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Year : 2022  |  Volume : 10  |  Issue : 2  |  Page : 89-98

Panchendriyartha Vipratipatti chapter of Sushruta Sutra Sthana – An explorative study

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

Date of Submission11-Oct-2022
Date of Decision23-Nov-2022
Date of Acceptance01-Dec-2022
Date of Web Publication21-Dec-2022

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

DOI: 10.4103/jihs.jihs_10_22

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Maharshi Sushruta has composed a treatise known as Sushruta Samhita around the 6th century BC. Sushruta Samhita lacks Indriya Sthana (a specialized section that deals with prognostic aspects), and prognostic knowledge is documented in the chapters from 28th to 33rd of Sutra Sthana (a specialized section that deals with Ayurvedic basic principles). Panchendriyartha Vipratipatti Adhyaya (PVA) is the 30th chapter of Sushruta Sutra Sthana (SSS) and it consists of 23 verses. Literature is still scarce on Arishtha Lakshanas of SSS and further studies are need of the hour. The aim of the present study is to explore the prognostic potential of the contents of PVA of SSS with the help of contemporary prognostic literature. Pathological conditions of sensory organs and/or sensory pathways with global or specific impairment of sensory functions are described in PVA chapter. Conditions such as auditory and visual hallucinations, auditory and visual perceptual distortions, aphasia, paradoxical heat and cold sensations, somatosensory disorders, disease-specific volatile organic compounds, quantitative and qualitative olfactory and gustatory impairments, Morgellons disease, cortical sensory syndrome, and mirror image agnosia associated with fatal outcome are mentioned in the PVA of SSS. Various new hypotheses generated by the present explorative study may open the doors for further research in to the development of novel Ayurvedic prognostic models or questionnaires.

Keywords: Arishtha Lakshana, Ayurveda, Indriya Sthana, Maharshi Sushruta, Sushruta Samhita, Sutra Sthana

How to cite this article:
Mamidi P, Gupta K. Panchendriyartha Vipratipatti chapter of Sushruta Sutra Sthana – An explorative study. J Integr Health Sci 2022;10:89-98

How to cite this URL:
Mamidi P, Gupta K. Panchendriyartha Vipratipatti chapter of Sushruta Sutra Sthana – An explorative study. J Integr Health Sci [serial online] 2022 [cited 2023 Jun 9];10:89-98. Available from: https://www.jihs.in/text.asp?2022/10/2/89/364605

  Introduction Top

Maharshi Sushruta was a great sage surgeon practiced Ayurveda around the 6th century BCE in ancient India. He has global popularity for his contributions in the field of surgery and is known as the Father of plastic surgery. Maharshi Sushruta has composed a treatise known as Sushruta Samhita and various ancient Indian scholars have written commentaries on it.[1] The text, divided into six sections, describes in detail the various branches of surgery, midwifery and other medical disciplines.[2] Sushruta Samhita lacks Indriya Sthana (a specialized section that deals with prognostic aspects), and prognostic knowledge is documented in the chapters from 28 to 33 of Sutra Sthana (a specialized section that deals with Ayurvedic basic principles). Arishta Vignana (prognostic knowledge) or Arishta lakshanas (fatal signs and symptoms) associated with poor prognostic conditions are explained in Sushruta Sutra Sthana (SSS) from chapters 28–33. Previous works published on Avaaraneeya Adhyaya (33rd chapter)[3] and Swabhava Vipratipatti Adhyaya (32nd chapter)[4] of SSS have highlighted the prognostic potential and clinical utility of the contents of these chapters.[3],[4]

Panchendriyartha Vipratipatti Adhyaya (PVA) is the 30th chapter of SSS and it consists of 23 verses. Pathological conditions of sensory organs, sensory processing disorders, global or specific impairment of sensory functions associated with poor prognosis are described in PVA chapter.[5] The word Panchendriyartha denotes five types of sensory stimuli or inputs (sight, sound, smell, taste, and touch) and Vipratipatti denotes sensory and perceptual alterations.[6] Ancient Ayurvedic texts contain scientific findings that are strikingly similar to modern discoveries and also they contain a huge repository of medical knowledge acquired through ages. The extensive research is required into these texts to explore the hidden potential especially in the area of Ayurvedic prognosis that had limited volume of research available. No studies have been published on the contents of PVA chapter till now as per our search and understanding. The present work is aimed to provide a comprehensive and critical analysis on the contents of a PVA chapter with the help of contemporary prognostic literature. The aim of the present narrative review is to interpret, critique, and to provide deep understanding of the contents of PVA chapter of SSS. Various new hypotheses or insights generated by the present narrative review may open the doors for further research works especially for the development of novel Ayurvedic prognostic models, questionnaires, checklists, etc.

  Review Methodology Top

A literature review was electronically performed using the PubMed database and Google Scholar web to findout relevant articles related to Ayurvedic prognostic studies and contemporary medical literature. Sushruta Samhita with Nibandha Samgraha and Bhanumati commentary has been referred. Ayurvedic texts such as Charaka Samhita, Ashtanga Samgraha, Ashtanga Hrudaya, Bhela Samhita, and Kashyapa Samhita have been referred. The search terms used were “Arishta Lakshana,” “Indriya Sthana,” “Charaka Indriya Sthana,” “Bhela Indriya Sthana,” “Kashyapa Indriya Sthana,” and “Sushruta Sutra Sthana,” “Panchendriyartha,”Vipratipatti,” “Sushruta Samhita,” and also relevant terms from the contemporary medical literature. Articles published in the English language were only considered. No search filters and Boolean operaters have been used while searching the databases. Articles of peer-reviewed journals published till September 2022, were only considered irrespective of their date of appearance at online. Scholarly articles that failed to describe the factors of interest for the present study were not considered. All those relevant articles that are having either supportive or contradicting findings to the present work have been included. Data obtained from these studies were compiled, interpreted, and presented as a narrative review.

