A COMPREHENSIVE STUDY OF SIRĀVYADHA W.S.R. TO ANATOMICAL & MARMA RELEVANCE OF THE LOWER EXTREMITY DISSERTATION SUBMITTED TO THE RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE DEGREE OF AYURVEDA VACHASPATI (M.D) IN RACHANA SHAREERA BY Dr. BINI UPENDRAN UNDER THE GUIDANCE OF Dr. RAMA BHAT. K.M M.D (Ayu) PROFESSOR, HOD & Vd. ALAPATI VINOD KUMAR M.D(Ayu)PhD ASST. PROFESSOR DEPARTMENT OF POST GRADUATE STUDIES IN RACHANA SHAREERA ALVA’S AYURVEDA MEDICAL COLLEGE MOODBIDRI - 574227 2010
A COMPREHENSIVE STUDY OF SIRĀVYADHA W.S.R. TO ANATOMICAL & MARMA RELEVANCE OF THE LOWER EXTREMITY, BINI UPENDRAN, DEPARTMENT OF POST GRADUATE STUDIES IN RACHANA SHAREERA ALVA’S AYURVEDA MEDICAL COLLEGE MOODBIDRI
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A COMPREHENSIVE STUDY OF SIRĀVYADHA W.S.R. TO
ANATOMICAL & MARMA RELEVANCE OF THE LOWER
EXTREMITY
DISSERTATION SUBMITTED TO THE
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE
IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE DEGREE OF
AYURVEDA VACHASPATI (M.D)
IN
RACHANA SHAREERA
BY
Dr. BINI UPENDRAN
UNDER THE GUIDANCE OF
Dr. RAMA BHAT. K.M M.D (Ayu) PROFESSOR, HOD
&
Vd. ALAPATI VINOD KUMAR M.D(Ayu)PhD ASST. PROFESSOR
DEPARTMENT OF POST GRADUATE STUDIES
IN RACHANA SHAREERA
ALVA’S AYURVEDA MEDICAL COLLEGE MOODBIDRI - 574227
2010
ALVA’S AYURVEDA MEDICAL COLLEGE
DEPARTMENT OF POST GRADUATE STUDIES IN
RACHANA SHAREERA
MOODBIDRI, KARNATAKA
DECLARATION
I hereby declare that this dissertation entitled “A Comprehensive Study of
Sirāvyadha W.S.R. to Anatomical & Marma Relevance of the Lower
Extremity” is a bonafide and genuine research work carried out by me
under the guidance of Dr. Rama Bhat. K. M. M.D (Ayu), Professor & HOD., and
Vd. Alapati Vinod Kumar M.D (Ayu)PhD, Asst. Professor, Dept. of P.G. Studies
in Rachana Shareera, Alva’s Ayurveda Medical College Moodbidri.
Dr. BINI UPENDRAN
III Year P.G. Scholar
Dept. of Rachana Shareera
Alva’s Ayurveda Medical College
Moodbidri 574227
Date:
Place: Moodbidri
ALVA’S AYURVEDA MEDICAL COLLEGE
DEPARTMENT OF POST GRADUATE STUDIES IN
RACHANA SHAREERA
MOODBIDRI, KARNATAKA.
CERTIFICATE
This is to certify that the dissertation entitled “A Comprehensive Study of
Sirāvyadha W.S.R. to Anatomical & Marma Relevance of the Lower
Extremity” submitted by Dr. Bini Upendran in partial fulfilment for the
degree of Ayurveda Vachaspathi (M.D) in Rachana Shareera, of Rajiv
Gandhi University of Health Sciences, Bangalore, is a record of research
work done by her during the period of her study in this institute, under my
guidance and supervision and the dissertation has not previously formed
the basis to the award of any degree, diploma, fellowship or other similar
titles.
I recommend this dissertation for the above degree to the University for the
approval.
Co-Guide Guide
Vd. ALAPATI VINOD KUMAR M.D (Ayu)PhD Dr. RAMA BHAT. K. M. M. D (Ayu).
Asst. Professor, Dept. of P.G Studies Professor & HOD., Dept. of P.G Studies in Rachana Shareera, in Rachana Shareera, Alva’s Ayurveda Medical College Alva’s Ayurveda Medical College Moodbidri 574227 Moodbidri 574227
Date:
Place: Moodbidri
ALVA’S AYURVEDA MEDICAL COLLEGE
DEPARTMENT OF POST GRADUATE STUDIES IN
RACHANA SHAREERA
MOODBIDRI, KARNATAKA.
CERTIFICATE
This is to certify that the dissertation entitled “A Comprehensive Study of
Sirāvyadha W.S.R. to Anatomical & Marma Relevance of the Lower
Extremity” is a bonafide research work done by Dr. Bini Upendran under
the guidance of Dr. Rama Bhat. K. M. M.D (Ayu), Professor & HOD., and Vd.
Alapati Vinod Kumar M.D (Ayu)PhD, Asst. Professor, Dept. of P.G Studies in
Rachana Shareera, for partial fulfilment of the requirement for the award
of the degree in Ayurveda Vachaspathi (M.D) in Rachana Shareera, of
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.
Date: Place: Moodbidri
Dr. RAMA BHAT. K. M. M.D (AYU)
Professor and H.O.D., Dept. of P.G. Studies in Rachana Shareera,
Alva’s Ayurveda Medical College Moodbidri 574227
ALVA’S AYURVEDA MEDICAL COLLEGE
DEPARTMENT OF POST GRADUATE STUDIES IN
RACHANA SHAREERA
MOODBIDRI, KARNATAKA.
ENDORSEMENT
This is to certify that the dissertation entitled “A Comprehensive Study of
Sirāvyadha W.S.R. to Anatomical & Marma Relevance of the Lower
Extremity” is a bonafide research work done by Dr. Bini Upendran under
the guidance of Dr. Rama Bhat. K. M. M.D (Ayu), Professor & HOD., and Vd.
Alapati Vinod Kumar M.D (Ayu)PhD, Asst. Professor, Dept. of P.G Studies in
Rachana Shareera, for partial fulfilment of the requirement for the award
of the degree in Ayurveda Vachaspathi (M.D) in Rachana Shareera, of
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.
PRINCIPAL
Alva’s Ayurveda Medical College Moodbidri 574227
Date:
Place: Moodbidri
COPYRIGHT
I hereby declare that the Rajiv Gandhi University of Health Sciences,
Karnataka shall have the rights to preserve, use and disseminate this
dissertation in print or electronic format for academic/research purpose.
Date: Place: Moodbidri
Rajiv Gandhi University of Health Sciences, Karnataka
Dr. BINI UPENDRAN III Year P.G. Scholar
Dept. of P.G. Studies in Rachana Shareera Alva’s Ayurveda Medical College
Moodbidri 574227
ACKNOWLEDGEMENT
The successful completion of this thesis depends largely on the
encouragement, guidance and support of many people. I take this opportunity to
express my gratitude to the people who have been instrumental in the completion
of this thesis.
I consider it a great privilege to record my deep sense of gratitude to Dr
Rama Bhat, Professor& HOD., Dept. of PG Studies in Rachana Shareera, for
providing an opportunity to carry out this work under his able guidance. I also
express my sincere gratitude to Vd. Alapati Vinod Kumar, for his all time
support, generous help and guidance. I would like to express my earnest gratitude
to Dr Giridhar M. Kanthi, for his timely guidance, help and constant support.
I express my holy gratitude to the chairman, Dr Mohan Alva, Alva’s
Education Foundation, Moodbidri for giving the opportunity to pursue my P.G. in
this esteemed institution.
I would like to express my sincere thanks to Dr Baidyanath Mishra, Dr
Suresh Negalaguli, Dr. Laksmeesh Upadhya, Dr. Vinaya Chandra Shetty,
Dr Subhada and Dr Ajay Ghosh for their scholarly guidance in carrying out
this research work.
I express my sincere love and gratitude to Dr M.K.Madankumar, Dr
Vivek unni K.K, Dr Sreekumar K, Dr Gisha Jyothis, Dr Maya Mukundan
and Dr Sarath for being with me by providing honest support to surmount each
& every barrier successfully.
I am highly indebted to Dr Anuprabha, Dr Prashanth D, Dr Binu B, Dr
Benoy Bhaskaran, Dr Leena P Nair, Dr. Arun Bhaskaran, Dr Rakhi CM, and
Dr Sheeja Chandran for their help and inspiration given at various stages of my
work.
I sincerely appreciate the assistance received from the non-teaching staff
of the institution during the course of my study.
I sincerely bow my head to my beloved parents Sri. late N. Upendran &
Smt. P. Letha, my words of gratitude seems feeble next to their deeds, I have no
words to express how extra ordinary they are, further I extend my thanks to my
loving brother Dr. Binu Upendran and my in laws for their love blessings and
never ending support throughout the span of my work and for being there for me.
I remember with respect my husband Dr A. Nandakumar. Prof &
H.O.D, Department of Rasasastra & Bhaishajya Kalpana, Amrita Ayurveda
Medical college, Kollam, for his love, affection, inspiration and encouragement
for over 18 years without whom this work wouldn’t have been possible, he has
lived in every line & page of this book and in my life all together.
I offer my special thanks to Dr K. Vasudeva Reddy, Dr Rabinarayan
Tripathi, Dr Geetha kumar, Mrs Sudha, Sri Subhash, Mr Vimal Syam, Mr
Syam, Dr Poojalekshmy, Mr Nitin Krishnan, Mr Muneer and Amala Jyothi
for their profound and unending support.
I express my love to my children Manjunath and Mahesh Narayan for
bearing my absence and inspiring me throughout my work.
I am ever indebted to the God almighty for showering his blessings upon
me and for making my hurdles lighter so that I could complete my work
satisfactorily.
Last but not least I offer my sincere apologies to any omission in the above
A Comprehensive Study of Sirāvyadha W.S.R. To Anatomical & Marma Relevance of The Lower Extremity Page 11
and in the next decade, England imported six million leeches a year from France
alone. Through the early decades of the century, hundreds of millions of leeches were
used by physicians throughout Europe.
Bloodletting was also popular in the young United States of America,
where Benjamin Rush (a signatory of the Declaration of Independence) saw the state
of the arteries as the key to disease, recommending levels of bloodletting that were
high even for the time. George Washington asked to be bled heavily after he
developed a throat infection from weather exposure. Almost 4 pounds (1.7 litres) of
blood was withdrawn prior to his death from a throat infection in 1799.
One reason for the continued popularity of bloodletting (and purging) was
that, while anatomical knowledge, surgical and diagnostic skills increased
tremendously in Europe from the 17th century, the key to curing disease remained
elusive, and the underlying belief was that it was better to give any treatment than
nothing at all. The psychological benefit of bloodletting to the patient (a placebo
effect) may sometimes have outweighed the physiological problems it caused.
Bloodletting slowly lost favour during the 19th century, but a number of other
ineffective or harmful treatments were available as placebos—mesmerism, various
processes involving the new technology of electricity, many potions, tonics, and
elixirs155.
