E-ISSN:2456-3110

Review Article

Apastambha Marma

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 09 Number 06 JUNE
Publisherwww.maharshicharaka.in

A review on Aplap Marma and Apastambha Marma

Snehal R B1*, Diksha R K 2, Gopal B S 3
DOI:10.21760/jaims.9.6.24

1* Snehal R Bisen, Post Graduate Scholar, Dept of Rachana Sharir, Government Ayurved College, Nagpur, Maharashtra, India.

2 Diksha R Kapgate, Post Graduate Scholar, Dept of Rachana Sharir, Government Ayurved College, Nagpur, Maharashtra, India.

3 Gopal B Sharma, Professor and HOD, Dept of Rachana Sharir, Government Ayurved College, Nagpur, Maharashtra, India.

Ayurveda is a science of mental, physical and spiritual well-being. Marmas is one of the most important concepts of Ayurveda. According to some Acharyas, Marmas are defined as the anatomical places where Mansa, Sira, Snayu, Asthi, Sandhi meet together. Total number of Marma’s is 107. Out of these Aplap and Apastambha Marma are considered as a Madhyasharirgata Marma (Urogata Marma). According to effect both are Kalantar Pranhar Marma and 2 in numbers. In this article an attempt is made to highlight the Anatomy, Position and Importance of Aplap and Apastambha Marma with its Viddha Lakshanas given in the Ayurveda literature.

Keywords: Aplap Marma, Apastambha Marma, Urogata Marma, Kalantar Pranhar Marma

Corresponding Author How to Cite this Article To Browse
Snehal R Bisen, Post Graduate Scholar, Dept of Rachana Sharir, Government Ayurved College, Nagpur, Maharashtra, India.
Email: 		Snehal R B, R Kapgate D, B Sharma G, A review on Aplap Marma and Apastambha Marma. J Ayu Int Med Sci. 2024;09(06):159-163.
Available From
https://jaims.in/jaims/article/view/3269

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-04-14 2024-04-24 2024-05-06 2024-09-16 2024-05-22
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Authors state no conflict of interest. Non Funded. The conducted research is not related to either human or animals use. 12.11 All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

© 2024by Snehal R B, R Kapgate D, B Sharma Gand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

J Ayu Int Med Sci 2024;09(06)159
Snehal R Bisen et al. A review on Aplap Marma and Apastambha Marma

Introduction

Ayurveda is a science of mental, physical and spiritual well-being. Ayurveda emphasizes good health and prevention and treatment of illness through lifestyle practices.[1]c Marmas is one of the most important concepts of Ayurveda. According to some Acharyas, Marmas are defined as the anatomical places where Mansa, Sira, Snayu, Asthi, Sandhi meet together.[2]

Marmas are body's vital points where Prana resides, injuries to them cause death or disability in the body which is difficult to cure. Marmas are considered to be Vishayardha of Shalya as they are delicate structures and to be protected during surgeries.[3]

Acharyas like Sushruta, Charaka and Vagbhata has mentioned total 107 Marmas in the body. Marmas are classified on different basis like structural or body organs involved, Effect of Trauma over the Marma area, Sites and locations of Marmas, Measurement/dimention of the Marma and by their Sankya (number of Marma).[4]

The Aplap and Apstambha Marma are comes under Urogata Marmas (Marmas of chest region). The location of Aplap Marma is below the Amsakuta & above the Parshwa whereas the Apstambha Marma is present on either side of the chest.[5]

Literature review

Aplap Marma
According to Acharya Sushrut the Aplap Marma is situated below both Ansakuta and above in the lateral flanks. Acharya Vagbhatta also mentioned that it is situated in between the back and chest below the Ansakuta.

