Prustamarma, sr


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Prushtha Marma W.S.R. To Stabdha Bahuta In Amsa Marmabhighata, Shivasharanayya M.Swamy, RACHANA SHAREERA, N.K.J. Ayurvedic Medical College & PG Centre, Bidar

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Prustamarma, sr

  1. 1. “ A Study On Prushtha Marma W.S.R. To Stabdha Bahuta In Amsa Marmabhighata ” By  Dr.Shivasharanayya M.Swamy A dissertation submitted to the R a j iiv G a n d h ii U n iiv e r s iit y o f H e a llt h S c iie n c e s ,, Raj v Gandh Un vers ty of Hea th Sc ences K a r n a t a k a ,, B a n g a llo r e . Karnataka Banga ore In partial fulfillment of the requirements for the degree of AYURVEDA VACHASPATHI - M.D (AYURVEDA) In  RACHANA SHAREERACo-Guide GuideDr.Shelly Divyadarshan Dr.N.G.Mulimani M.D.(SR) MD (SR) Post Graduate Department Of Rachana Shareera N.K.J. Ayurvedic Medical College & PG Centre, Bidar.  2010 
  2. 2.  R a j iiv G a n d h ii U n iiv e r s iit y o f H e a llt h S c iie n c e s ,,Raj v Gandh Un vers ty of Hea th Sc ences K a r n a t a k a ,, B a n g a llo r e . Karnataka Banga ore Declaration by the candidate I, hereby declare that this dissertation/thesis entitled “Astudy on Prushtha marma W.S.R. to Stabdha bahuta in Amsamarmabhighata” Is a bonafide and genuine research work carriedout by me under the guidance of Dr.N.G.Mulimani,M.D.(SR)Professor Department of Rachana Shareera.Date: Signature of the candidatePlace: Bidar Dr.Shivasharanayya M.Swamy
  3. 3. R a j iiv G a n d h ii U n iiv e r s iit y o f H e a llt h S c iie n c e s ,,Raj v Gandh Un vers ty of Hea th Sc ences K a r n a t a k a ,, B a n g a llo r e . Karnataka Banga ore Copyright Declaration by the candidate I here by declare that the Rajiv Gandhi University of HealthSciences, Karnataka shall declare the rights to preserve, use anddisseminate this dissertation/thesis in print or electronic format foracademic/research purpose.Date: Signature of the candidatePlace: Bidar Dr.Shivasharanayya M.Swamy © Rajiv Gandhi University of Health Sciences, Karnataka
  4. 4. R a j iiv G a n d h ii U n iiv e r s iit y o f H e a llt h S c iie n c e s ,, Raj v Gandh Un vers ty of Hea th Sc ences K a r n a t a k a ,, B a n g a llo r e . Karnataka Banga ore CERTIFICATE BY THE GUIDE This is to certify that the dissertation entitled “A study onPrushtha marma W.S.R. to Stabdha bahuta in Amsamarmabhighata” is a bonafide research work done by Dr.Shivasharanayya M.Swamy, in partial fulfillment of therequirement for the degree of Ayurveda Vachaspathi - M.D.(Ayurveda). Signature of the Co-Guide Signature of the Guide Dr.Shelly Divyadarshan Dr. N.G.Mulimani M.D.(SR) MD (SR) Lecturer, Professor, Department of Rachana Shareera Department of Rachana ShareeraNKJ Ayurvedic Medical College & P G Centre NKJ Ayurvedic Medical College & P G Bidar – 585403 Centre Bidar – 585403Date: Date:Place: Bidar Place: Bidar
  5. 5. ENDORSEMENT  BY  THE  HOD,,  PRINCIPAL/   ENDORSEMENT BY THE HOD PRINCIPAL/ HEAD  OF  THE  INSTITUTION   HEAD OF THE INSTITUTION This is to certify that the dissertation entitled “A study onPrushtha marma W.S.R. to Stabdha bahuta in Amsamarmabhighata” is a bonafide research work done by Dr.Shivasharanayya M.Swamy under the guidance ofDr.N.G.Mulimani. Prof department of Rachana Shareera.Seal and signature of H.O.D. Seal and signature of the Principal/DeanDr .N.G.Mulimani Dr.K.V.L.N Acharyulu. MD (SR) M.D. (Ayu)Prof & H.O.D Principal & DeanDept. Of Post Graduate Studies In N.K.J. A.M.C. & PG Centre,Rachana Shareera Bidar – 585403 Karnataka.N.K.J. A.M.C. & PG Centre,Bidar – 585403 Karnataka.Date: Date:Place: Bidar. Place: Bidar.
  6. 6. Acknowledgements This is the greatest moment to me to acknowledge the respected personalities who has given this opportunity and helped in doing my dream work of dissertation. First  and  foremost  I  have  to  acknowledge  to  my  parents  Sri  Mallayya  Swamy  and  Smt Mallamma swamy& my brother in law Sri Shivmurthy G & my brother Shivamurthy .Swamy.  I  am  very  much  indebted  to  my  esteemed  and  cherished  Guide  ProfDr.N.G.Mulimani MD (SR) H.O.D   P.G.Department  of  Rachana  Shareera  for providing an opportunity to carry out this work under his proficient guidance. I will be ever grateful  for  his  invaluable  guidance,  constructive  suggestions,  thought  provoking  ideas  in every stage of this work to achieve this milestone.   It is a great privilege to record my esteemed & deepest sense of gratitude to my Co‐guide  Dr.Shelly Divyadarshan   MD (SR)        P.G.Department of Rachana Shareera  for his able guidance,  all time support, generous help & affection throughout my work.  I consider it a great privilege to record my deepest sense of gratefulness to our Professor.  Dr.S.B. Kotur M.D (SR)  for his all time support, during this work.  I  also  express  my  sincere  gratitude  to  and  offer  my  sincere  thankfulness  to  my mentor Professor Dr Ashwinikumar. M.D (SR)  who is my well wisher and generous help during my dissertation work.  I wish to extend my heartiest thanks to the Principal Prof Dr.K.V.L.N Acharyulu.  N.K.J Ayurvedic Medical College & P.G. Centre for providing the necessary facilities in the college for conducting research work.  Any  amount  of  thankfulness  will  be  inadequate  for  all  the  department  teachers namely Sanjeevkumar jyoteppa for providing all possible guidance and support. I am highly indebted to my beloved senior and lecturer Dr.Anup. B for his constant enthusiastic and  I
  7. 7. affectionate pushes in my thoughts in time and again. I take an opportunity to be grateful to myteacher Dr.vijay Biradar. M.S (shalya)   for his cooperation in his service.   On this occasion I give my deepest gratitude to my teacher  Dr.Brahmanand. Swamy .  M.S  (shalya). I take this opportunity to convey my thanks to Vidwan P.G.Bhatt for his proper guidance during my dissertation work.   I  also  express  my  sincere  gratitude  to  and  offer  my  sincere  thankfulness  to Dr.Manik kulkarni M.D (Panchakarma) and all Panchakarma dept staff.  I wish to extend my heartiest thanks to the vice‐ Principal Dr. Prasanna V. Savanur for his active guidance during my dissertation work.   Sri. Vinod Bagali office supdt. , Sri. Lakshmikanth Reddy accountant, Shri Vidyanand kulkarni,  Mr.Ramesh  Chidre,  Mr  Chandrakant,  Mr  Kaddi,  Sri.  R.J.  Kadam  Librarian,Mr Rajkumar and Smt. Sakubai.  Department  assistant  Mr.  Sabeer,  Mr.  Abdul  and  all  the  other technical and non technical staff of the college for their cooperation and help.  In addition this I am also very grateful to my batch mates Dr Vivek Kulkarni DrSukhesh, Dr.Rajshekhar Tokare, Dr.Satyamma, Dr.Geeta Dolli, Dr.Satish Jalihal , DrPradeepraju,Dr Sameer, Dr Jyoti Hullale, Dr Jyoti Rajole.,Dr Sanjeev Trivedi,Dr.Baslingappa,Dr Omprakash, And I Extend My Regards To My Seniors Dr SantoshDixit, Dr Bapu Desai,Dr.Praveen Shegedar And, All My Seniors & Juniors Dr.Mohan.G,DrMallikarjun,Dr.Nagendra,Dr.Sujit. I  pick  up  this  precious  moment  for  appreciation  of  my  Friend  Dr  Vijay  Bulgundi Orthopedic Surgeon who helped me in modern aspect of my dissertation.  Lastly  I  acknowledge  my  thanks  to  those  who  have  directly  or  indirectly  extended their support for completion of my work.   Date:                                                                                                 Signature of the candidate Place:  Bidar              Dr.Shivasharanayya. M.swamy   II
  8. 8. ABBREVIATIONS  LIST OF ABBREVIATIONS ACCORDING TO REFERENCE BOOKS (AYURVEDIC) A.H › Ashtanga Hridaya. A.S › Ashtanga Samgraha. Ch.S › Charaka Samhita. K.S › Kashyapa Samhita. Su.S › Sushruta Samhita. ACCORDING TO STHANA OF SAMHITA Chi › Chikitsa Sthana. Sha › Shareera Sthana. Su › Sutra Sthana. U › Uttar Sthana. VI › Vimana Sthana.A study on Prushtha marma Stabdhabahuta in Amsamarmabhighata  Page III 
  9. 9. ABBREVIATIONS  LIST OF ABBREVIATIONS (MODERN) F › Female Fig. › Figure G › Grade Gr. › Group M › Male Min › minute No › Number O.P.D. › Outdoor patient department Sl. › Serial Yr › yearA study on Prushtha marma Stabdhabahuta in Amsamarmabhighata  Page IV 
  10. 10. ABSTRACT   ABSTRACT:- Marma is described as the vital spots in our body, injury to which ends invarious dangerous crises. The marma are 107, they are classified in various groups basedon their location like-: Shakhagata, udara uarahgata, Prushthagata & Jatrudwagata. Prushtha marma are 14 in number those are katikataruna, Kukundara, Nitamba,parshvasandhi, Brahati, Amsaphalaka and Amsamarma each two in number. Although the gross regional and the viddha laxanas are available in samhitas, butdetail description of particular structures present in Prusthamarma region are lacking inancient texts. Objectives of the study were complete literary review on prushtha marma andapplied anatomy of prushtha marma with special reference to clinical & structuralassessment of Amsamarmabhighata.METHODS:- The subject of this dissertation is both literal and observational study, data relatedto Prushtha marma were collected from various classics, objective and subjectiveparameters and observations of 30 patients of stabdhabahuta (Amsamarmabhighata) werecollected and anatomical variations were noted. All patients had the structural changes in Amsa pradesha in the form of fracture,dislocation, rupture of the ligaments, rotator cuff tear, frozen shoulder etc... But we have“A study on Prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata”  Page 1   
