Rav marma2009


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Rav marma2009

  1. 1. MCTTVEWOH{$HOPONUAruUA A}TN MANAGEilTEII.IT OT MARIffiBTilIGHAT THnff,reH Arfi,nivFr r $ffim rnADtir0srlAt FnATilffis lo f * f,, it 1.IJ,l: "/t 3 - 4 December,z00g Kanyakumari, Tamil Nadu ffi Wy R[$ HTR IYI NYU RUTIII UI IIYRPTff II NATIONAL ACADETT,IY OF AYURVEDA An autonomous organization under Deptt. of AyUSH, Ministry of Health & F.W., Govt. of lndia Dhanwantari Bhawan, Road No.66, Punjabi Bagh (W), New Delhi-110026
  2. 2. INTERACTIVE WORKSHOP ON OMARMA AND MANAGEMENT OF MARMABHIGHAT THROUGH AYURVEDA & OTHER TRADITIONAL PRACTICESO (3-4 December 2009) Kanyakumari Organizing Secretary & Editor Dr. V.V. PRASAD Director Organised by: RASHTRIYA AYURVEDA VIDYAPEETH (NATIONAL ACADEMY OF AYURVEDA) (An autonomous organization under Deptt. of AYtlSH, Ministry of Health & F.W., Govt. of India) Dhanwantari Bhawan, Road No.66, Punjabi Bagh (West), NEW DELHI - I l0 026.Telefax: 0I I -2522975 3 ; Phone : 25228548 E-mai I ay ur gy an(4)redil-fmai l..com, :Website :www.ravdeIhi(@nic.in {.AvidyapeethdeI hi@ gmail. cornRAV subscribes no responsibility for the views expressed or the material submitted by variousdoctors/resource persons to this book.
  3. 3. t, 1. Preface 1--11?. List of Contributing Experts iii3" , .List of Participating Experts tv-v4. List of Questioners vr-v11*5. Introduction to the sub,ject vl11-lX6. Trimarma 1-l 37. Marma Classification I1-418. Marma of Extremities 45-54g. Marma of Trunk 55.3510. h4arma of Head & l{eck 86-9sI 1. Miscellaneous 96-II7
  4. 4. Many consider Ayurvedic Rachana Sharir (anatomy) as a dull and boring subjectdealing with dead bodies, giving the reason that there are many topics in it that are reallydifficult to understand and comprehend well. Marma vigyan is the most intricate part of Rachana Sharir that requires systematicknowledge of Ayurvedic as well as modern anatomy and its applied aspect in relation totraumatology and internal medicine to decipher what is written in the ancient texts. Manyvital points/areas in the body are mentioned, which turn fatal or produce seriousconsequences on injury. Many students and young Ayurvedic teachers find this difficult toexplain and they think this subject as a monotonous and dead. I feel it as one of theliveliest subjects in Ayurveda because once we start understanding it in terms of modernanatomy, the matter starts unfolding itself. It is like someone fearing the ocean merelyimagining its depth and what lies under the sheer volume of water. But when a personstarts diving then he or she finds more and more fascinating marine life and underwaternatural structures. Ayurvedic marma vigyan is like an ocean with full of knowledge of vital points.The more and more the person reads more and more knowledge he/she acquires, andgradually the realization sets in that what amount of hard work has been put in behindwriting those ancient treaties and how much knowledge and experience those great rishishad! Even the verses written thousands of years ago hold true even today. Sadyopranahara manna and other marrnas produce more or less the same result on injury eventoday. Most mortalities result in during the golden hour (the very first hour after physicalinjury), since the injured person fails to get the required medical assistance despitetremendous advances made in modern medical field. The knowledge of the marma points in the body, which was said to have been usedin warfare and surgical procedures, ksharakarma, agnikarma etc., can well be utilized forpreventing/minimizing the damage to vital and other important organs. In order todocument the present day scientific understanding of this vital subject, we have decided tohold this workshop. There are a number of marma (varma) and kalari experts in southernparts of the country, who claim to utilize this knowledge, and their participation wouldhelp sharing the experiences on the subject. Hence, we have decided to hold the workshopat Kanyakumari. I hope the clarifications that unfold during these two days deliberations willsurely clear some of the doubts that the young students and teachers are having in theirmind and help understand the subject in a better way. Dr. Ramachandra B. Gogate, an eminent consultant of Ayurveda, practicingpresently at Pune, has given lucid details of marma and his experiences in dealing withemergencies requiring the application of the Ayurvedic principles in clinical cases. Thisintroduction to the subject was given in this book just before the chapters of questions andanswers. I sincerely thank him for this contribution in the book.
  5. 5. Rashtriya Ayurveda Vidyapeeth (RAV) has been conducting these interactiveworkshops, year after year, facilitating the one-to-one discussions among students, youngdoctors and senior faculty. The feedback, from junior as well as senior doctors that theseprograms are benefiting them to update and upgrade their knowledge, is encouraging us tocontinue these workshops on topics that require thorough deliberations for properappreciation. The experiences and wisdom of seniors are always helpful in the progress ofscience. The courses being run by RAV under Guru Shishya Parampara are helping theyoung Ayurvedic doctors to leam the intricacies of clinical practice and other relatedsubjects and developing interest to carry forward the science of Ayurveda. The support ofthe govemment and the Governing Body is enormous in this task. I would like to place on record the efforts made by the senior faculty in sparingtheir valuable time to write the answers/clarification to the questions of PG students andyoung teachers. I would like to express my heartfelt gratitude to Secretary and other offrcials of theDepartment of AYUSH; Rresident and other members of the Governing Body of RAV fortheir constant encouragement and support in all activities of RAV. I also thank mycolleagues in RAV for their painstaking efforts to accomplish the given tasks and Dr.Sandhya Patel for her assistance in preparation of the book. Dr. V.V. Prasad Director
  6. 6. CONTRIBUTING EXPERTS: 1. Dr. Ramachandra B. Gogate, l,Indru Bhawan,678, Nanapet, pune. 2.Dr. Veer Shetty Patil, ll-7-391N/29, Saraswati Nagar, Saidabad, Hyderabad. 3. Prof. Dinakar G. Thatte, 13, Prakash Puram, Nayi basti, Bhadewan, Aish Bagh, Lucknow. 4.Dr. Vijay V. Doiphode, Flat No. 6, Rajashree Apartments, Nilgiri Lane, Baner Roado Pune. 7 5. Prof. M. Dinakar Sarma, Department of Sharira Rachana, National Institute of Ayurveda, Amer Road, Jaipur. u 6. Dr. c. suresh Kumar, Triveni Nursing Home, vanchiyoor, Trivendrum. u 7. Dr. S.P. Tiwari, Professor of Rachana Sharir, CVMs Ayurvedic College, Vallabh Vidya Nagar, Anand. 8. Prof. K.B. sudhi Kumar, Deptt. of shalya Tantra, Govt. Ayurved college, Tripunithura, Cochin. 9. Dr. Mukund P. Erande, Principal, Sumathi Bhai Shah Ayurveda College, Malwadi, Hadapsar, Pune. 10. Prof. J. N. Mishra,F"-1632, Rajaji Puram, Lucknow. 11. Dr. Jyotsna, Professor of Rachnashariro MLR Ayurvedic College, Charkhi Dadri, Haryana. 12.Dr. U. Govinda Raju, Department of Sharira Rachana, SDMCollege of Ayurveda, Udupi, Karnataka.v/ 13. Dr. G.M. Kanthi, Prof & Head, Department of Sharira Rachana, SDMColtege of Ayurveda, Udupi, Karnataka. 14. Prof. v.v.Prasad, Director, Rashtriya Ayurveda vidyapeeth, New Delhi. ul
