Varnasvariyam Indriyam Adhyaya

Indriya Sthana Chapter 1.Fatal signs in complexion and voice

Varnasvariyam Indriyam Adhyaya

Section/Chapter	Indriya Sthana Chapter 1
Preceding Chapter	None
Succeeding Chapter	Pushpitakam Indriyam Adhyaya
Other Sections	Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana
Translator and commentator	Gopakumar
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.s05.002

Abstract

The chapter Varnasvariyam Indriyam Adhyaya is about arishta lakshana (near death signs) perceived by auditory and visual senses. Swara (Voice) is an audible feature, whereas color and complexion are visual features. Sudden change in frequency, rhythm, resonance, tone, the pitch of voice and complexion of the body is indicative of serious pathology of the body. The characteristic features of arishta are described in the chapter.
Keywords: arishta, fatal signs, near death signs, change in voice, change in complexion.

Introduction

Charak has placed Indriya Sthana (section about near death signs) before Chikitsa Sthana (section about the treatment of diseases) possibly, to guide physician when not to treat a patient. In this chapter of Indriya Sthana, Varnasvariyam Indriyam Adhyaya, Charak mentions near death signs and symptoms that can be directly observed by visual and other faculties. This chapter also describes prakriti, the natural disposition of an individual, and vikriti, or abnormalities , since such knowledge helps in discerning any sign of vikriti in a "healthy" individual. Three types of morbid conditions are observed namely, lakshana nimitta, caused by bodily marks, lakshya nimitta, caused by etiological factors which disturb the health, and nimitta anuroopa vikriti, a break down for no apparent reason resembling etiological factors. The chapter describes various near death signs with changes in color, the complexion of body parts and voice.

Sanskrit text, Transliteration and English Translation

अथातोवर्णस्वरीयमिन्द्रियंव्याख्यास्यामः||१||
इति ह स्माह भगवानात्रेयः||२||

athātōvarṇasvarīyamindriyaṁvyākhyāsyāmaḥ||1||
itihasmāhabhagavānātrēyaḥ||2||

athAto varNasvarIyamindriyaM vyAkhyAsyAmaH||1||
iti ha smAha bhagavAnAtreyaH||2||

Now we shall expound the chapter "Varnasvariyam Indriyam" (Fatal signs in complexion and voice). Thus said Lord Atreya.[1-2]

Note: This chapter deals with normal and abnormal color, complexion and voice in a person which especially relies on two "indriya" –visual and auditory faculty.

Factors for assessment of residual span of life

इह खलु वर्णश्च स्वरश्च गन्धश्च रसश्च स्पर्शश्च चक्षुश्च श्रोत्रं च घ्राणं च रसनं च स्पर्शनं च सत्त्वं च भक्तिश्च शौचं च शीलंचाचारश्च स्मृतिश्चाकृतिश्च प्रकृतिश्च विकृतिश्च बलं च ग्लानिश्च मेधा च हर्षश्च रौक्ष्यं च स्नेहश्च तन्द्रा चारम्भश्च गौरवं चलाघवं च गुणाश्चाहारश्च विहारश्चाहारपरिणामश्चोपायश्चापायश्च व्याधिश्च व्याधिपूर्वरूपं च वेदनाश्चोपद्रवाश्च च्छाया चप्रतिच्छाया च स्वप्नदर्शनं च दूताधिकारश्च पथि चौत्पातिकं चातुरकुले भावावस्थान्तराणि च भेषजसंवृत्तिश्च भेषजविकारयुक्तिश्चेति परीक्ष्याणि प्रत्यक्षानुमानोपदेशैरायुषः प्रमाणावशेषं जिज्ञासमानेन भिषजा||३||

iha khalu varṇaśca svaraśca gandhaśca rasaśca sparśaśca cakṣuśca śrōtraṁ ca ghrāṇaṁ ca rasanaṁ casparśanaṁ ca sattvaṁ ca bhaktiśca śaucaṁ ca śīlaṁ cācāraśca smr̥tiścākr̥tiśca prakr̥tiśca vikr̥tiśca balaṁ caglāniśca mēdhā ca harṣaśca raukṣyaṁ ca snēhaśca tandrā cārambhaśca gauravaṁ ca lāghavaṁ caguṇāścāhāraśca vihāraścāhārapariṇāmaścōpāyaścāpāyaśca vyādhiśca vyādhipūrvarūpaṁ cavēdanāścōpadravāśca cchāyā ca praticchāyā ca svapnadarśanaṁ ca dūtādhikāraśca pathi cautpātikaṁcāturakulē bhāvāvasthāntarāṇi ca bhēṣajasaṁvr̥ttiśca bhēṣajavikārayuktiścēti parīkṣyāṇipratyakṣānumānōpadēśairāyuṣaḥ pramāṇāvaśēṣaṁ jijñāsamānēna bhiṣajā||3||

iha khalu varNashca svarashca gandhashca rasashca sparshashca cakShushca shrotraM ca ghrANaM carasanaM ca sparshanaM ca sattvaM ca bhaktishca shaucaM ca shIlaM cAcArashca smRutishcAkRutishcaprakRutishca vikRutishca balaM ca glAnishca medhA ca harShashca raukShyaM ca snehashca tandrAcArambhashca gauravaM ca lAghavaM ca guNAshcAhArashcavihArashcAhArapariNAmashcopAyashcApAyashca vyAdhishca vyAdhipUrvarUpaM cavedanAshcopadravAshca cchAyA ca praticchAyA ca svapnadarshanaM ca dUtAdhikArashca pathicautpAtikaM cAturakule bhAvAvasthAntarANi ca bheShajasaMvRuttishca bheShajavikArayuktishcetiparIkShyANi pratyakShAnumAnopadeshairAyuShaH pramANAvasheShaM jij~jAsamAnena bhiShajA||3||

The following entities should be examined by the physician desiring to assess the residual span of life of the patient using direct observation, and inference such as:

• Physical appearance (complexion, appearance of eyes, ears, nose, tongue, skin), including attributes perceived by the senses (voice, smell, taste, touch, etc.)
• Behavioral traits (mood, upkeep, conduct, etc.)
• Dietary habits and lifestyle (regimens, ability to digest, etc.)
• Existing health conditions (signs of diseases, symptoms, complications, drug use, effect of medicines on illness and on the patient)

