Trividha Roga Vishesha Vijnaniya Vimana

Vimana Sthana Chapter 4. Three-fold clinical examination for comprehensive diagnosis of diseases

Abstract

This chapter deals with three methods of clinical examinations useful for understanding specific characteristics of diseases. These three methods are aptopadesha (authoritative instructions), pratyaksha (direct observation) and anumana (inference). These methods play a pivotal role not only in the diagnosis of a disease, but also in understanding whatever is knowable. In the beginning, one should faithfully go through the available authoritative literature available in that field of study. As per the guidelines of the literature, the physician should then proceed to perceive the direct observations, by his own senses. Many aspects of an ailment which are not perceivable by senses can be inferred by logic based on scriptures and by consulting experts. In this chapter, a set of assessment criteria has been provided for each method including pointers that help in determining what is to be examined by which method, how should something be examined, and what is to be inferred and on what basis, along with the authoritative sources of knowledge.

Keywords: Aptopadesha, Pratyaksha, Anumana, Diagnosis, Authoritative instructions, Direct observations, inference, examination methods and tools.

Trividha Roga Vishesha Vijnaniya Vimana

Section/Chapter	Vimana Sthana Chapter 4
Preceding Chapter	Janapadodhvansaniya Vimana
Succeeding Chapter	Sroto Vimana
Other Sections	Sutra Sthana, Nidana Sthana, Sharira Sthana, Indriya Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana

Introduction

Ayurveda has emphasized the importance, need and application of examination, and has stressed that even truth should be examined first and only then should be accepted. In Sutra Sthana, Chapter 11, four methods of examination of all existing and non-existing subjects of knowledge to be examined have been given. These four specific methods of examination are aptopadesha (knowledge from authoritative person and scriptures), pratyaksha (direct observation), anumana (inference) and yukti (logic based interpretation). For clinical examination of a patient, yukti pramana is included in anumana because inference should be included in tarka (logic) and yukti . The author did not feel the need for yukti to be done separately in clinical experiment, therefore three fold (trividha) method of examination has been described.

There are, however, limitations to these tools because all the three examinations should be applied, though sequentially (described later in the chapter), since one cannot rely completely on any one of these examinations. A wise physician should use all the three tools together for a thorough assessment of the disease and then reach the final diagnosis. A physician who understands and exercises such practice does not commit any mistake in the treatment of the patients.

It is also interesting to know that these three methods of examination have been defined (with little difference) in Sutra Sthana 11th chapter Tistraishaniya too. On the basis of critical analysis of the subject, it could be opined that the description of three examination methods in Vimana Sthana is much more scientific and applicable in clinical methods while the description of Sutra Sthana chapter Tistraishaniya is applicable in other fields.

Sanskrit Text, Transliteration and English Translation

अथातस्त्रिविधरोगविशेषविज्ञानीयं विमानं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

athātastrividharōgaviśēṣavijñānīyaṁ vimānaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

athAtastrividharogavisheShavij~jAnIyaM vimAnaM vyAkhyAsyAmaH||1||

iti ha smAha bhagavAnAtreyaH||2||

We shall now expound the chapter on the “Three-fold Examination Method and its tools”, for a complete diagnosis of a disease. Thus said Lord Atreya. [1-2]

Three methods for knowledge of disease

त्रिविधं खलु रोगविशेषविज्ञानं भवति; तद्यथा आप्तोपदेशः, प्रत्यक्षम्, अनुमानं चेति||३||

trividhaṁ khalu rōgaviśēṣavijñānaṁ bhavati; tadyathā āptōpadēśaḥ, pratyakṣam, anumānaṁ cēti||3||

trividhaM khalu rogavisheShavij~jAnaM bhavati; tadyathA AptopadeshaH, pratyakSham, anumAnaMceti||3||

Specific features of diseases can be determined in three ways – by means of aptopadesha (authoritative instruction), pratyaksha (direct observation), and anumana (inference). [3]

तत्राप्तोपदेशो नामाप्तवचनम्| आप्ता ह्यवितर्कस्मृतिविभागविदो निष्प्रीत्युपतापदर्शिनश्च| तेषामेवङ्गुणयोगाद्यद्वचनं तत् प्रमाणम्| अप्रमाणं पुनर्मत्तोन्मत्तमूर्खरक्तदुष्टादुष्टवचनमिति ; प्रत्यक्षं तु खलु तद्यत् स्वयमिन्द्रियैर्मनसा चोपलभ्यते| अनुमानं खलु तर्को युक्त्यपेक्षः||४||

