Dr. Srinivasa Acharaya
MD (Ay), Former Principal SDM Ayurveda College Udupi
AN APPROACH TO DIAGNOSIS
The diagnostic approach to any treatment is of prime importance. A physician by and far undertakes a heap of responsibilities as far as treatment of the patient is concerned. One can relate to an interesting simile in this regard. Consider how a monkey and a cat raise its child. The baby monkey clings onto the abdomen of the mother, as the monkey jumps from tree to tree, undertaking the whole responsibility of being safe by itself. However, the cat holds the kitten firmly by its mouth. Here the kitten rests the whole responsibility of it being safe on its mother, taking least responsibility of its own safety.
Similarly, as the patient approaches the physician, he no longer holds the responsibility of his health and shoulders that over to the doctor. The mode of approach here being similar to the cat.
A physician has to look into diagnosis, prescription, diet, other regimens etc, so that disease is attended to well. The first step is to have a thorough understanding of the diagnosis. Second, is to give appropriate treatment and the third and final step is to ensure regular follow up. Here, the right approach to diagnosis makes way for successful treatment.
Literature speaks tatra idam upadishanti budhimantaha:, rogamekaaikam ……
The initial approach is the quest to find out what is the cause for aggrevation of the doshas, its mode of aggrevation, type of dosha involved and the intensity by which it manifests – mild or severe. Also to understand whether the body or mind is involved, its symptoms and if there are any complications that may be involved. All such information sum up in understanding the diagnosis.
Unravel the story of the illness
This can be achieved by Darshan sparshana prashnai
Either by inspecting, examining or taking a detailed history of the illness all the signs and symptoms required for the diagnosis of the disease may be understood.
This can be achieved in 5 steps
i) Designation/ Name the disease
ii) Differential diagnosis
iii) Determine the type –
iv) Assess the stage
v) Explore the etiology
And the first step to diagnose a disease is to assess the samprapti ghatakas
(yatha dushtene doshene yatha chaanuvisarpataa
Nivrittihi aaamayasyaasou sampraptihi jaatihi aagatihi)
Understanding the dosha, dushya, srotas, dosha samchara sthana, pratyatmalinga, vyaktisthana etc makes it easier to name a disease.
I . Understand the dosha
Every symptom has a definite relation, which may be either physical or mental.
The rule is – a depleted dosha does not cause a disease. It is the aggravated dosha that causes a disease. In some cases, there may be exceptions where dosha may not be necessarily involved, the determining factors may be something else.
Eg – The exception is rajayakshma
When a person takes food, and if a grass or hair falls onto the food, then it is considered to be the premonitory symptom of rajayakshma, which is unrelated to the dosha, hence the exception.
II. Twin role of dosha
Symptoms have a relation with one or more doshas. These doshas which may either be reason for causing or modifuying the disease.
Eg – shotha is caused by kapha dosha, but divabali shotha has predominance of vata. Here, more importance has to be given to kapha and not vata. Kapha which is the causative dosha has to be diagnosed and treated here, accordingly than vata, which is the modified dosha. Hence, one has to consider it as simple shotha and not divabali shotha. Smilarly for kasa with expectoration, where causative dosha is kapha dosha and if its yellow in color then the modifying dosha is pitta dosha.
So in the first phase the causative relation is considered for diagnosis purpose and the modified doshas are considered to have a better understanding of the second stage, where the type of disease have to be assessed.
For every symptom, it is always best to consider the dosha vridhi , dosha prakopa, dosha dushti lakshana and ignore the dosha kshaya and dosha prakriti lakshana as this will help to reach to a diagnosis easily. Thereby, the treatments also becomes easier. However, this analysis has to be considered for only dosha and not dushya.
Eg –karshya can be considered as vata prakupitha lakshana and also kapha kshaya lakshana. Here approach needs to be considering the prakupitha dosha.
Hence, to deduce the diagnosis:
i) Consider all the symptoms
ii) Consider dosha dushti, prakopa lakshana
iii) Ignore the modifying dosha
iv) Ignore kshaya lakshana also
III. Considering the secondary factors
After determining dosha, the secondary factors need to be determined. These factors include dushya as well as mala, indriya, manas etc. A symptom is related to any one of these dushyas. Vriddhi, kshaya and dushti lakshana of the dushya needs to be assessed. Here, kshaya isn’t to be ignored.