Bad omens perceived by the physician on his way to patient's house, changed conditions of the patient's residence, signs and symptoms indicating the residual span of life may be evident on these factors. Hence physician should pay careful attention to each one of them and interpretation should be made based on his observations, knowledge and scriptural advice. [3]

तत्र तु खल्वेषां परीक्ष्याणां कानिचित् पुरुषमनाश्रितानि, कानिचिच्च पुरुषसंश्रयाणि|
तत्र यानि पुरुषमनाश्रितानि तान्युपदेशतो युक्तितश्च परीक्षेत, पुरुषसंश्रयाणि पुनः प्रकृतितोविकृतितश्च||४||

tatra tu khalvēṣāṁ parīkṣyāṇāṁ kānicit puruṣamanāśritāni, kānicicca puruṣasaṁśrayāṇi|
tatra yāni puruṣamanāśritāni tānyupadēśatō yuktitaśca parīkṣēta, puruṣasaṁśrayāṇipunaḥprakr̥titōvikr̥titaśca||4||

tatra tu khalveShAM parIkShyANAM kAnicit puruShamanAshritAni, kAnicicca puruShasaMshrayANi|
tatra yAni puruShamanAshritAni tAnyupadeshato yuktitashca parIkSheta, puruShasaMshrayANi punaHprakRutito vikRutitashca||4||

Some of the signs and symptoms are not apparent in a patient but can be observed in the surrounding of the patient. These are evaluated by logic based on scriptural instructions and inference. The factors not observed in patients are often circumstantial like an informer who comes with news of patient and the good/bad omens seen by the physician. Those which can be seen in patients are examined by observing their constitution and morbid conditions. But all these factors should be assessed wisely in the quest for the life of the patient. [4]

Factors responsible for natural constitution

तत्रप्रकृतिर्जातिप्रसक्ताच,कुलप्रसक्ताच,देशानुपातिनीच, कालानुपातिनी च वयोऽनुपातिनीच,प्रत्यात्मनियताचेति|
जातिकुलदेशकालवयःप्रत्यात्मनियता हि तेषां तेषां पुरुषाणां ते ते भावविशेषाभवन्ति||५||

tatraprakr̥tirjātiprasaktāca,kulaprasaktāca,dēśānupātinīca, kālānupātinī ca vayō'nupātinīca,pratyātmaniyatācēti|
jātikuladēśakālavayaḥpratyātmaniyatā hi tēṣāṁ tēṣāṁ puruṣāṇāṁtētēbhāvaviśēṣābhavanti||5||

tatra prakRutirjAtiprasaktA ca, kulaprasaktA ca, deshAnupAtinI ca, kAlAnupAtinI ca vayo~anupAtinI ca, pratyAtmaniyatA ceti|
jAtikuladeshakAlavayaHpratyAtmaniyatA hi teShAM teShAM puruShANAM te te bhAvavisheShAbhavanti||5||

The natural constitution of a person depends upon Jati (origin as per social structure), Kula (race), Desha (place), Kala (time and season), Vaya (age), Pratyatmaniyata (individual habits and habitat). The different variations seen in persons are based upon their origin as per social structure, race, place of living, season, age and individual habits.[5]

Types of pathological abnormalities

विकृतिःपुनर्लक्षणनिमित्ताच,लक्ष्यनिमित्ताच,निमित्तानुरूपाच||६||

vikr̥tiḥpunarlakṣaṇanimittāca,lakṣyanimittāca,nimittānurūpāca||6||

vikRutiH punarlakShaNanimittA ca, lakShyanimittA ca, nimittAnurUpA ca||6||

The pathological conditions are classified as:

• Lakshana nimitta: pathological appearance based on symptoms
• Lakshya nimitta : Diseases based upon etiological factors
• Nimittanurupa: This type of pathology is based on signs resembling with etiological factors. [6]

Symptom based abnormalities

तत्र लक्षणनिमित्ता नाम सा यस्याः शरीरे लक्षणान्येव हेतुभूतानि भवन्ति दैवात्; लक्षणानि हि कानिचिच्छरीरोपनिबद्धानि भवन्ति, यानि हि तस्मिंस्तस्मिन् काले तत्राधिष्ठानमासाद्य तां तां विकृतिमुत्पादयन्ति|७|

tatra lakṣaṇanimittā nāma sā yasyāḥ śarīrē lakṣaṇānyēva hētubhūtāni bhavanti daivāt; lakṣaṇāni hi kāniciccharīrōpanibaddhāni bhavanti, yāni hi tasmiṁstasmin kālētatrādhiṣṭhānamāsādya tāṁ tāṁ vikr̥timutpādayanti|7|

tatra lakShaNanimittA nAma sA yasyAH sharIre lakShaNAnyeva hetubhUtAni bhavanti daivAt; lakShaNAni hi kAniciccharIropanibaddhAni bhavanti, yAni hitasmiMstasmin kAle tatrAdhiShThAnamAsAdya tAM tAM vikRutimutpAdayanti|7|

The first type of pathological conditions are based on symptoms, whose causative factors are pre-determined by destiny in the form of physiognomic signs. Some of these signs may be latent in the body, and appear at particular time in particular parts of body giving rise to particular related morbid conditions. [7[1]]

Etiopathogenesis based abnormalities

लक्ष्यनिमित्ता तु सा यस्या उपलभ्यते निमित्तं यथोक्तं निदानेषु|७|

lakṣyanimittā tu sā yasyā upalabhyatē nimittaṁ yathōktaṁ [1] nidānēṣu|7|

lakShyanimittA tu sA yasyA upalabhyate nimittaM yathoktaM [1] nidAneShu|7|

The second type of pathological conditions are based on etiological factors which appear as per the etiopathogenesis described (in Nidana Sthana section). [7[2]]

