Mahachatushpada Adhyaya

Sutra Sthana Chapter 10. The four important components of Therapeutics

Mahachatushpada Adhyaya

Section/Chapter	Sutra Sthana Chapter 10
Tetrad/Sub-section	Nirdesha Chatushka
Preceding Chapter	Khuddakachatushpada Adhyaya
Succeeding Chapter	Tistraishaniya Adhyaya
Other Sections	Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana
Translator and commentator	Chandola H.M., Kajaria D.
Reviewer	Gujarathi R., Godatwar P.
Editor	Dixit U., Deole Y.S., Basisht G.
Year of publication	2020
Publisher	Charak Samhita Research, Training and Skill Development Centre
DOI	10.47468/CSNE.2020.e01.s01.012

Abstract

In the preceding chapter, four important aspects of healthcare including the standard qualities of physician, nursing staff, medicine and the patient were described. This chapter deals with guidelines for therapeutic management based on four types of prognosis of diseases. It is important to determine prognosis of a disease before starting the treatment to decide the quality of life of patient, and whether it will be diseased or disease free. Therefore, as the title suggests, the chapter is about four important components of therapeutic management of diseases.
Keywords: Prognosis of diseases, types of prognosis, importance of prognosis in therapeutics, curable, incurable, palliable diseases

Introduction

This chapter describes four types of diseases on the basis of prognosis and emphasizes the importance of knowledge of prognosis for successful management of disease. It is important to assess the prognosis of a patient before initiating treatment. Lord Atreya responds to the queries of Maitreya regarding the role of therapeutics in the eradication of disease and prescribes the four components of Healthcare Management. He suggests that even the most wise physician and the most efficient therapeutic measure cannot prevent or cure an ailment without knowing its prognosis. The chapter gives details of all the factors that are helpful in deciding the prognosis of a disease including Prakriti (body type). Some fundamental principles of management like nourishment therapy, fasting therapy, treating the root cause of disease, hot therapy and cold therapy are mentioned to exemplify the principle of dhatu samyata (maintenance of stable equilibrium or concept of homeostasis).

Sanskrit text, Transliteration and English Translation

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अथातो महाचतुष्पादमध्यायं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

athAtomahAcatuShpAdamadhyAyaMvyAkhyAsyAmaH||1||

iti ha smAhabhagavAnAtreyaH||2||

Now we shall expound chapter "Mahachatushpada" (Four important components of therapeutics). Thus said Lord Atreya.[1-2]

Four components of therapeutics

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चतुष्पादं षोडशकलं भेषजमिति भिषजो भाषन्ते, यदुक्तं पूर्वाध्याये षोडशगुणमिति, तद्भेषजं युक्तियुक्तमलमारोग्यायेति भगवान्पुनर्वसुरात्रेयः||३||

catuShpAdaMShoDashakalaMbheShajamitibhiShajobhAShante,yaduktaMpUrvAdhyAyeShoDashaguNamiti, tadbheShajaMyuktiyuktamalamArogyAyetibhagavAnpunarvasurAtreyaH||3||

According to physicians, therapeutics has four components which have sixteen qualities. The same has been stated in the preceding chapter, therapeutics with these sixteen qualities have the capacity to eliminate diseases, so said Lord Punarvasu Atreya.[3]

Maitreya’s Observation and Query

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नेति मैत्रेयः, किं कारणं? दृश्यन्तेह्यातुराः केचिदुपकरणवन्तश्च परिचारकसम्पन्नाश्चात्मवन्तश्च कुशलैश्चभिषग्भिरनुष्ठिताः समुत्तिष्ठमानाः, तथायुक्ताश्चापरे म्रियमाणाः; तस्माद्भेषजमकिञ्चित्करं भवति, तद्यथा- श्वभ्रेसरसि च प्रसिक्तमल्पमुदकं, नद्यां वा स्यन्दमानायांपांसुधाने वा पांसुमुष्टिः प्रकीर्ण इति; तथाऽपरे दृश्यन्तेऽनुपकरणाश्चापरिचारकाश्चानात्मवन्तश्चाकुशलैश्च भिषग्भिरनुष्ठिताः समुत्तिष्ठमानाः, तथायुक्ता म्रियमाणाश्चापरे| यतश्च प्रतिकुर्वन्सिध्यति, प्रतिकुर्वन्म्रियते; अप्रतिकुर्वन्सिध्यति, अप्रतिकुर्वन्म्रियते; ततश्चिन्त्यते भेषजमभेषजेनाविशिष्टमिति ||४||

