Clinical methods in Ayurveda

Clinical methods in Ayurveda : 

Clinical methods in Ayurveda by Dr. M.Srinivas Naik

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Why it is important ? ®úÉäMɨÉÉnùÉè {É®úÒIÉäiÉ iÉiÉÉä%xÉxiÉ®ú¨ÉÉè¹ÉvɨÉÂ* iÉiÉ& Eò¨ÉÇ Ê¦É¹ÉEÂò {ɝÉÉVYÉÉxÉ{ÉÖ´ÉÇ ºÉ¨ÉÉSÉ®äúiÉ* (CS. Su. 21/20)

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YÉÉxɤÉÖÊrù|ÉnùÒ{ÉäxÉ ªÉÉä xÉÉʴɶÉÊiÉ iÉk´ÉÊ´ÉiÉÂ* +ÉiÉÖ®úºªÉÉxiÉ®úÉi¨ÉÉxÉÆ xÉ ºÉ ®úÉäMÉÉÆʝÉÊEòiºÉÊiÉ** (CS.Vi. 4/11)

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Ê´ÉEòÉ®úxÉɨÉÉEÖò¶É™ôÉä xÉ ÊVÉÊâþªÉÉiÉ EònùÉSÉxÉ* xÉ Ê½þ ºÉ´ÉÇÊ´ÉEòÉ®úÉhÉÉÆ xÉɨÉÉiÉÉä%κiÉ wÉÖ´ÉÉ ÎºlÉÊiÉ&** (CS. Su. 18/44)

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Stay always in close observation

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Rogi – Roga pariksha Examination of patient is known as Rogi Pariksha and examination of Disease is known as Roga Pariksha. Roga Pariksha Rogi Pariksha Condition of the disease status in Man Man and his constitution His remainder health Final outcome = His remainder health (avasista svastha)

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What to examine ? How to examine ? Where to examine ?

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Aturabala (strength of the patient) Vyadhibala (strength of the disease) What to examine ? (Object to be examine)

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How to examine ? (Method of examination) Tribidha Pariksha – Darsana, Sparsana, prasna (Sus) – Aptopadesha, pratyaksha, Anumana (Ch) Chaturvidha Pariksha – Aptopodasha, pratyaksha, Anumana and Yukti Panchavidha Pariksha – Pancha indriya pariksha Sadvidha Pariksha – Prasna + Panchaindriya Prasna + Nidanpanchaka

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Where to examine ? (seat of examine) +ÉiÉÖ®úºªÉ JÉ™Öô EòɪÉÇnäù¶É (Ch. Vim) Sadanga pariksha - Hasta-2, pada-2, Antarathi (chest & abdomen) (Trayo dasa Srotas pariksha) Asta sthana pariksha Dasa sthana pariksha

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History taking → by Prasna Pariksha Physical examination + Systemic examination (Sadanga + Astasthana + Dasa sthana + Trayodasa srotas pariksha) → by Pancha indriya, Darsana Sparsana (Pratyaksha) Make a possible diagnosis → with the help of Aptopodesha, (Loka prakriti i.e. Desha, Kala. protyaksha & anumana. Atura prakriti – Saririk, Manasik Vyadhi prakriti – Nams, Rupa, Dosha, Dusya, Adhisthan, Srotadusti Prakaras) Identity the prognosis, intensity, location, causative factor, site of orgin etc. Make a principle of treatment → by Pancha Nidan Treatment

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Aptopadesha +É”ÉÉ ÁÉÊ´ÉiÉEÇòº¨ÉÞÊiÉʴɦÉÉMÉÊ´ÉnùÉä (CS.Vi. 4/2) Apta as those who are free from doubt (+Ê´ÉiÉEÇò) whose memory ( º¨ÉÞÊiÉ ) is unimpaired, who assess things dispassionately ( +ʴɦÉÉMÉÊ´ÉiÉ) and so on.

