Anujyotiyam Indriyam Adhyaya

Indriya Sthana Chapter 11. Signs and Symptoms of Imminent Death caused due to diminution of Agni

Anujyotiyam Indriyam Adhyaya

Section/Chapter	Indriya Sthana Chapter 11
Preceding Chapter	Sadyomaraneeyam Indriyam Adhyaya
Succeeding Chapter	Gomayachurniyam Indriyam Adhyaya
Other Sections	Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana
Translator and commentator	Pandya D.
Reviewer	Babu S.P.
Editors	Khandel S.K., Babu S.P., Deole Y.S., Basisht G.
Year of publication	2020
Publisher	Charak Samhita Research, Training and Skill Development Centre
DOI	10.47468/CSNE.2020.e01.s05.012

Abstract

This chapter explicates the signs and symptoms of imminent death due to diminution of Agni (factor responsible for digestion and metabolism). The components of life like lifespan, strength, complexion, enthusiasm, health, growth, luster, and immunity are dependent upon the status of agni. Diminution of its power causes generalized symptoms indicative of imminent death. Declaration of the estimated time for death might be based on experience of many experts of that time, which can now be reestablished in light of present scientific developments. The clinical signs and symptoms given in this chapter are useful as an additional information for assessment of prognosis.

Keywords: Anujyoti, Arishta, Bali,Agni, digestion.

Introduction

The present chapter deals with near death signs that arise due to decrease in digestive capacity of a person i.e. agni. The chapter indicates importance of digestive and metabolic functions of agni. The ingested food is helpful and nutritive to body only if, it passes through various digestive and metabolic processes successfully. This food nourishes the body at cellular level and it reflects in the form of good complexion, strength, good health, enthusiasm, and nourishment to formation of ojas. Some part of food digested with the help of agni nourishes sensory organs along with mana (mind) too. Ayurveda has emphasized the importance of quality and quantity of Agni for metabolic activity of the body, that if the agni works well, the person lives long and if it ceases; the person is going to die.[ Charak Samhita Chikitsa Sthana 15/4]

Some signs seen in diseased or in healthy person, with or without any significant/visible pathology leading to death, are mentioned. These signs occurs due to initiation of some life threatening disease with poor prognosis even in initial stage.

It is emphasized that any extreme alternation in body physiology or psychology, person’s own behavior, mental functions, etc. without any significant reason; is also one of the sign for death.

Mind supremacy is also highlighted, as the mental strength of a person declines due to advancement of disease; then the person is likely to die. Composition of physical body (sharira), sensoria (indriya), mind (sattva) and soul (atma) is called life (ayu). With advanced stage of disease, physical body gets damaged, sensoria may also get affected and soul becomes ready to leave the diseased body; in such situation only strong mind power can sustain life as physical body follows mind and vice versa.[ Charak Samhita Sharia Sthana 1/155]

It is elucidated that if person’s life span has ended; even good quality of physician, medicine or care taker are helpless. In a nutshell person’s life span is fixed and when it is gets finished, some signs are manifested called arishta.

Further, status of dying person is described briefly that, he may develop aversion to all loving and respectful persons, friends, food (and other basic essentials for surviving) etc. as his soul is almost in position to detach this body and preparing self to travel to other world. The chapter defines arishta with a new dimension. The concomitant aggravation of dosha (either qualitative or quantitative) with life-threatening diminution of dhatu is significant in the prediction of death.

Sanskrit text, Transliteration and English Translation

अथातोऽणुज्योतीयमिन्द्रियं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

athātō'ṇujyōtīyamindriyaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

athAto~aNujyotIyamindriyaM vyAkhyAsyAmaH||1||

iti ha smAha bhagavAnAtreyaH||2||

Now we shall expound the chapter "Anujyotiyam Indriyam" (Signs and Symptoms of Imminent Death caused due to diminution of Agni). Thus said Lord Atreya. [1-2]

