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== Introduction ==

== Introduction ==

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A physician cannot treat a patient if he does not possess a complete understanding of a disease [Cha.Sa.[[Vimana Sthana]] 4/12]. Accurate diagnosis of a disease is important before initiating any treatment, and any understanding of a disease’s manifestation is incomplete without understanding its ''nidana'' (etiology), ''poorvarupa'' (premonitory symptoms), ''linga'' (actual sign and symptoms), ''upashaya'' (pacifying factors) and ''samprapti'' (pathogenesis) – or the ''Nidana Panchaka'' (literally, the five components of ''nidana'') [Cha.Sa.Nidana Sthana 1/6].

A physician cannot treat a patient if he does not possess a complete understanding of a disease. [Cha.Sa.[[Vimana Sthana]] 4/12] Accurate diagnosis of a disease is important before initiating any treatment, and any understanding of a disease’s manifestation is incomplete without understanding its ''nidana'' (etiology), ''poorvarupa'' (premonitory symptoms), ''linga'' (actual sign and symptoms), ''upashaya'' (pacifying factors) and ''samprapti'' (pathogenesis) – or the ''Nidana Panchaka'' (literally, the five components of ''nidana''). [Cha.Sa.[[Nidana Sthana ]]1/6]

A disease’s lifecycle starts with certain premonitory symptoms and ends with its complete manifestation, or ''samprapti''. Between these two stages of the disease, the body shows various signs and symptoms that could be observed by any knowledgeable physician, using the ''Nidana Panchaka'' . Naturally, any disease, if diagnosed very early, could be prevented from manifesting itself through a variety of interventions [Cha.Sa.[[Sutra Sthana]] 10/7]. A proper understanding of the ''Nidana Panchaka'' helps the physician using various therapies, to establish an equilibrium among the patient’s ''doshas'', ''dhatus'', and ''mala'' – since it is the vitiation of these bodiy features that cause a disease. A therapy is considered pure or correct (''vishuddha'') when it cures the disease without giving rise to another disease [Cha.Sa.Nidana Sthana 8/23]. Curable diseases can progress to incurable if they are not properly treated [Cha.Sa.Nidana Sthana 8/35].

A disease’s lifecycle starts with certain premonitory symptoms and ends with its complete manifestation, or ''samprapti''. Between these two stages of the disease, the body shows various signs and symptoms that could be observed by any knowledgeable physician, using the ''Nidana Panchaka'' . Naturally, any disease, if diagnosed very early, could be prevented from manifesting itself through a variety of interventions. [Cha.Sa.[[Sutra Sthana]] 10/7] A proper understanding of the ''Nidana Panchaka'' helps the physician using various therapies, to establish an equilibrium among the patient’s ''doshas'', ''dhatus'', and ''mala'' – since it is the vitiation of these bodiy features that cause a disease. A therapy is considered pure or correct (''vishuddha'') when it cures the disease without giving rise to another disease. [Cha.Sa.[[Nidana Sthana]] 8/23] Curable diseases can progress to incurable if they are not properly treated. [Cha.Sa.[[Nidana Sthana]] 8/35]

''Nidana Panchaka'' described here can be supplemented with diagnostic tests and medical investigations to study a condition. Access to complete knowledge of dietary and lifestyle activities of a person, specific disease provoking factors, clinical history or health records of past diseases or conditions, and a thorough clinical examination of all bodily systems would help provide a complete view of a patient’s condition.   

''Nidana Panchaka'' described here can be supplemented with diagnostic tests and medical investigations to study a condition. Access to complete knowledge of dietary and lifestyle activities of a person, specific disease provoking factors, clinical history or health records of past diseases or conditions, and a thorough clinical examination of all bodily systems would help provide a complete view of a patient’s condition.   