Cause based abnormalities

निमित्तानुरूपा तु निमित्तार्थानुकारिणी या, तामनिमित्तां निमित्तमायुषः प्रमाणज्ञानस्येच्छन्ति भिषजो भूयश्चायुषः क्षयनिमित्तां प्रेतेलिङ्गानुरूपां, यामायुषोऽन्तर्गतस्य ज्ञानार्थमुपदिशन्ति धीराः|
यां चाधिकृत्य पुरुषसंश्रयाणि मुमूर्षतां लक्षणान्युपदेक्ष्यामः|
इत्युद्देशः|
तं विस्तरेणानुव्याख्यास्यामः||७||

nimittānurūpā tu nimittārthānukāriṇī yā, tāmanimittāṁ nimittamāyuṣaḥ pramāṇajñānasyēcchanti bhiṣajō bhūyaścāyuṣaḥ kṣayanimittāṁ prētēliṅgānurūpāṁ,yāmāyuṣō'ntargatasya [1] jñānārthamupadiśanti dhīrāḥ|
yāṁ cādhikr̥tya puruṣasaṁśrayāṇi mumūrṣatāṁ lakṣaṇānyupadēkṣyāmaḥ|
ityuddēśaḥ|
taṁ vistarēṇānuvyākhyāsyāmaḥ||7||

nimittAnurUpA tu nimittArthAnukAriNI yA, tAmanimittAM nimittamAyuShaH pramANaj~jAnasyecchanti bhiShajo bhUyashcAyuShaH kShayanimittAMpreteli~ggAnurUpAM, yAmAyuSho~antargatasya [1] j~jAnArthamupadishanti dhIrAH|
yAM cAdhikRutya puruShasaMshrayANi mumUrShatAM lakShaNAnyupadekShyAmaH|
ityuddeshaH|
taM vistareNAnuvyAkhyAsyAmaH||7||

The third type of pathological conditions is based upon the factors that resemble etiological factors, but in fact, they are not etiological factors in nature. It appear without any apparent cause and indicate the measure of the life-span particularly the signs of imminent death due to decadence of life. The physicians pay due importance to this for the knowledge of life (and death). Based on this, I will explain the signs observed in the person which indicate his imminent death. This is the summary. We shall explain this in detail. [7[3]]

Normal complexion

तत्रादितएववर्णाधिकारः|
तद्यथा- कृष्णः, श्यामः, श्यामावदातः, अवदातश्चेति प्रकृतिवर्णाः शरीरस्य भवन्ति; यांश्चापरानुपेक्षमाणो विद्यादनूकतोऽन्यथा वाऽपि निर्दिश्यमानांस्तज्ज्ञैः||८||

tatrāditaēvavarṇādhikāraḥ|
tadyathā- kr̥ṣṇaḥ, śyāmaḥ , śyāmāvadātaḥ, avadātaścēti prakr̥tivarṇāḥ śarīrasya bhavanti;yāṁścāparānupēkṣamāṇō vidyādanūkatō'nyathā vā'pi nirdiśyamānāṁstajjñaiḥ||8||

tatrAdita eva varNAdhikAraH|
tadyathA- kRuShNaH, shyAmaH [1] , shyAmAvadAtaH, avadAtashceti prakRutivarNAH sharIrasya bhavanti; yAMshcAparAnupekShamANo [2] vidyAdanUkato~anyathAvA~api nirdishyamAnAMstajj~jaiH||8||

There are four types of natural complexion – black, dark (blue or brown), dark-fair (blue or brown), fair white, There may some more complexions with combinations of such colors.[8]

Abnormal complexion

नीलश्यावताम्रहरितशुक्लाश्च वर्णाः शरीरस्य वैकारिका भवन्ति; यांश्चापरानुपेक्षमाणो विद्यात्प्राग्विकृतानभूत्वोत्पन्नान् | इति प्रकृतिविकृतिवर्णा भवन्त्युक्ताः शरीरस्य|
तत्र प्रकृतिवर्णमर्धशरीरे विकृतिवर्णमर्धशरीरे, द्वावपि वर्णौ मर्यादाविभक्तौ दृष्ट्वा; यद्येवं सव्यदक्षिणविभागेन, यद्येवंपूर्वपश्चिमविभागेन, यद्युत्तराधरविभागेन, यद्यन्तर्बहिर्विभागेन, आतुरस्यारिष्टमिति विद्यात्; एवमेव वर्णभेदोमुखेऽप्यन्यत्र वर्तमानो मरणाय भवति||९||

nīlaśyāvatāmraharitaśuklāśca varṇāḥ śarīrasya vaikārikā bhavanti; yāṁścāparānupēkṣamāṇōvidyātprāgvikr̥tānabhūtvōtpannān | iti prakr̥tivikr̥tivarṇā bhavantyuktāḥ śarīrasya|
tatra prakr̥tivarṇamardhaśarīrē vikr̥tivarṇamardhaśarīrē, dvāvapi varṇau maryādāvibhaktau dr̥ṣṭvā;yadyēvaṁ savyadakṣiṇavibhāgēna, yadyēvaṁ pūrvapaścimavibhāgēna, yadyuttarādharavibhāgēna,yadyantarbahirvibhāgēna, āturasyāriṣṭamiti vidyāt; ēvamēva varṇabhēdō mukhē'pyanyatra vartamānōmaraṇāya bhavati||9||

nIlashyAvatAmraharitashuklAshca varNAH sharIrasya vaikArikA bhavanti; yAMshcAparAnupekShamANo [1] vidyAt prAgvikRutAnabhUtvotpannAn [2] | iti prakRutivikRutivarNA bhavantyuktAH sharIrasya|
tatra prakRutivarNamardhasharIre vikRutivarNamardhasharIre, dvAvapi varNau maryAdAvibhaktau dRuShTvA; yadyevaM savyadakShiNavibhAgena, yadyevaMpUrvapashcimavibhAgena, yadyuttarAdharavibhAgena, yadyantarbahirvibhAgena, AturasyAriShTamiti vidyAt; evameva varNabhedo mukhe~apyanyatra [3] vartamAnomaraNAya bhavati||9||

The unnatural or pathological complexions include blue, blackish, coppery, green and snow white. Similarly, there are some other unnatural types of complexion which appear suddenly for unknown reason. These are the normal and abnormal complexions of body. Normal complexion in one half of the body and abnormal complexion in the other half and both are demarcated clearly by a line, same abnormality on left and right side of body, front and back side of body, upper and lower or internal and external parts of the body is considered arishta (near to death signs). Such demarcation abnormality on face and other parts too indicates death. [9]

वर्णभेदेन ग्लानिहर्षरौक्ष्यस्नेहा व्याख्याताः||१०||

varṇabhēdēnaglāniharṣaraukṣyasnēhāvyākhyātāḥ||10||

varNabhedena glAniharSharaukShyasnehA vyAkhyAtAH||10||

On the same line of differentiation of complexion, malaise and cheerfulness, roughness and unctuousness are described. [10]

