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Transcript of Hastamarma, sr
“A COMPREHENSIVE STUDY OF MARMAS IN THE HASTA (HAND)
W. S. R. TO THE SURFACE AND REGIONAL ANATOMY
(CADAVER DISSECTION)”
BY
DR.VIJAYNATH.V
Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.
In partial fulfillment of the requirements for the degree of
DOCTOR OF MEDICINE (M.D)
In
SHAREERA RACHANA
UNDER THE GUIDANCE OF
DR.U.GOVINDA RAJU
M.D (AYU), M.A (SANSKRIT), P.G.C.R, C.G.L
Professor & HOD
Dept of P.G. studies in Shareera Rachana.
DEPARTMENT OF POST GRADUATE STUDIES IN
SHAREERA RACHANA
S.D.M. COLLEGE OF AYURVEDA, UDUPI – 574118
2010 -11
DEDICATED TO
MY FAMILIY
FRIENDS
&
TEACHERS
Abbreviations ….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page III
List of Abbreviations used
A MüÉå : Amara kosha
A.¾û. : Ashtanga Hrudaya
A.¾û.zÉÉ : Ashtanga Hrudaya Shareera Sthana
A.¾û.ÌlÉ : Ashtanga Hrudaya Nidana Sthana
cÉ.xÉÇ : Caraka Samhita
cÉ.ÍcÉ : Caraka Samhita Chikitsa Sthana
cÉ.ÌlÉ : Caraka Samhita Nidana Sthana
cÉ.ÌuÉ : Caraka Samhita Vimana Sthana
cÉ.zÉÉ : Caraka Samhita Shareera Sthana
cÉ.xÉÔ : Caraka Samhita Sootra Sthana
cÉ¢ü : Cakrapani
pÉÉ.mÉë : Bhavaprakasha
U.ÌlÉ : Raja Nighantu
zÉ .Mü. SìÓ. : Shabdha Kalpa Druma
uÉÉ.uÉÉsÉ : Vachaspatyam,Volume.
zÉÉ xÉÇ mÉë : Sharangadhara Samhita Prathama khanda
xÉÑ xÉÇ : Susruta Samhita
xÉÑ.ÌlÉ : Susruta Samhita Nidana Sthana
xÉÑ zÉÉ : Susruta Samhita Shareera Sthana
xÉÑ xÉÑ : Susruta Samhita Sutra Sthana
Fig. : Figure
Abstract….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page IV
ABSTRACT
The advent of all branches of science and technology is aimed at developing
the living standards of man. The language of any science lies in its ability to provide
solutions to problems with clarity. It includes not only in inventing new things but
also documenting everything in a precise and standardized nomenclature.
Marma is one of the most widely described and at the same time one of the
most debated topics in our samhitas. Acharyas have agreed that the total number of
marmas present in our shareera are 107.Out of the 107 mentioned,11 are present in
each extremity and 5 in each Hasta(hand).They are (i) KSHIPRA (ii)
TALAHRUDAYA (iii) KURCHA (iv) KURCHASHIRA and (v)MANIBANDHA
respectively.
Though the description and the viddha lakshana’s of these marmas are
available in the Samhitas, the structures like muscles, ligaments, tendons, arteries,
veins, nerves etc. present in these regions, their anatomical description and their
applied aspects needs more clarification.
So a standardization of the nomenclature used by the Acharyas pertaining to
these marmas in comparison to the nomenclature of modern anatomy is essential.
Hence to fulfill the lacuna in this subject, the present work will be carried out.ie “A
comprehensive study of Marmas in the Hasta(Hand) w.s.r.to the surface and regional
anatomy (cadaver dissection).
Key Words:
Hasta, Hasta marma, Kshipra, Talahrudaya, Kurcha, Kurchashira, Manibandha.
Index….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page V
LIST OF CONTENTS
Sl. No. Contents Page No.
1. Introduction 1-2
2. Objectives 2-3
3. Review of literature 4-67
4. Methodology 68
5. Observation 69-73
6. Figures 74-80
7. Discussion 81-87
8. Conclusion 88-89
9. Summary 90-91
10. Reference 92-101
11. Bibliography 102-115
Index….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page VI
LIST OF TABLES
Table No. Description Page No.
1 Structural classification of marma 9
2 Classification of mamsapeshi according to shadangatwa 10
3 List of mamsapeshi in upper limb 11
4 List of mamsamarma 11
5 Classification of Sira according to shadangatwa 12
6 Classification of AvedhyaSiras according to shadangatwa 13
7 List of avedhyasiras in a limb 13
8 List of Siramarma 14
9 Classification of Snayu according to shadangatwa 15
10 List of Snayu in upper limb 15
11 List of Snayumarma 16
12 Classification of Sandhi according to shadangatwa 16
13 List of Sandhi in upper limb 17
14 List of Sandhimarma 18
15. Classification of asthi according to shadangatwa as per
SusrutaSamhita 19
16 List of asthi in upper limb as per SusrutaSamhita 19
17 Classification of asthi according to shadangatwa as per
CarakaSamhita 20
Index….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page VII
Table No. Description Page No.
18 List of asthi in Hasta as per CarakaSamhita 20
19 List of Asthimarma 21
20 List of Dhamanimarma 21
21 Classification of marma according to shadangatwa 22
22 Classification of marma according to prognosis 23
23 List of Sadyopranaharamarma 23
24 List of Kalantarapranaharamarma 24
25 List of Vaikalyakaramarma 25
26 List of Rujakaramarma 26
27 List of Swa-Panitalamarmas 27
28 List of marmas having Ardhangulapramana 28
29 List of marmas having one Ekangulapramana 29
30 List of marmas having Dwayangulapramana 29
31 List of marmas having Tryangulapramana 29
32 List of Dwisankhyamarmas 30
33 List of Chatursankhyamarmas 31
Index….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page VIII
LIST OF FIGURES
Figure No. Description Page No.
1A. Kshipra (Palmar Aspect) 74
1B Kshipra (Dorsal Aspect) 74
2A Talahrudaya (Palmar Aspect) 74
2B Talahrudaya (Dorsal Aspect) 74
3A Kurcha (Palmar Aspect) 75
3B Kurcha (Dorsal Aspect) 75
4A Kurchashira (Palmar Aspect) 75
4B Kurchashira (Dorsal Aspect) 75
5A Manibandha (Palmar Aspect) 75
5B Manibandha (Dorsal Aspect) 75
6 Anterior view of palm with vessels and nerves 76
7 Deep palmar arch and its branches 76
8 Surface anatomy of hand 77
9 Surface anatomy of hand (Bony Landmarks) 77
10 Muscles of Extensor Compartment 78
11 Extensor Digitorum 78
12 Extensor DigitiMinimi 78
13 Extensor Carpi Ulnaris 79
Index….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page IX
Figure No. Description Page No.
14 Flexor Tendons 79
15 Abductor PollicisBrevis 79
16 First dorsal interossei 80
17 Dissected Hand - Palmar surface 80
18 Dissected Hand - Palmar surface 80
Introduction…..
INTRODUCTION
The urge of mankind to fulfill its daily needs and the struggle for better living
standards is very much evident in the history of evolution. ‘Necessity is the mother of
invention’ and because of it the various methods and instrumentation to fulfill his
daily needs are getting advanced. Medical science is such an arena that has developed
by leaps and bounds in the last century. The eradication of small pox and
poliomyelitis are commendable ones.
Our great science of life “Ayurveda” has withstood the test of time in a
glorious manner. The manuscripts that are believed to have been written 2500 years
ago contain medications and treatment modalities that are potent even in the 21st
century man, whose lifestyle has entirely changed compared to the ancient one. It is
the eternal “TRIDOSHA” sidhantha that makes our branch of medical science
peerless.
In those times a vaidya had to deal with more exigencies during the time of
war and it might have been the reason why marma was given utmost importance in
our samhitas.Marma are the vital points when afflicted can cause death and need
utmost care while performing surgical proceedures.The details of marma are present
not only in our scriptures but also in Vedas ,Upanishads,Itihaasa and Puranaas.Apart
from our samhitas,Roman and greek mythology mention warriors who guarded their
cardinal points in the body with metal shields.
It is intelligence, skill and cognition that make man the superior being on
earth. Skill of the human lies mainly in his efficiency to perform various actions with
his hand. Acharya Susruta mentioned that “Hastameva pradhaanatamam yantranam”
(which means hand is the most important instrument).
Regional anatomy considers the organization of human body as segments or
major parts based on form and mass. Surface anatomy provides knowledge of what
lies under the skin and what surfaces are perceptible to touch (palpable) in the living
body at rest and in action.
Page 1
Susruta and Vagbhata have mentioned five marmas in the region of hand and a
humble effort is made here in interpreting and standardizing the terminology used in
the samhitas with that of modern anatomy.
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)
Objectives….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 2
OBJECTIVES
1. To make the comprehensive and the conceptual study on the marmas in the
Hasta (hand) as mentioned in texts, in the view of surface and regional
anatomy described in the contemporary medical science. 2. To study the marmas in Hasta (Hand) with modern surface and regional
anatomy by cadaver dissection.
Objectives….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 3
PREVIOUS WORK DONE
1. Gupta.S.K.-has done work on “Kshipra Marma ka vivechatmaka adhyayana”,
1991,National Institute of Ayurveda, Jaipur, Rajasthan University.
2. Borkar B.A. –has done work on “Urdhva-Shakhagata Vaikalyakara Marma: Ek
Rachanatmaka Adhyayana” ,1997, Govt.Ayurvedic College, Nagpur, Nagpur
University.
3. Agrawal Nidhi-has done work on”Shaka-Shareera: A study based on dissection
of cadavers’ w.s.r to applied anatomy”, 1999, National Institute of Ayurveda,
Jaipur,Rajasthan University.
4. Sharma Shyoram-has done work on”Marma-Shareera Vishayantargata Urdhva-
Shakhagata Marmon ka Rachanatmaka Adhyayana”, 2003, National Institute of
Ayurveda, Jaipur,Rajasthan University.
Historical review…
HISTORICAL REVIEW
The evidence of marma shareera has been found in many our ancient
scriptures like Vedas and Upanishads.
VEDIC PERIOD
Vedas are considered as the oldest compiled documents of hymns. They are
believed to have been compiled 5000 years ago. Rig Veda, the oldest and the foremost
one has many medicinal plants described in it. In Rig Veda reference of the words
like varman and drapi, which is some kind of body armor or corselet to protect the
body from assault of enemy weapons. Also we find the reference of the term Kavacha
or breast-plate for the protection1.
Viswakarma’s sharpened (Ayudh) weapon for Indra, which was known as
Vajrah.Indra tormented Vratra Asura (demon) with the help of same by attacking vital
points2.
They are certain unbelievable deeds attributed to Aswinidevas including plastic
surgery. They restored the mobility of Shayava whose leg was cut at three places3 and
blessed the queen Visphala, the wife of Khela Rajah with metal legs when she lost her
leg in the battlefield4.
It is also mentioned that fire (Agni) was used as the ultimate weapon to
destroy Marma5.
MARMA IN UPANISHAD
Plenty of material of anatomical interest is found in Chandagya Upanishad,
Kshirakopanishad, and Garbhopanishad. There are 107 marmas described in
Garbhopanishad6.
MARMA IN ITIHAASA
Marma have been referred in our itihaasa ie Ramayana and Mahabarata.The
arrow shot accidentally by Dasradh to the marma point of Shravan Kumar 7, slaying
of Duryodhana by Bhima with a blow on the thigh during the mace battle 8, slaying of
A comprehensive study of marmas in the hasta (hand) w.s..r. to the surface and regional anatomy (cadaver dissection)
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Historical review…
Lord Krishna by a hunter Jara in the foot and various references regarding the vitality
of marmas are encountered while reading the epics 9.
SAMHITA KALA
The description about Marma location and structures involved in Hasta
pradesha along with detailed explanation of Viddha lakshana, and diseases has been
explained in almost all the classical texts written during Samhita kala. All Acharyas
are accepted total number of Marmas is 107.
CARAKA SAMHITA
Acharya Caraka gave much importance to the Trimarmas these are Shira,
Hridaya and Basti by keeping physician in mind. He also mentioned that according to
the surgeon point of view, total numbers of Marmas are 107 in Chikitsa sthana 26th
chapter10.
SUSRUTA SAMHITA
Acharya Susruta gave much importance to Marma, he told detailed description
on Marma, their types, numbers, locations, symptoms if they injured in Shareera
sthana 6th chapter11.
DALHANA
Dalhana, the commentator of Susruta Samhita explained about Marma in
Shareera sthana 6th chapter12.
ASHTANGA SANGRAHA AND ASHTANGA HRUDAYA
The reference of Marma is available in both the grantha’s, Vruddha Vagbhata
mentioning about the Marma in 7th chapter and laghu vagbhata in 4th chapter of
shareera sthana respectively13,14.
KASHYAPA SAMHITA
Kashyapa accepted trimarma Shira Hrudaya and Basti as the view of Caraka
and told these three Marma are Mahamarma in Shareera sthana 4th chapter15.
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Historical review…
BHAVAPRKASHA
Bhavaprakasha mentioned detailed description regarding Marma similar to
Susruta in purva khanda garbha prakarana adhyaya16.
MODERN PERIOD
The surface and regional anatomy can be traced in various text books of
modern medicine.
Marma Vignana may be compared to the branch of Traumatology.
Traumatology and its various aspects are closely related to the pre surgical,
surgical and post surgical techniques. With the advent of industrial revolution and
machinery accidents involving motor vehicles and various instruments have now
become very common. As a result of that the techniques used in modern surgery have
also advanced and become painless compared to the ancient one.
A comprehensive study of marmas in the hasta (hand) w.s..r. to the surface and regional anatomy (cadaver dissection)
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Review of Literature….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 7
LITERARY REVIEW
UTPATTI OF MARMA SABDA
The origin of the word marma is seen in various texts as given below
AMARAKOSHA explains that the word marma is derived from Sanskrit term
mrunj-maranne or mru pranathyage.It means that which causes death or death like
miseries17.
SHABDHAKALPADRUMA describes the word marma is derived from mru
dhatu.Its meaning is explained as sandhisthanam or jeevasthanam18.
VACHASPATHYA says that the word Marman is taken from mru dhatu,
adding maneen prathyam Mru + Maneen=Maruman……………. Marman19.
Etymologically each letter of the word Marma has got specific meaning.
Ma-means prana or vayu, Repha denotes house or seat. Therefore marma means seat
of Prana or vayu.
DEFINITION OF MARMA
Acharya Susruta has defined marma as the anatomical site where Mamsa, Sira,
Snayu, Sandhi and Asthi meet together. Some experts are of the opinion that it does
not mean that all the structures must be collectively present at the site.Prana dwells at
these sites and so they are important 20.
Dalhana, the redactor of Susruta Samhita has opined that marma is one which
causes death. The vital spots if injured can cause death 21.
Narahari the author of Rajanighantu defined marma as the seat of life 22.
Acharya Caraka has opined that it is the site of Chetana,so the sense of pain
will be more in this region compared to other parts of the body 23.
Ashtanga Hrudayakara has defined marma as the site where Mamsa, Sira,
Snayu, Asthi, Sandhi and Dhamani confluence .He has also said that the sites which
are painful, tender and show unbearable throbbing after getting afflicted with an
injury should also be considered as Marma24.
Arunadatta, the redactor of Ashtanga Hrudaya explains that it is called as
marma because injury to that particular part brings out miseries equivalent to death 25 .
Bhavaprakasha has defined marma as the meeting place of Mamsa,Sira,Snayu,
Asthi and Sandhi where Prana or life resides.He supports the opinion of Susruta 26 .
Review of Literature….
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All the above definitions show the importance and vitality of the Marma points. Any
injury, trauma or disease affecting Marma will cause death or miseries equal to death.
MARMA RELATION WITH PANCHAMAHABHUTA AND
TRIDOSHA SIDHANTAAccording to Ayurveda, Panchamahabhuta (Prithvi, Ap, Tejo, Vayu and
Akasa) and Atma constitute the living body. The Panchamahabhoota samavaaya gets
contacted with Shareera and atma.The chetana or atma is Nirvikara paramatma and it
becomes vikarayukta when it comes in contact with panchamahabootatmaka shareera.
In a living being the state when the three doshas are functioning normally, the
agnis, the dhatus and malas function accordingly and if its atma, indriya and mana are
pleasant the state is defined as health27.
In a healthy living being, the prana circulates all over the shareera without any
obstruction. The derangement of physiological and psychological aspects cause
interruption of normal circulation of prana and causes diseases.Prana is dependent on
marma points.
Susruta has given a broad spectrum meaning to the word prana.The whole
physiological processes of our body are said to be done through the normal
functioning of soma, maruta and theja.The whole mental caliber or manas have got
three main gunas viz satwaguna, rajoguna and tamoguna.
Agni, Soma, Vayu, Satwa, Rajah, Tamah, Bhuthatma and Panchendriyas are
called Pranas28.It engulfs all basic factors that sustain life. Agni sustains life by
parinamam, Soma by poshanam,Vayu by chalanam (conduct, regulate and integrate
all functions).Satwah,Rajah,Tamah by converting themselves into manas.
Panchendriyas sustain by sensory perceptions and bhutatmas by its animating nature.
This is the crux of marma concept.
Susruta classified marma into agneya, soumya and vayavya, which is also
indirectly related with the tridosha.As agnitwa is predominant, the delicate avayavas
disintegrate easily. Soma by its sthira and sheeta guna resists the destructive action of
Agni.Vayu causes severe pain.
Review of Literature….
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CLASSIFICATION OF MARMA All the 107 marmas 29 are classified into five different groups
1. Structural classification (Asrayabhedena)
2. Regional classification (Shadangabhedena/avayavabhedena)
3. Prognostic classification/Traumatological classification (Vepathbhedena)
4. Dimensional classification (Manabhedena)
5. Numerical classification (Sankhyabhedena)
1. STRUCTURAL CLASSIFICATION
Susruta has opined that marma vasthu or constituting elememts of marma are
Mamsa, Sira, Snayu, Asthi and Sandhi.He classified marmas according to the
predominance of each structures present in that area such as Mamsa marma, Sira
marma, Snayu marma, Asthi marma and Sandhi marma.He also said that apart from
these 5 types no other types are found30.
Susruta classified marma into five types.They are 11 mamsa marma,41 Sira
marma,27 Snayu marma,8 Asthi marma and 20 Sandhi marma.
According to Vagbhata’s classification there are 10 Mamsa marma,8 Asthi
marma,23 Snayu marma,9 Dhamani marma,37 Sira marma and 20 Sandhi marma.
Marma Sushruta Vagbhata
Mamsa Marma 11 10
Sira Marma 41 37
Snayu Marma 27 23
Asthi Marma 8 8
Sandhi Marma 20 20
Dhamani Marma - 9
Total 107 107
Table 1-Structural classification of marma.
Review of Literature….
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a) MAMSA MARMA
Mamsa denotes mamsa peshi(muscles) in our body. It covers or conceals Sira,
Snayu, Parva(joints of bone),Asthi and Sandhi.Muscles are strong structures that give
stability to other structures also31.
Mamsa peshis show much variation in size and shape according to the site of
attachment such as thick or thin, large or small, short or circular, short or long, hard or
soft, smooth or rough32.
Modern medicine classified marma according to their
1) Structure - Striated or Non striated
2) Distribution- Skeletal, Cardiac and Visceral
3) Control- Voluntary or Involuntary
Susruta says that there are 500 mamsa peshi present in the shareera,out of
these 400 are in the Sakhas(extremities),66 in Koshta(trunk) and 34 in the greeva and
above(Head and neck).According to Vagbhata,there are 40 in the greeva and above
and 60 in koshta33.
PRADESHA SUSRUTA VAGBHATA
GREEVA PRATURDHWAM(HEAD&NECK) 34 40
KOSHTA (TRUNK) 66 60
SAKHA (EXTREMITIES) 400 400
TOTAL 500 500
Table 2- Classification of mamsa peshi according to shadangatwa.
Review of Literature….
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MUSCLES OF ONE LIMB SUSRUTA VAGBHATA
HASTANGULI 15 15
PRAHASTA 10 10
HASTATALA 10 10
HASTASYA UPARI 10 10
MANIBANDHA 10 10
PRAPANI (b/wMANIBANDHA&KURPARA) 20 20
KURPARA 5 5
PRABAHU 20 20
TOTAL 100 100
Table 3-List of mamsa peshi in upper limb
Susruta described 11 mamsa marmas.They are 4 Talahrudaya, 4 Indrabasti, 2
Stanarohita and 1 Guda marma34.
Vagbhata mentioned 10 only. He included Guda marma in Dhamani Marma
group35.
SUSRUTA No. VAGBHATA No.
TALAHRUDAYA 4 TALAHRUDAYA 4
INDRABASTI 4 INDRABASTI 4
STANAROHITA 2 STANAROHITA 2
GUDA 1
TOTAL 11 10
Table 4-List of mamsa marma
If an injury to the mamsa marma occurs it will lead to continuous bleeding, blood
resembling water in which meat is washed, pallor of skin, loss of function of sense
organs and instant death 36.
Review of Literature….
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B) SIRA MARMA
“Saranath sira”.Anything that flows is termed as Sira37. This is the basic
definition of Sira according to Caraka.
According to Susruta Siras are 700 in number. The functions of siras are
constant nourishment of entire body, keeping moistened to perform actions such as
flexion, extension, similar to large field nourished by channels of water. Their
spreading is like the ribs in a leaf 38.Nabhi is their moola (site of origin) and from here
these spread upwards downwards and sideways.
The arteries carry nutrients and oxygen to entire body constantly and the veins
remove the waste products. The distribution of vessels can be compared with that of
ribs spreading on a leaf and its function with that of small water channels in the field
irrigating corps.
All the siras are connected to the nabhi and it is said as the seat of prana.The
siras surrounds the nabhi as the spokes of a wheel 39.
Susruta and Vagbhata included Nabhi in the Sadyopranahara group.
Out of the 700 siras mentioned 400 are in the Sakha (extremities), 136 in the
Koshta (trunk) and 164 in Murdha(head and neck) 40.
PRADESHA NUMBER OF SIRAS
SAKHA (EXTREMITIES) 400
KOSHTA (TRUNK) 136
MURDHA (HEAD AND NECK) 164
TOTAL 700
Table 5- Classification of Sira according to shadangatwa
Out of the 700, there are 98 siras that are avedhya(should not be punctured).16
of them are in the Sakha,32 in the Koshta and 50 in the murdha 41.
Review of Literature….
