Article On Pramana-pdf

The Relevance of Pramana in Clinical Practice Dr. Anukul Chandra Kar M.D. (Ayurveda), Ph.D. (B H U)

Reader, Dept. of Vikriti Vigyan, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi- 221 005, India

Introduction Development of Science is based on new knowledge, which is a continuous process where the contribution comes from various sources. These sources of knowledge could be from an authoritative or highly enlightened person, precise perceptions, and circumstantial inferences or from a logical thinking. Ayurveda has vividly described these factors and this could be called as four pramanas, which will form the pillars of clinical practice and also its further development through research. Definition The Source or means by which a valid knowledge can be obtained is known as Pramana. General Application

f}fo/keso [kyq loZa lPpklPp% rL; prqfoZ/kk ijh{kk vkIrksins'k] izR;{ke~] vuqekua ;qfDr 'psfrA ¼p%lw% 11@17½ Everything in the universe can be divided into two (i)

True (Existent)

(ii)

False (Non-existent)

That can be examined by obtaining the knowledge from four sources of knowledge i.e Aptopdesha, Pratyaksha, Anumana and Yukti.

-1-

Number of Pramanas:Generally the means of obtaining knowledge are mainly three i.e. Pratyakasha, Anumana and Aptopdesha. But Charaka Samhita adds one more, the Yukti as fourth. Again both Charaka and Sushruta add Upamana as the fifth pramana to obtain knowledge. Infect, if we critically examine the Yukti and Upamana, these two can be included in Anumana and Pratyaksha respectively. But in the context of clinical application both Yukti and Upamana have been given an independent status. So finally the Pramanas are totally five in number, which can be applied clinically to obtain the knowledge about the disease. Order of Sequence Generally starts with Pratyakshya then Anumana next Aptopdesh and later on other pramanas like Yukti & Upamana. But in the context of clinical application, Aptopdesha is given the first preference to be followed successively by pratyaksha, Anumana & yukti etc. Why? The answer is what Charak Says

Kku leqnk;su iwoZ ijh{; jksxa loZnk loZeFkksÙkjdkye/;olkua enks"k Hkofr u fg Kkuko;osu d`RLus Ks;s KkueqRi|rs f=fo/ksRofLeu~ Kkuleqnk;s iwoZekIrksns'kkr~ Kkua rr% izR;{kkuqekukH;ke ijh{kksii|rsA fda áuqifn"Va iwoZ ;Ùkr~ izR;{kkuqekukH;ke~ ijh{kek.kks fo|kr~A¼p% fo 4@5½ First of all one should examine the various aspects of disease by employing all the Pramanas (sources of knowledge) so that the observations made thereafter are infallible. One can not acquire the complete knowledge of a thing in all its aspect simply by examining it through a part of these "Source of knowledge" Among all the sources of knowledge one should

-2-

acquire knowledge in the beginning through "Aptopdesha" and there after proceeds to examine that through pratyakhsha. Anumana and others. What is to be examined by Pratyakhsha and Anuman unless something is prima facie stated? That means one should obtain knowledge about a disease from the textual description and thereafter ascertain its various characteristics by examining the sign & symptoms of the disease already in memory through pratyaksha & Anumana. Specific characteristics of the diseases are difficult to understand. They cannot be ascertained without authoritative testimony. Therefore, a disease can be correctly diagnosed by examining its specific characteristics like etiology and other factors as mentioned in the texts through pratyaksha & Anuman. For example - A Jewel – An individual can observe the specific characteristics of a jewel if shown to him but he will not be able to correctly identify if he is not acquainted with the specific characteristics of the various types of jewels. Similarly, a physician ignorant of the specific characteristics of various types of diseases from authoritative testimony will not be able to correctly diagnose them. So Charak has given more emphasis to start with gaining knowledge about the disease either form the text or form the teachers and thereafter proceed with pratyaksha and Anumana etc. So, to a beginner all pramanas are very much necessary to understand correctly while after some experience and being a expert only two pramanas like pratyaksha and Aauman will be sufficient enough to correctly diagnose the disease.

