Mahachatushpada Adhyaya

(Sutra Sthana Chapter 10, Chapter on the Four Important Components of Therapeutics)

Abstract

In the preceding chapter, four important aspects of treatment including the best qualities of physician, nursing staff, medicine and the patient were described. This chapter deals with guidelines for healthcare 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 remaining life of the patient, and whether it will be diseased or disease free. Therefore, as the title suggests, the chapter is about four important components of 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. Acharya 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 (maintanence of stable equilibrium or concept of homeostasis).

Sanskrit text, transliteration and english translation

अथातोमहाचतुष्पादमध्यायंव्याख्यास्यामः||१||

इति ह स्माहभगवानात्रेयः||२||

athAtomahAcatuShpAdamadhyAyaMvyAkhyAsyAmaH||1||

iti ha smAhabhagavAnAtreyaH||2||

We shall now expound a detailed chapter on the four important components of therapeutics. Thus, said Lord Atreya.[1-2]

Four components of therapeutics

चतुष्पादंषोडशकलंभेषजमितिभिषजोभाषन्ते, यदुक्तंपूर्वाध्यायेषोडशगुणमिति, तद्भेषजंयुक्तियुक्तमलमारोग्यायेतिभगवान्पुनर्वसुरात्रेयः||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 PunarvasuAtreya.[3]

Maitreya’s observation and query

नेतिमैत्रेयः, किंकारणं? दृश्यन्तेह्यातुराःकेचिदुपकरणवन्तश्चपरिचारकसम्पन्नाश्चात्मवन्तश्चकुशलैश्चभिषग्भिरनुष्ठिताःसमुत्तिष्ठमानाः, तथायुक्ताश्चापरेम्रियमाणाः; तस्माद्भेषजमकिञ्चित्करंभवति, तद्यथा- श्वभ्रेसरसि च प्रसिक्तमल्पमुदकं, नद्यांवास्यन्दमानायांपांसुधानेवापांसुमुष्टिःप्रकीर्णइति; तथाऽपरेदृश्यन्तेऽनुपकरणाश्चापरिचारकाश्चानात्मवन्तश्चाकुशलैश्चभिषग्भिरनुष्ठिताःसमुत्तिष्ठमानाः, तथायुक्ताम्रियमाणाश्चापरे| यतश्चप्रतिकुर्वन्सिध्यति, प्रतिकुर्वन्म्रियते; अप्रतिकुर्वन्सिध्यति, अप्रतिकुर्वन्म्रियते; ततश्चिन्त्यतेभेषजमभेषजेनाविशिष्टमिति ||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

मैत्रेय !मिथ्याचिन्त्यतइत्यात्रेयः; किंकारणं, येह्यातुराःषोडशगुणसमुदितेनानेनभेषजेनोपपद्यमानाम्रियन्तइत्युक्तंतदनुपपन्नं, न हिभेषजसाध्यानांव्याधीनांभेषजमकारणंभवति; येपुनरातुराःकेवलाद्भेषजादृतेसमुत्तिष्ठन्ते, न तेषांसम्पूर्णभेषजोपपादनायसमुत्थानविशेषो[२]

नास्ति; यथाहिपतितंपुरुषंसमर्थमुत्थानायोत्थापयन्पुरुषोबलमस्योपादध्यात्, स क्षिप्रतरमपरिक्लिष्ट एवोत्तिष्ठेत्, तद्वत्सम्पूर्णभेषजोपलम्भादातुराः; येचातुराःकेवलाद्भेषजादपिम्रियन्ते, न च सर्वएवतेभेषजोपपन्नाःसमुत्तिष्ठेरन्, नहिसर्वेव्याधयोभवन्त्युपायसाध्याः, नचोपायसाध्यानांव्याधीनामनुपायेनसिद्धिरस्ति, न चासाध्यानांव्याधीनांभेषजसमुदायोऽयमस्ति[३]

