“Anthrmugho saktireva vidya” – Science of diagnosis in Ayurveda

(Knowledge is the power to perceive from within)

Diagnosing or realizing the disease is of great interest to not only physicians but also patients and their relatives. A patient may present various symptoms to a physician. He may examine the patient with all the possible measures to elicit the signs. But before prescribing the medicines, is he sure about the final diagnosis?

Identification of the exact nature of the disease or ‘The diagnosis’ is an essential step in medical practice. Without proper diagnosis, all the interventions are nonscientific and non-ethical. At the same time, accurate diagnosis will be an indispensable lantern in the journey of healing. So in every scientific medical system, there are some chapters devoted to diagnosis based on their terms and principles. Indian medical system, ayurveda also is not an exception. This traditional knowledge base possesses very rich data regarding various signs, symptoms and excellent clinical measures to assess them. However, it is no an easy job perhaps for many to arrive at a correct diagnosis.

Evolving trend in auyurvedic field makes the physician very much obsessed to modern diagnostic measures and to go after them. Mere western conclusions cannot contribute much for the development of a sole system like ayurveda. So a thorough study on ayurvedic diagnostics, based strictly on its own principles, is very essential.

Initially there were only senses to perceive the ailments. Even then, ancient Indian physicians were able to diagnose and treat the condition in line with their intuition built up on the basis of long term experience and perception. Later,as the medical science advanced, men studied the human body in detail and tried to probe in to the deep levels of the body facts, creating new measures and methods. The sprouting world of science has created so many sophisticated techniques. Now a days, people depend more on these measures to find out the facts, though the accuracy of many of them remain controversial even among the scientists. In spite of the scientific researches and inventions, human body and mind remain a mystic entity through decades. Hence it is the need of the time to grow beyond the modern diagnostic conclusions with the lamp of age old wisdom to the vast world of perceptions, Ayurvedic physicians can build up the enormous awareness through continuous efforts and sharpening thoughts.

Practicing the methods of diagnosis

“I know you’ve heard it a thousand times before. But it’s true — hard work pays off. If you want to be good, you have to practice, practice and practice”

First and foremost mistake on the part of ayurvedic physician seems to be the lack of proper clinical exercise. From the days of early student life itself, they often skip away from most of the clinical methods due to inconvenience. Later also, it won’t form a basic program laden by scientific steps in their clinical practice. The power to perceive from within, which is more superior to the observation with external sense organs, can be imparted only by constant clinical exercise. The interests, curiosities and needs felt by the individual will decide the dimensions through which he has to grow. Every physician should ignite this light of curiosity in his mind. This light should come from his compassion towards the patients. Simplicity in communication, kindness to patients and quest for knowledge are the three necessary qualities, a physician

should possess. ‘Vaidyas’ should have all these qualities a little more,as the divine healing science of India expects more from its followers.

To cure the sufferings of mankind, it is necessary to have a proper knowledge about the cause of the affliction and its detaila.As a primary step to this learning process, every medical student should develop the habit of examining the patient from ‘A’ to ‘Z’.Training with the prepared standard evaluation sheet, eventually will build up the ability to see the patient within a fixed outline in which all the essential details are enumerated. According to ayurveda, only through continuous exercise, one can attain the vision necessary for the proper diagnosis and treatment. The presentation of a disease in a particular patient may not be similar to the one in another. So, each one should form a fresh chapter for a physician. Diagnosis is an art, acquired slowly through years of painstaking study and professional experience.

Naming a disease is not an important thing in ayurveda. But diagnosing it in terms of involved factors, locations, and their degree of involvement etc has paramount relevance. With this view, an attempt is made here to arrange various concepts and measures scattered in different parts of the classic books for a better awareness of clinical diagnosis in ayurveda. This is an effort to interpret the clinical relevance of these facts in current day practice. There is no great claims about this book. This is not an outcome of very long clinical experiences, but an intention to revise the subject with a clinical orientation. The clinical experiences of our generation must have some scientific meaning which will contribute to our society and to ayurveda.Let this be a humble initiative to refresh our unique way of observation through continuous practice. I expect valuable criticisms and suggestions from teachers, students and practitioners for corrective measures which would be gratefully acknowledged.

Basic concepts of diagnosis in ayurveda

How we know?” is one of the toughest problems that has confronted the human mind from olden days itself. To frame an answer, human thought had gone a long way with constant research and observations. In India itself, various schools of thought were devoloped to explain the methods of acquiring true knowledge pertinent to universe. Actually these methods were adequate and could provide a thorough knowledge of all the materials and abstract aspect of the universe. The scientific sectors formed there after followed the different philosophical back grounds as well as the methods of perception in their practical applications.

Ayurveda is one of the most practical byproduct of Indian heritage. All the basic concepts and scientific theories in Ayurveda are formed based upon this Indian philosophy, mainly Nyaya and Vaiseshika thoughts. So Ayurveda generally admits three distinct means of valid knowledge as

• 1. Prathyksha (perception),
• 2. Anumana(inference) and
• 3. Aapthopadesa(verbal testimony) (Ref.Ch.su 11/17)

In Ayurveda, these are included under the technical term, Pramana. According to the definition, Pramana is the method of identification of real knowledge or valid experience, True knowledge of the human body and various abnormal conditions or diseases is very essential to treat in a proper way. True knowledge of the drugs also is very essential for the preparation of medicines. Thus in various aspects an Ayurvedic physician need proper knowledge and valid experience.

This needs the following units.

In Ayurvedic aspect, Pramatha is the physician, who wants to know the truth. Prameya or the object to be known is the patient.Knowledge or pramithi is regarding the abnormality or disease present in the patient. For this purpose, Pramatha need the methods Pramana. Based upon these pramanas, he can observe the prameya to acquire the pramithi. In another way, the whole process may be considered as proper identification or Diagnosis of the disease.

Pramatha

In the process of diagnosis,the most important and essential limb is the pramatha.He is the person ,one who tries to procure the actual truth behind an abnormality . This is a sacred work and requires the inscription of god upon his heart . Only a very experienced maan can identify the abnormality very easily . For this,he should try to aquire the wisdom in clinical field . He should be very thorough with the basic principles of our science and its scope for practical implementation.He is supposed to have the qualities in various fielda. According to ayurveda,a physician should be careful in the following fields;

• The physician should try to assess the nature of disease in various angles. If treated otherwise, his fame, reputations, wisdom, and knowledge -all will be in vein.
• Consultation fee should not be demanded from poor patients.
• The physician should feel empathy and compassion towards the patient.
• The physician should consider the patient as his own.
• He should be able to combine both the theoretical and practical knowledge in a good manner.
• Physician should not go to the patient’s home to examine him unless he has been invited from the patient’s part.
• Ensure that your professional conduct is above reproach.
• Do not exploit your patient or bystander for sexual, emotional or financial reasons.
• Patient’s personal matters,secrets or confidential informations should not be revealed to any third person.
• A male physician should not examine a female patient in the absence of female assistance.
• Don’t treat a patient who is unsuitable for treatment.

His conduct should be noble, calm and restrained. He should be intelligent, broad minded truthful, humble, pure, sincere, compassionate skillful, quick on the uptake of ideas,devoted to theory and practice and free from greed, anger and addictions. These are some of the important ethical aspects described in our classics (A.S.Su-2).

All the current ethical laws should be obeyed by a registered Ayurvedic doctor. There are four main principles of modern medical ethics:

• Autonomy – respect for the individual and their ability to make decisions with regard to their own health and future. Actions that enhance autonomy are thought of as desirable and actions that “dwarf’ an individual and their autonomy are undesirable.
• Beneficence – actions intended to benefit the patient or others
• Non-maleficence – actions intended not to harm or bring harm to the patient and others
• Justice being fair or just to the wider community in terms of the consequences of an action

(Informed consent:Doctors will give information about a particular treatment or test in order for the patient to decide whether or not you wish to undergo such treatment or test. This process of understanding the risks and benefits of treatment is known as informed consent. It is based on the moral and legal premise of patient autonomy)

There are somany rules and laws for the protection or comsumers in society. Patients are the consumers. Phycisians have the responsibility to learn all these laws and ethics. An ayurvedic physicians should have to practice all these concepts in a better way during his clinical practice. Ayurveda opines that the physician who is not entering in to the inner secrets of the patient’s mind will not succeed in proper diagnosis and treatment. This is a unique concept gifted by ayurveda to the medical world.

Prameya

Medical student doing experiments in the science of decution should read the Sherlock Homes. Before going for an investigation, Sherlock Homes and Watson, his constant companion, learns all the details about the strengths and weakness of the suspected person. Similarly, the patient should be assessed thoroughlybefore the analysis of disease. Prameya is the person from whom we want to identity the facts behind his abnormality. The nature of disease manifested in different persons may have vide range of variations. So, before going to the details of the disease,a thorough understanding of the person is essential for a proper diagnosis.For this purpose ayurveda has an assessment criteria based on ten fold factors. This is known as ‘Dasa vidha Pareeksha’.

Examination based on ten fold criteria (Ref.Ch.vi. 8/94)

According to Ayurveda, each individual is a separate entity with respect to the degrees of various body constituents. Each one may have individual variations in manifestation of same disease. So, for the correct diagnosis of the condition with respect to the particular individual, it is essential to have an idea about the nature of individual. He should be examined so as to obtain knowledge regarding the span of life,strenghth and integrity of morbidity.This helps to arrive at a proper diagnosis in terms of the intensity of derangement in functional factors. Though it is very difficult to measure this nature in all aspects, here are some important criteria based on which an individual can be assessed by the degree of his strength. This is a ten fold criteria and each one indicates the power of the body in different aspects.

• 1. Prakrithitha pareeksha (Examination based on basic constitution)

  The prakrithi of an individual refers to the genetically determined physical and mental make up. This is determined in relation to the thridoshas and thrigunas. The prakrithi represents the range of normalcy of proportion of the three doshas, vatha, pitha and kapha and the three gunas i.e: sathwa, raja and tama, in the psycho physical constitution of an individual. It is this range of proportion of thridoshas which determines the overall physique, physiology and psyche of a man. In the case of manasa prakrithi,the relative proportion of the thrigunas determines the varieties of human temperament and emotion.

  By assessing the prakrithi, we may have an idea about the general tendency of the body to undergo certain particular changes.We know that the samadhathu group of prakrithi is excellent, the dwandwaja group medium and ekadoshaja group is least prefered. Among the group of single dosha orientation, kapha prakrithi is relatively better, pithaja medium and vathaja least. Based on this, we can group the patients better,medium or poor. Eventhough the patient is in diseased state, there will not be any alterations in prakrithi.One should evaluate the basic constitution with the help of evaluation sheet given in rthe appendix. Though this is a time consuming process initially, gradually one can develop a simple and easy self pattern for the assessment of prakrithi.

• 2. Vikrithitha pareeksha (Examination based on morbidity)

  According to charakacharya, the strength of vikara (morbidity) should be judjed by the assessing the strength of Hethu(causative factors), Dosha, Dooshya, Prakrithi, Desa and Kala. These are factors, which can contribute to the degree of strength of the disease. From the severity or mildness of signs and symptoms, we can meassure the strength of doshas and dooshyas. From the knowledge of extend or severity mildness of nidana, we can assess the hethu bala also. If the prakrithi desa and kala are positively related with the dosha or dooshya, the disease will be strong. But the strength of the disease will be less if Prakrithi Desa and kala are negatively related with the Dosha qualities. The aim of vikrithi pareeksha is to assess whether the disease is Balavan Madhwa balavan or Alpa balavan, with respect to the patient.

• 3. Saratha pareeksha (Examination based on dhathu essence)

  Sara is a unique decisive factor for the assessment of health in specific levels. We know that the dhathus are the essential principles concerned with various functions of the body. Individual Dhathu has certain role in the formation of certain groups of structures and functions. Hence by the examination of these structures and functions, one may assess the strength of dhathu involved. There are eight saras decided in ayurveda. By analysis of the degree of presence of these factors ,assessment of the tissue level strength is possible. potent feature indicate the qualitative and quantitative strength of dhathu while fragile features tell about weak dhathu. Features in between, reveals the strength in medium level. Like the evaluation of prakrithi, initially we may feel it as a time consuming process. But for experienced physicians, this is also a simple process. Though the sarapareeksha may not be valuable in all cases, there are certain areas were it becomes so essential.

• 4. Samhanatha pareeksha (based on compactness of body parts )

  Samhanana refers to the nature of body build and is of three degrees. Pravara (excellent), Madhyama (medium) and Avara (poor). Persons who have well developed bones and joints, clear cut and well nourished muscles are said to belong to the first class: those with opposite qualities to the third class and those in between to the second class of physique. By darsana and sparsana,one can assess the samhanana of the body parts. This identification is also helpful in deciding the strength of the person.

• 5. Pramana pareeksha (Examination based on body measurement)

  Pramana refers to the measurement of the body as a whole and also of its each part. General measurement of various parts of the body is given in our classics. There are certain proportion in all these measurements. One should assess and compare these measurements in order to judge whether they have any abnormalities. If all the proportions are perfect and if they are almost near to the basic reference, the body is pravara. The degree just below that is madhyama and the degree below that is avara. From the pramana detailed in our classical texts, (Appendixevaluation sheet 3)it can be understood that the people possessed large body in those days. So it is our duty to reconstruct the ‘pramana evaluation sheet ‘according to present anthropometry .

