Prameha Nidana

Nidana Sthana Chapter 4. Diagnosis and etiopatheogenesis of Obstinate Urinary Disorders including diabetes

Prameha Nidana

Section/Chapter	Nidana Sthana Chapter 4
Preceding Chapter	Gulma Nidana
Succeeding Chapter	Kushtha Nidana
Other Sections	Sutra Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana
Translator and commentator	Chandola H.M., Kajaria D.
Reviewer	Kar A.C., Byadgi P.S., Sabnis M.
Editors	Khandel S.K., Godatwar P., Deole Y.S., Basisht G.
Year of publication	2020
Publisher	Charak Samhita Research, Training and Skill Development Centre
DOI	10.47468/CSNE.2020.e01.s02.005

Abstract

This chapter describes the disease prameha (group of obstinate urinary disorders including diabetes) as well as its etiopathogenesis, types, clinical features, prognosis, prodromal symptoms, complications, and a line of treatment. Though it is predominantly a kapha dosha disorder, there are variants involving all three doshas and ten dushya (body tissues and other elements). Excessive and turbid urination are the cardinal signs of all prameha. All those urinary and systemic diseases that cause copious quantities, as well as the abnormal (including turbid) quality of urination, come under the umbrella of prameha. This chapter briefly explains the importance of interaction of exogenous factors, endogenous and tissue response factors in the manifestation of the disease. The concept of genetic susceptibility to disease and effect of chronic disease on genes is also incorporated in this chapter.

Keywords: Factors affecting disease pathology, Prameha, diabetes, genetic susceptibility, prabhuta mutrata, polyuria, avila mutrata, turbid urine, vikarabhighata, urinary disorders.

Introduction

The fourth chapter in the Nidana Sthana, dealing with the diagnosis of prameha, follows the diagnosis of gulma disease associated with the mamsa dhatu. Twenty known types of prameha, including diabetes mellitus (madhumeha), have been described here. However, there could be innumerable variations of a disease based on the presence or absence of disease (provoking or mitigating) factors in the body. The manifestation of the disease depends upon the interaction between causative factors, dosha, dushya and the defense mechanism of the body. Some of these factors can also help determine if there could be a delayed or an early onset of the disease, the severity of the disease, etc. Various etiological factors of prameha are described here that lead to vitiation of kapha dosha, meda dhatu, and mutra. A vitiated kapha affects ten fluid-predominant body tissues, resulting in the production of excessive kleda (moisture/excess discharge of body fluids) that, when intermixed with meda (lipid)and mamsa (muscle protein), further vitiates mutra (urine) and results in prameha. A patient afflicted with diabetes mellitus, on an initial visit to the physician, may complain of numbness, tingling, burning sensation in feet, fatigue, dryness of mouth, drowsiness, etc. It is highlighted these signs and symptoms for an early diagnosis and management of prameha. Ten types of curable kaphaja prameha, six variants of yaapya (palliative) and four variants of incurable vataja prameha, totaling twenty types of prameha have been described here in this text. Prodromal symptoms, complications, treatment procedures (enumerated briefly), and some rules (do’s and don’ts) have been included in the course of this chapter.

Sanskrit Text, Transliteration and English Translation

अथातःप्रमेहनिदानंव्याख्यास्यामः||१||

इतिहस्माहभगवानात्रेयः||२|

athātaḥ pramēhanidānaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

AthAtaH Prameha nidAnaM vyAkhyAsyAmaH||1||

iti ha smAha bhagavAn AtreyaH ||2||

Now we shall expound the chapter "Prameha Nidana" (Diagnosis and etiopatheogenesis of Obstinate Urinary Disorders including diabetes). Thus said Lord Atreya. [1-2]

Types of Prameha

त्रिदोषकोपनिमित्ताविंशतिःप्रमेहाभवन्तिविकाराश्चापरेऽपरिसङ्ख्येयाः| तत्रयथात्रिदोषप्रकोपःप्रमेहानभिनिर्वर्तयतितथाऽनुव्याख्यास्यामः||३||

tridōṣakōpanimittā viṁśatiḥ pramēhā bhavanti vikārāścāparē'parisaṅkhyēyāḥ| tatra yathā tridōṣaprakōpaḥ pramēhānabhinirvartayati tathā'nuvyākhyāsyāmaḥ||3||

TridoShakopanimittA viMshatiH pramehA bhavanti vikArAshcApare~aparisa~gkhyeyAH | tatra yathA tridoShaprakopaH pramehAnabhinirvartayati tathA~anuvyAkhyAsyAmaH||3||

Due to vitiation of three dosha, (any of) twenty types of prameha could occur. However, there may be innumerable other variations of the disease. We shall now explain the ways in which vitiation of the three dosha leads to the manifestation of the various types of prameha. [3]

Process of Onset of Disease

इह खलु निदानदोषदूष्यविशेषेभ्यो विकारविघातभावाभाव प्रतिविशेषा भवन्ति| यदाह्येतेत्रयोनिदानादिविशेषाःपरस्परंनानुबध्नन्त्यथवा[१] कालप्रकर्षादबलीयांसोऽथवाऽनुबध्नन्तिनतदाविकाराभिनिर्वृत्तिः, चिराद्वाऽप्यभिनिर्वर्तन्ते, तनवोवाभवन्त्ययथोक्तसर्वलिङ्गावा; विपर्ययेविपरीताः;इतिसर्वविकारविघातभावाभावप्रतिविशेषाभिनिर्वृत्तिहेतुर्भवत्युक्तः||४||

iha khalu nidānadōṣadūṣyaviśēṣēbhyō vikāravighātabhāvābhāvaprativiśēṣā bhavanti| yadā hyētē trayō nidānādiviśēṣāḥ parasparaṁ nānubadhnantyathavā kālaprakarṣādabalīyāṁsō'thavā'nubadhnanti na tadā vikārābhinirvr̥ttiḥ,cirādvā'pyabhinirvartantē, tanavō vā bhavantyayathōktasarvaliṅgā vā; viparyayē viparītāḥ; itisarvavikāravighātabhāvābhāvaprativiśēṣābhinirvr̥ttihēturbhavatyuktaḥ||4||

Iha khalu nidAna doShadUShyavisheShebhyo vikAravighAtabhAvAbhAvaprativisheShA bhavanti| yadA hyete trayo nidAnAdivisheShAH parasparaM nAnubadhnantyathavA kAlaprakarShAdabalIyAMso~athavA~anubadhnantina tadA vikArAbhinirvRuttiH, cirAdvA~apyabhinirvartante, tanavovA bhavantyayathoktasarvali~ggAvA;viparyaye viparItAH; iti sarvavikAravighAtabhAvAbhAvaprativisheShAbhinirvRuttiheturbhavatyuktaH||4||

Here, the specific interaction of etiological factors with doshas and dushyas, as well as the presence or absence of disease-resisting factors (individual’s immunity or ability to resist the disease), influence the outcome regarding the manifestation of a disease (including prameha). Temporal factors (e.g. season) also play a role here. For example, if the interaction of etiological factors, doshas and dushyas are weak and these are antagonistic to each other, and if the influence of temporal factors (time or seasonal influence) are also weak, then either the disease does not manifest, or there is a delay in manifestation of the disease. In such cases, even if there is an onset of the disease, its severity could be low, or all of its signs and symptoms may not manifest. Thus, the presence or absence of specific factors determine the ability or otherwise of the body to resist all types of diseases. [4]

Etiology of Kaphaja Prameha

तत्रेमेत्रयोनिदानादिविशेषाःश्लेष्मनिमित्तानांप्रमेहाणामाश्वभिर्निर्वृत्तिकराभवन्ति; तद्यथा- हायनकयवकचीनकोद्दालकनैषधेत्कटमुकुन्दकमहाव्रीहिप्रमोदकसुगन्धकानां नवानामतिवेलमतिप्रमाणेनचोपयोगः, तथासर्पिष्मतांनवहरेणुमाषसूप्यानां, ग्राम्यानूपौदकानांचमांसानां,शाकतिलपललपिष्टान्नपायसकृशराविलेपीक्षुविकाराणां, क्षीरनवमद्यमन्दकदधिद्रवमधुरतरुणप्रायाणांचोपयोगः, मृजाव्यायामवर्जनं, स्वप्नशयनासनप्रसङ्गः, यश्चकश्चिद्विधिरन्योऽपिश्लेष्ममेदोमूत्रसञ्जननः, ससर्वोनिदानविशेषः||५||

बहुद्रवःश्लेष्मादोषविशेषः||६||

बह्वबद्धं मेदोमांसंशरीरजक्लेदःशुक्रंशोणितंवसामज्जालसीका रसश्चौजःसङ्ख्यातइतिदूष्यविशेषाः||७||

tatrēmē trayō nidānādiviśēṣāḥ ślēṣmanimittānāṁ pramēhāṇāmāśvabhirnirvr̥ttikarā bhavanti; tadyathā-hāyanakayavakacīnakōddālakanaiṣadhētkaṭamukundakamahāvrīhipramōdakasugandhakānāṁ navānāmativēlamatipramāṇēna cōpayōgaḥ, tathā sarpiṣmatāṁnavaharēṇumāṣasūpyānāṁ, grāmyānūpaudakānāṁ ca māṁsānāṁ, śākatilapalalapiṣṭānnapāyasakr̥śarāvilēpīkṣuvikārāṇāṁ,kṣīranavamadyamandakadadhidravamadhurataruṇaprāyāṇāṁ cōpayōgaḥ, mr̥jāvyāyāmavarjanaṁ, svapnaśayanāsanaprasaṅgaḥ, yaśca kaścidvidhiranyō'piślēṣmamēdōmūtrasañjananaḥ, sa sarvō nidānaviśēṣaḥ||5||

bahudravaḥ ślēṣmā dōṣaviśēṣaḥ||6||

bahvabaddhaṁ [2] mēdō māṁsaṁ śarīrajaklēdaḥ śukraṁ śōṇitaṁ vasā majjā lasīkā rasaścaujaḥsaṅkhyāta iti dūṣyaviśēṣāḥ||7||

TatrayonidAnAdivisheShAHshleShmanimittAnAMpramehANAmAshvabhirnirvRuttikarA bhavanti;tadyathAhAyanakayavakacInakoddAlakanaiShadhetkaTamukundakamahAvrIhipramodakasugandhakAnAMnavAnAmativelamatipramANenacopayogaH,
tathAsarpiShmatAM navahareNumAShasUpyAnAM,grAmyAnUpaudakAnAMcamAMsAnAM, shAkatilapalalapiShTAnnapAyasakRusharAvilepIkShuvikArANAM, kShIranavamadyamandakadadhidravamadhurataruNaprAyANAM copayogaH,mRujAvyAyAmavarjanaM,svapnashayanAsanaprasa~ggaH, yashcakashcidvidhiranyo~apishleShmamedomUtrasa~jjananaH,sa sarvonidAnavisheShaH||5||