-3-

That's why Charaka says

rLekf}fo/kk ijh{kk Kkuorka izR;{ke~ vuqekua p% f=fo/kk ok lgksins'ksu ¼p-fo% 4@5½ Definition of APTA

jtLreksH;ka fueqZDrk Lriks Kkuoysu ;s ;s"kka f=dkyeeya KkueO;kgra lnk vkIrk% f'k"Vk fooq)kLrs rs"kka okD;ela'k;e~ lR;a o{;fUr rs dLeknlR;a uhjtLrek% ¼p-lw-% 11@18&19½ Those enlightened and refined persons who are absolutely free from the predominance of rajas and Tamas by virtue of the power of penance and knowledge and who are always in possession of an uninterrupted knowledge pertaining to past, present and future are known as authorities (Apta). They are also known as Sista(Gentleman) and Vivuddha (enlightened persons). Their words are true beyond any doubt. How could such persons, relatively free from Rajas & Tamas may tell a lie? In fact one tells a lie either because of the defective knowledge or even if sound knowledge is there, due to attachment or hatred. So none of these three factors defective knowledge, attachment and hatred is present in the one who is absolutely free from rajas & tamas and whose intelligence is spotless due to predominance of the qualities of satwa. WHO ARE APTAS? Only such persons are considered to be authoritative who knows things in their entirety without any doubts and by virtue of their own realization. One cannot be authoritative if he knows things only piece meal by memory without any clear conception. Even though memory is

-4-

considered to be an accessory of the source of knowledge, still in the matter of scientific statement relating to things present, memory may not always serve to be an infallible source of knowledge. There are certain branches of knowledge like scriptures, Mathematics where memory plays an important role but in a branch of knowledge like science of medicine where direct and easy access to the various aspect of medicine is required, memory would not serve the purpose in as much as it often gives rise to wrong perception or often represents impossible images devoid of scientific aptness. Persons can further be considered to be authoritative only when they are free of prejudices of all kinds & who can see things objectively & in an infallible manner. This absolute authoritativeness can no doubt be found only in the Gods like Brahma & the ancient Rishis and Acharyas like Charak, Sushruta &other authors of Ayurvedic texts. Even an ordinary man who possess the above qualification and gained infallible knowledge on certain things by constant experience and intimate contact over a long period of time can also be considered as authorities with reference to the particular subject in which they are specialized. They can be any one irrespective of caste, creed, community and country (_";k;Z

EysNkuka lekua y{k.ke~ rFkk p O;ogkjk% izorZrs ¼U;k; n'kZu &okRlk;u Hkk";½

True knowledge that comes from any source is acceptable and

adoptable. Because the entire world is the teacher to the intellects (d`RLu

yksdks% oqf)erkekpk;kZ& p%fo% 8@14)

fg

So in this group Teachers,

Technicians working in the laboratories, nurses, pharmacists etc can be included as Apta.

-5-

According to Chakrapani, the patient and his well wishers can be regarded as Apta, because at the time of distress & suffering, he speaks only the truth as he will be genuily interested to get rid off the trouble. Information concerning his food and habits, the nature of his sufferings etc. are precisely only known to him not to others and the physician has to rely upon his words more than of others. So the patient also becomes an Apta to a fairly considerable extent. The patient, close relatives and other persons who are genuinly interested in the welfare of the patient can also be considered as Apta in many instances. The information they provide may be many times more correct and valuable than the sayings of the patient, especially when the patients are children, mentally deranged and incapable of talking due to diseases. Even if a father is cruel, his statements regarding his ailing child will undoubtedly be authoritative, if he possesses a sound mind, is not a fool nor attached otherwise. A note of warning is also necessary here that in the present day, we do come across some persons who are not actually having any disease or suffering but pretend to be patients by presenting some pain or distress and try to hoodwink the physician. It is therefore to be careful of such pretenders of illness and not to believe what all they say. Likewise, the statement true or false made by intoxicated, mad, illiterate and attached persons are not considered to be authoritative. A sound knowledge of various diseases and a through examination will help dispose off such false hood and misleading. "vizek.k

iqueZÙkksUeÙk ew[kZ jDr nq"Vknq"V opufefr ¼p%fo 4@4½"

-6-

Availability of Aptopdesh It is available in three forms. (i)

Scriptures – All Samhitas & text books

(ii)

Oral evidence & writer Communication – Teachers, Experts, Radiologists, Pathologists etc

(iii)

The patient & his well wishers – To be recorded as History of the patient

Clinical Application. The following factors of every disease are to be learnt from textbooks. (p%fo% 1.

izdksi.ka

2.

;ksfu

3.

mRFkkue~

- Nature of onset / Mode of manifestation

4.

vkRekue~

- Nature of disease (Seriousness or Acuteness)

5.

vf?k"Bkue

6.

osnue &

-Symptoms like pain etc.

7.

laLFkkue

– Signs

8.

'kCn] Li'kZ :i] jl] xU/k

4@6)

– Provoking factors of the disease

– Sources of origin or Doshas involved.

