Charaka Prameha Nidana: 4th Chapter

The 4th chapter of Charaka Samhitha Nidana Sthana is called Prameha Nidana. It deals with causes, pathology, types and symptoms of Prameha – urinary disorder including Diabetes mellitus, as per Ayurveda.

अथातः प्रमेह निदानं व्याख्यास्यामः||१||
इति ह स्माह भगवानात्रेयः||२||
athātaḥ prameha nidānaṃ vyākhyāsyāmaḥ||1||
iti ha smāha bhagavānātreyaḥ||2||
We shall now explore the chapter on the Diagnosis of Prameha (urinary disorder including Diabetes mellitus). Thus said Lord Atreya [1-2]

Types of Prameha

त्रिदोष कोप निमित्ता विंशतिः प्रमेहा भवन्ति विकाराश्चापरेऽपरिसङ्ख्येयाः|
तत्र यथा त्रिदोष प्रकोपः प्रमेहानभिनिर्वर्तयति तथाऽनुव्याख्यास्यामः||३||
tridoṣa kopa nimittā viṃśatiḥ pramehā bhavanti vikārāścāpare’parisaṅkhyeyāḥ|
tatra yathā tridoṣa prakopaḥ pramehānabhinirvartayati tathā’nuvyākhyāsyāmaḥ||3||

Due to the simultaneous vitiation of all the 3 Doshas, 20 types of Prameha as also innumerable other diseases are manifested.
We shall now explain the way in which the vitiation of the 3 Doshas leads to the manifestation of the various types of Prameha. [3]

For the brief version of this chapter, please read: Prameha – Ayurvedic Approach To Urinary Disorders

Specific features of etiological factors:
इह खलु निदान दोष दूष्य विशेषेभ्यो विकार विघातभावाभाव प्रतिविशेषा भवन्ति|
यदा ह्येते त्रयो निदानादि विशेषाः परस्परं नानुबध्नन्त्यथवा काल प्रकर्षादबलीयांसोऽथवाऽनुबध्नन्ति न तदा विकाराभिनिर्वृत्तिः, चिराद्वाऽप्यभिनिर्वर्तन्ते, तनवो वा भवन्त्ययथोक्तसर्वलिङ्गा वा; विपर्यये विपरीताः; इति सर्व विकार विघात भावाभाव प्रति विशेषाभिनिर्वृत्तिहेतुर्भवत्युक्तः||४||
iha khalu nidāna doṣa dūṣya viśeṣebhyo vikāra vighātabhāvābhāva prativiśeṣā bhavanti|
yadā hyete trayo nidānādi viśeṣāḥ parasparaṃ nānubadhnantyathavā kāla prakarṣādabalīyāṃso’thavā’nubadhnanti na tadā vikārābhinirvṛttiḥ, cirādvā’pyabhinirvartante, tanavo vā bhavantyayathoktasarvaliṅgā vā; viparyaye viparītāḥ; iti sarva vikāra vighāta bhāvābhāva prati viśeṣābhinirvṛttiheturbhavatyuktaḥ||4||

Specific features of causative factors, Doshas and Dhatus determine the bodily immunity or susceptibility to the manifestation of a disease. When they do not support each other or when they are weak due to temporal factors, then either the disease does not manifest itself or there is delay in manifestation or the disease is very mild or all its symptoms are not properly manifested. If the situations are contrary to what is mentioned above, the corresponding results will also be otherwise.Thus the specific factors which determine the ability or otherwise of the body to resist all types of diseases is described. [4]

Kaphaja Prameha

Nidana – Causative factors of Kaphaja Prameha:
तत्रेमे त्रयो निदानादि विशेषाः श्लेष्म निमित्तानां प्रमेहाणामाश्वभि र्निर्वृत्तिकरा भवन्ति; तद्यथा- हायनक यव कचीन कोद्दालक नैषधेत्कट मुकुन्दक महाव्रीहि प्रमोदक सुगन्धकानां नवानामतिवेलमति प्रमाणेन चोपयोगः, तथा सर्पिष्मतां नव हरेणु माष सूप्यानां, ग्राम्यानूपौदकानां च मांसानां, शाक तिल पलल पिष्टान्न पायस कृशरा विलेपीक्षु विकाराणां, क्षीर नव मद्य मन्दक दधि द्रव मधुर तरुण प्रायाणां चोपयोगः, मृजा व्यायाम वर्जनं, स्वप्न शयनासन प्रसङ्गः, यश्च कश्चिद्विधिरन्योऽपि श्लेष्म मेदो मूत्र सञ्जननः, स सर्वो निदान विशेषः||५||
बहुद्रवः श्लेष्मा दोष विशेषः||६||
बह्वबद्धं मेदो मांसं शरीरज क्लेदः शुक्रं शोणितं वसा मज्जा लसीका रसश्चौजःसङ्ख्यात इति दूष्य विशेषाः||७||
tatreme trayo nidānādi viśeṣāḥ śleṣma nimittānāṃ pramehāṇāmāśvabhi rnirvṛttikarā bhavanti; tadyathā- hāyanaka yava kacīna koddālaka naiṣadhetkaṭa mukundaka mahāvrīhi pramodaka sugandhakānāṃ navānāmativelamati pramāṇena copayogaḥ, tathā sarpiṣmatāṃ nava hareṇu māṣa sūpyānāṃ, grāmyānūpaudakānāṃ ca māṃsānāṃ, śāka tila palala piṣṭānna pāyasa kṛśarā vilepīkṣu vikārāṇāṃ, kṣīra nava madya mandaka dadhi drava madhura taruṇa prāyāṇāṃ copayogaḥ, mṛjā vyāyāma varjanaṃ, svapna śayanāsana prasaṅgaḥ, yaśca kaścidvidhiranyo’pi śleṣma medo mūtra sañjananaḥ, sa sarvo nidāna viśeṣaḥ||5||
bahudravaḥ śleṣmā doṣa viśeṣaḥ||6||
bahvabaddhaṃ medo māṃsaṃ śarīraja kledaḥ śukraṃ śoṇitaṃ vasā majjā lasīkā rasaścaujaḥsaṅkhyāta iti dūṣya viśeṣāḥ||7||

