Chapter XXXV - Examination of the patient

Now we shall discourse on the Chapter which deals with clinical observations (Aturopakramaniya-adhyarya).

A physician should first observe the vital condition (Ayu) of the patient before commencing the medical treatment. After that, the nature of the disease, the country and season of the year in which it has made its appearance, as well as the state of digestion, age, body, strength, disposition, habit, previous medicine, natural temperament and the power of endurance of the patient, etc. should be observed and carefully examined.

Characteristic features of a long lived man:—

Men, the dimensions of whose hands, legs, sides, back, nipples of the breast, teeth, face, shoulders and forehead exceed the average, as well as those whose eyes, arms, phalanges and fingers are longer than the ordinary ones should be regarded as going to live long. Those who have broad chests, broad eye-brows with broader spaces intervening between the muscles of the breasts, and who take in deeper inspirations of breath, will be long lived. Those whose necks, thighs, and generative organs are shorter than those of the average type, or those whose voices and umbilical cavities are deep, and whose breasts are unraised and thick-set, and external ears broad, fleshy and hairy, with the occipital region fully developed and protruded, will enjoy a longer span of life. Men, on whose bodies sandal paste and similar preparations begin to dry up from the head downward, while those applied over the chest become absorbed later, should be looked upon as persons endowed with an uncommonly longer duration of life.

The medical treatment of such a patient may be unhesitatingly taken in hand by a physician. Persons, exhibiting bodily features other than those described above, should be looked upon as short-lived men, while those, who are possessed of features common to men of both the above mentioned types, should be considered as keeping the mean between them as regards longevity (Madhyamayuh).

Authoritative verses on the subject:—

A man, with deep-set bones, ligaments, and veins, and tough and thick-set limbs, and firm and unflinching sense organs, as well as one whose body gradually develops a more and more symmetrical shape, should be looked upon as a long-lived man The man, who has not ailed for a single moment even from the day of his birth, and has been getting more and more strong-limbed every day through the cultivation of his inborn sense and a better knowledge of the laws of health, is sure to live to a good old age in the full enjoyment of his senses and intellect.

Madhyamayuh:—

Now, hear me describe the bodily features of a man of a mean or average duration of life (Madhyamayuh). The man, the integuments of whose lower eyelids are marked with two or three well-marked and extended lines or furrows, and whose legs and external ears are thick and fleshy, and the tip of whose nose is turned a little upward, and who has up-pointed lines directly running through the middle of his back, is expected to live up to the ripe old age of seventy years.

Specific traits of a short-lived man:—

Now, hear me describe the specific traits, which characterise the body of a short-lived man. A man with short phalanges of fingers, a narrow back, and external ears abnormally raised up from their natural seats, and who is possessed of a large penis, a high nose, a breast covered with ringlets of curly hair, and who exposes the gums of his teeth, or whose eyes roll while talking or laughing, is not expected to see more than twenty-five summers.

We shall now give the exact measures of the different limbs and members of the body for the better ascertainment of the duration of life of a patient under investigation.—The legs, the arms, and the head are called the limbs of the body, while their component parts are called the members (Avayavas). The great toe of a man, or the one next to it, measured with his own fingers should measure two fingers’ width in length, the lengths of the other toes (the third, fourth, and small ones) successively diminishing by a fifth part of that of his middle finger (Pradeshini).

The fore-sole and the sole proper respectively should measure four fingers’ width in length and five fingers’ width in breadth. The heel of the foot (Parshni) should measure five fingers’ width in length and four fingers’ width in breadth. The foot itself should measure fourteen fingers’ width in length. The girth of the foot, as well as the circumference of the middle parts of thighs and knee-joints, respectively should measure fourteen fingers in width.

The part of the leg between the ankle and the knee-joint should measure eighteen fingers’ width in length, while the part between the joint of the waist and the knee-joint should measure thirty-two fingers’ width in length, the entire leg thus measuring fifty fingers’ width in all. The length of the thigh is the same as that of the part lying between the heel and the knee-joint (Jangha).

The scrotum, the chin, the (two rows of) teeth, the exterior line of the nostrils, the roots of the ears, and the intervening space between the eyes, should respectively measure two fingers’ width in length. The non-erected penis, the cavity of the mouth, the two rows of teeth, the nose, the height of the neck, the ears, and the forehead, and the space intervening between the pupils of the eyes measure four fingers’ width in length.

