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REVIEW ARTICLE
Year : 2011  |  Volume : 32  |  Issue : 4  |  Page : 466-471  

Ritucharya : Answer to the lifestyle disorders


1 Internee, Department of Samhita and Siddhanta, J. B. Roy State Ayurvedic Medical College and Hospital, Kolkata, West Bengal, India
2 Lecturer, Department of Samhita and Siddhanta, J. B. Roy State Ayurvedic Medical College and Hospital, Kolkata, West Bengal, India
3 Lecturer, Department of Rasa shastra, J. B. Roy State Ayurvedic Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication14-May-2012

Correspondence Address:
Prasanta K Sarkar
J. B. Roy State Ayurvedic Medical College and Hospital, 170 172, Raja Dinendra Street, Kolkata 700 004, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-8520.96117

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   Abstract 

Ritu , the season, classified by different features expresses different effects on the body as well as the environment. Ayurveda has depicted various rules and regimens (Charya), regarding diet and behavior to acclimatize seasonal enforcement easily without altering body homeostasis. The prime principle of Ayurvedic system of medicine is preventive aspect, can be achieved by the change in diet and practices in response to change in climatic condition. This is a very important aspect of preventive medicine as mentioned in Ayurvedic texts. Lifestyle disorders are very common in the present era, basically originating from lack of following seasonal regimens due to lack of concentration in seasonal characteristics. A firm scientific analysis is the base, which holds true even on date. In this review article, various regimens in diet and lifestyle as mentioned in the classics of Ayurveda and their importance on lifestyle disorders has been discussed.

Keywords: Lifestyle disorders, seasonal regimens, seasonal variations in India


How to cite this article:
Thakkar J, Chaudhari S, Sarkar PK. Ritucharya : Answer to the lifestyle disorders. AYU 2011;32:466-71

How to cite this URL:
Thakkar J, Chaudhari S, Sarkar PK. Ritucharya : Answer to the lifestyle disorders. AYU [serial online] 2011 [cited 2020 Nov 27];32:466-71. Available from: https://www.ayujournal.org/text.asp?2011/32/4/466/96117


   Introduction Top


Ayurveda, the age old science of life, has always emphasized to maintain the health and prevent the diseases by following proper diet and lifestyle regimen rather than treatment and cure of the diseases. The basic principle followed in the Ayurvedic system of medicine is Swasthyashya Swasthya Rakshanam, which means to maintain the health of the healthy, rather than Aturashya Vikara Prashamanancha, means to cure the diseases of the diseased. [1] For this purpose the Dinacharya (daily regimen) and Ritucharya (seasonal regimen) have been mentioned in the classics of Ayurveda. [2]

With the change in season, the change is very evident in the environment we live in. We see various changes in bio-life around us, such as flowering in spring and leaf-shedding in autumn in the plants, hibernation of many animals with the coming of winter, and so on. As human being is also part of the same ecology, the body is greatly influenced by external environment. Many of the exogenous and endogenous rhythm have specific phase relationship with each other; which means that they interact and synchronize each other. If body is unable to adopt itself to stressors due to changes in specific traits of seasons, it may lead to Dosha Vaishamya, which in turn may render the body highly susceptible to one or other kinds of disorders. [3]

As adaptations according to the changes, is the key for survival , the knowledge of Ritucharya (regimen for various seasons) is thus important. People do not know or ignore the suitable types of food stuffs, dressing, and others regimen to be followed in particular season, this leads to derangement of homeostasis and causes various diseases, such as obesity, diabetes, hypertension, cancer, and so on. Lifestyle diseases are a result of an inappropriate relationship of people with their environment. Onset of these lifestyle diseases is insidious, delayed development, and difficult to cure. [4] In our country the situation is quite alarming due to rapid changing of disease profile. The World Health Organization has identified India as one of the nations that is going to have most of the lifestyle disorders in the near future. Nowadays, not only are lifestyle disorders becoming more common, but they are also affecting younger population. Hence, the population at risk shifts from 40+ to maybe 30+ or even younger. Already considered the diabetes capital of the world, India now appears headed toward gaining another dubious distinction of becoming the lifestyle-related disease capital as well. A study conducted jointly by the All India Institute of Medical Sciences and Max Hospital shows the incidence of hypertension, obesity, and heart disease is increasing at an alarming rate, especially in the young, urban population. According to the doctors, a sedentary lifestyle combined with an increase in the consumption of fatty food and alcohol is to blame cases of obesity, diabetes, hypertension, and so on.