  11. 11. ABSTRACT  only included the soft tissue injuries which hold all the structure together and supportsthe shoulder.OBSERVATIONS:- Subjective and objective parameters were taken to analyze the severity of thetrauma and range of signs & symptoms in each patient. As it is an observational studybased on clinical diagnosis, the student’s t-test was not used. Only the percentage of eachfinding was mentioned.INTERPRETATION & CONCLUSION:- Interpretation will be done on controversial points and conclusion drawn aftercompletion of observations.Key words:- Prishtha marma, Amsa marma & Stabdhabahuta. “A study on Prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata”  Page 2   
  12. 12. IndexSl. No. Contents Page No. 1 Introduction 1-2 2 Aims & Objectives 3 3 Review of literature 1. Historical review: 4-6 2. Ayurvedic review: 7-60 a) Concept of marma shareera 7-11 b) Classification of marma 12-13 c) Prushtha marma 14-60 3. MODERN REVIEW: 61-86 a)Katikataruna,Kukundara &Nitamba 61-65 b)Parshwasandhi marma 65 c)Brahati marma 66 d)Amsaphalaka marma 67 e)Amsa marma 68-76 f)Modern review of amsa marmabhighata 76-83 g)Sports medicine & Biomechanics 83-86 4 Photo plates 86-98
  13. 13. 5 Methodology 99-1046 Observations 105-1167 Discussion 117-1348 Conclusion 135-1379 Summery 138-13910 Reference Shlokas 140-14911 Bibliography 150-16412 Annexure 1-513 Master chart 1
  14. 14. LIST OF TABLESS.No Name of the table Page no 1. Classification of marma based on the structure 12 2. Classification of marma based on effect of injury 12 3. Classification of marma on location 13 4. Classification of marma based on numbers 13 5. Classification of prushtha marma 14 6. Bones of Nitamba marma 25 7. Muscles acting on shoulder girdle 75 8. The distribution of patients based on age 105 9. The distribution of patients based on sex 10610. The distribution of patients based on occupation 10711. The distribution of patients based on diet 10812. The distribution of patients based on shoulder pain 10913. The distribution of patients based on restricted movement 11014. The distribution of patients based on Tenderness 11115. The distribution of patients based on visible deformity 11216. The distribution of patients based on numbness 11317. The distribution of patients based on Arm drop sign 114
  15. 15. LIST OF FIGURESS.No Name of figure Page No 1 Limitations of amsa marma 59 2 Assesment for the joint mobility 102 Prushtha marma Photo plate 86 3 Bones & Joints of pelvic cavity Photo plate 86 4 Muscles of the gluteal region Photo plate 87 5 Nerves of pelvic cavity Photo plate 88 6 Ligaments of pelvic cavity  Photo plate88 7 vessels of pelvic cavity Photo plate88 8 Viscera of pelvic cavity Photo plate88 9 10 Scapula & Ribs Photo plate89 11 Muscles of the scapular region Photo plate89 12 Photo plate89 Brachial plexus 13 Vessels of the axilla Photo plate89 14 Photo plate89 Shoulder girdle articular surfaces 15 Photo plate90 Muscles & bursae 16 Photo plate90 Ligaments 17 Photo plate91 Bursae & Rotator cuff muscles 18 Photo plate91 Movements of the shoulder joint 19 Photo plate92 Muscles acting on shoulder girdle
  16. 16. 20   Photo plate93 Causes of Supraspinatus21 Painful arch syndrome Photo plate9322 Rotator cuff Muscles Photo plate9323 Shoulder joint diagram Photo plate9424 USG of Shoulder Normal Photo plate9425 Shoulder Diagram transeverse view Photo plate9526 USG of Shoulder Normal transeverse view Photo plate9527 Supraspinatus tendon full tear Photo plate9628 Supraspinatus tendon full tear & Bursitis Photo plate9629 Complete tear of Supraspinatus Photo plate9730 Radiological Finding of Shoulder Photo plate9831 Shoulder MRI;Rotator cuff injuries Photo plate98
  17. 17. LIST OF GRAPHSGraph Description Page No. No. 01 Incidence of Age 106 02 Incidence of Sex 107 03 Incidence of Occupation 108 04 Incidence of Diet 109 05 Incidence of Shoulder pain 110 06 Incidence of Restricted movement on abduction 111 07 Incidence of Tenderness 112 08 Incidence of visible deformity 113 09 Incidence of Numbness 114 10 Incidence of Arm drop sign 115 11 Incidence of modern diagnosis 116
  18. 18. LIST OF FLOW CHARTSFlow Description Page no.chartNo. 1 General Patho-physiology of marma 9  2 Mechanism 11 3 Structure of Katikataruna marma 16 4 Patho-physiology of katikataruna marma 18 5 Structure of Kukundara marma 23 6 Patho-physiology of Kukundara marma 24 7 Structure of Nitamba marma 27 8 Patho-physiology of Nitamba marma 30 9 Structure of Parshvasandhi marma 32 10 Patho-physiology of Parshvasandhi marma 36 11 Structure of Brahati marma 38 12 Patho-physiology of Brahati marma 40 13 Structure of Amsaphalaka marma 43 14 Patho-physiology of Amsaphalaka marma 45 15 Structure of Amsa marma 47 16 Patho-physiology of Amsa marma 50
  19. 19. INTRODUCTION   INTRODUCTION The human anatomy (shareera rachana) is an important for allied health sciences. It is oneof the fundamental subject to the health science. The ayurvedic life science is also based on the human anatomy and physiology (rachana& kriya), without the knowledge of shareera rachana and kriya, the physician cannot becomeperfect in the profession. So the ancient Acharyas like Sushruta, Charaka and Vagbhata were given importance tothe knowledge of rachana shareera. The acharya sushruta was mentioned in the shareera sthanaof sushruta samhita, other acharyas are also explained about the human anatomy in theirsamhitas. The human body dissection was described in sushruta samhita. Even though no descriptive anatomy of organ or structure is available in any samhitagranthas but our ancient have treated various diseases and performed the surgery perfectly andprecisely. If we gone through the marma shareera, These are vital points of the body. Theyare situated at various regions of the body. If any injury to the Marma points that leads todeformity of the structures, produces the severe pain, loss of movements, and even some timesthere may be a death. The Marma are still holding the power of anatomists and surgeons in highamount. It seems that Acharyas have described the regional anatomy in relation to the surfaceanatomy of Marma. Every Marma holds its own clinical importance and significant scientificvalues, while on research none can ignore this.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 1  
  20. 20. INTRODUCTION   Marma are vital areas regarded as conglomeration of mamsa, sira, snayu, asthi, andsandhi and named after their individual predominant structure.Prushtha Marma are 14 in number those are Katikataruna, Kukundara, Nitamba, Parshwasandhi, Brahati, Amsaphalaka and Amsa and the structures related to shoulderregion are the most exposed area to common injuries. The activities like weight lifting,swimming, cricket, fall on the outstretched arm causes the rupture of ligaments and muscles ofshoulder joint, leads to disability of the Amsa sandhi and bahu. Therefore selecting out this topicfor study will be a needful exercise for the subject Shareera Rachana. Symptomology like stabdhabahuta or bahukriyahara is almost an uncovered area ofstudy. Hence the surgical and anatomical evaluation of stabdhabahuta symptom under AmsaMarma will be need for research. Looking into the above feature though no study has yet been conducted on the vitalpoints of back especially on Amsa Marma with its degenerative process following on injuries,hence it is understood that still critical study is needed. “A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 2  
  21. 21. Aims & Objectives    Aims and objectives of the study: 1. Conceptual study of Prushtha Marma Shareera. 2. To study the underlying structures of Amsa marma and to fix its limitations. 3. To study the Stabdhabahuta in Amsa marmabhighata on modern parameters.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 3  
  22. 22. HISTORICAL REVIEW   HISTORICAL REVIEW In Vedic Literature: In Rigveda, a word Marma is found in connection with sharp weapon calledvajra,used by lord ‘Indra’ for the purpose of killing the demon ‘Virata’ by attacking theMarma sthanas.1 In Atharveda, references to Marma sthanas can be found in connection with thekilling of ‘skanda’ by lord ‘Indra’ and lord ‘Agni’.2Upanishads: In, ‘Garbhopanishad’we can find the word Marma reference to a quality ofknife which is capable of cutting the Marma of jaghana pradesha, 107 Marma are referredalong with anatomical structures of the body, 18 sensitive or vital parts or Marmadistributed at various places of the body are described for the practice of dharana, whichis achieved by concentration and withdrawal of mind from one spot to other spot of thebody.3 Epic Literature: In Ramayana, The king Dasharatha while hunting used shabdabhedhi arrowcapable of hitting the objector a person without even looking at which pierced the Marmasthana of shravanakumar resulting in death soon after the removal of arrow from thebody.4“A Study on prushtha Marma W.S.R. to Stabdhabahuta in Amsa Marmabhighata ”  Page 4  