Nidana

Pathogenic factors of Prameha:
The following  factors help in the immediate manifestation of Prameha due to Kapha. Of these factors, the etiological ones are as follows:

hāyanaka yava kacīna koddālaka naiṣadhetkaṭa mukundaka mahāvrīhi pramodaka sugandhakānāṃ navānāmativelamati pramāṇena copayogaḥ – Frequent and excessive intake of fresh corns like Hayanaka, Yavaka (a variety of Hordeum Vulare Linne), Cinaka, Uddalaka (cerebra odllam), Naisadha, Itkata, Mukundaka, Mahavrhi, Pramodaka and sugandhaka

tathā sarpiṣmatāṃ nava hareṇu māṣa sūpyānāṃ – Intake of Pulses like fresh Harenu (pisum Sativum Linn) and Masha (Phaseolus Radiatus Linn) with ghee

grāmyānūpaudakānāṃ ca māṃsānāṃ – Intake of the meat of domesticated , Marshy and aquatic animals
śāka tila palala piṣṭānna pāyasa kṛśarā vilepīkṣu vikārāṇāṃ – Intake of vegetables, Tila – Sesame (Sesamum indicum), oil cake of Tila – Sesame (Sesamum indicum), Pastry (Milk preparation), Krsara (gruel prepared of Tila – Sesame (Sesamum indicum), rice and blackgram, Vilepi ( a type of gruel prepared with four times of water) and preparations of sugarcane

kṣīra nava madya mandaka dadhi drava madhura taruṇa prāyāṇāṃ copayogaḥ – Intake of milk, fresh wine, immature curd and curd which are mostly liquid, sweet and immature in nature
mṛjā vyāyāma varjanaṃ – Avoidance of unction and physical exercise
svapna śayanāsana prasaṅgaḥ – Indulgence in sleep, bed rest and sedentary habits and
yaśca kaścidvidhiranyo’pi śleṣma medo mūtra sañjananaḥ – Resorting to even such other regimens which produce more of Kapha, fat and urine.
Kapha having liquidity in excess is the Dosha involved. Dhatus specially involved in this Prameha are:
Medas (fat)
Mamsa (muscle tissue)
Vasa (muscle fat)
Majja (marrow)
Kleda (body fluids)
Shukra (semen)
Rakta (blood)
Lasika (lymph) and
Rasa (Plasma) which later is also known as Ojas.
Of them, the first 4 Dhatus are of incurred quantity and decreases viscosity; remaining Dhatus are of increased quantity only. [5-7]

Samprapti

Samprapti – Pathogenesis of Kaphaja prameha:
त्रयाणामेषां निदानादि विशेषाणां सन्निपाते क्षिप्रं श्लेष्मा प्रकोपमापद्यते, प्रागति भूयस्त्वात्; स प्रकुपितः क्षिप्रमेव शरीरे विसृप्तिं लभते, शरीर शैथिल्यात्; स विसर्पञ् शरीरे मेदसैवादितो मिश्रीभावं गच्छति, मेदसश्चैव बह्व बद्धत्वान्मेदसश्च गुणैः समान गुण भूयिष्ठत्वात्; स मेदसा मिश्रीभवन् दूषयत्येनत्, विकृतत्वात्; स विकृतो दुष्टेन मेदसोपहितः शरीर क्लेद मांसाभ्यां संसर्गं गच्छति, क्लेद मांसयोरतिप्रमाणाभिवृद्धत्वात्; स मांसे मांस प्रदोषात् पूति मांस पिडकाः शराविका कच्छपिकाद्याः सञ्जनयति, अप्रकृतिभूतत्वात्; शरीर क्लेदं पुनर्दूषयन् मूत्रत्वेन परिणमयति, मूत्रवहानां च स्रोतसां वङ्क्षण बस्ति प्रभवाणां मेदःक्लेदोपहितानि गुरूणि मुखान्यासाद्य प्रतिरुध्यते; ततः प्रमेहांस्तेषां स्थैर्यमसाध्यतां वा जनयति, प्रकृति विकृति भूतत्वात्||८||
trayāṇāmeṣāṃ nidānādi viśeṣāṇāṃ sannipāte kṣipraṃ śleṣmā prakopamāpadyate, prāgati bhūyastvāt; sa prakupitaḥ kṣiprameva śarīre visṛptiṃ labhate, śarīra śaithilyāt; sa visarpañ śarīre medasaivādito miśrībhāvaṃ gacchati, medasaścaiva bahva baddhatvānmedasaśca guṇaiḥ samāna guṇa bhūyiṣṭhatvāt; sa medasā miśrībhavan dūṣayatyenat, vikṛtatvāt; sa vikṛto duṣṭena medasopahitaḥ śarīra kleda māṃsābhyāṃ saṃsargaṃ gacchati, kleda māṃsayoratipramāṇābhivṛddhatvāt; sa māṃse māṃsa pradoṣāt pūti māṃsa piḍakāḥ śarāvikā kacchapikādyāḥ sañjanayati, aprakṛtibhūtatvāt; śarīra kledaṃ punardūṣayan mūtratvena pariṇamayati, mūtravahānāṃ ca srotasāṃ vaṅkṣaṇa basti prabhavāṇāṃ medaḥkledopahitāni gurūṇi mukhānyāsādya pratirudhyate; tataḥ pramehāṃsteṣāṃ sthairyamasādhyatāṃ vā janayati, prakṛti vikṛti bhūtatvāt||8||

By the favorable combination of all 3 specific factors, viz causes, Doshas and Dhatus, Kapha gets immediately aggravated because of the excessiveness in quantity already attained by it and initiates the process of manifestation of Prameha. The aggravated Kapha spreads all over the body because body, it first of all gets mixed with Medas (fat) because there is an increase in the quantity and decrease in the viscosity of Medas Kapha itself is vitiated, it vitiates Medas while getting mixed with the latter.

