1. The Stage of Accumulation
The first stage of increase or accumulation of quality or quantity has been described fully in the chapter on Imbalance condition. Stage of decrease or hypo will only manifest the signs and symptoms of deficiency either in space or action, but the stage of increase has far-reaching effects. Increase shall have to be accommo�dated somewhere and the body being a limited space for accommodation or to bear the pressure of the extra matter or power, some irregula�rity or disorder occurs in the body, material increase being a static and localized thing, there may be local increase or growth of the particular tissue, it may disturb the neighbouring tissue and cause Inconvenience by mechanical pressure. But increase and continued accumulation of dynamic force of the triumvirate which are all- pervaisive and whose equilibrium is maintained on a very subtle fulcrum can be tolerated only to a limited stage which does not transgress the threshold of accommodative capacity of pentad of reserve foci. This stage may or may not produce actual disease condition but definitely serves as aid and predisposing condition to trauma or other etiological factors which act as immediate excitant to the triumvirate and herald the vitiation process, and usher in the incursion of disease condition. The general postulate of diagnosis of stages of increase and decrease of the function of triumvirate is described as follows:
"Now the signs of decrease of Vata, Pitta and Kapha are described to be decrease of their respective actions. There may be the loss of their normal functions or even the increase of contrary ones Increase of natural actions is the position indicated in the increase of humors The norm, the decrease and increase of humors are thus diagnosed." (Car Sut 18, 52-53)
Susruta describes some more definite premonitory symptoms when triumvirate imbalance is just on the threshold of vitiation. Recognition of these prodromal symptoms is given all importance by the author who considers this stage as the first or earliest therapeutic period.
�These are the seats of affection. In these the vitia get accu�mulated The cause of accumulation has been already stated. The symptoms of accumulated vitia are: stiffness and fullness of abdomen (due to Vata ), yellow tinge of the skin ( due to Pitta ), low tempe�rature. heaviness of limbs and lethargy ( due to Kapha ) and instinct of repugnance for the causative factors of accumulation of the respective vitia. This is the first stage for treatment.� (Sus. Sut 21, 18)
Careful personal regimen and simple prophylactic measures will ward off completely or to some extent the incidence of disease condition, if the condition is recognised at this stage and treatment started.
II The Stage of Provocation
This is the provocative reaction of the member of the triumvirate. This is generally subsequent to the triumvirate having reached the maximum point of increase or decrease and being at this moment irritated or provoked by an extraneous excitant etiological factor, endogenous or exogenous. This provocative reaction also may occur without previous imbalance condition if the immediate excitat factor is too strong for the triumvirate for adaptive reaction.
Incidence of additional pathogenetic factor to the already over-stressed and imbalanced triumvirate produces baneful poisonous or toxic effect on that body. Triumvirate come easily under the influence of these newly produced toxic effects, imb be them, and get themselves intoxicated and thus become vitiated. Once vitiated, it loses self-control and forgets normal duties and functions. It becomes erratic, irregular, disorganized, abnormal and morbific in function. Saviour of the body becomes the sinner of the body. It becomes a convert and an ally of the enemy. The hero of the physiology begins to play the part of the villain in the drama of pathology. It being itself vitiated, spreads the maleficent effects all over the body and causes vitiation of body-elements or body-channels wherever possible. When fully under intoxication or vitiation effects, it behaves as if possessed by the hostile excitant and does all the harm to its old master, the body.
This tragic conversion of the benevolent triumvirate into malevolent organization is the beginning of real vitiation pathogenesis This provoked condition is indeed the initiation of disease condition and the stage of diffusion, location, manifestation and termination are the further development of the behaviour of the provoked vitium or villa. If at the termination of this pathological process, vitiation effects are encountered successfully and nullified by the body vitality, the triumvirate is extricated from the pathological stage. Triumvirate then returns as the prodigal son and resumes his benevolent role of supporting the body.
Susruta ascribes definite syndromes to the provocation stage of each of the triumvirate, and considers this stage to be the second m importance for the practical therapeutics.(Sutra 21, 27)
Vagbhata�s definition of provocation is still more elucidating. He states
�Provocatian is that stage when a vitium moves in a wrong direction and manifests symptoms of its morbid condition and the feeling of illness denotes the occurrence of disease.� (Ast. Hid 12,23)
III The Stage of Diffusion or Pervasion of Vitiation Process
Susruta strikes an exceedingly astonishing concept when he tries to explain this process of diffusion �Now we shall describe the process of diffusion of vitiation process. Triumvirate provoked by the excitant etiological factors begin to increase just as the combination of rice-flour water and yeast give rise to increase (fermentation). And this increase naturally leads to overflow and spreading in the body�. (Sus Sutra. 21, 28)
Susruta compares this continuous process of increase to the phenomena of growth in yeast fermentation, thus anticipating by two thousand years the great discoverer of bacterial science, Louis Pasteur, who proved the truth of this concept to the world by physical methods. Equally astonishing is the biological postulate of growth and reproduc�tion which in Caraka�s words runs as follows:
�There is no seedling in the absence of seed�.
Which needed Virchow (1855 A. d ) and Flemming (1882 a. d ) to expound it again in the 19th century as important biological laws �Omnis cellula e cellula" and �omnis nucleus e nucleo" respectively and prove it by modern scientific means.
In this spreading stage, if the vitiating effect are too strong, the whole body may be overpowered and general or constitutional disease condition will result.
If the vitiating effects are not so strong as to disable the whole body, it may continue to move in the body, just as clouds do in the sky, till they find sufficient attraction for settling or definite obstruction to proceed further and produce disease condition at that site.
Susruta describes definite syndromes indicative of diffusive stage of each of the triumvirate and considers this stage as the third in importance from the therapeutic point of view (Sutra. 21, 32)
IV. The Stage of Location
This location may occur at any and every place Susruta says:
�Like the cloud in the sky, the vitium showers disease on the entire body or on a half of it or in whatever part or organ it is greatly provoked�� (Sus. Sut 21, 29)
�Affecting either the entire body, or half the body or only one limb or region of the body". (Car. Cik. 21, 7)
Why does it get located at a particular place?
Locus minoris resistentae of the particular system-organ or tissue or obstruction in the body channels may determine the location of the vitiating elements. This locus minoris resistentiae may be due to particular constitution of that system, organ, part or cell or it might be due to biological inferiority in growth or it might have been caused by damage to them, by previous trauma, stress, disease, or otherwise.
Susruta explains the reason of Location thus:
�Wherever the all-pervading vitia in their provoked state come into contact with an organ or tissue or part that is already impaired and hence susceptible, there occurs disease-phenomenon�. (Sus. Sutra 24, 10)
Caraka also states in the same way the reason of location in one place.
�The vitium pours down its vitiating element whenever it contacts a susceptible spot and causes disease condition there as a cloud pours down rain in a favorable region. This is the mode of local provocation of vitia.�� (Car. Cik 15, 37)
This stage of location is of great clinical importance for early diagnosis of disease condition.
Vitiation elements having attained foot-hold somewhere get gradually established therein and produce symptoms which will be indicative not only of the vitiation of the particular vttium or vitia, but also will be indicative of location or site where vitiation process has begun to spread. These combined symptoms help to localize the site of disease-condition. Susruta, the master clinician, differentiates the symptoms produced during this stage of location of vitiation process as the definite premonitory symptoms�����
�The premonitory symptoms manifest when the vitiation process is located From them the disease is recognised This is the fourth stage of therapeusis. �� (Sus Sat 21, 33)
And this stage of location manifested clinically by definite premonitory symptoms is the fourth period of importance for therapeutic purpose.
V. The Stage of Manifestation
Vyakti is the stage of manifestation of actual disease condition. Susruta correlates this pathological stage with the actual appearance of clinical phenomena of the disease.
