Siravyadha marma-sr

A COMPREHENSIVE STUDY OF SIRĀVYADHA W.S.R. TO

ANATOMICAL & MARMA RELEVANCE OF THE LOWER

EXTREMITY

DISSERTATION SUBMITTED TO THE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE DEGREE OF

AYURVEDA VACHASPATI (M.D)

IN

RACHANA SHAREERA

BY

Dr. BINI UPENDRAN

UNDER THE GUIDANCE OF

Dr. RAMA BHAT. K.M M.D (Ayu) PROFESSOR, HOD

&

Vd. ALAPATI VINOD KUMAR M.D(Ayu)PhD ASST. PROFESSOR

DEPARTMENT OF POST GRADUATE STUDIES

IN RACHANA SHAREERA

ALVA’S AYURVEDA MEDICAL COLLEGE MOODBIDRI - 574227

2010

ALVA’S AYURVEDA MEDICAL COLLEGE

DEPARTMENT OF POST GRADUATE STUDIES IN

RACHANA SHAREERA

MOODBIDRI, KARNATAKA

DECLARATION

I hereby declare that this dissertation entitled “A Comprehensive Study of

Sirāvyadha W.S.R. to Anatomical & Marma Relevance of the Lower

Extremity” is a bonafide and genuine research work carried out by me

under the guidance of Dr. Rama Bhat. K. M. M.D (Ayu), Professor & HOD., and

Vd. Alapati Vinod Kumar M.D (Ayu)PhD, Asst. Professor, Dept. of P.G. Studies

in Rachana Shareera, Alva’s Ayurveda Medical College Moodbidri.

Dr. BINI UPENDRAN

III Year P.G. Scholar

Dept. of Rachana Shareera

Alva’s Ayurveda Medical College

Moodbidri 574227

Date:

Place: Moodbidri



RACHANA SHAREERA

MOODBIDRI, KARNATAKA.

CERTIFICATE

This is to certify that the dissertation entitled “A Comprehensive Study of


Extremity” submitted by Dr. Bini Upendran in partial fulfilment for the

degree of Ayurveda Vachaspathi (M.D) in Rachana Shareera, of Rajiv

Gandhi University of Health Sciences, Bangalore, is a record of research

work done by her during the period of her study in this institute, under my

guidance and supervision and the dissertation has not previously formed

the basis to the award of any degree, diploma, fellowship or other similar

titles.

I recommend this dissertation for the above degree to the University for the

approval.

Co-Guide Guide

Vd. ALAPATI VINOD KUMAR M.D (Ayu)PhD Dr. RAMA BHAT. K. M. M. D (Ayu).

Asst. Professor, Dept. of P.G Studies Professor & HOD., Dept. of P.G Studies in Rachana Shareera, in Rachana Shareera, Alva’s Ayurveda Medical College Alva’s Ayurveda Medical College Moodbidri 574227 Moodbidri 574227

Date:

Place: Moodbidri



RACHANA SHAREERA


CERTIFICATE



Extremity” is a bonafide research work done by Dr. Bini Upendran under

the guidance of Dr. Rama Bhat. K. M. M.D (Ayu), Professor & HOD., and Vd.

Alapati Vinod Kumar M.D (Ayu)PhD, Asst. Professor, Dept. of P.G Studies in

Rachana Shareera, for partial fulfilment of the requirement for the award

of the degree in Ayurveda Vachaspathi (M.D) in Rachana Shareera, of

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

Date: Place: Moodbidri

Dr. RAMA BHAT. K. M. M.D (AYU)

Professor and H.O.D., Dept. of P.G. Studies in Rachana Shareera,

Alva’s Ayurveda Medical College Moodbidri 574227



RACHANA SHAREERA


ENDORSEMENT



Extremity” is a bonafide research work done by Dr. Bini Upendran under

the guidance of Dr. Rama Bhat. K. M. M.D (Ayu), Professor & HOD., and Vd.

Alapati Vinod Kumar M.D (Ayu)PhD, Asst. Professor, Dept. of P.G Studies in

Rachana Shareera, for partial fulfilment of the requirement for the award

of the degree in Ayurveda Vachaspathi (M.D) in Rachana Shareera, of

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.

PRINCIPAL

Alva’s Ayurveda Medical College Moodbidri 574227

Date:

Place: Moodbidri

COPYRIGHT

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation in print or electronic format for academic/research purpose.

Date: Place: Moodbidri

Rajiv Gandhi University of Health Sciences, Karnataka

Dr. BINI UPENDRAN III Year P.G. Scholar

Dept. of P.G. Studies in Rachana Shareera Alva’s Ayurveda Medical College

Moodbidri 574227

ACKNOWLEDGEMENT

The successful completion of this thesis depends largely on the

encouragement, guidance and support of many people. I take this opportunity to

express my gratitude to the people who have been instrumental in the completion

of this thesis.

I consider it a great privilege to record my deep sense of gratitude to Dr

Rama Bhat, Professor& HOD., Dept. of PG Studies in Rachana Shareera, for

providing an opportunity to carry out this work under his able guidance. I also

express my sincere gratitude to Vd. Alapati Vinod Kumar, for his all time

support, generous help and guidance. I would like to express my earnest gratitude

to Dr Giridhar M. Kanthi, for his timely guidance, help and constant support.

I express my holy gratitude to the chairman, Dr Mohan Alva, Alva’s

Education Foundation, Moodbidri for giving the opportunity to pursue my P.G. in

this esteemed institution.

I would like to express my sincere thanks to Dr Baidyanath Mishra, Dr

Suresh Negalaguli, Dr. Laksmeesh Upadhya, Dr. Vinaya Chandra Shetty,

Dr Subhada and Dr Ajay Ghosh for their scholarly guidance in carrying out

this research work.

I express my sincere love and gratitude to Dr M.K.Madankumar, Dr

Vivek unni K.K, Dr Sreekumar K, Dr Gisha Jyothis, Dr Maya Mukundan

and Dr Sarath for being with me by providing honest support to surmount each

& every barrier successfully.

I am highly indebted to Dr Anuprabha, Dr Prashanth D, Dr Binu B, Dr

Benoy Bhaskaran, Dr Leena P Nair, Dr. Arun Bhaskaran, Dr Rakhi CM, and

Dr Sheeja Chandran for their help and inspiration given at various stages of my

work.

I sincerely appreciate the assistance received from the non-teaching staff

of the institution during the course of my study.

I sincerely bow my head to my beloved parents Sri. late N. Upendran &

Smt. P. Letha, my words of gratitude seems feeble next to their deeds, I have no

words to express how extra ordinary they are, further I extend my thanks to my

loving brother Dr. Binu Upendran and my in laws for their love blessings and

never ending support throughout the span of my work and for being there for me.

I remember with respect my husband Dr A. Nandakumar. Prof &

H.O.D, Department of Rasasastra & Bhaishajya Kalpana, Amrita Ayurveda

Medical college, Kollam, for his love, affection, inspiration and encouragement

for over 18 years without whom this work wouldn’t have been possible, he has

lived in every line & page of this book and in my life all together.

I offer my special thanks to Dr K. Vasudeva Reddy, Dr Rabinarayan

Tripathi, Dr Geetha kumar, Mrs Sudha, Sri Subhash, Mr Vimal Syam, Mr

Syam, Dr Poojalekshmy, Mr Nitin Krishnan, Mr Muneer and Amala Jyothi

for their profound and unending support.

I express my love to my children Manjunath and Mahesh Narayan for

bearing my absence and inspiring me throughout my work.

I am ever indebted to the God almighty for showering his blessings upon

me and for making my hurdles lighter so that I could complete my work

satisfactorily.

Last but not least I offer my sincere apologies to any omission in the above

list and appeal to consider them as fortuitous.

Dr Bini Upendran

Moodbidri

LIST OF ABBREVATIONS

xÉÑ.zÉÉ. Suśruta Samhita Sareera Sthana

cÉ.xÉÔ. Caraka Samhita Sutra Sthana

A. WØû.zÉÉ. Astanga Hridaya Sareera Sthana

cÉ.ÍcÉ. Caraka Samhita Chikitsa sthana

A.xÉÇ.xÉÔ. Astanga Sangraha Sutra sthana

. xÉÑ.xÉÔ. Susruta Samhita sutra Sthana

A.WØû.xÉÔ. Ashtanga Hridaya Sutra Sthana

A.xÉÇ.xÉÔ. Ashtanga Sangraha Sutra Sthana

cÉ.zÉÉ. Caraka Samhita Sareera Sthana

i.e. That is

. cÉ.ÍcÉ. Caraka Samhita Chikitsa Sthana

cÉ.ÍxÉ. Charaka Samhita Sidhi Sthana

A.xÉÇ.zÉÉ. Ashtanga Sangraha Sareera Sthana

. pÉÉ.mÉë. Bhavaprakasa

v/s Versus

. Su. Śa. Susruta Samhita Sareera Sthana

zÉÉ.xÉÇ.mÉë.ZÉ Sarangadhara Samhita Prathama Khanda

Abstract

A Comprehensive Study of Sirāvyadha W.S.R. To Anatomical & Marma Relevance of The Lower Extremity

ABSTRACT

Background and Objectives

The study entitled “A Comprehensive Study of Sirāvyadha W.S.R. to

Anatomical & Marma Relevance of the Lower Extremity” is aimed to identify the

Sirās mentioned in Sirāvyadha Vidhi with comparison to the blood vessels of the

lower extremity as per the modern Anatomy.

Ācharya Suśruta has emphasized that Sirāvyadha helps in eliminating the

vitiated Doshas. He further clarifies that if all the five-fold purification procedures

cannot be performed due to lack of time then, „Raktamokshana‟ will serve the purpose

in emergency conditions.

Raktamokshana is one among the Pancha Vidha Śodhana therapy according to

Vāgbhata Ācharya, it is considered as Ardha Chikitsa or Sampūrna Chikitsa in

Shalyatantra.

Sirāvyadha is the most important method in all the conditions where

Raktamokshana is indicated. Though it has prime importance in the line of treatment

as per Shalya Chikitsa, the safety measures have to be taken to protect the Rakta

Dhatu which has the qualities of “Jeevana”.

The study includes a comprehensive literary review on Sites of Sirāvyadha of

lower limb and to compare and locate the anatomical structures and their relation with

Sirās of lower limb mentioned in Sirāvyadha. The study will be carried out on the

basis of literary review and cadaver dissection.

Abstract

A Comprehensive Study of Sirāvyadha W.S.R. To Anatomical & Marma Relevance of The Lower Extremity

Material and Methods

Literature related to the study collected from the classical texts and modern Anatomy

books.

Dissection of lower limb was carried out in the Dept. of Rachana Shareera,

Alva‟s Ayurveda Medical College, Moodbidri.

The concept of Sirāvyadha was reviewed and relevant information was

collected.

Five properly preserved Cadavers were dissected for structures related to

Sirāvyadha of lower limb and data was collected.

Results

The related structures in and around the sites of Sirāvyadha of lower limb

were viewed and assessed with the help of Ayurvedic and Modern reference.

Interpretation and Conclusion

So as to fulfil the above objectives, a thorough review of literature and

analysis was done. A creative and logical approach has been done to locate Sirās of

Sirāvyadha Sthanas in lower limbs with anatomical interpretation. The present study

reveals that Sirāvyadha is an effective modality of treatment and the Anatomical

knowledge, Marma relevance of Vedhya and Avedhya Sirās cannot be discarded.

Key Words

Sirā; Marma; Vein; Rachana Shareera; Raktamokshana; Sirāvyadha;

Venesection; Phlebotomy

CONTENTS

SL.NO TOPIC PAGE.NO

01 INTRODUCTION 01-04

02 OBJECTIVES 05

03 REVIEW OF LITERATURE

HISTORICAL REVIEW 06-14

REVIEW OF SIRAVYADHA 15-35

REVIEW OF MARMA 36-59

REVIEW OF VENOUS SYSTEM 60-71

REVIEW OF VEINS OF LOWER EXTREMITIES 72-92

04 METHODOLOGY 93

05 OBSERVATION 94-99

06 DISCUSSION 100-106

07 CONCLUSION 107-108

08 SUMMARY 109-110

09 REFERENCES 111-129

10 BIBILIOGRAPHY 130-133

11 ANNEXURE 134-136

LIST OF TABLES

SL:NO DESCRIPTION OF TABLES PAGE NO:

01 DOSHANUSARA SIRA SANKHYA 18

02 URDHVA JATRUGATA SIRAS 18

03 KOSTANGA SIRAS 19

04 SAKAGATA SIRAS 19

05 SITES OF SIRAVYADHA ACC. TO SUSHRUTA 27

06 SITES OF SIRAVYADHA ACC. TO VAGBHATA 28

07 SADHYAPRANAHARA MARMAS 41

08 KALANTARAPRANAHARA MARMAS 41

09 VISHALYAGHNA MARMAS 42

10 VAIKALYAKARA MARMAS 42

11 RUJAKARA MARMAS 42

12 CLASSIFICATION OF MARMAS ACC. TO SUSRUTA. &

VAGBHATA

43

13 MARMAS OF LOWER EXTREMITIES 57

LIST OF FIGURES

SL:NO DESCRIPTION OF IMAGES PAGE NO:

01 KSHIPRA MARMA 47

02 TALA-HRIDAYA MARMA 48

03 KURCHA MARMA 49

04 KURCHA SIRA MARMA 50

05 GULPHA MARMA 51

06 INDRABASTHI MARMA 52

07 JANU MARMA 53

08 ANI MARMA 54

09 URVI MARMA 55

10 LOKITAKSHA MARMA 56

11 VITAPA MARMA 57

12 MICROSCOPIC STRUCTURE OF VEIN 64

13 EMBRYONIC DEVELOPMENT OF BLOOD VESSELS 71

14 SUPERFICIAL VEINS OF LOWER LIMB (ANTERIOMEDIAL VIEW) 76

15 SUPERFICIAL VEINS OF LOWER LIMB 77

16 SUPERFICIAL AND PERFORAT ING VEINS OF LOWER LIMB 78

Introduction

A Comprehensive Study of Sirāvyadha W.S.R. To Anatomical & Marma Relevance of The Lower Extremity Page 1

INTRODUCTION

Ayurveda is a practical science of life with its principles universally applicable

to each individual for daily existence. Ayurveda speaks of every elements and facts of

human life offering guidance that have been tested and refined over many centuries to

all those who speak greater harmony, peace and longevity.

According to Ayurveda, our body is formed by the combination of Dosha

(Vata, Pitta & Kapha), Dhātu (Sapta Dhātu viz. Rasa, Rakta, Māmsa, Meda, Asthi,

Majja, Śukra) & Mala (Purisha, Mutra and Sweda).

All the tissues of the body contain Dosha, Dhātu & Mala in subtle amount.

Out of these, Tridoshas are considered as more important as they form a base in

nourishment and development of the body.

Whenever there is disequilibrium of Doshas, it directly affects the health of

the individual.

Hence, basic Ayurvedic treatment is based on two principles:

1.Śodhana Chikitsa: Elimination of excess Doshas from the body is known as

Śodhanachikitsa

2. Śamana Chikitsa: When the increased Doshas are brought into equilibrium with

the help of various medicines, the therapy is known as Śamanachikitsa.

However, out of these two therapies, ‘Śodhanachikitsa’ has great importance.

When Ayurvedic treatment is given, especially in chronic diseases or metabolic

disorders, Śodhanachikitsa has to be done before giving any palliative medicines so as

to achieve good results or prognosis.

Expulsion or removal of vitiated blood from the body is known as

Raktamokshana. This can be done either through the prominent superficial veins with

the help of simple scalp- vein canula (Sirāvyadha), with the help of Leech

Introduction


(Jalūkāvacharana), by taking multiple Incisions on a particular site (Prachāna

Karma), by sucking blood with the help of animal horn (Śringa) from the site where

prior incision is taken or removing blood with the help of empty dried bottle gourd

(Alābu).

Raktamokshana or Bloodletting is given prime importance in Panchakarma or

Śodhanachikitsa. It is said that a number of diseases which are otherwise incurable

can easily & effectively be cured only by Raktamokshana alone.

It can be said that half or rather entire Śalyatantra is equivalent to

‘Sirāvyadha’ alone i.e. a number of diseases are likely to be cured only through this

simplest technique.

Sirāvyadha is also accepted as half of the therapeutic measure in Śalyatantra

like Vasti in Kāyachikitsa105.

Ācharya Suśruta has mentioned diseases that are not relieved so quickly by

Snehana, Āswedanadi measures, in this situation; Sirāvyadha is an emergency

management to achieve better results106.

Rakta, the blood being the vehicle to carry & transport absorbed nutrients,

oxygen, metabolites etc. from place to place. So, correction of any abnormality in the

blood by taking it out solves a number of problems.

Ācharya Suśruta further says that, this is the only therapy which helps in

eliminating all the three vitiated Doshas at a time. He further advocate that if all the

five-fold purificatory procedure cannot be performed due to lack of time then, even

‘Raktamokshana’ can serve the purpose.

In Panchakarmachikitsa, the vitiated Doshas are purified whereas in

Raktamokshana the Rakta is let out along with vitiated Doshas where Rakta Dhātu is

predominant. The susceptibility of Rakta towards impurity is so versatile that the

Introduction


classics were compelled to agree upon Rakta as a fourth Dosha. Therefore Dūshita

Rakta should be let out to protect the health or to remove the disease. Since Pitta is

dependent on Rakta, Rakta-Mokshana decreases the quantum of enhanced Pitta,

henceforth Doshas and Pittaja Vyadhi are also relieved or cured by the therapy.

Sirāvyadha has been one of the most commonly used procedures amongst

various methods described in Indian Classical Surgery. The school of Suśruta applied

this technique therapeutically as well as prophylactically. The superficial veins are

considered to be most suitable for Sirāvyadha.

The knowledge of Marma, Sirās and vessels are essential for understanding

the concept of Sirāvyadha. Marmas are the vital points in the body which prove to be

fatal when subjected to trauma. Detail knowledge of Marma is important from

surgical point of view; surgical procedures like Agnikarma, Ksharakarma,

Raktamokshana etc, are used as a part of the surgery. While conducting these surgical

procedures, the knowledge of Marma Sthāna, is required, with proper knowledge of

Marma Sthāna we may perform the procedures without any complications. In trauma

condition the knowledge of trauma site, structures involving and deformity

identification is necessary. So in treatment and surgical procedures Marma study is

important.

Scope of Study

This study is aimed to identify the Sirās mentioned in Sirāvyadha Vidhi with

comparison to the blood vessels of the lower extremity as per the modern Anatomy.

Although the references are available in the original Ayurvedic texts, the

direct reference of sites of Sirāvyadha in Lower extremities in relation to its

anatomical significance is not available. Illustrated description regarding basic

Introduction


Ayurvedic concepts w.s.r. to sites of Sirāvyadha and its Marma correlation is not

much available in view of modern Anatomy.

In this study an attempt has been made to compile literature regarding

Sirāvyadha and its Marma relevance from a wide range of Ayurvedic texts. This

study also contains assessment of the superficial veins in 5 cadavers in relation to the

anatomical structures, mainly the veins in the lower extremities and identification of

related structures in the sites of Sirāvyadha.

Objectives


OBJECTIVES

1. To have a comprehensive literary review on Sirā Śārīra and Marma Śārīra.

2. To study the sites of Sirāvyadha of lower limb and their Marma relevance.

3. To compare and locate the anatomical structures and their relation with Sirās

of lower limb mentioned in Sirāvyadha and their Marma relevance.

4. To find out the anatomical structures situated at the sites of Sirāvyadha in the

lower limb with the help of Cadaveric dissection.

Review of Literature


HISTORICAL REVIEW

Historical Review of Sirāvyadha

Atharvaveda has documentary evidence for the knowledge of circulatory

system, which has been established the intense flow of water, colour like

“ArunaRohita, Tāmra, Dhūma” upwards, downwards and peripheral towards “Jala-

Sindhu1”.

The conduits for this colour fluid mentioned in this literature are known

Dhamani and Hira. The blood flowing in Hira differs from the blood of Dhamani1.

The bright red colour of fluid belongs to Dhamani, whereas coppery red toHira1.

The veins and arteries of the human body have been objects of study as long

as there has been interest in anatomy. Their significance, while not always well

understood, has been an important question in the history of anatomy and

physiology. Galen, 2nd Century A.D., described the Aorta as "a trunk divided into

many branches and twigs" that nourished the body. Ancient medical practitioners

were not initially even sure that arteries and veins did different things for the body,

though they quickly understood that they acted differently when cut veins being full

of blood and arteries seemingly empty.

In the Galenic tradition, the venous and arterial systems were entirely

distinct. Except for the small amount of blood that allegedly crossed through the

pores in the central septum from one side of the heart to the other to mix with the

spirits, the content of the two types of vessels was believed to be different , or at least

different in degree though same in kind. The veins contained blood - purely corporeal

fluid of the body - whiles the arteries a mixture of Pneuma and blood, an indication of

their connection to the spiritual as well as the material. They were associated with

different principal organs as well, namely, the liver with the veins and the heart with



the arteries. Their purposes were also distinct: veins conveyed the fluids that

maintained and nourished the body, while arteries disseminated vitality in the form of

spirits throughout the body.

In the middle Ages and early Renaissance, Galenic physiology continued to

present the arterial and venous systems as two distinct circulatory systems in the

human body. "All the arteries [emanate] from the heart, all the veins from the liver,"

declared the medieval anatomist Master Nicolas of Salerno in the late twelfth century.

The practice of bloodletting has been used by almost all cultures and societies

at some point in their medical history.

Bloodletting is one of the oldest medical practices, having been practiced

among ancient peoples including the Mesopotamians, the Egyptians, the Greeks,

the Mayans, and the Aztecs. In Greece, bloodletting was in use around the time

of Hippocrates, who mentions bloodletting but in general relied on dietary

techniques. Erasistratus, however, theorized that many diseases were caused by

plethoras, or overabundances, in the blood and advised that these plethoras be treated,

initially by exercise, sweating, reduce food intake and vomiting. Herophilus

advocated bloodletting. Archagathus, one of the first Greek physicians to practice

in Rome, also believed in the value of bloodletting.

The popularity of bloodletting in Greece was reinforced by the ideas of Galen,

after he discovered that not only veins but also arteries were filled with blood,

not air as was commonly believed at the time. There were two key concepts in his

system of bloodletting. The first was that blood was created and then used up; it did

not circulate, and so it could "stagnate" in the extremities. The second was that

humoral balance was the basis of illness or health, the four humours being blood,

http://en.wikipedia.org/wiki/Erasistratus

http://en.wikipedia.org/wiki/Archagathus



phlegm, black bile, and yellow bile, relating to the four Greek classical elements of

air, water, earth and fire. Galen believed that blood was the dominant humour and the

one in most need of control. In order to balance the humours, a physician would either

remove "excess" blood (plethora) from the patient or give them an emetic to induce

vomiting, or a diuretic to induce urination.

Galen created a complex system of how much blood should be removed based

on the patient's age, constitution, the season, the weather and the place. Symptoms of

plethora were believed to include fever, apoplexy, and headache. The blood to be let

was of a specific nature determined by the disease: either arterial or venous, and

distant or close to the area of the body affected. He linked different blood vessels with

different organs, according to their supposed drainage. For example, the vein in the

right hand would be let for liver problems and the vein in the left hand for problems

with the spleen. The more severe the disease, the more blood would be let. Fevers

required copious amounts of bloodletting.

The Talmud recommended a specific day of the week and days of the month

for bloodletting, and similar rules, though less codified, can be found among

Christian writings advising which saints' days were favourable for

bloodletting. Islamic medical authors too advised bloodletting, particularly for fevers.

The practice was probably passed to them by the Greeks; when Islamic theories

became known in the Latin-speaking countries of Europe, bloodletting became more

widespread. Together with cautery, it was central to Arabic surgery; the key

texts Kitabal-Qanun and especially Al-Tasrif li-man 'ajaza 'an al-ta'lif both

recommended it.

http://en.wikipedia.org/wiki/Cautery

http://en.wikipedia.org/wiki/The_Canon_of_Medicine



In the 2nd millennium, even after the humeral system fell into disuse, the

practice was continued by surgeons and barber-surgeons. Though the bloodletting was

often recommended by physicians, it was carried out by barbers. This division of

labour led to the distinction between physicians and surgeons. The red-and-white-

striped pole of the barbershop, still in use today, is derived from this practice: the red

represents the blood being drawn, the white represents the tourniquet used, and the

pole itself represents the stick squeezed in the patient's hand to dilate the veins.

Bloodletting was used to "treat" a wide range of diseases, becoming a standard

treatment for almost every ailment, and was practiced prophylactically as well as

therapeutically.

The benefits of bloodletting only began to be seriously questioned in the

second half of the 1800s. While many physicians in England at the time had lost faith

in the general value of bloodletting, some still considered it beneficial in some

circumstances, for instance to "clear out" infected or weakened blood or its ability to

"cause haemorrhages to cease"—as evidenced in a call for a "fair trial for blood-

letting as a remedy" in 1871. Bloodletting persisted into the 20th century and was

even recommended by Sir William Osler in the 1923 edition of his textbook “The

Principles and Practice of Medicine”.

A number of different methods were employed. The most common

was phlebotomy, or Venesection (often called "breathing a vein"), in which blood was

drawn from one or more of the larger external veins, such as those in the forearm or

neck. In arteriotomy, an artery was punctured, although generally only in the temples.

