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MARMAS IN THE HASTA (HAND) W. S. R. TO THE SURFACE AND REGIONAL ANATOMY (CADAVER DISSECTION)” VIJAYNATH.V, SHAREERA RACHANA, S.D.M. COLLEGE OF AYURVEDA, UDUPI

MARMAS IN THE HASTA (HAND) W. S. R. TO THE SURFACE AND REGIONAL ANATOMY (CADAVER DISSECTION)” VIJAYNATH.V, SHAREERA RACHANA, S.D.M. COLLEGE OF AYURVEDA, UDUPI

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  • “A COMPREHENSIVE STUDY OF MARMAS IN THE HASTA (HAND) W. S. R. TO THE SURFACE AND REGIONAL ANATOMY (CADAVER DISSECTION)” BY DR.VIJAYNATH.VDissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore. In partial fulfillment of the requirements for the degree of DOCTOR OF MEDICINE (M.D) In SHAREERA RACHANA UNDER THE GUIDANCE OF DR.U.GOVINDA RAJU M.D (AYU), M.A (SANSKRIT), P.G.C.R, C.G.L Professor & HOD Dept of P.G. studies in Shareera Rachana. DEPARTMENT OF POST GRADUATE STUDIES IN SHAREERA RACHANA S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574118 2010 -11
  • DEDICATED TO MY FAMILIY FRIENDS & TEACHERS
  • Abbreviations ….    List of Abbreviations used A MüÉå : Amara kosha A.¾û. : Ashtanga Hrudaya A.¾û.zÉÉ : Ashtanga Hrudaya Shareera Sthana A.¾û.ÌlÉ : Ashtanga Hrudaya Nidana Sthana cÉ.xÉÇ : Caraka Samhita cÉ.ÍcÉ : Caraka Samhita Chikitsa Sthana cÉ.ÌlÉ : Caraka Samhita Nidana Sthana cÉ.ÌuÉ : Caraka Samhita Vimana Sthana cÉ.zÉÉ : Caraka Samhita Shareera Sthana cÉ.xÉÔ : Caraka Samhita Sootra Sthana cÉ¢ü : Cakrapani pÉÉ.mÉë : Bhavaprakasha U.ÌlÉ : Raja Nighantu zÉ .Mü. SìÓ. : Shabdha Kalpa Druma uÉÉ.uÉÉsÉ : Vachaspatyam,Volume. zÉÉ xÉÇ mÉë : Sharangadhara Samhita Prathama khanda xÉÑ xÉÇ : Susruta Samhita xÉÑ.ÌlÉ : Susruta Samhita Nidana Sthana xÉÑ zÉÉ : Susruta Samhita Shareera Sthana xÉÑ xÉÑ : Susruta Samhita Sutra Sthana Fig. : Figure A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)  Page III 
  • Abstract….    ABSTRACT The advent of all branches of science and technology is aimed at developingthe living standards of man. The language of any science lies in its ability to providesolutions to problems with clarity. It includes not only in inventing new things butalso documenting everything in a precise and standardized nomenclature. Marma is one of the most widely described and at the same time one of themost debated topics in our samhitas. Acharyas have agreed that the total number ofmarmas present in our shareera are 107.Out of the 107 mentioned,11 are present ineach extremity and 5 in each Hasta(hand).They are (i) KSHIPRA (ii)TALAHRUDAYA (iii) KURCHA (iv) KURCHASHIRA and (v)MANIBANDHArespectively. Though the description and the viddha lakshana’s of these marmas areavailable in the Samhitas, the structures like muscles, ligaments, tendons, arteries,veins, nerves etc. present in these regions, their anatomical description and theirapplied aspects needs more clarification. So a standardization of the nomenclature used by the Acharyas pertaining tothese marmas in comparison to the nomenclature of modern anatomy is essential.Hence to fulfill the lacuna in this subject, the present work will be carried out.ie “Acomprehensive study of Marmas in the Hasta(Hand) w.s.r.to the surface and regionalanatomy (cadaver dissection).Key Words:Hasta, Hasta marma, Kshipra, Talahrudaya, Kurcha, Kurchashira, Manibandha.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page IV  
  • Index….    LIST OF CONTENTS Sl. No. Contents Page No. 1. Introduction 1-2 2. Objectives 2-3 3. Review of literature 4-67 4. Methodology 68 5. Observation 69-73 6. Figures 74-80 7. Discussion 81-87 8. Conclusion 88-89 9. Summary 90-91 10. Reference 92-101 11. Bibliography 102-115 A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page V  
  • Index….     LIST OF TABLESTable No. Description Page No. 1 Structural classification of marma 9 2 Classification of mamsapeshi according to shadangatwa 10 3 List of mamsapeshi in upper limb 11 4 List of mamsamarma 11 5 Classification of Sira according to shadangatwa 12 6 Classification of AvedhyaSiras according to shadangatwa 13 7 List of avedhyasiras in a limb 13 8 List of Siramarma 14 9 Classification of Snayu according to shadangatwa 15 10 List of Snayu in upper limb 15 11 List of Snayumarma 16 12 Classification of Sandhi according to shadangatwa 16 13 List of Sandhi in upper limb 17 14 List of Sandhimarma 18 Classification of asthi according to shadangatwa as per 15. 19 SusrutaSamhita 16 List of asthi in upper limb as per SusrutaSamhita 19 Classification of asthi according to shadangatwa as per 17 20 CarakaSamhita A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page VI   
  • Index….    Table No. Description Page No. 18 List of asthi in Hasta as per CarakaSamhita 20 19 List of Asthimarma 21 20 List of Dhamanimarma 21 21 Classification of marma according to shadangatwa 22 22 Classification of marma according to prognosis 23 23 List of Sadyopranaharamarma 23 24 List of Kalantarapranaharamarma 24 25 List of Vaikalyakaramarma 25 26 List of Rujakaramarma 26 27 List of Swa-Panitalamarmas 27 28 List of marmas having Ardhangulapramana 28 29 List of marmas having one Ekangulapramana 29 30 List of marmas having Dwayangulapramana 29 31 List of marmas having Tryangulapramana 29 32 List of Dwisankhyamarmas 30 33 List of Chatursankhyamarmas 31 A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page VII  
  • Index….    LIST OF FIGURES Figure No. Description Page No. 1A. Kshipra (Palmar Aspect) 74 1B Kshipra (Dorsal Aspect) 74 2A Talahrudaya (Palmar Aspect) 74 2B Talahrudaya (Dorsal Aspect) 74 3A Kurcha (Palmar Aspect) 75 3B Kurcha (Dorsal Aspect) 75 4A Kurchashira (Palmar Aspect) 75 4B Kurchashira (Dorsal Aspect) 75 5A Manibandha (Palmar Aspect) 75 5B Manibandha (Dorsal Aspect) 75 6 Anterior view of palm with vessels and nerves 76 7 Deep palmar arch and its branches 76 8 Surface anatomy of hand 77 9 Surface anatomy of hand (Bony Landmarks) 77 10 Muscles of Extensor Compartment 78 11 Extensor Digitorum 78 12 Extensor DigitiMinimi 78 13 Extensor Carpi Ulnaris 79 A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page VIII  
  • Index….    Figure No. Description Page No. 14 Flexor Tendons 79 15 Abductor PollicisBrevis 79 16 First dorsal interossei 80 17 Dissected Hand - Palmar surface 80 18 Dissected Hand - Palmar surface 80 A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page IX  
  •                                  Introduction…..  INTRODUCTION The urge of mankind to fulfill its daily needs and the struggle for better livingstandards is very much evident in the history of evolution. ‘Necessity is the mother ofinvention’ and because of it the various methods and instrumentation to fulfill hisdaily needs are getting advanced. Medical science is such an arena that has developedby leaps and bounds in the last century. The eradication of small pox andpoliomyelitis are commendable ones. Our great science of life “Ayurveda” has withstood the test of time in aglorious manner. The manuscripts that are believed to have been written 2500 yearsago contain medications and treatment modalities that are potent even in the 21stcentury man, whose lifestyle has entirely changed compared to the ancient one. It isthe eternal “TRIDOSHA” sidhantha that makes our branch of medical sciencepeerless. In those times a vaidya had to deal with more exigencies during the time ofwar and it might have been the reason why marma was given utmost importance inour samhitas.Marma are the vital points when afflicted can cause death and needutmost care while performing surgical proceedures.The details of marma are presentnot only in our scriptures but also in Vedas ,Upanishads,Itihaasa and Puranaas.Apartfrom our samhitas,Roman and greek mythology mention warriors who guarded theircardinal points in the body with metal shields. It is intelligence, skill and cognition that make man the superior being onearth. Skill of the human lies mainly in his efficiency to perform various actions withhis hand. Acharya Susruta mentioned that “Hastameva pradhaanatamam yantranam”(which means hand is the most important instrument). Regional anatomy considers the organization of human body as segments ormajor parts based on form and mass. Surface anatomy provides knowledge of whatlies under the skin and what surfaces are perceptible to touch (palpable) in the livingbody at rest and in action. Susruta and Vagbhata have mentioned five marmas in the region of hand and ahumble effort is made here in interpreting and standardizing the terminology used inthe samhitas with that of modern anatomy.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 1  
  • Objectives….   OBJECTIVES 1. To make the comprehensive and the conceptual study on the marmas in the Hasta (hand) as mentioned in texts, in the view of surface and regional anatomy described in the contemporary medical science. 2. To study the marmas in Hasta (Hand) with modern surface and regional anatomy by cadaver dissection.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)  Page 2  
  • Objectives….   PREVIOUS WORK DONE 1. Gupta.S.K.-has done work on “Kshipra Marma ka vivechatmaka adhyayana”, 1991,National Institute of Ayurveda, Jaipur, Rajasthan University. 2. Borkar B.A. –has done work on “Urdhva-Shakhagata Vaikalyakara Marma: Ek Rachanatmaka Adhyayana” ,1997, Govt.Ayurvedic College, Nagpur, Nagpur University. 3. Agrawal Nidhi-has done work on”Shaka-Shareera: A study based on dissection of cadavers’ w.s.r to applied anatomy”, 1999, National Institute of Ayurveda, Jaipur,Rajasthan University. 4. Sharma Shyoram-has done work on”Marma-Shareera Vishayantargata Urdhva- Shakhagata Marmon ka Rachanatmaka Adhyayana”, 2003, National Institute of Ayurveda, Jaipur,Rajasthan University.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)  Page 3  
  • Historical review…  HISTORICAL REVIEW The evidence of marma shareera has been found in many our ancientscriptures like Vedas and Upanishads. VEDIC PERIOD Vedas are considered as the oldest compiled documents of hymns. They arebelieved to have been compiled 5000 years ago. Rig Veda, the oldest and the foremostone has many medicinal plants described in it. In Rig Veda reference of the wordslike varman and drapi, which is some kind of body armor or corselet to protect thebody from assault of enemy weapons. Also we find the reference of the term Kavachaor breast-plate for the protection1. Viswakarma’s sharpened (Ayudh) weapon for Indra, which was known asVajrah.Indra tormented Vratra Asura (demon) with the help of same by attacking vitalpoints2. They are certain unbelievable deeds attributed to Aswinidevas including plasticsurgery. They restored the mobility of Shayava whose leg was cut at three places3 andblessed the queen Visphala, the wife of Khela Rajah with metal legs when she lost herleg in the battlefield4. It is also mentioned that fire (Agni) was used as the ultimate weapon todestroy Marma5.MARMA IN UPANISHAD Plenty of material of anatomical interest is found in Chandagya Upanishad,Kshirakopanishad, and Garbhopanishad. There are 107 marmas described inGarbhopanishad6. MARMA IN ITIHAASA Marma have been referred in our itihaasa ie Ramayana and Mahabarata.Thearrow shot accidentally by Dasradh to the marma point of Shravan Kumar 7, slayingof Duryodhana by Bhima with a blow on the thigh during the mace battle 8, slaying ofA comprehensive study of marmas in the hasta (hand) w.s..r. to the surface and regional anatomy (cadaver dissection)Page 4  
  • Historical review… Lord Krishna by a hunter Jara in the foot and various references regarding the vitalityof marmas are encountered while reading the epics 9.SAMHITA KALA The description about Marma location and structures involved in Hastapradesha along with detailed explanation of Viddha lakshana, and diseases has beenexplained in almost all the classical texts written during Samhita kala. All Acharyasare accepted total number of Marmas is 107.CARAKA SAMHITA Acharya Caraka gave much importance to the Trimarmas these are Shira,Hridaya and Basti by keeping physician in mind. He also mentioned that according tothe surgeon point of view, total numbers of Marmas are 107 in Chikitsa sthana 26thchapter10.SUSRUTA SAMHITA Acharya Susruta gave much importance to Marma, he told detailed descriptionon Marma, their types, numbers, locations, symptoms if they injured in Shareerasthana 6th chapter11.DALHANA Dalhana, the commentator of Susruta Samhita explained about Marma inShareera sthana 6th chapter12.ASHTANGA SANGRAHA AND ASHTANGA HRUDAYA The reference of Marma is available in both the grantha’s, Vruddha Vagbhatamentioning about the Marma in 7th chapter and laghu vagbhata in 4th chapter ofshareera sthana respectively13,14. KASHYAPA SAMHITA Kashyapa accepted trimarma Shira Hrudaya and Basti as the view of Carakaand told these three Marma are Mahamarma in Shareera sthana 4th chapter15.A comprehensive study of marmas in the hasta (hand) w.s..r. to the surface and regional anatomy (cadaver dissection)Page 5  
  • Historical review… BHAVAPRKASHA Bhavaprakasha mentioned detailed description regarding Marma similar toSusruta in purva khanda garbha prakarana adhyaya16.MODERN PERIOD The surface and regional anatomy can be traced in various text books ofmodern medicine. Marma Vignana may be compared to the branch of Traumatology. Traumatology and its various aspects are closely related to the pre surgical,surgical and post surgical techniques. With the advent of industrial revolution andmachinery accidents involving motor vehicles and various instruments have nowbecome very common. As a result of that the techniques used in modern surgery havealso advanced and become painless compared to the ancient one.A comprehensive study of marmas in the hasta (hand) w.s..r. to the surface and regional anatomy (cadaver dissection)Page 6  
  • Review of Literature…. LITERARY REVIEWUTPATTI OF MARMA SABDA The origin of the word marma is seen in various texts as given below AMARAKOSHA explains that the word marma is derived from Sanskrit termmrunj-maranne or mru pranathyage.It means that which causes death or death likemiseries17. SHABDHAKALPADRUMA describes the word marma is derived from mrudhatu.Its meaning is explained as sandhisthanam or jeevasthanam18. VACHASPATHYA says that the word Marman is taken from mru dhatu,adding maneen prathyam Mru + Maneen=Maruman……………. Marman19. Etymologically each letter of the word Marma has got specific meaning.Ma-means prana or vayu, Repha denotes house or seat. Therefore marma means seatof Prana or vayu.DEFINITION OF MARMA Acharya Susruta has defined marma as the anatomical site where Mamsa, Sira,Snayu, Sandhi and Asthi meet together. Some experts are of the opinion that it doesnot mean that all the structures must be collectively present at the site.Prana dwells atthese sites and so they are important 20. Dalhana, the redactor of Susruta Samhita has opined that marma is one whichcauses death. The vital spots if injured can cause death 21. Narahari the author of Rajanighantu defined marma as the seat of life 22. Acharya Caraka has opined that it is the site of Chetana,so the sense of painwill be more in this region compared to other parts of the body 23. Ashtanga Hrudayakara has defined marma as the site where Mamsa, Sira,Snayu, Asthi, Sandhi and Dhamani confluence .He has also said that the sites whichare painful, tender and show unbearable throbbing after getting afflicted with aninjury should also be considered as Marma24. Arunadatta, the redactor of Ashtanga Hrudaya explains that it is called asmarma because injury to that particular part brings out miseries equivalent to death 25 . Bhavaprakasha has defined marma as the meeting place of Mamsa,Sira,Snayu,Asthi and Sandhi where Prana or life resides.He supports the opinion of Susruta 26 .A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 7
  • Review of Literature….All the above definitions show the importance and vitality of the Marma points. Anyinjury, trauma or disease affecting Marma will cause death or miseries equal to death.MARMA RELATION WITH PANCHAMAHABHUTA ANDTRIDOSHA SIDHANTA According to Ayurveda, Panchamahabhuta (Prithvi, Ap, Tejo, Vayu andAkasa) and Atma constitute the living body. The Panchamahabhoota samavaaya getscontacted with Shareera and atma.The chetana or atma is Nirvikara paramatma and itbecomes vikarayukta when it comes in contact with panchamahabootatmaka shareera. In a living being the state when the three doshas are functioning normally, theagnis, the dhatus and malas function accordingly and if its atma, indriya and mana arepleasant the state is defined as health27. In a healthy living being, the prana circulates all over the shareera without anyobstruction. The derangement of physiological and psychological aspects causeinterruption of normal circulation of prana and causes diseases.Prana is dependent onmarma points. Susruta has given a broad spectrum meaning to the word prana.The wholephysiological processes of our body are said to be done through the normalfunctioning of soma, maruta and theja.The whole mental caliber or manas have gotthree main gunas viz satwaguna, rajoguna and tamoguna. Agni, Soma, Vayu, Satwa, Rajah, Tamah, Bhuthatma and Panchendriyas arecalled Pranas28.It engulfs all basic factors that sustain life. Agni sustains life byparinamam, Soma by poshanam,Vayu by chalanam (conduct, regulate and integrateall functions).Satwah,Rajah,Tamah by converting themselves into manas.Panchendriyas sustain by sensory perceptions and bhutatmas by its animating nature.This is the crux of marma concept. Susruta classified marma into agneya, soumya and vayavya, which is alsoindirectly related with the tridosha.As agnitwa is predominant, the delicate avayavasdisintegrate easily. Soma by its sthira and sheeta guna resists the destructive action ofAgni.Vayu causes severe pain.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 8
  • Review of Literature….CLASSIFICATION OF MARMAAll the 107 marmas 29 are classified into five different groups1. Structural classification (Asrayabhedena)2. Regional classification (Shadangabhedena/avayavabhedena)3. Prognostic classification/Traumatological classification (Vepathbhedena)4. Dimensional classification (Manabhedena)5. Numerical classification (Sankhyabhedena)1. STRUCTURAL CLASSIFICATION Susruta has opined that marma vasthu or constituting elememts of marma areMamsa, Sira, Snayu, Asthi and Sandhi.He classified marmas according to thepredominance of each structures present in that area such as Mamsa marma, Siramarma, Snayu marma, Asthi marma and Sandhi marma.He also said that apart fromthese 5 types no other types are found30. Susruta classified marma into five types.They are 11 mamsa marma,41 Siramarma,27 Snayu marma,8 Asthi marma and 20 Sandhi marma. According to Vagbhata’s classification there are 10 Mamsa marma,8 Asthimarma,23 Snayu marma,9 Dhamani marma,37 Sira marma and 20 Sandhi marma. Marma Sushruta Vagbhata Mamsa Marma 11 10 Sira Marma 41 37 Snayu Marma 27 23 Asthi Marma 8 8 Sandhi Marma 20 20 Dhamani Marma - 9 Total 107 107 Table 1-Structural classification of marma.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 9