Historical Review of Marma
Marma in Vedic period
The science of Marma is an integral part of all the Vedic sciences that
emerged in India in ancient times. The close observation of Vedic literature reveals
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that the first reference to „Marma’ can be traced out in Rig Veda. Warriors were
advised to protect the vital parts of their body before going to the battle field to come
back victorious without any harm to their Marma Sthanas.
At another place in Rig Veda, a word „Marma‟ is found in connection with the
sharp weapon called „Vajra‟, used by Lord „Indra‟ for the purpose of killing the
demon „Virata‟ by attacking the Marma sthanas2.
In „Garbhopanishad’, 107 Marmas are referred along with anatomical
structures of the body3.
In „Yogopanishad’ 18 sensitive or vital parts or Marmas distributed at various
places of the body are described for the practice of Dharana, which is achieved by
concentration and withdrawal of mind from one spot to other spot of the body4.
Marma in Epics
In Valmiki Rāmāyana
„Rāmāyana’ and „Mahābhārata’ are the two great epics of Indian literature. At
several places in Rāmāyana the word „Marma‟ is used in the context of injury and the
subsequent complications reflects the vulnerable point. Some important references are
given below.
The King Daśaratha (the father of Lord Rama) while hunting, used the
Śabdabhedhi arrow capable of hitting the object or a person without even looking at
which pierced the Marmasthāna of Śravanakumāra resulting in death soon after the
removal of arrow from his body5.
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„Bharata’, son of Daśaratha while travelling to meet Rāma, was provided
enroute with various comfortable beds and seats by Maharshi Bharadhwāja of
Chitrakut for the protection of vital parts6.
During the fight between the „Bāli’ and „Sugreeva’, Sri Rāma hits at the
Marmasthāna of „Bāli’ and he falls down with agonizing pain and died after arrow
was removed. These references points to ‘Viśalyaghna’ Marma described in
Ayurvedic texts7.
Hanuman, while entering into Lanka, happened to confront with a very
dreadful and peculiar demon „Sinhika’. He carefully observed the Marmas of the body
and killed the demon by piercing his sharp and long nails into the Marma Sthānas8.
In Yuddhakānda of Vālmīkirāmāyana, the Angada (son of Bāli) who was well
versed with Marmavidhya hits on the chest area (in between the two breasts) of the
demon „Mahāpārśva’ with his strong and powerful fist resulting in death of the
demon. On analysing, it appears that the Marma closely related to the heart region9.
At another place in Yuddhakānda, Rāvana hits the Marmasthāna of Lakshmana and
he falls down with agony10.
During the fight, Meghanada (Indrajit) hits the Marmasthāna of Rama and
Lakshmana and captivated them and tied them tightly with Nāga Pāśa11.
In Mahābhārata
In Mahābhārata also the use of word ‘Marma’ can be traced out in
Sauptikaparva and Bhīshmaparva. During the battle between the Kaurava and
Pāndava, the Aśwatthāma (son of Dronācharya) inflicted strong blow with his lion
like heels on the Vitapa Marma of the elephant12.
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In another place in Mahābhārata, king Duryodhana cries due to torn and
broken thigh, which pierced the Marma Sthāna13.
In the fight, Gajaraja (Elephant) was pierced by hundreds of arrows in his
Marma Sthanas by Shalya and his trunk was severed and Gajaraja fell on the ground
and subsequently died14.
If a close observation is made on the above narrations, it can clearly be
pointed out that the knowledge of Marma Vijnana was extensively well known since
Vedic period. Later on its progression can be observed in the Samhita period
especially in Śārīrasthāna of Suśrutasamhita.
The Buddhist text “Milindapanha”, a dialogue between King Milinda and the
monk Nāgasena, dating from the 2nd Century BC, explains unarmed self-defence as
one of the nineteen monastic arts.
It is possible that Traditional Chinese medicine adapted aspects of Marma
therapy, which has much common with acupuncture, from Ayurveda.
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REVIEW OF SIRĀVYADHA
Etymology of Sirāvyadha
सिनौतौतत इतत सिरा ।
That which binds or a quantity bound together
It is formed from the root „षिञ’ to bind
षिञ (बनधन) + रक सिरा
Any tubular vessel of the body – nerve, vein, artery, tendon;
As they are binding the whole body together by transporting blood to all over
the body
वयधनसमतत वयध: । that which cuts
वयध (ताड) + अऩ वयध:-
To pierce, to transfix, to hit, strike, wound
िरतयाभी रकतसमतत सिरा: । तािाा वयध: सिरावयध: ।
By which the blood is being taken all over the direction is"ÍxÉUÉ". Its piercing is
known as "ÍxÉUÉurÉkÉ:"
IMPORTANCE OF RAKTA DHATU
The main function of the blood is Jeevana. It is a synonym for Ayu or life. The
term Ayu stands for the combination of the body, sense organs mind and soul. There are
other synonyms also for it namely Śarīra, Indriyas, Satva, Ātmā, Samyoga, Dhāri and
Jeevita, etc. Blood keeps Śarīra, Ātmā and Indriyas in equilibrium. Jeevana is
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explained as one which causes Dhārana of life. The one thing which regains the Pūtibhāva
in the blood and prevents the body from decay is called Dhāri15.
Blood is stated to be the Mūla or root of the body as it causes the Dhārana
of the Śarīra or body.
Rakta nourishes the Māmsa Dhātu and causes Varna Prasādana of the body.
It nourishes the Sapthadhātus or tissues of the body. It produces strength in the body. It
gives Anubandhana (which transmigrates from one body to another) to life. In animals it
gives Samyojana to life. Through the skin it helps for the sensation of touch. It helps the
Indriyas to grasp their objects properly. Blood also maintains and keeps the
Jatharāgni in equilibrium.
Dhamani and Sirā were differentiated throughout the classical period, though
some of them differs and were not of the opinion that there was no basic difference in
Sirā, Dhamani and Srotas and they were synonym to each other. However, Samhitas
like Suśruta, Charaka and Vāgbhata presented the clear opinion about the
differentiation between Sirā, Dhamani and Srotas16, 17, 18
The fundamental difference between Dhamani v/s Sirā and Srotas is act of
Dhamana or pulsation. Thus, Dhamani is recognized by Dhamana action16.
The school of Suśruta observed that Sirā ought to differ from Dhamani due to
its origin, function, properties and classical observation.
Sirā is the tubular structure, where Sarana is performed and through this Rasa
Dhatvādi fluids flows through Sirā. The “Sarana” in this reference explains the flow
of various fluids through Sirā onwards. Srotas are the structures through which
Sravana occurs16.
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Sravana is the permeation of various fluids through the pores present in the
wall of Srotas. This explains the osmosis or permiasis, the veins spread in body like
venules in leaf. Root of Sirās is Nābhi according to Ayurveda, because from Nābhi
they spread upwards, downwards and obliquely. They nourish the body like river and
streams in term of Jala – Harini19.
Origin of Sirā
All the Sirās present in the body originate from the Umbilicus, and from there,
they spread to all directions. Prāna resides in the veins of the Umbilicus and the
Umbilicus is the seat / residence of the veins. The Umbilicus is surrounded by Sirās
similar to the axle hole being surrounded by spokes20.
Number & Distribution of Sirās
Sirās are 700 in number. By these Sirās, the entire body is constantly
nourished, kept lubricated / moistened to perform actions such as flexion, extension,
contraction, dilation etc., similar to a large field being nourished by small channels of
water. Their spreading is like the ribs in a leaf. Nābhi is their Mūla and from there,
these spread upwards, downwards and sidewards19.
Among these 700 Sirās, Mūlasirā are 40 in number. They are:
• Vātavaha - 10 in number
• Pittavaha - 10 in number
• Kaphavaha - 10 in number
• Raktavaha - 10 in number
The 10 Vāta carrying Sirās, on reaching the seat of Vāta, divide themselves
into 175;
The Pitta carrying Sirās divide into the same number in the seat of Pitta;
The Kapha carrying Sirās divide into the same number in the seat of Kapha;
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The Rakta carrying Sirās also divide into the same number in Yakrut and Pleeha.
Thus together they form 700 in number21.
Table No. 1 Showing Doshānusara Sirā Sankhya
There are 41 Sirās in parts above the shoulders (Ūrdhvajatru). Out of these, 14
are in the neck, 4 in the ears (2 in each ear), 9 in the tongue, 6 in the nose and 8 in the
eyes (4 in each eye).
Table No. 2 Showing Ūrdhvajatrugata Sirās
1. Karnagata 04
2. Jihwagata 09
3. Netragata 08
4. Nāsāgata 06
5. Greeva 14
Total 41
1. Vātavaha Sirās 41
2. Pittavaha Sirās 41
3. Kaphavaha Sirās 41
4. Raktavaha Sirās 41
Total 164
1. Vātavaha Sirās 175
2. Pittavaha Sirās 175
3. Kaphavaha Sirās 175
4. Raktavaha Sirās 175
Total 700
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In the Koshta, there are 34 Sirās. Out of these, 8 are in the Pelvis residing in
the anus and penis (4 each); 2 in each flanks; 6 in the back; 6 in the Abdomen and 10
in the Chest22.
Table No. 3 Showing Koshtagata Sirās
In each extremity, the number of Sirās are one hundred; out of them, the four
viz, one by name „Jāladhara‟ and three situated deep inside, should not be cut (i.e.
Avedhya Sirās)23
Table No. 4 Showing Śākhāgata Sirās
Vātavaha Sirās 25x4 100
Pittavaha Sirās 25x4 100
Kaphavaha Sirās 25x4 100
Raktavaha Sirās 25x4 100
Total 400
Koshtagata Sirās
Guda, Śiśna, Śroni 08
Pārśwa 04
Prushta 6
Udara 6
Vaksha 10
Total 34
Vātavaha Sirās 34
Pittavaha Sirās 34
Kaphavaha Sirās 34
Raktavaha Sirās 34
Total 136
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Thus, the 175 Vāta carrying Sirās are described. Similar is the manner of
classification of the remaining Sirās. In case of Pittavaha Sirā, 10 are distributed in
the eyes and two in the ears (1 each); similarly Raktavaha and Kaphavaha Sirās are
distributed22.
Functions of Sirā
Vāta, moving in its own Sirā bestows non-hindrance of all activities, non-
delusion in the functions of the mind and many other activities. When the aggravated
Vāta accumulates in its own Sirā, many diseases due to Vāta develop in the body24, 25.
Pitta moving in its own Sirā attends to functions such as brightness of colour
of the skin, taste perception, keenness of digestive fire, absence of disease
(maintenance of health) etc. when aggravated, Pitta accumulates in its own Sirā and
many diseases of Pitta origin develop in the body26, 27.
Kapha moving in its own Sirā bestows lubrication of the body, stability of the
joints, augmenting strength to the body etc. when aggravated, Kapha accumulates in
its own Sirā and many diseases of Kapha origin develop in the body28, 29.
Rakta, moving in its own Sirā performs functions such as supplying nutrition
to the tissues, bestowing colour and tactile sensation to the skin etc. when aggravated,
Rakta accumulates in its own Sirā and many diseases due to Rakta vitiation develop
in the body.30, 31
Sirās do not carry Vāta, Pitta or Kapha alone. Aggravated Doshas intimately
mix with each other and circulate in the Sirās are sure to over run their normal seats
since they carry all the Doshas. Hence, all Sirās are said to carry all the doshas32, 33.
