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REVIEW ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 22-47

Swabhava Vipratipatti 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 Submission22-Mar-2022
Date of Decision07-Jun-2022
Date of Acceptance07-Jun-2022
Date of Web Publication22-Aug-2022

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


DOI: 10.4103/jihs.jihs_4_22

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  Abstract 


Sushruta Samhita is an ancient Ayurvedic treatise predominantly focused on surgery. Maharshi Sushruta is considered as the father of Indian surgery. Arishtha Vijnana (concepts related to prognosis) has been documented in the chapters 28–33 of Sutra Sthana (section that deals with basic principles of Ayurveda). Swabhava Vipratipatti Adhyaya (SVA) is the 32nd chapter of Sushruta Sutra Sthana (SSS). Various pathological signs and symptoms, which denote fatal consequences, have been documented within seven verses in this chapter. Works are scarce on Arishtha Vijnana mentioned in SSS, and further, exploration is required. The aim of the present study is to explore the prognostic potential of the contents of SVA with the help of contemporary prognostic literature. Various pathological features having poor prognoses such as hypo- and hyper-pigmentation, hypo- and hypertonia, hypo- and hyperthermia, atrophy, hypertrophy, dystrophy, discoloration, sclerosis, ankylosis, dislocations, prolapse, abnormal involuntary movements, “-malacia,” “-megaly,” “micro- and macro-,” anhidrosis and hyperhidrosis, exophthalmos and enophthalmos, ptosis, neuromuscular disorders, lower motor neuron syndromes, autoimmune disorders with systemic manifestations, immunodeficiency syndromes, anorexia, cachexia, sarcopenia, carcinomas, dysfunctional tear syndrome, marasmic kwashiorkor, lymphedema, voice disorders (aphonia, hypophonia, dysphonia, etc.), dacrystic seizures, gastric outlet obstruction, epileptic drop attacks, priapism with cervical cord lesions, Tourette syndrome-plus, trichotillomania, and terminal lucidity can be seen in SVA chapter. The contents of SVA chapter of SSS seem to have prognostic importance, and the present study paves the way for the development of new hypotheses for future testing.

Keywords: Arishtha, lower motor neuron syndromes, Maharshi Sushruta, neuromuscular disorders, seizures, Sushruta Samhita


How to cite this article:
Mamidi P, Gupta K. Swabhava Vipratipatti Adhyaya of Sushruta Sutra Sthana - An explorative study. J Integr Health Sci 2022;10:22-47

How to cite this URL:
Mamidi P, Gupta K. Swabhava Vipratipatti Adhyaya of Sushruta Sutra Sthana - An explorative study. J Integr Health Sci [serial online] 2022 [cited 2022 Oct 5];10:22-47. Available from: https://www.jihs.in/text.asp?2022/10/1/22/354233




  Introduction Top


The Sushruta Samhita was written by the famous surgeon Maharshi Sushruta in the 6th century BCE. Maharshi Sushruta is recognized as the father of Indian surgery. Arguably, Sushruta Samhita is the oldest surgical textbook. Sushruta Samhita is divided into sections such as the Sutra Sthana, Nidana Sthana, Sharira Sthana, Chikitsa Sthana, Kalpa Sthana, and Uttara Tantra.[1] Sushruta Samhita does not contain Indriya Sthana (specialized section deals with prognostic aspects) such as Charaka Samhita and some other classical Ayurvedic texts. Maharshi Sushruta has documented Arishtha Vijnana (prognostic knowledge) in Sutra Sthana (chapters from 28 to 33). Opinion differences have been prevailing between Chakrapani and Dalhana (commentators on Sushruta Samhita) while naming the chapters of Sutra Sthana (chapters from 28 to 33) of Sushruta Samhita.[2]

Swabhava Vipratipatti Adhyaya (SVA) is the 32nd chapter of Sushruta Sutra Sthana (SSS). The term Swabhava denotes normal/physiological/natural and Vipratipatti refers to deviation or an error; hence, the chapter Swabhava Vipratipatti denotes various pathological conditions. SVA consists of seven verses that deal with the description of various pathological signs and symptoms which are fatal.[3] Previous works have explored the prognostic significance of Indriya Sthanas of various Samhitas'.[4],[5],[6],[7],[8],[9] The contents of SVA seem to have clinical significance and prognostic potential, and they need further exploration. The present study aims to explore the clinical and prognostic importance of the contents of SVA chapter with the help of contemporary prognostic literature.


  Methodology Top


Ayurvedic literatures such as Sushruta Sutra Sthana with Dalhana and Chakrapani commentaries, Charaka Indriya Sthana with Chakrapani commentary, Bhela Indriya Sthana, and Kashyapa Indriya Sthana have been referred. Relevant keywords have been used for searching various databases such as Google Scholar, Scopus, and PubMed both for Ayurvedic and contemporary medical literature. Open access articles and abstracts published in English language were only considered. No search filters have been used while searching various databases. Articles published till March 2022 were only considered irrespective of their publication year and date of appearance.


  Discussion Top


SVA chapter of SSS consists of seven verses. These verses deal with the description of various pathological signs and symptoms denoting an imminent death. Each verse of SVA chapter has been explored with the help of contemporary prognostic literature in the following sections [Table 1] and [Table 2].
Table 1: Clinical interpretation of Verse 3

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Table 2: Clinical interpretation of Verse 4

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Athaato Swabhava Vipratipatti Madhyayam – Bhagavaan Dhanwantari (Verses 1 and 2)

As per Verses 1 and 2, “now (Athaato), we discourse on the chapter entitled Swabhava Vipratipatti Adhyaya,” which is the compilation of some fatal pathological signs and symptoms. The term Swabhava denotes normal/physiological/natural and Vipratipatti refers to deviation or an error; hence, the chapter Swabhava Vipratipatti denotes various pathological conditions. The current chapter (SVA) contains the description of various fatal signs and symptoms, which denotes an imminent death.[3]

Swabhava Siddhaanaam – Chaangaanaam (Verse 3)

Any deviation (Vipratipatti/Anyatha Bhaavatam) from the normal (Swabhava) structure/anatomy (Guna) or function/physiology (Karma) of the body parts (Shariraikadeshaanaam) is considered as fatal and denotes an imminent death (Maranaaya) [Table 1].

Shuklaanaam Krishnatvam

White-colored (Shuklaanaam) sclera (Netraikadeshaanaam) turning into blackish/brownish/bluish (hyperpigmentation) (Krishnatvam) suddenly (Akasmaat) and without any visible cause (Nirnimittam) denotes an imminent death (Maranaaya).[3] Shuklaanaam Krishnatvam denotes hyperpigmentation of sclera due to some fatal conditions, such as heavy metal toxicity, scleromalacia (due to autoimmune diseases), choroidal or ciliary body melanoma, Addison's disease (bronze hyperpigmentation of sclera), and ochronosis (due to alkaptonuria) (bluish-black discoloration of sclera).[14]

Krishnaanaam Shuklataa

Two versions are available for Krishnaanaam Shuklataa (whitish discoloration of black-colored body parts): white pupil (Lochana Madhyasya Shuklataa) and premature (Taarunye) graying of hair (PGH) (Kesha Shmashru Lomnaam Cha Shuklataa).[3] Leukocoria means white pupil (Lochana Madhyasya Shuklataa) or cat's eye pupil, and it is often the first sign of a range of serious (Maranaaya) intraocular disorders. Leukocoria is commonly seen in cataract, Coat's disease, retinoblastoma (RB), retinopathy of prematurity, toxocariasis, Norrie's disease, retrolental fibroplasias, retinal detachment, persistent pupillary membrane, persistent hyperplastic primary vitreous, endophthalmitis, optic nerve coloboma, iris heterochromia, ametropia, astrocytic hamartoma, familiar exudative vitreoretinopathy, medullo epithelioma, and Toxoplasmosis, Other agents, Rubella, Cytomegalovirus, and Herpes simplex syndrome (TORCH).[16] PGH (Taarunye Kesha Shmashru Lomnaam Cha Shuklataa) is defined as graying of hair before the age of 30 years in Blacks and before 20 years in Caucasians. PGH is associated with an increased risk of myocardial infarction (MI), cardiovascular disease (CVD), low bone mineral density, hearing loss, and early mortality (Maranaaya). Hypomelanotic hair disorders having localized manifestations are albinism, neurocutaneous disorders (Griscelli, Chediak–Higashi, and Elejalde syndromes), Cross syndrome, Angelman syndrome, Prader–Willi syndrome (PWS), and metabolic syndromes (phenylketonuria, histidinemia, oasthouse disease, and homocystinuria). Poliosis is seen in piebaldism, Waardenburg syndrome, Woolf syndrome, and tuberous sclerosis. Canities subita is characterized by overnight (Akasmaat) graying of hair (Kesha Shmashru Lomnaam Cha Shuklataa).[16]

Raktaanaam Anya Varnatvam

Pathological discoloration (Shweta - pale/white, Peeta - yellow, Krishna - black/brown, Neela - purple/blue) (Anya Varnatvam) of the body parts (Netrananda - temporal side of the eye, Kara Tala - palms, Paada Tala - soles, Taalu - palate, Jihwa - tongue, and Oshtha - lips) suddenly (Aakasmikam), which are naturally reddish in color (Raktaanaam), denotes an imminent death (Maranaaya).[3] The present verse denotes various conditions such as central or peripheral cyanosis or acrocyanosis (Neela - bluish discoloration), melasma (brown-to-bluish gray discoloration - Krishna), acanthosis nigricans (dark brown-to-black discoloration - Krishna), macular amyloidosis (brownish-or-blackish discoloration - Krishna), Wilson's disease (WD, brownish discoloration - Krishna), acquired hypomelanosis (Shweta), severe anemia (Shweta/Peeta), chronic kidney disease (CKD) (pallor - Shweta/Peeta), oral pigmentation due to systemic diseases and malignancies (blue/purple vascular lesions - Neela, brown melanotic lesions - Krishna, and gray/black pigmentations - Krishna), jaundice (Peeta - yellow), peripheral vascular disease (PVD) (bluish discoloration - Neela), Raynaud's phenomenon (RP, ischemic phase-pallor or white - Shweta and deoxygenation phase - blue - Neela), postinflammatory hyperpigmentation (PIH) (darkish pigmentation - Krishna), Addison's disease (intraoral hyperpigmentation - Krishna), hepatocellular carcinoma (HCC) (yellow - Peeta), and other carcinomas (Maranaaya).[5]

Sthiraanaam Mrudutvam

Abnormal softness (Mrudutvam) of naturally hard or firm (Sthiraanaam) body parts such as hair (Kesha), moustache (Shmashru), nails (Nakha), teeth (Danta), skull or cranium (Shira), ligaments or connective tissue (Snaayu), and vasculature or body channels (Srotas) should be considered as fatal (Arishtha).[3] The term malacia denotes pathological softening (Mrudutvam) of an organ or tissue.[17] Various conditions such as osteomalacia (abnormal softening of the bones) (Asthivaha Sroto Mrudutvam), laryngomalacia, tracheomalacia, tracheobronchomalacia (Sroto Mrudutvam), pharyngomalacia, airway malacia (Praanavaha Sroto Mrudutvam), gastromalacia (Annavaha Sroto Mrudutvam), cerebral malacia, leukoencephalomalacia (Majjavaha Sroto Mrudutvam), periventricular malacia, cartilage malacia (Asthivaha Sroto Mrudutvam), and chondromalacia come under the pathological domains of Sthiraanaam Mrudutvam. Various skeletal dysplasias also come under the pathological category of Sthiraanaam Mrudutvam. Skeletal dysplasias or osteochondrodysplasias are a large heterogeneous group of disorders comprising abnormalities of bone or cartilage (Sthiraanaam) growth or texture (Mrudutvam). Various abnormalities involving skull (achondroplasia, cleidocranial dysplasia) (Shira) and axial and appendicular skeleton (spine, mandible, clavicle, ribs, and pelvis) can be seen in skeletal dysplasias. Spondyloepiphyseal dysplasia congenita, spondyloepiphyseal dysplasia tarda, multiple epiphyseal dysplasia, pseudoachondroplasia, chondrodysplasia punctata, mucopolysaccharidoses, Hurler's syndrome, Morquio's syndrome, metaphysial dysplasias (achondroplasia, hypochondroplasia, and chondroectodermal dysplasia [CED]), osteopenic dysplasias (osteogenesis imperfecta - OI), pkynodysostosis, osteopoikilosis, progressive diaphyseal dysplasia, etc., come under the broad category of skeletal dysplasias. Involvement of hair (Kesha), nail (Nakha), teeth (Danta), and cardiac abnormalities (leads to Maranaaya) can be seen in CED.[18] Bending (due to Mrudutvam) of the long bones, craniotabes (Shiro Mrudutvam), delayed fontanel closure (Shiro Mrudutvam), delayed teething (Danta Mrudutvam), carious teeth, enamel hypoplasia (Danta Mrudutvam), etc., can be seen in rickets. Deformities caused by softening of the bones (Mrudutvam) of the lower extremities develop once the infant starts walking in rickets. Hypotonia (Mrudutvam) and proximal myopathy can also be seen in rickets.[19] Mechanical ankle instability is induced by ligament laxity (Snaayu Mrudutvam).[20] The lax ligament syndrome (Snaayu Mrudutvam) is a comparatively common mild collagenopathy.[21] Sthiraanaam Mrudutvam may also denote another pathological entity, flaccidity. Various conditions such as acute flaccid paralysis, lower motor neuron (LMN) syndromes, and myopathies come under the category of Sthiraanaam Mrudutvam.

