a study on sandhi marma w. s. r. to regional and …

A STUDY ON SANDHI MARMA W. S. R. TO REGIONAL AND APPLIED ANATOMY OF KURPARA MARMA

BY

DR. SIBGATH ULLA SHARIFF R, B.A.M.S

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

In partial fulfillment of the requirements for the degree of

DOCTOR OF MEDICINE (AYURVEDA)

IN

SHAREERA RACHANA

UNDER THE GUIDENCE OF

DR. G. M. KANTHI. B.S.A.M.; D.H.A.; Ph. D (RACHANA)

PROFESSOR

DEPARTMENT OF P.G. STUDIES IN SHAREERA RACHANA

DEPARTMENT OF P. G. STUDIES IN SHAREERA RACHANA

S. D. M. COLLEGE OF AYURVEDA, UDUPI

2010 - 2011

Observation 52

Department of Shareera Rachana, SDMCA, Udupi.

STUDY METHOD

The dissection of five cadaver in which ten Elbow joint specimen has been carried

out as per the Cunningham’s Manual of practical anatomy. Dissection procedure carried

out layer by layer, observed and studied thoroughly.

SKIN:

The skin consists of hair follicles.

SUPERFICIAL FASCIA:

Following Structures were observed in superficial fascia –

Median Cubital vein.

Cephalic vein.

Basilica vein

DEEP FASCIA:

It is continuous with the fibers of the superficial fascia, and sends wide partition

or septa between the muscles from its deep surface.

BICIPITAL APONEUROSIS:

It is a strong slip which extends medially from the tendon of biceps into the deep

fascia. Thus it is indirectly attached to the subcutaneous, posterior border of the ulna

which is fused with the deep fascia.


DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled “A STUDY ON SANDHI

MARMA W. S. R. TO REGIONAL AND APPLIED ANATOMY OF KURPARA

MARMA” is a bonafide and genuine research work carried out by me under the

guidance of Dr. G. M. Kanthi, B.S.A.M.; D.H.A.; Ph. D, Professor & Head, Department of P.G.

Studies in Basic Principles.

.

DATE: Signature of the Candidate

PLACE: UDUPI (DR. SIBGATH ULLA SHARIFF. R)


CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled “A STUDY ON SANDHI

MARMA W. S. R. TO REGIONAL AND APPLIED ANATOMY OF KURPARA

MARMA” is a bonafide research work done by Dr. Sibgath Ulla Shariff R., in partial

fulfillment of the requirement for the degree of Doctor of Medicine in Ayurveda, under

my guidance.

Signature of the Guide

Dr. G. M. Kanthi B.S.A.M.; D.H.A.; Ph. D Professor,

DATE: Dept, of P.G Studies in Shareera Rachana,

PLACE: UDUPI S D M College of Ayurveda, Udupi


CERTIFICATE BY THE H.O.D, / PRINCIPAL HEAD OF THE

INSTITUTION

This is to certify that the dissertation entitled “A STUDY ON SANDH MARMA

W.S.R. TO REGIONAL AND APPLIED ANATOMY OF KURPARA MARMA” is

a bona fide research work done by Dr. Sibgath Ulla Shariff R under the guidance of

Dr. G. M. Kanthi, B.S.A.M,; D.H.A,; Ph. D, Professor & Head, Department of P.G. Studies in

Basic Principles.

Signature of the H.O.D. Signature of the Principal

Dr. U. Govindaraju Dr. U. N. Prasad M .D (Ayu) M. D (Ayu)

Dean & Head. Principal Dept. of P.G Studies in Shareera Rachana S D M College of Ayurveda, Udupi S D M College of Ayurveda, Udupi

DATE: DATE:

PLACE: UDUPI PLACE: UDUPI

COPYRIGHT

DECLARATION BY THE CANDIDATE

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

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

or electronic format for academic / research purpose.

DATE: Signature of the Candidate

PLACE: UDUPI (DR.SIBGATH ULLA SHARIFF. R)

© Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

DEDICATED

TO MY

BELOVED

PARENTS &

TEACHERS

Lists


INDEX

SL. NO. CONTENTS PAGE NO.

1 INTRODUCTION 1 – 2

2 OBJECTIVES 3 – 4

3 REVIEW OF LITERATURE 5 – 50

4 METHODOLOGY 51

5 OBSERVATION 52 – 56

6 REGIONS OF DISSECTION 57 – 59

7 RADIOLOGICAL FILMS 60 – 62

8 DISCUSSION 63 – 67

9 CONCLUSION 68

10 SUMMARY 69 – 70

11 SHLOKA’S 71 – 84

12 BIBLIOGRAPHY 85 – 101

Lists


LIST OF TABLES

Table No.

Description

Page No.

01.

Sadhya Pranahara Marma

10

02.

Kalantara Pranahara Marma

10

03.

Vishalyaghna Marma

11

04.

Vaikalyakara Marma

11

05.

Rujakara Marma

12

06.

Anguli Pramana

13

07.

Classification of Marma

14

08.

Urdhwa Shakhagata Marma

15 – 20

13.

Marma Paancha Bhoutikatva

21

14.

Rujakara Marma

27

15.

Classification of Synovial Joint

37

16.

Movements and Definition

40

Lists


LIST OF FIGURES

Figure number

Description

Page no.

01

Ligaments of Elbow Joint (Ant. Aspect)

48

02

Intracapsular & Annular Ligament.

48

03

Ligaments of Elbow Joint (Lateral Aspect)

49

04

Ligaments of Elbow Joint (Medial Aspect)

49

05

Posterior Aspect of Elbow Joint

50

06

Region of Elbow Joint( Right)

57

07

Articular Capsule

57

08

Capsular Ligament

58

09

Radial Collateral ligament

58

10

Ulnar Collateral Ligament

59

11

Articular Surfaces of Elbow joint

59

12

RadiologicalFindings

60 - 62

Acknowledgement


ACKNOWLEDGEMENT

At this jovial jiffy of elated integrate of my work, I meekly bow my head on the

feet of almighty who have poured in me constant shore up for the liberation of crossing

this mile stone as well as all success, progress & achievements in my life.

I am in short of words while paying my chivalrous & affable regards to my

admired Dad Sri Rahamath Ulla Shariff & my beloved Mother Fathima Begum, in whom

I experience the blessings of God, for their supports, sacrifice & encouragement which

brought me up to this stage. My inner strength, really none other than my beloved

Brother Sadath Ulla Shariff & my sister Dr. Saba Shabnam, whose prop up, suggestion,

adore & care is the dynamic force in each & every steps of my life.

I take this opportunity to express my earnest gratitude to The Principal, SDM

College of Ayurveda, UDUPI, Dr. U.N Prasad for letting me disentangle the world of

Ayurveda and explore the colossal possibilities.

I put into words my deepest feeling of admiration towards my beloved teacher &

guide, Dr. G .M. Kanthi, Prof. & H.O.D, Dept. of Basic Principle’s whose stirring

brainwave; persistent guidance finely tuned me to plot this murky task. Besides this, his

tangy prosperity always provided me enough courage to filch up with each & every task.

I am short of glossary to thank my beloved respected preceptor and honourable

Dean, Professor & HOD Dept. of Shareera Rachana, Dr. U. Govindraju whose masterly

suggestions & ablest guidance at every step which has molded, twisted, and enlightened

my elfin work into achievement.

I bring about my authentic thankfulness to Dr. V.K.S. Holla, Prof. Dept. of

Shareera Rachana, for his shrewd direction, stanch benefaction, logical & significant

suggestion which fictitious this activity a prolific.

I convey my ingenuous gratefulness to my adored tutor Dr. Krishnamurthy,

Lecturer, Dept. of Shareera Rachana, for his diligent work, gleaming conception for

various difficulties right from the beginning, which made this work possible.

Acknowledgement


I am indebted to utter my thanks to my beloved master of solutions Dr.Nithin

Kumar Lecturer, Dept. of Shareera Rachana, for his astute guidance & shall forever be

beholden to Dr. Rajendra Pai & Dr. Prahlad for their sensible direction.

It is my privilege to eloquent my heartfelt thanks to Dr.Muralidhara Sharma, Prof.

Dept of Shalya Tantra, whose sanguine views, noble nature, always put vigor in me to

overcome the obstacles.

I sequester this occasion to eloquent my gesticulate to resourceful Surgeons, Dr

Raju (MS Ortho), Dr. Satya Surendra Sai (MS Ortho), Dr. Shaanu Bag (MS Ortho), Dr.

Venkatesh (Gen. Surgeon) for their deliberating pedagogic views which helped me to

extract the concealed principles.

I wish to offer my earnest thanks to Former Deans Prof. Dr.B.V.Prasanaa, & Prof.

Dr. Shrinkanth U, for Post Graduate faculty, S.D.M. college of Ayurveda for their

encouragement and support.

I cannot move further before thanking to my cherished friends Dr. Thushara, Dr.

Seetharam, Dr.Vijaynath, Dr.Vipin, Dr. Shreekumar, Dr. Vineeth, Dr.Shailesh,

Dr.Ananth, Dr.Prakash, for being with me by providing honest support to surmount each

& every barrier successfully.

It is gaffe to my element if I won’t tell thanks to my seniors Dr. Anju, Dr. Harsha,

Dr. Pratibha, & Dr. Indu & also express appreciation to my juniors, Dr. Paramesh,

Dr.Shakti, Dr.Jyoti, Dr.Remitha, & Dr. Vibha for their academic support.

I am very thankful to Mr. Prabhakar, & Mr. Sadhu attenders dept. of Shareera

Rachana, staff of Library, Hospital, Samruddhi Xerox and all my volunteers for their

brand teamwork, which was very much requisite for the booming sleeve up of this work.

Last but not least I thank to Mrs. Radha and all those who have directly or

indirectly contributed to the successful completion of this notion work.

Abstract


ABSTRACT

Marma’s are described as the vital points in the human body, injury to which ends

in various hazardous crises. The Acharyas mentioned the total numbers of Marma are

107. Acharya Sushruta classified Marma as Mamsa Marma, Sira Marma, Snayu Marma,

Asthi Marma, Sandhi Marma. Archarya Vagbhata added one more classification as

Dhamani Marma, respectively.

Sandhi Marmas are twenty in number. The Kurpara Sandhi Marma is one among

the sandhi marm. It belongs to Vaikalyakara marma.

Although the gross regional and the Viddha lakshana’s are available in Samhitas,

but detail description of particular structures present in Kurpara Marma region are

lacking in ancient texts.

Objective of this study were to make the comprehensive and conceptual study on

Kurpara Marma as mentioned in texts, in the view of regional and applied anatomy

described in the contemporary science, and to study Kurpara Marma sthanagata shareera

with modern regional and applied anatomy by cadaver dissection and x-rays.

Literary and conceptual study will be on the data compilations from various

Classical books and cadaveric dissection is done to see the structures related to Kurpara

Marma pradesha and discussed particular regional anatomy and its applied anatomy and

structures involved with the help of x-ray is discussed related to the Kurpara marma.

Key words: Kurpara Marma, regional anatomy, applied anatomy.

Introduction 1

INTRODUCTION

Ayurveda is one of the most reliable, novel and complete ancient medical science

which have proved for more than 5000 years. Even though the modern science is

changing from time to time AYURVEDA has maintained its special place till date.

This science existed, such a long and extensive voyage of time, by its fundamental

principles. The unique themes of nature that have been scrutinized, analyzed researched

by the different Ayurvedic Scholars and then applied to the cure of human ailments are

THE BASIC PRINCIPLES OF AYURVEDA.

Without implementation of these principles any science cannot stand for long time

period. These principles are scattered through out the treatise and thus their study is need

of time.

.

Ayurveda has its own principles or concepts which stand in modern era also. The

concept of Marma is one such Imperative and Unique principle of Ayurveda.

Marma Vijnyana was developed as science of war. There are so many references

from Vedas regarding attack on Marmasthanas of enemies and protecting one’s Marmas

by wearing metallic protectants.

Marma’s 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 & Shastrakarma are used as a part of the

surgery. While conducting these surgical procedures, the knowledge of Marma Sthana, is

required, with proper knowledge of Marma Sthana we may perform the procedures

without any complications. In trauma condition the knowledge of trauma site, structures

involving and deformity identification is necessary. So treatment and surgical procedures

both aspect Marma study is important.


