‘‘Prameha: Classification, Aetiology and Pathogenesis’’
DR.VIKAS DUBEY, B.A.M.S(M.D)AYU B.V.D.U COLLEGE OF AYURVED MOB-9479427096 ,8237250287 E-MAIL ; drvikasdubey@rocketmail.com,
Abstract:
The classical texts of Ayurveda has described Prameha as a group of disorders of the urinary system( Vasti ) this is also part of Trimarma. Each sub type of Prameha has been defined on specific characteristics of abnormal urine. Classification of Prameha is based on different perspectives such as Genetics, Environmental Factors, Behavioural Changes and Food Habits. Nosology of diseases has been made on the basis of pathophysiology, manifestation of clinical features, and characteristics of thea bnormal urine. Each sub type is, therefore, not identical with the conditions mentioned in the classification of diseases in Modern Medicine. For instance, theview of many scholars that the Diabetes Mellitus as Madhumeha, is an incorrect interpretation because Madhumeha does not represent entire clinical course of Diabetes Mellitus. Madhumeha is a fatal condition, which represents a particular stage of Diabetes Mellitus and other diseases of the Kidney. The pathogenesis of prameha is described on the basis of Dosa – Dhatu – Mala Theory. Early stage ofthe disease manifests clinically due to the vitiation of Kapha predominantly. Gradualdevelopment of the disease may occur manifesting the features of vitiated Pittaand VSta on the influence of aggravating factors and inadequate attention in themanagement.
KEY WORDS:- Pameha,Trimarma,Hrdaya,Sirsa,Vasti(Urinary system)
· Introduction
Ayurveda mentions three major vital places of the body as Trimarma, which includes Hrdaya,
Sirsa and Vasti. Prameha, which is a group ofdiseases of Vasti (Urinary System) is
characterized by excessive passing of turbid urine.The term “Prameha” is derived from the root of Sanskrit language “Mih – Ksarane”, whichmeans passing of urine. The prefix “Pra”stands
for excessiveness. Therefore, the term“Prameha” literally stands for excessive passing
of urine1 1 . Excessive passing of urine – PrabhQtamutratS”and the Turbidity of urine – “Avilamu
tratS” are main characteristic features of“Prameha”. Therefore, the condition “Prameha”
can be basically defined as “a group ofdiseases of any cause, which manifests
“excessive passing of urine with or withoutturbidity of urine”.
The Classification of Prameha Prameha is included in the category of ‘Maharoga’, which consists of the most fatal conditionsthat are incurable – (Su.Ci.14.11)
Classification of Prameha has been made onthe basis of quantitative and qualitative analysis
of urine. The classical texts of Ayurveda,Carakasamhita, Susrutasamhita and As (hastangahrdayasamhits mention the 20 sub – typesof Prameha and different technical terms have
been used in the nosology of few conditions -(CS.Ni.4.38 , CS.Ci.6.61 , SS.Ni.6.262 , AS Ni
10.83).On the aetiological basis, Prameha isdivided into two categories as Congenital
{Prakrtija) and Acquired {Svakfta)9. Thecongenital type of Prameha is caused byhereditary and nonhereditary defects of the ovumand sperm -(SS.Ci.11.037).On the basis of pathophysiology, all types ofPrameha are the results of vitiation of tridosa and they are categorized into three groupsnamely Kaphajaprameha, Pittajaprameha and VStajaprameha according to the predominant dOsa – (CS.Ni.4.38, SS.Ni.67) and each categoryis divided into sub types on the basis of the characteristics of urine. been replaced by Raktameha,a synonym of Sorjitameha in addition to theother types of Pittajaprameha inCarakasamhita. Asthahgahrdayasarhhita hasfollowed the Carakasamhita in classifying the Vataja Prameha.