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Apta helps to know (Ch. Vim. 4/6) Aggravating factors Doshas involved Mode of manifestation Nature, like severity, chronicity etc. of diseases Site of affliction Pain characteristics Symptoms suggestive of the disease Associated with specific sounds, touch, colour, taste, smells etc. Complications Associated with symptoms of aggravation, mitigation etc. Prognosis Names Concomitants Do’s and don’t in treatment

Pratyaksha : 

Pratyaksha |ÉiªÉIÉÆ iÉÖ JÉ™Öô iÉtiÉ º´ÉªÉʨÉÎxpùªÉè¨ÉxɺÉÉ SÉÉä{É™ô¦ªÉiÉä** (CS. Ch. 4/4) ºÉ´ÉÇ<ÎxpùªÉÉlÉÉÇxÉÉiÉÖ®ú ¶É®úÒ®úMÉiÉÉxÉ {É®úÒIÉäiÉ* (CS. Vi. 4/7)

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Sl. No. Indriya Indriyartha 1. Srotra Gargling sound of Intestine, cracking sound in Joints including those in the fingers, voice of the patient, other sound like coughing, hiccup etc. 2. Chaksu Colour, shape, measurements, complexion, etc. natural or unnatural state of the body, sign of disease and lusture; fullness or emaciation indicating strength, vitality etc. 3. Ghrana Natural and unnatural smells comes from the patient body. 4. Sparsa Natural and unnatural feeling on touch. 5. Rasana Assess by interrogation only

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Anumana (Inference) Factors known by inference Sl. No. Factors examined Inferred from 1. Agni Power of digestion 2. Bala Capacity for exercise 3. Srotradi Capacity of perception 4. Manas Perception of specific objects 5. Vijnana Proper reaction 6. Raga Attachment to women 7. Moha Lack of understanding 8. Krodha Revengeful disposition 9. Soka Sorrowful disposition 10. Harsa Happiness +xÉÖ¨ÉÉxÉÆ xÉÉ¨É iÉEòÔ ªÉÖEòiªÉ{ÉäIÉ&** (CS. Vi. 4/4)

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11. Priti Satisfaction 12. Bhaya Apprehension 13. Dhairya Strength of mind 14. Virya Initiative 15. Avasthana Avoidance of mistake 16. Sraddha Request 17. Medha Power of comprehension 18. Sanja Recollection of name 19. Smrti Power of remembrance 20. Hriya Bashfulness 21. Sila Habitual intake 22. Dvesa Disinclination for taking 23. Upadhi Subsequent manifestations

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24. Dhrti Firmness 25. Vasyata Compliance with orders 26. Vaya, bhakti, satmya, vyadhisamutha Stage of life, habitat, conduciveness and characteristics of pain. 27. Gudhalinga vyadhi Exploratory therapy 28. Dosapramana visesa Measurement of provoking fact. 29. Ayush ksaya Bad prognostic signs. 30 Amala satva Initiation of useful work. 31. Grahanya mridudharanatva Interrogation of patient. 32. Svapna darsana Interrogation of patient. 33. Dvista-ista Interrogation of patient. 34. Sukra dukha Interrogation of patient.

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Sadvidha Pariksha Prasna Pariksha + Pancha indriya pariksha (of physician) Prasna Pariksha (Sus. Sut. 10/5) 1. näù¶É (Habbitate, Body parts) 2. EòÉ™ô (Time, season etc.) 3. VÉÉÊiÉ (Religion, family history) 4. ºÉÉi¨ªÉ (Palatability) 5. +ÉiÉRÂóEòºÉ¨Éi{ÉÊkÉ (History of Present illness) 6. ´ÉänùxÉɺɨÉÖSUôÉªÉ (Chief complaints) 7. ¤É™ô (Strength of disease & person) 8. +zÉ®úÉÊMÉí (Status of digestive power) 9. ´ÉÉiɨÉÖjÉ {ÉÖ®úÒ¹É |É´ÉÞkÉ - +|É´ÉÞkÉ (Information about stool status and urine) 10. EòÉ™ô|ÉEò¹ÉÉÇnù (Time duration of illness) Panchaindriya pariksha mentioned in Pratyaksha Pramana

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Sadanga pariksha Anga (Body parts) Srotas (system) Mula Avayava (other part) Srotadusti lakshan Sirogriba Manovaha srota Sira (head) Brain and its structure Attattavimivesha Apasmara Udakavaha srota Talu kloma Mouth, palate throat, pancreas skin Trisna Antaradhi Uras Pranavaha srotas Hridaya Mahasrota Nose, throat, lungs, sense organ Swasa (Breath in difficulty) Rasavaha srota Hridaya Dasa dhamani all the circulatory system Aruchi, anannabhilasa, vairasy, Tandra. Angamarda, Jwara, Pandu, Sthula & Karsya

