Parimarshaneeyam Indriyam Adhyaya

Indriya Sthana Chapter 3.Palpable signs of Imminent Death

Parimarshaneeyam Indriyam Adhyaya

Section/Chapter	Indriya Sthana Chapter 3
Preceding Chapter	Pushpitakam Indriyam Adhyaya
Succeeding Chapter	Indriyaneekam Indriyam Adhyaya
Other Sections	Sutra Sthana, Nidana Sthana, Vimana Sthana, Sharira Sthana, Chikitsa Sthana, Kalpa Sthana, Siddhi Sthana
Translator and commentator	Baghel M.S., Nadkarni M.
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.s05.004

Abstract

Palpation and percussion enables a physician to make important observations that helps in understanding the disease. Parimarshaneeyam Indriyam Adhyaya deals with signs and symptoms of imminent death; especially the ones which can be elicited by touch or palpation. The chapter talks about various changes that occur in different parts of the body along with various signs elicited by palpation like hardening, softening, bowing, displacement of body structures, changes in breathing patterns, extreme wasting along with deficiency of blood, structural and functional changes in eyes, body hair, and various body parts.

Keywords: lingam, sparsha, touch, palpation, fatal signs.

Introduction

Parimarshaneeyam Indriyam Adhyaya mainly deals with the moribund symptoms based on palpating various regions of the body. It follows Pushpitakam Indriyam Adhyaya that deals with the prognosis based on observing the changes in the odour or taste in the body. The reason for this sequence can be understood as the changes in the odor or taste can be felt easily and from far whereas to palpate the patient is a must. The chapter also precedes Indriyaneekam Indriyam Adhyaya, which deals with the prognosis based on observing the functioning of the sensory organs of the body.

Sanskrit text, Transliteration and English Translation

परिमर्शनीयेन्द्रियोपक्रमः
अथातः परिमर्शनीयमिन्द्रियं व्याख्यास्यामः||१||

इति ह स्माह भगवानात्रेयः||२||

वर्णे स्वरे च गन्धे च रसे चोक्तं पृथक् पृथक्|
लिङ्गं मुमूर्षतां सम्यक् स्पर्शेष्वपि निबोधत||३||

athātaḥ parimarśanīyamindriyaṁ vyākhyāsyāmaḥ||1||

iti ha smāha bhagavānātrēyaḥ||2||

varṇē svarē ca gandhē ca rasē cōktaṁ pr̥thak pr̥thak|
liṅgaṁ mumūrṣatāṁ samyak sparśēṣvapi nibōdhata||3||

athAtaH parimarshanIyamindriyaM vyAkhyAsyAmaH||1||

iti ha smAha bhagavAnAtreyaH||2||

varNe svare ca gandhe ca rase coktaM pRuthak pRuthak|
li~ggaM mumUrShatAM samyak sparsheShvapi nibodhata||3||

Now we shall expound the chapter "Parimarshaneeyam Indriyam"(Palpable signs of Imminent Death). Thus said Lord Atreya.[1-2]

The person who is about to die manifests various signs in terms of colour, voice, odour, taste in mouth which are described separately. Now we will learn about the signs of imminent death pertaining to touch. [3]

Assessment factors by palpation

स्पर्शप्राधान्येनैवातुरस्यायुषः प्रमाणावशेषं जिज्ञासुः प्रकृतिस्थेन पाणिना शरीरमस्य केवलं स्पृशेत्, परिमर्शयेद्वाऽन्ये|
परिमृशता तु खल्वातुरशरीरमिमे भावास्तत्र तत्रावबोद्धव्या भवन्ति|
तद्यथा- सततं स्पन्दमानानां शरीरदेशानामस्पन्दनं, नित्योष्मणां शीतीभावः, मृदूनां दारुणत्वं, श्लक्ष्णानां खरत्वं,सतामसद्भावः, सन्धीनां स्रंसभ्रंशच्यवनानि; मांसशोणितयोर्वीतीभावः, दारुणत्वं, स्वेदानुबन्धः, स्तम्भो वा; यच्चान्यदपिकिञ्चिदीदृशं स्पर्शानां लक्षणं भृशविकृतमनिमित्तं स्यात्|
इति लक्षणं स्पृश्यानां भावानामुक्तं समासेन||४||

