Chapter 4. Prameha Nidana (Chapter on Diagnosis of Obstinate Urinary Disorders)

Chapter 4.  Prameha Nidana (Chapter on Diagnosis of Obstinate Urinary Disorders)

अथातःप्रमेहनिदानंव्याख्यास्यामः||१||

इतिहस्माहभगवानात्रेयः||२|

athātaḥ pramēhanidānaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

Now we shall expound the chapter on the diagnosis of prameha. Thus, said Lord Atreya. [1-2]

Types of Prameha

त्रिदोषकोपनिमित्ताविंशतिःप्रमेहाभवन्तिविकाराश्चापरेऽपरिसङ्ख्येयाः| तत्रयथात्रिदोषप्रकोपःप्रमेहानभिनिर्वर्तयतितथाऽनुव्याख्यास्यामः||३||

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

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]

Process of Onset of Disease

इहखलुनिदानदोषदूष्यविशेषेभ्योविकारविघातभावाभावप्रतिविशेषाभवन्ति| 

iha khalu nidānadōṣadūṣyaviśēṣēbhyō vikāravighātabhāvābhāvaprativiśēṣā bhavanti|

Here, 

1. the specific interaction of etiological factors with doshas and dushyas - निदानदोषदूष्यविशेषेभ्यो, 

2. as well as the presence or absence / abhava of disease-resisting factors  -विकारविघातभावा (individual’s immunity or ability to resist the disease) - विकारविघातभावाभावप्रतिविशेषा, 

- influence the outcome regarding the manifestation of a disease (including prameha). 

यदाह्येतेत्रयोनिदानादिविशेषाःपरस्परंनानुबध्नन्त्यथवा[१] कालप्रकर्षादबलीयांसोऽथवाऽनुबध्नन्तिनतदाविकाराभिनिर्वृत्तिः, 

yadā hyētē trayō nidānādiviśēṣāḥ parasparaṁ nānubadhnantyathavā kālaprakarṣādabalīyāṁsō'thavā'nubadhnanti na tadā vikārābhinirvr̥ttiḥ,

3. . 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. 

चिराद्वाऽप्यभिनिर्वर्तन्ते, तनवोवाभवन्त्ययथोक्तसर्वलिङ्गावा; विपर्ययेविपरीताः;

cirādvā'pyabhinirvartantē, tanavō vā bhavantyayathōktasarvaliṅgā vā; viparyayē viparītāḥ; 

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. 

इतिसर्वविकारविघातभावाभावप्रतिविशेषाभिनिर्वृत्तिहेतुर्भवत्युक्तः||४||

 itisarvavikāravighātabhāvābhāvaprativiśēṣābhinirvr̥ttihēturbhavatyuktaḥ||4||

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

Etiology / nidana of Kaphaja Prameha

तत्रेमेत्रयोनिदानादिविशेषाःश्लेष्मनिमित्तानांप्रमेहाणामाश्वभिर्निर्वृत्तिकराभवन्ति; 

tatrēmē trayō nidānādiviśēṣāḥ ślēṣmanimittānāṁ pramēhāṇāmāśvabhirnirvr̥ttikarā bhavanti; 

An excessive intake of kapha-vitiating food articles or lifestyle activities / श्लेष्मनिमित्तानां contributes to severe manifestations of kaphaja prameha. 

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

tadyathā-hāyanakayavakacīnakōddālakanaiṣadhētkaṭamukundakamahāvrīhipramōdakasugandhakānāṁ navānāmativēlamatipramāṇēna cōpayōgaḥ, tathā sarpiṣmatāṁnavaharēṇumāṣasūpyānāṁ, grāmyānūpaudakānāṁ ca māṁsānāṁ, śākatilapalalapiṣṭānnapāyasakr̥śarāvilēpīkṣuvikārāṇāṁ,kṣīranavamadyamandakadadhidravamadhurataruṇaprāyāṇāṁ cōpayōgaḥ, mr̥jāvyāyāmavarjanaṁ, svapnaśayanāsanaprasaṅgaḥ, yaśca kaścidvidhiranyō'piślēṣmamēdōmūtrasañjananaḥ, sa sarvō nidānaviśēṣaḥ||5||