NetimaitreyaH, kiMkAraNaM? dRushyantehyAturAHkecidupakaraNavantashca paricArakasampannAshcAtmavantashcakushalaishcabhiShagbhiranuShThitAH samuttiShThamAnAH, tathAyuktAshcAparemriyamANAH; tasmAdbheShajamaki~jcitkaraMbhavati, tadyathA- shvabhresarasi ca prasiktamalpamudakaM, nadyAMvAsyandamAnAyAMpAMsudhAnevApAMsumuShTiHprakIrNaiti; tathA~apare dRushyante~anupakaraNAshcAparicArakAshcAnAtmavantashcAkushalaishca bhiShagbhiranuShThitAHsamuttiShThamAnAH, tathAyuktAmriyamANAshcApare| yatashcapratikurvansidhyati, pratikurvanmriyate; apratikurvansidhyati, apratikurvanmriyate; tatashcintyatebheShajamabheShajenAvishiShTamiti ||4||

Maitreya contradicts and puts query – “What is the reason that some patients managed by proper medicaments, attendants, and well qualified physicians, who are also having self control, soon recover from the diseases? On the other hand, in spite of all these, some die? So therapeutics is of no value (in the eradication of diseases). This is just like a drop of water thrown into a ditch or pond or a handful of dust thrown into a flowing river or on a heap of dust. On the contrary, even without proper medicaments, attendants, good physicians, patients having no self control, recover from the diseases, however others in the similar situation also die. To sum up: It may be said that therapeutic measures or no therapeutic measures, results are the same. For one who is taking recourse to therapeutic measures may sometime succeed in recovering from the diseases and may sometimes die as well. Similar is the case with one who does not pay any heed to therapeutic measures”. [4]

Reply by Atreya

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मैत्रेय !मिथ्या चिन्त्यत इत्यात्रेयः; किंकारणं, येह्यातुराः षोडशगुणसमुदितेनानेन भेषजेनोपपद्यमानाम्रियन्त इत्युक्तं तदनुपपन्नं, न हि भेषजसाध्यानां व्याधीनां भेषजमकारणं भवति; ये पुनरातुराः केवलाद्भेषजादृते समुत्तिष्ठन्ते, न तेषां सम्पूर्णभेषजोपपादनाय समुत्थानविशेषो नास्ति; यथा हि पतितं पुरुषं समर्थमुत्थानायोत्थापयन् पुरुषो बलमस्योपादध्यात्, स क्षिप्रतरमपरिक्लिष्ट एवोत्तिष्ठेत्, तद्वत्सम्पूर्णभेषजोपलम्भादातुराः; ये चातुराः केवलाद्भेषजादपि म्रियन्ते, न च सर्व एव ते भेषजोपपन्नाः समुत्तिष्ठेरन्, नहि सर्वेव्याधयो भवन्त्युपायसाध्याः, न चोपायसाध्यानां व्याधीनामनुपायेन सिद्धिरस्ति, न चासाध्यानां व्याधीनां भेषजसमुदायोऽयमस्ति, न ह्यलं ज्ञानवान्भिषङ्मुमूर्षुमातुरमुत्थापयितुं; परीक्ष्यकारिणो हि कुशला भवन्ति, यथा हि योगज्ञोऽभ्यासनित्य इष्वासो धनुरादायेषुमस्यन्नातिविप्रकृष्टे महति काये नापराधवान्भवति, सम्पादयति चेष्टकार्यं, तथा भिषक्स्वगुणसम्पन्न उपकरणवान्वीक्ष्यकर्मारभमाणः साध्यरोगमनपराधः सम्पादयत्येवातुरमारोग्येण; तस्मान्नभेषजमभेषजेनाविशिष्टं भवति||५||

