Chikitsaprabhritiya Adhyaya

Chikitsaprabhritiya Adhyaya
Section/Chapter	Sutra Sthana Chapter 16
Tetrad/Sub-section	Kalpana Chatushka
Preceding Chapter	Upakalpaniya Adhyaya
Succeeding Chapter	Kiyanta Shiraseeya Adhyaya
Other Sections	Nidana Sthana, Vimana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana
Translator and commentator	Murthy A.R.V., Magare R.
Reviewer	Galib, Sabnis M.
Editor	Mangalasseri P.
Date of publication	December 17, 2018

Sutra Sthana Chapter 16. Assessment and care in Panchakarma therapies

Abstract

This chapter describes the management of conditions arising during therapies. The assessment of correct and incorrect administration of therapeutic procedures, along with its treatment interventions are described. It also enlists indications for therapeutic intervention and their benefits with details of post therapeutic dietary management. The applicability of the theory of natural destruction of causative factors of disease (svabhavoparamvada) is discussed, that emphasizes need of therapeutic interventions for fast recovery to health.

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

Introduction

In continuation of the preceding Upakalpaniya Adhyaya this chapter elaborates on the remaining aspects of purification processes and their prerequisites which were not fully dealt there.The word prabhrita is derived from the verbal root bhr which suggests the sense of supporting, nourishing and offering. The term, chikitsaprabhrita 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 (under application) and atiyoga (over application), 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

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 "Chikitsaprabhritiya" (Assessment and care in Panchakarma therapies).” Thus said Lord Atreya.[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 and thighs, drowsiness , feeling as if covered with a wet hide (staimitya), onset of rhinitis and impediment to the function of vata are the signs and 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 and pitta, excessive thirst affliction with vitiated vata and fainting are the signs and 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 and also causing impediment of speech. One should therefore approach such a qualified and 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 and complexion, promotion of strength, plumpness, progeny and 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 and 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 and unctuous enema. This process of purification followed by rejuvenation or restoration of one’s health bestows happiness and 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 Siddhi Sthana (i.e., the Siddhi section of this treatise). [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]

Explanation 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 the 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 and longevity. By virtue of his aptitude to bestow physical happiness and longevity the physician is regarded as the donor of virtue, wealth and desires belonging to this mundane world and 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 and complicated conditions, the rationale of therapeutics and 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 Sthana of the treatise composed by Agnivesha and redacted by Charak.

Here also ends the fourth tetrad on the “Therapeutical Processes.”

Tattva Vimarsha (Fundamental Principles)

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 achieve 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 (Applied Inferences)

The physician should be especially skilled in therapeutic emesis vamana and therapeutic purgation 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 ghee, meat soup, milk, appetizing broth, massage and medicated enema.
Treatment for condition of excess purification (atiyoga) involves a regimen of medicated ghee and an oleation enema with oil prepared from vitality enhancer drugs (jeevaniya dravya).
Treatment for condition of insufficient/less purification (ayoga) considers analyzing 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 the theory of natural destruction of causative factors of disease (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. Diet (Ahara) 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. A healthy diet and other regimens help in maintaining longevity. However, the cause of death is unknown.
A skilled physician helps in maintaining the normal tissues and provides a healthy life with longevity. This helps in attaining four objectives of life viz. virtue(dharma), wealth (artha), gratification(kama) and emancipation(moksha).