sparśaprādhānyēnaivāturasyāyuṣaḥ pramāṇāvaśēṣaṁ jijñāsuḥ prakr̥tisthēna pāṇinā śarīramasyakēvalaṁ spr̥śēt, parimarśayēdvā'nyēna|
parimr̥śatā tu khalvāturaśarīramimē bhāvāstatra tatrāvabōddhavyā bhavanti|
tadyathā-satataṁ spandamānānāṁ śarīradēśānāmaspandanaṁ, nityōṣmaṇāṁ śītībhāvaḥ, mr̥dūnāṁdāruṇatva, ślakṣṇānāṁ kharatvaṁ, satāmasadbhāvaḥ, sandhīnāṁ sraṁsabhraṁśacyavanāni;māṁsaśōṇitayōrvītībhāvaḥ, dāruṇatvaṁ, svēdānubandhaḥ, stambhō vā; yaccānyadapi kiñcidīdr̥śaṁsparśānāṁ lakṣaṇaṁ bhr̥śavikr̥tamanimittaṁ syāt|
iti lakṣaṇaṁ spr̥śyānāṁ bhāvānāmuktaṁ samāsēna||4||

sparshaprAdhAnyenaivAturasyAyuShaH [1] pramANAvasheShaM [2] jij~jAsuH prakRutisthena pANinA sharIramasya kevalaM spRushet, parimarshayedvA~anyena|
parimRushatA tu khalvAturasharIramime bhAvAstatra tatrAvaboddhavyA bhavanti|
tadyathA- satataM spandamAnAnAM sharIradeshAnAmaspandanaM, nityoShmaNAM shItIbhAvaH, mRudUnAM dAruNatvaM, shlakShNAnAM kharatvaM,satAmasadbhAvaH [3] , sandhInAM sraMsabhraMshacyavanAni; mAMsashoNitayorvItIbhAvaH, dAruNatvaM, svedAnubandhaH, stambho vA; yaccAnyadapiki~jcidIdRushaM sparshAnAM lakShaNaM bhRushavikRutamanimittaM syAt|
iti lakShaNaM spRushyAnAM bhAvAnAmuktaM samAsena||4||

The physician who wants to use the method of palpation for measuring the remaining lifespan of a patient, should palpate his (patient’s) entire body with his hands, the hands being in normal condition. If the hands of the physician are not in normal condition, he should do so by using another person as a substitute for palpating the patient’s body.

While palpating patient’s body; following deviations should be studied keeping normal anatomy and physiology of the body in mind. Extreme deviations from normalcy in the body like the absence of pulsation in the pulsatile areas of the body, absence of warmth from warm regions of the body or the presence of hardness or rigidity in softer body structures can give important information in regards to the life span of the person. Similarly the presence of the signs like dislocation or displacement of joints, extreme alteration in perspiration, extreme emaciation or bulkiness of muscle etc. which are found without any apparent cause are to be studied to assess the span of life or the signs of death. [4]

Assessment by observation of body parts

तद्व्यासतोऽनुव्याख्यास्यामः- तस्य चेत् परिमृश्यमानं पृथक्त्वेनपादजङ्घोरुस्फिगुदरपार्श्वपृष्ठेषिकापाणिग्रीवाताल्वोष्ठललाटं स्विन्नं शीतं स्तब्धं दारुणं वीतमांसशोणितं वा स्यात्,परासुरयं पुरुषो न चिरात् कालं मरिष्यतीति विद्यात्|
तस्य चेत् परिमृश्यमानानि पृथक्त्वेनगुल्फजानुवङ्क्षणगुदवृषणमेढ्रनाभ्यंसस्तनमणिकपर्शुकाहनुनासिकाकर्णाक्षिभ्रूशङ्खादीनि स्रस्तानि व्यस्तानि च्युतानिस्थानेभ्यः स्कन्नानि वा स्युः, परासुरयं पुरुषोऽचिरात् कालं मरिष्यतीति विद्यात्||५||