Treatment of any disease is possible only after the proper knowledge of causative factors and sign and symptoms. Treatment principles described in [[Nidana Sthana]] should be incorporated in the ''upashaya'' (pacification factors). ''Nidana'' means the causative factor of the diseases. The term ''vyadhibodhakam'' means the diagnosis of diseases with the help of ''nidana, poorvarupa, rupa, upashaya'' and ''samprapti''. 1-2 [6]

Treatment of any disease is possible only after the proper knowledge of causative factors and sign and symptoms. Treatment principles described in [[Nidana Sthana]] should be incorporated in the ''upashaya'' (pacification factors). ''Nidana'' means the causative factor of the diseases. The term ''vyadhibodhakam'' means the diagnosis of diseases with the help of ''nidana, poorvarupa, rupa, upashaya'' and ''samprapti''. 1-2 [6]

If diseases are not properly known, one cannot start the treatment. Therefore, ''Nidanapanchaka'' (the five factors associated with understanding an affliction) is described as the specific measures to diagnose the disease [Cha.Sa.[[Nidhana Sthana 1/6].

If diseases are not properly known, one cannot start the treatment. Therefore, ''Nidanapanchaka'' (the five factors associated with understanding an affliction) is described as the specific measures to diagnose the disease. [Cha.Sa.[[Nidhana Sthana]] 1/6]

Vagbhata also endorsed these five components as the means of understanding the disease. [6] [8]

Vagbhata also endorsed these five components as the means of understanding the disease. [6] [8]

#''Poorvarupa'' caused due to ''doshadushyasammurchana'' (interaction of vitiated ''dosha'' and ''dushya'') that are different from the previous ones. e.g. feeling of hatred towards children or horripilation seen in ''jwara''. These types of ''poorvarupas'' are not seen when the ''jwara'' is manifested completely. But if they are seen then the prognosis of the disease is ''asadhyata'' (incurable). These signs are symptomatic of the diseases to be seen in the near future and do not indicate ''dosha'' predominance in that disease.  

#''Poorvarupa'' caused due to ''doshadushyasammurchana'' (interaction of vitiated ''dosha'' and ''dushya'') that are different from the previous ones. e.g. feeling of hatred towards children or horripilation seen in ''jwara''. These types of ''poorvarupas'' are not seen when the ''jwara'' is manifested completely. But if they are seen then the prognosis of the disease is ''asadhyata'' (incurable). These signs are symptomatic of the diseases to be seen in the near future and do not indicate ''dosha'' predominance in that disease.  

In some acute diseases, the disease is presented directly with signs and symptoms. In these cases, the unmanifested form of the actual symptoms (''rupa'') described in the text should be treated as the ''poorvarupa'' of a disease [Chakrapani on Cha.Sa.Nidana Sthana 1/8].

In some acute diseases, the disease is presented directly with signs and symptoms. In these cases, the unmanifested form of the actual symptoms (''rupa'') described in the text should be treated as the ''poorvarupa'' of a disease. [Chakrapani on Cha.Sa.[[Nidana Sthana]] 1/8]  

Vagbhata opines that ''poorvarupa'' are signs and symptoms that appear earlier to the actual disease, not specifically assignable to the ''doshas'' as they are mild (not clearly recognizable) and few in number. [A.H. Nidhana Sthana. 1/3] This is also substantiated in the Ashtanga Sangraha <ref>Vridha Vagbhata. Nidana Sthana, Cha.1 Sarvaroganidana Adhyaya verse 11. In: D V Pandit Rao, Editor. Ashtanga Sangraha. 1st ed. New Delhi: CCRAS;1991 </ref>

Vagbhata opines that ''poorvarupa'' are signs and symptoms that appear earlier to the actual disease, not specifically assignable to the ''doshas'' as they are mild (not clearly recognizable) and few in number. [A.H. Nidhana Sthana. 1/3] This is also substantiated in the Ashtanga Sangraha <ref>Vridha Vagbhata. Nidana Sthana, Cha.1 Sarvaroganidana Adhyaya verse 11. In: D V Pandit Rao, Editor. Ashtanga Sangraha. 1st ed. New Delhi: CCRAS;1991 </ref>

Gangadhara, commentator of [[Charak Samhita]], describes two types of ''Poorvarupa'':

Gangadhara, commentator of [[Charak Samhita]], describes two types of ''Poorvarupa'':

#'''''Samanya Poorvarupa''''' (general premonitory features): These are the general symptoms of disease which appear before the manifestation of the disease but do not indicate affliction of ''doshas''.