Bahudrava shleShmA doShavisheShaH ||6||

Bahvabaddham medo mAMsaM sharIrajakledaH shukraM shoNitaM vasA majjA lasIkA rasashcaujaHsa~gkhyAta iti dUShyavisheShAH ||7||

An excessive intake of kapha-vitiating food articles or lifestyle activities contributes to severe manifestations of kaphaja prameha. The following are some of the specific etiological factors for the kaphaja variant of this disease:

• Frequent and excessive intake of:
  • Newly harvested grains like hayanaka, yavaka (a variety of Hordeum vulgare Linn), chinaka, uddalaka,naishadha,itkata, mukundaka, mahavrihi, promodaka, and sugandhaka;
  • Newly harvested pulses like harenu (Pisum sativum Linn.) and masha (Phaseolus radiates Linn.), consumed with ghee;
  • The meat of domesticated, marshy and aquatic animals;
  • Vegetables, tila (Sesamum indicum Linn.) oil, cakes of tila, pastries, payasa (milk-based pudding), krisara (gruel prepared of tila, rice, and black gram), vilepi (a type of thick gruel), and sugarcane-based food preparations;
  • Milk, new wine, immature curd (curd which is mostly liquid and sweet);
  • Various dietary regimen that produces excess kapha, fat, and urine;
• Lifestyle related activities, including
  • Avoidance of physical exercise; and
  • Excessive sleep, bed rest and sedentary habits;

The kapha with excessive fluid component is specific vitiation in prameha. Specific dushyas of prameha include excess abaddha meda (loose fat), mamsa (muscle tissues), vasa (muscle fat), majja (marrow), kleda(body fluids), shukra (semen and reproductive tissues), rakta (blood), lasika (lymph) and rasa (plasma) and ojas (the purest of all dhatu). [5-7]

Pathogenesis

त्रयाणामेषांनिदानादिविशेषाणांसन्निपातेक्षिप्रंश्लेष्माप्रकोपमापद्यते, प्रागतिभूयस्त्वात्; सप्रकुपितःक्षिप्रमेवशरीरेविसृप्तिंलभते, शरीरशैथिल्यात्; सविसर्पञ्शरीरेमेदसैवादितोमिश्रीभावंगच्छति, मेदसश्चैवबह्वबद्धत्वान्मेदसश्चगुणैःसमानगुणभूयिष्ठत्वात्; स मेदसामिश्रीभवन्दूषयत्येनत्, विकृतत्वात्; सविकृतोदुष्टेनमेदसोपहितः शरीरक्लेदमांसाभ्यांसंसर्गंगच्छति, क्लेदमांसयोरतिप्रमाणाभिवृद्धत्वात्; समांसेमांसप्रदोषात्पूतिमांसपिडकाःशराविकाकच्छपिकाद्याःसञ्जनयति,

अप्रकृतिभूतत्वात्; शरीरक्लेदंपुनर्दूषयन्मूत्रत्वेनपरिणमयति, मूत्रवहानांचस्रोतसांवङ्क्षणबस्तिप्रभवाणां[१]मेदःक्लेदोपहितानिगुरूणिमुखान्यासाद्यप्रतिरुध्यते;ततःप्रमेहांस्तेषांस्थैर्यमसाध्यतांवाजनयति, प्रकृतिविकृतिभूतत्वात्||८||

trayāṇāmēṣāṁ nidānādiviśēṣāṇāṁ sannipātē kṣipraṁ ślēṣmā prakōpamāpadyatē, prāgatibhūyastvāt; sa prakupitaḥ kṣipramēva śarīrē visr̥ptiṁ labhatē,śarīraśaithilyāt; sa visarpañ śarīrē mēdasaivāditō miśrībhāvaṁ gacchati, mēdasaścaiva bahvabaddhatvānmēdasaśca guṇaiḥ samānaguṇabhūyiṣṭhatvāt; sa mēdasāmiśrībhavan dūṣayatyēnat, vikr̥tatvāt; sa vikr̥tō duṣṭēna mēdasōpahitaḥ śarīraklēdamāṁsābhyāṁ saṁsargaṁ gacchati, klēdamāṁsayōratipramāṇābhivr̥ddhatvāt; samāṁsē māṁsapradōṣāt pūtimāṁsapiḍakāḥ śarāvikākacchapikādyāḥ sañjanayati, aprakr̥tibhūtatvāt; śarīraklēdaṁ punardūṣayan mūtratvēna pariṇamayati,mūtravahānāṁ ca srōtasāṁ vaṅkṣaṇabastiprabhavāṇāṁ mēdaḥklēdōpahitāni gurūṇi mukhānyāsādya pratirudhyatē; tataḥ pramēhāṁstēṣāṁsthairyamasādhyatāṁ vā janayati, prakr̥tivikr̥tibhūtatvāt||8||

TrayAnAmesaM nidAnAdivisheShANAM sannipAte kShipraM shleShmA prakopamApadyate, prAgatibhUyastvAt; sa prakupitaH kShiprameva sharIre visRuptiM labhate, sharIrashaithilyAt;sa visarpa~j sharIre medasaivAdito mishrIbhAvaM gacchati, medasashcaiva bahvabaddhatvAnmedasashca guNaiH samAnaguNabhUyiShThatvAt;sa medasA mishrIbhavan dUShayatyenat, vikRutatvAt; sa vikRuto duShTena medasopahitaH sharIrakledamAMsAbhyAM saMsargaM gacchati, kledamAMsayoratipramANAbhivRuddhatvAt; sa mAMse Ma MsapradoShAt pUtimA MsapiDakAH sharAvikAkacchapikAdyAH sa~jjanayati, aprakRutibhUtatvAt; sharIrakledaM punardUShayanmUtratvena pariNamayati,mUtravahAnAM ca srotasAM va~gkShaNabastiprabhavANAM medaHkledopahitAni gurUNi mukhAnyAsAdya pratirudhyate; tataH pramehAMsteShAM sthairyamasAdhyatAM vA janayati, prakRutivikRutibhUtatvAt ||8||

Etiological factors (especially kapha-dominant ones), doshas, and dushyas mentioned in the preceding verses can trigger the manifestation of kaphaja prameha. The aggravated kapha spreads all over the body quickly because of flaccid muscles and fatty tissues. The kapha blends quickly with the medas (fat) – primarily because the fats typically are excessive in quantity and viscous and soft in "favorable" body conditions but also because kapha and medas share identical qualities. As kapha itself is vitiated, it vitiates medas in the process. The vitiated kapha - meda then mixes with mamsa (muscle tissues) and kleda (moisture/body fluid), in as much as these two are supposed to have already exceeded their quantity. Vitiation of the muscle tissues provides a congenial atmosphere for the manifestation of putrified carbuncles (pidika) like sharavika and kacchapika in the muscle. The liquid dhatus in the body get further vitiated and transformed into mutra (urine). Vrikka (kidney) and basti (urinary bladder) are at the two ends of the channels carrying urine; the openings of these channels get affected by [[[meda]] (fat) and kleda. The vitiated kapha obstructs the openings of these channels. This results in the manifestation of prameha which becomes chronic or incurable due to the affection of all qualities of kapha and simultaneous vitiation of homogenous and heterogenous dhatus. [8]

Signs, Types, and Prognosis of Kaphaja Prameha

शरीरक्लेदस्तुश्लेष्ममेदोमिश्रःप्रविशन्मूत्राशयंमूत्रत्वमापद्यमानःश्लैष्मिकैरेभिर्दशभिर्गुणैरुपसृज्यतेवैषम्ययुक्तैः; तद्यथा- श्वेतशीतमूर्तपिच्छिलाच्छस्निग्धगुरुमधुरसान्द्रप्रसादमन्दैः,तत्रयेनगुणेनैकेनानेकेनवाभूयस्तरमुपसृज्यतेतत्समाख्यंगौणंनामविशेषंप्राप्नोति||९||

तेतुखल्विमेदशप्रमेहानामविशेषेणभवन्ति; तद्यथा- उदकमेहश्च, इक्षुवालिकारसमेहश्च, सान्द्रमेहश्च, सान्द्रप्रसादमेहश्च, शुक्लमेहश्च, शुक्रमेहश्च,शीतमेहश्च, सिकतामेहश्च, शनैर्मेहश्च, आलालमेहश्चेति||१०||

तेदशप्रमेहाःसाध्याः;समानगुणमेदःस्थानकत्वात्, कफस्यप्राधान्यात्, समक्रियत्वाच्च||११||

śarīraklēdastu ślēṣmamēdōmiśraḥ praviśan mūtrāśayaṁ mūtratvamāpadyamānaḥ ślaiṣmikairēbhirdaśabhirguṇairupasr̥jyatē vaiṣamyayuktaiḥ; tadyathā-śvētaśītamūrtapicchilācchasnigdhagurumadhurasāndraprasādamandaiḥ, tatra yēna guṇēnaikēnānēkēna vā bhūyastaramupasr̥jyatē tatsamākhyaṁ gauṇaṁnāmaviśēṣaṁ prāpnōti||9||

tē tu khalvimē daśa pramēhā nāmaviśēṣēṇa bhavanti; tadyathā- udakamēhaśca, ikṣuvālikārasamēhaśca, sāndramēhaśca, sāndraprasādamēhaśca, śuklamēhaśca,śukramēhaśca, śītamēhaśca, sikatāmēhaśca, śanairmēhaśca, ālālamēhaścēti||10||

tē daśa pramēhāḥ sādhyāḥ; samānaguṇamēdaḥsthānakatvāt, kaphasya prādhānyāt, samakriyatvācca||11||

Sarirakledastu shleShmamedomishraH pravishan mUtrAshayaM mUtratvamApadyamAnaH shlaiShmikairebhirdashabhirguNairupasRujyate vaiShamyayuktaiH; tadyathA shvetashItam UrtapicchilAcchasnigdhagurumadhurasAndraprasAdamandaiH, tatra yena guNenaikenAnekenavA bhUyastaramupasRujyate tatsamAkhyaM gauNaM nAmavisheShaM prApnoti||9||

te tu khalvime dasha pramehA nAmavisheSheNa bhavanti; tadyathA- udakamehashca, ikShuvAlikArasamehashca, sAndramehashca, sAndraprasAdamehashca, shuklamehashca, shukramehashca, shItamehashca, sikatAmehashca, shanairmehashca, AlAlamehashceti||10||

te dasha pramehAH sAdhyAH; samAnaguNamedaHsthAnakatvAt, kaphasya prAdhAnyAt, samakriyatvAcca||11||

Fluids of the body (kleda) along with kapha and medas (fat) enter the vrikka (kidney) and basti (urinary bladder), transforming into mutra (urine). During this process, they acquire the morbid qualities of kapha, viz, white, cold, particulate, slimy, transparent, unctuous, heavy, sweet, dense, clear and slow. The morbid conditions are named after these qualities, one or many of which may dominate the process of pathogenesis.