Mrudunaam Sthirataa

Pathological hardening (Sthirataa) of soft (Mrudunaam) body parts or tissues such as Maamsa (muscle), Shonita (blood or vasculature), Meda (adipose tissue), Majja (neural tissue), Shukra (reproductive organs or tissues), Nabhi (umbilicus), Hrudaya (heart), Yakrut (liver), and Pleeha (spleen) should be considered as fatal (Maranaaya).[3] Sthirataa or Kaathinyam denotes various pathological entities such as sclerosis, fibrosis, plaque formation, calcification, rigidity, spasticity, and contractures. The word “sclero” represents hardening or thickening (Sthirataa or Kaathinyam). Scleroderma is a connective tissue disorder characterized by thickening and hardening (Kaathinyam) of the skin. Localized scleroderma affects mainly the skin, muscles (Maamsa), and bones; however, in systemic scleroderma, there is an involvement of the internal organs, such as digestive tract, heart (Hrudaya), lungs, and kidneys. In scleroderma, blood vessel damage (Shonita), excess fibrosis (Sthirataa/Kaathinyam), and injury to tissues occur that result in scar tissue formation (Kaathinyam) and accumulation of excess collagen.[22] Various other conditions such as multiple sclerosis (MS), systemic sclerosis (SSc), tuberous sclerosis complex, disseminated sclerosis, atherosclerosis, osteosclerosis, and medullary sclerosis also come under the category of Mrudunaam Sthirataa. Fibrosis is defined by the overgrowth, hardening, and/or scarring (Sthirataa or Kaathinyam) of various tissues (Maamsa, Shonita, Meda, Majja, etc.). Idiopathic pulmonary fibrosis (IPF), liver cirrhosis (Yakrut Kaathinyam), SSc, progressive kidney disease, and cardiovascular fibrosis (Shonita Kaathinyam) are considered as fibrotic diseases.[23] Cystic fibrosis (CF), oral submucous fibrosis (OSMF), myocardial/cardiac fibrosis, multiorgan fibrosis, etc., also come under the pathological entity of Mrudunaam Sthirataa. Plaques such as dental plaque, atherosclerotic plaque, carotid artery plaques, pleural plaques, Peyronie's disease (penile plaques), and Alzheimer's disease (AD) (senile plaques/neurofibrillary tangles/amyloid plaques) also represent Mrudunaam Sthirataa. Pathological calcifications (calcium builds up in a tissue and causing the tissue to harden) such as vascular calcification, intracranial calcification, coronary artery calcification, valvular calcification (calcific aortic valve disease), primary familial brain calcification, dystrophic calcification, calcific tendinitis, calcification of prostate, pancreatic calcification, Fahr's syndrome (basal ganglia calcification) etc. denote Mrudunaam Kaathinyam. The word spasticity (Sthirataa/Kaathinyam) means to pull or to tug. It can range from mild muscle stiffness to severe, painful, and uncontrollable muscle spasm (Maamsa Kaathinyam). If left untreated, it gives rise to spasms, limb contracture (Maamsa Kaathinyam), and deformity.[24] Mrudunaam Sthirataa may denote various pathological entities such as fibrosis, sclerosis, cirrhosis, spasticity, contractures, and calcifications.

Chalaanaam Achalatvam

Pathological absence of/loss of movements of (Achalatvam)/pulsations of (Aspandanam) Vaataashaya (colon), Sira (arteries), Sandhi (joints), Jihwa (tongue), etc., denotes an imminent death (Arishtha).[3] There are two types of motility (Chalaanaam) present in the colon, haustral contraction, and mass movement.[25] Vaataashaya Achalatvam denotes motility disorders involving colon, Hirschsprung disease (megacolon), gastroparesis, etc.[26] Aspandanam Sira denotes absence of pulsations. Various conditions such as low cardiac output due to cardiac failure, aortic stenosis, peripheral artery disease, acute arterial occlusion, Takayasu disease (pulseless disease), idiopathic dilated cardiomyopathy, shock, MI, valvular stenosis, pericardial tamponade, dissected aortic aneurysm, and vascular obstruction by thrombus or embolus can cause diminished pulse and may represent Aspandanam Sira.[7] Sandhi Achalatvam denotes ankylosis. Ankylosis of joints (Sandhi Achalatvam) can occur either due to intra-articular fibrosis or extra-articular contracture. The majority of bony ankylosis (Achalatvam) cases are due to suppurative arthritis. Complicating septic osteomyelitis (Arishtha) and dense fibrous ankylosis usually occur due to gonorrhea. Ankylosis of joints (Sandhi Achalatvam) may also occur as the result of tuberculosis (Arishtha?).[27] Sandhi Achalatvam also denotes contractions and deformities, resulting from diseases of the joints.[28] The seronegative spondyloarthropathies (characterized by Sandhi Achalatvam) are a group of autoimmune inflammatory diseases (Arishtha?) and they include ankylosing spondylitis (AS), psoriatic arthritis, reactive arthritis, spondylitis associated with Crohn's disease and ulcerative colitis, and undifferentiated spondyloarthropathies. Cervical spinal subluxation, respiratory failure, aortic regurgitation, and amyloidosis are fatal systemic complications (Arishtha) of AS.[29] Jihwa Achalatvam denotes reduced tongue movements. Decrease in tongue strength (Jihwa Achalatvam) is a prognostic of short survival (Arishtha) in amyotrophic lateral sclerosis (ALS). Slow tongue movements (Jihwa Achalatvam) have been observed in the severe group (Arishtha) of ALS cases.[30] Restricted tongue movements (Jihwa Achalatvam) can also be seen in OSMF which can undergo malignant transformation and increase risk of fatality (Arishtha).[31] Symptoms such as tongue weakening, wasting, and fasciculation along with flaccid dysarthria can be seen in bulbar LMN damage (Arishtha?).[32]

Achalaanaam Chalataa

Pathological or abnormal movement or dislocation or displacement (Chalataa) of body parts (those are immobile or static in normal conditions) (Achalaanaam) is considered as fatal (Arishtha).[3] Dalhana has provided some examples such as Maamsa Chalatvam (hyperkinetic movement disorders [HMDs], abnormal involuntary movements such as chorea, athetosis, myoclonus, tics, tremors, and stereotypies), Meda Chalatvam (abnormal body fat distribution, lipodystrophy), Asthi Chalatvam (skeletal dysplasias,  Ehlers-Danlos syndrome More Details [EDS], temporomandibular disorder), Nabhi Chalatvam (Beevor's sign,[33] a high or low or eccentric position of umbilicus due to various underlying pathological conditions or syndromes),[34] Naasa Maamsa Chalatvam (nasal septum deviation, benign or malignant intranasal tumors or nasal polyps, etc., causing disfiguration of nose), and Karna Maamsa Chalatvam (auricular benign or malignant masses causing disfiguration of ear) for describing the pathological conditions of Achalaanaam Chalataa.

Pruthunaam Samkshiptatvam

Shrinkage or constriction or contractures or atrophy (Samkshiptatvam or Swalpatvam) of naturally large or big or wide (Pruthunaam) body parts or organs denotes an impending death (Arishtha).[3] Shiro Samkshiptatvam or Shiro Swalpatvam denotes shrinkage of brain with increasing age,[35] dysmorphic syndromes of children (such as Noonan syndrome, PWS, Silver- Russell syndrome More Details,  Aarskog-Scott syndrome More Details, and Turner syndrome [TS]),[36] postnatal microcephaly (e.g., Rett syndrome),[37] acquired microcephaly (cerebrovascular incidents, hypoxia, and metabolic derangements and infections),[37] and autism (deceleration in rate of head circumference growth)[38] conditions. Lalaata Samkshiptatvam or Lalaata Swalpatvam denotes procerus sign (vertical wrinkling of the forehead) in atypical parkinsonian syndromes (e. g., progressive supranuclear palsy [PSP]),[39] dysmorphic syndromes of children,[33] and craniofacial abnormalities. Vaktra Samkshiptatvam or Vaktra Swalpatvam denotes conditions such as OSMF,[40] facial paralysis,[41]  Treacher Collins syndrome More Details,[42] and oral leukoplakia.[43] Amsa Samkshiptatvam or Amsa Swalpatvam denotes conditions such as dorsal scapular nerve neuropathy,[44] scapular winging,[45] atrophy of supraspinatus and/or infraspinatus muscles,[46] and facioscapulohumeral muscular dystrophy (FSHD).[47] Ura Samkshiptatvam or Ura Swalpatvam denotes a barrel-shaped chest in which the anteroposterior diameter of the chest is equal to or greater than its lateral diameter and the thoracic ratio becomes >0.9. Barrel-shaped chest is usually seen in advanced emphysema, aging, any chronic lung disease, and chronic obstructive pulmonary disease (COPD).[48] Ura Swalpatvam may also denote conditions such as restrictive lung disease including IPF, nonspecific interstitial pneumonia, sarcoidosis, silicosis, asbestosis, pneumoconiosis, berylliosis, hard metal fibrosis, farmer's lung, bird fancier's lung, bagassosis, hypersensitivity pneumonitis, SSc, pulmonary vasculitis, and pulmonary Langerhans cell histiocytosis. Conditions such as muscular dystrophy, ALS, and phrenic neuropathies are characterized by a reduced distensibility of the lungs, compromising lung expansion, and reduced lung volumes with reduced total lung capacity (Ura Swalpatvam).[49] Prushtha Samkshiptatvam or Prushtha Swalpatvam denotes pathological conditions of thoracolumbar spine with special reference to its height, symmetry, alignment, flexibility, and movements. Prushtha Swalpatvam represent conditions such as kyphoscoliosis,[50] spinal tuberculosis,[51] AS,[52] vertebral compression fractures,[53] spinal muscular atrophy (SMA),[54] and hereditary or acquired neuromuscular diseases (NMDs) involving thoracolumbar spine.[55] Acquired NMDs include peripheral neuropathies, ALS, poliomyelitis, Guillain–Barre syndrome (GBS), myasthenia gravis (MG), and polymyositis. Hereditary NMDs include such disorders as SMA, Charcot-Marie-Tooth (CMT) disease, congenital myasthenia, and Duchenne muscular dystrophy (DMD).[55]

Samkshiptaanaam Pruthutaa

Dilation or dilatation or -megaly or abnormal enlargement (Pruthutaa) of a body part or an organ denotes an impending death (Arishtha). Pruthutaa (dilation or dilatation or abnormal enlargement) of Drishti Mandala (pupil), Nakha (nails), Roma (hair), and Gulpha (ankle) is considered as Arishtha.[3] Drishti Mandala Pruthutaa denotes unilateral or bilateral nonreactive pupils, fixed or dilated pupils, as well as brisk, sluggish, and nonreactive pupils. Dilation of a pupil frequently denotes an irreversible condition. There is an inverse relationship between decreasing pupil reactivity (Drishti Mandala Pruthutaa) and increasing intracranial pressure. Abnormalities of pupillary response or anisocoria (pupil size asymmetries) (Drishti Mandala Pruthutaa) are often associated with neurological deteriorations, and they are correlated with poor neurological outcomes (Arishtha). Pupillary changes (Drishti Mandala Pruthutaa) in the neurological intensive care unit (ICU) are highly correlated with brainstem oxygenation and perfusion/ischemia (Arishtha).[56] In compressive third nerve palsy (TNP), the pupil becomes fixed and dilated (Drishti Mandala Pruthutaa) due to paralysis of sphincter pupillae. Ciliary muscle paralysis also leads to loss of accommodation (Drishti Mandala Pruthutaa).[57] Adie syndrome is associated with unilateral or bilateral tonically dilated pupils (Drishti Mandala Pruthutaa).[58] Nakha Pruthutaa denotes conditions such as clubbing of nails or macronychia. Nail clubbing is associated with systemic diseases, such as cyanotic congenital heart diseases, infective endocarditis, primary and metastatic lung cancer, bronchiectasis, lung abscess, CF, mesothelioma, inflammatory bowel disease, hepatic cirrhosis, acquired immunodeficiency syndrome (AIDS), and hypertrophic osteoarthropathy. Macronychia (Nakha Pruthutaa) is characterized by nails that are too and can be seen in local gigantism.[59] Roma Pruthutaa (thick hair) denotes conditions such as hypertrichosis or hirsutism. Hypertrichosis is the growth of hair (Roma) of an excessive amount and thickness (Pruthutaa) on any part of the body. Generalized hypertrichosis of vellus (Roma) or terminal hair can occur in universal hypertrichosis in which normally hairy areas such as back, thorax, and limbs show increase in thickness (Pruthutaa) and density of hair.[60] Acquired generalized hypertrichosis can be seen in traumatic brain injuries (TBIs), juvenile hypothyroidism, juvenile dermatomyositis, acromegaly, malnutrition, and advanced human immunodeficiency virus (HIV) infection. Patients presenting with the sudden appearance of acquired lanugo hairs should be screened for malignancy (Arishtha). Acquired hypertrichosis lanuginose patients may report a history of malignancy (Arishtha).[61] Gulpha Pruthutaa (ankle edema) denotes conditions such as chronic venous insufficiency, chronic lymphedema,[62] ankle and foot tuberculosis,[63] osteomyelitis, bone cyst, lymphoma, giant cell tumor, chondroblastoma, clear-cell chondrosarcoma, plasmacytoma, and  Rosai-Dorfman Disease More Details.[64]

Deerghaanaam Hrasvatvam

A naturally large or long body part or an organ (Deerghaanaam) that gradually or suddenly decreases in its size or length (Hrasvatvam) indicates an impending death (Arishtha).[3] Nayana Hrasvatvam (smaller eyes) denotes conditions such as microphthalmia. Complex microphthalmia (microphthalmia associated with other ocular disorders) (Hrasvatvam) can be seen along with sclerocornea, Peter's anomaly, persistent hyperplastic primary vitreous and retinal dysplasias, inadequate production of secondary vitreous, genetic cataracts, gestational-acquired infections, and noninfectious causes (maternal Vitamin A deficiency, fever, hyperthermia, exposure to X-rays, etc.).[65] Bhuja Hrasvatvam denotes conditions such as FSHD (rounding of the shoulders, wasting of rhomboids, and lateral winging of the scapulae),[47] scapulohumeral limb-girdle muscular dystrophy (LGMD) (Erb LGMD),[66] and scapuloperoneal spinal muscular atrophy.[67] Anguli Parva Hrasvatvam denotes acroosteolysis (resorption of terminal phalanges) with calcinosis seen in diffuse SSc (characterized by joint erosive deformation of distal interphalangeal joints, contractures, tendinopathy, etc.).[68] Anguli Parva Hrasvatvam may also denote CED characterized by the features such as genu valgum deformity, acroosteolysis (resorption of tips of phalanges), synmeta carpalism, and symphalangism.[18] Ucchwasa Hrasvatvam denotes short expiratory phase or reduction in the ability to expire the air (obstructive lung disease?). The obstructive lung disease asthma and COPD are among the main causes of mortality and morbidity.[69]

Hrasvaanaam Deerghatvam

A small or short body part or an organ (Hrasvaanaam) that increases in its size or length (Deerghatvam) indicates an impending death (Arishtha).[3] Jangha Deerghatvam (pathological increase of leg height) and Greeva Deerghatvam (pathological increase in neck length or relative neck length or height) denote conditions such as gigantism, pituitary adenoma,[70] and  McCune-Albright syndrome More Details.[71] Conditions such as Roberts syndrome[72] and excessive testosterone levels are associated with Medhra Deerghatvam (macro penis).[73]