tatrāptōpadēśō nāmāptavacanam| āptā hyavitarkasmr̥tivibhāgavidō niṣprītyupatāpadarśinaśca| tēṣāmēvaṅguṇayōgādyadvacanaṁ tat pramāṇam| apramāṇaṁ punarmattōnmattamūrkharaktaduṣṭāduṣṭavacanamiti ; pratyakṣaṁ tu khalu tadyat svayamindriyairmanasā cōpalabhyatē| anumānaṁ khalu tarkō yuktyapēkṣaḥ||4||

tatrAptopadesho nAmAptavacanam| AptA hyavitarkasmRutivibhAgavido niShprItyupatApadarshinashca| teShAmeva~gguNayogAdyadvacanaM tat pramANam| apramANaM punarmattonmattamUrkharaktaduShTAduShTavacanamiti ; pratyakShaM tu khalu tadyatsvayamindriyairmanasA copalabhyate| anumAnaM khalu tarko yuktyapekShaH||4||

Authoritative instructions are the teachings of apta (persons who are the most reliable). Apta are free from doubts, their memory is unimpaired, they know things in their entirety by determinate experience. They see things without any attachment or affection (nishpriti and nirupatapa). Because of these qualities, what they say is authentic. On the other hand, statements- true or false- made by intoxicated, mad, illiterate people and people with attachments are not to be considered as authoritative.

Pratyaksha or direct observation is that which is comprehensible by an individual through his own senses and mind.

Anumana or inference is the indirect knowledge based on Yukti i.e. reasoning, logic and experiments. [4]

त्रिविधेन खल्वनेन ज्ञानसमुदायेन पूर्वं परीक्ष्य रोगं सर्वथा सर्वमथोत्तरकालमध्यवसानमदोषं भवति, न हि ज्ञानावयवेन कृत्स्ने ज्ञेये ज्ञानमुत्पद्यते| त्रिविधे त्वस्मिन् ज्ञानसमुदये पूर्वमाप्तोपदेशाज्ज्ञानं, ततः प्रत्यक्षानुमानाभ्यां परीक्षोपपद्यते| किं ह्यनुपदिष्टं पूर्वं यत्तत् प्रत्यक्षानुमानाभ्यां परीक्षमाणो विद्यात्| तस्माद्द्विविधा परीक्षा ज्ञानवतां प्रत्यक्षम्, अनुमानं च;त्रिविधा वा सहोपदेशेन||५||

trividhēna khalvanēna jñānasamudāyēna pūrvaṁ parīkṣya rōgaṁ sarvathā sarvamathōttarakālamadhyavasānamadōṣaṁ bhavati, na hi jñānāvayavēna kr̥tsnē jñēyē jñānamutpadyatē| trividhē tvasmin jñānasamudayē pūrvamāptōpadēśājjñānaṁ, tataḥ pratyakṣānumānābhyāṁ parīkṣōpapadyatē| kiṁ hyanupadiṣṭaṁ pūrvaṁ yattat pratyakṣānumānābhyāṁ parīkṣamāṇō vidyāt| tasmāddvividhā parīkṣā jñānavatāṁ pratyakṣam, anumānaṁ ca; trividhā vā sahōpadēśēna||5||

trividhena khalvanena j~jAnasamudAyena pUrvaM parIkShya rogaM sarvathAsarvamathottarakAlamadhyavasAnamadoShaM bhavati, na hi j~jAnAvayavena kRutsne j~jeyej~jAnamutpadyate| trividhe tvasmin j~jAnasamudaye pUrvamAptopadeshAjj~jAnaM, tataH pratyakShAnumAnAbhyAMparIkShopapadyate| kiM hyanupadiShTaM pUrvaM yattat pratyakShAnumAnAbhyAM parIkShamANo vidyAt| tasmAddvividhA parIkShA j~jAnavatAM pratyakSham, anumAnaM ca; trividhA vA sahopadeshena||5||

First of all, one should examine the various aspects of diseases by employing all the three pramanas (i.e., the three methods of examination). Observations made on the nature of the disease thereafter are infallible. One cannot acquire authoritative knowledge about anything in all its aspects simply by examining it through a part of these “sources of knowledge”. Of all the sources of knowledge one should acquire knowledge in the beginning through authoritative instructions and, thereafter proceed to examine a thing through pratyaksha (direct observations), and anumana (inference). What is to be examined by “direct observations” and inference unless something can be studied prima facie. Hence, all the three methods of examination are always to be used in the sequence viz. aptopadesha, pratyaksha and anumana. In other words, it could be said that if a physician possesses the textual knowledge (aptopadesha) then, for him, there are only two methods of examinations. [5]

