Ashtanga Hridayam Nidanasthanam Chapter 10:  Prameha Nidanam Adhyaya (Diagnosis of diabetes, polyuria)

The 10th chapter of Nidanasthanam of Ashtanga Hridayam is named as Prameha Nidanam Adhyayah. This chapter deals with the explanation of ‘diagnosis of diabetes, polyuria’.

The topics covered in this chapter include –

–       Prameha Sankhya (kinds of diabetes)
–       Nidana (causes), Samprapti (pathogenesis), Sadhyasadhyata (prognosis), Rupa (clinical features) of prameha
–       Reasons for manifestation of many kinds of prameha (diabetes)
–       Kaphaja, Pittaja and Vataja Meha (diabetes) types and symptoms
–       Dhatukshayajanya and Avaranajanya Meha
–       Prameha Upadrava (complications of diabetes)
–       Prameha Pitaka (diabetes ulcers / carbuncles)
–       Sapekshya Nidana (differential diagnosis)
–       Prameha Purvarupa (premonitory symptoms of diabetes)
–       Prameha Sadhyasadhyata (prognosis of diabetes)

Pledge by the author(s)

अथातो प्रमेहनिदानं व्याख्यास्याम ।
इति ह स्माहुरात्रेयादयो महर्षय: ।

After having offered prayers to the God, henceforth we are going to explain the chapter pertaining to the explanation of ‘diagnosis of diabetes, polyuria’. Thus say (pledge) atreya and other sages.

Prameha Sankhya (kinds of diabetes)

प्रमेहा विंशतिस्तत्र श्लेष्मतो दश पित्ततः ।
षट् चत्वारोऽनिलात्तेषां
Prameha (polyuria, diabetes) are twenty, out of which ten are born from Slesma (Kapha), six types are due to Pitta and four from Anila (Vata).

Nidana (causes)

मेदोमूत्रकफावहम् ॥ १ ॥
अन्नपानक्रियाजातं यत्प्रायस्तत्प्रवर्तकम् ।
स्वाद्वम्ललवणस्निग्धगुरुपिच्छिलशीतलम् ॥ २ ॥
नवधान्यसुरानूपमांसेक्षुगुडगोरसम् ।
एकस्थानासनरतिः शयनं विधिवर्जितम् ॥ ३ ॥
Foods, drinks and activities which generally produce increase of Medas (fat), Mutra(urine) and Kapha are the chief causes, such as, foods which are sweet, sour, salt, unctuous difficult to digest, sticky and cold; fresh grains, wine, meat of animals of marshy regions, sugarcane juice, molasses and milk; (habit of) always sitting at a place sleeping without adopting its proper procedure.

Kaphaja Prameha Samprapti (pathogenesis)

बस्तिमाश्रित्य कुरुते प्रमेहान् दूषितः कफः ।
दूषयित्वा वपुःक्लेदस्वेदमेदोरसामिषम् ॥ ४ ॥
Vitiated Kapha gets localized in urinary bladder vitiates the water element in the body (vitiates) sweat, fat, plasma and muscle to produce Kaphaja Prameha.

Pittaja and Vataja Prameha Samprapti (pathogenesis)

पित्तं रक्तमपि क्षीणे कफादौ मूत्रसंश्रयम् ।
धातून् बस्तिमुपानीय तत्क्षयेऽपि च मारुतः ॥ ५ ॥
Kapha and its related Dhatus are decreased Imbalanced Pitta vitiates Rakta Dhatu and Kleda (moisture part) of the body, sweat, fat, plasma and musclegets lodged in residence of urine (urinary bladder) to cause Prameha of Pitta origin. Even Vata also causes Prameha,even Vata also causes Prameha, by dragging the Dhatus (watery tissues) into the bladder when they are depleted.

Sadhya Asadhyata (prognosis)

साध्ययाप्यपरित्याज्या मेहास्तेनैव तद्भवाः ।
समासमक्रियतया महात्ययतयाऽपि च ॥ ६ ॥
Prameha is classified as curable, controllable and rejectable, on the basis of their root cause of origin – Doshas. Based on identical therapy (Sama Kriya) for both Kapha Dosha and Prameha, in case of Kaphaja Prameha, unidentical, opposite therapies for Pitta and Prameha, in case of Pittaja Prameha and greater danger involved due to excessively aggravated Vata Dosha, in case of Vataja Prameha.

