Chikitsaprabhritiya Adhyaya

Chikitsaprabhritiya

Section/Chapter	Sutra Sthana Chapter 16
Tetrad/Sub-section	Kalpana Chatushka
Preceding Chapter	Upakalpaniya
Succeeding Chapter	Kiyanta Shiraseeya
Other Sections	Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana

(Sutra Sthana Chapter 16, Chapter on the Duties of a Qualified Physician)

Abstract

Chikitsaprabhritiya Adhyaya is the last chapter of the Kalpana Chatushka tetrad and describes the traits of a physician proficient in therapeutics, besides the consequences of appropriate as well as incorrect administration of therapeutic procedures, along with corrective interventions wherever applicable. This chapter also describes various indications for therapeutic intervention and their benefits, and questions and answers related the applicability of svabhavaparamvada (i.e. theory of natural destruction of causative factors of disease).

Keywords: Chikitsaprabhrita (equipped physician), bahudosha (signs of aggravated dosha), samshodhana (purification therapy), vishuddha koshtha (purified bowel), svabhavoparamavada (theory of natural destruction).

Introduction

A continuation of the preceding upakalpaneeyadhyayah and elaboration on the remaining aspects of purification processes and their prerequisites which were not fully dealt there. The word ‘prabhruta’ is derived from the verbal root ‘bhr’ which suggests the sense of supporting, nourishing and offering. Thus, chikitsaprabhruta is applied to mean that physician who is well equipped in terms of qualities and instruments and who can play proper supporting role in the management of diseases. The chapter emphasizes upon the need for a proficient and well equipped physician to ensure flawless treatment. The patient is also expected to be intelligent enough to be able to identify a good physician. The word virechana is used often for vamana and samshodhana as well. Clinical features of samyak yoga (appropriate application of a procedure), ayoga (underapplication) and atiyoga (overapplication) - and their management - have also been described. Diseases, their therapeutic response (so that they do not reoccur) and management of post-therapy cachexia have also been addressed in this chapter. Svabhavaparamavada is a phenomenon of natural destruction of health and disease. There is a continuous process of degeneration and regeneration of body tissues. The process of regeneration is known to great extent but the cause of degeneration and death is not known.

Sanskrit text, transliteration and english translation

१६. चिकित्साप्राभृतीयोऽध्यायः चिकित्साप्राभृतीयाध्यायोपक्रमः अथातश्चिकित्साप्राभृतीयमध्यायं व्याख्यास्यामः||१|| इति ह स्माह भगवानात्रेयः||२|| athātaścikitsāprābhr̥tīyamadhyāyaṁ vyākhyāsyāmaḥ||1|| iti ha smāha bhagavānātrēyaḥ||2|| athAtashcikitsAprAbhRutIyamadhyAyaM vyAkhyAsyAmaH||1|| iti ha smAha bhagavAnAtreyaH||2||

Now, we shall expound the chapter on the “Duties of a qualified physician.” (1-2)

चिकित्साप्राभृतो धीमान् शास्त्रवान् कर्मतत्परः| नरं विरेचयति यं स योगात् सुखमश्नुते||३|| यं वैद्यमानी त्वबुधो विरेचयति मानवम्| सोऽतियोगादयोगाच्च मानवो दुःखमश्नुते||४|| cikitsāprābhr̥tō dhīmān śāstravān karmatatparaḥ| naraṁ virēcayati yaṁ sa yōgāt sukhamaśnutē||3|| yaṁ vaidyamānī tvabudhō virēcayati mānavam| sō'tiyōgādayōgācca mānavō duḥkhamaśnutē||4|| cikitsAprAbhRuto dhImAn shAstravAn karmatatparaH| naraM virecayati yaM sa yogAt sukhamashnute||3|| yaM vaidyamAnI tvabudho virecayati mAnavam| so~atiyogAdayogAcca mAnavo duHkhamashnute||4||

A qualified physician is the one who is well acquainted with the principles of treatment, is learned and skilled in the practice of Ayurveda, and is known for promptness of action. A patient obtaining treatment in the form of emesis or purgation from such a physician, becomes healthy and attains happiness. On the other hand, if the patient receives treatment from a pretentious & ignorant physician, he subjects himself to potential complications because of excessive or inadequate treatment. (3-4)

Signs of proper purification: दौर्बल्यं लाघवं ग्लानिर्व्याधीनामणुता रुचिः| हृद्वर्णशुद्धिः क्षुत्तृष्णा काले वेगप्रवर्तनम्||५|| बुद्धीन्द्रियमनःशुद्धिर्मारुतस्यानुलोमता| सम्यग्विरिक्तलिङ्गानि कायाग्नेश्चानुवर्तनम् ||६|| daurbalyaṁ lāghavaṁ glānirvyādhīnāmaṇutā ruciḥ| hr̥dvarṇaśuddhiḥ kṣuttr̥ṣṇā kālē vēgapravartanam||5|| buddhīndriyamanaḥśuddhirmārutasyānulōmatā| samyagviriktaliṅgāni kāyāgnēścānuvartanam ||6||

daurbalyaM lAghavaM glAnirvyAdhInAmaNutA ruciH| hRudvarNashuddhiH kShuttRuShNA kAle vegapravartanam||5|| buddhIndriyamanaHshuddhirmArutasyAnulomatA| samyagviriktali~ggAni kAyAgneshcAnuvartanam ||6||

