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== Introduction ==

== Introduction ==

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In this chapter prodromal symptoms and dreams related to poor prognosis of diseases- fatality are described. In the first verse, Charak has emphasized that he will describe both common and special prodromal symptoms. This indicates that while there may be some prodromata which result out of normal pathogenesis, some are unusual and unexpected. In the next verse it has been said that if all prodromal symptoms are manifesting and are severe in nature then such a condition will be fatal. This principle is applicable to all other diseases also. Prodromal symptoms of [[kushta]] and [[prameha]] suggest that complications manifest before cardinal symptoms of the disease appear. If body metabolism in any disease is altered severely during latent phase of disease and complications are appearing before manifestation of full-fledged disease then such condition will be difficult to cure. Example of [[gulma]] suggests that there are certain diseases which are incurable in nature and prodromal symptoms related to such clinical conditions will always be precursors of imminent death. It is commonly seen that any person who is emaciated and have low immunity and strength, when affected by disease, has fatal consequences due to less resistance. This fact is explained with the example of [[shosha]]. Another important aspect regarding disease prognosis is that, if a person is continuously partaking causative factors or is in constant exposure to the causative factors, body will be unable to fight disease properly and thus there will be less chances of recovery from the disease. This point is also mentioned while describing prognosis of [[shosha]].

In this chapter prodromal symptoms and dreams related to poor prognosis of diseases- fatality are described. In the first verse, Charak has emphasized that he will describe both common and special prodromal symptoms. This indicates that while there may be some prodromata which result out of normal pathogenesis, some are unusual and unexpected. In the next verse it has been said that if all prodromal symptoms are manifesting and are severe in nature then such a condition will be fatal. This principle is applicable to all other diseases also. Prodromal symptoms of [[kushtha]] and [[prameha]] suggest that complications manifest before cardinal symptoms of the disease appear. If body metabolism in any disease is altered severely during latent phase of disease and complications are appearing before manifestation of full-fledged disease then such condition will be difficult to cure. Example of [[gulma]] suggests that there are certain diseases which are incurable in nature and prodromal symptoms related to such clinical conditions will always be precursors of imminent death. It is commonly seen that any person who is emaciated and have low immunity and strength, when affected by disease, has fatal consequences due to less resistance. This fact is explained with the example of [[shosha]]. Another important aspect regarding disease prognosis is that, if a person is continuously partaking causative factors or is in constant exposure to the causative factors, body will be unable to fight disease properly and thus there will be less chances of recovery from the disease. This point is also mentioned while describing prognosis of [[shosha]].

From the above discussion it is clear that prodromal symptoms can be useful in predicting diagnosis of any disease. But now question arises whether it is practically possible to predict prognosis with prodromal symptoms? We should admit that it is very difficult and one will need years of experience to attain such competence. Another important fact is that the prediction of prognosis can be done from [[purvarupa]] only after disease manifestation. Charak states that [[purvarupa]] converting into a particular disease in future can be termed a prognostic sign. This indicates that we cannot predict by only prodromal symptoms. We have to look into whether disease was produced after [[purvarupa]] or not. For example, delirium in [[raktapitta]] is indicator of poor prognosis. If delirium is seen in any patient but he is not developing [[raktapitta]] we cannot predict poor prognosis. In this condition, after manifestation of [[raktapitta]] we need to ask the patient whether he suffered from delirium before disease manifestation or not. It is a retrospective inquiry about [[purvarupa]] based on which a prospective prediction may be made. We will have to follow detailed retro-prospective approach and will need proper patient history comprising of each and every detail from prodromal symptoms to disease manifestation. Thus practically, prodromal symptoms are helpful only after disease manifestation as they are not independent. Since accompanying symptoms may also lead to predictions, they can also be regarded as tools of predictive prognosis. This might be the reason that Sushruta and Vagbhata have not described dreams in reference of [[purvarupa]] but have described in ''rupavastha'' (stage of disease manifestation).

From the above discussion it is clear that prodromal symptoms can be useful in predicting diagnosis of any disease. But now question arises whether it is practically possible to predict prognosis with prodromal symptoms? We should admit that it is very difficult and one will need years of experience to attain such competence. Another important fact is that the prediction of prognosis can be done from [[purvarupa]] only after disease manifestation. Charak states that [[purvarupa]] converting into a particular disease in future can be termed a prognostic sign. This indicates that we cannot predict by only prodromal symptoms. We have to look into whether disease was produced after [[purvarupa]] or not. For example, delirium in [[raktapitta]] is indicator of poor prognosis. If delirium is seen in any patient but he is not developing [[raktapitta]] we cannot predict poor prognosis. In this condition, after manifestation of [[raktapitta]] we need to ask the patient whether he suffered from delirium before disease manifestation or not. It is a retrospective inquiry about [[purvarupa]] based on which a prospective prediction may be made. We will have to follow detailed retro-prospective approach and will need proper patient history comprising of each and every detail from prodromal symptoms to disease manifestation. Thus practically, prodromal symptoms are helpful only after disease manifestation as they are not independent. Since accompanying symptoms may also lead to predictions, they can also be regarded as tools of predictive prognosis. This might be the reason that Sushruta and Vagbhata have not described dreams in reference of [[purvarupa]] but have described in the stage of disease manifestation.