Notes: The above brief statement is explained as follows; the ten kinds of Prameha produced by Kapha are curable because in them, the causative Dosha and Dusyas (tissues and wastes) are identical (of the same qualities) and so drugs and therapies are the same for both (identical therapy). The six kinds produced by Pitta, are controllable but persist till death because in these the causative Dosha (Pitta) and the Dushyas (tissues and wastes) are of different qualities and so drugs therapies have to be different (non-identical therapy). The four kinds produced by Vata are incurable because of the risk of grave complication/ secondary diseases arising due to loss of all tissues.

Rupa (clinical features)

Samanya Lakshana (common symptoms)

सामान्यं लक्षणं तेषां प्रभूताविलमूत्रता ।
The common symptoms in all of them areincreased quantity and Turbidity of the urine.

Reasons for many manifestations of prameha

दोषदूष्याविशेषेऽपि तत्संयोगविशेषतः ॥ ७ ॥
मूत्रवर्णादिभेदेन भेदो मेहेषु कल्प्यते ।
Though the doshas and Dusyas are similar, due to the peculiarities of their combination, there occurs differences in Prameha types, in color etc. (other properties) of urine in prameha, the types of Prameha are described further.

Kaphaja Meha (diabetes caused by Kapha)

1. Udaka Meha

अच्छं बहु सितं शीतं निर्गन्धमुदकोपमम् ॥ ८ ॥
मेहत्युदकमेहेन किञ्चिच्चाविलपिच्छिलम् ।
In Udaka Meha the person passes urine which is,clear (not turbid) large in quantity, white, cold,odorless, resembling water,sometimes with slight turbidity and sliminess.

2. Ikshu Meha

इक्षो रसमिवात्यर्थं मधुरं चेक्षुमेहतः ॥ ९ ॥
In Iksumeha, the urine is like the juice of sugarcane and very sweet.

3. Sandra Meha

सान्द्रीभवेत्पर्युषितं सान्द्रमेहेन मेहति ।
In Sandra Meha urine becomes thick, when kept over-night.

4. Sura Meha

सुरामेही सुरातुल्यमुपर्यच्छमधो घनम् ॥ १० ॥
In Sura Meha the urine resembles Sura (alcohol) with clear liquid in the top portion and thick and dense bottom portion.

5. Pishta Meha

संहृष्टरोमा पिष्टेन पिष्टवद्बहलं सितम् ।
In Pista Meha, the person has horripilations, voids urine which is thick like a solution of corn flour and is white in colour.

6. Shukra Meha

शुक्राभं शुक्रमिश्रं वा शुक्रमेही प्रमेहति ॥ ११ ॥
In Sukra Meha the urine is, like semen or mixed with semen.

7. Sikata Meha

मूर्ताणून् सिकतामेही सिकतारूपिणो मलान् ।
Patient of Sikata meha passes urine containing dirty particles resembling sand.

8. Sheetameha

शीतमेही सुबहुशो मधुरं भृशशीतलम् ॥ १२ ॥
Patient of Sheetameha passes large quantities of urine, which is sweet and very cold.

9. Shanairmeha

शनैः शनैः शनैर्मेही मन्दं मन्दं प्रमेहति ।
The patient of Shanairmeha passes excessive quantity of urine, very frequently, very slowly.

10. Lala Meha

लालातन्तुयुतं मूत्रं लालामेहेन पिच्छिलम् ॥ १३ ॥
Due to Lalameha, the urine appears threaded, like saliva and is slimy.

Pittaja Meha (Urinary disorders caused by Pitta)

1. Kshara Meha

गन्धवर्णरसस्पर्शैः क्षारेण क्षारतोयवत् ।
In Ksara Meha –the urine resembles solution of Alkali has smell, colour, taste and touch of alkali water.

2, 3 – Neela Meha, Kala Meha

नीलमेहेन नीलाभं कालमेही मषीनिभम् ॥ १४ ॥
In Nila Meha it (urine) is blue. In Kala Meha, urine resembles ink (black).

