GULPHA MARMA

In human body 107 Marma are classified on the basis of structural, regional, dimensional and numerical classification. The knowledge of Marma was depicted in vedopanishads and puranas. It is advised not to injure these Marma points because oninjury it may lead to deformity, pain or death as the vital energy (prana) is residing in the vicinity of these points. Hence it is said that the surgeon who is having the knowledge of Marma can operate well without complication.

In Ayurveda the role of Sushruta is most important, his description about Sharir is considered as best in all. Marma is unique concept of Ayurveda but the description present in Ayurvedic literature is based on the limited practical information present in that old era.

These ancient parameters cannot be applicable in today’s modern scientific word. Therefore it is important to understand the concept of Marma and prove it practically by showing its exact anatomical location and position on the body.

Keeping in mind aim and objectives, this research especially highlights about the The Gulpha Marma and study of its Rujakaratwa. To carry out this concept first the detail literature about Marma is reviewed. Simultaneously related modern literature is also studied in details. With the help of both the review, it is our attempt to corelate the Ayurvedic concepts with modern terminology.

Discussion on the basis of literature review-

Study of Gulpha Marma and all related to it, has been carried out by collecting references from different Ayurvedic texts and modern Anatomy text books and studied critically and analysed.

The oldest reference about Marma is found in Rigveda .Along with Rigveda there are several references regarding Marma in Yajurveda ,Ramayana, and Mahabharata etc. Sushruta being a surgeon described the Marma in detail with their numbers, type , sizes, locations, effects of injury etc. Whereas Charak gives the description about only three Marma Hridaya, Shir and Basticalled as base of the body and other all Marma are dependent of these Marma.

Sushruta stated that Marma is a site in the body where Mamsa, Sira , Snayu,  Asthi, and Sandhi are combined together and considered it as a location of prana that is life . Whereas Vagbhata stated that, Marma  is a point in the body when given pressure from outside causes pain, tenderness and show abnormal pulsation.

From these we can say that Marmas are related to the vital parts of body and has energies of the body. This connects the body, mind and prana.. According to modern science vital organs or part of body is an organ that is essential function in the living such as heart, brain, and lungs etc. The concept of tripod of life given by modern science is similar to the trimarma concept of Acharya Charaka. Though Marma are uniquely described in Ayurveda, the vital organ or parts are most important in both the sciences.

The Marma composed of five structures or factors they are mamsa, sira, snayu, asthi and Sandhi,  Laghu Vagbhata  added a Dhamani factor to this group.

Gulpha Marma is one among Sandhi Marma and Rujakar Marma. Its size is mentioned as two angulas( Swa angula).

Discussion on Location of Marma-

The Gulpha Marma lies in the Gulpha region, the detail discussion of this point is as follows:-

The word Gulpha means where the Pada (foot) and Jangha meet together or the part of body where the foot is connected with the leg.

 According to Dr. Ghanekar, Gulpha is ankle joint includes tibiofibular and talocrural articulation, when there is any injury on Gulpha there may be symptoms like: Ruja, stabdha padata, and khanjata.

According to Amarkosh Gulpha means Padasya granthi.

 According to modern literature the ankle, or the talocrural region, is the region where the foot and the leg meet. The ankle includes three joints: The ankle joint, proper or Talocrural joint,   Subtalar joint, and Inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantar flexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.

The main bones of the ankle region are the Talus (in the foot), and the Tibia and Fibula (in the leg). The talus is also called the ankle bone. The talocrural joint is a synovial hinge joint that connects the distal ends of the Tibia and Fibula in the lower limb with the proximal end of the Talus. The articulation between the Tibia and the Talus bears more weight than that between the smaller Fibula and the Talus.

   My first aim of study is to determine the exact anatomical location of Gulpha Marma according to Ayurveda and modern science.

-So after comparing the Ayurvedic and modern view & performing the dissection we concluded that the exact location of Gulpha Marma is nothing but the joint between tibia, fibula and talus and other structures related to lateral aspect of Ankle joint.

