Sushruta Samhita Nidanasthana Chapter 6 Prameha Nidanam (Diabetes)

The 6th chapter of Nidanasthana of Sushruta Samhita is named as Prameha Nidanam Adhyaya. This chapter deals with Diabetes.

अथातः प्रमेहनिदानं व्याख्यास्यामः ।। १ ।।
यथोवाच भगवान् धन्वन्तरिः ।।२ ।।
We will now expound Prameha Nidanam- diagnosis of Diabetes (Polyuria) as revealed by the venerable Dhanvantari.

Nidana Causes

दिवास्वप्नाव्यायामालस्यप्रसक्तं शीतस्निग्धमधुरमेद्यद्रवान्नपानसेविनं पुरुषं जानियात् प्रमेही भविष्यतीति ||३||

The person who indulges in the below mentioned causative factors should be considered as the one who would become a patient of prameha in future –

–        Constantly sleeping during the day time
–        Not indulging in physical activities and being lazy
–        Excessive and regular consumption of foods and drinks which are cold, unctuous, sweet, fatty and liquid

Samprapti: Pathogenesis

तस्य चैवम्प्रवृत्तस्यापरिपक्वा एव वातपित्तश्लेष्माणो यदा मेदसा सहैकत्वमुपेत्य मूत्रवाहिस्रोतांस्यनुसृत्याधो गत्वा बस्तेर्मुखमाश्रित्य निर्भिद्यन्ते तदा प्रमेहाञ्जनयन्ति ||४||

In persons who are indulged in the above said etiological factors
↓
immature vata, pitta and kapha get mixed with medas – fat tissues
↓
the doshas along with medas now travel downward along the mutravaha srotas i.e. channels which convey urine
↓
these doshas now get localized at the bastimukha i.e. orifice / opening of the urinary bladder and
↓
begin to flow out, mixed with urine and
↓
gives rise to a disease called as Prameha

Purvarupa: Premonitory symptoms

तेषां तु पूर्वरूपाणि- हस्तपादतलदाहः स्निग्धपिच्छिलगुरुता गात्राणां मधुरशुक्लमूत्रता तन्द्रा सादः पिपासा दुर्गन्धश्च श्वासस्तालुगलजिह्वादन्तेषु मलोत्पत्तिर्जटिलीभावः केशानां वृद्धिश्च नखानाम् ||५||

Their premonitory symptoms are –

• Burning sensation in the hands and feet (palms and soles)
• Unctuousness, sliminess and heaviness of the body / skin
• Elimination of white colored urine which is sweet in taste and smells bad
• Stupor
• Debility
• Excessive thirst
• Difficulty in breathing
• Excessive accumulation / deposition of dirt in palate, throat, tongue and teeth
• Matting of hairs on the head
• Excessive growth of hairs and nails

Rupa: Signs and Symptoms

तत्राविलप्रभूतमूत्रलक्षणाः सर्व एव प्रमेहा भवन्ति ||६||
The generalized symptoms of all kinds of Prameha are –

–        Avila mutrata – turbidity of urine and
–        Prabhuta mutrata – increased quantity of urine

सर्व एव सर्वदोषसमुत्थाः सह पिडकाभिः ||७||
All varieties of prameha and prameha pidakas i.e. eruptions born out of prameha are ‘sarva dosha samuttha’ i.e. caused by all three doshas aggravated together.

Bheda: Kinds

तत्र, कफादुदकेक्षुवालिकासुरासिकताशनैर्लवणपिष्टसान्द्रशुक्रफेनमेहा दश साध्याः, दोषदूष्याणां समक्रियत्वात्; पित्तान्नीलहरिद्राम्लक्षारमञ्जिष्ठाशोणितमेहाः षड् याप्याः, दोषदूष्याणां विषमक्तियत्वात्; वातात् सर्पिर्वसाक्षौद्रहस्तिमेहाश्चत्वारोऽसाध्यतमाः, महात्ययिकत्वात् ||८||

10 kinds of prameha arise from kapha –

• Udakameha,
• Iksuvalikameha,
• Surameha,
• Sikatameha,
• Shanairmeha,
• Lavanameha,
• Pistameha,
• Sandrameha,
• Sukrameha and
• Phenameha

These ten types of prameha caused by kapha are curable. This is because the treatment for both the doshas and dushyas i.e. tissues involved in the pathogenesis of kaphaja prameha are common.  

Six types of Prameha arise from Pitta. They are –

• Nilameha,
• Haridrameha,
• Amlameha,
• Ksarameha,
• Manjisthameha and
• Sonitameha (Raktameha)

These six types of prameha caused by pitta can be controlled but cannot be treated completely. The reason is that the treatments for doshas and dushyas involved in the pathogenesis are different from each other.