– Location in organs of body & mind

– Association with specific sounds,

Touch, Colours Taste or Smell 9. 10.

minzoe~- Complications o`)LFkku {k;lefUore~

- Symptoms of aggravation, normalcy

and alleviations 11. mndZe~ 12.ukekfu

¼mÙkj dkyhu Qye~½ &

Names of diseases

-7-

- Prognosis (Fate of disease)

13. ;ksx – Concomitants / Prescribed medicines 14.

izrhdkjkFkZ izo`fÙkjFkok fuo`fr ¼iF;kiF;½-

Prescriptions &

prohibitions in the treatment.

Pratyaksha This is the second method but most important method of examination Definition

vkResfUnz; euksFkkZuka lfUud"kZkr~ izorZrs O;Drk rnkRos ;k oqf) izR;{ka lk fu:P;rs ¼p%lw 11@20½Perception / Observation, definite and immediate arising from the correlation (coming together) of Atma, Indriya (sense organs) Manas (mind) and the Indriyarthas (objects) is known as Pratyakksha. With a proper correlation true or correct knowledge (Prama or Satgyana) is obtained while improper correlation makes for false or incorrect knowledge (Bhrama / Mithyajnana). Man is endowed with five jnanendriyas & he makes use of them every minute to obtain knowledge of things in and around him. This is the first method by which the physician also tries to understand the condition of health & disease. Charak observes, "Seeking to know the nature of a disease, the physician should explore by means of his sense organs, the entire field of sensible data present in the patient's body in the following means Indriyadhisthana

Indriya Visaya

Pariksha

Eye (Chakshu)

Rupa (Sight)

Darsana (Inspection)

Twak (Skin)

Sparsha (Touch)

Sparshana (Palpation)

Srotra (Ears)

Sabda (Sound)

Sravana (Ascultation &

-8-

Percussion) Ghrana (nasa)

Gandha (Smell)

Ghrana (Olfaction)

Jihwa (Tongue)

Rasa (Taste)

Rasana (gustation)

Quantum of Information Available From Each one of sensory Faculties Eye (Inspection) Skin (Palpation)

Ear (Auscultation)

Nose (Olfaction)

Jihwa (Gustation)

In the context of Rogipariksha information available from each one of these sensory faculties varies in proportion. The first Indirya eye obtains a good lot of information about the condition of various organs and functions of the body both in health and disease. This quantum goes on decreasing with each successive Indriyas that of Jihwa (Tongue or taste) being very less. Charak has no doubt advocated all Indriyas to be made use of for clinical examination but makes a provision to eliminate the Rasapariksha examination by taste. Because it happens to be inappropriate, ineticuette & even injurious to lick the body of the patient or taste various Dhatu & Malas, hence it is inadvisable and also impractical. The knowledge about Rasa pariksha can be obtained by other means like Anumana Pariksha or Yukti. That's why Charak says -9-

losZfjfUnz;S% lokZfufUnz;kFkkZukrqj'kjhjxrku~ ijh{ksr] vU;= jlKkukr~ ---- jla rq [kYokrqj'kjhjxrfefUnz; oS"kf;deqI;quqekunoxPNsr~ uáL; izR;{ks.k xzg.keqii|rs ¼p-fo- 4@7½ Clinical Application 1. Darshan Pratyaksha (Inspection) a.

o.kZ laLFkku izek.k Nk;k&

Colour / Shape / Quality /External

appearance, Measurement, number, proportion, complexion or lusters b.

'kjhj izd`fr fodkjkS&

Normal and abnormal appearance of

body and organs. c.

vuqDrkfu &What ever else not described here but comes within the preview of eyes.

- Sankhya (Number/ counting) Chesta, Gati (spandana/ movement) pulsation, Throbbing etc. d. X-ray findings, USG finding, CT scan findings, Microscopic vision & magnifying lenses can be included.

2. Sparshan Pariksha (Palpation)

Li'kZa p ikf.kuk izd`frfod`fr ;qDre~ ¼p% fo% 4@7½ It is the hands of the physician that are essential for this examination. No detail description is available about the information to be obtained by this examination in Vimanasthana. But in Indriyasthana in reference to know the prognosis of the disease by palpation it is described in detail. Method :- izd`fr

fLFkrsu ikf.kuk 'kjhjeL; dsoya Li`'ksr~

- 10 -

Touch the entire body of the patient with the palm neither too hot nor too cold. The following factors are to be examined.

lrra LiUnekukuka 'kjhjns'kukeLiUnue~

(i)

- Absence of Pulsation in

such of the organs of the body which pulsate constantly like pulse examination

fuR;ks"e.kka 'khfrHkko

(ii)