अंसकूटयोरधस्तात पार्श्वोपरिभागयोरपलापौ नाम,

तत्र रक्तेन पूयभाव गतेन मरण ॥ सू.शा.६/२६ [6]

पृष्ठवंशोरसोमध्ये तयोरेव च पार्श्वयो: | अधोअंसकूटयो विद्यादपलापख्य मर्म तयो: कोष्ठेअसृजापूर्णे नश्येद्या तेन पूयताम || अ.ह्र.शा ४/१६[7]

Classification of Aplap Marma
1. Dimension - ½ Angul
2. Effect - Kalantar Pranahar Marma
3.Shadanganusar - Madhyasharirgata Marma
4. Structural basis - Sira Marma
5. Number – 2

Jaims_3269_03

Regional anatomy of Aplap Marma[5]
1. Mamsa - Pectoralis major & minor
2. Sira - Axillary artery, Superior thoracic artery, acromiothoracic artery, lateral thoracic artery, subscapular artery, lymphatics & lymph glands.
3. Snayu - Clavipectoral fascia, brachial plexus
4. Asthi - Ribs, scapula & clavicle
5. Sandhi - Gleno-humeral joint.

Axillary artery[8]
a. Origin - at the lateral margin of the first rib, before which it is called the subclavian artery.
b. The pectoralis minor muscle is used as a landmark for dividing the axillary artery into three parts:

1. First part - the part of the artery superior to the pectoralis minor.
2. Second part - the part of the artery posterior to the pectoralis minor.
3. Third part - the part of the artery inferior to the pectoralis minor.

Branches of axillary artery
1. Superior thoracic,
2. Thoracoacromial,
3. Lateral thoracic,
4. Subscapular,
5. Anterior circumflex humeral,
6. Posterior circumflex humeral

jaims_3269_01


J Ayu Int Med Sci 2024;09(06)160
Snehal R Bisen et al. A review on Aplap Marma and Apastambha Marma

Brachial plexus[9]
1. The brachial plexus is a network of nerves formed by the anterior rami of the lower four cervical nerves and first thoracic nerve (C5, C6, C7, C8, and T1).
2. This plexus extends from the spinal cord, through the cervico-axillary canal in the neck, over the first rib, and into the armpit.
3. It supplies afferent and efferent nerve fibers to the chest, shoulder, arm, forearm, and hand.

Clinical significance
A significant injury to the axillary artery will often present with one or more of the hard signs of vascular injury (loss of pulse, active arterial haemorrhage, expanding haematoma and bruit / thrill over a haematoma) indicating ischaemia and / or active haemorrhage. Clinical symptoms due to trauma include cardiac arrest or hemodynamic insufficiency due to massive hemorrhagic or cardiac tamponade, and dyspnea due to hemothorax or hemoptysis.

Apastambha Marma
According to Acharya Sushrut the location of Apstambha Marma is mentioned as on the two sides of the chest, which purvey air. In Astanga Hridaya, Viddha Lakshana of the Apastambha Marma is mentioned as the Raktena Purna Kosta[10] (accumulation of blood in the chest) instead of Vata Purna Kosta as mentioned in Susruta Samhita.[11]

उभयत्रोरसो नाडयौ वातवहे अपस्तंभौ नाम

तत्र वातपूर्णकोष्ठतया कासश्वासाभयां च मरणम ॥ सु.शा.६/२६[6]

अपस्तम्भावुर: पार्श्वे नाड्यावनिलवाहिनी |

रक्तेन पूर्णकोष्ठ्योत्र श्वासात्कासाच्च नश्यति || अ.ह्र.शा ४/१५[7]

Classification of Apstambha Marma
1. Dimention - 1/2 Angul
2. Effect - Kalantar Pranahar Marma
3. Shadanganusar - Madhyasharirgata
4. Structural basis - Sira Marma (Su.)/Dhamani Marma (Va.)
5. Number – 2

Regional anatomy (Marma Vastu)[5]
1. Mamsa - Bronchus, Bronchiole
2. Sira - Bronchial artery & vein, Pulmonary artery & vein, common carotid artery, sub clavian artery
3. Snayu - Phrenic & Vagus nerve,
4. Asthi - Ribs, sternum, 3rd thoracic vertebra
5. Sandhi - Sterno-costal joint

Bronchus[12]
1. Trachea ends at the level of the sternal angle (T5) where it divides into two main bronchi, one for each lung. Each main bronchus branches out into smaller intrapulmonary bronchi that supply air to the various pulmonary lobes and segments.