Introduction 2

Even in today’s fast life it is very important to protect our Marma Sthanas because of

heavy road traffic which results in accidents causing injury to Marmas. Developing

science invents new military armaments increasing severity of injury during war.

SCOPE OF STUDY

Severe traumatic injuries to Sandhi Marma are very common in today’s advance

life. The incidence of trauma takes place in road accidents of two wheeler and four

wheelers. Pedestrians also gets injury to Kurpara Sandhi when they land in un – noticed

ditched in the street, or fall. Many people twist, sprain and fracture their Kurpara Sandhi

in bath rooms or accidentally toppling over small barricades in the house hold or in the

streets. Ladies slip their feet over slippery kitchens or over the staircases. In players,

while playing the game of football, hockey,cricket, kabaddi, kho – kho etc. The incidence

of severe traumatic injuries to Krupara Sandhi is very common. This was identified at the

time of Ayurveda and such vulnerable spots in the body were called as ‘Marmas’.

The Anatomical changes taking place at Kurpara Sandhi after trauma, injuries

and its correlations with Karupara Sandhi Marma as Vaikalyakara Marma is not fully

worked upon and this knowledge is useful for the precaution, medical and surgical

traumatic of Kurpara Sandhi injured patient and players. So I’m inspired to select this

topic for my research work.


Aims & objectives 3

I) AIMS:

The main aim is to study the Anatomical Structural changes taking place at

Kurpara Sandhi after severe traumatic injuries.

2) OBJECTIVES:

To study the Marma Shareera.

To study the Vaikalyakara Marma in detail.

To study the Kurpara Marma according to Ayurvedic concept.

To study the Kurpara Sandhi Shareera (Anatomy) from Ayurvedic and Modern

point of view.

To compare the Anatomical changes taking place at Kurpara Sandhi after severe

traumatic injuries (i.e. Marmaghata) to the Granthokta Viddha Lakshanan of

Kurpara Marma as Vaikalyakara Marma.

To find out the Anatomical structures situated at the site of Kurpara Marma with

help of Cadaveric dissection.


Aims & objectives 4

PREVIOUS WORK DONE

1. Gupta N.B – Sandhi marmonke samanya pariprekshya mein seemanta marma ka

vaisyanika adhyayan.1991, NIA,Jaipur.

2. Borkar B.A – Urdhwa shakhagata vaikalyakara marma; ek rachanatmaka

adhyayana, 1997, Govt.Ayurved College, Nagpur.


Historical Review 5

HISTORICAL REVIEW

The Marma Sthanas are consider as the vital points in the body, injury to those

Marma Sthanas will leads to different consequences according to their type, location,

structure and effect as they belongs. Sandhi Marmas are one among the marma

classification explained by Acharyas.

Here an attempt has been made to study on Sandhi Marma with special reference

to regional and applied anatomy of Kurpara Marma from Vedic period up to the 21st

century.

VEDIC PERIOD

In Atharvaveda, the term Marma has been point out; if injury takes on Marma

Sthana then it cause death. Also we find the reference of the term Kavacha or corselet or

breast-plate for the protection of Marma Sthanas.

In Rig-veda, reference of the words like varman and drapi, that is some kind of

body armor or corselet to protect the body from assault of enemy weapons on Marma

Sthanas.

The king of then has also been advised to keep their vital parts covered with

“Kavacha” a kind of protector.1

Vishwakarma sharpened Ayudha (weapon) for Indra which was known as Vajra

to be used.

God Indra tormented Vratra(demon) with the help of same by attacking on Marma

sthaana.2

The plastic surgery was practiced in Vedic period due to frequent wars. Ashwini

devas performed plastic surgery on Shayava at three cut places and made him to move.3

Vishphala was rehabilitated by Ashwini kumara providing artificial iron legs.4

Fire (Agni) was used to be the greatest weapon to destroy Marma Sthanas.5

MARMA IN UPANISHAD

Following references can be consider regarding Marma and associated subject

available in different Upanishad.


Historical Review 6

Description of vessels and blood circulation.6

Vascular injuries.7

Characteristics of Sira and Dhamani.8

Physio-anatomy of Hrudaya.9

Marma and Kavacha.10

Marma .11

Dhamani.12

107 Marma’s described in Garbhopanishad.13

PURANA KALA

In Mahabharata the great epic, also we find many references for the Marma or the

Varman.14

In Ramayana, the arrow triggered accidentally by Dasharatha on Marma sthana of

Shravana kumara.15

SAMHITA KALA

The description about Marma Sthanas and structures involved in Sandhi Marma

pradesha along with detailed explanation of Viddha lakshana, and diseases has been

explained in almost all the classical texts written during Samhita kala. All Acharyas are

accepted total numbers of Marmas are 107.

CHARAKA SAMHITA

Acharya Charaka given much importance to the Trimarmas - these are Shira,

Hridaya and Basti by keeping physician in mind. He also mentioned that according to the

surgeon point of view, total numbers of Marmas are 107 in Chikitsa sthana 26th chapter.16

SUSHRUTA SAMHITA

Acharya Sushruta given much importance to Marma Sthansa, he explained

detailed description on Marma, their types, numbers, locations, symptoms if they injured

in Shareera sthana 6th chapter.17


Historical Review 7

DALHANA

Dalhana, the commentator of Sushruta Samhita explained about Marma in

Shareera shthana 6th chapter.18

ASTANGA SANGRAHA AND ASTANGA HRUDAYA

Reference of Marma and its classification is also available in both the grantha’s.

Vruddha Vaagbhata mention about the mama in 7th chapter and laghu vagbhata in 4th

chapter.19, 20

KASHYAPA SAMHITA

Kashyapa accepted trimarma Shira Hridaya and Basti as the view of Charaka and

consider these three Marma are Mahamarma in Shareera sthana 4th chapter.21

BHAVAPRKASHA

Bhava prakasha mentioned detailed description regarding Marma similar to

Sushruta in purva khanda garbha prakarana adhyaya.22

MODERN PERIOD

In the field of modern anatomy and medicine, the vital point structures related to

surface, regional and applied anatomy can be traced in various text books.

Marma Vignana may be taken as synonym of Traumatology. Preference of

surgery is a skill which requires perfect knowledge of pre operative, operative and post

operative measures. The history of trauma can be anticipated from the date, survival is

the fittest existing.

Trauma has posed a major civil problem of today. Widespread use of auto

mobiles and frank use of fire arms have lead to trauma epidemic.


Review of Literature 8

REVIEW OF LITERATURE

MARMA SHABDHA VYUTPATTEE

Marma word meaning is Jeeva sthana.

According to Shabda Kalpa Druma, Marma word is derived from Mru Dhatu

combined with Manin Pratyaya gives rise to word Marma which means Jeeva sthane,

sandhi sthane or taatparya.23

MARMA SHABDA NIRUKTI

Marma’s are the specific locations on the human body, which when traumatized,

will either surely cause death or permanent deformity with extreme pain.24

MARMA DEFINATIONS

‘Marma’s (vital spots) consists of aggregate of Mamsa, Sira, Snayu, Asthi, Sandhi

in which Prana by nature stays, that is why injury to marma’s leads to respective

consequences’.25

Dalhana explains Prana as Agnyadaya.26

Aacharya Sushruta explains the Dvadasha Pranas as Agni, Soma, Vayu, Satva,

Rajasa, Tamasa, Panchaendriyas and Bhutatma are considered as Prana, because right

from the fertilization they perform and control the functions of life till death.27

Acharya Charaka explains Dasha Prana as Murdha, Kantha, Hridaya, Nabhi,

Guda, Basti, Ojah, Shukra, Shonita and Mamsa. First six ie Murdha, Kantha, Hridaya,

Nabhi, Guda, Basti are comes under Marma Sankhya.28

According to Ashtanaghridya, Marma is that spot of the body which exhibits a

peculiar pulsation or unusual throbbing and cause pain on pressure..29

Marma’s are considering as Jeevadharani, where mainly prana resides. 30

The point of the body which leads to death when injured is marma.31



The Marmas (vital spots) are so called because they cause death when injured and

they are the meeting place of Mamsa, Asthi, Snayu, Dhamani, Siras and Sandhi, life

entirely resides in them.32

That which leads to death or which gives misery to individual similar to death when

injured is called Marma. This clarifies that some marma on injury are fatal, some are fatal

after period of marmas when injured.33

CLASSIFICATION OF MARMA

There are total 107 Marma’s in the human body34.These are classified according to

location types, structures involved, and effect wise after trauma. They are classified into

five types.

It is clear mentioned that there is no any other sixth type of Marma than Mamsa, Sira,

Snayu, Asthi, Sandhi.35

‘Dalanhacharya’ states that though Marmas can be classified in to many subtypes, all

of them can be included in five principal types explained by Sushrutacharya. This

principal is also applicable to ‘Dhamani’ Marma, described by Vaghabhattacharya.36

I) CLASSIFICATION ACC. TO SHADANGA SHARIRA 37, 38, 39

1) Shakhagata - 11 (11x4) = 44

2) Madhya Shareera - 14 + 12 = 26

3) Jatru Urdhwgata Marma - = 37

. -

Total = 107



II. CLASSIFICATION ACC. TO EFFECT OF MARMA

1. SADHYA PRANAHARA MARMA40, 41

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

1)

3)

5)

7)

Shrungataka 04

Shankha 02

Guda 01

Basti 01

2)

4)

6)

8)

Adhipati 01

Kantha Sira (Matruka) 08

Hridaya 01

Nabhi 01

Table – 1: Showing Sadhya Pranahara Marma

2. KALANTARA PRANAHARA MARMA42, 43


1)

3)

5)

7)

9)

11)

Stanamula 02

Apalapa 02

Simanta 05

Kshipra 04

Katikatarua 02

Bruhati 02

2)

4)

6)

8)

10)

12)

Stana Rohita 02

Apstambha 02

Talahridaya 04

Indrabasti 04

Parshva Sandhi 02

Nitamba 02

Table – 2: Showing Kalantara Pranahara Marma



3. VISHALYAGHNA MARMA 44, 45


1) Utkshepa 02 2) Sthapani 01

Table – 3: Showing Vishalyaghna Marma

4. VAIKALYAKARA MARMA 46, 47


1)

3)

5)

7)

9)

11)

13)

15)

17)

Lohitaksha 04

Janu 02

Kurcha 04

Kurpara 02

Kakshadhara 02

Krukatika 02

Amsa-Phalaka 02

Nila 02

Phana 02

2)

4)

6)

8)

10)

12)

14)

16)

18)

Aani 04

Urvi 02

Vitapa 02

Kukundhara 02

Vidhura 02

Amsa 02

Apanga 02

Manya 02

Avarta 02

Table – 4: Vaikalyakara Marma



5. RUJAKAR MARMA48, 49


1)

3)

Gulpha 02

Kurcha Shira 04 2) Manibandha 02

Table – 5: Showing the Rujakara Marma



III. CLASSIFICATION OF MARMAS

ACCORDING TO ANGULI PRAMANA 50

Sr. No.

AnguliPranam

Name of Marma

Total

No.

