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Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 107-121

Avaaraneeya Adhyaya of Sushruta Sutra Sthana - An explorative study

Department of Kaya Chikitsa, R. B. Ayurvedic Medical College and Hospital, Agra, Uttar Pradesh, India

Date of Submission16-Oct-2021
Date of Decision21-Jan-2022
Date of Acceptance21-Jan-2022
Date of Web Publication15-Mar-2022

Correspondence Address:
Dr. Prasad Mamidi
Department of Kaya Chikitsa, R. B. Ayurvedic Medical College and Hospital, Agra, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jihs.jihs_27_21

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Sushruta Samhita is an ancient Ayurvedic text deals mainly with surgical knowledge. Sushruta has documented Arishta Vignaana (prognostic knowledge) in the chapters 28 to 33 of Sutra Sthana. Avaaraneeya Adhyaya is the 33rd chapter of Sushruta Sutra Sthana. The term Avaraneeya denotes various untreatable conditions. Avaaraneeya Adhyaya consists of 26 verses that deal with the description of various poor prgnositc conditions or diseases. The contents of Avaaraneeya Adhyaya chapter are unique and require further exploration. No work has been conducted on Avaaraneeya Adhyaya chapter of Sushruta Sutra Sthana till date. The present study is aimed to evaluate the prognostic importance of the contents of Avaaraneeya Adhyaya chapter with the help of contemporary prognostic literature. Various databases have been searched to collect relevant data by using appropriate keywords. Clinical interpretation of the verses have revealed various fatal conditions with poor prognosis such as end of life stages, multiple chronic conditions and signs & symptoms of terminal illnesses. The contents of Avaaraneeya Adhyaya chapter of Sushruta Samhita Sutra Sthana seem to be having clinical and prognostic significance and clinical applicability. The present study provides inputs for future research works on Ayurvedic prognostic science.

Keywords: Arishta Vignaana, Bipolar disorder, Delirium, Maharshi Sushruta, Septic shock, Sushruta Samhita

How to cite this article:
Mamidi P, Gupta K. Avaaraneeya Adhyaya of Sushruta Sutra Sthana - An explorative study. J Integr Health Sci 2021;9:107-21

How to cite this URL:
Mamidi P, Gupta K. Avaaraneeya Adhyaya of Sushruta Sutra Sthana - An explorative study. J Integr Health Sci [serial online] 2021 [cited 2023 Mar 29];9:107-21. Available from: https://www.jihs.in/text.asp?2021/9/2/107/339654

  Introduction Top

Sushruta Samhita is an ancient Ayurvedic (Indian traditional system of medicine) text deals mainly with surgical knowledge. Maharshi Sushruta had lived 2000 years ago and he is considered as a specialist in various surgical procedures.[1] A wide variety of complicated surgical procedures have been documented in Sushruta Samhita and they are surprisingly applicable even in the present time.[1] Sushruta is the most celebrated physician and surgeon in India. Many of his contributions to surgery preceded similar discoveries in the western world.[2] Sushruta Samhita consists 184 chapters, description of 1120 medical conditions, 300 surgical procedures, details of 650 drugs (of plant, animal, and mineral origin) and 121 instruments.[3] Sushruta Samhita does not contain Indriya Sthana (a specific section of the text deals with prognostic aspects) like Charaka Samhita and other classical Ayurvedic texts. Words like Arishta and Indriya refer to fatal signs and symptoms that denote an impending death of a patient. Sushruta has documented Arishta Vignaana (prognostic knowledge) in the chapters 28–33 of Sutra Sthana (a specific section of the text consists of basic principles or key concepts). There are minor variations between Chakrapani and Dalhana (commentators on Sushruta Samhita) while naming the chapters of Sutra Sthana of Sushruta Samhita (chapters from 28 to 33).[4]

Avaaraneeya Adhyaya (AA) is the 33rd chapter of Sushruta Sutra Sthana (SSS). The term Vaarana denotes treatment and Avaarana refers to untreatability, hence the chapter Avaraneeya denotes various untreatable conditions. AA consists of 26 verses that deal with the description of various poor prgnositc conditions/diseases.[5] Previous works have explored the prognostic significance of Indriya Sthana's of Charaka Samhita[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19] and Bhela Samhita.[20],[21],[22],[23],[24],[25],[26] The progonstic aspects documented in the chapters of SSS (chapters 28–33) have been unexplored to date. The content of AA seems to have prognostic potential and need further exploration. The present study aims to analyse the prognostic importance of the contents of AA chapter with the help of contemporary prognostic literature.

  Methodology Top

Ayurvedic literature related to SSS, Charaka Indriya Sthana and Bhela Indriya Sthana along with their commentaries has been referred. Relevant key words such as “Indriya Sthana,” “Charaka Indriya Sthana,” “Bhela Indriya Sthana,” “Arishta Lakshanas,” “Prameha Upadrava,” “End-of-life stages,” “multiple chronic conditions,” “signs and symptoms of terminal illnesses,” “complications of diabetes,” “complications of neurological conditions,” “lethal skin diseases,” “complex fistulae,” “complications of hemarrhoids,” “acute urinary retention,” “obstructed labor,” “refractory ascites,” “febrile delirium,” “infective endocarditis,” “brain stem dysfunction,” “sepsis-associated encephalopathy,” “septic shock,” “paraneoplastic syndrome,” “delirium,” “infective gastroenteritis,” “hypovolemic shock,” “extrapulmonary tuberculosis,” “genitourinary tuberculosis,” “intra-abdominal abscesses,” “anemia of chronic disease,” “lung metastases,” “upper gastrointestinal bleeding,” “bipolar disorder,” “status epilepticus,” “typical absence seizures,” etc., have been used for searching databases such as PubMed, Scopus, and Google scholar both for Ayurvedic and prognostic literature. Open access articles and abstracts published in the English language were only considered. Articles published till September 2021, were only considered irrespective of their date of appearance and publication year. No filters were applied during search.

  Discussion Top

AA chapter of SSS consists of 26 verses. These verses deal with the description of various diseases having poor prognosis.[5] Each verse of AA chapter has been explored with the help of modern prognostic literature in the following sections [Table 1].
Table 1: Verses of “Avaaraneeya Adhyaya” and their clinical interpretation

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“Athaato avaaraneeyam--bhagavaan dhanwantari” (Verse 1 and 2)[5]

As per verses 1 and 2, “now (Athaato) we shall discourse on the chapter entitled Avaaraneeya,Adhyaya, which treats of incurable diseases (Avaaranaa Vyaadhayah).” The word Vaarana denotes treatment or treatable conditions, whereas Avaarana denotes untreatable conditions; hence, the current chapter is entitled as AA as it contains the description of various untreatable conditions.[5] Toward the end of life (EOL), most people acquire a serious progressive illness that interferes with their activities of dailiy livings until death. Three distinct illness trajectories have been identified in people suffering with progressive chronic illnesses: A trajectory with steady progression and having a clear terminal phase (e.g., cancer); a trajectory with gradual decline, interrupted by episodes of acute deterioration and some recovery, with more sudden, seemingly unexpected death (e.g., respiratory and heart failure); and a trajectory with prolonged gradual decline (people with dementia or typical of frail elderly people).[27] EOL care is defined as care that helps people having an advanced, incurable, progressive, and serious illness (Avaaranaa Vyaadhayah) to live as well as possible until they die. Hospice care is a type of palliative care program for people in the final months of life and is considered when the person's condition deteriorates and active treatment does not control disease (Avaaraneeyam). Since progressive deterioration and death is anticipated, the emphasis of care moves from active treatment of disease to treatment to control symptoms and give comfort (Avaaraneeyam).[28] Various progressive, deteriorating, chronic, and incurable conditions (Avaaranaa Vyaadhayah) seen especially at EOL stages are compiled in the present chapter (AA). The conditions explained in the chapter AA does not require active treatment (as they are incurable) (Avaaraneeya) and need hospice care.