Criteria of knowledge of disease

तत्रेदमुपदिशन्ति बुद्धिमन्तः- रोगमेकैकमेवम्प्रकोपणमेवंयोनिमेवमुत्थानमेवमात्मानमेवमधिष्ठानमेवंवेदनमेवं संस्थानमेवंशब्द स्पर्शरूपरसगन्धमेवमुपद्रवमेवंवृद्धिस्थानक्षयसमन्वितमेवमुदर्क मेवन्नामानमेवंयोगं विद्यात्; तस्मिन्नियं प्रतीकारार्था प्रवृत्तिरथवा निवृत्तिरित्युपदेशाज्ज्ञायते||६||

tatrēdamupadiśanti buddhimantaḥ- rōgamēkaikamēvamprakōpaṇamēvaṁyōnimēvamutthānamēvamātmānamēvamadhiṣṭhānamēvaṁvēdanamēvaṁ saṁsthānamēvaṁśabdasparśarūparasagandhamēvamupadravamēvaṁvr̥ddhisthānakṣayasamanvitamēvamudarka mēvannāmānamēvaṁyōgaṁ vidyāt; tasminniyaṁ pratīkārārthā pravr̥ttirathavā nivr̥ttirityupadēśājjñāyatē||6||

tatredamupadishanti buddhimantaH-rogamekaikamevamprakopaNamevaMyonimevamutthAnamevamAtmAnamevamadhiShThAnamevaMvedanamevaMsaMsthAnamevaMshabdasparsharUparasagandham
evamupadravamevaMvRuddhisthAnakShayasamanvitamevamudarkamevannAmAnamevaMyogaM vidyAt; tasminniyaM pratIkArArthA pravRuttirathavA nivRuttirityupadeshAjj~jAyate||6||

Using the aptopadesha method of examination, one acquires knowledge as described here using the following terms that wise men, or apta, use to understand a disease:

• Prakopanam : provoking factors, viz. process of the vitiation of the doshas

• Yoni: Source of doshas

• Uthanam: onset of a disease

• Atmanam: The cardinal sign and symptoms.

• Adhishthanam: Site, which could be the body or the mind or both

• Vedanam: signs and symptoms

• Sansthanam (location): amashaya, pakwashaya, avayava vishesha, or in micro channels

• Shabda, sparsha, rupa, rasa, gandham(five senses): Altered sensorium.

• Updravam: Complications

• Vriddhi sthana kshayam (Increased, decreased, balanced): Whether dosha, dhatu and mala are increased, decreased, or in balance

• Udarakam: Prognosis

• Namanam: Nomenclature

• Pravritti: Indicated treatment

• Nivritti: Contraindication

Using the above framework, one could gather all the knowledge necessary of a disease [6]

Knowledge by direct perception

प्रत्यक्षतस्तु खलु रोगतत्त्वं बुभुत्सुः सर्वैरिन्द्रियैः सर्वानिन्द्रियार्थानातुरशरीरगतान् परीक्षेत, अन्यत्र रसज्ञानात्; तद्यथा- अन्त्रकूजनं, सन्धिस्फुटनमङ्गुलीपर्वणां च, स्वरविशेषांश्च, ये चान्येऽपि केचिच्छरीरोपगताः शब्दाः स्युस्ताञ्छ्रोत्रेण परीक्षेत; वर्णसंस्थानप्रमाणच्छायाः शरीरप्रकृतिविकारौ, चक्षुर्वैषयिकाणि यानि चान्यान्यनुक्तानि तानि चक्षुषा परीक्षेत; रसं तु खल्वातुरशरीरगतमिन्द्रियवैषयिकमप्यनुमानादवगच्छेत्, न ह्यस्य प्रत्यक्षेण ग्रहणमुपपद्यते, तस्मादातुरपरिप्रश्नेनैवातुरमुखरसं विद्यात्, यूकापसर्पणेन त्वस्य शरीरवैरस्यं, मक्षिकोपसर्पणेन शरीरमाधुर्यं, लोहितपित्तसन्देहे तु किं धारिलोहितं लोहितपित्तं वेति श्वकाकभक्षणाद्धारिलोहितमभक्षणाल्लोहितपित्तमित्यनुमातव्यम्, एवमन्यानप्यातुरशरीरगतान् रसाननुमिमीत; गन्धांस्तु खलु सर्वशरीरगतानातुरस्य प्रकृतिवैकारिकान् घ्राणेन परीक्षेत; स्पर्शं च पाणिना प्रकृतिविकृतियुक्तम्| इति प्रत्यक्षतोऽनुमानादुपदेशतश्च परीक्षणमुक्तम्||७||