The ten kaphaja prameha variants are as follows:

1. Udakameha
2. Ikshuvalikarasameha
3. Sandrameha
4. Sandraprasadameha
5. Shuklameha
6. Shukrameha
7. Sheetameha
8. Sikatameha
9. Shanirameha
10. Alalameha

These are curable because:

1. The medas (fat) and kapha have similar properties and loci,
2. The kapha is dominant, and
3. Both medas and kapha are amenable to the same treatment. [9-11]

Specific Features of Types of Kaphaja Prameha

तत्रश्लोकाः श्लेष्मप्रमेहविशेषविज्ञानार्थाभवन्ति-||१२||

अच्छंबहुसितंशीतंनिर्गन्धमुदकोपमम्| श्लेष्मकोपान्नरोमूत्रमुदमेहीप्रमेहति||१३||

अत्यर्थमधुरंशीतमीषत्पिच्छिलमाविलम्| काण्डेक्षुरसमङ्काशंश्लेष्मकोपात्प्रमेहति||१४||

यस्यपर्युषितंमूत्रंसान्द्रीभवतिभाजने| पुरुषंकफकोपेनतमाहुःसान्द्रमेहिनम्||१५||

यस्यसंहन्यतेमूत्रंकिञ्चित्किञ्चित्प्रसीदति| सान्द्रप्रसादमेहीतितमाहुःश्लेष्मकोपतः||१६||

शुक्लंपिष्टनिभंमूत्रमभीक्ष्णंयःप्रमेहति| पुरुषंकफकोपेनतमाहुःशुक्लमेहिनम्||१७||

शुक्राभंशुक्रमिश्रंवामुहुर्मेहतियोनरः| शुक्रमेहिनमाहुस्तंपुरुषंश्लेष्मकोपतः||१८||

अत्यर्थमधुरंशीतंमूत्रंमेहतियोभृशम्| शीतमेहिनमाहुस्तंपुरुषंश्लेष्मकोपतः||१९||

मूर्तान्मूत्रगतान्दोषानणून्मेहतियोनरः| सिकतामेहिनंविद्यात्तंनरंश्लेष्मकोपतः||२०||

मन्दंमन्दमवेगंतुकृच्छ्रंयोमूत्रयेच्छनैः| शनैर्मेहिनमाहुस्तंपुरुषंश्लेष्मकोपतः||२१||

तन्तुबद्धमिवालालंपिच्छिलंयःप्रमेहति| आलालमेहिनंविद्यात्तंनरंश्लेष्मकोपतः||२२||

इत्येतेदशप्रमेहाःश्लेष्मप्रकोपनिमित्ताव्याख्याताभवन्ति||२३||

tatra ślōkāḥ ślēṣmapramēhaviśēṣavijñānārthā bhavanti-||12||

acchaṁ bahu sitaṁ śītaṁ nirgandhamudakōpamam| ślēṣmakōpānnarō mūtramudamēhī pramēhati||13||

atyarthamadhuraṁ śītamīṣatpicchilamāvilam| kāṇḍēkṣurasamaṅkāśaṁ ślēṣmakōpāt pramēhati||14||

yasya paryuṣitaṁ mūtraṁ sāndrībhavati bhājanē| puruṣaṁ kaphakōpēna tamāhuḥ sāndramēhinam||15||

yasya saṁhanyatē mūtraṁ kiñcit kiñcit prasīdati| sāndraprasādamēhīti tamāhuḥ ślēṣmakōpataḥ||16||

śuklaṁ piṣṭanibhaṁ mūtramabhīkṣṇaṁ yaḥ pramēhati| puruṣaṁ kaphakōpēna tamāhuḥ śuklamēhinam||17||

śukrābhaṁ śukramiśraṁ vā muhurmēhati yō naraḥ| śukramēhinamāhustaṁ puruṣaṁ ślēṣmakōpataḥ||18||

atyarthamadhuraṁ śītaṁ mūtraṁ mēhati yō bhr̥śam| śītamēhinamāhustaṁ puruṣaṁ ślēṣmakōpataḥ||19||

mūrtānmūtragatān dōṣānaṇūnmēhati yō naraḥ| sikatāmēhinaṁ vidyāttaṁ naraṁ ślēṣmakōpataḥ||20||

mandaṁ mandamavēgaṁ tu kr̥cchraṁ yō mūtrayēcchanaiḥ| śanairmēhinamāhustaṁ puruṣaṁ ślēṣmakōpataḥ||21||

tantubaddhamivālālaṁ picchilaṁ yaḥ pramēhati| ālālamēhinaṁ vidyāttaṁ naraṁ ślēṣmakōpataḥ||22||

ityētē daśa pramēhāḥ ślēṣmaprakōpanimittā vyākhyātā bhavanti||23||

tatra shlokAH shleShmapramehavisheShavij~jAnArthA bhavanti-||12||

acchaM bahu sitaM shItaM nirgandhamudakopamam| shleShmakopAnnaro mUtramudamehI pramehati||13||

atyarthamadhuraM shItamIShatpicchilamAvilam| kANDekShurasama~gkAshaM shleShmakopAt pramehati||14||

yasya paryuShitaM mUtraM sAndrIbhavati bhAjane| puruShaM kaphakopena tamAhuH sAndramehinam||15||

yasya saMhanyate mUtraM ki~jcit ki~jcit prasIdati| sAndraprasAdamehIti tamAhuH shleShmakopataH||16||

shuklaM piShTanibhaM mUtramabhIkShNaM yaH pramehati| puruShaM kaphakopena tamAhuH shuklamehinam||17||

shukrAbhaM shukramishraM vA muhurmehati yo naraH| shukramehinamAhustaM puruShaM shleShmakopataH||18||

atyarthamadhuraM shItaM mUtraM mehati yo bhRusham| shItamehinamAhustaM puruShaM shleShmakopataH||19||

mUrtAnmUtragatAn doShAnaNUnmehati yo naraH| sikatAmehinaM vidyAttaM naraM shleShmakopataH||20||

mandaM mandamavegaM tu kRucchraM yo mUtrayecchanaiH| shanairmehinamAhustaM puruShaM shleShmakopataH||21||

tantubaddhamivAlAlaM picchilaM yaH pramehati| AlAlamehinaM vidyAttaM naraM shleShmakopataH||22||

ityete dasha pramehAH shleShmaprakopanimittA vyAkhyAtA bhavanti||23||

The specific features of different types of kaphaja prameha are as follows (in verses):

1. In udakameha the individual passes large quantities of water-like urine which is transparent, white, cold and without any smell.
2. In iksuvalikarasameha, the patient passes urine resembling sugarcane juice which is exceedingly sweet, cold, slightly saline, and turbid.
3. In sandrameha, the viscosity of urine of the individual increases when kept overnight.
4. In sandraprasadameha, the urine of the patient become partly viscous and partly clear when kept overnight.
5. In suklameha, the patient passes urine having opaque, white color like that of pasted flour.
6. In shukrameha patient passes semen-like urine or urine mixed with semen.
7. In sheetameha, the patient gets frequent micturition which is exceedingly sweet and cold.
8. In siktameha, vitiated doshas pass with urine in the form of small gravels.
9. In shanirameha, the patient passes small quantity of urine with difficulty and very slowly.
10. In alalameha, the patient passes urine which is phlegm-like and slimy as if full of threads.

Thus, the ten types of prameha due to vitiation of kapha have been explained. [12-23]

Etiology and Types of Pittaja Prameha

उष्णाम्ललवणक्षारकटुकाजीर्णभोजनोपसेविनस्तथाऽतितीक्ष्णातपाग्निसन्तापश्रमक्रोधविषमाहारोपसेविनश्चतथाविधशरीरस्यैवक्षिप्रंपित्तंप्रकोपमापद्यते, तत्तुप्रकुपितंतयैवानुपूर्व्याप्रमेहानिमान्षट्क्षिप्रतरमभिनिर्वर्तयति||२४||

तेषामपितुखलुपित्तगुणविशेषेणैवनामविशेषाभवन्ति; तद्यथा- क्षारमेहश्च, कालमेहश्च, नीलमेहश्च, लोहितमेहश्च, माञ्जिष्ठमेहश्च, हारिद्रमेहश्चेति||२५||

तेषड्भिरेवक्षाराम्ललवणकटुकविस्रोष्णैःपित्तगुणैःपूर्ववद्युक्ताभवन्ति||२६||

uṣṇāmlalavaṇakṣārakaṭukājīrṇabhōjanōpasēvinastathā'titīkṣṇātapāgnisantāpaśrama krōdhaviṣamāhārōpasēvinaśca tathāvidhaśarīrasyaiva kṣipraṁ pittaṁprakōpamāpadyatē, tattu prakupitaṁ tayaivānupūrvyā pramēhānimān ṣaṭ kṣiprataramabhinirvartayati||24||

tēṣāmapi tu khalu pittaguṇaviśēṣēṇaiva nāmaviśēṣā bhavanti; tadyathā- kṣāramēhaśca, kālamēhaśca, nīlamēhaśca, lōhitamēhaśca, māñjiṣṭhamēhaśca,hāridramēhaścēti||25||

tē ṣaḍbhirēva kṣārāmlalavaṇakaṭukavisrōṣṇaiḥ pittaguṇaiḥ pūrvavadyuktā bhavanti||26||

uShNAmlalavaNakShArakaTukAjIrNabhojanopasevinastathA~atitIkShNAtapAgnisantApashrama krodhaviShamAhAropasevinashca tathAvidhasharIrasyaiva kShipraM pittaM prakopamApadyate, tattu prakupitaM tayaivAnupUrvyA pramehAnimAn ShaT kShiprataramabhinirvartayati||24||

teShAmapi tu khalu pittaguNavisheSheNaiva nAmavisheShA bhavanti; tadyathA- kShAramehashca, kAlamehashca, nIlamehashca, lohitamehashca, mA~jjiShThamehashca, hAridramehashceti||25||

te ShaDbhireva kShArAmlalavaNakaTukavisroShNaiH pittaguNaiH pUrvavadyuktA bhavanti||26||

Pitta gets immediately aggravated in an individual whose body is pre-conditioned by abovementioned (verse 5) factors and exposed to factors such as the following:

1. Intake of hot, sour, salty, alkaline and pungent foods;
2. Intake of food before the digestion of the previous meal;
3. Exposure to excessively hot sun, heat of the fire, physical exertion and anger; and
4. Intake of mutually contradictory food articles.