  Observations and Discussion Top

PVA chapter of SSS consists of 23 verses that deals with various fatal signs and symptoms related to sensory organs and/or sensory systems. Aturagata (diseases of the nervous system and sense organs), Aturagrahya (sensory and perceptual alterations), and Aturagatagrahya (diseases of the nervous system and sense organs associated with sensory and perceptual alterations) Aristhta Lakshanas are documented in this chapter. Arishta Lakshanas are classified into two broad categories, i.e., Baahya (external factors) and Antara (internal factors) according to Chakrapani (commentator of Bhanumati commentary on Sushruta Samhita). After describing Baahya Arishta Lakshanas in the previous chapters (28th and 29th chapters of SSS), PVA chapter has been planned to describe the Antargata Arishta Lakshanas.[5],[6] Critical analysis with interpretation has been carried out for each and every verse of PVA chapter with the help of contemporary medical literature in the following sections [Table 1] and [Table 2].
Table 1: Clinical interpretation of Verses of Panchendriyartha Vipratipatti Adhyaya

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Table 2: Prognostic terminology in Panchendriyartha Vipratipatti Adhyaya

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Athaata Panchendriyartha Vipratipatti - Vyasatastu Nibodha Me (Verse 1–3)

The current chapter (PVA) deals with the sensory and perceptual alterations (Panchendriyartha Vipratipatti) of five senses and their prognostic significance. In summary (Tat Samaasena), abnormalities (Vikruti Bhavet) of normal physical condition (Shareera Prakruti) or change in behaviour or personality (Sheela Vikrtui) denotes an imminent death (Arishtam).[5] A detailed description (Vyasatastu) is provided (Nibodha) in the following verses. Various sensory and perceptual distortions, physical illnesses, behavioural and personality changes associated with poor prognosis are described in this chapter.

Shrunoti Vividhaan - Cha Nihsvanaan (Verse 4)

A person, who hears (Shrunoti) a wide variety of (Vividhaan) sounds (Shabdaan) such as divine voices (Divyaanaam) or ocean sounds (Samudra Nihsvanaan) or sounds of the city (Pura Nihsvanaan) or sound of clouds thundering (Megha Nihsvanaan), etc., in their absence (Abhaavata) indicates an imminent death (Gataayusham).[5] The present verse denotes various auditory hallucinations or tinnitus associated with fatal conditions. Auditory hallucinations are sensory perceptions of hearing (Shrunoti Shabdaan) in the absence of an external stimulus (Abhaavata). Auditory hallucinations can refer to a plethora of sounds (Samudra, Pura, Megha Nihsvanaan); however, when the hallucinations are voices (Divyaanaam), they are distinguished as auditory verbal hallucinations (Shrunoti Vividhaan Shabdaan Divyaanaam Abhaavata). Auditory hallucinations can be seen in a wide variety of psychiatric conditions such as schizophrenia, bipolar disorder, depression, head trauma, parasomnias, dissociative disorders, and personality disorders; neurological conditions such as cerebral tumors, temporal lobe epilepsy (TLE), delirium, viral encephalitis, brainstem vascular lesions, neurodegenerative conditions and peripheral neuropathies; other conditions such as autoimmune disorders, and acquired immunodeficiencies are also associated with auditory hallucinations. Patient with auditory hallucinations may attempt suicide (Gataayusham?).[7] Tinnitus, the perception of sound (Shrunoti Shabdaan) in the absence of an auditory stimulus (Abhaavata), may include potentially life-threatening conditions or may represent an ominous condition (Gataayusham). Pulsatile tinnitus can be arterial or venous in origin and seen in atherosclerosis of the carotid artery, arteriovenous fistulas, thrombosis of the dural venous sinus, dissecting aneurysms, fibromuscular dysplasia of the carotid artery, hypertension, intracranial hypertension, venous hum, vascular neuroendocrine tumours of the skull base (glomus tympanicum), and a high-riding jugular bulb (Gataayusham?).[8]

Taan Svanaan Na - Vipareetaan Shrunoti Cha (Verse 5)

A person, who is unable to hear (Svanaan Na Avagruhnati), or hearing sounds in a distorted way (Manyate Anya Shabdavat) such as hearing (Shrunoti) urban sounds (Graamya Svanaan) as forest sounds (Aranya Svanaan) and vice versa denotes an imminent death (Gataayusham).[5] The present verse denotes either sensorineural hearing loss - SNHL (Svanaan Na Avagruhnati) or auditory perceptual distortions (Manyate Anya Shabdavat) due to fatal (Gataayusham) pathological diseases. Hearing loss (Svanaan Na Avagruhnati) can be caused by damage to the central and peripheral auditory systems. SNHL (Svanaan Na Avagruhnati) can be seen in degenerative processes associated with aging, drugs having ototoxic side effects, chronic conditions such as adiposity, diabetes mellitus, cardiovascular diseases, peripheral neuropathy and autoimmune forms of ear diseases (rheumatoid arthritis, systemic lupus erythematosus, sarcoidosis, Cogan's syndrome, and others). Older persons with hearing loss (Svanaan Na Avagruhnati) have higher rates of hospitalization, death, falls and frailty, dementia and depression (Gataayusham?).[9] Lesions in the cochlea, auditory nerve, and central auditory pathway induce SNHL (Svanaan Na Avagruhnati). Hearing loss (Svanaan Na Avagruhnati) is closely associated with cognitive decline and dementia (Gataayusham?). Various neurological disorders such as Alzheimer's disease (AD), Parkinson's disease (PD), Huntington's disease (HD), and autism spectrum disorders are accompanied by hearing impairments and other auditory dysfunctions (hearing loss, abnormal speech discrimination, and sound lateralization, hyperacusis, difficulty in sound discrimination, speech sound encoding, etc.) (Svanaan Na Avagruhnati and Manyate Anya Shabdavat). Hearing loss (Svanaan Na Avagruhnati) can also affect the prognosis of these diseases to some extent (Gataayusham).[10]