��We shall hereafter describe the actual manifestation of disease�
This disease condition may be a general disease or a syste�matic disease, or a disease of one part or limb according to the location of settling and establishing of the vitiation elements. This is the beginning of organic or structural changes in the body.
The disease-cndition may be classified in two groups general or local and both these groups, can again be subdivided into acute and chronic types.
1. Acute types
If the vitiation elements are too strong, time and place very favourable to them, and the body constitution very weak or susceptible to disease condition, vitiation or morbific process spreads over the entire body very abruptly and the body is overpowered immediately. The body then succumbs completely and passes in full vitiation stage to be followed generally by dissolution.
Such conditions are described by Caraka as follows.
�O Worshipful one! I see in the bodies of human beings a fell disease which spreads with the virulence of snake-venom. Those men who are attacked by this fulminating disease succumb to it speedily, unless treated promptly Now concerning this disease, we are m great need of enlightenment� (Car Cik. 21, 6-7)
If after the immediate stunning, stupefaction and vitiation, the vital power of the body rises to the occasion and rallies all his anti-forces or antibodies to save the situation, and extraneous factors of time and environment become helpful to the body, the issue takes the reverse turn and vitiation process becomes lessened and if the counter-action will continue successfully, the body with its triumvirate organization becomes free from vitiation altogether and the man survives. (Car Cik 6 54-56)
2 Chronic types
The general disease condition may have periodical or chrome clinical course if the fighting forces on either side are nearly of equal strength. Fighting forces are vitiation elements versus body-constitu�tion and body-elements, season, time and other environmental factors may be helpful to either side. Fluctuation in the strength of either side of the fighting forces or supporting help from extraneous sources may cause abatement or aggravation of the disease condition. Such kind of warfare continues for a long time till one side gets sufficiently powerful to subdue the other Caraka describes such oscillations in disease condition as under:
"The morbid toxic factors having opposition from the anti-bodies, cause remittent fever which periodically rises and remits.� (Car. Cik. 3, 62)
B Local Disease Condition
If the vitiation process locates and gets established in a localized area, organ or tissue, the same phenomenon of encounter occurs but on a smaller scale and in limited space. Such localized reaction may also occur in the body without the previous internal vitiation process if that local part receives a powerful trauma physical, chemical or biological from external source. These exogenous etiological factor are tenned Agantuka to be differentiated from the endogenous ones which are termed Nlja. A long list of such exogenous and endogenous etiological factors is given in Caraka Samhita. (Car Sutra 18, 4 and 6)
The differential diagnosis between disease conditions produced by endogenous causes and by exogenous causes is described by Caraka as under:
The exogenous one begins with pain and later on leads to the discordance of Vata, Pitta and Kapha. But in the endogenous one, discordance of Vata Pitta and Kapha occurs first and later of gives rise to pain. (Car. Sutra 20, 7)
Fight in a localized area of the body has the advantage of receiving great help from the body in general. The entire body concentrates all his fighting forces at the war-site to give a regular pitched battle.
The local concentration of warfare phenomena makes the localization of disease area an easy task to the clinician. When the regular pitched battle is decided at the site, all fighting forces and equipment are brought and concentrated at the spot. Thus the part becomes enlarged and appears swollen. There is an acute stage of whole atmosphere. All these signs of local warfare are easily observed by the clinician. It is a happy coincidence to find that the ancient clinicians both of the east and west have grouped these clinical appearances in four groups and described them as the classical signs of such local warfare reaction
Caraka describes as follows �
�The swelling which is characterized by pain, burning, redness and pricking pain should be diagnosed to be a suppurated swelling�� (Car Cik. 25, 52)
Similarly Celsus in A. D 50 described calor, rubor, tumor and dolor as four cardinal signs manifesting the local phenomena of inflammatory reaction. Caraka considers swelling (tumor) as the pathognomic of such conditions.
��It causes edema with its pathognomic symptoms of swelling". (Car Cik 12, 8)
� It is marked by steady swelling, so it is edema with swelling�� (Commentary by Cakrapani).
And so such conditions are termed or in Ayurveda.
Susruta calls this local phenomenon of swelling as ________ .(Sus Sutra 17-3)
Clinicians in Greece gave dominance to the other signs viz, redness and heat and called this local phenomenon as inflammatory reaction, redness and heat being the qualities of the �flame.
This difference in dominance of particular signs in two countries may be an interesting subject to the student of ethnology. As race with Kapha constitution will react with swelling as more prominent sign and race with Pitta will have heat and redness as more dominant signs.
(1) Acute inflammatory conditions.
The same process as it occurs in general disease condition takes place in localized disease condition but on a smaller scale.
It has the advantage of getting help from the body but it may put the whole body to a disadvantage if vitiation or morbific elements get an upper hand and crossing the limit of war-area spread in the neighbouring parts or in the whole body.
These are described as complications of local inflammatory reactions. Caraka mentions the following complications:
�Acute spreading affection, hemiplegia, vascular thrombosis, convulsions, stupefaction, insanity, acute pain in the wound, fever, thirst, lock-jaw, cough, vomiting, diarrhea, hiccup, dyspnea and tremors are the sixteen complications of wounds, described by the specialists m the subject of wounds�. (Car Cik. 25, 29-30)
The local disease conditions terminate in the same way as the general disease condition. But the results are less serious ReBolu tion and dissolution of the local part indicate the success or failure of the body in the encounter.
(2) Chronic Inflammatory Condition:
When the fighting forces are nearly equi-balanced, Prolonged war with fluctuation on either side continues till some decisive factor comes in aid of either party and concludes the scene of warfare. This is considered the fifth best of the therapeutic period. Though it is late, it is better than too late which is the sixth or last period of treatment as the terminating stage of the disease.
We shall now give some of the comparative data of descri�ption of such local inflammatory processes found in Ayurveda and modern medical treatise.
Inflammation - Variation in Intensity of Classical signs is due to the Domineering Action of Particular Vitium
Celsus in A. D 50 described the four cardinal signs mani�festing the local phenomena of inflammatory reaction. They are calor, rubor, tumor and dolor and they were co-related with the four humors of the microcosm i. e, body-constitution, the four corner stones in the humoral pathology of Hippocrates these were again correlated to the four proto-elements of the macrocosm i. e. the world as described by the philosopher-physician Empedocles who regarded these four proto-elements as the roots of all things.
In India macrocosmic and microcosmic concept was of a triad, but practical surgeons often found blood which is rather a structural system more convenient and useful in diagnosis and treatment specially of local disease-conditions. Susruta thus tried to give nearly the same status to blood as to triumvirate and described four categories
�The diseases pertaining to the body have their origin in blood and drink ingested on account of the vitiation and discordance of Vata, Pitta, Kapha and he Blood'. (Sus Sut 1, 25)
While commencing on (his verse, Dalhana gives the following explanation for including Blood in the categories of constitutional classification
�The Blood is included because in a wound there is the dominance of blood among the vitia�. (Commentary by Dalhana)
Susruta clarified this point by stating that blood is secondary to and dependent upon the primary triumvirate of vitial categories,
�Because the blood is never provoked without the vitia (Sus Sut 21, 25)
Blood is included under the Pitta category when the three vitial categories are taken in consideration.
�That born of Blood is like that of Pitta.�
�That born of Blood is to be known like that of Pitta."
It is really interesting to find that equal importance is given to the description of inflammation in Susruta Samhita, a treatise on Surgery, as is done in the modern surgical text books. In both we find that the description of diseases is initiated with this subject and a large number of chapters is devoted in each to give detailed and exhaustive description of this inflammatory phenomenon in general. Nearly 1/15 of the text in each, deals with this pathological process alone. Susruta concludes this subject by generalization of the local pathological process in the following words.