  • Review of Literature….a) MAMSA MARMA Mamsa denotes mamsa peshi(muscles) in our body. It covers or conceals Sira,Snayu, Parva(joints of bone),Asthi and Sandhi.Muscles are strong structures that givestability to other structures also31. Mamsa peshis show much variation in size and shape according to the site ofattachment such as thick or thin, large or small, short or circular, short or long, hard orsoft, smooth or rough32. Modern medicine classified marma according to their1) Structure - Striated or Non striated2) Distribution- Skeletal, Cardiac and Visceral3) Control- Voluntary or Involuntary Susruta says that there are 500 mamsa peshi present in the shareera,out ofthese 400 are in the Sakhas(extremities),66 in Koshta(trunk) and 34 in the greeva andabove(Head and neck).According to Vagbhata,there are 40 in the greeva and aboveand 60 in koshta33. PRADESHA SUSRUTA VAGBHATA GREEVA PRATURDHWAM(HEAD&NECK) 34 40 KOSHTA (TRUNK) 66 60 SAKHA (EXTREMITIES) 400 400 TOTAL 500 500 Table 2- Classification of mamsa peshi according to shadangatwa.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 10
  • Review of Literature…. MUSCLES OF ONE LIMB SUSRUTA VAGBHATA HASTANGULI 15 15 PRAHASTA 10 10 HASTATALA 10 10 HASTASYA UPARI 10 10 MANIBANDHA 10 10 PRAPANI (b/wMANIBANDHA&KURPARA) 20 20 KURPARA 5 5 PRABAHU 20 20 TOTAL 100 100 Table 3-List of mamsa peshi in upper limb Susruta described 11 mamsa marmas.They are 4 Talahrudaya, 4 Indrabasti, 2Stanarohita and 1 Guda marma34. Vagbhata mentioned 10 only. He included Guda marma in Dhamani Marmagroup35. SUSRUTA No. VAGBHATA No. TALAHRUDAYA 4 TALAHRUDAYA 4 INDRABASTI 4 INDRABASTI 4 STANAROHITA 2 STANAROHITA 2 GUDA 1 TOTAL 11 10 Table 4-List of mamsa marmaIf an injury to the mamsa marma occurs it will lead to continuous bleeding, bloodresembling water in which meat is washed, pallor of skin, loss of function of senseorgans and instant death 36.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 11
  • Review of Literature….B) SIRA MARMA “Saranath sira”.Anything that flows is termed as Sira37. This is the basicdefinition of Sira according to Caraka. According to Susruta Siras are 700 in number. The functions of siras areconstant nourishment of entire body, keeping moistened to perform actions such asflexion, extension, similar to large field nourished by channels of water. Theirspreading is like the ribs in a leaf 38.Nabhi is their moola (site of origin) and from herethese spread upwards downwards and sideways. The arteries carry nutrients and oxygen to entire body constantly and the veinsremove the waste products. The distribution of vessels can be compared with that ofribs spreading on a leaf and its function with that of small water channels in the fieldirrigating corps. All the siras are connected to the nabhi and it is said as the seat of prana.Thesiras surrounds the nabhi as the spokes of a wheel 39. Susruta and Vagbhata included Nabhi in the Sadyopranahara group. Out of the 700 siras mentioned 400 are in the Sakha (extremities), 136 in theKoshta (trunk) and 164 in Murdha(head and neck) 40. PRADESHA NUMBER OF SIRAS SAKHA (EXTREMITIES) 400 KOSHTA (TRUNK) 136 MURDHA (HEAD AND NECK) 164 TOTAL 700 Table 5- Classification of Sira according to shadangatwa Out of the 700, there are 98 siras that are avedhya(should not be punctured).16of them are in the Sakha,32 in the Koshta and 50 in the murdha 41.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 12
  • Review of Literature…. PRADESHA NUMBER OF AVEDHYA SIRAS SAKHA (EXTREMITIES) 16 KOSHTA (TRUNK) 32 MURDHA (HEAD AND NECK) 50 TOTAL 98 Table 6- Classification of Avedhya Siras according to shadangatwa Out of the 16 avedhya siras, there are 4 of them in each limb. They areJaladhara, Urvi and Lohithaksha 42 . NAME OF AVEDHYA SIRA IN A LIMB TOTAL NUMBER JALADHARA 1 URVI 2 LOHITAKSHA 1 TOTAL 4 Table 7- List of avedhya siras in a limb Siras are classified into four types Vata vaha,Pitta vaha,Kapha vaha and Raktavaha.But Susruta has again clarified that siras do not carry Vata alone,Pitta alone orKapha alone. These four siras (Chaturvidha siras) in the body found situated generallyin the sites of marma.They maintain the body by nourishing Snayu, Asthi, Mamsa andSandhi 43. Susruta has mentioned the presence of 41 Sira marmas while Vagbhata hasmentioned only 37.Sringataka, Apasthambha and Apanga Marmas are classified asSira marma by Susruta but Vagbhata has classified these under Dhamani and Snayugroups’ respectively.Kakshadhara and Vitapa marma are classified under Sira marmaby Vagbhata but Susruta has included them in the Snayu group 44&45. If the sira marma gets injured it will lead to continuous bleeding of thick bloodthat too in large quantity. From this thirst, giddiness, dyspnoea, delusion and hiccupwill manifest leading to death 46.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 13
  • Review of Literature…. TOTAL TOTAL Sl.No. SUSRUTA Sl.No. VAGBHATA No. No. 1 NEELA 2 1 NEELA 2 2 MANYA 2 2 MANYA 2 3 MATHRUKA 8 3 MATHRUKA 8 4 STHAPANI 1 4 STHAPANI 1 5 PHANA 2 5 PHANA 2 6 STANAMOOLA 2 6 STANAMOOLA 2 7 APALAPA 2 7 APALAPA 2 8 HRUDAYA 1 8 HRUDAYA 1 9 NABHI 1 9 NABHI 1 10 PARSWASANDHI 2 10 PARSWASANDHI 2 11 BRUHATHI 2 11 BRUHATHI 2 12 LOHITAKSHA 4 12 LOHITAKSHA 4 13 URVI 4 13 URVI 4 14 SRINGATAKA 4 14 KAKSHADHARA 2 15 APANGA 2 15 VITAPA 2 16 APASTHAMBHA 2 16 TOTAL 41 TOTAL 37 Table 8- List of Sira marmaC) SNAYU MARMA Though Mamsa is one among the saptadhatus, Snayu has been mentioned asthe Upadhatu of Medho dhatu by Caraka 47. Susruta while detailing about Snayu has given a wonderful simily.He hasgiven a poetic verse stating that just like planks of wood when fastened by ropesbecome capable of carrying huge weights, similarly the various sandhis present in ourshareera become capable of weight bearing because of Snayu 48. These may be compared to ligaments and tendons in modern anatomy. Snayus are of 4 types.They are Prathanavathy, Vruttha, Prudhu and Sushira.Pratahanavathy are present in Sakhas (extremities) and Sandhis (joints). Vruttha are also called as Kandaras.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 14
  • Review of Literature…. Sushira are present in Amasaya, Pakwasayanta and Basti.Prudhu is present inParswa, Uras, Prushta and Shiras 49. The total number of Snayu is mentioned by Susruta as 900.Out of them 600are present in the 4 Sakhas (extremities), 230 in Koshta (trunk), 70 in GreevapratiUrdham (head and neck) 50. TOTAL NUMBER OF PRADESHA SNAYU SAKHAS (EXTREMITIES) 600 KOSHTA (TRUNK) 230GREEVA PRATYOORDHAM(HEAD & NECK) 70 TOTAL 900 Table 9- Classification of Snayu according to shadangatwa As mentioned above 150 snayus are present in each extremity. PRADESHA TOTAL NUMBER OF SNAYU HASTANGULI 30 HASTATALA KURCHA MANIBANDHA 30 PRAPANI 30 KURPARA 10 PRABAHU 40 KAKSHADHARA 10 TOTAL 150 Table 10- List of Snayu in upper limb Susruta has enlisted 27 snayu marmas whereas Vagbhata has 23.Susrutaincluded Vitapa, Kakshadhara and Vidhura in Snayu group but Vagbhata includedthem in Sira/Dhamani group.Susruta included Apanga in Sira marma whereasVagbhata considered it as a Snayu marma51&52. If snayu marma gets injured it will lead to severe convulsions, pain, difficultyin movements like riding, sitting etc. and may even lead to death 53.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 15
  • Review of Literature….Sl.No SUSRUTA TOTAL No. Sl.No VAGBHATA TOTAL No 1 ANI 4 1 ANI 4 2 KURCHA 4 2 KURCHA 4 3 KURCHASHIRA 4 3 KURCHASHIRA 4 4 KSHIPRA 4 4 KSHIPRA 4 5 AMSA 2 5 AMSA 2 6 BASTI 1 6 BASTI 1 7 UTKSHEPA 2 7 UTKSHEPA 2 8 VITAPA 2 8 APANGA 2 9 VIDHURA 2 10 KAKSHADHARA 2 TOTAL 27 TOTAL 23 Table 11- List of Snayu marmaD) SANDHI MARMA Sandhi according to Sharangadhara binds various structures and are coveredby kapha 54 Susruta has mentioned a total number of 210 sandhi in the shareera. Out ofthese 68 are present in the sakhas, 59 in the koshta and 83 in greeva pratyoordhwam55. PRADESHA TOTAL NUMBER OF SANDHI SAKHA (EXTREMITIES) 68 KOSHTA (TRUNK) 59 GREEVA PRATYOORDHWAM 83 TOTAL 210 Table 12- Classification of Sandhi according to shadangatwaA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 16
  • Review of Literature…. PRADESHA TOTAL NUMBER OF SANDHI HASTANGULI 14 MANIBANDHA 1 KURPARA 1 KAKSHADHARA 1 TOTAL 17 Table 13- List of Sandhi in upper limb Susruta has basically classified sandhi into two types a) Chestavanta(movable) 56b) Sthira (immovable) .Later he broadly classified them into eight types. They areKora, Ulookhala, Samudga, Prathara, Thunnasevani, Vayasathunda, Mandala andShankhavartha 57.1. KORASANDHI-They are found Anguli(finger), Manibandha (wrist),Gulpha(ankle), Janu(knee), KURPARA (elbow). All these joints have uniaxial movementsonly except Manibandha. So it can be correlated with Hinge type of Synovial jointmentioned in modern anatomy.2. ULOOKHALA SANDHI-They are found in Kaksha (axilla),Vamkshana (groin)and Dasana (teeth). Axilla and groin are formed by the shoulder and hip joints. Bothcan be correlated to the ball and socket type of synovial joints with a range ofmovements such as flexion, extension, adduction, abduction, medial rotation, lateralrotation and circumduction.Dasana (teeth) are fixed in its socket, no movement ispossible.3. SAMUDGA SANDHI-They are said to resemble a box with a lid and are found inAmsapeeta (Scapula) Guda (Rectum/Anus) Nitamba (buttock).These joints can becorrelated with Coraco-Clavicular joint, Sacro-Coccygeal joint, Ilio-Sacral joint. Verylittle movement is possible in these joints.4. PRATHARA SANDHI-They are said to be in the shape of round boat and found inGreeva(neck) and Prushtavamsa(vertebral column).5. THUNNASEVANI SANDHI-They are said to resemble sutures and are found inSira kapala (skull bones) and kati kapala (pelvis).They are sthira or fixed sandhi.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 17
  • Review of Literature….6. VAYASATHUNDA-They are said to resemble the beak of a crow. It is present intwo sides of Hanu and can be correlated to tempero-mandibular joint.7. MANDALA-They are round or circular in shape and are present in nadi of Kanta(throat), Hrudaya (heart), Netra (eye) and Kloma.8 .SHANKHAVARTA-They are said to be spiral, helical or conch shaped and foundin Srotra Sringataka (ear). There is no difference of opinion between Susruta and Vagbhata in thenumber of sandhi marma.Both have mentioned 20 of them and are Janu, KURPARA,Seemanta, Adhipati, Gulpha, Manibandha, Kukundara, Avartha, Krukatika 58. If the sandhi marma is injured the person feels as though the injury site iscovered with thorns. There will be shortening of the limb after healing. It may also leadto marked decrease in mobility and strength. It may also cause emaciation, lamenessand swelling in the joints 59. TOTAL TOTALSl.NO SUSRUTA VAGBHATA NUMBER NUMBER 1 JANU 2 JANU 2 2 KURPARA 2 KURPARA 2 3 SEEMANTA 5 SEEMANTA 5 4 ADHIPATI 1 ADHIPATI 1 5 GULPHA 2 GULPHA 2 6 MANIBANDHA 2 MANIBANDHA 2 7 KUKUNDARA 2 KUKUNDARA 2 8 AVARTHA 2 AVARTHA 2 9 KRUKATIKA 2 KRUKATIKA 2 TOTAL 20 TOTAL 20 Table 14-List of Sandhi marmaE) ASTHI MARMA The poetic verse of Susruta is very much evident in many contexts becausesome of the similes he uses to clarify the shareera rachana are enjoyable at the sametime closely related to the nature. While explaining ashti marma he has detailed thatA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 18
  • Review of Literature….just like the trees remain intact because of their hardcore similarly asthis act as acentral axis by providing support and strength to the shareera. In our science of ayurveda the number of asthi(bones) in the shareera areentirely different from that of modern medical science.Acharya Susruta hasmentioned 300 Asthi whereas Caraka has mentioned 360 in comparison to the 206mentioned in modern medicine. The inclusions of teeth, cartilage and rings of tracheaetc as asthi have contributed to the increase in the number of Asthi. Out of 300 asthis, 120 are present in sakhas, 63 in greeva pratyoordhwam(head & neck), 117 in Sroni(pelvis),Parswa(flanks), Prushta(back) and Uras(chest)together 60. PRADESHA TOTAL NUMBER OF ASTHIS SAKHA (EXTREMITIES) 120 SRONI,PARSWA,PRUSHTA,URAS 117 (PELVIS,FLANKS,BACK,CHEST) GREEVA PRATYOORDHWAM 63 (HEAD AND NECK) TOTAL 300 Table 15- Classification of asthi according to shadangatwa as per Susruta Samhita Out of the 30 asthis present in each sakhas,15 are present in hastanguli,10 inTala,Koorcha and Manibandha,1 in Manika,2 in Prapani, 1in KURPARA Sandhi and1in Prabahu 61. PRADESHA TOTAL NUMBER OF ASTHI HASTANGULI 15 HASTATALA,KOORCHA,MANIBANDHA 10 MANIKA 1 PRAPANI 2 KURPARA 1 PRABAHU 1 TOTAL 30 Table 16- List of asthi in upper limb as per Susruta SamhitaA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 19
  • Review of Literature…. According to Carakacharya a total number of 360 asthi are present in theshareera and out of these 128 are present in sakhas,140 in koshta and 92 ingreevapratyoordhwam (head & neck) 62 . PRADESHA TOTAL NUMBER OF ASTHIS SAKHA (EXTREMITIES) 128 SRONI,PARSWA,PRUSHTA,URAS (PELVIS,FLANKS,BACK,CHEST) 140 GREEVA PRATYOORDHWAM (HEAD AND NECK) 92 TOTAL 360 Table 17- Classification of asthi according to shadangatwa as per Caraka Samhita PRADESHA TOTAL NUMBER OF ASTHIS NAKHA 5 HASTANGULI 15 HASTA SALAKA 5 HASTA ADISTHANA 1 HASTA MANIKASTHI 1 Table 18- List of asthi in Hasta as per Caraka Samhita Susruta has classified the bones into five types. They arei) Kapalasthi-are present in Janu(knee), Nitambha(buttock), Amsa(shoulder),Ganda(neck), Talu(palate), Sankha(temples) and Siras(head).ii) Ruchakasthi-are teethiii) Tarunasthi-(youngbones/cartilages) are present in Ghrana(nose), Karna(ear),Greeva (neck) and Akshikosa (cartilages of superior palpebra).iv) Valayasthi-(curved/irregular bones) are present in parswa (flanks), Prushta(back),Uras(chest).All these are related with ribs.v) Nalakasthi-(tubular/long bones).All remaining bones are considered asNalakasthi63.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 20
  • Review of Literature…. Asthi is one among the marma vasthu and are numbered as eight by Susrutaand Vagbhata.They are Shankha, Kateekataruna, Nitambha and Amsaphalaka.Shankha marma is prognostically Sadyopranahara, Kateekataruna and Nitambhabelong to Kalantarapranahara group and Amsaphalaka is included in Vaikalyakaramarma group 64. If Asthi marma is injured it will cause discharge of scanty fluid that too mixedwith bone marrow. Intermittent pain will also be present 65. Sl.No SUSRUTA No. VAGBHATA No. 1 SHANKHA 2 SHANKHA 2 2 KATEEKATARUNA 2 KATEEKATARUNA 2 3 NITAMBHA 2 NITAMBHA 2 4 AMSAPHALAKA 2 AMSAPHALAKA 2 TOTAL 8 TOTAL 8 Table 19- List of Asthi marmaF) DHAMANI MARMA Carakacharya has given the basic definition of Dhamani as anything thatpulsates37. Susruta has mentioned 24 dhamanis that originate from Nabhi.10 of themmove upwards, 10 of them downwards, and 4 in sideways 66. Acharya Vagbhata introduced the classification of Dhamani marma.Ninemarmas come under this group and they are Guda, Apasthambha, Vidhura andSringataka 67. NAME No. GUDA 1 APASTHAMBHA 2 VIDURA 2 SRINGATAKA 4 TOTAL 9 Table 20- List of Dhamani marmaA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 21
  • Review of Literature…. According to Susruta Guda is mamsa marma,Vidhura is snayu marma whereasApasthambha and Sringataka are sira marmas. If an injury occurs to the dhamani marma it will cause haemorrhage in whichblood which is frothy and warm flows out with a sound and the person easily looseshis consciousness 68.2. REGIONAL CLASSIFICATION Shareera is divided into 6 parts. They are Shiras, Antharadi (thorax andabdomen), 2 bahu (upper limb), 2 sakthi (lower limb).Here shiras is considered as themost important part and the vitality diminishes towards antharadi, bahu and sakthi 69. Among 107 marmas,there are 44 present in the sakthi (11 in eachextremities),3 in Koshta,9 in uras (thorax),14 in prushta (back) and 37 Jathroordhapart (head and neck) 70. Carakacharya has also agreed to the theory of 107 marmas but has highlitedthe TRIMARMA concept (3 marmas) .They are the Shiras, Hrudaya and Basti. He hasmentioned that the prana resides in three sites 71. PRADESHA NUMBER OF MARMAS SAKHA (BAHU MARMA&SAKTI MARMA) 44 UDARA MARMA 3 URO MARMA 9 PRUSHTA MARMA 14 JATROORDHWA MARMA 37 TOTAL 107 Table 21 – Classification of marma according to shadangatwaA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 22
  • Review of Literature….3.PROGNOSTIC CLASSIFICATION Depending on the prognosis of marmabhighata, it is divided into five types bySusruta and Vagbhata. They are Sadyopranahara, Kalantarapranahara, Vishalyaghna,Vaikalyakara and Rujakara 72. PROGNOSTICSl.No No. DOSHA PREDOMINANCE CLASSIFICATION 1 SADYOPRANAHARA 19 AGNEYA 2 KALANTARAPRANAHARA 33 AGNEYA,SOUMYA 3 VISHALYAGHNA 3 VAYAVYA 4 VAIKALYAKARA 44 SOUMYA 5 RUJAKARA 8 SOUMYA,AGNEYA,VAYAVYA TOTAL 107 Table 22– Classification of marma according to prognosisI) SADYOPRANAHARA- As the name suggests these marma cause death ormarana immediately or within a span of 7 days. These marmas are predominant ofagneya bhavas.They are 19 in number and are Adhipati, Guda, Hrudaya, Kantasira,Nabhi, Shankha,Sringataka and Basti 73,74. Sl.No. NAME OF MARMA No. STRUCTURE 1 ADHIPATI 1 SANDHI 2 GUDA 1 MAMSA(DHAMANI) 3 HRUDAYA 1 SIRA 4 KANTASIRA 8 SIRA 5 NABHI 1 SIRA 6 SHANKHA 2 ASTHI 7 SRINGATAKA 4 SIRA(DHAMANI) 8 BASTI 1 SNAYU TOTAL 19 Table 23- List of Sadyopranahara marmaA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 23
  • Review of Literature….II) KALANTARAPRANAHARA-As the name suggests these marma cause deathonly after a certain period of time ie within a fortnight or month. These marmas arepredominant of Agneya and Soumya gunas. There are a total of 33 marmas includedin this group & are Apalapa, Apasthambha, Stanarohita, Stanamoola, Kateekataruna,Parswasandhi, Bruhati and Nitambha 75,76. Sl. No. NAME OF MARMA No. STRUCTURE 1 SEEMANTA 5 SANDHI 2 TALAHRUDAYA 4 MAMSA 3 KSHIPRA 4 SNAYU 4 INDRABASTI 4 MAMSA 5 APALAPA 2 SIRA 6 APASTHAMBHA 2 SIRA 7 STANAROHITA 2 MAMSA 8 STANAMOOLA 2 SIRA 9 KATEEKATARUNA 2 ASTHI 10 PARSWASANDHI 2 SIRA 11 BRUHATI 2 SIRA 12 NITAMBHA 2 ASTHI TOTAL 33 Table 24- List of Kalantarapranahara marmaIII) VISHALYAGHNA MARMA-These marma are vayu predominant. As long asthe vayu remains inside obstructed or prevented by the shalya, the person survives.When the shalya is removed from the site, vayu residing in the fatal area will go outresulting in immediate death. There are three vishalyaghna marma described in oursamhitas77,78.They are UTKSHEPA-2 and STHAPANI-1.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 24
