Changes

The present chapter begins with an enumeration of diseases afflicting the head and describes the significance of head, followed by the description of five varieties of head diseases with headache as the main symptom and five types of heart diseases with different clinical presentations. Thereafter, sixty two permutations and combinations in the form of ''sannipata'' (involvement of three ''doshas'') and ''samsarga'' (involvement of two ''doshas''), based on variations in quantum of increased or decreased state of involved ''doshas'', along with descriptions of symptoms of twelve varieties of ''sannipata'' have been described in this chapter. Also described are eighteen conditions caused by decrease of ''doshas, dhatus, mala'' and ''ojas'', along with plausible reasons for all the decrease taking place in the body. Further, definition and characteristics of ''ojas'' have been provided in brief with a specific variety of ''Avrita Madhumeha'' (diabetes due to obstructive ''vata'') in which ''ojas'' is excreted out in urine. The description of ''avrita madhumeha'' resembles diabetes mellitus type II (NIDDM) and seems to represent the disease of third ''marma'' (vital organ) i.e. ''basti''. Skin infection is a common complication of diabetes mellitus. Therefore it is described in detail under the heading of ''prameha pidika'' (carbuncles). Seven types of inflammatory swellings viz. ''sharavika, kacchapika, jalini, sarshapi, alaji, vinata'' and ''vidradhi'' are described in detail with a disclaimer stating that these can also occur independently due to vitiation of ''medas''. The chapter ends with references to various ''gati'' (states) of ''dosha'' that are related to health as well as disease.

The present chapter begins with an enumeration of diseases afflicting the head and describes the significance of head, followed by the description of five varieties of head diseases with headache as the main symptom and five types of heart diseases with different clinical presentations. Thereafter, sixty two permutations and combinations in the form of ''sannipata'' (involvement of three ''doshas'') and ''samsarga'' (involvement of two ''doshas''), based on variations in quantum of increased or decreased state of involved ''doshas'', along with descriptions of symptoms of twelve varieties of ''sannipata'' have been described in this chapter. Also described are eighteen conditions caused by decrease of ''doshas, dhatus, mala'' and ''ojas'', along with plausible reasons for all the decrease taking place in the body. Further, definition and characteristics of ''ojas'' have been provided in brief with a specific variety of ''Avrita Madhumeha'' (diabetes due to obstructive ''vata'') in which ''ojas'' is excreted out in urine. The description of ''avrita madhumeha'' resembles diabetes mellitus type II (NIDDM) and seems to represent the disease of third ''marma'' (vital organ) i.e. ''basti''. Skin infection is a common complication of diabetes mellitus. Therefore it is described in detail under the heading of ''prameha pidika'' (carbuncles). Seven types of inflammatory swellings viz. ''sharavika, kacchapika, jalini, sarshapi, alaji, vinata'' and ''vidradhi'' are described in detail with a disclaimer stating that these can also occur independently due to vitiation of ''medas''. The chapter ends with references to various ''gati'' (states) of ''dosha'' that are related to health as well as disease.

The diseases related to ''trimarma'', or the three vital organs, have also been described in the 26th chapter of [[Chikitsa Sthana]] [[ Trimarmiya Chikitsa]] and later in 9th chapter of [[Siddhi Sthana]] [[Trimarmiya Siddhi]]. While the [[Sutra Sthana]] helps provide the fundamental approaches to treating these diseases, the [[Chikitsa Sthana]] primarily addresses the management aspects and [[Siddhi Sthana]] describes the internal and external traumas of these organs. As per  Ayurveda, there are 107 marmas that are considered to be points of ''prana'' (vital energy) and are located in various parts of the body. It is accepted that injuries to ''marma'' -external, internal or psychological  - may either cause immediate death or permanent deformities (some of which may cause complications and death at a later stage). Among these 107 ''marmas'', Charaka has given utmost importance to the head, the heart and the urinary bladder. Among these three, the head is foremost as it is central to all senses and is the prime location of ''prana''. This is the reason why other texts have compared human body with an inverted-tree model (with roots at the top and branches at the bottom).

