| Section/Chapter/topic | Nidana / Vyadhi / Shatkriyakala |
|---|---|
| Authors | Khandel S.K.1 Baghel M. S.1 |
| Reviewer | Basisht G.2 |
| Editor | Deole Y.S.2 |
| Affiliations |
1Director, ArogyaLaxmi, Jaipur, India 2Charak Samhita Research, Training and Development Centre, I.P.G.T.& R.A., Jamnagar, Gujarat, India |
| Correspondence email: | carakasamhita@gmail.com |
| Date of first publication: | August 31, 2020 |
The diagnosis and therapeutics in Ayurveda are based on clinical observation and assessment. Diagnosis at an early stage of the disease is emphasized, when abnormalities in body-mind functions are vague and non-specific. In current times, the diseases are diagnosed when pathological, biochemical manifestations have surfaced. However, at this stage, many times it is difficult to reverse the pathogenesis and restore health. Clinical diagnosis at an early stage can provide great input to manage a disease and prevent it from being untreatable. More than 30 centuries ago, Sushruta - the father of Surgery in his compendium Sushruta Samhita has given the concept of shatkriyakala (six stages of disease evolution for treatment interventions). In this compendium, after careful study of the inflammatory process in open wounds (vrana)[1], he conceptualized the natural history of disease evolution. The concept of kriyakala (stage of treatment intervention or strategy) describes the mode and stages of the development of the disease. There are six distinct formative patterns or stages of manifestation of diseases. Each stage has its own characteristic symptoms to enable a treating physician to recognize the disturbance at the early formative stage of the disease.
It also helps with prognosis and adopting preventive and curative measures.
Ayurveda advocates that if the deranged dosha is checked or subdued in their primitive evolutionary phase (chayavastha), they may not be able to proceed with subsequent changes. [Su.Sa. Sutra Sthana 21/37][1] However if left unresolved, they may gain strength and intensity. Therefore, good knowledge of the concept of kriyakala (stage of treatment intervention or strategy) is necessary for the recognition of the disease process at an early stage, viz. the stage of accumulation (chayavastha) to arrest further developments.
Six stages of pathogenesis
The six identified stages are as below:
Table 1: Six Stages of Pathogenesis
| Sr.No | Stage | Ayurvedic Term | State of Pathogenesis | |
|---|---|---|---|---|
| 1 | Accumulation of dosha at own site | Sanchaya | Sub clinical observations | |
| 2 | Vitiation at own site | Prakopa | Sub clinical observations | |
| 3 | Spread out through body channels | Prasara | Preclinical observations | |
| 4 | Localization at different sites | Sthan samshraya | Pre monitory features | |
| 5 | Manifestation | Vyakti | Dosha specific general clinical manifestations | |
| 6 | Termination or Culmination | Bheda | Differentiation, Aggression, Complications |
Factors influencing disease evolution
There are three natural dimensions of disease evolution. They should be understood before going into the clinical manifestations.
- Environmental influence on humans in the form of seasonal effects
- Diurnal effects are consequent of transient fluctuations of dosha (circadian rhythm).
- Physiological variations of the body at the level of defense mechanism
Natural cumulative factors of transient fluctuation of dosha
The natural cumulative process of intrinsic factors like tridosha can cause natural remission too, therefore they do not participate in the evolutionary process of a disease.
Table 2: Natural cumulative factors of transient fluctuation of dosha
| Sr.No | Factor | Vata | Pitta | Kapha | |
|---|---|---|---|---|---|
| 1 | Age | Elder age | Youth | Childhood | |
| 2 | Food | Post digestion phase | Intermediate phase of digestion or during digestion | Initial phase of digestion or just after ingestion | |
| 3 | Day time | Evening | Mid-day | Morning | |
| 4 | Night time | Late night | Mid night | Early night | |
| 5 | Season | Summer | Winter | Spring | |
| 6 | Emotions | Grief, lust, fear | Anger, envy | Satiety, inertia | |
| 7 | Tastes | Bitter, pungent and astringents | Pungent, sour and salty | Sweet, salty and sour | |
| 8 | Foods | Bread, dried and preserved foods | Hot, acidic and spicy foods | Sweets and heavy unctuous foods |
Three patho-physiological stages
There are three stages of the natural processes of tridosha pathophysiology described by Charak and Vagbhata.
