A Study on Siddha Urinary Diagnostic Methodology Neerkkuri and Neikkuri in Adhiratha Azhutham ( Hypertension )

Background: In Siddha system of medicine, diagnosis of the disease is based on Ennvagai thervukal (Eight fold examination), in which Neerkkuri Neikkuri (Urine examination) is one among them. It is an effective and sensitive measure for the diagnosis and prognosis of diseases. Objectives: This study was conducted to establish the validity of prognostic and diagnostic patterns of Neikkuri (Oil on urine sign)in hypertension patients and to assess the association between the Neikkuri patterns with respect to pH and specific gravity of urine. Methods and Material: Urine samples of 40 diagnosed patients of hypertension aged between 30 to 60 years were collected. Ten healthy volunteers were also selected as control group for comparison. Biochemical analysis was done in the urine samples with urine reagent strip to confirm health status of the subjects. A drop of sesame oil was dropped over 50 ml of each urine sample and behaviour (shape of the oil spread, direction and spread time) was observed. Results: Half of the samples of urine of hypertension patients showed circular shape initially and then vacuolating to turn out into a sieve pattern and in remaining others at least a single vacuolation amounting to ring pattern indicative of Pitham were shown. Also, the urine of the hypertension patients were characterised by straw colour and aromatic odour, absence of froth and specific gravity 1.003-1.010.Volume of urine voided ranged from 1-1.5 lit and pH between 5.1-6.In most of the cases the dissemination dynamics of oil drop observed were of slow spreading nature which indicates good prognosis. Conclusion: It is concluded that hypertension has got mixed prognosis which may indicate the variation in the amenability of hypertension to the treatment. The study explored the veracity of the investigative procedure in diagnosis and prognosis of hypertension with Neikkuri examination.


INTRODUCTION
Siddha system is one of the ancient systems of medicine which flourished in South India along with the Dravidian culture.Siddhars out of their supernatural wisdom have bestowed to this world many wonderful remedies for myriad type of ailments. [1]In Siddha system the main methodology of diagnosis of the disease is based on Envagai thervu (Naadi, Naa, Niram, Mozhi, Vizhi, Malam, Neer (Neerkkuri -Neikkuri) and Sparisam) according to Sage Theraiyar. [2,3,4]Among these, Neerkkuri -Neikkuri is one of the ancient diagnostic tools handled by Siddhars which is not used widely nowadays.

Christian et al.: Siddha Urinary Diagnostic Methodology Neerkkuri and Neikkuri in Hypertension
[8][9][10][11] Hypertension is one the most important public health problems nowadays.About 25% of persons in the general population are hypertensive.Hypertension has affected more than 800 million individuals worldwide.[23][24] This study has explored the possibility of establishing the veracity of the investigative procedure used in the assessment of diagnosis and prognosis of the Adhiratha azhutham (hypertension) and to ensure a validated technique made available to Siddha Physicians.

Study setting
This was a prospective observational non randomized controlled trial study, which was carried out in the out patients and inpatients departments of NoiNaadal department, Ayothidoss Pandithar Hospital, National Institute of Siddha, Tambaram Sanatorium, Chennai.The duration of the study was one year (2011 -2012).The study was conducted after the Institutional Ethical Committee clearance (No.NIS/6-20/Res/IEC/10-11). Normal treatment procedures in National Institute of Siddha were followed and the data collections from the patient were kept confidential.Informed consent was obtained from the patient prior to the enrolment.This study involved only the performing investigations mentioned in the protocol.Appropriate measures were taken to prevent infection.

Criteria for exclusion
Hypertensive patients with serious complications associated with any other systemic diseases were excluded.

Study enrolment
Patients were informed about the study and a written consent was obtained for this study.A total of 100 subjects (80 hypertensive cases and 20 healthy, non-hypertensive subjects) were screened from the Out patients and Inpatients departments.Based on the inclusion criteria, a total number of 40 hypertensive patients were included and 10 healthy volunteers were selected as control group for comparison.Thus, we had two groups, one for hypertension and second for healthy group.

Evaluation of Clinical parameters
Complete clinical history, complaints, duration and examination findings were recorded in a prescribed format in the history and clinical assessment forms separately.Siddha parameters such as seven body components (udal thathukkal), [6] three humours (mukkutram), [6] and eight fold examination (ennvagaithervu) were assessed.Radial arterial pulse (Naadi) was examined through the three fingers of the physician on wrist of the patient and felt for the strength of Vatham, Pitham and Kapham.The pulse appraisal, pulse character and pulse play were assessed.Vatham is felt in the index finger, Pitham in the middle finger and Kapham under the ring finger.According to Siddha, the normal ratio of these three naadis are supposed to be 1: ½: ¼ for vatham, pitham and kabham respectively.If two naadis are elevated together, then it was noted as vatha pitham, pitha vatham and kaba pitham.Naa (Tongue) was examined for appearance, color, taste and salivary secretion.Patient`s complexion (Niram) and voice (Mozhi) were examined.Eyes (Vizhi) were examined for color of the sclera and lacrimal secretion.The warmth of the body, sweating and presence of pain were assessed by touch (sparisam).Stool (Malam) was examined for its color, odor and consistency.Urine (Moothiram) was examined for color, odor, frothiness, density, quantity and deposits. [7,8]Wrist circummetric sign(Manikkadai nool), [2] Habitat (Nilam), Season (kaalam), [1] and Astrology (Sodhidam) were also documented.

