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  • 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
  • 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.
  • 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
  • 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.
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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 $DM College of AyurvedaKuthpady, UDUPI. Kuthpady, UDUPI.Dr. Jyoti More Dr. Kunal LaharePG Scholar Final Year, Sharir Rachana PG-scholar 2nd Year, Sharir RachanaSumatibhai Shah Ayurued Sumatibhai Shah Al,urvedMahavidyalaya MahavidyalayaHadapsar, PUNE. Hadapsar, PUNE. vll
  • t I Draximal I I -- il-tatanges bone !{ig ** .J: distal phalang€s ** *i middle phalangeg ,.i :rr4, i@ 20rtr7 Encyclopedia Erilanniea, lnc.
  • Bimalleolous fracturewww.fotosearch.com/il lustration/f ractu re. html www. netmedicine.com/xray/xr. htm Trimalleolus fracture
  • www.gemed .com.ail...lproducts/cme_bflow.html Femoral artery, vein & nerve http ://www. med. unc.edu/medil l/images/brachialplexus.jpg brachial plexus orthoi nf o. aaos. orq/topic.cf m ?topic=A00077...Birth injury- Erbs palsy. The child is unable to raise his right hand.
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  • Pampiniform plexus r* Wap/dl*. ugts /lffiat&tfin {.j " tgrtrFttlsm nroia dril*r W.tg M**try* ..ir.:,h4il*#f.nt ,**t#fftEW 4Wrv.qbl n. EllctttdJa** gs;|bg04 ld,t l,, t ,- : .. r+*rnr, tWWt$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
  • 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.
  • 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
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  • 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
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  • 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
  • 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.
  • 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)
  • 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)
  • 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
  • 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
  • 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
  • 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
  • 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)
  • 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
  • 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
  • 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)
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Sushrut has stressed the significance of the impact of trauma on marrna areas. If thetrauma is of mild intensity and is at some distance or away from the proper site of marma, theresult of prior type of marma may convert into that of next type of marma. The word antahas been used to represent the surrounding or very close area of mafina. Therefore, it isadvised that the surgery should be performed leaving the exact site of marma. (Prof. D.G. Thatte) Apart from many factors that are common while considering severity of wounds (foreg. sadyahpranahar); the site and the structures involved are the factors which discriminatethe severity of the wounds (parinam of wounds). These factors have been appreciated by theschool of Sushrut. Today major lesions of the pumps (hridaya) and the conduits (srotas) inthe circulatory system, major hazards of trauma can be repaired and replaced, which makesquestion mark on the significance of marma in general and sadyahpranhar in particular.Major incursions upon respiration can be reversed; major and proximal interruptions inperipheral neural transmission can be repaired, but these all are under certain conditions andskill of the surgeon. Therefore, in non availability of those facilities, pranhar marma stillholds the significance. (Prof. J.N. Mishra) It all depends on the type of trauma. In an organized, well-planned surgical trauma byan expert surgeon on a structure considered to the vulnerable will not cause sadyopranaharaeffect of the surgical trauma. However, if any structure is in advertantly cut during surgerythere is a danger to the life of a patient, but such complication may be overcome by timelycorrections or actions. When anesthesia is administered, neurohumoral response to traumaduring surgery is minimized or absent. So effect of trauma is not felt by the patient. But thepatient may succumb to injury due to blood loss. (Dr. V.S. Patil) No comparison between surgery and injury. Sadhya pranahara maffnas are describedin the context of abhighat. (Prof. M. Dinakara Sarma) The advancements in medical technology have improved surgical carc and reducedthe mortality. Though heart is transplanted during the time of transplantation, an artificialunit works to continue the cardiac frrnctions; the body is not working without heart. So thevital organs are still vital but technology had made it possible to win over the fatal effects. (Dr. K.B. Sudhi Kumar) Mortality rate has indeed been reduced significantly with immediate medical andsurgical assistance provided to the patient, but still majority of the sadyopranahar marmascan be called so in the present time. Mortality from trauma occurs during three diffferenpeaks; immediately after trauma, early period and late period. The reason for immediatedeath is apnea, severe brain or high spinal cord injury, or rupture of heart or large bloodvessels. Early death occurs within minutes to hours and is often due to a subdural hematoma,epidural hematoma, hemothorax, pneumothorax, ruptured spleen, liver laceration or pelvicfracturs. This period is known as golden hour. Late death occurs days or weeks after theinjury. So not all the time assistance is provided within this golden hour and the patient 18
  • succumbs to the injury. Planned surgery should not be compared with accident unless someunexpected complication or error takes place during it. (Prof. V.V. Prasad)2.4. How we can decide marmas ghatak kaal, according to modern science? d5t gw{TaTaqa"rdT{qfu, EF.rar<rggr"recrFr qflrdrqrgr, Tr€r:rntryertrFrM g fffir 6qrFd-{rg dnqfu, frersqrsrazrFr Mr qo_-pr"-efy"-ar6 arserk r r (9. eil. orzz) (Dr. Jyoti More) Ghaatak kaal cannot be speculated as it will depend on strength of the patient,severity of trauma, the time elapsed between trauma and treatment, and the effects produced. (Dr. R.B. Gogate & Dr. Mukund Erande) Trauma is a leading cause of death in the first three decades of life and ranks fourthamong causes of death overall. Automobile traumas dominate, in many stances the marginbetween survival and death is narrow enough. Maintenance of adequate airway holds thehighest priority particularly in patients of injuries to head, neck and thorax. Similarobservation is found in classical books of Ayurveda, since out of nineteen sadyahpranaharmarlnas, 15 belong to neck and thorax, which are instant fatal. Mortality and morbidity were both shown to improve if patients with serious woundswere evacuated within 10 days after wounding. This shows that the first week is consideredto be very important from the mortality point of view. Hypovolemic and even cardiogenic shocks are occasionally seen as a consequence ofsepsis. Many of these patients, however, succumb in days or weeks later on from septicshock. Bacteremic shock was first described in 1951 by Wais Ben. The treatment of septicshock is much more difficult than treatment of either hypovolemic or cardiogenic shock. Thisdifferentiates primary and secondary causes of death and subsequent ghaatak kala. (Prof. J.N. Mishra) As explained iu reply No. 2.3, ghatak kaal of marrnas depends on the severity oftrauma and time lapsed in providing effective medical aid. However, in less severe type oftrauma, the complication may arise at alater stage due to infection and patient may succumb. (Dr. V.S. Patil) It is based upon the significance of the structures involved that determines the span offatality. The span actually shows relative importance that is to be given. The severity of theabhighata can also make the span subjective. (Dr. C. Suresh Kumar) We can explain marmas ghatak kaal depending on the intensity of the abhighata. Inthe commentary on the same stanza, Dalhana has explained - o-<rftrcrg art-ofu sffi gft elq; araffi g o-raratd-E arstrap6do-aerorqr (9. elr. 6/2s qE g€ur) (Prof. M. Dinakara Sarma) We can decide manna ghataka kala on the basis of patho-physiology of that particularmarmaand strength of injury to that marrna. If the strength of injury is more violent, bleeding 19
  • will be more. So due to excess blood loss patient may die very soon. If any foreign bodyenters inside the particular marma area and stay there for long time then it may causesepticemia. So patient will die after some days. (Dr. K.B. Sudhi Kumar)2.5. Please explain the anatomical consideration to differentiate sadhyopranaharmarma and kalantar pranahar marma. (Dr. Devendrappa Budi) The difference between sadyah pranahar marma and kalantar pranahar marma can beas following-i) Sadyah pranahar marma: Traumatic death occurs following injury. Death may beinstantaneous, within a first few hours or within a week of accident. Mostly such deathoccurs due to overwhelming primary injury to vital organs like head, heart, urinary system,liver, lung or great vessels like aorta or vena cava. These injuries are irrecoverable.According to Ayurveda such deaths can be termed as sadyah pranahar marrna.ii) Kalantar pranahar marma: In this type of injury, the patient may succumb to death aftera gap of a few days to a month. In this type, the injury afflicts vulnerable body areas wherem|jality or morbidity is preventable. In such injuries mortality is delayed by skilled clinicalassistance. Such injury points are termed kalantar pranahar marTna. (Prof. D.G. Thatte) Mortality and morbidity were both shown to improve if patients with serious woundswere evacuated within 10 days after wounding. This shows that the first week is consideredto be very important from the mortality point of view and such vital areas were isolated bythe school of Sushrut under the category of sadyahpranahar where skilled management andrapid intervention may save the lifeSushrut observed many secondary causes leading to fatal results for want of either surgicalskill management or proved anatomy, which comes under kalantarpranahar. (Prof. J.N. Mishra) Most of the sadyo-pranahara marTnas are located in siras ie head and neck region,which is considered mahamarma. However, the other sadyo-pranahra marmas viz guda, basti,nabhi, hriday are located in the trunk out of which hriday is in the chest region and is morevulnerable. kalantara pranahara maffnas are mostly located in the extremities and trunk,mainly chest region *i are less vulnerable. They are not vital organs except simant in scalpregion of the skull. (Dr. V.S. Patil) Sfu<rg, aiq+reai tiqraraft ---- r (9. eTT. o) It means that in a point where all the five assemble (mamsa, sira, snayu, asthi and sandhi) it is sadyopranahara. If there is only four then it should be kalantara pranahara. If there are.three structures seen in an areathen it is vishalyaghna, two structures cause vaikalyakara and one structure will lead to excessive pain and termed as rujakara. (Dr. C. Suresh Kumar) 20
  • If sadyah pranahara marrnas are hit in its vicinity they become kalantara pranahara marrnas. 3rA ---- zra ulanef, r (g. eTT. 6/22 q{ s-€lrr) (Prof. M. Dinakara Sarma) Sadyopranhar marunas are those where major artery, vein or the vital organ like heart or brain is involved anatomically. In the making of the kalantarpranhar marma it is found that there is the involvement of artery or vein with medium state of thickness e.g. part of brain not dealing with higher control of life process or fleshy part of muscle, or any other factor causing specific type of infection. These rnay be the anatomical considerations to differentiate both. (Prof. S.P. Tiwari) -rf, qrsrat-d-t frcfi $-rdrdtur qrcqfrr @ ftE{ a6@qsrrqrd,-irfr frergq qrur€r{cr r to-ero-i ordla-q z*es-ft... n g. srr. 6/22srt ftEq r el-ff+ lM Aeqr 1) It is the effect of trauma on a particular marmasthana. If the stroke is perfectly on the central part with sufficient force it will be sadyopranahar; if it is less, it will be converted into next category. 2) After-effect of removal of foreign body. 3) Constant pain giving. 4) Ushna and shita tatva classification. 5) Severity of trauma. 6) Blood loss 7) Aftereffect on the part due to damage done to structures like muscles, bones, nerves, tendons, etc. (Dr. R.B. Gogate & Dr. Mukund Erande) Sadyopranahara mannas have all the 5 structural components i.e. mamsa, sira etc. butkalantara pranahara marma are having only 4 components. So in case of injury damage willbe to all structural components in sadyopranahara matma and similarly in kaiantarapranaharc martna. (Dr. K.B. Sudhi Kumar) aqfFr arierRffi. fu Erarrcrd ta. fre]&qqrrnffi; @ e{rerrcrtcr€r;*n (g eTT. otr s) gdrff sr-rgtrFei m-d arduri tl-gfud eefu=-rra-aaffiQxrft r efucna:zieNssdfrsfterrd Efr erdE r zrfu ?Hfd ddFr Eie&&sB aitrsMRe-E-ars snFre-qrf*ce", qrRffiqoErrsqa I ----- r (g. err. 6/1 s q{rcar) All the five components i.e. mamsa etc are found in ali marrnas but their amountvaries; hence depending on this and also amount of parthivadi mahabhutas the result mayvary. Sadyopranahar marrnas are dominant in agni, while kalantarpranahar marrnas aresaumya. For further explanation about involvement of agni and soma and the outcome whenany 9f these two get involved, please refer to the reply no. 2.7. As stated by Sushrut andDalhana the number of components is not responsible for the outcome of injury to marma. 21-
  • +fudrgail{r8-di dqraraft ET+TEITEIT fug-srdi a"i, irEftft €d"Ta{.Irri aieft E d-qrfr "-rEet*ffineref: r €?T: zqEeii {frdfFr u-dT edera-qa ggrR r e-aeznfrerftrdgelFraEefui srtr€rir: q€rflq qarrtq zr-dfFr aiz+r8B u-+tr adFr +rs-dfrara-eqr (9. eTT. 6/17 q-{ e*€.4) (Prof. V.V. Prasad)2.6. Though Sushrut and Vagbhat have classified kshipra marma under kalantarpranahar variety, why has Sushrut expressed the opinion that kshipra marma cansometimes be sadyah pranahar? (Dr. Vijaynath V.) During Vagbhats time some new drugs must have been evolved to stop bleeding. Asper Sushruts comment, there are many chances that the trauma to kshipra marma could leadto sadyopranaharatva.It is the bleeding from unsupported vessel (which may be the outcomeof certain dreaded organisms like Cl. tetani). (Dr. R.B. Gogate & Dr. Mukund Erande) No doubt, Sushrut and Vagbhat have identified kshipra marma as kalantar pranaharmarma, but this marma can also sometimes convert into sadyah pranahar marrna becausemostly rusted metallic injury easily damages the web between thumb and index finger andsimilarly in the web between greater toe and second toe. The following is the observation byme when in my younger age I was living in village of Dish Banda (UP). The house wife,while using gandasa and chaku or hansia for cutting grass, injured web of her firiger andbecame a victim of teatanus bacilli leading to instant death. In injuries to both the marmas,the patient can be saved by proper management after giving tetanus vaccine. Sometimes tle"onset of disease like tetanus manifests later (kalantar). Also in such cases proper care is takenby cleaning the wound and administration of tetanus vaccine. It may also delay the time(kaal) of death or save the patient from complications like death. Therefore, kshipra andtalahriday marnas may convert into kalantar pranahar marna. Please also remember that each Acharya has individually recorded his own personalclinical observations in the texts. (Prof. D.G. Thatte) This marma is situated between the big toe / thumb and second toe / finger. Thepopular impression that tetanus is specially liable to follow a wound between the thumb andindex finger is due to the fact that those like gardeners, who dig much and grave diggers arelikely to excoriate the skin in that area and contaminate with soil. Other occasional causes arepenetration of the sole by nail in the shoe etc (Bailey H. and Love M. 1972). The acute tetanus occurs within 15 days of inoculation and the shorter the incubationperiod the higher the mortality. Death occurs from cardiac failure, pulmonary oedema oroccasionally from asphyxia (Bailey H. and Love M. 1972). The historical background of this disease followed by trautna is very relevant tokshipra marna with reference to site. The abrasion of skin from khurpi holding betweenthumb and index finger for digging soil or reposing manure, similarly in the peasants holdingthe plough between big toe and second toe causes tetanus. Sushrut observed this infection interms of kshipra marrna. (Prof. J.N. Mishra) 22
  • Kshipra marrna is classified under kalantara pranahara marna by both the Acharyasbut can be sadyo-pranahara some times, if the infection sets in resulting into septicemia orbleeding occurs due to injury to blood vessels present in its vicinity. In view of the presentscenario, there is no possibilily of fatality. (Dr. V.S. Patil) Same as2.4 (Dr. C. Suresh Kumar) If kshipra marrna is hit with great intensity and in its center the injury may causedeath. ad ----- zt€r u+iq"f r (9. en. 6/22 q{ s€Err) (Prof. M. Dinakara Sarma) kshipra marrna injury is more violent it will act as sadyopranahara marma, but Ifwhen injury is less or near the kshipra marma, then it will act as kalantara pranahara manna. (Dr. K.B. Sudhi Kumar) Kshipra marma is a site to attract the infection of tetanus, and the incubation periodfor tetanus bacilli is 1-6 days variable from I day to several months .This is the reason for thevariability in the prognosis under kshipra marrna. Some times because of tetanus kshipratakes life within a few days like other pranahar marrnas. (prof. s .p. Tiwari)2.7. i{ITrz grrr-gcrFr STrdaqrfr r (g. en. o)€r€r: qroras ad srrd+{r dA E r sTF-a eftr *+ * qq ffi B I tc{r gg-tT eqrqfFro qeT A qq 6T trrtq ww; fu-qr p 3 ue-q errrq * B5rrF;ro gar fr rmfu€1T q51 aftf t rr+ftss * ffi we fu-qr qr$ z (Dr. R.B. Shukla) Bleeding and severity of trauma make the difference. ln case of basti marma itis theextravasation of urine. o Its quantity and speed of infection in the abdominal cavity. o Quantity of blood loss and the availability of anticoagulants in body, calcium, K, female hormone, platelets. o Patient is under anticoagulant drugs like aspirin, heparin. . . Disease conditions like kamala or raktapitta must also be taken into consideration. o Patient is hypertensive. (Dr. R.B. Gogate & Dr. Mukund Erande) It is wrong to say that Sushrut gave philosophical aspect of death due to weaken agnirather it is absolute scientific. The basic finding of survival of tissue is indicated by thetemperature, showing the metabolic activity going on, as a result of which the bio energy isbeing produced and reflected through body temperature. If it is lost, it clearly indicates thecomplete loss of bio energy which is the final verdict of cellular death. (Prof. J.N. Mishra) 23
  • There are four types of siras in the body carrying in them three doshas and raktaseparately. They are connected with marmas and thereby do tarpana of the whole body.When these marmas are traumatized, there will be raktasrava (bleeding) leading to dhatu(rakta) kshaya resulting into vata prakopa. This will in turn cause mobilization and vitiationof pitta as a result severe pain occurs, which is a cardinal sign of marmabhighata. Later, othercomplications may arise leading to fatality Immediate reflex vasodilatation after trauma results in fall of blood pressure leadingto loss of consciousness (shock) and if not attended, death may follow. Loss of bloodresulting in diminished venous retum and diminished cardiac output ultimately may result inloss of blood supply to vital parts such as brain, heart etc. It is a traumatic shock. (Dr. V.S. Patil) Agneya principle is relevant to enzymatic regulation, which controls all the metabolicactions. Once the metabolic actions fail the body collapses. (Dr. C. Suresh Kumar) We should not try to measure every thing that is said in Ayurveda with modernparameters. Dalhana has that explained bhutatma is present in marmas and when it is injureddeath occurs. zila arsa qrEfrrd I I (g. eTT. a rt o) (Prof. M. Dinakara Sarma) As quoted under Su. Sh. 6 sadyopranahar marma are agneya. This is almost anauthentic concept. They are said to be agney because usually in case of any injury to them,the cause of death is loss of blood or detrimental supply of blood. Since blood (rakta dhatu) isagneya and its loss causes death it is proven that loss of agni causes death. In other words Hbis holder of 02 and 02 is the source of energy among animals (C6H12O6 + 6C2 6H2O + :6CO2 + energy). Energy is agni and agni is energy; so sadyopranahar marmas are agneya. (Prof. S.P. Tiwari) Agni has a major role of maintaining body metabolism. In case of severe bleedingdue to injury ton sadyopnnahara manna the body temperature goes down and patient goes inhypothermic state and ultimately dies. It is due to sluggishness of body metabolism causingless heat production and death is the result of failed metabolic processes. (Dr. K.B. Sudhi Kumar) Measuring the pancha mahabhuta gunas and their functional role in the body onmodern parameters is a dlfficult task. However, the effects of agni guna mostly resemble thatof the catabolic activity. Agni, one of the pranas, resides predominantly in the sadyahpranahar marnas. Vitiation or reduction of this agni may cause cessation of respiration at thecellular level in the vital organs. Hypothetically influence of manna injuries may be regarded as the abnormalfunctional aspects of free radicals, cellular enzymes, and metabolic products. Molecular levelstudy can be considered in respect to mahabhuta gunas. Rakta is predominant of agni guna. Hemorrhage, as a hypothetical consideration, mayresult into the loss of agni guna and consequently lead to death. @r. U. Govind Raju) 24
  • srFa arg: er=i {Gt€tiF[: titffir a[drdfr grorT: (9. €TT. B/3) "ffi I 3TF-6rs{ qrcr6arrtrcb-dq-cF-itr6-t+r€r6-rdi triqa}ft-orai e]-dernagrr-draisquri erlMerd m-*trrM freiq,, | (g. eTT. A/3 qE5€q a-6r) This reference shows that this principle is not metaphysical (darshanik) but isphysiological (based on Ayurvedic physiological principles). Agni is shakti of ushma in theform of panchbhautic constitution of all the five types of pitta in all body dhatus. All themetabolic activities carried out in all body tissues can be considered by agni. We need towork on which kind of metabolic actions get disturbed due to injury (and the organ or thetissue affected) that ultimately result in death. zffiR+ Tcr:Et=rifrift{ q u a-Cg grerer: $z+i eganur qraftr* r. fuffier$ft,rrlt (9. en. ozs s) aF-a-givrgeffiffi srd+{r?lorffi"f I (9. eTT. 6/16 q{ 3;€sr A-cb"r) (Prof. V.V. Prasad)2.8. Even though the marmas such as kshipra and talahriday cause immediate death(according to acharyas) why are they not included under the sadya pranahar marma?Instead they are included in kalantar pranahar marma. (Dr. R. C. Satish Kumar) See the answer of 2.6. Additionally, bleeding from these two maffnas is not like aburst aneurism; it is comparatively slow. Also, the prognosis is quite dependant on bloodpressure of the patient. (Dr. R.B. Gogate & Dr. Mukund Erande) Cause of death in kshipra and talahriday is usually secondary. Therefore, they areincluded in kalantar pranahar marma. Instant death is infrequent depending upon incubationperiod etc. (Prof. J.N. Mishra) Inclusion of kshipra and talahriday under kalantarapranaharc is appropriate sincethere is no threat of fatality if they are traumatized except in a very rare condition. (Dr. V.S. Patil) Kshipra and talahriday can cause death, rarely immediate death. This again dependson the tivrata of abhighata and the site. srd ---- erer u+eqef r (9. eIT. 6/22 uu =cl-r) (Prof. M. Dinakara Sarma) They are equally pranahar marrnas as said by Sushrut (Su. Sha. 6142 & 43). They arenot included under sadyopranahar marms because usually under usual injuries they takeconsiderable time in causing death. (Prof. S.P. Tiwari) Kshipra and talahriday marmas have only 4 structures viz snayu, mamsa, sira andsandhi. Acharyas have told that death occurs only sometimes. Practically, if the injury is notproperly managed then the rujakara will be a vaikalyakara, vaikalyakara will be kalantara 25
  • pranahara, and kalantara will be sadyo pranahara. It also depends on the severity of injury.All the hve structural elements are affected due to severe trauma it can be sadyopranahara. (Dr. K.B. Sudhi Kumar) In cases of kshipra and talhridaya the cause of death seems to be the infections causedby Clostridium (tetani and welchi). In case of tetanus, if the infection is severe and the incubation is shorter then it causessevere tetanus, but when the incubation is longer it is comparatively easy to handle. Usuallythe incubation is long. (Prof. Jyotsna)2.9. How can we explain vishalyghna marma on the basis of modern traumatologicalprinciples? Impacted foreign body produces pressure on blood vessels and prevent, br".olffYrlcase of flow of mastulang strava from skull from cranial cavity, we put a plug of hair. Presently different packing material is available, which produces pressure andcontrols the bleeding. Pressure bandage, (tourniquet), electric cautery, bypass surgery anddifferent suturing techniques are employed. It also depends on the effectivity of onescoagulation mechanism (Dr. R.B. Gogate & Dr. Mukund Erande) The importance of this marma is due to specific design of anatomy of the regionwhich during the trauma, fractured bone, behaves like hemostat and immediate removal mayprove fatal due to severe hemorrhagic (intracaranial) shock and death, whereas delayedsurgical intervention gives an opportunity to heal injured vessels and later on surgicalremoval of foreign body restores the life. (Prof. J.N. Mishra) Vishalyaghna marma can be explained on the basis of modern traumatologicalprinciple in following way. If there is trauma at the site of vishalyaghna matma, there is penetration of foreignbody which is pushed deeper. Till such weapon or foreign body remains inside the marmasite it shall not cause any danger to life, but the moment it is pulled out there shall be profusebleeding leading to shock and death. There is sudden entry of vayu which leads to death. The best examples of such marna site are sthapani marma located between twoeyebrows at the forehead and intercostal spaces in thoracic wall. Observations regardingthese two marrnas will be explained in detail at the time of deliberations of the workshop. (Prof. D.G. Thatte) As long as piercing object remains in situ, it prevents loss of blood and flow ofneurohumoral byproducts, which is otherwise main factor in fatality due to shock. However,the piecing foreign object may not be allowed to remain in situ and has to be removed tofacilitate wound management to prevent fatality. (Dr. V.S. Patit) Removal of foreign body witl lead to more extensive damage to vital organs andstructures than the symptoms, which may arise while maintaining the foreign body there. (Dr. C. Suresh Kumar) 26
  • In case of vishalyaghna marma, external shalya (foreign body) acts as hemostatic. Ifwe suddenly remove that shalya it causes further damage to the structure and causes severebleeding. So if we remove that shalya then sudden death will occur. However, under propersupervision, in a well-equipped surgical theatre and with emergency measures it is nowpossible to prevent the deterioration; hence, death can be prevented. (Dr. K.B. Sudhi Kumar) This requires a research work to reveal the mystery. As an example, a hypothesis ispresented here for this understanding. If an arrow or a sharp weapon punctures the superiorsagittal sinus lying behind the point of sthapani this will open the sinus and let the blood outforcefully. This will lead to sudden fall in cerebral blood pressure and ultimately to death.Since the falling of blood pressure in the cerebrum is the cause of death it will suffice us tosay that the escape of vata out of shir leads to death due to injury to vishalyaghna marma. (Prof. S.P. Tiwari) Utkshepa and sthapani are the vishalyaghna maffnas. Squamous part of the temporal bone is thin and translucent. Even the temporalis givesprotection to it. A sharp weapon can penetrate through it. Middle meningeal artery, anteriordiploic vein and their branches are vital structures at this site. They may cause intracranialhemorrhage on damage.Hypothetical view: 1. Intact instrument that pierces the blood vessel through the bone may cause slowhemorrhage and its removal may cause profuse bleeding. 2. The weapon, after piercing the body, may become tightly adherent to some vitalstructure and its removal may cause fatal damage. (Dr. U. Govind Raju)2.10. Please explain the concept of vaishalyghna marma. fteregrrraslFr Mr q ---- | (g. eTT. 6/23) (Dr. Jairaj P. Basarigidad) The concept of vishalyaghna marrna can be explained on the basis of followingobservation by Sushrut. Sushrut has fundamentally accepted that each of the five types of marma narratedmay convert from sadyah to kalantar, kalantar to vishalyaghna and vishalayaghna tovaikalyakar type. This observation of Sushrut is based on the significant anatomy of marmaarea. If the trauma is of mild type and is at some distance or away from the exact site of themarna, the result of marma would be according to next type of marma. The word anta trasbeen used to represent surrounding or area very close to subsequent marma. For examplebrachial artery, which is next to axillary artery, is the second most important artery to belacerated by violent movement. Occasionally it is ruptured during the reduction of an olddislocation of shoulder. This may cause severe hemorrhage and death (Prof. D.G. Thatte) Even modern surgery believes that post traumatic foreign body is not removedimmediately in all cases. It is not removed in cases where foreign body works as haemostat.It is always removed later on. (Prof. J.N. Mishra) 27
  • Rcler to reply No, 2.Q. (Dr. C. Suresh Kumar) Vishalyaghna mafina causes death only when shalya is removed. However, if thestrength of violence is more it can cause sudden death. So vishalyaghna marma andvaikalyakar marma can act as sadyopranahara marrna, if the injury involves more basicstructures of all five as described for sadyo pranahara (if iniury is more it can damagemamsadi structures, blood vessels or brain tissue causing sudden death). (Dr. K.B. Sudhi Kumar)2.11. According to modern concept, if any foreign body causes injury it should beremoved as early as possible to save the tife of the persons. Howevero in the case ofvishalya pranahara marma it is just opposite. How can we understand this in? (Dr. R. C. Satish Kumar) The questioner must develop a vision in this regard. When I was a professor of SharirRachana in state Ayurvedic College we also thought in this regard. As asked by me a few ofmy students inserted a pointed nail in the intercostal space. This was then hammered withlightest possible strokes gradually piercing the structures within the intercostal space likeintercostal muscles, vessels and finally parietal pleura until it reached within the pleuralspace. At this point we stopped hammering the nail. We took photographs of every stage.Finally we extracted it out. It was presumed that after taking out this shalya there must havebeen free entry of air in to pleural cavity causing vatapurna koshthata (pneumothorax), whichleads to fatality. Same thing has been written by Sushrut that vishalyaghna manna causes death byvata vikara- ftereqpreqrFr qrs-arB r (gg-d) This means that vishalyaghna marmas are vataj in property. So long as vata remainsinside (obstructed by the shalya) the patient survives, but as soon es shalya (foreign body) isextracted out, the vata escapes from the marma sthan, and the patient dies. Therefore, onelives if the shalya is in situ and one dies if it is taken out; or else if the shalya comes olrtautomatically after suppuration from marma sthan, the patient can survive. (Prof: D.G. Thatte) According to the modern concept any foreign body causing injury should be removedas early ur posibl" to save the life, but not always. If the foreign body behaves like lifesaver, it should be retained as long as removal threatens life. (Prof. J.N. Mishra) Vishalyaghna marrnas are 3 in number. All the three are located on the face. Sthapaniis said to be sira maffna while utkshepa is a snayu marrna. The parimana of all the threemarTnas is % anguli. They are supposed to have serious complications, if the foreign bodystuck there is forcefully removed. It is explained that the forceful removal of foreign bodycauses exit of some vital bhavapadartha along with prana. If the foreign body remains at thesite of entry, it seals the aperture and prevents the expulsion of the bhavapadartha. We consider the site of all the three vishalyghna mannas. All are situated on thebones of the skull. These skull bones are made of 2 layers and at some places there are 28