– Coldness in organs which normally remain

constantly hot – Temperature of the body to be examined by touching. (iii)

e`nquka nk:.kRoa- Hardness in soft organs

(iv)

'y{.kkauk [kjRoa

(v)

lrkelnHkko

(vi)

lU/khuka lzal Hkza'k P;oukfu

– Roughness in smooth organs

- Absence of organs which are normally present – Major or minor dislocation of joints

downwards or side wards. (vii)

ekal 'kkf.kr;ksokZrhHkko

– Exessive diminution of muscle tissue &

blood. (viii)

nk:.kRoa

(ix)

Losnkuqo)% LrEHkks ok & Persistent sweating or its total absence

- Appearance of hardness

3. Sravana Pratyaksha (Auscultation / Percussion) The ears of the physician, no doubt the essential organ for this examination but its application directly over the body of the patient is rarely done, that too is inevitable. The use of hearing aid i.e. instrument like stethoscope of the present day has become an indispensable part of the examination. Even in ancient times a Sravana yantra hearing instrument in the form of a hollow tube was - 11 -

being used and the modern stethoscope is nothing but an improvement on it. Percussion: - Another method of Shravana Pariksha is based upon the principle of transmission of sound s through a medium. An artificial sound is created over some part of the body & by nature and intensity of this sound being reflected back; the condition of the organ underlying is understood. So here, ear is indirectly used for this purpose. Clinical Application (a) vU=dwtua

&

Bowel sounds / gurgling sound of intestine

(b) lfU/kLQqVueaxqfy

ioZ.kka p &

Cracking sound in the joints

including those in the fingers. (c)

Lojfo'ks"kka p & Voice of the patients

(d)

vuqDrkfu &

What ever else not mentioned here like sound of

coughing & percussion notes to be examined by this method. 4. Gandha Pariksha The physician should cultivate the practice of smelling various substances of the body and must train himself to detect their normal or abnormal smell and it is by training that the nose can be made efficient in detecting the smell. Compared to animals, man is poor in his capacity of smell detection; the only thing required is a little bit of training & tolerance. He should not feel reluctant to smell if circumstances warrant. A pleasant smell or an unpleasant smell should be taken with equal regard and decision whether either one is normal or abnormal should be taken after careful consideration.

- 12 -

Information -

xU/kkLrq [kyq loZ'kjhxrkukrqjL; izd`froSdkfjdku~ ?kzk.ksu ijh{ksrA The Ganda (Smell), normal or abnormal of the patient's body & its individual components deserves examination. 5. Rasapariksha (Gustation ) – Tastes of the various factors in the body of the patients are no doubt the objects of the gustatory sense organ. They can however be ascertained by inference not by direct observation. Information (i) Taste of the mouth of patient - By interrogation (iz'u

ijh{kk½ (ii) Impairment of taste of body – By noting the behaviour of lice etc.  Sweet – attraction of flies  Bad taste – Going away of lice from the body Lice remain in body only when the taste of the body is normal and conducive to their existence. When there is any abnormalcy in the taste of the body, they leave it. (iii) Bleeding from the body - Whether vitiated by Pitta? Intake by dog & crow indicates not vitiated by Pitta. Now –a –days various laboratory tests are being adopted to determine the taste of many materials of the body.  Urine Sugar (e?kqj ) - By Benedict’s test / Uristix.  Acidic (vEy) / Alkaline ({kkj) by pH paper, Ketone body test etc.  Bile (frDr) - Bile Salt/ Pigment tests etc.

- 13 -

The information available through these methods are no doubt based on Anumana but can be substituted for Pratyaksha.

ANUMANA Though this is the third method of obtaining knowledge but it has more importance than pratyaksha because

izR;{ka fg vYie~] vuYieizR;{kefLr] ;nkxekuqeku;qfDrfHk:iyH;rs ¼p-lw% 11@7½ Scope of perception is limited and there exists a vast multitude of unperceivable things, which has to be understood by Agama (texts), Anumana (inference) & yukti (reasoning). Definition: vuqekua

rq [kyq rdksZ;qDR;is{k

Anumana is based ion argument accompanied by logical reasoning and comes into operation when the person so inferring has the prior knowledge of Pratyakhsha of that thing he is inferring. Also can be defined as a new series of information when one applies his own intelligence on Pratyaksha Pratyaksha  Application of Buddhi  New information = Anuman So Charak defines it Anumana is that which having its base on observation (Pratyaksha) enables one to conclude in three ways (i) Inferring the effect from cause (Future Knowledge) Example – By observing the seed one can have knowledge of fruit, which is yet to come. - 14 -

(ii) Inferring the cause from effect (Past knowledge) – By seeing pregnancy one can have the past knowledge of sexual intercourse. (iii) General inference (Present Knowledge) – Based on routine observation – By seeing smoke one can have knowledge of fire.