tadvyāsatō'nuvyākhyāsyāmaḥ- tasya cēt parimr̥śyamānaṁ pr̥thaktvēnapādajaṅghōrusphigudarapārśvapr̥ṣṭhēṣikāpāṇigrīvātālvōṣṭhalalāṭaṁ svinnaṁ śītaṁ stabdhaṁ dāruṇaṁvītamāṁsaśōṇitaṁ vā syāt, parāsurayaṁ puruṣō na cirāt kālaṁ mariṣyatīti vidyāt|
tasya cēt parimr̥śyamānāni pr̥thaktvēnagulphajānuvaṅkṣaṇagudavr̥ṣaṇamēḍhranābhyaṁsastanamaṇikaparśukāhanunāsikākarṇākṣibhrūśaṅkhādīnisrastāni vyastāni cyutāni sthānēbhyaḥ skannāni vā syuḥ, parāsurayaṁ puruṣō'cirāt kālaṁ mariṣyatīti vidyāt||5||

tadvyAsato~anuvyAkhyAsyAmaH- tasya cet parimRushyamAnaM pRuthaktvena pAdaja~gghorusphigudarapArshvapRuShTheShikApANigrIvAtAlvoShThalalATaMsvinnaM shItaM stabdhaM [1] dAruNaM vItamAMsashoNitaM vA syAt, parAsurayaM puruSho na cirAt kAlaM [2] mariShyatIti vidyAt|
tasya cet parimRushyamAnAni pRuthaktvenagulphajAnuva~gkShaNagudavRuShaNameDhranAbhyaMsastanamaNikaparshukAhanunAsikAkarNAkShibhrUsha~gkhAdIni srastAni vyastAni cyutAni sthAnebhyaHskannAni [3] vA syuH, parAsurayaM puruSho~acirAt kAlaM mariShyatIti [4] vidyAt||5||

Now I will elaborate upon what I have stated above. If on individual palpation; the feet, calves, thighs, buttocks, belly, both the flanks, vertebral column, hands, neck, palate, lips, forehead are found to be soaked in perspiration, are cold, show stiffness or absence of sensation, inflexibility, or are deficient of flesh or blood, then the physician should note that the person is nearing the end of his live and will die soon.

The physician should similarly palpate separately ankles, knees, pelvis, anus, scrotum, penis, navel, nipples, rib cage, chin, nostrils, ears, eyes, eyebrows, temples to see if these are lax, broken, loosened, displaced from their normal position. If so then the physician should consider that the patient will face death in a short span of time. [5]

Observation of respiration and eyes

तथाऽस्योच्छ्वासमन्यादन्तपक्ष्मचक्षुःकेशलोमोदरनखाङ्गुलीरालक्षयेत्|
तस्य चेदुच्छ्वासोऽतिदीर्घोऽतिह्रस्वो वा स्यात्, परासुरिति विद्यात्|
तस्य चेन्मन्ये परिमृश्यमाने न स्पन्देयातां, परासुरिति विद्यात्|
तस्य चेद्दन्ताः परिकीर्णाः श्वेता जातशर्कराः स्युः, परासुरिति विद्यात्|
तस्य चेत् पक्ष्माणि जटाबद्धानि स्युः, परासुरिति विद्यात्|
तस्य चेच्चक्षुषी प्रकृतिहीने, विकृतियुक्ते- अत्युत्पिण्डिते, अतिप्रविष्टे, अतिजिह्मे, अतिविषमे, अतिमुक्तबन्धने, अतिप्रस्रुते,सततोन्मिषिते, सततनिमिषिते, निमिषोन्मेषातिप्रवृत्ते, विभ्रान्तदृष्टिके, विपरीतदृष्टिके, हीनदृष्टिके, व्यस्तदृष्टिके,नकुलान्धे, कपोतान्धे, अलातवर्णे, कृष्णपीतनीलश्यावताम्रहरितहारिद्रशुक्लवैकारिकाणां वर्णानामन्यतमेनातिप्लुते वास्यातां, तदा परासुरिति विद्यात्|
अथास्य केशलोमान्यायच्छेत्, तस्य चेत् केशलोमान्यायम्यमानानि प्रलुच्येरन् न चेद्वेदयेयुस्तं परासुरिति विद्यात्|
तस्य चेदुदरे सिराः प्रकाशेरञ् श्यावताम्रनीलहारिद्रशुक्ला वा स्युः, परासुरिति विद्यात्|
तस्य चेन्नखा वीतमांसशोणिताः पक्वजाम्बववर्णाः स्युः, परासुरिति विद्यात्|
अथास्याङ्गुलीरायच्छेत्; तस्य चेदङ्गुलय आयम्यमाना न स्फुटेयुः, परासुरिति विद्यात्||६||