2. Beyond moving air throughout your lungs, the bronchi are responsible for protecting your lungs from possible infection or injury. Mucus cells lining the bronchi moisturize the air as it enters your lungs.

3. Clinical significance - Bronchial injury is rare and serious complication after a blunt trauma, It can lead to recurrent pneumothorax, empyema, atelectasis, pneumonia, mediastinitis and respiratory failure.

Pulmonary vessels[13]
a. The pulmonary arteries and the pulmonary veins are the vessels of the pulmonary circulation; which means they are responsible for carrying the oxygenated blood to the heart from the lungs and carrying the deoxygenated blood from the heart to the lungs.
b. Main pulmonary artery divides into right pulmonary artery and left pulmonary artery. Your right and left pulmonary arteries lead to your right lung and left lung, respectively.
c. Clinical significance

1. Injury to pulmonary vessels leads to symptoms like breathing difficulty, stridor, and respiratory failure due to airway blockage, subcutaneous emphysema, hoarseness of voice or aphonia, haemoptysis, and other symptoms due to associated injury.


J Ayu Int Med Sci 2024;09(06)161
Snehal R Bisen et al. A review on Aplap Marma and Apastambha Marma

2. Clinical findings of tracheobronchial injuries (TBIs) include subcutaneous emphysema, pneumomediastinum, and pneumothorax.[14]

Phrenic nerve[15]
1. The Phrenic nerve is a mixed nerve arising from the anterior rami of C3-C5 spinal nerves, which are components of the cervical plexus.
2. It arises in the neck and descends vertically through the thorax to end on the diaphragm.
3. It is the only nerve that provides motor innervation to the diaphragm, with the left and right phrenic nerves innervating their corresponding ipsilateral hemidiaphragms.
4. Thus, the phrenic nerve stimulates the movements and plays a crucial role in breathing.
5. Clinical Significance - Injury to one phrenic nerve leads to paralysis of the ipsilateral diaphragm, often leading to symptoms of dyspnea, may improve with time. If both phrenic nerves are injured, both diaphragms are affected.

Discussion and Conclusion

The location of Apalap Marma is considered below both Ansakuta and above in the lateral flanks. Viddha Lakshanas of Aplap Marma includes Rakta Puyatwa & leads to death. Acharya Sushrut and Vagbhata mentioned it as a Sira Marma (blood vessels).

As above given structures can be correlated to the Aplap Marma are mainly axillary artery with its branches & brachial plexus. A significant injury to the axillary artery will often present with one or more of the hard signs of vascular injury (loss of pulse, active arterial haemorrhage, expanding haematoma and bruit / thrill over a haematoma) indicating ischaemia and / or active haemorrhage. Clinical symptoms due to trauma include cardiac arrest or hemodynamic insufficiency due to massive hemorrhagic or cardiac tamponade, and dyspnea due to hemothorax (Raktpurn Koshta) or hemoptysis (Rakta Puyatwa).

A study performed by McCready RA., Procter CD. & Hyde GL and published in journal of vascular surgery. 3(1):24-31, 1986, also proved that traumatic vascular injuries to the axillary and subclavian vessels are often associated with formation of hematoma that leads to permanent neurologic impairment by compression or direct injury to the brachial plexus.

The location of Apastambha Marma is considered as in the chest bilaterally. The number of Marma mentioned are two and that which conduct Vayu (air). Hence this description goes in favour of principle bronchus carrying the respiratory air to the lungs. The trachea cannot be considered because the number of trachea is only one.[16]

Apastambha Marma is considered structurally under Sira/damani Marma, which is considered commonly as blood vessels. Here it can be correlated with Pulmonary vessels and Phrenic nerve. The Viddha Lakshana of the Apastambha Marma is mentioned as Vata Purna Kosta (Pneumothorax) in Sushruta Samhita and as Rakta Purna Kosta (Haemothorax) in Astanga Hridaya. But the symptoms like Kasa (Cough), Swasa (Breathlessness) and Marana (Death) are similar in both the texts.

