Ayurveda the divine science of life -9

Ayurveda the divine science of life

  PART 1: Theory and practice of A-yurveda

9. De´sam: the environment in which the patient

lives

10. A¯ha¯ra: the dietary habits of the patient.

9.6 Du¯ s.yam

For a disease to develop, there are three factors that

must be present: a ‘cause’ or ‘causes’ (nida¯na), the

vitiation of the dos.as, and the subsequent impact

upon the dha¯tus. A cause cannot act independently

to initiate a disease, but does so only through the vitiation

of the dos. as, which then act upon the dha¯tus

to bring about their vr. ddhi (‘increase’) and ka´sa¯ya

(‘decrease’). Each dha¯tu should thus be examined to

determine its status, which will indicate which dos.as

are involved in the illness:

Rasa

Vr. ddhi: kapha laks.an. as, e.g. of phlegm, mucus discharge.

Ka´sa¯ya: va¯ta laks.an. as, e.g. dryness, fatigue, emaciation,

impotency, infertility, increased sensitivity to

sonic vibrations.

Rakta

Vr. ddhi: pitta laks.an. as, e.g. skin diseases, hepatomegaly,

splenomegaly, hepatitis, jaundice, abscess with

infection and inflammation, arthritis, gout, haemorrhages

of the mouth, nose or anus (rakta pitta), reddish

discoloration of the eyes, skin and urine.

Ka´sa¯ya: va¯takapha laks.an. as, e.g. desire for sour

and warming foods, anaemia, hypotension, dryness of

the body.

Ma¯m. sa

Vr. ddhi: kapha laks.an. as, e.g. lymphadenitis, lymphadenopathy,

goitre, malignant tumours, fibroids,

abscesses, obesity.

Ka´sa¯ya: va¯ta laks.an. as, e.g. emaciation, fatigue,

a lack of coordination, muscular atrophy.

Medas

Vr. ddhi: kapha laks.an. as, e.g. fatigue, shortness of

breath, sagging of breasts, buttocks and abdomen,

obesity.

Ka´sa¯ya: va¯ta laks.an. as, e.g. nervous irritability, weak

eyesight, dryness, osteoarthritis, poor mineralisation,

emaciation.

Asthi

Vr. ddhi: kapha laks.an. as, e.g. bone spurs, bone cancer,

gigantism, acromegaly.

Ka´sa¯ya: va¯ta laks.an. as, e.g. osteoporosis, brittle

bones, splitting or cracking fingernails, alopecia, tooth

decay.

Majja¯

Vr. ddhi: kapha laks.an. as, e.g. heaviness, lassitude and

hypertrophy, swelling of joints, muscular paralysis.

Ka´sa¯ya: va¯ta laks.an. as, e.g. sensation of weakness

or lightness in the bones, joint pain, rheumatism, vertigo,

progressive blindness, loss of sensory function.

´Sukra

Vr. ddhi: kaphapitta laks.an. as, e.g. insatiable sexual

urges, seminal calculi, odorous perspiration, greasy

skin, greasy hair, acne.

Ka´sa¯ya: va¯ta laks.an. as, e.g. impotency, infertility,

premature ejaculation, erectile dysfunction, chronic

prostatitis, chronic urethritis.

An.d.

a¯n.u

Vr. ddhi: kaphapitta laks.an. as, e.g. insatiable sexual

urges, a consistently short oestrus cycle, odorous perspiration,

greasy skin, greasy hair, acne.

Ka´sa¯ya: va¯ta laks.an. as, e.g. frigidity, infertility,

amenorrhoea, chronic leucorrhoea, premenstrual

depression, menstrual blood which is pellet-like and

malodorous, chronic menstrual pain.

9.7 Ka¯lam

Ka¯la literally means ‘time’, and, in regard to the examination

of the patient, refers to the progression or the

staging of the condition or disease in relation to a therapeutic

regimen. This is not to assess the progress of

the condition in relation to biological rhythms or determine

a prognosis as in ka¯la sam. pra¯pti, so much as it

Clinical methodology and case history 107

is to understand the difference between the administration

of a timely remedy (ka¯laha) and an untimely

one (aka¯lah). Even though a certain remedy could be

helpful to the patient, it must be in accordance with

the current signs and symptoms, but with the ultimate

aim of re-establishing the balance between the

dos.as, dha¯tus and malas. In the case of diarrhoea

(atisa¯ra), for example, remedies such as Ja¯tı¯phala

(Myrsitica fragrans) that are stambhana (‘constipating’,

‘cooling’) should not be used too soon. Instead

the treatment should be directed to agni first with the

use of dı¯panapa¯cana remedies. In another example,

ka¯la could refer to the supplementation of iron and

vitamin B complex in persons with a chronic bacterial

infection. In this example, the vitamin–mineral combination

could prove helpful to address an underlying

nutritional deficiency, but should only be given after

the infection has been completely resolved, as the bacteria

can utilise these nutrients to assist in their

own reproduction. Thus, ka¯la is the development

of a treatment protocol based upon individual factors

such as the staging or progression of the

condition.

9.8 Prakr. ti

The knowledge of the patient’s prakr. ti is helpful in

determining their underlying strength (bala¯), in

developing individualised preventative regimens, and

in formulating a prognosis. In the latter case, a vikr. ti

that corresponds with the prakr. ti is usually more

difficult to treat.

The different prakr. tis are based upon the primary

gun. as that they display. Tables 9.1–9.3 correlate the

qualities of the dos.as with the physical characteristics

that form the prakr. ti.

