Prameha Chikitsa (प्रमेह चिकित्सा) | Chikitsa sthana | CHARAK SAMHITA

Now we shall expound the chapter " Prameha Chikitsa" (Management of Urinary Diseases including diabetes). Thus said Lord Atreya. [1-2]

prameha chikitsa

Prameha is characterized by increased frequency and quantity of urination.

आस्यमुखं स्वप्नमुखं दधिनि ग्राम्यौदकानुपरसा : पयांसि | नवान्नपानं गुडवैकृतं च प्रमेहहेतु: कफकृच्छ सर्वां || [4]

Etiology of Prameha :

Over-indulgence in the pleasure of sedentary habits, excess sleep, curds, soup of meat of domesticated and aquatic animals and animals inhabiting marshy land, milk and its preparations, freshly harvested food articles, freshly prepared drinks, preparations of jaggery and all kapha aggravating factors are responsible for causation of Prameha.[4]

Dushya (vitiated factors) and Pathogenesis (संप्राप्ति)

कफ प्रमेह संप्राप्ति - प्रकुपित कफ → मेदोधातु-मांसधातु-बस्तिस्थित(मुत्राशय) क्लेद दुष्टि → कफज प्रमेह

पित्तज प्रमेह संप्राप्ति - प्रकुपित पित्त → मेद-मांस-क्लेद दुष्टि → पित्तज प्रमेह

वातज प्रमेह संप्राप्ति - प्रकुपित वात → वास-मज्जा-ओजादि धातु दुष्टि & स्थान संश्रय in बस्ति → वातज प्रमेह

Different doshas having entered the urinary tract in vitiated condition give rise to the respective types of meha with their own dominance. [5-6]

Classification and Prognosis

  • Kapahaja pramehas are of 10 types and they are curable (साध्य) because of their compatibility of the therapies meant for their cure (Samakriyatva-समक्रीयत्व)
  • Pittja pramehas are of 6 types and they are only palliable (याप्य) because of their incompatibility of the therapies meant for their treatment.
  • Vatika pramehas are of 5 types and they are incurable (असाध्य) because of their incompatibility with therapies and dreadful nature of vata leading to complications [7]

Vitiating factors involved in pathogenesis

Doshas like kapha, pitta and vata, and Dushyas like medas, rakta, shukra, ambu (body fluid), vasa (muscle fat), lasika (lymph), majja, rasa, ojas and mamsa are responsible for the causation of 20 types of prameha.

20 types of prameha

कफज मेह 10 उदकामेह, इक्षुमेह, सान्द्रमेह, सान्द्रप्रसादमेह, शुक्लमेह, शुक्रमेह,
शीतामेह, शनैमेह, सिक्तामेह, लालामेह
पित्तज मेह 6 क्षारामेह, कालमेह, नीलमेह, हारिद्रमेह, मान्जिष्टमेह, रक्तामेह
वातज मेह 5 मज्जामेह, वसामेह, लसीकामेह, मधुमेह
1. उदकमेह The Urine resembling water
2. इक्षुमेह The Urine resembling sugarcane juice
3. सान्द्रमेह The Urine having high density (thick urine)
4. सान्द्रप्रसादमेह Precipitating (high density in lower layers of urine)
5. शुक्लमेह The Urine having white color
6. शुक्रमेह The Urine containing seminal fluid
7. शीतामेह The Urine with cold touch
8. शनैमेह The Urine passing out slowly
9. सिक्तामेह The Urine containing sand like particles
10. लालामेह The Urine containing slimy materials lime saliva
11. क्षारामेह The Urine resembling the solution of alkalis
12. कालमेह The Urine having black color
13. नीलमेह The Urine having blue color
14. हारिद्रमेह The Urine having yellow color like haridra
15. मान्जिष्टमेह The Urine having reddish color like manjishta
16. रक्तामेह The Urine having blood in it
17. मज्जमेह The Urine mixed with majja or bone marrow
18. वसामेह The Urine mixed with vasa or muscle fat
19. लसीकामेह The Urine mixed with lasika or lymph. Or the patient urinates more in quantity like elephant
20. मधुमेह The Urine mixed with Ojas

Criteria of Diagnosis

Different types of prameha are characterized by the color, taste, touch and smell of the respective dosha. Vatika varieties of prameha are characterized by grayish or reddish coloration of urine, pain and attributes of majja, etc. These types of vatika prameha are uncurable. [12]

