Nidana Panchaka is one of Ayurveda's several diagnostic procedures. It is the most significant way for determining the source of an illness, as well as predicting its prognosis. Nidana Panchaka comprises of five items which are Nidana (etiological factors), Purvaroopa (primordial symptoms), Roopa (signs and symptoms), Upashaya (like and dislike) and Samprati (etiopathogensis) (etiopathogensis). Diagnosis of sickness depends on Tridoshas which are Vata, Pitta, Kapha which are responsible for any disease that arises in the body. These imbalances in the Doshas of the body are caused by etiological variables such as a person's lifestyle and eating habits. Prior to seeking therapy for a condition, a proper diagnosis is required. There are numerous additional procedures for diagnosing the ailment, such as Ashtavidha Pareeksha, Dashavidha Pareeksha, and Chaturvidha Pareeksha, but the focus of this article is on the significance of Nidana Panchaka.
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The science of Ayurveda originated with the need to understand and cure diseases and to maintain the of the human being. This basic Ayurveda tenet is best explained in the Sanskrit verse "Swasthasya swaasthya rakshanama aturasya vikara prashamanam cha1. For the completion of this tenet, Hetu (cause), Linga (symptoms) and Aushadha (medicine) i.e., concept of Trisutra is also mentioned in Ayurveda2. Out of these three sutras two are meant for diagnosis of disease and the third one is meant for treatment purpose. That means in Ayurveda, Roga Pariksha is not only important rather it is the foremost part for further success results. The correct diagnosis of a disease is essential in curing the disease. Acharya Charaka has said that before the planning of treatment, the correct diagnosis is of a disease is very much essential. That means a physician should examine the disease thoroughly before prescribing medicine In Ayurvedic classical texts, the only available means of diagnosis were pramanas i.e. Aaptopadesha pramana3, Pratyaksha pramana (includes five sense organs i.e. Eyes, Ears, Nose, Skin Tongue), Anumana pramana and Yukti pramana. These methods used for the understanding the Dosha, Dooshya and site of Dosha-Dooshya sammurchhna4. Today with the advancement in the Medical field, the diagnosis of the disease can be done in the beginning and the progress of the disease can be stopped. But sometimes the patient can’t afford the costly imagining techniques like CT scan, MRI etc. Thus we have to know the diagnosis according to Ayurveda which helps in reducing the burden on the suffering patients5. In Ayurveda there are five means of diagnosis (Nidana Panchaka) name-ly Nidana (cause or etiology), Purvarupa (Prodromal symptoms or Premonitory symptoms), Rupa (Specific sign and symptoms or clinical features), Upasaya (Relieving and Aggravating factors), Samprapti (Patho- genesis)6.
The physician who without properly diagnosing the disease starts its treatment succeeds by chance even if he is well-versed in management with drugs. The one, who knows the character of the disease, is well versed in all the therapeutic measures and is acquainted with the factors such as place, time etc. succeeds undoubtedly7. These five elements collectively or selectively help in making the accurate diagnosis. By knowing the concept of Nidana Panchaka physician can diagnose the disease at an earlier stage and hence forth can plan for the treatment well there by preventing further complications.
Aim & Objectives
1. To understand the concept of Nidana Panchaka from the available ancient Ayurvedic texts and online information available on internet.
2. To understand the clinical importance of Nidana Panchaka.
Nidana (Etiological Factors)
Nidana is the causative factors of disease. The word ‘Nidana’ is used in two different contexts i.e. etiological factors and second is diagnosis of diseases. For example- The etiological factors describe for the swasa roga are vidahi, guru, vishtambhi bhojana along with raja, dhuma as an environmental factors. So these are the vyadhijanak nidana (etiological fac- tors) for the disease and the diagnosis is swasa roga (vyadhi bodhak nidana).
Clinical Importance of Nidana
Knowledge of Nidana Helps in Identifying the Causes of the Disease
If the Nidana is not identified we can’t isolate them. Ifthe causative factors are in contact with the body for a longer time, the disease caused by them keeps worsening with time and become incurable.
Nidana Gives A Clue Towards the Chronicity of the DisorderE.g. If the patient having liver cirrhosis has a history of consumption of alcohol for long time, we can speculate that the disease is a chronic one and has got stubborn (depending on the periodicity of drinking alcohol).
