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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
lrl(·i-( ªi¬ ¬( ¬·¤i¬·¤ n-¤ ¤nl(·ii ¤º|·ii ~i·ni¤(ºi
¤-¤·i- ~·-i· ¤l·n º¤ln| (¤¬ ···/)
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.
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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
ni· ¬-(i¤· ¤( ¤º|·¤ ºin ¬((i ¬(-·ii-iº¬i¬-·¤(¬i· -(i·i
·i(ln · lr ni·i(¤(· ¬--· n¤ ni·--¤nn l¤l(·i -(l--· ni·¬-(i¤
¤(-i·ni(ºiin ni· nn ¤-¤·ii·-i·i·¤i- ¤º|·ii¤¤nn| l¬ r·¤l(·- ¤(
¤-in ¤-¤·ii·-i·i·¤i- ¤º|·i-iºii l(nin|(¤ l( «r)
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
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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.
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That's why Charaka says
n--ilrl(·ii ¤º|·ii ni·(ni ¤-¤·i- ~·-i· ¤ l¤l(·ii (i ¬ri ¤(ºi·
(¤.l( «r)
Definition of APTA
º·-n-i·¤i l·-·ni -n¤i ni·(¬· ¤
¤·ii l¤¬i¬--¬ ni·-·¤irn ¬(i
~i·ni lºi·-i l((-i-n n·ii (i·¤-¬ºi¤-
¬-¤ (·¤l·n n ¬--i(¬-¤ ·|º·-n-i
(¤.¬. ···s÷·s)
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
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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 (~·¤i¤
-¬si·i ¬-i· ¬·iºi- n·ii ¤ ·¤(riºi ¤(nn (·¤i¤ (ºi· ÷(i-¬i¤·
·ii·¤) True knowledge that comes from any source is acceptable and
adoptable. Because the entire world is the teacher to the intellects (¬--· lr
¬i¬i (l--ni-i¤i¤i÷ ¤l( s·«) So in this group Teachers,
Technicians working in the laboratories, nurses, pharmacists etc can be
included as Apta.
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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.
"~¤-iºi ¤·--ii·--i -ªi º·n (·-i(·- (¤·l-ln (¤l( ««)"
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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.
(¤l( «c)
1. ¤¬i¤ºi – Provoking factors of the disease
2. ¤il· – Sources of origin or Doshas involved.
3. ¬-·ii·- - Nature of onset / Mode of manifestation
4. ~i--i·- - Nature of disease (Seriousness or Acuteness)
5. ~l·i·-i·- – Location in organs of body & mind
6. ((·- ÷ -Symptoms like pain etc.
7. ¬-·ii·- – Signs
8. ºi·( -¤ºi ª¤ º¬ n··i – Association with specific sounds,
Touch, Colours Taste or Smell
9. ¬¤((- - Complications
10. (--·ii· ·i¤¬-l·(n-~ - Symptoms of aggravation, normalcy
and alleviations
11. ¬(¬- (¬-iº ¬i¬|· ¤¬-) - Prognosis (Fate of disease)
12.·i-il· ÷ Names of diseases
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13. ¤in – Concomitants / Prescribed medicines
14. ¤n|¬iºi·i ¤(l-iº·i(i l·(ln (¤·¤i¤·¤)- Prescriptions &
prohibitions in the treatment.
Pratyaksha
This is the second method but most important method of examination
Definition
~i--l·(¤ -·i·ii·i ¬l··¬·iin ¤(nn
·¤·ni n(i-( ¤i (l- ¤-¤·i ¬i l·ª·¤n (¤¬ ··za).