  • Review of Literature….IV)VAIKALYAKARA MARMA-These marma are soumya in nature and becauseof the sthirata and saitya gunas, soma maintains life even after injury. They are 44 innumber and are Ani, Kurcha, Vitapa, Vidhura, Amsa, Lohitaksha, Apanga, Neela,Manya, Urvi, Phana, Janu, KURPARA, Kukundara, Kakshadhara,Krukatika,Avarthaand Amsaphalaka 79,80. Sl.No. NAME OF MARMA No. STRUCTURE 1 ANI 4 SNAYU 2 KURCHA 4 SNAYU 3 VITAPA 2 SNAYU 4 VIDHURA 2 SNAYU 5 AMSA 2 SNAYU 6 LOHITAKSHA 4 SIRA 7 APANGA 2 SIRA 8 NEELA 2 SIRA 9 MANYA 2 SIRA 10 URVI 4 SIRA 11 PHANA 2 SIRA 12 JANU 2 SANDHI 13 KURPARA 2 SANDHI 14 KUKUNDARA 2 SANDHI 15 KAKSHADHARA 2 SNAYU 16 KRUKATIKA 2 SANDHI 17 AVARTHA 2 SANDHI 18 AMSAPHALAKA 2 ASTHI TOTAL 44 Table 25- List of Vaikalyakara marmaA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 25
  • Review of Literature….V) RUJAKARA MARMA-These marmas have predominance of Agni and Vayubhootas and produce severe pain. There are 8 marma in this group and they areKurchasira, Gulpha and Manibandha 81,82. Sl No. NAME OF MARMA No. STRUCTURE 1 KURCHASHIRA 4 SNAYU 2 GULPHA 2 SANDHI 3 MANIBANDHA 2 SANDHI TOTAL 8 Table 26- List of Rujakara marma It is also quoted by Susruta that if the sadyopranahara marma is afflicted at itsborder it may become kalantarapranahara.If kalantarapranahara marma is afflicted atits border it may become vaikalyakara.If vishalyaghna marma is afflicted at its borderit may become vaikalyakara.If vaikalyakara marma is afflicted at its border it willbecome rujakara marma.If rujakara marma is afflicted at its border it may cause mildpain 83. It has also been mentioned in Susruta Samhita that the Kshipra marma cansometimes be sadyopranahara 84.PANCHABHAUTIK CONSTITUTION OF MARMAS 85 It is quoted by Susruta that Sadyapranahara marmas are agneya in nature. Justas agni or fire quickly extinguishes everything similarly agneya guna of these marmaswill kill a person easily. Kalantarapranahara marmas are agni and soma gunayukta. Due to the evennature of fire and water death will not occur spontaneously but over a short period oftime. Vishalyaghna marmas are fatal after the extraction of the shalya embedded inthe site because the vayu will remain obstructed by the shalya and as soon as theshalya is extracted, vayu escapes out and will lead to the death of the individual.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 26
  • Review of Literature…. Vaikalyakara marmas are soma guna pradhana and due to the sthiratva (stable)and saityatva (frozen) nature will sustain life. Rujakara marmas are agni and vayu guna pradhana thus causing severe pain. It is also opined that pain is caused by Panchamahabhootas.It is due topredominance of agni and vayu that pain occurs. Ap or jaleeyabhoota is also said tocause pain in kaphaja wounds.4) DIMENSIONAL CLASSIFICATION 86 Susruta and Vagbhata explained the dimensions of all 107 marmas in angulas.This is for the surgeons to get an exact idea of the surface anatomy while performingsurgical procedures. Shastra karma, Kshara karma and Agni karma should be avoidedin the site of marma.According to the dimension of marma, it is divided into 5 types.1. Swa-Panitala 2.Ardhangula 3.Ekangula 4.Dwayangula 5. Trayangula Sl. NO NAME OF MARMA TOTAL NUMBER 1 HRUDAYA 1 2 BASTI 1 3 GUDA 1 4 NABHI 1 5 NEELA 2 6 MANYA 2 7 KURCHA 4 8 SRINGATAKA 4 9 SEEMANTA 5 10 MATRUKA 8 Table 27- List of Swa-Panitala marmasA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 27
  • Review of Literature…. Sl.No. NAME OF MARMA TOTAL No. 1 ADHIPATI 1 2 ANI 4 3 AMSA 2 4 AMSAPHALAKA 2 5 APANGA 2 6 APASTHAMBHA 2 7 AVARTHA 2 8 BRUHATI 2 9 INDRABASTI 2 10 KATEEKATARUNA 2 11 KRUKATIKA 2 12 KSHIPRA 2 13 KUKUNDARA 2 14 LOHITAKSHA 2 15 NITAMBHA 2 16 PARSWASANDHI 2 17 PHANA 2 18 SANKHA 2 19 STANAROHITA 2 20 STHAPANI 2 21 TALAHRUDAYA 4 22 UTKSHEPA 2 23 VIDHURA 2 Table 28- List of marmas having Ardhangula pramanaA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 28
  • Review of Literature…. Sl. No. EKANGULA MARMAS TOTAL No. 1 URVI 4 2 KURCHASHIRA 4 3 VITAPA 2 4 KAKSHADHARA 2 Table 29- List of marmas having one Ekangula pramana Sl.No. DWAYANGULA MARMAS TOTAL No. 1 STANAROHITA 2 2 GULPHA 2 3 MANIBANDHA 2 Table 30- List of marmas having Dwayangula pramana TRYANGULA Sl.No. TOTAL No. MARMAS 1 JANU 2 2 KURPARA 2 Table 31- List of marmas having Tryangula pramana It is also told that the surgical operations should be performed afterconsidering the measurement of the marmas so as to avoid them. Even an injury to itsborders might lead to death. So the site of marmas should be avoided altogether 87.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 29
  • Review of Literature….6. NUMERICAL CLASSIFICATION Marmas are classified according to their number present in the particulargroup. Namelyi)EKA SANKHYA = 6ii)DWI SANKHYA = 52iii)CHATUR SANKHYA = 36iv)PANCHA SANKHYA = 5v)ASHTA SANKHYA = 8SIX EKA SANKHYA MARMAS1. HRUDAYA2. GUDA3. BASTI4. NABHI5. STHAPANI6. ADHIPATI Sl.No. Name of Marma Sl.No. Name of Marma 1 GULPHA 14 NEELA 2 JANU 15 MANYA 3 MANIBANDHA 16 KRUKATIKA 4 KURPARA 17 UTKSHEPA 5 AMSA 18 STANAMOOLA 6 KAKSHADHARA 19 STANAROHITA 7 AMSAPHALAKA 20 APALAPA 8 VITAPA 21 APASTHAMBHA 9 SHANKHA 22 BRUHATI 10 APANGA 23 KUKUNDARA 11 AVARTHA 24 KATEEKATARUNA 12 VIDHURA 25 PARSWASANDHI 13 PHANA 26 NITAMBHA Table 32- List of Dwi sankhya marmasA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 30
  • Review of Literature…. Sl No. NAME OF MARMA 1 TALAHRUDAYA 2 KSHIPRA 3 KURCHA 4 KURCHASIRA 5 ANI 6 URVI 7 LOHITAKSHA 8 INDRABASTI 9 SRINGATAKA Table 33- List of Chatur sankhya marmasPANCHASANKHYA MARMA = SEEMANTAASHTASANKHYA MARMA=MATHRUKAHASTA The term hasta has been defined in the Amarakosha as something that spreadsor originates from Bahu 88. The synonyms of Pani, Sama, Saya, Panchasakha, Kara, Bhuja, Kuli,Bhujadala have all been designated to the word hasta in Shabdhakalpadruma 89. In Monier Williams the term hasta has been given the meaning hand, holdingin or by the hand, to take into the hand etc 90. Acharya Susruta in the 7th chapter of the Sutra sthana ie Yantra vidhi hasmentioned hasta as the pradhana yantra.This is due to the fact that without the help ofhasta none of the yantras can function. The functioning of all the yantras is based onthe efficiency of the hand 91. Similarly panitala and padatala has been mentioned as anuyantra by Susruta 92. Susruta has detailed the pramana shareera in the 35th chapter of the sutrasthana ie Aturopakramaneeya.In this chapter he has mentioned the followingpramaana 93. Pramaana of Hasta (Length of hasta)- 24 Angula Parimaana of Buja (Length of the entire upper limb)- 32 Angula Length between manibandha and KURPARA- 16 AngulaA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 31
  • Review of Literature…. Ayaama (length) of Hastatala- 4 Angula Vistara (width) of Hastatala- 6 Angula Length between Angushta moola and Pradeshini(index finger) is 5 Angula. Dalhana has clarified that by the term ‘hasta’ Susruta has meant the regionbetween the KURPARA and the tip of the madhyamanguli (middle finger) 94. In the 8th chapter of the Caraka Samhita ie Rogabishagjeetiyam vimanamwhile detailing about the pramana pareeksha Caraka has described that the length of PRABAHU = 16 ANGULA (ARM) PRAPANI = 15 ANGULA (FOREARM) HASTA = 12 ANGULA (HAND) Hence the total length of the upper limb is 43 Angula 95. So there exists a difference of opinion on the terminologies pani, panitala andhasta. But a clear cut differentiation of the arm, forearm and hand has been given byCaraka.So here in the dissertation work; terminology of Hasta has been used to denotehand. There are five anguli in each Hasta. These Anguli are considered amongpratyangas 96. There are four kandaras97, four jalas98, two kurchas 99 , three asthisanghatas100, twenty-six asthis, fifteen sandhis, sixty snayus & fifty five mamsa peshislocated in located in Hasta .HASTA MARMA They are five in number and are KSHIPRA, TALAHRUDAYA, KURCHA,KURCHASHIRA & MANIBANDHA.I) KSHIPRA (Fig.1A,1B) It is the marma which is first detailed in the Susruta Samhita.Etymology: Kshipra takes it root from the word ‘kship’ and has been assigned withthe synonyms Seeghra and Twarita in Shabdhakalpadruma101 .It is meant as to throw, cast, send, dispatch etc in Monier Williams dictionary102 .Location-It is located between the angushta and anguli103,104.Classification- Snayu marma. Sakha marma. Kalantarapranahara marma and sometimes Sadyopranahara.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 32
  • Review of Literature…. Ardhangula Pramana. Catursankhya.Effect- An injury to the marma will lead to marana due to akshepaka 103,104.Arunadattahas detailed that the akshepaka mentioned here is the vatavyadhi 105. It is detailed that in akshepaka roga the aggravated vata dosha permeates alldhamanis leading to frequent and repeated convulsions and spasm of muscles. 106,107 Here the terminology of dhamani has been detailed as nadi by Dalhana 108suggesting the involvement of nervous system in it .Dalhana has also mentionedthat in this the whole akshepa of the body takes place109.Arunadatta has interpretedthe word ‘Aakshipati’ as ‘Aakramati’ or attacking 110. It has also been mentioned that when the limbs get severed, the blood vesselsget contracted to allow only little hemorrhage and such persons, though having severeaffliction, do not die like tree with several branches cut off survives 111.II) TALAHRUDAYA (Fig.2A, 2B) It is the marma which is first detailed in the Ashtanga Hrudaya.Etymology: In Shabdhakalpadruma it is meant as the hrudaya or centre of padatala 112.In Monier Williams dictionary ‘Tala’ is meant as surface, level, flat roof (of a house)etc.and ‘Talahrudaya’ as sole of foot 113.Location-It is located in the centre of palm in straight line with the middle finger(Madhyamanguli/Anamika) 114,115.Classification: Mamsa marma. Sakha marma. Kalantarapranahara marma. Ardhangula Pramaana. Chatursankhya.Effect- An injury to the marma will lead to marana caused due to ruja114, 115.III) KURCHA (Fig.3A,3B)Etymology: Kurcha assumes its name from the root words ‘kur+chat’ according toSabdakalpadruma116.In Monier Williams dictionary it is meant as a bunch ofanything, bundle of grass etc117.Location-It is situated two angula above the Kshipra marma 118,119.Classification- Snayu marma. Sakha marma. Vaikalyakara marma.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 33
  • Review of Literature…. Swapanitala pramana. Chatursankhya.Effect- An injury to the marma will lead to the Bhramana and Vepana of the limb.Vagbhata has used the word Kampa instead of Vepana118,119. The term Kampa has been assigned with the meanings trembling, tremor, 120shaking etc. in Monier Williams’s dictionary and the word Vepana has beenassigned with the meaning quivering, trembling, fluttering etc 121.IV) KURCHASHIRA (Fig.4A, 4B)Etymology: Kurchashira has been defined as the shira of Kurcha inShabdhakalpadruma122 .It has been meant as the upper part of the palm of the handand foot in Monier Williams dictionary 123.Location-It is situated just below the manibandha sandhi 124,125.Though in the sloka itis mentioned as below the gulpha it has been cleared later that the manibandha marmain upper limb is homologous to the gulpha marma in lower limb 126.Classification- Snayu marma. Sakha marma. Rujakara marma. Dwayangula pramana. Chatursankhya.Effect-An injury to the marma will lead to Sopha and Ruja 124,125.V) MANIBANDHA (Fig.5A, 5B)Etymology-Manibandha has been defined in Shabdhakalpadruma as the meeting pointof prakoshta and pani127.In Monier Williams dictionary the term mani has been meantas jewel, gem or a pearl and manibandha as fastening or putting on of wrist128.Dalhana has mentioned that it is the moola of paani129.Location-It is located at the meeting point of prapani and hasta 95. So it has been dealtunder the topic of hasta marma.Classification- Sandhi marma. Sakha marma. Rujakara marma. Dwayangula pramana. Dwisankhya.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 34
  • Review of Literature….Effect- According to Susruta an injury to the marma will lead to ‘Kundata’ 130.Theterm Kundata has been clarified by Dalhana as inability or inefficiency to functionwith hand131.CONCEPT OF RUJA Manibandha and Kurchashira are classified as Rujakara marmas. The termRuja is dealt in many contexts. In Amarakosha the term ruja has been used in the following senses.Ruk,Ruja,Upatap, Roga, Vyadhi, Gada, Amaya and Saptarogamatha 132. Monier Williams explains the word Ruja as Rujati or to break, break open,destroy, to cause pain, injure, afflict etc. 133. Acharya Susruta has detailed about many types of pain in the VranasravaVigyaneeya Adhyaya 134.Todana - pricking of needle Vidarana - burstingBhedana – piercing Kampana - quiveringTadana – thrashing Shoola - colicChedana – cutting Vikirana - radiatingAyama – expanding Poorana - fullnessManthana – churning Stambhana - stiffnessVikshepana – shooting Dahana - burningChumchumayana – tingling Utpatan - uprootingAvabhanjana-breaking The standard definition of pain is that of the International association for thestudy of pain:135 “An unpleasant sensory or emotional experience associated with actual orpotential tissue damage is described in terms of such damage. Pain is alwayssubjective. Each individual learns in the application of word with experiences relatedto injury in early life. It is unquestionable a sensation in a part of the body but it isalso unpleasant and therefore also an emotional experience. Many people report painin presence of tissue damage or any likely pathophysiological cause, usually thishappens for psychological reasons. There is no way to distinguish their experiencefrom that due to tissue damage if we take this subjective report.”A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 35
  • Review of Literature….TYPES OF PAIN 1361. Neuropathic Pain - Pain that is initiated or caused by a primary lesion ordysfunction in the nervous system e.g.:- radicular pain due to herniated or degeneratedvertebral disc.2. Visceral Pain – Pain that is located in the visceral organs as well as the parietalperitoneum, pleura and pericardium.3. Psychogenic Pain – is generated by the mind and emotions. A pain is a subjectiveperception, the attitude and mood of an individual which effects its perception. Mentalactivity in the descending inhibitory pathways results decrease in perception of pain.4. Nociceptive Pain – Pain that is result of irritation of a nociceptor. This is thecommon pain experience in myofascial tissue of the joint complex. Pain is also classified into acute or chronic based on the quality of sensationand duration. But in the case of ruja it is better to moderate with the definition of Rujakarain Vacaspatya which states that ‘Rujaam rogam karoti’ which means anything thatleads to roga is ruja 137.CONCEPT OF ANGULI PRAMANA Pramana is a tool through which valid knowledge is obtained138. Mana is theact of measuring different items which comprises different branches like tula, Anguli,prasta. Anguli pramana is a unit of measure followed in olden days to denote theAyama, vistara, parinaha, utsedha etc139.ANGULA CAN BE TAKEN AS: 1) Width of the madhyama parva of the madhyama angula 140. 2) Measurement obtained by taking the length of the madhyama angula and dividing it by five 141. 3) Measurement obtained by taking the width of the palm and then dividing by four 142. 4) Nakha tala bhaga of angushtha 143.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 36
  • Review of Literature-anatomy of hand ANATOMY OF HAND PALMAR SURFACE 144 The human hand is designed: (i) for grasping (ii) for precise movements (iii) forserving as a tactile organ.Skin –The skin of the palm is: (i) thick for protection of underlying tissues, (ii)immobile because of its firm attachment to the underlying palmar aponeurosis, and(iii) creased. All of these characters increase the efficiency of the grip. The skin is supplied by spinal nerves C6, C7, C8 through the median and ulnarnerve.Superficial fascia – The superficial fascia of the palm is made up of dense fibrousbands which bind the skin to the deep fascia (palmar aponeurosis) and divide thesubcutaneous fat into small tight compartments which serve as water-cushions duringfirm gripping. The fascia contains a subcutaneous muscle, the Palmaris brevis, whichhelps in improving the grip by steadying the skin on the ulnar side of the hand. Thesuperficial metacarpal ligament which stretches across the roots of the fingers over thedigital vessels and nerves is a part of this fascia.Deep Fascia- The deep fascia is specialized to form :(i) the flexor retinaculam at thewrist,(ii) the palmar aponeurosis in the palm, and (iii) the fibrous flexor sheaths in thefingers. All three form a continuous structure which holds the tendons in position andthus increases the efficiency of the grip.DORSUM OF THE HAND145Skin – The skin of the dorsum of the hand is thin, hairy and moves freely over theunderlying extensor tendons and deep fascia.Superficial fascia – It presents a dorsal subcutaneous space which contains the dorsalvenous arch and the dorsal digital nerves derived from the superficial terminal branchof radial nerve and dorsal branch of ulnar nerve.Dorsal venous arch – The dorsal digital veins from the adjacent sides of the fingersjoin in the interdigital clefts to form three dorsal metacarpal veins which unite witheach other and form a dorsal venous network proximal to the metacarpal heads. Thisnetwork receives the blood from the radial side of index finger and both sides of thethumb as well as from the ulnar side of little finger. Most of the blood from the palmalso reaches dorsal venous plexus through the perforating veins in order to avoidA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 37 