“Upadravaistu ye jushtaa--duschikitsya mahagadaah” (Verse 3 and 4)[5]

The diseases (Vyaadhayo) that are associated with (Jushtaa) many complications (Upadravaistu), being treated without (Vinaa) rejuvenating and restorative medicines (Rasaayana), speedily assume (Yaanti) incurable character (Avaaryataam). The following eight conditions, Vata Vyadhi (neurological conditions), Prameha (syndrome that includes various clincial conditions such as urinary tract infections, diabetes, pre-diabetes, metabolic syndrome etc.), Kushta (dermatological conditions), Arsha (piles), Bhagandara (fistula in ano), Ashmari (renal calculi), Mudha Garbha (obstructed fetus/false presentations) and Udara (abdominal dropsy) are called Maha Gada or Ashta Maha Gadas and they are extremely hard to cure (Duschikitsya).[5] Ashta Maha Gadas can be considered as eight chronic disease clusters or multiple chronic conditions (MCCs) associated with negative outcomes. Negative outcomes (Yaanti Avaaryataam) can be defined in three ways, complications, failure to cure, and sequelae. Complications (Upadravaistu) are defined as any deviation from the normal postoperative course. Sequelae are an “after-effect' of surgery that is inherent to the procedure. If the original purpose of surgery has not been achieved, this is not a complication but a “failure to cure” (Yaanti Avaaryataam).[29] Without (Vinaa) using Rasaayana therapies it is not possible to treat Ashta Maha Gadas. Rasaayana is a specialized branch of Ayurveda, which comprises use of herbs, herbo-mineral formulations, diet, lifestyle and virtuous conduct to achieve the optimum health and homeostasis. Rasaayana drugs have various pharmacological actions such as anti-aging, cognitive enhancing, antioxidant, adaptogenic, nootropic, and immunomodulatory effects.[25] Ashta Maha Gadas are MCCs or eight chronic disease clusters frequently associated with complications and negative outcomes and they are untreatable without Rasaayana drugs.

“Praana maamsa kshayah--sarvaaneva vivarjayet” (Verse 5 and 6)[5]

A physician with any regard to professional success should avoid (Vivarjayet) to treat a patient laid up with any of the preceding diseases (Ashta Maha Gadas), marked by complications (Upadravai Jushtaan) such as, Praana Kshaya (vital power decline/fatigue), Maamsa Kshaya (cachexia/sarcopenia), Sosha (emaciation/tuberculosis), Trishna (excessive thirst/dehydration/electrolyte imbalance), Chardi (vomiting), Jwara (fever/sepsis), Atisaara (diarrhoea), Murcha (delirium/stupor/coma), Hikka (hiccough), and Shwaasa (dyspneoa).[5] Breathing disorder (Shwaasa), consciousness decline (Murcha), vital power decline (Praana Kshaya), reduced oral intake, feces disorder (Atisaara), blood pressure decline, change in skin color, patient odor, edema, body temperature decline, bedsore or wound deterioration, body weight reduction (Sosha), cyanosis, and oliguria are the most frequently seen conditions during EOL stages or just before death.[30] Findings from previous studies have demonstrated dying trajectories that incorporate physical, social, spiritual and psychological decline towards death.[31] The cluster of potential signs and symptoms (Etai Upadravai Jushtaan) to be anticipated in the last days are pain, dyspnea (Shwaasa), delirium, dysphagia, weakening of voice, loss of appetite, nausea and vomiting (Chardi), incontinence, weakness and fatigue (Praana Maamsa Kshaya) loss of consciousness (Murcha), dry mouth (Trishna?), and noisy upper airway secretions.[32] The term Vivarjayet in verse 5and6 refers to transitions in care during the EOL stages towards hospice care or palliative care rather than indulging in active treatment. The signs and symptoms mentioned in verse 5and6 (Praana Maamsa Kshaya etc.) refer to physical signs and symptoms of terminal illnesses.

“Shoonam supta tvacham—vatavyadhirvinaashayet” (Verse 7)[5]

Symptoms such as Shoonam (edematous swelling), Supta Tvacham (complete anesthesia of the affected part), Bhagnam (fractures), Kampa (tremors or abnormal involuntary movements), Aadhmaana (distention of the abdomen), and Rujaarta (aching and colic pain) in a Vata Vyadhi patient denotes an imminent death (Vinaashayet).[5] The word Shoonam in Vata Vyadhi context may represent cerebral edema due to various underlying causes. Cerebral edema can be categorized into either vasogenic, osmotic, cellular, and interstitial causes. Cerebral edema stems from tumor, hypoxia, trauma, infection, metabolic derangements and acute hypertension.[33] With focal or diffuse cerebral edema (Shoonam) the patient can develop increased intracranial pressure which typically presents with altered mental status to coma and death (Vinaashayet).[33] Supta Tvacham denotes numbness commonly seen in neuropathic conditions. Polyneuropathies (PNPs) or peripheral neuropathies are the most common type of disorder of the peripheral nervous system in the elderly and they can have a multitude of etiologies (inflammatory, endocrinological, toxic, nutritive and tumor related) and concomitant disorders (Vata Vyadhi?). Diabetic neuropathy (DN), alcohol-induced neuropathy, toxic neuropathies, Vitamin deficiency-induced neuropathy, and immune-mediated neuropathy (Guillain − Barré syndrome, chronic inflammatory polyradiculoneuropathy, paraproteinemic neuropathies, paranodopathies, multifocal motor neuropathy, and vasculitic neuropathies) comes under the category of PNPs.[34] Peripheral neuropathy is often distressing and sometimes disabling or even fatal (Vinaashayet).[35] It has been proved that various neurological disease categories (Vata Vyadhi) such as autoimmune, dementia related, developmental, movement, neuromuscular, trauma, stroke, and psychological can impart changes in bone homeostasis and mass and increase fracture risk (Bhagnam).[36]

The word Kampa indicates tremors. Tremor (Kampa) is a hyperkinetic movement disorder characterized by rhythmic oscillations of one or more body parts and it can be disabling. Various etiological subtypes of tremor (Vata Vyadhi?) are recognized, essential tremor, Parkinsonian tremor, head and voice tremor, dystonic tremor, orthostatic tremor, tremor due to multiple sclerosis or lesions in the brainstem or thalamus, neuropathic tremor, and functional or psychogenic tremor. The most severe organic tremors (Kampa) usually show a poor response to medical treatment (Vinaashayet).[37] The word Aadhmaana in verse 6 denotes an abdominal bloating associated with neurological conditions. As many neurotransmitters, signalling pathways and anatomical properties are common to the enteric nervous system (ENS) and central nervous system (CNS), pathophysiological processes that underlie CNS disease (Vata Vyadhi?) often have enteric manifestations (Aadhmaana?). The pathophysiology that gives rise to CNS disorders (Vata Vyadhi?) therefore might also be operative in the ENS (Aadhmaana?). Transmissible spongiform encephalopathies, autistic spectrum disorders), Parkinson disease, Alzheimer disease, amyotrophic lateral sclerosis, and varicella zoster virus (VZV) infection are the examples of disorders with both gastrointestinal (GI) (Aadhmaana?) and neurological consequences (Vata Vyadhi?). Many GI disorders, such as irritable bowel syndrome, chronic intestinal pseudo-obstruction and gastroparesis are idiopathic.[38] Common conditions associated with neuropathic pain (Rujaarta) include postherpetic neuralgia, trigeminal neuralgia, painful radiculopathy, DN, human immunodeficiency virus (HIV) infection, leprosy, amputation, peripheral nerve injury pain, cancer, spinal cord injury, stroke or cerebrovascular diseases, neurodegenerative diseases, syringomyelia, demyelinating diseases (MS, transverse myelitis, and neuromyelitis optica), prediabetes and other metabolic dysfunctions, infectious diseases, immune and inflammatory disorders, inherited neuropathies and channelopathies.[39] The complications of various neurological conditions indicating poor prognosis have been mentioned in verse 7.

