|Year : 2020 | Volume
| Issue : 2 | Page : 109-117
Mumurshiyam of Bhela Indriya Sthana: An Explorative Study
Kshama Gupta, Prasad Mamidi
Department of Kaya Chikitsa, SKS Ayurvedic Medical College and Hospital, Mathura, Uttar Pradesh, India
|Date of Submission||12-Aug-2020|
|Date of Decision||19-Oct-2020|
|Date of Acceptance||02-Nov-2020|
|Date of Web Publication||12-Jan-2021|
Dr. Kshama Gupta
Department of Kaya Chikitsa, SKS Ayurvedic Medical College and Hospital, Mathura, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Similar to “Agnivesha tantra” (popularly known as “Charaka samhita”), “Maharshi Bhela” has composed an Ayurvedic treatise known as “Bhela samhita.” Bhela samhita consists of 8 sections (sthana) and 120 chapters (adhyaya). “Indriya sthana” is one of the eight sections of “Bhela samhita” and it comprises 12 chapters. “Bhela Indriya sthana” deals with estimating life span and various prognostic aspects. “Mumurshurindriyam” is the third chapter of “Bhela indriya sthana.” The word “mumurshu” denotes a dying person and the chapter “mumurshurindriyam” contains the description of various signs and symptoms seen in the patients with terminal illness or end-of-life stages. Although previous works have explored “Charaka indriya sthana,” studies on “Bhela indriya sthana” are lacking. The present work is aimed to explore the contents of “Mumurshurindriyam” (third chapter) of “Bhela indriya sthana.” “Murmushurindriyam” chapter contains the description of conditions which are commonly seen during end-of-life stages. Various concepts/conditions such as end-of-life dreams and visions, deathbed communications, near death experiences, out-of-body experiences, visual hallucinations, delusions, dementia, delirium, organic psychosis, central auditory perception disorder, age-related hearing loss, late life psychosis, lower gastrointestinal bleeding, colon cancer, inflammatory bowel disease, end-stage renal disease, chronic kidney disease, diabetic ketoacidosis, central diabetes insipidus, spontaneous rupture of urinary bladder, myiasis, and medical etiquette are documented in this chapter by “Maharshi Bhela.” “Maharshi Bhela” has provided a list of signs and symptoms or clinical features in this chapter based on which questionnaire or screening methods can be developed, which can be used in prognostic research. Further research is required to substantiate the claims made in this chapter. The present study paves the path for future research directions.
Keywords: Bhela indriya sthana, Bhela samhita, Charaka indriya sthana, Charaka samhita, Indriya sthana, Maharshi Bhela
|How to cite this article:|
Gupta K, Mamidi P. Mumurshiyam of Bhela Indriya Sthana: An Explorative Study. J Integr Health Sci 2020;8:109-17
| Introduction|| |
Similar to “Agnivesha tantra” (popularly known as “Charaka samhita”), “Maharshi Bhela” has composed “Bhela tantra” which later developed as “Bhela samhita.” Among the six disciples of “Acharya Punarvasu Atreya,” “Maharshi Bhela's” position was number two, “Maharshi Agnivesha” standing at the top. Planning and arrangement of the subject matter in the “Bhela samhita” is similar to those in the “Charaka samhita,“ but the former is incomplete in many respects. Apart from the similarities with other texts, “Bhela samhita” has a number of peculiar ideas which give originality to the work. “Maharshi Bhela” was contemporary to “Maharshi Agnivesha” (1000-2000 BC). Maharshi Bhela has given a lot of and notable contributions to Ayurveda.
Bhela samhita consists of 8 sections (sthana) and 120 chapters (adhyaya). “Indriya sthana” is one of the eight sections of “Bhela samhita” and it comprises 12 chapters. “Bhela Indriya sthana” deals with estimating life span and various prognostic aspects. “Arishta lakshanas” (fatal signs and symptoms denotes imminent death) are documented throughout “Bhela indriya sthana.” Various parameters to evaluate the health and/or quality of life objectively are also available in “Bhela indirya sthana.” “Mumurshurindriyam” is the third chapter of “Bhela indriya sthana,” which contains the description of various “arishta lakshanas” associated with terminal illness. The concepts mentioned in this chapter are unique and different from other Ayurvedic classical texts., Previous works conducted on “Charaka indriya sthana” have established clinical significance, prognostic potential, and applicability in the present era.,,,,,,,,,,,, “Bhela indriya sthana” is unexplored till date though it contains various unique concepts. The present work is aimed to explore the contents of the third chapter “Mumurshurindriyam” of “Bhela indriya sthana.”