4. Haridra Meha

हारिद्रमेही कटुकं हरिद्रासन्निभं दहत् ।
The patient of Haridra Meha passes urine which is Pungent, resembles turmeric (yellow in color), associated with burning sensation.

5. Manjishta Meha

विस्रं माञ्जिष्ठमेहेन मञ्जिष्ठासलिलोपमम् ॥ १५ ॥
Due to Manjishta Meha, urine is foul smelling, resembles solution of Manjista (slight red in color).

6. Rakta Meha

विस्रमुष्णं सलवणं रक्ताभं रक्तमेहतः ।
Due to Raktameha, urine is foul smelling, hot slight salty and resembles blood (red in color).

Vataja Meha (diabetes caused by Vata)

1. Vasameha

वसामेही वसामिश्रं वसां वा मूत्रयेन्मुहुः ॥ १६ ॥
In Vasameha the urine is mixed with muscle fat. The patient urinates only the fat or urine mixed with fat, repeatedly

2. Majjameha

मज्जानं मज्जमिश्रं वा मज्जमेही मुहुर्मुहुः ।
In Majja Meha – the person passes only marrow or urine mixed marrow frequently.

3. Hastimeha

हस्ती मत्त इवाजस्रं मूत्रं वेगविवर्जितम् ॥ १७ ॥
सलसीकं विबद्धं च हस्तिमेही प्रमेहति ।
In Hasti Meha, the person passes urine in large quantities, urination happens like an elephant in rut, continuously without force, mixed Lasika (lymph) and with obstruction (difficulty).

4. Madhumeha

मधुमेही मधुसमं
In Madhumeha the person passes urine resembling honey (in taste).

Two types of Madhumeha – Dhatukshayajanya and Avaranajanya Meha (diabetes caused due to destruction of tissues and due to obstruction of passages)

Two types of Madhumeha

जायते स किल द्विधा ॥ १८ ॥
क्रुद्धे धातुक्षयाद्वायौ दोषावृतपथेऽथवा ।
This (Madhumeha) arises in two ways, by the aggravation of Vata caused by a Dhatuksaya- depletion/loss of tissues or by obstruction of Vata’s path by the Doshas covering it.

Severity of Dosha Avruta type of Madhumeha

आवृतो दोषलिङ्गानि सोऽनिमित्तं प्रदर्शयेत् ॥ १९ ॥
क्षीणः क्षणात्क्षणात् पूर्णो भजते कृच्छ्रसाध्यताम् ।
In the obstructed kind, it (Vata) exhibits the symptoms of the Dosha covering it, without any other reason. Hence the bladder is found sometimes empty and sometimes full, and the disease becomes difficult to cure.

All Types of Prameha turn Madhumeha over time

कालेनोपेक्षिताः सर्वे यद्यान्ति मधुमेहताम् ॥ २० ॥
मधुरं यच्च सर्वेषु प्रायो मध्विव मेहति ।
सर्वेऽपि मधुमेहाख्या माधुर्याच्च तनोरतः ॥ २१ ॥
All varieties (of Prameha) if neglected will, over a period of time, become Madhumeha. All those in which the urine is sweet resembling honey and the body also becomes sweet, hence all chronic Pramehas are called Madhumeha.

Prameha Upadrava (complications / secondary diseases)

1. Upadravas of Kaphaja Pramehas –

अविपाकोऽरुचिश्छर्दिर्निद्रा कासः सपीनसः ।
उपद्रवाः प्रजायन्ते मेहानां कफजन्मनाम् ॥ २२ ॥
Poor digestion, anorexia, vomiting, excessive sleep, cough and nasal catarrh are the complications / secondary diseases of Prameha arising from Kapha.

2. Upadravas of Pittaja prameha

बस्तिमेहनयोस्तोदो मुष्कावदरणं ज्वरः ।
दाहस्तृष्णाम्लको मूर्छा विड्भेदः पित्तजन्मनाम् ॥ २३ ॥
Pain in the bladder and penis, exudations from the scrotum, fever, burning sensation, excessive thirst, sourness (increased acidity), fainting loose bowels are the Upadrava of Prameha arising from Pitta.