Weakness, lightness, fatigue, attenuation of diseases, improved taste perception, restoration of the functioning of heart, improved complexion, proper appetite and thirst, timely passage of natural urges, feeling of cleanliness in intellect, sense organs and mind, proper movement of vata, and proper digestion (including metabolic activities) are the signs and symptoms of correctly administered purification therapy. (5-6) Signs of inadequate purification: ष्ठीवनं हृदयाशुद्धिरुत्क्लेशः श्लेष्मपित्तयोः| आध्मानमरुचिश्छर्दिरदौर्बल्यमलाघवम्||७|| जङ्घोरुसदनं तन्द्रा स्तैमित्यं पीनसागमः| लक्षणान्यविरिक्तानां मारुतस्य च निग्रहः||८|| ṣṭhīvanaṁ hr̥dayāśuddhirutklēśaḥ ślēṣmapittayōḥ| ādhmānamaruciśchardiradaurbalyamalāghavam||7|| jaṅghōrusadanaṁ tandrā staimityaṁ pīnasāgamaḥ| lakṣaṇānyaviriktānāṁ mārutasya ca nigrahaḥ||8||

ShThIvanaM hRudayAshuddhirutkleshaH shleShmapittayoH| AdhmAnamarucishchardiradaurbalyamalAghavam||7|| ja~gghorusadanaM tandrA staimityaM pInasAgamaH| lakShaNAnyaviriktAnAM mArutasya ca nigrahaH||8||

Spitting or drooling, abnormal functioning of heart, precipitation (utklesha) of shleshma and pitta, distension of abdomen , anorexia, vomiting, debility, absence of lightness (heaviness or sluggishness), laxity in calf muscles & thighs, drowsiness , feeling as if covered with a wet hide (staimitya), onset of rhinitis and impediment to the function of vata are the signs & symptoms of inadequate purification. (7-8) Signs of excess purification therapy: विट्पित्तकफवातानामागतानां यथाक्रमम्| परं स्रवति यद्रक्तं मेदोमांसोदकोपमम्||९|| निःश्लेष्मपित्तमुदकं शोणितं कृष्णमेव वा| तृष्यतो मारुतार्तस्य सोऽतियोगः प्रमुह्यतः||१०|| viṭpittakaphavātānāmāgatānāṁ yathākramam| paraṁ sravati yadraktaṁ mēdōmāṁsōdakōpamam||9|| niḥślēṣmapittamudakaṁ śōṇitaṁ kr̥ṣṇamēva vā| tr̥ṣyatō mārutārtasya sō'tiyōgaḥ pramuhyataḥ||10||

