Hypertension kc006 gdg


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Evaluation of the effect of Vachamamsyadi yoga in Raktapeedanadhikyata (Hypertension),
Shivakumarayya .S. Hiremath, Post Graduate Studies & Research Center, D.G. MELMALAGI AYURVEDIC MEDICAL COLLEGE, GADAG

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Hypertension kc006 gdg

  1. 1. “Evaluation of the effect of Vachamamsyadi yoga in Raktapeedanadhikyata (Hypertension)” Thesis submitted to the Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore. In partial fulfillment of regulations for the Award of the degree of DOCTOR OF MEDICINE (AYURVEDA VACHASPATHI) By Shivakumarayya .S. Hiremath Guide Dr. Ch. Ranga Rao. M.D. (Ayu) Professor and Head of the Department Post Graduate and Research Center D. G. M. Ayurvedic Medical College, Gadag. Co-Guide Dr. Siva Rama Prasad Ketamakka. M.D. (Ayu) Reader in Kayachikitsa Post Graduate and Research Center D.G.M. Ayurvedic Medical College, Gadag. POST GRADUATE AND RESEARCH CENTRE (KAYACHIKITSA) D.G.M.AYURVEDIC MEDICAL COLLEGE, GADAG. 1997-2001
  2. 2. This is to certify that Shivakumarayya .S. Hiremath (M.D. (Ayurveda) Kayachikitsa), has worked for his thesis on the topic entitled“Evaluation of the effect of Vachamamsyadi yoga in Raktapeedanadhikyata(Hypertension)”. Clinical trials are done under my supervision and guidance.This thesis makes a distinct advance on scientific lines in the abovesubject and the findings are highly significant at the statisticalevaluation and have considerably contributed to the presentknowledge of the subject. I am fully satisfied with his original work and hereby forward thethesis for the evaluation of adjudicators. Co-Guide Dr. Siva Rama Prasad Kethamakka M.D. (Ayu) (Osm) Reader in Kayachikitsa Head of the Department Postgraduate and Research Center (Kayachikitsa) D.G.M. Ayurvedic Medical College, Gadag.
  3. 3. This is to certify that the contents of this thesis entitled “Evaluation ofthe effect of Vachamamsyadi yoga in Raktapeedanadhikyata(Hypertension)” has been worked out by Shivakumarayya .S. Hiremath,under my supervision and close guidance and co guidance of Dr. Siva RamaPrasad Kethamakka, M.D. (Ayu) (Osm). Even though this disease, Hypertension has not been mentioned inAyurvedic texts, the etiology, pathogenesis etc., as developed and explained byShivakumarayya .S. Hiremath is unique and scientific and will definitely help inexplaining the disease in Ayurvedic parlance and further planning themanagement. This work is applied, scientific and an original contribution in the field ofresearch in Ayurveda. I am fully satisfied with the work and recommend the thesis to be putbefore the adjudication. Guide Dr.Ch.Ranga Rao M.D. (Ayu) (Osm) Professor and head of the department Post graduation and research center Kayachikitsa D.G.M. Ayurvedic Medical College, Gadag.
  4. 4. Acknowledgement I am highly indebted to my guide Dr. Ch. Ranga Rao H.O.D. post graduate andresearch center in Kayachikitsa, shri D.G.M Ayurvedic Medical College, Gadag for hisvaluable suggestions and guidance in completing this work successfully. I have my hearty acknowledgement to my co guide Dr. K.Siva Rama Prasad, forhis guidance, supervision and suggestions for the early completion of this research work. I am thankful to Dr. G.B. Patil principal shri D.G.M Ayurvedic College Gadag forhis help during my study. I am also indebted to Dr. Ashok kumar panda and Dr. M.C patil, lecturers P.GDepartment of Kayachikitsa for their suggestions and comments in this study. I wish to convey thanks to my teachers Dr. G.S Juktihiremath, Dr. C.MSarangamath, Dr. S.A patil, Dr. G.S Hiremath, Dr. C.S Hiremath, Dr. U.V Purad, Dr. V.MMalagoudar, Dr. R.K Gacchinamath, Dr.B.G Swamy, Dr. S.S Avvani and all other U.Glecturers for their help and suggestions during my post graduation studies. I wish to thank Dr. V.S Hosamath, physician in Gadag for his help during mystudy. I sincerely thank my beloved classmates Dr. V.B Kotturshetter, Dr. A.S Patil,Dr.(Smt) Yashoda Mudigoudar, Dr. S.T Hombal, for their deep co operation andinvolvement in the P.G study. I am also thankful to all my post graduate colleagues Dr. B.M Mulkipatil, Dr.R.Y.Shettar, Dr. J.I Hiremath, Dr. Suresh R.D, Dr. S.K Tiwari, Dr. C.V. Rajashekar,Dr.Shyal kumar, Dr. Jayaprakash, Dr. Anil Kumar Bacha, Dr. V.N. Kulkarni and Dr. D.Sitarama prasad, for their constant cooperation and help.
  5. 5. I am highly indebted to my beloved parents Mr. and Mrs. Shankarayya, T.Hiremath and to my Uncle Dr. S.T Hiremath, my brother Totayya, Chandru and sistersDr. Vijjaya lakshmi, Mangala, Geeta and Shaila, for their love and affection renderedthroughout my career. I wish to convey my thanks to beloved shri V.M Mundinamani and Mr.S.B.Sureban for supplying me essential references in the study. I wish to thank the physicians nursing of the hospital and their co-operation. I thanks to Mr. P.M. Nanda kumar for his help in the statistical evaluate. I wish to convey my thanks to beloved Dr. S.H. Doddamani, K.B.Stavaramath,J.V. Aravanashi, Veeresh Kumbar and K.H.Surakoda for their encouragement and help. I thanks to my beloved patients who are involved constantly in this clinical studyand obliged my advise by which this study able to get finished in stipulated time. Iexpress my thanks to the persons who directly or indirectly helped me in the study. Lastly I pay my deep homage and tribute to my former teacher late Prof. Dr.V.V.S. Sastri for his selection of this valuable project. Shivakumarayya .S. Hiremath
  6. 6. “Evaluation of the effect of Vachamamsyadi yoga in Raktapeedanadhikyata (Hypertension)” By Shivakumarayya .S. Hiremath Under the guidance of Dr.Ch.Ranga Rao And Co-Guidance of Dr.K.Siva Rama PrasadSection - I IntroductionDefinition Pages: 1 to 10Physiological out look of “Blood pressure” Ama in hypertensionHypertension in Ayurveda Srotas in hypertensionProposal Focus on the titleHistorical review Contents of the thesisInfluence of neurosis (Vata) in hypertension Pages: 11 to 31 Circulation of the bloodSection - II Literary review Internal transport system ofShareera the body PranavataIntroduction Location of pranavataDosha and Dooshya Functions of pranavata Concept of dosha in relation to Sirasthita pranavata Hypertension Urahsthita pranavata Dushya and srotas Vyanavata Agnimandya Location of vyanavata Dietetic causes Functions of the Vyanavata Behavioral causes Functions of the heart Other causes RasavahasrotasHridaya (heart) Rakta peedana Nirukti of hridaya Srotavaigunya Embryological development Surface anatomy Inner view of the heart Spandana of HridayaInterference of Pleeha with hridaya Contents
  7. 7. Nidana Pages: 33 to 62Definition of Hypertension Epidemiology of hypertension PrevalenceRaktagavata Level of pressureRaktavrita vata Genetic InfluencesSiragata vata Environmental InfluencesBhrama Geographical aspectsRoudhira Mada Age and Sex in HypertensionRaktapradoshaja vikaras Hypertension and body weightAvruta Vata pittavrutha prana vayu Pathophysiology Pittavruta udana vataMurcha Primary hypertensionsanyasa ( coma) Primary (essential) hypertensionDhamani pratichaya Genetic factorsClassification of hypertension Dietary influences Sodium chloride intakeSymptomatic classification of hypertension Protein intake Labile hypertension Alcohol Stable hypertension Soft waterClassification by blood pressure (level) Psychological factorsreadings Haemo dynamic changes Mild hypertension Neural changes Moderate hypertension Secondary hypertension Severe hypertension (Hypertension with identifiable cause)Classification by severity of vascular lesions Hormonal contraceptives Stage I Hypertension due to organic Stage II disease Stage III Clinical features of hypertensionClassification by etiology Differential diagnosis of hypertension Essential hypertension Renal hypertension Secondary hypertension Primary aldosteronismClassification by age groups conn’s disease Juvenile hypertension Cushing’s syndrome Hypertension in the elderly Contents
  8. 8. Chikitsa Pages: 63 to 82Management of hypertension ReserpineGeneral stagetegy Alpha methyldope Weight reduction Guanethidine Salt restriction Clonidine Smoking Labetolol Relaxation techniques Choice of anti hypertensive drugs Chikitsa in Ayurveda (in special situations) Management with drugs HypertensionSteps care treatment of hypertension in childrenMild hypertension in the elderly Vasodilators in pregnancy Diuretics in ischaemic heart disease Beta-blockers in cardiac failure Calcium antagonists in renal insufficiency Angiotensin convertor enzyme Pathya and Apathya Inhibitors Antiadrenergic drugsSection - III Material and methods Pages: 83 to 114 Drug review Composition of vachamamsyadi yoga Punarnava (Boerhavia diffuse Linn.) Gokshura(Tribulas terrestris Linn.) Jatamamsi (Nordostachys jatamansi DC.) Vacha (Acorus calamus Linn.) Drug preparation Storage of vachamamsyadi yoga Posology Review of methodology ObservationsSection - IV Discussion and conclusion Pages: 115 to 134 SummarySection - V Present trends and Bibliography Contents
  9. 9. List of ChartsChart number – 1 Demographic data for “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Chart number – 2 Complaints for “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Chart number – 3 Diet and drug history in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Chart number – 4 Emotional status and Family history in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Chart number – 5 Assessment in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)” Systolic hypertensionChart number – 6 Assessment in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)” Diastolic hypertensionChart number – 7 Statistical Assessment in “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Chart number – 8 Significance table of “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)” Contents