tathā'syōcchvāsamanyādantapakṣmacakṣuḥkēśalōmōdaranakhāṅgulīrālakṣayēt|
tasya cēducchvāsō'tidīrghō'tihrasvō vā syāt, parāsuriti vidyāt|
tasya cēnmanyē parimr̥śyamānē na spandēyātāṁ, parāsuriti vidyāt|
tasya cēddantāḥ parikīrṇāḥ śvētā jātaśarkarāḥ syuḥ, parāsuriti vidyāt|
tasya cēt pakṣmāṇi jaṭābaddhāni syuḥ, parāsuriti vidyāt|
tasya cēccakṣuṣī prakr̥tihīnē, vikr̥tiyuktē- atyutpiṇḍitē, atipraviṣṭē, atijihmē, ativiṣamē, atimuktabandhanē,atiprasrutē, satatōnmiṣitē, satatanimiṣitē, nimiṣōnmēṣātipravr̥ttē, vibhrāntadr̥ṣṭikē, viparītadr̥ṣṭikē,hīnadr̥ṣṭikē, vyastadr̥ṣṭikē , nakulāndhē, kapōtāndhē, alātavarṇē,kr̥ṣṇapītanīlaśyāvatāmraharitahāridraśuklavaikārikāṇāṁ varṇānāmanyatamēnātiplutē vā syātāṁ, tadāparāsuriti vidyāt|
athāsya kēśalōmānyāyacchēt, tasya cēt kēśalōmānyāyamyamānāni pralucyēran na cēdvēdayēyustaṁparāsuriti vidyāt|
tasya cēdudarē sirāḥ prakāśērañ śyāvatāmranīlahāridraśuklā vā syuḥ, parāsuriti vidyāt|
tasya cēnnakhā vītamāṁsaśōṇitāḥ pakvajāmbavavarṇāḥ syuḥ, parāsuriti vidyāt|
athāsyāṅgulīrāyacchēt; tasya cēdaṅgulaya āyamyamānā na sphuṭēyuḥ, parāsuriti vidyāt||6||

tathA~asyocchvAsamanyAdantapakShmacakShuHkeshalomodaranakhA~ggulIrAlakShayet|
tasya ceducchvAso~atidIrgho~atihrasvo vA syAt, parAsuriti vidyAt|
tasya cenmanye parimRushyamAne na spandeyAtAM, parAsuriti vidyAt|
tasya ceddantAH parikIrNAH shvetA jAtasharkarAH syuH, parAsuriti vidyAt|
tasya cet pakShmANi jaTAbaddhAni syuH, parAsuriti vidyAt|
tasya ceccakShuShI prakRutihIne, vikRutiyukte- atyutpiNDite, atipraviShTe, atijihme, ativiShame, atimuktabandhane, atiprasrute, satatonmiShite, satatanimiShite,nimiShonmeShAtipravRutte, vibhrAntadRuShTike, viparItadRuShTike, hInadRuShTike, vyastadRuShTike [5] , nakulAndhe, kapotAndhe, alAtavarNe,kRuShNapItanIlashyAvatAmraharitahAridrashuklavaikArikANAM varNAnAmanyatamenAtiplute vA syAtAM, tadA parAsuriti vidyAt|
athAsya keshalomAnyAyacchet, tasya cet keshalomAnyAyamyamAnAni pralucyeran na cedvedayeyustaM parAsuriti vidyAt|
tasya cedudare sirAH prakAshera~j shyAvatAmranIlahAridrashuklA vA syuH, parAsuriti vidyAt|
tasya cennakhA vItamAMsashoNitAH pakvajAmbavavarNAH syuH, parAsuriti vidyAt|
athAsyA~ggulIrAyacchet; tasya ceda~ggulaya AyamyamAnA na sphuTeyuH, parAsuriti vidyAt||6||

The physician should similarly examine the patient’s respiration, two sides of the neck, teeth, eye-lashes, eyes, hair covering the head as well as body hair, abdomen, nails and fingers.

