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|title=Prameha Nidana

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|keywords=Factors affecting disease pathology, Prameha, diabetes, genetic susceptibility, prabhuta mutrata, polyuria, avila mutrata, turbid urine, vikarabhighata, urinary disorders, charak samhita, ayurveda

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

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

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<big>'''Nidana Sthana Chapter 4. Diagnosis and etiopatheogenesis of Obstinate Urinary Disorders including diabetes '''</big>

<big>'''Nidana Sthana Chapter 4. Diagnosis and etiopatheogenesis of Obstinate Urinary Disorders including diabetes '''</big>

{{Infobox

{{Infobox

|title = Prameha Nidana

|title = Prameha Nidana

|label4 = Other Sections

|label4 = Other Sections

|data4 = [[Sutra Sthana]], [[Vimana Sthana]],  [[Sharira Sthana]],  [[Indriya Sthana]], [[Chikitsa Sthana]], [[Kalpa Sthana]], [[Siddhi Sthana]]

|data4 = [[Sutra Sthana]], [[Vimana Sthana]],  [[Sharira Sthana]],  [[Indriya Sthana]], [[Chikitsa Sthana]], [[Kalpa Sthana]], [[Siddhi Sthana]]

== Introduction ==

== Introduction ==

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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, meda,'' 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.

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.

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==Sanskrit Text, Transliteration and English Translation==

==Sanskrit Text, Transliteration and English Translation==

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

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'' ===

=== Types of Prameha ===

 

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Due to vitiation of three ''doshas'', (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 ''doshas'' leads to the manifestation of the various types of ''prameha''. [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]

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=== Process of Onset of Disease ===

=== Process of Onset of Disease ===

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इहखलुनिदानदोषदूष्यविशेषेभ्योविकारविघातभावाभावप्रतिविशेषाभवन्ति|

इह खलु निदानदोषदूष्यविशेषेभ्यो विकारविघातभावाभाव प्रतिविशेषा भवन्ति|

यदाह्येतेत्रयोनिदानादिविशेषाःपरस्परंनानुबध्नन्त्यथवा[१]

यदाह्येतेत्रयोनिदानादिविशेषाःपरस्परंनानुबध्नन्त्यथवा[१]

कालप्रकर्षादबलीयांसोऽथवाऽनुबध्नन्तिनतदाविकाराभिनिर्वृत्तिः,  

कालप्रकर्षादबलीयांसोऽथवाऽनुबध्नन्तिनतदाविकाराभिनिर्वृत्तिः,  

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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.  

Here, the specific interaction of etiological factors with ''[[dosha]]s'' and ''[[dushya]]s'', 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, ''[[dosha]]s'' and ''[[dushya]]s'' 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]

Thus, the presence or absence of specific factors determine the ability or otherwise of the body to resist all types of diseases. [4]

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=== Etiology of ''Kaphaja Prameha'' ===

=== Etiology of ''Kaphaja Prameha'' ===

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बहुद्रवःश्लेष्मादोषविशेषः||६||

बहुद्रवःश्लेष्मादोषविशेषः||६||

बह्वबद्धं[१]मेदोमांसंशरीरजक्लेदःशुक्रंशोणितंवसामज्जालसीका

बह्वबद्धं मेदोमांसंशरीरजक्लेदःशुक्रंशोणितंवसामज्जालसीका रसश्चौजःसङ्ख्यातइतिदूष्यविशेषाः||७||

रसश्चौजःसङ्ख्यातइतिदूष्यविशेषाः||७||

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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:

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:

*Frequent and excessive intake of:

**Newly harvested grains like ''hayanaka, yavaka'' (a variety of Hordeum vulgare Linn), ''cinaka, uddalaka,naishadha,itkata, mukundaka,'' ''mahavrihi, promodaka,'' and ''sugandhaka'';

**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;  

**Newly harvested pulses like ''harenu'' (Pisum sativum Linn.) and ''masha'' (Phaseolus radiates Linn.), consumed with ghee;  

**The meat of domesticated, marshy and aquatic animals;

**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;

**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);

**Milk, new wine, immature curd (curd which is mostly liquid and sweet);

**Various dietary regimen that produces excess ''kapha'', fat, and urine;

**Various dietary regimen that produces excess ''[[kapha]]'', fat, and urine;

*Lifestyle related activities, including

*Lifestyle related activities, including

**Avoidance of physical exercise; and

**Avoidance of physical exercise; and

**Excessive sleep, bed rest and sedentary habits;  

**Excessive sleep, bed rest and sedentary habits;  

The ''kapha'' with excessive fluid component is specific vitiation in ''prameha''.