तथा पिप्लुव्यङ्गतिलकालकपिडकानामन्यतमस्यानने जन्मातुरस्यैवमेवाप्रशस्तं विद्यात्||११||

tathā pipluvyaṅgatilakālakapiḍakānāmanyatamasyānanē janmāturasyaivamēvāpraśastaṁ vidyāt||11||

tathA pipluvya~ggatilakAlakapiDakAnAmanyatamasyAnane janmAturasyaivamevAprashastaM vidyAt||11||

Similarly, sudden appearance of piplu (Acne), vyanga (Pigmented skin), tilakalaka (Mole) and pidaka (Boil) on the face of the patient is inauspicious. [11]

नखनयनवदनमूत्रपुरीषहस्तपादौष्ठादिष्वपि च वैकारिकोक्तानां वर्णानामन्यतमस्य प्रादुर्भावो हीनबलवर्णेन्द्रियेषुलक्षणमायुषः क्षयस्य भवति||१२||

यच्चान्यदपि किञ्चिद्वर्णवैकृतमभूतपूर्वं सहसोत्पद्येतानिमित्तमेव हीयमानस्यातुरस्य शश्वत्, तदरिष्टमिति विद्यात्| इति वर्णाधिकारः||१३||

nakhanayanavadanamūtrapurīṣahastapādauṣṭhādiṣvapi ca vaikārikōktānāṁ varṇānāmanyatamasyaprādurbhāvō hīnabalavarṇēndriyēṣu lakṣaṇamāyuṣaḥ kṣayasya bhavati||12||

yaccānyadapi kiñcidvarṇavaikr̥tamabhūtapūrvaṁ sahasōtpadyētānimittamēva hīyamānasyāturasyaśaśvat,tadariṣṭamitividyāt|itivarṇādhikāraḥ||13||

nakhanayanavadanamUtrapurIShahastapAdauShThAdiShvapi ca vaikArikoktAnAM varNAnAmanyatamasya prAdurbhAvo hInabalavarNendriyeShu lakShaNamAyuShaHkShayasya bhavati||12||

yaccAnyadapi ki~jcidvarNavaikRutamabhUtapUrvaM sahasotpadyetAnimittameva hIyamAnasyAturasya shashvat, tadariShTamiti vidyAt| iti varNAdhikAraH||13||

Sudden appearance of any one of the abnormal colors in nails, eyes, face, urine, stool, hands, legs and lips together with diminished strength, complexion and senses indicate imminent death. Such other abnormal complexions too that appear suddenly for the first time without any apparent cause in the patient with constant deterioration of health are the signs of death. [12-13]

Normal and abnormal voice

स्वराधिकारस्तु- हंसक्रौञ्चनेमिदुन्दुभिकलविङ्ककाककपोतजर्जरानुकाराः प्रकृतिस्वरा भवन्ति; यांश्चापरानुपेक्षमाणोऽपि विद्यादनूकतोऽन्यथा वाऽपि निर्दिश्यमानांस्तज्ज्ञैः|
एडककलग्रस्ताव्यक्तगद्गदक्षामदीनानुकीर्णास्त्वातुराणां स्वरा वैकारिका भवन्ति; यांश्चापरानुपेक्षमाणोऽपि विद्यात्प्राग्विकृतानभूत्वोत्पन्नान् | इति प्रकृतिविकृतिस्वरा व्याख्याता भवन्ति||१४||

svarādhikārastu- haṁsakrauñcanēmidundubhikalaviṅkakākakapōtajarjarānukārāḥ prakr̥tisvarā bhavanti;yāṁścāparānupēkṣamāṇō'pi vidyādanūkatō'nyathā vā'pi nirdiśyamānāṁstajjñaiḥ| ēḍakakalagrastāvyaktagadgadakṣāmadīnānukīrṇāstvāturāṇāṁ svarā vaikārikā bhavanti;yāṁścāparānupēkṣamāṇō'pi vidyāt prāgvikr̥tānabhūtvōtpannānitiprakr̥tivikr̥tisvarāvyākhyātābhavanti||14||

svarAdhikArastu- haMsakrau~jcanemidundubhikalavi~gkakAkakapotajarjarAnukArAH prakRutisvarA bhavanti; yAMshcAparAnupekShamANo~api [1]vidyAdanUkato~anyathA vA~api nirdishyamAnAMstajj~jaiH|
eDakakalagrastAvyaktagadgadakShAmadInAnukIrNAstvAturANAM [2] svarA vaikArikA bhavanti; yAMshcAparAnupekShamANo~api [3] vidyAtprAgvikRutAnabhUtvotpannAn [4] | iti prakRutivikRutisvarA vyAkhyAtA bhavanti||14||

The normal human voice resembles the voice of hamsa (swan), krauncha (demoiselle crane), nemi (wheel), dundubhi (kettle drum), kalavinka (house sparrow), kaka (crow), kapota (dove) and jarjara (a type of drum). The voice of person with disease resembles that of sheep and is feeble, inaudible, indistinct, choked, hoarse, painful and stammering. Thus normal and abnormal voices are described. [14]

तत्र प्रकृतिवैकारिकाणां स्वराणामाश्वभिनिर्वृत्तिः स्वरानेकत्वमेकस्य चानेकत्वमप्रशस्तम्| इतिस्वराधिकारः||१५||

इति वर्णस्वराधिकारौ यथावदुक्तौ मुमूर्षतां लक्षणज्ञानार्थमिति||१६||

tatra prakr̥tivaikārikāṇāṁ svarāṇāmāśvabhinirvr̥ttiḥ svarānēkatvamēkasya cānēkatvamapraśastam|itisvarādhikāraḥ||15||

iti varṇasvarādhikārau yathāvaduktau mumūrṣatāṁ lakṣaṇajñānārthamiti||16||

If the abnormal and inauspicious voices occur suddenly, or rhythm, tone, pitch, resonance and frequency of voice changes on sudden onset, it is inauspicious (there is a grave indication of imminent death).[15]

Various fatal signs in complexion

भवन्तिचात्र-
यस्यवैकारिकोवर्णःशरीरउपपद्यते| अर्धे वा यदि वा कृत्स्ने निमित्तं न च नास्ति सः||१७||