  23. 23. HISTORICAL REVIEW   During the fight between the ‘Vali’ and ‘Sugreeva’ Sri Rama hits at the Marmasthana of Vali and he falls down with agonizing pain and died after arrow was removed.These references points to vishalyagna Marma described in ayurvedic texts.5 Hanuman, while entering into Lanka, happened to confront with a very dreadfuland peculiar rakshasi ‘sinhika’ He carefully observed the Marma of the body and killedthe rakshasi by piercing his sharp and long nails into the Marma sthalas.6 The Meghanatha hits the Marma sthana of Lakshmana and falls down withagony.7 During the fight, Meghanada hits the Marma sthala of the Rama and Lakshamanaand captivated them and tied them tightly With Nag pasha.7 In Mahabharata also, the use of word Marma can be traced out inSauptikaparva and Bhishma parva.During the battle between the Kaurava and pandava,the Ashwathhama inflicted strong blow with his lion like heels on the vitapa Marma ofthe elephant.8 In another place, king Duryodhana cries due to torn and broken thigh, whichpierced the Marma sthana.9 On the above narrations if a close observation is made, it can clearly be pointedout that the knowledge of Marma vigyana was extensively well known since Vedicperiod (4000BC) Later on its progression can be observed in the samhita granthasespecially in sushruta samhita shareer sthana.10“A Study on prushtha Marma W.S.R. to Stabdhabahuta in Amsa Marmabhighata ”  Page 5  
  24. 24. HISTORICAL REVIEW     But later, during Sushruta’s period the knowledge was acquired based onthe dissection of cadavers. Later the Aristotle never dissected the human body but had a rough idea about thevessels. Celsius (20BC) though wrote work on medicine but gave too little glimpse ofanatomy. Thus modern anatomy is only four hundred years old. The first publicdissection took place at Vienna on 12 February 1404. In 1565, queen Elizabeth ofEngland permitted dissection on executed criminals. Thus, the ancient Indian knowledgeon anatomy and dissection was considered superior to any of the anatomy in the world upto 15th century. But afterwards, no efforts were made to improve the knowledge andremained dormant and stagnated. However,after 19th century again devoped and made thebranches like Surface antomy, radiological Anatomy,Embryology etc …. “A Study on prushtha Marma W.S.R. to Stabdhabahuta in Amsa Marmabhighata ”  Page 6  
  25. 25. AYURVEDIC REVIEW  AYURVEDIC REVIEWCONCEPT OF MARMA SHAREERAVyutpatti of word MarmaMru maneen jeevasthaane, Sandhisthaane taatparye cha10” Word meaning of Marma is jeevasthaana sandhisthana.Nirukti of Marma That which causes death on injury is called Marma or painful condition in whichthe patient experiences pain same as death.11Definition of Marma“Marmaani naama maamsa siraa snaayu asthi sandhi sannipatah;teshu svabhaavata eva praanatishtanti”12 Marma consists of aggregate of Mamsa, Sira, Snayu, Asthi, Sandhi in whichparticularly Prana by nature stays. That which leads to death or which gives misery toindividual similar to death when injured is called Marma.13 Marma are that part of the body which exhibits a peculiar sensation or unusualthrobbing and causing pain on pressure.14 Marma are so called because they cause death when they are injured and they aremeeting place of Mamsa, Asthi, Snayu, Dhamani, Sira, Sandhi and life entirely resides inthem.15 The place where Mamsa, Sira, Snaayu, Asthi, and Sandhi present as Marma inwhich specifically Prana is situated.16,17,18“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 7  
  26. 26. AYURVEDIC REVIEW  Marma are jeeva darana places in the body.19 Marma are called a jeevaagaara, that is jeeva takes shelter in Marma.20 The pointof the body which leads to death when injured called Marma.21Prana In persons generally Soma (Kapha), Maruta (Vaayu), and Tejas ( Pitta), andRajas, Satva, and Tamas along with Atma stays in Marmas, that is why they do notsurvive if injury takes place on Marma.22,23 These are said to be Prana according toSushruta. There are said to be 10 seats of Prana that is Dasha Pranayatanas by AcharyaCharaka. Those are two Shankha, Three Marma (Shira, Hrudaya and Basti), Kantha,Rakta, Shukra, Ojas, and Guda.24 Acharya Charaka again mentioned Pranayatanas inShareera sthana as Murdha, Kantha, Hrudaya, Nabhi, Guda, Basti, Oja, Shukra, Shonita,and Mamsa.25Acharya Vagbhata in both Hrudaya and Sangraha mentioned same asAcharya Charaka.26 Acharya Kashyapa told Dasha Pranayatana’s as Murdha, Hrudaya,Basti, Kantha, Shukra, Shonita, two Shankha, Guda, among these he called first three areMahaMarma.27General structure of MarmaMarma consists of aggregate of Mamsa, Sira, Snayu, Asthi, Sandhi in which particularlyPrana by nature stays.28 In persons generally Soma(Kapha), Maruta (Vaayu), Tejas( Pitta), Rajas, Satva, and Tamas along with Atma stays in Marmas, that is why they do“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 8  
  27. 27. AYURVEDIC REVIEW not survive if injury takes place on Marma. By injury Shareerika and Manasika dosha areaggravated which destroy body and mind and finally Atma leaves the body.29 Flow Chart No.1“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 9  
  28. 28. AYURVEDIC REVIEW General symptoms of Marma Viddha lakshana30 Vishama spandana- Variation in pulsation of vessels in pulsatory places ofparticular Marma pradesha is due to Viddha and structural impairment. Vishama ruk-Deferent type of pain will be felt on putting pressure on Marma Viddha pradesha.Antah (peripheral region) Viddha and Madhya Viddha lakshana The structure of the Marma generally includes 2 parts, Madhya and Antah(peripheral region) parts.Madhya Viddha (central region) – Injury to the Madhya (central part) of the Marma occurs, and then cardinalsymptoms related to particular Marma appears.Example- Shankha Marma Madhya Viddha leads to Marana.Antah (peripheral region) Viddha- Injury to the Antah (peripheral region) pradesha of the Marma occurred theninstead of showing cardinal signs; it converted in to successive Marma lakshana So many times patient came with Marma Viddha lakshana will not exhibitcardinal symptoms. This is because in injury to peripheral part of Marma Rachanainvolved.On observation it is clinically very difficult to demark peripheral and centralpart of Marma. But on the basis of symptomatology and also Acharya Sushruta’s conceptof Antah (peripheral region) and Madhya Viddha, will guide us to determine theprognosis. Example- sometimes Shankha Marma Viddha will not lead to Sadhyo Marana,“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 10  
  29. 29. AYURVEDIC REVIEW patient may die after a month. It means in this condition, only peripheral part of ShankhaMarma injuries Flow Chart No.231“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 11  
  30. 30. AYURVEDIC REVIEW CLASSIFICATION OF MARMAClassification of Marma is done depending upon structures involved, effect of Marmainjury, place of situation, measurement of Marma, and number of Marma.Table No 1: Classification of Marma based on structure32,33,34Marma Sushruta Vagbhata Bhavaprakasha Mamsa 11 10 11 Sira 41 37 47 Snayu 27 - 21 Asthi 8 8 8 Sandhi 20 20 20 Dhamani - 9 - Total 107 107 107Table No 2: Classification of Marma based on effect of injury35 Sadyopranahara 19 Kalantara pranahara 33 Vaikalyakara 44 Rujakara 8 Vishalyaghna 3 Total 107“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 12  
  31. 31. AYURVEDIC REVIEW Table No 3: Classification of Marma on location36 Shakhagata 44 Udara uraha gata 12 Prushtha gata 14 Jatrurdhvagata 37 Total 107Table No 4: Classification of Marma based on numbers37 One in number vitapa, kakshadhara, guda, basti, hrudaya, nabhi, sthapani, adhipati Two in number gulpha, janu, stana moola, stana rohita, apalapa, apasthambha, Katika taruna, kukundara, nitamba, parshva Sandhi, bruhati, amsaphalaka, amsa, krukatika, viduara, phana, apanga, aavarta, Utkshepa, shankha Four in number kshipra, talahrudaya, koorcha, koorcha shira, indra basti, ani, oorvi, lohitaksha, srungataka Five in number SeemantaEight in number matruka,“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 13  
  32. 32. AYURVEDIC REVIEW PRUSHTHA MARMA38 Prushtha marma are situated at the back of the trunk. Those are 14 in number arekateekataruna, kukundara, nitamba, parshwasandhi, brahati, amsaphalaka and amsa, each2 in number.Table No 5: Classification of prushtha marma (figure no-1)MARMA NUMBER SIZE STRUCTURE TRAUMA EFFECTKateekataruna 2 ½ anguli Asthi VaikalyakaraKukundara 2 ½ anguli Sandhi VaikalyakaraNitamba 2 ½ anguli Asthi KalantarapranaharaParswasandhi 2 ½ anguli Sira KalantarapranaharaBrahati 2 ½ anguli Sira KalantarapranaharaAmsaphalaka 2 ½ anguli Asthi VaikalyakaraAmsa 2 ½ anguli Snayu Vaikalyakara1.KATIKA TARUNA:- Kati – low back region,39 Taruna – young, Trauma here it refers as it may be thecartilaginous bone or ossification process is going on. In the low back region the fivesmall bones are ossified and forms single bone called “Katikpalasthi” (Sacrum). Thatregion is called “Kati” pradesha On both sides of the prushtha vamsha (vertebral column) in each shroni kanda(hip bone), there are kateekataruna marma situated. Injury to them gives rise to pallor,“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 14  