  • Review of Literature-anatomy of handpressure during grasping. From the radial side of the venous plexus the blood isconveyed proximally by the cephalic vein and from the ulnar side by the basilic vein.Deep Fascia- It is thin and covers the extensor tendons of the digits on the dorsum ofhand. Proximally at the back of the wrist, it is continuous with the extensorretinaculum, and at the sides’ continous with the palmar fascia. A dorsal subaponeurotic space intervenes between the deep fascia and thedorsal surfaces of metacarpal bones and dorsal interossei muscles. The space isoccupied by the extensor tendons of the hand, dorsal digital expansions, dorsal carpalarch and their dorsal metacarpal branches. SKELETON OF HAND146The hand’s skeleton has three regions. 1) The Carpus 2) The Metacarpus 3) The Phalanges In this description proximal and distal are used in preference to superior andinferior and palmar and dorsal rather than anterior and posterior.1) THE CARPUSProximally in lateral to medial order areSCAPHOID, LUNATE, TRIQUETRAL, PISIFORM and in the distal row areTRAPEZIUM, TRAPEZOID, CAPITATE and HAMATE.The proximal row is convex proximally and concave distally.The distal row is convex proximally and flat distally.A) SCAPHOID It is the largest bone in the proximal row and has a long axis which is distallateral and slightly palmar in direction. It has 6 surfaces.i) Palmar surface: Its round tubercle on the dorsolateral part of its palmar surface isdirected anterolaterally and is an attachment of the flexor retinaculum and abductorpollicis brevis, it is crossed by the tendon of flexor carpi radialis.ii)Dorsal surface: It is rough, slightly grooved, narrower than the palmar surface andpierced by small nutrient foramina, often restricted to the distal half, an observation ofclinical significance.iii) Lateral surface: It is narrow, rough, non-articular and has the radial collateralligament attached to it.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 38 
  • Review of Literature-anatomy of handiv) Medial surface: It articulates with capitate below and lunate above by a deepconcave and a semilunar area respectively.v) Proximal surface: It is convex and smooth and articulates with lateral part ofinferior surface of lower end of radius.vi) Distal surface: The surface for trapezium and trapezoid is continuous and convex.B) LUNATE It is approximately semilunar and articulates between the scaphoid andtriquetral in the proximal carpal row. It has 6 surfaces.i) Palmar surface:a) It is rough, triangular, wider and larger than the rough dorsal surface.b) Nearly triangular, non articular.ii) Dorsal surface:a) Rough small quadrilateral surface, non-articular.iii) Lateral surface:a) Presents a semilunar surface for articulation with scaphoid bone.iv) Medial surface:a) Presents a quadrilateral area for articulation with the base of triquetral bone.v) Proximal surface:a) Convex.b) Articulates with medial part of inferior surface of lower end of radius.vi) Distal surface:a) Deeply concaveb) Articulates with medial part of the head of capitate bone.C) TRIQUETRAL It is pyramidal or wedge shaped. It possesses 6 surfaces.i) Palmar surface:a) It has one oval or circular facet at its distal part which articulates with pisiformbone .Margins of the facet give attachment to Piso-triquetral ligament.ii) Dorsal surface:a) It is continuous with proximal surface.iii) Lateral surface:a) It forms base of the wedge and bears a square facet for articulation with lunatebone.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 39 
  • Review of Literature-anatomy of handiv) Medial surface:a) It forms apex of the wedge and gives attachment to ulnar collateral ligament ofwrist joint.v) Proximal surface:a) It is a smooth surface facing upwards.b) It articulates with triangular articular disc of inferior radio-ulnar joint.vi) Distal surface:a) It has a concavo-convex surface.b) It articulates with hamate.D) PISIFORM It is a pea shaped, smallest and the most medial bone of the proximal row. Itpossesses only one articular facet which faces backwards .It has 4 surfaces.i) Palmar surface:a) It is very narrow and ridge like.b) It gives insertion to flexor carpi ulnaris above and attachment to Piso-metacarpaland Piso-hamate ligaments below.ii) Dorsal surface:a) It possesses a circular facet which articulates with triquetral bone. Its margins giveattachment to Piso-triquetral ligament.iii) Lateral surface:a) It is flat.b) It has an indistinct vertical ridge to which is attached flexor retinaculum.E) TRAPEZIUM It is the lateral most bone of the distal row and is identified by the presence ofa crest (or tubercle) and a groove on the palmar surface. It possesses 6 surfaces.i) Palmar surface:a) It presents a tubercle (crest) and a groove; the groove lodges the tendon of flexorcarpi radialis.b) Margins of the groove give attachment to flexor retinaculum.c) Tubercle (crest) gives origin to thenar muscles- Abductor pollicis brevis. Opponens pollicis. Flexor pollicis brevis.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 40 
  • Review of Literature-anatomy of handii) Dorsal surface:a) It is long and narrow.b) It is related to radial artery.iii) Lateral surface:a) It is roughened and non-articular.b) It gives attachment to radial collateral ligament of wrist joint and capsular ligamentof carpo-metacarpal joint of thumb.iv) Medial surface:a) It bears an elongated area for articulation with trapezoid.b) The distal part of medial surface has a rectangular facet for articulation with lateralpart of the base of 2nd metacarpal.v) Proximal surface:a) It bears an oval facet which articulates with scaphoid.vi )Distal surface:a) It bears a large concavo-convex or saddle-shaped facet which articulates with thebase of its metacarpal bone.F) TRAPEZOID Small bone which is very irregular in shape; Boat-shaped.It possess 6 Surfaces-i) Palmar & ii) Dorsala) Roughened and non-articular,b) Dorsal surface gives origin to some fibres of oblique head of Adductor pollicis.iii) Proximal:a) Rectangular surface which articulates with scaphoid.iv) Distal:a) Hollowed.b) Articulates with the base of 2nd metacarpal.v) Lateral:a) Bears a convex facet which articulates with trapezium.vi) Medial:a) Bears a nearly square-shaped concave facet which articulates with the distal part ofcapitate bone.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 41 
  • Review of Literature-anatomy of handG) CAPITATE Largest of all carpal bones and is identified by the presence of a more or lessrounded convex surface called ‘head’. It possesses 6 surfaces:i) Proximal:a)Nearly rounded and convex all around; it is called the Head.b) Lateral part of the head articulated with scaphoid, while medial part articulates withlunate.ii) Distal:a) Nearly triangular and forms a concavo-convex facet for articulation with the baseof 3rd metacarpal.b) Its lateral border has a concave strip for articulation with the base of 2ndmetacarpal.c) Its dorso-medial angle has a small facet for articulation with the base of 4thmetacarpal.iii) Lateral:a) On its distal part is a facet for articulation with trapezoid. This facet is continuouswith the facet of scaphoid.b) It presents a constriction which constitutes the neck.iv) Medial:a) Larger and flat.b) Bears a large facet for articulation with hamate.c) Distal part of this surface is non-articular and gives attachment to intersseousligament.v) Palmar & vi) Dorsal:a)Rough surfaces; dorsal surface is larger than palmar surface. Adductor pollicis(oblique head) arises from palmar surface.H) HAMATE It is wedge-shaped and is identified by the presence of a hook-like processwhich projects from the distal part of its palmar surface. It posses 6 surfaces.i) Palmar:a)Roughened,A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 42 
  • Review of Literature-anatomy of handb) On its distal part is hook-like process. Concavity of the process faces laterallywhile it is convex medially. It forms medial boundary of the carpal tunnel.Tip of process gives attachment to flexor retinaculum. Convex surface of the processgives origin to Opponens digiti minimi and Flexor digiti minimi brevis.c) There is a groove at the distal part of the base of the hook. It transmits the deepterminal branch of ulnar nerve.ii) Dorsal: Roughened for ligamentous attachments.iii) Distal:a) Roughened.b) Divided into 2 articular areas by faint ridge-Smaller lateral facet articulates with the base of 4th metacarpal.Larger medial facet articulates with the base of 5th metacarpal.iii) Proximal:a)It forms apex of the wedge.b) Bears a narrow facet for articulation with lunate.v) Medial: It is concavo-convex and articulates with triquetral.vi) Lateral: Bears an oval facet for articulation with capitate.2.THE METACARPUS Metacarpal bones are 5 in number and numbered from lateral to medial side.They are short long bones.PARTS: i) Head: rounded. ii) Base: expanded. iii) Shaft.i) Head: Lies distally and articulates with proximal phalanx. It is larger than the baseand produces the prominence of knuckles.ii) Base: Lies proximally and articulates with distal row of carpal bones and with oneanother-except 1st metacarpal which does not articulate with 2nd metacarpal.iii) Shaft: Its palmar surface is concave and the dorsal surface is convex. The dorsalsurface has a flattened triangular area in its distal part. Lateral and medial surfacesencroach on the proximal part of dorsal surface. The shaft gradually becomes thickerfrom above downwards.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 43 
  • Review of Literature-anatomy of handINDIVIDUAL METACARPAL BONES:A) FIRST METACARPAL BONEa)Shortest and thickest of all other metacarpals.b) Palmar surface of shaft is divided into a larger lateral and a smaller medial part byan indistinct line.c) Base has only one concave-convex facet for articulation with trapezium. This helpsin identification.d) Heads has two tubercles at medial and lateral corners on palmar surface.ATTACHMENTS:i) Opponens pollicis: Inserted into lateral border and adjoining part of palmar surfaceof shaft.ii) 1st Dorsal interosseous (radial head): arises from medial border and adjoining partof palmar surface of shaft.iii) Abductor pollicis longus: inserted into lateral side of base.iv) 1st Palmar intersseous: arises from medial side of palmar surface of base.B) SECOND METACARPAL BONEa)Longest of all other metacarpals.b) Recognized by the presence of a groove on its base which articulates withtrapezoid. The groove is bounded on its medial side by a ridge which articulates withcapitate.c) Shaft is prismoid in shape and possesses 3 surfaces – Medial, Lateral and Dorsal.ARTICULATIONS:i) Quadrilateral facet on lateral side of the base with trapezium.ii) Medial side of the base with lateral side of the base of 3rd metacarpal.iii) Groove on proximal aspect of the base with trapezoid.ATTACHMENTS:i) Extensor carpi radialis longus: inserted into dorsolateral aspect of the base.ii) Flexor carpi radialis: inserted into palmar surface of the base.iii) 1st Dorsal interosseous (ulnar head): arises from lateral surface of shaft.iv) 2nd Palmar interosseous (radial head): arises from dorsal aspect of medial surfaceof shaft.v) 2nd Dorsal interosseus (radial head): arises from dorsal aspect of medial surface ofshaft.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 44 
  • Review of Literature-anatomy of handvi)Collateral ligament of metacarpo-phalangeal joint: to tubercles at the side of thehead.C) THIRD METACARPAL BONE It is recognised by the presence of styloid process projecting proximally fromradial side the dorsal surface of its base. It possesses 3 surfaces-Medial, Lateral andDorsal.ARTICULATIONS:Base a) With capitate bone proximally. b) With 2nd metacarpal by a strip-like facet laterally. c) With 4th metacarpal by two small, oval, discrete facets medially.ATTACHMENTS:i) Flexor carpi radialis : Inserted into palmar surface of the base.ii) Extensor carpi radialis brevis: inserted into dorsal surface of the base on its radialside.iii) Adductor pollicis (oblique head): arises from palmar aspect of the base.iv) 2nd Dorsal interosseous (ulnar head): arises from lateral surface of shaft.v) 3rd Dorsal intreosseous (radial head): arises from medial surface of shaft.vi) Adductor pollicis (transverse head): arises from the palmar ridge separating medialand lateral surfaces. No palmar interossei muscle is attached to this bone.D) FOURTH METACARPAL BONEIt is recognised by:a) Presence of two small, discrete oval facets on lateral aspect of the base whicharticulate with facets on medial aspect of 3rd metacarpal bone.b) Presence of one elongated facet on medial aspect of the base for articulation withbase of 5th metacarpal bone.c) Proximal surface of the base has a quadrilateral facet for articulation with hamate. The lateral surface of shaft is divided into palmar and dorsal areas by a ridge.ATTACHMENTS:i) 3rd Palmar interosseous: arises from palmar aspect of lateral surface of shaft.ii) 3rd Dorsal interosseous (ulnar head): arises from dorsal aspect of lateral surface ofshaft.iii) 4th Dorsal intersseous (radial head): arises from medial surface of shaft.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 45 
  • Review of Literature-anatomy of hand E) FIFTH METACARPAL BONEIt is recognised by:a) Presence of a tubercle on medial aspect of the base, there being no facet.b) Lateral aspect of the base has an elongated facet for articulation with the base of 4thmetacarpal bone.A facet on proximal surface of the base articulates with hamate.ATTACHMENTS:i) Extensor carpi ulnaris: inserted on tubercle.ii) Opponens digiti minimi: inserted into medial surface of shaft.iii) 4th Palmar interosseous: arises from palmar aspect of lateral surface of shaft.iv) 4th Dorsal interosseous (ulnar head): arises form dorsal aspect of lateral surface ofshaft.3.PHALANGES There are 14 in number, two for the thumb and three for the four fingers.PARTS: i) Base: lies proximally. ii) Shaft: lies in the middle. iii) Head: lies distally.Apart from the skeleton the major components of the hand are1. Twenty Intrinsic muscles2. Two arteries-Radial and Ulnar3. Three nerves-Radial Ulnar and Median1. TWENTY INTRINSIC MUSCLES147 The intrinsic muscles of the hand serve the function of adjusting the handduring gripping and also for carrying out fine skilled movements. The origin andinsertion of these muscles is within the territory of the hand. There are 20 muscles in the hand, as follows:I. a. Three muscles of thenar eminence i) Abductor policis brevis. ii) Flexor pollicis brevis. iii) Opponens pollicis. b. One adductor of thumb i) Adductor pollicis.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 46 
  • Review of Literature-anatomy of handII. Four hypothnar musclesi ) Palmaris brevis.ii) Abductor digiti minimi.iii) Flexor digiti minimi.iv) Opponens digiti minimi. The above four are muscles of hypothenar eminence.III. Four lumbricals.IV. Four palmar interossei.V. Four dorsal interossei. These muscles are described below.I.A.MUSCLES OF THENAR EMINENCEi) Abductor Pollicis BrevisOrigin:a) Tubercle of the scaphoid.b) Crest of the trapezium.c) Flexor retinaculum.Insertion:a) Lateral side of the base of the proximal phalanx of the thumb.Nerve supply: Median nerve (C8, T1).Action: Abduction of the thumb at the metacarpophalangeal and carpometacarpaljoints. Abduction is associated with medial rotation.ii) Flexor Pollicis BrevisOrigin: The superficial head takes origin froma) The crest of the trapezium.b) The flexor retinaculum.The deep head arises from the trapezoid and capitate bones.Insertion: Lateral side of the base of the proximal phalanx.Nerve Supply: It is supplied by the median nerve. The deep head may be supplied bythe deep branch of the ulnar nerve.Action: Flexion of the thumb.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 47 
  • Review of Literature-anatomy of handiii) Opponens PollicisOrigin:a) Crest of trapezium.b) Flexor retinaculum.Insertion: Lateral half of the palmar surface of the first metacarpal bone.Nerve supply: Median nerve (C8, T1).Action: Opposition of the thumb. This is combination of flexion and medial rotation.I.B .I) ADDUCTOR POLLICIS (Adductor of thumb)Origin: The muscle has two heads-oblique and transverse. The oblique head arises from:a) The capitate bone.b)The base of the 2nd and 3rd metacarpal bones.The transverse head arises from the palmar aspect of the third metacarpal bone.Insertion: Medial side of the base of the proximal phalanx of the thumb.Nerve Supply: Deep branch of ulnar nerve (C8,T1).Action: The muscle adducts the thumb from the flexed or abducted position. Themovement is forceful in gripping.ACTIONS OF THENAR MUSCLES In studying the actions of the thenar muscles, it must be remembered that themovements of the thumb take place in planes at right angels to those of the otherdigits because the thumb (first metacarpal) is rotated medially through 90 degrees.Flexion and extension of the thumb take place in the plane of the palm; and abductionand adduction at right angles to the plane of palm. Movement of the thumb across thepalm to touch the other digits is known as opposition. This movement is acombination of flexion and medial rotation.II HYPOTHENAR MUSCLESa) Palmaris BrevisThis muscle is superficial and lies just under the skin.Origin: From flexor retinaculum and palmar aponeurosis.Insertion: Skin along medial border of the hand.Nerve Supply: Ulnar nerve, superficial branch (C8, T1).Action: Helps in gripping by making the hypothenar eminence more prominent, andby wrinkling the skin over it.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 48 
  • Review of Literature-anatomy of handb) Abductor Digiti MinimiOrigin: This muscle arises from the pisiform bone.The origin extends on to the tendon of the flexor carpi ulnaris (proximally) and on tothe pisohamate ligament (distally).Insertion: Ulnar side of the base of the proximal phalanx of the little finger.Nerve Supply: Deep branch of ulnar nerve (C8, T1).Action: Abduction of little finger at the metacarpophalgeal joint.c) Flexor Digiti MinimiOrigin: a) Hook of the hamate bone.. b) Flexor retinaculum.Insertion: Ulnar side of the base of the proximal phalanx of the little finger.Nerve Supply: Deep branch of the ulnar nerve (C8, T1).Action: Flexion of the little finger at the metacarpophalangeal joint.d)Opponens Digiti MinimiOrigin: a) Hook of the hamate bone.. b) Flexor retinaculum.Insertion: Medial surface of the shaft of the fifth metacarpal bone.Nerve supply: Deep branch of ulnar nerve (C8,T1).Action: Flexor of the fifth metacarpal and rotates it laterally (as making the palmhollow).III. LUMBRICAL MUSCLES Lumbrical muscles are four small muscles that take origin from the tendons ofthe flexor digitorum profundus. They are numbered from lateral to medial side.Origin: The first lumbrical arises from the radial side of the tendon for the indexfinger. The second lumbrical arises form the radial side of the tendon for the middlefinger. The third lumbrical arises from contiguous sides of the tendons for the ringand little finger.Insertion: The tendons of the first, second, third and fourth lumbricals pass backwardson the radial side of the second, third, fourth and fifth metacarpophalngeal jointsrespectively. They are inserted into the dorsal digital expansions of the correspondingdigits.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 49 