The vitiated Kapha along with vitiated Medas gets inasmuch as these 2 are supposed to have already exceeded their quantity. Vitiation of the muscle tissue provides a congenial atmosphere for the manifestation of putrefied carbuncles like Saravika and Kacchapika in the muscle.

The liquid Dhatus of the body are further vitiated and transformed into urine. Kidneys and bladder are the root (controlling organs) of the channels carrying urine and the openings of these channels obstructs them. This results in the manifestation of Prameha which becomes chronic or incurable due to the affection of all the qualities of kapha and also due to the simultaneous vitiation of homogeneous and heterogeneous Dhatus. [8]

Signs, varieties, prognosis

Signs of Kaphaja Prameha, Varieties and Prognosis:
शरीरक्लेदस्तु श्लेष्म मेदो मिश्रः प्रविशन् मूत्राशयं मूत्रत्वमापद्यमानः श्लैष्मिकैरेभिर्दशभिर्गुणैरुपसृज्यते वैषम्य युक्तैः; तद्यथा- श्वेत शीत मूर्त पिच्छिलाच्छ स्निग्ध गुरु मधुर सान्द्र प्रसाद मन्दैः, तत्र येन गुणेनैकेनानेकेन वा भूयस्तरमुपसृज्यते तत्समाख्यं गौणं नाम विशेषं प्राप्नोति||९||
ते तु खल्विमे दश प्रमेहा नाम विशेषेण भवन्ति; तद्यथा- उदकमेहश्च, इक्षुवालिका रस मेहश्च, सान्द्र मेहश्च, सान्द्रप्रसाद मेहश्च, शुक्लमेहश्च, शुक्रमेहश्च, शीतमेहश्च, सिकतामेहश्च, शनैर्मेहश्च, आलालमेहश्चेति||१०||
ते दश प्रमेहाः साध्याः; समान गुण मेदःस्थानकत्वात्, कफस्य प्राधान्यात्, समक्रियत्वाच्च||११||
śarīrakledastu śleṣma medo miśraḥ praviśan mūtrāśayaṃ mūtratvamāpadyamānaḥ ślaiṣmikairebhirdaśabhirguṇairupasṛjyate vaiṣamya yuktaiḥ; tadyathā- śveta śīta mūrta picchilāccha snigdha guru madhura sāndra prasāda mandaiḥ, tatra yena guṇenaikenānekena vā bhūyastaramupasṛjyate tatsamākhyaṃ gauṇaṃ nāma viśeṣaṃ prāpnoti||9||
te tu khalvime daśa pramehā nāma viśeṣeṇa bhavanti; tadyathā- udakamehaśca, ikṣuvālikā rasa mehaśca, sāndra mehaśca, sāndraprasāda mehaśca, śuklamehaśca, śukramehaśca, śītamehaśca, sikatāmehaśca, śanairmehaśca, ālālamehaśceti||10||
te daśa pramehāḥ sādhyāḥ; samāna guṇa medaḥsthānakatvāt, kaphasya prādhānyāt, samakriyatvācca||11||

Signs of Kaphaja Prameha, Varieties and Prognosis:
Fluid Dhatus of the body along with Kapha and Medas (fat) enter into the kidneys and bladder and get transformed into urine. During this process they acquire then morbid qualities of Kapha, viz,
Śveta – whiteness
Śīta –coldness
Mūrta – viscosity
Picchilā – sliminess
Achha – transparency
Snigdha – unctuousness
Guru – heaviness
Madhura – sweetness
Sāndra prasāda – density combined with clarity and
Mandaiḥ – slowness
This Vitiates the morbid condition is named after these qualities- many of which may dominate the process of pathogenesis.

Types

Types of Kaphaja Prameha: 
Udakameha (Hydruria)
Iksuvalikarasameha (glycosuria)
Sandrameha (Chyluria)
Sandraprasadameha (Belluria)
Suklameha (passing of white urine)
Sukrameha (spermaturia)
Sheetameha (Phosphaturia)
Sikatameha (Graveluria)
Sannairmeha (Slow micturition)
Alalameha (Pruria)
These 10 types of Prameha are curable because:
The Medas (fat) having homogenous properties are affected
The Kapha is dominant and
Both these two factors are amenable to the same type of treatment [9-11]