Premonitory Signs and Symptoms

  • स्वेद - sweating
  • अङ्ग गन्ध - body odor
  • शिथिल अङ्ग - flabbiness of the body
  • शय्यासन - liking for constantly lying on bed
  • स्वप्नसुख - sitting, sleeping and leading an easy life
  • अरति - a feeling as if the cardiac region is covered with extraneous material.
  • Exudation of excreta from eyes, tongue and ears
  • धनान्गत - corpulence of the body
  • केशनखातिव्रुद्धि - Excessive growth of hairs and nails
  • शीतप्रियत्वा - liking of cold things
  • गलतालुशोष - Dryness of throat and palate
  • Sweet taste in the mouth
  • करपाददाह - Burning sensation in hands and legs and swarmimg of ants on the urine - these are the premonitory signs and symptoms of prameha. [13-14]

Principles of management (प्रमेह चिकित्सा सूत्र)

स्थुल: प्रमेहि बलवानिहैक: कृशस्तथैकः परिदुर्बलश्च | सबृम्हण तत्र कृशस्य कार्यं संशोधनं दोशबलाधिकस्य || [25]

Patients suffering from prameha are classified into two categories viz. 1) Those who are obese and strong, and 2) Those who are emaciated and weak.

Patients belong to the latter (कृश प्रमेहि - दुर्बल) should be given nourishing therapy ( शमन & बृम्हन चिकित्सा).

Patients belong to the former category (स्थूल प्रमेहि - बलवान) should be given elimination therapy ( शोधन चिकित्सा)

  • The oleated patient should be given recipes described in Kalpa sthana with a view of eliminating metabolic waste through both upward and downward tracts i.e निदान परिवर्जन.
  • After the waste products (excess metabolic bi-products) are eliminated from the body, the patient should be given santarpana (संतर्पण) or nourishment therapy. because apatarpana (depletion) therapy in this condition may produce gulma, consumption (क्षय), pain in phallus and urinary bladder including kidneys (मेहनबस्तिशूल) and retention of urine (मूत्रग्रह). Such patients should be given santarpana therapy depending upon their power of digestion. [16-17]

Samshamana chikitsa (pacification therapy) : If the patient of prameha is not eligible for samshodhana or elimination therapy, samshamana or allevitation therapies are given. [18]

Pathya (पथ्य) - diet

The patient suffering from prameha should be given following food :

  1. Mantha (मन्थ) (flour of different types of corn mixed with water), Kashayas (deoctions), यव चूर्ण (barley powder), यव लेह (linctus prepared of barley ) and other light - eatables.
  2. Yavaudana (cooked barley) without adding any unctous articles, वत्य (barley parridge), सक्तु (roasted corn flour) and अपूप (pancakes) mixed with meat soup of gallinaceous and pecker birds and animals inhabitting arid land.
  3. old shali rice cooked and mixed with the soup of mudga (green gram) etc., and preparations of bitter vegetables; and
  4. Cooked shashtika rice and तृण धान्य mixed with oil of दन्ति, इन्गुडी, अतसी, and सर्षप.

Sahstika rice with shyamaka etc., truna dhanya with yava as predominant food is advised for prameha patients.

Various food recepies of yava with honey are indicated in kapha dominant prameha.

Barley soaked in the decoction of triphala and kept overnight should be mixed with honey. It is refreshing (तर्पण) diet. It should be taken by the patient suffering from prameha regularly to overcome the disease. Barley should be soaked separately with each of decoctions prescribed for the treatment of kaphaja prameha and taken by patient in the form of saktu (roasted flour), apupa (pancake), dhana (roasted barlley) and other types of eatables along with jaggery.

Various eatables prepared from the barley or bamboo seed or wheat previously eaten by asses, horses, cows, swans and deer and collected from their dung should be given to the patient suffering from prameha. [19-24]

Specific therapies

संशोधनोल्लेखनलङ्घनानि काले प्रयुक्तानि कफप्रमेहान| जयन्ति प्रतिप्रभवान विरेकः संतर्पण: संशमनो विधिश्च || [25]

Purificatory therapies including specifically emesis and fasting therapies, administered at appropriate time, cure kaphaja types of prameha. Similarly, pittja types of prmeha are overcome by purgation, santarpana (refreshing therapy) and alleviation therapies.[25]

Various formulations :

The patient suffering from prameha should take the decoction of दार्वी, सुराःवा, त्रिफला and मुस्ता mixed with honey. He may also take हरिद्रा (turmeric) along with juice of amalaki. [26]

Decoctions of kaphaja prameha

The following ten decoctions should be mixed with honey and given to patients suffering from kaphaja prameha :

  1. Decoction of haritaki, katphala, musta and lodhra
  2. Decoction of patha, vidanga, arjuna and dhavana
  3. Decoction of haridra, daruharidra, tagar and vidanga
  4. Decoction of kadamba, shala, arjuna and dipyaka
  5. Decoction of darvi, vidanga, khadira and dhava
  6. Decoction of surahva, kushta, agaru and chandana
  7. Decoction of darvi, agnimantha, triphala and patha
  8. Decoction of patha, nurva and shvadamshtra
  9. Decoction of yavani, ushira, abhaya, and guduchi ; and
  10. Decoction of chavya, abhaya, chitraka and sapta parna.