Perception / 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 &
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Percussion)
Ghrana (nasa) Gandha (Smell) Ghrana (Olfaction)
Jihwa (Tongue) Rasa (Taste) Rasana (gustation)
Quantum of Information Available From Each one of sensory Faculties
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
Eye (Inspection)
Skin (Palpation)
Ear (Auscultation)
Nose (Olfaction)
Jihwa
(Gustation)
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¬(lºl·(¤ ¬(il·l·(¤i·ii·inººiº|ºnni· ¤º|·in ~·¤¤ º¬ni·in .... º¬
n ªi~(inººiº|ºnnl-l·(¤ (·il¤¬-·¤·-i·((n·sn ·r-¤ ¤-¤·iºi
nrºi-¤¤nn (¤.l(. «/)
Clinical Application
1. Darshan Pratyaksha (Inspection)
a. (ºi ¬-·ii· ¤-iºi si¤i÷ Colour / Shape / Quality /External
appearance, Measurement, number, proportion, complexion or
lusters
b. ºiº|º ¤¬ln l(¬iºi÷ Normal and abnormal appearance of
body and organs.
c. ~··nil· ÷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)
-¤ºi ¤ ¤ilºi·i ¤¬lnl(¬ln ¤·n- (¤ l( «/)
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 :- ¤¬ln l-·in· ¤ilºi·i ºiº|º--¤ ¬(¬ -¤ºin
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Touch the entire body of the patient with the palm neither too hot nor too
cold.
The following factors are to be examined.
(i) ¬nn -¤·(-i·i·i ºiº|º(ºi·i--¤·(·- - Absence of Pulsation in
such of the organs of the body which pulsate constantly like pulse
examination
(ii) l·-¤i·-ºii ºi|ln·ii( – Coldness in organs which normally remain
constantly hot – Temperature of the body to be examined by
touching.
(iii) -(·i (iªºi-(- Hardness in soft organs
(iv) º¬·ºii·i ªiº-( – Roughness in smooth organs
(v) ¬ni-¬(·ii( - Absence of organs which are normally present
(vi) ¬··i|·i ¬¬ ·iºi ·¤(·il· – Major or minor dislocation of joints
downwards or side wards.
(vii) -i¬ ºiilºin¤i(in|·ii( – Exessive diminution of muscle tissue &
blood.
(viii) (iªºi-( - Appearance of hardness
(ix) -((i·(- -n-·ii (i ÷ Persistent sweating or its total absence
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
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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) ~·¤¬·· ÷ Bowel sounds / gurgling sound of intestine
(b) ¬l··i-¤-·-nl¬ ¤(ºii ¤ ÷ Cracking sound in the joints
including those in the fingers.
(c) -(ºl(ºi·ii ¤ ÷ Voice of the patients
(d) ~··nil· ÷ 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.
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Information -
n··ii-n ªi¬ ¬(ºiº|nni·inº-¤ ¤¬ln(¬ilº¬i· ·iiºi· ¤º|·in|
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 (¤º·
¤º|·ii)
(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 (-·iº ) - By Benedict’s test / Uristix.
 Acidic (~-¬) / Alkaline (·iiº) by pH paper, Ketone body test etc.
 Bile (ln·n) - Bile Salt/ Pigment tests etc.
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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
¤-¤·i lr ~~¤- ~·~¤-¤-¤·i-l-n ¤(in-i·-i·¤l·nl·iª¤¬·¤n
(¤.¬ ··/)
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: ~·-i· n ªi¬ n¬i¤·-¤¤·i
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.
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(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 (º· ¬n· )
5. Moha – by lack of understanding (~l(ni· ·)
6. Anger – by revengeful disposition (¬i·i-l·i(irºi)
7. Grief – by Sorrowful disposition (ºii¬- (·¤·)
8. Joy – by happiness (r·i-i-i(·)
9. Pleasure – by satisfaction (reflected by the appearance of face & eyes)
(¤|ln ni·iºi)
10. Fear – by Apprehension (·i¤ l(·ii(·)
11.Courage – by strength of mind even when one is in dangerous
situation (·i¤-l(·ii(·)
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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: (l- ¤º¤ln ¤i ·ii(i· (r¬iººi ¤in·i·
¤l·nl-¤¬i¬i ¬i n¤i ¤|(n ¬i·¤n ¤¤i
(¤¬ ··zr)
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.
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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
~i¤-¤ ·i- ¤(·¤·i·¤-¤ ¬i(º¤-l·i¬-¤ ¤¬iºi·
(¤ l( s«z)
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 ((º· ) 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.
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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.

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