Ritucharya is prominently discussed in the first few chapters of most of the Samhitas of Ayurveda. Prevention of disease to maintain health is being the first and foremost aim of the holistic science of Ayurveda. In Tasyashitya chapter of Charaka Samhita, it is said "Tasya Shitadiya Ahaarbalam Varnascha Vardhate. Tasyartusatmayam Vaditam Chestaharvyapasrayam," which means 'the strength and complexion of the person knowing the suitable diet and regimen for every season and practicing accordingly are enhanced. [5] Main theme of this chapter is to make people aware concerning the methods to live in accordance with the environment. In this article, the Ritucharyas mentioned in the classics of Ayurveda have been discussed and emphasis has been given on the likely impact of Ritucharya on lifestyle disorders.

Classification of season

The year according to Ayurveda is divided into two periods Ayana (solstice) depending on the direction of movement of sun that is Uttarayana (northern solstice) and Dakshinayana (southern solstice). Each is formed of three Ritus (seasons). The word Ritu means "to go." It is the form in which the nature expresses itself in a sequence in particular and specific in present forms in short, the seasons. [6]

A year consists of six seasons, namely, Shishira (winter), Vasanta (spring), and Grishma (summer) in Uttarayan and Varsha (monsoon), Sharata (autumn), and Hemanta (late autumn) in Dakshinayana. As Ayurveda has its origin in India, the above seasonal changes are observed predominantly in Indian subcontinent.

Uttarayana and its effect

Uttarayana indicates the ascent of the sun or northward movement of the sun. In this period the sun and the wind are powerful. The sun takes away the strength of the people and the cooling quality of the earth. It brings increase in the Tikta (bitter), Kashaya (astringent), and Katu (pungent) Rasa (taste), respectively, which brings about dryness in the body and reduces the Bala (strength). It is also called Adana Kala.

According to modern science, this can be compared with the gradual movement of earth around the sun to the position, in which the rays of the sun falls perpendicularly at 30 degree meridian of the North Pole on June 21 st every year, called as summer solstice. The northward journey of the Sun from Tropic of Capricorn to Tropic of Cancer happens.

During Uttarayana the seasonal changes in Indian subcontinent is from Shishira (winter) to Vasanta (spring) and to Grishma (summer). The period can be compared to mid-January to mid-July, when warmness and dryness in weather increases. It has an overall debilitating effect on environment, to which human being is also a part.

Dakshinayana and its effect

Dakshinayana indicates the descent of the sun or movement of the sun in southern direction. In this period, the wind is not very dry; the moon is more powerful than sun. The earth becomes cool due to the clouds, rain, and cold winds. Unctuousness sets in the atmosphere and Amla (sour), Lavana (salty), and Madhura (sweet) Rasa are predominant, so the strength of person enhances during this period. It is also called Visarga Kala.

According to modern science, this can be compared with the gradual movement of the earth around the sun to the position, in which the rays of the sun fall over 30 degree meridian of the South Pole perpendicularly on December 21 st every year, is called as winter solstice. The southward movement of the Sun occurs from Tropic of Cancer to Tropic of Capricorn.

During Dakshinayana, the seasonal changes occur in the Indian subcontinent from Varsha (monsoon) to Sarata (autumn) and to Hemanta (late autumn). This period can be compared to mid-July to mid-January, when cool sets, and due to which anabolic activity dominates over the catabolic activity in the environment.

State of strength

In the beginning of Visarga Kala and ending of Adana kala, that is, during Varsha and Grishma, weakness occurs. In the middle of the solstices, that is, during Sharata and Vasanta, strength remains in moderate grade and in the end of Visarga Kala and in the beginning of Adana Kala, that is, during Hemanta and Shishira, maximum strength is seen. [7]

Regimen of different seasons

Shishira (winter)

General condition


Mid-January to mid-March (approximately) is considered as Shishira Ritu (winter). During this season, the environment remains cold, along with cold wind. The predominant Rasa and Mahabhuta during this season are Tikta (bitter) and Akasha, respectively. The strength of the person becomes less, deposition of the Kapha Dosha occurs and Agni (catabolism) remains in a higher state.