Neikkuri (oil on urine sign)
To reduce the dietary influence on urine formation and to avoid the influence of in equality in duration of sleep on urine quality, every patient was advised to sleep early (before 9 pm) with usual intake of water during the dinner.The diet was balanced with appropriate proportion of all six tastes.Early in the morning, the patients were asked to collect the mid-stream urine of the first urination of the day in a clean and neat bottle.Urine thus collected was poured in a round wide mouthed glass bowl (capacity of 200 ml), kept on a flat surface and was allowed to stand.After ascertaining that the urine was still and devoid of disturbance or ripples or other influences of the wind, then it was examined in a day light in morning. [2,5]Sesame oil (It was procured from mill as freshly ground sesame seeds in traditional stone grinder (chekku) without any additives added) was then taken in a dropper and a drop of oil was instilled over the surface of urine gently (keeping a distance of 3 cm above the surface of the urine) without disturbing / touching the surface.It was then left for a few minutes and the oil drop spreading pattern on the urine surface was observed. [19 -21]The observations were then recorded and photography was taken.5 slides of picture were taken -1 minute after dropping of oil, after 3 minutes, after 5 minutes, after 7 minutes and after 10 minutes.

Statistical Analysis
All collected data were entered in to computer using MS Access/ MS Excel Software.The data were analysed using STATA Software under the guidance of Senior Research Officer (Statistics), National Institute of Siddha.The level of significance were 0.05.Descriptive analysis were made.The Statistical analysis for the significance of different diagnostic Neerkkuri-Neikkuri were done using Student 't' test and chi-square test for quantitative and qualitative data respectively.

RESULTS
Out of the 80 cases screened, 40 hypertensive cases were included and among 20 normal subjects screened, 10 normal subjects were included for this study.Table 1 shows 15% of cases falling in the age group of 30-40 years, 32.5% of cases in the age group of 41-50 years and 52.5% of cases in the age group of 51-60 years.Table 1 shows 60% of cases were female.67.5% of cases had the Naadi nadai of Vatha pitham, 27.5% cases had Pitha vathamand 5% of cases had Kaba pitham.Most of the cases had Vatha pitha Naadi.Ratha pitha disease is said to be associated with Vatha pitha Naadi. [1,2,5] Te 1 shows among the cases, the colour of the urine was colourless in 2.5%, straw coloured in 72.5%, yellow coloured in 22.5% and dark yellowish in 2.5%.In most of the cases, the colour of the urine observed was of straw colour.It also shows that, the odour of urine was aromatic in 55%, ammoniacal in 30% and putrid in remaining 5% odour.Among the cases, froth of the urine was absent in 87.5% and the remaining 12.5% presented with froth in the urine.Table 1 shows that 5% of cases passed 500ml -1lit of urine per day, 87.5% of cases passed 1.1 to 1.5 lit per day and the remaining 7.5% of cases passed 1.6-2 lit per day.Table 1 shows, the specific gravity of the urine were between 1.003-1.010 in 62.5%, 12.5% had specific gravity between 1.011-1.015,22.5% had specific gravity between 1.016-1.020and 2.5% had specific gravity between 1.021-1.025.Among the cases, 37.5% of cases had pH between 5.1-6, 35% of cases had pH between 6.1-7 and remaining 27.5% of cases had pH above 7.
Table 2 shows that in most of the cases, with the coin shaped Neikkuri pattern, they had pH between 6.1-7.Table 3 shows in sizable number of cases, with the coin Neikkuri, had specific gravity of their urine between 1.003-1.010.Table 4 shows that there is a moderate correlation between systolic blood pressure and pH value.There was also a correlation between diastolic blood pressure and pH value.But there was no correlation between systolic and diastolic blood pressures with specific gravity.
Table 5 shows in most of the cases, oil drops were of slow spreading nature which indicates good prognosis.Table 6 shows in most of the cases the shape of neikkuri observed were of vacuolated sieve and vacuolated.According to sage Theran, the ring pattern in neikkuri are said to be associated with the pitham humour in urine. [5]For a neikkuri shape to take a ring pattern there needs to be a large vacuole to fill in the spreaded expanse of the instilled oil drop.So vacuole of a larger form is predominantly presumed to be because of pitham in the urine. [5,2] heran also stated that the smaller vacuoles presenting as a constellation and appearing like a sieve is because of kabam. [5]Kabam when blends with the pitham, the larger vacuoles become smaller and make the neikkuri pattern to look like a sieve, which according to Sage Gowthamar, is indicative of bad prognosis. [1,2,5,9] Pl 1 showsin Day 1-In most of the cases, the shapes of the neikkuri patterns observed in 3, 7 and 10 minutes were of coin and circular shapes (Figure 1-7).Plate 2 shows in Day 2 -In most of the cases, the shape of the neikkuri observed in 3, 7 and 10 minutes were of coin and circular shapes.Plate 3 shows in Day 3 -In most of the cases, the shape of the neikkuri observed in 3, 7 and 10 minutes were of coin, egg and circular shapes.Plate 4 and plate 5 shows about the Neikkuri patterns of urine in the pH ranging between 5.1 -7 and above, were of coin shapes till 7 minutes of observation.In 10 minutes circular and mitre shaped patterns (Figure 2) were observed.
Plate 9 shows in specific gravity 1.016-1.020group, Neikkuri shape in 3 minutes were of coin, circular, bear face, seed, shield, tortoise and white chowry shapes.7 minutes-bird shape (Figure 1) and 10 minutes were of human face shape.Plate 10 shows the neikkuri pattern observed in samples with specific gravity 1.020-1.025at 3 minutes (67%) and 7 minutes (18.2%) were of coin, animal and tortoise shell shapes.In 10 min were of coin, tortoise and miter shapes.(Figure 4,5,6) Plate 11 shows group 1, most of the cases, the shape of the neikkuri observed in 3, 7 and 10 minutes were coin, circular, egg, disc, human face, lotus leaf, mountain and white chowry shapes.Plate 12 shows group 2, in which most of the cases, the shape of neikkuri observed in 3 minutes,7 minutes and 10 min were of coin, circular, egg, white chowry and bird.Plate 13 shows Neikkuri results in normal subjects/ healthy volunteers.In all the cases, the urine samples were of straw coloured, aromatic in odour and the voided urine volume ranged between 1.1 to 1.5 lit/day, pH between 5.1 to 6 and specific gravity 1.003 -1.010.The result obtained were within normal limits.Plate 14 shows in most of the cases, the shape of the neikkuri observed on Day 1, 2 and 3 in 3 minutes,7 minutes and 10 minutes were of coin and circular shapes.Plate 15 shows in most of the cases with pH range between 5.1-6 and 6.1-7 shape of neikkuri observed in 3 and 7 min were of coin shape.
Plate 16 shows in most of the cases with specific gravity range between 1.003-1.010and 1.011-1.015shape of neikkuri in 3minutes and 7 minutes with coin shaped.
In most of the cases, the shape of the neikkuri observed in 3 minutes,7 minutes and 10 minutes were of coin and circular and jasmine bud shapes. [5,9] ifferentiation could be made between the neikkuri pattern in normal subjects and the study samples of hypertension on close and continued observation.In control group of normal subject's samples, no vacuolated sieve pattern was observed.Hence, it may be construed that it is the pitham that is responsible for the vacuole formation in neikkuri patterns (Figure 7).And in hypertension, pitham in ratham or blood is excreated in the urine as well, [5] which could be the manifestation of vacuolated sieve patterns in Neikkuri examination of hypertension patients. [2,3,4,5]

