अथातः प्रमेहनिदानं नामाध्यायं व्याख्यास्यामः । इति ह स्माहुरात्रेयादयो महर्षयः ॥ १॥
We will now expound the chapter called Prameha nidana-diagnosis of diabetes; thus said Atreya and other great sages. (1)
Prameha bheda – Types of diabetes
विंशतिः प्रमेहा भवन्ति । तद्यथा । कफादुदकेक्षुसान्द्रसुरापिष्टशुक्रसिकताशीतशनैर्लालाप्रमेहाः दश । पित्तात् क्षारकालनीलहारिद्रमाञ्जिष्ठशोणितमेहाः षट् । वाताद्वसामज्जहस्तिमधुमेहाश्चत्वार इति ॥२॥
Prameha are (of) twenty (kinds); from kapha are produced udaka (meha), iksu (meha), sandra (meha), sura (meha), sukra (meha) sikata (meha), sita (meha) sanair (meha) andlala (meha) – the ten kinds; from pitta are produced kshara (meha), kala (meha), nila (meha), haridra (meha) manjistha (meha) and sonita (rakta) meha- the six kinds; from vata are produced the vasa (meha), majja (meha), hasti (meha) and madhu (meha) – the four kinds. (2)
Prameha Samprapti – Diabetes pathogenesis
तेषां यत्किञ्चिदाहारविहारजातं श्रेष्ममेदोमूत्रजननं स हेतुः ।
तत्र वातपित्तमेद: क्लेदमांसशुक्ररसैरन्वितो बस्तिगतः श्रेष्मा प्रमेहान् जनयति । तैः कफशोणिताभ्यां च युक्तं पित्तम् । तैर्वसालसीकामज्जौजोभिश्च वायुः ॥३॥
The cause for all of them, is indulgence in foods and activiti which increase the production of slesma (kapha), medas (fat) and mutra (urine); slesma (kapha) followed by (associating with) vata, pitta, medas (fat), kleda (moisture of the body), mamsa (musclar tissues), sukra (semen) and rasa ( lymph/plasma) and getting localised in the urinary bladder produces prameha (diabetes); or pitta in association with kapha, sonita (blood) and others; or vayu (vata) in association with lasika (lymph), majja (bone marrow), and ojas (produce prameha). (3)
त्रयाणामपि दोषाणां श्रेष्मा प्रमेहेषु प्राक् प्रकोपमापद्यते श्रेष्माधिष्ठानत्वान्मूत्रस्य ।
तद्वृद्धेर्मेद एव च तेन प्रथमं दूष्यतेऽत्यन्तसभागत्वात् । तदनन्तरं देहक्लेदादयः ।
ततः श्रेष्मादिक्षये पित्तं प्रबलीभवच्छोणितमपि दूषयति ।
तत्क्षयेऽपि वायुर्वसादीन् धातून् शरीरस्य परमसारभूतान् बस्तिमाकृष्य मूत्रेण सह विसृजति ॥४॥
Out of the three doshas, kapha gets aggravated (increased) first in prameha because mutra (urine) is the seat of slesma ( kapha), from its ( kapha) increase medas ( fat tissue) becomes vitiated first because of its closest similarity (in qualities and properties), followed next by the other body fluids. Further with the decrease of slesma (kapha), pitta becoming powerful, vitiates even the sonita (blood), after the decrease of blood, vata ( getting aggravated) draws the vasa (muscle fat) and other dhatus (tissues) which are the important essence of the body, to the bladder and eliminates them mixed with urine. (4)
Prameha Sadhyasadhyata – Prognosis of Diabetes
तस्मात् कफपित्तवातजाः क्रमेण साध्ययाप्यासाध्याः । तथा पित्तजाः संसृष्टदोषमेदः – स्थानत्वाद्विरुद्धोपक्रमत्वाच्च । वातजाः पुनः क्षीणेषु धातुषु महात्ययतया विरुद्धोपक्रमत्वाच्च । मेदसि तु नातिदुष्टे पित्तजा अपि साध्यतां गच्छेयुः ॥५॥
Hence, those (prameha) caused by kapha, pitta and vata are curable, controllable and incurable respectively; those due to pitta are so because of the combination of doshas, residing in the medas ( fat tissue) and of (necessity of) opposite kinds of treatments; those due to vata (are so) because of arising from decreased dhatus, of causing emergency and (necessity of) opposite kinds of treatment; even those caused by pitta become curable if medas (fat) is not vitiated greatly. (5)
धातुसम्पर्कात् पुनः सर्वमेहेषु मूत्रमाविलं भूरि च भवति । दोषाणां दूष्याणां चोत्कृष्टापकृष्टसंयोगेन मूत्रवर्णरसस्पर्शगन्धविशेषाद्वर्णानामिव शुक्लकृष्णादीनां शबलकल्माषादयः प्रमेहाणां प्रभेदा भवन्ति ॥ ६ ॥
