Sushruta Samhita Sutrasthana Chapter 35 Aturopakramaniya Adhyaya (Examination of the Patient)

The 35th chapter of Sutrasthana of Sushruta Samhita is named as Avaraniya Adhyaya. This chapter deals with Examination of the Patient.

अथात आतुरोपक्रमणीयमध्यायं व्याख्यास्यामः ॥१॥
यथोवाच भगवान् धन्वन्तरिः॥।२॥

We will now expound the chapter by name Aturopakramaniya – attempting treatment of the patient (examination of the patient) – as revealed by the venerable Dhanvantari.

Examination of Ayus, lifespan is the priority

आतुरमुपक्रममाणेन भिषजाऽऽयुरादावेव परीक्षितव्यं; सत्यायुषि व्याध्युत्वग्रिवयोदेहबलसत्त्वसात्म्यप्रकृतिभेषजदेशान् परिक्षेत॥३॥

Before commencing the treatment of the patient, the physician should first examine his Ayus i.e. lifespan.

Because only if the life span of the patient is remaining (patient has longevity) the other factors like Vyadhi (disease), Rtu (season), Agni (digestive power), Vayah (age), Deha (body built), Bala (strength) Satva (mind) Satmya (habituations accustoms), Prakrti (constitution), Bhesaja (drug) and Desa (habitat) should be examined.

Ayus Pariksa: Examination of lifespan

तत्र महापाणिपादपार्श्वपृष्ठस्तनाग्रदशनवदनस्कन्धललाटं दीर्घाङ्गुलिपर्वोच्छवासप्रेक्षणबाहु, विस्तीर्णभ्रूस्तनान्तारोरस्कं, ह्रस्वजङ्घामेढ्रग्रीवं, गम्भीरसत्त्वस्वस्वरनाभिम् , अनुच्चैर्बद्धस्तनम्, उपचितमहारोमशकर्णं, पश्चान्मस्तिष्कं , स्नातानुलिप्तं मूर्धानुपूर्व्या विशुष्यमाणशरीरं पश्चाच्च विशुष्यमाणहृदयं पुरुषं जानीयाद्दीर्घायुः खल्वयमिति। तमेकान्तेनोक्रमेत्। एभिर्लक्षणैर्विओअरीतैरल्पायुः; मिश्रैर्मध्यमायुरिति॥४॥

Signs of Dirghayu (long span of life) – The person who has long lifespan will present with the below mentioned features –

–       his hands, feet, flanks, tip of the breasts, teeth, face, shoulders and forehead are big in size
–       his fingers and the joints of the fingers, expirations, eyes and arms are long;
–       his brows, space in between the breasts and chest are broad;
–       his calves, penis and neck are short;
–       his mind, voice and umbilicus are deep;
–       his breasts are not greatly elevated but are firm;
–       his ears and back of the head (posterior part) are well grown (muscular), big and hairy;
–       whose body first starts drying from the head after having taken head bath and anointing and the region of the heart dries later,

Such a person should be treated with all efforts.

Signs of Alpayu (less or short span of life) – The person who has less life span will present with the features opposite to those explained above (in the context of deerghayu).

Signs of Madhyamayu (medium span of life) – The person who has medium life span will present with the mixed features (as those of deergha and alpayu).

Signs of long lifespan

गूढसन्धिसिरास्नायुः  संहताङ्गः स्थिरेन्द्रियः।
उत्तरोत्तरसुक्षेत्रो यः स दीर्घायुरुच्यते॥५॥
गर्भात् प्रभृत्यरोगोयः शनैः समुपचीयते।
शरीरज्ञानविज्ञानैःस दीर्घायुः समासतः ॥६॥

Some verse here:-

The person is said to have a long span of life if he has

–       deep located (concealed) bony joints, veins and ligaments,
–       compact (well developed) body,
–       steady sense organs,
–       each succeeding division of  the body (commencing from the feet to the head) better than its preceding

Madhyamayu: Person of Moderate lifespan

मध्यमस्यायुषो ज्ञानमत ऊर्ध्वं निबोधो  मे।
अधस्तादक्षयोर्यस्य लेखाः स्युर्व्यक्तमायताः ॥७॥
द्वेवा तिस्त्रो ऽधिका वाऽपि पादौ कर्णौच मांसलौ॥
नासाग्रमूर्ध्वं च भवेदूर्ध्वं लेखाश्च पृष्ठतः ॥८॥
यस्य स्युस्तस्य परममायुर्भवति सप्ततिः ॥

Now I will describe the features of the person having a medium life span.