“Yathoktopadravaavishta--prameho hanti maanavam” (Verse 8)[5]

A case of Prameha (diabetes or metabolic syndrome) associated with polyuria (Ati Prasruta), carbuncles (Prameha Pidika) and other complications (Upadravaavishta) as mentioned in the classical Ayurvedic texts denotes an imminent death (Hanti Maanavam).[5] Trishna (excessive thirst), Atisaara (diarrhoea), Jwara (fever), Daha (burning sensation), Daurbalya (debility), Arochaka (anorexia), Avipaaka (indigestion), Angamarda (body aches), Kasa (cough), Bhrama (giddiness), Tamah/Moorcha (loss of consciousness), Shoola (colic), Makshikopasarpana (surrounded by houseflies), Alasya (lassitude), Pratishyaya (common cold), Saithilya (flaccidity), Kapha Praseka (excessive salivation), Chardi (vomiting), Nidra (hypersomnia), Shwasa (dyspnoea), Vrushana Avadaarana (scrotal dermatitis/tinea cruris), Medhra Toda/Vasti Bheda (pelvic pain), Hrut Shoola (cardiac pain), Nidra Naasha/Anidra (insomnia), Pandu Roga (anaemia), Loulya (greediness/hyperphagia), Stambha (rigidity/spasticity), Kampa (tremors), Baddha Purishata (fecal obstruction), Udavarta (a diseas caused by upward movement of Vata Dosha), Sosha (cachexia/tuberculosis), Kandu (pruritis), Ati Prasruta (polyuria), and Puti Maamsa Pidika (carbuncles with sloughing) are considered as Prameha Upadravas (complications).[40] Diabetes (Prameha) can affect many different organ systems and it can lead to serious complications (Hanti Maanavam). Microvascular complications include neuropathy (characterized by Daha, Angamarda, Shoola, Alasya, Saithilya, Daurbalya, and Kampa), nephropathy (Ati Prasruta), and retinopathy. Macrovascular complications include cardiovascular disease (CVD) such as heart attack (Hrut Shoola?), chest pain (Hrut Shoola?), coronary heart disease, congestive heart failure and stroke (Stambha-rigidity/spasticity and Saithilya-flaccidity), and peripheral vascular disease. Other complications include dental disease, reduced resistance to infections such as pneumonia and influenza (Kasa, Arochaka, Jwara, Pratishyaya, Shwasa and Kapha Praseka).[41]

GI involvement in diabetic patiencts can present with esophageal dysmotility (Udavarta/Kapha Praseka/Chardi?), gastro-esophageal reflux disease (Udavarta?), gastroparesis (Baddha Purishata?), enteropathy (Atisaara/Baddha Purishata?), nonalcoholic fatty liver disease (Avipaaka?) and glycogenic hepatopathy. Autonomic neuropathy of the esophageal musculature in diabetic patients results in abnormal peristalsis (Udavarta?), spontaneous contractions and reduced lower esophageal sphincter tone. Symptoms of gastroparesis include nausea (Kapha Praseka), vomiting (Chardi), early satiety (Avipaaka?), postprandial fullness (Avipaaka?), bloating (Udavarta?) and upper abdominal pain (Hrut Shoola?).[42] The greater frequency of infections in diabetic patients (Prameha) is caused by the hyperglycemic environment that favors immune dysfunction, micro and macro-angiopathies, neuropathy, decrease in the antibacterial activity of urine, GI and urinary dysmotility. Respiratory infections (Streptococcus pneumonia, influenza, H1N1 and tuberculosis) (Jwara, Arochaka, Kasa, Pratishyaya, Kapha Praseka, Shwasa, Sosha etc.), urinary tract infections (UTIs) (cystitis, pyelonephritis and perinephric abscess) (Ati Prasruta, Jwara, Shoola, Medhra Toda, Vasti Bheda etc.), GI and liver infections (Helicobacter pylori infection, oral and esophageal candidiasis, hepatitis B and C and enteroviruses) (Arochaka, Avipaaka, Chardi, Atisaara, Baddha Purishata, etc.), skin and soft-tissue infections (foot infection, necrotizing fasciitis, and Fournier's gangrene) (Puti Maamsa Pidika, Makshikopasarpana, Murcha etc.), head and neck infections (otitis), fungal infections (Candida and mucormycosis) (Vrushana Avadaarana and Kandu) and others (HIV) are common in diabetic patients. Infectious diseases in diabetes mellitus (DM) may result in metabolic complications such as hypoglycaemia (Bhrama, Murcha etc.), diabetic ketoacidosis (Shwasa-Kussumaul breathing/hyperventilation/metabolic acidosis), and coma (Murcha).[43] Carbuncle or infective gangrene (Puti Maamsa Pidika) of skin and subcutaneous tissue, commonly seen in uncontrolled diabetes (Prameha) and other immunocompromised states, the infection may spread in the subcutaneous plane and forms multiple pus points or sinuses (Puti Maamsa Pidika).[44] Diabetic patients have shown higher rates of insomnia (Nidra Nasha/Anidra), poor sleep quality and excessive daytime sleepiness (Nidra). Sleep disturbances (Nidra and Anidra) in diabetic patients may be due to the nature of the disease or due to peripheral neuropathy and polyuria.[45] Ati Prasruta may also represent end-stage renal disease or chronic kidney disease. Verse 8 is the compilation of various fatal (Hanti Maanavam) complications (Upadravaavishta) of diabetes (Prameha) [Table 2].
Table 2: Prameha Upadravas with their relevant clinical conditions

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“Prabhinna prasrutaangam cha--kushtam hanteeha kushtinam” (Verse 9)[5]

A case of Kushta (leprosy or skin diseases) characterized by spontaneous bursting (Prabhinna) of the affected parts (Anga), hoarse voice (Hata Swara), and blood-shot eyes (Rakta Netram), and not responding to Panchakarma (five major purificatory procedures), usually ends in death (Hanteeha).[5] Prabhinna Prasrutaanga represents necrosis or gangrene or ulceration of skin and subcutaneous tissues, whereas Hata Swara and Rakta Netra denote laryngitis/vocal cord paralysis and ophthalmological signs (conjunctivitis or iridocyclitis) respectively. Hansen's disease (HD) known as Leprosy, is a chronic, disabling, and deforming infection. The Ridley–Jopling classification divides the leprosy spectrum into five groups: Tuberculoid (TT), borderline tuberculoid, borderline–borderline, borderline lepromatous, and lepromatous. Iridocyclitis can be seen in patients with HD. Ophthalmological signs can be seen in various fatal skin infections such as cellulitis, Lyme disease, staphylococcal scalded skin syndrome (SSSS), VZV and Herpes zoster (zoster ophthalmicus and acute rentinal necrosis). Laryngitis (in rhinoscleroma) and pharyngitis (in VZV and toxic shock syndrome-TSS) can also be seen in various lethal skin infections. Necrosis can be seen in skin infections such as HD, necrotizing faciitis, cellulitis, ecthyma gangrenosum, necrotizing vasculitis, pyoderma gangrenosum, polyarteritis nodosa, toxic epidermal necrolysis, TSS, systemic lupus erythematosus (SLE), SSSS, streptococcal TSS, necrotizing soft tissue infections, HIV, atypical mycobacteriosis, mycobacteria other than tuberculosis or nontuberculous mycobacteria, systemic mycoses and viral infections (VZV and Herpes zoster). Vocal cord paralysis, disseminated intravascular coagulation, gangrene and even death can occur in TSS.[46] Lucio's phenomenon (LP) or Lucio reaction is a severe form of lepra reaction type 2. It affects patients with diffuse lepromatous leprosy with erythematous spots of limbs leading to bulla, epidermal necrosis, necrotizing vasculitis and ulceration. Lethality is not uncommon in LP.[47] Verse 9 represents lethal skin disease with systemic manifestations.

“Trishnaarochaka shoolaartam-arsho vyadhirvinaashayet” (Verse 10)[5]

Hemorrhoids (Arshas) associated with (Samyukta) complications such as excessive thirst (Trishna), pain/colic (Shoola), excessive hemorrhage (Ati Prasruta Shonitam), local oedema (Shopha), and diarrhoea (Atisaara) leads to death (Vinaashayet).[5] Severe pain (Shoola) may occur with complications of hemorrhoids (e.g., prolapse with incarceration and ischemia or thrombosis).[48] Bleeding (Ati Prasruta Shonitam) often indicates first degree hemorrhoids but rectal bleeding (Ati Prasruta Shonitam) must arouse suspicion of more serious pathology such as carcinoma of the cecum (Vinaashayet?). Pain (Shoola) is due to complications of haemorrhoids such as thrombosis or strangulation. Diarrhea (Atisaara) may be the cause of hemorrhoids but do not occur as a result.[49] Grade III and grade IV hemorrhoids can be complicated by thrombosis, ulceration, infection, and necrosis. Most common presentation of strangulated prolapsed hemorrhoids is pain (Shoola), ulceration, and infection. Trapped hemorrhoidal mass by the sphincter outside the anus leads to obstruction to venous return (Shopha), edema (Shopha), and strangulation. Complicated (strangulated) hemorrhoids (Arshas) cause significant morbidity to the patients (Vinaashayet).[50] Trishna or excessive thrist may arise due to hypovolemia caused by excessive bleeding from complicated haemorrhoids. Verse 10 describes the complications of hemorrhoids.