In all mehas (diabetes), urine will be turbid and large in quantity, because of the association with the dhatus (tissues); the difference in colour, taste, touch and smell (of urine) occur because of greater or lesser degrees of combination of the doshas and the dhatus (the vitiated – dhatus and maias); similarly so even in respect of colour; colours such as white, black etc. give rise to sabala, kalmasa, etc.; based on these (the colour, taste, smell, touch) (of urine) prameha is classified into different kinds. (6)
Prameha Purvarupa – Pre Diabetes symptoms
तेषां पूर्वरूपाण्यतिवृद्धिर्नखादीनां जटिलीभावश्च केशानां माधुर्यमास्यस्य तालुकण्ठशोषः पिपासा मलाधिक्यं बहिःकाये कायछिद्रेषु च शीतेच्छा स्नेहः स्वेदः सुप्तता चाङ्गेषु पाणिपाददाहोतिमाधुर्यात् पिपीलिकोपसर्पणं विस्त्रगन्धता च मूत्रशरीरयोः शुक्लता च मूत्रे श्वासनिद्रातन्द्रालस्यप्रकर्षश्च ॥७॥
Their premonitary symptoms are-great increase of nails, etc. (size of the surrounding area i,e; the finger tips or increase of rate of growth of nails), matting ( sticking together ) of the hairs, sweet taste in the mouth, dryness of the palate, throat, thirst, increase of waste products on the exterior (the skin) and also in the orifices of the body (eyes,ears, nose, mouth, urethra, anus, skin pores ), desire for cold, greasiness of the body, perspiration, loss of tactile sensation, burning sensation in the hands ( palms) and feet (soles), ants swarming to the body because of excess of sweetness,bad smell of the urine and body, whiteness of the urine, difficult respiration, sleep, stupor, and lazyness. (7)
Prameha Lakshana – Clinical features of Diabetes
तत्र शीतं श्वेतमगन्धमच्छमुदकमिवोदकमेहीमेहति । इक्षुरसमिवातिमधुरं शीतमीषत्पिच्छिलाविलमिक्षुमेही । पर्युषितं सान्द्रीभवत् सान्द्रमेही। सुरातुल्यमुपरिप्रसन्नमधःसान्द्रं सुरामेही । हृष्टरोमा पिष्टमिव सान्द्रं सितं च पिष्टमेही । शुक्राभं शुक्रमिश्रं वा शुक्रमेही । सरुजं ससिकतं सिकतामेही । प्रायो मधुरम् तिशीतं शीतमेही । मन्दंमन्दं शनैः शनैः शनैर्मेही । पिच्छिलं तन्तुबद्धमिव लालामेही। वर्णगन्धरस्पशैंः स्रुतक्षारोपमं क्षारमेही। उष्णं मषीकालं कालमेही । सफेनमच्छमम्लं चाषपत्रनीलं नीलमेही । कटुकं सदाहं हरिद्रा- युक्तमिव हारिद्रमेही । विस्त्रं मञ्जिष्ठोदकवर्णमिव मञ्जिष्ठामेही। विस्त्रमुष्णं सलवणं शोणितसङ्काशं शोणितमेही । वसामिश्रं वसां वा वसामेही । मज्जमिश्रं मज्जानं वा मज्जमेही । सलसीकं मधुरमवेगं लसीकयैव च विबद्धमनुबद्धमजस्त्रं मत्त इव हस्ती स्रवति हस्तिमेही ॥८॥
The patient of Udaka meha eliminates urine which is cold, white, with no smell, clear and resembling water.
In Iksu meha he eliminates urine which is very sweet like juice of sugarcane, cold, slightly slimy and turbid.
In Sandra meha he passes urine which becomes thick on standing for sometime. In Sura meha the urine resembles sura (beer), with its top portion clear and bottom portion thick (with turbidity).
In Pista meha the patient will have (frequent) horripilations and passes urine resembling (solution of) flour, thick and cold.
In Sukra meha, he passes urine resembling semen or even mixed with it.
In Sikata meha, he passes urine with pain and mixed with gravel.
In sita meha, he passes urine which is generally sweet and very cold.
In Sanair meha, he passes urine very slowly and frequently,
In Lala meha, he passes urine which is slimy and having threads In Kshara meha, he passes urine which resemble solution of alkali in respect of colour, smell, taste and touch.
In Kala meha he passes urine which is warm and black like ink. In Nila meha he passes urine which is mixed with froth,clear, sour, blue like the feather of casa bird (blue jay).
In Haridra meha, he passes urine which is pungent, accompanied with burning sensation, urine appears as though mixed with (powder of) haridra ( turmeric ). In Manjista meha, he passes urine which is foul smelling, and resembling the solution of manjista.