viTpittakaphavAtAnAmAgatAnAM yathAkramam| paraM sravati yadraktaM medomAMsodakopamam||9|| niHshleShmapittamudakaM shoNitaM kRuShNameva vA| tRuShyato mArutArtasya so~atiyogaH pramuhyataH||10|| Elimination of feces, pitta, kapha, and vata in succession, excessive discharge of blood that looks like fat and flesh (washed), supernatant water or watery excretion of black colored blood without shleshma & pitta, excessive thirst affliction with vitiated vata and fainting are the signs & symptoms of overpurgation. (9-10) वमनेऽतिकृते लिङ्गान्येतान्येव भवन्ति हि| ऊर्ध्वगा वातरोगाश्च वाग्ग्रहश्चाधिको भवेत्||११|| चिकित्साप्राभृतं तस्मादुपेयाच्छरणं नरः| युञ्ज्याद् य एनमत्यन्तमायुषा च सुखेन च||१२|| vamanē'tikr̥tē liṅgānyētānyēva bhavanti hi| ūrdhvagā vātarōgāśca vāggrahaścādhikō bhavēt||11|| cikitsāprābhr̥taṁ tasmādupēyāccharaṇaṁ naraḥ| yuñjyād ya ēnamatyantamāyuṣā ca sukhēna ca||12|| vamane~atikRute li~ggAnyetAnyeva bhavanti hi| UrdhvagA vAtarogAshca vAggrahashcAdhiko bhavet||11|| cikitsAprAbhRutaM tasmAdupeyAccharaNaM naraH| yu~jjyAd ya enamatyantamAyuShA ca sukhena ca||12|| In case of excessive administration of emesis, the symptoms are identical to that observed in the case of purgation. In addition, overemesis may result in diseases of vata, affecting the upper part of the body & also causing impediment of speech. One should therefore approach such a qualified & well-versed physician for the administration of any purification therapy. (11-12) Signs of excess aggravated dosha and indications of purification therapy: अविपाकोऽरुचिः स्थौल्यं पाण्डुता गौरवं क्लमः| पिडकाकोठकण्डूनां सम्भवोऽरतिरेव च||१३|| आलस्यश्रमदौर्बल्यं दौर्गन्ध्यमवसादकः| श्लेष्मपित्तसमुत्क्लेशो निद्रानाशोऽतिनिद्रता||१४|| तन्द्रा क्लैब्यमबुद्धित्वमशस्तस्वप्नदर्शनम्| बलवर्णप्रणाशश्च तृप्यतो बृंहणैरपि||१५|| बहुदोषस्य लिङ्गानि तस्मै संशोधनं हितम्| ऊर्ध्वं चैवानुलोमं च यथादोषं यथाबलम्||१६|| avipākō'ruciḥ sthaulyaṁ pāṇḍutā gauravaṁ klamaḥ| piḍakākōṭhakaṇḍūnāṁ sambhavō'ratirēva ca||13|| ālasyaśramadaurbalyaṁ daurgandhyamavasādakaḥ| ślēṣmapittasamutklēśō nidrānāśō'tinidratā||14|| tandrā klaibyamabuddhitvamaśastasvapnadarśanam| balavarṇapraṇāśaśca tr̥pyatō br̥ṁhaṇairapi||15|| bahudōṣasya liṅgāni tasmai saṁśōdhanaṁ hitam| ūrdhvaṁ caivānulōmaṁ ca yathādōṣaṁ yathābalam||16|| avipAko~aruciH sthaulyaM pANDutA gauravaM klamaH| piDakAkoThakaNDUnAM sambhavo~aratireva ca||13|| AlasyashramadaurbalyaM daurgandhyamavasAdakaH| shleShmapittasamutklesho nidrAnAsho~atinidratA||14|| tandrA klaibyamabuddhitvamashastasvapnadarshanam| balavarNapraNAshashca tRupyato bRuMhaNairapi||15|| bahudoShasya li~ggAni tasmai saMshodhanaM hitam| UrdhvaM caivAnulomaM ca yathAdoShaM yathAbalam||16|| Indigestion, anorexia, corpulence, anemia, heaviness, exhaustion, eruption of pimples and wheals (bumps or itchy sores), pruritis, sluggishness, indolence, weakness, foul smell of the body, lassitude, precipitation (utklesha) of kapha and pitta, sleeplessness or excessive drowsiness, impotency, impediment to intelligence, inauspicious dreams, and loss of strength and complexion in spite of taking nourishing diet and right therapy are the signs and symptoms of patients having excess of morbid doshas. An experienced, skilled physician would advise and administer purification therapy taking into consideration the dosha status and strength of the patient . (13-16) Benefits of purification therapy: एवं विशुद्धकोष्ठस्य कायाग्निरभिवर्धते| व्याधयश्चोपशाम्यन्ति प्रकृतिश्चानुवर्तते||१७|| इन्द्रियाणि मनोबुद्धिर्वर्णश्चास्य प्रसीदति| बलं पुष्टिरपत्यं च वृषता चास्य जायते||१८|| जरां कृच्छ्रेण लभते चिरं जीवत्यनामयः| तस्मात् संशोधनं काले युक्तियुक्तं पिबेन्नरः||१९|| ēvaṁ viśuddhakōṣṭhasya kāyāgnirabhivardhatē| vyādhayaścōpaśāmyanti prakr̥tiścānuvartatē||17|| indriyāṇi manōbuddhirvarṇaścāsya prasīdati| balaṁ puṣṭirapatyaṁ ca vr̥ṣatā cāsya jāyatē||18|| jarāṁ kr̥cchrēṇa labhatē ciraṁ jīvatyanāmayaḥ| tasmāt saṁśōdhanaṁ kālē yuktiyuktaṁ pibēnnaraḥ||19|| evaM vishuddhakoShThasya kAyAgnirabhivardhate| vyAdhayashcopashAmyanti prakRutishcAnuvartate||17|| indriyANi manobuddhirvarNashcAsya prasIdati| balaM puShTirapatyaM ca vRuShatA cAsya jAyate||18|| jarAM kRucchreNa labhate ciraM jIvatyanAmayaH| tasmAt saMshodhanaM kAle yuktiyuktaM pibennaraH||19|| Administration of therapies, leading to elimination of vitiated doshas, results in the following effects: enhancement of digestion / metabolism, pacification of diseases, restoration of normal health, improvement in clarity of sense organs, mind, intellect & complexion, promotion of strength, plumpness, progeny & virility, delayed ageing, and longevity. Therefore, one should take recourse to a skillfully administered purificatory therapy at an appropriate time. (17-19) Prevention of recurrence of disease: दोषाः कदाचित् कुप्यन्ति जिता लङ्घनपाचनैः| जिताः संशोधनैर्ये तु न तेषां पुनरुद्भवः||२०|| दोषाणां च द्रुमाणां च मूलेऽनुपहते सति| रोगाणां प्रसवानां च गतानामागतिर्ध्रुवा||२१|| dōṣāḥ kadācit kupyanti jitā laṅghanapācanaiḥ| jitāḥ saṁśōdhanairyē tu na tēṣāṁ punarudbhavaḥ||20|| dōṣāṇāṁ ca drumāṇāṁ ca mūlē'nupahatē sati| rōgāṇāṁ prasavānāṁ ca gatānāmāgatirdhruvā||21||