In scarification (not to be confused with scarification, a method of body

modification), the "superficial" vessels were attacked, often using a syringe, a spring-

loaded lancet, or a glass cup that contained heated air, producing a vacuum within.

http://en.wikipedia.org/wiki/Prophylaxis



There was also a specific bloodletting tool called a scarificator, used primarily in 19th

century medicine. It has a spring-loaded mechanism with gears that snaps the blades

out through slits in the front cover and back in, in a circular motion. The case is cast

brass, and the mechanism and blades steel. One knife bar gear has slipped teeth,

turning the blades in a different direction than those on the other bars.

William Harvey disproved the basis of the practice in 1628, and the

introduction of scientific medicine, la méthodenumérique, allowed Pierre Charles

Alexandre Louis to demonstrate that phlebotomy was entirely ineffective in the

treatment of pneumonia and various fevers in the 1830s. Nevertheless, in 1840, a

lecturer at the Royal College of Physicians would still state that "blood-letting is a

remedy which, when judiciously employed, it is hardly possible to estimate too

highly", and Louis was dogged by the sanguinary Broussais, who could recommend

leeches fifty at a time.

Bloodletting was used to treat almost every disease. One British medical text

recommended bloodletting for acne, asthma, cancer, cholera, coma, convulsions,

diabetes, epilepsy, gangrene, gout, herpes, indigestion, insanity, jaundice, leprosy,

ophthalmia, plague, pneumonia, scurvy, smallpox, stroke, tetanus, tuberculosis, and

for some one hundred other diseases. Bloodletting was even used to treat most forms

of haemorrhaging such as nosebleed, excessive menstruation, or haemorrhoidal

bleeding. Before surgery or at the onset of childbirth, blood was removed to prevent

inflammation. Before amputation, it was customary to remove a quantity of blood

equal to the amount believed to circulate in the limb that was to be removed.

Leeches became especially popular in the early nineteenth century. In the

1830s, the French imported about forty million leeches a year for medical purposes,

http://en.wikipedia.org/wiki/Fran%C3%A7ois-Joseph-Victor_Broussais



and in the next decade, England imported six million leeches a year from France

alone. Through the early decades of the century, hundreds of millions of leeches were

used by physicians throughout Europe.

Bloodletting was also popular in the young United States of America,

where Benjamin Rush (a signatory of the Declaration of Independence) saw the state

of the arteries as the key to disease, recommending levels of bloodletting that were

high even for the time. George Washington asked to be bled heavily after he

developed a throat infection from weather exposure. Almost 4 pounds (1.7 litres) of

blood was withdrawn prior to his death from a throat infection in 1799.

One reason for the continued popularity of bloodletting (and purging) was

that, while anatomical knowledge, surgical and diagnostic skills increased

tremendously in Europe from the 17th century, the key to curing disease remained

elusive, and the underlying belief was that it was better to give any treatment than

nothing at all. The psychological benefit of bloodletting to the patient (a placebo

effect) may sometimes have outweighed the physiological problems it caused.

Bloodletting slowly lost favour during the 19th century, but a number of other

ineffective or harmful treatments were available as placebos—mesmerism, various

processes involving the new technology of electricity, many potions, tonics, and

elixirs155.

Historical Review of Marma

Marma in Vedic period

The science of Marma is an integral part of all the Vedic sciences that

emerged in India in ancient times. The close observation of Vedic literature reveals



that the first reference to „Marma’ can be traced out in Rig Veda. Warriors were

advised to protect the vital parts of their body before going to the battle field to come

back victorious without any harm to their Marma Sthanas.

At another place in Rig Veda, a word „Marma‟ is found in connection with the

sharp weapon called „Vajra‟, used by Lord „Indra‟ for the purpose of killing the

demon „Virata‟ by attacking the Marma sthanas2.

In „Garbhopanishad’, 107 Marmas are referred along with anatomical

structures of the body3.

In „Yogopanishad’ 18 sensitive or vital parts or Marmas distributed at various

places of the body are described for the practice of Dharana, which is achieved by

concentration and withdrawal of mind from one spot to other spot of the body4.

Marma in Epics

In Valmiki Rāmāyana

„Rāmāyana’ and „Mahābhārata’ are the two great epics of Indian literature. At

several places in Rāmāyana the word „Marma‟ is used in the context of injury and the

subsequent complications reflects the vulnerable point. Some important references are

given below.

The King Daśaratha (the father of Lord Rama) while hunting, used the

Śabdabhedhi arrow capable of hitting the object or a person without even looking at

which pierced the Marmasthāna of Śravanakumāra resulting in death soon after the

removal of arrow from his body5.



„Bharata’, son of Daśaratha while travelling to meet Rāma, was provided

enroute with various comfortable beds and seats by Maharshi Bharadhwāja of

Chitrakut for the protection of vital parts6.

During the fight between the „Bāli’ and „Sugreeva’, Sri Rāma hits at the

Marmasthāna of „Bāli’ and he falls down with agonizing pain and died after arrow

was removed. These references points to ‘Viśalyaghna’ Marma described in

Ayurvedic texts7.

Hanuman, while entering into Lanka, happened to confront with a very

dreadful and peculiar demon „Sinhika’. He carefully observed the Marmas of the body

and killed the demon by piercing his sharp and long nails into the Marma Sthānas8.

In Yuddhakānda of Vālmīkirāmāyana, the Angada (son of Bāli) who was well

versed with Marmavidhya hits on the chest area (in between the two breasts) of the

demon „Mahāpārśva’ with his strong and powerful fist resulting in death of the

demon. On analysing, it appears that the Marma closely related to the heart region9.

At another place in Yuddhakānda, Rāvana hits the Marmasthāna of Lakshmana and

he falls down with agony10.

During the fight, Meghanada (Indrajit) hits the Marmasthāna of Rama and

Lakshmana and captivated them and tied them tightly with Nāga Pāśa11.

In Mahābhārata

In Mahābhārata also the use of word ‘Marma’ can be traced out in

Sauptikaparva and Bhīshmaparva. During the battle between the Kaurava and

Pāndava, the Aśwatthāma (son of Dronācharya) inflicted strong blow with his lion

like heels on the Vitapa Marma of the elephant12.



In another place in Mahābhārata, king Duryodhana cries due to torn and

broken thigh, which pierced the Marma Sthāna13.

In the fight, Gajaraja (Elephant) was pierced by hundreds of arrows in his

Marma Sthanas by Shalya and his trunk was severed and Gajaraja fell on the ground

and subsequently died14.

If a close observation is made on the above narrations, it can clearly be

pointed out that the knowledge of Marma Vijnana was extensively well known since

Vedic period. Later on its progression can be observed in the Samhita period

especially in Śārīrasthāna of Suśrutasamhita.

The Buddhist text “Milindapanha”, a dialogue between King Milinda and the

monk Nāgasena, dating from the 2nd Century BC, explains unarmed self-defence as

one of the nineteen monastic arts.

It is possible that Traditional Chinese medicine adapted aspects of Marma

therapy, which has much common with acupuncture, from Ayurveda.



REVIEW OF SIRĀVYADHA

Etymology of Sirāvyadha

सिनौतौतत इतत सिरा ।

That which binds or a quantity bound together

It is formed from the root „षिञ’ to bind

षिञ (बनधन) + रक सिरा

Any tubular vessel of the body – nerve, vein, artery, tendon;

As they are binding the whole body together by transporting blood to all over

the body

वयधनसमतत वयध: । that which cuts

वयध (ताड) + अऩ वयध:-

To pierce, to transfix, to hit, strike, wound

िरतयाभी रकतसमतत सिरा: । तािाा वयध: सिरावयध: ।

By which the blood is being taken all over the direction is"ÍxÉUÉ". Its piercing is

known as "ÍxÉUÉurÉkÉ:"

IMPORTANCE OF RAKTA DHATU

The main function of the blood is Jeevana. It is a synonym for Ayu or life. The

term Ayu stands for the combination of the body, sense organs mind and soul. There are

other synonyms also for it namely Śarīra, Indriyas, Satva, Ātmā, Samyoga, Dhāri and

Jeevita, etc. Blood keeps Śarīra, Ātmā and Indriyas in equilibrium. Jeevana is



explained as one which causes Dhārana of life. The one thing which regains the Pūtibhāva

in the blood and prevents the body from decay is called Dhāri15.

Blood is stated to be the Mūla or root of the body as it causes the Dhārana

of the Śarīra or body.

Rakta nourishes the Māmsa Dhātu and causes Varna Prasādana of the body.

It nourishes the Sapthadhātus or tissues of the body. It produces strength in the body. It

gives Anubandhana (which transmigrates from one body to another) to life. In animals it

gives Samyojana to life. Through the skin it helps for the sensation of touch. It helps the

Indriyas to grasp their objects properly. Blood also maintains and keeps the

Jatharāgni in equilibrium.

Dhamani and Sirā were differentiated throughout the classical period, though

some of them differs and were not of the opinion that there was no basic difference in

Sirā, Dhamani and Srotas and they were synonym to each other. However, Samhitas

like Suśruta, Charaka and Vāgbhata presented the clear opinion about the

differentiation between Sirā, Dhamani and Srotas16, 17, 18

The fundamental difference between Dhamani v/s Sirā and Srotas is act of

Dhamana or pulsation. Thus, Dhamani is recognized by Dhamana action16.

The school of Suśruta observed that Sirā ought to differ from Dhamani due to

its origin, function, properties and classical observation.

Sirā is the tubular structure, where Sarana is performed and through this Rasa

Dhatvādi fluids flows through Sirā. The “Sarana” in this reference explains the flow

of various fluids through Sirā onwards. Srotas are the structures through which

Sravana occurs16.



Sravana is the permeation of various fluids through the pores present in the

wall of Srotas. This explains the osmosis or permiasis, the veins spread in body like

venules in leaf. Root of Sirās is Nābhi according to Ayurveda, because from Nābhi

they spread upwards, downwards and obliquely. They nourish the body like river and

streams in term of Jala – Harini19.

Origin of Sirā

All the Sirās present in the body originate from the Umbilicus, and from there,

they spread to all directions. Prāna resides in the veins of the Umbilicus and the

Umbilicus is the seat / residence of the veins. The Umbilicus is surrounded by Sirās

similar to the axle hole being surrounded by spokes20.

Number & Distribution of Sirās

Sirās are 700 in number. By these Sirās, the entire body is constantly

nourished, kept lubricated / moistened to perform actions such as flexion, extension,

contraction, dilation etc., similar to a large field being nourished by small channels of

water. Their spreading is like the ribs in a leaf. Nābhi is their Mūla and from there,

these spread upwards, downwards and sidewards19.

Among these 700 Sirās, Mūlasirā are 40 in number. They are:

• Vātavaha - 10 in number

• Pittavaha - 10 in number

• Kaphavaha - 10 in number

• Raktavaha - 10 in number

The 10 Vāta carrying Sirās, on reaching the seat of Vāta, divide themselves

into 175;

The Pitta carrying Sirās divide into the same number in the seat of Pitta;

The Kapha carrying Sirās divide into the same number in the seat of Kapha;



The Rakta carrying Sirās also divide into the same number in Yakrut and Pleeha.

Thus together they form 700 in number21.

Table No. 1 Showing Doshānusara Sirā Sankhya

There are 41 Sirās in parts above the shoulders (Ūrdhvajatru). Out of these, 14

are in the neck, 4 in the ears (2 in each ear), 9 in the tongue, 6 in the nose and 8 in the

eyes (4 in each eye).

Table No. 2 Showing Ūrdhvajatrugata Sirās

1. Karnagata 04

2. Jihwagata 09

3. Netragata 08

4. Nāsāgata 06

5. Greeva 14

Total 41

1. Vātavaha Sirās 41

2. Pittavaha Sirās 41

3. Kaphavaha Sirās 41

4. Raktavaha Sirās 41

Total 164

1. Vātavaha Sirās 175

2. Pittavaha Sirās 175

3. Kaphavaha Sirās 175

4. Raktavaha Sirās 175

Total 700



In the Koshta, there are 34 Sirās. Out of these, 8 are in the Pelvis residing in

the anus and penis (4 each); 2 in each flanks; 6 in the back; 6 in the Abdomen and 10

in the Chest22.

Table No. 3 Showing Koshtagata Sirās

In each extremity, the number of Sirās are one hundred; out of them, the four

viz, one by name „Jāladhara‟ and three situated deep inside, should not be cut (i.e.

Avedhya Sirās)23

Table No. 4 Showing Śākhāgata Sirās

Vātavaha Sirās 25x4 100

Pittavaha Sirās 25x4 100

Kaphavaha Sirās 25x4 100

Raktavaha Sirās 25x4 100

Total 400

Koshtagata Sirās

Guda, Śiśna, Śroni 08

Pārśwa 04

Prushta 6

Udara 6

Vaksha 10

Total 34

Vātavaha Sirās 34

Pittavaha Sirās 34

Kaphavaha Sirās 34

Raktavaha Sirās 34

Total 136



Thus, the 175 Vāta carrying Sirās are described. Similar is the manner of

classification of the remaining Sirās. In case of Pittavaha Sirā, 10 are distributed in

the eyes and two in the ears (1 each); similarly Raktavaha and Kaphavaha Sirās are

distributed22.

Functions of Sirā

Vāta, moving in its own Sirā bestows non-hindrance of all activities, non-

delusion in the functions of the mind and many other activities. When the aggravated

Vāta accumulates in its own Sirā, many diseases due to Vāta develop in the body24, 25.

Pitta moving in its own Sirā attends to functions such as brightness of colour

of the skin, taste perception, keenness of digestive fire, absence of disease

(maintenance of health) etc. when aggravated, Pitta accumulates in its own Sirā and

many diseases of Pitta origin develop in the body26, 27.

Kapha moving in its own Sirā bestows lubrication of the body, stability of the

joints, augmenting strength to the body etc. when aggravated, Kapha accumulates in

its own Sirā and many diseases of Kapha origin develop in the body28, 29.

Rakta, moving in its own Sirā performs functions such as supplying nutrition

to the tissues, bestowing colour and tactile sensation to the skin etc. when aggravated,

Rakta accumulates in its own Sirā and many diseases due to Rakta vitiation develop

in the body.30, 31

Sirās do not carry Vāta, Pitta or Kapha alone. Aggravated Doshas intimately

mix with each other and circulate in the Sirās are sure to over run their normal seats

since they carry all the Doshas. Hence, all Sirās are said to carry all the doshas32, 33.

Vātavaha Sirās are Aruna in colour; Pittavaha Sirās are warm and blue in colour;

Kaphavaha Sirās are cold, white and stable; Raktavaha Sirās are Rohini in colour and

neither very hot nor very cold34.



Vedhya and Avedhya Sirās

Ācharyas described Vedhya Sirās are those which can be interfered within

surgical process. They present no serious complications, when affected. It is also

mentioned that through these veins only the safer bloodletting should be done for

curing various diseases.

Avedhya Sirās are those on which the injury must be avoided during surgery.

In Vedic period, there is no mention about Avedhya or Vedhya Sirās. Although they

have mentioned that in vascular injury the outflow of the blood should be checked35,

36.

In Samhita period, Charaka described two Vedhya Sirās in connection with

the disease Unmāda, Vishamajwara and Apasmāra at two places i.e. Śankha Pradeśa

and Keśānta Pradeśa37.

The school of Suśruta exerts few selected fatal veins. Avedhya Sirās are

surgically important since trauma during surgery proves fatal. This also infers that

school of Suśruta was advanced in vascular surgery. They were aware of these Sirās

which need care during surgery.

The school of Suśruta describes Vedhya Sirās specifically in connection with

the diseases which are cured by Sirāvyadha e.g. In Gridhrasi, the Sirā of Jānu should

be considered as the Vedhya Sirā, which when flexed and tourniqueted proliferates

and this mean they are all superficial veins, which are used for Sirāvyadha to purify

the Dūshita Rakta.

Astanga Sangraha and Astanga Hridaya too have mentioned Vedhya Sirās but

they have given them in connection with the disease. No mention of specific Sirā for a

particular disease has been made. In this regard, they included the Vedhya Sirā in their

respective places of Roga and there the Sirā should be visible.



However the Avedhya Sirās are the vessels which are prohibited for the

Sirāvyadha.

The vascular injuries were reported in Vedic literature but there was no

description of Avedhya Sirā35, 36.

It appears that school of Charaka took task of Vedhya Sirās for the first time,

but he did not mention specifically the Avedhya Sirās.

The school of Suśruta mentions specific and detailed description of

Sirāvyadha as well as Avedhya Sirās for the first time in the history of medicine and

surgery. He mentioned 98 Avedhya Sirās which should be taken care by the physician

or surgeon at the time of Sirāvyadha or any other surgical condition. Any trauma of

these structures may lead to morbidity or death38.

Four hundred veins are present in the Śākhās, one hundred and thirty six are

present in the Koshta and one hundred sixty four are present in the parts above the

shoulders. Among these, sixteen in the extremities, thirty two in the trunk and fifty

above the shoulders are to be considered as Avedhya39, 40.

There are one hundred veins in each of the extremities; out of which one by

name Jāladhara, two which are situated deep inside known as Urvi and one by name

Lohitāksha are not to be punctured. Thus sixteen veins of the Śākhās are Avedhya41.

Vāgbhata also mentioned the number of Avedhya Sirās as Ācharya Suśruta,

but he has slightly modified the knowledge of Avedhya Sirās. His concept is that apart

from these 98 Avedhya Sirās, those Sirās which are oblique, short, tortuous and

narrowly placed in the subject should also be included under this heading42.



INDIVIDUAL AVEDHYA SIRĀS OF EXTREMITIES AND ITS CORRELATION WITH MARMA Urvi

This is an Avedhya Sirā as well as a Sirā Marma situated in the middle of

thigh. Injury to this causes atrophy/wasting of muscles of the thigh from the loss of

blood. It is a Vaikalyakara Marma102.

Vāgbhata, Dalhana, Indu and Arunadutta have followed Suśruta. Dr. B.G.

Ghanekar has considered the probabilities of the hypotrophy of the muscles on injury

to midline of thigh, in this view femoral vessels and saphenous nerve are the

responsible structures. He has also stressed that femoral vessels would produce loss of

blood and injury to saphenous nerve may develop hypotrophy of the lower limb (B.

G. Ghanekar – Su. Śa. Pages 192, 1976).

2) Lohitāksha

This is Avedhya Sirā as well as Sirā Marma according to Suśruta.

This Marma is situated above Urvi Marma and below Vankshana Sandhi (Hip

joint) at the root of the Ūru. On injury this causes paralysis of the muscles or wasting

of the Sakthi (lower limb) due to loss of blood. It is a Vaikalyakara Sirā Marma103.

Vāgbhata, Indu, Dalhana and Arunadutta have followed Suśruta whereas Dr.

B. G. Ghanekar has mentioned femoral triangle in respect to this Marma.

This injury of this region should produce the same condition as narrated in

Urvi (B. G. Ghanekar – Su. Śa. Pages 192, 1976). Lohitāksha Marma involves the

ilio-femoral and brachio-axial segment of the vessels.

Jāladhara, Urvi and Lohitāksha are Avedhya Sirās and Sirā Marma in upper

extremities is under the same name and descriptions41. According to Suśruta there are

400 Sirās in extremities, but only 4 Sirās in each limb are Avedhya. Jāladhara



situated externally is one in each extremity, 3 internal Sirās (2 – Urvi and 1 –

Lohitāksha), thus total 16 Avedhya Sirās in extremities23, 39, 40.

This opinion does not appear to be different in terms of modern surgery. B. G.

Ghanekar suggests Jāladhara for great saphenous and cephalic veins – Urvi,

Lohitāksha for femoral artery and vein, brachial artery and vein and axillary artery

and vein (B. G. Ghanekar – Su. Śa. Page 210, 1976).

Avedhya Sirās denote prohibition of Sirāvyadha, if they undergo trauma due to

surgery or injury, they may produce pathological conditions. Ghanekar‟s concept for

Avedhya Sirās of extremities being major vessels of limbs give the idea of vascular

phenomenon, but he has not discussed them for Avedhya point of view with accurate

reasoning.

Individual Vedhya Sirās of Extremities

The school of Suśruta has mentioned the Vedhya Sirās of extremities in

connection of the disease which are most probably the superficial veins of the limbs.

Suśruta mentioned that the disease of Gridhrasi and Viśvachi, the knee and elbow

should be flexed and the limb should be tourniquet to proliferate the veins. The

Vedhya Sirā for Gridhrasi is four Angulas below or above the Jānu Marma and

Vedhya Sirā for Viśvachi is four fingers below or above the Kūrpara45.

Raktamokshana

The word „Rakta‟ means- coloured, dyed, tinged, painted, crimson, and blood

red.

The word „Mokshana‟ is derived from the root „Moksha’ means „to relieve‟ or

„to let out‟. Therefore letting out of blood is known as Raktamokshana.



The process of Raktamokshana can be traced back to Vedic period only and

not beyond that. In the Kouśika Sutra of Atharvaveda, references of Raktamokshana

by leech application are found. (Atridev, A.D.1960)

During the period of Buddha, this process was in regular practice, which could

be easily understood from Pilindivachha, a patient of Buddha in whom he did

Raktamokshana by Śringa for Parvavata (Atridev, A.D.1960).

Bloodletting is the withdrawal of often considerable quantities of blood from

a patient to cure or prevent illness and disease. It was the most

common medical practice performed by doctors from antiquity up to the late 19th

century, a time span of almost 2,000 years. It is conceivable that historically, in the

absence of other treatments for hypertension, bloodletting could sometimes have had

a beneficial effect in temporarily reducing blood pressure by a reduction in blood

volume.

The importance of bloodletting as medicinal agent, in comparison with other

means of treatment in various respects, is equivocal to other remedies when properly

administered. Different methods are in use for taking away the blood for therapeutic

purposes, by (1) phlebotomy – where blood is drawn from available veins. (2)

Arteriotomy – where artery is punctured (3) Scarification – Scraping of superficial

cells with syringe. Venesection or phlebotomy is much more effective than any other

modes of treatment. Likewise in modern era also Phlebotomy (Venesection) is part of

treatment, Performed in different conditions like –Polycythemia Vera,

hemochromotosis, hepatitis B, hepatitis C and C C F.



Phlebotomy

Phlebo vein, tome to cut

Venesection

Opening of a vein for withdrawal of blood. Although phlebotomy is a

synonym for Venesection in clinical practice, phlebotomy refers to therapeutic

bloodletting, such as removing some blood to lower the viscosity of blood of a patient

with Polycythemia.

Webster‟s defines phlebotomy as phle bot omy / Fli-bat-eh-mee\n: The letting

of blood in the treatment of diseases. i.e. Venesection.155

The term phlebotomy refers to the drawing of blood for laboratory analysis

or blood transfusion

Raktamokshana is of two types –

1) Śastra-Visrāvana

It is the process which is done by the iron instruments. It is of two types43:



i) Prachāna: It should be done in straight line, such lines not joining

together, being even, not very superficial. The instrument should be

used quickly without damaging vital spots and joints44.

ii) Sirāvyadha: It is the procedure of puncturing a vein.

2) Anuśastra-Visrāvana

It is more preferable for delicate persons because they are not made by iron

instruments etc. It consists of four methods –

i) Jalauka

ii) Shrunga

iii) Alābu

iv) Ghati Yantra

Ācharya Vāgbhata has considered the Anuśastra as Jalauka, Kshāra, Dāha

Karma, Kacha, Nakha, Pāshśna etc. and suggested to treat similarly.

Sites of Sirāvyadha in lower extremities45

Table No. 5 Showing Sites of Sirāvyadha according to Suśruta

Disease Site of Sirāvyadha Pādadāha, Pādaharsha, Apabāhu, Chippa, Visarpa, Vātaśonita, Vātakantaka, Pādadāri, Vicharchika

2 Angula above Kshipra Marma with Vrīhimukha Śastra

Vataja Slīpada 4 Angula above the Gulpha Sandhi Pittaja Slīpada 4 Angula below the Gulpha Sandhi Kaphaja Slīpada 4 Angula above the Kshipra Marma Kroshtukasīrsha, Khanja, Pangu, Vātavedana 4 Angula above Gulpha Apachi 4 Angula below Indrabasti Marma Gridhrasi 4 Angula above or below Jānu Sandhi Galaganda Ūru Mūla Sirā is subjected to Sirāvyadha



TABLE No. 6 Showing the Sites of Sirāvyadha according to Vāgbhata46

Disease Site of Sirāvyadha Galaganda, Gala Vidradhi Sirā in the Ūru is subjected to Vyadha Gridhrasi Sirā 4 Angula above or below the Jānu Apachi 2 Angula below Indrabasti Kroshtukaseersha, Sakthivata Ruja 4 Angula above the Gulpha Pādadāha, Vātaśonita, Pādaharsha, Chippa Vipādikā, Pādadāri & Vātakantaka

2 Angula above Kshipra Marma

Indications of Sirāvyadha

Diseases of the skin, tumours, swelling and diseases arising from blood will

never occur in persons indulging in bloodletting (generally in Śarad Ritu) 47.

