Posted on

Chapter 33 — Prameha, Prameha – pidaka Nidanam

The 33rd chapter of Madhava Nidana deals with Prameha, Prameha –
pidaka Nidanam i.e., Polyuria/ Diabetes Carbuncles.

Etiology —
आस्यासुखं स्वप्नसुखं दधीनि ग्राम्यौदकानूपरसाः पयांसि | 
नवान्नमान्नं गुडवैकृतं च प्रमेहहेतुः कफकृच्च सर्वम् || १ || 

āsyāsukhaṁ svapnasukhaṁ dadhīni grāmyaudakānūparasāḥ payānsi |
navānnamānnaṁ guḍavaikr̥taṁ ca pramēhahētuḥ kaphakr̥ccasarvam || 1 |

Causes of Polyuria include the following:

  • Indulgence in sitting on soft cushions for long periods and thus
    avoiding physical activity,
  • Sleeping for long hours,
  • Frequent intake of curds
  • Flesh of domestic animals, from aquatic or marshy places,
  • Milk and its preparations

It is also produced due to

  • regular consumption of fresh grains,
  • Puddings made of sugar and its other products and
  • All other similar items that provoke kapha in the body. 1

Prognosis —  

मेदश्च मांसं च शरीरजं च क्लेदं कफो बस्तिगतः प्रदूष्य | 
करोति मेहान् समुदीर्णमुष्णैस्तानेव पित्तं परिदूष्य चापि || २ || 
क्षीणेषु दोषेष्ववकृष्य धातून् संदूष्य मेहान् कुरुते अनिलश्च | 
साध्याः कफोत्था दश, पित्तजाः षड् याप्या, न साध्यः पवनाच्चतुष्कः || ३ || 
समक्रियत्वाद्विषमक्रियत्वान्महात्ययत्वाच्च यथाक्रमं ते |   

mēdaśca mānsaṁ ca śarīrajaṁ ca klēdaṁ kaphō bastigataḥ pradūṣya |
karōti mēhān samudīrṇamuṣṇaistānēva pittaṁ paridūṣya cāpi || 2 ||
kṣīṇēṣu dōṣēṣvavakr̥ṣya dhātūn sandūṣya mēhān kurutē anilaśca |
sādhyāḥ kaphōtthā daśa, pittajāḥ ṣaḍ yāpyā, na sādhyaḥ pavanāccatuṣkaḥ |3
samakriyatvādviṣamakriyatvānmahātyayatvācca yathākramaṁ tē |

When kapha located in the urinary bladder vitiates the fat (meda), muscle (mamsa) and body fluids (kleda), it causes diabetes of the Kaphaja Type; Likewise, if the pitta affects these parts of the body, Vata also brings about vitiation in them and generates Prameha. As there is a similarity between the causative doshas and the vitiated dhatus in terms of identical properties, the ten kinds of prameha caused by kapha are easily curable. As there is a dissimilarity between the causative doshas and the vitiated dhatus in terms of identical properties, six types of prameha are caused by pitta which are all controllable. While four types of Vata induced prameha are simply incurable as vitiated dhatus of the body (mamsa, kleda and meda) are lost in Vata induced pramehas. 2-3

The components involved in the twenty types of Diabetes syndrome — 

कफः सपित्तः पवनश्च दोषा, मेदो – अस्र – शुक्राम्बु – वसा – लसीकाः | 
मज्जा रसौजः पिशितं च दूष्याः, प्रमेहिणां विंशतिरेव मेहाः || ४ || 

kaphaḥ sapittaḥ pavanaśca dōṣā, mēdō – asra – śukrāmbu – vasā – lasīkāḥ |  
majjā rasaujaḥ piśitaṁ ca dūṣyāḥ, pramēhiṇāṁ vinśatirēva mēhāḥ || 4 || 

The causative doshas are formed by the twenty varieties of prameha, Vata, pitta and kapha together; the tissues are fat (meda), blood (asrk), semen (shukra), Body fluids (ambu), muscle fat (vasa), tissue fluid (lasika), marrow (majja), lymph (rasa) essence of all the ojas (dhatus) and muscle tissue (pishita). 4

Prodromal features — 

दन्तादीनां मलाद्यत्वं प्राग्रूपं पाणि – पादयोः | 
दाहः चिक्कणता देहे तृट् स्वाद्वास्यं च जायते || ५ ||  

dantādīnāṁ malādyatvaṁ prāgrūpaṁ pāṇi – pādayōḥ | 
dāhaḥ cikkaṇatā dēhē tr̥ṭ svādvāsyaṁ ca jāyatē || 5 ||

