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Parimarshaneeyam of Charaka Indriya Sthana - An Explorative Study
Parimarshaneeyam of Charaka Indriya Sthana - An Explorative Study
(Part - 1)
IJA A M
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INTERNATIONAL JOURNAL OF AYURVEDA & ALTERNATIVE MEDICINE pISSN-2395-3985
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REVIEW ARTICLE
DOI: https://doi.org/10.36672/ijaam.2019.v07i05.003
1. Professor, Dept of Kayachikitsa, SKS Ayurvedic Medical College & Hospital, Mathura, Uttar Pradesh,
India, Contact No. +91 7567222856, E-mail- drprasadmamidi@gmail.com
2. Professor, Dept of Kayachikitsa, SKS Ayurvedic Medical College & Hospital, Mathura, Uttar Pradesh,
India, Contact No. +91 7567222309, E-mail: drkshamagupta@gmail.com
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Mamidi P. et.al., Parimarshaneeyam of Charaka Indriya Sthana - An Explorative Study Int. J. Ayu. Alt. Med., 2019; 7(5): 183-191
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REVIEW ARTICLE
PARIMARSHANEEYAM OF CHARAKA INDRIYA STHANA – AN EXPLORATIVE STUDY
Abstract:
YAVAGU (GRUEL)
Samhitas are considered as highly codified store houses of ancient wisdom. The Charaka samhita (an ancient Indian textbook of
medicine written thousands of years before), as available in its present form consists 8 ‘Sthanas’ (sections) and ‘Indriya sthana’
(section which deals with prognosis) is one among them. Indriya sthana deals with various fatal signs and symptoms which denote
imminent death and prognostication of life expectancy in the patients who are at end-of-life stages. Indriya sthana of Charaka
samhita contain 12 chapters and ‘Parimarshaneeyam indriyam’ is the 3rd chapter of Indriya sthana. ‘Parimarshaneeyam indriyam’
chapter contains various arishta lakshanas (fatal signs and symptoms which indicates imminent death) which can be elicited by
touch or palpation. Various clinical conditions (surgical and ophthalmological) and methods of diagnosing them by using palpation
were described in this chapter. The present study is aimed to explore the contents of this chapter and to analyse their role and
potential in clinical prognostication. Concepts such as medical ethics & etiquette regarding palpation are mentioned in this
chapter. Various pathological technical terms like ‘Aspandanm’ (absence of pulsations), ‘Darunatvam’ (stony hardness or
induration), ‘ Kharatvam’ (sclerosis or licehnification or scaling), ‘Asat bhava’ (atrophy), ‘Sramsa’ (subluxations), ‘Bhramsha’
(dislocations), ‘Swedanubandha’ (hyperhidrosis), ‘Sweda stambha’ (anhidrosis), ‘Mamsa shonita veeti bhava’ (cachexia/ sarcopenia
/atrophy), ‘ Sheetam’ (hypothermia), ‘Stabdham’ (rigidity / spasticity), ‘Chyuta’ (prolapse), and ‘Skanna’ (clotting) etc are
mentioned in this chapter along with arishta lakshanas related to eyes which are having profound clinical importance. The
concepts mentioned in this chapter needs to be standardized. Further research works are required to substantiate the opinions
or claims mentioned in this chapter.
symptoms which indicates imminent death) which can to the patient while doing palpation.
be elicited by touch or palpation. The word
‘Parimarshana’ denotes touch or palpation; hence the ‘pirmzRyeÖa=Nyen’
Mamidi P. et.al., Parimarshaneeyam of Charaka Indriya Sthana - An Explorative Study Int. J. Ayu. Alt. Med., 2019; 7(5): 183-191
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communication and is the study of touch and of the are associated with an extremely high mortality rate.