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PRADESHA NUMBER OF AVEDHYA SIRAS
SAKHA (EXTREMITIES) 16
KOSHTA (TRUNK) 32
MURDHA (HEAD AND NECK) 50
TOTAL 98
Table 6- Classification of Avedhya Siras according to shadangatwa
Out of the 16 avedhya siras, there are 4 of them in each limb. They are
Jaladhara, Urvi and Lohithaksha 42 .
NAME OF AVEDHYA SIRA IN A LIMB TOTAL NUMBER
JALADHARA 1
URVI 2
LOHITAKSHA 1
TOTAL 4
Table 7- List of avedhya siras in a limb
Siras are classified into four types Vata vaha,Pitta vaha,Kapha vaha and Rakta
vaha.But Susruta has again clarified that siras do not carry Vata alone,Pitta alone or
Kapha alone. These four siras (Chaturvidha siras) in the body found situated generally
in the sites of marma.They maintain the body by nourishing Snayu, Asthi, Mamsa and
Sandhi 43.
Susruta has mentioned the presence of 41 Sira marmas while Vagbhata has
mentioned only 37.Sringataka, Apasthambha and Apanga Marmas are classified as
Sira marma by Susruta but Vagbhata has classified these under Dhamani and Snayu
groups’ respectively.Kakshadhara and Vitapa marma are classified under Sira marma
by Vagbhata but Susruta has included them in the Snayu group 44&45.
If the sira marma gets injured it will lead to continuous bleeding of thick blood
that too in large quantity. From this thirst, giddiness, dyspnoea, delusion and hiccup
will manifest leading to death 46.
Review of Literature….
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Sl.No. SUSRUTA TOTAL
No. Sl.No. VAGBHATA
TOTAL
No.
1 NEELA 2 1 NEELA 2
2 MANYA 2 2 MANYA 2
3 MATHRUKA 8 3 MATHRUKA 8
4 STHAPANI 1 4 STHAPANI 1
5 PHANA 2 5 PHANA 2
6 STANAMOOLA 2 6 STANAMOOLA 2
7 APALAPA 2 7 APALAPA 2
8 HRUDAYA 1 8 HRUDAYA 1
9 NABHI 1 9 NABHI 1
10 PARSWASANDHI 2 10 PARSWASANDHI 2
11 BRUHATHI 2 11 BRUHATHI 2
12 LOHITAKSHA 4 12 LOHITAKSHA 4
13 URVI 4 13 URVI 4
14 SRINGATAKA 4 14 KAKSHADHARA 2
15 APANGA 2 15 VITAPA 2
16 APASTHAMBHA 2 16
TOTAL 41 TOTAL 37
Table 8- List of Sira marma
C) SNAYU MARMA
Though Mamsa is one among the saptadhatus, Snayu has been mentioned as
the Upadhatu of Medho dhatu by Caraka 47.
Susruta while detailing about Snayu has given a wonderful simily.He has
given a poetic verse stating that just like planks of wood when fastened by ropes
become capable of carrying huge weights, similarly the various sandhis present in our
shareera become capable of weight bearing because of Snayu 48.
These may be compared to ligaments and tendons in modern anatomy.
Snayus are of 4 types.They are Prathanavathy, Vruttha, Prudhu and Sushira.
Pratahanavathy are present in Sakhas (extremities) and Sandhis (joints).
Vruttha are also called as Kandaras.
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Sushira are present in Amasaya, Pakwasayanta and Basti.Prudhu is present in
Parswa, Uras, Prushta and Shiras 49.
The total number of Snayu is mentioned by Susruta as 900.Out of them 600
are present in the 4 Sakhas (extremities), 230 in Koshta (trunk), 70 in Greevaprati
Urdham (head and neck) 50.
PRADESHA TOTAL NUMBER OF
SNAYU
SAKHAS (EXTREMITIES) 600
KOSHTA (TRUNK) 230
GREEVA PRATYOORDHAM(HEAD & NECK) 70
TOTAL 900
Table 9- Classification of Snayu according to shadangatwa
As mentioned above 150 snayus are present in each extremity.
PRADESHA TOTAL NUMBER OF SNAYU
HASTANGULI 30
HASTATALA KURCHA MANIBANDHA 30
PRAPANI 30
KURPARA 10
PRABAHU 40
KAKSHADHARA 10
TOTAL 150
Table 10- List of Snayu in upper limb
Susruta has enlisted 27 snayu marmas whereas Vagbhata has 23.Susruta
included Vitapa, Kakshadhara and Vidhura in Snayu group but Vagbhata included
them in Sira/Dhamani group.Susruta included Apanga in Sira marma whereas
Vagbhata considered it as a Snayu marma51&52.
If snayu marma gets injured it will lead to severe convulsions, pain, difficulty
in movements like riding, sitting etc. and may even lead to death 53.
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Sl.No SUSRUTA TOTAL No. Sl.No VAGBHATA TOTAL No
1 ANI 4 1 ANI 4
2 KURCHA 4 2 KURCHA 4
3 KURCHASHIRA 4 3 KURCHASHIRA 4
4 KSHIPRA 4 4 KSHIPRA 4
5 AMSA 2 5 AMSA 2
6 BASTI 1 6 BASTI 1
7 UTKSHEPA 2 7 UTKSHEPA 2
8 VITAPA 2 8 APANGA 2
9 VIDHURA 2
10 KAKSHADHARA 2
TOTAL 27 TOTAL 23
Table 11- List of Snayu marma
D) SANDHI MARMA
Sandhi according to Sharangadhara binds various structures and are covered
by kapha 54
Susruta has mentioned a total number of 210 sandhi in the shareera. Out of
these 68 are present in the sakhas, 59 in the koshta and 83 in greeva pratyoordhwam55.
PRADESHA TOTAL NUMBER OF SANDHI
SAKHA (EXTREMITIES) 68
KOSHTA (TRUNK) 59
GREEVA PRATYOORDHWAM 83
TOTAL 210
Table 12- Classification of Sandhi according to shadangatwa
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PRADESHA TOTAL NUMBER OF SANDHI
HASTANGULI 14
MANIBANDHA 1
KURPARA 1
KAKSHADHARA 1
TOTAL 17
Table 13- List of Sandhi in upper limb
Susruta has basically classified sandhi into two types a) Chestavanta(movable)
b) Sthira (immovable) 56.Later he broadly classified them into eight types. They are
Kora, Ulookhala, Samudga, Prathara, Thunnasevani, Vayasathunda, Mandala and
Shankhavartha 57.
1. KORASANDHI-They are found Anguli(finger), Manibandha (wrist),Gulpha
(ankle), Janu(knee), KURPARA (elbow). All these joints have uniaxial movements
only except Manibandha. So it can be correlated with Hinge type of Synovial joint
mentioned in modern anatomy.
2. ULOOKHALA SANDHI-They are found in Kaksha (axilla),Vamkshana (groin)
and Dasana (teeth). Axilla and groin are formed by the shoulder and hip joints. Both
can be correlated to the ball and socket type of synovial joints with a range of
movements such as flexion, extension, adduction, abduction, medial rotation, lateral
rotation and circumduction.Dasana (teeth) are fixed in its socket, no movement is
possible.
3. SAMUDGA SANDHI-They are said to resemble a box with a lid and are found in
Amsapeeta (Scapula) Guda (Rectum/Anus) Nitamba (buttock).These joints can be
correlated with Coraco-Clavicular joint, Sacro-Coccygeal joint, Ilio-Sacral joint. Very
little movement is possible in these joints.
4. PRATHARA SANDHI-They are said to be in the shape of round boat and found in
Greeva(neck) and Prushtavamsa(vertebral column).
5. THUNNASEVANI SANDHI-They are said to resemble sutures and are found in
Sira kapala (skull bones) and kati kapala (pelvis).They are sthira or fixed sandhi.
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6. VAYASATHUNDA-They are said to resemble the beak of a crow. It is present in
two sides of Hanu and can be correlated to tempero-mandibular joint.
7. MANDALA-They are round or circular in shape and are present in nadi of Kanta
(throat), Hrudaya (heart), Netra (eye) and Kloma.
8 .SHANKHAVARTA-They are said to be spiral, helical or conch shaped and found
in Srotra Sringataka (ear).
There is no difference of opinion between Susruta and Vagbhata in the
number of sandhi marma.Both have mentioned 20 of them and are Janu, KURPARA,
Seemanta, Adhipati, Gulpha, Manibandha, Kukundara, Avartha, Krukatika 58.
If the sandhi marma is injured the person feels as though the injury site is
covered with thorns. There will be shortening of the limb after healing. It may also lead
to marked decrease in mobility and strength. It may also cause emaciation, lameness
and swelling in the joints 59.
Sl.NO SUSRUTA TOTAL
NUMBER VAGBHATA
TOTAL
NUMBER
1 JANU 2 JANU 2
2 KURPARA 2 KURPARA 2
3 SEEMANTA 5 SEEMANTA 5
4 ADHIPATI 1 ADHIPATI 1
5 GULPHA 2 GULPHA 2
6 MANIBANDHA 2 MANIBANDHA 2
7 KUKUNDARA 2 KUKUNDARA 2
8 AVARTHA 2 AVARTHA 2
9 KRUKATIKA 2 KRUKATIKA 2
TOTAL 20 TOTAL 20
Table 14-List of Sandhi marma
E) ASTHI MARMA
The poetic verse of Susruta is very much evident in many contexts because
some of the similes he uses to clarify the shareera rachana are enjoyable at the same
time closely related to the nature. While explaining ashti marma he has detailed that
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just like the trees remain intact because of their hardcore similarly asthis act as a
central axis by providing support and strength to the shareera.
In our science of ayurveda the number of asthi(bones) in the shareera are
entirely different from that of modern medical science.Acharya Susruta has
mentioned 300 Asthi whereas Caraka has mentioned 360 in comparison to the 206
mentioned in modern medicine. The inclusions of teeth, cartilage and rings of trachea
etc as asthi have contributed to the increase in the number of Asthi.
Out of 300 asthis, 120 are present in sakhas, 63 in greeva pratyoordhwam
(head & neck), 117 in Sroni(pelvis),Parswa(flanks), Prushta(back) and Uras(chest)
together 60.
PRADESHA TOTAL NUMBER OF ASTHIS
SAKHA (EXTREMITIES) 120
SRONI,PARSWA,PRUSHTA,URAS
(PELVIS,FLANKS,BACK,CHEST) 117
GREEVA PRATYOORDHWAM
(HEAD AND NECK) 63
TOTAL 300
Table 15- Classification of asthi according to shadangatwa as per Susruta Samhita
Out of the 30 asthis present in each sakhas,15 are present in hastanguli,10 in
Tala,Koorcha and Manibandha,1 in Manika,2 in Prapani, 1in KURPARA Sandhi and1
in Prabahu 61.
PRADESHA TOTAL NUMBER OF ASTHI
HASTANGULI 15
HASTATALA,KOORCHA,MANIBANDHA 10
MANIKA 1
PRAPANI 2
KURPARA 1
PRABAHU 1
TOTAL 30
Table 16- List of asthi in upper limb as per Susruta Samhita
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According to Carakacharya a total number of 360 asthi are present in the
shareera and out of these 128 are present in sakhas,140 in koshta and 92 in
greevapratyoordhwam (head & neck) 62 .
PRADESHA TOTAL NUMBER OF ASTHIS
SAKHA (EXTREMITIES) 128
SRONI,PARSWA,PRUSHTA,URAS
(PELVIS,FLANKS,BACK,CHEST)
140
GREEVA PRATYOORDHWAM
(HEAD AND NECK)
92
TOTAL 360
Table 17- Classification of asthi according to shadangatwa as per Caraka Samhita
PRADESHA TOTAL NUMBER OF ASTHIS
NAKHA 5
HASTANGULI 15
HASTA SALAKA 5
HASTA ADISTHANA 1
HASTA MANIKASTHI 1
Table 18- List of asthi in Hasta as per Caraka Samhita
Susruta has classified the bones into five types. They are
i) Kapalasthi-are present in Janu(knee), Nitambha(buttock), Amsa(shoulder),
Ganda(neck), Talu(palate), Sankha(temples) and Siras(head).
ii) Ruchakasthi-are teeth
iii) Tarunasthi-(youngbones/cartilages) are present in Ghrana(nose), Karna(ear),
Greeva (neck) and Akshikosa (cartilages of superior palpebra).
iv) Valayasthi-(curved/irregular bones) are present in parswa (flanks), Prushta(back),
Uras(chest).All these are related with ribs.
v) Nalakasthi-(tubular/long bones).All remaining bones are considered as
Nalakasthi63.
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Asthi is one among the marma vasthu and are numbered as eight by Susruta
and Vagbhata.They are Shankha, Kateekataruna, Nitambha and Amsaphalaka.
Shankha marma is prognostically Sadyopranahara, Kateekataruna and Nitambha
belong to Kalantarapranahara group and Amsaphalaka is included in Vaikalyakara
marma group 64.
If Asthi marma is injured it will cause discharge of scanty fluid that too mixed
with bone marrow. Intermittent pain will also be present 65.
Sl.No SUSRUTA No. VAGBHATA No.
1 SHANKHA 2 SHANKHA 2
2 KATEEKATARUNA 2 KATEEKATARUNA 2
3 NITAMBHA 2 NITAMBHA 2
4 AMSAPHALAKA 2 AMSAPHALAKA 2
TOTAL 8 TOTAL 8
Table 19- List of Asthi marma
F) DHAMANI MARMA
Carakacharya has given the basic definition of Dhamani as anything that
pulsates37.
Susruta has mentioned 24 dhamanis that originate from Nabhi.10 of them
move upwards, 10 of them downwards, and 4 in sideways 66.
Acharya Vagbhata introduced the classification of Dhamani marma.Nine
marmas come under this group and they are Guda, Apasthambha, Vidhura and
Sringataka 67.
NAME No.
GUDA 1
APASTHAMBHA 2
VIDURA 2
SRINGATAKA 4
TOTAL 9
Table 20- List of Dhamani marma
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According to Susruta Guda is mamsa marma,Vidhura is snayu marma whereas
Apasthambha and Sringataka are sira marmas.
If an injury occurs to the dhamani marma it will cause haemorrhage in which
blood which is frothy and warm flows out with a sound and the person easily looses
his consciousness 68.
2. REGIONAL CLASSIFICATION
Shareera is divided into 6 parts. They are Shiras, Antharadi (thorax and
abdomen), 2 bahu (upper limb), 2 sakthi (lower limb).Here shiras is considered as the
most important part and the vitality diminishes towards antharadi, bahu and sakthi 69.
Among 107 marmas,there are 44 present in the sakthi (11 in each
extremities),3 in Koshta,9 in uras (thorax),14 in prushta (back) and 37 Jathroordha
part (head and neck) 70.
Carakacharya has also agreed to the theory of 107 marmas but has highlited
the TRIMARMA concept (3 marmas) .They are the Shiras, Hrudaya and Basti. He has
mentioned that the prana resides in three sites 71.
PRADESHA NUMBER OF MARMAS
SAKHA (BAHU MARMA&SAKTI MARMA) 44
UDARA MARMA 3
URO MARMA 9
PRUSHTA MARMA 14
JATROORDHWA MARMA 37
TOTAL 107
Table 21 – Classification of marma according to shadangatwa
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3.PROGNOSTIC CLASSIFICATION
Depending on the prognosis of marmabhighata, it is divided into five types by
Susruta and Vagbhata. They are Sadyopranahara, Kalantarapranahara, Vishalyaghna,
Vaikalyakara and Rujakara 72.
Sl.No PROGNOSTIC
CLASSIFICATION No. DOSHA PREDOMINANCE
1 SADYOPRANAHARA 19 AGNEYA
2 KALANTARAPRANAHARA 33 AGNEYA,SOUMYA
3 VISHALYAGHNA 3 VAYAVYA
4 VAIKALYAKARA 44 SOUMYA
5 RUJAKARA 8 SOUMYA,AGNEYA,VAYAVYA
TOTAL 107
Table 22– Classification of marma according to prognosis
I) SADYOPRANAHARA- As the name suggests these marma cause death or
marana immediately or within a span of 7 days. These marmas are predominant of
agneya bhavas.They are 19 in number and are Adhipati, Guda, Hrudaya, Kantasira,
Nabhi, Shankha,Sringataka and Basti 73,74.
Sl.No. NAME OF MARMA No. STRUCTURE
1 ADHIPATI 1 SANDHI
2 GUDA 1 MAMSA(DHAMANI)
3 HRUDAYA 1 SIRA
4 KANTASIRA 8 SIRA
5 NABHI 1 SIRA
6 SHANKHA 2 ASTHI
7 SRINGATAKA 4 SIRA(DHAMANI)
8 BASTI 1 SNAYU
TOTAL 19
Table 23- List of Sadyopranahara marma
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II) KALANTARAPRANAHARA-As the name suggests these marma cause death
only after a certain period of time ie within a fortnight or month. These marmas are
predominant of Agneya and Soumya gunas. There are a total of 33 marmas included
in this group & are Apalapa, Apasthambha, Stanarohita, Stanamoola, Kateekataruna,
Parswasandhi, Bruhati and Nitambha 75,76.
Sl. No. NAME OF MARMA No. STRUCTURE
1 SEEMANTA 5 SANDHI
2 TALAHRUDAYA 4 MAMSA
3 KSHIPRA 4 SNAYU
4 INDRABASTI 4 MAMSA
5 APALAPA 2 SIRA
6 APASTHAMBHA 2 SIRA
7 STANAROHITA 2 MAMSA
8 STANAMOOLA 2 SIRA
9 KATEEKATARUNA 2 ASTHI
10 PARSWASANDHI 2 SIRA
11 BRUHATI 2 SIRA
12 NITAMBHA 2 ASTHI
TOTAL 33
Table 24- List of Kalantarapranahara marma
III) VISHALYAGHNA MARMA-These marma are vayu predominant. As long as
the vayu remains inside obstructed or prevented by the shalya, the person survives.
When the shalya is removed from the site, vayu residing in the fatal area will go out
resulting in immediate death. There are three vishalyaghna marma described in our
samhitas77,78.
They are UTKSHEPA-2 and STHAPANI-1.
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IV)VAIKALYAKARA MARMA-These marma are soumya in nature and because
of the sthirata and saitya gunas, soma maintains life even after injury. They are 44 in
number and are Ani, Kurcha, Vitapa, Vidhura, Amsa, Lohitaksha, Apanga, Neela,
Manya, Urvi, Phana, Janu, KURPARA, Kukundara, Kakshadhara,Krukatika,Avartha
and Amsaphalaka 79,80.
Sl.No. NAME OF MARMA No. STRUCTURE
1 ANI 4 SNAYU
2 KURCHA 4 SNAYU
3 VITAPA 2 SNAYU
4 VIDHURA 2 SNAYU
5 AMSA 2 SNAYU
6 LOHITAKSHA 4 SIRA
7 APANGA 2 SIRA
8 NEELA 2 SIRA
9 MANYA 2 SIRA
10 URVI 4 SIRA
11 PHANA 2 SIRA
12 JANU 2 SANDHI
13 KURPARA 2 SANDHI
14 KUKUNDARA 2 SANDHI
15 KAKSHADHARA 2 SNAYU
16 KRUKATIKA 2 SANDHI
17 AVARTHA 2 SANDHI
18 AMSAPHALAKA 2 ASTHI
TOTAL 44
Table 25- List of Vaikalyakara marma
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V) RUJAKARA MARMA-These marmas have predominance of Agni and Vayu
bhootas and produce severe pain. There are 8 marma in this group and they are
Kurchasira, Gulpha and Manibandha 81,82.
Sl No. NAME OF MARMA No. STRUCTURE
1 KURCHASHIRA 4 SNAYU
2 GULPHA 2 SANDHI
3 MANIBANDHA 2 SANDHI
TOTAL 8
Table 26- List of Rujakara marma
It is also quoted by Susruta that if the sadyopranahara marma is afflicted at its
border it may become kalantarapranahara.If kalantarapranahara marma is afflicted at
its border it may become vaikalyakara.If vishalyaghna marma is afflicted at its border
it may become vaikalyakara.If vaikalyakara marma is afflicted at its border it will
become rujakara marma.If rujakara marma is afflicted at its border it may cause mild
pain 83.
It has also been mentioned in Susruta Samhita that the Kshipra marma can
sometimes be sadyopranahara 84.
PANCHABHAUTIK CONSTITUTION OF MARMAS 85
It is quoted by Susruta that Sadyapranahara marmas are agneya in nature. Just
as agni or fire quickly extinguishes everything similarly agneya guna of these marmas
will kill a person easily.
Kalantarapranahara marmas are agni and soma gunayukta. Due to the even
nature of fire and water death will not occur spontaneously but over a short period of
time.
Vishalyaghna marmas are fatal after the extraction of the shalya embedded in
the site because the vayu will remain obstructed by the shalya and as soon as the
shalya is extracted, vayu escapes out and will lead to the death of the individual.
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Vaikalyakara marmas are soma guna pradhana and due to the sthiratva (stable)
and saityatva (frozen) nature will sustain life.
Rujakara marmas are agni and vayu guna pradhana thus causing severe pain.
It is also opined that pain is caused by Panchamahabhootas.It is due to
predominance of agni and vayu that pain occurs. Ap or jaleeyabhoota is also said to
cause pain in kaphaja wounds.
4) DIMENSIONAL CLASSIFICATION 86
Susruta and Vagbhata explained the dimensions of all 107 marmas in angulas.
This is for the surgeons to get an exact idea of the surface anatomy while performing
surgical procedures. Shastra karma, Kshara karma and Agni karma should be avoided
in the site of marma.According to the dimension of marma, it is divided into 5 types.
1. Swa-Panitala 2.Ardhangula 3.Ekangula 4.Dwayangula 5. Trayangula
Sl. NO NAME OF MARMA TOTAL NUMBER
1 HRUDAYA 1
2 BASTI 1
3 GUDA 1
4 NABHI 1
5 NEELA 2
6 MANYA 2
7 KURCHA 4
8 SRINGATAKA 4
9 SEEMANTA 5
10 MATRUKA 8
Table 27- List of Swa-Panitala marmas
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Sl.No. NAME OF MARMA TOTAL No.
1 ADHIPATI 1
2 ANI 4
3 AMSA 2
4 AMSAPHALAKA 2
5 APANGA 2
6 APASTHAMBHA 2
7 AVARTHA 2
8 BRUHATI 2
9 INDRABASTI 2
10 KATEEKATARUNA 2
11 KRUKATIKA 2
12 KSHIPRA 2
13 KUKUNDARA 2
14 LOHITAKSHA 2
15 NITAMBHA 2
16 PARSWASANDHI 2
17 PHANA 2
18 SANKHA 2
19 STANAROHITA 2
20 STHAPANI 2
21 TALAHRUDAYA 4
22 UTKSHEPA 2
23 VIDHURA 2
Table 28- List of marmas having Ardhangula pramana
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Sl. No. EKANGULA MARMAS TOTAL No.