The premonitory features are —

  • Accumulation of dirt on the teeth, mouth, eyes, nose, ears and
  • feeling of burning sensation in the palms and soles,
  • Stickiness of the skin all over the body,
  • Thirst and
  • Sweet taste in the mouth. 5

General clinical features — 

सामान्यं लक्षणं तेषां प्रभूताविलमूत्रता | 
दोष – दूष्याविशेषे अपि तत्संयोगविशेषतः || ६ || 
मूत्रवर्णादिभेदेन भेदो मेहेषु कल्प्यते | 

sāmānyaṁ lakṣaṇaṁ tēṣāṁ prabhūtāvilamūtratā |
dōṣa – dūṣyāviśēṣē api tatsanyōgaviśēṣataḥ || 6 ||
mūtravarṇādibhēdēna bhēdō mēhēṣu kalpyatē |

Its characteristic features include —

  • An increased quantity and turbidity of urine due to the combination of doshas and dushyas.

Depending on the colour of the urine associated, different types of pramehas have been classified accordingly. 6

Kaphaja Prameha — 

अच्छं बहु सितं शीतं निर्गन्धमुदकोपमम् || ७ ||
मेहत्युदकमेहेन किञ्चिदाविल – पिच्छिलं |
इक्षो रसमिवात्यर्थं मधुरं चेक्षुमेहतः ||८||
सान्द्रीभवेत् पर्युषितं सान्द्रमेहेन मेहति |
सुरामेहि सुरातुल्यमुपर्यच्छमधो घनम् ||९ ||
संहृष्टरोमा पिष्टेन पिष्टवदब्हलं सितम् |
शुक्राभं शुक्रमिश्रं वा शुक्रमेहि प्रमेहति || १० ||
मूर्ताणून सिकतामेहि सिकतारुपिणो मलान् |
शीतमेही सुबहुशो मधुरं भृशशीतलम् || ११ ||
शनैः शनैः शनैर्मेही मन्दं मन्दं प्रमेहति |
लालातन्तुयुतं मूत्रं लालामेहेन पिच्छिलं || १२ ||

acchaṁ bahu sitaṁ śītaṁ nirgandhamudakōpamam |7 | mēhatyudakamēhēna kiñcidāvila – picchilaṁ |
ikṣō rasamivātyarthaṁ madhuraṁ cēkṣumēhataḥ ||8||
sāndrībhavēt paryuṣitaṁ sāndramēhēna mēhati |
surāmēhi surātulyamuparyacchamadhō ghanam ||9 ||
sanhr̥ṣṭarōmā piṣṭēna piṣṭavadabhalaṁ sitam |
śukrābhaṁ śukramiśraṁ vā śukramēhi pramēhati || 10 ||
mūrtāṇūna sikatāmēhi sikatārupiṇō malān |
śītamēhī subahuśō madhuraṁ bhr̥śaśītalam || 11 ||
śanaiḥ śanaiḥ śanairmēhī mandaṁ mandaṁ pramēhati |
lālātantuyutaṁ mūtraṁ lālāmēhēna picchilaṁ || 12 ||

Features of urine in case of Udakameha include —

  • Discharge of urine that is clear, copious, white, and cold,
  • An absence of odour,
  • Little turbidity and greasiness and
  • resemblance to the pure water.

In case of Ikshumeha, the urine discharged —

  • Turns sweet like the juice of sugarcane.

The Sandrameha affected urine, if kept undisturbed for sometime in a pot assumes thickness.

The urine discharged in case of Surameha resembles —

  • Alcoholic beverage prepared with flour (Sura) with clear fluid and sediments at the bottom and the top.

The urine discharged in case of Pistameha appears thick as though —

  • mixed with flour and is white in colour. The patient experiences horripilation.

The Shukrameha affected urine resembles the semen or even it might be mixed with the same.

The urine discharged in case of Sikatameha contains small particles resembling sand.

The urine discharged in case of Sitameha,

  • is copious, sweet in taste and very cold to touch.

The urine discharged in case of Shanairmeha is frequent but slow.

The urine discharged in case of Lalameha resembles the saliva; it appears in shape of threads and is sticky.