pratyakṣatastu khalu rōgatattvaṁ bubhutsuḥ sarvairindriyaiḥ sarvānindriyārthānāturaśarīragatān parīkṣēta, anyatra rasajñānāt; tadyathā- antrakūjanaṁ, sandhisphuṭanamaṅgulīparvaṇāṁ ca, svaraviśēṣāṁśca, yē cānyē'pi kēciccharīrōpagatāḥ śabdāḥ syustāñchrōtrēṇa parīkṣēta; varṇasaṁsthānapramāṇacchāyāḥ , śarīraprakr̥tivikārau, cakṣurvaiṣayikāṇi yāni cānyānyanuktāni tāni cakṣuṣā parīkṣēta; rasaṁ tu khalvāturaśarīragatamindriyavaiṣayikamapyanumānādavagacchēt, na hyasya pratyakṣēṇa grahaṇamupapadyatē, tasmādāturaparipraśnēnaivāturamukharasaṁ vidyāt, yūkāpasarpaṇēna tvasya śarīravairasyaṁ, makṣikōpasarpaṇēna śarīramādhuryaṁ, lōhitapittasandēhē tu kiṁ dhārilōhitaṁ lōhitapittaṁ vēti śvakākabhakṣaṇāddhārilōhitamabhakṣaṇāllōhitapittamityanumātavyam, ēvamanyānapyāturaśarīragatān rasānanumimīta; gandhāṁstu khalu sarvaśarīragatānāturasya prakr̥tivaikārikān ghrāṇēna parīkṣēta; sparśaṁ ca pāṇinā prakr̥tivikr̥tiyuktam| iti pratyakṣatō'numānādupadēśataśca parīkṣaṇamuktam||7||

pratyakShatastu khalu rogatattvaM bubhutsuH sarvairindriyaiH sarvAnindriyArthAnAturasharIragatAnparIkSheta, anyatra rasaj~jAnAt; tadyathA- antrakUjanaM, sandhisphuTanama~ggulIparvaNAM ca,svaravisheShAMshca, ye cAnye~api keciccharIropagatAH shabdAH syustA~jchrotreNa parIkSheta;varNasaMsthAnapramANacchAyAH , sharIraprakRutivikArau, cakShurvaiShayikANi yAnicAnyAnyanuktAni tAni cakShuShA parIkSheta; rasaM tukhalvAturasharIragatamindriyavaiShayikamapyanumAnAdavagacchet, na hyasya pratyakSheNagrahaNamupapadyate, tasmAdAturapariprashnenaivAturamukharasaM vidyAt, yUkApasarpaNena tvasyasharIravairasyaM, makShikopasarpaNena sharIramAdhuryaM, lohitapittasandehe tu kiM dhArilohitaMlohitapittaM veti shvakAkabhakShaNAddhArilohitamabhakShaNAllohitapittamityanumAtavyam,evamanyAnapyAturasharIragatAn rasAnanumimIta; gandhAMstu khalu sarvasharIragatAnAturasyaprakRutivaikArikAn ghrANena parIkSheta; sparshaM ca pANinA prakRutivikRutiyuktam| iti pratyakShato~anumAnAdupadeshatashca parIkShaNamuktam||7||

A physician who wants to examine the patient and diagnose the disease through pratyaksha (direct observations) method of examination should examine with his own senses (all senses except the one relating to the gustatory organ, i.e., taste), in the body of the patient.

The following should be examined by auscultation

• Antrakoojanam: Gurgling sound in the intestine indicating sound of movement;

• Sandhisphutanam: Crackling sound in the joints including those in the fingers;

The following are perceived by auditory measures

• Swara visheshana: Voice patterns of the patient; and

• Shabda: Such other sounds in the body of the patient which are normally found in the human body like respiratory and cardiovascular sounds and also the sounds which are produced through percussion and auscultation etc.

By tactile perceptions

The physician should touch various body parts of the patients, and examine signs of abnormality in terms of the body temperature, skin texture (rough- unctuous), presence of moisture (dry-wet), eruptions, pitting, tenderness, etc.

By visual examination

• Colour, shape, measurement and complexion;

• Natural and unnatural features of the body found in normal and abnormal states; and

• Others which can be examined visually like signs of the disease, lustre and appearance of the body and other organs (inspection method of examination from top to bottom of the person)

Gustatory examinations can be inferred by following observations

Taste of the various tissues in the body of the patient are undoubtedly the objects of the gustatory sense organ and can be ascertained by inference and not by direct observation. Therefore, the taste in the mouth of the patient should be ascertained by interrogation. For example, sweet taste of the body can be inferred when flies are attracted towards the body. In the case of bleeding from the body, if there is a doubt about the nature of the blood, it should be resolved by giving the blood to dogs and crow to taste. Intake of the blood by dogs and crows is indicative of its purity and rejection by these animals indicates that the blood is vitiated by pitta, i.e. the patient is suffering from raktapitta. Similarly, other tastes in the patient’s body can be inferred.