Four kinds of prameha arise from Vata. They are –

• Sarpimeha,
• Vasameha,
• Ksaudrameha and
• Hastimeha

The above mentioned four types of prameha caused by vata are greatly incurable. This is because it produces great danger of losing tissues and also life.

Manifestation (Pathogenesis) of Kaphaja, Pittaja and Vataja Pramehas

तत्र वातपित्तमेदोभिरन्वितः श्लेष्मा श्लेष्मप्रमेहाञ्जनयति, वातकफशोणितमेदोभिरन्वितं पित्तं पित्तप्रमेहान्, कफपित्तवसामज्जमेदोभिरन्वितो वायुर्वातप्रमेहान् ||९||

Kaphaja Prameha – is produced by aggravated kapha getting associated with vata, pitta and medas – fat.

Pittaja Prameha – is produced by aggravated pitta getting associated with vata, kapha, rakta and medas.

Vataja Prameha – is produced by aggravated vata getting associated with kapha, pitta, vasa – muscle fat, majja – bone marrow and medas – fat.

Kaphaja Pramehas: Diabetes of Kapha Origin

तत्र, श्वेतमवेदनमुदकसदृशमुदकमेही मेहति; इक्षुरसतुल्यमिक्षुवालिकामेही; सुरातुल्यं सुरामेही; सरुजं सिकतानुविद्धं सिकतामेही; शनैः सकफं मृत्स्नं शनैर्मेही; विशदं लवणतुल्यं लवणमेही; हृष्टरोमा पिष्टरसतुल्यं पिष्टमेही; आविलं सान्द्रं सान्द्रमेही; शुक्रतुल्यं शुक्रमेही; स्तोकं स्तोकं सफेनमच्छं फेनमेही मेहति ||१०||

Pittaja Prameha: Diabetes of Pitta Origin

अत ऊर्ध्वं पित्तनिमित्तान् वक्ष्यामः- सफेनमच्छं नीलं नीलमेही मेहति; सदाहं हरिद्राभं हरिद्रामेही; अम्लरसगन्धमम्लमेही; स्रुतक्षारप्रतिमं क्षारमेही; मञ्जिष्ठोदकप्रकाशं मञ्जिष्ठामेही; शोणितप्रकाशं शोणितमेही मेहति ||११||

After this, we will describe six types of pittaja prameha

Vataja Prameha: Diabetes of Vata Origin

अत ऊर्ध्वं वातनिमित्तान् वक्ष्यामः- सर्पिःप्रकाशं सर्पिर्मेही मेहति; वसाप्रकाशं वसामेही; क्षौद्ररसवर्णं क्षौद्रमेही; मत्तमातङ्गवदनुप्रबन्धं [१] हस्तिमेही मेहति ||१२||

Further, we will describe Prameha produced by Vata:-

Upadrava: Complications / Secondary Diseases

मक्षिकोपसर्पणमालस्यं मांसोपचयः प्रतिश्यायः शैथिल्यारोचकाविपाकाः कफप्रसेकच्छर्दिनिद्राकासश्वासाश्चेति श्लेष्मजानामुपद्रवाः; वृषणयोरवदरणं बस्तिभेदो मेढ्रतोदो हृदि शूलमम्लीकाज्वरातीसारारोचका वमथुः परिधूपनं दाहो मूर्च्छा पिपासा निद्रानाशः पाण्डुरोगः पीतविण्मूत्रनेत्रत्वं चेति पैत्तिकानां; हृद्ग्रहो लौल्यमनिद्रा स्तम्भः कम्पः शूलं बद्धपुरीषत्वं चेति वातजानाम् |
एवमेते विंशति प्रमेहाः सोपद्रवा व्याख्याताः ||१३||

Thus, the twenty varieties of diabetes and their complications have been described.

Prameha Pidaka: Diabetic Eruption

तत्र वसामेदोभ्यामभिपन्नशरीरस्य त्रिभिर्दोषैश्चानुगतधातोः प्रमेहिणो दश पिडका जायन्ते |
तद्यथा- शराविका, सर्षपिका, कच्छपिका, जालिनी, विनता, पुत्रिणी, मसूरिका, अलजी, विदारिका, विद्रधिका चेति ||१४||
Ten kinds of Prameha Pidaka i.e. eruptions or carbuncles arise in patients suffering from prameha having abundance of vasa – muscle fat and medas – fat in their body. In these people, the three doshas together invade the tissues giving rise to prameha pidaka. The ten kinds of prameha pidaka are –

i. Saravika,
ii. Sarsapika,
iii. Kacchapika,
iv. Jalini,
v. Vinata,
vi. Putrini,
vii. Masurika,
viii. Alaji,
ix. Vidarika and
x. Vidhradika

