Chapter 4 Trividha Roga Vishesha Vijnaniya Vimana adhyaya - (Chapter on the Three-Fold Clinical Examination Method for complete Diagnosis of Diseases)

• Chapter 4

   Trividha Roga Vishesha Vijnaniya Vimana adhyaya 

  - (Chapter on the Three-Fold Clinical Examination Method for complete Diagnosis of Diseases)

  
  
  अथातस्त्रिविधरोगविशेषविज्ञानीयं विमानं व्याख्यास्यामः||१||
  इति ह स्माह भगवानात्रेयः||२||
  
  
  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||
  
  
  Specific features of diseases can be determined in three ways – by means of 
  1. aptopadesha (authoritative instruction), 
  2. pratyaksha (direct observation), and 
  3. anumana(inference). [3]
  
  
  Aptopadesha 
  तत्राप्तोपदेशो नामाप्तवचनम्| 

  Authoritative instructions are the teachings of Aptas (persons who are the most reliable).  

  
  

  Apta Lakshana ; features of truthful reliable persons

  
  

  आप्ता ह्यवितर्कस्मृतिविभागविदो निष्प्रीत्युपतापदर्शिनश्च| तेषामेवङ्गुणयोगाद्यद्वचनं तत् प्रमाणम्| 

  
  

  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. 
• 
  
• अप्रमाणं पुनर्मत्तोन्मत्तमूर्खरक्तदुष्टादुष्टवचनमिति ; 
• 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
प्रत्यक्षं तु खलु तद्यत् स्वयमिन्द्रियैर्मनसा चोपलभ्यते| 
•  is that which is comprehensible by an individual through his own senses and mind.




Anumana or inference 
अनुमानं खलु तर्को युक्त्यपेक्षः||४||
• is the indirect knowledge based on 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||


At First , 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 

1. pratyaksha (direct observations), and

 2. anumana (inference). 

What is to be examined by “pratyaksha / direct observations” and anumana / inference unless something can be studied prima facie. 

Hence, all the three methods of examination are always to be used in the sequence viz. 

1.aptopadesha, 

2.pratyaksha and 

3.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||


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 / Pratyaksha



प्रत्यक्षतस्तु खलु रोगतत्त्वं बुभुत्सुः सर्वैरिन्द्रियैः सर्वानिन्द्रियार्थानातुरशरीरगतान् परीक्षेत, अन्यत्र रसज्ञानात्;  
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            
• तद्यथा- अन्त्रकूजनं, सन्धिस्फुटनमङ्गुलीपर्वणां च, 

  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               
• स्वरविशेषांश्च, ये चान्येऽपि केचिच्छरीरोपगताः शब्दाः स्युस्ताञ्छ्रोत्रेण परीक्षेत;

  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 visual examination / netra
• वर्णसंस्थानप्रमाणच्छायाः शरीरप्रकृतिविकारौ, चक्षुर्वैषयिकाणि यानि चान्यान्यनुक्तानि तानि चक्षुषा परीक्षेत;  
• 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 / jihva
रसं तु खल्वातुरशरीरगतमिन्द्रियवैषयिकमप्यनुमानादवगच्छेत्, न ह्यस्य प्रत्यक्षेण ग्रहणमुपपद्यते, तस्मादातुरपरिप्रश्नेनैवातुरमुखरसं विद्यात्, 


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  /  anumana and not by direct observation. Therefore, the taste in the mouth of the patient should be ascertained by interrogation. 


Use of animals to examine body fluids
यूकापसर्पणेन त्वस्य शरीरवैरस्यं, मक्षिकोपसर्पणेन शरीरमाधुर्यं, लोहितपित्तसन्देहे तु किं धारिलोहितं लोहितपित्तं वेति श्वकाकभक्षणाद्धारिलोहितमभक्षणाल्लोहितपित्तमित्यनुमातव्यम्, एवमन्यानप्यातुरशरीरगतान् रसाननुमिमीत;


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 / ghrana

गन्धांस्तु खलु सर्वशरीरगतानातुरस्य प्रकृतिवैकारिकान् घ्राणेन परीक्षेत;
Normal and abnormal smells of the entire body of the patient should be examined by the olfactory sense organ. [7]

By tactile perceptions / sparsa

स्पर्शं च पाणिना प्रकृतिविकृतियुक्तम्| इति प्रत्यक्षतोऽनुमानादुपदेशतश्च परीक्षणमुक्तम्||७||

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.

Knowledge by inference / anumana



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||


Charaka 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 vyayama 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- artha 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
• Ayusha 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.
• Grahanyastu 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||
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 aptopadesha, direct observation / pratyaksha and inference / anumana. [9]


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


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||
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||


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||


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 Charaka.