Comprehend of Patho-physiological Changes & Consequential Prognosis in Marmabhighata (Injury to Marma)

„Marma‟ literary communicates the sense of vital parts of the body. The science of Marma is an unique approach of Ayurveda and established to help the practice of surgery. There are total 107 Marma‟s in the human body. These are classified into five types according to location, structures involved, effect and consequences or prognosis of the trauma over there. Any type of Marmabhighata (injury to Marma) is likely to produce subjective manifestations governed by the extent and the nature of injuries to the Marmas. Tridosha in the body have their Panchabhautik origin. The Pancha mahabhautas are the main constituting component of Tridosha such that, the consequence of traumatised Marma has got direct bearing on the predominance of Tridoshas over there. Any trauma to these Marmas is likely to provoke both the Shareerik and Manasik dosha which thereby affects the body (Sharira) and Mind (Mana). So, as the base (body and Mind) gets affected, the Jeevatma or Bhootatma itself ceases to exit. This changes in Marma after injury such as deformities and delayed healing mainly depends upon the consequences that occur due to patho-physiological changes over Marma. Keyword: Marma, Marmabhighata, injury to Marma, Tridosha, Panchabhuta, Consequences


I. INTRODUCTION
""Marma Sharira" a science of vital anatomical sites with higher life value, has been established to help the practice of surgery in Ayurveda. Sushruta "the father of surgery" has signified this science by equating it, as "half of the knowledge of surgery [1]. He has elaborated that there are 107 such anatomical sites/points (vulnerable) lies in the body [2,3] which need special attention of the clinicians during practice. This vital point of the body is having very technical and practical utilization from traumatic attack and diagnosis of various diseases.
The term "Marma" literary communicates the sense of vital parts of the body. Any injuries or mechanical involvement directly affecting the sites of Mamas are likely to take away the life. Knowledge pertaining the structure and location of Marma in the body finds better scope in the battle field, when enemies counteract each other. The biggest war recorded in the history of India with the highest causality was the battle of Mahabharata [4].
In comparison to an elaborate and tedious description of all the structures of the body, the knowledge of regional Anatomy finds its better scope in the management of the injuries involving the Marma or the vital parts of the body. Besides the perfect knowledge of Anatomy the surgeons have to rely upon their own experiences and take care of the vital structures like nerves, arteries, joints and tendons, etc. Knowledge of Marma popularised the excellence of Indian surgeons in the field of the surgery even though the details of anatomical approaches in the field concerned was not performed.
Marma's are the specific locations on the human body, which when traumatized, will either surely cause death or permanent deformity with extreme pain [5,6]. Marmas are the juncture of Mamsa (muscular tissue), Sira (blood vessels), Snayu (nerve or tendons or ligament), Asthi (bone tissue) and Sandhi (joints). The Pranas are specifically situated in Marmas by the virtue of their nature, hence a trauma to any one of these Marmas will invariably causes physical disturbances in accordance with their particular types [7,8].
Marmabhighata (trauma or injury to Marma) is likely to produce subjective manifestations governed by the extent and the nature of injuries to the Marmas. The behaviour of Marma after injury or consequences are the end results in relation to existence of life process. Such consequences are the deformities precipitating over the body, time factor etc are mainly depends upon the prognosis and its patho-physiological changes. This consequential prognosis of Marmabhighata has been the unique approach of Ayurveda.

III. CLASSIFICATION
107 numbers of Marmas has been structurally classified into five types depending on the structures involved like Mamsa (muscles), Sira (blood vessels), Snayu (nerve or tendons or ligament), Asthi (bones) and Sandhi (joints). These Marmas are named as Mamsa Marma, Sira Marma, Snayu Marma, Asthi Marma and Sandhi Marma. In general, depending on the predominance of anyone of these above said structures, the body Marmas have been designated accordingly [9].  107 Marmas present all over the body are preciously situated over the trunk and the extremities. In view of significance, the Marmas situated over the trunk carry more importance in comparison to those situated over the extremities. Ayurveda emphasizes upon the Shiras (Head), Hridaya (Heart) and Vasti (Bladder) of the body, designated as Trimarma (Three vital parts) [11] and specifically indicated that these are the special seat of Pranas or life out of 107 Marmas.

