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….


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)

Page 4


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.


Page 5


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.


Page 6

Review of Literature….


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 .



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.



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.



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.



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.



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.



PRADESHA NUMBER OF AVEDHYA SIRAS


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.



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.



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.



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


KOSHTA (TRUNK) 59

GREEVA PRATYOORDHWAM 83

TOTAL 210

Table 12- Classification of Sandhi according to shadangatwa



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.



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



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


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



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 .



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


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.



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



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



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



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.



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



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.



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



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



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.



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



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



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.



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.


Sakha marma.

Vaikalyakara marma.



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.


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.



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.”



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.

Review of Literature-anatomy of hand

A comprehensive study of marmas in the hasta (hand) w.s.r. to the surface and regional anatomy (cadaver dissection)Page 37

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



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.



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.


a) It forms base of the wedge and bears a square facet for articulation with lunate

bone.



iv) Medial surface:

a) It forms apex of the wedge and gives attachment to ulnar collateral ligament of

wrist joint.


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.


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.



ii) Dorsal surface:

a) It is long and narrow.

b) It is related to radial artery.


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.


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.



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,



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.



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.



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.



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.



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.



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.



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.



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.



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.



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.



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.



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.



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.



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.



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



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.



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.



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.



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).



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.



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.



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



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



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.



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 ……


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…


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…


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…


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…


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…


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….


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….


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….


Fig 6: Anterior view of palm with vessels and nerves

Fig 7: Deep palmar arch and its branches

Figures….


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….


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….


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….


First dorsal interossei

Fig 16:First dorsal interossei

Fig 17: Dissected Hand Palmar surface

Fig 18: Dissected Hand Palmar surface

Discussion…


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…


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…


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…


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…


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…


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…


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….


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….


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….


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….


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….


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 qÉÉÇxÉÍxÉUÉxlÉÉruÉÉÎxjÉxÉÎlkÉxÉÌ³ÉmÉÉiÉÉ :, iÉãwÉÑ xuÉpÉÉuÉiÉ :LuÉ ÌuÉvÉãwÉãhÉ mÉëÉhÉÉÎxiÉ¸ÎliÉ,

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. xÉÌ³ÉmÉÉiÉ: ÍxÉUÉxlÉÉrÉÑxÉÎlkÉqÉÉÇxÉÉÎxjÉxÉqpÉuÉ |

qÉqÉÉïÍhÉ iÉãwÉÑ ÌiÉ¸ÎliÉ mÉëÉhÉÉ: ZÉsÉÑ ÌuÉvÉãwÉiÉ :|| (pÉÉ.mÉë. 3/223)

27. xÉqÉSÉåwÉ xÉqÉÉÎalÉ¶É xÉqÉkÉÉiÉÑ qÉsÉÌ¢ürÉÉ:

mÉëxÉ³ÉÉiqÉåÎlSìrÉqÉlÉÉ: xuÉxjÉ CirÉÍpÉkÉÏrÉiÉå|| (xÉÑ.xÉÔ.15/41)

28. AÎalÉ:xÉÉãqÉÉãuÉÉrÉÑ: xÉiuÉÇUÇeÉxiÉqÉ: mÉ§cÉãÎlSìrÉÉÍhÉpÉÔiÉÉiqÉãÌiÉ 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, rÉxqÉÉ³ÉÉãmÉsÉprÉliÉã |( xÉÑ.vÉÉ. 6/3)

31. ÍxÉUÉxlÉÉxuÉÎxjÉmÉuÉÉïÍhÉ xÉlkÉrÉ¶É zÉUÏËUhÉÉqÉç ||

mÉåzÉÏÍpÉ : xÉÇuÉ×iÉÉlrÉ§É oÉsÉuÉÎliÉ pÉuÉlirÉiÉ: || (xÉÑ.zÉÉ. 5/38)