| Review Methodology|| |
Ayurvedic literature regarding “Bhela Indriya sthana” has been collected from different published versions of Bhela samhita and also relevant references from other classical Ayurvedic texts. Relevant books were also searched from the institutional library where the present work has been carried out. Electronic databases such as “Google” and “Google Scholar” have been searched to find out the relevant studies as well as reviews published till “July 2020,” irrespective of their appearance/publication year. Relevant key words have been used for both Ayurvedic and terms related to contemporary medicine for search. Abstracts, full text articles, case reports, and book chapters in “English language” and open access were only included in the present work.
| Contents of Mumurshurindriyam|| |
The word “mumurshu” denotes a dying person and the current chapter “mumurshurindriyam” contains the description of various signs and symptoms seen in the patients with terminal illness or characteristics of a person just about to die. Initial verses of “mumurshurindriyam” chapter were missing and the available version contains only 9 verses. The following description deals with the exploration of available 9 verses.
| Results and Discussion|| |
“Dhita swapne taam ratrim naativartate” (verse 1)
As per the above verse, “the person who has been getting such type of dreams (?) will die before that night ends or dies within a few hours.” This verse is broken and incomplete; hence, it is very difficult to understand the exact meaning. Based on the available portion of the verse, it can be assumed that a person or a patient who gets a particular type of dreams (swapna) will die within a few hours or before that night ends (raatrim naativartate). It denotes characteristic dreams which are seen in the persons or patients (taam) just before death. The dream is a unique psychodynamically informative instrument, which includes feelings, percepts, memories, impulses, fantasies, conflicts, wishes, defenses, and images of others and self. Dream analysis can be used in a variety of clinical settings to assist in diagnostic assessment, evaluation of clinical change, psychodynamic formulation, and the management of medically ill patients. Dreams may serve as the initial indicators of transference, impending crisis, resistance, conflict resolution, acting-out, and decision-making. The symbolic message or manifest imagery of dreams often informs about the central problem or clinical issue. Dreams, visions, and other transpersonal communications occur as part of the dying process, and they are called end-of-life dreams and visions (ELDVs) or deathbed communications (DBCs). ELDVs are common (50%–60%) and can occur months, weeks, days, or few hours before death. The most common ELDVs reported are those in which the dying patients describe seeing deceased family, friends, or religious figures. ELDVs had a positive correlation with the symptom burden and decreased in frequency or disappeared when the symptom burden diminished. ELDVs are “distressing” in nature. Inductive content analysis of ELDVs has found six categories, comforting presence, preparing to go, watching or engaging with the deceased, loved ones waiting, distressing experiences, and unfinished business. ELDVs are characterized by a consistent sense of realism and marked emotional significance. ELDVs may be a profound source of potential meaning and comfort for the dying and therefore warrant clinical attention and further research. “Maharshi Bhela” in the present verse has documented ELDVs seen in terminally ill patients.
“Iyam me shishti shibika—gataayuriti tam vidu” (verse 1)
As per the above verse, the dying patient (aarta) inappropriately (pralaapa) says that “palanquin (shishti shibika) which is attractive and decorated with precious stones (vaidhurya mani yanrita) has arrived to take him away.” Near-death experiences (NDEs) are reported by many patients who are suffering with terminal illness and during the state of unconscious, comatose, or clinically dead. NDEs such as “seeing colorful things,” “brighter and attractive colors/images,” and “increased vision (360o/3D/zooming camera like vision)” are most common. An out-of-body experience (OBE) is the apparent separation of consciousness from the body. NDEs are medically inexplicable and cannot be explained by known physical brain function. Common features of NDEs and OBEs include mystical elements, euphoria, peace, serenity, and acceptance. NDE experiences are extraordinary, scientifically challenging, lies beyond our normal sensorium, and understanding of consciousness. NDEs include pleasant experiences such as leaving their own bodies, passing down a dark tunnel toward a brilliant light, peace, and bliss of death. Gold standard to identify veridical NDEs includes awareness of being dead, positive mood such as euphoria, happiness, and well-being, OBE, entering a tunnel-like structure, perception of a light or heavenly or hellish landscape or sounds or music or different temporal perception, encounter with deceased religious figures, relatives, or beings of light and experience of a life review. NDE memories are different from imagined memories and much more similar to memories of real events, in terms of detail richness, self-referential, and emotional information. NDE memories of some people appear to have significant consequences on their lives (real NDE experiencers/real NDErs). In the present verse, seeing “well-decorated palanquin” to pick up the patient/self denotes positive, euphoric, self-referential, and emotional content, which is similar to NDEs and/or OBE.
