Marma

Marma are the vital areas of the body. Injury to these areas can cause death or serious damage to body or health. Marma is one of the unique and important topics discussed in Ayurveda. It plays an essential role in surgery. Hence it is called Shalya Vishayardha (half knowledge of surgery).

Marmas are the sites of prana (soul), agni (light or heat: a source of eternal energy), soma (water or an eternal source of calmness) and panchamahabhuta (five fundamental elements). Prognosis after injury, significantly depends on the composition of these vital energies.

The science of Marma was known to mankind from Vedic period, and it has especially been designed to determine the prognosis of injuries at the time of war. Simultaneously, marma knowledge was applied to cause fatal trauma to the enemy leading to victory on the battlefield. Acharya Charaka mentions the 107 Marmas in Charak Samhita (100BCE-200BC). However, being a physician, Charak has emphasized three major marmas, which are shira (head), hridaya (heart), and basti (urinary bladder). He gave a vivid description in Charak Samhita [Cha. Sa. Chikitsa Sthana 26/01]. Acharya Sushruta also identified 107 Marmas in the human body. As a surgeon, he contributed detailed explanations on this topic. Acharya Vagbhata also mentioned 107 marmas in Sharira Sthana of Ashtanga Hridaya with slight variation. The present article describes marma concept, surface anatomy, and practical application.

Contributors

Section/Chapter/topic	Concepts/Marma
Author	Kasar N.V.1
Reviewer	Basisht G.2,
Editor	Deole Y.S.3
Affiliations	1 Department of Rachana Sharir, G.J.Patel Institute of Ayurvedic Studies and Research, New Vallabh Vidyanagar, Gujarat, India 2 Rheumatologist, Orlando, Florida, U.S.A. 3 Department of Kayachikitsa, G.J.Patel Institute of Ayurvedic Studies and Research, New Vallabh Vidyanagar, Gujarat, India
Correspondence emails	drnileshvk@gmail.com, carakasamhita@gmail.com
Publisher	Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India
Date of publication:	November 12, 2022
DOI	In process

Etymology

The word ‘Marma’ is derived from the basic Sanskrit word ‘mri’, meaning ‘death’. The vital points of the body causing death after infliction is called ‘Marma’ [Su. Sa. Sharira Sthana Dalhana 6] [Ash. Sa. Sha. 7]. It is also considered to be the vital part of body causing death, unbearable pain, or permanent disability after injury. [Ash. Hri. Sha. Arundatta Tika 4]

Definition

Marma is defined as the anatomical structure where mansa (fleshy part or muscles), sira (vessels), snayu (ligaments), asthi (bones) and sandhi (articulations) are assembled and form a complex structure, which is also the site of prana (vital energy). [Su. Sa. Sharira Sthana 6/15] The body part that shows uncharacteristic pulsation with severe pain after infliction is called marma [Ash. Hri. Sha. 4/37]. Injury to marmas show fatal signs such as hypoxia, hypotension, hypovolemic shock (due to profuse blood lose) and severe pain. It can cause sudden death due to injury to cardiovascular center or respiratory center, as seen in capital punishment. Injury to marma may result in permanent disability as seen in upper or lower motor neuron lesions or injury to peripheral nerves or may be due to avascular necrosis. Or it may produce severe intolerable pain on infliction; such remarkable areas are known as ‘Marma’.

Classification of marma

Marmas are classified based on body part, structure, prognosis, dimension, and its basic constitution.

I. Based on body parts

Marmas are classified into five categories based on their location on body:

1. Sakthi marma (located in lower extremities)
2. Bahu marma (located in the upper extremities)
3. Ura and udarastha (in the region of thorax and abdomen)
4. Prushtha (in the back)
5. Jatrurdhva (in head and neck) [Su. Sha. Ghanekar Tika 6/4].

There are 11 Marmas in each extremity, making the total number 44. 12 marmas are in the trunk. On the back, the number is 14, and 37 marmas are present in the head and neck region.

II. Based on structural components

The marma has been classified into five groups according to the structural components.