32. iÉÉxÉÉÇ oÉWûsÉmÉåsÉuÉxjÉÔsÉÉhÉÑmÉ×jÉÑuÉ×¨É¾ûxuÉSÏbÉïÎxjÉU-

qÉ×SÒzsÉ¤hÉMüMïüzÉpÉÉuÉÉ: xÉlkrÉÎxjÉUÉxlÉÉrÉÑmÉëcNûÉSMüÉ

rÉjÉÉmÉëSåzÉ Ç xuÉpÉÉuÉiÉ LuÉ pÉuÉÎliÉ || (xÉÑ.zÉÉ.5/40)



33. mÉgcÉ mÉåzÉÏzÉiÉÉÌlÉ pÉuÉÎliÉ | iÉÉxÉÉÇ cÉiuÉÉËU zÉiÉÉÌlÉ zÉÉZÉÉxÉÑ, MüÉå¸å wÉOíéwÉÌ¹ , aÉëÏuÉÉÇ mÉëirÉÔkuÉïÇ

cÉiÉÑÎx§ÉÇzÉiÉç | (xÉÑ.zÉÉ.5/37)

34. iÉ§É iÉsÉ¾ûSrÉålSìoÉÎxiÉaÉÑSxiÉlÉUÉåÌWûiÉÉÌlÉ qÉÉÇxÉxrÉqÉqÉÉïÍhÉ (xÉÑ.zÉÉ.6/7)

35. qÉÉÇxÉeÉÉÌlÉ SzÉålSìÉZrÉiÉsÉ¾ûixiÉlÉUÉåÌWûiÉÉ : | (A.¾èû.zÉÉ.4/39)

36. ÌuÉ®ãÅeÉxÉëqÉxÉ×Yx§ÉÉuÉÉã qÉÉÇxÉkÉÉuÉlÉuÉ¨ÉlÉÑ : |

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)



44. नीलधमनीमातृकाशृङ्गाटकापाङ्गस्थपनीफणस्तनमलूापलापापस्तम्भहृदयना

िभपा र्सिन्धबृहतीलोिहताक्षो र्ः िसराममार्िण | (xÉÑ.zÉÉ.6/7)

45. xmiÉÌ§ÉÇzÉÎixÉUÉ´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¤ÉrÉÉ¨É×Qè pÉëqÉ´uÉÉxÉ qÉÉãWûÌWûkqÉÉÍpÉUliÉMü: || (A.¾ûû.vÉÉ.4/50)

47. UxÉÉiÉç xiÉlrÉÇ iÉiÉÉå U£üqÉxÉ×eÉ: MühQûUÉ: ÍxÉUÉ:|

qÉÉÇxÉÉ²xÉÉ 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)



52. xlÉÉrÉÑ qÉqÉÉïÍhÉ §ÉrÉÉåÌuÉÇzÉÌiÉUÉhÉrÉ: |MÔücÉïMÔücÉïÍzÉUÉå/mÉÉÇ… Í¤ÉmÉëÉåi¤ÉåmÉÉÇxÉoÉxiÉrÉ: (A.¾èû.zÉÉ.4/41)

53. AÉrÉÉqÉÉ¤ÉãmÉMü xiÉqpÉÉ: x§ÉÉuÉeÉãÅprÉÉÍkÉMüÇ ÂeÉÉ ||

rÉÉlÉxjÉÉlÉÉxÉlÉÉvÉÎiMü uÉæMüsrÉqÉjÉuÉÉÅliÉMü: | (A.Wû.vÉÉ.4/48)

54. xÉlkÉrÉ¶ÉÉ…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 Ì²ÌuÉkÉÉ¶Éå¹ÉuÉliÉ:,ÎxjÉUÉ¶É || (xÉÑ.zÉÉ.5/24)