Perceiving objects such as a well decorated palanquin (in their absence) denotes visual hallucinations. 'Pralaapa' (irrelevant or incoherent or inappropriate speech) and 'Aarta' (suffering with terminal illness) represent a condition of delirium. The present verse denotes delirium with visual hallucinations. Delirium is one of the most common neuropsychiatric problems and it is prevalent at the end of life, particularly during the final 24–48 h. The occurrence rate of delirium is as high as 88% before death; hence, at the end of life, all patients can be considered at high risk of delirium. Delirium is caused by various medical conditions such as metabolic disturbances, infections, drug effects, and intracranial processes. Delirium is characterized by symptoms (e.g., hallucinations and delusions) that are suggestive of a primary psychotic illness. Visual hallucinations are the most common type of hallucination seen in delirium. A strong positive correlation has been established between visual hallucinations and the number of active somatic diagnoses in patients with delirium. Delirium is characterized by disorganized thinking, manifested by incoherent speech and rambling or irrelevant conversation, or unclear or illogical flow of ideas. Impairment of judgment, loss of insight or poor insight, delusions (paranoid and persecutory being the most common), perceptual disturbances including illusions, and misinterpretations can also occur. Visual hallucinations are the most frequent and even they can appear during the day as soon as the patient closes his eyes in delirium patients. Complex visual hallucinations are persistent in DLB (dementia with Lewy bodies). Visual hallucinations in delirium typically involve different types of animals or signs and shapes. Auditory, tactile, musical, and lilliputian hallucinations may also occur. “Maharshi Bhela” has documented the commonly seen conditions such as NDEs, OBE, and Visual hallucinations in delirium in patients with terminal illness in the present verse.
“Prajwalatyapi yo deepe—chaapurvaaniva naasti sa” (verse 2)
Perceiving everything as dark (even in the presence of bright light) (tama eva pashyati) and having abnormal perception of sounds or voices (vipratibudhyate) indicates an imminent death. The word “tama eva pashyati” may denote pathological conditions such as cortical blindness or decreased or loss of visual acuity or age-related vision loss or neurovascular ophthalmological conditions. Vision loss is caused by problems at any point (pupil-retina-optic nerves-occipital lobes) along the visual pathway from the eyes to the brain, and sudden vision loss denotes an emergency. Vision may become cloudy or blurry, completely absent (tama eva pashyati), or affected by floaters. Retinal artery or vein occlusion, retinal detachment, and inflammation of the blood vessels that supply the eye and the optic nerve can also cause vision loss. Ischemia to the occipital lobe of the brain is another common cause of sudden vision loss. Elderly people require more lighting in the surroundings to see properly than younger people. Decreased contrast sensitivity, reduced depth perception, and visual field deficits (tama eva pashyati) are associated with aging. Elderly people find it difficult to adapt in bright light (prajwalatyapi yo deepe) and darkness and they also are unable to tolerate glare. There is a strong positive association between age-related eye conditions and increased mortality. Cataract (nuclear cataract) or lens opacity can be considered as marker for aging. Decreased visual acuity, vision impairment, nuclear opacities, high intraocular pressure, retinopathy, and glaucoma have been found to be strongly associated with mortality. Many of these researchers have speculated that lens opacities are a biological marker for aging., The decreased survival of AREDS (age-related eye disease study) participants with AMD (acute macular degeneration) and cataract suggests that these conditions may reflect systemic rather than only local processes. Cortical blindness is the partial or complete loss of vision (tama eva pashyati) in the normal-appearing eye and occurs due to damaged visual field in the occipital cortex of the brain. In patients with posterior cerebral artery infarct, as occipital lobe which contains the primary visual cortex is usually affected and patients may present with visual impairment only.
