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|title=Mahachatushpada Adhyaya

|title=Mahachatushpada Adhyaya

|type=article

|type=article

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<big>'''Sutra Sthana Chapter 10. The four important components of Therapeutics '''</big>

<big>'''Sutra Sthana Chapter 10. The four important components of Therapeutics '''</big>

{{Infobox

{{Infobox

|data7  = Gujarathi R., Godatwar P.

|data7  = Gujarathi R., Godatwar P.

|label8 = Editor  

|label8 = Editor  

|data8  = Dixit U., Deole Y.S., Basisht G.

|data8  = Dixit U., [[Yogesh Deole|Deole Y.S.]], [[Gopal Basisht|Basisht G.]]

|label9 = Year of publication  

|label9 = Year of publication  

|data9 =  2020

|data9 =  2020

}}

}}

<big>'''Abstract'''</big>

<big>'''Abstract'''</big>

 

<p style="text-align:justify;">In the preceding chapter, four important aspects of healthcare including the standard qualities of physician, nursing staff, medicine and the patient were described. This chapter deals with guidelines for therapeutic management based on four types of prognosis of diseases. It is important to determine prognosis of a disease before starting the treatment to decide the quality of life of patient, and whether it will be diseased or disease free. Therefore, as the title suggests, the chapter is about four important components of therapeutic management of diseases. </br>

<div style="text-align:justify;">In the preceding chapter, four important aspects of healthcare including the standard qualities of physician, nursing staff, medicine and the patient were described. This chapter deals with guidelines for therapeutic management based on four types of prognosis of diseases. It is important to determine prognosis of a disease before starting the treatment to decide the quality of life of patient, and whether it will be diseased or disease free. Therefore, as the title suggests, the chapter is about four important components of therapeutic management of diseases. </div>

'''Keywords''':  Prognosis of diseases, types of prognosis, importance of prognosis in therapeutics, curable, incurable, palliable diseases

'''Keywords''':  Prognosis of diseases, types of prognosis, importance of prognosis in therapeutics, curable, incurable, palliable diseases

</div>

</p>

== Introduction ==

== Introduction ==

# As preordained, the patient has survived for a certain period by following a wholesome regimen and as such has enjoyed a little relief, but even a slightest carelessness might quickly aggravate the condition

# As preordained, the patient has survived for a certain period by following a wholesome regimen and as such has enjoyed a little relief, but even a slightest carelessness might quickly aggravate the condition

# The disease has affected deep seated ''[[dhatus]]''

# The disease has affected deep seated ''[[dhatu]]s''

# The disease involves a number of ''[[dhatus]]''

# The disease involves a number of ''[[dhatu]]s''

# It affects the vital organs and joints  

# It affects the vital organs and joints  

# It affects the patient continuously for a long time (chronic), and

# It affects the patient continuously for a long time (chronic), and

Likewise, the following factors would determine the absolute incurability of the disease:

Likewise, the following factors would determine the absolute incurability of the disease:

# Disease caused by the vitiation of all the three ''doshas''

# Disease caused by the vitiation of all the three ''[[dosha]]s''

# Disease that transcend all therapeutic measures

# Disease that transcends all therapeutic measures

# Diseases that involves all the systems

# Diseases that involves all the systems

# Disease causing excitement, restlessness and confusion

# Disease causing excitement, restlessness and confusion

<div style="text-align:justify;">

<div style="text-align:justify;">

# Proper administration of therapeutic measures hastens the process of cure in case of curable diseases. Therefore, correct diagnosis and prognosis at the earliest by the physician is important for getting better results with treatment. [5]

# Proper administration of therapeutic measures hastens the process of cure in case of curable diseases. Therefore, correct diagnosis and prognosis at the earliest by the physician is important for getting better results with treatment. [5]

# The treatment should be aimed at restoring physiological equilibrium. The various ways to bring this equilibrium are to increase the depleted nutrients, nourish those who are weak and emaciated, and reduce the one who are obese, those afflicted by heat with cooling measures and those afflicted by cold with heating measures. Proper measures to replenish the deficient dhatus (tissue elements, doshas and malas) and deplete those that are in excess should be adopted. Thus these therapeutic measures give us the best result in the management of diseases. [6]The diseases can be categorized under four types on the basis of their prognosis viz.  