Apatana Dhraminaam Patana Dharmitvam

Falling of (Patana Dharmitvam) scalp hair (Kesha Patana), facial hair or beard hair (Shmashru Patana), body hair (Roma Patana), and nails (Nakha Patana) without any known or visible cause (Akasmaat) should be considered as fatal (Arishtha).[3] Alopecia areata (AA) often arises suddenly (Akasmaat), and it usually affects a round patch of the scalp at first (Kesha Patana) and then spreads in a centrifugal or multilocular pattern. AA is associated with inflammatory and autoimmune diseases such as atopic eczema, Hashimoto's thyroiditis, Graves' disease, and vitiligo.[74] Patients with AA have a higher risk of mortality (Arishtha) associated with self-harm, psychiatric diseases, and malignant diseases including lung cancer.[75] In patients with cancer, alopecia (Kesha Patana) can be a direct consequence of the disease itself (e.g., malnutrition, scalp metastases, and paraneoplastic syndromes) (Arishtha).[76] Autoimmune diseases (Arishtha?) including thyroid disease, vitiligo, lupus erythematosus, pernicious anemia, celiac disease, ulcerative colitis, and multiple sclerosis have been found associated with alopecia (Kesha Patana).[77] AA of the beard (BAA) or AA barbae (Shmashru Patana) can be seen in atopic dermatitis.[78] BAA (Shmashru Patana) can be associated with autoimmune conditions, such as diabetes mellitus (DM), psoriasis, Helicobacter pylori infection, Sjogren's syndrome, and thyroid disorders.[79] The hair of the entire scalp and the whole body can be affected, which are called alopecia totalis (AT) (Kesha Patana) and alopecia universalis (AU) (Kesha, Shmashru, and Roma Patana), respectively. The extent of involvement, pattern and long duration of hair loss, a positive family history, nail involvement (Nakha Patana?), atopic diseases, and other autoimmune diseases are also known as predictors of poor prognosis (Arishtha) in patients with AA.[80] Nail changes (Nakha Patana?) are more frequently seen in the severe (Arishtha?) forms of AA, and it possibly reflects a more refractory disease (Arishtha). Fingernails can become dystrophic, with erythematous blotches (striated lunulae) with regular and superficial pitting and nail fragility (trachyonychia) (Nakha Patana?). Nail brittleness (onychorrhexis) (Nakha Patana?) and pain in the fingertips can also be found.[81] AA can be divided into alopecia focalis (patchy hair loss) (Kesha or Shmashru or Roma Patana), AT (total loss of scalp hair) (Kesha Patana), and AU (complete loss of scalp and body hair) (Kesha, Shmashru, and Roma Patana). Onychodystrophy (Nakha Patana) can be seen in AA patients. Nail change (Nakha Patana?) is an associated abnormality of AA and includes nail pitting, longitudinal striations, brittleness, red lunula, trachyonychia, and Beau's lines.[82]

Patana Dhraminaam Apatana Dharmitvam

Absence or reduced output of (Apatana Dharmitvam) sweat (Sweda Apatana), urine (Mutra Apatana), and feces (Purisha Apatana) without any known or visible cause (Akasmaat) should be considered as fatal (Arishtha).[3] Sweda Apatana denotes anhidrosis (inability to sweat). Anhidrosis (Sweda Apatana) can be potentially life-threatening (Arishtha). Central and neuropathic anhidrosis (Sweda Apatana) is caused by tumors, infarctions, alterations of the hypothalamus, medulla, pons, or spinal cord, Horner, Ross, or  Shy-Drager syndrome More Details, autoimmune autonomic neuropathy, and peripheral neuropathy due to DM, leprosy, alcoholism, amyloidosis, and drugs. Peripheral causes due to sweat gland abnormalities (Sweda Apatana) include genetic disorders such as ectodermal dysplasias, incontinentia pigmenti, Fabry disease, Bazex-Dupré-Christol syndrome, destruction from tumors, burns, SSc, Sjogren's syndrome, acrodermatitis chronica atrophicans, obstruction from miliaria, psoriasis, ichthyoses, eczematous dermatoses, and bullous diseases.[83] Anuria (Mutra Apatana) can be seen in acute kidney injury (AKI), sepsis, cardiorenal and hepatorenal syndromes, hypovolemia, nephrotoxic drugs, vasculitis, glomerulopathy, rhabdomyolysis, multiple organ dysfunction syndrome, CKD, end-stage renal disease (ESRD), acute tubular necrosis,[84] and renal ischemia.[85] Purisha Apatana may denote either fecal impaction (FI) or severe constipation. FI (Purisha Apatana) is a common problem in the elderly and other at-risk groups (Arishtha). It has been associated with high morbi-mortality (Arishtha). Fecal impaction (Purisha Apatana) is associated with various complications such as colon ulceration, colitis, systemic toxicity, colon perforation, mechanical obstruction of the colon, Hirschsprung disease, Chagas disease, megacolon, and death (Arishtha?).[86] In the elderly, constipation (Purisha Apatana) can present not only with mechanical complications, such as perforation and obstruction, but also with delirium and failure to thrive as well (Arishtha).[87]

Akasmaat Shaitya – Chaangaanaam (Verse 3)

Increase (Aushnya) or decrease (Shaitya) in temperature of body parts (Angaanaam), increase (Snigdha) or decrease (Ruksha) in the unctuousness of body parts, increased spasticity or rigidity or stiffness (Prastambha) of body parts, discoloration (Vaivarnya) of body parts, and weakness (Avasaadanam) of body parts without any known or visible cause denote an imminent death (Arishtha).[3]

Hasta Paada Ucchwasaadishu Shaityam

Warm (Swabhaava Ushnata Yukteshu) body parts or organs becoming colder (Shaityam) denote an imminent death (Arishtha). Cold hands (Hasta Shaityam), cold feet (Paada Shaityam), and decreased exhaled breath temperature (EBT, Ucchwasa Shaityam) should be considered as fatal (Arishtha).[3] Cold hands (Hasta Shaityam) indicate that the body is trying to retain heat.[88] RP is an exaggeration of the normal physiological response to cold exposure (Hasta Shaityam) with a triphasic color change of the digits. Raynaud's is the common presenting symptom for various connective tissue diseases such as lupus, scleroderma, and mixed connective tissue disease.[89] Hasta Paada Shaityam may also represent hypothermia due to conditions such as malnutrition, hypoglycemia, diabetic ketoacidosis, hypothyroidism, hypopituitarism, adrenal failure, renal failure, sepsis, shock, anorexia nervosa, dementia, schizophrenia, hepatic encephalopathy, stroke, Parkinson's disease (PD), multiple system atrophy (MSA), myopathy, peripheral neuropathy, Wernicke encephalopathy, ALS, and MS.[90] Cold extremities (Hasta Paada Shaityam) can be seen in connective tissue disease, peripheral neuropathy, hypothyroidism, and Flammer syndrome. Local and systemic hypoxia and vascular dysregulation are the well-known assumed pathologies of Flammer syndrome.[91] Cold hypersensitivity in the hands and feet (CHHF) is a sensation of coldness in the hands and feet (Hasta Paada Shaityam) or having a heightened cold sensation in a relatively low temperature area. CHHF is associated with DM, dyslipidemia, degenerative arthritis, chronic gastritis, gastroduodenal ulcer, reflux esophagitis, chronic rhinitis, hypertension, stroke, fatty liver, and angina pectoris (Arishtha?).[90] Cold extremities (Hasta Paada Shaityam) are normally a symptom of the complex syndrome known as primary vascular dysregulation. Cold extremities are normally a sign of reduced blood flow that can occur due to arteriosclerosis or dysregulation (e.g., vasospasms).[92]

Ucchwasa Shaityam denotes cold or reduced temperature of exhaled breath. EBT is a new method to detect and monitor pathological processes in the respiratory system. It is a noninvasive method and can be used for the evaluation of airway inflammation. It has been observed that an increase in age was associated with a decrease (Shaityam) in EBT (Ucchwasa).[93] The measurement of EBT can be done with a hand-held device that assesses the temperature plateau over multiple breaths.[94]

Patients with asthma have higher increases of EBT.[95] EBT reduction (Ucchwasa Shaityam) is associated with mean pulmonary artery pressure increase. Pulmonary hypertension (PH) can be correlated to the majority of cardiovascular and respiratory disorders (Arishtha?). EBT was lower (Ucchwasa Shaityam) in patients with more severe PH (Arishtha?). Reduced EBT values may reflect a decreased bronchial vascularization due to vascular degeneration in more advanced stages of PH (Arishtha?).[96]

Phutkaaraadishu Aushnyam

Increased temperature (Aushnyam) of mouth exhalations (Phutkaara) or increased EBT (Phutkaara Aushnyam?) or increased oral temperature (Phutkaara Aushnyam?) is considered as fatal (Arishtha).[3] EBT is correlated with oral temperature. EBT and oral temperature denote changes in the systemic temperature and are more accurate than auricular or axillary temperature.[97] Microbial activity in the oropharyngeal tract significantly contributes to the concentration of nitrogen oxides in exhaled breath condensate. Bacteria in the mouth can influence exhaled nitric oxide concentration (leads to increased temperature of mouth exhalations?).[98] In the oral cavity, temperature may be reached up to 37°C (Aushnyam). During exhaling also, humidity may be reached up to 96% in oral exhalations (Phutkaara). These conditions may provide a suitable environment for bacterial growth (Arishtha?).[99] The true temperature of gas at the mouth is less than 37°C (Swabhaavena Sheetatva Yukteshu Phutkaaraadishu). Expired air temperature measured at the level of the lips (Phutkaara) during a maximal forced expiratory maneuver in humans has shown a difference in between normal subjects and those with chronic airflow limitation (Arishtha?). Patients with chronic airflow limitation showed a higher expired temperature (Phutkaara Aushnyam) than that found in the normal subjects. Oral temperature also has a profound effect on expired temperature.[100] Hence, Phutkaara Aushnya (increased temperature of mouth exhalations) may represent an underlying fatal pulmonary disease or high oral temperature due to a systemic disease (inflammatory?).

Nayana Taarakaadishu Raukshyam

Roughness or dryness (Raukshyam) of sclera (Nayana?) and/or pupil (Taaraka or Nayana Taaraka) denote an impending death (Arishtha).[3] Dry eye syndrome or keratoconjunctivitis sicca (Nayana Raukshyam) is characterized by inflammation of the ocular surface and lacrimal glands. Dry eye symptoms (Nayana Taarakaadishu Raukhyam) may be a manifestation of a systemic disease, and they may denote a life-threatening condition (Arishtha). Patients with dry eye (Nayana Raukshyam) are prone to bacterial keratitis. Sjogren's syndrome is an autoimmune disease associated with lacrimal gland lymphocytic infiltration. Evaporative dry eye (Nayana Raukshyam) may occur due to  Meibomian gland More Details disease. Mucin deficiency due to Stevens–Johnson syndrome or ocular cicatricial pemphigoid is the underlying mechanism of dry eye. Systemic disorders, such as DM, thyroid disease, rheumatoid arthritis, and systemic lupus erythematosus (SLE) can also lead to dry eye (Nayana Taarakaadishu Raukshyam).[101] The structures such as the ocular surface (cornea, conjunctiva, and accessory lacrimal glands), meibomian glands, the main lacrimal gland (Nayana Taarakaadishu), and the innervation between them may be affected in dry eye disease (Raukshyam). Severe complications (Arishtha) of dry eye disease (Nayana Taarakaadishu Raukshyam) are observed in Sjogren's syndrome, ichthyosis, Stevens–Johnson syndrome, and xerophthalmia.[102]

Anabhyakta Kesha Twagaadishu Snigdhatvam

If scalp hair (Kesha) or skin (Twak) becomes sticky or excessive greasy (Snigdhatvam) without the application of oil (Anabhyakta), then it should be considered as a fatal sign (Arishtha).[3] Excessive greasiness or stickiness (Snigdhatvam) of scalp hair (Kesha) and/or skin (Twak) denotes excessive sebum production or seborrhea. Increased sebum production (cause Snigdhatvam) is higher in immunocompromised patients (Arishtha?) than in healthy adults. Conditions associated with excessive sebum production (Snigdhatvam) such as seborrheic dermatitis are more commonly seen in AIDS patients (Arishtha?). The present verse denotes an excessive sebum production (Snigdhatvam) due to underlying immunocompromised states or opportunistic scalp fungal infections or carcinomas or autonomic dysfunctions and conditions (Arishtha) due to which the scalp hair becomes sticky or oily or greasy (Snigdhatvam).[4]

Prastambha Angaanaam

Excessive rigidity or spasticity or hypertonia (Prastambha) of the body parts (Angaanaam) should be considered as a fatal sign (Arishtha).[4] Hypertonia (Prastambha) is a symptom of upper motor neuron dysfunction, and it is an umbrella term that includes all conditions characterized by stiff or tight muscles (Angaanaam?). Lower limb (Angaanaam?) spasticity (Prastambha) can be seen in stroke, MS, cerebral palsy (CP), and spinal cord injury (SCI) (Arishtha?). Rigidity (Prastambha) is a symptom seen with basal nuclei lesions, such as PD.[103] Spasticity (Prastambha) is a common consequence of lesions of upper motor neurons causing upper motor neuron syndrome.[104] Spasticity, rigidity, cramps, tetanic spasms, myotonia, neuromyotonia, and contractures (Prastambha) are the different names of clinical features related to muscle hypertonus. Muscle hypertonia (Prastambha) can be seen in various NMDs such as PD.[105] Rigidity or spasticity (Prastambha) can be seen in atypical parkinsonian syndromes (Arishtha?) such as PSP, MSA, corticobasal degeneration, and dementia with Lewy bodies,  Parkinsonism More Details-dementia-ALS, Huntington disease (HD), spinocerebellar ataxia, WD, frontotemporal dementia, and primary lateral sclerosis.[39] Spasticity (Prastambha) can also be seen in anoxia, TBI, and various neurodegenerative diseases (Arishtha?).[106] Dystonic symptoms (Prastambha) in childhood are seen in disorders of developmental delay, CP, autism, and neurometabolic, neuroinflammatory, and neurogenetic disorders (Arishtha?).[107] Prastambha Angaanaam denotes spasticity, rigidity, cramps, tetanic spasms, myotonia, neuromyotonia, contractures, etc.