57. iÉ LlÉå xÉlkÉrÉÉå/¹ÌuÉkÉÉ:- MüÉåUÉåsÉÔZÉsÉ xÉÉqÉÑª mÉëiÉU iÉÑ³ÉxÉåuÉlÉÏ uÉÉrÉxÉiÉÑhQ ûqÉhQûsÉ zÉ„¡ûÉuÉiÉÉï:|

iÉåwÉÉqÉ…¡ÓûÍsÉ qÉÍhÉoÉlkÉ aÉÑsT üeÉÉlÉÑ MÔümÉïUåwÉÑ MüÉåUÉ:xÉlkÉrÉ:, Mü¤ÉÉ uÉXç¤ÉhÉ SzÉlÉåmÉÔsÉÔZÉsÉÉ:,

AÇxÉmÉÏPû aÉÑS pÉaÉ ÌlÉiÉqoÉåwÉÑ xÉÉqÉÑªÉ:, aÉëÏuÉÉ mÉ×¸uÉÇzÉrÉÉå: mÉëiÉUÉ:, ÍzÉUMüOûÏ MümÉÉsÉåwÉÑ iÉÑ³ÉxÉåuÉlrÉ:,

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×üMüÉÌOûMüÉ¶ÉåÌiÉ 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 xÉwÉ¹ÏÌlÉ zÉiÉÉlrÉxjlÉÉÇ xÉWû SliÉÉåsÉÔZÉsÉlÉZÉålÉ | iÉ±jÉÉ-²ÉÌ§ÉÇzÉ6ûliÉÉ:,²ÉÌ§ÉÇzÉ6liÉÉåsÉÔZÉÉÌlÉ

ÌuÉÇzÉÌiÉlÉïZÉÉ, wÉ¹Ï mÉÉÍhÉmÉÉSÉ…¡ÓûsrÉxjÉÏÌlÉ, ÌuÉÇzÉÌiÉ mÉÉÍhÉmÉÉSzÉsÉÉMüÉ:,cÉiuÉÉËlÉç

mÉÉÍhÉmÉÉSzÉsÉÉMüÉÍkÉ¸ÉlÉÉÌlÉ, ²Éæ qÉÍhÉMüÉæ WûxiÉrÉÉå:, (cÉ.zÉÉ.7/6)



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/liÉUÉÍkÉ²Éæï oÉÉWÒû xÉÎYjÉlÉÏÌiÉ xÉqÉÉxÉiÉ: |

wÉQû…¡ÇqÉ…Ç¡ mÉëirÉÇ…¡Çû iÉxrÉÉÍ¤É¾ûSrÉÉÌSMüqÉç || (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 iÉ¥É¥ÉÉ: ||

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)



74. lÉÉÍpÉvÉZXûÉÍkÉmÉÉmÉÉlÉWûcNØûaXûÉOûMüoÉxiÉrÉ :

A¹Éæ cÉ qÉÉiÉ×MüÉ : xÉbÉÉæ ÌlÉblÉlirÉãMüÉã³ÉÌuÉÇvÉÌiÉ :

xÉmiÉÉWû mÉUqÉxiÉãwÉÉÇ MüÉsÉ MüÉsÉxrÉ MüwÉïhÉã || (A.¾ûû.vÉÉ.4/52-53)

75. uÉ¤ÉÉãqÉqÉÉïÍhÉ xÉÏqÉliÉiÉsÉÍ¤ÉmÉëãlSìoÉxiÉrÉ : |

MüOûÏMüiÉÂhÉã xÉlkÉÏ mÉμÉïeÉÉæ uÉ×WûiÉÏ cÉ rÉÉ ||

ÌlÉiÉqoÉÌuÉÌiÉ cÉæiÉÉÌlÉ MüÉsÉÉliÉUWûUÉÍhÉ iÉÑ || (xÉÑ.vÉÉ.6/10)

76. §ÉrÉÎx§ÉÇvÉSmÉxiÉqpÉiÉsÉWûimÉÉμÉïxÉlkÉrÉ : |

MüOûÏiÉÂhÉxÉÏqÉliÉxiÉlÉqÉÑsÉãlSìoÉxiÉrÉ :