9.9 Vayah.

Vayah.

refers to the age of the patient and the life

span. According to Caraka a variety of factors are

involved in the determination of lifespan. These

include the actions of previous lives as well as the

actions of one’s current life, such as the prevention of

injury, the consumption of wholesome foods, the successful

treatment of disease and the pursuit of

Kapha gun.as Manifestations

Guru Heaviness and largeness of body;

bones, veins and tendons well

covered

Snigdha Oiliness of body

´Sita Mild hunger and thirst, mild

perspiration, dislikes cold

Mr. du Suppleness of tissues, pleasing

appearance

Sthira Slow in initiating activity, slow and

deliberate movement; slow digestion

Picchila Smoothly gliding joints, smoothness

of skin, clarity of complexion

TABLE 9.1 Kapha prakr. ti.

Pitta gun.as Manifestations

Us.n.

a Intolerance of hot things, ruddy

complexion, increased density of

moles and freckles, thin hair

Tiks.n.

a Strong hunger and strong thirst,

angular features

Snigdha Moistness of body

Laghu More muscular, less fat

Drava Increased excretion of the malas

(perspiration, faeces and urine)

Sara Physically active, moves quickly

TABLE 9.2 Pitta prakr. ti.

Va¯ta gun.as Manifestations

Laghu Thinness of body; bones, tendons

and veins prominent

´Sita Intolerance of cold, stiffness

Ru¯ks.

a Dryness and coarseness of skin and

hair; dry faeces

Cala Constantly moving, active, fidgety

Vi´sada Cracking and popping of the joints

Su¯ks.

ma Instability in movement

TABLE 9.3 Va¯ta prakr. ti.

108 PART 1: Theory and practice of A-yurveda

spiritual happiness. In A¯yurvedic terms, the life span is

divided into three parts:

1. Ba¯lya (‘child’ hood): Childhood encompasses the

time from birth onwards until puberty (vr. ddhi).

During childhood it is said that kapha is the predominant

dos.a, indicated by the soft, fat and

moist bodies of children, and the minor congestive

conditions that often occur as the immune

system develops. Psychologically, however, the

dominant dos.a during childhood is va¯ta, as children

are highly suggestive, sensitive and attuned

to both negative and positive influences in their

environment.

2. Madhya (‘middle’ age): Middle age encompasses

the time from puberty until the first stages of physical

degeneration (pariha¯ni) begin to manifest, by

about the age of 60 or 70. The height of middle

age occurs in the 3rd and 4th decades in which the

body is full grown (sampu¯rn.

ata), and the person

is at the height of their physical prowess, skill and

mental aptitude. During this time pitta is the

dominant dos.a both physically and psychologically,

accounting for the ability to understand

one’s duties and responsibilities and project one’s

will in the world.

3. Jı¯rn.

a (‘old’ age): Old age encompasses the period

of time from the first stages of physical degeneration

until death; that is from the 6th and 7th

decades onwards. Physically, this time is marked

by the influence of va¯ta, indicated by the encroaching

influences of cold, dry and light qualities

that promote physical degeneration and

a gradual decline in strength, memory, speech and

courage. Psychologically this period of life most

closely resembles that of kapha, and many seniors

can be seen to display kaphaja qualities such

as compassion, sentimentality and generosity,

although psychological factors are also affected by

the increasing influence of va¯ta, which in conjunction

with kapha can promote psychological

traits such as confusion, lethargy and dullness of

mind.

Based on the concept of prakr. ti, kaphaja

prakr. tis are stated to have the longest lifespan, followed

by pittaja prakr. ti, and then va¯taja prakr. ti,

which typically has the shortest. Apart from prakr. ti,

a variety of A¯ yurvedic texts provide a number of features

that can be used to determine health and

longevity. When a baby was born a number of factors

were taken into consideration to determine potential

longevity. According to Caraka there is a specific symmetry

in babies that generally indicates a long life. The

ears should be large and thick, with large lobes and a

large tragus (the auricular cartilage anterior to the

external meatus). The forehead should be broad and

have three transverse lines, and the hair on the head

should be soft, moist and thick. The nose should be

straight and the nasal bone wide, the jaw should

be broad and large, and the lips should be neither very

thin nor very thick. The neck should be neither thin

nor thick, and the chest should be broad. The arms and

hands should be large and plump, and the nails of

the hand should be firm, round, and slightly convex.

The waist should be less than three-quarters the width

of the chest. The buttocks should be round, firm and

plump. The thighs should be round and plump, and

taper downwards. The calves, ankles and feet should

be rounded and soft, and be neither excessively thin

nor too thick.

In adults, the As.t.

a¯ñga Hr.

daya indicates that the

hair should be soft, the forehead high, and the ears

should be thick and broad. The sclera of the

eyes should be white, and demonstrate a clear demarcation

between the iris and sclera, the eyes protected

by thick eyelashes. The nose should have a slightly

elevated tip, with a straight and full septum. The lips

should be red and thick, the lower jaw and chin fully

developed, the teeth large, thick, smooth and evenly

placed, and the tongue pink, broad and thin. The

neck should be short, thick and round, and the shoulders

should be firm and muscular. The abdomen

should be firm, even, and smooth, and the umbilicus

with a right whorl. The nails should be pink, smooth,

thick, convex and hard. The hands and feet should be

large, the fingers long and separate. The vertebral

column and joints should be large, but hidden by the

surrounding tissues. The lustre of the skin should be

slightly greasy and shining. Derivations from this

ideal include the eight unsatisfactory body types

(nindita), including arom. a (‘absence of body hair’),

atiloma (‘excess body hair’), atikr.s.

n.

a (‘excessively

dark skin’), atigaura (‘excessively white skin’),

atisthu¯la (‘obesity’), atikr. ´sa (‘asthenia’),

atidı¯rgha (‘excessively tall’) and atihrasva (‘excessively

short’).