Knowledge of Nidana Helps in Making a Correct Diagnosis
In case of uncertainty about the diagnosis of any disorder, analysis of Nidana or etiological factors will help to clarify the state of the disease. E.g. In case of Vata, it can be vitiated by one or more factors like sheeta guna (cold quality), ruksha guna (dry quality), kashaya rasa (astringent taste), katu rasa (pungent taste), ativyayama (excessive exercise), avarana (ob-truction of activities of vata by other elements of the body) etc. The knowledge of each of these etiological factors which aggravate Vata will help the physician to make good prognosis, make the exact diagnosis of the disease, correlate the causes with the effect (disease and its symptoms), help the patient to keep away the causative factors and plan for right treatment protocol.
Knowledge of Nidana will Help in Planning Specific Treatment
In each case, the treatment will differ and will depend on the cause. E.g. If Pitta is vitiated by ushna guna (hot quality), the treatment and medicines should be antagonistic to ushna i.e. sheeta upashaya and chikitsa(comforts and treatments predominant in cold potency) should be preferred.
Knowledge of Nidana helps in rectifying the causative factors causing the disease
‘Sankshepataha Kriya Yogo Nidana Parivarjanam. The best and simplest form of the treatment is avoiding the causative factors, which are responsible for causation of disease and it is the primary step to prevent further pathogenesis. The understanding of Nidana helps a physician to counsel the patient to keep away the factors, foods and activities which are contradictory to them. It will not only aid in framing aright treatment protocol, it will also help in designinga good diet and lifestyle protocol where in many dis- orders can be avoided while following the wholesome and good parts of life.
Purvarupa (Prodromal Features)
The symptoms which give indication of a future disease are known as prodromal symptoms. These are the symptoms which are not expressed clearly and appeared before the manifestation of a disease. These prodromal features helps to know the dosha responsible for that particular disease but not the nature of forthcoming disease. Basically there are two types of puravrupa, one which indicate the forthcoming disease but doesn’t specify the involvement of dosha is known as samanya purvarupa (general prodromal symptoms). Second variety of puravrupa is known as vishishta (specific) purvarupa, in which appearance ofprodromal symptoms observed specifically by specific dosha.
Clinical Importance of Puravarupa
For Diagnosis of Disease
If two diseases are having identical Nidana, then Purvarupa help in making correct diagnosis. E.g. Acharya Charak told in chikitsa sthana chapter 17th, Nidana of Hikka (Hiccup) and Swasa (Dyspnea) are identical. Here disease will be diagnosed in its Purvarupa avastha (Stage) with the help of specific prodromal symptoms such as heaviness in throat and chest, astringent taste in mouth and gurgling sound in abdomen are the prodromal symptoms of Hikka while hardness in bowel, pain in sides, compression in cardiac region, miss passage of vital breath are prodromal symptoms of Swasa8.
For Differential Diagnosis
E.g. If the color of the urine is either yellow or mixed with blood eliminated through the urine without the manifestation of prodromal symptoms and sign of Prameha (Diabetes), such patient should not be diagnosed as Prameha rogi (Diabetes), on other hand it diagnosed as Raktapitta14 (Bleeding disorder).
For Treatment of Disease
With the help of knowing puravrupa of disease we can detect the disease at an earlier (i.e. before the actual manifestation of disease) stage and plan for treatment can be started to prevent further manifestation of disease. E.g. In Jwara, Langhana chikitsa is indicated in Purvarupa and in Ashmari, Snehadi karma is indicated in puravrupa avastha to cure the disease from root.
For Prognosis of Disease
If number of prodromal symptoms is few, then the disease is easily curable. If Purvarupa manifest with moderate intensity then disease is krichhasadhya (difficult to cure). If all the prodromal features are present in a patient then the disease is going to be incurable.
Rupa (Specific Sign and Symptoms)
Rupa of a disease indicate the actual onset of the manifestation process. When the rupa appears, the disease become more pronounced obvious and clearly defined symptoms. The pathogenesis gives rise to various symptoms of the disease. These symptoms and doshas are inseparably associated with each other throughout the disease. Hence the pathogenesis (Dosha dushya sammurcchhana) occurring inside the body is expressed externally as the symptoms of that disease9. i.e. It indicates the specific disease by manifesting specific symptoms of that disease. E.g. Burning sensation in shoulder, sides of the chest, hands, feet and fever is the cardinal symptoms of Rajyakshma (Tuberculosis), excessive unclean urination in Prameha (Diabetes).
