stage of kidney failure due to diabetic nephropathy presence of excessive ammonical substance in urine.
• Sukrameha – Spermaturia (patient passes semen like urine or urine mixed with semen)
  • Autonomic diabetic neuropathy leading to retrograde ejaculation of sperm.

2.Pittaja prameha- (Stage of infection & inflammation in diabetes)

• Ksharameha- the patient passes urine having the smell, color, taste and touch like those of alkalies. (pH of urine become alkaline)
  • Increased urinary pH due to UTI in diabetes.
  • Alkaline fermentation causes an ammoniacal smell, and patients with diabetic ketoacidosis produce urine that may have a sweet or fruity odor.
• Kalameha- the patient passes black color urine.
  • Highly concentrated urine due to dehydration.
• Nilameha- the patient passes urine having sour taste and color like that of the feather of casa bird.
  • Blue colour urine indicative of bacterial urinary tract infection
• Raktameha- the patient passes urine having red colour, saline taste and smell like that of raw fish.
  • Microscopic hematuria.
• Manjishthameha- the patient passes frequent urine having the smell like that of raw flesh and color like that of the juice of manjistha (Rubia cordifolia Linn.)
  • Gross hematuria due to UTI
• Haridrameha- the patient passes urine having pungent taste and color like that of the juice of haridra (Curcuma longa Linn.)
  • dark yellow color urine due to dehydration. Highly concentrated urine due to UTI/ dark yellow color due to jaundice.

3. Vataja prameha- (Type-1Diabetes mellitus)

• Vasameha - Lipiduria (prence of lipid in urine) in Nephrotic syndrome associated with type-1 diabetes mellitus (30-40%) known as Kimmelstiel –Wilsone Syndrome.
• Majjameha– presence of bone marrow.
• Lasikameha/ Hastimeha- Proteinuria/ diabetic ketoacidosis due to diabetes mellitus
• Ojomeha/ Madhumeha- Type – 1 Diabetes mellitus

Parameter of urinalysis used in above

1. Physical parameters

• Color
  • Raktameha, haridrameha, majjisthameha, kalameha etc.
• Appearance
  • Cloudy: Shuklameha
  • Layered: Sandrameha, Sandraprasadameha.
• Foamy
  • Lalameha
• Temperature
  • Shitameha

2. Chemical parameters

• pH
  • Ksharameha
• Specific Gravity
  • Udakameha

3. Microscopic Examination

• Hematuria
  • Manjjisthameha
• Red blood casts
  • Raktameha
• Crystalluria
  • Siktameha
• Leukocytes
  • Shuklameha
• Nitrite
  • Shitameha
• Protein
  • Lalameha, Lasikameha
• Blood
  • Raktameha
• Glucose
  • Ikshumeha, Madhumeha
• Bilirubin
  • Haridrameha

Vivid description of manjjisthameha, raktameha, siktameha clearly indicate evolved observation skills of physicians. Analyzing the details of urine characteristics the scientific approach of Ayurveda is established. It is really appreciable that a disease can be classified and identified at every stage merely by urinalysis.

Importance of Barley

Barley should constitute the principal ingredient of food of the patient suffering from prameha. The patient suffering from kaphaja prameha should take eatable prepared of barley mixed with honey.

Barley soaked in the decoction of triphala and kept overnight should be mixed with honey. It is a refreshing (tarpana) diet. It should be taken by the patient suffering from prameha regularly to overcome the disease. Barley should be soaked separately with each of decoctions prescribed for the treatment of kaphaja prameha and taken by the patient in the form of saktu (roasted flour), apupa (pan-cake), dhana (fried barley) and other types of eatables along with jaggery.

Various eatables prepared from the barley or bamboo seed or wheat previously eaten by asses, horses, cows, swans and deer and collected from their dung should be given to the patient suffering from prameha.

Importance of Barley in Diabetes

Charaka gives much emphasis on the use of barley (yava) in prameha. Barley has hypoglycemic effect along with its potent lipid reducing effect and it is best ruksha diet that helps in depleting excess of fat while providing essential energy required for maintaining daily life. Dutch researchers used a crossover study with 10 healthy men to compare the effects of cooked barley kernels and refined wheat bread on blood sugar control. The men ate one or the other of these grains at dinner, then were given a high glycemic index breakfast (50g of glucose) the next morning for breakfast. When they had eaten the barley dinner, the men had 30% better insulin sensitivity the next morning after breakfast6.

Scientists at the Functional Food Centre at Oxford Brookes University in England fed 8 healthy human subjects chapatis (unleavened Indian flatbreads) made with 0 g, 2g, 4g, 6g or 8g of barley beta-glucan fiber. They found that all amounts of barley beta-glucan lowered the glycemic index of the breads, with 4g or more making a significant difference7.

In a crossover study involving 17 obese women at increased risk for insulin resistance, USDA scientists studied the effects of 5 different breakfast cereal test meals on subjects’ insulin response. They found that consumption of 10g of barley beta-glucan significantly reduced insulin response8.

University of Connecticut researchers reviewed 8 studies evaluating the lipid-reducing effects of barley. They found that eating barley significantly lowered total cholesterol, LDL (“bad”) cholesterol, and triglycerides, but did not appear to significantly alter HDL (“good”) cholesterol9.

Barley intake significantly reduced serum cholesterol and visceral fat, both accepted markers of cardiovascular risk10. 25 adults with mildly high cholesterol were fed whole grain foods containing 0g, 3g or 6g of barley beta-glucan per day for five weeks, with blood samples taken twice weekly. Total cholesterol and LDL (“bad”) cholesterol significantly decreased with the addition of barley to the diet11. Thus use of barley is very beneficial in diabetes.

Contemporary management of prameha

Disease management: 1. Wholesome diet 2. Exercise 3. Pacification of dosha

Important medicines: 1. Shilajatu 2. Asana 3. Jambu 4. Yashada 5. Kumbha 6. Haridra 7. Amalaki 8. Tikta rasa

Pacification Treatment

Type	Medicine	Dose	Time	Vehicle
1 Kapha dominant	1. Juice of Bilva leaves	10-20 ml	Between two meals, two times	Milk

Future Scope for Research

1. Fundamental studies to observe link between meda (adipose tissue) and urinary disorders are needed. 2. Searching herbs describe in the chapter for their potential in reducing FFAs and blood glucose level. 3. Clinical studies to evaluate the efficacy of anti-lipidemic drugs and its comparision with hypoglycemic drugs in the management of type-2 diabetes mellitus. 4. Elaborating Urinalysis by adding new parametes like temperature for determing the abnormal physical characteristic of urine in different disease like assessing the presence of ketones in urine by low temperature of urine. 5. Analysis of urine at different stages of diabetes for the assessment of its progression and prognosis.

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