These are the ten varieties of Kaphaja type of the disease prameha. 7-12

Paittika Pramehas —

गन्ध – वर्ण – रस – स्पर्शैः क्षारेण क्षारतोयवत् |
नीलमेहेन नीलाभं कालमेही मसीनिभम् || १३ ||
हारिद्रमेही कटुकं हरिद्रासन्निभं दहत् |
विस्रं मञ्जिष्टमेहेन मञ्जिष्टासलिलोपमम् || १४ ||
विस्रमुष्णं सलवणं रक्ताभं रक्तमेहतः | 

gandha – varṇa – rasa – sparśaiḥ kṣārēṇa kṣāratōyavat |
nīlamēhēna nīlābhaṁ kālamēhī masīnibham || 13 ||
hāridramēhī kaṭukaṁ haridrāsannibhaṁ dahat |
visraṁ mañjiṣṭamēhēna mañjiṣṭāsalilōpamam || 14 ||
visramuṣṇaṁ salavaṇaṁ raktābhaṁ raktamēhataḥ |

The six varieties of Pittaja Prameha are —

The urine passed in case of Ksarameha resembles —

  • Solution of Alkali in smell, colour, taste, and touch

The urine passed in case of Nilameha is —

  • Blue

The urine passed in case of Kalameha

  • it is like Charcoal

The urine passed in case of Haridrameha is —

  • Pungent,
  • deep yellow  and
  • the patient experiences burning sensation during urination.

The urine passed in case of Manjisthameha, is —

  •  Foul smelling and
  • it resembles decoction of the plant Rubia cordifolia (Manjistha)

The urine in case of Raktameha is

  • Foul smelling,
  • Hot,
  • salty in taste and
  • blood red in colour. 13-14

Vatika Pramehas —

वसामेहि वसामिश्रं वसाभं मूत्र येन्मुहुः || १५ ||
मज्जाभं मज्जमिश्रं वा मज्जमेही मुहुर्मुहुः |
कषायं मधुरं रूक्षं क्षौद्रमेहं वदेद्बुधः || १६ ||
हस्ती मत्त इवाजस्रं मूत्रं वेगविवर्जितम् |
सलसीकं विबद्धं च हस्तीमेही प्रमेहति || १७ ||

vasāmēhi vasāmiśraṁ vasābhaṁ mūtra yēnmuhuḥ || 15 ||
majjābhaṁ majjamiśraṁ vā majjamēhī muhurmuhuḥ |
kaṣāyaṁ madhuraṁ rūkṣaṁ kṣaudramēhaṁ vadēdbudhaḥ || 16 ||
hastī matta ivājasraṁ mūtraṁ vēgavivarjitam |
salasīkaṁ vibaddhaṁ ca hastīmēhī pramēhati || 17 ||

The urine discharged in case of Vasameha, is mixed with muscle fat or appears like that and is voided frequently.

The urine discharged in case of Majjameha, is mixed with marrow or appears like that and is voided frequently.

The urine discharged in case of Ksaudrameha, looks like a decoction, is sweet and non sticky.

In case of Hastimeha, the person passes urine continuously like an elephant in heat, slowly without pressure while the urine is mixed with tissue fluid (lasika).  15-17

Complications of Pramehas —

अविपाको अरुचिश्च्छर्दिर्निद्रा कासः सपीनसः |
उपद्रवाः प्रजायन्ते मेहानां कफजन्मनाम् || १८ ||

avipākō aruciścchardirnidrā kāsaḥ sapīnasaḥ |
upadravāḥ prajāyantē mēhānāṁ kaphajanmanām || 18 ||

Complications of Kaphaja Prameha include the following —

  • Indigestion
  • Loss of appetite
  • Vomiting
  • Excess of sleep
  • Cough and
  • Running of the nose. 18

बस्ति – मेहनयोस्तोदो मुष्कावदरणं ज्वरः |
दाहस्तृष्णा अम्लिका मूर्च्छा विड्भेदः पित्तजन्मनाम् || १९ ||

basti – mēhanayōstōdō muṣkāvadaraṇaṁ jvaraḥ |
dāhastr̥ṣṇā amlikā mūrcchā viḍbhēdaḥ pittajanmanām || 19 ||

Complications of Pittaja Pramehas include —

  • Pain in the urinary bladder and penis
  • Cracks in the skin of the scrotum
  • Fever and
  • Feeling of burning sensation,
  • Thirst
  • Sour belching,
  • Fainting, and
  • Diarrhoea. 19

वातजानामुदावर्तः कम्प – हृद् ग्रह – लोलताः |
शूलमुन्निद्रता शोषः कासः श्वासश्च जायते | |२०||

vātajānāmudāvartaḥ kampa – hr̥d graha – lōlatāḥ |
śūlamunnidratā śōṣaḥ kāsaḥ śvāsaśca jāyatē ||20||

Complications of Vataja Prameha include the following —

  • Movement of wind in upward direction inside the stomach,
  • Tremors
  • Heartaches
  • and desire for eatables of all tastes
  • Pain in the bladder and penis
  • Loss of sleep
  • Emaciation
  • Cough and
  • Dyspnea. 20

