A literary study of Purvarupa ( Prodromal features) w . s . r . to

. ABSTRACT In Ayurvedic science , diagnosis of disease is done with help of Nidan Panchaka. In five -fold examination , Purvarupa is one of the component part of Nidan Panchak. Purvarupa means prodromal features of diseases . Any disease does not appear suddenly . Time taken between etiological factors intake to appearance of specific disease is of purvarupa. They are premonitory features that manifest before the actual emergence of disease . These symptoms could be doshaj or adoshaj. Purvarupa are of two types , general and specific . Careful understanding of purvarupa helps in differential diagnosis of diseases . Purvarupa also helps to determine the prognosis of any disease . Appearance of all purvarupa of any disease are considered of bad prognosis and incurable . At purvarupa stage , treatment modalities for any disease are simpler or easier . So the knowledge of Purvarupa is essential . In samhitas the purvarupa (prodromal features) of Prameha vyadhi are described very well . As the Prameha vyadhi is asadhya i n its chronic stage as well as it may cause many serious complications if it is not treated and controlled in early stage , it is very important to know the disease in very primary stage . This is possible by detecting the prameha purvarupas in patient as earlier as we can . So that we can diagnose this stage and can prevent to develop it further in vyaktavastha. So in this article an attempt is made to elaborate the importance of Purvarupas and to compile the purvarupas of Prameha from all Ayurvedic samhitas.

Purvaroopa which is an important factor of Nidan Panchak is defined as the typical features that are seen before manifestation of any disease. Prameha which is included under Medavaha Srotodusthi can be defined as metabolic disorder in which patients urinate frequently & profusely. It is considered as "silent killer" in today"s society. It is estimated that 77. 2 million people in India, who are suffering from Pre-Diabetic condition. Diabetes is the most common metabolic disorder which is prevalent in every part of the world and is a major public health challenge of the twenty-first century. International diabetes federation (IDF) shows that 285 million adults (20-79 years) are affected by this disorder in 2010. Epidemiological trends indicate that without proper control and prevention, its prevalence will increase further to 438 million in 2030.
Hence, special precautions as well as early diagnosis is essential to prevent the complication of Diabetes. It can only be possible when it will be identified in early stage or at the time of Purvaroopa avastha(Prodromal stage) of Prameha. The Acharyas of Ayurveda had also described about the Purvaroopa avastha of Prameha in their respective Samhitas(Classical texts of Ayurveda). If we compare all the Prodormal features of Prameha described by our Acharyas then we can find a lot of similarities between them. These typical similarities will be very much helpful to diagnose the case in earlier stage and to prevent further vyaktavastha and its complications.

Discussion (Review of literature)
According to Ayurvedic science, diseases occur due to imbalance of dosha (vata, pitta, kapha). This imbalance is created due to intake of nidan. Nidansevan directly do not cause any disease but it causes dosha sanchay initially and then prakopa and prasara of doshas if they continued further nidansevan. The disease appears when complete pathogenesis takes place in body. In the course of disease(samprapti) there is a stage of sthana-samshraya. Symptoms which appear due to dosha-dushya sammurchhna during sthana samshraya stage are called purvarupa. Although purvarupa of many diseases are mentioned in books, in some diseases, existence of milder form of roopa (sign or symptoms) can be called as purvarupa. Purvarupa is essential and useful tool to identify a future disease i. e. prodromal stage .

Definition of Purvarupa / Pragroopa
Pragrupa are said to be those symptoms which are seen before the manifestation of the main disease (which they denote The premonitory symptoms which give a clue regarding the forthcoming disease but no idea about the doshas involved in it, are called samanya purvarupas. This means that the samanya purvarupas indicate the forthcoming disease but do not give us an idea of the dosha involved in the causatlon of disease or its types. E. g shrama (fatigue), arati (discomfort, body pains) and vivarnata (discoloration) etc. are the common purvarupas or premonitory symptoms of Jwara (fever). These symptoms suggest that the fever is going to be manitested after sometime or in future if patient continue to consume nidan and takes no preventive measures at this stage. But these symptoms will not reveal the involvement of specific doshas i. e. whether the Jwara which is supposed to get manifested is Vataja (fever caused due to vitiated vata) or Pittaja (fever caused due to vitiated pitta) etc.