Pitch perception (Graamya Aranya Svanaan) is often poorer (Vipareetaan Shrunoti) in individuals with hearing impairment (Svanaan Na Avagruhnati). Both frequency discrimination and modulation perception are highly impaired (Vipareetaan Shrunoti) in people with auditory neuropathy.[11] Sound textures (e.g., sounds produced by fire, wind, insect swarms, and water) are a broad class of acoustic stimuli (Arnaya and Graamya Svanaan) found in everyday listening environments. Hearing loss (Svanaan Na Avagruhnati) commonly distorts the coding and representation of the sound in the auditory system and affects sound perception, including sound source separation, spectral and temporal resolution, and pitch and loudness perception (Manyate Anya Shabdavat and Vipareetaan Shrunoti).[12] Svanaan Na Avagruhanti denotes hearing loss or impairment (SNHL); Manyate Anya Shabdavat denotes auditory dysfunctions or distortions and Graamya, Aranya Svanaan Vipareetaan Shrunoti denotes sound texture identification and discrimination abnormalities seen in various neurological illnesses associated with poor prognosis.

Dvishat Shabdeshu - Gataayusham (Verse 6)

The person, who rejoices (Ramate) at the voice of his enemies or verbal abuses (Dvishat Shabdeshu) and is annoyed (Kupyati) at that of his own devoted friends (Suhrut Shabdeshu), or who suddenly (Akasmaat) loses hearing capacity (Na Shrunoti) without any visible reason, should be considered as already on the threshold of death (Gataayusham).[5] Semantic variant of primary progressive aphasia (svPPA) is a neurodegenerative disease characterized by diminished global cognitive effieciency, semantic memory impairment, emotion recognition deficits, dysfunction of visual and working memory, and executive functioning (Dvishat Shabdeshu Ramate Suhrut Shabdeshu Kupyati). The disintegration of conceptual or emotional knowledge about the social world plays a prominent role in social cognition impairment (Dvishat Shabdeshu Ramate Suhrut Shabdeshu Kupyati). A close relationship between emotion recognition, valence processing, and emotion concept knowledge (Dvishat Shabdeshu Ramate Suhrut Shabdeshu Kupyati) in svPPA has been observed. Cognitive functioning with special reference to social cognition strongly relies on semantic knowledge. Patients with svPPA have made valence errors during the facial emotion recognition task (when one emotion was mistaken for another of a different valence) (Dvishat Shabdeshu Ramate Suhrut Shabdeshu Kupyati). The number of valence errors correlated with emotion conceptual knowledge as well as with reduced gray matter volume in the brain regions in svPPA patients (Gataayusham?).[13] There is a direct evidence for a neurological basis of impaired speech recognition (Dvishat Shabdeshu Ramate Suhrut Shabdeshu Kupyati). The higher rate of speech recognition difficulties (Dvishat Shabdeshu Ramate Suhrut Shabdeshu Kupyati) are seen in epilepsy patients.[14] Wernicke's aphasia is characterized by impaired language comprehension (Dvishat Shabdeshu Ramate Suhrut Shabdeshu Kupyati). Wernicke's aphasia is seen in ischemic stroke affecting the posterior temporal lobe of the dominant hemisphere, an embolic stroke that affects the inferior division of the middle cerebral artery, cerebral tumors, brain trauma, central nervous system infections, and degenerative brain disorders (Gataayusham?).[15] Dvishat Shabdeshu Ramate Suhrut Shabdeshu Kupyati denotes speech recognition deficits and/or valence errors seen in various neurological conditions such as svPPA, Wernicke's aphasia.

Akasmaat Na Shrunoti

Sudden sensorineural hearing loss (SSNHL) (Akasmaat Na Shrunoti) is characterized by loss of hearing of 30 dB over a period of <72 h and it is considered as otolaryngologic emergency (Gataayusham). Pyogenic ventriculitis (PV) is a very severe intracranial infection associated with high mortality (Gataayusham). PV with SSNHL (Akasmaat Na Shrunoti) as a major primary symptom may become life-threatening (Gataayusham).[16] Etiology of SSNHL (Akasmaat Na Shrunoti) fall into one of several broad categories including infectious (bacterial, cryptococcal meningitis, HIV, Lyme disease [LD], mumps, Lassa fever, mycoplasma, syphilis, and toxoplasmosis), autoimmune (Behcet's disease, Cogan's syndrome, SLE, and autoimmune inner ear disease), traumatic, vascular (stroke and sickle cell disease), neoplastic (vestibular schwannoma, petrous meningiomas, petrous apex metastases, and myeloma), metabolic (diabetes and hypothyroidism), and neurological (migraine, MS, and pontine ischemia) (Gataayusham?).[17]

Yastu Ushnamiva Gruhnaati - Daahena Peedyate (Verse 7)