Specific characteristic of Kaphaja Prameha:
तत्र श्लोकाः श्लेष्म प्रमेह विशेष विज्ञानार्था भवन्ति-||१२||
अच्छं बहु सितं शीतं निर्गन्धमुदकोपमम्|
श्लेष्मकोपान्नरो मूत्रमुदमेही प्रमेहति||१३||
अत्यर्थमधुरं शीतमीषत्पिच्छिलमाविलम्|
काण्डेक्षु रसमङ्काशं श्लेष्म कोपात् प्रमेहति||१४||
यस्य पर्युषितं मूत्रं सान्द्रीभवति भाजने|
पुरुषं कफ कोपेन तमाहुः सान्द्र मेहिनम्||१५||
यस्य संहन्यते मूत्रं किञ्चित् किञ्चित् प्रसीदति|
सान्द्र प्रसाद मेहीति तमाहुः श्लेष्मकोपतः||१६||
शुक्लं पिष्टनिभं मूत्रमभीक्ष्णं यः प्रमेहति|
पुरुषं कफकोपेन तमाहुः शुक्ल मेहिनम्||१७||
शुक्राभं शुक्रमिश्रं वा मुहुर्मेहति यो नरः|
शुक्रमेहिनमाहुस्तं पुरुषं श्लेष्म कोपतः||१८||
अत्यर्थमधुरं शीतं मूत्रं मेहति यो भृशम्|
शीत मेहिनमाहुस्तं पुरुषं श्लेष्म कोपतः||१९||
मूर्तान्मूत्रगतान् दोषानणून्मेहति यो नरः|
सिकतामेहिनं विद्यात्तं नरं श्लेष्म कोपतः||२०||
मन्दं मन्दमवेगं तु कृच्छ्रं यो मूत्रयेच्छनैः|
शनैर्मेहिनमाहुस्तं पुरुषं श्लेष्मकोपतः||२१||
तन्तु बद्धमिवालालं पिच्छिलं यः प्रमेहति|
आलालमेहिनं विद्यात्तं नरं श्लेष्म कोपतः||२२||
इत्येते दश प्रमेहाः श्लेष्म प्रकोप निमित्ता व्याख्याता भवन्ति||२३||
tatra ślokāḥ śleṣma prameha viśeṣa vijñānārthā bhavanti-||12||
acchaṃ bahu sitaṃ śītaṃ nirgandhamudakopamam|
śleṣmakopānnaro mūtramudamehī pramehati||13||
atyarthamadhuraṃ śītamīṣatpicchilamāvilam|
kāṇḍekṣu rasamaṅkāśaṃ śleṣma kopāt pramehati||14||
yasya paryuṣitaṃ mūtraṃ sāndrībhavati bhājane|
puruṣaṃ kapha kopena tamāhuḥ sāndra mehinam||15||
yasya saṃhanyate mūtraṃ kiñcit kiñcit prasīdati|
sāndra prasāda mehīti tamāhuḥ śleṣmakopataḥ||16||
śuklaṃ piṣṭanibhaṃ mūtramabhīkṣṇaṃ yaḥ pramehati|
puruṣaṃ kaphakopena tamāhuḥ śukla mehinam||17||
śukrābhaṃ śukramiśraṃ vā muhurmehati yo naraḥ|
śukramehinamāhustaṃ puruṣaṃ śleṣma kopataḥ||18||
atyarthamadhuraṃ śītaṃ mūtraṃ mehati yo bhṛśam|
śīta mehinamāhustaṃ puruṣaṃ śleṣma kopataḥ||19||
mūrtānmūtragatān doṣānaṇūnmehati yo naraḥ|
sikatāmehinaṃ vidyāttaṃ naraṃ śleṣma kopataḥ||20||
mandaṃ mandamavegaṃ tu kṛcchraṃ yo mūtrayecchanaiḥ|
śanairmehinamāhustaṃ puruṣaṃ śleṣmakopataḥ||21||
tantu baddhamivālālaṃ picchilaṃ yaḥ pramehati|
ālālamehinaṃ vidyāttaṃ naraṃ śleṣma kopataḥ||22||
ityete daśa pramehāḥ śleṣma prakopa nimittā vyākhyātā bhavanti||23||

The features of different types of Prameha caused by Kapha are given below:
Acchaṃ bahu sitaṃ śītaṃ nirgandhamudakopamam –
In Udakameha (Hydruria) the individual passes large quantity of water like urine which is transparent, white, cold and without any smell.
Atyarthamadhuraṃ śītamīṣatpicchilamāvilam kāṇḍekṣu rasamaṅkāśaṃ śleṣma kopāt pramehati – In Iksuvalikarasameha (glycosuria) the patient passes urine like the sugar cane juice which is exceedingly sweet, cold, slightly saline and turbid.
In Sandrameha (Chyluria) the patient passes urine like the sugar cane juice which is exceedingly sweet, cold, slightly saline and turbid.
In Sandraprasada meha (belluria) the urine of the patient becomes partly viscous and partly clear when kept overnight.
In Shukla Meha the patient passes urine having white color like that of pasted flour.
In Sukrameha (spematuria) the patient passes semen like that of pasted flour.
In Sheeta Meha  (Phoshpturia) the patient gets frequent maturation which is exceedingly sweet and cold
In Sikata meha (graveluria), the vitiated Doshas come through the urine in the form of small hard things.
Mandaṃ mandamavegaṃ tu kṛcchraṃ yo mūtrayecchanaiḥ| śanairmehinamāhustaṃ puruṣaṃ śleṣmakopataḥ –
In Shanair meha, the patient passes small quantity of urine with difficulty and very slowly
In Alalameha (pyuria), the patient passes urine which is slime phlegm and as if full of threads.
Thus ends 10 types of Prameha due to the vitiation of Kapha are explained [12-23]

Pittaja Prameha

Nidana – Causes and types of Pittaja Prameha:
उष्णाम्ल लवण क्षार कटुकाजीर्ण भोजनोप सेविनस्तथाऽतितीक्ष्णातपाग्नि सन्तापश्रम क्रोध विषमाहारोप सेविनश्च तथाविधशरीरस्यैव क्षिप्रं पित्तं प्रकोपमापद्यते, तत्तु प्रकुपितं तयैवानुपूर्व्या प्रमेहानिमान् षट् क्षिप्रतरमभिनिर्वर्तयति||२४||
तेषामपि तु खलु पित्तगुण विशेषेणैव नामविशेषा भवन्ति; तद्यथा- क्षारमेहश्च, कालमेहश्च, नीलमेहश्च, लोहितमेहश्च, माञ्जिष्ठमेहश्च, हारिद्रमेहश्चेति||२५||
ते षड्भिरेव क्षाराम्ल लवण कटुक विस्रोष्णैः पित्तगुणैः पूर्ववद्युक्ता भवन्ति||२६||
uṣṇāmla lavaṇa kṣāra kaṭukājīrṇa bhojanopa sevinastathā’titīkṣṇātapāgni santāpaśrama krodha viṣamāhāropa sevinaśca tathāvidhaśarīrasyaiva kṣipraṃ pittaṃ prakopamāpadyate, tattu prakupitaṃ tayaivānupūrvyā pramehānimān ṣaṭ kṣiprataramabhinirvartayati||24||
teṣāmapi tu khalu pittaguṇa viśeṣeṇaiva nāmaviśeṣā bhavanti; tadyathā- kṣāramehaśca, kālamehaśca, nīlamehaśca, lohitamehaśca, māñjiṣṭhamehaśca, hāridramehaśceti||25||
te ṣaḍbhireva kṣārāmla lavaṇa kaṭuka visroṣṇaiḥ pittaguṇaiḥ pūrvavadyuktā bhavanti||26||