• 6. Sathwa pareeksha (Examination based on quality of mind)

  Persons who posssess majority of sathwa guna charecterestics are called ‘Sathwikas’ or Sathwa sara. A sathwika person is best among men, is able to face any hardship-physical or mental-without much difficulty, does not succumb to diseases, and if happened to become sick is able to resist it and get cured quickly. These people are called pravara sathwas(excellent mental temperament).Persons who possess more of rajo guna moderately succumbs to diseases, suffer very much, and do not respond well to drugs. Being unsteady in all activities,these people get in to more troubles. Such people are called Madhya sathwas(medium mental temperament.) Persons who possess more of tamo guna are the lowest in mental activity. They succumb to diseases very quickly suffer for long, neglect proper treatment and become vitimas of it sooner or later. They are called avara sathwas(poor menta in temperament)

• 7.Sathiya pareeksha (lixamination based on food habits)

  While examining a patient, it is important to collect the data regarding his food and regime to which he is accustomed to. Generally they are wholesome and beneficial to him. Sathmya means the various foods, habits and customs persons are used to cover long periods of time by continuous use and not getting harmed from them. According to ayurvedic concepts, Sarvarasa sthmya is excellent. Ekarasa sathmya Avara. Persons using less than sarvarasa and more than ekarasa can be considered as madhyama rasa sathmyas.Addictions to alcohol, tobacco, coffee, etc. will make the sathmya as Avara.

• 8. Aahara sakthi pareeksha (Examination based on digestive power)

  This comprises the assessment of power of ingestion (abhyavaharuna) and digestion jarana),which inturn forms the assessment of Agni From the capacity to digest food, physician can infer the nature of agni. In kaphanubandha koshta, the status of agni is manda(less).In pithanubandha koshta, that is theekshnathigh and sharp) and in vathanubandha koshta,Vishama (unsteady). The nature of agni is very important as far as the health is concerned. Basic reason for all the diseases is indigestion and dismetabolism.So enquire about the nature and intake of food and also about the incidences of improper digestion.

• 9. Vyayama sakthi (Examination based on exercise power)

  Vyayamasakthi inturn forms the assessment criteria for sareera bala. From the occupational history of a head load worker, one can assess his strength. By the clinical methods of assessment of power of muscles, the strength of his muscles can be evaluated By watching the easiness or difficulty in accomplishing the activity, physician gets an idea regarding the degree of debility or strength of the patient.

• 10. Vaya pareeksha (Examination based on the age)

  Knowledge of the age is very important to assess the strenght of the body as it tells about the nutrition of the body in general.Up to the sixteenth year, since the dhathu has not attained full maturity ,all their components are incomplete,poor in strength, not having all their charecterestic features, in capable of hard work and of poor resistance to diseases. Body parts are very soft,tender,mind and mental power not fully developed. Kapha is the predominant dosha during this time. During the middle period, man attains his full capacities both physically and mentally.Pitha is the predominant dosha during this period. During the jeerna stage,dhathus become thin and weak, some parts become worn out and fall off, their colour and texture undergo changes . Generally the body becomes vulnerable to various degenerative conditions. Vatha is the predominant dosha in this stage. Also in many diseases, it can be observed that the prevalent group comes in certain particular age limits. So, vaya pareeksha is useful not only in assessing the body strength but also in diagnosing the cases.

Pramana

Pramana consists of the methods of examination. The knowledge of ‘Prathipathi'( the actual perception of the condition -Ch.Vi.8/86). is the aim of examination. “Prathipathi’ is the actual perception of the condition (Ch.Vi.8/86). According to various schools of thought, there are various methods described in our classics. Single means, dual means, triple means etc are some examples. Each one is relevant with respect to their extended applications. Generally, ayurveda accepts three methods for diagnosis, Aapthopadesa, Prathyksha and Anumana. (Ch.vi 4) The collective interpretation of these methods is called Yukthi(Pertinancy).

Aapthopadesa

“Give me six hours to chop down a tree and I will spend the first four sharpening the axe”.-Abraham Lincon

Aapthopadesa is the authoritatively written basic knowledge behind every scientific statement in Ayurveda. It is the principal medium of formal education and primary back ground for all the clinical examinations, diagnosis and treatments. It is the existing reference point of information and is helpful in interpreting Prathyaksha and Anumana In clinical examination aspect, Aapthopadesa provides the knowledge of disease in various ways such as

• Causative factors,
• Prodromal symptoms,
• Clinical features (signs &symptoms),
• Name,
• Pathogenesis,
• Parts effected,
• Prognosis,
• Complications and
• the after effects.

In treatment aspect, it provides the basic treatment pattern, Individual drugs and combination etc,for different conditions.

Aapthopadesa is the clinical knowledge for clinical examination. Clinical knowledge means the detailed scientific information about various diseases. Despite any scientific reference about the disease and their nature, what will the physician can examine for? The eye sees only what the mind is prepared to realize. So, we should acquire thorough knowledge about the different aspects of various abnormal conditions or diseases, before going for the clinical examination. This is the basic criteria or infra structure to build up further examination details. Then, prathyaksha and anumana pareeksha will have a particular direction, leading to the correct diagnosis. One, who already has the textual knowledge, can depend simply on Prathyaksha and Anumana for examination purpose. Otherwise, he should refer the books for the better correlation for the signs &symptoms with textual images.

Prathyaksha

This is the most effective examination method, as it provides the direct evidence of the abnormality present in the patient.In prathyaksha pareeksha, using the five faculties of perception, one physician receives first hand information of signs. Each sense organ has its own importance in different aspects. But eyes and ears are more important in prathyaksha pareeksha.

Ideal conditions for panchendriya pareeksha

A genuinely interested physician, a co-operative patient and a quiet, warm and well lit room are very necessary for an effective panchendriya pareeksha. Colour or artificial lights should be avoided. These may mask changes in skin colour. Extraneous sounds, foul smell and other distressing elements should be avoided from the room. Presence of toomany people near the examination table is not advisable. For complete examination, the patient should be asked to take off their cloths and should then be covered by a blanket or dressing gown.

Darsana pareeksha

Keeping the patient in good light and at a convenient close range, observe all over the body, not over looking or bye-passing any change however minute it be. If needed, physician can seek the help of any magnifying instruments also. It is advantageous to compare the observation of any part of the body with its counter part in the other half.

According to charakacharya, Varna (colour), Samsthana (Shape), Pramana (number and propotion). Prakrithi-Vikrithi(normal and abnormal) and Chhaya(complexion) are to be assessed by darsana pareeksha. In addition to that, whichever features can be identified with eyes, those can be included under ‘Darsana pareekshya bhavas’. Samanya bhava (General appearance-degree of illness) Deha sthithi (Physical attitude) Chalathwam (Movements. The gait) etc also can be assessed. Each factor has its own normality in each individual. (Ch.sa 8/51.su.su 4.As. san.sa 832).Comparing with the normal, one should be able find out the abnormality.

Perception through vision starts when the patient enters the consultation room. The manners of the patient should be simply brought under the purview of darsana pareeksha. There are somany subjective features described in ayurvedic texts to assess by vision. We solely depend upon darsana pareeksha to diagnose certain specific features,in certain conditions.( Table 2-2)

Instead of these direct darsana, with the help of modern methods like X-ray, Angiogram, Endoscopy, Doppler scan etc. better visualisant of the minute details of internal abnormality is possible now. Consider them as an extended form of darsana pareeksha itself. Try to be familiar with these methods and applied aspects to have a better perception of the disease.

Sparsana pareeksha

This is the assessment of normality or abnormality in patient’s body by touching with the hand. The palm and flat of the fingers are placed gently and moved from place to place to detect any abnormality. The part to be examined should be kept in a position of relaxation of its muscles

Factors to be noted are – Presence of any abnormal mass, its site, shape, size, surface, edge, consistency, mobility and attachments. Qualities of the part felt include temperature, softness, thickness, movements, etc.

Sravana pareeksha

According to charakacharya, Anthra koojanam (Gurgling from abdomen),Sandhisphutanam (krepitus from joints)Swara visesha (nature of voice) and Anye (other typical sounds in certain conditions)etc. should be ascertained by Sravana pareeksha. These can be heard directly while examining the patient. But now there are so many refined instruments like stethoscope to identify the various internal sounds.

Auscultation The stethoscope is applied over the parts of the body which produce sounds normally during their working or on such parts in which the physician suspects the possibility of sound when they are abnormal. The heart lungs, and intestines are the general sites for auscultation. In the case of fracture of bones, gas or liquid under the skin, degenerative changes of joints etc, slight movement itselt produces sounds.

Percussion -Another method of sravana pareeksha is based upon the principle of transmission of sounds through a medium-(Percussion). Though it is not directly mentioned in Ayurveda, there is enough freedom for a physician to develop the methods of examination for a better under sanding of the disease. Percussion is a combined method of sparsana and sravana pareeksha. In this, an artificial sound is created over some parts of the body and by the nature and intensity of this sound, being reflected back; the condition of the organ underneath is assessed.

The sound over a hollow organ is of increased pitch and is called “Resonant while that over a solid organ is of decreased pitch and is called “Dull”. The degree of these sounds also differ. Examiner, well experienced with normal percussion sounds in a normal body can easily imagine the chances of abnormality inside, from the variations in percussion sounds.

Gandha pareeksha

By olfaction the physician can identify certain typical changes

• 1. In kardama visarpa-sava gandha(smell of putrified dead body)
• 2. Sannipathika oshta rogam-Durgandha( bad smell)
• 3. Conditions of poothisrava-Durgandha etc are some examples described in classics.
• 4. Intake of some medicines alcohol, chemicals or poisons also create some typical smells from the body.
• 5. While describing the Arishta lakshanas, it is said that the smell of different flowers if arising from the body, it indicates recent death of the person.

If we analyze body smells of different persons, it will have certain particular nature. This is due to the nature of milieu internal – dosha, dooshya, mala etc. Pathological alterations create changes in these and so surely there will be some alterations in gandha also. But only by keen observation, it can be detected. So by experience, a physician can develop the ability to detect the possible chances of internal pathology only by feeling the smell in certain typical conditions.

Rasa pareeksha

Though examination by physician’s tongue is explained in classics, now a days , the pratical implementation is very difficult. This difficulty was felt in ancient days also. So some Acharyas had described the indirect methods for Rasanendriya pareekshya, by nothing the behaviour of insects like ants, flies, lice etc. If a swarm of ants were to flock to the pot or place where a person has urinated, it is clear that the urine is pleasant to them hence must be sweet: If a group of ants repeatedly flock to his body, it should be understood that his sweat is sweet. Lice increasing on head suggest that the condition of scalp is good for their growth. If these creatures desert from the body, that indicates the unpleasan of the body.

Now-a-days, various laboratory tests are being adopted to determine the taste of various body materials. Though this method is an Anumana pareeksha, it can be substituted for prathyaksha, as is a little bit difficult to do with physician’s tongue. According to susruthacharya,prasna pareeksha is the sixth means by which examiner can have many informations. In prathyaksha pareeksha, this can also be included.

Prasna pareeksha

The mode of obtaining information from the patient is by prasna or questioning interrogation) for which he gives answers. The information thus revealed will be very use full in determining the disease. Example:

• • What is your name?
• • How old are you?
• • From were are you coming?
• • What you are doing now? /What was your job?
• • How long are you suffering from this difficulty?
• • What do you think about the reason of this disease?
• • How and when it started?
• • What are the special features do you feel in this condition?
• • What are the treatments you have undergone so far?
• • What was the result of that treatment?

This can supply information on many important points like Rogi nama (name of the patient) Linga(Sex), Vayasage) Desa(Place). Vrithi (occupation), Avadhi (Duration), Karana (cause). Uthan Adhishtana (site), Athma swabhava (nature of the disease),Vedana (symptoms)Vridhi or kshaya(aggrevating /Redusing factor) Pravrithi (Treatments done sofar) Nivrithi (Effects or results of such a treatment) etc.

Anumana pareeksha

Ayurveda has adopted anumana as a means of getting information about health and disease. There are many things which the physician will not be able to understand by his sensory perception Vast knowledge lay unperceivable by prathyaksha. So that should be understood mainly by Anumana pramana, which is logical reasoning. There are three subdivitions for Anumana.

• 1. Inferring the effect from the cause (poorvavath)
• 2. Inferring the cause from the effect (seshavath)
• 3. Based upon routine observation in many ways such as through upamana, yukthi etc.(samanyathodrishta)

Examples in daily Practice

• • If the patient is a general head load worker-we may assume his vyayamasakthi as Pravara by anumana
• • we may estimate a patient’s vyavamasakthi by treadmill test to elicit exccercise induced ischemia in relevent cases of chestpain. We may quantify the vyayamasakthi by walking distence in TAO and time taken for walking a distence in arthritic manifestations.
• • During history taking a detailed food list including the quantity and frequency, with recent changes is essential to asses the Jarana sakthi. Man who is used to have heavy foods in lesser quantity and light foods in large quantity might be pointing to lesser but stable natured digestive capacity – as for a kapha prakrithi

There are so many examples quoted in classics for anmana pareeksha.

• • 1. Bala by vyayama sakthi

    By observing the power in certain actions,strength of a particular part of a patient’s body can be assessed. To test the strength of the muscles of one upper limb, the patient will be asked to hold examiner’s hand with his hand, and to make it as tight as possible. The tightness will be less by a weak muscled hand. Emaciated patients are not able to do any heavy exercise.