The person, who perceives (Gruhnaati) cold (Sheetam) as hot (Ushnamiva), hot (Ushnam) as cold (Sheetavat) and gets burning sensation (Daahena Peedyate) from coldish skin lesions (Sheeta Pidaka) will not survive.[5] Similar verse is explained in the Yasya Shyaaveeyam (5th chapter) of Bhela Indriya Sthana.[18] The present verse denotes paradoxical heat (PH) or paradoxical burning sensations and paradoxical cold sensations due to lesions or diseases of the somatosensory system. PH is an illusion of skin heat (Ushnamiva/Daahena Peedyate) or perception of heat when the actual skin temperature is cool (Sheetam Ushnamiva). PH is seen in patients with central demyelination, peripheral demyelinating neuropathies, MS,[19] central poststroke pain,[20] uremic polyneuropathy,[21] blockage of myelinated afferents by pressure or ischaemia, etc.[18] Lesions or diseases of the somatosensory nervous system can lead to disordered and altered transmission of sensory signals (Ushnamiva Gruhnaati Sheetam and Ushnam Sheetavat) into the spinal cord and the brain.[20] Paradoxical cold (Ushnam Sheetavat Gruhnaati) is defined as a perception of cold (Sheetavat) in response to a gradually increasing thermal stimulus (Ushnam). The characteristics of thermal pain (cold pain and heat pain) (Daahena Peedyate) are dependent on the integrity of nonnoxious thermal sensations. A sensation of pricking pain (Peedyate) is elicited when a thermal sensation is completely disrupts and noxious thermal stimulation completely loses its thermal quality. When only one thermal sensory modality is intact, both noxious and innocuous stimuli acquire the characteristics of that intact modality leading to paradoxical sensations (Ushnamiva Gruhnaati Sheetam and Ushnam Sheetavat).[22] Sheeta Pidaka denotes noninflammatroy skin lesions; Daahena Peedyate represents burning sensation or neuropathic pain seen in peripheral or ischemic neuropathy. Sheeta Pidako Daahena Peedyate denotes noninflammatory skin lesions associated with peripheral neuropathy due to various neurological conditions (leprosy neuropathy?).

Ushnagaatre Atimaatram - Angachedamathapi Va (Verse 8)

The person shivering (Sheetena Pravepate) when the temperature of his body is considerably high (Ushnagaatre Atimaatram); The person, who has lost the faculty of touch, and does not feel any pain in any part of the body (Na Abhijaanaati) when it is struck (Prahaaraat) or amputated (Angachedaat) should be considered as nearer to death.[5] Ushnagaatre Atimaatram Sheetena Pravepate denotes central hyperthermia associated with dysfunction of brainstem thermoregulatory pathways. There is an anatomical, neurotransmitter, and functional specificity of the synaptic integration sites (the dysfunction of which may cause Ushnagaatre Atimaatram Sheetena Pravepate) within both the central efferent pathway for shivering (Sheetena Pravepate) and the central afferent pathway conveying cutaneous thermal information (Ushnagaatre Atimaatram) to the preoptic area (POA).[23] Diabetic patients with autonomic neuropathy have shown impaired thermoregulation.[24] Integration of temperature information from spinothalamocortical pathways and from the lateral parabrachial nucleus, located at the brainstem, occurs in the hypothalamic POA. Multiple brainstem regions are important in central temperature regulation. Injury to the brainstem will affect thermostasis. Hyperthermia (Ushnagaatre Atimaatram) from a central cause is associated with increased morbidity and mortality (Gataayusham). Dysfunction of brainstem thermoregulatory pathways may explain the intractable rise in temperature (Ushnagaatre Atimaatram). The intractability of fever (Ushnagaatre Atimaatram) caused by intracerebral hemorrhages is due to the direct compression of brainstem and hypothalamic thermoregulatory centers. The central hyperthermia syndrome is characterized by temperature fluctuations within a short period of time.[25]

Na Abhijaanaati Prahaaraan and Angachedam

Na Abhijaanaati Prahaaram and Angachedam denote complete loss of pain sensation due to damage of the somatosensory nervous system and severe neuropathy. Sensory loss (Na Abhijaanaati) may be associated with various pathophysiological mechanisms in damaged and surviving afferent nerve fibers such as conduction block, ectopic impulse generation, central and peripheral sensitization. Sensory neuronopathies are characterized by severe proprioceptive and vibration deficits along with a pan-modality sensory loss (Na Abhijaanaati Prahaaram and Angachedam) in the affected extremities. Conditions such as chronic inflammatory demyelinating polyneuropathy (CIDP), GBS, cryptogenic sensory polyneuropathy (CSPN), metabolic disorders, drugs, toxins, vasculitis, hereditary neuropathies, multifocal-acquired demyelinating sensory and motor neuropathy, infectious causes (leprosy, HIV, LD, and sarcoidosis), compressive mononeuropathy, radiculopathy, plexopathy in diabetes, B12 deficiency, ganglionopathy, chronic immune sensory polyradiculopathy etc., are associated with sensory loss (Na Abhijaanaati Prahaaram and Angachedam).[26]

Paanshuneva Avakeernaani - Yasya Gaatraani Bhavanti Hi (Verse 9)

Sensation (Manyate) of dust (Paanshu) smeared (Avakeernaani) all over the body (Gaatraani) and discoloration (Varna Anyataa) with spontaneous appearance (Bhavanti) of blue (Neela) or red (Lohita) or multicoloured (Varna Anyataa) stripes (Raajyo or Rekhaa) on the skin indicates an imminent death to the patient (Gataayusham). The present verse denotes Morgellons disease (MD). MD is a dermatological condition characterized by multicolored (Varna Anyataa) filaments (Raajyo or Rekhaa) embedded within or protruding out from the skin spontaneously. The filaments are varied in nature with white, red (Lohita), blue (Neela), green or black coloration (Varna Anyataa), and they resemble microscopic textile fibers (Raajyo or Rekhaa). Formication (sensation of something crawling on skin) (Paanshuneva Avakeernaani) is also one of the characteristic features of MD. MD is associated with spirochetal infection caused by Borrelia, as well as infection with pathogenssuch as Helicobacter pylori and Treponema denticola. Most patients with MD also have a diagnosis of LD.[27] Along with the development of fibers or materials (Raajyo or Rekhaa) from the skin, cutaneous lesions (Varna Anyataa) and abnormal perceptions (Paanshuneva Avakeernaani) are also common in MD patients. Twisted black, brown, and red fibers (Lohita Rekhaa) can be seen as buried in the skin of MD patients.[28] Patients of MD may experience formication, described as biting, stinging, crawling and creeping sensations (Paanshuneva Avakeernaani).[29] Ekbom has found hairs, 'little threads (Raajyo or Rekhaa)', and 'grains of sand (Paanshu)' in patient specimens.[30]