# The treatment should be aimed at restoring physiological equilibrium. The various ways to bring this equilibrium are to increase the depleted nutrients, nourish those who are weak and emaciated, and reduce the one who are obese, those afflicted by heat with cooling measures and those afflicted by cold with heating measures. Proper measures to replenish the deficient [[dhatu]]s (tissue elements, [[dosha]]s and [[mala]]s) and deplete those that are in excess should be adopted. Thus these therapeutic measures give us the best result in the management of diseases. [6]The diseases can be categorized under four types on the basis of their prognosis viz.  

# Easily curable,  

# Easily curable,  

# Curable with some difficulty,  

# Curable with some difficulty,  

| Severity of signs/ symptoms ||  Mild  || Moderate || Severe  || Severe and advanced stages  

| Severity of signs/ symptoms ||  Mild  || Moderate || Severe  || Severe and advanced stages  

|-

|-

| ''Dosha''  involved in disease  || Opposite to one’s ''prakriti'' [constitution]  ||  Same as of ''prakriti'' /favorable to disease  || Same as of ''prakriti'' /favorable to disease  || Same as of ''prakriti'' /favorable to disease   

| ''[[Dosha]]''  involved in disease  || Opposite to one’s ''[[Prakriti]]'' [constitution]  ||  Same as of ''[[Prakriti]]'' /favorable to disease  || Same as of ''[[Prakriti]]'' /favorable to disease  || Same as of ''[[Prakriti]]'' /favorable to disease   

|-

|-

| ''Dushya'' [body tissues affected]  || Opposite to one’s ''prakriti'' [constitution]  || Same as of ''prakriti'' /favorable to disease  || Same as of ''prakriti'' /favorable to disease  || Many tissues, deep seated and Favorable to disease  

| ''[[Dushya]]'' [body tissues affected]  || Opposite to one’s ''[[Prakriti]]'' [constitution]  || Same as of ''[[Prakriti]]'' /favorable to disease  || Same as of ''[[Prakriti]]'' /favorable to disease  || Many tissues, deep seated and Favorable to disease  

|-

|-

| Place of living of patient  ||  Opposite to one’s ''prakriti'' [constitution] || Same as of ''prakriti'' /favorable to disease  || Same as of ''prakriti'' /favorable to disease  || Same as of ''prakriti'' /favorable to disease  

| Place of living of patient  ||  Opposite to one’s ''[[Prakriti]]'' [constitution] || Same as of ''[[Prakriti]]'' /favorable to disease  || Same as of ''[[Prakriti]]'' /favorable to disease  || Same as of ''[[Prakriti]]'' /favorable to disease  

|-

|-

| Season/ time of affection /Age  || Opposite to one’s ''prakriti'' [constitution]  ||  Same as of ''prakriti'' /favorable to disease  || Same as of ''prakriti'' /favorable to disease  || Same as of ''prakriti'' /favorable to disease  

| Season/ time of affection /Age  || Opposite to one’s ''[[Prakriti]]'' [constitution]  ||  Same as of ''[[Prakriti]]'' /favorable to disease  || Same as of ''[[Prakriti]]'' /favorable to disease  || Same as of ''[[Prakriti]]'' /favorable to disease  

|-

|-

| Movement of ''dosha'' || One sided  ||  Two sided  || Many ways for movements || All ways for movements/all systems involved  

| Movement of ''[[dosha]]'' || One sided  ||  Two sided  || Many ways for movements || All ways for movements/all systems involved  

|-

|-

| Duration of onset || New onset  ||  Chronic, but still recent || Very chronic and continuously affecting the patient  || Very chronic and continuously affecting the patient

| Duration of onset || New onset  ||  Chronic, but still recent || Very chronic and continuously affecting the patient  || Very chronic and continuously affecting the patient

| Complications || No  ||  Minor/less complications  || Many complications  || Many complications with bad prognostic signs  

| Complications || No  ||  Minor/less complications  || Many complications  || Many complications with bad prognostic signs  

|-

|-

| Number of involved Dosha ||  One  ||  Two || Two  || Three

| Number of involved [[Dosha]] ||  One  ||  Two || Two  || Three

|-

|-

| Body  || Can tolerate all medicines  ||  Occurred in pregnancy, children, old age  || Affecting vital organs, major joints || Weak body, Affecting vital organs, major joints  

| Body  || Can tolerate all medicines  ||  Occurred in pregnancy, children, old age  || Affecting vital organs, major joints || Weak body, Affecting vital organs, major joints  

In the contemporary medical system, the curable and incurable signs and symptoms of diseases are well understood but the criteria for deciding the prognosis are different than [[Ayurveda]]. There is availability of advanced technology in the form of imaging, biochemical, immunological, molecular and genetic studies etc. for diagnosis and assessment of prognostic factors of diseases.