Clinical methodology and case history 109

9.10 Bala¯m

The term bala¯ refers to the strength of an individual,

and is of three types. Sahaja¯ bala¯m is the innate

strength of the individual, and corresponds to the

para ojas. Thus the strength that an individual is

born with generally corresponds with the prakr. ti,

with kaphaja prakr. ti being the strongest, pittaja

prakr. ti being moderately strong, and va¯ttika

prakr. ti being the weakest. Yuktikr. tham is the

‘acquired’ strength of an individual, corresponding

with apara ojas. This corresponds with the ‘dietary’

(a¯ha¯ra) and ‘lifestyle habits’ (sa¯tmya) of the individual.

Ka¯lajam is the strength of an individual that is

based upon the ‘seasonal influence’ (r.

tucarya¯). The

ideal manifestation of strength is a well-developed

musculature with a good ability to carry heavy loads,

and to walk up hills relatively easily.

Caraka states that there are three grades to bala¯,

listed as pravara, madhya and avara bala¯.

Pravara bala¯ is ‘great strength’, madhya bala¯ is

‘medium strength’, and avara bala¯ is ‘poor

strength’. The importance in distinguishing the

strength of the individual is found in the varying

strengths of medicines that could potentially be

administered during treatment. If tiks.n.

a dravyas

are given to a weakened individual for example, the

result could be harmful or even fatal. Weak persons

are thus given mr. du (‘soft’) and sukuma¯ra (‘mild’)

dravyas. On the other hand, if such remedies were

given to a strong person, there may be no change in

the course of the disease, which may indicate the

need for a stronger approach.

Caraka also mentions that the ka¯la sam. pra¯pti, or

the appearance of signs and symptoms, may sometimes

obscure the true nature of the condition, and

that this is a potential error the physician must guard

against. Caraka states that strong individuals suffering

from a severe disease may manifest only mild

symptoms. Similarly, a weak patient suffering from

a mild disease may manifest severe symptoms. If

remedies that are weak or mild in nature are given to

the strong patient suffering from a strong disease,

Caraka states that the disease will eventually get

worse. If strong remedies are used in a weak patient

suffering from a mild disease, the patient will also get

worse.

9.11 Agni

Caraka says that agni is the focal point of treatment,

and the root of bala¯ (‘strength’), arogya (‘health’),

a¯yus (‘longevity’), varna (‘complexion’), sukha (‘happiness’),

ojas (‘resistance to disease’), and tejas

(‘energy’). Thus, the digestive capacity of the patient

should be ascertained. Generally speaking, the agni is

assessed according to the influence of the dos.as

Va¯ttika afflictions of agni are associated with

a vis.ama¯gni, or an irregular digestion. Paittika conditions

are associated with a tiks.n.

a¯gni, or a digestion

that is unusually strong and fast. Kaphaja conditions

are associated with a mañda¯gni, or a digestion that is

weak and slow (see 4.1 Agni: the fire of digestion and

metabolism).

9.12 Sattva

Sattva is an assessment of the patient’s mental and

emotional state. Sattva can be classified in two ways:

by determining the general mental and emotional

capacity, and by assessing the predominance of

sattva, rajas or tamas. The strength of an individual’s

mental capacity is graded according to their

ability to withstand mental, physical and emotional

hardship. Pravaram is the ability to withstand a

high degree of hardship, such that adverse conditions

are faced with courage, grace and hope.

Madhyamam is the ability of an individual to withstand

hardship only when they have the love and

support of others around them, and when they

realise that they are not the only person in the world

that is experiencing dukha (‘sorrow’). Individuals

classified as avaramhave a difficult time gaining any

strength from others, and have little ability to face

hardship on their own. They are susceptible to fear

and cannot tolerate any negative influences (such as

media reports of tragedies) or the sight of physical

injury.

Sattva is also an assessment of the patient’s mental

and emotional orientation, classified according to the

predominance of sattva, rajas, or tamas. Please

review section 3.3 Trigun. a manas: the qualities of

the mind.

110 PART 1: Theory and practice of A-yurveda

9.13 Sa¯tmya

Sa¯tmya means what is ‘normal’, or the ‘habit’ of the

patient, referring specifically to their current lifestyle

habits, generally in context with the disease being

treated, as well as other factors such as the prakr. ti

and de´sa. Ultimately, it is an assessment of whether

these habits are conducive to the successful treatment

of the condition, and if these habits are congruent

with the patient’s prakr. ti and ancestral background.

In a rather obvious example, the consumption of

devitalised and refined food in a patient suffering

from a debilitating condition would be asa¯tmya, or

incongruent with the needs of the patient. Similarly,

the same person staying up late at night would also

be asa¯tmya. Thus, encouraging the patient to eat an

easily digestible diet of whole foods and making sure

to get adequate sleep would be an example of recommendations

that are sa¯tmya. In another example,

the consumption of foods that have a guru and

snigdha quality in a patient with a kaphaja prakr. ti

would also be asa¯tmya, as would a lifestyle that is

luxurious and deficient in strenuous physical

exercise.

Sa¯tmya also refers to the need for the patient to

consume an appropriate diet, with an emphasis

towards those foods that are generally regarded as

being high in quality. Traditionally speaking, some

A¯

yurvedic commentators elevate certain dietary articles

over others, such as rakta ´sa¯li (red rice) among

grains, saindhava (rock salt) among salts, dra¯ks.

a¯

(grapes) among fruits, jı¯vantaka tuber (Leptadenia

reticulata) among vegetables, ghr. ta (clarified butter)

among fats, and ena ma¯m. sa (venison) among meats.