The maximum age (lifespan) of a person is said to be seventy years (and this is considered to be moderate lifespan) if he –

–              has well manifest, broad, two, three or more lines below the Aksa (clavicles);
–              has feet and ears which are more muscular,
–              has an elevated tip of the nose and
–              has vertical lines appearing on the back

Alpayu: Person of short lifespan

जघन्यस्यायुषो ज्ञानमत ऊर्ध्वं निबोध मे॥९॥
ह्रस्वानि यस्यपर्वाणि सुमहच्चापि मेहनम् ॥
तथोरस्यवलीढानि न च  स्याप्तृष्ठमायतम् ॥१०॥
ऊर्ध्वं च श्रवणौ स्थानान्नासा चोच्चा   शरीरिणः ॥
हसतो जल्पतो वाऽपि दन्तमांसं प्रदृश्यते॥
प्रेक्षते  यश्च  विभ्रान्तं स जीवेत्पञ्चविंशतिम्॥११॥

Next, I am going to describe the features of persons having short lifespans.

The maximum age (lifespan) of a person is said to be twenty five years only (and this is considered to be minimum / short lifespan) if he –

–       has short bony joints (of the fingers),
–       has big penis,
–       has chest having hairs appearing in circles (whirls),
–       has back which is not broad,
–       has ears and nose located slightly up (than their usual place)
–       exhibits his gums during laughing or talking and
–       has sight which is unsteady

Sarira Pramana: Measurements of the body

अथ पुनरायुषो विज्ञानार्थमङ्गप्रत्यङ्गप्रमाणसारानुपदेक्ष्यामाः । तत्राङ्गन्यन्तराधिसक्त्थिबाहुशिरांसि,  तदवयवाः प्रत्यङ्गानीति। तत्र, स्वैरङ्गुकैः पादाङ्गुष्ठप्रदेशिन्यौ द्वचङ्गुलायते ; प्रदेशिन्यासु मध्यमानामिकाकनिष्टिका  यथोत्तरं पञ्चमभागहीनाः; चतुरङ्गलायते  पाञ्चाङुलविस्तृते प्रपदपादतले; पञ्चचतुरङ्गुलायतविस्तृता पार्ष्णिः ;  चतुर्दशाङ्गुलायतः पादः चतुर्दशाङ्गुलपरिणाहानि पादगुक्फजङ्घाजानुमध्यानि; अष्ठादशाङ्गुला जङ्घा, जानूपरिष्टाच्च  द्वात्रिंशदङ्गुलम् , एते  पञ्चाशत्; जङ्घायामसमावूरु; द्व्चङ्गुलानि  वृषणचिबुकदशननासापुटभागकर्णमूलभूनयनान्तराणि;  चतुरङ्गुलानि  मेहनवदन अन्तरनासाकर्णललाटग्रीवोच्छ्रायदृष्टच न्तराणिह् द्वासशाङ्गुलानि भगविस्तारमेहननाभिहृदयग्रीवास्तनान्तर्रमुखायाममणिबन्धप्रकोष्ठस्थौल्यानि: इन्द्रबस्तिपरिणाहांसपीथकूर्परान्तरायामःषोड्शाङ्गुलः; चतुर्विंशत्यङ्ग्लो हस्तः ; द्वात्रिंशदङ्गुलपरिमाणौ भूजौ; द्वत्रिंशत्परिणाहावूरु ; मणिबन्धकूर्परात्नरं  षोडशाङ्गुलं तलं षटूचतुरङ्गुलायामविस्तारम्ः अङ्गुष्ठमूलप्रदेशिनीश्रवणापाङ्गान्तरमध्यङ्गुल्यौ पञ्चाङ्गुले;  अर्धपञ्जाङ्गुले प्रदेशिन्यनामिके; सार्धत्र्यङ्गुलौ कनिष्ठाङ्गुष्ठौ; चतुर्विंशतिविस्तारपरिणाहं मुखग्रीवं; त्रिभागाङ्गुलविस्तारा नासापुटमर्यादा; मस्तकादवटुकेशान्तो दशाङ्गुलः ; कर्णावटवन्तरं चतुर्शाङ्गुलं ; पुरुषोरः प्रमाणविस्तीर्णा स्त्रीश्रोणिः;  अष्ठादशाङ्गुलविस्तारमुरः ; तत्प्रमाणा पुरुशस्य कटी; सविंशमङ्गुल शतं पुरुषायाम् इति॥१२॥

After this, the Pramana – measurements of the body and its parts and Sara – excellence of tissues will be described, in order to understand the knowledge of life.

The shad angas i.e. six major body parts are as below mentioned –

–       Antaradhi (trunk) – 1 in number
–       Sakthi (legs) – 2 in number
–       Bahu (arms) – 2 in number and
–       Siras (head including the neck) – 1 in number

Pratyangas i.e. minor parts are the organs or parts in each of these angas.