Maitreya! mithyAcintyataityAtreyaH; kiMkAraNaM, ye hyAturAHShoDashaguNasamuditenAnenabheShajenopapadyamAnAmriyantaityuktaMtadanupapannaM, na hi bheShajasAdhyAnAMvyAdhInAMbheShajamakAraNaMbhavati; ye punarAturAHkevalAdbheShajAdRutesamuttiShThante, nateShAMsampUrNabheShajopapAdanAyasamutthAnavisheShonAsti; yathA hi patitaMpuruShaMsamarthamutthAnAyotthApayanpuruShobalamasyopAdadhyAt, sakShiprataramaparikliShTa evottiShThet, tadvatsampUrNabheShajopalambhAdAturAH; ye cAturAHkevalAdbheShajAdapimriyante,na ca sarvaevatebheShajopapannAHsamuttiShTheran, nahisarvevyAdhayobhavantyupAyasAdhyAH, nacopAyasAdhyAnAMvyAdhInAmanupAyenasiddhirasti, nacAsAdhyAnAMvyAdhInAMbheShajasamudAyo~ayamasti, nahyalaMj~jAnavAnbhiSha~gmumUrShumAturamutthApayituM; parIkShyakAriNo hi kushalAbhavanti, yathA hi yogaj~jo~abhyAsanityaiShvAsodhanurAdAyeShumasyannAtiviprakRuShTemahatikAynAparAdhavAnbhavati, sampAdayaticeShTakAryaM, tathAbhiShaksvaguNasampannaupakaraNavAnvIkShyakarmArabhamANaHsAdhyarogamanaparAdhaHsampAdayatyevAturamArogyeNa; tasmAnnabheShajamabheShajenAvishiShTaMbhavati||5||

To this Lord Atreya remarks, “Oh Maitreya! The conclusion derived by you is not correct. Because, to say that the patients adopting the therapeutic measures having the sixteen qualities die is not borne out of facts. Therapeutic measures can never be ineffective in curable diseases. Similarly, even in such cases where patients are cured without proper medication, it should be understood that had there been proper administration of therapeutic measures the process of cure would have been quicker and better. This can be likened to the lifting of a healthy person who has fallen. He can no doubt get up himself but if he is helped and lifted by another person, he would get up sooner and without much difficulty. Similar is the case with patients stated to have been cured without adequate therapeutic measures. Then there is the case where patients die even by taking recourse to adequate therapeutic measures. It is not that all patients taking recourse to therapeutic measures are necessarily cured because all diseases are not curable. Diseases that are curable can be cured only by taking recourse to therapeutic measures. Those that are not curable will certainly not respond to the treatment and not even the ablest physician is capable of curing the moribund patient. An able physician always proceeds with their treatment after proper examination. As an archer having the knowledge and practice (of archery) shoots arrows with the help of his bow and does not commit mistakes in hitting a massive body nearby and thus accomplishes his object, so a physician endowed with his own qualities and other accessories proceeding with the act (of treatment) after proper examination will certainly cure a curable patient without fail. So it is not correct to say that there is no difference between the application and non-application of therapeutic measures”. [5]

General Principles of Management

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इदं च नः प्रत्यक्षं- यदनातुरेण भेषजेनातुरं चिकित्सामः , क्षाममक्षामेण, कृशं च दुर्बलमाप्याययामः, स्थूलं मेदस्विनमपतर्पयामः, शीतेनोष्णाभिभूतमुपचरामः, शीताभिभूतमुष्णेन, न्यूनान्धातून्पूरयामः, व्यतिरिक्तान्ह्रासयामः, व्याधीन्मूलविपर्ययेणोपचरन्तः सम्यक्प्रकृतौ स्थापयामः; तेषां नस्तथाकुर्वतामयं भेषजसमुदायः कान्ततमो भवति||६||

idaM ca naHpratyakShaM- yadanAtureNabheShajenAturaMcikitsAmaH, kShAmamakShAmeNa, kRushaM ca durbalamApyAyayAmaH, sthUlaMmedasvinamapatarpayAmaH, shItenoShNAbhibhUtamupacarAmaH, shItAbhibhUtamuShNena, nyUnAndhAtUnpUrayAmaH, vyatiriktAnhrAsayAmaH, vyAdhInmUlaviparyayeNopacarantaHsamyakprakRutausthApayAmaH; teShAMnastathAkurvatAmayaMbheShajasamudAyaH kAntatamobhavati||6||