Prognostic features of impending death and declining lifespan within a year

अणुज्योतिरनेकाग्रो दुश्छायो दुर्मनाः सदा|
रतिं न लभते याति परलोकं समान्तरम्||३||

aṇujyōtiranēkāgrō duśchāyō durmanāḥ sadā|
ratiṁ na labhatē yāti paralōkaṁ samāntaram||3||

aNujyotiranekAgro dushchAyo durmanAH sadA|
ratiM na labhate yAti [1] paralokaM samAntaram||3||

The person always (suffering from) with poor digestion, unstable or agitated mind, diminished luster, weak mental strength and restlessness goes to other world [dies] within a year. [3]

बलिं बलिभृतो यस्य प्रणीतं नोपभुञ्जते|
लोकान्तरगतः पिण्डं भुङ्क्ते संवत्सरेण सः||४||

सप्तर्षीणां समीपस्थां यो न पश्यत्यरुन्धतीम्|
संवत्सरान्ते जन्तुः स सम्पश्यति महत्तमः||५||

विकृत्या विनिमित्तं यः शोभामुपचयं धनम्|
प्राप्नोत्यतो वा विभ्रंशं समान्तं तस्य जीवितम्||६||

baliṁ balibhr̥tō yasya praṇītaṁ nōpabhuñjatē|
lōkāntaragataḥ piṇḍaṁ bhuṅktē saṁvatsarēṇa saḥ||4||

saptarṣīṇāṁ samīpasthāṁ yō na paśyatyarundhatīm|
saṁvatsarāntē jantuḥ sa sampaśyati mahattamaḥ||5||

vikr̥tyā vinimittaṁ yaḥ śōbhāmupacayaṁ dhanam|
prāpnōtyatō vā vibhraṁśaṁ samāntaṁ tasya jīvitam||6||

baliM balibhRuto yasya praNItaM nopabhu~jjate|
lokAntaragataH piNDaM bhu~gkte saMvatsareNa saH||4||

saptarShINAM samIpasthAM yo na pashyatyarundhatIm|
saMvatsarAnte jantuH sa sampashyati mahattamaH||5||

vikRutyA vinimittaM yaH shobhAmupacayaM dhanam|
prApnotyato vA vibhraMshaM samAntaM tasya jIvitam||6||

When a person offers bali (an offering a piece of daily meal) to crow and it does not accept it this indicates of death within a year for the offering person.[4]

If a person is not able to see the star Arundhati situated adjacent to the constellation of Saptarshi (The Great Bear), he succumbs to death one year thereafter. [5]

Sudden gain or loss of luster, body weight, or wealth without any reasons indicates death of the person within one year thereafter. [6]

Prognostic features of impending death and declining lifespan within six months

भक्तिः शीलं स्मृतिस्त्यागो बुद्धिर्बलमहेतुकम्|
षडेतानि निवर्तन्ते षड्भिर्मासैर्मरिष्यतः||७||

bhaktiḥ śīlaṁ smr̥tistyāgō buddhirbalamahētukam|
ṣaḍētāni nivartantē ṣaḍbhirmāsairmariṣyataḥ||7||

bhaktiH shIlaM smRutistyAgo buddhirbalamahetukam|
ShaDetAni nivartante ShaDbhirmAsairmariShyataH||7||

Sudden changes in likings, gentleness, memory, sacrifices, intellect and strength these six attributes in a person indicate the death within a time of six months. [7]

धमनीनामपूर्वाणां जालमत्यर्थशोभनम्|
ललाटे दृश्यते यस्य षण्मासान्न स जीवति||८||

लेखाभिश्चन्द्रवक्राभिर्ललाटमुपचीयते|
यस्य तस्यायुषः षड्भिर्मासैरन्तं समादिशेत्||९||

dhamanīnāmapūrvāṇāṁ jālamatyarthaśōbhanam|
lalāṭē dr̥śyatē yasya ṣaṇmāsānna sa jīvati||8||

lēkhābhiścandravakrābhirlalāṭamupacīyatē|
yasya tasyāyuṣaḥ ṣaḍbhirmāsairantaṁ samādiśēt||9||

dhamanInAmapUrvANAM jAlamatyarthashobhanam|
lalATe dRushyate yasya ShaNmAsAnna sa jIvati||8||

lekhAbhishcandravakrAbhirlalATamupacIyate|
yasya tasyAyuShaH ShaDbhirmAsairantaM samAdishet||9||