3. Complications of Vataja Prameha

वातिकानामुदावर्तकम्पहृद्ग्रहलोलताः ।
शूलमुन्निद्रता शोषः कासः श्वासश्च जायते ॥ २४ ॥
Bloating of abdomen (upward movement of Vata), tremors, catching pain in the region of the heart, excess desire for foods and drinks, pain in the abdomen, loss of sleep, dryness (of the mouth, throat etc); cough and dyspnoea. These compilications arise due to Vataja Pramehas.

Prameha Pitaka (diabetes ulcer / carbuncles)

शराविका कच्छपिका जालिनी विनतालजी ।
मसूरिका सर्षपिका पुत्रिणी सविदारिका ॥ २५ ॥
विद्रधिश्चेति पिटिकाः प्रमेहोपेक्षया दश ।
सन्धिमर्मसु जायन्ते मांसलेषु च धामसु ॥ २६ ॥
Saravika, Kacchapika, Jalini, Vinata, Alaji, Masurika, Sarasapika, Putrini, Vidrarika and Vidhradhi – are the ten eruptions / ulcers caused due to negligence of prameha appearing on the joints, vital spots and muscular parts during the course of diabetes.

Prameha Pitaka (diabetes ulcer / carbuncles)

1. Sharavika Prameha Pidaka

अन्तोन्नता मध्यनिम्ना श्यावा क्लेदरुजान्विता ।
शरावमानसंस्थाना पिटिका स्याच्छराविका ॥ २७ ॥
Saravika is Pitaka (carbuncles /ulcers), having elevated edges and depressed center, black in color, associated with exudation and pain, resembling a saucer in size and shape.

2. Kacchapika Prameha Pidaka

अवगाढार्तिनिस्तोदा महावस्तुपरिग्रहा ।
श्लक्ष्णा कच्छपपृष्ठाभा पिटिका कच्छपी मता ॥ २८ ॥
Kacchapika is Pitaka having severe (deep) pain, pricking pain, continuous or intermittent, extends over a large area, smooth and resembles the shell of a tortoise.

3. Jalini Prameha Pidaka

स्तब्धा सिराजालवती स्निग्धस्रावा महाशया ।
रुजानिस्तोदबहुला सूक्ष्मच्छिद्रा च जालिनी ॥ २९ ॥
Jalini is stable, stiff, has venous network, greasy (unctuous) exudates, has big cavity inside, with severe pain, severe pricking pain, has minute openings.

4. Vinata Prameha Pidaka

अवगाढरुजाक्लेदा पृष्ठे वा जठरेऽपि वा ।
महती पिटिका नीला विनता विनता स्मृता ॥ ३० ॥
Vinata is big sized eruption, developing either on the back or on the abdomen, blue in color having severe (deep) pain exudation and pointed downwards.

5. Alaji Prameha Pidaka

दहति त्वचमुत्थाने भृशं कष्टा विसर्पिणी ।
रक्तकृष्णातितृट्स्फोटदाहमोहज्वरालजी ॥ ३१ ॥
Alaji has burning sensation with elevation of the skin, very difficult to bear, spreads to other places, reddish-black in color accompanied with severe thirst, boils (appearing in different places of the body), and burning sensation all over the body, delusion and fever.

6. Masurika Prameha Pidaka

मानसंस्थानयोस्तुल्या मसूरेण मसूरिका ।
Masurika resembles Masura (lentil) in size and shape.

7. Sarshapi Prameha Pidaka

सर्षपामानसंस्थाना क्षिप्रपाका महारुजा ॥ ३२ ॥
सर्षपी सर्षपातुल्यपिटिकापरिवारिता ।
Sarsapika is like Sarsapa (mustard seed) in size and shape, ulcerates soon, has severe pain surrounded by eruptions, resembling mustard seeds.

8. Putrini, Vidarika Prameha Pidaka

पुत्रिणी महती भूरिसुसूक्ष्मपिटिकाचिता ॥ ३३ ॥
विदारीकन्दवद्वृत्ता कठिना च विदारिका ।
Putrini is a big eruption, surrounded by many small eruptions. Vidarika is round like the tuber of Vidani and hard.