Bloodletting is the method of treatment indicated in diseases caused due to the

vitiation of Raktadhātu like Visarpa (erysipelas), Vidradhi (abscess), Plīha (Diseases

of Spleen), Gulma, Agnisadana (Dyspepsia), Jwara (Fever), Mukha Roga (Diseases

of mouth), Netra Roga (Diseases of Eye), Śiro Roga (Diseases of Head), Mada

(Intoxication), Trishnā (Thirst), Lavanāsyata (Salty taste in the mouth), Kushta (Skin

diseases), Vātarakta, Raktapitta, Katu and Amlodgāra (Pungent and Sour eructation),

Bhrama (Giddiness) etc.48,49,50

Contraindications of Sirāvyadha51

Sirāvyadha should not be done in the following persons:

Bāla (very young) and Sthavira (very old), as they are weak and the Dhatus

are in an immature state;

Rūksha, Kshatakshīna (wounded and debilitated), as it may cause

“Vataprakopa”;

Bhīru (timid persons), as there will be “Tamobahulata”, and faint by seeing

the blood;



Pariśrānta (tired persons), as Vāta gets vitiated in such persons and affects the

whole body;

Madyapa (alcoholics), as they will go to Mūrcchā again due to the intoxicated

condition;

Adhvastrīkarśita (emaciated as a result of long journey and sexual

intercourse), as it may cause “Vātaprakopa”;

Vāmita and Virikta (those who have undergone Vamana and Virechana

therapies), as it may aggravate Vāta;

Āsthapita and Jāgarita (those who have undergone Āsthapanavasti and who

have not slept at night), as it may further aggravate Vāta;

Anuvāsita (those who have undergone Anuvāsanavasti), as there will be

Mandāgni which leads to “Agnimāndya”;

Klība (impotent), as there will be Śukrakshaya along with Alpasattva which

will definitely lead to Vināśa of such person;

Kriśa and Garbhini (emaciated and pregnant women), as there will be

Dhatukshaya in both cases;

Kāsa and Śwāsa, as the Dhatus are in Apachiyāvastha which may lead to

complications;

Pravruddha Jwarāvastha (chronic fevers), as it leads to complications such as

Pralāpa etc.

Ākshepaka Vata, Pakshāghāta Those who observe Upavāsa (fasting) and

those who are afflicted with Pipāsā and Mūrcchā

Those veins which are prohibited from puncturing (Avedhya Sirās), which are

invisible though indicated for puncturing, which are visible but not controlled (from



moving apart), which are not raised (engorged by pressure from a tourniquet etc.)

though controlled, such veins should not be punctured51.

As bloodletting is very necessary in the above mentioned diseases ideally,

leeches should be applied; however Sirāvyadha is the last choice. Even in those who

are prohibited for it, when they are affected by poisons or are in an emergency,

Sirāvyadha can be done52.

Sirāvyadha should not be done on days which are very cold, very hot, with

heavy breeze and very cloudy and never in the healthy persons (except Śarad Ritu) 53.

Also, those who have swelling all over the body, who are emaciated due to

intake of sour food (for a long time), who are suffering from disease such as anaemia,

haemorrhoids, abdominal enlargement,tiredness, oedema and pregnant women54.

Importance of Marma in the context of Sirāvyadha

While explaining the contraindications of Sirāvyadha, Suśruta in

Śārīrasthāna, describes that the Avedhya Sirās in each of the lower extremities are 4

in number; i.e. Jāladhara – 1, Urvi – 2, Lohitāksha – 1 and these are considered as

Marmāśrita and hence should not be venesected. If venesected, it may cause

disability or death55, 56.

Materials required for Sirāvyadha

For better performance of Sirāvyadha and for the management of the

complications, the following materials should be arranged prior to the procedure:

Cot, Stools, pots of water, pieces of cloth (gauze piece, swabs), drugs like

Tagara, Elā, Śīta, Śivā, Kushta, Pāthā, Vidanga, Bhadradāru, Trikatu, Agāradhuma,

Haridrā, Arkānkura, Chūrna (slaked lime) etc. to promote bleeding; drugs like

Lodhra, Madhuka, Priyangu, Gairika, Rasānjana, Śālmali, Śankha Chūrna, Yava,



Godhūma, Māshā, Chūrna (slaked lime), Vata, Aśwattha, Aśwakarna, Palāśa,

Vibhītaka, Sarja, Arjuna, Dhanwana, Dhātakī, Śālasāra, bark of Arimeda, sprout and

latex of Tinduka, Śrīveshtaka, Mrtkapala (potsherds), Mrināla, powder of Anjana

(Antimony sulphide), ashes of Kshauma, Lākshā or powder of Samudraphena and

also any other substances useful to stop bleeding and its complications57.

Vyadhana Pramāna (Size of Puncture)

In muscular areas, puncturing should be of the size of the Yava (barley grain)

in other areas it should ½ Yava or one Vrīhi (rice) using a Vrīhimukha Śastra.

Veins on the bones should be punctured to the size of ½ of Yava using a

Kutharika Śastra58.

Vyadhana Kāla (suitable time) for Sirāvyadha

Three suitable times of Sirāvyadha are mentioned. During Varsha Ritu (rainy

season), it should be done on days which are not cloudy; during Grishma Ritu

(summer season) at the time which is cool; during Hemanta Ritu (winter season) at

mid-day59.

Sirāvyadha Vidhi (Procedure)

Bloodletting should be done by the physician on the day which is neither very

cold nor very hot, neither before sudation (Swedana) therapy nor after too much of

sudation. It should be adopted after the patient has been satisfied with a drink of

Yavāgū (thin gruel) mixed with ghee or oil60.

The physician after determining the strength of the disease and the patient,

should give him either Māmsarasa or Yavāgū (thin gruel) mixed with ghee or oil as a

drink; Then the patient should be duly oleated (Snehana) and fomented (Swedana).

Afterwards he should be made to sit on a stool of the height of the knee, placing his

elbows on his knees, placing the feet together comfortably on the floor. At the level of



the lower border of the hairs of the head, a tight bandage should be tied making use of

a moist cloth, leather or inner bark of a tree. The patient should then be asked to keep

the thumbs inside his fists, cover them with cloth and clench them as hard as he can,

accompanied with biting the teeth one over the other as hard as possible, inflating his

mouth. This will be the method to control and raise the veins which are facing

upwards and which are forbidden.

Then the physician should raise the vein by tapping on it with his middle

finger triggered by the thumb. On finding the vein has risen up, is pulsating and full

for touch, he should hold the Kutharika Śastra with his left hand keeping its handle

up, place it on the vein in its centre, and tap it with middle finger or press it with the

middle of the thumb. At places where the vein is hidden or the skin is thick, the

cutting of the vein should be done by carefully pressing with the thumb61.

Samyak Vidha Lakshanas (Proper Puncture)

When proper instrumentation (puncturing) has been done, blood flows out in a

stream for a period of one Muhūrta and then stops on its own accord; this should be

understood as proper puncturing.

Just as yellow liquid flows out first from flowers of Kusumbha (when crushed)

similarly vitiated blood flows out first when veins are punctured62.

When the blood stop by itself after adequate flow, then it should be considered

as pure (un vitiated and as properly drained).

Asrāva Dosha (Effects of Absence or Inadequate flow)

If the vitiated blood is not let out (in sufficient quantity) it gives rise to Śopha

(Swelling), Dāha (Burning sensation), Raga (redness), Pāka (ulceration) and Vedanā

(Pain) 63.

Atisrāva Dosha (Effects of Excess Flow)



Sirāvyadha if done during the time of summer (excess heat), if Swedana has

been done in excess, if the puncturing is very much and if done by an unskilled or

inexperienced physician , then the blood flows out in great quantity. Such excess flow

of blood produces Śirobhitāpa (Headache), Āndhya (Blindness), Adhimantha, Timira,

Dhātu kshaya, Ākshepaka, Dāha, Pakshāghāta, Ekāngavāta, Hikkā (Hiccough),

Śwāsa, Kāsa, Pāndu and death64.

Srāva Pramāna (Quantity of Flow)

In persons who are strong and have great accumulation of Doshas and who

have suitable age (middle age), maximum one Prastha (768 ml) of blood should be

allowed to flow out after Sirāvyadha65.

Dushta Vyadhana (Improper Puncturing)

Dushta Vyadhana (Improper puncturing) is of twenty as follows:

1. Durviddha is that which puncture made by a minute sharp instrument, blood

flow being invisible and having pain and swelling.

2. Atividdha is that puncture which is more than the required measurement,

blood flow either goes inside the body of flows out in large quantity.

3. Kunchita is also similar to the above.

4. Picchita is that puncture which is made with a blunt instrument, the vein

attaining thickness

5. Kuttita is that in which puncturing is done often, not getting blood and vein is

hurt by the instrument.

6. Aprasrta is that in which blood flow does not occur due to cold, fear or

fainting.

7. Atyudīrna is that puncture made by a sharp and thick instrument.



8. Anteviddha is that puncture which causes scanty flow of blood.

9. Pariśushka is that in which there is depletion of blood in the vein but it is

filled with air.

10. Kūnita is that in which quarter portion of the vein is punctured and little

quantity of blood only flows out.

11. Vepitā is that in which binding is made at improper place, puncturing done

with trembling hand, giving rise to tremors of the body and loss of

consciousness.

12. Anuthitaviddha is that in which the symptoms of Vepitā occur.

13. Śastrahata is that in which the vein is cut, producing copious flow and

stoppage of functions of the body part.

14. Tiryakviddha is that in which the instrument is pushed into the vein through

its side and slightly.

15. Aviddha is that in which the instrument is used without making a wound (not

puncturing at all).

16. Avyadhya is that in which the puncture is not done by the instrument.

17. Vidruta is that in which the puncturing is done when the physician is

unsteady.

18. Dhenuka is that in which the body part is hit greatly many times to raise the

vein and flow of blood occurs again and again.

19. Punahpunar Vidha is that in which the vein is punctured many times because

of using a small (minute) sharp instrument.

20. Puncture done on ligaments, Bones, Veins, Joints and fatal spots (Marma)

gives rise to pain, swelling, deformity or death66, 67.

Raktasrāva Nirodha Karma (Methods of Preventing Bleeding)



There are four methods of preventing bleeding from the vein –

1. Sandhāna – Joining the edges of the wound;

2. Skandana – Promoting clotting;

3. Pāchana – Closing the wound;

4. Dahana – Burning or Cauterization

Drugs which are astringent will join or unite the wound; Drugs which are cold

makes the blood to clot, Ash or Alkali drugs will adhere and closes the wound and

Cauterization will constrict the veins68.



REVIEW OF MARMA

Etymology

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Etymologically the word ‘Marma’ is derived from a Sanskrit root word ‘Mri’

indicative of Jeevasthāna, Sandhisthāna respectively.

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In Halayudha Kośa, the description represents the same of Jeevasthāna in

collective form of Sirā, Snāyu, Sandhi, Māmsa and Asthi.

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Śabdakalpadruma also holds the description regarding Marma.

In Śabdamanidarpana, the meaning of Marma coincides with the description

of above references.

That which kill the individual are the Marmas69

The point of the body which leads to death when injured70

The word Marma denotes a point of vital importance in the body, a mortal, a

vulnerable point or a sensitive point where vital force or life is situated. Further, it is a

conglomeration of various structures like Māmsa, Sirā, Snāyu, Asthi and Sandhi and

its Visesha Svabhāva is, it is the seat of Prāna.

Brihatrayees and Laghutrayees are the main treatises of Ayurveda and

references of Marma are found in these treatises.

As Per Charaka

Ācharya Charaka in his treatise Charaka Samhita, 29th Chapter of Sutra

Sthāna has mentioned the ten Prānāyatanas and the three Marma Sthānas i.e. Śiras ,

Hridaya and Vasti are included in the Prānāyatanas or the seats of Prāna71.



Again in the 7th Chapter of Śārīrasthāna, six Marmasthānas are mentioned in

close relation with Prānāyatanas. In addition to the three Marmas, Charaka in

Sūtrasthāna described the other important sites such as Kantha, Nābhi, and Guda as

the Marmasthāna of the body72.

Out of ten Prānāyatanas, six are labelled as the seat of life. But on observing

the remaining four Prānāyatanas i.e. Ojus, Śonita, Śukra and Jihwa also possesses the

presence of Prāna in them. Charaka also referred number of Marmas as 107 in the

body. But no detailed description on these 107 Marmas is found in Charaka Samhita.

In Chikitsasthāna, the emphasis is given on three Marma (Śiras, Hridaya and

Vasti) as the special seats of Prāna in the body out of 10773.

Ācharya Punarvasu emphasized the clinical significance of these three

Marmasthānas while treating the patient74.

Further in Chikitsa Sthāna, while explaining the Śirorogas and diseases

occurring in the nasal passage, the Vāyu is the main causative factor in the

etiopathogenesis of the disease. The Vāyu situated in the head influences the Marma

of nasal passage and produces the Kshavathu like symptoms75.

In 9th Chapter of Siddhi Sthāna, it is stated that the 107 Marmas are distributed

all over the body in trunk and extremities respectively. Any Abhighāta to any one of

these Marmas results in pain or death as the Prāna or Chetana is situated close to

these Marmas. The Marmas of the trunk region carry more importance than that of

extremities because the Śiras, Hridaya and Vasti are located in this area76.

The overall importance is given for three Marmas and it clearly indicates that

the destruction of any of these Marmas is bound to lead to the end of life process

immediately. Hence one must be very careful to protect the Marmas from both

intrinsic and extrinsic factors77.



As per Suśruta

The Suśruta Samhita, an exclusive treatise on Surgery has devoted a separate

chapter in Śārīrasthāna for Marma Śarīra. Here the types, location, the structure and

patho- physiological changes of Marmas are explained in detail. Suśruta has stated

significantly that any injury to these Marmas cause death or physical disabilities.

Hence the knowledge of Marma is essential78.

Surgeons while performing any Śastra Karma (Surgical procedure) are

advised to keep in their mind the location of these Marmas and the structures situated

in their vicinity to avoid injury to these vital parts79.

The definition of Marma suggests that it is the conglomeration of various

structures like Māmsa, Sirā, Snāyu, Asthi and Sandhi where the Prāna resides.

Therefore, injury to any of these invariably causes death or disability or pain80.

As per Vāgbhata

Like other scholars, Vriddha Vāgbhata has also mentioned 107 Marmas

distributed all over the body. According to him, there are 11 Marmas in each

extremity, 26 in trunk region and 37 in the region above the Head & Neck81.

He was also particular in mentioning the consequences result after mild or

severe injuries to the Marmas. According to him, even small injury to the Marma is

also troublesome and painful.

Diseases occurring in the Marmasthānas always produce painful effects and

are managed with a great effort; hence one should be careful to protect the Marmas82.

Vāgbhata also advised to take care of dietetics and regimens of life which are

useful for the promotion of life process, so as to protect and maintain the life process

even when the Marmas are pierced or injured83.



The inclusion of Rakta in ten Prānāyatanas indicates the significance of blood

in the body, when there is piercing injuries to the Marmas resulting in excessive and

profuse bleeding84.

The types, number, location and distribution of Marmas over the extremities,

trunk, head & neck are similar in both Astanga Hridaya and Astanga Sangraha85.

In another context, while explaining the nutritional supply to whole body,

Vāgbhata has described four types of Sirās i.e. Vāta, Pitta, Kapha and Rakta carrying

channels and are situated in Marmasthānas. Any injury to these may cause death due

to excessive loss of blood or aggravation of Pitta causing increased thirst, emaciation,

toxicity, confusion, perspiration, weakness and looseness of the body86.

Vriddha Vāgbhata also holds similar views about the consequences resulting

from injuries to these Marmasthānas and their protection. One should be careful in

protecting Marmas from Kshāra, Visha and Agni with great efforts. Severe injury to

the body away from Marmasthāna may allow the person to survive but an injury at

the site of Marma may produce severe pain87.

Other texts

Kāśyapa Samhita has also mentioned the Dasaprānāyatanas. They are

Mūrdha, Hridaya, Vasti, Kantha, Ojus, Śukra, Śonita, the two Śankhapradesa and

Guda in which Prāna is situated. Among these ten Prānāyatanas, the Mūrdha and

Vasti have been given great importance and named as Mahamarma of the body88.

Sārangadhara also describes 107 Marmas. He accepts that Marma is the place

where the life principles are seated89.

Bhāvamiśra also recognized the Marma as the conglomeration of Sirā, Snāyu,

Sandhi, Māmsa and Asthi, where the life principle is seated. The total number, types

and consequences of Marmas are identical with that of Suśruta90.



Ayurveda considers Marmas as 50 percent of the Śalyatantra, because when

Marma is injured, the individual either dies or gets severe pain and deformity.

Therefore, Suśruta advises the surgeons at every step of operation, to be

cautious about these Marmas while giving an incision, Raktamokshana, Agnikarma

etc.

Hence recognizing and considering the significance of Marma, a surgeon

should not injure even the surroundings of Marmas also. So incisions or cauterization

or Venesection must be done far away from the Marmas.

Components of Marma:

Marma include Soma, Maruta, Tejah, Rajah, Satva, Tamah etc. in which the

Prāna resides. Its Abhighāta leads to death or deformity91.

Classification of Marmas:

The classification of Marma is mainly based on structural predominance of a

particular Dhātu in a Marma point and the symptoms produced due to trauma.

According to Suśruta, Marma is a conglomeration of anatomical structures

namely Māmsa (muscle), Sirā (blood vessels), Snāyu (ligaments and nerves), Asthi

(bone) and Sandhi (joints).

Suśruta has classified Marmas on various anatomical basis which are as follows92:-

1) Prognostic basis: On prognosis of the patient as a result of Abhighāta and its

ultimate result in relation to Kāla

2) Location basis: the location of Marma identified on Shadangaśārīra

3) Morphological basis: i.e. Māmsa, Snāyu, Sandhi, Asthi, Dhamani and Sirā.



Classification Acc. to Shadanga Sharira 93, 94, 95

1) Shakhagata - 11 (11x4) = 44

2) Madhya Shareera - 14 + 12 = 26

3) Jatru Urdhwgata Marma - = 37

. -

Total = 107

Classification Acc. to Effect on Marma

Sadhya Prānahara Marma96, 97

Table No. 7 : Showing Sadhya Prānahara Marma

Sr. No. Name No. Sr. No. Name No.

1)

3)

5)

7)

Śrungātaka 04

Śankha 02

Guda 01

Basti 01

2)

4)

6)

8)

Adhipati 01

Kantha Sirā (Matruka) 08

Hridaya 01

Nābhi 01

Kālāntara Prānahara Marma98, 99

Table No. 8: Showing Kālāntara Prānahara Marma


1)

3)

5)

7)

9)

11)

Stanamūla 02

Apālāpa 02

Sīmanta 05

Kshipra 04

Katikataruna 02

Bruhati 02

2)

4)

6)

8)

10)

12)

Stana Rohita 02

Apstambha 02

Talahridaya 04

Indrabasti 04

Pārśwa Sandhi 02

Nitamba 02



Viśalyaghna Marma 100, 101

Table No. 9: Showing Viśalyaghna Marma


1) Utkshepa 02 2) Stapani 01

Vaikalyakara Marma 102, 103

Table N0.10: Showing Vaikalyakara Marma


1)

3)

5)

7)

9)

11)

13)

15)

17)

Lohitāksha 04

Jānu 02

Kūrcha 04

Kūrpara 02

Kakshadharā 02

Krukatikā 02

Amsa-Phalaka 02

Nīla 02

Phana 02

2)

4)

6)

8)

10)

12)

14)

16)

18)

Āni 04

Urvi 02

Vitapa 02

Kukundara 02

Vidhura 02

Amsa 02

Apānga 02

Manya 02

Āvarta 02

Rujakara Marma104, 105

Table No.11: Showing the Rujakara Marma


1)

3)

Gulpha 02

Kūrcha Śira 04

2) Manibandha 02



Table No. 12: Showing the Classification of Marmas acc. to Suśruta & Vāgbhata

Sr. No. Classification Suśruta Vāgbhata

1. Rachanānusara

(Structural

Classification)

1. Māmsa 11

2. Sirā 41

3. Snāyu 27

4. Asthi 08

5. Sandhi 20

1. Māmsa 10

2. Sirā 37

3. Snāyu 23

4. Asthi 08

5. Sandhi 20

6. Dhamani 09

2. Shadangānusāra

(Regional

Classification)

1. Upper Extremity 22

2. Lower Extremity 22

3. Abdomen & Thorax 12

4. Back of the Trunk 14

5. Heat & Neck 37

1.Upper Extremity 22

2. Lower Extremity 22

3. Abdomen & Thorax 12

4. Back of the Trunk 14

5. Head & Neck 37

3. Parināmānusāra (Prognostic Classification)

1. Sadhya Prānahara 19 2. Kālāntara Prānahara 33 3. Viśalyaghna 03 4. Vaikalyakara 44 5. Rujakara 08

1. Sadhya Prānahara 19

2.Kālantara Prānahara 33

3. Viśalyaghna 03

4.Vaikalyakara 44

5. Rujakara 08

4. Pramāna Bheda

(Metrical Classification )

1.Pānitala 29

2. Three Anguli 04

3. Two Anguli 06

4. One Anguli 12

5. Half Anguli 56

1.Pānitala 29

2. Three Anguli 04

3. Two Anguli 06

4. One Anguli 12

5. Half Anguli 56



General Symptoms of Marmābhighāta

‘Marmāghata’ leads to ‘Dehaprasupti’, ‘Gurutā’, Sammoha, Śitakāmita, Sweda,

Mūrcchā, Vamihi, Śwāsa.106

Effect on Marmas

If Sadhya Prānahara Marma gets injured it may lead to Kālāntara Prānahara

or death. If Kālāntara Prānahara Marma gets injured it may lead to Vaikalyakara. If

Viśalyaghna gets injured it may lead to Vaikalyakara. If Vaikalyakara gets injured it

will leads to distress and pain after a certain period while Rujakara Marma injury

leads to mild pain.107

Types of Marmāghata

An effect of stroke on Marma due to incision, stabbing, burning, and external

stroke will produce same as symptoms of Marmāghāta.108

Importance of Marma

Experts say that surgical operations are performed after considering the

measurement of the Marma’s so as to avoid them. As injured even on margin Marma

leads to death, the site of vital spots should be avoided altogether.109

Importance of Marma Pramāna

An incision should be made at the spot a finger’s width remote from the Urvi,

Kūrcha Śira, Vitapa, Kaksha, and a Pārśwa Marma, whereas, a clear space of two

fingers should be avoided from its situation in making any incision about Stanamūla,

Manibandha or Gulpha Marma. Similarly a space of four fingers should be avoided in

respect of the four Śrungātaka, five Sīmanta and ten Marmas in neck Nīla etc; a space



of half a finger being the rule in respect of the remaining (fifty six). Men, versed in

the science of surgery, have laid down the rule that, in a case of surgical operation, the

situation and dimension of each local Marma should be first take into account and the

incision should be made in a way as an incision, even extending or effecting in the

least, the edge or the side of the Marma, may prove fatal. Hence, all the Marma

Sthānas should be carefully avoided in surgical operation. 110, 111

Importance of Marma in Chikitsa

In human beings; Vata, Pitta and Kapha are situated in Basti, Hridaya and

Śiras respectively. Due to their vital locations, they should be eliminated by the

nearest routes.112

Śiras, Hridaya and Basti are most important ‘Marmas’ out of all hundred

seven, as they are major sites for, Kapha, Pitta and Vāta respectively.113

Importance of Marma in Śalyatantra

Knowledge of Marma is very important to do Śastra Karma. Ācharya Suśruta

explains that the surgeon should apply the Śastra following the direction of hairs

avoiding Marmas, Sirā, Snāyu, Asthi, Sandhi and Dhamani till pus is seen.114

Ācharya Suśruta also explains that Kshāra should not be applied to Marma

Sthānas, Sirās, Snāyu, Sandhis, Taruna Asthi, Sevani, Dhamani, Throat, Nābhi, Nail

bed, Penis, Srotas and thin muscle parts and eyes.115

Marmas are said to cover half the Jurisdiction of surgery because persons die

immediately if they are injured even if some of them survive due to surgeon’s

efficiency they definitely become victim of disability.116



Importance of Sirā in Marma

This is further corroborated by the fact that the four classes of Sirā or vessels

(which respectively carry the Vāta, Pitta, Kapha and the Rakta) are found to enter into

the Marmas for the purpose of maintaining the moisture of the local Snāyu, Asthi,

Māmsa and Sandhi and thus sustain the organism. The Vāyu aggravated by an injury

to a Marma, blocks up (those four classes of vessels) in their entire course throughout

the organism and gives rise to great pain which extends all over the body. 117

Marmas of Lower Limb118

1. Kshipra119

Location: in between the big toe and the first toe.

Number: 2 Marma points, one on each foot

Type: Snāyu

Size: ½ Anguli

Anatomical Structures: Adductor hallucis and lumbricals, posterior tibial nerve,

dorsal metatarsal artery, plantar arch and medial plantar artery, metatarsophalangeal

joint.

Qualities related to Injury: Kālāntaraprānahara type of Marma

Symptoms if injured: Injury may impair the functions of adduction and flexion of

the great toe. Damage to the artery may cause bleeding, hematoma inside the plantar

aponeurosis and toxaemia.



Fig: 1 Image of Kshipra Marma

2. Talahridaya120

Location: Centre of the sole in line with the middle toe, plantar aspect of the third

tarso-metatarsal joint, where the external plantar artery sweeps across the plantar arch

of the foot.


Type: Māmsa

Anatomical structures: Flexor digitorum brevis and longus muscles, Adductor

hallucis, flexor digitorum accessorius muscles, plantar arch and tributaries of

saphenous vein.