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Raktavaha Srotas Yakrit pleeha Liver, spleen and ?Bone marrow ( Sarakta meda ) Skin disease, kamala different inflammatory condition Udara Annavaha srotas Annanalika Amasaya Mouth, stomach, deadenun , small intestine and abdominal viscera Avipaka , aruchi , chardi Purisavaha srota Pakwasaya Guda Caecum Colon Sigmoid colon Rectum Anus Atisara Mutravaha srota Vasti Vangshana Both kidney Ureter Urinary bladder Urethra Prabhut mutrata Mutrakriccha Mutraghat Sukravaha srota Sepha Vrisana Testes Epidedymes Spermatic cord Klaivya Aharsa Alpayu Roga kranta (genetic defect) Garbhapata Medovaha srota Vrikka vapavahan Fats all over the body Astanindita purusha , Prameha , Sthoulya

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Sakha Mamsavaha srota Muscle Tendon Ligaments Skin Muscle all over the body Adhi mamsa, Arbuda, Mamsa keela, Galasaluka, Galaganda, Gandamala, Upajihbika, Ganda, Puti mamsa, Galasundi Astivaha srota Medas Jaghana All bones Adhyasthi , Asthibheda , Asthisula , Danta bheda , Danta sula , Adhidanta , Problem of Hair, Nail & beard. Discoloration of Asthi and danta . Majjavaha srota Asthi sandhi All bone marrow including Synovial fluid Parbaruka , Bhrama , Murcha , Tamasa darsana , Arusa Sthula , Mulanang , Parbajang Darsana . Swedavaha srota Meda Romakupa Skin, Hair follicle Atisweda Asweda

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Astavidha Pariksha (Objective method of eight fold examination) Nadi Pariksha How can we examine ? Where to examine ? What should observe ?

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Observation Palpate Nadi and observe the character of Vata, Pitta and Kapha by index, middle and ring finger respectively. Rates, Rhythm, amplitude and volume Try to find out the findings of different categories of diseases reflected in Nadi. Observe the walking pattern of different animals like swan, eartwarm, elephant, frog, crow, snake, peacock etc.

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Observation of Rate, Rhythm and amplitude and volume by Ayurvedic way Pulse Rate Rhythm Amplitude Volume Character Vatic ++++ High ↑or↓ varied + Low + Low Sarpagati Paittik ++ Moderate ↑ Normal ++++ High ++ Moderate Mandukagati Kaphaja + Low → Moderate ++ Moderate ++++ High Hamsagati

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Amplitude Volume Rhythm Understanding of Rate, Rhythm, Amplitude and volume of pulse

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Ayurvedic terminology in relation to Rate, Rhythm, amplitude and volume Rate – Capala (unsteady), teebra (fast), Manda (slow) Rhythm – Kutila (shaky), Kampavata (Shaky), Cancala (unsteady), Vakra (curved), Ksina (feeble), Vispharita (Broad) Amplitude – Vikampita (Throbbing), Sphut (Prominent) Ushna (hot) Volume – High volume – Guru (heavy), Picchila (Slimy) Garista (Firm), Gambhira (Firm) Kathina (hard) Low volume – Suksma (Subtle), Jada (lethargic) Mridu (soft), Krisha (thin) Krura (dry)

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Mutra pariksha According to Ayurvedic According to Modern Colour Physical examination Chemical examination Micros copical examination Consistency Character Quality Taste Smell

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Tailavindu pariksha Behavior of oil drop in urine Velocity, direction and mode of spread Pattern form and other characteristics 1. Slow circular spread • 1. Like lotus flower • 2. Rapid spread • 2. Like Visnu ’ s conch • 3. East, West, North and Southward spread (Jvara) • 3. Like hamsa (swan) • 4. Splits into no. of particles like a sieve • +++ 4. Like gaja (elephant) • 5. No spread •• ++++ 5. Like parvata (mountain) • 6. Very rapid spread with foams •• 6. Like tree • 7. Scatters itself into small particles immediately •• 7. Sinks in urine ••••• 8. Mixes well with the urine •• 8. Stays like a dot ••