The emphasis in the patient’s diet, however, should be

to choose the healthiest local foods available, with an

emphasis upon de´sa, or ancestral influences. Thus

for people of Northern European descent the Indian

red rice may not be the most appropriate and best

food, and measures should be undertaken to implement

the ancestral diet to as great a degree as possible.

Within the confines of sa¯tmya, however, the

emphasis should still be as varied as possible, and all

six rasas should be present in the diet. This kind of

diet is called pravaram, or ‘wholesome’. When only

one or two rasas, such as salt and sweet, are dominant

in the diet, this is called avaram, or ‘unwholesome’.

9.14 De´sam

The term de´sa means habitat, and in the context of

examination refers to environmental factors in the

patient’s life. This includes the current residence of the

patient, the place of birth, and the knowledge of what

constitutes a polluted environment.

Generally speaking, a living environment is of three

basic types:

1. Ja¯n. gala: arid environments

2. Anu¯pa: marshy environments

3. Sadha¯ran.

a: temperate environments.

The dos.a that is predominant in a ja¯n. gala environment

is va¯ta. People who inhabit a ja¯n. gala

environment are said to have coarse and hard bodies,

but are strong and long-lived. A ja¯n. gala environment

is said to produce few diseases, due to the laghu and

ru¯ks.

a qualities of this environment, which tends to

inhibit the formation of a¯ma. The dos.a that is predominant

in an anu¯pa environment is kapha. People

who inhabit an anu¯pa environment are said to have

soft bodies, are more delicate, and have a shorter life

span. An anu¯pa environment is said to produce many

diseases, due to the snigdha and ´sita qualities of this

environment, which tend to promote the formation of

a¯ma. Inhabitants of a sadha¯ran.

a environment may

experience both the qualities of ja¯n. gala and anu¯pa,

but experience them to a lesser degree. In a

sadha¯ran.

a environment there is no dos.a that is particularly

dominant, and thus the dos.as here are influenced

more by dietary and lifestyle habits.

In examining de´sa, the place of birth should also be

taken into account. The type of environment in which

the patient gestated and was born in will always have

an influence upon what kind of weather is preferred.

A patient born in a warm tropical environment, for

example, will tend to have a body that is adjusted to

this kind of environment, even if this is not representative

of their ancestral environment. If such a person

were to move to a more northerly environment, he or

she would experience the cold to a greater degree, but

be more tolerant of warm weather than his or her

peers born in a temperate environment. Over time,

however, the body will begin to adapt to a new environment,

especially if measures are taken to implement

wholesome local diets and lifestyle regimens.

Thus, a person born in a warm tropical environment

Clinical methodology and case history 111

and now living in a colder environment could ameliorate

the influence to a certain degree by eating more

warming foods and making sure to get plenty of exercise

during winter. Conversely, a patient born in a

more northerly, temperate environment would do well

when visiting tropical countries to avoid the intense

heat of the day and by eating foods that are cooling to

the body.

Lastly, de´sa refers to the general health of our local

ecology. Caraka list features in air, water and land

quality that can indicate polluted elements in our ecology.

Polluted in this sense includes many elements,

including those of natural origin as well as from

human activity.

1. Air pollution: foul and abnormal smells, smoke,

haze, gases, alterations to the colour of the atmosphere,

blowing sand or dust; the appearance of the

sun and moon as coppery, reddish or white coloured;

constant cloud; absence of wind, excessively high

winds or constantly shifting winds; seasonal abnormalities;

frequent meteorites and thunderbolts.

2. Water pollution: foul or abnormal smell, taste,

appearance or texture; a decline in the diversity

and number of aquatic species; absence of birds.

3. Land pollution: abnormalities in the natural

smell, colour, taste and texture of the land; having

a withered, dried or broken appearance; large

tracts of land covered exclusively in weedy plants;

an abundance of animal pests (rodents, mosquitoes,

flies, cockroaches, etc.); behaviour of local

animals that can be regarded as bewildered,

painful and confused; behaviour of its human

inhabitants that can be regarded as immoral, dishonest

and impolite; noise pollution (sounding as

if the ‘country is seized by demons’).

According to Caraka, these factors found in air,

water and land pollution ultimately give rise to epidemic

disease.

9.15 A¯ ha¯ ra

A ¯

ha¯ra is an analysis of the patient’s current diet

against what has been determined to be sa¯tmya, as

well as the strength of digestion (agni). Rather than

simply asking them what they eat, it is often more

effective to have the patient record each food and beverage

each day and the time it was consumed in a journal,

as well as record any symptoms. The modern

usage of techniques such as Coco’s pulse test, which

are said to help determine the presence of allergenic

foods in the diet, can also be used by these patients to

determine which foods are avaram (‘unwholesome’).

The patient should be taught to recognise and record

even minor symptoms experienced after eating, such

as an increase in catarrh, minor skin irritations or flatulence.

Generally speaking, kaphaja afflictions to

agni will be noted as symptoms and signs that appear

during or just after eating while the food is still in the

stomach; paittika symptoms and signs will noted

within 3–4 hours after eating, while the food is transiting

the small intestine; va¯taja afflictions to agni

tend to occur within 8–10 hours after eating, when

the food is transiting the colon. When an individual is

able to consume a large amount of food on a regular

basis the person is said to have a good a¯ha¯ra ´sakti

(digestive power), whereas a person who cannot eat

much without bloating or discomfort is said to have a

poor a¯ha¯ra ´sakti.