1. Mansa marma (in which the fleshy part is dominant)
2. Sira marma (vascular structures are dominant)
3. Snayu marma (the predominant structures are ligaments)
4. Asthi marma (osseous tissue is predominant here)
5. Sandhi marma (at the area of articulation) [Su. Sha. Ghanekar Tika 6/3].

Mansa marmas are 11 in number, sira marmas are 41, snayu marmas are 27, asthi marmas are 8 and sandhi marmas are 20 in number.

In Ashtanga hridaya, additionally, dhamani marma is described as a separate category. Dhamani marma has a dominance of specific tubular or cord-like structures. In Ashtanga Hridaya the mansa marmas are 10 in number, sira marmas are 37, snayu marmas are 23, asthimarmas are 8, sandhi marmas 20 and, dhamani marmas are 9 in number.

III. Based on prognosis after injury

According to prognosis (symptoms after infliction), marma is classified into five types:

1. Sadyapranahara marma (leads to immediate death)
2. Kalantara pranahara marma (death after few days)
3. Vishalyaghna marma (a person may die if the foreign body is removed soon after penetration)
4. Vaikalyakara marma (injury causes permanent disability)
5. Rujakara marma (unbearable pain occurs after injury) [Su. Sha. Ghanekar Tika 6/14].

After an injury to sadyapranahara marma the person dies soon after injury or within seven days [Su. Sha. Ghanekar Tika 6/30] as it has a predominance of agni (light or heat: a source of eternal energy, deities which empower entire life). Injury to sadyapranahara marma affects agni leading to sudden death [Su. Sha. Ghanekar Tika 6/23].

Injury to kalantara pranhara marma results in death within 15 to 30 days [Su. Sha. Ghanekar Tika 6/30] because it has predominance of agni (light or heat: a source of eternal energy, deities which empower entire life) and Soma (water or an eternal source of calmness). Their injury leads to death after a certain period due to the presence of Soma energy. [Su. Sha. Ghanekar Tika 6/23].

Vishalyaghna marmas also cause death only when the shalya (foreign body) is removed soon after injury. As the vishalyaghna marma predominates with vayu mahabhuta, the penetrated foreign body obstructs the opening. The vayu can’t escape from it, and a person can survive. Extraction of the foreign body causes the evacuation of vayu from vital sites, and the person dies immediately. But the person can survive if the foreign body comes out automatically after purulence.

Injury to vaikalyakara marma causes permanent disability. The chances of death are negligible due to soma energy (water or an eternal source of calmness). It provides stability that protects the life of a person. [Su. Sha. Ghanekar Tika 6/23]

Rujakara Marma shows dominance of agni and vayu mahabhuta. Due to the dominance of agni and vayu mahabhuta, infliction to this marma causes severe pain. [Su. Sha. Ghanekar Tika 6/23].

If the injury site is near marma (not exactly on it), then the intensity of the symptoms will be less. The injury nearer to sadyapranahara marma causes death after 15 days as it appears like a kalantara pranahara marma. As the similar condition occurs with kalantara pranahara marma or vishalyaghna marma, it seems like vaikalyakara marma. When the injury is in the periphery of vaikalyakara marma, it causes severe pain, as in rujakara marma. If the latter is injured in the periphery, it gives minimal pain. [Su. Sha. Ghanekar Tika 6/23].

Vishalyaghna or vaikalyakara marma sometimes causes death if they get brutally injured. Likewise, although kshipra marma is kalantara pranahara marma, may cause sudden death [Su. Sha. Ghanekar Tika 6/30].

The sadyapranahara marma are 19 in number, kalantara pranahara 33, vishalyaghna marma are 03, vaikalyakara marmas are 44 and rujakara marmas are 08 in number.

Clinical aspect

Injury to temporal region, vertex, neck, cervical region, occipital region, brain stem, cardiac area, hypogastric region (rupture of urinary bladder) can cause sudden death or death after few days. The reason may be suppression of some neurological centers, profuse blood loss,cerebral oedema, pain shock infarction or infection and inflametion. This type of circumstances occur with injury to sadyapranahar marma.

