Article NIMHANS Journal

Ancient Hindu Concept of Neurology and Neuro Surgery (AnAnalysis of Caraka)

Volume: 01 Issue: 02 July 1983 Page: 133-140Vinod Kumar Srivastava, - Department of Neurosurgery, National Institute of Mental Health & Neuro

Sciences, Bangalore 560 029, India

AbstractCaraka Samhita represents the knowledge of medicine about 2000 years ago in India. Onreviewing the treatise, it appears that neurological symptoms were well recognised. An attemptwas also made to explain their patho mechanism. But lack of anatomical knowledge regardingbrain kept them in dark regarding their true clinical correlation.

Key words -Shirorog,Epilepsy,Sleep,Spastic paraplegia'Shirorog',Epilepsy,Sleep,Spastic paraplegia

Caraka's concept of central nervous system was quite vague. It is evident from lack of a term, which1 could be equatedwith brain, as it is known to-day [1]. Despite these lacunae, physicians of his time were keen observers. They observedsymptoms and classified and explained them in their own way. Caraka's neurology would consists of elucidation of majorsymptom-complexes and the underlying patho-mechanism, as it was understood then.

Material and MethodCaraka Samhita was reviewed in detail and any knowledge pertaining to neurology and neurosurgerywas compiled. An attempt has been made to enumerate the neurological symptoms and try tounderstand, if Caraka knew their correlation with brain or mind.

Results

Caraka has used the term head in a very broad sense, for it includes E.N.T. and psychiatric ailments aswell. While enumerating the names of diseases of head, Caraka mentions hemicrania, pain in the wholehead, giddiness, facial paralysis, head tremor, spasm of throat, neck or jaws and also includes coryzaand diseases of mouth, nose, eyes and ears [2].Head diseases in general are caused by [3]:1. Suppression of natural urges2. Day sleep3. Waking at night4. Intoxication5. Talking too loud6. Exposure to frost at night7. Facing head-winds8. Excessive sex act9. Inhalation of unwholesome odours10. Dust, smoke11. Cold heat12. Over eating of heavy and sour articles, and greens13 Use of very cold water14. Trauma of the head15. Morbid chyme16. Excessive weeping17. Supression of tears18. Onset of rains19. Mental affliction.20. Abnormal clime and seasonMechanism, which produces diseases of head is through various humors vitiating the blood in thehead. As is found in Hindu medicine elsewhere in the body, there is too much of stress on varioussymptoms of head disease rather than diagnostic entities.Major symptom-complexes pertaining to neurology described in Caraka Samhita are:1. Head ache2. Epilepsy3. Syncope, intoxication and fainting4. Disorders of sleep5. Head injuries6. Spastic paraplegia7. Antarayama, Bahirayama, danda8. Facial paralysis9. Hemiplegia10. Sociatica11. Khalli12. LeprosyIt would be interesting to deal with each of them separately.

1.Head Ache

There are five types of headache described, though Caraka uses a general term 'Shirorog' for them [4].(i)

Vata type:Increased Vata enters the vessels in the head and gets provoked under following conditions, giving riseto this type of disease [5].a. Loud speechb. Excessive talkc. Strong drinksd. Waking at nighte. Excessive sex actf. Suppression of natural urgesg. Fastingh. Traumai. Severe purgation and vomittingj. Excessive weepingk. Griefl. Fearm. Terrorn. Load carryingo. Way faringp. Severe emaciatingIn this type of disease, there is intense pain in both temples and splitting sensation in the nape. There isa sensation of heat and severe pain in the forehead in between the two eyebrows. There is an associatedpain and noise in the ear. Patient feels as if eyes are being extracted. There is whirling of head. Itappears as if all joints in the body have been separated out. Vessels are seen throbbing excessively andneck becomes stiff [6].(ii)

Pitta type:It is caused by the use of [7]:a. Pungent and acid articlesb. Saltc. Alkalid. Winee. Angerf. Heat and fireHere also patient gets headache, but element of burning sensation in the eyes is much more. Patientfeels thirsty and feels like taking cold things. Patient has giddiness and perspiration also.(iii)

Kapha type:It is caused by [9]:a. Indulgence in sedentary lifeb. Sleep

c. Intake of heavy, unctuous and excessive dietThere is more numbness, stiffness and heaviness in the head, there is associated torpor. Patient remainslethargic and loses appetite [10].(iv)