Diet regimen

Foods having Amla (sour) as the predominant taste are preferred. Cereals and pulses, wheat/gram flour products, new rice, corn, and others, are advised. Ginger, garlic, Haritaki (fruits of Terminalia chebula), Pippali (fruits of Piper longum), sugarcane products, and milk and milk products are to be included in the diet.

Foods having Katu (pungent), Tikta (bitter), Kashaya (astringent) predominant Rasa are to be avoided. Laghu (light) and Shita (cold) foods are advised to be prohibited.

Lifestyle

Massage with oil/powder/paste, bathing with lukewarm water, exposure to sunlight, wearing warm clothes are mentioned to follow.

Vata aggravating lifestyle like exposure to cold wind, excessive walking, sleep at late night, are to be avoided.

Vasanta (spring)

General condition


The approximate time is from mid-March to mid-May. This season is considered as season of flowering and origin of new leaves. Predominant Rasa and Mahabhuta during this season are Kashaya (astringent), and Prithvi and Vayu, respectively. Strength of the person remains in medium degree, vitiation of Kapha Dosha occurs and Agni remains in Manda state.

Diet regimen

One should take easily digestible foods. Among cereals, old barley, wheat, rice, and others are preferred. Among pulses, lentil, Mugda, and others, can be taken. Food items tasting Tikta (bitter), Katu (pungent), and Kashaya (astringent) are to be taken. Besides those, honey is to be included in the diet. Meats like that of Shahsa (rabbit), which are easy to digest can be taken.

Foods which are hard to digest are to be avoided. Those which are Sheeta (cold), Snigdha (viscous), Guru (heavy), Amla (sour), Madhura (sweet) are not preferred. New grains, curd, cold drinks, and so on, are also to be prohibited.

Lifestyle

One should use warm water for bathing purpose, may do exercise during Vasant Ritu. Udvartana (massage) with powder of Chandana (Santalum album), Kesara (Crocus sativus), Agaru, and others, Kavala (gargle), Dhooma (smoking), Anjana (collyrium), and evacuative measures, such as Vamana and Nasya are advised.

Day-sleep is strictly contraindicated during this season.

Grishma (summer)

General condition


Mid-May to mid-July (approximately) is considered as Grishma (summer) season. Environment is prevalent with intense heat and unhealthy wind. The river-bodies dried and the plants appear lifeless. The predominant Rasa is Katu (pungent) and Mahabhuta are Agni and Vayu. The strength of the person become less, deposition of Vata Dosha occurs, but the vitiated Kapha Dosha is pacified during this season. Agni of the person will remain in mild state.

Diet regimen

Foods which are light to digest-those having Madhura (sweet), Snigdha (unctuous), Sheeta (cold), and Drava (liquid) Guna, such as rice, lentil, etc, are to be taken. Drinking plenty of water and other liquids, such as cold water, buttermilk, fruit juices, meat soups, mango juice, churned curd with pepper, is to be practiced. At bedtime milk with sugar candy is to be taken.

Lavana and food with Katu (pungent) and Amla (sour) taste and Ushna (warm) foods are to be avoided.

Lifestyle

Staying in cool places, applying sandal wood and other aromatic pastes over the body, adorning with flowers, wearing light dresses and sleeping at day time are helpful. During night one can enjoy the cooled moonrays with breeze. Excessive exercise or hardwork is to be avoided; too much sexual indulgence and alcoholic preparations are prohibited.

Varsha (monsoon)

General condition


Mid-July to mid-September (approximately) is considered as Varsha Ritu. During this season the sky is covered by clouds and rains occur without thunderstorm. The ponds, rivers, etc., are filled with water. The predominant Rasa and Mahabhuta during this season are Amla (sour), and Prithvi and Agni, respectively. The strength of the person again becomes less, vitiation of Vata Dosha and deposition of Pitta Dosha, Agni also gets vitiated.

Diet regimen

Foods having Amla (sour) and Lavana (salty) taste and of Sneha (unctuous) qualities are to be taken. Among cereals, old barley, rice, wheat, etc., are advised. Besides meat soup, Yusha (soup), etc. are to be included in the diet. It is mentioned that one should take medicated water or boiled water.

Intake of river water, churned preparations having more water, excessive liquid and wine are to be avoided. The foods, which are heavy and hard to digest, like meat, etc., are prohibited.