Following are considered bad prognostic features:

• If patient breaths either too long or too short of a breath
• Absence of pulsation in vessels of neck.
• Teeth are coated, abnormally white and have sugar/crystal like deposits on it.
• Eye-lashes are matted together.
• Eyes have lost physiological characteristics or are seen abnormal in any manner like- too bulging, too retracted, too oblique or squinted, too distorted, too loosened within their structure, having too much watery discharge, are either continuously open or closed, continuously blinking, with unstable vision, abnormal vision, deficient vision, have lost their keenness of vision (or color blindness), night blind, sees everything complete white or black, or red.
• If, patient sees halo of different colors like- black, yellow, blue, blackish, coppery, green, turmeric, white or any other abnormal color. Absence of pain on plucking hair from any part of his body.
• Visibly prominent veins on abdominal region and appear to have various colors like-black, copper, blue, turmeric-like or white.
• If the nails are drained of blood and flesh, they look dark purple in color.
• Lastly physician should examine the patient’s finger. If there is no cracking sound while stretching or pulling the fingers,it should be known that the person will not survive.[6]

Summary

तत्र श्लोकः-
एतान् स्पृश्यान् बहून् भावान् यः स्पृशन्नवबुध्यते|
आतुरे न स सम्मोहमायुर्ज्ञानस्य गच्छति||७||

tatra ślōkaḥ-
ētān spr̥śyān bahūn bhāvān yaḥ spr̥śannavabudhyatē|
āturē na sa sammōhamāyurjñānasya gacchati||7||

tatra shlokaH-
etAn spRushyAn bahUn bhAvAn yaH spRushannavabudhyate|
Ature na sa sammohamAyurj~jAnasya gacchati||7||

Here is the re-capitulatory verse:

The physician who, by palpation ascertains various palpable signs, will never be confused regarding the matter of prognostic knowledge regarding life span of a patient. [7]

Tattva Vimarsha(Fundamental Principles)

Palpation of patient, observation of respiration, eyes can suggest prognosis of disease.

Vidhi Vimarsha (Applied Inferences)

The physician who, by palpation ascertains various palpable signs, will never be confused regarding the matter of prognostic knowledge regarding life span of a patient. [7]

Parimarshaneeyam Indriyam Adhyaya deals with signs and symptoms of imminent death or moribund symptoms; specifically those are elicited by touch or palpation. The chapter commences with the importance of palpation as a modality for diagnosis and any changes in the body indicative of imminent death. The signs of imminent death are seen as abnormal manifestations which cannot be explained as they appear without any reason. These can be seen as absence of pulsation in the areas of the body that are pulsatile, coldness in the warm areas of the body, rigidity in softer body parts, roughness in the body parts that are slimy in nature, the inexplicable absence of body parts; laxity, bowing or displacement of joints, excessive deficiency of flesh or blood, solidity of flesh or blood, excessive perspiration or stiffness, and/or whatever other similar symptoms that can be demonstrated by palpation. The important point to note here is that all the signs and symptoms seen here as well as other chapters of Indriya Sthana are seen without any causative factors. The rest of the Charak Samhita excluding the Indriya Sthana comprises of various signs and symptoms due to vitiation of dosha. [Cha.Sa.Indriya Sthana 3/4]

Examples of palpation

The carotid artery is palpated with the thumb or finger tips placed at the upper end of the thyroid cartilage along the medial border of the sternocleidomastoid muscle. The absence of pulsation in carotid artery usually results from atherosclerosis or carotid artery stenosis. The pulsations of jugular veins or the study of carotid circulation by using color Doppler test can provide more information on cerebral health which can give important information on the life span of the individual.

Thermoregulatory center of hypothalamus actively monitors thermostasis. If this gets altered it’s a sign of fatality. Sudden drop of body temperature could be a result of an injury, hemorrhage, acute illness or shock. A persistently low temperature is commonly seen in emaciation or wasting diseases, hypothyroidism or Simmonds diseases (post-partum hypopituitarism).