शरावमात्रा तद्रूपा निम्नमध्या शराविका |
गौरसर्षपसंस्थाना तत्प्रमाणा च सार्षपी ||१५||
सदाहा कूर्मसंस्थाना ज्ञेया कच्छपिका बुधैः |
जालिनी तीव्रदाहा तु मांसजालसमावृता [१] ||१६||
महती पिडका नीला पिडका विनता स्मृता [२] |
महत्यल्पाचिता ज्ञेया पिडका सा तु पुत्रिणी ||१७||
मसूरसमसंस्थाना ज्ञेया सा तु मसूरिका |
रक्ता सिता स्फोटवती दारुणा त्वलजी भवेत् ||१८||
विदारीकन्दवद्वृत्ता कठिना च विदारिका |
विद्रधेर्लक्षणैर्युक्ता ज्ञेया विद्रधिका बुधैः ||१९||

‘These pidakas are produced by the same varieties of prameha which have been described by me’ says the master.

Sadhyasadhyata: Prognosis

ये यन्मयाः स्मृता मेहास्तेषामेतास्तु तत्कृताः |२०|
गुदे हृदि शिरस्यंसे पृष्ठे मर्मणि चोत्थिताः |
सोपद्रवा दुर्बलाग्नेः पिडकाः परिवर्जयेत् ||२०||

The patient of prameha should be rejected and not treated when –

–        The pidakas have developed in the rectum or anus, region of heart, head, shoulders, back and marmas – vital organs / spots
–        There is presence of complications
–        The person has durbala agni i.e. weak digestive capacity

Incurability of Vataja Prameha

कृत्स्नं शरीरं निष्पीड्य मेदोमज्जवसायुतः |
अधः प्रक्रमते वायुस्तेनासाध्यास्तु वातजाः ||२१||

Prameha caused by vata is said to be incurable because in this condition, the aggravated vata on getting associated with fat, bone marrow and muscle fat, squeezes the entire body, moves downwards and expels the urine mixed with fat, marrow and muscle fat.

Criteria of diagnosing a person as diabetic

प्रमेहपूर्वरूपाणामाकृतिर्यत्र दृश्यते |
किञ्चिच्चाप्यधिकं मूत्रं तं प्रमेहिणमादिशेत्  ||२२||
कृत्स्नान्यर्धानि वा यस्मिन् पूर्वरूपाणि मानवे |
प्रवृत्तमूत्रमत्यर्थं तं प्रमेहिणमादिरोत् ||२३||
A person can be considered to have prameha when he has premonitory symptoms of prameha along with slight increase in quantity of urine.

The person should also be considered to be a pramehi i.e. one suffering from prameha if he has all or even half of premonitory symptoms and has great increase in the quantity of urine.

पिडकापीडितं गाढमुपसृष्टमुपद्रवैः |
मधुमेहिनमाचष्टे स चासाध्यः प्रकीर्तितः ||२४||
स चापि गमनात् स्थानं स्थानादासनमिच्छति |
आसनादृणुते शय्यां शयनात् स्वप्नमिच्छति ||२५||
One should be designated as a patient of Madhumeha if –

–        He is greatly suffering from prameha pidakas
–        Has severe complications of the disease

This condition is incurable.

The patient suffering from Madhumeha will desire –

• To stand, instead of walking
• To sit, instead of standing
• To sit on a comfortable chair, instead of sitting on the ground
• To lie down on a bed, instead of sitting in a chair
• To sleep, instead of simply lying down

Analogy to explain formation of different kinds of Prameha

यथा हि वर्णानां पञ्चानामुत्कर्षापकर्षकृतेन संयोगविशेषेण शबलबभ्रुकपिलकपोतमेचकादीनां वर्णानामनेकेषामुत्पत्तिर्भवति, एवमेव दोषधातुमलाहारविशेषेणोत्कर्षापकर्षकृतेन संयोगविशेषेण प्रमेहाणां नानाकरणं भवति ||२६|| 

Colors such as Sabala (variegated color, spotted), Babhru (deep brown), Kapila (brown, tawny), Kapota (grey), Mecaka (dark blue), etc. are manifested just by increase or decrease of quantity taken while combining the five kinds of colors.  Similarly, different kinds of prameha are caused due to increase or decrease of proportions in the combination of doshas, dhatus, mala and ahara – food.

Transformation of Pramehas into Madhumeha

भवति चात्र-
सर्व एव प्रमेहास्तु कालेनाप्रतिकुर्वतः [१] |
मधुमेहत्वमायान्ति तदाऽसाध्या भवन्ति हि ||२७||

Once verse here: –

If not treated at proper time, all kinds of prameha will transform into Madhumeha and hence become incurable.

इति सुश्रुतसंहितायां निदानस्थाने प्रमेहनिदानं नाम षष्ठोऽध्यायः ||६||
Thus ends the Sixth chapter by name Prameha Nidana- in Nidana Sthana of Susrutha Samhita.