III. MARMABHIGHATA
Any Injury to Marma due to incision, stabbing, burning or external blow is termed as Marmabhighata which is mild or severe in nature [12]. In general, any type of Marmabhighata is likely to produce subjective manifestations governed by the extent and the nature of injuries to the Marmas. In dealing with the manifestations, more emphasis has been given on the consequences produced as a result of trauma.
Certain clinical features like Bhrama (confusion), Pralapa (delirium), Dourvalya (weakness), Chittanasha (lack of consciousness), Strastanga (restlessness), loss of sensation of parts, rise in body temperature, loss of function of the joints, unconsciousness, shallow breathing, severe pain, bleeding, loss of perception of senses, giddiness, paleness of the body, burning sensation over the cardiac area and postural un stability are commonly seen when Marmas are traumatized [13,14]. All these symptoms are found in a condition where death is sure. Besides the general manifestation of the Marmabhighata, following specific manifestations are observed when the body components like Mamsa, Sira, Snayu, Asthi and Sandhi marmas are injured [15].
Mamsa Marma: continuous bleeding, reduced viscosity of blood, blood resembles like washed water of meat, pallor skin, loss of function of sense organs & speedy death.
Sira Marma: Constant flow of thick blood in large quantity, their manifests thirst, giddiness, dyspnoea, delusion (confusion or fainting) and hiccups which ultimately leads to death. These symptoms are suggestive of cut injury to the blood vessels particularly veins.
Snayu Marma: Ayama (contraction or bending) or atrophy of body, Akshepa (convulsion), Sthambha (stiffness of the body), Severe pain, inability in riding, sitting and standing, distortion of Snayu. Marmabhighata is suggestive of injuries to nerve or nerve plexus. Most of the symptoms like rigidity, pain, convulsion etc are specific symptoms of nerve injury.
Asthi Marma: Discharge of thin fluid mixed with bone marrow intermittently and severe pain continuously.
Sandhi Marma: Sense of feeling of full of thorns at the site of injury, squeezing of organ or lameness even when wound is completely healed up, loss of strength and movement, emaciation or atrophy (affected body organ) and swelling or oedema of the Joints (distal).
Dhamani Marma: Flow of warm, frothy blood with a sound and the person becomes unconscious.
Above all the sign and symptoms are results when Marma is injured. Apart from these, various sign and symptoms or some specific disease are produced in Individual Marma also [16].  Kakshadhara In between the chest and arm pit Precipitates paralysis of the limb    If Vishalyghna gets injured it may lead to Vaikalyakara. If Vaikalyakara Marma gets injured It will leads to distress and pain after a certain period while Rujakara Marma injury leads to mild pain [17].