1 URVI 4
2 KURCHASHIRA 4
3 VITAPA 2
4 KAKSHADHARA 2
Table 29- List of marmas having one Ekangula pramana
Sl.No. DWAYANGULA MARMAS TOTAL No.
1 STANAROHITA 2
2 GULPHA 2
3 MANIBANDHA 2
Table 30- List of marmas having Dwayangula pramana
Sl.No.TRYANGULA
MARMAS TOTAL No.
1 JANU 2
2 KURPARA 2
Table 31- List of marmas having Tryangula pramana
It is also told that the surgical operations should be performed after
considering the measurement of the marmas so as to avoid them. Even an injury to its
borders might lead to death. So the site of marmas should be avoided altogether 87.
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6. NUMERICAL CLASSIFICATION
Marmas are classified according to their number present in the particular
group. Namely
i)EKA SANKHYA = 6
ii)DWI SANKHYA = 52
iii)CHATUR SANKHYA = 36
iv)PANCHA SANKHYA = 5
v)ASHTA SANKHYA = 8
SIX EKA SANKHYA MARMAS
1. HRUDAYA
2. GUDA
3. BASTI
4. NABHI
5. STHAPANI
6. ADHIPATI
Sl.No. Name of Marma Sl.No. Name of Marma
1 GULPHA 14 NEELA
2 JANU 15 MANYA
3 MANIBANDHA 16 KRUKATIKA
4 KURPARA 17 UTKSHEPA
5 AMSA 18 STANAMOOLA
6 KAKSHADHARA 19 STANAROHITA
7 AMSAPHALAKA 20 APALAPA
8 VITAPA 21 APASTHAMBHA
9 SHANKHA 22 BRUHATI
10 APANGA 23 KUKUNDARA
11 AVARTHA 24 KATEEKATARUNA
12 VIDHURA 25 PARSWASANDHI
13 PHANA 26 NITAMBHA
Table 32- List of Dwi sankhya marmas
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Sl No. NAME OF MARMA
1 TALAHRUDAYA
2 KSHIPRA
3 KURCHA
4 KURCHASIRA
5 ANI
6 URVI
7 LOHITAKSHA
8 INDRABASTI
9 SRINGATAKA
Table 33- List of Chatur sankhya marmas
PANCHASANKHYA MARMA = SEEMANTA
ASHTASANKHYA MARMA=MATHRUKA
HASTA The term hasta has been defined in the Amarakosha as something that spreads
or originates from Bahu 88.
The synonyms of Pani, Sama, Saya, Panchasakha, Kara, Bhuja, Kuli,
Bhujadala have all been designated to the word hasta in Shabdhakalpadruma 89.
In Monier Williams the term hasta has been given the meaning hand, holding
in or by the hand, to take into the hand etc 90.
Acharya Susruta in the 7th chapter of the Sutra sthana ie Yantra vidhi has
mentioned hasta as the pradhana yantra.This is due to the fact that without the help of
hasta none of the yantras can function. The functioning of all the yantras is based on
the efficiency of the hand 91.
Similarly panitala and padatala has been mentioned as anuyantra by Susruta 92.
Susruta has detailed the pramana shareera in the 35th chapter of the sutra
sthana ie Aturopakramaneeya.In this chapter he has mentioned the following
pramaana 93.
Pramaana of Hasta (Length of hasta)- 24 Angula
Parimaana of Buja (Length of the entire upper limb)- 32 Angula
Length between manibandha and KURPARA- 16 Angula
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Ayaama (length) of Hastatala- 4 Angula
Vistara (width) of Hastatala- 6 Angula
Length between Angushta moola and Pradeshini(index finger) is 5 Angula.
Dalhana has clarified that by the term ‘hasta’ Susruta has meant the region
between the KURPARA and the tip of the madhyamanguli (middle finger) 94.
In the 8th chapter of the Caraka Samhita ie Rogabishagjeetiyam vimanam
while detailing about the pramana pareeksha Caraka has described that the length of
PRABAHU = 16 ANGULA (ARM)
PRAPANI = 15 ANGULA (FOREARM)
HASTA = 12 ANGULA (HAND)
Hence the total length of the upper limb is 43 Angula 95.
So there exists a difference of opinion on the terminologies pani, panitala and
hasta.
But a clear cut differentiation of the arm, forearm and hand has been given by
Caraka.So here in the dissertation work; terminology of Hasta has been used to denote
hand.
There are five anguli in each Hasta. These Anguli are considered among
pratyangas 96.
There are four kandaras97, four jalas98, two kurchas 99 , three asthi
sanghatas100, twenty-six asthis, fifteen sandhis, sixty snayus & fifty five mamsa peshis
located in located in Hasta .
HASTA MARMA They are five in number and are KSHIPRA, TALAHRUDAYA, KURCHA,
KURCHASHIRA & MANIBANDHA.
I) KSHIPRA (Fig.1A,1B)
It is the marma which is first detailed in the Susruta Samhita.
Etymology: Kshipra takes it root from the word ‘kship’ and has been assigned with
the synonyms Seeghra and Twarita in Shabdhakalpadruma101 .
It is meant as to throw, cast, send, dispatch etc in Monier Williams dictionary102 .
Location-It is located between the angushta and anguli103,104.
Classification- Snayu marma.
Sakha marma.
Kalantarapranahara marma and sometimes Sadyopranahara.
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Ardhangula Pramana.
Catursankhya.
Effect- An injury to the marma will lead to marana due to akshepaka 103,104.Arunadatta
has detailed that the akshepaka mentioned here is the vatavyadhi 105.
It is detailed that in akshepaka roga the aggravated vata dosha permeates all
dhamanis leading to frequent and repeated convulsions and spasm of muscles. 106,107
Here the terminology of dhamani has been detailed as nadi by Dalhana
suggesting the involvement of nervous system in it 108.Dalhana has also mentioned
that in this the whole akshepa of the body takes place109.Arunadatta has interpreted
the word ‘Aakshipati’ as ‘Aakramati’ or attacking 110.
It has also been mentioned that when the limbs get severed, the blood vessels
get contracted to allow only little hemorrhage and such persons, though having severe
affliction, do not die like tree with several branches cut off survives 111.
II) TALAHRUDAYA (Fig.2A, 2B)
It is the marma which is first detailed in the Ashtanga Hrudaya.
Etymology: In Shabdhakalpadruma it is meant as the hrudaya or centre of padatala 112.
In Monier Williams dictionary ‘Tala’ is meant as surface, level, flat roof (of a house)
etc.and ‘Talahrudaya’ as sole of foot 113.
Location-It is located in the centre of palm in straight line with the middle finger
(Madhyamanguli/Anamika) 114,115.
Classification: Mamsa marma.
Sakha marma.
Kalantarapranahara marma.
Ardhangula Pramaana.
Chatursankhya.
Effect- An injury to the marma will lead to marana caused due to ruja114, 115.
III) KURCHA (Fig.3A,3B)
Etymology: Kurcha assumes its name from the root words ‘kur+chat’ according to
Sabdakalpadruma116.In Monier Williams dictionary it is meant as a bunch of
anything, bundle of grass etc117.
Location-It is situated two angula above the Kshipra marma 118,119.
Classification- Snayu marma.
Sakha marma.
Vaikalyakara marma.
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Swapanitala pramana.
Chatursankhya.
Effect- An injury to the marma will lead to the Bhramana and Vepana of the limb.
Vagbhata has used the word Kampa instead of Vepana118,119.
The term Kampa has been assigned with the meanings trembling, tremor,
shaking etc. in Monier Williams’s dictionary 120 and the word Vepana has been
assigned with the meaning quivering, trembling, fluttering etc 121.
IV) KURCHASHIRA (Fig.4A, 4B)
Etymology: Kurchashira has been defined as the shira of Kurcha in
Shabdhakalpadruma122 .It has been meant as the upper part of the palm of the hand
and foot in Monier Williams dictionary 123.
Location-It is situated just below the manibandha sandhi 124,125.Though in the sloka it
is mentioned as below the gulpha it has been cleared later that the manibandha marma
in upper limb is homologous to the gulpha marma in lower limb 126.
Classification- Snayu marma.
Sakha marma.
Rujakara marma.
Dwayangula pramana.
Chatursankhya.
Effect-An injury to the marma will lead to Sopha and Ruja 124,125.
V) MANIBANDHA (Fig.5A, 5B)
Etymology-Manibandha has been defined in Shabdhakalpadruma as the meeting point
of prakoshta and pani127.In Monier Williams dictionary the term mani has been meant
as jewel, gem or a pearl and manibandha as fastening or putting on of wrist128.
Dalhana has mentioned that it is the moola of paani129.
Location-It is located at the meeting point of prapani and hasta 95. So it has been dealt
under the topic of hasta marma.
Classification- Sandhi marma.
Sakha marma.
Rujakara marma.
Dwayangula pramana.
Dwisankhya.
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Effect- According to Susruta an injury to the marma will lead to ‘Kundata’ 130.The
term Kundata has been clarified by Dalhana as inability or inefficiency to function
with hand131.
CONCEPT OF RUJA Manibandha and Kurchashira are classified as Rujakara marmas. The term
Ruja is dealt in many contexts.
In Amarakosha the term ruja has been used in the following senses.Ruk,Ruja,
Upatap, Roga, Vyadhi, Gada, Amaya and Saptarogamatha 132.
Monier Williams explains the word Ruja as Rujati or to break, break open,
destroy, to cause pain, injure, afflict etc. 133.
Acharya Susruta has detailed about many types of pain in the Vranasrava
Vigyaneeya Adhyaya 134.
Todana - pricking of needle Vidarana - bursting
Bhedana – piercing Kampana - quivering
Tadana – thrashing Shoola - colic
Chedana – cutting Vikirana - radiating
Ayama – expanding Poorana - fullness
Manthana – churning Stambhana - stiffness
Vikshepana – shooting Dahana - burning
Chumchumayana – tingling Utpatan - uprooting
Avabhanjana-breaking
The standard definition of pain is that of the International association for the
study of pain:135
“An unpleasant sensory or emotional experience associated with actual or
potential tissue damage is described in terms of such damage. Pain is always
subjective. Each individual learns in the application of word with experiences related
to injury in early life. It is unquestionable a sensation in a part of the body but it is
also unpleasant and therefore also an emotional experience. Many people report pain
in presence of tissue damage or any likely pathophysiological cause, usually this
happens for psychological reasons. There is no way to distinguish their experience
from that due to tissue damage if we take this subjective report.”
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TYPES OF PAIN 136
1. Neuropathic Pain - Pain that is initiated or caused by a primary lesion or
dysfunction in the nervous system e.g.:- radicular pain due to herniated or degenerated
vertebral disc.
2. Visceral Pain – Pain that is located in the visceral organs as well as the parietal
peritoneum, pleura and pericardium.
3. Psychogenic Pain – is generated by the mind and emotions. A pain is a subjective
perception, the attitude and mood of an individual which effects its perception. Mental
activity in the descending inhibitory pathways results decrease in perception of pain.
4. Nociceptive Pain – Pain that is result of irritation of a nociceptor. This is the
common pain experience in myofascial tissue of the joint complex.
Pain is also classified into acute or chronic based on the quality of sensation
and duration.
But in the case of ruja it is better to moderate with the definition of Rujakara
in Vacaspatya which states that ‘Rujaam rogam karoti’ which means anything that
leads to roga is ruja 137.
CONCEPT OF ANGULI PRAMANA Pramana is a tool through which valid knowledge is obtained138. Mana is the
act of measuring different items which comprises different branches like tula, Anguli,
prasta. Anguli pramana is a unit of measure followed in olden days to denote the
Ayama, vistara, parinaha, utsedha etc139.
ANGULA CAN BE TAKEN AS:
1) Width of the madhyama parva of the madhyama angula 140.
2) Measurement obtained by taking the length of the madhyama angula and
dividing it by five 141.
3) Measurement obtained by taking the width of the palm and then dividing by
four 142.
4) Nakha tala bhaga of angushtha 143.
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ANATOMY OF HAND PALMAR SURFACE 144
The human hand is designed: (i) for grasping (ii) for precise movements (iii) for
serving as a tactile organ.
Skin –The skin of the palm is: (i) thick for protection of underlying tissues, (ii)
immobile because of its firm attachment to the underlying palmar aponeurosis, and
(iii) creased. All of these characters increase the efficiency of the grip.
The skin is supplied by spinal nerves C6, C7, C8 through the median and ulnar
nerve.
Superficial fascia – The superficial fascia of the palm is made up of dense fibrous
bands which bind the skin to the deep fascia (palmar aponeurosis) and divide the
subcutaneous fat into small tight compartments which serve as water-cushions during
firm gripping. The fascia contains a subcutaneous muscle, the Palmaris brevis, which
helps in improving the grip by steadying the skin on the ulnar side of the hand. The
superficial metacarpal ligament which stretches across the roots of the fingers over the
digital vessels and nerves is a part of this fascia.
Deep Fascia- The deep fascia is specialized to form :(i) the flexor retinaculam at the
wrist,(ii) the palmar aponeurosis in the palm, and (iii) the fibrous flexor sheaths in the
fingers. All three form a continuous structure which holds the tendons in position and
thus increases the efficiency of the grip.
DORSUM OF THE HAND145
Skin – The skin of the dorsum of the hand is thin, hairy and moves freely over the
underlying extensor tendons and deep fascia.
Superficial fascia – It presents a dorsal subcutaneous space which contains the dorsal
venous arch and the dorsal digital nerves derived from the superficial terminal branch
of radial nerve and dorsal branch of ulnar nerve.
Dorsal venous arch – The dorsal digital veins from the adjacent sides of the fingers
join in the interdigital clefts to form three dorsal metacarpal veins which unite with
each other and form a dorsal venous network proximal to the metacarpal heads. This
network receives the blood from the radial side of index finger and both sides of the
thumb as well as from the ulnar side of little finger. Most of the blood from the palm
also reaches dorsal venous plexus through the perforating veins in order to avoid
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pressure during grasping. From the radial side of the venous plexus the blood is
conveyed proximally by the cephalic vein and from the ulnar side by the basilic vein.
Deep Fascia- It is thin and covers the extensor tendons of the digits on the dorsum of
hand. Proximally at the back of the wrist, it is continuous with the extensor
retinaculum, and at the sides’ continous with the palmar fascia.
A dorsal subaponeurotic space intervenes between the deep fascia and the
dorsal surfaces of metacarpal bones and dorsal interossei muscles. The space is
occupied by the extensor tendons of the hand, dorsal digital expansions, dorsal carpal
arch and their dorsal metacarpal branches.
SKELETON OF HAND146
The hand’s skeleton has three regions.
1) The Carpus
2) The Metacarpus
3) The Phalanges
In this description proximal and distal are used in preference to superior and
inferior and palmar and dorsal rather than anterior and posterior.
1) THE CARPUS
Proximally in lateral to medial order are
SCAPHOID, LUNATE, TRIQUETRAL, PISIFORM and in the distal row are
TRAPEZIUM, TRAPEZOID, CAPITATE and HAMATE.
The proximal row is convex proximally and concave distally.
The distal row is convex proximally and flat distally.
A) SCAPHOID
It is the largest bone in the proximal row and has a long axis which is distal
lateral and slightly palmar in direction. It has 6 surfaces.
i) Palmar surface: Its round tubercle on the dorsolateral part of its palmar surface is
directed anterolaterally and is an attachment of the flexor retinaculum and abductor
pollicis brevis, it is crossed by the tendon of flexor carpi radialis.
ii)Dorsal surface: It is rough, slightly grooved, narrower than the palmar surface and
pierced by small nutrient foramina, often restricted to the distal half, an observation of
clinical significance.
iii) Lateral surface: It is narrow, rough, non-articular and has the radial collateral
ligament attached to it.
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iv) Medial surface: It articulates with capitate below and lunate above by a deep
concave and a semilunar area respectively.
v) Proximal surface: It is convex and smooth and articulates with lateral part of
inferior surface of lower end of radius.
vi) Distal surface: The surface for trapezium and trapezoid is continuous and convex.
B) LUNATE
It is approximately semilunar and articulates between the scaphoid and
triquetral in the proximal carpal row. It has 6 surfaces.
i) Palmar surface:
a) It is rough, triangular, wider and larger than the rough dorsal surface.
b) Nearly triangular, non articular.
ii) Dorsal surface:
a) Rough small quadrilateral surface, non-articular.
iii) Lateral surface:
a) Presents a semilunar surface for articulation with scaphoid bone.
iv) Medial surface:
a) Presents a quadrilateral area for articulation with the base of triquetral bone.
v) Proximal surface:
a) Convex.
b) Articulates with medial part of inferior surface of lower end of radius.
vi) Distal surface:
a) Deeply concave
b) Articulates with medial part of the head of capitate bone.
C) TRIQUETRAL
It is pyramidal or wedge shaped. It possesses 6 surfaces.
i) Palmar surface:
a) It has one oval or circular facet at its distal part which articulates with pisiform
bone .Margins of the facet give attachment to Piso-triquetral ligament.
ii) Dorsal surface:
a) It is continuous with proximal surface.
iii) Lateral surface:
a) It forms base of the wedge and bears a square facet for articulation with lunate
bone.
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iv) Medial surface:
a) It forms apex of the wedge and gives attachment to ulnar collateral ligament of
wrist joint.
v) Proximal surface:
a) It is a smooth surface facing upwards.
b) It articulates with triangular articular disc of inferior radio-ulnar joint.
vi) Distal surface:
a) It has a concavo-convex surface.
b) It articulates with hamate.
D) PISIFORM
It is a pea shaped, smallest and the most medial bone of the proximal row. It
possesses only one articular facet which faces backwards .It has 4 surfaces.
i) Palmar surface:
a) It is very narrow and ridge like.
b) It gives insertion to flexor carpi ulnaris above and attachment to Piso-metacarpal
and Piso-hamate ligaments below.
ii) Dorsal surface:
a) It possesses a circular facet which articulates with triquetral bone. Its margins give
attachment to Piso-triquetral ligament.
iii) Lateral surface:
a) It is flat.
b) It has an indistinct vertical ridge to which is attached flexor retinaculum.
E) TRAPEZIUM
It is the lateral most bone of the distal row and is identified by the presence of
a crest (or tubercle) and a groove on the palmar surface. It possesses 6 surfaces.
i) Palmar surface:
a) It presents a tubercle (crest) and a groove; the groove lodges the tendon of flexor
carpi radialis.
b) Margins of the groove give attachment to flexor retinaculum.
c) Tubercle (crest) gives origin to thenar muscles-
Abductor pollicis brevis.
Opponens pollicis.
Flexor pollicis brevis.
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ii) Dorsal surface:
a) It is long and narrow.
b) It is related to radial artery.
iii) Lateral surface:
a) It is roughened and non-articular.
b) It gives attachment to radial collateral ligament of wrist joint and capsular ligament
of carpo-metacarpal joint of thumb.
iv) Medial surface:
a) It bears an elongated area for articulation with trapezoid.
b) The distal part of medial surface has a rectangular facet for articulation with lateral
part of the base of 2nd metacarpal.
v) Proximal surface:
a) It bears an oval facet which articulates with scaphoid.
vi )Distal surface:
a) It bears a large concavo-convex or saddle-shaped facet which articulates with the
base of its metacarpal bone.
F) TRAPEZOID Small bone which is very irregular in shape; Boat-shaped.
It possess 6 Surfaces-
i) Palmar & ii) Dorsal
a) Roughened and non-articular,
b) Dorsal surface gives origin to some fibres of oblique head of Adductor pollicis.
iii) Proximal:
a) Rectangular surface which articulates with scaphoid.
iv) Distal:
a) Hollowed.
b) Articulates with the base of 2nd metacarpal.
v) Lateral:
a) Bears a convex facet which articulates with trapezium.
vi) Medial:
a) Bears a nearly square-shaped concave facet which articulates with the distal part of
capitate bone.
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G) CAPITATE
Largest of all carpal bones and is identified by the presence of a more or less
rounded convex surface called ‘head’.
It possesses 6 surfaces:
i) Proximal:
a)Nearly rounded and convex all around; it is called the Head.
b) Lateral part of the head articulated with scaphoid, while medial part articulates with
lunate.
ii) Distal:
a) Nearly triangular and forms a concavo-convex facet for articulation with the base
of 3rd metacarpal.
b) Its lateral border has a concave strip for articulation with the base of 2nd
metacarpal.
c) Its dorso-medial angle has a small facet for articulation with the base of 4th
metacarpal.
iii) Lateral:
a) On its distal part is a facet for articulation with trapezoid. This facet is continuous
with the facet of scaphoid.
b) It presents a constriction which constitutes the neck.
iv) Medial:
a) Larger and flat.
b) Bears a large facet for articulation with hamate.
c) Distal part of this surface is non-articular and gives attachment to intersseous
ligament.
v) Palmar & vi) Dorsal:
a)Rough surfaces; dorsal surface is larger than palmar surface. Adductor pollicis
(oblique head) arises from palmar surface.
H) HAMATE
It is wedge-shaped and is identified by the presence of a hook-like process
which projects from the distal part of its palmar surface.
It posses 6 surfaces.
i) Palmar:
a)Roughened,
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b) On its distal part is hook-like process. Concavity of the process faces laterally
while it is convex medially. It forms medial boundary of the carpal tunnel.
Tip of process gives attachment to flexor retinaculum. Convex surface of the process
gives origin to Opponens digiti minimi and Flexor digiti minimi brevis.
c) There is a groove at the distal part of the base of the hook. It transmits the deep
terminal branch of ulnar nerve.
ii) Dorsal: Roughened for ligamentous attachments.
iii) Distal:
a) Roughened.
b) Divided into 2 articular areas by faint ridge-
Smaller lateral facet articulates with the base of 4th metacarpal.
Larger medial facet articulates with the base of 5th metacarpal.
iii) Proximal:
a)It forms apex of the wedge.
b) Bears a narrow facet for articulation with lunate.
v) Medial: It is concavo-convex and articulates with triquetral.
vi) Lateral: Bears an oval facet for articulation with capitate.
2.THE METACARPUS
Metacarpal bones are 5 in number and numbered from lateral to medial side.
They are short long bones.
PARTS: i) Head: rounded.
ii) Base: expanded.
iii) Shaft.
i) Head: Lies distally and articulates with proximal phalanx. It is larger than the base
and produces the prominence of knuckles.
ii) Base: Lies proximally and articulates with distal row of carpal bones and with one
another-except 1st metacarpal which does not articulate with 2nd metacarpal.
iii) Shaft: Its palmar surface is concave and the dorsal surface is convex. The dorsal
surface has a flattened triangular area in its distal part. Lateral and medial surfaces
encroach on the proximal part of dorsal surface. The shaft gradually becomes thicker
from above downwards.