1. Stage of accumulation (chaya)
Three dosha (bio-energies) increase at their own natural sites beyond the physiological threshold. This may be due to a circadian rhythm or seasonal variations or pre pathological conditions.
2. Stage of vitiation (prakopa)
In this stage, the bio-energies are ready to move out of their natural abode/site. This state may be responsible for all pathological states if remission is not achieved. [ Charak Samhita)
3. (a) Stage of remission (prashama)
At this stage, the excessive accumulation of bio-energies is controlled by natural mechanisms or by dietetic modifications. This happens physiologically if all bio energies (tridosha) return to their natural limits and abodes due to the compliance of a good lifestyle, seasonal regimen, etc. Thus, the process of disease formation is stopped at this stage only.
3. (b) Stage of transmission or spread (prasara)
However, if a person follows an unsuitable diet or excess exercise, or due to provocation by agni, the dosha may transgress from natural sites (koshtha) to peripheral tissues (shakha) [Cha. Sa. Sutra Sthana 28/31]. They may proceed to further stage of disease i.e. stage of transmission or spread to other sites (prasara). At this stage, Vata gets rhythmic acceleration causing transmission of morbid (doshik) materials in channels. [Cha. Sa. Sutra Sthana 28/31]
Six pathological stages of a disease
The six stages of pathogenesis of disease are shown in figure 1.
I. Stage of accumulation (sanchaya)
This is the inceptive phase of a disease when dosha accumulates and stagnate within their natural site of predominance. Vague and non-specific features are diagnosable with minute observations.
Identifying features
- Dullness or fullness of the abdomen due to sluggish digestion is observed due to the accumulation of vata dosha
- The dullness of color and complexion due to accumulation of pitta dosha
- Lower energy and subnormal temperature due to the accumulation of kapha dosha iv. An aversion of similar qualities of dosha and attraction towards opposites
Principle of management in this stage
Avoid “similar” diet and lifestyle, Using “opposites” diet and lifestyle
Example
Fatigue, distended abdomen, loss of appetite occurs at the very early stage of most of the viral fevers even during the incubation period of infections. Primary features are often ignored by the patients and physicians both. Hence the first opportunity of the treatment is lost. If this stage is observed and proper interventions are done, then the disease progression can be prevented or disease with mild symptoms will occur.
II.Stage of vitiation (prakopa)
Previously accumulated and stagnated dosha within their own site are further aggravated and get ready to spread all over the body with the following symptoms:
- Variable pains - by vitiated vata
- Burning & sucking sensation - by vitiated pitta
- Retention of fluids - by vitiated kapha
Management suggested is the pacification of aggravated dosha by use of dissimilar diet or lifestyle.
This is the second opportunity of management if diagnosed at this level. These signs may appear due to the micro inflammatory process in the tissues, which forms the backbone for the disease process.
III. Stage of spread or transmission (prasara)
At this stage there are two possibilities:
III.(a) Remission or prashama
The [[dosha] may return back to normalcy and to their normal sites, and stop further progression, if they are vitiated in the first two stages. Dosha may return to normalcy either naturally (swabhavik) or due to the employment of appropriate therapeutic measures. Thus, leading to the absence of disturbances (vikaras). [A. Hr. Sutra Sthana 12/24][2]
Supportive factors for remission
- Wholesome & beneficial food (hita ahara)
- Daily & seasonal regimen of lifestyle (hita vihara)
- Sensible suitable use of senses (satmya indriyartha)
- Intact intelligence, patience & memory (pragya)
- The empowered state of body mind and digestion (deha bala, chetas bala & agni bala)
- Followings expert’s advice (aptopsevi)
- Charity & truthfulness (data & satyaparata) etc.
III.(b) Spread or prasara
- If above said precautions are neglected, following factors lead to spread of vitiated dosha through the blood circulation.
- Spicy, excessive & incompatible diet
- Strength of body, mind and digestive capacity is less
- Misused senses, and intelligence
- Disease agents (nidana) not avoided
- Remission suspends dosha flow out into circulation and spread over the body
- Thus, this third stage of disease manifestation (3rd kriyakala) is a turning point for the next phase of disease evolution.