Í¤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. sÉÉãÌWûiÉÉ¤ÉÉÍhÉ 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 :

xÉeÉÉlÉÑsÉÉãÌWûiÉÉ¤ÉÉÍhÉMü¤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)



83. iÉ§É xÉ±: mÉëÉhÉWûUqÉliÉã ÌuÉbS MüÉsÉÉliÉUãhÉ qÉÉUrÉÌiÉ |

MüÉsÉÉliÉUmÉëÉhÉWûUqÉliÉã ÌuÉbSÇ uÉæMüsrÉqÉÉmÉÉSrÉÌiÉ |

ÌuÉvÉsrÉblÉÇ oÉæMüsrÉMüUÇ cÉ pÉuÉÌiÉ |

uÉæMüsrÉMüUÇ MüÉsÉÉliÉUãhÉ YsÉãvÉrÉÌiÉ ÂeÉÉÇ cÉ MüUÉãÌiÉ |

ÂeÉÉMüUqÉiÉÏÌiÉuÉëuÉãSlÉÇ pÉuÉÌiÉ || (xÉÑ.vÉÉ.6/22)

84. Í¤ÉmÉëÉÍhÉ MüSÉÍcÉSÉzÉÑ qÉÉUrÉÎliÉ | (xÉÑ.zÉÉ.6/23)

85. iÉ§É xÉbÉ: mÉëÉhÉWûUÉÍhÉ AÉalÉãrÉÉÌlÉ, AÎalÉaÉÑhÉãwuÉÉvÉÑ ¤ÉÏhÉãwÉÑ¤ÉmÉrÉÎliÉ |

MüÉsÉÉliÉU mÉëÉhÉWûUÉÍhÉ xÉÉæqrÉÉalÉãrÉÉÌlÉ, AÎalÉaÉÑhÉãwuÉÉvÉÑ ¤ÉÏhÉãwÉÑ ¢üqÉãhÉ

cÉ xÉÉãqÉaÉÑhÉãwÉÑ MüÉsÉÉliÉUãhÉ ¤ÉmÉrÉÎliÉ |

ÌuÉvÉsrÉmÉëÉhÉWûUÉÍhÉ uÉÉrÉurÉÉÌlÉ, vÉsrÉqÉÑZÉÉuÉÂbSÉã rÉÉuÉSliÉuÉÉïrÉÑÎxiÉ¸ÌiÉ

iÉÉuÉelÉÏuÉÌiÉ, ESèkÉ×iÉqÉÉ§Éã iÉÑ vÉsrÉã qÉqÉïxjÉÉlÉÉÍ´ÉiÉÉã uÉÉrÉÑÌlÉïw¢üÉqÉÌiÉ, iÉxqÉÉiÉç

xÉvÉsrÉÉã eÉÏuÉÌiÉ ESèkÉ×iÉvÉsrÉÉã ÍqÉërÉiÉã | (mÉÉMüÉimÉÌiÉiÉvÉsrÉÉã uÉÉ eÉÏuÉÌiÉ)

uÉæMüsrÉMüUÉÍhÉ xÉÉæqÉÉã ÌWû ÎxjÉUiuÉÉcNæûirÉÉccÉ mÉëÉhÉÉuÉsÉqoÉlÉÇ MüUÉãÌiÉ |

ÂeÉÉMüUÉhrÉÎalÉuÉÉrÉÑaÉÑhÉpÉÔÌrÉ¸ÉÌlÉ, 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 mÉ§cÉ cÉ aÉsÉã SvÉ rÉÉÌlÉ cÉ uSã |

iÉÉÌlÉ xuÉmÉÉÍhÉiÉsÉMÑüÎ§cÉiÉxÉÇÍqÉiÉÉÌlÉ vÉãwÉÉhuÉãÌWû mÉËUÌuÉxiÉUiÉÉãÅaXûsÉÉkÉïqÉç || (xÉÑ.vÉ.6/28,29)