  • Review of Literature-anatomy of handNerve Supply: (i) The first and second lumbricals by the median nerve (C8, T1). (ii) The third and fourth lumbricals by the deep branch of the ulnar nerve (C8, T1). Actions: The lumbrical muscles flex the metacarpophalangeal joints, and extend the interphalangeal joints of the digit into which they are inserted. IV.PALMAR INTEROSSEI Palmar interossei are four small muscles placed between the shafts of the metacarpal bones. They are numbered from lateral to medial side.Origin:i) First palmar interosseous muscle from the medial side of base of the firstmetacarpal bone.ii) Second palmar interosseous muscle from the medial half of the palmar aspect ofthe shaft of the second metacarpal bone.iii) Third palmar interosseous muscle form the lateral interosseous muscle from thelateral part of the palmar aspect of the shaft of the fourth metacarpal bone.iv) Fourth palmar interosseous from the lateral part of the palmar aspect of the shaftof the fifth metacarpal bone.Insertion:Each muscle is inserted into the dorsal digital expansion of one digit. It may also beattached to the base of the proximal phalanx of the same digit. The digits into whichindividual palmar interossei are inserted are as follow.i) First muscle: Medial side of thumb.ii) Second muscle: Medial side of the index finger.iii) Third muscle: Lateral side of the fourth digit.iv) Fourth muscle: Lateral side of the fifth digit.Note that the middle finger does not receive the insertion of any palmar interosseousmuscle.Nerve supply:All palmar interossei are supplied by the deep branch of the ulnar nerve (C8, T1).Actions:All palmar interossei adduct the digit to which they are attached towards the middlefinger. In addition, they flex the digit at the metacarpophalangeal joint and extend it atthe interphalangeal joints.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 50 
  • Review of Literature-anatomy of handV.DORSAL INTEROSSEI (Fig. 16) Like the palmar interossei the dorsal interossei are four small muscles placedbetween the metacarpal bones, and are numbered from lateral to medial side.Origin:i) First dorsal interosseous: Shafts of first and second metacarpals.ii) Second dorsal interosseous: Shafts of second and third metacarpals.iii) Third dorsal interosseous: Shafts of third and fourth metacarpals.iv) Fourth dorsal interosseous: Shafts of fourth and fifth metacarpals.Insertion:Each muscle is inserted into the dorsal digital expansion of the digit and into the baseof the proximal phalanx of that digit. The digit into which individual muscles areinserted are as follows:i) First: Lateral side of index finger.ii) Second: Lateral side of middle finger.iii) Third: Medial side of middle finger.iv) Fourth: Medial side of fourth digit.Note that the middle finger receives one dorsal interosseous muscle on either side;and that the first and fifth digits do not receive any insertion.Nerve Supply:All dorsal interossei are supplied by the deep branch of the ulnar nerve (C8, T1).Actions:All dorsal interossei cause abduction of the digits away from the line of the middlefinger. This movement occurs in the plane of palm in contrast to the movement ofthumb where abduction occurs at right angels to the plane of palm. Note thatmovement of the middle finger to either medial or lateral side constitutes abduction.Also note that the first and fifth digits do not require dorsal interossei as they havetheir own abductors. In addition (like the palmar interossei), the dorsal interossei flex themetacarpophalangeal joint of the digit concerned and extend the interphalangealjoints.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 51 
  • Review of Literature-anatomy of handINSERTION OF FLEXORS OF FOREARM148 (Fig. 14)Superficial compartment:1. Flexor carpi radialis to the palmar surface of the base of 2nd &3rd metacarpal bones.2. Palmaris longus to the distal half of flexor retinaculum and the apex of the palmaraponeurosis.3. Flexor carpi ulnaris to the pisiform bone.4. Flexor digitorum superficialis to the corresponding sides of middle phalanx.Deep compartment:5. Flexor digitorum profundus to the palmar surface of the base of the distal phalanx.6. Flexor pollicis longus to the palmar surface of the distal phalanx of thumb.INSERTION OF EXTENSORS OF FOREARM (Fig. 10, 11, 12, 13 & 15)Superficial compartment:1. Extensor carpi radialis longus to the dorsum of base of the second metacarpal bone.2. Extensor carpi radialis brevis to the dorsal aspect of bases of second&thirdmetacarpal bones.3. Extensor digitorum collateral slips inserted to the dorsalaspect of the base of thedistal phalanx&intermediate slip is inserted into the dorsal aspect of the base of themiddle phalanx.4. Extensor digiti minimi is inserted to the dorsal aspect of the base of the middlephalanx and the base of the distal phalanx through the dorsal digital expansion.5. Extensor carpi ulnaris to the medial side of the base of the 5th metacarpal bone.Deep compartment:6. Abductor pollicis longus to the lateral side of base of first metacarpal bone.7. Extensor pollicis longus to the base of distal phalanx of thumb.8. Extensor pollicis brevis to the dorsal surface of base of Proximal phalanx of thumb.9. Extensor indicis joins tendon of Extensor digitorum for the index finger.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 52 
  • Review of Literature-anatomy of handFLEXOR RETINACULUM149 It is a strong fibrous band crosses the front of carpus&converts its anteriorconcavity into the carpal tunnel, through which pass flexor tendons of digits&mediannerve. It is transversely short measuring 2.5 to 3 cm in breadth.Attached Medially toa) Pisiform and hook of Hamate.Laterally toa)Superficial laminae to the tubercles of Scaphoid and Trapezium.b) Deep laminae to the medial lip of groove of Trapezium.Proximally Retinaculum is continuous with the fascia covering Flexor digitorumsuperficialis muscle and antebrachial fascia.Distally it is continuos with the palmar aponeurosis and palmar fascia,and providesorigin to the thenar and hypothenar muscles.STRUCTURES PASSING SUPERFICIAL TO FLEXOR RETINACULUMi) Palmaris Longus muscle.ii) Palmar cutaneous branch of median nerve.iii) Palmar cutaneous branch of ulnar nerve.iv) Superficial palmar branch of radial artery.v) Ulnar nerve and ulnar vessels.STRUCTURES PASSING DEEP TO FLEXOR RETINACULUM1. Median nerve.2. Tendons of Flexor digitorum superficialis.3. Tendons of Flexor digitorum profundus.4. Tendon of Flexor pollicis longus.5. Tendon of Flexor carpi radialis lies on the groove of Trapezium betweensuperficial&deep slips of retinaculum.EXTENSOR RETINACULUM150 It is an oblique fibrous band, derived from deep fascia and stretches across thedorsal surface of the wrist to retain extensor tendons in position.Attachments: Laterally to the anterior border of radius above its styloid process.Medially, the fibres slope downward and medially,and are attached to the pisiformand triquetral bone.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 53 
  • Review of Literature-anatomy of handThe retinaculum is not attached to ulna, otherwise it would prevent pronation.Beneath extensor retinaculum there are 6 osseo fascial compartments for 9 tendonsFrom lateral to medial side:1 .Abductor Pollicis Longus & Extensor Pollicis Brevis.2. Extensor Carpi Radialis Longus & Extensor Carpi Radialis Brevis.3. Extensor Pollicis Longus.4. Four tendons of Extensor Digitorum & tendon of Extensor Indicis.5. Extensor Digiti Minimi.6. Extensor Carpi Ulnaris.PALMAR APONEUROSIS151It is a thick triangular portion of deep fascia that lies in the central region of the palm.It has an APEX at flexor retinaculum and a BASE near the head of metacarpals It isdivided into 3 parts i) Central part ii) Medial part iii) Lateral partTriangular in shapeApex blends with the distal border of flexor retinaculum.Base splits into four digital slips for the medial four fingers.Each slip divides into superficial and deep set of fibres.Superficial fibres join with the Dermis and blend with the superficial transverseligament.Deep set of fibres of each slip divides into two bands, which are attached to the deeptransverse ligament of palm, palmar ligaments of metacarpophalangeal joints, bases ofproximal phalanges and blends with the fibrous sheaths.FIBROUS FLEXOR SHEATHS OF THE DIGITS152a) To retain flexor tendons in position all 5 digits are provided with a strongunyielding fibrous sheath which extend from metacarpal head to the base of the distalphalanx.b) Fibrous sheath of the thumb contains the tendon of flexor pollicis longus only.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 54 
  • Review of Literature-anatomy of handc) In the medial 4 fingers the sheaths are occupied by 2 tendonsi) of flexor digitorum profundus to reach the base of the distal phalanx.ii) of flexor digitorum superficialis which gets inserted to the sides of middlephalanx. Each sheath crosses 3 jointsa) metacarpo phalangealb) proximal interphalangealc) distal interphalangeal The sheaths present a series of thick zones over the phalanges and thin zonesover the joints. Recent analysis shows that the thicker zones are arranged proximo-distally asa) 5 annular pulleys.b) 4 intervening pulleys .FASCIAL SPACES IN THE PALM153a) Three facial lined potential spaces limited by fibrous septa warrant attention in thepalm because of surgical importance. They are MID-PALMAR, THENAR & PULPSPACES.b) Deep to the aponeurosis, flexor tendons and lumbrical muscles lies a large fasciallined central palmar space which is limited at the sides by medial& lateral palmarsepta. This is subdivided by a intermediate fibrous septum extending from the fasciacovering the undersurface of flexor tendons to the palmar surface of third metacarpalbone into the mid-palmar space on ulnar side and the thenar space on the radial side.MID-PALMAR SPACETriangular in shape. Boundaries area) In front flexor tendons of little, ring& middle fingers with their synovial sheathsand 3rd &4th lumbrical muscles.b) Behind-dense fascia covering the interossei&metacarpal bones of 3rd &4th spaces.c) Laterally by intermediate fibrous septum.d) Medially by hypothenar muscles separated by medial palmar septum.e) Proximally space is closed by attachment of parital layer of ulnar bursa.f) Distally, the space extends as diverticula to the webs of fingers along the fascialsheaths of 3rd & 4th lumbrical muscles.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 55 
  • Review of Literature-anatomy of handTHENAR SPACETriangular in shape. Boundaries area) In front by muscles of thenar eminence, flexor tendon of the index finger, first &second lumbrical muscles.b) Behind by Adductor pollicis (distal border).In the web of the thumb, thenar space iscontinuous with a slit-like interval between Adductor pollicis & first dorsalinterosseus muscle.c) Laterally by tendon of flexor pollicis longus and its sheath. This tendon is separatedfrom thenar muscles by lateral palmar septum.d) Medially by intermediate fibrous septum.e) Proximally extent is same as midpalmar.f) Distally spaces extend as fascial diverticula along 1st &2nd lumbrical tendons tointerdigital clefts.RADIAL BURSA154 Where two structures slide freely over each other, e.g.: muscle, tendon or skin overbone or fascia, the friction between them is reduced by the presence of bursa. This is aclosely lined sac lined with a smooth synovial membrane which normally secretes asmall amount of glutinous fluid into the sac. When there is irritation or infection of thebursa the secretion is increased and the bursa becomes swollen, tight and tender, as in abunion. Similarly synovial sheaths enclose tendons where the range of movement isconsiderable, e.g.: the tendons sliding in the fingers. The digital synovial sheath of the little finger is continuous proximally with theulnar bursa and that of the thumb with the radial bursa.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 56 
  • Review of Literature-anatomy of handARTERIES OF THE PALM155 (Fig.6) The terminal parts of ulnar and radial arteries on reaching the palm,anastomose with each other to form superficial and deep palmar arches.SUPERFICIAL PALMAR ARCH The ulnar artery, accompanied by ulnar nerve on its medial side, enters thepalm superficial to the flexor retinaculum and on the radial side of pisiform bone.Beneath the palmaris brevis the artery divides into superficial branch is the directcontinuation of the ulnar artery and forms the main contribution of the superficialpalmar arch. Superficial palmar arch is arterial arcade which lies beneath the palmaraponeurosis and in front of long flexor tendons, lumbrical muscles and palmar digitalbranches of median nerve. The arch is formed by the superficial terminal branch ofulnar artery and completed on the lateral side by one of the following arteries – a. Superficial palmar branch of radial artery. b. Arteria princeps pollicis or Princeps pollicis artery. c. Arteria radialis indicis or Radialis indices artery. d. Arteria nervi mediana which accompanies the median nerve. The convexity of the arch is directed distally on a level with the distal border of outstretched thumb.Branches: Four palmar digital arteries arise from the convexity of the arch. The mostmedial digital branch passes along the ulnar side of the little finger. The remainingthree branches form the common palmar digital arteries which proceed distally to theweb between the fingers, where each joins with the palmar metacarpal artery of thedeep palmar arch and then divides into two proper palmar digital arteries to supply theadjacent fingers. Therefore, the superficial palmar arch does not supply the radial side of indexfinger and both sides of the thumb.DEEP PALMAR ARCH (Fig.7) It is an arterial arcade formed by the anatomists between terminal end ofradial artery and the deep branch of ulnar artery. The radial artery enters the handbetween the two heads of first dorsal introsseous muscle, appears in the palm betweenthe oblique and transverse heads of adductor policies and continues as the deeppalmar arch. In the interval between the first dorsal interosseous and adductorA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 57 
  • Review of Literature-anatomy of handmuscles, the radial artery gives off two branches – arteria princeps pollicis and arteriaradialis inidicis. The former divides into two palmar digital branches to supply thetwo sides of the thumb; the latter supplies the radial side of the index finger. The deepbranch of ulnar artery, accompanied by the deep branch of ulnar nerve, passes deeplybetween the abductor and flexor digiti minimi and then runs laterally below the hookof hamate bone to complete the deep palmar arch.BRANCHES:a)Three palmar metacarpal arteries – These arise from the convexity of the arch, passdistally on the interosseous muscles of second to fourth spaces and in the websbetween the fingers anastomose with the common palmar digital branches of thesuperficial arch.b) Three perforating arteries – pass dorsally between the two heads of second tofourth dorsal interossei, and anastomose with the dorsal metacarpal arteries. Theiraccompanying veins drain most of the blood of the palm into the dorsal venousplexus.c) Recurrent branches extend proximally in front of the carpal bones and anastomosewith the anterior carpal arch.NERVES OF THE PALM 156MEDIAN NERVE: The median nerve enters the palm beneath the distal border of flexorretinaculum, where it enlarges and flattens before, dividing into lateral and medialbranches. Prior to division the nerve provides a recurrent muscular branch from itslateral side which curls upward around the distal border of flexor retinaculum andsuperficial to the tendon of flexor pollicis longus to supply the three muscles of thethenar eminence (abductor and flexor pollicis brevis, opponens pollicis). The lateral branch subdivides into three proper palmar digital nerves to supplythe skin of both sides of the thumb and radial side of the index finger; the branch tothe index finger provides a muscular twig to the first lumbrical. Summary of distribution of median nerve in the hand- It supplies five muscles(three thenar muscles, first and second lumbricals) and the skin of the lateral three andone-half of the digits, including the joints of the digits and local blood vessels.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 58 
  • Review of Literature-anatomy of handPALMAR DIGITAL NERVES: These are derived from median and superficial branch of ulnar nerves.Initially he digital nerves lie deep to the superficial palmar arch. As they pass distallyalong with the palmar digital vessels in the inter-digital clefts, both vessels and nervelie between superficial and deep transverse metacarpal ligaments. Here the palmardigital nerves appear in front of or superficial to the vessels and maintain thatrelationship along the digits. This is due to the fact that the nerves provide richcommunication to the sensitive pulp of the finger tips, and the digital arteries aredirected towards the nail bed to avoid the pressure of gripping. Each proper digital nerve gives articular branches to the metacarpophalangealand interphalangeal joints, supplies the skin of the palmar aspect of the digit includingthe pulp space, nail bed and provides dorsal branches to supply the skin over thedorsal surface of middle and terminal phalanges. In the thumb, however, the dorsalbranch supplies the skin over the distal phalanx only.ULNAR NERVE: The ulnar nerve, accompanied by ulnar artery on its lateral side, appears in thepalm superficial to the flexor retinaculum and on the radial side of the pisiform bone.Beneath the palmaris brevis in the proximal part of hypothenar eminence, the nervedivides into superficial and deep terminal branches. The superficial terminal branch gives a muscular twig to the palmarisbrevis, and subdivides into two branches;a) A proper palmar digital nerve which supplies the ulnar side of the little finger, andb) A common palmar digital nerve which receives a communication from the nearestcommon digital branch of median nerve and then subdivides into two proper digitalnerves to supply the adjacent sides the ring and little fingers. The digital nerves supply, in addition to palmar skin, metacarpophalangeal andinterphalangeal joints, local blood vessels, pulp spaces and nail beds and the skin ofthe dorsal surface over the middle and terminal phalanges of the medial one and halfof the digits. The deep terminal branch of ulnar nerve, accompanied by correspondingbranch of ulnar artery, passes deeply between the origins of abductor and flexor digitminimi, pierces the opponens digiti minimi and then turns laterally lodging in agroove below the hook of hamate bones. It follows the concavity of the deep palmararch and passes deep to the long flexor tendons.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 59 