1) One Anguli 1) Urvi - 04

1) Vitap – 02

2. Kurcha Shira – 04

2. Kakshadhar – 02

10

2) Two Anguli 1. Stanmula – 02

3. Gulpha – 02

2. Manibandha – 02

06

3) Three Anguli 2. Kurpara – 02 Jaanu- 02 04

4) Four Anguli 1. Hridaya – 01

3. Kurcha – 04

5. Nabhi – 01

7. Simanta – 05

9. Neela – 02

2. Basti – 01

4. Guda – 01

6. Shrungataka – 04

8. Matruka – 08

10. Manya - 02

29

5) Half Anguli 1. Adhipati – 01

3. Talahridya – 04

5. Indra-basti – 04

7. Apastambha – 02

10.Parshvasandhi – 02

14. Nitamba – 02

16. Utkshepa – 02

18. Aani – 04

20. Vidhura – 02

22. Amsa – 02

23. Apanga - 02

24. Phana - 02

2. Shankha – 02

4. Kshipra - 04

6. Apalapa – 02

8. Stanarohita – 02

9. Katikataruna – 02

11. Bruhati – 02

13. Sthapani – 01

15. Lohitaksha- 04

17. Kukundara – 02

19. Krukatika – 02

21. Amsa-Phalaka – 02

26. Avarta – 02

56

Table – 6: Showing the Anguli Pramana



CLASSIFICATION OF MARMAS ACC. TO ACHARYA SUSHRUTA

& VAGBHATA

Sr. No. Classification Sushruta Vagbhata

1. Rachananusara

(Structural

Classification)

1. Mamsa 11

2. Sira 41

3. Snayu 27

4. Asthi 08

5. Sandhi 20

1. Mamsa 10

2. Sira 37

3. Snayu 23

4. Asthi 08

5. Sandhi 20

6. Dhamani 09

2. Shadangaanusara

(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 Extreity 22

2. Lower Extremity 22

3. Abdomen & Thorax 12

4. Back of the Trunk 14

5. Head & Neck 37

3. Parinamanusara

(Prognostic

Classification)

1. Sadhya Pranahara 19

2. Kalantara Pranahara 33

3. Vishalyaghna 03

4. Vaikalyakara 44

5. Rujakara 08

1. Sadhya Pranahara 19

2. Kalantara Pranahara 33

3. Vishalyaghna 03

4. Vaikalyakara 44

5. Rujakara 08

4. Pramana Bheda

(Metrical Classification )

1. Panitala 29

2. Three Anguli 04

3. Two Anguli 06

4. One Anguli 12

5. Half Anguli 56

1. Panitala 29

2. Three Anguli 04

3. Two Anguli 06

4. One Anguli 12

5. Half Anguli 56

Table – 7: Showing Classification of Marma



URDHWA SHAKHAGATA MARMA51

Sr.

No

.

Name Sthana Rachan

a

Anusara

Parinama

Anusara

Pramana Anatomical Structure

Involved

Viddha Lakshanas

1. Kshipra - 2 Angustha

Agnuli

Madhye

Snayu

Marma

Kalantara

Pranhara

Marma

½ Anguli 1. Flexor Policis Brevis M.Abductor

Policis Brevis M. Adductor Policis. 1st

Palmar & Dorsal Interossei.

2. Inter Meta Carpal Joint of 1st & 2nd

Metacarpels.

3. Arteria, Radialis Indicis & Princeps

Policis.1st Dorsal Metacarpel Art.

4.Lat.Division Median N. Recurrent

Muscular Branches of Median N.

Aakshepakena

Maranam.

2.

Talahridaya

- 2

Madhyama

Anguli

Anu

Purvena

Mdhya

Mamsa

Marma

Kalantara

Pranhara

Marma

½ Anguli

1. Tendon of Flexor Digitorum,

Superficialis & Profondus, Adductor

Policis Transverse Head,

PalmarAponeurosis, 2nd & 3rd Palmar

interossei muscles, 2nd & 3rd Lumbricals.

Ruja and Marana.



Talasya 2. Superficial & Deep Palmar Arch.

3. Deep br.of Ulnar N & Communicating

br. Medial branch of Median N.

4. Deep transverse metacarpal lig.binding

the metcarpals.

3. Kurcha-2 2 Angula

Proximal to

Kshipra on

both sides

(Ant &

Post).

Snayu

Marma

Vaikalyakara

Marma

4 Anguli 1.Tendon of, Extensor Policis Longus,

Extensor Digitorum, Extensor Indicis,

Extensor Carpi Radialis Longus,

Extensor Carpi Radialis Brevis, & Flexor

Carpi Radialis.

2. Deep br.of Radial N or

Post.Interosseous N.

3. Inter Metacarpal & Carpometacarpal

Articulations.

Bhramana & Vepana



4. Kurcha

Shira-2

Below

Manibhand

ha

Snayu

Marma

Rujakara

Marma

1 Anguli 1. Tendon of, Flexor Digitorum

Superficialis & Profundus. Apex of

Palmar Aponeurosis. Flexor

Retinaculum.

2. Intercarpal Joints & Carpo metacarpal

joints.

3. Superficial br. Of Ulnar N.

4. Lig.of Intercapal & Carpometacarpal

joints.

Ruja & Shopha.

5 Mani

bandha-2

Junction of

forearm &

hand.

Sandhi

Marma

Rujakara

Marma

2 Anguli Wrist Joint

Upper – Inf.surface of lower end of the

radius and articular disc of the inferior

radioulnar joint.

Lower –Scaphoid, Lunate and Triquetral

bones.

Ligaments –Articular capsule, palmar

radio & ulnarcarpal lig, dorsal

radiocarpal lig, RCL & UCL

Kunthata



6 Indra basti-2 Middle of

forearm

Mansa

Marma

Kalantar

Pranhar Marma

½ Anguli 1. Palmaris Longus, Flexor Carpi

Radialis & Ulnaris. Flexor Digitorum

Profundus, Superficialis, Flexor Policis

Longus M.

2. Muscular br.of Ulnar A & Ant.

Interosseous A, Muscular br. Of Radial

Art.

Shonita Kshayena

Maranam.



7. Kurpara-2 Junction

b/w arm &

forearm

Sandhi Vaikalyakara

Marma

3 Anguli Elbow Joint

Upper – Capitulum & trochlea of

humerus.

Lower – Upper surface of the head of the

radius articulates with the capitulum,

trochlear notch of the ulna articulates

with the trochlea of humerus.

Sup.radio ulnar joint, humeroradial

humero ulnar and sup.radiounlar joint.

Capsular lig, Ant & Post lig,

RCL & UCL, Annular lig.

Kunihi.

8. Ani-2 3 Anguli

above the

Krupara on

both ant. &

post.

Aspect.

Snayu

Marma

Vaikalyakara

Marma

½ Anguli

1. Biceps, Brachialis and Triceps M.

2.Radial N, Median N,

Musculocutaneous N

Shopha & Vridhi.

9. Bahvi-2 Middle of Sira Vaikalyakara 1 Anguli 1. Biceps Brachii & Brachialis Muscle. Shonita Kshaya &



Arm. Marma Marma 2. Brachial A.

3.Brachial V.

Sakthi Shosha.

10. Lohitaksha-

2

Above the

Bahvi

below the

Kakshadha

ra in

Bahumoola

Sira

Marma

Vaikalyakara

Marma

½ Anguli 1. Teres Major & Latissimus Dorsi M.

2.3rd part of Axillary A, Ant. & Post.

Circumflex humeral A.

3. Axillary Vein.

Lohita Kshayena

Maranam or

Pakshaghata.

11. Kakshadhar

a-2

Middle of

chest &

axilla.

Snayu

Marma

Vaikalyakara

Marma

1 Anguli 1. Teres Major, Latissimus Dorsi,

Pectoralis Major and Subscapularis M.

2. Brachial Plexus with its branches.

Pakshaghata.

Table – 8: Showing Urdhwa Shakhagata Marma



MARMA PANCHABHOUTIKATVA52

Sr. No. Type of Marma Total No. MahaBhuta Effect after injury

1. Sadhya Pranahara 19 Agni Immediate loss of Agni Mahabhuta

Causing death immediate or within

one week

2. Kalantara

Pranahara

33 Agni &

soma

Immediate loss of agni but gradual

loss of Soma Mahabhuta (i.e. within

one month)

3. Vishalyaghna 03 Vayu Marmas fatal after extraction of

shalya are predominant of vayu, as

long as vayu stays inside obstructed

by the tip of the shalya the person

lives but as soon as it is extracted

vayu positioned at the site of marma

comes out ie, why the patient

survives till the shalya is there and

after its extraction he dies or if the

shalya comes out after suppuration

then also survives.

4. Vaikalyakara 44 Soma Marmas causing disabilities are

predominance of Soma Mahabhuta,

due to firmness and coldness sustain

life.

5. Rujakara 08 Agni &

Vayu

Marmas casusing pain are

predominant in qualities of Agni &

Vayu Mahabhuta as they particularly

cause pain, some how ever say that

pain is related to all 5 bhutas.

Table – 9: Showing Pancha bhoutikatva of marma



PRANA ADHISHTAN IN MARMANaturally ‘Prana’ reside in Marma.53

Soma, Maruta, and Tejas as well as Satva, Raja and Tama along with Bhutatma

stays in marmas. That is why if any injury takes place on marma the person will not

survive.54

Marma’s are comsiderd as ‘Jivanadhara’ by Rishi Muni’s, and also mentioned

‘Prana’ is situated in the marma sthanas.55

Acharya Charaka explains Trimarmas ie Basti, Hridaya, Shira are Ashraya for

prana. If any kind of pressure occurs over these marmas, the Vata gets aggravated and

produce different kinds of vedana or may also leads to death.56

Marma sthana is the combination of Mamsa, Sira, Snayu, Asthi and Sandhi with

each other, and ‘Prana’ especially situated in the marma sthana.57

Marma’s are so called because they cause death when injured and they are the

meeting place of Mamsa, Sira, Snayu, Asthi and Sandhi.58

Agni, Soima, Vayu, Satva, Raja, tama, Panchgnyanendriya, Bhutatma are called

‘Prana’ & this ‘Prana’ resides in Marma-sthana.59

GENERAL SYTMPTOMS OF MARMABHI GHATA ‘Marmaghata’ leada to ‘Dehaprasupti’, ‘Guruta’, Sammoha, Shitakamita, Sweda,

Murcha, Vamihi, Shwasa..60

1) MAMSA MARMA VIDDHA LAKSHANA When Mamsa, Marma is injured, there will be continuous bleeding, viscosity of blood

is reduced, blood resembles meat washed water, pallor of the skin, loss of function of

sense organs & quick death of the person.61

2) SNAYU MARMA VIDDHA LAKSHANA When Snayu Marma, are injured, there will be bending of the body, convulsions,

very severe pain, inability for riding, sitting etc. distortions of anga or even death of a

person. 62



3) SIRA MARMA VIDDHA LAKSHANA

When Sira Marma are injured, blood which is thick flows out of sira

continuously in large quantity, due to blood loss, thirst, giddiness, dyspnoea, delusion,

unconsciousness and hiccup manifest leading to death of a person. 63

4) ASTHI MARMA VIDDHA LAKSHANA When Asthi Marma are injured, there is discharge of thin fluid mixed with bone

marrow intermittently and severe pain contineously.64

5) SANDHI MARMA VIDDHA LAKSHANA When Sandhi Marma are injured, the site of injury feels as though full of thorns, even

after healing of the wound there is shortening of the arm, lameness, decrease of strength

and movement, emaciation of body and swelling of joints occurs.65

6) ACC. TO VAGBHAT DHAMANI MARMA VIDDHA

LAKSHANA When Dhamani Marma are injured, the blood flows out frothy and warm comes out

with a sound and the person becomes unconscious.66

EFFECT OF MARMA’S If Sadhya Pranahara Marma gets injured it may leads to Kalantara Pranahar or

death. If Kalantara Pranahara Marma gets injured it may lead to Vaikalyakara. If

Vishalyghna gets injured it may lead to Vaikalykara. If Vaikalyakara gets injured it wil

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

mild pain.67

TYPES OF MARMA GHATA An effect of stroke on Marma due to incision, stabing, burning, and external

stroke will produce same as symptoms of Marmaghata.68



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.69

IMPORTANCE OF MARMA PARIVISTARA / PRAMAN An incision should be made at the spot a finger’s width remote from the Urvi,

Kurcha Shira, Vitapa, Kaksha, and a Parshva Marma, whereas, a clear space of two

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

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

respect of the four shringataks, five simantas and ten Marmas in neck nila 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 sthanas should

be carefully avoided in surgical operation. 70, 71

IMPORTANCE OF MARMAS IN CHIKITSA In human beings; vata, pitta and kapha are situated in Basti; Hridaya and Shiras

respectively. Due to their vital locations, they should be eliminated by the nearest roots.72

Shira, Hriday and Basti are most important ‘Marmas’ out of all hundred seven, as

they are major sites for, kapha, pitta and vata respectively.73

IMPORTANCE OF MARMA IN SHALYA TANTRA

Knowledge of Marma is very important to do Shastra Karma. Acharya Sushruta

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

avoiding Masrmas, Siras, Snayus, Asthi, Sandhi and Dhamani’s till pus is seen.74

Acharya Sushruta also explains that kshara should not be applied to Marma Sthanas,

Siras, Snayus, Sandhis, Taruna asthi, Sevani, Dhamani, Throat, Nabhi, Nail bed, Pennis,

Sroatas and thinly muscle parts and eyes.75



Marmas are said to be cover half of 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.76