doShAH kadAcit kupyanti jitA la~gghanapAcanaiH| jitAH saMshodhanairye tu na teShAM punarudbhavaH||20|| doShANAM ca drumANAM ca mUle~anupahate sati| rogANAM prasavAnAM ca gatAnAmAgatirdhruvA||21|| Morbid doshas relieved by fasting & digestive drugs may sometimes get aggravated again, but those that are evacuated by purification therapies do not recur. Doshas, like plants, if not uprooted completely, would recur or relapse almost certainly. (20-21) Post purification measures: भेषजक्षपिते पथ्यमाहारैरेव बृंहणम्| घृतमांसरसक्षीरहृद्ययूषोपसंहितैः||२२|| अभ्यङ्गोत्सादनैः स्नानैर्निरूहैः सानुवासनैः| तथा स लभते शर्म युज्यते चायुषा चिरम्||२३|| bhēṣajakṣapitē pathyamāhārairēva br̥ṁhaṇam| ghr̥tamāṁsarasakṣīrahr̥dyayūṣōpasaṁhitaiḥ||22|| abhyaṅgōtsādanaiḥ snānairnirūhaiḥ sānuvāsanaiḥ| tathā sa labhatē śarma yujyatē cāyuṣā ciram||23|| bheShajakShapite pathyamAhAraireva bRuMhaNam| ghRutamAMsarasakShIrahRudyayUShopasaMhitaiH||22|| abhya~ggotsAdanaiH snAnairnirUhaiH sAnuvAsanaiH| tathA sa labhate sharma yujyate cAyuShA ciram||23|| For those weakened by purification therapy, restoration of one’s health could be done by prescribing a nourishing diet regimen that would include ghee, relishing soup (including preparations with meat), and milk. The patient should also be advised massage, bath, and evacuative & unctuous enema. This process of purification followed by rejuvenation or restoration of one’s health bestows happiness & longevity to the patient. (22-23) Treatment of excess and inadequate purification therapy: अतियोगानुबद्धानां सर्पिःपानं प्रशस्यते| तैलं मधुरकैः सिद्धमथवाऽप्यनुवासनम्||२४|| यस्य त्वयोगस्तं स्निग्धं पुनः संशोधयेन्नरम्| मात्राकालबलापेक्षी स्मरन् पूर्वमनुक्रमम्||२५|| स्नेहने स्वेदने शुद्धौ रोगाः संसर्जने च ये| जायन्तेऽमार्गविहिते तेषां सिद्धिषु साधनम्||२६|| atiyōgānubaddhānāṁ sarpiḥpānaṁ praśasyatē| tailaṁ madhurakaiḥ siddhamathavā'pyanuvāsanam||24|| yasya tvayōgastaṁ snigdhaṁ punaḥ saṁśōdhayēnnaram| mātrākālabalāpēkṣī smaran pūrvamanukramam||25|| snēhanē svēdanē śuddhau rōgāḥ saṁsarjanē ca yē| jāyantē'mārgavihitē tēṣāṁ siddhiṣu sādhanam||26|| atiyogAnubaddhAnAM sarpiHpAnaM prashasyate| tailaM madhurakaiH siddhamathavA~apyanuvAsanam||24|| yasya tvayogastaM snigdhaM punaH saMshodhayennaram| mAtrAkAlabalApekShI smaran pUrvamanukramam||25|| snehane svedane shuddhau rogAH saMsarjane ca ye| jAyante~amArgavihite teShAM siddhiShu sAdhanam||26||

For those suffering from symptoms of excessive administration or application of purification activities, ingestion of ghee and oil processed with sweet drugs or anuvasana type of enema is prescribed. 

In cases of inadequate administration or application, one should be given oleation therapy followed by evacuative therapy again, considering the dose, time, strength of the patient and factors responsible for inadequate cleansing earlier. Management of disorders arising out of improper oleation, fomentation and purification therapies as well as post- purification dietetic regimen program is described subsequently in the Siddhi section. (24-26) Swabhavoparama vada (theory of natural destruction): जायन्ते हेतुवैषम्याद्विषमा देहधातवः| हेतुसाम्यात् समास्तेषां स्वभावोपरमः सदा||२७|| jāyantē hētuvaiṣamyādviṣamā dēhadhātavaḥ| hētusāmyāt samāstēṣāṁ svabhāvōparamaḥ sadā||27|| jAyante hetuvaiShamyAdviShamA dehadhAtavaH| hetusAmyAt samAsteShAM svabhAvoparamaH sadA||27|| Discordance of the causative factors results in disequilibrium of the tissue elements (dhatus) of the body. Conversely, concordance of tissue elements is restored by means of restoring the concordance of causative factors. However, the resolution / destruction of the existing always happens naturally in the course of time. (27) प्रवृत्तिहेतुर्भावानां न निरोधेऽस्ति कारणम्| केचित्तत्रापि मन्यन्ते हेतुं हेतोरवर्तनम्||२८|| pravr̥ttihēturbhāvānāṁ na nirōdhē'sti kāraṇam| kēcittatrāpi manyantē hētuṁ hētōravartanam||28|| pravRuttiheturbhAvAnAM na nirodhe~asti kAraNam| kecittatrApi manyante hetuM hetoravartanam||28|| There is always a cause for the manifestation of beings but none exists for their annihilation. However, some scholars are of the opinion that the noncontinuance of their causative factors is the very cause of their annihilation. (28) Query by Agnivesha: एवमुक्तार्थमाचार्यमग्निवेशोऽभ्यभाषत| स्वभावोपरमे कर्म चिकित्साप्राभृतस्य किम्||२९|| भेषजैर्विषमान् धातून् कान् समीकुरुते भिषक्| का वा चिकित्सा भगवन्! किमर्थं वा प्रयुज्यते||३०|| ēvamuktārthamācāryamagnivēśō'bhyabhāṣata| svabhāvōparamē karma cikitsāprābhr̥tasya kim||29|| bhēṣajairviṣamān dhātūn kān samīkurutē bhiṣak| kā vā cikitsā bhagavan! kimarthaṁ vā prayujyatē||30|| evamuktArthamAcAryamagnivesho~abhyabhAShata| svabhAvoparame karma cikitsAprAbhRutasya kim||29|| bheShajairviShamAn dhAtUn kAn samIkurute bhiShak| kA vA cikitsA bhagavan! kimarthaM vA prayujyate||30||