113

10.1 As

˙

t

˙

a?stha?na pariks

˙

a?: THE EIGHT

METHODS OF DIAGNOSIS

There are several methods of diagnosis (parı칔s

˙

a¯) in

A¯

yurveda, identified as as

˙

t

˙

a칢tha칗a parı칔s

˙

a¯, consisting

of eight (as

˙

t

˙

a¯) seats (stha칗a):

1. Akr

˙

ti parı칔s

˙

a¯: observation of the build and general

physical characteristics

2. 큆abda parı칔s

˙

a¯: examination of the voice

3. Dr

˙

k parı칔s

˙

a¯: examination of the eyes and eyesight

4. Spar큦a parı칔s

˙

a¯: palpation

5. Mu칣ra parı칔s

˙

a¯: examination of urine

6. Purı칢

˙

a parı칔s

˙

a¯: examination of faeces

7. Na칍

˙

ı?parı칔s

˙

a¯: examination of the pulse

8. Jihva parı칔s

˙

a¯: examination of the tongue.

The purpose of diagnosis in A¯yurvedic medicine is

simply to collect data. Some of these techniques are

a matter of ‘direct perception’ (pratyaks

˙

a), such as

akr

˙

ti and spar큦a parı칔s

˙

a?, whereas others are a matter

of ‘inference’ (anuma칗a), such as na칍

˙

ı?parı칔s

˙

a¯. It

is always easier to base an overall diagnosis on something

that can be directly perceived. Although inferential

methods like na칍

˙

ı?parisks

˙

a?can offer deep

insights, they are notoriously difficult to quantify and

in many cases two practitioners can come to entirely

different conclusions using the same methods. Ideally,

the practitioner should base any diagnostic conclusions

on three aspects: the ‘case history’ (a칛topade큦a),

‘direct observation’ (pratyaks

˙

a), and ‘inference’

(anuma칗a). Where a treatment is based on only one

or two of these components, the treatment may not be

appropriate.

OBJECTIVES

● To understand and discuss specialised

clinical techniques in A¯ yurveda.

PART 1

Chapter 10

CLINICAL EXAMINATION

114 PART 1: Theory and Practice of A¯ yurveda

10.2 Akr

˙

ti parı칔s

˙

a¯: THE OBSERVATION

OF BUILD

The observation of a patient’s overall physical structure

is a useful means of understanding the general

state of nutrition, eliminative functions and any obvious

disease characteristics. It is important to add that

all observations are relative to the racial heritage of

each person. The observation of the patient’s general

characteristics should begin as soon as the patient

enters the room, and may be noted down when convenient.

The following are the basic characteristics to

look for, understood in the context of tridos

˙

a (indicated

by V, P or K):

1. Frame: whether large (K); medium (P); small (V)

2. Musculature and adiposity: overweight, welldistributed

(K); well-muscled (P); asthenic, or overweight

in upper body only (V)

3. Complexion: pale and white (K); yellowish to red

(P); translucent, greyish (V)

4. Face: large eyes, thick eyelashes, thick eyebrows,

large septum, rounded nose, thick lips (K);

medium eyes, reddish sclera, thin eyelashes and

eyebrows, sharp nose, ruddy face, acne on cheeks

(P); smallish eyes, dark circles under eyes, dry skin,

deviated septum (V)

5. Hair: thick, wavy (K); thin, balding (P); dry, split

ends (V)

6. Fingernails: strong, thick, white (K); soft, pink,

peeling, frequent hang-nails (P); brittle, ridged,

variable shape (V).

Akr

˙

ti is a method of assessment that can potentially

confuse the practitioner, because elements of the

prakr

˙

ti may be taken to be the vikr

˙

ti. As a general

rule of thumb, look for features that appear to represent

pathological changes as opposed to constitutional

factors. Thus the patient’s frame or facial structure

may tell us little about the vikr

˙

ti, but the skin, hair, fat

distribution and complexion typically provide more

immediate indications of a disease process. In severe

wasting or obesity, however, the frame may indeed tell

us about the pathology. Generally speaking, determine

if the weight gain or weight loss is proportional to the

skeletal structure. Thus true pathological wasting is

noted by disproportionately large bony prominences,

and true obesity by a fleshy structure on a comparatively

small frame (e.g. small hands and feet) or regions

of disproportionate adiposity (e.g. truncal-abdominal

obesity).

Akr

˙

ti also involves observing how a patient moves

their body, whether they are slow and lethargic

(kapha), fast and determined (pitta), or confused and

disorientated (va칣a).

10.3 큆abda parı칔s

˙

a¯: VOICE DIAGNOSIS

The voice can indicate many things about a person’s

health, his or her resistance to disease, as well as mental,

emotional and spiritual development. Generally

speaking, voices that are melodious, deep, laughing,

pleasing to the ear, like water flowing through a creek,

are considered to be kapha in nature, expressing a harmonious

mind and a tranquil emotional life. Immune

function is typically strong although there may be

a tendency towards cardiovascular stasis, diabetes, and

emotions such as sentimentality and worry. Voices that

are harsh, passionate, critical, loud and angry are considered

to be pitta, expressing a sharp mind and a florid

emotional life. There may be ulcerous conditions, head

injuries, and hepatic congestion. Voices that are weak,

confused, subtle, and alternate between fast and slow

are considered to be va칣a, expressing a disassociated

mind and a chaotic emotional life. There may be

exhaustion, constipation, chronic illness and anxiety.

10.4 Dr

˙

k parı칔s

˙

a?: EXAMINATION

OF THE EYES

The examination of the eyes in A¯yurvedic medicine is

a somewhat less detailed process compared to specialised

assessment techniques such as iridiagnosis, but

many of the same principles can be employed. Dr

˙

k

parı칔s

˙

a?is used to assess both eye function and what the

eyes reveal about the rest of the body. The typical tools

required when examining the eyes include a high-powered

flashlight to illuminate the eye and at least a

5hand lens to note its discrete features.