Netrayo Anga Avayavaanaam Vaivarnyam

Discoloration (Vaivarnyam) of the eye (Netra), other body parts, and organs (Anga Avayavaanaam) insidiously (Akasmaat) denotes an imminent death (Arishtha).[3] Neela (blue/purple), Shyaava (brown/black), Taamra (reddish brown), Harita (green/yellowish green), and Shukla (pallor) are considered as pathological complexions, and sudden manifestation of them (without having any known cause) is considered as Arishtha (fatal).[5]

Skin becomes deadly pale or earth-like color or turns white (Vaivarnyam) in end-of-life (EOL) stage of senile dementia cases (Arishtha), and they are the characteristic signs of impending death (Arishtha).[108] Netrayo Vaivarnyam may denote Kayser–Fleischer rings caused by copper deposition in Descemet's corneal membrane, and they are visible by naked eye as a golden-brownish pigmentation (Vaivarnyam) around the limbus. WD may sometimes present with generalized hyperpigmentation (Vaivarnyam) of the skin. Pigmented purpuric dermatoses (Vaivarnyam) are seen in late-stage diabetes in patients with nephropathy and retinopathy (Arishtha?). Anga Avayavaanaam Vaivarnyam (discoloration of body parts or skin) may denote various fatal (Arishtha) underlying conditions such as cyanosis, melasma, Addison's disease, PIH, cutaneous amyloidosis, acanthosis nigricans, purpura, fungal infections in immunocompromised patients, HCC, hypomelanosis or hypopigmentation, basal cell carcinoma and squamous cell carcinoma (SCC), scleroderma, SLE, inflammatory and infectious dermatoses, Sturge– Weber syndrome More Details, melanocytic nevi, carcinoid syndrome, acroperniosis, melanoma, PVD, acrocyanosis, RP, and mottling at EOL stages. Skin acts like a mirror for various underlying diseases, especially malignancies. Internal malignancies (Arishtha) may lead to a number of cutaneous manifestations (Anga Avayavaanaam) such as flushing (Vaivarnyam) seen in carcinoid syndrome.[5]

Angaanaam Avasaadanam

Avasaadanam denotes either weakness or fatigue or flaccidity or hypotonia or floppiness. Weakness is a decrease in muscle strength, whereas fatigue is tiredness (with or without exertion). Weakness beginning in childhood may be the result of DMD. Localized (Angaanaam) and sudden onset of weakness suggests a cerebrovascular accident, progressive and severe weakness and fatigue indicate metastatic carcinoma, weakness exacerbated by effort and relieved by rest denotes MG, proximal muscle weakness suggests a myopathy, and distal muscle weakness indicates pyramidal tract disorder or peripheral neuropathy. Medical causes for fatigue and weakness include neurological (e.g., MG), malignant (e.g., pancreatic cancer), endocrine-metabolic (e.g., hypothyroidism), infectious (e.g., infectious mononucleosis), hematological (e.g., iron deficiency anemia), pulmonary (e.g., chronic obstructive lung disease), cardiac (e.g., heart failure), inflammatory (e.g., Crohn's disease), hepatic (e.g., hepatitis), renal (e.g., renal failure), and miscellaneous (e.g., nutritional deficiencies). Weakness and fatigue (Avasaadanam) may represent the first vague warning of disease (Arishtha?).[109] Acute neuromuscular paralysis (ANMP) is a common neurological emergency (Arishtha) characterized by rapid-onset muscle weakness (Anga Avayavaanaam Avasaadanam), progressing to maximum severity. ANMP carries high mortality (Arishtha), and it may lead to bulbar palsy, respiratory muscle weakness (Avasaadanam Angaanaam), or autonomic dysfunction. GBS is the most frequent cause of ANMP, and it accounts for respiratory muscles weakness (Angaanaam Avasaadanam) associated with neuromuscular disorders. ANMP can be seen in anterior horn cell disorders, poliomyelitis, West Nile virus, peripheral neuropathy, polyradiculopathy, porphyria, diphtheria, cytomegalovirus (CMV) polyradiculopathy, Lyme neuroborrelosis, toxins, polymyositis, dermatomyositis, acute rhabdomyolysis, etc., (Arishtha?). Complications of critical illness such as critical illness myopathy, critical illness neuropathy, and neuromuscular blockade are now considered as the main cause of weakness (Avasaadanam) in the seriously ill patients (Arishtha).[110] Progressive-acquired or hereditary NMDs are caused by an abnormality of any component of the LMN. Many NMDs are multisystem disorders affecting multiple organ systems (Anga Avayavaanaam) and characterized by muscle weakness or fatigue or floppiness or hypotonia (Avasaadanam) [Table 1].[55]

Swebhya staanebhya – Guru laghutvaani (Verse 4)

A body part or an organ, hanging down from its natural position (Avastrasta), or becoming raised (Utkshipta) or twisted round (Bhraanta), or cast obliquely or deviated laterally (Avakshipta) from its natural seat, or dropping off (Patita) or dislocation (Vimukta), or protruded (Nirgata), or drawn inward (Antargata), or suddenly becoming light (Laghutva) or heavy (Gurutva) without any visible cause (Akasmaat) should be considered as fatal (Arishtha) [Table 2].[3]

Avastrastvam Bhru Pakshmaadeenaam

The word Avastrastvam denotes hanging down (Pralambanam) or descent (Adha) of a body part or an organ from its normal anatomical position (Sthaanaat). Bhru Avastrastvam denotes brow ptosis, and Pakshma Avastrastvam denotes blepharoptosis. Acquired brow ptosis (Bhru Avastrastvam) can be caused by conditions such as aging, damage to the facial nerve, MG, myotonic dystrophy, oculopharyngeal muscular dystrophy, myopathy, viral infections, Ramsay Hunt syndrome, melanoma, SCC, and acoustic neuroma (Arishtha?).[111] Involutional blepharoptosis (Pakshma Avastrastvam) is multifactorial, and it is commonly seen in aging population. Thyroid disease, systemic collagen disease, myopathy, and/or cerebrovascular diseases are the medical conditions (Arishtha?) associated with abnormalities of position and motility of upper eyelid (Pakshma).[112]

Utkshiptatvam Bhru Pakshmaadeenaam

The word Utkshiptatvam denotes rising up or ascent (Urdhwa Gamanam) of a body part or an organ from its normal anatomical position (Sthaanaat). Bhru Utkshiptatvam denotes eye brow elevation, and Pakshma Utkshiptatvam denotes lagophthalmos. Hyperkinesis of the unilateral frontalis muscle may cause asymmetric brow elevation (Bhru Utkshiptatvam?). Conditions such as stroke, malignancy, trauma, and history of facial palsy (Arishtha?) can cause eyebrow asymmetry. Patients elevate the eyebrow (Bhru Utkshiptatvam) on the affected side to compensate ptosis (Bhru Avastrastvam), which may result in eyebrow asymmetry. Skeletal asymmetry of the orbital region can also cause eyebrow asymmetry (Bhru Utkshiptatvam with or without Bhru Avastrastvam). Eyebrow elevation (Bhru Utkshiptatvam) is a natural compensatory response to blepharoptosis (Pakshma Avastrastvam).[13] Lagophthalmos is defined as defective or incomplete closure of the eyelids (Pakshma Utkshiptatvam?). Paralytic lagophthalmos (Pakshma Utkshiptatvam) is caused by infections, tumors, trauma, and neurological, metabolic, idiopathic, toxic, and iatrogenic factors. Incomplete blink and lagophthalmos (Pakshma Utkshiptatvam) are seen in patients with PD and ocular myopathies (Arishtha?). History of head, neck, and cutaneous malignancy is the risk factor (Arishtha) in cases of lagophthalmos (Pakshma Utkshiptatvam).[13]

Chakshuraadeenaam Bhramanam

Bhraantatvam denotes circular movements or whirling, and Chakshu Bhramanam denotes abnormal eye movements, especially opsoclonus. Abnormal eye movements are common and prominent in movement disorders. Ocular motility examination should include recording of ocular misalignment, range of eye motion, involuntary eye movements, triggered nystagmus, saccades, optokinetic nystagmus, smooth pursuit, vestibulo-ocular reflex, and vergence eye movements. Various ocular motor deficits can be seen in movement disorders such as PD, PSP syndrome or HD, cortico-basal syndrome, MSA, ataxic syndromes such as spinocerebellar ataxia, Friedreich ataxia, episodic ataxia, ataxia telangiectasia, ataxia-oculomotor apraxia, paraneoplastic cerebellar degeneration, and HMDs such as essential tremor, WD, and Whipple's disease.[113] Opsoclonus is characterized by rapid, repetitive conjugate eye movements (Chakshu) that are involuntary, chaotic, arrhythmic, and multidirectional (horizontal, vertical, and torsional components) (Bhraantatvam or Bhramanam) without intersaccadic intervals. Opsoclonus-myoclonus syndrome (dancing eye and dancing feet syndrome) is associated with paraneoplastic syndromes (small cell lung cancer, ovarian teratoma, breast carcinoma, non-Hodgkin's lymphoma, malignant melanoma, and renal adenocarcinoma) (Arishtha?) and systemic infections.[114] Video-oculography (VOG) is an effective user- and patient-friendly tool to quantify eye movements, including changes in velocity, latency, and accuracy of saccades. Testing with VOG helps to quantify the eye movement abnormalities, to assess the progression of disease and also the response to treatment.[115]

Chakshuraadeenaam Avakshiptatvam

The word Avakshiptatvam denotes lateral deviation (Tiryak Kshiptatvam) or displacement of a body part or an organ or eyes (Chakshu). Horizontal conjugate eye deviation of both eyes away from the midline toward one side (Tiryak Kshiptatvam) is a common finding in unilateral infra- and supra-tentorial central lesions (Arishtha?). Partial and forced conjugate eye deviations (Tiryak Kshiptatvam) are found in patients with right hemispheric stroke (Arishtha?). Conjugate eye deviation (Tiryak Kshiptatvam) can be found in lesions involving the vestibular system. Patients with unilateral medullary infarction show conjugate eye deviation (Tiryak Kshiptatvam).[116] Internuclear ophthalmoplegia is an ocular movement disorder characterized by impaired adduction (Tiryak Kshiptatvam) of the ipsilateral eye (Chakshu) with nystagmus of the abducting eye, and it is seen in infarctions, demyelinating disorders such as MS, trauma, tentorial herniation, infections, tumors (medulloblastoma, glioma, lymphoma, metastases), vasculitis (SLE, Sjogren's syndrome), iatrogenic injury, and brainstem hemorrhage (Arishtha?). Similar clinical picture can also be seen in conditions such as VI nerve palsy, lateral gaze palsy, and one-and-half syndrome.[117] The eye in a “down-and-out” position (Tiryak Kshiptatvam) can be seen in third-nerve palsy (TNP), and it is an important sign of life-threatening aneurysms (Arishtha). TNP is caused by vascular ischemia, trauma, intracranial neoplasm, and hemorrhage (Arishtha?). DM and hypertension are the most common systemic causes of acquired TNP.[118] Conjugate eye deviation is a sustained shift in horizontal gaze (Tiryak Kshiptatvam) toward the affected hemisphere, and it can be seen in acute stroke (Arishtha?). Eye deviation (Tiryak Kshiptatvam) may be away in some cases from the side of the brain lesion such as in thalamic infarction (Arishtha?).[119] Gaze deviation (Tiryak Kshiptatvam) with a destructive lesion (e.g., stroke) of the frontal lobe, the patient “looks at the lesion,” and gaze deviation with an irritative lesion (e.g., hemorrhage), the patient “looks away from the lesion.”[120]

Shirogreevaadeenaam Adhaaryamaanata

The word Patitatvam denotes falling off (Adhaaryamaanata) or floppiness (Adhaaryamaanata) of a body part such as head and neck (Shirogreeva). Dropped head syndrome (DHS) (also known as floppy head syndrome) (Shirogreeva Adhaaryamaanata) manifests due to weakness (cause Adhaaryamaanata) of the posterior neck muscles (Greeva), and it can be identified with “chin on the chest” as well as “difficulty maintaining a forward gaze.” DHS can be seen in patients with NMDs (Arishtha?).[121] Various conditions have been found to be associated with DHS, and they can be categorized into neurological (ALS, PD, MSA, cervical dystonia, postpolio syndrome, cervical myelopathy, tardive dyskinesia, chronic inflammatory polyneuropathy), neuromuscular (MG, Lambert-Eaton myasthenic syndrome), muscular (inflammatory and noninflammatory myopathies, isolated neck extensor myopathy, and other causes (malignancy) (Arishtha?). Patients with DHS show difficulty holding up their head (Shrio Adhaaryamaanata).[122] In infant head lag, the head seems to flop around (Shiro Adhaaryamaanata) or lags posteriorly (Shirogreeva Adhaaryamaanata) behind the trunk. Head-and-neck control is affected by various conditions such as prematurity, cerebral injury, low birth weight, and environmental factors. Neonatal/infantile hypotonia with persistent or severe head lag (Shirogreeva Adhaaryamaanata) can be seen in conditions such as chromosome disorders (PWS), hypoxic-ischemic injuries, cerebral dysgenesis, SCIs, SMA, congenital hypomyelination neuropathy, familial dysautonomia, infantile neuronal degeneration, CNS infections, MG, muscular dystrophies, and myopathies (Arishtha?).[123]

Sandheenaam Moksha

The word Vimuktatvam denotes subluxation (Sramsa) or dislocation (Bhramsha) of joints (Sandheenaam). As per Parimarshaneeyam Adhyaya (3rd chapter) of Charaka Indriya Sthana, Sramsa (subluxation), Bhramsha (dislocation), and Dhaavana (deviation or varus or valgus deformities) of joints (Sandheenaam) could be fatal.[6] Generalized joint laxity and hyperlaxity (cause Vimuktatvam of Sandhi) can be seen in connective tissue disorders, such as EDS, Marphan syndrome, OI, and benign hypermobility syndrome. Acquired joint hyperlaxity is seen in athletes. The term “multidirectional instability” is defined as symptomatic involuntary instability (Vimuktatvam) in more than one direction.[6] Various joint dislocations and subluxations (shoulder, elbow, hip, finger, toe, temporomandibular joint, knee, sternoclavicular joint, patella, etc.) associated with fatal consequences come under the category of Sandheenaam Moksha.