Vātavaha Sirās are Aruna in colour; Pittavaha Sirās are warm and blue in colour;
Kaphavaha Sirās are cold, white and stable; Raktavaha Sirās are Rohini in colour and
neither very hot nor very cold34.
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Vedhya and Avedhya Sirās
Ācharyas described Vedhya Sirās are those which can be interfered within
surgical process. They present no serious complications, when affected. It is also
mentioned that through these veins only the safer bloodletting should be done for
curing various diseases.
Avedhya Sirās are those on which the injury must be avoided during surgery.
In Vedic period, there is no mention about Avedhya or Vedhya Sirās. Although they
have mentioned that in vascular injury the outflow of the blood should be checked35,
36.
In Samhita period, Charaka described two Vedhya Sirās in connection with
the disease Unmāda, Vishamajwara and Apasmāra at two places i.e. Śankha Pradeśa
and Keśānta Pradeśa37.
The school of Suśruta exerts few selected fatal veins. Avedhya Sirās are
surgically important since trauma during surgery proves fatal. This also infers that
school of Suśruta was advanced in vascular surgery. They were aware of these Sirās
which need care during surgery.
The school of Suśruta describes Vedhya Sirās specifically in connection with
the diseases which are cured by Sirāvyadha e.g. In Gridhrasi, the Sirā of Jānu should
be considered as the Vedhya Sirā, which when flexed and tourniqueted proliferates
and this mean they are all superficial veins, which are used for Sirāvyadha to purify
the Dūshita Rakta.
Astanga Sangraha and Astanga Hridaya too have mentioned Vedhya Sirās but
they have given them in connection with the disease. No mention of specific Sirā for a
particular disease has been made. In this regard, they included the Vedhya Sirā in their
respective places of Roga and there the Sirā should be visible.
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However the Avedhya Sirās are the vessels which are prohibited for the
Sirāvyadha.
The vascular injuries were reported in Vedic literature but there was no
description of Avedhya Sirā35, 36.
It appears that school of Charaka took task of Vedhya Sirās for the first time,
but he did not mention specifically the Avedhya Sirās.
The school of Suśruta mentions specific and detailed description of
Sirāvyadha as well as Avedhya Sirās for the first time in the history of medicine and
surgery. He mentioned 98 Avedhya Sirās which should be taken care by the physician
or surgeon at the time of Sirāvyadha or any other surgical condition. Any trauma of
these structures may lead to morbidity or death38.
Four hundred veins are present in the Śākhās, one hundred and thirty six are
present in the Koshta and one hundred sixty four are present in the parts above the
shoulders. Among these, sixteen in the extremities, thirty two in the trunk and fifty
above the shoulders are to be considered as Avedhya39, 40.
There are one hundred veins in each of the extremities; out of which one by
name Jāladhara, two which are situated deep inside known as Urvi and one by name
Lohitāksha are not to be punctured. Thus sixteen veins of the Śākhās are Avedhya41.
Vāgbhata also mentioned the number of Avedhya Sirās as Ācharya Suśruta,
but he has slightly modified the knowledge of Avedhya Sirās. His concept is that apart
from these 98 Avedhya Sirās, those Sirās which are oblique, short, tortuous and
narrowly placed in the subject should also be included under this heading42.
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INDIVIDUAL AVEDHYA SIRĀS OF EXTREMITIES AND ITS CORRELATION WITH MARMA Urvi
This is an Avedhya Sirā as well as a Sirā Marma situated in the middle of
thigh. Injury to this causes atrophy/wasting of muscles of the thigh from the loss of
blood. It is a Vaikalyakara Marma102.
Vāgbhata, Dalhana, Indu and Arunadutta have followed Suśruta. Dr. B.G.
Ghanekar has considered the probabilities of the hypotrophy of the muscles on injury
to midline of thigh, in this view femoral vessels and saphenous nerve are the
responsible structures. He has also stressed that femoral vessels would produce loss of
blood and injury to saphenous nerve may develop hypotrophy of the lower limb (B.
G. Ghanekar – Su. Śa. Pages 192, 1976).
2) Lohitāksha
This is Avedhya Sirā as well as Sirā Marma according to Suśruta.
This Marma is situated above Urvi Marma and below Vankshana Sandhi (Hip
joint) at the root of the Ūru. On injury this causes paralysis of the muscles or wasting
of the Sakthi (lower limb) due to loss of blood. It is a Vaikalyakara Sirā Marma103.
Vāgbhata, Indu, Dalhana and Arunadutta have followed Suśruta whereas Dr.
B. G. Ghanekar has mentioned femoral triangle in respect to this Marma.
This injury of this region should produce the same condition as narrated in
Urvi (B. G. Ghanekar – Su. Śa. Pages 192, 1976). Lohitāksha Marma involves the
ilio-femoral and brachio-axial segment of the vessels.
Jāladhara, Urvi and Lohitāksha are Avedhya Sirās and Sirā Marma in upper
extremities is under the same name and descriptions41. According to Suśruta there are
400 Sirās in extremities, but only 4 Sirās in each limb are Avedhya. Jāladhara
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situated externally is one in each extremity, 3 internal Sirās (2 – Urvi and 1 –
Lohitāksha), thus total 16 Avedhya Sirās in extremities23, 39, 40.
This opinion does not appear to be different in terms of modern surgery. B. G.
Ghanekar suggests Jāladhara for great saphenous and cephalic veins – Urvi,
Lohitāksha for femoral artery and vein, brachial artery and vein and axillary artery
and vein (B. G. Ghanekar – Su. Śa. Page 210, 1976).
Avedhya Sirās denote prohibition of Sirāvyadha, if they undergo trauma due to
surgery or injury, they may produce pathological conditions. Ghanekar‟s concept for
Avedhya Sirās of extremities being major vessels of limbs give the idea of vascular
phenomenon, but he has not discussed them for Avedhya point of view with accurate
reasoning.
Individual Vedhya Sirās of Extremities
The school of Suśruta has mentioned the Vedhya Sirās of extremities in
connection of the disease which are most probably the superficial veins of the limbs.
Suśruta mentioned that the disease of Gridhrasi and Viśvachi, the knee and elbow
should be flexed and the limb should be tourniquet to proliferate the veins. The
Vedhya Sirā for Gridhrasi is four Angulas below or above the Jānu Marma and
Vedhya Sirā for Viśvachi is four fingers below or above the Kūrpara45.
Raktamokshana
The word „Rakta‟ means- coloured, dyed, tinged, painted, crimson, and blood
red.
The word „Mokshana‟ is derived from the root „Moksha’ means „to relieve‟ or
„to let out‟. Therefore letting out of blood is known as Raktamokshana.
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The process of Raktamokshana can be traced back to Vedic period only and
not beyond that. In the Kouśika Sutra of Atharvaveda, references of Raktamokshana
by leech application are found. (Atridev, A.D.1960)
During the period of Buddha, this process was in regular practice, which could
be easily understood from Pilindivachha, a patient of Buddha in whom he did
Raktamokshana by Śringa for Parvavata (Atridev, A.D.1960).
Bloodletting is the withdrawal of often considerable quantities of blood from
a patient to cure or prevent illness and disease. It was the most
common medical practice performed by doctors from antiquity up to the late 19th
century, a time span of almost 2,000 years. It is conceivable that historically, in the
absence of other treatments for hypertension, bloodletting could sometimes have had
a beneficial effect in temporarily reducing blood pressure by a reduction in blood
volume.
The importance of bloodletting as medicinal agent, in comparison with other
means of treatment in various respects, is equivocal to other remedies when properly
administered. Different methods are in use for taking away the blood for therapeutic
purposes, by (1) phlebotomy – where blood is drawn from available veins. (2)
Arteriotomy – where artery is punctured (3) Scarification – Scraping of superficial
cells with syringe. Venesection or phlebotomy is much more effective than any other
modes of treatment. Likewise in modern era also Phlebotomy (Venesection) is part of
treatment, Performed in different conditions like –Polycythemia Vera,
hemochromotosis, hepatitis B, hepatitis C and C C F.
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Phlebotomy
Phlebo vein, tome to cut
Venesection
Opening of a vein for withdrawal of blood. Although phlebotomy is a
synonym for Venesection in clinical practice, phlebotomy refers to therapeutic
bloodletting, such as removing some blood to lower the viscosity of blood of a patient
with Polycythemia.
Webster‟s defines phlebotomy as phle bot omy / Fli-bat-eh-mee\n: The letting
of blood in the treatment of diseases. i.e. Venesection.155
The term phlebotomy refers to the drawing of blood for laboratory analysis
or blood transfusion
Raktamokshana is of two types –
1) Śastra-Visrāvana
It is the process which is done by the iron instruments. It is of two types43:
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i) Prachāna: It should be done in straight line, such lines not joining
together, being even, not very superficial. The instrument should be
used quickly without damaging vital spots and joints44.
ii) Sirāvyadha: It is the procedure of puncturing a vein.
2) Anuśastra-Visrāvana
It is more preferable for delicate persons because they are not made by iron
instruments etc. It consists of four methods –
i) Jalauka
ii) Shrunga
iii) Alābu
iv) Ghati Yantra
Ācharya Vāgbhata has considered the Anuśastra as Jalauka, Kshāra, Dāha
Karma, Kacha, Nakha, Pāshśna etc. and suggested to treat similarly.
Sites of Sirāvyadha in lower extremities45
Table No. 5 Showing Sites of Sirāvyadha according to Suśruta
Disease Site of Sirāvyadha Pādadāha, Pādaharsha, Apabāhu, Chippa, Visarpa, Vātaśonita, Vātakantaka, Pādadāri, Vicharchika
2 Angula above Kshipra Marma with Vrīhimukha Śastra
Vataja Slīpada 4 Angula above the Gulpha Sandhi Pittaja Slīpada 4 Angula below the Gulpha Sandhi Kaphaja Slīpada 4 Angula above the Kshipra Marma Kroshtukasīrsha, Khanja, Pangu, Vātavedana 4 Angula above Gulpha Apachi 4 Angula below Indrabasti Marma Gridhrasi 4 Angula above or below Jānu Sandhi Galaganda Ūru Mūla Sirā is subjected to Sirāvyadha
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TABLE No. 6 Showing the Sites of Sirāvyadha according to Vāgbhata46
Disease Site of Sirāvyadha Galaganda, Gala Vidradhi Sirā in the Ūru is subjected to Vyadha Gridhrasi Sirā 4 Angula above or below the Jānu Apachi 2 Angula below Indrabasti Kroshtukaseersha, Sakthivata Ruja 4 Angula above the Gulpha Pādadāha, Vātaśonita, Pādaharsha, Chippa Vipādikā, Pādadāri & Vātakantaka
2 Angula above Kshipra Marma
Indications of Sirāvyadha
Diseases of the skin, tumours, swelling and diseases arising from blood will
never occur in persons indulging in bloodletting (generally in Śarad Ritu) 47.