 Structural study of Gulpha Marma shows 5 compositions as is correlated as:-

v  MAMSA-  Fibularis (peroneus) longus, fibularis brevis, superior fibular (peroneal) retinaculum

v  SIRA-  Perforating branch of Fibular (peroneal) Artery, Fibular nerve

v  SNAYU- Lateral ligament of the ankle which consists of three separate ligaments 1. Anterior talofibular ligament, a flat weak band 2. Calcaneofibular ligament 3. Posterior talofibular ligament.

v  ASTHI – Tibia, Lateral malleolus of Fibula and Talus.

v  SANDHI - Joint between Tibia, Fibula and Talus.

1) As we know Gulpha Marma is Rujakar Marma and after Aghat over Gulpha Marma symptoms appears Ruja (pain), Stabdhapadata (restrictedmovement) and Khanjata (functional deformity). According to Severity Khanjata is most severe symptom of aghata over Gulpha Marma.

2) The articulation between the tibia and the talus bears more weight than that between the smaller fibula and the talus. So after aghata over ankle joint maximum chances of injury in lateral side or fibulotaller joint as tibiotalur joint is more stable than fibuatalur joint .and lateral collateral ligament is weaker than medial collateral ligament. So the Ruja on the lateral side is more than medial side.

3) A sprained Ankle is nearly always an inversion injury involving twisting of the weight bearing planter flexed foot. The lateral ligament is injured because it is much weaker than the medial ligament that resists inversion at the Talocrural joint^.

4) Sushrta as classified Gulpha Marma as Sandhi Marma and if any type of injury occurs over Gulpha Marma than maximum chances of joint injury and main symptom appears that is pain i.e Ruja so it is a Rujakar Marma.

5) Ankle sprain is the term used for ligament injuries of the ankle joint. And ligaments are making stable the joints. Commonly, it is an inversion injury, and the lateral collateral ligament is sprained. Sometimes, an eversion force may result in a sprain of the medial collateral ligament of the ankle. This condition gives rise to tremendous pain which is associated with all joints. But there is high prevalence in ankle Joint. So it is clear that ankle sprain is ligament injury and ligament is important part of Sandhi so if ligament is injured than the chances of Sandhi injury increases.

ON THE BASIS OF COMPOSITION OF MARMA -

   Aacharya Sushuruta has defined Marma as the site where “Mamsa, Sira, Snayu, Asthi, Sandhi sannipata, teshu svabhaavath eva Praanasthistanti.” It means Marma is a not individual structure actually Marma is a group of structure which contains Mamsa (muscles) Sira (vein, artery, nerve) Snayu (ligament) Asthi(bone) Sandhi (joint) and where they meet to together that can be said Marma.

According to the predominance of these structures the Marma also differs. As we know Gulpha Marma is a Sandhi Marma and Rujakar Marma so this Marma is a Sandhi predominant Marma, but other structures are also (Mamsa, Sira, Snayu and Asthi) involved in the Marma. Some experts are of the opinion that it does not mean that all the structure may be collectively present at the site.

After detail study of Ayurvedic and modern literature and dissection it  is concluded that Gulpha Marma which is a Sandhi Marma is situated at the junction of Pada (foot) and Jangha (leg) is called Gulpha or Ankle joint.

In my point of view Sandhi Marma means if there is any trauma(aghat) or injury at ankle region that directly affect the (Gulpha sandhi) Ankle joint,  in other words at ankle region any type of  injury causes easily injury to Sandi (ankle joint).

DISCUSSION ON PRAMANA-

Pramana of a Marma is so important that the surgical operations should be performed after considering the measurement of the marmas so as to avoid them. Even an injury to its borders may lead to deformity or loss of function

All Marmas have been explained in terms of definite pramana in samhitas it helps in the determination of location of the marma.

Among 107 Marma only 2 Marma having two angula (svanguli) pramana these are Gulpha and manibandha. Over these two Marma both are Sandhi Marma and Sushrut told that location of  manibandha in wrist joint same as Gulpha in adhosakha and both are rujakar Marma.

2.  Angula pramana of Gulpha Marma means, that area where there is maximum chances of injury to the Gulpha Marma . And in ankle region maximum chances of injury is at the lateral side because of weaker lateral collateral ligament.