Qualities related to injury: Kālāntaraprānahara type of Marma

Symptoms if injured: Injury may cause impairment of the function of flexion and

extension of phalanges and adduction of the great toe. Severe bleeding may occur due

to injury to the plantar arch.



Fig: 2 Image of Tala-Hridaya Marma

3. Kūrcha121

Location: The main point is two Anguli proximal and half Anguli medial to the centre

of the sole of the foot (web between the first and second metatarsal phalangeal joint),

but the entire Marma covers a large area. Its large size of four Anguli can only be

explained if it includes the points at the root of the other toes.


Type: Snāyu

Size: 4 Anguli

Anatomical structures: Tendon of flexor hallucis longus and abductor hallucis

muscle, medial plantar nerve, medial plantar, dorsal metatarsal and arcuate arteries.

Qualities related to Injury: Vaikalyakara type of Marma

Symptoms if injured: Injury may cause damage to the bones and ligaments resulting

disco ordination of the muscles of the foot. The shape of the foot may get distorted.



Fig: 3 Image of Kūrcha Marma

4. Kūrchaśira122

Location: just below the ankle joint.

Number: 2 Marma points one on each leg

Type: Snāyu

Size: 1 Anguli

Anatomical structures: Peroneous brevis and longus muscles, peroneal artery and

tributaries of short saphenous vein, peroneal nerve.

Qualities related to Injury: Rujakara type of Marma

Symptoms if injured: Damage to the ligaments and bone may cause severe pain

along with the impairment of the functions of the foot.



Fig: 4 Image of Kūrcha- Shira Marma

5. Gulpha123

Location: The ankle joint, particularly the sensitive point on the inside and below the

protuberance of the bone.

Number: 2 Marma points one on each ankle

Type: Sandhi

Size: 2 Anguli

Anatomical structures: Flexor hallucis longus and brevis, tibilias posterior and

flexor digitorum longus muscles, posterior tibial artery and vein.

Qualities related to Injury: Rujakara type of Marma

Symptoms if injured: Injury to the joint will cause pain, rigidity and impair the

functions of flexion and extension.



Fig: 5 Image of Gulpha Marma

6. Indrabasti124

Location: The point at the middle of the line, joining the posterior surface of the

calcaneum with the centre of the popliteal fossa


Type: Mamsa

Size: ½ Anguli

Anatomical structures: Gastrocnemius, soleus and plantaris muscles, peroneal

(branch of posterior tibial) and posterior tibial artery and vein, posterior tibial nerve.

Qualities related to Injury: Kālāntaraprānahara type of Marma

Symptoms if injured: At this vital point, the posterior tibial artery is more important

than any other muscle or ligament. Injury may impair the functions of the foot. If the

artery is damaged, there will be severe bleeding, shock and collapse.



Fig: 6 Image of Indra Basti Marma

7. Jānu125

Location: The Knee Joint as a whole. Various sensitive points around the knee can be

located.

Number: 2 Marma points, one on each leg

Type: Sandhi

Size: 3 Anguli

Anatomical structures: Knee joint; articular capsule, posterior cruciate ligament,

oblique posterior ligament; quadriceps femoris, Sartorius, and biceps femoris

muscles; popliteal artery and vein; femur, tibia and patella bones; medial popliteal

nerve.


Symptoms if injured: can cause severe pain, oedema, difficulty in walking and

impairment of the functions of the Knee joint.



Fig: 7 Image of Janu Marma

8. Āni126

Location: Three Anguli above the knee joint.


Type: Snāyu

Size: ½ Anguli

Anatomical structures: Medial and lateral ligaments of the Knee joint; Quadriceps

tendon, adductor Magnus, Gastrocnemius, and biceps femoris muscles; femoral

artery; tributaries of femoral vein and saphenous vein.


Symptoms if injured: Injury will cause severe pain and loss of functions of the knee.



Fig: 8 Image of Ani Marma

9. Urvi127

Location: Centre of the thigh

Number: 2 Marma points one on each thigh

Type: Sirā

Size: 1 Anguli

Anatomical structures: Femoral artery and vein; Drainage to the superficial inguinal

glands; Saphenous nerve; Sartorius, rectus femoris, adductor longus, pectineus, vastus

lateralis, gracilis, and biceps femoris muscles.


Symptoms if injured: Injury to the important structures passing through this vital

point – artery, nerve and vein – can cause wasting, dysfunction of the muscles and

bleeding.



Fig: 9 Image of Urvi Marma

10. Lohitāksha128

Location: 2 Anguli lateral to the symphysis pubis where the femoral artery passes; in

the femoral triangle.


Type: Sirā

Size: ½ Anguli

Anatomical structures: Femoral artery and tributaries of femoral vein; femoral

nerve; Drainage to the superficial inguinal glands; Psoas major and pectineal muscles.


Symptoms if injured: Injury can cause death from loss of blood and paralysis of the

lower limb.



Fig: 10 Image of Lohithaksha Marma

11. Vitapa129

Location: In between the groin and scrotum.

Number: 2 Marma points

Type: Snāyu

Size: 1 Anguli

Anatomical structures: In men – Spermatic cord, prostate gland deep inside the

pelvis.

In women – round ligament of uterus


Symptoms if injured: Impotence and sperm deficiency in men; Infertility in women.



Fig: 11 Image of Vitapa Marma

Table No. 13 Showing the Marmas of the Lower Extremities

Name Location Number Type Size (in Anguli)

Anatomical Structures

Type as per prognosis

Symptoms of injury

Kshipra Between the big toe and the first toe.

2 Snāyu 1/2 Adductor hallucis, posterior tibial nerve, dorsal metatarsal artery, plantar arch and medial plantar artery, metatarsophalangeal joint.

Kālāntaraprānahara

Ākshepaka and Marana

Talahridaya Centre of the sole in line with the middle toe.

2 Mamsa 1/2 Flexor digitorum brevis and longus muscles, Adductor hallucis, flexor digitorum accessorius muscles, plantar arch and tributaries of saphenous vein. .


Death from pain.



Kūrcha Two Angulas above Kshipra Marma.

2 Snāyu 4 Tendon of flexor hallucis longus and abductor hallucis muscle, medial plantar nerve, medial plantar, dorsal metatarsal and arcuate arteries.

Vaikalyakara

Bhramana and Vepana of the foot.

Kūrchaśira Just below the ankle joint.

2 Snāyu 1 Peroneous brevis and longus muscles, Peroneal artery and tributaries of short saphenous vein, Peroneal nerve.

Rujakara

Ruja and Shopha

Gulpha The ankle joint, particularly the sensitive point on the inside and below the protuberance of the bone.

2 Sandhi 2 Flexor hallucis longus and brevis, tibilias posterior and flexor digitorum longus muscles, posterior tibial artery and vein.

Rujakara Ruja, Sthabda padatha and Khanjatha

Indrabasti The point at the middle of the line, joining the posterior surface of the calcaneum with the centre of the popliteal fossa

2 Mamsa 1/2 Gastrocnemius, soleus and plantaris muscles, Peroneal (branch of posterior tibial) and posterior tibial artery and vein; Drainage of lymph vessels to the popliteal lymph glands, Posterior tibial nerve.


Rakta kshaya and Marana

Jānu The Knee Joint as a whole. Various sensitive points around the knee can be located.

2

Sandhi 3 Knee joint; articular capsule, posterior cruciate ligament, oblique posterior ligament; quadriceps femoris, Sartorius, and biceps femoris muscles; popliteal artery and vein; femur, tibia and patella bones; medial popliteal nerve.

Vaikalyakara

Khanjatha



Āni Three Anguli above the knee joint

2

Snāyu 1/2 Medial and lateral ligaments of the Knee joint; quadriceps tendon, adductor Magnus, Gastrocnemius, and biceps femoris muscles; femoral artery; tributaries of femoral vein and saphenous nerve.

Vaikalyakara

Sophia and Shaba Sakthitha

Urvi Centre of the thigh.

2

Sira 1 Femoral artery and vein; drainage to the superficial inguinal glands; saphenous nerve; Sartorius, rectus femoris, adductor longus, pectineus, vastus lateralis, gracilis, and biceps femoris muscles.

Vaikalyakara

Rakta kshaya and Sakthi Shosha.

Lohitāksha 2 Anguli lateral to the symphysis pubis where the femoral artery passes; in the femoral triangle.

2 Sira 1/2 Femoral artery and tributaries of femoral vein; femoral nerve; drainage to the superficial inguinal glands; Psoas major and pectineal muscles.

Vaikalyakara

Lohithaksha , Pakshāghāta and Marana

Vitapa In between the groin and scrotum.

2 Snāyu 1 In men – Spermatic cord, prostate gland deep inside the pelvis. In women – round ligament of uterus.

Vaikalyakara

Shandya and Alpashukratha



VENOUS SYSTEM

Vein is a blood vessel carrying deoxygenated (dark red) blood to the heart,

except for the pulmonary veins, which carry oxygenated blood132.

The first systematic description of the venous system was given by André

Vesale (alias Vesalius) in De humanis corporis fabrica (1543). Vesalius‟ venous

anatomy was almost complete containing some omissions, like venous valves and

perforating veins. In addition, Vesalius furnished a good description of the structure

of the venous wall. He differentiated the internal coat of the veins in two layers. The

internal one contained contractile fibers, though “dissimilar from those of skeletal

muscles, arranged, from within outwards, circularly, obliquely and longitudinally.”

The outer coat was formed by a loose network borrowed from surrounding

structures133.

Veins are characterized by relatively thin wall and large capacitance compared

to arteries. The structural plan of the wall is similar to that of other vessels, where the

amount of muscle is considerably less than in arteries. In most veins, especially in the

limbs, muscle is arranged circularly. Longitudinal muscle is present in iliac, portal,

renal veins and in superior and inferior vena cava. On the contrary, muscular tissue is

absent in placental veins, retinal veins; but these veins are consisting of endothelium

supported by variable amount of connective tissue. Pressure within the venous system

doesn‟t exceed 5 mm of Hg. As the vein grows larger it decreases upto zero. Because

they contain small amount of muscle and usually vein have limited influence on blood

flow.

Due to any cause when there is sudden fall in blood pressure, there is reflex

constriction in vein to compensate the blood loss and tend to maintain the venous

return to the heart. Most veins have valves to prevent reflux of blood flow. When



blood flow reverses, if the semilunar valves cusps, not close properly, then blood fills

in expanded valve of the vein giving rise to knotted appearance to the distended vein.

Leg venous return is against gravity. Valves are of great importance. Blood is moved

towards the heart by intermittent pressure produced by contractions of the

surrounding muscles which are absent in thorax and abdominal veins134.

After flowing through the capillaries, blood collects in the distal end of the

thoroughfare channel and flows into a venule. In the venous circulation, blood flows

from smaller vessels into progressively larger ones; hence, instead of giving off

branches as arteries do, veins receive smaller tributaries, just as a river receives

water from the many streams that form its tributaries.

Venules range from about 15 to 100 m in diameter. The proximal part of a

venule has only a few fibroblasts around it and is quite porous; therefore venules, like

capillaries, exchange fluid with the surrounding tissues. Farther along, a venule

acquires a tunica media of smooth muscle. Even the largest veins, however, have

relatively sparse muscular and elastic tissue compared to arteries.

Venous sinuses are veins with especially thin walls, large lumens, and no

smooth muscle. Examples include the coronary sinus of the heart and the dural

sinuses of the brain. Because they are farther away from the heart, veins have much

lower blood pressure than arteries. In large arteries, it averages 90 to 100 mmHg and

surges to 120 mmHg during systole, whereas in veins it averages about10 mmHg and

fluctuates very little with the heart beat. This has significant implications for the form

and function of veins.

Since they need not withstand high pressure, veins have thinner walls than

arteries, with less muscular and elastic tissue. They collapse when empty and look

relatively flattened or irregular in histological sections



Since their walls are so thin, veins expand more easily and accommodate more

blood than arteries do. About 54 percent of the blood is found in the systemic veins at

rest (fig. 20.7); veins are therefore called capacitance vessels.

The pressure in the veins is not high enough to push blood upward against the

pull of gravity to the heart. The upward flow of blood depends on the massaging

action of skeletal muscles and the presence of one-way venous valves that keep the

blood from dropping down again when the muscles relax. These valves, similar to the

semilunar valves of the heart, occur especially in medium veins of the arms and legs;

they are absent in very small and very large veins, veins of the ventral body cavity,

and veins of the brain. Varicose veins result in part from the failure of these valves135.

Composition of vein

Veins are composed of essentially three coats as that of arteries. But there are

variations in their relative thickness. If arteries are to be distinguished from veins

following reasons may be given

The wall of a vein is very thin than the artery.

The tunica media contains much collagen than arteries. The amounts of elastic

tissue are much less.

In arteries tunica media, is usually thicker than the adventitia. In contrast the

adventitia of veins is thicker than the media. In some large veins the adventitia

contains a considerable amount of elastic and muscle fibres which run in a

predominantly longitudinal direction. These fibres facilitate elongation and

shortening of the vena cava with respiration.

A clear distinction between the tunica intima, media and adventitia cannot be

made out in small veins as all these layers consist predominantly of fibrous

tissue. Muscle is conspicuous by its complete absence in venous spaces of



erectile tissue, in veins of cancellous bone, dural venous sinuses, retinal veins

and placental veins136.

Microscopic Structure of Vein

The walls of the veins have three layers called tunics:

1. The tunica externa (tunica adventitia1) is the outer most layer. It consists of

loose connective tissue that often merges with that of neighbouring blood vessels,

nerves, or other organs. It anchors the vessel and provides passage for small nerves,

lymphatic vessels, and smaller blood vessels. Small vessels called the vasa vasorum

supply blood to at least the outer half of the wall of a larger vessel. Tissues of the

inner half of the wall are thought to be nourished by diffusion from blood in the

lumen.

2. The tunica media, the middle layer, is usually the thickest. It consists of smooth

muscle, collagen, and sometimes elastic tissue. The smooth muscle is responsible for

the vasoconstriction and vasodilatation of blood vessels.

3. The tunica intima (tunica interna), the inner layer, is exposed to the blood. It

consists of a simple squamous endothelium overlying a basement membrane and a

sparse layer of fibrous tissue. The endothelium acts as a selectively permeable barrier

to blood solutes, and it secretes vasoconstrictors and vasodilators to be considered

later. It also provides a smooth inner lining that normally repels blood cells and

platelets. However, platelets may adhere to a damaged endothelium. During

inflammation, leukocytes also adhere loosely to it by means of cell-adhesion

molecules produced by the endothelial cells137.



Fig: 12 Image of Microscopic Structure of Vein

Vasa Vasorum

Nourishment of tissue of vessel wall is provided by blood circulating vessels

itself. Large vessels have own vascular supply within adventitia, in the form of

network of vessels called Vasa vasorum. Vasa vasorum originate from and drains into

adjacent vessels which are peripheral branches138.

Developmental Anatomy of Blood Vessels139

The human yolk sac has little yolk to nourish the developing embryo, blood

and blood vessel. Formation starts as early as 15-16 days in the mesoderm of the yolk

sac, chorion, and body stalk. Blood vessels develop from isolated masses and cords of

mesenchyma in the mesoderm called blood islands. Spaces soon appear in the islands



and become the lumens of the blood vessels. Some of the mesenchymal cells

immediately around the spaces give rise to the endothelial lining of the blood vessels.

Mesenchyme around the endothelium forms the Tunics of the larger blood vessels.

Growth and fusion of blood islands form an extensive network of blood vessels

throughout the embryo.

Development of Veins

The cardiovascular system is the first major system to function in the embryo.

The primordial heart and vascular system appear in the middle of the third week of

embryonic development. The heart starts to function at the beginning of fourth week.

This precocious heart development is necessary because the rapidly growing embryo

can no longer satisfy its nutritional and oxygen requirement by diffusion alone.

Consequently, there is a need for an efficient method of acquiring oxygen and

nutrients from the maternal blood and disposing of carbon dioxide and waste

products.

Angiogenesis or blood vessel formation begins in the extra-embryogenic

mesoderm of the yolk sac, connecting stalk, and chorion. Embryonic blood vessels

begin to develop about two days later. The early formation of the cardiovascular

system is correlated with the absence of a significant amount of yolk in oocyte and

yolk sac and the consequent urgent need for blood vessels to bring oxygen and

nourishment to the embryo from the maternal circulation through the placenta. At the

end of the second week, embryonic nutrition is obtained from the maternal blood by

diffusion through the extra embryonic coelom and yolk sac. During the 3rd week,

primordial uteroplacental circulation develops. Primordial blood vessels cannot be



distinguished structurally as arteries or veins, but are named according to their future

fates and relationship to the heart.

The formation of the embryonic vascular system involves two processes:

vasculogenesis and angiogenesis. Blood vessel formation in the embryo and extra

embryonic membranes during the 3rd week may be summarized as follows:

- Mesenchymal cells differentiate into endothelial cells precursor - angioblasts

(vessel-forming cells), which aggregate to form isolated angiogenic cell

clusters-blood islands.

- Small arteries appear within the blood islands by confluence of intercellular

clefts.

- Angioblasts flatten to form endothelial cells that arrange themselves around

the cavities in the blood island to form the endothelium.

- These endothelium lined cavities soon fuse to form networks of endothelial

channels. (Vasculogenesis).

- Vessels sprout into adjacent areas by endothelial budding and fuse with other

vessels (angiogenesis).

Blood cells develop from the endothelial cells of vessels (hemangioblasts) as

they develop on the yolk sac and allantois at end of the third week. Blood formation

does not begin in the embryo until the 5th week. It occurs first in the various parts of

the embryonic mesenchyme, chiefly the liver and later in the spleen, bone marrow and

lymph nodes. Foetal and adult erythrocytes are derived from the different

hematopoietic progenitor cells. The mesenchymal cells surrounding the primordial

endothelial blood cells differentiate into the muscular and connective tissue elements

of the vessels. The earliest sign of the heart is appearance of paired endothelial strands

- angioblastic cords in the cardiogenic mesoderm during the 3rd week. These cords



canalize to form heart tubes, which fuse to form the tubular heart late in the 3rd week.

The heart begins to beat at 23rd day. An inductive influence from the anterior

endoderm stimulates early formation of the heart. The development of heart and blood

vessels is controlled by a cascade of regulatory genes and signalling molecules.

Three paired veins drain into the tubular heart of a four-week embryo -

- “Vitelline veins” return poorly oxygenated blood from the yolk sac.

- “Umbilical veins” carry oxygenated blood from the primordial placenta.

- “Common cardial veins” return poorly oxygenated blood from the body of the

embryo.

The vitelline veins follow the yolk stalk into the embryo. The yolk stalk is the

narrow tube connecting the yolk sac with the midgut. After passing through the

septum transversum, the vitelline veins enter the venous end of the heart - the “sinus

venosus”. As the liver primordium grows into the septum transversum the hepatic

cords anastomose around pre-existing endothelium lined spaces. These spaces, the

primordial of the “hepatic sinusoids”, later become linked to the vitelline veins. The

“hepatic veins” form from the remains of the right vitelline vein in the region of the

developing liver.

The portal vein develops from an anastomosis network formed by the vitelline

veins around the duodenum.

The „umbilical veins‟ run on each side of the liver and carry well oxygenated

blood from the placenta to the sinus venosus. As the liver develops, the umbilical

veins lose their connection with the heart and empty into liver. The right umbilical

vein disappears during the seventh week, leaving the left umbilical veins as the only



vessel carrying well-oxygenated blood from the placenta to the embryo.

Transformation of the umbilical veins may be summarized as follows;

- The right umbilical vein and the caudal part of the left umbilical vein between

the liver and sinus venosus degenerate.

- The persistent caudal part of the left umbilical vein becomes the umbilical

vein, which carries all the blood from the placenta to embryo.

- A large venous shunt - the ductus venosus develops within the liver and

connects the umbilical vein with the inferior vena cava.

The cardinal veins constitute the main venous drainage system of the embryo.

The anterior and posterior cardinal veins drain cranial and caudal part of the embryo,

respectively. The anterior and posterior cardinal veins join the common cardinal

veins, which enter the sinus venosus. During the 8th week of embryonic development,

the anterior cardinal vein becomes connected by an anastomosis which shunts blood

from the left to the right anterior cardinal vein. This anastomotic shunt becomes the

left brachio-cephalic vein when caudal part of the left anterior cardinal vein

degenerates. The superior vena cava forms from the right anterior cardinal vein and

the right common cardinal vein.

The posterior cardinal veins develop primarily as the vessels of the

mesocephalic (interim kidneys) and largely disappears with this transitory kidneys.

The only adult derivatives of the posterior cardinal veins are the root of the azygos

vein and the common iliac veins. The subcardinal and supracardinal veins gradually

replace and supplement the posterior cardinal veins. The sub-cardinal vein appears

first. They are connected with each other through the subcardinal anastomosis and

with the posterior cardinal veins through the nephric sinusoids. The sub-cardinal veins

form the stem of the left renal vein, the suprarenal veins, the gonadal veins and



segment of InferiorVenaCava. The supracardinal veins are the last pair of vessels to

develop. They become disrupted in the region of the kidneys. Cranial to this, they

become united by the anastomosis i.e. represented in the adult by the azygos and

hemi-azygos veins. Caudal to the kidneys, the left supracardinal veins degenerates,

but the right supracardinal veins becomes the inferior part of the IVC.

Development of Superior Vena Cava140

The precardinal veins enlarge as the head and brain develop. They are further

augmented by the subclavian veins from the upper limb buds, and so become the chief

tributaries of the common cardinal veins, which gradually assume an almost vertical

position in association with the descent of the heart into the thorax. That part of the

original precardinal vein rostral to the subclavian is now the internal jugular vein, and

their confluence is the brachio-cephalic vein of each side. The right and left common

cardinal veins are originally of the same diameter. By the development of a large /

transverse connection, the left brachio-cephalic vein carries blood across from the left

to the right. The part of the original right precardinal vein between the junction of the

two brachio-cephalic and azygos veins forms the upper part of the superior vena cava,

the caudal part of the latter vessel is formed by the right common cardinal vein.

Caudal to the transverse branching of the left brachio-cephalic the left precardinal and

left common cardinal veins largely atrophy, the former constituting the terminal part

of the left superior intercostal vein; while the latter is represented by the ligament of

the left vena cava and the oblique vein of the left atrium. The remainder of the left

superior intercostal is developed from the cranial end of the post cardinal vein and

drains the second, third, and occasionally the fourth intercostal veins. The oblique

vein passes downwards across the back of the left atrium to open into the coronary

sinus which, as already indicated, represents the persistent left horn of the sinus



venosus. Right and left superior venae cavae are present in some animal and

occasionally in mankind.

Development of Inferior Vena Cava

The inferior vena cava (IVC) forms during a series of changes in the

primordial veins of the trunk that occur as blood, returning from the caudal part of the

embryo, is shifted from the left to the right side of the body. The IVC is composed of

four main segments

- A hepatic segment derived from the hepatic vein (proximal part of right

vitelline vein) and hepatic sinusoids.

- A prerenal segment derived from the right subcardinal vein.

- A renal segment derived from the subcardinal-supracardinal anastomosis.

- A postrenal segment derived from the right supracardinal vein.

The early postcardinal veins communicate across the midline via an inter-post-

cardinal anastomosis between the iliac veins, and become the major part of the

definitive left common iliac vein. It diverts an increasing volume of blood into the

right longitudinal veins, which accounts for the ultimate disappearance of the most of

those on the left.

The supracardinal veins receive the larger venous drainage of the growing

body wall. The right supracardinal vein persists and forms the greater part of the post

renal segment of the IVC. The continuity of the vessel is maintained by the

persistence of the anastomosis of between the right supracardinal and right

subcardinal vein in the renal collar.



In summary, therefore, the inferior vena cava is formed from below upwards

by the confluence of common iliac veins; short segment of the right postcardinal vein,

the postcardinal-supracardinal anastomosis, part of the right supra-cardinal vein, a

new anastomotic channel of dual origin, the hepatic segment of the inferior vena cava;

and the cardiac termination of the right vitelline hepatocardiac vein.

Fig No: 13 Embryonic development of cardiovascular system and Blood vessels



VEINS OF THE LOWER EXTREMITIES

Development of Vessels in the Lower Limb

The axial artery of the lower limb arises from the dorsal root of the umbilical

artery and courses along the dorsal surface of the thigh, knee and leg. Below the knee

it lies between the tibia and popliteus, and in the leg it lies between the crural

interossoeus membrane and tibialis posterior. It gives off a perforating artery that

traverses the sinal tarsus to form a dorsal network and ends distally in a plantar

network. The femoral artery passes along the ventral surface of the thigh, opening a

new channel to the lower limb. It arises from a capillary plexus that is connected

proximally with the femoral branches of the external iliac artery and distally with the

axis artery. At the proximal border of popliteus the axis artery splits into primitive

posterior tibial and peroneal branches: these run distally on the dorsal surface of

popliteus and tibialis posterior to gain the sole of the foot. At the distal border of

popliteus the axis artery gives off a perforating branch that passes ventrally between

the tibia and the fibula and then courses to the dorsum of the foot, forming the

anterior tibial artery and dorsalis pedis artery. The primitive peroneal artery

communicates with the axis artery at the distal border of popliteus and in its course in

the leg.