In terms of one’s own Angula (breadth of a finger – 1.8 cm. approximately) –

–              the big toe and second toe are two angula (3.6 cm) each in length;
–              the third, fourth and fifth toes are less by one-fifth angula each in their succeeding order;
–              the forefoot and sole each are of four angula (7.8 cm) in length and five angula (9.0 cm) in breadth;
–              the heel / ankle is five angula (9 cm) in length and four angula (7.8cm) in breadth;
–              the foot  is fourteen angula (25.2 cm) in length;
–              the middle part of the foot, heel, calf, and knee are fourteen angula (25.2 cm) in circumferences;
–              calf  is eighteen angula (32.6 cm) in length
–              above the knee (thigh) it is thirty two angula (65.2cm) in length;
–              these together (calf, knee and the region above the knee) are fifty Angula (90cm) in length,
–              the thigh is equal to the calf in length (32.cm);

Dimensions of other structures of the body –

According to Acharya Dalhana – the length / height of a person should be calculated when he is standing on his toes while he is raising his arms upwards.

पञ्चविंशे ततो वर्षे पुमान् नारी तु षोडशे ।       
समत्वागतवीर्यौ तौ जानीयात् कुशलो भिषक ॥१३॥
देहः स्वैरङ्गुलैरेष यथावदनुकीर्तितः
युक्तः प्रमाणोनानेन  पुमान् वा यदि वाऽङ्गना॥१४॥
दीर्घमायुरवाप्रोति वित्तं  च महदृच्चति।
मध्यमं मध्यमैरायुर्वित्तं हिनैस्तथाऽवरम् ॥१५॥

Some verses here:-

A man would attain full growth and vitality at the age of twenty-five years. On the other hand, a woman would attain her full growth and vitality at the age of sixteen years. An intelligent physician should know and understand this.

One’s own angula i.e., finger breadth measurement alone is taken to take the measurements of the body. Longevity and plenty of wealth will be attained by man or woman who have these normal measurements of the body. Those having moderate and poor measurements would attain medium and short lifespan respectively.

Sara excellence of mind and tissue

अथ सारान्  वक्ष्यामः- स्मृति भक्तिप्रज्ञाशौचशौर्थोपेतं  कल्याणाभिनिवेशं सत्वसारं विद्यात्ः , स्निग्धसंहतश्चेतास्थिदन्तनखं बहुलकामप्रज्ं शुक्रेण; अकृशमुत्तमबलं स्निग्धगम्भीरस्वरं सौभाग्योपपत्रं  महानेत्रं च मज्ज्ञाः  महाशिरः स्कन्धं दृढदन्तहन्वस्थिनखमस्थिभिः  स्निग्धमूत्रस्वेदस्वरं बृहच्छरीरमायासासहिष्णुं मेदसा; अच्छिद्रगात्रं गूढास्थिसन्धिं मांसोन;स्निग्धताम्रनखनयनतालुजिह्वौष्ठपाणिपादतलं  रक्तेन;सुप्रसन्नमृदुत्वग्रोमाणं त्वक्सारं विद्यादिति। एषां पूर्वं पूर्वं प्रधानमायुः सौभाग्ययिरिति॥१६॥
विशेषतो ऽङ्गप्रत्यङ्गप्रमाणदथ सारतः ।
परीक्ष्यायुः सुनिपुणो भिषक सिध्यति कर्मसु ॥१७॥

After this, Sara i.e. excellent qualities of tissues will be described.

Among these, one’s lifespan and prosperity are determined by the earlier ones, in preceding order.

The intelligent physician would become successful in all his activities pertaining to treatment if he examines the measurements of the angas and pratyangas i.e. major and minor body parts and excels in the same.

Vyadhi pariksha: Examination of diseases

व्याधिविशेषास्तु  प्रागभिहिताः;  सर्व एवैते त्रिविधाः- साध्या, याप्याः  प्रत्याख्येयाश्च । तत्रैतान् भूयस्त्रिधा, परीक्षेत-किमयमौपसर्गिकः; प्राक्केवलः, अन्यलक्षण इति। तत्र, औपसर्गिको नाम यः पूर्वोत्पन्नं व्याधिं जघन्यकालजातो व्याधिरुपसॄजति, स तन्मूल  एवोपद्रवसंज्ञः, प्रक्केलमो  नाम यः प्रगेवोत्पन्नो व्याधिरपूर्वरूपोऽनुपद्रवश्च; अन्यलक्षणो नाम यो भाविष्यद्वचाधिख्यापक:, स पूर्वरूपसंज्ञः । तत्र, सोपद्रवमन्योन्याविरोधेनोपक्रमेत, बलवन्तमुपद्रवं वा; प्राक्केवलं यथास्वं  प्रति कुर्वीत; अन्यलक्षणे त्वादिव्याधौ प्रयतेत॥१८॥

The details of the diseases have been given earlier through chapter 1 and 24.