The entire length of the vaginal canal should measure twelve fingers’ width. The space lying between the penis and the umbilicus, as well as the one intervening between the chest and the upper end of the throat (lit: neck), like the one lying between the tips of the two nipples of the breast, should measure twelve fingers’ width in length. The length of the entire face should measure twelve fingers’ width. The girth round the wrist and the fore-arm of a man should measure twelve fingers.

The girth round the knee-joint is sixteen fingers’ width and the length between the wrist and the elbow should measure sixteen fingers’ width. The part of the arm between the elbow and the tip of the middle finger should measure twenty-four fingers’ width in all. The length of the entire arm measures thirty-two fingers’ width, and the girth round the thighs should measure thirty-two fingers’ width. The palm of the hand should measure six fingers’ width in length and four fingers’ width in breadth. The space between the bottom of the ball of the thumb to the root of the index finger, as well as the space between the root of the ears to the outer corner or angle of the eyes, should measure five fingers’ in length. The middle finger should measure five fingers’ width in length. The index and the ring-fingers respectively should measure four and a half fingers in length, the thumbs and the little fingers respectively measuring three and a half fingers.

The fissure of the mouth should measure four fingers in length. The girth round the neck should measure twenty fingers. Each of the cavities of the nostrils should measure one and three quarter parts of a finger in length. The region of the iris occupies a third part of the entire area of the cornea. The region of the pupil should measure a ninth part thereof.

The arch extending from the hairy extremity of the templar region to the middle point of the back of the head should measure eleven fingers. The distance between the middle of the head and the terminal point of the hairy portion of the neck should measure ten fingers in length. The girth of the neck measured from the back of one ear to that of the other should be fourteen fingers. The length of the pelvic region of a young woman measured from below the anterior side of the thigh joints should be found to be equal to the breadth of the chest (Vakshah) in a male subject (twelve fingers).

The thigh of a woman should be eighteen fingers in breadth and equal to that of the waist of a man. The entire length of a male human body should be a hundred and twenty fingers.

Authoritative verse on the subject:—

An intelligent physician should regard the organism of a man of twenty-five or of a woman of sixteen years of age, as fully developed in respect of the maturity of the seven fundamental principles of the body such as, serum, blood, etc.. The dimensions of the different limbs and members of the body, laid down above, should be understood as to have been measured by the standard of one’s (man’s or woman’s) own finger’s width, and a person, whose limbs and organs are found to correspond to the above-said measures, is sure to live to a good and hearty old age, as a necessary and befitting sequel to a happy and prosperous career in life. In the case of a partial correspondence of one’s limbs and organs to the above-said measures and proportions, a man should be regarded as having an average life and prosperity. A person whose limbs fall short of the abovesaid measures should be regarded as an indigent and short-lived person.

Physical temperament (Sara):—

Now we shall describe the characteristic traits of the different preponderant principles (Sara) or temperaments of the human organism. A man, who is possessed of a good retentive memory, and is intelligent, valorous and cleanly in his habits, and whose mind is graced with such rare and excellent virtues as, purity of thought, and a fervent and unflinching devotion to gods and the reverend, and who exerts himself for the furtherance of the absolute good, should be regarded as a man of Satvasara (psychic or illumined) temperament.

A man with glossy, white and close-set bones, teeth, and nails and who has begotten a large family of children, and shows a marked amative tendency, should be looked upon as a man in whom the principle of semen decidedly preponderates. A man with a thin and sinewy body, and who exhibits traits of excessive strength, and possesses a deep resonant voice, and a pair of large and handsome eyes, and who is successful in ever y walk of life, should be looked upon as one in whom the principle of marrow preponderates. A man with a large head, and a large pair of shoulders, and having firm teeth, bones, cheek-bones, and finger-nails, should be considered as one in whom the principle of bone preponderates.

A man with a large and bulky body, and who is capable of enduring a large amount of fatigue 01 -physical exertion, and who naturally talks in a soft and melodious voice, and whose bodily secretions such as urine and perspiration are characterised by coldness should be regarded as one of a fatty temperament. A man with an erect and upright frame, and deep-set bones, and joints in thick layers of flesh, should be regarded as one in whom the principle of flesh predominates.

A man, whose finger nails, eyes, tongue, palate, lips, palms of hands and soles of feet are glossy, and tinged with a shade of red, should be looked upon as one in whom blood forms the essential and predominant principle. A man with a soft, smooth and pleasant skin and hair should be considered as one in whom serum (Tvak) forms the essential principle of the body. In respect of worldly success and longevity, men of each of the aforesaid types should be successively judged inferior to men belonging to the one preceding it in the above order of enumeration.