  • cavities, which are called as air sinuses. The air sinuses are spaces where some air is trapped.These air spaces are occupied by inflammatory fluid in case of infection. The sthapanimarma is at the site of frontal air sinus, while the utkshepa are on either side of forehead. All the three are of lz angula dimension, which is about I cm in length, breadth anddepth. When a foreign body traverses about I cm no vital organ is situated other than thesinus. The sira and mamsa (the explained marma structures) also do not indicate presence ofa vital organ. The nature of foreign body (fragments of bullet or the proximal pointed part of anarrow) is such that the so called aperture is improperly sealed. For sake of arguments, it canbe explained that the foreign body will injure some of the brain parts and seal the aperturepreventing expulsion, but it is not understandable. Presence of an arrow in head or bullet partin front and sides of face is also most uncomfortable situation. Some soldiers showed fragments of bullets and parts of bomb shell in some parts oftheir brain during autopsy. It was observed that they were harboring those foreign materialsfor many years without any complications. However, such areas are not considered to bevishalyaghnamarma. The situation of vishalyahna marrna, as explained in classics, is possible in a structurelike a bag containing some vital material in the liquid form. The foreign body will seal theaperture and will not allow the material to come out. Thus, so long as the foreign body is insitu, there will be no serious effects. Forceful extraction of the foreign body will causeseepage of the contents leading to serious complications including shock. The examples ofsuch structures are stomach, urinary bladder, gall bladder, lungs etc. Forceful extraction of foreign body from lungs will lead to pneumothorax,hemothorax and eventually death. The contents of stomach or bladder will not come out dueto sealing of an aperture by the foreign body itself but removing of the foreign bodyforcefully will cause exit of the fluids leading shock. However, these organs are notconsidered as vishalyghna marmas. The 3 sites of marma and their explanations from site,structure, extent point of view are not understandable. It is seen that shirodhara, a procedure used for various psycho and neurologicaldisorders, has very encouraging results. However, this success cannot be attributed to theexisting anatomy at the site. It must be the yoga that may be responsible for the break in thesamprapti of above referred manas vikaras. Principles of shatchakras must be playing a rolefor this success. Considering the above situation and available study material, it is difficult tounderstand the significance of vishalyaghna manna. (Prof. Vijay V. Doiphode) Refer to reply No. 2.9. (Dr. C. Suresh Kumar) It is not always indicated to remove the shalya from the spot without knowing theparts affected. Even higher investigative procedures are required sometimes to identify theinvolved muscle, vessel or nerve. In any vishalyaghna marma injury, if we remove theshalya, threat always remains for a heavy bleeding hence it is not at all wise to remove it.However, in surgical theatre it can be managed because adequate facilities are available. Inthose days the management procedure might not be sufficient, so it was instructed not toremove. Even today many neurosurgeons prefer to keep external bodies inside brain, if it is 29
  • thought that it is not going to do any harm, because brain surgery always accompaniesneurological deficits in early or later period of life. (Dr. K.B. Sudhi Kumarl2.12. All sandhi marmas are vaikalyakar exeept manibandha and gulpha, which arerujakar marmas. How can we explain this? (RAV) Movements of gulpha and manibandha joints are more than knee, hip and elbowjoints. Chain of metatarsal and tarsal bones is likely to get damaged, which results in morepain. About 13 -14 bones articulate with each other and are likely to get traumatized in amore complicated way resulting in more intense pain. Also there are a very few bursae in themanibandha or ankle regions. There is crossing over of tendons in a complex manner at wristand ankle areas. At the ankle joint, the axis of movements is oblique which makes the thingsmore troublesome.Ruja is subjective sensation described by injured person. It may be less or more depending onthe vyadhi ksham or vyadhi aksham sharer. Intensity could only be judged by movements atthe joints. (Dr. R.B. Gogate & Dr. Mukund Erande) Injured bony joints (sandhis) develop vikalata (handicap). This is true because jointsare bound by snayu (ligaments), which allow desired movements. If any of the snayu(ligament) of joint is tom the desired movements of affected joint are not accuratelyperformed. Ruja (pain) is not a permanent feature in these sandhis. Gulpha and manibandhasandhis are complex joints and termed in Ayurveda as sanghata (complex) joints The manibandha and the gulpha sandhis are complex joints and are more stable.I Wrist joint complex: Wrist complex joints has two joints viz- a) Radiocarpal b) Midcarpal It has following movements- o Dorsiflexion o Palmar flexion o Radial deviation o Ulnar deviationWhy wrist joint is complex: - Joini lies between the concave lower articular surface of the radius and the triangularfibrocartilage of the lower radioulnar joint proximally and the concave articular surface ofthe scaphoid, lunate and triquetral bones distally. The midcarpal joint lies between the scaphoid, lunate and triquitral bones proximally, and tr ap ezium, tr ap ezo i d, c ap itate and hamate d i stal ly.Stability of the wrist complex depends on:i) Capsules: The radiocarpal joint is enclosed by a strong but somewhat loose capsule. The.uprul. of midcarpal joinf is anatomically separate from the radiocarpal joint. The fibers ofthe joint capsule merge with the ligament.if Ligaments: The carpal bones are firmly bound together by interosseous, palmar anddorsal radio carpal ligaments and ulnar and radial collateral ligaments. The palmar radiocarpal 30
  • ligament is the strongest and most important in stabilizing the wrist complex. If this ligamentis torn the patient has carpal instability.iii) Tendons: The tendons passing towards the hand add more stability to the joint.iv) Bone shape: With the exception of the lunate bone, the carpal bones are broad on theirdorsal aspect and narrower on their palmar aspect, which possibly accounts for the jointbeing more stable when the palm is flexed.Movement of the wrist joint: When palmar flexion, ulnar deviation, dorsiflexion and radial deviation occur insequence, circumduction occurs. There are no active muscular forces applied to the proximalrow of carpal bones which serve as a mechanical link between the radius and the distalcarpals (to which muscular forces are applied). Movement of the distal row of carpal bonesmust be transmitted to the proximal row by an intercarpal bridge, which is provided byscaphoid and supported by the wrist ligaments.II- Ankle joint complex: Ankle is a hinge joint between the lower ends of tibia and fibula, whichaccommodates the body of the talus in the mortise form by the medial and lateral malleoliand the lower articular surface of the tibia. The integrity of the ankle joint is dependent on theinferior tibiofibular ligament supplemented by collateral ligaments. The structure providesstability together with the necessary mobility in one plane only.Ligaments of the ankle joint:i) The inferior tibiofibular ligament: This maintains the contact between fibula and tibiaand it is so strong that stresses tend to separate the bones.ii) The medial collateral (deltoid) ligament: It is fan-shaped and extremely strong ligamentconsisting of superficial and deep fibers.iii) The lateral collateral ligament: It is composed of three separate bands, the anterior andposterior tibiofibular ligament and calcaneofibular ligament which are weaker than themedial collateral ligament (prof. D.G. Thatte) Manibandha and gulpha sandhi can be studied under three heads namely: tendon,ligament and bones. The ligaments predominate in sports injury or in day to day locomotion.This joint is one of the most frequently injured areas of the body since being the connectinglink between stable leg bone and the mobile foot. The site and function with structuralanatomy leads predominantly to ligamental injury. The sprain is more painful than fracture,where there is compensatory loss of tissue (Prof. J.N. Mishra) The vaikalyakar and rujakar effects of trauma are based on severity of trauma at aparticular point. More over, not all sandhi marmas are situated in asthi sandhis; some arelocated in other dhatu sandhis. (Dr. V.S. Patil) Orthopedic surgeons say that sprain is always more painful and requires a longerperiod of immobilization than the fracture, particularly so if the ligaments are ruptured.-Gulpha is the commonest site of sprain; so it is said as a rujakar marna (also its collateralligaments are called kurchashir marma). Manibandha marrna (and its kurchashira) are justm"atching presentation like gulpha. Some anatomists say that dense connective tissues are 31
  • very rich in sensory supply including pain receptors and proprioceptors. This may be thecause behind this concept. (Prof. S.P. Tiwari) The statement is partially correct. Adhipati is sadyohpranahara marrna. Simanta iskalantara pranahara r,vhile gulpha and manibandha are rujakara, and others are vaikalyakarc.Acharyas have classified marmas based on different criteria like location of marma, size ofmarrna, constitution of marma, number of marma and effect of injuries to marmas. Pain,vaikalya, sadyohpranaharatva etc. are consequences of marrna injury. As pain is morepredominant feature in injuries of some miuma. These marnas are considered as rujakaramaflna. Practically also in gulpha and manibandha like distal joints; deformity occurs lessthan proximal joint injuries. (Dr. K.B. Sudhi Kumar) Comparison between two types of classification is not logical. Adhipati being asandhi marrna is classified as sadyah pranahar. Simanta, a sandhi marma, belongs tokalantara pranahar group. Manibandha is not weight bearing and has a wide range of movements. Bleedingfrom this area can easily be controlled. Statistically less number of deformities might havebeen observed by Sushrut in less severe injuries. Hence, it is considered under rujakaravariety. In case of ankle, it is very strong hinge joint with articulating bone surfaces andligaments. Vessels and nerves are protected by strong fibrous structures. Janu is acomplicated joint. Kukundara, avarta and krikatika are located in the trunk and neck regions.Rujakara mannas are located only in the distal parts of extremities. Deformities withdislocations, vessels and nerve injuries might have been observed less. Hence, Sushrut mighthave considered it under rujakara group. However, severe irj,rry and insufficient management may lead to deformity as told bySushrut. On the whole, the classification might be based on the statistical data available inthose days, which also depends on the prevailing instruments, weapons, facilities,circumstances and equipment etc. in the warfare. (Dr. U. Govind Raju)2.13. Why are rujakar marmas considered as a separate division? Ruja is considered asthe characteristic feature of all marmas. (Ref: Cha. Si. 9/3; A.H. Sha. O,t , ,rr.R.Indu) Ruja is the main symptom of marmaghata. In rujakar marrna, ruja is very severe andit remains for a long time. In other type of marma, ruja is there but it leads to death insadyopranahara and kalantarpranaharu marna. In case of vaikalyakara marma, it isimpossible to do movements due to severe pain; or the part gets atrophied due to damage ofnerves and blood vessels. It depends on the structures present at marma point. Severity ofpain depends on the force of impact and the structures involved. Ruja is a subjective sensation described by the patient, which largely depends on thepatients pain threshold and obviously on the immune power. (Dr. R.B. Gogate & Dr. Mukund Erande) 32
  • Ruja (pain) is a very common symptom in a large wound. It has been observed thatthe most common site of ruja is somatic pain, which is often well localized in sprained ankle. There are certain circumstances in which pain is provoked by specific posture iri which ajoint is involved. The feeling of pain also depends on how do you cope with the pain, butwhile assessing the quantum of pain one should consider the area or site of the pain inrelation to its complexity. The threshold and tolerance of pain varies between patient topatient and also in the same person in the different circumstances. It also varies in individuals willingness to speak about his discomfort (vikalta). Therefore Charak andVagbhat both have accepted that pain is considered as characteristic feature of all types ofmarmabhighat. In spite of the truth mentioned above concerning pain (ruja) there are certain areaswhere more pain is a reality. For example piles above the pectinate line in anal canal, thoughate true, are less painful because they are being supplied by autonomous nerves whereas pilesbelow the pectinate line are false piles, but are very painful because they are supplied bysomatic nerves, which are branches of pudendal nerve. Similarly all such areas on the bodysurface, which have mucodermal junction, are very painful.. Best examples are eyelidmargins, margins of lips and margins of anal lips where a smallest fissure can causeexcruciating pain. According to Ayurveda vaikalyakar marmas are those types of marmas where thepatient can be saved from injury or trauma of little intensity, but the patient becomespermanently handicapped or develops disability only to lead passive life. Such traumacommonly takes place on vaikalyakar marma areas (anatomical sites). Rujakar marma are those types of trauma that affect mostly those parts wherecontinuous pain persists for a longer time. The above-mentioned paragraphs are the fundamentals for identifying vaikalyakarand rujakar marunas separately depending upon the development of permanent disability ofprolonged pain. Having clarified the above definitions of vikalata or ruja, manibandh and gulpha candefinitely be identified as rujakar because of their complexity. As already mentioned aboveboth the joints are complex joints The pain of rujakar marma is chronic, intermittent or constant that lasts for a longerperiod. It is somewhat diffrcult to treat chronic pain and it needs professional expert care. Allabove features are predominantly present in rujakar marTna like manibandh and gulphasandhi because of their complexity. Therefore terming them clinically as rujakar is justified. (Prof. D.G. Thatte) There are three fates to any wound. The first is entrapment of vital organs, second isthe noncompensatory loss of tissue and the third is compensatory loss of tissue.But residual pain is at the cost of compensation. Rujakar belongs to third variety to definethat the pain is first sign of morbidity (prof. J.N. Mishra) Even though ruja (pain) is a main characteristic feature in all marmabhighata it maynot last for a longer time once the management is over. However, in certain marmabhighata,ruja continues to be present even after the management. Therefore, such marmas areclassified separately (Dr. v.s. pat) -tJ
  • Even though ruja is a cofirmon feafure, some other clinical features may over shadowthe pain because of the structure involved. No major structure comes under rujakar marmas,hence pain is the only the pronounced syrnptom. (Dr. C. Suresh Kumar) The marmas that are having only ruja as pradhan vedhan lakshana are classified asrujakara marmas and marmas having ruja as anubandha vedhan lakshana are not classifiedunder this group (prof. M. Dinakara Sarma) Although pain is a feature in all marma injuries, severity of pain will be more inrujakara mannas. Slight ittjury of these marmas can elicit pain- (Dr. K.B. Sudhi Kumar) Reply under question No. 2.] 2 may be referred for better understanding. (Prof. S.P. Tiwari) The motive of classification of marmas under rujakara group may be that on inj,rrythey produce severe and long standing pain and may be that the symptoms of other varietiesof marmas are observed less. The structures in these marmas might have been observed asless exposed to severe injuries. In abhighata of other types of mannas ruja is an associated symptom. (Dr. U. Govind Raju) Though the ruja is the feature of injury to all marmas but the separate division asrujakar marmas is essential because these are the marmas where ruja persists even after thebest management of the injury on these points (prof. Jyotsna)2.14. Agneya, saumyagneya and vayaviya gunas are present in sadyah pranahar,kalantar pranahar and vishalyaghna marma respectively. What should practically beconsidered by these gunas? How do we explain these from modern point of view? (Ref:Su. Sha.6/17) rhese marmas are successively less severe. Agneya *5o"* Tfitffi:tlltilpredominant at that point i. e. sadyopranahara. Agni means chetana (energy of the body). It is the main element of living organism.If it is lost by trauma, death is imminent. It is comparable with oxygen. Due to loss ofoxygen, nerve tissue gets damaged within 3 seconds. Saumagneya is present inkalantarapranhara rr&nrul At this point the vital structures are not predominantly present.Agneya: arterial loss of blood i. e. rohini: dhamani - traumaticSaumya-agneya: i)Venous blood loss (slow): nila. ii) Flow of mastulunga srava Fluid loss- i. e. CSFVishalyghna: impacted foreign body especially near lungs, liver, bladder or big bloodvessele.Our body is udakamaya and the shieta tatva is dominant. With the loss of blood, which is ofushna guna, shita tatxa rcmains. Marma becomes saumya-agneya, looses the oja and results 34
  • in death. To stop the bleeding, anticoagulants in the body start their work. They are of shitaguna (Dr. R.B. Gogate & Dr. Mukund Erande) Sadyahpranahar marma according to philosophy of Ayurveda represents agneyaguna; in trauma the conservation of the volume of the extra cellular fluid is preferred thanmaintenance of its exact biochemical composition. This is achieved by reducing water lossand conservation of sodium ions. The sodium ions represent agneya virtues and waterrepresents saumya virtues. If preservation of sodium ions fails there is peripheral vasculardilatation causing irreversible shobk and death, but if water is retained through sodium ionpreservation maintaining the circulatory volumes, the life stays, which is found in kalantarpranahar marrna. In vishalyaghna through vayaviya virtues the life is held up. The moment itfades the life is at stake. These events have been documented. (Prof. J.N. Mishra) o Agneya means enzymatic function or a metabolic function o Saumya means water balance and secretory function e Vayu means neuroregulatory functionAny imbalance may lead to wide spread clinical imbalance. (Dr. C. Suresh Kumar) The gunas of sadyopranahara maffnas can be practically adopted in treatment.Sadyopranahara and kalantarapranahara marrna injury can result in acute or delayed shock.Agni is responsible for all metabolic activities and due to slow metabolic activity thehypothermic condition arises, mostly as a result of hypovolemic or neurogenic shock. Hencein sadyopranahara marnas agni has been told to be predominant. Saumyata inkalantarapranahara marma may be due to its delay complication only. In case of vayaviyamannas we can consider a block in circulation (also an important function of vyan vayu) thatmostly causes stretch on pain receptors and other complications lead to pain. Its extractionmay cause rapid exit of blood from the respective body part that may later leading touncontrolled bleeding and death. (Dr. K.B. sudhi Kumar)2.15. According to Sushrut guda comes under mamsa marma, where as according tovagbhat it is dhamani marma. How can we justify this difference? (Dr. Jayasankar. S) According to the reference and documentation on a series of patients in Vietnam war,the greatest mortality that resulted after control of hemorrhage and shock in wounds of colonand anorectal region was from sepsis. In anorectal injuries undoubtedly at bigger places therewill be less time between the injury and definite treatment due to ready availability of theblood replacement, widespread use of antibiotics andimprovement in methods of patidntmanagement in the post operative period. The above observation shows that two conditions are significant, haemorragic shockand sepsis. The first is concerned with vessels and the second with muscles. (Prof. J.N. Mishra) 35
  • Classification of guda marma under mamsa marma appears to be more appropriatebased on fatal effect of traurna. If it is considered as a dhamani marma, the symptoms oftrauma would have been a hemorrhage leading to death. But no such description is given. Inmy opinion the act of defecation is performed by pravahini, visarjini and samvarani i.e. lowerpart of ampulla of rectum, internal sphincter and external sphincter respectively. Thus, theio**r part of guda is a marma sthan. Sudden stretch over these structures may produce reflexshock and even death, if not treated. This type of sudden shock is observed during digitalexamination of anal canal, which oocurs due to sudden stretch of sphincteric muscles, moreso in the presence acute anal fissure. If guda is considered as a dhamani maffna, only piecing type of injury may damageblood v-essels in the region and hemorrhage may take place leading to death. (Dr. V.S. patil) Guda marma is single and located in anal canal. It is a mamsa muuma, consisting ofexternal sphincter ani, internal sphincter ani and levator ani. It is supplied with inferiorhemorrhoidal nerve plexus and inferior hemorrhoidal artery and vein. The muscular analcanal forms a sphincter at the distal end of the gastrointestinal tract. In adult the canal isabout 4 cm long. The dentate or pectinate line is present in the anal canal. The mucosa above the linehas an autonomic nerve supply and is insensitive to cutting and pricking, where as the skinbelow is supplied by the inferior rectal branch of pudendal nerve and is acutely sensitive tothese stimuli. The venous drainage of the mucosa is upward into the inferior mesenteric and portalcirculation whereas that of the skin below is into the systemic venous circulation. This isrelevant in the spread of malignant tumors. A crack br fissure in the skin of anal canal, extending from the dentate line to the analverge is associated with local inflammation and spasm of the sphincter causing severe painon defecation as this area is sensitive with rich somatic nerve supply. During surgical procedures like anal dilatation, if the anesthesia is not properly given,the patient reacts-immediately; if this is neglected the patient may go in shock, whichultimately leads to death. Sushrut has considered guda as mamsa mafina. According to modern anatomy,internal and external sphincters together form the sphincter mechanism of the anal canal.The internal sphincter is downward extension of the circular layer of the rectal muscle walland is thus a smooth muscle tube under control of the autonomic system. The externalsphincter surrouhds the internal and is continuous with the fibers of the levator ani muscle. The upper part of the extemal sphincter at the level of anorectal junction is thepuboratalis muscle,which forms a sling around the anorectal junction. Because of predominant presence of muscles guda is mamsa marrna- Vessels orhemorrhoidal plexus is present at the site of guda marma. Internal hemonhoids are associated with dilation of superior rectal plexus of veins inthe anal columns. The superior rectal veins (portal) communicate with the middle and inferior rectal veins in the anal columns. The superior rectal veins (portal) communicate withthe middle and inferior rectal veins (systemic). They have no va.lves and back pressure in the portal venous system will, therefore, fill the hemorrhoidal plexus. Rectal bleeding is the main symptom of intemal .hemorrhoids.The blood is characteristically blight red like arterial blood. It has been suggested that the internal 36
  • hemonhoidal plexus is like a corpus cavernosum with direct arteriovenous communications.So it might have been considered as a dhamani marma. Injurv to guda marma will cause death due to shock ot"?$l:;:vijay "r v. Doiphode) We have to address this in two different angles. It is the difference only in nomenclature, as we were not rigid in nomenclature untilthe Sixth Intemational Anatomical Congress at Paris, which approved a standard and unifiednomenclature for anatomy and was known as the Paris Nomina Anatomica. Vagbhat has classified marmas containing srotas and that do not have the lakshanasof sira (saranat sira) as dhamani e.g. guda, apastambha. (Dr. C. Suresh Kumar) While explaining.the classification, based on structures of marmas, Achary has usedthe word khalu, which means there are no structures other than the hve structures; they aremamsa, sira, snayu, asthi and sandhi. The remaining all other structures have to be related toany of these five structures. In the context of marma the word sira has been used as vesselbut not as vein. If we look at the structure of guda i.e. rectum it has four coats viz serous,muscular, areolar and mucous. The muscular coat (tunica muscularis) of rectum consists of an external longitudinal,and an internal circular layer of non-striped muscular fibres. The longitudinal musce frbres around the rectum spread out and form a ayer, which completely encircles this portion of the gut. It is thicker on the anterior and posterior surfaces than on the lateral surfaces, where it forms two bands. In addition, two bands of plain muscular tissue arise from the second and third coccygeal vertebrae and pass downward and forward to blend with the longitudinal muscular fibres on the posterior wall of the anal canal. These are known as the rectococcygeal muscles. The circular fibres in the rectum form a thick layer, and in the anal canal they become numerous and constitute the sphincter ani internus. Anal sphincter: This comprises external and internal sphincter components. The internal anal sphineter is a continuation of the inner circular smooth muscle of the rectum. The external anal sphincter is a skeletal muscular tube which, at its rectal end, blends with puborectalis to form an area of palpable thickening termed as anorectal ring. The competence of the latter is fundamental to anal continence. The blood supply to the upper anal canal is from the superior rectal artery (derived from the inferior mesenteric artery) whereas the lower anal canal is supplied by the inferior rectal artery (derived from the internal iliac artery). As mentioned previously, the venous drainage follows suit and represents a site of porto-systemic anastomosis. The upper anal canal is insensitive to pain as it is supplied by autonomic nerves only. The lower anal canal is sensitive to pain as it is supplied by somatic innervations. Cancer (carcinoma) of the rectum is a common clinical finding that remains localized to the rectal wall for a considerable time. At first, it tends to spread locally in the lymphatics around the circumference of the bowel. Later, it spreads upward and laterally along the lymph vessels, following the superior rectal and middle rectal arteries. Venous spread occurs late, and because the superior rectal vein is a tributary of the portal vein, the liver is a common site for secondary deposits. Once the malignant tumor has extended beyond the confines of the rectal wall, knowledge of the anatomic relations of the rectum will enable a physician to assess the structures and organs likely to be involved. In both sexes, a posterior 37
  • penetration involves the sacral plexus and caq cause severe intractable pain down the leg inthe distribution of the sciatic nerve. A lateral penetration may involve the ureter. An anteriorpenetration in the male may involve the prostate, seminal vesicles, or bladder. In females, thevagina and uterus may be invaded. Internal hemorrhoids are varicosities of the tributaries of the superior rectal(hemonhoidal) vein and are covered by mucous membranes. The tributaries of the vein,which lie in the anal columns at the 3,7, and 11 oclock positions (when the patient is viewedin the lithotomy position) are particularly liable to become varicosed. Anatomically, ahemorrhoid is therefore a fold of mucous membrane and submucosa containing a varicosedtributary of the superior rectal vein and a terminal branch of the superior rectal artery.External hemorrhoids are varicosities of the tributaries of the inferior rectal (hemorrhoidal)vein as they run laterally frorn the anal margin. (Prof. M. Dinakara Sarma) In the case of bleeding piles the blood is red (pure) because of porta-cavalanastomosis. This was why Vagabhat has called it a dhamani marma. Guda is a karmendriya,so Sushrut has considered it as a mamsa marrna. (Prof. S.P. Tiwari) Guda is matrij avayava, mridu and mamsaj. When we put our finger in rectum, it feelshot. Rectal temperature is more than skin. We can feel the pulsation. It is the shunt area(vent), which balances the portosystemic circulation. If the portal pressure is raised there isbleeding through rectum. For vaikal.vakara ses ans$,er given at ?.9 Sushrut has stated it as mamsa marrna because it is a muscular part. Anal canal issurrounded by muscles and fibrous tissue. IschiorOctal fossa is present on both sides. ButSushrut has also stated it as sadyopranahar marrna. There is sudden death after traumabecause it is also surrounded by plexus of both vessels i.e. veins and arteries. There is alsoplexus of nerves. Hence it leads to sudden death. Sushrut knew all these sharer rachana, butmamsa is predominant. Therefore he has stated it as mamsa marma. According to Vagbhat it is dhamani marma. Dhamani means large blood vessels.Because he has stated that - era* frfiTg q frff na} €rfi-*: Tiwr ffi +rdfr r (gq A-ol)Therefore dhamani should be considered as artery. Damage to this structure leads to death. Itis responsible for viddha lakshana. Hence Vagbhat has stated it as a dhamani maffna. (Dr. R.B. Gogate & Dr. Mukund Erande) The periods of these two books are different. Sushrut might have mentioned these,based only on extemal structure of guda while Vagbhat has given more emphasis to outcomeof injury to guda, which is mostly due to injury to the deep vessels. (Dr. K.B. Sudhi Kumar)2.16. Why has Sushrut not mentioned dhamani marma while giving importance todhamani, snayu etc? (RAV) 38
  • Sushrut has stated that there is no structure other than mamsa, sira, snayu, asthi andsandhi. That means that he has considered sira as dhamania sg traE qfrtbor arqrh aafFr al-dk r qsr*qaaqi r (9, err.)Dhamanis are great and nutrient arteries, and are also called as rohini. In Ashtang Hriday, itisexplaine9ut- . d G e.rrm q+eroEq;*rsi trfi-6fr-** ftr*a-tr, I 3{. €. QrT" @t €ran-dftEnrwrr ffi a{dft I era;*, frftTe q ft+-Er. I (Dr. R.B. Gogate & Dr. Mukund Erande) Yes, this is true that mamsa, sira, snayu asthi and sandhi are important structural unitsin the formation of a marma site but Sushrut has not considered dhamani separately as arnarma. This is probably due to his lack in observation regarding surgical complications. (Prof. D.G. Thatte) Sushrut has mentioned dhamani marma also but under sira marma. Sushrut hasconsidered sira as vessels. For example nila and manya mafina are under sira marma butwhile detailing they have been said as dhamani. (Prof. J.N. Mishra) Sushrut has probably included dhamani mannas under mamsa and sira marrnas,which produce symptoms similar to dhamani mannabhighata e.g. bleeding (hemonhage). (Dr. V.S. Patil) He has mentioned dhamani marma, but with different name. Marma Vagbhat Sushrut Sringataka Dhamani Sira Vidhura Dhamani Snayu Apastambha Dhamani Sira Guda Dhamani Mamsa (Dr. C. Suresh Kumar) We find references that sira,dhamani, nadi etc are paryayas. So he must havegrouped together under the heading sira marma. (Prof. M. Dinakara Sarma) Sushrut has mentioned all constituents of body like siras, dhamani, asthi, sandhi etc indetail in sharer sankhya vyakarana. The term marma is given only to those parts, which seemto be vital and injuries to them will result in serious health hazards. Because the word sirahas got multiple meanings such as srotas, vessels etc, he rnight have used it to include allthose as marmas (Dr. K.B. Sudhi Kumar) Sushuts concept of sira is very extensive. He has described four types of sira namelyvatavaha, pittavaha shieshmavaha and raktavaha. Though raktavaha siras are ref-erred to asarteries (dhamanis), but since they are covered under sira all vascular marmas are categorizedunder sira marma. (Prof. S.P. Tiwari) 39