All these diseases and each of these diseases are of three types. They are –

–       Sadhya Vyadhi – curable diseases
–       Yapya Vyadhi – controllable / manageable but not totally curable type of diseases
–       Pratyakhyeya Vyadhis – incurable / reject-able diseases

These three types of diseases should once again be examined so as to determine to which of the below mentioned categories they belong to i.e. whether they are one among the below mentioned three types –

–       Upasarga – secondary diseases
–       Prak-kevala – primary diseases or
–       Anya laksana – symptoms other than its own

Upasarga – is a condition or disease which manifests after the main disease has manifested. It develops later than the disease which has already manifested and after that, it remains with it (existing disease). It branches out from the main disease or as an effect of the main disease and is called as Upadrava – complications of a disease or associated secondary disease.

Prakkaevala – is a condition or a disease which has manifested earlier than the disease which manifests later. So, Prakkevala occurs first and later comes the main disease. This condition is without purvarupas i.e. premonitory symptoms and also will not have upadravas i.e. complications.

Anya laksana – is a condition or a disease which indicates that a disease will be manifesting in future days. This is also known as Purvarupa i.e. premonitory symptoms or prodromata of diseases.

When the disease is associated with upadrava i.e., complication, both these conditions should be treated in such a way that there is no interference with one another. Or, the powerful upadravas should be addressed and treated first and the main, primary disease should be treated appropriately, as required.

The first disease i.e. the primary disease itself shall be treated in case of Anya Laksana.

नास्ति  रोगो विना दोषैर्यस्मात्तस्माद्विचक्षणः ।
अनुक्तमपि दोषाणं लिङ्गैर्व्याधिमुपाचरेत् ॥१९॥

One verse here:-

All the diseases are caused by aggravated doshas and no disease will manifest without the involvement of doshas. Therefore, an intelligent disease should identify the doshas in spite of them not being mentioned and treat them promptly.

Rtu Pariksha: Examination of season

प्रागभिहिता ऋतवः ॥२०॥|
शिते शीतप्रतीकारमुष्णे चोष्णनिवारणम् ।
कृत्वा कुर्यात् क्रियां प्राप्तां क्रियाकालं न हापयेत्॥२१॥
अप्राप्ते वा क्रियाकालं प्राप्ते  वा न  कृता क्रिया।
क्रिया हीनाऽतिरिक्ता वा साध्येष्वपि न सिध्यति ॥२२॥
या ह्युदीर्णं शमयति नान्यं व्याधिं  करोति  च ।
सा क्रिया, न तु या व्याधिं हरत्यन्यमुदीरयेत्॥२३॥

Different Rtus i.e. seasons have already been described earlier in chapter 6.

Treatment during cold seasons – In cold seasons, the treatment should be opposite of coldness of the season i.e. hot treatments, to remove excess cold.

Treatment during hot seasons – In these seasons, the treatment should be opposite of heat i.e. cold treatments, to remove excess heat.

There are different stages of activities of doshas and those stages should not be neglected. Treatments should be planned and executed promptly as per these stages of the diseases.

Treatment will not succeed even in curable diseases if it is done earlier to the proper time meant for it. Similarly, treatment will also not succeed if it is inadequate or administered in excess.

Ideal treatment is that which cures the aggravated diseases and would not give rise to yet another disease or complication. That treatment which helps in curing one disease and also gives rise to yet another disease is not ideal.

Agni Pariksha: Examination of the digestive fire

प्रागभिहितो  ऽगिरन्नस्य पाचकः। स चतुर्विधो भवति- दोषानभीपन्न एकः; वोक्रियामापन्नस्त्रिवोधो भवति-विषमो वातेन, तीक्ष्णःपित्तेन,मन्दः श्लेष्मणा, चतुर्थः समः सर्वसाम्यादिति। तत्र, यो यथाकालमुपयुक्तमन्नं सम्यक् पचति स समः समैर्दोषैः’ य ः कदाचित्   सम्यक् पचति,  ज्कदाचिदाध्मानशूलोदावर्ततिसारजठरगौरवान्त्रकूजनप्रवाहणानि कृत्वा स विषमः  य  प्रभूतमप्युक्तमन्नमाशु पचति  स तीक्ष्णः , स  एवाभिवर्धमानोऽत्यग्रिरित्याभाअष्यते,  स मुहुर्मुहुः प्रभूतमप्युपयुक्तमन्नमाशु  पचति, पाकाने च गलताल्वोष्ठशोषदाहसंतापाञ्ज्चनयति ; यस्त्वल्पमप्युपयुक्तमुदरशिरोगौरवकासश्चासप्रसेकच्छर्दिगासदनानि कृत्वा महता कालेन पचति, स मन्दः ॥२४॥