Cancer is one of the leading causes of death and disease worldwide today. Various changes like rigidity in soft tissues (e.g. breast cancer) and roughness in mucosal membranes (changes seen in gastric cancer) or extreme wasting are a few changes associated with cancer. Absence of normally existing body parts can be understood as atrophy of various glands or overall muscle atrophy.

Assessment by palpation of body parts

The abnormal signs on palpation of body parts, observation of respiratory pattern and eyes can indicate specific underlying morbidity. The probable abnormal conditions are summarized in table 1 and 2. These parameters can be applied for clinical assessment of relevant factor. There is a wide scope for research on implementing these practices to predict prognosis and life span of individual.

Table 1: Specific signs on palpation of body part and probable relevant morbidity

Body Parts	Probable Related diseases
Ankle (gulpha)	Foot drop / Functional or chronic ankle instability / Predislocation syndrome / Subluxations and dislocations of ankle joint / Inflammatory joint disease / Multiple sclerosis / Amyotrophic lateral sclerosis / Charcot-Marie-Tooth disease etc
Knee(janu)	Subluxation & dislocation of patella / Genu valgum& varum / Rickets / Inflammatory joint diseases / Rupture of quadriceps tendon
Inguinal region or Hip joint (vankshana)	Acetabular rim syndrome / Avascular necrosis / Hip dysplasia / Labral tears / Dislocation of hip / Femoroacetabular impingement (FAI) / Acetabular dysplasia / Poliomyelitis / Femoral neck fracture (due to osteoporosis)
Anus( Guda)	Rectal prolapse or Procidentia / Adenocarcinoma of rectum or sigmoid colon / Rectosigmoid tumour / Ischio rectal abscess etc
Testicle / Scrotum( Vrishana)	Acquired cryptorchidism / Testicular torsion / various tumours of testes / Anteversion and inversion of testis etc
Penis(Medhra)	Peyronie’s disease / Lichen sclerosis / Fournier’s gangrene / Buried penis / Idiopathic partial thrombosis of corpus cavernosum (IPT) / Ischemic priapism etc
Umbilicus(Nabhi)	Exomphalos / Umbilical or paraumbilical hernias / Everted umbilicus due to intra abdominal neoplasms etc
Shoulder(Amsa)	Subluxation & dislocation of shoulder / winging of the scapula / Sprengel’s deformity / Glenohumeral joint dysplasia / Rotator cuff disease (RCD) / Adhesive capsulitis (frozen shoulder) / Subacromial impingement syndrome (SIS) / Labral tears etc
Breast(Stana)	Benign tumours and carcinoma of breast / Retracted, deviated, inverted and flattened nipples (due to abscess or neoplasms)
Wrist(Manika)	Radial or ulnar deviation / Flexion deformity / Rheumatoid hand / Madelung’s deformity / Preiser’s disease / Kienbock’s disease / Ligament tears / Motor neuron disease (MND) / Wrist drop / Varus and Valgus deformities of wrist / Rickets / Lunate or perilunate dislocations etc
Rib(parshuka)	Metastatic rib lesions / Gorham disease / Chondrosarcoma / Fibrous dysplasia / Rib fractures / Cervical rib / Paget disease / Kyphosis / Scoliosis / Rachitic rosary etc
Jaw(hanu)	Subluxation or dislocation or ankylosis of TMJ (Temporomandibular joint) / Trismus / Oromandibular dystonia
Nose(nasika)	Saddle nose / Septal deviation / Sinonasal tumours / Rhinoscleroma / Leprosy / Nasal polyps etc
Ear(karna)	Protruding or bat ears / Cup shaped or low-set ears in Down syndrome / Cauliflower ears / Mastoid abscess / Ear tumours
Eye(akshi)	Exophthalmos (in Graves’ disease) / Enophthalmos / Squint / Retro orbital or orbital tumours / Ophthalmoplegia etc
Eyebrow(bhru)	Madarosis / Facial nerve palsy / Horner syndrome / Myasthenia gravis / Brow tumours like pleomorphic adenoma etc
Temple region(shankha)	Multiple venous malformations with phleboliths at temples / Giant cell arteritis / Intra cranial abscess / Temporal osteitis or myositis / Multiple myeloma / Maxillary carcinoma etc

