Chapter 12 - 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

Sushruta says—

[Suśrutasaṃhitā Sūtrasthāna 24.8]

“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 transcend but fall within the triad of Vata, Pitta and Kapha”.

Caraka modifies this statement slightly differentiating endogenous diseases which are primarily due to triumvirate discordance from exogenous diseases where external trauma is primary and triumvirate discordance develops later on

[Carakasaṃhitā Sūtrasthāna 18.5]

“All endogenous diseases never occur without the discordance of Vata, Pitta and Kapha”.

[Carakasaṃhitā Sūtrasthāna 19.6]

“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

[Suśrutasaṃhitā Sūtrasthāna 24.8]

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 Sushruta suggest various methods of classification of diseases for the purpose of nomenclature Caraka, after enumerating various ways of grouping the disease conditions (Vimāna 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.

[Carakasaṃhitā Vimānasthāna 6.5]

“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”.

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 classification 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.

Sushruta says:

[Suśrutasaṃhitā Uttaratantra 66.8]

“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 vitium-wise (nānātmaja) tissue-wise (rasādhi-dhātuja), organ-wise (avayavaja) 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.

Triumvirate-wise Nomenclature

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 Samsarga (saṃsarga) and the condition of tri-discordance is termed Sannipata (sannipāta)

Vitium-wise Nomenclature (nānātmaja)

There are certain disease conditions which affect only one vitium. They are the specific affection of that paricular vitium. They are termed (nānātmaja—specific) to differentiate them from (sāmānyaja—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 vitmm-wise classification

Tissue-wise Nomenclature (rasādhi-dhātuja)

When body-tissues where vitiation process is located play a more important and urgent part than the triumvirate, the disease is named after that particular body-tissue. This is the tissue-wise classification.

Susruta states:—

[Suśrutasaṃhitā Sūtrasthāna 24.8]

“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”.

Dalhana while commenting on this, clarifies saying that though the disease conditions are classified and named according to the body-tissues where vitiation process is located, it is only a secondary denomination of the primary vitial classification. This is how it should always 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 (avayavaja)

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 (lakṣaṇātmaka)

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., (jvara—fever), Atisara (atisāra—diarrhea), and Vrana (vraṇa—wound), Shotha (śotha—swelling), (bhagna—fractures). This is the symptom-wise or sign-wise nomenclature.

Cause-wise Nomenclature (nidānātmaka)

If the etiological factor was playing an exclusive part in the production of disease, the disease was designated after that etiological factor viz., Krimiroga (kṛmiroga—Helminthiasis), Visharoga (viṣaroga—Toxicosis), Madatyaya (madātyaya—alcoholism), Ashmari (aśmarī—Lithiasis) 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 body, 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 be 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.

[Carakasaṃhitā Sūtrasthāna 18.42, 44, 47]

“When classified according to cause, pam, 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 ascertaing [ascertaining?] all these three things, begins treatment intelligently and systematically will not err in therapeutic procedure”