And we see with our own eyes that we cure a patient by taking a recourse to curative therapeutic measures- the depleted body elements by increasing them. We give nourishment to those who are weak and emaciated. We administer reducing therapy to the one who is obese. We treat patients afflicted by heat with cooling measures and the one afflicted by cold with heating measures. We adopt proper measures to replenish the deficient dhatus (tissue elements, doshas and malas) and deplete those that are in excess. We thus bring back the physiological state by treating the diseases with those having opposite properties of causative factors. Thus the group of therapeutic measures gives us the best result in the management of diseases. [6]

Knowledge of prognosis

Consequences of treatment after knowing prognosis

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भवन्तिचात्र- साध्यासाध्यविभागज्ञो ज्ञानपूर्वं चिकित्सकः| काले चारभते कर्म यत्तत्साधयति ध्रुवम्||७||

अर्थविद्यायशोहानिमुपक्रोशमसङ्ग्रहम्| प्राप्नुयान्नियतं वैद्यो योऽसाध्यं समुपाचरेत्||८||

bhavanticAtra- sAdhyAsAdhyavibhAgaj~joj~jAnapUrvaMcikitsakaH| kAlecArabhate karma yattatsAdhayatidhruvam||7||

arthavidyAyashohAnimupakroshamasa~ggraham| prApnuyAnniyataMvaidyoyo~asAdhyaMsamupAcaret||8||

A physician who can distinguish between curable and incurable diseases and initiates treatment in time with the full knowledge (about the various aspects of the therapeutics) can certainly accomplish his objective (of curing the disease). On the other hand, a physician who undertakes the treatment of an incurable disease would undoubtedly subject himself to the loss of wealth, knowledge and fame and will also earn bad reputation and other royal sanctions or punishments. [7-8]

Types of Prognosis

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सुखसाध्यं मतं साध्यं कृच्छ्रसाध्यमथापि च| द्विविधं चाप्यसाध्यं स्याद्याप्यं यच्चानुपक्रमम् ||९||

साध्यानां त्रिविधश्चाल्पमध्यमोत्कृष्टतां प्रति| विकल्पो, न त्वसाध्यानां नियतानां विकल्पना||१०||

sukhasAdhyaMmataMsAdhyaMkRucchrasAdhyamathApi ca| dvividhaMcApyasAdhyaMsyAdyApyaMyaccAnupakramam||9|| sAdhyAnAMtrividhashcAlpamadhyamotkRuShTatAMprati| vikalpo, natvasAdhyAnAMniyatAnAMvikalpanA||10||

Curable diseases are of two types- one that can be cured easily and the other with some difficulty. Similarly, incurable diseases are of two types, viz., one which is palliable and the other which is absolutely irreversible. Again, the curable diseases have three alternants depending upon the moderate and excellent methods required to cure them. This alternative is, however, not possible with regard to diseases which are absolutely incurable. [9-10]

Prognostic criteria for easily curable diseases

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हेतवः पूर्वरूपाणि रूपाण्यल्पानि यस्य च| न च तुल्यगुणो दूष्यो न दोषःप्रकृतिर्भवेत्||११||

न च कालगुणस्तुल्यो न देशो दुरुपक्रमः| गतिरेका नवत्वं च रोगस्योपद्रवो न च||१२||

दोषश्चैकः समुत्पत्तौ देहः सर्वौषधक्षमः| चतुष्पादोपपत्तिश्च सुखसाध्यस्य लक्षणम्||१३||

hetavaHpUrvarUpANirUpANyalpAniyasya ca| na ca tulyaguNodUShyonaDoshaH prakRutirbhavet||11||

na ca kAlaguNastulyonadeshodurupakramaH| gatirekAnavatvaM ca rogasyopadravona ca ||12||

DoshashcaikaHsamutpattaudehaHsarvauShadhakShamaH| catuShpAdopapattishcasukhasAdhyasyalakShaNam||13||