The aggravated pitta following the same pathogenic process (as mentioned for kaphaja prameha) and manifests into one of six types of pittaja prameha. The process of manifestation is quicker than that of kaphaja meha. According to the characteristics of pitta, they are named as follows:

1. Kharameha
2. Kalameha
3. Nilameha
4. Raktameha
5. Manjisthameha
6. Haridrameha

As described in earlier chapters, these variants also manifest due to permutations and combinations of the six qualities of pitta,i.e., alkaline, sour, saline, pungent, hot and having smell like that of raw fish. [24-26]

Specific Features of Types of Pittaja Prameha

सर्वएवतेयाप्याःसंसृष्टदोषमेदःस्थानत्वाद्विरुद्धोपक्रमत्वाच्चेति||२७||

तत्रश्लोकाःपित्तप्रमेहविशेषविज्ञानार्थाभवन्ति-||२८||

गन्धवर्णरसस्पर्शैर्यथाक्षारस्तथाविधम्| पित्तकोपान्नरोमूत्रंक्षारमेहीप्रमेहति||२९||

मसीवर्णमजस्रंयोमूत्रमुष्णंप्रमेहति| पित्तस्यपरिकोपेणतंविद्यात्कालमेहिनम्||३०||

चाषपक्षनिभंमूत्रमम्लंमेहतियोनरः| पित्तस्यपरिकोपेणतंविद्यान्नीलमेहिनम्||३१||

विस्रंलवणमुष्णंचरक्तंमेहतियोनरः| पित्तस्यपरिकोपेणतंविद्याद्रक्तमेहिनम्||३२||

मञ्जिष्ठोदकसङ्काशंभृशंविस्रंप्रमेहति| पित्तस्यपरिकोपात्तंविद्यान्माञ्जिष्ठमेहिनम्||३३||

हरिद्रोदकसङ्काशंकटुकंयःप्रमेहति| पित्तस्यपरिकोपात्तंविद्याद्धारिद्रमेहिनम्||३४||

इत्येतेषट्प्रमेहाःपित्तप्रकोपनिमित्ताव्याख्याताभवन्ति||३५||

sarva ēva tē yāpyāḥ saṁsr̥ṣṭadōṣamēdaḥsthānatvādviruddhōpakramatvāccēti||27||

tatra ślōkāḥ pittapramēhaviśēṣavijñānārthā bhavanti-||28||

gandhavarṇarasasparśairyathā kṣārastathāvidham| pittakōpānnarō mūtraṁ kṣāramēhī pramēhati||29||

masīvarṇamajasraṁ yō mūtramuṣṇaṁ pramēhati| pittasya parikōpēṇa taṁ vidyāt kālamēhinam||30||

cāṣapakṣanibhaṁ mūtramamlaṁ mēhati yō naraḥ| pittasya parikōpēṇa taṁ vidyānnīlamēhinam||31||

visraṁ lavaṇamuṣṇaṁ ca raktaṁ mēhati yō naraḥ| pittasya parikōpēṇa taṁ vidyādraktamēhinam||32||

mañjiṣṭhōdakasaṅkāśaṁ bhr̥śaṁ visraṁ pramēhati| pittasya parikōpāttaṁ vidyānmāñjiṣṭhamēhinam||33||

haridrōdakasaṅkāśaṁ kaṭukaṁ yaḥ pramēhati| pittasya parikōpāttaṁ vidyāddhāridramēhinam||34||

ityētē ṣaṭ pramēhāḥ pittaprakōpanimittā vyākhyātā bhavanti||35||

sarva eva te yApyAH saMsRuShTadoShamedaHsthAnatvAdviruddhopakramatvAcceti||27||

tatra shlokAH pittapramehavisheShavij~jAnArthA bhavanti-||28||

gandhavarNarasasparshairyathA kShArastathAvidham| pittakopAnnaro mUtraM kShAramehI pramehati||29||

masIvarNamajasraM yo mUtramuShNaM pramehati| pittasya parikopeNa taM vidyAt kAlamehinam||30||

cAShapakShanibhaM mUtramamlaM mehati yo naraH| pittasya parikopeNa taM vidyAnnIlamehinam||31||

visraM lavaNamuShNaM ca raktaM mehati yo naraH| pittasya parikopeNa taM vidyAdraktamehinam||32||

ma~jjiShThodakasa~gkAshaM bhRushaM visraM pramehati| pittasya parikopAttaM vidyAnmA~jjiShThamehinam||33||

haridrodakasa~gkAshaM kaTukaM yaH pramehati| pittasya parikopAttaM vidyAddhAridramehinam||34||

ityete ShaT pramehAH pittaprakopanimittA vyAkhyAtA bhavanti||35||

All these types of prameha are palliable (but not fully curable) because the loci of vitiated medas in the pathogenesis of this disease are closer to those of the affected doshas and the treatment of pitta and medas is in mutual contradiction. The specific features of different types of prameha caused by pitta are given below:

1. In ksharameha the patient passes urine having the smell, color, taste and touch similar to those of alkalies.
2. In kalameha the patient passes large quantities of black or dark urine.
3. In nilameha the patient passes urine having sour taste and color like that of the feather of the blue jay.
4. In raktameha the patient passes urine having red color, saline taste and smell like that of raw fish.
5. In manjisthameha the patient passes urine frequently, and the urine smells like raw flesh and looks like the juice of manjistha (Rubia cordifolia Linn.).
6. In haridrameha the patient passes urine having pungent taste and color like that of the juice of haridra (Curcuma longa Linn.).

Thus, six varieties of prameha due to vitiation of pitta are explained. [27-35]

Etio-pathogenesis of Vataja Prameha

कषायकटुतिक्तरूक्षलघुशीतव्यवायव्यायामवमनविरेचनास्थापन-शिरोविरेचनातियोगसन्धारणानशनाभिघातातपोद्वेगशोकशोणितातिषेक- जागरणविषमशरीरन्यासानुपसेवमानस्यतथाविधशरीरस्यैवक्षिप्रंवातः प्रकोपमापद्यते||३६||

सप्रकुपितस्तथाविधेशरीरेविसर्पन्यदावसामादायमूत्रवहानिस्रोतांसिप्रतिपद्यतेतदावसामेहमभिनिर्वर्तयति; यदापुनर्मज्जानंमूत्रबस्तावाकर्षतितदामज्जमेहमभिनिर्वर्तयति; यदातुलसीकांमूत्राशयेऽभिवहन्मूत्रमनुबन्धंच्योतयतिलसीकातिबहुत्वाद्विक्षेपणाच्चवायोःखल्वस्यातिमूत्रप्रवृत्तिसङ्गं[१]करोति, तदासमत्तइवगजःक्षरत्यजस्रंमूत्रमवेगं, तंहस्तिमेहिनमाचक्षते; ओजःपुनर्मधुरस्वभावं, तद्यदारौक्ष्याद्वायुःकषायत्वेनाभिसंसृज्यमूत्राशयेऽभिवहतितदामधुमेहंकरोति||३७||

kaṣāyakaṭutiktarūkṣalaghuśītavyavāyavyāyāmavamanavirēcanāsthāpana-śirōvirēcanātiyōgasandhāraṇānaśanābhighātātapōdvēgaśōkaśōṇitātiṣēka-jāgaraṇaviṣamaśarīranyāsānupasēvamānasya tathāvidhaśarīrasyaiva kṣipraṁ vātaḥ prakōpamāpadyatē||36||

sa prakupitastathāvidhē śarīrē visarpan yadā vasāmādāya mūtravahāni srōtāṁsi pratipadyatē tadā vasāmēhamabhinirvartayati; yadā punarmajjānaṁmūtrabastāvākarṣati tadā majjamēhamabhinirvartayati; yadā tu lasīkāṁ mūtrāśayē'bhivahanmūtramanubandhaṁ cyōtayati lasīkātibahutvādvikṣēpaṇācca vāyōḥkhalvasyātimūtrapravr̥ttisaṅgaṁ [11] karōti, tadā sa matta iva gajaḥ kṣaratyajasraṁ mūtramavēgaṁ, taṁ hastimēhinamācakṣatē; ōjaḥ punarmadhurasvabhāvaṁ, tadyadā raukṣyādvāyuḥ kaṣāyatvēnābhisaṁsr̥jya mūtrāśayē'bhivahati tadā madhumēhaṁ karōti||37||

KaShAyakaTutiktarUkShalaghushItavyavAyavyAyAmavamanavirecan AsthApana shirovirecanAtiyogasandhAraNAnashanAbhighAtAtapodvegashokashoNitAtiSheka- jAgaraNaviShamasharIranyAsAnupasevamAnasya tathAvidhasharIrasyaiva kShipraM vAtaH prakopamApadyate||36||

sa prakupitastathAvidhe sharIre visarpan yadA vasAmAdAya mUtravahAni srotAMsi pratipadyate tadA vasAmehamabhinirvartayati; yadA punarmajjAnaM mUtrabastAvAkarShati tadA majjamehamabhinirvartayati; yadA tu lasIkAM mUtrAshaye~abhivahanmUtramanubandhaM cyotayati lasIkAtibahutvAdvikShepaNAcca vAyoH khalvasyAtimUtrapravRuttisa~ggaM karoti, tadA sa matta iva gajaH kSharatyajasraM mUtramavegaM, taM hastimehinamAcakShate; ojaH punarmadhurasvabhAvaM, tad yadA raukShyAdvAyuH kaShAyatvenAbhisaMsRujya mUtrAshaye~abhivahati tadA madhumehaM karoti||37||

Vata gets immediately aggravated in an individual whose body is pre-conditioned by above mentioned (verse 5) factors and exposed to the following factors:

1. Excessive intake of astringent, pungent, bitter, rough, light and cold things;
2. Excessive indulgence in sex and physical exercise.
3. Excessive administration of emesis, purgations, asthapana type of enema and shirovirechana (elimination of doshas from the head),and
4. Suppression of the manifested urges, fasting, trauma due to assault, exposure to sun, anxiety, grief, excessive bloodletting, staying awake at night, and irregular posture of the body.

The aggravated vata spreads throughout the body, and along with vasa (muscle fat), enters the ureter leading to the manifestation of vasameha. When it carries marrow to the urinary bladder, it results in majjameha.