Tridiscordance type:This is caused by imbalance of all the three above mentioned humors, and so symptoms of all the threeare combined [11].(v)

Krimija type:It is caused by [12]:a. Excess intake of til, milk and jaggeryb. Over eatingc. Eating putrified or promiscuous foodBecause of these factors, worms are born in the head and give rise to a severe piercing or cutting pain.There is associated itching, swelling and fetor. Worms, can also be demonstrated [13].Apart from above mentioned types, two other types have been described.1. Lalatarchativedanam: (Hemicrania or migraine) [14] - It is said to affect only one half of the

head.2. Suryavarta [15] - This is a type of headache which increases as the day advances and decreases as the

sun sets. The mechanism explained has been that the morbid matter gets liquified after sunrise andstarts flowing causing headache. After sunset, liquid gets congealed in the head and so, headachedecreases.

Association of headache with vomiting, blurring of vision and giddiness was not very clearlyunderstood.Treatment: It consists of maintaining the homeostasis between the three humors: Vata, Pitta andKapha. Various herbal and ghee preparations have been mentioned.

2.Epilepsy"It is defined as a paroxysmal loss of consciousness due to disturbance of memory and understandingof the mind, attended with convulsive seizures" [16].Persons more prone to epilepsya. Imbalance in the homeostasis of the three humors [17].b. Persons whose minds are obscured by passion and ignorance [18].c. Those who break dietary rules and consume unclean and improper articles.d. Those who abuse the general rules of health.e. Those who perform wrongful bodily activity.Mechanism: When the dormant humors get provoked suddenly by desire, anger, fear, greed,infatuation, excitement, grief, worry or anxiety, they occlude the channels of hrdayam and sense organsand so, man does not perceive any sense and falls into a fit.Premonitory symptoms: Following are the premonitory symptoms as suggested by Caraka:a. Spansmodic movements of eyebrow musclesb. Constant disorderly movement of the eye.

c. Acousmad. Dribbling of saliva and nasal dischargee. Inappetence.f. Anorexiag. Indigestionh. Cardiac spasmi. Distention of abdomenj. Debilityk. Bone fracturel. Body achem. Delusionn. Faintingo. Giddinessp. Frequent dreams of intoxication, dancing, piercing, trembling, falling etc.Epilepsy can be caused by injury to hrdayam and sira. Caraka recognised four types of epilepsy.(i)

Vata type:It is characterised by frequent attacks of transient loss of consciousness. Patient regains consciousnessvery fast. During the attack, eyes bulge and frothing occurs in the mouth. There is an incoherentspeech. Respiration is difficult. Head is drawn to one side. There is irregular clenching of fingers.Hands and feet are restless. Nails, eyes, face and skin are dusky red in colour. Patient gets a visual auraof forms, which are hard, dusky red or black in colour. Patient trembles and gnashes his teeth [19].(ii)

Pitta type:Here also, there are frequent attacks of transient loss of consciousness. Consciousness is immediatelyregained. There is stertorous breathing and the patient keeps tossing on the ground. Nails, eyes, faceand skin are yellow or copper coloured. Patient sees visual aura of blood smeared, fierce, terrifying,blazing and angry looking forms. Patient feels thirsty and feels, as if the whole world is in flames [20].(iii)

Kapha type:This is different from others in the fact that patient loses consciousness slowly and then regains it alsoslowly, Patient usually falls on the ground. Convulsive movements are not very strong. There isdribbling of saliva from the mouth. Nails, eyes, face and skin are pale. Patient gets visual aura ofwhite, heavy glossy shapes. Body remains cold [21].(iv)

Tridiscordance type:This is caused because of disturbances in all three humors. Symptoms are a combination of all thethree. This form is considered to be incurable [22].Apart from these four principle types, Caraka mentions epilepsy of the exogeneous type, whereadditional symptoms are present apart from the symptoms, pertaining to one of three humors, asmentioned above.