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9. Spreads like a serpent + 9. Like kurma (tortoise ) •• 10. Spreads like a ring ++ 10. Like man without head •• 11. Spreads towards South ••• 11. Like lion, goat, monkey •• 12. Spreads towards agneya nairrta, vayavya, isana ••• 12. Moves without spreading ••• 13. Lengthnes like a serpent + 14. Floats like a boat + 15. Like umbrella ++ 16. Ring like pattern ++ 17. Production of bubbles ++ 18. Stays like a pearl +++ 19. Mixes with urine +++ 20. Sinks without spreading +++

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Possible inferences : • Good prognosis •• Grave prognosis ••• Arista laksana + Vatika disease ++ Paittika disease +++ Slesmaja disease ++++ Tridosaja disease Source : Holistic Principles of Ayurvedic medicine by Prof. R.H. Singh

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Mala Pariksha Sama-Nirama state by Jala taran Pariksha Tridosik vitiation and related manifestation Quantity, quality, frequency and smell of stool Asses ama as an antigenic material

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Jihva Pariksha Kapha & ama disorder– Big, soft, flabby, pale, coated tongue Pitta disorder – Soft, sharp, red, moist tongue Vatic disorder – Thin, dry, coarse, furred and pigmented tongue. Basically Tongue is examined for colour, presence of papilla, shape, size, movement, fissures, coated or not, pain and ulceration

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Sabda Pariksha Examination of various normal and abnormal sound of the patient 1. Voice – Kaphaja – Guru Swara (heavy voice) Paittaka – Sphuta Swara (clear voice) Vatic – In between the two Others Minmina – Nasal voice Gadgad swara – Stammering voice Avyakta Swara – Indistinctness Ksama Swara – Low pitch voice Jarjara – Harsh sound Kampita – Tremulous voice Nasta Swara – Aphonia 2. Capacity of hearing 3. Normal physiological sound, respiration cardiac sound etc. 4. Pathological sound

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Normal sparsa – Seeta, Ushna, pourusha, khara, kathina etc. Colour of the skin Consistency of skin Different disease afflicted in skin Sparsa Pariksha

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Drik pariksha Colour Movement Reflection of anxiety and depression Doshik predominant Vatic – Small, flickering, dry, dusky and pigmented eye Paittik – Sharp, bright, moist, pink Kaphaja – Big, whitish, clean, slow moving eye

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Akriti Pariksha Size and shape of the body to be examined (Height, weight, chest circumference, waist circumference, any physical deformity, astaninditiya purusha, any abnormal posture like dhanustambha, hanugraha, ardita, pakshaghat, grivagraha and gridhrasi etc. and akriti of ulcer, bite marks etc.)

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Dasavidha Pariksha Prakriti ¶ÉÖGò¶ÉÉäÊhÉiÉ ºÉƪÉÉäMÉä ªÉÉä ¦É´ÉäuùÉä¹É =iEòiÉ&* |ÉEÞòÊiÉVÉÉǪÉiÉä iÉäxÉ iɺlÉÉ ¨Éä ™ôIÉhÉÆ ¸ÉÞhÉÖ** (Su. Sha. 4/62) Basic Division EòÉ™ôMɦÉÉÇ¶ÉªÉ |ÉEÞòÊiÉ - Genetic constitution VÉÉiɶɮúÒ®ú |ÉEÞòÊiÉ - Acquired constitution

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Contributory factor for to make prakriti ¶ÉÖGò¶ÉÉäÊhÉiÉ |ÉEÞòÊiÉ EòÉ™ôMɦÉÉÇ¶ÉªÉ |ÉEÞòÊiÉ ¨ÉÉiÉÖ®úɽþÉ®úʴɽþÉ®ú |ÉEÞòÊiÉ ¨É½þɦÉÖiÉÊ´ÉEòÉ®ú |ÉEÞòÊiÉ (CS. Vi. 8/95) VÉÉÊiÉ |ɺÉHòÉ, EÖò™ô|ɺÉHòÉ, näù¶ÉxÉÖ{ÉÉÊiÉxÉÒ, EòÉ™ôÉxÉÖ{ÉÉÊiÉxÉÒ, ´ÉªÉÉäxÉÖ{ÉÉÊiÉxÉÒ, |ÉiªÉÉi¨ÉÊxɪÉiÉÉ (CS. Ind. 1/5)