Prognosis

Fatal Prognosis —

यथोक्तोपद्रवाविष्टमतिप्रस्रुतमेव च |
पिडकापीडितं गाढः प्रमेहो हन्ति मानवम् || २१ ||

yathōktōpadravāviṣṭamatiprasrutamēva ca |
piḍakāpīḍitaṁ gāḍhaḥ pramēhō hanti mānavam || 21 ||

The serious diabetes syndrome associated with the complications like excessive urination as mentioned above, and those implicating patients of pidaka type boils, turns out to be fatal. 21

Incurability —

जातः प्रमेहि मधुमेहिनो वा
न साध्य उक्तः स हि बीजदोषात् |
ये चापि केचित् कुलजा विकारा
भवन्ति तांस्तान् प्रवदन्त्यसाध्यान् || २२ || 

jātaḥ pramēhi madhumēhinō vā
na sādhya uktaḥ sa hi bījadōṣāt |
yē cāpi kēcit kulajā vikārā
bhavanti tānstān pravadantyasādhyān || 22 ||

Those patients who are said to be incurable include the following —

  •  A person who is born with hereditary diabetes (prameha) or
  • A person who is suffering from madhumeha because of a congenital defect.

In the same manner, there are several other incurable hereditary diseases too. 22

Prognosis of Madhumeha —

सर्व एव प्रमेहास्तु कालेनाप्रतिकारिणः |
मधुमेहत्वमायान्ति तदा असाध्या भवन्ति हि || २३ ||
मधुमेहे मधुसमं जायते स किल द्विधा |
क्रुद्धे धातुक्षयाद् वायौ दोषावृतपथे अथवा || २४ ||

sarva ēva pramēhāstu kālēnāpratikāriṇaḥ |
madhumēhatvamāyānti tadā asādhyā bhavanti hi || 23 ||
madhumēhē madhusamaṁ jāyatē sa kila dvidhā |
kruddhē dhātukṣayād vāyau dōṣāvr̥tapathē athavā || 24 ||

If varieties of diabetes are not treated properly, it will move on to the stage of madhumeha that is incurable. In Madhumeha, the urine passed by the patient remains sweet like honey and it is of two kinds, viz. one due to morbid increase in Vata (vrdhhi) caused by dhatu and depletion of tissues (ksaya) and another that is caused by blockage of the channels of Vata. 23-24

आवृतो दोषलिङ्गानि सो अनिमित्तं प्रदर्शयन् |
क्षणात् क्षीणः क्षणात् पूर्णो भजते कृच्छ्र साध्यताम् || २५ ||

āvr̥tō dōṣaliṅgāni sō animittaṁ pradarśayan |
kṣaṇāt kṣīṇaḥ kṣaṇāt pūrṇō bhajatē kr̥cchra sādhyatām ||25 ||

Thus, the vata that is halted produces a number of complications and there is unexplained fluctuation in the degree of vitiation of various doshas. This situation remains changing in terms of its severity and the prameha of this variety turns to be difficult to cure. 25

Madhumeha — Definition —

मधुरं यच्च मेहेषु प्रायो मध्विव मेहति |
सर्वे अपि मधुमेहाख्या माधुर्याच्च तनोरतः || २६ ||

madhuraṁ yacca mēhēṣu prāyō madhviva mēhati |
sarvē api madhumēhākhyā mādhuryācca tanōrataḥ || 26 ||

The features of Doshas appear sometimes mild and sometimes severe in case of blockage of channels. Madhumeha means any variety of prameha in which the urine tastes like honey and the whole body becomes sweet.26

Pidakas associated with Pramehas —

शराविका कच्छपिका जालिनी विनता अलजी |
मसूरिका सर्षपिका पुत्रिणी सविदारिका || २७ ||
विद्रधि चेति पिडका प्रमेहोपेक्षया दश |
सन्धिर्मर्मसु जायन्ते मांसलेषु च धामसु || २८ ||

śarāvikā kacchapikā jālinī vinatā alajī |
masūrikā sarṣapikā putriṇī savidārikā || 27 ||
vidradhi cēti piḍakā pramēhōpēkṣayā daśa |
sandhirmarmasu jāyantē māmsalēṣu ca dhāmasu || 28 ||

The ten types of blisters or boils or pidakas in relation to pramehas are —

  • Sharavika
  • Kacchapika
  • Jaalini
  • Vinata
  • Alaji
  • Masurika
  • Sarshapika
  • Putrini
  • Vidarika and
  • Vidradhi.