“Shabdaani vipratibudhyeta” denotes various pathological conditions such as central auditory perception disorders (CAPD), age-related hearing loss (ARHL), auditory agnosia (apperceptive/associative agnosia), pure word deafness, central deafness and dementia. Age-related CAPD is characterized by poor speech understanding in noisy environments or with competing speech and speech perception. These problems may be due to degeneration of the central neural auditory pathways in the elderly. Speech perception impairment (shabdaani vipratibudhyeta) is also linked to other cognitive functions (i.e., executive and attentive functions). Age-related CAPD may be fundamental in determining an increased occurrence of cognitive decline and Alzheimer's disease (AD). The CAPD-cognition link has been summarized by the provocative term “the cognitive ear,” suggesting that hearing function is not only processed by the ear but also by the auditory and other associative cortical areas. Central auditory processing dysfunction, a common disability in patients with dementia or AD, often results in auditory processing deficits (shabdaani vipratibudhyeta). Such patients have difficulty comprehending speech in noisy or crowded settings, difficulty in separating or grouping different sound sources in the auditory environment, and unable to differentiate various messages presented concurrently to the two ears. Cerebrovascular disease (CVD) is the most prevalent neurological disorder and it can cause various types of auditory dysfunction (shabdaani vipratibudhyeta). Cortical auditory disorders considerably vary and the variety of descriptions, such as auditory agnosia, apperceptive agnosia, pure word deafness, central deafness, and reversible cortical (central) auditory dysfunction, indicates substantial overlap and thus a spectrum of related auditory processing disorders. Auditory dysfunction (shabdaani vipratibudhyeta) can be seen in various conditions such as cerebral infarction and cerebral ischemia (bitemporal infarction and ischemia, anterior inferior cerebellar artery infarction (AICA), non-AICA origin posterior circulation infarction and cerebral venous thrombosis), intracerebral hemorrhage (ICH) (bilateral ICH, cerebellar, and brainstem hemorrhage), subarachnoid hemorrhage (cerebral aneurysm and cerebral vasospasm), cerebrovascular malformation (arteriovenous malformation, dural arteriovenous fistula, cavernous angioma, venous angioma, and capillary telangiectasia), moyamoya disease, superficial siderosis, and during the chronic stages of CVD., “Maharshi Bhela” has documented conditions such as reduced visual acuity (due to aging or neurovascular pathology or other eye diseases) and CAPD with or without ARHL (due to aging or CVD or neurodegenerative conditions) in the present verse.
“Avaakshiraa pralambaami—saptaaham naativartate” (verse 3)
A person speaking irrelevantly or inappropriately (pralapan) like “I am hanging (pralambaami) with my head downwards (avaakshiraa); hence change my name (in reverse order)”, he will not survive more than 7 days (dies within a week). The present verse denotes a fixed, false belief (he has been hanging with his head downward) that conflicts with reality. Such types of fixed, firm beliefs which are based on inadequate grounds and not amenable to rational argument or evidence are called as delusions. The condition mentioned in the above verse denotes delusional beliefs that are causing or leading or indicates death within a week (saptaaham naativartate). A person with a delusion is absolutely convinced that the delusion is real regardless of evidence to the contrary. Delusions are a symptom of either a neurological, medical, or mental disorder. Delusions are present in mental disorders such as psychotic disorders, schizophrenia, schizoaffective disorder, delusional disorder, schizophreniform disorder, shared and brief psychotic disorder, substance-induced psychotic disorder, bipolar disorder, major depressive disorder with psychotic features, delirium, and dementia. Delusions may also occur in frontotemporal dementias including Pick's disease. Delusions are the most common psychotic symptom in patients with dementia of the Alzheimer's type (DAT). The delusions seen in DAT may be “misidentifications” due to cognitive impairment rather than true psychotic symptoms.
Psychotic disorders are common in late life and they often have varied etiologies, different clinical presentations, and are associated with significant morbidity and mortality. Psychotic disorders in late life develop due to the complex interaction between various biological, social, psychological, and environmental factors. Delusions, hallucinations, disorganized thinking (speech), grossly disorganized motor behavior (including catatonia), and negative symptoms are considered as psychotic symptoms. Causes for late-life psychosis are late-onset schizophrenia, delusional disorder, psychosis associated with various dementias and neuropsychiatric disorders, delirium, and secondary to organic causes. Psychosis is a common complication in other non-AD dementias (vascular dementia, Parkinson's disease dementia and Lewy body dementia More Details). The prevalence of delusions and hallucinations remained substantially high in elderly patients with delirium. “Maharshi Bhela” has provided an example of delusion occurring a week before death and it indicates various conditions such as dementia, delirium, and organic psychosis.
“Marmaani dalitaaneeva—mumurshushcha sahochyate” (verse 4 and 5)
Person suffering with severe pain at vital points (marmaani dalitaaneeva), discoloration of body such as black (krishna), blue/purple (neela) and pallor (vivarna), loose motions/diarrhea (atisaara), and passing stools that are having abnormal odor such as foul (durgandhi), carcase (kunapa), putrid (putikam), blood (lohita gandha), and fishy odor (matsya gandha) should be considered as dead (i.e., will die soon) (mumurshu). Abnormal stool color and odor associated with pain at vital points (such as head, heart/chest, and lower abdomen/bladder) and diarrhea are associated with mortality or death as per the above verse. The above verse indicates various conditions such as inflammatory bowel disease (IBD), ulcerative colitis, Crohn's disease, ischemic colitis, gangrenous ischemic colitis, infectious colitis, upper/lower gastrointestinal bleeding (LGIB), malabsorption syndrome, steatorrhea, small intestinal bacterial overgrowth, colorectal neoplasms, and carcinoma associated with comorbid diseases or terminal illness.