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INDIVIDUAL METACARPAL BONES:
A) FIRST METACARPAL BONE
a)Shortest and thickest of all other metacarpals.
b) Palmar surface of shaft is divided into a larger lateral and a smaller medial part by
an indistinct line.
c) Base has only one concave-convex facet for articulation with trapezium. This helps
in identification.
d) Heads has two tubercles at medial and lateral corners on palmar surface.
ATTACHMENTS:
i) Opponens pollicis: Inserted into lateral border and adjoining part of palmar surface
of shaft.
ii) 1st Dorsal interosseous (radial head): arises from medial border and adjoining part
of palmar surface of shaft.
iii) Abductor pollicis longus: inserted into lateral side of base.
iv) 1st Palmar intersseous: arises from medial side of palmar surface of base.
B) SECOND METACARPAL BONE
a)Longest of all other metacarpals.
b) Recognized by the presence of a groove on its base which articulates with
trapezoid. The groove is bounded on its medial side by a ridge which articulates with
capitate.
c) Shaft is prismoid in shape and possesses 3 surfaces – Medial, Lateral and Dorsal.
ARTICULATIONS:
i) Quadrilateral facet on lateral side of the base with trapezium.
ii) Medial side of the base with lateral side of the base of 3rd metacarpal.
iii) Groove on proximal aspect of the base with trapezoid.
ATTACHMENTS:
i) Extensor carpi radialis longus: inserted into dorsolateral aspect of the base.
ii) Flexor carpi radialis: inserted into palmar surface of the base.
iii) 1st Dorsal interosseous (ulnar head): arises from lateral surface of shaft.
iv) 2nd Palmar interosseous (radial head): arises from dorsal aspect of medial surface
of shaft.
v) 2nd Dorsal interosseus (radial head): arises from dorsal aspect of medial surface of
shaft.
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vi)Collateral ligament of metacarpo-phalangeal joint: to tubercles at the side of the
head.
C) THIRD METACARPAL BONE
It is recognised by the presence of styloid process projecting proximally from
radial side the dorsal surface of its base. It possesses 3 surfaces-Medial, Lateral and
Dorsal.
ARTICULATIONS:
Base a) With capitate bone proximally.
b) With 2nd metacarpal by a strip-like facet laterally.
c) With 4th metacarpal by two small, oval, discrete facets medially.
ATTACHMENTS:
i) Flexor carpi radialis : Inserted into palmar surface of the base.
ii) Extensor carpi radialis brevis: inserted into dorsal surface of the base on its radial
side.
iii) Adductor pollicis (oblique head): arises from palmar aspect of the base.
iv) 2nd Dorsal interosseous (ulnar head): arises from lateral surface of shaft.
v) 3rd Dorsal intreosseous (radial head): arises from medial surface of shaft.
vi) Adductor pollicis (transverse head): arises from the palmar ridge separating medial
and lateral surfaces. No palmar interossei muscle is attached to this bone.
D) FOURTH METACARPAL BONE
It is recognised by:
a) Presence of two small, discrete oval facets on lateral aspect of the base which
articulate with facets on medial aspect of 3rd metacarpal bone.
b) Presence of one elongated facet on medial aspect of the base for articulation with
base of 5th metacarpal bone.
c) Proximal surface of the base has a quadrilateral facet for articulation with hamate.
The lateral surface of shaft is divided into palmar and dorsal areas by a ridge.
ATTACHMENTS:
i) 3rd Palmar interosseous: arises from palmar aspect of lateral surface of shaft.
ii) 3rd Dorsal interosseous (ulnar head): arises from dorsal aspect of lateral surface of
shaft.
iii) 4th Dorsal intersseous (radial head): arises from medial surface of shaft.
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E) FIFTH METACARPAL BONE
It is recognised by:
a) Presence of a tubercle on medial aspect of the base, there being no facet.
b) Lateral aspect of the base has an elongated facet for articulation with the base of 4th
metacarpal bone.
A facet on proximal surface of the base articulates with hamate.
ATTACHMENTS:
i) Extensor carpi ulnaris: inserted on tubercle.
ii) Opponens digiti minimi: inserted into medial surface of shaft.
iii) 4th Palmar interosseous: arises from palmar aspect of lateral surface of shaft.
iv) 4th Dorsal interosseous (ulnar head): arises form dorsal aspect of lateral surface of
shaft.
3.PHALANGES
There are 14 in number, two for the thumb and three for the four fingers.
PARTS: i) Base: lies proximally.
ii) Shaft: lies in the middle.
iii) Head: lies distally.
Apart from the skeleton the major components of the hand are
1. Twenty Intrinsic muscles
2. Two arteries-Radial and Ulnar
3. Three nerves-Radial Ulnar and Median
1. TWENTY INTRINSIC MUSCLES147
The intrinsic muscles of the hand serve the function of adjusting the hand
during gripping and also for carrying out fine skilled movements. The origin and
insertion of these muscles is within the territory of the hand.
There are 20 muscles in the hand, as follows:
I. a. Three muscles of thenar eminence
i) Abductor policis brevis.
ii) Flexor pollicis brevis.
iii) Opponens pollicis.
b. One adductor of thumb
i) Adductor pollicis.
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II. Four hypothnar muscles
i ) Palmaris brevis.
ii) Abductor digiti minimi.
iii) Flexor digiti minimi.
iv) Opponens digiti minimi.
The above four are muscles of hypothenar eminence.
III. Four lumbricals.
IV. Four palmar interossei.
V. Four dorsal interossei.
These muscles are described below.
I.A.MUSCLES OF THENAR EMINENCE
i) Abductor Pollicis Brevis
Origin:
a) Tubercle of the scaphoid.
b) Crest of the trapezium.
c) Flexor retinaculum.
Insertion:
a) Lateral side of the base of the proximal phalanx of the thumb.
Nerve supply: Median nerve (C8, T1).
Action: Abduction of the thumb at the metacarpophalangeal and carpometacarpal
joints. Abduction is associated with medial rotation.
ii) Flexor Pollicis Brevis
Origin: The superficial head takes origin from
a) The crest of the trapezium.
b) The flexor retinaculum.
The deep head arises from the trapezoid and capitate bones.
Insertion: Lateral side of the base of the proximal phalanx.
Nerve Supply: It is supplied by the median nerve. The deep head may be supplied by
the deep branch of the ulnar nerve.
Action: Flexion of the thumb.
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iii) Opponens Pollicis
Origin:
a) Crest of trapezium.
b) Flexor retinaculum.
Insertion: Lateral half of the palmar surface of the first metacarpal bone.
Nerve supply: Median nerve (C8, T1).
Action: Opposition of the thumb. This is combination of flexion and medial rotation.
I.B .I) ADDUCTOR POLLICIS (Adductor of thumb)
Origin: The muscle has two heads-oblique and transverse.
The oblique head arises from:
a) The capitate bone.
b)The base of the 2nd and 3rd metacarpal bones.
The transverse head arises from the palmar aspect of the third metacarpal bone.
Insertion: Medial side of the base of the proximal phalanx of the thumb.
Nerve Supply: Deep branch of ulnar nerve (C8,T1).
Action: The muscle adducts the thumb from the flexed or abducted position. The
movement is forceful in gripping.
ACTIONS OF THENAR MUSCLES In studying the actions of the thenar muscles, it must be remembered that the
movements of the thumb take place in planes at right angels to those of the other
digits because the thumb (first metacarpal) is rotated medially through 90 degrees.
Flexion and extension of the thumb take place in the plane of the palm; and abduction
and adduction at right angles to the plane of palm. Movement of the thumb across the
palm to touch the other digits is known as opposition. This movement is a
combination of flexion and medial rotation.
II HYPOTHENAR MUSCLES
a) Palmaris Brevis
This muscle is superficial and lies just under the skin.
Origin: From flexor retinaculum and palmar aponeurosis.
Insertion: Skin along medial border of the hand.
Nerve Supply: Ulnar nerve, superficial branch (C8, T1).
Action: Helps in gripping by making the hypothenar eminence more prominent, and
by wrinkling the skin over it.
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b) Abductor Digiti Minimi
Origin: This muscle arises from the pisiform bone.
The origin extends on to the tendon of the flexor carpi ulnaris (proximally) and on to
the pisohamate ligament (distally).
Insertion: Ulnar side of the base of the proximal phalanx of the little finger.
Nerve Supply: Deep branch of ulnar nerve (C8, T1).
Action: Abduction of little finger at the metacarpophalgeal joint.
c) Flexor Digiti Minimi
Origin: a) Hook of the hamate bone.
. b) Flexor retinaculum.
Insertion: Ulnar side of the base of the proximal phalanx of the little finger.
Nerve Supply: Deep branch of the ulnar nerve (C8, T1).
Action: Flexion of the little finger at the metacarpophalangeal joint.
d)Opponens Digiti Minimi
Origin: a) Hook of the hamate bone.
. b) Flexor retinaculum.
Insertion: Medial surface of the shaft of the fifth metacarpal bone.
Nerve supply: Deep branch of ulnar nerve (C8,T1).
Action: Flexor of the fifth metacarpal and rotates it laterally (as making the palm
hollow).
III. LUMBRICAL MUSCLES
Lumbrical muscles are four small muscles that take origin from the tendons of
the flexor digitorum profundus. They are numbered from lateral to medial side.
Origin: The first lumbrical arises from the radial side of the tendon for the index
finger. The second lumbrical arises form the radial side of the tendon for the middle
finger. The third lumbrical arises from contiguous sides of the tendons for the ring
and little finger.
Insertion: The tendons of the first, second, third and fourth lumbricals pass backwards
on the radial side of the second, third, fourth and fifth metacarpophalngeal joints
respectively. They are inserted into the dorsal digital expansions of the corresponding
digits.
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Nerve Supply:
(i) The first and second lumbricals by the median nerve (C8, T1).
(ii) The third and fourth lumbricals by the deep branch of the ulnar nerve (C8, T1).
Actions: The lumbrical muscles flex the metacarpophalangeal joints, and extend the
interphalangeal joints of the digit into which they are inserted.
IV.PALMAR INTEROSSEI
Palmar interossei are four small muscles placed between the shafts of the
metacarpal bones. They are numbered from lateral to medial side.
Origin:
i) First palmar interosseous muscle from the medial side of base of the first
metacarpal bone.
ii) Second palmar interosseous muscle from the medial half of the palmar aspect of
the shaft of the second metacarpal bone.
iii) Third palmar interosseous muscle form the lateral interosseous muscle from the
lateral part of the palmar aspect of the shaft of the fourth metacarpal bone.
iv) Fourth palmar interosseous from the lateral part of the palmar aspect of the shaft
of the fifth metacarpal bone.
Insertion:
Each muscle is inserted into the dorsal digital expansion of one digit. It may also be
attached to the base of the proximal phalanx of the same digit. The digits into which
individual palmar interossei are inserted are as follow.
i) First muscle: Medial side of thumb.
ii) Second muscle: Medial side of the index finger.
iii) Third muscle: Lateral side of the fourth digit.
iv) Fourth muscle: Lateral side of the fifth digit.
Note that the middle finger does not receive the insertion of any palmar interosseous
muscle.
Nerve supply:
All palmar interossei are supplied by the deep branch of the ulnar nerve (C8, T1).
Actions:
All palmar interossei adduct the digit to which they are attached towards the middle
finger. In addition, they flex the digit at the metacarpophalangeal joint and extend it at
the interphalangeal joints.
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V.DORSAL INTEROSSEI (Fig. 16)
Like the palmar interossei the dorsal interossei are four small muscles placed
between the metacarpal bones, and are numbered from lateral to medial side.
Origin:
i) First dorsal interosseous: Shafts of first and second metacarpals.
ii) Second dorsal interosseous: Shafts of second and third metacarpals.
iii) Third dorsal interosseous: Shafts of third and fourth metacarpals.
iv) Fourth dorsal interosseous: Shafts of fourth and fifth metacarpals.
Insertion:
Each muscle is inserted into the dorsal digital expansion of the digit and into the base
of the proximal phalanx of that digit. The digit into which individual muscles are
inserted are as follows:
i) First: Lateral side of index finger.
ii) Second: Lateral side of middle finger.
iii) Third: Medial side of middle finger.
iv) Fourth: Medial side of fourth digit.
Note that the middle finger receives one dorsal interosseous muscle on either side;
and that the first and fifth digits do not receive any insertion.
Nerve Supply:
All dorsal interossei are supplied by the deep branch of the ulnar nerve (C8, T1).
Actions:
All dorsal interossei cause abduction of the digits away from the line of the middle
finger. This movement occurs in the plane of palm in contrast to the movement of
thumb where abduction occurs at right angels to the plane of palm. Note that
movement of the middle finger to either medial or lateral side constitutes abduction.
Also note that the first and fifth digits do not require dorsal interossei as they have
their own abductors.
In addition (like the palmar interossei), the dorsal interossei flex the
metacarpophalangeal joint of the digit concerned and extend the interphalangeal
joints.
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INSERTION OF FLEXORS OF FOREARM148 (Fig. 14) Superficial compartment:
1. Flexor carpi radialis to the palmar surface of the base of 2nd &3rd metacarpal
bones.
2. Palmaris longus to the distal half of flexor retinaculum and the apex of the palmar
aponeurosis.
3. Flexor carpi ulnaris to the pisiform bone.
4. Flexor digitorum superficialis to the corresponding sides of middle phalanx.
Deep compartment:
5. Flexor digitorum profundus to the palmar surface of the base of the distal phalanx.
6. Flexor pollicis longus to the palmar surface of the distal phalanx of thumb.
INSERTION OF EXTENSORS OF FOREARM (Fig. 10, 11, 12, 13 & 15)
Superficial compartment:
1. Extensor carpi radialis longus to the dorsum of base of the second metacarpal bone.
2. Extensor carpi radialis brevis to the dorsal aspect of bases of second&third
metacarpal bones.
3. Extensor digitorum collateral slips inserted to the dorsalaspect of the base of the
distal phalanx&intermediate slip is inserted into the dorsal aspect of the base of the
middle phalanx.
4. Extensor digiti minimi is inserted to the dorsal aspect of the base of the middle
phalanx and the base of the distal phalanx through the dorsal digital expansion.
5. Extensor carpi ulnaris to the medial side of the base of the 5th metacarpal bone.
Deep compartment:
6. Abductor pollicis longus to the lateral side of base of first metacarpal bone.
7. Extensor pollicis longus to the base of distal phalanx of thumb.
8. Extensor pollicis brevis to the dorsal surface of base of Proximal phalanx of thumb.
9. Extensor indicis joins tendon of Extensor digitorum for the index finger.
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FLEXOR RETINACULUM149
It is a strong fibrous band crosses the front of carpus&converts its anterior
concavity into the carpal tunnel, through which pass flexor tendons of digits&median
nerve. It is transversely short measuring 2.5 to 3 cm in breadth.
Attached Medially to
a) Pisiform and hook of Hamate.
Laterally to
a)Superficial laminae to the tubercles of Scaphoid and Trapezium.
b) Deep laminae to the medial lip of groove of Trapezium.
Proximally Retinaculum is continuous with the fascia covering Flexor digitorum
superficialis muscle and antebrachial fascia.
Distally it is continuos with the palmar aponeurosis and palmar fascia,and provides
origin to the thenar and hypothenar muscles.
STRUCTURES PASSING SUPERFICIAL TO FLEXOR RETINACULUM
i) Palmaris Longus muscle.
ii) Palmar cutaneous branch of median nerve.
iii) Palmar cutaneous branch of ulnar nerve.
iv) Superficial palmar branch of radial artery.
v) Ulnar nerve and ulnar vessels.
STRUCTURES PASSING DEEP TO FLEXOR RETINACULUM
1. Median nerve.
2. Tendons of Flexor digitorum superficialis.
3. Tendons of Flexor digitorum profundus.
4. Tendon of Flexor pollicis longus.
5. Tendon of Flexor carpi radialis lies on the groove of Trapezium between
superficial&deep slips of retinaculum.
EXTENSOR RETINACULUM150
It is an oblique fibrous band, derived from deep fascia and stretches across the
dorsal surface of the wrist to retain extensor tendons in position.
Attachments: Laterally to the anterior border of radius above its styloid process.
Medially, the fibres slope downward and medially,and are attached to the pisiform
and triquetral bone.
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The retinaculum is not attached to ulna, otherwise it would prevent pronation.
Beneath extensor retinaculum there are 6 osseo fascial compartments for 9 tendons
From lateral to medial side:
1 .Abductor Pollicis Longus & Extensor Pollicis Brevis.
2. Extensor Carpi Radialis Longus & Extensor Carpi Radialis Brevis.
3. Extensor Pollicis Longus.
4. Four tendons of Extensor Digitorum & tendon of Extensor Indicis.
5. Extensor Digiti Minimi.
6. Extensor Carpi Ulnaris.
PALMAR APONEUROSIS151
It is a thick triangular portion of deep fascia that lies in the central region of the palm.
It has an APEX at flexor retinaculum and a BASE near the head of metacarpals It is
divided into 3 parts i) Central part ii) Medial part iii) Lateral part
Triangular in shape
Apex blends with the distal border of flexor retinaculum.
Base splits into four digital slips for the medial four fingers.
Each slip divides into superficial and deep set of fibres.
Superficial fibres join with the Dermis and blend with the superficial transverse
ligament.
Deep set of fibres of each slip divides into two bands, which are attached to the deep
transverse ligament of palm, palmar ligaments of metacarpophalangeal joints, bases of
proximal phalanges and blends with the fibrous sheaths.
FIBROUS FLEXOR SHEATHS OF THE DIGITS152
a) To retain flexor tendons in position all 5 digits are provided with a strong
unyielding fibrous sheath which extend from metacarpal head to the base of the distal
phalanx.
b) Fibrous sheath of the thumb contains the tendon of flexor pollicis longus only.
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c) In the medial 4 fingers the sheaths are occupied by 2 tendons
i) of flexor digitorum profundus to reach the base of the distal phalanx.
ii) of flexor digitorum superficialis which gets inserted to the sides of middle
phalanx.
Each sheath crosses 3 joints
a) metacarpo phalangeal
b) proximal interphalangeal
c) distal interphalangeal
The sheaths present a series of thick zones over the phalanges and thin zones
over the joints. Recent analysis shows that the thicker zones are arranged proximo-
distally as
a) 5 annular pulleys.
b) 4 intervening pulleys .
FASCIAL SPACES IN THE PALM153
a) Three facial lined potential spaces limited by fibrous septa warrant attention in the
palm because of surgical importance. They are MID-PALMAR, THENAR & PULP
SPACES.
b) Deep to the aponeurosis, flexor tendons and lumbrical muscles lies a large fascial
lined central palmar space which is limited at the sides by medial& lateral palmar
septa. This is subdivided by a intermediate fibrous septum extending from the fascia
covering the undersurface of flexor tendons to the palmar surface of third metacarpal
bone into the mid-palmar space on ulnar side and the thenar space on the radial side.
MID-PALMAR SPACE
Triangular in shape. Boundaries are
a) In front flexor tendons of little, ring& middle fingers with their synovial sheaths
and 3rd &4th lumbrical muscles.
b) Behind-dense fascia covering the interossei&metacarpal bones of 3rd &4th spaces.
c) Laterally by intermediate fibrous septum.
d) Medially by hypothenar muscles separated by medial palmar septum.
e) Proximally space is closed by attachment of parital layer of ulnar bursa.
f) Distally, the space extends as diverticula to the webs of fingers along the fascial
sheaths of 3rd & 4th lumbrical muscles.
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THENAR SPACE
Triangular in shape. Boundaries are
a) In front by muscles of thenar eminence, flexor tendon of the index finger, first &
second lumbrical muscles.
b) Behind by Adductor pollicis (distal border).In the web of the thumb, thenar space is
continuous with a slit-like interval between Adductor pollicis & first dorsal
interosseus muscle.
c) Laterally by tendon of flexor pollicis longus and its sheath. This tendon is separated
from thenar muscles by lateral palmar septum.
d) Medially by intermediate fibrous septum.
e) Proximally extent is same as midpalmar.
f) Distally spaces extend as fascial diverticula along 1st &2nd lumbrical tendons to
interdigital clefts.
RADIAL BURSA154
Where two structures slide freely over each other, e.g.: muscle, tendon or skin over
bone or fascia, the friction between them is reduced by the presence of bursa. This is a
closely lined sac lined with a smooth synovial membrane which normally secretes a
small amount of glutinous fluid into the sac. When there is irritation or infection of the
bursa the secretion is increased and the bursa becomes swollen, tight and tender, as in a
bunion. Similarly synovial sheaths enclose tendons where the range of movement is
considerable, e.g.: the tendons sliding in the fingers.
The digital synovial sheath of the little finger is continuous proximally with the
ulnar bursa and that of the thumb with the radial bursa.
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ARTERIES OF THE PALM155 (Fig.6)
The terminal parts of ulnar and radial arteries on reaching the palm,
anastomose with each other to form superficial and deep palmar arches.
SUPERFICIAL PALMAR ARCH
The ulnar artery, accompanied by ulnar nerve on its medial side, enters the
palm superficial to the flexor retinaculum and on the radial side of pisiform bone.
Beneath the palmaris brevis the artery divides into superficial branch is the direct
continuation of the ulnar artery and forms the main contribution of the superficial
palmar arch.
Superficial palmar arch is arterial arcade which lies beneath the palmar
aponeurosis and in front of long flexor tendons, lumbrical muscles and palmar digital
branches of median nerve. The arch is formed by the superficial terminal branch of
ulnar artery and completed on the lateral side by one of the following arteries –
a. Superficial palmar branch of radial artery.
b. Arteria princeps pollicis or Princeps pollicis artery.
c. Arteria radialis indicis or Radialis indices artery.
d. Arteria nervi mediana which accompanies the median nerve.
The convexity of the arch is directed distally on a level with the distal border
of outstretched thumb.
Branches:
Four palmar digital arteries arise from the convexity of the arch. The most
medial digital branch passes along the ulnar side of the little finger. The remaining
three branches form the common palmar digital arteries which proceed distally to the
web between the fingers, where each joins with the palmar metacarpal artery of the
deep palmar arch and then divides into two proper palmar digital arteries to supply the
adjacent fingers.
Therefore, the superficial palmar arch does not supply the radial side of index
finger and both sides of the thumb.