The master having thus given his version Agnivesha inquired- if the natural resolution (of disorders) be in the very nature of things then what is the necessity of a qualified physician? Which discordant body elements are harmonized by the physician by means of therapy? After all what does the treatment amount to? And what is its objective? (29-30) Reply by Punarvasu: तच्छिष्यवचनं श्रुत्वा व्याजहार पुनर्वसुः| श्रूयतामत्र या सोम्य! युक्तिर्दृष्टा महर्षिभिः||३१|| न नाशकारणाभावाद्भावानां नाशकारणम्| ज्ञायते नित्यगस्येव कालस्यात्ययकारणम्||३२|| tacchiṣyavacanaṁ śrutvā vyājahāra punarvasuḥ| śrūyatāmatra yā sōmya! yuktirdr̥ṣṭā maharṣibhiḥ||31|| na nāśakāraṇābhāvādbhāvānāṁ nāśakāraṇam| jñāyatē nityagasyēva kālasyātyayakāraṇam||32|| tacchiShyavacanaM shrutvA vyAjahAra punarvasuH| shrUyatAmatra yA somya! yuktirdRuShTA maharShibhiH||31|| na nAshakAraNAbhAvAdbhAvAnAM nAshakAraNam| j~jAyate nityagasyeva kAlasyAtyayakAraNam||32|| Hearing these words from his disciple, Punarvasu responded, “Hear, oh gentle one! The rationale the great sages have given in this respect is that the cause of destruction of entities cannot be comprehended, because no such cause exists, just as in case of time, which is always in the process of swift movement automatically gets destroyed. Being transitory by nature, things perish even as they are born. (31-32) शीघ्रगत्वाद्यथा भूतस्तथा भावो विपद्यते|३३|| निरोधे कारणं तस्य नास्ति नैवान्यथाक्रिया||३३|| śīghragatvādyathā bhūtastathā bhāvō vipadyatē|33|| nirōdhē kāraṇaṁ tasya nāsti naivānyathākriyā||33|| shIghragatvAdyathA bhUtastathA bhAvo vipadyate|33| nirodhe kAraNaM tasya nAsti naivAnyathAkriyA||33|| There is neither a cause for things to perish nor there is a possibility of bringing out a change in the innate tendency of destruction. (33) Definition of chikitsa and duty of a physician: याभिः क्रियाभिर्जायन्ते शरीरे धातवः समाः| सा चिकित्सा विकाराणां कर्म तद्भिषजां स्मृतम्||३४|| कथं शरीरे धातूनां वैषम्यं न भवेदिति| समानां चानुबन्धः स्यादित्यर्थं क्रियते क्रिया||३५|| yābhiḥ kriyābhirjāyantē śarīrē dhātavaḥ samāḥ| sā cikitsā vikārāṇāṁ karma tadbhiṣajāṁ smr̥tam||34|| kathaṁ śarīrē dhātūnāṁ vaiṣamyaṁ na bhavēditi| samānāṁ cānubandhaḥ syādityarthaṁ kriyatē kriyā||35|| yAbhiH kriyAbhirjAyante sharIre dhAtavaH samAH| sA cikitsA vikArANAM karma tadbhiShajAM smRutam||34|| kathaM sharIre dhAtUnAM vaiShamyaM na bhavediti| samAnAM cAnubandhaH syAdityarthaM kriyate kriyA||35|| Therapeutics therefore consists of measures or operations by way of which concordance of the tissue elements can be sustained and this (achieving concordance of tissue elements) constitutes the duty of the physician. Therapy is administered with the sole objective of ensuring that no discordance prevails in tissue elements and that there is sustenance of continued concordance. (34-35).