Vishist or vishesha purvarupa( dosha specific premonitory symptoms).
The symptoms which not only give a clue regarding the forthcoming disease but also give us an idea of the dosha taking part in the causation of the disease are called Vishesha purvarupas. E. g. Yawning as a purvarupa of Vataja Jwara (fever caused by vitiated vata), burning eyes as the purvarupa of Pittaja Jwara (fever caused by vitiated pitta) and tastelessness as purvarupa of Kaphaja Jwara (fever caused by vitiated kapha). Aappearance of all purvarupa mentioned in samhitas is a bad prognosis for a disease because it becomes incurable.
Purvarupas are again classified as follows:

Maanasa Purvarupas ( psychologeal prodromal symptoms):
The premonitory symptoms of a disease appearning only at the manas level are called Maanasa purvarupas. E. g. Dislike to common desires, aversion to the elderly advices, vaichitya, arati etc.

Shareera
Manasa Purvarupas (psychosomatic): These are the prodromal symploms of a disease which occur both at physical and mental planes. E. g. Desire to have amla (sour) and lavana (salt) rasatmaka foods or dislike of madhura rasa (sweet taste or foods )are examples of sharira maanasa purvarupas. In this instance, desire and disike (of tastes) are mental manifestations . And consumption and non-consumption of these tastes of that particular person is a physical manifestation. Sthanasanshraya is the stage of pathogenesis in which the vitiated doshas lodge in the tissues causing damage therein. In this stage, the vitiated and vimargagami doshas which are displaced from their places in the 3 rd stage of Kriya Kala (Prasara, or stage of overflow) are circulating in the body in seek of a lodgment. Vata dosha due to its sancharanshil quality takes other doshas like Kapha and Pitta with it and take them to other places. When these vitiated and aggressive doshas find a weak and susceptible dhatus (tissues), they invade and get lodged in them. This is called dosha-dushya sammurchana. Since the doshas get lodged (samshraya) in certain places i. e. tissues (sthana), this stage of kriyakala is called sthanasamshraya or stage of lodgement of doshas. These doshas in the later stage contaminate and damage the dhatus leading to the manifestation of various diseases (depending on the tissue, organ or strotas in which these vitiated doshas get lodged). In this stage the sammurchhana of doshas and dushyas (dhatus) is not complete, we can say (is immature) and the samprapti (pathogenesis) of the disease is also not complete, therefore the disease is also not manifested completely.