Authoritative verse on the subject:—

A qualified physician should examine the duration of life in a patient with the help of the aforesaid measures of limbs and the essential bodily principles, before proceeding to take up his medical treatment, and his professional success should be decidedly increased thereby.

All the diseases, whose names have been specifically enumerated before, may be grouped under any of the three different heads as the curable, the suppressible (Yapya) and the incurable (lit: fit to be pronounced as hopeless).

Each of these different types, in its turn, should be carefully observed so as to determine whether it is a primary or an independent disease, or merely an accessory or sympathetic one, or the premonitory indication of an incipient distemper in its incubative stage.

An Aupasargika (sympathetic) disease is merely a symptom developed in the course of an original or primary malady, and which has its foundation in the very nature or component factors of the pre-existing distemper. A disease, which manifests itself from the commencement of a case and is neither an accessory symptom, nor a premonitory indication of any other distemper, is called a Prak-kevala (primary or original) one. A disease which indicates the advent of a future or impending malady is called a Purvarupam (premonitory stage or indication of a disease).

The medicinal remedy to be administered in any particular case should be selected with an eye to the curative virtues of each of its components, so as not to clash with the nature (cause) of the disease and its accompanying symptoms, and to prove simultaneously soothing to both of them. On the contrary, a violent unfavourable symptom should be first attended to and checked in a case where it would be found to have grown stronger and more distressing or dangerous than the original malady in course of which it has been developed.

A primary or independent malady, unattended with any of the distressing or unfavourable symptoms, should be treated according to its indications and the nature of the deranged humours involved therein, while in an incubative disease the treatment should consist in subduing a premonitory symptom as soon as it would make itself manifest.

Authoritative Verse on the subject:—

As there is not a single disease, which can make its appearance without the participation of any of the deranged bodily humours, a wise physician is enjoined to administer medicines according to the specific features of the deranged humours involved in a disease whose nature and treatment have not even been described in any book on medicine. The different seasons of the year have been described before.

Metrical Texts:—

In the cold season, a disease should be treated with measures and remedies endued with the virtue of destroying or warding off cold, while in summer the medicinal treatment should consist of measures and applications capable of allaying the heat. The medical treatment of a disease should be commenced just at the opportune moment, which should not be allowed to expire in vain under any circumstances whatsoever. A course of medical treatment commenced at an inopportune moment, or not resorted to at the advent of its proper time, as well as over or insufficient medication, proves abortive even in a curable type of disease. The proper medical treatment (of a disease) is that which successfully copes with the malady under treatment, and arrests the recrudescence of a fresh one by way of sequel, and not that, which, though subduing a particular distemper, is immediately followed by a new one.

It has been demonstrated before that the food of a man is digested only with the help of the digestive fire or heat (Pachakagni), which may be divided into four different kinds (states). One of these kinds is due to it not being in any way affected by the deranged humours of the body, while the other three are respectively ascribed to the fact of their becoming so deranged. The digestive fire or heat becomes irregular or fitful (Vishamagni) through the action of the deranged Vayu, becomes keen, through the action of the deranged Pitta, and dull or sluggish, through the action of the deranged Kapha. The fourth kind (Sama) continues in a state unaffected by any of the morbid humoural constituents of the body owing to their maintaining the normal equilibrium.

Samagni and Vishamagni:—

The digestive heat, which fully digests the ingested food at the proper time without the least irregularity, thus reflecting the continuance of the bodily humours in their normal state, is called Samagni. The digestive heat which is irregular in its action, and which sometimes helps the process of complete digestion, and produces distension of the abdomen, colic pain, constipation of the bowels, dysentery, ascites, heaviness of the limbs, trumbling in the intestines, and loose motions (diarrhea) at other times, is called Vishamagni.

Tikshnagni:—

The digestive heat, which helps the digestion of even a heavy meal within an incredibly short space of time, is called “Keen” (Tikshnagni) and which becoming abnormally augmented begets an excessive or voracious appetite (Atyagni), helps a glutton to digest his frequent meals, and produces a parched throat, palate and lips, heat and other discomforts.

Mandagni:—

The digestive fire or heat which causes the tardy digestion even of a scanty meal, and produces heaviness of the abdomen and head, cough, difficult breathing, water-brash, nausea, and weariness of the limbs simultaneously with the taking thereof, is called dull of sluggish (Mandagni).