“Vatamurtrapurishaani--yasya tam parivarjayet” (Verse 11)[5]

A patient suffering with fistula-in-ano (Bhagandara), characterized by an emission (Prasravanti) of flatus (Vata), urine (Mutra), fecal matter (Purisha), worms (Krimi), and semen (Shukram) through the ulcerated locality, should be given up as lost (Parivarjayet).[5] Rectourethral fistulas (RUF) are uncommon pathologic communications between the rectum and lower urinary tract. Several etiologies of acquired RUFs are, prostate and rectal cancer, diverticular disease, trauma, Crohn's disease, and abscess rupture. Rectal passage of sperm (Prasravanti Shukram) involves fistulous rectal connections with the ejaculatory duct or seminal vesicles due to malignancy or inflammatory bowel disease (Parivarjayet?). Management of these fistulous connections is complex (Parivarjayet).[51] Stercoracious discharges (Prasravanti Purisham) from an external opening of fistulous track (Bhagandaraat) can be seen in extrasphincteric fistulas in HIV patients.[52] Myiasis (infestation by maggots) (Krimi) of a rectocutaneous fistula (Bhagandaraat) has been documented in a subject suffering from bone metastases (Parivarjayet?).[53] Anal myiasis (Krimi) is rare and can be seen in preexisting carcinomatous ulcers, condyloma accuminata, fistula-in-ano (Bhagandara) and gangrenous haemorrhoids (Parivarjayet?).[54] High trans-sphincteric, suprasphincteric fistula, and extrasphincteric fistulas (Bhagandara) are more complex than simple intersphincteric fistulas and are more difficult to treat (Parivarjayet). Curved tracts such as horse-shoe and semi-horse shoe fistulas are often more difficult to excise (Parivarjayet). Fistulas with secondary extensions (supralevator, infralevator, or ischeoanal) (Bhagandara) may persist or recur (Parivarjayet). The medical comorbidities of the patient such as DM, immunocompromised conditions and Crohn's disease may lead to recurrence (Parivarjayet).[55] Conditions explained in verse 11 denote various complex fistulas such as enterorectal, vesicorectal, prostate-rectal, colorectal-vaginal, and colonic and anorectal fistulous tracks that are having poor prognosis.

“Prashuna nabhi vrushanam-sikata sharakaraanvitam” (Verse 12)[5]

A patient of urolithiasis (Ashmari) suffering from crystals (Sharkara) and gravel (Sikata) in the urine and having edema (Prashuna) of the scrotum (Vrushanam) and the umbilicus (Nabhi), retention of urine (Ruddha Mutram), and colic pain (Rugaanvitam) will not survive (Kshapayatyaashu).[5] Migrant urethral calculi (Ashmari/Sikata/Sharkara) that is formed in the kidney/bladder, moves to and blocks the urethra. Migrant calculi can cause pain (Rugaanvitam), feeling of pelvic pressure, acute urinary retention (unable to void urine with bladder distension) (Ruddha Mutram) and irritative symptoms. Acute urinary retention is the situation of unable to void urine (Ruddha Mutram), thus distention of bladder (Prashuna Nabhi?) causing pain (Rugaanvitam).[56] Stones (Ashmari) blocking the urine flow (Ruddha Mutram) may lead to hydronephrosis (Prashuna?), renal atrophy, and life-threatening complications (Kshapayatyaashu) such as urinary infection, perinephric abcess or urosepsis. Drainage of an infected obstructed kidney is a medical emergency, and may result in death (Kshapayatyaashu) if left untreated. The onset of pain (Rugaanvitam) is usually sudden, typically felt in the loin, and radiating to the groin and genitalia (scrotum or labia) (Prashuna Vrushanam?).[57] Sensory fibers from both the upper ureter and the testis (Vrushanam) travel through spinal cord segments T11 and T12. Hence, distension (Prashuna?) of upper ureter (e. g., due to a ureteral stone) (Ashmari) may cause referred pain (Rugaanvitam) to the testis (Vrushanam) and lower ureteral distension (Prashuna?) may result in ipsilateral scrotal pain.[58] Verse 12 represents acute urinary retention due to obstruction by calculi and its fatal consequences.

“Garbhakoshaparaa sango-yathoktaaschaapyupadravah” (Verse 13)[5]

A case of false presentation (Mudhagarbha) having an extreme constriction of the mouth of the uterus (Garbhakosha Sanga), development of the peculiar pain of childbirth, which is known as Makkalla, tonic rigidity of the vagina (Yoni Samvrutih), and situation of the placenta (Aparaa Sanga) at a wrong place along with other symptoms (convulsions, cough, dyspnea, vertigo etc.) (Yathokta Upadrava) denotes an imminent death (Hanyaat) of that parturient woman (Striyam).[5] Mudha Garbha refers to an obstructed labor. Garbha Kosha-Paraa Sanga indicates etiher over clinging of fetus in the uterus or attachment of fetus in other than its normal place. The word Paraa Sanga also represents rupture of uterus that can be seen in case of obstructed labour and is considered as one of the serious complication even modern era. Garbha Kosha-Paraa Sanga can be considered as considered as rupture uterus that can occur at any time of delivery or uterus with congenital anomalies such as didelyphs uterus, septate uterus and fibroid uterus etc. Makkalla is characterized by spasmodic pain of uterus, and in the context of obstructed labour it denotes either intrapartum hemorrhage associated with severe pain or tetanic or spasmodic contractions. Yoni Samvrutih denotes cervical dystocia or contracted pelvis. Mudhagarbha is big reason of maternal and infant mortality (Hanyaat Striyam) in modern scenario also.[59] Aparaa Sanga word has been used in some of the Ayurvedic texts instead of Paraa Sanga.[5] Aparaa Sanga represents placental abnormalities or placenta previa or low-lying placenta etc. which can cause obstructed labor. Verse 13 denotes malpresentation of the fetus causing obstructed labor associated with complications (Yathokta Upadrava) and maternal mortality (Hanyaat Striyam).

“Paarshwa bhangaanna vidvesha-varjayet udaraarditam” (Verse 14)[5]

A patient suffering from Udara (ascites), complaining of flank pain (Paarshwa Bhanga), aversion to food (Anna Vidvesha), edema (Shopha), diarrhea (Atisaara) and recurrence of water accumulation (Puryamaanam) in abdominal cavity (Udaram) even after undergoing purgative therapy (Viriktam), such a patient should be considered as incurable (Varjayet).[5] Viriktam Puryamaanam Cha Udaram indicates refractory ascites. Refractory ascites is defined as ascites that does not recede or that recurs shortly (Puryamaanam) after therapeutic paracentesis, despite sodium restriction and diuretic treatment (similar to Viriktam). To date, there is no approved medical therapy (Varjayet) specifically for refractory ascites (Udaraarditam). Refractory ascites is associated with complications such as dilutional hyponatremia, hepatorenal syndrome, spontaneous bacterial empyema, hepatic hydrothorax, spontaneous bacterial peritonitis, and umbilical hernia. The increased intra-abdominal pressure forces fluid into the pleural space through the diaphragm leads to the accumulation of fluid into the pleural space. As a result, severe dyspnea, dry cough, pleuritic chest pain (Paarshwa Bhanga), cardiac tamponade, and empyema may develop.[60] Reduced appetite (Anna Vidvesha?), early satiety (Anna Vidvesha?), malabsorption, diarrhoea (Atisaara) and abnormalities in gut motility can be seen in cirrhotic patients. Tense ascites (Udara) appears to have a negative impact on meal-induced accommodation of the stomach (cause Anna Vidvesha?).[61] At end-stage (Varjayet?) cirrhosis, ascites (Udara) causes symptoms including abdominal distention (Puryamaanam), nausea and vomiting, early satiety (Anna Vidvesha?), dyspnea, lower-extremity edema (Shopha), and reduced mobility.[62] Verse 14 denotes refractory ascites associated with cirrhosis of liver and its complications.