  33. 33. AYURVEDIC REVIEW discoloration of the skin, due to hemorrhage or blood flows, disfiguration of the body andultimately leads to death. 40 According to Dalhana, kateekataruna marma are asthi marma structurally, havingkalantara pranahara consequences and covers an area half angula and bilateral.41 It is situated on either side of the vertebral column, on the ear like bones of thepelvis are the two kateekataruna marma injury to these causes pallor due to loss of blood,emaciation and death.42Location On the both sides of the vertebral column where kati kapaala Asthi meet withShroniphalaka Asthi. It means sacro-iliac joint. In this region “Katika taruna is present”.Pramana Half Anguli Pramana on both sides of sacro-iliac joint of pelvic cavity. It isapproximately 1cm in diameter circular area on the pelvic cavity.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 15  
  34. 34. AYURVEDIC REVIEW  Flow Chart No.3“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 16  
  35. 35. AYURVEDIC REVIEW Viddha Laxanas:-1. Samanya lakshanaa. After injury to this Asthi marma leads to rupture of major blood vessels because in thisregion Asthi protecting major blood vessels of pelvic cavity with main nerves.b. Severe bleeding.2. Vishesha lakshana43a. Shonita kshaya- loss of blood, this is due to rupture of major blood vessels in pelviccavity near to the sacro-iliac joint.b. Pandu- due to blood loss, pallor is the main symptom. This is the first stage ofbleeding.c. Vividha varna – this is due to moderate blood loss, means other than pale yellow, littlebit bluish coloration starts to occur. Sometimes it exhibits mixed colour, this is secondstage of bleeding.d. Heena roopata – this is the third stage of bleeding due to excessive blood loss&distortion of pelvic girdle, leads to heena roopata.e. Marana – this is last stage of bleeding, means it leads to death hypovolemia.f. For this process it may take a month, so Marana may occur in a month.3. Madhya and Antah (peripheral region) Viddha lakshana.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 17  
  36. 36. AYURVEDIC REVIEW a. Madhya Viddha lakshana – cardinal signs and symptoms- Kalantara pranaharab. Antah (peripheral region) Viddha lakshana – It is converted in to VaikalyakaraMarma. Flow Chart No.4“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 18  
  37. 37. AYURVEDIC REVIEW  It is situated on the back of the body on the both sides of the lower spine. The areaof the hip on both the sides of the sacrum can be included in this and since it is asthimarma, it may be related bone or bony joint. And because it produces loss of blood,anaemia, distortion of hip & giving ugly look to the person (i.e deformity of pelvicgirdle). The possibility of rupture of blood vessels along with the fracture, dislocation ofparticularly sacro-iliac joint can be thought of. In compression injury fracture dislocation of sacro-iliac joint and distortion ofpelvic takes place, accompanied by injury to blood vessels especially common iliacvessels at its bifurcation giving.we can give the another openion that superior glutialartery it is direct branch from the internel iliac artery injury to this gives rise tohemorrhage, leading to panduta, etc. According to the classics this marma is included under the asthi marma. Injury tothis marma leads posterior weight transmitting segment injury which is important fromthe locomotion point of view are more disabling. Katikataruna injury, which producesfracture and dislocation with severe hemorrhage and distortion of normal shape of pelvis,suggests the following possibilities. The signs and symptoms of trauma over this marmapoint to a possibility of joint involvement which produces instability of a pelvis andproduce sever hemorrhage and result in change of normal shape of pelvis. All these threesymptom complexes are possible if the sacro-iliac joint is taken as kateeka taruna. Theinternal iliac vessels which lies in the vicinity, will produce intra pelvic hemorrhage on“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 19  
  38. 38. AYURVEDIC REVIEW trauma and produce obvious distortion of normal contour of pelvis, resulting in ‘HEENARUPA’ and ultimately death due to hemorrhage or sepsis & shock. Based on these the kateeka taruna marma seems to be anatomically situated onthe back adjacent to the both the sides of the lower spine where both the hip bone jointswith the sacrum. Dalhana mentioned this marma as asthi marma, satisfies the bonystructures or joints found in the area concerned. But while considering the loss of blood,pale and distortion of hip arises ugly look to the person, the possibility of rupture ordislocation of the bony structures usually caused by crush injury, inturn blood vessels andnerves are damaged producing loss of blood (anaemia) and ultimately leading to death. The important anatomical structures lie in the sroni pradesha are inferior &superior gluteal arteries and nerves, internal pudendal artery & the sciatic nerve. If incase any damage to any arteries may leads to excess bleeding and consenquently deathtakes place after some time. Any injury to the sciatic nerve produces loss of sensation andthe movements of the muscles innervated with the nerve. According to the Vd RR Pathak, the posterior aspect of the ilium, bifurcation ofcommon iliac artery opposite lumbosacral articulation, in to the external iliac and thehypogastric arteries the corresponding iliac veins and sacroiliac ligaments should betaken as the anatomical structures involved in the kateek taruna marma, Dr. V.S Patil alsostands with the same view. Dr. B.G Ghanekar enumerated the anatomical structures involved in the area ofthis marma as sciatic notch, but the description does not justify because the sciatic notchis deeply situated.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 20  
  39. 39. AYURVEDIC REVIEW  Dr Avinash Lele, in the secrets of marma accounted the anatomical structuresinvolved in this marma as posterior aspect of the ileum, sacro-iliac ligament, superiorgluteal artery, and vein draining common iliac lymph gland, sacral plexus, gluteusmaximus muscle, and as per their view this marma is not accepted as asthi marma. According to P.V. krishnarao the important anatomical structures correspondingto kateekataruna marma are the posterior aspect of the ileum, bifurcation of the commonilac artery, opposite to the lumbo-sacral articulation. Astthi marma viddha laxana: When asthi marma are injured there is discharge of thin fluid mixed with bonemarrow and intermittent pain.44 The learned surgeon well versed in the scripture should diagnose the patient whohas severe pain day and night and who gets no relief in any posture as suffering from aninjury to bone.2. KUKUNDARA MARMA Kukundara marma is situated on both sides of prushtha vamsha and the lateralsides of the outer part of the jaghana asthi and an injury to this marma causes loss ofsensation and movements in lower part of the body.45 It is a sandhi marma in nature, vaikalyakara in consequence and extends over anhalf angula area (Dalhana)46According to chakrapani there are two deviated parts over the sphik47“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 21  
  40. 40. AYURVEDIC REVIEW According to Haranachandra the word kati means jaghana, the marma are situated on theboth sides of vertebral column and they are in whirl in shape.48Location: On the two flanks, outside the buttocks and on either sides of the vertebral columnare the two kukundara, injury to this leads to loss of sensation and the movements of thelower parts of the body.Pramana:½ Angula Pramana, outside the buttocks and on either sides of the vertebral column. It isapproximately 1cm in diameter circular area on the pelvic cavity. According to the Gananathsen , the kukundara marma counted as ischialtuberosity .Vd.R R pathak counted this marma as to the sacro-iliac articulation overwhich the sacral nerves arising from the sacral plexus and passes and emerges out thepelvis through the greater sciatic foramen. As per the openion of Dr.Avinash Lele the anatomical structures under themarma as ischial bone, inferior gluteal artery and vein, inferior pudendal artery and vein,gluteus maximus muscle and levator ani muscles.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 22  
  41. 41. AYURVEDIC REVIEW  Flow Chart No.5“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 23  
  42. 42. AYURVEDIC REVIEW  Flow Chart No.6“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 24  
  43. 43. AYURVEDIC REVIEW   Sandhi marma viddha laxana: Progressive (muscular) atrophy, severe pain, decrease of strength, oedema all around and a loss of all movements are the features of an injury to the movable and the immovable joints49. Injury to the sandhi marma the site injury feels as though full of thorns, even after healing of wound there is a shortening of the arm, lameness, decrease of strength, movements and emaciation of the body and swelling of the joints.50..  3.NITAMBA MARMA: Nitamba marma is situated above the sroni kanda (hip bone), which covers the ashaya and connects the lateral part of the vertebral column. An injury to this marma leads to shosha (atrophy) in the lower extremity and weakness, which ultimately causes death.51 Table No:6 Shroni phalakasthi Nitambasthi Hip bone 2 Bhagasthi Pubic symphysis 1 (both together) Trikasthi Sacrum 1 Gudasthi Coccyx 1 “A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 25   