The following are the factors that determine the nature of the diseases which are easily curable:

1. Causes, premonitory symptoms, and other signs and symptoms that are mild,
2. Qualities of dhatus involved are not in common with those of the doshas,
3. Doshas constituting the prakriti (physical and mental constitution) of the patient are not similar
4. The season is not conducive to the growth of the disease
5. The geographical and bodily positions are not conducive to the growth of the disease
6. Location of the disease is confined to only one system
7. Recently originated (not chronic)
8. Having no complications
9. Only one dosha is involved in the pathogenesis of the disease
10. The body is amenable to all kinds of the medicaments and
11. Fourfold therapeutic measures are available. [11-13]

Prognostic criteria for curable diseases with difficulty

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निमित्तपूर्वरूपाणां रूपाणां मध्यमे बले| कालप्रकृतिदूष्याणां सामान्येऽन्यतमस्य च||१४||

गर्भिणीवृद्धबालानां नात्युपद्रवपीडितम्| शस्त्रक्षाराग्निकृत्यानामनवं कृच्छ्रदेशजम्||१५||

विद्यादेकपथं रोगं नातिपूर्णचतुष्पदम्| द्विपथं नातिकालं वा कृच्छ्रसाध्यं द्विदोषजम्||१६||

nimittapUrvarUpANAMrUpANAMmadhyame bale| kAlaprakRutidUShyANAMsAmAnye~anyatamasya ca||14||garbhiNIvRuddhabAlAnAMnAtyupadravapIDitam| shastrakShArAgnikRutyAnAmanavaMkRucchradeshajam||15||

vidyAdekapathaMrogaM nAtipUrNacatuShpadam| dvipathaMnAtikAlaMvAkRucchrasAdhyaMdviDoshajam||16||

Following are the factors that determine the nature of the diseases which are difficult to get cured:

1. Causes, premonitory symptoms and other signs and symptoms are of slightly serious nature
2. The qualities of any one of the kala (season), prakriti (physical including mental constitution) and dhatus (tissue elements) are favorable to the disease (doshas)
3. The person suffering from the disease is a pregnant woman, old, or child
4. There are moderate types of complications
5. The diseases in which treatment, surgery, application of alkalis and cauterization are involved
6. The diseases that are not new could we say chronic disease or diseases not of recent onset?
7. The diseases occurring in vital parts and joints
8. Diseases involving only one system but not fully supported by the four fold therapeutic measures.
9. Diseases extending to two systems but not very chronic, and
10. Diseases that are caused by the vitiation of two doshas. [14-16]

Prognostic criteria for palliable diseases

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शेषत्वादायुषो याप्यमसाध्यं पथ्यसेवया| लब्धाल्पसुखमल्पेन हेतुनाऽऽशुप्रवर्तकम्||१७||

गम्भीरं बहुधातुस्थं मर्मसन्धिसमाश्रितम्| नित्यानुशायिनं रोगं दीर्घकालमवस्थितम्||१८||

विद्याद्द्विदोषजं,...|१९|

sheShatvAdAyuShoyApyamasAdhyaMpathyasevayA| labdhAlpasukhamalpenahetunA~a~ashupravartakam||17||

gambhIraMbahudhAtusthaMmarmasandhisamAshritam| nityAnushAyinaMrogaMdIrghakAlamavasthitam||18||

vidyAddviDoshajaM,...|19|

The palliable group of diseases are characterized as follows:

1. As preordained, the patient has survived for a certain period by following a wholesome regimen and as such has enjoyed a little relief, but even a slightest carelessness might quickly aggravate the condition
2. The disease has affected deep seated dhatus
3. The disease involves a number of dhatus
4. It affects the vital organs and joints
5. It affects the patient continuously for a long time (chronic), and
6. The disease is caused by the vitiation of the two doshas. [17-18]

Prognostic criteria for incurable diseases

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...तद्वत्प्रत्याख्येयं त्रिदोषजम्| क्रियापथमतिक्रान्तं सर्वमार्गानुसारिणम्||१९||

औत्सुक्यारतिसम्मोहकरमिन्द्रियनाशनम्| दुर्बलस्य सुसंवृद्धं व्याधिं सारिष्टमेव च||२०||