Sudden appearance of extremely shiny and prominent vasculature on fore head of an individual indicates that maximum life span of less than six months. [8]

A person, on whose forehead crescent shaped grooves develop, is supposed to die after six months. [9]

Prognostic features of impending death and declining lifespan within one month

शरीरकम्पः सम्मोहो गतिर्वचनमेव च|
मत्तस्येवोपलभ्यन्ते यस्य मासं न जीवति||१०||

रेतोमूत्रपुरीषाणि यस्य मज्जन्ति चाम्भसि|
स मासात् स्वजनद्वेष्टा मृत्युवारिणि मज्जति||११||

हस्तपादं मुखं चोभे विशेषाद्यस्य शुष्यतः|
शूयेते वा विना देहात् स च मासं न जीवति||१२||

śarīrakampaḥ sammōhō gatirvacanamēva ca|
mattasyēvōpalabhyantē yasya māsaṁ na jīvati||10||

rētōmūtrapurīṣāṇi yasya majjanti cāmbhasi|
sa māsāt svajanadvēṣṭā mr̥tyuvāriṇi majjati||11||

hastapādaṁ mukhaṁ cōbhē viśēṣādyasya śuṣyataḥ|
śūyētē vā vinā dēhāt sa ca māsaṁ na jīvati||12||

sharIrakampaH sammoho gatirvacanameva ca|
mattasyevopalabhyante yasya mAsaM na jIvati||10||

retomUtrapurIShANi yasya majjanti cAmbhasi|
sa mAsAt svajanadveShTA mRutyuvAriNi majjati||11||

hastapAdaM mukhaM cobhe visheShAdyasya shuShyataH|
shUyete vA vinA dehAt sa ca mAsaM na jIvati||12||

Sudden appearance of tremors on body, drowsiness along with altered gait and speech resembling of an insane person cannot survive even for a month. [10]

If semen, urine and feces of an individual sink in water as well as have aversion from own relatives, will sink in the water of death within one month. [11]

If there is noticeable emaciation or swelling of hands and feet along with face and without body (trunk) involvement, he will not survive for more than a month.[12]

Prognostic features of impending death and declining lifespan

ललाटे मूर्ध्नि बस्तौ वा नीला यस्य प्रकाशते|
राजी बालेन्दुकुटिला न स जीवितुमर्हति||१३||

प्रवालगुटिकाभासा यस्य गात्रे मसूरिकाः|
उत्पद्याशु विनश्यन्ति न चिरात् स विनश्यति||१४||

ग्रीवावमर्दो बलवाञ्जिह्वाश्वयथुरेव च|
ब्रध्नास्यगलपाकश्च यस्य पक्वं तमादिशेत्||१५||

सम्भ्रमोऽतिप्रलापोऽतिभेदोऽस्थ्नामतिदारुणः |
कालपाशपरीतस्य त्रयमेतत् प्रवर्तते||१६||

प्रमुह्य लुञ्चयेत् केशान् परिगृह्णात्यतीव च|
नरः स्वस्थवदाहारमबलः कालचोदितः||१७||

lalāṭē mūrdhni bastau vā nīlā yasya prakāśatē|
rājī bālēndukuṭilā na sa jīvitumarhati||13||

pravālaguṭikābhāsā yasya gātrē masūrikāḥ|
utpadyāśu vinaśyanti na cirāt sa vinaśyati||14||

grīvāvamardō balavāñjihvāśvayathurēva ca|
bradhnāsyagalapākaśca yasya pakvaṁ tamādiśēt||15||

sambhramō'tipralāpō'tibhēdō'sthnāmatidāruṇaḥ |
kālapāśaparītasya trayamētat pravartatē||16||

pramuhya luñcayēt kēśān parigr̥hṇātyatīva ca|
naraḥ svasthavadāhāramabalaḥ kālacōditaḥ||17||