“Yastaamyati Visangnashcha-Jwarena Mriyate Narah” (Verse 15)[5]

A fever (Jwara) paitent suffering from loss of consciousness (Taamyati), not reacting to external stimuli (Visangna), or not feeling comfortable in sitting or lying or in any other position (Shete Nipatito Va) and afflicted with chills (Sheetaardito) though complaining of a burning sensation within (Antarushna), such a patient will not survivie (Mriyate).[5] Delirium is considered as a serious problem in acute care settings (Mriyate) and it is classified as hypoactive, hyperactive and mixed subtypes. Hyperactive delirium (Shete Nipatito Va) is characterized by restlessness, agitation, hyper vigilance, hallucinations and delusions. Patients with hypoactive delirium present with lethargy and sedation, respond slowly to questioning, and psychomotor retardation (Visangna). Delirium is characterized by an altered level of consciousness (Taamyati) and global disturbance of cognition or perceptual abnormalities (Visangna).[19] Fever (Jwara) is the common manifestation of various bacterial and viral infections. The presenting clinical signs of cerebral malaria are severe headache, irritability, delirium (Taamyati and Visangna), coma (Taamyati and Visangna), hyperpyrexia (Jwara and Antarushna), convulsion and meningism. Delirium (Taamyati and Visangna), convulsion, meningeal irritation, psychosis and ataxia may be noted in typhoid fever. Chills (Sheetaardito) with fever (Antarushna) can be found in sinusitis, staphylococcal pneumonia, liver abscess, malaria and leptospirosis. Agitation/distress (Shete Nipatito Va) can be seen in hypoxia associated with fever (Jwara and Antarushna).[63] Shaking chills or shivering is defined as a perception of cold (Sheetaardito) and involuntary muscle tremors that persist for several minutes. Febrile delirium refers to an acute and transient confusional state (Taamyati and Visangna) with high fever (Jwara and Antarushna).[64] Sepsis is a clinical syndrome that is characterized by a dysregulated inflammatory response to severe infection. Hypothermia (Sheetaardito) relative to baseline body temperatures (Antarushna) may also signal life-threatening infection (Mriyate), particularly in sepsis.[65] Verse 15 denotes febrile delirium.

“Yo Hrushta Roma Raktaaksho--Jwaro hanti Maanavam” (Verse 16)[5]

A fever (Jwara) patient developing symptoms such as, piloerection/horripilation (Hrushta Roma), hard swelling with severe pain in the cardiac region (Hridi Sanghaata Shoolavaan), blood-shot or congested eyes (Raktaaksho), and mouth breathing (Vaktrena Uchwasantam) indicates an imminent death to that patient (Hanti Maanavam). Features such as subconjunctival haemorrhage or keratoconjunctivitis (Raktaaksho), myocarditions and/or pericarditis (Hridi Sanghaata Shoolavaan), dyspnea (causing Vaktrena Uchwasantam?) and fever (Jwara) with chills (causing Hrushta Roma) can be seen in various viral and/or bacterial upper and/or lower respiratory tract infections (URTIs and LRTIs) or acute febrile systemic infections.[66] Fever (Jwara), chills (Hrushta Roma?), malaise, and fatigue are the common symptoms of infective endocarditis (IE) Patients. Symptoms related to cardiopulmonary system such as chest pain (Hridi Sanghaata Shoolavvan), dyspnea (causing Vaktrena Uchwasantam?), decreased exercise tolerance, orthopnea, and paroxysmal nocturnal dyspnea (causing Vaktrena Uchwasantam?) in IE patients should raise concern for underlying aortic or mitral valve insufficiency. Patients with chest pain (Hridi Sanghaata Shoolavvan) or dyspnea (causing Vaktrena Uchwasantam?) warrant early consideration of other potentially life-threatening (Hanti Maanavam) cardiopulmonary processes such as acute coronary syndrome (ACS), pulmonary embolism (PE), and pneumonia. Conditions such as ACS, acute heart failure, aortic dissection, myopericarditis, PE, pneumonia, and empyema mimic the clinical picture of IE.[67] Fever (Jwara) sometimes accompanies acute myocardial infarction. The infectious cardiological disease classically associated with fever (Jwara) is endocarditis. Most cases of pericarditis (causes Hridi Sanghaata Shoolavaan?) are idiopathic or of viral origin. The patients of endocarditis may complain of shivering (Hrushta Roma).[68] Various ocular complications can be seen in the patient of IE such as Roth's spots, subconjunctival hemorrhages, chorioretinitis, orbital cellulitis and endophthalmitis (Raktaaksho). IE continues to be associated with high morbidity and mortality (Hanti Maanavam).[69] The condition documented in verse 16 may represent febrile systemic infections or LRTIs or URTIs or IE.

“Hikka Shwasa Pipaasaartam-Naram Kshapayati Jwarah” (Verse 17)[5]

A weak/emaciated (Ksheenam) fever (Jwara) patient complaining of hiccup (Hikka), dyspnea (Shwasa), thirst (Pipaasaartam), unconsciousness or fainting or acute confusional states (Moodham), abnormal eye movements (Vibhranta Lochanam) and breathing difficulty (Satatam Uchwasinam), will not survive (Kshapayati).[5] Sepsis associated encephalopathy (SAE) is characterized by a change in mental status, especially that of awareness/consciousness and cognition (Moodham). SAE can manifest early in the course of a sepsis (Jwara?) or manifests later as multiorgan dysfunction syndrome (MODS) (leads to Kshapayati?) in refractory septic shock. SAE is characterized by agitation, confusion (Moodham), disorientation (Moodham), irritability, hypersomnolence, stupor, and coma (Moodham) along with systemic inflammatory response syndrome (SIRS) (Jwara?) and sepsis. Severe sepsis (Jwara?) leads to MODS which can further contribute to the severity of encephalopathy often culminating in coma (Moodham). Dyselectrolytemia (may leads to Pipaasaartam) is one of the cause or features of metabolic encephalopathies. Hyperventilation (Shwasa/Satatam Uchwasinam) in SAE is often due to respiratory alkalosis in the early, delirious phase (Moodham) and in severe sepsis (Jwara).[70]

Verse 17 may also represent a condition of delirium associated with sepsis and/or septic shock. Sepsis was defined as a microbial infection that produces fever (Jwara), tachycardia and tachypnoea (Shwasa). Septic shock is characterized by hypotension and abnormalities of perfusion despite the provision of adequate fluid resuscitation (indicate Pipaasaarta?). Sepsis is characterized by six types of organ dysfunction such as, neurological (altered mental status) (Moodham), pulmonary (hypoxaemia) (Shwasa/Satatam Uchwasinam), cardiovascular (shock) (Moodham), renal (oliguria and increased creatinine concentration) (Pipaasaartam?), haematological and hepatic. Patients with sepsis typically present with altered mental status manifested by lethargy (Ksheenam?), confusion or delirium (Moodham). Respiratory failure (Shwasa/Satatam Uchwasinam) in sepsis is due to inflammatory damage to alveolar membranes. Patients with sepsis may have profound, life-threatening hypoxaemia (indicate Shwasa/Satatam Uchwasinam?).[71] Electrolyte imbalance (indicate Pipaasaarta?) is one of the miscellaneous causes of hiccups (Hikka). Severe and prolonged hiccup (Hikka) may lead to exhaustion, fatigue, malnutrition (Ksheenam), weight loss (Ksheenam), dehydration (Pipaasaarta) and even death (Kshapayati) in the extreme situations.[72] Dehydration (Pipaasaarta) is a contributing factor for delirium (Moodham).[73] The presence of vertical extraocular eye movements (Vibhranta Lochanam) may suggest locked-in syndrome (Moodham). The presence of repetitive movement of the eyes (Vibhranta Lochanam) may be suggestive of seizure (febrile seizures?).[74] Spontaneous eye movements (Vibhranta Lochanam) appear to be affected in delirious patients (Moodham).[75] Hence, the clinical features mentioned in verse 17 may represent febrile delirium with sepsis or septic shock.