Clinical Importance of Rupa
For Diagnosis of Disease
Few diseases have no prodromal symptoms like Vata vyadhi, Ksataksheena and their diagnosis is made only by observing its clinical feature (i.e. In Rupa- avastha). By seen the cardinal sign and symptoms of disease we can diagnose the disease. E.g. Distention of abdomen, gurgling sound in abdomen, edema in legs and hands, diminish power of Agni, smoothness of chin, emaciation are the cardinal signs and symptoms of Udara roga (Ascites).
For Differential Diagnosis of Disease
By observing the signs - symptoms and detailed history of patient we can diagnose the disease which has similar sign and symptoms. E.g. Cough and Tuberculosis, Annadravasoola (Pain is aggravate after intake of food) and Parinamadravasoola (Pain is relief after intake of food) only few symptoms are common.
For Treatment of Disease
Knowledge of Rupa is very much important for planning specific treatment of disease. E.g. Mansa gatavata and Mansa aavrita vata. If we know the exact sign and symptoms of these disease than only we can start the specific treatment. For Mansa gatavata Purgation, non-unctuous enema and pacificatory measures are applied and for Mansa aavritavata- fomentation, massage, meat soup, milk and unctuous substance are applied. In Jwara, Aamjwara (Langhan), Pachyamanjwara (Deepan, pachan drugs), Niramjwara (Virechana - purgation).
For Prognosis of Disease
If all the symptoms of disease are produced, then that disease is difficult to cure.
For Detection of Cause
The symptoms help in detection of cause. E.g. In leprosy (Kushtha) the symptoms like pain, dryness, black discoloration etc. indicate involvement of vata dosha. This also indicates that the patient must have taken vata provocating diet in past.
Upasaya (Relieving and Aggravating Factors)
When a patient is relieved of symptoms and feel comfortable by the diet, daily regimen and medicine, then these relieving factors are called as Upasaya. The relief should not be temporary. The symptoms should be reduced permanently.
E.g. Cold water gives relief to thirst and burning sensation in case of Nava jwara fora short period but later aggravate the condition. This doesn’t come under upasaya. And opposite to this, the agravating factors are called as Anupasaya. These factors help in making correct diagnosis. The relieving factors are having properties opposite to that of cause of disease or disease itself or both. Acharya Chakrapani has told about 18 types of upasaya10.
Clinical Importance of Upasaya
For Diagnosis of Disease
Relieving factors helps in making correct diagnosis, when it is difficult to diagnose a disease due to obscure or mysterious manifestation. Then by the use of aggravating or relieving factors we can diagnose the disease. E.g. In obstructive jaundice the medicine “Trikatu powder” will give relief. But if it is not an obstructive jaundice then the symptoms will aggravate due to hot and sharp property of the medicine.
For Treatment of Disease
This upasaya and anupasaya also help in treatment of disease. If we know the causative factor of any disease simply we can plan for specific treatment with the help of Hetu vipreeta upasaya. E.g. Remain awake at night to reduce kapha increased by day slee; Acharya Charaka has said that if Hetu vipreeta treatments not effective then we can plan for Vyadhi vipreet or Hetu Vyadhi vipreeta treatment. E.g. Usage of turmeric in diabetes is Vyadhi vipreet treatment. Usage of swelling and vata reducing drug (Dashmoola kwath) in edema due to vata is Hetu Vyadhi vipreeta treatment11.
As long as three Doshas (Functional entities), seven Dhatus (Structural entities) and three Mala (Excretory products) are in normal (Balanced) state there is no disease occur. When etiological factors disturbed this balanced state then disease will be manifest. The changes which take place in the body from initiation of the etiological factors to the manifestation of symp- toms are collectively known as Samprapti (Pathogenesis). The Dosha vitiated due to various causes are moving in various directions in the body. Depending upon the cause or type of vitiation and direction or route followed by the vitiated doshas, there is a settlement (Dosha-dushya sammurchchhana) at the defective site (kha-vaigunya) or organs and produce variety of disease.
E.g. when provocated doshas get set- tled in Abdomen they give rise to diarrhea, flatu-lence, ascites, abscesses, tumors etc12.