विषमो वातजान् रोगांस्तीक्ष्णः पित्तानिमित्तजान्॥
करोत्यग्रिस्तथा मन्दो विकारान् कफसंभवान् ॥२५॥

It has been stated earlier (chap-21) that Agni (digestive fire) cooks the food. It is of four kinds, viz one not vitiated by (associated with) the Doshas and three others which are functioning improperly – such as –

–       Vishama (agni) – the nature of fire is erratic and is influenced by vata,
–       Tiksna (agni) – the nature of fire is intense / powerful and is influenced by pitta,
–       Manda (agni) – the nature of fire is weak and is influenced by slesma (kapha) and the fourth one is
–       Sama (agni) – this type of fire is balanced / normal and is due to the normalcy or equilibrium of all the doshas

Samagni – This agni would digest the food that has been consumed at usual and proper time properly. Samagni means normal digestive fire. This state of agni is due to the normalcy of all the doshas.

Vishamagni – Visama means erratic or irregular. The digestive fire which is vishama sometimes digests the food properly and sometimes cooks the food while producing flatulence, abdominal pain, upward movement of gases in the abdomen, diarrhoea, abdominal heaviness, gurgling in the intestines and straining at defecation.

Tikshnagni – That which cooks the ingested food very quickly in spite of the quantity of the food being more is known as Tiksnagni – active or powerful digestive power. Teekshnagni is also called as Atyagni which means hyperactive digestive fire, when the agni is severely increased. Atyagni digests the food very quickly in spite of large quantities of food consumed often. At the end of the digestion, it produces dryness of the throat, palate and lips and also a feeling of burning sensation and heat exhaustion.

Mandagni means weak digestive fire. This kind of agni digests the food after a long period of time even though the ingested food is less in quantity. It produces heaviness of the abdomen and head, cough, breathlessness, excessive salivation, vomiting and excessive weakness of the body.

While Vishamagni gives rise to Vataja diseases, Tikshnagni and Mandagni gives rise to pittaja and kaphaja diseases respectively.

Treatment principles for Sama, Visama, Tiksna and Manda Agnis

तत्र, समे परिक्षणं कुर्वीत; विषमे स्निग्धाम्ललवणैः क्रियाविशेषैः प्रतिकुर्वीत; तीक्ष्णे मधुरस्निग्धशीतैर्विरेकैश्च ; एवमेवात्यग्रै, मन्दे कटुतिकषायैर्वमनैश्च॥२६॥

The physician should take care that the Samagni should always be protected.

Visamagni should be treated by using the below mentioned substances i.e. foods are herbs which are –

–              Snigdha – unctuous
–              Amla – sour and
–              Lavana – salty

Tiksnagni should be treated by using the substances i.e. foods and herbs which are –

–              Madhhura – sweet,
–              Snigdha – fatty and
–              Shita – cold and
–              Virechana – administration of purgation

Similarly, Atyagni should be treated by administering buffalo milk, curd and ghee.

Mandagni should be treated by using the substances i.e. foods and herbs which are –

–              Katu – pungent,
–              Kashaya – astringent and
–              Vamana – administration of emesis

Role of Vata in kindling the agni

जाठरो भगवानग्रिरीश्वारोऽन्नस्य पाचकः ।
सौक्ष्म्याद्रसानाददानो विवेक्तुं मैव शक्यते॥२७॥
प्राणापानसमानैस्तु सर्वतः पवनैस्त्रिभिः ।
ध्मायते पाल्यते चापि स्वां स्वां गतिमवस्थितैः ॥२८॥

Agni is considered to be ‘God in the belly’. This digestive fire which is located in the jathara – stomach and digests all the foods we consume is known as ‘Bhagavan Ishwara’ – Almighty God himself. It is not possible to perceive him because he is subtle (minute).

The Agni, who is God, receives substances which are having sweet and other tastes and digests them for growth and maintenance of the body. The three types of vata i.e. prana, apana and samana being in their normal places (seats) will cause an increase (kindle) of jataragni (digestive fire located in the stomach, intestines). This kindled agni will digest the food properly.