Clinical Application – Ayurveda has adopted Anumana as a means of getting information about health & disease. There are many things, which the physician will not be able to understand by his sensory perception only & so has to infer them. Charak has enumerated the following as coming under the domain of Anumana and has given the method of operation for each. 1. Agni – by power of digestion 2. Valam (strength) - by capacity for exercise. 3. Condition of senses – by capacity to perceive the respective objects 4. Rajoguna – by attachment to women (jt%

laxsu

)

5. Moha – by lack of understanding (vfoKkusu) 6. Anger – by revengeful disposition (Øks/kefHknªksgs.k) 7. Grief – by Sorrowful disposition ('kksde~

nSU;su)

8. Joy – by happiness (g"kZekeksnsu) 9. Pleasure – by satisfaction (reflected by the appearance of face & eyes) (izhfr

rks"ks.k½

10. Fear – by Apprehension (Hk;

fo"kknsu)

11.Courage – by strength of mind even when one is in dangerous situation (/kS;Zefo"kknsu)

- 15 -

12.Energy – by initiative in such actions as are normally difficult to perform.

Besides these, so many factors are mentioned in the text, which is to be examined by Anumana.

YUKTI Mentioned as fourth Pramana by Charak and strictly speaking included in Anumana itself. Definition:

cqf) i';fr ;k Hkkoku~ cgqdkj.k ;ksxtku~ ;qfDrfL=dkyk lk Ks;k =hoxZ% lk/;rs ;;kß ¼p%lw% 11@25½

The intellect, which perceives things as outcomes of combination of multiple causative factors, valid for the past, present, & future is known as Yukti or can be defined as the knowledge arising out of many things when operating together. Example – Sweet music from instrument – due to combination of strings, fingernails & body of instrument.  Harvest – due to combination of water, tilling operation, seeds & season.  Treatment – Combination of Chatuspada.

What he tries to explain here is that by pressing into services of many tricks, plan, appliances & inventions, we become aware of such things which we are unable to grasp by our ordinary sense faculties. The whole information is the result of logical reasoning, assumption or inference out of observed facts, such knowledge being definitely indirect.

- 16 -

Clinical Application  Use of thermometer- in mercury column   in temperature of body  Urine containing sugar – detected by benedict's solution, which turn it into brick red.  All Chemical test in laboratory  Graph obtained from ECG machine  X-rays, USG, Scanning, Animal experiments – All are nothing but the implication of Yukti pramana.

UPAMANA (Comparative knowledge / Analogy) Both charak & Sushruta describe this Definition

vkSiE;a uke ;nU;sukU;L; lkn`';ef/kd`R; izdk'kua ¼p% fo% 8@42½ Exposition based on the similarity of the one with the other is Aupamya/ Analogy or Gaining knowledge of a little known object or rare objects by comparing with the better-known objects Method – Among the two objects which are mutually similar One, Which is better known is taken as a effect of comparison - as a means of explaining the less known object of comparison Example: A staff (n.M ) is better known to people. So if somebody explains that the disease "Dandaka" (Characterized by rigidity of muscles) which is rarely seen is similar to a staff in symptoms, even laymen would be able to identify the disease as and when one suffers from it.

- 17 -

Clinical Application 1. To give knowledge about the rare disease in clinical teaching by comparing with the better-known objects (due to non-availability of such diseases or patients in more numbers). Dandaka – with staff Tetany - with bow etc.

2. To name the drugs & to identify by remembering the analogy with the known objects.  Sankhapuspi – flower like conch  Danta vija (Dadima) – Seed just like teeth etc. 3. To name some diseases by comparing with known objects  Saravika  Kachhapika etc.

References 1. Charak:

Charak

Samhita,

Chowkhambha

Publications

Varanasi- English Commentary by Vd. Bhagwan Dash. 2. K.R. Srikantha Murthy: Doctrines of Pathology in Ayurveda Chowkhambha Publications Varanasi, 3. K.R. Srikantha Murthy : Clinical Methods in Ayurveda Chowkhambha Publications, Varanasi. 4. Singh R.H. – Kayachikitsa vol-1, Chowkhambha Publications, Varanasi 5. Sushruta – Sushruta Samhita, Chowkhambha Publications, Varanasi Commentary by Ambika Datta Sastri.

- 18 -