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 ''dhatus'').  [5-7]

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]

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=== Pathogenesis ===

=== Pathogenesis ===

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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]

Etiological factors (especially ''[[kapha]]''-dominant ones), ''[[dosha]]s'', and ''[[dushya]]s'' 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 ''[[dhatu]]s'' 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 ''[[dhatu]]s''. [8]

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=== Signs, Types, and Prognosis of ''Kaphaja Prameha'' ===

=== Signs, Types, and Prognosis of ''Kaphaja Prameha'' ===

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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.

Fluids of the body (''kleda'') along with ''[[kapha]]'' and ''[[meda]]s'' (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.

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The ten ''kaphaja prameha'' variants are as follows:

The ten ''kaphaja prameha'' variants are as follows:

These are curable because:

These are curable because:

#The ''medas'' (fat) and ''kapha'' have similar properties and loci,  

#The ''[[meda]]s'' (fat) and ''[[kapha]]'' have similar properties and loci,  

#The ''kapha'' is dominant, and   

#The ''[[kapha]]'' is dominant, and   

#Both ''medas'' and ''kapha'' are amenable to the same treatment. [9-11]

#Both ''[[meda]]s'' and ''[[kapha]]'' are amenable to the same treatment. [9-11]

=== Specific Features of Types of ''Kaphaja Prameha'' ===

=== Specific Features of Types of ''Kaphaja Prameha'' ===

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#In ''shukrameha'' patient passes semen-like urine or urine mixed with semen.

#In ''shukrameha'' patient passes semen-like urine or urine mixed with semen.

#In ''sheetameha'', the patient gets frequent micturition which is exceedingly sweet and cold.

#In ''sheetameha'', the patient gets frequent micturition which is exceedingly sweet and cold.

#In ''siktameha'', vitiated ''doshas'' pass with urine in the form of small gravels.

#In ''siktameha'', vitiated ''[[dosha]]s'' pass with urine in the form of small gravels.

#In ''shanirameha'', the patient passes small quantity of urine with difficulty and very slowly.

#In ''shanirameha'', the patient passes small quantity of urine with difficulty and very slowly.

#In ''alalameha'', the patient passes urine which is phlegm-like and slimy as if full of threads.

#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]

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

=== Etiology and Types of ''Pittaja Prameha'' ===

=== Etiology and Types of ''Pittaja Prameha'' ===

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''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:

''[[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:

#Intake of hot, sour, salty, alkaline and pungent foods;

#Intake of hot, sour, salty, alkaline and pungent foods;

#Intake of food before the digestion of the previous meal;

#Intake of food before the digestion of the previous meal;

#Intake of mutually contradictory food articles.

#Intake of mutually contradictory food articles.

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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:

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:

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#''Kharameha''

#''Kharameha''

#''Haridrameha''

#''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]

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'' ===

=== Specific Features of Types of ''Pittaja Prameha'' ===

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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:

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

#In ''ksharameha'' the patient passes urine having the smell, color, taste and touch similar to those of alkalies.

#In ''ksharameha'' the patient passes urine having the smell, color, taste and touch similar to those of alkalies.

#In ''haridrameha'' the patient passes urine having pungent taste and color like that of the juice of ''haridra'' (Curcuma longa Linn.).

#In ''haridrameha'' the patient passes urine having pungent taste and color like that of the juice of ''haridra'' (Curcuma longa Linn.).

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

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

=== Etio-pathogenesis of ''Vataja Prameha'' ===

=== Etio-pathogenesis of ''Vataja Prameha'' ===

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

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

#Excessive intake of astringent, pungent, bitter, rough, light and cold things;

#Excessive intake of astringent, pungent, bitter, rough, light and cold things;

#Excessive indulgence in sex and physical exercise.

#Excessive indulgence in sex and physical exercise.

#Excessive administration of emesis, purgations, asthapana type of enema and ''shirovirechana'' (elimination of ''doshas'' from the head),and

#Excessive administration of emesis, purgations, asthapana type of enema and ''shirovirechana'' (elimination of ''[[dosha]]s'' from the head),and

#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.

#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''.

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''.  

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]

''[[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]

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=== Incurability of ''Vataja Prameha'' and its Other Characteristics ===

=== Incurability of ''Vataja Prameha'' and its Other Characteristics ===

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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.