Decoctions of pittaja prameha

The following ten decoctions should be mixed with honey and given to the patients suffering from pittaja prameha :

  1. Decoction of ushira, lodhra, arjuna, lalachandana
  2. Decoction of ushira, musta, amalaka and abhaya
  3. Decoction of patola, nimba, amalaka and amrita
  4. Decoction of mustra, abhaya, padmaka and vrishaka
  5. Decoction of lodhra, ambu, kaliyaka and dhataki
  6. Decoction of nimba, arjuna, amrita, nisha and utpala
  7. Decoction of shirisha, sarja, arjuna and keshara
  8. Decoction of priyangu, padma, utpala and kimshuka
  9. Decoction of ashvatta, patha, asana and vatasa
  10. Decoction of katankateri (daruharidra), utpala and mustaka. [30-32]

Decoctions for all types of prameha

Two recipes of decoction are described for the treatment of all varieties of prameha. These decoctions can be used for the preparation of mantha ( a drink prepared of roasted corn flour mixed with water), for the impregnation of barley and for the preparation of different kinds of food and drinks.

Medicated oils and medicated ghee prepared by cooking with these decoctions should be administered to patients suffering from vatika prameha. These decoctions correct the vitiated medas and kapha, and the aggravated vayu in these patients gets alleviated by the unctuous ingrediets (viz., oil and ghee) included in three recepies [33-34]

Formulations for kaphaja and pittaja pramehas

कंपिल्लक चूर्ण, barks of सप्तचन्दन, बिभितकी, रोहितकी and कुटज and flowers of कपित्थ should be added with honey , made to a लेह (linctus) and taken by the patients suffering from kaphaja and pittaja prameha.

1 अक्ष of the paste of above mentioned drugs should be mixed with the juice of amalaki and given at appropriate time to patients suffering from kaphaja and pittaja prameha. After the digestion of this potion, the patient should be given to eat पुराणमन्नं (old rice cooked) and mixed with the delicious soup of meat of animals living in arid land.[35-36]

Formulations for vata associated in kaphaja and pittaja prameha :

If vayu is secondarily aggravated along with either kapha or pitta, then the patient should be administered unctuous preparations. For the pitta aggravation, medicated ghee should be processed with the decoction of pitta alleviating drugs. त्रिकन्तक, अश्मन्तक, सोमवल्क, भल्लातक, अतिविष, लोध्र, वच, पटोल, अर्जुन, निम्बी, मुस्ता, हरिद्रा, पद्मक, दिप्यक, मञ्जिष्ठ, अगरु and चन्दन all these drugs together should be used in the preparation of medicated oil for the treatment of kaphaja prameha which is associated with secondarily aggravated vayu. In case of pitta dominance, ghee shall be processed with above mentioned drugs.

If the signs and symptoms of all the three doshas are manifested, then with all the above mentioned drugs together, ghee and oil both in a mixed form should be cooked and given to the patient.

Recipe for all types of prameha :

The decoction of triphala, darunisha, vishala and musta should be mixed with the paste of haridra and honey. Intake of this potion cures all types of prameha even these are manifested in acute form. [37-40]

Madhava asava (माधवासव)

Ingredients

लोध्र, शटि, पुष्करमूला, एल, मूर्वा, विडङ्ग, त्रिफला, यमनि, चाव्य, प्रियङ्गु, क्रमुक, विशाल, हिरततिक्त, कतुरोहिनी, भरन्गी, नट, चित्रक, पिप्पलिमूला, कुष्ठ, अतिविष, पथ, कालिङ्गक, केशर, इन्द्रवरुनि, नख, पत्र, मारीच and प्लव

1 कर्ष (10gm) of each of these drugs should be boiled in 1 द्रोण (10.24 liter) of water till one-fourth remains. This decoction along with half its quantity of honey should be kept inside a ghee smeared jar for fort night, This is called Madhavasava. It instantaneously cures Kaphaja and paittika types of meha when administered.