Due to the large quantity of lasika (lymphs) in the body and also due to the property of vata to dissipate things, lasika entering the urinary bladder produces large quantity of urine, causing a continuous urge for micturition and, thus, passing copious amounts of urine continuously (even) without any pressure, like an elephant (hasti) gone amuck. Thus, this is also known as hastimeha. Ojas is, by nature, of sweet taste. However, its roughness causes vata to convert it into an astringent tasting element. This vata-afflicted ojas, when gets into the urinary bladder, causes madhumeha. [36-37]

Incurability of Vataja Prameha and its Other Characteristics

इमांश्चतुरः प्रमेहान् वातजानसाध्यानाचक्षते भिषजः, महात्ययिकत्वाद्विरुद्धोपक्रमत्वाच्चेति||३८||

तेषामपि पूर्ववद्गुणविशेषेण नामविशेषा भवन्ति; तद्यथा- वसामेहश्च, मज्जमेहश्च, हस्तिमेहश्च, मधुमेहश्चेति||३९||

तत्र श्लोका वातप्रमेहविशेषविज्ञानार्था भवन्ति-||४०||

वसामिश्रं वसाभं वा मुहुर्मेहति यो नरः| वसामेहिनमाहुस्तमसाध्यं वातकोपतः||४१||

मज्जानं सह मूत्रेण मुहुर्मेहति यो नरः| मज्जमेहिनमाहुस्तमसाध्यं वातकोपतः||४२||

हस्ती मत्त इवाजस्रं मूत्रं क्षरति यो भृशम्| हस्तिमेहिनमाहुस्तमसाध्यं वातकोपतः||४३||

कषायमधुरं पाण्डु रूक्षं मेहति यो नरः| वातकोपादसाध्यं तं प्रतीयान्मधुमेहिनम्||४४||

इत्येते चत्वारः प्रमेहा वातप्रकोपनिमित्ता व्याख्याता भवन्ति||४५||

एवं त्रिदोषप्रकोपनिमित्ता विंशतिः प्रमेहा व्याख्याता भवन्ति||४६||

imāṁścaturaḥ pramēhān vātajānasādhyānācakṣatē bhiṣajaḥ, mahātyayikatvādviruddhōpakramatvāccēti||38||

tēṣāmapi pūrvavadguṇaviśēṣēṇa nāmaviśēṣā bhavanti; tadyathā- vasāmēhaśca, majjamēhaśca, hastimēhaśca, madhumēhaścēti||39||

tatra ślōkā vātapramēhaviśēṣavijñānārthā bhavanti-||40||

vasāmiśraṁ vasābhaṁ vā muhurmēhati yō naraḥ| vasāmēhinamāhustamasādhyaṁ vātakōpataḥ||41||

majjānaṁ saha mūtrēṇa muhurmēhati yō naraḥ| majjamēhinamāhustamasādhyaṁ vātakōpataḥ||42||

hastī matta ivājasraṁ mūtraṁ kṣarati yō bhr̥śam| hastimēhinamāhustamasādhyaṁ vātakōpataḥ||43||

kaṣāyamadhuraṁ pāṇḍu rūkṣaṁ mēhati yō naraḥ| vātakōpādasādhyaṁ taṁ pratīyānmadhumēhinam||44||

ityētē catvāraḥ pramēhā vātaprakōpanimittā vyākhyātā bhavanti||45||

ēvaṁ tridōṣaprakōpanimittā viṁśatiḥ pramēhā vyākhyātā bhavanti||46||

imAMshcaturaH pramehAn vAtajAnasAdhyAnAcakShate bhiShajaH, mahAtyayikatvAdviruddhopakramatvAcceti||38||

teShAmapi pUrvavadguNavisheSheNa nAmavisheShA bhavanti; tadyathA- vasAmehashca, majjamehashca, hastimehashca, madhumehashceti||39||

tatra shlokA vAtapramehavisheShavij~jAnArthA bhavanti-||40||

vasAmishraM vasAbhaM vA muhurmehati yo naraH| vasAmehinamAhustamasAdhyaM vAtakopataH||41||

majjAnaM saha mUtreNa muhurmehati yo naraH| majjamehinamAhustamasAdhyaM vAtakopataH||42||

hastI matta ivAjasraM mUtraM kSharati yo bhRusham| hastimehinamAhustamasAdhyaM vAtakopataH||43||

kaShAyamadhuraM pANDu rUkShaM mehati yo naraH| vAtakopAdasAdhyaM taM pratIyAnmadhumehinam||44||

ityete catvAraH pramehA vAtaprakopanimittA vyAkhyAtA bhavanti||45||

evaM tridoShaprakopanimittA viMshatiH pramehA vyAkhyAtA bhavanti||46||

These four types of prameha (vasameha, majjameha, hastimeha, and madhumeha) due to the vitiation of vata are known to be serious conditions and are incurable because of the contradictions involved in their treatment.

As in the case of other pramehas, these variants are also named after the attribute involved in the pathogenesis. Their specific features are as follows:

1. In vasameha, the patient frequently passes urine mixed with vasa or having the appearance of vasa. It is incurable and caused by the aggravation of vata.
2. In majjameha, the patient frequently passes urine mixed with majja. It is incurable and caused by the aggravation of vata.
3. In hastimeha, the patient passes large quantities of urine frequently “like an elephant gone amuck”, as mentioned earlier. It is incurable and caused by the aggravation of vata.
4. In madhumeha, the patient passes urine sweet and astringent in taste, pale in color and ununctuous. It is incurable and caused by the aggravation of vata.

Thus explained are the four variants of vataja prameha and twenty types of prameha (due to vitiation of the three doshas).[38-46]

General Prodromal Features of Prameha

त्रयस्तुखलुदोषाःप्रकुपिताःप्रमेहानभिनिर्वर्तयिष्यन्तइमानि पूर्वरूपाणिदर्शयन्ति; तद्यथा- जटिलीभावंकेशेषु, माधुर्यमास्यस्य, करपादयोःसुप्ततादाहौ, मुखतालुकण्ठशोषं, पिपासाम्, आलस्यं, मलंकाये,कायच्छिद्रेषूपदेहं, परिदाहंसुप्ततांचाङ्गेषु, षट्पदपिपीलिकाभिश्चशरीरमूत्राभिसरणं, मूत्रेचमूत्रदोषान्, विस्रंशरीरगन्धं, निद्रां, तन्द्रांचसर्वकालमिति||४७||

trayastu khalu dōṣāḥ prakupitāḥ pramēhānabhinirvartayiṣyanta imāni pūrvarūpāṇi darśayanti; tadyathā- jaṭilībhāvaṁ kēśēṣu, mādhuryamāsyasya, karapādayōḥsuptatādāhau, mukhatālukaṇṭhaśōṣaṁ, pipāsām, ālasyaṁ, malaṁ kāyē, kāyacchidrēṣūpadēhaṁ, paridāhaṁ suptatāṁ cāṅgēṣu, ṣaṭpadapipīlikābhiścaśarīramūtrābhisaraṇaṁ, mūtrē ca mūtradōṣān, visraṁ śarīragandhaṁ, nidrāṁ, tandrāṁ ca sarvakālamiti||47||

Trayastu khalu doShAH prakupitAH pramehAnabhinirvartayiShyanta imAni pUrvarUpANi darshayanti; tadyathA- jaTilIbhAvaM kesheShu, mAdhuryamAsyasya, karapAdayoH suptatAdAhau, mukhatAlukaNThashoShaM, pipAsAm, AlasyaM, malaM kAye, kAyacchidreShUpadehaM, paridAhaM suptatAM cA~ggeShu, ShaTpadapipIlikAbhishca sharIramUtrAbhisaraNaM, mUtre ca mUtradoShAn, visraM sharIragandhaM, nidrAM, tandrAM ca sarvakAlamiti||47||

The three vitiated doshas, while causing prameha, produce the following prodromal symptoms:

1. Matting of hair;
2. Sweet taste in the mouth;
3. Numbness and burning sensation in hands and feet;
4. Dryness in mouth, palate, and throat;
5. Thirst and laziness;
6. Increased amount of bodily waste excretion from the body sweat pores;
7. Adherence of bodily wastes to the orifices of the body (like ear, eyes, nose and body pores)
8. Burning sensation and numbness in various organs of the body;
9. Attraction of insects and ants to the body and urine;
10. Appearance of turbidity or other abnormalities in the urine;
11. Smell of raw flesh in the urine; and
12. Excessive sleep and continuous drowsiness. [47]

General Complications and Principles of Treatment

उपद्रवास्तुखलुप्रमेहिणांतृष्णातीसारज्वरदाहदौर्बल्यारोचकाविपाकाः पूतिमांसपिडकालजीविद्रध्यादयश्चतत्प्रसङ्गाद्भवन्ति||४८||

तत्रसाध्यान्प्रमेहान्संशोधनोपशमनैर्यथार्हमुपपादयंश्चिकित्सेदिति||४९||

upadravāstu khalu pramēhiṇāṁ tr̥ṣṇātīsārajvaradāhadaurbalyārōcakāvipākāḥ pūtimāṁsapiḍakālajīvidradhyādayaśca tatprasaṅgādbhavanti||48||

tatra sādhyān pramēhān saṁśōdhanōpaśamanairyathārhamupapādayaṁścikitsēditi||49||

UpadravAstu khalu pramehiNAM tRuShNAtIsArajvaradAhadaurbalyArocakAvipAkAH pUtimAMsapiDakAlajIvidradhyAdayashca tatprasa~ggAdbhavanti||48||

tatra sAdhyAn pramehAn saMshodhanopashamanairyathArhamupapAdayaMshcikitsediti||49||

Complications associated with prameha are thirst, diarrhea, fever, burning sensation, weakness, anorexia, and indigestion. Carbuncles that putrify muscle tissues, like alaji and vidradhi, appear during the chronic stage of the disease.

Of all these variants, the curable types of prameha should be treated with the appropriate elimination and alleviation therapies on time. [48-49]

Consequences of Prameha

भवन्तिचात्र- गृध्नुमभ्यवहार्येषुस्नानचङ्क्रमणद्विषम्| प्रमेहःक्षिप्रमभ्येतिनीडद्रुममिवाण्डजः||५०||

मन्दोत्साहमतिस्थूलमतिस्निग्धंमहाशनम्| मृत्युःप्रमेहरूपेणक्षिप्रमादायगच्छति||५१||

यस्त्वाहारंशरीरस्यधातुसाम्यकरंनरः| सेवतेविविधाश्चान्याश्चेष्टाःससुखमश्नुते||५२||

bhavanti cātra- gr̥dhnumabhyavahāryēṣu snānacaṅkramaṇadviṣam| pramēhaḥ kṣipramabhyēti nīḍadrumamivāṇḍajaḥ||50||

mandōtsāhamatisthūlamatisnigdhaṁ mahāśanam| mr̥tyuḥ pramēharūpēṇa kṣipramādāya gacchati||51||

yastvāhāraṁ śarīrasya dhātusāmyakaraṁ naraḥ| sēvatē vividhāścānyāścēṣṭāḥ sa sukhamaśnutē||52||

Bhavanti cAtra- gRudhnumabhyavahAryeShu snAnaca~gkramaNadviSham| pramehaH kShipramabhyeti nIDadrumamivANDajaH||50||

mandotsAhamatisthUlamatisnigdhaM mahAshanam| mRutyuH prameharUpeNa kShipramAdAya gacchati||51||

yastvAhAraM sharIrasya dhAtusAmyakaraM naraH| sevate vividhAshcAnyAshceShTAHsa sukhamashnute||52||

Thus, it can be said: As the birds are attracted towards the trees where their nests are situated, similarly prameha is attracted to people who are gluttonous, who have an aversion to bathing, or who have an aversion to physical exercises. Death immediately comes in the form of prameha to those who are very lethargic and morbidly obese.