87. LiÉimÉëqÉÉhÉqÉÍpÉuÉÏ¤rÉ 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)



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 qÉ±qÉ…¡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. Í¤ÉmÉëÇ =Í¤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¤ÉmÉëqÉÉ¤ÉåmÉqÉÉUhÉqÉç || (A.¾û.zÉÉ.4/3)

105. AÉ¤ÉåmÉMüÉZrÉålÉ uÉÉiÉurÉÉÍkÉlÉÉ qÉÉUrÉÌiÉ (AÂhÉS¨É,A.¾û.zÉÉ.4/3)

106. rÉSÉ iÉÑ kÉqÉlÉÏ: xÉuÉÉï:MÑüÌmÉiÉÉå/prÉåÌiÉ qÉÉÂiÉ: ||

iÉSÉÍ¤ÉmÉirÉÉzÉÑ qÉÑWÒûqÉÑïWÒûSåïWÇû qÉÑWÒû¶ÉU:

qÉÑWÒûqÉÑïWÒûxiÉSÉ¤ÉåmÉÉSÉ¤ÉåmÉMü CÌiÉ xqÉ×iÉ: || (xÉÑ.ÌlÉ.50/51)



107. rÉjÉÉ iÉÑ kÉqÉlÉÏ: xÉuÉÉï: ¢Ñü®Éå/prÉåÌiÉ qÉÑWÒûqÉÑïWÒû:

iÉjÉÉ/…¡ûqÉÉÍ¤ÉmÉirÉåwÉ urÉÉÍkÉUÉ¤ÉåmÉMü: xqÉ×iÉ: | (A.¾û.ÌlÉ.15/16)

108. kÉqÉlrÉÉå lÉÉŽ: | (QûsWûhÉ, xÉÑ.ÌlÉ.50/51)

109. iÉSÉ¤ÉåmÉÉiÉç SåWûÉ¤ÉåmÉÉiÉç | (QûsWûhÉ, xÉÑ.ÌlÉ.50/51)

110. AÉÍ¤ÉmÉÌiÉ = 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 iÉsÉ¾ûSrÉÇ lÉÉqÉ,iÉ§É mÉÉSxrÉ pÉëqÉhÉuÉåmÉlÉå pÉuÉiÉ:

(xÉÑ.zÉÉ.6/24)

115. qÉkrÉå mÉÉSiÉsÉxrÉÉWÒûUÍpÉiÉÉå qÉkrÉqÉÉ…¡ÓûÍsÉqÉç

iÉsÉ¾û³ÉÉqÉ ÂeÉrÉÉ iÉ§É ÌuÉ®xrÉ mÉgcÉiÉÉ (A.¾û.zÉÉ.4/2)

116. MÑüUç +cÉOû ÌlÉmÉÉiÉlÉÉiÉç SÏbÉï:| (zÉ.Mü.SìÓ.)

118. Í¤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)



130. ÌuÉzÉåwÉxiÉÑ qÉhÉÏoÉlkÉå MÑühPûiÉÉ | (xÉÑ.zÉÉ.6/24)

131. MÑühPûiÉÉ MüUxrÉÉMüqÉïhrÉiuÉqÉç (QûsWûhÉ. xÉÑ.zÉÉ.6/24)

134.EiÉFkuÉïÇxÉuÉïuÉëhÉuÉåSlÉÉuÉ¤rÉÉqÉç:iÉÉåSlÉpÉåSlÉiÉÉQûlÉcNåûSlÉÉrÉÉqÉlÉqÉljÉlÉÌuÉ¤ÉåmÉhÉcÉÑqÉÑcÉÑqÉÉrÉlÉÌlÉSïWûlÉÉuÉpÉg

cÉlÉxTüÉåOûlÉÌuÉSÉUhÉÉåimÉÉOûlÉMüqmÉlÉÌuÉÌuÉkÉzÉÔsÉÌuÉzsÉåwÉhÉÌuÉÌMüUhÉxiÉqpÉlÉmÉÔUhÉxuÉmlÉÉMÑügcÉlÉÉ…¡ÓûÍzÉMüÉ:

xÉÇpÉuÉÎliÉ; (xÉÑ.xÉÔ.22/11)