.Kaphaja Prameha
Kaphajaprameha, which includes ten types ofPrameha namely Udakameha, IksubSlikSrasameha(Iksumeha), SSndrameha, SSndr -aprasSdameha, Suklameha, Sukrameha,S\itameha , Sanairmeha , SikatSmeha , andLdlSmeha – (CS.Su.19.3.91 , CS.Ni.4.102).Susruta refers to the terms Pistameha ,SurSmeha, Lavanameha and Phenameha –(SS.Ni. 6.102-7) instead of Sandraprasadameha,
Suklameha, SJtameha, Alaiameha ofCarakasamhita while AsthSrigahrdayasarii hitsrefers to Udakameha, Iksumeha,SSndrameha, Sukrameha, SJtameha,Sanairmeha, SikatSmeha, Pistameha, Surameha and Lalameha – (AHS.Ni.10.8-133).
Pittaja Prameha
Pittaja Prameha, which includes six types ofPrameha, namely KsSrameha, Kaiameha,
Nllameha, Lohitameha, MSnjistameha andHaridrameha – (CS.Su.19.121 3 . CS.Ni.4.2513).
Susruta refers to the terms Amlameha andSorjitameha (SS.Ni.6.112 7 ) instead of KSIameha and Lohitameha of Carakasamhita,while AsthSngahrdayasarhhitS has followed themCarakasamhita but Lohitameha has beenreplaced by Sorjitameha of Susrutasamhita –(AHS.Ni.10.14-153).
VatajaPrameha Carakasamhita includes four types of VatajaPrameha, namely VasSmeha, MajjSmeha,
Hastimeha and Madhumeha – (CS.Su.19.121,CS.Ni.4.91, CS.Ci.6.71. Susrutasamhita refers
to the terms Sarpirmeha and Ksaudrameha –(SS.Ni.6.122-7 ) instead of Majjameha and
Madhumeha of Carakasamhita while AsthShgahrdayasarnhita has followed Carakasamhita (AHS Ni 10.16 -183)
Aetiology of Prameha
Origination of Prameha is symbolically expressed in Carakasamhita as it occured dueto excessive drinking of Ghee (Havisa) when the Lord Daksa was destroying the sacrifice -(CS.Ni.8.111 8 ) . The aetiological factors mentioned in classical texts are common forall types of Prameha. Aetiological factors can be classified according to the nature of effecton the kidney. Susrutasamhita has emphasized
two categories: Hereditary and Acquired.Hereditary causes include the defects of Bija (Sperm or Ovum). Acquired causes of Prameha include inappropriate food and life style -(SS.Ci.11.032).
Genetic Factors
Susrutasamhita has identified the geneticinvolvement in pathogenesis of Prameha –
SS.Ci.11.032). Carakasamhita mentions that, indescribing the prognosis of Prameha, genetic
involvement of the disease is a cause of poorprognosis. Further Cakrapanidatta, the great
commentator of Carakasamhita, also elaboratesthat the Prameha may be hereditary or
congenital due to defects of Bija (Sperm orOvum)-(CS.Ci.6.578).
Carakasamhita states that congenital type ofdiseases can occur due to defect in bija,
bijabhSga or bfjabhSgSvayavS (CS.Sa.4.308).The bija, bijabhSga and bijabhSgSvayava can
be compared with Ovum and Sperm,Chromosomes and Genes respectively.
Cakrapanidatta comments that this defect isdue to the indulgence in inappropriate foods at
the time of pregnancy. Carakasamhita furtherstates that excessive use of sweet taste during
pregnancy may cause birth to a child affectedwith Prameha and obesity (CS.Sa.8.218).
Genetic influence and factors that affect thefoetal nutrition are the primary causes of
Prameha. In comparison to the modernmedicine, Diabetes Mellitus is a leading
disease, which shows abnormalities in the urineand causes renal damage. Genetics involvement
is accepted as a significant aetiolgical factor -Level “A” evidence4 Monogenic forms and
susceptibility genes have also been identifiedin both forms of Diabetes Mellitus Type 1 and
Type 2.