Prognostication: Signs of incurability have also been suggested by Carakaa. Tridiscordance type of epilepsyb. If it occurs in debilitated personsc. If it is long standing

Fatal prognosis has been suggested in the following situations:a. If a man, while fully awake, perceives darkness, which does not exist (visual hallucinations) or hears sounds, which do not exist (auditory hallucinations), he is destined to die

[23].b. If a man with epilepsy, dreams that he is intoxicated with drink and dances in dreams, prognosis is fatal

[24].c. If a man's jaws, sides of the neck and eyes get stiffened, he is destined to die [25].

Frequency of fits can be once in every fortnight, every twelve days or once in a month [26]. Caraka hasissued a warning for the epileptics that they should be especially protected from water, fire, trees,mountains and irregular surfaces, lest they might injure themselves.Treatment: Treatment consists of clearing channels by drastic purificatory measures. Enemata are goodfor vata type. Purgation for pitta type and emesis has been suggested for kapha type of epilepsy. Manysedative recipes have been suggested. Fumigation and drastic procedures like temporal veinvenesection have been suggested as difference modes of treatment, meant to clear the vitialed bloodfrom the sira [27].

3.Syncope, Intoxication and FaintingCaraka differentiates between the three by the fact that syncope does not subside without treatment,whereas intoxication and fainting are transient phenomena and subside on their own even withouttreatment [28].Syncope results from humors in vital parts of the body getting provoked, which in turn paralysesspeech and other functions of body and mind. The patient appears like a log of wood and would die, ifnot treated urgently. Treatment consists mainly in stimulating the body by inhalation of snuffs,pricking needles or even branding the body. Strong wines mixed with pungent articles have beensuggested. Blood letting has also been suggested.Intoxication is a state, where though the patient has not consumed any alcohol, behaves like adrunkard. Three types of intoxication have been defined [29].(i)

Vata type:In this type, patient speaks excessively and fast. Speech is indistinct. Patient is unstable and there isgross incoordination. Patient looks dry, dusky or red.(ii)

Pitta type:Here speech is hard. Patient picks up quarrel and likes fighting. Patient is red, yellow or dark incomplexion.(iii)

Kapha type:Here speech is scanty, incoherent or irrelevant. Patient is lethargic and indolent. Complexion here ispale.

Tridiscordance type: This is a type, where patient exhibits a combination of all the above threetypes.It must be made clear here that intoxication is a transient phenomenon and abates on its own.Fainting again has been divided into four types based on dysfunction of the humors.(a) Vata type: Just before fainting. Space looks blue, black, or red in this type. Patient gets tremors,

pain in the limbs and severe pain in the cardiac region. Patient looks emaciated and has a dusky orred complexion.

(b) Pitta type: In this type, space appears red, green or yellow. Patient faints and perspires profusely.He gets very thirsty.

(c) Kapha type: Patient feels as if there is a cloud of darkness, then faints and recovers after a longtime. Patient feels extremely heavy after the attack and has excessive nausea and salivation.

(d) Tridiscordance type: This is a combination of three and patient gets convulsions also.

Looking at the description, some of the severe cases of fainting probably overlap with epilepsy, asCaraka mentions presence of convulsive movement in these patients also. Regarding treatment ofintoxication and fainting, purificatory procedures have been suggested. Some ghee preparations havealso been advised. In severe cases, blood letting has also been advised [30].

4.Disorders of SleepWhen mind and senses get disconnected with sense objects because of tiresomeness a person fallsasleep [31]. Caraka mentions 6 types of sleep [32].a. Sleep because of tamasb. Sleep produced by kaphac. Sleep produced by weariness of mind and bodyd. Sleep which precedes any illnesse. Sleep which is due to diseasef. Sleep produced because of nightOf these, the sixth type of sleep has been termed as mother sleep and is considered physiological ornatural sleep, the rest five being pathological in nature. Insomnia and hypersomnia, both wererecognised by Caraka and their treatment was specified [33].

5.Head InjuriesIt has been stressed by Caraka that head injuries can be fatal [34]. In head injury patient can haverigidity of the sides of neck, facial paralysis and agitation of the eyes (? nystagmus). There can bestupefaction, severe headache loss of movement, cough, dyspnoea, trismus, dumbness, stutteringspeech and ptosis. Twitching of cheeks, yawning attacks, ptyalism and aphasia can also result [35]. Ithas also been mentioned that injury to the head can cause impairment of mind and understanding andcan result in insanity.