The following are some of the specific etiological factors for the kaphaja variant of this disease:

• Frequent and excessive intake of अतिप्रमाणेनचोपयोगः:

1. नवानामतिवेलम Newly harvested grains like 

• hayanaka हायनक, 
• yavaka (a variety of Hordeum vulgare Linn)यवक, 
• चीनको cinaka, 
• उद्दालक uddalaka, 
• नैषधे naishadha, 
• इत्कट itkata, 
• मुकुन्दक mukundaka, 
• महाव्रीहि-mahavrihi, 
• प्रमोदक promodaka, and 
• sugandhaka सुगन्धकानां , ;

2. Newly harvested pulses like 

• harenu (Pisum sativum Linn.) हरेणु and 
• masha माष सूप्यानां
• (Phaseolus radiates Linn.), consumed with ghee  सर्पिष्मतांन

3. The meat मांसानां of ग्राम्या domesticated, आनूपौ marshy and उदकानां aquatic animals;

4. 

• Vegetables, शाक
• tila (Sesamum indicum Linn.) oil, तिल पलल
• cakes of tila, pastries, पिष्टान्न
• payasa (milk-based pudding), पायस
• krisara (gruel prepared of tila, rice, and black gram), कृशरा
• vilepi (a type of thick gruel), and विलेपी
• sugarcane-based food preparations;इक्षुविकाराणां

5. 

• Milk क्षीर, 
• new wine नवमद्य, 
• immature curd (curd which is mostly liquid and sweet);  मन्दकदधिद्रवमधुरतरुणप्रायाणांचोपयोगः

6. Various dietary regimen that produces सञ्जननः 

• excess kapha श्लेष्म, 
• fat मेदो, and 
• मूत्र urine;

7. Lifestyle related activities, including

• Avoidance of physical exercise; मृजाव्यायामवर्जनं, and
• Excessive sleep स्वप्नशयना, bed rest आसनand sedentary habits प्रसङ्गः;

बहुद्रवःश्लेष्मादोषविशेषः||६||

बह्वबद्धं[१]मेदोमांसंशरीरजक्लेदःशुक्रंशोणितंवसामज्जालसीका रसश्चौजःसङ्ख्यातइतिदूष्यविशेषाः||७||

bahudravaḥ ślēṣmā dōṣaviśēṣaḥ||6||

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

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

Specific dushyas of prameha include excess 

1. abaddha meda (loose fat)मेदो 
2. mamsa (muscle tissues)मांसं 
3. vasa (muscle fat)वसा
4. majja (marrow)मज्जा , 
5. kleda (body fluids) शरीरजक्लेदः
6. shukra (semen and reproductive tissues)शुक्रं
7. rakta (blood)शोणितं
8. lasika (lymph) लसीका
9. rasa (plasma) रस
10. ojas (the purest of all dhatus) ओज

Pathogenesis

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

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

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

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

Signs, Types, and Prognosis of Kaphaja Prameha

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

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

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

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

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

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

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

The ten kaphaja prameha variants are as follows:

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

These are curable because:

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

Specific Features of Types of Kaphaja Prameha

तत्रश्लोकाः श्लेष्मप्रमेहविशेषविज्ञानार्थाभवन्ति-||१२||

अच्छंबहुसितंशीतंनिर्गन्धमुदकोपमम्| श्लेष्मकोपान्नरोमूत्रमुदमेहीप्रमेहति||१३||

अत्यर्थमधुरंशीतमीषत्पिच्छिलमाविलम्| काण्डेक्षुरसमङ्काशंश्लेष्मकोपात्प्रमेहति||१४||

यस्यपर्युषितंमूत्रंसान्द्रीभवतिभाजने| पुरुषंकफकोपेनतमाहुःसान्द्रमेहिनम्||१५||

यस्यसंहन्यतेमूत्रंकिञ्चित्किञ्चित्प्रसीदति| सान्द्रप्रसादमेहीतितमाहुःश्लेष्मकोपतः||१६||

शुक्लंपिष्टनिभंमूत्रमभीक्ष्णंयःप्रमेहति| पुरुषंकफकोपेनतमाहुःशुक्लमेहिनम्||१७||

शुक्राभंशुक्रमिश्रंवामुहुर्मेहतियोनरः| शुक्रमेहिनमाहुस्तंपुरुषंश्लेष्मकोपतः||१८||