Verse 17 may also denote another condition, brainstem dysfunction in critically ill patients. Brainstem dysfunction is caused by various acute or chronic insults (stroke, infections, tumors, inflammation and neurodegeneration), and it can contribute to impairment of consciousness (Moodham), cardiocirculatory and respiratory failure (Shwasa/Satatam Uchwasinam), and thus increased mortality (Kshapayati). Refractory hiccups (Hikka) may be seen with lesions of the posterolateral medulla oblongata and persistent hiccups (Hikka) can be found in the patients of lateral medullary syndrome. Neurological respiratory dysfunction (Shwasa/Satatam Uchwasinam) may occur due to brainstem injury. Injuries to the upper pons increase the tidal volume and decrease the respiratory rate and injuries of the lower pons are associated with respiratory asynchrony (Shwasa/Satatam Uchwasinam). Ataxic breathing (irregular pauses and apnea periods) and central apnea (Shwasa/Satatam Uchwasinam) are observed in rostro-ventral medulla oblongata injuries and associated with poor outcomes (Kshapayati). Electrolyte disturbances (indicate Pipaasaarta?) may impair brainstem responses. Hyperthermia (Jwara?) is the manifestation of central thermic regulation dysfunction due to the involvement of centres at midbrain and pons. Various oculomotor anomalies (due to the involvement of cranial nerve nuclei III, IV and VI) (Vibhranta Lochanam) can be seen in brainstem dysfunction. Abnormal spontaneous eye position and movements (Vibhranta Lochanam) can be found in patients with brainstem lesions and also in comatose patients (Moodham). Brainstem dysfunction could account for some features of delirium, such as fluctuations in arousal and attentional impairment (Moodham). Sepsis (Jwara?) may compromise the brainstem perfusion.[76] By considering all these facts, it can be assumed that the clinical features described in verse 17 represents various conditions such as brainstem dysfunction in critically ill patients or SAE or febrile delirium associated with sepsis or septic shock.

“Aavilaaksham Prataamyantam-Naram Naashayati Jwarah” (Verse 18)[5]

A case of fever (Jwara) becomes fatal (Naashayati) in a patient, found to be having dull, clouded, or tearful eyes (Aavilaaksham), impairment of consciousness (Prataamyantam), hypersomnolence (Ateeva Nidraayuktam), and extremely emaciated and anaemic (Ksheena Shonita Maamsam).[5] Paraneoplastic syndrome (PNS) involves a multi-organ system in the body with complex and heterogeneous clinical manifestations in the setting of underlying malignancy (leads to Naashayati?). Cognitive dysfunction, personality changes, and psychosis can be seen in PNS patients. Paraneoplastic encephalitis/encephalomyelitis is characterized by diverse and complex symptoms arising from cerebellar encephalitis, limbic encephalitis, brainstem encephalitis, and myelitis. It is characterized by cognitive dysfunction, depression, personality changes, hallucinations, seizures, somnolence (Ateeva Nidraayuktam), autonomic dysfunction etc. Hematologic manifestations of the PNS can be manifested as pallor (Ksheena Shonita), fatigue, dyspnea etc. Fever (Jwara), cachexia (Ksheena Maamsa), anorexia, dysgeusia etc., can also be found in PNS.[77] Paraneoplastic optic neuropathy (Aavilaaksham) is characterized by ocular symptoms, optic neuritis, retinitis, inflammatory vitritis and progressive loss of vision and found in cases of lung carcinoma and thymoma. Many CNS disorders such as demyelinating (MS, monosymptomatic optic neuritis), infectious (viral, bacterial, sphirochetal, mycobacterial, protozoal and nematodal), inflammatory-autoimmune (polyarteritis nodosa, Wegener granulomatosis, RA with Sjogren's syndrome, SLE and sarcoidosis, Behcet's disease) and neoplastic (lymphoma and PNSs) affect the posterior segment of the eye (cause Aavilaaksham?).[78] Paraneoplastic encephalomyelitis should be considered as a cause of acute confusion/delirium (Prataamyati) in older patients where there is no obvious precipitant.[79] Cancer anorexia-cachexia syndrome (Ksheena Shonita Maamsam) is the most frequent PNS occurring in oncologic patients and is considered as a poor prognosticator (Naashayati). Patients usually present with weight loss (Ksheena Maamsam?), lipolysis, muscle wasting (Ksheena Maamsam?), anorexia, chronic nausea, inflammation (Jwara?), and asthenia.[80] Patients with hypoactive delirium (Prataamyati?) present with lethargy and sedation (Ateeva Nidraayuktam), respond slowly to questioning, and show little spontaneous movement.[81] The hypoactive form is more common among older persons, and is associated with higher rates of complications and mortality (Naashayati).[82] Verse 18 represents PNS or delirium.

“Shwasa Shoola Pipaasaartam-Atisaaro Vinaashayet” (Verse 19)[5]

An emaciated or weak (Ksheenam) patient suffering with dyspnea (Shwasa), colic (Shoola), excessive thirst (Pipaasaartam), fever (Jwara), and diarrhea (Atisaara), will not survive (Vinaashayet).[5] Patients with diarrhea (Atisaara) may complain of abdominal pain or cramping (Shoola), vomit, bloating, flatulence, fever (Jwara), and bloody or mucoid stools. Dry mucous membranes, poor skin turgor, and delayed capillary refill are signs of dehydration (indicate Pipaasaartam?). The outcomes for patients who are well hydrated are excellent but patients at extremes of age may not tolerate (Vinaashayet?) any degree of dehydration (Pipaasaartam?).[83] Dehydration (Pipaasaartam?) leads to hypovolemic shock and death (Vinaashayet?). E. coli, Shigella,  Salmonella More Details enterica, Campylobacter and Aeromonas are the most common bacterial enteropathic pathogens. The most frequently identified causative viruses include rotavirus, caliciviruses, astrovirus and enteric adenovirus.[84] Hypovolemic shock occurs as a result of extracellular fluid loss (Pipaasaartam?) such as retractable vomiting and/or diarrhea (Atisaara). The most common clinical features suggestive of shock include hypotension, tachycardia, tachypnea (Shwasa?), abnormal mental status, mottled skin, oliguria (denote Pipaasaartam?), metabolic acidosis etc.[85] Verse 19 respresents conditions like infectious gastroenteritis and/or hypovolemic or septic shock.

“Shuklaaksham Annadveshta-Yakshmaa Hanteeha Maanavam” (Verse 20)[5]

A patient of tuberculosis (Yakshma) suffering with complications like whitish or pale eyes (Shuklaaksham), loss of appetite or anorexia (Anna Dvesha), dyspnea (Urdhwa Shwasa Nipiditam), execessive or frequent micturition (Bahu Mehantam), and difficulty in micturition (Krichrena Mehantam), such a patient will die soon (Hanteeha).[5] The word Shuklaaksha denotes either anemia (Rakta Kshaya) or ocular tuberculosis. Ocular tuberculosis is an extrapulmonary infection with variable manifestations. A nongranulomatous uveitis manifests as small white keratic precipitates (Shuklaaksham). Choroidal tubercles may appear as white (Shuklaaksham), gray, or yellow lesions. In tuberculous lid disease, the everted upper eyelid may show diffuse, cheesy white areas (Shuklaaksham) of necrosis involving the upper tarsal border.[86] The most common symptoms of active tuberculosis (Yakshma) are fever, anorexia or reduced appetite (Anna Dvesha), weight loss (Maamsa Kshaya?), night sweats, anemia (Rakta Kshaya), and persistent cough. In extensive and long-lasting pulmonary disease (leads to Hanteeha?), patients may report breathlessness (Urdhwa Shwasa Nipiditam). Breathlessness (Urdhwa Shwasa Nipiditam) is the predominant symptom, caused by pleural effusion in tuberculosis (Yakshma). Tuberculous peritonitis is characterized by acute symptoms of fever, anorexia (Anna Dvesha), and weight loss (Maamsa Kshaya?).[87] Genitourinary tuberculosis (GUTB) (Yakshma) comprises 20% of all extrapulmonary tuberculosis (EPTB). Following pulmonary tuberculosis, some individuals can develop GUTB after 5–25 years. An increased incidence of GUTB is found in people suffering from immunodeficiency like HIV/acquired immunodeficiency syndrome. Descending infection involves the ureter and bladder, leading to stricture and fibrosis with subsequent urinary tract obstruction (Krichrena Mehantam) and hydronephrosis. Acute urethritis in GUTB manifests as a mycobacterial discharge and often results in chronic stricture formation (Krichrena Mehantam). Patient with GUTB may present with recurrent or resistant UTIs, irritative urinary symptoms like frequency (Bahu Mehantam?), dysuria (Krichrena Mehantam), and urgency (Bahu Mehantam?) and nonspecific symptoms like fever, weight loss (Maamsa Kshaya?), and backache.[88] Verse 20 denotes EPTB or pulmonary tuberculosis or GUTB associated with complications.