Tarry feces (krishna) and bloody feces (lohita gandha?) are symptoms that commonly appear in the end-of-life phase (they are known as “Kanibaba” which means death-bed feces) (mumurshu). A typical case of ischemic colitis is characterized by abdominal pain (marmaani dalitaaneeva), gastro-intestinal bleeding (lohita gandha?/krishna) and diarrhea (atisaara). Ulcerative colitis, Crohn's disease, transient ischemic colitis, gangrenous ischemic colitis, and infectious colitis ( Salmonella More Details, Shigella, Campylobacter, Yersinia More Details, and Aeromonas) are associated with abdominal pain (marmaani dalitaaneeva) and bloody diarrhea (atisaara with krishna varna and lohita gandha). LGIB is a significant worldwide cause of morbidity and mortality in the elderly (mumurshu). Conditions such as diverticulosis coli, vascular ectasia, ischemic colitis and colonic neoplasms are more common that cause LGIB in elderly population. Melena is the passage of black (krishna), tarry, foul-smelling stools (durgandhi/kunapa/putrid) as a result of degradation of blood to hematin. Hemorrhoids, anal fissures, and malignant colorectal neoplasms are the most common causes of LGIB, and benign colorectal neoplasms, ulcerative colitis, infectious and ischemic colitis, and radiation colitis are less common causes of LGIB in Asia. Cardiovascular disease, hypertension, renal disease, diabetes mellitus (DM), and malignancy are the comorbid diseases (marmaani dalitaaneeva) associated with LGIB. Krishna, neela, and vivarnata associated with “marmaani dalitaaneeva” denote various comorbid diseases associated with diarrhea such as atherosclerotic cardiovascular disease (cause of ischemic bowel disease), atrial fibrillation (embolic events leading to ischemic bowel disease), aortic valvular disease (vascular ectasia of the colon), CVD, DM, and malignancy that are characterized by increased morbidity and mortality (mumurshu).
Stool color change (krishna/neela/vivarna) may be associated with the occurrence of bile duct disease, upper and LGIB, and colon cancer (mumurshu). The observation of stool odor (durgandhi/kunapa/putika/lohita gandha and matsya gandha) has been used to diagnose gastrointestinal diseases and to evaluate bowel conditions. The type of malodorous components is influenced by many factors such as age, diet, health status, and use of drugs. The concentrations of pyridine, acetic acid, propionic acid, butyric acid, iso-valeric acid, and n-valeric acid are more than 10-100000-fold higher than normal levels in diarrhea (atisaara). They are many undecomposed proteins caused by abnormal fermentation and indigestion and form fatty acids and N-containing compounds. Methyl mercaptan might be produced only when the balance of intestinal flora is disturbed. Feces with a strong odor (durgandhi/kunapa/putika/lohita gandha and matsya gandha) are now associated with future occurrences of colon cancer, arteriosclerosis, and liver disorders. The ammonia odor of feces is thought to be product of putrefaction process (putika). Sulfur-containing compounds (hydrogen sulfide, methyl mercaptan, methyl sulfide, and dimethyl disulfide), nitrogen-containing compounds (trimethylamine [TMA], ammonia, formaldehyde, acetaldehyde, and propylaldehye), fatty acids (pyridine, acetic acid, propionic acid, butyric acid, iso-valeric acid, and n-valeric acid), and other compounds (pyridine and pyrrole) are malodorous compounds (that may cause durgandhi/kunapa/putika/lohita gandha and matsya gandha) found in human feces.
TMA has been described as smelling like rotting fish (matsya gandha), rotting eggs, garbage (kunapa), or urine. Bacterial overgrowth in the small bowel may contribute to the odor associated with uremia by increasing the TMA production. Volatile organic compounds (VOCs) in feces may denote potential health consequences (mumurshu/marmaani dalitaaneeva). Feces often smell abnormal (durgandhi/kunapa/putika/lohita gandha and matsya gandha) during gastrointestinal disease. Volatile patterns from feces of patients with ulcerative colitis, Clostridium. difficile, and Campylobacter jejuni were each significantly different. Stool tests can be easily used in primary care in the differential diagnosis of disorders such as gastrointestinal infections, malabsorption syndromes, and IBDs. Stool should also be macroscopically checked in terms of color, consistency, quantity, shape, odor, and mucus. Black, tarry stool (krishna) is observed in upper gastrointestinal bleeding and red-colored stool is observed in LGIB. Among heterogeneous cancer patients, the prevalence of moderate-to-severe diarrhea (atisaara) has been reported. GI tract tumors and neuroendocrine tumors may cause diarrhea. Diarrhea and its complications (mumurshu/marmaani dalitaaneeva) such as acute dehydration, renal insufficiency, dramatic weight loss, electrolyte imbalances, weakness, and infection are debilitating and life-threatening in cancer patients (mumurshu). “Maharshi Bhela” has used stool examination (physical/macroscopic) to diagnose the potential life-threatening consequences.