   

   

Biomarkers are recent advancements can be the answer to above problem as we do not need to wait for disease manifestation and can predict prognosis by seeing values of biomarkers related to that disease. In 2001, a consensus panel at the National Institutes of Health defined the term biomarker as ‘a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention or other health care intervention’.<ref>Torres-Bugarín O, Zavala-Cerna MG, Nava A, Flores-García A, Ramos-Ibarra ML. Potential Uses, Limitations, and Basic Procedures of Micronuclei and Nuclear Abnormalities in Buccal Cells. Disease Markers. 2014;2014:956835.</ref> Biomarker defined as alteration in the constituents of tissues or body fluids provide a powerful approach to understanding the spectrum of chronic disease with application in at least 5 areas like screening, diagnosis, prognostics, prediction of disease recurrence and therapeutic monitoring.<ref>Pradeep Sahu et al, Biomarkers: An Emerging Tool for Diagnosis of a Disease and Drug Development, Asian J. Res. Pharm. Sci. 2011; Vol. 1: Issue 1, Pg 09-16 </ref> The biomarker is either produced by the diseased organ (e.g., tumor) or by the body in response to disease. Before diagnosis, markers could be used for screening and risk assessment. Tumor classification, stage and sometimes grade are generally used to assess prognosis. Researches in the field of biomarkers may give us chance to know prognosis of disease in early stage.

Biomarkers are recent advancements can be the answer to above problem as we do not need to wait for disease manifestation and can predict prognosis by seeing values of biomarkers related to that disease. In 2001, a consensus panel at the National Institutes of Health defined the term biomarker as ‘a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention or other health care intervention’.<ref>Torres-Bugarín O, Zavala-Cerna MG, Nava A, Flores-García A, Ramos-Ibarra ML. Potential Uses, Limitations, and Basic Procedures of Micronuclei and Nuclear Abnormalities in Buccal Cells. Disease Markers. 2014;2014:956835.</ref> Biomarker defined as alteration in the constituents of tissues or body fluids provide a powerful approach to understanding the spectrum of chronic disease with application in at least 5 areas like screening, diagnosis, prognostics, prediction of disease recurrence and therapeutic monitoring.<ref>Pradeep Sahu et al, Biomarkers: An Emerging Tool for Diagnosis of a Disease and Drug Development, Asian J. Res. Pharm. Sci. 2011; Vol. 1: Issue 1, Pg 09-16 </ref> The biomarker is either produced by the diseased organ (e.g., tumor) or by the body in response to disease. Before diagnosis, markers could be used for screening and risk assessment. Tumor classification, stage and sometimes grade are generally used to assess prognosis. Researches in the field of biomarkers may give us chance to know prognosis of disease in early stage.

Another important aspect mentioned in this chapter is concept of dreams. The descriptions related to dreams are found abundantly in the ancient oriental classics, specifically the Atharvaveda, Upanishadas, Puranas, Darshanas and [[Ayurveda]]]. The description of the ''doshika'' dreams of the Atharvaveda is similar to that in [[Ayurveda]]. Dreams are mentioned while describing [[purvarupa]], ''rupa'' and [[arishta lakshanas]].<ref>Sonali S. Tendulkar and R. R. Dwivedi, ‘Swapna’ in the Indian classics: Mythology or science?,Ayu. 2010 Apr-Jun; 31(2): 170–174. </ref> Sushruta states that sex of the unborn child can be predicted and Vagbhata says that ''doshika [[prakriti]] can be known by the help of dreams.

Another important aspect mentioned in this chapter is concept of dreams. The descriptions related to dreams are found abundantly in the ancient oriental classics, specifically the Atharvaveda, Upanishadas, Puranas, Darshanas and [[Ayurveda]]]. The description of the ''doshika'' dreams of the Atharvaveda is similar to that in [[Ayurveda]]. Dreams are mentioned while describing [[purvarupa]], [[rupa]] and [[arishta lakshanas]].<ref>Sonali S. Tendulkar and R. R. Dwivedi, ‘Swapna’ in the Indian classics: Mythology or science?,Ayu. 2010 Apr-Jun; 31(2): 170–174. </ref> Sushruta states that sex of the unborn child can be predicted and Vagbhata says that ''doshika [[prakriti]] can be known by the help of dreams.

Subject of dreams is dealt in very scientific manner. According to Charak, dreams occur when person is in relatively wakeful state. This has been proved now by the researches that dreams mainly occur in the rapid-eye movement (REM) stage of sleep—when brain activity is high and resembles that of being awake. In the late 19th century, psychotherapist Sigmund Freud developed a theory that the content of dreams is driven by unconscious wish fulfillment. Freud called dreams the "royal road to the unconscious”.<ref>Jeannette Y. Wick; Guido R. Zann, Drugs and Dreams, J Am Pharm Assoc (2003) 2002;42:385-390. </ref> To Freud, no dream was of entertainment value, they all held important meanings. Dreams reflect the dreamer’s mental, emotional, and physical state. This fact is well established in this chapter while describing classification of dreams. Dreams are based on our day to day interactions and so are classified as dreams seen, heard, felt etc. Two of the seven types, one which predict prognosis and one which is due to vitiation of [[dosha]] are said to have fatal consequences.

Subject of dreams is dealt in very scientific manner. According to Charak, dreams occur when person is in relatively wakeful state. This has been proved now by the researches that dreams mainly occur in the rapid-eye movement (REM) stage of sleep—when brain activity is high and resembles that of being awake. In the late 19th century, psychotherapist Sigmund Freud developed a theory that the content of dreams is driven by unconscious wish fulfillment. Freud called dreams the "royal road to the unconscious”.<ref>Jeannette Y. Wick; Guido R. Zann, Drugs and Dreams, J Am Pharm Assoc (2003) 2002;42:385-390. </ref> To Freud, no dream was of entertainment value, they all held important meanings. Dreams reflect the dreamer’s mental, emotional, and physical state. This fact is well established in this chapter while describing classification of dreams. Dreams are based on our day to day interactions and so are classified as dreams seen, heard, felt etc. Two of the seven types, one which predict prognosis and one which is due to vitiation of [[dosha]] are said to have fatal consequences.