  10. 10. List of FiguresFigure no 1: Graphical demonstration of Decreased systolic Hypertension in regular intervals In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure no 2: Graphical demonstration of Decreased diastolic Hypertension in regular intervals In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure no 3: Showing sex ratio In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure no 4: Religion distribution In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure number 5: Occupation distribution In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure number 6: Economical status distribution In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure number 7: Diet distribution In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure number 8: Group study In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)” Contents
  11. 11. Figure number 9: Chief complaints In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure number 10: Associated features In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure number 11: Diet and drug history In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure number 12: Emotional status In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure number 13: Family history In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)”Figure number 14: Result In the “Evaluation of the effect of Vachamamsyadi yoga in Rakta peedanadhikyata (Hypertension)” List of PhotographsPhotograph-1 Punarnava (Boerhavia diffuse Linn.)Photograph-2 Gokshura (Tribulas terrestris Linn.)Photograph-3 Jatamamsi (Nordostachys jatamansi DC.)Photograph-4 Vacha (Acorus calamus Linn.) Contents
  12. 12. Hypertension most commonly heard clinical state in the older age groups ofpatients. They suffer with the risen arterial blood pressure giving rise the signs andsymptoms such as giddiness or dizziness (Bhrama), headache (Sirahsoola), fatigue(Angasada), insomnia (Nidranasha) and palpitation (Hritdrava). An Ayurvedicpractitioner get confused as the nomenclature of Hypertension was not included inclassical texts and neither of Acharyas has affirmed such a condition elaborately. The Hypertension, called as “Salient Killer”, drawn the attention of W.H.O. in1978 and declared that year as “Hypertension year”. This disorder definitely has itsaction over decreasing the life span by 10 to 20 years causing cardiac and renaltroubles. Further it can be said it is an important factor in increasing the morbidity andmortality due to the cardiovascular pathology.DEFINITION: The definition of Hypertension is as follows. “Abnormally high tension,especially a state of abnormally increased blood pressure with Electro cardiographevidence of cardio arterial derangement (left ventricular preponderance)”1 andvernacularly “abnormally high blood pressure” and “great emotional tension”2. Otherwise it is as abnormally increased blood pressure exerting on the arterial andarterioles more then 120mm Hg systolic and 80-mm Hg diastolic pressures. TheWHO has recommended that blood pressure of 160/95 mm Hg or above in adultsshould be considered as Hypertension. 1 Introduction
  13. 13. As there is no definitive definition universally accepted, the joint Nationalcommittee (JNC-4) of United states on detection, evaluation and treatment of highblood pressure defines Hypertension as systolic blood pressure (SBP) of 140 mm Hgor more and diastolic blood pressure (DBP) of 90 mm Hg or more. Table 1 Classification of BP in Adults aged 18 years or older 3Diastolic Blood pressureBP range Category #< 85 Normal Blood pressure85 to 89 High normal Blood Pressure90 to 104 Mild Hypertension105 to 114 Moderate Hypertension> 115 Severe HypertensionSystolic Blood pressure when DBP< 90BP range Category< 140 Normal Blood pressure140 to 159 Borderline systolic Hypertension> 160 Isolated Systolic Hypertension# A Classification of borderline is isolated systolic hypertension (SBP 140-159 mmHg) or Isolated hypertension (SBP>160 mm Hg ) takes precedence over high normalBP (DBP 85-89 mm Hg ) when both occur in the same patient. High normal BP (DBP85-89 mm Hg) takes precedence over a classification of normal BP (SBP 140 mmHg) when both occur in the same patient. 2 Introduction
  14. 14. Blood pressure is a continuous physical variable and is complex, beinginfluential by many factors. An individual can show variations through out the daydepending on physical activity, body posture, mental activity, emotional status, theenvironment and consumption of drugs, alcohol and tobacco. Dynamic or isometricexercise can also risk blood pressure in normal subjects.4Physiological out look of Definition “Blood pressure”: Blood pressure is generated by cardiac out put which is determined by therate and force of heartbeat and the resistance to the flow of blood through vessels5 inthe arterial system and the viscosity of blood6. Apart from it is the resultant of anumber of forces, among the chief of which are the contractions of the heart and theperipheral resistance provided by the arterioles, although the elastic recoil of thelarge arteries and the state of capillary bed are also of importance7.Hypertension in Ayurveda: Ayurveda is based on the humoral theory and establishes that the Tridoshashave its effect over the body. These humors move all over the body. The Vata, Pittaand Kapha rule the ages of child, youth and old age8. It also has its effect on thedivisions of the day and night, and also to the food; where dosha vitiation is seennaturally contributed by the external factors. While describing the diseases developed by the doshas exclusively inCharaka samhita Sutra stana under the heading of Nanatmaja vyadhi, explained 3 Introduction
  15. 15. eighty varieties of vataja, forty varieties of Pittaja and twenty varieties of Kaphajavyadhis9. As there is no specific nomenclature available in relation to Hypertension fromclassical textbooks, we have to see the corresponding Disease State from variousAyurvedic textbooks. Charaka has very clearly expressed all the disease anddisorders or states of illness, may not be known with specific nomenclature, butgrouped under particular modalities of classification. There by no definitive andpermanent name can be attributed to a particular condition as it is expected tochange with time to time according to its presentation. Thus by understanding thedosha state, site of appearance and its signs and symptoms, we have to come forconclusion and treat the state of disease or illness on the basis of vikalpa i.e.combinations and permutations of doshas10. Different names are recommended for the Hypertension or the HypertensiveStates are as follows – 1. Bhrama 2. Dhamani pratichaya 3. Mada 4. Moorcha 5. Pittavrita udanavata 6. Rakta gata vata 7. Raktachapadhikyata 8. Raktapradoshaja vikara 9. Raktavriddha pittavrita vata 10. Roudhiryamada 4 Introduction
  16. 16. 11. Sanyasa 12. Siragata vata 13. Ucha rakta bhara 14. Ucha rakta chapaProposal: But when the lakshanas of Hypertension are observed with itspathophysiology, the present proposed name “Raktapeedanadhikyata” will berelatively clear to explain state of Hypertension. As Charaka explained, there may be only one cause for one disease or samecause may give rise many diseases. Some times we may find so many causes givesrise or develops one disease or many causes develops many diseases11. Thus, thepresent selected disease has many synonyms, according to the state of developmentof the disease or with respect to that of the disease development. The Vata nanatmaja vyadhi consists of three conditions that appear in theprocess of Hypertension pathogenesis. They are Hritdrava (palpitation), Bhrama(Dizziness) and Aswapna (sleeplessness)12. The appearance of the above said inVata age and rutukala is of physiological and if it appears with Pitta and Kaphaassociation or age and rutukala, it becomes pathological. If Dhamani pratichaya(atherosclerosis)13, one out of twenty Kaphaja diseases appears or associates withthe aging factor have more responsibility to give rise Hypertension orRaktabharadhikyata. 5 Introduction
  17. 17. Historical review: In ancient days the Hypertension was not described as an individual disorder.It may be because of less prevalence as they followed strict daily and seasonalregimens and also not much psychological interference in daily routine. But theywere not ignorant of the conditions developed by the psychological pressuredisturbances. There by they placed them under the nanatmaja vyadhis, related totheir cause and mode of development. Much more such symptoms are explained andtagged with Vata, which can be said as that to be under neural control impairmentand very few conditions are with Pitta and Kapha. Until 1920’s, Hypertension was considered that as beneficial, even through in1733 Stephen Hales measured first time Atrial blood pressure. He demonstrated in adramatic fashion, that the blood in arteries is under a great deal of pressure. His workwas published by Royal society in 1733 as two volumes. The instrument developed by Stephen Hales14 was improved by Karl Ludwig(1816-1895) improved the Instrument developed by Stephen Hales by adding a floatin the measuring cylinder. Karl Vierodt (1818-1884) constructed a sphegmographtracking the human pulse, which estimates the blood pressure by puncturing thevessel. It was difficult and also painful for the patient. This method was greeted byBritish medical journal and followed by Samual Von Bach (1880) and later developedby Scipione Riya Rocci in 1896. 6 Introduction