DISCUSSION ON THE BASIS OF OBSERVATIONAL STUDY-

To study clinical aspects of Ankle sprain thirty (30) numbers of patients were examined according to criteria of assesment given in material and method.

The observation and findings are given below.

Study of patients according to Age wise distribution reveals that 10   (33.33%) patients belongs to age group of 10-20 years. In this study highest incidence of ankle sprain is in the 10 to 20 year age group.

  Religion plays no role in ankle sprain

        According to occupation more cases are registered from working group, most of them were having sedentary life style, sitting job in office, but over travelling also.

 Marital status of patients plays no role in ankle sprain.

According to Prakruti vata kaphaj Prakruti is more prone for ankle sprain.

        After examining the patient according to symptoms 30 (100%) patients are founded having symptoms of Ruja (pain), Stabhdhapadata (restricted movement), not any patients are observed having lakshana of Khanjata (functional deformity).

Most of the ankle sprain patient having ankle sprain due to forcefully inversion twisting of the ankle joint. And only 25% having eversion injury.

On the basis of symptoms most of the patients are found to have distressing and horrible type of pain according to VAS scale, as it is the most common symptom of ankle sprain.

It means most of the patients having sprain of the lateral side of ankle sprain and lateral collateral ligament got injured.

Study of patient according to site of pain (25) 83.33 % patient were having maximum tenderness at lateral side of the ankle region and (5) 16.66 % patient were having symptoms at medial aspect of the ankle region.

Result

Maximum pain intensity found in ankle sprain patient measured by vas scale was over lateral side of the ankle region.

After examining the patients, 20% were having mild pain, 30% were having moderate pain and 50% were having severe pain.

DISCUSSION BASED ON CLINICAL ANATOMY & VIDDHA LAKSHANA-

Ankle sprains are one of the most common sports injuries, almost millions people are evaluated each year for ankle sprain and account for 25% of all sports related injuries.

Over all, incidence of ankle sprain is 2.15 per 1000 person per year and is highest in the 15 to 19 years  age group. The ankle is usually injured by indirect violence. Although the mechanism is described as if the foot moved on a fixed tibia, but in practice ankle fracture always occur whilst the tibia moves along with the body.

ADDUCTION (INVERSION) INJURIES-

  Adduction injuries are commoner than abduction injuries as the foot is more stable in aversion, when the foot is forcefully deducted.

1^st degree –There is partial tear or rupture of the lateral ligament. This is a very common injury and is often called sprain of the ankle. The mortis is absolutely stable in this condition. Occasionally the tip of the fibula may also be avulsed.

2^nd degree- With continued adduction or inversion upwards from the medial angle of the mortis the mortis is now unstable causing medial shift of the talus

3^rd degree – Due to forward movement of the tibia with the momentum of the body, the posterior fragment of the tibia fractured leading to complete diastases.

Vidhhalakchana of Marma

If the Sandhimarma is injured the person feels as through the injury site is covered with full of thorns. There will be shortening of the limb even after healing the wound. It may also lead to marked decrease in mobility and strength. It may also cause emaciation, lameness and swelling in the joints.

                   FURTHER SCOPE FOR THE STUDY

v  The study can be taken as the clinical study. The injured cases related to Marma point can be taken from the trauma centres and military hospitals.

v  Practical importance of a particular Marma can only be experienced by taking guidance of Marma practitioner.

v  Ankle sprains are most common sports injuries in foot ball players. Almost million people are evaluated each year for ankle sprain and account for 25% of all sports related injuries. So this study can be used for the sports injury treatment.

Tinospora Cordifolia is a wonder drug.

Ambervel, Amrita, Gilo, Giloe, Giloya, Glunchanb, Guduchi, Gulancha Tinospora, Gulvel, Gurcha, Heart-Leaved Moonseed..

Tinospora cordifolia is a shrub that is native to India. Its root stems, and leaves are used in Ayurvedic medicine.

Tinospora cordifolia is used for diabetes, high cholesterol, allergic rhinitis (hay fever), upset stomach, gout, lymphoma and other cancers, rheumatoid arthritis (RA), hepatitis, peptic ulcer disease (PUD), fever, gonorrhea, syphilis, and to boost the immune system.