  • 2.17. Which are sites of dhamani marma according to modern science? Manycommentators consider them as artery, vein or nerve. (Dr Kunal Lahare) Dhamani is artery: rasayani. Et E-fi-* snurr ffi el-dfr I eraftai gft e+ro-fi-at .. s-+6 d-s-6-r +trEi e+erq srpi erd-ff ftfeT# fr€r E-fl-ff E-qfu sei ftrqft I .Artery is the only structure, which receives its blood supply through its internal linings.Srotomul - dhamani. if this gets cut it leads to srotonasha e. g. mesenteric artery in case ofannavaha srotas or hepatic artery in case of raktavaha srotas.Ref. - shleshma vikar, hridayalepa, dhamani pratichaya, visha chikitsa - dhamani bandha. 3rqloa-€rrug $fto-q frrur arqwr eftaar r (9. en. zrza) gqffEq €rqa ar$ | @E tortesz) era-a zdqararai erfte r (q. €. zr+) en erryft e+r *oe{rfM r (rro"rqa ar$fufl-d) sraeq ft+Er 3rir Eed qs€qrf a fre+flr fu"T f){s6 I W 4aoi qfr q€isrf,l"Ti €Id etaq I IIf the big arteries are cut off, and if they develop traumatic embolus (as in trochanter fractureof femur), the effect will be death due to loss of supply to ital organs like shira, hriday; but ifcollateral circulation is established within short time, sadyopranaharatva is converted tovaikalyakaratva. (Dr. R.B. Gogate & Dr. Mukund Erande) All the dhamanis (arteries) are very vital structural units, which are directlycontinunation of systemic vessels like arch of the aorta, axillary artery, brachiai artery andulnar artery in the arm. Similarly in abdomen it is abdominal aorta, common iliac artery andits branches extemal internal iliac arteries continue as femoral, anterior tibial and posteriortibial artery. So are all the paired and single branches of abdominal aorta. The commentators who have termed them as attery, vein and nerye were not havingprecise knowledge of these structures. They, being only Sanskrit commentators and notanatomist, have talked in a most confusing manner. We, the present day scholars ofAyurveda, must develop of prior vision about the structure. (Prof. D.G. Thatte) Dhamani marma mentioned by Vagbhat and Sushrut are the arteries that need specialmention. (Prof. J.N. Mishra) In my opinion hriday, nabhi, nila, manya and matrika marmas, described as siramanna, can be included under the dhamani marma based on traumotological symptoms. Shankha manna mentioned under asthi marma can also be accepted as dhamani or siramarma. (Dr. V.S. Patil) In Charak Samhita we find references that sira, dhamani, nadi, srotas etc areparyayas. So he must have grouped them together under the headps tjT:3"" (Prof. M. Dinakara Sarma) 40
  • It is very difficult to specify sira or dhamani as vein or artery respectively. Thesevessels are more prone to inju-ry. It is difficult to manage bleeding; it mostly causes death.very often this might have been considered under dhamani maffna. (Dr. K.B. Sudhi Kumar)2.18. marma sharira we find two different marma classifications vizz sira Inmarma and dhamani marma. How should this be exactly understood in terms ofmarma shar,ir? If we grossly consider this as sira marma does it include all the vessels? - (Dr. Sibgath Ulla Shareef) A modern student of anatomy, who has visualized every structure independently,knows the characteristic features of arteries (dhamani) and veins (sira). Therefore thereshould be no confusion while labelling a particular structure as sira or dhamani marma. Asfar as inclusion of both as vessels will be a gross mistake because an injury on dhamanimarrna is more fatal than the sira marma. Injury to Dhamani will cause profuse blood lossdue to more pulse pressure in arteries than veins, because veins have passive flow and thuswill cause minimal or slow bleeding. (Prof. D.G. Thatte) In marma sharir there is no significant difference in Sushruts sira (vessels) mafinaand Vagbhat,s dhamani (artery) marma. Sushruts classification is more relevant sincearteries,leins and nerves, mosi of the time, run together and it is very difficult to identifyclinically the arterial or venus bleeding separately. However, Sushrut differentiated thearterial and venus bleeding by their mode of bleeding (Prof. J.N. Mishra) Blood vessels present in a particular marma sthan can be included and understood asdhamani or sira 1nu.-ur, since symptomatalogy of marmabhighata of sira and dhamanimafina are similar. (Dr. V.S. Patil) Yes, it includes all vessels. (Prof. M. Dinakara Sarma) whose injuries Sushrut has explained only sira marmas, which include all the vessels more vessels that are cause heavy bleeding. Besides some of these, Vagbhat has observed have been classified under more fatal and are diffrcult in management; and hence, they might dhamani marrna (Dr. K.B. sudhi Kumar) yes, if we grossly consider sira and dhamani marmas under one group called sira marna, this group .iitt itrrt,tae all the marmas with an artery or a vein. (Prof. S.P. Tiwari) 2.1g. Sira marma and dhamani marma vedhan lakshanas are mentioned in the following verses, but the symptoms can be observed in both sira and dhamani ,rrur*ug-hut, then how we can differentiate both of them? fr"r;rdq* sr<a-qd c6q€a?1t 4t
  • : lt (er.6. en. +tso) sci aerqffiwi errftr* Has u (er.6 en. +r+e) (Dr. Kunal Lahare) Dhamani is rohini: artery. -T5rT5.sn dr-rGreT:qlffi Argar ft55r I fr-<TtErenrq dl6Trrq, effar aN: frersr, 6qtTE I I arqaa6Fgg frfto-er: ftrur arqwrsn-trdr I (9. Q[, 7 / 1 B)Sira is to be taken as nila: vein.Even as per modern science, there is not much difference in the oxygen composition of arteryand vein so that we can treat the patients by doing raktamokshana by siravyadha and not bydhamanimoksha. The pressure in the vein is less than that in artery. (Dr. R.B. Gogate & Dr. Mukund Erande) The question is self explanatory. Ahata and vedana are synonyms. (Dr. C. Suresh Kumar) Even though lakshanas of both marma kshatas seem to be similar, in sira marTnakshata, there is bahu asruk sruti and its consequences. In dhamani marmabhighata thebleeding will be phenayukta and with {rabda. The difference may lie with ashukarita i.e.fatality within a short period or over a period along with above-discussed factors. (Dr. K.B. Sudhi Kumar)2.2o. €E dd d zqar qe snenfta affowr den sS a-d +1 iq S srrslT{qg sser err*{ +t Efu * Bqffra sqar d 3refiilEltTT Tfi-d Affi Bgtrdk ad ai€ strrs 6r dd E r gs$ tq * Tffi€rq # * qq *ff B lqai sm er€r rFT g@ tnrlq fu{r S ffi E r Eqfre ga<k a-d ?q6IT et€qqraar * aisa-d *t gg ff frrtr ad arqar s{fu6 gfu } aur ? "{Trer (Dr. R.B. Shukla) According to Sushrut (Su. Sha. 10/4) mamsa is full of blood and it may bleed tothreaten life in case of injqry. Muscular ischemia due to excessive hemorrhage causes non-salvageable necrosis of muscle, which promotes clostridial myositis associated with pain,swelling, edema and toxaemia. Toxemia depresses the adrenals causing hypotension andsudden death. Here the cause of death is not hemorrhage but clostridial myositis. (Prof. J.N. Mishra) If we look at the location of indrabasti of lower limb it is the region where soleusmuscle is related. This muscle has many blood sinusoids where blood is stored and laterpushed upwards by its contraction. Due to this reason, when injury takes place, there will bemore loss of blood but still it has to be related to mamsa marma only as the mamasa gives aroom for blood to stay in that particular region. In all the injuries of marma vastus there willbe blood loss in marrna vastus, but the amount of the blood which is expeled out will bedissimilar from the different structures and it has been said by Dalhana as - EA-d Rrupri -----tr{rftqftrAsft eilFraroraaFreef u a (g. err. 6 / 1 tr{re.r) (Prof. M. Dinakara Sarma) Some muscles are vascular e.g. calf muscles; hence they bleed a lot. Indrabasti isstated as mamsa marma but the site of marma is very vascular. Therefore its location is stated 42
  • anterior in upper extremity and posterior in lower extremity. The viddha lakshanas occur dueto damage of blood vessels but the marma cannot be stated as sira manna because siras(blood vessels) are deeply situated, while the muscle mass in lower limb is quite bulky. Asper modem anatomy it is stated to be the site of peripheral heart because of the pumpingaction of calf muscles for propulsion of venous blood from lower limbs towards heart. (Dr. R.B. Gogate & Dr. Mukund Erande) Mild injury to indrabasti causes abhighata to mamsa only, but only deep injury willproduce bleeding. It is due to the fact that the anatomically it is a mamsa but many. bloodvessels lie interiorly and only a forceful trauma can lead to more bleedingif they are injured. (Dr. K.B. Sudhi Kumar) The case of indrabasti is a model to understand the value of determining structure.The significance of the structure in this account cannot be denied. Though Sushrut hasreferred that death is because of hemorrhage, but often the cause of death is pulmonaryembolism induced by crushing injury in fleshy part of calf muscles that let myoglobin (aprotein) into circulation. Myoglobin blocks the capillaries of the lungs and causes pulmonaryobstruction. This proves the value of muscle under mamsa manna. Some times death isbecause of hemorrhage caused by the rupture of vessels at the lower part of popliteal fossa orof great saphenous vein. (Prof. S.P. Tiwari) 2-21 . rr* d dis, RrsI, tsang, s{fr€T o z{fq * s{frFtr tqErr a-S qr$ qrft rtr* "tttd ggiT fr err$s Eerra d qufia f6* 3 r g$fru @ _or T{4r et<: *q"trq;{rT aft Hq1 arqr B r qsfr errfr{ Eerrd fr teft, €r9, srfter sf>et, fu{r-tfi d sfltfrEr, cerr% gsru Frg ord q"fi# * srer51rq *dn e I sid, fu{r aen oT qofia sftsrrR rd or qoFq sm teft, snfr applied/surgical anatomys ucr fr d-o.re o-c eil qrEu qr qS ? (Dr. R.B. Shukla) q6 T{.q B fu al-d {qld fr ariT{, fr€t, EIrg, s{fr€I Ezi erafq sc+arsfr +1 zrg<r+ t-f,dr B sfu 6;{ff t sn€rrt qE aff 6r t-44r +< A a-otro-sr "{fEr*n 6;* o* E r q-s{ sseaoaf E1qr €-€ qra rft 961 Ei-{-dTr fu a1-fr Er oof.Tteft cqrg sTrR 3rq -sqqrs* or e"fra o-sA "=tal-q zffors fu-qr qrar wr srgfuaafi *on-r q-{-g erera * fta-} ffi frRre qT a-d + sTf-erqrtrq "trra* o} frr{r + ftTe" s,c{ dd fr ftera Rrsr, €rq-ff 3rar frRre "qar 6r ersa-*q"*E;-e ff .,rrqdr 3{TE?qeF B r gs+ Ti{af fr fta e*o s6i7uftq 3-E* o] aafFr ,; *E sqarmd . tl-q fte)$"1grrrrffi<; ffi a+rE-rarrrsdlt (tr.et. 6/1s) (Prof. D.G. Thatte) Marma is confluence of five tissues, which constitutes specific seat of life. Therefore,individual tissues have separate identity. Definitely they may be accepted under thedescription of relevant peshi, snayu etc. with reference to their applied aspect. (Prof. J.N. Mishra) The applied or surgical anatomy of peshi and snayus cannot be related to the marmaviddha lakshanas. For exalple the ,nuyur, which have bien explained in the 5th chapter. Allthe snayus have not been reiated to the marmas, especially sushira snayus, which are related 43
  • to the endings of amashaya and pakvashaya. These are, not related to marmas; then how canwe relate all the snayus with the marma vidha lakshana? (Prof. M. Dinakara Sarma) or which seem to Acharya has considered only those parts, which have marana actionbe vital as marmas. (Dr. K.B. Sudhi Kumar) presenled Description of asthi, peshi, sira, dhamani, snayu etc. is systemic anatomy is an appliedby Sushrut *Lit" marma sharir is regional anatomy. Though marma shariranatomy but being *w *""ft exclusiie in nature, it has nothing suitable to be mixed withformer; instead it will create confusion among the students. (Prof. S.P. Tiwari) than these five. But Sushrut has told that no more variety of marmas is present other can present in any of thestructures other than the mamsa, sira, sna-yu, asthi and sandhimannas. itself is entirely an applied anatomy and hence all the As such maffna sharirastructures described in these regions are having applied importance (Dr. U. Govind Raju) 44
  • CHAPTER.III MARMA OF EXTREMITIES3.1. Injury to kshipra marma causes akshepak and death. What is the pathophysiologybehind this? (Su. Sha.6124) (Dr. Joshi George) Same answer as given to question No. 2.6. ftrsi ara ad, aq fu6;{qrMw aEui; ---- r (tr. err. 6/24) (Prof. D.G. Thatte) Sushrut has observed tetanus through kshipra marma, which causes akshepak anddeath. Read answer of Qs. No. 2.6 and 2.8. (Prof. J.N. Mishra) Injury to this manna can lead to death by akshepaka (convulsions). This can only beexplained that this wound would get infected and lead to tetanus, which might be verycommon then. After the advent of modern antibiotics this is well under control. Thus, theinjury may lead to death due to akshepaka. Akshepaka, being a vata vyadhi, samprapti ofvata vyadhi is the sequel of injury. (Dr. C. Suresh Kumar) Injury to kshipra causes akshepak and death. It is because of the fact that givenanatomical site is most suitable site for the growth of bacillus tetani. The symptoms underkshipra correlate with the symptoms of tetanus. Varying period of death in this marma is alsomatching the incubation period of tetanus (1 day to months). This is an obviouspathophysiology (prof. S.p. Tirvari) eft*E era-fu 6*g urwfi-E qq;req aqr o-$fr rPathophysiology: Because^ of "-fii hypovolemic or neurogenic shock due to sudden painful stimulicausing severe splanchnic vasodilatation the patient goes under cardiac arrest. Often it maybe life threatening due to hypoxia. Akshepaka may be due to hypoxia, hypokalemia,hyponatremia etc. Hypothermia, acidosis and hypovolemia are the conditions worsening inhemorrhage. (Dr. K.B. Sudhi Kumar) Sushrut has described that the result of injury to kshipra is death by akshepak. Asimilar condition known as dhanurvat in the Indian classics is found and appears close totetanus. Tetanus is an acute nervous system intoxication caused by fixation in the CNS of atoxin from gram ave anaerobic bacillus Cl. tetani. The organism is found mainly in the soiland in the faeces of animals and humans. It enters the body by wound contamination. It ismore susceptible to punctured wounds or necrotic lesions but even the clean wounds mayalso be inoculated. "The popular impression that tetanus is specially liable to follow a wound betweenthe thumb and index finger is due to the fact that those who dig much such as gardener andgrave digger are likely to excoriate the skin and contaminate it with soil" (Love and Bailey20,lfh edition 1959). 45
  • By above observations it seems that the cause of death due to akshepak described bySushrut is nothing but the tetanus and the munna point of kshipra is a common site ofpiercing wounds in diggers and farmers. (Prof. JYotsna)3.2. According to Su. Sha. 6/33 chhedan has been advised in case of kshata to thekshipra and talahridhay marmas. It has also been told that death may occur due to theincrease of vata which is caused by loss of blood. What is the significance of chhedan inthis condition? 6or. Dr. Jayasankar. s) During trauma blood vessels as well other structures get crushed which is responsiblefor infection. Due to chhedan blood vessels are cut but they get constricted due to pressurecreated on them.s€q .... @ sg qunq srqare-fifr IBg qrFrq-{+E a{-dfu sr.r €areE qd-dftr}g veffig gft IChhedana against the hard structures of kshipra and talHriday results in crushing of vesselsand results in haemostasis. This procedure is always completed by the dahan of this stump bydeeping in hot oil which causes raktastambhan and prevents infection. (Dr. R.B. Gogate & Dr. Mukund Erande) First of all reference mentioned in the para of Qs. i.e., Su. Sha. 6i33 regardingchhedan is wrong. For rest read nerve of Arnold. Otherwise no miracle has been noticedeither in form ofreference or experience. (Prof. J.N. Mishra) Chhedan (amputation of hand and foot rcspectively) has been advised for kshipra andtalahriday in the above stanza.E;"q""r.it ffi eiaffig: Tid=i c-.r€"-es-di Efdrs e-d-+a r (€. ?TT.6/31-s2 ut se-r) (Prof. M. Dinakara Sarma) One of the indications for amputation in trauma is to save life in crush injuries andentrapment injuries. Marmas are vital points of the body. Kshipra and talahriday are similarto roots in a tiee. So, injuries to these marmas arc fatal and hence amputation is advised byavoiding injuries to these marmas (sic). @r. K.B. Sudhi Kumar) The Cl. welchi and Ct. tetani are anaerobic bacteria responsible for causing gasgangrene and tetanus. These causes appear to be close to the Sushruts observation of deathin injury to these marmas. Chhedan on these points causes the wound to open and it becomesdifficult for these anaerobic bacteria to grow. (Prof. Jyotsna)3.3. qrflF qd wroe a-d E fu-€ oeft oaft 3{r€IT?T * qfturra Ersq fr-+aargEEET"A-6T to-e-cn-c d qfrurd A qrdr El tsr da er. ufirgarc +6r"r) 46
  • Viddha lakshana of gulpha marma has been stated as stiffness of leg orshortening of leg (khanjata) whichresults from severe trauma is vaiklyakara, the stiffnessis rujakaia. Ankle complexis made up of about 14 bones articulated in an intricate manner.it is iuite likely that the alignment among the bones is lost to a greater or lesser degree very obvious.whichis observLd in orthopaedic practice. So that vaikalyakaratva is All these conditions are dependent on the trauma and structures involved in it produce pain, which has no- As ankle joint bears body weight, it is always bound torelation to site of trauma (Dr. R.B. Gogate & Dr. Mukund Erande) Gulpha marma can be studied under three heads namely tendons, ligaments and and ligaments usually bybones. Abnormal and excessive forces produce injury to the bones due toindirect violence. The involvement may produce post traumatic vikalata. Spraintendons and ligaments cause ruja. (Prof. J.N. Mishra) evsn a rujukara marrna can become vaikalyakara. It If effect of trauma is extensive,all depends on the velocity of trauma and damage to the underlying structures. (Dr. V.S. Patil) life Ankle is a major joint. One may invariably injure it many times during ones Potts injuries, seen around the ankle, are some among the common injuries that wetime.come across (Dr c sr (Dr. C. Suresh Kumar) If injury to ankle joint causes only sprain (due to rupture of ligaments), gulpha mar -ma (Potts fracture or trimaleolar is considered as rujak*; Unt if the i"j"ry involves the bones vaikalyakar. This is fracture) or the joi"t (iirrocation or-tni joint) then gulpha is called because of severity of trauma. (prof. s .p. Tiwari) weight bearing joints. In Gulpha is a sandhi manna (ankle joint). It is one of the most case of any derang"-."t in this loint, ii wili cause loss of normal functioning of limb ie painful consequence only limping. However,-in most of the londitions it causes a severely @r. K.B. Sudhi Kumar) tear, malleolar fractures, Gulpha is classified under rujakar mannas. Sprains, ligament hair line, irr"o*plete fracturei are cofirmon at the site of ankle Dislocations are *d uncommon as it is u ,iuut. hinge joint. As it is a weight bearing structure minor abnormality ilffi;Ji" fur"""ity if not treated properly or in prolonged illness such as tarsal tunnel sYndrome. (Dr. U. Govind Raju) 3.4. Lohitaksha is a vaikalyakara marma. Please explain its role in manifestation of nakshaeahata. ::T;;-aa"*"+"t asoi qenEn* qT ---- | fg err arz+) (Dr. Jairaj P. Basarigidad) 47
  • dFtner *osoz qd I 3E{* fu€i cTerlT .rT=r eiftaer+q awi qeTrqrd B qr tsr Fqr E IafrE-arer ad or r€rrET steitiepr s-oq+ t-err F+1 3 I TerTr fr 3n11dcrr, 3n-fl *Brrft 3*{ itrff *ff "ia-d s}E Jt qt s+r6r ,iq.T EI-ET e I 3rrrE E r #t-n3ir€n"f *E zqsq or frar B ?il nftr"ft -qe ?ilegg grur qa eat * 6ag ded-s B r 3rr* 3rr€rr. +1 ?ftfirr o-q *ft -at- 58"ft sfuhcn of errffi + Bqrft B r ffi q: -.S B r Frrr* 3-g{+ zargs+ or Tilqtry a-is +* A r s*{q€rrqFd d zl-+ar B r q,t B-+r 6rF +ft B "qrg3f I Site of lohitaksha marma is below hip joint and at the root of thigh. At thissite femoral vein, artery and nerve are present which supply to whole thigh. In severetrauma blood vessels get damaged subsequently profuse bleeding that leads to death.There is also injury to vertebral column and lumbar area or damage to sciatic or femoralnerve in most of the cases. (Dr. R.B. Gogate & Dr. Mukund Erande) This is true that according to Sushrut lohitaksha marma is vaikalyakar manna and due to abhighat on this marrna pakshaghat (hemiplegia) and then lastly death occurs as its complication. Lohitaksha marma, which is placed in front of thigh (or axilla in the arm), can be recognized as femoral sheath in thigh, which contains from medial to lateral femoral vein, femoral artery and outside the sheath laterally femoral nerye. Similarly this close relationship of femoral vessels with femoral nerve and in axila close relationship of cords of brachial plexus with brachial vessels are important to understand because injury in the front of thigh below the inguinal ligament may cause excessive bleeding and neurological deficit by injuring the femoral nerve. Therefore there is every possibility of pakshaghat due to neurological deficit in extensor muscles of front of thigh ultimately producing handicap or vikalata. The muscles supplied by femoral nerve are just about 2 im below the inguinal ligaments. Femoral nerve divides into anterior and posterior branches. The anterior sulpfies the sartorius and posterior supplies rectus femoris, three vasti and the articular g.n". Similarly the hip joint and knee joint are also supplied by the nerve. Therefore an injury to this nerve may cause vikalata in hip and knee joint both. Similarly the wounds in thi gioin may cause paralysis of quadriceps femoris and sensory deficit on the anterior medial side ofthigh and medial side of leg. The nerve to vastus medialis (special) contains numerousproprioceptive fibers from the knee joint from the thickness of nerve.What is proprioceptive fiber? These are the minute fibers of a nerve supplying a particular muscle crossing a joint.These fibers create awareness of posture, movement and ehanges in equilibrium and also theknowledge of position and weight in relation to the body. Similarly the axillary vessels andnerve are the representative of lohitaksha ma.rma in axilla. There also axillary artery, theaxillary vein and axillary cords of brachial plexus, which can be damaged due to marmaghat.In axilla the roots coming out from C5, C6, C7 and Cg and T1 contribute in the formation ofbrachial plexus. These roots join to form trunks. Each trunk divides into ventral and dorsaldivisions. These divisions join to form three cords viz medial, lateral and posterior cords. Thedifferent branches of these cords supply the muscles of the upper limb. abhighat to the roots,trunk and cord of the brachial plexus may produce characteristic defecti. The commonneurological deficits due to injury to the lohitaksha manna of axilla are claw hand. At thesame time injury to the axillary artery and axillary vein may cause severe hemorrhage. Theartery can be effectively compressed against the humerous in lower part atthe lateral level of 48
  • movements. Occasionally it is ruptured during the reduction of an old dislocation ofshoulder. This may cause severe hemorrhage leading to death. (Prof. D.G. Thatte) In spite of advancement in vascular surgery, the result of repair of lower femoralartery trauma remains poor. In Northem Ireland there was a unique series of patientsbelonging to the vast majority of lower femoral vascular injuries qaused by low velocitybullets. Five patients had limb amputation. In nine, limb function was poor following re-vascularization. This poor function (pakshaghata) was due to severe calf muscle wastingfollowing ischemic necrosis. @rof. J.N. Mishra) If injury to brachial artery takes place there is a possibility of blood loss leading tofatality. Injury to nerve may result in loss of function of the arm (vaikalyakara). (Dr. V.S. Patil) Ischemia leads to hemiplegia. Sakthyal<shno swangot yukta rakta varna charma yukta" that is the definition oflohitaksha. According to the text the injury causes pakshaghata. Here the author is referringonly to the monoplegia of the affected limb. (Dr. C. Suresh Kumar) Lohitaksha can be taken as femoral and axillary vessels in lower and upper limbsrespectively. We know the proximity of nerves to blood vessels in these regions. Any injuryto lohitaksha may cause damage and impair functions of nerves around the blood vessels.This can be construed as pakshaghata. (Prof. M. Dinakara Sarma) Lohitaksha is a sira maffna, and also a vaikalyakara marrna. GfrFd€r+d arssi rrsrrqrd qr r Any severe injury to major blood vessels like iliac, femoral, axillary etc. may causehypovolemia and hypoxia. Thrombus and embolus formation lead to circulatory failure andmay cause neryous dysfunction, which in tum may cause pakshaghata. (Dr. K.B. Sudhi Kumar) At the site of lohitaksha marma there are four structures namely great saphenous vein,femoral nerve, femoral artery and femoral vein. Injury involving the blood vessels will leadto death, but when femoral nerye is injured it will lead to pakshaghata. Site of, marma isupper part of femoral triangle close to the saphenous opening. (Prof. S.P. Tiwari)3.5. Death occurs as a viddha lakshana of lohitaksha marma. How does one justify this?Because lohitaksha is basically a vaikalyakara marma, and usually vaikalyakaramarmas do not cause marana. (Dr. Seetharama Mithanthaya) Please refer to the reply No. 3.4. (Dr. R.B. Gogate & Dr. Mukund Erande) 49
  • There is no description of death due to trauma on lohitaksha marma. (Prof. J.N. Mishra) Major artery is the basic structure that may cause death due to ischemia. (Dr. C. Suresh Kumar) parinama in lohitaksha marma depends on the intensity and vicinity of marmasadanam. p4kshaghat and maranam may happen in lohitaksha viddha cases on the principleof- {d Td rrz-€€t 6Td 6-}fr I (g. en. 6/22 q{ s€sr) (Prof. M. Dinakara Sarma) pakshaghat justifies the state of vailkalyakarata in lohitaksha. Any vaikalyakarmarma *uy tirr inio kalantar pranahar when there is severe injury. This is the theory ofSushrut (Sh. Sh. 6130). Thus the state of pranharatva as presented here is true anduncontroversial. (Prof. S.P. Tiwari) may be due to hypovolemic or vasovagal shock. Sushrut has also inferred that Itsometimes it is possible that vishalyaghna and vaikalyakara marma can tum sadyo- orkalantara- pranahara marma. (Dr. K.B. Sudhi Kumar)3.6. Howdoes vitap marmaghata cause impotency? Please explain on the bases ofanatomy and its PathoPhYsiolory. (Dr. Jairaj P. Basarigidad) tieTor gqoreit: sidt fudq-oI|?T, ffi qTu@q 3]-ctrgcFcTT EIT I It will depend on whether the trauma is bilateral or unilateral. In unilateraltrauma exactly on spermatic cord (shukravahini) is likely to produce alpa shukrata Inbilateral, partial avuision may result in alpa shukrata which is the one of the causesof impotency. (Dr. R.B. Gogate & Dr. Mukund Erande) The content of inguinal canal is spermatic chord. The injury in this region mayproduce obstructive puthology in vas deferens or the vascular damage, which may causeindirect effect on entire reproductive scenario (Prof. J.N. Mishra) Vitapa manna is in close association with pudendal nerve. Injury to pudendal nerve r predisposes imPotencY. r Injury tt the above structure can cause necrosis of the testes, resulting in impotency structure to be taken into and otigospermia or azoospermia in male. But for the female the consideration here is the round ligament of the uterus (Dr. C. Suresh Kumar) zieror gq"T...........fueti ard I 50
  • This refers to the spermatic cord coming out from the inguinal canal throughsuperficial inguinal ring and entering the scrotal sac. Naturally, injury to spermatic cord willlead to impotency (prof. M. Dinakara Sarma) The nerve fibers are enclosed along with the blood vessels and lymphatics in aconnective tissue sheath called spermatic cord. Injury to this cord may result in impotencyand oligozoospermia. (Dr. K.B. Sudhi Kumar) Vitap marma is located between testes and inguinal canal; better site may be the partof groin close to the extemal inguinal opening. Testicular nerve and artery are also otherimportant structures involved in making of vitap marma. If these structures are cut they,willlead to impotency (prof. s.p. Tiwgri)s.7. f{eq 3ryd tiersr a EIqnT + ftq Rerd 6}dr Bt ErE Frg q.Drc oT ard Brg-eer err$q +1 Eft; * qgi €rg wger war d Spermatic fascia, vas deferens,pampiniform plexus, ilioinguinal nerve, superficial inguinal ring fr * q6i qg +f,S r{qr 3rf}rn-d ffi Ba (Dr. R.B. Shukla) Vitapa marma is the snayu marma and it consists of spermatic cord, whichleads to impotency in trauma. Here we have to consider spermatic cord with itscoverings. Thise are internal spermatic fascia,cremasteric facia encloses some striatedmuscular fasciculi constitute the cremaster and are continuos with the obliques internusabdominis. External spermatic fascia - is a thin fibrous stratum continuous superiorlywith the aponeurosis of the obliquus externus abdominis. These structures can beconsidered ur rnuy, (Grays Anatomy, 36th Ed., Page 1418) In females the trauma results in mahayoni. There is no retention of spenn as vault isbroader. Trauma also results in cutting of the fibres of round ligament which resultsin retroversion of uterus . This is one of the causes of sterility. (Dr. R.B. Gogate & Dr. Mukund Erande) Vas deferens, ilio inguinal nerye and vessels. (Prof. J.N. Mishra) This marma is a snayu mafina. According to the effects of marmaghata it is vaikalyakara. The area of its extent is about one angula, and it lies between gtoin (vankshana) and testis (wishana). Some scientists argue that since testes (vrishana) are not available in female body the presence of vitapa -**u is doubtful. This is a grossly mistaken interpretation. Vitapa manna is very much present in female body, rather it is having a more important need to significance. Similar to testes (vrishana), muscles of external genitalia (labia majora) be-considered. The manna will be between these structures in females The site and one angula extent of the marma indicate the spot to be near inguinal canal. In case of male, thi-s is the area where superficial inguinal ring, spermatic cord nerve are consisting of spermatic fascia, vas deferens, pampiniform plexus and ilioinguinal 5l
  • present. This marma is of vaikalyakara type causing shandhata and pain. The trauma willlead to rupture (cut) of the cord structure and will lead to accidental vasectomy preventingthe passage of sperms from testis to urethra. Absence of sperms in semen will naturally leadto impotency. Trauma to the associated nerves will cause pain and impaired pampiniformplexus that will lead to swelling and thereby vikalata. In case of females, in this area round ligament of uterus is present. Round ligament isresponsible for maintaining anteversion of uterus. Cutting the round ligament will lead toretroversion, which is a common cause of sterility in females (?). Injury to other adjacentnerves will cause pain and vikalata. Surgeons have made use of the knowledge of marma vigyan for preventing seriouscomplications during labor. In case of cephalopelvic disproportion, labor leads to vaginal teari.e. vitapa bheda. Vitapa bheda is a marmaghata that leads to complications as explained inmarmaghata. To avoid these complications during such labor, vitapa chheda (episiotomy) isdone in which a cut is made avoiding marna area, so that additional passage for deliveringthe fetus is created. Vitapa is said to be a snayu manna. The organs present include nerves, a cordlikestructure and even veins. None of these is a snayu. Then how does one explain the structureas snayu is a logical question. All these structures cause the effects but technical explanationof snayu may not be available. All these structures must be considered to be responsible tocause complications and must be considered as snayu with limited understanding of themarmaghata lakshanas. If the explanation available in Ayurvedic literature and the existing organs, effects,extent etc are taken into consideratibn vitapa is one of the few marmas where all theexplanation in the books and actual anatomy match. (Prof. Vijay V. Doiphode) tueq nd i sea fr s6a ?ftrr*r €* gffi *%""fft.;ffi,isi"ouy The spermatic cord itself is a rope like structure and is a snayu. It is a supportive andholding structure to the vasa differentia. Spermatic fascia is also the structure involved in thismarma. These structures suggest us to accept it as a snayu marma. (Prof. S.P. Tiwari) Mostly spermatic fascia. (Dr. ICB. Sudhi Kumar)3.8. Vitap marm& lies between vankshana and vrishana while kakshadhar marma liesin between vaksha and kaksha. How can we correlate that marmaghat on both marmasleads to same disease (shandhya and alpa shukrata) as their positions are different? qa11 ,1a1opgqsrffi ffiiqer:Fer*de+ o€rqs, afue ffi a r (g err orz+)frqrrT: (Dr. Shweta) It may traumatize the milk line which may result in impotency (Dr. R.B. Gogate & Dr. Mukund Erande) 52
  • Kakshadhar marmaghat does not produce the same disease; rather it is disputed andstill needs explanation. Vitap produces shandya and alpashukrata and kakshadar producespakshaghata (Sh. Sha. 6 I 3 l -32) (Prof. J.N. Mishra) Kakshadhar marma is situated in the chest in the vicinity of lohitaksha near thearmpit. Anatomical structure in the region would be brachial plexus with auxiliny artery.Injury leads to paralysis, wasting of small muscles of hand with sensory loss. Even duringanesthesia over stretching of limb may cause damage to circumflex nerve, resulting intoparalysis. Vitap marma is situated in the fold of thigh towards scrotum. The correspondinganatomical structures are superficial inguinal ring and its contents such as ilioinguinal nerve,genitofemoral nerve and spermatic cord. Injury to these structures may cause impotency dueto blockage of vas deferens. Inadvertent damage to testicular artery may result in testicularatrophy. The symptomatology of trauma in these two marmas can be accepted as similar. Inmy view it seems to be quoted only to compare the counter location in upper and lowerextremities for description. (Dr. V.S. Patil) According to Sushrut kakshadhara marma is a snayu marma while according toAshtangahriday it is a sira marma. It is one angula in measurement and present betweenvaksha (pectoral region) and kaksha (axilla). The injury of brachial plexus will lead tomuscular weakness. This vikalata due to muscle weakness is justified by trauma to thenerves. It is nowhere mentioned that marmaghata of kakshadhara manna causes shandhataand alpla shukrata. Therefore, no explanation is needed. The comparison is only as far as site is concemed. However, the results ofmarmaghata are entirely different and can be explained considering the anatomy at the site. (Prof. Vijay V. Doiphode) In the case of kakshadhara, Acharya has said- ftelwa-eg o€ilelt e€rreriT: IThere is no shandatva or alpa shukrata in the case of kakshadhara abhighata. (Prof. M. Dinakara Sarma) Different symptomatology is presented under kakshadhara marma. Sushrut hasreferred pakshaghat with kakshadhar 6€relt qenqrcr,r (E. elr. orz+) There is no similarity between two. (Prof. S.P. Tiwari) In Sanskrit nomenclature it is possible to use a term to describe different condition indifferent context. In Ashtangahridaya symptom of kakshadhara injury is kunitva. Hence, itshould be understood accordingly. (Dr. K.B. Sudhi Kumar)s.g. EF€ qrs M frsrrdr B fu gqur 3f,qrrd qs 3rrErr-T* d-s d{ur H€er fi-grffi B I fu-{ aft er 3rdqq +} trd * oq fr r*srg afi tr6-qr rrqr I g€ttFr tnrntFr{Er d s-+ar Ea (Dr. R.B. Shukla) 53