Snaataanuliptam - Gataayusham (Verse 10)

The person who is surrounded by (Bhajante) blue flies (Neela Makshikaa) after a bath (Snaata) and application an anointment (Anulipta), and also the person whose body emits a fragrant smell (Sugandhi) without application of any kind of perfume (Akasmaat) indicates an imminent death (Gataayusham).[5] Similar verses have been explained in Pushpitakam chapter of Charaka Indriya Sthana[31] and Pushpeeyam chapter of Bhela Indriya Sthana.[32] The person who emits different types of body odours like a floral garden is called Pushpita and it is considered as Arishta (fatal) when it manifests all of a sudden (Akasmaat) without having any visible or known reason. Arishta odors are classified as Shubha/Sugandha (auspicious/good/pleasant) and Ashubha/Durgandha (inauspicious/bad/unpleasant). Body odours can be altered by various intrinsic and extrinsic factors. A wide variety of volatile organic compounds (VOCs) are emitted by the humans. The characteristic odour of every person is called “body odour signature” and it is an essential source of information about the odour producer. Body odors are considered as individual's 'odour finger prints'. Disease specific VOCs can be used as diagnostic olfactory biomarkers for various metabolic, infectious, genetic and other diseases (Gataayusham?). These diseases can alter the odour finger prints of an individual by changing the ratio of VOCs (quantitative and qualitative). Specific diseases and their states are associated with specific odors (Sugandhi?). Human skin odours are known to attract (Bhajante Neela Makshikaa) specific insects. By observing the attractiveness (Bhajante Neela Makshikaa) to insects, physician can indirectly assess the changes or condition of blood chemistry in a particular individual. Different odours such as carbon dioxide, carboxylic acid, ammonia and sweat compounds contribute to attraction of the insects (Bhajante Neela Makshikaa). Insects aggregate around sources of ammonia and a mixture of different odors and compounds like CO2, carboxylic acids, and other sweat compounds contributes to attraction of the insects. Insects show specific zoophilic or anthrophilic behavior and all species of insects are not equally attracted to humans. Chemical signals provide information about an individual's genetic compatibility, infection status, and changes in endocrine and immune systems (Gataayusham?), which can be detected indirectly by Bhajante Neela Makshikaa.[31],[32] The present verse denotes pathological body odours or disease specific VOCs produced by a patient having a fatal illness.

Vipareetena Gruhnaati - Tam Prachakshate (Verse 11 and 12)

The person who has been suffering with altered perception (Vipareetena Gruhnaati) of taste (Rasa) or complete loss (Na Samvetti) of taste (Rasa) associated with implausible or uncertain changes in the physiological state of body humors (Dosha Abhivriddhi or Dosha Saamya) denotes an imminent death (Gataayusham).[5] Taste impairments (dysgeusia) are alterations of normal gustatory functioning (Vipareetena Gruhnaati Rasaan) that includes loss of complete taste sensations (ageusia) (Na Samvetti Rasaan), partial reductions (hypogeusia), or over-acute taste sensations (hypergeusia). Ageusia, hypogeusia (Na Samvetti Rasaan). and hypergeusia are quantitative taste disturbances, whereas parageusia (distorted taste sensations) (Vipareetena Gruhnaati Rasaan) and phantogeusia (hallucinatory taste sensations) are qualitative taste disorders. Causes of altered taste perception (Vipareetena Gruhnaati Rasaan) are multiple and consist of both genetic and environmental factors, including aging, exposure to chemicals, drugs, trauma (damage to cranial nerves, brain contusion and hemorrhage), high alcohol consumption, cigarette smoking, poor oral health, malnutrition, kidney and liver failure, uremia, diabetes, lichen planus, burning mouth syndrome, neurodegenerative conditions (dementia and Parkinson syndrome) and viral infections (influenza, COVID-19, rhinoviruses and hepatoviruses) (Gataayusham?). Persistent dysgeusia (Vipareetena Gruhnaati Rasaan) can cause serious complications (Gataayusham?) such as unhealthy eating habits, raising the risk of metabolic and cardiovascular diseases, undernutrition and malnutrition, deteriorating nutritional status and quality of life (uncertain Dosha Abhivriddhi and/or Dosha Saamya).[33] The present verse denotes various qualitative and quantitative taste disturbances associated with fatal illnesses.