How does it work?

Tinospora cordifolia contains many different chemicals that might affect the body. Some of these chemicals have antioxidant effects. Others might increase the activity of the body's immune system. Some chemicals might have activity against cancer cells in test animals. Most research has been done in test tubes or in animals. There isn't enough information to know the effects of Tinospora cordifolia in the human body.

•             Allergies (hay fever). A particular extract of Tinospora cordifolia (Tinofend, Verdure Sciences) seems to significantly decrease sneezing and nasal itching, discharge, and stuffy nose after about 2 months of treatment.

•             Diabetes.

•             High cholesterol.

•             Upset stomach.

•             Gout.

•             Cancer, including lymphoma.

•             Rheumatoid arthritis.

•             Liver disease.

•             Stomach ulcer.

•             Fever.

•             Gonorrhea.

•             Syphilis.

•             To counteract a suppressed immune system.

•             Other conditions.

Diabetes: Tinospora cordifolia might lower blood sugar levels. Use it cautiously if you have diabetes, and monitor your blood sugar levels. The doses of your diabetes medications might need to be adjusted.

"Autoimmune diseases" such as multiple sclerosis (MS), lupus (systemic lupus erythematosus, SLE), rheumatoid arthritis (RA), or other conditions: Tinospora cordifolia might cause the immune system to become more active, and this could increase the symptoms of autoimmune diseases. If you have one of these conditions, it's best to avoid using Tinospora cordifolia.

Tinospora cordifolia might decrease blood sugar. Diabetes medications are also used to lower blood

Bhaw prakash nighantu

अथ लङ्केश्वरो मानी रावणो राक्षसाधिपः | रामपत्नीं बलात्सीतां जहार मदनातुरः ||१||

ततस्तं बलवान् रामो रिपुं जायापहारिणम् | वृतो वानरसैन्येन जघान रणमूर्धनि ||२||

हते तस्मिन्सुरारातौ रावणे बलगर्विते | देवराजः सहस्राक्षः परितुष्टश्च राघवे ||३||

तत्र ये वानराः केचिद्राक्षसैर्निहता रणे |तानिन्द्रो जीवयामास संसिच्यामृतवृष्टिभिः ||४||

ततो येषु प्रदेशेषु कपिगात्रात्परिच्युताः | पीयूषबिन्दवः पेतुस्तेभ्यो जाता गुडूचिका ||५||

गुडूची नामानि-

गुडूची मधुपर्णी स्यादमृताऽमृतवल्लरी | छिन्ना छिन्नरुहा छिन्नोद्भवा वत्सादनीति च ||६||

जीवन्ती तन्त्रिका सोमा सोमवल्ली च कुण्डली | चक्रलक्षणिका धीरा विशल्या च रसायनी |

चन्द्रहासा वयस्था च मण्डली देवनिर्मिता ||७|| गुडूची कटुका तिक्ता स्वादुपाका रसायनी |

संग्राहिणी कषायोष्णा लघ्वी बल्याऽग्निदीपनी | दोषत्रयामतृड्दाहमेहकासांश्च पाण्डुताम् ||८||

कामलाकुष्ठवातास्रज्वरकृमिवमीन्हरेत् | प्रमेहश्वासकासार्शःकृच्छ्रहृद्रोगवातनुत् ||९||

Dhanwantry nighantu.

गुडूच्यमृतवल्ली च छिन्ना छिन्नरुहाऽमृता | छिन्नोद्भवाऽमृतलता धारा वत्सादनी स्मृता ||१||

सैवोक्ता सोमवल्ली च कुण्डली चक्रलक्षणा | प्रोक्ता नागकुमारी च च्छिन्नाङ्गी ज्वरनाशिनी ||२||

जीवन्ती मधुपर्णी च तन्त्रिका देवनिर्मिता | वयःस्था मण्डली सौम्या विशल्याऽमृतसम्भवा ||३||

पिण्डामृता बहुच्छिन्ना सा चोक्ता कन्दरोहिणी | रसायनी मृत्तिका च चन्द्रहासा भिषिग्जिता |