- [[Rakta] or blood is the vehicle to carry or spread dosha into the whole body from their normal sites. At this stage, stimulated dosha, circulating in the blood, enter into the tissues/organs/ systems of the body called dhatu.
- The pathway of disseminated dosha is srotas or microchannels.
Features
The features in srotas or microchannels are manifested as:
- Painful distension of abdomen accompanied by rumbling noise & shifting pains - By vata
- Hot flashes, regurgitation and sucking sensations - By pitta
- Nausea and excess salivation - By kapha
Treatment and precautions at this stage
- Avoid antagonistic Diet (viruddhahar)
- Avoid suppression of natural urges (vegavarodha)
- Avoid exhaustive activities, stress, sex
- Avoid adulterants and intoxicants
- Practice daily and seasonal purification
IV. Localization stage at other site (sthansamshraya)
- This is a prodromal stage and symptoms of the disease start to appear but these may be specific or non-specific.
- Provoked and circulating dosha may get localized in specific microchannels/organs/tissues (dosha-dushya sammurcchana).
- These dosha interact with defense mechanism of body - dhatu.
- During invasive interactions of morbid factors, future features of disease may start to appear.
- Morbid disease-producing factors (dosha) as interacting with vital defense mechanisms of body (dhatu) at the levels of transporting and transforming microchannels (srotas)
- At this stage, the disease-causing factors are localized and can be named like – diarrhea and skin disorders (atisara & kushtha)
- At this stage, the vitiated dosha are localized at structural and functional impairments leading to loss of patency of channels.
These structural and functional impairments are called kha vaigunya and are caused by:
- Specific causes for all 13 microchannels
- Genetic predisposition
- Personalized body constitutions
- Personalized mental constitutions
- Organ damaging factors
- Four features of defects of channels viz. increased flow, obstruction, the formation of nodules, and improper direction of movement
Treatment at this stage
- Practice for the avoidance of impairing factors listed specifically for all the 13 major involved channels
- Rejuvenation and protection of the vital organs
V. Stage of manifestation (vyakti)
This is the stage of full manifested disease as a result of invasive interaction of morbid factors into defensive healthy tissues (dosha-dushya sammurcchana) with its characteristic symptomatology. At this stage, the disease can be named properly. This stage is comprised of:
- Weakened digestion– agni,
- Vitiated morbid factors – dosha,
- Impaired micro channels – srotas,
- Debilitating defense mechanism – dhatu,
- Resulting pathologies in organs – avayava
Treatment suggested at this stage
Restoration of normalcy or vikriti vighata:
- Improve digestion
- Restore dosha equilibrium
- Repair the microchannels and organs
- Refresh the carrier (blood)
- Rehabilitation of body tissues
- Non recurrence of disease
VI. Stage of differentiation/ termination (bheda)
This is the stage of differentiation/ termination/ rehabilitation of symptomatology. In this stage, disease becomes sub-acute, chronic, or incurable. When disease further progresses, it may produce complications becoming incurable or severe complications leading to death or may cause temporary/ permanent disability. Otherwise in self-limiting disorders, the disease may get cured itself by body and rehabilitation will be required. This is the last opportunity of the management, where all the possible management is to be applied.
- In this last phase of disease might be restored without disability.
- The importance of recognizing this stage is important for prognosis.
- Recognition of this stage is also important to know the predisposition for further new disease (Nidanarthkaratva)
- In this last stage, disease may lead to temporary/ permanent disability.
- It may advance to in-curability/ complications / death on account of neglect of treatment suggested in earlier stages.
- With strong therapeutic interventions, the health might be restored without disability.
Suggested as rehabilitative therapies or prakriti sthapana
- Prevent/limit the complications
- Prevent genetic transmissions to offspring
- Rehabilitation of disabilities
- Rejuvenation for nonoccurrence of diseases
Summary
Thus the clinical observations, pathological events, treatment interventions and intensity of host:antigen interactions can be summarized as shown in figure 2.
Abbreviations
Cha. = Charak, Su. = Sushruta, Sa. = Samhita, A. = Ashtanga, Hr.= Hridayam