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:

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:

#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''.

#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]]''.

#In ''majjameha'', the patient frequently passes urine mixed with ''majja''. It is incurable and caused by the aggravation of ''vata''.

#In ''majjameha'', the patient frequently passes urine mixed with ''majja''. It is incurable and caused by the aggravation of ''[[vata]]''.

#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''.

#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]]''.

#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''.

#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]

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

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=== General Prodromal Features of ''Prameha'' ===

=== General Prodromal Features of ''Prameha'' ===

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

The three vitiated ''[[dosha]]s'', while causing ''prameha'', produce the following prodromal symptoms:

#Matting of hair;

#Matting of hair;

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.  

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]

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

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=== Summary ===

=== Summary ===

#Causative factors of the diseases and those about various types of ''prameha'';

#Causative factors of the diseases and those about various types of ''prameha'';

#Combination of ''doshas'' and ''dhatus'';

#Combination of ''[[dosha]]s'' and ''[[dhatu]]s'';

#Signs and symptoms (of different types of ''prameha'');

#Signs and symptoms (of different types of ''prameha'');

#The process of manifestation of ten, six and four varieties of ''prameha'' caused by ''kapha, pitta,'' and ''vata'' respectively.

#The process of manifestation of ten, six and four varieties of ''prameha'' caused by ''[[kapha]], [[pitta]],'' and ''[[vata]]'' respectively.

#Prognosis, premonitory symptoms and complications; and

#Prognosis, premonitory symptoms and complications; and

#Their line of treatment. [53-55]

#Their line of treatment. [53-55]

== Tattva Vimarsha (Fundamental Principles) ==

== Tattva Vimarsha (Fundamental Principles) ==

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#''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''.

#''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''.

#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.   

#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.   

#''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''.

#''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''.

#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.

#Prognosis of ''prameha'' depends on the quantity and quality of ''[[dosha]]s'' and the resistance capacity of ''[[dhatu]]s''. 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.

#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.

#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.

#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), ''oja'' (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.  

#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.  

#To treat ''prameha'', the above mentioned factors with the loci in urinary system of the bladder, kidneys shall be treated well.

#To treat ''prameha'', the above mentioned factors with the loci in urinary system of the bladder, kidneys shall be treated well.

#The quality and specific characteristics observed in urine are biomarkers in diagnosis and assessment of ''prameha''.

#The quality and specific characteristics observed in urine are biomarkers in diagnosis and assessment of ''prameha''.

=== The process of onset of disease ===

=== 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:  

''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:  

#No disease

#No disease

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 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<ref> Shastri A. Sushruta Samhita, [[Ayurveda]]- Tattva- Samdipika commentary, 14th ed. Varanasi, India : Chaukhambha Publications, 2003. </ref>  <ref> Gupta KA, Vagbhata’s Astanga Samgraha.Bombay, India: Nirnaysagar Press, 1951. </ref>. These are briefly listed below, along with lifestyle factors and psychological factors that lead to the onset of ''prameha'':

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<ref> Sushruta. Nidana Sthana, Cha.6 Pramehanidana. In: Shastri A, Editor. Tattva- Samdipika Sushruta Samhita. 14th ed. Varanasi: Chaukhambha Publications, 2003. </ref>  <ref> Vridha Vagbhata. Nidana Sthana, Cha.10 Pramehanidana. In: Gupta KA, Editor. Ashtanga Sangraha. 1st ed. Bombay: Nirnaysagar Press;1951</ref>. These are briefly listed below, along with lifestyle factors and psychological factors that lead to the onset of ''prameha''

#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.

#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.

=== The classification of ''prameha'' ===

=== The classification of ''prameha'' ===

==== Classification by ''Dosha''/Stage of Progression ====

==== 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''<ref> Shastri KN, Chaturvedi GN. Agnivesha, Charak Samhita, Vidyotini Commentary. Varanasi, India : Chaukhamba Bharti Academy, 2004. </ref> <ref> Shukla VD, Tripathi RD. Agnivesha, Charak Samhita, Vaidyamanorama Hindi Commentary. Delhi, India; Chaukhamba Sanskrit Pratisthana, 2002. </ref>. 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''.  