  18. 18. In 1905, Karokoff a Russian, introduced the auscaltatory method of estimatingblood pressure. With in few years Sphegmamanometer took place with thestethoscope. The mercury column and spring dial sphegmamanometers wereintroduced in 20th century. Late 20th century with advancements in electronics haspresented digital sphegmamanometer to the medical community apart from ECG andDoplar studies, which will provide scope to measure, blood pressure15.Influence of Neurosis (Vata) in Hypertension: In 1965, Myas Nikov contended that the under lying factor of Hypertensivedisease is neurosis, as the term is interpreted by Pavlov. According to thishypothesis, the principle etiological factor of hypertensive disease is psychologicalover strain leading to impaired regulation of the vascular tone. This hypothesis is atthe support of Ayurvedic dosha, Vata interference in producingRaktapeedanadhikyata. But at present it lost its popularity as contemporary cliniciansregard essential hypertension as a disease of uncertain origin16.Ama in Hypertension: Ayurveda speaks about dhamanipratichaya (arteriosclerosis) as anassociated condition with hypertension responsible for 30% of population sufferingfrom hypertension. The rest of 70% are solemnly under the neurotic control or maybe associated with Pitta other wises the Agni17, which is the most common cause ofinitiating a pathological state by diminishing. Diminished Agni causes Ama18, and thatAma, an endotoxin equaling to that of poison causes the pathology either localized orgeneralized. 7 Introduction
  19. 19. Srotas in Hypertension: Out of the samprapti ghatakas, the srotas is very important. Here inhypertension the Raktapeedanidhikyata, the hridaya as organ and correspondingrasvahasrotas as the srotas involved has been expressed the hridaya corresponds tothoracic heart along with arteries attached with hridayam and dasha dhamani). Withthe above Myasnilkov’s statement even sirohridaya i.e. brain (neural control) withcranial nerves and its involvement can be thoroughly discussed. But as hridaya(thoracic), especially the left ventricle of the heart counters the increased resistancein areterial blood pressure and also leads to its hypertrophy which is manifested atfirst by intensified apex beat, rounded left ventricular apex and characteristic ECGchanges19. We can more precisely think of the Urohridaya instead of sirohridaya, asthe Urohridaya is under the control of sirohridaya, that the consideration ofsirohridaya is stand still. Along with the rasavaha srotas, the annavaha srotas is also to be consideredas a srotas, which permits the intake of aetiological factors in the form of vijateeyadravyas converted in to sajateeya dravyas by the presence of Agni. At last themootravaha srotas which regulates the pressure of liquid part circulated in the bodyi.e. rasa – rakta complex is also to be drawn attention.Focus on the title: Present study as a part and parcel of fulfillment of “Ayurveda Vachaspathi”(Doctor of medicine), M.D. Ayurveda under Rajeev Gandhi University of heathsciences, Bangalore was titled as “Evaluation of the effect ofVachamamsyadi yoga in Raktapeedanidhikyata (Hypertension)”. 8 Introduction
  20. 20. There are few established anti hypertensive drugs with the combination ofsarpagandha (Rauwalfia serpentina) used in India because of its sedative and antihypertensive property. Reserpine, the main alkaloid of Sarpagandha was isolatedand practiced as anti hypertensive medicine. Present study under the Ayurvedic principles suggests only regulating andeliminating the waste byproducts from the body, which are over loaded in the body.These toxins can be eliminated through either gastrointestinal tract or through urinarytract. As it is found that the thickened vessels of renal interrupt formation of urination,two herbs which support urination has been selected in the composition. They arePunarnava (Boerhavia diffuse Linn.) and Gokshura (Tribulas terrestris Linn.). Anotherperennial herb Jatamamsi (Nordostachys jatamansi DC.) also called Spiknardpossesses an important action on central nervous system. This herb also has diureticeffect along with nerve sedative action. The fourth herb included in the study isVacha (Acorus calamus Linn.) is nervine and rejuvenator along with its action overcirculatory system. It has been successfully used by Dr.B.R.K.R.Ayurvedic collegepostgraduate and research center and found having efficacy over hypertension alongwith tranquilizer effect. With preset inclusive and exclusive criteria the selection of patient is selectedfrom Postgraduate and research center, D.G.M.Ayurvedic medical college, Gadag,and medicine was administrated under the supervision. The literary and part,observations and results are expressed in stipulated chapters as under – 9 Introduction
  21. 21. “Evaluation of the effect of Vachamamsyadi yoga in Raktapeedanadhikyata (Hypertension)” by Shivakumarayya .S. Hiremath 1. Introduction Historical review Focus on title 2. Literary review Shareera (Physiology and Anatomy) Nidana (etiology) Samprapti (Pathophysiology) Chikitsa (Classical treatment) 3. Material and methods Drug review Punarnava (Boerhavia diffuse Linn.) Gokshura (Tribulas terrestris Linn.) Jatamamsi (Nordostachys jatamansi DC.) Vacha (Acorus calamus Linn.) Drug preparation Review of methodology Observations 4. Discussion and conclusion Summary Present trends Bibliography Special case sheet of Raktapeedanadhikyata 10 Introduction
  22. 22. References:1 Dorland’s Pocket medical dictionary ,pp3102 The pocket Oxford dictionary of current English, pp4323 ****, based on the average of two or more readings on two or more occasions, pp4804 Ibid, pp4805 Shareera kriya vijnan, pp4256 Text book of medicine, R.J.Vakil, pp7727 Text book of pathology, W.Boyd, pp5868 A.H.Sareera,1/89 Charaka Sutra 20/1010 Charaka Sutra 18/4611 Charaka Nidana, 8/2812 Charaka sutra 20/1213 Ibid 20/1514 A literary search on Raktachapadhikyata, S.H.Doddamani, pp1-215 Ibid, pp516 Differential diagnosis of internal disease, A.V.Vinogradov, pp8817 Susruta Sutra, 21/918 A.Hridaya Sutra, 13/25 & Arunadutta on it Bhavaprakasha Madhyama Khanda 1/59 Vijaya Rakshita on Madhava Nidana 25/219 Differential diagnosis of internal disease ,pp89 11 Introduction
  23. 23. INTRODUCTION For any research the collection of available source of hypothesis’s and itsemphasis is necessary. At present study “ Evaluation of the effect of vachamamsyadiyoga in Raktapeedanadhikyata “ (Hypertension), it has clear interventions with that ofVata and avritavata. In Charaka Samhita, while describing the complication of avritaVata in vatavyadhi Chikitsa Charaka affirms due to neglect of Avaritavatas, cardiacdisorder, abscess, spleen enlargement, Gulma and diarrhea appear ascomplications1. At the above reference we can draw a conclusion that in case ofHypertension as Raktapeedanadhikyata. The involvement of Vata with itscharacteristic feature “ Gati 2“ is known to ancient Acharyas; the influence of Gati withits momentum and pressure exertion over Srotases especially to Dhamanis wherethe Rasa Rakta complex flow is witnessed. This Rasa Rakta complex is propelled orejected into conduits of its attachment3. Thus a detailed study of Hridaya – Thoracicheart with its attachments are necessary to be studied in detail or part from theSrotases involved viz. Rakta and Mootravaha Srotases in the study. As the clear description is available about the involvement of hridaya (thoracicheart) along with Pleeha, a moola stana of Rakta vaha srotas; even though notdirectly concern with Raktapeedana in Dhamanis and Siras, its involvement can notbe ruled out. At this juncture a detailed anatomical and physiological study is necessaryapart from pathophysiology of Raktapeedanadhikyata i.e., Hypertension. 11 Literary review - Shareera
  24. 24. Dosha and Dooshya Present day scholars of Ayurveda Dr. P.D. Joshi, Dr Gurudeep singh and DrShukla done the research on dosha pattern in essential hypertension and decided itas Vata pradhana Vyadhi with Pitta and Kapha association. At the observation of the disease, hypertension we found that the involvementof Dhamani pratichaya, a Kapha nanatmaja vikara is associated with hypertension.Not only Dhamani pratichaya even nidranasha a condition with Pitta vitiation is alsofound. We can not be certain that the nidranasha as exclusively of Pitta vikara and itmay appear with Vata vitiation also. But the observations are more suggestive withabove referred scholars in Ayurveda in comparison to Acharya shri vishwanathdwivedi who has correlated hypertension to roudhir mada and raktaja vikara. Here inthis concern Rakta can be one out of these Dooshya as it is flowing in the vessels ofblood along with Rasa and ejected out through hridaya for its “Jeevana “ function. Dosha Vata Anubandha dosha Pitta – nidranasha Kapha – Angasada Dooshaya Rasa Rakta Adhistana Hridaya; thoracic heart with its connections Brain with cranial nerves especially Vegas Dhamani Sira 12 Literary review - Shareera