कन्या कन्दोद्भवा कन्दाऽमृतकन्दगुडूचिका ||४|| गुडूची स्वरसे तिक्ता कषायोष्णा गुरुस्तथा |

त्रिदोषजन्तुरक्तार्शःकुष्ठज्वरहरा परा ||५|| गुडूच्यायुष्प्रदा मेध्या तिक्ता सङ्ग्राहिणी बला |

ज्वरतृट्पाण्डुवातासृक्छर्दिमेहत्रिदोषजित् ||६|| गुडूची कफवातघ्नी पित्तमेदोविशोषिणी |

रक्तवातप्रशमनी कण्डूविसर्पनाशिनी ||७|| कन्दोद्भवा गुडूची च कटूष्णा सन्निपातहा |

विषघ्नी ज्वरभूतघ्नी वलीपलितनशिनी ||८|| घृतेन वातं सगुडा विबन्धं पित्तं सिताढ्या मधुना कफं च

वातास्रमुग्रं रुबुतैलमिश्रा शुण्ठ्याऽऽत्मवातं शमयेद्गुडूची ||९|| गुडूच्याममृता छिन्ना छिन्नाङ्गा ज्वरनाशिनी |

Sodhal nighantu

छिन्नोद्भवाऽमृतलता वयःस्था देवनिर्मिता ||९६||

कुण्डली मण्डली श्यामा विशल्या नागकन्यका |

चक्राङ्गी सोमवल्ली च धारा वत्सादनी तथा ||९७||

जीवन्ती मधुपर्णी च तन्त्रिका च गुडूचिका |९८|

Herbs use full in hair growth

1-BHRINGRAJ

2- AMALA        

3-NEEM           

4- RITHA

5-SHIKAKAI

7-ASHWAGANDHA

8-BRAHAMI

9-JATAMANSI

10-METHI (FENUGREEK)

11-COCONUT

12-ALOE VERA

13-JOJOBA

14-YOGHURT

                       What to eat-

 1-Meat, fish, milk, cheese, eggs, yogurt, soybean

 2-Liver, fish oil, eggs, fortified milk; red, yellow, and orange vegetables are good    sources     of vitamin A, as are some dark green leafy vegetables like spinach.

3-Brown rice, Cauliflower, Mushrooms, Oats, Sunflower seeds, Walnuts, Soya, Peas, lentils, Cooked egg yolk, etc

4-Fresh peppers, citrus fruits, melons berries, potatoes, tomatoes and dark green leafy vegetables

5-Green leafy vegetables, nuts, grains, vegetable oils, and most ready-to-eat cereals, which are fortified with vitamin E.

6-Marmite, Calf's liver, Chickpeas, Endive

7-Green leafy vegetables, kidney beans, and bran

8-Seafood, oysters, oat

9-Good sources of copper are liver again, seafood, nuts, and seeds.

10-Rice, oats, lettuce, parsnips, asparagus, onion, strawberry, cabbage, cucumber, leek, sunflower seeds, celery, rhubarb, cauliflower, and Swiss chard.

Vomiting

1-Vomiting, also known as emesis, puking, barfing, throwing up, among other terms, is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the nose.

2-Vomiting can be caused by a wide variety of conditions; it may present as a specific response to ailments like gastritis or poisoning, or as a non-specific sequela of disorders ranging from brain tumors and elevated intracranial pressure to overexposure to ionizing radiation. The feeling that one is about to vomit is called nausea, which often proceeds, but does not always lead to, vomiting. Antiemetics are sometimes necessary to suppress nausea and vomiting. In severe cases, where dehydration develops, intravenousfluid may be required. Self-induced vomiting can be a component of an eating disorder, such as bulimia nervosa, and is itself now an eating disorder on its own, purging disorder.

Complications

1-Aspiration

2-Dehydration and electrolyte imbalance

3-Dentistry

Recurrent vomiting, such as observed in bulimia nervosa, may lead to destruction of the tooth enamel due to the acidity of the vomit. Digestive enzymes can also have a negative effect on oral health, by degrading the tissue of the gums.