नीलंवायदिवाश्यावंताम्रंवायदिवाऽरुणम्| मुखार्धमन्यथा वर्णो मुखार्धेऽरिष्टमुच्यते||१८||

स्नेहोमुखार्धेसुव्यक्तोरौक्ष्यमर्धमुखेभृशम्| ग्लानिरर्धे तथा हर्षो मुखार्धे प्रेतलक्षणम्||१९||

तिलकाःपिप्लवोव्यङ्गाराजयश्चपृथग्विधाः| आतुरस्याशुजायन्तेमुखे प्राणान् मुमुक्षतः||२०||

पुष्पाणिनखदन्तेषुपङ्कोवादन्तसंश्रितः| चूर्णको वाऽपि दन्तेषु लक्षणं मरणस्य तत्||२१||

ओष्ठयोःपादयोःपाण्योरक्ष्णोर्मूत्रपुरीषयोः| नखेष्वपिचवैवर्ण्यमेतत्क्षीणबलेऽन्तकृत्||२२||

यस्यनीलावुभावोष्ठौपक्वजाम्बवसन्निभौ| मुमूर्षुरिति तं विद्यान्नरो धीरो गतायुषम्||२३||

एकोवायदिवाऽनेकोयस्यवैकारिकःस्वरः| सहसोत्पद्यते जन्तोर्हीयमानस्नास्ति सः||२४||

यच्चान्यदपिकिञ्चित्स्याद्वैकृतंस्वरवर्णयोः| बलमांसविहीनस्यतत्सर्वं मरणोदयम् ||२५||

bhavanti cātra-
yasya vaikārikō varṇaḥ śarīra upapadyatē|
ardhē vā yadi vā kr̥tsnē nimittaṁ na ca nāsti saḥ||17||

nīlaṁ vā yadi vā śyāvaṁ tāmraṁ vā yadi vā'ruṇam|
mukhārdhamanyathā varṇō mukhārdhē'riṣṭamucyatē||18||

snēhō mukhārdhē suvyaktō raukṣyamardhamukhē [1] bhr̥śam|
glānirardhē tathā harṣō mukhārdhē prētalakṣaṇam||19||

tilakāḥ piplavō vyaṅgā rājayaśca pr̥thagvidhāḥ|
āturasyāśu jāyantē mukhē prāṇān mumukṣataḥ||20||

puṣpāṇi nakhadantēṣu paṅkō vā dantasaṁśritaḥ|
cūrṇakō vā'pi dantēṣu lakṣaṇaṁ maraṇasya [2] tat||21||

ōṣṭhayōḥ pādayōḥ pāṇyōrakṣṇōrmūtrapurīṣayōḥ|
nakhēṣvapi ca vaivarṇyamētat kṣīṇabalē'ntakr̥t||22||

yasya nīlāvubhāvōṣṭhau pakvajāmbavasannibhau|
mumūrṣuriti taṁ vidyānnarō dhīrō gatāyuṣam||23||

ēkō vā yadi vā'nēkō yasya vaikārikaḥ svaraḥ|
sahasōtpadyatē jantōrhīyamānasya nāsti saḥ||24||

yaccānyadapi kiñcit syādvaikr̥taṁ svaravarṇayōḥ|
balamāṁsavihīnasya tat sarvaṁ maraṇōdayam [3] ||25||

tatra ślōkaḥ-
iti varṇasvarāvuktau lakṣaṇārthaṁ mumūrṣatām|
yastau [4] samyagvijānāti nāyurjñānē sa muhyati||26||

bhavanticAtra-
yasyavaikArikovarNaHsharIraupapadyate|
ardhe vA yadi vA kRutsne nimittaM na canAstisaH||17||

nIlaM vA yadi vA shyAvaM tAmraM vA yadi vA~aruNam|
mukhArdhamanyathA varNo mukhArdhe~ariShTamucyate||18||

sneho mukhArdhe suvyakto raukShyamardhamukhe bhRusham|
glAnirardhe tathA harSho mukhArdhe pretalakShaNam||19||

tilakAH piplavo vya~ggA rAjayashca pRuthagvidhAH|
AturasyAshu jAyante mukhe prANAn mumukShataH||20||

puShpANi nakhadanteShu pa~gko vA dantasaMshritaH|
cUrNako vA~api danteShu lakShaNaM maraNasya tat||21||

oShThayoH pAdayoH pANyorakShNormUtrapurIShayoH|
nakheShvapi ca vaivarNyametat kShINabale~antakRut||22||

yasya nIlAvubhAvoShThau pakvajAmbavasannibhau|
mumUrShuriti taM vidyAnnaro dhIro gatAyuSham||23||

eko vA yadi vA~aneko yasya vaikArikaH svaraH|
sahasotpadyate jantorhIyamAnasya nAsti saH||24||

yaccAnyadapi ki~jcit syAdvaikRutaM svaravarNayoH|
balamAMsavihInasya tat sarvaM maraNodayam ||25||

If half of the face there is blue, blackish, coppery or tawny color and the color of the remaining half is otherwise. Manifestation of unctuousness in one half of the face and roughness in the other half is inauspicious.

The appearance of swelling in one-half of the face and emaciation in the other half. Spontaneous appearance of various types of tila (black mole), piplu (port wine mark),vyanga (freckles), and raji (spots like mustard) on the face of the patient.

The appearance of flowers like spots in nails and teeth and sticky and powdery substance over the teeth is an indicator of death. Discoloration of lips, legs, heels, eyes, urine, stool and nails of the patient are indicators of diminished strength.

When both the lips become bluish like ripe fruits of jambu, this is a clear indication of death.

In a patient who is very much weak, due to Ojokshaya (immune depletion) along with any changes occur in voice either as single problem or multiple issues, that indicates death.

In chronic immune deficient person, there is all possibilities of dhatusaraheenatha (Severe wasting of tissues) can lead to abnormal voice.

Such other abnormalities in voice and complexion of an individual who is devoid of strength and flesh also indicate imminent death.[17-25]

Summary

तत्रश्लोकः-
इति वर्णस्वरावुक्तौ लक्षणार्थं मुमूर्षताम्| यस्तौ सम्यग्विजानाति नायुर्ज्ञाने स मुह्यति||२६||

tatraślōkaḥ-
itivarṇasvarāvuktaulakṣaṇārthaṁmumūrṣatām|
yastau samyagvijānāti nāyurjñānē sa muhyati||26||

tatra shlokaH-
iti varNasvarAvuktau lakShaNArthaM mumUrShatAm|
yastau [4] samyagvijAnAti nAyurj~jAne sa muhyati||26||

Thus the fatal signs related with complexion and voice are described. One who knows the details of these facts will not be confused in knowing lifespan of patient.