In the contemporary medical system, the curable and incurable signs and symptoms of diseases are well understood but the criteria for deciding the prognosis are different than [[Ayurveda]]. There is availability of advanced technology in the form of imaging, biochemical, immunological, molecular and genetic studies etc. for diagnosis and assessment of prognostic factors of diseases.

Inspite of such sophisticated tools, prognostic criteria are limited to diseases only. Overdependence on these studies has caused enormous increase in the cost of medical care. On the other hand, assessment of prognostic criteria of [[Ayurveda]] based on understanding ''prakriti'' (body type) with ''dosha, dhatu, mala, agni,'' and ''indriya'' are for both health and disease. These are entirely clinical and fairly accurate depending upon the clinical acumen of Ayurvedic physician. The concept of personalized medicine known to modern medicine is very limited at this time and is helpful in certain cancers and genetic diseases only. In future, it will be helpful to use a combination of prognostic criteria of both systems to provide better care at less expense.

Inspite of such sophisticated tools, prognostic criteria are limited to diseases only. Overdependence on these studies has caused enormous increase in the cost of medical care. On the other hand, assessment of prognostic criteria of [[Ayurveda]] based on understanding ''[[Prakriti]]'' (body type) with ''[[dosha]], [[dhatu]], [[mala]], [[agni]],'' and ''[[indriya]]'' are for both health and disease. These are entirely clinical and fairly accurate depending upon the clinical acumen of Ayurvedic physician. The concept of personalized medicine known to modern medicine is very limited at this time and is helpful in certain cancers and genetic diseases only. In future, it will be helpful to use a combination of prognostic criteria of both systems to provide better care at less expense.

=== Medical model and healthcare system ===

=== Medical model and healthcare system ===

[[Ayurveda]] holds the view that some diseases are incurable right from the beginning and also provides the details of the factors that cause such diseases. Therefore, it is irrational to apply therapeutic measures for such diseases. However, research shows that incurable diseases such as  type-1 Diabetes mellitus (resembling with Vataja prameha) can become less severe with treatment factoring in all prognosis outcomes.  

[[Ayurveda]] holds the view that some diseases are incurable right from the beginning and also provides the details of the factors that cause such diseases. Therefore, it is irrational to apply therapeutic measures for such diseases. However, research shows that incurable diseases such as  type-1 Diabetes mellitus (resembling with Vataja prameha) can become less severe with treatment factoring in all prognosis outcomes.  

Type-1 diabetes meets all the criteria described above for incurability, like vitiation of all three ''doshas'', affliction of ten ''dushyas'' with the nature of involved ''dosha'' and ''dushya'' are same (''kapha dosha'' and ''meda dushya'') along with ''prakriti'' compatibility of patient (predominance in ''kaphaja prakriti'', like in an obese patient). Again due to genetic predisposition, ''kapha'' loses its natural characteristics, becoming liquefied and  losing its usual properties. There is vitiation of ''vata dosha'' due to depletion of all ''dhatus'', especially ''oja'' (the ultimate resultant of all seven ''dhatu'' metabolism). The pathogenesis of the disease starts with the admixture of vitiated ''kapha'' and ''meda'' and progression successively to involve other ''dhatus'' like ''mamsa, kleda'' etc. The ''dhatus'' are depleted so quickly that the body is unable to replenish it, ultimately leading to death. Thus, Diabetes Mellitus, is not merely a disease but a syndrome, proves to be fatal due to many complications like diabetic neuropathy, nephropathy, microangiopathy, cardiomyopathy, retinopathy, skin complications, as well as emergency crises such as hypoglycemic shock and diabetic ketoacidosis. There is successive involvement of all body tissues involving connective tissues, nerve tissues, muscle tissue etc, leading to severe depletion of insulin due to autoimmune degeneration of beta pancreatic cells. Genetic abnormalities cause impaired glucose, lipid and protein metabolism. Type-1 diabetes mellitus is an autoimmune disorder and destruction of body tissues by autoantibody is very fast causing loss of immune- intolerance and immune-component (''oja'') thus impairing body defense mechanism. There is disturbance in production and clearance of lipoprotein causing hampered functioning of insulin resulting in hyperglycemia and producing microvascular complications like retinopathy and nephropathy. However, for macrovascular complications, including neuropathy, pathogenesis starts before the onset of diabetes i.e. at the stage of lipid abnormalities. These factors make Type 1 Diabetes mellitus difficult to treat. The treatment consists of life-long insulin replacement by exogenous insulin. This is an example of an incurable disease although there is a lot of research work going on to find an effective remedy for this ailment.  