The femoral artery gradually increases in size. Coincidentally, most of the axis

artery disappears; however, proximal to its communication with the femoral artery,

the root of the axis artery persists as the inferior gluteal artery and the arteria comitans

nerviischiadici.

The proximal parts of the primitive posterior tibial and peroneal arteries fuse:

they remain separate distally. Ultimately, much of the primitive peroneal artery



disappears; however, a part of the axis artery is incorporated in the permanent

peroneal artery.

In the lower limb the preaxial vein becomes the long saphenous vein, which

drains into the femoral vein at the saphenous opening. The postaxial vein becomes the

short saphenous vein, which passes deep and joins the popliteal vein141.

Veins of the Lower Limb142

The veins of the lower limb can be subdivided, like those of the upper limb,

into superficial and deep groups. The superficial veins are subcutaneous and lie in the

superficial fascia; the deep veins accompany the major arteries. Both groups have

valves, which are more numerous in the deep veins and also more numerous than in

the veins of the upper limb. Venous plexuses occur within and between some of the

lower limb muscles.

The principal named superficial veins are the long and short saphenous veins.

Their numerous tributaries are mainly unnamed.

Deep veins of the lower limbs accompany the arteries and their branches.

Plantar digital veins arise from plexuses in the plantar regions of the toes, connect

with dorsal digital veins and unite four plantar meta-tarsal veins. These run in the

intermetatarsal spaces and connect by perforating veins with dorsal veins then

continue to form a day plantar arterial arch. From this arch, medial and lateral plantar

veins run near the corresponding arteries. They communicate with the long and short

saphenous veins before forming the posterior tibial veins behind medial malleolus.

The posterior tibial veins accompany the posterior tibial artery. They receive

veins from the calf muscles, especially the venous plexus in soleus, and connect with



the superficial veins and with the peroneal veins. The latter, running with their artery,

receive branches from soleus and superficial veins.

The anterior tibial veins are continuations of venae comintantes of the dorsalis

pedis artery. They leave the extensor region between the tibia and fibula, pass through

the proximal end of the interossoeus membrane, and unite with the posterior tibial

veins to form the popliteal vein at the distal border of popliteus.

Considerable of the venous drainage is of great importance because in the

lower limb venous blood has to ascend against gravity. This is aided by a number of

local factors, the failure of which gives rise to varicose veins. The veins of lower limb

may be classified into three groups143.

I. Superficial Veins

II. Deep Veins

III. Perforating Veins

I. Superficial Veins: They include the great and small saphenous veins and their

tributaries. They lie in the superficial fascia, on the surface of the deep surface.

They are thick walled because of the presence of smooth muscle and some

fibrous and elastic tissues in their walls.

II. Deep Veins: These are the anterior and posterior tibial, peroneal, popliteal, &

femoral veins and their tributaries. They accompany the arteries, and are

supported by powerful surrounding muscles. The valves are more numerous in

deep veins than in superficial veins. They are more efficient channels than the

superficial veins because of the driving force of muscular contraction.



III. Perforating Veins: They connect the superficial with the deep veins. Their

valves permit only one way flow of blood, from the superficial to the deep

veins. There are about five perforators along the great saphenous vein, and one

perforator along the small saphenous vein.

Superficial Veins of Lower limb

(1) The dorsal venous arch lies on the dorsum of the foot over the proximal part of

the meta-tarsal bones. It receives four dorsal meta-tarsal veins each of which is

formed by the union of two dorsal digital veins

(2) The great or long saphenous vein is formed by the union of the medial end of

the dorsal venous arch with the medial marginal vein which drains the medial

side of the medial surface of tibia obliquely, and runs along its medial border

to reach the back of the knee. The saphenous nerve runs in front of the great

saphenous vein.

(3) The small or short saphenous vein is formed by the union of the lateral end of

the dorsal venous arch with lateral marginal vein, draining the lateral side of

the little toe. It passes upwards behind the lateral malleolus to reach the back

of the leg. The sural nerve accompanies the small saphenous vein.

Both saphenous veins are connected to the deep veins through the perforating

veins.



Fig No: 14 Showing Superficial Veins of the Lower Limb



Fig No: 15 Showing Superficial veins of the Lower limbs



Fig No: 16 Showing Superficial and Perforating veins of the lower limb

Great or Long Saphenous Vein144

Saphes Easily seen.

The saphenous vein can be easily seen in the leg. Venous drainage acquires

importance as blood has to flow up against the gravity.



The long saphenous vain, is the largest and longest superficial vein of the

lower limb. It starts on the dorsum of the foot from the medial of the dorsal venous

arch, and runs upwards in front of the medial malleolus along the medial side of the

leg, and behind the knee. In the thigh, it inclines forwards to reach the saphenous

opening where it pierces the cribriform fascia and opens into the femoral vein.

In its course through the thigh the long saphenous vein is accompanied by the

branches of the medial femoral cutaneous nerve. Before piercing the cribriform fascia,

it receives three named tributaries corresponding to the 3 cutaneous arteries and also

many unnamed tributaries.

It contains about 10-15 valves which prevent back flow of the venous blood,

which tends to occur because of gravity. One valve is always present at the saphenous

femoral junction. Incompetence of these valves makes the vein dilated and tortuous

leading to varicose vein.

In almost its entire extent the vein lies in superficial veins, but it has many

connections with the deep veins, especially in the leg. The veins are also connected to

the deeps veins of the limb by perforating veins. There are three medial perforators

just above the ankle, one perforator just below the knee and another one in the region

of the adductor canal. The perforating veins are also provided with valves which

permit flow of blood only from the superficial to deep vein.

Tributaries

At the ankle the long saphenous vein drains the sole by medial marginal veins.

In the leg it often connects with the short saphenous vein and with deep veins via

perforating veins. Just distal to the knee it usually receives three large tributaries from



the front of the leg, from the tibial malleolar region and from the calf. The tributary

draining the tibial malleolar region is formed delicate veins overt the medial malleolus

and then ascends the medial aspect of the calf as the posterior arch vein.

It connects with posterior tibial venae comintantes by a series of perforating

veins. These are usually three equally spaced between the medial malleolus and the

mid calf. More than three such perforators are uncommon and an arch vein perforators

above mid calf is only very rarely found.

Above the posterior crural arch vein, perforating veins join the long saphenous

vein, or one of its main tributaries at the two main sites. The first is at a level in the

upper calf indicated by its name, the tibial tubercle. Perforator; the second is in the

lower / intermediate third of the thigh where it perforates the deep fascial roof of the

subsartorial canal to join the femoral vein.

In the thigh the long saphenous vein receives many tributaries. Some open

independently; whilst others converge to form large named channels that frequently

pass forwards the basal half of the femoral triangle before joining the long saphenous

near its termination. These may be grouped as follows: one or more large postero-

medial tributaries, one or more large antero-medial tributaries, four or more peri-

inguinal veins. The postero-medial vein of the thigh, large and sometimes double,

drains a large superficial region indicated by its name. It has radiological and surgical

significance. One of its lower radicles is often continuous with short saphenous vein.

The postero-medial vein is sometimes named the accessory saphenous vein; through

some restrict the term accessory to a lower, postero-medial tributary when two are

present. Another large vessel, the antero-lateral vein of the thigh usually commences

from an anterior network of veins in the distal thigh and crosses the apex and distal



half of the femoral triangle to reach the long saphenous vein. As the latter traverses

the saphenous opening, it is joined by the superficial epigastric, superficial circumflex

iliac and superficial external pudendal veins. Their mode of union varies. Superficial

epiagastric and circumflex iliac veins drain the inferior abdominal wall, the latter also

receiving tributaries from the proximo-lateral region of thigh. The long saphenous

vein is often harvested for grafts used both in peripheral and coronary arterial surgery.

Surface Marking of long Saphenous Vein145

It can be marked by joining the following points, although it is easily visible in

living subjects:

(a) First point on the dorsum of foot at the medial end of the dorsal venous arch

(b) Second point on the anterior surface of the medial malleolus

(c) Third point on the medial border of the tibia at the junction of the upper two

thirds and lower one third of the leg

(d) Fourth point at the adductor tubercle

(e) 5th point just below the centre of the saphenous opening.

Its formation on the dorsum of the foot, its course along the entire length of

the lower limb and its termination into femoral vein. It contains about 10-20 valves.

There is one valve that lies just before the vein pierces the cribriform fascia and

another at its termination into the femoral vein.

Short Saphenous Vein146

The short saphenous vein starts on the lateral side of the foot and ascends up

on the back of the leg to end in the popliteal vein. The vein is formed on the dorsum

of the foot by the union of the lateral end of the dorsal venous arch with the lateral



marginal vein. In lower third of the calf it ascends lateral to the calcaneal tendon,

lying on the deep fascia and covered only by superficial fascia and skin. In the leg it

ascends lateral to the tendocalcaneus, and then along the middle line of the calf, to the

lower part of the popliteal fossa. Here it pierces the deep fascia and opens into the

popliteal vein. It drains the lateral border of the foot, the heel and the back of the leg.

It is connected with the great saphenous and with deep veins.

Tributaries

The short saphenous vein connects with deep veins on the dorsum of the foot,

receives many cutaneous tributaries in the leg, and sends several communicating

branches proximally and medially to join the long saphenous vein. Sometimes a

communicating branch ascends medially to the accessory saphenous vein. This may

be the main continuation of the short saphenous vein. In the leg, the short saphenous

vein lies near the sural nerve, it has 7-13 valves one near its termination. Its mode of

ending is variable, it may join the long saphenous vein in the proximal thigh or it may

bifurcate, one branch joining the long saphenous, the other the popliteal or deep

posterior femoral veins. Sometimes, it ends distal to the knee in the long saphenous or

sural muscular vein.

Surface Marking

It can be marked by joining the following points, although this vein is also

easily visible in its lower part:

(a) A point on the dorsum of the foot at the lateral end of the dorsal venous arch

(b) Second point behind the lateral malleolus.

(c) Third point just lateral to the tendocalcaneus above the lateral malleolus.



(d) Fourth point at the centre of the popliteal fossa.

Its formation on the dorsum of the foot, course along the back of the leg, and

termination into the popliteal vein.

Just before piercing the popliteal fascia, it may give a communicating branch

to the accessory saphenous vein. Sometimes, the whole of the small saphenous vein

opens into the great saphenous vein through the accessory saphenous vein.

Occasionally, the small saphenous vein ends below the knee either in the great

saphenous vein, or in the deep muscular veins of the leg.

Perforating Veins147

As already mentioned, they connect the superficial with the deep veins. There

are classified as follows:

Indirect Perforating Veins

Indirect perforating veins connect the superficial veins with the deep veins

through the muscular veins.

Direct Perforating Veins

Direct perforating veins connect the superficial veins directly with deep veins.

The great and small saphenous veins are the large direct perforators.

(a) In the thigh: the adductor canal perforator connects the great saphenous vein

with the femoral vein in the lower part of the adductor canal.

(b) Below the knee: one perforator connects the great saphenous vein or the

posterior arch vein with the posterior tibial vein.

(c) In the leg: (i) a lateral perforator is present at the junction of the middle and

lower third of the leg. It connects the small saphenous vein or one of its



tributaries with peroneal vein. Medially, there are three perforators which

connect the posterior arch vein with the posterior tibial vein.

(d) The upper medial perforator lies at the junction of the middle and lower thirds

of the leg.

(e) The middle medial perforator lies above the medial malleolus.

(f) The lower medial perforator lies posteroinferior to the medial malleolus.

Deep Veins of Lower Limb148

Posterior Tibial Veins

The posterior tibial veins accompany the posterior tibial artery. They receive

tributaries from the calf muscle and connections from the superficial veins and the

peroneal veins. Posterior tibial vein is formed by the union of the medial and lateral

plantar veins posterior to the medial malleolus.

Anterior Tibial Veins

The anterior tibial vein is the superior continuation of the dorsalis pedis vein

in the foot. It extends between the tibia and fibula and unites with the posterior tibial

to form the popliteal vein at the distal border of the popliteus.

Popliteal Vein149

It begins at the lower border of the popliteus by the union of veins

accompanying the anterior and posterior tibial arteries, and posterior tibial arteries. It

is medial to the popliteal artery in the lower part of the fossa; posterior to the artery in

the middle and postero-lateral to it in the upper part of the fossa. The vein continues

as the femoral vein at the opening in the adductors magnus.

The popliteal vein receives -



(1) The small saphenous vein and

(2) The vein corresponding to the branches of the popliteal artery.

Profunda Femoris Vein

The profunda femoris vein lies anterior to its artery, and has tributaries

corresponding to the branches of the artery. Through these tributaries it connects

distally with the popliteal and proximally with the inferior gluteal veins. It sometimes

drains medial and lateral circumflex femoral veins. It has a valve just before it

terminates.

Femoral Vein150

The femoral vein accompanies its artery beginning at the adductor opening, as

the continuation of the popliteal vein, and ending posterior to the inguinal ligament as

the external iliac vein. In the distal adductor canal, it is postero-lateral to the femoral

artery, more proximally in the canal, and in the distal femoral triangle, it is posterior

to it, proximally, at the base of the triangle, it is medial. The vein occupies the middle

compartment of the femoral sheath, between the femoral artery and canal, fat in the

latter allowing expansion of the vein. It has many muscular tributaries; 4-12 cm distal

the inguinal ligament the profunda femoris vein joins it posteriorly and then the long

saphenous vein, which enters anteriorly. Veins accompanying the superficial

epigastric, superficial circumflex iliac and external pudendal arteries join the long

saphenous vein before it enters the saphenous opening. Lateral and medial circumflex

femoris veins are usually tributaries of the femoral. There are usually four or five

valves in the femoral vein. The two most constant are just the distal to the entry of the

profunda femoris and near the inguinal ligament.



Deep and Superficial Venous Systems of the Foot151

Plantar digital veins arise from the plexuses in the plantar regions of the toes,

connecting with dorsal digital veins and uniting into four plantar metatarsal veins. The

latter run in the intermetatarsal spaces and connect by perforating veins with dorsal

veins, then continue to form the deep plantar venous arch that accompanies the plantar

arterial arch. From this venous arch, medial and lateral plantar veins run near the

corresponding arteries and after communicating with the great and small saphenous

veins, from the posterior tibial veins behind the medial malleolus.

The principal named superficial veins are the great and small saphenous. Their

numerous tributaries are mostly unnamed.

Dorsal digital veins receive rami from the plantar digital veins in the clefts

between the toes and then join to form dorsal metacarpal veins, which are united

across the proximal parts of the metatarsal bones in a dorsal venous arch. Proximal to

this arch, an irregular dorsal venous network receives tributaries from deep veins and

is continuous, proximally with a venous network in the leg. At each side of the foot,

this network connects with medial and lateral marginal veins, which are both formed

mainly by veins from more superficial parts of the sole. In the sole, superficial veins

form a plantar cutaneous arch across the roots of the toes and also drain into the

medial and lateral marginal veins. Proximal to the plantar arch there is a plantar

cutaneous venous plexus, especially dense in the fat of the heel. It connects with the

plantar cutaneous venous arch and other deep veins, but drains mainly into the

marginal veins. The veins of the sole are an important part of the lower limb ‘venous

pump’ system aiding return of the blood up the limb. Intermittent to enhance this flow



and so reduce the risk of deep vein thrombosis during periods of increased risk, e.g.

after surgery.

Valves in Superficial veins of the lower extremity

The great saphenous vein has 10 to 12 valves, which are more numerous in the

leg than in the thigh. These valves are usually located just inferior to the perforating

veins. The perforating veins also have valves.

Venous valves are cusps of endothelium with cup like valvular sinuses that fill

from above. When they are full, the valve cusps occlude the lumen of the vein,

thereby preventing reflux of blood distally, making flow unidirectional. The valvular

mechanism also breaks the column of blood in the saphenous vein into shorter

segments reducing back pressure. Both effects make it easier further the

musculovenous pump to overcome the force of gravity to return the blood to the heart.

As it ascends in the leg and thigh, the great saphenous vein receives numerous

tributaries and communicates in several locations with the small saphenous vein.

Tributaries from the medial and posterior aspects of the thigh frequently unite to form

an accessory saphenous vein (Fig. 5.10B). When present, this vein becomes the main

communication between the great and small saphenous veins. Also, fairly large

vessels—the lateral and anterior cutaneous veins--arise from networks of veins in the

inferior part of the thigh and enter the great saphenous vein superiorly, just before it

enters the femoral vein. Near its termination, the great saphenous vein also receives

the superficial circumflex iliac, superficial epigastric, and external pudendal veins.



The small saphenous vein arises on the lateral side of the foot from the union

of the dorsal vein of the small (little) toe with the dorsal venous arch. The small

saphenous vein:

• Ascends posterior to the lateral malleolus as a continuation of the lateral

marginal vein

• Passes along the lateral border of the calcaneal tendon

• Inclines to the midline of the fibula and penetrates the deep fascia

• Ascends between the heads of the gastrocnemius muscle

• Empties into the popliteal vein in the popliteal fossa.

Although many tributaries are received by the saphenous veins, their diameter

remains remarkably uniform as they ascend the limb. This is possible because the

blood they receive is continuously shunted from these superficial veins in the

subcutaneous tissue to the deep veins by means of the many perforating veins.

The perforating veins penetrate the deep fascia close to their origin from the

superficial veins and contain valves that, when functioning normally, only allow

blood to flow from the superficial veins to the deep veins. The perforating veins pass

through the deep fascia at an oblique angle so that when muscles contract and the

pressure increases inside the deep fascia, the perforating veins are compressed. This

also prevents blood from flowing from the deep to the superficial veins. This pattern

of venous blood flow from superficial to deep is important for proper venous return

from the lower limb because it enables muscular contractions to propel blood toward

the heart against the pull of gravity (musculovenous pump)152.



Valves in superficial veins of the lower extremity usually are located near to

the termination of major tributaries. Some valves are well developed with marked

sinusoid dilation at their base; others are more delicate in their structure. In the great

saphenous there are about six valves, with more valves located below than above the

knee. A nearly constant valve of great saphenous vein is at 2–3 cm distal to its

confluence with the femoral vein. Valves in the short saphenous vein are closer to

each other than in the great saphenous. Valves in communicating branches between

the short saphenous vein and great saphenous are oriented to direct blood from the

small to the great saphenous vein. Similar to superficial veins, deep veins have more

valves in the calf than in the thigh. Tibial veins are densely packed with valves,

whereas there are only one or two valves in the popliteal vein. In the femoral vein

there are three to five valves, with one of them located just distal to the junction of the

deep femoral vein. There is usually one valve in the common femoral vein. Major

perforating veins have one to three valves, all located below the level of the fascia,

that direct flow toward the deep veins. Small perforating veins are usually valve less.

Perforating veins of the foot are without any valves or with valves that direct flow

towards the superficial veins153.

Applied Anatomy of the veins of Lower limb154

Venous Pump of the Lower Limb

Within the closed fascial compartments of the lower limb, the thin-walled,

valved venae comitantes are subjected to intermittent pressure at rest and during

exercise. The pulsations of the adjacent arteries help move the blood up the limb.



However, the contractions of the large muscles within the compartments during

exercise compress these deeply placed veins and force the blood up the limb.

The superficial saphenous veins, except near their termination, lie within the

superficial fascia and are not subject to these compression forces. The valves in the

perforating veins prevent the high-pressure venous blood from being forced outward

into the low-pressure superficial veins. Moreover, as the muscles within the closed

fascial compartments relax, venous blood is sucked from the superficial into the deep

veins.

Varicose Veins

A varicosed vein is one that has a larger diameter than normal and is elongated

and tortuous. This condition commonly occurs in the superficial veins of the lower

limb and, although not life-threatening, is responsible for considerable discomfort and

pain.

Varicosed veins have many causes, including hereditary weakness of the vein

walls and incompetent valves; elevated intra-abdominal pressure as a result of

multiple pregnancies or abdominal tumors; and thrombophlebitis of the deep veins,

which results in the superficial veins becoming the main venous pathway for the

lower limb. It is easy to understand how this condition can be produced by

incompetence of a valve in a perforating vein. Every time the patient exercises, high-

pressure venous blood escapes from the deep veins into the superficial veins and

produces a varicosity, which might be localized to begin with but becomes more

extensive later.

The successful operative treatment of varicosed veins depends on the ligation

and division of all the main tributaries of the great or small saphenous veins, to

prevent a collateral venous circulation from developing, and the ligation and division



of all the perforating veins responsible for the leakage of high-pressure blood from the

deep to the superficial veins. It is now common practice to remove or strip the

superficial veins in addition. Needless to say, it is imperative to ascertain that the deep

veins are patent before operative measures are taken.

Great Saphenous Vein Cut down Exposure of the great saphenous vein through a skin incision is usually performed at

the ankle. This site has the disadvantage that phlebitis (inflammation of the vein wall)

is a potential complication. The great saphenous vein also can be entered at the groin

in the femoral triangle, where phlebitis is relatively rare; the larger diameter of the

vein at this site permits the use of large-diameter catheters and the rapid infusion of

large volumes of fluids.

Anatomy of Ankle Vein Cut down The procedure is as follows:

The sensory nerve supply to the skin immediately in front of the medial

malleolus of the tibia is from branches of the saphenous nerve, a branch of the

femoral nerve. The saphenous nerve branches are blocked with local

anesthetic.

A transverse incision is made through the skin and subcutaneous tissue across

the long axis of the vein just anterior and superior to the medial malleolus.

Although the vein may not be visible through the skin, it is constantly found at

this site.

The vein is easily identified, and the saphenous nerve should be recognized;

the nerve usually lies just anterior to the vein.



Anatomy of Groin Vein Cut down

The area of thigh skin below and lateral to the scrotum or labia majorum is

supplied by branches of the ilioinguinal nerve and the intermediate cutaneous

nerve of the thigh. The branches of these nerves are blocked with local

anaesthetic.

A transverse incision is made through the skin and subcutaneous tissue

centered on a point about 1.5 in. (4 cm) below and lateral to the pubic tubercle.

If the femoral pulse can be felt (may be absent in patients with severe shock),

the incision is carried medially just medial to the pulse.

The great saphenous vein lies in the subcutaneous fat and passes posteriorly

through the saphenous opening in the deep fascia to join the femoral vein

about 1.5 in. (4 cm), or two fingerbreadths below and lateral to the pubic

tubercle. It is important to understand that the great saphenous vein passes

through the saphenous opening to gain entrance to the femoral vein. However,

the size and shape of the opening are subject to variation.

The Great Saphenous Vein in Coronary Bypass Surgery

In patients with occlusive coronary disease caused by atherosclerosis, the

diseased arterial segment can be bypassed by inserting a graft consisting of a portion

of the great saphenous vein. The venous segment is reversed so that its valves do not

obstruct the arterial flow. Following removal of the great saphenous vein at the donor

site, the superficial venous blood ascends the lower limb by passing through

perforating veins and entering the deep veins.

The great saphenous vein can also be used to bypass obstructions of the

brachial or femoral arteries.

Methodology


METHODOLOGY

Source and Method of Collection of Data

The subject of thesis is both conceptual and observational study by cadaver

dissection.

Material and methods

Source of data

Literary and conceptual study was on the data completions from the

Brihatrayees, Laghutrayees, and other classical books including journals, presented

papers, previous work done and co-related, analyzed with the knowledge of

contemporary science on the subject.

Dissection of the lower limb in five cadavers was carried out in the

Department of Rachana Shareera, Alva’s Ayurveda Medical College. Observations

were analyzed and co-related in the view of sites of Siravyadha and its anatomical and

Marma relevance in the lower extremity.

Method of collection of the data

Books, thesis, journals including published on the concept related to subject

will be reviewed and related information will be collected and analyzed scientifically.

Cadaver and specimen study will be conducted in Rachana Sareera Dept. of

Alva’s Ayurveda Medical College, Moodbidri.

Assessment Criteria

Observation and identification of the regional anatomy of Lower limb on the

cadaver dissection and was correlated with Anatomical and Marma relevance

explained in Ayurveda classics, and the superficial veins of the lower limb were

observed.

Observation


OBSERVATION

The dissection of five cadavers in which ten lower limb specimen has been

carried out as per the Cunningham’s Manual of practical anatomy. Dissection

procedures were carried out layer by layer, observed and different structures and their

relations with each other were studied thoroughly. The structures which are related to

the Marmasthānas of the lower limb were observed in detail.

THIGH

Front of the Thigh

Skin: The skin consists of hair follicles.

Superficial Fascia: Following Structures were observed in superficial fascia –

Superficial fatty layer

Deep membranous layer

Cutaneous nerves

Great saphenous vein and its tributaries

Superficial inguinal lymph nodes

Deep Fascia/ Fascia Lata: Following Structures were observed in Deep fascia –

Femoral sheath, vein, artery

Ilio tibial tract

Tensor fascia Lata

Sartorius

Quadriceps femoris

Iliacus

Observation


Psoas majors

Medial Side of Thigh

Following Structures were observed –

Adductor longus

Adductor brevis

Adductor magnus

Gracilis

Pectineus

Obturator nerve

Obturator artery

Medial circumflex femoral artery

Back of Thigh

Semitendinosus

Semimembranosus

Biceps femoris

Sciatic nerve

Branches of Profunda femoris artery.