Lifestyle

Use of boiled water for bath and rubbing the body with oil properly after bath is advised. Medicated Basti (enema) is prescribed as an evacuative measure to expel vitiated Doshas.

Getting wet in rain, day-sleep, exercise, hard work, sexual indulgence, wind, staying at river-bank, etc., are to be prohibited.

Sharat (autumn)

General condition


The period between mid-September to mid-November is Sharat Ritu (autumn). During this time the Sun becomes bright, the sky remains clear and sometimes with white cloud, and the earth is covered with wet mud. The predominant Rasa is Lavana (salty) and predominant Mahabhutas are Apa and Agni. The strength of the person remains medium, pacification of vitiated Vata Dosha and vitiation of Pitta Dosha occur, and activity of Agni increases during this season.

Diet regimen

Foods are having Madhura (sweet) and Tikta (bitter) taste, and of Laghu (light to digest) and cold properties are advised. Foods having the properties to pacify vitiated Pitta are advised. Wheat, green gram, sugar candy, honey, Patola (Trichosanthes diocia), flesh of animals of dry land (Jangala Mamsa) are to be included in the diet.

Hot, bitter, sweet, and astringent foods are to be avoided. The food items, such as fat, oils, meat of aquatic animals, curds, etc., are also to be not included in the diet during this season.

Lifestyle

Habit of eating food, only when there is a feeling of hunger is recommended. One should take water purified by the rays of sun in day time and rays of moon at night time for drinking, bathing, etc. It is advised to wear flower garlands, and to apply paste of Chandana (Santalum album) on the body. It is said that moon rays in the first 3 h of night is conducive for health. Medical procedures, such as Virechana (purging), Rakta-Mokshana (blood letting), etc, should be done during this season.

Day-sleep, excessive eating, excessive exposure to sunlight, etc., are to be avoided.

Hemanta (late autumn)

General condition


Mid-November to mid-January is considered as Hemanta (late autumn) Ritu. Blow of cold winds starts and chillness is felt. Predominant Rasa during this season is Madhura and the predominant Mahabhutas are Prithivi and Apa. The strength of a person remains on highest grade and vitiated Pitta Dosha gets pacified. Activity of Agni is increased.

Diet regimen

One should use unctuous, sweet, sour, and salty foods. Among cereals and pulses, new rice, flour preparations, green gram, Masha, etc., are mentioned to be used. Various meats, fats, milk and milk products, sugarcane products, Shidhu (fermented preparations), Tila (sesame), and so on, are also to be included in the diet.

Vata aggravating foods, such as Laghu (light), cold, and dry foods are to be avoided. Intake of colddrinks is also contraindicated.

Lifestyle

Exercise, body and head massage, use of warm water, Atapa-sevana (sunbath), application of Agaru on body, heavy clothing, sexual indulgence with one partner, residing in warm places is recommended.

Exposure to strong and cold wind, habit of day sleep, etc., are mentioned to be avoided. [2],[8],[9],[10],[11],[12],[13]


   Discussion Top


This is the way the ancient sages set up the regimen for various seasons on analytical reasoning to obtain Swastha (health) and prevent the diseases. The examples set by them stand as a hint to decide other dos' and don'ts' in the regimen-Ritucharya [Table 1].
Table 1: Table summarizes the seasonal Do's and Don'ts

Click here to view


The environmental factors include the nature of the land, water, and various atmospheric phenomena, including temperature, humidity, wind, rain, clouds, and atmospheric pressure. All these environmental factors undergo a continuous change and at a time, no two moments are exactly alike in a given place. Thus with the rising Sun the temperature keeps on rising and gradually drops at night. The maximum and minimum temperature fluctuates daily but it is highest in summer and lowest in winter. Similarly, all these factors show diurnal as well as seasonal variations and these variations for a particular time are known as season. [14]

A study on animals with seasonal changes revealed the effects of photoperiod on immune function and hormone synthesis which influence the development of opportunistic disease. [15] Another study indicated that free-living species from many regions can seasonally modulate glucocorticoid release. In other words, the magnitudes of both unstressed and stressed glucocorticoid concentrations change depending on the time of the year. [16]