DEEP PALMAR ARCH (Fig.7)
It is an arterial arcade formed by the anatomists between terminal end of
radial artery and the deep branch of ulnar artery. The radial artery enters the hand
between the two heads of first dorsal introsseous muscle, appears in the palm between
the oblique and transverse heads of adductor policies and continues as the deep
palmar arch. In the interval between the first dorsal interosseous and adductor
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muscles, the radial artery gives off two branches – arteria princeps pollicis and arteria
radialis inidicis. The former divides into two palmar digital branches to supply the
two sides of the thumb; the latter supplies the radial side of the index finger. The deep
branch of ulnar artery, accompanied by the deep branch of ulnar nerve, passes deeply
between the abductor and flexor digiti minimi and then runs laterally below the hook
of hamate bone to complete the deep palmar arch.
BRANCHES:
a)Three palmar metacarpal arteries – These arise from the convexity of the arch, pass
distally on the interosseous muscles of second to fourth spaces and in the webs
between the fingers anastomose with the common palmar digital branches of the
superficial arch.
b) Three perforating arteries – pass dorsally between the two heads of second to
fourth dorsal interossei, and anastomose with the dorsal metacarpal arteries. Their
accompanying veins drain most of the blood of the palm into the dorsal venous
plexus.
c) Recurrent branches extend proximally in front of the carpal bones and anastomose
with the anterior carpal arch.
NERVES OF THE PALM 156
MEDIAN NERVE:
The median nerve enters the palm beneath the distal border of flexor
retinaculum, where it enlarges and flattens before, dividing into lateral and medial
branches. Prior to division the nerve provides a recurrent muscular branch from its
lateral side which curls upward around the distal border of flexor retinaculum and
superficial to the tendon of flexor pollicis longus to supply the three muscles of the
thenar eminence (abductor and flexor pollicis brevis, opponens pollicis).
The lateral branch subdivides into three proper palmar digital nerves to supply
the skin of both sides of the thumb and radial side of the index finger; the branch to
the index finger provides a muscular twig to the first lumbrical.
Summary of distribution of median nerve in the hand- It supplies five muscles
(three thenar muscles, first and second lumbricals) and the skin of the lateral three and
one-half of the digits, including the joints of the digits and local blood vessels.
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PALMAR DIGITAL NERVES:
These are derived from median and superficial branch of ulnar nerves.
Initially he digital nerves lie deep to the superficial palmar arch. As they pass distally
along with the palmar digital vessels in the inter-digital clefts, both vessels and nerve
lie between superficial and deep transverse metacarpal ligaments. Here the palmar
digital nerves appear in front of or superficial to the vessels and maintain that
relationship along the digits. This is due to the fact that the nerves provide rich
communication to the sensitive pulp of the finger tips, and the digital arteries are
directed towards the nail bed to avoid the pressure of gripping.
Each proper digital nerve gives articular branches to the metacarpophalangeal
and interphalangeal joints, supplies the skin of the palmar aspect of the digit including
the pulp space, nail bed and provides dorsal branches to supply the skin over the
dorsal surface of middle and terminal phalanges. In the thumb, however, the dorsal
branch supplies the skin over the distal phalanx only.
ULNAR NERVE:
The ulnar nerve, accompanied by ulnar artery on its lateral side, appears in the
palm superficial to the flexor retinaculum and on the radial side of the pisiform bone.
Beneath the palmaris brevis in the proximal part of hypothenar eminence, the nerve
divides into superficial and deep terminal branches.
The superficial terminal branch gives a muscular twig to the palmaris
brevis, and subdivides into two branches;
a) A proper palmar digital nerve which supplies the ulnar side of the little finger, and
b) A common palmar digital nerve which receives a communication from the nearest
common digital branch of median nerve and then subdivides into two proper digital
nerves to supply the adjacent sides the ring and little fingers.
The digital nerves supply, in addition to palmar skin, metacarpophalangeal and
interphalangeal joints, local blood vessels, pulp spaces and nail beds and the skin of
the dorsal surface over the middle and terminal phalanges of the medial one and half
of the digits.
The deep terminal branch of ulnar nerve, accompanied by corresponding
branch of ulnar artery, passes deeply between the origins of abductor and flexor digit
minimi, pierces the opponens digiti minimi and then turns laterally lodging in a
groove below the hook of hamate bones. It follows the concavity of the deep palmar
arch and passes deep to the long flexor tendons.
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The deep branch supplies muscular branches to the three hypothenar muscles,
third and fourth lumbricals, all dorsal and palmar interossei, adductor pollicis and
occasionally to the deep part of flexor pollicis brevis. It also provides articular
branches to the intercarpal and carpometacarpal joints, and vascular branches to the
deep palmar arch and its branches.
Summary of ulnar never distribution in the hand- It supplies all intrinsic muscles of
the hand, except three thenar muscles and first and second lumbricals, and the
cutaneous branches to the medial one and a half the fingers including the ulnar side of
the hand.
DORSAL BRANCH OF ULNAR NERVE:
It appears on the medial side of the back of the wrist after piercing the deep
fascia, and divides usually into two dorsal digital nerves-one proper digital nerve to
supply the skin on the ulnar side of the little finger and the other is common digital
nerve which divides into two branches to supply the adjacent sides of the little and
ring fingers and receives communications from the nearest digital branch of radial
nerve.
The dorsal digital nerves of the little finger extend up to the base of the distal phalanx,
and those of the ring finger extend up to the base of the middle phalanx.
WRIST (RADIO-CARPAL) JOINT 157
It is a bi-axial ellipsoid joint. The proximal articular surface presents an
elliptical socket, formed by the distal articular surface of the radius and the articular
surface of the radius and the articular disc of the inferior radio-ulnar joint.
The distal articular surface is convex with reciprocal outline and is formed by
the scaphoid, lunate and triquetral bones with interosseous ligament connecting the
carpal bones together.
LIGAMENTS:
The wrist joint possesses capsular ligament with synovial membrane, radial
and ulnar collateral ligaments.
CAPSULAR LIGAMENT:
The fibrous capsule surrounds the joint is attached close to the peripheral
margin of the proximal and distal articular surfaces including the articular disc. Thus
the head of ulna is excluded from the joint by the articular disc.
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The capsule blends in front and behind the palmar and dorsal radio-carpal
ligament. Both ligaments extend infero-medially from the lower end of radius to the
corresponding surfaces of the proximal row of carpal bones and to the capitate. This is
to ensure the maximum functional use of the hand during pronation and supination.
RADIAL COLLATERAL LIGAMENT: It is thickening of the lateral part of the
capsule and extends from the styloid process of radius to the scaphoid and trapezium.
ULNAR COLLATERAL LIGAMENT: It extends from the ulnar styloid process to
the triquetral and pisiform bones.
Arterial supply: Supplied by the palmar and dorsal carpal arches, derived from the
anterior interosseus, anterior and posterior carpal branches of radial and ulnar arteries,
and recurrent branches of the deep palmar arch.
RELATIONS OF THE WRIST:
Infront: (proximal to flexor retinaculum)-Beneath the deep fascia structures are
mentioned from lateral to medial side and arranged in superficial, intermediate and
deep planes.
Superficial: Flexor carpi radialis, palmaris longus and flexor carpi ulnaris.
Intermediate: Radial artery (resting on anterior surface of distal part of radius),
median nerve (between flexor carpi radialis and palmaris longus, and postero-lateral
to the tendon or palmaris longus) four tendons of flexor digitorum superficials,
(tendons for middle and ring fingers in superficial plane, tendons for index and little
fingers in deep plane), ulnar vessels and ulnar nerve.
Deep:Flexor policis longus, anterior interosseous vessels and nerve, flexor digitorum
profundus.
Behind: beneath the extensor retinaculum the the retinaculum bridges over the
grooves and attached to the ridges in between the grooves, thus dividing into six
osseo-fibrous compartments.
Structures within the compartments are mentioned from lateral to medial side:
Abductor pollicis longus and extensor pollicis brevis, extensor carpi radialis longus
and brevis, extensor pollicis longus (medial to dorsal tubercle of Lister), extensor
digitorum and deep to it extensor indicis along with the posterior interosseous nerve
and anterior interosseous artery, extensor digiti minimi, extensor carpi ulnaris
(between the head and the styloid process of ulna).
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Movements: Movements at the wrist joint are associated with considerable range of
movements at the mid-carpal joint, because they are produced by the same groups of
muscles. Combination of wrist and mid-carpal joints is considered as link joint.
Active movements permitted at the joint complex are flexion, extension,
adduction, and circumduction. Axial rotation is not possible because of ovoid outline
of the wrist joint.
Flexion: Its range is about 850, and takes place more at the mid-carpal joint than at the
wrist joint. With flexed fingers, carpal flexion is diminished due to increased tension
in the extensors.
Extension:It is more limited in range of about 600, and occurs mainly at the wrist
joint. This explains why the proximal articular surfaces of the scaphoid and lunate
bones are more extensive on the posterior surface.
Abduction (ulnar deviation): It is more extensive than abduction due to short ulnar
styloid process. Range of abduction is about 450, and it is mostly done at the wrist
joint.
Abduction (radial deviation): Its extent is only about 150 it takes place almost
exclusively at the mid-carpal joint.
Circumduction: It is a combination of flexion, abduction, extension and abduction or
in reverse order.
MUSCLES PRODUCING MOVEMENTS
Flexion: Flexor carpi radialis and ulnaris act as prime movers, and assisted by flexor
digitorum superficialis and profundus, flexor pollicis longus and abductor pollicis
longus.
Extension: Extensor carpi radialis longus and brevis, extensor carpi ulnaris acts as
prime movers and assisted by extensor digitorum, extensor indicis, extensor pollicis
longus and extensor digiti minimi.
Abduction: Simultaneous contractions of flexor and extensor carpi ulnaris.
Abduction: Abductor pollicis longus, and simultaneous contractions of flexor carpi
radialis, extensor carpi radialis longus and brevis.
Spinal segments controlling wrist movement:
Flexion – C6, C7.
Extension – C6, C7.
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SURFACE LANDMARKS158 (Fig.8, Fig.9)
1. Styloid process of the radius projects 1cm lower than the styloid process of ulna. It
can be felt in the upper part of the anatomical snuff box.
2. Styloid process of the ulna projects downwards from the posteromedial aspect of
the lower end of the ulna.
3. Pisiform bone can be felt at the base of the hypothenar eminence (medially).
4. Hook of Hamate lies one finger breadth below the pisiform bone, in line with the
ulnar border of the ring finger. It can be felt only on deep palpation through the
hypothenar muscles.
5. Tubercle of Scaphoid can be felt at the base of the thenar eminence in a depression
just lateral to the tendon of flexor carpi radialis.
6. Tubercle (crest) of Trapezium may be felt on deep palpation inferolateral to the
tubercle of scaphoid.
7. Tendons of flexor carpi radialis,palmaris longus and flexor carpi ulnaris can be
identified in front of wrist when the hand is flexed against resistance.Tendons lie in
the order from lateral to medial.
8. Pulsations of radial artery can be felt in front of lower end of the radius just lateral
to the tendon of flexor carpi radialis.
9. Pulsations of ulnar artery can be felt by careful palpation just lateral to the tendon
of flexor carpi ulnaris.
10. Anatomical snuff box is a depression which appears on the lateral side of the
wrist when the thumb is extended.
APPLIED ANATOMY
i) COLLES’ FRACTURE159: A Colles’ fracture is a fracture of the radius within 2.5
cm of the wrist with or without avulsion of the ulnar styloid process and with a
characteristic deformity. The lower fragment is usually tilted backwards, shifted
backwards with a tilt radially.
ii) REVERSED COLLES’ FRACTURE OR SMITH’S FRACTURE160: A transverse
fracture of the lower end of the radius with forward shift and tilt (displaced anteriorly
and tilted anteriorly) is known as Smith’s fracture. It is called reverse Colles’ because
the deformities when viewed from the side radiologically are just opposite to those
seen in a Colles’ fracture. Fracture line may at times be oblique extending to the wrist
joint. This is fracture- dislocation. This is known as Barton’s fracture.
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iii) FRACTURE OF THE SCAPHOID161: The scaphoid is the most frequently
fractured carpal bone. It often results from a fall on the palm when the hand is
abducted, the fracture occurring across the narrow part (‘waist’) of the scaphoid. Pain
occurs primarily on the lateral side of the wrist, especially during dorsiflexion and
abduction of the hand.
Initial radiographs of the wrist may not reveal a fracture; often this injury is
misdiagnosed as a severely sprained wrist. Radiographs taken 10-14 days later reveal
a fracture because bone resorption has occurred there. Owing to the poor blood supply
to the proximal part of the scaphoid, union of the fractured parts may take at least 3
months.
Avascular necrosis of the proximal fragment of the scaphoid may occur and
produce degenerative joint disease of the wrist. In some cases, it is necessary to fuse
the carpals surgically (arthrodesis).
iv) FRACTURE OF THE HAMATE161: It may result in the non-union of the
fractured body parts because of the traction produced by the attached muscles.
Because the ulnar nerve is close to the hook of the hamate, the nerve may be injured
by this fracture, causing decreased grip strength of the hand. The ulnar artery may
also be damaged when the hamate is fractured.
v) FRACTURE OF THE METACARPALS161: The metacarpals (except the 1st) are
closely bound together; hence isolated fractures tend to be stable. Furthermore, these
bones have a good blood supply, and fractures usually heal rapidly. Severe crushing
injuries of the hand may produce multiple metacarpal fractures, resulting in instability
of the hand. Fracture of the fifth metacarpal, often referred to as the boxer’s fracture,
occurs when an unskilled person punches someone with a closed fist. The head of the
bone rotates over the distal end of the shaft, producing a flexion deformity.
vi) INFECTION OF RADIAL BURSA162: In fact true synovitis of the flexor pollicis
longus always brings about the condition. This is evident by the fact that swelling of
the thumb is seen to extend into the thenar eminence. The thumb is held flexed.
Swelling may be seen just proximal to the flexor retinaculum on the lateral side.
vii) STENOSING TENOVAGINITIS 163
a) De Quervain’s disease: De Quervain first explained this disease in 1895.In this
condition the fibrous sheath containing extensor pollicis brevis and abductor pollicis
brevis and abductor pollicis longus tendon becomes fibrosed and thickened, so that
the intrathecal lumen becomes narrowed. It occurs at a point 11/2 inches or 3.25 cm
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above the tip of the radial styloid process.. It is on the lateral aspect of lower end of
the radius where the tendons lie in shallow bony groove.
The main symptom is pain on the radial side of the wrist particularly
following actions like wringing clothes. There is also weakness of the grip and of the
thumb. Pain becomes aggravated by abduction and extension of the thumb.
b) Trigger Finger: This is a condition of stenosing tenovaginitis of flexor tendons. In
this condition there is obstacle to voluntary flexion or extension of the finger. When
the finger is extended, it is difficult to do so, but when the obstructed portion is
crossed, the finger suddenly straightens with a snap; hence it is called ‘Trigger
Finger’.
c) Mallet Thumb: This resembles mallet finger. The extensor pollicis longus may be
cut anywhere or it may rupture at the wrist in rheumatoid arthritis or it may rupture
following fracture of lower end of radius.
viii) Carpal-Tunnel Syndrome164: This is a condition in which the median nerve is
compressed at the wrist as it passes through the carpal tunnel. The compression can be
caused by skeletal abnormalities, swelling of other tissues within the tunnel or
thickness of retinaculum. The predominant signs are pain, paraesthesia, pins and
needles in the finger and loss of coordination of fingers.
ix) Ulnar claw hand165: This nerve has a high susceptibility of getting injured in the
region of wrist that produces ulnar claw hand. The little and ring fingers are affected.
The metacarpophalangeal joints are hyperextended and the interphalangeal joints are
flexed.
x) True claw hand165: This occurs when the ulnar nerve and median nerve are both
injured at the wrist. The main sign of this is the inability to oppose the thumb. The
paralysis of the short muscles of the thumb leads to a deformity called Ape-like hand
in which the thumb is permanently adducted and laterally rotated.
COMPLICATIONS OF MARMA ABHIGATA166
A) ASPHYXIA: This is related to Marmas situated in the chest region such as
Hrudaya, Stanamoola, Stanarohita, Apalapa and Apasthambha. Hrudaya is directly
related to primary asphyxia whereas other marmas are most of the time concerned to
secondary asphyxia and Susruta has dealt thorax, intra-thoracic conditions. eg: cardiac
tamponade, surgical emphysema, pneuomothorax, hydrothorax, pyothorax and
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haemothorax. This condition is quickly fatal and if not relieved the death can ensue in
minutes.
B) HEAMORRHAGE: After cardiopulmonary involvement the hemorrhage is next
in importance and should be rapidly controlled by whatever means are available.
Susruta highlights the surgical conditions of certain injured muscles. Though
anaerobic conditions associated with myositis could not come on the surface, however
bleeding muscle and important mamsa marma such as Talahrudaya, Indrabasti, Guda,
Stanarohita marma posing fatal condition have definitely been considered.
C) SHOCK167: is a condition in which circulation fails to meet the nutritional needs of
the cells and at the same time fails to remove the metabolic waste products.
Types:
i) Haematogenic or Hypovolaemic shock: This type of shock is due to loss of blood,
plasma or body water and electrolytes or in one word loss of intravascular volume. It
is often caused by heamorrhage, vomiting, diarrhea, dehydration etc. This is clinically
manifested by low cardiac output, tachycardia, low blood pressure and
vasoconstriction revealed by cold clammy extremities.
ii) Traumatic shock: This type of shock is caused by major fractures, crush injuries,
burns, extensive soft tissue injuries and intra-abdominal injuries. This causes an
intravascular inflammatory response with increase in vascular permeability, which
requires large volumes of colloidal and crystalloid fluid for resuscitation.
iii) Neurogenic shock: This is caused by paraplegia, quadriplegia, trauma to the spinal
cord or spinal anesthesia. Such shock is primarily due to blockade of sympathetic
nervous system resulting in loss of arterial and venous tone with pooling of blood in
the dilated peripheral venous system.
Vasovagal or Vasogenic shock is also a part of neurogenic shock in which
there is pooling of blood due to dilatation of peripheral vascular system particularly in
the limb muscle and in the splanchnic bed. This cause reduced venous return to the
heart leading to low cardiac output and bradycardia. Blood flow to the brain is
reduced causing cerebral hypoxia and unconsciousness.
Psychogenic shock, which may follow sudden fright from unexpected bad
news or at the site of horrible accident, is also included in this group.
iv) Cardiogenic shock: This type of shock is caused by injury to the heart, myocardial
infarction, cardiac arrhythmias or congestive cardiac failure. In this condition the
heart fails to pump blood.
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v) Septic shock: Such type of shock is most often due to gram negative septicaemia.
Such type of shock may occur in cases of severe septicaemia, cholangitis, peritonitis
or meningitis. In early stages cardiac output increases, but vascular resistance
decreases due to dilated cutaneous arteriovenous shunts. In late cases, vascular
permeability increases, so that the blood volume decreases leading to hypovolaemia.
In further advanced cases the cardiac function is damaged due to toxins liberated by
the organisms.
vi)Miscellaneous types: These include anaphylatic shock and insulin shock.
D) Tetanus168: This potentially fatal condition, also called “lock jaw” is caused by
Clostridium tetani, a Gram positive spore-forming bacillus occurring naturally in the
intestines of humans and animals and in the soil. It enters the body through a wound
and replicates thriving on the anaerobic conditions present in devitalized tissues. It
produces tetanospasmin, a potent exotoxin that binds to neuromuscular junctions of
the C.N.S neurons, rendering them incapable of neurotransmitter release. This leads to
failure of inhibition of motor reflex responses to sensory stimulation.
The result is generalized contractions of agonist and antagonist muscles
causing tetanic spasms. The medium incubation period is 7 days, ranging from 4-14
days.
Early symptoms are painful spasms of the masseter and facial muscles
resulting in the classical ‘risus sardonicus’. The spasms spread to involve the muscles
of respiration and the laryngeal musculature. Spasms of the paravertebral and extensor
limb contracture produce ‘opisthotonos’ an arching of the whole body.
Laryngeal muscle spasm lead to aponea and if prolonged to asphyxia and
respiratory arrest. The spasms can be brought on the slightest of sensory stimuli. They
may be sustained and severe enough to produce long bone fractures and joint
dislocations.
E) GAS GANGRENE169: This is a rapid spreading infective gangrene of the muscles
characterized by collection of gas in the muscles and subcutaneous tissue. As this
condition is caused by Clostridial infection, it is also called ‘Clostridial myonecrosis’.
Methodology ……
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METHODOLOGY
Source of data:
Literary and conceptual study was done on the data compilations from
the Bruhatrayees, Laghutrayees, and other classical books including journals,
presented papers, previous work done and co-related, analyzed with the
knowledge of contemporary science on the topic “A comprehensive study of
marmas in the Hasta (Hand) w.s.r to the surface and regional anatomy
(cadaver dissection).”
Dissection of region on marmas in Hasta on cadavers in the dissection
hall at S.D.M. College of Ayurveda, Udupi was done. Observations were
analyzed and co-related in the view of ancient description of marmas in Hasta
and special reference to modern science.
Method of collection of the data:
Literary works, Books, Journals including published ones on the
concept related to subject will be reviewed and related information will be
collected and analyzed scientifically.
Cadaver study was conducted on ten hands of five cadavers in
Shareera Rachana dept. of S.D.M. College of Ayurveda, Udupi.
Assessment criteria:
Observation of surface and regional anatomy on cadaver dissection and
co-related with the shareera of marmas in the Hasta region as explained in
Ayurveda classics.
Observation…
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OBSERVATION
The dissection on ten hands of five cadavers was carried out in the department
of anatomy of S.D.M.C.A, Udupi as per the Cunningham’s manual.
Skin and Superficial fascia around the region of the wrist joint was removed.
Superficial fascia contained dense bundles of fibrous tissue connecting the
skin to the palmar aponeurosis in the palm and is thickened transversely in the webs
of the fingers to form the superficial transverse metacarpal ligament.
On the proximal part of the hypothenar eminence, the Palmaris Brevis muscle
was identified which passes from the skin on the ulnar border of the hand to the
palmar aponeurosis.
FLEXOR RETINACULUM which is a fibrous band and modification of deep
fascia was identified. It was attached to the Scaphoid and Trapezium laterally.
Medially it is attached to the Pisiform and Hamate bones.
The ulnar nerve and vessels, palmar cutaneous branch of the median and ulnar
nerves and the tendon of Palmaris longus muscle were found to pass superficial to it.
The median nerve and the four muscles of the flexor compartment were
observed passing deep to the carpal tunnel.
Palmaris Longus was found inserted into the distal half of flexor retinaculum
and the apex of palmar aponeurosis.
PALMAR APONEUROSIS is a thick triangular portion of deep fascia that
lies in the central region of the palm. Its apex at flexor retinaculum, base near the head
of metacarpals and its four slips were identified.