  7. 7. PARTICIPATING EXPERTS : 1. Vaidya S.K. Mishr ar 604,Tower Apartments, Swasthya Vihar, New Delhi.,t 2. Dr. M.R. Vasudevan Namboothiri, Director, Ayurvedic Medical Education, Govt. Of Kerala, Trivendrum.,/3. Dr. P. Madhavankutty Varier, Dy. Chief Physiscian, Arya Vaidya Sala, Kottakkal.- 4. Dr. T. Sreekumar, Vaidyaratnam Ayurveda College, Thaikattusery, Ollur, Trissur .5. Dr. Mohan Kumar, Vinayaka Nursing Home, Paalackal,l-hrissur. 6. Dr. Sreevaths, Director, Ayurveda College,z4z-BTrichi Road, RVS Campus Coimbatore 641402. 7. Dr. S. Vidyadaran, Principal, Ayurveda College, Puthur, Kottarakara, Kollam. 8. Dr. P. Sankaran kutty, Retd. DME, Parameswari, Ayurveda College Road, Kunnumpuram, Thiruvananthapuram. g. Dr. Ratnakaran, Principal, Ahalya Ayurveda College, Palakad. 10. Dr. P. Sankaran kutty, Retd. DME, Parameswari, Ayurveda College Road, Kunnumpuram, Thiruvananthapuram. 11. Dr. P.K. Mohan Lal, Bhavani Nursing Home, Naalanchira, Trivendrum. 12.Dr. T.S. Jayan, Senior Medical Officer, Govt. Ayurvedic Flospital, Varkala, Trivendrum. 13. Dr. Vijayan Nangelil, Nangeli Ayurvedic l{ospital, Nellikuzhi P.O., Kothamangalam, Ernakulam. 14. Dr. Mohammad Iqbal, Asst. Prof. , Vaidyaratnam Ayurvedic College, Thaikattusery, Olluro Trissur. 15. Dr. Mathews, Dist. Ayurveda I{ospital,fhiidupuzha East, Idukki. 16. Dr. P.P. Pathrose, Parufhuvayalil Ayurwedic Ilospital, Keezhillam, Perumbavoor, Ernakulam. 17. Dr. Murali, Prof. Dept. of Kayachikitsa, Ayurvedic College, Puthiakavu, Tripunithara, Brnakulam. 18. Dr. K. Sreekumar, Specialist Medical Officer, Govt. Ayurvedic l{ospital, Palakad. iv
  8. 8. 19. Dr. R. Chandrasekharan, Nagarajuna Ayurvedic and Dhanwanthari Hospital, Kallattumukku, Manakkad, Trivendrum. ,20. Dr. c.B. Sajeev Kumar, House No.34l3993, Azacl Road, Kalur p. o, Ernakulam.2l.Dr. Shyam Krishnan, Medical officer, Govt. Ayurvedic Hospital, vengaloor, Muttakkad P.O., Trivendrum.22.Dr. Gopa Kumar, Reader, Dept. Of Nidana, Govt. Ayurvedic College, Trivandrum.23.Dr. K. Amrut Kumar Chand, Undavalli Centre,fadepalli, Guntur District, A.P.24.Dr. L.Mahadevan, Dr.Mahadev lyers sri sarada Ayurveda Hospital, Derisanamcope, Dt. Kanyakumari
  9. 9. QUESTIONERS: Dr. Thakur Prasad Sahu Dr. Jairaj P. Basarigidad Medical Officer (Ayurveda) Lecturer Directorate of Medical & Health Department of P.G studies in Services, Govt. of India Panchakarma Moti Daman, DAMAN D.G.M Ayurveda Medical Coilege Union Territory of Daman & Diu. GADAG.582I03 KARNATAKA. Dr. Santosh N. Belavadi Dr. Pranita S. Joshi Deshmukh Lecturer & In charge of Lecturer, Department of Sharirkriya Department of P.G studies in Sumatibhai Shah Ayurveda College Panchakarma Malwadi, Hadapsar D.G.M Ayurveda Medical College PUNE-411028 GADAG-582 103, KARNATAKA Dr. Devendrappa. Budi Dr. Nimesh G. Kachhiapatel H.O.D., Department of panchakarma RMO S. V. P. Rural Ayurvedic Medical J. S. Ayurved College and College P. D. Patet Ayurved FlospitalBADAMI - 587201 NADIAD - 387001 (cujarat)KARNATAKADr. Jairaj P. Basarigidad Dr. R.B. ShuklaLecturer LecturerDepartment of P:G studies in Dept. of Rachana SharirPanchakarma Rishikul State Ayurvedic CollegeD.G.M Ayurveda Medical College HARTDWAR (U.K.)GADAG.582 103 KARNATAKADr. A. Sulochana Dr. M. B. RamannavarSenior Lecturer, Assistant ProfessorPrasuti Unit P.G. Dept. of Rachana SharirDr. B.R.K.R. Govt. Ayurvedic College Shri BM Kakanwadi Ayurveda CollegeHYDERABAD. Shahpur, BELGAUM.Dr. Suvarna P. Nidagundi Dr. Pradeep Kumar ChouhanLecturer ReaderDepartment of P.G studies in Shubhadeep Ayurveda Medical CollegeRasashastra Gram: Datauda, Khandava RoadDGM Ayurveda Medical College INDORE.GADAG.582103Dr. Swati S. Bedekar Dr. Nilesh PhuleReader LecturerDept. of Rachana Sharir Dept. of Rachana SharirSumatibhai Shah Ayurved Sumatibhai Shah AyurvedMahavidy alay a Had apsar, PUNE Mahavidy alay a Hadapsar, PUNE411028. 411028. VI
  10. 10. Dr. Tapasya Gupta Dr. Mukesh Shukla Lecturer HOD, Deptt. Of Kayachikitsa SSMD Ayurvedic College KGMP Ayurvedic College MOGA (Punjab) MUMBAI. Dr. Joshi George Dr. R. C. Satish Kumar 2"dYear PG Scholar, Panchakarma 2nd Year PG Scholar, Rasa Shastra Shri DGM Ayurveda Medical College Shri DGM Ayurveda Medical College GADAG, Karnataka. GADAG, Karnataka.Dr. D.G. Sanath Kumar Dr. S. JayasankarPG Scholar, Panchakarma PG Scholar, PanchakarmaShri DGM Ayurvetla Medical College Shri DGM Ayurveda Medical CollegeGADAG, Karnataka. GADAG, Karnataka. .Dr. R.Indu Dr. V. VijaynathFinal year PG Scholar, Rachana Sharir 2nd Year PG Scholar, Sharir RachanaS.D.M. College of Ayurveda S.D.M. College of AyurvedaKuthpady, UDUPI. Kuthpady, UDUPI.Dr. B. Harshavardhan Dr. Anju ThomasFinal year PG Scholar, Sharir Rachana Final year PG Scholar, Sharir RachanaS.D.M. College of Ayurveda S.D.M. College of AyurvedaKuthpady, UDUPI. Kuthpady, UDUPI.Dr. P.C. Vipin Dr. Prathibha Prasanna2"d Year PG Scholar, Sharir Rachana Final year PG Scholar, Sharir RachanaS.D.M. College of Ayurveda, SDIVI College of AyuruedaKuthpady, UDUPI. Kuthpady, UDUPI.Dr. Seetharama Mithanthaya Dr. Sibgath Ulla ShareefFinal year PG Scholar, Sharir Rachana 2"d Year PG Scholar, Sharir RachanaSDM College of Ayurveda $DM College of AyurvedaKuthpady, UDUPI. Kuthpady, UDUPI.Dr. Jyoti More Dr. Kunal LaharePG Scholar Final Year, Sharir Rachana PG-scholar 2nd Year, Sharir RachanaSumatibhai Shah Ayurued Sumatibhai Shah Al,urvedMahavidyalaya MahavidyalayaHadapsar, PUNE. Hadapsar, PUNE. vll
  11. 11. t I Draximal I I -- il-tatanges bone !{ig ** .J: distal phalang€s ** *i middle phalangeg ,.i :rr4, i@ 20rtr7 Encyclopedia Erilanniea, lnc.
  12. 12. Bimalleolous fracturewww.fotosearch.com/il lustration/f ractu re. html www. netmedicine.com/xray/xr. htm Trimalleolus fracture
  13. 13. www.gemed .com.ail...lproducts/cme_bflow.html Femoral artery, vein & nerve http ://www. med. unc.edu/medil l/images/brachialplexus.jpg brachial plexus orthoi nf o. aaos. orq/topic.cf m ?topic=A00077...Birth injury- Erbs palsy. The child is unable to raise his right hand.
  14. 14. DaaF Valn Thrcmborlr {trUTl hrdh.ila ffi, O 3000 Sodr,tf df tftiamnlhml ftrilohgy www. rad i o Io gy. ucsf . ed u/i r/d ee pve i nth ro m bos siStlF pf Prdmsnary Embqlu* @ 2003 Sor:isty cl lnterrenlional Radalogy www. rad iolooy. ucsf . ed u/i r/deepvei nth rom bosis
  15. 15. Pampiniform plexus r* Wap/dl*. ugts /lffiat&tfin {.j " tgrtrFttlsm nroia dril*r W.tg M**try* ..ir.:,h4il*#f.nt ,**t#fftEW 4Wrv.qbl n. EllctttdJa** gs;|bg04 ld,t l,, t ,- : .. r+*rnr, tWWt$lqg* i; t:,;:.t .: Bdwbt *qiikfl* tfiI q*srAl ***al?(rn :i *W*h.,,r| !ffirj"iry4$ f.riflr W**p.t hrlgl{rf,nd}&d#6 g*rf d{E6p?ffi qai*, rieP*.* ; ".a.{ !l1gg btrstw*t e*4d- ?gxtfut*fl ktdg,rel* lrtltr,a*anatomvtopics.wordpress.com/.../ TLnica dartos- muscl€ in thc :.n www.malecontraceptives.org/.../heat bioloqy.ohp Pampiniform plexus
  16. 16. lltgnnG rril:,, Famprnilorm kgament ol Ovarian iiii.,r- plexui ol v6ins l,r: and v6i4 4.t: i,i.i . lsthmus fub31 l,rr:.i;r.: ftarian trrn:tr-,, lri:,rr3iir.t r,n. Finbiae lnternal rllas art$ry Vaganal ,i, tifr - Asc6nding b(anch ol ut€rins arlery and v€rn r,i,trr.i branch Ol ul€rin€ aflory Vaginal venous pi:J!,.: lnt€mel gud€ndal a4ery Porllflor vaas,Figure 3.19. Elood rupply ind vtnoui drainagc of ut rur, viglna, ind ov.rlrt. ThE broad ligamen! ol the uleru$ islBmoved to show lh6 €nastomosrno branch€s ol th€ ovarian BrtGry from th€ aorta and ths ut€rin6 art6ry fro; th€ internal ihac Brterysupplying lh€ 6v4ry. ulenn€ tube. and ulerus. The velns lollow a similar parl€m. llowing retrograds lo lhe arteries, bul €r€ moreplexiform. tncluding a pernpinilorm plsxus rGlat€d lo lh6 a.,orv and continuous ulsrin; and vagin5t pl8ruses {cotl€clively, theulerovagifial plexus).anatomVtopics.wordpress.com/.../ Explanation :Analogue of vitap marma in female Case Presentation: Missed rectal injury A22year old man presented to the trauma centre 3 days following a stab wound to the right buttock. He had initially been seen at another hospital where a 1.5cm wound to the outer aspect of the right buttock had been cleaned and stitched. He represented due to pain in the buttock and appearance of aicmblack patch around the buttock wound. He had nevercomplained of any rectal pain or bleeding. Examination at the trauma centre included digital rectal examination and rigid sigmoidoscopy/proctoscopy, revealing some blood and pus and an injury to the lateral rectal wall. The patient wis transferiedimmediately to the operating room for debridement of the buttock wound and defunctioning colostomy. Onthe operating table the nectroci patch on the buttock had expanded to approximately 8tm in diameter.Debridement was commenced but could not keep pace with the rapidly spreading necrotizinf fasciitis.The patient eventually died on the operating table when it became apparent the sepsis had spread toinclude his upper and lower limbs.