�This summary of the types of pain and color is not limited to wounds but is applicable to all types of inflammation. Hence the physician should regard all inflammations like wounds."(Sus. Sut. 22, 13)
Classification of a subject may be made from various points of view to help the understanding of the subject. Modern surgical text books classify inflammation generally in the following types:
A Acute or subacute
B Acute or Chronic
C Parenchymatous or Interstitial
D. Serous-Catarrhal-Fibrinotis-Hemorrhagic or Suppurative
These classifications are done either according to the intensity of the process, or to the tune it takes to develop, or according to the tissues it attacks or the exudation which it gives rise to Ayurveda classifies the inflammation in three groups of constitutional triumvirate.
This triumvirate classification has greater significance in clinical diagnosis and practical therapeutics It is done from clinical- pathological-cum-physiological point of view.
If the etiological factor is excitant of a particular vitium, or any particular vitium of the constitution is predisposed to disease condition, the signs and symptoms characteristic and pathognomic of that particular vitium will be more dominant than the signs of other two vitia.
If two vitia are dominant and acting in combination, signs of two will be manifested dominantly. If all three, all signs will be aggravated.
The pathognomic signs of each of triumvirate are as follows:
�There is no pain without Vata, and burning without Pitta and no swelling without Kapha, nor is there redness and suppura�tion without blood. These are the respective signs of the vitia and the blood� (Ast. Hrd Sutra 29, 6)
Pitta and blood�heat and redness (rudor) (calor)
These four signs correspond very closely to the triple response of Thomas Lewis. It is the clinical experience of every physician and surgeon that there is wide variation in intensity and rate of development of these classical signs. This can be well explained if we understand the full concept of Vaso neurotic constitution.
The phenomenon of inflammatory reaction is the resultant of the action of etiological excitant and reaction of Vaso-neurotic constitution. Threshold of contraction and dilatation of arterioles and capillaries vary in each individual and also the capillary permeability. This is due to Vaso-neurotic individual constitution.
Thus Vaso-neurolic constitution of the individual plays an important part in the phenomena of Inflammation, Krogh while describing the Vaso-neurotic constitution declares:
�I shall say, finally, a few words about the so-called Vaso- neurotic constitution."
It is characterized by the great lability or downright instabi�lity of the innervation of the vascular system which manifests itself in the capillaries as well as in the arteries. Frequent changes in the lunervation occur either spontaneously or from comparatively trivial causes.�
The redness is brought about by opening up and dilatation of capillaries and venules, the heat by the increased flow of blood due to dilatation of arterioles, and the SWEEPING by exudation of fluid from vessels due to their increased permeability, and the PAIN finally by the stimulation of nerves.
Though these reactions occur in the interest of the body it is possible that some of the reaction if occurring in excess may often be harmful, similarly some occurring poorly may not be of effective use. The knowledge of constitutional tendency of the man as a whole as of the Vaso-neurotic constitution of the local organ or part affected and also of the particular exciting action of the etiological factors may help to control or rectify this protective and restorative reaction to the best advantage of the body. Here is the need of the study of the constitutional triumvirate. Triumvirate concept may open up a subtler field of research in the action of etiological factors as well as behaviour of body tissues.
VI The Stage of Termination
This is the end or termination of the vitiation process. In general disease-condition the person may completely recover. If his body vitality can counteract the incursion successfully or may suffer dissolution if the invading forces are too powerful for his body vitality.
If any of them is not able to subdue the other totally and bring about decisive conclusion, the disease condition may persist for a prolonged period.
Similarly in local disease condition too, there may occur complete resolution or dissolution or death of the local part (Necrosis, gangrene or ulcer). Local disease condition has one special method of termination and disposal or elimination of waste or morbified matter. It is the process of suppuration.
�It tends to suppurate if it is not possible to sedate it by special external or internal treatment, or if the treatment given is wrong or if the morbidity is in excess.� (Sus Sut. 17, 5)
This will end in producing the condition of wound. If the conclusive termination is not brought about by either party being subactive and not able to subdue totally the other, the chronic inflammatory condition or chronic wound condition such as fistula or sinus my continue for a long period.
This is the last or sixth stage of therapeutic period advised by Susruta. The description of various stages of vitiation pathology ends with a verse that explains the reasons of thorough study and diagnosis of each stage from practical therapeutic point of view. Treatment started in the earlier stage will be easier and simpler than if started late when vitiation process has gained strength and intensified.
��Vitiation process checked or subdued in the accumulation process, fails to produce any further development, but allowed to progress, it gains in strength and intensity in the course of its further development." (Sus Sutra 21, 37)
The principles of treatment during the vitiation process are formulated primarily with a view to eliminate or get rid of the vitiated morbid matter resulting from the pathological processes and accumulated in the body. For the purpose of such elimination, the neatest and simplest outlet or body channel was chosen. Thus came into practice the treatment known as the pentad of eliminatory or purificatory procedures.
�These drugs should be used as emetics by the physician, in way not harmful to the body, in gastrogenic disorders characterized by morbid accumulation of Kapha and Pitta" (Car Sut. 2, 8)
� should be prescribed for purgation when the morbid humors have accumulated in the colon.� (Car. Sutra 2, 10)
This purificatory therapy was put into operation in a rather strong degree in order to accomplish the complete elimination of the morbid matter. The procedure required that the body be previously prepared, before undergoing such a strong method of treatment, by oleatlon and sudation procedures. These procedures facilitated the easy elimination of morbid matter. Caraka says :
�Oleation cures the morbidity of Vata, makes the body soft and disintegrates the accumulation of morbid matter, while sudation liquefies the morbid matter which is stuck up in the minute channels of the body of the person who has undergone oleation therapy.� (Car Siddhi 1, 7)
When the body is found to be not fit and intolerant of such a radical treatment, the line chosen was to bring about the gradual digestion of the morbid matter, a concept so similar to the detoxication conjugation concept of modern physiology. The liver is believed to play an important part in protecting the organism from various toxic substances. This detoxifying function is believed to involve the process of oxidation and conjugation into relatively non-toxic substances which are subsequently eliminated in the bile and the urine
�In the early stage of fever starvation, sudation, time-effect, diet of gruels and articles of bitter taste, digest the imperfectly digested morbid matter in the body�. (Car Cik. 3, 142)
After the complete riddance from morbid matter, the treatment consists in supplying the deficit and strengthening the body vitality by drugs as well as dietetic regimen. This process is called rehabilitation. (Car Sutra 15, 16)
Some more Concepts of Pathological Conditions or Processes in Ayurveda
We shall now review briefly the concepts the ancients held regarding the following pathological conditions or processes.
1. �The concept of epidemic and pandemic diseases
2. �The concept of sources and spread of infection or contagion.
3-4. The concept of growth and multiplication of morbific elements m the body and their mode of spread and action.
5. Certain abnormal conditions of the body-appearance
The Concept of Epidemic and Pandemic Diseases
In epidemic diseases they observed that the constitution of the body is not able to play any part in counter-acting the incursion of infesting elements. The etiological factor has all the voice in the disease-phenomena. Hence the uniformity of symptoms and clinical courses observed as the etiological factor, is uniform. Constitution which is an individual concern is out of game, hence very little individual variation can occur in the clinical picture and course of the disease. In chrome diseases, individual constitution is able to create resistance and in such condition pronounced individual differences in the clinical course can occur
Caraka Samhita devotes one chapter to explain the concept of Epidemiology (Vimana 3). It is a thought provoking concept and probably progress in radiation physics may be able one day to find the equivalence in value between the physical and spiritual universe and rediscover the truth laid down by Atreya.