Type-1 diabetes meets all the criteria described above for incurability, like vitiation of all three ''[[dosha]]s'', affliction of ten ''[[dushya]]s'' with the nature of involved ''[[dosha]]'' and ''[[dushya]]'' are same (''[[kapha]] [[dosha]]'' and ''[[meda]] [[dushya]]'') along with ''[[Prakriti]]'' compatibility of patient (predominance in ''kaphaja [[prakriti]]'', like in an obese patient). Again due to genetic predisposition, ''[[kapha]'' loses its natural characteristics, becoming liquefied and  losing its usual properties. There is vitiation of ''[[vata dosha]]'' due to depletion of all ''[[dhatu]]s'', especially ''[[oja]]'' (the ultimate resultant of all seven ''[[dhatu]]'' metabolism). The pathogenesis of the disease starts with the admixture of vitiated ''[[kapha]]'' and ''[[meda]]'' and progression successively to involve other ''[[dhatu]]s'' like ''[[mamsa]], [[kleda]]'' etc. The ''[[dhatu]]s'' are depleted so quickly that the body is unable to replenish it, ultimately leading to death. Thus, Diabetes Mellitus, is not merely a disease but a syndrome, proves to be fatal due to many complications like diabetic neuropathy, nephropathy, microangiopathy, cardiomyopathy, retinopathy, skin complications, as well as emergency crises such as hypoglycemic shock and diabetic ketoacidosis. There is successive involvement of all body tissues involving connective tissues, nerve tissues, muscle tissue etc, leading to severe depletion of insulin due to autoimmune degeneration of beta pancreatic cells. Genetic abnormalities cause impaired glucose, lipid and protein metabolism. Type-1 diabetes mellitus is an autoimmune disorder and destruction of body tissues by autoantibody is very fast causing loss of immune- intolerance and immune-component (''[[oja]]'') thus impairing body defense mechanism. There is disturbance in production and clearance of lipoprotein causing hampered functioning of insulin resulting in hyperglycemia and producing microvascular complications like retinopathy and nephropathy. However, for macrovascular complications, including neuropathy, pathogenesis starts before the onset of diabetes i.e. at the stage of lipid abnormalities. These factors make Type 1 Diabetes mellitus difficult to treat. The treatment consists of life-long insulin replacement by exogenous insulin. This is an example of an incurable disease although there is a lot of research work going on to find an effective remedy for this ailment.  