Each of the dos

˙

as plays a key role in the function of

the eyes. Kapha governs the supply of nutrients

(a칑a칞a rasa) to the eye, whereas pitta is involved in

the metabolism and discharge of wastes into the

venous system that drains the eye. Va칣a plays a key

role to ensure a balance between kapha and pitta in

the eye, as well as the proper movement of the eye and

Clinical examination 115

the conduction of the visual images to the brain via

the optic nerve. The vitiation of one, two or three of

the dos

˙

as in the eye are understood by correlating

these signs and symptoms with the laks

˙

an

˙

as, or

clinical features of the dos

˙

as (see: 2.6 Tridos

˙

a

laks

˙

an

˙

as: symptomology of the dos.as):

● Kaphaja afflictions to the eyes manifest as a sticky,

white exudate, orbital swelling or oedema, itching,

and whitish discolorations of the lens, iris, sclera or

conjunctiva. The patient complains of whitish or

clear spots that impair vision. The eyes seem to

move lazily, have a gentle gaze, and open and close

slowly. A dull frontal or sinus headache may

accompany symptoms, with nausea and a weak

appetite.

● Pittaja afflictions to the eyes manifest as a purulent,

yellowish-green exudate, inflammation and

burning sensations, photophobia, and yellowish,

red or greenish discolorations of the lens, iris, sclera

or conjunctiva. The patient complains of yellowish,

red or greenish spots or streaks that impair vision,

and may complain of hallucinations. The eyes are

bright and moist, and stare with intensity. A sharp,

burning headache pain over the eyes or temples

may accompany symptoms, with loose motions,

thirst and burning sensations.

● Va칣aja afflictions to the eyes manifest as dryness

and scratchiness of the eyes, impaired eye movement,

ocular muscle spasm, rapid eye movement

and twitching, squinting and fluttering of the eyelids.

The eyes are lustreless and dull, may appear

contracted within the eye-sockets, and may be surrounded

by a purplish or bluish colour. The patient

complains of dark-coloured spots that impair

vision, or sporadic and intense flashes of light.

A severe lancinating pain in the eyes and head may

accompany symptoms, with anxiety, nervousness,

constipation and other vattika symptoms.

As mentioned, dr

˙

k parı칔s

˙

a?can also be used to

assess other regions of the body, based on the concept

that each discrete region of the body is a holographic

representation of the entire body (e.g. the ear, hand,

tongue, foot, etc.). Using the A¯yurvedic concept of the

rogama칞gas the structure of the iris can be divided

into three basic concentric regions, each of which

corresponds with the three pathways of disease:

the an˜tarma칞ga (the inner), the madhyama

rogama칞ga (the middle) and the ba칑ya rogayana

(the outer) (see 8.8 Rogama칞gas: the pathways of

disease). The areas just outside the pupil, but contained

within the collarette (the ‘wreath’ that surrounds

the pupil) indicates the status of the

an˜tarma칞ga, or inner pathway, comprising the digestive

system and aspects of the respiratory system. The

madhyama rogama칞ga, or middle pathway, is found

just outside the collarette and extends near to the

edges of the iris, and comprises the central and

peripheral nervous systems, the endocrine, renal and

musculoskeletal systems, and the viscera such as

heart, liver, spleen, pancreas and lungs. The ba칑ya

rogayana, or outer pathway, is contained in the

periphery of the iris, comprising the lymphatic, circulatory

and integumentary systems.

Another useful method to assess the iris is to divide

the regions of the eye into three regions that represent

the stha칗as, or seats of influence, of va칣a, pitta and

kapha (see 2.4 Stha칗a: residence of the dos.as). If we

examine the iris like the face of a clock, these three

regions can be easily identified:

● In a clockwise direction, the regions roughly

located between 9 and 11 o’clock, and 1 and

3 o’clock, represent the regions of the body contained

within the kapha stha칗a, i.e. the head,

neck, lungs, heart, etc.

● In a clockwise direction, the regions roughly

located between 7 and 9 o’clock, and 3 and

5 o’clock, represent the regions of the body contained

within the pitta stha칗a, i.e. the liver, gall

bladder, stomach, pancreas, spleen, etc.

● In a clockwise direction, the regions roughly

located between 5 o’clock and 7 o’clock, and at the

top from 11 to 1 o’clock, represent the regions of

the body contained within the va칣a stha칗a, i.e. the

pelvis, colon, kidneys, adrenals, reproductive

organs, and the central nervous system, etc.

By noting features in these regions, such as the

stromal density of the iris and pigmentation, and by

correlating these to the symptomology of the dos

˙

as

(see 2.6 Tridos.a laks.an.as: symptomology of the

dos.as), the iris may indicate a particular dysfunction

in a specific region of the body. Stromal density of the

iris is an important consideration in traditional iridiagnosis,

and while the density of these fibres does not

change over time, they may be an indication of constitutional

defects in a particular region of the

body. Impairments in stromal density are seen as an

116 PART 1: Theory and Practice of A¯ yurveda

interruption in the fibres that make up the iris, giving

rise to craters and cavities, referred to as lacunae, that

are best seen by shining a bright light across the surface

of the iris.

10.5 Spar큦a parı칔s

˙

a?: PALPATION

Palpation is an especially important diagnostic tool that

is too often ignored by practitioners. In the Western

herbal tradition, the eclectic physician John M. Scudder

(1874) states in his text Specific Diagnosis that practitioners

should acquaint themselves ‘. . . with the education

of the blind, to see the range of this sense which in the

majority has such imperfect development’. Such sentiments

are reflective of A¯yurvedic practices, in which the

senses of the pracitioner become finely attuned through

daily meditative practices. The sensation of touch arises

from the influence of va칣a, the impetus and vehicle of

thought and emotion. By developing the skill of palpation

the practitioner has access to a body of knowledge

that can guide the overall diagnosis and remove much

guesswork from the diagnostic equation.