By olfactory examinations

Normal and abnormal smells of the entire body of the patient should be examined by the olfactory sense organ. [7]

Knowledge by inference

इमे तु खल्वन्येऽप्येवमेव भूयोऽनुमानज्ञेया भवन्ति भावाः| तद्यथा- अग्निं जरणशक्त्या परीक्षेत, बलं व्यायामशक्त्या, श्रोत्रादीनि शब्दाद्यर्थग्रहणेन, मनोऽर्थाव्यभिचरणेन, विज्ञानं व्यवसायेन, रजःसङ्गेन, मोहमविज्ञानेन, क्रोधमभिद्रोहेण, शोकं दैन्येन, हर्षमामोदेन, प्रीतिं तोषेण, भयं विषादेन, धैर्यमविषादेन, वीर्यमुत्थानेन, अवस्थानमविभ्रमेण, श्रद्धामभिप्रायेण, मेधां ग्रहणेन, सञ्ज्ञां नामग्रहणेन, स्मृतिं स्मरणेन, ह्रियमपत्रपणेन, शीलमनुशीलनेन, द्वेषं प्रतिषेधेन, उपधिमनुबन्धेन , धृतिमलौल्येन, वश्यतां विधेयतया, वयोभक्तिसात्म्यव्याधिसमुत्थानानि कालदेशोपशयवेदनाविशेषेण, गूढलिङ्गं व्याधिमुपशयानुपशयाभ्यां, दोषप्रमाणविशेषमपचारविशेषेण, आयुषः क्षयमरिष्टैः, उपस्थितश्रेयस्त्वं कल्याणाभिनिवेशेन, अमलं सत्त्वमविकारेण, ग्रहण्यास्तु मृदुदारुणत्वं स्वप्नदर्शनमभिप्रायं द्विष्टेष्टसुखदुःखानि चातुरपरिप्रश्नेनैव विद्यादिति||८||

imē tu khalvanyē'pyēvamēva bhūyō'numānajñēyā bhavanti bhāvāḥ tadyathā agniṁ jaraṇaśaktyā parīkṣēta balaṁ vyāyāmaśaktyā, śrōtrādīni śabdādyarthagrahaṇēna, manō'rthāvyabhicaraṇēna, vijñānaṁ vyavasāyēna, rajaḥsaṅgēna, mōhamavijñānēna, krōdhamabhidrōhēṇa, śōkaṁ dainyēna, harṣamāmōdēna, prītiṁ tōṣēṇa, bhayaṁ viṣādēna, dhairyamaviṣādēna, vīryamutthānēna avasthānamavibhramēṇa, śraddhāmabhiprāyēṇa, mēdhāṁ grahaṇēna, sañjñāṁ nāmagrahaṇēna, smr̥tiṁ smaraṇēna, hriyamapatrapaṇēna, śīlamanuśīlanēna, dvēṣaṁ pratiṣēdhēna, upadhimanubandhēna , dhr̥timalaulyēna, vaśyatāṁ vidhēyatayā, vayōbhaktisātmyavyādhisamutthānāni kāladēśōpaśayavēdanāviśēṣēṇa, gūḍhaliṅgaṁ vyādhimupaśayānupaśayābhyāṁ, dōṣapramāṇaviśēṣamapacāraviśēṣēṇa, āyuṣaḥ kṣayamariṣṭaiḥ, upasthitaśrēyastvaṁ kalyāṇābhinivēśēna, amalaṁ sattvamavikārēṇa, grahaṇyāstu mr̥dudāruṇatvaṁ svapnadarśanamabhiprāyaṁ dviṣṭēṣṭasukhaduḥkhāni cāturaparipraśnēnaiva vidyāditi||8||

ime tu khalvanye~apyevameva bhUyo~anumAnaj~jeyA bhavanti bhAvAH| tadyathA- agniM jaraNashaktyA parIkSheta, balaM vyAyAmashaktyA, shrotrAdInishabdAdyarthagrahaNena, mano~arthAvyabhicaraNena, vij~jAnaM vyavasAyena, rajaHsa~ggena,mohamavij~jAnena, krodhamabhidroheNa, shokaM dainyena, harShamAmodena, prItiM toSheNa, bhayaMviShAdena, dhairyamaviShAdena, vIryamutthAnena , avasthAnamavibhrameNa,shraddhAmabhiprAyeNa, medhAM grahaNena, sa~jj~jAM nAmagrahaNena, smRutiM smaraNena,hriyamapatrapaNena, shIlamanushIlanena, dveShaM pratiShedhena, upadhimanubandhena [3] ,dhRutimalaulyena, vashyatAM vidheyatayA, vayobhaktisAtmyavyAdhisamutthAnAnikAladeshopashayavedanAvisheSheNa, gUDhali~ggaM vyAdhimupashayAnupashayAbhyAM,doShapramANavisheShamapacAravisheSheNa, AyuShaH kShayamariShTaiH, upasthitashreyastvaMkalyANAbhiniveshena, amalaM sattvamavikAreNa, grahaNyAstu mRududAruNatvaMsvapnadarshanamabhiprAyaM dviShTeShTasukhaduHkhAni [4] cAturapariprashnenaiva vidyAditi||8||