Dosage : 2 pala (80 ml)

Indication - pandu, arsha, aruchi, grahani dosha, kilasa and different types of kushta. [41-44]

Dantyasava and Bhallatakasava

In the above mentioned decoction, 8 palas of danti, 8 palas of sugar and the same quantity of honey should be added and processed. Similarly, in the above mentioned decoction 4 palas of bhallataka, 8 palas of sugar and the same quantity of honey should be added and processed. These two asavas (namely dantyasava and bhallatakasava) are useful in the treatment of prameha.[45]

Beneficial diet and drinks :

The patient suffering from prameha should drink sarodaka-सरोदक (water boiled with the heart-wood of khadira etc.,), kushodaka- कुशोदक (water boiled with kusha), Madhudaka-मधुदक (water mixed with honey), triphala rasa (juice or decoction of triphala) or Sidhu- सिधु (a types of wine) which is properly fermented or Madhvika-मध्विक (another type of wine) which is of superior quality and is prepared after fermenting for a long time.

Spit-roasted meat of animals and birds and different eatables prepared of barley should be given to the patient to eat. Different types of prameha caused by over-nourishment should be alleviated by administration of elimination therapy (संशोधन), अरिष्ट (arishta - a type of wine), decoctions and types various types of linctus (लेह).

Persons habitually taking भृष्ट यव (roasted barley), dry corn-flour, मुद्ग(mudga), अमलकी do not suffer from prameha, श्वित्र (leucoderma), मुत्रकृच्छ (dysuria) and कफज कुष्ट. [46-48]

Various external applications :

Pramehas get immediately cured by different types of execise, unction, bath, sprinkling of water over the body and application of ointment made of sevya (ushira), tvak, ela, agaru, chandana etc. [50]

Indication of apatarpana treatment

Aggravated kleda (liquid element of the body), medas (adipose tissue) and kapha are responsible for the causation of prameha. keeping this in view, the physician, in the beginning, should administer depletion therapies to patients suffering with kapha and pitta dominat types of prameha. [50]

Vata dominant prameha

Formulations described earlier for vatika prameha are actually meant for vata dominant prameha where vayu is secondarily (subsequently) aggravated. If the vayu is primarily aggravated in prameha because of excessive depletion of tissue elements, then it is curable and physician need not make efforts to treat. [52]

Prevention of prameha

Etiological factors responsible for the causation of different types prameha should be avoided even after prameha are manifested. The causative factors described shall be avoided during the treatment of those particular diseases (even after its manifestation). [53]

Differentiation between raktapitta and prameha :

If the color of the urine is yellow or if blood is excreted through urine without the prior manifestation of premonitory signs and symptoms of prameha, such a person should not be diagnosed as a patient of prameha. He should be diagnosed as raktapitta (a disease characterized by bleeding from different parts of the body). [54]

Two types of prameha patient

if the patient suffering from prameha passes urine is sweet, slimy and honey-like, then there are two possibilities. It is caused either by diminution of doshas having vata-dominant type or by over-nourishment having kapha dominant type.[55]

Prognosis

Kapha dominant and pitta dominant types of prameha, if preceded by their premonitory signs and symptoms, are incurable. Similarly, vatika prameha, where vayu is aggravated right from the beginning is incurable (असाध्य). Pitta dominant types of prameha are generally palliable (याप्य). But they are curable (साध्य) if medas (adipose tissue) is not vitiated. [56]

Incurability of hereditary diseases

Patients who suffer from prameha since birth (congenital) and those who are borne of prameha parents (hereditary) are not curable because of the morbidity of genes (बीज). Similarly, other heredidity (kulaja/famlial) ailments are considered as incurable.[57]

Treatment of prameha pidaka

Seven types of prameha pidaka (boils) of patients suffering from prameha described in quadrate on diseases (rogadhika) are to be treated by expert surgeons with the help of shastras (surgical operations), samshodhana (cleansing) and ropana (healing therapies). [58]

Summary

Here are the recapulatory verses :The causes, dosha, dushya, curability, characteristics of urine in prameha, two types of patients, three modes of treatment, disadvantages of excess depletion therapy, various food items of yava, mantha, various decoctions used in the treatment of prameha, medicated oils, ghee preparations, linctus's, diet articles, fermented preparations like asava, various exercises, baths, massage, fragrant applications all these are described in the management of prameha. [59-61]

Thus, end the 6th chapter dealing with the treatment of prameha of chikitsa shtana of Agnivesha's work as redacted by charaka. [6]

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