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''<ref> Shastri KN, Chaturvedi GN, Charak. Nidana Sthana, Cha.4 Pramehanidana ver.3. In: Shastri KN, Chaturvedi GN, Editors. Vidyotini Commentary Charak Samhita.1st ed. Varanasi: Chaukhamba Bharti Academy;2004. </ref> <ref> Shukla VD, Tripathi RD. Charak. Nidana Sthana, Cha.4 Pramehanidana ver.3. In: Shukla VD, Tripathi RD Vaidyamanorama Commentary Charak Samhita.1st ed. Delhi; Chaukhamba Sanskrit Pratisthana, 2002. </ref>. 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''<ref> Chandola HM, Bhatia S. Concept of Diabetes mellitus in [[Ayurveda]] and its treatment with certain indigenous drugs. AYU Int 2001;1:84-87. </ref>. Charak says that any of these three types of ''prameha'' can be precipitated directly, depending upon genetic predisposition and improper diet and lifestyle.  

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''<ref> Chandola HM, Bhatia S. Concept of Diabetes mellitus in [[Ayurveda]] and its treatment with certain indigenous drugs. AYU Int 2001;1:84-87. </ref>. 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<ref> Tripathi SN,  Chandola HM.Study on variations in diabetes mellitus (Prameha) with special reference to plasma insulin, cortisol and catecholamines. In Bajaj JS,ed. Diabetes mellitus in Developing Countries. New Delhi, India: Interprint, 1984:125-128. </ref>. 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.<ref> Sharma H, Chandola HM..Prameha in [[Ayurveda]]: Correlation with Obesity, Metabolic Syndrome, and Diabetes Mellitus.Part 1-Etiology, Classification, and Pathogenesis. The Journal of Alternative and Complementary Medicine.2011. 17(6):491-496. </ref>   

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<ref> Tripathi SN,  Chandola HM.Study on variations in diabetes mellitus (Prameha) with special reference to plasma insulin, cortisol and catecholamines. In Bajaj JS,ed. Diabetes mellitus in Developing Countries. New Delhi, India: Interprint, 1984:125-128. </ref>. 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.<ref> Sharma H, Chandola HM..Prameha in [[Ayurveda]]: Correlation with Obesity, Metabolic Syndrome, and Diabetes Mellitus.Part 1-Etiology, Classification, and Pathogenesis. The Journal of Alternative and Complementary Medicine.2011. 17(6):491-496. </ref>   

#''Krisha pramehi'' refers to asthenic diabetic patients and corresponds to ''krisha pramehi'' corresponds to patients with Type-I diabetes.<ref> Kajaria Divya, Chandola H.M. Dislipidemia Cause or Consequence of Diabetes- Reanalyzing the pathogenesis with the vision of [[Ayurveda]]. Journal of Diabetes and Health, Photon. 2014. </ref>   

#''Krisha pramehi'' refers to asthenic diabetic patients and corresponds to ''krisha pramehi'' corresponds to patients with Type-I diabetes.<ref> Kajaria Divya, Chandola H.M. Dislipidemia Cause or Consequence of Diabetes- Reanalyzing the pathogenesis with the vision of [[Ayurveda]]. Journal of Diabetes and Health, Photon. 2014. </ref>   

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)<ref> Pandey Rashmi, Dubey N., Tripathi NS. Ayurvedic Concept of Lifestyle Ailments and its Healing Through Traditional Regimen., 2015, Scholars Journal of Applied Medical Sciences, 3(3H):1599-1601 </ref>. 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''.

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)<ref> Pandey Rashmi, Dubey N., Tripathi NS. Ayurvedic Concept of Lifestyle Ailments and its Healing Through Traditional Regimen., 2015, Scholars Journal of Applied Medical Sciences, 3(3H):1599-1601 </ref>. When this resultant ''[[meda]]'' is also coupled with vitiated ''[[dosha]]s'' (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.<ref> Kumar Manish, Kivadassanavar MB et al. Screening of Serum Insulin in Obese Individual WSR to Sthaulya: An Observational Study. 2016. European Journal of Pharmaceutical and Medical Research, 2016,3(9),638-640 </ref>  

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.<ref> Kumar Manish, Kivadassanavar MB et al. Screening of Serum Insulin in Obese Individual WSR to Sthaulya: An Observational Study. 2016. European Journal of Pharmaceutical and Medical Research, 2016,3(9),638-640 </ref>  

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.