In certain cases, the injured person can't die soon after injury. But after 15 days he/she may show severe complications such as infection, septicemia, electrolytes imbalance, toxisity, mal functioning of vital organs or blood loss. This type of condition seen in burn cases or injury to pectoral region (lungs or pleura), hypochondriac region (partial rupture of liver or spleen), extremities (blood vessels) or some part of back. This type of conditions can be due to injury to kalantara pranahara marma.

Sometimes it is seen that injury to hollow organ can cause death if an untrained person tries to remove the foreign body from the site. The content of that organ may come out (it may be blood, urine, body fluids) and may lead to pain shock or severe acute inflammation causing death. This is seen in injury to urinary bladder or liver. Such type of cases are only handled by skilled person or else the symptoms mentioned in vishalyaghna pranahara marma ocours and the life of patient may be in danger.

During road traffic accident or surgery the muscles, peripheral nerves, tendons, ligaments, bones or joints may get affected. It can cause long term or permenant disability as seen in Earb’s palsy, Klumpke’s palsy. Injury to axillary nerve causes loss of abduction of shoulder. Injury to radial nerve causes wrist drop. Injury to common peroneal nerve causes foot drop. Injury to ligaments and joints causes mal functioning of joints. Mal-union of fracture causes difficulty in movement. Hamstring tear in soccer player can affect flexion of knee. Tear in tendon of pectoralis major muscle is seen in weight lifters. It can affect adduction and flexion of shoulder. Such type of permanent disabilities seen in injuries to vaikalyakara marma.

Undue movement of any synovial articulation causes severe pain as seen in sprain. It is due to partial injury to ligaments or tendons followed by inflammation. Similarly in fracture unbearable pain occur as seen in rujakara marma.

IV. Based on measurements

In the ancient era, the length, height, width, etc. was measured by ‘fingers’. The finger is the unit for measuring any solid object called ‘Angula’. For the measurement of body structure, one should consider the width of own figures. Based on dimensions, the marmas are classified into five categories:

1. Eka angula (one finger in dimension)
2. Dvi angula (two fingers in dimension)
3. Traya angula (three fingers in dimension)
4. Chatwari angula (four fingers in dimension)/ panitala (size of own palm)
5. Ardha Angula (half angula) [Su. Sha. Ghanekar Tika 6/39].

The ek angula marmas are 12, dwi angula are 6, traya angula are 4, chatwari angula are 27 and ardha angula marmas are 58.

V. Based on predominance of elements

As each marma has a predominance of one or two basic elements, it has been divided into five groups:

1. Agni dominant
2. Agni-soma dominant
3. Vayu dominant
4. Soma dominant
5. Agni-vayu dominant.

The name, number, and classification of marma is given in table 1.

The location, symptoms and, structural anatomy of individual marma is given in table 2.

Importance of marma in preservation and prevention of health

Understanding the vital areas of our body is essential while treating the patient with yantra (medical equipment), shastra (surgical instruments), kshara (corrosive chemicals like alkali) and agni (cautery) [Su.Sa. Sutra Sthana 1/1]. During these procedures, the surgeon should have complete knowledge of marma (vital parts). Otherwise, instead of benefits, the patient may land in specific complications. Injury to the marma or in the periphery of the marma site can bring patient’s life in danger [Su. Sha. Ghanekar Tika 6/40]. For this reason, knowledge of marma sharira is considered as half part of surgery. [Su. Sha. Ghanekar Tika 6/44] The treatment of certain marmas with their signs and symptoms of infliction is mentioned. Infliction to kshipra and talahridaya marma (located in palms and soles) causes profuse bleeding that aggravates vata and may prove fatal for life. In such a condition, a surgeon can amputate the distal part of the extremity from the wrist or ankle to save the patient. [Su. Sha. Ghanekar Tika 6/42-43]

While performing surgery the surgeon should know the vivid structural anatomy and its variation with probabilities of that particular region. In Cholecystectomy, the surgeon should know the variations in biliary apparatus otherwise bile leaks in peritoneum leads to biliary peritonitis and causes death. Similarly during open reduction surgery on elbow joint dislocation with fracture may damage ulnar, radial, or median nerve can cause paralysis.