Tattva Vimarsha (Fundamental Principles)

• The prognosis of disease leading to death can be predicted by keen observation of complexion, color of body parts and voice. [3]
• The natural constitution of a person depends upon Jati (caste), Kula (race), Desha (place), Kala (time and season), Vaya (age), Pratyatmaniyata (individual habits and habitat). The different variations seen in persons are based upon their caste, race, place of living, season, age and individual habits. [5]
• The complexion is a tool to assess malaise, cheerfulness, dryness and unctuousness in body i.e. the circulatory and metabolic state of body. [9]

Vidhi Vimarsha (Applied Inferences)

Factors indicating bad prognosis

Sudden change in following factors indicate bad prognosis or near death signs:

Complexion, voice, smell, taste, touch, eyes, ears, nose, tongue, skin, psyche, desire, cleanliness, conduct, behavior, memory, shape, nature, strength, malaise, intellect, exhilaration, dryness, unctuousness, drowsiness, heaviness, lightness, qualities, diet, regimens, digestion of food, manifestation of disease, disappearance of disease, characters of disease, premonitory signs of the disease, symptoms, complications, administration of proper medicine, and effect of medicine on disease, luster, shadow, dream, state of informer about the patient. Bad omens perceived by the physician on his way to patient’s house, changed conditions of the patient’s residence, signs and symptoms indicating the residual span of life may be evident in these factors. Hence physician should pay careful attention to each one of them and interpretation should be made based on his observations, knowledge and scriptural advice.

The examination of complexion does not just mean the color only. It also includes objects of visual perception like coarseness, glossiness etc. Abnormal swara (voice) include fluctuations in the normal quality of sounds produced (hoarseness of voice, dysphonia), absence of the normal physiological sounds like absence of peristalsis in peritonitis, presence of abnormal sounds like crepitus in joints & crepitation, rhonchi etc. in lungs. Abnormalities in touch include tactile perception of abnormal hardness, softness, warmth etc.

Three types of morbid conditions

The morbid conditions are of three types. Such as those indicated by bodily marks, those caused by etiological factors and those resemble etiological factors.

Visible end stage manifestations

Lakshana nimitta include visible end stage manifestations. The abnormal color produced can be considered as ojokshaya lakshana (depletion of quality of tissue). In Raktarshas (bleeding piles), when there is excessive bleeding, it may lead to poor complexion, strength, enthusiasm and depleted ojas. If proper measure is not taken the condition may become fatal. The unnatural color of skin can be compared with the cyanotic conditions, discoloration seen in the fatal hepatic and renal pathologies etc. Appearance of white spots, white nails and loss of pigmentation can be seen in chronic liver failure.

In chronic kidney disease, the conjunctival deposition of calcium leads to redness and gritty feeling in the eye called uremic red eye. Also deposition of calcium as a band in the lamina proprea of cornea leads to band keratopathy.

In chronic hepatic failure, erythematous patches may appear over many parts of the body, especially over the chest wall and supraclavicular regions.

Appearance of abnormal complexion in the entire or half of the body of the individual without any significant reason can be due to abnormal peripheral circulation. Oxygenation can affect the complexion. In deep vein thrombosis (DVT) alteration in pigmentation is well appreciated.

When both the lips become bluish like ripe fruits of jambu, this is a clear indication of death. As per modern science this condition is similar to central cyanosis. It is directly due to Vata Pratilomata (reverse direction of Vata) in different organs. The main srotas involved are Rasavaha srotas and Raktavaha Srotas.

Abnormal voices

• In sannipatha jwara - swarasada (low pitched voice) is a lakshana.
• In kshathaja kasa - paravatha ivaakoojan (cooing sound like that of a pigeon comes out of the throat)
• In Apatantraka –kapota iva koojan ( make sound like a pigeon).
• In Tetanus -sudden death occurs due to laryngeal spasm .
• Dysphonia—Disturbance of phonation is due to disturbance in vocal cords. Strained, harsh, low pitched voice, nasal voice.
• In laryngeal tumors like supra glottic cancer and glottis cancer hoarseness of voice is a late symptom.

In fact the abnormal changes in color and voice of the patient reflect serious changes in the physiology. Deep seated pathologies of cardio vascular system, Respiratory system, endocrine system often presents with color changes. Similarly lesions in the central nervous system can lead to changes in the voice. Dysarthria, Dysphasia and Dysphonia which may become fatal. In short this chapter highlights the events related with major systems in the body which can cause death.

Assessment of various prognostic factors

Various assessment scales and tools can be applied for objective assessment of the factors described in the chapter. The following tables depict probable tools and scales of assessment. These parameters can be applied for clinical assessment of relevant factors. There is a wide scope for research on implementing these practices to predict prognosis and life span of individual. Furthermore, each of these factors is elaborated in forthcoming chapters of this section (Indriya Sthana).