Jihwa and Netra Bahirnissaranam

The word Nirgatatvam denotes coming out or protruding or bulging out (Bahirnissaranam) of a body part. Jihwa Bahirnissaranam denotes protrusion of the tongue. Tongue protrusion (Jihwa Bahirnissaranam) is an early sign of deep neck space infections such as parapharyngeal abscess.[124] Tongue protrusion (Jihwa Bahirnissaranam) can also be seen in tongue carcinoma (Arishtha).[125] Intermittent or sustained, severe, involuntary tongue protrusion (Jihwa Bahirnissaranam) can be seen in patients with a dystonic syndrome. Speech, swallowing, and breathing difficulties can be life-threatening (Arishtha). Causes include neuroacanthocytosis, neurodegeneration, Lesch-Nyhan syndrome, postanoxic, and tardive dystonia.[126] Macroglossia may cause protrusion of the tongue (Jihwa Bahirnissaranam) and total obstruction of the airway that subsequently leads to cerebral anoxia and sudden cardiac arrest (Arishtha).[127] Tongue protrusion (Jihwa Bahirnissaranam) is usually a component of oromandibular dystonia (OMD) or Meige's syndrome. OMD may occur as secondary to disorders such as CNS trauma, WD, hypoxic brain damage, metabolic disorders, and ischemic and demyelinating lesions in the upper brainstem (Arishtha?).[128] Tongue protrusion (Jihwa Bahirnissaranam) can also be seen in neuroacanthocytosis syndromes. Tongue protrusion (Jihwa Bahirnissaranam) is a striking and early finding in chorea-acanthocytosis.[129] Netra Bahirnissaranam denotes proptosis or exophthalmos of an eye. Proptosis, the protrusion (Nirgatatvam) of the eyeball (Netra) from the orbit (Sthaanaat), occurs due to various causes such as infectious (orbital cellulitis, mucormycosis, and mucocele), inflammatory (thyroid eye disease, granulomatosis with polyangiitis or Wegener's granulomatosis, sarcoidosis, and idiopathic orbital inflammation), vascular (orbital hematoma, retrobulbar hemorrhage, carotid-cavernous fistulas, orbital varices, orbital lymphatic malformations, capillary and cavernous hemangioma), orbital tumors, and other malignancies that can be life-threatening (Arishtha).[130]

Jihwa Netra Naasaadeenaam Antargatatvam

The word Antargatatvam denotes a body part that is drawn inward or pull inward (Antah Pravesha). Jihwa Antargatatvam denotes complete tongue protrusion palsy or tongue atrophy or paralysis of the tongue. Complete failure of tongue protrusion (Jihwa Antargatatvam) occurs after bilateral simultaneous cortical or hypoglossal nerve lesions or tandem ipsilateral peripheral (hypoglossal nerve/cranial nerve XII) and central (cortical) lesions (Arishtha?).[131] Tongue atrophy with or without fasciculation and difficulty in protruding the tongue (Jihwa Antargatatvam) can be seen in conditions such as NMDs (ALS),[132] bulbar and pseudobulbar palsy,[133] SMA,[54] and ischemic stroke (Arishtha?).[134] Infranuclear or supranuclear lesions of cranial nerve XII (hypoglossal nerve) causes paralysis, atrophy (Jihwa Antargatatvam), and fasciculation of the tongue on the ipsilateral or contralateral side. ALS, polio, syringobulbia, infarction, intraspinal tumors, lesions that affect the spinal accessory nerve, basilar meningitis due to granulomatous infection, or carcinoma (Arishtha?) can produce hypoglossal lesions.[135] Netra Antargatatvam denotes enophthalmos. Enophthalmos is defined as the posterior displacement of the globe in an anteroposterior plane within the orbit (Netra Antah Pravesha). It can be seen in orbital fractures, silent sinus syndrome, chronic maxillary sinus atelectasis, neurofibromatosis, age-related fat atrophy, orbital varices, lipodystrophy, linear scleroderma,  Parry-Romberg syndrome More Details, HIV infection, metastatic orbital disease, and fibrosis (Arishtha?).[136] Naasa Antargatatvam denotes saddle nose deformity (SND) (loss of height of the nose due to collapse of the nasal bridge) (Naasa Antah Pravesha), and its causes include traumatic, iatrogenic, inflammatory, infective, autoimmune, vasculitic, metabolic, drug-related, and degenerative causes. SND can also be seen in advanced SCC of the nasal septum (Arishtha?).[137]

Baahu Shira Sakthyaadeeni Laghutvam

The word Laghutvam denotes reduced mass or volume of an organ or a body part, and when it manifests without any visible or known cause (Akasmaat), it should be considered as fatal. Shiro Laghutvam denotes atrophy of the brain, and Baahu and Sakthi Laghutvam denote site-specific muscle (skeletal) loss. Brain mass is known to decrease (predominant loss in gray matter) (Shiro Laghutvam?) after severe weight loss in patients with anorexia nervosa (Arishtha?).[138] The brain shrinks (Shiro Laghutvam?) with increasing age, and the incidence of white matter lesions, stroke, and dementia (Arishtha?) also rises with age. The volume of the brain and/or its weight decline (Shiro Laghutvam) with age after age 40 at a rate of around 5% per decade. The shrinking of the gray matter (due to neuronal cell death) (Shrio Laghutvam) is commonly found in aging population.[35] Loss of muscle mass (Baahu and Sakthi Laghutvam?) is one of the most important changes associated with aging. Sarcopenia is characterized by critically low levels of muscle mass (Baahu and Sakthi Laghutvam?) that is associated with premature mortality (Arishtha).[139] Site-specific upper leg muscle loss (Sakthi Laghutvam) displayed an age-related increasing pattern. Severe muscle loss (Baahu and Sakthi Laghutvam) leads to increased risk of physical disability, metabolic disorders, cognitive decline, and mortality (Arishtha). Site-specific upper arm muscle loss (Baahu Laghutvam) is found in men aged 70–79 years. Site-specific upper arm muscle loss (Baahu Laghutvam) may be associated with a combination of age-related declines in physical activity and systemic etiologic factors (i.e., circulating cytokines and anabolic hormones, low-grade inflammation, insulin resistance, and nutrition) for age-related muscle loss (Laghutvam?).[140]

Akshi Pakshmaadeeni Gurutvam

The word Gurutvam denotes increased mass or volume of an organ or a body part that is pathological. Akshi Gurutvam denotes various conditions such as glaucoma,[141] eye cancers and orbital tumors,[142] bacterial, viral, fungal, and parasitic infections of the eye,[143] subconjunctival hemorrhage, and conditions causing exophthalmos.[144] Pakshma Gurutvam denotes conditions such as blepharitis,[145] monilethrix, pili torti, scurvy, Menkes syndrome, malignant tumors of hair follicles (primary mucinous carcinoma), eye lash infections, and infestations.[146]

Pravaala Varna Vyanga Praadurbhaava

Manifestation of reddish discoloration or rash or erythema (Atyanta Rakta Varna) suddenly without any known or visible cause (Akasmaat) is considered as fatal (Arishtha).[3] Vyanga is considered as facial melanosis characterized by painless (Niruja), bluish-black or brownish patches (Shyaava Varna), or pigmentation on face.[147] In the present verse, Vyanga with reddish discoloration (Raktatvam Vaikrutam) on face instead of brownish or blackish hyperpigmentation (Shyaavatvam Praakrutam) is considered as fatal (Vaikrutam/Arishtha).[3] SLE is a disease of unknown etiology (Akasmaat) characterized by appearance of malar rash (an erythematous rash over the cheeks and nasal bridge) (Atyanta Rakta Varna/Pravaala Varna Vyanga/Raktatvam), photosensitivity, and discoid rash. Other skin manifestations related to but not specific to SLE include RP, livedo reticularis (a reddish purple rash associated with severe vasculitis) (Pravaala Varna Vyanga), panniculitis (lupus profundus), bullous lesions, vasculitic purpura, telangiectasias, and urticaria. Complications of lupus can be serious and even life-threatening (Vaikrutam/Arishtha).[148] Erythroderma is a life-threatening (Arishtha) dermatitis described as an intense and widespread erythema (Atyanta Rakta Varna/Pravaala Varna Vyanga/Raktatvam). It occurs due to cutaneous and systemic diseases such as infections and malignancy (Arishtha?).[149] Stevens–Johnson syndrome and toxic epidermal necrolysis are characterized by skin tenderness, epidermal necrosis, erythema (Atyanta Rakta Varna/Pravaala Varna Vyanga/Raktatvam), and desquamation. Staphylococcal toxic shock syndrome is characterized by generalized erythema (Atyanta Rakta Varna/Pravaala Varna Vyanga/Raktatvam) with desquamation, fever, hypotension, and potential multisystem failure (Arishtha).[150]

Lalaate Siraanaam Darshanam

Bulging or prominent forehead (Lalaate) arteries or veins (Siraanaam) without any visible or known cause (Akasmaat) should be considered as fatal (Arishtha).[3] Bulging forehead veins (Lalaate Siraanaam) are seen in superior vena cava syndrome (SVCS). SVCS associated with malignancy leads to a significant drop in survival (Arishtha). Patients with cerebral and laryngeal edema associated with SVCS can develop life-threatening symptoms and suddenly die (Arishtha). Patients with SVCS as a result of lung cancer usually die within 24 months (Arishtha).[151] Spider veins (Siraanaam) are a colloquialism for telangiectasias (Siraanaam), and they are most often found on the legs and face (Lalaate?). Telangiectasia (Siraanaam) is the result of local anoxia, chronic venous insufficiency, varicosity, and incompetent valves in the deep venous network. The vascular neogenesis from local anoxia causes the small vessels to bulge and branch out, resulting in a spider-like appearance (Siraanaam Darshanam).[152] In frontal fibrosing alopecia (FFA), the frontal veins (Siraanaam) are evident (Darshanam) due to atrophy of the overlying skin of the forehead (Lalaate). Prominent venous vasculature on the forehead (Lalaate Siraanaam Darshanam) can be seen in patients with FFA.[153] Prominent (Darshanam) temporal artery (Siraanaam Lalaate?) can be seen in patients with polyarteritis nodosa associated with peripheral vascular disease (a necrotizing vasculitis that can be progressive and fatal) (Arishtha).[154] Temporal artery abnormalities such as prominent or enlarged (Darshanam) temporal artery (Siraanaam Lalaate?) can be seen in giant cell arteritis patients.[155]

Naasaavamsho Pidakotpatti

The word Naasaavamsho denotes bridge of the nose and Pidaka denotes an ulcer or skin lesion. Manifestation (Utpatti) of any ulcer or abnormal growth (Pidaka) either in nasal septum (Naasaavamsho?) or in nasal cavity without any visible or known reason (Akasmaat) is considered fatal (Arishtha).[3] Naasaavamsho Pidakotpatti having fatal consequences may denote various conditions such as malignancies of the nasal septum,[156] sinonasal malignancies (SCC, adenocarcinoma, olfactory neuroblastoma, malignant melanoma, and adenoid cystic carcinoma), sarcomas (chondrosarcoma and rhabdomyosarcoma), and hemoproliferative tumors (lymphoma).[157] The exophytic fungiform papilloma (Pidaka?) originates from the mucosa of the nasal septum (Naasaavamsho). B-cell lymphomas (Pidaka?) originate from the nasal septum (Naasaavamsho). The late symptoms of lymphoma are nonhealing ulcers (Pidaka?) and septum and bone destruction (Naasaavamsho). The spectrum of behaviors of lymphomas ranges from chronic indolent tumors (Pidaka?) to rapidly growing tumors (Pidaka?). Nasal septum (Naasaavamsho) is the most common origin for sinonasal mucosal malignant melanoma (Arishtha?).[158]

Lalaate Prabhaata Kaale Sweda

Excessive sweating (Sweda) on the forehead (Lalaate) during daytime (Prabhaata Kaale) without any visible or known cause (Akasmaat) should be considered as fatal (Arishtha).[3] Eccrine sweat glands are responsible for focal hyperhidrosis (FH, Sweda) and their density is highest in the forehead (Lalaate) along with palms and soles. FH (Lalaate Sweda) can be differentiated from generalized hyperhidrosis based on the medical history specific to location of excessive sweating (Sweda), duration of the presentation, family history, age at onset, and the absence of any apparent cause (Akasmaat). Gustatory sweating (Frey's syndrome) is also a form of focal hyperhidrosis (Sweda). Patients with FH generally do not sweat during sleep (only occurs in Prabhaata Kaala).[159] Emotional-induced sweating (Sweda) tends to be localized to forehead (Lalaate) and other parts of the body.[160] FH can occur on the entire face but especially on the forehead (where the highest concentration of eccrine sweat glands is found) (Lalaate Sweda), and it is predominantly diurnal (Prabhaata Kaale).[161] Secondary hyperhidrosis can be seen in pregnancy, menopause, obesity, autonomic degenerative disorders, fever, cerebral infarction, SCI, DM, Harlequin syndrome, hyperthyroidism, tuberculosis, pheochromocytoma, chronic infection, eccrine hamartomas, lymphomas, carcinoid syndrome, AIDS, and endocarditis (Arishtha?).[162]

Netra Rogaadvinaa Ashru Pravarutti

Excessive tears (Ashru Pravarutti) in the absence of eye disease (Netra Rogaadvinaa) should be considered fatal (Arishtha).[3] Netra Rogaadvinaa in the present verse denotes a hidden or silent disease rather than absence of an eye disease. True epiphora is an overflow of tears (Ashru Pravrutti) over the cheek. Primary-acquired nasolacrimal duct obstruction is the most common cause for epiphora. The secondary causes, which include infectious, neoplastic, inflammatory, traumatic, and mechanical blockage, are called secondary-acquired nasolacrimal drainage obstruction. Various causes such as fungus ball, pyogenic granuloma, sinonasal inverted papilloma, sinonasal inverted papilloma with synchronous SCC, and SCC of the lacrimal sac (Arishtha?) produce epiphora (Ashru Pravarutti).[163] Crocodile tears syndrome (CTS), also known as Bogorad syndrome, is characterized by lacrimation (Ashru Pravarutti) secondary to olfactory, gustatory stimuli, and mastication (Netra Rogaadvinaa). CTS is a complication of Bell's palsy. A slow-flow venous malformation of the petrous bone and facial nerve (Netra Rogaadvinaa?) may also cause CTS (Ashru Pravarutti).[164] Netra Rogaadvinaa Ashru Pravarutti may also denote dysfunctional tear syndrome.[165]

Gomaya Choornaabham Rajaso Uttamaange

Appearance of (Darshanam) cow dung-colored (Gomaya Choornaabham) powder (Rajas) on the scalp (Uttamaange) without any visible or known cause (Akasmaat) is considered fatal (Arishtha).[3] It has been found that seborrheic dermatitis (SD)/dandruff/Malassezia fungal proliferation (Gomaya Choornaabham Rajaso Darshanam) is commonly seen in patients with AIDS and PD (Arishtha?). Adult SD presents most often on the face and scalp (Uttamaange). The higher positive cultures of Malassezia species in immunocompromised patients (Arishtha?) confirm that impaired cellular immunity may favor fungal survival on the skin. SD is found in immunodeficiency (lymphoma and HIV-AIDS) and neurological and psychiatric conditions (PD, stroke, Alzheimer's dementia, autonomic dysfunction, and major depression).[11] Uremic frost (white-colored powdery frost can be seen, especially over the face and limbs) (Darshanam Rajaso Uttamaange) is a manifestation of advanced CKD (Arishtha?). The frost consists of a white or yellowish (Gomaya Choornaabham?) coating of urea crystals (Rajas) on the beard area and other parts of the face (Uttamaange), neck, and on the trunk. It occurs due to eccrine deposition of urea crystals (Rajas) on the skin of patients with severe uremia (Arishtha?).[9] Gomaya Choornaabham Rajaso Darshanam Uttamaange denotes either SD in immunocompromised patients or uremic frost in CKD patients.