The three muscles of the thenar eminence were identified. The Abductor
Pollicis was the lateral muscle and Flexor Pollicis Brevis was the medial one. These
two form the superficial lamina and the deeper lamina was constituted by the
Opponens Pollicis.
The four hypothenar muscles were identified. Hypothenar eminence was
constituted by abductor digiti minimi medially and Flexor Digiti Minimi lateral to it.
Observation…
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ULNAR NERVE gave a dorsal branch 5 cm above the medial side of the back
of the wrist which gave a proper digital nerve which supplied the skin on the ulnar
side of the little finger and another common digital nerve which divide into two
branches to supply the adjacent sides of the little and ring fingers .It received
communication from the nearest branch of radial nerve.
It entered the palm on the lateral side of the pisiform bone, superficial to the
flexor retinaculum. It then passed deep to the Palmaris brevis muscle and subdivided
into superficial and deep terminal branches. Superficial terminal branch was
identified. Deep terminal branch which passed deep to the flexor tendons was also
identified.
MEDIAN NERVE entered the palm deep to the flexor retinaculum in the
carpal tunnel. Palmar cutaneous branch pierced the deep fascia and supplies the skin
of the thenar eminence and central region of the arm. Recurrent muscular branch
curled upwards and supplied three muscles of thenar eminence.
The Lateral and Medial branches of Median nerve were distinguishable.
ULNAR ARTERY entered the palm by passing superficial to the flexor
retinaculum. Beneath the palmar aponeurosis it anastomosis with the radial artery to
form the superficial and deep palmar arches.
Superficial palmar arch was found deep to the Palmaris Brevis and Palmar
aponeurosis. It then crossed the palm over the lumbricals and the digital branches of
the median nerve.
It gave away four digital branches which supplied the medial three and a half
fingers.
The deep branch of the ulnar artery arised in front of flexor retinaculum
immediately beyond the pisiform bone. Soon it passed between the flexor and
abductor digiti minimi to join and complete the deep palmar arch.
RADIAL ARTERY passes through the anatomical snuff box and divides to
form the superficial and deep arches. The branches identified were
a) To the lateral side of the dorsum of the thumb.
Observation…
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b) Dorsal metacarpal artery was identified.
c) In palm it gave off a branch Princeps pollicis artery which was identified.
d) Radialis indicis artery was also identified.
WRIST JOINT:
The wrist is surrounded by the thickened band of deep fascia ie both the
retinacula.
The three muscles of the thenar eminence and the four hypothenar muscles
were identified.
After cutting and reflecting the two retinacula, thenar and hypothenar muscles
a clear view of the wrist joint was obtained.
The distal end of the radius articulated medially with the ulna(ulnar notch) and
inferior surface of the lower end of the radius was found articulated with the Scaphoid
and Lunate bones.
The capsular ligament was identified.
The Dosal radiocarpal ligament on the dorsal aspect of the joint was identified.
The Radial collateral ligament was identified.
The Ulnar collateral ligament was identified.
Anterior interosseus nerve and the posterior interosseus nerve were identified.
Flexor carpi ulnaris was found inserted into the pisiform bone.
Lying on the deeper plane were the tendons of flexor digitorum superficialis
and flexor digitorum profundus.
Originating from the tendons of flexor digitorum profundus four lumbricals
were observed.The first two were unipinnate and the remaining two bipinnate and
were inserted to the dorsal digital expansions of the corresponding digits.
Deep palmar arch was formed by the anastomosis between the deep branch of
the radial artery and the deep branch of the ulnar artery. It passed across the bases of
Observation…
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metacarpals and interossei and lay undercover of the oblique head of the adductor
pollicis, flexor tendons and lumbricals.
It gave away three palmar metacarpal arteries, three perforating arteries and
recurrent branches.
The four palmar interossei muscles were spotted positioned between the shaft
of the metacarpal bones.
Flexor Carpi Radialis was found inserted into the palmar surface of the bases
of the second and third metacarpal bones.
RADIAL NERVE, posterior cutaneous nerve of the forearm was found to
supply the region of skin around the wrist and dorsum of the hand.
The superficial branch of radial nerve after piercing the deep fascia supplied to
the lateral 2/3rd of the dorsum of the hand and the dorsal surfaces of the thumb and
lateral two and a half fingers through five dorsal digital nerves. The lateral three were
proper digital nerves and the medial two are common digital nerves.
EXTENSOR RETINACULUM which is an oblique fibrous band and
modification of deep fascia was observed. Laterally it was found attached to the
anterior border of the radius above the styloid process and medially to the pisiform
and triquetral bones.
The six osseofacial compartments along with the nine muscles of the extensor
compartment were identified.
Extensor Carpi Radialis Longus was found inserted into the dorsum of the
base of the second metacarpal bone.
Extensor Carpi Radialis Brevis was found inserted into the dorsal aspect of the
base of the second and third metacarpal bones.
Extensor Digitorum, the intermediate slip was found inserted into the dorsal
aspect of the base of the middle phalanx. The collateral slips reunited to get inserted
into the dorsal aspect of the base of the distal phalanx.
Observation…
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Extensor Digiti Minimi was found inserted into the dorsal aspect of the base of
the middle phalanx and terminal phalanx along with the tendon of extensor digitorum
for the fifth digit.
Extensor Carpi Ulnaris was found inserted to the medial side of the base of the
fifth metacarpal bone.
Abductor Pollicis Longus was found inserted to the lateral side of the base of
the first metacarpal and the other part to the trapezium.
Extensor Pollicis Longus was found inserted in the dorsal aspect of the base of
the thumb.
Extensor Pollicis Brevis was found inserted in the dorsal surface of the base of
the proximal phalanx of the thumb.
Extensor Indicis was found inserted along with the ulnar side of tendon of
extensor digitorum for the index finger.
The four dorsal interossei were also found placed between the metacarpal
bones on the dorsal aspect with the origin, insertion and nerve supply as mentioned in
literary review.
Figures….
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SURFACE MARKINGS OF HASTA MARMA
Fig: 1A- Kshipra (Palmar Aspect) Fig: 1B- Kshipra (Dorsal Aspect)
Fig: 2A- Talahrudaya (Palmar Aspect) Fig: 2B- Talahrudaya (Dorsal Aspect)
Figures….
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Fig: 3A- Kurcha (Palmar Aspect) Fig: 3B- Kurcha (Dorsal Aspect)
Fig: 4A- Kurchashira (Palmar Aspect) Fig:4B- Kurchashira (Dorsal Aspect)
Fig: 5A- Manibandha (Palmar Aspect) Fig: 5B- Manibandha (Dorsal Aspect)
Figures….
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Fig 6: Anterior view of palm with vessels and nerves
Fig 7: Deep palmar arch and its branches
Figures….
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1. Extensor retinaculum. 2. Flexor retinaculum. 3. Head of metacarpals. 4. Ulnar artery. 5. Radial artery. 6. Level of Superficial palmar arch. 7. Level of Deep palmar arch.
Fig 8: Surface anatomy of hand
Fig 9: Surface anatomy of hand (Bony Landmarks)
Figures….
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CADAVER DISSECTION PHOTOS
Extensor carpi radialis longus
Extensor carpi radialis brevis
Abductor pollicis longus
Extensor pollicis brevis
Extensor pollicis longus
Fig 10: Muscles of Extensor Compartment
Fig 11: Extensor Digitorum
Extensor digitorum
Extensor digiti Minimi
Fig12: Extensor Digiti Minimi
Figures….
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Extensor carpi ulnaris
Fig 13:Extensor Carpi Ulnaris
Flexor digitorum superficialis
Flexor digitorum profundus
Fig 14: Flexor Tendons
Abductor pollicis brevis
Fig 15:Abductor Pollicis Brevis
Figures….
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First dorsal interossei
Fig 16:First dorsal interossei
Fig 17: Dissected Hand Palmar surface
Fig 18: Dissected Hand Palmar surface
Discussion…
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DISCUSSION
The terminology of Hasta has variable opinion among acharyas.In the present
study the region from manibandha sandhi (wrist joint) and below has been considered
as Hasta. Manibandha has been mentioned as panimoola (root of hand) by Dalhana.
There are five marmas in this region and are discussed below.
KSHIPRA MARMA
The region of the marma is the web space between the first and second
metacarpal bone i.e. between the thumb and index finger. The distance between the
root of the thumb and the tip of the index finger is given as 5 Angula and the
pramanaof the marma is half angula.There is a difference of opinion among scholars
about the understanding of pramana shareera when it comes to the marma
shareera.Many opine that it is the length, some consider it as the width, some as depth
and some as diameter of a circle .It is more appropriate to take it as length, width and
depth from a presumed centre. In the present study the width of the madhyama parva
of the madhyama angula is taken as anguli.
The structures that pass through this region are
i) Radialis indicis artery/Arteria radialis indicis.
ii) Princeps pollicis artery/Arteria princeps pollicis.
(in the interval between the first dorsal interosseus and adductor muscle)
iii) Deep branch of radial artery that proceeds to form deep palmar arch.
iv) Recurrent branch of median nerve which supplies the thenar muscles.
v) Three proper palmar digital nerves of the lateral branch of the median nerve
which supply the skin of both sides of the thumb and radial side of index
finger.
vi) First lumbrical.
vii) First palmar interossei.
viii) First dorsal interossei.
ix) Transverse and oblique head of adductor pollicis.
x) Radial bursa.
xi) Superficial terminal branch of Radial nerve and its dorsal digital branches.
Discussion…
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It is a snayu marma, kalantarapranahara in nature. It is also mentioned that
sometimes the marma can be sadyopranahara.It has also been explained that death
will occur due to akshepaka.
Acharya Susruta has mentioned that this marma can sometimes turn into
sadyopranahara. Akshepaka is one among vatavyadhis mentioned by Susruta and
Vagbhata.In akshepaka the vayu entering the dhamani will cause severe spasm and
convulsions in the individual. More of that the attacks will be frequent.Dalhana has
interpreted the dhamani as nadi which possibly indicates the involvement of nervous
system in the vyadhi.
It has been mentioned that in the Kshipra marma abhigata,there will be severe
blood loss which will lead to the vata prakopa.
The convulsions and spasm caused by an injury due to severe blood loss is closely
adherent with the similar sign found in Tetanus (Lock Jaw).The sign of ‘opisthotonos’
mentioned in tetanus is strikingly similar to the akshepaka.
The hand and the leg are the two main body parts that makes man an efficient
being on earth. Our samhitas were written at a time when human life was not
mechanized and man had to do all his daily chores like cutting grass, wood etc. with
his hand and feet. So they were more exposed to soil and dirt and hence had an easy
chance to get wounded. The site of marmas in the hand and feet were more
susceptible to injury and infection.
The methodology of management of sepsis might have been different at the time
of Susruta.So this could be one of the reasons why amputation has been indicated in
kshipra marma abhigata to prevent further spread of infection to upper limb.
Apart from that the incubation period of clostridium tetani is mentioned to be in
between 4-14 days which strikingly matches with the fact that the a person injured in
the kalantarapranahara marma will die within 15-30 days.
There are 20 intrinsic muscles in our hand and Susruta might have classified most
of them as snayu, due to their small size which led to the classification of Kshipra as a
snayu marma.Since thumb is the master finger, the first web space was given more
importance compared to others.
Discussion…
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 83
TALAHRUDAYA MARMA
The etymology of the word can be assumed that it means the ‘hrudaya’(centre) of
the hastatala.So the derived name Talahrudaya.
The region of the marma is in the centre of the palm in straight line with the
middle finger and the pramana of marma is given as half angula and is a mamsa
marma of the kalantarapranahara variety.
The structures passing through this region are
i) Palmar aponeurosis.
ii) Tendons of flexor digitorum superficialis.
iii) Tendons of flexor digitorum profundus.
iv) Second and third lumbricals.
v) Superficial palmar arch.
vi) Medial division of median nerve.
vii) Second and third dorsal interossei.
viii) Communicating branch between the superficial terminal branch of radial nerve
and dorsal branch of ulnar nerve.
The signs of marma vidda lakshana given are ruja and marana. Though ruja (pain)
is a common manifestation of all major injuries in this case it will be severe due to the
close adherence of neurovascular network. Any rupture in the superficial palmar arch
will lead to severe haemorrhage and a piercing or blunt injury will definitely damage
the median nerve. This will definitely lead to traumatic shock or vasovagal shock.
Apart from that the person can also easily get infected with tetanus which will lead to
death.
The possible reason in classifying talahrudaya as a mamsa marma is because the
skin and palmar aponeurosis gives a fleshy and thick protection to the underlying
structures.
It is also significant to note that amputation is advised in talahrudaya marma
abhigata like kshipra marma to prevent further sepsis.
Discussion…
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 84
KURCHA MARMA
The etymology of the word kurcha suggests that it is in the shape of a brush.
The region of the marma is two angula above the kshipra marma.There occurs a
doubt whether the two angula is to be taken towards the region of wrist joint or
towards the termination of fingers. The marmas are described in humans starting from
the extremities of the limb and upwards. So it is appropriate to consider it towards the
region of wrist joint. The marma is of swapanitala pramana.It is a snayu marma of the
vaikalyakara variety.
The structures passing through this region are
i) Palmar aponeurosis dividing into central, medial and lateral part.
ii) Tendons of Flexor digitorum superficialis and Flexor digitorum profundus coming
out of the flexor retinaculum and spreading out distally like the end of brush.
iii) Mid palmar space and Thenar space.
iv) Tendons of Extensor Digitorum and Extensor Indicis.
The signs of marma viddha lakshanas according to Susruta are Hasta Bhramana
and Vepana.According to Ashtanga Hrudaya the signs are Hasta Bhramana and
Kampa.
This can be interpreted as tremors and rotation of hand to the medial or lateral
side. This is because the supply to any one of the group of twenty intrinsic muscles of
the hand is impaired, it will lead to the hyperextension of metacarpophalangeal joints
as in claw hand or laterally rotated thumb as in ape-like hand. This can be interpreted
as hasta bhramana.Also a trauma could lead to the progressive shortening of palmar
aponeurosis causing Dupuytren’s contracture, which also is a vikalata.
Apart from that any rupture in the tendon will lead to hematoma and collection of
puss in the mid palmar and thenar space. These conditions will lead to severe non
compensatory loss of tissues that might lead to vikalata.
Discussion…
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 85
KURCHASHIRA MARMA
The etymology of the word suggests that it is named so because it is fastened up at
one end like a brush.
The region of marma is below and on both sides of the manibandha.The marma is
one angula in pramana and is a snayu marma of rujakara variety.
Assuming from the shape of the marma it has to be understood that the flexor and
extensor tendons coming under the flexor and extensor retinaculum has to be taken
into account. Here the kurcha or brush like appearance is made up of the confluence
of various tendons, nerves and the kurchashira appearance (fastening of brush is
formed by the flexor and extensor retinaculum present below the joint).The structures
passing deep to the retinacula are
1. Median nerve.
2. Tendons of Flexor digitorum superficialis.
3. Tendons of Flexor digitorum profundus.
4. Tendon of Flexor pollicis longus.
5. Tendon of Flexor carpi radialis lies on the groove of Trapezium between the
superficial&deep slips of retinaculum.
6. The tendon of Palmaris longus is inserted into the superficial part of flexor
retinaculum.
7. The nine tendons of the muscles of the extensor compartment in six osseofacial
compartments also pass deep to the extensor retinaculum
The possible reason for classifying kurchashira as a snayu marma is due to the
predominance of snayu in the region.
Kurchashira marma is classified as rujakara marma.Another fact is that an injury
at that level will lead to vaikalyata(deformity).The reasoning is that most of the
manifestations involving injury to the nerves and vessels are found much below the
wrist joint.
Discussion…
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 86
For example the entrapment of median nerve in the carpal tunnel leads to the
wastage of thenar muscles, which lies below the manibandha and kurchashira
marma.So the predominant sign of any injury to this marma has to be ruja.
MANIBANDHA
The etymology of the word suggests that it means a string of mani(beads) joined
together. The arrangement of the carpal bones gives a string like appearance.
It is located at the meeting point of prapani and hasta.The marma is two angula in
pramana and is a sandhi marma of rujakara variety.
The structures occupying this region are
i) Lower part of radius and ulna.
ii) Radial and Ulnar collateral ligaments.
iii) Capsular ligament.
iv) Tendons of the muscles of the flexor and extensor compartment.
Fractures of the wrist joint involving the lower end of the radius (Colles’ fracture
and Smith’s fracture) are very common. Fracture of the Scaphoid is also very
common.
Manibandha is classified as a sandhi marma because it joins the forearm and hand.
Among the sandhi marmas only manibandha and gulpha are classified as rujakara
marmas. Many reasons can be attributed for classifying manibandha as a rujakara
marma.The first one is that it is not a weight bearing joint and it has a wide range of
movements. Second one is that the haemorrhage in this region can easily be
controlled.
Third one is that Susruta might have statistically observed less number of
deformities in this region. However severe injury and lack of proper management may
lead to deformity as mentioned by Susruta.
Discussion…
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 87
There are three fates for any wound. One is the entrapment or involvement of vital
organs, second is the non compensatory loss of tissue and third is the compensatory
loss of tissue. Rujakara marma belongs to the third variety where pain is the first sign
of morbidity.
It is also significant to mention that scaphoid fracture is often misdiagnosed as
severely sprained wrist .Secondly owing to the poor blood supply to the proximal part
of scaphoid, union of fractured parts takes a minimum of three months. This
substantiates that the patient will have to suffer the pain for three months. Avascular
necrosis of the proximal segment of scaphoid may lead to degenerative joint disease
of the wrist in which the patient has to suffer long standing pain.
Fracture of the Hamate bone may result in the malunion of the fractured bony
parts because of the traction produced by the attached muscles. Also the ulnar nerve
and artery can get damaged since it lies close to the hook of hamate bone.Ulnar nerve
if injured will cause decreased grip strength.
These are some anatomical facts which substantiate the classification of
manibandha as rujakara marma.
Another point to note is that any entrapment or injury to a vessel or nerve
manifests below the manibandha (wrist joint).
Again the injury to manibandha marma leads to ‘kundata’ (inability to perform
actions with hand).The ruja or pain will be so severe that makes the hand inefficient
or the ruja that has occurred due to the abhigata will slowly lead to
‘karsyaakarmanata’.
The wrist joint has a wide range of motions and also aids in transmitting weights
from hand to forearm which makes it more susceptible to overuse injuries of
ligaments, compressive neuropathies, dislocations, fractures etc.
Manibandha is a sandhi marma and so all the structures involved in the formation
of wrist joint should be considered under this marma.
Conclusion….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 88
CONCLUSION
Though there are variable opinions in the Samhitas regarding the concept of
Hasta, the present study has considered the region between the manibandha sandhi
(wrist joint) and madhyama anguli paryanta (tip of the middle finger) as Hasta
(Hand).
The region of Kshipra marma is the web space between the first and second
metacarpal bone where a confluence of vessels, nerves and muscles take place. It is
classified as a snayu marma that may be due to the predominance of tendons of the
muscles of flexor and extensor compartment of forearm and small intrinsic muscles of
the hand. It is classified as kalanatarapranahara marma and sometimes may become
sadyopranahara. When the nerves and vessels get afflicted it may cause death due to
akshepaka (vata vyadhi).
The region of Talahrudaya marma is the centre of the palm in straight line
with the middle finger which contains the superficial palmar arch, tendons of the
muscles of flexor and extensor compartment of forearm, intrinsic muscles and nerves
of the hand shielded by a thick layer of skin, superficial fascia and palmar
aponeurosis. This thick shield or covering justifies the reason of classifying it as a
Mamsa marma. The injury afflicting the closely adherent neurovascular network leads
to ruja and marana.
The region of Kurcha marma is two angula above the Kshipra marma where
the spreading out of palmar aponeurosis and tendons of the flexor and extensor
compartment takes place. The mid palmar space, thenar space also occupies the
region. The predominance of tendons of various muscles and the short intrinsic
muscles of the hand justifies the classification of this marma as snayu marma. When
afflicted it leads to hasta bhramana and kampa.Hasta bhramana is a vikalata and so it
justifies the classification of kurcha as vaikalyakara marma.
The region of Kurchashira marma is below manibandha sandhi. The vessels,
nerves and the tendons beneath the flexor and extensor retinaculum gives the shape of
a head of the brush. The predominance of extensor and flexor tendons passing through
the region justifies the classification of this marma in the snayu variety.
Conclusion….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 89
Any injury afflicting this marma leads to sopha and ruja, at the same time the
region where the pathology manifests is mostly below the site of marma as in carpal
tunnel syndrome. So the classification of this marma as rujakara is justified.
The region of manibandha marma is the meeting point of prapani and hasta. It
is a sandhi marma and the lower part of radius, ulna, scaphoid ,lunate, triquetral and
the ligaments of wrist joint come in this region. The long standing pain caused due to
the wrongly diagnosed scaphoid fracture,malunion of fractured hamate bone and
sprain of the wrist joint all justifies the classification of this marma under
vaikalyakara variety.
The marma shastra was propogated mainly to save the life of a person in a
critical condition as during warfare. So Acharyas might not have taken all the
anatomical points into consideration while performing the rescue procedure.
Summary….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 90
SUMMARY
The study entitled “A comprehensive study of marmas in the Hasta (Hand) w.s.r to the surface and regional anatomy (cadaver dissection)” comprises of 8 chapters namely Introduction, Objectives, Review of literature, Methodology, Observations & Result, Discussion, Conclusion & Summary.
Chapter-1: Introduction
It gives compact idea of the subject of discussion namely marma shareera. The
relevance of this topic especially based on their anatomical importance also highlighted.
Chapter-2: Objectives
It gives an idea about Aims & Objectives of the study.
Chapter-3: Review of literature
Review of literature is sub divided into Historical review, Ayurvedic review, and
Modern review.
Historical review – It consists of references pertaining to Marma in various
ancient literatures of Vedic period, Samhita period and Sangraha Kala.
Ayurvedic Review- It elaborates the details & importance of Marma in various
ancient Ayurvedic texts, it also details all available references related to marma and hasta
marma. This chapter also contains the tables which details the classification of different
marmas and marma vasthu in our shareera.
Modern Review- It deals with detailed anatomy of the hand.
Chapter-4: Methodology
This chapter explains method of Data collection, Assessment criteria and
methodology.
Chapter-5: Observation
It embraces the inference drawn based on the studies conducted.
Summary….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 91
Chapter-6: Discussion
It comprises the details of the collected data and comparison with those
mentioned in the ancient literature & modern anatomy texts.
Chapter-7: Conclusion
It consists of conclusion drawn from the work carried out.
Chapter-8: Summary
It summarizes the entire work.