...tadvatpratyAkhyeyaMtriDoshajam| kriyApathamatikrAntaMsarvamArgAnusAriNam||19||

autsukyAratisammohakaramindriyanAshanam| durbalasyasusaMvRuddhaMvyAdhiMsAriShTameva ca||20||

Likewise, the following factors would determine the absolute incurability of the disease:

1. Disease caused by the vitiation of all the three doshas
2. Disease that transcends all therapeutic measures
3. Diseases that involves all the systems
4. Disease causing excitement, restlessness and confusion
5. Disease which affects the sense organs
6. The affected person is usually weak and the disease is sufficiently advanced, and
7. The disease having bad prognostic signs. [19-20]

Importance of prognosis

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भिषजा प्राक्परीक्ष्यैवं विकाराणां स्वलक्षणम्| पश्चात्कर्मसमारम्भः कार्यः साध्येषु धीमता||२१||

साध्यासाध्यविभागज्ञो यः सम्यक्प्रतिपत्तिमान्| न स मैत्रेयतुल्यानां मिथ्याबुद्धिं प्रकल्पयेत्||२२||

bhiShajAprAkparIkShyaivaMvikArANAMsvalakShaNam| pashcAtkarmasamArambhaH kAryaHsAdhyeShudhImatA||21||

sAdhyAsAdhyavibhAgaj~joyaHsamyakpratipattimAn| nasamaitreyatulyAnAMmithyAbuddhiMprakalpayet||22||

A wise physician should examine the distinctive features of the diseases first and then start his treatment (only) of the curable diseases. So a physician who can distinguish between curable and incurable diseases, and who possesses the right applications, will not subscribe to the wrong notions prevailing among pseudo- physicians like Maitreya, and say that he will certainly succeed in curing diseases. [21-22]

Summary

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तत्रश्लोकौ-

इहौषधं पादगुणाः प्रभवो भेषजाश्रयः| आत्रेयमैत्रेयमती मतिद्वैविध्यनिश्चयः||२३||

चतुर्विधविकल्पाश्च व्याधयःस्वस्वलक्षणाः| उक्ता महाचतुष्पादे येष्वायत्तं भिषग्जितम्||२४||

tatrashlokau-

ihauShadhaMpAdaguNAHprabhavobheShajAshrayaH| AtreyamaitreyamatImatidvaividhyanishcayaH||23||

caturvidhavikalpAshcavyAdhayaHsvasvalakShaNAH| uktAmahAcatuShpAdeyeShvAyattaMbhiShagjitam||24||

In brief, therapies, prognostic criteria of the disease and its importance in therapeutics, two different views (in this connection) of Atreya and Maitreya, the conclusion, four types of prognosis of diseases and its characteristics are described in this “Detailed chapter on Therapeutics”. Treatment of diseases depends upon these considerations. [23-24]

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इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते श्लोकस्थाने महाचतुष्पादो नाम दशमोऽध्यायः||१०||

ityagniveshakRutetantrecarakapratisaMskRuteshlokasthAnemahAcatuShpAdonAmadashamo~adhyAyaH||10||

Thus ends the tenth “Detailed chapter on four important components of the Therapeutics” chapter of Sutra section of Agnivesha’s work as redacted by Charak.[10]

Tattva Vimarsha (Fundamental Principles)

1. Proper administration of therapeutic measures hastens the process of cure in case of curable diseases. Therefore, correct diagnosis and prognosis at the earliest by the physician is important for getting better results with treatment. [5]
2. The treatment should be aimed at restoring physiological equilibrium. The various ways to bring this equilibrium are to increase the depleted nutrients, nourish those who are weak and emaciated, and reduce the one who are obese, those afflicted by heat with cooling measures and those afflicted by cold with heating measures. Proper measures to replenish the deficient dhatus (tissue elements, doshas and malas) and deplete those that are in excess should be adopted. Thus these therapeutic measures give us the best result in the management of diseases. [6]The diseases can be categorized under four types on the basis of their prognosis viz.
3. Easily curable,
4. Curable with some difficulty,
5. Palliable and
6. Absolutely irreversible or incurable. [9-10]
7. The following factors should be considered to determine prognosis of disease [ 11-20]