Charak observed that the objects known by direct perceptions are very limited, whereas the range of inference is fairly vast in areas that are not known by our means of perception, i.e., sense organs. Here, reasoning and logic already stated in scriptures need to be used. The following subjects could be understood through anumana (inference):

• Agnim jaran shaktya- Digestion by quality and quantity of food taken and digested or not digested.

• Balam vyayam shaktya- Physical strength of the person to be examined with the performance of the exercise or the physical work.

• Shrotradeeni- shabdadi artha grahanena-The sensory ability with clarity and accuracy of perception of their respective objects.

• Mano- avyabhicharnena - Inappropriate mental perceptions, even in the presence of all other senses along with their respective objects. Absence or altered perception indicates dissociation of mind with senses.

• Vigyanam vyavsayena- skills can be judged by one’s occupation.

• Rajah sangena - attachments by involvement

• Moham avigyanena- ignorance, has no skills, without occupation, remains idol.

• Krodham abhidrohena- anger by choosing measures for revenge

• Shokam dainyena- grief by poverty of thinking

• Harsham aamoden- pleasure by way of celebrations.

• Preetim Toshena- affection by satisfaction.

• Bhayam vishadena- fear by duration and severity of anxiety.

• Dhairyam avishadena - patience by facing adversities without fear and anxiety

• Veeryam utthanena- bravery by way of initiation of difficult task

• Avasthanam avibhramena- stability by absence of doubts and confusions

• Shriddha abhiprayena- faith by purposiveness

• Medha grahnena- wisdom by retaining threshold

• Sangya namgrahanena- mental awakening instantaneous identification

• Smriti smarnena- memory by recalling ability

• Hriyam apatrapnena- shy by drooping of eyelids.

• Sheelam anusheelnena- obedience by constant following

• Dvesham pratishedhena- hatred by duration of staying away

• Upadhi anubandhena- fraudulent attitude.

• Dhriti alaulyena- tolerance by long standing and non shifting attitude

• Vashyata vidheyataya- controllability by following of righteous conduct

• Vaya kalen- age by chronological time

• Bhakti deshen- liking a place, person and surroundings with opportunistic intentions.

• Satmya upshayena- habituation by suitability

• Vyadhi vedanaya- diseases by symptomatology

• Goodha linga vyadhi- mysterious diseases by therapeutic measures

• Dosha pramana- quantity of morbidity by potential causative factors

• Aysha kshaya- near death signs of imminent death (Arishta)

• Shreyatwam: signs of regaining health, when the patient thinks welfare of all.

• Amalam Satwam- purity of mind by freedom from illusionary attachments.

• Granyastu mridu darunatwam- abdominal comforts and discomforts by sleep quality and by interrogations. [8]

Importance of three fold examination

भवन्ति चात्र- आप्ततश्चोपदेशेन प्रत्यक्षकरणेन च| अनुमानेन च व्याधीन् सम्यग्विद्याद्विचक्षणः||९||

bhavanti cātra-

āptataścōpadēśēna pratyakṣakaraṇēna ca| anumānēna ca vyādhīn samyagvidyādvicakṣaṇaḥ||9||

bhavanti cAtra- Aptatashcopadeshena pratyakShakaraNena ca| anumAnena ca vyAdhIn samyagvidyAdvicakShaNaH||9||

To sum up this chapter, it can be said that the wise should properly understand a disease by means of three methods, i.e., the words documented by the wise, direct observation and inference. [9]

सर्वथा सर्वमालोच्य यथासम्भवमर्थवित्| अथाध्यवस्येत्तत्त्वे च कार्ये च तदनन्तरम्||१०||

sarvathā sarvamālōcya yathāsambhavamarthavit| athādhyavasyēttattvē ca kāryē ca tadanantaram||10||

sarvathA sarvamAlocya yathAsambhavamarthavit| athAdhyavasyettattve ca kArye ca tadanantaram||10||