त्यागाद्विषमहेतूनां समानां चोपसेवनात्| 

विषमा नानुबध्नन्ति जायन्ते धातवः समाः||३६|| समैस्तु हेतुभिर्यस्माद्धातून् सञ्जनयेत् समान्| चिकित्साप्राभृतस्तस्माद्दाता देहसुखायुषाम्||३७|| धर्मस्यार्थस्य कामस्य नृलोकस्योभयस्य च| दाता सम्पद्यते वैद्यो दानाद्देहसुखायुषाम्||३८|| tyāgādviṣamahētūnāṁ samānāṁ cōpasēvanāt| viṣamā nānubadhnanti jāyantē dhātavaḥ samāḥ||36|| samaistu hētubhiryasmāddhātūn sañjanayēt samān| cikitsāprābhr̥tastasmāddātā dēhasukhāyuṣām||37|| dharmasyārthasya kāmasya nr̥lōkasyōbhayasya ca| dātā sampadyatē vaidyō dānāddēhasukhāyuṣām||38|| tyAgAdviShamahetUnAM samAnAM copasevanAt| viShamA nAnubadhnanti jAyante dhAtavaH samAH||36|| samaistu hetubhiryasmAddhAtUn sa~jjanayet samAn| cikitsAprAbhRutastasmAddAtA dehasukhAyuShAm||37|| dharmasyArthasya kAmasya nRulokasyobhayasya ca| dAtA sampadyate vaidyo dAnAddehasukhAyuShAm||38|| By abstaining from factors that give rise to discordance and practicing those that promote concordance, the discordant elements do not persist and concordance is maintained. As the well-equipped physician effects the production of balanced tissue elements by means of his expertise, he is regarded as the bestower of bodily health, happiness & longevity. By virtue of his aptitude to bestow physical happiness & longevity the physician is regarded as the donor of virtue, wealth & desires belonging to this mundane world & the world eternal. (36-38) Summary: तत्र श्लोकाः- चिकित्साप्राभृतगुणो दोषो यश्चेतराश्रयः| योगायोगातियोगानां लक्षणं शुद्धिसंश्रयम्||३९|| बहुदोषस्य लिङ्गानि संशोधनगुणाश्च ये| चिकित्सासूत्रमात्रं च सिद्धिव्यापत्तिसंश्रयम्||४०|| या च युक्तिश्चिकित्सायां यं चार्थं कुरुते भिषक्| चिकित्साप्राभृतेऽध्याये तत् सर्वमवदन्मुनिः||४१|| tatra ślōkāḥ- cikitsāprābhr̥taguṇō dōṣō yaścētarāśrayaḥ| yōgāyōgātiyōgānāṁ lakṣaṇaṁ śuddhisaṁśrayam||39|| bahudōṣasya liṅgāni saṁśōdhanaguṇāśca yē| cikitsāsūtramātraṁ ca siddhivyāpattisaṁśrayam||40|| yā ca yuktiścikitsāyāṁ yaṁ cārthaṁ kurutē bhiṣak| cikitsāprābhr̥tē'dhyāyē tat sarvamavadanmuniḥ||41||

tatra shlokAH- cikitsAprAbhRutaguNo doSho yashcetarAshrayaH| yogAyogAtiyogAnAM lakShaNaM shuddhisaMshrayam||39|| bahudoShasya li~ggAni saMshodhanaguNAshca ye| cikitsAsUtramAtraM ca siddhivyApattisaMshrayam||40|| yA ca yuktishcikitsAyAM yaM cArthaM kurute bhiShak| cikitsAprAbhRute~adhyAye tat sarvamavadanmuniH||41|| Benefits that accrue from the treatment received through a qualified physician as against that received through an unqualified one, the signs and symptoms of adequate, inadequate and excessive administration of evacuative therapies, the signs and symptoms of excessive morbidity, advantages of evacuative therapy, principles of treatment in successful & complicated conditions, the rationale of therapeutics & the intent with which the physician administers the therapy -all this has been described by the sage in this chapter on the “duties of a qualified physician.” (39-41) Thus, ends the sixteenth chapter on the “duties of a qualified physician” of the Sutra segment of the treatise composed by Agnivesha and redacted by Charaka. Here also ends the fourth tetrad on the “Therapeutical Processes.” Tattva Vimarsha: • A skillful physician is critical to the successful administration of a Panchakarma therapy and a patient who can identify such a physician is of equal importance. • The proper administration of purification therapy is important to achive positive health benefits, uprooting the disease and preventing recurrence. • Discordance of the causative factors results in disequilibrium of the tissue elements (dhatus) of the body. Conversely, concordance of tissue elements is restored by means of restoring the concordance of causative factors. • The resolution / destruction of the existing always happen naturally in the course of time. • There is always a cause for the manifestation of beings, but there is no cause for their annihilation. • Ayurvedic treatment is aimed towards creating balance in dosha and dhatus and sustaining it. • The skilled physician should make all efforts to normalize the tissues of the body.

Vidhi Vimarsha: • The physician should be especially skilled in vamana and virechana procedures. • If the patient develops weight loss and debility after purification therapy, he should be given a rejuvenation treatment in the form of a nourishing dietary regimen that includes ghrita (clarified butter), meat soup, milk, appetizing broth, massage and medicated enema. • Treatment for atiyoga involves a regimen of medicated ghrit and an oleation enema with oil prepared from jeevaniya dravya (vitality enhancer drugs). • Treatment for aayoga considers analysing mistakes made in the earlier procedure and repeating the procedure with correct doses or measures of drugs, while factoring in seasonal effects, and the physical constitution of the patient. • Details of the procedures are given in Siddhi Sthana. • The purpose of understanding svabhaavaparamavada is to understand the cause and effect relationship between health and disease. The factors that cause abnormality in tissues, when removed, lead to a healthy state. Ahar (diet) with the same qualities as those of the tissues enhance or strengthen the qualities of the tissues, while diet with opposite qualities will decrease it. Regeneration and degeneration of body tissues is a continuous process. Healthy diet and other regimen help in maintaining longevity. However, the cause of death is unknown. • At the end of the chapter, qualities of a physician skilled in therapeutics are described. Such a physician helps in maintaining the normal tissues and provides a healthy life with longevity so that a person can achieve dharma, artha, kama and moksha.

