Madhava-Nidana of Madhavakara With the Commentary of Madhukosa (An Ancient Text on Ayurvedic Diagnosis)

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Diagnosis forms the most significant part of medicine. The development of the science of diagnosis through successive stages of history makes not only an interesting read but it also equips one with the experiences, successes and the learning achieved by countless generations in the yore and helps one to address problems of the future in an organized way. The pre-modern diagnostics as prevalent and propounded by seers like Caraka and Susruta and countless other scholars was precisely put together by the Madhava Nidana authored by Madhavakara somewhere in 9th century AD. The work seems to have immediately caught the attention of physicians in India and abroad who found it the most serviceable text on diagnostics. Small wonder, many scholars produced commentaries on Madhava Nidana across the country. These commentaries detailed the ideas contained in the work and on occasions, even advanced, and repudiated the assumptions of Madhavakara as well as that of great seers of the yore. A reading into the various commentaries on Madhava Nidana demonstrates the background of Argumentative Indian Prof. Amartya Sen has been talking about recently. It also demonstrates the old Indian spirit of tolerance and the practice of lending a patient ear to the diverse and contradictory views.

Nonetheless, it is only a truism that decline of Ayurveda mostly owed to its poor standards of diagnostics. Therefore, it is significant that an authentic text on Ayurvedic diagnosis along with is Commentary is brought to the access of English knowing readers. In preparing the present work, it was a matter of satisfaction for us as we attempted to add modern perspectives every here and there in the text.

It is hoped that through the present work, the students of Ayurveda, the practicing physicians, and those interested in Indian History could have a better understanding of pre-modern Indian society as well as its medicine.

Kanjiv Lochan obtained Ph. D on History of Ayurveda and related medicines from the Center of Historical Studies, Jawaharlal Nehru University, New Delhi. He has been awarded a Visiting Scholar Status from Department of History and Philosophy of Science, University of Cambridge, UK and been a Visiting Associate Prof. of History of Science with the Mahidol University, Bangkok, Thailand. Presently he is teaching history under Ranchi University, Ranchi, Jharkhand. He lives at a rural town Lohardaga, of this state.

Diagnosis forms the most significant part of medicine. The development of the science of diagnosis through successive stages of history makes not only an interesting read but it also equips one with the experiences and successes and the learning achieved by countless number of generations in the yore. It no doubt helps one to address problems of the future in an organized way. The string of a bow, if stretched deep, helps the arrow measure a long distance without doubt. Likewise, as experts and knowledgeable opine, proper discovery and analysis of the past help us to plan for a longer future and in a better perspective.

Ayurveda regards the state of not being well as unpleasant or misery (duhkha) i.e., disease. The diseases are classified into three major categories: adhibhautika, adhidaivika and adhydtmika. Although the disease-state is predominantly a condition of imbalance of the so called dosas, dhatus and malas, in final presentation it is notably influenced by the seat (adhisthana) of their vitiation.

The Ayurvedic diagnosis in principle is a qualitative diagnosis, not in terms of the name of a specific disease, but it is an elaborately descriptive procedure to determine the nature of the disease and its aetio-pathogenesis. As the objective of the diagnosis is complex, the methodology too has to be complex covering the comprehensive aetio-pathological dimensions in a patient. In order to materialize this, Ayurveda sought a dual approach of what may be called the rogi-roga pariksa. Ayurveda is the only system of medicine in the world that has conceived the idea of identifying the patient and the disease together. An Ayurvedic physician does not examine his patient only as a diseased entity but it also assesses an individual with all his or her attributes including his or her constitution, temperament, and life-style. A physician explores the person in the patient and the health in his or her diseased state.

The important component of the entire diagnostic exercise is to judge and estimate the remaining health avasista svasthya] of a patient. It is for this purpose that Caraka describes the tenfold dimensions dasa-vidha pariksa. A patient has to be examined to evaluate ten aspects of (dasavidha pariksa) namely: (1) his constitution (prakrti) including his mental and psychophysical aspects, (2) disease susceptibility (vikrti) (3) quality of tissues (sara); (4) compactness of body (samhanana) (5) body measures or anthropometry (pramana); (6) suitability or adaptability (satmya) (7) mental strength (sattva); (8) digestive power (ahara sakti); (9) exercise - the capacity to endure (vyayama sakti) and (10) the rate of ageing (vaikarana).