  17. 17. Source of image:Ayurvedic view: Though the reference does not mention the use of foreign body by the kumbhikperson the possibility does exist and this kind of abnormal behavior appears to persist since ancienttime. Insertion or retention of such a foreign body may cause rectal injury and out of embarrassmentthe patient may delay seeking medical aid, which may further aggravatetrr! in;ury. d Tisuqqfq. d g gqq c-{dtr qrfio: q q ft*q: ----l t $. vn. z7+o) i: EL -c: I E n. r.Ja - tl E TTEFjlirAfjES.rj 1 t-Jh,t www. malefertilitv.md/treatment-options-male-i... Portacaval anastomosis
  18. 18. ,tivrn tdrlt ..1stlnl c Lat*iamlira. ll|f ftcltt! t.rinl r !t I Lrl n$i| a.ts | ir,l iltlcl " Lil.rlladfl R$tlutfif tl,JiF fttd a i1*{ p I itltry btirltd{larsir , .!:: It!r,lt t iu":rr, *l*d a i,. :{,i* illtrgt! F.d*rr irl| u6bt Btnflr.. ${r{ d Furg c./iftrJr-l ldrrr r 1.r -i ttdat$l I to*J -llorr.td. OllpuFrd er.* .fl,i|.. Itri *#rufiant frbr{F fiull Dorc tr!:f -irb"n, ltdd au qfliB ndrt.d bjt fi*{ ipp4rq ${Bdfrdlui ol Far. I rnr ,r lrjdandd ! P! rrit I C*l d rlilu Lr - i6.r!tlX lItfF l(rdt,l "- frfirl r &{d rrl$; i.t .n txltl D I rl!ri, Fillrhl ! ol uttre* ire! .lbq oldlhat b lllllf{rllH* .. , lilirydrr$h.i0l riint Fntnnlralrl* * Prnadr E ftr.id lr.dl]dll I anatomvtopics.wordpress.com/anatomytopics.wordpress.com/ Structures below, and surrounding nabhi Chest tube Re-expan&d lung tomoqraphv.wordpress. com/2007/1 1 /Pneumothorax is very painful and potentially life threatening. It may occur on the bases of several underlying diseases,but mostly due to trauma (e.g. broken ribs), rupture of an emphysematosus bulla, trans-thoracic fine needle biopsy, or as aresult ofartificial respiration. It is life threatening because it acutely diminishes lung capacity and causes the dislocation ofthe greater vessels. Most patients complain of a sharp, sudden pain and may become cyanotic very quickly. Dislocation ofthe mediastinum may result in insuffrcient cardiac output, and ifblood circulation does not match demand, the patient maycollapse or even die.
  19. 19. www. medivisuals.com/intubation.aspx HemothoraxTHE MECHANISM OF AFLAIL CHEST inspiration mediastlnum shifts with each breath www. pri marv-surqerv. orq/.../html/sect0255. htm I Flailchest
  20. 20. ll.il{.hqthttp://www.biologyreference.com/images/biol_02_img02 1 8.jpg . middle ear anatomy
  21. 21. S*gitnl $inur $uhnctrnoid$ubsrmhnoid Aflch$dd grrrulrtion Durt rn*er Anrhndid $upcrior $rgitnl $inulInE*vcnmclllar Thirrd rrcntridtForentrr chotoid olc*ue Sqgirnl iinurChisrmrdc cr*crn $ylviur *qucduct Pinritrry *find Innrpcdunarlrr cr*trn $tnigfrr rinur funr -- Fourth vcnricle Rightlarcml htto*rc$elhrcbftcrn rpcrru* ofdrc fuutth ucntrh{e lvt+dufla obloagim Id*disn ipcrruft $pindentnlcrnd founh r+nrh{t Spind rubrmh:roid ryaac Cincrnr ffir1Fa http://sci. rutgers.edu/dynarticles/scischem ialSagittal_brain 1 . gif
  22. 22. BLOOD VESSELS OF THE NECK ANTERIOR VIEW a- bradriocephalic vein h - internal jugular vein c- subclavian vein d - eNternal jugular vein e - right crtrrunon carotid perficial temporal illary Posterior auricular ipital Facial ual pharyngeal Superior thyroidhttp://upload,wikimedia.org/wikipedia/commons/d/dO/External_carotid_artery.png
  23. 23. INTRODUCTION TO THE SUBJECT Marmavigyan is a very extensive study or a large series of observations after particular types of trauma at different points of human body as well as accidents occurring during various surgeries, removal of various types of foreign bodies from different parts oT body, warfare wounds, attacks of wild animals during those days and also the various complications of panchkarma therapy. Hence, they have been classified as Sadyahpranahara, Kalantarapranahara, Vaifulyakara, Rujakara, etc..Also, the observations of the underlying structures especially after a trauma, leading to bleeding, extravasations of fluids, CSF leakage. the area covered and depth etc. were also consideied thoroughly. The basic motto of Marmavigyan as elaborated by Sushrut was to prevent vaidya prurnudu iuring surgery (like excessive bleeding leading to pakshaghat). When anaesthesia was developedl the manifestations like loss of taste, smell, deafness were looked upon to diagnose the site of trauma in certain regions, which are the effects produced due to a typical trauma. The whole marrna concept dates back to a period of about 1500 B.C. when an important factor of anesthesia was not available. The few references quoted in Sushrut do not establish the evidence of major surgeries of thorax and abdomen, aithough, plastic surgery has been described in detail. But it must .be noted here, that it is the *g".y canied out outside and in the area of non-involvement of any significant marna. The present success in surgery is the mainly the outcome of anesthesia techniques anddrugs. In spite of modern investigations like sonography" MRI, CT scan, and different typesof endoscopes and operating microscopes; graded cautery, suturing materials, antibiotics, IVfluids, blood transfusion, 02 etc are available, still the modem ,"i"n". says that this is notenough and much more is unknown. Hence, it all depends on the skills ofihe surgeon, whoplays a major role in all branches including healthy status. Even, the majoi surgicalprocedures during those times were done with the permission of the King. It was natural thatin such a case, the vital areas should be avoided during surgical pro"*Jur... These are thefindings after trauma or after vaidya pramada. At present the success depends heavily on the facilities available and the time lapsebetween the trauma and reporting to hospital. Results of particular types of operative procedures differ in pHCs, district hospitals,teaching hospitals and hospitals in Pune, Mumbai, Delhi and financial condition, of th.patient. Hence, we can not think of missingdhe knowledge of marmas, only because of latestknowledge and treatment. This is true.in this country, where majority of tire population stillcan not afford the expensive ultramodern treatment modalities and hence. we have toremember the marmas described in Ayurveda. Although due to modern treatmgnt we can save the life of patient, but some disabilityis always left behind as Sushrut has quoted. It is still important forprobable diagnosis when the patient has received the trauma.Ancient traumas were different from the traumas at present; this is also an important fact. Itis the experience that the very principles have helped me when I was working at a talukaplace in Ratnagiri district, where there was no electricity, no anaesthetist, IV fluids andlikewise. One has to depend for these materials at the places like Chiplun, Kolhapur orRatnagiri, which are about 60 miles away. Most of the patients were below poverty line; stillI could do caesarian sections, tubectomies, testicular torsions, meningoceGs, reductions ofselective fractures etc. It is true that the volume of such operativ-es was quite low ascompared to that of my surgical procedures in pune.