As far as possible, all factors should be discussed in their entirety. After examining the disease by aptopadesha, the physician should obtain knowledge regarding the nature of disease and the therapies required therefore. [10]

कार्यतत्त्वविशेषज्ञः प्रतिपत्तौ न मुह्यति| अमूढः फलमाप्नोति यदमोहनिमित्तजम्||११||

kāryatattvaviśēṣajñaḥ pratipattau na muhyati| amūḍhaḥ phalamāpnōti yadamōhanimittajam||11||

kAryatattvavisheShaj~jaH pratipattau na muhyati| amUDhaH phalamApnoti yadamohanimittajam||11||

One who is well versed in the specific nature of the disease as well as the therapies required therefore seldom fails to act properly. It is only he who acts properly that reaps the results of proper action (i.e. achieves success). [11]

ज्ञानबुद्धिप्रदीपेन यो नाविशति तत्त्ववित् | आतुरस्यान्तरात्मानं न स रोगांश्चिकित्सति||१२||

jnānabuddhipradīpēna yō nāviśati tattvavit | āturasyāntarātmānaṁ na sa rōgāṁścikitsati||12||

j~jAnabuddhipradIpena yo nAvishati tattvavit | AturasyAntarAtmAnaM na sa rogAMshcikitsati||12||

When a physician who, even if well versed in knowledge of the disease and its treatment does not try to enter into the heart of the patient by virtue of the light of his knowledge, he will not be able to treat the disease. [12]

Summary

तत्र श्लोकौ- सर्वरोगविशेषाणां त्रिविधं ज्ञानसङ्ग्रहम्| यथा चोपदिशन्त्याप्ताः प्रत्यक्षं गृह्यते यथा||१३||

ये यथा चानुमानेन ज्ञेयास्तांश्चाप्युदारधीः| भावांस्त्रिरोगविज्ञाने विमाने मुनिरुक्तवान्||१४||

tatra ślokau-

sarvarōgaviśēṣāṇāṁ trividhaṁ jñānasaṅgraham| yathā cōpadiśantyāptāḥ pratyakṣaṁ gr̥hyatē yathā||13|| yē yathā cānumānēna jñēyāstāṁścāpyudāradhīḥ| bhāvāṁstrirōgavijñānē vimānē muniruktavān||14||

tatra shlokau- sarvarogavisheShANAM trividhaM j~jAnasa~ggraham| yathA copadishantyAptAH pratyakShaM gRuhyate yathA||13|| ye yathA cAnumAnena j~jeyAstAMshcApyudAradhIH| bhAvAMstrirogavij~jAne vimAne muniruktavAn||14||

To sum up again,

Three methods for the determination of all types of diseases are - factors understood by the instructions of apta (sages), by direct observation and inference, along with the methods prescribed in respective chapters for specific subject.[13-14]

इत्यग्निवेशकृते तन्त्रे चरकप्रतिसंस्कृते विमानस्थाने त्रिविधरोगविशेषविज्ञानीयं विमानं नाम चतुर्थोऽध्यायः||४||

ityagnivēśakr̥tē tantrē carakapratisaṁskr̥tē vimānasthānē trividharōgaviśēṣavijñānīyaṁ vimānaṁ nāma caturthō'dhyāyaḥ||4||

Thus ends the fourth chapter of Vimana Sthana on “The determination of the three factors for understanding the specific characteristics of diseases” of Agnivesha’s work as redacted by Charak.

Tattva Vimarsha / Fundamental Principles

• Diagnosis of a disease should be done thoroughly using the trividha pariksha consisting of aptopadesha (authoritative knowledge), pratyaksha (physical examination by direct observation) and anumana (interpretation, evaluation and assessment).

Vidhi Vimarsha / Applied Inferences

Trividharogavisheshavijnaniyam solely deals with the methods of clinical examination of the patient. Various types of examinations viz. rogapariksha, rogipariksha, trividha pariksha, shadvidha pariksha, ashtavidha pariksha, and dashavidha pariksha are described in Ayurveda for the examination of the patient and the diagnosis of the disease. All these examinations do not go beyond the trividha pariksha described in this chapter. Aptopadesha gives all the details of the disease i.e. its causative factors, pathogenesis and treatment and thus, provides all the theoretical knowledge of the disease which is helpful during clinical examination. Pratyaksha deals with direct examination of the patient by the physician. The physician has to use all his senses during the examination, in which he has to look for various signs and symptoms, changes in the color etc. Any information collected through anumana and pratyaksha cannot provide all the details of existing pathologies in the body. Now the physician has to use his own intellect and tries to establish the relation between the signs and symptoms and the likely pathologies in the body. He has to use his logic and reasoning and apply it properly in finalizing the vitiated doshas in the body. Anumana helps the physician to deduce and draw inferences where it is not possible to visualize or see, in order to draw certain conclusions or understand causation of an ailment.