“Madhumehi vasamehi—sa vai prokta paraasuka” (verse 6)
Sudden manifestation of “Madhu meha” (DM), “Vasa meha” (lipiduria/proteinuria), “Sarpi meha” (lipiduria) and “Bahu meha” (polyuria) denotes death or associated with high mortality.
Premeha is a syndrome which includes a wide variety of clinical conditions characterized by increased quantity of urine associated with or without the increased frequency of micturition. The word “Prameha” refers to repeated (prakarsha) excessive (prabhoota) and turbid urination in terms of frequency, quantity and clarity. The terms “madhu meha” and DM are analogus; madhu means honey and madhu meha means passing of large quantity of sweet urine. DM is a common chronic disease and has multiple complications. Untreated diabetes leads to multi organ and systemic injury, including to the heart, kidneys, nerves, and blood vessels, and increase the death rate caused by diabetes complications. People with diabetes have a two-fold increased risk for cardiovascular mortality. DM also increases the risk of chronic kidney disease (CKD) which is a major predictor of long-term mortality. Diabetes at the baseline is associated with increased mortality risk due to cardiovascular disease, influenza and pneumonia, chronic lower respiratory diseases, and kidney disease. DM is the leading cause of CKD and approximately 20%–30% of patients with type 2 DM have renal impairment, classified as moderate-to-severe CKD (glomerular filtration rate [GFR] <60 mL/min/1.73 m2). The combination of diabetes and CKD is associated with increased morbidity and mortality due to an increased cardiovascular risk. “Madhu meha” mentioned in the above verse denotes DM associated with complications and increased mortality.
Vasa meha and Sarpi meha
“Vasa meha” (patient frequently passes urine mixed with fat) and “Sarpi meha” (patient frequently passes urine mixed with bone marrow like substance or fat) are considered as “Vataja prameha” types (according to Acharya Sushruta) and they are associated with poor prognosis. Both “Vasa meha” and “Sarpi meha” denotes presence of lipid substances in urine and can be considered as “lipiduria” and/or “proteinuria.” Urinary lipid excretion was much greater in patients with the nephrotic syndrome. Lipoprotein is lost through damaged glomeruli in patients with proteinuria of any etiology. Nephrotic syndrome is recognized by the presence of proteinuria along with hypoalbuminemia, edema, hyperlipidemia (hypertriglyceridemia and hypercholesterolemia), and lipiduria. Lipiduria is thought to be secondary to hyperlipidemia, and it mostly results from filtration of HDL particles. These lipids are found in oval fat bodies, fatty casts, or free-floating lipid globules. Proteinuric disease is a major risk factor for renal failure and cardiovascular morbidity. The impact of CKD includes increased risk of mortality, end-stage renal disease (ESRD), cardiovascular disease, mineral and bone disease, and other comorbidities. Proteinuria is an independent risk factor for progressive kidney function decline as well as all-cause mortality. High proteinuria is associated with rapid GFR decline and also predicted renal death. “Vasa meha” and “Sarpi meha” mentioned in the present verse denotes various conditions such as CKD, ESRD and nephritic syndrome associated with increased mortality.
“Bahu meha” denotes “polyuria.” Central diabetes insipidus (CDI)) or neurogenic DI is the most common form of DI. Children with acute injury to the nervous system and CDI have a high mortality. Onset of CDI can be abrupt (due to injury or trauma) or gradual (due to tumor or idiopathic causes). The primary symptoms of DI include persistent polyuria (producing 8-16 L of dilute urine a day) and polydipsia. Other symptoms associated with DI are dizziness, weakness, nocturia, fatigue, and dehydration (fever, dry skin and mucus membranes, weight loss, and poor skin turgor). Hypotension and tachycardia with decreased right atrial and pulmonary artery occlusion pressures and an altered level of consciousness may also occur in DI/polyuria. Polyuria can be seen in diabetic ketoacidosis (DKA). Polyuria may occur with any form of paroxysmal arrhythmia with rapid heart rate. Acute drainage of an obstructed urinary tract can result in uncontrolled, unregulated urine production known as “Post obstructive diuresis” (POD). POD patients are at risk of hypovolemia, electrolyte, and acid-base disturbances. Pathological POD is associated with complications such as volume depletion, hyponatremia or hypernatremia, hypokalemia, hypomagenesemia, metabolic acidosis, shock, and death. “Bahu meha” mentioned in the present verse denotes DI, DKA, and POD conditions associated with high mortality rate.