अत्यर्थमधुरंशीतंमूत्रंमेहतियोभृशम्| शीतमेहिनमाहुस्तंपुरुषंश्लेष्मकोपतः||१९||

मूर्तान्मूत्रगतान्दोषानणून्मेहतियोनरः| सिकतामेहिनंविद्यात्तंनरंश्लेष्मकोपतः||२०||

मन्दंमन्दमवेगंतुकृच्छ्रंयोमूत्रयेच्छनैः| शनैर्मेहिनमाहुस्तंपुरुषंश्लेष्मकोपतः||२१||

तन्तुबद्धमिवालालंपिच्छिलंयःप्रमेहति| आलालमेहिनंविद्यात्तंनरंश्लेष्मकोपतः||२२||

इत्येतेदशप्रमेहाःश्लेष्मप्रकोपनिमित्ताव्याख्याताभवन्ति||२३||

tatra ślōkāḥ ślēṣmapramēhaviśēṣavijñānārthā bhavanti-||12||

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

atyarthamadhuraṁ śītamīṣatpicchilamāvilam| kāṇḍēkṣurasamaṅkāśaṁ ślēṣmakōpāt pramēhati||14||

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

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

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

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

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

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

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

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

ityētē daśa pramēhāḥ ślēṣmaprakōpanimittā vyākhyātā bhavanti||23||

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

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

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

Etiology and Types of Pittaja Prameha

उष्णाम्ललवणक्षारकटुकाजीर्णभोजनोपसेविनस्तथाऽतितीक्ष्णातपाग्निसन्तापश्रमक्रोधविषमाहारोपसेविनश्चतथाविधशरीरस्यैवक्षिप्रंपित्तंप्रकोपमापद्यते, तत्तुप्रकुपितंतयैवानुपूर्व्याप्रमेहानिमान्षट्क्षिप्रतरमभिनिर्वर्तयति||२४||

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

तेषड्भिरेवक्षाराम्ललवणकटुकविस्रोष्णैःपित्तगुणैःपूर्ववद्युक्ताभवन्ति||२६||

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

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

tē ṣaḍbhirēva kṣārāmlalavaṇakaṭukavisrōṣṇaiḥ pittaguṇaiḥ pūrvavadyuktā bhavanti||26||

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

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

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

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

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

Specific Features of Types of Pittaja Prameha

सर्वएवतेयाप्याःसंसृष्टदोषमेदःस्थानत्वाद्विरुद्धोपक्रमत्वाच्चेति||२७||

तत्रश्लोकाःपित्तप्रमेहविशेषविज्ञानार्थाभवन्ति-||२८||

गन्धवर्णरसस्पर्शैर्यथाक्षारस्तथाविधम्| पित्तकोपान्नरोमूत्रंक्षारमेहीप्रमेहति||२९||

मसीवर्णमजस्रंयोमूत्रमुष्णंप्रमेहति| पित्तस्यपरिकोपेणतंविद्यात्कालमेहिनम्||३०||

चाषपक्षनिभंमूत्रमम्लंमेहतियोनरः| पित्तस्यपरिकोपेणतंविद्यान्नीलमेहिनम्||३१||

विस्रंलवणमुष्णंचरक्तंमेहतियोनरः| पित्तस्यपरिकोपेणतंविद्याद्रक्तमेहिनम्||३२||

मञ्जिष्ठोदकसङ्काशंभृशंविस्रंप्रमेहति| पित्तस्यपरिकोपात्तंविद्यान्माञ्जिष्ठमेहिनम्||३३||