Bloodletting is the method of treatment indicated in diseases caused due to the
vitiation of Raktadhātu like Visarpa (erysipelas), Vidradhi (abscess), Plīha (Diseases
of Spleen), Gulma, Agnisadana (Dyspepsia), Jwara (Fever), Mukha Roga (Diseases
of mouth), Netra Roga (Diseases of Eye), Śiro Roga (Diseases of Head), Mada
(Intoxication), Trishnā (Thirst), Lavanāsyata (Salty taste in the mouth), Kushta (Skin
diseases), Vātarakta, Raktapitta, Katu and Amlodgāra (Pungent and Sour eructation),
Bhrama (Giddiness) etc.48,49,50
Contraindications of Sirāvyadha51
Sirāvyadha should not be done in the following persons:
Bāla (very young) and Sthavira (very old), as they are weak and the Dhatus
are in an immature state;
Rūksha, Kshatakshīna (wounded and debilitated), as it may cause
“Vataprakopa”;
Bhīru (timid persons), as there will be “Tamobahulata”, and faint by seeing
the blood;
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Pariśrānta (tired persons), as Vāta gets vitiated in such persons and affects the
whole body;
Madyapa (alcoholics), as they will go to Mūrcchā again due to the intoxicated
condition;
Adhvastrīkarśita (emaciated as a result of long journey and sexual
intercourse), as it may cause “Vātaprakopa”;
Vāmita and Virikta (those who have undergone Vamana and Virechana
therapies), as it may aggravate Vāta;
Āsthapita and Jāgarita (those who have undergone Āsthapanavasti and who
have not slept at night), as it may further aggravate Vāta;
Anuvāsita (those who have undergone Anuvāsanavasti), as there will be
Mandāgni which leads to “Agnimāndya”;
Klība (impotent), as there will be Śukrakshaya along with Alpasattva which
will definitely lead to Vināśa of such person;
Kriśa and Garbhini (emaciated and pregnant women), as there will be
Dhatukshaya in both cases;
Kāsa and Śwāsa, as the Dhatus are in Apachiyāvastha which may lead to
complications;
Pravruddha Jwarāvastha (chronic fevers), as it leads to complications such as
Pralāpa etc.
Ākshepaka Vata, Pakshāghāta Those who observe Upavāsa (fasting) and
those who are afflicted with Pipāsā and Mūrcchā
Those veins which are prohibited from puncturing (Avedhya Sirās), which are
invisible though indicated for puncturing, which are visible but not controlled (from
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moving apart), which are not raised (engorged by pressure from a tourniquet etc.)
though controlled, such veins should not be punctured51.
As bloodletting is very necessary in the above mentioned diseases ideally,
leeches should be applied; however Sirāvyadha is the last choice. Even in those who
are prohibited for it, when they are affected by poisons or are in an emergency,
Sirāvyadha can be done52.
Sirāvyadha should not be done on days which are very cold, very hot, with
heavy breeze and very cloudy and never in the healthy persons (except Śarad Ritu) 53.
Also, those who have swelling all over the body, who are emaciated due to
intake of sour food (for a long time), who are suffering from disease such as anaemia,
haemorrhoids, abdominal enlargement,tiredness, oedema and pregnant women54.
Importance of Marma in the context of Sirāvyadha
While explaining the contraindications of Sirāvyadha, Suśruta in
Śārīrasthāna, describes that the Avedhya Sirās in each of the lower extremities are 4
in number; i.e. Jāladhara – 1, Urvi – 2, Lohitāksha – 1 and these are considered as
Marmāśrita and hence should not be venesected. If venesected, it may cause
disability or death55, 56.
Materials required for Sirāvyadha
For better performance of Sirāvyadha and for the management of the
complications, the following materials should be arranged prior to the procedure:
Cot, Stools, pots of water, pieces of cloth (gauze piece, swabs), drugs like
Talahridaya Centre of the sole in line with the middle toe.
2 Mamsa 1/2 Flexor digitorum brevis and longus muscles, Adductor hallucis, flexor digitorum accessorius muscles, plantar arch and tributaries of saphenous vein. .
Kālāntaraprānahara
Death from pain.
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Kūrcha Two Angulas above Kshipra Marma.
2 Snāyu 4 Tendon of flexor hallucis longus and abductor hallucis muscle, medial plantar nerve, medial plantar, dorsal metatarsal and arcuate arteries.
Vaikalyakara
Bhramana and Vepana of the foot.
Kūrchaśira Just below the ankle joint.
2 Snāyu 1 Peroneous brevis and longus muscles, Peroneal artery and tributaries of short saphenous vein, Peroneal nerve.
Rujakara
Ruja and Shopha
Gulpha The ankle joint, particularly the sensitive point on the inside and below the protuberance of the bone.
2 Sandhi 2 Flexor hallucis longus and brevis, tibilias posterior and flexor digitorum longus muscles, posterior tibial artery and vein.
Rujakara Ruja, Sthabda padatha and Khanjatha
Indrabasti The point at the middle of the line, joining the posterior surface of the calcaneum with the centre of the popliteal fossa
2 Mamsa 1/2 Gastrocnemius, soleus and plantaris muscles, Peroneal (branch of posterior tibial) and posterior tibial artery and vein; Drainage of lymph vessels to the popliteal lymph glands, Posterior tibial nerve.
Kālāntaraprānahara
Rakta kshaya and Marana
Jānu The Knee Joint as a whole. Various sensitive points around the knee can be located.
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Āni Three Anguli above the knee joint
2
Snāyu 1/2 Medial and lateral ligaments of the Knee joint; quadriceps tendon, adductor Magnus, Gastrocnemius, and biceps femoris muscles; femoral artery; tributaries of femoral vein and saphenous nerve.
Vaikalyakara
Sophia and Shaba Sakthitha
Urvi Centre of the thigh.
2
Sira 1 Femoral artery and vein; drainage to the superficial inguinal glands; saphenous nerve; Sartorius, rectus femoris, adductor longus, pectineus, vastus lateralis, gracilis, and biceps femoris muscles.
Vaikalyakara
Rakta kshaya and Sakthi Shosha.
Lohitāksha 2 Anguli lateral to the symphysis pubis where the femoral artery passes; in the femoral triangle.
2 Sira 1/2 Femoral artery and tributaries of femoral vein; femoral nerve; drainage to the superficial inguinal glands; Psoas major and pectineal muscles.
Vaikalyakara
Lohithaksha , Pakshāghāta and Marana
Vitapa In between the groin and scrotum.
2 Snāyu 1 In men – Spermatic cord, prostate gland deep inside the pelvis. In women – round ligament of uterus.
Vaikalyakara
Shandya and Alpashukratha
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VENOUS SYSTEM
Vein is a blood vessel carrying deoxygenated (dark red) blood to the heart,
except for the pulmonary veins, which carry oxygenated blood132.
The first systematic description of the venous system was given by André
Vesale (alias Vesalius) in De humanis corporis fabrica (1543). Vesalius‟ venous
anatomy was almost complete containing some omissions, like venous valves and
perforating veins. In addition, Vesalius furnished a good description of the structure
of the venous wall. He differentiated the internal coat of the veins in two layers. The
internal one contained contractile fibers, though “dissimilar from those of skeletal
muscles, arranged, from within outwards, circularly, obliquely and longitudinally.”
The outer coat was formed by a loose network borrowed from surrounding
structures133.
Veins are characterized by relatively thin wall and large capacitance compared
to arteries. The structural plan of the wall is similar to that of other vessels, where the
amount of muscle is considerably less than in arteries. In most veins, especially in the
limbs, muscle is arranged circularly. Longitudinal muscle is present in iliac, portal,
renal veins and in superior and inferior vena cava. On the contrary, muscular tissue is
absent in placental veins, retinal veins; but these veins are consisting of endothelium
supported by variable amount of connective tissue. Pressure within the venous system
doesn‟t exceed 5 mm of Hg. As the vein grows larger it decreases upto zero. Because
they contain small amount of muscle and usually vein have limited influence on blood
flow.
Due to any cause when there is sudden fall in blood pressure, there is reflex
constriction in vein to compensate the blood loss and tend to maintain the venous
return to the heart. Most veins have valves to prevent reflux of blood flow. When
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blood flow reverses, if the semilunar valves cusps, not close properly, then blood fills
in expanded valve of the vein giving rise to knotted appearance to the distended vein.
Leg venous return is against gravity. Valves are of great importance. Blood is moved
towards the heart by intermittent pressure produced by contractions of the
surrounding muscles which are absent in thorax and abdominal veins134.
After flowing through the capillaries, blood collects in the distal end of the
thoroughfare channel and flows into a venule. In the venous circulation, blood flows
from smaller vessels into progressively larger ones; hence, instead of giving off
branches as arteries do, veins receive smaller tributaries, just as a river receives
water from the many streams that form its tributaries.
Venules range from about 15 to 100 m in diameter. The proximal part of a
venule has only a few fibroblasts around it and is quite porous; therefore venules, like
capillaries, exchange fluid with the surrounding tissues. Farther along, a venule
acquires a tunica media of smooth muscle. Even the largest veins, however, have
relatively sparse muscular and elastic tissue compared to arteries.
Venous sinuses are veins with especially thin walls, large lumens, and no
smooth muscle. Examples include the coronary sinus of the heart and the dural
sinuses of the brain. Because they are farther away from the heart, veins have much
lower blood pressure than arteries. In large arteries, it averages 90 to 100 mmHg and
surges to 120 mmHg during systole, whereas in veins it averages about10 mmHg and
fluctuates very little with the heart beat. This has significant implications for the form
and function of veins.
Since they need not withstand high pressure, veins have thinner walls than
arteries, with less muscular and elastic tissue. They collapse when empty and look
relatively flattened or irregular in histological sections
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Since their walls are so thin, veins expand more easily and accommodate more
blood than arteries do. About 54 percent of the blood is found in the systemic veins at
rest (fig. 20.7); veins are therefore called capacitance vessels.
The pressure in the veins is not high enough to push blood upward against the
pull of gravity to the heart. The upward flow of blood depends on the massaging
action of skeletal muscles and the presence of one-way venous valves that keep the
blood from dropping down again when the muscles relax. These valves, similar to the
semilunar valves of the heart, occur especially in medium veins of the arms and legs;
they are absent in very small and very large veins, veins of the ventral body cavity,
and veins of the brain. Varicose veins result in part from the failure of these valves135.
Composition of vein
Veins are composed of essentially three coats as that of arteries. But there are
variations in their relative thickness. If arteries are to be distinguished from veins
following reasons may be given
The wall of a vein is very thin than the artery.
The tunica media contains much collagen than arteries. The amounts of elastic
tissue are much less.
In arteries tunica media, is usually thicker than the adventitia. In contrast the
adventitia of veins is thicker than the media. In some large veins the adventitia
contains a considerable amount of elastic and muscle fibres which run in a
predominantly longitudinal direction. These fibres facilitate elongation and
shortening of the vena cava with respiration.
A clear distinction between the tunica intima, media and adventitia cannot be
made out in small veins as all these layers consist predominantly of fibrous
tissue. Muscle is conspicuous by its complete absence in venous spaces of
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erectile tissue, in veins of cancellous bone, dural venous sinuses, retinal veins
and placental veins136.