“Prameheta yada jantu—durlabham tasya jeevitam” (verse 7)
According to the above verse, “when an individual urinate drop by drop (bindum bindum) associated with great pain (savedanam) and rupture of the bladder (bhinna vasti) will die soon (durlabham jeevitam).” Patients with spontaneous urinary bladder rupture (bhinna vasti) may present with severe abdominal pain (savedanam) and distension with difficulty micturition (bindum bindum). Most cases of spontaneously ruptured bladder (bhinna vasti) are associated with trauma, pregnancy, or bladder cancer. Congenital or acquired urethral strictures are associated with enuresis (bindum bindum) and spontaneous rupture of urinary bladder (bhinna vasti). Predisposing conditions such as chronic urinary retention, decreased strength of the bladder wall, chronic inflammation, tumors, radiation cystitis, and binge drinking can increase intravesical pressure and ultimately leads to spontaneous rupture of urinary bladder (bhinna vasti). If untreated, it can lead to severe complications such as sepsis, renal failure, hyperkalemia, and even death (durlabham jeevitam). Spontaneous bladder perforation (bhinna vasti) in neonates may occur secondary to obstructive uropathy. Other predisposing conditions include congenital bladder diverticulum, neurogenic bladder, pelvic masses, and hypoxia. Clinical presentation includes history of failure to micturate or dribbling (bindum bindum) with abdominal distension and uremia. The present verse denotes a condition of spontaneous urinary bladder rupture due to obstructive uropathy, which may eventually lead to death.
“Krimayo bahavo yasya—naushadham tasya siddhyati” (verse 8)
As per the above verse, “the patient from whose body (aaturasya shareerasya) or from his bed (shayanasya) many worms or insects (krimi) constantly coming/flowing out (nissaranti) denote imminent death (na aushadham siddhyati). Insects coming out of the body parts of a bed ridden patient denote a condition of “Myiasis.” Myiasis is defined as an infestation on humans and vertebrate animals by larvae of insects (krimi) on living or dead tissue from the host or on fluid substances. Myiasis is an infestation of live vertebrates (humans and/or animals) with dipterous larvae (krimi). There are two main systems for categorizing myiasis: Anatomical (sanguinivorous-blood sucking, cutaneous-furuncular and migratory, wound and cavitary myiasis-cerebral, aural, nasal, and ophthalmomyiasis) (aaturasya shareerasya) and ecological classifications. Myiasis is an embarrassing and repugnant disease in which poor hygiene, poor sanitation, inadequate garbage disposal leaving organic material exposed (which attracts insects), low socioeconomic status, sitting or lying on the ground, climatic conditions, and an abundance of exposed preexisting suppurative lesions are the most important risk factors. Patients, who lack adequate medical and nursing care, elderly patients, psychiatric patients and other chronic bed ridden patients are more prone to wound infestation (due to their inability to discourage the flies from depositing eggs or larvae on wounds). Dermatological conditions have also been described to be a predisposing factor for myiasis-causing flies. Majority of flies that cause myiasis in humans belongs to the blowfly group (family calliphoridae) or the housefly group (family muscidae) (krimi). Based on the affected body part, different types of myiasis such as cutaneous myiasis, creeping myiasis, wound myiasis, myiasis of body cavities, and accidental myiasis (aaturasya shareerasya) can be seen.
Chrysomya bezziana larvae (krimi) are characterized by feeding aggressively on the living tissues and body fluids of the host, which leads to severe tissue, bone destruction, and even death (na aushadham siddhyati). The larvae destroy living tissues and cause deep, painful, ulcerative lesions associated with bleeding and purulent discharge. Secondary infections, fever, weight loss, and inflammation may follow. The larvae can destroy bones, nasal sinuses, hard palate, orbital cavities, eyeballs, hearing apparatus, and teeth. Such aggressive invasion of the host body can lead to serious complications including debility, limb amputation, blindness, and death (na aushadham siddhyati). Elderly patients being bedridden, wheelchair bound, debilitated, and suffering with multiple underlying illnesses (aaturasya shareerasya) are more prone to acquire this condition. The age-related diseases; noninfectious chronic diseases; and other conditions such as dementia, mental disorders, stroke, cancer, DM, hypertension, neurological disorders, HIV and hepatitis virus infections, postpartum lochia, pregnancy, childbirth, drug addiction, dermatological conditions, infections (especially ear infections), and debility (aaturasya shareerasya) make the person vulnerable for acquiring myiasis. Maggot infestation (krimi) is a condition in which the fly maggots feed off and develop in the tissues of living organisms. Maggot therapy has three core beneficial effects on a wound: debridement, disinfection, and enhanced healing. Maggots debride wounds quickly and effectively, without damage to viable tissue. “Maharshi Bhela” has documented a condition of “Myiasis.”