A human clinical study was carried out by Mallika et al. to assess the biophysical and biochemical changes occurring due to Ritusandhi. Clinical study shows provocation of Tridosha with the dominance of Vata and Kapha provocation. In this study during Ritusandhi frequently, Jwara, Pratishyaya, and Alasya Lakshnas were met with. In Agnibala also although remarkable changes are seen, they are not up to pathologic mark. Regarding the biochemical changes, there is a varied pattern-sometimes increasing and decreasing, but all these are within the range of normal variations. The variation in biochemical values are seen but not remarkable. [3]

One study carried out by Jangid et al. on the concept of Ritus and their effect on Bala reported that the overall effect of Hemanta Ritu on Bala of healthy volunteers was maximum, effect of Vasanta Ritu was moderate and the effect of Varsha Ritu was minimum, and concluded that Hemanta is the Ritu of Pravara Bala, Vasanta is the Ritu of Madhyama Bala and Varsha is the Ritu of Avara Bala. Results of the study support the principles of Ayurveda. [14]

Many other systems of medical science have observed the influence of seasonal rhythm in physical and mental health. To quote Hippocrates, "Whoever wishes to investigate medicine properly should proceed thus in the first place to consider the seasons of the year and what affect each of them produces." [17] Even in Tibetan system of medicine, seasons are regarded as one of the fundamental factors in etiology and pathology, and a powerful instrument in the prevention of diseases.

In Ayurveda, the knowledge of Ritucharya is a first hand guide to the concept of Kriya-Kala, which describes the modes and stages of the development of diseases, with regard to the state of different Doshas-Vatu, Pitta, and Kapha in accordance with the changes of time. A good understanding of it is very much essential for early diagnosis and prognosis for adopting preventive and curative measures.

It is to be known that disharmony in the Doshas-Vatu, Pitta, and Kapha results in Roga (disease). And aim of the science of Ayurveda is to maintain the harmony. With changes in diet and lifestyle, there are changes in the state of Tridosha, which is bound to affect us, resulting disharmony, causing lifestyle diseases. Ritu acts as Vyanjaka or Nimittakarana in the aggravation and manifestation of disease. For example, an evening (afternoon) headache is essentially with Vata predominance. Diseases due to Vata show a tendency to aggravate during the rainy season. [18]

It has been observed that there is an increased occurrence of flu, dry skin in winter, heat stroke in summer, pollen allergy in spring, high incidence of air and water borne diseases in rainy season, and skin diseases in autumn. Thus it can be said that physiology vindicates the concept of Ritucharya. [19] Studies have even revealed the increased incidence of Asthma attack in winter season. There is also a reference of Seasonal Affective Disorder in modern science. [20]

Peoples' diet changed substantially in the second half of 20 th century, generally with increased consumption of meat, dairy products, vegetable oils, fruit juice, and alcoholic beverages, and decreased consumption of starchy staple foods, such as bread, potatoes, rice, and maize flour. These observations suggest that the diets [or lifestyle] of different populations might partly determine the rates of cancer, and other lifestyle disorders, such as obesity, diabetes, cardiovascular diseases, etc. [21] In 1900, the top three causes of death in the United States were pneumonia/influenza, tuberculosis, and diarrhea/enteritis. Communicable diseases accounted for about 60% of all deaths. In 1900, heart disease and cancer were ranked number 4 and 8, respectively. Since the 1940s, the majority of deaths in the United States have resulted from heart disease, cancer, and other degenerative diseases. And, by the late 1990s, degenerative diseases accounted for more than 60% of all deaths. [22]

Already considered the diabetes capital of the world, India now appears headed towards gaining another dubious distinction of becoming the lifestyle-related disease capital as well. A study conducted jointly by the All India Institute of Medical Sciences and Max Hospital shows that the incidence of hypertension, obesity, and heart disease is increasing at an alarming rate, especially in the young, urban population. [23]

Doctors however say a strict diet and regular exercise along with cholesterol controlling drugs can go a long way in checking lifestyle diseases. But with the knowledge of Ritucharya we can surely avoid these by practicing regimen in accordance with the Ritu to maintain the harmony of the Tridosha and to stay healthy ever. Growing public awareness, with the support of the government and corporate wellness programs may help arrest the rapid increase in the incidence of such diseases, saving lives and crores of rupees in costs.