During spinal surgeries there may be the chances of trauma to spinal roots that leads to lower motor neuron palsy.

The neck is the most delicate region of our body while performing the surgeries on neck region for example in thyroidectomy severe bleeding may obstruct air way leads to respiratory distress, or sometime injury to recurrent laryngeal nerve cazuses permanent hoares voice.

Common symptoms due to injury to marma

Heaviness, drowsiness, dizziness, syncope, cold extremity, perspiration, vomiting, and dyspnoea are common symptoms due to Marma's infliction [Ash. Sa. Sha. 7]. Giddiness, delirium, falling, confusion, loss of movement, seizures, fever, laxity in body parts, fainting, dyspnoea, severe pain caused by vata, bleeding that appears like meat wash (mamsa dhavana) and loss of sensory perception are the general symptoms of injury to vital part.[Su. Sa. Sutra Sthana 25/34-35]

Marma chikitsa (marma therapy) in the south Indian system of medicine

South Indian practitioners have developed specific therapies based on vital points different from ayurvedic classics. In Kerala, the knowledge of marma is preserved in the form of ‘Kalaripayattu’. In Malayalam, kalari literally means ‘practice ground’ & payattu means ‘exercise’. Practitioners of Kalaripayattu employ the knowledge of marma for self-defense techniques & healing purposes.

Synonyms

Marma, Varmam (Siddha), Praanasakthi (sage Patanjali), Vethasatthi (Thriumoolar), Marma Vidyaka (Telgu), Kaalam, Puravi, Yogam, Saram, Pranam, Swaasam, Kalai, Sivam, Vassi.

Marma therapy in Siddha medicine

According to Siddha medicine, Varmam points (vital points) are the places in the body where the subtle Varmam energy is found.[i] There are 108 such vital points in the human body divided into two groups: Padu Marma and Thodu Marma. The Padu Marmas are 12 and Thodu Marmas are 96 in number. Clinically the Padu Marmas are essential. Manipulating or stimulating Marma points in the management of diseases is called ‘marma chikitsa (marma therapy)’ and humans have the inherent power to heal through these points. Through stimulation of marma by various means and methods, the prana (vital energy) existing in it may be directed to remove blockages (even in remotely connected areas) and stimulate energy flow thus resulting in a state of healthy body, mind, and spirit. A judicious application of pressure on appropriate Marma can restore the normal functioning of prana (in affected body parts) where improper manipulation may cause severe pain, disability, deformity and even death.[ii]

There are 12 methods of varmam application as follows,[iii]

1. Gentle movement
2. Mild movements
3. Clenching the varmam point along with the muscle
4. Slippery pinches
5. Mild tapping
6. Gentle stroking with fingers
7. Pressing point with a single finger
8. Balancing the energy of the points in the bone and joints
9. Placing the energy on the varmam point
10. Transferring energy from one point to another
11. Strengthening one nerve as that of the other
12. Touching and lifting the varmam point

All these 12 method can be executed on varmam point. The siddhars had propounded that the application of these 12 techniques on single point is capable of curing 48 different diseases. ‘Maathrai’ means the method of touching the varmam point by the fingers and can be considered as a unit to apply pressure on vital point.

Importance of marma therapy:[iv]

1. Removes blocks in energy channels (srotas)
2. Pacifies doshas bringing them to a normal path (especially vyana vayu which controls autonomic nervous system)
3. Creates physical, mental, and emotional flexibility
4. Creates an opportunity to experience powerful and dynamic transformation at physical, mental, emotional, and spiritual levels by building a positive link with the unconscious mind.

Fig.1(a): Marma of lower extremities

Fig.1(b): Marma of lower extremities

Fig.2: Marma of upper extremities

Fig.3: Marma of head & neck region

Fig.4(a): Marma-anterior aspect of body Fig.4(b): Marma-posterior aspect of body