  24. 24. Ayurvedic guidelines only helped me i.e. "Ashukriya" and the incision techniquesadvocated by Sushrut. Following examples can explain some idea in this regard. This is a story in Ratnagiri District, Maharashtra, in the past, when electricity wasvery.scarce, nor was the anesthetist available as already noted. General anesthesia was notallowed at PHC level. In Konkan region, ladies are so thin that we could palpate thevertebrae per abdomen.1) A Medical officer was operating upon a lady that has delivered four days back. Tubectomywas being done under anesthesia. The patient was so thin that we could count her thoracicand lumbar vertebrae. He took a central, midline sub-umbilical incision (fundus of uterus asthe guideline), where there are no muscles. Patient moved a little on the table and surgeon?sknife cut opened the aorta resulting in a table-death.This inciience reminded me two facts -A. Left sided incision as described by Ayurveda would have saved the patient.B. Depth of a marma could not be always a dimension of marma, but breadth is a morecorrect understanding.2) A PHC Medical officer was operating upon a lady for tubectomy under local. through asmall incision which was left lateral. While making efforts to catch fallopian tubes, coils ofsmall intestines came out due to straining of the patient. He tried to put them in through smallincision but was not successful. He called me for help. I went with my sterile drum withinstruments and equipments of G.A. but it was not allowed under the general anesthesia. Iextended the previous incision upwards and put all the intestines in the abdonainal cavity.Tubectomy was done as incision was big. This again proved the following principles taughtby Ayurveda that the incision should be always big enough. (Ayatashcha Vishaalshcha) andwhen necessary, extend it upwards - Chhidrodara / Baddhagudodara. Ayurveda helped me.3) It was a rainy season. My taluka place was disconnected from big towns like Chiplun,Ratnagiri, Kolhapur for four days due to floods. A lady of obstructed labour reported me, who was in labour pains; but baby had atransverse presentation. Cesarean section (C.S.) was badly essential, but there were no IVfluids available at all due to inevitable difficulties. C.S. was essential to save mother and ifpossible baby also. (narim cha rakshayet yatnatah). So, I injected 100 cc 250lo glucoseintravenously and did the classical C.S. under local anesthesia as quickly as possible, andagain injected the same amount of glucose instantly. Thus, I could save the mother and babyboth, with no complication. Dictum of Ayurveda again proved here "Ashukriya1 and nearestapproach, which helped me. Reviewing these three examples, it can be said, that even though, the advances inmodern surgery have reduced mortality and also reduced the percentage of defects of trauma,majority of Indians are either below poverty line or can not afford the expensive gadgets foradvanced treatment, especially in rural regions. Many of our Ayurvedic graduates arepracticing in villages and hence, we should not forget the principles laid down by Ayurvedaand especially the Marmavigyan. (Dr. Ramachandra B. Gogate)
  25. 25. TRIMARMA
  26. 26. CHAPTER - I TRIMARMA 1;1. Shira, hriday, and basti are trimarma. However, shira is anga and hriday is upanga. Why? (Reft Su. Sha 5/3) (Dr. Thakur Prasad Sahu) In Ayurveda, shadanga sharir is stated for descriptive purpose. Body is divided into 6main parts i.e. shadanga. In modern anatomy also body is divided into 6 parts for study i.e. 4extremities,-head,and neck, thorax and abdomen. It is also related to garbhavigyan i.e ile$ rffigz6;.q qE-ffirHriday is not included in this grouping i.e. it is categorized as upanga. Body is having themain madhyam anga and five tubercles are formed over it. e-S-+ azacrrqRrsr dqfus-or{ yatid rThe parts that are derived from shadangas or developed later (as from the ectoderm,mesoderm, and endoderm) are called as upangas or pratyangas. Small parts developed stililater from these are called pratyang, which are developmentaily differeni from anga or smallparts of main organ @r. R.B. Gogate & Dr. Mukund Erande) Yes,.In Trimarmiya chapter Charak has identified shira, hriday and basti as sadyahpranahar marrna, but Sushrut hai recognized shira as anga where as hriiay as upanga. This isbecause while doing dissection of cadaver, shira is considered as a part of body while hridayis considered as one of the parts of the antaradhi (trunk). That is why shira has teen named asanga while hriday as an upanga. (prof. D.G. Thatte) Trimarma as shira, hriday and basti has not been classified on the basis of anga andupanga, prof. J.N. Mishra) Charak has considered trimarma concept. He has considered trimarma from aphysicians point of view. Whethei it is anga or upaogu, the structural and functional aspectsmake the difference. He has never considered any shakha marmas. He has considered onlythese three marmas because these are the controllers of all activities and hence are termed asroot (Cha. Si.). (Dr. C. Suresh Kumar) Shira is a part of shadanga sharir. Hriday is a part of koshthanga. Hriday is neither anupanga nor a pratyanga (prof. M. Dinakara sarma) Sira is among shadanga while hriday and basti come under koshthanga. In CharakSharirasthan as well as Sushrut Sharirasthan there is no consideration of it as an upanga orpratyanga. @r. K.B. Sudhi Kumar)
  27. 27. Because trimarma concept is derived by Charak the contents of Sushrut Samhita donot have any relevance with this. According to Charak (Ch.Sh.7/5 & 7lI0) shir and griva arepresented in combination as sharir anga (subdivision of the body) and hriday is presented askoshthanga. Since shir is not separately presented the term shir, as widely applied, seems tobe synonymous to brain (e.g. shirahshul, shiroroga, shirogada and shirah kamp). Both,included under trimarma, are in proper order showing no controversy (Prof. S .P. Tiwari)1.2. According to Ashtanghriday shira is considered as anga while hriday is consideredas upanga even though both are vital and considered among three marmas. Why? (Dr. Suvarna P.Nidagundi) Classification of mafinas has not been done according to anga or upangas. It is basedon the effects of trauma or diseases of those organs. Shira, hriday, basti (mutra nirmiti) arethe most active organs. They create good or bad results within a very short time and henceare important. This is applicable in their diseased conditions or when they get affected inother disease conditions. Development of kotha in limbs (in kshipra marma) in prameha shallusually result in deformity. (Dr. R.B. Gogate & Dr. Mukund Erande) See answer No. 1.1 (Prof. D.G. Thatte) Hriday is considered not as upanga rather it is pratyang (AH.Sha.3l1). There is noreference in Ayurveda, which reveals that upanga (pratyang) can not be considered as vitalpoint. (Prof. J.N. Mishra)Definition of marma: Marma is a conglomeration of anatomical structures namely mamsa(muscle), sira (blood vessels), snayu (ligaments and nerves), asthi (bone) and sandhi fioints). o Ma means prana or vayu, the repha indicates house or seat. Hence, the word marma means seat of vayu or prana. o Vaghbat has expressed the same idea. The term Marma is derived from the Sanskrit term Mring marane or Mru prana tyage. That which causes death or death-like miseries. o According to Dalhana, the commentator of Sushrut Samhita, marma is that which kills. . The Ashtangsan grahahas described the marrna as that particular parl of the body that is fatally vulnerable to injury. o If any area fulfills all or any one of the above criteria, we can term it as marma irrespective of whether it is anga, upanga or whatever. (Dr. C. Suresh Kumar) Hriday is a koshthanga.It is not an upanga. (Prof. M. Dinakara Sarma) Description and classification of marmas are on the basis of the prana tatva present indifferent parts of the body that tend to cause severe pain or death during an injury. It was not 2
  28. 28. only merely an anatomical division. Later those marmas have been again classified accordingto their anatomical or physiological importance. On the other hand anga-pratyanga is adivision of parts of body i.e. only anatomical classification. It should not be confused withmanna classification (Dr. K.B. sudhi Kumar)1.3. q{?F + Brd-d fr ek +1 d Frar Bz g@ zrersrrErs d-d d d a-SAIuTEIT qT Z . (sr. uffwgdru +Frur) There are two important elements in body viz ushna tatva and shita tatva. Thedynamic balance of these two tatvas is mainly maintained by basti. When these two organsi.e. hriday and basti are affected in disease conditions e. g. basti in prameha or hriday inshleshma vikriti, the chances of recovery are always less. Hence, basti is important. (Dr. R.B. Gogate & Dr. Mukund Erande) a ofrf,, ftrs s*z 6e+ o1 srfrrre-oqf a-d ?€rl-d Fc{fus arar B qzEn..Fmfo ermg afi qs ora zl-rg fr sn ar$ B fu e-g*r-r: ftrE (?-s), Gnq ed)Ed eftf, srefq eftFr€r {dd-6 eiz<rra ffi ffi g-crrr aei atrnerq q-gs sqidrB, $gerT: sr+o. 3r+rreq M + e-S erdz sirr ** E r Erelr ag*e # sfEr€FttrTqrq # + zFrg.r ftrs d p+aFrS fr oaft aft sro-i€r qr d zr-oarB r srer fr 6e+ 6f 6rffi eraGr$ fr era-*€r (errdfu-c+) *e "cFrgilcr zff z{a+r+ar saftE r eft qeltp gffi tRft r+ar B ffi ag.+6 d orsq ra=Ir.+TZF erft A zl-s-ftB I ge{ flft + -Frsr *dd ffi{ d-.D-{ # q?g +} rrrer zb-{ zTcb"Ir B r ag*5d orsor 3-ffi sErFE trra-aftq zqarsfr d E-g.n qrs dr* ts r gtft rrerrE erto t€s6ra{ur fr-d e{co-} E ffi qgqr gd fi# E z-aarsfr d ftr€ft sG@ # +zFrsq erer: 6q d zr-6-tr Br o€ qrs trrr M d srrfl B fu frrc fr srfD+qra*+ S qr e-* fr srfla+ena d-sr srtqFro S er g-ffi ffi ae-dqfssar o] eft q-df6z ffi Eft eftu qq d "crrcilzr r 3r.r: gd ffi fr T+ars* i;rrft Bo1 frelq oq * sa, qrsr6{ a-dfr qt * :t€ ts I gffi d za-ar fr fu€fr "i-flr6}e + E5rsur €rqd ff4d ffi{ * zra-.er fr E-€ sq*osw 3TrdeqqtBr "rafl;nAcute renal failure: Acute renal failure is the abrupt stoppage of renal functions. It is often reversiblewithin a few days to a few weeks. Acute renal failure may result in sudden life threateningreactions in the body with the need for an emergency treatment.Causes: l Acute nephritis 2.Damage of renal tubules by poison like lead or mercury 3. Renal ischemia developing due to drug-induced shock. 4. Acute tubular renal failure 5. Fluid transftrsion 6. Sudden fall in blood pressure during hemorrhage, diarrhea or acute burn. 7. Blockage of ureter due to renal stonetreatures: l. Oliguria 2. Anwia 3. Proteinuria 4. Hematuria 5. Edema 6. Hypertension within a few days (because of increased volume of ECF) 7. Acidosis - retention of metabolic end products a J