IMPROTANCE OF SIRA IN MARMA This is further corroborated by the fact that the four classes of sira or vessels

(which respectively carry the vata, pitta, kapha and the rakta) are found to enter into the

Marmas for the purpose of maintaining the moisture of the local Snayu, Asthi, Mamsa

and Sandhi and thus sustain the organism. The vayu agrevated 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. 77

SADYHA PRANHARA MARMA (INSTANTLY FATAL)

Time of fatal effect:

Trauma to Sadhya pranhara Marma causes death immediately or within seven

days.78

COMPOSITION AND VIDDHA LAKSHANA All the five elements together constitute Sadhya Pranahara Marma, Trauma to this

Marma, results in inability of sense organs to perceive their respective subjects. Mind and

intelligence can’t function properly severe pain precedes the death.79

CAUSES OF DEATH Sadhya pranhara Marma has Agni element in it prominently. If it is traumatized,

fire element vanishes. Hence, immediate death occurs.80

Rakta- Dhatu holds human- body. It is basic pillar of our body. By any means, we

should protect it, as life (Prana) resides in this dhatu.81

Blood loss should not be neglected because ‘Prana’ resides in blood. 82



KALANTARA PRANHARA MARMA

Marmaghata period (15 days to the month) 83

COMPOSITION AND VIDDHA LAKSHANAAgni and Soma resides at the site of these Marmas. First there is a loss of Agni

and then loss of ‘Soma’ and then death occurs.84

Damage to Kalantara Pranahara Marma causes ‘Dhatu-Kshay’, which results in

extreme pain leading to eventual death. 85

VISHALYAGHNA MARMA

FATAL PERIOD Fatal period of Vishalyaghna Marma is not described Death does not occur until

weapon exists at site of entry. As soon as weapon is removed death occurs.86

VIDDHA LAKSHNA OF VISHALYAGHNA MARMA This Marma is the house for Vayu Mahabhuta. As soon as weapon is removed,

Mamsa, Vasa, Majja, Mastulunga are all dried. It causes shwasa, Kasa and results in

death.87

CAUSES OF DEATH Marmas fatal after extraction of shalya are predominant in vayu, as long as vayu

stays inside obstructed by the tip of the shalya the person lives but as soon as it is

extracted vayu positioned at the site of marma comes out that is why the patient survives

till the shalya is there and after its extraction he dies or it the shalya comes out after

suppuration then also survives.88

Vishalyaghna becomes vaikalyakara if it is pierced at the end or margin and also

if the injury is not serves. On the contrary if it is severe it can become Kalantara

Pranahara.89



VAIKALYAKARA MARMA Soma guna is predominant in Vaikalyakara Marma, which does the Sthiratva,

Sheetatva and also does the Prana Avalambana.90

If this Marma is traumatized, permanent disability is produced. Fatal period of

Marmaghata Kala is not given.91

VIDHA LAKSHANA If Vaikalyakara Marma is traumatized death supervences immediately or after

some time.92

RUJAKARA MARMA 93, 94 , 95

There are 8 Rujakara Marma in human body

Sr. No. Name No.

1) Gulpha Marma 02

2) Manibandh Marma 02

3) Kurcha Shira 04

Total No. 08

Table – 14: Showing Rujakara Marma

DEFINATION A marma which produce pain after injury is called as Rujakara Marma.96

MARMAGHATA PERIOD A marmaghata period of Rujakara Marma is not mentioned in Samhita but

practically pain is felt on Marma site after injury immediately.

SWABHAVA Rujakara Marma are predominant in qualities of Agni & Vayu as they particularly

cause pain; some or however say that pain is related to all the five mahabhutas.97



PERIOD OF FATALITY No fatality has been mentioned. Only it wil produce severe pain.98

KURPARA MARMA SHAREERA AND VIDDHA LAKSHANA The word Kurpara means Elbow.99

The word Kurpara means Kaphoni which means Elbow.100

Kurpara is the junction between Prapani and Prabahu.101

Kurpara means Kaphoni which is also called Kuhuni.102

There are two Kurpara Sandhi Marma’s are present and their pramana is 2 angula,

which are Vaikalyakara in nature.103

Kurpara Marma resembles the Janu Marma, on injury it will leads to Kunitva.104

KUNIHI The word Kunihi means Kubjitakaraha.105

The word Kunihi means Sankuchita Bahu Madhya.106

The word Kunitvam means Bahu Pani Anguli Kubjata.107

Kunihi means Vikruta Karaha.108



AYURVEDIC VIEW OF SANDHI SHARIRA

NIRUKTI OF SANDHI Sandhi’s are the junction of Bones and are seat of kapha; they help to keep the

body parts together.109

SANDHI UTPATTI Sandhi word is derived from the root san + dha + ki which mean sandhanamiti

means that which holds together, joining or binding.

According to Aacharya Charaka and Sushruta during 3rd month of gestation

development of all body parts takes place simultaneously in subtle nature.110

SANDHI RACHANA Anatomically two separate entities constitute a joint. From the mobility and

dislocation point of view Sushruta has considered only bony joints, while from the point

of establishing the equilibrium of internal environment the dosha, Dhatu etc.111

Bones play vital role in the Dharana Karma of Sharira and bones are joined to

each other with the help of Mamsa, Sira Snayu binding together to form joints. Hence the

Mamsa, Sira, Snayu and Asthi binding each other are collectively can be considered as

Sandhi.112

Acharya Sushruta described the importance of sandhi and snayu as, Man built a

ship by to many bindings and then the ship can able to float with various types of

weight.113

SANDHI AND GARBHA BHAVA Aacharya Charaka has described the Garbhaja Bhava in Sharirsthana while

describing pitruja bhavas of Garbha, Aacharya illustrated Pitruja Bhava’s such as Asthi,

Sira, and Snayu which are also constituents of joints.114



SANDHI AND MAHABHAUTIKATVA The matruja, pitruja bhavas etc are also the products of Mahabhuta along with the

touch, tactile organs, roughness, impulsion, shaping of dhatus and physical activities are

derived from Vaayu.115

All the movements like Aakunchan, Prasaran, and Gamana etc. are Vayaviya

Bhava. There is also Prithvi Mahabhuta predominance in Sandhi due to presence of

bones, muscles and tendons in Sandhis.116

SANDHI AND DOSHA The Kapha is responsible for Sthiratva, Snigdhatva, and Sandhi Bandhana. 117

The Shlesma that resides in Sandhi named as Shleshaka Kapha. It facilitates free

movements of the Sandhi and lubricates it as well.118

SANDHI AND DOSHASTHANA SAMBHANDHA Joints are the structures which come under the circulatory system of Vata and

Asthi is the major Dhatu associated with joints and which is the seat of Vata Dosha .119

SANDHI AND PRAKRUTI Person of vata prakruti is krush and his sandhi becomes sashabda.120

The joints of person having pitta prakruti are shithila and binded by mansa.121

Joint of kapha prakruti persons are stable, snigdha and shlistha and binded by

muscle i.e. goodha.122

SANDHI AND KALA The fourth kala is known as shlesmadhara kala lies with in the Sandhi. It

lubricates the joint and allows free movements of area of the bones and lines the fibrous

capsule of the elbow joint.123



DUSTI LAKSHAN OF MAJJAVAHA SROTAS When majja vaha srotas gets vitiated due to nidana, there are symptoms like joint

pains, crepetaion of attempted movement; vertigo etc. hence to keep proper working of

sandhi majja vaha srotas must be normal.124

AYURVEDIC CLASSIFICATION OF SANDHI Sandhi are classified into 2 kinds viz - 1) Chestavanta and 2) SthiraSandhi.125

The cheshtavanta means movable joints. The sthira sandhi’s are again classified in

to 2 types 1) Alpa Cheshtavanta (Slightly Movable) and 2) Bahu Cheshtavanta (Freely

Movable). So the cheshtavanta sandhi’s usually present in shakha’s, and hanu pradesha.

Alpa chala sandhi presents in the kati (intervertebral joint region). The Sthira Sandhi is

present in the Shiras.

SANDHI SANKHYA According charak there are only 200 joints in the body.126

According to Sushruta there are 210 joints in the body. According to

Shadangaanusara, in Shakha – 68, in Koshtha – 59, in Greeva pradesha – 83 Sandhi’s are

present.127

DESCIPTIION AND TYPES OF JOINTS 128

1. Kora Sandhi : Resembles a budding flower.

These are present in Interphalangeal joint, Wrist joint,

Ankle joint, Knee joint and Elbow joint.

2. Ulukhala Sandhi : Resembles the shape of Mortar ie a Stone Grinder.

These joints are present in Shoulder, Hip, and Teeth with

the gums.

3. Samudaga Sandhi : Resembles like a covered base, fittend into one another.

These are present in Acromio clavicular joint, Sacro

coccygeal joint, Pubic symphysis, Illio sacral joint.

4. Pratara : Resembles Floating joints ie supported by a cushion.



These are present in Vertebral column.

5. Tunnasevani : Resembles Suture like in shape.

These joints are present in flat bones of Skull and between

three parts of Hip bone.

6. Vayastunda : Resembles A Crow’s beak like portion.

These are present in Temporo mandibular joint.

7. Mandala Sandhi : Resembles like Cirucular.

These are present in Kantha nandi, Hridaya naadi, Netra

naadi, Kloma naadi.

8. Sahnkhavarta : Resembles Spiral shaped like shell of common Snail.

These are present in Shrungatakas of ears present in

petrous part of temporal bone. Bony labrynth of cochlea.

KURPARA SANDHI

It is a chesta vanta sandhi of Kora variety.

It comes under Sandamsha kora sandhi.129



MODERN REVIEW

INTRODUCTION Joints are meeting place of Bones.130

Joint is a point of contact between bones, bwtween cartilage and bones, or

between teeth and bones.131

In anatomical usage, a joint is a junction between two or more bones or cartilages.

The term articulation means a joint in Latin. The term arthrology (i.e. study of joints)132

or term arthritis (i.e. study of joints ) or term arthritis (i.e. inflammation of a joint) are

derived from term arthron which means a joint in Greek.

CLASSIFICATION OF JOINTS133, 134,

The joints can be classified according to their structure and function.

A) FUNCTIONAL CLASSIFICATION It is based upon the degree of mobility of the joints. They are of three types.

1. Immovable joints (synarthrosis)

2. Slightly movable joints (amphiarthrosis)

3. Freely movable joints (diarthrosis)

SYNARTHROSES These are immovable joint. It is of 3 types.

1. Suture – Frontal Suture.

2. Gomphosis – Roots of teeth with sockets of the alveolar processes of the

maxilla and mandible.

3. Synchondrosis – joint connects the epiphysis and diaphysis of growing bone.


Observation 55


Brachioradialis –

Radial Nerve branch.

Origin on Flexor group of forearm muscles from medial epicondyle.

Extensor Muscles –

Triceps –

Radial nerve branch.

Anconeus –

Radial nerve branch.

Origin of Extensor group of forearm muscles from lateral epicondyle

ELBOW JOINT:

Nerve Supply –

The joint receives branches from the Ulnar, Median, Radial, Musculocutaneous

nerves.

Ligaments –

1) Capsular Ligament.

• Synovial membrane.

2) Anterior Ligament and Posterior Ligament.

3) Ulnar Collateral ligament.

4) Radial Collateral ligament.

5) Annular ligament.

6) Quadrate ligament.

Observation 56


Articular surfaces –

Upper –

The capitulum & trochlea of humerus.

Lower –

1) Upper surface of the head of radius articulates with the capitulum.

2) Trochlear notch of the ulna articulates with trochlea of the humerus.

Here some of the x –ray reports has been collected and attempt is made to identify

the structures involved in the kurpara marma abhighatha.


AMPHIARTHROSES

These are slightly movable joints. It is of 2 types.

1. Syndesmosis – Distal articulation between the tibia and fibula.

2. Symphysis – Pubic symphysis.

DIARTHROSIS Freely movable joints. It is of 6 types.

1. Gliding Joint – Carpals, Tarsals.

2. Hinge Joint – Knee, Elbow, Ankle & Interphalangeal joints.

3. Pivot joint – Atlas rotates around the dense of Axis.

4. Condyloid Joint – The Temporomandibular joint and metacarpophalangeal

joint.

5. Saddle Joint – The joint between trapezium of the carpus and metacarpal of

thumb.