If performing a complete examination the patient

should be asked to remove his or her clothes and lay

supine on an examining table, covered with a sheet or

light blanket. The practitioner may examine each area

of the body separately, folding up the portion of the

sheet that is covering the part of the body to be

inspected. The examining room should be well lit,

preferably with natural light, and warm enough for an

unclothed patient. All of the body regions should be

examined, paying close attention to the cervical region,

the axila, the abdomen and the inguinal region.

There are five primary factors in spar큦a: moisture,

temperature, texture, mobility and turgor, and

sensitivity:

1. Moisture is assessed by distinguishing perspiration,

oiliness and dryness. Moist skin would typically

indicate kapha or pitta, but this feature

has to be assessed in context with other features,

such as temperature and colour. Thus, in greasy

and inflamed skin, such as acne, this would indicate

a pitta or a combined pitta-kapha condition.

If on the other hand the skin is moist but

cool, this would suggest kapha. In va칣tika conditions

there will be dryness, flakiness, roughness,

discoloration, tenesmus, irregularities,

a lack of symmetry and hardness. A patient who,

for all intents and purposes, appears to be kapha

but has dry skin, may in fact be hypothyroid,

a combined va칣a-kapha condition. Similarly,

inflamed skin that is dry indicates a combined

va칣a-pitta condition.

2. Temperature is assessed with the back of the fingers,

identifying the warmth or coolness of the

skin, paying particular attention to any areas that

appear red. Paittika conditions such as hyperthyroidism

will be noticed as a generalised warmness

as in a fever, and va칣a-kapha conditions such as

hypothyroidism will be noted as a generalised

coolness. Focal areas that are warm or cool to the

touch suggest local inflammation and a circulatory

deficiency, respectively.

3. Texture is assessed by noting characteristics such

as smoothness and roughness of the skin, but also

the topography, such as areas that seem knotted,

hard, pinched or fibrotic. Patients with a hypofunctioning

thyroid will often manifest rough, dry

skin, which is a va칣a-kapha condition. Women

who complain of cyclic breast pain may have

fibrotic nodules that can be assessed in the breast

tissue at certain times during the oestrous cycle.

Nodules that appear slowly and do not change

12

6

7 5

1

9 3

11

Antarmarga

Madhyama rogamarga

Bahya rogayana

Vata

Pitta

Pitta

Kapha

Vata

Kapha

Figure 10.1 Tridos.ic eye assessment.

Clinical examination 117

with the oestrous cycle, however, may be dermoid

cysts or a tumour, suggesting kapha or a combined

kapha-pitta disorder. Similarly, subcutaneous

cysts found elsewhere in either men,

women or children are usually related to pitta

and kapha.

4. Mobility and turgor are assessed by lifting a fold

of skin and noting the ease by which it moves

(mobility) and the speed with which it returns to

normal (turgor). In oedema (kapha) there will be

decreased mobility, whereas in dehydration (va칣a)

there will be decreased turgor. With inflammation

(pitta) there will be immobility.

5. Sensitivity is noted by how the patient responds

to the practitioner’s touch. Light touches and

gentle rubbing tends to pacify va칣a but aggravates

pitta. Medium to strong pressure tends to

pacify pitta, whereas this may or may not alleviate

kapha. Upward movements tend to alleviate

kapha, whereas downward motions tend to

reduce pitta and va칣a.

10.6 Mu?tra parı칔s

˙

a¯: EXAMINATION

OF URINE

The assessment of the urine requires that the patient

collect a small amount of urine at midstream, into

a clean, clear plastic or glass vessel. Once voided, urine

will oxidise very quickly and the original aromatic

odour will degrade into one dominant in ammonia,

and thus an assessment should be made as soon as

possible after voiding. Stale urine that has not been

refrigerated will often be much darker and cloudier

than original due to the proliferation of bacteria. In

A¯

yurvedic assessment there are five basic aspects to

urine examination:

1. Colour and transparency. In health, the urine

should be a clear pale yellow colour, but under the

influence of different foods, herbs, and supplements

the colour may display some variability.

Bright yellow, almost neon in colour, is often the

result of vitamin B-complex supplementation.

Pink or reddish urine that suggests blood but is

translucent may be due to anthocyanins, a pigment

found in red vegetables such as beets.

Patients who subsist on diets high in protein may

have a greenish urine due to the presence of

a potassium salt of indole, formed by the putrefaction

of protein in the intestine. Herbal laxatives

such as A칞agvadha fruit (Cassia fistula), Turkey

Rhubarb root (Rheum palatum) or Cascara

Sagrada bark (Rhamnus purshiana) contain

anthraquinones that can colour the urine orange.

Food coloring agents can colour the urine, such as

methylene blue, present in some proprietary pills,

which can colour the urine green. Drugs can also

colour the urine, such as tetracyclines (yellow),

phenindione (pink), rifampicin and phenazopyridine

(red), and methyldopa and iron sorbitol (black).

After ruling out the variety of exogenous

agents that can colour the urine, the practitioner

can then freely examine the urine. In dehydration

(va칣a) the urine will be an amber, dark yellow or

orange colour, depending on the severity of the

condition. Although small amounts of blood are

undetectable, larger amounts can give the urine

a smoky appearance. Bile pigments can give the

urine a brownish colour with a green tint at the

surface, and when shaken in a test tube will cause

a yellow froth, indicating a paittika disorder.