Table 1: Factors affecting prognosis of disease

Factors/criteria	Curable		Incurable
	Easily curable	Curable with difficulty	Palliable	Absolutely incurable
Causative factors	Less	More	More	All
Premonitory signs	Less	More	More	All
Severity of signs/ symptoms	Mild	Moderate	Severe	Severe and advanced stages
Dosha involved in disease	Opposite to one’s Prakriti [constitution]	Same as of Prakriti /favorable to disease	Same as of Prakriti /favorable to disease	Same as of Prakriti /favorable to disease
Dushya [body tissues affected]	Opposite to one’s Prakriti [constitution]	Same as of Prakriti /favorable to disease	Same as of Prakriti /favorable to disease	Many tissues, deep seated and Favorable to disease
Place of living of patient	Opposite to one’s Prakriti [constitution]	Same as of Prakriti /favorable to disease	Same as of Prakriti /favorable to disease	Same as of Prakriti /favorable to disease
Season/ time of affection /Age	Opposite to one’s Prakriti [constitution]	Same as of Prakriti /favorable to disease	Same as of Prakriti /favorable to disease	Same as of Prakriti /favorable to disease
Movement of dosha	One sided	Two sided	Many ways for movements	All ways for movements/all systems involved
Duration of onset	New onset	Chronic, but still recent	Very chronic and continuously affecting the patient	Very chronic and continuously affecting the patient
Complications	No	Minor/less complications	Many complications	Many complications with bad prognostic signs
Number of involved Dosha	One	Two	Two	Three
Body	Can tolerate all medicines	Occurred in pregnancy, children, old age	Affecting vital organs, major joints	Weak body, Affecting vital organs, major joints
Nature of treatment	Medicines	Surgical/ agni/ kshara	Continuous treatment needed	transcend all therapeutic measures
Four pillars of management /patients nature	With all qualities of physician, patient, nurse and medicines available	Not with all qualities	The patient lives, get relief for some time after following wholesome regimen and the disease gets triggered after a little exposure to causative factors also	All senses of patients are affected, signs like undue excitement, restlessness, confused state of mind with bad prognostic signs

A wise physician should always consider above factors to determine prognosis of a disease and then start treatment. [21]

Vidhi Vimarsha (Applied Inferences)

Contemporary approach

In the contemporary medical system, the curable and incurable signs and symptoms of diseases are well understood but the criteria for deciding the prognosis are different than Ayurveda. There is availability of advanced technology in the form of imaging, biochemical, immunological, molecular and genetic studies etc. for diagnosis and assessment of prognostic factors of diseases. Inspite of such sophisticated tools, prognostic criteria are limited to diseases only. Overdependence on these studies has caused enormous increase in the cost of medical care. On the other hand, assessment of prognostic criteria of Ayurveda based on understanding Prakriti (body type) with dosha, dhatu, mala, agni, and indriya are for both health and disease. These are entirely clinical and fairly accurate depending upon the clinical acumen of Ayurvedic physician. The concept of personalized medicine known to modern medicine is very limited at this time and is helpful in certain cancers and genetic diseases only. In future, it will be helpful to use a combination of prognostic criteria of both systems to provide better care at less expense.

Medical model and healthcare system

In 1971, the famous psychiatrist R.D. Laing coined a term ‘Medical model’ in his book “The Politics of the Family and Other Essays”, for the set of procedures in which all doctors are trained. This set includes complaint, history, physical examination, ancillary tests if needed for making diagnosis, treatment, and prognosis. The medical model has proven highly successful, and even indispensable, in many contexts. The concepts of "disease" and "injury" are central to this model. An important aspect of the medical model is its focus on the identification of pathology of disease and an attempt to remove or control it (offense strategy). There is less attention paid to the capability of human body to heal itself or understanding what health is and ways to preserve, protect and rejuvenate health. That is why there is no defense strategy in modern medical system to prevent disease. There are vaccinations to prevent certain known infectious diseases and address mitigating factors causing chronic diseases, such as ischemic heart disease. That appears to be the reason for increasing incidences of autoimmune and degenerative diseases.

