Indriya Sthana

Preamble of Indriya Sthana (Section on Determinants of Remaining Lifespan of Patients)

This section of Caraka Samhita called Indriya Sthana deals with the signs and symptoms useful in determining the remaining lifespan of patients (also called arishta lakshana). In the present era, because of advancements in medical sciences, many arishta lakshanas are well treatable and cannot be considered as "predictors" of death as they used to even a few centuries back. However, these signs and symptoms could serve as important indicators of prognosis of disease and therefore, would be helpful in the management of patients.

Life begins with the association of consciousness, or the atma, with the five fundamental elements (earth, air, fire, ether, and water, or thepanchamahabhuta) and ends in the dissolution of this association. Since this union (that results in a living being) is by no means permanent and since there is always a possibility of dissolution or death anytime, Ayurvedic texts emphasized on identifying certain signs and symptoms that could forebear, with some level of certainty, imminent death. This section is dedicated to such determinants and is structured in the form of 12 chapters:

• Signs and symptoms (arishtas) of imminent death specific to pathologies afflicting sense organs that can be perceived by sensory deficiencies (e.g., varna (color), swara (voices/sounds), gandha (smell), rasa (taste), sparsha(touch),along with chhaya (complexion) and prabha (radiance)) are addressed in chapters Arnaswariya, Pushpitendriya, Parimashneeya, Indriyaneeka, Pannarupiya and Shyavnimitta.

Even though all of these cannot be explained by rational scientific parameters, some of these signs and symptoms have been documented and reported as having been experienced by people in various parts of the world. Within the treatise (Charaka Samhita), physicians have been instructed to thoroughly examine the patient for certain telltale signs that indicate terminal illness and investigate using biomarkers. The treatise then advises physicians to stop any therapeutic treatment being given to such terminal patients and provide them palliative care instead.

When a person enters the final stage of the dying process, two different dynamics are at work and are closely interrelated and interdependent. On the physical plane, the body begins the final process of shutting down, which will end when all the physical systems cease to function. Usually, this is an orderly and undramatic progressive series of physical changes, which are not medical emergencies requiring invasive interventions. These physical changes are a normal and natural way in which the body prepares itself for death. The other dynamics of the dying process, per Ayurveda, are on a spiritual and psychological plane. The spirit of the dying person begins the final process of leaving the body, its immediate environment, and all (material/worldly) attachments. This release also tends to follow its own priorities, which may include the resolution of unfinished tasks of practical nature and reception of permission to “let go” from one's kin. In these events, the spirit prepares to move from this existence to the next dimension of life. The most appropriate response to the spiritual and psychological changes is that which supports and encourages this release and transition.

Palliative care to the terminally ill/dying patients is provided today in all communities across the world. It is a specialized field of healthcare that encompasses educational and training programs organized to educate family members/relatives/attendants to ensure patient care is not neglected especially in terminal cases. The World Health Organization (WHO) defines palliative care as 'an approach that improves the quality of life of individuals and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual'. The aging of the population, with the numerous chronic debilitating and malignant conditions associated with growing older, has focused attention on palliative care. The terminal state is an integral process and a time to reconcile differences so that patient and family may accept death with a minimum of physical, spiritual, and psychosocial anguish. Hospice care is a specialized philosophy and system of care for the terminally ill patient that accepts death in an affirmative way and provides palliative care and emotional support to dying patients and their families. Hospice and palliative care philosophy lays emphasis on relieving suffering and improving quality of life at the end of life in order to permit experiences that will have positive meaning. The role of the physician is central in providing this care. When recovery is uncertain it is better to discuss this rather than giving false hope to the patient and family. This is generally perceived as strength in the doctor-patient relationship and helps to build trust. Charaka also supports this view and states that those near death should not be treated. Thus it becomes important that physician should be well trained in identifying features of impending death. In order to care for dying patients it is essential to “identify dying”. This aim can be attained by applying the knowledge given in these chapters. Presently to predict prognostic value, few tools have been designed. Most widely-used prognostic tool is the Palliative Performance Scale (PPS) which has been studied primarily in inpatient settings and in patients with cancer. Few researches are ongoing to develop tools for prognosis in other diseases also. Research can be done to develop a scale based on parameters described in Ayurvedic Arishta Vigyana and these chapters can also contribute a lot in making such kind of tool. Before going into the details of these chapters, an overview of concepts laid down in previous chapters of Charaka Samhita, regarding the importance of sense organs (Indriya),in constitution and dissolution of life will be helpful to understand this process. 1. What is Indriya sthana ? • Indra means prana (life.) • The seat of prana (life) in the body is Sneha or Ojus (a subtlest substance of final outcome of digestion of all body tissues, like a clarified butter obtained from the milk). ( Ch. Su. 30 / 11). • Indriya (sense organs) are said to be the linga (symptom) of prana, which is consumer of the life forces (prana).