The individual who follows a dietary regimen or lifestyle that brings his doshas and dhatus to a state of equilibrium is said to be leading a healthy life. [50-52]

Summary

तत्रश्लोकाः- हेतुर्व्याधिविशेषाणांप्रमेहाणांचकारणम्| दोषधातुसमायोगोरूपंविविधमेवच||५३||

दशश्लेष्मकृतायस्मात्प्रमेहाःषट्चपित्तजाः| यथाचवायुश्चतुरःप्रमेहान्कुरुतेबली||५४||

साध्यासाध्यविशेषाश्चपूर्वरूपाण्युपद्रवाः| प्रमेहाणांनिदानेऽस्मिन्क्रियासूत्रंचभाषितम्||५५||

tatra ślōkāḥ- hēturvyādhiviśēṣāṇāṁ pramēhāṇāṁ ca kāraṇam| dōṣadhātusamāyōgō rūpaṁ vividhamēva ca||53||

daśa ślēṣmakr̥tā yasmāt pramēhāḥ ṣaṭ ca pittajāḥ| yathā ca vāyuścaturaḥ pramēhān kurutē balī||54||

sādhyāsādhyaviśēṣāśca pūrvarūpāṇyupadravāḥ| pramēhāṇāṁ nidānē'smin kriyāsūtraṁ ca bhāṣitam||55||

Tatra shlokAH- heturvyAdhivisheShANAM pramehANAM ca kAraNam| doShadhAtusamAyogo rUpaM vividhameva ca||53||

Dasha shleShmakRutA yasmAt pramehAH ShaT ca pittajAH| yathA ca vAyushcaturaH pramehAn kurute balI||54||

sAdhyAsAdhyavisheShAshca pUrvarUpANyupadravAH| pramehANAM nidAne~asmin kriyAsUtraM ca bhAShitam||55||

To sum up:

In this chapter on the diagnosis of prameha the following topics were discussed:

1. Causative factors of the diseases and those about various types of prameha;
2. Combination of doshas and dhatus;
3. Signs and symptoms (of different types of prameha);
4. The process of manifestation of ten, six and four varieties of prameha caused by kapha, pitta, and vata respectively.
5. Prognosis, premonitory symptoms and complications; and
6. Their line of treatment. [53-55]

इत्यग्निवेशकृतेतन्त्रेचरकप्रतिसंस्कृतेनिदानस्थानेप्रमेहनिदानंनाम चतुर्थोऽध्यायः||४||

ityagnivēśakr̥tē tantrē carakapratisaṁskr̥tē nidānasthānē pramēhanidānaṁ nāma caturthō'dhyāyaḥ||4||

ityagniveshakRute tantre CharakapratisaMskRute nidAnasthAne pramehanidAnaM nAma caturtho~adhyAyaH||4||

Thus, ends the fourth chapter on the diagnosis of prameha.

Tattva Vimarsha (Fundamental Principles)

1. Nidana (etiological factors), dosha, and dushya are three major factors that cause any disease. Besides these, there are temporal influences, pre-existing conditions, genetic predispositions, as well as the presence or absence of resisting factors in the host body that decide the propensity of the affliction of a disease, including prameha.
2. The onset of disease pathology, its severity and progress depend upon the cumulative effect of interaction between above-mentioned factors. If the disease resisting factors in the host body are stronger than the disease provoking factors, then the disease doesn't occur or occurs with less severity or with fewer symptoms. On the contrary, the disease is severe, acute, and fully manifested in the case of stronger disease provoking factors.
3. Prameha is a syndrome and not one disease entity. The manifestation of each of the twenty types of prameha depends upon the dominant dosha, as well as a host of etiological factors and dushya at play. A common theme applicable to all the types, though, is prolonged exposure to the etiological factors (excess consumption of specific dietary articles and a sedentary lifestyle). Genetic predisposition also increases the propensity of an individual getting afflicted with prameha.
4. Prognosis of prameha depends on the quantity and quality of doshas and the resistance capacity of dhatus. If they have similar site and properties, the prognosis is good due to the similarity in treatment principles. If they are dissimilar, the prognosis is bad because of contradiction in treatment principles.
5. Vitiated kapha dosha and meda dhatu form the basis of pathogenesis of prameha. Further, the vitiation of pitta and vata dosha is observed as per their etiological factors to manifest respective types.
6. The excessive abaddha meda (loose fat), mamsa (muscle proteins), kleda (body fluids), shukra (reproductive tissues), shonita (blood), vasa (muscle fats), majja (bone marrow), rasa (body fluid with plasma), ojas (vital essence of all tissues) are important factors involved in pathogenesis of prameha. Hence the treatment is targeted to correct the imbalances in these tissue components.
7. To treat prameha, the above mentioned factors with the loci in urinary system of the bladder, kidneys shall be treated well.
8. The quality and specific characteristics observed in urine are biomarkers in diagnosis and assessment of prameha.

Vidhi Vimarsha (Applied Inferences)

The process of onset of disease

Nidana, dosha, and dushya are the inherent factors involved in the pathogenesis of diseases. In addition to these inherent factors, the host also has antibodies and disease resisting factors in him. If the resisting factors are weak and kala, or temporal influences (seasonal variations, age), are strong enough for the inherent causes of the disease, then the disease will be severe with complications and rapid progression. If all the four factors (i.e., nidana, dosha, dushya, and kala) are not strong enough then any of the following manifestations may occur:

1. No disease
2. Delayed onset
3. Mild
4. A few signs and symptoms present.

In this chapter, the importance of exogenous (disease causative agents/pathogens), endogenous (deranged body defense mechanism) factors and tissue response in the development of the disease is emphasized. The disease appears either when the exogenous factor (pathogen) is strong enough to overcome the defense mechanism of the body or when the tissue response to exogenous factors or adaptive responses to foreign agents is deranged.

The etymology of prameha

In Sanskrit, the word mih (from which meha is derived) denotes water, to wet, and to emit semen. Regarding the above explanation, we can easily postulate that the disease prameha resulted because of an excessive excretion of something (ati-pravrittija). Prameha comprises of all those diseases that cause clinical abnormalities in urine due to derangement of metabolism at the level of tissues (dhatvagnimandya).

The scope of prameha

Prameha is a complex syndrome encompassing obesity, metabolic syndrome, diabetes insipidus, alkaptonuria, hemoglobinuria, lipiduria, diabetes mellitus and more. At the gross level, prameha is considered an endocrinal and metabolic disorder. Classification of prameha as sahaja (hereditary) and apathyanimittaja (acquired) favors the correlation of madhumeha as diabetes mellitus. The pathological foci of the disease lie in the kidney (vrikka) causing the destruction of nephrons (srotomukh pratirudhyante).

The classification of prameha on the basis of onset as sahaja/jataja pramehi madhumehi (hereditary) and apathyanimittaja pramehi (acquired) could be considered analogous to the classification of diabetes conditions as congenital/ Type-I, insulin dependent diabetes mellitus (IDDM) and acquired/ Type-II, non insulin-dependent diabetes mellitus (NIDDM) respectively.

Considering the pathogenesis, two types of prameha patients are as given below:

Sahaja prameha/ jatah pramehi (hereditary)

In Ayurveda, the words sahaja and jatah indicate genetic predisposition to the disease.

Broadly, in hereditary diseases there may be two contributing factors:

1. A certain defect in the sperm and ovum (referred to as bija dosha) results in a genetic disorder or genetic predisposition to disease. Regarding prameha, Charak Samhita mentions that excessive indulgence in madhura rasa (foods/ drinks with a sweet taste) by the parents is the chief cause of this chromosomal damage to the sperm and ovum.
2. An intrauterine environment that negatively affects the development of the fetus due to the mother’s diet, lifestyle, or adverse psychological state during pregnancy. This congenital aspect can trigger the disease process for which there is a genetic predisposition. Regarding prameha, the overindulgence of madhura rasa by the mother during pregnancy is likely to trigger prameha.

The diet, lifestyle, and adverse psychological state of the mother during lactation (and only during the stage of pregnancy)may also play a decisive role in precipitating prameha in the infants. In addition, excessive intake of madhura rasa during childhood can contribute to the onset of prameha in children who are genetically predisposed. Thus, hereditary predisposition and unwholesome dietary and lifestyle choices, especially excessive intake of madhura rasa, can play a combined role to cause hereditary prameha. The description of sahaja prameha in Sushruta Samhita and jatah prameha in Charak Samhita are quite similar to that of type-I diabetes (also known as insulin- dependent diabetes mellitus or juvenile- onset diabetes). Jatah pramehi madhumehino, as defined in Charak Samhita, correlates with type-I diabetes beginning in early childhood.

Apathyanimittaja prameha (acquired)

The acquired form of prameha (apathyanimittaja pramehi), in contrast, is a lifestyle condition caused due to sedentary, or inactive living, and psychologic factors include depression and stress.

The description of apathyanimittaja prameha in Sushruta Samhita is very similar to that of type-II diabetes. The types of food and drink likely to precipitate this disease have been enumerated in all the classical Ayurvedic texts . These are briefly listed below, along with lifestyle factors and psychological factors that lead to the onset of prameha

1. Dietary factors: Excessive intake of yogurt, meat of aquatic animals, milk, new grains, food/drinks containing sugar and jaggery (an unrefined form of cane sugar), cold foods, sweet foods, liquid foods, foods that are heavy to digest, and slimy foods.
2. Lifestyle factors: Sedentary lifestyle, excessive sitting, excessive sleeping, sleeping during the daytime, lack of exercise, and laziness.
3. Psychological factors: Disturbance in mental health caused by extremes of psyche such as vishada(depression) and bipolar disorder.

All types of prameha ultimately morph into madhumeha which is incurable. From the standpoint of its pathology and clinical manifestation, madhumeha can be correlated with diabetes mellitus. Certain forms of kaphaja prameha could be considered to be very similar (if not identical) to maturity onset diabetes (MODY) or type -II diabetes or NIDDM. Udakameha is analogous to diabetes insipidus, while certain pittaja prameha relate to urinary tract infection and glomerulonephritis relates to diabetes and its complications (diabetic patients are more prone to developing UTI due to deranged immunity).