The rules and ethics that governed the medical system in ancient times remain the same even today. A step ahead of the contemporary classification of diseases, Ayurveda advocates the classification of diseases on the basis of prognosis before applying therapeutic measures as the basis of treatment for restoration of health. There are many diseases that are still incurable and according to medical ethics, it is essential to give proper information to the patient regarding diagnosis, management, and prognosis. Withholding the truth or giving wrong assurance is unethical and punishable. Thus, one should ascertain the prognosis of disease before proceeding with any course of treatment and then share the outcome with the patient.

Changes in prognosis with advanced medical care

Ayurveda holds the view that some diseases are incurable right from the beginning and also provides the details of the factors that cause such diseases. Therefore, it is irrational to apply therapeutic measures for such diseases. However, research shows that incurable diseases such as type-1 Diabetes mellitus (resembling with Vataja prameha) can become less severe with treatment factoring in all prognosis outcomes.

Type-1 diabetes meets all the criteria described above for incurability, like vitiation of all three doshas, affliction of ten dushyas with the nature of involved dosha and dushya are same (kapha dosha and meda dushya) along with Prakriti compatibility of patient (predominance in kaphaja prakriti, like in an obese patient). Again due to genetic predisposition, [[kapha] loses its natural characteristics, becoming liquefied and losing its usual properties. There is vitiation of vata dosha due to depletion of all dhatus, especially oja (the ultimate resultant of all seven dhatu metabolism). The pathogenesis of the disease starts with the admixture of vitiated kapha and meda and progression successively to involve other dhatus like mamsa, kleda etc. The dhatus are depleted so quickly that the body is unable to replenish it, ultimately leading to death. Thus, Diabetes Mellitus, is not merely a disease but a syndrome, proves to be fatal due to many complications like diabetic neuropathy, nephropathy, microangiopathy, cardiomyopathy, retinopathy, skin complications, as well as emergency crises such as hypoglycemic shock and diabetic ketoacidosis. There is successive involvement of all body tissues involving connective tissues, nerve tissues, muscle tissue etc, leading to severe depletion of insulin due to autoimmune degeneration of beta pancreatic cells. Genetic abnormalities cause impaired glucose, lipid and protein metabolism. Type-1 diabetes mellitus is an autoimmune disorder and destruction of body tissues by autoantibody is very fast causing loss of immune- intolerance and immune-component (oja) thus impairing body defense mechanism. There is disturbance in production and clearance of lipoprotein causing hampered functioning of insulin resulting in hyperglycemia and producing microvascular complications like retinopathy and nephropathy. However, for macrovascular complications, including neuropathy, pathogenesis starts before the onset of diabetes i.e. at the stage of lipid abnormalities. These factors make Type 1 Diabetes mellitus difficult to treat. The treatment consists of life-long insulin replacement by exogenous insulin. This is an example of an incurable disease although there is a lot of research work going on to find an effective remedy for this ailment.

Recent research has shown some herbs have effect on beta pancreatic cells to induce endogenous insulin production. Meshashringi (Gymnema Sylvester (Retz.) R.Br.; Gurmar) Kutaki (Picrorrhiza kurroa),Kiratatikta (Swertia chirata (Roxb.) Buch.-Hum , Mamejjaka (Enicostema littorale Blume) and Pterocarpus marsupium have proven to reduce blood glucose levels by modifying the prognostic factors of type 1 diabetes in experimental animals. Thus yearly detection and treatment of an incurable disorder like diabetes mellitus, by means of addressing prognostic factors at an early stage of disease, may prevent the progression of the ailment further into becoming incurable.

This chapter has emphasized the importance of understanding the prognosis of diseases and the factors causing them. Recent research in the field of Ayurveda has shown that incurable diseases can be controlled by addressing the prognostic factors and there is a need for both Ayurveda and contemporary medicine researchers to work together.

Future scope for research

1. Research studies should be conducted to assess the impact of modern medical facilities , geared with sophisticated medical infrastructure, skilled nursing staff, and features to handle emergency services, in controlling the mortality and morbidity of a disease.
2. Data can be collected to estimate the usefulness as well as limitations of therapeutics in the management of curable and incurable diseases.

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