THE LEG

The following structures were observed in Front of Leg and Dorsum of Foot -

Superficial Fascia of the Leg

Superficial veins

Cutaneous nerves

Observation


Lymphatics

Small Unnamed arteries

The Dorsal Venous Arch

Great / Long Saphenous Vein

Small / Short Saphenous Vein

The Saphenous Nerve & its Infra Patellar branch

The Lateral Cutaneous nerve of the Calf

The Superficial Peroneal Nerve

The Sural Nerve

The Deep Peroneal Nerve

The Digital branches of Medial and Lateral Plantar Nerves

Deep Fascia of the Leg

Superior Extensor Retinaculum

Inferior Extensor Retinaculum

Muscles

Tibialis anterior

Extensor Hallucis Longus

Extensor Digitorum Longus

Peroneus Tertius

Extensor Digitorum brevis

Anterior Tibial artery

Dorsalis pedis artery and its branches

Deep Peroneal nerve

Observation


Lateral Side of the Leg

Peroneus longus

Peroneus brevis

Superficial Peroneal nerve

Superior personal Retinaculum

Medial Side of the Leg

Great Saphenous vein

The Saphenous nerve

Tibial collateral ligament

Anserine Bursae

Back of the Leg

Superficial fascia

Small and Great Saphenous veins, tributaries.

Cutaneous nerves.

Medial and Lateral Calcaneal arteries.

Deep fascia

Superficial transverse fascial septum

Deep transverse fascial septum

Flexor Retinaculum

Muscles

Gastrocnemius

Soleus

Observation


Plantaris

Popliteus

Flexor Digitorum longus

Flexor Hallucis longus

Tibialis posterior

Posterior tibial artery

Peroneal artery

Tibial nerve.

Sole of Foot

Superficial Fascia

Cutaneous nerves and vessels

Superficial transverse Metatarsal ligaments

Deep Fascia

Plantar Aponeurosis

Deep transverse metatarsal ligaments

Fibrous flexor sheaths in the toes

Muscles

Flexor Digitorum Brevis

Abductor Hallucis

Abductor Digiti Minimi

Flexor Digitorum Longus

Flexor Digitorum Accessorius

Lumbricals

Flexor Hallucis Longus

Observation


Flexor Hallucis Brevis

Adductor Hallucis

Flexor Digiti Minimi Brevis

Extensor Digitorum Brevis

Extensor Hallucis Brevis

Discussion


DISCUSSION

Ayurveda is a holistic science which provides medical as well as surgical

treatment for various diseases based on their etiopathogenesis. Principle of

management is selected logically which is appropriate to a particular patient.

The term „Sirās’ and ‘Dhamanis’ are as old as Vedas. They have been

generally used in the same sense. But these are not synonymous. In general, Sirās

mean blood vessels. According to Charaka, definition of Sirā, Dhamani and Srotas is

said as “Dhmānāt dhamanyah, Sravanāt Srotāmsi, Saranat sirāh”. But on the basis of

interpretation of commentators „Dhamani‟ is a channel connected to the heart which

is thick whereas „Sirā‟ is a thin blood vessel.

Sirās are 700 in number. By these Sirās, the entire body is constantly

nourished, kept lubricated / moistened to perform actions such as flexion, extension,

contraction, dilation etc.

Among these Sirās, Ācharyas clearly differentiated between the Vedhya and

Avedhya Sirās. Vedhya Sirās are those which can be interfered with surgical

procedures and the Avedhya Sirās are those on which injury must be avoided during

surgery.

Though all the Brihatrayees made considerable remarks on Vedhya and

Avedhya Sirās, Suśruta has clearly mentioned the Vedhya Sirās specifically in

connection with the diseases which are cured by Sirāvyadha. However, the Avedhya

Sirās are the vessels which are prohibited for Sirāvyadha.

Suśruta has mentioned 98 Avedhya Sirās which should be taken care of by the

physician or a surgeon at the time of Sirāvyadha or during any other surgical

procedure. Any trauma to these structures may lead to morbidity or death.

Discussion


Sirāvyadha is a significant therapeutic tool, when judiciously administered.

Suśruta has explained that Sirāvyadha is accepted as half of the therapeutic measure

in Śalyatantra like Vasti in Kāyachikitsa. Half of the health hazards can be managed

by Sirāvyadha as Rakta being the chief causative factor in the manifestation of

diseases. So Raktamokshana by different modalities is much more effective in

resolving pathogenesis.

In general, various mechanisms in body, such as local blood supply, local

metabolism, local drainage system etc, are improved and fresh active RBCs are

produced by proper bloodletting. Hepato-cellular function is improved by enzymatic

activity due to release of hormones. Sympathetic function is improved and as it

directly stimulates bone marrow, immune related T-lymphocytes are produced.

Because of the above mentioned facts, Sirāvyadha Vidhi has got its own importance

on the basis of scientific background.

Raktamokshana is one of the important Para-surgical procedures denoting the

letting of impure blood outside the body. Different modalities of Raktamokshana can

be adopted, but Sirāvyadha is one among the Śaśtrāvacharanas. Of course, it appears

to be surprising that different sites have been advocated in different diseases. Why

can‟t a common site be selected in all diseases, is the point being raised here. To

analyze this context, different hypothesis and patho-physiological mechanisms can be

employed, as the basic unit of the body is cell. Each cell adopts a different mechanism

to perform various functions. So the term „homeostasis‟ is used, to denote

maintenance of an equilibrium condition in the internal environment. The function of

circulation is to serve the needs of the tissues such as nutrients, oxygen, hormones and

also to transport the waste products away from the body. When tissues are active they

need more blood flow. Heart normally cannot increase its cardiac output more than

Discussion


four to seven times. Therefore, it is not possible to increase the blood flow

everywhere in the body. When a particular body part demands increased flow, micro-

vessels of each tissue are monitoring the tissue needs, such as availability of oxygen

and nutrients and the accumulation of waste products, these in turn control local blood

flow to the level of tissue need. The microcirculation of each type of tissue in the

body is specially organized to serve special needs. Every cell has got their own

microcirculation to maintain its equilibrium internal environment.

On the basis of this general information, the dictum of Suśruta is found to be

more suitable. Ācharya Suśruta has mentioned seven sites of Sirāvyadha and five

sites of Sirāvyadha have been mentioned by Vāgbhata. The sites have been explained

in relation to marma, so the knowledge of marma and anatomical structures related to

it are very much significant in clinical application.

The sites of Sirāvyadha in the lower limb are mentioned in relation to various

diseases. For example, in diseases such as Pādadāha, Pādaharsha, Apabāhu, Chippa,

Visarpa, Vātaśonita, Vātakantaka, Vicharchika, Pādadāri, the site of Sirāvyadha is 2

Angula above Kshipra Marma. The anatomical structures in the Kshipra marma are

the plantar arch, plantar artery, Adductor hallucis, posterior tibial nerve, medial

plantar artery, metatarsophalangeal joints etc. Injury to this marma causes Ākshepaka

and death. To avoid injury to this region Ācharya selected the site of Sirāvyadha 2

Angula above the Kshipra Marma. The superficial vein situated at this site of

Sirāvyadha is the medial metatarsal vein (branch of dorsal venous arch)

In Vātaja Slīpada, Kroshtukasīrsha, Khanja, Pangu, Vātavedana, the site of

Sirāvyadha is 4 Angula above the Gulpha Sandhi. The anatomical structures in the

Gulpha marma are the flexor hallucis longus and brevis, tibialis posterior, flexor

Discussion


digitorum longus muscle, the posterior tibial artery and vein etc. Its injury causes

Ruja, Sthabda Padatha and Khanjatha. To avoid the injury to these structures,

Ācharya selected 4 Angula above the Gulpha Sandhi. The superficial vein situated in

this site of Sirāvyadha is the short saphenous vein.

In Pittaja Slīpada, the site of Sirāvyadha is 4 Angula below the Gulpha

Sandhi. The anatomical structures in the Gulpha Marma are the flexor hallucis longus

and brevis, tibialis posterior, flexor digitorum longus muscle, the posterior tibial

artery and vein etc. Its injury causes Ruja, Sthabda Padatha and Khanjatha. To avoid

the injury to these structures, Ācharya selected 4 Angula below the Gulpha Sandhi.

The superficial vein situated in this region is the branch of dorsal venous arch.

In Kaphaja Slīpada, the site of Sirāvyadha is 4 Angula above the Kshipra

Marma. The anatomical structures in the Kshipra Marma are the plantar arch, plantar

artery, Adductor hallucis, posterior tibial nerve, medial plantar artery,

metatarsophalangeal joints etc. Injury to this marma causes Ākshepaka and death. To

avoid injury to this region Ācharya selected the site of Sirāvyadha 4 Angula above the

Kshipra Marma. The superficial vein situated at this site of Sirāvyadha is the branch

of dorsal venous arch.

In Apachi, the site of Sirāvyadha is 4 Angula below Indrabasti. The

anatomical structures are Gastrocnemius, soleus and plantaris muscles, Peroneal

(branch of posterior tibial) and posterior tibial artery and vein, Posterior tibial nerve

etc. soleus is also called the peripheral heart. Injury to this Marma causes

Raktakshaya and death. To avoid injury to these structures, Suśruta selected the site of

Sirāvyadha 4 Angula below Indrabasti. The superficial vein situated in this site of

Sirāvyadha is short saphenous vein and perforating veins.

Discussion


In Gridhrasi, the site of Sirāvyadha is 4 Angula above or below the Jānu

Sandhi. The anatomical structures are Knee joint; articular capsule, posterior cruciate

ligament, oblique posterior ligament, quadriceps femoris, Sartorius, and biceps

femoris muscles; popliteal artery and vein; femur, tibia and patella bones; medial

popliteal nerve etc. Injury to this Marma causes Khanjatā. To avoid injury to these

structures, Suśruta selected the site of Sirāvyadha 4 Angula above or below the Jānu

Sandhi. The superficial vein situated at this site of Sirāvyadha is great saphenous

vein, short saphenous vein and its tributaries

In Galaganda, Ūrumula Sirā is subjected to Sirāvyadha. The superficial vein

situated at this region is the femoral vein.

There are 98 Avedhya Sirā s, out of which one by name Jāladhara, two which

are situated deep inside known as Urvi, and one by name Lohitāksha are not to be

punctured.

Urvi is an Avedhya Sirā as well as Sirā Marma situated in the middle of the

thigh. Injury to this causes atrophy or wasting of muscles of the thigh due to loss of

blood. It is a Vaikalyakara Marma. Dr. B.G. Ghanekar has considered the

probabilities of the atrophy of the muscles on injury to midline of thigh, in this view

femoral vessels and saphenous nerve are the responsible structures. He has also

stressed that femoral vessels would produce loss of blood and injury to saphenous

nerve may develop atrophy of the lower limb

Lohitāksha is an Avedhya Sirā as well as Sirā Marma. This Marma is situated

above Urvi Marma and below Vankshana Sandhi (Hip joint) at the root of the Ūru.

On injury, this causes paralysis of the muscles or wasting of the Sakthi (lower limb)

due to loss of blood. It is a Vaikalyakara Sirā Marma. Dr. B. G. Ghanekar has

mentioned femoral triangle in respect to this Marma.

Discussion


According to Suśruta there are 400 Sirās in extremities, but only 4 Sirās in

each limb are Avedhya. Jāladhara situated externally is one in each extremity, 3

internal Sirās (2 – Urvi and 1 – Lohitāksha), thus total 16 Avedhya Sirās in

extremities. B. G. Ghanekar suggests Jāladhara for great saphenous vein, Urvi,

Lohitāksha for femoral artery and vein.

As per the literary review, the concept of Śodhana therapy in Ayurveda is

discussed; Doshas should always be removed from the nearest route. For example, in

Vātadusti – Vasti, in Pittadusti – Virechana, in Kaphadusti - Vamana, this is

depending upon their Mūlasthānas. Likewise, as Raktamokshana is also one of the

Śodhana therapies, it is recommended to remove the vitiated blood from nearest route

of Roga Adhisthāna. It has been considered that the main function of the blood is

Jeevana, responsible for health, where as its Dusti causes various diseases. So

Sthānika Raktamokshana has been advised in different diseases.

The sites of Sirāvyadha were dealt by Suśruta with the sole aim that the

Dūshita Rakta is expelled out from the nearest route. He has recommended only Sirās

which is superficially situated for Sirāvyadha. On the contrary, the Sirās which are

deeply situated are referred as Avedhya Sirās, where Sirāvyadha is contraindicated.

When we review the anatomy, on the basis of literary principles, the sites of

Sirāvyadha dealt by Suśruta are found to be appropriate. Bloodletting from a

particular site is effective in resolving the pathology of a disease condition and

beneficial in neutralizing the physiological mechanisms by various changes in the

body. The body has got its own capacity to compensate during blood loss, performing

many defensive actions to resolve pathology and to maintain homeostasis.

Discussion


Marma is the conglomeration of Māmsa, Sirā, Snāyu, Asthi and Sandhi in

which Prāna resides. So, an injury to a Marma leads to fatal consequences. The four

types of Sirās carrying the Doshas and Rakta separately are connected with all the

Marmas as well. In case of trauma, blunt or piercing over the Marmas, there will be

Raktasrāva leading to Dhātu kshaya resulting in Vāta Prakopa which in turn leads to

mobilization and vitiation of Pitta. This causes severe pain accompanied by Trishnā,

Śosha, Bhrama and later death preceded by excessive sweating. Suśruta emphasizes

more on Vāta Prakopa and its role in destroying the normal physiological functions

and producing excessive pain leading to unconsciousness.

Thus Marmābhighāta leads to a condition of shock when the trauma is severe.

As we know shock is a sudden upset in the normal physiological function or

homeostasis. It is a reflex vasodilatation and fall in blood pressure, loss of

consciousness and sometimes leading to death.

Conclusion


CONCLUSION

On the basis of information collected under the review of literature and

discussion, the evolved conclusions are presented below:

1. Raktamokshana procedure was practiced by almost all cultures and

societies at some point in their medical history.

2. Sirāvyadha is an effective treatment for many diseases when other

methods of treatment fail.

3. Knowledge of Marmasthāna is required to carry out the Sirāvyadha

procedure effectively.

4. Ācharyas have given a clear description of the sites of Sirāvyadha in

various diseases which are scientific and can be anatomically correlated.

5. Suśruta has mentioned the Vedhya Sirās of extremities in connection with

the disease which are most probably the superficial veins of the limbs.

6. It has been clearly mentioned the procedure of Sirāvyadha should not be

conducted on Avedhya Sirās which are Marmāśrita.

7. Except the Avedhya Sirās, all the Vedhya Sirās are suitable for performing

the Sirāvyadha procedure.

8. Thorough knowledge of the superficial veins of Lower extremities is a

prerequisite for understanding the sites of Sirāvyadha in the lower limbs.

Though the Anatomical identification and significance of sites of Sirāvyadha

is clear, the study would not be complete unless the sites of Sirāvyadha are clinically

evaluated to prove their therapeutic efficacy.

Conclusion


Recommendation for Future Study

As the concept of Sirā Shareera and Sirāvyadha Vidhi Shareera are still

unclear to grasp and adopt, Shalyatantra scholars can continue clinical study on

individual site of Sirāvyadha in individual diseases to evaluate therapeutic efficacy of

Sirāvyadha.

Summary


SUMMARY

The present study entitled “A comprehensive study of Sirāvyadha w.s.r. to

anatomical and Marma relevance of the lower extremity” comprises of seven

Chapters.

Chapter – I

This Chapter deals with an introduction to Śodhana Chikitsa and gives a

description of the role of Raktamokshana highlighting Sirāvyadha and its

significance. It also deals with the importance of Marma Śarīra in the concept of

Sirāvyadha and the scope of the study.

Chapter – II

This Chapter gives an outline of the study objectives

Chapter – III

This Chapter details about the literary view which is subdivided into four parts

– Historical review, Review of Sirāvyadha, Review of Marma and Modern review.

Historical review discusses references of Sirāvyadha and Marma from

classical works of Vedic, Pauranic , Samhita period and Modern Era.

Ayurvedic review of Sirāvyadha deals with etymology, classification of Sirās,

description regarding Vedhya and Avedhya Sirās, Sites of Sirāvyadha in Lower

extremities with its Marma relevance and Sirāvyadha Vidhi in detail.

Ayurvedic review of Marma explains the definition of Marma, Classification

of Marmas, importance of Marma in Chikitsa and detailed description of Marmas of

Lower limb.

Modern review gives a detailed description regarding the modern concept of

anatomy of venous system and Veins of Lower extremities with its applied aspect.

Summary


Chapter – IV

In this Chapter, need for study, materials and methods and an outline of the

dissection procedure of the superficial veins of Lower extremities were explained.

Chapter – V

In this chapter,the observations following the dissection of lower limb were

recorded.In the discussion, conceptual study regarding sites of Sirāvyadha in the

Lower extremities and its anatomical and Marma relevance has been highlighted.

Chapter – VI

In this Chapter, the conclusions drawn from various Chapters have been

included.

Chapter – VII

This chapter summarizes the entire work.

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wÉÎOè§ÉÇzÉŠ zÉiÉÇ MüÉå¸å cÉiÉÑ:wÉ¹Ç cÉ qÉÔkÉïÌlÉ || (xÉÑ.zÉÉ.7/20)

40. zÉÉZÉÉxÉÑ wÉÉåQûzÉ ÍxÉUÉ: MüÉå¸å ²ÉÌ§ÉÇzÉSåuÉ iÉÑ |

mÉgcÉÉzÉ‹§ÉÑhÉ¶ÉÉåkuÉïqÉurÉkrÉÉ: mÉËUMüÐÌiÉïiÉÉ: || (xÉÑ.zÉÉ.7/21)

41. iÉ§É ÍxÉUÉzÉiÉqÉåMüÎxqÉlÉç xÉÎYjlÉ pÉuÉÌiÉ; iÉÉxÉÉÇ eÉÉsÉkÉUÉ iuÉåMüÉ, ÌiÉxÉë¶ÉÉprÉliÉUÉ: -

iÉ§ÉÉåuÉÏïxÉÇ¥Éå ²å, sÉÉåÌWûiÉÉ¤ÉxÉÇ¥ÉÉ cÉæMüÉ, iÉÉxiuÉurÉkrÉÉ:; LiÉålÉåiÉUxÉÎYjÉ oÉÉWÕû cÉ urÉÉZrÉÉiÉÉæ;

LuÉqÉzÉx§ÉM×üirÉÉ: wÉÉåQûzÉ zÉÉZÉÉxÉÑ | (xÉÑ.zÉÉ.7/22)

42. AuÉåkrÉÉxiÉ§É MüÉixlrÉåïlÉ SåWåûÅ¹ÉlÉuÉÌiÉxiÉjÉÉ |

xÉƒ¡ûÏhÉÉï aÉëÍjÉiÉÉ: ¤ÉÑSìÉ uÉ¢üÉ: xÉÎlkÉwÉÑ cÉÉÍ´ÉiÉÉ: || (A.WØû.zÉÉ.3/34)

43. zÉx§ÉÌuÉxÉëÉuÉhÉÇ Ì²ÌuÉkÉÇ - mÉëcNûÉlÉÇ, ÍxÉUÉurÉkÉlÉÇ cÉ || (xÉÑ.xÉÔ.14/25)

44. iÉ§É, GeuÉxÉÇMüÐhÉïÇ xÉÔ¤qÉÇ xÉqÉqÉlÉuÉaÉÉRûqÉlÉÑ ÉlÉqÉÉzÉÑ cÉ zÉx§ÉÇ mÉÉiÉrÉålqÉqÉïÍxÉUÉxlÉÉrÉÑxÉlkÉÏlÉÉÇ

cÉÉlÉÑmÉbÉÉÌiÉ || (xÉÑ.xÉÔ.14/26)

45. iÉ§É mÉÉSSÉWûmÉÉSWûwÉïÍcÉmmÉÌuÉxÉmÉïuÉÉiÉzÉÉåÍhÉiÉuÉÉiÉMühOûMüÌuÉcÉÍcÉïMüÉmÉÉSSÉUÏ mÉëpÉ×ÌiÉwÉÑ Í¤ÉmÉëqÉqÉïhÉ

EmÉËU¸ÉSè ½…¡ÓûsÉå uÉëÏÌWûqÉÑZÉålÉ ÍxÉUÉÇ ÌuÉkrÉåiÉç, zsÉÏmÉSå iÉÎŠÌMüÎixÉiÉå rÉjÉÉ uÉ¤rÉiÉå, ¢üÉå¹ÒMüÍzÉU:

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eÉÉlÉÑxÉlkÉåÂmÉrÉïkÉÉå uÉÉ cÉiÉÑU…¡ÓûsÉå aÉ×kÉëxrÉÉÇ, FÂqÉÔsÉxÉÇÍ´ÉiÉÉÇ aÉsÉaÉhQåû, (xÉÑ.zÉÉ.8/17)

46. aÉsÉaÉhQÇû FÂqÉÔsÉxÉÇÍ´ÉiÉÉqÉç | aÉ×kÉëxrÉÉÇ eÉÉlÉÑxÉlkÉåÂmÉrÉïkÉÉå uÉÉ cÉiÉÑU…¡ÓûsÉå |

AmÉcrÉÉÍqÉlSìoÉxiÉåUkÉxiÉÉiÉç SèurÉ…¡ÓûsÉå | ¢üÉå¹ÒMüzÉÏwÉåï xÉÎYjÉuÉÉiÉÂeÉÉxÉÑ cÉ

aÉÑsTüxrÉÉåmÉËU¹ÉŠiÉÑU…¡ÓûsÉå | SÉWûWûwÉïÍcÉmmÉuÉÉiÉzÉÉåÍhÉiÉuÉÉiÉMühOûMüÌuÉmÉÉÌSMüÉmÉÉSSÉUÏmÉëpÉ×ÌiÉwÉÑ

mÉÉSUÉåaÉåwÉÑ Í¤ÉmÉëqÉqÉïhÉ EmÉËU¹ÉiÉç SèurÉ…¡ÓûsÉå | (A.xÉÇ.xÉÔ.36/8)

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47. iuÉaSÉåwÉÉ aÉëljÉrÉ: zÉÉåTüÉ UÉåaÉÉ: zÉÉåÍhÉiÉeÉÉ¶É rÉå |

U£üqÉÉå¤ÉhÉzÉÏsÉÉlÉÉÇ lÉ pÉuÉÎliÉ MüSÉcÉlÉ || (xÉÑ.xÉÔ.14/34)

48. ÌuÉxÉmÉïÌuÉSìÍkÉmsÉÏWûaÉÑsqÉÉÎalÉxÉSlÉeuÉUÉlÉç |

qÉÑZÉlÉå§ÉÍzÉUÉåUÉåaÉqÉSiÉ×QèsÉuÉhÉÉxrÉiÉÉ: || (A.WØû.xÉÔ.27/3)

49. MÑü¸uÉÉiÉÉxÉëÌmÉ¨ÉÉxÉëMüOèuÉqsÉÉåÌªUhÉpÉëqÉÉlÉç |

zÉÏiÉÉåwhÉÎxlÉakÉÃ¤ÉÉ±æÂmÉ¢üÉliÉÉ¶É rÉå aÉSÉ: || (A.™.xÉÔ.27/4)

50. xÉqrÉYxÉÉkrÉÉ lÉ ÍxÉkrÉÎliÉ iÉå cÉ U£ümÉëMüÉåmÉeÉÉ: |

iÉåwÉÑ xÉëÉuÉÌrÉiÉÑÇ U£üqÉÑÌSìMÇü urÉkÉrÉåÎixÉUÉqÉç || (A.™.xÉÔ.27/5)

51. oÉÉsÉxjÉÌuÉUÃ¤É¤ÉiÉ¤ÉÏhÉpÉÏÂmÉËU´ÉÉliÉqÉ±mÉÉkuÉx§ÉÏMüÍzÉïiÉuÉÍqÉiÉÌuÉËU£üÉxjÉÉÌmÉiÉÉlÉÑuÉÉÍxÉiÉ

eÉÉaÉËUiÉYsÉÏoÉM×üzÉaÉÍpÉïhÉÏlÉÉÇMüÉxÉµÉÉxÉzÉÉåwÉmÉëuÉ×®euÉUÉ¤ÉåmÉMümÉ¤ÉÉbÉÉiÉÉåmÉuÉÉxÉÌmÉmÉÉxÉÉqÉÔcNûÉï

mÉëmÉÏÌQûiÉÉlÉÉÇ cÉ ÍxÉUÉÇ lÉ ÌuÉkrÉåiÉç, rÉÉ¶ÉurÉÉkrÉÉ: urÉÉkrÉÉ¶ÉÉSØ¹É: SØ¹É¶ÉÉrÉÎl§ÉiÉÉ:

rÉÎl§ÉiÉÉ¶ÉÉlÉÑÎijÉiÉÉ CÌiÉ| (xÉÑ.zÉÉ.8/3)

a. oÉÉsÉxjÉÌuÉUrÉÉåUxÉÇmÉÔhÉï¤ÉÏhÉkÉÉiÉÑiuÉÉiÉç ÍxÉUÉÇ lÉ ÌuÉkrÉåiÉç |

b. Ã¤É¤ÉiÉ¤ÉÏhÉÉlÉÉÇ uÉÉiÉmÉëMüÉåmÉpÉrÉÉiÉç ÍxÉUÉÇ lÉ ÌuÉkrÉåiÉç |

c. pÉÏUÉå¶É iÉqÉÉåoÉWÒûsÉiuÉÉiÉç sÉÉåÌWûiÉSzÉïlÉålÉ qÉÔcNûÉïpÉrÉ³É ÌuÉkrÉåiÉç |

d. mÉËU´ÉÉliÉxrÉ ´ÉqÉMÑüÌmÉiÉÉå uÉÉiÉ: zÉÉåÍhÉiÉÉuÉxÉåcÉlÉålÉÉÌiÉmÉëÉoÉsrÉÇ mÉëÉmrÉ zÉUÏUurÉÉmÉÉSMü: xrÉÉiÉç |

e. qÉ±mÉxrÉ qÉSÌuÉÍ¤ÉmiÉÍcÉ¨ÉxrÉÉÌiÉqÉÔcNûÉïMüUiuÉÉiÉç |

f. AkuÉx§ÉÏMüÍzÉïiÉxrÉ uÉÉiÉmÉëMüÉåmÉpÉrÉÉ³É ÌuÉkrÉåiÉç |

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g. uÉÉliÉÌuÉËU£ürÉÉåUM×üiÉxÉÇxÉeÉïlÉrÉÉåUmÉÏiÉxlÉåWûrÉÉåuÉïqÉlÉÌuÉUåMüÉlÉliÉUqÉåuÉ uÉÉiÉmÉëMüÉåmÉpÉrÉÉiÉç ÍxÉUÉÇ lÉ