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What should we examine for prakriti assessment? 1. Physique, physiology and psychology (Anthroscopic examination) 2. Measurement of the body part which may not changes (Anthropometric examination) Height, thickness of bone, eyes, neck (short, long), chest (wide, narrow) By (a) Linea dimension (measurement of the length of tibia) (b) Horizontal dimension (Biacromial distance) (c) Height : Weight ratio (d) BSA 3. Physiological examination (Appetite, Sleep, Bowel, Dreams) 4. Psychological score (Intelligence, memory)

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Vikriti Ê´ÉEÞòÊiɯûSªÉiÉä Ê´ÉEòÉ®ú&* (Ch. Vim. 8/110) Examination done to know Vikriti How can we Known Dusha By clinical manifestation on complains and by history taking (i.e. Subjective & objectives parameters) Dusya Prakriti (constitution) Desha (habitat) Kala ( seasone ) Bala (strength) Lakshana (symptom of the illness)

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Sara pariksha ºÉÉ®ú ¶É¤näùxÉ Ê´É¶ÉÖrùiÉ®úÉä vÉÉiÉÖ¯ûSªÉiÉä* (Ch. Vim. 8/102 Chakrapani) Qualitative analysis of tissue element (dhatu) is known as sara pariksha Sara Anatomical & physical character Clinical importance (prabal, abar, madhyam) Twaka sara Unectous & lasture skin, smooth, clear, fine and less numerous deep rooted tender hair Asses the hydration and nutrition Rakta sara Reddishness of ear, eye, tongue, nose, face, lips palate, nail, forehead & genitelia Assess Hb% concentration and palloreness Mamsa sara Well developed muscle in all over the body specially temporal, forehead nape of neck, shoulder abdomen, axilla, chest & joint Assess volume of muscles tone Muscle wasting (atrophy) hypatrophy Pseudophypertrophy

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Meda sara Unctousness of complexion, voice, eyes, hair of scalp and other part of body, nail, teeth, lips, eye & faces Assess balance fat in the body Dryness of skin Seborrhoea Dandruff Excessive oleation Asthi sara Robust, heel, ankle, knee, collar bones, chin, head, joint, bones, nail and teeth Assess bony tendernes , pain and tenderness Majja sara Softness of all organ, eye, strength unctuous complexion and voice, robust, long and rounded joint Assess joint structure, bone marrow assessment by investigation Sukra sara Gentleness, gentle looking, teeth unctuous, round, strong & beautiful, clean unctuous voice & complexion, dazzling appearance, large bootock , strong & loved by the partners satisfaction sexual life both partners Adequate sexual function and fertility Satwa sara Stable and concentrate mind and interested in good work and sincere Psychiatric assessment

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Samhanans ºÉƽþxÉÆ ºÉƽþÊiÉ* Ch. Vim. 8/116 This refers to the examination of compactness of organ and structures (physical construction, compactness & strength) Uttama Madhyam Heena

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Bone structure (symmetrical, equal or not) Joint position, power and movement Muscle power & structure Good blood circulation with normal blood pressure How can we assess it ?

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Pramana Measurement of the body part is known as pramana In classic - anguli of the patient is considered as standard parameters Sama pramana - good prognosis Visama pramana - Bad prognosis

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Satmya (Adaptability or Homologation) ºÉÉi¨ªÉÆ xÉÉ¨É iÉnÂù ªÉnùÉi¨Éx{ÉÖ{ɶÉäiÉä* (CS. Vi. 1/20) The substance which are homologous to the body is known as satmya.

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As per Susrutas (Sus. Sut. 35/39-40) näù¶ÉºÉÉi¨ªÉ (Habbitats & adaptability to body) EòÉ™ôºÉÉi¨ªÉ (Time related & seasond variation) VÉÉÊiɺÉÉi¨ªÉ (Race) @ñiÉÖºÉÉi¨ªÉ (Seasond) ®úÉäMɺÉÉi¨ªÉ (Related to disease) =nùEòºÉÉi¨ªÉ (water palatable) Ênù´Éɺ´É{ÉîºÉÉi¨ªÉ (day dreams palatable) ®úºÉºÉÉi¨ªÉ (all taste palatable) Prabar satmya – Adaptability of all diet like meat, fish, ghee, oil and all rasas Abara salmya – one rasas is satmya other are asatmya Madhyam satmya – In between the above two