Eg – kshaya as in pandu, where there is rakta kshaya
Hence, take into consideration –
i) Dhatu vridhi dushti kshaya pradosha lakshana
ii) Mala vriddhi ksaya lakshana
iii) Indriya pradosha lakshana
iv) Mano dushti lakshana
IV. Consider the Srotas
Every symptom has an involvement with the srotas . This may rerfer either to the bahya or abhyantara srotas.
For diagnostic purpose, the abhyantara / adrisya srotas have to be considered, not the bahya/ drishya srotas. Even if the symptoms vary or exceed in number, all the symptoms have to be assessed for their individual sroto involvement, hence making a precise diagnosis.
Srotamnsi nasike karne…..annavaahini
To understand the sroto involvement, one may categorize the symptom based on their distribution –ie, those which are spread on the center or on the peripheries.
Eg: shotha (shakashrita srotas) and swasa (skandashrita srotas)
Name the relevant srotas of dhatu, mala, indriya and manas affected. For peripheral symptoms single srotas may be affected. For central symptoms, two srotas may be involved – one the dhatuvaha srotas and the other which is very specific to the skanda pradesha.
Eg – shotha – rasavaha
Swasa – rasavaha, praanavaha
Pralapa – raktaaha, manovaha
One exception is the sweda vaha srotas, which involves the medavaha srotas also. Determining the srotas is simple as in case of peripheral doshas, the dhatu involved is itself the srotas and if the symptoms are in the center, then two srotases have to be mentioned.
V. Assessing the Sancharasthana
Determination of sancharasthana can be done on the basis of distribution of the symptoms. Symptoms may be categorized into 2 – constitutional and local symptoms. Constitutional symptoms are that which involves the whole body.
Eg – jwara , daurbalya
Local symptoms affect one part of the body
Eg – gulma, ,mandala
IV. Assessing the Pratyatma lakshana
These are factors without which the disease will not occur. This involves considering the symptom that is most severe. Suppose a person suffers from pain abdomen, loose stool or distension of abdomen, one can diagnose it as udarashoola, atisara or anaha.
Eg – if a person suffers from 20 loose stools, with slight distension of abdomen, the pratyatmalaskhana is atisara and not anaha here.
It may be udarashoola if the patient has severe pain and not atisara, even if he may have two loose stools.
The pratyatma laskshana may be that which is most persistent, most chronic, widely distributed, or with the most evident symptom or site. The examples may be as follows:-
Most persistent – if in a skin disease, the itching is more severe than discharge or extent of leision, then itching becomes the pratymalinga
Most chronic – if the pt has weakness and loss of strength in one half of the body associated with shoulder pain, one can diagnose it as pakshaghata instead of avabahuka.
Widely disatributed – Having multiple leisions in multiple areas, throughout the whole body. Here itching or redness may not be the main feature, rather the extent may be as like scaling in ekakushta
Having diagnostic significane – as in exertional dyspnea which is the leading symptom in pandu
Where the pratyatma linga is present that is the vyaktasthana
VII. Explore the Nidana
Comparatively easier causative factors are the following:
i- External trauma
ii- Illness, if transmitted from co-habitants
iii- Illness, if is inherited
iv- Any exposure immediately before illness (eg – virudha ahara causing chardi, or suryaaghata leading to death )
v- Incompatible / Allergic factors (Atma asatmya) – rajo , dhuma etc
Comparitively difficult nidana to determine is when more people exposed to a factor and only some suffer, where the cause is not rightly known.
VIII. Naming the disease
§ Etiology – Paanatyaya, Avarana, Kalayakhanja
§ Organ affected – Prameha pidaka
§ Organ and symptom – Hruthshoola, paadadaari
§ Morbid Physiology – Nidranasha
§ Dosha involved – Vata vyadhi
§ Morbidity of dosha – Amla pitta, sheetapitta
§ Dhatu affected – Shukradushti
§ Structural damage – Sandhimoksha, Gudabhramsha
§ Leading presentation – jwara, atisara, chardi swasa
§ Interacting dosha dushya – Raktapitta
§ Simile of symptom – Gulma, bhrama
§ Incidence – Aadyavaata
After assessing all the samprapthi ghatakas, tally those with the disease determined.
These steps involve in coming to a conclusion of the diagnosis of the disease and thereby lead to inculcate appropriate treatment for the same.
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