Prameha Pitaka (diabetes ulcer / carbuncles)

विद्रधिर्वक्ष्यतेऽन्यत्र तत्राद्यं पिटिकात्रयम् ॥ ३४ ॥
पुत्रिणी च विदारी च दुःसहा बहुमेदसः ।
सह्याः पित्तोल्बणास्त्वन्याः सम्भवन्त्यल्पमेदसः ॥ ३५ ॥
तासु मेहवशाच्च स्याद्दोषोद्रेको यथायथम् |
प्रमेहेण विनाप्येता जायन्ते दुष्टमेदसः |
तावच्च नोपलक्ष्यन्ते यावद्वस्तुपरिग्रहः ॥ ३६ ॥
Vidhradi will be described elsewhere (in the next chapter). Out of these, the first three (Saravika, Kacchapika and Jalini), Putrini and Vidarika are difficult to bear (and also to threat), these arise from predominance of fat tissue, the remaining and those having predominance of Pitta and arise from less fat are bearable (and easy to treat). In these (eruptions) the recognition of aggravation of Doshas is similar to that of (the kinds of) diabetes. These eruptions occur even without Prameha, due to vitiation of fat tissue but are not taken note of (treated) till they get localized (permanently at one place).

Sapekshya Nidana (differential diagnosis)

हारिद्रवर्णं रक्तं वा मेहप्राग्रूपवर्जितम् ।
यो मूत्रयेन्न तं मेहं रक्तपित्तं तु तद्विदुः ॥ ३७ ॥
If a person passes urine having the color either or turmeric, deep yellow) or of blood (red) without the appearance of premonitory symptoms of diabetes, he should not be understood as having Prameha (diabetes) but be taken as having Raktapitta (bleeding diseases).

Prameha Purvarupa (premonitory symptoms of diabetes)

स्वेदोऽङ्गगन्धः शिथिलत्वमङ्गे शय्यासनस्वप्नसुखाभिषङ्गः ।
हृन्नेत्रजिह्वाश्रवणोपदेहो घनाङ्गता केशनखातिवृद्धिः ॥ ३८ ॥
शीतप्रियत्वं गलतालुशोषो माधुर्यमास्ये करपाददाहः ।
भविष्यतो मेहगणस्य रूपं मूत्रेऽभिधावन्ति पिपीलिकाश्च ॥ ३९ ॥
Excessive sweating, bad smell of the body, looseness / flaccidity of the body parts, desire for the comfort of the bed, seat and sleep: thickening of the heart, eyes, tongue and ears; stoutness of body, greater increase of (growth rate) hairs and nails, desire for cold, dryness of the throat and palate, sweet taste in the mouth burning sensation of the palms and soles; swarming of ants towards his urine are the premonitory symptoms of the groups of diabetes.

Prameha Sadhyasadhyata (prognosis of diabetes)

दृष्ट्वा प्रमेहं मधुरं सपिच्छं मधूपमं स्याद्विविधो विचारः ।
सम्पूरणाद्वा कफसम्भवः स्यात् क्षीणेषु दोषेष्वनिलात्मको वा ॥ ४० ॥
Finding diabetes, which urine being sweet, sticky, and resembling honey, the physician gets doubt on two points; whether it is born from Kapha caused by over nutrition or whether it is born from Anila (Vata) caused by decrease of the Doshas(under-nutrition).

Prameha Sadhya asadhyata (prognosis of diabetes)

सपूर्वरूपाः कफपित्तमेहाः क्रमेण ये वातकृताश्च मेहाः ।
साध्या न ते पित्तकृतास्तु याप्याः साध्यास्तु मेदो यदि नातिदुष्टम् ॥ ४१ ॥
Prameha caused by Kapha and Pitta (all varieties),having all the premonitory symptomsand those caused by Vata,are not curable after long timethose caused by pitta are controllable;and in which the fat tissue is not greatly vitiated (increased) are curable.

इति श्री वैद्यपति सिंहगुप्तसूनु श्रीमद्वाग्भटविरचितायामष्टाङ्गहृदयसंहिताया तृतीये निदानस्थाने प्रमेहनिदानं नाम दशमोऽध्याय: ।।१०॥
Thus ends the chapter- Prameha – diabetes, urinary tract disorders Nidana – the tenth in Nidanasathana of Astangahrdaya Samhita composed by Srimad Vagbhata, son of Sri Vaidyapati Simhagupta.