Shatkriyakala and
The dosha dushya sammurchana can be halted and the further stages of kriya kala i. e. Vyaktha Avastha (stage of manifestation of disease) and Bheda Avastha (Stage of vyakti of specific dosha involvement of the disease) can be prevented by early diagnosis and treatment. Thus disease formation can be prevented. When the disease is completely formed, all lakshanas appear in the vyakta Avastha (5th stage). During the process of Sthana Samshraya (when the samprapti has not been completed and the disease has not yet manifested), the vitiated doshas produce certain unclear symptoms which indicate the forthcoming disease. These symptoms of an impending disease (yet to be manifested disease) are called Purvarupas. The symptoms which occur after the completion of dosha dushyasammurchana (complete contamination of dhatus by morbid dushyas or dhatus) are called lakshanas (symptoms of a manifested disease).
When dosha-dushya sammurchana starts following sthanasamshraya of doshas, the prodromal symptoms (purvarupas) starts occuring. These symptoms indicate the initial stage of the disease and demands attention in the form of prompt treatment.
Prodromal the initial contact of doshas and dushyas at already impaired or weak channel (strotas) giving an alarming sign of the disease of that strotas, which will appear in future. This occurs following the sthanasamshraya or lodgment of doshas in the dhatus. These kriyakal i. e. Sanchay, prakopa, prasara and sthansanshraya gives a person an opportunity to take precautionary steps forward, like nidan parivarjan or to follow other simple upakramas or remedies for dosha shaman to prevent the condition from getting converted into further kriyakala i. e. Vyakti and bhedavastha. Purvarupas are the symptoms which are seen in the sthansanshray avastha of shatkriyakal and they occur before the manifestation of the disease. They may even continue after the manifestation of disease, along with the course of the disease or may disappear before the actual disease is manifested. In the Purvarupavastha, the strength (bala)of dosha, dhatu amalgamation will be weak, as it is a primitive stage [15]. Therefore the damage to the tissues also will be least. Since the damage of the tissues is less, early diagnosis of this condition and prompt treatment will prevent the disease progression and consequent formation of stage of manifestation of disease (Vyakta avastha, i. e. 5th stage of pathogenesis) and stage of manifestation of dosha specific involvement (Bheda avastha i. e. 6 stage of Kriya Kala). The prodromal symptoms Purvarupas)will be fewer and weaker in comparison to the rupas (symptoms of a manifested disease). They are also unclear and latent(avyakta). This by itself is characteristic feature of the Purvarupas. Since Purvarupas are fewer and feebler, the treatment of the disease at this stage i. e. stage of prodromal symptoms will be comparably easy. Samanya Purvarupas will not reveal the dosha involvement in the formation of a disease.
In the beginning of manifestation, the purvarupas (samanya purvarupas) might indicate an impending disease but will not reveal the doshas involved in the causation of the disease. In some cases or in later stages, the involvement of doshas too will be indicated (vishishta purvarupas) promptly. When the purvarupas get matured and get clearly manifested in the 5h stage of pathogenesis (kriya kala), i. e. Vyakta avastha, they will denote the manifested diseases and will be called as rupas (symptoms of a manifested disease). Further progression of the disease beyond stage of manifestation will lead to stage (Bheda Avastha). The purvarupas will lead to rupas, when the disease is not treated or proper precautions are not taken at the stage of manifestation of purvarupas (sthana samshraya). Some of the purvarupas may continue to exist in the actual condition of the disease also (manifested disease). In this instance, the purvarupas have matured to form rupas or the purvarupas have been transformed into rupas and clearly manifested. Example, yawning which is a purvarupa of jwara, will also (may) continue to persist even in the acute condition of manifested Jwara i. e. in the rupavastha of the Jwara alongwith the other lakshanas(symptoms).
Some purvarupas progress, some disappear. All the purvarupas do not progress to form the rupas in the vyakta Avastha [16]. Some purvarupas disappear at the stage or during the process of becoming rupas. In some diseases, the pragrupas contradictory to rupas may occur. E. g. Instead of sensation of temperature (deha santapa), rigors and chills occur before the onset of fever. Similarly constipation (vidsanga) occurs before manifestation of diarrhea in the purvarupa of atisara (diarrhea). In most of the diseases, are all the rupas i.

a) For diagnosis of diseases:
In nidanpanchak, one nidan can be a cause several diseases. In such situation, only nidan is insufficient to provide any clue about disease. For example, excessive intake of madhura rasatmaka food and drinks can cause prameha, sthaulya and other kaphaja vyadhis. Even patient also does not give correct history of nidan sevan. Purvarupa knowledge helps in diagnosing the disease early. As purvarupas help in early recognition of the diseases, early understanding of the pathology and pathological elements, and nature of the impending disease, it helps in preventing the disease process at the earliest and halting the disease process before its progression into the main disease and its complications. Knowledge of purvarupas help in preventing the next stages of disease formation of Kriya Kala . The physician can prevent the vyakta (stage of manifestation of disease and manifestation of symptoms) and bheda (stage of complications) of the disease with a precise knowledge of purvarupa avastha.
The efforts of the physician should be to detect the pathology as early as possible and try to control and cure it. Purvarupas are the early clues regarding the developing pathology-dosha-dushya sammurchana. Hence the forthcoming disease, its nature, severity etc. can be diagnosed at an early stage before the manifestation of the main disease with the help of knowledge of purvarupa.