Vayas Pariksha: Examination of age

वयस्तु  त्रिविधं-बाल्यं, मध्यं, वृद्धमिति । तत्रोनषोडाशवर्श्षीया बालाः । ते त्रिविधा:-क्षिरपाः, क्षीरात्रादा, अन्नादा इति। तेषु संवत्सरपराः क्षीरपाः, द्विसंवत्सरपराः क्षीरान्नादाः,  परतोऽन्नादा इति। षोडशसप्तत्योरन्तरे मध्यं वयः। तस्य विकल्पो- वृद्धिः, यौवनं, संपूर्णता,  परिहाणिरिति। तत्र, आविंशतेर्वृद्धिः, आत्रिंशतो  यौवनम्, आचत्वारिंशतः  सर्वधात्विन्द्रियबलवीर्यसंपूर्णता, अत ऊर्ध्वमीषत्परिहाणिर्यावत्  सप्ततिरिति। सप्ततेरुर्ध्वं क्षीयमाणधात्विन्द्रियबलवीर्योत्साहमन्यहनि  वलीपलितखालित्यजुष्टं कासश्वासप्रभृतिभिरुपद्रवैरभिभूयमानं सर्वक्रियास्वसमर्थं जीर्णागरमिवाभिवृष्टमवसीदन्तं वृद्धमाचक्षते ॥२९॥

तत्रोत्तरोतरासु वयोवस्थासुत्तरोत्तरा भेषजमात्राविशेषा भवन्ति, ऋते च परिहाणेः ; तत्राद्यापेक्षया प्रतिकुर्वीत॥३०॥

Vayas means age. It is of three types. They are –

–       Balya – childhood / young age,
–       Madhya – middle age and
–       Vriddha – old age

1. Balya – means children. It includes all those who are less than sixteen years of age.

They are of three kinds –

i.          Ksirapa- who drinks only milk
ii.          Ksirannada – who consume both milk and solid food and,
iii.          Annada – he who eats solid food only

Children up to one year of age are called Ksirapa. Children up to two years of age are called Kshirannada. The children above that period (2 years of age) are called Annada.

2. Madhya Vaya (middle age) – includes all individuals who fall in the age group between sixteen and seventy years of age. They are again of four kinds and are as mentioned below –

i.          Vridhi (growth),
ii.          Yauvana (youth, adolescence),
iii.          Sampurnata (full growth / maturity) and
iv.          Parihani (diminution)

Vriddhi i.e. growth of the body takes place up to twenty years of one’s life.

Yauvana is up to thirty years of age i.e. between twenty and thirty years of age.

Sampurnata – is up to forty years of age i.e. between thirty and forty years and is marked with full growth of all the tissues, senses, strength and vitality.

Parihani – is between forty and seventy years of age which is marked by slight diminution in growth of tissues and also sense faculties, strength and vitality.

3. Vriddha / Vardhakya – old age / senility – includes all persons above seventy years of age. It is marked with diminution of tissues. There is also deterioration of sense faculties, strength, vitality and enthusiasm, day after day, with passing time.

The person who is called a vriddha i.e. old man, just survives like an old house which is constantly drenching in the rain and develops –

–       Skin wrinkling
–       Greyness of hairs,
–       Baldness of hairs,
–       Cough,
–       Dyspnoea,
–       Many complications,
–       Inability to perform all the activities

In succeeding ages or stages of life, the dose of the medicine administered should be in increasing dose. This rule is not applicable for Parihani age group of people. In this age, the dose of medicines should be the same as that given at the first stage of life / first age group i.e. balya.

बाले  विवर्धते  श्लेष्मा  मध्यमे पित्तमेव  तु।
भूयिष्ठं वर्धते वायुर्वृद्धे  तद्दीक्ष्य योजयेत् ॥३१॥
अग्रिक्षारविरेकैस्तु  बालवृद्धौ विवर्जयेत् ।
तत्साध्येषु विकारेषु मृद्वीं कुर्यात्  क्रियां शनैः ॥३२॥

Some verse here:-

Establishing the relationship between doshas and age, –

–              Kapha increases greatly during balya – childhood or young age
–              Pitta increases during Madhya vaya i.e. middle age and
–              Vata increases during vardhakya / vriddha Avastha i.e. during old age

Knowing that, treatments shall be planned in accordance to dosha predominance / increase at different stages of / ages of life.

The below mentioned treatments shall be avoided during young and old ages –

Agni Karma – use of thermal cautery
Ksara Karma – use of alkaline cautery
Virechana – purgation

These treatments should be done slowly and in a mild way if it becomes very much necessary to administer these in the mentioned age groups or if the diseases manifested in these persons is curable only by these treatments.

Deha Pariksha: Examination of body physique

देहः  स्थूलः कृशो, मध्य, इति प्रागुपदिष्टः ॥३३॥

The body / physique is of three kinds (as stated in chapter 15) –

–       Sthula (stout, corpulent),
–       Krsa (emaciated, thin) and
–       Madhya (medium / moderate).