  • 2. Agni by jarana sakthi

    Simply by asking the food habit, quality and quantity of intake, the physician tries to asses the digestive power of the patient. If he is taking heavy, cold items, but not having any digestive problem,he may be having good agni bala. In patient’s having low digestive power,a bulky food creates digestive as well as associated complaints. Nature of digestive power gives an idea mainly about Jadaragni. Other form of agni (dhathwgni & bhoothgni) should be assessed by other methods.

  • 3.Smruthi by smarana

    In so many abnormal conditions, the patient may lose his ability to remember things. To assess the power of recollection, the physician can ask various questions regarding names, incidents, recent or past activities, etc. His answers provide an idea about the level of his memory power.

4. Gooda linga vyadhi by Upasaya/anupasaya

• In many diseases, the actual signs & symptoms may be masked due to various reasons. If they are not enough to give an idea about the condition of disease, one can test the patient with certain drugs/foods or with some activities. By analyzing the response to these treatments, inference about the pathology can be made.

Like this various examples are sited in classics.(Table 2-3)

In so many conditions, it becomes necessary to infer the interni pathology by observing the external features of the disease. Comme sense and experience are the two main needs for proper inference,

Yukthi pareeksha

According to some schools of thought, the yukthi pareeksha is one of the important means of assessment. This is a collective form of anumana pareeksha itself. The discrimination power which arranges the multiple factors that makes an event in such a way that it discribes the past, present and the future of the event is named as Yukthi.

The examples from texts depict the nature of Yukthi. The favorable association of water, cultivation, seeds and season makes plants. The merger of the six factors makes fetus. The combination of churning log, churning stick, and the person to make the friction generates flames. Prudence with optimal standards of the physician, medicine, nurse and the patient results in healing.

This pramana is based upon the logical thinking, by which one become aware of such things which are unable to grasp by ordinary sense faculties. It can be regarded as a gate way to the source knowledge and to access the benefits of knowledge. It helps to visualizes the event in such a way that physician can predict the future of the present events from the course it had in the past. It envisages the future possibilities in a disease, when not intervened and when interrupted with each mode of treatments.

For e.g.,

• 1. The graph obtained through E.C.G.machine will be correlated with the signs & symptoms in patients to reach at a better diagnosis.
• 2. A patient came with a swelling over the leg with a history of chills and fever. By doing all the examinations and investigations we reach at the diagnosis as ‘sleepada'(Elephantiasis). In the way of diagnosis, different factors may contribute.(Table 2-4)

When all the above logics are put together substantiate the presence of Sleepada(Filariasis), it is called Yukthi.

Pramanas are not separate water tight compartments. Commonly these four methods or a combination of these four are used in making a diagnosis. Probably the most common is the hypothetico-deductive approach.An initial hypothesis or hypotheses are generated at the very early presentation of the problem, from existing knowledge, associations and experience. Further questions or examinations direct towards supporting or refuting these first ideads. If an hypothesis is discarded.an alternative one is considered and treated in the same way Several hypotheses can be actively considered at any one time.Both awareness of probabilities (prevalence) of disease and knowledge of causal pathways are important. Doctors build up their own internal library of patterns on the basis of their experience and existing knowledge.

Pramithi

Pramithi is the actual knowledge about various aspects of standard and its variations. The fundamental knowledge regarding different factors involved in the structural and functional aspects of body is very necessary for exact diagnosis. From the above mentioned course, the physician trys to reach at a clearcut diagnosis. Depending upon the precision of examination methods. the nature of the knowledge may change the final diagnosis should be viable for further therapeut procedures.

In the back pages, some basic impressions about the process of diagnosis are described. It is essential to be familiar with the qualities of a good physician, medical ethics criteria for the evaluation of a patient and basics of the methods of diagnosis for an effective and valuable diagnosis.

STUDENT EXERCISES

Please see the Evaluation sheets in the appendix

• 1. Try to observe his general appearance, movements and special features, each person you see,
• 2. Try to observe the persons in terms of Prakrithi and saara.
• 3. Try to list out all the features and find out dwidosha prakrithi with their percentage of dosha distribution.find the mix up of saraas along with Prakrithi and predict the natural tendencies of development and resistance to each diseases, with reference to ones age, place, occupation etc.
• 4. Before you start examining a patient, have a friendly talk ,sothat they may feel much relaxed.
• 5. Learn to use and experience your eyes, ears, tongue (to ask questions), nose and the hand purpose fully as a routine practice. Practice is the best master.
• 6. You can’t see what you don’t know.So go through the books every day to have a thorough knowledge.Keep the books always with you and clear the doubts immediately.Dont wait for an another day.
• 7. Try to observe the patient, keeping the textual references in mind .Try to correlate his signs and symptoms with the textual references.Bring the patient to the clinical discussion room and discuss the case with others.
• 8. Make data sheets and tables for each patient.Feel every patient as a separate chapter
• 9. Devolop the communicating skills with each patient. The only weapon that becomes sharper with constant use is the tongue. Assess the performance with discussion group.

THEME ACTIVITIES

• 1. Have an observation on a particular person and present the data collected. Time allotted-10 minutes.
• 2. Present self prakrithi with subjective and objective observations. Time allotted -5 minutes
• 3. Present a study on references of Panchendriya pareeksha in different chapters.
• 4. Debate on Modern diagnostics Vs Panchendriya pareeksha

Vikriti pareeksha in ayurveda consultation

While a Patient is sitting before you, you expect to get answer for the following questions,

• 1. What are the symptoms?
• 2. Where and when it occurred?
• 3. Which factors are involved?
• 4. Why it happened? and,
• 5. How it turned out?

The answer for the above questions can be obtained by the evaluation of the following data.

• 1. Symptoms presented by the patient (Roopa pareeksha)
• 2. Involved location (Srotho pareeksha)
• 3. Involved factors (Vikrithi pareeksha)
• 4. Causative factors (Nidana pareeksha)
• 5. The pathogenesis (Samprapthi design)

The features of the disease in a patient get its provisional identification from the presenting complaints and from elicited signs, to some extend. Further evaluation concentrate upon the category of these features with respect to the srothas involved. Advanced evaluation must concentrate upon the level of involved factors.Assessment of the etiolovical factors has its own relevance in next step. With all the above findings: physician will make a diagnosis.

These are not fivefold watertight compartments. Each and every finding can be intermingled properly for a better awareness of the condition. For study purpose it is better to start from vikrithi pareeksha.

During pathogenesis,basic body factors are altered fromnormalcy. These alterations will manifest as the signs and symptoms in the body.By the assessment of signs and symptoms, the physician tries to assess the degree of involvement of these factors in the manifestation of the disease. Vikrithi pareeksha consists of the assessment of the following factors.

• Doshas.
• Dooshyas,
• Agni and
• Adhishtanas.

Whenever the body suffers from diseases, all these 4 units show certain alterations in different degrees from normalcy.

Doshas

The dosha has certain quantity, qualities and fuction. The condition in which all these are in their normalcy, is called dosha samya. This condition contributes to the well being of the body. From the normalcy, dosha may undergo variations. Generally dosha has three main states-Normal, Increased and Decreased (Sthana, Vridha and kshaya respectively). In clinical assessment of the degree of vitiation of dosha,in vikrithi pareeksha, the following points are to be considered (according to madhukosa-1)

1.Prakritha-vaikritha (Natural-unnatural)

Manifested symptoms are the indicators of dosha variation. If the variation-both diurnal and seasonal -is in line with its respective physiological change as described above, that kind of alteration is called Prakritha dushti (Natural vitiation). Alterations, which are not in accordance with this physiological change are called Vaikritha dushti (Unnatural vitiation). Physiological variations of dosha- (Table 3-1)

During pre-degree age, many timesI had witnessed the strength ofat the col unity lege bus stop! In the company of college mates, even a calm

Student may dare throw stones at the buses.Even a Police SI may not be able to control him at that avenue. The same student may be very submissive at another bus stop, devoid of his company. The first situation can be associated with Prakritha and the second one with Vaikritha.

Eg.

Relevance :

• • 1.If the pathological alteration of dosha shows a positive relation with physiological one, that can create a more serious pathology because of the synergic effect.Other conditions will not be as serious as the first .
  • 2. To asses the prognosis of the condition. (‘AthulayaPrakruthi’ disease is considered in easily curable vriety).
  • 3. To select the appropriate drugs

2. Anubandhya-anubandha (major-accompanying)

In Kerala, typically we perceive only three climatic seasons. Hot season, rainy season and cold season. This can be represented as follows.

• More kapha predominant deseases are seen at the beginning of hot season, vatha diseases in the initial days of rainy season and Paithika diseases in last few days of rainy season.
• Prevalence of the specific disease will be more in the respective season.

  Eg:Conjunctivitis, a pitha predominant disease spreads very quickly during the months of august and septhember

• Curability rate will be less

  Eg: Vathika type of rheumatoid complaints are very difficult to heal in rainy season.

In political meetings, there are some persons who always accompany the leader. And also one of the leaders show an upper hand over others. This leader’s proposals are supported by all others, while he leaves the stage, others follow him.Like this. In all diseased conditions, there is a chance of involvement of more than one dosha. In sannipathika conditions, though all the three doshas are involved, one typical dosha will have some critical role. That is the pradhana dosha or anubandhya dosha and the accompanying doshas are known as anubandha doshas.

From the following features of pradhana dosha, we can identify them.(Ch.chi 6)

• 1. Swathanthratha
• 2. Vyaktha lingatha
• 3.Yadhoktha samudhanopasamathwam

1. Swathanthratha

Anubandhya is swathanthra and Anubandha is parathanthra. Swathanthra dosha has independent causative factors. In its transformation stages, it will not have much influence with other factors.

2. Vyakthalingatha

The signs& symptoms due to the pradhana dosha cannot be influenced so notably by other factors. Presenting complaints have more relation with this factor.

3. Yadhoktha samudhanopasamathwam

A review of the aetiological factors of a disease reveals that they coincide with the vitiating causes explainedin the ayurvedic classics. If we are trying to assess the prominent dosha by giving a test dose of suitable medicines to reduse it, then it gives a positive result. Thus we can reach at the conclusion about the major dosha.

Anubandha dosha do not possess all these peculiarities. Due to alleviation of major dosha, anubandha dosha also get alleviated. But care should be taken to select medicines which do not vitiate the anubandha doshas during the course of treatment.

Major properties and functions of doshas (Table 3-2)

3. Prakrithi Vikrithi

Non pathogenic status of dosha, which is inherent in the individual is known as the prakrithi.It does’nt undergo changes from birth to death. Prakrithi determines a person’s biological peculiarities But vikrithi is the vitiated condition of dosha due to various reasons. So physicians should be able to identify vikritha doshas from normal prakrithi

4. Sama-nirama (with indigested –without indigested)

Assessment of the association or dissociation of aama with the vitiated dosha is very essential. At the first stage of vitiation it may have the close relation with dismetabolized materials called ama. Then the dosha dooshya are known as sama dosha/ sama dooshya.Later in due course or due to treatment, this material get metabolized. Then they are known as nirama dosha/niramadooshya. The treatment pattern is entirely different for those. So, strict identification of the stage is very essential.(Appendix-Evaluation sheet-4)

5.Gathi (states)

According to parinama (transformation),Disa (direction) and Adhishtana (location), dosha has three particular gathis.

1. Transformation: Instead of having normal state, dosha can have states of reduction and increase in its quality and/or quantity

( Table3-3)

2 Direction: The aggrevated dosha tends to migrate from is natural abode It may ascent or descent or even take a lateral move

3. Directions of Raktha pitha

3.Path way :The pacularity of location plays a major role in the manifestation of a pathology. Thus a disease may manifest through external internal/middle pathogenic trail (roga marga).The six dhatus and twak constitute the bahyaroga marga.Koshta forms the abhyanthara rogamarga while the vital structures like marma,asthi sandhi etc constitute the madhyama roga marga Koshta gatha diseases are comparatively easy to heal while the sakha gatha rogas are not that much easy, madhyama marga gatha rogas have very poor prognosis.

Some of the structures like asthi are placed both in bahya and madnya ma roga marga. But the dhatu mentioned under the heading of bahya ro gamarga is asthaayi and is more superficial. Dhatus included in madhyama roga marga is of sthaayi type and is deeper. The treatment design and so the drug of choice for the same dosha differ according to the roga marga. This is the logic behind the selection of ashta choorna,guloochyadi kashaya and and guggulu thikthaka kashaya to treat vatha in koshta,raktha and marma respectively.

6.Dosha vikrithi avastha ( vitiated states)

Discrete descriptions of symptomatology of vitiated dosha may create confusions. But they have defenite obiectives. Vitiated dosha presents as:

• Vridha (Symptoms of increased dosha)
• Kupitha (Morbid functions of dosha)
• Nanathmaja vyadhi (Independent disease)
• Samanyaja vyadhi (Dependent disease)

1.Dosha vridhi (Symptoms due to increased dosha) These are the typical presenting complaints from which we can infer the concerned dosha. If patient presents roughness of skin, it is an indicator of vatha vridhi. Yellowishness in eye and urine indicate pitha aggravation Heaviness is a direct marker of kapha. (Table 3-3).