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 ''[[dhatu]]s''), 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'' ===

=== ''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.<ref> extracts from http://www.jbsoweb.com/admin/php/uploads/215_pdf.pdf </ref>

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.<ref> extracts from http://www.jbsoweb.com/admin/php/uploads/215_pdf.pdf </ref>

=== Various ''dushyas'' involved in the pathogenesis ===

=== Various ''[[dushya]]s'' involved in the pathogenesis ===

==== ''Medadhatu'' ====

==== [[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:<ref> sourced from http://www.slideshare.net/ayurmitra/madhumeha-kc041-gdg </ref>  

''[[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:<ref> sourced from http://www.slideshare.net/ayurmitra/madhumeha-kc041-gdg </ref>  

#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.<ref> sourced from http://www.slideshare.net/ayurmitra/madhumeha-kc041-gdg </ref>

#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.<ref> sourced from http://www.slideshare.net/ayurmitra/madhumeha-kc041-gdg </ref>

#Quantitative: ''Bahu''(excess): Here in the pathogenesis, ''meda'' is in excess quantity. This ''medadhatu'' 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.  

#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 ''[[dhatu]]s'' 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.

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]] ====

==== [[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'' (Ca.Ni. 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 <ref> May, RC et al. 1996. Glucocorticoids and acidosis stimulate protein and amino acid catabolism in vivo. Kidney Int. 1996 Mar;49(3):679-83. </ref>. Amino acids breakdown in liver results in increased production of urea<ref> Vaudevan et al. 2011. Textbook of biochemistry for medical students, Sixth Edition, JP Medical Publishers </ref> 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.

It is one of the main ''[[dushya]]s'' (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 <ref> May, RC et al. 1996. Glucocorticoids and acidosis stimulate protein and amino acid catabolism in vivo. Kidney Int. 1996 Mar;49(3):679-83. </ref>. Amino acids breakdown in liver results in increased production of urea<ref> Vaudevan et al. 2011. Textbook of biochemistry for medical students, Sixth Edition, JP Medical Publishers </ref> 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]] ====

''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.

''[[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]] ====

''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.

''[[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]] ====

''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.

[[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'' ====

==== [[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).

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.

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'' ====

==== [[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''.

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'' ====

==== [[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''.

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'' ====

==== 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,<ref> Parfitt A. 1982 The coupling of bone formation to bone resorption: a critical analysis of the concept and of its relevance to the pathogenesis of osteoporosis. Metab Bone Dis Relat Res 4:1–6. </ref>  <ref> Mundy G 1989 Local factors in bone remodeling. Rec Prog Horm Res 45:507–531. </ref> bone loss is noted when the amount of bone resorption exceeds the amount of new bone formation.  

Among the ten ''[[dushya]]s'' 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,<ref> Parfitt A. 1982 The coupling of bone formation to bone resorption: a critical analysis of the concept and of its relevance to the pathogenesis of osteoporosis. Metab Bone Dis Relat Res 4:1–6. </ref>  <ref> Mundy G 1989 Local factors in bone remodeling. Rec Prog Horm Res 45:507–531. </ref> 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<ref> Hayward M, Fiedler-Nagy C 1987 Mechanisms of bone loss: rheumatoid arthritis, periodontal disease and osteoporosis. 22:251–254. </ref>  <ref> Tuominen J, Impivaara O, Puukka P, Ronnenmaa T 1999 Bone mineral density in patients with type 1 and type 2 diabetes. Diabetes Care 22:1196–1200. </ref>  <ref> Krakauer J, McKenna M, Burderer N, Rao D, Whitehouse F, Parfitt A 1995 Bone loss and bone turnover in diabetes. Diabetes 44:775–782. </ref>  <ref> Macey L, Kana SM, Jingushi S, Terek RM, Borretos J, Bolander ME 1989 Defects of early fracture-healing in experimental diabetes. J Bone Joint Surg Am 71:722–733. </ref>. 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<ref> Gebauer G, Lin S, Beam H, Vieira P, Parsons J 2002 Low-intensity pulsed ultrasound increases the fracture callus strength in diabetic BB Wistar rats but does not affect cellular proliferation. J Orthop Res 20:587–592. </ref>  <ref> Barrett-Conner E, Holbrook T 1992 Sex differences in osteoporosis in older adults with non-insulin-dependent diabetes mellitus. JAMA 268:3333–3337. </ref>  <ref> Loe H 1993 Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 16:329–334. </ref>  <ref> Nelson R, Shlossman M, Budding L, Pettitt DJ, Saad MF, Genco RJ, Knowler WC1990 Periodontal disease and NIDDM in Pima Indians. Diabetes Care 13:836–840. </ref>. The reasons for the lower bone mineral density in type 1 diabetes are not known.