These symptoms can be correlated with Bronchial injury which leads to recurrent pneumothorax, empyema, atelectasis, pneumonia, mediastinitis and respiratory failure. And Injury to pulmonary vessels leads to symptoms like breathing difficulty, stridor, and respiratory failure due to airway blockage, subcutaneous emphysema, hoarseness of voice or aphonia, hemoptysis. tracheobronchial injuries (TBIs) include subcutaneous emphysema, pneumomediastinum, and pneumothorax.

The incidence of airway injury is about 1–3% of all blunt chest injuries. Approximately 75% of the injuries occur within 2 cm from the carina which goes in favour of Ardhangulapramana of that particular part.[17]

Considering the literature related to Apastambha Marma and different case reports, the area about 2 cm lateral to carina which is the common site of injury in the bronchus can be taken as location of the Marma. As it is a Sira/Dhamani Marma it is better to include the pulmonary vessels under the Marma responsible for maintaining the patency of Vatavaha Nadi.[11]

References

1. Tripathi R., Charak Samhita, Vol.1, Chaukhamba Sanskrit Pratisthan, Delhi, 2013, Sutrasthan, Adhyaya no.30, Shloka no.26, Pg no.447

2. Shastri K.A., Sushruta Samhita, Part 1, Chaukhambha Sanskrit Sansthan, Varanasi, Reprint 2017, Sharirsthan, Adhyay 6, Verse 16, Pg no.69


J Ayu Int Med Sci 2024;09(06)162
Snehal R Bisen et al. A review on Aplap Marma and Apastambha Marma

3. Shastri K. A. Sushrut Samhita, Vol.1, Chaukhamba Sanskrit sansthan, Varanasi, 2016, Sharirsthan, Adhyaya number 6, Shloka number 35, p. no- 77

4. Ghanekar B.G.: Sushruta samhita with Ayurvedarahasya dipika (Hindi) commentary, Merchand laxmandas publication:Delhi 2004 ,delhi, pg no. -10, 198.

5. Kundu, Essence of Marma, Chaukhamba Prakashan, 1st edition 2022, pg no. 44-45.

6. Shastri K.A., Sushruta Samhita, Part 1, Chaukhambha Sanskrit Sansthan, Varanasi, Reprint 2018, Sharirsthan, Adhyay 6, Pg no.73

7. Tripathi B., Astangahrdayam of Srimadvagbhata, Chaukhamba Sanskrit Pratisthan delhi, Reprinted-2019, Shrirsthan, Adhyay no.4, pg no.391

8. https://en.m.wikipedia.org/wiki/Axillary_artery

9. https://en.m.wikipedia.org/wiki/Brachial_plexus

10. Sharma SP. Shareera Sthana chapter 7 verse 24 Astanga Sangraha with Sashilekha Sanskrit commentary of Indu.2nd ed. Varanasi (India): Chaukambha Orientalia; 2008; p.326.

11. Uma B. Gopal, Bedekar Swati Sanjay, Bharadwajvinaya Shankara, Kulkarni B.G. A review on Apastambha marma. Int. J. Res. Ayurveda Pharm. Mar - Apr 2016;7(2):1-3 http://dx.doi.org/10.7897/2277-4343.07244

12.https://my.clevelandclinic.org/health/body/21607-bronchi

13.https://www.kenhub.com/en/library/anatomy/pulmonary-arteries-and-veins

14.https://www.ncbi.nlm.nih.gov/books/NBK547677/#:~:text=Clinical%20signs%20and%20symptoms%20consistent,hemoptysis%2C%20dysphonia%2C%20or%20dysphagia

15. https://www.physio-pedia.com/Phrenic_Nerve

16. Thorat B.B. Jape R.R. An Ayurvedic Concept on Apastamba Marma - A Review Article, AIIRJ, vol-6, issue-10, oct-2019, ISSN No. 2349-638x

17. Hippargi SH. Traumatic Bronchial Rupture: an unusual case of Tension Pneumothorax. International Journal of Emergency Medicine. April 2010; 3: 193-95.


J Ayu Int Med Sci 2024;09(06)163