Nilayanam Kanka Kaaka Kapotam Uttamaange

Birds such as Kanka (heron), Kaaka (house crow), and Kapota (pigeon) fly over or sit over (Nilayanam) one's head (Uttamaange) should be considered fatal (Arishtha).[3] The person nearer to death may emit different types of odors (Pushpita) that are abnormal and acquired. Hundreds of volatile organic compounds (VOCs) are emitted from the human body. Disease-specific VOCs can be used as diagnostic biomarkers of infectious, metabolic, genetic, and other diseases. Body odors can be considered as individual odor fingerprints, and pathological processes can modify them by producing new VOCs or by changing the ratio of VOCs. Various disease states are associated with a characteristic odor. Birds (Kanka, Kaaka, and Kapota?) can detect odors in several ecological contexts. The ability to detect the chemical cues of predators and use them to ascertain predators can be seen in some bird species such as Passeriformes (house crow - Corvus splendens) (Kaaka). Birds are able to perceive odors in the process of foraging. Vultures and insectivorous birds appear to use olfaction to locate carcasses and to find their food. Birds can detect the chemical cues emitted by the prey. Natural predators are able to detect the chemical cues of their prey. Predatory birds could be visually attracted to the ultraviolet light reflected by the feces and urine marks of their mammal prey.[166] The person nearer to death (Arishtha) may emit disease-specific VOCs, and birds such as Kanka, Kaaka, and Kapota may detect those chemical cues and fly near to those persons.

Mutra Purisha Vriddhi Abhunjaanaanaam

Increased amount and/or frequency of urine (Mutra Vriddhi) and feces (Purisha Vriddhi) in spite of reduced food and/or water (Abhunjaanaanaam) intake should be considered as fatal (Arishtha).[3] Mutra Vriddhi with Abhunjaanaanaam denotes polyuria with reduced intake of food and/or water. Polyuria (Mutra Vriddhi) is commonly seen in critically ill patients. Various syndromes such as acute nonoliguric renal failure, polyuria of sepsis, and inappropriate secretion of antidiuretic hormone (Arishtha?) are associated with polyuria. Purisha Vriddhi with Abhunjaanaanaam denotes diarrhea or excessive quantity and/or frequency of stool in spite of reduced intake of food. Diarrhea (Purisha Vriddhi) is commonly seen in patients with advanced cancer (may be associated with cachexia and reduced appetite) (Abhunjaanaanaam). Cancers can cause malabsorption syndromes (Purisha Vriddhi) that are characterized by increased fecal fat (Purisha Vriddhi?).[7] Cachexia is associated with increased morbidity (Arishtha), and it is seen in malabsorption (Purisha Vriddhi?). Cachexia occurs in the majority of cancer patients before death (Arishtha).[167]

Tat Pranaasho Vaa Bhunjaanaanaam

The word Tat Pranaasho denotes Mutra Pranaasha and Purisha Pranaasha. Decreased amount and/or frequency of urine (Mutra Pranaasha) and feces (Purisha Pranaasha) in spite of normal food and/or water (Bhunjaanaanaam) intake should be considered as fatal (Arishtha).[3] Mutra Pranaasha denotes auria or oliguria or urinary retention in critically ill patients (Arishtha). Oliguria (Mutra Pranaasha) is observed in many critically ill patients such as AKI and chronic liver disease (Arishtha). Urinary retention (Mutra Pranaasha) can be classified as obstructive (benign prostatic hyperplasia, meatal stenosis, prostate cancer, gynecologic malignancy, pelvic mass, bladder calculi or neoplasm, gastrointestinal or retroperitoneal malignancy, urethral strictures, etc.), infectious and inflammatory, neurological (autonomic neuropathy, DM, GBS, herpes zoster virus, Lyme disease, pernicious anemia, cerebrovascular disease, MS, brain tumors, PD, Shy-Drager syndrome, dysraphic lesions, spinal cord hematoma, spinovascular disease, transverse myelitis, tumors of conus medullaris, etc.), and others (urethral sphincter dysfunction) (Arishtha).[7] Decreased urine output (Mutra Pranaasha) can be seen in CKD that is associated with adverse clinical outcomes such as ESRD, CVD, and increased mortality (Arishtha).[168] Purisha Pranaasha denotes either low quantity of feces or FI in critically ill patients (Arishtha). Low fecal weight (Purisha Pranaasha?) and slow bowel transit time are thought to be associated with bowel cancer risk (Arishtha). Low stool weight (Purisha Pranaasha) is associated with conditions such as constipation, irritable bowel syndrome, gallstones, disordered anorectal function, and abnormal cells in breast ducts (Arishtha?). FI (Purisha Pranaasha?) is a common finding in diverticulitis, in colon cancer, and in the elderly population (Arishtha?). FI is associated with risks of complications (Arishtha) such as bowel obstruction, stercoral ulcers, perforation, and peritonitis.[7]

Shoolotpatti Stanamoola Hrudaya Urassu Cha

Pain (Shoola) at right and left hypogastric regions or right and left upper quadrants (Stanamoola), left hypochondriac region or cardiac region (Hrudaya), and chest wall (Uras) should be considered as fatal (Arishtha).[3] Various conditions such as chest wall syndrome (CWS), coronary heart disease (CHD), CVD, acute coronary syndrome/MI, gastrointestinal disorders, respiratory diseases, and esophageal disorders can cause chest pain (Shoolotpatti Urassu Cha). Chest pain (Shoolotpatti Urassu Cha) may also be caused by acute and life-threatening conditions (Arishtha) such as CHD,[169] pulmonary embolism, and acute coronary syndrome.[170] Chest pain (Shoolotpatti Urassu Cha) is located in the left anterior thoracic region (Shoolotpatti Hrudaya) between the sternum and the anterior axillary line and in the retrosternal region in the patients with CHD and CWS. The pain of gastroesophageal reflux disease is located mainly in the retrosternal region.[171] Right and left upper quadrant pain (Shoolotpatti Stanamoolayo?) can be seen in conditions such as cholecystitis, cholelithiasis, cholangitis, colitis, diverticulitis, hepatic abscess, hepatitis, pneumonia, pulmonary embolus, nephrolithiasis, pyelonephritis, angina, MI, pericarditis, esophagitis, gastritis, peptic ulcer, pancreatitis, pancreatic mass, aortic dissection, and mesenteric ischemia.[172]

Madhye Shoonatvam Anteshu Parimlaayitvam

Swollen or edematous middle body (chest and abdomen) (Madhye Shoonatvam) along with emaciated or atrophied (Parimlaayitvam) peripheral parts of the body (upper and lower limbs) (Anteshu) should be considered as fatal (Arishtha).[3] The present verse denotes various conditions such as marasmus, kwashiorkor, protein energy malnutrition (PEM), distal myopathies, peripheral neuropathies, and NMDs. Marasmus is associated with high mortality (Arishtha). The general appearance is shrunken and wasted (Parimlaayitvam) due to reduced levels of subcutaneous fat in malnutrition cases. Lesser (<115 mm) middle upper arm circumference (MUAC) (Anteshu Parimlaayitvam) is one of the diagnostic features of marasmus. Marasmic kwashiorkor child may present with growth stunting, wasting (Parimlaayitvam), and edema (Shoonatvam). Abdominal distension (Madhye Shoonatvam), edema (Shoonatvam), and an enlarged fatty liver can also be seen. Severe muscle wasting (sarcopenia) (Parimlaayitvam) can be found in some patients with cirrhosis and hepatocellular cancer (Madhye Shoonatvam?).[12] Distal myopathy presents with weakness of distal extremities and progressive atrophy of the corresponding distal muscles (Anteshu Parimlaayitvam) at the onset; other muscles can be affected at a later stage of the disease.[173]

FSHD has a distinct initial pattern of muscle involvement, affecting the facial muscles, shoulder girdles, and upper arms (Anteshu Parimlaayitvam), followed by weakness of the trunk, distal lower extremities (Anteshu Parimlaayitvam), and more proximal muscles later in the disease course. Protuberant abdomen (Madhye Shoonatvam) can also be seen in FSHD.[47] Aging is accompanied by major changes including a progressive decrease in muscle mass, strength, and quality (Anteshu Parimlaayitvam?) accompanied by an increase in fat mass (Madhye Shoonatvam?). Hypogonadal states are also associated with increased truncal obesity (Madhye Shoonatvam?), which might contribute to high concentrations of cytokines that further contribute to sarcopenia (Parimlaayitvam).[174] Muscle wasting with muscle volume decrease in the quadriceps femoris muscle (Anteshu Parimlaayitvam) and in abdominal muscles (may lead to protruberant abdomen-Madhye Shoonatvam?) can be seen in ICU patients (Arishtha). Ultrasonographic measurements in ICU patients have shown reduced muscle size and muscle quality decline in both upper and lower limb muscles (Anteshu Parimlaayitvam).[175]

Viparyayo Vaa

The word Viparyayo Vaa denotes Ante Shoonatvam with Madhye Parimlaayitvam. Swelling or edema of the upper and lower limbs (peripheral edema) (Ante Shoonatvam) along with emaciated or atrophied or lean (Parimlaayitvam) central body (chest and abdomen) (Madhye) should be considered as fatal (Arishtha).[3] Peripheral edema (Ante Shoonatvam) can be seen in various conditions such as right ventricular failure, constrictive and restrictive cardiomyopathy, end-stage liver disease, cirrhosis of liver, acute and chronic renal failure, nephrotic syndrome, PEM, malabsorption, kwashiorkor, lymphedema, angioedema, and myxedema.[176]

Ardhaange Shwayathu Sosho Anga Pakshayorvaa

Edema (Shwayathu) or weakness or atrophy (Sosha) in half of the body (Ardhaange or Paksha) (right or left or upper or lower) should be considered as fatal (Arishtha).[3] Lymphedema and venous edema can also be bilateral unequal and bilateral equal (Ardhaange Shwayathu). Older patients may present with bilateral leg edema (Ardhaange Shwayathu) due to cardiac, renal, hepatic, and endocrine causes. An endocrine disorder can be accompanied with bilateral swelling (Shwayathu). Slow-onset unilateral or bilateral edema (Shwayathu) in older patients may occur due to retroperitoneal masses (Arishtha) compressing the inferior vena cava or iliac veins in the abdomen and pelvis.[177] Bilateral upper arm swelling (Ardhaange Shwayathu) can be seen in patients with esophageal adenocarcinoma.[178] Patients with psoriatic arthritis may present with bilateral upper extremity lymphedema (Ardhaange Shwayathu).[179] Loss of muscle strength may be complete (paralysis, plegia) or incomplete (weakness, paresiss) (Sosha?). Ardhaange Sosha and Pakshayo Sosha represent conditions such as hemiplegia (one side of the body is paralyzed) (Sosha Pakshayo), paraplegia (paralysis of both legs) (Ardhaange Sosha), and diplegia (paralysis of like parts on the two sides of the body) (Ardhaange Sosha). Ischemic stroke is characterized by weakness in one-half of the body (Pakshayo Sosha). Hereditary spastic paraplegia patients may present with progressive weakness in lower extremities (Ardhaange Sosha). CMV polyradiculopathy is clinically characterized by lower extremity weakness (Ardhaange Sosha). Trauma, vascular diseases, infections, and inflammatory and autoimmune disease may affect the spinal cord and can cause paraplegia (Ardhaange Sosha). Chronic myelopathies including spondylotic myelopathy, vascular malformations, retrovirus-associated myelopathy (HIV), syringomyelia, MS, combined subacute degeneration (Vitamin B12 deficiency), tabes dorsalis, and familial spastic paraplegia may represent Ardhaange Sosha.[5]

Nashta Heena Vikala Vikruta Swarataa

Voice disorders (Vikruta Swarataa) such as Nashta (aphonia), Heena (hypophonia), Vikala (stuttering or stammering), and Vikruta (dysphonia) are considered as fatal (Arishtha).[3] The voices such as Edaka (sheep), Kala (feeble), Grasta (inaudible), Avyakta (indistinct), Gadgada (chocked), Kshaama (hoarse or rough), Deena (difficulty or painful), and Anukeerna (stuttering or stammering) are considered as pathological, and they denote an imminent death (Arishtha). Various factors such as organic (vocal cord malformations, trauma, inflammation, infections, and neoplasms), neurological, and functional causes can produce dysphonia. Voice abnormalities (Vikruta Swarataa) can be seen in conditions such as transient ischemic attack, seizures, migraine aura, MS, NMDs, MG, unilateral vocal cord palsy (seen in primary and metastatic lung, laryngeal, thyroid, and CNS carcinomas), neoplasm of the larynx, pharynx, lungs, thyroid and lymphoma, mediastinal metastases from the breast, lungs, or other cancers, as well as in immunocompromised patients (Arishtha).[5]