  • Trauma on testes neither produces non-compensatory nor compensatory loss oftissue (Prof JN Mishra) after a blow or injury cause As per definition, marmas are spots on the !99y, whichdeath or severe pain. Thlse are the vitar spots on different parts of the body. According to severe pain can be considered as athis definition, a blow on scrotum or the eye ball causingmaffna. considering the 107 spots mentioned as marrnas all are not so frequently exposed to procedures.such trauma (or blowi it are likery to be _injured during different surgical "isushrut has advocated that these spots stroula be protected; otherwise serious complicationswill arise. Scrotum is an area which is not so much exposed for surgical complicatiols andhence not included in the list of marmani however considering the marma definition as**ittg severe pain, it should be considered as amarma (Prof. VijaY V. DoiPhode) limb equally They knew that there Acharya has considered the upper limb and lower arteries and veins that served the functions; andwas almost equal number of bones, muscles, vitapa andany injury to **u could cause similar damage. However, while considering context should be considered askakshadhara the word shandata in kaksadharaincapacitating and this means that due to the injury the limb becomes incapacitated (Dr. C. Suresh Kumar) qrar f.rdq 4d i r+asa rtrqErTe # spermatic cord testes epididymus fta-qr qrfrry erof M Dinakara sarma) srotas, whigh also. has got greater Vrishanas are the srotomulas of shukravaha be because of this reason it has not been repeated importance like maJa- H"n"., it might (Dr. K.B. Sudhi Kumar) never a cause of death Pain may be Pain is a subjective phenomenon and is also the already is a cardiac case But in that case predisposing factor for death if the patient (testes) arrest and not the pain This is why wishana actual cause of O"utf, *ill be the ,*iiu. themselves are not defined u* -ur-uiy a"rh*t Also the pain is not chronic, but is always to be named.even as rujakar mafma of a short duration. so vrishana is not considered (Prof. S.P Tiwari) 54
  • CHAPTER - IV MARMA OF TRUNK4.1. What is exact location of guda marma (Ref. Su. Sha. 6/6)? Guda marma is mamsamarma (Sushrut) and dhamani marma (Vagbhat). It is a sadyapranhar marma and isof four angul pramana. But when, we see at anal canal and rectum it is longer than it.Then what is exact location of guda marma? (Dr. K.D. Sathe) Measurement of guda is 4 angulis or it can be said that the area of pravahani, visarjaniand sanvarani is guda which is four anguli. Guda marma is situated at the anus. Its pramana is four anguli. Anguli pramanashould be considered as diameter of peripheral circle. According to following sutra, it isclear.d5r ftei oraratur art-ofr r "r€r:9Tor6{t But sometimes we should consider ptamana as periphery as well as depth also. Herewe have to consider guda marma is 4 angula deep and 4 angula diameter also. Thereforeanatomical structure should be as follows - anal canal, its internal structure, sphincter aniexternus and internus muscles -levator ani, its part pubo-rectalis muscle, anococcygealbody, membranous part of urethra, plexus of rectal vessels and pelvic neryes (from GraysAnatomy). Guda is an area, which covers pravahini, visarjani and samvarani. It is 4 angulaapproximately. (Su.Ni.Dalhan 2 o 16) (Dr. R.B. Gogate & Dr. Mukund Erande) Guda maffna is attached to sthulantra (large intestine) and serves as the passage ofvata (flatus) and mala (feces). The rectum begins as a continuation of the sigmoid colon at 3d sacral vertebra andends by becoming continuous with the anal canal at the anorectal junction. The junction lies2 to 3 cm in front of and a little below the tip of coccyx. The rectum is 12 cm long. Upperpart has diameter of 4 cm and the length of anal canal is 3.8 cm. It extends from the anorectaljunction to the anus. Considering modern science guda marma includes whole of the anal canal and lowerpart of rectum. The size of guda marrna, as described by Sushrut and Vagbhat, is about thesize of ones folded palm. In modern anatomy boundaries of this area can be appreciated as - o Anterior - penineal body o Posterior - tip of coccyx o On each side - ischial tuberosity Thus the area covered by the lines joining these points can be assumed as area of guda marma. (Prof. D.G. Thatte) Anal canal and anus measure above 7.8 cms i.e., roughly four fingers. (Prof. J.N. Mishra) Situation of this maffna is in the anorectal region through which the flatus and feces expelled. Injury to this marma is fatal. The word guda is derived from the root gu 55
  • which means shabda and also gu purishotsarge. Immediate death is due to shock bystimulation of the nerve plexus and the nerves supplying the muscle in the anal region. Charak has desiribed two types of guda namely uttara guda and adhara guda.Chakrapanidatta, in his commentary, has commented that uttara guda is a place where fecesare collected, while adhara guda expels it Anal canal, as per Grays Anatomy, is 3.5 cm. Sushrut says that this is 4 anguli inextent, which means the lower part of the intestines were also taken into consideration. Thisis the area, where the filum terminale ends. So, any injury to this will lead to shock and laterto death. (Dr. C. Suresh Kumar) G.gda marrna is 4 angula, which is visualized by arsho yantra. Anal canal and someportion of lower and middle houstean valves, there is a thick wall in the lower part of theiectum and while the upper part is thinner. This junction can be identified during perabdomen operation of rectal prolapse. We can consider up to that area. (Dr. K.B. Sudhi Kumar) The location and parivistar (measurement) of a marrna are directed on body surface,not in the cavities. Under guda marma the perineum centered with anus is called as gudamailna and it is extensive equal to a four anguli pftImana or svapanitala kunchita. (Prof. S .P. Tiwari) Guda marna is anatomically sthulantra pratibadha. Prominent structures present inthis area are anal canal, rectum, anal sphincters, pelvic diaphragm, patarectal fossae, rectalpouches, peritoneal folds and its contents. Out of these structures, blood vessels seem to be*ot. uiiut as they form portosystemic anastomosis. Bony or cartilaginous support is notavailable, against which lhe blood vessels can be compressed to arrest the bleeding; loosetissues and ipaces are present around them. Possibility of perforation due to injrnies throughthe walls into surrouniing peritoneal spaces is also important. Measurement of rectum ismore than that of marma. Hence, the observations of two Acharyas might be different. Hemorrhoids, fistulae, tumors are chronic manifestations. Hence, they usually do not cause sudden death. However, injury to the sites of these diseases (when already manifest) may lead to sudden death as a result of hemorrhage, shock, sepsis etc. There are no reported incidences of guda kshata during the karma basti and anatomical basis also doei not support any kind of kshata in this regard. In case of errors (as basti vyapat, kriya lopa) in the procedures basti may cause kshata. In case of Uuil hom injuries it is important to note which structures are involved and possibilities of injury how much severe and to what extent they are injured. There are quite etc. Each injury should be studied and f"n"ou,lng gluteal muscles, sacrotuberous ligament analysed anatomically. (Dr. u. Govind Raju) 4.2. Sushrut has considered guda as mamsa marma and any injury to it will cause sudden death, but vaghbat has considered it as dhamani marma and its injury may cause bleeding with sound and the individual may become unconscious. why is this difference? (Ref: Su. Sha. 6th chapter & A.H. Sha. 4th chapter). (Dr. ViPin P. C.) 56
  • Guda is a mamsa manna as it is soft and having a lot of muscular tissue. At the sametime it is also rich in blood suppiy and a site of porto-systemic shunt, which is a vital part ofportal circulation. So that both Sushrut and Vagbhat seem to be correct from theirperspectives. (Dr.R.B. Gogate & Dr. MukundErande) No doubt Sushrut has considered guda as mamsa marma and an injury to it can causesudden death. This observation of Sushrut appears to be partially correct because injury tothe muscles around the guda may damage sympathetic (L1 andL2) and parasympathetic (S2,53 and 54) nerve through the superior rectal and inferior mesenteric hypoglossal plexuses. Sympathetic nerves are vasoconstrictor, inhibitory to the rectal musculature andmotor to the internal sphincter. Parasympathetic nerves are motor to the musculature of therectum and inhibitory to the internal sphincter. Any injury to this area may cause severe painand shock leading to death. Vagbhats observation that the guda is dhamani marrna and injury to it may causebleeding leading to unconsciousness and death is also true because there may be profusebleeding from the rich venous plexuses round the guda; and artery supplying superior rectalartery is a direct continuation of inferior mesenteric artery (systemic artery). An injury to itmay cause profuse bleeding leading to shock and death. (Prof. D.G. Thatte) If the injury is not major, it might end up in bleeding and the patient might loose hisconsciousness. If the injury is major, then apart from bleeding the patient can developneurological shock and sometimes injury can turn fatal. . The consideration of guda as mamsa maffna by Sushrut and as dhamani marma byVagbhat shows the incorporation of the contemporary concepts. (Dr. C. Suresh Kumar) Anatomically guda is mamsa bahulya. Sudden death may occur due to neurogenicshock. It also produces bleeding. The guda is much more complex structure and any bleedingis very difficult to stop, so for emphasizing the clinical importance Vagbhat might haveincluded it in dhamani marma. (Dr. K.B. Sudhi Kumar) Sushrut has considered guda as mamsa marma while Vagbhat has considered it asdhamani manna. In my opinion both the observations made in those days are correct becauseeven today the common complications of injuries of the anal region are l.sepsis and 2.hemorrhage. I give you certain references to support. "The rectal or anal canal may be injured in a number of ways as by falling in a sittingpostrne on a spiked or blunt pointed object, the upturned leg of a chair, bundle of broom, forkor a broken stick, all result in anal injury. Also by fetal head during child birth, enemanozzle, during sigmoidscopy usually in the patients of ulcerative proctolitis or amoebicdysentery. Sigmoidoscopy performed under general anesthesia is especially dangerous. Splitperineum is a lacerated wound of perineum involving the anal carral" (Love and Bailey,1e81). Any definite pattern of the injrlry has not been assessed but the cause of death isgenerally hemorrhage or sepsis. 57
  • "Wounds of the colon and anorectal region are one of the most severe groups ofinjuries confronting the combat surgeon in Vietnam. After control of the hemorrhage andshock the greatest mortality in war wound resulted from sepsis." (Ganchron M I levesson,G S and M C Nareore, J T surgical management of traumatic injuries of the colon andrectum, 1970) A report of 26 patients comprising of injury to the anus and extra peritoneal rectumrevealed that injuries varied from isolated damage of rectum to massive perineal injuries withloss of perineal soft tissue. Sigmoid colostomy was performed to divert the fecal stream andto prevent either continued functions, and distension of damaged rectum or continued soilageof massive perineal wounds. In these cases 8 patients developed sepsis. Two patients hadpost operative oozing. One patient developed bleeding from stress ulcer. Five patients died-folto*itrg surgery uod t*o died of sepsis. Sepsis was by far the commonest problem (56%) ofall complications regardless of the site of injury or method of repair. (Gandrow et al 1970) It proves that both the observations made by Sushrut and Vagbhat are correct.Because of the sepsis cornmon in soft tissue injury of the rectum Sushrut has described it asmamsa marma. The second most common complication in anorectal injuries is thehemorrhage; this is why vagbhat might have considered it as dhamatt *ut*ui*rof. Jyotsna)A.3.1tis said that any injury to guda quickly leads to the death. How can we justify thisin hemorrhoids, fistula, cancer of the rectum etc? (Dr. R. C. Satish Kumar) Injury to guda quickly leads to death. It is not a completely correct statement. Onlysevere trauma leads to death. During operative procedures patient is under anesthesia,therefore, operative procedure is possible. But death is very common in abdomino perinealdissection for cancer rectum. In the surgical procedures on rectum, if the suture is slipped due to infection orvaidyapramada there may be excessive bleeding. I have seen a patients death due tounconirolled bleeding. In the cases of acute fissure in ano, forceful PR exam orinstrumentation (procloscopy etc.) also results in shock. This is why the PR exam iscontraindicated in fissure in ano of acute variety. In abdomino-perineal resections for cancerrectum, it is a very common incidence that the patient goes in shock when we pull out therectum. Even in rectal prolapse, sudden manual reposition leads to shock. In the 4th stage of general anesthesia, there is dilatation of rectaf sphincter (Murchha4th Stage). (Dr. R.B. Gogate & Dr. Mukund Erande) The answer of this question can be clearly understood by knowing the theories ofvasovagal shock or hypovolemic shock Rtt t6. three conditions are basically primary pathology but anyattempt todisseminate them by manual or surgical maneuvering can easily be done in same patient. The cases of external injury in anal region are not so common. According to Sushrut,injury to guda marma results in instant death. This can be possible under two conditions -i) Vasovagal attack: This is a primary neurogenic shock characterized by sudden stoppage of heartfollowing reflex st-imulation of vagus nerve endings. It causes circulatory failure leading toprofounJfall in blood pressure. Such death occurs with dramatic suddenness within seconds 58
  • or at the most in a few minutes. Consciousness is lost usually instantaneously on theseoccasions and death follows soon.ii) Hypovolemic shock: An injury to anal region may cause severe hemorrhage and reduction in bloodvolume, which may lead to death. (Prof. D.G. Thatte) Hemorroides, fistula, cancer of the rectum are not related to trauma, whereas marmais next face of trauma. (Prof. J.N. Mishra) Recent advancements have made these diseases curable or manageable in an easierway than which was prescribed in the Samhita period. (Dr. C. Suresh Kumar) Hemorrhoids, fistulae, cancer of the rectum all are nija vyadhis. Guda abhighat isagantuj in orgin. These should not be confused. However, as Charak says we should becautious to prevent and treat diseases of this region, because they bring a lot of discomfort inlife. (Dr. K.B. Sudhi Kumar) The cancer of rectum and fistula-in-ano are not the injuries, but are the diseases.When hemorrhoids bleed they can be put under injury. A massive, regularly bleeding pilemay lead to death in due course because of hemorrhagic anemia, like a kalantar pranaharmarma. Sushrut has said,that sadyoapranahar marma may get changed into kalantar pranaharmarrna with mild type of injury. Sometimes by the mistake of surgeon during operation ofpiles patient dies. This is because of the guda marmabhighat. (Prof. S.P. Tiwari)4.4.In AshtanghridaY, guda is described as dhamani marama but anatomically it iscomposed more of mamsa and a very little rakta. Is there any specific reason to sayguda as dhamani marma? (Dr. Pranita S. Joshi Deshmukh) predominantly it is a muscular part. Sphincture ani internus and externus as well aslevator ani muscles aie related to it, prominent gluteal muscles cover it, therefore Sushrut hasmentioned it as mamsa marrna, but its viddha lakshana is given as sudden death. Deathoccurs due to damage of blood vessel plexus, portosystemic shunt and nerve plexus whichare present around there.and in the wall of anal canal. Therefore, Vagbhat has mentioned it asdhamani marrna. (Dr. R.B. Gogate & Dr. Muhund Erande) As is known to all guda marma has both rich blood supply (vessels) and mamsa.Therefore Sushrut has considered it as mamsa marma while Vagbhat has considered it asdhamani marna.Muscles around guda are- o Levator ani o . Internal sphincter 59
  • o External sPhincter o Longitudinal muscle laYer and sphincters o conjoint longitudinal coat between the internal and external analDhamani and sira (vessels) around guda are- o Superior rectal artery and its branches . Middle rectal arterY o Inferior rectal artety and its branches . Sacral arterY o External rectal venous Plexus o Superior rectal vein o Middle rectal vein o Inferior rectal vein o Perianal vein marma separately He hasPlease remember that Sushrut has never mentioned of dhamani marma Vagbhat has mentionedtaken all veins and arteries under one heading i.e. siradhamani mafina seParatelY. profuse bleeding preceded Any trauma to these vessels on guda malma can cause toby unconsciousness and finally death (prof. D.G. Thatte) marma Vagbhat has taken into It should be infened that while considering dhamani have prompted him to consider allaccount certain openings or tubular structures thaimightthese into dhamani manna (Dr. c. suresh Kumar) because of porta- It is seen that in bleeding piles there is the discharge of pure. blood vagbhats opinion of considering guda cavar anastomosis. This may be the cause behind maflna as a dhamani marma (prof. s .p. Tiwari) Please refer to the rePlY No 42 (Prof. Jyotsna) structure and any bleeding- is As discussed earlier guda is anatomically a complex importance Vagbhat might have included very difficult to stop, ;; f"t eirphasizing itt ttini.ut it in dhamani manna (Dr. K.B. Sudhi Kumar) marma. Is there any chance of guda 4.5. Guda is said to be one of the pranadhisthan marma kshata during karmabasti (30 bastis)? (Dr. Santosh N. Belavadi) instrumentation may cause careful basti karma will never lead to death. A forceful death (Dr RB Gogate & Dr Mukund Erande) 60
  • In any basti of guda there is direction to be aware of marma. Guda is definitely a seatof life being sadyahpranahar and wrongful use of basti may produce ghatak parinamdepending upon intensity and site. (Prof. J.N. Mishra) Guda kshata can occur if faulty basti netra is used in basti, but the chances ofmarmabhi ghata ar e remote. (Dr. V.S. Patil) No, when performed in a proper way there should not be any kshat. (Dr. C. Suresh Kumar) No doubt in any type of basti there may be damage to guda, if it is not administered ina properway. For that, Charak has explained in Netrabasti Vyapat Siddhi adhyaya. (Prof. M. Dinakara Sarma) Basti vyapad is possible always if we are at fault in any single point, even a tikshnadravya can affect the soft membrane of guda. (Dr. K.B. Sudhi Kumar)4.6. In many patients, bull horn injury (which injures guda) does not cause suddendeath. Then why is guda sadhya-pranhara marma? (Dr. Pranita S. Joshi Deshmukh) It indicates that the trauma is not exactly at the site of marma. (Dr. R.B. Gogate & Dr. Mukund Erande) Please re{er to the repl,v No. 4.1 to know the detail of guda manna. I have neither confronted nor ever seen a case ofbull horn injury. Therefore the causeof sudden death could not be ascertained due to bull horn. The questioner is requested toauthentically quote any such case practically seen or ever.reported in a journal, book orpaper. Though it is often reported that even while doing rectal examination by finger, oftensudden death occurs. No doubt it has been observed that while doing rectal examination by a welllubricated finger and after proper counseling or consoling the patient before digitalexamination the patient may feel little pain or trouble. It was observed that pulse rateincreased during per rectum examination due to severe pain (in patients suffering fromfissure in ano). Increased pulse rate, sweating and in some cases syncope may also occur.Therefore it is felt that even minor trauma to rectal tissue can cause syncope and even provefetal. This is a type of vasovagal attack. When patient suffering from inflamed hemorrhoids is asked to strain to see the pilemasses excessive blood may gush out producing unconsciousness due to hypovolemic shockand may also lead to death. Therefore there is all chance of instant death. If by chance a bullhorn is pushed through the anus to the anal canal, as a criminal act, may cause death. Authorhimself has witnessed that during ragging in professional institutions in the form of torture byputting head of the femur into the anus and then pushed inside and that has led to vasovagalshock and death (prof. D.G. Thatte) 6l
  • It is wrong to say that bull horn injury does not cause sudden death. The possibility ofshock and peritonitis cannot be ruled out. (prof. J.N. Mishra) Bull hom injury to guda may result in bleeding. However, if horn forcibly enters theanal canal there is a possiUiiity of shock due to over stretching of sphincters. (Dr. V.S. Patil) That shows the lesser gravity of the extent of the injury. This is the area where thef,rlum terminale ends. So any injurv to this point will lead to shock %fU:j]::l Kumar) Sadyopranaharafra may be due to neurorgenic shock or uncontrolled bleeding. Wheninju.y is m.rch more extensive it can cause peritonitis. Now various measures are available tocontrol the infection, bleeding and to maintain heart pumping capacity. Hence, during ancientperiod it might be causing death more often than now. (Dr.K.B. Sudhi Kumar) Bull horn ittjnry to guda marma death in some though not in all does causeindividuals with such injury. This is why guda maffna is said to be sadyopranahar marrna.Whether the person would survive or die after a lapse of time depends on mild or moderatetype of injury. (Prof. S .P. Tiwari)4.7. ln Ayurveda basti (bladder) is sadyah pranhar marma. Please explain whichspecific disease according to modern medicine would be sadyah pranahar. (Dr. Nimesh. G. Kachhiapatel) It becomes sadyopranahar during the perineal approach for ashmari when bastiavarana cuts oPen at two places or at savarana pradesh (i. e. peritoneal lining). This is avaidya pramada. Sudden decompression of urine in basti jathara sometimes leads to death due tosevere bleeding. eB *difr{ ffir (Dr. R.B. Gogate & Dr. Mukund Erande) The questioner has considered basti as bladder. It is to be noted here that brain, heartand kidney are the most important and vital organs, which need utmost care. They are thetarget organs of many diseases like hypertension and diabetes mellitus. In Ayurveda "o-*bnthe term basti has always remained controversial. This term i.e. basti is mostly used forenema. In panchkarma therapy basti term is used but now they use the term netrabasti forurinary bladder. There is a specific term for urinary bladder in Ayurveda i.e. mustrashaya andnot basti. Therefore basti term should not be used any more for bladder only but for wholeurinary system i.e. kidney, ureter, bladder and urethra. Any injury or trauma, whether it is.*og.nonr or endogenous, causes damage to the renal parenchyma leading ultimately to fuilure and death. Acute renal failure or uninary obstruction at any site of urinary tract."nu=li.e ureter, urinary bladder or urethra may cause uremia leading to death 62
  • The clinical importance of basti has already been discussed in the answer to questionNo. 1.2 (Prof. D.G. Thatte) Basti is a manna and is sadyahpranahar in relation to trauma, not the disease. (Prof. J.N. Mishra) Intra- or extra-peritoneal rupture of basti (blader) may result into peritonitis. It can beaccepted as basti marmabhighata. (Dr. V.S. Patil) No such explanation can be given as such. (Dr. C. Suresh Kumar) There is a lot of difference between disease and injury. In the context of marma it hasto be related with inj.ry but not disease as per Sushrut, because he has considered it on injurybasis. But as per Charak the concept is based on disease. There he has explained about someof the diseases related to concerned marma and in relation to basti he has not mentioned allthe diseases related to it. (Prof. M. Dinakara Sarma) We have alreadydiscussed it in above answer. Sometimes retention of urine can alsocause shock. We should keep in mind that marrna concept is mostly for injury and agantuj medicalvyadhi or may be for surgical precaution. In aspect, only possible things arepievention and treatment based on samprapti vighatan. So, a disease or nija vyadhi is a resultbf long process of completion of the total samprapti and it may not be the same as thesamprapti of an abhighata. However, many simple diseases can cause death. For example ifbteeiing is not properly managed or proper anti infective precautions are not taken simplehemorrhoid can be fatal due to septic or hypovolemic shock. (Dr. K.B. Sudhi Kumar) Basti marma is called as sadyopranahar. Any injury causing serious urinaryobstruction or rupture of bladder attracts infection and then causes peritonitis or nephritis thatmay cause death. Incurable renal infections and kidney failure may lead to death. (Prof. S.P. Tiwari) Basti is considered as sadyopranahar marma. By the overall description found in theclassics we can consider it as urinary bladder. In the marma sharira the problem arises in the understanding of the aghat parinambecause the types of injuries which can cause such symptoms are not described. I got areference from a study, which is cited here: ..Rupture of the bladder may be produced generally at the posterior and upper surfaceby blows, crushes or kicks on the hypogastric region especially when it is distended withurine. Sometimes very slight violence may rupture the bladder without any external sign of (usuallyinj,rry. Rupture 1;1uy ulro or..tt from fall, sharp fragments of fractured pelvic bones p"ritoneal) or a sharp weapon penelrating through the vagina or rectum (Modi N. J.)."rttu Modi reports the case on ttt" I lth nov. 1923. *A woman was run over by bullock cartand died immediately. There was no external mark of injury to the abdominal wall, but there 63
  • was extravasation of blood in the muscles of the abdomen across its lower part above thepubis with rupture of the bladder in its upper part and fracture of the pubis and iliac bones." Death in rupture of bladder may occur suddenly from shock but usually occurs inthree to seven days from peritonitis due to the extravasation of urine in the peritoneal cavityor from suppuration due to the urine being extravasated in to the surrounding tissue if thebladder is ruptured at its extra peritoneal portion. (Prof. Jyotsna)4.8. The anguli parimana of nabhi marma has been described as four anguli byDalhana (Nibandhasangraha tika Su. Sha. 6/39). The same has been quoted in the casesof nila, manya, ashta matruka, guda, shrungatak, simant marmas. Should thisdimension be considered as - a. Width of the area where marma is located. b. Depth of the area of marma.Nabhi pradesh, when dissected leads to many structures layer by layer e.g. a) Paraumbilical vein forming a site for portacaval anastomosis. b) Abdominal aorta (its bifurcation into, common iliac arteries) (Dr. Swati S. Bedekar) It is the width of the manna from umbilicus. Depth will always change dependingupon krushata and sthulata (Dr. R.B. Gogate & Dr. Mukund Erande) The question raised by scholar is important because the anatomical structure around amafina makes it sadyah, kalantar or vishalyaghna etc. Related structures within the width ofthb marma, which may be vital for life, might be important during surgical intervention ForexampleD Th; arch of the aorta and pulmonary trunk have a very important relation than the arch ofaorta and left main bronchus.ii) Esophagus, which is related to the left atrium of heart. Though it is not situated in itsbroader area but at a deeper level they are close neighbors. From above example, the constitution of a malma in relation to width and depth isequally irnportant. - As far as the nabhi marrna is concerned a clinician must learn the relative anatomy ofthe structures in the periphery of it or at deeper levels from layer to layer. The important structures around the nabhi should be taken into consideration when we talk of anguli praman in width. But when anguli praman is used in sense of depth i.e. from superficial to deepbelow the umbilicus theie is superfici al fatty layer called as fascia camper and at the deeperlevel is membranous layer known as fascia scarpa. (Prof. D.G. Thatte) Width of area. (Prof. J.N. Mishra) Extent of marmasthan of a particular maffna is taken on the basis of width in terms of anguli pramana. However, force of trauma may be transmitted to the deeper structures underneath the area. Also see answers to cluestions ncl. 4.9 tp 4.12. (Dr. V.S. Patit) 64
  • . Width of the area where marma is located. o Depth of the area of marma.Nabhi pradesh, when dissected, shows many structures layer by layer e.g. o Periumbilical vein forming a site for portacaval anastomosis. . Abdominal aorta (its bifurcation into common iliac arteries)Mainly the width of the area and in a few cases (where it is involved) the depth of thestructure also should be considered. (Dr. C. Suresh Kumar) The anguli parimana of nabhi marma has been described as four angulis by Dalhana.This dimension should be considered as width and depth of area where nabhi marma islocated. Nabhi is called siraprabhava considering the garbhavastha. The structures present atthe site of nabhi marma are superficially inferior epigastric vessels and rectus abdominismuscle; deeply grahani (agnisthan), agnyashaya, inferior vena cava and abdominal aorta.Injury to these structures will cause death. In case of nila, manya, ashta matrika, guda, shringatak and Simanta the 4 angulidimension should be considered as length of area of marma. (Prof. Vijay V. Doiphode) The measurement of the marmas has to be considered on external surface area onlybut not the depth. It can be understood by the commentary of Dalhana on 22nd stanza,v,therehe explained as -3r* frra sr-ff+ ftrd ---- zrs c*eqef r (9. eTT. 6/22 trE s€q es-r) (Prof. M. Dinakara Sarma) It may be three dimensional, if the extent injury is much more and it will involvemany more structures (Dr. K.B. sudhi Kumar) Parivistar of marma refers to the width of area where marrna is located, and it is in theform of radial extension. Nabhi marma is not different in this regard. The depth andstructures in depth determine the mild, moderate or severe state of injuries (atividdha oralpaviddha). Paraumbilical veins are minor veins and are unlikely to cause death, where asabdominal aorta is avery important structure and it will lead to death, if ruptured. (Prof. S.P. Tiwari) Nabhi marma is located between pakvashaya and amash aya, andis sira prabhava. Itslocation need not be measured from the surface of the skin. Texts are not specific whether themeasurements are length, depth or width. Hence, suitabledirection can be adopted. Anystructures that are vital in nature at the level of umbilicus can be considered as nabhi marma.Vessels around the umbilicus, anterior abdominal wall muscles, aponeuroses, fibrous sheaths,peritoneum, ligaments, viscera (coils of intestine), mesenteric artery, testicular artery, aorta,inferior vena cava, renal vessels, nerve trunks and mesentery are some of these which arehaving vital importance. Blood vessels seem to be relatively more vital and on injury theymay lead to immediate death. (Dr. u. Govind Raju) 65