  25. 25. Concept of dosha in relation to Hypertension The vitiated doshas are the prime important factors for a disease, they arecapable of the vitiating the other body elements like dhatus, malas and srotases46.Doshas in kshaya (decreased state) are not capable of progressing through thestages of kriyakalas to produce samprapti47. Doshas in vriddhi (increased state)manifest different specific symptoms and effects of the vitiation of particular doshas.Dushya and srotas : Next to doshas the most important contributing factors of disease are dushyaand srotas. Among the body substance dosha, Dhatu and Mala, the latter two areconsidered as dushyas. Doshas travel in the body through the channels (Srotases)and these are formed of different Dhatus. Therefore greater importance should begiven to Dhatus. The deformity of Srotases is called khavaigunya. "kha" means akasa orcavity. Srotas being a channel, it necessarily consists hallow portion inside with acovering wall around it48. Sthana samsraya is the stage of samprapti where doshasget lodged in Srotases and start the process of amalgamation with them (doshadooshya sammurehana In short all the bodily activities are entirely dependent onSrotases. All the doshas, Dhatus and Mala are dependent on Srotases for theirformation, conduction and destruction49. Hence, when Srotases get deformed, theactivities of dosha, Dhatu and Mala also become favorable for the genesis of adisease. This state of dosha - dushya sammoorchana corresponds to the phase ofthe manifestation of prodromal symptoms or poorvaroopa. 13 Literary review - Shareera
  26. 26. It is therefore evident that in the event of the impairment of the integrity of asrotas, a Dhatu either located in its own place or circulating through its srotasdefinitely becomes morbid. In the present context the Rasa is the substanceconveyed by the 10 Dhamanis and it is the Rasa that has the altered physico-chemical properties, which can change the physiology of the Dhamanis.Agnimandya; Charaka has clearly explained the importance of Agni; "When the Agni isextinguished, man dies; when a man is endowed with its adequately, he lives long ingood health. When it is deranged he falls sick. Therefore the function of the Agni issaid to be the main stay of life"50. In the present context, Agni may be disturbed under the following aspects;1. Dietetic causes : 1. Irregular diet habits. 2. Over-eating 3. Ingestion of the following types of food: a) Heavy and indigestible b) Raw and uncooked c) Fried foods d) Which are rooksha and sita (cold) e) Which can cause irritation and inflammation of the stomach. 14 Literary review - Shareera
  27. 27. f) Unclean and contaminated foods g) Soaked in too much of water and also for long duration. h) Food containing articles which are incompatible to one another. i) Ingestion of food before the previous meal is completely digested. j) Ingested foods disgusting or for which one has an aversion.2. Behavioral causes : 1. Intense emotional stresses such as grief, raga, worry, fear etc. 2. Irregulars sleep habits. 3. Lack of physical exercises 4. Suppression of natural urges. 5. Use of defective and faulty methods of vamana, vireka and sneha karmas.3) Other causes : 1. Emaciation due to any disease. 2. Faults or changes in desha, kala and ritu. Because of this impairment, the functions of jatharagni viz., sanghatabheda,dahana, tapana, parinamana and paravritti of the food are not effected properly. Byvirtue of asrayasrayee bhave, the impaired function of jatharagni leads to thedefective functioning of the pittadharakala (grahani). Therefore the functions of the 15 Literary review - Shareera
  28. 28. samanavata are also disturbed, leading to the erratic motility of the gastrointestinaltract. Two kinds of effects are envisaged: - 1. The grahani holds the food for longer duration leading to its fermentation resulting in the release of the toxic substances collectively known as Ama. 2. The grahani does not hold the food ill it is digested but pushes the partly digested food downward into the pakvasaya and sthulantra, effecting a rapid evacuation. The kayagni being located in its own place, not only takes part in thedigestion of the food, but also contributes to and augments the functions of otherPitta51. Therefore it is clearly evident that on the event of the impairment of thefunction of the jathargni the functions of the other Pitta are also impaired52. So thecause and/or conditions which contribute to the impairment of the jatharagni can alsodisturb the functional activity of the other Agni.HRIDAYA (heart) The heart (cardiac) is an important visceral organ made of Mamsa Dhatusituated in thorax apparently in between two nipples3a. It is particularly muscular andcontractile tubular segment interposed between the veins and arteries; situated inmiddle mediastinum covered by fibrous pericardium4. 16 Literary review - Shareera
  29. 29. NIRUKTI OF HRIDAYA: The term “hridaya” consists of three roots; ‘hri’, ‘da’ and ‘in’ and theyrespectively mean, harana, dana and ayana (gati) which indicates three importantfunctions meaning the receipt, giving away and moving on continuously activity of thetwo earlier functions. Therefore the word hridaya explains and signifies the functionalaspect of an organ and its identification depends on the substance, which is being“received”, “given away” and the organ thus functioning continuously for thepurpose4a. In the light of the above definition, there are certain organs in the body whichcan qualify to be called as “Hridaya” like the thoracic heart, the lungs and the centralnervous system etc. In view of the water freely moving in and out, even every jivaparamanu or cell can be designated as “Hridaya”. In the present context ofhypertension, Hridaya clearly indicates the thoracic heart only.Embryological development5 Hridaya is said in Astanga sangraha as developed from Sleshma and Rakta6.It is one out of the Matru janita avayava along with Pleeha7 in third month foetusdevelops heart which has attached to the mother and mother called as “Dwohridi”:The heart which is developed by mother is attached with Rasa vahaka nadi ofmother. The desires of foetus is thus expressed by the mother8 according tokritaveerya hridaya develops first as it is the seat of the Buddhi and manas andvetoed by Dhanvantari as all the anga pratyangas are going to be developed atonce9. It is explained in Sustruta Samhita the hridaya develops in 4th month. 17 Literary review - Shareera
  30. 30. Rather it can be said in between the 3rd and 4th months of pregnancy thehridaya is going to be developed which is chetanastana10, 11.Surface anatomy Aorta and the pulmonary trunk mainly hide the superior border of the heart,formed by the upper margins of the atria. The right border of the heart formed by theright atrium extends from the right end of the superior border to a point on the rightsixth costal cartilage 1-2 from the margin of the sternum. This border is slightlyconvex to the right. The inferior border of the heart, formed mainly by the rightventricle. It extends from the inferior extremity of the right border to a point (apex ofthe heart) in the fifth left inter costal space immediately medial to a vertical linedropped through the mid-point of the clavicle (midclavicular line). Normally thisborder is slightly concave to inferior and becomes convex and gives the globularshape incase of hypertrophy. A convex line to the left joining the left ends of thesuperior and interior borders marks the left border. It is formed by mainly the leftventricle and the left auricle and forms a small part of this border at superiorsurface12. From the Ayurvedic classics it has been said hridaya is a Sira marmasituated in between the two breasts in the chest, looks like as that of the opening ofthe Amashahya13. It has on its left side Pleeha and Puppusa and to the right Yakritand Kloma14. Its shape resembles the inverted long bud having chambers in it15. Intaittariyoparishat, relative placement has explained with Nabhi- the neval region itwas said Nisti above to the umbilicus the Nisti means 9 inches approximately. Infurther at the same context it was explain heart look like an inverted lotus bud having 18 Literary review - Shareera
  31. 31. down with its muscular pouch attached to the veins and arteries, 9 inches above tothe umbilicus16. Such hridaya is said as the placement for Ojas, Pranavahasrotas,Rasavahasrotas, Buddhi, and Manas of so many important factors dealt in Ayurveda.Inner view of the heart 17 The heart in adults completely divided into right and left sides and look like adouble barreled tube, receiving blood at one end (the atria) from veins and pumping itout at the other end (the ventricles) into the arteries. Since the heart must pumpblood in only one direction it is provided values to insure against back flow from areason higher to one of lower pressure. The inner lining of the heart continues with the intima of the vesselsconnecting to it, is known as the endocardiaum; and does not differ especially fromthe intima of the blood vessels. It also forms valves that lie between the atria andventricles and at the bases of the two great arterial tunnels living the heart. The muscular part equaling to the media of blood vessels, is a special type ofmuscle (cardiac muscle) found only in the heart and great vessels as the attach to italthough it is striated like voluntary muscle, it differs from in all other respects. The cardiac muscle fibers so branching and anastamos that it is impossible todetermine to limits of a fiber. Indeed, the myocardium of both ventricles is actuallyone continues muscle mass, and the myocardium of the both atria is anothercontinuos mass. Because of the continuity an impulse for contraction originating in anatrium can spread through out the arterial musculature; similarly, an impulseoriginating in a ventricle can spread throughout the ventricular musculature with all or 19 Literary review - Shareera