lalATe mUrdhni bastau vA nIlA yasya prakAshate|
rAjI bAlendukuTilA na sa jIvitumarhati||13||

pravAlaguTikAbhAsA yasya gAtre masUrikAH|
utpadyAshu vinashyanti [2] na cirAt sa vinashyati||14||

grIvAvamardo balavA~jjihvAshvayathureva ca|
bradhnAsyagalapAkashca yasya pakvaM tamAdishet||15||

sambhramo~atipralApo~atibhedo~asthnAmatidAruNaH [3] |
kAlapAshaparItasya trayametat pravartate||16||

pramuhya lu~jcayet keshAn parigRuhNAtyatIva [4] ca|
naraH svasthavadAhAramabalaH [5] kAlacoditaH||17||

Appearance of crescent shaped blue lines on fore head, face and pelvic region indicates that the person will not survive. [13]

If eruption of masurika (small pox like lesions) on body, having appearance of coral beds (bright red), subsides immediately after its manifestation, the person will die immediately. [14]

A person having acute and severe squeezing type of pain in neck, swelling of tongue along with inflammation of scrotum, throat and mouth should be considered as ripen (for death). [15]

Excessive giddiness, extreme delirium and severe piercing type of pain in bones, manifestation of these three symptoms together indicates that the person is captured by death. [16]

A person, who pulls out his hair in fainting state, eats food like healthy person and still remains weak should be considered as captured by death. [17]

समीपे चक्षुषोः कृत्वा मृगयेताङ्गुलीकरम्|
स्मयतेऽपि च कालान्ध ऊर्ध्वगानिमिषेक्षणः ||१८||

शयनादासनादङ्गात् काष्ठात् कुड्यादथापि वा|
असन्मृगयते किञ्चित् स मुह्यन् कालचोदितः||१९||

samīpē cakṣuṣōḥ kr̥tvā mr̥gayētāṅgulīkaram|
smayatē'pi ca kālāndha ūrdhvagānimiṣēkṣaṇaḥ ||18||

śayanādāsanādaṅgāt kāṣṭhāt kuḍyādathāpi vā|
asanmr̥gayatē kiñcit sa muhyan kālacōditaḥ||19||

samIpe cakShuShoH kRutvA mRugayetA~ggulIkaram|
smayate~api ca kAlAndha UrdhvagAnimiShekShaNaH [1] ||18||

shayanAdAsanAda~ggAt kAShThAt kuDyAdathApi vA|
asanmRugayate ki~jcit sa muhyan kAlacoditaH||19||

The person who searches for his own fingers and hands putting them before his eyes and smiles with upward gaze and unblinking should be considered as blinded by approaching death. [18]

A person who is lying on his bed but is searching for his bed continuously, sitting on chair and searching his own seat, searching his own organs, walking with the stick and searching the same, and searching the walls of his own room, or while working with something and searching the same, are the symptoms of the imminent death of that person. [19]

अहास्यहासी सम्मुह्यन् प्रलेढि दशनच्छदौ|
शीतपादकरोच्छ्वासो यो नरो न स जीवति||२०||

आह्वयंस्तं समीपस्थं स्वजनं जनमेव वा|
महामोहावृतमनाः पश्यन्नपि न पश्यति||२१||

ahāsyahāsī sammuhyan pralēḍhi daśanacchadau|
śītapādakarōcchvāsō yō narō na sa jīvati||20||

āhvayaṁstaṁ samīpasthaṁ svajanaṁ janamēva vā|
mahāmōhāvr̥tamanāḥ paśyannapi na paśyati||21||

ahAsyahAsI sammuhyan praleDhi dashanacchadau|
shItapAdakarocchvAso yo naro na sa jIvati||20||

AhvayaMstaM samIpasthaM svajanaM janameva vA|
mahAmohAvRutamanAH pashyannapi na pashyati||21||

Person who laughs without any reason, acts stupid, teeth and gums are covered with dirt, biting his lips and whose feet, arms are too cold and disappointingly takes long breaths will not survive for long. [20]