  • 4.9. Please explain how the nabhimarma is sadyahpranahar along with its structure ofmarma according to modern science. q€rarTer*de* frrsrqeror alffi:, a{rfr s* an"it --.-- r (g- en. 6/2s) (Dr. Kunal Lahare) The great vessels like abdominal aorta and venacava in the umbilical region arehaving high rate of fatal results in spite of surgical interventions. (Prof. J.N. Mishra) It is necessary to confirm which organ represents nabhi before studying itsmarabhighat lakshanas and their interpretations. Different authors have mentioned the termnabhi in different contexts. o Su. Utt. Chapters No. 40,42 & 50 o Su. Ni. Chapters No. 1,7 &9 o Su. Sha. Chapters No. 6 &7 . Cha. Chi. ChaptersNo. 5,17,18,20 &28 o Cha. Sha. Chapter No. 8 o A.H. Ni. Chapter No. 7 o M.N. & Madhukosha tika Chapter No. 26 o A.S. Sha. Chapters No. 2 to I & I 1.All the above references explain about the structure and functions of nabhi, its role insamprapti of various diseases, different treatment modalities etc. Considering theexplanations available from the references quoted above it is very difficult to single out anotg* that can be considered as nabhi. If we consider the explanation available from theabove references nabhi should have follovving signs and symptoms - o Should feel biting pain at the site before diarrhea (atisara) o Patient of hemorrhoids (arsha) should feel it in drawing and swollen when the disease becomes incurable. o Should be site of hikka. o Should feel pain around this area during vaman. o when there is collection of gas in stomach, the pain is felt around umbilicus. o Gulmas are present between nabhi and hriday. o Similarly baddhagudodar is present between these two ofgans. o Charak and Sushrut have included nabhi as one of the koshtanga while Vruddha Vagbhat has considered it as a pratyanga. o It is one of the pranaYatanas. o 24 dhamanis evolve from nabhi. o Nabhi is supposed to have mulasthana of 700 sirasWith the above information it is felt that following organs can be considered as nabhi. 1) Thetopographic umbillicus. 2) Diaphragm. 3) Heart 4) Pancreas 5) Spinal cord 6) Duodenum However, since heart and duodenum are considered as separate koshtanga they cannot be considered as nabhi. Thus we can consider nabhi externally as umbillicus (a topographic 66
  • landmark) and internally as pancreas, diaphragm and duodenum. Pakvashaya (largeintestine), hepatic flexure and splenic flexure are below diaphragm and above umbillicus. The transverse colon flexes just below the umbilicus. Therefore these organs can beconsidered in context of nabhi. However, pittasthan is between amashay and pakvashaya,which is nothing else but part of small intestine. Since nabhi is at a higher level thanpakvashaya, any part of pakvashaya cannot be considered as nabhi and hence exceptpun"r"ur and diaphragm no other organ can be considered as nabhi. When we consider nabhi as origin of siras, the question arises whether they arevessels or nerves? There is no structure like conglomerations of arteries or veins around this area but there are some nerve plexuses such as phrenic, splenic, suprarenal, hepatic, left gastric, renal etc. Since nabhi is considered as one of the koshthangas it may not be correct to consider these plexuses to be nabhi. .herefore The mesentery is viscous, has arteries, veins and nerves as well. 1 it is thought that mesentery be considered as nabhi. The hiccougtr is due to irritation of diaphragm and since nabhi is seat of hikka, diaphragm can be considered as nabhi. To sum up, considering all the above controversies, it is not possible to name a single organ as nabhi. With reference to topography, nabhi should be considered as umbilicus and with reference to marma, nabhi will include the following organs (naval) o Diaphragm. o Duodenum. . Pancreas o Mesentery . Some nerve plexuses. If the o.gun, referred above are considered to be nabhi, the explanation of nabhi assadyoapranaharamanna and one of the trimarmas can be understood. It is also necessary to consider other organs like kidneys, supraenals which may getinjured during marmaghata of nabhimarma. Then only the serious complications ofmarmaghata ofnabhi could be understood. (Prof. Vijay V. DoiPhode) Nabhi is a sira maffna. it is situated between amashaya and pakvashaya. The artery or abdominal organs such as duodenum, transverse colon, small intestine, celiac blunt or ,uperio, meseiteric artery are situated behind the umbilical region. Trauma, whether puncturing, may rupture the blood vessels. Extravasation of blood results in collection of blood in abdominal carrity leading to generalized peritonitis and death. Blunt trau|a is as a whole, is known to cause hematoma in mesentety du. to impact of trauma. Abdomen, vulnerable since all vital organs are situated in it (Dr. V.S. Patil) Shock may be the reason. It may be neurogenic or hemorrhagic. Simple injury will not cause sudden death. However, if the abdominal aorta is disrupted then it can cause instant death due to shock and hemorrhage. The deep injury may also cause reflex stoppage of the heart. (Dr C Suresh Kumar) Nabhi is situated in the medial plane of the anterior abdominal wall related to linea alba, which is tendinous median raphe formed by the union of aponeuroses of anterior 67
  • abdominal wall muscles. In this plane there are no vessels or nerves, and is the saf6 plane tobe taken for any surgical procedures. But it has a post operation complication i.e., due to lackof blood vessels it will not heal properly, which may lead to incisional hemia. Due to thisinjury over nabhi becomes lethal to the life of the patient. (Prof. M. Dinakara Sarma) Sadyah pranaharatva due to injury in nabhi may be due to neurogenic shock or septicshock (mostly if peritoneum is involved). If it is not treated on emergency basis or properinfection control is not done it can be fatal very early. (Dr. K.B. Sudhi Kumar)4.10. Which of the organs included in nabhi causes the instant death? (Dr. Suvarna P. Nidagundi) Great vessels like abdominal aorta and venacava of umbilical region. (Prof. J.N. Mishra) Nabhi : a wheel Nabhya: Centre part of a wheel Nah is the root word of nabhi which means Nah bandhane that which is attached,otherwise that which is detached only very late. Another meaning of nabhi is to burst, tear,break, destroy, hurt or injure. No organ is included in nabhi and it is nabhi alone. (Dr. C. Suresh Kumar) Among the organs of koshtha only hriday, basti and guda are taken as marmas. Butwith regards to nabhi miuma no specific organ is related and protrusion of abdominalcontents will be seen in injury to the nabhi marrna (prof. M. Dinakara sarma) No specific organ can be correlated with nabhi marna. If we are considering thepathological aspects for an anatomical basis, many structures can be taken according to theintensity of injury i.e. it can involve many structures of the abdomen. (Dr. K.B. Sudhi Kumar)4.11. Why is nabhi called sadya pranahara marma? (Dr. Thakur Prasad Sahu) Since penetrating wounds are fatal, there is increase in frequency of GSI and splinterinjuries (Prof. J.N. Mishra) Fatality depends on the extent of injury. Death may be due to neurogenic shock andinj.rty to the abdominal aorta or even any principal vessel resulting in extensive bleeding atthe spot of injury. Considering external or gross anatomy of nabhi it is difficult todemonstrate its sadyopranaharatva. But as we are discussing marma no structure should beconsidered at the visible or gross anatomy of the suggesting structures name (as nabhi at theconcerned site of visible or gross anatomy). It is better to think in a possible trauma to that 68
  • point, which could even be a very extensive one. If we are discussing in the present scenariowe also should keep in mind that traumas were mostly due to warfare injury at that time orattack by animals; so we should have some modihcation of it. Our present concept shouldalso give a space to road traffic accidents, gunshot injuries etc. (Dr. K.B. Sudhi Kumar)4.12. IJLow do we justiff nabhi as sadhyopranahara marma on the basis of anatomicalknowledget ,Dr. Devendrappa Budi) It contains caput medusae, remnants of yolk sac, patent urachus and hepatic artery,Meckels diverticulum attached to umbilicus, and major structures like mesentery, aorta,IVC, common bile and pancreatic duct are there.The patient dies due to severe bleeding if the mesentery, aorta or IVC are injured. (Dr. R.B. Gogate & Dr. Mukund Erande) Yes, it is true that nabhi marma has been identified as sadyah pranahar marrna and islocated between pakvashay and amashay. It is also termed as sira manna with an area ofchaturangula. Apparently this description belongs to the fetal life, because of umblicalvessels. There are arteries and veins both of which play a vital role in fetal nutrition. Here theterm sira creates confusion because the terms artery and vein are just opposite. After birth there is no apparent relation between nabhi and blood vessels but there arecertain anatomical structures which lie in the abdomen behind nabhi. If the importantstructures are damaged death may occur due to shock. These important structures are - o On the surface of the anterior abdominal wall, there is a vestigeal scar known as umblicus or nabhi. o In normal position the scar can be marked anteriorly between third and fourth lumbar vertebrae. But in infants and persons with pendulous abdomen it is at the lower region. The umbilicus is a water shed point because above this level the lymph and venous blood flows are in upward direction while both these flows are downwards below this plane. These do not cross umbilical plane. . Skin around the umbilicus is supplied by Tl0 segment of the spinal cord. o The tributaries of the portal vein anastomose with systemic veins portocaval anastomosis. In portal hypertension these tributaries open up to join to form dilated veins from umbilicus and form caput medusae. However, the blood flow in the dilated veins is normal, and does not break the barrier of the water shed line. Keeping this anatomy in view, any trauma which occurs in umbilicus either by strokeor by a penetrating weapon may cause hemonhage or severe pain and even death. Other than above anatomical facts the clinical importance of nabhi (umbilicus) can bementioned or understood by following points- o Remnants of the vitellointestinal duct may form a tumor of the umbilicus (raspbeny red tumor, or cherry red tumor). Persistence of a patent vitellointestinal duct results in a fecal fistula of the umbilicus. o Persistence of the urachus may form a urinary fistula opening at the umbilicus. o In early fetal life, some loops of intestine normally herniate out of the abdomen in the region of the umbilicus. The oondition may persist and is then called exomphalos. 69
  • Failure of development of infraumbilical part of anterior abdominal wall results in a condition called ectopic vesicae in which the interior of the urinary bladder is exposed on the surface ofthe bodY. o [n later life, weakness of abdominal wall may lead to the formation of hernia at the umbilicus. (Prof. D.G. Thatte) Heart works with the help of great vessels. That means rasa is received by IVC andprana is received through pulmonary vessels and both rasa and prana are supplied to wholetody through aorta and its branches. So it is the sira marrna. - The vessels of the heart, valves of heart, cardiac muscles, blood supply of the heart(coronary arteries) and conducting system of the heart, each and every structure of it isimportant for its functioning. We can perform surgeries because of advances in anesthesiaand the instruments and equipments available nowadays for life saving (Prof. Vijay V. DoiPhode) lhe ansuer is sirnilar to that of-4.9. (Prof. M. Dinakara Sarma) Nabhi is a sadyopranahar marrna because of the following structures involved in itsmaking and underiying the umbilicus (nabhi)- o Abdominal aorta o Inferior vena cava o Small intestine o Peritoneum Rupture of smallRupture of abdominal aorta or inferior vena cava may lead to sudden death.intestine may cause intestinal obstruction causing death Peritoneum may atttact acuteinfection, and because of peritonitis there will be death (Prof. S.P. Tiwari) the An injury to nabhi marrna, which is the root of all the shiras and situated between marma measuring theamashaya urrb tt pakvashaya, ends in death within a day. It is a shira "length offour finger and belonging to sadyopranahar group The surface anatomy of ttt" maffna is also indicated in the text. According to Sushrutand others this is a shira **-u and instantly fatal, when injured. Dr. Ghanekar is of the viewthat whole of the abdomen is a marma sthal. He has divided it in to two parts, the upper partas a nabhi pradesh and lower one as a basti pradesh. Some otheq modern thinkers suggestnabhi as nabhi pradesh (umbilical region) Umbilical region contains duodenum, colon, small intestine, celiac uiety or superlor meseuteric arterY. Penetrating wounds abdomen ale as a rule dangerous and may cause death of immediately from shock and intestinal hemorrhage. Rupture of the intestine occufs frequently irom violent blows, kicks, falls, vehicular accidents, crushes or compressions in the naval region (Modi N.J. p.285286,1977) of The advances have b..n ,.rponsible for the recent fall in the mortality rate penetrating abdominal injuries (Mc.I-eord RAH 1966) All penetrating ittjuries of the abdominal are of course potentially lethal, but the danger is not immediate unless there is associated major vascular injury. A gun shot wound 70
  • that simultaneously penetrates both a major artery or vein and the intestine is particularlylethal because of the contamination produced at the site of vascular repair. When a majorblood vessel is involved in the penetrating abdominal wound, immediate surgical explorationis indicated to control hemorrhage. Rapid bleeding in associated injury from major bloodvessel causes all of the classical signs and symptoms of hypovolemic shock (Drapanas T.and Litwin, M. S. 1972). In a series of 546 cases of hepatic injury there was only 5%o mortality if the liver wasthe only organ involved. The portal venous system injury carries a mortality of 33Yo (LevinA, Grahan J. M. et al 1978). In the wounds of pancreas and duodenum the mortality is 20o/o or higher even afterthe pancreaoduodenectomy. Many victims of gun shot wounds of the duodenum die beforereaching the hospital because of the proxirnity of duodenum to the aorta and vena cava(Kelly G. et al 1978, Corley R.D. 1975). The irfuries of small intestine are relatively easy tocorrect if the vascular injury is not involved (Swan K.G. 1980). In colon injuries mortalityranges from 7 to 15 %o (Steele M. et all97l and Locicero et al 1975). On the other hand injuries to the great vessels of the abdomen and pelvis remain achallenging problem to the trauma surgeons. Probably the most challenging injuries thesurgeons are facing is that involving penetration of the aorta in region of the celiac orsuperior mesenteric arteries. Traumatic injuries to the inferior vena cavq carry a highmortality rate (Cheek R.C. et al 1975). Even after many innovative techniques designed to bypass the injury, allowing moretime and better visibility for safe repair 44 -53 0/o succumb despite surgical interventions(Allen R.E. et al 1972, Turpin J. et al 1977). The mortality is especially high withsuprarenal and inferior vena caval injuries as compared to infrarenal inferior vena cavalinjuries. The above discussion considering the trauma of the different viscera along with greatvessels and there mortality rate compel us to conclude that the injuries involving greatvessels in the umbilical region have a high rate of fatal results in spite of surgicalinterferences. This is really an appreciation for Sushrut who had such a keen observation inthe absence of the modern advances in the surgery. Sushruts version about vulnerability ofnabhi is still upheld. The umbilical region is 9.5 cm. in length (Grant 195_8) and about 4 inches or 10 cm.according to Conninghum, which is equal to 4 fingers mentioned by Sushrut. (Prof. Jyotsna)4.13, Heart is sadyah pranahar marma. Please explain which part of heart is affectedfor its sadyah pranaharata. (Dr. Nimesh. G. Kachhiapatel) Areas of right and left coronary arteries, especially the aortic sinuses from wherethese arteries originate - Heart measures about 4 anguli in depth and width. Large vessels likearch of aorta, pulmonary trunk, pulmonary veins get damaged. Coronary artery gets crushed,which hampers the blood supply to heart leading to death. (Dr. R.B. Gogate & Dr. Mukund Erande) Please remember that heart has its own independent autonomic supply. Heart musclespossess inherent synchronicity i.e. its innervation merely modulates this. Heart has its own 7l
  • conducting system (fibrous skeleton). The pacemaker is the sinoatrial node in the wall of theright atrium at the top of crista terminalis. From the SA node the impulse passes to theatrioventricular node in the lower end of atrial septum beside the coronary sinus opening.There are probably several distinct routes along which irnpulses pass in the atrial wall,although they are not histologically distinct. From the AV node specialized cardiac musclefibers (Purkinje fibers) start from the bundle of His. These penetrate the fibrous skeleton thatseparates the atria from the ventricles and then pass into the ventricular septum. About halfway down the septum it divides into right and left branches. The left bundle passes to theapex and up the left side of the heart. The right bundle crosses to the inferior side of theventricle in the septomarginal (moderator) band, an identifiable ridge in the wall of the rightventricle. Yes, it is true that heart is a sadyah pranahar marma. As far as the exact part of heartwhich when affected result in sadyah pranaharta is pacemaker or SA node. It is a specificpoint in every mammalian heart. SA node is a small strip of modified cardiac muscle,situated in the superior part of lateral wall of right atrium justbelow the opening of superiorvena cava. The fibers of this node do not have contractile elements. These fibers arecontinuous with fibers of atrial muscle, so that the impulses from the SA node spread rapidlythrough atria. Destruction of SA node causes immediate stoppage of the heart beat and death.But sometimes the AV node becomes the pacemaker and starts generating the impulses, butthe rate is slow. The cooling of SA node decreases heaft rate, whereas, warming of SA nodeincreases heart rate. But always remember that the electrical activity of heart starts only fromSA node. There is one more important principle which affects the contractile property of theheart muscle i.e. All or None law. This means *hen a stimulus is applied, whatever may bethe strength, the whole cardiac muscle rebounds to the maximum or it does not give responseatall (Prof. D.G. Thatte) Whole heart is sadyahpranahar, but left ventricle ismore vulnerable. (irof. J.N. Mishra) Hriday is one of the important maha narmas situated in the chest. It is a very vitalorgan in the body and is the seat of triguna and chetana. Right atrium of the heart, atrio-ventricular valve, inferior vena cava, right pulmonaryartery and veins and ascending aorta and pericardium, right coronary vessels are si{uated inthe area. Injury to any of these vessels or pericardium may lead to cardiac arrest. Injury,whether local or general, and whether blunt or penetrating, may cause many complicationssuch as fracture of ribs, cough, flail chest, rupture of great vessels and pericardium. Theeffect of injury depends on the severity and the extent of involvement of pleura, lungs etc.Death due to heart failure is a common occuffence. Even mental trauma like shock or stresscan also cause death (Dr. v.S. pat) Any part of the organ can lead to death upon malfunction. (Dr. C. Suresh Kumar) 72
  • As per Ayurveda the whole heart is to be involved but not any one part of the heart.Although it is the seat of manas and ojas, it is very difficult to specify which of the heartcontains these two. (Prof. M. Dinakara Sarma) Injury to any section of a heart can be fatal, so it is better to consider it as a whole. (Dr. K.B. Sudhi Kumar) A11 four cavities (atria and ventricles), arch of aotta, pulmonary aftery, pulmonaryvein and both vena cavae, if ruptured will lead to sudden death. SA node in particular ifpunctured will cause death. Basal part of the arch of aorta is important for the formation ofcoronary artery. Blockage in coronary artery will lead to infarction, which is also one causeof sadyopranaharata. Formation of free radicals in cardiac muscles (because of sudden entryexcessive of oxygen) after ischemic cardiac condition, may convert it into kalantar pranaharmarma. It is an important issue to evaluate at this point for better understanding. (Prof. S.P. Tiwari) There is no doubt that heart is one of the tripods of life (Modi N.J.).Death may occurfrom primary or neurogenic shock without any visible injury or from the inhibitory action ofthe nerve plexus caused by blow on the stomach on the upper part of the abdomen. Deathresults from psychic factors due to reflex vagal inhibition of the heart from pain felt in ainjury to the genitalia (Modi N.J.). The recent reports indicate that the gun shot wounds are more common causes ofpenetrating chest injuries leading to cardiac trauma (Evans J. et al 1979). A gun shot woundof tfr. heart is more often fatal than is a stab wound to the organ (Sogg W.t. et al 1958) Theright ventricle is most commonly the site of penetrating cardiac injury. Left ventrical, rightatiium, left atrium follow"in the order of frequency (Trinkte J.K. et al1979,, Deaux et all979,Evan J. et al 1979). Injuries to the left ventricle carry the worst prognosis. Gun shot wounds are lesslikely to produce pericardial tamponade than stab wounds because the former are moreutroriut"d with through and through injuries to both myocardium and pericardium (WilsonR.f. and Bassett J.S. 1966, Yao 1968). The cardiac tamponade proves fatal if not explored immediately (Love and Bailley). In a study of 50 cases of cardiac wounds it has been found that 6l% of these casesinvolved the left ventricle with a mortality of 52% and right ventricle with 46oh mortality.Multiple chamber involvement was present in some cases with the correspondingly highmortaiity rate. Injuries such as injuries to the coronary artery, aorta and pulmonary trunk arecommon in gun shot wounds were cent per cent fatal (Ashish K.M. et al1979). In my opinion the length of the ventricular portion of the sternocostal surface can beconsidered as the pariman of hriday marma. (Prof. Jyotsna)4.14. Hriday marma measurement is mentioned as 3 angula. Which exact part shouldbe considered as marma? Hriday has dimension of inore than 3 angula. How can weutilize this knowledge of hriday marma in the current practice of medicine andsurgery? Hriday is sidyahpranahar marma. How can we reduce the fatality with theuse of presently available techniques? (Dr. Seetharama MithanthaYa) 73
  • The measurement of surface anatomy of heart is similar to classical findings. Fatalitycan be reduced by skilled surgery and also by reducing time between injury and medical aidProvided (Prof. J.N. Mishra) Presently available techniques have made the treatment of cardiac ailments risk free,which might not have been the situation during the Samhita period. Hence, they are termedas sadyahpranahara marma and advised against surgical intervention. Any injury can causesevere hemorrhage, shock and death. @r. c. suresh Kumar) It should be kep in mind that Ayurvedic terminologies are having versatile use. Here,we should consider this fdct in hriday manna also. We should not stick to the name alwaysbut to the intention and the context. Heart may not be the meaning of hriday mafina, but it isa manna point. Hriday has been told as,three angula but hriday marma is of panitalapramana. ThiS includes whole heatr as heart is of a fist .;ize. Hence, if we are considering athree dimensional strcture and even in a vertical row a road injury can injure total heart, aortaas well as the lungs (Dr.K.B. sudhi Kumar)4.15. What is anilavahi nadi in the description of apastambha marma? (RAV) The term vatavaha nadi has been used in text but the questioner has used the termanilavahi. Both the terms are used for a pipe through which air passes to and fro. Thisstructure is termed as apastambha. The trachea and its bifurcation are anilavahi or vatavahi.The bronchi enter the root of respective lung and after reaching the lung the right bronchusdivides into three while the left {ivides into two (as there are three lobes in right lung andtwo lobes in left lung). Therefore, Sushruthas very clearly mentioned in chapter 6 as follows 3srffi qrs-* Erd-Ea srq?a"€t ffi, ?r5r drdq"fq+E-dqr+Te+eqrs{reqi q arssrEu r (g en arzs) (prof.D.G.Thatte) Anilavahi nadi is principal bronchi, trachea, which convey air during inspiration andexpiration Trauma to this manna damages o**bl":i1f;H_*Til.. lvror.,rnd Erande) Both the hila of lungs, right and left bronchi and pulmonary vessetrs can be consideredas structure in apastambha marma. An injury may cause pneumothorax resulting inrespiratory distress and consequently it may.lead to death, if not treated in time. It is alsopossible that in severe trauma, fracture of bronchus may cause mediastinal surgicalemphysema and heamothorax leading to serious complication. Bronchi may be consideredas anilavahi nadis. (Dr. V.S. Patil) Anilavahi nadi may have been proposed due to rich supply of nerves or even vesselsbecause vyana transports the blood earrying prana along with it ftrrera fficq r (errs-urere) (Dr. K.B. Sudhi Kumar) 74
  • 4.16. What are the specific location of nitamba marma, parshvasandhi marma andkatikataruna marma? (IIAV) Parshvasandhi - extemal iliac vessels. Nitambha marma - ala of the ileum. Katikatarun - sciatic nerve in sciatic notch. (Prof. J.N. Mishra) Nitamba marma is basically asthi marma. Injury produces atrophy of lower limbslater leading to death. It is located at upper part of iliac bone, the iliac crest, which covers andprotects thepelvic orgaiis such as mutrashaya and pakvashaya. Parshva sandhi is a sira marma. Injury to it leads to hemorrhage and death at alaterstage. This marma is located on the back of the trunk between highest point of iliac crest(kati) and sub-costal region. Anatomical structures are lower poles of kidneys. Injury tokidneys may cause hemorrhage leading to death at alater stage. Katikataruna is an asthi marma on the back on either side of lower spine at sacroiliacjoints. Injury to blood vessels (common iliac) may cause severe hemorrhage, distortion of normal contour of pelvis, and the symptoms of fracturd or dislocation of hip joints (sacroiliacjoint). (Dr. V.S. Patil)Nitamba: " Location of the marna is above the shronikand (pelvic girdle) and both the sides ofthe vertebral column. Injury to this marma leads to the atrophy of the lower limb and evendeath in course of time. Many scholars opine that nitamba manna lies above the pelvis on the back. This isapparently due to the mistranslation of Sushrut Samhitas shloka. There it is to be taken asshroni, instead of upon (upari) the shroni phalaka. Nitamba literally refers to hips and this ismore appropriate as an injury to this marma causes atrophy of legs due to the injury to sciaticn *rr. The rectification of word aashyacchhadano (Su. Sha. 6126) asashayachhada byVagbhat is also suitable as the location of this manna (on pelvic girdles) encapsulates thecavity of the pelvis.Parshvasandhi: Location of these marmas is between costal cartilage and the pelvis, corresponding tlthe vessels of kidney seen medially and upwards. Injury tothis marma causes collection ofblood in the abdominal cavity and causes danger of life. Ittjuty to this marmas (coeliac axes), which are situated medially below the extremitiis of tn" side (parshva), and which lie attached at the middle between the loins fillsthe koshtha with blood and results in death.Katikataruna: These marmas are situated on both the sides of the vertebral column corresponding tothe posterior aspect of the ilium. These are two in number and are asthi marmas. They arekalanthara pr*ihutu and of half anguli in extent es ifris is of taruna nature itls advisable to consider this as sacroiliac articulation (Dr. C. Suresh Kumar) 75
  • Location of katikataruna marma: a-* geder ............E;&o-aoor rThese are located on the both sides of vertebral column and related closelv to theshronikanda asthis (hip bones).Location of nitamba marma:stlFrd-6ru-s ffi IThese are located above the shroni and cover the ashayas and are related to the flanks.Location of parshvasandhi marma:slef:rTfief Eeanq qT"+{t-dft 1These are located to the lower lateral portion and above upwards between the jaghana andparshva. (Prof M. Dinakara Sarma)Nitamba marma: Ala of the ileum (it may cause injury to common iliac vein and sacralplexus).Parshvasandhi: Right and left lumbar regions where kidneys are located.Katikataruna: Just above the sacroiliac joints (it may cause injury to sciatic nerve). (Dr. K.B. Sudhi Kumar) Nitamba marma may be located at the center of iliac part of hip bone, parshvasandhi joint and katiktaruna at the lowest constricted parl of ileum (supra acetabularat the sacroiliacregion). (Prof. S .P. Tiwari)4.l7.ln the definition of nitamba marma, it is mentioned gffierqr-ar<ft qreoffi; qd ffi---r (g. en. 6/26) srnerqras* effdrer-qfterrqd, ---- r (8. eTT. 6/26 c-s s-c6"T)Sushrut, Ashtanghriday and Ashtangsamgrah have considered amashaya, mutrashayaand pakvashaya respectively what can be concluded here? (Dr. Anju Thomas) Amashaya pidhayako is pakvahsya pidhayako; this is correct pathabheda. (Dr. R.B. Gogate & Dr. Mukund Erande) The point is still controversial and requires more study. I{owever, ashaya appears tosignify pelvic cavity particularly mutrashaya etc. (Prof. J.N. Mishra) Upper part of iliac bones (pelvic bones) on either side of vertebral column protectsthe pelvic organs, such as pakvashaya, mutrashaya etc but not amashaya. (Dr. V.S. Patil) These structures can be proximally related to these marma points. (Dr. C. Suresh Kumar) It is very difficult to specify all the characters described in the texts for most of thegluteal marrnas. Anatomically also it is very complex but according to the pathologydescribed by some acharyas, above correlation should be considered. Here, the explanation 76
  • by Sushrut and Dalhan for nitamba is specifying the covering protection by the ileum to the visceral organ, so it is better to understand grossly this intention. (Dr. K.B. Sudhi Kumar) 4.18. In the viddha lakshana of nitamba marma, Sushrut has mentioned adhahkayashosha whereas Ashtang Hriday and Ashtang Samgrah have mentioned adhahkayashopha. How can this be explained? (Dr. Anju Thomas) Shosha occurs in neurological damage and shopha occurs in vascular damage. (Dr. R.B. Gogate & Dr. Mukund Erande) Both are possible depending upon nature and subsequent effect of injury. Vascular haemorrhage of the area will cause adhahkayashopha and vascular insufficiency may be due to arterio venus fistula or aneurysm will cause adhahkayashosha. (Prol. J.N. Mishra) The structures are essentially related with the blood vessels and nerves. Injury to blood vessel leads to extravasation of blood thereby shopha while nerve injury may lead to shosha. (Dr. C. Suresh Kumar) In Ashtangasamgraha daurbalya is also mentioned along with adhah kayashopha, which may be correlated with adhahkaya shosha. If we consider practically we find that there is always a loss of sensation, motor loss as well as local edema in many a traumatic cases. Especially in acute traumatic cases, edema is a general feature. Hence, Vagbhat has emphasized on acute consequence, whereas Sushrut might be referring to the later consequence (Dr. K.B. sudhi Kumar) Adhah kayashosha as presented by Sushrut seams to be a correct symptom. This marma used to be involved during gada yuddha in old time. We can imagine what can happen in gada yuddha. The trauma may cause fracture of pelvis and crushing of gluteus muscles. Crush injury in the fleshy part of muscles may lead to pulmonary embolism and death, and fractured pelvis may develop wasting of lower body, weakness and death. (Prof. S .P. Tirvari) 4.19. While explaining nitamba marma, why has Ashtanga Hridayakar quoted tarunasthigau? sner{r€r<ift * g frrdr$ a-ounRer$ I (sr.6. en. 4/21) (Dr. Anju Thomas)-J t"t* Taruna asthigata is referred to as crest of iliac bones on either side of pelvis. (Dr. V.S. Patil) lt is a sacro-iliac joint and is formed by the cartilaginous adhesions. (Dr. C. Suresh Kumar) 77