All the twenty types of prameha should be considered as distinct disorders. For example, kalameha can be considered as an alkaptonuria-a disease of tyrosine and phenylalanine metabolism. Vasameha can be considered as lipiduria (as in nephrotic syndrome).

Causative factors of prameha/diabetes mellitus

Type I Diabetes

Type-I diabetes is a multi-genomic disease and heredity plays an important role in determining an individual’s predisposition to it. Secondly, type-I diabetes is an autoimmune disease in which insulin itself could trigger an attack on beta cells by white blood cells (T-cells). Finally, there are environmental factors such as foods, viruses and toxins that could trigger an early onset of the disease.

Type II Diabetes

Food articles that are high in saturated fats, including dairy products (especially whole-milk products like cream and full-fat yogurt), red meat and meat juice (mamsarasa) are known to increase the probability of contracting type II diabetes. High saturated fats lead to increase in adipose tissue secretory factors (ATSF), or resistine, that cause insulin resistance.

Another important causative factor for type-II diabetes is an inactive/sedentary lifestyle. According to a World Bank report, almost 10% of all deaths reported worldwide in 2008 could be attribute to inactivity, due largely to four major diseases, including type II diabetes. ,

Jaggery and jaggery products including sugar (gudavaikritum)

A study published in the International Journal of Diabetes in Developing Countries showed that jaggery and sugar have nearly the same glycemic values. This means that when consumed, both raise blood glucose levels by approximately equal values. The only difference is that the release of glucose from jaggery is comparatively slower than sugar as it is a complex sucrose which takes longer to break down. (Note: Glycemic Index is a unit which measures the amount of glucose released into the blood by a food source. Foods which release more glucose into the blood will have a high Glycemic Index value and vice versa.)

The classification of prameha

Classification by Dosha/Stage of Progression

As for all other disease systems described in Ayurvedic texts, prameha has been classified according to the predominant dosha in the disease process. Ayurveda describes three distinct categories of prameha by dosha, i.e., kaphaja, pittaja, and vataja prameha . However, it is important to note here that the dominance of a dosha varies as the disease progresses. In the initial stage, kapha is in excess, which vitiates meda and kleda causing kaphaja prameha.

Further progression results in the loss (or kshaya) of kapha. Pitta then predominates, which vitiates the blood (rakta), precipitating pittaja prameha. Further progression results in loss of pitta. This leads to vitiation of vata, which weans the body of vital substances/vital essence through urine, precipitating vataja prameha. Charak says that any of these three types of prameha can be precipitated directly, depending upon genetic predisposition and improper diet and lifestyle.

Correlating the doshic classification of prameha with the etiology, kaphaja and pittaja prameha are always apathyanimittaja prameha (acquired), while vataja prameha can be hereditary or acquired. If kaphaja and pittaja prameha are not managed properly, in due course of time they lead to madhumeha (a subtype of vataja prameha), which is a terminal stage of the disease and is said to be incurable. This disease can be equated with the terminal stage of type 2 diabetes, which progresses to insulin- dependent diabetes. It has been observed that in the pittaja stage of prameha, there is a tendency toward moderate hyperglycemia, which may be due to increased adrenal medullary and cortical activities. In vataja prameha, there may be severe hyperglycemia with hypoinsulinemia.

As mentioned earlier, prameha can be correlated with obesity, metabolic syndrome, and diabetes mellitus. The early manifestation of the disease process in these conditions is characterized by lipid, carbohydrate, and protein metabolism disturbances accompanied by glycosuria, proteinuria, etc., which can be equates with a kaphaja condition (i.e., which can be easily controlled and cured. Pittaja prameha can be correlated with the inflammatory conditions accompanied with diabetes like urinary tract infection and diabetic ketoacidosis. The advanced stage of disease, with metabolic disturbances associated with loss of immunity, correlates with type 2 diabetes that has progressed to insulin dependent diabetes, and correlates with the hereditary form of type 1 diabetes, which both correlate with vataja prameha. Both of these forms are incurable as described by Charak.

Prameha classified according to physique

Charak Samhita has classified the patients of prameha into two main categories on the basis of their body constitution with regard to physique::

1. Sthula pramehi refers to obese diabetic patients and corresponds to individuals with Type 2 diabetes, and
2. Krisha pramehi refers to asthenic diabetic patients and corresponds to krisha pramehi corresponds to patients with Type-I diabetes.

Research shows that sedentary lifestyle, coupled with an excessive intake of sugar-rich substances lead to a build up of toxins that could be equated to ama (or toxins resulting from improperly digested food and metabolic products). This ama then leads to the formation of meda (fat). When this resultant meda is also coupled with vitiated doshas (primarily, kapha and vata), and agni (the digestive processes), it provides for a conducive ground for the causation of prameha.

Modern scientific research also correlates insulin resistance with obesity, where insulin resistance increases with weight gain and reduces with weight loss. Hormones such as resistin (derived from adipose tissues) provide for a direct link between obesity and diabetes, as they cause insulin resistance.

In Ayurveda, much emphasis has been given to the role of meda in the pathogenesis of prameha. However, its role is not only as a dushya (disturbed functioning of the dhatus), but something more than that. Bahudrava shleshma (kapha that contains too much liquid) joins and affects meda, causing it to become abadha (unobstructed or fluid) in nature. This form of meda has been described to have an effect on mamsa (muscle tissue), thereby increasing the volume of body fluid. This has been described as sharira- kleda (body fluid). This route of pathogenesis for prameha is closely related to obesity.

Samprapti (pathogenesis) of prameha

The scientific utility of this chapter lies in the fact that in prameha the vitiated kapha first vitiates meda dhatu followed by mamsa and other dushya and then finally vitiates mutra to manifest as prameha. This signifies that hyperglycemia is preceded by dyslipidiemias. One more interesting fact is that the main culprit of the disease i.e. kapha is inherently denatured, means it loses its natural properties due to hereditary defect what we know today as genetic susceptability. Furthermore, it is added that if a disease appeared due to genetic default, then it is incurable. A step ahead from the present contemporary knowledge, it is mentioned that as genetic modulation can cause disease similarly a chronic disease can cause gene modulation and vice-versa.

Various dushyas involved in the pathogenesis

Meda dhatu

Meda vitiation is common and dominant dushya in the pathogenesis of madhumeha. Kapha and meda both have close resemblance in regard to functions as well as in regard to qualitative parameters. Both get vitiated more or less by same etiological factors. In madhumeha vitiation of meda results by two ways:

1. Qualitative: Abaddha (loose): The normal function of meda is to produce unctousness in the body along with drudhatva (compactness). This abadhatva (looseness) causes derangement in the structure of meda producing shaithilya (flabbiness) in the body this can be well correlated with FFA excess.
2. Quantitative: Bahu(excess): Here in the pathogenesis, meda is in excess quantity. This meda dhatu is aparipakva (immature). It obstructs the path of vayu along with kapha. This provoked vata increases the agni, so patient eats more and more food causing excessive deposition of aparipakva meda. This in turns causes severe depletion of the other dhatus and produces various sign and symptoms.

Excess of fat in the body get converted into FFA and is utilized in energy metabolism especially in the muscles causing retention of glucose in the blood. Increased appetite in medoroga is due to increased body demand, which is explained to be due to hyperinsulinism or increased secretion of growth hormone. Diabetes has been compared with the fasting state of the body, ketosis is nothing else but the advanced fasting stage of the body, so the deleterious effect of long fast specially in the patient of obesity is same as in diabetic stage.

Mamsa dhatu

It is one of the main dushyas (vitiating factors) described by Charak in regards to prameha. He narrated it especially in kaphaja prameha and avaranjanya madhumeha. Mamsa and Kapha possess similar qualities and both give strength to the body. When vitiated, mamsa loses its normal consistency and develops shaithilya and provide space in between for the accumulation of morbid matter. That in turn results in putimamsa pidika. [Cha.Sa.Nidana Sthana 4/8] Mamsa dushti can be compared to deranged protein metabolism which is an integral part of diabetes mellitus. Research studies have found that glucocorticoid activities and acidosis stimulates protein and amino acid catabolism . Amino acids breakdown in liver results in increased production of urea and these free amino acids can be compared with abaddha mamsa. Putimamsa and pidaka are the morbid states of mamsa dhatu. Two major changes take place in mamsa dhatu - protein degradation and reduction in its blood supply, both of which along with elevated blood sugar level form a favorable media for the growth and multiplication of microorganisms. The results are putrefaction and evolution of multiple septic foci in mamsa dhatu. Diminished protein synthesis hampers the healing process and these complications adopt chronic course.

Majja dhatu

Majja dhatu is not vitiated to maximum extent but vata causes its kshaya i.e. depletion. Thus vitiated majja produces symptoms like netragaurava (heaviness in eyes), angagaurava(heaviness in body) in patient of madhumeha. The ketone bodies production due to excessive utilization of fat may be referred to dushti of vasa and majja. Murchcha (temporary loss of consciousness) occurs due to dushti of majja in diabetes mellitus. The condition of hyperglycemic coma is characterized by the accumulation of ketone bodies.

Shukra

Shukra also get vitiated in the pathogenesis and produces symptoms like daurbalya (fatigue) and krichavyavayata (difficulty in sexual intercourse), because normal functions of shukra is to maintain dehabala. It also plays role in the precipitation of sahaja (genetic) prameha. Sexual impotency and testicular hypofuctions have been reported in diabetes mellitus.

Ojas

Ojas as dushya is mainly involved in vataja prameha i.e. ojomeha (madhumeha). The symptoms of ojakshaya manifests, like gurugatrata (heaviness in body), nidra (sleepiness), tandra (drowsiness) and daurbalya (fatigue) can be correlated with immunocompromised stage in diabetes mellitus due to deranged immunity.

Kleda

This is one of the body components mainly involved in the pathogenesis. The literary meanings of kleda are wetness, moisture and dumpness etc. The physiology of kleda is mainly related with mutra and sweda along with meda. Thus, when kleda is involved then it directly affects the above factors. In normal physiology mutra and sweda maintain the balance of kleda. Especially sweda holds it in the body and mutra gets excreted out of the body according to the body condition and requirement. If kleda gets vitiated it directly affects the physiology of mutra and sweda and disrupts the assemblage of bodily elements causing shaithilya. Thus, the symptoms manifest due to kleda vitiation are prabhutamutrata (polyuria), swedavrddhi (increased sweating), shaithilya (weakness), daurgandhya (bad smell) and avilamutrata (polyuria).

The glycosuria raises the osmolar concentration of the urine and osmotic diuresis resulting in water and sodium loss along with potassium leads to generalized weakness in the patient of diabetes mellitus. The level of catecholamines is increased in DM causes excessive sweating that further leads to loss of electrolytes such as sodium and chlorides through the skin. The whole phenomenon described under kleda can be correlated with water and electrolyte imbalance.