Loud shout to call relatives and other people sitting nearby, severe visual hallucinations for non-existing things, observed in the person whose mind is covered by severe delusion [of death].[21]

Physician's ethical code to abstain from prescription

अयोगमतियोगं वा शरीरे मतिमान् भिषक्|
खादीनां युगपद्दृष्ट्वा भेषजं नावचारयेत्||२२||

ayōgamatiyōgaṁ vā śarīrē matimān bhiṣak|
khādīnāṁ yugapaddr̥ṣṭvā bhēṣajaṁ nāvacārayēt||22||

ayogamatiyogaM vA sharIre matimAn bhiShak|
khAdInAM yugapaddRuShTvA bheShajaM nAvacArayet||22||

A wise physician should abstain from treating a patient when he observes that the patient’s body is simultaneously responding both excessively and deficiently to sensory stimuli. [22]

Near death signs

अतिप्रवृद्ध्या रोगाणां मनसश्च बलक्षयात्|
वासमुत्सृजति क्षिप्रं शरीरी देहसञ्ज्ञकम्||२३||

वर्णस्वरावग्निबलं वागिन्द्रियमनोबलम्|
हीयतेऽसुक्षये निद्रा नित्या भवति वा न वा||२४||

atipravr̥ddhyā rōgāṇāṁ manasaśca balakṣayāt|
vāsamutsr̥jati kṣipraṁ śarīrī dēhasañjñakam||23||

varṇasvarāvAgnibalaṁ vāgindriyamanōbalam|
hīyatē'sukṣayē nidrā nityā bhavati vā na vā||24||

atipravRuddhyA rogANAM manasashca balakShayAt|
vAsamutsRujati kShipraM sharIrI dehasa~jj~jakam||23||

varNasvarAvagnibalaM vAgindriyamanobalam|
hIyate~asukShaye nidrA nityA bhavati vA na vA||24||

In case of extreme advancement of the disease and weaker psychological strength, the soul immediately leaves the body. [23]

Near the end of life there is general decline in complexion, voice, agni, speech and state of mind, as well as sleep pattern alters. [24]

Features and fate of unfaithful patients

भिषग्भेषजपानान्नगुरुमित्रद्विषश्च ये|
वशगाः सर्व एवैते बोद्धव्याः समवर्तिनः||२५||

एतेषु रोगः क्रमते भेषजं प्रतिहन्यते|
नैषामन्नानि भुञ्जीत न चोदकमपि स्पृशेत्||२६||

bhiṣagbhēṣajapānānnagurumitradviṣaśca yē|
vaśagāḥ sarva ēvaitē bōddhavyāḥ samavartinaḥ||25||

ētēṣu rōgaḥ kramatē bhēṣajaṁ pratihanyatē|
naiṣāmannāni bhuñjīta na cōdakamapi spr̥śēt||26||

bhiShagbheShajapAnAnnagurumitradviShashca ye|
vashagAH sarva evaite boddhavyAH samavartinaH||25||

eteShu rogaH kramate bheShajaM pratihanyate|
naiShAmannAni bhu~jjIta na codakamapi spRushet||26||

Those who hate physician, medicine, food (and drink), teacher (spiritual teacher), and friends; are considered to be already under the grip of God of death. [25]

In such people, the disease progress occurs unrestricted and the medicine remains ineffective. The wise physician should not take his offerings in any form, even in form of food and drinks. [26]

Limitation of healthcare systems

पादाः समेताश्चत्वारः सम्पन्नाः साधकैर्गुणैः|
व्यर्था गतायुषो द्रव्यं विना नास्ति गुणोदयः||२७||

pādāḥ samētāścatvāraḥ sampannāḥ sādhakairguṇaiḥ|
vyarthā gatāyuṣō dravyaṁ vinā nāsti guṇōdayaḥ||27||

pAdAH sametAshcatvAraH sampannAH sAdhakairguNaiH|
vyarthA gatAyuSho dravyaM vinA nAsti guNodayaH||27||

Availability of all four basic components of treatment i.e. doctor, medicament, care taker and patient with their desirable quality are of no value in regard to the person who is at the end of his life and there is no response to treatment.[27]

