Chapter 1 - Background on the concept of Tridosha pathogenesis

It is necessary to understand the background of the origin and growth of an idea or concept to be able to fully adjudge the degree of its validity. This is even more true in the case of a concept which relates to the working and maintenance of the life currents of the psycho-somatic constitution of man specially in the case of that concept which under the title of Tridosha (tridoṣa) in India and under that of Hippocratic constitutional or humoral theory in the West has remained for centuries the central doctrine of health and disease. The meaning and interpretation of the terminology, having got degenerated and distorted during the long period of two thousand years, received a temporary setback during the dominance of the analytical age of localistic study of individual organs, tissues and cells.

But the recent evolution of microbiology, the progess of knowledge of nutrition and metabolism, the concept of integrative functioning of endocrine glands and the vegetative nervous system and the studies of allergy and immunity have revived the clinical interest in the study of constitutional or integrated or synthetic concept of the personality of man as a whole.

Arturo Castiglioni, the great medical historian, describing this modern revival of ancient constitutional concept as neo-Hippocratism says,

“Such principles indicate the orientatation of Modern Medicine toward a neo-Hippocratism (a term introduced by the author in 1925), return to some of the classical principles of medical thought Modern medicine, today turns to a dynamic, synthetic and unitarian direction after a period in which a morphologic, analytical, localistic tendency dominated. It is a return to the classical concepts of the ancient sage of Cos, focussed on the well-being of the individual and the improvement of the race, seeking for the cause of the disease, its prevention and cure, both in the individual and in his environment. The study of the nature and the cause of disease is progressing more and more along the lines of an integrated physical, chemical, bacteriological, experimental and above all clinical methods, in which the study of economic and social conditions also are important. It is significant that the best type of clinician is learning and teaching how best to utilise all the weapons at hand in the laboratory as well as at the bedside to focus more efficiently on the one vital item, the study and treatment of the patient. The careful physician is convinced that no test, however important and decisive it may be, can take the place of a synthetic clinical opinion and the personal judgement of an intelligent and experienced clinician as to the condition of the patient and of the community.”

At this junctre of an era of revival of the constitutional concept, not only in India but in the whole world, it will be certainly interesting and instructive to study the Tridosha doctrine. The Tridosha concept of Ayurveda is the earliest constitutional concept Its germ can be seen even in the Rigveda but it was systematised and evolved as a scientific concept during the golden period of Ayurveda in India. If the true connotation of the terms in which such a concept is embodied is fully understood against the background of its origin and growth, much needless argumentation and opposition based on misunderatanding will be eliminated.

India, The Source

India is probably the source of the humoral theory of the Greeks and the Romans Dr Cyril Elwood M D. in his book “Medicine in Persia” states that this doctrine “was taught in unmistakable terms in the holy books of the Hindus From India it was carried to the Groeks [Greeks?] by way of Persia.”

Dr. George Draper M D in the book ‘Human Constitution in Clincal Medicine’ makes a similar statement:

“Indeed in ancient India the school of Ayurvedic medicine gave instructions for evaluating a patient’s nature. Later, in the medical disciplines of Persia and still later in the teachings of Hippocrates, aimilar advice is given to the pupils of Aesculapius.”

It is interesting to note that Castiglioni iu the ‘History of Medicine’ declares while giving a resume of the Ayurvedic system,

“The Ayurvedic system, according to those who have studied it carefully and appreciate its value, is important for its fundamental teaching. The theory of Tridosha is a kind of humoral doctrine which even today or perhaps especially today affords great interest for students. It affirms the existence of three Dosas or essential principles which pervade all the tissues, secretions and excretions and determine health and disease”

The Triumvirate (Tridosha)

For this reason the present attempt is confined to the providing of such a picture of the background, of the origin and gradual evolution of the concept of the triumvirate of pathogenesis i.e., of the Tridosha pathogenesis, the three determinants of pathogenetic and pathognomic phenomena comprising what is generally called Constitutional Pathology. These determinants of pathological variations, are in fact, when in a normal and well-balanced condition, the fundamental functionaries of the physiological state of the living organism Harmonious working of these three functionaries is health and their discordance is disease

Sir Michael Foster’s remark, “the science of meteorology that cannot be divided into the science of good weather and the science of bad weather,” can be aptly applied to the subject of health which cannot be divided in the science of good health and the science of bad health

Claude Bernard, the great physiologist, believed in the unity of science of physiology and pathology. He began the course of his lectures with the explanation that there is only one physiology whose domain is the study of normal and pathological functions. In actual fact, his work was almost as much concerned with pathological physiology as with the normal physiology

Thus the Tridosha is a concept of trinity of functional organisations applicable to and operative in both the realms of health and disease i. e. physiology and pathology of each and every form of life, from the ameba to man. Thus pathology becomes physiological in outlook enabling one to study disease conditions from the physiological point of view. The pathological processes are so co-ordinated with vital physiological processes that they can be interpreted in a common terminology.