Charak has described the entire clinical examination in this chapter. There is no fourth tool required for clinical examination except aptopadesha, pratyaksha and anumana. In Ayurveda, emphasis is given to the use of the five senses in examining a patient. First hand information gathered through the physical examination by five senses is critical to the process of diagnosis. These three types of examinations are also used to assess bad prognosis of the disease and to identify the arishta (signs and symptoms of imminent death) also.

Examinations like inspection, palpation, percussion and auscultation are part of pratyaksha pariksha. Nowadays, various new techniques like X-ray, USG, CT Scan, MRI etc. are in use that help augment pratyaksha pariksha. Abnormal findings suggest the underlying pathologies in the body with the use of anumana pariksha. But over-dependence on technology has made the doctors move away from the use of their sensory perception and from prima facie clinical diagnosis. Excessive use of technology makes the process of diagnosis more complicated, costly and time consuming. The most important disadvantage of using technology is that it is reducing the use of logic and reasoning (yukti) by a physician. It also has influence on the doctor patient relationship. The most important thing which has been described by Charak is to enter in to the soul of the patient to make correct diagnosis and is somewhere missing due to excessive use of technology. Proper use of trividha pariksha by a physician with required use of technology, will help him to reach up to the diagnosis immediately, correctly and will also be cost effective to the patient.

Glossary

1. āptōpadēśaḥ (AptopadeshaH; आप्तोपदेशः ): The unimpeachable truth of enlightened men; the 1st proof of justifying knowledge
2. pratyakṣaṁ (pratyakSham, प्रत्यक्षम् ): The cognition arising at the instant of the conjugation of the soul, mind, senses, and object .
3. anumānam (anumAnaM, अनुमानं ): the process through which the knowledge of the unseen facts is inferred on the basis of direct observation
4. parīkṣa (parīkṣā, परीक्षा ): investigation or examinations which leads to correct knowledge
5. avibhāgavid (avibhAgavid,अविभागविद): A person who knows the complete subject
6. yōnim (yonim, योनि): Source, Origin
7. utthāna (utthAna, उत्थान): the act of standing up or rising,
8. ātmānam (AtmAnaM, , आत्मानम): Own
9. udarka (udarka, उदर्क): Remote consequence, future result of the action
10. sandhisphuṭanam (sandhisphuTanama,सन्धिस्फुटनम): Joint Cracking or bursting sound
11. śarīravairasyaṁ (sharIravairasyaM,शरीरवैरस्यं): Bad taste of the body
12. śarīramādhuryaṁ (sharIramAdhuryaM, शरीरमाधुर्यं): Sweet taste of the body
13. lōhitapittaṁ (lohitapittam,लोहितपित्त..): Suffering from bleeding disorder—
14. agniṁ (agnim, अग्निं): Digestive faculty, fire of the stomach
15. balaṁ (balam, बलं): Strength, stamina
16. vijñānaṁ (vij~jAnaM, विज्ञानं ): Knowledge, wisdom, science
17. rajaḥ (rajaH, रजः ): Emotion, affection, quality of passion
18. mōha (moha, मोह): Inability to discriminate, Delusion, confusion, error
19. vīrya (vIrya, वीर्य): Courage, heroic deed
20. avasthāna (avasthAna, अवस्थान): Condition, Situation
21. śraddhām (zraddhAM, श्रद्धा.. ): Desire, Believe, Faith, belief
22. mēdhāṁ (medhAM,मेधां): Intelligence, wisdom
23. sañjñāṁ (saMjJA, सञ्ज्ञां): Designation, Recognition, Consciousness
24. hriyam (hriyam,ह्रिय..): Shame, Timidity, Modesty, Shyness
25. upadhim (upadhim,उपधि…): Fraud
26. dhr̥ti (dhRuti, धृति): Self command, Courage
27. gūḍhaliṅgaṁ vyādhi (gUDhali~ggaM vyAdhi,गूढलिङ्गं व्याधि): Disease with Mysterious, hidden signs
28. ariṣṭa (ariShTa,अरिष्ट): Natural phenomenon approching death, Fatal, Disastrous
29. pratipatti (pratipatti,प्रतिपत्ति ): Action, determination, conclusion
30. tattvavit (tattvavit,तत्त्ववित्): A person who knows the truth
31. upadrava (upadrava, उपद्रव): Supervenient, complications
32. antrakūjanaṁ (antrakUjanaM, अन्त्रकूजनं ): Rumbling of the bowels