  32. 32. none law. It is built in such a way rhythmical transmission initiated by the nerveimpulses keeps the heart contracting and relaxing in regular intervals. In comparisonatria musculature is thin as the work at low pressure. Ventricular musculature thickerespecially of left ventricular as it has to pump the blood for the entire the body, whereas right pumps blood only to the lungs. No much reference is available about the heart description at themicrostructure level in Ayurveda except it has “Agarakarnika” i.e., chambers, fromCharaka Samhita18. According to Susruta it is made up of two mamsa peshis18a andexample by Dalhana with reference to its channels have their origin in khadantarmi.e., the organ cavity the hridaya18b. Hridaya is the source of the ten Dhamanis, whichspread throughout the body, giving of even small branches during their courseultimately end as Srotamsi which are perforce extremely fine tubules withinnumerable openings or pores in their walls, through which Rasa sravana takesplace18c.Spandana of Hridaya Hridaya is chetana sthana sthana35 i.e., the seat of chetana. The term“Chetana” is being understood as animated, alive, living etc, The life of Hridaya isexpressed in the form of akunchana and prasanana (contraction and relaxation)together termed as spandana. The spandana is characterized by the akunchana andprasarana of the hritpeshi is maintained by the chetana or swayam prerana shakti i.e.the auto stimulating quality. Due to its spandana, the hridaya is able to spread Rasaand Rakta through the body for the Preenana and Jeevana kriyas. 20 Literary review - Shareera
  33. 33. Interference of Pleeha with hridaya While discussing the complications of avrita Vata Charaka has placed Pleehaalong with hridaya to get the complications. Light has to focus how and why thePleeha (spleen) appears here in the context. Pleeha is placed left in the abdomen left side to that of heart, little down to it.It is described as the mula for Raktavahasrotas19and Rakta20. Chakrapani in furtheradded the Rasavahasrotomula viz. hridaya and 10 Dhamanis are to be consideredas Rakta stanas21. Thus the importance and interference with the Rasavahasrotas toRaktavahasrotas is explainable. At present we have to eliminate the interference ofPleeha to give rise a disease state in Rasavahasrotomula i.e., hridaya, ashypertension in association with Rakta. The spleen is includes in a part of the mesentery of the stomach, and itsparenchyma resembles that of lymph nodes, yet it is a part of the blood vascularsystem. Lymphatic within the spleen are confined to its capsule and to largetrabeculae, so that the lymphatic nodules of the spleen add lymph directly to theblood stream instead of delivering them first into lymphatic vessels, as lymph nodesdo. Phagocytic walls of the sinusoids, a part of the reticuloendothelial system, are thechief elements concerned with the destruction of the red blood cells and the removalof the iron component from them in order that this can be used again in forming newcells. The spleen filters the blood and participates with other parts of thereticuloendothelial system in the formation of antibodies22. The processes of filtrationof crystalloid and waste recyclable product of the blood it helps to maintain the 21 Literary review - Shareera
  34. 34. viscosity and specific gravity of the blood. There by blood will not be flooded withunnecessary colloids and crystalloid to maintain normal blood pressure. Otherwise itwill be resulted into blood pressure rise.Circulation of the blood The circular movement of the blood (Dhatu) in the body has been mentionedwhile describing the Dhatu parinama or the transformation of one Dhatu into another.The movement of the Dhatus (which nourish the body) goes on eternally like (themotion of) a wheel23. Chakrapani has pinpointed the Dhatus as the Rasa Dhatu etc. The simile of the wheel is significant here. This indicates not only the circularmovement, which is continuous, without any rest is dependent upon the ejectingforce of the hridaya i.e., the stimulus of the vyanavata to the Hritpeshi.Internal transport system of the body: Srotamsi (conduits) represents the internal transport system of the body. Theterm Srotas means a channel - it is derived from the Sanskrit root "sru sravana"meaning to exude, to ooze, and to permeate. Charaka has defined it is "sravahatsrotamsi" meaning, the structure through which "sravanam" takes place24. Accordingto Charaka, no structure in the body can grow and develop or waste and atrophy,independent of Srotamsi that transport Dhatus, which later, are constantly subjectedto (metabolic) transformations. And the Srotamsi supplies the needs oftransportation25. The Srotamsi of the body comprise of channels of different kindsand they are separately named according to the site and functions. At the present 22 Literary review - Shareera
  35. 35. context, the names Dhamani and Sira are relevant to the circulation of the blood.Says Charaka; they are spoken of as Dhamanis because they pulsate, as Srotamsibecause they permit oozing and Siras because they maintain a continuous flow ofblood (Rasa - Rakta)"26. The Dhamanis are stated to have their origin in the heart27. In view of the arrangement made by Charaka, specially when studiedtogether with the description of characteristic features of different parts of thevascular system, it is clear that the Dhamanis end in the Srotamsi (capillaries) whichin turn unite to form Siras (veins). Thus hridaya, Dhamanis, Srotamsi and Sirasconstitute a single circulatory unit, which regulate the proper flow of blood andnutritional supply to the body. The hridaya occupies a central place in the circulatory system as the organsupplying the motive force for the movement of the Rasa - Rakta combination andalso as a source of Dhamanis. There are two subdivisions of Vata, namely Pranavata and Vyanavata whichare stated to be concerned with the function of the hridaya. In brief the action ofPranavata is hridaya Dharana and that of Vyanavata is to eject the Rasa-Raktacombination for circulation throughout the body.PRANAVATA The word "prana" is composed of the root "an" with a prefix "pra" "na" meansto breath, to live. In view of this definition, the Pranavata should be responsible for allvital functions, which are essential for human existence. The definition "pranayatitiprana" also indicates the relationship of Pranavata with respiratory act. 23 Literary review - Shareera
  36. 36. Location of Pranavata: Charaka and Vagbhata28 state Shiras (head or mastishka) to be the seat ofPranavata. Pranavata is sated to traverse in the regions of oral cavity, ears neck andchest for the proper control and discharge of its functions.Functions of Pranavata: According to Charaka, the functions of Pranavata are the following; 1. Respiration (swasakriya) 2. Deglutition 3. Spitting out (stheevanam) 4. Sneezing (kshavadhu) 5. Belching (udgaram) Susruta states that Pranavata assists the different vitalizing principles of thebody in discharging their functions in life, deglutition and contribution to the generalsustenance of the body29. In addition, Vagbhata states that Pranavata maintains the actions of hridaya(heart), Manas, Buddhi, Indriya (sensory organ) and supports the Dhamanis(probably the vasomotor functions i.e., circulatory system)30. One of the functions ofprana vata is hridaya dharana31. The word dharana is derived from the Sanskrit root"dhri". Which means to hold in check, to restrain and "charana" indicates thepreserving, sustaining, protecting etc. Therefore the function of Pranavata, is to beunderstood as a check or restraint on Hridaya Spandana, for the preservation orprotection of the organ. 24 Literary review - Shareera
  37. 37. The functions are to be considered as those of an organ/region or part of anorgan, having a shape of Nabhi and situated in the brain. The functions likerespiration, maintenance or the actions of the heart and circulatory system,deglutition, spitting out, sneezing, bleaching and the functional maintenance of thesensory organs are peripheral in nature and so the impulses have to leave thecentral nervous system for their proper execution. On the other hand the functionslike the regulation of the sensory input, and consciousness which belong to theManas and Buddhi are central in character and the impulses have to reach therespective higher centers. Therefore some scholars, based on the regions of actions, have furthersubdivided the Pranavata as: -1) Sirasthita Pranavata which is located in the head and2) Urahsthita Pranavata which is located in the cheat. The sirasthita Pranavata may regularly move down into the chest through the neck, to join the urahsthita Pranavata that goes to the oro-nasal region, ears and eyes through the throat. It carryout the acts of sneezing, belching etc; it is clearly stated that Pranavata is controlling the hridaya and also the Dhamanis (hridaya dharana and Dhamani dharana). Hridaya is located in Uras and the Dhamanis are spread throughout the body. Since the hridaya has to conduct the "vikshepa karma" for the blood to circulate throughout the body, the conditions of the Dhamanis are particularly relevant and associated with the function of the hridaya. 25 Literary review - Shareera