Microscopic Structure of Vein
The walls of the veins have three layers called tunics:
1. The tunica externa (tunica adventitia1) is the outer most layer. It consists of
loose connective tissue that often merges with that of neighbouring blood vessels,
nerves, or other organs. It anchors the vessel and provides passage for small nerves,
lymphatic vessels, and smaller blood vessels. Small vessels called the vasa vasorum
supply blood to at least the outer half of the wall of a larger vessel. Tissues of the
inner half of the wall are thought to be nourished by diffusion from blood in the
lumen.
2. The tunica media, the middle layer, is usually the thickest. It consists of smooth
muscle, collagen, and sometimes elastic tissue. The smooth muscle is responsible for
the vasoconstriction and vasodilatation of blood vessels.
3. The tunica intima (tunica interna), the inner layer, is exposed to the blood. It
consists of a simple squamous endothelium overlying a basement membrane and a
sparse layer of fibrous tissue. The endothelium acts as a selectively permeable barrier
to blood solutes, and it secretes vasoconstrictors and vasodilators to be considered
later. It also provides a smooth inner lining that normally repels blood cells and
platelets. However, platelets may adhere to a damaged endothelium. During
inflammation, leukocytes also adhere loosely to it by means of cell-adhesion
molecules produced by the endothelial cells137.
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Fig: 12 Image of Microscopic Structure of Vein
Vasa Vasorum
Nourishment of tissue of vessel wall is provided by blood circulating vessels
itself. Large vessels have own vascular supply within adventitia, in the form of
network of vessels called Vasa vasorum. Vasa vasorum originate from and drains into
adjacent vessels which are peripheral branches138.
Developmental Anatomy of Blood Vessels139
The human yolk sac has little yolk to nourish the developing embryo, blood
and blood vessel. Formation starts as early as 15-16 days in the mesoderm of the yolk
sac, chorion, and body stalk. Blood vessels develop from isolated masses and cords of
mesenchyma in the mesoderm called blood islands. Spaces soon appear in the islands
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and become the lumens of the blood vessels. Some of the mesenchymal cells
immediately around the spaces give rise to the endothelial lining of the blood vessels.
Mesenchyme around the endothelium forms the Tunics of the larger blood vessels.
Growth and fusion of blood islands form an extensive network of blood vessels
throughout the embryo.
Development of Veins
The cardiovascular system is the first major system to function in the embryo.
The primordial heart and vascular system appear in the middle of the third week of
embryonic development. The heart starts to function at the beginning of fourth week.
This precocious heart development is necessary because the rapidly growing embryo
can no longer satisfy its nutritional and oxygen requirement by diffusion alone.
Consequently, there is a need for an efficient method of acquiring oxygen and
nutrients from the maternal blood and disposing of carbon dioxide and waste
products.
Angiogenesis or blood vessel formation begins in the extra-embryogenic
mesoderm of the yolk sac, connecting stalk, and chorion. Embryonic blood vessels
begin to develop about two days later. The early formation of the cardiovascular
system is correlated with the absence of a significant amount of yolk in oocyte and
yolk sac and the consequent urgent need for blood vessels to bring oxygen and
nourishment to the embryo from the maternal circulation through the placenta. At the
end of the second week, embryonic nutrition is obtained from the maternal blood by
diffusion through the extra embryonic coelom and yolk sac. During the 3rd week,
primordial uteroplacental circulation develops. Primordial blood vessels cannot be
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distinguished structurally as arteries or veins, but are named according to their future
fates and relationship to the heart.
The formation of the embryonic vascular system involves two processes:
vasculogenesis and angiogenesis. Blood vessel formation in the embryo and extra
embryonic membranes during the 3rd week may be summarized as follows:
- Mesenchymal cells differentiate into endothelial cells precursor - angioblasts
(vessel-forming cells), which aggregate to form isolated angiogenic cell
clusters-blood islands.
- Small arteries appear within the blood islands by confluence of intercellular
clefts.
- Angioblasts flatten to form endothelial cells that arrange themselves around
the cavities in the blood island to form the endothelium.
- These endothelium lined cavities soon fuse to form networks of endothelial
channels. (Vasculogenesis).
- Vessels sprout into adjacent areas by endothelial budding and fuse with other
vessels (angiogenesis).
Blood cells develop from the endothelial cells of vessels (hemangioblasts) as
they develop on the yolk sac and allantois at end of the third week. Blood formation
does not begin in the embryo until the 5th week. It occurs first in the various parts of
the embryonic mesenchyme, chiefly the liver and later in the spleen, bone marrow and
lymph nodes. Foetal and adult erythrocytes are derived from the different
hematopoietic progenitor cells. The mesenchymal cells surrounding the primordial
endothelial blood cells differentiate into the muscular and connective tissue elements
of the vessels. The earliest sign of the heart is appearance of paired endothelial strands
- angioblastic cords in the cardiogenic mesoderm during the 3rd week. These cords
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canalize to form heart tubes, which fuse to form the tubular heart late in the 3rd week.
The heart begins to beat at 23rd day. An inductive influence from the anterior
endoderm stimulates early formation of the heart. The development of heart and blood
vessels is controlled by a cascade of regulatory genes and signalling molecules.
Three paired veins drain into the tubular heart of a four-week embryo -
- “Vitelline veins” return poorly oxygenated blood from the yolk sac.
- “Umbilical veins” carry oxygenated blood from the primordial placenta.
- “Common cardial veins” return poorly oxygenated blood from the body of the
embryo.
The vitelline veins follow the yolk stalk into the embryo. The yolk stalk is the
narrow tube connecting the yolk sac with the midgut. After passing through the
septum transversum, the vitelline veins enter the venous end of the heart - the “sinus
venosus”. As the liver primordium grows into the septum transversum the hepatic
cords anastomose around pre-existing endothelium lined spaces. These spaces, the
primordial of the “hepatic sinusoids”, later become linked to the vitelline veins. The
“hepatic veins” form from the remains of the right vitelline vein in the region of the
developing liver.
The portal vein develops from an anastomosis network formed by the vitelline
veins around the duodenum.
The „umbilical veins‟ run on each side of the liver and carry well oxygenated
blood from the placenta to the sinus venosus. As the liver develops, the umbilical
veins lose their connection with the heart and empty into liver. The right umbilical
vein disappears during the seventh week, leaving the left umbilical veins as the only
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vessel carrying well-oxygenated blood from the placenta to the embryo.
Transformation of the umbilical veins may be summarized as follows;
- The right umbilical vein and the caudal part of the left umbilical vein between
the liver and sinus venosus degenerate.
- The persistent caudal part of the left umbilical vein becomes the umbilical
vein, which carries all the blood from the placenta to embryo.
- A large venous shunt - the ductus venosus develops within the liver and
connects the umbilical vein with the inferior vena cava.
The cardinal veins constitute the main venous drainage system of the embryo.
The anterior and posterior cardinal veins drain cranial and caudal part of the embryo,
respectively. The anterior and posterior cardinal veins join the common cardinal
veins, which enter the sinus venosus. During the 8th week of embryonic development,
the anterior cardinal vein becomes connected by an anastomosis which shunts blood
from the left to the right anterior cardinal vein. This anastomotic shunt becomes the
left brachio-cephalic vein when caudal part of the left anterior cardinal vein
degenerates. The superior vena cava forms from the right anterior cardinal vein and
the right common cardinal vein.
The posterior cardinal veins develop primarily as the vessels of the
mesocephalic (interim kidneys) and largely disappears with this transitory kidneys.
The only adult derivatives of the posterior cardinal veins are the root of the azygos
vein and the common iliac veins. The subcardinal and supracardinal veins gradually
replace and supplement the posterior cardinal veins. The sub-cardinal vein appears
first. They are connected with each other through the subcardinal anastomosis and
with the posterior cardinal veins through the nephric sinusoids. The sub-cardinal veins
form the stem of the left renal vein, the suprarenal veins, the gonadal veins and
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segment of InferiorVenaCava. The supracardinal veins are the last pair of vessels to
develop. They become disrupted in the region of the kidneys. Cranial to this, they
become united by the anastomosis i.e. represented in the adult by the azygos and
hemi-azygos veins. Caudal to the kidneys, the left supracardinal veins degenerates,
but the right supracardinal veins becomes the inferior part of the IVC.
Development of Superior Vena Cava140
The precardinal veins enlarge as the head and brain develop. They are further
augmented by the subclavian veins from the upper limb buds, and so become the chief
tributaries of the common cardinal veins, which gradually assume an almost vertical
position in association with the descent of the heart into the thorax. That part of the
original precardinal vein rostral to the subclavian is now the internal jugular vein, and
their confluence is the brachio-cephalic vein of each side. The right and left common
cardinal veins are originally of the same diameter. By the development of a large /
transverse connection, the left brachio-cephalic vein carries blood across from the left
to the right. The part of the original right precardinal vein between the junction of the
two brachio-cephalic and azygos veins forms the upper part of the superior vena cava,
the caudal part of the latter vessel is formed by the right common cardinal vein.
Caudal to the transverse branching of the left brachio-cephalic the left precardinal and
left common cardinal veins largely atrophy, the former constituting the terminal part
of the left superior intercostal vein; while the latter is represented by the ligament of
the left vena cava and the oblique vein of the left atrium. The remainder of the left
superior intercostal is developed from the cranial end of the post cardinal vein and
drains the second, third, and occasionally the fourth intercostal veins. The oblique
vein passes downwards across the back of the left atrium to open into the coronary
sinus which, as already indicated, represents the persistent left horn of the sinus
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venosus. Right and left superior venae cavae are present in some animal and
occasionally in mankind.
Development of Inferior Vena Cava
The inferior vena cava (IVC) forms during a series of changes in the
primordial veins of the trunk that occur as blood, returning from the caudal part of the
embryo, is shifted from the left to the right side of the body. The IVC is composed of
four main segments
- A hepatic segment derived from the hepatic vein (proximal part of right
vitelline vein) and hepatic sinusoids.
- A prerenal segment derived from the right subcardinal vein.
- A renal segment derived from the subcardinal-supracardinal anastomosis.
- A postrenal segment derived from the right supracardinal vein.
The early postcardinal veins communicate across the midline via an inter-post-
cardinal anastomosis between the iliac veins, and become the major part of the
definitive left common iliac vein. It diverts an increasing volume of blood into the
right longitudinal veins, which accounts for the ultimate disappearance of the most of
those on the left.
The supracardinal veins receive the larger venous drainage of the growing
body wall. The right supracardinal vein persists and forms the greater part of the post
renal segment of the IVC. The continuity of the vessel is maintained by the
persistence of the anastomosis of between the right supracardinal and right
subcardinal vein in the renal collar.
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In summary, therefore, the inferior vena cava is formed from below upwards
by the confluence of common iliac veins; short segment of the right postcardinal vein,
the postcardinal-supracardinal anastomosis, part of the right supra-cardinal vein, a
new anastomotic channel of dual origin, the hepatic segment of the inferior vena cava;
and the cardiac termination of the right vitelline hepatocardiac vein.