Apart from this, the chronological progression (kriyakala) of the disease is also to be analyzed too, as learning this helps a proper management of the disease. The fundamental philosophy behind the concept of kriyakala is to advocate an early diagnosis and appropriate intervention in order to reverse the disease process at the earliest. The ix kriyakalas, according to Susruta, are: (i) Sancaya- accumulation of dosas; (ii) Prakopa - vitiation or aggravation of dosas; (iii) Prasara or spread of vitiated dosas; (iv) Sthana samsraya -localization of vitiated dosas at defective sites; (v) Vyakti - manifestation of the disease; and (vi) Bheda - further advancement and complications.

Ayurveda describes detailed methods of case history and clinical examination with certain specific approaches. It lays special stress on intimate doctor-patient relationship or high quality rapport in order to achieve the necessary understanding of a patient and his ailments. A successful physician has to be not only well trained and knowledgeable but also adequately wise, intelligent, transparently sincere too, and in close rapport with his patient. Caraka stresses that 'unless a physician succeeds in entering the innermost area (antaratma) of his patient in the light of the lamp of his (the physician's) knowledge and wisdom, he cannot treat him' (CS, Vs. 4.19).

Ayurveda identifies the fundamental importance of examining a patient by application of direct perception (pratyksa) and inference (anumana). In addition, however, it accepts verbal or textual knowledge as testimony (aptopadesa), the orally transmitted tradition, or a record of observational experience of Ayurvedic experts in diagnosis in the same way as a student of modern medicine accepts the textual as well as his educator's exposition. Pratyaksa, anumana and aptopadesa are collectively named the trividha pramana or trividha pariksa (three methods of diagnostic knowledge or examination). According to Caraka, the fourth but an important supplementary diagnostic approach, is yukti. A physician should try to obtain information of a disease through experimentation or planned investigations to either confirm or negate his perceptions of the causative factors of disease based on the first three methods. As for the examination or diagnosis of a disease in a patient, eight chosen points (astavidha pariksa) form the general examination: pulse, urine stool, tongue, voice and speech, skin, eyes and the face, followed by the examination of a patients head and neck, chest, abdomen, and limbs.

Throughout the pre-modern ages and across the globe, the medicine of India remained the best tradition of the world. This assumption is reinforced through stances of attempts to duplicate Indian medical traditions or part of that in ancient Greece and China. Nonetheless, the medical science in Europe was revolutionized in the 19th century and later by advances in chemistry and laboratory techniques and equipment, old ideas of infectious disease epidemiology were replaced with bacteriology. Much in medicine that is now taken for granted was undreamed of even as recently as 40 years ago. Progress in diagnosis, in preventive medicine and in treatment, both medical and surgical, has been rapid and breathtaking. Presently smallpox has been eradicated, poliomyelitis practically banished, tuberculosis has become curable and coronary artery disease surgically relievable.

The credit of advancing medicine goes to certain inventing brains that were facilitated through discoveries and advancement in physics, chemistry, botany and the like. Such inventors were not essentially physicians or surgeons. Nonetheless, medicine was directly benefitted through their inventions.

To name some of them, it may be recalled that Andreas Vesalius (1514-1564) of Belgium was an anatomist who authored in 1543, a very useful work on the human anatomy, De humani corporis fabrica (On the Workings of Human Body). Even though, anatomy has advanced tremendously, Vesalius is often referred to as the founder of modern human anatomy. Edward Jenner (1749- 1823) was an English scientist who is known to have introduced the smallpox vaccine in the year 1796.

Stethoscope was invented in France in 1816 by Rene- Theophile-Hyacinthe Laennec. Louis Pasteur (1822-1895) of France invented what was named as pasteurization. His discovery that most infectious diseases are caused by germs, known as the "germ theory of disease," is one of the most important findings in medical history. He solved the mysteries of rabies, anthrax, chicken cholera, and silk-worm diseases, and contributed to the development of the first vaccines.