Table 1: Assessment of prognostic factors

Sr.no.	Prognostic factor	Assessment scales / questionnaires / instruments
1	Complexion (varna)	Fitzpatrick skin type, Reflectance spectroscopy, Minolta chromameter, Mexameter (using erythematic and melanin indices), C.L.B.T assessment;
2	Voice (swara)	Linear analog scale of assessment - voice quality (LASA-VQ), Vocal performance questionnaire (VPQ), Vocal tract discomfort (VTD), Evaluating voice disability - Quality of life questionnaire (EVD-QOL), Speech disability questionnaire (SDQ), Voice handicap index (VHI), Voice symptom questionnaire (VSQ), Vocal fatigue index (VFI) etc;
3	Smell (gandha)	Odor fingerprints, Odor signatures, E-nose, Byoshu, Gas chromatography, Gas chromatography with mass spectrometry etc;
4	Taste (rasam)	Biomarkers, Measuring various blood components, Breathalyser, VOCs (volatile organic compounds) etc;
5	Touch (sparsha)	Thermography, Tenderness grading scale, Virtual palpation on 3D computer models, Elastography etc;
6	Sensory organs (jnanendriya)	Sensory over-responsivity scale (sensOR), Multi-Modality unusual sensory experiences questionnaire (MUSEQ), The Launay slade hallucination scale (LSHS), Cardiff anomalous perception scale (CAPS), Osteba critical appraisal cards, Sensory integration and Praxis test, The sensory profile, Perceived stress scale (PSS) etc;
7	Psyche (sattva)	Mental health quality of life, The satisfaction with life scale (SWLS), Scale of self esteem (Rosenberg scale), Quality of life index for mental health, Quality of well being scale, Mini mental status examination (MMSE) etc;
8	Interest (bhakti)	The mood, interest and pleasure questionnaire (MIPQ), Strong interest inventory test etc;
9	purity or cleanliness (shaucham)	Hygiene behavior scale (HBS), Hand washing behavior scale Terms of planned behavior model, Yale-Brown obsessive compulsive scale (Y-BOCS), Cleaning and Hygiene scale etc;
10	Modesty (sheelam)	Philadelphia geriatric centre morale scales, The big five personality test (BFPT), The traits personality questionnaire 5 (TPQue5), Rorschach ink blot technique, Minnesota multiphasic personality inventory, Eysenck personality inventory, Maudsley personality questionnaire etc;
11	Behavioral conduct (achara)	Behavior and symptom identification scale (BASIS), Client adjustment rating scale, Social behavior assessment schedule, Social maladjustment schedule etc;
12	Memory (smriti)	Addenbrookes cognitive assessment - Revised (ACE-R), Abbreviated mental test score (AMTS), General practitioner assessment of cognition (GPCOG), Memory impairment screen (MIS), Montreal cognitive assessment (MoCA), PGI memory scale, Test your memory (TYM) etc;
13	Built (akruti)	Anthropometric measurements like height, weight, circumference, skin fold thickness and several other measurements;
14	Fundamental constitution (prakriti)	Prototype Prakriti Analysis tool (PPAT), AyuSoft Prakriti software, Ayurveda child personality inventory (ACPI), Mysore tridosha scale etc;
15	Morbidity (vikruti)	Computerized adaptive assessment of disease impact (DICAT), Quality of life disease impact scale (QDIS), Multi group confirmatory factor analysis (MGCFA), Item response theory (IRT), Disease specific quality of life scales (QOLs) etc;
16	Strength or energy (bala)	Modifiable activity questionnaire (MAQ), Previous week modifiable activity questionnaire (PWMAQ), Recent physical activity questionnaire (RPAQ), International physical activity questionnaire (IPAQ), 7 day physical activity recall (PAR) etc;
17	Languor (glani)	Fatigue severity scale, Fatigue questionnaire, Multidimensional fatigue inventory, Fatigue impact scale, Visual analogue scale - Fatigue etc;
18	Intellect (medha)	Classification of intellectual and other psychological impairments functioning, Mental residual functional capacity assessment (MRFC), Wechsler adult intelligence scale (WAIS-IV), Boston naming test, Controlled oral word association, Hopkins verbal learning test - Revisited;
19	Exhilaration (harsh)	Affect balance scale, General well being index, The positive and negative syndrome scale (PANSS), Quality of life enjoyment and satisfaction questionnaire etc;
20	Dryness (raukshya)	Surface characterizing impedance monitor (SCIM), Nova Dermal Phase Meter etc;
21	Unctuousness (sneha)	Moisture Map, Dermaflex, Biospec imager, SkinChip, Skicon, Corneometer, Dermal Torque Meter, Twistometer etc;
22	Drowsiness (tandra)	Pittsburgh sleep quality index (PSQI), Holland sleep disorder questionnaire (HSDQ), Gorningen sleep quality scale (GSQS), Karolinska sleepiness scale (KSS), Expanded consensus sleep diary (CSD-E) etc;
23	Onset (arambha)	Various screening tests like Mini-Cog, 6-CIT, The informant questionnaire on cognitive decline in the elderly (IQCODE), Geriatric depression screening scale, The Hospital anxiety and depression scale etc;
24	Heaviness (gaurava)/ lightness (laghava)	Increased or decreased specific gravity of sputum, semen, urine and faeces etc which can be measured by laboratory investigations like sputum, semen, urine analysis;
25	Quality of diet (ahara guna)	Diet satisfaction questionnaire (DSat-45), RESIDE dietary guideline index (RDGI), Food frequency questionnaire (FFQ), Dietary behavior questions (DBQ) etc;
26	Lifestyle (vihara)	Simple lifestyle indicator questionnaire (SLIQ), The healthy lifestyle and personal control questionnaire (HLPCQ), Lifestyle questionnaire related to cancer, Health protective behaviour scale etc;
27	Post digestion effect (ahara parinama)	Questionnaire to assess digestion and metabolism (jatharagni), Self assessment tool to estimate digestion capacity (Agni bala), VAS scales, Metabolic markers etc;
28	Disease and its prediction (vyadhi and purvarupa)	Severity scales, screening instruments or questionnaires, VAS (visual analogue scales) etc;
29	Complaints (vedana)	Oswestry disability index (ODI), Roland & Morris disability questionnaire, VAS, Graphic rating scale (GRS), Numerical rating scale (NRS), Verbal rating scale (VRS), McGill pain questionnaire (MPQ), Pain-O-Meter etc;
30	Complications (upadrava)	Patient reported outcome measures (PROM), Patient reported experience measures (PREM), EQ-5D, EQ-VAS etc;
31	Luster (chchaya), shadow (pratichchaya)	Red reflex test, Radio diagnosis & imaging, Kirlian photography, Fitzpatrick skin type scale, C.L.B.T assessment, Computerized analysis of shadows, studies on cast shadows etc;
32	Dreams (swapna darshana)	Nightmare distress questionnaire (NDQ), Beliefs about dream questionnaire (BADQ), Chinese version of Van Dream anxiety scale (CVDAS), Dream survey questionnaire (DSQ) etc;
33	Messenger (doota adhikara)	Caregiver strain index (CSI), Zarit burden interview, Care related quality of life, Burden scale for family caregivers, Care giving knowledge questionnaire (CKQ-My), Caregiver burden scale - Indian population (CBS-IP), Caregiver confidence in sign/symptom management scale (CCSM), Revised scale of care giving self efficacy (RSSE), Self efficacy questionnaire for Chinese family caregivers (SEQCFC) etc;

Assessment of complexion

The normal complexion can be compared and related to different skin types as per Fitzpatrick skin type given in table 2.