  29. 29. 8. Increased blood creatinine i.e. more than 8.5 l 9. Coma during acidosis resulting in death within a few hours. erSs t sr@ sifi qr z*Eirr €-+ eft* qrgqrr-o d-fr +A E t-trr arETrb-{gg-d slz qr6 * ga ffi S ad e<rrd 61 q-d-d F{n * | fu{ aft +{r te+raa B fu +qq tr1 aft te+r zerra atrclT cITe[ ffi z+sqrongs ad B r (Prof. D.G. Thatte) In emergency management, the monitoring of excretory system is also importantalong with assessment of cardiovascular and nervous system. The function of kidney may beclinically evaluated by observing and examining urinary bladder. Ayurveda has practical andclinical approach towards medicine. The conservation of life in post traumatic condition ismonitored as below: a. orientation - shiras (brain) b. cardiopulmonary status - (hriday with pulmons) c. urinary output i.e., status of bladder. It is clear that the bladder is the only structure, which could be included in trimarmaagainst other sadyahpranahar marmas (prof. J.N. Mishra) Read this answer in continuation with question no i.l. There are various viewsregarding this poinl. Trimarma and sadyahpranahara are two different types of classificationdone by two different authors. While critically analyzing we believe that the sthana of vata is below nabhi and bastiis the main organ there. The sthana of kapha is in head and neck, out of which shiras is themain player. The most important organ in pitta sthana is hriday. Frankly speaking, theserepresent the three doshas in marma. (Dr. C. Suresh Kumar) trr-d-# A qfta t sTfrF€ fire ud €cr-q sfr zrqrftw E r rrelT Frd-dfrfu-ml qETa srrqrd qro d qftn-q-ar B sils rs-s srora{ ad ere o-d qerras{rqrd gg-d +t } r (Prof. M. Dinakara Sarma) Basti has been considered one among sadyopranahara marmas in Trimarmas becauseamong ljarrtrrfErErfteiffirlrgcq I 6adefra-draft q qGtr aa-aarF g nShringatak, adhipati and shankha are included in shira. Hriday has already been consideredseparately. Basti and guda are interrelated according to Su. Ni.3i18. Basti has got morephysiological importance than nabhi. It is told to be the uttam pranayatan It plays animportant role in functioning of apana vayu. Moreover, mostly due to the dosha gatis andbeing a srotomula it has got a more important role than nabhi. Still, according to Cha. Chi.261291basti will represent all marmas of the lower abdominal region, hence it is justified toinclude it among trimarma. (Dr. K.B. Sudhi Kumar) Under sadyopranahar marmas only basti and hriday are functional organs. Shankha,shringatak and adhipati marmas are covered under shir. Rest of the marTnas viz matruka, 4
  30. 30. nabhi and guda are frrnctional organs dealing with some action. The pathology developed inthe functional organs always leads to crisis in life. Perhaps this is the cause why Charak hasincluded only basti and hriday under trimarmas with shir. (Prof. S.P. Tiwari) Basti, like shiras and hriday, is an important organ in the body, help in maintenanceof homeostasis of water and electrolytes. oEd-{g i ErrS(*)di ad q*rurlsqoerai@i qft€r (qfttud €fr uraale:), vgf}+ea a-q}tffi,fff}ruf,raBrE ffi erSzqr (a. f+. er+) : As regards the bladder, located as it is in the perineum amidst the channels carryingthe semen and urine, it is the seat of urinary secretion and also the resort of all the channelsconveying the aqueous element even as the ocean is the resort of all the rivers of the earth.With a network of channels known as vital ones emanating from these centres, the body ispervaded even as the sky is pervaded by the rays of the sun (prof. v.v. prasad)1.4. What is the justification in giving importance to trimarmas (Charak Samhita) when107 marmas are enumerated? (RAr) Shira, hriday and basti are three marrnas, which are situated in the median plane ofbody. Brain and spinal cord are also the axial structures and nerves emerging from spinalcord, cerebrum, and brainstem are related to different organs, which are situated in themedian plane or other parts of body. Remaining 104 marmas are situated on either side ofmedian plane and they all are related to three main marmas. Similarly, blood vessels i.e.arteries originate from the heart and supply to whole body and retum deoxygenated bloodftom whole body to heart. (Dr. R.B. Gogate & Dr. Mukund Erande) Charak has definitely given more clinical significance to shira, hriday and bastibecause from physicians point of view these three organs are usually involved in most of theacute pathological conditions leading to instant death. (Prof. D.G. Thatte) Charak belongs to the school of physicians and the subject of post traumaticpreservation of life in emergency has already been explained under Q. no. 1.2. (Prof. J.N. Mishra) Because these three control the entire system. Reference says - ed6"a1 qderaq sTftfrq erEt eeier errsreranf}a-affier r +s.ffiqd-dfi-srqi zrqRro fi-sr ar-dfr ffi+e-"€r telqrq r rTT errsrflrla* trfre$w;enfsrdrB ar8qift+, errsrai a<rf}laarq rSenFf,+a*sfr eeftaRrtift+ a-eqaanq?TEr{€[ ICharak has adopted a separate and entirely different concept while describing marma.Charak, being a physician, has considered the marma conservatively. He has given onlylimited importance to shakha maffnas. He has considered trimarma, because these are thecontrollers of all activities and termed as root (Cha. Si). Chakrapanidatta has commented that injuries on these vital organs affect the prana asit is seated here. He has compared this to the destruction of wall paint that occurs
  31. 31. simultaneously when the wall is destroyed. Any destruction to any of these three vital organswill destroy the prana and also could turn fatal or cause irreparable damage. (Dr. C. Suresh Kumar)Trimarmas belong to kaya chikitsa-oriented classification and it has been said as grTurTslqTcl gE - a-Ararcrqi zerrfl I (a. fu. zot+)This means "these trimarmas are the seats"+q! of pranas and due to vitiated doshas of the bodythese can cause grave diseases, which can be called as mahagadas, so listen regarding theirprevention of these marmas". This is the explanation give by Charak regarding trimarmas.Acharya has explained this concept based on pathophysiology rather than traumatic injury.So, on the grounds of chikitsa, these three marmas have a greater importance than remaining 104 marmas based on pathophysiology. Whereas Sushrut has explained 107 marrnas basedon traumatic injury, which is shalya-oriented and he has classified the marmas as kalantar,vishalyaghna, vaikalyakar and rujakara. In the manifestation of a disease or in the injuries,mainly doshas will be vitiated but the difference is that in injuries the structure (anatomy)will be affected first then the doshas are affected; whereas in the diseases doshas are affectedfirst, the structure (anatomy) will be affected later on. (Prof. M. Dinakara Sarma) Description of trimarma is to emphasize their importance amongst all. It is mostly aphysiology-based classification. The most important physiological unit of human body isshiras (that includes brain, the controller of all the human functions). Hriday includes heartand lungs, the circulatory and respiratory heads respectively. Basti includes bladder as wellas kidney. Sushrut has emphasized these for the ease of surgery as well as traumamanagement. (Dr. K.B. Sudhi Kumar) Charak was a physician and as a physician he has experienced the highest vital valuesin three systems viz NS, CVS and renal system, to which shir, hriday and basti belongrespectively. Pathology in these organs is always a threat to life that is why these three arecalled as trimarma. (Prof. S.P. Tiwari) aarurcrai gg1.5. uerrd l (q. fr. 26/4) "*q! by mahagada? Chakrapani has used the term mahamarma.What do we understandWhat is the difference between marma and mahamarma? (Dr. Santosh N. Belavadi) Technically there is no difference between marma and mahagad. It is more or lessrelated to the effects of vata-avrittatatva on different marmas. (Dr. R.B. Gogate & Dr. Mukund Erande) Mahamarma is trimarma, whereas marma means all107 maffnas. "Vat vyadhi premehasshya kushtam arshonbhagandaram ashmari mudh garbhashya tathaiyve vodaramashtsmam astavete prakateya dush chikitsa maha gada". (Prof. J.N. Mishra)