Basically there are two types of samprapti i.e. Samanya samprapti (It includes Shatkriyakala 6 stages for the better understanding of pathogenesisand appropriate time for treatment, and it is common for all disease) and Vishista samprapti (It includes Samkhya, Pradhanya, Vidhi, Vikalpa, Bala, Kala). Vishistasamprapti i.e Samkhya, Pradhanya, Vidhi,Vikalpa, Bala, Kala samprapti.13, 14, 15
Samkhya Samprapti (Enumeration of Disease)
After the diagnosis of disease it is classified according to specific pathogenesis into further types. This total number of the types is known as Samkhya samprapti.
E.g. Seven types of kushta (Leprosy), Seven types ofPidaka (Carbuncles), six types of Atisara (Diarrhea). Pradhanya samprapti (Degree of doshic vitiation): This samprapti helps in identification of dominance ofdosha in case of two or more dosha are involved. Iftwo doshas are vitiated, the comparative term i.e. Tara, is used to indicate the predominant one. If allthe three doshas get vitiated then superlative term “Tama” is used to indicate the most predominant one. It required dominant dosha should be treated first. The subordinate dosha may be treated afterwards.
Vidhi Samprapti (Variety of Disease)
It is a subtype of disease like two varieties Endogenous (Nija) and Exogenous (Aagntuja). Four varieties of disease based on prognosis i.e. curable, incurable, mild, acute. E.g. Haemorrhagic disorder (Rakta pitta): Three types according to route of the bleeding i.e. upwards, downwards, oblique. According to prognosis, the disease is curable, incurable and difficult to cure. So this samprapti helps in prognosis of disease. If disease is Asadhya (incurable), then physician shouldn’t treat the disease otherwise lead to loss of money, knowledge, Yasha etc.
Vikalpa Samprapti (Proportional Analysis of Dosha)
When two or more vitiated doshas are involved in pathogenesis their symptoms produced. The different character is reflected in the symptoms according to level of vitiated doshas. The doshas having greater degree of vitiation produce more symptoms. This is also known as “Anshansh kalpna”. The doshas may get vitiated by all the character of them or by only one character. E.g. Pain is produce by vata, when provocated by its dry and cold qualities. The Pea and Sugarcane possess all these qualities, so eating of peas and sugarcane causes provocation of vata (i.e. intensi ty of pain will be increase).
Bala Samprapti (Strength of Disease)
The strength of disease is more when the severity of provocation of dosha is more. Such diseases are in- curable or very difficult to treat. When all the causative factors are there, all the premonitory symptoms and main symptoms are expressed clearly then that disease is more severe. The disease involving important body elements (Like Marma) and vital organs are more severe.
Kala Samprapti (Time Factors)
The effect of day, night, period of digestion, season on the dosha brings about variations in the pathogenesis and symptoms of disease. The symptoms are increased or decreased according to the time. E.g. In Vatika Gulma intensity of pain increase after digestion of food (i.e. in empty stomach) and become mild after taking food. In Pittaj Gulam, intensity of pain increase during digestion of food. Whether the disease is curable or incurable is also depend on time or season.
E.g. Kaphaj jwara in vasanta ritu is curable.
Ayurveda says that before the planning of treatment, the correct diagnosis of the disease is very much essential which means a physician must examine the disease thoroughly before prescribing medicine. Nidana panchaka is a tool for diagnosing a disease at various stages. Naming of disease is not given that much importance, but knowing the definite etiological factors, dosha vitiation, pathogenesis or progress of disease and to check it at early stage is given prime importance. In short, avoiding the causative factor is an important part of treatment of any disease. In modern concept of medicine, treatment of a disease starts after actual appearance of a disease. But in Ayurveda, good knowledge of purvarupa may help physician to curb a forthcoming disease in its early stages because treatment at this stage would require minimal or simpler modalities. Rupa stage helpful for planning of specific treatment. Upashaya plays an important role in diagnosis as well as treatment of disease. The samprapti gives knowledge about provocating doshas, route of the disease, involved dhatus and srotas (system or organ) affected. This is useful in deciding the specific treatment. Each component of Nidana Panchaka individually as well as collectively helps in diagnosis of disease. If one component indicates to- wards a disease then other aspects of Nidana Panchaka confirm the diagnosis.