2.Dosha kopa (Morbid functions)

These are the pathological processes due to aggrevated dosha at its particular point of action (Table 3-4).

Single course of action or processes in combination will result in a particular alteration in body function. For eg, in the pathology of inflammation, the sequence of changes is as under:

The degree of involvement of each dosha differs in each case and thus causing the specific pathophysiological process.

Morbid functions of the vitiated doshas (C.S-20/12.15,17) Table 3-5

3. Nanathmaja vyadhi (Independent disease)

Single dosha morbidity manifests through these forms. Here, there is little role for influencing factors.

4. Samanyaja vyadhi ( Dependent disease)

The various diseases described in different chapters of our classical text include ailments of multiple dosha-dooshy morbidity. Other samprapthi ghatakas also plays their role here. Qualitative derangement of dosha has paramount role here. They manifest through various clinical signs and symptoms. They can be represented as follows;

VATA (Table 3-6)

PITTA (Table 3-7)

KAPHA (Table 3-8)

The involvement of individual dosha can be assessed by analyzing the signs &symptoms in patients with the help of the above table. In different conditions, the nature of presentation may have assorted forms with different degrees of dosha involvement. Involvement of kapha in a skin lesion may present as itching while that in a joint disorder may manifest as oedema. Though pain is the classical symptom of vitiated vatha, it can also be presented as tremour, emaciation or rigidity as in kampa vatha(parkinson’s disease), Mamsasosha (Musculardystrophy and pakshaghatha(paralysis). While practising a wide range of signs & symptoms,site or location of the pathology is relevant.Pain itself may present as theevra, mushtidanda hathopama,aggrevating on movement redusing on pressing etc. This is due to the specificity of the sites were the dosha is located. This helps for precise clinical diagnosis.

Site related manifestations of vatakopa (A.H.Ni 16)

(Table 3-9)

Site related manifestations of Pithakopa (Table 3-10)

Site related manifestations of Kaphakopa (table 3-11)

7. Dosha janya vikara (Disease caused)

Depending upon the degree of dosha-dooshya involvement and the nature of sammorchana, there will be a variety of features for disease. Assessment of these signs&symptoms give inference about the exact fractional involvement of involved factors.

8.Aavarana (Occlusion with influencing factor)

Concept of avarana is not a rigid and complex subject.It may seems to be difficult when we consider the involved factors in macrolevels. Avarana is a functional influence by subordinate factor on main dosha. These are not separate diseases, but the pathophysiological processes which can lead to the manifestation of diseases. It occurs due to the imbalance in qualities of some subordinate functional factors.eg;

Kapha has the functions to provide Sthairya(stability), Snigdatha (lubrication to the body) etc.with the help of qualities such as Seetha (cool),Mridu (soft),Snigdha unctuous),Guru(heavy) etc. Increase in the quality of guru guna may reduce the integrity of lubricating function. This reduction in lubrication may reduce the easiness in transportation of vatha. This is the pathophysiology behind kaphavritha vatha, in which the functional imbalance of ‘chala’guna of vatha happened due to the deranged qualities of kapha. Though the symptoms of kaphavritha vatha may have some similarity with that of ‘kaphavatha samsargaja lakshanas ‘this is a seperate entity in theoretical as well as in practical aspects.

A clinical understanding of avarana is necessary for the diagnosis and management of various disorders. This can be made possible only by learning the symptoms of various avarana and tracing them in different patients(Appendix-Evaluation sheet-5). There may be the involvement of a variety of different avarana in a single disease itself.They are very significant in clinical point of view.

Dooshya

Dooshya consists dhaathu, upadhaathu,and mala. In clinical viewpoint, all these functional factors are very significant as they are associated obviously with many diseased conditions. The dhathus are the supporting units distributed in the body in different levels. They can nourish the body for different functions, in normal state their change from normal range, will result in manifestation of certain symptoms (Appendix-Evaluation sheet-6).

The following table describes the clinical relevance of upadhathus

(Table 3-12)

Mala are incidentals to all kinds of transformations. Waste products are subsidiary outcome of the dynamics of the life the life which works by transformations of different kinds. The formation of waste products is an index of life activities. Deviation from their normalcy indicate alteration of life activity. A simple urine routine or stool examination can provide lots of informations about the pathology. The Qualitative variations of malas can be assessed by analyzing the features described in our classics.

Icrease or decrease of other mala can be infered from the increase or decrease in the rate of their production in the body.

Agni-Diagnostic importance

According to ayurveda, Agni is the most important factor in the a maintenance of the body. The nature of agni change in abnormal conditions. Interventions without a proper assessment of agni may aggrevate the condition. So in every disease, we have to evaluate the state of agni in different levels.

We know that there are different forms of agni in our body Jadaragni, Dhathwagni, Bhoothagni etc, perform their respective functions by the transformation of heterogenous nutrients in to homogenous poshaka bhava.Dysfunctions of these units result in the malformation of body constituents and the malfunctioning of various A systems. This inturn points towards the alteration in the state of agni Jarana sakthi is an indicator of jadaragni.

Jarana sakthi can be assessed by certain questions about the food habits. Quality and quantity of food intake, time, discomforts related with food intake, etc give information regarding this.

Agni is not an independent factor. It can be influenced by the doshas- kapha, pitha and vatha. Due to this influence, the digestive power and hence the digestive process shows variation. Hence from the variation in the nature of digestion, one can infer the condition of influencing dosha.

Digestion of food by Jadaraagni results in break down of food into five distinct physico-chemical groups,viz parthiva, aapya, taijasa, vayavya and naabhasa.In further ourse, bhoothagni acts upon these groups and thus converting them in to their minute forms. Due to the pathology of bhoothagni individual elementals fail to undergo proper transformation, producing a by-product of indigestion-Ama, in the level of initial metabolism. This indigested mass stagnates continuously, which eventually leads to the deformities in the body systems.

The best example of bhuthagni mandya is the devolopment of allergic skin diseases, immediately after the intake of some particular food items. In some persons certain fractions of bhuthagni may be deficient. This results in the manifestation of many allergic presentations.

In many cases, jadaragni and bhoothagni are normal, but dhathwagni does not perform well, resulting in serious diseases. But it is not easy to assess the dhathwagni mandya as that of jadaragnimandya rom the . It is infered from the malfunctions of respective dhathus and related parts.Upasaya can provide clues to the status of dhatwagni activities.

12 years old ajay kumar was a muscular dystrophy patient.In or in the ayurveda view this was discussed as a case of mamsadhathwagni normal mandya. His appetite was very fine. A doctor prescribed him ‘Indukantham ghritham’ which on intake worsened the muscular ruate the weakness. Stoping the ghritha, doctor gave powder of purified ‘chithraka’ (plumbago) to him in a very small dose to stimulate the deeper dhathwagni. Gradually he came back to his previous state. Then doctor pective prescribed a very small quantity of ‘Indukanthaghritham’ mixed with Chithraka choorna daily. The result was very amazing. This shows how upasaya helps in the assessment of dhatwagni.

Adhishtana

The next important factor in the assessment of vikrithi is the Adhishtana. Adhishtana means the abode of the disease process. More than one location may be involved in the course of a single disease.But these different locations are interconnected in the various phases of pathogenic process through different srothas. In this sense, the assessment of location can be done by examining the involved srothas.

Koshta pareeksha

Three types of koshtas are identified, namely mridu,madhyama and kroora on the basis of the response to the virechana dravya.Koshta is an index of easiness in diffusion of fluid materials through Cell membrane from tissues to the koshta,if the movement of fluid proceds quite easily,the koshta is mridu, or with difficulty, the koshta is kroora. Madhyama koshta exhibit moderate nature in this regard. This character of the body depends mainly upon the nature of the surrounding walls(sakha).In persons of vatha prakrithi,this wall is rigid in those of pithaprakrithi,it is of more elastic and in those of kapha prakrithi, it is all moderate nature. Even though this koshta pareeksha has been explained to in relation with mahasrotas by Charaka,this concept can be extended to other koshtas like the nasal and respiratory passages also.

STUDENT EXERCISES

• 1. From bedside, collect the data regarding levels of dosha vitiation with the help of tables given in the Appendix.
• 2. Assess the Dhaathu and Mala dushti with reference chart.
• 3. Try to assess the condition of different Agnis.

THEME ACTIVITY

• 1. Present the data regarding the Vikrithi.collected from bedside in discussion group and make comments. Do not discuss about the name of disease or treatment aspects.

MODEL DISCUSSION

Anitha: In this patient, do you think the aggrevated vatha has any association with Aama?

Biju: Yes, surely.the aggrevated vatha is associated with aama in this patient (Saama vatha)

Anitha: How you could say this?

Biju: Based on the classical reference, we can make a table like this to assess the role of Aama in vatharoga.

Since the patient have six criteria positive and only one criterion negative, it is strongly suggestive of the presence of Aama,

Sreeja: Fine Then how we can assess the dissociation of Aama?

Anitha :Absecence of these signs and symptoms except pain and presence of dryness (Rookshatha) suggest the dissociation

Srotho pareeksha in ayurveda consultation

Human body is a conglomeration of srothases. For the purpose of study, they are described as some special channels distributed all over the body. Each srothas has its own distinctiveness also. A scientific and classified ayurvedic study should comprise detailed knowledge about each of these channels. The adhistana of diseases is described in ayurveda in terms of dhatus or tissue elements and srotamsi or channels of circulation. Srotamsi comprise blood vessels, lymphatics and semipermeable intercellular spaces in walls of tissue cells. Srotas or channels are mostly named according to the poshaka dhatus they carry. In addition to dhatuvaha srotas there are transportation channels for other elements like praana vayu ,water etc which are named accordingly, In the study of pathology, the concept of srothas is so important as the diseases won’t be shaped without the involvement of the srothas. The very nature of that srothas influences significantly in determining the features of the disease. The region, where dosha dooshya sammorchana had taken place and the channels through which it procedes, etc are very important for a physician in the diagnostic point of view. This is assessed by the scientific analysis of signs and symptoms. (Appendix Evaluation sheet-7).It is our duty to visualize the internal derrangement to depict the actual pathology behind the condition, while we come across these signs&symptoms.

The structural and functional integrity of srothases determines the nature of physiological processes inside these specific channels. Irregularity in their structure and function leads to the mal absorption of nutrients by these srothases and thus to dismetabolism. This in turns results in malnutrition of sthayee dhathus, causing a wide range of clinical manifestations.

Different srothases in human body

According to basic classific four kinds of srotodushti are explained,

1. Atipravrithi :

Increased functioning in concerned srothases in connection with formation, transportation or excretion of body substances. E g; In medhovridhi, medodhatu is produced in excess by medovaha srotas. Rapid propulsion of food from amasaya to grahani is an example of quick transportation.

• Some other eg:
• Excessive urination – prameha
• Excessive watery stools – atisara

2. Sanga:

This is caused by disturbance in the mechanism of contraction and relaxation of srotases. This leads to any of the following condition

• i)Reduction in the size or viscera
• ii) A permanent enlargement of viscera due to atony of muscles,
• iii) Disturbance in transportation due to obstacles in path or
• iv) Permanent constriction.

Consequently, metabolites may accumulate in the srotas. In ayurvedic terms, the couse of obstruction may be ama, kapha, salya or upalepa.

For eg:

Mutrkricchra, Vibandha Jwara and amavatha, Rudhapatha kamala and tamaka swasa etc.

3. Siragrandhi :

Formation of nodules and new growths at certain spots due to the lose of functional integrity of these parts. Eg; Arsas

4. Vimarga gamana:

In each and every srothas, there is a specific course of circulation for the involved factor. Due to the disturbance in equilibrium, the factors may take a deviation from their usual course, entering into unusual paths. This leads to specific clinical manifestations.

Eg; Kamala (aggrevated vatha will dislodge pitha to unusual paths, causing its quantitative increase in blood)

Doshaja lakshanas

The signs & symptoms due to the aggrevation and reduction of each dosha has already been enumerated. Depending on the aggrevated dosha, the dushti lakshana of the affected srothas show variation. We know some signs&symptoms, which develop when the dosha invade and get localized in the dhathus (gatha dosha lakshanas).Due to doshadhathu vitiation, symptoms are devoloped through these srothases as the srothases are nonseperable from the related dhathu.

Vatha lakshanas-Ch.Chi28/24-37;Ma .niV.V15-21;A. Sang Ni.19/3

Pitha lakshanas-As.Sang.sul9/3 Kapha lakshana- As.Sang.su19/3

The subtle details regarding the srothas can be procured by considering the particular portion of that srothas thus the dushti lakshana of a srothas can be understood as different group of lakshanas prodused by the dushti of different portions of that single srothas. (Appendixevaluation sheet-8)

Examination of the mind

The mind is a special subject, which is highly important in clinical point of view.Mind is not a structural entity. This is beyond the limits of our direct perception. We can assess the nature of mind in each body by examining certain faculties which are seemed to be the different forms of functional presentation of mind.

Analysis of symptoms

In symptom analysis, it is useful to have a table by which we can infer some points regarding the abnormality. A model of such a table is given below

As an example, one srothas can be considered.

Rakthavahasrothas

Common signs &symptoms pointed are,

Kushta,Visarpa, Pidaka, Neelika, Vyanga, Piplava, Tila kalaka, Dadru, Charmadalam, Swithram, Pama, Koda, Asramandalam, Raktha, pitham, Asrigdaram, Gudapakam, aasyapakam, Medra pakam, Pleeha, Gulma, Vidradhi, Kaamala

In kushta’ itself, wide range of forms are there. Similarly all the manifestations have variations.Apply the proper examination methods to assess them.

