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Hastamarma, sr

  1. 1. “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
  3. 3. 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 
  4. 4. 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  
  5. 5. 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  
  6. 6. 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   
  7. 7. 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  
  8. 8. 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  
  9. 9. 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  
  10. 10.                                  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  
  11. 11. 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  
  12. 12. 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  
  13. 13. 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  
  14. 14. 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  
  15. 15. 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  
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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 
  47. 47. 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 
  48. 48. 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