“Shwasa Shoola Pipaasa-Gulmino Mrutyumeshyatah” (Verse 21)[5]

A patient suffering with benign or malignant abdominal tumors (Gulma), and on the verge of death (Mrutyumeshyatah), exhibits symptoms such as laboured and painful respiration (Shwasa), colic pain (Shoola), unquenchable thirst (Pipaasa), anorexia or loss of appetite (Anna Dvesha), loss of consciousness (Mudhata), anemia/weight loss/cachexia/sarcopenia (Durbalatvam), and the sudden obliteration of the tumorous or glandular formation (Granthi).[5] Granthi Mudhata also denotes the disappearance or absence of signs of Gulma. Gulma denotes benign or malignant abdominal tumors.[89] The lung is one of the most common sites of cancer metastasis and it is considered a significant cause of morbidity and mortality (leads to Mrutyumeshyatah?). Cancers that can metastasize to lung parenchyma include breast, lung, colorectal cancer, uterine leiomyosarcoma, head/neck squamous cell carcinomas, osteosarcoma, testicular, adrenal, thyroid, choriocarcinoma, and hypernephroma. Patients with lung metastasis either have a known primary tumor (Gulma?) or present the first time with the lung metastasis (Granthi Mudhata or Gulmasya Adarshanam). They can be asymptomatic also (Gulmasya Adarshanam). Systemic symptoms like fatigue (Durbalatvam), nausea, anorexia (Anna Dvesha) and weight loss (Durbalatvam) and localized symptoms like pleurisy or pleural effusion, dyspnea (Shwasa), electrolyte disturbances (cause Pipaasa?) etc. can be seen in lung metastases.[90] Abdominal metastases (Gulma?) of lung cancer are clinically silent (Granthi Mudhata or Gulmasya Adarshanam) most of the time. The majority of the patients with abdominal metastases (Gulma?) of lung cancer had a history of abdominal pain (Shoola), melaena, nausea and vomiting (cause Anna Vidvesha?) and weight loss (Durbalatvam).[91] Cancer cachexia (Durbalatvam) is a direct cause of complications in cancer patients (Mrutyumeshyatah) and it is related to conditions such as sarcopenia, anorexia (Anna Dvesha) and asthenia (Durbalatvam).[92] Verse 21 represents a condition of either lung metastases with primary intra-abdominal/intra-pelvic carcinoma or intra-abdominal metastases with primary carcinoma of lungs or benign intra-abdominal/intra-pelvic growths.

“Aadhmaatam Baddha niShyandam-Vidradhirnaashayennaram” (Verse 22)[5]

A patient of Vidradhi (abscess) exhibiting fatal symptoms such as as distension of the abdomen (Aadhmaatam), retention of pus (Baddha Nishyandam), vomiting (Chardi), hiccup (Hikka), thirst (Trishna), pain of a varied character (Ruja) and dyspnea (Shwasa), will die soon (Naashayet).[5] Intra-abdominal abscesses (Vidradhi) can be classified as visceral (hepatic or splenic) or nonvisceral (subphrenic or pelvic), intra-peritoneal or extra-peritoneal. Clinical presentation of abdominal abscesses (Vidradhi) is as heterogeneous and multifaceted ranging from asymptomatic to septic shock. Most abscesses that are partially treated or masked (Baddha Nishyandam?) may later leads to SIRS with MODS (Naashayet?).[93] Abdominal abscesses (Vidradhi), subphrenic abscesses (Vidradhi), bowel obstruction etc., can cause persistent hiccups (Hikka).[94] A bowel obstruction frequently causes abdominal pain (Ruja), nausea, vomiting (Chardi), constipation-to-obstipation (Baddha Nishyandam?), and distention (Aadhmaatam). Blockage (Baddha) of digested products during obstruction leads to emesis (Chardi). Frequent emesis (Chardi) can lead to fluid deficits (cause Trishna) and electrolyte abnormalities (cause Trishna). A serious and life-threatening complication (Naashayet) of bowel obstruction (Baddha) is strangulation. Tissue infarction due to strangulation progresses to bowel necrosis, perforation, and sepsis/septic shock (Naashayet?). Intraabdominal abscesses (Vidradhi), pneumonia (Shwasa?), respiratory failure (Shwasa?), sepsis, death (Naashayet) etc., are the some of the complications of bowel obstruction (Baddha).[95] Abdominal overdistension (Aadhmaatam) can affect respiratory mechanics by causing a cranial shift of the diaphragm, reducing chest wall compliance and lung volume (leads to Shwasa?).[96] Condition documented in verse 22 denotes either an intra-abdominal abscess associated with complications or bowel obstruction.

“Paandu Danta Nakho Yashcha-Paandu Rogi Vinashyati” (Verse 23)[5]

An anemic (Paandu) patient (Rogi) having pale teeth (Paandu Danta), pale nails (Paandu Nakha), pale conjunctiva (Paandu Netra) and seeing everything in pale colour (Paandu Sanghaata Darshee), such a patient (Paandu Rogi) will not survive (Vinashyati). The word Paandu denotes Shwetatvam (pallor or whitish discoloration).[5] Signs used in the diagnosis of anemia (Paandu) are pallor of the conjunctivae (Paandu Netra), nail beds (Paandu Nakha), face, and palms. Only pallor of the conjunctivae (Paandu Netra), nail beds (Paandu Nakha), and palms can be used in patients of any race. Conjunctival pallor (Paandu Netra) is a more accurate indicator of the presence of anemia than pallor of the other body parts.[97] Anemia (Paandu) is a multifactorial having a wide variety of etiologies such as malaria, worm infestation, nutritional deficiencies, liver cirrhosis, leukemia, cancer, postpartum hemorrhage, rupture of duodenal ulcer, tuberculosis, cyanotic heart disease, sickle cell anemia, thalassemia, SLE, and chronic renal disease.[98] Patient (Rogi) with severe anemia (Paandu) of chronic iron and vitamin B12 deficiency may show pale gingival and oral mucosa (Shwetatvam/Paandu).[99] Thalassemia patients' gums and the lining of their mouth (Paandu Danta?) become pale due to anaemia.[100] The white spot lesions (WSL) is defined as subsurface enamel porosity from carious demineralization that presents itself as a milky white (Panndu Danta?) opacity when located on smooth surfaces.[101] The patients with dental caries present with various symptoms such as a white spot (Shwetatvam/Paandu Danta?) on the tooth surface, hypomineralization and hypoplasia of the tooth, WSL or periapical pathology, and pigmented lesion of the tooth.[102] WSLs are most often found on enamel smooth surfaces (Shwetatvam/Paandu Danta?) close to the gingiva.[103] Significant associations found with tooth decay (WSL-Paandu Danta?) and iron deficiency anemia (Paandu). Many children who have had extensive caries (WSL-Paandu Danta?) were malnourished and also have iron deficiency anemia (Paandu). Severe early childhood caries (WSL-Paandu Danta?) may be a risk marker for iron deficiency anemia (Paandu).[104] In Anemic retinopathy loss of vision (Paandu Sanghaata Darshee?) can be a presenting complaint. At the macula, hemorrhages, edema, or hard exudates can cause impairment of vision (Paandu Sanghaata Darshee?). Vision loss (Paandu Sanghaata Darshee?) may occur due to disc edema or optic neuropathy.[105] Verse 23 denotes various fatal complications of anemia or anemia of chronic disease.