ÌuÉkrÉåiÉç |

h. AÉxjÉÉÌmÉiÉeÉÉaÉËUiÉrÉÉåqÉïÂimÉëMüÉåmÉpÉrÉÉ³É ÌuÉkrÉåiÉç |

i. AlÉÑuÉÉÍxÉiÉxrÉ qÉlSåÅalÉÉæ pÉÔrÉÉåÅÎalÉqÉÉl±pÉrÉÉiÉç |

j. YsÉÏoÉxrÉ mÉëkÉÉlÉkÉÉiÉÑ¤ÉrÉåhÉÉsmÉxÉ¨uÉiuÉålÉ cÉ ÌlÉÍ¶ÉiÉÌuÉlÉÉzÉÉiÉç |

k. M×üzÉxrÉ aÉÍpÉïhÉÏlÉÉÇ cÉÉåmÉ¤ÉÏhÉkÉÉiÉÑiuÉÉiÉç SåWûxÉÇSåWûpÉrÉÉiÉç |

l. MüÉxÉµÉÉxÉzÉÉåÌwÉhÉÉqÉmrÉmÉcÉÏrÉqÉÉlÉkÉÉiÉÑiuÉålÉ SåWûxÉlSåWûpÉrÉÉ³É ÌuÉkrÉåiÉç |

m. mÉëuÉ×®euÉUxrÉÉxÉ×YxÉëÉuÉåhÉ mÉësÉÉmÉÉÌSpÉrÉÉiÉç ÍxÉUÉÇ lÉ ÌuÉkrÉåiÉç |

52. mÉëÌiÉÌwÉ®ÉlÉÉqÉÌmÉ cÉ ÌuÉwÉÉåmÉxÉaÉåï AÉirÉÌrÉMåü cÉ ÍxÉUÉurÉkÉlÉqÉmÉëÌiÉÌwÉ®qÉç | (xÉÑ.zÉÉ.8/5)

53. lÉæuÉÉÌiÉzÉÏiÉå lÉÉirÉÑwhÉå lÉ mÉëuÉÉiÉå lÉ cÉÉÍpÉëiÉå ||

ÍxÉUÉhÉÉÇ urÉkÉlÉÇ MüÉrÉïqÉUÉåaÉå uÉÉ MüSÉcÉlÉ || (xÉÑ.zÉÉ.8/7)

54. AjÉÉÌuÉxÉëÉurÉÉ: - xÉuÉÉï…¡ûzÉÉåTü: ¤ÉÏhÉxrÉ cÉÉqsÉpÉÉåeÉlÉÌlÉÍqÉ¨É:,

mÉÉhQÒûUÉåarÉzÉïxÉÉåSUÏzÉÉåÌwÉaÉÍpÉïhÉÏlÉÉÇ cÉ µÉrÉjÉuÉ: || (xÉÑ.xÉÔ.14/24)

55. ÍxÉUÉzÉiÉÉlÉÉÇ xÉmiÉÉlÉÉÇ zÉUÏUåwÉÑ zÉUÏËUhÉÉqÉç |

AzÉx§ÉM×üirÉÉ lÉuÉÌiÉxiÉjÉÉÅ¹Éæ cÉ ÌuÉÌlÉÌSïzÉåiÉç ||

xmÉÎlSlrÉÉå eÉsÉkÉÉËUhrÉÉå rÉÉ¶É qÉqÉïxÉqÉÉÍ´ÉiÉÉ: || (xÉÑ.zÉÉ.7/ÌlÉoÉlkÉxÉÇaÉëWû)

56. uÉæMüsrÉÇ qÉUhÉÇ cÉÉÌmÉ urÉkÉÉ¨ÉÉxÉÉÇ kÉëÑuÉÇ pÉuÉåiÉç || (xÉÑ.zÉÉ.7/19)

57. mÉëÉaÉåuÉ cÉÉåmÉMüsmÉrÉåcNûrÉlÉÉxÉlÉÉåSMÑüqpÉuÉx§ÉmÉ–ûÉÌS |

iÉjÉÉ rÉjÉÉsÉÉpÉÇ cÉ iÉaÉUæsÉÉzÉÏiÉÍzÉuÉMÑü¸mÉÉPûÉÌuÉQû…¡ûpÉSìSÉÂ -

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Ì§ÉMüOÒûMüÉaÉÉUkÉÔqÉWûËUSìÉMüÉïƒ¡ÓûUlÉ£üqÉÉsÉcÉÔhÉïqÉxÉ×YxÉëÉuÉhÉÉrÉ | AxÉ×YxjÉÉmÉlÉÉrÉ cÉ

sÉÉåkÉëqÉkÉÑMüÌmÉërÉ…¡ÓûmÉ¨É…¡ûaÉæËUMüUxÉÉgeÉlÉzÉÉsqÉsÉÏzÉ„¡ûrÉuÉaÉÉåkÉÔqÉqÉÉwÉcÉÔhÉïqÉç |

uÉOûÉµÉijÉÉµÉMühÉïmÉsÉÉzÉÌoÉpÉÏiÉMüxÉeÉÉïeÉÑïlÉkÉluÉkÉÉiÉMüÐxÉÉsÉxÉÉUÉËUqÉåSÌiÉlSÒMü -

iuÉaÉƒ¡ÓûUÌlÉrÉÉïxÉ´ÉÏuÉå¹Mü qÉ×iMümÉÉsÉqÉ×hÉÉsÉÉgeÉlÉcÉÔhÉïqÉç |

¤ÉÉæqÉqÉwÉÏsÉÉ¤ÉÉxÉqÉÑSìTåülÉcÉÔhÉïÇ uÉÉ | iÉjÉÉlrÉŠÉÌiÉxÉëÑiÉU£üurÉÉmÉimÉëiÉÏMüÉUÉåmÉMüUhÉqÉç |

(A.xÉÇ.xÉÔ.36/9)

58. qÉÉÇxÉsÉåwuÉuÉMüÉzÉåwÉÑ rÉuÉqÉÉ§ÉÇ zÉx§ÉÇ ÌlÉSkrÉÉiÉç, AiÉÉåÅlrÉjÉÉÅkÉïrÉuÉqÉÉ§ÉÇ uÉëÏÌWûqÉÉ§ÉÇ uÉÉ uÉëÏÌWûqÉÑZÉålÉ,

AxjlÉÉqÉÑmÉËU MÑüPûÉËUMürÉÉ ÌuÉkrÉåSkÉïrÉuÉqÉÉ§ÉqÉç || (xÉÑ.zÉÉ.8/9)

59. urÉpÉëå uÉwÉÉïxÉÑ ÌuÉkrÉå¨ÉÑ aÉëÏwqÉMüÉsÉå iÉÑ zÉÏiÉsÉå |

WåûqÉliÉMüÉsÉå qÉkrÉÉ»åû zÉx§ÉMüÉsÉÉx§ÉrÉ: xqÉ×iÉÉ: || (xÉÑ.zÉÉ.8/10)

60. iÉxqÉÉ³É zÉÏiÉå lÉÉirÉÑwhÉå lÉÉÎxuÉ³Éå lÉÉÌiÉiÉÉÌmÉiÉå |

rÉuÉÉaÉÔÇ mÉëÌiÉmÉÏiÉxrÉ zÉÉåÍhÉiÉÇ qÉÉå¤ÉrÉåÎ°wÉMçü || (xÉÑ.xÉÔ.14/31)

61. AjÉ M×üiÉxuÉxirÉrÉlÉqÉÉiÉÑUÇ urÉÉÍkÉoÉsÉxÉÉiqrÉÉ±uÉå¤rÉ ÎxlÉakÉÇ eÉÉ…¡ûsÉUxÉÇ rÉuÉÉaÉÔÇ uÉÉ mÉÉrÉÌrÉiuÉÉ

qÉÑWÕûiÉïqÉÉ§ÉqÉÉµÉÉÍxÉiÉÇ mÉÔuÉÉïºåûÅmÉUÉÀåû uÉÉ…¡ûÉUiÉÉmÉÉåwhÉoÉÉwmÉÉlrÉiÉUåhÉ ÎxuÉ³ÉÇ eÉÉlÉÔÎcNíûiÉå qÉ×SÉuÉÉxÉlÉå

eÉÉlÉÑÌlÉÌWûiÉMÔümÉïUÇ xÉqÉÎxjÉiÉmÉÉSÇ mÉëirÉÉÌSirÉqÉÑmÉuÉåzÉrÉåiÉç | MåüzÉÉliÉåcÉ msÉÉåiÉcÉqÉïuÉsMüsÉmÉ–

ûÉlrÉiÉqÉålÉ oÉlkÉÏrÉÉiÉç | iÉiÉ¶ÉÉrÉiÉålÉ uÉx§ÉÉ…¡Óû¸aÉpÉåïhÉ qÉÑÌ¹²rÉålÉÉiÉÑUÉå rÉjÉÉxuÉÇqÉlrÉå ÌlÉmÉÏQûrÉå¬liÉæ¶É

SliÉÉlÉç | aÉhQûÉæ cÉÉkqÉÉmÉrÉåiÉç | (A.xÉÇ.xÉÔ.36/10)

62. xÉqrÉMçü zÉx§ÉÌlÉmÉÉiÉålÉ kÉÉUrÉÉ rÉÉ xÉëuÉåSxÉ×Mçü |

qÉÑWÕûiÉïÇ Â®É ÌiÉ¸åŠ xÉÑÌuÉ®ÉÇ iÉÉÇ ÌuÉÌlÉÌSïzÉåiÉç ||

rÉjÉÉ MÑüxÉÑqpÉmÉÑwmÉåprÉ: mÉÔuÉïÇ xÉëuÉÌiÉ mÉÏÌiÉMüÉ |

References


iÉjÉÉ ÍxÉUÉxÉÑ ÌuÉ®ÉxÉÑ SÒ¹qÉaÉëå mÉëuÉiÉïiÉå || (xÉÑ.zÉÉ.8/11-12)

63. iÉ¬Ò¹Ç zÉÉåÍhÉiÉqÉÌlÉÌ¾ïûrÉqÉhÉÇ zÉÉåTüSÉWûUÉaÉmÉÉMüuÉåSlÉÉ eÉlÉrÉåiÉç || (xÉÑ.xÉÔ.14/29)

64. AirÉÑwhÉåÅÌiÉÎxuÉ³ÉåÅÌiÉÌuÉ®åÅ¥ÉæÌuÉïxÉëÉÌuÉiÉqÉÌiÉmÉëuÉiÉïiÉå; iÉSÌiÉmÉëuÉ×¨ÉÇ

ÍzÉUÉåÅÍpÉiÉÉmÉqÉÉlkrÉqÉÍkÉqÉljÉÌiÉÍqÉUmÉëÉSÒpÉÉïuÉÇ kÉÉiÉÑ¤ÉrÉqÉÉ¤ÉåmÉMÇü SÉWÇû mÉ¤ÉÉbÉÉiÉqÉåMüÉ…¡ûÌuÉMüÉUÇ

ÌWû‚üÉÇ µÉÉxÉMüÉxÉÉæ mÉÉhQÒûUÉåaÉÇ qÉUhÉÇ cÉÉmÉÉSrÉÌiÉ || (xÉÑ.xÉÔ.14/30)

65. oÉÍsÉlÉÉå oÉWÒûSÉåwÉxrÉ uÉrÉ:xjÉxrÉ zÉUÏËUhÉ: |

mÉUÇ mÉëqÉÉhÉÍqÉcNûÎliÉ mÉëxjÉÇ zÉÉåÍhÉiÉqÉÉå¤ÉhÉå || (xÉÑ.zÉÉ.8/16)

66. SÒ¹urÉkÉÉ ÌuÉÇzÉÌiÉ: - SÒÌuÉï®ÉÅÌiÉÌuÉ®É MÑüÎgcÉiÉÉ ÌmÉÎŠiÉÉ MÑüÌ–ûiÉÉÅmÉëxÉëÑiÉÉÅirÉÑSÏhÉÉïÅliÉå ÌuÉ®É

mÉËUzÉÑwMüÉ MÔüÍhÉiÉÉ uÉåÌmÉiÉÉÅlÉÑÎijÉiÉÌuÉ®É zÉx§ÉWûiÉÉ ÌiÉrÉïÎauÉ®ÉÌuÉ®ÉÅurÉkrÉÉÌuÉSìÓiÉÉ kÉålÉÑMüÉ mÉÑlÉ:

mÉÑlÉÌuÉï®É ÍxÉUÉxlÉÉruÉÎxjÉxÉÎlkÉqÉqÉïxÉÑ cÉåÌiÉ || (xÉÑ.zÉÉ.8/18)

67. iÉ§É rÉÉ xÉÔ¤qÉzÉx§ÉÌuÉ®ÉÅurÉ£üqÉxÉ×Mçü xÉëuÉÌiÉ ÂeÉÉzÉÉåTüuÉiÉÏ cÉ xÉÉ SÒÌuÉï®É,

mÉëqÉÉhÉÉÌiÉËU£üÌuÉ®ÉrÉÉqÉliÉ: mÉëÌuÉzÉÌiÉ zÉÉåÍhÉiÉÇ zÉÉåÍhÉiÉÉÌiÉmÉëuÉ×Ì¨ÉuÉÉï xÉÉÅÌiÉÌuÉ®É,

MÑüÎgcÉiÉÉrÉÉqÉmrÉåuÉÇ, MÑühPûzÉx§ÉmÉëqÉÍjÉiÉÉ mÉ×jÉÑsÉÏpÉÉuÉqÉÉmÉ³ÉÉ ÌmÉÎŠiÉÉ, AlÉÉxÉÉÌSiÉÉ mÉÑlÉ:

mÉÑlÉUliÉrÉÉå¶É oÉWÒûzÉ: zÉx§ÉÉÍpÉWûiÉÉ MÑüÌ–ûiÉÉ, zÉÏiÉpÉrÉqÉÔcNûÉïÍpÉUmÉëuÉ×¨ÉzÉÉåÍhÉiÉÉ AmÉëxÉëÑiÉÉ,

iÉÏ¤hÉqÉWûÉqÉÑZÉzÉx§ÉÌuÉ®ÉÅirÉÑSÏhÉÉï, AsmÉU£üxÉëÉÌuÉhrÉliÉåÌuÉ®É, ¤ÉÏhÉzÉÉåÍhÉiÉxrÉÉÌlÉsÉmÉÔhÉÉï

mÉËUzÉÑwMüÉ, cÉiÉÑpÉÉïaÉÉxÉÉÌSiÉÉ ÌMüÎgcÉimÉëuÉ×¨ÉzÉÉåÍhÉiÉÉ MÔüÍhÉiÉÉ, SÒ:xjÉÉlÉoÉlkÉlÉÉ²åmÉqÉÉlÉÉrÉÉ:

zÉÉåÍhÉiÉxÉÇqÉÉåWûÉå pÉuÉÌiÉ xÉÉ uÉåÌmÉiÉÉ, AlÉÑÎijÉiÉÌuÉ®ÉrÉÉqÉmrÉåuÉÇ, ÍNû³ÉÉÅÌiÉmÉëuÉ×¨ÉzÉÉåÍhÉiÉÉ

Ì¢ürÉÉxÉ…¡ûMüUÏ zÉx§ÉWûiÉÉ, ÌiÉrÉïMçü mÉëÍhÉÌWûiÉzÉx§ÉÉ ÌMüÎgcÉcNåûwÉÉ ÌiÉrÉïÎauÉ®É, oÉWÒûzÉ: ¤ÉiÉÉ

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References


oÉWÒûzÉÉåÅuÉbÉ–ûlÉÉSÉUÉåWûSèurÉkÉÉ qÉÑWÒûqÉÑïWÒû: zÉÉåÍhÉiÉxÉëÉuÉÉ kÉålÉÑMüÉ, xÉÔ¤qÉzÉx§ÉurÉkÉlÉÉ¯WÒûzÉÉå ÍpÉ³ÉÉ

mÉÑlÉ: mÉÑlÉÌuÉï®É, xlÉÉruÉÎxjÉÍxÉUÉxÉÎlkÉqÉqÉïxÉÑ ÌuÉ®É ÂeÉÉÇ zÉÉåTÇü uÉæMüsrÉÇ qÉUhÉÇ cÉÉmÉÉSrÉÌiÉ ||

(xÉÑ.zÉÉ.8/19)

68. cÉiÉÑÌuÉïkÉÇ rÉSåiÉÎ® ÂÍkÉUxrÉ ÌlÉuÉÉUhÉqÉç |

xÉlkÉÉlÉÇ xMülSlÉÇ cÉæuÉ mÉÉcÉlÉÇ SWûlÉÇ iÉjÉÉ ||

uÉëhÉÇ MüwÉÉrÉ: xÉÇkÉ¨Éå U£Çü xMülSrÉiÉå ÌWûqÉqÉç |

iÉjÉÉ xÉÇmÉÉcÉrÉå°xqÉ SÉWû: xÉÇMüÉåcÉrÉåiÉç ÍxÉUÉ: || (xÉÑ.xÉÔ.14/39-40)

69. qÉÉUrÉÎliÉ CÌiÉ qÉqÉÉïÍhÉ | (xÉÑ.vÉÉ. 6/3)

70. qÉëÏrÉiÉåÅÎxqÉlÉÅ…¡ûÉåmÉWûiÉå | (AÂhÉSiÉ, A.Wû.vÉÉ.4)

71. SzÉæuÉÉrÉiÉlÉÉlrÉÉWÒû: mÉëÉhÉÉ rÉåwÉÑ mÉëÌiÉÌ¸iÉÉ: |

zÉ„¡ûÉæ qÉqÉï§ÉrÉÇ MühPûÉå U£Çü zÉÑ¢üÉæeÉxÉÏ aÉÑSqÉç || (cÉ.xÉÔ.29/3)

72. SzÉ mÉëÉhÉÉrÉiÉlÉÉÌlÉ; iÉ±jÉÉ - qÉÔkÉÉï, MühPû:, ™SrÉÇ, lÉÉÍpÉ:, aÉÑSÇ, oÉÎxiÉ:, AÉåeÉ:, zÉÑ¢Çü,

zÉÉåÍhÉiÉÇ, qÉÉÇxÉÍqÉÌiÉ | iÉåwÉÑ wÉOèû mÉÔuÉÉïÍhÉ qÉqÉïxÉÇZrÉÉiÉÉÌlÉ || (cÉ.zÉÉ.7/9)

73. xÉmiÉÉå¨ÉUÇ rÉSÒ£Çü zÉUÏUxÉÇZrÉÉqÉÍkÉM×üirÉ iÉåprÉ: |

qÉqÉÉïÍhÉ oÉÎxiÉÇ ™SrÉÇ ÍzÉU¶É mÉëkÉÉlÉpÉÔiÉÉÌlÉ uÉSÎliÉ iÉe¥ÉÉ: || (cÉ.ÍcÉ.26/3)

74. mÉëÉhÉÉ´ÉrÉÉiÉç, iÉÉÌlÉ ÌWû mÉÏQûrÉliÉÉå uÉÉiÉÉSrÉÉåÅxÉÔlÉÌmÉ mÉÏQûrÉÎliÉ |

iÉixÉÇÍ´ÉiÉÉlÉÉqÉlÉÑmÉÉsÉlÉÉjÉïÇ qÉWûÉaÉSÉlÉÉÇ ´É×hÉÑ xÉÉæqrÉ ! U¤ÉÉqÉç || (cÉ.ÍcÉ.26/4)

75. xÉÇxmÉ×zrÉ qÉqÉÉïhrÉÌlÉsÉxiÉÑ qÉÔÎklÉï ÌuÉwuÉYmÉjÉxjÉ: ¤ÉuÉjÉÑÇ MüUÉåÌiÉ |

¢Ñü®: xÉ xÉÇzÉÉåwrÉ MüTÇü iÉÑ lÉÉxÉÉzÉ×…¡ûÉOûMübÉëÉhÉÌuÉzÉÉåwÉhÉÇ cÉ || (cÉ.ÍcÉ.26/104)

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mÉÏQûÉ pÉuÉÌiÉ, cÉåiÉlÉÉÌlÉoÉlkÉuÉæzÉåwrÉÉiÉç | iÉ§É zÉÉZÉÉÍ´ÉiÉåprÉÉå qÉqÉïprÉ: xMülkÉÉÍ´ÉiÉÉÌlÉ aÉUÏrÉÉÇÍxÉ,

zÉÉZÉÉlÉÉÇ iÉSÉÍ´ÉiÉiuÉÉiÉç; xMülkÉÉÍ´ÉiÉåprÉÉåÅÌmÉ ™¯ÎxiÉÍzÉUÉÇÍxÉ iÉlqÉÔsÉiuÉÉcNûUÏUxrÉ ||

(cÉ.ÍxÉ.9/3)

77. iÉåwÉÉÇ §ÉrÉÉhÉÉqÉlrÉiÉqÉxrÉÉÌmÉ pÉåSÉSÉµÉåuÉ zÉUÏUpÉåS: xrÉÉiÉç, AÉ´ÉrÉlÉÉzÉÉSÉÍ´ÉiÉxrÉÉÌmÉ ÌuÉlÉÉzÉ:;

iÉSÒmÉbÉÉiÉÉ¨ÉÑ bÉÉåUiÉUurÉÉÍkÉmÉëÉSÒpÉÉïuÉ:, iÉxqÉÉSåiÉÉÌlÉ ÌuÉzÉåwÉåhÉ U¤rÉÉÍhÉ oÉÉ½ÉÍpÉbÉÉiÉÉÌSprÉ¶É ||

(cÉ.ÍxÉ.9/5)

78. qÉqÉÉïÍhÉ zÉsrÉÌuÉwÉrÉÉkÉïqÉÑSÉWûUÎliÉ rÉxqÉÉŠ qÉqÉÉïxÉÑ WûiÉÉ lÉ pÉuÉÎliÉ xÉ±: |

eÉÏuÉÎliÉ iÉ§É rÉÌS uÉæ±aÉÑhÉålÉ MåüÍcÉ¨ÉåmÉëÉmlÉÑuÉÎliÉ ÌuÉMüsÉiuÉqÉxÉÇzÉrÉÇ ÌWû || (xÉÑ.zÉÉ.6/33)

79. LiÉimÉëqÉÉhÉqÉÍpÉuÉÏ¤rÉ uÉSÎli ÉiÉe¥ÉÉ: zÉx§ÉåhÉ MüqÉïMüUhÉÇ mÉËUWØûirÉ MüÉrÉïqÉç |

mÉÉµÉÉïÍpÉbÉÉÌiÉiÉqÉmÉÏW ûÌlÉWûÎliÉ qÉqÉï iÉxqÉÉÎ® qÉqÉïxÉSlÉÇ mÉËUuÉeÉïlÉÏrÉqÉç || (xÉÑ.zÉÉ.6/30)

80. qÉqÉÉïÍhÉ qÉÉÇxÉÍxÉUÉxlÉÉruÉÎxjÉxÉÎlkÉxÉÍ³ÉmÉÉiÉÉ:; iÉåwÉÑxuÉpÉÉuÉiÉLuÉÌuÉzÉåwÉåhÉ mÉëÉhÉÉÎxiÉ¹ÎliÉ;

iÉxqÉÉlqÉqÉïxuÉÍpÉWûiÉÉxiÉÉÇxiÉÉlÉçpÉÉuÉÉlÉÉmÉ±liÉå || (xÉÑ.zÉÉ.6/15)

81. xÉmiÉÉå¨ÉUÇ qÉqÉïzÉiÉqÉç | iÉ§É cÉiÉÑ¶ÉiuÉÉËUÇzÉcNûÉZÉÉxÉÑ wÉQèû ÌuÉÇzÉÌiÉUliÉUÉkÉÉæ xÉmiÉÌ§ÉÇzÉSÕkuÉïqÉç |

(A.xÉÇ.zÉÉ.7/3)

82. qÉqÉÉïÍpÉbÉÉiÉ: xuÉsmÉÉåÅÌmÉ mÉëÉrÉzÉÉå oÉÉkÉiÉåiÉUÉÇ

UÉåaÉÉ qÉqÉÉï´ÉrÉÉxiÉ²SÒmÉ¢üÉliÉÉ rÉ¦ÉiÉÉåÅÌmÉ cÉ || (A.xÉÇ.zÉÉ.7/36)