The Origin of inquiry into Pathogenetics

It is but stating the obvious to say that all inquiry into the nature of phenomena starts from the latter’s quality of opposition to the full and happy flow and expression of life Pain and suffering, death and disease, fear and frustration arouse the spirit of inquiry and investigation in man. The philosophers of the Sankhya school start their inquiry into the nature of life provoked by the presence of suffering.

[Sāṃkhyakārikā 1]

“On account of affliction from the threefold misery, inquiry (should be instituted) into the means for its removal”

The Caraka Samhita also ascribes, to the emergence of disease among men interfering with the fulfilment of the purposive-ness of their lives, the effort of the sage-scholars in acquiring the right knowledge of disease and its remedial measures.

[Carakasaṃhitā Sūtrasthāna 1.15-17]

“Health is the supreme foundation of virtue, wealth, enjoyment and salvation Now, diseases are the destroyers of health, of the good life and even of life itself. Thus has arisen the great impediment to the progress of humanity What shall be the means of remedying it? Having observed thus they sat in meditation”.

[Carakasaṃhitā Sūtrasthāna 1.25]

“He, the sage of great understanding soon learned correctly by single-minded devotion the whole science of life tribased and extending without end”.

It is thus that distressed and goaded by pain and suffering, physical and mental, the effort of inquiry started and bore fruit in the shape of the discovery of the threefold determinants of all Physiological and Pathological processes of life

Inquiry must be Adequate and Scientific

It is not enough if the effort of inquiry is merely sincere and intense in guaranteeing the correctness of the results. The method adopted must be sound, adequate, rational and consistent with the fundamental facts of the physical and biological laws of the universe. The first of such positively scientific efforts was made by the Sankhya thinkers.

They emphasised the necessity of scientific knowledge and the following verse from the Caraka Samhita will ever remain the arch-aphorism as the guiding principle of all inquiry.

[Sūtrasthāna 30.84]

“The whole of suffering which cleaves to the mind and body has ignorance for its basis and conversely all happiness is founded in clear scientific knowledge”

What is Science?

From the various definitions and explanations given of science it becomes clear that science is in the method and not in the thing Science is:—

1. “Any department of systematised knowledge”

2. “A branch of study concerned with observation and with classification of facts specially with the establishment of verifiable general laws”.

3. “Accumulated knowledge systematised and formulated with reference to the discovery of general truths or the operation of general laws.”

These are some of the dictionary meanings of the word “Science” In practical life and in the usage of common parlance too, we understand by scientific thought, speech or action, a systematic process of evolution wherein each succeeding part is derived from its preceding part by the inevitable compulsion of logic and which relation such parts will maintain at any time or place, given the attendant circumstances

Karl Pearson in his “Grammar of Science” states,

“The man who classifies facts of any kind whatever, who sees their mutual relations and describes their sequences is applying the scientific method and is a man of science”

Science, thus, is the critical systematic knowledge based on generalizations. It is an investigation into the nature of facts, facts not selected at random but in their comprehensive entirety. The scientist systematises the data, records the observations and draws conclusions therefrom which ultimately assume the form of a formula or a universal truth. He proceeds rationally and logically through all his investigations. It is the cumulative product of both the processes of analysis and synthesis, the knowledge of individual ideas and things against the background of universal laws and concepts

The Totality of Knowledge

It is necessary again to remember that the totality of knowledge of things was aimed at by these ancient scientific thinkers. The understanding of any part merely in creation without the knowledge of the whole and the inter-relations of the parts was inadequate and liable to lead to wrong conclusions

[Carakasaṃhitā Vimānasthāna 4.5]

“The knowledge of the whole cannot accrue from the knowledge of merely a part” (Carakasaṃhitā Vimānasthāna 4.5)

The total concept led them to an all-comprehensive and synthetic method of study. The knowledge of the past was acquired but with special reference to the relation it bore to the whole i.e. to the present and the future. The knowledge of the parts was coordinated and placed in the proper perspective of the whole. They studied the nature of the whole in its entirety. This concept led to the study of man as a whole, i.e., as complete unit.