In Sonita meha (rakta meha) he passes urine which is foul smelling, slightly salty and resembling blood (in colour).
In Vasa meha he passes urine mixed with vasa) muscle fat) or eliminates musclefat itself.
In Majja meha, he passes urine mixed with majja (bone marrow) or marrow itself, In Lasika meha, he passes urine mixed with lasika (lymph) sweet in taste, without force or passes lymph itself.
In Hasti meha he passes urine without continuous stream, in short bouts, slowly, for long time like an elephant in rut.(8)
ओजः स्निग्धमधुरं तद्रौक्ष्याद्वायुः कषायत्वेनोपसृजति तेन कषायमधुरानुयातं मध्विव मेहति मधुमेही । स तु द्विधा कैश्चिदिष्यते । धातुक्षयेणानिलकोपाद्दोषावरणेन वा । तदावृतो हि वायुराहारप्रसाद मादाय मुहुर्मुहुरनिमित्तं दोषलिङ्गानि वृद्धिक्षयौ चाविर्भावयन् कृच्छ्रसाध्यं मधुमेहं प्रवर्तयति । सर्व एव चोपेक्ष्यमाणा मधुमेहत्वमायान्ति । तस्मात्सर्वेऽपि मधुमेहशब्देनोच्यन्ते । यतः सर्वेष्वपि प्राङ्मध्विव मधुरं मेहति मधुररसश्चास्य देहो भवतीति ॥ ९ ॥
Ojas which is untous and sweet is converted by vata, to become dry (non-unctous) and astringent, such ojas which is astringent and little of sweet, produces Madhu meha in which the patient possess urine resembling honey. Some say, it is of two kinds, viz, 1 ) that due to increase of vata due to dhatuksaya (loss of tissues); and 2) that due to avarana of the doshas. When vata gets obstructed in its normal routes (direction, function etc) it vitiates the nutrient portion of the food repeatedly without any other cause, produces symptoms of either increase or decrease of the doshas and gives rise to Madhu meha which is very difficult to cure. All the other pramehas, if neglected will become Madhu meha ultimetely, hence all of them are called as Madhumeha generally, because in all of them the urine will be sweet and the body also attains sweet taste at their commencement. (9)
Prameha Upadrava – Complications of Diabetes
तत्र प्रतिश्यायः शरीरशैथिल्यमरोचकाविपाकौ प्रसेकच्छर्दिर्निद्रा कासश्च श्रेष्मजानामुपद्रवा भवन्ति । वृषणावदरणं बर्तिमेढ्रतोदोऽम्लकः पिपासा ज्वरो दाहो मूर्च्छातीसारः पाण्डुरोगश्च पित्तजानाम् । हृद्ग्रहो लौल्यमनिद्रता कम्पः शूलं बद्धपुरीषत्वं शोषः कासः श्वासश्च वातजानाम् ॥१०॥
Running in the nose, flacidity (looseness) of the body, loss of appetite (or taste), indigestion, excess salivation, vomiting, sleep and cough are the complications (secondary diseases) of pramehas of slesma (kapha) origin.
Crack or fissures (of the skin) of the scrotum, pricking pain in the urinary bladder and penis, sourness (increased acidity in the stomach) thirst, fever, burning sensation, fainting, diarrhoea, and anaemia are the (complications) of prameha of pitta origin.
Catching pain in the heart, sensuousness (desire for satisfying all the sense organs) loss of sleep, tremors, pain, constipation, dryness (wasting), cough and dyspnoea are the complications of pramehas of vata origin. ( 10 )
Prameha pidaka – diabetic eruptions
अथैवमस्य मेद: क्लेदादिभिरभिष्यण्णदेहस्य दोषैरनुगतधातोः प्रमेहाभिवृद्धौ मांसलेष्ववकाशेषु सन्धिमर्मसु च प्रदेशविशेषाश्रयत्वात् प्राणापहारिण्यो भूयः कष्टतमोपद्रवा दश पिटका जायन्ते । सुतरां चाध:काये । तदभिमुखा हि प्रमेहिणां दोषाः । तद्यथा | शराविका कच्छपिका जालिनी पुत्रिणी विदारिका सर्षपिका मसूरिकालजी विनता विद्रधिश्च ॥११॥
Further, in patients of prameha (diabetes) their body made weak by loss of medas (fat), kleda (body fluids) etc, the doshas vitiating all the dhatus (tissues) in the later stages of the disease, there develop ten kinds of pitakas (eruptions/ulcers) in places predominant of muscles, joints and vital parts, these developing on such specific places are mostly fatal and very difficult complications, they manifest commonly in the lower parts of the body because the doshas are more prone towards them (lower parts) in prameha (diabetes), these are (named as) saravika, kachchapika, jalini, putrini, vidarika, sarsapika, masurika, alaji, vinata and vidradhi. (11)
तत्र श्यावा क्लेदवेदनायुक्ता निम्नमध्योन्नतौष्ठा शरावसंस्थानप्रमाणा शराविका । महामूलावगाढार्तितोदा शुक्ष्णा कच्छपपृष्ठनिभा कच्छपिका । महाशयार्तितोदा स्तब्धा स्निग्धस्त्राविणी सूक्ष्मच्छिद्रा मांससिराजालावृता जालिनी । महती पिटकाभिरल्पाभिराचिता पुत्रिणी | कठिना विदारीकन्दवद्वत्ता विदारिका । शीघ्रपाका महावेदना सर्षपाकृतिप्रमाणा तद्विधाभिश्चपिटकाभिश्चिता सर्षपिका। मसूराकारप्रमाणा मसूरिका। त्वचमुत्थान एव दहन्ती स्फौटैरावृता विसर्पन्ती रक्ता कृष्णातितृणमोहज्वरकरी दाहभूयिष्ठातिकष्टा चालजी | महती नीलावगाढरुजाक्लेदा पृष्ठोदरान्यतराधिष्ठाना विनताविनता । विद्रधिस्तु वक्ष्यते पृथगेव ॥१२॥
Of them, Saravika is blue black, with exudation and pain, depressed in the centre and raised in its edges resembling a saucer in shape and size.