Vivarna Pushpa Praadurbhaavo Danta Mukha Nakha Shareereshu

Sudden (without having any known or visible cause) appearance (Praadurbhaavo) of noninflammatory or nonreddish (Anujjwala Varna) discoloration or pigmentation (Vivarna Pushpa) on teeth (Danta), face (Mukha), nails (Nakha), and whole body (Shareereshu) indicates an imminent death (Arishtha).[3] Pushpa Praadurbhaavo Danteshu indicates dental plaque or chalky white discoloration (Vivarna) of teeth or dental calculus. White spot lesions (WSLs) (Pushpa?) appear as a milky white opacity (Anujjwala Varna) on teeth (Danta). WSLs (Pushpa Praadurbhaavo Danteshu) are also seen in fluorosis, hypomaturation, hypomineralization, and hypoplasia. Dental fluorosis is characterized by symmetrical patterns of enamel discoloration (Vivarna), and it presents as enamel flecking to diffuse opaque mottling superimposed on chalky white or dark brown or black areas (Anujjwala Varna Pushpa Danteshu). Periodontitis is characterized by dental plaque (Pushpa) and periodontal pockets (Pushpa), and it is positively associated with the risk of oral, lung, and pancreatic cancers (Arishtha).[4] Chronic periodontitis is associated with CHD, CVD, COPD, pneumonia, head and neck SCC, oral cavity SCC, lung, kidney, pancreas, and hematological cancers (Arishtha).[6] Vivarna Pushpa Praadurbhaavo Mukheshu denotes sudden manifestation of various hyperpigmented skin lesions.[3] Sudden appearance of Piplu (acne), Vyanga (hyperpigmentation or discoloration), Tilakaalaka (mole or nevus), and Pidaka (papules or vesicles or blisters) on the face indicates an imminent death (Arishtha). Vivarna Pushpa Praadurbhaavo Mukheshu may denote various conditions such as basal cell carcinoma, SCC, scleroderma, SLE, inflammatory and infectious dermatoses,  Sturge-Weber syndrome More Details, viral and fungal skin infections, melanocytic nevi, carcinoid syndrome, melanoma, and cutaneous manifestations due to various internal malignancies (Arishtha).[5]

Nail findings may denote a plethora of systemic conditions. Chromonychia is a nail disorder (Nakheshu) characterized by onycholysis and green-black discoloration (Anujjwala Varna Pushpa Praadurbhaavo) of the nail bed. Vivarna Pushpa Praadurbhaavo Nakheshu may denote nail surface abnormalities (beau's lines, longitudinal ridging, nail pitting, and onychoschizia) and abnormalities related to nail color (leukonychia, melanonychia, splinter hemorrhages, HIV-associated dyschromia, and white nail, red nail, and yellow nail syndrome). Melanonychia (Vivarna Pushpa Praadurbhaavo Nakheshu) is a longitudinal or transverse brownish black pigmentation (Anujjwala Varna) of the nail (Nakheshu) seen in lichen planus, melanocytic nevus or malignant melanoma, hemochromatosis, thyroid disease, HIV infection, malnutrition, and Addison's disease (Arishtha?). Yellowish discoloration of nails (Anujjwala Varna Nakheshu) denotes severe form of liver disease or hemolysis (Arishtha?). Splinter hemorrhages (Vivarna Pushpa Praadurbhaavo Nakheshu) in nails can be seen in psoriasis, infective endocarditis, rheumatic heart disease, SLE, antiphospholipid syndrome, and congenital heart diseases (Arishtha?).[11] Vivarna Pushpa Praadurbhaavo Shareereshu denotes sudden manifestation (Akasmaat Praadurbhaavo) of hyperpigmented skin lesions or discoloration (Vivarna) all over the body (Shareereshu) due to various underlying fatal systemic diseases (Arishtha) as explained in the previous sections, “Krishnaanaam Shuklatvam,” “Shuklaanaam Krishnatvam,” “Raktaanaam Anya Varnatvam,” and “Netrayo Anga Avayavaanaam Vaivarnyam.”

Apsu Kapha Purisha Retaamsi Nimajjati

The patient whose sputum (Kapha), stool (Purisha), and semen (Retas) do not float on water or sink in water (Nimajjati Apsu) indicates an imminent death (Arishtha) to that patient.[3] Sputum (Kapha) may sink in water (Apsu Nimajjati) due to increased specific gravity caused by the various abnormal components in it. Carcinomas, tuberculosis, lung abscesses, various inflammatory and infectious diseases of the respiratory tract, cystic fibrosis, asthma, COPD, and bronchiectasis (Arishtha) may lead to the increased specific gravity of sputum (due to the presence of pus cells, cell debris, bacteria, and various other abnormal components of sputum) (Kapha Apsu Nimajjati).[8] Retaamsi Apsu Nimajjati (sinking of semen in water) denotes various conditions such as pyospermia (pus and high white blood cell concentrations in the semen due to infections) and hemospermia (blood in the semen). Chronic hematospermia can be seen in prostatitis, polyps, cysts, stones, telangiectasias, varices, carcinoma, condylomas, hemangiomas, sarcoma, strictures, infections, leukemia, epididymo-orchitis, lymphoma, and testicular tumors (Arishtha?). Various abnormal components of semen (Retas) may increase the specific gravity (leads to Apsu Nimajjati).[8] Various abnormal components of stool (Purisha) increase the specific gravity or hardness or weight of the stool (leads to Apsu Nimajjati) in various conditions such as pancreatic or intestinal diseases, carcinomas of gastrointestinal tract, ulcerative colitis, and megacolon (Arishtha?).[10]

Drushti Mandale Bhinna Vikruta Rupaani Aalokyante

If any abnormal shapes or images or objects (Bhinna Vikruta Rupaani) are noticed, when looking at a person's eye (Drushti Mandale) indicates an imminent death (Arishtha) to that person.[3] The present verse indicates distortion or loss of the image (Bhinna Vikruta Rupaani) reflected (Aalokyante) in the pupil (Drushti Mandala) of patient's eye. Same phenomenon is used as “Red reflex testing” to test corneal or pupil reflections for diagnosing various eye diseases. A darkened reflex (absent red reflex) indicates cataract, a hazy cornea, a hemorrhage, or a scar. A white reflex indicates a malignant tumor, a retinal infection, a cataract, or a scar. Leukocoria or a white pupillary reflex can be seen in RB, infantile cataracts, systemic syndromes, TORCH, Coat's disease, corneal scarring, toxocariasis, and optic disc coloboma (Arishtha?).[7] The present verse represents the analysis of corneal reflections for estimating prognosis.

Snehaabhyakta Kesha Anga Iva Yo Bhaati

Sudden manifestation (Akasmaat) of greasy or oily (Snehaabhyakta Iva Bhaati) skin (Anga?) and/or scalp hair (Kesha) should be considered as fatal (Arishtha).[3] Excessive greasiness or stickiness (Snehaabhyakta Iva) or scalp hair (Kesha) is due to excessive production of sebum due to various underlying conditions. Increased sebum production (may cause Snehaabhyakta Iva Bhaati) is higher in immunocompromised patients (Arishtha?). Seborrheic dermatitis has been reported to occur significantly in AIDS patients (Arishtha?).[4] Oily skin (Snehaabhyakta Iva Anga) is a common dermatologic concern characterized by larger facial pores and an unclean or greasy appearance (Snehaabhyakta Iva Bhaati). Premenopausal women during ovulation and conditions with elevated androgen levels (congenital adrenal hyperplasia and androgen-secreting tumors of ovaries or adrenal glands) (Arishtha?) are associated with oily skin.[180]

Yashcha Durbalo – Trishnaabhibhoota

A person suffering with weakness (Durbala), loss of appetite (Bhakta Dvesha), diarrhea (Atisaara), cough (Kaasa), and thirst (Trishna) will not survive for long (Arishtha).[3] The present verse denotes malignancies of either respiratory or gastrointestinal tract associated with cancer anorexia-cachexia syndrome (CACS). In the last days of life (Arishtha), cancer patients often experience progressive functional decline (Durbala) and many symptoms such as anorexia-cachexia (Bhakta Dvesha and Maamsa Heena), dysphagia, delirium, and decreased ability and desire to eat/drink (Bhakta Dvesha?) with weight loss (Durbala). Cough (Kaasa) is one among the many symptoms that is prevalent in the last 7 days of life (Arishtha). These symptoms can have a major impact on nutrition and hydration, contributing to reduced oral intake, dehydration (may cause Trishna), and weight loss (Durbala/Bala Heena).[181] Loss of appetite (Bhakta Dvesha), cough (Kaasa), diarrhea (Atisaara), fatigue (Durbala), etc., symptoms can be seen in lung cancer patients (Arishtha?). Malnutrition (Durbala and Bhakta Dvesha) is often seen in patients with advanced cancer, and it does not respond to treatment (Arishtha).[182]

Ksheena Chardi – Shoolaabhipannasya Manushya

A person suffering with weakness (Ksheena), vomiting (Chardi), loss of appetite (Bhakta Dvesha), frothy sputum mixed with blood and pus (Saphena Puya Rudhira Vaami), hoarseness of voice (Hata Swara), and pain (Shoola) will die (Arishtha).[3] The present verse denotes conditions such as life-threatening lung abscesses or excavating bronchial carcinomas. The clinical features of lung abscess in children include a cough, fever, tachypnea, dyspnea, chest pain (Shoolaabhipanna), vomiting (Chardi), sputum production (Saphena Vaami?), weight loss (Ksheena), and hemoptysis (Rudhira Vaami). Lung abscess remains a life-threatening condition (Arishtha).[183] Early signs and symptoms of lung abscess include fever, cough, night sweats, dyspnea, weight loss, and fatigue (Ksheena) and chest pain (Shoolaabhipanna). Cough remains productive, sometimes followed by hemoptysis (Saphena Rudhira Vaami). Excavating bronchial carcinomas such as squamocellular or microcellular carcinoma (Arishtha?) are commonly present with thicker wall compared to infectious lung abscess. Absence of febricity, purulent sputum (Saphena Puya Vaami), and leukocytosis can indicate the carcinoma (Arishtha?) and not the infective disease.[184] Cough, hemoptysis (Saphena Rudhira Vaami), thoracic inlet (Pancoast) syndrome with shoulder and arm pain (Shoolaabhipanna), chest pain, bone pain (Shoolaabhipanna), voice change (due to involvement of recurrent laryngeal nerve) (Hata Swara), phrenic nerve involvement (Chardi?), and weight loss (Ksheena) are the possible presenting features of lung cancer (Arishtha?).[185]

Shoona Kara Charana – Jwara Kaasaabhibhuta

Features such as edema (Shoona) of hands (Kara), feet (Charana), and face (Vadana), weakness (Ksheena), loss of appetite (Anna Dvesha), muscular atrophy (Shithila Maamsa Pinda) of calf (Jaanu Gulphaantaraala Sthita), shoulder (Amsa), palms (Paani), and soles (Paada), fever (Jwara), and cough (Kaasa) indicate an imminent death (Arishtha).[3] The present verse denotes various conditions such as marasmic kwashiorkor with respiratory tract infections, HIV wasting syndrome, and NMDs with bulbar involvement. The general appearance is shrunken and wasted due to reduced levels of subcutaneous fat in marasmus (Shithila Maamsa Pinda). Weight loss (Ksheena) is most noticeable in the groin, axilla, buttocks, face, and thigh. Pitting edema (Shoona Kara Charana) can be seen in kwashiorkor. Reduced MUAC (Shithila Maamsa Pinda) is a characteristic of marasmus. Edema leads to a characteristic round-faced appearance (Shoona Vadana). Bilateral pitting pedal edema (Shoona Charana) is a characteristic of kwashiorkor. Respiratory tract infections (Jwara and Kaasa) are associated with marasmus.[186] Acquired peripheral neuropathies are the most common NMDs. Other acquired NMDs include ALS, poliomyelitis, GBS, MG, and polymyositis. Hereditary NMDs are SMA, CMT disease, congenital myasthenia, and DMD. NMDs are characterized by muscle weakness/atrophy/wasting (Srasta Pindika Amsa Paani Paada). Patients with focal shoulder girdle weakness, as in FSHD and LGMD, may show characteristic patterns of muscle atrophy (Shithila Maamsa Pinda) and scapular displacement (Srasta Amsa). Involvement of palatal, pharyngeal, and laryngeal muscles may produce dysphagia (Anna Dvesha?). Chewing, swallowing (Anna Dvesha?), and speech articulation difficulties denote bulbar involvement, and they may lead to aspiration pneumonias or recurrent pulmonary infections (Jwara and Kaasa). A history of weight loss (Ksheena) may be due to recurrent illnesses, nutritional compromise, swallowing difficulty, or progressive lean tissue atrophy (Shithila Maamsa). Many NMDs are multisystem disorders affecting multiple organ systems (Arishtha?).[55]

Yastu Purvaahne Bhukta – Sa Shwaasaanmriyate

Features such as postprandial vomiting (Purvaahne Bhuktam Aparaahne Chardayati) containing undigested food materials or particles or nonbilious (Avidagdha?), diarrhea (Atisaara), and dyspnea (Shwaasa) indicate an imminent death (Mriyate).[3] The present verse denotes gastric outlet obstruction (GOO) due to various fatal underlying causes. Peptic ulcer disease, Crohn's disease, tuberculosis, strictures, large gastric polyps, Bouveret's syndrome, annular pancreas, pancreatic pseudocyst, and bezoars are the benign causes for GOO. Pancreatic and gastric cancer, lymphomas, duodenal carcinoma, biliary tract carcinoma, ampullary carcinoma, and metastatic malignancies are the causes for malignant GOO (Arishtha?).[187] Trichobezoars (masses made of hair) can cause GOO along with nausea, vomiting (Chardi), weight loss, malnutrition, diarrhea (Atisaara), etc., Trichotillomania (TTM) and trichophagia can cause increased airway resistance as a primary component of laryngeal collapse and unusual dyspnea (Shwaasa).[188] Patients with malignant bowel obstruction typically present with colicky abdominal pain, anorexia, nausea, vomiting (Chardi), paradoxical diarrhea (Atisaara), and fecal incontinence (i.e., overflow diarrhea) (Atisaara) suggest partial obstruction. Dyspnea (Shwaasa) may also occur in malignant ascites (Mriyate?).[189] Chronic pyloric obstruction can cause delayed gastric emptying with postprandial gastric distention and vomiting of food more than 8 h after a meal (Purvaahne Bhuktam Aparaahne Chardayati).[190] Dyspnea (Shwaasa) can be seen in chronic granulomatous disease (CGD) with GOO. GOO may be the initial presentation of CGD.[191] Gastric pneumatosis is seen in GOO and patients may present with dyspnea (Shwaasa) and repetitive vomiting (Chardi).[192]