Eg;

Path of inference

ANUMANA (Inferences)

• * features are of a vathika type of skin disease *
• * Aetiological factors may be Rookshadi Ahara/Vihara

YUKTHI

• * The samprapthi of this condition can be expressed as follows
• *Apthopadesa pramana leads us to the true knowledge that the above mentioned features come under KAPALA kushta

Confirmation:

*For the conformation, do proper sneha kriya as upasaya.

An example of logistic deduction in to a diagnosis is described. Let it be an example of symptom analysis in each separate Srothas.One can utilise the elaborate methods of system examination described in modern texts to extend the frame of scientific resoning.

This simple example shows how the logistic deduction can take the investigator to the diagnosis. This is done in a single condition of vitiation of rakthavaha srothas,ie; kushta. Such an attempt can be made in the case of other diseases due to rakthavaha srothodushti. The same method can be extended to the diseases of other srothases too.

STUDENT EXERCISES

• 1. Enlist the signs and symptom of diseases corresponding to each srothas
• 2. Try to visualize the srothas in each body. Then expand the idea of Srothas in wide angles.
• 3. Make a comparative study on system examination and Srothopareeksha.
• 4. Exercise the srothopareeksha in detail in every case possible irrespective of the disease.

THEME ACTIVITY

• 1. Each student should present a ‘Srothopareeksha’ with reference to system examination.
• 2. Establish the statement that “Modern clinical methods are the extentions of Ayurveda pareeksha vidhi” with proper examples in a discussion group.
• 3. Study the relevance of objective parameters like X-ray, USG scan etc to expand the concept of Srothopareeksha.

Nidana panchaka in ayurveda consultation

Ayurveda enumerates five important means for diagnosis. Five fingers in a hand is arranged in such a way that we can have a strong grip over the objects. Similarly, awareness of the five fold principle help us to have a strong grip over the actiopathology of the disease. This includes Nidana, Poorva roopa, Roopa, Samprapthi and Upasaya. Each technical term is indicative of different phases taking place in the manifestation of a disease. Actually this is the screen play behind a disease. So, understanding of each of these helps us in arriving at the possible diagnosis. Some diseases can just be diagnosed by any one of the five means, if it is known or recognized accurately by itself. But to judge the disease in all the possible aspects, it is necessary to adopt the other means.

An old gentleman, Sri.Kumaran aged 65 came to the OPD presenting occasional bleeding and burning per rectum.Initially we get only some vague symptoms from the patient. Then by detailed examination and investigation methods, physicians could elicit some signs also. These signs and symptoms can be included under ‘Roopa’ sometimes patients may be able to remember the premonitory symptoms also-(Poorva roopa). Only by these two means, one may arrive at a possible diagnosis.

When the symptoms are unclear, or masked by some factors, the signs should be elicited by some other means. We can test it by assessing the response of the body to some external stimuli or medicines.

This is Upasaya.

The next question which may arise in the mind of the examiner’s mind is, why these factors are vitiated and up to which extend they are vitiated. Study of ‘Nidana‘among Nidana panchaka is points towards this.

Further questions that should be answered are, how the vitiated factors had transported through the body? What changes they had undergone? What made them to create a disease? What will be the fate of the disease? etc. The answers to these questions lead the examiner to the concept of Samprapthi. Assessment up to samprathi may provide the clear picture of altered milieu interior.

Each one of the above needs detailed descriptions in clinical background for a better frame work of methods of diagnosis in ayurveda. The order of disease progression goes from nidana to roopa through poorvaroopa. From roopa, it may progress towards healing or towards complications. Classical references also follow this order of description.But, Roopa is the first factor we often come across while examining a patient.

Roopa

Roopa is the presentation or the actual manifestation of the disease. This happens only after dosha dooshya sammoorchana. The roopa (signs & symptoms) may change from time to time according to theprogress or retrogress of the disease.Roopa is the prominent diagnostic key of a disease and hence a thorough knowledge of the various roopas of each disease is essential for a physician. Generally,signs & symptoms in a particular disease can be identified under

• 1.Doshaja lakshanas
• 2.Dhathujalakshanas
• 3.Srotho dushtija lakshanas
• 4.Agni/Amaja lakshanas and
• 5.Oja kshaya lakshanas.

It is not that much easy to classify each and every symptoms since they are the results of combinations of the dosha and dooshya in different proportions (dosha dooshya sammurchana) Still,grouping may help us to identify the extend of involvement of the dosha and dooshya in specific srothas. Eg;

Vathika pandu(ch.chi16) Features

+ Increased

– Reduced

But, it is not easy to correlate all the features of any disease to the derrangement of any one of the factors. This is due to the fact that,certain features are resulted from from the combination of more than one factor.Since a number of permutations and combinations of all these factors are probable.

deflectio increas ab

Also each factor possesses more than one quality. The positive or negetive deflection of one or the other quality of a particular factor is described as the the increase or decrease of that factor. This possibility can be observed in the mentioned example.

Importance of the knowledge of Rupa

1) Indicator of the vitiated dosha and its qualities

A mere symptom Soola suggests the involvement of vata along with its rooksha and seeta qualities. Similarly the Daha suggests the presence of pitta with its ushnaguna. The presence of symptoms of two or more dosha suggests the samsarga or sannipatha type of vitiation.

2) Indicator of the site of pathology:

The disease is manifested at the site where the srothorodha (Obstruction) is already present. So in many cases, the signs and symptoms have connections with the sites of dosha -dooshya sammoorchana. Features of Urakshatha will direct us towards the lesion in Uras (chest region), while the symptoms of Hridroga direct us towards Hridaya. In many skin diseses, we can see localized lesions restricted to certain parts. The signs will reveal the chance of inlaid morbidity in that region.

3) For the confirmation of disease:

A group of symptoms collectively suggests a particular disease. For example the ekadasha rupa like kasa, amsatapa, jwara etc occuring together help the physician to diagnose the disease definitely as Rajayakshma.

4) To have idea about the prognosis:

The severity of majority of the symptoms suggests the prognosis to be grave while a few or mild symptoms suggests good prognosis.

5) Indirect indicator of nidana:

As rupa indicate the vitiated dosha, it indirectly indicates the cause of vitiation. The Symptoms of Kshayaja kasa give an idea about the cause as the food habits and life style which can cause emaciation and roughness of Dhathus. This helps to avoid the indulgence with the causative factors.

6)Direct indicator of the disease:

Some times, certain definite signs & symptoms will direct towards the actual diagnosis. Being a good listener, a physician must be calm enough to listen to all the complaints and history that the patient reveals. The ‘readiness to hear contribute a major part of care for the patient. In sanskrit, the word ‘susroosha’ means the ‘eagerness to hear’.If any essential information is missing, the physician can interrupt with some questions with clear objectives so that the answers should be able to complete the essential informations for a clear diagnosis.

What are the complaints you feel? When they had started? Where are they felt exactly? What are the special features of the complaint?etc are some of the common questions which can be asked to elicit roopa.

There are a number of subjective roopas described in ayurvedic classical texts. How we can assess the qualities such as snigdathwa or guruthwa ? How we measure the intensity of pain or itching? Ayurveda give the freedom to formulate up-to-date and region specific assessment scales. We can use the updated and standardized scales of any medical community or customize them according to our need.

Continuous practice is the only option to be familiar with these parameters. While we run a long way through this practice, we may be able to formulate some typical objective protocols for the assessment. While preparing a severity evaluation chart, if some parameters are found to be impractical,they must be excluded and those points which are logically practical should be included.subjective parameters can be converted in to objective by using some measurable index scale and asking the patient to choose the appropriate scoring for his/her discomfort as in the following chart.

Nidana

Nidana is the real cause of the disease. As we know, the disease process starts as a result of various influences from various sources.So we cannot blame upon a single factor for the causation of a disease. In clinical point of view, the role of each group of causes should be evaluated. They can give a clue about the degree of involvement of various nidanas, which is essential for assessing the strength of diseases.

Let us go through some of the terms denoting the nature of causes and their relevance in a clinical point of view.

1. Sannikrishta nidanas : Over indulgence in cold and oily food may cause some kaphaja disorders. This may cause aggrevation of kaphaja symptoms in certain chronic patients. In some patients; this may work as a triggering factor also. The food and activities for a few days before the manifestation of disease may reveal the sannikrishta nadanas. For instance,many patients with acute ‘arditha’, during their discussion with the physician,used to confess that they had had a long night journey sitting in the window seat of the bus. Similarly lying on the bare floor also was reported as one of the strong immediate causes of the disease. Here the exposure to cold/sleeplessness etc are the immediate causes of the condition by aggrevating the seetha and rooksha properties of vatha.creating sthambhana on face.

2. Viprakrishta nidana : To identify this one has to travel back to the history of food habits and life styles of the patient. The patient should be allowed to give the details of his past food habits and activities. From these points, we may be able to find out some important causes of dosha vitiation and the srothodushti. The chances of involvement of various factors should be analized. If the viprakrishta nidana could not be traced, it was attributed to the activities of previous birth.

3. Dosha hethu, Vyadhi hethu and Ubhaya hethu: Distinct division or classification is possible for the group of nidanas detailed for each disease. Some causative factors aggravate dosha (pitha kopa due to spicy or sour tastes),while some directly cause disease(transmission of AIDS due to sexual contact with carrier). Some etiological factors act as vitiating cause for dosha and vyadhi simultaneously. (working for long time in damp conditions may cause rheumatism,long distance bike ride through a duty area may cause allergic cough.)

The relevance of each one should be correlated with the samprapthi of the disease,so that the degree of involvement of each factors can be identified.

The knowledge of Nidana

The knowledge of Nidana is useful mainly, in two ways.

1) Differential diagnosis:

When the signs and symptoms of two or more diseases are very extremely identical, a precise diagnosis becomes very difficult.In such conditions if we are able to trace out the exact aetiological factors then the definite diagnosis becomes possible. It is because of the etiologocal factors which are different for various diseases which, on the other hand have similar symptomatology. For example, sopha or oedema Occurs due to various etiological factors. If a patient presented with localised oedema with itching, tells that on the previous day he touched accidentally a bhallathaka tree, the physician can easily diagnose the case as ‘Vishaja sopham’in which the contact with visha vriksha is an important cause. In a patient with enlarged abdomen, who reveals his addiction to alcohol, the physician may have clue about his live deformity without performing palpation.

2) For avoiding the cause (nidana parivrjana):

Nidana parivarjana is of great importance in the preventive as well as in the curative aspect of the disease management. Extremely aggravated rooksha guna which lead to vathakopa may be caused by extensive physical labour, especially if the patient is a mannual labourer. The physician can advice the patient to limit his physical strain further. The identification of specific causative organism of a disease is essential for the invention and usage of specific immunization- here the knowledge of nidana is made useful for the prevention of disease. Avoidance of cause also helps in the degradation of samprapthi.

Certain specific diseases are chased definite aetiological factors. So if we succed to find out such causes,they direct us towards the diagnosis. (Not the name of the diease itself; but the factors involved)

For eg;

• Ingestion of large quantity of food is a cause of Ajeerna.
• Eating of mud is a specific cause of panduroga
• Hard manual work is a cause for vathika diseases
• Excess vidaahi food is a cause for Raktha dushti vikaras,
• Prolonged use of steroids results in complications like oedema and osteoporosis

History-Family, Accidents, Treatment, Personal etc are some of the questions can be asked to elicit nidana through prasna pareeksha.Some other questions;

• What is the Age, Religion and Economical status?
• What are the common food habits?
• What are the habits, Addictions, Occupation?
• Whether you had any previous diseases?

Purvarupa

A recorded popular poem that can be heard from an amplifier and a temporary dars with empty chairs in a busstand together suggest that there may a political meeting after a while.Similarly, prior to a major disease,some prodromal symptoms can be observed.

Poorvarupa, the prodromal symptoms manifest during the sthana samsraya of vitiated doshas. It is very relevant because of the high health consciousness of our society.Even a slight discomfort may lead people to a doctor in order to rule out the chance of devolopment of serious disease. On feeling a slight discomfort itself, they may consult a doctor in doubt of the signal of any serious disease.

In the classical description of rupa, we can observe full-fledged symptoms. But now, we may not see such patients. Since they mask these symptoms with allopathic drugs. Still, very often we may come across the signal symptoms. Symptoms like low digestive power, heaviness in abdomen, weakness of lower limbs, frequent muscle cramps, general weakness, disturbed bowel habits etc may not indicate a specific disease to an allopathic doctor, but these are warning symptoms of arsas’ for an ayurvedic doctor. Here we can make initial interventions with the drugs and advices to correct apana vaigunya.

Importance of the knowledge of Purvarupa

1) For the early detection of disease: It gives an idea about the evolving pathology at an early stage even before the actual onset of the disease. It also gives clues regarding the nature and severity of the forthcoming disease.

2) Indicator of curability (sadhyasadhyatha): The greater number and severity of purvarupa indicates a difficult prognosis and vice versa.