  • Review of Literature-anatomy of hand The deep branch supplies muscular branches to the three hypothenar muscles,third and fourth lumbricals, all dorsal and palmar interossei, adductor pollicis andoccasionally to the deep part of flexor pollicis brevis. It also provides articularbranches to the intercarpal and carpometacarpal joints, and vascular branches to thedeep palmar arch and its branches.Summary of ulnar never distribution in the hand- It supplies all intrinsic muscles ofthe hand, except three thenar muscles and first and second lumbricals, and thecutaneous branches to the medial one and a half the fingers including the ulnar side ofthe hand.DORSAL BRANCH OF ULNAR NERVE: It appears on the medial side of the back of the wrist after piercing the deepfascia, and divides usually into two dorsal digital nerves-one proper digital nerve tosupply the skin on the ulnar side of the little finger and the other is common digitalnerve which divides into two branches to supply the adjacent sides of the little andring fingers and receives communications from the nearest digital branch of radialnerve.The dorsal digital nerves of the little finger extend up to the base of the distal phalanx,and those of the ring finger extend up to the base of the middle phalanx.WRIST (RADIO-CARPAL) JOINT 157 It is a bi-axial ellipsoid joint. The proximal articular surface presents anelliptical socket, formed by the distal articular surface of the radius and the articularsurface of the radius and the articular disc of the inferior radio-ulnar joint. The distal articular surface is convex with reciprocal outline and is formed bythe scaphoid, lunate and triquetral bones with interosseous ligament connecting thecarpal bones together.LIGAMENTS: The wrist joint possesses capsular ligament with synovial membrane, radialand ulnar collateral ligaments.CAPSULAR LIGAMENT: The fibrous capsule surrounds the joint is attached close to the peripheralmargin of the proximal and distal articular surfaces including the articular disc. Thusthe head of ulna is excluded from the joint by the articular disc.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 60 
  • Review of Literature-anatomy of hand The capsule blends in front and behind the palmar and dorsal radio-carpalligament. Both ligaments extend infero-medially from the lower end of radius to thecorresponding surfaces of the proximal row of carpal bones and to the capitate. This isto ensure the maximum functional use of the hand during pronation and supination.RADIAL COLLATERAL LIGAMENT: It is thickening of the lateral part of thecapsule and extends from the styloid process of radius to the scaphoid and trapezium.ULNAR COLLATERAL LIGAMENT: It extends from the ulnar styloid process tothe triquetral and pisiform bones.Arterial supply: Supplied by the palmar and dorsal carpal arches, derived from theanterior interosseus, anterior and posterior carpal branches of radial and ulnar arteries,and recurrent branches of the deep palmar arch.RELATIONS OF THE WRIST:Infront: (proximal to flexor retinaculum)-Beneath the deep fascia structures arementioned from lateral to medial side and arranged in superficial, intermediate anddeep planes.Superficial: Flexor carpi radialis, palmaris longus and flexor carpi ulnaris.Intermediate: Radial artery (resting on anterior surface of distal part of radius),median nerve (between flexor carpi radialis and palmaris longus, and postero-lateralto the tendon or palmaris longus) four tendons of flexor digitorum superficials,(tendons for middle and ring fingers in superficial plane, tendons for index and littlefingers in deep plane), ulnar vessels and ulnar nerve.Deep:Flexor policis longus, anterior interosseous vessels and nerve, flexor digitorumprofundus.Behind: beneath the extensor retinaculum the the retinaculum bridges over thegrooves and attached to the ridges in between the grooves, thus dividing into sixosseo-fibrous compartments. Structures within the compartments are mentioned from lateral to medial side:Abductor pollicis longus and extensor pollicis brevis, extensor carpi radialis longusand brevis, extensor pollicis longus (medial to dorsal tubercle of Lister), extensordigitorum and deep to it extensor indicis along with the posterior interosseous nerveand anterior interosseous artery, extensor digiti minimi, extensor carpi ulnaris(between the head and the styloid process of ulna).A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 61 
  • Review of Literature-anatomy of handMovements: Movements at the wrist joint are associated with considerable range ofmovements at the mid-carpal joint, because they are produced by the same groups ofmuscles. Combination of wrist and mid-carpal joints is considered as link joint. Active movements permitted at the joint complex are flexion, extension,adduction, and circumduction. Axial rotation is not possible because of ovoid outlineof the wrist joint.Flexion: Its range is about 850, and takes place more at the mid-carpal joint than at thewrist joint. With flexed fingers, carpal flexion is diminished due to increased tensionin the extensors.Extension:It is more limited in range of about 600, and occurs mainly at the wristjoint. This explains why the proximal articular surfaces of the scaphoid and lunatebones are more extensive on the posterior surface.Abduction (ulnar deviation): It is more extensive than abduction due to short ulnarstyloid process. Range of abduction is about 450, and it is mostly done at the wristjoint.Abduction (radial deviation): Its extent is only about 150 it takes place almostexclusively at the mid-carpal joint.Circumduction: It is a combination of flexion, abduction, extension and abduction orin reverse order.MUSCLES PRODUCING MOVEMENTSFlexion: Flexor carpi radialis and ulnaris act as prime movers, and assisted by flexordigitorum superficialis and profundus, flexor pollicis longus and abductor pollicislongus.Extension: Extensor carpi radialis longus and brevis, extensor carpi ulnaris acts asprime movers and assisted by extensor digitorum, extensor indicis, extensor pollicislongus and extensor digiti minimi.Abduction: Simultaneous contractions of flexor and extensor carpi ulnaris.Abduction: Abductor pollicis longus, and simultaneous contractions of flexor carpiradialis, extensor carpi radialis longus and brevis.Spinal segments controlling wrist movement:Flexion – C6, C7.Extension – C6, C7.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 62 
  • Review of Literature-anatomy of handSURFACE LANDMARKS158 (Fig.8, Fig.9) 1. Styloid process of the radius projects 1cm lower than the styloid process of ulna. It can be felt in the upper part of the anatomical snuff box. 2. Styloid process of the ulna projects downwards from the posteromedial aspect of the lower end of the ulna. 3. Pisiform bone can be felt at the base of the hypothenar eminence (medially). 4. Hook of Hamate lies one finger breadth below the pisiform bone, in line with the ulnar border of the ring finger. It can be felt only on deep palpation through the hypothenar muscles. 5. Tubercle of Scaphoid can be felt at the base of the thenar eminence in a depression just lateral to the tendon of flexor carpi radialis. 6. Tubercle (crest) of Trapezium may be felt on deep palpation inferolateral to the tubercle of scaphoid. 7. Tendons of flexor carpi radialis,palmaris longus and flexor carpi ulnaris can be identified in front of wrist when the hand is flexed against resistance.Tendons lie in the order from lateral to medial. 8. Pulsations of radial artery can be felt in front of lower end of the radius just lateral to the tendon of flexor carpi radialis. 9. Pulsations of ulnar artery can be felt by careful palpation just lateral to the tendon of flexor carpi ulnaris. 10. Anatomical snuff box is a depression which appears on the lateral side of the wrist when the thumb is extended.APPLIED ANATOMYi) COLLES’ FRACTURE159: A Colles’ fracture is a fracture of the radius within 2.5cm of the wrist with or without avulsion of the ulnar styloid process and with acharacteristic deformity. The lower fragment is usually tilted backwards, shiftedbackwards with a tilt radially.ii) REVERSED COLLES’ FRACTURE OR SMITH’S FRACTURE160: A transversefracture of the lower end of the radius with forward shift and tilt (displaced anteriorlyand tilted anteriorly) is known as Smith’s fracture. It is called reverse Colles’ becausethe deformities when viewed from the side radiologically are just opposite to thoseseen in a Colles’ fracture. Fracture line may at times be oblique extending to the wristjoint. This is fracture- dislocation. This is known as Barton’s fracture.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 63 
  • Review of Literature-anatomy of handiii) FRACTURE OF THE SCAPHOID161: The scaphoid is the most frequentlyfractured carpal bone. It often results from a fall on the palm when the hand isabducted, the fracture occurring across the narrow part (‘waist’) of the scaphoid. Painoccurs primarily on the lateral side of the wrist, especially during dorsiflexion andabduction of the hand. Initial radiographs of the wrist may not reveal a fracture; often this injury ismisdiagnosed as a severely sprained wrist. Radiographs taken 10-14 days later reveala fracture because bone resorption has occurred there. Owing to the poor blood supplyto the proximal part of the scaphoid, union of the fractured parts may take at least 3months. Avascular necrosis of the proximal fragment of the scaphoid may occur andproduce degenerative joint disease of the wrist. In some cases, it is necessary to fusethe carpals surgically (arthrodesis).iv) FRACTURE OF THE HAMATE161: It may result in the non-union of thefractured body parts because of the traction produced by the attached muscles.Because the ulnar nerve is close to the hook of the hamate, the nerve may be injuredby this fracture, causing decreased grip strength of the hand. The ulnar artery mayalso be damaged when the hamate is fractured.v) FRACTURE OF THE METACARPALS161: The metacarpals (except the 1st) areclosely bound together; hence isolated fractures tend to be stable. Furthermore, thesebones have a good blood supply, and fractures usually heal rapidly. Severe crushinginjuries of the hand may produce multiple metacarpal fractures, resulting in instabilityof the hand. Fracture of the fifth metacarpal, often referred to as the boxer’s fracture,occurs when an unskilled person punches someone with a closed fist. The head of thebone rotates over the distal end of the shaft, producing a flexion deformity.vi) INFECTION OF RADIAL BURSA162: In fact true synovitis of the flexor pollicislongus always brings about the condition. This is evident by the fact that swelling ofthe thumb is seen to extend into the thenar eminence. The thumb is held flexed.Swelling may be seen just proximal to the flexor retinaculum on the lateral side.vii) STENOSING TENOVAGINITIS 163a) De Quervain’s disease: De Quervain first explained this disease in 1895.In thiscondition the fibrous sheath containing extensor pollicis brevis and abductor pollicisbrevis and abductor pollicis longus tendon becomes fibrosed and thickened, so thatthe intrathecal lumen becomes narrowed. It occurs at a point 11/2 inches or 3.25 cmA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 64 
  • Review of Literature-anatomy of handabove the tip of the radial styloid process.. It is on the lateral aspect of lower end ofthe radius where the tendons lie in shallow bony groove. The main symptom is pain on the radial side of the wrist particularlyfollowing actions like wringing clothes. There is also weakness of the grip and of thethumb. Pain becomes aggravated by abduction and extension of the thumb.b) Trigger Finger: This is a condition of stenosing tenovaginitis of flexor tendons. Inthis condition there is obstacle to voluntary flexion or extension of the finger. Whenthe finger is extended, it is difficult to do so, but when the obstructed portion iscrossed, the finger suddenly straightens with a snap; hence it is called ‘TriggerFinger’.c) Mallet Thumb: This resembles mallet finger. The extensor pollicis longus may becut anywhere or it may rupture at the wrist in rheumatoid arthritis or it may rupturefollowing fracture of lower end of radius.viii) Carpal-Tunnel Syndrome164: This is a condition in which the median nerve iscompressed at the wrist as it passes through the carpal tunnel. The compression can becaused by skeletal abnormalities, swelling of other tissues within the tunnel orthickness of retinaculum. The predominant signs are pain, paraesthesia, pins andneedles in the finger and loss of coordination of fingers.ix) Ulnar claw hand165: This nerve has a high susceptibility of getting injured in theregion of wrist that produces ulnar claw hand. The little and ring fingers are affected.The metacarpophalangeal joints are hyperextended and the interphalangeal joints areflexed.x) True claw hand165: This occurs when the ulnar nerve and median nerve are bothinjured at the wrist. The main sign of this is the inability to oppose the thumb. Theparalysis of the short muscles of the thumb leads to a deformity called Ape-like handin which the thumb is permanently adducted and laterally rotated.COMPLICATIONS OF MARMA ABHIGATA166A) ASPHYXIA: This is related to Marmas situated in the chest region such asHrudaya, Stanamoola, Stanarohita, Apalapa and Apasthambha. Hrudaya is directlyrelated to primary asphyxia whereas other marmas are most of the time concerned tosecondary asphyxia and Susruta has dealt thorax, intra-thoracic conditions. eg: cardiactamponade, surgical emphysema, pneuomothorax, hydrothorax, pyothorax andA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 65 
  • Review of Literature-anatomy of handhaemothorax. This condition is quickly fatal and if not relieved the death can ensue inminutes.B) HEAMORRHAGE: After cardiopulmonary involvement the hemorrhage is nextin importance and should be rapidly controlled by whatever means are available.Susruta highlights the surgical conditions of certain injured muscles. Thoughanaerobic conditions associated with myositis could not come on the surface, howeverbleeding muscle and important mamsa marma such as Talahrudaya, Indrabasti, Guda,Stanarohita marma posing fatal condition have definitely been considered. 167C) SHOCK : is a condition in which circulation fails to meet the nutritional needs ofthe cells and at the same time fails to remove the metabolic waste products.Types:i) Haematogenic or Hypovolaemic shock: This type of shock is due to loss of blood,plasma or body water and electrolytes or in one word loss of intravascular volume. Itis often caused by heamorrhage, vomiting, diarrhea, dehydration etc. This is clinicallymanifested by low cardiac output, tachycardia, low blood pressure andvasoconstriction revealed by cold clammy extremities.ii) Traumatic shock: This type of shock is caused by major fractures, crush injuries,burns, extensive soft tissue injuries and intra-abdominal injuries. This causes anintravascular inflammatory response with increase in vascular permeability, whichrequires large volumes of colloidal and crystalloid fluid for resuscitation.iii) Neurogenic shock: This is caused by paraplegia, quadriplegia, trauma to the spinalcord or spinal anesthesia. Such shock is primarily due to blockade of sympatheticnervous system resulting in loss of arterial and venous tone with pooling of blood inthe dilated peripheral venous system. Vasovagal or Vasogenic shock is also a part of neurogenic shock in whichthere is pooling of blood due to dilatation of peripheral vascular system particularly inthe limb muscle and in the splanchnic bed. This cause reduced venous return to theheart leading to low cardiac output and bradycardia. Blood flow to the brain isreduced causing cerebral hypoxia and unconsciousness. Psychogenic shock, which may follow sudden fright from unexpected badnews or at the site of horrible accident, is also included in this group.iv) Cardiogenic shock: This type of shock is caused by injury to the heart, myocardialinfarction, cardiac arrhythmias or congestive cardiac failure. In this condition theheart fails to pump blood.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 66 
  • Review of Literature-anatomy of handv) Septic shock: Such type of shock is most often due to gram negative septicaemia.Such type of shock may occur in cases of severe septicaemia, cholangitis, peritonitisor meningitis. In early stages cardiac output increases, but vascular resistancedecreases due to dilated cutaneous arteriovenous shunts. In late cases, vascularpermeability increases, so that the blood volume decreases leading to hypovolaemia.In further advanced cases the cardiac function is damaged due to toxins liberated bythe organisms.vi)Miscellaneous types: These include anaphylatic shock and insulin shock.D) Tetanus168: This potentially fatal condition, also called “lock jaw” is caused byClostridium tetani, a Gram positive spore-forming bacillus occurring naturally in theintestines of humans and animals and in the soil. It enters the body through a woundand replicates thriving on the anaerobic conditions present in devitalized tissues. Itproduces tetanospasmin, a potent exotoxin that binds to neuromuscular junctions ofthe C.N.S neurons, rendering them incapable of neurotransmitter release. This leads tofailure of inhibition of motor reflex responses to sensory stimulation. The result is generalized contractions of agonist and antagonist musclescausing tetanic spasms. The medium incubation period is 7 days, ranging from 4-14days. Early symptoms are painful spasms of the masseter and facial musclesresulting in the classical ‘risus sardonicus’. The spasms spread to involve the musclesof respiration and the laryngeal musculature. Spasms of the paravertebral and extensorlimb contracture produce ‘opisthotonos’ an arching of the whole body. Laryngeal muscle spasm lead to aponea and if prolonged to asphyxia andrespiratory arrest. The spasms can be brought on the slightest of sensory stimuli. Theymay be sustained and severe enough to produce long bone fractures and jointdislocations.E) GAS GANGRENE169: This is a rapid spreading infective gangrene of the musclescharacterized by collection of gas in the muscles and subcutaneous tissue. As thiscondition is caused by Clostridial infection, it is also called ‘Clostridial myonecrosis’.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 67 