Further reading: 1. Caraka, Caraka Samhita, Sutra sthana 16, Ayurveda Deepika Commentry of Chakrapani edited by Vd. Jadavji Trikamji Acharya, Chaukhamba Surbharati Prakashan, Varanasi (विरेचयतीत्यत्र वामयतीत्यपि बोद्धव्यं, विरेचनशब्दस्य वमनेऽपि प्रवृत्तेः)| 2. Caraka, Caraka Samhita, Sutra sthana 16/34, Ayurveda Deepika Commentry of Chakrapani edited by Vd. Jadavji Trikamji Acharya, Chaukhamba Surbharati Prakashan, Varanasi (यावता यस्य वस्तुन उचितो योगः स योगः, तस्य स्वल्पो वा योगः सर्वथा वा अयोगो अयोग उच्यते, तस्यैवातिमात्रयोगो ,विकारकरोऽतियोगः, अनुचितसम्बन्धेन तु वस्तुनो मिथ्यायोगः) 3. Caraka, Caraka Samhita, Sutra sthana 16/12, Ayurveda Deepika Commentry of Chakrapani edited by Vd. Jadavji Trikamji Acharya, Chaukhamba Surbharati Prakashan, Varanasi (वमनातियोगे विट्पित्तकफवातानामिति न योजनीयं, येन वमनप्रयोगे कफपित्तानिलागमरूपः क्रमो भवेत्) 4. Susruta, Susruta Samhita, Sutrasthana 41/6, Nibadhasangraha commentry by Dalhana, Chaukhamba Orientelia, 6th edition, Varanasi, 1997 (तत्र, विरेचनद्रव्याणि पृथिव्यम्बुगुणभूयिष्ठानि, पृथिव्यापो गुर्व्यः, तानि गुरुत्वादधो गच्छन्ति, तस्माद्विरेचनमधोगुणभूयिष्ठमनुमानात् वमनद्रव्याण्यग्निवायुगुणभूयिष्ठानि, अग्निवायु हि लघू, लघुत्वाच्च तान्यूर्ध्वमुत्तिष्ठन्ति, तस्माद्वमनमप्यूर्ध्वगुणभूयिष्ठम्; उभयगुणभूयिष्ठमुभयतोभागम्; आकाशगुणभूयिष्ठं संशमनं; साङ्ग्राहिकमनिलगुणभूयिष्ठम्, अनिलस्य शोषणात्मकत्वात्; दीपनमग्निगुणभूयिष्ठं, तत्समानत्वात्; लेखनमनिलानलगुणभूयिष्ठं; बृंहणं पृथिव्यम्बुगुणभूयिष्ठम्; एवमौषधकर्माण्यनुमानात् साधयेत् ||६||) 5. Caraka, Caraka Samhita, Sutra sthana 16/16, Ayurveda Deepika Commentry of Chakrapani edited by Vd. Jadavji Trikamji Acharya, Chaukhamba Surbharati Prakashan, Varanasi बहुदोषस्य लिङ्गानि तस्मै संशोधनं हितम् | ऊर्ध्वं चैवानुलोमं च यथादोषं यथाबलम् ||१६|| 6. Caraka, Caraka Samhita, Vimana sthana 8/89-90, Ayurveda Deepika Commentry of Chakrapani edited by Vd. Jadavji Trikamji Acharya, Chaukhamba Surbharati Prakashan, Varanasi (कार्यं धातुसाम्यं, तस्य लक्षणं | विकारोपशमः| परीक्षा त्वस्य- रुगुपशमनं, स्वरवर्णयोगः, शरीरोपचयः, बलवृद्धिः, अभ्यवहार्याभिलाषः, रुचिराहारकाले, अभ्यवहृतस्य चाहारस्य काले सम्यग्जरणं, निद्रालाभो यथाकालं, वैकारिणां च स्वप्नानामदर्शनं, सुखेन च प्रतिबोधनं, वातमूत्रपुरीषरेतसां मुक्तिः, सर्वाकारैर्मनोबुद्धीन्द्रियाणां चाव्यापत्तिरिति||८९|| कार्यफलं सुखावाप्तिः, तस्य लक्षणं- मनोबुद्धीन्द्रियशरीरतुष्टिः||९०||) 7. Susruta, Susruta Samhita, Sutrasthana 21, Nibadhasangraha commentry by Dalhana, Chaukhamba Orientelia, 6th edition, Varanasi, 1997 (समदोषः समाग्निश्च समधातुमलक्रियः | प्रसन्नात्मेन्द्रियमनाः स्वस्थ इत्यभिधीयते ||४१||) 8. Kashyapa, Kashyapa Samhita, Khilasthana 5/6-7, Chaukhamba Orientelia, Varanasi, (अन्नाभिलाषो भुक्तस्य परिपाक: सुखेन् च । स्रुष्ट्विण्मुत्रवातत्वं शरीरस्य् च लाघवम् ।। सुप्रसन्नेन्द्रियत्वं च सुखस्वप्नप्रबोधनम । बलवर्णयुषां लाभ: सौमनस्यं समाग्निता ।।) 9. Caraka, Caraka Samhita, Sutra sthana 16, Ayurveda Deepika Commentry of Chakrapani edited by Vd. Jadavji Trikamji Acharya, Chaukhamba Surbharati Prakashan, Varanasi (निद्रानाशो वातप्रधानेन दोषेण; अतिनिद्रता श्लेष्मप्रधानेन||१३-१९||