Sugandham Vetti - Tam Vinirdishet (Verse 13)

The man, who perceives (Vetti) a fetid odour (Durgandham) as a fragrant perfume (Sugandham), or one fragrant (Sugandham) to be fetid (Vetti Durgandham), or one who is unable to perceive the smell (Gandham Na Jaanaati) of a burning lamp wick that has just been extinguished (Shaante Deepe), or the one who has entirely lost the faculty of smell (Gandham Na Jaanaati), should be considered as dead (Gataasum).[5] Anosmia is the total inability to perceive the odorants (Gandham Na Jaanaati) and hyposmia is a partial loss of smell. Parosmia is a distorted smell perception (Gruhneete Vaa Anyathaa Gandham) in the presence of an odorant stimulus and phantosmia is an olfactory hallucination perceived in the absence of an odorant stimulus. Parosmia (Gruhneete Vaa Anyathaa Gandham) can occur due to traumatic brain injury, postupper respiratory tract infection, sinonasal diseases, toxins/drugs, TLE, PD and MS (Gataasu?).[34] Smell disorders (Gruhneete Vaa Anyathaa Gandham and Gandham Na Jaanaati) are seen in idiopathic Parkinson's syndrome, Lewy-Body dementia, multi-system atrophy, HD, heredoataxias, motor neuron diseases, schizophrenia, depression, sarcoidosis, lupus erythematodes, hypothyroidism, diabetes, kidney and liver failure, and tumors (esthesioneuroblastoma, intranasal carcinomas and benign/malignant brain tumours) (Gataasu).[35] Olfactory loss (Gandham Na Jaanaati) can be an early marker of neurodegenerative disorders and it has been associated with increased mortality (Gataasu).[36] The present verse denotes quantitative and qualitative olfactory impairments associated with fatal illnesses.

Dwandvaani Ushna Himaadeeni - Anyaamshcha Yo Nara (Verse 14)

The man, who is unable to differentiate (Vipareetena Gruhnaati) between hot and cold (Ushna Himaadeeni), seasonal variations (Kaala), lack of orientation in terms of place, time, person, dimensions (Disha), space (Avastha) and loss of all other discriminatory abilities (Anyaamshcha Dwandvaani Bhaavaani) denotes an imminent death (Gataayusham).[5] The present verse denotes conditions such as cortical sensory syndrome or somatosensory dysfunction or delirium associated with impairment of various sensory modalities such as stereognosis, proprioception, orientation (time, place and person), spatial orientation, elementary sensations (touch, pain, temperature, and vibration), kinaesthesia etc. Astereognosis is the impairment of recognition of the objects (Vipareetena Gruhnaati) by somatosensory discrimination of the texture, size, weight, and shape of the objects. Postcentral parietal lesions, Alzheimer's disease, dementia, stroke, neoplasms, trauma, ischemic infarction of the parietal region, brainstem tumour or ischemic lesions, extramedullary tumours of the foramen magnum and high posterior cord lesions due to MS (Gataayusham?) also produce astereognosis. Impaired stereognosis (Vipareetena Gruhnaati) in parietal lobe disease can lead to tactile apraxia (a disturbance of hand movements for interaction with an object) (Vipareetena Gruhnaati Dihsa or Avastha?).[37] Most stroke survivors suffer several somatosensory deficits (body senses such as temperature, touch, pain, and proprioception) (Vipareetena Gruhnaati Ushna Himaadeeni Disha Avastha). Stroke affects one or more of the sensory modalities (Vipareetena Gruhnaati Anyaamshcha Dwandvaani Bhaavaani) in varying degrees. Corticoparietal stroke involves discriminatory modalities of sensation (Anyaamshcha Dwandvaani Bhaavaani) like proprioception (Disha) and stereognosis (Anyaamshcha Dwandvaani Bhaavaani).[38] The pseudothalamic sensory syndrome is characterized by an impairment of elementary sensation (pain, touch, vibration and temperature) (Vipareetena Gruhnaati Ushna Himaadeeni Anyaamshcha Dwandvaani Bhaavaani). The cortical sensory syndrome is characterized by an isolated loss of discriminative sensation (stereognosis, graphesthesia, position sense) (Vipareetena Gruhnaati Disha Avastha Anyaamshcha Dwandvaani Bhaavaani). The atypical sensory syndrome is characterized by a sensory loss involving all modalities of sensation.[39] Delirium is characterized by the sudden and global impairment in cognition manifested as difficulty in orientation (impaired awareness of oneself and one's surroundings in terms of time, place and person) (Vipareetena Gruhnaati Kaala Disha Avastha), memory, language and thought, visuospatial abilities (impaired capacity to construct and draw geometric configurations) (Vipareetena Gruhnaati Disha Avastha), illusions and hallucinations (Vipareetena Gruhnaati Anyaamshcha Bhaavaani).[40]

Diva Jyoteemshi - Vyadhimavaapnuyaat (Verse 15–23)