  • Methodology …… METHODOLOGY Source of data: Literary and conceptual study was done on the data compilations from the Bruhatrayees, Laghutrayees, and other classical books including journals, presented papers, previous work done and co-related, analyzed with the knowledge of contemporary science on the topic “A comprehensive study of marmas in the Hasta (Hand) w.s.r to the surface and regional anatomy (cadaver dissection).” Dissection of region on marmas in Hasta on cadavers in the dissection hall at S.D.M. College of Ayurveda, Udupi was done. Observations were analyzed and co-related in the view of ancient description of marmas in Hasta and special reference to modern science. Method of collection of the data: Literary works, Books, Journals including published ones on the concept related to subject will be reviewed and related information will be collected and analyzed scientifically. Cadaver study was conducted on ten hands of five cadavers in Shareera Rachana dept. of S.D.M. College of Ayurveda, Udupi. Assessment criteria: Observation of surface and regional anatomy on cadaver dissection and co-related with the shareera of marmas in the Hasta region as explained in Ayurveda classics.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 68 
  • Observation…   OBSERVATION The dissection on ten hands of five cadavers was carried out in the departmentof anatomy of S.D.M.C.A, Udupi as per the Cunningham’s manual. Skin and Superficial fascia around the region of the wrist joint was removed. Superficial fascia contained dense bundles of fibrous tissue connecting theskin to the palmar aponeurosis in the palm and is thickened transversely in the websof the fingers to form the superficial transverse metacarpal ligament. On the proximal part of the hypothenar eminence, the Palmaris Brevis musclewas identified which passes from the skin on the ulnar border of the hand to thepalmar aponeurosis. FLEXOR RETINACULUM which is a fibrous band and modification of deepfascia was identified. It was attached to the Scaphoid and Trapezium laterally.Medially it is attached to the Pisiform and Hamate bones. The ulnar nerve and vessels, palmar cutaneous branch of the median and ulnarnerves and the tendon of Palmaris longus muscle were found to pass superficial to it. The median nerve and the four muscles of the flexor compartment wereobserved passing deep to the carpal tunnel. Palmaris Longus was found inserted into the distal half of flexor retinaculumand the apex of palmar aponeurosis. PALMAR APONEUROSIS is a thick triangular portion of deep fascia thatlies in the central region of the palm. Its apex at flexor retinaculum, base near the headof metacarpals and its four slips were identified. The three muscles of the thenar eminence were identified. The AbductorPollicis was the lateral muscle and Flexor Pollicis Brevis was the medial one. Thesetwo form the superficial lamina and the deeper lamina was constituted by theOpponens Pollicis. The four hypothenar muscles were identified. Hypothenar eminence wasconstituted by abductor digiti minimi medially and Flexor Digiti Minimi lateral to it.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 69  
  • Observation…   ULNAR NERVE gave a dorsal branch 5 cm above the medial side of the backof the wrist which gave a proper digital nerve which supplied the skin on the ulnarside of the little finger and another common digital nerve which divide into twobranches to supply the adjacent sides of the little and ring fingers .It receivedcommunication from the nearest branch of radial nerve. It entered the palm on the lateral side of the pisiform bone, superficial to theflexor retinaculum. It then passed deep to the Palmaris brevis muscle and subdividedinto superficial and deep terminal branches. Superficial terminal branch wasidentified. Deep terminal branch which passed deep to the flexor tendons was alsoidentified. MEDIAN NERVE entered the palm deep to the flexor retinaculum in thecarpal tunnel. Palmar cutaneous branch pierced the deep fascia and supplies the skinof the thenar eminence and central region of the arm. Recurrent muscular branchcurled upwards and supplied three muscles of thenar eminence. The Lateral and Medial branches of Median nerve were distinguishable. ULNAR ARTERY entered the palm by passing superficial to the flexorretinaculum. Beneath the palmar aponeurosis it anastomosis with the radial artery toform the superficial and deep palmar arches. Superficial palmar arch was found deep to the Palmaris Brevis and Palmaraponeurosis. It then crossed the palm over the lumbricals and the digital branches ofthe median nerve. It gave away four digital branches which supplied the medial three and a halffingers. The deep branch of the ulnar artery arised in front of flexor retinaculumimmediately beyond the pisiform bone. Soon it passed between the flexor andabductor digiti minimi to join and complete the deep palmar arch. RADIAL ARTERY passes through the anatomical snuff box and divides toform the superficial and deep arches. The branches identified werea) To the lateral side of the dorsum of the thumb.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 70  
  • Observation…  b) Dorsal metacarpal artery was identified.c) In palm it gave off a branch Princeps pollicis artery which was identified.d) Radialis indicis artery was also identified.WRIST JOINT: The wrist is surrounded by the thickened band of deep fascia ie both theretinacula. The three muscles of the thenar eminence and the four hypothenar muscleswere identified. After cutting and reflecting the two retinacula, thenar and hypothenar musclesa clear view of the wrist joint was obtained. The distal end of the radius articulated medially with the ulna(ulnar notch) andinferior surface of the lower end of the radius was found articulated with the Scaphoidand Lunate bones. The capsular ligament was identified. The Dosal radiocarpal ligament on the dorsal aspect of the joint was identified. The Radial collateral ligament was identified. The Ulnar collateral ligament was identified. Anterior interosseus nerve and the posterior interosseus nerve were identified. Flexor carpi ulnaris was found inserted into the pisiform bone. Lying on the deeper plane were the tendons of flexor digitorum superficialisand flexor digitorum profundus. Originating from the tendons of flexor digitorum profundus four lumbricalswere observed.The first two were unipinnate and the remaining two bipinnate andwere inserted to the dorsal digital expansions of the corresponding digits. Deep palmar arch was formed by the anastomosis between the deep branch ofthe radial artery and the deep branch of the ulnar artery. It passed across the bases ofA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 71  
  • Observation…  metacarpals and interossei and lay undercover of the oblique head of the adductorpollicis, flexor tendons and lumbricals. It gave away three palmar metacarpal arteries, three perforating arteries andrecurrent branches. The four palmar interossei muscles were spotted positioned between the shaftof the metacarpal bones. Flexor Carpi Radialis was found inserted into the palmar surface of the basesof the second and third metacarpal bones. RADIAL NERVE, posterior cutaneous nerve of the forearm was found tosupply the region of skin around the wrist and dorsum of the hand. The superficial branch of radial nerve after piercing the deep fascia supplied tothe lateral 2/3rd of the dorsum of the hand and the dorsal surfaces of the thumb andlateral two and a half fingers through five dorsal digital nerves. The lateral three wereproper digital nerves and the medial two are common digital nerves. EXTENSOR RETINACULUM which is an oblique fibrous band andmodification of deep fascia was observed. Laterally it was found attached to theanterior border of the radius above the styloid process and medially to the pisiformand triquetral bones. The six osseofacial compartments along with the nine muscles of the extensorcompartment were identified. Extensor Carpi Radialis Longus was found inserted into the dorsum of thebase of the second metacarpal bone. Extensor Carpi Radialis Brevis was found inserted into the dorsal aspect of thebase of the second and third metacarpal bones. Extensor Digitorum, the intermediate slip was found inserted into the dorsalaspect of the base of the middle phalanx. The collateral slips reunited to get insertedinto the dorsal aspect of the base of the distal phalanx.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 72  
  • Observation…   Extensor Digiti Minimi was found inserted into the dorsal aspect of the base ofthe middle phalanx and terminal phalanx along with the tendon of extensor digitorumfor the fifth digit. Extensor Carpi Ulnaris was found inserted to the medial side of the base of thefifth metacarpal bone. Abductor Pollicis Longus was found inserted to the lateral side of the base ofthe first metacarpal and the other part to the trapezium. Extensor Pollicis Longus was found inserted in the dorsal aspect of the base ofthe thumb. Extensor Pollicis Brevis was found inserted in the dorsal surface of the base ofthe proximal phalanx of the thumb. Extensor Indicis was found inserted along with the ulnar side of tendon ofextensor digitorum for the index finger. The four dorsal interossei were also found placed between the metacarpalbones on the dorsal aspect with the origin, insertion and nerve supply as mentioned inliterary review.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 73  
  • Figures…. SURFACE MARKINGS OF HASTA MARMA Fig: 1A- Kshipra (Palmar Aspect) Fig: 1B- Kshipra (Dorsal Aspect) Fig: 2A- Talahrudaya (Palmar Aspect) Fig: 2B- Talahrudaya (Dorsal Aspect)A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 74 
  • Figures…. Fig: 3A- Kurcha (Palmar Aspect) Fig: 3B- Kurcha (Dorsal Aspect) Fig: 4A- Kurchashira (Palmar Aspect) Fig:4B- Kurchashira (Dorsal Aspect) Fig: 5A- Manibandha (Palmar Aspect) Fig: 5B- Manibandha (Dorsal Aspect)A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 75 
  • Figures…. Fig 6: Anterior view of palm with vessels and nerves Fig 7: Deep palmar arch and its branchesA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 76 
  • Figures…. 1. Extensor retinaculum. 2. Flexor retinaculum. 3. Head of metacarpals. 4. Ulnar artery. 5. Radial artery. 6. Level of Superficial palmar arch. 7. Level of Deep palmar arch. Fig 8: Surface anatomy of hand Fig 9: Surface anatomy of hand (Bony Landmarks)A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 77 
  • Figures…. CADAVER DISSECTION PHOTOS Extensor pollicis longus Extensor carpi Extensor pollicis radialis brevis brevisExtensor carpiradialis longus Abductor pollicis longus Fig 10: Muscles of Extensor Compartment Extensor digitorum Fig 11: Extensor Digitorum Extensor digiti Minimi Fig12: Extensor Digiti Minimi A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 78 
  • Figures…. Extensor carpi ulnaris Fig 13:Extensor Carpi Ulnaris Flexor digitorum profundus Flexor digitorum superficialis Fig 14: Flexor Tendons Abductor pollicis brevis Fig 15:Abductor Pollicis BrevisA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 79 
  • Figures…. First dorsal interossei Fig 16:First dorsal interossei Fig 17: Dissected Hand Palmar surface Fig 18: Dissected Hand Palmar surfaceA comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 80 
  • Discussion…  DISCUSSION The terminology of Hasta has variable opinion among acharyas.In the presentstudy the region from manibandha sandhi (wrist joint) and below has been consideredas Hasta. Manibandha has been mentioned as panimoola (root of hand) by Dalhana. There are five marmas in this region and are discussed below.KSHIPRA MARMA The region of the marma is the web space between the first and secondmetacarpal bone i.e. between the thumb and index finger. The distance between theroot of the thumb and the tip of the index finger is given as 5 Angula and thepramanaof the marma is half angula.There is a difference of opinion among scholarsabout the understanding of pramana shareera when it comes to the marmashareera.Many opine that it is the length, some consider it as the width, some as depthand some as diameter of a circle .It is more appropriate to take it as length, width anddepth from a presumed centre. In the present study the width of the madhyama parvaof the madhyama angula is taken as anguli. The structures that pass through this region are i) Radialis indicis artery/Arteria radialis indicis. ii) Princeps pollicis artery/Arteria princeps pollicis. (in the interval between the first dorsal interosseus and adductor muscle) iii) Deep branch of radial artery that proceeds to form deep palmar arch. iv) Recurrent branch of median nerve which supplies the thenar muscles. v) Three proper palmar digital nerves of the lateral branch of the median nerve which supply the skin of both sides of the thumb and radial side of index finger. vi) First lumbrical. vii) First palmar interossei. viii) First dorsal interossei. ix) Transverse and oblique head of adductor pollicis. x) Radial bursa. xi) Superficial terminal branch of Radial nerve and its dorsal digital branches.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 81  
  • Discussion…  It is a snayu marma, kalantarapranahara in nature. It is also mentioned thatsometimes the marma can be sadyopranahara.It has also been explained that deathwill occur due to akshepaka. Acharya Susruta has mentioned that this marma can sometimes turn intosadyopranahara. Akshepaka is one among vatavyadhis mentioned by Susruta andVagbhata.In akshepaka the vayu entering the dhamani will cause severe spasm andconvulsions in the individual. More of that the attacks will be frequent.Dalhana hasinterpreted the dhamani as nadi which possibly indicates the involvement of nervoussystem in the vyadhi. It has been mentioned that in the Kshipra marma abhigata,there will be severeblood loss which will lead to the vata prakopa. The convulsions and spasm caused by an injury due to severe blood loss is closelyadherent with the similar sign found in Tetanus (Lock Jaw).The sign of ‘opisthotonos’mentioned in tetanus is strikingly similar to the akshepaka. The hand and the leg are the two main body parts that makes man an efficientbeing on earth. Our samhitas were written at a time when human life was notmechanized and man had to do all his daily chores like cutting grass, wood etc. withhis hand and feet. So they were more exposed to soil and dirt and hence had an easychance to get wounded. The site of marmas in the hand and feet were moresusceptible to injury and infection. The methodology of management of sepsis might have been different at the timeof Susruta.So this could be one of the reasons why amputation has been indicated inkshipra marma abhigata to prevent further spread of infection to upper limb. Apart from that the incubation period of clostridium tetani is mentioned to be inbetween 4-14 days which strikingly matches with the fact that the a person injured inthe kalantarapranahara marma will die within 15-30 days. There are 20 intrinsic muscles in our hand and Susruta might have classified mostof them as snayu, due to their small size which led to the classification of Kshipra as asnayu marma.Since thumb is the master finger, the first web space was given moreimportance compared to others.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 82  
  • Discussion… TALAHRUDAYA MARMA The etymology of the word can be assumed that it means the ‘hrudaya’(centre) ofthe hastatala.So the derived name Talahrudaya. The region of the marma is in the centre of the palm in straight line with themiddle finger and the pramana of marma is given as half angula and is a mamsamarma of the kalantarapranahara variety.The structures passing through this region arei) Palmar aponeurosis.ii) Tendons of flexor digitorum superficialis.iii) Tendons of flexor digitorum profundus.iv) Second and third lumbricals.v) Superficial palmar arch.vi) Medial division of median nerve.vii) Second and third dorsal interossei.viii) Communicating branch between the superficial terminal branch of radial nerveand dorsal branch of ulnar nerve. The signs of marma vidda lakshana given are ruja and marana. Though ruja (pain)is a common manifestation of all major injuries in this case it will be severe due to theclose adherence of neurovascular network. Any rupture in the superficial palmar archwill lead to severe haemorrhage and a piercing or blunt injury will definitely damagethe median nerve. This will definitely lead to traumatic shock or vasovagal shock.Apart from that the person can also easily get infected with tetanus which will lead todeath. The possible reason in classifying talahrudaya as a mamsa marma is because theskin and palmar aponeurosis gives a fleshy and thick protection to the underlyingstructures. It is also significant to note that amputation is advised in talahrudaya marmaabhigata like kshipra marma to prevent further sepsis.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 83  
  • Discussion… KURCHA MARMA The etymology of the word kurcha suggests that it is in the shape of a brush. The region of the marma is two angula above the kshipra marma.There occurs adoubt whether the two angula is to be taken towards the region of wrist joint ortowards the termination of fingers. The marmas are described in humans starting fromthe extremities of the limb and upwards. So it is appropriate to consider it towards theregion of wrist joint. The marma is of swapanitala pramana.It is a snayu marma of thevaikalyakara variety. The structures passing through this region arei) Palmar aponeurosis dividing into central, medial and lateral part.ii) Tendons of Flexor digitorum superficialis and Flexor digitorum profundus comingout of the flexor retinaculum and spreading out distally like the end of brush.iii) Mid palmar space and Thenar space.iv) Tendons of Extensor Digitorum and Extensor Indicis. The signs of marma viddha lakshanas according to Susruta are Hasta Bhramanaand Vepana.According to Ashtanga Hrudaya the signs are Hasta Bhramana andKampa. This can be interpreted as tremors and rotation of hand to the medial or lateralside. This is because the supply to any one of the group of twenty intrinsic muscles ofthe hand is impaired, it will lead to the hyperextension of metacarpophalangeal jointsas in claw hand or laterally rotated thumb as in ape-like hand. This can be interpretedas hasta bhramana.Also a trauma could lead to the progressive shortening of palmaraponeurosis causing Dupuytren’s contracture, which also is a vikalata. Apart from that any rupture in the tendon will lead to hematoma and collection ofpuss in the mid palmar and thenar space. These conditions will lead to severe noncompensatory loss of tissues that might lead to vikalata.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 84  