135. ÂeÉÉMüU – ÂeÉÉÇ UÉåaÉÇ MüUÉåÌiÉ (uÉÉcÉ.uÉÉsÉ 6)

136. mÉëqÉÏrÉiÉå AlÉålÉåÌiÉ mÉëqÉÉhÉÇ ¥ÉÉlÉqÉÉ§ÉqÉÏÎmxÉiÉqÉç | (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. AXÒûsÉvÉoSålÉÉ§ÉÉ…¡Óûû¸lÉZÉiÉsÉpÉÉaÉÇaÉ×ºûÎliÉ | (AÉRûqÉssÉ vÉÉ.xÉÇ.mÉë.1/35-36)

Bibliography. . . . . .


BIBILOGRAPHY1. Rishi kumar P.R.S. Sharma &Ram Chandra, editor. Atharvaveda Vol 1 – 8.

Muradabad: Sanatana Dharma Yantralaya; 1988. (7:2/123/1)

2. N. S. Sontakke, editor. Rigveda, commentary by – Shri Marsyachandra, Puna:

Vedic Samshodhana Mandal; Vol 1 to 10 (1:11/61/6)





5. Rishi kumar P.R.S. Sharma &Ram Chandra, editor. Atharvaveda Vol 1 – 8.

Muradabad: Sanatana Dharma Yantralaya; 1988. (8:2/3/17)

6. Pt. Ram Chandra Shastri Kinjawarkar, editor. Garbhopanishad; 108 Upanishada,

Mathura: Jagadeesh Prasad Bhutiya Bambai Bhusthan Press. Pp: 2949, p: 1933.

7. Valmiki. Motilal Jalan, editor. Ramayana, I part. Gorakhpur: Geeta Press. 1960.

63:45-53.

8. Veda Vyasa.Swami Jagadishwaranand Saraswati,editor.Mahabharatha.Arya

Sahitya Bhavan;2008. Pp-1312, p-876.

9. Veda Vyasa.Swami Jagadishwaranand Saraswati,editor.Mahabharatha.Arya

Sahitya Bhavan;2008. Pp-1312, p-1287.

10. Agnivesa. Vaidya Jadavji Trikamji Acharya, editor. Caraka Samhita revised by

Caraka and Drdhabala with Sri Cakrapanidatta Ayurvedadipika Commentary in

Sanskrit. 5th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 2008. Pp-738, p- 597.

11. Susruta. Yadavji Trikamji Acharya, editor. Susruta Samhita with Nibandha

Sangraha of Dalhanacharya. 8thed. Varanasi: Chaukhambha Orientalia; 2008. Pp-824,

p- 369.



p- 369.

13. Vriddha Vagbhata. Shiv Prasad Sharma, editor. Ashtanga Sangraha with Sasilekha

commentary of Indu. 1st ed Varanasi: Chaukhambha Sanskrit series office; 2006. Pp-

965, p- 319.



14. Vagbhata. Harisadasivasastri Paradakara Bhisagacarya, editor. Ashtanga

Hrudayam with Sarvangasundara of Arunadatta & Ayurvedarasayana of Hemadri.

Varanasi: Chaukhambha Orientalia; 2005. Pp-956, p- 409 .

15. Vruddha Jeevaka. Kasyapa Samhita or Vruddha Jeevaka Tantra, revised by

Vatsya with Sanskrit introduction by Nepal Rajaguru Pandit Hemaraja Sharma. 7th ed.

Varanasi: Chaukhambha Sanskrit Samsthan; 2000 Pp- 364, p- 76.

16. Bhavamishra. Brahma Shankar Misra, editor. Bhavaprakasha Part I with Hindi

commentary by Pandit Sri. Brahma Shankar Misra. 8th ed. Varanasi: Chaukhambha

Sanskrit Sansthan; 2003. Pp: 960; p. 66.