  • He rnight have considered the tendons of serratus anterior or other soft tissuesresembling a tarunasthi. (Dr. K.B. Sudhi Kumar)4.20. Confirmation of bruhati marma on the basis of the reference in Su. Sha.6/31. (Dr. Swati S. Bedekar) Brahti maffna are situated on the posterior thoracic wall at the level of stanamula.Brihati marma has been recognized by Sushrut as sira marma and also kalantara marma. Itcovers the ardhangula areas. In this area subscapular and transverse cervibal arteries can beseen in practical anatomy.According to Sushrut rFl-a-d[c4T{qefq-d geaiers gdff, ?r5r e ;---- r (€. eTT. arza) In this quotation the term shonit atipravritti is a complication leading to loss of blood;death is must. This first needs explaination. . Injury to brahti marma causes blood loss and its complication leads to death. o Anastomosis round the body of scapula occurs in three vessels viz subscapular, supraspinousand infraspinous. o Suprascapular artery- branch of thyrocervical thunk from first part of subqlavian artery o Deep branch of transverse cervical artery; a branch of thyrocervical trunk; o Circumflex scapular artery; a branch of subscapular artery from third part of axillary artery. Collateral circulation is established between it and first part of subclavian and third part of axillary arteries. (prof. D.G. Thatte) Triangle of auscultation, where sixth posterior intercostal artery directly coming fromaorta is unprotected. The penetrating wounds of the lungs, pleura and pericardium do notneed thoracotomy necessarily but bleeding from intercostal arteries and vessels at the root oflungs open the door for emergency thoracotomy due to bleeding complication. (Prof. J.N. Mishra) Brihati is situated on both sides of spine on the back in the thorax at the level ofstanamula. Anatomically it is situated at the base of the lung and diaphragm and bare area ofinferior angle of scapula. If intercostal subscapular artery or intercostal vessels are injured,hemorrhage takes place leading to serious complications (Dr. V.S. pat) Brihati manna is a sira marma of ldalantar pranhar fype, located at the same level asthat of stanamula on the posterior aspect, approximately at the level of 6th rib. The nipple liesapproximately over the 4th intercostals space. The breast extends vertically from 2nd to 6th riband horizontally from lateral border of stemum to mid axillary line. These are 2 in number each of tA anguli. The important blood vessels are the posterior intercostal arteries (branchesof aorta) and intercostal veins (drain in to the azyogos and accessory hemiazygos vein). Viddhalakshan have been given in Su. Sha. 6 - 31. The inj,ry to.this region may leadto bleeding and complications due to bleeding gradually causes death. (Prof. Vijay V. Doiphode) 78
  • This marma is situated on the posterior side corresponding to the base of breast,trateral to the vertebral column on the both sides. These are two in number and are siramarrnas and kalantara pranahara also. Injury to these marmas treads to continuous bleedingand endangers life in course of the time due to complications. Anatomically this is the placewhere two vital arteries pass; right side hepatic artery and the left side splenic artery. Injuryto this area will cause heavy bleeding and thereby death. . .l (Dr. C. Suresh Kumar) It may be correlated with intracostal arteries and veins. ( (Dr. K.B. Sudhi fmar)4.21. Why is there difference between Sushrut, A.S.kar Vagbhat and A.H.kar Vagbhatfor locating brihati marma? gqieil 3isr{rtr: r (ggd, steffid-6) gqier STT€rq I (st€) (Dr. Anju Thomas) Not much difference is there. Pristhavansho ubhayatah is more precise description. (Dr. R.B. Gogate & Dr. Mukund Erande) Please do not be misled by language of text. The author of Ashtang Sangrah andAshtang Hriday is one and he is Vagbhat. As far as Sushrut is concerned he has preciselyidentified the location of brahati marma in pristha vansha. Therefore there should be noconfusion regarding the spotting of brahati marma. (Prof. D.G. Thatte) There is no basio difference, only the way is different (Prof. J.N. Mishra) Brihati marrna is a sira marrna of kalantar pranhar type, located.at the same level asthat of stanamula on the posterior aspect, approximately at the level of 6th rib. The nipple liesapproximately over the 4th intercostals space. The breast extends vertically from 2no to 6n riband horizontally from lateral border of sternum to mid axillary line. These ate2in numbereach of Yz angali. The important blood vessels are the posterior intercostal arteries (branchesof aorta) and intercostal veins (drain in to the ivyogos and accessory hemiazygos vein).Viddhalakshan have been given in Su. Sha. 6 - 31. The injury to this region may lead tobleeding and complications due to bleeding gradually causes death. (Prof. Vijay V. Doiphode) The structure may be extending into all these areas (Dr. c. suresh Kumar) Both the descriptions seem to be the same. Both of them have told it to be locatedstraight on the back of stanamula on both sides of vertebra. In the commentary by Arunadattaalso prishthavamshashraye has been inlerpreted as - gweienv serqqred qftrd-Afut r (srerea) (Dr. K.B. Sudhi Kumar)4.22.Stanais devoid of muscle. How can we interpret the stanarohit marma? (Dr. A. Sulochana) 79
  • Stana consists of ligament of Cooper. This band of fibrous septum traverses throughthe interlobular spaces and connects the skin with deep fascia. Between the skin and breastthere is a pad of fat except a{eola which consists of layer of non-striated muscle fibres,lymphatics and venous plexus. Pectoral and serratus muscles should be included as the part and parcel of stana,internal malnmary artery passes beneath this site. (Dr. R.B. Gogate & Dr. Mukund Erande) go-+sed Fq-sgd-€er{rer:, q<a*G-e, ffi dfrffiWf+)wqrorc{eqre{reqi q m; ---- | (9. eTT. atzs) According to Sushrut stanarohita marrna can be located on the anterior wall of thoraxjust two angulas above the nipple. Sushrut has labeled it as mamsa marma. This version is very objective because It isabove chuchuk (nipple) or two angula above the nipple of the marlmary gland. If onepalpates this area deeper structure is pectoralis major and pectoralis rninor muscle of pectoralregion. That is why Sushrut has identified it as mamsa manna. Severe trauma on this area can easily cause hemothorax (i.e. raktapurna koshthata)due to injury to the blood vessels of this area like internal mammary artery. Other than injuryto the vessels there can be hemorrhage in the lung cavity, which manifests in the form ofhemoptysis in tuberculosis, carcinoma or compression injury. It may also cause intemalhemorrhage (raktapurnakoshtata) (Prof. D.G. Thatte) Transversus thoracic and pectoralis major muscles associated with the internal mammaryartery are the structures to be considered for stanarohit marma. (Prof. J.N. Mishra) Stana is not devoid of muscle. It is placed on pectoral muscles. Stana, as referred inthis context, is not indicative of female stana only. (Dr. V.S. Patil) Location of this marrna is two fingers above the nipples on both sides. Injury to thismarma leads to hemorrhage (into the lungs or outside the lungs) and eirdangers life causingcough and dyspnea. This is a mamsa marna and is kalarfiara pranahara and is of half anguliin extent. As this is a mamsa mafina some interpret this as pectoralis major muscle; but injuryto this mafina should cause raktapurna koshthata. This muscle being very superficial chancesof hemothorax due to this are highly rare. Hence the following structures are considered. o Descending aorta o Pulmonary artery r Pulmonary veins (Dr. C. SureshKumar) In this context he has used the word as stanarohita, which means this marma issituated above the stana but not related to stana. (Prof. M. Dinakara Sarma) 80
  • Though breast is a modified sebaceous gland, it is rich in fibromuscular septa. It isunderlined by superficial and deep fascia. It lies over pectoralis major and serratus anteriormuscles. So though it is structurally not muscular, beneath to it muscles are abundant. On theother hand stana marma is present in both male as well as female. While considering a malestana, it will include total muscles only. So, considering stanarohita marma as a mamsamarma is structurally not wrong (Dr. K.B. sudhi Kumar) Stanarohit is a mamsa maffna. The pectoralis major muscle is underlying at the site ofmaflna. Stana refers to male anatomy rather than female anatomy. As such at the site ofmarma, stana holds no significance except showing land mark. (Prof. S.P. Tiwari)4.23. What are exact sites of bruhati, stanamula and stanarohit marmas? In case ofbruhati marma the site stated is wd-{ar{qa]-qd grserigls q6fr, I (g- en- otzo)But in case of stanmula and stanrohit the site stated are €ad"$Hrq Erigdgerqd maq* | (9. en. arzs) E-d-€o.+od ciEigilger{rd: wqiFft | (9. en. 6/zs)Above marmas are stated in relation to stana chuchuka i.e. nipples of breast and infemale the position of nipples varies according to size of breast and shape of breast withage changes. (Dr. Nilesh Phule) Landmark for location of marma is stanachuchuka. Though it is variable, but inabnormal condition its anatomical description lies on fifth intercostals space. (Prof. J.N. Mishra) Stanamula and stanarohita are situated on the front side of chest in relation to breast(or nipple). Stanamula is 2 angula inferior to base of the breast, whereas stanarohita issuperior to breast on either side. Regarding brihati the answer to questions no. 4.20 & 4.21ean be referred. . (Dr.V.S. Patit) Above marmas are stated in relation to stana chuchuka i.b. nipples of breast and infemale the position of nipples varies according to size of breast and shape of breast with agechanges.Stanamula This is situated two fingers below the breast on both sides. This is a sira manna and akalantara pranahara. It is two anguli in extent. Injury to this marma endangers life by frllingthe koshtha with kapha and causes cough and dyspnea. The fatal cause is kasa and shvas withkaphapuma koslrtha. Kaphapuma koshtha invariably denotes collection of fluid in the pleural cavity thatcauses dyspnea and cough. Some interprets thft as pleurisy and pneumonia. Pleurisy is acondition in which fluid is accumulated in the pleural cavity. Traurna is considered to be oneof the major causes of the pleurisy. It may be due to some extemal cause like fali, accidents,stabbing etc., or due to internal cause like complications of surgeries etc. If not treatedproperly, it will lead to death. 81
  • Next condition is of kaphapurna kosthata, which is suggestive of pneumonia. Thecause of pneumonia is usually Pneumococci. Due te trauma the micro organism enter bronchithrough the wound. This is kalantarapranahara marma. The death may be due toinflammation caused by Pneumococci. This condition is said to have some similarity withshvasanka jvara (Dr. Gananath Sens). (Dr. C. Suresh Kumar) The location of stanmula, stanarohit and brihati (as mentioned by Sushrut) are twofigures inferior to the nipples, two figures superior to the nipples and on the back in thestraight line of stanmula respectively. The female breast and its variability do not have anysignificance with the surface anatomy of these marrnas, because maffna sharir is a marshalanatomy and was developed on the basis of war injuries. Only male nipples are thedetermining factor for location of marma in this regard. (prof. s .p. Tiwari) EtdqiT: E{aTeIir: geaiere qFS drd I Stanmula ruja means exactly opposite to the lower part of nipple (4th intercostalsspace- Rowlings surface marking) i.e. 2 angula below the nipple. According to modernsii"n.", inferior angle of scapula lies on the 6th intercostal space oi 7h rib. Hence 2 angula below stanmamoola reaches the 7th rib. Therefore, bruhati marrnashould be situated on inferior angle of scapula.Stanamula- raa*, 3Ter{arq 3lqga€+Tqd: taa-{d rAs explained above, stanamula marma lies 2 angula below the nipple i.e. 2 angula below the4th intircostal space (6th intercostal space or 7th rib). Here the structure should be interpretedas bronchus and alveoli. Affected structures are not related to breast or lactiferous duct. It isrelated to ribs and underlined structures.oqtqoi6)w-qr -Fr+feqr€ITeqi ffi IStanarohita - Tf,a-€tr+sed srqa-g+rera: laaiBd ara ra-s sft6qlf .olw-er orrrcqrufiaqi q ffi n g.err. 6/s4It is situated2 angula above the nipple, i.e., it should bi on the 3d rib or 2nd intercostalsspace. Due to bleeding, thoracic cavity is filled with blood therefore we should considerblood vessels as anatomical structures. Lactiferous ducts are not damaged. (Dr. R.B. Gogate & Dr. Mukund Erande) Brihati had been discussed previously. Stanarohita may be anatomically considered aslower portion of pectoralis major and stanamula can be considered as internal mammaryartery. Stanamula has been told to be of one finger, so it may differ sometimes in females ofdifferent age groups but the stanarohita is mostly the same in all. In biology no rules areconstant; so deviation is always possible. (Dr. K.B. Sudhi Kumar)4.24. Please explain the difference in sites of stanamula and stanarohit marma,according to their viddha lakshanas? Earf,"€ffirq qligd-garq-d, a3aq*, mr oqrqrHwqr(oraeer*navi) m; €-d-€6-+o.ed qEigcrge{ercr: a-a-nG-R, ffi (Dr. Kunal Lahare) 82
  • Stanamula marmas are situated two angulis below each mammary gland whilestanarohita marrnas arc located two angulas above the nipples on either side. Trauma to stanamula causes kaphapurna koshthata giving rise to kasa, shvas andmrityu (death). Kaphapurna koshthata can be tal<en as pyothorax or pus like expectorationduring coughing. Trauma to stanarohita causes raktapuma koshthata (hemothorax). These arethe basic differences between the two maffnas. (Prof. D.G. Thatte) Differences in sites of stanamula and stanarohit are already given by school ofSushrut and others (prof. J.N. Mishra) It can be explained on the basis of the anatomy of the structures lying in that area. (Prof. J.N. Mishra) Same as explained in 4.19 anci 4.20. Pneumothorax or hemothorax is possible. (Dr. V.S. Patit) It is very difficuit to differentiate these two anatomicalty; injury seems to affect lungsand vessels (Dr. K.B. Sudhi Kumar)4.2s. qr. eTT. 6/2s d wa{r ard qs srrqrd d 6sEf dwl ffi B| ErFi#i- #a61q EFd $ eq€ tDT s6a B En a€ a erT er6 +-{d a-dEn*T- fr Ba (Dr.TapasyaGupta) The kaphapurnakoshthata (pyothorax) develops after a trauma to stanamula marma. Itis mostly due io infection and is dehnitely a complication of maffna abhighat. The fbrmationof pus within thorax can never happen without any injury or infection. Therefore thiscondition never comes up in a natural way of marma svabhav. In kaphapurnakosthata more expectoration occurs commonly due to bronchitis,bronchiectasii oi pulmonary tuberculosis. A trauma on chest wall may cause secondaryinfection. Infammatory serous effusion may occur as a complication of injury to the chestwall. In most of ther" .ur6 exudate becomes purulent. All these conditions give rise to kasa (cough) and shvas (dyspnea). If not lreated properly, it complicates and leads to mrityu (death) (Prof. D.G. Thatte) It can be explained on the basis of the anatomy of the structures lying in that atea. (Prof. J.N. Mishra) It is related to the bronchus and injury to this structure leads to excessive secretions into the lung cavity 1or. c. suresh Kumar) Here the word koshtha seems to represent the thorax with the pulmonary units. possible with late Hence, u, u ,"rrrlt of injury to it pneumothorax and hemothorax are 83
  • possibilities of infection leading to pneumonia, empyema, pulmonary tuberculosis etc. So accordingly kaphapurna koshthata, kasa, shvas can be correlated and in case of stanarohita, raktapurna koshthata can be explained (Dr. K.B. sudhi Kumar) 4.26. What is koshtha in the context of marma? How do we analyze kaphapurna koshthata, lohitapurna koshtha and vatapurna koshthata on Ayurvedic base? Lohitapurna koshthata is a feature in stanarohita and parshvasandhi marmas. Stanarohita is an uraha marma where as parshva sandhi marma is a prushtbagatamarma. (Ref: Su. Sha.6125-26). (Dr. Prathibha Prasanna) 3r€r:riledfffiz qffi rnq-dqp+deq*, ftrd{ sed q d<Tdrq qre*Eiftr4ra, - a-* d@ olwqr ffi r ftrer ard rn@ E;]g6irr I1 Kaphapumata: Traumatic pleurisy. It is manifested by no air entry, dull note onpercussion, and dyspnea on clinical examination.2. Lohitapurnata: Dull note, respiratory distress, shita shvasata (amla shishira priti, sirashaithilya), which is an important sign.3. Vatapurnakoshthata: Pneumothorax, pneumoperitoneum or surgical emphysema. There isresonant note, nonentry of air in lungs. If there is emphysema, there is crepitus. Parshva sandhi marma should be considered as situated above the iliac crest, below12tr rib and lateral to vertebral column. As it is sira marma the viddha lakshna is i;;i6;;kosthata. Hence we have to consider large blood vessels, which are common iliac vessels. (Dr. R.B. Gogate & Dr. Mukund Erande) The word koshtha has been used in context of the thoracic cavity and not for themarma itself. The following terms are pathological states of thoracic cavity. o Kaphapurnakoshthata(pyothorax) o Lohitapurnakoshthata (hemothorax) o Vatapurnakoshthata(pneumothorax) All are complications of abhighat (trauma) on these marmas of anterior thoracic wall.They are stanamula, stanarohit and brihati marmas. Kaphapurnakoshthata,raktapurnakoshathata and vatapurnakoshthata are all pathogenic conditions of pleural cavityor lung as a result of marmabhighat. Vatapurnakoshthta is a complication or abhighat of apstambha ma(na. Thelohitapuma koshthata is a complication of abhighat on stanarohita marma andkaphapurnakoshthata is a pathogenic condition of abhighat on stanarohita marma. Lohitapurna koshthata is a feature of abhighat to stanarohita marma. It can also be acomplication of parshvasandhi marma abhighat. Stanarohita and parshvasandhi both marmasare located on thorax (urasa). However, parshvasandhi marma has been spotted as prishthagatmarma (back of the thorax). Trauma or injury whether caused on anterior wall or posteriorwall of thorax will have the same effect on plural cavity and lung. (Prof. D.G. Thatte) Koshtha denotes cavity in reference of marma. Kaphapuma koshtha, lohitpurnakoshtha and vatapurna koshta are thoracic empyema, haemothorax and pneumothorax 84
  • respectively. Lohitpurna koshtha in stanrohit is haemothorax and lohitpurna koshtha inparshvasandhi marma is intra pelvic hemorrhage. (Prof. J.N. Mishra) Koshta, as defined by Sushruta, is the site of ama (amashaya), agni (grahani), pakva(pakvashaya), mutra (urinary system), rudhir (raktavata srotas) and phuphphusa. Soanatomically koshtha means cavities of trunk, which include urahkoshtha (thorax) andudarkoshtha (abdomen). Lohitapurna koshthata is a feature in stanarohita, which is related with urokoshtha soit is given in uromarma. Lohitapurna koshthata is also a feature in parshvasandhi, which is related toudarakoshtha. Though it is prishthagata manna the anatomical structure related with thismarna is sleed in udarkoshtha. (Prof. Vijay V. Doiphode) There is no rigidity in the terminology till very recent times. Here what is meant justthoracic cage. (Dr. C. Suresh Kumar) Though the word koshtha has been used in two differently quoted marmas, asexplained above, it is better to accept lungs for stanarohita and stanamula and the abdominalpart in case of parshvasandhi. Now it becomes easy to explain vatapurnakoshthata aspneumothorax, kaphapurnakoshthata as bronchopneumonia and raktapurna koshthata ashemothorax. These are consequences of marmabhighata, so there should be no difference inAyurvedic or modern pathologic considerations. (Dr. K.B. Sudhi Kumar)4.27. ---- Ecra{mreqerqd: gwierw 96ff, r* (g. eitrrarfrrgfu BfrMEfiq}; r en. arza)Marmaghat on bruhati marma leads to heavy bleeding. Can this be treated with raktasthapan and vyan vayu chikitasa? Vyan vayu is dehasanchari and has been allottedmost of the vital functions; one of them is raktasravan. So can Tan vayu chikitsa be ofany help in marmaghat? (Dr. Girdhar Thakre) It is doubtful to treat brihatimarma by rakta sthapan and vyan vayu chikitsa becauseof anatomy of the marna and this needs surgery. (Prof. J.N. Mishra) It can be clinicallv tried. (Dr. C. Suresh Kumar) Marmabhighata is an acute condition. Sushrut has advocated that no rule should bestrict in emergency. According to need of the situation, vaidya need to manage it. Forbleeding, hemostatic is the first major need and it can be done in any way. Vyan vayu is nodoubt responsible for circulation but Sushrut has not mentioned much about it in shonitasthapana. We need to decide the strategy accordingly. (Dr" K.B. Sudhi Kumar) 85
  • CHAPER. V MARMA OF HEAD AND NECK5.1. What is exact site of Vidhur marma according to modern science? qtufgq+sq:eiflrt frg!, a-* <rftft I fg. en- 6/27) (Dr. Jyoti More) Vidhura is situated just postero inferior to the ear. Posterior auricular artery and nerve aresituated just behind the ear and if injured may cbuse deafness. (Prof. J.N. Mishra) Vidhur marma is located at the stylomastoid foramen, inferior to the mastoid process. (Prof. S.P. Tiwari) frg! ara, d5[ erfErd{ a5ufgwa, sr€r:"iflr* I larga-flffi qftFra ffi srerfz3a q I g. eTT. 6 s{EknE qtofi*: Fr# Agt gFrdrfrqft I 3{.Eierr. 4Vidhur manna is present at postero inferior side of external ear. That is exactly on themastoid process. Trauma to Vidhur marrna results in deafness.Explanation: Posterior wall of middle ear is related to mastoid process. There is a foramentermed as aditus to antrum, which is a connection between middle ear and mastoid antrumDue to this aditus air pressure of the middle ear is balanced. Below that there is fossa incudis,which lodges the short process of incus. Trauma to vidhur marrna damages above structuresthat are rllut"d to hearing, hence result in ddafness. Temporalis muscle origins fromtemporal lines and gets inserted on ramus of mandible. It covers the mastoid process that isVid-hur m€rm4 hence it is a snayu marrna. It is a site of avedhya sira because this part issupplied by very important vessels e.g. branch of vagus nerve, auriculotemporal nerve,vertical part of iacial canal, which lodges facial nerve and stylomandibular artery Hence, itis a dhamani marma and site of avedhya sira (Dr. R.B. Gogate & Dr. Mukund Erande) According to Sushrut Vidhur maffna is a snayu marrl;ra, but Vagbhat has included it indhamani marma, which is situated posteroinferior to ear lobe and trauma to it causesdeafness. Anatomically, posterior auricular artery and nerve are situated just behind the ear,which if injured, may cause deafness. A blunt trauma may rupture the tympanic membraneresulting indeafness. VIII nerve is deep, which is unlikely to get damaged. (Dr. V.S. Patil) The word Vidhur is derived from the root Dhura: weight. This word is formed byVigata Dhura : Cheshta nashta, or imbalance of the body. The location_ of this marma isbetrind the pinna of the ear. It is seen near the pit-like structure seen behind the ear. They aretwo in number. Its prognosis is vaikalya. They are half anguli in parimana. As this word suggests that any injury causes imbalance of the body; hence thiscan only be the vestibule-cochlear apparatus of the middle ear. (Dr. C. Suresh Kumar) Vidhur manna has been told to be present below karnaprishtha and cause deafness onabhighata. Sushrut has considered it as snayu marrna, hence it could be the membranous 86
  • labyrinth, or middle or internal ear. However, generally in a trauma only a single part will benot affected; all nearby structures will be affected and as a result bleeding iJ obvious. Thismight be the reason that Ashtangahriday has accepted it as a dhamani -u.*u. It will be verydifficult to find the site of injury and manage bleeding. (Dr. K.B. Sudhi Kumar) Vidhur is considered as a dhamani maffna by Vagbhat and has been included as a siteof avedhya sira in Siravarnavibhakti chapter of sushrut Sharirsthan. Posterior auricular vessels do not have much importance in producing deafness. Itssmall branch supplies to posterior part of the tympanic cavity. But clinically, pathology ofthis artery in causing deafness can not be ignored. Stapedius muscle reacts to the sound waves and its abnormality interferes to causedeafness. Mastoid antrum and air cells are also important to consider. A thin plate bf boneseparates it from sigmoid sinus. In case of damage it communicates with the posterior cranialfossa. Air cells extend to the osseous part of extemal auditory meatus. Cells extend into thesquamous part of the temporal bone. It also extends into the petrous part upto the auditorytube and carotid canal. Mastoiditis may spread into the cranial cavity. A blow on the mastoidpart can possibly produce deafness. (Dr. U. Govind Raju)5.2. Please explain how injury to Vidhur marma leads to deafness on the basis ofmodern parlance (Su. Sha. 6127. (Dr. Devendrappa Budi) Piease reter tn the repl-v No. 5.1. (Dr. R.B. Gogate & Dr. Mukund Erande) The point is the exact entry of the auditory nerve, vestibulocochlear apparatus andinjury to it leads to badhirya. (Dr. C. Suresh Kumar) Vidhur marma is a snayu marma. The most suitable structure will be the tympanicmembrane, injury to which leads to complete deafness. (Prof. M. Dinakara Sarma) As discussed earlier in either of the considerations (either snayu or dhamani), thedamage to middle ear or posterior auricular vessel respectively may cause deafness. (Dr. K.B. Sudhi Kumar) Below the mastoid process, there is stylomastoid foramen. From the stylomastoidforamen, there is the entry of stylomastoid artery, which is the branch of posterior auricularartery. Its branch, posterior tympanic artery, supplies to the tympanic membrane. It alsosupplies to mastoid air cells and semicircular canal. Though tympanic membrane is suppliedby more arteries but stylomastoid artery is more important. When this artery is severed it maylead to deafness (badhirya). There may be one more causes of deafness due to vedhan ofvidhur manna. For example the fracture of mastoid process involving the petrous part oftemporal bone will cut the cochrear nerye causing deafness (prof. S .p. Tiwari) 87
  • 5.3. Vidhur marama is a vaikalyakara (structurally) snayu marma (parinamatah) andis ll2 anguli in measurement. Its viddhalakshana is badhirya (deafness). Whichanatomical structure can be considered as vidhur mamra (Su. Sha. 6137)? Is it any ofthe following?a) Posterior auricular vesselsb) Stapedius musclec) Some different structure in middle / internal earVidhur is considered as a dhamani marma by Vagbhat and has bgen included as a siteof avedhya sira in Siravarnavibhakti chapter of Sushrut Sharirsthari. (Dr. M. P. Erande) Please re{br to the repl.v No. 5.1. (Dr. R.B. Gogate) Posterior auricular neurovascular bundles. : (Prof. J.N. Mishra) Vidhur is considered as a dhamani mailna by Vagbhat and has been included as a siteof avedhya sira in Siravarnavibhakti chapter in Sushrut Sharirsthan. Auditory Nerve. (Dr. C. Suresh Kumar) The structures, which have. been mentioned, can be considered as having secondaryimportance as the main structure to be related to this marma is the tympanic membrane. (Prof. M. Dinakara Sarma) : Vidhur is a marma point andall the three structures can be involved and causedeafness, so it is diffrcult to specify a single structure for it. (Dr. K.B. Sudhi Kumar) Posterior auricular afiery and its branch namely stylomastoid artery are the importantstructures in the making of vidhur marma. Because of these arteries the marma is placedunder dhamani manna by Vagbhat. As such there is no controversy in designating it as thesite of aveddhya sira; siravedha at this point may lead to marmabhighat, (Prof. S.P. Tiwari)5.4. Sthapani marma has been quoted as siramarma (structurally) and vishalyaghna(parinamatah) (Su. Sha. 6/17). Which structure should be considered as sthapani?Sthapani is ardhanguti by measurement. Hence the only structure at such depth isfrontal air sinus. Superior sagittal sinus is much more deep (deeper than ardhanguli)which is considered by many scholars as the sife of sthapani marma. Clinicallyspeaking, the penetrating wounds to sthapani marma seem to affect the frontal air sinuswhich can lead to imminent death if removed immediately after trauma. There is a needto have the proper interpretation of exact site of the sthapani *u.*u rr. M. p. Erande) 88
  • Sthapani marma is situated at the glabella. Below that, frontal sinus is present.Occasionally emissary vein from nose pusr"r through foramen caecum from posterior tofrontal sinus and opens into the superior sagittal sinus. (Henry Gray) Refer to Applied anatomy by A.K.Dutta - Thrombosis of the superior sagittal sinusmay take place due to spread of infection from the nose. The shalya comes out itself by fibrosis (natural process) around the foreign body orthe infection. During infection resulting in paka and throwing out of the foreign bodyautomatically causes the vessels shut down in response to fibrosis. (Dr. R.B. Gogate) Sthapani marma consists of frontal air sinus containing vessels. (Prof. J.N. Mishra) Sthapani manna is said to be situated between the eye brows. It is a sira marma.Important superficial anatomical structures are anterior facial vein at its formation point,which communicates with cavernous sinus through ophthalmic veins on both sides of frontalsinus. Further deep are septum of felix cerebri and superior sagittal sinus. A piercing alrowmay penetrate into these structures through frontal sin-us. It may penetrate further deep intofelix cerebri resulting into bleeding of cerebral veins causing subdural hemorrhage, which ispotentially fatal. As long as affow remains in situ, it may prevent bleeding, but wheninfection sets in, it may spread and reach the brain leading to death. (Dr. V.S. Patil) Site of sthapani marma is between two eyebrows. The measurement of sthapani ishalf finger, which refers to its extension at the body surface, not the depth. We can see thatsuperior sagittal sinus is located at this point. Though lying in depth it is an importantstructure in the making of sthapani marma. If any sharp weapon like alrow punctures thesuperior sagittal sinus and is extracted there will be the forceful escape of blood from thesinus. A substantibl blood loss with force will cause the fall in cerebral blood pressureleading to death. The same phenomenon is presented by Sushrut by the fact that the escape ofvayu causes death. Frontal air sinus has no value in causing death. It cannot display any suchphenomenon. (Prof. S .P. Tiwari) It may be glabella or superior sagittal sinus that may lead to uncontrolled bleedingafter removing the shalya. (Dr. K.B. Sudhi Kumar) Measurement of marmas need not always be from the surface. Superior sagittal sinusis larger than ardhangula. Penetrating weapon (like arrow in the olden days) should pierce thebone, aponeurosis, meninges etc to reach the sinus. Keeping the measurement in view, extentof sinus present exactly behind the sthapani can be considered as that limited area assusceptible to injury. Effect of injury on both the sites of superior sagittal sinus and frontalair sinuses does not support the vishalya pranaharatva. Sagittal sinuslfs relatively suitable tobe correlated with sthapani manna as it causes much severe complications and death. Clinical and experimental data and postmortem evidences are necessary to confirmthe precise location of marma. (Dr. U. Govind Raju) 89
  • 5.5. Sthapani is one of vaishalyghna marmas Please explain its anatomicalconsideration and pathophysiology of injury. (Dr. Jairaj P. Basarigidad) Kindly refer to the rePlY No. 54. (Dr. R.B. Gogate & Dr. Mukund Erande) Frontal air sinus with compound fracture is likely to get infected through nose;therefore a pressure Pad is applied over the scalp to obliterate the sinus after excision ofdepressed bone and the rtt r*r lining of the sinus. Three months later the sinus area is (Love andexposed and the scalP is freed from ihe duramater for restoration of deformityBailey). (Prof. J.N. Mishra) Sthapani is the name of the anatomical part on the lower side of frontal bone between may notthe eye brows, above the nasal ridge near the arch of the frontal veins. Usually thisbe tender in normal person until it is pressed hard with the thumb. Just below this area inside venousthe skull, lie the uenb.ts reservoir of the brain, the superior sagittal and the cavernoussinuses. The word sthapani may be of Yogic significance to This is glabelta. There ihe frontal veins and emissary vein go to the foramen cecum to death.form superior s-agittal sinus. If the dart is removed by force bleeding occurs leading (Dr. C. Suresh Kumar) Sthapani marina is a sira manna but still it has been considered as vishalyghnamarma. n inis location the frontal sinus and superior sagittal sinus vein with folds of pressure, which is*"ning". are mairrly related. Injury in this place will affect the intracranialrelated tovayu (Prof- M. Dinakara sarma) Please refer to the rePlY No. 5.4. (Dr. K.B. Sudhi Kumar) Kindly refer to the rePlY No. 5.4 (Prof. S.P. Tiwari) of shringataka marma (Ref. Su. Sha. 6110)? Shringataka 5.6. What is exact location marma is a sira marma (Sushrut) and a dhamani marma (Vagbhat) It is also a cavernous sinus *oyop"uoahar marma. Mostly we correlate with cavernous and inner what is its exact location? @r. K.D. Sathe) Please explain the shringatak marma according to modern science. (Dr. Nimesh G. KachhiaPatel) qrsreile-rRr fu€r ziaffiai frrsrqiaen qiarrd=+.rB, dIft Tdrfr aafFr d-dlft qrdawlq I q I gQrT 6 ganfr a-ErsgaErffr"ft ersr:sroraaFr 90