2. Process of Indriyadushti (damage of sensory system)

• A state of perfect health is Anirvedovart lakshananam (life without the perception of being alive) means zero symptom. ( Ch. Su. 25/ 40) • Marker for this zero symptom state is Ojus or sneha which is the seat of prana. • Ojus is all pervading, subtlest essence of every micro particle of the body, because it has dominance of Akash mahabhoota (space). This property of akasha is called Apratighata. • Ojus or Sneha provides and maintains a requisite space, a non - resistant insulation between two micro particles, like a dew drop on lotus petal without harming mutual existence. This zero resistant state provides a required space for smooth and effortless movement of dosha, dhatu and mala (all biological substances) and allows them to perform all physiological functions smoothly, called a stage of homeostasis. • Overuse, underuse and misuse of indriya or senses is called Asatmyendriyartha samyoga where inappropriate consumption of this isolator insulation of Ojus or sneha occurs resulting in increase of roukshya or roughness which causes a painful perception.

3. Clinical importance of Indriya • The first chapter of Sutrasthana stresses upon the cause of all mental and physical diseases as asatmyendriyarth samyoga (injudicious use of senses), leading to premature deterioration of senses causing shortening of life. (Ch. Su. 1 / 54). • Sensory organs are exposed to enormous sensations from the external world, voluntarily or involuntarily, all the time. These sensations are of varying degree of traumatic, unpleasant or pleasant in nature. • Whereas the physical body takes limited amount of food and drinks, the senses encounter enormous stimuli, because indriya buddhi (sensory centres in brain) always remains open and active and acts as extension of brain. • Constantly sensing such traumatic stimuli, reduces the lifespan of indriya than other organs of body. • With this reason Upnishad prays loudly for life of indriya “ jeevem sharadh shatam, pasyemah shardah shatam, shrinuyamah ..........” • To accomplish the optimum span of life, for prevention of disease, promotion of health, and repair of sensorium, with the judicious uses of all senses, the yam, niyam (Do’s and Don’ts) and sadvritta (code and conducts) are mentioned in detail in Indriyopakramneeya chapter (Ch.su.8). • If a person does not take care of indriya, than the life forces deteriorate prematurely, resulting in death, or become inefficient to carry the sensory functions in the middle of the expected lifespan or earlier. • This inefficiency of indriya caused by injudicious use, manifests several signs and symptoms of imminent or instantaneous death. • These are categorically described in 12 chapters of indriya sthan, with useful tools for measuring life span, remaining life and clinical diagnosis of severity of disease.

Conclusion • Signs and symptoms of imminent death (Arishtas) described in following 12 chapters are specific for pathologies of sensory organs which can be assessed by sensory deficiencies. These are varna (color), swara (voices/sounds), gandha (smell), rasa (taste), sparsha(touch),along with chhaya (complexion) and prabha (radiance). These are detailed in Varnaswariya, Pushpiitendriya, Parimashneeya, Indriyaneeka, Pannarupiya and Shyavnimitta chapters. • The clinically useful early symptoms which are alarming and serious are mentioned in Purvarupeeya. • Gomaychurniya, Anujyoti, Avakshirsheeya and Sadyomarneeya chapters give examples of arishta seen in physical body or Bahyakarana, and pertaining to the Antahkaran (mental, intellectual, emotional, para psychological and para sensorial) symptoms, with sakun( good / bad consequential happening)), doota( messenger), swapna ( dreams) and miscellaneous occult sciences. The evidences laid down in these chapters may establish an ayurveda based clinical diagnostic methodology. It is need of the time to re understand this section, to remove the misconception, in certain minds where indriya sthana is unfortunately labelled as arishta sthana, only for pre death symptoms.