1. The Study of Man as a whole

Man was studied in his whole personality which is the dynamic organization within the individual of those psycho-physical systems that determine his unique adjustment to his environment. This led to the study of his constitution i.e., that aggregate of inherited characteristics, which, modified by environment, determine the man’s reaction to environmental factors.

2. The Study of the Universe for the discovery of all the Sources or factors of pain

The whole series of causes and sources of pain and suffering extending over the whole universe was included in the investigation

1. Totality of Man-cum environment,
2. Totality of environmental factors which become sources of pain or disease,
3. Totality of methods of investigation which covered all aspects of time and space,
4. Totality of things that were used as medication.

According to the Sankhya view, all misery is of three kinds, viz.,

1. Internal = of the body-mind.
2. External=of the physical world.
3. Spiritual = from supernatural sources.

Sushruta further sub-divides these three categories into seven which will be described in detail later on in the section on Etiological factors

Thus there remains nothing left uninvestigated in the universe, which can cause pain or suffering to man. It is an all-comprehensive classification.

3. The All-comprehensive method of Investigation

This method of investigation evolved a system which encompassed all the possible states of time and space. Time whether present, past or future, and space whether near or remote as well as things visible or invisible normal or abnormal, were all made possible of study by this system of investigation

[Carakasaṃhitā Sūtrasthāna 11.26]

“These are the methods of investigation, and there is no other left, which constitute the means by which all things are examined”

4. Totality of Things in the world used as Medication

The therapeutic science left no article or natural element unused.

[Carakasaṃhitā Sūtrasthāna 26.12]

“There is found in the world no substance that may not be used as medicine”

Thus to understand man, the subject of medical science, one has to understand not only the whole man but also the environment which begot and which sustains him and which is the cause of “ease” or “dis-ease” and which is also the source of medicaments. This environment therefore consists of the whole universe surounding him

The Need for Analysis

Thus the aim of the totality of knowledge required a very varied and extensive field of study for its attainment. It needed also some method of simplifying the study and classification or the analytic method became very necessary. This orderly arrangement and systematization gave some basic formula for generalization and a progressive field for research. The analytic process was carried on till the least common measure of classification was arrived at

The Sankhya classifies the universe into three categories:

1. the phenomenal physical world (vyakta),
2. the subtle or imperceptible world (avyakta) and
3. the principle of spirit that underlies the manifold vital forms and activities (jña).

From Metaphysics to Science

The medical propounders took the aid of the classification of things as held by both the Sankhya and the Vaisheshika schools, the latter enlisting the totality of things under the categories of Substance, Quality, Action, Generality, Particularity and Co-existence. From purely metaphysical methods Ayurveda passed ou to the physical and expert mental methods that physical categories and terms such as Substance, Quality and Action involve.

Atreya reduces the universe to nine substances viz., the five proto-elements, the mind, the spirit, time and space.

[Carakasaṃhitā Sūtrasthāna 1.48]

These combine to form the two main groups of things inanimate and animate.

All physical substances are reduced to the five categories of proto-elements and each proto-element is ascribed certain specific qualities, the total number of all the qualities coming to twenty in number. Thus the body-substance, environmental factors necessary for life-process, causative or curative factors of diseases—all these were reduced to a specific number of qualities whose use or avoidance could be prescribed in an arithmetical ratio

As a result of the analytical process, they arrived at the conclusion that each substance or thing consisted of an aggregate of five inter-related systems each possessing quite different and specific qualities. These systems they termed proto-elements or. The quality of each proto-element was determined and the manifestation of particular qualities of its specific grade or intensity in a substance depended upon the relative proportions of the proto-elements m that particular substance

This formula of proto-elements served the purpose in dealing with the merely physical Realities. But biological entities had two more factors to reckon with mind and spirit, which utilised and transformed physical matter to suit life’s purposes. Both these are dynamic forces, and cannot be observed by physical means (avyaktavyaktakarmā). They are to be known by the effects they produce on the body and their nature is the object of inferential knowledge.

The combination of physical and vital forces in the biological world gave rise to the individuality of organic existence which needs special organizations to maintain the harmonious and coordinated working of both the physical and the vital systems of the organism. The organization of bodily constituents is this mark of all living creatures and it is in this that they differ especially from inanimate things.

The formula of physical matter cannot adequately explain the phenomena of the biological world which is characterized by organization. One is a static existence while the other is a dynamic creative process Hence was felt the need to evolve the formula of biological function All living organisms need minimum triple organization for their life processes.

1. The organization of fluid-balance of the body (water-balance system) -A specie fluid matrix is essential to full expression of life phenomena. This organization has to maintain the specific consistency and structure of the fluid matrix under the stress of varying environmental factors.