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<ref> Hayward M, Fiedler-Nagy C 1987 Mechanisms of bone loss: rheumatoid arthritis, periodontal disease and osteoporosis. 22:251–254. </ref>  <ref> Tuominen J, Impivaara O, Puukka P, Ronnenmaa T 1999 Bone mineral density in patients with type 1 and type 2 diabetes. Diabetes Care 22:1196–1200. </ref>  <ref> Krakauer J, McKenna M, Burderer N, Rao D, Whitehouse F, Parfitt A 1995 Bone loss and bone turnover in diabetes. Diabetes 44:775–782. </ref>  <ref> Macey L, Kana SM, Jingushi S, Terek RM, Borretos J, Bolander ME 1989 Defects of early fracture-healing in experimental diabetes. J Bone Joint Surg Am 71:722–733. </ref>. 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<ref> Gebauer G, Lin S, Beam H, Vieira P, Parsons J 2002 Low-intensity pulsed ultrasound increases the fracture callus strength in diabetic BB Wistar rats but does not affect cellular proliferation. J Orthop Res 20:587–592. </ref>  <ref> Barrett-Conner E, Holbrook T 1992 Sex differences in osteoporosis in older adults with non-insulin-dependent diabetes mellitus. JAMA 268:3333–3337. </ref>  <ref> Loe H 1993 Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 16:329–334. </ref>  <ref> Nelson R, Shlossman M, Budding L, Pettitt DJ, Saad MF, Genco RJ, Knowler WC1990 Periodontal disease and NIDDM in Pima Indians. Diabetes Care 13:836–840. </ref>. The reasons for the lower bone mineral density in type 1 diabetes are not known.

=== ''Vataja prameha'' as type 1 diabetes mellitus ===

=== ''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.

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.

[[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.<ref> https://www.slideshare.net/sprince33/glomerulonephritis accessed on 12 June 2017 </ref>   

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.<ref> https://www.slideshare.net/sprince33/glomerulonephritis accessed on 12 June 2017 </ref>   

===''Poorvarupa'' (prodromal symptoms) of ''prameha'' ===

===''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.<ref> https://www.coursehero.com/file/pd3u7l/Ketones-include-acetone-beta-hydroxybutyrate-and-acetoacetate-Progressive-rise accessed on 12 June 2017 </ref> 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<ref> Hampton T. Studies probe oral health diabetes link. JAMA 2008; 300:2471-2473. </ref>. 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.

For ''prameha'', these symptoms include excessive sweat, body odor, laziness, inclination towards rest, presence of excessive ''[[mala]]s'' (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.<ref> https://www.coursehero.com/file/pd3u7l/Ketones-include-acetone-beta-hydroxybutyrate-and-acetoacetate-Progressive-rise accessed on 12 June 2017 </ref> 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<ref> Hampton T. Studies probe oral health diabetes link. JAMA 2008; 300:2471-2473. </ref>. These findings may relate to the prodromal symptoms of excessive excretion of ''[[mala]]s'' 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.

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.<ref> http://press.endocrine.org/doi/10.1210/jcem.86.3.7304 accessed on 12 June 2017 </ref>

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 ''[[dhatu]]s''), 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.<ref> http://press.endocrine.org/doi/10.1210/jcem.86.3.7304 accessed on 12 June 2017 </ref>

=== Causes of lipoprotein abnormalities in diabetes <ref> Goldberg J.Ira . Diabetic Dyslipidemia: Causes and Consequences .The Journal of Clinical Endocrinology & Metabolism. 2001.  86 (3): 965-971. </ref>===  

=== Causes of lipoprotein abnormalities in diabetes <ref> Goldberg J.Ira . Diabetic Dyslipidemia: Causes and Consequences .The Journal of Clinical Endocrinology & Metabolism. 2001.  86 (3): 965-971. </ref>===  

! rowspan="1"| Asadhya(difficult to manage)

! rowspan="1"| Asadhya(difficult to manage)

|-

|-

| Dosha predominance Body constitution according to physique|| Kaphaja Obese || Pittaja || Vataja Asthenic

| [[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)  

| Etiology || Acquired ||  Acquired||  Hereditary (type-1 diabetes) Acquired (advanced, insulindependent stage of type-2diabetes)  

*[[Prameha Chikitsa]]  

*[[Prameha Chikitsa]]  

* [[Kiyanta Shiraseeya Adhyaya]]

* [[Kiyanta Shiraseeya Adhyaya]]

==References==

==References==