#'''''Samanya Poorvarupa''''' (general premonitory features): These are the general symptoms of disease which appear before the manifestation of the disease but do not indicate affliction of ''doshas''.

#'''''Vishesha Poorvarupa''''' (specific premonitory features): These are the general symptoms of disease which manifest before the manifestation of the disease and indicate involvement of ''doshas''[Gangadhar on Cha.Sa.Nidana Sthana.1/5].

#'''''Vishesha Poorvarupa''''' (specific premonitory features): These are the general symptoms of disease which manifest before the manifestation of the disease and indicate involvement of ''doshas''.[Gangadhar on Cha.Sa.[[Nidana Sthana]].1/5]

==== ''Rupa'' (clinical signs and symptoms) ====

==== ''Rupa'' (clinical signs and symptoms) ====

''Rupa'' indicates the specific characteristics of the disease as it progresses, such as the dominance of ''doshas'', various stages viz., ''ama'' (immature), ''pakva'' (mature), etc. They however, do not include such other factors of diagnosis of the diseases like ''nidana, upashaya'' and ''samprapti''[Chakrapani on Cha.Sa.Nidana Sthana 1/9].

''Rupa'' indicates the specific characteristics of the disease as it progresses, such as the dominance of ''doshas'', various stages viz., ''ama'' (immature), ''pakva'' (mature), etc. They however, do not include such other factors of diagnosis of the diseases like ''nidana, upashaya'' and ''samprapti''.[Chakrapani on Cha.Sa.[[Nidana Sthana]] 1/9]

''Rupa'' includes the following signs and symptoms:

''Rupa'' includes the following signs and symptoms:

===''Upashaya'' (pacification):===

===''Upashaya'' (pacification):===

''Upashaya'' implies such factors that bring about happiness. It provides diagnostic aid for diseases which are otherwise difficult to diagnose. ''Upashaya'' is broadly divided in two groups:[Chakrapani on Cha.Nidana Sthana 1/10]

''Upashaya'' implies such factors that bring about happiness. It provides diagnostic aid for diseases which are otherwise difficult to diagnose. ''Upashaya'' is broadly divided in two groups:[Chakrapani on Cha.Sa.[[Nidana Sthana]] 1/10]

#Drugs etc. that are antagonistic to the cause of the disease or the disease itself.  

#Drugs etc. that are antagonistic to the cause of the disease or the disease itself.  

#Drugs etc. that are not antagonistic either to the cause of the disease or to the disease itself but when employed, they actually alleviate the condition by counteracting either the disease or the cause of it.  

#Drugs etc. that are not antagonistic either to the cause of the disease or to the disease itself but when employed, they actually alleviate the condition by counteracting either the disease or the cause of it.  

#''Hetu-vyadhi viparitarthakari aushadha'' (drugs which seem to be working against the causative factors and the disease though not actually so; i.e., working as placebos)

#''Hetu-vyadhi viparitarthakari aushadha'' (drugs which seem to be working against the causative factors and the disease though not actually so; i.e., working as placebos)

#''Hetu-vyadhi viparitarthakari anna'' (food which is working against the causative factors and the disease though not actually, i.e., working as placebo)

#''Hetu-vyadhi viparitarthakari anna'' (food which is working against the causative factors and the disease though not actually, i.e., working as placebo)

#''Hetu-vyadhi viparitarthakari vihara'' (regimen which is working against the causative factors and the disease though not actually against.) [Chakrapani on Cha.Sa.Nidana Sthana 1/10]

#''Hetu-vyadhi viparitarthakari vihara'' (regimen which is working against the causative factors and the disease though not actually against.) [Chakrapani on Cha.Sa.[[Nidana Sthana]] 1/10]

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=====Various examples of ''upashaya'':=====

=====Various examples of ''upashaya'':=====

''Aagati'': Literally means the manifestation and remission of the disease. In this process of disease manifestation (''samprapti''), the physician gets the knowledge in the form of qualitative and quantitative progress of the disease.  