3) For precise diagnosis: When the symptoms of the disease are misguiding, the history of specific purvarupa helps to reach the correct diagnosis. For example, burning sensation in eye (pithannayanayordaha) is stated as the poorvaroopa of paithika jwara,while anorexia(Kaphadannaruchirbhaveth) is of kaphaja jwara. Whatever may be the confusing symptoms in later stage, the role of the specific dosha becomes clear with the definite prodromal symptom by itself.

Importance of the knowledge of Upasaya

To arrive at a diagnosis of any disease, a specific group of symptoms is essential. But when such a group of symptoms is not marked or that appears with feeble strength, or do not appear at all, a method of trial and error treatment becomes helpful to arrive at a correct diagnosis.

Conditions in which the actual symptoms are lacking or masked, a treatment is given on the assumption that it is of a particular disease The increase or decrease of symptoms due to this stimulation helps us to arrive at the correct diagnosis. We can utilize the upasaya not only to determine the disease but also to determine the altered quality of dosha .If the application of sneha aggrevates the pain and edema at a joint, the involvement of ama or avarana in that case can be understood.

This is an exploratory theory in which medicines, diet and activities are advised to confirm the diagnosis. In day to day practice, knowingly or unknowingly we use this theory in many conditions.

1. In vatha roga, in order to elucidate the role of kaphavarana, we do ‘udwarthana’. If the patient is improved, we can infer the influence of kaphavarana. If the symptoms are aggravated, it may be a pure vathika condition. Then we can start direct vala samana treatment.

2. If the cold food aggravates breathing distress, it is diagnosed as tamaka swasa, whereas if such measures actually alleviate respiratory distress, it is diagnosed as pratamaka.

3. In allergic non productive cough, in order to confirm the dosha involvement, we can give ghee preparations like rasnadi ghritha.If it gets reduced, it is sure that the disease is vatha paithika.

Samprapthi

Disease is an experiment of nature; we see only the results, while we are ignorant of the conditions under which the experiment has been performed. Step by step, samprapthi (etiopathogenesis) must unveil these conditions. It progresses from observation to correlation, from correlation to deduction and thus this rational experimentation may accomplish in the final perception of whole disease. Samprapthi explains the disease as life under altered conditions and so tries to understand life in terms of a change in this integration. Complex internal and external factors determine the disease, which manifests itself in alteration of form and function. So it is the final objective of pathology to recognize all fundamental factors in their action and interaction in order to investigate for further details.

Samprapthi is defined as ‘the description of the evolution of the disease in seqential order, commencing with dosha vaishamya till the disease manifests fully. It includes the vaishamya of dosha, dooshya (dhathu and mala) agni and Srothas, nature and classification of disease etc. Such information is very helpful to the physician both for correct diagnosis of the disease and for deciding the appropriate treatment. Mainly six kinds of samprapthis are mentioned (charaka.ni). These are for the definite assessment of different factors involved in the whole process of pathology. From the review of samprapthi, one must be able to give remarks upon the following particulars.

Dosha

• Sthanika dosha, Aganthu dosha
• Vaishamya[Vridha (increased),Ksheena (decreased)]
• Amanubandha
• Alterations from normal guna (qualitative deformation)
• Alterations from normal karma

Dooshya

• Aspect of vridhi(increase in respect of)
• Dravyatha (Quantitative)
• Gunatha (Qualitative)
• Karmmatha (Functiional)

Srothas

• Name of the srothas and the parts involved
• Kinds of srotho dushti-Athi pravrithi/sanga/grandhi/vimarga gamana

Ojas

• Visramsa/Vyapath/Kshaya

Agni

• Koshtagni-Manda/Theekshna/Vishama
• Dhathwagni- Manda/Theekshna/Vishama

Vyadhi nirdesa

• • physician should study mainly two aspects of vyadhis.

From a general examination,we determine the predominance in a disease. Specific examinations provide an ide the nature of the condition.Naming of the disease can give infor about the exact form of the disease. This is necessary for communi and for academic process.

Apart from the Vikrithi vijnana the following important of the disease should also be considered.

• Group in which the disease can be included
• Stage of the disease
• Adhishtana or location of the disease.
• Strength of the dosha
• Possible complications
• Prognostic criteria

Group in which the disease can be included

There are several types of classifications for every disease. The classification is based on certain particular aspect of the diseased condition. Some are based on the causation while some are based on the severity. Each type is intended to give an idea in a particular angle about the disease. If it is possible to include the condition under a particular group, that itself will provide lot of information regarding the nature and fate of the disease. For example, the seven fold classification as Aadibala pravritha, Janmabala pravritha etc. information about the causation and the strength of vikrithi. The types such as Nija and Aganthu narrate the role of endogenous or exogenous factors in the causation of the disease. Sasthra kriya sadhya and Snehadi kriya sadhya are another classification which implies the mode of treatment that should be adopted. This in turn explains the stage of pathology that had already happened inside. The classification such as Apatharpanotha and Santharpanotha shows the nature of development of the disease. From this we can infer the nature of the internal pathology.

Stages of the disease

In case taking, understanding the stage of the abnormality is very mportant. The pathology begins gradually and it goes through certain paths causing various signs and symptoms in the body. These clinical features change continuously with respect to the internal changes. The factors involved in the initial stage may not participate in the final stage of the disease. The strength of influencing factors also changes during coarse of the disease. Amavastha and Niramavstha indicate the participation of ama in the particular state of the disease. Uthana and Gambheera indicate the level of dhathu involvement. Different stages of kriya kala the state of progression of pathology. Vegavastha and Avegavastha indicate the phase of attack and phases between the attacks of the disease. This in turn shows the particular nature of dosha dooshya sammoorchana inside the body. Assessment of Dosha pakavastha and Dhathu pakavastha are highly essential in determining the nature of progression of the disease.

Adhishtana or location of the disease.

Apart from the particular pinpointed location of the abnormality, ayurveda give stress to find out the particular region of body in which the pathology had happened. These are the Roga margas and each condition should be assessed along with their respective channels. This informs about the pathology and the extention of involvement. Dosha gathi also is related to this. Various locations may have involvement due to the nature of samprapthi. Samprapthi of ‘udaavartha’ reveals a particular transmission of vitiated vatha and involvement of different locations in line with this.

UDAVARTHA

Assessment of the strength of dosha

In Ashtanga hridaya, there is a reference to evaluate the strength of dosha in order to choose the suitable drug. This is done by the examination based on ten factors. They are dooshya, desa, bala, kala , anala, prakrithi, vaya, sathwa, sathmya and aharaavastha.The involvement of each factor in the pathogenesis and it’s influence on the strength of vitiated dosha must be subjected to the analysis of physician.

Dooshya

If the involved dooshya and dosha possess identical quality,there may be an increase in the strength of dosha. The strength of dosa is unaltered when the dosha is and dushya are of distinctively different qualities.

Desa

We know the relation of topographic region/locality with doshas. If the patient’s locality contributes to the vitiation of involved doshas, the strength of dosha is increased.

Bala

We can judge the strength of the patient in a variety of ways. A strong patient resists the vitiation of doshas. But in the weak,doshas may easily undergo alteration and vitiation

. Kala

The kala is devided into Adana and Visarga. In Adana kala,body strength is reduced while in Visarga kala, it is improved. These divisions also have some subdivisions. With respect to these divisions, strenght of dosha change

Anala

The role of agni in determining the strength of dosha is indisputable. Agni mandya results in vitiation of many factors. Persons in whom the agni is manda, general body strength and digestive power is reduced. This strengthens the dosha vitiation.

Prakrithi

Among the seven prakrithi, the samadosha is considered as the best while the dwandwaja prakrithi is abhorred. In ekadoshaja prakrith group.vatha prakrithi is inferior and kapha prakrithi is superior. Dosha! vitiation, which is identical to the prakrithi becomes stronger. For example, vathika disease in vathaprakrithi is more serious than in kapha pitha prakrithi.

Possible complications

In many diseases, if untreated, the morbid factors are vitiated further, causing various complications in body. By knowing the vitiated dosha, dooshya,roga marga,avastha etc,we can evaluate the gravity of conseqences. So at the time of examination itself, a physician should be able to foresee these complications.

Prognostic criteria

Prognosis of a disease is determined by the following factors

Age, sex, mental power These are the main bodily determinants. Youthful age, Male sex and the mental power to refrain nsuitable food and activities definitely can help in process. As the age adwances, regenerative power of body also making the prognosis bad. In females, the healing process is sidered to be less effective than in male. Habit of self indulgence is indicator of inferior mental power. Persons with such a mental make not stick on to the strict pattern of diet and regimen even for the cure of disease, thus making the prognosis bad.

Causes of the disease with minimum and less potent uses heal easily. Others create greater morbidity in internal atmosphere and hold on to the body for long time.

Parts affected If, no vital organs are affected by the disease.healing is easy. Vital organs are the controlling centers of body in many aspects. So disturbance in their equilibrium creates severe morbidity in many parts.

Prodromal symptoms Prodromal features will inform about the severity of forcoming disease. So, if they are less in number and strength.disease may not be that much severe.

Specific features These are the actual outcome of internal morbidity. Directly they indicate the severity or mildness of internal abnormality.

Complications can inform the extent of internal morbidity Disease with many complications is difficult to cure.

Characters of easily curable diseases

• Involvement of dissimilar dosha –dooshya, dosha-rithu,dosha-desa and dosha deha prakrithi
• Roga marga-confined to anyone roga marga
• Disease born from cone dosha
• Onset-recent
• Planetary influences-beneficial

Relevance of the types of samprapthi

The types of samprapthis like Sanghya, vidhi, vikalpa, pradhanya, bala and kala are not mentioned merely for the elaboration of concepts, but they have their own respective clinical relevance.

Sanghya samprapthi indicates the possible forms of a single disease. Vidhi samprapthi informs about the nature of prognosis. Vikalpasamprapthi gives idea about the fractional involvement of various factors in the disease process. Pradhanya samprapthi describes the prominence of dosha involvement while bala and kala indicate about the strength of various influencing factors in the process.

Assessment of the fractional qualities -the final diagnosis

Bodily factors also have the properties like rasa guna veerya,vipaka and karma (Ref. rasavaiseshika soothran).In normalcy, dosha-dooshya bases possess a normal range of these properties. But disease is an event in which these properties get altered by the influence of some etiological factors. Every patho physiological process can be assessed on the basis of alteration in the qualitative functions of doshas in the body.

To evaluate the features (functions) in the body, the following table can provide guide line.

Nidana panchaka ultimately provides an idea regarding the reasons and the degree of alteration of these qualities in the body.As the science has evolved from the basis of panchabhootha theory to thridosha theory through reductionism, the presenting features of the patient should guide us to correlate them with the microlevel alterations in the fractional qualities of bodily factors.

Based on their qualitative functions,dosha can be depicted like the following

In every pathophysiological process, these changes happen singly or in combination in different degrees.Analysis on this basis provide essential indepth perception about the disease. Modern knowledge regarding the pathology can be utilized to extend this concept.

STUDENT EXERCISES

• 1. Arrange nidanapareeksha of each discase in separate tables.
• 2. Try to differentiate between different diseases with reference to the samprapthi.
• 3. Perform the examination up to nidanapanchaka pareeksha.
• 4. Try to correlate the concepts of pathology in different systems with the concept of samprapthi.

Students in clinical discussion room

THEME ACTIVITY

• 1. Present the study reports of aetiopathology of some diseases with reference to Nidanapanchaka and elaborate the concept in wide angle.
• 2. Make visualization of ayurvedic concepts of nidanapanchaka with the help of modem pathology.
• 3. Present the case studies getting published in old or new medical journals and critically analyze the nature of presentation.
• 4. Prepare a complete sample case sheet purely in Ayurvedic outlook.
• 5.55 yr gentleman, presented with the weakness of both lowerlimbs for 6 months. The onset was gradual and now he is not able to get up and to walk even a small distance without any support. Make a discussion on this case and arrive at a possible diagnosis. After that you refer the appendix…… What do you feel?
• 7.23 yr young boy presented with tremor over the right hand for 6 yrs. He had undergone many types of treatments from different institutions The condition was diagnosed as parkinsonism but the treatment could not give any relief to him. While examining the patient in detail, the doctor got a striking point from his history. His father had liver cirrhosis and he was expired due to that disease. When the boy’s liver was palpated it was a little large. USG reported to liver abnormality. When the boy was referred to an expert physician,he also felt his large liver on palpation.The physician was sure about some hepatic pathology …. discuss on various possibilities.

(In LFT, his SGPT was elevated. The serum-ceruloplasmin concentration was below normal. It was a case of Wilson’s disease, in which inpaired copper homeostasis is the pathology In clinical presentation, it may have gastrointestinal, neurological or psychological manifestation. When he has under gone proper chelation therapy was given to the patientwith D-penicillamine, he got good relief for his tremor)

A part of clinical discussion about the samprapthi of kamala’.

(Swaraj briefly presented the case)

Anoop: By definition, samprapthi should reveal the mode of aggravation of doshas, involved dooshyas, type of srotho vaigunya, nature of sthana samsraya and state of agni. Here what is the condition of dosha?

Swaraj: As I told earlier, he had indulgence in kapha vatha vitiating food and life habits. His food were seetha,guru and madhura. This may be the reason for kapha prakopa. He used to do hard physical works continuously and had the habit of vegarodha. This may be the reason for vathakopa. This vathakapha prakopaka nidana can lead to both vishama and manda status of agni.

Sreejaya : You mean both the types at the same time?