  38. 38. Dhamani dharana kendras is also located in the area of Pranavata and is animportant center in that area. Its effect on Dhamanis is of two types: 1) Sankochana (contraction) 2) Vikasana (dilatation) These two functions are possible only due to the presence of mamsa peshisin the Dhamanis. The contraction of these peshis causes the decrease in the caliberof the vessels (vaso - constriction) and the relaxation causes the dilatation. Theseare two separate areas in the Dhamani dharana kendra, the stimulation of one causecontraction and the stimulation of the other dilatation. The main function of Rakta is Jeevana kriya to all the tissues of the body.Therefore Rakta is kept in circulation by the spandana of the hridaya. The decreasein the caliber of the Dhamanis produces a decrease in the supply of the "prana" vayuand therefore the hridaya is stimulated for increased and forceful spandana, therebyincreasing the Raktapeedana. The decrease in the caliber of Dhamanis also causesincreased peripheral resistance. Thus the Dhamani dharana kendra can eitherincrease or decrease of the activity of hridaya.VYANAVATALocation of vyanavata : Charaka and Susruta have not mentioned any specificplace regarding the location of the Vyanavata, except that it pervades swiftlythroughout the body32. According to Vagbhata, the Vyanavata is located in Hridaya but traverses throughout the body swiftly33. 26 Literary review - Shareera
  39. 39. Vagbhata states that the Vyanavata is located in "Hridaya" needs someelucidation in view of the fact that location and function of the nervous system relatesto Vata. And the phenomenon of Vata is the phenomenon of nerve impulses. Theword Hridaya signification is of an anatomical organ that depends on the dravya orsubstance, with the functions "receiving" and "give away" and the organ thusfunctioning continuously for this purpose. This can be better appreciated with theunderstanding of the functions of Vyanavata.Functions of the Vyanavata The important functions of the Vyanavata can be two in the present context: • Function of the Rasa is the nourishment of the body i.e., the dhatus34 • Effecting the outflow of the blood The circulation of Rasa (Rakta is also included) is due to the vikshepa karmaof the heart, caused by the contraction of the musculature of the organ, due to thestimulation by the Vyanavata. Effecting the outflow of the blood depends not only on the effective ejectingcapacity of the heart but also the caliber of the blood vessels. An increase in thequantity of the circulating blood causes an increased outflow. Therefore function ofVyanavata is to be understood as to increase the caliber of the blood vessels. It may be noticed from the above details that the Pranavata and Vyanavataact in opposite directions with reference to the heart and blood vessels. Pranavatanot only checks or restrict the hridaya spandana but also constricts the blood 27 Literary review - Shareera
  40. 40. vessels. The Vyanavata increases the hridaya spandana with forceful contraction ofthe heart musculature and increases the caliber of the blood vessels.Functions of the heart Many functions have been mentioned in relation to Hridaya. The whole bodyincluding viscera, consciousness, sense faculties, five objects of senses, Atmatogether with its qualities like happiness etc; mind and its objects are all located inthe hridaya36. The heart represents the entire sense perception, animation andmoreover the heart is the substratum of the Ojas and it controls the mind37. As theentire girder supports bamboo framework of the thatch, so the heart represents thesubstratum of all the entities38. The circulation of Rasa-Rakta is maintained by three factors: -1) The muscular structure of the heart through its contractions and relaxation. The heart is made up of two muscles. The main characteristic of the muscle in the body is its contraction and relaxation.2) The heart working as a pump i.e., the heart through its working takes in the blood during relaxation and gives out the same during contraction. The definition of the word Hridaya explains its functional nature. Since hridaya is seat of Rasa and Rakta, Hridaya takes in and gives out the Rasa Rakta combination by continuously functioning for the maintenance of the circulation.The actual reference regarding the contraction and relaxation of the heart is found in Yoga- vasistha as “Whenever expansion (relaxation) and contraction in the duct situated in the heart occurs ….”. This statement clearly explains that the heart 28 Literary review - Shareera
  41. 41. contracts and relaxes regularly. That the heart works continuously for Charaka implicitly explains the maintenance of the circulation while dealing with the functions of Vyanavata. "The Rasa Dhatu (the Rakta is also included) is circulated continuously through every part of the body simultaneously by the Vyanavata, by virtue of its physiological function of projection"39. Vyanavata is stated to be located in hridaya. The two words used regarding the continuity of this function are "Ajasram" is Avisratam i.e., without any rest and of the word sada is "sarvakalam i.e., at all times. This function of the heart, which is chetana stahana explained as the self stimulating nature, to take in and give out blood continuously without any rest resembles the action of a pump which supplies a liquid material. 3) The circular movement of the blood in the body is done by Rasavahasrotas.Rasavahasrotas: Rasa is the important adya Dhatu, because it has dhatu poshak dravyas(nutrient substances) for all Dhatus in it. And also the nourishment to other Dhatus isthrough it. This Rasa Dhatu is capable of spreading all over the body. Ahara Rasapertains to the prasada bhaga of ahara, which has been treated as Rasa40. Thefunction of Rasa Dhatu is preenana41. It indicates the function of satisfying orgratifying. The Rasa is produced in koshta (annavahasrotas) from food aftercompletion of the pakvavastha (digestion) to be absorbed through the walls of thekoshta. The circulation of Rasa by hridaya is to maintain the life by propernourishment to the body. 29 Literary review - Shareera
  42. 42. Hridaya is the Rasa sthana, it is also the moolastana of Rasavahasrotas42.According to Susruta, hridaya and rasa-vahini Dhamanis are the moolas ofRasavahasrotas43. Hridaya is also the seat of Rakta and other fluids which arecapable of circulating in the body44. Therefore the hridaya is not to be considered asthe seat of Rasa only and similarly are the dasa (ten) dhamanis. Since Rakta is alsoa (partially) fluid Dhatu, with its main function as jeevana kriya, to be continuouslymaintained and also circulated by the hridaya. It is clear that the Rasa and Raktamove together for the maintenance of these functions. Rakta Dhatu contains the cellswith raktamsha, which are not capable of entering most microscopic srotas. But dueto its quality of sukshma, Rasa penetrates into all Srotases. The Rasa - Rakta iscirculating in a combined state. Because of the inability of the cellular components ofthe Rakta to enter all Srotases; the Rakta with its raktamsha ceases to move furtherwhile the Rasa proceeds carrying the nutrients. Therefore hridaya and Rasavahinidhamanis should be considered as the moolas of Rasavahasrotas. Rasa is ejected by the hridaya into circulation and moves in the dasadhamanis and their branches. The Dhamanis are stated to have khani (pores ) intheir walls through which Rasa passes through to all parts of the body very much likethe minute passages present in a lotus stem45. Therefore these pores present in thewalls of the Dhamanis are also considered rasavahinisrotas. Because of the ashrayashrya bhava (interdependence) between the srotasand the substance conveyed through it, any change in the composition of Rasa canvitiate the Rasavahasrotas and also its moola i.e., hridaya. 30 Literary review - Shareera
  43. 43. Rakta peedana There is no definite information regarding the normal or abnormal states ofraktapeedana (blood pressure) in Ayurvedic classics. The word "peedana" indicatespressure and its adhikyata is an increase in the pressure in line with the actionnoticed in the arteries (Dhamanis). But Rakta peedana or blood pressure is definedas the lateral pressure exerted by blood on the vessels walls while flowing through it.Since the rasa-rakta combination is forcefully ejected by hridaya for the maintenanceof preenana and jeevana kriyas, into the Dhamanis, some pressure is exerted byrasa-rakta on the Dhamanis. Therefore two issues are taking part here; • blood with its flow, (here blood is a combination rasa and rakta) • the blood vessels (or) artery (Dhamani) This indicates that any change in these two is likely to effect a change in theraktapeedana. The flow of blood is dependent on the vikshepa karma of the hridaya.Therefore provided the dhamanis are in a healthy state; the vikdhepa karma of thehridaya and the raktapeedana are maintained by the akunchna of the hritpeshisthrough the action of Vyanavata. So the maintenance of normal raktapeedana is dueto an equilibrium state between the actions of Vyanavata and Pranavata, which hasthe function of "Dhamani dharana" also. Rakta adhika peedana indicates a sustainedincrease in the raktapeedana and it is a feature of several distinct diseases.1. Reduction in the caliber due to a vitiated state of Pranavata or a disturbance in the equilibrium in functions of Pranavata and Vyanavata. 31 Literary review - Shareera
  44. 44. 2. Srotavaigunya of the Dhamani caused by a change in the structure. This is mainly due to dhamaniprtichaya; which is caused by a change in the composition of the rasa-rakta. These two sates cause a reduction in the essential kriyas of Preenana and Jeevana to the tissues of the body. Therefore in order to keep the tissues alive, the hridaya is forced to increase the ejecting power with a consequent increase in raktapeedana. 32 Literary review - Shareera