We shall cite now the passages that explain the reasons why a large number of people are affected by a common ailment at one and the same time and why there is uniformity of clinical course of disease in spite of the individual variations of constitution in men and what are the main sources of such ailments. Caraka in Vimana 3 treats the subject thus.
"5 But, how does the simultaneous destruction of commun�ities, consisting as they do of individuals who differ from one another in constitution, diet, physique, vitality, habits, psychic make-up and age, take place by the incidence of one single disease?
6-(i) Unto him replied the worshipful Atreya, O, Agnivesa! though a community may be heterogeneous in respect of the constitution etc, of its individual members, there are other common factors which being adversely affected will cause simultaneous outbreak of diseases having similar symptoms. It is these that devastate whole populations.
6. The factors that affect a people in common are: the winds, the waters, the country and the seasons.
 (l) of these, the wind, if of the following description, is to be known as disease-inducing viz. unseasonal, totally becalmed, violently blowing, exceedingly rough, intensely cola, intensely hot, excessively dry, excessively humid, fearfully clamorous, blowing from contrary directions and clashing with itself, extremely rotatory (whirlwind), and charged with unwholesome odors, moisture, sand, dust and smoke.
7-(ii). The water of the following description is to be known as bereft of virtue, having an extremely aberrant smell, color, taste and touch, abounding with putrescent matter, deserted by aquatic birds, in which the aquatic creatures are atrophied and which is unpleasant.
7 (iii) The country of the following description is to be known as unwholesome, having color, taste and touch that are unnatural, excessively damp, abounding in serpents beasts of prey, mosquitoes, locusts, flies mice, owls, birds and animals such as the jackal and abounding in woods of weeds and Ulupa grass, abounding in creepers where crops have either fallen, withered or been destroyed in an unprecedented manner, where the winds are smoky, where the sound of birds is unceasing; where the baying of dogs always assails the ears where herds of animals and flocks of birds of various kinds are always in a state of alarm and pain; where amidst the people, morality, truth, modesty, custom, character and virtue have either declined or been given up, where the waters are always agitated and upheaving, which is frequently subjected to the incidence of meteorites thunderbolts and earthquakes, where nature is full of menacing sounds and sights, where the sun, the moon and the stars are frequently covered by dry, coppery, ruddy and grey clouds and which lastly, is as if full of constant alarm and lamentation, crying, fright and darkness as if visited by gnomes, and as if abounding in sounds of lamentation
7 (iv). A season which is of the following description is to be known as unwholesome; evincing characteristics that are opposite to normal, or evincing its characteristics in an excessive or deficient degree.
 The learned declare these very four factors when possessed of the morbidity described above, to be destructive of populations, when not so blemished they are said to be wholesome.
8. But even when these depopulating factors have turned inauspicious, there is no fear of diseases to those persons who are served with medicines that have been culled beforehand.
12 Even if all the four factors including Time, become vitiated, as long as men are sustained by medicines, so long will they remain free of disease.
14 For them moreover, the rightful use of vitalizing medications is recommended, the maintenance of the body by means of the medicinal herbs culled beforehand is also commended (Car. Vimana 3, 5- 14)
2 The Concept of Sources and Spread of infection or Contagion
A Sources of Infection or Contagion
Regarding the sources of infection in epidemic diseases Caraka lays down that the wholesale vitiation of the air, water, country and season are the sources of vitiation.
��The factors that affect a people in common are the winds, the waters, the country and the season.� (Car. Vim. 3, 6)
"The learned declare these very four factors when possessed of the morbiditv described above, to be destructive of populations, when not so blemished, they are said to be wholesome." (Car. Vim 3, 7)
Susruta states that epidemic diseases spread from man to man.
�Dermatosis, fever, consumption and eye-sore are infectious diseases and spread from man to man.�� (Sus Sutra 5, 34)
3. Concept of Growth and Multiplication of Morbific elements in the Body And their Mode of Spread and Action
Susruta compares the growth of vitiating elements to yeast fermentation which has already been explained in the chapter of vitiating pathogenesis (Sus Sutra 21, 28). Here the simile of yeast fermentation used to explain the increase of growth of morbific elements is quite suggestive.
Caraka seems to have a clearer awareness of the biological factor involved fn the vitiating elements. He refers the phenomenon of the periodicity of fever to the recurring cycles of growth, spread, spending itself out and withdrawal of the vitiating element. This description agrees fully with the cycle of evolution of malarial parasite in the human body. Caraka illustrates this by using the simile of the seed and the soil.
�Just as the seed lies dormant in the soil and germinates in season, in the same manner the toxic matter lies quiescent in the body-element and flares up when the time is ripe.
Thus the morbific factor gathering strength and biding the propitious time, manifests itself as the tertian or the quartan fever as soon as the disease-resisting power in the body is lowered
In this manner, the disease-generating factors, having worked themselves out, lapse into quiescence and retire to their respective stations in the body, then mustering up their strength, once again, these toxic elements afflict the patient with fever at their own ripe times.� (Car Cik 3, 68-70)
As the seed begins to grow at its proper time so does the morbid factor. Morbid factor having increased in amount and gaining strength and getting the favourable time for action and not being counter-acted by anti-bodies, causes the disease symptoms. Having expended all the power and getting powerless it reconciles or returns to its original soil and growth, and repeats the cycle of growth, spread, action and return.
(4) Certain Abnormal Conditions of Body-appearance
They had observed certain abnormalities in appearance of the persons who where otherwise living in good health. So these condi�tions are not grouped under the disease list but they are described in a separate chapter just after the enumeration of all the disease conditions.
The eight censurable body conditions described therein are as follows. Obesity or Tenuity, Dwarfism or Gigantism, Albinism or Pigmentation and Hirsuites or Baldness. (Car Sutra 21-3) These are probably connected with some abnormality of the function of Glandular system of the body The body has however adjusted to live in health.
X. IMPORTANCE OF KNOWLEDGE OF CONSTITUTION OF THE BODY IN THE STUDY OF DISEASE CONDITION AND PRACTICAL THERAPEUTICS
3. Significance of Constitutional Factors in the Etiology of
4. Significance of Constitutional factors in the Clinical course of
5. Significance of Constitutional factors in prognostics.
6. Significance of Constitutional factors in practical Therapeutics
1. Significance of Constitutional Factors in the Etiology of Disease
If the balance-constant of the vitium which is dominant in the constitution of the individual is placed on a higher threshold the person is more sensitive or affective to the etiological factors which are the excitants of that particular vitium. The threshold of tolerance is transgressed even a smaller degree of exciting factors. This is the relative condition of predisposition or susceptibility.
The constituent vitium whose threshold of sensitivity or affectlvity is on a lower level, will require unusually a larger degree of exciting factors to manifest disease condition. This is the relative condition of immunity.
Caraka states :
�In a person of the Vata habitus who is given to indulgence in Vata-provoking things, the Vata is readily aggravated; not so the other two humors��.
Similarly in the Pitta patient, who is given to the indulgence of Pitta-provoking things, the Pitta is readily aggravated, not so the the other two humors.
Similarly in the person of Kapha habitus given to indulgence in Kapha-piovokmg things, Kapha is readily aggravated; not so the other two humors� (Car. Vim. 6, 16-18)
ii. Significance of Constitutional Factors in Clinical Course of Disease
Caraka Samhita gives a succint but a clear account of the part constitution plays in the production of the clinical picture of the disease and lays down as a general clinical law that manifestation of actual disease condition is the resultant of the varying interaction of the etiological factors, the triumvirate of constitution and the body-tissues.
"Here we shall describe the suppression or the incidence of the disease which occurs as a result of the variations in the etiological factors, intensity of morbid humors and -susceptibility of the body elements.