17. Amarasimha. Haragovinda Shastri,editor. Amarakosha. Varanasi: Choukambha

Sanskrit Sansthan; 2006, Pp- 667, p-656 .

18. Radakant dev. Varada Prasad, editor. Shabda kalpa druma. Vol 5. ed. Delhi: Naga

publishers; 1987. Pp- 792, p-641.

19. Taranatha Tarkavachaspati,editor.Vachaspatyam.Vol 6.ed.Chaukhambha Sanskrit

Series Office;1970 Pp:5442;p.4738.



p- 371.



p- 369.

22. Narahari.Indra Dev Tripady,editor.Rajanighantu.Varanasi.Chaukhambha

Krishnadas Academy;Pp-803,p-586.






Varanasi: Chaukhambha Orientalia; 2005. Pp-956, p- 413.



Varanasi: Chaukhambha Orientalia; 2005. Pp-956, p- 413



26. Bhavamishra, Pandit Sri. Brahma Shankar, editor. Bhavaprakasha Part I with

Hindi commentary by Pandit Sri. Brahma Shankar Misra. 8th edition; Varanasi:

Chaukhambha Sanskrit Sansthan; 2003; Pp-960; p-65.



p- 75.



p- 354.



p- 369.



p- 369.



p- 368.



p- 368.



p- 367.



p- 370.














p- 376.



p- 376.



p- 377.



p- 377.



p- 378.



p- 372.



p- 370.














p- 367.



p- 367.



p- 367.



p- 370.







54. Sharangadhara. Pandit Parasurama Sastri, editor. Sarangadhara Samhita with

Adhamallas’s Dipika & Kasirama’s Gudhartha dipika commentary. 5th ed. Varanasi:

Chaukhambha subharti prakashan; 2002. Pp-398, p-52.



p- 366.



p- 366.



p- 367.



p- 370.








p- 365.



p- 365.



Sanskrit. 5th ed. Varanasi: Chaukhambha Sanskrit Sansthan; 2008. Pp-738, p- 337



p- 366.



p- 370.






p- 384














p- 370.






p- 370.

73.Susruta. Yadavji Trikamji Acharya, editor. Susruta Samhita with Nibandha


p- 370.






p- 370.






p- 370.






p- 370.








p- 370.






p- 372.



p- 372.



p- 371.



p- 374.



p- 375.


Sanskrit Sansthan; 2006, Pp- 667, p- 299 .

89. Radakant dev. Varada Prasad, editor. Shabdhakalpa druma. Vol 5. ed. Delhi:

Naga publishers; 1987. Pp- 555, p-526.

90. Monier Williams.M., editor.A Sanskrit to English Dictionary.Delhi:Motilal

Bawarsidass;2005.Pp-1333,p-1294



p- 30.



p- 34.





p- 170.



p- 170.









p- 364.



p- 365.



p- 365.



p- 365.

101. Radakant dev. Varada Prasad, editor. Shabdhakalpa druma. Vol 2. ed. Delhi:


102. Monier Williams.M,editor. A Sanskrit to English Dictionary.Delhi:Motilal

Bawarsidass;2005.Pp-1333,p-1294.



p- 372.











p- 264.






p- 264.



p- 264.






p- 375.

112. Radakant dev. Varada Prasad, editor. Shabda kalpa druma. Vol 2. ed. Delhi:


113. Monier Williams.M.,editor. A Sanskrit to English Dictionary.Delhi:Motilal




p- 372.








117. Monier Williams.M., editor. A Sanskrit to English Dictionary.Delhi:Motilal




p- 372.










123. Monier Williams.M.,editor A Sanskrit to English Dictionary.Delhi:Motilal




p- 372.






p- 372.

127. Radakant dev. Varada Prasad, editor. Shabda kalpa druma. Vol . ed. Delhi: Naga

publishers; 1987. Pp- 792, p-576.