They develop on —

  •  Joints
  • Vital Parts and
  • fleshy part of the body. 27-28

Clinical features —

अन्तोन्नता तु तद्रूपा निम्नमध्या शराविका |
गौरसर्षपसंस्थाना तत्प्रमाणा च सर्षपी || २९ ||
सदाहा कूर्मसंस्थाना ज्ञेया कच्छपिका बुधैः |
जालिनी तीव्रदाहा तु मांसजालसमावृता || ३० ||
अवगाढरुजाक्लेदा पृष्टे वा अप्युदरे अपि वा |
महती पिडका नीला विनता नाम सा स्मृता || ३१ ||
महात्यल्पाचिता ज्ञेया पिडका चापि पुत्रिणी |
मसूराकृतिसंस्थाना विज्ञेया तु मसूरिका || ३२ ||
रक्ता सिता स्फोटचिता दारुणा त्वलजी भवेत् |
विदारीकन्दवद् वृत्ता कठिना च विदारिका || ३३ ||
विद्रधेर्लक्षणैर्युक्ता ज्ञेया विद्रधिका तु सा |

antōnnatā tu tadrūpā nimnamadhyā śarāvikā |
gaurasarṣapasansthānā tatpramāṇā ca sarṣapī || 29 ||
sadāhā kūrmasansthānā jñēyā kacchapikā budhaiḥ |
jālinī tīvradāhā tu mānsajālasamāvr̥tā || 30 ||
avagāḍharujāklēdā pr̥ṣṭē vā apyudarē api vā |
mahatī piḍakā nīlā vinatā nāma sā smr̥tā || 31 ||
mahātyalpācitā jñēyā piḍakā cāpi putriṇī |
masūrākr̥tisansthānā vijñēyā tu masūrikā || 32 ||
raktā sitā sphōṭacitā dāruṇā tvalajī bhavēt |
vidārīkandavad vr̥ttā kaṭhinā ca vidārikā || 33 ||
vidradhērlakṣaṇairyuktā jñēyā vidradhikā tu sā |

  • Sharavika — a blister with elevated edges and depressed centre.
  • Sharshapika — when the blister is comparable to the white mustard seeds in colour and size.
  • Kacchapika — resembles the tortoise shell and causes burning sensation.
  •  Jaalini — blister looks like a sieve of muscle fibres and that produces severe burning sensation.
  • Vinataa — are big sized boils appearing on the back or stomach, with hard, blue, big sized tubercles associated with pain and exudation.
  • Putrini — is a big ulcer with small boils spread around.
  • Masurika — is an ulcer that looks like pea (masura) in shape
  • Alaji — is a boil which is red or white in colour, it is very painful and it usually bursts out
  • Vidarika and Vidari –– are both hard and roundly shaped.
  • Vidradhika — is the boil in which all the features of an abscess is found. 29-33

Aetiology of Pidaka —

ये यन्मयाः स्मृता मेहास्तेषामेतास्तु तन्मयाः || ३४ ||

विना प्रमेहमप्येता जायन्ते दुष्टमेदसः |
तावच्चैता न लक्ष्यन्ते यावद्वास्तुपरिग्रहः || ३५ ||

yē yanmayāḥ smr̥tā mēhāstēṣāmētāstu tanmayāḥ || 34 ||

vinā pramēhamapyētā jāyantē duṣṭamēdasaḥ |
tāvaccaitā na lakṣyantē yāvadvāstuparigrahaḥ || 35 ||

A particular variety of prameha is caused by the ulcers that are also caused by the doshas that generate prameha. These ulcers can occur in the following persons:

  • Persons in whom fat, adipose tissue (medas) has undergone abnormal change.

The ulcers could occur to even those without diabetes (prameha). However, until they get localized in specified parts these boils cannot be recognized. 34-35

गुदे हृदि शिरस्यंसे पृष्टे मर्मसु चोत्थिताः |
सोपद्रवा दुर्बलाग्नेः पिडकाः परिवर्जयेत् || ३६ ||

gudē hr̥di śirasyansē pr̥ṣṭē marmasu cōtthitāḥ |
sōpadravā durbalāgnēḥ piḍakāḥ parivarjayēt || 36 ||

The patients of ulcers who must be refused (by the wise physician) treatment include the following —

  • Persons who have developed these ulcers in the rectum, region of the head, shoulders, on the back and vital parts of the body,
  • along with the complications and
  • the ones who possess a poor digestive capacity. (As they are incurable) 36

इति श्रीमाधवकरविरचिते माधवनिदाने प्रमेह – प्रमेहपिडकानिदानं समाप्तम् || ३३ ||

iti śrīmādhavakaraviracitē mādhavanidānē pramēha – pramēhapiḍakānidānaṁ samāptam || 33 ||

Thus concludes the chapter of Prameha.