6. Ball and Socket Joint – Shoulder and Hip joints.

B) STRUCTURAL CLASSIFICATION 1) Fibrous joints

2) Cartilaginous joints

3) Synovial joints

Fibrous Joint – If there is no synovial cavity and the bones are held together by fibrous

connective tissue.

Cartilagenous Joint – If there is no synovial cavity and the bones are held together by

cartilage.

Synovial Joint – If there is a synovial cavity and the bones forming the joint are united by

a surrounding articular capsule and frequently by accessory ligaments.



SYNOVIAL JOINTS 135

These joints possess a cavity and the articular ends of bones forming the joint are

enclosed in a fibrous capsule. As a result they are separate by a narrow cavity, the

articular cavity (or the joint cavity), which is filled with a fluid called synovial fluid (like

an egg albumin), which acts as a lubricant. The synovial joints are the most evolved and

freely movable joints. They are often termed as diarthrodial joints.

THE CHARACTERISTIC FEATURES OF SYNOVIAL JOINTS ARE

AS FOLLOWS 1. The articular surfaces are covered by a thin plate of hyaline cartilage.

2. The cavity of the joint is lined by synovial membrane except over the articular

cartilages.

3. The cavity is filled with synovial fluid secreted by synovial membrane which

provides lubrication to the articular surfaces and nutrition to the articular

cartilages.

4. Some additional structures are present within the joint cavity, e.g.: (a) articular

discs are usually composed of fibrocartilage, (b) fat pads, and (c) tendons.

COMPONENTS OF SYNOVIAL JOINTS AND THEIR FUNCTINAL

SIGNIFICANCE The following are the components of synovial joints:

1. Fibrous capsule: It completely invests the joints like a sleeve and encloses a synovial cavity. It is

attached by continuous lines to the bones forming the joint close to the articular

cartilages.

Function: The fibrous capsule stabilizes the joint in such a way that it permits

movements but resists dislocation.


Observation 53


ELBOW REGION

CUBITAL FOSSA:

Cubital fossa is a triangular fossa forms the hollow depression on the front of the

elbow.

Boundaries:

Base –

It is formed by an imaginary line joining right & left epicondyles of humerus.

Apex –

It is directed below & is formed by the convergence of the lateral & medial

boundaries.

Laterally –

Medial border of the brachioradialis.

Medially –

Lateral border of the pronator teres.

Floor –

Brachialis & Supinator muscles.

Roof –

Deep fascia of forearm, bicipital aponeurosis. Superficial to bicipital aponeurosis

lie median cubital vein, medial and lateral cutaneous nerves of forearm.

Observation 54


CONTENTS OF CUBITAL FOSSA:

NERVES –

Cutaneous Nerve –

Medial cutaneous nerve.

Lateral cutaneous nerve.

Posterior cutaneous nerve.

Median Nerve.

Radial Nerve.

VESSELS –

Brachial Artery

Radial Artery

Ulnar Artery.

Common interosseous Artery.

vAnterior and Posterior Interosseous Arteries

MUSCLES OF THE ELBOW REGION:

The muscle which produces flexion and extension movements was recognized.

Flexor Muscles -

Brachialis –

Musculocutaneous Nerve & Radial Nerve branch.

Biceps Brachii –

Musculocutaneous Nerve branch.


2. Ligaments :

These are thickened bands of collages fibers

a. True ligaments:

Permit the movements in one plane and prevent unwanted movements in other

plane. In addition they also stabilize the joint.

b. Accessory ligaments:

Provide additional reinforcement the joint and limit the range of movements.

3. Synovial membrane :

It is a thin highly vascular membrane of connective tissue lining the inside of the

fibrous capsule is reflected from the fibrous capsule is reflected onto the bone, which

covers right up to the articular cartilage.

Function: The synovial membrane produces synovial fluid in sufficient quantity to

keep the surfaces properly lubricates.

4. Articular cartilage:

With few exceptions the articular cartilage is made up of hyaline cartilage.

Function: The articular cartilage provides smooth friction free movements and

resists compression forces.

5. Articular disc or meniscus:

The articular discs are pads on fibrocartilage interposed between the articular

surfaces of some joints.

Function: Helps in lubrication of a joint by maintaining an interval between the

articular surfaces.

6. Bursae:

These are pouch – like sacs of connective tissue filled with synovial fluid, found

near certain synovial joints.



Function: The function of bursae is to cushion certain muscles and to facilitate the

movement of tendons or muscles over bony or ligamentous surfaces.

7. Fat pads:

These are pads of fat placed between synovial membrane and fibrous capsule or

between synovial membrance and bone, e.g. acetabular fat of hip joint.

Function: As fat is very plaint, the pads can accommodate themselves to changing

condition of the joint during different movements.

CLASSIFICATION OF SYNOVIAL JOINT136

Synovial joint and Its Sub Classification

Plane

Hinge

Pivot

Condylar

Ellipsoidal

Saddle

Ball

and

socket

Intercarpal

Elbow

Superior

Radioulnar

Temporo-

Mandibular

Radio-

carpal

(wrist)

First

Carpo-

metacarpal

Hip joint

Intertarsal

Knee

Median

atlanto-

axial

Metacarpo-

phalangeal

Atlanto –

occipital

Sterno –

clavicular

Shoulder

joint

Intermetatar

sal

Ankle

Metacarpo –

Phalangeal

Calcaneo –

cuboid

Incudo –

stapedial

(smallest)

Intermetaca

rpal

Interphalang

eal

Metatarso

–

phalangeal

Incudo –

malleolar

(smallest)

Table – 15: Showing classification of Synovial joint



Uniaxial Joint In these joints the movements occur in one plane around a transverse axis.

Eg: Elbow joint etc.

Biaxial Joints In these joints the movements occur in tow planes or axis. Eg: Knee joint.

.

Multiaxial (polyaxial) Joints

In these joitns movements occur in three planes or axis.

Eg: Shoulder.

ACCORDING TO THE NUMBER OF ARTICULATING BONES

Simple Joints When two bones articulate in the formation of a joint.

E.g. interphalangeal joints of fingers.

Compound Joints More than two bones articulate within the capsule.

Eg.Wrist joint, Elbow joint.

Complex Joint When joint cavity is divided by an intra - articular disc.

Eg. Temporomandibular joint, acromioclavicular joint, sternoclavicular joint.



MOVEMENTS OF SYNOVIAL JOINTS Active Movements

Gliding or slipping movements.

Angular movements.

Rotary or circular movements.

BLOOD SUPPLY TO SYNOVIAL JOINTS It is derived from the periarticular network of arteries (circulus articularis

vasculosus) that surround the joint Articular cartilages are avascular.

The fibrous capsule and ligament have poor blood supply.

The synovial membrane is richly supplied by blood.

NERVE SUPPLY TO SYNOVIAL JOINTS The synovial joints have rich nerve supply. Sensory nerve fibers conveying pain.

Sensory nerve fibers conveying proprioceptive sensations

Autonomic fibers which have vasomotor effects.

HILTON’S LAW The Hilton’s law states that the nerves supplying the joint also supply the muscles

regulating the movements of the joint and skin over the joint.

CLINICAL CORRELATION If the joint is excessively stretched or suffers from a disease or injury, the

irritation of nerves supplying the joint cause muscles acting on the joint to contract in

such way that the joint is brought in a position of maximum comfort to protect the joint.

The pain of the joint is referred to skin overlying the joint.



MOVEMENT’S DEIFINITIONS

Movement Definition

Angular movements

Flexion Bending (decreasing joint angle) the joint

occasionally backward, e.g. knee joint

Extension Straightening the joint (increasing the joint

angle)

Abduction Movement away from the midline of the

body.

Adduction Combination of flexion, extension,

abduction and adduction

Special Movements

Rotation Movement round the long axis of the bone

Supination Turning the palm of the hand forward or

upward

Pronation Turning the palm of the hand backward or

downward

Inversion Turning the sole of the foot inwards

Eversion Turning the sole of the foot outwards

Protraction Forward movement parallel to ground.

Retraction Pulling back the protracted part

Elevation Lifting upward

Depression Moving downward

Table – 16: Showing Movement’s Deifinitions



LAST’S FORMULATION OF SEGMENTAL INNERVATION Segmental Innervation of the joints

Segmental Regulating of the joint movements

Joint Segmental innervations

Hip L 2, 3, 4, 5

Knee L3, 4, 5 and S1

Ankle L4, 5 and S1, 2

Segment regulating the movements

Hip joint Flexion Extension

L 2, 3 L 4, 5

Knee joint Extension Flexion

L 3, 4 L 5, S1

Ankle joint Dorsilflexion Plantarflexion

L 4, 5 S1, 2

FACTORS MAINTAINING THE STABILITY OF SYNOVIAL JOINTS

1. Bones

2. Ligaments

3. Muscles

ELBOW JOINT137

It is a compound joint and consists of humeroulnar & humero radial parts; the

latter is continuous with the superior radio – ulnar joint. All the three components posses

one synovial cavity & are collectively known as cubital articulation. But for functional

consideration, the elbow joint is restricted to the humero – ulnar & humero – radial parts

and basically forms a hinge joint, permitting flexion and extension.



Humero – Ulnar part

It is formed by the articulation between the trochlea of humerus and the trochlear

notch of ulna. Humero – ulnar joint is of hinge variety, the lower end of humerus presents

two non articular depressions – coronoid fossa in front and deeper and triangular

olecranon fossa behind. The coronoid fossa accommodates the anterior margin of the

ulnar coronoid process in flexion; the tip of the olecranon process of ulna occupies the

olecranon fossa in extension.

The trochlear notch of ulna is reciprocally saddle shaped and formed by the

articular surfaces of olecranon and coronoid processes, separated by a non articular

narrow strip.

Humero – Radial part

Structurally, it is a ball and socket type. The ball is represented by the capitulum

of humerus which is articular in front, and below. The disc like concave upper surface if

the head of radius forms its socket. The radial head comes in contact with the lower

surface of capitulum in extension and rotates on its anterior surface during flexion; in full

flexion peripheral rim of the head lodges in a depression, radial fossa, above the

capitulum.

Superior Radio – ulnar joint

It is a pivot joint between the strip of the articular circumference of the head of

radius and the osseo – fibrous ring, formed by the radial notch of ulna and the annular

ligament. The radial head rotates with in the ring; one fifth of the ring is bony and four –

fifth fibrous.

Ligaments of the elbow joint

It posses capsular ligament, ulnar and radial collateral ligaments.

Capsular ligament

The fibrous capsule envelops the joint completely. It is thin in front and behind to

permit flexion and extension, and is thickenend at the two sides in the form of collateral

ligaments in order to provide stability of the joint.



Proximally, the fibrous capsule is attached to the lower end of humerus in a

continuous line, which excludes the two epicondyles but includes the three fossae to gain

attachments along the upper margins of the coronoid and radial fossae, and falling short

of upper limit of olecranon fossa. Distally, it is attached to the margins of the trochlear

notch and blends with the annular ligament of the superior radio – ulnar joint.

The synovial membrane lines the inner surface of fibrous capsule and the bones

with in the capsule including the three fossae and extends upto the periphery of articular

cartilage. Cushions of extra – synovial fat fill up the three fossae.

Ulnar collateral (Medial) ligament

It is triangular in shape and extends from the lower part of medial epicondyle to

the medial margins of trochlear notch. The ligament consists of three bands – anterior,

posterior, and inferior. The anterior band is attached to tubercle on the medial margin of

the coronoid process; the posterior band is attached to the medial margin of olecranon

process; the inferior band extends obliquely between the olecranon and coronoid

processes, and forms a foramen between the band and the trochlear notch through which

the extra – capsular fat is continuous with intra capsular fat.

The medial ligament is overlapped by the triceps, flexor carpi ulnaris and flexor

digitorum superficialis, and is closely related with ulnar nerve.

Radial collateral (Lateral) ligament

It forms a triangular expansion and extends from the lateral epicondyle to the

annular ligaments. It is intimately related to the supinator and extensor carpi radialis

brevis muscles.

Annular ligament

It keeps the radial head in position and is attached to the two ends of radial notch

of ulna. The ligament is some what cup shaped presenting smaller circumference below.

The annular ligament is continuous above with the fibrous capsule of elbow joint.



Quadrate ligament

A few fibers from annular ligament form a thin quadrate ligament which covers

the synovial membrane reflected on to the radial neck.