Non • Genetic Factors
Nutrition:
Epidemiological studies have reported a higherincidence of Type 2 Diabetes Mellitus in
subjects with a low birth weight. The hypothesisthat nutrition of the mother can profoundly affect
the metabolic outcome of the offspring has beenconfirmed by elegant mechanistic animal
studies. Low birth weight is accepted as asignificant aetiological factor – Level “A”
evidence. Poor nourishment of the foetusincreases the risk of metabolic syndrome and
Type 2 Diabetes Mellitus and postnatal over -nutrition may aggravate the syndrome4.
Food Habits
Excessive utility of foods that increases bodyweight, fat content of the body (CS.Ni.4.141)
and foods that are acid, salt – (CS.Su.17.381)and sweet – (SS.Ni.6.37) in taste are main
causes of Prameha.Excessive utility of food that possesses the
properties such as Sita and Snigdha –(SS.Ni.6.37) and rice prepared from recent
harvest, water obtained from recent rain, leadto increase the constituents such as Slesma,
Pitta, Medas and Mamsa – (CS.Su.17.381).These conditions affect the proper function of
vata. The vitiated vata attracts dja and propelsit into vasti, which causes Madhumeha
(CS.Su.17.381, CS.Su.17.78-821), which is themost difficult to cure and is the fatal state of
the clinical course of Prameha.Excessive use of food that are sweet in taste,
excessive use of rice obtained from recentharvest, recently prepared alcohol, meats
obtained from terrestrial animals (Anupa) andaquatic animals (Audaka) and diary products,
sweets prepared from Jaggery and Pisfaka(foods prepared from flour) etc are the causes
of over nutrition (CS.Su.23.21).According to the modern research, which
confirms the facts mentioned in ancientAyurvedic texts, high frequency of intake of
foods rich in carbohydrate, protein ornitrosamine compounds too will increase the
risk of insulin dependant diabetes in human6.Proteins from cows’ milk may trigger the
autoimmune response that destroys Beta cellsof pancrease in laboratory rats. It has been
suggested that proteins in cows’ milk are alsorisk factors for human diabetes1 2 . Children who
develop diabetes are often breast fed for ashorter period1
Behaviour:-
Excessive sleeping, desire for sleeping duringthe day time, indulgence in long-term sitting,
lack of exercise (sedentary life style) -(CS.Ni.4.141), lack of thinking, lack of
m e d i c i n a l p u r i f i c a t i o n s , d e s i r e forPrameha Pidaka – (CS.Su.17.3-41,
CS.Su.17.381 , CS.Su.23.21 , SS.Ni.6.37). inaddition to, Kota, Kandu, Pandu, Jvara,
Kustha, Visucika derived from Ama, Mutrakrcchra, Arocaka, Tandra, Dvajabhahga,
Atistulata (Obesity), Lasyness, Heaviness ofthe body, Indriyas and Srotas filled with Mala,
Difficulty in concentration of mind, Thoughtfulness, Oedema and other related
conditions – (CS.Su.23.21).
Secondary Causes of Prameha
Obesity
Obesity can act as a secondary cause in thegenesis of Prameha – (CS.Ni.4.14′). Obesity
and Leanness depend on the state of Rasa(Nutrients). Excessive use of food that cause
the increase of Kapha, excessive repetition ofintake of meal, absence of exercises and
sleeping during the day time are the reasons ofobesity, which leads to serious complications
such as Prameha, Vidradhi, Pidaka, Svasa andVatavyadhietc – (SS.Su.15.387).
Modern investigations show that there is globalepidemic of obesity affecting all ages and is
associated with insulin resistance, impairedglucose tolerance and cardiovascular diseases.
Physical inactivity is independently associatedwith increased insulin resistance. Lifestyle
changes in subjects with impaired glucosetolarence decreases progression to Diabetes
Mellitus. Physical inactivity has also been accepted as a significant aetiological factor –
Level “A” evidence.
