Chapter 10 - Importance of Knowledge of Constitution of the Body

[Full title: Importance of Knowledge of Constitution of the Body in the Study of Disease Condition and Practical Therapeutics]

1. Significance of Constitutional Factors in the Etiology of disease.
2. Significance of Constitutional factors in the Clinical course of disease.
3. Significance of Constitutional factors in prognostics.
4. 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 by a smaller degree of exciting factors. This is the relative condition of predisposition or susceptibility.

The constituent vitium whose threshold of sensitivity or affectivity 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:

[Carakasaṃhitā Vimānasthāna 6.16-18]

“In a person of the Vata habitus who is given to indulgence in Vata-provokmg 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-provoking things, Kapha is readily aggravated; not so the other two humors”.

2. 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.

[Carakasaṃhitā Nidānasthāna 4.4]

“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 in 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 conditions, there occur contrary results. Thus are laid down the different causes of the modes of incidence or suppression of all diseases”.

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 (“na vikārābhimirvṛtiḥ[?]”—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 (“vikārā bhavanti-aṇuvikārajananam[?]”—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 (“careṇa jananam”—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 (“ayathokta-sarvaliṅga[?]”—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 (“yathokta-sarvaliṅga”—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 (“śīghraṃ nirvartamānā mahānto yathoktasarvaliṅgāḥ[?]”—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.

Epidemic:

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 Janapadoddhvamsa (janapadoddhvaṃsa) 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.

[Carakasaṃhitā Vimānasthāna 3.6]

“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”.

These postulates can well be interpreted in simple mathematical formula as under:—

Disease = Etiological factors
                ————————
               Vitia and body-tissues

3. 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:

[Carakasaṃhitā Sūtrasthāna 10.7]

“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”.

He divides the disease condition in four categories from prognostic point of view.

[Carakasaṃhitā Sūtrasthāna 10.9]

“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 pre absolutely irremediable”.

Constitutional factors play an important part in determining these four prognostic categories, moreover the knowledge of constitutional 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

4. 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 is 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:—

[Carakasaṃhitā Sūtrasthāna 2.16]

“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”.

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.

[Carakasaṃhitā Vimānasthāna 8.94]

“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”.

The keenness in Ayurveda regarding the accuracy in dosage becomes too evident even in the term Matra (mātrā) meaning measure, which has been selected for denoting dosage, the word Matra (mātrā) is derived from the root Ma (√mā—“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 (√dā=“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.

[Carakasaṃhitā Vimānasthāna 1.3]

“Treatment depends on the accurate recognition of the measure of humors and the other factors”.

The significance of knowledge of constitution in determining the personal regimen of the individual has already been described (Carakasaṃhitā Sūtrasthāna 1.62).

To attain the ideal of easy comprehension combined with exactitude, the ancients reduced the therapeutic science nearly to mathematical formula

Ingestion of food and drug was the sole method of administration at that time; and hence taste Rasa 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. (Carakasaṃhitā Vimānasthāna 1.6)

The mathematical formula concerning Dosa (doṣa) and Rasa did not end here. As Dosa was worked out by combination and permutation method to 63 forms, so Rasa was also worked out to 63 forms by the same method (Carakasaṃhitā Sūtrasthāna 26.22)

Rasa was also considered in its “Taru” and “Tama” comparative and superlative state as was Dosa (doṣa) considered (Carakasaṃhitā Sūtrasthāna 26.23). Thus Rasadosha-vimana (rasadoṣavimāna)[?] 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 aud achieved by the ancients Caraka who devotes one full section Vimana (vimāna) 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 interrelation of Rasa and Dosha (doṣa). in great detail in the first chapter of Vimana and thus emphasizes the great importance of accurate knowledge of constitutional factors (doṣavimāna) for practical therapeutics.

The following remark of the great physician William Osler well emphasizes the importance of constitutional factors in the clinical manifestation of disease. It gives the inter-relations of the soil and the seed.

The Soil

“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 of the nature of the ground upon which the seed falls. “Some seeds by the wayside and the fowls of the air came and devoured em 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 thorns 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.