  • Discussion… KURCHASHIRA MARMA The etymology of the word suggests that it is named so because it is fastened up atone end like a brush. The region of marma is below and on both sides of the manibandha.The marma isone angula in pramana and is a snayu marma of rujakara variety. Assuming from the shape of the marma it has to be understood that the flexor andextensor tendons coming under the flexor and extensor retinaculum has to be takeninto account. Here the kurcha or brush like appearance is made up of the confluenceof various tendons, nerves and the kurchashira appearance (fastening of brush isformed by the flexor and extensor retinaculum present below the joint).The structurespassing deep to the retinacula are1. Median nerve.2. Tendons of Flexor digitorum superficialis.3. Tendons of Flexor digitorum profundus.4. Tendon of Flexor pollicis longus.5. Tendon of Flexor carpi radialis lies on the groove of Trapezium between thesuperficial&deep slips of retinaculum.6. The tendon of Palmaris longus is inserted into the superficial part of flexorretinaculum.7. The nine tendons of the muscles of the extensor compartment in six osseofacialcompartments also pass deep to the extensor retinaculum The possible reason for classifying kurchashira as a snayu marma is due to thepredominance of snayu in the region. Kurchashira marma is classified as rujakara marma.Another fact is that an injuryat that level will lead to vaikalyata(deformity).The reasoning is that most of themanifestations involving injury to the nerves and vessels are found much below thewrist joint.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 85  
  • Discussion…  For example the entrapment of median nerve in the carpal tunnel leads to thewastage of thenar muscles, which lies below the manibandha and kurchashiramarma.So the predominant sign of any injury to this marma has to be ruja.MANIBANDHA The etymology of the word suggests that it means a string of mani(beads) joinedtogether. The arrangement of the carpal bones gives a string like appearance. It is located at the meeting point of prapani and hasta.The marma is two angula inpramana and is a sandhi marma of rujakara variety.The structures occupying this region arei) Lower part of radius and ulna.ii) Radial and Ulnar collateral ligaments.iii) Capsular ligament.iv) Tendons of the muscles of the flexor and extensor compartment. Fractures of the wrist joint involving the lower end of the radius (Colles’ fractureand Smith’s fracture) are very common. Fracture of the Scaphoid is also verycommon. Manibandha is classified as a sandhi marma because it joins the forearm and hand. Among the sandhi marmas only manibandha and gulpha are classified as rujakaramarmas. Many reasons can be attributed for classifying manibandha as a rujakaramarma.The first one is that it is not a weight bearing joint and it has a wide range ofmovements. Second one is that the haemorrhage in this region can easily becontrolled. Third one is that Susruta might have statistically observed less number ofdeformities in this region. However severe injury and lack of proper management maylead to deformity as mentioned by Susruta.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 86  
  • Discussion…  There are three fates for any wound. One is the entrapment or involvement of vitalorgans, second is the non compensatory loss of tissue and third is the compensatoryloss of tissue. Rujakara marma belongs to the third variety where pain is the first signof morbidity. It is also significant to mention that scaphoid fracture is often misdiagnosed asseverely sprained wrist .Secondly owing to the poor blood supply to the proximal partof scaphoid, union of fractured parts takes a minimum of three months. Thissubstantiates that the patient will have to suffer the pain for three months. Avascularnecrosis of the proximal segment of scaphoid may lead to degenerative joint diseaseof the wrist in which the patient has to suffer long standing pain. Fracture of the Hamate bone may result in the malunion of the fractured bonyparts because of the traction produced by the attached muscles. Also the ulnar nerveand artery can get damaged since it lies close to the hook of hamate bone.Ulnar nerveif injured will cause decreased grip strength. These are some anatomical facts which substantiate the classification ofmanibandha as rujakara marma. Another point to note is that any entrapment or injury to a vessel or nervemanifests below the manibandha (wrist joint). Again the injury to manibandha marma leads to ‘kundata’ (inability to performactions with hand).The ruja or pain will be so severe that makes the hand inefficientor the ruja that has occurred due to the abhigata will slowly lead to‘karsyaakarmanata’. The wrist joint has a wide range of motions and also aids in transmitting weightsfrom hand to forearm which makes it more susceptible to overuse injuries ofligaments, compressive neuropathies, dislocations, fractures etc. Manibandha is a sandhi marma and so all the structures involved in the formationof wrist joint should be considered under this marma.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 87  
  • Conclusion….   CONCLUSION Though there are variable opinions in the Samhitas regarding the concept ofHasta, the present study has considered the region between the manibandha sandhi(wrist joint) and madhyama anguli paryanta (tip of the middle finger) as Hasta(Hand). The region of Kshipra marma is the web space between the first and secondmetacarpal bone where a confluence of vessels, nerves and muscles take place. It isclassified as a snayu marma that may be due to the predominance of tendons of themuscles of flexor and extensor compartment of forearm and small intrinsic muscles ofthe hand. It is classified as kalanatarapranahara marma and sometimes may becomesadyopranahara. When the nerves and vessels get afflicted it may cause death due toakshepaka (vata vyadhi). The region of Talahrudaya marma is the centre of the palm in straight linewith the middle finger which contains the superficial palmar arch, tendons of themuscles of flexor and extensor compartment of forearm, intrinsic muscles and nervesof the hand shielded by a thick layer of skin, superficial fascia and palmaraponeurosis. This thick shield or covering justifies the reason of classifying it as aMamsa marma. The injury afflicting the closely adherent neurovascular network leadsto ruja and marana. The region of Kurcha marma is two angula above the Kshipra marma wherethe spreading out of palmar aponeurosis and tendons of the flexor and extensorcompartment takes place. The mid palmar space, thenar space also occupies theregion. The predominance of tendons of various muscles and the short intrinsicmuscles of the hand justifies the classification of this marma as snayu marma. Whenafflicted it leads to hasta bhramana and kampa.Hasta bhramana is a vikalata and so itjustifies the classification of kurcha as vaikalyakara marma. The region of Kurchashira marma is below manibandha sandhi. The vessels,nerves and the tendons beneath the flexor and extensor retinaculum gives the shape ofa head of the brush. The predominance of extensor and flexor tendons passing throughthe region justifies the classification of this marma in the snayu variety.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 88   
  • Conclusion….   Any injury afflicting this marma leads to sopha and ruja, at the same time theregion where the pathology manifests is mostly below the site of marma as in carpaltunnel syndrome. So the classification of this marma as rujakara is justified. The region of manibandha marma is the meeting point of prapani and hasta. Itis a sandhi marma and the lower part of radius, ulna, scaphoid ,lunate, triquetral andthe ligaments of wrist joint come in this region. The long standing pain caused due tothe wrongly diagnosed scaphoid fracture,malunion of fractured hamate bone andsprain of the wrist joint all justifies the classification of this marma undervaikalyakara variety. The marma shastra was propogated mainly to save the life of a person in acritical condition as during warfare. So Acharyas might not have taken all theanatomical points into consideration while performing the rescue procedure.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 89   
  • Summary….  SUMMARY The study entitled “A comprehensive study of marmas in the Hasta (Hand) w.s.rto the surface and regional anatomy (cadaver dissection)” comprises of 8 chapters namelyIntroduction, Objectives, Review of literature, Methodology, Observations & Result,Discussion, Conclusion & Summary.Chapter-1: Introduction It gives compact idea of the subject of discussion namely marma shareera. Therelevance of this topic especially based on their anatomical importance also highlighted.Chapter-2: Objectives It gives an idea about Aims & Objectives of the study.Chapter-3: Review of literature Review of literature is sub divided into Historical review, Ayurvedic review, andModern review.  Historical review – It consists of references pertaining to Marma in variousancient literatures of Vedic period, Samhita period and Sangraha Kala. Ayurvedic Review- It elaborates the details & importance of Marma in variousancient Ayurvedic texts, it also details all available references related to marma and hastamarma. This chapter also contains the tables which details the classification of differentmarmas and marma vasthu in our shareera. Modern Review- It deals with detailed anatomy of the hand.Chapter-4: Methodology This chapter explains method of Data collection, Assessment criteria andmethodology. Chapter-5: Observation It embraces the inference drawn based on the studies conducted.A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 90  
  • Summary…. Chapter-6: Discussion It comprises the details of the collected data and comparison with thosementioned in the ancient literature & modern anatomy texts.Chapter-7: Conclusion It consists of conclusion drawn from the work carried out.Chapter-8: Summary It summarizes the entire work. A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 91  
  • Reference Shlokas…. REFERENCE17. qÉ×+qÉlÉÏlÉ, qÉ× +mÉëÉhÉirÉÉaÉå (A.MüÉå.3/5/30)18. qÉ×+xÉuuÉïkÉÉiÉÑprÉÉå qÉÌlÉlÉ , xÉÎlkÉxjÉÉlÉqÉç ,eÉÏuÉxjÉÉlqÉç | (zÉ.Mü.SìÓ)19. qÉqÉïlÉ- qÉ×+qÉÌlÉlÉ (uÉÉcÉ.uÉÉsÉ.5)20. qÉqÉÉïÍhÉ qÉÉÇxÉÍxÉUÉxlÉÉruÉÉÎxjÉxÉÎlkÉxÉ̳ÉmÉÉiÉÉ :, iÉãwÉÑ xuÉpÉÉuÉiÉ :LuÉ ÌuÉvÉãwÉãhÉ mÉëÉhÉÉÎxiɸÎliÉ, iÉxqÉÉlqÉqÉïxuÉÍpÉWûiÉÉxiÉÉÇxiÉÉlÉç pÉÉuÉÉlÉÉmÉbÉliÉã || (xÉÑ. vÉÉ. 6/25)21. qÉÉUrÉliÉÏÌiÉ qÉqÉÉïhrÉÑcrÉliÉå | (QûsWûhÉ. xÉÑ.vÉÉ. 6/३)22. eÉÏuÉ xjÉÉlÉÇ iÉÑ qÉqÉï xrÉÉ‹ÏuÉÉaÉÉUÇ iÉSÒcrÉiÉå| (UÉ.ÌlÉ.qÉlÉÑwrÉÉÌSuÉaÉï,87)23. iÉåwÉÉqÉlrÉiÉqÉmÉÏQûÉrÉÉÇ xÉqÉÉÍkÉMü mÉÏQûÉ pÉuÉÌiÉ,cÉåiÉlÉÉÌlÉoÉlkÉ uÉæzÉåwrÉÉiÉç | (cÉ.ÍxÉ.9/3)24. qÉÉÇxÉÉÎxjÉxlÉÉrÉÑqÉlÉÏÍxÉUxÉÎlkÉxÉqÉÉaÉqÉ:xrÉÉlqÉqÉãïÌlÉ cÉ lÉãlÉÉ§É xÉÑiÉUÉÇ cÉÏÌuÉiÉÇ ÎxjÉiÉqÉç || (A.Wû.vÉÉ. 4/38)25. qÉUhÉMüÉËUiuÉÉlqÉqÉï qÉUhÉ xÉSØvÉSÒ: ZÉSÉÌrÉiuÉÉSÕ uÉÉ | (AÂhÉS¨É.A.¾èû.xÉÔ.4/37)26. xÉ̳ÉmÉÉiÉ: ÍxÉUÉxlÉÉrÉÑxÉÎlkÉqÉÉÇxÉÉÎxjÉxÉqpÉuÉ | qÉqÉÉïÍhÉ iÉãwÉÑ ÌiɸÎliÉ mÉëÉhÉÉ: ZÉsÉÑ ÌuÉvÉãwÉiÉ :|| (pÉÉ.mÉë. 3/223)27. xÉqÉSÉåwÉ xÉqÉÉÎalÉ¶É xÉqÉkÉÉiÉÑ qÉsÉÌ¢ürÉÉ: mÉëxɳÉÉiqÉåÎlSìrÉqÉlÉÉ: xuÉxjÉ CirÉÍpÉkÉÏrÉiÉå|| (xÉÑ.xÉÔ.15/41)28. AÎalÉ:xÉÉãqÉÉãuÉÉrÉÑ: xÉiuÉÇUÇeÉxiÉqÉ: mɧcÉãÎlSìrÉÉÍhÉpÉÔiÉÉiqÉãÌiÉ mÉëÉhÉÉ: || (xÉÑ.vÉÉ. 4/3)29. .xÉmiÉÉå¨ÉUÇ qÉqÉïzÉiqÉç (xÉÑ.zÉÉ.6/2)30. iÉÉÌlÉ qÉqÉÉïÍhÉ mÉgcÉÉiqÉMüÉÌlÉ pÉuÉÎliÉ; i±jÉÉ-qÉÉÇxÉqÉqÉÉïÍhÉ, ÍxÉUÉqÉqÉÉïÍhÉ, xlÉrÉÑqÉqÉÉïÍhÉ, AÎxjÉqÉqÉÉïÍhÉ, xÉÎlkÉqÉqÉÉïÍhÉ cÉåÌiÉ | lÉ ZÉsÉÑ qÉÉÇxÉÍxÉUxlÉÉruÉÉÎxjÉxÉÎlkÉurÉÌiÉUãMãühÉÉlrÉÉÌlÉ qÉqÉÉïÍhÉ pÉuÉÎliÉ, rÉxqÉɳÉÉãmÉsÉprÉliÉã |( xÉÑ.vÉÉ. 6/3)31. ÍxÉUÉxlÉÉxuÉÎxjÉmÉuÉÉïÍhÉ xÉlkÉrÉ¶É zÉUÏËUhÉÉqÉç || mÉåzÉÏÍpÉ : xÉÇuÉ×iÉÉlrÉ§É oÉsÉuÉÎliÉ pÉuÉlirÉiÉ: || (xÉÑ.zÉÉ. 5/38) 32. iÉÉxÉÉÇ oÉWûsÉmÉåsÉuÉxjÉÔsÉÉhÉÑmÉ×jÉÑuÉרɾûxuÉSÏbÉïÎxjÉU- qÉ×SÒzsɤhÉMüMïüzÉpÉÉuÉÉ: xÉlkrÉÎxjÉUÉxlÉÉrÉÑmÉëcNûÉSMüÉ rÉjÉÉmÉëSåzÉ Ç xuÉpÉÉuÉiÉ LuÉ pÉuÉÎliÉ || (xÉÑ.zÉÉ.5/40)A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 92 
  • Reference Shlokas….33. mÉgcÉ mÉåzÉÏzÉiÉÉÌlÉ pÉuÉÎliÉ | iÉÉxÉÉÇ cÉiuÉÉËU zÉiÉÉÌlÉ zÉÉZÉÉxÉÑ, MüÉå¸å wÉOíéwÉ̹ , aÉëÏuÉÉÇ mÉëirÉÔkuÉïÇ cÉiÉÑÎx§ÉÇzÉiÉç | (xÉÑ.zÉÉ.5/37)34. iÉ§É iÉsɾûSrÉålSìoÉÎxiÉaÉÑSxiÉlÉUÉåÌWûiÉÉÌlÉ qÉÉÇxÉxrÉqÉqÉÉïÍhÉ (xÉÑ.zÉÉ.6/7)35. qÉÉÇxÉeÉÉÌlÉ SzÉålSìÉZrÉiÉsɾûixiÉlÉUÉåÌWûiÉÉ : | (A.¾èû.zÉÉ.4/39)36. ÌuÉ®ãÅeÉxÉëqÉxÉ×Yx§ÉÉuÉÉã qÉÉÇxÉkÉÉuÉlÉuɨÉlÉÑ : | mÉÉhQÒûiuÉÍqÉÎlSìrÉÉ¥ÉÉlÉÇ qÉUhÉÇ cÉÉxÉÑ qÉÉÇxÉeÉã || (A.Wû.vÉÉ.4/47)37. kqÉÉlÉÉ®qÉlrÉ: xÉëuÉhÉÉiÉç xÉëÉåiÉÉÇÍxÉ xÉUhÉÉÎixÉUÉ (cÉ.xÉÔ.30/12)38. स िसराशतािन भविन्त; यािभिरदं शरीरमाराम इव जलहािरणीिभः के दार इव च कु ल्यािभरुपि तेऽनुगृ ते चाकु न सारणािदिभिवशेषैः मप सेवनीनािमव तासां तानाःतासां नािभमूर्ल, तत ु ं सरन्त्यूध्वर्मधिस्तयर्क् च || (xÉÑ.zÉÉ.7/3)39. नािभस्थाः ािणनां ाणाः ाणा ािभ ुर्पाि ता | िसरािभरावृता नािभ नािभिरवारकै ः || (xÉÑ.zÉÉ.7/5)40. िसराशतािन चत्वािर िव ाच्छाखासु बुि मान् | षिट् श शतं को े चतुःष ं च मूधर्िन || (xÉÑ.zÉÉ.7/20)41. शाखासु षोडश िसराः को े ाि शदेव तु || प ाश ुण ोध्वर्म ध्याः पिरकीितताः || (xÉÑ.zÉÉ.7/21)42. त िसराशतमेकिस्मन् सिक्थ्न भवित; तासां जालधरा त्वेका, ित ाभ्यन्तराः- त ोव सञ्ज्ञे , लोिहताक्षसञ्ज्ञा चैका, (xÉÑ.zÉÉ.7/22) े43. चतुिवधा यास्तु िसराः शरीरे ायेण ता ममर्सु सि िव ाः ाय्विस्थमांसािन तथैव सन्धीन् सन्तप्यर् देहं ितयापयिन्त (xÉÑ.zÉÉ.6/18)A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 93 
  • Reference Shlokas….44. नीलधमनीमातृकाशृङ्गाटकापाङ्गस्थपनीफणस्तनमूलापलापापस्तम्भहृदयना िभपा सिन्धबृहतीलोिहताक्षो र्ः िसराममार्िण | (xÉÑ.zÉÉ.6/7) र् 45. xmiȨ́ÉÇzÉÎixÉUÉ´rÉÉ: oÉ×WûirÉÉæ qÉÉiÉ×MüÉ lÉÏsÉå qÉlrÉå Mü¤ÉÉkÉUÉæ TühÉÉæ | ÌuÉOûmÉå ¾ûSrÉÇ lÉÉÍpÉ mÉÉμÉïxÉlkÉÏ xiÉlÉÉkÉUå AmÉÉsÉÉmÉÉæ xjÉmÉlrÉÑurÉï¶ÉiÉxÉëÉå sÉÉåÌWûiÉÉÌlÉ cÉ | (A.¾û.zÉÉ. 4/42)46. ÍxÉUÉqÉqÉïurÉkÉã xÉÉlSìqÉeÉxÉëÇ oÉWûxÉ×uÉY§ÉuÉãiÉç | iÉi¤ÉrÉɨÉ×Qè pÉëqÉ´uÉÉxÉ qÉÉãWûÌWûkqÉÉÍpÉUliÉMü: || (A.¾ûû.vÉÉ.4/50)47. UxÉÉiÉç xiÉlrÉÇ iÉiÉÉå U£üqÉxÉ×eÉ: MühQûUÉ: ÍxÉUÉ:| qÉÉÇxÉɲxÉÉ iuÉcÉ: wÉOèû cÉ qÉåSxÉ: xlÉÉrÉÑxÉÇpÉuÉ:|| (cÉ.ÍcÉ.15/17)48. नौयर्था फलकास्तीणार् बन्धनैबर्हुिभयुर्ता | भारक्षमा भवेदप्सु नृयु ा सुसमािहता || एवमेव शरीरे ऽिस्मन् यावन्तः सन्धयः स्मृताः| ायुिभबर्हुिभबर् ास्तेन भारसहा नराः|| (xÉÑ.zÉÉ. 5/33-34)49. ायू तुिवधा िव ा ास्तु सवार् िनबोध मे तानवत्यो वृ ा पृथ् शुिषरास्तथा || तानवत्यः शाखासु सवर्सिन्धषु चाप्यथ वृ ास्तु कण्डराः सवार् िवज्ञेयाः कु शलैिरह || आमप ाशयान्तेषु बस्तौ च शुिषराः खलु पा रिस तथा पृ े पृथुला िशरस्यथ || (xÉÑ.zÉÉ. 5/30-32)50. नव ायुशतािन |तासां शाखासु षट्शतािन, े शते ि श को , े ीवां त्यूध्व स ितः | (xÉÑ.zÉÉ.5/29)51. आणी(िण)िवटपकक्षधरकू चर्कूचर्िशरोबिस्तिक्ष ांसिवधुरोत्क्षेपाः ायुममार्िण | (xÉÑ.zÉÉ.6/7)A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 94 
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  • Reference Shlokas….92. उपयन् ाण्यिप- र ुवेिणकाप चमार्न्तवल्कललताव ा ीलाश्ममु रपािणपादतलाङ्गुिलिजह्वा- दन्तनखमुखबाला कटकशाखा ीवन वाहणहषार्यस्कान्तमयािन क्षाराि भेषजािन चेित | (xÉÑ.xÉÔ.7/15)93. चतुिवशत्यङ्गुलो हस्तः; ाि शदङ्गुलपिरमाणौ भुजौ, मिणबन्धकू पर्रान्तरं षोडशाङ्गुल; तलं षट्चतुरङ्गुलायामिवस्तारम्; ं अङ्गु मूल देिशनी वणापाङ्गान्तरमध्यमाङ्गुल्यौ प ाङ्गुले ….. (xÉÑ.xÉÔ.35/12)94. WûxiÉÉå A§É MÑümÉïUÉÌS qɱqÉ…¡ÓûsrÉliÉmÉrÉïliÉÉå ¥ÉårÉÈ| (QûsWûhÉ. xÉÑ.xÉÔ.35/12)95. wÉÉåQûzÉÉ…¡ÓÇûsÉÉæ mÉëoÉÉWÒû, mÉgcÉSzÉÉ…¡ÓÇûsÉÉæ mÉëmÉÉÍhÉ, WûxiÉÉæ ²ÉSzÉÉ…¡ÓÇûsÉÉæ | (cÉ.ÌuÉ.8/117)96. wÉOèû mÉgcÉÉzÉiÉç mÉëirÉ…¡ûÉÌlÉ. . . . . cÉiuÉÉËU mÉÉÍhÉmÉÉS. . . .| (cÉ.zÉÉ 7/11)97. wÉÉåQûzÉ MühQûUÉ iÉÉxÉÉÇ cÉiÉxÉëÈ mÉÉSrÉÉåÈ iÉÉuÉirÉÉå WûxiÉ aÉëÏuÉ mÉ×¹åwÉÑ| (xÉÑ.zÉÉ 5/11)98. मांसिसरा ाय्विस्थजालािन त्येकं चत्वािर; तािन मिणबन्धगुल्फसंि तािन परस्परिनब ािन परस्परगवािक्षतािन चेित, यैगर्वािक्षतिमदं शरीरम् | (xÉÑ.zÉÉ 5/12)99. wÉOèû MÔücÉÉïÈ, iÉå WûxiÉ mÉÉS aÉëÏuÉ qÉãQíåûwÉÑ, WûxiÉrÉÉåÈ ²Éæ, mÉÉSrÉÉåÈ ²Éæ|| (xÉÑ.zÉÉ 5/13)100. चतुदशास्थ्नां सङ्घाताः; तेषां यो गुल्फजानुवङ्क्षणेषु, एतेनेतरसिक्थ बाहू र् च ाख्यातौ, ि किशरसोरे कैकः| (xÉÑ.zÉÉ 5/16)101. ͤÉmÉëÇ =ͤÉmÉç + xTüÉÌrÉiÉÎgcÉuÉgcÉÏÌiÉ zÉÏbÉëÇ,iuÉËUiÉÇ (zÉ.Mü.SìÓ)103. त§Éç पादस्याङ्गु ाङ्गुल्योमर्ध्ये िक्ष ं नाम ममर्, त§É िव स्याक्षेपके ण मरणं (xÉÑ.zÉÉ.6/24)104. A…¡Óû¸É…¡ÓûÍsÉqÉkrÉxjÉÇ Í¤ÉmÉëqÉɤÉåmÉqÉÉUhÉqÉç || (A.¾û.zÉÉ.4/3)105. AɤÉåmÉMüÉZrÉålÉ uÉÉiÉurÉÉÍkÉlÉÉ qÉÉUrÉÌiÉ (AÂhÉS¨É,A.¾û.zÉÉ.4/3)106. rÉSÉ iÉÑ kÉqÉlÉÏ: xÉuÉÉï:MÑüÌmÉiÉÉå/prÉåÌiÉ qÉÉÂiÉ: || iÉSÉͤÉmÉirÉÉzÉÑ qÉÑWÒûqÉÑïWÒûSåïWÇû qÉÑWÒû¶ÉU: qÉÑWÒûqÉÑïWÒûxiÉSɤÉåmÉÉSɤÉåmÉMü CÌiÉ xqÉ×iÉ: || (xÉÑ.ÌlÉ.50/51)A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 99 
  • Reference Shlokas….107. rÉjÉÉ iÉÑ kÉqÉlÉÏ: xÉuÉÉï: ¢Ñü®Éå/prÉåÌiÉ qÉÑWÒûqÉÑïWÒû: iÉjÉÉ/…¡ûqÉÉͤÉmÉirÉåwÉ urÉÉÍkÉUɤÉåmÉMü: xqÉ×iÉ: | (A.¾û.ÌlÉ.15/16)108. kÉqÉlrÉÉå lÉÉŽ: | (QûsWûhÉ, xÉÑ.ÌlÉ.50/51)109. iÉSɤÉåmÉÉiÉç SåWûɤÉåmÉÉiÉç | (QûsWûhÉ, xÉÑ.ÌlÉ.50/51)110. AÉͤÉmÉÌiÉ = AÉ¢üqÉÌiÉ (AÂhÉS¨É, A.¾û.ÌlÉ.15/16)111.िछ ेषु पािणचरणेषु िसरा नराणां सङ्कोचमीयुरसृगल्पमतो िनरे ित || ाप्यािमत सनमु मतो मनुष्याः सि छ शाखतरुवि धनं न यािन्त || िक्ष ेषु त सतलेषु हतेषु र ं गच्छत्यतीव पवन रुजं करोित || एवं िवनाशमुपयािन्त िह त िव ा वृक्षा इवायुधिनपातिनकृ मूलाः || तस्मा योरिभहतस्य तु पािणपादं छे माशु मिणबन्धनगुल्फदेशे || (xÉÑ.zÉÉ.6/32,33)112. iÉsÉxrÉ mÉÉSiÉsÉxrÉ ¾ûSrÉÍqÉuÉ, mÉÉSiÉsÉxrÉ qÉkrÉqÉç | CÌiÉ WåûqÉcÉlSì: | (zÉ.Mü.SìÓ.)114. qÉkrÉqÉÉ…¡ÓûsÉÏqÉlÉÑmÉÔuÉåïhÉ qÉkrÉå mÉÉSiÉsÉxrÉ iÉsɾûSrÉÇ lÉÉqÉ,iÉ§É mÉÉSxrÉ pÉëqÉhÉuÉåmÉlÉå pÉuÉiÉ: (xÉÑ.zÉÉ.6/24)115. qÉkrÉå mÉÉSiÉsÉxrÉÉWÒûUÍpÉiÉÉå qÉkrÉqÉÉ…¡ÓûÍsÉqÉç iÉsɾû³ÉÉqÉ ÂeÉrÉÉ iÉ§É ÌuÉ®xrÉ mÉgcÉiÉÉ (A.¾û.zÉÉ.4/2)116. MÑüUç +cÉOû ÌlÉmÉÉiÉlÉÉiÉç SÏbÉï:| (zÉ.Mü.SìÓ.)118. ͤÉmÉëxrÉÉåmÉËU¹ÉSÒpÉrÉiÉ: MÔücÉÉåï lÉÉqÉ, iÉ§É mÉÉSxrÉ pÉëqÉhÉ uÉåmÉlÉå pÉuÉiÉ: | (xÉÑ.zÉÉ.6/24)119. iÉxrÉÉåkuÉïÇ ²rÉ…¡ÓûsÉå MÔücÉï: mÉÉSpÉëqÉhÉMüqmÉM×üiÉç | (A.¾û.zÉÉ.4/3)122. MÔücÉïxrÉ ÍzÉU CuÉ ÍzÉUÉå/xrÉ | CÌiÉ WåûqÉcÉlSì:| (zÉ.Mü.SìÓ.)124. aÉÑsTüxÉlkÉåUkÉ EpÉrÉiÉ: MÔücÉïÍzÉU:,iÉ§É ÂeÉÉzÉÉåTüÉæ;| (xÉÑ.zÉÉ.6/24)125. aÉÑsTüxÉlkÉåUkÉ: MÔücÉïÍzÉU: zÉÉåTüÂeÉÉMüUÇ || (A.¾û.zÉÉ.4/3)126. ÌuÉzÉåwÉxiÉÑ rÉÉÌlÉ xÉÎYjlÉ aÉÑsTü-eÉÉlÉÑ ÌuÉOûmÉÉÌlÉ,iÉÉÌlÉ oÉÉWûÉæ qÉÍhÉoÉlkÉMÔümÉïUMü¤ÉkÉUÉÍhÉ; (xÉÑ.zÉÉ.6/24)127. mÉëMüÉå¸mÉÉhÉÏ xÉÎlkÉxjÉÉlÉqÉç | CirÉqÉUPûÏMüÉrÉÉÇ pÉUiÉ: | (zÉ.Mü.SìÓ)129. qÉÍhÉoÉlkÉÇ mÉÉÍhÉqÉÔsÉÇ (QûsWûhÉ.xÉÑ.zÉÉ.6/24)A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 100 
  • Reference Shlokas….130. ÌuÉzÉåwÉxiÉÑ qÉhÉÏoÉlkÉå MÑühPûiÉÉ | (xÉÑ.zÉÉ.6/24)131. MÑühPûiÉÉ MüUxrÉÉMüqÉïhrÉiuÉqÉç (QûsWûhÉ. xÉÑ.zÉÉ.6/24)134.EiÉFkuÉïÇxÉuÉïuÉëhÉuÉåSlÉÉuɤrÉÉqÉç:iÉÉåSlÉpÉåSlÉiÉÉQûlÉcNåûSlÉÉrÉÉqÉlÉqÉljÉlÉÌuɤÉåmÉhÉcÉÑqÉÑcÉÑqÉÉrÉlÉÌlÉSïWûlÉÉuÉpÉg cÉlÉxTüÉåOûlÉÌuÉSÉUhÉÉåimÉÉOûlÉMüqmÉlÉÌuÉÌuÉkÉzÉÔsÉÌuÉzsÉåwÉhÉÌuÉÌMüUhÉxiÉqpÉlÉmÉÔUhÉxuÉmlÉÉMÑügcÉlÉÉ…¡ÓûÍzÉMüÉ: xÉÇpÉuÉÎliÉ; (xÉÑ.xÉÔ.22/11)135. ÂeÉÉMüU – ÂeÉÉÇ UÉåaÉÇ MüUÉåÌiÉ (uÉÉcÉ.uÉÉsÉ 6)136. mÉëqÉÏrÉiÉå AlÉålÉåÌiÉ mÉëqÉÉhÉÇ ¥ÉÉlÉqÉɧÉqÉÏÎmxÉiÉqÉç | (cÉ¢ü. cÉ.ÌuÉ 8/7)139. qÉÉlÉÇ iÉÑsÉÉ…¡ÓûÍsÉ mÉëxiÉÉåÈ| (A. MüÉå 2/9/85)140. MåüÍcÉiÉç qÉkrÉqÉÉXÒûÍsÉMüÉrÉÉxiÉÑ qÉkrÉqÉmÉuÉïÍqÉiÉÉXÒûsÉÍqÉÌiÉ | (AÉRûqÉssÉ vÉÉ.xÉÇ.mÉë. 1/35-36)141. qÉkrÉqÉÉ…¡ÓûsrÉÉæ mÉgcÉÉXÒûsÉå | (xÉ.xÉÑ. 35/12)142. iÉsÉÇ wÉOèûcÉiÉÑU…¡ÓûsÉÉrÉÉqÉÌuÉxiÉÉUqÉç| (xÉ.xÉÑ. 35/12)143. AXÒûsÉvÉoSålÉɧÉÉ…¡Óû ¸lÉZÉiÉsÉpÉÉaÉÇaÉ׺ûÎliÉ | (AÉRûqÉssÉ vÉÉ.xÉÇ.mÉë.1/35-36)A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 101 
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