न ह्यलंज्ञानवान्भिषङ्मुमूर्षुमातुरमुत्थापयितुं; परीक्ष्यकारिणोहिकुशलाभवन्ति, यथाहियोगज्ञोऽभ्यासनित्यइष्वासोधनुरादायेषुमस्यन्नातिविप्रकृष्टेमहतिकायेनापराधवान्भवति, सम्पादयतिचेष्टकार्यं, तथाभिषक्स्वगुणसम्पन्नउपकरणवान्वीक्ष्यकर्मारभमाणःसाध्यरोगमनपराधःसम्पादयत्येवातुरमारोग्येण; तस्मान्नभेषजमभेषजेनाविशिष्टंभवति||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]

Some principles of management

इदं चनःप्रत्यक्षं- यदनातुरेणभेषजेनातुरंचिकित्सामः , क्षाममक्षामेण, कृशं च दुर्बलमाप्याययामः, स्थूलंमेदस्विनमपतर्पयामः, शीतेनोष्णाभिभूतमुपचरामः, शीताभिभूतमुष्णेन, न्यूनान्धातून्पूरयामः, व्यतिरिक्तान्ह्रासयामः, व्याधीन्मूलविपर्ययेणोपचरन्तःसम्यक्प्रकृतौस्थापयामः; तेषांनस्तथाकुर्वतामयंभेषजसमुदायःकान्ततमोभवति||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, dosas 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]

Importance of determination of prognosis

भवन्तिचात्र- साध्यासाध्यविभागज्ञोज्ञानपूर्वंचिकित्सकः| कालेचारभतेकर्मयत्तत्साधयतिध्रुवम्||७||

अर्थविद्यायशोहानिमुपक्रोशमसङ्ग्रहम्| प्राप्नुयान्नियतंवैद्योयोऽसाध्यंसमुपाचरेत्||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

सुखसाध्यंमतंसाध्यंकृच्छ्रसाध्यमथापिच| द्विविधंचाप्यसाध्यंस्याद्याप्यंयच्चानुपक्रमम् ||९||

साध्यानांत्रिविधश्चाल्पमध्यमोत्कृष्टतांप्रति| विकल्पो, न त्वसाध्यानांनियतानांविकल्पना||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

हेतवःपूर्वरूपाणिरूपाण्यल्पानियस्य च| न च तुल्यगुणोदूष्यो न दोषःप्रकृतिर्भवेत्||११||

न च कालगुणस्तुल्यो न देशोदुरुपक्रमः| गतिरेकानवत्वं च रोगस्योपद्रवो न च||१२||

दोषश्चैकःसमुत्पत्तौदेहःसर्वौषधक्षमः| चतुष्पादोपपत्तिश्चसुखसाध्यस्यलक्षणम्||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

निमित्तपूर्वरूपाणांरूपाणांमध्यमेबले| कालप्रकृतिदूष्याणांसामान्येऽन्यतमस्य च||१४||

गर्भिणीवृद्धबालानांनात्युपद्रवपीडितम्| शस्त्रक्षाराग्निकृत्यानामनवंकृच्छ्रदेशजम्||१५||

विद्यादेकपथंरोगंनातिपूर्णचतुष्पदम्| द्विपथंनातिकालंवाकृच्छ्रसाध्यंद्विदोषजम्||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 recnt 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. Not clear
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

शेषत्वादायुषोयाप्यमसाध्यंपथ्यसेवया| लब्धाल्पसुखमल्पेनहेतुनाऽऽशुप्रवर्तकम्||१७||

गम्भीरंबहुधातुस्थंमर्मसन्धिसमाश्रितम्| नित्यानुशायिनंरोगंदीर्घकालमवस्थितम्||१८||

विद्याद्द्विदोषजं,...|१९|

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

gambhIraMbahudhAtusthaMmarmasandhisamAshritam| nityAnushAyinaMrogaMdIrghakAlamavasthitam||18||

vidyAddviDoshajaM,...|19|

The palliable group of diseases are characterized as follows:

1. As pre-ordained, 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

...तद्वत्प्रत्याख्येयंत्रिदोषजम्| क्रियापथमतिक्रान्तंसर्वमार्गानुसारिणम्||१९||

औत्सुक्यारतिसम्मोहकरमिन्द्रियनाशनम्| दुर्बलस्यसुसंवृद्धंव्याधिंसारिष्टमेव 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 transcend 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. What prognostic signs? [19-20]

Importance of prognosis

भिषजाप्राक्परीक्ष्यैवंविकाराणांस्वलक्षणम्| पश्चात्कर्मसमारम्भःकार्यःसाध्येषुधीमता||२१||

साध्यासाध्यविभागज्ञोयःसम्यक्प्रतिपत्तिमान्| न स मैत्रेयतुल्यानांमिथ्याबुद्धिंप्रकल्पयेत्||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

तत्रश्लोकौ-

इहौषधंपादगुणाःप्रभवोभेषजाश्रयः| आत्रेयमैत्रेयमतीमतिद्वैविध्यनिश्चयः||२३||

चतुर्विधविकल्पाश्चव्याधयःस्वस्वलक्षणाः| उक्तामहाचतुष्पादेयेष्वायत्तंभिषग्जितम्||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]

इत्यग्निवेशकृतेतन्त्रेचरकप्रतिसंस्कृतेश्लोकस्थानेमहाचतुष्पादोनामदशमोऽध्यायः||१०||

ityagniveshakRutetantrecarakapratisaMskRuteshlokasthAnemahAcatuShpAdonAmadashamo~adhyAyaH||10||

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

Tattva vimarsha

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. 1. easily curable, 2. Curable with some difficulty, 3. palliable and 4. Absolutely irreversible or incurable. (9-10)
3. The following factors should be considered to determine prognosis of disease [ 11-20]

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

In 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 citeria 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.

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. [1] 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 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 addressing mitigating factors causing chronic diseases, such as ishemic heart disease. That appears to be the reason for increasing incidences of autoimmune and degenerative diseases.[2]

The rules and ethics that governed the medical system in the ancient times remain the same even today. A step ahead of the contemporary classification of diseases, Ayurveda advocates 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.

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 or 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 ~ 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) [4-7], Kutaki (Picrorrhiza kurroa)[8],Kiratatikta (Swertia chirata (Roxb.) Buch.-Hum [9-12], Mamejjaka (Enicostema littorale Blume) [13-14] and Pterocarpus marsupium [15-18] 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 Modern 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.

Glossary of Technical Terms

1. चतुष्पादंcatuShpAdaM- Four limbs(four essential components) of therapeutics viz, Physician, Medicine, Attendant and Patient. 2. उपकरणंupakaraNaM- Measures and means used for the management of diseases (Medicine in present context). 3. कर्मैवदैवसञ्ज्ञकंकारणंkarmaivadaivasa~jj~jakaMkAraNaM- Idiopathic causes (in the form of effects of past deeds of that person). 4. जनपदोद्ध्वंस –janapadoddhvaMsan- Epidemiology 5. पथ्यpathya- a specific diet and regimen prescribed during drug therapy based on the principle that drug action is influenced by dietary components and specific regimens. 6. प्रत्याख्येयं – Incurable diseases. 7. परीक्ष्यैवं – Clinical examination 8. yäpyaroga- Diseases havingbad prognosis.The diseases in which remedies applied afford relief to the patient, but within a short span relapse again. Such type of disease can be controlled only at the time of medication. 9. Dhätugatävasthä - A chronic sate of disease. A chronic stage of the disease wherein the vitiated dosa move in to deeper body tissues and thus hampering its prognosis 10. Leenadoshävasthä- Concealed and Opportunistic dosä. The abnormal state of the vitiated doñäwhere in they become concealed in the body channels and remain opportunistic to cause abnormality in the body in presence of a favorable condition. Reference:

1. Laing, Ronald (1971). The Politics of the Family and Other Essays. Routledge. 2. Basisht GK. Symbiohealth-Need of the hour. AYU [serial online] 2011 [cited 2016 Jun 1];32:6-11. Available from: http://www.ayujournal.org/text.asp?2011/32/1/6/85715 3. GBD 2013 Mortality and Causes of Death, Collaborators (17 December 2014). "Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.". Lancet 385: 117–71. 4. Leach MJ. Gymnema sylvestre for diabetes mellitus: A systematic review. J Alter Complement Med 2007; 13: 977-983. 5. Shanmugasundaram ER, Gopinath KL, Radha Shanmugasundaram K, Rajendran VM. Possible regeneration of the islets of Langerhans in streptozocin- diabetic rats given Gymnema sylvestre leaf extracts. J Ethnnopharmacol 1990; 30: 265-279. 6. Baskaran K, Kizar Ahamath B, Radha Shanmugasundaram K, Shanmugasundaram ER.Antidiabetic effect of a leaf extract from Gymnema sylvestre in non-insulin – dependent diabetes mellitus patients. J Ethnnopharmacol 1990; 30: 295-300. 7. Shanmugasundaram ER, Rajeswari G, Baskaran K, et al. Use of Gymnema sylvestre leaf extract in the control of blood glucose in in insulin- dependent diabetes mellitus. J Ethnnopharmacol 1990; 30: 281-294. 8. Joy KL, Kuttan R. Anti-diabetic activity of Picrorrhiza kurroa extract. J Ethnopharmacol. 1999 Nov 1;67(2):143-8. 9. Bajpai M, Asthana RK, Sharma NK, et al. Hypoglycemic effect of swerchirin from the hexane fraction of Swertia chirayita. Plant Med 1991; 57: 102-104. 10. Sekar BC, Mukherjee B, Chakravarti RB, Mukherjee SK. Effect of different fractions of Swertia chirayita on the blood sugar level of albino rats. J Ethnnopharmacol 1987; 21: 175-181. 11. Chandrasekar B, Bajpai MB, Mukherjee SK.Hypoglycemic activity of Swertia chirayita (Roxb ex Flem) Karst. Indian J Exp Bio. 1990; 28: 616-618. 12. Saxena AM, Bajpai MB, Murthy PS, Mukherjee SK. Swerchirin induced blood sugar lowering of streptozotocin treated hypoglycemic rats. Indian J Exp Biol 1993; 31:178-181. Saxena AM, Bajpai MB, Murthy PS, Mukherjee SK.Mechanism of blood sugar lowering by a swerchirin- containing hexane fraction (SWI) of Swertia chirayita. Indian J Exp Biol 1993; 31:178-181. 13. Upadhyay UM, Goyal RK. Efficacy of Enicostemma littorale in type-2 diabetic patients. Phytother Res 2004; 18:233-235. 14. Prince PS, Srinivasan M. Enicostemma littorale Blume aqueous extract improves the antioxidant status in alloxan induced diabetic rat tissues. Acta Pol Pharm 2005; 62: 363-367. 15. Kirana Halagappa, H.N. Girish, B.P. Srinivasan . The study of aqueous extract of Pterocarpus marsupium Roxb. on cytokine TNF-α in type 2 diabetic rats. Indian J Pharmacol. 2010; 42(6): 392–396. 16. Chakravarthy, B.K., Gupta, S., Gambhir, S.S., Gode, K.D. Pancreatic Beta cell regeneration. A novel anti-diabetic mechanism of Pterocarpus marsupium Roxb. Ind. J. Pharmacol. 1980.12; 123-127. 17. Jahromi, M.A., Ray, A.B., Chansouria, J.P.N. Antihyperlipidemic effect of flavonoids from Pterocarpus marsupium. J.Nat. Prod. 1993. 56; 989-994. 18. Ahmad, F., Khalid, P., Khan, M.M., Rastogi, A.K., Kidwai J.R. Insulin like activity in (-) epicatechin. Acta. Diabetol. Lat. 1989. 26; 291-300.