Bastavat Vilapan – Srasta Mushka

The patient who falls to the ground (Bhumau Patati) with crying (Vilapan) like a goat (Bastavat) and exhibits sagging testicles (Srasta Mushka) should be considered as dead (Arishtha).[3] The present verse denotes a condition of dacrystic epilepsy. Dacrystic seizures are characterized by paroxysmal stereotyped crying (Vilapan) with lacrimation, grimacing, sobbing, sad facial expression, yelling, and a subjective feeling of sadness. Crying seizures may present as “spasmodic crying” (Bastavat Vilapan?). Patients with dacrystic seizures generally have an underlying structural brain lesion and often have a poor prognosis (Arishtha).[193] Uncontrollable attacks of weeping (Bastavat Vilapan?) culminating in loss of consciousness and falling (Bhumau Patati) can be seen in glioma of interpeduncular space infiltrating upper pons, third nerve, and optic chiasms (Arishtha?).[194] Ictal crying (Vilapan) can be seen in hypothalamic hamartoma (HH), tumors, vascular malformations, hippocampal sclerosis, and cerebral infarction (Arishtha?). Crying seizures (Vilapan) have been found to be associated with frontal or temporal focal epilepsy and simple or complex partial seizures. More than half of the patients with HH also suffer from other types of seizures, such as falling seizures (Bhumau Patati).[195] Falling (Bhumau Patati) may occur during an epileptic seizure, and it can be seen in partial seizures also when secondary generalization follows. Falls may result from an atonia in postural muscles, leading to a loss of balance (Bhumau Patati). Epileptic drop attacks (Bhumau Patati) are defined as a sudden fall without warning, associated with or without loss of consciousness. Epileptic drop attacks may also occur due to a brief atonia of antigravitational muscles (atonia of cremaster muscle and cause sagging testicles - Srasta Mushka).[196]

Stabdha Medhro Bhagna Greeva Pranashtha Mehanashcha

Clinical features such as having penile erections (Stabdha Medhra), curved neck or cervical pathology (Bhagna Greeva or Nata Greeva), and penile damage or loss of erections (Pranashtha Mehana) should be considered fatal (Arishtha).[3] The present verse denotes priapism associated with its complications such as erectile dysfunction (ED) or penile damage due to an underlying cervical spinal cord lesions or SCIs. Priapism is defined as a prolonged and persistent erection of the penis (Stabdha Medhra) without sexual stimulation. Complications of priapism (Stabdha Medhra) are devastating due to the irreversible erectile damage and resultant ED (Pranashtha Mehana). Penile erection in priapism (Stabdha Medhra) lasts greater than 4 h and associated with risks of structural damage to the penis (Pranashtha Mehana) and permanent ED.[197] Lesions and injuries of the cervical spinal cord (Bhagna Greeva or Nata Greeva) are most frequently associated with priapism (Stabdha Medhra). Low-flow ischemic priapism (Stabdha Medhra) may lead to permanent corporal fibrosis and permanent impotence (Pranashtha Mehana).[198]

Praagvisushyamaana Hrudaya Aaardra Shareera

Chest (Hrudaya) drying off (Visushyamaana) earlier (Praak) compared to other body parts (Aaardra Shareera) indicates an imminent death (Arishtha) and also higher temperature in chest. Various chest diseases and conditions (Hrudaya) such as contusions, fractures, carcinomas, lymphomas, melanomas, and infections are commonly associated with regional vasodilation, hyperthermia, hyperperfusion, hypermetabolism, and hypervascularization that (Arishtha?) may generate a higher temperature heat source (in chest) and may cause drying it off earlier (Praagvisushyamaana) when compared to other parts of the body (Aaardra Shareera).[11]

Yashcha Loshtham – Karna Keshaamshcha

The person (Yashcha), who strikes (Abhihanti) a stone (Loshtham) with a stone (Loshthena), or a piece of wood (Kashtham) with a piece of wood (Kashthena), or who plucks or pulls (Chinatti) grass (Trinaani), or who bites (Dashati) his/her lower lip (Adharoshtham) and licks (Ledhee) the upper one (Uttaroshtham), or pulls (Aalunchati) his/her ears (Karnau) and pulls (Aalunchati) his/her hair (Kesha), or dishonors or insults (Dveshthi), the gods (Deva), the Brahmanas (Dvija), the teachers (Guru), as well as his/her own physician (Vaidya), friends and relations (Suhrudyaam), should be regarded as fatal signs (Arishtha).[3] Striking a stone with another stone (Abhihanti Loshtham Loshthena), a piece of wood with another piece of wood (Abhihanti Kashtham Kashthena), and plucking grass (Chinatti Trinaani) denotes motor tics. Lip biting (Adharoshtham Dashati) and pulling ears (Aalunchati Karnau) denote self-injurious behavior (SIB). Hair-pulling (Aalunchati Kesha) denotes TTM. Licking the upper lip (Uttaroshtham Ledhee) denotes motor tics,[199] and dishonoring or insulting gods, Brahmins, teachers, physicians, friends, etc., (Deva Dvija Guru Vaidya Suhrudyaam Dveshthi) denotes impulsivity, sudden unpredictable anger, temper outbursts, irritability, aggression, etc., seen in intermittent explosive disorder, impulse-control disorder, borderline personality disorder, oppositional defiant disorder (ODD), conduct disorder (CD), attention-deficit/hyperactivity disorder (ADHD), and TS.[200]

Stereotypic movement disorder is characterized by nonfunctional repetitive movements (Abhihanti Loshtham Loshthena, Kashtham Kashthena, Chinatti Trinaani, and Aalunchati Karnau). Hair-pulling (Aalunchati Kesha) may be one of a number of body-focused repetitive behaviors that are seen in the general population.[201] Tics appear as sudden, rapid, stereotyped, purposeless motor movements that involve discrete muscle groups (Abhihanti Loshtham Loshthena, Kashtham Kashthena, Chinatti Trinaani and Aalunchati Karnau). TS is a neuropsychiatric disorder involving multiple motor (Abhihanti Loshtham Loshthena, Kashtham Kashthena, Chinatti Trinaani, and Aalunchati Karnau) and phonic tics. TS is characterized by involuntary movements, echopraxia (a tendency to repeat movements) (Abhihanti Loshtham Loshthena, Kashtham Kashthena, Chinatti Trinaani, and Aalunchati Karnau), copropraxia (lewd and obscene gestures with hands or tongue) (Chinatti Trinaani and Uttaroshtham Ledhee), coprolalia (socially inappropriate words or phrases expressed in a loud, explosive manner) (Deva Dvija Guru Vaidya Suhrudyaam Dveshthi), SIB (tongue or lip biting) (Adharoshtham Dashati), rage attacks, anger, irritability, and aggression (Deva Dvija Guru Vaidya Suhrudyaam Dveshthi). Biting one's tongue or lip (Adharoshtham Dashati) is a type of SIB.[202] TS is commonly comorbid with ADHD, obsessive compulsive disorder (OCD), autism, anxiety, depression, learning difficulties, personality disorder, impulse control, aggression, ODD, and CD. The present verse denotes a condition of Tourette syndrome-plus associated with various comorbid conditions.[200]

Yasya Vakraanuvakragaa – Praadurbhaavo Veti

A disease that manifests due to the influence (Peedayanti) of an abnormal/inauspicious planetary (Graha) positions (Garhita or Nindita Sthana) (either retrogade or zigzag movement – Vakraanuvakragaa) related to the natal asterism of the patient indicates death (Arishtha). A person struck by lightning (Ashani) or a falling meteor (Ulkaa) also will not survive (Arishtha), especially during inauspicious planetary positions (Nindita Sthanagata Graha). Other inauspicious factors (Garhita Lakshana) related to a person's own house (Griha), wife (Daaraa), bed (Shayana), seat (Aasana), conveyance (Yaana), riding-animal (Vaahana), gems (Mani and Ratna), utensils (Upakarana), etc., also indicate an imminent death (Arishtha).[3] Astrology (Jyotish Shaastra) is the art of predicting or determining the influence of the planets (Graha) and stars (Janma Nakshatra) on human health and disease.[203] Various inauspicious signs (Garhita Lakshana) explained in the Ayurvedic classical texts can only be understood through Jyotish Shaastra. Jyotish Shaastra recognizes the influence of planets (Graha) on human life as well as destiny of human beings. Different energies emitted by different planets reach the earth and influence humans and their surroundings. The planetary (Graha) energies will influence our thoughts and actions. The changes or disturbances that are seen in our environment are due to specific configuration of planets. Shakuna Shaastra or Nimitta Shaastra is related to Jyotish Shaastra. The omens can be classified as good or bad according to Shakuna Shaastra and based on which predictions can be made. Nimitta, Shakuna, and Jyotisha give an indication regarding the past deeds of the patient and outcome of patient's current clinical condition (Arishtha?); hence, physician should be alert to detect these signs (Garhita Lakshana).[11]

Chikitsyamaana – Tadgataayusha (Verse 5)

A patient who is emaciated (Praksheena Maamsa), weak (Praksheena Bala), not responding to a standard (Samyak) treatment (Chikitsyamaana) and progressive deterioration (Abhivardhate) of his/her condition (Vikaara) indicates poor prognosis (Gataayusha). The present verse indicates an irreversible pathology and/or multi organ failure and/or terminal illness with cachexia. EOL care is defined as care that helps those with advanced, progressive, incurable, and serious illness (Vikaaro Abhivardhate) to live well until they die (Gataayusha). Hospice/palliative care is a program for patients in their final months of life (Gataayusha) and is considered when the person's condition deteriorates (Vikaaro Abhivardhate) and active treatment (Samyak Chikitsyamaana) does not control disease (Vikaaro Abhivardhate). Cachexia, cancer-induced cachexia (CIC), CACS, sarcopenia (Praksheena Bala Maamsa), etc., cannot be reversed (Samyak Chikitsyamaano Vikaaro Abhivardhate) and associated with poor prognosis (Gataayusha).[11]

Nivartate Mahavyadhi – Sa Vinashyati (Verse 6)

A person (Yasya) getting spontaneous remission (SR) (Sahasaa Nivartate) from his/her chronic or deep-seated or progressively deteriorating condition (Mahavyadhi) indicates an imminent death (Vinashyati), and also, a person (Yasya) who does not respond (Na Cha Drishyate) to nutritional food (Aahaara Phalam) will also not survive for long (Vinashyati).[3] The present verse denotes a phenomenon that has been referred as “lightening up before death,” “terminal lucidity,” or “premortem surge.” SRs (Sahasaa Nivartate) have been observed in a number of patients suffering from the dementias, brain tumors, strokes, brain abscesses, meningitis, and chronic schizophrenia (Mahavyadhi?). Patients during the weeks before death (Vinashyati) have shown increased vitality and general improvement (Sahasaa Nivartate). These lucid episodes or SRs (Sahasaa Nivartate) directly precede the precipitous clinical decline and death of the patient (Vinashyati). There is a strong association between unexpected lucidity (Sahasaa Nivartate) and death (Vinashyati).[204] SR of cancer is defined as a partial or complete, permanent, or temporary disappearance (Sahasaa Nivartate) of some or all relevant parameters of a diagnosed malignant disease (Mahavyadhi?) without any medical treatment or with inadequate treatment. Neither does SR of a primary cancer prevent secondary malignancies, nor is SR synonymous with good health (that indicates Vinashyati).[205] Cachexia and CIC cannot be reversed with protein and/or caloric intake and by feeding alone. Weight continues to drop (Na Cha Aahaara Phalam Drishyate) in CIC as there is no accepted therapy (leads to Vinashyati?) for it. Significant increases in caloric intake and use of enteral and parenteral nutrition are not always beneficial (Na Cha Aahaara Phalam Drishyate) in CIC patients (Vinashyati).[11]

Yetaanyarishtha Rupaani – Sammato Bhavet (Verse 7)

The physician (Bhishak) who can detect and fully interpret (Samyak Budhyate) the fatal signs and symptoms (Arishtha Rupaani) explained in this chapter (Etaani) is honored (Sammato) by the king (Raajna) for his/her prognostic skills in determining the curable (Saadhya) or incurable nature (Asaadhya) of a disease.[3] Simple clinical intuition is the most common method of predicting (Saadhya Asaadhya Parikshaayaam) survival in clinical practice. To improve prognostic skills general clinicians, it is important to learn from other clinicians who have expertise in the specified area (Samyak Budhyate Arishtha Rupaani). The level of experience of the clinician (Bhishak) is a factor that improves accuracy (Samyak Budhyate Arishtha Rupaani) in prognostication. Job title, optimism, experience, gender, age, ethnicity, religion, length of time working in palliative care or years of experience, and board certification (Raajna Sammati?) are the individual characteristics of the clinicians (Bhishak) who have expertise in prognostication (Samyak Budhyate Arishtha Rupaani) [Table 2].[206]


  Conclusion Top


A wide variety of pathological conditions have been documented in SVA chapter. The contents have been condensed within seven verses. Various prognostic scales or questionnaires can be prepared based on these seven verses and they can be implemented in Ayurvedic hospitals for prognostication purposes. Latest technological advances and instruments can be incorporated to assess or quantify or identify or to standardize the objective parameters mentioned in SVA chapter such as Ucchwasa Shaityam (decreased EBT), Phutkaara Aushnyam (increased temperature of mouth exhalations), Chakshur Bhramanam (VOG), Sakthi Baahu Laghutvam (site-specific skeletal muscle loss that can be measured by magnetic resonance imaging or dual-energy X-ray absorptiometry or ultrasound measured total skeletal muscle mass), Nashta, Heena, Vikala and Vikruta Swara (voice print recognition or voice analysis), Apsu Kapha Purisha Retaamsi Nimajjati (measuring specific gravities of sputum, stool, and semen), and Drishti Mandale Vikruta Rupaani Aalokyante (corneal reflection analysis). It seems that Maharshi Sushruta might have performed autopsy studies to determine the pathological features such as Shiro Laghutvam (atrophy of the brain?), Akshi Gurutvam (increased intraocular pressure due to various eye diseases?), Mrudutvam (-malacia), Kaathinyatvam (sclerosis or calcification or fibrosis), Deerghatvam (macro-?), Hrasvatvam (micro-?), Samkshiptatvam (constriction or cirrhosis?), Pruthutaa (-megaly or dilation), Patana Dharmitvam (prolapse?). It seems that Maharshi Sushruta has developed various organ morphometric parameters (Deerghatvam, Hrasvatvam, Samkshiptatvam, Pruthutaa, Gurutvam, Laghutvam, Snigdhatvam, and Rukshatvam) and used them in prognostication. The present exploratory review has generated various hypotheses for future research works.

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Conflicts of interest

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