  • It is situated in the pharynx and structures related to it are present on the roof of the pharynx, which is the base of brain. Base of brain contains cavernous sinus. All blood vessels and neryes which supply to the nose, ea.r, eyeball and tongue"are related to caverno"r ri"ur. Therefore cavernous sinus must be interpreted as the exact point of shringataka mafina. Latetalto the cavernous sinus, internal carotid artery and its branches, oculomotor, abducent, ophthalmic, trochlear, maxillary, mandibular nerves (their sites of origins) are present. Pituitary gland is present in the center of 4 cavemous sinuses (Dr. R.B. Gogate & Dr. Mukund Erande) Exact location is neurohypophyseal fossae in middle cranial fossa. The struclure iscavernous sinus. (Prof. J.N. Mishra) Shringataka marma is a sira or dhamani marma and also sadyopranahar marmasituated atthejunction of all vessels, which are nourishing nose, ear, eye and tongue. Theseare four in number. In my opinion, anatomically cavemous sinus, which is placed betweentwo dura surrounded by III, IV and VI cranial nerves (motor), which supply tb eye; V nerve(trigeminal) supplying to nose, tongue, ear etc. and inter carotid urt"ty, which traversesthrough this area are the marrna sthanas. These appear to be more appropriate.Etymologically the word denotes configuration of planets, triangular space or a mountainhaving three peaks. Blows on the front or back (of head) leads to displacement of brain proportionallycausing stretching effect over junctional tissues of commissure and corpus collosum. Theforce may be transmitted to cavernous sinus causing intracranial hemorrhage resulting intoneurological complications and death. This is derived from the word Shring + ada + gatau. The word rnr,r*"1?l;X,rl.o*#i1?the root Shr: himsayam (summit of a mountain), a place where four roads meet. In the middle of the siras that inigate the nose, ear, eye and tongue, there is a crossway or the sringhatakas They are four in number. According to Sushrut they are sira marma and according toVagbhat they are dhamani marma. They are sadyopranahara maffna and four anguli in extent. The site of this marna is in talu (soft palate), where the cavities of the four indriyas(the sense of taste, hearing, smell, and vision) meet. Any injury here will lead to injury tomedulla oblongata, which leads to bulbar paralysis and above-said symptoms. The openingof all these in the talu are termed as shringataka marma. Being a sira marma, and four in number are also suggestive of the circulus arteriosusof Willis. (Dr. C. Suresh Kumar) Shringatak a may be considered as cavernous and intercavernous sinus that form ananastomosis between the vessels supplying eye as well as nasal parts. In trauma, excessbleeding occurs due to injury to the sinus as well to internal structures. As discussed earlierthe sira marrnas that cause heavy bleeding, which is difficult to stop as well as death morequickly might have been considered as dhamani by Vagbhat. (Dr. K.B. Sudhi Kumar) 9t
  • Theoretically it may be circle of Willis, but practically it is cavernous sinus. Anyinjury to this point will cause death. The severe bleeding will result into sudden fall ofcerebral blood pressure and ultimately death because of complications. The injury to circle ofWillis is always secondary, and to cavernous sinus it is primary, because injury always affectfrom the basal part of the cranium. Hence, cavernous sinus should be practically consideredmost significant. (Prof. S.P. Tiwari) Lateral area of sphenoid in the middle cranial fossa is rdlated to several structures,such as cavernous sinus with its tributaries, superior orbital hssure, optic canal, internalcarotid artery, abducent nerve, oculomotor nerve, trochlear nerve, ophthalmic and maxillarydivisions of trigeminal nerve etc. Tributaries of the cavernous sinus are superior and inferiorophthalmic veins, superficial and middle cerebral veins, central vein of retina and inferiorcerebral veins. Both sinuses are intercommunicated by inter cavernous sinuses. Cavernoussystem has no valves thus allows flow in both directions. Possible clinical problems aresuppuration of paranasal cavities, meningitis, ophthalmic problems, communication betweencavernous sinus and carotid artery. The word dhamani is used in references for nervous pathways. Here, blood vesselsand nerves are vital in nature. Hence, the approach of both the Acharyas might be differenton their experience. (Dr. U. Govind Raju)5.7. The sneha administered through nasamarga will reach shringatak marma (Su. Chi.40130 Dalhana). What is the role of shringatak marma and sneha here? (Dr. Santosh N. Belavadi)an:r+r Rr$ dIT: I Sneha administered thtough nose does not reach shringataka marrna. It reaches theroot of the nose at cribriform plate with nerves and vessels. There appears no role betweenshringataka marma and sneha. (Prof. J.N. Mishra) We can approach through nasa marga in any illness that affects shira. If the vitiateddosha is vata we can administer sneha as nasya and also administer rechana nasya for kaphajvikaras. . (Dr. C. Suresh Kumar) Nasya has been told to be effective all over the head i.e. urdhva jatru. Here, thecavernous sinuses are connected with vessels supplying many indriyadhishthanas. Hence,they may be triggering or activating these systems and imparting their medicinal effect. (Dr. K.B. Sudhi Kumar) This is just a myth, nothing more than this. Any sneha cannot pass the layers of nasalmucosa i.e. epithelium and connective tissue layer. If sneha is absorbed in any form it willenter the circulation after getting absorbed by the cells. So, sneha has nothing to do withshringataka miuma. (Prof. S.P. Tiwari) 92
  • 5.8. Please explain anatomical consideration of adhipati marma and explain itspathophysiolory of injury. (Dr. Jairaj P. Basarigidad) & (Dr. Devendrappa Budi) Adhipati manna is situated on the head at keshavarta. That is at the lambda point. It isthe joining of sutures of parietal and occipital bones; therefore it is sandhi ma.rma. Just belowthe lambda, there is superior sagittal sinus. Due to trauma, superior sagittal sinus getsdamaged which results in profuse bleeding and leads to death. @r. R.B. Gogate & Dr. Mukund Erande) Adhipati marma is an oblivious point at the crown of the head. The interperietalsuture does exist here and confluence of parietal emissary veins and superior sagittal sinusare the underlining structures. Injury causes infection or hemorrhage depending upon thenature of injury and leading to death. (Prof. J.N. Mishra) Adhipati marma is located on the back of the head. The underlying constitutingstructures are confluence of venous sinus namely superior sagittal and transeverse sinusesand emissary veins. The associated structures are 4th ventricle and medulla oblongata withpons. Any injury at this point may lead to rupture of venous sinus causing severe intracranialiremonhag.,-*hi"h may directly create compression symptoms and death, or through 4thventricle pressure on medulla and pons holding cardiac and respiratory centers. A simpleopen injury to this marrna, if infected, .fldy cause transfer of infection to the meningesthrough emissary veins resulting into meningitis, encephalitis and ultimately death. (Prof. S.P. Tiwari) Adhipati marrna is situated in the cranium where blood vessels are joining togetherforming a sinus. It is a sandhi marma. Etymologically, adhipati denotes commander, chief ortop (of the head). Confluence of sinuses takes place, where superior sagittal, straight and transverse sinusesmeet on the back of the cerebrum near internal occipital protuberance at the convex border ofthe felix cerebri covered by dura along with lacuna lateralize (inegular venous recesses),which contain arachnoid granules. On surface marking, it is situated in the vicinity ofposterior fontanel and at mid line posteriorly along the sagittal suture. Injury, whetherpenetrating or blunt, may cause rupture of sinus along with arachnoid granules, therebydisturbing the absorption of cerebrospinal fluid into the blood, resulting in severeneurological complications and finally death (Dr. V.S. pat) Cranial vault injury will damage the structure around the brain. This is a combination of two word Adhi + Pa. Adhi means urdhva or top. Pa meansrakshati; hence adhipati means that which controls and safeguards from the top. The locationof this marma is within the cranial vault. It corresponds with an area called medullaoblongata (adhipati) in the mid brain nearer to its surface where the ten cranial nerves of boththe sides take their origin as nuclei from the middle line appearing as if hairs spread out insemicircular manner of each side. 93
  • Description: Within the vault (crown) of the head above there is (another) coming together of thesiras and joints. This is like the whorls of the hair and is called the adhipati, the master. Ifinjured this leads to immediate death. - It comes under sandhi marma category, sadya pranahara in prognosis and also is halfanguli in extent. According to Gananatha Sen, adhipati marma is the junction of five siras termed asmahasiravarta. It is a sadyopranaharu marma. It is seated inside the paschima kapala. Inanother context he has said that this marma is a randhra in the paschima madhya simanta ofkapala. This is that part in the body which, when injured, causes severe pain, respiratory andcirculatory failure and fall in btrood pressure. (Dr. C. Suresh Kumar) Adhipati may be considered the confluence of sinuses or torcular herophili. It, beingan anastomosis of many blood vessels, can lead to excess bleeding and even sudden death. (Dr. K.B. Sudhi Kumar) Confluence of sinuses at the internal occipital protuberance - superior sagittal sinus,its communications with transverse sinuses, occipital sinus and veins of nose, scalp, anddiploic vein are vitally important. Thrombosis and suppuration may spread out in relatedareas. Hemorrhage is the main pathology that may lead to death. (Dr. U. Govind Raju)5.9. What is the exact site of kanthasira marma? Is it an artery or a vein? qian@rqFpfr: ehf) oo-oksr q521l- 6eri qkdre+(sft) q :aFa wd aarR g rr €. en. 6/s) (Dr. Kunal Lahare) Kanthasira means ashtau matruka mafina. As they are 8 in number, we shouldconsider all large vessels present on both sides of neck. Those are external and internalcarotid arteries and external and internal jugular veins. Trauma to these structures results inprofuse bleeding and that leads to death (Dr. R.B. Gogate & Dr. Mukund Erande) The vessels situated in lower 213 of neck on both sides of kanthanadi are kanthasiramanna. It is both artery and vein. (prof. J.N. Mishra) Kanthasira marmas are located in the lateral sides of neck. These are four bloodvessels on each side of the neck. The measurement of the marrnas together is said as paanital.As such carotid artery,vertebral dery, external jugular vein and internal jugular vein may betaken as matrika (kanthanadi) marma. Injury to these will certainly lead to death. Some timesit is seen that a person dies after one or more months of a partial strangulation of neck. It isthe example of sadyahpranhar marma changing into kalantar pranahar. Phenomenon ofpathogeneiis is very clear in this regard. On strangulation of the neck for a very short timein...lr a compleie blockage of blood circulation in the brain and when circulation isresumed quickly, there is sudden entry of oxygen in the tissues of the brain. This results into 94
  • either very excessive supply or excessive saturation of oxygen in the tissues. Excessiveoxygen in the tissues leads to oxygen toxicity and formation of free radicals in-the tissues.Free radicals gradually damage the tissues causing fatal pathological ;diri;, -ultimately death (conversion of sadyahpranahar *ur-ulo kalantar p.unihu," -- ""d -ur-ul. (Prof. S.P. Tiwari) Matrika marma is situated at the root of the neck, measuring four inches on either sideof the neck. It is a sira marma and sadyopranahar (fatal), The important blood vessels at the root of neck are subclavian, common carotid, jugularveins, which are branches of source vessels. These may be considered as matrika marrna orkanthasira marma- Since the effect of trauma is sudden death, the damage to vagus nerve andsympathetic plexus in the vicinity of four angulas can also be included. fiercing injury to theabove vessels may cause severe bleeding leading to death or may damage apical pllura in theregion resulting in hematoma leading to death- Even blunt trauma to theie structures maycause vasovagal reflex resulting in irreversible shock and death. (Dr. V.S. patil) It is neither an artery nor a vein. It is an air passage. (Dr. C. Suresh Kumar) The description of kanthasira is very confusing. It is very difficult to specify whetherit is an artery or a vein. It is possible to include even n"rv"s. Grossly nila and manya are toldto be present adjacent to kanthanadi on both sides hence, it can be considered asjugular veinsand carotid arteries and can be fatal even in a mild trauma. The pathological features oftrauma i.e aphasia, change in talking pattern and lack of taste sensation in tlongue, show theinjury to glassopharyngeal nerves as well as hypoglossal nerves. Though all these arepossible but exact correlation is very difficult. (Dr. K.B. Sudhi Kumar) 95
  • CHAPTER. VI MISCELLANEOUS6.1. According to Charak, Kashyap and Sushrut there are 3 mahamarmas viz shir,hriday and basti while according to Vriddha Vaghbhat there are 7 mahamarmas, whichinclude jihva-bandhan, kanth, nabhi and guda in addition to the earlier ones. Pleaseexplain which are the mahamarmas? (Dr. Jyoti More) By gradation, they all are mahamarmas. (Dr. R.B. Gogate & Dr. Mukund Erande) Charak, Kashyap and Sushrut have considered three mahamarmas, which are to becared during critical injuries, whereas Vriddha Vagbhat has considered seven mahamarmas,which are life-threatening. (Prof. J.N. Mishra) The three maha maffnas i.e. shira, hriday and basti are accepted by Charak, Kashyapand Sushrut. Vriddha Vagbhat has added other marmas i.e. jihva, bandhan, kantha, nabhi andguda as maha marmas. They can be explained as following-Jihva-bandhan: This term can be translated as frenulum lingual. This is an importantstructure to produce proper twisting of the tongue while swallowing and speaking. Tongue isalso an organ of taste or gustatory organ. Loss of taste sensation is called ageusia. Other thantaste tongue is an organ ofspeech. The vocal cords create Sound but only creation ofsound isnot sufficient. It should be equally intelligible and for the proper articulation, the tonguealong with pharyngeal muscles, mandibular movements and palate are essential. All theseorgans modify the crude voice produced by the larynx to create understandable speech. Allthese organs are supplied by following cranial nerves- o Pharyngeal muscle - X nerve o Tongue - XII nerve . Muscles of facial expression - VII nerve o Mandibular movement - V nerve o Palate-Xand Vnerve Vridha Vagbhat has identified it as an important marma.Kantha:The kantha is also an organ of voice and can be translated as larynx. This is also onereason why Vridha Vagbhat has included it as a maha marrna. The explanation concerning the importance of nabhi and guda has already beendescribed in the answers to question No.s 4.1, 4.9. Prof. D.G. Thatte) If we appreciate the value of sadyopranhar marma, we have to accept the separateentity of three mahamarmas (trimarma) and not the others, as the same is approved by thetwo among three of Brthattrayi, by virtue of their medical values. (Prof. S .P. Tiwari) These are the conceptual difference between the two great authors, which may beaccepted or discarded according to ones own discretion (Dr. C. Suresh Kumar) 96
  • Sushrut has not described 3 mahamarmas. According to Charak and Kashyap 3mahamarmas are shira, hriday and basti. This mahamatma word appears in CharikaSamhita Siddhisthan chapter No. 9, which is completely wriuen by Dridhabal. Also he hasmentioned this word for treatment purpose. But Kashyap has explained this word inSharirasthan, where the counting of organs is mentioned. First he has mentioned 107 marmasand then 3 mahamarmas to show the importance of these 3 marmas. Also the details of thesemarmas are not available in samhitas. Vriddha Vagbhat has explained the wordmahamarma in the context of 10 pranayatanas. In that the first 7 marmas are mentioned asmahamarma. There jivha bandhana is not mentioned as mafina in marmavibhaga sharira.Marma classification is based on trauma; it is very difficult to injure this area. VriddhaVagbhat wants to emphasize the importance of these pranayatanas. So we should consideronly 3 mahamarmas. (Dr. K.B. Sudhi Kumar) Owing to the clinical importance observed by the Vriddha Vagbhat seven mahamarmas might be grouped. Structural entities, where especially pranas are located can beconsidered as marmas. Because jihva bandhan is an anatomical component and one of thepranayatanas, it might have been described as marma. But, it is not observed by any otherauthor as marma and nor even mentioned in manna chapter of Asthanga Sangraha. It is alsonot classified under any marma subclassification. Extrinsic muscles of the tongue (hypoglossus) can be considered as jihva bandhan. An injury in this region might have been observed causing damage. For example aknockout blow in the region of mandible may affect the brain stem and further leading tounconsciousness. (Dr. U. Govind Raju)6.2. Most of the modern surgeons perform surgeries without knowing any marmasharir, but in Ayurveda marma sharir is quoted as the half of the shalya tantra. Then isthere any relevance between marma sharir and modern surgery? @r. K.D. Sathe) Principles are given in surgery. The incisions are taken considering the nerve andblood supply. Although there is no direct thought of marma sharir in modern surgery, everyattempt is made even today to avoid vital and dangerous areas by modern surgeons also;otherwise many complications occur in the present era also if due precautions are not taken. (Dr. R.B. Gogate & Dr. Mukund Erande) It is important to have not only the structural knowledge or morphological details ofmarma points but the knowledge of minute details of gross and microscopic anatomy are alsorequired to become a good surgeon. Modern surgeons are well versed and well acquainted with the detailed anatomy ofthe human body right from embryonic life till the end of life. Sushrut has also emphasized onleaming human anatomy right from the superficial structure i.e. skin to deeper anatomy forbecoming a skilled surgeon. er$;i sden {rd a-{<r +E "il f}rqq 3rrgtd e+ orerSa +< *o:geq<q I (q. % orte) q weFanu *sqdarftFeqq, *E od*ss=ftg tgBa rr (q. z1. 6/16) 97
  • Modem surgeons know various types of incisions given on the body surface keepingin mind the firndamental principle in relation to bhedan karma, which is as following- The knowledge of marma never goes in vain but it keeps the surgeon all the timecarefrrl and conscious while putting the knife and removing wound. (Prof. D.G. Thatte) It is wrong to say that modern surgeons perform surgeries without knowing any vitalpoints of the body; rather they are more particular about anatomy of marmas, which meansvulnerable structures. Elective surgery initiates the injury, whereas civil and military woundsinitiate surgery limiting the duration of injury phase due to interference of marma. Fatalityrate of trauma is reduced gradually because surgeons have started understanding betweenelective surgery and trauma surgery with difference. (Prof. J.N. Mishra) Of course, when the description of maffna sharir was evolved in the later part B.C.sophisticated surgical measure, as we have now, were not available to the surgeons and henceit was advised to avoid the marma sthan from surgical procedures. Even in present daycertain types of sections are not practiced very much; the modern surgeon tends to eitherpostpone or avoid, or opt for this surgery only in case need arises. Also see the quotation inSushruterdor a eSeiq r (Dr. C. Suresh Kumar) This will be wrong to say that surgeons perform surgery without the knowledge ofmarmas. In fact they know the applied anatomy. Applied anatomy is the modern form ofmarlna sharir. Difference between the two is only because of time, language, methods andsize of materials. Scientific values and application of both are same. So the theory of marmabeing half of the surgery is true as said by Sushrut. Similar quotations are also available inthe subject of applied and surgical anatomy in modern. (Prof. S.P. Tiwari) No doubt the modern surgeons do not have any knowledge of marma but they will behaving the complete knowledge of anatomy of body with its applied or surgical aspect, whichis essential for all the surgeons. Because of this knowledge of each and every structure underthe knife, a surgeon can prevent surplus cuts on the body and thereby help prevent thecomplications during a surgery. (Prof. M. Dinakara Sarma) A modern surgeon will be well aware about vital structures of body, which arenothing but marmas in other terms. Because of that during surgery they are making specificincisions like oblique, horizontal etc. and during operation they are not disturbing these areas.For example operative care of vas deferens is taken in hernia,. (Dr. K.B. Sudhi Kumar) Though allopathic surgeons perform most sensitive and complicated surgeries, theyalso face many diffrculties and obstacles, and sometimes even failures. They also avoid somestructures while making incision. 98
  • Marma sharir is based on the clinical experiences. If marma sharir is explored furtherwith modern tools there would be possibilities of more success and with less effort in themodern surgery (Dr. U. Govind Raju)6.3. What is the relevance of studying ancient traumatology in modern era ivhereintensive trauma care system and emergency management have developed in modernsurgery? (RAV) This is possible only in the big cities. India is still a land of villages. (Dr. R.B. Gogate & Dr. Mukund Erande) There are two parts of surgical aspects; one is the traumatic problems at certain vitalareas and another is surgical answers through excelled skill of management. The study ofmarrna only tells the specific anatomy of the body that is prone to life threats and traumasurgery gives the message of success on problems through the developments. (Prof. J.N. Mishra) Still there is room for marma sharir. Need of the time is to work together for thebetterment of human service and development of science. Knowledge of marma sharir is alsoimportant for preventive purposes, for both trauma and diseases. (Prof. S.P. Tiwari) Ancient traumatology has got significztnce mostly for an Ayurvedic practitioner. Notonly surgical practice, all sorts of medical practice are incomplete without proper knowledgeof marma. It allows understanding of many consequenees of diseases on Ayurvedicprinciples. Many patients come to us after marmabhighata with a traumatic or postsurgicalproblem, or a complication. For example after shirobhighata many patients get paralysis, butafter treating the ulcer of injury, complications like paralysis still remain. Thesecomplications are better treated with Ayurvedic principles and knowledge of ancienttraumatology. Many ancient texts are available in incomplete form. It is also possible thatthey might have had separate branch and textbooks for marma chikitsa. The incomplete andunexplained surgical texts need a proper knowledge of marma. This we can analyze withkantha marmabhighata as told in Sushrut Samhita Chikitsasthan 2130 and shirobhighatatreatment in 2169-7A. The given treatment is very diffrcult to do now. If we develop thesetreatments, patients will be getting more benefits and lesscomplications. (Dr. K.B. Sudhi Kumar) Marma sharir is also concerned with the pranas, treatment procedures and surgeryapart from traumatology. Even modern traumatology, despite the advancement, has its owndrawbacks and failures. Appropriate clinical research and re-establishment of marma theorymay certainly become complementary to modern surgery. (Dr. U. Govind Raju)6,4. How do we simplify concept of marma to undergraduate students? (Dr. M. B. Ramannavar) 99
  • It can be taught well during surgical procedures and dissection. (Dr. R.B. Gogate & Dr. Mukund Erande) Marma is one of the medical sciences, which require special care and protectionduring the critical surgical management as compared to other places. (Prof. J.N. Mishra) Marma sharir can be simplified for undergraduate students. Following suggestions aresubmitted for due consideration on this account. o Philosophical part be either explained on scientific parameter or be removed. o Every other point like praman, marakatva (fatality), marakakaal should be scientifically made clear. There should be no confusion in this regard among the students. o Those marmas, which cannot be explained scientifically and remain doubtful be put in separate category by the name of sandigdh& trlsrrrl&s: o List of marmas be innovated by adding more names of vital points, e.g. vankshana (hip joint), kati (lumber), yakrit (liver), pliha (spleen) etc. o Material of study should be renovated by adding the new knowledge exhaustively from modern science. (Prof. S P Tiwari) The contemporary developments have contributed a lot to the management of trauma,especially where surgery is required. But still in cases where non surgical management canbeperformed Ayurveda has its own role to play in a very significant way. It is already simple and suitable to a professional student. (Dr. C. Suresh Kumar) o With the collection of our books and other upanishads, yogas etc. o With the help of 3 dimensional computerized pictures. o With the knowledge of our basic concepts of sira, dhamani srotas (1t collection of references of sira, dhamani , strotas and their diseases, treatments etc.) o With doing dissections by Sushrut methods. o With all Ayurvedic basic principals like agni, mutra nirmiti, agni vardhan ahar after raktamokshana etc. @r. K.B. Sudhi Kumar) Entire maffna descriptions as available in the texts are concerned with appliedanatomy. Hence, the gross anatomy is very little. This topic may -be incorporated in brief inSharir Rachana and in detail in the clinical subjects like shalya, shalakya and panchakarma.This may help avoid confusion among the undergraduate students. (Dr. U. Govind Raju)6.5. Please explain the scope of marma vigyan in the day today clinical practice. (Dr. DevendraPPa Budi) 100
  • It may be useful while performing the karmas like viddha, agnikarma and diagnosisof probable trauma (Dr. R.B. Gogate & Dr. Mukund Erande) Marma vigyan gives brief account of the vital areas where general physicians andsurgeons would prefer to refer to specialist trauma surgeon, otherwise they will earn badname (prof. J.N. Mishra) It is very clear that the effects of marmaghata are due to the fact that the particularsite is a conglomeration of many important structures like arteries, nerves, ligaments etc.Trauma to these structures definitely will cause serious complications like sudden or delayed death; the severity of the complications will depend upon the severity of trauma. All the marmas are the seats of prana. Owing to this close association of chetana, injury to a marma will produce severe sufferings. According to Sushrut, marrna contains elements of a) soma, V&yu and tejas b) sattva, . raja and tamas, and prana. After injury all these structures tend to get injured leading to serious effects. It is true that due to improved surgical procedures and drastically improved anesthesiaand resuscitation measures, chances of marmaghata leading to serious complications arereduced. Even with improved anesthesia and surgical procedures a very well sedated andproperly relaxed patient may show signs of surgical shock, if the rectal sphincter is stretched.The distended urinary bladder is not emptied completely for fear of shock. These are theexamples of marmaghata effects. In case of heart block, gentle cardiac massage and external pressure on heart stimulatethe heart. Controlled pressure on the marrna does not cause marmaghata. On the contrarygentle pressure on the structures having prana and other important structures is helpful torestart the temporarily stopped functions of an important organ involved with the marma. Important procedure of shirobhyanga for many psycho-neurotic problems is done atthe site of sthapani rnarma. Anatomically this arca may not be relevant but considering theresults it must have significance from yoga shastra, particularly from Charaks point of view. Thus, even though it is agreed that the improved anesthesia, surgery and resuscitationprocedures reduce the chances of marmaghata and serious complications, the relevance ofmanna vigyana is still very much in existence. The concentrated energy (panchamahabhuta and prana) at the mailna site must beused for treating the organs associated and in the vicinity of the marma. For example snehan,massage procedures like nabhi basti at the nabhi marma may be very much useful fordiseases ofthe organs around nabhi. (Prof. Vijay V. Doiphode) Knowledge of marma vigyan is useful in day-to-day clinical practice. Someconsiderations are presented here in this regard. o Serious attention should be given to even a mild injury to sadyopranahar marma and watch technique carefully by"keeping the patient in ICU. o Any of mamsa marma may cause early death because of pulmonary embolism when it is really a crushing itjuty. Early clinical examination and surgical decision are very important in this regard. 101
  • requires long . Every marmabhighat, if it is showing symptoms even after one month, (tissue healers) and home care with ruruyuriu (general tonics and antioxidants), ropan care management. Every rujakar m€rma, when injured require long-term immobilization, but not o We should massage. tvtassale is only a part-ofrehabilitation therapy in this regard. accept it without Prejudice. principles of o For the care of vaiialyakar marmabhighat we have to follow all the complications Ayurvedic as well as modern orthopedics without prejudice. Chronic require long term Ayurvedic treatment . Increase of dose with consideration of toxicity of the drug is a good policy, in any emergency case for gaining good results oxygen facility is must for a clinic and hospital dealing with marma . chikitsa. (Prof. S.P. Tiwari) Many Patients rePorting to the OPD may have various history of injury in reach a perfectpredisposing the present clinical condition. It requires skill to analyse anddiagnosis. (Dr. C. Suresh Kumar) practice the diseases We have already discussed the importance of marma. In medical and pathya-apathya shouldaffecting the marmas slould be dealt witir caution. Swasthavritta practice it adds a lot to understandbe explained in more detail to the patients. In orthopedic and treatmentporriUt. complications as well as possible anatomy of marma involved to understand and schedule theaccordingly. The agni, saumya and vayaviya concept can helptreatments based on dosha involvement .or. K.B. sudhi Kumar)6.6. Please exPlain significance of pancha mahabhutatva in the understanding ofmarma for clinical use. @r. Pranita S. Joshi Deshmukh)6.6. What is the relation between marma and mahabhuta? (Dr Thakur Prasad Sahu) 6.6. Can we practically explain the relation between mahabhuta and marma concept of Ayurveda? Please clarifY. (Dr. Suvarna P.Nidagundi) o.o. :rafqra fr ftfu-er fr ffi d wr ed?r6r B ? (v. rfrrqw d€r"r) 6.6. Please explain the influence of panchamahabhuta in the outcome (whether it would be fatal or oog of marma. How would this be done? (Dr. Devendrappa Budi) perspective We have to look to the ushna and shita tatva in this (Dr. R.B. Gogate & Dr. Mukund Erande) 102
  • There is no- clinical use of panch maha bhuta with reference to marma, - but it gives subjective explanation for the constitution of tissues participating itt 111u.-u. (Prof. J.N. Mishra) Panchamahabhautic consideration of marmas, as presented by Sushrut, is itself ambiguous, then how the values of panchamahabhuta can be fixed for clinical practice. In my opinion such considerations should be taken significant only in medicine. (Prof. S.P. Tiwari) Each and every object, irrespective of living or non living, is considered to be panchabhauthika in origin as per the Ayurvedic concep. Accordinglyihe marmas also follow suit. It becomes relevant in the analysis of prognosis olmarma lsaJhya-asadhyata) (Dr. C. Suresh Kumar) As described above, mostly panchamahabhuta involvement helps to determine thedosha involvement or guna vriddhi and select most suitable drugs or kriya for it. (Dr. K.B. Sudhi Kumar) Direct references about the effects of pancha mahabhuta gunas (saumya, agneya, vayaviya etc) in the management of the abnormalities of marma pradesha are not given in thetexts. However, the g-unas may influence the effects of marmas as these pre-clominantlypossess one or more of these gunas. Once the abnormality is manifested, the line of treatmentis similar to that of any other place but with a special precaution in regard to the *urr.ru. Although trauma to the head can lead to brain injuries, not atl of the damage is due tothe impact alone. Most of the damage may be due to the release of large number of freeradicals i.e., charged oxygen molecules from the damaged cells. Free radiials cause damageby disrupting cellular Dl{A and enzymes and altering the permeability of plasma membrane.Hence, the liberation of free radicals may be due to the abnormal agni guna. Nafurally one or more gunas exist in the places of marma. Ao* Ar they involve in thevitiation of doshas is not clear. Hence, a hypothetical conclusion may be drawn that the typeand individuality of marma may be given more importance clinicllly and gunasconsidered in general. -uy L. (Dr. U. Govind Raju)6.7. Why do so many patients complain of backache after spinal anesthesia? Is thereany marma injury? If yes, what is the line of treatment? (Dr. Thakur prasad Sahu) Bad technique, broad bore needle, formation of a constricting ring. Agnikarma is anuseful treatment for this problem. @r. R.B. Gogate & Dr. Mukund Erande) SoT:. patients complain backache after spinal anesthesia because of inadequatepuncture of ligamentus subflavum, which does not heal properly and cause pain. (Prof. J.N. Mishra) 103