Importance of knowledge of prognosis

परीक्ष्यमायुर्भिषजा नीरुजस्यातुरस्य च|
आयुर्ज्ञानफलं कृत्स्नमायुर्ज्ञे ह्यनुवर्तते||२८||

parīkṣyamāyurbhiṣajā nīrujasyāturasya ca|
āyurjñānaphalaṁ kr̥tsnamāyurjñē hyanuvartatē||28||

parIkShyamAyurbhiShajA nIrujasyAturasya ca|
Ayurj~jAnaphalaM kRutsnamAyurj~je hyanuvartate||28||

The physician should always assess the prognostic signs of life in diseased as well as in healthy person. Because the knowledge of prognostic signs of life and diseases helps to decide remaining lifespan and hence treatment can be planned accordingly. [28]

Summary

तत्र श्लोकः-
क्रियापथमतिक्रान्ताः केवलं देहमाप्लुताः|
चिह्नं कुर्वन्ति यद्दोषास्तदरिष्टं निरुच्यते||२९||

tatra ślōkaḥ-
kriyāpathamatikrāntāḥ kēvalaṁ dēhamāplutāḥ|
cihnaṁ kurvanti yaddōṣāstadariṣṭaṁ nirucyatē||29||

tatra shlokaH-
kriyApathamatikrAntAH kevalaM dehamAplutAH|
cihnaM kurvanti yaddoShAstadariShTaM nirucyate||29||

Here is the re capitulatory verse: The signs originated due to extensively vitiated and pervaded dosha throughout the body, and already transcended the stage of the treatment are called arishta (signs of death). [29]

Tattva Vimarsha (Fundamental Principles)

• Optimum quality and quantity of agni is necessary for sustenance of life.
• Stable mental status, complexion and mental strength are markers to predict lifespan of patient.
• Sudden changes in likings, gentleness, memory, sacrifices, intellect and strength in a person are pre-indications of death.
• Altered sensorium and psychological status leading to various delusions and hallucinations are pre-indicators of death.
• Near the end of life there is general decline in complexion, voice, agni, speech and state of mind, as well as sleep pattern alters.
• The prognostic signs of life in diseased as well as in healthy person shall always be assessed. This helps to decide remaining lifespan and planning treatment.
• The signs originated due to extensively vitiated and pervaded dosha throughout the body, and already transcended the stage of the treatment are called arishta (signs of death).

Vidhi Vimarsha (Applied Inferences )

Role of agni in near death signs

Metabolic process and thermoregulatory center situated in hypothalamus play key role to generate and maintain body temperature respectively. Reduced temperature shows slow metabolic process and gradually it ceases completely, causing death. With the help of healthy digestive power and proper metabolic activity; food nourishes the body and provide macro and micronutrients to the body.[ Charak Samhita Chikitsa Sthana 15/3] [verse 3]

Psychological and age related changes in near death signs

In any manner, hampered blood or oxygen supply to the brain leads to lack of concentration, weakness of mental functions or agitation. Deposition of any toxic substance or progressive degenerative changes of mind also leads to such symptoms. Ageing and death are considered as natural process with passage of time.[ Charak Samhita Sharira Sthana 4/36] With declining phase of life, ageing symptoms start to appear, as new cell production is almost stops and older cell destruction continues. With the passage of senescence; weakness, decreasing appetite, muscular wasting, decreased fluid intake, neurological dysfunctions, decreasing level of consciousness etc. are common symptoms manifest and gradually leads to cessation of life. [verse 3]

Every individual has good appetite and capability of digesting foods he regularly ingests. Ksheerada(only on milk), ksheera-anna(milk and rice products), annada (staple foods), are three basic stages of life. During ageing process, gradual reduction in both qualitative consumption and digestive abilities are observed. This in turn influences the individual’s physical and mental wellbeing leading to reduction in life span ending in death.[verse 3]