Vasa

Charak described it as a subtype of vatajaprameha i.e. vasameha. Vasa is the upadhatu (minor tissue or sub-tissue) of mamsa and the unctuousness present in the mamsa dhatu is called vasa.

Lasika

This is one of the liquid component present just beneath the skin. Lasika also get vitiated by vata resulting lasikameha. There is no direct reference related to vasa and lasika dushti.

Exclusion of asthi as a dushya

Among the ten dushyas of prameha, asthi (bone) is not included. According to modern physiology, bone is a tissue that undergoes frequent remodeling and has a large capacity for regeneration. In the adult remodeling occurs so that the skeleton is replaced approximately every 10–11 yr. This physiological remodeling is initiated by osteoclasts that re-absorb bone and is followed by the formation of an equivalent amount of new bone by osteoblasts, bone loss is noted when the amount of bone resorption exceeds the amount of new bone formation.

Diabetes has also been associated with a net loss of bone. A number of studies have reported that type 1 diabetes alters bone remodeling by reducing the formation of new bone, leading to osteopenia. This has been shown by a decrease in bone mineral density in humans and alterations in the formation of new bone in animal studies . In contrast, the presence of bone loss in type 2 diabetes is less clear, and current understanding suggests that this form of diabetes is not typically associated with osteopenia . The reasons for the lower bone mineral density in type 1 diabetes are not known.

Vataja prameha vis a vis type 1 diabetes mellitus

The pathogenesis of vataja prameha is similar to that of type-1 diabetes mellitus. Vata is agitated due to various precipitating causes acts on the body in such a way that there is passage of vasa (fat), majja (bone marrow), lasika (lymph), and ojas (essence of the body /immune substances / vitality) through the urine. This condition indicates impaired renal function as a result of diabetes, leading to a dire prognosis. Due to dhatukshaya (loss of body tissues) the patient become very weak and emaciated.

Charak Samhita deals with very specific pathogenesis for madhumeha, which is a subtype of vataja prameha. When an individual excessively consumes the foods that cause prameha, [kapha]] and pitta become vitiated, then adipose tissues and muscle tissuses become disturbed and causes impaired functioning of vata. Subsequently vata gets vitiated and extends to urinary bladder along with ojas, resulting in ojas being expelled in the urine. In Ayurveda, ojas is considered vital to the maintanence of health; its loss in prameha leads to many complications, including prameha pidika (boils and carbuncles). This advanced condition is comparable to non-insulin –dependent type -2 diabetes progressing into insulin dependent diabetes. It is the stage of diabetes in which there are complications, including nephropathy, which result in vital substances of the body being excreted through urine.

Among patients with significant proteinuria, the degeneration of cells within epithelial casts may result in a characteristic "Maltese Cross" appearance and a fatty cast. These droplets are composed of cholesterol esters and cholesterol, which may also be observed free in the urine. This may be correlated with vasameha (lipiduria). Majjameha can be correlated with appearance of waxy casts in urine in advanced renal failure. Waxy cast are thought to be the last stage of the degeneration of a granular cast. Since this degenerative process is probably slow, it is most likely observed in nephrons with much diminished flow. Waxy casts are therefore most consistent with the presence of advanced renal failure.

Hastimeha can be correlated with polyuria in diabetic ketoacidosis due to osmotic dieresis and electrolyte imbalance. Insidious increased thirst (i.e. polydipsia) and urination (i.e. polyuria) are the most common early symptoms of diabetic ketoacidosis (DKA).

Poorvarupa (prodromal symptoms) of prameha

For prameha, these symptoms include excessive sweat, body odor, laziness, inclination towards rest, presence of excessive malas (waste products) in the eyes, ears, teeth, throat, palate, and tongue (buccal cavity), excessive growth of hair and nails, matting of the hair, excessive thirst, a sweet taste in the mouth, a burning sensation in the hand and feet, attraction of insect and ants toward the body and urine, and so on. Diabetes has close relationship to conditions within the oral cavity. It leads to adverse changes in gums and periodontal tissues: effects that may be evident even before clinical diabetes is recognized and diagnosed. Periodontal diseases are associated with higher levels of insulin resistance and are often a precursor of type 2 diabetes as well as with the higher levels of glycated hemoglobin. These findings may relate to the prodromal symptoms of excessive excretion of malas in the buccal cavity. A sweet taste in the mouth is a prodromal symptom that may be explained by the presence of glucose of saliva. If blood glucose levels are high, glucose is also present in the saliva, which can increase cavities and increase the risk of oral candidiasis.

A burning sensation in the hands and feet is an important feature of neuropathy that results from diabetes mellitus. Excessive sweat as a consequence of obesity may result in bacterial growth that leads to body odor. Excessive thirst may be directly related to disturbed glucose metabolism. Thus, the symptoms described in the poorvarupa of prameha include prediabetic symptoms and the early manifestation (vascular changes, obesity, etc.) of diabetes or subclinical diabetes.

The role of meda (fat/adipose tissues) is of great importance in the pathogenesis of prameha. Its role is not as dushya (disturbed functioning of the dhatus), but something more than that. According to Charak Samhita, bahudrava shleshma (kapha that contains too much liquid) joins and affects meda, causing it to become abaddha (unobstructed or fluid) in Ayurveda. This has been described as sharira-kleda (body of fluid) in Ayurveda. Thus, excess water in the blood causes increased diuresis. It is very important to elaborate the term bahudrava shlesma. Shleshma/ kapha is one among the three basic humors regulating all physiological and psychological process in the living organism. At its normal state, it causes binding of body tissues i.e. maintain the tissues integrity, represent the normal cell mediated immunity etc. Bahudrava means that kapha loses its natural properties and get vitiated, it is important to mention here that this derangement may be acquired or congenital, Whatever may be the cause this vitiated kapha, it is unable to perform its normal functions. Describing the physical properties of kapha it is mentioned that it is unctuous in touch and looks like ghrita (ghee). Thus, it can be said that [kapha]] in body represents lipid components of the body and vitiated kapha can be correlated with dyslipidemia. Role of dyslipidemia and metabolic abnormalities in the pathogenesis of diabetes is very obvious and well elaborated in modern medicine. Among the metabolic abnormalities that commonly accompany diabetes are disturbances in the production and clearance of plasma lipoproteins. Moreover, development of dyslipidemia may be a harbinger of future diabetes. A characteristic pattern, termed diabetic dyslipidemia, consists of low high density lipoprotein (HDL), increased triglycerides, and postprandial lipemia. This pattern is most frequently seen in type 2 diabetes and may be a treatable risk factor for subsequent cardiovascular disease.

Causes of lipoprotein abnormalities in diabetes

Defects in insulin action and hyperglycemia could lead to changes in plasma lipoproteins in patients with diabetes. Alternatively, especially in the case of type 2 diabetes, the obesity/insulin-resistant metabolic disarray that is at the root of this form of diabetes could, itself, lead to lipid abnormalities exclusive of hyperglycemia.

The lipoprotein abnormalities commonly present in type 2 diabetes, previously termed noninsulin-dependent diabetes mellitus, include hypertriglyceridemia and reduced plasma HDL cholesterol. In addition, low density lipoprotein (LDL) are converted to smaller, perhaps more atherogenic, lipoproteins termed small dense LDL. In contrast to type 1 diabetes, this phenotype is not usually fully corrected with glycemic control. Moreover, this dyslipidemia often is found in prediabetics, patients with insulin resistance but normal indexes of plasma glucose. Therefore, abnormalities in insulin action and not hyperglycemia per se are associated with this lipid abnormality. Several factors are likely to be responsible for diabetic dyslipidemia: insulin effects on liver apoprotein production, regulation of lipoprotein lipase (LpL), actions of cholesteryl ester transfer protein (CETP), and peripheral actions of insulin on adipose and muscle.

Different colors of Urine

White

• Phosphaturia is usually intermittent, occurring following a meal or after ingesting a large quantity of milk.
• Pyuria (abundant white blood cells) in association with an infection of the urinary tract.
• White cloudy urine can rarely be due to chyluria (lymph fluid), resulting from a communication with between the lymphatic system and the urinary tract.

Red / Pink

• The presence of red cells, free hemoglobin (from broken down red blood cells), or myoglobin (from broken down muscle cells)
• Hemoglobinuria - urinary tract infection, urinary stone, or urinary malignancy.

Blue / Green

• An inherited form of high calcium (called "familial hypercalcemia") can result in blue urine, which has lent this disease the nickname "blue diaper syndrome". Another metabolic disorder, indicanuria, can cause blue urine due to tryptophan indole metabolites.

Brown /Black

• Melanin and melanogen, found in the urine of patients with melanoma, will darken standing urine from the air-exposed surface downward.
• Alcaptonia, a rare hereditary disease, the urine will turn dark after being exposed to the air over a period of time due to the presence of homogentisic acid.
• Urinary hydroxyphenylpyruvic acid excretion due the metabolic disorder tyrosinosis will also cause urine to be brown-black in color.
• In porphyria cutanea tarda, the urine will appear reddish brown in natural light but fluoresces pink under ultraviolet light.

Prognosis

On the basis of prognosis, patients of prameha have been classified into three groups: Sadhya (curable), Yapya (controllable), and Asadhya (difficult to manage).

Features of Prameha Classified on the Basis of Prognosis

	Sadhya(curable)	Yapya(controllable)	Asadhya(difficult to manage)
Dosha predominance Body constitution according to physique	Kaphaja Obese	Pittaja	Vataja Asthenic
Etiology	Acquired	Acquired	Hereditary (type-1 diabetes) Acquired (advanced, insulindependent stage of type-2diabetes)
Stage of disease process	Early/ without complications	Acute/ young adults	Chronic/ advanced with complications
Clinical manifestation	Mild hyperglycemia due to disturbed carbohydrate and fatty acid metabolism Hyperinsulinemia	Moderate hyperglycemia due to hyperadrenalism	Severe hyperglycemia due to hypoinsulinemia

Future Scope for Research

1. Assessment criteria for the classification of various types of Prameha based on both physical as well as laboratory parameters.
2. Scaling the Prameha on the basis of modern investing tools so that the management can be done on the basis of classification.
3. Comparison of Purvarupa (prodromal signs & symptoms) of Prameha with that of Pre-diabetic stage of diabetes and establishing the laboratory parameters for its diagnosis so that Diabetes can be successfully prevented.
4. Searching Genes common for Diabetes and Dyslipididemia and collecting data of prevalence of diabetes associated with dyslipidemia.
5. Collecting data to search the most prevalent type of dyslipidemia in diabetes.
6. Retroprospective clinical study to establish the fact that dyslipidemia is the cause of diabetes and not the consequence of diabetes.

Related Chapters

• Prameha Chikitsa
• Kiyanta Shiraseeya Adhyaya

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