Swaraj: Yes. It is the vishamatha in the condition of mandagni. So the doshas and ama produced will be related to this agni, which causes sanga, a charecterestic phenomenon in kamala.

Fathima : How we can differentiate it with the ama in koshta saghasritha kamala?

Swaraj : In koshtasaghasritha,pitharoopi -vidagda-ama, that is saama pitha is produced. This is according to the cause of vitiation. In the next stage. prasara occurs as seen in kriyakala. Here the vitiated doshas, kapha and vatha, along with ama circulates through raktha to different parts of the body and block the pithavaha srothomarga.

Anoop: Why and how? there are somany other srothases also.

Swaraj: I think this may be due to some inherent causes produsing srotho vaigunya in the pithavaha srothases.

Anusree : Few days back in some monthly journal I had read an article which explained the nature of this occlusion in some monthly article. There may be vathika avarodha or kaphaja avarodha. In some types of sakhasritha kamal there is aggravation of vatha along with soshana of pitha vaha srothas due to an excess in rooksha guna. This soshana of marga can lead to the sanga of normal pith or it can help or promote the kapha to get blocked there.

Anoop: This type blockage of bile duct can be correlated with constriction of bile duct.Can’t we?

Anusree : Yes. In another type, kapha itself may cause obstruction due to its aggravated qualities-sthirathwa and pichilathywa. Kapha gets blocked in the region of khavaigunya, mainly in pitha marga and in some cases, rakthavaha srothomoola .

Fathima : what is the reason for peethavarna of nethra and thwak in this case?

Swaraj: By the avarodha in pitha marga, vitiated vatha takes the raktha malaroopa pitha in to the sakhas causing the vimarga gamana. When this vimargagamitha pitha combines with prakrutha pitha in raktha, sthanika vrudhi of pitha takes place. This is the reason for peetha varnatha of nethra moothra and thwak.

Anoop : The margaavarodha of malaranjaka pitha is more important in sakhasritha kamala as described by chakrapanidatha. The haridravarna is seen in nethra, moothra and thwak only. but not in pureesha. Hence the sanga should be known in mala ranjaka pithamarga.

Swaraj : This is an excellent finding. We can use it to explain many modern findings… (discussion follows…)

Ashta Sthaana pareeksha in ayurveda consultation

“Practice as if you are the worst; perform as if you are the best.”

Some methods of diagnosis cannot be termed irrelevant, only because we are not practicing it often. Ashtasthana pareeksha is one among them. This examination is based upon the theory that there are eight predominent aspects for a person, depending on which his health or ill health can be assessed. These eight aspects are the expressions of various physiological events inside the body.Even in the world of modern measures,subjective diagnostic acumens like ‘ashtasthana’has its own relevance due to it’s economic as well as easiness in measurement. But it needs high precision from the part of physician, which can only be nurtured through constant practice. These eight aspects (Ref. Yoga rathnakaram) are,

• 1. Nadi(pulse)
• 2.Moothram(Urine)
• 3.Malam(Faeces)
• 4. Jihwa(Tongue)
• 5.Sabda(voice)
• 6.Sparsa(Touch)
• 7.Drik(Eyes)
• 8.Aakrithi(Physiognomy)

1.NADI PAREEKSHA

Ayurveda has long used the pulse diagnosis as one of the main diagnostic tool to evaluate the homeostasis in the body. Almost all of the ancient medicines have used the pulse diagnosis as a useful method to check the body. In Ayurveda, the principle of pulse diagnosis has not been refered to in the charaka or susrutha samhitha. It was from the 13 century that sargadhara taught the nadi vijnana in sargadhara samhitha.Acharyas like Ravana and Kanada who wrote independent texts in addition to Yogarathnakara and Sargadhara samhitha who devoted independent chapters successfully contributed to the total acceptance of this science. Pulse examination is a practical science which became popular and controvertial depending on the social and educational status of Ayurveda. This can only be taught by long experience The decline of the Guru- sishya tradition and increasing velocity of life have made this science un acceptable. But if experienced properly, Nadi vijnana can contribute much in the field of diagnosis.

Nadi pareeksha is actually the examination of the arterial pulse in various parts of the body. The nadi is continuously having pulsations through out the span of life. Actually, the pulse is caused by the beating of heart and consequent movement of the rasa-raktha through the blood vessels. Vyanavayu is the mechanical force that pulls the fluid through it. Vyana is kritsna deha chari and mahajava(traveling the whole body! with innate acceleration). It is the root mechanical force behind all internal physiology.

Rasa dhathu, being the medium for thridoshas to circulate all over the body, whatever the abnormality found in the primary flow will reflect in further transformations also. Change in tissue level transformations may create alterations in primary flow. So nadi pareeksha is a very good tool for the assessment of internal changes. As E.C.G, E.E.G, Ultra sound , radio active isotopes etc. are used to detect the disease, continuous practice of pulse examination can successfully be employed to know the internal environment of the body.

Sites of pulse examination

It is described that there are three and a half crores of nadis in the body, of these only 24 are palpable of them only 8 are selected for examination.

• 1) Hastha nadi : Situated at a distance of 2 angulis at the manibandha wrist. Reveals the condition of dosha, fever and agni.
• 2)Pada nadi : Located at about 2 angulis below the ankle joint. Reveals health ability to work, presence oflife and freedom from fevers.
• 3) Kantha nadi : Located at about 2 angulis from the root of the neck. It reveals fear,anger grief and exhaustion.
• 4) Nasa nadi : Located at about 2 angulis from the root of the nose. It reveals the desire passion, lust,diseases of the head,ears and mouth.
• 5) Kamna nadi : located at about 2 angulis in front of the ears.
• 6) Akshi nadi Located at about angulis inside the upper eye lids
• 7) Jihwa nadi Located at about 2 angulis inside the mouth under the tongue.
• 8)Medra nadi Located at about 2 angulis under the penis.

Though all these are accessible for examination, hastha nadi by itself is capable of revealing the informations that could be elicited by pulse examination. So the usually embloyed method for nadi pareeksha is hasthanadi pareeksha.

Method

The physician should place the first three fingers (index, middle and ring) of his right hand on the pulse at a distance of 1 finger below the base of the thumb on the lateral side of the wrist of the patient. If necessary, the physician may support the right elbow of the patient with his left hand. The fingers of the physician should be placed softly but firmly so that even a slight throbbing can be understood. The examination is better done thrice with a few seconds of interval in between.

The three fingers placed in position over the hasthanadi, will indicate the condition of the three doshas.

At whichever finger the physician gets a forcible movement, the corresponding dosha is said to be prominent or increased. The fingers Kept on the pulse for examination should be lifted and kept again and again .Actually the nature of physician’s touch depends on what he wants to check from the examination. For eg, if one wants to test the’Nadi bala’, then one has to apply pressure and if one wants to know the condition of the arteries, then he has to rotate it. One should first decide the process of examination and carry it out accordingly. The findings obtained must be kept in mind and then correlated. The Acharyas Heaviness instructed to examine carefully the pulse beat and then arrive at a diagnosis.

Factors to be noted during Nadipareeksha

• 1.spandana sanghya (rate)
• 2.gathi(character)
• 3.Gunas(qualities)

Spandana sanghya

Rhythmic functioning of heart, which causes the pulsation of nadi,will produce certain fixed rate in pulse flow also. In anew born child, it is 140/mt while in an adult it is 72/mt.Physiological variation is possible. But if the spandanasanghya increases or decreases considerably from the normal, it indicates some internal abnormality.

Gathi

The character of the pulsation is described as resembling the movement of some common animals or birds. While we are feeling the pulse we should remember the movement of these familiar creatures.In classics, Jalooka, sarpa, mandooka,etc are taken as examples. Definitely,in an initial stage, it is very difficult to understand these movemennts. So, continuous and long practice is necessary. Acquiring a clear knowledge of beats and correlating it with others is the criterion of this science. We can depict the charecte of movement like this,

strong style=”font-style: italic;”>Gunas The qualities of nadi, like thickness, volume, softness, temperature, hardness etc also should be noted.

Methodology of guna pareeksha and their uses

Nadi bala, Laya, and Poornnatha are the extra points to be notedwhile examining the pulse.

Features

Nadi bala-‘balavathi prabala,sabala, nirbala, durbala’

Laya – ‘sama, sarala prasanna,niyamitha, vishama, vishama gamini, trutitha, gathi koutilva’

Poornnatha-sthoola,poorna,apoorna riktha,sookshma, etc.

Taking all these in to consideration,nadi lakshanas are described under three main headings for healthy,various diseased conditions and for person nearing his death.

Healthy(swastha nadi)

In swastha , though the nadi gathi is normal, it may undergo diurnal as well as seasonal variations.

After exercise, sexual intercourse,food intake etc the pulse may change. Depending on the nature of food intaken also the nature of pulse may change. An ideal healthy nadi should be suvyaktha(clearly perceptible), Nirmala (Unmixed), Amanda(not very slow) and Achanchala (not unsteady)

Abnormal nadi spandana

In conditions of vridhi of two doshas, nadi presents signs of both. In sannipatha, nadi will be very rapid, irregular, curved and unsteady.resembles the movement of the kashtakutta-wood pecker., lavaka(quail) tithira, varthaka(wild goose) and bhramara(big bee)

In some texts, the nature of nadis during disease are also described.For eg.

Asadhya nadi (Pulse denoting bad prognosis)

Eg.

Mrithyu nadi

Pulse indicting the forthcoming death)

Example

Traditional way of pulse examination is a skill work. Try to learn it from those who really practice it. There were somany good physicians who practiced nadee pareeksha in better way, especially in north India.All the ayurvedic students must read the historical novel, AROGYA NIKETHANAM’ in which the story of conflict between Ayurveda and Modern medicine is portrayed through Jeevan masai, an old veteran physician who was well versed in ‘nadee pareeksha’.

2. MOOTHRA PAREEKSHA

Moothra is one of the important waste products of the body and its examination yields valuable informations for the determination of both helth and ill health. It is a drava mala possessing properties such as eeshat peethathwa (light yellow colour), Apichila (non greasy), Anavila (Clear), Ushna, Theekshna and kshara gunas. Its normal quantity reckned as 4anjalis

(1500 ml) per day.

It is preferable to collect the first morning specimen as far as possible. The sample is to be collected in a clean vessel, preferably in a sterilized glass jar. The first and last streams of urine should be avoided.

The method of examination

Rasana (gestation) is not done directly. Observing the approach of ants or insects towards the urine, the taste was known during the ancient days. Now we have various methods to identify the taste

Signs of vitiated doshas in Urine

Lakshanas of moothra vridhi and kshaya

Common vikrithis of Moothra

1. Athi pramana(increased quantity)

2. Alpa pramana(decreased quantity)

3. Vaivarnya (Discolouration)

4.Gandha vikrithis(abnormal smell)

5. Sparsana (detection by touch)

THAILA BINDU PAREEKSHA

Medieval Ayurvedic texts describe an interesting method urine examination called thaila bindu pareeksha. A small quantity of urine is taken in a broad mouthed glass vessel and kept un disturbed in a place free from breeze and other kinds of disturbing factors. A moderate sized drop of thila thaila( sesame oil) is taken with a stick and is allowed to fall on the surface of the urine, from a height of 2-3 inches gently without disturbing the urine. The temperature, humidity rate of air circulation, intensity of light and the force of the oil drop are controlled. The fate of the oil drop is carefully observed as it spreads and assumes different shapes etc. The after effects of the drop as it dips in urine, whether it is broken into pieces, or remains as a single drop, moves in which directions, moves slowly, fastly or very fastly; all these deserve clinical interpretation. If we are analyzing through modern vision, the behavior of the oil drop on the urine surface depends upon a number of physio chemical properties of urine including its surface tension, pH, specific gravity etc. The following description gives the gist of classical descriptions.

3. SPARSA PAREEKSHA

This is a method to understand the condition of the various parts of the body in respect of their normal or abnormal gunas. This has not been elaborately dealt in the texts. It is said that the touch of a pitha rogi is ushna(hot), that of a kapha rogi is Seetha(cold) and pichila(greasy)while that of a vatha rogi is seeth and rooksha(dry.rough), in cases of mixtures, the qualities are also mixed.In addition to this, the features of various abnormal masses, such as mobility hardness, contour etc can be judged by sparsa pareeksha.

4. DRIK PAREEKSHA

Proper examination of the eye will provide far more information about various body functions as well as abnormalities to an experienced physician. According to Yogarathnakara, following are the feature of dosha vitiation in eye.

5. SABDA PAREEKSHA

Every person have a certain characteristic voice which makes him different from the others. The process of voice production has various influencing factors in side the body. Udana vatha is the main factor involved in this process. Udana which is located at the chest region will move towards neck and nose to accomplish the process of voice production .This is voluntary ans liable to undergo great changes as the person desires. Persons of kapha prakrithi have guru swara (heavy voice), while those of pitha prakrithi a sphuta swara (clear voice) where as voices other than these two characterizes vatha prakrithi persons. Various types of sounds are,

Vikritha swaras(abnormal voice)

6. AKRITHI PAREEKSHA

According to prakrithi, desa, jathi etc, human body features may differ in some extent. But the proportion of body parts relative to other parts remains almost same. There are classical references regarding the normal measurements and shape of various body parts. By the assessment of these features, we can have an idea about the normal and abnormal forms of the body. In current pracice,various anthropomtric ranges should be analyzed with respect to the current social scenario.