  32. 32. Charak has considered 107 marmas with equal importance. He has also consideredthree marmas more important among the equals. As the shakhas are dependent upon thetrunk, the marmas located in the trunk assume more clinical significance than the shakhamafinas. Out of all marmas of the trunk, the trimarmas are given higher clinical relevancesince they control the entire system and hence, the term mahamarma. (Dr. C. Suresh Kumar) Udavart and anah are explained in Trimarmiya Chikitsa. In this context Charak hasexplained about the marmas as aafFrdfu-6-{qRr{€q --- |So in the order of trimarmas he has explained basti first, then hriday and lastly siras and inthe same order the diseases have been explained in relation to these marmas. When he hadstarted about diseases he had first started with udavart and anah, which must be related tobasti itself. If we look at the samprapti apan vayu is mainly involved along with pakvashayawhereas both of these two are related to basti marma. (Prof. M. Dinakara Sarma) Maha means the superiority. Mahagadas are those diseases with higher mortality ormorbidity, hence more care is required to be exercised during treatment and in fact should beprevented before proper manifestation. Like Chakrapani, Charak has used the termmahamarma for trimarma. This is mostly due to their greater impofiance than others. Atmany places the term mahagada has been used in Charak Chikitsasthan. It seems only toemphasize the importance of the disease. (Dr. K.B. Sudhi Kumar) Under the present reference mahagada and mahamarrna are synonymous. The termmahagada was applied to give more appeal on the issue. This is obvious under the givenquotation. Giving separate heading to the group of three marmas by Charak was an attempt toform a separate specialty under marrna vigyan similar to panchakarrna separated from kayachikitsa or to orthopedics separated from general surgery in modern science (on the basis ofmedicinal values); otherwise trimarmas are also the marmas (prof. s .p. Tiwari) qtrrq ftelqa qr"i}qq.fr ardft ardrq 6aurBrar, grulr sq-;fr,ererr @i E5i nrers-o-gq* r aeif}r-aranfrlfr-qrunsrqrqi €e-qr*diffir6d 116r +sri arqft6, iqi d-drctrqrqi e-{sr&f,i zeri I ffi ETdeitrrdrarfrft E-Eerftlzitrrorat rsrurcrai zenfuft frfueera1r (a. fu. 26/s q{s€q 8-6-r) o Pranas are sheltered in heart etc. o So the diseases affecting such vital organs are highly morbid (mahan) and hence they need to be protected from the pathogenesis of such mahan diseases. . Once the diseases have established it is difficult to cure them (krichhratam) (as told by Sushrut). o There is no difference between mahamarma and mahagada. Highly morbid diseases that affect these three marrnas are mahagadas and these three marrnas are called mahamarma. daFo-qRrgrq B + futDler {dtrfl o.r} ftFen eprutr{ I qrA-oT * qqa-ar ardfu d€€r e-ffi en€urfirEIT: | (9. €IT. o) (Prof. V.V. Prasad) 7
  33. 33. in Trimarmiya.Chikitsa1.6. What is the relevance of explaining udavarta and anahaAdhyaya (Ch. Chi. 26)? Is there any involvement of any one of the three marmas insamprapti of these diseases? If yes, how? (Dr. Sanath Kumar D.G) ,Udavarta means -sdad{ (sud) srra-d arflut eftq-{ S s+ ssrad IAnaha means1. sii{€[ sneard dr5.il qftWEq I2. er€r qrd: Er€fu-r €Ri 3nft5e frrEft I a er€* s-qd a s{F sed srrara: tr€r qrqA rq.g. ta/32s. F-+q frE"i end erqri or a1eil trg"nsEred I sffiruf qrE-dr-dr fuEEi eqrq qerrqraf a qaf,* € 3{Tar6: IThe udavarta and anaha are included in Trimarmiya Chikitsa because they are-AAfAfuf E-Cgff< @TE[€F: IThis indicates that the.disease conditions, which occur due to them, affect basti marma,which is iir their vicinity due to which there is enhancement of symptoms. Basti karma hasbeen indicated in Trimarmiya chikitsa, some of which is also indicated in anaha andudavarta. This is the only reason why they have been included in chikitsa adhyaya oftrimarma. (Dr. R.B. Gogate & Dr. Mukund Erande) Udavarta and anaha are the nidanarthkar rog of shirabhitap etc. specially related totrimarma; they have been explained in trimarma chikitsa. (Prof. J.N. Mishra) Charak has given equal importance to all 107 marmas. At the same time he hasthrown light on the significance of the trimarmas. Charak has a clinical approach to it ratherthan a surgical approach. He has described the disease pertaining to the trimarmas along withthe management of it in a medical way. (Dr. C. Suresh Kumar) During various panchakarma procedures mannas should be kept in mind. Forexample when we conduct vaman karma we have to keep in mind regarding hriday becauseboth of them have relation with vagus nerye, which can get stimulated and may lead to somecomplications. In the shastra, they have already mentioned about vyapat related to individualpanchakarmas. So if we keep those vyapats in mind automatically we can prevent thedamages to the marmas. Similarly it can be understood for other procedures too. (Prof. M. Dinakara Sarma) If we analyze the lakshanas of udavarta and anaha, we can see that the first organsmentioned to be affected in udavarta are basti and hdday while in anaha they are hriday andsira. @-j---t (a.fr.zora) 6riarqeta-+ r It has been emphasized to protect trimarmas from vayu. In these two diseases vata ismostly in aggravated condition in the madhyam rogamarga and there are more chances to
  34. 34. affect the nearer abhyantara rogamarga, but in the samprapti of these diseases these tWo maynot beinvolved (Dr. K.B. sudhi Kumar) std q +rn d-6esGrd-cerr afi-qqre-F€-.rr: g*{r: r (a. fu. zarro) o_ift ft--dred-{t-{iri @-dflEqrd-tdd: g*{ff r 2;aqft3-rceg<S{roryr (q. fu. zoto) "qrqnThese references denote that all the vatavyadhis, hridroga and basti roga evolve fromudavarta. This could be the reason why Charak has mentioned udavaarta and anaha inTrimarmiya Chiti sitadhyay. None of the three marmas is initially involved in the samprapti of both the diseases;in fact it is the other way round. However, upaghat (injury) of basti does cause udavarta. Quite understandably thetrauma to the bladder or kidneys (bastau is dvivachan) causes all the features mentioned inthis verse because of immobility of intestine and local inflammation. a* 6af}ra* orl+eqruTtrf,erq ftrt-crrDraAa@rufraarrftd---- d-[Sg qrd{tq-dTFd6 .i@ s-6t--d-daJc.fl s+Gr.+r$arjq5i@, r(q. fr+. sro) (Prof. V.V. Prasad)1.7. Please comment on precautionary measures to be taken for marmas likesadyopranahar, vaikalyakar marma etc during various panchakarma procedures onmarmas like hriday basti in cardiac region, basti in gudagata marma or shirodhara inshirogata marma etc. (Dr. Mukesh Shukla) Hriday basti is done externally so no vaiyda pramada is possible or expected. In a fewconditions burns and blisters are likely to develop if the temperature of oil has not beenchecked. Gudabasti is a safe procedure. Now a day we use rubber catheter, which does notcause trauma. If the level and speed of basti dravya is well monitored, the basti will notproduce any pramad (complication) or any ill effects. If guda marmaghata has led tointestinal perforation, basti is contraindicated. In shirobhi ghata shirodhara, shirobasti or agnikarma is performed. The procedure isto be stoppedas soon as samyak lakshnas are observed. In traumatic wounds on skull theabove treatment is not indicated. No treatment like dressing, replacement of fractured skullbones, stopping of mastulunga srava is recommended. This regimen is to be followedaccording to the type of injury. (Dr. R.B. Gogate & Dr. Mukund Erande) In hriday basti only moderately warTn oil and liquids are used. Guda Vasti - dimensions of basti netra and lubrication of urethra are properly done to avoid injtty to guda marrna. Shirodhara - very hot oil is not used. (Prof. J.N. Mishra)
  35. 35. All the procedures are non invasive and hence they do not harm the structures or its functions. However, it is advisable to avoid heavy and hard massage and there should bejudicious usage of sneha intemally. (Dr. C. Suresh Kumar) By this version Charak wanted to say about how to protect the trimarmas from theinternal factors i.e. from doshas. To make this clear he has used the word - z<-rergmrgotf-aq ---- rthat means dinacharya, ritucharya, aharavidhi etc have to be followed appropriately to protectthese marmas from the vitiated doshas. Vitiation of doshas takes place due to improper diet.daily regimen etc. So it is clear that Charaks concept of trimarma is mainly based on marmadushti, not the marma vedhan. (Prof. M. Dinakara Sarma) Shirobasti and hridbasti are not panchakarma procedures. if we do them ati yogashould be avoided as more ushna or snigdha may cause complications. Regarding basti everydetail of precautions are available in the texts. (Dr. K.B. Sudhi Kumar) Panchakarma therapy is a shodhan chikitsa (restorative therapy). It is non injurious soit cannot be considered a contraindication in trimarma. However, vaman may be especiallyavoided in cardiac cases. Basti chikitsa can be given in cardiac cases with due caution. Asbasti can be given when guda is injured so can be use of shirodhara in cases with head injury.Shirodhara may be good therapy in neuromedical problems involving shira. (Prof. S .P. Tiwari)1.8. Charak has quoted the following verse. How do we understand this? Justify how tocare marma. erwrsff*i trnei eret-gdrgdddq r scq-"aftFeraeq aqdsri qfrqraeq I r (q. ft+. a n o) (Dr. Santosh N. Belavadi) In health, all the routines must be carried out carefully so that marmaghata is avoided.In diseased condition, while treating the disease, care should be taken so that the vital organsare not affected. During the treatment of prameha, vaidya has to take due precautions so thatmutravaha srotas is protected, and also retinopathy does not develop. In treating anaha orudavart marrnas have to be protected. (Dr. R.B. Gogate & Dr. Mukund Erande) Swasthavritta should be followed without fail but during the disease marma should betaken care of. (Prof. J.N. Mishra) This shloka is not only for the care of marmas. Charak has mentioned this for thegeneral well being and hence it is applicable to maffna as well. (Dr. C. Suresh Kumar) l0