  45. 45. 1 Charaka Chikitsa, 28/236,2372 Susruta Sutra, 21/53 Bhela Sutra, 20/346 Madhava nidana 1/25 Madhukosha on it47 Charaka Sutra 17/6248 Susruta Sutra 24/1049 Charaka Vimana 5/350 Charaka Chikitsa 15/451 Astanga Hridaya Sutra 12/1252 Charaka Chikitsa 15/193a Su.Sareera. 6/254 Text book of Anatomy, Henry Hollinshed, pp784a satapatha brahamana, brihadaranya kand, 14, cha. 18. Brahamana 4-1.5 Grays Anatomy,6 Astanga Sangraha Sarira, 5-49 ; Su.Sa.3/12 ; A.san.sa. 5-147 Charaka Sarira, 3/138 Charaka Sarira, 3/169 Susruta Sarira, 3/1810 Bhela Sarira, 7/12 Cunnighams manual of practical anatomy, vol-2, pp4513 Susruta Sarira, 6/4014 Susruta Sarira, 4/3115 Astanga Sangraha Sarira, 516 Taittariyopanishat17 API text book of medicine18 Charaka Sutra, 30/518a Susruta Sarira 5/3718b Susruta Sarira 9/13 Dalhana on it.18c Charaka Sutra 30/3, Astanga Hridaya Sarira 6/4635 susruta sarira19 Charaka Vimana, 5/820 Susruta Sarira,9/1221 Charaka Chikitsa,24/35 Chakrapani22 Text book of Anatomy, Henry Hollinshed, pp8023 Charaka Chikitsa 15/2124 Charaka Sutra 30/1225 Charaka Vimana 5/326 Charaka Sutra 30/1227 Charaka Sutra 30/328 Charaka Chikitsa 28/6 Astanga Hridaya Sutra 12/429 Susruta Nidana 1/13).30 Astanga Sangraha Sutra 20/4 ; Astanga Hridaya Sutra 12/4,531 Astanga Sangraha Sutra 20/4 indu on it32 Charaka Chikitsa 28-9 Susruta Nidana 1-17)33 Astanga Sangraha Sutra 20-4 Astanga Hridaya Sutra 12-6)34 Susruta Sutra 15/536 Charaka Sutra 30/437 Charaka Sutra 30/6,738 Charaka Sutra 30/539 Charaka Chikitsa 15/3640 Charaka sutra 24/ Chakrapani41 Susruta Sutra 15/542 Charaka Vimana 5/843 Susruta Sutra 19/1244 Charaka Chikitsa 24/35 Chakrapani45 Susruta Sarira 9/10 33 Literary review - Shareera
  46. 46. Definition of Hypertension: - In the adult, rise of systolic pressure above to 140mm Hg. and of diastolicpressure higher then 90mmHg, are usually considered as hypertensive levels,although such a sharp distinction is not reliable unless considered in relation to age. The blood pressure may be persistently above or below the normal range.The high range then the normal is termed as Hypertension and low as Hypotension.Hypertension is defined arbitrarily, at level above generally accepted normal values.High blood pressure (hypertension) is the condition in which occurs abnormalsustained increase of the pressure exerted by the arterial wall to flowing blood. The clinical syndrome of hypertension appears to be a result of the elevateddiastolic pressure; usually the systolic pressure is also raised, but it need not be. Alsosome times systolic hypertension may occur without a diastolic pressure elevation.Systolic hypertension alone is not believed to be clinically important, unless very highlevels threatened integrity of the blood vessels.Disease considered as hypertension in 20th century authors is as follows.1. RAKTAGAVATA: The disease Raktagata Vata, which is mentioned under the context ofVatavyadhi, can be correlated with essential hypertension. Separate nidana have notbeen mentioned far Raktagavata, so samanya nidana mentioned for Vatavyadhi can 33 Literary review - Nidana
  47. 47. be considered as etiology for the Raktagata Vata. Some Ayurvedic scholars havementioned that Raktagata Vata as Raktavata.Charaka broached lakshanas as - Teevraruja Santapa Vaivarnya Krishatha Aruchi Stambata soon after having food (charaka chikitsa 28/31) Vagbhata also mentions almost all the symptoms, which are mentioned byCharaka, in addition with - Swapam Raga and Bhrama ( AH.NI.15/10) Shri sudarshan shastri and shri yandunandanopadhya while writing vyakhyaof Raktagata Vata says that the word Raktachapa has to consider as hypertension.Acording to Kaviraj Gananathsen, the conditions Raktagata Vata and Vata Rakta areone and the same. But Sri Sudarshan Shastri and Sri Yandunandanopadhyaconferred opinion, as Raktagata Vata is nothing but hypertension.2. Raktavrita vata: Charaka has described the disease Raktavrita vata under the context ofVatavyadhi but no other Acharyas have mentioned regarding this disease. Raktavrita 34 Literary review - Nidana
  48. 48. vata resembles to that of Raktagata vata. They are Daha in between twak, mamsaand Vedana saragayukta shota and mandala.3. Siragata vata: Siragatavata is described under Vatavyadhi. Charaka, Susrutha andVagbhata describe it. When there is vata prakopa in siras, it causes many diseasessuch as vata sambava vyadhies. Lakshanas mentioned under siragata vata are - mandaruja, shopha, kampa no spandana in siras but there will be akunchana in them. ( CHA. CHI.28/36) Susrutha and Yogaratnakar supported Charaka in all aspects.4. Bhrama: The literal meaning of Bhrama is rotation. As a disease, it has been explained asa feeling that a person experiences the fast rotation in the shiras similar to that of fastrotating wheel. Charaka has considered the Bhrama as one out of the vatajananatmaja vyadhi. Here Bhrama corresponds to Giddiness and Vertigo. Bhrama is adisease not only concerned to the shiras but also considered as RaktapradoshajaVyadhi. Chakrapani dutta, has explained Bhrama as a smruthi mohaha that meanshallucination in his commentary. (CHA.SU.20/11) 35 Literary review - Nidana
  49. 49. Vagbhata has mentioned that this is because of vata dosha (AH.SU.11/61) whereas Charaka affirmed it as sanchaya of vata dosha blocked by vitiated pitta dosha.(CHA.CHI.28/31). Bhrama explained as a prodromal symptom of some diseases.It is also said as symptom and complication of many diseases.5. Roudhira Mada: Mada is, mado Harshaglanopanay (BH.Part 1) it means, Harsha and glani ofRakta takes place. I.e; increased gati and matra of rakta takes place or other wiseutkarsha or aakarsha of rakta is called mada. In charaka samhita 43 types of raktajavydhies are mentioned and mada is one among them. (CHA.CHI.28/31) On the other hand there are seven types of madas explained. Vataja, pittaja,kaphaja, sannipataja, vishaja and roudhiramada. (BH.P.part1). Roudhira mada isconsidered as hypertension by Acharya shree Vishwanath Dwivedi and clarifieddushya involved in this disease is as Rakta. In Roudhira mada, initially the vitiation of blood results into increased Rakta,and there by altered Akunchana and Purana of Raktavaha and siras takes place.Then it confers to Roudhira mada.6. Raktapradoshaja vikaras : In charaka samhita totally 43 diseases are mentioned in vidhishonita adhyayaall these diseases come under the rakta pradoshaja vikara. In this group mada,raktapitta etc., diseases are considered. (SUS.SU.24/9, CHA.SU.24/11-16)(AS.SU.36/7) Hypertension is considered under the Raktapradoshaja vikara, due tothe involvement of Rakta Dhatu. 36 Literary review - Nidana
  50. 50. 7. Avruta Vata Some of the avrutha vata are also considered under the heading ofhypertension. They are Pittavruta pranavata and Pittavruta udanavata. pittavrutha prana vayu: The lakshanas mentioned are • murcha, • daha, • bhrama, • soola, • vidaha, • chardi and • sheeta kamatwa.(CHA.CHI.28/218) Pittavruta udana vata : The pittavruta udanavata lakshana are • murcha, • daha, • shoola, • daha in the nabhi and urah region, • ojobransha, • shwasa, and • klama. (CHA.CHI.25/220) 37 Literary review - Nidana
  51. 51. 8. Murcha and sanyasa : Murcha is disease of raktavaha srothas which is due to vikrutha pitta andtamo guna i.e, both sharirika and manasika vyadhi. Murcha can be considered assyncope, which is mentioned, in modern science. A simple faint or temporary loss ofconsciousness due to cerebral and it is important to note that giddiness, faintness oractual syncope is much more frequently due to peripheral circulatory failure. According to Astanga hridaya mada, murcha and sanyasa are the diseases ofrasa, rakta and samjnavaha sroto dusti. Acharya Susruta explained 6 types ofmurcha vataja, pittaja, kaphaja, raktaja, madyaja and vishaja. While explaining aboutthe raktaja murcha, it is due to smell of blood or by seeing the blood it occurs. Srisudarshan shastri and sri yadundana upadhyaya opined that murcha occurring inrakta vata or high blood pressure can be raktaja murcha.9. sanyasa ( coma): sanyasa is disease of samajnavaha srotas and also called as gambhiramurcha. If murcha is not treated properly it leads to Sanyasa. According to modernscience coma is a state of unnatural heavy deep and prolonged sleep oftenaccompanied by slow irregular breathing and consequently ending in to death. (indexof different diagonisis by herbet french).10. Dhamani pratichaya: According to Charaka Dhamani pratichaya is one of the kaphaja nanatmajavyadhi. The description of dhamai prathichaya as available in Nidhana Chikitsa 38 Literary review - Nidana
  52. 52. hastamalaka is ati poornata of dhamani. This atipoornata of dhamani is because ofadhika poshana or excess nourishment. Due to adhika poshna specially Rasa and Rakta increases and interrupts themovements in Dhamanis there by they get stretched under the influence of fullnessof the Rasa, Rakta (vriddhi) Dhatu. With this the Gati becomes manda and guru. Themanda is the counter guna of Vata, thus it infers the Vata vitiation. The Vata vitiationaggravates the Vata, and there by it increases Vata gunas such as chalatva.Chakrapani, Gangadhara and Yogendrenath annotated on the word dhamanipratichaya, dhamaniupalepa to denote atherosclerosis. Brief description and opinion of Brihatrayee about different conditionsresembles Hypertension is as follows: S.No Diseases Charaka Susruta Vagbhata1 Raktagaa vata + + +2 Raktapradoshaja vikara + + +3 Raktavrita vata + + +4 Raktavata +5 Pittavruta Pranavata +6 Pittavruta Vyanavata +7 Bhrama + + +8 Mada + + +9 Murcha + + +10 Sanyasa + + +11 Dhamani pratichaya +12 Siragata vata + + +13 Roudhira mada + 39 Literary review - Nidana