The man, who sees (Pashyati) stars (Jyoteemshi) ablaze (Jwalitaaneeva) in the broad daylight (Diva), perceives (Pashyati) bright (Jwalantam) sun (Suryam) during nights (Raatrau) and/or feeble (Chandra Varchasam) sun (Suryam) at daytime (Diva); the person who seems to witness (Pashyati) the phenomena of rainbow (Shakrachaapa) and lightning (Tadillataa) even in the absence of any rain cloud (Ameghe); perceives (Pashyati) lightening (Taditvat) or black (Asitaa) rainy clouds (Megha) in the clear blue sky (Nirmale Gagane); the man, who perceives (Pashyati) the sky (Ambaram) as possessed of (Samkulam) celestial cars (Vimaana) or chariots and palaces (Praasaada), or perceives (Pashyati) the air (Anilam) as a solid material (Murtimantam), or to whom the earth (Medini) appears (Pashyati) to be enveloped (Aavrutam) in frost (Neehaara) or smoke (Dhooma), or in a sheet of linen (Vaasa), or chequered with cross lines (Ashtapadaakaaram Lekhaa), or blazing with fire (Pradeeptamiva), or immersed in water (Plutamiva Ambhasaa); the person who is unable to see (Na Pashyati) the Polar star (Dhruva Nakshatram), the Arundhati star and the milky way (Aakaasha Ganga); The man, who fails to see (Na Pashyati) his own image (Chaaya) reflected in a mirror (Aadarsha), in the moonlight (Jyotsna), or in hot water (Ushna Toyeshu), or sees (Pashyati Vaa) but distorted reflections of himself (Vikrutaam) or identifying (Pashyati) their own reflected images (Chaaya) in the mirror (Aadarsha) and mistake them as strangers, Gods, or enemies (Anya Satvajaam); the man, who perceives (Pashyati) dogs (Shva), crows (Kaaka), herons (Kanka), vultures (Grudhra), and supernatural beings such as Preta (ghost), Yaksha (a type of demi-god), Rakshasa (demon), Pishacha (satan) and Naaga (serpent) or any other abnormal forms (Vikrutaam) in their absence; the man, to whom fire (Vahni) appears (Eekshate) to be free of its natural accompaniment of smoke (Vidhumam), or that it is possessed of a colour resembling the hue of the breast feathers of a peacock (Mayura Kanthaabham), should be considered as nearer to death (Gataayusham). The manifestation of the above mentioned phenomenon in a diseased person (Aaturasya) indicates death (Mrutyu) whereas in a healthy person (Swastho) they indicate future illness (Vyadhimavaapnuyaat).[5] The present verse indicates visual perceptual distortions (VPDs), visual illusions, and visual hallucinations associated with various neurological or psychiatric or ophthalmological illnesses. Similar descriptions as that of the present verse can be seen in the Indriyaaneekam (4th) chapter of Charaka Indriya Sthana,[41] Mumurshiyam, (3rd),[42] Yasya Shyaaveeyam, (5th)[18] Gomaya Churneeyam, (9th),[43] Chaaya (10th),[44] Pushpeeyam, (11th),[32] and Avaakchitiyam (12th)[45] chapters of Bhela Indriya Sthana.

  Hyperchromatopsia and Photopsia Top

Diva Jyoteemshi Jwalitaaneeva Pashyati (perceiving stars during daytime as illuminated or aflame), Pashyati Raatrau Suryam Jwalantam (perceiving bright sun at nights), and Pradeeptamiva Lokam Pashyati (perceiving everything as bright and illuminated) denotes photopsia or hyperchromatopsia. Perceiving the objects as if they are illuminated or aflame (Pradeeptamiva or Jwalitaaneeva Pashyati) denotes either photopsia or hyperchromatopsia. Photopsia is characterized by the presence of perceived flashes of light (Diva Jyoteemshi Pashyati?) in visual field and in hyperchromatopsia colors appears as highly saturated, bright, and luminescent (Pradeeptamiva or Jwalitaaneeva Pashyati) due to which objects (Raatrau Suryam, Diva Jyoteemshi and Lokam) have a glittering appearance (Pradeeptamiva or Jwalitaaneeva or Jyoteemshi). In hyperchromatopsia, the colors are so hyperintense (Pradeeptamiva or Jwalitaaneeva) that the patients close their eyes. Patients describes a light as powerful as the sun (Raatrau Suryam Jwalantam?) and may perceive shocking colors (Ameghe Shakrachaapa) or perceive fire (Pradeeptamiva or Jwalitaaneeva). Posterior vitreous detachment (PVD), retinal detachments and tears, age-related macular degeneration (AMD), migraine, central serous chorioretinopathy, hypoglycemia, intraocular lens reflections, vertebrobasilar insufficiency, retinitis pigmentosa, blue field entoptic phenomenon, Charles Bonnet syndrome (CBS), and metastatic adenocarcinoma to the brain (Gataayusham) are the most important causes for photopsia. The photopsias associated with PVD and retinal detachment are characterized by lightning or flash morphology (Ameghe Tadillataa).[32]

  Achromatopsia, Dyschromatopsia, Scieropia and Myodesopsia Top

Pashyati Suryam Diva Chandra Varchasam (perceiving bright daytime sun as dull or hazy) denotes achromatopsia or dyschromatopsia. Visual snow syndrome (VSS) is characterized by a positive visual disturbance (Raatrau Suryam Jwalantam or Diva Jyoteemshi Jwalitaaneeva Pashyati or Pradeeptamiva or Jwalitaaneeva Pashyati) over the entire visual field. VSS patients describe their visual disturbances as constant flashing lights (Pradeeptamiva or Jwalitaaneeva Pashyati) or small flashing dots or a granular or hazy image (Pashyati Suryam Diva Chandra Varchasam?).[45] Glaucoma patients describe their vision as “fuzzy” or “less clear” or “difficult to read” or “hazy” or “cloudy” (Nirmale Gagane Asitaan Meghaan Ghanaan and Dhooma Nihaara Vaasa Aavrutam Pashyati Medini). Blurriness or dimness or cloudiness (Dhooma Nihaara Vaasa Aavrutam Pashyati Medini) can be seen in glaucoma patients.[18] For achromatopsia (loss of colour vision) patients, the world appears as if it has been drained of colour and even bright and saturated colours look pale (Pashyati Suryam Diva Chandra Varchasam). Patients with achromatopsia cannot perceive, name and sort any colour, although they are still able to sort shades of gray (Dhooma Nihaara Vaasa Aavrutam Pashyati Medini and Pashyati Suryam Diva Chandra Varchasam). Scieropia refers to darkening of vision such as a patient whose vision is dimmed as if seeing everything at twilight (Dhooma Nihaara Vaasa Aavrutam Pashyati Medini and Pashyati Suryam Diva Chandra Varchasam) and it manifests due to diffuse occipital damage (Gataayusham?). Scierneuropsia is a psychogenic visual symptom in which perceived objects lack their usual brightness (Pashyati Suryam Diva Chandra Varchasam), and thus appear to be in a shadow (Dhooma Nihaara Vaasa Aavrutam Pashyati Medini). Cerebral dyschromatopsia is an impaired colour perception (Mayura Kanthaabham Vahnimeekshate) due to an acquired brain lesion especially temporo-occipital white matter damage (Gataayusham?). Ashtapadaakaaram Lekhaa Pashyati denotes myodesopsia or floaters. Most patients with myodesopsia described the floaters as spots, threads (Lekhaa), hair-like (Lekhaa), hollow circles, and cobwebs (Ashtapadaakaaram Lekhaa?). Myodesopsia is seen in various conditions like PVD, optic neuritis, chronic myeloid leukemia, vitreous syneresis, retinal detachments, vitritis, cystoids macular edema etc., (Gataayusham?).[41]