In 1928, Alexander Fleming discovered Penicillin and won the Nobel Prize in Physiology or Medicine in the year 1945 jointly along with Ernst Boris Chain of UK and Sir Howard Walter Florey of Australia. Jules Jean Baptiste Vincent Bordet (1870-1961) who was a Belgian immunologist and microbiologist, described phagocytosis of bacteria by white blood cells. In 1898, he established how hemolysis evoked by exposure of blood serum to foreign blood cells. The Nobel Prize in Physiology or Medicine was awarded to him in 1919 for his discoveries relating to immunity.

Such advancement in medicine could be achieved in the backdrop of the progress achieved through the age of enlightenment that followed the Renaissance and Industrial Revolution. However, before medicine could be advanced, the background of this advancement was prepared many where in the world. As the invention of wheel by the unknown Homo erectus paved the way to lunar mission, the theories and products of early medicine man in terms of diagnosis, cure, and rehabilitation of patients could not be ignored by history even if they are considered too rudimentary. After all, the primitive and the advanced have all been concerned with the human beings and their welfare.

Thus, presenting an analytical reading of the Madhava Nidana that is the most authentic work on diagnosis pre-modern India produced addresses a need of the day. The pre-modem diagnostics as prevalent and propounded by seers like Caraka and Susruta and others has been precisely put together by the Madhava Nidana authored by Madhavakara. Madhavakara, somewhere in 9th century AD compiled passages on diagnostics scattered through the works of Caraka and Susruta and countless other scholars of Ayurveda to produce the work. The work seems to have immediately caught the attention of physicians who found the work the most serviceable text on diagnostics. Small wonder, many scholars have produced commentaries on Madhava Nidana across the globe. These commentaries detailed the ideas of Madhavakara and on occasions, even advanced, and repudiated the assumption of Madhavakara as well as that of great seers of the yore. A reading into the various commentaries on Madhava Nidana demonstrates the background of argumentative Indian Prof Amrtya Sen has been talking about recently. It also demonstrates the old spirit of tolerance and the practice of lending a patient ear to the diverse and contradictory views.

However, it is only a truism that decline of Ayurveda mostly owes to its poor standards of diagnostics. Therefore, it is significant that an authentic text on Ayurvedic diagnosis along with its Commentary is brought to the access of English knowing readers. In preparing the present work, it was a matter of satisfaction for us as we attempted to fill up a significant lacuna in Ayurvedic studies in English. The present work presents critical readings of the text of Madhava Nidana and the Madhu Kosa Commentary on it by Vijayaraksita and Srikanthadatta. This Madhu Kosa has profusely involved comments of several scholar physicians like Gayadasa, Jejjata, Jatukarna and Videha. Thus, combined with Madhu Kosa, the Madhava Nidana presents an almost exhaustive Compendium of the science of diagnostics as prevalent in pre-modern India. To facilitate the readers, we have attempted to present modern perspectives on various diseases throughout the pages of present work. We have tried to present an updated account of various modern findings as far as possible. None-theless, as medicine is a complex issue, one need to consult competent physicians before referring to various assumptions of the present book.

It is hoped that through the present work, the learned readers would have a better understanding of pre-modern medicines that laid the foundation of healing art in India. Our failure to understand the intricacies of the medicine in past might hinder our goals to provide health for all. Moreover, medicine is a complex issue. Apart from the technical aspects, it relates to the multiple issues like sociology, culture, and religion. The old works of medicine like the Madhava Nidana encompasses these multiple factors. Thus, in terms of understanding the cultural milieu of the medicine in India, the significance of Madhava Nidana can never be over-emphasized.

The western system of medicine contains an intricate knowledge of Anatomy, Chemistry, and Biochemistry of the body but little knowledge of the socio-cultural nuances that affect a holistic understanding of the disease and the diseased. The future of medicine and the human race will greatly depend on the advancement of our understanding of diagnostics. Only through this advancement, we shall be able to effectively address illnesses in the future. We could control the problems such as those seen in our growing elderly population, the HIV, Cancer, Diabetes, and the like. In conclusion, as you read the pages of this publication of Madhavakara's Diagnostics, you will receive the gifts compiled from countless years of scholarly labours in the understanding of health and illness in one of the earliest civilizations on the earth.