Urine that has been allowed to stand unrefrigerated

may become darker than when first voided,

due to the presence of pus or phosphates.

Urine in kaphaja conditions will tend to be

clear and pale, and if turbid, will have a slightly

cloudy appearance suggesting the presence of calculi,

mucus or semen. In paittika conditions the

urine will tend to be yellow to red in colour. In

va칣tika conditions the colour of the urine can be

variable, either clear or quite dark, and is variable

in consistency and turbidity. A feature of va칣a,

however, is that the urine has a tendency to be

quite bubbly and frothy when voided, or when

poured from one vessel into another. In severe

va칣tika conditions the urine has a greasy appearance,

indicating the excretion of ma칖

˙

sa and

medas, found in the endstage of diseases such as

madhumeha (diabetes mellitus).

2. Odour and taste. In all methods of examination

A¯

yurvedic medicine requires the practitioner to

utilise all his or her five senses, but in regard to the

assessment of urine and faeces indirect methods

(anuma칗a) were utilised for the sensation of

taste. One interesting method was to place a small

amount of the patient’s urine in a dish and wait to

see if any insects were attracted to the urine, as is

118 PART 1: Theory and Practice of A¯ yurveda

the case in madhumeha, or diabetes mellitus, in

which the urine contains a disproportionate

amount of sugar. This technique, however, is not

suited to a modern clinical setting, and thus

reagent strips can be used to assess for glucose.

Urine in kapha conditions will typically have a

sweet smell. Urine in va칣tika conditions typically

displays a bitter or astringent smell, but in severe

conditions can also smell quite sweet: the difference

between kapha and va칣a will be the volume

excreted and the colour. Paittika conditions will

typically have a strong, pungent and foul smelling

odour.

3. Temperature. In kaphaja and va칣tika conditions

the relative temperature of the urine will be

cool, whereas in paittika conditions the urine will

be quite warm.

4. Volume and frequency. In both kaphaja and

paittika conditions the volume tends to be copious,

although the frequency is otherwise normal.

In kapha conditions the voiding of urine may take

an exceptionally long time and has very little force,

although the frequency is otherwise normal. In

va칣tika conditions the volume is decreased and

the frequency high, indicating a renal impairment

or spasm.21

5. Symptoms. Paittika conditions will display

a burning, cutting or searing pain upon evacuation.

Concomitant symptoms may include burning

diarrhoea, skin eruptions and fever. Va칣tika conditions

display a prickling pain that migrates from

place to place and varies in severity, accompanied

by a sense of fullness and abdominal oedema.

There may also be frequent shooting or stinging

pains that arise in the perineal area, indicating

spasm. Associated symptoms may be anxiety, fear,

constipation and arthritis. Kaphaja conditions

display symptoms such as a sense of obstruction,

but not to the same extent as va칣a. There is usually

little pain, but there may be some fluid retention

and generalised oedema. Concomitant symptoms

in kaphaja conditions may include a loss of

appetite, nausea and sinus congestion.

In relation to disorders of the urinary tract, the designation

of va칣a, pitta or kapha indicates the

progression of the disease. Paittika diseases are acute,

often involving a bacterial infection. Kapha conditions

are chronic symptoms that arise from dietary and

lifestyle neglect, rather than a specific pathogen,

although a chronic yeast infection is a feature of

kapha and a칖a. Va칣tika conditions often represent

end-stage conditions, whether the result of damage

caused by chronic infection or chronic abuse, and are

often very challenging conditions.

A number of texts, including Dash and Junius’

A Handbook of Ayurveda, describe an additional method

in mu?tra parı칔s

˙

a¯, by the use of dropping small quantities

of unrefined sesame oil in a urine sample. This

technique should be performed in full sunlight, and the

urine should be kept in a clear, wide-mouthed vessel.

About five to ten drops of the oil are dropped into the

urine sample, and after about 15 seconds the oil will

begin to spread across the surface of the urine. If the

oil spreads fast, the prognosis is good and there will be

quick recovery from the condition. If the oil does not

spread, or spreads very slowly, the prognosis is poor,

and recovery may take some time. If the oil settles on

the bottom of the glass, it is said that the disease is

incurable.

The movement and direction in which the oil

spreads may also be taken into consideration. If the oil

moves in an easterly direction this is an indication of a

good prognosis and a quick recovery from the condition.

If the oil spreads to the south it indicates an

exacerbation of the condition or an incipient fever, and

that recovery may take some time. Movement in

a northerly direction indicates good health, or that

recovery will occur soon. Movement in a westerly

direction indicates that while the condition may continue

for some time, it is not serious and that health

will once again be restored.

The pattern that the oil takes also tells the practitioner

something about the condition. If the oil takes the

appearance of a snake this indicates a va칣tika disorder.

If the oil develops into an umbrella-like shape, this is an

indication of pitta. If the oil separates into round pearllike

shapes, this is an indication of kapha. Practitioners

who are very skilled at mu칣ra parı칔s

˙

a?can also see

other shapes that may indicate the prognosis.

Generally, shapes that suggest a plough, tortoise, buffalo,

honeycomb, arrow or a sword indicate a poor

prognosis. Shapes that have a circular shape or suggest

a swan, lotus, or an elephant indicate a good prognosis.

A pool of oil on the surface of the urine that contains

tiny holes like a sieve or looks like a human body suggests

spiritual possession or the fruition of negative

karma.

Clinical examination 119

10.7 Purı칢

˙

a parı칔s

 

Om Tat Sat

                                                        

(Continued...) 

(My humble salutations to   Sreeman Todd Caldecott, Elsevier’s Health Sciences and others other eminent medical scholars and doctors   for the collection)