Nidana

Nidana – Causes and types of Pittaja Prameha:
Pitta gets immediately aggravated in an individual whose body is affected by conditions mentioned above (in para 7) due to the following:-
uṣṇāmla lavaṇa kṣāra kaṭukājīrṇa bhojanopa sevina – Intake of hot, sour, saline, alkaline and pungent food
stathā’titīkṣṇātapāgni – Intake of food before the digestion of the previous meal
santāpaśrama krodha sevinaśca – Exposure to excessively hot sun, heat of the fire, physical exertion and anger and
viṣhama aahara sevina – Intake of mutually contradictory food articles.
The aggravated Pitta following the same pathogenic process (as mentioned in para 8) manifest 6 types of Prameha. The process of manifestation here is quicker than that of the Kaphameha.

Types, features

Types of Pittaja Meha: 
Ksarameha (Alkalinuria)
Kalameha (Melanuria)
Nilameha (Indigouria)
Raktameha (Hematuria)
Manjisthameha (Hemoglobinuria)
Haridrameha (Urobilinuria)
As described before, these varieties of Prameha are also manifested due to the permutation and combination of the 6 qualities of Pitta which are sour, saline, pungent, hot and having smell like that of raw flesh. [24-26]

Pathological characteristics Pittaja Prameha:
सर्व एव ते याप्याः संसृष्ट दोष मेदःस्थानत्वाद्विरुद्धोपक्रमत्वाच्चेति||२७||
तत्र श्लोकाः पित्त प्रमेह विशेष विज्ञानार्था भवन्ति-||२८||
गन्ध वर्ण रस स्पर्शैर्यथा क्षारस्तथाविधम्|
पित्तकोपान्नरो मूत्रं क्षारमेही प्रमेहति||२९||
मसी वर्ण मजस्रं यो मूत्रमुष्णं प्रमेहति|
पित्तस्य परिकोपेण तं विद्यात् काल मेहिनम्||३०||
चाषपक्षनिभं मूत्रमम्लं मेहति यो नरः|
पित्तस्य परिकोपेण तं विद्यान्नीलमेहिनम्||३१||
विस्रं लवणमुष्णं च रक्तं मेहति यो नरः|
पित्तस्य परिकोपेण तं विद्याद्रक्तमेहिनम्||३२||
मञ्जिष्ठोदक सङ्काशं भृशं विस्रं प्रमेहति|
पित्तस्य परिकोपात्तं विद्यान्माञ्जिष्ठमेहिनम्||३३||
हरिद्रोदक सङ्काशं कटुकं यः प्रमेहति|
पित्तस्य परिकोपात्तं विद्याद्धारिद्रमेहिनम्||३४||
इत्येते षट् प्रमेहाः पित्त प्रकोप निमित्ता व्याख्याता भवन्ति||३५||
sarva eva te yāpyāḥ saṃsṛṣṭa doṣa medaḥsthānatvādviruddhopakramatvācceti||27||
tatra ślokāḥ pitta prameha viśeṣa vijñānārthā bhavanti-||28||
gandha varṇa rasa sparśairyathā kṣārastathāvidham|
pittakopānnaro mūtraṃ kṣāramehī pramehati||29||
masī varṇa majasraṃ yo mūtramuṣṇaṃ pramehati|
pittasya parikopeṇa taṃ vidyāt kāla mehinam||30||
cāṣapakṣanibhaṃ mūtramamlaṃ mehati yo naraḥ|
pittasya parikopeṇa taṃ vidyānnīlamehinam||31||
visraṃ lavaṇamuṣṇaṃ ca raktaṃ mehati yo naraḥ|
pittasya parikopeṇa taṃ vidyādraktamehinam||32||
mañjiṣṭhodaka saṅkāśaṃ bhṛśaṃ visraṃ pramehati|
pittasya parikopāttaṃ vidyānmāñjiṣṭhamehinam||33||
haridrodaka saṅkāśaṃ kaṭukaṃ yaḥ pramehati|
pittasya parikopāttaṃ vidyāddhāridramehinam||34||
ityete ṣaṭ pramehāḥ pitta prakopa nimittā vyākhyātā bhavanti||35||

Pathological characteristics Pittaja Prameha:
All these types of Prameha are palliable because the site Medas which is vitiated in the pathogenesis of this disease is closer to threat of the affected Dosha that is Pitta and also because the treatment of Pitta and Medas is involved in mutual contradiction.