2. The organization of Thermal balance:—Specific heat is necessary to digest and assimilate material from the environmental world and convert it into one’s own body parts and also to maintain the optimal heat of the body for full expression of life phenomena

3.The Organization of Vital balance:—Vital force is essential for the purpose of creative evolution, progress, power of organization aud such other vital processes which characterize life and differentiate animate from inanimate things

Specific Biological Terms

But as the physical body forms a part of the biological living organism, the physical formula has to be co-ordinated with and incorporated into this triumvirate of biological organizations to evolve a specific biological formula of the triad of Vata, Pitta and Kapha. The five categories of physical matter are transformed into three by the method of earth and water being grouped into one, and air and ether being combined together, with the result that all the five physical proto-elements found place in the living organism being translated into the biological forces of Vata, Pitta and Kapha, i.e., air and ether being combined into Vata, fire turned into Pitta and water and earth combined into Kapha.

[Aṣṭāṅgasaṃgraha A. 20.2]

A specific terminology was evolved for this triumvirate of biological categories, which is significant both of static existence as well as dynamic force viz, of Kapha which signifies (by ka=water) aqueous proto-element of the physical formula and which (by the addition of pha=phalati iti) signifies the evolutionary process of biological formula. Thus the whole word gives the sense of the organization of fluid matrix wherein the biological process of the evolution of life is carried out. The synonym (śleṣmā) is even more significant of the biological process of cohesion denoting the colloidal matrix or milieu for the vital play.

Pitta derived from (tap—“to heat”) is significant of the function of heat. Vata is derived from (vā—“to move”) and is quite suggestive of dynamic or functional process.

Thus these thinkers were forced to analyse and classify the elements of the phenomenal universe and their direct and indirect products and their various modes and forms of combination in bringing about the substances and dualities and actions that the physical sciences and medicine particularly have to deal with as their subjects and aho the biological organizations into which they were translated by the magic of the vital force

This endeavour to analyse, re group, classify and denominate the physical and biological facts and laws heralded the usherance of medicine into the stage of a science.

The Characteristics of the Golden Age

The central theory of Ayurveda—the theory of the triumvirate of Vata, Pitta and Kapha, is the product of an age which is universally regarded as the most brilliant in the long annals of man. This age which was marked by the most intense intellectual activity in the East as well as in the West, particularly in India and Greece, not only laid the foundations of thought on which the world has continued to build but has to its credit achievements which are still the crowning glory in art, literature, philosophy and medicine

The age which in Greece threw up intellectual giants like Plato and Aristotle Pythagoras and Hippocrates, was in India responsible for the rise of the seers of the Upanisads and of Ayurveda. Philosophy was at this time the supreme pursuit of the thinking man, and it was to the philosopher’s counter that people came for the ultimate concepts of life. The arts and the sciences were, to be sure actively cultivated, but they played a subservient role to philosophy, the undisputed queen in the realm of thought

This meant that specialization was allowed but the final verdict did not he with the specialist but with the general overseer, the philosopher? who alone was in a position to assess the value of the contributions made by the specialists. The result was the development of a coordinated outlook which studied the parts but which also studied them as forming the whole. It was this synthetic or integrated outlook which has given us the Tridosha concept of Ayurveda.

This view is based on the concept that any manifestation of life must involve the coming together of the three factors of the spirit, the mind and the body, the tripod on which the world is based

This coming together or assemblage of spirit, mind and body which we know as life, was studied both in in its constituents and as a whole. The individual study of the parts gave rise to several special branches of study such as metaphysics, psychology and the physical or natural sciences; while the attempt to study the living conglomerate as a whole, became the special concern of the physician whose business. It was to keep it a going concern and in perfect condition for as long as it was possible.

It was at this time when the physician occupied the exalted place, when medicine and metaphysics were equally the domain of the Vaidya—the man of knowledge, that the Ayurvedic classics came to be written by men who were admittedly the wisest of the age. Hippocrates says that the nearest thing io divinity is the physician who is also a philosopher. If this is so, who can deny that men like Atreya and Dhanvantari are as near-gods as any that mortality can breed?

It is to these physician-philosophers of the golden age of India that we owe the concept of life as embodied in the Caraka and the Sushruta, a complete and integrated concept which is so broad-based that in its main outline it must hold good for all time. It is true that the perception of these sages could not claim the advantage of the elaborations due to mechanical devices that are possible today. But their integrated and total vision of the organism along with the nodus operandi of its threefold organization and the means adopted to preserve and prolong its existence and functioning, is as supreme today in its validity as when it was first promulgated.