6.Spastic ParaplegiaKapha mixed with fat dominates over vata and pitta and produces a disease called 'Urustambh'. Thereare symptoms of heaviness, fatigue and contraction in both lower limbs. Muscles of calf and thigh areexhausted. Patient has no control over his legs. While standing or walking he feels as if his feet andthighs are broken and some one is propelling him forwards [36], [37], [38].If this condition continues further, patient gets severe pain and tremors in both lower limbs and

ultimately dies. Caraka considers such a disease of recent origin as curable and has dealt with it indetail. Caraka also advises swimming as an exercise for patients with spastic paraplegia [39].

7.Antarayama, [40], Bahirayama [41], Danda (? Tetanus)If vata gets localised in the neck, it causes spasticity of neck. Caraka later defines two types ofspasticity of neck. If the head is an extended position, it is called Bahirayama [41] and if head is inflexed position, it has been termed as Antarayama [40].Further Caraka describes opisthotonic posture and says that patient complains of pain in the neck.Patient has associated lock jaw and dies of this [42]. At another place, Caraka mentions that muscles ofhands, feet, head, back and lips become so rigid that the whole body behaves like a staff (Danda) [43].This condition has been declared as incurable. It is apparent that these are cases of tetanus, probablybeing described at varying grades of severity.

8.Facial ParalysisOcclusion of vata in marrow causes facial paralysis. It has been described separately and also incombination with hemiplegia. At one place, facial paralysis has been described in association with acondition, where patient has lower cranial nerve palsies, as suggested by the symptomatology [44].

9.Hemiplegia [46]

Excessively increased vata is supposed to reduce blood in one half of the body and cause hemiplegia[37]. With hemiplegia, facial deviation is also associated, which produces asymmetry of nose, eyebrow,forehead, eye and jaw. There is usually loss of movement. Sensation of pain and speech are also lost[45]. If such a paralysis affects only one limb, it has been termed as monoplegia [46].

10.SciaticaIn this condition, hip, thigh, knee and calf are progressively affected. There is stiffness, pain andpricking sensation in the legs [47]. Most commonly, such a condition results from disorders of vata. Ifit occurs because of a combination of vata and kapha, torpor, heaviness and anortexia get added up.

11.KhalliThis is a condition, where there is kneading pain, that goes to feet, calf, thigh and shoulder [48].

12.LeprosyThree types of leprosy have been described by Caraka, i.e., red, coppery and white. Further descriptivedetails have been given [49]. Even loss of sensation due to leprosy also appears to be recognised [50].

DiscussionHindus were very keen observers. They recognised most of the symptoms, as we know them to-day.They also had a sound way of reasoning, since pathomechanism was explained for each of thesesymptoms. What they lacked was the anatomical knowledge regarding brain as a structure. Correlativepathology, especially regarding central nervous system could not develop.Coming to specific details, the list of causes, that can give rise to diseases of head in general deals withcauses, that can lead to sinusis and also psychosis and neurosis. This obviously showed that they hadno clear idea of brain, nor could they correlate it with nervous symptoms.

Epilepsy, being caused by blockage of vessels of hrdayam again confirms that though they understoodmind, they were not clear about its anatomical substrate.Detailed description of spastic paraplegia definitely merits admiration. They also realised that it wasbecause of some problem in the back.Surprisingly Caraka has no idea about congenital disorders like hydrocephalus and Spina bifida. Howcould such entities escape detection is difficult to understand, especially so, when a full chapter hasbeen devoted to embryology. It must be worth recalling here that Caraka Samhita represents the stateof knowledge of Hindu medicine 2000 years ago and is not a one-man treatise. It was the result of aconference of physician sages, and so great care must have been taken to compile the whole of medicalknowledge, as it existed then.Regarding inflammatory disorders, probably 'Psychic fever [51]' is the only entity described. This toodoes not appear to be an equivalent of pyogenic meningitis and appears more to be the description of adelirious state following hyperpyrexia. Certain patients with spastic paraplegia appear to be afflictedwith Koch's spine, which has been described in great detail, for it must have been quite common then.Tetanus also seems to have been quite prevalent.Trauma to head has been described and head has been recognised as one of the marmas. But headinjury has not been discussed in detail, except repeating time and again, that it can be fatal. Trauma tospinal cord or back does not appear to be recognised.There was no concept of degeneration and demyellination nor do symptom-complexes suggest such anetiology in any of the descriptions. Metabolic diseases in the Ayurvedic sense have been described inplenty. In fact, the cause for each symptom has been explained on the imbalance of pitta, vata andkapha.To sum up, Caraka's knowledge regarding neurology was limited only to compilation of symptoms orsymptom-complexes. No clinico-anatomical correlation was attempted. Management was based oncorrecting the balance between the three humors. Since concept of brain as a structure did not exist,surgery on it could not be contemplated, as is confirmed by Susruta, which is considered a surgicaltreatise of more or less the same time.