characteristics that are involved, including the gender Hypothermia is one of the most important prognostic
and age of the communicators (physician and patient), factors for poor outcome in trauma patients. Old age,
duration, location, action (speed and manner of comorbid conditions, and comatose state are associated
approach that precede the touch), intensity (pressure with an increased incidence of spontaneous
exerted), frequency and sensations caused by the touch hypothermia in patients with brain injury. [6] Two
(degrees of comfort and discomfort generated in the important cutaneous microvascular disorders that may
communicating agents). Another aspect when studying be related to altered reflex or local thermoregulation
tacesics is related to ‘where’ the person is touched (it are ‘Raynaud phenomenon’ and ‘Erythromelalgia’.
influences the degree of embarrassment), context, age, Reduced vascular density, impaired local vasodilator
intention and cultural diversity. When performing responsiveness, and reflex sympathetic dysfunction are
palpation, the physician should remember that, responsible for above two conditions. [7] Decreased
misinterpretations may occur which may cause local temperature also suggests ischemia or reduced
embarrassment and discomfort. Therefore, personal blood flow to that part.
factors, communication skills, attitudes, beliefs, values
and even technical knowledge must be considered ‘m&dUna< daé[Tvm!’
while doing palpation. [4] Before doing palpation ‘Mrudunaam darunatvam’ [Verse 4] [3]
physician should be alert regarding various factors like Those structures or body parts which are soft in nature
religious or cultural background, gender and part of the becoming hard or firm on palpation (hard or firm
body, education level and patient’s position in society consistency) is considered as arishta. For example, on
etc. palpation, hard consistency of liver denotes primary or
secondary malignancy of liver. On palpation, ‘hard but
‘stt< SpNdmanana< zrIrdezanamSpNdnm!’ yielding consistency’ is found in chondroma, ‘bony
Satatam ---- aspandanam [Verse 4] [3] hard yielding consistency’ denotes osteoma, ‘stony
Diminished or absent pulses in the various arteries hard consistency’ denotes carcinoma and ‘variable
examined may be indicative of impaired blood flow consistency’ denotes malignancy either carcinoma or
due to a variety of conditions. All pulses (brachial, sarcoma.
radial, and ulnar arteries of the upper extremities and
the femoral, popliteal, dorsalis pedis, and posterior ‘ðú[ana< orTvm!’
tibial arteries of the lower extremities) should be ‘Slakshnaanaam kharatvam’ [Verse 4] [3]
palpated bilaterally. The aorta and temporal arteries The word ‘Kharatva’ denotes various pathological
also can be palpated. Diminished pulses are ominous in conditions like fibrosis or sclerosis or hyperplasia or
children and they suggest cardiac failure or shock. patches or lichenification or scaling etc. Fibrosis is the
Absent or weak pulses in the arm may result from a formation of excess fibrous connective tissue in an
coarctation of the aorta. If the pulse is of low volume organ or tissue. Sclerosis is the stiffening of a tissue or
and amplitude (hypokinetic), it suggests low cardiac anatomical structure, caused by a replacement of the
output in shock or myocardial infarction. Idiopathic normal organ-specific tissue with connective tissue.