कर्शयेद्धं हयेच्चापि  सदा स्थूलकृशौ नरौ।
रक्षणं चैव मध्यस्य कुर्वीत सततं भिषक्॥३४॥

The physician should manage the below mentioned body frames in the below mentioned way –

–       Thinning therapies should always be administered to the stout persons.
–       Stoutening therapies should always be given to thin individuals.
–       The moderate persons should always be protected and allowed to be as such.

Bala pariksha: Examination of strength

बलमभिहितगुणं दौर्बल्यं तु स्वभावदो षजरादिभिरवेक्षितव्यम् । यस्माद्वलवतः सर्वक्रियाप्रवृत्तिस्तस्माद्वलमेव प्रधनमधिकरणाम् ॥३५॥
केचित् कृशाः प्राणवन्तःस्थूलाश्चाल्पबला नराः ॥
तस्मात् स्थिरत्वं व्यायामैर्बलं वैद्यः प्रतर्कयेत् ॥३६॥

Earlier in chapter 15, the qualities of bala – strength have been explained. Dourbalya i.e. loss of strength should be Its weakness should be estimated by considering the swabhava – normalcy (constitution), doshas, jara – old age etc factors. The bala or strength itself is important for all the activities since all kinds of treatments are meant to be administered to strong persons only.

We can observe that some emaciated persons are strong. On the other hand, some people would have less strength in spite of being stout. Therefore, the inference of stamina and strength of an individual should be estimated by the physician by analysing one’s capacity to do and tolerate exercises.

Satvapariksha: Examination of mental power

सत्वं तु  व्यसनाभ्युदयक्रियादिस्थाने ष्वविक्लवकरम् ॥३७॥
सत्त्ववान् सहते  सर्वं संस्तभ्यात्मानमात्मना॥
राजसः स्तभ्यमानोऽन्यैः सहते नैव तामसः ॥३८॥

Sattva can be defined as the capacity of the mind which does not cause the below mentioned –

–       Frustration / misery or agony even at times of sorrow,
–       Joy or happiness
–       And other emotions like fear, anger etc

The person having predominance of Sattva Guna would himself remain under control. He would tolerate grief, happiness etc. and all other emotions equally.

The person who has predominance of Rajo Guna would tolerate grief, happiness etc when controlled by others.

The person who has predominance of Tamo Guna cannot tolerate grief or happiness or any such emotions.

Satmya Pariksha: Examination of Habituations

सात्मयानि तु देशकालजातुरोगव्यायामोदकदिवास्वप्ररसप्रभृतीनि प्रकृतिविरुद्धान्यपि यान्यबाधकराणि  भवन्ति॥।३९॥
यो रसः कल्पते यस्य सुखायैव निषेवितः।
व्यायामजातमन्यद्धा तत् सात्म्यमिति निर्दिशेत् ॥४०॥

Satmya (habituation, accustomization) includes habitat, time, caste (family), season, disease, exercise (physical activities), water (foods and drinks), day sleep, tastes (substances of different tastes) and such others which in spite of being opposite of / different from (qualities of) one’s own constitution) will not harm the person.

Satmya means habituation or getting accustomed. It includes –

–       Tastes or substances having such tastes which would bestow happiness and health only, when regularly consumed,
–       Exercises which would bestow happiness and health only, when regularly done / practiced
–       Habitats, seasons etc. which would bestow happiness and health only

Prakriti – Bheshaja Pariksha: Examination of constitution and drugs

The details of examination of Prakriti and Bheshaja (medicines) will be described later.

Desa Pariksha: Examination of land regions

देशस्त्वानूपो  जाङ्गलः साधारण इति। तत्र, बहूदकनिम्रोन्नतनदीवर्षगहनो मृदुशीतानिलो बहुमहापर्वतवृक्षो मृदुसुकुमारोपचितशरीरमनुष्यप्रायः कफवातरोगभूयिष्ठश्चानूपः; आकाशसमः प्रविलाल्पकण्टकिवृक्षप्रायोऽल्पवर्षप्रस्रवणोदपानोदकप्राय उष्णदारुणवातः प्रविरलाल्पशैलः स्थिरकृशशरीरमनुष्यप्रायो वातपित्तरोगभूयिष्ठश्च जाङ्गलः ;  उभयदेशलक्षणः  साधारण इति॥४२॥

Desa means land or regions of land. They are classified into three types i.e.