If these three factors, mainly the etiological factors etc, do not mutually associate or support, or if they do so after a long lapse of time, or m a very mild form, either there occurs no manifestation of the disease at all or the disease takes a long period to evolve, or appears in an ambulatory or abortive form. Under the contrary condi�tions, there occur contrary results. Thus are laid down the different causes of the modes of incidence or suppression of all diseases". (Car. Nid. 4, 4)
Concerning the resultant of the encounter of etiological factors with the vitia and susceptible body tissues, the author describes the following possibilities �
1. If the etiological excitant and constitutional vitia and body tissues are not mutually agreeable at all, that is the excitant factors and vitia are of the opposite types and the body tissues are resistant or more or less immune to them, then there does not occur any manifestation of disease-condition. (no manifestation of disease-condition)
2 If the excitant and vitia and body tissues are mutually agreeable but all of them are so mild or weak that all combined together do not suffice to produce a full disease condition, there will be manifestation of a mild abortive or ambulatory type of disease condition mild or latent or ambulatory type of disease-condition)
3. If mutual agreement and combination of all these three factors are gulfed by a long interval, there will be a delayed development of disease. The disease condition has a prolonged clinical course. Incubation period is long and clinical course is chronic or prolonged chronic disease condition).
Under the above mentioned two conditions the disease does not run a fixed, regular or constant clinical course. It rather manifests diversified clinical pictures. It may not manifest all the classical symptoms of the disease condition, or it may manifest them in irregular way. There may not be orderly sequence maintained in the development of symptoms or the symptoms may be intensely manifested in one part of the body tissue or system and there may be no symptoms at all in other parts, or manifestation of symptoms may be delayed or prolonged. (Manifestation of symptoms in an irregular way).
4 If the etiological exciting factors, constitutional vitia and the body tissue are mutually agreeable, there will be full development of the disease condition manifesting all classical symptoms in due order of time and in degree of intensity giving a text-book-type picture of the disease-condition. (Disease condition with typical manifestation of symptoms).
5. If the etiological excitant is more severe and acute, the vitia just on the threshold of excitement, and body tissues quite predisposed, the result is the manifestation of very acute or even fulminant type of disease condition which runs a very acute course and there is great exaggeration of general or local symptoms. (Disease conditions with acute or grave clinical course manifesting all symptoms).
These are the general postulates of manifestation of clinical course in any disease condition. Constitutional factor being an individual factor, there will always result individual differences in the clinical picture course and termination of the disease.
There are some disease conditions where constitutional factors are unable to play any part or counteract the incursion of the etiological factors. Caraka describes such a state of things to occur in epidemic and pandemic diseases where the incursion is so strong, powerful and sudden that the constitutional factors are not able to counteract at all, and so all people with varying constitution suffer simultaneously from a severe type of disease condition and run nearly uniform clinical course.
�There are other common factors which being adversely affected, will cause simultaneous outbreak of diseases having similar symptoms It is these that devastate whole populations." (Car Vim 3,6)
These postulates can well be interpreted in simple mathematical formula as under:�
Disease = Etological factors
���������������� Vitia and body-tissues
III Significance of Constitutional Factors in Prognostics
Caraka gives great consideration to constitutional factors in foretelling the prognosis Constitution is given equally an important place in the branch of prognostics by Hippocrates Caraka emphasizing the value of the knowledge of prognostics to the physician to attain full success in practice, states.
�The physician who knows the differential diagnosis between the curable and the incurable diseases and begins treatment with full knowledge of the case and in time, obtains success for his effort without fail' (Car. Sut. 10, 7)
He divides the disease condition in four categories from prognostic point of view.
�The curable diseases are of two kinds: those that are easily cured and those that are cured with difficulty. The incurable diseases also fall into two categories' those that are palliable and those that are absolutely irremediable" (Car. Sut 10, 9)
Constitutional factors play an important part in determining these four prognostic categories, moreover the knowledge of constitu�tional factors helps the physician to some extent to know the prognosis and thus enables Him to fore-arm and prepare for future line of treatment of disease-condition.
IV. Significance of Constitutional Factors in Practical Therapeutics
The diligence of the skilful clinicians who previously determined the exact role placed by each viz., etiological excitant, constitutional triumvirate and nature of body-tissue, becomes fully fruitful when practical therapeutics are to be prescribed.
The text books of modern medicine prescribe treatment for Homo-sapiens in general giving the limit of minimum and maximum dose which can be safely administered to man without harm. This is the scientific formula worked out fully by experimental and observational methods and properly standardized, and is hence all-essential for correct guidance and is valid for the average. But practical application and use of this scientific knowledge in the best interest of each individual�s the real art of medicine.
All the achievements of the practical knowledge of disease or drugs or even diagnostic skill, will be to no purpose if it is not combined with practical art of scientific application of therapeutic measures which alone can bring the full success in treatment.
Caraka states this very forcibly.
�The art of prescription depends on the knowledge of dosage and time, and on this art, in turn, depends success; hence the skilful physician stands ever superior to those possessing merely a theoretical knowledge of drugs��. (Car Sutra 2, 16)
It is essential to understand and study environmental etiological excitant but the knowledge of individual constitution of the patient which plays such an important role in the phenomena of disease is not only equally necessary but rather an indispensable pre-requisite to the exact determination of the dose for that particular stage of disease in that particular constitution of man. It is hardly necessary to emphasise the need for meticulous accuracy in dosage as deviation on either side fails to produce fully the desired results. A small dose is not sufficient to counteract the disease condition while larger dose may produce excessive effects ou the body and may even be harmful to the body at times.
�A rash administration of a very strong medication without examination, on a weak patient, will upset him
But in strong persons affected with a strong disease, weak medicine administered without examination becomes useless�.(Car Vim 8, 94)
The keenness in Ayurveda regarding the accuracy in dosage becomes too evident even in the term 'Maatra' meaning measure, which has been selected for denoting dosage, the word is derived from the root �Maa to measure' thus significant stress is laid on accurate measuring.
While the word Dose is derived from Greek (doses-didomi= give ) which is cognate to the Sanskrit root (da=to give) where the significant meaning is mere giving.
And to attain accuracy in dosage is the main purpose of the detailed study of the constitution of triumvirate.
�Treatment depends on the accurate recognition of the measure of humors and the other factors". (Car. Vim 1, 3)
The significance of knowledge of constitution in determining the personal regimen of the individual has already been described. ( Car Sutra 1-62 >
To attain the ideal of easy comprehension combined with exactitude, the ancients reduced the therapeutic science nearly to mathematic. A formula Ingestion of food and drug was the sole method of admini�stration at that time; and hence taste which was the main index, was grouped into six categories to fit easily with the three categories of triumvirate of constitution, and they evolved further the general formula co-ordinating each of the triumvirate with a group of three of the taste categories. One group of three increasing and the remaining other group decreasing the force of each of the vitia. (Car Vim. 1, 6)
The mathematical formula concerning Dosa and Rasa did not end here. As Dosa was worked out by combination and permu�tation method to 63 forms, so Rasa was also worked out to 63 forms by the same method (Car Sutra. 26, 22).
Rasa was also considered in its 'Tara' and 'Tama' comparative and superlative state as was Dosa considered. (Car. Sutra. 26, 23)
Thus specific determination of Rasa and Dosa and reducing them to mathematical formula of inter-relation is the most significant attainment of exactness in practical therapeutics conceived and achieved by the ancients. Caraka who devotes one full section Vimana of 8 chapters to this specific determination of all details of various factors concerned in production of disease as well as the factors important in diagnosis and treatment, discusses this interrela�tion of Rasa and Dosa in great detail in the first chapter of Vimana and thus emphasizes the great importance of accurate knowledge of constitutional factors for practical therapeutics.
The following remark of the great physician William Osier well emphasizes the importance of constitutional factors in the clinical manifestation of disease. It gives the inter-relations of the soil and the seed.
