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International Journal of Ayurveda
and Pharma Research

Review Article

A REVIEW ON COMPREHENSIVE UNDERSTANDING OF APASTAMBHA MARMA AND ITS CLINICAL

SIGNIFICANCE
Daiarisa Rymbai1*, Anju Thomas2
*1Post Graduate Scholar, 2Associate Professor, Department of Rachana Sharir, Sri Dharmasthala
Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India.
ABSTRACT
The word Marma denotes the vital spots of the body. Marma Shareera is widely discussed in
Ayurveda. The structural entity of these spots is not clearly explained in the classical texts so we
cannot rule out the exact structural components involved. Apastambha Marma is one among 107
Marma explained in Classical textbooks. According to Sushruta, it is classified under Sira variety
and it is an Urogata Kalantara Pranahara Marma. But Vagbhata has mentioned it as a type of
Dhamani Marma on the basis of its structural entity. It measures about 1/2 Angula Pramana.
Acharya Sushruta mentions its location as Uras, bilaterally where two Vatavaha Sira (tubular
structures carrying air) are seen. Vagbhata says that it is situated in the Uras on both sides of the
Parshwa. The Viddha Lakshana of this Marma as per Sushruta is Vatapoornakoshtataya, Kasa,
Shwasa and Marana. However, there is a difference of opinion with Vagbhata; he has explained
Raktena Poornakoshta instead of Vatapoornakoshtataya. Result: The marked area for the
Apastambha Marma is at the level of 3rd costal cartilage on both the sides of the chest just lateral to
the midline. As the measurement in Angula (1 cm) is not apparent so it is taken as the lengthwise,
breadth wise and depth-wise. Conclusion: The area of about 2 cm lateral to carina which is the
common site of injury in the bronchus can be taken as the site of Apastambha Marma as rupture of
the bronchus leads to pneumothorax and the individual will show symptoms of breathing difficulty
such as Kasa, Shwasa and in severe cases it may lead to the death. This explanation holds true for
the Viddha Lakshana mentioned by Sushruta. Taking Shonitapoornakoshta this into consideration,
pulmonary and bronchial vessels can be taken as the structures involved in Apastambha Marma
which also holds good for the explanation of structural composition as per Vagbhata also i.e., it is a
Dhamani Marma. Thus, we can conclude that the two Principal Bronchus along with the
pulmonary vessels and bronchial vessels should be considered as the site of Apastambha Marma.
KEYWORDS: Marma, Apastambha Marma, Sira, Dhamani.
INTRODUCTION
The concept of Pratyanga was explained by is two in number. The injury effect of this Marma is
Sushruta after explaining the formation of Garbha mentioned as Vatapoornakoshtataya, kasa, Shwasa
and definition of Shareera. He considered Marma as which ultimately leads to Marana. [5] There is also a
Pratyanga based on Sankhya. Marma Shareera is
[1] mention of Raktapoornakoshta as the effect of injury
one of the important topic discussed in Ayurveda. and it is a type of Dhamani Marma. [6]
Different schools of thoughts have analyzed this REVIEW OF LITERATURE
subject differently and developed their own thoughts. Anguli Pramana of Apastambha Marma is 1/2
Acharya Charaka has mentioned 107 Marma but he Angula.[7] The measurement of half Angula is
discussed mainly Trimarma namely Hrudaya, Shiras approximately 1 cm.[8] Sushruta mentions that it is
& Basti. [2] Acharya Sushruta also described in detail located in the Uras on both sides where two
about these 107 Marma along with their Viddha Vatavahasira (tubular structures carrying air) are
Lakshana.[3] Marma is considered as half of the seen. The Viddhalakshana of this Marma is
knowledge of Shalyatantra, as injury to these areas Vatapoornakoshtataya, Kasa, Shwasa and Marana. [9]
can be fatal; if anyone survives by the efficiency of the Vagbhata says that it is situated in the Uras on both
physician, he is sure to suffer from deformities post sides of the Parshwa. It is the site where Vatavahasira
effect.[4] The Apastambha Marma is an Urogata carrying Anila (air) are located. Injury to this Marma
Kalantarapranahara Marma and it is a Sira Marma. It
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 Daiarisa Rymbai, Anju Thomas. A Review on Comprehensive Understanding of Apastambha Marma and its Clinical Significance
will lead to Raktena Poornakoshta, Shwasa, Kasa and Haemothorax refers to collection of blood
Nashyate.[10] According to Aruna Datta, it is between chest wall and lung. If the haematocrit is
mentioned that it is two in number.[11] Recent authors more than half of that in the peripheral blood, the
have correlated different locations for Apastambha patient is considered to have a haemothorax. [18] The
Marma. It lies medial and downwards of the nipples most common cause is traumatic injury to the chest