7. JIHWA PREEKSHA

Jihwa gives valuable information to determine the health or ill health of a person. As we know, this is not only a direct indicator of stomach disorders but of other systemic disorders also.Jiwha pareeksha is based on Darsana, Sparsana, Ghrana and Prasna regarding the rasabodhaka sakthi.

Prakritha lakshanas During health, the tongue is raktha (red),thanu(thin),slakshna (smooth), sama(even) and having aayama and vistharopapanna (proportionate in length and breadth and also to the cavity of the mouth) Vikritha lakshanas

Lakshanas of dosha vridhi

Arishta lakshana

Krishna, Khara,alpaakrithi

Vikrithis commonly met with are, Varnavikrithi (abnormal colour)

Swetha (whitish,pale)

Kapha vridhi,Pandu roga

Akrithi vikrithi (Abnormal shape)

Jihwa lepa. (coating on tongue)

Directly indicates the presence of Ama.

8. MALA PAREEKSHA

Examination of pureesha gives much information regarding the condition of the doshas, dhathus,ahara paka etc.both in health and in diseased states.

Collection of material for examination

The entire quantity expelled at a time preferably the first in the early morning is to be collected in a clean vessel.By Darsana, Sparsana, Ghrana, Prasna and by Yukthi, a physician can reach at many conclusions.

Lakshanas of dosha vikrithi in pureesha

By yukthi, physician can assess many many factors

Time, Number and Quantity of Motion

The time of the voiding of motion with a view to study the preponderance or other wise of dosha in the stool as described in related in books was found necessary. A normal man is stated to void stools twice a day, even though his occupation and habits are factors which may influence he timing. Prakruthi or temperament of the individual also is to be considered, A person whose prakruthi is paithika is stated to pass stool for a number of times, where as in the case of a person belonging to Vatha prakruthi ,it is considered to be less. In an abnormal state of health as in athisara and pravahika,the quantity and number of motion may be increased. This may be due to impairment of jadaragni and production of Ama.

Akrithi or appearance of the stool

This relates to the form in which sakrith is voided. Normal sakruth should be well formed and resemble a ripe banana fruit or in other words it must be cylindrical in shape. Such an appearance is suggestive of the integrity of the passage as well as the consistency of the stool. The function of pindeekarana of stool has been attributed to the pakwasaya. In fact the food residue along with some excretions from the large intestine get a definite cylindrical form due to the pressure of the wall of the colon during peristalsis. This peristalsis in its turn, is regulated by the condition of the agnyadhishtana i.e grahani,thus the appearance of the stool is indicative of the condition of the colon as well as Jadaragni.

Samhathathwa or consistency

The consistency of normal stool resembles that of butter in summer timei.e.semiliquid. It varies in different individuals according to their habitates and the food, they consume. In people with irregular habits of defaecation, the stool remains in the colon for a long time and more drava soshana takes place from it to make it dry. On the other hand, in athisara, due to violent peristalsis,absorption of water is hampered and in consequence, the motion is liquid. Again, in some conditions where there is the presence of toxic irritant material,physical.chemical or bacterial more water is exudated from the intestinal blood vessels to make them liquefied, and evacuated as in basillary dysentery and cholera etc.

Persons taking much vegetable leaves a large quantity of undigested cellulose material to be eliminated through the bowel which makes the consisteney of the stool, as semiliquid. But when non vegetarian meals are taken, much of it is absorbed leaving a small amount of residue which is hard. The habit of taking large quantity of water may cause liquidity of the stool.In Vatha dushti, the consistency of the stool has been described as sushka, thanu, vijjala, in pitha dushti it becomes drava and in kapha dushti,it becomes tanthumath. Thus from the consistency of the stool, the functional states of jadaragni as well as dhathwagni can be studied and described.

Varna or colour of pureesha

Colour of normal pureesha varies from light to dark brown. Vatha vitiates the stool to produce Krishna (black).syava (grayish blue)or aruna(reddish) colours. Pitha produces Neela(blue), Peetha (vellow).raktha (red)or Krishna (black) colours and kapha produces swetha (white) colour.

Gandha or smell

Smell furnish information about the function of pakwasaya. Gandha of sakrith may vary according to the diet taken.Local conditions like more putrefaction,gangrene of the colon.cancer of large or small intestine etc, may give rise to particular kinds of smells. These diseases are also related to ama at the level of dhathwagni or dhathwagni mandya as it is also called. Putrefaction, though a normal event becomes more active when there is more of undigested protein material is in the colon which in its turn is correlated to jadaragni mandya.

Jala pareeksha

This test is carried out by depositing a small quantity of the specimen to a cup of clean tap water and the following points are noted: (Ref. chakrapani on ch.chi.19/5)

Is it avasadi (sinks and dissolves)or viplutha(floats and spread)?.The interpretation of the observation made by jala pareeksha are on the lines furnished hereunder;

Arishta lakshana

Arishta lakshanas are those signs and symptoms which herald the oncoming death. There is no death without Arishta lakshanas and there will be not be long life after their appearance. The direct involvement of doshas or dooshyas cannot be attributed in these features. But there are features due to over vitiated dosha or dooshya which resemble very much with Arishta lakshanas. Hence, in the diagnostic point of view, the knowledge of true Arishta is highly essential Ayurveda has emphasised to these features and in all classics; since some chapters are dedicated to explain them.

Classification

1. Purusha samsraya-Features found on the body of the patient

2. Purusha anasraya- Features out side the body of the person

Former is given greater importance. This is again divided in to three groups

1. Lakshana nimitha-These are certain features present since the birth of the person such as Hastharekha or Pada rekha(lines on the palms/soles).

2. Lakshya nimitha-These are fatal features appearing in the course of various diseases affecting human beings. We find elaborate descriptions in ayurvedic classics and such descriptions are very relevant to medical science.

3. Nimitha roopa – These are fatal features which invariably appear in every person prior to his death without any other reason, except death.

Charaka has explained Arishtas of nine different types associated with

• 1) The sense organs and their respective sensations.
• 2) The organs of the body,
• 3) Mental symptoms and dreams.
• 4) Poorvaroopas.
• 5) Roopas.
• 6) Chhaya and prathichaya.
• 7) The agent or messenger (dootha).
• 8) Matters observed by the doctor in the way or street while visiting patient’s house.
• 9) Hints suggesting Arishta in the family of the patient.

The pathology behind Arishta is obscure. Some opines that this is due to the disturbance in equilibrium of natural constitution, prakrithi’ which remain unaltered since birth. We have to study these signs and symptoms in detail and try to experience them in various dying persons. Some ayurvedic scholars have done researches in this field with the help of casualty medical officers in allopathic medical colleges. According to their findings ayurvedic references are highly relevant and specific in certain conditions. Try to understand these symptoms with the help of experienced physicians.

Prediction of death and breaking the bad news to the relatives becomes relevant due to the following reasons:

• • The impact of death on the family system creates a structural void that requires homeostatic adjustments. Early information may help them to adgust slowly with the reality.
• • According to medical ethics, if possible patient must be informed about his forecoming death and he should be allowed to arrange essential formalities in family setting.
• • Dying patient has certain rights. If possible allow him to fulfill them

STUDENT EXERCISES

• 1. Exercise the practice of Ashtasthaana pareeksha in as many patient as possible. Observe the variations.
• 2. Compare the modern findings with these factors
• 3. Conduct a survey among Ayurvedic doctors practicing these examination methods
• 4. Assess the dosha predominance only by individual examination these focuses.
• 5. Assess the dosha predominance only by the exercising this.
a) Quality of pulse Vakra. Ushna I Vegavathi Sthira Seetha Kadina b) Gathi is like Sarpa Jalooka Mandooka Kaka I Kulinga Hamsa Paravatha Kapotha
• 6. Draw the gathi of nadi in each patient in a graph paper and compare it with the movement of creatures described.
• 7. Assess the dosha predominance only by the exercising the Jihwa pareeksha
a) Colour Syavaaruna Athi raktha Peetha Swetha? b) Appearance-Sphutitha Athislakshna Khara c) Feel-Khara Mridu Kadhina d) Taste-Kashaya Madhura Lavana

THEME ACTIVITY

• 1. Present the study report on the relevance of Ashtasthanapareeksha in present day diagnosis.
• 2. Present your subjective findings in Mala, Moothra, Jihwa and in nethra of some normal and of some diseased.

Investigation in ayurveda medicine

The oldest investigative procedure used in medicine is the analysis of physical characterestics of some important body fluids like blood.sputum and semen. There are references in ayurvedic texts regarding these investigations. Alteration from their normal characters indicate the disturbance respective functional systems. Though somany valuable modern techniques are implemented in the current investigations, ancient methods remain unique with their relation to dosha and dooshya. Here is a trial to assess the involvement of doshadooshya through these investigations.

Sukra pareeksha(Examination of semen)

Charakacharya has described detailed physical examination of eight characters of sukra (semen),where as susrutha has described eight different pathological conditions of sukra.The semen analysis is done to watch for the following characters.

• 1) Phenilatwa(froathy)
• 2) Tanutwa(thinness or decreased density)
• 3) Rukshatwa (roughness-increased pH)
• 4) Vivarnatwa (discoloured)
• 6) Poothi gandha (putrid smell)
• 7) Anya dhathu samsrishtata presene of non spermatozoal material)
• 8) Avasaditwassedimentation propert

A fresh sample of semen is collected and kept in a watch glass. It is analyzed for the above mentioned characters by close watch, touch and smell and also by observing its character when one or two drops are added to water presence of the following features indicate certain abnormalities present in sukra.

Interpretation

Nishtyutha pareeksha

Nishtyutha is the mala roopa kapha, prodused as a result of the transformation of rasa dhathu to raktha dhathu. Normally it is very less in quantity and whitish in colour. But in some pathological conditions, the nature of nishtyutha changes considerably. So by examining the altered nature med nature of nishtyutha, we may be able to identify the pathology

The factors for for which the examination is done are,

• 1) Bahuthwa(increased quantity)
• 2) Sathatham(increased frequency)
• 3) Vivarna(discolouration)
• 4) Avilathwa(turbidity)
• 5) Vilepa(stickyness)
• 6) Pichilathwa(increased viscosity)
• 7) Sthyana (inseparable)
• 8) Thanthumath(thready)
• 9) Poothigandha(bad smell)

Practically this is done by taking a fresh sample of nishtyutha sputum)in a watch glass. By watch, touch, smell and also by adding the sample in water, we can assess these features. Presence of these features indicates certain abnormalities present in certain body parts, where the malaroopa kapha is produced in excess.

1) Bahuthwa (increased quantity)

Excess in quantity indicates the abnormality in transformation of rasadhathu to rakthadhathu. This is due to the excess amount of undigestive forms in rasadhathu or due to any abnormality in digestive power at the level of(rasadhathwagni or raktha dhathwagni).

2) Sathatham(increased frequency)

This is assessed by interogation with the patient. This may be due to abnormality in passage or transporting system of expectorant. We know that the proper expectoration (shteevana) is the function of Prana vayu. So, some abnormality in the division of vayu which has the control over shteevana may result in such conditions.

3) Vivarna(discolouration)

Discolourations indicate various deformities. Yellowish whitesama kapha(kapha associated with aama) Yellow -Pooya kapha(Kapha associated with pyogenic diseases) ,Red-Rakthanwitha kapha(in Urakshatha, kshathaja kasa, rajayakshma etc.), Blackish-Dhoomanwitha kapha(due to dust particles)

4) Avilathwa(turbidity)

Avilathwa is seen in sama kapha. This indicates the undigested forms of materials in malaroopa kapha.

5) Vilepa(stickyness)

This also indicates the amanubandhatwa of kapha

6) Pichilathwa(increased viscosity)

Indicates sama kapha.

7) Sthyana(inseparable)

Indicates sama kapha

8) Thanthumath(thready)

Indicates sama kapha

9)Poothigandha(bad smell)

Bad smell in nishtyutha is an indicator of certain amanubandha of kapha. This happens mainly in rajayakshma.

Raktha pareeksha

In investigative point of view, raktha(blood)is indispensable for diagnosis in modern era. In olden days,raktha pareeksha was performed based on it’s physical characterestics.

Visratha, Dravatha, Raga, Spandanam and laghutha are the features of raktha with respect to the involved bhoothas. Raktha is Anushnaaseetham (not much hot or cold) ,Madhuram(sweetish) Kinchith lavanam(slightly salty) Snigdham(unctuous)Raktham in varna (reddish). First of all, these features should be standardized by using them in normal healthy individuals. Then alterations can be studied as the variation from normalcy.

Features of raktha associated with excess

• Vatha-Aruna, Visada, Phenayuktha, Thanu
• Pitha-Peetha, Asitha, Hot, slowly clotting
• Kapha-Eeshath pandu, Pichilam, Thanthumath, Ghanam

Some of the abnormal features

Presence of these features indicates pathology in raktha or related parts . These physical findings may relevant in pathologies effecting the rakthavaha srothas.

STUDENT EXERCISES

• In a case of primary infertility,semen report is with you. Perform the physical examination in an Ayurvedic way and correlate the findings.
• Analyze the alterations in the physical qualities of semen, before and after giving specific drugs
• Discuss the relevance of Raktha pareeksha with reference to chronic Eczema.