  Mirror Image Agnosia Top

Na Pashyati Chaaya Jyotsana Aadarsha Ushna Toyeshu (unable to recognize the self-image in moon light, mirror and hot water) and Chaaya Pashyati Ekaangaheenam Vikrutam Anya Satvajam (distorted perception of reflected images of objects or persons) denotes a condition of mirror image agnosia (MIA). Failure to recognize (Na Pashyati) the self-images (Chaaya) is known as MIA and it is seen in patients with parietal lobe atrophy and in dementias (Gataayusham?). Patients have specific difficulty in identifying (Na Pashyati) their own reflected images (Chaaya) in the mirror (Aadarshe) and mistake them as strangers, Gods, or enemies (Chaaya Pashyati Vikrutam Vaa Anya Satvajam).[46] Posterior cortical atrophy (PCA) is a neurodegenerative condition that affects the visual-processing pathways due to the pathology in the visual association areas and it manifests with visual symptoms such as visual agnosia (Chaaya Na Pashyati) and prosopagnosia (Chaaya Vikrutam Pashyati). It is also seen in AD, Dementia with Lewy bodies (DLB), poststroke vascular dementia (Gataayusham?) etc.[47] Na Pashyati Nakshtra Arundhati Dhruva Akaasha Ganga (unable to see polar star, milky way and other spatial objects) denotes various conditions such as visual agnosia, visual apperceptive agnosia, nuclear cataract, AMD, severe retinopathy, glaucoma, cortical blindness (Gataayusham?) etc.[43]

  Visual Hallucinations Top

Pashyati Ameghe Shakrachaapa Tadillataa (perceiving rainbow and lightening in the absence of clouds), Pashyati Vimaana Yaana Praasaada Samkula Ambaram (perceiving celestial cars and castles in the clear sky), Pashyati Anilam Murtimantam (perceiving air as a solid material), Pashyati Lokam Plutamiva Ambhasaa (perceiving everything as immersed in water), Vidhoomam Vahnimeekshati (perceiving fire as smokeless), Shwa Kaaka Kanka Grudhra Preta Rakshasa Pishaachaanaam Pashyati (perceiving various animate and inanimate or supernatural beings in their absence) denotes visual hallucinations associated with fatal illnesses. Visual hallucinations can be seen in various neurological, ocular, medical, and psychiatric disorders. Simple visual hallucinations include photopsia (Pradeeptamiva, Jwalitaaneeva, and Tadillataa), lines (Ashtapadaakaaram Lekhaa) or patterns and they may be multicoloured (Shakrachaapa) and they can be seen in vitreous detachment, optic neuritis, migraine, occipital lobe seizures and tumours (Gataayusham) etc. Complex visual hallucinations are well formed and often involve animals (Shwa, Kaaka, Kanka and Grudhra), figures in bright colours (Preta, Rakshasa, Pishaacha, Uraga and Naga) and they can be seen in delirium, dementias, PD, Complex partial seizures (CPS), Creutzfeldt-Jakob disease (CJD), schizophrenia, Peduncular hallucinosis (PH), MS, migraine coma, CBS and Alice in wonderland syndrome. The content of the visual hallucinations (Pashyati) range from coloured shapes (Shakrachaapa) and patterns to well defined recognizable forms such as faces (Preta, Rakshasa, Pishaacha, Uraga and Naga), animals (Shwa, Kaaka, Kanka and Grudhra), objects (Praasaada) and scenes (Vimaana Yaana).[44] Visual perceptual abnormalities are seen in psychiatric conditions such as major depression, mania, personality disorders, substance abuse, panic attacks, schizophrenia, posttraumatic stress disorder, and Wernicke Korsakoff syndrome with encephalopathy (Gataayusham?).[32] The present verse (15–23) indicates various visual perceptural distortions, visual hallucinations, MIA and visual pathway diseases associated with poor prognosis [Table 1] and [Table 2].

  Conclusion Top

Maharshi Sushruta has documented various poor prognostic conditions in the Sutra Sthana of Sushruta Samhita from 28th to 33rd chapters. PVA is the 30th chapter of SSS and it consists of 23 verses. Various fatal signs and symptoms related to sensory organs and/or sensory pathways are explained in this chatper. Aturagata (diseases of the nervous system and sense organs), Aturagrahya (sensory and perceptual alterations) and Aturagatagrahya (diseases of the nervous system and sense organs associated with sensory and perceptual alterations) Aristhta Lakshanas (fatal signs and symptoms) are documented in this chapter. Conditions such as auditory hallucinations, auditory perceptual distortions, sensorineural hearing loss, aphasia, PH and cold sensations, somatosensory disorders, central hyperthermia syndrome, dysfunction of brainstem thermoregulatory pathways, sensory neuropathies, disease-specific VOCs, quantitative and qualitative olfactory and gustatory impairments, cortical sensory syndrome, visual perceptual distortions, MIA and visual hallucinations associated with fatal outcome are mentioned in the PVA of SSS. Various new hypotheses generated by the present explorative study may open the doors for further research into the development of novel Ayurvedic prognostic models or questionnaires.

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  [Table 1], [Table 2]


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