  53. 53. ClassificationThe purpose of a classification of hypertension is 1. To provide an easy and reliable method for the personification of each patient. 2. To assess the severity of disease by reference to epidemiological data so that risk can be restricted and appropriate treatment can be instituted.Classification of hypertension 1. Symptomatic classification of hypertension; a) Labile (Borderline or Transitory) hypertension. b) Stable hypertension. • Moderate • Severe 2. Classification by blood pressure (level) readings; a) Mild hypertension b) Moderate hypertension c) Severe hypertension 3. Classification by severity of vascular reasons; a) stage I b) stage II c) stage III 4. Classification by cause; a) Hypertension due to administration of drugs. (Iatrogenic hypertension) b) Hypertension disease of pregnancy c) Other disease (renal hypertension) 5. Classification by age groups; a) Juvenile hypertension b) Hypertension in the elderly 40 Literary review - Nidana
  54. 54. 1. Symptomatic classification of hypertension:- The determination of arterial pressure permits the classification into “Labile andpermanent hypertension”. The later may be either moderate or severe. Such aclassification is purely symptomatic and gives no information concerning the etiologyof the disease.a) Labile hypertension:- Labile hypertension has many synonyms: - • Borderline or Transitory hypertension. • The pre-hypertensive state • Hyper dynamic circulatory syndrome and • Hyperkinetic heart. The term ”Labile” means little. The term labile (or borderline) hypertension is usedto describe subjects in whom arterial pressure is above to arbitrarily selected thresh-hold or the values between the normal and hypertensive range. Labile hypertensionpatients have no constant haemo dynamic or biological characteristics. Theprognosis for their hypertension is highly variable, and the value of treatment has notbeen demonstrated.b) Stable hypertension: - The stable hypertension may be divided into two groups, according to gravity: i) Moderate or Benign and ii) Severe or malignant (some times also termed accelerated) 41 Literary review - Nidana
  55. 55. Classification by stages of development introduces as authority element forassessing disease severity. The rate of progression of hypertension varies from oneindividual to another depending on the environmental and genetic backgrounds.Arterial hypertension may be classified in three separate ways:- 1) By the blood pressure level 2) By the extent of damage to organs and 3) By the etiology2) Classification by blood pressure (level)readings:- a) Mild hypertension: - Diastolic pressure is between 90 to 140mm Hg is said as mild hypertension. Regular medical surveillance is advisable and the value of anti-hypertensive drugs is being evaluated. b) Moderate hypertension :- Diastolic pressure is between 105 and 114mm Hg is said as moderate hypertension. Benefit has been demonstrated from the use of anti-hypertensive drugs at these blood pressure levels. c) Severe hypertension :- Diastolic pressures are 114mm Hg or above, at these blood pressure reading carries a distinctly high risk to the patient. Prompt anti-hypertensive treatment is always advisable. 42 Literary review - Nidana
  56. 56. 3) Classification by severity of vascular lesions:-(Classification according to extent of organ damage; stages of hypertension) Classification of this kind indicates the extent of the disease, the rate of progression of hypertension highly varies depending on many influences from one individual to another, but the extent of organ involvement corresponds most closely to the level of pressure. However both blood pressure and organ impairment should be evaluated separately. Since markedly high pressures, carrying a high risk, organ damage has to be evaluated with reference to the rise of blood pressure.a) Stage I: - No objective signs of organic involvement are evident. This is defined by theabsence of signs of vascular disease. There are normal retinal vessels, renalfunction, and electrocardiogram and cardiac radiography. Functional disorders; suchas headache, should always be considered with caution before being attributed to therise in blood pressure.b) Stage II: - At least one of the following signs of organ involvement is present. - Left ventricular hypertrophy on physical examination, chest x-ray, Electro cardiograph, echo-cardio graph etc., - Generalized and local narrowing of the retinal arteries. - Protenuria and/or slight elevation of plasma creatinine concentration.d) Stage III:- • Both symptoms and signs have appeared as a result of damage to various organs from hypertensive disease. These include: 43 Literary review - Nidana
  57. 57. • Heart - left ventricular failure or congestive heart failure, ischaemia; stroke; angina; myocardial infarction• Optic Fundi - retinal hemorrhages and exudates with or without papilloedema.• Kidneys - renal failure, Renal insufficiency.• Brain - cerebral, cerebellar, or brain stem hemorrhage, cerebral or coronary thrombosis and hypertensive encephalopathy, ,• Vessels: dissecting aneurysm arterial occlusive disease.4) Classification by etiology: a) Essential hypertension: - The great majority of patients with elevated blood pressure have no identifiable cause for this. These subjects are defined as essential hypertensives. The research is carried out on the haemodynamics and endocrinology of essential hypertension to characterize it.b) Secondary hypertension: - Secondary hypertension in contrast to essential hypertension must be classified precisely and definitively. Diagnosis can permit specific treatment; which is usually more effective and less expensive than that of drug treatment. This is defined as hypertension with identifiable cause. The possible causes are classified below.• Hypertension due to the administration of drugs (iatrogenic hypertension) 44 Literary review - Nidana
  58. 58. Iatrogenic hypertensive forms of hypertension are easily discovered by questioning and also can be cured by withdrawing the hypertensive agents. They include: 1) Use of estrogen - Progesterone derivatives as contraceptives or estrogen treatment for other reasons. Withdrawal of therapy often but not always, returns the blood pressure readings to normal. 2) Abuse of compounds containing glycyrrhetive acid- (liquorice biogastrone) 3) Abuse of vaso-constrictive nasal drops. 4) Abuse of analgesics, which may lead to renal lesions. - Hormonal contraceptives. - Liquorice and carbenoxolone - ACTH and cortico steroids• Hypertension disease of pregnancy :- This is a form of hypertension specific to pregnancy, and which occurs after 24thweek and more often after the 30th week of gestation. There may be accompanyingedema and proteinuria. Eclampsia is defined by the onset of convulsions.• Renal disease :- Renal hypertension frequently accompanies a wide variety of renal arterial abnormalities. These include the various conditions. 1. Glomerulopathies 2. Renal involvement in collagenoses 3. Tuber lesions 4. Infections 5. Interstitial nephropathies and 6. Tumors 45 Literary review - Nidana
  59. 59. Renovascular hypertension results from narrowing or occlusion of one or bothrenal arteries, which alters the excretory and endocrine function of the kidneys. Renal diseases, (renal artery stenosis; glomerulonephritis; pyelonephritis;radiation nephritis; renal tuberculosis, renal cysts; hydronephrosis; renal tumorincluding renin secreting tumors and renal failure) and diseases of the adrenal cortex(primary hyperaldosteronism, cushing’s syndrome, tumors producing excess of othercorticosterioids e.g. corticosterone and desoxycortone and inborn errors ofcorticosteriod biosynthesis) along with the diseases of the adrenal medulla(pheochromocytoma) are included in this category.5) Classification by age groups: - a) Juvenile hypertension : Hypertension in young people (juvenile hypertension) is now the subject of very much more research at present which has to be considered from two points of view, clinical and epidemiological. b) Hypertension in the elderly :- 65 years and over groups however should not looked at in isolation from the younger members and blood pressure trends, weight trends, coronary risk factors and other cardio-vascular aspects are to be regularly monitored. The systolic verses diastolic pressure and the risk of coronary heart verses diastolic pressures are relevant to the questions of hypertension in the elderly. There are few assumptions regarding hypertension is - 46 Literary review - Nidana
  60. 60. • Systolic pressure elevation is unimportant and it is only diastolic pressure elevation that contributes to morbidity and mortality. • Women tolerate hypertension well. • An elevated level of hypertension is often a ‘normal’ concomitant of aging.Epidemiology of hypertension 1) Prevalence: - It has been repeatedly emphasized that in Europe and U.S.A high blood pressure is very prevalent. The systolic pressure increases with age and the diastolic pressure increases up to age 55-60 when it tends to level off. The types of hypertension have also been studied in various population groups to identify those believed to be primary as contrasted with those of secondary origin. Primary hypertension is responsible for about 93% of hypertensive adults. 2) Level of pressure :- The mortality ratio was seen to rise above the standard risk when diastolic pressure exceeded 83mm Hg and when the systolic pressure exceeded 127mm Hg. The risk is doubled with systolic values above 158 mm Hg and diastolic above 97mm Hg. Studies have confirmed that the mortality rises in proportion to the height of the systolic and diastolic blood pressures. 3) Genetic and Environmental Influences: - Population studies of varying size have been used to assess the continuation of genetic factors in hypertension. The monozygous twins have a higher 47 Literary review - Nidana