Functional and Organic Defects of Urinary System
The retroward action of Vata due to the functional and organic defects of urinary system (Vasti)
leading to urinary retention cause Prameha ,Mutradosa (abmormalities of urine), Sukradosa
(abnormalities of seman and seminal fluid),Mutraghata (obstructions of the urinary system)
– (SS.Ni.3.272). Asmarf (urinary calculi) too isone of the leading causes of Prameha specially
Sikatameha , Sarkarameha andBhasmakhyameha (SS.Ni.3.13-152).
Stress
Evidences from animal studies and mechanisticstudies suggest a relationship between stress
and insulin resistance with predisposition toType 2 Diabetes Mellitus and it has been
accepted as an aetiological factor – Level “B”evidence (Partial acceptance subject to
confirmation.
Iatrogenic Causes of Prameha
Administration of medical procedures and medicines, which are liable to cause renal
damage may produce Prameha. Indication ofDharaka Ausadha (Antidiarrhoeal Drugs) is an
example – (Su.Ut.40.29 – 302). According tomodern investigations, many chemicals, which
are administered as medicine, are identified ascauses of renal damage.
Aetiology of Slesmaja Prameha
Carakasamhita refers to the specific aetiologyin respect to the major categories of Prameha.
Food and changes in lifestyle are the predominantcauses of Kaphaja Prameha, in which
Iksumeha is included. According toCarakasamhita, aetiology of Slesmaja
Prameha includes;Excessive utility of cereals such asHayanaka, Yavaka, Cinaka, Uddalaka,
Naisada , Itkata , Mukundaka ,Mahavrrhi, Pramodaka andSugandhaka (CS.Ni.4.58).Excessive utility of food prepared fromHarenu obtained from recent harvest,Juice of Masa with Ghee, meats
obtained from domestic animals,aquatic animals and animals ofmarshy lands, saka, food preparedfrom gingelly and flour (Pi$taka),Diary products, Kusara,Vilepi, foodprepared from sugar cane, curd which
is not prepared properly, liquids andsweets etc – (CS.Ni.4.5B).Absence from physical exercise and
massages, excessive sleeping, longterm sitting and others, whichincrease Meda and urine -(CS.Ni.4.58).
These factors play a major role in the pathogenesisof Iksumeha and modern investigations
also accept the sedantory life style as anaetiological factor of Diabetes Mellitus Type 2.
Aetiology of Pittaja Prameha
Aetiology of Pittaja Prameha includes Excessive use of material, whichpossess the qualities such as U$na,Amla , Lavana, Ksara, Kafuka andTik$na,Use of inappropriately prepared food or food that are liable to inappropriatedigestion; use of incompatible food,which cause the aggravation of pitta
Excessive exposure to sunlight and heat; excessive exertion and anger -(CS.Ni.4.71).
These aetiological factors may cause damagesof the kidney directly or indirectly.
Aetiolgy of Vataja Prameha
Aetiology of Vataja Prameha includes;Excessive use of material, whichpossess the qualities such as kasayakatu, tikta, ruksa, laghu, sita; Excessive indulgence of sexuality and exertion, excessive exposure tosunlight, uncontrolled feelings, sorrow,keeping awake at night, inappropriatepostures of the body, refrains fromnatural urges and trauma; Excessive administration of Emesis, Purgation,Asthapana type of enema andSirovirecana, fasting, and excessivebloodletting;These factors will aggravate the Vata –
(CS.Ni.4.91 ) especially Vyana and Apana,causing Prameha and Sukradosa-(SS.Ni.1.207).
Pathogenesis
The aetiological factors mentioned above lead to increase the body constituents such asSlesma, Pitta, Meda and Mamsa, which willmake the person fatty, weight gained andincrease the viscosity of body – (CS.Su.17.381,CS.Su.23.21 , SS.Ni.6.37). The vitiated dosa produces diseases according to the places,
where they deposit and the Prameha occursdue to the deposition of vitiated dosa in Vasti –
(SS.Su.21.337).