128. Monier Williams.M.,editor A Sanskrit to English Dictionary.Delhi:Motilal




p- 373.





p- 373.



p- 373.


Sanskrit Sansthan; 2006, Pp- 667, p-281 .





p- 109.

135. Mishra.J.N and Pradeep Kumar Chauhan.Marma and its management.Varanasi:

Chaukhambha Orientalia;Pp-254,p-72.


Chaukhambha Orientalia;Pp-254,p-73.

137. Taranatha Tarkavachaspati,editor.Vachaspatyam.Vol 6.ed.Chaukhambha

Sanskrit Series Office;1970 Pp:5442;p.4809.

138. Agnivesha. Vaidya Jadhavji Trikamji Acharya, editor. Charaka Samhitha revised

by Charaka and Dridhabala with Sri Chakrapanidatta Ayurvedadipika Commentary in

Sanskrit. 5th ed. Varanasi: Choukambha Sanskrit Sansthan; 2008. Pp-738, P No- 262.


Sanskrit Sansthan; 2006, Pp- 667, p- 438.


Adhamallas’s Dipika & Kasirama’s Gudhartha dipika commentary. 5th ed Varanasi:

Choukhamba subharti prakashan;. 2002. Pp-398, p- 9.

141. Susruta. Yadavji Trikamji Acharya, editor. Sushrutha Smhitha with Nibandha

Sangraha of Dalhanacharya. 8thed. Varanasi: Choukambha Orientalia; 2008. Pp-824,

p- 150.

142. Susruta. Yadavji Trikamji Acharya, editor. Sushrutha Smhitha with Nibandha

Sangraha of Dalhanacharya. 8thed. Varanasi: Choukambha Orientalia; 2008. Pp-824,

p- 150.




Adhamallas’s Dipika & Kasirama’s Gudhartha dipika commentary.5th ed. Varanasi:

Choukhamba subharti prakashan; 2002. Pp-398, p- 9.

144. Chaurasia.B.D., editor. Human Anatomy, part I.4th ed. New Delhi: CBS

Publishers&Distributors; 2004. Pp-288, p-112.

145. Datta A.K., editor. Essentials of Human Anatomy, part III. 4th ed.Kolkata:

Current Book International Publishers; 2009. Pp- 274, p-98.

146. Poddar.S.&Ajay Bhagat.,editor.Handbook of Osteology,12th ed.Patna:Scientific

Book Company;2007.Pp-372,p-233.


Publishers&Distributors; 2004. Pp-288,p-114.

148. Romanes.G.J.,editor. Cunningham’s Manual of Practical Anatomy, Vol I.15th

ed. Newyork:Oxford University Press;2006.Pp-263,p-117.

149. Datta A.K., editor. Essentials of Human Anatomy, part III. 4th ed. Kolkata:










154. Romanes.G.J., editor. Cunningham’s Manual of Practical Anatomy, Vol I.15th

ed. Newyork: Oxford University Press; 2006.Pp-263,p-11.








Publishers&Distributors; 2004. Pp-288,p-99.



159. Das.S., editor.A Concise Textbook of Surgery, 3rd ed.Calcutta:Das.S;2001.Pp-

1324,p-350.


1324,p-352.

161. Keith.L.Moore&Arthur.F.Dalley, editor. Clinically Oriented Anatomy,5th

ed.Baltimore:Lippincott Williams&Wilkins;2006.Pp-1209,p-738.


1324,p-352.


1324,p-280.


1324,p-282.


Publishers&Distributors; 2004. Pp-288, p-124.


Chaukhambha Orientalia; Pp-254, p-36.


1324,p-8.

168. Norman.S.Williams, Christopher.J.K.Bulstrode, Ronan O’Connell.P., editor.

Bailey & Love’s Short Practice of Surgery,25th ed.London:Edward Arnold Publishers

Ltd;Pp-1513,p-419.


1324,p-137.

Hastamarma, sr

Documents

Transcript of Hastamarma, sr