With global warming and variation in the advent of season, it can surely be a query, of the importance of Ritucharya in the present scenario. It is to be understood that the background on which Ritucharya is based, that is, Dosha and Panchamahabhuta theory. Although today Ritus do not follow uniformity, the level of Dosha and Panchamahabhuta can be analyzed accordingly, to decide the regimen, to which this knowledge of Ayurveda holds as a pathfinder. These principles surely demand a closer observation for clarity.

 
   References Top

1.Kushwaha HC, editor. Acharya Charaks' Charak Samhita. Pratham Bhag, Varanasi: Chowkhamba Orientalia; 2009.  Back to cited text no. 1
    
2.Tripathi B, editor. Acharya Charaks' Charak Samhita. Varanasi: Chowkhamba Surbharati Prakashan; 2007.  Back to cited text no. 2
    
3.Mallika KJ. Critical study of Swastha-Catuska w.s.r. to Biophysical and Biochemical changes in Rtusandhi. MD (Ayu) Thesis. Jamnagar: Gujarat Ayurved University; 2002.  Back to cited text no. 3
    
4.Steyn K, Fourie J, Bradshaw D. The impact of chronic diseases of lifestyle and the major risk factors on mortality in South Africa. S African Med J 1992;82:227-31.  Back to cited text no. 4
    
5.Tripathi B, editor. Acharya Charaks' Charak Samhita. Varanasi: Chowkhamba Surbharati Prakashan; 2007.   Back to cited text no. 5
    
6.Monier-Williams M. A dictionary English and Sanskrit. Delhi: Motilal Banarsidass Publishers Private Limited; 1999.  Back to cited text no. 6
    
7.Rao Mangalagowri V. Text Book of Svasthavritta. Varanasi: Chaukhamba Orientalia; 2007.   Back to cited text no. 7
    
8.Srikanthamurthy KR, editor. Acharya Vagbhatas' Ashtanga Samgraha. Varanasi: Chaukhamba Orientalia; 2005.   Back to cited text no. 8
    
9.Tripathi B, editor. Acharya Vagbhars' Ashtanga Hridaya. Varanasi: Chowkhamba Surbharati Prakashan; 2007.  Back to cited text no. 9
    
10.Panda SK. Basic Principles of Kriya Sharira. New Delhi: Chaukhamba Orientalia; 2006.  Back to cited text no. 10
    
11.Brahmavarchas. Ayurved Darshan. Shantikunj: Vedmata Gayatri Trust; 2005.   Back to cited text no. 11
    
12.Pandey PD. Swasthya Rakshak. Indore: Nirogdham Prakashan; 2004.   Back to cited text no. 12
    
13.Sharma A. Watch Your Food. Ayurveda Health Tourism 2009;12:17-21.  Back to cited text no. 13
    
14.Jangid C, Vyas HA, Dwivedi RR. Concept of Ritus and their effect on Bala. AYU Int Res J Ayurveda 2009;30:11-5.  Back to cited text no. 14
    
15.Nelson RJ, Demas GE. Seasonal changes in immune function. Q Rev Biol 1996;71:511-48.  Back to cited text no. 15
[PUBMED]    
16.Romero LM. Seasonal changes in plasma gluco-corticoid concentrations in free-living vertebrates. Sci Direct 2002;9:1147-51.  Back to cited text no. 16
    
17.Lloyd GE, editor. Hippocratic Writings. Trans. Chadwick J and Mann WN. London: Penguin; 1978.  Back to cited text no. 17
    
18.Agnives CR. 'Matter that matters'. Vaidyam. Kerala Ayurveda Limited 2010;3:19-21.  Back to cited text no. 18
    
19.Valiathan MS. Towards Ayurvedic Biology. Bangalore: Indian Academy of Sciences; 2006.  Back to cited text no. 19
    
20.Tabers Cyclopedic Medical Dictionary. 18 th ed. New Delhi: Jaypee Brothers Medical Publisher (P) Ltd; 2000.  Back to cited text no. 20
    
21.Key TJ, Allen NE, Spencer EA. The effect of diet on risk of cancer. Lancet 2002;360:861-8.  Back to cited text no. 21
    
22.Vailant GE, Mukamal K. Successful aging. Am J Psychiatry 2001;158:839-47.  Back to cited text no. 22
    
23.Gary E, Fraser, David JS. Ten Years of Life: Is It a Matter of Choice? Arch Intern Med 2001;161:1645-52.  Back to cited text no. 23
    



 
 
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