    लङ्घनपाचनाभ्यां रोगकारणीभूतदोषप्रकोपहरणमात्रे कृते रोगो यो निवृत्तः स    
    मूलभूताशयव्यवस्थितदोषानुच्छेदाद्यत्किञ्चिदनुगुणकालादिप्राप्त्या पुनः कुपितदोषेण भवतीति भावः||२०-२१||)

10. Caraka, Caraka Samhita, Sutra sthana 16/21 YN , Ayurveda Deepika Commentry of Chakrapani edited by Vd. Jadavji Trikamji Acharya, Chaukhamba Surbharati Prakashan, Varanasi (प्रसवानां फलपुष्पपत्रादीनां ।) 11. Caraka, Caraka Samhita, Sutra sthana 16/22, Ayurveda Deepika Commentry of Chakrapani edited by Vd. Jadavji Trikamji Acharya, Chaukhamba Surbharati Prakashan, Varanasi (तेन भेषजेन बृंहणं निषेधति, भेषजस्य वीर्यप्रधानस्य तदा दुःसहत्वात् |) 12. Caraka, Caraka Samhita, Sutra sthana 16/28, Ayurveda Deepika Commentry of Chakrapani edited by Vd. Jadavji Trikamji Acharya, Chaukhamba Surbharati Prakashan, Varanasi (यस्मात् सर्व एव भावाः प्रदीपार्चिर्वदुत्पत्तौ ,कारणापेक्षिणः, विनाशे तु

              द्वितीयक्षणाविद्यमानत्वलक्षणे सहजसिद्धे न हेत्वन्तरमपेक्षन्ते; यतो न स्वाभाविकरूपे हेत्वन्तरापेक्षा    
             भवति, नह्युत्पन्नः खङ्गः स्वाभाविके लौहमयत्वे कारणान्तरमपेक्षते; तदेवं सर्वेषामेव भावानां स्वाभाविके   
             नाशे विषमधातूनामपि  नाशः स्वाभाविक एवेति भावः| व्याधिप्रशमे च चिकित्सापेक्षकं पक्षान्तरमाह-  
             केचिदित्यादि| तत्रापि विनाशेऽपि, हेतुं कारणं, हेतोरवर्तनमिति उत्पादकहेतोरभावं, मन्यन्त इति योजना| 
               एवमपि हेतुपरम्परायाः क्षणिकत्वेन तत्कार्याणामपि स्वभावादेव नित्यं  
              सन्निहितस्वहेतुविनाशरूपविनाशहेतूनां न विनाशहेतुचिकित्सापेक्षेति भावः||२८||)

13. Susruta, Susruta Samhita, Sutrasthana 6/13, Nibadhasangraha commentry by Dalhana, Chaukhamba Orientelia, 6th edition, Varanasi, 1997 (तत्र पैत्तिकानां व्याधीनामुपशमो हेमन्ते, श्लैष्मिकाणां निदाघे, वातिकानां शरदि[१]

      स्वभावत एव; त एते सञ्चयप्रकोपोपशमा व्याख्याताः[२] ||१३||) 

14. Vagbhata, Ashtanga Hridaya, Sutrasthana 12/ 24, Chaukhamba Amarabharati Prakashan, 2nd edition, Varanasi, (चय प्रकोप प्रशमा वायोर्ग्रीष्मादिषु त्रिषु । वर्षादिषु तु पित्तस्य श्लेष्मण: शिशिरादिषु )।

Glossary of technical terms  cikitsāprābhr̥t ( chikitsAprAbhRut ; चिकित्साप्राभृत ) :- A fully equipped physician.  bhēṣajakṣapitē (bheShajakShapite; भेषजक्षपिते ) :- Weakened by purifactory medication.  bahudōṣasya (bahudoShasya; बहुदोष ) :- Signs of excessive morbidity.  mēdōmāṁsōdakōpamam ( medomAMsodakopamam ; मेदोमांसोदकोपमम् ) :- Just like the water washed after flesh & fat.  viśuddhakōṣṭh (vishuddhakoShTh ; विशुद्धकोष्ठ ) :- Purified.  vaidyamānī ( vaidyamAnI ; वैद्यमानी ) :- The badly lit who considers him as a Vaidya ; pretentious & ignorant physician.  kāyāgnēścānuvartanam (kAyAgneshcAnuvartanam ; कायाग्नेश्चानुवर्तनम् ) :- Regular peristalsis & restoration of body temperature.  vyājahāra ( vyAjahAra ; व्याजहार ) :- Said.  saṁśōdhanaṁ (saMshodhanaM ; संशोधनं ) :- Purification.  svabhāvōparamaḥ ( svabhAvoparamaH ; स्वभावोपरमः ) :- Natural Resolution.  hētōravartanam (hetoravartanam ; हेतोरवर्तनम् ) :- Non continuance of causative factors.