The diseases related to ''trimarma'', or the three vital organs, have also been described in the 26th chapter of [[Chikitsa Sthana]] [[ Trimarmiya Chikitsa]] and later in 9th chapter of [[Siddhi Sthana]] [[Trimarmiya Siddhi]]. While the [[Sutra Sthana]] helps provide the fundamental approaches to treating these diseases, the [[Chikitsa Sthana]] primarily addresses the management aspects and [[Siddhi Sthana]] describes the internal and external traumas of these organs. As per  Ayurveda, there are 107 marmas that are considered to be points of ''prana'' (vital energy) and are located in various parts of the body. It is accepted that injuries to ''marma'' -external, internal or psychological  - may either cause immediate death or permanent deformities (some of which may cause complications and death at a later stage). Among these 107 ''marmas'', Charak has given utmost importance to the head, the heart and the urinary bladder. Among these three, the head is foremost as it is central to all senses and is the prime location of ''prana''. This is the reason why other texts have compared human body with an inverted-tree model (with roots at the top and branches at the bottom).

The ''shiroroga'', or the disease(s) of the head, are various clinical representations of headache and vary depending upon ''dosha''-dominance and ''krimi''-infestation. Though headache is a common form of five major types of ''shiroroga'', different manifestations of headache can give an idea of the predominant ''dosha'' which may further decide the course of treatment. Similarly ''hridroga'' (heart diseases) and diseases associated with the urinary bladder mentioned in this chapter are also due to ''dosha'' predominance and ''krimi'' infestation.  

The ''shiroroga'', or the disease(s) of the head, are various clinical representations of headache and vary depending upon ''dosha''-dominance and ''krimi''-infestation. Though headache is a common form of five major types of ''shiroroga'', different manifestations of headache can give an idea of the predominant ''dosha'' which may further decide the course of treatment. Similarly ''hridroga'' (heart diseases) and diseases associated with the urinary bladder mentioned in this chapter are also due to ''dosha'' predominance and ''krimi'' infestation.  

Various permutations and combinations of ''dosha'' have been analysed that help in understanding the pathogenesis of a disease. It is always a matter of debate as to why there are so many diseases and why does a disease have so many different manifestations or forms, depending upon an individual. One answer is that the ''dosha'' involved in pathogenesis varies in the forms of either ''vriddhi'' (increase) or ''kshaya'' (decrease), and that a typical permutation or combination of such ''doshas'' can manifest the disease in a different way. The verses 45, 46, and 47 deal with ''ashayapkarsha'' (pulling ''dosha'' from its location) in which a dominant or increased ''vata'' pulls the normal ''pitta'' and ''kapha'' away from their “seats” and manifests its own features there. Therefore, confusion can occur in the diagnosis and management of the disease. In addition, the concept of ''vikalpa samprapti'' (variable pathogenesis) can be a reason for such varied presentations of the disease, since per ''vikalpa samprapti'', the involvement of various properties of ''dosha'' may differ depending upon the etiological factors. Eighteen types of ''kshaya'' (decreased state) of ''dosha, dhatu,'' ''mala'' and ''ojas'' that may play a significant role in disease pathogenesis are also considered in this chapter. ''Madhumeha'' (Diabetes mellitus) which is also termed as ''ojomeha'' in other texts is one of the ''prameha'' where excessive ''kshaya'' of ''ojas'' takes place. One of its presentations (or forms) is caused due to ''avaranajanya samprāpti'' (obstructive pathogenesis), as explained in this chapter. ''Madhumeha'' is one among twenty types of ''prameha'' characterised by excessive frequency and quantity of urination. The primary ''dosha'' associated with ''madhumeha'' is ''vata'' and two types of pathogenesis of ''madhumeha'' have been discussed in [[Charaka Samhita]]. In the first type, ''dhatukshaya'' (decreased state of body tissue) causes ''vata'' provocation and all the clinical features of a vitiated ''vata'' are present in the patient of ''kshayaja madhumeha'' (Diabetes mellitus type 1) (Charaka Nidana 4/36-44). In the second type, there is an initial involvement of ''kapha, pitta, mamsa'' and ''medas dhātu'', that in turn make ''avarana'' (to get covered or overlapped) of ''vata'' leading to manifestation of ''madhumeha'' (diabetes mellitus type 2) where features of k''apha, pitta, medas'' and ''mamsa dushti'' are also observed. Here, therefore, the main line of treatment (i.e., for Type 2) involves pacifying  ''kapha, pitta,'' ''medas'' and ''mamsa''. Various ''gati'' of ''dosha'' that are responsible for healthy and diseased states are dealt at the end of the chapter. Charaka has also stressed upon the significance of a regular healthy diet. It can be said that in the 17th chapter, a multi-faceted approach to understanding various presentations of diseases has been mentioned, aided with examples.