  44. 44. AYURVEDIC REVIEW  According to Acharya Dalhana it is an asthi marma in nature,in consequences causekalantara pranahara marma.52 According to vagbhata this marma is located above the ear like bones of thepelvis, concealing the visceral organs and composed of cartilages. Any injury to thismarma leads to swelling and debility of the lower part, and and lastly leads to death.53 Dr . R. R Pathak has accounted floating ribs, the lumbar plexus along with theother important structures as the anatomical contents of the nitamba marma. In the context of Shroni panchaka, Acharya Sushruta told two Nitambasthi. So theshroni panchaka is nothing but the union of five bones in pelvic region. So hip bone, specifically ilium and ischium are considered as Nitambasthi, andthe region is called “Shroniphalaka” region.LocationAbove the Jaghana karna of pelvic bone is covering pelvic organ. It is located interior tothe pelvic cavity on the both sides of lateral aspect of the iliac bone. This is nothing butlocation of lumbo- sacral plexus and its branches in interior of the pelvic cavity.Pramana Half Anguli Pramana on both sides of the interior of the pelvic cavity. It isapproximately one cm diameter circular area of the pelvic cavity.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 26  
  45. 45. AYURVEDIC REVIEW  Flow Chart No.7“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 27  
  46. 46. AYURVEDIC REVIEW Viddha lakshana1. Samanya lakshanaa. After injury, Sthanika dhatu kshaya; due to dhatu kshaya, Vata prakopa, it may leads tosarva Shareera dhatu kshaya or specific rakta dhatu kshaya.b. Vividha vedana – due to involvement of sensory nerves.2. Vishesha lakshana54a. Adhah kaaya shosha – Adhah kaya shosha means loss of sensory and motor activity oratrophy of lower limb.b. Daurbalya - General debility or lower limb debility. Due to rakta dhatu kshaya andVata prakopa, general debility may occur otherwise involvement of the motor andsensory nerve leads to debility in lower limb only.c. Marana – involvement of the major blood vessels severe bleeding may occur that leadsto hypovalemia, it may be end up with Marana.3. Antah (peripheral region) and Madhya Viddha lakhanaa. Madhya viddh lakshana – cardinal signs and symptoms (Adhah kaya shosha,Daurbalya and Marana).b. Antah (peripheral region) Viddha lakshana – it is converted in to Vaikalyakara Marma,it means if the Marana not occur, it may end up with deformity of the lower limbs. Daurbalya due to general Dhatu kshaya or Rakta dhatu kshaya. After injury theperson may die after a month. This depends on the nature of the patho-physiology.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 28  
  47. 47. AYURVEDIC REVIEW Within this period if Chikitsa Chatushpada’s are available, the person may survive or endup with sensory and motor loss of lower limb as a deformity.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 29  
  48. 48. AYURVEDIC REVIEW  Flow Chart No.8“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 30  
  49. 49. AYURVEDIC REVIEW 4. PARSWA SANDHI MARMA:Location:55 It is situated inferior to and in the middle of the lateral flanks being attached to it.They are obliquely placed of conjoined together in order and attached to the lateral sidesof bony part hidden by it.Pramana:56 Half anguli Pramana on both sides of the Poster-interior part of the Abdomino-pelvic cavity. It is approximately one cm diameter circular area of the Abdomino-pelviccavity. Injury at this site fills up koshta with blood leading to death.57 It is kalantarapranahara, sira marma structurally. Dr.sharma has considered iliac artery and its branches regarding this marma. Hehas reached this idea by considering filling of koshta (pelvic cavity) with hemorrhage.Dr. Pathak has given his own comments, The structures responsible for this marma arerenal arteries and veins. Dr patil has located the site of marma between the highest pointof kati and the subcostal region. The possibility of probable structures involved in theinjury could be the lower part of liver on right side or spleen on the left side inferiorvenacava and descending aorta, it is ardhangula in pramana measured by all classicalbooks. Dr.pathak has measured half an inch. This marma is situated in pelvicregion(shroni guha).“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 31  
  50. 50. AYURVEDIC REVIEW  Flow Chart No.9 .“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 32  
  51. 51. AYURVEDIC REVIEW  Regarding its surface anatomy, it is situated in between the jaghana parswaobliquely and superiorly,It is sira marma and injury to this causes delayed death(kalantarapranahara). Due to bleeding filling up the pelvis with blood. Sharma and Ghanekar havesuggested common iliac arteries responsible for this marma. It is to be recalled here thatVagbhata has confirmed about the marma lying inside the pelvis placed obliquely frombelow upwards at the joint where the five pieces of parshuka conjoined together in anorder and attached to the lateral side where the bony part is situated .This vascular marmalying in the iliac fossa near the sacroiliac joint in the pelvis. The iliac vessels rarelypresent isolated uncomplicated wounds. Such wounds are usually complicated byfracture of the pelvis or by a perforating wound of the abdominopelvic cavity. In otherwords they are observed only in connection with extensive traumatic lesions such asusually in death on the battle field. The immediate and formidable hemorrhage followedby death.The external iliac and its companion vein have been injured by bullet traversing the iliacfossa either obliquely or front to back or by spent shell fragments arrested by contactwith the vessels. Tuffier has reported a case of this description to the “The societe Dechirurgic” which was observed by Letoux. A fragment of a bomb extend at the level ofanterior superior iliac spine, the opening wound did not reveal the vascular injury whichwas manifested 15 days later by the appearance of the secondary diffuse hematoma .Theexternal iliac artery was ligated ,death followed ,however as the result of secondaryhemorrhage. Soubbotitch has reported two cases of hematoma resulted from a wound ofexternal iliac, one recovered and other died after double ligature of the vessels.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 33  
  52. 52. AYURVEDIC REVIEW  Wounds of the gluteal region leading to injury of gluteal vessels and nerves aremore frequently observed at field ambulences then wounds of external iliac .They usuallyresult from shell wounds, rarely bullet wounds of the buttock. On one occasion it wasseen that shell fish traversed the buttock and penetrated the iliac fossa into the pelvis.These extensive injuries are extremely serious and their gravity is enhanced by thepresence of co-existing vascular lesions. Wounds of the gluteal and pudendal arteries rarely give rise to serious externalhemorrhage therefore they are more attractive to trauma surgeons. The external iliacartery and vein may together be severed in gunshot wound or may be intermittently oraccidentally divided during pelvic operation. A challenging problem facing the trauma isthe gunshot wound to the pelvis which may generate secondary missiles of bomb andcause multiple injuries to branches of the venous plexus; The mortality of 50% has beenreported. Attempts at suture, ligation, cautery and clipping are all made difficult by therapidity with which the relatively small pelvic cavity of male fills with blood, despite theemployment of multiple suction units. Ligation of major vessels rarely helps. The discussion suggests that there are two regions, which seems to be responsiblefor this marma they are pelvic cavity and gluteal region. The vessels of extremities areiliac vessels and their external branches.The bleeding from gluteal region also notapparent but manegable.However ligation or control of bleeding of pelvic vessels arevery difficult rather unmanegable.Therefore these vessels are suggestive forparswasandhi marma.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 34  
  53. 53. AYURVEDIC REVIEW  The common iliac artery bifurcates into external and internal iliac artery at thepoint superior 1/3rd (2 inch) of the imaging line drawn on the surface of the abdomenjoining the point of aortic bifurcation (3/4th inch below the umbilicus ) and mid inguinalpoint.the diameter of the aorta and inferior venacava are approximately 1 inch each.Thecourse of these vessels are also comparable with the description of sushruta’sparswasandhi marma. The gunshot wound to the pelvis involving the pelvic vessels bymissiles of bone or pallets is a challenging problem for the trauma surgeon even thoughthe fatality is quite high.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 35  
  54. 54. AYURVEDIC REVIEW  Flow Chart No.10“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 36  
  55. 55. AYURVEDIC REVIEW 5.BRAHATI MARMA:Location:58Just opposite the stanamula bilaterally on the back are brahati marmas. The injuries of theregion has high tendency of severe bleeding resulting to complications and terminatesinto death.It is kalantara pranahara, sira marma structurally. This word derived from the Sanskrit root Brahat means huge. The region of thismarma is back of the thorax. Its surface anatomy is the area on the surface of the backcorresponding to nipples. The anatomical structure responsible for the traumatic result issira (vessels)and the delayed death (kalantara pranahara). Pramana:59 Half Anguli Pramana on both sides of the Poster-interior part of the Thoraco-abdominal cavity. It is approximately 1cm diameter circular area of the Thoraco-abdominal cavity.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 37  