dilated cardiomyopathy, valvular stenosis, pericardial Hyperplasia is enlargement of an organ or tissue caused
tamponade, or constrictive pericarditis can also cause by an increase in the reproduction rate of its cells,
low cardiac output and small peripheral pulses. generally seen in the initial stages of cancer. Rough or
Absence of a pulse could also suggest an occlusion by scaly or patchy skin is observed in various skin
thrombus, embolus, or dissection. Unilateral absence conditions like chronic eczema, secondary syphilis,
of a pulse can aid in the diagnosis of a dissected aortic leishmaniasis, onchodermatitis, icthyosis and
aneurysm. Intermittent loss of pulse can be seen in tuberculoid leprosy etc. Rough skin is also seen in
cardiac tamponade and cardiac herniation. [5] hypothyroidism (myxoedema). ‘Kharatva’ also
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muscle and adipose tissue loss. Cachexia correlates hypovolemia, left ventricular failure, and mitral
with poor performance status and quality of life with a stenosis. [15]
high mortality rate in cancer patients. [10] According to
‘dNta> pirkI[aR> ñeta jatzkRra>’
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porosity caused by demineralization gives the lesion a process, or peripheral neuropathies. The peripheral
milky appearance which can be found on the smooth neuropathies can be broadly subdivided into the
surfaces of teeth. White spot lesions are also seen in myelinopathies and axonopathies. Sensory
fluorosis, hypomineralization, hypomaturation and neuronopathy (ganglionopathy) is seen in cancer
hypoplasia. [16] Chronic periodontitis is an infectious (paraneoplastic), idiopathic sensory neuropathy and
inflammatory disease caused by the bacteria of the HIV related neuropathy. Most of the patients with
dental plaque, resulting in the progressive destruction sensory loss associated with peripheral neuropathy
of the tissues that support the teeth. Plaque (e.g., cryptogenic sensory polyneuropathy or CSPN
accumulation (pirkI[aR #it mlilPta), calculus formation and diabetes) clinically show diminished light touch,
(jatzkRra), gingival redness and swelling, gingival
pin, and vibration sensation. [20] Hypoesthesia is also
seen in tabes dorsalis, parietal lobe lesions, Brown-
bleeding and suppuration may occur spontaneously in
sequard syndrome (BSS) and leprosy.
periodontitis. Chronic periodontitis is associated with
coronary heart disease (CHD), atherosclerotic ‘%dre isra> àkazer|! ZyavtaènIlhirÔzuKla va’
cardiovascular disease or its sequelae, COPD, bacterial
‘Udare siraaha ---- shuklaa vaa’ [Verse 6] [3]
pneumonia, and rheumatoid arthritis. Chronic
Enlarged tortuous superficial abdominal veins are seen
periodontitis is associated with head and neck
in various conditions like IVCS (inferior vena cava
squamous cell carcinoma (HNSCC), especially in the
syndrome), hepatic sarcoidosis, portal hypertension,
oral cavity, followed by the oropharynx and larynx. A
cirrhosis of liver with caput medusae, alcoholic liver
significant association was found between the history
disease, Budd chiari syndrome, and spider nevi in
of periodontitis and risk of developing lung, kidney,
hepatitis C etc.
pancreas, and hematological cancers. However, the
most consistent increased risk was noted in the studies ‘noa> vItma<szaei[ta> pKvjaMbvv[aR> ’
of oral and esophageal cancers and periodontal disease. ‘Nakhaa --- varnaaha’ [Verse 6] [3]
Gastric and pancreatic cancers had an association with Discoloration of nails (purple or blue or black) along
periodontitis in most of the studies. Patients with with atrophy denotes various underlying systemic
periodontal disease were more likely to have poorly diseases. Cyanosis may manifest as blue or purple
differentiated oral cavity squamous cell carcinoma discoloration of the nail bed and digits due to lower
(SCC). [17] oxygen saturation causing accumulation of
deoxyhemoglobin in the small blood vessels of the
‘púmai[ jqabXdain’ extremities. Central cyanosis is caused by congenital
‘Pakshmaani jataabaddhaani’ [Verse 6] [3] heart diseases whereas peripheral cyanosis is caused by
Matted eyelashes can be seen in ‘Blepharitis’. Matted vasoconstriction and diminished peripheral blood flow
eyelashes may also denote ‘Seborrheic deramtitis’ due to exposure to cold, shock, congestive cardiac
(SD). SD often presents as well-defined erythematous failure, and peripheral vascular disease. Melanonychia
plaques with greasy-looking, yellowish scales of (brown or black lines on nails) may be due to an
varying extents in regions rich in sebaceous glands, underlying melanocytic nevus or malignant melanoma,
such as the scalp, the retro-auricular area, face hemochromatosis, malnutrition, thyroid disease,
(nasolabial folds, upper lip, eyelids and eyebrows), and smoking, HIV infection, and Addison's disease. [21]
the upper chest. SD is more prevalent in immune- Vasoreactive individuals often have a perniotic
compromised patients such as HIV/AIDS patients and circulation, especially at the hands and feet
patients with lymphoma. SD is also associated with (acroperniosis). At rest, a perniotic circulation is
neurological disorders and psychiatric diseases, such as characterized by a cold purplish (pKvjaMbvv[R) periphery.