–       Anupa Desa – marshy land
–       Jangala Desa – arid lands and
–       Sadharana Desa – moderate lands

Anupa Desha – Below mentioned are the features of Anupa Desa – marshy land. These lands have –

–              More of water
–              Ups and downs on the ground,
–              Rivers,
–              Rainfall
–              Soft and cold winds,
–              Plenty of high mountains and trees,
–              People who have soft, tender and well-built body,
–              More of kaphaja and vataja diseases manifested

Jangala Desha – Below mentioned are the features of Jangala Desa – arid or desert-like regions. These lands have –

–       Lands which are even, similar to sky
–       Few, small trees grown apart,
–       Thorny trees
–       Less rainfall
–       Less of streams and reservoirs of water,
–       Strong winds which are hot,
–       Small hills which are apart from one another,
–       People who have stable and emaciated body
–       More of Vataja and Pittaja diseases manifested

Sadharana Desha – The moderate region / land will have features of both the above kinds i.e. Anupa and Jangala kinds of lands.

समाः साधारणो यस्माच्छीतवर्षोष्ममारुताः ।
दोषाणां समता जन्तोस्तस्माधारणो मतः ॥४३॥

In Sadharana Desa, since cold, rain, heat and wind are all moderate in nature, even the doshas in human beings are also moderate (normal) in nature. Therefore, this land is called Sadharana.

न तथा बलवन्ताः स्युर्जलजा वा स्थलाहृताः ।
स्वदेशे निचिता दोषा अन्यस्मिन् कोपमागताः॥४४॥
उचिते वर्तमानस्य नास्ति देशकृतं भयम् ।
आहारस्वप्रचेष्टादौ तद्देशस्य गुणे सति ॥४५॥

Just like the living beings living in the water (acquatic animals) are not as powerful on the land as they are in water (which is their natural dwelling place), the doshas which are accumulated in their region (region or geographical region favourable for their accumulation) when get aggravated in a different region, will not produce as powerful diseases as they would produce in their own regions. (Example – Diseases produced in marshy regions are not strong (powerful, severe) if brought to arid regions (by the patient changing his habitat) and vice- versa.)

If people are indulged in good foods, sleep and activities like exercise etc, they will not have any fear of developing ‘region related / specific diseases’ in spite of the doshas (which would cause diseases) having their qualities similar to that region.

Roga Sadhyasadhyata: Curability and incurability of Diseases

देश प्रकतिसात्म्यर्तुविरीतोऽचिरोस्थितः ।
संपत्तौ भिषगादीनां बलसत्त्वायुषां  तथा॥४६॥
केवलः  समदेहाग्रेः  सुखसाध्यतमो गदः ।
अतोऽन्यथा   त्वसाध्यः  स्याक्तृच्छो  व्यामिश्रलक्षणः ॥४७॥

Diseases having the below mentioned features are considered as Susadhya – easily curable –

–       Different from the nature of habitat, constitution, habituation and season,
–       Of recent onset
–       Having availability of all the four limbs bestowed with their good qualities i.e. physician, medicine, caretakers and patient
–       Patient endowed with strength, good mind and longevity
–       Devoid of complications
–       Has normal body power
–       Has normal digestive power

In Asadhya – incurable diseases, the features are opposite to those of the Susadhya Vyadhis mentioned above.

In Krichchra Sadhya – diseases which are curable with difficulty, there are mixed features.

Chikitsa Krama: Mode of treatments

क्रियायास्तु  गुणालाभे क्रियामन्यां प्रयोजयेत्॥
पूर्वस्यां शान्तवेगायां न क्रियासंकरो हितः ॥४८॥

Sometimes a particular treatment may not yield results when administered in a disease. In such cases, when a disease is not cured by any one treatment, another treatment should be administered only after the effects (bouts) of the earlier treatment has subsided. It is not good or beneficial to mix different treatments at the same time.

गुणालाभोऽपि सपदि यदि सैव क्रिया हिता॥
कर्तव्यैव  तदा व्याधिः कृच्छसाध्यमो यदि ॥४९॥

When the desired result or relief is not obtained quickly in a disease by one treatment, the same treatment should be continued for some more time, if it is comfortable for the patient.

य एवमेनं विधिमेकरुपं बिभर्ति कालादिवशेन धीमान् ।
स मृत्युपाशाञ्जगतो  गदौघाञ्छिनति भैषज्यपरश्वधेन॥५०॥

As said above, if a wise physician administers one i.e. most important treatment by considering time etc. factors, he will be able to save the people of the world by cutting the multitude of diseases which are in the form of death noose, with the axe of drugs (medicines).

इति  श्रीसुश्रुतसंहितायां सुत्रस्थने  आतुरोपक्रमणीयो नाम पञ्चत्रिंशोऽध्यायः ॥३५॥

Thus, ends the Thirty fifth chapters by name Aturopakramaniya in Sutra Sthana of Susruta samhita.