Table 2: Assessment of normal complexion (varna)

Normal complexion (varna)	Skin colour	Fitzpatrick skin type
Krishna	Black	Type VI
Shyama	Brown	Type V
Shyama-Avadata	Light brown	Type III & Type IV
Avadata-Gaura	Fair or White	Type I & Type II

Observations of abnormal complexion and relevant morbidities

Clinical observations in change of complexion can be suggestive of probable underlying morbidities. These are summarized in the following table 3.

Table 3: Bad prognostic factor related to change in complexion

Observation	Probable relevant disease or pathology
Discoloration of whole body [ Cha.Sa. Indriya Sthana 1/9]	Cyanosis; Melasma; Addison’s disease; Post-inflammatory hyper pigmentation; Cutaneous amyloidosis; Acanthosis nigricans; Wilson’s disease; Purpura; Fungal infections in immunocompromised patients; Jaundice; Hepatocellular carcinoma; Pallor; Hypomelanosis or hypopigmentation; Vitiligo;
Discoloration of right half of body [Cha.Sa.Indriya Sthana 1/10]	Harlequin color change;
Discoloration of upper half of body [Cha.Sa.Indriya Sthana 1/10]	Differential cyanosis; Reverse differential cyanosis; Spinal cord injury (SCI); Paraplegia;
Discoloration of dorsal or posterior surface of the body [Cha.Sa.Indriya Sthana 1/10]	Venous stasis in chronic bed ridden patients;
Discoloration of internal or external mucosal surfaces [Cha.Sa.Indriya Sthana 1/10]	Acquired generalized hyper pigmentations due to various underlying conditions; Oral pigmentation; Sino-nasal melanosis; Nevus of Ota;
Unilateral facial discoloration [Cha.Sa.Indriya Sthana 1/10]	Unilateral facial flushing in Harlequin syndrome; Horner’s syndrome; Parry-Romberg syndrome;
Unilateral numbness or hyperesthesia in body [Cha.Sa.Indriya Sthana 1/10]	Hemiplegia or hemiparesis; Paraplegia or paraparesis; Diplegia; HSP (Hereditary spastic paraplegia); CMV (cytomegalovirus) polyradiculopathy; SCI; Myelopathies;
Unilateral numbness or hyperesthecia on face [Cha.Sa.Indriya Sthana 1/10]	DAN (Diabetic autonomic neuropathy); Anhidrosis & Hyperhidrosis; SCI; Cervical spine pathology; Unilateral facial seborrhoea in Ramsay-Hunt syndrome & Facial paralysis;
Unilateral unctuousness or dryness of body [Cha.Sa.Indriya Sthana 1/10]	Paraplegia; SCI; Myelopathy;
Appearance of moles, freckles, pimples on body [Cha.Sa.Indriya Sthana 1/11]	Basal cell carcinoma; Squamous cell carcinoma; Scleroderma; SLE (Systemic lupus erythematosus); Inflammatory & Infectious dermatoses; Sturge-Weber syndrome; Fungal & Viral skin infections; Melanocytic nevi; Hyper pigmentations; Carcinoid syndrome;
Abnormal discoloration of nails, eyes, face, urine, stools, hands, legs, lips etc. [Cha.Sa.Indriya Sthana 1/12]	Cyanosis; Melanonychia; Acroperniosis; Chemosis; Jaundice; Panda eye; Iris nevi; Horner’s syndrome; Melanoma; Alkaptonuria; Black water fever; Biliary obstruction; Upper and lower gastrointestinal bleeding; Peripheral vascular disease (PVD); Acrocyanosis; Raynaud’s phenomenon; Mottling at end-of-life stages;
Other sudden changes in complexion [Cha.Sa.Indriya Sthana 1/13]	Cyanosis, Pallor and Erythrosis seen in ALTE (Apparent Life-Threatening Events) & BRUE (Brief Resolved Unexplained Events);

Observations of abnormal voice and relevant morbidities

Clinical observations in change of voice can be suggestive of probable underlying morbidities. These are summarized in the following table 4.

Table 4: Bad prognostic factor related to change in voice

Abnormal voice	Relevant disease or pathology
Hoarseness or raspiness like a sheep [Cha.Sa.Indriya Sthana 1/14]	Due to structural changes of vocal cords (Acute or chronic laryngitis, Polyps etc);
Feeble [Cha.Sa.Indriya Sthana 1/14]	Aphonic palilalia; Hypophonia; Paresis of vocal cords; LMN (lower motor neuron) lesions;
Subdued or Inaudible) [Cha.Sa.Indriya Sthana 1/14]	Aphonia; Hypophonia; LMN (lower motor neuron) lesions; ALS (Amyotrophic lateral sclerosis); MG (Myasthenia gravis); TIA (Transient ischemic attack) etc;
Indistinct or Indistinguishable) [Cha.Sa.Indriya Sthana 1/14]	Aphonia; Aphonic palilalia; Progressive supranuclear palsy; Bilateral upper brainstem lesions;
Chocked or stammering [Cha.Sa.Indriya Sthana 1/14]	Spastic or Spasmodic dysphonia; Dysarthria (bilateral cerebral lesions, cerebral glioma of parietal origin etc);
Hoarse or rough [Cha.Sa.Indriya Sthana 1/14]	Hyperkinetic dysarthria; Structural lesions and inflammatory conditions of larynx;
Faint or painful [Cha.Sa.Indriya Sthana 1/14]	Dysphasia; Dysphonia; Motor or Broca’s Aphasia; Inflammatory lesions of the pharynx and larynx; Neoplasms of larynx, pharynx, lungs, and thyroid; Lymphoma; Mediastinal metastases pressing laryngeal nerves; Unilateral vocal cord palsy (UVCP) etc;
Stuttering or stammering [Cha.Sa.Indriya Sthana 1/14]	Spastic paralysis; Dysarthria; Rigidity; Spasms of muscles of articulation;
Other abnormal voices [Cha.Sa.Indriya Sthana 1/15]	Migraine Aura; TIA; MG; ALS; LMN lesions; UVCP; Multiple sclerosis (MS); Epilepsy; Carcinomas of larynx, pharynx, lungs, and thyroid; Lymphoma; Mediastinal metastasis; Cancer cachexia etc;

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

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References