83. qÉqÉïurÉÉmiÉåÅÌmÉ SåWåûÅÎxqÉ³ÉÉrÉÑqÉïqÉÉïÍhÉ U¤ÉÌiÉ |

AÉrÉÑwrÉÉhrÉåuÉ xÉåuÉåiÉ xÉSÉ iÉxqÉÉÌ²cÉ¤ÉhÉ: || (A.xÉÇ.zÉÉ.7/35)

84. AqÉqÉïÌuÉ®ÉåÅÌmÉ lÉUcNåûSpÉåSÉÌS mÉÏÌQûiÉ: |

AÌiÉÌlÉxÉ×iÉU£ü¶É xÉ±xirÉeÉÌiÉ eÉÏÌuÉiÉqÉç || (A.xÉÇ.zÉÉ.7/39)

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85. xÉmiÉÉå¨ÉUÇ qÉqÉïzÉiÉqÉç iÉåwÉÉqÉåMüÉSzÉÉÌSzÉåiÉç |

mÉ×jÉYxÉYjlÉÉåxiÉjÉÉ oÉÉÀûÉåx§ÉÏÍhÉ MüÉå¸å lÉuÉÉåUÍxÉ || (A.xÉÇ.zÉÉ.7/3)

86. cÉiÉÑ®Éåï£üÉ: ÍxÉUÉxiÉÑ rÉÉ: ||

iÉmÉïÎliÉ uÉmÉÑ: M×üixlÉÇ iÉÉ qÉqÉÉïhrÉÉÍ´ÉiÉÉxiÉiÉ: |

iÉi¤ÉiÉÉi¤ÉiÉeÉÉirÉjÉïmÉëuÉ×¨ÉåkÉÉïiÉÑxÉÇ¤ÉrÉå ||

uÉ×®¶ÉsÉÉå ÂeÉxiÉÏuÉëÉ: mÉëiÉlÉÉåÌiÉ xÉqÉÏUrÉlÉç |

iÉåeÉxiÉSÒ®iÉÇ kÉ¨Éå iÉ×whÉÉzÉÉåwÉqÉSpÉëqÉÉlÉç ||

ÎxuÉ³ÉxÉëxiÉzsÉjÉiÉlÉÑÇ WûUirÉålÉÇ iÉiÉÉåÅliÉMü: | (A.™.zÉÉ.4/64-65)

87. qÉqÉÉïÍpÉbÉÉiÉ: xuÉsmÉÉåÅÌmÉ mÉëÉrÉzÉÉå oÉÉkÉiÉåiÉUÉqÉç |

UÉåaÉÉ qÉqÉÉï´ÉrÉÉxiÉ²imÉë¢üÉliÉÉ rÉ¦ÉiÉÉåÅÌmÉ cÉ || (A.™.zÉÉ.4/70)

88. SzÉæuÉÉrÉiÉlÉÉlrÉÉWÒû: mÉëÉhÉÉlÉÉÇ iÉÉÌlÉ qÉå ´ÉÑhÉÑ ||

qÉÔkÉÉïÅjÉ ™SrÉÇ oÉÎxiÉ: MühPûÉæeÉ: zÉÑ¢üzÉÉåÍhÉiÉqÉç |

zÉ„¡ûÉæ aÉÑSÇ iÉiÉx§ÉÏÍhÉ qÉWûÉqÉqÉÉïÍhÉ cÉÉÌSiÉ: ||

(MüÉzrÉmÉxÉÇÌWûiÉÉ - zÉUÏUÌuÉcÉrÉzÉÉUÏUqÉkrÉÉrÉ/4/11-12)

89. qÉqÉÉïÍhÉ eÉÏuÉkÉÉUÉÍhÉ mÉëÉrÉåhÉ qÉÑlÉrÉÉå eÉaÉÑ: | (zÉÉ.xÉÇ.mÉë.ZÉ -5/38)

90. xÉÍ³ÉmÉÉiÉ: ÍzÉUÉxlÉÉrÉÑxÉÎlkÉqÉÉÇxÉÉÎxjÉxÉqpÉuÉ: |

qÉqÉÉïÍhÉ iÉåwÉÑ ÌiÉ¸ÎliÉ mÉëÉhÉÉ: ZÉsÉÑ ÌuÉzÉåwÉiÉ: || (pÉÉ.mÉë.mÉÔuÉïZÉhQû-3/223)

91. xÉÉåqÉqÉÉÂiÉiÉåeÉÉÇÍxÉUeÉ: xÉ¨uÉiÉqÉÉÇÍxÉcÉ ||

qÉqÉïxÉÑmÉëÉrÉzÉ: mÉÑÇxÉÉÇpÉÔiÉÉiqÉÉ cÉÉuÉÌiÉ¹iÉå ||

qÉqÉïxuÉÍpÉWûiÉÉxiÉxqÉÉ³ÉeÉÏuÉÎliÉzÉUÏËUhÉ: || (xÉÑ.zÉÉ.6/35)

92. xÉmiÉÉå¨ÉUÇqÉqÉïzÉiÉqÉç | iÉÉÌlÉqÉqÉÉïÍhÉmÉgcÉÉiqÉMüÉÌlÉpÉuÉÎliÉ; iÉ±jÉÉ-qÉÉÇxÉqÉqÉÉïÍhÉ,

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ÍxÉUÉqÉqÉÉïÍhÉ, xlÉÉrÉÑqÉqÉÉïÍhÉ, AÎxjÉqÉqÉÉïÍhÉ, xÉÎlkÉqÉqÉÉïÍhÉcÉåÌiÉ | (xÉÑ.zÉÉ.6/3)

iÉÉlrÉåiÉÉÌlÉmÉgcÉÌuÉMüsmÉÉÌlÉpÉuÉÎliÉ; iÉ±jÉÉ-xÉ±:mÉëÉhÉWûUÉÍhÉ, MüÉsÉÉliÉUmÉëÉhÉWûUÉÍhÉ, ÌuÉzÉsrÉblÉÉÌlÉ,

uÉæMüsrÉMüUÉÍhÉ, ÂeÉÉMüUÉÍhÉcÉåÌiÉ | (xÉÑ.zÉÉ.6/8)

93. iÉãwÉÉqÉãMüÉSvÉæMüÎxqÉlÉç xÉÎYjÉlÉ pÉuÉÎliÉ, LiÉãlÉãiÉUxÉÎYjÉ oÉÉWÕû cÉ urÉÉZrÉÉiÉÉæå |

ESUÉãUxÉÉåuSÉïSvÉ, cÉiÉÑSïvÉ mÉ× ã, aÉëÏuÉÉÇ mÉëirÉÔkuÉïÇ xÉmiÉÌ§ÉÇvÉiÉç || (xÉÑ.vÉÉ.6/5)

94. xÉmiÉÉãiÉUÇ qÉqÉï vÉiÉqÉç iÉãwÉÉqÉãMüÉSvÉÉÌSvÉãiÉç |

mÉ×jÉMç xÉYjlÉÉã: iÉjÉÉ oÉÉWûÉåx§ÉÏÍhÉ MüÉã¸ã lÉuÉÉãUÍxÉ ||

mÉ×¸ã cÉiÉÑSïvÉÉãkuÉïÇ iÉÑ eÉ§ÉÉåÎx§ÉÇzÉŠ xÉmiÉ cÉ || (A. ™. vÉÉ. 4/1-2)

95. xÉmiÉÉãiÉUÇ qÉqÉïvÉiÉÇ, iÉ§É cÉiÉÑ¶ÉiuÉÉËUÇvÉcNûÉZÉÉxÉÑ,

wÉQèÌuÉÇvÉÌiÉUliÉUUÉkÉÉæ, xÉmiÉÌ§ÉÇvÉRÕûkuÉïÇqÉç || (A .xÉ. zÉÉ.7/3)

96. ´É×aXûÉOûMüÉlrÉÍkÉmÉÌiÉ : vÉZÉçXûÉæ MühPûÍxÉUÉ aÉÑSqÉç |

WûSrÉÇ oÉÎxiÉlÉÉÍpÉ cÉ klÉÎliÉ xÉkÉÉãWûiÉÉÌlÉ iÉÑ || ( xÉÑ.vÉÉ. 6/9)

97. A¹Éæ cÉ qÉÉiÉ×MüÉ : xÉbÉÉæ ÌlÉblÉlirÉãMüÉã³ÉÌuÉÇvÉÌiÉ ||

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

98. uÉ¤ÉÉãqÉqÉÉïÍhÉ xÉÏqÉliÉiÉsÉÍ¤ÉmÉëãlSìoÉxiÉrÉ: |

MüOûÏMüiÉÂhÉã xÉlkÉÏ mÉµÉïeÉÉæ uÉ×WûiÉÏ cÉ rÉÉ |

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

99. §ÉrÉÎx§ÉÇvÉSmÉxiÉqpÉiÉsÉWûimÉÉµÉïxÉlkÉrÉ: |

MüOûÏiÉÂhÉxÉÏqÉliÉxiÉlÉqÉÑsÉãlSìoÉxiÉrÉ: |

Í¤ÉmÉëÉmÉÉsÉÉmÉoÉ×WûiÉÏÌlÉiÉqoÉxiÉlÉUÉãÌWûiÉÉ: |

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100. Ei¤ÉãmÉÉæ xjÉmÉlÉÏ cÉæuÉ ÌuÉvÉsrÉklÉÉÌlÉ ÌlÉÌSïvÉãiÉ | (xÉÑ.vÉÉ.6/11)

101. Ei¤ÉãmÉÉæxjÉmÉlÉÏ §ÉÏÍhÉ ÌuÉvÉsrÉblÉÉÌlÉ iÉ§É ÌWû ||

uÉÉrÉÑqÉÉïÇxÉuÉxÉÉqÉeeÉqÉxiÉÑsÉÑXaÉûÉÌlÉ vÉÉãwÉrÉlÉç |

vÉsrÉÉmÉÉrÉã ÌuÉÌlÉaÉïcNûlÉç zÉçuÉÉxÉÉiMüÉxÉÉccÉ WûlirÉxÉÑlÉç || (A.Wè.vÉÉ.4/55-56)

102. sÉÉãÌWûiÉÉ¤ÉÉÍhÉ eÉÉlÉÑuÉÉïMÔücÉï ÌuÉOûmÉMÔümÉïUÉ : ||

MÑüMÑülSUã Mü¤ÉkÉUã ÌuÉkÉÑUã xÉM×üMüÉÌOûMãü ||

AÇxÉÉÇxÉTüsÉMüÉmÉÉXaÉç lÉÏsÉã qÉlrÉã TühÉÉæ iÉjÉÉ ||

uÉæMüsrÉUÉhÉÉlrÉÉWÒûUÉuÉiÉÉæï ²Éæ iÉjÉæuÉ cÉ | (xÉÑ.vÉÉ.6/12-13)

103. TühÉÉuÉmÉÉXaÉçûÉæ ÌuÉkÉÑUã lÉÏsÉã qÉlrÉã M×üMüÉÌOûMãü |

AÇxÉÉÇxÉTüsÉMüÉuÉiÉïÌuÉOûmÉÉãuÉÏïMÑüMÑülSUÉ ||

xÉeÉÉlÉÑsÉÉãÌWûiÉÉ¤ÉÉÍhÉMü¤ÉÉkÉ×Mçü MÔücÉïMÑümÉïUÉ : |

uÉæMüsrÉÍqÉÌiÉ cÉiuÉÉËU cÉiuÉÉËUÇvÉccÉ MÑüuÉïlÉã ||

WûUÎliÉ iÉÉlrÉÉÌmÉ mÉëÉhÉÉlÉç MüSÉÍcÉSÍqÉbÉÉiÉiÉ: || (A.Wû.vÉÉ. 4/57-58)

104. aÉÑsTüÉæ uSÉæ qÉÍhÉoÉlkÉÉã uSÉæ uSã uSã MÑücÉïÍvÉUÉÇÍxÉ cÉ |

ÂeÉÉMüUÉÍhÉ eÉÉlÉÏrÉÉS¹ÉuÉãiÉÉÌlÉ oÉÑÎbSqÉÉlÉç || (xÉÑ.vÉÉ.6/14)

105. A¹Éæ MÔücÉïÍvÉUÉãaÉÑsTüqÉÍhÉoÉlkÉÉ ÂeÉÉMüUÉ: | (A.Wû.vÉÉ.4/59)

106. SãWûmÉëxÉÑÎmiÉaÉÑïÂiÉÉ xÉÇqÉÉãWû: vÉÏiÉMüÉÍqÉiÉÉ |

xuÉãSÉã qÉÔcNûÉï uÉÍqÉ: µÉÉxÉÉã qÉqÉÉïÌuÉbSxrÉ sÉ¤ÉhÉqÉç || (A.xÉÇ.vÉÉ.7/47)

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MüÉsÉÉliÉUmÉëÉhÉWûUqÉliÉã ÌuÉbSÇ uÉæMüsrÉqÉÉmÉÉSrÉÌiÉ, ÌuÉvÉsrÉblÉÇ oÉæMüsrÉMüUÇ cÉ pÉuÉÌiÉ,

uÉæMüsrÉMüUÇ MüÉsÉÉliÉUãhÉ YsÉãvÉrÉÌiÉ ÂeÉÉÇ cÉ MüUÉãÌiÉ,

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

108. NãûSpÉãSÉÍpÉbÉÉiÉãprÉÉã SWûlÉÉ±ÉUhÉÉSÌmÉ |

EmÉbÉÉiÉÇ ÌuÉeÉÉÌlÉrÉÉlqÉqÉïhÉÉÇ iÉÑsrÉsÉ¤ÉhÉqÉç || (xÉÑ.vÉÉ.6/41)

109. LiÉimÉëqÉÉhÉqÉÍpÉuÉÏ¤rÉ uÉSÎliÉ iÉe¥ÉÉ: vÉx§ÉãhÉ MüqÉïMüUhÉÇ mÉËUWûirÉ MüÉrÉïqÉç ||

mÉÉvoÉÉïÍpÉbÉÉÌiÉiÉqÉmÉÏWû ÌlÉWûÎl¨É qÉqÉï iÉxqÉÉÎbS qÉqÉïxÉSlÉÇ mÉËUuÉeÉïlÉÏrÉqÉç || (xÉÑ.vÉÉ. 6/30)

110. EurÉï: ÍvÉUÉÇÍxÉ ÌuÉOûmÉã cÉ xÉMü¤ÉmÉÉµÉï LMæüMü qÉÇQûaÉÑsÉÍqÉiÉÇxiÉlÉmÉÔuÉïsÉqÉç ||

ÌuÉkrÉÅaÉÑsÉuSrÉÍqÉïiÉÉÇ qÉÍhÉoÉlkÉaÉÑsTüÇ §ÉÏhrÉãuÉ eÉÉlÉÑ xÉmÉUÇ xÉWûMÔümÉïUÉprÉÉqÉç ||

Wû¯ÎxiÉ MÔücÉï aÉÑSlÉÉÍpÉ uÉSÎliÉ qÉÔÎklÉï cÉiuÉÉËU mÉÇcÉ eÉ aÉsÉã SvÉ rÉÉÌlÉ cÉ uSã ||

iÉÉÌlÉ xuÉmÉÉÍhÉiÉsÉMÑüÇÍcÉiÉ xÉÇÍqÉiÉÉÌlÉ vÉãwÉÉhrÉuÉãÌWû mÉËUÌuÉxiÉÉUiÉÉãÇÅaÉÑsÉÉkÉïqÉç ||

mÉÉ´uÉÉïÍpÉ±ÉÌiÉiÉqÉÌmÉWû ÌlÉWûÎliÉ qÉqÉï iÉxqÉÉÇÎuS qÉqÉïxÉSlÉÇ mÉËUuÉeÉïlÉÏrÉqÉç || ( xÉÑ.vÉÉ.6/28-30)

111. mÉÇcÉÉvÉiwÉOè cÉ qÉqÉÉïÍhÉ, ÌiÉsÉÌuÉëÌWû xÉqÉÉlrÉçÌmÉ | C¹ÉÌlÉ qÉqÉÉïhrÉlrÉãwÉÉqÉç || (A.Wû.vÉÉ.4/63)

112. uÉÉiÉÌmÉ¨ÉMüTüÉlÉ×hÉÉÇ oÉÎxiÉWûlqÉÔkÉï xÉÇ ÉrÉÉ :| iÉxqÉÉ¨ÉixjÉÉlÉxÉÉÍqÉmrÉÉ®iÉïurÉÉ uÉqÉlÉÉÌSÍpÉ:||

AkrÉÉiqÉsÉÉãMüÉã uÉÉiÉÉkÉæsÉÉãïMüÉã uÉÉiÉUuÉÏ lSÒÍpÉ: | mÉÏQûrÉiÉã kÉÉrÉïiÉã cÉæuÉ ÌuÉM×üiÉÉÌuÉM×üiÉæxiÉjÉÉ ||

ÌuÉÂbSæUÌmÉ lÉ iuÉãiÉã aÉÑhÉÉæblÉïÎliÉ mÉUxmÉUqÉç | SÉãwÉÉ: xÉWûeÉxÉÉiqrÉiuÉÉÌ²wÉÇ bÉÉãUqÉWûÏÌlÉuÉ ||

Ì§ÉqÉqÉïeÉÉlÉÉÇ UÉãaÉÉhÉÉÇ ÌlÉSÉlÉÉM×üÌiÉpÉãwÉqÉç |

ÌuÉxiÉUãhÉ mÉ×jÉÉÎaS¹Ç Ì§ÉqÉqÉÏïrÉã ÍcÉÌMüÎixÉiÉã || (cÉ.ÍcÉ.26/291-294)

113. xÉmiÉÉã¨ÉUÇ qÉqÉïvÉiÉÇ rÉSÒ£üÇ vÉUÏU xÉÇZrÉæqÉÍkÉM×üirÉ iÉãprÉ : |

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qÉqÉÉïÍhÉ oÉÎxiÉ WûSrÉÇ ÍvÉUc´É| mÉëkÉÉlÉpÉÑiÉÉÌlÉ uÉSÎliÉ iÉ¥É¥ÉÉ: ||

mÉëÉhÉ´ÉrÉÉiÉç iÉÉÌlÉ ÌWû mÉÏQûrÉliÉã uÉÉiÉÉSrÉÉãÅxÉÔlÉÌmÉ mÉÏQûrÉÎliÉ |

iÉixÉÇÍ´ÉiÉÉlÉãqÉlÉÑmÉÉsÉlÉÉjÉï qÉWûÉaÉSÉlÉÉ ´ÉÑhÉÑ xÉÉæqrÉ U¤ÉÉqÉç ||4|| (cÉ.ÍcÉ 26/3-4)

114. iÉiÉ: --- mÉëirÉ‰ÑZÉÉå uÉæ±Éå qÉqÉïÍxÉUÉxlÉÉrÉÑxÉlkrÉÉÎxjÉkÉqÉlÉÏ: mÉËUWûUlÉç, AlÉÑsÉÉåqÉÇ

zÉx§ÉÇ ÌlÉSkrÉÉSÉmÉÔrÉSzÉïlÉÉiÉç, xÉM×üSåuÉÉmÉWûUåcNûx§ÉqÉÉzÉÑ cÉ; ---|| (xÉÑ,xÉÔ. 5/7)

115. iÉjÉÉ qÉqÉïÍxÉUÉxlÉÉrÉÑxÉÎlkÉ iÉÂhÉÉÎxjÉxÉåuÉlÉÏkÉqÉlÉÏaÉsÉlÉÉÍpÉlÉZÉÉliÉ: zÉåTü:

xÉëÉåiÉ: xuÉsmÉqÉÉÇxÉåwÉÑ cÉ SåzÉåwuÉ¤ÉhÉÉå¶ÉlÉ SkrÉÉSlrÉ§É uÉiqÉïUÉåaÉÉiÉç || (xÉÑ.xÉÔ. 11/29)50

116. qÉqÉÉïÍhÉ zÉsrÉÌuÉwÉrÉÉkÉïqÉÑSÉWûUÎliÉ rÉxqÉÉŠ qÉqÉïxÉÑ WûiÉÉ lÉ pÉuÉÎliÉ xÉ±:|

(xÉÑ.zÉÉ. 6/33)

117. cÉiÉÑÌuÉïkÉÉ rÉÉxiÉÑ ÍxÉUÉ: vÉUÏUã mÉëÉrÉãhÉ iÉÉ qÉqÉïxÉÑ xÉÍ³ÉuÉ¹É : |

xlÉÉruÉÎxjÉ qÉÉÇxÉÉÌlÉ iÉjÉæuÉ xÉÎlkÉlÉç xÉliÉmrÉï SãWûÇ mÉëÌiÉmÉÉsÉrÉÎliÉ || (xÉÑ.zÉÉ.6/18)

118. iÉ§ÉxÉÎYjÉqÉqÉÉïÍhÉ Í¤ÉmÉëiÉsÉWØûSrÉMÔücÉïMÔücÉïÍzÉUÉåaÉÑsTåülSìoÉÎxiÉeÉÉluÉÉhrÉÑÌuÉïsÉÉåÌWûiÉÉ¤ÉÉÍhÉ

ÌuÉOûmÉÇcÉåÌiÉ | (xÉÑ.zÉÉ.6/6)

119. iÉ§ÉmÉÉSxrÉÉ…¡Óû¸…¡ÓûsrÉÉåqÉïkrÉåÍ¤ÉmÉëÇlÉÉqÉqÉqÉï, iÉ§ÉÌuÉ®xrÉÉ¤ÉåmÉMåühÉqÉUhÉÇ;

120. qÉkrÉqÉÉ…¡ÓûsÉÏqÉlÉÑmÉÔuÉåïhÉqÉkrÉåmÉÉSiÉsÉxrÉiÉsÉWØûSrÉÇlÉÉqÉ, iÉ§ÉÂeÉÉÍpÉqÉïUhÉÇ;

121. Í¤ÉmÉëxrÉÉåmÉËU¹ÉSÒpÉrÉiÉ: MÔücÉÉåïlÉÉqÉ, iÉ§ÉmÉÉSxrÉpÉëqÉhÉuÉåmÉlÉåpÉuÉiÉ:;

122. aÉÑsTüxÉlkÉåUkÉEpÉrÉiÉ: MÔücÉïÍzÉU:, iÉ§ÉÂeÉÉzÉÉåTüÉæ;

123. mÉÉSeÉ†¡ûrÉÉå: xÉlkÉÉlÉåaÉÑsTü:, iÉ§ÉÂeÉ: xiÉokÉmÉÉSiÉÉZÉgeÉiÉÉuÉÉ;

References


124. mÉÉÎwhÉïmÉëÌiÉeÉ†¡ûÉqÉkrÉåClSìoÉÎxiÉ:, iÉ§ÉzÉÉåÍhÉiÉ¤ÉrÉåhÉqÉUhÉÇ;

125. eÉ†¡ûÉåuÉÉï: xÉlkÉÉlÉåeÉÉlÉÑ, iÉ§ÉZÉgeÉiÉÉ;

126. eÉÉlÉÑlÉFkuÉïqÉÑpÉrÉiÉx§rÉ…¡ÓûsÉqÉÉÍhÉ, iÉ§ÉzÉÉåTüÉÍpÉuÉ×Î®: xiÉokÉxÉÎYjÉiÉÉcÉ;

127. FÂqÉkrÉåEuÉÏï, iÉ§ÉzÉÉåÍhÉiÉ¤ÉrÉÉiÉçxÉÎYjÉzÉÉåwÉ:;

128. EurÉÉïFkuÉïqÉkrÉÉåuÉÇ¤ÉhÉxÉlkÉåÃÂqÉÔsÉåsÉÉåÌWûiÉÉ¤ÉÇ, iÉ§ÉsÉÉåÌWûiÉ¤ÉrÉåhÉqÉUhÉÇmÉ¤ÉÉbÉÉiÉÉåuÉÉ;

129. uÉÇ¤ÉhÉuÉ×wÉhÉrÉÉåUliÉUåÌuÉOûmÉÇ, iÉ§ÉwÉÉhžqÉsmÉzÉÑ¢üiÉÉuÉÉpÉuÉÌiÉ; (xÉÑ.zÉÉ.6/24)

130. ÍxÉUÉurÉkÉÍ¶ÉÌMüixÉkÉïÇ zÉsrÉiÉl§Éå mÉëMüÐÌiÉïiÉ: |

rÉjÉÉ mÉëÍhÉÌWûiÉ: xÉqrÉaoÉÎxiÉ: MüÉrÉÍcÉÌMüÎixÉiÉå|| (xÉÑ.zÉÉ.8/23)

131. xlÉåWûÉÌSÍpÉ: Ì¢ürÉÉrÉÉåaÉælÉï iÉjÉÉ sÉåmÉlÉæUÌmÉ |

rÉÉlirÉÉzÉÑ urÉÉkÉrÉ: zÉÉÎliÉÇ rÉjÉÉ xÉqrÉMçü ÍxÉUÉurÉkÉÉiÉç || (xÉÑ.zÉÉ.8/22)

132. Taber: Cyclopedic Medical Dictionary, 20th Edition, 2005, Edited by Donald

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133. John J. Bergan: The Vein Book, Published by Elsevier Academic Press, California, 2007, p 2

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Annexure




Annexure


Short Saphenous Vein

Perforating Vein

Annexure


Short Saphenous Vein and its superficial branches

Siravyadha marma-sr

Documents

Transcript of Siravyadha marma-sr