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Sattva pareeksha ºÉi´É¨ÉÖSªÉiÉä ¨ÉxÉ&* iÉSUô®úÒ®úºªÉ iÉxjÉEò¨ÉÂ, +Éi¨ÉºÉƪÉÉäMÉÉiÉÂ** (CS. Vi. 8/119) Assessment of mental stamina is known as sattva pariksha. Prabar (high) Satwa guna pradhan Abara (low) Tama guna pradhan Madhyam (modurate) Rajaguna pradhan

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How can we asses it? By taking the clinical history Response of the patient towards physician How he explain the history? He believe to the physician or not? Is he irritating? Is he over talking? Is he taking all medicine timely?

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Ahar Sakti +ɽþÉ®ú¶ÉÊHòiɝÉäÊiÉ +ɽþÉ®úºÉÊHò®úlªÉ´É½þ®úhɶÉEòiªÉ SÉ {É®úÒIÉÉ; ´É™ôɪÉÖ¹ÉÉä +ɽþÉ®úɪÉiÉä** (CS. Vi. 8/120) The capacity of food is to judge from the capacity to ingest and capacity of digest the food, strength and longevity is develops upon food.

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Prabar Abara Madhyama Assess the different stages of Agni by Samagni Visamagni Teeksnaagni Madagni Clinical Assessment of Ahara Sakti (Ch. Chi. 15/50-51)

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Vyayama Sakti (Examination of body power) ¶É®úÒ®ú SÉäŸõÉ ªÉÉ SÉäŸõÉ ºlÉäªÉÉÇlÉÉÇ ¤É™ô´ÉÌvÉxÉÒ* näù½þ ´ªÉɪÉÉ¨É ºÉÆJªÉÉiÉÉ ¨ÉÉjɪÉÉ iÉÉÆ ºÉ¨ÉÉSÉ®äúiÉÂ** (Ch. Su. 7/31) The limited physical activity (exercise) which stabilized our body part and increased power is known as vyayama. How can we assess Vyayama sakti can be asses by capacity of physical activity, ability to do work Uttam Madhyama Heena

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Vayah parkisha (investigation of age) Investigation of age by clinically is known as vayah pariksha Childhood Timely (Kalakrita) Middle age Untimely (Akalakrita) Old age

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Case history taking Proforma Name : Age (vaya) Sex (jati) Religion (Jati) : Date of admission (Kala) : Address (Desha) : 1. Vedana Samucaya with Kalaprakarshot (chief complaints with duration) 2. History of Present illness (Atanka Samuetapatti Krama) 3. History of Past illness (Nidan artha kara Roga) 4. Treatment History (Oushadha Satmya Pariksha) 5. Family History (Kula and Jati Prasakta) 6. Personal History (Pratyatma miyata vritta) Diet (Aharsakti) Appetite (Antaragni) Sleep (Nidra) Urine & stool Pariksha (mutra pravritta, apravritta) Addiction – okasatmya

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7. Physical examination Pallor, Icterus, Cyanosis, Clubbing, Odema, Lymphonode, Thyroid, BP, Pulse, Pigmatara, JVP, Height , Weight ( Astavidha pariksha and Panchanendriya pariksha) 8. System examination Srota pariksha - Darsana (inspection) - Sparsana (palpation & percussion) - Sabda pariksha (Auscultation) - Srotadusti prakara Aturabala pariksa – Dasavidha pariksha

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10. Label of diagnosis Prakriti Laka prakriti Atura prakriti Dosha Dusya Adhisthar Srota Srota dusti prakara Anubadha / Anubandhya Lakshana Roga marga Final Diagnosis (Vyadhi nama) Panchanidan pariksha Sadhya/Asadhyata vicchara (prognosis) Punciple of treatment (chikitsa sutra) Treatment (chikitsa)

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Acknowledgement I am very much thankful to Prof. R.H. Singh, BHU for his valuable lecture during my P.G. study Dr. D. Kalita , Principal, GAC, Assam for encourage me for new thinking and development of Ayurveda in relation to modern era. Dr. Srikant Babu Perugu , Vijayawada for enclourage me to present this paper.

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Thank You