Parkinson’s disease (PD), neuroleptic induced In perniosis, cold can cause vasoconstriction severe
parkinsonism, tardive dyskinesia, traumatic brain enough to induce temporary distal ischaemia. This
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injury, epilepsy, facial nerve palsy, spinal cord injury, prolonged vasoconstriction would be able to cause
depression, chronic alcoholic pancreatitis, hepatitis C prolonged relative hypoxia at the periphery which may
virus and in patients with congenital disorders such as cause pulp atrophy (vItma<szaei[t) and secondary
Down syndrome. [18]
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cavitation caused by phalanx flexion, and thereby Raynaud phenomenon, brain injury or severe trauma,
attenuates or eliminates the audible ‘pop’ or cracking Wernicke encephalopathy, Multiple sclerosis,
of the knuckles. Articular and other musculoskeletal paroxysmal hypothermia with hyperhidrosis, severe
manifestations of secondary hyperparathyroidism have infections and endocrinal abnormalities etc), [6&7]
been a longstanding concern for patients with chronic ‘StBxm!’ (Hypertonia or rigidity or spasticity etc seen in
kidney disease. [23] Benign joint hypermobility diseases of basal ganglia or extrapyramidal system
syndrome (BJHS) is characterized by generalized joint such as parkinsonism, Huntington’s disease, dystonia,
laxity and hypermobility. Hypermobility may occur in Tourette syndrome, Wilson’s disease, blepharospasm,
several different connective tissue disorders including and other conditions like fibromyalgia,
Marfan syndrome, Ehlers–Danlos syndrome (EDS), hypothyroidism, tetanus, epilepsy, and frozen shoulder
and osteogenesis imperfecta, Down syndrome, etc), ‘daé[m!’ (Stony hardness seen in carcinoma or
metabolic disorders (homocystinuria and
hyperlysinemia) and Juvenile rheumatoid arthritis. [24] sarcoma) and ‘vItma<szaei[tm!’ (Pulmonary, cardiac and
cancer cachexia or atrophy seen in carcinoma and
‘sNxIna< ö<sæ<zCyvnain’ various other chronic debilitating diseases) occurring
‘Sandheenaam --- chyavanaani’ [Verse 4] [3] spontaneously (without any visible or known reason or
ö<s> mnaGgmnm! , æ<zStu sudUraxaegmnm!, xavn< tu paZvRtae gmnm!. cause) at various parts of the body (feet, legs, thighs,
buttocks, abdomen, spine, ribs, neck, hands, palate, lips
‘Sramsaha --- gamanam’ [Chakrapani, Verse 4] [3]
and forehead) denote Arishta lakshana’s.