Various permutations and combinations of ''dosha'' have been analysed that help in understanding the pathogenesis of a disease. It is always a matter of debate as to why there are so many diseases and why does a disease have so many different manifestations or forms, depending upon an individual. One answer is that the ''dosha'' involved in pathogenesis varies in the forms of either ''vriddhi'' (increase) or ''kshaya'' (decrease), and that a typical permutation or combination of such ''doshas'' can manifest the disease in a different way. The verses 45, 46, and 47 deal with ''ashayapkarsha'' (pulling ''dosha'' from its location) in which a dominant or increased ''vata'' pulls the normal ''pitta'' and ''kapha'' away from their “seats” and manifests its own features there. Therefore, confusion can occur in the diagnosis and management of the disease. In addition, the concept of ''vikalpa samprapti'' (variable pathogenesis) can be a reason for such varied presentations of the disease, since per ''vikalpa samprapti'', the involvement of various properties of ''dosha'' may differ depending upon the etiological factors. Eighteen types of ''kshaya'' (decreased state) of ''dosha, dhatu,'' ''mala'' and ''ojas'' that may play a significant role in disease pathogenesis are also considered in this chapter. ''Madhumeha'' (Diabetes mellitus) which is also termed as ''ojomeha'' in other texts is one of the ''prameha'' where excessive ''kshaya'' of ''ojas'' takes place. One of its presentations (or forms) is caused due to ''avaranajanya samprāpti'' (obstructive pathogenesis), as explained in this chapter. ''Madhumeha'' is one among twenty types of ''prameha'' characterised by excessive frequency and quantity of urination. The primary ''dosha'' associated with ''madhumeha'' is ''vata'' and two types of pathogenesis of ''madhumeha'' have been discussed in [[Charak Samhita]]. In the first type, ''dhatukshaya'' (decreased state of body tissue) causes ''vata'' provocation and all the clinical features of a vitiated ''vata'' are present in the patient of ''kshayaja madhumeha'' (Diabetes mellitus type 1) (Charak Nidana 4/36-44). In the second type, there is an initial involvement of ''kapha, pitta, mamsa'' and ''medas dhātu'', that in turn make ''avarana'' (to get covered or overlapped) of ''vata'' leading to manifestation of ''madhumeha'' (diabetes mellitus type 2) where features of k''apha, pitta, medas'' and ''mamsa dushti'' are also observed. Here, therefore, the main line of treatment (i.e., for Type 2) involves pacifying  ''kapha, pitta,'' ''medas'' and ''mamsa''. Various ''gati'' of ''dosha'' that are responsible for healthy and diseased states are dealt at the end of the chapter. Charak has also stressed upon the significance of a regular healthy diet. It can be said that in the 17th chapter, a multi-faceted approach to understanding various presentations of diseases has been mentioned, aided with examples.

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Ityagniveśakr̥te Tantre Carakapratisamskr̥te ślokasthāne kiyantaḥśirasīyo Nāma saptadaśoadhyāyaḥ ||17||

Ityagniveśakr̥te Tantre Carakapratisamskr̥te ślokasthāne kiyantaḥśirasīyo Nāma saptadaśoadhyāyaḥ ||17||

Thus seventeenth chapter of [[Sutra Sthana]] compiled by Agnivesha and revised by Charaka entitled [[Kiyanta Shiraseeya Adhyaya]] is completed (17).