Meta-physical observations near death

As per the principle of Yatha Brahmande Tatha Pinde, whatever is present in the universe, that is present in the human body. Hence there should be some connections between human body and the universe. When the soul is preparing for detachment from the body to start its journey to other world, there should be some indications from the universe as indicator of impending death. As per Indian tradition, offerings of food to birds specially to crow and non-acceptance of offering by crow may indicate the preparation of soul for detachment from living body. Inability to see Arundhati in the sky is another indication of the same. [ verse 4–5]

Clinical observations in near death signs

Acute loss or gain of luster or body weight can be the result of carcinogenic condition or severe catabolic changes taking place in the body that can be fatal for the person. [ verse 6]

Brain regulates multiple functions related to sensory, motor and autonomous nervous system like emotions, intellect and many other activities. Amygdala, and physiological functioning of limbic system of brain, are responsible for proper emotions and its expression. If these are deviated grossly, it shows involvement of higher center in pathogenesis and poor prognosis.

Gradual cessation of the functions is a clear indication of either degenerative changes or space occupying lesion (SOL) in the specific area. Acute toxicity of brain also leads to acute degeneration of brain cells or infarction that leads to hampering of function. [verse 7]

Sudden appearance of crescent shaped streaks or blood vessel network on forehead may relate with Amyloidosis. It is a rare disease that occurs when a protein (albumoid) substance gets deposited in person’s organ. This abnormal protein is usually produced in bone marrow and can be deposited in any tissue or organ. The prognosis is poor. [verse 8-9]

If person having combination of dual type of activity of mind i.e. exaggerated (in form of tremor), and diminished activity (in form of stupor), simultaneously; is supposed to die within a month. These dual types of signs may indicate increased intracranial pressure (ICP) due to localized mass like hematoma, neoplasm, abscess, edema, infarction, obstruction in CSF circulation, diffuse brain edema (like encephalitis, meningitis, or diffuse head injury), thrombosis, or idiopathic intracranial hypertension.

Symptoms of raised ICP are altered mental state, lethargy, irritability, slow decision making and abnormal social behavior. Ultimate result of the pathophysiology of such condition is stupor, coma and death. Rapidly rising ICP leads to syncope, seizures. These neurologic changes seen in increased ICP are mostly due to hypoxia and hyper apnea. [verse 10]

If fecal matter or other excreta are mixed with ama, it sinks straight in water due to its heaviness. Same concept is applied to other body discharge or dhatu too. Fecal matter is the end product of digestion. Hence, if it sinks in water it shows incomplete or improper digestion of food. Shukra is the last dhatu and hence all subtle tissue metabolic processes (dhatvagni) contribute (directly or indirectly) in its formation. To sink shukra in water is indicative that the ama associated state of dhatu. To get dipped all the three i.e. feces, urine and semen shows impairment of jatharagni along with dhatvagni functions leading to qualitative mal-formation of all dhatu. Such situation has been considered as fatal. [verse 11]

Muscular wasting of hands and feet is a type of neurogenic muscular atrophy with poor prognosis.

Swelling over both extremities along with face is an indication of damage of two vital organ simultaneously i.e. heart and kidney and hence survival of patient is difficult.[verse 12]

Appearance of blue lines occurs in various conditions. This may be indication of venous congestion due to heart, lungs and liver diseases, requiring attention while scaling the span of life. [verse 13]

Immediate disappearance of manifested small pox subsequently develops acute toxemia and hence leads to death. [verse 14]

Combined manifestation of stiff neck along with inflamed throat and scrotum and swollen tongue is the condition of tertiary stage of syphilis when the person develops syphilitic meningitis (complication of untreated syphilis), is a life threatening condition. [verse 15]

Hallucinations in near death signs

Visual (or even other sensorial) hallucinations are often part of the dying experience. Person may unknowingly involve in such activities with such illusions. This is the phase when the soul is getting ready to detach from the body and to travel for another world. The dying may turn their focus to “another world”, and thus may see (or feel other sensorial hallucination of) some unusual things, he may see or talk to such people who are already died. [verse 18-19]