The word ‘ö<s>’ denotes subluxation (subluxation of
‘tSy cet! p&wKTven guL) janu v<][ gud v&;[ meF+na_y<sStn mi[k pzuRka hnu
temporomandibular joint or TMJ), ‘æ<z>’ denotes
naiska k[aRi] æU zŒadIin öStain VyStain Cyutain Swane_y> SkÚain va
dislocation (shoulder dislocation) and ‘xavn<’ denotes
Syu>’
deviation (ulnar deviation in rheumatoid arthritis) or
‘Tasya chet --- vaa syuhu’ [Verse 5] [3]
varus or valgus deformities (genu valgum & genu
Manifestation of various pathological features
varum) of various joints. Generalized joint laxity is
characterized by increased length and elasticity of (spontaneously without any known cause) like, ‘öSt’
normal joint restraints, resulting in an increased range (subluxation or dislocation or laxity or flaccidity), ‘VySt’
of motion and increased distractibility. This (altered or dispersed or seperated), ‘Cyut’ (prolapsed or
hyperlaxity can be congenital and acquired. Congenital fallen or dropped), and ‘SkÚ’ (trickled down or emitted
hyperlaxity is caused by connective tissue disorders,
or thickening or clotting) at various body parts (ankle,
such as Ehlers-Danlos syndrome, Marphan syndrome,
knee, inguinal, anus, testicles, penis, umbilicus, wrist,
osteogenesis imperfecta, and benign hypermobility
breast, shoulder, ribs, jaw, nose, ears, eyes, eyebrows
syndrome. Acquired joint hyperlaxity is seen in
and temple region) indicates or denote Arishta (Table
athletes (swimmers, gymnasts, pitchers, etc). The term
1).
“multidirectional instability” (MDI) is defined as
symptomatic involuntary instability of the ‘tSy ce½]u;I àk&ithIne ivk&ityuKte ATyuiTpi{fte Aitàivòe Aitijüe Aitiv;me
glenohumeral joint in more than one direction (anterior
AitmuKtbNxne Aitàs&te sttaeiNmi;te sttinimi;te inim;aeNme;aitàv&Tte
and/or posterior, and inferior). [25] Hypermobility is
seen in various conditions like ‘Benign joint ivæa<td&iòke ivprItd&iòke hInd&iòke VyStd&iòke nkulaNxe kpaetaNxe Alatv[eR
hypermobility syndrome’ (BJHS), Marfan syndrome, k&:[pItnIlZyavtaèhirthirÔzuKlvEkairka[a< v[aRnamNytmenaitPlute va
‘Ehlers–Danlos syndrome’ (EDS), and osteogenesis Syata< tda prasuirit iv*at!’
imperfecta, ‘Down syndrome’, metabolic disorders
‘Tasya chet ---- vidyaat’ [Verse 6] [3]
(homocystinuria and hyperlysinemia) and ‘Juvenile
Various aristha lakshana’s related to netra (eye) are
rheumatoid arthritis’. [24]
explained in the above verse (Table 2).
188
‘tSy cet! pirm&Zyman< p&wKTven pad j<"aeé iS)gudr paZvR p&óei;ka pai[ ¢Iva
CONCLUSION:
taLvaeó llaq< iSvÚ< zIt< StBx< daé[< vItma<szaei[t< va Syat! ’ Some medical ethics & etiquette regarding palpation
‘Tasya chet --- vaa syaat’ [Verse 5] [3]
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‘Swedanubandha’ (hyperhidrosis), ‘Sweda stambha’ which are having profound clinical importance. The
(anhidrosis), ‘Mamsa shonita veeti bhava’ (cachexia / concepts mentioned in this chapter needs to be
sarcopenia / atrophy), ‘ Sheetam’ (hypothermia), standardized. Further research works are required to
‘Stabdham’ (rigidity / spasticity), ‘Chyuta’ (prolapse), substantiate the opinions or claims mentioned in this
and ‘Skanna’ (clotting) etc are mentioned in this chapter.