IV. DISCUSSION
The prognostic consequence of Marmabhighata is the patho-physiological changes precipitating over the concerned part of the body. The five categories like Sadya Pranahara, Kalantar Pranahar, Vaikalyakara Vishalaghna, and Rujakara have been worked out based on the end results that one has to face soon after injuries over the Marmas. The consequences and the symptomatology point out the prognosis of the case are variable as per site and locations of the Marmas and its injury. It is apparent from the above said statement that if all the types of Marmas are injured extensively they may all prove fatal.
Trauma to Sadya Pranahara Marmas results in inability of sense organs to perceive their respective subjects. Mind and intelligence can"t function properly and severe pain precedes the death. Fatal period of death is immediate or within seven days. It is noted that this group of Marmas possesses Agni Mahabhuta as fiery properties get very quickly inflamed and they prove fatal to the life. When Kalantara Pranahara Marma is injured, loss of Agni, Soma and Dhatus (blood etc) causes extreme pain leading to eventual death. Fatal time is 15 days to one month. As this group of Marmas posses Agni as well as Saumya guna (properties), Agni guna gets inflamed rapidly but Saumya guna takes a considerable time in diminishing. Thus this group of Marmas prove fatal after some time of Injury. An injury to any of the Vaikalyakara Marmas produced permanent disability of the affected part. Death supervenes immediately or after some time. As this group of Marmas possesses Saumya guna, it supports the Prana by virtue of its stabilising and cooling properties. Injured Vishalyaghna marmas causes Shwasa (Asthma), Kasa (Cough) and results in death. Death does not occur until weapon exists at site of entry. As soon as weapon is removed death occurs. Vishalyghna Marmas are Vataja in properties, so long as the Vata remains due to obstruction by the Shalya (foreign body) & patient survives. But as soon as the Shalya is extracted out, the Vata escapes from the Marma sthana and patient dies. Therefore, if the Shalya comes out after suppuration in Marmasthana then the patient can survive. Injured Rujakara Marmas gives rise to various types of pain or pain like condition in affected organs, which ultimately results in deformity of the same part. This group of Marmas are predominant in Agni and Vayu gunas. They are specially pain germinating in their properties. On the contrary, one says that the pain results from all Panchbhutas [18].
In another context Sushruta has further illustrated the presence of Trigunas, Mahagunas and the Bhootatma (Supreme power or life principle) in the Marmas also, where Soma (Jala Tatva), Maruta (Vayu Tatva), Teja (Agni Tatva) representing the Tridosas in the body and Satva, Raja, Tama as well as the Bhootatma are situated. Hence injuries to these Marmas are likely to result fatal [19].
The Tridosha in the body have got their Pancha Bhautik origin. The basic elements of Pancha bhautik are the main constituting component of Tridosha. It is seen in the above verse that the consequence of traumatised Marma has got direct bearing on the predominance of Tridoshas over there.
This description though gives more emphasis for the presence of Sharirik dosha and Manasik dosha at the site of Marma but in true sense both the doshas are purgating all over the body. Any trauma to these Marmas are likely to provoke both the Shareerik and Manasik dosha which thereby affect the Sharira & Mana (body and mind) and thus when the base (body and mind) is afflicted the Jeevatma or Bhootatma itself ceased to be there.
Again, there are four types of Siras i.e., Vata, Pitta, Kapha, and Rakta carrying channels in the body. These channels remain seated in Marma sthanas and any injury to them may lead to death due to excessive loss of the blood and other body tissues resulting into aggravation of Pitta which in turn, causes increased thirst, emaciation, toxicity, unconsciousness, severe perspiration, weakness and looseness of body [20].

V. CONCLUSION
Marma have been taken up as a vulnerable points or weak point in the body which when gets injured or traumatized leads to fatality. In view of underneath body component structures like Mamsa, Sira, Snayu, Asthi and Sandhi, the Marmas have been accepted as a juncture of these structures. The Marmabhighata on such structures are likely to precipitate the paralysis or atrophy or weaknesses in the limbs are over the areas supplied by them or other specific diseases or death arises. The consequences or the prognostic changes occurring due to trauma over these five types of Marmas are not due to predominance of Doshas or Dhatus present over the area concerned, but it is the Swabhava (natural inode quality) of that particular Marma which determines the end results. The intensity of trauma that decides the prognosis irrespective of structural components like Mansa, Sira, Snayu etc or functional elements like Doshas.
In present day of advance surgery, there should be clear-cut knowledge of vascular system, nervous system, muscles and their origin insertion, ducts and their courses, with a view to have an expertise operations on the patients. The ancient literature, no doubt, lacks with the knowledge of advance anatomical background in comparison to the present advances in the field. Though knowledge of anatomy and physiology of today have really removed the mystery of surrounding structure situated at the site of Marmas and minimized or made more less or nil the hazardous and dangerous task for surgeon. The concept of Marma described in ancient literature is possibly to make the subject matter more crystallized, based on the wide experience of expertise surgeons paying more attention towards the vital structures like arteries, veins, nerves tendons and ligaments. The surgeons based on their practical knowledge could map out the dangerous spots of the body and consequently postulate their own theory of Marma. This was the reason that made the surgery of ancient India to get more popularized and enabled it to achieve the highest position during the days of ancient civilization of the world.