Various kinds of hallucinations are indications of altered psychological state of dying person, and to have laughter without any specific cause is also result of such hallucinations. To lick own lips is the sign of dehydration and coldness of breath and extremity are the indication of almost reducing function of heart and hence, stoppage of blood flow to concerned area. [ verse 20] Delusions along with altered sensorial organ is the sign of death. [verse 21]

Days or hours before death, the dying person becomes less and less responsive to voice and touch and may not awaken. (Sometimes, quite unexpectedly, the person may appear well and even look as if he/she is going to recover. The person may be alert and talkative. But it does not mean that he is getting well; of course the time may be used as a “window of opportunity” to say what you need to say and have closure). [verse 8] These all of sudden recovery changes also denote signs of near death. [verse 25]

As per ancient classical texts, life span of everyone is fixed and pre-ordained. No one can add years to the life only quality of life can be improved with medications. The same thing is meant here when it is said that death is the destiny of patient and that desirable quality of medicine, human resource and all other things cannot make the person outlive his destined lifespan.[verse 27]

Bad prognostic features and relevant disease pathologies

Prognostic features described in this chapter can be observed in various disease pathologies as shown in table 1. There is a wide scope of research to study the exact clinical correlation of the features, underlying disease pathologies and prognosis of impending death in prescribed time. This can open a new window in critical care management systems.

Table 1: Disease or pathologies related to prognostic feature

Reference verse	Probable relevant disease condition
Cha.Sa.Indriya Sthana 11/3	BPSD (behavioural and psychological symptoms of dementia); Delirium;
Cha.Sa.Indriya Sthana 11/7	Frontotemporal dementia; Vascular dementia; Alzheimer’s dementia; BPSD; Major neurocognitive disorders (NCDs);
Cha.Sa.Indriya Sthana 11/8	Arterial tortuosity syndrome (ATS); Temporal arteritis; Malignant hypertension; Telangiectasia;
Cha.Sa.Indriya Sthana 11/10	Wernicke-Korsakoff syndrome; Ataxia; Parkinson disease (PD); Dementia with Lewy bodies (DLB); Demyelinating diseases;
Cha.Sa.Indriya Sthana 11/11	Various infectious, neoplastic pathologies of male genital, urinary and gastrointestinal tracts;
Cha.Sa.Indriya Sthana 11/12	Progressive, acquired neuromuscular diseases (NMDs); Myopathies; Neuropathies; Angioedema; Erythropoeiticprotoporphria (EPP); Hepatic, cardiac and renal edema;
Cha.Sa.Indriya Sthana 11/14	Petechial or purpuric rash; Viral infections;
Cha.Sa.Indriya Sthana 11/15	Mumps orchitis; Lymphadenopathy; Epstein-Barr virus (EBV); Autoimmune diseases;
Cha.Sa.Indriya Sthana 11/16	Delirium; Bone metastasis; Acute myeloid leukemia (AML);
Cha.Sa.Indriya Sthana 11/17	Trichotillomania; Frontotemporal dementia; Vascular dementia; Lewy body disease; Delirium; Major neurocognitive disorders (NCDs);
Cha.Sa.Indriya Sthana 11/18-19	Asomatognosia; Autotopagnosia; Motor apraxia; Finger agnosia; Exploratory procedures (EPs); Brain stem vascular lesions; ABS (Anton-Babinski syndrome); Delirium;
Cha.Sa.Indriya Sthana 11/20	Delirium; Hemorrhagic shock; Cardiogenic shock;
Cha.Sa.Indriya Sthana 11/21	Prosopagnosia; Visual agnosia; Dementia; Delirium;
Cha.Sa.Indriya Sthana 11/22	Age related sensory impairment or decline; Hallucinations;
Cha.Sa.Indriya Sthana 11/23	Delirium; Dementia;
Cha.Sa.Indriya Sthana 11/24	Delirium; Dementia; End of life stages;
Cha.Sa.Indriya Sthana 11/25	‘Anger’ in second stage of a dying process; Projection of anger in a dying patient;

Acknowledgement: The contributors acknowledge support of Dr. M. Prasad and Dr.G.Kshama for providing table 1 from their published article referred in this chapter.