“Ityetaani bhishak drushtwa—yathamargam chikeershaka” (verse 9)
The present verse denotes that “the physician should not attempt to treat (na chikitsaam prayunjeeta) patients who have been suffering with the any of the features (lakshanani mumurshataam) discussed in previous verses.” Various conditions discussed so far in this chapter are incurable (lakshanani mumurshataam) and treatment will become futile; hence, physician should avoid treating (na chikitsaam prayunjeeta) such type of cases. The present verse discusses the subject of futile treatment (na chikitsaam prayunjeeta) in the case of a hopelessly ill patient (lakshanani mumurshataam). The medical technology today can keep a patient alive for an unlimited time, in spite of the fact that his/her quality of life is beyond the lowest limit ethically and morally accepted. Two types of futile treatments (treatment that would not be beneficial to the patient) are recognized, “the physiological futility” (includes that treatment which cannot achieve a desired physiological effect) and “the goal-defined futility” (treatment which has no efficiency regarding the patient's goals, such as restoring previous level of function, survival to hospital discharge, or the ability to live independently). Futile treatment can be defined as an effort to provide a benefit to a patient that is highly likely to fail. Negative effects on job satisfaction, psychological and physical well-being and self-image, consequent burnout, and thoughts of quitting the profession are the negative effects of the futile treatment on the moral mood of treating physician. In most parts of the world (especially undeveloped or developing countries), the supply of critical care is limited because of scarcity of funds and manpower (especially countries like India). Futile treatment may present an opportunity cost. It seems to be obvious that keeping a terminal patient in intensive care unit and providing futile treatment would affect the fate of other critically ill patients who could benefit from being admitted to a specialized unit.
The diagnosis of a hopelessly ill patient (suffering with an irreversible medical condition), meaning that he/she would not benefit at all (would be futile) from treatment, is subjective. Providing non-beneficial treatments especially at the end-of- life stages is against the ethical principles of medicine. The futile treatment creates a financial burden on medical institution, since there is not a single hospital with an unlimited budget and unrestricted capabilities to treat critically ill patients (especially in countries like India). The physician has to act in a transparent manner, to explain everything he is doing, and to keep in close contact with the patient's family. It is a known fact that local regulations and prescriptions regarding the attitude toward the hopelessly ill patient could be very different from place to place and from country to country, but the main concept is the obligation to take into consideration both the patient's interests and the community needs is universal and well recognized globally. “Maharshi Bhela” has documented the medical etiquette followed thousands of years ago in the present verse regarding treating hopelessly ill patients. The concepts mentioned in this chapter [Table 1] were valid thousands of years ago and they still hold true today.
| Conclusions and Implications|| |
“Mumurshiyam indriyam” is the third chapter of “Indriya sthana” of “Bhela samhita,” which deals with the description of various conditions seen in the patients with terminal illness or clinical features shown by a person just about to die. Most of the content is unique and not explained in other classical Ayurvedic texts. Various concepts/conditions such as ELDVs, DBCs, NDEs, OBEs, visual hallucinations, delusions, dementia, delirium, organic psychosis, CAPD, ARHL, late life psychosis, LGIB, colon cancer, IBD, ESRD, CKD, DKA, CDI, spontaneous rupture of urinary bladder, myiasis, and medical etiquette are documented in this chapter by “Maharshi Bhela.” “Maharshi Bhela” has provided a list of signs and symptoms/clinical features in this chapter, which seems to have clinically applicability, inexpensiveness, simplicity, noninvasiveness, convenient, accurate (?), and suitable for application in low- or middle-income countries like India to diagnose terminal illness or end-of-life stages. Questionnaire or screening methods can be developed based on the clinical features mentioned by “Maharshi Bhela” in this chapter to use in prognostic research. Although further research is still required to substantiate the claims, the descriptive results of the present study provide fundamental understanding on potential ideas and pave the path for future research directions.
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