Fig No: 13 Embryonic development of cardiovascular system and Blood vessels
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VEINS OF THE LOWER EXTREMITIES
Development of Vessels in the Lower Limb
The axial artery of the lower limb arises from the dorsal root of the umbilical
artery and courses along the dorsal surface of the thigh, knee and leg. Below the knee
it lies between the tibia and popliteus, and in the leg it lies between the crural
interossoeus membrane and tibialis posterior. It gives off a perforating artery that
traverses the sinal tarsus to form a dorsal network and ends distally in a plantar
network. The femoral artery passes along the ventral surface of the thigh, opening a
new channel to the lower limb. It arises from a capillary plexus that is connected
proximally with the femoral branches of the external iliac artery and distally with the
axis artery. At the proximal border of popliteus the axis artery splits into primitive
posterior tibial and peroneal branches: these run distally on the dorsal surface of
popliteus and tibialis posterior to gain the sole of the foot. At the distal border of
popliteus the axis artery gives off a perforating branch that passes ventrally between
the tibia and the fibula and then courses to the dorsum of the foot, forming the
anterior tibial artery and dorsalis pedis artery. The primitive peroneal artery
communicates with the axis artery at the distal border of popliteus and in its course in
the leg.
The femoral artery gradually increases in size. Coincidentally, most of the axis
artery disappears; however, proximal to its communication with the femoral artery,
the root of the axis artery persists as the inferior gluteal artery and the arteria comitans
nerviischiadici.
The proximal parts of the primitive posterior tibial and peroneal arteries fuse:
they remain separate distally. Ultimately, much of the primitive peroneal artery
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disappears; however, a part of the axis artery is incorporated in the permanent
peroneal artery.
In the lower limb the preaxial vein becomes the long saphenous vein, which
drains into the femoral vein at the saphenous opening. The postaxial vein becomes the
short saphenous vein, which passes deep and joins the popliteal vein141.
Veins of the Lower Limb142
The veins of the lower limb can be subdivided, like those of the upper limb,
into superficial and deep groups. The superficial veins are subcutaneous and lie in the
superficial fascia; the deep veins accompany the major arteries. Both groups have
valves, which are more numerous in the deep veins and also more numerous than in
the veins of the upper limb. Venous plexuses occur within and between some of the
lower limb muscles.
The principal named superficial veins are the long and short saphenous veins.
Their numerous tributaries are mainly unnamed.
Deep veins of the lower limbs accompany the arteries and their branches.
Plantar digital veins arise from plexuses in the plantar regions of the toes, connect
with dorsal digital veins and unite four plantar meta-tarsal veins. These run in the
intermetatarsal spaces and connect by perforating veins with dorsal veins then
continue to form a day plantar arterial arch. From this arch, medial and lateral plantar
veins run near the corresponding arteries. They communicate with the long and short
saphenous veins before forming the posterior tibial veins behind medial malleolus.
The posterior tibial veins accompany the posterior tibial artery. They receive
veins from the calf muscles, especially the venous plexus in soleus, and connect with
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the superficial veins and with the peroneal veins. The latter, running with their artery,
receive branches from soleus and superficial veins.
The anterior tibial veins are continuations of venae comintantes of the dorsalis
pedis artery. They leave the extensor region between the tibia and fibula, pass through
the proximal end of the interossoeus membrane, and unite with the posterior tibial
veins to form the popliteal vein at the distal border of popliteus.
Considerable of the venous drainage is of great importance because in the
lower limb venous blood has to ascend against gravity. This is aided by a number of
local factors, the failure of which gives rise to varicose veins. The veins of lower limb
may be classified into three groups143.
I. Superficial Veins
II. Deep Veins
III. Perforating Veins
I. Superficial Veins: They include the great and small saphenous veins and their
tributaries. They lie in the superficial fascia, on the surface of the deep surface.
They are thick walled because of the presence of smooth muscle and some
fibrous and elastic tissues in their walls.
II. Deep Veins: These are the anterior and posterior tibial, peroneal, popliteal, &
femoral veins and their tributaries. They accompany the arteries, and are
supported by powerful surrounding muscles. The valves are more numerous in
deep veins than in superficial veins. They are more efficient channels than the
superficial veins because of the driving force of muscular contraction.
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III. Perforating Veins: They connect the superficial with the deep veins. Their
valves permit only one way flow of blood, from the superficial to the deep
veins. There are about five perforators along the great saphenous vein, and one
perforator along the small saphenous vein.
Superficial Veins of Lower limb
(1) The dorsal venous arch lies on the dorsum of the foot over the proximal part of
the meta-tarsal bones. It receives four dorsal meta-tarsal veins each of which is
formed by the union of two dorsal digital veins
(2) The great or long saphenous vein is formed by the union of the medial end of
the dorsal venous arch with the medial marginal vein which drains the medial
side of the medial surface of tibia obliquely, and runs along its medial border
to reach the back of the knee. The saphenous nerve runs in front of the great
saphenous vein.
(3) The small or short saphenous vein is formed by the union of the lateral end of
the dorsal venous arch with lateral marginal vein, draining the lateral side of
the little toe. It passes upwards behind the lateral malleolus to reach the back
of the leg. The sural nerve accompanies the small saphenous vein.
Both saphenous veins are connected to the deep veins through the perforating
veins.
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Fig No: 14 Showing Superficial Veins of the Lower Limb
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Fig No: 15 Showing Superficial veins of the Lower limbs
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Fig No: 16 Showing Superficial and Perforating veins of the lower limb
Great or Long Saphenous Vein144
Saphes Easily seen.
The saphenous vein can be easily seen in the leg. Venous drainage acquires
importance as blood has to flow up against the gravity.
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The long saphenous vain, is the largest and longest superficial vein of the
lower limb. It starts on the dorsum of the foot from the medial of the dorsal venous
arch, and runs upwards in front of the medial malleolus along the medial side of the
leg, and behind the knee. In the thigh, it inclines forwards to reach the saphenous
opening where it pierces the cribriform fascia and opens into the femoral vein.
In its course through the thigh the long saphenous vein is accompanied by the
branches of the medial femoral cutaneous nerve. Before piercing the cribriform fascia,
it receives three named tributaries corresponding to the 3 cutaneous arteries and also
many unnamed tributaries.
It contains about 10-15 valves which prevent back flow of the venous blood,
which tends to occur because of gravity. One valve is always present at the saphenous
femoral junction. Incompetence of these valves makes the vein dilated and tortuous
leading to varicose vein.
In almost its entire extent the vein lies in superficial veins, but it has many
connections with the deep veins, especially in the leg. The veins are also connected to
the deeps veins of the limb by perforating veins. There are three medial perforators
just above the ankle, one perforator just below the knee and another one in the region
of the adductor canal. The perforating veins are also provided with valves which
permit flow of blood only from the superficial to deep vein.
Tributaries
At the ankle the long saphenous vein drains the sole by medial marginal veins.
In the leg it often connects with the short saphenous vein and with deep veins via
perforating veins. Just distal to the knee it usually receives three large tributaries from
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the front of the leg, from the tibial malleolar region and from the calf. The tributary
draining the tibial malleolar region is formed delicate veins overt the medial malleolus
and then ascends the medial aspect of the calf as the posterior arch vein.
It connects with posterior tibial venae comintantes by a series of perforating
veins. These are usually three equally spaced between the medial malleolus and the
mid calf. More than three such perforators are uncommon and an arch vein perforators
above mid calf is only very rarely found.
Above the posterior crural arch vein, perforating veins join the long saphenous
vein, or one of its main tributaries at the two main sites. The first is at a level in the
upper calf indicated by its name, the tibial tubercle. Perforator; the second is in the
lower / intermediate third of the thigh where it perforates the deep fascial roof of the
subsartorial canal to join the femoral vein.
In the thigh the long saphenous vein receives many tributaries. Some open
independently; whilst others converge to form large named channels that frequently
pass forwards the basal half of the femoral triangle before joining the long saphenous
near its termination. These may be grouped as follows: one or more large postero-
medial tributaries, one or more large antero-medial tributaries, four or more peri-
inguinal veins. The postero-medial vein of the thigh, large and sometimes double,
drains a large superficial region indicated by its name. It has radiological and surgical
significance. One of its lower radicles is often continuous with short saphenous vein.
The postero-medial vein is sometimes named the accessory saphenous vein; through
some restrict the term accessory to a lower, postero-medial tributary when two are
present. Another large vessel, the antero-lateral vein of the thigh usually commences
from an anterior network of veins in the distal thigh and crosses the apex and distal
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half of the femoral triangle to reach the long saphenous vein. As the latter traverses
the saphenous opening, it is joined by the superficial epigastric, superficial circumflex
iliac and superficial external pudendal veins. Their mode of union varies. Superficial
epiagastric and circumflex iliac veins drain the inferior abdominal wall, the latter also
receiving tributaries from the proximo-lateral region of thigh. The long saphenous
vein is often harvested for grafts used both in peripheral and coronary arterial surgery.
Surface Marking of long Saphenous Vein145
It can be marked by joining the following points, although it is easily visible in
living subjects:
(a) First point on the dorsum of foot at the medial end of the dorsal venous arch
(b) Second point on the anterior surface of the medial malleolus
(c) Third point on the medial border of the tibia at the junction of the upper two
thirds and lower one third of the leg
(d) Fourth point at the adductor tubercle
(e) 5th point just below the centre of the saphenous opening.
Its formation on the dorsum of the foot, its course along the entire length of
the lower limb and its termination into femoral vein. It contains about 10-20 valves.
There is one valve that lies just before the vein pierces the cribriform fascia and
another at its termination into the femoral vein.
Short Saphenous Vein146
The short saphenous vein starts on the lateral side of the foot and ascends up
on the back of the leg to end in the popliteal vein. The vein is formed on the dorsum
of the foot by the union of the lateral end of the dorsal venous arch with the lateral
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marginal vein. In lower third of the calf it ascends lateral to the calcaneal tendon,
lying on the deep fascia and covered only by superficial fascia and skin. In the leg it
ascends lateral to the tendocalcaneus, and then along the middle line of the calf, to the
lower part of the popliteal fossa. Here it pierces the deep fascia and opens into the
popliteal vein. It drains the lateral border of the foot, the heel and the back of the leg.
It is connected with the great saphenous and with deep veins.
Tributaries
The short saphenous vein connects with deep veins on the dorsum of the foot,
receives many cutaneous tributaries in the leg, and sends several communicating
branches proximally and medially to join the long saphenous vein. Sometimes a
communicating branch ascends medially to the accessory saphenous vein. This may
be the main continuation of the short saphenous vein. In the leg, the short saphenous
vein lies near the sural nerve, it has 7-13 valves one near its termination. Its mode of
ending is variable, it may join the long saphenous vein in the proximal thigh or it may
bifurcate, one branch joining the long saphenous, the other the popliteal or deep
posterior femoral veins. Sometimes, it ends distal to the knee in the long saphenous or
sural muscular vein.
Surface Marking
It can be marked by joining the following points, although this vein is also
easily visible in its lower part:
(a) A point on the dorsum of the foot at the lateral end of the dorsal venous arch
(b) Second point behind the lateral malleolus.
(c) Third point just lateral to the tendocalcaneus above the lateral malleolus.
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(d) Fourth point at the centre of the popliteal fossa.