The specific features of different types of Prameha caused by Pitta are as follows:
pitta prameha viśeṣa vijñānārthā bhavanti gandha varṇa rasa sparśairyathā kṣārastathāvidham –
In Ksarameha (Alkalinuria) the patient passes urine having the smell, color, taste and touch like those of alkaline.
In Kalameha (Melanuria) the patient passes large quantity of black urine.
masī varṇa majasraṃ yo mūtramuṣṇaṃ pramehati –
In Neelameha (indigouria) the patient passes urine having sour taste and color like that of the feather of the Casa Bird (blue jay).

visraṃ lavaṇamuṣṇaṃ ca raktaṃ mehati yo naraḥ –
In Raktameha (Hematuria) the patient passes urine having red color, saline taste and smell like that of raw flesh

mañjiṣṭhodaka saṅkāśaṃ bhṛśaṃ visraṃ pramehati –
In Manjistha meha (hemoglobinuria) the patient frequently passes urine having the smell like that of raw flesh and color like that of the juice of Manjistha (rubia cordifolia Linn).

haridrodaka saṅkāśaṃ kaṭukaṃ yaḥ pramehati –
In Haridra meha (urobilinuria) the patient passes urine having pungent tastes and color like that of the juice of Haridra (turmeric – Curcuma longa)
Thus 6 varieties of Prameha due to the vitiation of Pitta are explained. [27-35]

Vataja Prameha

Nidana and Samprapti – Pathogenesis of Vataja Prameha:
कषाय कटु तिक्त रूक्ष लघु शीत व्यवाय व्यायाम वमन विरेचनास्थापन-शिरोविरेचनातियोग सन्धारणानशनाभिघातातपोद्वेगशोक शोणितातिषेक- जागरण विषम शरीरन्यासानुपसेवमानस्य तथा विध शरीरस्यैव क्षिप्रं वातः प्रकोपमापद्यते||३६||
स प्रकुपितस्तथाविधे शरीरे विसर्पन् यदा वसामादाय मूत्रवहानि स्रोतांसि प्रतिपद्यते तदा वसा मेहमभिनिर्वर्तयति; यदा पुनर्मज्जानं मूत्रबस्तावाकर्षति तदा मज्ज मेहमभिनिर्वर्तयति; यदा तु लसीकां मूत्राशयेऽभिवहन्मूत्रमनुबन्धं च्योतयति लसीकातिबहुत्वाद्विक्षेपणाच्च वायोः खल्वस्यातिमूत्रप्रवृत्ति सङ्गं करोति, तदा स मत्त इव गजः क्षरत्यजस्रं मूत्रमवेगं, तं हस्तिमेहिनमाचक्षते; ओजः पुनर्मधुरस्वभावं, तद् यदा रौक्ष्याद्वायुः कषायत्वेनाभिसंसृज्य मूत्राशयेऽभिवहति तदा मधुमेहं करोति||३७||
kaṣāya kaṭu tikta rūkṣa laghu śīta vyavāya vyāyāma vamana virecanāsthāpana-śirovirecanātiyoga sandhāraṇānaśanābhighātātapodvegaśoka śoṇitātiṣeka- jāgaraṇa viṣama śarīranyāsānupasevamānasya tathā vidha śarīrasyaiva kṣipraṃ vātaḥ prakopamāpadyate||36||
sa prakupitastathāvidhe śarīre visarpan yadā vasāmādāya mūtravahāni srotāṃsi pratipadyate tadā vasā mehamabhinirvartayati; yadā punarmajjānaṃ mūtrabastāvākarṣati tadā majja mehamabhinirvartayati; yadā tu lasīkāṃ mūtrāśaye’bhivahanmūtramanubandhaṃ cyotayati lasīkātibahutvādvikṣepaṇācca vāyoḥ khalvasyātimūtrapravṛtti saṅgaṃ karoti, tadā sa matta iva gajaḥ kṣaratyajasraṃ mūtramavegaṃ, taṃ hastimehinamācakṣate; ojaḥ punarmadhurasvabhāvaṃ, tad yadā raukṣyādvāyuḥ kaṣāyatvenābhisaṃsṛjya mūtrāśaye’bhivahati tadā madhumehaṃ karoti||37||

Nidana, Samprapti

Nidana and Samprapti – Pathogenesis of Vataja Prameha:
Vata gets immediately in an individual whose body is afflicted with the conditions mentioned above (in para 7) due the following:-
kaṣāya kaṭu tikta rūkṣa laghu śīta aahara – Excessive intake of astringent, pungent, bitter, rough light and credit things.
Ati vyavāya vyāyāma – Excessive indulgence in sex and physical exercise

vamana virecanāsthāpana-śirovirecanātiyoga – Excessive administration of emesis, purgation, Asthapana type of enema and Sirvovirecana (elimination of Doshas from the head)

sandhāraṇānaśanābhighātātapodvega śoka śoṇitātiṣeka jāgaraṇa viṣama śarīranyāsānupasevamānasya tathā vidha śarīrasyaiva kṣipraṃ vātaḥ prakopamāpadyate – Resorting to suppression of the manifested urges, fasting, assault, exposure to sun, anxiety, grief, excessive bloodletting, keeping awake at night and irregular posture of the body.

The aggravated Vata in that type of body spreads, and along with Vasa (muscle fat), enters into channels carrying urine leading to the manifestation of Vasameha (lipuria). When it carries marrow to the urinary bladder then it results in Majjameha (Myelouria).

Due to the excess in quality of Lasika (lymph) and also due to the property of Vata to dissipate things, when the lymph entering into the urinary bladder produces large quantity of urine, the patient feels continuous urge for micturtion and passes large quantity of urine continously (even) without any pressure like an elephant gone amuck. This is known as Hastimeha (diabetes insipidus).
Ojas, by nature is of sweet taste. When due to the roughness, Vata converts it into that of astringent taste and takes it into the urinary bladder, due to its roughness, this causes Madhumeha (Diabetes mellitus) [36- 37]