�Many years ago I drew the parallel between infection in tuberculosis and the parable of the sower, which though now some what hackneyed illustrates in an effective way the importance o the nature of the ground upon which the seed falls. �Some seeds by the wayside and the fowls of the air came and devoured them up.' These are the bacilli scattered broadcast outside the body, an immense majority of which die. Some fell upon stony places. These are the bacilli that find lodgment in many of us, perhaps, with the production of a small focus, but nothing comes of it; they wither away because they have no root.' 'Some fell among thorns, and the thorn sprang up and choked them.� This represents the cases of tuberculosis, latent or active, in which the seed finds the soil suitable and grows, but the conditions are not favourable, as the thorns, representing the protecting force of the body, get the better in the struggle. �But others fell on good ground and sprang up and bore fruit an hundredfold.�
This parallel which the author applied to the tuberculosis may be generalized for all disease conditions. The seed is the bacteria and the soil the body constitution.
XI THE ETIOLOGICAL FACTORS OF DISEASE
Caraka classifies all etiological factors of diseases generally into two types, i.e. endogenous and exogenous (Car. Sutra 18, 4 and 6). Susruta pursues the subject further into its metaphysical origins and declares in his treatise in keeping with the general concept in all branches of the science that disease is the occurrence of suffering (Sus Sutra 24, 4). That suffering is of three kinds.
(1) Having its source in oneself
(2) Having its source in physical elements and creatures of the world
(3) Having its source in natural and supernatural agencies.
This triad of etiological categories is in accordance with the Sankhya concept of the triad of the causes of all suffering Susruta makes further subdivision from a practical point of view of this triad so as to make seven categories of disease in the light of their etiological factors.
They are thus:
A Endogenous Category
1. Hereditary diseases. Inherited disease conditions from inherent defect in genesis of one�s parents. These are genetic etiological factors.
2 Congenital disease - The disease conditions which result during the fetal period of life in the mother�s womb. These are congenital etiological factors.
3. Nutritional or metabolic diseases - It also includes psychic and somatic conditions due to internal derangement of function or structures. These are the nutritional or metabolic etiological factors.
B Exogenous Category
The group of diseases that are due to all kinds of trauma or injury from physical, chemical and biological sources. (Car Sutra 18, 4)
7. �Diseases resulting from abnormality of climate and season.
8. �Those of supernormal origin or nature such as pandemics, epidemics, emergent conditions due to atmospheric upheaval and such other dreadful disease-conditions difficult to explain ordinarily
9. �Natural conditions or disabilities characterizing human life such as hunger, thirst, sleep, fatigue, decay, senescence and death.
These types of conditions may act either as exciting factors or as predisposing factors. (Car Sutra 20, 4-5) and they may act either as immediate or as remote causes.
Those above-mentioned classifications are exhaustive and the entire varieties of etiological factors both biological and material are comprehended by them.
XII NOSOLOGY AND THE TRIUMVIRATE
In the drama of vitiation though a number of factors or actors take part, the main plot ever remains connected with or swings round the behaviour of the triumvirate.
Once the members of the triumvirate are set into the stage of excitement by the endogenous or exogenous vitiating or toxic factors, the whole body or part of the body becomes the stage or site where the triumvirate pours out and diffuses the vitiating elements and there develops the general or special or local scenes depending upon the site and strength of the body versus the intensity of invading vitiating factors and the method and technique of war adopted by each of them as well as the effects of environmental factors.
All pathological processes and the consequent disease-conditions are represented by the signs and symptoms associated primarily with the triad of vitia. Thus in the broadest outline all disease-conditions are comprehended by this triad
�Vata, Pitta and Kapha are the cause of all diseases, for the latter show their symptoms, and are found to be caused by direct observation and by the authority of tradition. Just as the entire universe of evolutes cannot transcend the triad of natural forces of Sattva, Rajas and Tamas, similarly the totality of diseases cannot trancend but fall within the triad of Vata, Pitta and Kapha.� (Sas. Sutra 24, 8)
Caraka modifies this statement slightly differentiating endo�genous diseases which are primarily due to triumvirate discordance from exogenous diseases where external trauma is primary and triumvirate discordance develops later on.
�All endogenous diseases never occur without the discordance of Vata, Pitta and Kapha�.
�Only the disorders produced by the exogenous causes are different."
Yet in view of their special sites of localisation and affection, and the consequent variation in manifestations of forms and in view of the various etiological factors giving rise to diseases, the physician may have to give different names to specify each of such conditions.
The body consists of so many varieties of tissues, organs and structural and functional systems and of millions of cells each of which may be said to have its own separate life, that the pathological conditions affecting them in their individual or even combined forms would be innumerable. And so varied are the manifestations of each of these vitia and of their combined conditions that every degree of variation or proportion in their combination would require a special name, thus giving rise to an endless number of names. Expressing the impracticability of this, Caraka says, �When classified according to cause, pain, color, site, form and nomenclature, the number of these diseases becomes really countless."
Thus a simpler and more comprehensive classification is necessary for purposes of practical therapeusis. Only, the classifications should be all-comprehensive while yet allowing of the recognition of peculiar deviations from their fold.
And so some systems should be adapted for general classification which would be comprehensive of all diseases conditions and at the same time simple but significant guide in the selection of curative measures which is the ultimate aim of the science of medicine.
The classical writers like Caraka and Susruta suggest various methods of classification of diseases for the purpose of nomenclature. Caraka, after enumerating various ways of grouping the disease conditions (Vimana 6, 3) declares at the end of the discourse that the triumvirate-wise classification is the only possible practical method which is all-comprehensive and of significance in diagnosis and practical therapeutics.
�Now the diseases are innumerable, there being an unlimited number of them The morbific humors, on the contrary, are strictly numerable there being a limited number of them" (Car. Vim. 6, 5)
It is therefore the right thing to classify diseases only in the light of their vitial aspect as that is the pathological plank on which the science itself stands.
It is only after the basic system is formulated of classifica�tion in the light of pathological processes, that a resort should be taken to specify and designate particular disease conditions in order to enhance the detailed knowledge of diseases and facilitate the specific line of treatment. But to simply multiply the labels of disease names and describe their individual signs and symptoms without an appreciation of the basic category to which all such symptoms are common, is an unimaginative and unscientific approach to the subject.
After having a comprehensive system or framework of general disease-classification, names of particular disease condition may be added on as the knowledge of that condition is fully understood
It is not to be inferred that no progress or evolution was made in the nosological science after establishing the triad of vitial classification. That the science was kept ever progressive becomes evident when one finds that total number of disease conditions which have been given definite names, number about 1120.
�The number of disease conditions is 1120�
The whole list has been enumerated by the commentator Dalhana in 40 verses.
The basic categories were according to the triumvirate organization, and hence any disease condition was first grouped under that organization which was predominantly disorganized. With the advance of knowledge, the sub-grouping was made vitiumwise, tissue-wise, organwise or according to specific condition. But whatever be the progress made in detailed knowledge of disease, it will not diminish the importance of triumvirate-wise classification which has fundamental importance in diagnosis, prognosis and complete success of treatment.
Each and every disease condition falls under this heading. It may be the discordance of one vitium or the discordance of two or all three, the condition of bi-discordance is termed (Sansarga) and the condition of tri-discordance is termed (Sannipata).
There are certain disease conditions which affect only one vitium. They are the specific affection of that paricular vitium. They are termed (specific) to differentiate them from (general).
This is the system-wise classification. There are 80 disease conditions due to Vata, 40 disease conditions due to Pitta and 20 disease conditions due to Kapha. This is the organization-wise or vitium-wise classification
When body-tissues where vitiation process is located play a more important and urgent part than the triumvirate, the disease is named that particular body-tissue. This is the tissue-wise classification.