Table 2: Specific signs on eyes and probable relevant morbidity

Prognostic feature	Probable related morbidity
Exophthalmos(atyutpindite)	Graves ophthalmopathy / Retro orbital or orbital tumours / Orbital cellulitis / Severe glaucoma etc
Enophthalmos(atipravishte)	Horner’s syndrome / Marfan syndrome / Duane’s syndrome / Silent sinus syndrome / Phthisis bulbi / Atrophy etc
Crossed eyes(atijimhe)	Squint or Strabismus / Acquired paralytic strabismus in Diabetes / Graves disease / Guilain-Barre syndrome (GBS) / Stroke / Brain tumours / Hydrocephalus / Cerebral palsy etc
Uneven(ativishame)	Irregular astigmatism / Keratoconus / Central cornea islands / Map-Dot-Fingerprint dystrophy (MDF) / Cysts or tumours in one eye etc
Plegia(ati mukta bandhane)	Ophthalmoplegia / Myasthenia gravis / GBS / Kearns-Sayre syndrome / Foville’s syndrome / Internuclear ophthalmoplegia / Multiple sclerosis / Parinaud’s syndrome / Stroke / Wernicke encephalopathy / Cavernous sinus syndrome / Paralysis of cranial nerves (CN III, IV & VI) etc
Watering eyes(ati prasrite)	Epiphora / Allergic or infective conjunctivitis / Trichiasis / Ectropion / Keratitis / Corneal ulcers / Chalazion / Bell’s palsy / Dacrocystitis / Punctal eversion / Stevens-Johnson syndrome / Neoplasms etc
Lagophthalmos(satatonmishite)	Lagophthalmos / Symblepharon formation / Acquired oculomotor synkinesis / Exophthalmos / Facial palsy / Ectropion etc
Drooping / Ptosis(satatanimishite)	Ptosis / Ocular myopathies / Horner’s syndrome / Cranial nerve palsy (CN III) / Myasthenia gravis / Stevens-Johnson syndrome / Atrophy etc
Excessive blinking(Nimisha-unmesha atipravritte)	Corneal abrasion / Trichiasis / Inflammatory or allergic conditions of eyes / Benign essential blepharospasm / Meige syndrome / Tics etc
Dancing eyes(vibhranta drishtike)	Nystagmus / Cataracts / Strabismus / Meniere’s disease / Multiple sclerosis / Stroke / B12 or Thiamine deficiencies / Brain tumours etc
Distorted vision(viparita drishtike)	Metamorphopsia / Age related macular degeneration / Astigmatism / Keratoconus / Glaucoma / Migraine / Epiretinal membrane etc
Defective vision(heena drishtike)	Central retinal artery or vein occlusion / Ischemic optic neuropathy / Vitreous haemorrhage / Retinal detachment / Acute glaucoma / Transient ischemic attack / Tumours or infections in brain etc
Oscillopsia(vyasta drishtike)	Seizures / Multiple sclerosis / Superior oblique myokymia / Stroke / Meningitis / Brain tumours / Meniere’s disease etc
Nyctalopia(nakulandhe)	Congenital high myopia / Tapeto-retinal degeneration / Glaucoma / Cataract / Diabetes / Retinitis pigmentosa / Vitamin A deficiency etc
Hamarlopia(kapotandhe)	Cone dystrophy / Achromatopsia / Central lenticular opacity / Central cataracts / Cancer associated retinopathy (CAR) etc
Bloodshot eyes(alata varne)	Chemosis / Various inflammatory & allergic conditions / Acute conjunctivitis / Sub conjunctival haemorrhage / Glaucoma etc
Eye colour changes(anya vaikarika varnani)	Panda eye / Jaundice / Heterochromia iridis / Iris nevi / Pigment dispersion syndrome / Horner’s syndrome / Osteogenesis imperfecta / Arcus senilis / Keyser Fleischer ring in Wilson’s disease 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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