Thus seventeenth chapter of [[Sutra Sthana]] compiled by Agnivesha and revised by Charak entitled [[Kiyanta Shiraseeya Adhyaya]] is completed (17).

=== ''Tattva Vimarsha'' ===

=== ''Tattva Vimarsha'' ===

==== ''Indriya Buddhi'' (centres of senses in the brain) ====

==== ''Indriya Buddhi'' (centres of senses in the brain) ====

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While describing ''pancha-panchaka'' principle of perception by five ''jnanaindriya'' [Cha. Su. 8/3], Charaka mentions five ''indriya'' (senses), five ''indriya adhisthana'' (sense organs), five ''indriya dravya'' (specific matter which enable the senses to perceive), five ''artha'' (specific objects to be perceived by sense) and five ''indriya-buddhi'' (final sensation). The five ''indriya'' are the five senses and the five ''indriya adhisthana'' are the five external sites of senses for example eyes for vision and ears for hearing, but site of  the ''indriya-buddhi'' is not mentioned. In this regard, the following observations may be taken into consideration:

While describing ''pancha-panchaka'' principle of perception by five ''jnanaindriya'' [Cha. Su. 8/3], Charak mentions five ''indriya'' (senses), five ''indriya adhisthana'' (sense organs), five ''indriya dravya'' (specific matter which enable the senses to perceive), five ''artha'' (specific objects to be perceived by sense) and five ''indriya-buddhi'' (final sensation). The five ''indriya'' are the five senses and the five ''indriya adhisthana'' are the five external sites of senses for example eyes for vision and ears for hearing, but site of  the ''indriya-buddhi'' is not mentioned. In this regard, the following observations may be taken into consideration:

Charaka mentions that ''prānavāhi srotāmsi'' of ''indriya'' are situated in the head and are connected with the body as sun is connected with its rays. Therefore, diseases such as ''ardita'' (facial paralysis), ''cheshta nasha'' (paralysis) and disorders of eye movement etc. are due to trauma to the head [Ca Sii 9/4]. In this chapter, the physical location of all the ''indriya'' has been mentioned to be the head, hence on the basis of these observations, it can be concluded that the ''indriya-buddhi'' are also situated in head. ''Indriya buddhi'' is that vital part of a sense that decides the final knowledge of the perceived object. Hence sense centres situated in the cortex region of the brain represent the ''indriya buddhi'' [12]

Charak mentions that ''prānavāhi srotāmsi'' of ''indriya'' are situated in the head and are connected with the body as sun is connected with its rays. Therefore, diseases such as ''ardita'' (facial paralysis), ''cheshta nasha'' (paralysis) and disorders of eye movement etc. are due to trauma to the head [Ca Sii 9/4]. In this chapter, the physical location of all the ''indriya'' has been mentioned to be the head, hence on the basis of these observations, it can be concluded that the ''indriya-buddhi'' are also situated in head. ''Indriya buddhi'' is that vital part of a sense that decides the final knowledge of the perceived object. Hence sense centres situated in the cortex region of the brain represent the ''indriya buddhi'' [12]

   

   

'''Classification of ''shiroroga'':''' Generally, ''shiroroga'' implies any type of disease afflicting the head. Therefore, Charaka enlisted diseases such as hemicrania (''ardhavabhedaka''), headache (''sarvam va rujyati shirah''), coryza (''pratishyaya''), diseases of mouth, nose, eyes and ears which cause headache (''mukha-nasa-akshi-karna-roga''), giddiness/vertigo (''sirobhramah''), facial paralysis (''ardita''), tremors of the head (''shirasah kampa'') and stiffness of the neck, nape and jaw (''gala-manya-hanu-grahah'') as ''shiroroga''. Hence, in general, shiroroga includes diseases occurring in the skull, its orifices and the structure related to it. As per this classification ''shiroroga'' includes ''vatika, paittika, kaphaja, sannipataja'' and ''krimija shiroroga''.   