Vataja Prameha Asadhyata

Asadhyata – incurable characteristics of Vataja Prameha:
इमांश्चतुरः प्रमेहान् वातजानसाध्यानाचक्षते भिषजः, महात्ययिकत्वाद्विरुद्धोपक्रमत्वाच्चेति||३८||
तेषामपि पूर्ववद्गुण विशेषेण नाम विशेषा भवन्ति; तद्यथा- वसामेहश्च, मज्जमेहश्च, हस्तिमेहश्च, मधुमेहश्चेति||३९||
तत्र श्लोका वात प्रमेह विशेष विज्ञानार्था भवन्ति||४०||
वसामिश्रं वसाभं वा मुहु र्मेहति यो नरः|
वसामेहिनमाहुस्तमसाध्यं वातकोपतः||४१||
मज्जानं सह मूत्रेण मुहुर्मेहति यो नरः|
मज्जमेहिनमाहुस्तमसाध्यं वातकोपतः||४२||
हस्ती मत्त इवाजस्रं मूत्रं क्षरति यो भृशम्|
हस्तिमेहिनमाहुस्तमसाध्यं वातकोपतः||४३||
कषाय मधुरं पाण्डु रूक्षं मेहति यो नरः|
वातकोपादसाध्यं तं प्रतीयान्मधुमेहिनम्||४४||
इत्येते चत्वारः प्रमेहा वात प्रकोप निमित्ता व्याख्याता भवन्ति||४५||
एवं त्रिदोष प्रकोप निमित्ता विंशतिः प्रमेहा व्याख्याता भवन्ति||४६||
imāṃścaturaḥ pramehān vātajānasādhyānācakṣate bhiṣajaḥ, mahātyayikatvādviruddhopakramatvācceti||38||
teṣāmapi pūrvavadguṇa viśeṣeṇa nāmaviśeṣā bhavanti; tadyathā- vasāmehaśca, majjamehaśca, hastimehaśca, madhumehaśceti||39||
tatra ślokā vāta prameha viśeṣa vijñānārthā bhavanti||40||
vasāmiśraṃ vasābhaṃ vā muhurmehati yo naraḥ|
vasāmehinamāhustamasādhyaṃ vātakopataḥ||41||
majjānaṃ saha mūtreṇa muhurmehati yo naraḥ|
majjamehinamāhustamasādhyaṃ vātakopataḥ||42||
hastī matta ivājasraṃ mūtraṃ kṣarati yo bhṛśam|
hastimehinamāhustamasādhyaṃ vātakopataḥ||43||
kaṣāya madhuraṃ pāṇḍu rūkṣaṃ mehati yo naraḥ|
vātakopādasādhyaṃ taṃ pratīyānmadhumehinam||44||
ityete catvāraḥ pramehā vāta prakopa nimittā vyākhyātā bhavanti||45||
evaṃ tridoṣa prakopa nimittā viṃśatiḥ pramehā vyākhyātā bhavanti||46||

These 4 varieties of Prameha due to the Vitiation of Vata are known to be incurable because of their seriousness and also because of the contradiction involved in their treatment.
As in the case of other Pramehas, these varieties of Prameha are also named after the attributes involved in the pathogenesis.

Types

Types of Vataja prameha: 
Vasameha (Lipuria)
Majjameha (Myelo-Uria)
Hastimeha (Diabetes Insipidus) and
Madhumeha (Diabetes Mellitus).

The specific features of different of Prameha caused by Vata are given below:
In Vasameha (lipuria) which is incurable and caused by the aggravation of Vata the patient frequently passes urine mixed with Vasa (muscle fat) or having the appearance of Vasa

Majjānaṃ saha mūtreṇa muhurmehati yo naraḥ majjamehinamāhustamasādhyaṃ vātakopataḥ –
In Majjameha (myelo-Uria) which is incurable and caused by the aggravation of Vata the patient passes urine mixed with Majja (marrow)

Hastī matta ivājasraṃ mūtraṃ kṣarati yo bhṛśam –
In Hastimeha (Diabetes insipidus) which is incurable and caused by the aggravation of Vata, the patient frequently passes large quantity of urine frequently like an elephant gone amuck.

Kaṣāya madhuraṃ pāṇḍu rūkṣaṃ mehati yo naraḥ –
In Madhumeha (Diabetes Mellitus) which is incurable and caused by the aggravation of Vata the patient passes large quantity of urine, sweet and astringent in taste, pale in color and ununctuous.

The 4 varieties of Prameha due to the aggravation of Vata are thus explained. Thus the 20 types of Prameha due to the aggravation of the 3 Doshas are explained. [38-46]

Prameha Poorvaroopa

त्रयस्तु खलु दोषाः प्रकुपिताः प्रमेहानभिनिर्वर्तयिष्यन्त इमानि पूर्वरूपाणि दर्शयन्ति; तद्यथा- जटिलीभावं केशेषु, माधुर्यमास्यस्य, करपादयोः सुप्तता दाहौ, मुख तालु कण्ठ शोषं, पिपासाम्, आलस्यं, मलं काये, कायच्छिद्रेषूपदेहं, परिदाहं सुप्ततां चाङ्गेषु, षट्पद पिपीलिकाभिश्च शरीर मूत्राभिसरणं, मूत्रे च मूत्रदोषान्, विस्रं शरीरगन्धं, निद्रां, तन्द्रां च सर्वकालमिति||४७||
trayastu khalu doṣāḥ prakupitāḥ pramehānabhinirvartayiṣyanta imāni pūrvarūpāṇi darśayanti; tadyathā- jaṭilībhāvaṃ keśeṣu, mādhuryamāsyasya, karapādayoḥ suptatā dāhau, mukha tālu kaṇṭha śoṣaṃ, pipāsām, ālasyaṃ, malaṃ kāye, kāyacchidreṣūpadehaṃ, paridāhaṃ suptatāṃ cāṅgeṣu, ṣaṭpada pipīlikābhiśca śarīra mūtrābhisaraṇaṃ, mūtre ca mūtradoṣān, visraṃ śarīragandhaṃ, nidrāṃ, tandrāṃ ca sarvakālamiti||47||