DISCUSSION
Neerkkuri and neikkuri are very sensitive and exclusively Siddha methods of diagnostic urine examination       propounded by sage Theraiyar. [2,3,4 5]This is an efficient method in elucidating the prognosis of the given disease.
In this controlled study, the Neikkuri of hypertension urine showed the characteristics of pitham manifesting as expanding of oil drop in circular fashion

Figure 7 :
Figure 7: Formation of vacuoles in Neikkuri sign.Plate 1: Different patterns of Neikkuri observed in day 1.

4 :Plate 5 :Plate 6 : 010 Plate 8 : 9 : 020 Plate 10 :
initially and then vacuolating to turn out in to a sieve pattern in half of the patients and in remaining others at least a single vacuolation amounting to ring pattern indicative of pitham, particularly showing up in urine.The urine of the hypertension patients were characterised by straw colour, aromatic odour, absence of froth and specific gravity 1.003-1.010.Volume of urine voided ranged from 1-1.5 lit and pH between 5.1-6.In most of the cases the dissemination dynamics of oil drop observed were of slow spreading nature which indicates good prognosis. [2,3,4,5]Christian et al.: Siddha Urinary Diagnostic Methodology Neerkkuri and Neikkuri in Hypertension Plate Neikkuri patterns according to pH value: 5.1 to 6. Neikkuri patterns according to pH value: 6.1 to 7. Neikkuri patterns according to pH value: Above 7. Plate 7: Neikkuri patterns according to specific gravity range: 1.003 to 1.Neikkuri patterns according to specific gravity range: 1.011 to 1.015.Plate Neikkuri patterns according to specific gravity range: 1.016 to 1.Neikkuri patterns according to specific gravity range: 1.021 to 1.025 Plate 11: Different patterns of Neikkuri observed in Group I (Systolic>140 <170 or/and Diastolic >90 <100)

Table 6 : According to formation of vacuolation S.no Vacuolation Patterns Number of cases Percentage
Christian et al.: Siddha Urinary Diagnostic Methodology Neerkkuri and Neikkuri in Hypertension