Bursae in relation to the joint

Above the olecranon, between the triceps tendon and capsule of the joint.

A subcutaneous bursa on the dorsal triangular surface of olecranon process;

Between the biceps tendon and the smooth anterior part of radial tuberosity.

Arterial supply

From the numerous periarticular branches derived from the anastamosis around

the elbow.

Anastamosis around the elbow joint links the brachial artery with the upper ends

of the radial & ulnar arteries. It supplies the ligaments and bones of the joint. The

anastamosis can be subdivided into the following parts.

Infront of lateral epicondyle of the humerus, the anterior descending (radial

collateral) branch of the profunda brachii anastamosis with the radial recurrent branch of

the radial artery.

Behind the lateral epicondyle of the humerus, the posterior descending branch of

profunda brachii artery anastamoses with the interosseous recurrent branch of the

posterior interosseous artery.

Infront of the medial epicondyle of the humerus, the inferior ulnar collateral

branch of the brachial artery, and occasionally a branch from the superior ulnar collateral

artery, anastamoses with the anterior ulnar recurrent branch of the ulnar artery.

Behind the medial epicondyle of the humerus, the superor ulnar collateral branch

of the brachial artery anastamoses with the posterior ulnar recurrent branch of the ulnar

artery, and a branch from the inferior ulnar collateral artery.



Nerve supply

The joint is mainly supplied by :

Muculo- cutaneous nerve supplies the anterior part of capsule through the branch

to the brachialis.

Radial nerve to the posterior and lateral part of the capsule through the nerve to

anconeus and the ulnar collateral branches;

Ulnar nerve to the ulnar collateral ligament.

Movements

The chief movements at the elbow joint are flexion and extension.The ulnar is

slightly pronated in extension and supinated in flexion.

The range of flexion is about 1500, and is limited only when the flexor surfaces of

the arm and forearm approximate. Hand to mouth movement consists of flexion at the

elbow, and medial rotation at the shoulder joint or pronation of the radius at the radio

ulnar joint.

Full extension at the elbow is reached when the arm and the forearm assume

straight line. Extension makes the joint close – packed and is limited bythe tension of the

anterior part of the capsule and the muscles in front of the joint along with the

accommodation of the tip of the olecranon in the olecranon fossa.

Pronation

During pronation the head of radius spins within the annular ligament around a

more or less a vertical axis and retains its position lateral to the ulna. But the lower end of

radius, carrying the hand with it, rotates forward and medially across the lower part of

ulna. In this process the interosseous membrane in spiralised.

Supination

The rotation is reversed, the lower end of radius regains its original position

lateral to the ulna and the interosseous membrane is despiralised.



Carrying angle

When the elbow is fully extended and the forearm supinated, the arm and the fore

arm form an obtuse angle which is open on the lateral side. This is known as carrying

angle which measure about 1630, so bhrachialis, biceps brachii and at the ulnar border of

the forearm does not come in close contact wit the lateral surface of the thigh and this

facilitates to carry a heavy object grasped by the hand.

Muscles producing movements

Flexion

Brachioradials; chief flexor muscle is brachialis. The biceps acts best when the

forearm is supinated and acts a spurt muscles; the brachioradilis acts best in mid prone

postion and represents a shunt muscle.

In flexion against resistance pronator teres and flexor carpi radialis comes into play.

Extension

Triceps anconeus and assisted by gravity.

Pronation

Pronator quadrates, assisted by pronator teres, flexor carpi radialis and gravity.

Anconeus assists lateral displacement of ulna in full pronation.

Supination

Supinator in extension, and biceps brachii in flexion.

Spinal segment controlling the movements

Flexion – c5 and c6

Extension – c7 and c8.



REGIONAL ANATOMY – ELBOW Structures which passes through the elbow joint:

In front:

Brachialis, tendon of biceps, median nerve, medial cutaneous nerve of forearm,

lateral cutaneous nerve of forearm, and brachial artery, median cubital vein, receives

tributay of median antebrachial vein.

Behind:

Triceps and anconeus, posterior cutaneous of forearm, medial & lateral cutaneous

nerve of forearm.

Medially:

Common origin of superficial flexor muscles of forearm, flexor carpi ulnaris and

ulnar nerve, basilica vein.

Laterally:

Common origin of superficial extensor muscles of forearm, supinator, extensor

carpi radialis brevis, radial nerve and its superficial and deep branches, cephalic vein.



NORMAL ANATOMY OF ELBOW JOINT

Fig – 1 Shows Ligaments of Elbow Joint Anterior Aspect

Fig – 2 Shows Intra Capsular & Annular Ligament.



Fig – 3 Shows Ligaments of Elbow Joint Lateral View.

Fig – 4 Shows Ligaments of Elbow Joint medial View.



Fig – 5 Shows Posterior Aspect of Elbow Joint


Methodology 51

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 will be on the data completions from the

Bruhatrayees, Laghutrayees, and other classical books including journals, presented

papers, previous work done and co-related, analyzed with the knowledge of

contemporary science on the subject.

Dissection of the Kurpara Sandhi marma region in the dept. of Shareera Rachana

of S.D.M. College of Ayurveda, Udupi was carried. Observations are analyzed and co-

related in the view of ancient description of Kurpara Sandhi Marma and its viddha

lakshana with special reference to modern science.

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 Shareera Rachana dept. of

S.D.M. Ayurveda College, Udupi.

Assesment Criteria Observation and identification of the regional anatomy of Kurpara marma sthana

on the cadaver dissection and co- related with Kurpara marma shareera explained in

Ayurveda classics Kurpara marma vidha lakshanas are identified with the help of modern

parameters like x – ray and structures were identified.


Dissection Photo 57


Dissection Photos

Fig-5: Right Elbow Region

Fig-6: Articular Capsule

Dissection Photo 58


Fig-7: Capsular Ligament

Fig-8: Radial Collateral Ligament

Dissection Photo 59


Fig-9: Ulnar Collateral Ligament

Fig-10: Articular Parts

Radiological findings 60


RADIOLOGICAL FINDINGS OF ELBOW JOINT

1) Left Elbow Joint X-Ray AP & Lateral View shows Coronoid Process Fracture

3) Right Elbow Joint X-Ray AP & Lateral View shows Medial Epicondyle Fracture



5) Left Elbow Joint X-Ray Lateral View shows Supra Condylar Fracture with dislocation of Elbow and Radioulnar Joint.

7) Right Elbow Joint X-Ray Lateral View shows Lateral Collateral ligament avulsion



5) Right Elbow Joint X-Ray AP & Lateral View shows Fracture of Neck of Radius and Coronoid Process of Ulna.

6) Left Elbow Joint X-Ray Lateral View Show Supra Condylar Fracture

Discussion 63

DISCUSSION Study of Kurpar Sandhi Marma has been carried out by collecting reference from

different Ayurvedic literature and modern anatomy text books and studied critically.

Structures present in the Kurpara Marma pradesha are identified with the help of

dissection. Structural changes were studied in Kurpara marmabhighata with the help of x-

ray, AP and Lateral view.

The Kurpara marma lies in the Kurpara sandhi, the detail discussion of these

points are as follows:

LOCATION As per the available reference from Samhita, the exact location of Kurpara sandhi

marma is mentioned as junction between Hasta and Baahu. So the junction of hasta and

bahu may be considering as elbow joint.

MAMSAAccording to Acharya Sushrutha 5 peshi’s are present in the Kurpara sandhi. We

won’t find any detail reference regarding these peshi’s present in the Kurpara Sandhi.

While dissecting the elbow region we observed the following muscles which are present

in and around the elbow joint. So the peshi’s may consider which helps in movement of

elbow joint and are originated and insertion in relation to Elbow Joint.

Anteriorly – Following muscles were observed -

Tendon of Biceps & Bicipital Aponeurosis.

Brachialis.

Brachioradialis.

Origin of Flexor Group of Muscles of forearm from the medial epicondyle.

Origin of Extensor Group of Muscles of forearm from the lateral epicondyle.

Posteriorly – Following muscles were observed-

Anconeus.

Tendon of Triceps muscle.

Pronator teres.


Discussion 64

SIRA As such there is no direct reference about Sira’s present in the Kurpara sandhi

region, but in the context of Siravyadha vidhi sharira while explaining the Sira vyadha in

the disease Yakrutdalyodara, it has been explained as Sira vyadha should be done at the

Dakshina Kurpara sandhi and in Plihodara at Vama Kurpara sandhi. So with this

reference we may consider the Sira’s lies in the Kurpara sandhi Marma. The superficial

veins like Cephalic, Basilic and Cubital veins in the marma sthana.

SNAAYUPrathaanavathi variety of snaayu present in urdhwa shaakha. As Kurpara sandhi is

present in the urdhwa shaakha, we can state that snaayu present in the Kurpara sandhi is

also of prathaanavathi variety. Acharya Sushruta has explained ten snayu’s are present in

Kurpara Sandhi. The snayu which are also helps in binding the bones. The ligaments

which are present at the elbow joint may be considered as snayu’s which are mentioned

in the Samhita’s.

According to modern explanation the following ligaments are found during

dissection in the elbow joint.

Capsular ligament.

Anterior and Posterior ligaments.

Ulnar collateral ligament.

Radial collateral ligament.

Annular ligament.

Quadrate ligament.

ASTHIAachaarya Sushrutha opines that, there is one Kurpara asthi in the Kurpara

sandhi. In the elbow region the articular parts of the humerus, radius and ulna are

observed as bony parts which help to form the elbow joint. These bony parts may

consider as the asthi in the marma sthana.


Discussion 65

SANDHI The Kurpara sandhi is a Sandamsha Kora variety of Cheshtavanta sandhi. The

shleshaka kapha and shleshmadhara kala are located in all the sandhi’s. This shleshma

dhara kala and shleshaka kapha will help for the free movement of joint and protection of

the joint. As per modern concern this joint is hinge variety of synovial joint. The same

synovial membrane and synovial fluid may correlate with the shleshmadhara kala &

shleshaka kapha respectively. According to modern science the elbow joint includes -

• Humeroradial joint – Hinge joint.

• Humeroulnar joint – Hinge joint.

• Superior radioulnar joint – Pivot joint.

These joints may be correlated with classification explained by Dr. Gananath Sen

as total elbow joint as a Kora sandhi. Kora sandhi sub varieties are Khalla Kora,

Paraspara Kora, Chakra Kora and Sandamsha Kora. The humero radial and humero

ulnar joint are types of sandamsha kora (hinge joint), the superior radio ulnar joint is

chakra kora sandhi (pivot joint) variety of Kora shndhi.

DISCUSSION ON PRAMANA The demarcation of a marma is the determination of location of marma. This may

be measured by an anguli pramana which was specified in the Samhitas. Here the praman

of the kurpar marma is 3 angula pramana.The area occupied by the marma is explained in

terms of own finger’s breadth (svanguli). While mentioning the pramana of Kurpara

marma it is mentioned just as 3 angula pramana, without much explanation about its

upper limit and lower limit of the site, and also regarding the length breadth and depth of

the marma. So we may consider 3 angula pramana equally as length, breadth or as

diameter present over the middle of Kurpara sandhi . The 3 anguli praman of kurpara

marma may consider the structures involving in and around the elbow joint. The anguli

pramana has considered as per Acharya Sushruta.


Discussion 66

DISCUSSION ON PRANA Marma’s consists of aggregate of Mamsa, Sira, Snayu, Asthi and Sandhi in which

Prana by nature resides, that is why injury to marma’s leads to respective consequences.

Acharya Dalhana comments that Prana is Agnyadaya. Acharya Sushruta mentioned

Prana by nature and especially resides in the marma, particularly Acharya Sushruta

mentioned Sapta Prana takes ashraya in marma i.e Soma, Maruta, Tejas, Satva, Raja,

Tama and Bhutatma. While on commenting on dwadasha prana Dalhana gives openion

that Soma, Maruta, Tejas as Tridosha and Satva, Raja, Tama as Triguna these are the

vital things which on injury leads to hazardous consequences in any marma sthana.

By injury to the marma both shareerika and manasika dosha’s are gets aggravated

which mya destroys both shareera and manas.