Where the body elements or tissues get vitiated and play a major part in the birth of disease, the conditions are referred to the particular tissue concerned, such as disease of the nutrient fluid, of the blood, of the flesh, of the fat, of the bone, of the marrow or of the semen." (Su-> Sutra 24, 8)
Dalhana while commenting on this, clarifies saying that though the disease conditions are classified and named according to the body - tissues vs here vitiation process is located, it is only a secondary denomination of the primary vitial classification. This is how it should be understood. He gives an interesting simile to explain this.
�Just as when a person is said to be scalded by heated ghee, heated oil, heated copper or iron, he is really scalded by heat through these various media, similarly when the disease is said to be due to body-tissues like blood, nutrient fluid etc., it is really due to the vitia of Vata etc, working through these tissues.�
Organ wise Nomenclature
Similarly organ-wise classification and nomenclature is done whenever the structure and functions of that particular organ play an important part in producing the signs and symptoms of the disease viz, 94 diseases of the eye, 18 diseases of the ear 18 diseases of the nose, 74 diseases of the mouth etc.
Symptom-wise or Sign-wise Nomenclature
Where one particular symptom or sign was too dominant to color the whole clinical picture, the disease was named after that symptom or sign viz., fever, diarrhea, and wound, swelling, fractures. This is the symptom-wise or sign-wise nomenclature
If the etiological factor was claying an exclusive part in the production of disease, the disease was designated after that etiological factor viz. Helminthiasis, Toxicosis, alcoholism, Liathiasis etc
The local part or condition or any special factor playing a more dominant and urgent part than the triumvirate may be allowed to have its own special name applied to the disease condition to facilitate the understanding of the disease and the immediate practical line of treatment to be adopted, but this cannot be done at the cost of or by complete avoidance of triumvirate-wise consideration. Triumvir ate wise classification is the fountain-head of all sub-classifications. Triumvirate pervades every cell and intercellular space of the body.
and controls every function. Nothing can happen or exist which does not fall under this heading.
The above mentioned conditions or factors may be for the time being dominant and more urgent, but the clinical course of the disease condition has many factors to count, adaptive or the reserve power of the body, regenerative or recuperative power, resistant or digestive power of the body, all these things which are the essentials of vitial phenomena will be better understood if primary triumvirate- wise classification is constantly kept in view.
The triumvirate, thus being the grammar of all pathological processes occurring in the bodv, becomes the primer of Nosology.
With such basic importance of triumvirate-wise classification of disease-condition, it is but natural that the intensive study of the details of this triumvirate will be carried out,
The specific conditions of diseases notwithstanding it is helpful to arrive at the least common measure of all diseases. It is only thus that practical therapeusis can he scientific and intelligible to the expert and the average healer alike. The triumvirate of vitia offers such a basic scope for the reduction of diseases to their simplest classification.
The concept of nosology in its most comprehensive import has been laid down significantly by Caraka in the following verses.
"When classified according to cause, pain, colour, site, form and nomenclature, the number of these diseases becomes really countless. A physician need never be ashamed if he is not able to name a disease, as there can be no definite standardization of nomenclature of all diseases. The physician who after ascertaining all these three things, begins treatment intelligently and systematically will not err in therapeutic procedure.� (Car Sul. 18, 42-44-47)
Thus these medical thinkers thought of diseases and classified them from the point of view of both biological scientist as well as of the practical clinician. The particularly medical aspect of Ayurveda which in its entirety is the biological grasp of the secret workings of the life mechanism, is based on practical utility. Its understanding and approach to disease and its treatment, is immediate and ready-made It is calculated to avoid much waste of time and vacillation and to help the physician possessed of even the most elementary enlightenment to take note of the basic nature of the disorder by the symptoms in the light of the three basic genera of Vata, Pitta and Kapha and start suitable medication with the least delay. A further investigation into its general and local aspects can await delay without further aggravation of the condition, if this general line of therapeusis is already afoot. In seventy out of a hundred cases, this elementary method of tackling even is bound to produce salutary effect. It is for the intelligent physician, meanwhile to make closer scrutiny and investigation into the finer blends and overlappings of the vitia, the causative factors, the site of affection, the degree of the morbid condition and the indications and contra-indications in the measures of therapeusis and the likely complications.
Caraka described the actual nature of the cryptic method of his exposition and the suggestive nature of the system propounded, thus like the initial handful of grain carried by the mendicant and the seeds in�������� the hand ������ of the sower, these aphorisms though small in measure yield to the intelligent physician abundant result i.e. complete knowledge of the subject. It is thus a guide to the intelligent physician in the use of�������� his powers of imagination� and logic. But for the mediocre it is good to follow the method laid down. Following it in the prescribed way, such a physician accomplishes his task successfully or errs only very slightly if at all, owing to the succint nature of the exposition." (Car Vimana 8, 149.)
These teachers so formulated their instruction that even the man of moderate intelligence might fully benefit by it and the etiology, pathology and the principles of co ordination between the disease and the drug are all expounded in terms that are easy to understand and retain in mind, that are true to the manifestations in health and disease and that are capable of being put into practice with the least delay and demand on the physician�s intellectual initiative. Such a system though simple and un-intricate in its broad outline, is yet eminently fruitful in application and eliminates the grave risks of Incompetence and pretentious ignorance. It is an attempt to reduce medicine to a rule of thumb, a practical chart to guide the learned and the unlearned alike.
But it is elastic and comprehensive enough to allow of the most intricate and exhaustive details of the various branches of science. All the accumulated knowledge of experiment and microscopic observations can be made to enrich the picture bound by these outlines and can contribute to the furtherance of the objective of medicine if only the basic direction of the perspective and the light offered by the physiology and pathology of the triumvirate be never lost sight of. They are the stars that guide the helmsman at the head of the ship of life, and to ignore them is to allow the ship of life to drift and. be wrecked against the hidden rocks of disease and death. The attempt at completing the picture of Ayurveda, filling it with the rich detail that modern medicine has culled from the depths of life is the responsibly of the future medical student and scholar who asserts bis heirship to the wisdom of the east and the west, or the ancients and moderns alike.
This brief and general outline of the physio patholo�gical nature and significance of the triumvirate which forms the fulcrum of all life-processes is intended mainly for the general reader who is to be introduced to the Caraka Samhita. It is not fit here to go into the intricacies of detail on the subject as would interest the researcher and the learned practitioner.
The triumvirate of biological organizations determines, as we have seen, the constitution of each individual. And Caraka has dwelt elaborately on the attributes of the various types of human constitution both from the purely psychic point of view (Car Sar 4, 37-40) as well as from the somatic point of view (Car Vim 8, 95-100) in terms of habitus or the preponderant constituent vitium.
An intimate and deep knowledge of Ayurveda will enable the practical clinician of its immense value in the matter of early diagnosis i.e. long before any actual structural and deep-seated functional disorders have crept into the organism, as well as in the procedures of active immunization and prophylaxis. The daily diet and behaviour of the individual and his continual adjustment to the demands of the changing environment are to be built upon the facts of constitutional pecularity. The details of normal living, not to speak of the exigencies of therapeusis are to be patterned in view of the fundamental diathesis of the man. The understanding of constitu�tion in its fullness provides the key to allergic reactions and psychic and somatic is osyucracies. This aspect of medicine is thus all important to the clinician and Ayurveda with its various branches is the a wheel whose spokes are fixed firmly and converge to the navel of the concept of the three villa. Thus it is that this physio- pathological perspective is all-embracing in its scope and deserves the most intense and searching scrutiny by the modern medical scholar. It is only thus and then that its soundness as a faithful representa�tion of the body organization and mechanism of functioning, and the extent of its practical applicability and utility can be appreciated It is a subject for profound study and judgement for the sincere and serious-minded student of medicine.