Metrical Texts:—

The digestive fire of the Vishama kind brings on diseases characterised by the derangement of the Vayu. A keen (Tikshna) digestive fire brings on bilious (Pittaja) affections, while a sluggish (Manda) fire gives rise to diseases marked by a deranged state of the Kapha. Endeavours should be made to keep the digestive fire of the Sama type (normal or regular appetite^[1]) in an unimpaired state. The one known as Vishama (irregular) should be corrected by a diet consisting of emollient, acid or saline substances. In a case of abnormally keen digestive fire, the medical treatment should consist in prescribing purgatives and a diet in the composition of which sweet, cooling, and fatty or albuminous matters largely enter. The same treatment should be adopted in (Atyagni) as marked in cases of voracious appetite, and a diet consisting of buffalo-milk, or its curd (Dadhi) and liquid buffalo-butter should be prescribed for the patient in addition. Emetics should be administered in a case of dull or sluggish digestion (Mandagni), and the patient should be restricted to a diet consisting of articles of a pungent, astringent or bitter taste.

Metrical Texts:—

The fire, that burns within a person, is godly in its subtle essence, and possesses the divine attributes of atom-like invisibility, weightlessness, etc., and is the digestant of food. It takes up the lymph chyle of different tastes for the purpose of digestion, and is invisible owing to its extremely subtle essence. The three vital Vayus known as Prana, Apana and Samana, located in their own spheres within the organism, feed it and keep it burning.

The three stages of man may be roughly described as

1. infancy or childhood,
2. youth or middle age,
3. and old age or dotage.

Childhood extends up to the sixteenth year of life, and children may be divided into three different classes, according as they are fed on milk, or on milk and boiled rice or on boiled rice alone. A child lives exclusively on milk up to the first year of its life, it is fed on milk and boiled rice (hard food) up to the second year, and is thenceforward nourished with boiled rice (hard food).

The middle age of a man extends from the sixteenth to the seventieth year of his life, and exhibits the traits of growth, youth, arrest of development and decay.

The process of growth or building goes on up to the twentieth year of life, when youth or the age of maturity sets in and holds sway over the body of a man up to the thirtieth year of his life,—the strength, semen, and all the organs and vital principles of the body attain (their) full maturity at the age of forty. Thenceforth decay gradually sets in up to the seventieth year of life. After that the strength and energy of a man dwindle day by day. The organs and virility grow weak and suffer deterioration. The hair turns to a silvery white, the parched skin looks shrivelled and becomes impressed with marks of dotage (crow’s feet-marks). The skin hangs down and becomes flabby, the hair begins to fall off, and symptoms of alopecia mark the smooth, sheen and balded pate. The respiration becomes laboured and painful. The body, worn out like an old and dilapidated building, shakes with fits of distressing cough. Such a man is incapable of all acts, and does but imperfectly perform all bodily functions. He has grown old.

The dose of medicine should be increased with the age of a patient till the age of decay, and reduced after the expiry of the seventieth year to the quantity (which is usually prescribed for an youth of sixteen).

Authoritative verses on the Subject:—

Kapha is increased during the years of childhood and Pitta in middle age; while an increase of Vayu (nervous derangement) marks the closing years of life. The use of strong or drastic purgatives, and cauterisation are alike prohibited in cases of children and old men. They should be used only in weakened or modified forms if found indispensably necessary.

It has been stated before that the body of a person is either stout, thin or of an average (middling) bulk. A stout person should be reduced in bulk with depletive measures, while a physician should try to make a thin patient gain in flesh. A human body, which is neither too thin nor too stout, should be made to maintain its shapely rotundity.

We have already discoursed on the strength of the body. Now in a particular case under treatment, it is primarily incumbent on the physician to enquire whether the patient is naturally weak, or has become so through a deranged condition of the bodily humours or old age. And since it is the strength of a patient which makes all remedial measures (such as cauterisation, etc.) possible, it should be regarded as the grandest auxiliary to a medical treatment of whatsoever nature it may be.

Metrical Texts:—

There are some men who are strong though thin; while others are weak, though stout; and accordingly a physician should determine the bodily strength of a patient by enquiring about the capacity of his physical endurance and labour. Sattvam or fortitude denotes a kind of (stoic) indifference of one’s mind to sensations and sources of pleasure or pain.