chapter along with arishta lakshanas related to eyes
k[R (Ear) Protruding or bat ears / Cup shaped or low-set ears in Down syndrome / Cauliflower ears / Mastoid
abscess / Ear tumours
Ai] (Eye) Exophthalmos (in Graves’ disease) / Enophthalmos / Squint / Retro orbital or orbital tumours /
Ophthalmoplegia etc
æU (Eyebrow) Madarosis / Facial nerve palsy / Horner syndrome / Myasthenia gravis / Brow tumours like
pleomorphic adenoma etc
zŒ (Temple region) Multiple venous malformations with phleboliths at temples / Giant cell arteritis / Intra cranial abscess
/ Temporal osteitis or myositis / Multiple myeloma / Maxillary carcinoma etc
ATyuiTpi{fte Graves ophthalmopathy / Retro orbital or orbital tumours / Orbital cellulitis / Severe glaucoma etc
(Exophthalmos)
Aitàivòe Horner’s syndrome / Marfan syndrome / Duane’s syndrome / Silent sinus syndrome / Phthisis bulbi /
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Atrophy etc
(Enophthalmos)
Aitijüe Squint or Strabismus / Acquired paralytic strabismus in Diabetes / Graves disease / Guilain-Barre
syndrome (GBS) / Stroke / Brain tumours / Hydrocephalus / Cerebral palsy etc
(Crossed eyes)
Aitiv;me Irregular astigmatism / Keratoconus / Central cornea islands / Map-Dot-Fingerprint dystrophy (MDF) /
Cysts or tumours in one eye etc
(Uneven)
AitmuKtbNxne Ophthalmoplegia / Myasthenia gravis / GBS / Kearns-Sayre syndrome / Foville’s syndrome / Internuclear
ophthalmoplegia / Multiple sclerosis / Parinaud’s syndrome / Stroke / Wernicke encephalopathy /
(Plegia)
Cavernous sinus syndrome / Paralysis of cranial nerves (CN III, IV & VI) etc
Aitàs&te Epiphora / Allergic or infective conjunctivitis / Trichiasis / Ectropion / Keratitis / Corneal ulcers /
Chalazion / Bell’s palsy / Dacrocystitis / Punctal eversion / Stevens-Johnson syndrome / Neoplasms etc
(Watering eyes)
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sttaeiNmi;te Lagophthalmos / Symblepharon formation / Acquired oculomotor synkinesis / Exophthalmos / Facial palsy
/ Ectropion etc
(Lagophthalmos)
sttinimi;te Ptosis / Ocular myopathies / Horner’s syndrome / Cranial nerve palsy (CN III) / Myasthenia gravis /
Stevens-Johnson syndrome / Atrophy etc
(Drooping / Ptosis)
inim;aeNme;aitàv&Tte Corneal abrasion / Trichiasis / Inflammatory or allergic conditions of eyes / Benign essential
blepharospasm / Meige syndrome / Tics etc
(Excessive blinking)
ivæa<td&iòke Nystagmus / Cataracts / Strabismus / Meniere’s disease / Multiple sclerosis / Stroke / B 12 or Thiamine
deficiencies / Brain tumours etc
(Dancing eyes)
ivprItd&iòke Metamorphopsia / Age related macular degeneration / Astigmatism / Keratoconus / Glaucoma / Migraine
/ Epiretinal membrane etc
(Distorted vision)
hInd&iòke Central retinal artery or vein occlusion / Ischemic optic neuropathy / Vitreous haemorrhage / Retinal
detachment / Acute glaucoma / Transient ischemic attack / Tumours or infections in brain etc
(Defective vision)
VyStd&iòke Seizures / Multiple sclerosis / Superior oblique myokymia / Stroke / Meningitis / Brain tumours / Meniere’s
disease etc
(Oscillopsia)
nkulaNxe Congenital high myopia / Tapeto-retinal degeneration / Glaucoma / Cataract / Diabetes / Retinitis
pigmentosa / Vitamin A deficiency etc
(Nyctalopia)
kpaetaNxe Cone dystrophy / Achromatopsia / Central lenticular opacity / Central cataracts / Cancer associated
retinopathy (CAR) etc
(Hamarlopia)
Alatv[eR Chemosis / Various inflammatory & allergic conditions / Acute conjunctivitis / Sub conjunctival
haemorrhage / Glaucoma etc
(Bloodshot eyes)
ANy vEkairk v[aRin 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
(Eye discoloration)
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