  56. 56. AYURVEDIC REVIEW  Flow Chart No.11Dr. H.P Sharma has translated this marma into anastomoses around the scapula. Dr.R.Rpathak has discussed for the vessels at the hilum of the liver at right side and vessels atthe hilum of spleen at left side.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 38  
  57. 57. AYURVEDIC REVIEW  Etymologically the word brahati denotes symbolic number 36, or part of the bodybetween the breast and back. Hence the base of the lungs, diaphragm and the bare area atthe inferior angle of scapula with sub scapular artery or intercostals vessels behind thepleura in the intercostals space may be included in this marma. An injury to this marmamay produce the excessive bleeding leading to serious complications. It has beenmeasured ardhangula in pramana by all classical books. Dr Pathak has mentioned it ishalf an inch. Dr Sharma and Ghanekar opines that anastomosis around the scapula. Maycorrelated to this marma. Dr. V.S Patil has included base of the lungs, bare area at theinferior angle of the scapula, diaphragm or intercostals muscles behind the scapula areresponsible for this marma. The triangle of auscultation lies behind the scapula bounded above by trapezius,below by latissimus dorsi and laterally by the vertebral border of scapula and the exposedpart of the rhomboideus muscle, However the triangle of auscultation is the area ofchoice where sixth inter costal artery lies in the sixth intercostal space within the triangleof auscultation in its approach from below upwards oblique to run in the sixth costalgroove at the angle of the rib. If this artery ruptures leads to intrathoracic hemorrhagecomplications leading to death. The penetrating injury on the back of the chest usuallycomplicates due to uncontrollable bleeding. The fracture of the lower part of the scapula,bullet or fractured rib usually produces complications.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 39  
  58. 58. AYURVEDIC REVIEW  Flow Chart No.12“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 40  
  59. 59. AYURVEDIC REVIEW 6.AMSA PHALAKA MARMA: On the dorsal aspect of the body the marma is associated with trika.60It is asthimarma . Injury to this leads to muscular atrophy and loss of sensation or numbness torelated area.Location:61 It is located in prushtha ( posterior aspect of thorax) on both sides of the prushthavamsha(vertebral column) related to the “Trik”.Pramana 62 Half Anguli Pramana near to the superior angle of the scapula, a circular area is made with 1cm diameter. Below this cervical enlargement of spinal cord is situated. According to Prof. J.N Mishra this marma considered,The amsaphalaka marma issomewhere in the superior part of the back, It lies in both lateral sides of the vertebralcolumn, This marma is in the close relationship with scapula. The nerve supplying the upper extremity is an essential part of the marma,because any injury to this marma may cause atrophy of muscles those are attached to theamsaphalaka and numbness of the upper extremity. Therefore this can be taken as thesite of the suprascapular notch is the anatomical site where all the above said conditionscan be found with this fact. According to sushruta the marma is an asthi marma. This statement is doubtfulbecause traumatological effect of this marma cannot be correlate with this. The wasting“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 41  
  60. 60. AYURVEDIC REVIEW and numbness is possible only after the involvement of nerve supplying to the upperextremity. Probably the above said version of sushruta was based on the presence of thescapula in the close relationship with this marma. Sushruta has said that any injury to thismarma causes numbness (swapa) and wasting (shosha ) of the upper extremity.63This isreliable because an injury to this marma may damage to the branches of the brachialplexus along with the damage of supraclavicular nerve and artery the damage mayfollow- If foreign body penetrates the deeper parts severe damage of the brachial plexus ispossible this will lead to paralysis of the upper extremity. If foreign body penetrates the deeper parts leaving light impact, moderate damageof brachial plexus is possible. If foreign body penetrates to the superficial part damage to the suprascapularnerve and artery will be resulted. This will cause paralysis of abductor muscles of theshoulder joint along with wasting of the same.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 42  
  61. 61. AYURVEDIC REVIEW  Flow Chart No.13“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 43  
  62. 62. AYURVEDIC REVIEW Viddha lakshana1. Samanya lakshana64a. Patient will not die after injury to the Amsaphalaka Marma, but leads to vikalata.b. Pain due to increased Vata.2. Vishesha lakshana65a. Bahu shosha – Bahu means arm region, but Dalhana commentary gives the idea asupper limb. This is because depend on the involvement of Brachial plexus branches.b. Bahu shopha – As arm atrophy. This is due to involvement of all the upper limb motornerves ( Radial, Ulnar, Median, Musculo cutanious nerves).3. Antah (peripheral region) and Madhya Viddha lakshana.a. Madhya Viddha lakshana – cardinal symptoms, means bahu shosha as a deformity.b. Anth Viddha lakshana- converted in to Rujakara Marma, the person feels pain forlong duration. This will cause numbness and wasting due to partial loss of functions.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 44  
  63. 63. AYURVEDIC REVIEW  Flow Chart No.14“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 45  
  64. 64. AYURVEDIC REVIEW  7. AMSA MARMA:- It is situated between the root of the arm on one side and the neck on the other.This ties shoulder and amsapeetha together. Here there are ligaments binding the scapulawith the clavicle. Injury to this marma, results in stiffness of the limb with loss offunction66. It includes all the soft tissues like muscles, tendons,ligaments etc, which takepart in the formation of shoulder joint with scapula. An injury to these structures maycause rupture of the muscles, ligaments resulting in dislocation of joint,that leads to lossof function of the shoulder joint. According to vagbhata the injury to Amsa marma leads to bahukriyahara i.e lossof function of upper limb.67 Amsa marma includes the structures related to shoulderregion are the most exposed area to common injuries. The activities like weight lifting,swimming, cricket, fall on the outstretched arm causes the rupture of ligaments andmuscles of the shoulder joint, leads to the disability of the amsa sandhi andbahustabdhata.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 46  
  65. 65. AYURVEDIC REVIEW  Flow Chart No.15“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 47  
  66. 66. AYURVEDIC REVIEW Definition of Stabdhabahuta: This term is mentioned in Su.Sa. Sha.6/35, while explaining about theAmsamarmabhighata, he says injury to the Amsa marma leads to the Stabdhabahuta,Herethe broad meaning of stabdhabahuta is “Bahukriyanasha”according to AyurvedaShabdakosha,that means loss of functions of the upper limb.Accoding to A.Hru. Shatraumatological effect of Amsa marma is ‘Bahukriyahara’ means same as that of themeaning of stabdhabahuta. Lastly we can consider the Stabdhabahuta is the impairmentof the upper limb.Causes for the stabdhabahuta: Mainly due to the abhighata to the Amsa pradesha, in modern era the injuries like, 1. Sports injuries 2. Heavy weight lifting 3. RTA (Road traffic accidents) 4. Fall on the outsretched arm 5. Over exertionSamprapti of Stabdhabahuta: Here the Stabdhabahuta is not a disease, it is a symptom where theAmsamarmabhighata takes place.According to Gayadas in Nyayachandrika of Ni1/82 The major structural impairment in the conjoined structure of shoulder or Amsa is“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 48  
  67. 67. AYURVEDIC REVIEW due to Amsastha shleshma or shleshaka kapha. Vitiation of the shleshma leads to thedryness of the Amsabandhana and lastly emaciation of Amsa pradesha takes place-ultimately it leads to deformity of the shoulder, However the samprapti of stabdhabahutais shown in the flow chart 16.Clinical features of Stabdhabahuta:Samanya marmabhighata laxana are:67(1) 1. Vicheshtana 2. Urdhvavata 3. Vayukruta tivra ruja 4. Stabdhata 5. KriyanashaAmsa marma is a snayu marma structurally, it measures about half anguli, if injury to theSnayu marma leads to the following laxanas-67(2) 1. Koubjyam (Shortening) 2. Shareeravayavasaada (svakarmanyaasamrthyam)-loss of functions 3. Kriyasvashaktiriti (Loss of movements like Abduction, Adduction, Flexion extension etc,) 4. Ruja (Pain) “A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 49  
  68. 68. AYURVEDIC REVIEW        Flow Chart No.16“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 50  