Pathogenesis of Slesmaja Prameha
Increased s)esma due to the influence ofrespective aetiological factors (Nidana) willvitiate dosa and affect the dusya (Tissues). Thevitiated Slesma will disseminate throughout the body arid amalgamate with Meda, Kleda andMamsa, which lead to generate gangrenes {Putimamsaja Pidaka) such as Saravika,
Kacchapika etc. The contaminated Kleda is converted into urine, which consists of thecharacteristics of vitiated Slesma. VitiatedMeda and Kleda affect the urinary systemobstructing the channels. Slesmaja Pramehaincludes ten sub-types classified on the basis of characteristics of urine.The characteristics, which are similar to thoseof Slesma, includes whiteness, coldness,hardness, viscousness, clearness,
smoothness, heaviness, sweetness, ability toseparate into two layers as condensed and clear and the unpleasant smell of urine -(CS.Ni.4.51). At the initial stage of the disease, dosa will not be properly metabolized. Theunmetabolized dosa amalgamate with Meda –(SS.Ni.6.47)and propel into the channels
carrying urine, which flow downward to excrete through the opening of Vasti(SS.Ni.6.47). Any
type of Kaphaja Prameha can arise at this stage.Generally all the three dosa, which involve in
genesis of Prameha, affect the constituentssuch as Meda, Rakta, Sukra, Ambu, Vasa,
Lasika, Majja, Rasa, Qfa, and Mansa of Vasti- (CS.Ci.6.6, CS.Ci.6.81). Dosa, which enters the
vasti, contaminates urine and produces Prameha – (CS.Ci.6.41). Predominance of vitiated dosa in Kaphaja Pramehas is Kapha and the mainly affected dusya is Meda. All subtypes of Kaphaja Prameha occur due to the amalgamation of vitiated Kapha, Vata and Pitta with Meda -(Su.Ni.6.97).
Pathogenesis of Pittaja Prameha
This is the second stage of Prameha, where the paths are obstructed by Meda causing the
impairment of proper functions of vata, whichincreases the function of Agni (TTksnagni) and
results in dryness of food and swift digestion -(CS.Su.21.5-7, CS.Ni.4.71). Pittaja Prameha
occurs due to the amalgamation of vitiated pitta,vata and kapha with dusya such as blood –
(SS.Ni.6.97,CS.Su.24.51)and Meda –(SS.Ni.6.97). Pittaja Prameha includes the six
sub-types on the basis of characteristics ofurine, which are similar to those of pitta such
as alkalinity, acidity, salty, pungentness, usna,and smell of raw flesh (CS.Ni.4.71).
Pathogenesis of Vataja Prameha
This is the tertiary stage of the Prameha. The person, who has excessive fat, will be broken
down as fire burns forest, causing various typesof complications – (CS.Su.21.5-71).
In comparison to Diabetes Mellitus, breakdownof fat occurs at this stage causing diabetic
ketoacidosis. The vitiated vata, disseminatedthrough out the body bringing the lymph into
the channels of urine, produces Vasameha.When vata brings Majja, Lasika (Tissue fluids)
and Oja into urine, it produces Majjameha,Hastimeha and Madhumeha respectively
(CS.Ni.4.91).Hastimeha will excrete excessive volume Hastimeha will excrete excessive volume of
urine very slowly but it remains residual of urine in the bladder because of vitiated Vata –
(CS.Ni.4.91). Probably it may be due to thedefects of neurogenic control on bladder.