Its formation on the dorsum of the foot, course along the back of the leg, and
termination into the popliteal vein.
Just before piercing the popliteal fascia, it may give a communicating branch
to the accessory saphenous vein. Sometimes, the whole of the small saphenous vein
opens into the great saphenous vein through the accessory saphenous vein.
Occasionally, the small saphenous vein ends below the knee either in the great
saphenous vein, or in the deep muscular veins of the leg.
Perforating Veins147
As already mentioned, they connect the superficial with the deep veins. There
are classified as follows:
Indirect Perforating Veins
Indirect perforating veins connect the superficial veins with the deep veins
through the muscular veins.
Direct Perforating Veins
Direct perforating veins connect the superficial veins directly with deep veins.
The great and small saphenous veins are the large direct perforators.
(a) In the thigh: the adductor canal perforator connects the great saphenous vein
with the femoral vein in the lower part of the adductor canal.
(b) Below the knee: one perforator connects the great saphenous vein or the
posterior arch vein with the posterior tibial vein.
(c) In the leg: (i) a lateral perforator is present at the junction of the middle and
lower third of the leg. It connects the small saphenous vein or one of its
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tributaries with peroneal vein. Medially, there are three perforators which
connect the posterior arch vein with the posterior tibial vein.
(d) The upper medial perforator lies at the junction of the middle and lower thirds
of the leg.
(e) The middle medial perforator lies above the medial malleolus.
(f) The lower medial perforator lies posteroinferior to the medial malleolus.
Deep Veins of Lower Limb148
Posterior Tibial Veins
The posterior tibial veins accompany the posterior tibial artery. They receive
tributaries from the calf muscle and connections from the superficial veins and the
peroneal veins. Posterior tibial vein is formed by the union of the medial and lateral
plantar veins posterior to the medial malleolus.
Anterior Tibial Veins
The anterior tibial vein is the superior continuation of the dorsalis pedis vein
in the foot. It extends between the tibia and fibula and unites with the posterior tibial
to form the popliteal vein at the distal border of the popliteus.
Popliteal Vein149
It begins at the lower border of the popliteus by the union of veins
accompanying the anterior and posterior tibial arteries, and posterior tibial arteries. It
is medial to the popliteal artery in the lower part of the fossa; posterior to the artery in
the middle and postero-lateral to it in the upper part of the fossa. The vein continues
as the femoral vein at the opening in the adductors magnus.
The popliteal vein receives -
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(1) The small saphenous vein and
(2) The vein corresponding to the branches of the popliteal artery.
Profunda Femoris Vein
The profunda femoris vein lies anterior to its artery, and has tributaries
corresponding to the branches of the artery. Through these tributaries it connects
distally with the popliteal and proximally with the inferior gluteal veins. It sometimes
drains medial and lateral circumflex femoral veins. It has a valve just before it
terminates.
Femoral Vein150
The femoral vein accompanies its artery beginning at the adductor opening, as
the continuation of the popliteal vein, and ending posterior to the inguinal ligament as
the external iliac vein. In the distal adductor canal, it is postero-lateral to the femoral
artery, more proximally in the canal, and in the distal femoral triangle, it is posterior
to it, proximally, at the base of the triangle, it is medial. The vein occupies the middle
compartment of the femoral sheath, between the femoral artery and canal, fat in the
latter allowing expansion of the vein. It has many muscular tributaries; 4-12 cm distal
the inguinal ligament the profunda femoris vein joins it posteriorly and then the long
saphenous vein, which enters anteriorly. Veins accompanying the superficial
epigastric, superficial circumflex iliac and external pudendal arteries join the long
saphenous vein before it enters the saphenous opening. Lateral and medial circumflex
femoris veins are usually tributaries of the femoral. There are usually four or five
valves in the femoral vein. The two most constant are just the distal to the entry of the
profunda femoris and near the inguinal ligament.
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Deep and Superficial Venous Systems of the Foot151
Plantar digital veins arise from the plexuses in the plantar regions of the toes,
connecting with dorsal digital veins and uniting into four plantar metatarsal veins. The
latter run in the intermetatarsal spaces and connect by perforating veins with dorsal
veins, then continue to form the deep plantar venous arch that accompanies the plantar
arterial arch. From this venous arch, medial and lateral plantar veins run near the
corresponding arteries and after communicating with the great and small saphenous
veins, from the posterior tibial veins behind the medial malleolus.
The principal named superficial veins are the great and small saphenous. Their
numerous tributaries are mostly unnamed.
Dorsal digital veins receive rami from the plantar digital veins in the clefts
between the toes and then join to form dorsal metacarpal veins, which are united
across the proximal parts of the metatarsal bones in a dorsal venous arch. Proximal to
this arch, an irregular dorsal venous network receives tributaries from deep veins and
is continuous, proximally with a venous network in the leg. At each side of the foot,
this network connects with medial and lateral marginal veins, which are both formed
mainly by veins from more superficial parts of the sole. In the sole, superficial veins
form a plantar cutaneous arch across the roots of the toes and also drain into the
medial and lateral marginal veins. Proximal to the plantar arch there is a plantar
cutaneous venous plexus, especially dense in the fat of the heel. It connects with the
plantar cutaneous venous arch and other deep veins, but drains mainly into the
marginal veins. The veins of the sole are an important part of the lower limb ‘venous
pump’ system aiding return of the blood up the limb. Intermittent to enhance this flow
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and so reduce the risk of deep vein thrombosis during periods of increased risk, e.g.
after surgery.
Valves in Superficial veins of the lower extremity
The great saphenous vein has 10 to 12 valves, which are more numerous in the
leg than in the thigh. These valves are usually located just inferior to the perforating
veins. The perforating veins also have valves.
Venous valves are cusps of endothelium with cup like valvular sinuses that fill
from above. When they are full, the valve cusps occlude the lumen of the vein,
thereby preventing reflux of blood distally, making flow unidirectional. The valvular
mechanism also breaks the column of blood in the saphenous vein into shorter
segments reducing back pressure. Both effects make it easier further the
musculovenous pump to overcome the force of gravity to return the blood to the heart.
As it ascends in the leg and thigh, the great saphenous vein receives numerous
tributaries and communicates in several locations with the small saphenous vein.
Tributaries from the medial and posterior aspects of the thigh frequently unite to form
an accessory saphenous vein (Fig. 5.10B). When present, this vein becomes the main
communication between the great and small saphenous veins. Also, fairly large
vessels—the lateral and anterior cutaneous veins--arise from networks of veins in the
inferior part of the thigh and enter the great saphenous vein superiorly, just before it
enters the femoral vein. Near its termination, the great saphenous vein also receives
the superficial circumflex iliac, superficial epigastric, and external pudendal veins.
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The small saphenous vein arises on the lateral side of the foot from the union
of the dorsal vein of the small (little) toe with the dorsal venous arch. The small
saphenous vein:
• Ascends posterior to the lateral malleolus as a continuation of the lateral
marginal vein
• Passes along the lateral border of the calcaneal tendon
• Inclines to the midline of the fibula and penetrates the deep fascia
• Ascends between the heads of the gastrocnemius muscle
• Empties into the popliteal vein in the popliteal fossa.
Although many tributaries are received by the saphenous veins, their diameter
remains remarkably uniform as they ascend the limb. This is possible because the
blood they receive is continuously shunted from these superficial veins in the
subcutaneous tissue to the deep veins by means of the many perforating veins.
The perforating veins penetrate the deep fascia close to their origin from the
superficial veins and contain valves that, when functioning normally, only allow
blood to flow from the superficial veins to the deep veins. The perforating veins pass
through the deep fascia at an oblique angle so that when muscles contract and the
pressure increases inside the deep fascia, the perforating veins are compressed. This
also prevents blood from flowing from the deep to the superficial veins. This pattern
of venous blood flow from superficial to deep is important for proper venous return
from the lower limb because it enables muscular contractions to propel blood toward
the heart against the pull of gravity (musculovenous pump)152.
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Valves in superficial veins of the lower extremity usually are located near to
the termination of major tributaries. Some valves are well developed with marked
sinusoid dilation at their base; others are more delicate in their structure. In the great
saphenous there are about six valves, with more valves located below than above the
knee. A nearly constant valve of great saphenous vein is at 2–3 cm distal to its
confluence with the femoral vein. Valves in the short saphenous vein are closer to
each other than in the great saphenous. Valves in communicating branches between
the short saphenous vein and great saphenous are oriented to direct blood from the
small to the great saphenous vein. Similar to superficial veins, deep veins have more
valves in the calf than in the thigh. Tibial veins are densely packed with valves,
whereas there are only one or two valves in the popliteal vein. In the femoral vein
there are three to five valves, with one of them located just distal to the junction of the
deep femoral vein. There is usually one valve in the common femoral vein. Major
perforating veins have one to three valves, all located below the level of the fascia,
that direct flow toward the deep veins. Small perforating veins are usually valve less.
Perforating veins of the foot are without any valves or with valves that direct flow
towards the superficial veins153.
Applied Anatomy of the veins of Lower limb154
Venous Pump of the Lower Limb
Within the closed fascial compartments of the lower limb, the thin-walled,
valved venae comitantes are subjected to intermittent pressure at rest and during
exercise. The pulsations of the adjacent arteries help move the blood up the limb.
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However, the contractions of the large muscles within the compartments during
exercise compress these deeply placed veins and force the blood up the limb.
The superficial saphenous veins, except near their termination, lie within the
superficial fascia and are not subject to these compression forces. The valves in the
perforating veins prevent the high-pressure venous blood from being forced outward
into the low-pressure superficial veins. Moreover, as the muscles within the closed
fascial compartments relax, venous blood is sucked from the superficial into the deep
veins.
Varicose Veins
A varicosed vein is one that has a larger diameter than normal and is elongated
and tortuous. This condition commonly occurs in the superficial veins of the lower
limb and, although not life-threatening, is responsible for considerable discomfort and
pain.
Varicosed veins have many causes, including hereditary weakness of the vein
walls and incompetent valves; elevated intra-abdominal pressure as a result of
multiple pregnancies or abdominal tumors; and thrombophlebitis of the deep veins,
which results in the superficial veins becoming the main venous pathway for the
lower limb. It is easy to understand how this condition can be produced by
incompetence of a valve in a perforating vein. Every time the patient exercises, high-
pressure venous blood escapes from the deep veins into the superficial veins and
produces a varicosity, which might be localized to begin with but becomes more
extensive later.
The successful operative treatment of varicosed veins depends on the ligation
and division of all the main tributaries of the great or small saphenous veins, to
prevent a collateral venous circulation from developing, and the ligation and division
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of all the perforating veins responsible for the leakage of high-pressure blood from the
deep to the superficial veins. It is now common practice to remove or strip the
superficial veins in addition. Needless to say, it is imperative to ascertain that the deep
veins are patent before operative measures are taken.
Great Saphenous Vein Cut down Exposure of the great saphenous vein through a skin incision is usually performed at
the ankle. This site has the disadvantage that phlebitis (inflammation of the vein wall)
is a potential complication. The great saphenous vein also can be entered at the groin
in the femoral triangle, where phlebitis is relatively rare; the larger diameter of the
vein at this site permits the use of large-diameter catheters and the rapid infusion of
large volumes of fluids.