DISCUSSION ON MARMA VIDDHA LAKSHANA The Sandhi marma viddha lakshana’s are Vastu Shookarivakirna, Rudhe (the site

of injury feels as though full of thorns, even after healing of the wound) and Kunihi

(shortening of arm) Khanjata (lameness), Bala cheshta kshaya (decrease of strength &

movement), Shosha (emaciation), and Parva shopha sandhija (swelling of joints). Except

Khanjata all other lakshana’s like Vastu Shookarivakirna, Kuni, Bala cheshta kshaya,

Shosha and Parva shopha sandhija are seen in the Kurpara marma viddha lakshana.

Immediately after injury person feels the injury site as though full of thorns because of

the fractured bony fragments or due to damage to the nerves of elbow joint.

The fracture of the bones and related muscle injury definitely leads to shortening

of the limb i.e. Kunihi. Because of the nerve and vessel injury along with shortening of

limb there will be decrease in strength, movements and also there will emaciation of the

limb.

The vaikalyakara marma are predominance of Soma guna, firmness and coldness

are the quality of soma sustains life. This can be interpreted as Shleshaka kapha present

in the sandhi gets vitiated when the marma viddha occurs leading to vikalata. Kapha

dosha is predominantly formed from Ap mahabhoota, it is sheeta guna yukta and it is

responsible for the strength of our body and therefore it is called as Balasa. Thus kapaha

is responsible for sustaining life.


Discussion 67

DISCUSSION ON X – RAY: As a diagnostic tool, radiography has proved of great value in detection of the

early stages of deep seated diseases, when the possibility of cure is greatest. But here as

far as concern to our study we have collected x-ray report just to identify the structures

involving in Kurpara marma viddha. In most of the X-rays, a fracture of the bones which

forms the elbow joint was observed. So as per the observation we may consider Kunihi

i.e. Sankuchita Baahu madhye is because of fractures of bones like Lower end of

Humerus, upper ends of Radius and Ulna. In fact fractures will lead to damage of

surrounding structures like muscle, ligaments, and vessels. Here in the elbow region most

of the muscles get insertion in the form of tendon. So any tendon injury will lead to loss

of particular movement.


Conclusion


68

CONCLUSION

Kurpara marma sthana is the region of kurpara sandhi (elbow joint), which is

formed by the articulations of the lower end of the humerus, and upper end of the

radius and ulna including surrounding structures.

According to the observation, the fracture and dislocation of bones at the elbow

joint may leads to Kunihi (shortening of the limb), and it is the viddha lakshana of

Kurpara marma,

The injury to the nerves, blood vessels, muscles and ligaments may leads to

decrease in length, strength, movements and also there will emaciation of the

limb.

The vaikalyakara marmas are predominance of Soma guna, due to the soma guna

predominance firmness and coldness sustains life. Shleshaka kapha is soma guna

and responsible for Bala and maintenance of the life.

Other viddha lakshanas according to Acharya Vagbhata are Vastu

Shookarivakirna, Rudhe (the site of injury feels as though full of thorns, even

after the healing of the wound) and Khanjata (lameness), Bala cheshta kshaya

(decrease of strength & movement), Shosha (emaciation), and Parva shopha

sandhija (swelling of joints). These lakshanas may be observed clinically.

Summary


69

SUMMARY

The dissertation entitled “A STUDY ON SANDHI MARMA W.S.R TO

REGIONAL AND APPLIED ANATOMY OF KURPARA MARMA” comprises of 8

chapters namely Introduction, Objectives, Review of literature, Methodology,

Observation, Discussion, Conclusion and Summary.

Chapter 1:

General information regarding the Sandhi Marma and Kurpara Marma Viddha

lakshanas, has been covered in the introduction part of dissertation along with need of

this study in the present scenario is been highlighted.

Chapter 2:

Gives an plan about aims and objectives of the study.

Chapter 3:

This chapter explains Review of literature is subdivided into Historical review,

Ayurvedic review, and Modern review of the subject.

Historical review section comprises of references pertaining to Marma.

In Ayurvedic review, definition, location, measurement, classification, effect of

injury of Marma Pradesha explained in detail.

In the modern review detail gross regional and applied anatomy of Elbow joint

has been explained.

Chapter 4:

Methodology chapter explains about method of data collection, inclusion criteria,

exclusion criteria, assessment criteria and dissection procedure of Kurpara Marma

(Kurpara Sandhi).

Summary


70

Chapter 5:

The inferences based on radiological findings are presented in the observation

chapter. Photo plate of cadaver dissection of Kurpara Sandhi and x-rays of Elbow region

are also presented in this chapter.

Chapter 6:

In the discussion part, conceptual study regarding Marma and Kurpara Marma

Viddha lakshana has been highlighted along with radiological aspects of Elbow joint

injury.

Chapter 7:

Conclusion drawn from various sections of the work is given.

Chapter 8:

This chapter summarizes the entire work.

Shlokas 71


SHLOKA REFERENCE:

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Shlokas 78


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78) iÉ§É xÉ±: mÉëÉhÉWûUÉÍhÉ xÉmiÉUÉ§ÉÉprÉliÉUÉlqÉÉUrÉÎliÉ || (xÉÑ.vÉÉ. 6/23)372

79) CÇÌSìrÉÉjÉãïwuÉxÉÇmÉëÉÌiÉqÉïlÉÉã – oÉÑÎbS: ÌuÉmÉrÉïrÉ:

ÂeÉgcÉ ÌuÉÌuÉkÉÉxiÉÏuÉëÉ pÉuÉlirÉÉvÉÑWûUã WûiÉã || (xÉÑ.vÉÉ.6/36)375

80) iÉ§É xÉ±: mÉëÉhÉWûUÉhrÉÉalÉãrÉÉÌlÉ, AÎalÉaÉÑhÉãwuÉÉvÉÑ ¤ÉmÉrÉÎliÉ || (xÉÑ.vÉÉ.6/17)371

81) SãWûxrÉ ÂÍkÉUÇ qÉÑsÉÇ ÂÍkÉUãhÉæuÉ kÉÉrrÉïiÉã |

iÉxqÉÉ±¦ÉãlÉ xÉÇU¤rÉÇ U£üÇ eÉÏuÉ CÌiÉ ÎxjÉÌiÉ: || (xÉÑ.xÉÔ 14/44)66

82) lÉ cÉ ¤ÉhÉqÉÌmÉ EmÉã¤ÉãiÉ |

mÉëÉhÉ: mÉëÉhÉpÉ×iÉÉÇ U£üÇiÉi¤ÉrÉÉiÉç ¤ÉÏrÉiÉã AlÉsÉ: |

uÉkÉïiÉå cÉ AÌlÉsÉxrÉ iÉxqÉÉiÉç rÉÑYirÉÉ oÉ×ÇWèûhÉqÉç AÉcÉUåiÉç || (A.xÉ.xÉÔ. 36/19)249

83) MüÉsÉÉliÉU mÉëÉhÉWûUÉÍhÉ mÉ¤ÉÉlqÉÉxÉÉuSÉ iÉãwuÉÌmÉ iÉÑ

Í¤ÉmÉëÉÍhÉ MüSÉÍcÉiÉ AÉvÉÑ qÉÉUrÉÎliÉ || (xÉÑ.vÉÉ. 6/23)372

84) MüÉsÉÉliÉUmÉëÉhÉWûUÉÍhÉ xÉÉæqrÉÉalÉãrÉÉÌlÉ, AÎalÉaÉÑhÉãwuÉÉvÉÑ

¤ÉÏhÉãwÉÑ ¢üqÉãhÉ cÉ xÉÉãqÉaÉÑhÉãwÉÑ MüÉsÉÉliÉUãhÉ ¤ÉmÉrÉÎliÉ || (xÉÑ.vÉÉ.6/16)371

85) WûiÉã MüÉsÉÉliÉUblÉã iÉÑ kÉëÑuÉÉã kÉÉiÉÑ¤ÉrÉÉã lÉ×hÉÉqÉç |

iÉiÉÉã kÉÉiÉÑ¤ÉrÉÉelÉliÉÑuÉãïSlÉÉÍpÉ¶É lÉvrÉÌiÉ || (xÉÑ.vÉÉ.6/37)375

Shlokas 80


86) ÌuÉvÉsrÉmÉëÉhÉWûUÉÍhÉ uÉÉrÉurÉÉÌlÉ, vÉsrÉqÉÑZÉÉuÉÂbSÉã

rÉÉuÉSliÉuÉÉïrÉÑÎxiÉ¸ÌiÉiÉÉuÉelÉÏuÉÌiÉ ESèkÉ×iÉqÉÉ§Éã iÉÑ vÉsrÉã qÉqÉïxjÉÉlÉÉÍ´ÉiÉÉã uÉÉrÉÑÌlÉw¢üÉqÉÌiÉ,

iÉxqÉÉiÉç xÉvÉsrÉÉã eÉÏuÉirÉÑSèkÉ×iÉvÉsrÉÉã ÍqÉërÉiÉã | ( mÉÉMüÉimÉÌiÉiÉvÉsrÉÉ uÉÉ ÎeÉuÉÌiÉ) ||

(xÉÑ.vÉÉ. 6/16)371

87) Ei¤ÉãmÉÉæ xjÉmÉlÉÏ §ÉÏÍhÉ ÌuÉvÉsrÉblÉÉÌlÉ, §ÉrÉ ÌWû |

uÉÉrÉÑqÉÉïÇxÉuÉxÉÉqÉelÉqÉxiÉÑaXûÉÌlÉ vÉÉãwÉrÉlÉç |

vÉsrÉÉmÉÉrÉã ÌuÉÌlÉaÉïcNûlÉç शu्ÉÉxÉÉiMüÉxÉÉccÉ WûlirÉxÉÔlÉç || (A.Wû.vÉÉ.4/55-56)415

88) ÌuÉvÉsrÉmÉëÉhÉWûUÉÍhÉ uÉÉrÉurÉÉÌlÉ, vÉsrÉqÉÑZÉÉuÉÂbSÉã

rÉÉuÉSliÉuÉÉïrÉÑÎxiÉ¸ÌiÉiÉÉuÉelÉÏuÉÌiÉ ESèkÉ×iÉqÉÉ§Éã iÉÑ vÉsrÉã qÉqÉïxjÉÉlÉÉÍ´ÉiÉÉã uÉÉrÉÑÌlÉw¢üÉqÉÌiÉ,

iÉxqÉÉiÉç xÉvÉsrÉÉã eÉÏuÉirÉÑSèkÉ×iÉvÉsrÉÉã ÍqÉërÉiÉã | ( mÉÉMüÉimÉÌiÉiÉvÉsrÉÉ uÉÉ ÎeÉuÉÌiÉ)

(xÉÑ.vÉÉ. 6/16)371

89) ÌuÉzÉsrÉblÉÇ uÉæMüsrÉMüUÇ cÉ pÉuÉÎliÉ | (xÉÑ. zÉÉ. 6/22)372

90) uÉæMüsrÉMüUÉÍhÉ xÉÉæqrÉÉÌlÉ, xÉÉåqÉÉå ÌWû ÎxjÉUiuÉÉcNæûirÉÉŠ mÉëÉhÉÉuÉsÉqoÉlÉÇ MüUÉåÌiÉ | (xÉÑ.zÉÉ.6/16)37

91) yiÉå uÉæMüsrÉMüeÉlÉlÉå MåüuÉsÉÇ uÉækrÉlÉæmÉÑhÉÉiÉç |

zÉUÏUÇ Ì¢ürÉrÉÉ rÉÑ£Çü ÌuÉMüsÉiuÉqÉuÉÉmlÉÑrÉÉiÉç || (xÉÑ.zÉÉ.6/38)375

92) uÉæMüsrÉMüUÉÍhÉ cÉ MüSÉÍcÉSirÉÍpÉWûiÉÉÌlÉ qÉÉUrÉÎliÉ || (xÉÑ.zÉÉ.6/23)372

93) aÉÑsTü ²Éæ qÉÍhÉoÉlkÉ ²Éæ ²å ²å MÔücÉïÍzÉUÉÇÍxÉ cÉ ।

ÂeÉMüUÉÍhÉ eÉÉÌlÉrÉÉS¹ÉuÉãiÉÉÌlÉ oÉÑÎbSqÉÉlÉç || (xÉÑ.vÉÉ.6/14)370

Shlokas 81


94) ÂeÉÉMüUÉhrÉÎalÉuÉÉrÉÑxÉÉãqÉaÉÑhÉoÉÉWÒûsrÉÉiÉç || (A.xÉÇ.vÉÉ. 7/60)324

95) A¹Éæ MÔücÉï ÍvÉUÉã aÉÑsTü qÉÍhÉoÉlkÉÉ ÂeÉÉMüUÉ : | (A.Wû.vÉÉ. 4/59)415

96) ÂeÉÉMüUÉÍhÉ qÉqÉÉïÍhÉ ¤ÉiÉÉÌlÉ ÌuÉÌuÉkÉÉ ÂeÉ:|

MÑüuÉïlirÉliÉã cÉ uÉæMüsrÉÇ MÑüuÉãïkÉuÉvÉaÉÉã rÉÌS || (xÉÑ.vÉÉ.6/40)376

97) ÂeÉMüUÉhrÉÎalÉuÉÉrÉÑaÉÑhÉpÉÔÌrÉ¸ÉÌlÉ, ÌuÉzÉåwÉiÉ¶É iÉÉå ÂeÉMüUÉå; mÉÉgcÉ pÉÉæÌiÉMüÐÇ cÉ ÂeÉÉqÉÉWÒûUåMåü ||