''Aagati'': Literally means the manifestation and remission of the disease. In this process of disease manifestation (''samprapti''), the physician gets the knowledge in the form of qualitative and quantitative progress of the disease.  

While the symptoms of a disease manifest completely after pathogenesis (''samprapti''), still for the purpose of diagnosis, the knowledge of ''samprapti'' is not as important as the knowledge of ''linga'' (symptoms). Hence ''samprapti'' is described at the end [Chakrapani on Cha.Sa.[[Nidana Sthana]] 1/11].

While the symptoms of a disease manifest completely after pathogenesis (''samprapti''), still for the purpose of diagnosis, the knowledge of ''samprapti'' is not as important as the knowledge of ''linga'' (symptoms). Hence ''samprapti'' is described at the end. [Chakrapani on Cha.Sa.[[Nidana Sthana]] 1/11]

Vagbhata has defined these synonyms as:  “The process of manifestation of the disease, by the morbid ''doshas'' (humors) which are circulating all over the body, is known as ''samprapti'' or ''jati'' or ''agati''. [A.H Nidana Sthana 1/8] [11]

Vagbhata has defined these synonyms as:  “The process of manifestation of the disease, by the morbid ''doshas'' (humors) which are circulating all over the body, is known as ''samprapti'' or ''jati'' or ''agati''. [A.H Nidana Sthana 1/8]<ref name=Hridaya>Vagbhata. Ashtanga Hridayam. Edited by Harishastri Paradkar Vaidya. 1st ed. Varanasi: Krishnadas Academy;2000.</ref> [11]

In order to allay the apprehension of incomplete description of ''samprapti'' for each disease, the ''samprapti'' in general of all diseases is described here in this chapter[Chakrapani on Cha.Sa.[[Nidana Sthana]] 1/11].

In order to allay the apprehension of incomplete description of ''samprapti'' for each disease, the ''samprapti'' in general of all diseases is described here in this chapter.[Chakrapani on Cha.Sa.[[Nidana Sthana]] 1/11]  

Vagbhata has not described ''vidhi samprapti''. He has described only five kinds of ''samprapti'' i.e. ''samkhya, vikalpa, pradhanya, bala'' and ''kala samprapti''. [A.H Nidana Sthana 1/9] ''Pradhanya samprapti'' indicates the primacy of a ''samprapti''. [A.H Nidana Sthana 1/10] When a ''dosha'' gets vitiated and becomes a causative factor of a disease, it does not necessarily mean that all its attributes also get vitiated. Vitiation of ''vata'' for example may mean aggravation of its coldness, lightness or ununctuousness.  

Vagbhata has not described ''vidhi samprapti''. He has described only five kinds of ''samprapti'' i.e. ''samkhya, vikalpa, pradhanya, bala'' and ''kala samprapti''. [A.H Nidana Sthana 1/9]<ref name=Hridaya/> ''Pradhanya samprapti'' indicates the primacy of a ''samprapti''. [A.H Nidana Sthana 1/10]<ref name=Hridaya/> When a ''dosha'' gets vitiated and becomes a causative factor of a disease, it does not necessarily mean that all its attributes also get vitiated. Vitiation of ''vata'' for example may mean aggravation of its coldness, lightness or ununctuousness.  

''Kala samprapti'' means the type that is governed by seasonal variations. Aggravation/ manifestation of ''shleshmika/kaphaja'' type of fever during winter season is the example of seasonal variation. Some [[Ayurveda]] practitioners attribute an extreme form of manifestation to deeds in the patient’s past life, and define ''vidhi samprapti'' as an affliction attributed to such deeds [Chakrapani on Cha.Sa.Nidana Sthana 1/11]. The timing of disease manifestation shows variation in the ''samprapti'' or pathogenesis. This aspect of ''samprapti'' helps in clearly determining the specific characteristics of a disease.