Anatomy of Ankle Vein Cut down The procedure is as follows:
The sensory nerve supply to the skin immediately in front of the medial
malleolus of the tibia is from branches of the saphenous nerve, a branch of the
femoral nerve. The saphenous nerve branches are blocked with local
anesthetic.
A transverse incision is made through the skin and subcutaneous tissue across
the long axis of the vein just anterior and superior to the medial malleolus.
Although the vein may not be visible through the skin, it is constantly found at
this site.
The vein is easily identified, and the saphenous nerve should be recognized;
the nerve usually lies just anterior to the vein.
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Anatomy of Groin Vein Cut down
The area of thigh skin below and lateral to the scrotum or labia majorum is
supplied by branches of the ilioinguinal nerve and the intermediate cutaneous
nerve of the thigh. The branches of these nerves are blocked with local
anaesthetic.
A transverse incision is made through the skin and subcutaneous tissue
centered on a point about 1.5 in. (4 cm) below and lateral to the pubic tubercle.
If the femoral pulse can be felt (may be absent in patients with severe shock),
the incision is carried medially just medial to the pulse.
The great saphenous vein lies in the subcutaneous fat and passes posteriorly
through the saphenous opening in the deep fascia to join the femoral vein
about 1.5 in. (4 cm), or two fingerbreadths below and lateral to the pubic
tubercle. It is important to understand that the great saphenous vein passes
through the saphenous opening to gain entrance to the femoral vein. However,
the size and shape of the opening are subject to variation.
The Great Saphenous Vein in Coronary Bypass Surgery
In patients with occlusive coronary disease caused by atherosclerosis, the
diseased arterial segment can be bypassed by inserting a graft consisting of a portion
of the great saphenous vein. The venous segment is reversed so that its valves do not
obstruct the arterial flow. Following removal of the great saphenous vein at the donor
site, the superficial venous blood ascends the lower limb by passing through
perforating veins and entering the deep veins.
The great saphenous vein can also be used to bypass obstructions of the
brachial or femoral arteries.
Methodology
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METHODOLOGY
Source and Method of Collection of Data
The subject of thesis is both conceptual and observational study by cadaver
dissection.
Material and methods
Source of data
Literary and conceptual study was on the data completions from the
Brihatrayees, Laghutrayees, and other classical books including journals, presented
papers, previous work done and co-related, analyzed with the knowledge of
contemporary science on the subject.
Dissection of the lower limb in five cadavers was carried out in the
Department of Rachana Shareera, Alva’s Ayurveda Medical College. Observations
were analyzed and co-related in the view of sites of Siravyadha and its anatomical and
Marma relevance in the lower extremity.
Method of collection of the data
Books, thesis, journals including published on the concept related to subject
will be reviewed and related information will be collected and analyzed scientifically.
Cadaver and specimen study will be conducted in Rachana Sareera Dept. of
Alva’s Ayurveda Medical College, Moodbidri.
Assessment Criteria
Observation and identification of the regional anatomy of Lower limb on the
cadaver dissection and was correlated with Anatomical and Marma relevance
explained in Ayurveda classics, and the superficial veins of the lower limb were
observed.
Observation
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OBSERVATION
The dissection of five cadavers in which ten lower limb specimen has been
carried out as per the Cunningham’s Manual of practical anatomy. Dissection
procedures were carried out layer by layer, observed and different structures and their
relations with each other were studied thoroughly. The structures which are related to
the Marmasthānas of the lower limb were observed in detail.
THIGH
Front of the Thigh
Skin: The skin consists of hair follicles.
Superficial Fascia: Following Structures were observed in superficial fascia –
Superficial fatty layer
Deep membranous layer
Cutaneous nerves
Great saphenous vein and its tributaries
Superficial inguinal lymph nodes
Deep Fascia/ Fascia Lata: Following Structures were observed in Deep fascia –
Femoral sheath, vein, artery
Ilio tibial tract
Tensor fascia Lata
Sartorius
Quadriceps femoris
Iliacus
Observation
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Psoas majors
Medial Side of Thigh
Following Structures were observed –
Adductor longus
Adductor brevis
Adductor magnus
Gracilis
Pectineus
Obturator nerve
Obturator artery
Medial circumflex femoral artery
Back of Thigh
Semitendinosus
Semimembranosus
Biceps femoris
Sciatic nerve
Branches of Profunda femoris artery.
THE LEG
The following structures were observed in Front of Leg and Dorsum of Foot -
Superficial Fascia of the Leg
Superficial veins
Cutaneous nerves
Observation
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Lymphatics
Small Unnamed arteries
The Dorsal Venous Arch
Great / Long Saphenous Vein
Small / Short Saphenous Vein
The Saphenous Nerve & its Infra Patellar branch
The Lateral Cutaneous nerve of the Calf
The Superficial Peroneal Nerve
The Sural Nerve
The Deep Peroneal Nerve
The Digital branches of Medial and Lateral Plantar Nerves
Deep Fascia of the Leg
Superior Extensor Retinaculum
Inferior Extensor Retinaculum
Muscles
Tibialis anterior
Extensor Hallucis Longus
Extensor Digitorum Longus
Peroneus Tertius
Extensor Digitorum brevis
Anterior Tibial artery
Dorsalis pedis artery and its branches
Deep Peroneal nerve
Observation
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Lateral Side of the Leg
Peroneus longus
Peroneus brevis
Superficial Peroneal nerve
Superior personal Retinaculum
Medial Side of the Leg
Great Saphenous vein
The Saphenous nerve
Tibial collateral ligament
Anserine Bursae
Back of the Leg
Superficial fascia
Small and Great Saphenous veins, tributaries.
Cutaneous nerves.
Medial and Lateral Calcaneal arteries.
Deep fascia
Superficial transverse fascial septum
Deep transverse fascial septum
Flexor Retinaculum
Muscles
Gastrocnemius
Soleus
Observation
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Plantaris
Popliteus
Flexor Digitorum longus
Flexor Hallucis longus
Tibialis posterior
Posterior tibial artery
Peroneal artery
Tibial nerve.
Sole of Foot
Superficial Fascia
Cutaneous nerves and vessels
Superficial transverse Metatarsal ligaments
Deep Fascia
Plantar Aponeurosis
Deep transverse metatarsal ligaments
Fibrous flexor sheaths in the toes
Muscles
Flexor Digitorum Brevis
Abductor Hallucis
Abductor Digiti Minimi
Flexor Digitorum Longus
Flexor Digitorum Accessorius
Lumbricals
Flexor Hallucis Longus
Observation
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Flexor Hallucis Brevis
Adductor Hallucis
Flexor Digiti Minimi Brevis
Extensor Digitorum Brevis
Extensor Hallucis Brevis
Discussion
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DISCUSSION
Ayurveda is a holistic science which provides medical as well as surgical
treatment for various diseases based on their etiopathogenesis. Principle of
management is selected logically which is appropriate to a particular patient.
The term „Sirās’ and ‘Dhamanis’ are as old as Vedas. They have been
generally used in the same sense. But these are not synonymous. In general, Sirās
mean blood vessels. According to Charaka, definition of Sirā, Dhamani and Srotas is
said as “Dhmānāt dhamanyah, Sravanāt Srotāmsi, Saranat sirāh”. But on the basis of
interpretation of commentators „Dhamani‟ is a channel connected to the heart which
is thick whereas „Sirā‟ is a thin blood vessel.
Sirās are 700 in number. By these Sirās, the entire body is constantly
nourished, kept lubricated / moistened to perform actions such as flexion, extension,
contraction, dilation etc.
Among these Sirās, Ācharyas clearly differentiated between the Vedhya and
Avedhya Sirās. Vedhya Sirās are those which can be interfered with surgical
procedures and the Avedhya Sirās are those on which injury must be avoided during
surgery.
Though all the Brihatrayees made considerable remarks on Vedhya and
Avedhya Sirās, Suśruta has clearly mentioned the Vedhya Sirās specifically in
connection with the diseases which are cured by Sirāvyadha. However, the Avedhya
Sirās are the vessels which are prohibited for Sirāvyadha.
Suśruta has mentioned 98 Avedhya Sirās which should be taken care of by the
physician or a surgeon at the time of Sirāvyadha or during any other surgical
procedure. Any trauma to these structures may lead to morbidity or death.
Discussion
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Sirāvyadha is a significant therapeutic tool, when judiciously administered.
Suśruta has explained that Sirāvyadha is accepted as half of the therapeutic measure
in Śalyatantra like Vasti in Kāyachikitsa. Half of the health hazards can be managed
by Sirāvyadha as Rakta being the chief causative factor in the manifestation of
diseases. So Raktamokshana by different modalities is much more effective in
resolving pathogenesis.
In general, various mechanisms in body, such as local blood supply, local
metabolism, local drainage system etc, are improved and fresh active RBCs are
produced by proper bloodletting. Hepato-cellular function is improved by enzymatic
activity due to release of hormones. Sympathetic function is improved and as it
directly stimulates bone marrow, immune related T-lymphocytes are produced.
Because of the above mentioned facts, Sirāvyadha Vidhi has got its own importance
on the basis of scientific background.
Raktamokshana is one of the important Para-surgical procedures denoting the
letting of impure blood outside the body. Different modalities of Raktamokshana can
be adopted, but Sirāvyadha is one among the Śaśtrāvacharanas. Of course, it appears
to be surprising that different sites have been advocated in different diseases. Why
can‟t a common site be selected in all diseases, is the point being raised here. To
analyze this context, different hypothesis and patho-physiological mechanisms can be
employed, as the basic unit of the body is cell. Each cell adopts a different mechanism
to perform various functions. So the term „homeostasis‟ is used, to denote
maintenance of an equilibrium condition in the internal environment. The function of
circulation is to serve the needs of the tissues such as nutrients, oxygen, hormones and
also to transport the waste products away from the body. When tissues are active they
need more blood flow. Heart normally cannot increase its cardiac output more than
Discussion
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four to seven times. Therefore, it is not possible to increase the blood flow
everywhere in the body. When a particular body part demands increased flow, micro-
vessels of each tissue are monitoring the tissue needs, such as availability of oxygen
and nutrients and the accumulation of waste products, these in turn control local blood
flow to the level of tissue need. The microcirculation of each type of tissue in the
body is specially organized to serve special needs. Every cell has got their own
microcirculation to maintain its equilibrium internal environment.
On the basis of this general information, the dictum of Suśruta is found to be
more suitable. Ācharya Suśruta has mentioned seven sites of Sirāvyadha and five
sites of Sirāvyadha have been mentioned by Vāgbhata. The sites have been explained
in relation to marma, so the knowledge of marma and anatomical structures related to
it are very much significant in clinical application.
The sites of Sirāvyadha in the lower limb are mentioned in relation to various
diseases. For example, in diseases such as Pādadāha, Pādaharsha, Apabāhu, Chippa,
Visarpa, Vātaśonita, Vātakantaka, Vicharchika, Pādadāri, the site of Sirāvyadha is 2
Angula above Kshipra Marma. The anatomical structures in the Kshipra marma are