1.Srivastava V K, [Ancient Hindu Concept of Anatomy of Nervous System (An Analysis of Caraka)]NIMHANS Journal Page: 1(1): 31-35, 19832.The Caraka Samhita, Edited, translated and published by Shree Gulabkunverba Ayurvedic Society, Jam Nagar, India

Page: 2: 17, 13, 14 p271, 19493.Ibid Page: 2: 17: 8-11, p 270, 19494.Ibid Page: 2: 17: 22, p 273, 19495.Ibid Page: 2: 17: 16-18, p 272, 19496.Ibid Page: 2: 17: 19-21, p 273, 19497.Ibid Page: 2: 17: 22, p 273, 19498.Ibid Page: 2: 17: 23, p 273, 19499.Ibid Page: 2: 17: 24, p 274, 194910.Ibid Page: 2: 17: 25, p 275, 194911.Ibid Page: 2: 17: 26, p 274, 194912.Ibid Page: 2: 17: 27, p 274, 194913.Ibid Page: 2: 17: 29, p 275, 194914.Ibid Page: 4: 9: 74-76, p 2808, 194915.Ibid Page: 4:9: 79-80 and 3/4, p 2809, 1949

16.Ibid Page: 3: 10: 3, p 1679, 194917.Ibid Page: 3: 10: 4, p 1679, 194918.Ibid Page: 3: 10: 5, p 1679, 194919.Ibid Page: 3: 10: 9, p 1681, 194920.Ibid Page: 3: 10: 10, p 1681, 194921.Ibid Page: 3: 10: 11, p 1681, 194922.Ibid Page: 3: 10: 12, p 1681, 194923.Ibid Page: 3: 5: 22, p 1217, 194924.Ibid Page: 3: 5: 23 p 1217, 194925.Ibid Page: 3: 5: 24, p 1218, 194926.Ibid Page: 3: 10: 13 p 1682, 194927.Ibid Page: 3: 10: 14-68 p 1682-1694, 194928.Ibid Page: 2: 24: 42 p 390, 194929.Ibid Page: 2: 24: 30-38, p 388-390, 194930.Ibid Page: 2: 24: 46, p 391, 194931.Ibid Page: 2: 21: 35, p 355, 194932.Ibid Page: 2: 21: 58, p 360, 194933.Ibid Page: 2: 21: 61, p 361, 194934.Ibid Page: 4: 9: 9, p 2792, 194935.Ibid Page: 4: 9: 6-(2), p 2788, 194936.Ibid Page: 4: 27: 1-14, p 2355-2358, 194937.Ibid Page: 4: 28: 72-74, p 2387, 194938.Ibid Page: 2: 19: 4-8, p 324, 194939.Ibid Page: 4: 27: 59-59 and 1/2, p 2369, 194940.Ibid Page: 4: 28: 43-44, p 2380, 194941.Ibid Page: 4: 28: 45-46, p 2380, 194942.Ibid Page: 4: 28: 49-49 and 1/2, p 2381, 194943.Ibid Page: 4: 28: 51-51 and 1/2, p 2381, 194944.Ibid Page: 4: 28: 38-42, p 2379, 194945.Ibid Page: 4: 28: 38-42, p 2379, 194946.Ibid Page: 4: 28: 53-55, p 2379, 194947.Ibid Page: 4: 28: 56-56 and 1/2, p 2383, 194948.Ibid Page: 4: 28: 57, p 2383, 194949.Ibid Page: 2: 19: 4-6, p 323, 194950.Ibid Page: 3: 7: 11-12, p 1567, 194951.Ibid Page: 3: 3: 32, p 1399, 1949