Premonitory symptoms of Prameha:
The 3 vitiated Doshas while initiating the process of manifestation of various types of Prameha produces the following pre-monitory symptoms:
Jaṭilībhāvaṃ keśeṣu – Matting of the hair
Mādhuryamāsyasya – Sweet taste in the mouth
Karapādayoḥ suptatā dāhau -Numbness and burning sensation in hands and feet
Mukha tālu kaṇṭha śoṣaṃ -Dryness in mouth, palate and throat
Pipāsām -Thirst
Aalasyaṃ – laziness
malaṃ kāye – Increased amount of excreta from the body
Kāyacchidreṣūpadehaṃ – Adherence of excreta in the orifices of the body
Paridāhaṃ suptatāṃ cāṅgeṣu – Burning sensation and numbness in various organs of the body
Shaṭpada pipīlikābhiśca śarīra mūtrābhisaraṇaṃ – Attraction of insects and by the body and urine
Mūtre ca mūtradoṣān – Appearance of abnormalities in the urine
Visraṃ śarīragandhaṃ – Smell of raw flesh in the urine and
Nidrāṃ, tandrāṃ ca sarvakālamiti – Excessive sleep and continuous drowsiness. [47]

Prameha Upadrava

Prameha Upadrava – Complications and line of treatment:
उपद्रवास्तु खलु प्रमेहिणां तृष्णातीसार ज्वर दाह दौर्बल्यारोचकाविपाकाः पूतिमांस पिडकालजी विद्रध्यादयश्च तत्प्रसङ्गाद्भवन्ति||४८||
तत्र साध्यान् प्रमेहान् संशोधनोपशमनैर्यथार्हमुपपादयंश्चिकित्सेदिति||४९||
upadravāstu khalu pramehiṇāṃ tṛṣṇātīsāra jvara dāha daurbalyārocakāvipākāḥ pūtimāṃsa piḍakālajī vidradhyādayaśca tatprasaṅgādbhavanti||48||
tatra sādhyān pramehān saṃśodhanopaśamanairyathārhamupapādayaṃścikitsediti||49||

Complications of Prameha are
Trshuna – thirst
Atisara – diarrhoea
Jvara – fever
Daha – burning sensation
Daurbalya – weakness
Arochaka – anorexia and
Avipaka – indigestion
pūtimāṃsa piḍakālajī vidradhyādayaśca tatprasaṅgādbhavanti – Carbuncles which putrefy the muscle tissues like Alaji and Vidradhi appear during the chronic stage of the disease.
Of them the curable types of Prameha is treated with the appropriate elimination and alleviation therapies. [48-49]

Etiology

Brief etiology:
भवन्ति चात्र- गृध्नुमभ्यवहार्येषु स्नान चङ्क्रमणद्विषम्|
प्रमेहः क्षिप्रमभ्येति नीडद्रुममिवाण्डजः||५०||
मन्दोत्साहमतिस्थूलमतिस्निग्धं महाशनम्|
मृत्युः प्रमेह रूपेण क्षिप्रमादाय गच्छति||५१||
यस्त्वाहारं शरीरस्य धातु साम्यकरं नरः|
सेवते विविधाश्चान्याश्चेष्टाः स सुखमश्नुते||५२||
bhavanti cātra- gṛdhnumabhyavahāryeṣu snānacaṅkramaṇadviṣam|
pramehaḥ kṣipramabhyeti nīḍadrumamivāṇḍajaḥ||50||
mandotsāhamatisthūlamatisnigdhaṃ mahāśanam|
mṛtyuḥ prameha rūpeṇa kṣipramādāya gacchati||51||
yastvāhāraṃ śarīrasya dhātu sāmyakaraṃ naraḥ|
sevate vividhāścānyāśceṣṭāḥ sa sukhamaśnute||52||

Thus it said:
As the birds are attracted towards the trees where it lays their nests similarly, Prameha affects people who are voracious eaters and have aversion to bath and physical exercises.
Death immediately comes in the form of Prameha to those who are less enthusiastic, over corpulent, over unctuous and gluttons.
The individual who takes such diets and resorts to such regimens which bring about normal state of the Dhatus in the body leads a happy life. [50-52]

Conclusion:
तत्र श्लोकाः- हेतु र्व्याधि विशेषाणां प्रमेहाणां च कारणम्|
दोष धातु समायोगो रूपं विविधमेव च||५३||
दश श्लेष्मकृता यस्मात् प्रमेहाः षट् च पित्तजाः|
यथा च वायुश्चतुरः प्रमेहान् कुरुते बली||५४||
साध्यासाध्य विशेषाश्च पूर्वरूपाण्युपद्रवाः|
प्रमेहाणां निदानेऽस्मिन् क्रियासूत्रं च भाषितम्||५५||
tatra ślokāḥ- hetu rvyādhi viśeṣāṇāṃ pramehāṇāṃ ca kāraṇam|
doṣa dhātu samāyogo rūpaṃ vividhameva ca||53||
daśa śleṣmakṛtā yasmāt pramehāḥ ṣaṭ ca pittajāḥ|
yathā ca vāyuścaturaḥ pramehān kurute balī||54||
sādhyāsādhya viśeṣāśca pūrvarūpāṇyupadravāḥ|
pramehāṇāṃ nidāne’smin kriyāsūtraṃ ca bhāṣitam||55||

To sum up:
In this chapter of Prameha Nidana, following topics have been discussed:-
Causative factors of diseases and those (specially) pertaining to various types of Prameha
Combination of Doshas and Dhatus
Signs and symptoms (of different types of Prameha)
Process of manifestation of 10, 6 and 4 varieties of Prameha caused by Kapha, Pitta and Vata respectively
Their prognosis, premonitory symptoms and complications and
Their line of treatment [53- 55]

इत्यग्निवेशकृते तन्त्रे चरक प्रति संस्कृते निदान स्थाने प्रमेह निदानं नाम चतुर्थोऽध्यायः||४||
ityagniveśakṛte tantre caraka pratisaṃskṛte nidānasthāne prameha nidānaṃ nāma caturtho’dhyāyaḥ||4||
Thus ends the 4th chapter on the Diagnosis of Prameha of the section on Diagnosis of Diseases (Nidana sthana) of Agnivesha’s work as redacted by Charaka.
Chapter edited by Dr Malini Bhat.

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