''Kala samprapti'' means the type that is governed by seasonal variations. Aggravation/ manifestation of ''shleshmika/kaphaja'' type of fever during winter season is the example of seasonal variation. Some [[Ayurveda]] practitioners attribute an extreme form of manifestation to deeds in the patient’s past life, and define ''vidhi samprapti'' as an affliction attributed to such deeds. [Chakrapani on Cha.Sa.[[Nidana Sthana]] 1/11]  The timing of disease manifestation shows variation in the ''samprapti'' or pathogenesis. This aspect of ''samprapti'' helps in clearly determining the specific characteristics of a disease.

Vagbhata describes that ''bala samprapti'' is important to assess the severity of disease. [A.H Nidana Sthana 1/11] [12-5]

Vagbhata describes that ''bala samprapti'' is important to assess the severity of disease. [A.H Nidana Sthana 1/11]<ref name=Hridaya/> [12-5]

==== Significance of knowledge of ''nidana'' ====

==== Significance of knowledge of ''nidana'' ====

#Knowledge of causative factors plays an important role in the prognosis of diseases. A disease becomes more difficult to cure with the rise in number of causative factors responsible for the diseases [Cha.Sa.[[Sutra Sthana]] 10/14].

#Knowledge of causative factors plays an important role in the prognosis of diseases. A disease becomes more difficult to cure with the rise in number of causative factors responsible for the diseases. [Cha.Sa.[[Sutra Sthana]] 10/14]

#''Nidanaparivarjana'' i.e. avoiding the causative factors of disease is the key principle professed here for the management of diseases. So in the absence of knowledge of causative factors, the management of the diseases will become difficult [Cha.Sa.[[Vimana Sthana]] 7/30].

#''Nidanaparivarjana'' i.e. avoiding the causative factors of disease is the key principle professed here for the management of diseases. So in the absence of knowledge of causative factors, the management of the diseases will become difficult. [Cha.Sa.[[Vimana Sthana]] 7/30]

#Treatment of disease incorporates the use of drugs, food articles and regimen having opposite properties to that of causative factors which is not possible without knowledge of causative factors.

#Treatment of disease incorporates the use of drugs, food articles and regimen having opposite properties to that of causative factors which is not possible without knowledge of causative factors.

#To treat the newly originated diseases, a physician should have the knowledge of the involved ''doshas'', causative factors and the location of the disease.  

#To treat the newly originated diseases, a physician should have the knowledge of the involved ''doshas'', causative factors and the location of the disease.  

Sushruta described six stages of ''dosha'' vitiation and progression of disease known as ''shat kriyakala'' (periods of activity). They are as under:

Sushruta described six stages of ''dosha'' vitiation and progression of disease known as ''shat kriyakala'' (periods of activity). They are as under:

*''Sanchaya'' (accumulation): In this stage ''dosha'' undergo mild increase at their own site. This accumulation produces mild symptoms. If the person recognises these instincts and acts accordingly, the ''doshas'' can be brought to the normal condition without much effort. [Su.Sa.Sutra Sthana 21/18]

*''Sanchaya'' (accumulation): In this stage ''dosha'' undergo mild increase at their own site. This accumulation produces mild symptoms. If the person recognises these instincts and acts accordingly, the ''doshas'' can be brought to the normal condition without much effort. [Su.Sa.Sutra Sthana 21/18]<ref name=Susruta>Sushruta. Sushruta Samhita. Edited by Jadavaji Trikamji Aacharya. 8th ed. Varanasi: Chaukhambha Orientalia;2005.</ref>

*''Prakopa'' (aggravation): In this stage, ''doshas'' gets vitiated further at their own site and exhibit some specific symptoms. By suitable changes in daily routine one can overcome these conditions. [Su.Sa.Sutra Sthana 21/27]