A man of strong fortitude (Sattyika temperament) is capable of enduring everything, or any amount of pain by repressing his mind with the help of his will or intellect. A man of a Rajasika turn of mind (strong, active, energetic) may be made to patiently submit to a course of painful medical treatment by means of persuasive counsels and the logic of the inevitable, whereas a man of a Tamasika temperament (a worldly cast of mind characterised by Nescience) is simply overwhelmed at the prospect of bodily pain.

Later on, we shall have occasion to deal with the different types of physical treatment and of remedial agents in general. A particular country, or a season of the year, a particular disease or a peculiar mode of living, any particular kind of physical labour or exercise, or the specific properties of the water of any particular locality, or day sleep, or a juice of any particular taste, is or are said to be congenial (Satmya) to a man, or a man is said to be naturalised to these conditions and environments, when they fail to produce any injurious effect on his health, though naturally unwholesome to others.

Metrical Texts:—

A thing of any taste whatsoever, or any kind of habit or physical exercise is said to be congenial to a man which, instead of in any way telling on his health, contributes to his positive pleasure and comfort.

Features of an Anupa country:—

A country may be classed either as an anupa, Jangala or a Sadharana one, according to its distinctive physical features. An Anupa (watery or swampy) country contains a large number of pools, and is wooded and undulated with chains of lofty hills traversing its area, and which is impassable owing to its net-works of rivers and sheets of accumulated rain-water rippling before the currents of the gentle, humid air. It is inhabited by a race of stout, shapely and soft-bodied men, susceptible to Vatala and Kaphaja diseases.

Features of Jangala and Sadharana countries:—

The country, which presents a flat surface and whose dull monotony is enlivened here and there by scanty growths of thorny shrubs and the tops of a few isolated hills or knolls, and in which the waters from springs and wells, accumulated during the rains, become nearly drained, and strong gales of warm wind blow (during the greater part of the year) making its inhabitants, though thin, strong, tough, and sinewy in their frames, subject to attacks of diseases, is called Jangala. A country, which exhibits features common to both the aforesaid classes, is called Sadharana or ordinary.

Authoritative Verses on the Subject:—

A country derives the epithet of Sadharana from the ordinary character of its heat, cold and rainfall, and from the fact of the bodily humours maintaining their normal state of equilibrium within its confines. A disease originated in, and peculiar to a particular country fails to gain in intensity, if brought over to, and transplanted in a country of a different character. A man, who observes a regimen of diet and conduct soothing to the deranged bodily humours accumulated in the country he has come from, and aggravated and manifest in the shape of a disease in the country he has been living for the time being, need not apprehend any danger from the altered conditions of his new abode, for the fact of his not observing a regimen of diet and conduct regarded beneficial in consideration of the physical features of the latter place. A disease of recent growth or origin unattended with any distressing or unfavourable complications, and unsuited to the nature of the country^[2], the season of the year,^[3] the temperament,^[4] and^[5] the adopted or congenial or naturalised traits of the physique of a patient with a regular and unimpaired state of digestion (Samagni), and who exhibits traits of strength, fortitude and longevity and commands the co-operation of the four commendable factors of a course of medical treatment, readily yields to medicine.

A disease, which is marked by features other than those described above, should be regarded as incurable, while the one exhibiting traits common to both the abovesaid types, should be looked upon as extremely hard to cure.

In the case of a former medicine proving abortive, a different one should not be resorted to as long as the effect of the first would last, inasmuch as a mixture or a confusion of medicinal remedies tends to produce a positively injurious effect. A medicine or any medicinal measure, failing to produce any tangible effect, may be repeated in quick succession in a difficult or dangerous disease, if it be empirically found to be beneficial in the case under treatment. The intelligent physician, who, considering the nature of the season, etc., fully conforms to the abovesaid rules of medical treatment, conquers the bodily distempers and dispels the gloom of Death from the world with his medical skill.

 

Thus ends the Thirty-fifth Chapter of the Sutrasthana in the Sushruta Samhita, which treats of clinical observations.

Footnotes and references:

[1]:

There is a difference between “Agni” and “appetite.” Agni includes bile and pancreatic secretions, and hence indicates the stale of one’s digestion. Appetite, though not an unerring indicator of the process, is the effect of Agni.

[2]:

As the development of a disease due to the deranged Kapha in a country of the Jangala type.

[3]:

As the attack of a bilious distemper in forewinter, or of a Vataja malady in autumn, or of a Kaphaja affection in summer.

[4]:

As the appearance of Kaphaja disease in a patient of bilious temperament.

[5]:

As the appearance of a Kaphaja disease in a subject habituated to the use of viands of pungent taste.