  36. 36. There is an indication of tikshana basti in apatantrak chikista. If we look at theSushrut Samhita Sushrut has not given any specific treatment of marma in sharira sthana orin any other sthanas. He has mentioned that vayu is the dosha, which is going to be affectedin all the marma abhighata, so vitiated vayu should be treated first in all the marma vedhan.No doubt basti is mainly related to vayu but surely basti cannot be given in all themarmabhighata. Relentlessness of vitiated vayu will be variable in different maffna vastus.Since marrnas are injured by external trauma we should also adopt vran chikista in marma-abhighata. (Prof. M. Dinakara Sarma) Cha. Si. 9/10 is a best sutra to demonstrate the importance of svasthavritta and maffnaraksha in two lines. In this shloka both aspects of damage to marma have been considered - 1. Protection of marma points from external injury (agantuj vyadhis) should always be keptin mind by a person and during surgery.2. To prevent the marma from nija vyadhis. Svasthavritta has got an important role in this aspect. Nasya, abhyang and snana havebeen told to strengthen the body as well as manna points like shira, hriday. It has also got thecapacity to reduce the effect of injuries on them. (Dr. K.B. Sudhi Kumar) We may protect trimarma from any pathogenesis by normal diet rich in antioxidants,by fresh air for protection of hriday and shir, and by excessive drinking of water for basti etc.Physical and emotional protections are equally important for shir and hriday. Use of helmetfor shir and caring of blood pressure for hriday maffna are also points to be considered in thisaccount. (Prof. S.P. Tiwari)1.9. Charak has explained marmabhighat chikitsa in Siddhisthan. In case of kupitavayu in mastaka shiro-abhyanag, svedan, snehapan, nasyakarma and dhumapan areexplained (Cha.Si.9/ 8). Please justify its relevance. (Dr. Santosh N. Belavadi) This condition is developed by vikruta sharir doshas at a particular place and hence istreatable. There is no structural damage. In kupit vayu in mastaka shiroabhyang and snehpanare done for vatashaman. Svedan, nasyakarma and dhumapan are carried out to removemarga-avarodha. (Dr. R.B. Gogate & Dr. Mukund Erande) Shirogat kupit vayu can be managed only by vata vyadhi chikitsa (Ch. Chi. 917).Nostrils are the nearest part of urdhwang. Therefore, medication through nostrils with nasyaand dhoom effects shira. The shiroabhyang, sweden, snehapan may be taken as pwva karma. (Prof. J.N. Mishra) Charak has included the management of marmabhighata in Siddhisthana where he hasincluded many other diseases that can be treated in the medical way. 11
  37. 37. Vatavitiation in kapha sthana (shira) should be treated considering both vata andkapha. Hence, snehapan, svedan and abhyang will pacify vata and rechan nasya and tikshnadhumapan will take care of kapha. (Dr. C. Suresh Kumar) In Siddhisthan it is quoted that - --- - ^4f."d g drdrq-qe sre{ffi: 6-dfTff=de1alftffi, r (a. ft+. ore)Because in a traumatic condition vata is the principal dosha to be affected; in sadyovrana alsosame has been quoted. So the first line of treatment is vatashaman i.e. abhyanga, svedan,upanaha. Snehapan, seka, upanaha are also told for sadyovrana. Again, shira is the kaphasthana so after the treatment of vata, kapha should be treatedaccording to principle with avapidan etc. In the case of kupit vayu in mastaka, shiroabhyanga will X. ;;::- :t ;:and serotonin in different parts of brain, which are inhibitor to reticular formation and theyfunction as relaxant. Snehan will equally work on the same line. Svedan functions to reducethe detrimental status of pH (acidosis) and normalizes the pH in plasma maintaininghomeostasis. Nasya may be a stimulant to the GABAnergic neurons in olfactory bulb.Dhumapan is a route of administration of drug. Selected drugs, when applied with dhumapan,will function as a medicine. This way these therapies will be effective for kupit vayu inmastaka. (Prof. S .P. Tiwari)1.10. Why is tikshna basti contraindicated in apatantrak chikitsa (Ch. Si. 9/20)?Apatantrak is one of the hriday marmabhighataj vikaras and basti is considered as bestchikitsa for marma abhighata (Cha. Si. 917). Why have Acharyas not explained anybasti yogas? If basti is useful please explain which basti can be used. (Dr. Sanath Kumar D.G) In apatantraka tikshna basti is contraindicated. Its samprapti is as follows - € effir clrg: ?€ITorT-r ged frqg* Q-€: I dseq 6<ei anur Rru eid q Sseq u (ar.ft. erra-orf$ft-Ea;172"; Q-@: € i.ffi zrrg srqr* arf-ar zisrq r Eiqg €E"f sr€r Rrz eid ameeq u (ar.F. qra-emFrhcra/2a q{ A-6-r) In apatantraka, signs and symptoms alter according to the admixture of other doshas. eierar 6r€re[: *eorr a Farc+rq z€-@reT: I efrerar EdrA cEc reT: elerar er Far: r Efr E-{+dT e}ercnef zild futr6GTdr?H, alftelera FrE-d <ri g trra qfrar Tqrq Efr arrq, I€@ - means all.In short, apan vata occupies the sthan in shira, hriday and shakha in apatantrak. It acts onshira and hriday, which are maffnasthanas. When tikshna basti is given (and that too rapidlyand forcefully) it is likely to do karshana rather than shodhan. Empty (rikta) srotas suddenlyattracts more vayu and will make the condition worse. Hence shodhan should be 1) Mridu and slow. 2) In small quantity and t2
  38. 38. 3) Frequent.Here the drugs for basti chikitsa should be selected in such a way that it will protect marmaslike shira and hriday. a-qr qrur{:;i q gft .:ftftratgea srfu€d org: fu6aqa srs}q€IT?TcF: IIn this condition we can think of shad asthapan skandha and two anuvasan sthavar, jangamskandha. Here, uttamanga should be elevated slowly. Also padabhyanga is to be done slowly. (Dr. R.B. Gogate & Dr. Mukund Erande) Basti chikitsa is the best for vatavyadhi but rukshabasti will vitiate like adding fuel tothe fire. Therefore, tikshna (ruksha) basti is contra-indicated in apatantraka as it mayaggravate vata. Apatantraka not only involves hriday but shiras also. Basti is the best here, as vatadosha is mainly responsible for the pathology ( Ch.Vi.7/l2 & 81137). (Prof. J.N. Mishra) Apatantraka is a disease of stimulated nerve structures and hence, tikshna basti leadsto further stimulation of these nerve structures. There are various basti yogas enumerated in Charak Samhita and Ashtangahriday,which could be used for marmabhighata e.g. Erandamuladi (A.H. Ka. 417). In CharakSiddhi it is said trr q-src€Irtrcrstiflq ftrflr+ A qrgqrlrd-{qi€} ---- r (a. ftr. sra)Various yogas are narrated in Cha. Si. 9i9. (Dr. C. Suresh Kumar) eieraqe€-{Seur a Faeq e-€roreT: IApatantraka is a vata vyadhi. Initially pranavaha srotas is covered with kapha. So, afterremoving the srotavarodha with kriyas like avapidan nasya, shuddha vata treatment should bestarted. In vata vyadhi also tikshna shodhan has been contraindicated and tikshna shodhanalso is not appropriate to care for manna as the tikshna shodhan can again aggravate vata. Itmeans we can use mridu shodhan. Chakrapani has also favored this fact efrerarffio-gcraq rHence, we can opt for mridu niruha or sneha basti without any contradiction. (Dr. K.B. Sudhi Kumar) 13
  40. 40. CHAPTER. II CLASSIFICATION OF MARMA2.1. What is the basis of classification of marmas as mamsa, snayu, dhamani etc? (RAV)A) As per the after effect of trauma.B) Structures involved e.g. mamsa, snayu, sira etc. It seems that they definitely knew the inter-relationship between the effects of traumaand the structures involved. (Dr. R.B. Gogate & Dr. Mukund Erande) Sushrut has classified marmas on various anatomical basis which are as follows -1) Prognostic basis: on prognosis of the patient as a result of abhighat (Trauma) and itsultimate result in relation to time (kaal)2) Location basis: the location of marma identified on shadang sharir (6 body parts)3) Morphological basis: i.e. mamsa, sna)ru, sandhi, asthi, dhamani and sira. In present scenario the pattern of trauma has changed because of etiological factorslike terrorism, communal riots, road accidents, chemicals, industrial hazards. All these typesof traumas with definitive quantum of force are man-made disasters. If a surgeon wants toassess the medico legal value of such trauma on structures like asthi, sandhi, snayu, dhamaniand sira etc, which are the important units of body, he can give justified medical evidence forawarding the cost of damage. (Prof. D.G. Thatte) The importance of surgical tissue has been laid down with reference to the injury andpost traumatic residue inspite of management. The surgical tissue from superficial to deepare:a. Skinb. Superfacial fasciac. Deep fasciad. Musclee. Vesselsf. Ligaments and tendonsg. Bonesh. JointsFirst three tissues do not have post traumatic residue excepting mild cosmetic changes likescar. Last five tissues when constitute special seat of life (pran), they are known as marTna,since they leave functional residue. (Prof. J.N. Mishra) The word Marma denotes a point of vital importance in the body, a mortal,vulnerable point or sensitive point where vital force or life is situated. Further, it is aconglomeraiion of various structures (dhatus) like mamsa (muscular tissue) sira (bloodu"rilr;, snayu (nervous tissue), asthi (bone tissue) and sandhi fioints) and is a reservoir of t4