Reference Shlokas….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 92
REFERENCE
17. qÉ×+qÉlÉÏlÉ, qÉ× +mÉëÉhÉirÉÉaÉå (A.MüÉå.3/5/30)
18. qÉ×+xÉuuÉïkÉÉiÉÑprÉÉå qÉÌlÉlÉ , xÉÎlkÉxjÉÉlÉqÉç ,eÉÏuÉxjÉÉlqÉç | (zÉ.Mü.SìÓ)
19. qÉqÉïlÉ- qÉ×+qÉÌlÉlÉ (uÉÉcÉ.uÉÉsÉ.5)
20. qÉqÉÉïÍhÉ qÉÉÇxÉÍxÉUÉxlÉÉruÉÉÎxjÉxÉÎlkÉxÉ̳ÉmÉÉiÉÉ :, iÉãwÉÑ xuÉpÉÉuÉiÉ :LuÉ ÌuÉvÉãwÉãhÉ mÉëÉhÉÉÎxiɸÎliÉ,
iÉxqÉÉlqÉqÉïxuÉÍpÉWûiÉÉxiÉÉÇxiÉÉlÉç pÉÉuÉÉlÉÉmÉbÉliÉã || (xÉÑ. vÉÉ. 6/25)
21. qÉÉUrÉliÉÏÌiÉ qÉqÉÉïhrÉÑcrÉliÉå | (QûsWûhÉ. xÉÑ.vÉÉ. 6/३)
22. eÉÏuÉ xjÉÉlÉÇ iÉÑ qÉqÉï xrÉÉ‹ÏuÉÉaÉÉUÇ iÉSÒcrÉiÉå| (UÉ.ÌlÉ.qÉlÉÑwrÉÉÌSuÉaÉï,87)
23. iÉåwÉÉqÉlrÉiÉqÉmÉÏQûÉrÉÉÇ xÉqÉÉÍkÉMü mÉÏQûÉ pÉuÉÌiÉ,cÉåiÉlÉÉÌlÉoÉlkÉ uÉæzÉåwrÉÉiÉç | (cÉ.ÍxÉ.9/3)
24. qÉÉÇxÉÉÎxjÉxlÉÉrÉÑqÉlÉÏÍxÉUxÉÎlkÉxÉqÉÉaÉqÉ:xrÉÉlqÉqÉãïÌlÉ cÉ lÉãlÉÉ§É xÉÑiÉUÉÇ cÉÏÌuÉiÉÇ ÎxjÉiÉqÉç ||
(A.Wû.vÉÉ. 4/38)
25. qÉUhÉMüÉËUiuÉÉlqÉqÉï qÉUhÉ xÉSØvÉSÒ: ZÉSÉÌrÉiuÉÉSÕ uÉÉ | (AÂhÉS¨É.A.¾èû.xÉÔ.4/37)
26. xÉ̳ÉmÉÉiÉ: ÍxÉUÉxlÉÉrÉÑxÉÎlkÉqÉÉÇxÉÉÎxjÉxÉqpÉuÉ |
qÉqÉÉïÍhÉ iÉãwÉÑ ÌiɸÎliÉ mÉëÉhÉÉ: ZÉsÉÑ ÌuÉvÉãwÉiÉ :|| (pÉÉ.mÉë. 3/223)
27. xÉqÉSÉåwÉ xÉqÉÉÎalÉ¶É xÉqÉkÉÉiÉÑ qÉsÉÌ¢ürÉÉ:
mÉëxɳÉÉiqÉåÎlSìrÉqÉlÉÉ: xuÉxjÉ CirÉÍpÉkÉÏrÉiÉå|| (xÉÑ.xÉÔ.15/41)
28. AÎalÉ:xÉÉãqÉÉãuÉÉrÉÑ: xÉiuÉÇUÇeÉxiÉqÉ: mɧcÉãÎlSìrÉÉÍhÉpÉÔiÉÉiqÉãÌiÉ mÉëÉhÉÉ: || (xÉÑ.vÉÉ. 4/3)
29. .xÉmiÉÉå¨ÉUÇ qÉqÉïzÉiqÉç (xÉÑ.zÉÉ.6/2)
30. iÉÉÌlÉ qÉqÉÉïÍhÉ mÉgcÉÉiqÉMüÉÌlÉ pÉuÉÎliÉ; i±jÉÉ-qÉÉÇxÉqÉqÉÉïÍhÉ, ÍxÉUÉqÉqÉÉïÍhÉ, xlÉrÉÑqÉqÉÉïÍhÉ,
AÎxjÉqÉqÉÉïÍhÉ, xÉÎlkÉqÉqÉÉïÍhÉ cÉåÌiÉ | lÉ ZÉsÉÑ qÉÉÇxÉÍxÉUxlÉÉruÉÉÎxjÉxÉÎlkÉurÉÌiÉUãMãühÉÉlrÉÉÌlÉ qÉqÉÉïÍhÉ
pÉuÉÎliÉ, rÉxqÉɳÉÉãmÉsÉprÉliÉã |( xÉÑ.vÉÉ. 6/3)
31. ÍxÉUÉxlÉÉxuÉÎxjÉmÉuÉÉïÍhÉ xÉlkÉrÉ¶É zÉUÏËUhÉÉqÉç ||
mÉåzÉÏÍpÉ : xÉÇuÉ×iÉÉlrÉ§É oÉsÉuÉÎliÉ pÉuÉlirÉiÉ: || (xÉÑ.zÉÉ. 5/38)
32. iÉÉxÉÉÇ oÉWûsÉmÉåsÉuÉxjÉÔsÉÉhÉÑmÉ×jÉÑuÉרɾûxuÉSÏbÉïÎxjÉU-
qÉ×SÒzsɤhÉMüMïüzÉpÉÉuÉÉ: xÉlkrÉÎxjÉUÉxlÉÉrÉÑmÉëcNûÉSMüÉ
rÉjÉÉmÉëSåzÉ Ç xuÉpÉÉuÉiÉ LuÉ pÉuÉÎliÉ || (xÉÑ.zÉÉ.5/40)
Reference Shlokas….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 93
33. mÉgcÉ mÉåzÉÏzÉiÉÉÌlÉ pÉuÉÎliÉ | iÉÉxÉÉÇ cÉiuÉÉËU zÉiÉÉÌlÉ zÉÉZÉÉxÉÑ, MüÉå¸å wÉOíéwÉ̹ , aÉëÏuÉÉÇ mÉëirÉÔkuÉïÇ
cÉiÉÑÎx§ÉÇzÉiÉç | (xÉÑ.zÉÉ.5/37)
34. iÉ§É iÉsɾûSrÉålSìoÉÎxiÉaÉÑSxiÉlÉUÉåÌWûiÉÉÌlÉ qÉÉÇxÉxrÉqÉqÉÉïÍhÉ (xÉÑ.zÉÉ.6/7)
35. qÉÉÇxÉeÉÉÌlÉ SzÉålSìÉZrÉiÉsɾûixiÉlÉUÉåÌWûiÉÉ : | (A.¾èû.zÉÉ.4/39)
36. ÌuÉ®ãÅeÉxÉëqÉxÉ×Yx§ÉÉuÉÉã qÉÉÇxÉkÉÉuÉlÉuɨÉlÉÑ : |
mÉÉhQÒûiuÉÍqÉÎlSìrÉÉ¥ÉÉlÉÇ qÉUhÉÇ cÉÉxÉÑ qÉÉÇxÉeÉã || (A.Wû.vÉÉ.4/47)
37. kqÉÉlÉÉ®qÉlrÉ: xÉëuÉhÉÉiÉç xÉëÉåiÉÉÇÍxÉ xÉUhÉÉÎixÉUÉ (cÉ.xÉÔ.30/12)
38. स िसराशतािन भविन्त; यािभिरद ंशरीरमाराम इव जलहािरणीिभः
केदार इव च कुल्यािभरुपि तेऽनुगृ ते चाकु न सारणािदिभिवशेषैः
मुप सवेनीनािमव तासां तानाःतासां नािभमूर्ल,ं तत सरन्त्यूध्वर्मधिस्तयर्क् च ||
(xÉÑ.zÉÉ.7/3)
39. नािभस्थाः ािणना ं ाणाः ाणा ािभ ुर्पाि ता |
िसरािभरावृता नािभ नािभिरवारकैः || (xÉÑ.zÉÉ.7/5)
40. िसराशतािन चत्वािर िव ाच्छाखासु बुि मान् |
षिट् श शतं को ेचतुःष ंच मधूर्िन || (xÉÑ.zÉÉ.7/20)
41. शाखासु षोडश िसराः को े ाि शदवे तु ||
प ाश ुण ोध्वर्म ध्याः पिरकीितताः || (xÉÑ.zÉÉ.7/21)
42. त िसराशतमेकिस्मन् सिक्थ्न भवित; तासां जालधरा त्वेका,
ित ाभ्यन्तराः- त ोव सञ्ज्ञे ,े लोिहताक्षसञ्ज्ञा चैका, (xÉÑ.zÉÉ.7/22)
43. चतुिवधा यास्तु िसराः शरीरे
ायेण ता ममर्सु सि िव ाः
ाय्विस्थमांसािन तथैव सन्धीन्
सन्तप्यर् दहे ं ितयापयिन्त (xÉÑ.zÉÉ.6/18)
Reference Shlokas….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 94
44. नीलधमनीमातृकाशृङ्गाटकापाङ्गस्थपनीफणस्तनमलूापलापापस्तम्भहृदयना
िभपा र्सिन्धबृहतीलोिहताक्षो र्ः िसराममार्िण | (xÉÑ.zÉÉ.6/7)
45. xmiȨ́ÉÇzÉÎixÉUÉ´rÉÉ:
oÉ×WûirÉÉæ qÉÉiÉ×MüÉ lÉÏsÉå qÉlrÉå Mü¤ÉÉkÉUÉæ TühÉÉæ |
ÌuÉOûmÉå ¾ûSrÉÇ lÉÉÍpÉ mÉÉμÉïxÉlkÉÏ xiÉlÉÉkÉUå
AmÉÉsÉÉmÉÉæ xjÉmÉlrÉÑurÉï¶ÉiÉxÉëÉå sÉÉåÌWûiÉÉÌlÉ cÉ | (A.¾û.zÉÉ. 4/42)
46. ÍxÉUÉqÉqÉïurÉkÉã xÉÉlSìqÉeÉxÉëÇ oÉWûxÉ×uÉY§ÉuÉãiÉç |
iÉi¤ÉrÉɨÉ×Qè pÉëqÉ´uÉÉxÉ qÉÉãWûÌWûkqÉÉÍpÉUliÉMü: || (A.¾ûû.vÉÉ.4/50)
47. UxÉÉiÉç xiÉlrÉÇ iÉiÉÉå U£üqÉxÉ×eÉ: MühQûUÉ: ÍxÉUÉ:|
qÉÉÇxÉɲxÉÉ iuÉcÉ: wÉOèû cÉ qÉåSxÉ: xlÉÉrÉÑxÉÇpÉuÉ:|| (cÉ.ÍcÉ.15/17)
48. नौयर्था फलकास्तीणार् बन्धनैबर्हुिभयुर्ता |
भारक्षमा भवेदप्सु नृयु ा सुसमािहता ||
एवमेव शरीरेऽिस्मन ् यावन्तः सन्धयः स्मृताः|
ायुिभबर्हुिभबर् ास्तेन भारसहा नराः|| (xÉÑ.zÉÉ. 5/33-34)
49. ायू तुिवधा िव ा ास्तु सवार् िनबोध मे
तानवत्यो वृ ा पृथ् शुिषरास्तथा ||
तानवत्यः शाखासु सवर्सिन्धषु चाप्यथ
वृ ास्तु कण्डराः सवार् िवज्ञेयाः कुशलैिरह ||
आमप ाशयान्तेष ुबस्तौ च शुिषराः खलु
पा रिस तथा पृ ेपृथुला िशरस्यथ || (xÉÑ.zÉÉ. 5/30-32)
50. नव ायुशतािन |तासां शाखासु षट्शतािन, ेशते ि श को ,े
ीवा ं त्यूध्व स ितः | (xÉÑ.zÉÉ.5/29)
51. आणी(िण)िवटपकक्षधरकूचर्कूचर्िशरोबिस्तिक्ष ांसिवधुरोत्क्षेपाः ायुममार्िण | (xÉÑ.zÉÉ.6/7)
Reference Shlokas….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 95
52. xlÉÉrÉÑ qÉqÉÉïÍhÉ §ÉrÉÉåÌuÉÇzÉÌiÉUÉhÉrÉ: |MÔücÉïMÔücÉïÍzÉUÉå/mÉÉÇ… ͤÉmÉëÉåi¤ÉåmÉÉÇxÉoÉxiÉrÉ: (A.¾èû.zÉÉ.4/41)
53. AÉrÉÉqÉɤÉãmÉMü xiÉqpÉÉ: x§ÉÉuÉeÉãÅprÉÉÍkÉMüÇ ÂeÉÉ ||
rÉÉlÉxjÉÉlÉÉxÉlÉÉvÉÎiMü uÉæMüsrÉqÉjÉuÉÉÅliÉMü: | (A.Wû.vÉÉ.4/48)
54. xÉlkÉrɶÉÉ…Ç¡ û xÉlkÉÉlÉÉiÉç SåWåû mÉëÉå£üÉ MüTüÉÎluÉiÉÉ | (zÉÉ.xÉÇ.mÉÔ.5/36)
55. सङ्ख्यातस्तु दशो रे ेशते| तेषा ंशाखास्व षि ः,एकोनषि ः को ,े
ीवा ं त्यूध्व यशीितः | एकैकस्यां पादाङ्गुल्या ं य यः, ावङ्गु ,े ते चतुदर्श;
जानुगुल्फवङ्क्षणेष्वेकैकः, एवं स दशकैिस्मन् सिक्थ्न भविन्त | (xÉÑ.zÉÉ.5/26)
56. xÉlkÉrÉxiÉÑ Ì²ÌuÉkÉɶÉå¹ÉuÉliÉ:,ÎxjÉUÉ¶É || (xÉÑ.zÉÉ.5/24)
57. iÉ LlÉå xÉlkÉrÉÉå/¹ÌuÉkÉÉ:- MüÉåUÉåsÉÔZÉsÉ xÉÉqÉѪ mÉëiÉU iÉѳÉxÉåuÉlÉÏ uÉÉrÉxÉiÉÑhQ ûqÉhQûsÉ zÉ„¡ûÉuÉiÉÉï:|
iÉåwÉÉqÉ…¡ÓûÍsÉ qÉÍhÉoÉlkÉ aÉÑsT üeÉÉlÉÑ MÔümÉïUåwÉÑ MüÉåUÉ:xÉlkÉrÉ:, Mü¤ÉÉ uÉXç¤ÉhÉ SzÉlÉåmÉÔsÉÔZÉsÉÉ:,
AÇxÉmÉÏPû aÉÑS pÉaÉ ÌlÉiÉqoÉåwÉÑ xÉÉqÉѪÉ:, aÉëÏuÉÉ mÉ׸uÉÇzÉrÉÉå: mÉëiÉUÉ:, ÍzÉUMüOûÏ MümÉÉsÉåwÉÑ iÉѳÉxÉåuÉlrÉ:,
WûluÉÉåÂpÉrÉxiÉÑ uÉÉrÉxÉiÉÑhQûÉ:, MühPû ¾ûSrÉ lÉå§É YsÉÉåqÉlÉÉQûÏwÉÑ qÉhQûsÉÉ:, ´ÉÉå§É - ´ÉÚ…¡ûÉOûMåüwÉÑ
zÉ„¡ûÉuÉiÉÉï:| iÉåwÉÉÇ lÉÉqÉÉÍpÉUåuÉÉM×üirÉ: mÉëÉrÉåhÉ urÉÉZrÉÉiÉÉ: || (xÉÑ.zÉÉ.5/27)
58. eÉÉlÉÑMÔümÉïUxÉÏqÉliÉÉÍkÉmÉÌiÉaÉÑsTüqÉÍhÉoÉlkÉMÑüMÑülSUÉuÉiÉïM×üMüÉÌOûMüɶÉåÌiÉ xÉÎlkÉqÉqÉÉïÍhÉ|| (xÉÑ.zÉÉ.6/7)
59. uÉxiÉÑ vÉÔMæüËUuÉÉÌMühÉïÇ ÂSã cÉ MÑüÌlÉZÉgeÉiÉÉ |
oÉsÉcÉã¹É¤ÉrÉ: vÉÉãwÉ: mÉuÉïvÉÉãTü¶É xÉÎlkÉcÉã | (A.Wû.vÉÉ.4/51)
60. तेषां सिवशमिस्थशत ंशाखासु, स दशो रं शत ं ोिणपा र्पृ ोरःसु, ीवां त्यूध्व ि षि ः
एवमस्थ्नां ीिण शतािन पूयर्न्ते || (xÉÑ.zÉÉ.5/18)
61. एकैकस्यां तु पादाङ्गुल्यां ीिण ीिण तािन प दश, तलकूचर्गलु्फसंि तािन
दश, पाष्ण्यार्मेकं, जङ्घायां ,े जानुन्येकम्, एकमूरािवित ि शदवेमेकिस्मन्
सिक्थ्न भविन्त, एतेनेतरसिक्थ बाहू च ाख्यातौ | (xÉÑ.zÉÉ.5/19)
62. §ÉÏÍhÉ xÉwɹÏÌlÉ zÉiÉÉlrÉxjlÉÉÇ xÉWû SliÉÉåsÉÔZÉsÉlÉZÉålÉ | iɱjÉÉ-²Ȩ́ÉÇzÉ6ûliÉÉ:,²Ȩ́ÉÇzÉ6liÉÉåsÉÔZÉÉÌlÉ
ÌuÉÇzÉÌiÉlÉïZÉÉ, wÉ¹Ï mÉÉÍhÉmÉÉSÉ…¡ÓûsrÉxjÉÏÌlÉ, ÌuÉÇzÉÌiÉ mÉÉÍhÉmÉÉSzÉsÉÉMüÉ:,cÉiuÉÉËlÉç
mÉÉÍhÉmÉÉSzÉsÉÉMüÉÍkɸÉlÉÉÌlÉ, ²Éæ qÉÍhÉMüÉæ WûxiÉrÉÉå:, (cÉ.zÉÉ.7/6)
Reference Shlokas….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 96
63. एतािन प िवधािन भविन्त; त था- कपालरुचकतरुणवलयनलकसञ्ज्ञािन
तेषां जानुिनतम्बांसगण्डतालुशङ्खिशरःसुकपालािन दशनास्तु रुचकािन
ाणकणर् ीवािक्षकोषेष ुतरुणािन, पा र्पृ ोरःसुवलयािन,शेषािण नलकसञ्ज्ञािन ||
(xÉÑ.zÉÉ.5/20)
64. कटीकतरुणिनतम्बांसफलकशङ्खास्त्विस्थममार्िण | (xÉÑ.zÉÉ.6/7)
65. qÉ‹ÉÎluÉiÉÉãÅcNûÉã ÌuÉÎcNû³É: xÉëÉuÉÉã ÂMç cÉÉÎxjÉqÉqÉÉïÍhÉ | (A.¾ûû.vÉÉ.4/48)
66. तासां तु खलु नािभ भवाणां धमनीनामूध्वर्गा दश, दश चाधोगािमन्यः,चत िस्तयर्ग्गाः |
(xÉÑ.zÉÉ.9/4)
67. aÉÑSÉmÉxiÉÇpÉÌuÉkÉÑU´Éç…ÇaÉÉOûÉÌlÉ lÉuÉÉÌSzÉåiÉç | qÉqÉÉïÍhÉ kÉqÉlÉÏxjÉÉÌlÉ (A.¾û.zÉÉ.4/41)
68. U£üÇ xÉvÉoSTãülÉÉãwhÉÇ kÉqÉlÉÏxjÉã ÌuÉcÉãiÉxÉ: | (A.¾û.zÉÉ.4/49)
69. ÍzÉUÉå/liÉUÉÍkɲÉæï oÉÉWÒû xÉÎYjÉlÉÏÌiÉ xÉqÉÉxÉiÉ: |
wÉQû…¡ÇqÉ…Ç¡ mÉëirÉÇ…¡Çû iÉxrÉÉͤɾûSrÉÉÌSMüqÉç || (A.¾û.3/1)
70. तेषामेकादशैकिस्मन् सिक्थ्न भविन्त, एतेनेतरसिक्थ बाहू च ाख्यातौ,
उदरोरसो ार्दश, चतुदर्श पृ ,े ीवा ं त्यूध्व स ि शत् (xÉÑ.zÉÉ.6/5)
71. xÉmiÉÉã¨ÉUÇ qÉqÉïvÉiÉÇ rÉSÒ£üÇ vÉUÏU xÉÇZrÉæqÉÍkÉM×üirÉ iÉãprÉ : |
qÉqÉÉïÍhÉ oÉÎxiÉ WûSrÉÇ ÍvÉUc´É| mÉëkÉÉlÉpÉÑiÉÉÌlÉ uÉSÎliÉ iɥɥÉÉ: ||
mÉëÉhÉ´ÉrÉÉiÉç iÉÉÌlÉ ÌWû mÉÏQûrÉliÉã uÉÉiÉÉSrÉÉãÅxÉÔlÉÌmÉ mÉÏQûrÉÎliÉ |
iÉixÉÇÍ´ÉiÉÉlÉãqÉlÉÑmÉÉsÉlÉÉjÉï qÉWûÉaÉSÉlÉÉ ´ÉÑhÉÑ xÉÉæqrÉ U¤ÉÉqÉç || ( cÉ.ÍcÉ.26/3,4)
72. तान्येतािन प िवकल्पािन भविन्त; त था- स ः ाणहरािण, कालान्तर ाणहरािण,
िवशल्य ािन, वैकल्यकरािण, रुजाकरािण चेित त§Éç स ः ाणहराण्येकोनिवशितः,
कालान्तर ाणहरािण यि शत्, ीिण िवशल्य ािन, चतु त्वा रश कैल्यकरािण,अ ौ
रुजाकराणीित | (xÉÑ.zÉÉ.6/8)
73. ´É×aXûÉOûMüÉlrÉÍkÉmÉÌiÉ : vÉZÉçXûÉæ MühPûÍxÉUÉ aÉÑSqÉç |