XIV THE IDEAL OF HEALTH IN AYURVEDA
The ideal of health varies from a mere disease-free condition to that of positive and perfect health Ayurveda set up for itself the very lofty ideal of positive health, perfect to the minutest detail.
The concept of health is In its undivided and integrated form of body-mind The definition of man in Ayurveda is the aggre�gate of body, mind and spirit, and its concept of health if not only physical health but mental and spiritual health too Its personal hygiene known as Swastha-Vrtta is supplemented by
or the right life which inculcates the discipline of the senses and mind and the regulation of the moral life so as to accord with the happi�ness and good not of the individual merely but of the humanity as a whole. It is therefore social and universal in its conception and application, and comprehends a physical, mental and ethical framework of life. It is an entire concept of life that Ayurveda expounded embodying philosophy, eugenics and ethics.
Again the concept of health is individualized as no two persons are found alike in appearance or behaviour. The very word Swastha meaning healthy signifies by the term in one s own individual consti�tution. Thus was the concept of individual constitution or brought to bear upon the subject. Ancient Greek masters and the sages of India like Caraka and Susruta have built up their systems of health and disease on this bed-rock of constitution, and this concept of constitution remains as sound as ever in its logic and practical efficacy.
Its objective moreover aimed at the fullest survival and even to overcome the handicaps of nature and age. This concept gave rise to Vitalization and Virilification systems of therapy.
This setting up of a lofty standard of health had to be imple�mented by an equally high standard of diagnostic methods, so detailed and perfect in all their aspects as to detect even a very minute and ordinarily unnoticeable deviation from the specific norm of the individual. It is easy to set up norms for organizations which are simple and are on the lower rungs of the ladder of biological evolution. But the higher and subtler the organization are the greater will be the liability to disorganization, and it is in these cases that the diagnostic methods necessitate the highest sensitiveness in detecting deviations.
The three main organizations are of Vata, Pitta and Kapha These three co-exist in a single constitution. They are so diverse in nature and function that their equilibrium can be maintained only on a highly sensitive and delicate fulcrum. But this is not all the three are not static and they have continual to adapt themselves to the ever changing environmental factors. The environmental factors appearing in a little more, less or altered form are likely to cause the disturbance of this subtle equilibrium of the triumvirate.
The edge of this sensitiveness is blunted when the concept is not that of ideal health. The trivial deviations go unnoticed and are left uncared for. But when the ideal is that of perfect psycho-somatic health, the deviation, however small and insignificant it may seem, is noted and cared for. Anything which is not to the mark is considered a positive source of trouble. Even the slightest deviation is enough to start the ringing of warning bells of impending alarm.
The criterion of ideal health in Ayurveda is "the best mood in the working of the spirit, senses and mind.�
The Psyche is the most sensitive galvanometer in the body, the psychic changes are more or less subjective symptoms but fortuna�tely for the physician they are indicated reflexively on this external features of the body by way of inherent and prevailing spirit, life mood, reactive affectivity and tempo peculiar to the personality. The mani�festations, are perhaps too clear to go unnoticed by the attending persons, but it requires a keen clinical sense to transcribe this script of reflex indication into a comprehensible form by observation, interpretation and correlation. Lord Chesterfield has rightly remarked that if we wish to know the real sentiments of the person we are conversing with, we should look into his face, for he can more easily command his words than his features. Life is ever moulding our expressions, our inner thoughts are written indelibly on our faces.
Even transient disturbances are not allowed to escape unnoticed by Ayurveda It stresses upon the diagnosis of even transient distur�bances and attempts to restore the lost equilibrium. It also advises the prophylactic measures to counter such adverse environmental factors in This is the most glorious part of the highest concept of perfect health and the practical application of it in the maintenance thereof.
The maintenance of the norm and the prevention or deviation from the norm thus becomes the field of Ayurveda. What then is the norm or the normal condition according to Ayurveda? Definitions are always difficult to formulate and it is specially so in this case as it is a common experience that no two individuals are completely alike physically, physiologically, psychologically or in vital reactions. And hence the art of medicine necessitates the study of the individual man. Thus any definition of the Norm in Ayurveda will have to be defined from the individual point of view. Each individual is different from the other and so the norm of one will not be the norm of another.
For theoretical purposes, the norm of man in general can be described as a range of values to be aceepted as a standard found to be the average in persons who apoear healthy and free from disability or disease.
But for practical application the study of the individual will be necessary to achieve accuracy in diagnosis and therapeutics. Susruta while describing the norm of the individual states as under -
�It is not possible to lay down or standardize the exact measure of the triumvirate, body-elements or the excretory matter owing to their varying nature in the process of adaptation to the continually changing environmental factors as well as individual variations of the body constitution." (Sus Sut. 15,37)
If a physician wants to know the state of equilibrium of all these he can do it only by finding the signs of perfect health in that individual. The expert physician diagnoses indirectly their imbalance condition of these body-elements by finding the person not in perfect mood� (Sus, Set. 15, 38-39).
�A person possessing the equilibrium of the triumvirate, balance condition of gastric fire, and harmonious working of digestion, assimilation and elimination processes and the best mood of spirit, senses and mind, is said to be in perfect health." (Sus Sut. 15,41)
Thus Ayurveda has dynamic and creative view of health, for health can never be a mere static condition, it must grow like life or fall. Hence the need for constant vigilance in its promotion and for revitalizing it as a factor for intensive enjoyment of the delight of living. Life must be lived as a delight or it must yield place to disease and death. There is no no-man's land where it can remain neutral and static. In dealing with this aspect of health Ayurveda holds the palm over all other known systems of medical thought. The healthy man should be as vigilant and diligent in the maintenance and enhancement of his health as the sick one is in the riddance of disease. Such a double aspect has also been ascribed to medicament.
�Now medicine is of two kinds, one kind is promotive of vigour in the healthy, the other destructive of disease in the ailing," (Car Cik. 1,4)
The regimen of conduct known as hygiene, social and individual, and a good life which includes the control of the senses and the mind is calculated to turn man into a noble citizen of the world, and lead him a step higher in the ladder of evolution. This is medically very efficacious in lifting man above the dangers of psychic and nervous disorders that are on the increase as a result of the heavy drain on the nervous energies of man due to the distractions, cants and make-believes, enormous and injurious ambition and frustration that modern civilized life involves. This psychic regimen provides the wholesome nutrition for the mind even as the physical regimen does to the physical body.
Caraka draws a beautiful picture of the life of a man in possession of ideal physical and psychic health who not only enjoys fully the life himself, but at the same time adds to the happiness and comfort of the whole world.
"Now the life of such a man is called happy as is not afflicted with either bodily or mental ailments, as is, in particular, endowed with youth, strength, virility, reputation, enterprise and boldness befitting his abilities, is actuated in his deeds by the combined urge of knowledge, science, the senses and the sense-objects, is possessed of multifarious and delightful amenities accruing from great wealth, all whose efforts are prosperous and who can plan as he likes. A life that is contrary to this is deemed unhappy.
The life of that man is said to be good who is a well-wisher of all creatures, who does not covet other people�s goods, who is a teller of truth, who is peace-loving, who acts with deliberation, is not negli�gent, is devoted to the three ends ( viz., virtue, wealth and enjoy meat ) without letting any one end come into conflict with the other two, who is reverential to those who are worthy of reverence, of a scholarly, scientific and retiring disposition, partial to the companion of elders, of well curbed passions of desire, anger, envy, pride and conceit; constantly given to charitable acts; devoted always to austerity, knowledge and quietude, endowed with spiritual insight, one-minded, contemplative of the good in this world and the next, and endowed with memory and understanding. That life which is of the opposite nature is said to be �not good.' ( Car Sutra 30, 24 )