Fatal conditions such as Jvara, Pidaka and Bhagandara occur in the case of excessive
growth of fat due to the influence of vitiated vata and Vataja Prameha also arises – (CS.Su.21.5-
71). Vataja Prameha occurs due to the amalgamation of vitiated vata, kapha and pitta
with Vasa, Majja and Meda – (SS.Ni.6.97). Thevitiated vata also attracts oja and propels it into
vasti, which causes Madhumeha, the final and the most serious stage, which is difficult to cure
– (CS.Su.17.381). All types of Prameha lead to Madhumeha due to lack of management
Conclusion
Slesmaja, Pittaja, and Vataja Prameha represent three clinical stages of renal damage. Slesmaja Prameha is the initial stage,where the function of kidney is impaired mildly.Pittaja Prameha, the second clinical stage of Prameha, shows moderately impaired renalfunctions and at the third stage, the VatajaPrameha, renal functions are affected severely.In comparison, Diabetes Mellitus passes thesethree clinical stages during its clinical course.
The stage of impaired glucose tolerance, whichmay show polyuria without sugars in urine, can
be included in Udakameha. The stage of impaired glucose tolerance, which showspolyuria and glycosuria, are included in Iksumeha. The stage of impaired glucose
tolerance, which shows polyuria, glycosuria and albuminuria are included in Sandrameha and
so forth.
. References:
1. Buddhadasa R, Eds. 1960. Carakasamhita,Department of State Languages, Colombo.
2. Buddhaddsa R, Eds. 1962. Susrtasamhita,Department of State Languages, Colombo.
3. Buddhadasa, R., Ed. 1964. Asthangahrdayasamhita, 1″ Edi, Department of State Languages, Colombo.
4. Diabetes Association of Sri Lanka, 2002. Diabetesin Asia 2002; 4 m international conference. Colombo.
5. Elliot, R.B., Martin. J.M.. 1984. Dietary protein: atrigger of insulin dependent diabetes in the BB rat.Diabetolodia 26: 297-299.
6. Gisela G Dahlquist., Leif G Blom., Lars Ake
7. Jadavji Trikamji Acarya, Eds. 1931. Susrtasamhita,Nirnayasagar Press, Bombay.
8. Jadavji Trikamji Acarya, Eds. 1994. Carakasamhita– 4′” edi, CaukhambhaSamskrit Samsthan, Varanasi.
9. Krishnamurthy, K.H.; Sharma, P.V., 2000. BhelansamhitSr. Chapter VI. 155-157. Chaukhamba
Visvabharathi, Varanasi.
10. Patterson, C.C., Thorogood, M., Smith, P.G.,Heasman, M.A., Clarke, I.A., Mann, J.I., 1983.
Epidemiology of Type 1 (insulin dependant) diabetes in Scotland 1968-1976: evidence of an increasingincidence. Diabetologia 24: 238-243.
11. Radhakantadeva. Eds. 1813. Sabdakalpadruma
Vol III: 285. Calcuta.
12. Scott, F.W., Daneman, D., Martin, J.M., 1983.Evidence of a critical role of diet in the developmentof insulin dependant diabetes mellitus. DiabetesRes: 1 5 3 – 157.
13.Sharma, R.K., Das, B., 1998. Agnivesa’s
AUTHOR BIO:
Dr.Vikram Chauhan (MD-AYURVEDA) is an Ayurvedic practitioner based in Mohali, India. He is spreading the knowledge of ancient healing treatment of Ayurveda not only in India but also abroad. He has researched age old formulas from ancient Ayurvedic text books to restore health and save human beings from the worst side-effects of chemical based treatments. Dr.Vikram Chauhan is also the author of ‘Ayurveda- God’s Manual For Healing’, an informative book for people interested in learning basics of Ayurveda, diet and principles of healing according to Ayurveda system of medicine. He is CEO and Founder of Planet Ayurveda Products, Planet Ayurveda Clinic and Krishna Herbal Company.
Website – www.planetayurveda.com
Contact:
DR.VIKAS DUBEY, B.A.M.S(M.D)AYU B.V.D.U COLLEGE OF AYURVED MOB-9479427096 ,8237250287 E-MAIL ; drvikasdubey@rocketmail.com,