(xÉÑ.zÉÉ.6/16)371

98) ÂeÉÉMüUqÉiÉÏuÉëuÉåSlÉÇ pÉuÉÌiÉ || (xÉÑ.zÉÉ.6/22)372

101) mÉëmÉÉÍhÉ mÉëoÉÉWÒû qÉkrÉå MÔümÉïU: || (A.xÉÇ.zÉÉ 7/16)320

102) MÔümÉïU: MüTüÉåÍhÉ: ‘MÑüWÒûhÉÏ’ CÌiÉ sÉÉåMåü|| (xÉÑ.zÉÉ. 6/24)373

103) MÔümÉïUÉæ – MüTüÉåÍhÉeÉÉæ ²Éæ xÉÎlkÉqÉqÉÉïhÉÏ ²rÉ…ÓûsÉÉæ uÉæMüsrÉMüUÉæ iÉ§É oÉÉWÒûqÉkrÉå xÉƒûÉå.cÉ: ||

(pÉÉ.mÉë.3/233)70

104) MÔümÉïUÇ eÉÉlÉÑuÉiMüÉæhrÉÇ iÉrÉÉåÌuÉïOûmÉuÉimÉÑlÉ: |

Mü¤ÉÉ¤ÉqkrÉå Mü¤ÉÉkÉ×Mçü MÑüÍhÉiuÉÇ iÉ§É eÉÉrÉiÉå || (A.¾û.zÉÉ 4/9)410

105) MÑüÍhÉ: MÑüÎoeÉiÉMüU: || (cÉ.ÍxÉ.2/21)690

106) MÑüÍhÉ: xÉƒÓû.ÍcÉiÉ oÉÉWÒûqÉkrÉ: || (xÉÑ.zÉÉ.6/24)373

107) MÑüÍhÉiuÉÇ – oÉÉWÒûmÉÉhrÉ…Óû.ÍsÉMÑüoeÉiÉ || (A.¾û.zÉÉ. 4/9)410

108) MÔümÉïUå ÌuÉ¬å iÉjÉÉ MÑüÍhÉiÉÉ ----- MÑüÍhÉ ÌoÉM×üiÉMüU: || (A.xÉÇ.zÉÉ 7/16)320

109) xÉlkrÉ¶ÉÉ…û. xÉlkÉÉlÉÉ¬åWåû mÉëÉå£üÉ: MüTüÉÎluÉiÉÉ : || (zÉÉ.mÉë.5/36)52

Shlokas 82


110) iÉ×iÉÏrÉã WûxiÉmÉÉSÍvÉUxÉÉÇ mÉgcÉ ÌmÉhQûMüÉ ÌlÉuÉïiÉïliÉãÅ…û.mÉëirÉ…û. ÌuÉpÉÉaÉ¶É xÉÔ¤qÉÉã pÉuÉÌiÉ ||

( xÉÑ.vÉÉ. 3/18)352

111) AxjlÉÉÇ iÉÑ xÉlkÉrÉÉã WûÉãiÉã MãüuÉsÉÉ: mÉËUMüÐÌiÉïiÉÉ: |

mÉãvÉÏxlÉÉrÉÑÍxÉUÉhÉÉÇ iÉÑ xÉÎlkÉxÉZXûrÉÉ lÉ ÌuÉ±iÉã || (xÉÑ.vÉÉ. 5/28)367

112) qÉÉÇxÉÉlrÉ§É ÌlÉoÉbSÉÌlÉ ÍxÉUÉÍpÉ: xlÉÉrÉÑÍpÉxiÉjÉÉ |

AxjÉÏlrÉÉsÉqoÉlÉÇ YOíûuÉÉ lÉ vÉÏrÉïliÉã mÉiÉÎliÉ uÉÉ || (xÉÑ.vÉÉ.5/23)366

113) lÉÉærÉïjÉÉ TüsÉMüÉxiÉÏhÉÉï oÉlkÉlÉæoÉïWÒûÍpÉrÉÑïiÉÉ |

pÉÉU¤ÉqÉÉ pÉuÉSãmxÉÑ lÉ×rÉÑ£üÉ xÉÑxÉqÉÉÌWûiÉÉ |

LuÉqÉãuÉ vÉUÏUãÅÎxqÉlÉç rÉÉuÉliÉ: xÉlkÉrÉ: xqÉ×iÉÉ: |

xlÉÉrÉÑÍpÉoÉïWÒûÍpÉoÉïbSÉxiÉãlÉ pÉÉUxÉWûÉ lÉUÉ: || (xÉÑ.vÉÉ. 5/33,34)367

114) MåüzÉzqÉ´ÉÑlÉZÉsÉÉåqÉSliÉÉÎxjÉÍxÉUÉxlÉÉrÉÑkÉqÉlrÉ: zÉÑ¢Çü cÉåÌiÉ (ÌmÉiÉ×eÉÉÌlÉ) || (cÉ.zÉÉ.3/7)390

115) qÉÉiÉ×eÉÉSrÉÉãÅmrÉxrÉ qÉWûÉpÉÔiÉÌuÉMüÉUÉ LuÉ |, uÉÉruÉÉiqÉMüÇ xmÉvÉï:

xmÉvÉïlÉÇ UÉæxrÉÇ mÉëãUhÉÇ kÉÉiÉÑurÉÑWûlÉÇ cÉã¹É¶É vÉÉUÏrÉï: || (cÉ.vÉÉ.4/8)318

116) rÉSÒcduÉÉxÉmÉë´uÉÉxÉÉãlqÉãwÉÌlÉqÉãwÉÉMÑügcÉlÉmÉëxÉÉUhÉaÉqÉlÉmÉëãUhÉkÉÉUhÉÉÌS iÉuSÉrÉuÉÏrÉÇ xmÉvÉï: xmÉvÉïlÉÇ cÉ,||

(cÉç.vÉÉ.7/16)339

117) ´sÉãwqÉÉ ÎxjÉUiuÉÎxlÉakÉiuÉxÉÎlkÉoÉlkÉ¤ÉqÉÉÌSÍpÉ: || (A.Wû.xÉÔ. 11/3)182

118) xÉÎlkÉxjÉ: zsÉåwqÉÉ xÉuÉïxÉÎlkÉ xÉÇzsÉåwÉÉiÉç xÉuÉï xÉlkrÉlÉÑaÉëWÇû MüUÉåÌiÉ || (xÉÑ.xÉÔ.29/14)

Shlokas 83


119) mÉYuÉÉzÉrÉ MüÌOû xÉÎYjÉ ´ÉÉå§ÉÉÎxjÉxmÉzÉïlÉåÎlSìrÉqÉç |

xjÉÉlÉÇ uÉÉiÉxrÉ iÉ§ÉÉÌmÉ mÉYuÉÉkÉÉlÉÇ || (A.¾û.xÉÔ.12/1)192

120) M×üvÉSÏbÉÉïM×üiÉrÉ: xÉvÉoSrÉÉiÉÉ: || (A.Wû.zÉÉ. 3/87)402

121) qÉãkÉÉuÉÏ mÉëÍvÉÍjÉsÉxÉÎlkÉoÉlkÉqÉÉÇxÉÉã || (A.Wû.zÉÉ.3/92)403

122) zsÉåwqÉ aÉÔRûÎxlÉakÉÎzsÉ¹ xÉlkrÉÉÎxjÉqÉÉÇxÉ: || (A.Wû.zÉÉ. 3/96)404

123) cÉiÉÑjÉÏï ´sÉãwqÉkÉUÉ xÉuÉïxÉÎlkÉwÉÑ mÉëÉhÉpÉ×iÉÉÇ pÉuÉÌiÉ |

xlÉãWûÉprÉ£ãü rÉjÉÉ WûÉ¤Éã cÉ¢üÇ xÉÉkÉÑ mÉëuÉiÉïiÉã |

xÉlkÉrÉ: xÉÉkÉÑ uÉiÉïliÉã xÉÇÎ´sÉ¹: ´sÉãwqÉlÉ iÉjÉÉ || (xÉÑ.vÉÉ.4/14-15)356

124) ÂMç mÉuÉïhÉÉÇ pÉëqÉÉã qÉÔcNûÉï SvÉïlÉ iÉqÉxÉxiÉjÉÉ |

AÂwÉÉÇ xjÉÔsÉqÉÔsÉÉlÉÉÇ mÉuÉïeÉÉlÉÉÇ cÉ SvÉïlÉqÉç |

qÉeeÉmÉëSÉãwÉÉiÉç,|| (cÉ.xÉÔ. 28/17)17

125) xÉlkÉrÉxiÉÑ ÎuSÌuÉkÉÉ¶Éã¹ÉuÉliÉ:, ÎxjÉUÉ¶É |

vÉÉZÉÉxÉÑ WûluÉÉã: MüOûrÉÉÇ cÉ cÉã¹ÉuÉliÉxiÉÑ xÉlkÉrÉ: |

vÉãwÉÉxiÉÑ xÉlkÉrÉ: xÉuÉãï ÌuÉ¥ÉãrÉÉ ÌWû ÎxjÉUÉ oÉÑkÉæ: || (xÉÑ.vÉÉ. 5/24,25)366

126) ²å xÉÎlkÉ zÉiÉå।| (cÉ.zÉÉ.7/14)338

127) xÉZXûcÉÉiÉxiÉÑ SvÉÉã¨ÉUã ²å vÉiÉã | iÉãwÉÉÇ vÉÉZÉÉxuÉ¹wÉÌ¹:,

LMüÉãlÉwÉÌ¹: MüÉã¸ã, aÉëÏuÉÉÇ mÉëirÉÔkuÉïÇ §rÉvÉÏÌiÉ: || (xÉÑ.vÉÉ. 5/26)366

Shlokas 84


128) iÉ LiÉå xÉlkÉrÉÉåÅ¹ÌuÉkÉ: - MüÉåUÉåsÉÔZÉsÉxÉÉqÉÑª mÉëiÉUiÉÑ³ÉxÉåuÉlÉÏuÉÉrÉxÉiÉÑhQûqÉhQûsÉzÉ„û.uÉiÉÉï: |

iÉåwÉÉqÉ…Óû.ÍsÉqÉÍhÉoÉlkÉaÉÑsTüeÉÉlÉÑMÔümÉïUåwÉÑ MüÉåUÉ: xÉlkÉrÉ:, Mü¤ÉÉuÉÇ¤ÉhÉSzÉlÉåwÉÑsÉÔZÉsÉÉ:,

AÇxÉmÉÏPûaÉÑSpÉaÉÌlÉiÉqoÉåwÉÑ iÉÑ³ÉxÉåuÉlrÉ:, yluÉÉåÂpÉrÉiÉxiÉÑ uÉÉrÉxÉiÉÑhQûÉ:, MühPû¾ûSrÉlÉå§ÉYsÉÉåqÉlÉÉQûÏwÉÑ qÉhQûsÉÉ:,

´ÉÉå§É´É…ûÉ.OûMåüwÉÑ zÉ„ûÉ.uÉiÉÉï | iÉåwÉÉÇ lÉÉqÉÍpÉUåuÉÉM×üiÉrÉ: mÉëÉrÉåhÉ urÉÉZrÉÉiÉÉ : ||

(xÉÑ.zÉÉ.5/27)367

Bibiliography


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