*''Prakopa'' (aggravation): In this stage, ''doshas'' gets vitiated further at their own site and exhibit some specific symptoms. By suitable changes in daily routine one can overcome these conditions. [Su.Sa.Sutra Sthana 21/27]<ref name=Susruta/>

*''Prasara'' (spreading): The status of ''doshas'' again increases further and ''doshas'' spread nearby sites and invade the sites of other ''doshas'' to produce symptoms. If the person continues to indulge in unhealthy food and regimen, then the disease progresses to the next stage. [Dalhana on Su.Sa.Sutra Sthana 21/32]

*''Prasara'' (spreading): The status of ''doshas'' again increases further and ''doshas'' spread nearby sites and invade the sites of other ''doshas'' to produce symptoms. If the person continues to indulge in unhealthy food and regimen, then the disease progresses to the next stage. [Dalhana on Su.Sa.Sutra Sthana 21/32]<ref name=Susruta/>

During the first three stages, the unhealthy food and activities increases the ''doshas'' and produces mild abnormalities. These three stages can be co-related with ''nidana'' (''hetu'') of ''nidanapanchaka''.

During the first three stages, the unhealthy food and activities increases the ''doshas'' and produces mild abnormalities. These three stages can be co-related with ''nidana'' (''hetu'') of ''nidanapanchaka''.

**''Vimargagamana'' – Movement of fluids in wrong direction

**''Vimargagamana'' – Movement of fluids in wrong direction

The site where these ''doshas'' lodge together to progress towards disease, is the site of origin of disease. This is the stage of actual commencement of the disease. It is characterized by manifestation of some moderate symptoms which indicate the forthcoming disease. These are known as ''poorvarupa''. This stage can be co-related with ''poorvarupa'' of ''nidanapanchaka''. [Dalhana on Su. Sa. Sutra Sthana 21/33]

The site where these ''doshas'' lodge together to progress towards disease, is the site of origin of disease. This is the stage of actual commencement of the disease. It is characterized by manifestation of some moderate symptoms which indicate the forthcoming disease. These are known as ''poorvarupa''. This stage can be co-related with ''poorvarupa'' of ''nidanapanchaka''. [Dalhana on Su. Sa. Sutra Sthana 21/33]<ref name=Susruta/>

*''Vyakti'' (manifestation): This is the stage of full manifestation of the disease with all its characteristic sign and symptoms. These sign and symptoms are known as ''rupa''. This stage can be co-related with ''rupa'' of ''nidanapanchaka''. [Dalhana on Su. Sa. Sutra Sthana 21/34]

*''Vyakti'' (manifestation): This is the stage of full manifestation of the disease with all its characteristic sign and symptoms. These sign and symptoms are known as ''rupa''. This stage can be co-related with ''rupa'' of ''nidanapanchaka''. [Dalhana on Su. Sa. Sutra Sthana 21/34]<ref name=Susruta/>

*''Bheda'' (complication): In this stage, the abnormalities become more profound and irreversible in spite of the best treatment. Sometimes ''upadravas'' (complications) or ''arishta lakshanas'' (bad prognostic signs) can be seen in this stage. This stage also can be co-related with ''rupa'' of ''nidanapanchaka''. [Dalhana on Su. Sa. Sutra Sthana 21/35]

*''Bheda'' (complication): In this stage, the abnormalities become more profound and irreversible in spite of the best treatment. Sometimes ''upadravas'' (complications) or ''arishta lakshanas'' (bad prognostic signs) can be seen in this stage. This stage also can be co-related with ''rupa'' of ''nidanapanchaka''. [Dalhana on Su. Sa. Sutra Sthana 21/35]<ref name=Susruta/>

The abnormal changes taking place in the body after exposure to the causative factors up to the manifestation of the disease is called as ''samprapti''. This includes progress of the disease from first to sixth ''kriyakala''.

The abnormal changes taking place in the body after exposure to the causative factors up to the manifestation of the disease is called as ''samprapti''. This includes progress of the disease from first to sixth ''kriyakala''.