at the level of the third thoracic vertebra. It controls due to punctured wound from a broken rib or blunt
Kledakakapha, asthivaha and Medovaha srotas.[12] In force from car accident. This ruptured membrane
an article, it was mentioned that the area of spills blood into the pleural space which has no way
Apastambha Marma corresponds to the bronchus and to be drained. Its symptoms include chest pain
it is located in front of the chest, the divisions of the especially when breathing. Massive haemothorax is
wind pipe which enter the lungs. Recent authors have when the accumulation of blood is large, being atleast
also interpreted different structures to be correlated 1000 millilitres (1 litre). This can lead to shock.
to Apastambha Marma. It was opined that the DISCUSSION
pulmonary artery and tributaries of pulmonary vein, The location of Apastambha Marma is
descending aorta, drainage to pectoral group and mentioned as bilateral of the chest where two
tracheo-bronchial as well as broncho-pulmonary Vatavaha Nadi (which purvey air) are situated. The
segments, pectoralis major, pectoralis minor and gross location is marked laterally on the two sides of
intercostal muscles are the structures which can be the third costal cartilage which roughly corresponds
correlated to Apastambha Marma. [12] Reference of to the location of hila of the lungs. Both the hila of the
Phrenic nerve, Vagus nerve, common carotid artery lungs where right and left pulmonary bronchi are
and subclavian vein to be considered as Apastambha situated should be included in this as injury to this
Marma was also found. Most of the references found area causes pneumothorax resulting in respiratory
for the structure to be considered as Apastambha distress leading to death which is the Viddha
Marma included bronchus as one of the common Lakshana mentioned for Apastambha Marma. The
structure along with other structures. [13] pulmonary root connects the medial surface of the
Kalantara Pranahara Marma possesses the lung to the heart and trachea and it is composed of a
qualities of Soma and Agni. Agni is quick in action and group of structures which either enter or exit the
it will be extinguished immediately but the quality of hilum. The structures are principal bronchus,
Soma is such that it disappears gradually. Hence, pulmonary artery, two pulmonary veins, bronchial
when these two Guna are combined, they produce an arteries and veins, a pulmonary autonomic plexus,
effect which has the qualities of both and thus, its lymph vessels, bronchopulmonary lymph nodes and
effect will be seen after a certain period of time and loose connective tissue, all these are enveloped by
not immediately. [14] the pleura. [19]
Rapid accumulation of blood (Raktapoorna The ApastambhaMarma is 1/2 Angula. Half
koshta) and air (Vatapoornakoshta) in thoracic cavity Angula is approximately 1 cm. [20] In classical texts,
can be due to perforation of a lung or large bronchus. each Marma has its own dimension as- half Angula,
Pulmonary injury and injuries involving the pleural One Angula, two Angula, three Angula and four
space includes pneumothorax and Haemothorax. Angula but the dimension of Marma is not mentioned
Pneumothorax refers to the presence of air in in terms of length, breadth, and depth hence the
the pleural space which occurs when air leaks in to measurement is taken in all these aspects.
the space between the lung and chest wall. Thus, air As per Ayurveda classics each Marma is
pushes on the outside of the lung and makes it composed of Mamsa, Sira, Snayu, Asthi and Sandhi but
collapse.[15] It may be spontaneous or due to trauma out of this one structure is predominant in each
to the chest. Traumatic pneumothorax is usually Marma and hence it is classified accordingly.
caused by some penetrating injury to the chest wall, Sushruta has mentioned Apastambha Marma as a Sira
but sometimes the trauma pierces the lung and thus Marma.[21] Sira are the tubular structures (nerve,
leads to the accumulation of air within the pleural vein, arteries, tendons etc.) in the body or the
spaces.[16] Pneumothorax can be a complete lung structures where the action of Sarana (continuous
collapse or a collapse of only a portion of the lung. [17] flow) takes place. According to Acharya Vagbhata, it
Pneumothorax may have as much clinical significance is a Dhamani Marma. Dhamani is a structure which
as a fluid collection in the lungs because it also causes carry Rasa all over the body and maintains the
compression, collapse and atelectasis of the lung and Poshana of the body.[22] They are those structures
may be responsible for marked respiratory that which blows or strokes and they start pulsating
distress.[16] Its symptoms include sudden chest pain when they get filled with nutrient fluid.
and shortness of breath.