  69. 69. AYURVEDIC REVIEW AMSA PRADESHA:- Before dealing with the Amsa marma let us know the shoulder & scapular regionaccording to Ayurvedic scholors. In amsa pradesha includes nine structural complexes are present. Those are asfollowes–Amsa,amsakuta,amsadesha,amsapinda,amsapeetha,amsaphalaka,amsabandhana,Amsamul & amsasandhi.These are described according to different Ayurvedic scholors. These terms has beenexplained in the sushruta samhita-sutra, shareera, nidana,chikitsasthana, charaka vimanasthana,vagbhata shareera & nidana sthana. The dictionary meaning of amsa term is Bhuja,shira,and skandha, “Asyatesamahanyate bharadina”functionally this region is responsible for the weight bearingpart. This site consists of certain important structures-bones, ligaments, vessels andnerves.Bones: Parts of the scapula,clavicle,and upper part of the humerus.Joints: Shoulder joint Acromioclavicular joint“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 51  
  70. 70. AYURVEDIC REVIEW Ligaments & muscles: (1) Coracoacromial ligament (2) Capsular ligament (3) Glenoid labrum (4) Transverse humeral ligament (5) Bursae-8 (6) Rotator cuff muscles & associated musclesBy observing these structures we can consider that this site is vital one, because injury tothis leads to loss or deformity of the upper limb i.e nothing but the stabdhabahuta orBahukriyahara. Based on their references we will come to know that Amsa marma is thecomplex structure. Let us discuss one by one, among the nine terms as according to ayurvedicscholors. 1. AmsaAmsa is included under the prushtha marma 68Among them amsaphalaka is an Asthimarma, but the amsa marma is snayu marma. 69 Amsa marma is a snayu marma structurally, If we discuss about snayu based onmany references (shastracharchaparishad) we can call it as ligament, somewhere it isconsidered as nerve or tendon. But depending upon the situations we can name it to“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 52  
  71. 71. AYURVEDIC REVIEW different structures as above said, traumatic effect on amsa marma (snayu) leads to thefunctional deformity so, it is known as VAIKALYAKARA MARMA. Vaikalyakaramarma kalantaram kleshayati rujaam cha karoti.70 All the vaikalyakara marma are later converted into rujakara one. By this reasonthis marma can neigther be considered as nerve or tendon,but this may be considered ascomplex structures like ligaments, muscles, tendons, bursae & nerves, Hence amsamarma is the CORACOACROMIAL ARCH or ACROMIOCLAVICULAR JOINT orSUBACROMIAL BURSA. Based on these observations without any disputs, we canconfine it to SHOULDER REGION, ACROMIAL REGION & SCAPULARREGION(PRATYKSHA SHARIR). According to Kashyapa samhita sutrasthana laxanadhyaya, The amsa term ismentioned, as -“shushkamsah daridra….. snigdhamsah krushaka,peenamsa adhya,kathinamsah shura, shithilamsoashakta, unnatamsah puman prashasyate, brashtamsakanya.”71 Based on this explaination of Kashyapa we can consider it as shoulder andacromial region. According to Charaka vimana sthana while explaining the pramana sharira hementioned “ ashthangulou skandhou shadangulou amsou.”72 8 Angula-skandha 6 Angula-amsa Based on this anthropometry“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 53  
  72. 72. AYURVEDIC REVIEW  Skandha kshetra is scapular region Amsa kshetra is Acromial region. 2. Amsakuta This term can be seen in the sushruta shareera 6 chapter In A. Hru.sha-4/16 Apalapa is one of the sira marma, traumatic effect of this marma fills the blood inthe thoracic cavity later is converted into pus formation lastly leads to death. Here,Anatomically the Apalapa is the beginning part of lungs or pleural sac, Exactly above theapalapa is the AMSA KUTA or ACROMION REGION73,74. The kuta is considered as Acromion process of the scapula which is veryprominent structure in the shoulder region. 3. Amsadesha Here Desha means place or region.“Amsa desha” is that area where the amsa hasspreaded its vicinity.This term has been mentioned in the sushruta Nidanasthana 1stchapter.Here in Amsa desha – emaciation of structure which bind the amsa i.eAMSABANDHANA takes place.and constriction of the siras related to Amsa takesplace.This clinical feature is known as Avabahuka.75According to Dalhana the definitionof amsadesa is “Amsasameepopalakshito deshoamsadesha”76 The area which is superior to Amsa is Amsadesha. Due to the effect of aggravatedvata over conjoined structures of Amsa and related vessels and nerves has been said to be“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 54  
  73. 73. AYURVEDIC REVIEW the cause for the manifestation of Avabahuka. We can compare to the brachial plexuspalsy to the Avabahuka. Where the compression of brachial plexus and related bloodvessels takes place. Here the amsabandhana is the conjoined structures of shoulder joint (Amsasandhi)related ligaments and muscles of the shoulder region i.e Rotator cuff. Hence area occupied by the Rotator cuff muscles, axillary vessels and ligamentsrelated to the shoulder joint and injury to this leads to loss of functions of Bahu is knownas Avabahuka or were the amsa marma is also present. Overall that area is Amsa desha orshoulder region. 4. Amsapinda In Sushruta shareera 5th chapter,whIle explaining “SHODASHA KANDARA” he described the praroha and he named Amsapinda as Agrapraroha, and Dalhanacharya clearly explained this term as77 “Hastagatanaam chatusrunamuparigatanamamsapindo bahushiro agrapraroha iti.”78 Here Bahushira is the synonyme of amsa. No doubt here amsa panda is rounded structural area and above that area kandaras or prarohas are converged,Bahushira (Part of Amsa) is the spherical shaped structure containing muscles. The area over the greater tuberosity of humerus which is attached with the deltoid muscle is called deltoid prominency. So it bears spherical shape i.e Amsapindika.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 55  
  74. 74. AYURVEDIC REVIEW   5. Amsapitha According to Gananathsen saraswati,glenoid cavity is compared to the Amsapeetha. Again this term has been explained in Sushruta sutrasthana and sharir sthana-(1) While explaining the Anga-pratyanga measurement, Sushruta has quated.(2) While explaining the types of sandhi-he quated “Amsapeethagudabhaganitambeshu saamudgah.” 79 By observing these quotations the anthropometry inbetween Amsa peetha and kurpara is 16 angula,and here we can consider amsapeetha as a exterior border of the scapular and shoulder region.80 We can give another openion; Inbetween Amsapeetha sandhi and kurpara sandhi 16 angula length. But Dalhanacharya commentated Amsa peetha as Bahushira i.e “Amsapeetho Baahushirah;” and amsapeetha sandhi as one of the type of ‘Saamudga 81 sandhi’ But the dictionary meaning of peetha is Aasanam & Saamudga is Samputaka, However the area of amsapeetha is accomodates in the area of Amsa. Hence, By observing above said explaination we can consider Amsapeetha as scapula and Amsapeetha sandhi as Acromioclavicular joint, because it is one of the Saamudga sandhi and it is situated just above the shoulder joint. By discussing all these points based on the quotation of AMSA MARMA in Su.Sa. sha- 6th chapter and A.Hru.Sha 4th chapter we will come to know that all above said structures like Amsa peetha,bahushira etc…are included under the Amsa marma. “A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 56   
  75. 75. AYURVEDIC REVIEW  6. Amsaphalaka In Kashyapa Samhita sharira sthana while explaining the Asthi sankhya,hementioned Amsaphalakas are Asthi they are two in number. “Dwaamsavamsaphalakaavapi dwaveva chakshakou.”82According to him amsa-2 Amsaphalaka-2 Akshakasthi-2Here,we should think about the Amsa because he considered these are also asthi and 2 innumber. But these structures or parts we can include under the spines of scapula,according to sushruta a mass are included under the kapalasthi.Finally we can consider Amsa as acromion process and Amsaphalaka as scapula. 7. Amsabandhana This term already we discussed in the Amsadesha topic.Sushruta nidana vatavyadhi chapter while explaining the Avabahuka vatavyadhi,hementioned the term Amsabandhana-“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 57  
  76. 76. AYURVEDIC REVIEW  In the area of the Amsa-underground structures impaired by the aggravation ofvata and rakta due to injury to the amsabandhana that leads to the compression of siraslastly the disease Avabahuka.83 Here the structures which bind the BAHUSHIRA,AMSAPEETHA, GREEVAinbetween these the amsa marma is present.the amsa which is bounded by the SNAYU &PESHI i.e the ligaments of the shoulder joint & Rotator cuff muscles, if injury to these 84structures that leads to ‘BAHUKRIYAHARA’ or STABDHABAHUTA and lastlyvitiation of the vata and rakta takes place that leads to AVABAHUKA. According to Gayadas-in Nyayachandrika,By this quotation we will come to know that the major structural impairment in theconjoined structure of shoulder or Amsa is due to Amsastha shleshma or shleshakakapha. Vitiation of the shleshma leads to the dryness of the Amsabandhana and lastlyemaciation of Amsa pradesha takes place-ultimately it leads to deformity of theshoulder.85 But according to modern science wasting of muscles are due to the injury ofmotor nerve paralysis. By this explaination we can consider that structures underlying the shoulder andscapular region are effected, mainly due to the trauma, like Rotator cuff injuries, frozenshoulder,tearing of ligaments etc….these are resulted into the dislocation of shoulderjoint, ultimately that leads to Bahukriyahara or STABDHABAHUTA. 8. Amsamula“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 58  