  • There is no marma quoted by Sushrut at lumbar area, but the site is clinically veryimportant for considering it as a marrna in the present era. There are many causes to acceptthis thought. Amalaki, Guggulu with cow milk will be helpful in these cases. (Prof. S.P. Tiwari) There is a possibility of injury to marma following spinal anesthesia, but invariablynot in all cases. It has to be clinically assessed before the line of treatment is decided upon. (Dr. C. Suresh Kumar) According to our opinion the spinal anesthesia is not a marma injury beicause we aredoing with knowledge andavoiding the marmas. Also backache is not a symptom of marmainjurY (Dr. K.B. sudhi Kumar) Marma injury cannot be ruled out as one word in the spinal anesthesia, but theprocedure as a routine does not cause any injury. One the main effects of the anesthesia is the relaxation of structures ofmusculoskeletal system. As the reflexes are absent, any movement during the period ofanesthesia is not protected by the body. Any wild movemeni may cause simple or irreversibledamage to the tissues and consequently may lead to backache. However, in the cases of variations (e.g. extending to a low level) in the spinal cord,extension may also cause complications. (Dr. U. Govind Raju)6.8. Do marmas other than the three marmas mentioned in Charak Samhita have anysignificance in medical treatment or panchakarma treatment? (Reft Cha. Si. 9/10) (Dr. M. B. Ramannavar) Guda in panchkarma (basti chikitsa), pradhamana nasya in hypertensive patients,viddha in jivha roga, nabhi - cupping. (Dr. R.B. Gogate & Dr..Mukund Erande) Trimarma are related to maintaining the physiology of the body through the control,active transport and equilibrium of biochemistry, therefore they are cared during the criticalmedical management @rof. J.N. Mishra) The trimarmas are given the elevated status only because of their roles in maintainingthe internal environment constantly by regulating all other functions. Charak himself hasaccepted the significance of 107 marmas individually. (Dr. C. Suresh Kumar) Most of the marmabhighatas lead to development of vatavyadhi, so we should focus on that. Charak has also mentioned 10 pranayatans in this context. Panchakarma, cornplications of panchakarma and treatment of these complications are all mentioned in Siddhisthan (also in Sushrut Samhita Chikitsasthan). (Dr. K.B. Sudhi Kumar) 104
  • Charak himself has narrated clearly the relative importance of the marrnas. Trunkmannas are important than the marmas of extremities. Among the mannas of trunktrimarmas are more important. Obviously, all marmas have their own significance butpriority is given to trimarmas. Charak also advised to treat all marmas with appropriatemeasures. (Dr. U. Govind Raju)6.9, Is there any role of panchakarma in marmabhighat chikista? (Dr. Devendrappa Budi) Snehan - svedan in conditions occurring due to vata avranaand in contusion. @r. R.B. Gogate & Dr. Mukund Erande) Panchkarma is definitely playing a vital role after post traumatic management. (Prof. J.N. Mishra) aerq ek 6d tl-di ffifrq rn-d a-d qEendqr (a. ft+. s/a) Invariably it is there because in later course, marmabhigata will pave way forimbalance of tridosha, more of vata. We have to either do shodhan chikitsa or shamanchikitsa for the disease. Panchakarma will have a definite role to play. (Dr. C. Suresh Kumar) Yes, basti is the ultimate line of treatment for marmabhighata. Differentpanchakarmas are needed for different marmabhighata. For example virechan inpakvashayagata shalya, vaman in amshayagata rakta etc are employed. After curing injury,panchakarma is the ultimate treatment for complications e.g. virechan in paralysis etc. Otherpara panchakarma procedures like abhyanga, pichu, shirobasti etc are also helpful. (Dr. K.B. Sudhi Kumar) Except the treatment procedures of the diseases of trimarma in Charak, specialcontext of management of manna related diseases is not found in the samhitas. Variouspanchakarma procedures are indicated to treat the shira, hridaya and vasti rogas in Charakavimana like vasti, nasya, parisheka. The same procedures are also adopted for any maflnainjury as per the necessity. Tikshna vasti, tikshna kshara, excessive swedana etc are caniedout with precaution. (Dr. U. Govind Raju)6.10. Please explain what precautions should be taken and any special attention is givento marma points whe performing abhyang .or. sanath Kumar D.G) Not known, apparently not. (Dr. R.B. Gogate & Dr. Mukund Erande) During cry of manna, abhyanga should not be used or there should be only gentleapplication (Prof. J.N. Mishra) 105
  • Excess pressgre should never be applied while performing abhyanga since it maystimulate those points producing undesirable effects at times. Abhyanaga means only application of oil, but not rubbing because while describing During abhyangadinacharya Vagblat has mentiotti-a uUny*ga, vyayama and"then mardan.with mardan wi should take precautious about marrna. If the disease is there at that time, to movements onremove the doshas, we should give different types of pressure and directionalthat area. (Dr KB Sudhi Kumar)6.11. There is a practice of Kalari chikitsa in Kerala since ancient time. What is itsrelevance in marma chikitsa? please clarify @r. Santosh N. Belavadi) Any injury or trauma to a marma poinl- needs an emergency treatment. Treatmentdepends upon ihe-site of trauma in which a specific anatomy is involved: o Patient is conscious or unconscious. o The first aid equipment available at the time and site of trauma Ambulatory ftrfp depending upon the type of a:$ula19e- like four r wheeler, two wheeler, U.tttoct cai, train,-railways or airplanes. Even if these ambulatory sources are not available the patient can be brought io a nearby hospital manually after giving primary care or first aid.Therefore all emergencies in the case of marmabhighat can be managed if there is a moralwill Grof DG Thatte) Kalari chikitsa may be useful in post traumatic residue (Prof. J.N. Mishra) Kalari is basically intended to train the individual for self defence, which has contributed singnificantlly towards the management of trauma in a highly relevant manner extemal medicines The both by different t.eft"iq".. of manipulations and internal and systern-still contribute a lot to the clinical scenario (Dr. C. Suresh Kumar) .marma word has been used by Kalari chikitsak it is very,different from Though the extent but it has got a lot of Ayurveda point of views. The concepts can be similar to a small yuddha i.e- like martial art (war difference. Kalari was traditionally used for people doing with or without instrumentg. It i; the technique to **ug. pain, dislocation of different numbers of joints by rnassage and some iechniques of maniiulation. They are having only 64 based on muscular and ligament mannas that only covers four limbi and trunk.-It is mostly practice and it satisfies only part of injuries. Hence it has got more importance for orthopedic r"u.*u concept in Ayurveda. (Dr. K.B. sudhi Kumar) 108 crucial In Kerala Kalari pattu is known for martial arts. They have identified points as.mannas and out of which, twelve are extremely critical 106
  • 1. The players protect themselves from the injury to these points during play. 2- Skillful abhyanga or foot massage is performed with special intereiton these points which facilitates to tune the flexibility of the musculoskeletal system as per the needs of martial arts and Kathakali (dance). 3. Management of injuries of marma regions is also practiced with specific medicines, massages, tailas and splints etc in Kerala as marma chikitsa. 4. Massage as a special technique is in practice in the management of certain diseases expecting the improvement of flow of prana and subseq,r"ttl reversal of thePathologY (Dr. u. Govind Raju)6.12. What is the relevance of marma and massage ehikitsa practiced in southern partsof dur country? How can it be interpreted? Massage has been contraindicated ur p""modern surgery, wherever there is swelling due to any trauma on any part of body.Methodology of massage in relation to marma chikitsa needs greater elafioration. (Dr. M. P. Erande) Marma does not mean a magic. Same is true for Ayurveda. Any thing that fails on thescientific parameters is never a true. Ayurveda is also a science and not a magic. Massage, aspracticed in south India, is applied in old cases but not in new cases and it is fare. There isvery high scope for massage as a rehabilitation therapy in vaikalyakar and rujkar marmas. Itwill not be fare to apply massage in the new cases of marmabhighat. (Prof. S.P. Tiwari) In South India, where massage is practiced, it is not at all performed when there isexcess amount of swelling. Only when the swelling becomes under control massage isindicated as a management measure. The medicated oils, powders etc used at the time ofmassage bring in the desired clinical effect. (Dr. C. Suresh Kumar) A9 explained in the previous question in Kerala massage therapy had got a importantcontribution from Kalari chikitsa. Similarly in Tamilnadu Agastiar system had influenced it.Some other traditional systems are also there having similarity to Ayurvedic description. Inthese systems also mild massage (not drastic massage) with more application of oil andbandage are done. It is a wrong conception that massage is done over swelling. After sevendays only more massage is employed. (Dr. K.B. Sudhi Kumar) Greater exploration and research are required in the massage therapy. In south India it is practiced in thp management of certain pathological conditions andsatisfactory results are also appreciated. The hypothetical consideration bJhind this therapy isto improve the free flow of prana in right direction and there by leading to achievement of.aviltt ^ium among the doshas. (Dr. U. Govind Raju)6.13. What is the emergency treatment in marmabhighata? (Dr. Santosh N. Belavadi) 107
  • The treatment of marmaghatawill primarily depend upon the effects produced by theaghata. The effects will primarily vary as per the site and severity of trauma. The severe thetrauma serious will be the results. The signs and symptoms will be as per the type of marmae. g. ruj akara, vaikalyakara, sadyopranahara etc. In addition to the symptoms and signs produced as per the type of marma,marmaghata will produce following signs and symptoms - The marmas, where some vessels are injured, lead to blood loss and signs of shockare evident. Marmaghata particularly of sadyopranahara marrna needs immediate attention. Anemergency treatment, all measures to replenish the loss of blood, fluids, electrolytes andother essentials need to be adopted. Management of shock must be a priority in most of thecases. The bleeding is due to cutting of a vessel. To stop the bleeding, application of atourniquet at higher level, ligation or cauterization of the injured artery can be done. Thereare many drugs to reduce the internal and external inflammation (swelling, pain, buming etc)when the condition of shock is alleviated. These procedures can be adopted. In southem parts bf India, a mixture of herbomineral ingredients (?) is used fortreatment of marmaghata. Actually the line of treatment will depend on management of shock or bleeding andother associated signs and symptoms (prof. vijay v. Doiphode) There should be care of trimarma in marmabhighata and only skilled vaidya shouldhandle it with updated knowledge of surgery and technology. (Prof. J.N. Mishra) o Treatment of shock o Control of bleeding r Blood replacement r Immobilizationof the affected part, if possible.All shall depend on the type of marmabhighata and the facilities available. (Dr. R.B. Gogate & Dr. Mukund Erande) o Provide resuscitation method r Maintain clear airway o Control bleeding, if present o Maintenance of fluid balance and 108
  • o All other emergency measures, which are necessary, ffi&y be employed. (Dr. C. Suresh Kumar) s€aerei q sffi€rr+d r (sr.zi. err. arze) Sadyowana treatment should be done for first 7 days. After stopping the bleeding asmentioned in sadyovrana treatment, assess the doshas, dushya, disease, complications andsymptoms, and then treatment should be given. (Dr. K.B. Sudhi Kumar)6.14. Surgical intervention or accidental injuries are no more marmaghata in currentscenario. Systemic disorders are distorting the marma structures and hence medicaldisorders are more valuable in marmaghata concept e.g. rheumatoid arthritis causingmitral stenosis, pulmonary tuberculosis causing urahkshata etc. Please give a kindopinion and explanation for these changes in tissues due to marmaghata. (Dr. Pranita S. Joshi Deshmukh) No, they are the effects of diseases on particular marmas and the pathology is quiteslow. After thorough interpretation of Sushruts quotings in sharirsthana and at many otherplaces, and considering the importance and difficulties in surgery during those days, it isquite evident that emphasis was given on external trauma; although marrna has beenmentioned as the parr of madhvama rogam*r" "l;"jrffi: [:ffiTffo". Mukund Erande) It is a prejudicial thinking that accidental injuries are no more marmaghata in currentscenario. Systemic disorders distort the marma structures as upadrava. Moreover, intensity ofcare and precautions are notaltered. (prof. J.N. Mishra) This is wrong to say that surgical intervention and accidental injuries are no moremarmabhighat. If there is wrong application of surgery at the marma point, it will bemarmabhighat and accidental injuries on marma point will be also marmabhighat. Systemicdisorders are always diseases attracting internal medicine. Pathogenesis under trimarma isdifferent entity, as it is based on the medical values of systems. (Prof. S.P. Tiwari) Urahkshata may predispose pulmonary tuberrculosis, RHD may predispose mitralstenosis. But by themselves the uras and mitral valve are not maffnas but are parts of marmaalonO. Marmabhigata may predispose system disorders, either instant or latent e.g. kukundarmarmabhighata. (Dr. C. Suresh Kumar) Marma concept of Sushrut seems to be based on agantuk abhighata while RA andtuberculosis are nija vyadhis with different pathophysiologies, so they should not beconsidered among marmabhighata. Trimarma concept in Charak Samhita may be interpretedfor swasthavritta anupalana for their prevention. In other way understanding the danger tomarma, earlier control of the disease should be attempted first. @r. K.B. Sudhi Kumar) 109
  • Even though the surgical intervention in traumatic (accidental) injuries is welladvanced, further researches are being continued in this field to overcome manycomplications, technical problems and for easy appropriate solutions. Many complicationsur" obr.*"d even after prolong advanced treatment. Hence, exploring marma sharira can notbe ignored. There is no doubt that extemal or internal injury to marma leads to abnormality. Theflow of pranas and panchabhautika configuration are disturbed. These further lead to dosha-dhatu uuirhutttyu. Texts also confirm indirectly by indicating to give special importance inthe treatment. However, exploring individual marmabhighat in all aspects is essential tounderstand the concept. @r. U. Govind Raju)6.15. What is the parameter to demarcate and measure the given marma? (RAv) The demarcation of a marma is the determination of location of marma. It is done onthe basis of nomenclature, location anatomy, symtomatology, structural category andmeasurement of marma. For measurement of marma the smallest scale is ardhanguli praman,which is different from person to person but normally it is equal to lcm in radius. (Prof. S.P. Tiwari) Sushrut and others have already given parameters to demarcate and measure the marma.It requires only translating into present criteria and scenario. (Prof. J.N. Mishra) It is yet to be evolved with widespread deliberation and experimental studies. (Dr. C. Suresh Kumar) Anguli panitala etc are measurement units that have been used then (in earlier time)but in contemporary applied aspect they may differ some time. In trimarmas, it may be totalorgan and not a particular Part. (Dr. K.B. Sudhi Kumar) There is no any specific parameter to measure the pramana of marma because there isno any particular explanation about in what way to consider depth, width orcircumference.So as suih there is no any particulafparameter or information about this. (Dr. G.M. Kanthi) The motto of description of maflnas is - to protect them from external or internalinjuries; to prevent the surgical injuries in these areas; to give special attention during themanagement of abnormalities related to the marmas. Stmounding areas of marmas are alsoconsidered as special points. Different types of classifications ate made to meet differentgoals. By satisfying all these conditions, demarcation and measurement of mannas aredifficult unless other wise clinically proved with satisfactory results. (Dr. U. Govind Raju) 110
  • 6.16. Anguli pramanas of all marma are told. What does it indicate? How should wemeasure and in which direction/plane? Is it length, breadth or depth of marma? (Ref:Su. Sha.6/25) (Dr. Harshavardhan B.) It is the surface area measured in anguli pramana, just like even today clinicalmeasurement of diseased liver and spleen is done in hngers along the axis of structures. (Prof. J.N. Mishra) Anguli praman of marma is not the length, the width or the depth. It is parivistar,which means radial extension from a point. Parivistar is the word used by Sushrut. (Prof. S.P. Tiwari) It may be in any direction depending on the structure. The anguli pramananarrated in various other books of marma chikitsa has certain significance. It is not only thesurface area but also the force needed to stimulate. It is defined as the force needed to pierceone anguli of ones finger into a stem of plantain in an approximate distance of one metre. Itis also said, if you want to teach you should use Yq anguli force and for treatment :use Yzanguli force and to injure use full force (Marmapirangi). (Dr. C. Suresh Kumar) Measurement in anguli, which was used in earlier time for measurement purpose,may be used in different planes. They might be dealing with length, breadth or width as wellas depth. (Dr. K.B. Sudhi Kumar)6.17. Is the measurement of marma given in the aspect of length or width? How do welocate the exact marma point based on measurement? Measurements are told for allmarmas but how to measure the particular marma is not mentioned. (Ref: Su. Sha.6t28-29) (Dr. Prathibha Prasanna) Maximum pain producing point is the marma. (Dr. R.B. Gogate & Dr. Mukund Erande) Specific measurements have been given to every marma. Rest is as above Qs. No.6.16. (Prof. J.N. Mishra) The extent of marma is explained in terms of anguli. The area occupied by the maffnais explained in terms of own finger breadth (svanguli). To have proper understanding of theextent length, breadth as well as depth need to be taken into account e.g. I angula willindicate the site of marma is 1 angula long, 1 angula broad and I angula deep. The directionor plane of the marma will depend on the site of marma. (Prof. Vijay V. Doiphode) Measurement is neither in the aspect of length nor in width, but it is parivistar (radialextension from a point). Ardhanguli may normally be I cm or half of the width of middlefinger of the respective person. This may be considered as a fool proof method. Please referto reply under 6.15 for more detail. (Prof. S.P. Tiwari) 111
  • It may be in any direction depending upon the structure. (Dr. C. Suresh Kumar) Measurement given in the aspect of both length and width or even depth should beconsidered. Exact marma point is diffrcult to state. It may differ in different kind of marmas. (Dr. ICB. Sudhi Kumar)6.18. Marmas are physiological points or anatomical points because we are not gettingmuch vital structures in so many points ex. guda is sadyopranahara marma. How canwe justify by using pramanath rachananusar etc ? (Dr. M. B. Ramannavar) For some mahamarmas viz shir, hriday and basti marmas are anatomical andphysiological points, but for others these are particularly surgicoanatomical points. There isno controversy under guda. Guda is sadyopranahar, because of its fatality throughhemorrhagic complications or through intestinal obstruction caused by injury in themusculature of anal canal and perineal region. As the perineal region is corresponding to thesize of paanital and guda marma is mamsa manna as referred by Sushrut. Hence, there is nocontroversy in this regard. (Prof. S.P. Tiwari) No anatomy appears without physiology. Anatomy is cause and physiology is effect.Guda as sadyahpranahar marma and its measurements have already been discussed. (Prof. J.N. Mishra) Marmas are basically anatomic parts and invariably anatomy and physiology are twosides of the same coin which are interdependent. Mainly, neurological shock is responsiblefor the clinical lesion in guda marmabhigat. (Dr. C. Suresh Kumar) Marmas are mostly anatomical structures producing pathophysiological effects ininjury. @r. K.B. Sudhi Kumar) Marmas are the points having both applied physiological as well as anatomicalimportance as per the textual references. As far as the vitality of the structures is concerned -the effect ofinjury depends on force applied, nature offorce or weapon, extent and kind ofthe area involved, general strength of the body of the person injured and efltcacy of themanagement etc. Death occurs by irreversible cessation of firnctions of heart, lung and brain.An injury to sadyah pranahar marma, depending on the above conditions may leadsubsequently to death. For example: in case of injury to guda" due to porto-systemicanastomosis and venous plexuses, suggestive of heavy bleeding points, there is lack of bonyor dense support against which it can be compressed to arrest the hemorrhage; hence,bleeding may lead to shock. (Dr. U. Govind Raju)6.19. Ctassical text has mentioned specific pramana for each marma, how does onemeasure this? Should it be in anterioposterior or in transverse direction? (Dr. M. B. Ramannnavar) lt2
  • 6.19. Does the angula praman of marma indicate length, depth or width? What is thesignificance of this? (Dr. Vivek B. Patil)6.te. "rdrfg* xnrsT + e{Telrq q{ ct+6 dd +t physioanatomical entities e}d* we frsr i;rr$ a (Dr. R.B. Shukla) Already discussed but more so physio-anatomical entities of any mulrma needs fulldescription, it cannot be clarified only on the basis of marma anguli pramana. (Prof. J.N; Mishra) Measurement of structures included can be based on the physioanatomical entities (Dr. K.B. Sudhi Kumar)6.20. What are the different sites of sevani marma in male and female? (Dr. Kunal Lahare) There is no sevani marma; rather there are seven sevanis, out of which five are simantmarma situated in shiras. (Prof. J.N. Mishra) Sevant is not a marma. It is not quoted by Sushrut in sharirsthan. Other references do marmanot sufftce to say it a (prof. s .p. Tiwari) Marmas are not different sites depending upon gender. (Dr. C. Suresh Kumar) Can be considered to be in median raphae. (Dr. K.B. Sudhi Kumar) Sushruta in general did not explain sivani manna. He told simanta marrna in ashmarichikitsa adhyaya. The special reference given to sivani marrna is especially related to sastrakarma. So here we can consider the perineal raphe mainly related to perineum and anothersivani ie linea alba (Dr. G.M. Kanthi) Sivani in females, coresponding to sepha in males, can be compared with clitoris.Anatomically suture like arrangement is not seen in the clitoris but it is homologous to thepenis and also injury to this is not so easy to treat. Sivani is not considered as mafina. (Dr. U. Govind Raju)6.21. Should we consider sevani as marma as Sushrut has told in Chikitsasthan? ffi g6a{"ft grtd-si qa*frr qr+q; ---- n (Dr. Jyoti More) 113
  • yes, it is a commonly occuring accident while removing ashmari by perineal route oreven perineal prostatectomy in the earlier days of modem surgery In perineal trauma we getsuch patients (Dr. R.B. Gogate & Dr Mukund Erande) No. (Prof. J.N. Mishra) Refer to above rePlY (6.20). (Prof. S.P. Tiwari) Sevani can be considered as a maflna since it is also a vital point (Dr. K.B. Sudhi Kumar) explained that this Sushrut has advised not to incise the sevani during the surgery andcauses severe pain. Sevani itself is a suture and practically it is difficult to get sutured againand healed p.operty. probably this could be the i.utott for not including it in marma as it isnot a seat of ptunur and not a common site of injury in warfare. (Dr U. Govind Raju)6.22. While applying a kshara to the affected area, sushrut has cautioned to take greatcare. How ."o ttrir 6e correlated to the expanse of marma? The same querry appears in avoid for agnikarmarelation to agnikarma where the site of marma has been advised to(Su. Su.31/11 & Su. Su. 12112)? Kshara is applied on ih" surface area of the affected region. If it is a tikshna This can be kshara, it may harm the marma point in case of accidental application related to irritation of cutaneous nerves underlying the marma point. Hereo the be considered as more dilemma happens as to whether some particular marma should sensitive than others, which when irritated causes instant death or damage to underlying structures Su. Su. lll28129) /n- rM. P. Erande) (Dr. In viddha chikitsa and agnikarma, proper care and technique will never cause damage to any marrna fl)r. R.B. Gogate & Dr Mukund Erande) Ksharakarm a and agnikarma are among surgical measures according to Sushrut and others, therefore, the doctrine is the same. Similar precautions have to be taken as in surgery preferred to be obliged Any violence over marrna may harm it; only skilled vaidya is (Prof. J.N. Mishra) Kshara is applied on the surface area of the affected region. If it is a tikshna kshara, it may harm the marma point in case of accidental application. This can be related to irritation happens as to whether of cutaneous nerves underlying the marma point. Het", the dilemma some particular marma should be considered as more sensitive than others, which when (Su Su 11/ 28-29) irritated causes instant death or damage to underlying structures (Dr. C. Suresh Kumar) tl4
  • Guda is among sadyopranahararrtarma, hence while applying kshar or agni care is taken to see that they affect only the pathological parts, but not the normal tissues. practically also we see that they aggravate the pain if they touch the normal tissues. Some times damage to vessels may result in excess bleeding as well as vasovagal shock. (Dr. K.B. Sudhi Kumar) 623 Marmas are vital areas in our body for which kshara, agni and shashtra karma are contraindicated. Then what is surgical importance of marma sharir? (Dr. M. B. Ramannnavar) o To avoid them during surgical procedures and o For probable diagnosis for further reparable surgery. (Dr. R.B. Gogate & Dr. Mukund Erande) Marma sharir exposes the importance of skilled vaidya, who should maflnas. This knowledge also saves the vaidya from bad name. only take care of (Prof. J.N. Mishra) Knowledge of marma sharir is presented for preventive purpose, so that the vital areas in the body are protected from injuries and run b" -*uged better if trauma to occurs, and the disabilities can be prevented. This is why agni, kshar and marmas shastra karma are contraindicated under prevention. Thus the surgical importance of marma sharir is proved. (Prof. S.P. Tiwari) As told above. Contemporary advances have made the surgery easy now a day. Thesewere not available then. (Dr. C. Suresh Kumar) Surgical importance is to deal these areas cautiously. As discussed above these areintended only to remove the pathology and should be applied on it, but not on the normaltissue. (Dr. K.B. Sudhi Kumar)9-24- *a, ano1, aq, ffi, F, a-q t ereft ad # s{Ekfu aa qrqA E f6 arrofuo *q err$Fo N a} q errfrfue; *q "-d} E r *+n ar51fuotfr rr+nfua 6se E r qat ar# + fr-{rc fr ErEr, aErr ?G}r rr qra fua ouq}6it afrphysioanatomically we fu-qr GrT ErrD?rT B qqr ? (Dr. R.B. Shukla) Tridoshas are subjective explanation of marma, but sattva, rajas, tamas and vatapittakapha can be expressed in terms of marma but are under agantuja rogu. (Prof. J.N. Mishra) Soma, maruta, agni concepts have been discussed previously. It is definite thataccording to the state of sattva, ru1a and tama in a person the ruja{ara property will beaffected. However, it is very diffrcult to explain the role of these in thepathogenesis. -uhugunur (Dr. K.B. Sudhi Kumar) 115
  • A lot of work is required to be done by Ayurvedic fratemity in this regard. Forexample CT scan or MRI can assist in establishing the biochemical differences betweensattva-, rajas- and tamas-dominated individuals. Presently available investigative proceduresmay be useful in establishing some of the parameters related to soma, marut and tej. Pleaserefer to the reply no.2.7. (Prof. V.V. Prasad)6.25. Sushrut has explained treatment of all types of diseases except marma abhighateven though he knew its importance. Why? (Ref: Su. Sha.6) (Dr. Harshavardhan B.) Sushrut advises to avoid them during surgical procedure as there was lack ofanaesthesia, complete anatomical and physiological knowledge from surgical perspective.Anastomosis surgery was not possible. (Dr. R.B. Gogate & Dr. Mukund Erande) Marma needs surgical interventions, not the medical treatment alone. School ofSushrut knew that surgery is a skill, which changes from time to time and develops with thepace of time. Therefore, skilled vaidya has been mentioned by Sushrut to take care ofmannas (Prof. J.N. Mishra) The knowledge of marma was utilized by three groups of people o Ayurvedic practitioners o Siddha practitioners e Martial art practitionersAll these people have their own principles and philosophies that they meticulously follow.The information on maffna in Ayurveda was primarily used to avoid surgery in that area.Siddha practitioners were utilizing the knowledge to treat and also to avoid getting hurt. Inmartial arts people were making use of this knowledge to o To prevent getting hurt o To treat o To inflict maximum possible irreparable injury to the opponentSushrut has left this to the kaya chikitsak. He has given prominence only to shalya tantra inhis treatise. (Dr. C. Suresh Kumar) The main motto behind the description of marrna is to make the physician cautiousduring surgery and treatment. In Sharirsthan it has been emphasized to locate these structuresas well as their pathology. Marmabhighata lakshanas mostly resemble mada, murcchha,sanyasa, raktasruti, vataprakopa in sadyovrana and many time shalya abhighata, bhagna,sandhichyuti and vatavyadhis. These treatments have been detailed in other parts of theSamhita. Secondly, different marmas will have different features according to the tissueinvolved in their anatomy and severity of injury to them. Hence they need to be treatedaccordingly. Mostly after seven days, treatment will be like that of nijavyadhis. All thesehave been described in different places so might not have been repeated in Sharirsthan. (Dr. K.B. Sudhi Kumar) 116
  • ::# Sushrut has given special importance to protect the marmas from injuries (surgical oraccidental) and marmabhighat. He might be of the opinion that management could beplanned according to general principles, depending on the structures involved and severityand symptoms of injury. (Dr. U. Govind Raju)6.26. q. q: 11/4a fr T{6 e zrueer zbr a-d sGaqra fr Efiflra€r fuqr B,fu€ 3rrqrd gg-d e dfr fu-qr B sr€T S qo.qrFr fi znu-su o) eqa Frg 6tr rBrrrus{r ga a;* T{a Frrg: Id gs q{ fr Frg cren 5o-g"T qi ErF Trq o-ed or tTrsd wr Ba (Dr. Tapasya Gupta) The meaning of kandara is to be taken in relation to diseases concerned.Asrujam kandara sira (dhatutpatti) in kamala agnikarma is done at the base of the thumb.kandara bahu pristhta - vishwachi - vat vahinya - nakhamule antahkandara snayu pratanah I (Dr. R.B. Gogate & Dr. Mukund Erande) Kandara is a part of snayu or in other words kandara makes up snayu and snayu isconsidered as one of the constituents of making up of marma. (Dr. C. Suresh Kumar) It seems to be a wrong interpretation of Charaks quotes. Charak has only consideredshira, hriday and basti as marmas; remaining are included under madhyama rogamarga notunder malma. Chalgapani has clarified the difference between kandara and snayu. They havedifferently stated with different numbers in human body so they are considered differently. (Dr. K.B. Sudhi Kumar) In the context of asthi-samyoga, snayu and kandara have been mentioned as they arecoexisting to bind the structures at the sites of joints. Kandaras are not included among thestrucfures of the maffna. In general, Sushrut has also defined large snayus as kandaras.Hence, kandaras need not be essentially present at the sites of marrna. Kandaras can beinterpreted with large and long fibrous materials (as tendons) which help binding differentstructures. Snayu is defined as bandhan of mamsa, asthi, medas etc. They are present in marmaplaces also and can be correlated with ligaments, sphincters, fascial folds, fascia and itsmodifications like aponeurosis, retinaculae, sheeths. @r.U.Govind Raju) It7