WûSrÉÇ oÉÎxiÉlÉÉÍpÉ cÉ klÉÎliÉ xÉkÉÉãWûiÉÉÌlÉ iÉÑ || (xÉÑ.vÉÉ. 6/9)
Reference Shlokas….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 97
74. lÉÉÍpÉvÉZXûÉÍkÉmÉÉmÉÉlÉWûcNØûaXûÉOûMüoÉxiÉrÉ :
A¹Éæ cÉ qÉÉiÉ×MüÉ : xÉbÉÉæ ÌlÉblÉlirÉãMüÉã³ÉÌuÉÇvÉÌiÉ :
xÉmiÉÉWû mÉUqÉxiÉãwÉÉÇ MüÉsÉ MüÉsÉxrÉ MüwÉïhÉã || (A.¾ûû.vÉÉ.4/52-53)
75. uɤÉÉãqÉqÉÉïÍhÉ xÉÏqÉliÉiÉsÉͤÉmÉëãlSìoÉxiÉrÉ : |
MüOûÏMüiÉÂhÉã xÉlkÉÏ mÉμÉïeÉÉæ uÉ×WûiÉÏ cÉ rÉÉ ||
ÌlÉiÉqoÉÌuÉÌiÉ cÉæiÉÉÌlÉ MüÉsÉÉliÉUWûUÉÍhÉ iÉÑ || (xÉÑ.vÉÉ.6/10)
76. §ÉrÉÎx§ÉÇvÉSmÉxiÉqpÉiÉsÉWûimÉÉμÉïxÉlkÉrÉ : |
MüOûÏiÉÂhÉxÉÏqÉliÉxiÉlÉqÉÑsÉãlSìoÉxiÉrÉ :
ͤÉmÉëÉmÉÉsÉÉmÉoÉ×WûiÉÏÌlÉiÉqoÉxiÉlÉUÉãÌWûiÉÉ : |
MüÉsÉÉliÉUmÉëÉhÉWûUÉ qÉÉxÉqÉÉxÉÉbSïeÉÏÌuÉiÉÉ :| (A.¾û.vÉÉ.4/53, 54)
77. Ei¤ÉãmÉÉæ xjÉmÉlÉÏ cÉæuÉ ÌuÉvÉsrÉklÉÉÌlÉ ÌlÉÌSïvÉãiÉ | (xÉÑ.zÉÉ.6/11)
78. xjÉmÉlÉÏ §ÉÏÍhÉ ÌuÉvÉsrÉblÉÉÌlÉ iÉ§É ÌWû |
uÉÉrÉÑqÉÉïÇxÉuÉxÉÉqÉelÉqÉxiÉÑsÉÑaXûÉÌlÉ vÉÉãwÉrÉlÉç |
vÉsrÉÉmÉÉrÉã ÌuÉÌlÉaÉïcNûlÉç ´uÉÉxÉÉiMüÉxÉÉccÉ WûlirÉxÉÑlÉç | (A.¾û.vÉÉ.4/55-56)
79. sÉÉãÌWûiÉɤÉÉÍhÉ eÉÉlÉÑuÉÉïMÔücÉï ÌuÉOûmÉMÔümÉïUÉ : |
MÑüMÑülSUã Mü¤ÉkÉUã ÌuÉkÉÑUã xÉM×üMüÉÌOûMãü ||
AÇxÉÉÇxÉTüsÉMüÉmÉÉaXûÉ lÉÏsÉã qÉlrÉã TühÉÉæ iÉjÉÉ |
uÉæMüsrÉUÉhÉÉlrÉÉWÒûUÉuÉiÉÉæï uSÉæ iÉjÉæuÉ cÉ | (xÉÑ.vÉÉ.6/12-13)
80. TühÉÉuÉmÉÉaXûÉæ ÌuÉkÉÑUã lÉÏsÉã qÉlrÉã M×üMüÉÌOûMãü |
AÇxÉÉxÉTüsÉMüÉuÉiÉïÌuÉOûmÉÉãuÉÏïMÑüMÑülSUÉ :
xÉeÉÉlÉÑsÉÉãÌWûiÉɤÉÉÍhÉMü¤ÉÉkÉ×Mç MÑücÉïMÑümÉïUÉ : |
uÉæMüsrÉÍqÉÌiÉ cÉiuÉÉËU cÉiuÉÉËUÇvÉccÉ MÑüuÉïlÉã ||
WûUÎliÉ iÉÉlrÉÉÌmÉ mÉëÉhÉÉlÉç MüSÉÍcÉSÍqÉbÉÉiÉiÉ: || (A.¾ûû.vÉÉ.4/57-58)
81. aÉÑsTüÉæ uSÉæ qÉÍhÉoÉlkÉÉã uSÉæ uSã uSã MÑücÉïÍvÉUÉÇÍxÉ cÉ |
ÂeÉÉMüUÉÍhÉ eÉÉlÉÏrÉÉS¹ÉuÉãiÉÉÌlÉ oÉÑÎbSqÉÉlÉç || (xÉÑ.vÉÉ.6/14)
82. A¹Éæ MÔücÉïÍvÉUÉãaÉÑsTüqÉÍhÉoÉlkÉÉ ÂeÉÉMüUÉ: | (A.¾ûû.vÉÉ.4/59)
Reference Shlokas….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 98
83. iÉ§É xɱ: mÉëÉhÉWûUqÉliÉã ÌuÉbS MüÉsÉÉliÉUãhÉ qÉÉUrÉÌiÉ |
MüÉsÉÉliÉUmÉëÉhÉWûUqÉliÉã ÌuÉbSÇ uÉæMüsrÉqÉÉmÉÉSrÉÌiÉ |
ÌuÉvÉsrÉblÉÇ oÉæMüsrÉMüUÇ cÉ pÉuÉÌiÉ |
uÉæMüsrÉMüUÇ MüÉsÉÉliÉUãhÉ YsÉãvÉrÉÌiÉ ÂeÉÉÇ cÉ MüUÉãÌiÉ |
ÂeÉÉMüUqÉiÉÏÌiÉuÉëuÉãSlÉÇ pÉuÉÌiÉ || (xÉÑ.vÉÉ.6/22)
84. ͤÉmÉëÉÍhÉ MüSÉÍcÉSÉzÉÑ qÉÉUrÉÎliÉ | (xÉÑ.zÉÉ.6/23)
85. iÉ§É xÉbÉ: mÉëÉhÉWûUÉÍhÉ AÉalÉãrÉÉÌlÉ, AÎalÉaÉÑhÉãwuÉÉvÉÑ ¤ÉÏhÉãwÉѤÉmÉrÉÎliÉ |
MüÉsÉÉliÉU mÉëÉhÉWûUÉÍhÉ xÉÉæqrÉÉalÉãrÉÉÌlÉ, AÎalÉaÉÑhÉãwuÉÉvÉÑ ¤ÉÏhÉãwÉÑ ¢üqÉãhÉ
cÉ xÉÉãqÉaÉÑhÉãwÉÑ MüÉsÉÉliÉUãhÉ ¤ÉmÉrÉÎliÉ |
ÌuÉvÉsrÉmÉëÉhÉWûUÉÍhÉ uÉÉrÉurÉÉÌlÉ, vÉsrÉqÉÑZÉÉuÉÂbSÉã rÉÉuÉSliÉuÉÉïrÉÑÎxiɸÌiÉ
iÉÉuÉelÉÏuÉÌiÉ, ESèkÉ×iÉqÉɧÉã iÉÑ vÉsrÉã qÉqÉïxjÉÉlÉÉÍ´ÉiÉÉã uÉÉrÉÑÌlÉïw¢üÉqÉÌiÉ, iÉxqÉÉiÉç
xÉvÉsrÉÉã eÉÏuÉÌiÉ ESèkÉ×iÉvÉsrÉÉã ÍqÉërÉiÉã | (mÉÉMüÉimÉÌiÉiÉvÉsrÉÉã uÉÉ eÉÏuÉÌiÉ)
uÉæMüsrÉMüUÉÍhÉ xÉÉæqÉÉã ÌWû ÎxjÉUiuÉÉcNæûirÉÉccÉ mÉëÉhÉÉuÉsÉqoÉlÉÇ MüUÉãÌiÉ |
ÂeÉÉMüUÉhrÉÎalÉuÉÉrÉÑaÉÑhÉpÉÔÌrɸÉÌlÉ, ÌuÉvÉãwÉiÉc´É iÉÉæ ÂeÉÉMüUÉæ | (xÉÑ. vÉÉ. 6/16)
86. EurÉï: ÍzÉUÉÇÍxÉ ÌuÉOûmÉå cÉ xÉMü¤ÉmÉÉμÉåï LMæüMüqÉÇaÉÑsÉÍqÉiÉÇ xiÉlÉmÉÔuÉïqÉÔsÉÇ
ÌuÉSèkrÉaXçsÉuSrÉÍqÉiÉÇ qÉÍhÉoÉlkÉaÉÑsTüÇ §ÉÏhrÉãuÉ eÉÉlÉÑ xÉmÉUÇ xÉWû MÔümÉïUÉprÉÉqÉç ||
WûSèoÉÎxiÉMÔücÉïaÉÑSlÉÉÍpÉ uÉSÎliÉ qÉÔÎklÉï cÉiuÉÉËU mɧcÉ cÉ aÉsÉã SvÉ rÉÉÌlÉ cÉ uSã |
iÉÉÌlÉ xuÉmÉÉÍhÉiÉsÉMÑüΧcÉiÉxÉÇÍqÉiÉÉÌlÉ vÉãwÉÉhuÉãÌWû mÉËUÌuÉxiÉUiÉÉãÅaXûsÉÉkÉïqÉç || (xÉÑ.vÉ.6/28,29)
87. LiÉimÉëqÉÉhÉqÉÍpÉuÉϤrÉ uÉSliÉ iÉe¥ÉÉ: vÉx§ÉãhÉ MüqÉïMüUhÉÇ mÉËUWûirÉ MüÉrÉïqÉç |
mÉÉvoÉÉïÍpÉbÉÉÌiÉiÉqÉmÉÏWû ÌlÉWûÎl¨É qÉqÉï iÉxqÉÉÎbS qÉqÉïxÉSlÉÇ mÉËUuÉeÉïlÉÏrÉqÉç || (xÉÑ.vÉÉ. 6/30)
88. oÉÉWûÉæ mÉëxÉÉËUiÉmÉÉhÉÉæ WûxiÉ: || (A.MüÉå.)
89. WûxiÉ:-mÉÉÍhÉ:,xÉqÉ:,zÉrÉ: | CirÉqÉUqÉÉsÉÉ || mÉgcÉzÉÉZÉ:| CirÉqÉU:
MüU: pÉÑeÉ:| CÌiÉ eÉOûÉkÉU || MÑüÍsÉ: pÉÑeÉÉSsÉ: | CÌiÉ zÉoSiÉÉUÉuÉÍsÉ || (zÉ.Mü.SìÓ.)
91. यन् शतमकेो रम्; अ हस्तमेव धानतमं यन् ाणामवगच्छ ( क कारणं ? यस्मा स्तादतृे
यन् ाणाम वृि रेव) तदधीनत्वा न् कमर्णाम ्| (xÉÑ.xÉÔ.7/3)
Reference Shlokas….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 99
92. उपयन् ाण्यिप-
र ुवेिणकाप चमार्न्तवल्कललताव ा ीलाश्ममु रपािणपादतलाङ्गिुलिजह्वा-
दन्तनखमुखबाला कटकशाखा ीवन वाहणहषार्यस्कान्तमयािन क्षाराि भेषजािन चेित |
(xÉÑ.xÉÔ.7/15)
93. चतुिवशत्यङ्गुलो हस्तः; ाि शदङ्गलुपिरमाणौ भुजौ, मिणबन्धकूपर्रान्तरं
षोडशाङ्गुल;ं तलं षट्चतुरङ्गुलायामिवस्तारम्;
अङ्गु मूल दिेशनी वणापाङ्गान्तरमध्यमाङ्गुल्यौ प ाङ्गुले ….. (xÉÑ.xÉÔ.35/12)
94. WûxiÉÉå A§É MÑümÉïUÉÌS qɱqÉ…¡ÓûsrÉliÉmÉrÉïliÉÉå ¥ÉårÉÈ| (QûsWûhÉ. xÉÑ.xÉÔ.35/12)
95. wÉÉåQûzÉÉ…¡ÓÇûsÉÉæ mÉëoÉÉWÒû, mÉgcÉSzÉÉ…¡ÓÇûsÉÉæ mÉëmÉÉÍhÉ, WûxiÉÉæ ²ÉSzÉÉ…¡ÓÇûsÉÉæ | (cÉ.ÌuÉ.8/117)
96. wÉOèû mÉgcÉÉzÉiÉç mÉëirÉ…¡ûÉÌlÉ. . . . . cÉiuÉÉËU mÉÉÍhÉmÉÉS. . . .| (cÉ.zÉÉ 7/11)
97. wÉÉåQûzÉ MühQûUÉ iÉÉxÉÉÇ cÉiÉxÉëÈ mÉÉSrÉÉåÈ iÉÉuÉirÉÉå WûxiÉ aÉëÏuÉ mÉ×¹åwÉÑ| (xÉÑ.zÉÉ 5/11)
98. मांसिसरा ाय्विस्थजालािन त्येकं चत्वािर; तािन मिणबन्धगुल्फसंि तािन
परस्परिनब ािन परस्परगवािक्षतािन चेित, यैगर्वािक्षतिमद ंशरीरम् | (xÉÑ.zÉÉ 5/12)
99. wÉOèû MÔücÉÉïÈ, iÉå WûxiÉ mÉÉS aÉëÏuÉ qÉãQíåûwÉÑ, WûxiÉrÉÉåÈ ²Éæ, mÉÉSrÉÉåÈ ²Éæ|| (xÉÑ.zÉÉ 5/13)
100. चतुदर्शास्थ्नां सङ्घाताः; तेषां यो गुल्फजानुवङ्क्षणेषु, एतेनेतरसिक्थ बाहू
च ाख्यातौ, ि किशरसोरेकैकः| (xÉÑ.zÉÉ 5/16)
101. ͤÉmÉëÇ =ͤÉmÉç + xTüÉÌrÉiÉÎgcÉuÉgcÉÏÌiÉ zÉÏbÉëÇ,iuÉËUiÉÇ (zÉ.Mü.SìÓ)
103. त§Éç पादस्याङ्गु ाङ्गुल्योमर्ध्य े िक्ष ं नाम ममर्, त§É िव स्याक्षेपकेण मरण ं(xÉÑ.zÉÉ.6/24)
104. A…¡Óû¸É…¡ÓûÍsÉqÉkrÉxjÉÇ Í¤ÉmÉëqÉɤÉåmÉqÉÉUhÉqÉç || (A.¾û.zÉÉ.4/3)
105. AɤÉåmÉMüÉZrÉålÉ uÉÉiÉurÉÉÍkÉlÉÉ qÉÉUrÉÌiÉ (AÂhÉS¨É,A.¾û.zÉÉ.4/3)
106. rÉSÉ iÉÑ kÉqÉlÉÏ: xÉuÉÉï:MÑüÌmÉiÉÉå/prÉåÌiÉ qÉÉÂiÉ: ||
iÉSÉͤÉmÉirÉÉzÉÑ qÉÑWÒûqÉÑïWÒûSåïWÇû qÉÑWÒû¶ÉU:
qÉÑWÒûqÉÑïWÒûxiÉSɤÉåmÉÉSɤÉåmÉMü CÌiÉ xqÉ×iÉ: || (xÉÑ.ÌlÉ.50/51)
Reference Shlokas….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 100
107. rÉjÉÉ iÉÑ kÉqÉlÉÏ: xÉuÉÉï: ¢Ñü®Éå/prÉåÌiÉ qÉÑWÒûqÉÑïWÒû:
iÉjÉÉ/…¡ûqÉÉͤÉmÉirÉåwÉ urÉÉÍkÉUɤÉåmÉMü: xqÉ×iÉ: | (A.¾û.ÌlÉ.15/16)
108. kÉqÉlrÉÉå lÉÉŽ: | (QûsWûhÉ, xÉÑ.ÌlÉ.50/51)
109. iÉSɤÉåmÉÉiÉç SåWûɤÉåmÉÉiÉç | (QûsWûhÉ, xÉÑ.ÌlÉ.50/51)
110. AÉͤÉmÉÌiÉ = AÉ¢üqÉÌiÉ (AÂhÉS¨É, A.¾û.ÌlÉ.15/16)
111.िछ ेष ु पािणचरणषे ुिसरा नराणा ंसङ्कोचमीयुरसृगल्पमतो िनरेित ||
ाप्यािमत सनमु मतो मनुष्याः सि छ शाखतरुवि धनं न यािन्त ||
िक्ष ेषु त सतलेषु हतेषु र ं गच्छत्यतीव पवन रुज ंकरोित ||
एवं िवनाशमपुयािन्त िह त िव ा वृक्षा इवायुधिनपातिनकृ मूलाः ||
तस्मा योरिभहतस्य तु पािणपाद ंछे माश ुमिणबन्धनगुल्फदशे े|| (xÉÑ.zÉÉ.6/32,33)
112. iÉsÉxrÉ mÉÉSiÉsÉxrÉ ¾ûSrÉÍqÉuÉ, mÉÉSiÉsÉxrÉ qÉkrÉqÉç | CÌiÉ WåûqÉcÉlSì: | (zÉ.Mü.SìÓ.)
114. qÉkrÉqÉÉ…¡ÓûsÉÏqÉlÉÑmÉÔuÉåïhÉ qÉkrÉå mÉÉSiÉsÉxrÉ iÉsɾûSrÉÇ lÉÉqÉ,iÉ§É mÉÉSxrÉ pÉëqÉhÉuÉåmÉlÉå pÉuÉiÉ:
(xÉÑ.zÉÉ.6/24)
115. qÉkrÉå mÉÉSiÉsÉxrÉÉWÒûUÍpÉiÉÉå qÉkrÉqÉÉ…¡ÓûÍsÉqÉç
iÉsɾû³ÉÉqÉ ÂeÉrÉÉ iÉ§É ÌuÉ®xrÉ mÉgcÉiÉÉ (A.¾û.zÉÉ.4/2)
116. MÑüUç +cÉOû ÌlÉmÉÉiÉlÉÉiÉç SÏbÉï:| (zÉ.Mü.SìÓ.)
118. ͤÉmÉëxrÉÉåmÉËU¹ÉSÒpÉrÉiÉ: MÔücÉÉåï lÉÉqÉ, iÉ§É mÉÉSxrÉ pÉëqÉhÉ uÉåmÉlÉå pÉuÉiÉ: | (xÉÑ.zÉÉ.6/24)
119. iÉxrÉÉåkuÉïÇ ²rÉ…¡ÓûsÉå MÔücÉï: mÉÉSpÉëqÉhÉMüqmÉM×üiÉç | (A.¾û.zÉÉ.4/3)
122. MÔücÉïxrÉ ÍzÉU CuÉ ÍzÉUÉå/xrÉ | CÌiÉ WåûqÉcÉlSì:| (zÉ.Mü.SìÓ.)
124. aÉÑsTüxÉlkÉåUkÉ EpÉrÉiÉ: MÔücÉïÍzÉU:,iÉ§É ÂeÉÉzÉÉåTüÉæ;| (xÉÑ.zÉÉ.6/24)
125. aÉÑsTüxÉlkÉåUkÉ: MÔücÉïÍzÉU: zÉÉåTüÂeÉÉMüUÇ || (A.¾û.zÉÉ.4/3)
126. ÌuÉzÉåwÉxiÉÑ rÉÉÌlÉ xÉÎYjlÉ aÉÑsTü-eÉÉlÉÑ ÌuÉOûmÉÉÌlÉ,iÉÉÌlÉ oÉÉWûÉæ qÉÍhÉoÉlkÉMÔümÉïUMü¤ÉkÉUÉÍhÉ;
(xÉÑ.zÉÉ.6/24)
127. mÉëMüÉå¸mÉÉhÉÏ xÉÎlkÉxjÉÉlÉqÉç | CirÉqÉUPûÏMüÉrÉÉÇ pÉUiÉ: | (zÉ.Mü.SìÓ)
129. qÉÍhÉoÉlkÉÇ mÉÉÍhÉqÉÔsÉÇ (QûsWûhÉ.xÉÑ.zÉÉ.6/24)
Reference Shlokas….
A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection) Page 101
130. ÌuÉzÉåwÉxiÉÑ qÉhÉÏoÉlkÉå MÑühPûiÉÉ | (xÉÑ.zÉÉ.6/24)
131. MÑühPûiÉÉ MüUxrÉÉMüqÉïhrÉiuÉqÉç (QûsWûhÉ. xÉÑ.zÉÉ.6/24)
134.EiÉFkuÉïÇxÉuÉïuÉëhÉuÉåSlÉÉuɤrÉÉqÉç:iÉÉåSlÉpÉåSlÉiÉÉQûlÉcNåûSlÉÉrÉÉqÉlÉqÉljÉlÉÌuɤÉåmÉhÉcÉÑqÉÑcÉÑqÉÉrÉlÉÌlÉSïWûlÉÉuÉpÉg
cÉlÉxTüÉåOûlÉÌuÉSÉUhÉÉåimÉÉOûlÉMüqmÉlÉÌuÉÌuÉkÉzÉÔsÉÌuÉzsÉåwÉhÉÌuÉÌMüUhÉxiÉqpÉlÉmÉÔUhÉxuÉmlÉÉMÑügcÉlÉÉ…¡ÓûÍzÉMüÉ:
xÉÇpÉuÉÎliÉ; (xÉÑ.xÉÔ.22/11)
135. ÂeÉÉMüU – ÂeÉÉÇ UÉåaÉÇ MüUÉåÌiÉ (uÉÉcÉ.uÉÉsÉ 6)
136. mÉëqÉÏrÉiÉå AlÉålÉåÌiÉ mÉëqÉÉhÉÇ ¥ÉÉlÉqÉɧÉqÉÏÎmxÉiÉqÉç | (cÉ¢ü. cÉ.ÌuÉ 8/7)
139. qÉÉlÉÇ iÉÑsÉÉ…¡ÓûÍsÉ mÉëxiÉÉåÈ| (A. MüÉå 2/9/85)
140. MåüÍcÉiÉç qÉkrÉqÉÉXÒûÍsÉMüÉrÉÉxiÉÑ qÉkrÉqÉmÉuÉïÍqÉiÉÉXÒûsÉÍqÉÌiÉ | (AÉRûqÉssÉ vÉÉ.xÉÇ.mÉë. 1/35-36)
141. qÉkrÉqÉÉ…¡ÓûsrÉÉæ mÉgcÉÉXÒûsÉå | (xÉ.xÉÑ. 35/12)
142. iÉsÉÇ wÉOèûcÉiÉÑU…¡ÓûsÉÉrÉÉqÉÌuÉxiÉÉUqÉç| (xÉ.xÉÑ. 35/12)
143. AXÒûsÉvÉoSålÉɧÉÉ…¡Óûû¸lÉZÉiÉsÉpÉÉaÉÇaÉ׺ûÎliÉ | (AÉRûqÉssÉ vÉÉ.xÉÇ.mÉë.1/35-36)
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