हरिद्रोदकसङ्काशंकटुकंयःप्रमेहति| पित्तस्यपरिकोपात्तंविद्याद्धारिद्रमेहिनम्||३४||

इत्येतेषट्प्रमेहाःपित्तप्रकोपनिमित्ताव्याख्याताभवन्ति||३५||

sarva ēva tē yāpyāḥ saṁsr̥ṣṭadōṣamēdaḥsthānatvādviruddhōpakramatvāccēti||27||

tatra ślōkāḥ pittapramēhaviśēṣavijñānārthā bhavanti-||28||

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

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

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

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

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

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

ityētē ṣaṭ pramēhāḥ pittaprakōpanimittā vyākhyātā bhavanti||35||

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

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

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

Etio-pathogenesis of Vataja Prameha

कषायकटुतिक्तरूक्षलघुशीतव्यवायव्यायामवमनविरेचनास्थापन-शिरोविरेचनातियोगसन्धारणानशनाभिघातातपोद्वेगशोकशोणितातिषेक- जागरणविषमशरीरन्यासानुपसेवमानस्यतथाविधशरीरस्यैवक्षिप्रंवातः प्रकोपमापद्यते||३६||

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

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

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

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

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

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

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

Incurability of Vataja Prameha and its Other Characteristics

इमांश्चतुरः प्रमेहान् वातजानसाध्यानाचक्षते भिषजः, महात्ययिकत्वाद्विरुद्धोपक्रमत्वाच्चेति||३८||

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

तत्र श्लोका वातप्रमेहविशेषविज्ञानार्था भवन्ति-||४०||

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

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

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

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

इत्येते चत्वारः प्रमेहा वातप्रकोपनिमित्ता व्याख्याता भवन्ति||४५||

एवं त्रिदोषप्रकोपनिमित्ता विंशतिः प्रमेहा व्याख्याता भवन्ति||४६||

imāṁścaturaḥ pramēhān vātajānasādhyānācakṣatē bhiṣajaḥ, mahātyayikatvādviruddhōpakramatvāccēti||38||

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

tatra ślōkā vātapramēhaviśēṣavijñānārthā bhavanti-||40||

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

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

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

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

ityētē catvāraḥ pramēhā vātaprakōpanimittā vyākhyātā bhavanti||45||

ēvaṁ tridōṣaprakōpanimittā viṁśatiḥ pramēhā vyākhyātā bhavanti||46||

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

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

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

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

General Prodromal Features of Prameha

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

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

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

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

General Complications and Principles of Treatment

उपद्रवास्तुखलुप्रमेहिणांतृष्णातीसारज्वरदाहदौर्बल्यारोचकाविपाकाः पूतिमांसपिडकालजीविद्रध्यादयश्चतत्प्रसङ्गाद्भवन्ति||४८||

तत्रसाध्यान्प्रमेहान्संशोधनोपशमनैर्यथार्हमुपपादयंश्चिकित्सेदिति||४९||

upadravāstu khalu pramēhiṇāṁ tr̥ṣṇātīsārajvaradāhadaurbalyārōcakāvipākāḥ pūtimāṁsapiḍakālajīvidradhyādayaśca tatprasaṅgādbhavanti||48||

tatra sādhyān pramēhān saṁśōdhanōpaśamanairyathārhamupapādayaṁścikitsēditi||49||

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

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

Consequences of Prameha

भवन्तिचात्र- गृध्नुमभ्यवहार्येषुस्नानचङ्क्रमणद्विषम्| प्रमेहःक्षिप्रमभ्येतिनीडद्रुममिवाण्डजः||५०||

मन्दोत्साहमतिस्थूलमतिस्निग्धंमहाशनम्| मृत्युःप्रमेहरूपेणक्षिप्रमादायगच्छति||५१||

यस्त्वाहारंशरीरस्यधातुसाम्यकरंनरः| सेवतेविविधाश्चान्याश्चेष्टाःससुखमश्नुते||५२||

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

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

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

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

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

Summary

तत्रश्लोकाः- हेतुर्व्याधिविशेषाणांप्रमेहाणांचकारणम्| दोषधातुसमायोगोरूपंविविधमेवच||५३||

दशश्लेष्मकृतायस्मात्प्रमेहाःषट्चपित्तजाः| यथाचवायुश्चतुरःप्रमेहान्कुरुतेबली||५४||

साध्यासाध्यविशेषाश्चपूर्वरूपाण्युपद्रवाः| प्रमेहाणांनिदानेऽस्मिन्क्रियासूत्रंचभाषितम्||५५||

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

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

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

To sum up:

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

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

इत्यग्निवेशकृतेतन्त्रेचरकप्रतिसंस्कृतेनिदानस्थानेप्रमेहनिदानंनाम चतुर्थोऽध्यायः||४||

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

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