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 Int. J. Ayur. Pharma Research, 2020;8(Suppl 2):112-116
The Rachananusara composition of as well as pneumothorax, apparently this condition
Apastambha Marma includes the following: Mamsa: may commonly occur at this site of hila of the lungs
Pectoralis major muscle, External Intercostal muscles where windpipe or vessels enter or leave the lung. [23]
between 2nd and 3rd and 3rd and 4th costal cartilages, The main presenting feature of chest injury
Internal Intercostal Muscles to the 2nd, 3rd and 4th was pneumothorax and haemopneumothorax (83 %)
ribs, Transversus thoracis Muscle; Sira: Bronchial with the majority having fractured ribs.[24]
Veins, Pulmonary Veins, Bronchi; Snayu Pneumothorax refers to the presence of air in the
(neuroconnective tissue): Elastic connective tissue pleural space which may be spontaneous or due to
which helps in recoiling of lungs, pleura, trauma to the chest. A pneumothorax is collapsed
endothoracic fascia, phrenic nerve, Vagus Nerve, lung which may be a complete lung collapse or of
Pulmonary Plexus. Asthi: Ribs, 2nd, 3rd, 4th costal only a portion of the lung. It occurs when air leaks in
cartilages, incomplete or semicircular cartilaginous to the space between the lung and chest wall.
plates of bronchial tree. Sandhi: 2nd, 3rd & 4th Haemothorax refers to collection of blood between
costochondral junctions, region of carina, region chest wall and lung. The symptoms are chest pain
between the manubrium sterni and body of sternum; especially when breathing, cold, pale or clammy skin,
Dhamani: Pulmonary Artery. rapid heart rate, low blood pressure, tense, rapid or
Marma are classified according to shallow breathing, feeling of restlessness, anxiety.
traumatological effect as- Sadya Pranahara, If the pulmonary artery is injured, there will
Kalantara Pranahara, Vishalyagnya, Vaikalyakara, be difficulty in breathing and in severe cases it may
and Rujakara Marma. The Viddha Lakshana of the lead to death due to insufficient blood flow from the
individual Marma has also been explained by right ventricle to the lungs. However, there will be
Sushruta. Acharya Sushruta and Vagbhata mentioned hypoxia of the lungs if the pulmonary veins are
it as Kalantara Pranahara Marma. Sushruta injured due to insufficient supply of blood
mentioned the Viddha Lakshana of Apastambha (oxygenated) from the lungs to the heart. Blood gets
Marma as Vatapoornakoshtataya, Kasa, Shwasa and accumulated in the pleural cavity which holds true
Marana whereas Vagbhata mentioned it as for the Viddha Lakshana mentioned by Vagbhata i.e.,
Raktapoornakoshta instead of Vatapoornakoshta. Shonitapoornakoshta if the pulmonary vessels and
Kalantara Pranahara Marma possess the qualities of bronchial vessels are injured at the point of
Soma and Agni. Agni is quick in action and hence it Apastambha Marma. The amount of blood
will be extinguished immediately but the quality of accumulated depends on the impact of injury. This
Soma is such that it disappears gradually. Hence, shows that injury to the Apastambha Marma has led
when these two Guna are combined, they produce an to entry of foreign substances with the rupture of
effect which has the qualities of both thereby the blood vessels in the walls of the bronchus which in
effect will be seen only after acertain period of time turn is responsible for symptoms like Shonitapoorna
and not immediately. koshta (Haemothorax), Kasa (cough reflex) and
Sushruta opined that bilaterally in the chest Shwasa (breathlessness). Taking the Viddha Lakshana
are two Vatavaha Nadi’s which cause death on injury of Kasa, Shwasa, Raktapoornakoshta and Marana into
due to symptoms like Kasa and Shwasa by filling up consideration, pulmonary vessels and bronchial
of thorax with Vayu whereas Vagbhata in Ashtanga vessels can be taken as the structure involved in
Sangraha is of the view that the thorax gets filled Apastambha Marma. It holds good for the explanation
with blood which in turn produces Kasa and Shwasa as per Vagbhata also i.e., it is a Dhamani Marma.
on injury to this Marma. When the phrenic nerve is injured, the symptoms
According to recent author, Dr. Patil, he has seen are hiccups and the most severe impact is
suggested that both the hila of lungs where right & paralysis of the diaphragm which prevents the
left bronchi are situated should be considered as the patient to be able to regulate breathing on his/her
site of Apastambha Marma as injury to this site own. This structure can be taken into account
causes pneumothorax resulting in respiratory considering the Viddha Lakshana of Kasa, Shwasa and
distress leading to death. It is possible that due to Marana. Rupture of the bronchus leads to
trauma the fragments of ribs pierce the bronchus due pneumothorax and the individual will show
to which there is leakage of air through the vent of symptoms of breathing difficulty. When the
the bronchus and may cause mediastinal surgical mediastinal pleura is punctured pneumothorax can
emphysema and haemothorax leading to serious be seen which will cause breathing related symptoms
complications like respiratory failure and death. It such as Kasa, Shwasa and in severe cases it may lead
appears that the injury to windpipe along with to the death of the individual. Bronchus can be
vascular rupture would certainly cause haemothorax correlated to Vatavahanadi which Sushruta and

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 Daiarisa Rymbai, Anju Thomas. A Review on Comprehensive Understanding of Apastambha Marma and its Clinical Significance
Aruna Dutta has clearly mentioned while mentioning 7. Raja Radhakantadeva. Shivaradaprasadvasuna
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Cite this article as: *Address for correspondence

Daiarisa Rymbai, Anju Thomas. A Review on Comprehensive Understanding Dr Daiarisa Rymbai
of Apastambha Marma and its Clinical Significance. International Journal of Post Graduate Scholar,
Ayurveda and Pharma Research. 2020;8(Suppl 2):112-116. Department of Rachana Sharir,
Source of support: Nil, Conflict of interest: None Declared Sri Dharmasthala Manjunatheshwara
College of Ayurveda and Hospital,
Hassan, Karnataka, India.
Email: dia.linda8@gmail.com

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