'''Classification of ''shiroroga'':''' Generally, ''shiroroga'' implies any type of disease afflicting the head. Therefore, Charak enlisted diseases such as hemicrania (''ardhavabhedaka''), headache (''sarvam va rujyati shirah''), coryza (''pratishyaya''), diseases of mouth, nose, eyes and ears which cause headache (''mukha-nasa-akshi-karna-roga''), giddiness/vertigo (''sirobhramah''), facial paralysis (''ardita''), tremors of the head (''shirasah kampa'') and stiffness of the neck, nape and jaw (''gala-manya-hanu-grahah'') as ''shiroroga''. Hence, in general, shiroroga includes diseases occurring in the skull, its orifices and the structure related to it. As per this classification ''shiroroga'' includes ''vatika, paittika, kaphaja, sannipataja'' and ''krimija shiroroga''.   

In addition, in [[Siddhi Sthana]], four more diseases occurring in the head have been described in detail viz. ''shankhaka, ardhavabhedaka,'' ''suryavarta,'' and ''anantavata'' [Ca Si 9/71-87]. In these ''shiroroga'', ''nasya''(nasal errhines) has been indicated [Ca Si 9/88]. In all nine ''shiroroga'' (five in this chapter, and four in [[Siddhi Sthana]]) that mention headache as a key symptom. Other varieties of ''shiroroga'' mentioned in other texts are ''raktaja'' and ''kshayaja'' [Sushruta Uttara 25/3] and ''shirah-kampa'' [As Hr.Uttara 23/9].(Verse 6)

In addition, in [[Siddhi Sthana]], four more diseases occurring in the head have been described in detail viz. ''shankhaka, ardhavabhedaka,'' ''suryavarta,'' and ''anantavata'' [Ca Si 9/71-87]. In these ''shiroroga'', ''nasya''(nasal errhines) has been indicated [Ca Si 9/88]. In all nine ''shiroroga'' (five in this chapter, and four in [[Siddhi Sthana]]) that mention headache as a key symptom. Other varieties of ''shiroroga'' mentioned in other texts are ''raktaja'' and ''kshayaja'' [Sushruta Uttara 25/3] and ''shirah-kampa'' [As Hr.Uttara 23/9].(Verse 6)

''Prameha pidika'' mentioned in this chapter usually occurs as a complication of ''avaranjanaya samprapti'' of ''madhumeha'' as ''medas dushti'' occurs in this type of ''madhumeha'', the factor, a must for pathogenesis of ''prameha pidika''. This resembles with presentation of metabolic syndrome which includes dys-lipidemia (Verse 82-111).  

''Prameha pidika'' mentioned in this chapter usually occurs as a complication of ''avaranjanaya samprapti'' of ''madhumeha'' as ''medas dushti'' occurs in this type of ''madhumeha'', the factor, a must for pathogenesis of ''prameha pidika''. This resembles with presentation of metabolic syndrome which includes dys-lipidemia (Verse 82-111).  

Charaka has mentioned seven varieties of ''prameha pidika'' whereas Sushruta and Vagbhata have added three more to this list that includes ''masoorika, putrini'' and ''vidarika''.

Charak has mentioned seven varieties of ''prameha pidika'' whereas Sushruta and Vagbhata have added three more to this list that includes ''masoorika, putrini'' and ''vidarika''.

The ''shiroroga'' described in this chapter are various clinical presentations of headache depending upon ''dosha'' dominance and ''krimi'' infestation. ''Krimi'' in Ayurveda is a generic term for a large number of pathological organisms ranging from microorganisms found in blood (''raktaja krimi'') to intestinal worms as well as external parasites such as lice [Cha. Vi. 7/11-13]

The ''shiroroga'' described in this chapter are various clinical presentations of headache depending upon ''dosha'' dominance and ''krimi'' infestation. ''Krimi'' in Ayurveda is a generic term for a large number of pathological organisms ranging from microorganisms found in blood (''raktaja krimi'') to intestinal worms as well as external parasites such as lice [Cha. Vi. 7/11-13]

The forms or manifestations of headache (and referred headache) associated with a ''shiroroga'' may include migraine, stress induced headache, cluster headache, chronic paroxysmal hemicraina, and  miscellaneous forms not associated with structural lesions or headache associated with vascular disorders.