“Lohitam Chardayedyastu-Raktapittee Vinashyati” (Verse 24)[5]

A patient of Rakta Pitta (bleeding disorders) complaining of hemoptysis or hemetemesis (Lohitam Chardayet), and viewing everything red or blood-coloured (Raktaanaam Cha Dishaam Drashthaa) with his blood-shot eyes (Lohitekshanah), should be considered as dead (Vinashyati).[5] Hematemesis is the vomiting of blood (Lohitam Chardayet) and one of the symptoms of acute upper GI bleeding. The frequency (the word Bahusho mentioned in verse 24, defined as Bahuvaaram by Dalhana which means frequent episodes of hematememsis), amount, and duration of bleeding allow the examiner to determine whether the patient is having a major life-threatening hemorrhage (Vinashyati) or only minor bleeding. Common causes for hematemesis (Lohitam Chardayet) are peptic ulcer, cirrhosis with gastric or esophageal varices, gastritis, esophagitis, Mallory–Weiss tears, and cancers. Advanced malignancies and diseases of the heart, liver, kidneys, or lungs may cause profuse bleeding (Vinashyati?). Hematemesis (Lohitam Chardayet) indicates that a potentially lethal situation may be developing and that may lead to shock, tissue hypoxemia, lactic acidosis, and ultimately, death (Vinashyati).[106] Vitreous, retinal and subretinal haemorrhages (cause Lohitekshanah) along with epistaxis can be seen in von Willebrand's syndrome.[107] Patients with hereditary bleeding disorders (Rakta Pitta) rarely present with intraocular or orbital hemorrhage (cause Lohitekshana?) as the initial symptom.[108] The symptoms include haziness of the visual field, blurry vision, shadows, red hues (Raktaanaam Cha Dishaam Drashthaa), appearance of spots or floaters in the vision, and, in severe cases, blindness.[11] Verse 24 denotes bleeding disorders or coagulopathies associated with fatal consequences.

“Avaangmukhastunmukho Vaa-Unmaadena Vinashyati” (Verse 25)[5]

An insane (Unmaada) person, whose head angled or turned upwards (Urdhwa Mukha) and/or downwards (Adho Mukha), suffering with weakness (Ksheena Bala), cachexia/sarcopenia (Ksheena Maamsa) and insomnia (Jaagarishnu), that person will die eventually (Vinashyati).[5] The word Adho Mukha denotes depression and Urdhwa Mukha denotes mania, both of them in a same person denote a condition of Bipolar disorder (BD). Depression is characterized by the encapsulation of the body, loss of drive and interest (anhedonia) (Ksheena Bala?), psychomotor inhibition, bodily constriction, depressive mood, psychomotor inhibition (with reduced gestures, speech and actions) and lack of energy (Ksheena Bala). A bowed posture, lowered head (Adho Mukha) and leaden heaviness show the dominance of forces pressing downwards (Adho Mukha) in depression. Mania is characterised by a centrifugal expansion (cause Urdhwa Mukha?), sense of omnipotence, appropriation, superficial elation (feelings of flying or floating), vital euphoria, and grandiosity (cause Urdhwa Mukha?).[109] Individuals with major depressive disorder showed increased head flexion (Adho Mukha) and an increased thoracic kyphosis (Adho Mukha?).[110] BD, in either the manic or depressive phase, results in significant weight loss (Ksheena Bala). BD is one among the many psychiatric conditions (Unmaada) associated with unintentional weight loss (Ksheena Bala). Patients with BD died prematurely (Vinashyati) due to multiple causes such as CVD, diabetes, chronic obstructive pulmonary disease, influenza, pneumonia, injuries, and suicide.[111] The seriously mentally ill (Unmaada) are at a higher risk of death (Vinashyati) from comorbid conditions such as cancer (leads to cachexia, sarcopenia and asthenia-Ksheena Maamsa Bala), CVD, and respiratory and GI illness, leading to reduced life expectancy (Vinashyati).[112] BD (Unmaada?) has a chronic course and associated with premature mortality (Vinashyati).[113] Bipolar (Unmaada?) is known to be comorbid with a number of medical and psychiatric conditions.[114] Sleep disturbance (Jaagarishnu) is a core symptom of BD (Unmaada?). Reduced need for sleep in mania and insomnia in depression can be experienced nearly every day in BD patients. High rates of insomnia and parasomnias can also be found in BD patients.[115] It seems that verse 25 represents BD associated with premature mortality.

“Bahusho Apasmarantam-Apasmaaro Vinaashayet” (Verse 26)[5]

A case of Apasmaara (epilepsy) proves fatal (Vinaashayet) in a person, who is extremely emaciated (Praksheenam), and whose eye-brows (Bhruvam) are constantly moving (Chalita) and whose eyes (Netraabhyaam) seem fixed in an unnatural (Vikurvaanaam) stare.[5] Status epilepticus (SE) (Bahusho Apasmarantam) is a common medical emergency associated with high morbidity and mortality (Vinaashayet). SE persists for a sufficient length of time or is repeated frequently (Bahusho-Bahuvaaraan). Myoclonic SE following severe hypoxic-ischemic insult, viral encephalitis, and prion disease has poor prognosis (Vinaashayet). Nonconvulsive SE (NCSE) is characterized by abnormal mental status, unresponsiveness, ocular motor abnormalities (Chalita Bhruvam and Netraabhyaam Vikurvaanaam), and persistent electrographic seizures. Abnormal eye movements (nystagmoid eye jerks, repeated blinking, hippus, and persistent eye deviation) (Chalita Bhruvam and Netraabhyaam Vikurvaanaam) are one of the characteristic features of NCSE.[116] Absence seizures occur in multiple generalized epilepsies including childhood absence epilepsy, juvenile absence epilepsy, juvenile myoclonic epilepsy and Lennox-Gastaut syndrome. Absence epilepsy is known as “pyknolepsy” (pyknos means very frequent or grouped) (Bahusho-Bahuvaaraan).[117]

Absence seizures (Apasmaara) are characterized by a blank stare, and a brief upward rotation of the eyes (Netraabhyaam Vikurvaanaam). Typical absence seizures (TAS) are characterized by transient impairment of consciousness (absence) (Apasmaara) with polyspike-slow wave discharges. The most common features of TAS are clonic or myoclonic jerking of the eyelids, eyebrows, and eyeballs, including random or repetitive eye closures and horizontal or vertical nystagmus-like ocular movements (Chalita Bhruvam and Netraabhyaam Vikurvaanaam). TAS is a syndrome with frequent (several to many per day) (Bahusho-Bahuvaaraan) and severe absences.[118] Staring (Netraabhyaam Vikurvaanaam?) can be observed in absence seizures (Apasmaara). Loss of consciousness (Apasmaara?) can be found in focal seizures. Forceful rotation of head and eyes (Chalita Bhruvam and Netraabhyaam Vikurvaanaam) to a specific side can be found in versive seizures. Tonic eye deviation (Netraabhyaam Vikurvaanaam) may be associated with versive movements and may occur due to excessive activation of the contralateral frontal eye field (FEF). Epileptic nystagmus (Netraabhyaam Vikurvaanaam) can be caused by focal onset seizures. Eyelid myoclonia is characterized by forceful twitches of the eyelid that may include the eyebrows (Chalita Bhruvam and Netraabhyaam Vikurvaanaam). Eyelid flutter (Netraabhyaam Vikurvaanaam) can be seen in occipital/temporal/frontal lobe seizures.[119] Epileptic gaze deviations (Chalita Bhruvam and Netraabhyaam Vikurvaanaam) can be induced by cortical excitation in FEFs, the temporal cortex, or the parietooccipital cortex and are frequently seen in occipital lobe epilepsy (OLE). Transient horizontal eye deviations (Chalita Bhruvam and Netraabhyaam Vikurvaanaam) are the chief symptoms of OLE. Versive horizontal epileptic eye movements (Chalita Bhruvam and Netraabhyaam Vikurvaanaam) have been correlated with frontal, parietal, temporal, occipital, and generalized seizures (Apasmaara).[120] Eyelid myoclonus (Chalita Bhruvam and Netraabhyaam Vikurvaanaam) can be seen in patients with frontal epileptic activity (Apasmaara).[121] Verse 26 represents either SE or absece seizures associated with high mortality.

  Conclusion Top

AA is the 33rd chapter of Sushruta Samhita Sutra Sthana which consists of 26 verses. Clinical interpretation of the verses denote various fatal conditions having poor prognosis such as EOL stages, MCCs, signs and symptoms of terminal illnesses, complications of diseases like diabetes, neurological conditions, dermatological conditions and haemorrhoids, complex fistulae, refractory ascites with liver cirrhosis, febrile delirium, sepsis, septic shock, PNS, SAE, brain stem dysfunction, infectious gastroenteritis, EPTB, GUTB, lung metastases with primary intra-abdominal carcinoma, intra-abdominal abscesses and their fatal complications, chronic anemia and its complications, coagulopathies, bipolar disorder and status epilepticus. The contents of AA seem to have prognostic significance and clinical applicability even in the present era. The present study provides inputs for future research works on Ayurvedic prognostic science.

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Conflicts of interest

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  [Table 1], [Table 2]


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