b) For treatment:
Treatment modalities can be decided on the basis of purvarupa like ghritpaan on appearance of purvarupa of vataj-jwara (sushruta), laghu aharsevan or langhan on appearance of Jwara purvarupa(charak).
Knowledge of purvarupa helps in early start of treatment. With good knowledge of purvarupa the physician can diagnose the disease at the earliest. This will help him to plan the treatment and medications at the earliest, before the disease gets manifested with its full blown symptoms. The treatment at this stage is also easier and doesn't need an aggressive approach. Appropriate treatment planned and implemented at purvarupa stage succeed www.ayurline.in E-ISSN: 2456-4435 pg. 8 in preventing the disease or in minimizing its severity. If the pathology is understood and destroyed (samprapti bhanga) in purvarupa avastha itself, the disease pathology doesn't progress to its further stages.

c) For prognosis:
The purvarupas indicate the sadhyata, asadhyata (prognosis) of a disease. Prognosis of any disease can also be determined by examining purvarupa.
Few purvarupas along with mild nidan intake(alpa hetu) and mild rupa(alpa lakshanas) shows that the disease is sukhsadhya. According to Acharya Charak, if alI purvarupa of any disease appears together, it is called Arishta because disease become incurable . The greater the number of purvarupa and more the severity, it indicates the severity of vitiation (morbidity) of the doshas and severity of the nature of the disease. If the purvarupas of a given disease are more in number or if they are severe in intensity, then the prognosis of the disease will be bad . Similarly the less number of purvarupas of any disease or their feebleness indicate good prognosis (saadhya), i. e. that the disease can be easily curable.

d) For differential diagnosis of diseases:
Knowledge of purvarupa helps in differential diagnosis of an existing disease. For example, patient urinating dark yellow or red coloured urine without purvarupa of prameha confirms diagnosis of existing raktapitta. Sushruta samhita and all other major and concerned books of Ayurveda discuss about purvarupa. Aim of mentioning purvarupa before discussing treatment of any disease is to diagnose future disease at early stage and nip it in its bud with nidanparivarjana or minimal treatment. Prameha is a medovaha strotodushtijanya vikara. The two chief symptoms described in samhita are prabhuta (Excessive) and avil (turbid) mutrata. There are 20 types of prameha, which shows different abnormalities regarding colour, constituents and swarupa of urine according to vitiated doshas. All types of pramehas get convert into madhumeha which is chronic stage of disease and its prognosis is also not good(Asadhya). Prameha vyadhi which is similar to Diabetes Mellitus, is known as a silent killer. It can bring many complications to many systems, if not controlled or properly treated. But as it is a lifestyle disorder, if it is diagnosed in early stage, i. e. prediabetes, it can be controlled with changes in diet and lifestyle. The premonitory stage of diabetes, i. e. prediabetes is the stage in which the prodromal symptoms or purvarupas of vyadhi can be observed. Prameha purvarupas compiled from all Ayurvedic samhitas are as follows.

Acharya
Sharangadhara has not described anything about prameha.

Harita Samhita
Acharya Harita has described about prameha, its classification, its treatment but has not described anything about purvarupa avastha of prameha in Harita Samhita.  Purvarupa like karpadasuptata, daha (numbness and burning of soles), visra shareera gandha (foul odour in the body), shatpada pipilika sharira mutra abhisarana (ants crawling/attracted on body and urine) appears when there is marked hyperglycemia in blood for long or as complications of Diabetes mellitus. Knowledge of purvarupa must be combined with other components of roga pariksha like nidan and upshaya. It helps to prevent samprapti at early stages and avoidance of future disease.

Conclusion:
Metabolic disorder like Diabetes Mellitus is increasing like a rapid fire in the society as it affects all the age groups & all social economic groups. So, it is quite difficult to save the society from Diabetes Mellitus if the diagnosis and treatment procedure are delayed. So the need of the hour is to screen the common people in terms of awareness programme in both urban & rural areas. So the Prodromal features of prameha can be screened earlier and appropriate treatment will be given by holistic method as mentioned in Ayurveda. It could also be concluded that purvarupa along with othe components of nidan panchak holds great importance in roga pariksha (diagnosis of any disease).