Recent research has shown some herbs have effect on beta pancreatic cells to induce endogenous insulin production. ''Meshashringi'' (Gymnema Sylvester (Retz.) R.Br.; Gurmar) ''Kutaki'' (Picrorrhiza kurroa)<ref>Joy KL, Kuttan R. Anti-diabetic activity of Picrorrhiza kurroa extract.J Ethnopharmacol. 1999 Nov 1;67(2):143-8. </ref>,''Kiratatikta'' (Swertia chirata (Roxb.) Buch.-Hum <ref>Bajpai M, Asthana RK, Sharma NK, et al. Hypoglycemic effect of swerchirin from the hexane fraction of Swertia chirayita. Plant Med 1991; 57: 102-104. </ref>  <ref>Saxena AM, Bajpai MB, Murthy PS, Mukherjee SK. Swerchirin induced  blood sugar lowering of streptozotocin treated hypoglycemic rats. Indian J Exp Biol 1993; 31:178-181.</ref>, ''Mamejjaka'' (Enicostema littorale Blume)<ref>Upadhyay UM, Goyal RK. Efficacy of Enicostemma littorale in type-2 diabetic patients. Phytother Res 2004; 18:233-235. </ref>  <ref>Prince PS, Srinivasan M. Enicostemma littorale Blume aqueous extract improves the antioxidant status in alloxan induced diabetic rat tissues. Acta Pol Pharm 2005; 62: 363-367. </ref>and Pterocarpus marsupium <ref>Kirana Halagappa, H.N. Girish,  B.P. Srinivasan. The study of aqueous extract of Pterocarpus marsupium Roxb. on cytokine TNF-α in type 2 diabetic rats.  Indian J Pharmacol. 2010; 42(6): 392–396. </ref>  <ref>Ahmad, F., Khalid, P., Khan, M.M., Rastogi, A.K., Kidwai J.R. Insulin-like activity in epicatechin. Acta. Diabetol. Lat. 1989. 26; 291-300. </ref>have proven to reduce blood glucose levels by modifying the prognostic factors of type 1 diabetes in experimental animals. Thus yearly detection and treatment of an incurable disorder like diabetes mellitus, by means of addressing prognostic factors at an early stage of disease, may prevent the progression of the ailment further into becoming incurable.  

Recent research has shown some herbs have effect on beta pancreatic cells to induce endogenous insulin production. ''Meshashringi'' (Gymnema Sylvester (Retz.) R.Br.; Gurmar) ''Kutaki'' (Picrorrhiza kurroa)<ref>Joy KL, Kuttan R. Anti-diabetic activity of Picrorrhiza kurroa extract.J Ethnopharmacol. 1999 Nov 1;67(2):143-8. </ref>,''Kiratatikta'' (Swertia chirata (Roxb.) Buch.-Hum <ref>Bajpai M, Asthana RK, Sharma NK, et al. Hypoglycemic effect of swerchirin from the hexane fraction of Swertia chirayita. Plant Med 1991; 57: 102-104. </ref>  <ref>Saxena AM, Bajpai MB, Murthy PS, Mukherjee SK. Swerchirin induced  blood sugar lowering of streptozotocin treated hypoglycemic rats. Indian J Exp Biol 1993; 31:178-181.</ref>, ''Mamejjaka'' (Enicostema littorale Blume)<ref>Upadhyay UM, Goyal RK. Efficacy of Enicostemma littorale in type-2 diabetic patients. Phytother Res 2004; 18:233-235. </ref>  <ref>Prince PS, Srinivasan M. Enicostemma littorale Blume aqueous extract improves the antioxidant status in alloxan induced diabetic rat tissues. Acta Pol Pharm 2005; 62: 363-367. </ref>and Pterocarpus marsupium <ref>Kirana Halagappa, H.N. Girish,  B.P. Srinivasan. The study of aqueous extract of Pterocarpus marsupium Roxb. on cytokine TNF-α in type 2 diabetic rats.  Indian J Pharmacol. 2010; 42(6): 392–396. </ref>  <ref>Ahmad, F., Khalid, P., Khan, M.M., Rastogi, A.K., Kidwai J.R. Insulin-like activity in epicatechin. Acta. Diabetol. Lat. 1989. 26; 291-300. </ref>have proven to reduce blood glucose levels by modifying the prognostic factors of type 1 diabetes in experimental animals. Thus yearly detection and treatment of an incurable disorder like diabetes mellitus, by means of addressing prognostic factors at an early stage of disease, may prevent the progression of the ailment further into becoming incurable.  

#Research studies should be conducted to assess the impact of modern medical facilities , geared with sophisticated medical infrastructure, skilled nursing staff, and features to handle emergency services,  in controlling the mortality and morbidity of a disease.  

#Research studies should be conducted to assess the impact of modern medical facilities , geared with sophisticated medical infrastructure, skilled nursing staff, and features to handle emergency services,  in controlling the mortality and morbidity of a disease.  

#Data can be collected to estimate the usefulness as well as limitations of therapeutics in the management of curable and incurable diseases.

#Data can be collected to estimate the usefulness as well as limitations of therapeutics in the management of curable and incurable diseases.

== References ==

== References ==