  77. 77. AYURVEDIC REVIEW  According to Shastracharcha parishad, the amsa mula is correlated into apex ofthe axilla.where the brachial vessels and brachial plexus are situated. If injury to thisleads to the paralysis of the upper limb takes place i.e STABDHABAHUTA. By observing this discussion we can approach that apex of the axilla is included inthe area of the AMSA MARMA 9. Amsasandhi Amsa sandhi rachana shareera vivechana: This is a major joint of the upper limb. This is one type of chala and ulookhalasandhi. This joint is formed by the articulation of Pragandasthi, Akshakasthi andAmsaphalakasthi. Pratanavati type of Snayu covers this Sandhi. Acharya Sushruta states thatSnayu is binding material of Mamsa, Asthi and Medha. Like a boat made up of planksand timber, tightened together by means of large number of bindings is enabled to floaton the water and to carry cargo. Similarly in the body all the Sandhis are tightened up bylarge number of Snayus, which enables the body to bear the weight. Sheshmadhara Kala is present in this joint and seceretes shleshaka kapha. thisact as a lubricant for the joint and helps in protection and movements of the Sandhi.Acharaya Sushruta has described that the rachana of Sandhi as like a wheel having anaxis. When the axis is lubricated by putting oil on it, the wheel can move freely andfriction does not occur. In the same way the bones or joints can move freely in thepresence of Shleshma.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 59  
  78. 78. AYURVEDIC REVIEW  The word Amsa denotes the shoulder; the Amsa Marma is situated within theline of the area joining head (murdha). Neck (Greeva) and the arm (bahu). This is aSnayu Marma to a length of half fingers width (1 cm). The physical matrixes that are present in amsa marma are Mamsa, Sira, Snayu,Sandhi and Asthi. It is one of Vaikalyakara marma, and trauma to this will producedisability of the shoulder joint. Location & Pramana of Amsa marma87 To make the limitations of Amsa marma, we should know about the classicaldefinition of amsa marma which correlates with the modern science. • Bahumurdha (Amsapindika)- Deltoid prominency-1st point • Amsapitha- Upper 1/4th of .Exterior border of the scapular and shoulder region-2nd point • Skandha-shoulder joint-3rd point • Greeva -Root of the Neck-4th point • Amsabandhana-Soft tissues of shoulder & scapular region which hold the above said points. Joining of all these points one by one and make the half angula point at the centre of all above said structure,that forms the Amsa marma.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 60  
  79. 79. AYURVEDIC REVIEW Figure No: 1 Limitations of Amsa marma“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 61  
  80. 80. MODERN REVIEW   MODERN REVIEWModern review of katikataruna, kukundara and Nitamba marma:ANATOMICAL REVIEW OF GLUTEAL REGION: The Gluteal region forms the prominence at the upper posterior parts of lowerlimb.Gluteal maximus is the largest muscle of the region which indirectly extends till thetibia bone, so that it can act simultaneously on both the hip and knee joints. The ischial tuberosity on which one sits underlies this muscle. The gateway to thegluteal region, the greater sciatic notch; the thickest nerve of the body, the sciatic nerve,also lie beneath this huge antigravity postural muscle. One neurovascular bundle formedby pudendal nerve and vessels just appear into the gluteal region from the sciatic notch todisappear fast through the lesser sciatic notch to supply anything and everything in theregion of the perineum.INTRODUCTION: The gluteal region overlies the side and back of the pelvis,extending from the iliaccrest above to the gluteal fold below. The lower part of the gluteal region which presentsa rounded bulge due to the excessive amount of subcutaneous fat is known as buttock ornatis. The anterosuperior part of the region seen in a side view is called the hip. Themuscles, nerves and vessels emerging from pelvis are covered by gluteus maximus andbuttock.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 61  
  81. 81. MODERN REVIEW  SUPERFICIAL FASCIA: It is heavily laden with fat, more so in females, and is tough and stringy over theischial tuberosity where it forms an efficient cushion for supporting the body weight inthe sitting posture, It contains cutaneous nerves, vessels and lymphatics.DEEP FASCIA: The deep fascia above, and in front of the gluteus maximus i.e over the gluteusmedius, is thick, dense, opaque and pearly white over the gluteus maximus, however, it isthin and transparent, the deep fascia splits and encloses the gluteus maximus muscle.MUSCLES OF THE GLUTEAL REGION (Figure no-4) These muscles are the gluteus maximus, the gluteus minimus, the gluteusmedius,the piriformis, the superior and inferior gemilli, the obturator internus andexternus and the quadrates femoris, the tensor fasciae latae which lies on the lateral sideof the thigh. ACTIONS OF THE GLUTEAL REGION: The muscles of the gluteal region form only three functional groupsThe gluteus maximus is the chief extensor of the thigh at the hip joint.The gluteus medius and the gluteus minimus are powerful abductors of the thigh.Remaining are the lateral rotators of the thigh.The tensor fasciae latae is an abductor and medial rotator of the thigh and extensor ofknee.“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 62  
  82. 82. MODERN REVIEW  STRUCTURES DEEP TO THE GUTEUS MAXIMUS:-Muscles:-(1) Remaining all gluteal muscles.(2) Origin of the four hamstring muscles from the ischial tuberosity.(3) Insertion of the pubic fibres of the adductor magnus.(B) VESSELS (Figure no-6)(1)Superior gluteal vessels(2)Inferior gluteal vessels(3)internel pudendal vessels(4)Ascending branch of the medial circumflex femoral artery.(5)Trochenteric anastomoses,formed by the descending branches of the superior gluteal arteryThe ascending branches of the medial and lateral circumflex femoral artery.(C)NERVES:-(Figure no-5)Superior gluteal(L4,5, S1)Inferior gluteal (L5, S1, S2)Sciatic (L4,5,Si,2,3)Posterior cutaneus nerve of the thigh(S1,2,3 )Nerve to the quadrates femoris (L4,5,S1)Pudendal nerve (S2,3,4)Nerve to the obturator internus(L5,S1,S2)“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 63  
  83. 83. MODERN REVIEW  (D)BONES & JOINTS (Figure no-2,3)(1)Ilium (2)Ischium with ischial tuberosity;(2) Upper end of femur with the greater trochanter;(3) Sacrum and coccyx(4) Hip joint and sacroiliac joint(E)LIGAMENTS:- (Figure no-7)(1) Sacrotuberous(2)Sacrospinous and(3)IschiofemoralCLINICAL APPLICATION OF THE GLUTEAL MUSCLES:- Intermuscular injections are given in the anterosuperior quadrant of the glutealregion,i.e in the glutei medius and minimus, to avoid injury to large blood vessels andnerves which pass through the lower part of this region. When gluteus maximus is paralysed as in muscular atrophy, the patient cannotstand up from a sitting posture without support. Such patients, while trying to stand up,rise gradually, supporting their hands first on the legs and then on the thighs; they climbon themselves. When the glutei medius and minimus are paralyzed, the patient cannot walknormally, He sways or waddles on the paralysed side to clear the opposite foot off the“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 64  
  84. 84. MODERN REVIEW  ground, this is known as LURCHING GAIT; when bilateral it is called WADDLINGGAIT. These all are we can apply to the traumatological effect of lower three pairedmarmas of the back i.e kukundara, kateekataruna & nitamba marmaMODERN REVIEW OF PARSHWASANDHI MARMA The parshwasandhi marma is the area lying inside the abdomino-pelvic cavity atposterior wall. It is placed obliquely from below upwards at the joint where the fivelumbar vertebrae are arranged together in an order and further sacralized, attached to thelateral side where the bony part is situated. This marma deeply reaches to the posteriorabdomino-pelvic cavity. By observing this explanation, the parshwasandhi marma may be considered asthe vessels related to the posterior abdomino-pelvic cavity i.e major vessels are thecommon iliac artery which bifurcates into external & internal iliac artery and inferiorvena cava. The associated structures involved in this marma are:MUSCLES: (1) Psoas major (2) Psoas minor (3) Iliacus (4) Quadratus lumborumNERVES:(l) Lumbo-sacral plexus(2) Lumbar sympathetic chain“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 65  
  85. 85. MODERN REVIEW  VESSELS:(1) Abdominal aorta & its branches(2) Bifurcation of common iliac artery(3) Inferior vena cava & its tributaries Organs of urinary system (Ureter, urinary bladder, etc)MODERN REVIEW OF BRAHATI MARMA The brahati marma is the area lying in the triangle of auscultation which liesbehind the scapula, bounded above by trapezius, below by latissimus dorsi and laterallyby the vertebral border of scapula and the exposed part of rhomboideus muscle. The vessels of this area may be directly correlates to the brahati marma i.e 6thintercostal vessels,deeply related to the branches of celiac trunk i.e hepatic artery, splenicartery and portal vein.The associated structures involved in this marma are:MUSCLES: (Figure-4)1. Trapezius2. Latissimus dorsi3. Levator scapulae4. Rhomboideus major5. Rhomboideus minor6. Erector spinaeNERVES:1. Intercostal nerves (6 & 7th )“A Study on prushtha marma W.S.R. to Stabdhabahuta in Amsa marmabhighata ”  Page 66