4-Receptors on the floor of the fourth ventricle of the brain represent a chemoreceptor trigger zone, known as the area postrema, stimulation of which can lead to vomiting. The area postrema is a circumventricular organ and as such lies outside the blood–brain barrier; it can therefore be stimulated by blood-borne drugs that can stimulate vomiting or inhibit it.

Contents

Gastric secretions and likewise vomit are highly acidic. Recent food intake appears in the gastric vomit. Irrespective of the content, vomit tends to be malodorous.

The content of the vomitus (vomit) may be of medical interest.

1-      Fresh blood in the vomit is termed hematemesis ("blood vomiting"). Altered blood bears resemblance to coffee grounds (as the iron in the blood is oxidized) and, when this matter is identified, the term coffee-ground vomiting is used.

2-      If the vomiting reflex continues for an extended period with no appreciable vomitus, the condition is known as non-productive emesis or "dry heaves", which can be painful and debilitating.

Color of vomit

            1-Bright red      -            bleeding from the esophagus

      2- Dark red vomit with liver-like clots suggests profuse bleeding in the stomach, such as             from a perforated ulcer

     3-   Coffee-ground-like vomit suggests less severe bleeding in the stomach,

            4-Yellow vomit suggests bile, indicating that the pyloric valve is open and bile is flowing into the stomach from the duodenum (this is more common in older people)

Differential diagnosis

Vomiting may be due to a large number of causes, and protracted vomiting has a long differential diagnosis.

Digestive tract

•           Gastritis (inflammation of the gastric wall)

•           Gastroenteritis

•           Gastroesophageal reflux disease

•           Celiac disease

•           Non-celiac gluten sensitivity

•           Pyloric stenosis (in babies, this typically causes a very forceful "projectile vomiting" and is an indication for urgent surgery)

•           Bowel obstruction

•           Overeating

•           Acute abdomen and/or peritonitis

•           Ileus

•           Food allergies (often in conjunction with hives or swelling)

•           Cholecystitis, pancreatitis, appendicitis, hepatitis

•           Food poisoning

•           In children, it can be caused by an allergic reaction to cow's milk proteins (Milk allergy or lactose intolerance)

Causes in the sensory system:

•           Movement: motion sickness (which is caused by overstimulation of the labyrinthine canals of the ear)

•           Ménière's disease

Causes in the brain:

•           Concussion

•           Cerebral hemorrhage

•           Migraine

•           Brain tumors, which can cause the chemoreceptors to malfunction

•           Benign intracranial hypertension and hydrocephalus

Metabolic disturbances (these may irritate both the stomach and the parts of the brain that coordinate vomiting)

•           Hypercalcemia (high calcium levels)

•           Uremia (urea accumulation, usually due to renal failure)

•           Adrenal insufficiency

•           Hypoglycemia

•           Hyperglycemia

Pregnancy:

•           Hyperemesis, morning sickness

Drug reaction

•           Alcohol

•           opioids

•           selective serotonin reuptake inhibitors

•           many chemotherapy drugs

•           some entheogens (such as peyote or ayahuasca)

•           Norovirus (formerly Norwalk virus or Norwalk agent)

•           Swine influenza

•           Bulimia Nervosa

•           Purge disorder

Emetics

An emetic, such as syrup of ipecac, is a substance that induces vomiting when administered orally or by injection.

·         Salt water and mustard water have been used since ancient times as emetics.Care must be taken with salt, as excessive intake can potentially be harmful.

·         Copper sulfate was also used in the past as an emetic. It is now considered too toxic for this use.

·         Hydrogen peroxide is used as an emetic in veterinary practice.

Other types

            Projectile vomiting refers to vomiting that ejects the gastric contents with great force. It is a classic symptom of infantile hypertrophic pyloric stenosis, in which it typically follows feeding and can be so forceful that some material exits through the nose.

 Treatment

An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion sickness and the side effects of medications such as opioids and chemotherapy.

Antiemetics act by inhibiting the receptor sites associated with emesis. Hence,

 1-anticholinergics,

2-antihistamines,

3-dopamine antagonists,

4-serotonin antagonists, and cannabinoids

Epidemiology

Nausea and/or vomiting are the main complaints in 1.6% of visits to family physicians in Australia.