Kachchapika is deep rooted, solid (hard), very painful, smooth and resembling a tortoise shell.
Jalini is occupying a large area, with severe pain, immoveable, exudes fatty material, has minute openings, and network of muscles and veins.
Putrini is a big pitaka (eruption) surrounded by many small ones, Vidarika is hard, round like the tuber of vidari,
Sarsapika undergoes ulceration quickly, has severe pain, is of the shape and size of sarsapa (mustard seed) and many in number. Masurika resembles masura (lentil) in shape and size,
Alaji arises from the skin, has viscles with burning sensation, covering all around, spreading to other places, red or black, causing severe thirst, delusion and fever, accompanied with burning sensation predominantly and very difficlt to cure.
Vinata is big, bluish, hard, painful, exudating, deep seated and situated on the back, abdomen and other places. (12)
Vidradhi will be described seperately- (in the next chapter) .
तासामाद्याः पञ्चातिबलश्लेष्ममेदः सम्भवेन मूलव्याध्येकरूपत्वात्तवृद्धिकारितया दुःसहाः । न त्वितराः पित्तोल्बणतयाल्पकफमेदोभावात् । प्रमेहवशाच्च पिटकासु यथास्वं दोषोद्रेको भवतीति । भवति चात्र श्लोकाः ॥१३॥
Among these, the first five are difficult to tolerate because of their origin from very strong (greatly increased), slesma (kapha) and medas (fat) and undergoing increase or decrease in accordance with the primary diseases (kind of prameha), the remaining (second five) are not so because of predominance of pitta and arising from little of kapha and medas. Aggravation (increase) of doshas happen even in the eruptions because of their association with prameha (the primary diseases). (13)
Some verses more
प्रमेहेण विनाप्येता जायन्ते दुष्टमेदसः । तावच्च नोपलक्ष्यन्ते यावद्वस्तुपरिग्रहः ॥१४॥
These (pitakas) arise from the vitiated medas (fat) even without prameha (diabetes), but are not recognised till they get localised (in the dhatus and places of the body. (14) हारिद्रवर्णं रक्तं वा मेहप्राग्रूपवर्जितम् । यो मूत्रयेन्न तं मेहं
The person who voids urine which is haridra (deep yellow) or red and without the prodromal symptoms of prameha (diabetes) should not be declared as having prameha (diabetes) but as one having raktapitta (haemorrhagic disease). (15)
दृष्ट्वा प्रमेहं मधुरं सपिच्छं मधूपमं स्यात् द्विविधो विचारः ।
सम्पूरणाच्छ्रलेष्मसमुद्भवः स्यात् क्षीणेषु दोषेष्वनिलात्मको वा ॥१६॥
Having noticed elimination of large quantity of urine which is sweet, slightly slimy (or turbid) and resembling honey, two points should be considered (carefully), whether the disease is caused by slesma (kapha) increased by over-nutrition or whether it is caused by vata from the decrease of the other doshas. ( 16 )
सपूर्वरूपाः कफपित्तमेहाः क्रमेण ये वातकृताश्च मेहाः ।
साध्या न ते पित्तकृतास्तु याप्याः साध्यास्तु मेदो यदि नातिदुष्टम् ॥१७॥
Pramehas produced by kapha and pitta and having few (and mild) prodromal symptoms are curable and those produced by vata are not so, in that manner; those produced by pitta are controllable (and persist for life), and even curable if the medas (fat) is not greatly vitiated. ( 17 )
॥ इति दशमोऽध्यायः ॥
Thus ends the Tenth chapter.