  41. 41. prana. These are the physiological and structural vulnerable points or weak points in thebody, which when traumatized may lead to fatality. Therefore, the classification of marma ismainly based on structural predominance of a particular tissue (dhatu) in a marma points andthe symptoms produced on trauma. For example mamsa, sira, snayu, asthi, sandhi, dhamanietc or sadyopranahara,kalantar pranahara, vaikalyakara, vishalyaghna and rujukara marrnas. Other classification is based on the location of marmas on the body such as head andneck, chest, abdomen, back and extremities, or extent of vulnerability or trauma on aparticular marrna such as ardhanguli, ekanguli, dvi-angula, tri-anguli and paritala marma etc. (Dr. V.S. Patil) According to Sushrut, marma is a conglomeration of anatomical structures namelymamsa (muscle), sira (blood vessels), snayu (ligaments and nerves), asthi (bone) and sandhi(oints). The above statements clearly help in deriving a conclusion that there are certain vitalanatomical points in the body, which are having a secret and significant life values and theyare composed of nerves, muscles, blood vessels, joints, ligament and bones. It is notnecessary that all these structures should be present collectively at a time of the compositionof marma. Even if only two structures are present it may constitute a marrna point. These are the basic constituents of the human body and nothing else. Other than this ithas so far been found to be the functional unit of human body and hence, such a classificationand the marnas are in turn made up of these structures. (Dr. C. Suresh Kumar) z{tr rH-td aafFr zieNsft diTffiffiE arcrarE snf}rmarf}reurRffieeerzq r (Prof. M. Dinakara Sarma) The basis of classification of marma as mamsa, sira etc. is based on predominantstructures (i.e. mamsa, sira, etc.), involved in a particular marma sthana. (Dr. K.B. Sudhi Kumar) Sushrut and Vagbhat have valued the structural and functional predominance of thestructures in the making of marma e.g. mamsa in mamsa marma, snayu in snayu marma anddhamani in dhamani marrna.This was how structural classification was fixed. (Prof. S.P. Tiwari)2.2. Which are the sadyapranahar marmas in this modern era as many of thesadyapranahar marmas told by Sushrut are observed treatbble? (Dr. Kunal Lahare) In modem era all the pranharmarmas are treatable subject to the availability of experttreatment and time lapsed between the trauma and the treatment. (Dr. R.B. Gogate & Dr. Mukund Erande) Definitely in the present days the management of surgical cases has much improvedor has been made easy; yet the anatomical importance of sadyah pranahar marrna remains,particularly when such major cases do not ggt proper and instant ambulatory help or whenprehospital management is not available. This situation is very common in remote villages,rural arbas, deep forests or on high altitudes like Himalayas or for soldiers guarding the 15
  42. 42. boundaries of country and resisting the infiltrators or terrorists. Thus the quick managementof sadyah pranahar manna remains very signihcant. (Prof. D.G. Thatte) The post traumatic stage has achieved a lot of progress tfrrough research andexperience, which has changed the scenario of traumatic result. Those which were instantfatal have been replaced by recovery but the residual post traumatic effect can not be overruled. This fuither confirms the findings of Sushrut that a marna of one parinam may changeinto the other as per the intensity of trauma, the kind of inflecting instrument used, the loss oftissue suffered, the time lapsed between trauma and medical aid and the kind of serviceincluding the status of the hospital with medical force available to the patient. The alterationin any above condition will definitely influence the post traumatic parinam. Therefore,sadyahpranahar still holds the relevance (prof. J.N. Mishra) Many of the sadyo-pranahara marmas are manageable or treatable in the present eraof technical advancement in the field of medicine or surgery. It all depends on the severity oftrauma, extent of damage and time lapsed in providing medical aid etc. In injury to skull(where many marmas are located) probably no time is available to save the life of a patient,but if extent of damage is less and timely help or aid is provided, a life of a patient can besaved. Availability of emergency medical services like well-equipped ambulance, mannedwith efficient staff, minimizes the mortality. (Dr. V.S. Patil) At present we are able to do extensive surgeries on almost all marmas. This isbecause of the advances that have been made.in the field of surgery. Now a day, due tothemaintenance of functipns of the vital organs during any surgical procedure, extensivesurgeries can be performed in those vital organs which might not have been available duringthe period of Sushrut. (Dr. C. Suresh Kumar) Through planned and systematic surgical procedures sadhya pranahara mannas aretreatable in modern era. However, traumatic injuries are always grave. Hence, there cannotbe comparison between planned surgical procedures and traumatic injuries. (Prof. M. Dinakara Sarma) Though the most of sadyopranahar marma, as described by Sushrut, are treatable theintensity of trauma on the site of marma is always the determining factor whether the marmais.treatable or not. A high intensity trauma on all the sadyoapranahar marma normally causesdeath within a short time. Still in present time it.is unmanageable. Sushrut has also said that amild injury on sadyopranahar maffna will make it kalantar pranahar, which is well treatable. (Prof. S.P. Tiwari) Sushrut has told 19 sadyopranahara mannas. However, now a days due todevelopment of modern medical technologies all 19 marma are not seen to cause early death. T6
  43. 43. Only shringataka, adhipati, shankha, kanthasira can be considered as sadyopranahara marnas. But still if emergency care is not be provided, all the 19 marmas can be sadyopranahar. (Dr. K.B. Sudhi Kumar) 2.3. Which structures should be considered as sadyah pranahar marma in the present era on the background of advances in anesthesia and surgery? Many structures considered sadya pranahar marma by Charak and Sushrut are now a day operated directly e.g. a structure like heart is taken out and the procedures Iike coronary bypass or replacement of heart valves is undertaken. This is the outcome of advanced methods of anesthesia. So that relationship of anesthesia is required to be analyzed on the background ofsadya pranharatva ofthe particular structure. (Dr. Swati S. Bedekar) The present achievement is only due to smooth and safe anesthesia, understanding ofanatomy and histopathology, endoscopic revolution, operating microscope, ,onogruphy,suturing material and antibiotics. These things have changed the panorama to treat the traumacases of all types. Also planned surgery has become a routine ritual. (Dr. R.B. Gogate & Dr. Mukund Erande) As stated by questioner the advancement in methods of anesthesia in present scenariofor the management of sadyah pranahar marna that abhighat can be operated directly is notcorrect. No doubt the advancement in surgical techniques like invention of minimal invasivesurgery (MIS) such as transurethral resection of prostate in BPH or laparoscopic method ofcholecystectomy is adopted. The advantages of these procedures are o No big incision - o No damage to bigger vessels, which causes profuse bleeding during surgery and require greater amount of blood transfusion o Quick wound healing and o Short post operative stay in hospital. o Patient may also become medically fit for attending his priorities. o Besides,hazards like cardiac arrest can also be avoided by keeping patient in ICU for early recovery.These techniques definitely help in treating acute surgical problems or sadyah pranaharmarma easily. Other than this even if the subject is saved from immediate death due to earlyprehospital management, the patient may become handicapped and live with permanentdisability. Even Ayurveda says that sadyah pranahar marmabhighat can be converted intokalantar pranahar ma(na and kalantar pranahar marTna into rujakar marna. In this referencefollowing lines of Sushrut can be quoted. ?f5r Tr€r:9p6566; EEi ErTdrdtw drqqft, @ fr*gi Eerstd M*o-e-+nqr<-ofr, q arEft, M-oraratr zdererfr t;-ali ;o-*fr, aor+-t-e-ffi<;i arqft r r (g. eTr. arzz) I.tjury at periphery or very close to sadyah pranahar manna kills the patient after along time. Injury at periphery of kalantar pranahar malma produces disability. Thevaikalyakar marrna, if injured, at periphery creates trouble after sometime and produces pain.Similarly injury to rujakar marrna produces mild pain, if it is very close to the periphery ofmanna. t7