The forms or manifestations of headache (and referred headache) associated with a ''shiroroga'' may include migraine, stress induced headache, cluster headache, chronic paroxysmal hemicraina, and  miscellaneous forms not associated with structural lesions or headache associated with vascular disorders.

Similarly the five presentations of heart diseases have also been mentioned in this chapter that resemble different manifestations of chest pain and could be in the form of angina, pain associated with myocardial infarction and dissecting aortic aneurysm, pericarditis, oesophageal spasm, or musculo-skeletal chest pain. The clinical picture of cardiac disorders is quite similar to the features of ''hridroga'' mentioned in [[Charaka Samhita]], such as choking or constriction, squeezing, crushing, burning or aching chest pain, or a feeling of sharp, tearing or stabbing chest pain that is usually felt retrosternally and may radiate to the left arm or more rarely to the right arm and then to the throat, jaws and teeth, or through the back. In addition to the individual features of five types of ''hridaroga'', in [[Chikitsa Sthana]], the general sign and symptoms of  ''hridroga'' such as  discolouration, syncope, fever, cough, hiccups, dyspnoea, vomiting, water brash, chest discomfort, indigestion or distaste of mouth are also mentioned (Ca Ch 26/78). These are  mentioned as common symptoms of heart disease in medicine books.

Similarly the five presentations of heart diseases have also been mentioned in this chapter that resemble different manifestations of chest pain and could be in the form of angina, pain associated with myocardial infarction and dissecting aortic aneurysm, pericarditis, oesophageal spasm, or musculo-skeletal chest pain. The clinical picture of cardiac disorders is quite similar to the features of ''hridroga'' mentioned in [[Charak Samhita]], such as choking or constriction, squeezing, crushing, burning or aching chest pain, or a feeling of sharp, tearing or stabbing chest pain that is usually felt retrosternally and may radiate to the left arm or more rarely to the right arm and then to the throat, jaws and teeth, or through the back. In addition to the individual features of five types of ''hridaroga'', in [[Chikitsa Sthana]], the general sign and symptoms of  ''hridroga'' such as  discolouration, syncope, fever, cough, hiccups, dyspnoea, vomiting, water brash, chest discomfort, indigestion or distaste of mouth are also mentioned (Ca Ch 26/78). These are  mentioned as common symptoms of heart disease in medicine books.

Carbuncles are common complications occurring in uncontrolled diabetes patients where the infection spreads extensively in the dermal and underlying soft tissue. This presents itself as a  complex localized abscess or as several separate abscesses with multiple discharge sinuses usually caused due to staphylococcus aureus infection.   

Carbuncles are common complications occurring in uncontrolled diabetes patients where the infection spreads extensively in the dermal and underlying soft tissue. This presents itself as a  complex localized abscess or as several separate abscesses with multiple discharge sinuses usually caused due to staphylococcus aureus infection.   

=====Table 3: Types of Pidika in different classics:=====

=====Table 3: Types of Pidika in different classics:=====

{| class="wikitable"

{| class="wikitable"

! Sr. No. !! Types of ''Pidikā'' !! ''Charaka'' !! ''Sushruta'' !! ''Vagbhata'' !! ''Bhoj'' !! ''Kāshypa''

! Sr. No. !! Types of ''Pidikā'' !! ''Charak'' !! ''Sushruta'' !! ''Vagbhata'' !! ''Bhoj'' !! ''Kāshypa''

|-

|-

| rowspan="1" style="text-align: left;" | 1

| rowspan="1" style="text-align: left;" | 1